Bones

( Fig. 10-1 )

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  accessory bone: an extra bone that may develop in the carpus of the wrist as seen on radiographs; an anomaly.

  
  
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  carpal bones: the eight bones of the anatomic wrist, arranged in a proximal and distal row, and held firmly together by ligaments. The proximal row from lateral to medial (radial to ulnar) includes the scaphoid (navicular), lunate (semilunar), triquetrum (triangular), and pisiform. The distal row leading from the thumb side is composed of the trapezium (greater multangular), trapezoid (lesser multangular), capitate (os magnum), and hamate (unciform).

  
  
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  carpus: the wrist; term applied to the structures of the wrist including the carpal bones.

  
  
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  fossae (fossa, sing.): the scaphoid and lunate fossae are normal recesses in the articular surface of the distal radius that allow articulation of the scaphoid and lunate, respectively.

  
  
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  hamulus: not a separate bone; this term is used to describe the hook of the hamate in the wrist.

  
  
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  Lister’s tubercle: bony prominence in the dorsum of distal radius bone that the EPL tendon traverses around en route to distal phalanx of thumb. It also separates the second (ECRL and ECRB) and third (EPL) extensor compartments.

  
  
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  metacarpals: the five long bones of the hand in the palm area. The bases of the metacarpal bones articulate proximally with the distal row of carpal bones.

  
  
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  phalanges (phalanx, sing.): the bones of the thumb and fingers. Each phalanx has a proximal base, shaft, neck, and distal head. There are two phalanges in the thumb (proximal and distal) and three phalanges in each of the four digits (proximal, medial, and distal).

  
  
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  sesamoids: small bones on the medial and lateral side of the base of the proximal phalanx of the thumb (metacarpophalangeal [MCP] joint). The sesamoids articulate with the head of the metacarpal bone to which muscles are attached. A sesamoid bone may also be found on the lateral side of the MCP joint of the index finger and medial side of the MCP joint of the little finger.

  
  
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  sigmoid notch: the articular surface on the distal radius that accepts the ulna in the distal radioulnar joint.

  
  
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  styloids: bony protuberances off the radius and ulna that act as attachment sites for the radial and ulnar collateral ligaments, respectively. The ulna styloid base is also an attachment for the triangular fibrocartilage complex.

  
  
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  tubercles: bony prominences that provide ligamentous attachment. In the hand, these include the scaphoid, trapezium (does not have any ligamentous attachments), and the hook of the hamate .

  
  
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  tuft: the terminal bony expansion of the distal phalanx.

Fig. 10-1Bones of the right hand and wrist, dorsal surface. (From Anthony C, Kolthoff N: Textbook of anatomy and physiology, ed 9, St Louis, 1975, Mosby.)

Joints

The joints of the hand are remarkable for the variability of motion that supports the fingers and thumbs in many tasks (e.g., the carpometacarpal [CMC] joint of the thumb can move in all planes). The joints of the phalanges are the proximal and distal joints and are referred to as:

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  distal interphalangeal (DIP)

  
  
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  interphalangeal (IP)

  
  
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  proximal interphalangeal (PIP)

  
  

  The joints of the metacarpal, phalangeal, and carpal bones are referred to as:

  
  
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  metacarpophalangeal (MCP)

  
  
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  carpometacarpal (CMC)

  
  

  The joints of the carpal bones and the radius are referred to as:

  
  
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  midcarpal (MC)radiocarpal (RC)

  
  
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  scaphotrapeziotrapezoidal (STT)

  
  
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  radiostyloid

  
  
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  radioscaphoid

  
  
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  radiolunate (RL)

  
  
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  capitolunate (CL)

  
  
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  scapholunate (SL)

  
  
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  lunotriquetral (LT)

  
  
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  distal radial ulnar joint (DRUJ)

  
  
  
  
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    volar plate: a thickening of the joint capsule of the volar aspect of the MP and IP joints that prevent hyperextension of these joints. Proximally, these begin with the check-rein ligaments.

    
    
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    radial/ ulnar collateral ligaments: Ligaments that stabilizes the MP and IP joints on both the radial and ulnar aspects of the joints respectively. Both the RCL and UCL are separated into two components: proper collateral ligaments (connects bone to bone: MC to PP or PP to MP or MP to DP) and accessory collateral ligaments (connects bone to volar plate)

  
  

Muscles and Tendons

There are large muscles in the forearm that insert into the bones of the hand by means of their tendons. These extrinsic muscles cause the hand and fingers to flex and extend (close and open). The intrinsic muscles are small and originate within the hand ( Figs. 10-2 and 10-3 ). These control positioning and, to a large extent, functional coordination of the fingers. In normal hand function, all these groups work together in intricate unison.

Muscles of the anterior aspect of the human hand; the palmar aponeurosis has been removed. (From DiDio LJA: Synopsis of anatomy, St Louis, 1970, Mosby.)

Muscles of the anterior aspect of the human hand. (From DiDio LJA: Synopsis of anatomy, St Louis, 1970, Mosby.)

Pulleys

Pulleys are thickened portions of flexor tendon sheaths that hold tendons in place. They are labeled as annular or cruciate, depending on the orientation of the fibers of the pulley. The most proximal pulley is located on the volar plate of the MCP joint and is labeled annular 1 (A1) and then annular 2 through 5. A1, A3, and A5 pulleys are located volar to the MCP, PIP, and DIP joints respectively. A2 and A4 pulleys are attached to the PP and MP bones, and these are the pulleys (primarily A2) that provide most of the force to hold the flexor tendons down to the bone during finger flexion to avoid bowstringing of the flexors. The cruciate pulleys are similarly labeled C1 through C3 ( Fig. 10-4 ).

Fig. 10-4This anatomic diagram of various parts of flexor sheath is helpful in understanding gliding of tendon. Maintenance of second annulus (A2) and fourth annulus (A4) is essential to retain appropriate angle of approach and prevent bowstringing of flexor tendons or tendon graft. (From Doyle JR, Blythe W: In American Academy of Orthopaedic Surgeons : symposium on tendon surgery in the hand , St Louis, 1975, Mosby.)

A1	zone II	C1	zone II
A2	zone II	C2	zone I
A3	zone II	C3	zone I
A4	zone I	AO	zone IV (palmar fascia)

 

Ligaments and Fascia

There are numerous ligaments named for the bones to which the ligaments are attached.

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  deep transverse metacarpal l.: specific distal ligaments between the second, third, fourth, and fifth MCP volar plates.

  
  
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  juncturae tendinum: tendinous interconnection between extrinsic extensors over the dorsum of the hand. These allow synchronized digital extension; also called connexus intertendineus.

  
  
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  transverse carpal l.: the strong ligamentous band that lies across the arch of the carpal bones forming the roof of the carpal tunnel. It covers the median nerve and binds down the nine long flexor tendons of the thumb and fingers. It also serves as the floor of Guyon’s canal. Also known as flexor retinaculum and volar carpal l.

  
  
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  triangular l.: interconnecting fibers that join the two lateral bands dorsally and hold them in place. They are located over the proximal end of the middle phalanx just distal to the insertion of the central slip of the extensor tendon;

  
  
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  Vickers ligament: volar fibrous band that runs from radius to the lunate, implicated in Kienböck disease.

Finger Ligaments

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  accessory collateral l.: originates radially or ulnarly from center of the head of the metacarpal or the phalanx and inserts into the volar plate of that joint. It is taut with the joint in straight extension ( Fig. 10-5 ).

  
  
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  beak l.: volar ulnar ligament that stabilize the CMC joint of the thumb; originates on the volar aspect of the triscaphe joint and inserts on the volar ulnar surface of the proximal thumb metacarpal.

  
  
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  dorsal radial l.: primary stabilizer for thumb CMC joint.

  
  
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  proper (main) collateral l.: originates radially or ulnarly from center of rotation of the head of the metacarpal or the phalanx and inserts into the volar bony aspect of the proximal base of the phalanx flair of the adjoining bone. L. helps to prevent radial or ulnar deviation of the joints. It is taut with the joint in 30 degrees of flexion.

  
  
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  volar plate: thick l. structure across the volar aspect of the MCP or PIP or DIP joints connecting the volar base of the head of the metacarpal or phalanx bone to the volar aspect the adjoining proximal base of the phalanx flair of the adjoining bone. It prevents the dorsal subluxation of finger joints and is attached to the accessory radial and ulnar collateral ligaments of that joint.

Palm

Miscellaneous

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  anatomic snuff box: the area of the lateral wrist formed between the extensor pollicis longus tendon medially, and abductor pollicis longus and extensor pollicis brevis tendons laterally. With the thumb abducted and extended, a triangular depression is made on the dorsum of the wrist at the radial border.

  
  
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  carpal tunnel: space in the wrist created by the volar carpal ligament. This space contains the flexor tendons of the fingers and thumb (FDS × 4, FDP × 4, and FPL), as well as the median nerve.

  
  
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  Guyon canal: space between the hamate and pisiform bones at the wrist for the ulnar artery and nerve, covered by the palmar fascia. Floor is the transverse carpal ligament.

  
  
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  hook of hamate: bony prominence (tubercle) that provides ligamentous attachment for the transverse carpal ligament; hamulus.

  
  
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  ligamentum subcruentum: the loose, richly vascularized connective tissue that sits near the ulnar styloid in between the limbs of the distal radial ulnar joint ligament.

  
  
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  Lister tubercle: bony prominence on the distal dorsal radius for the EPL to change its direction in line with the alignment of the thumb metacarpal bone.

  
  
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  radial lunate angle: an angle created by the line perpendicular to the line connecting the distal tips of the lunate on the lateral x-ray with the long axis of the radius. This is used to estimate dorsal intercalated segment instability and volar intercalated segment instability deformities in wrist injuries. The radial lunate angle should be a straight line (180 deg).

  
  
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  scapholunate angle : an angle created by the line perpendicular to the line connecting the distal tips of the lunate on the lateral x-ray with the long axis of the scaphoid. This is used to estimate the flexion deformity of the scaphoid with respect to the lunate. Normal angle is 45 degrees with a range of 30 to 60 degrees.

  
  
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  slider crank mechanism: an engineering model of scaphoid motion in carpal kinematics.

The Fingers

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  central slip: the portion of the extensor tendon that inserts into the middle phalanx; also called tendon.

  
  
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  cutaneous l.: ligaments that restrain the skin during finger motion and include the following:

  
  
  
  
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    Cleland l.: fibrous tissue bands on the lateral side of the fingers that stabilize the skin during finger movement, dorsal to Grayson l.

    
    
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    Grayson l.: fibrous tissue bands of the finger extending from the volar DIP and PIP joints to the lateral skin.

  
  
  
  
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  distal pulp: the mass of tissue of the volar distal finger. It is the soft cushion of the palmar surface of the distal phalanx.

  
  
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  dorsal expansion: the fibers spreading laterally at the base of the dorsal hood.

  
  
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  extensor hood: the fanlike expansion of the extensor communis tendon over the dorsum and sides of the MCP joints. This complex structure brings together intrinsic and extrinsic tendons to control IP joint extension and MP joint flexion or extension.

  
  
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  interdigital commissure: floor of the webspace between two digits, which follow a very specific anatomic pattern and must be carefully reconstructed in syndactyly surgery.

  
  
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  knuckle pad: the thick skin over the dorsum of the DIP and PIP joints of the finger.

  
  
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  lateral bands: the portions of the intrinsic muscle tendons that run laterally across the proximal phalanx to the dorsum of the DIP and PIP joints.

  
  
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  septa: fibrous tissue structures in fat pad of the fingertips.

  
  
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  skin creases: indentations in the skin at the point of natural motion points of the finger. The digital skin creases are labeled proximal, medial, and distal.

  
  
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  webspace: the skin web area between the base of the fingers.

The Nail

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  cuticle: the skin edge immediately covering the base of the fingernail.

  
  
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  eponychium: thin skin covering (epidermis) at the base of the nails on the dorsal surface; also called cuticle.

  
  
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  germinal matrix: the cells that generate the tissues that eventually form the nail from the base of the nail; primitive stage of development.

  
  
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  hyponychium: the thickened epidermis immediately under the distal portion of the nail; also called subungual tissue.

  
  
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  lunula: the white crescentic (half-moon-shaped) area at the base of the nail.

  
  
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  nail matrix: the proximal portion of the nail bed from which growth mainly proceeds; also, the tissue on which the deep aspect of the nail rests; also called matrix unguis and nail bed.

  
  
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  nail plate: the hard plate of the distal end of the dorsum of the fingers and thumbs. This rigid outer covering extends approximately 8 mm under the nail fold (perionychium) and arises from the nail bed (matrix unguis).

  
  
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  paronychium: a fold of skin (nail folds) that surrounds the nail at the base; the epidermis bordering the nail; also called perionychium.

  
  
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  subungual space: the potential space between the nail and nail bed; common site for a hematoma.

  
  
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  unguis: the horny cutaneous plate on the dorsal surface of the distal end of a finger; also called the finger nail.

Nerves and Arteries

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  antebrachial cutaneous n.: lateral antebrachial cutaneous nerve provides sensation in the lateral forearm and very proximal volar base thumb. Medial antebrachial cutaneous nerve provides sensation in the medial forearm and olecranon.

  
  
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  axolemma: a column of neuronal cytoplasm enclosed by cell membrane including cell body, dendrites, and the axon.

  
  
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  Cannieu-Riché Anastomosis: a neural connection between the deep branch of ulnar nerve and branches of median nerve at the thenar eminence.

  
  
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  common digital arteries and nerves : the main branch of the various nerves or arteries in the palm; these then divide into the proper digital arteries and nerves ( Fig. 10-6 ).

  
  

  
  

  
  

  

  
  

  
  

  Fig. 10-6Deep and superficial volar carpal ligaments. (Adapted from Chang J, Neligan PC: Plastic Surgery, Vol 6: Hand and Upper Extremity, ed 4, 2018, Elsevier.)

  
  

  
  

  
  

  

  
  

  
  

  Fig. 10-5Accessory and proper collateral ligaments of the proximal interphalangeal joint. (From Chung KC, Brown M: Capsulotomy for proximal interphalangeal contracture. In: Chung KC, editor. Operative techniques: hand and wrist surgery , ed 3, 2018, Elsevier.)

  
  
  
  
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  dorsal digital artery and nerve: common and proper, the branches of artery and nerve in the dorsum of the finger.

  
  
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  intercompartmental supraretinacular arteries: these are series of arteries that branch off of the radial artery and supply the dorsal aspect of the distal radius and are described by the relationship to the extensor compartment of the wrist and the extensor retinaculum. These are generally fairly superficial in nature and are used in the formation of vascularized pedicle-based bone grafts.

  
  
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  lateral antebrachial cutaneous nerve of forearm: sometimes provides sensation to the lateral side of the thumb metacarpal area.

  
  
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  Martin-Gruber connection: a connection between the median and ulnar nerve in the forearm in which fibers that normally travel with the ulnar nerve from the brachial plexus distally travel with median nerve until the midforearm and only enter the median nerve at that connection; also called Martin-Gruber anastomosis.

  
  
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  median n.: the nerve that conducts sensations from the hand to the central nervous system and crosses under the small volar carpal ligament. Supplies some of the small muscles of the thumb, including the opponens, the superficial head of the flexor pollicis brevis (FPB), and the abductor pollicis brevis, but not the thumb adductor and the deep head of the FPB; provides sensation for most of the palm and volar thumb, long and index fingers, and thumb side of the ring finger. The motor branch controls muscles surrounding the thumb.

  
  
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  Meissner corpuscles: pressure receptors at nerve endings in the skin.

  
  
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  proper volar digital nerve and artery: the nerves and arteries after they have divided in the palm and travel along the two volar sides of the finger.

  
  
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  radial a.: major artery on the thumb side of the palm and wrist.

  
  
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  Riche-Cannieu connection: the deep motor branch of the ulnar nerve may send a branch to join the motor branch of the median nerve. The relevance is that in injuries to the median nerve at the wrist, one may still retain motor function at the wrist.

  
  
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  superficial and deep palmar arterial arches: the superficial and deep connecting arcades of the radial and ulnar artery in the palm.

  
  
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  superficial branch of radial nerve: this nerve supplies sensation only; sensory distribution is over the dorsum of the thumb, index finger, long finger, and radial side of the ring finger.

  
  
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  ulnar a.: artery on the little finger side of the palm and wrist.

  
  
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  ulnar n.: the nerve crossing the wrist through the Guyon canal and supplying the adductor pollicis, deep head of the flexor pollicis brevis, and all small muscles of the hand, except the thumb and first two lumbricals. The sensation supplied is to the little finger and the little finger side of the ring finger.

  
  
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  Vater-Pacini corpuscle: pain pinpoint receptor.

  
  
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  vinculae: blood vessel bridges to the flexor tendons having a vinculum breve and vinculum longum.

Arthritic Deformities

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  arthritis mutilans: a form of inflammatory arthritis manifesting extreme loss of bone stock; medullary, cancellous bones and markedly same with cortices, characteristic of psoriatic arthritis.

  
  
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  attenuation of tendons: erosion and eventual rupture of tendons by diseased synovium or bony spurs; also called attrition attenuation of tendons.

  
  
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  crystalline arthropathy: with chronic crystal formation there is recurrent joint inflammation, typically with fever and leukocytosis that affects fingers, wrists, and elbows; medical and surgical treatment indicated.

  
  
  
  
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    gout: caused by hyperuricemia, increased blood levels of uric acid.

    
    
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    pseudogout: the deposition of calcium pyrophosphate crystals with episodic inflammation of wrist and MP joints; also called chondrocalcinosis.

  
  
  
  
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  degenerative arthritis: commonly seen in the following joints: DIP Heberden nodes; PIP Bouchard nodes; MCP posttraumatic or infection; CMC digits associated with CMC bossing; trapeziometacarpal (thumb); intercarpal (triscaphe, radiolunate, triquetrohamate, lunatotriquetral), radioscaphoid (seen in postscaphoid nonunions or with scapholunate advanced collapse wrist).

  
  
  
  
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    scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC): after untreated scaphoid nonunion or untreated scapholunate dissociation, there is rotatory subluxation of the scaphoid. Typically will start with radiostyloid arthritis followed by radioscaphoid arthritis and eventually to capitolunate arthritis with proximal migration of the capitate, sparing the radiolunate joint.

  
  
  
  
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  grind test: a diagnostic test to clinically determine the presence of basal joint arthritis of the thumb by exerting axial pressure on the thumb metacarpal to the trapezium.

  
  
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  inflammatory arthritis: rheumatoid hand deformities that include the following: flexor or extensor tenosynovitis, tendon ruptures, caput ulnar syndrome (Vaughn-Jackson syndrome), intercarpal collapse or volar carpal subluxation, MP volar collapse with ulnar deviation, thumb digits, boutonnière deformity, swan-neck deformity, carpal tunnel syndrome, and intrinsic contractures.

  
  
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  progressive systemic sclerosis (PSS): typically scleroderma, Raynaud subcutaneous calcinosis, resorption of the distal tufts. Diffuse hand involvement with skin thickening and fibrosis.

  
  
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  psoriatic arthritis (PA): typically of the DIP, but any joint can be affected. Joint pain and stiffness can have similar clinical picture to rheumatoid arthritis.

  
  
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  pyogenic arthritis: bacterial infection of a joint.

  
  
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  systemic lupus erythematosus (SLE): deformity similar to rheumatoid arthritis with pain and swelling in the mid-PIP joints and the wrists. Usually systemic, there is relative sparing of articular cartilage until late.

Neuropathies

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  allodynia: a perception of nonpainful stimulus as painful. This is a symptom of complex regional pain syndrome.

  
  
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  complex regional pain syndrome: syndrome of abnormally intense, inappropriately prolonged pain, not a reflection of actual or impending tissue damage commonly seen after trauma, in a variety of neurogenic and vascular sequelae; formerly called reflex sympathetic dystrophy. Type I is due to trauma. Type II is due to iatrogenic causes, i.e., surgery.

  
  
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  compressive neuropathy: loss of motor or sensory nerve function, acute or chronic, caused by extrinsic compression. Entrapment can occur within tight fibroosseous tunnels or as a result of tumor, hemorrhage, or metabolic changes, causing swelling of soft tissues around the nerve. Compressive neuropathies can result in ischemia damage to the nerve.

  
  
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  dysesthesia: an unpleasant spontaneous sensation occurring in patients with chronic regional pain syndrome.

  
  
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  hyperesthesia: increased sensitivity to a stimulus that would normally not be painful; seen commonly in chronic regional pain syndrome.

  
  
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  hyperpathia: a state of exaggerated and painful response to stimulation seen in complex regional pain syndrome.

  
  
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  Jeanne s.: hyperextension of the MCP joint of the thumb doing key pinch or gross grip caused by paralysis of the adductor pollicis muscle, which acts as a first metacarpal adductor seen commonly in ulnar nerve palsy.

  
  
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  Klumpke palsy: a paralysis caused by isolated injury to the C8 and T1 nerve roots either in birth plexus injuries or traumatic injuries later in life.

  
  
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  phantom limb pain: a sensation after amputation of a limb. The patient may still have sensation that the amputated part is still present. This may be painful and may be due to representation of the limb in the terminal neuromatous stumps in the amputated part.

  
  
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  Pitres Testut s.: an inability to actively move the long finger in radial and ulnar deviation with palm placed flat on the table. Demonstrating paralysis of the second and third dorsal interosseous muscles in ulnar nerve palsy.

  
  
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  Pollock s.: loss of extrinsic power with inability to flex the distal joint of the ring and little fingers because of the weakness of the flexor digitorum profundus through the fourth and fifth fingers in ulnar nerve palsy.

  
  
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  posttourniquet syndrome: characterized by edema, stiffness, pallor, and weakness without paralysis, and subjective numbness without objective anesthesia caused by prolonged use of tourniquet in upper-extremity surgery.

  
  
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  reflex sympathetic dystrophy (RSD): usually posttraumatic (major or minor) pain dysfunction syndrome. Thought to be due to abnormal modulation of afferent pain signals with possible short-circuiting of somatic and autonomic nerve fibers. Attendant autonomic nervous system hyperactivity will produce abnormal peripheral small vessel response to cold and heat stimulus. Symptoms include hyperpathia (increased pain at rest), allodynia (painful response to a nonpainful stimulus), erythema (brawny edema), joint stiffness, and loss of skin elasticity. Osteoporosis and complete loss of dexterity result. Bone scan and tomography are diagnostic, and treatment includes physical therapy, oral medications, and a sympathetic ganglion blockade; also called autonomic dystrophy, chronic regional pain syndrome (CRPS), shoulder-hand syndrome, Sudeck atrophy, causalgia, and sympathetic maintained pain syndrome (SMPS).

  
  
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  Roo classification: classification of thoracic outlet syndrome depending on the segment of the brachial plexus involved, either upper, lower, or combined compressions.

  
  
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  Roo test: a clinical test to diagnose thoracic outlet syndrome in which the patient abducts both arms 90 degrees and flexes with 90 degrees of elbow flexion, repeatedly opening and closing the hands to elicit numbness, tingling, or weakness in both hands.

  
  
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  Semmes-Weinstein monofilament tests: an array of monofilaments placed perpendicular to wooden or plastic rods that are held against the skin in progressive thickness and progressive skin resistance used to test innervation and density at the fingertips in nerve injury areas.

  
  
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  Spurling test: a clinical test for cervical nerve root compression by compressing the nerve root at the foraminal exit in the cervical spine. Compression is applied to the patient’s head. A positive test represents a spray of numbness and pain shooting down the ipsilateral arm.

  
  

  Sunderland Classification for Grades of Nerve Injury

  
  
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  traction injury: refers to injury to nerve tissue from an over-pull that exceeds 10% of resting length, resulting in neuronal dysfunction, which is commonly seen in brachial plexus injuries. This injury may also pull the nerve root out of the cervical spine resulting in pseudoceles.

Congenital Anomalies

Muscle and Tendon Disorders

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  boutonnière deformity: usually caused by a central slip rupture of the middle phalanx with an injury to the triangular ligaments. Volar subluxation of the lateral bands below the flexion axis of the PIP joint will cause a fixed flexion attitude of the PIP joint.

  
  
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  carpal pedal spasm: an intrinsic plus position with wrist flexion usually seen in hypercalcemia.

  
  
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  de Quervain disease: stenosing tenosynovitis of the first dorsal extensor compartment, usually involving the extensor pollicis brevis and abductor pollicis longus.

  
  
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  intersection syndrome: pain from the intersection of the abductor pollicis longus and extensor pollicis brevis that cross over the extensor carpi radialis longus and the extensor carpi radialis brevis, usually due to repetitive resisted extension in sports and some industrial activity.

  
  
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  Landsmeer test: a test that elicits a tight oblique retinacular ligament of Landsmeer as seen in boutonnière’s deformity, in which passively extending the PIP joint sends the IP joint into a tight, fixed-extension posture. Also, the particular anatomy of Landsmeer ligament is volar to the PIP joint and dorsal to the DIP joint.

  
  
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  lumbrical plus finger deformity: a condition in which there is overactivity of the lumbricals, creating a paradoxical extension of the PIP and DIP joints with attempted flexion of the fingers.

  
  
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  “no man’s land”: usually refers to an injury to the digital flexor tendons at zone II (under the tendon sheath and pulleys). Until recently, injury to this area was fraught with technical difficulty and poor results.

  
  
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  peritendinitis stenosans/digitus saltans: an archaic term used to describe conditions of stenosing tenosynovitis such as those found in de Quervain disease, flexor carpi radialis tendonitis, and trigger digits.

  
  
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  quadriga: in a setting in which the profundus tendon to a digit is contracted or repaired too tightly, there will be a limitation of proximal excursion of the remaining flexor digitorum profundus (FDP), causing a weak grip (as all the FDP tendons usually share a common muscle belly).

  
  
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  tendovaginitis: form of tendon entrapment seen in trigger digits and de Quervain tenosynovitis by tight retinaculum or tenosynovitis obliterating the space between the tendons and the overlying retinaculum.

  
  
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  tetraplegia: neurologic injury secondary to cervical spine trauma. Altered functional capacity of the hand, depending on the level of injury. This will also dictate operative and nonoperative intervention. A system has been devised:

  
  
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  trigger finger: entrapment of finger flexor tendons usually under the proximal A1 pulleys; usually caused by a disproportion between the flexor tendon and the flexor tendon sheath. Usually, the cause is obscure, with thickening of the pulley tissues or nodular formation about the tendon. This can be acquired secondarily (e.g., resulting from diabetes, rheumatoid arthritis, or gout). Conservative measures and steroid injections may help, but surgery is usually curative.

  
  
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  Vaughn–Jackson syndrome: rupture of ring and little finger extensors caused by synovitis at the distal radial ulnar joint.

  
  
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  Volkmann contracture: contracture affecting the volar forearm musculature as a result of scarring after an ischemic insult. This is the usual sequela of an untreated volar muscle compartment syndrome (seen in muscle crush injuries or forearm fracture). Circulation is usually impaired in the center of the forearm. The flexor digitorum profundus and FPL muscles are most severely affected. There is a mild, moderate, classic, or severe type.

  
  
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  washer woman’s sprain: an archaic description of de Quervain tenosynovitis, tendinopathies of the tendons of the first dorsal extensor compartment.

Vascular Disorders

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  acrocyanosis: seen in Raynaud phenomenon. With exposure to cold, the fingers become deep blue and cold. This is usually caused by peripheral vasospasm.

  
  
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  Bain and Begg classification: arthroscopic assessment of lunate and other joint surfaces affected by Kienböcks disease.

  
  
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  Buerger disease: an inflammatory thrombosis seen in smokers, usually in men. Digital arteries are affected. The disease is progressive, leading to digital loss and possibly loss of the whole hand. Also called thromboangiitis obliterans.

  
  
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  hypothenar hammer syndrome: an ulnar artery aneurysm or thrombosis caused by repetitive striking of the hypothenar eminence and the hook of hamate region against a hard, blunt object; typically, localized pain, digital pallor, and cold sensibility are common symptoms.

  
  
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  Kienböck disease: a posttraumatic, vascularly mediated avascular necrosis of the lunate with subsequent collapse, dislocation, and arthrosis. Magnetic resonance imaging and bone scan have fine-tuned the classification; also called isolated dislocation.

Traumatic Disorders and Terms

• 
  

  annulus fracture: fractures of the hook of the hamate usually caused by compression force as a direct blow.

  
  
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  Barton fracture: an intraarticular fracture involving either the dorsal or the volar lip of the distal radius resulting in either dorsal or volar subluxation of the lunate.

  
  
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  Bennet’s fracture: intraarticular fracture of the base of the thumb metacarpal with proximal migration displacement of the metacarpal due to the attachment of the APL tendon on the base of the thumb metacarpal.

  
  
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  chauffeur’s fracture: displaced fracture of the radial styloid accompanied by ulnar translocation of the carpus.

  
  
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  dye punch fracture: a type of intraarticular distal radius fracture involving the compression of the lunate facet of the distal radius.

  
  
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  factitious edema: history of minor trauma followed by persistent dorsal forearm pain, swelling, and tenderness caused by repeated self-inflicted trauma; also called secretan edema.

  
  
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  fragment specific fixation: a method of repairing the distal radius using a small plate to fix small fractures to the main body of the bone.

  
  
• 
  

  gamekeeper’s thumb: an abduction laxity of the thumb at the MCP joint caused by acute or chronic disruption of the ulnar collateral ligament of the finger joint.

  
  
• 
  

  Holstein-Lewis fracture: a fracture of the distal humerus in which the radial nerve is in particular jeopardy. The proximal spike of the spiral fracture breaks through the lateral cortex of the humerus near where the radial nerve is most grossly opposed to the bone.

  
  
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  Hotchkiss fracture: a classification system describing fractures of the radial head and neck in trauma situation.

  
  
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  hypothenar hammer syndrome: a rare occupational or recreational condition that may be due to repetitive microtrauma to the ulnar artery at the level of the Guyon canal.

  
  
• 
  

  interdigital contracture: results from extensive scarring about the hand resulting in cicatrix forming in between the digits and preventing digital abduction; seen commonly in severe burns of the hand.

  
  
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  Jahss maneuver: a method of closed reduction of metacarpal neck fractures flexing the MCP joint and the PIP joint and pushing upward on the flexed PIP joint while applying a cast, flexing the MCP joint into maximal flexion. The PIP joint is usually then brought out into extension.

  
  
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  lunotriquetral dissociation: a condition whereby a lunate becomes volar-flexed in sagittal plane because of a dissociation between it and the adjacent triquetrum.

  
  
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  malrotation: a condition whereby there is a mismatch between the proximal and distal ends of a fracture of a tubular bone in which the distal end of the fracture rotates relative to the proximal end on its long axis. This can cause finger overlap.

  
  
• 
  

  Melone classification: a four-part classification of distal radius fractures that identifies specific intraarticular fragments of the distal radius and ranks them in order of severity based on displacement.

  
  
• 
  

  negative pressure therapy: a technique that uses a suction apparatus on a mangling high-energy wound. This technique removes exudates, decreases edema, closes the dead space, and promotes wound healing commonly seen in the treatment of wartime injuries. Also called vacuum assisted closure (VAC).

  
  
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  peritendinous fibrosis: scarring around a tendon.

  
  
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  pseudoclawing: an intrinsic minus position with MCP hyperextension and PIP joint flexion caused by flexion malunion of metacarpal neck fractures.

  
  
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  radial styloidectomy: the excision of the radial styloid done usually in conjunction with scaphoid excision and four-poster fusions in the reconstruction of scapholunate advanced collapse wrist. reverse Bennet’s fracture: intraarticular fracture of the base of the fifth metacarpal with proximal migration displacement of the metacarpal due to the attachment of the ECU tendon on the base of the fifth metacarpal.

  
  
• 
  

  Rolando fractures: comminuted intraarticular fractures of the base of the thumb metacarpal.

  
  
• 
  

  scaphoid ring sign: a scapholunate dissociation in which the scaphoid collapses into flexion and has a foreshortened view on the anteroposterior x-ray. The distal end of the scaphoid appears to have radial band with a ring superimposed on it.

  
  
• 
  

  scaphoid shift test: a test that determines the integrity of the scapholunate ligament by mobilization from pressure supply to the palmar tuberosity of the scaphoid while the wrist is moved from ulnar to radial deviation. A positive test is seen in a patient with scapholunate dissociation. The scaphoid no longer can strain proximally and subluxes out of the scaphoid fossa of the distal radius. When the pressure is released, the scaphoid goes back into position and a typical snapping occurs. Also called Watson test .

  
  
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  scapholunate ballottement test: with the lunate stabilized with the thumb and index finger and the scaphoid held over the other hand, a dorsal volar alternating pressure between the scaphoid and the lunate elicits pain and crepitance as well as instability of the joint in scapholunate dissociation.

  
  
• 
  

  Secretan syndrome: rare disorder characterized by woody edema of the dorsum of the hand seen typically in association with a crush injury or self-induced injury.

  
  
• 
  

  sheer testing for lunotriquetral dissociation: a ballottement test for lunotriquetral dissociation secondary to interosseous injury. The lunate and triquetrum are held stably by the thumb and index fingers of both hands shifted dorsally and volarly relative to one another. A positive test elicits crepitance, pain, and increased movement between the lunate and triquetrum.

  
  
• 
  

  skier’s thumb: an acute rupture of the ulnar collateral ligament of the MCP joint of the thumb seen commonly in skiers, but generally seen in fall on outstretched hands, hyperabducting the thumb at the MP joint. Historically called the gamekeeper’s thumb.

  
  
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  Stener lesion: in a complete tear of the ulnar collateral ligament of the MCP joint of the thumb, the ligament may avulse distally and roll up proximally, causing an interposition of the adductor aponeurosis. Nonoperative treatment usually results in a chronically unstable thumb.

  
  
• 
  

  turret exostosis: a painful mass on the dorsal aspect of the middle phalanx seen on lateral x-ray as an exostosis; also called a bone spur. This is believed to be traumatic in origin.

  
  
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  ulnar impaction syndrome: excessive pressure from the ulnar aspect of the carpus, notably the lunate onto the distal end of the ulna in those situations in which the distal radius has been shortened leaving an ulnar positive variance.

Specific Dislocations

Nail and Skin Disorders

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  acanthosis nigricans: dull, gray, friable nails with leukonychia; can be an external marker of an internal malignancy.

  
  
• 
  

  acquired digital fibrokeratoma: benign tumors of fibrous tissue usually found on the hands and feet. These are flesh-colored with thornlike projections with a raised erythematous skin rash at the base. These are otherwise known as acral fibrokeratomas.

  
  
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  acrolentiginous melanoma: an unusual variant of melanomas found on the palmar surface of the hand and nail apparatus.

  
  
• 
  

  beak nail deformity: with amputation of the tip of the distal phalanx, the nail may grow over the edge of the finger. It is unsightly and occasionally painful. Also called hook nail and nail horn.

  
  
• 
  

  Bowen disease: the eponym given to intraepidermal squamous cell carcinoma known as squamous cell carcinoma in situ.

  
  
• 
  

  chromonychia: color changes in the nail unit.

  
  
• 
  

  clubbing: a raising of the nail bed resulting in a club appearance of the end of the finger caused by fibrovascular hyperplasia of the nail unit; a sign of lung disease.

  
  
• 
  

  digital fibrokeratoma: a benign tumor of fibrous tissue origin occurring on the tips of the fingers.

  
  
• 
  

  Dupuytren contracture: hereditary process of the palmar fascia, occasionally extending into the fingers, in which fibroblasts are characterized as “myofibroblasts” and can lead to severe contractures and nodular proliferation (skin dimples). There are three phases: proliferative (nodular), involutional, and resolved. In the resolved state, the remaining constricting tissue is referred to as bands. Also called palmar fibromatosis.

  
  
• 
  

  epidermoid cyst: benign cyst composed of epidermal fragments that have been pushed to the deeper layers by minor trauma; also called inclusion cyst.

  
  
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  keratosis: premalignant lesions seen in sun-exposed, fair-skinned individuals causing skin atrophy and telangiectasias. If allowed to progress, it may become squamous cell carcinoma.

  
  
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  leukonychia: whitening of the nail plate.

  
  
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  macronychia: an unusually large or wide nail.

  
  
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  micronychia: small, short, or narrow nail.

  
  
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  onychalgia: nail unit pain.

  
  
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  onychia: inflammation of the nail plate.

  
  
• 
  

  onychogryphosis: nail plate hypertrophy that is hornlike resulting from trauma; also called onychogryposis and ram’s horn deformity.

  
  
• 
  

  onycholysis: distal separation of the nail plate from the underlying nail bed.

  
  
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  onychomadesis: proximal separation of the nail plate from the nail matrix.

  
  
• 
  

  onychomycosis: fungal infection of the nail unit.

  
  
• 
  

  onychophagia: nail biting.

  
  
• 
  

  onychoptosis: loss of the nail plate.

  
  
• 
  

  onychorrhexis: spontaneous longitudinal splitting of the nail plate.

  
  
• 
  

  pincer deformity or trumpet nail deformity: a pathologic curling of the nail plate and nail bed with ingrowing of the nail plate into the nail folds and progressive pinching off of the soft tissue of the distal fingertips, which results in pain and deformity.

  
  
• 
  

  pitted nail: surface pits of nails less than 1 mm in diameter; may be a sign of psoriasis.

  
  
• 
  

  pterygium: scarring of the eponychial fold and the nail fold to the nail bed in nail trauma leading to functional and esthetic deformities such as absence of nail growth or splitting of the nail. This has also been associated with nail bed ischemia and collagen vascular disease.

  
  
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  racket nail: thumbnail shorter than it is wide. Usually, the distal ends of the fingers are also short.

  
  
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  reedy nail: fingernail marked by longitudinal furrows.

  
  
• 
  

  sclerodactyly: a scleroderma in which the fingers become thin and shiny with sclerotic skin at the tip, which is due to subcutaneous and intracutaneous calcinosis and diffused fibrosis of the collagen.

  
  
• 
  

  scleroderma: an autoimmune disease that causes the skin of the hands to become thin, tense, and shiny; IP joint stiffness, distal ischemic ulceration, and auto-amputation are common.

  
  
• 
  

  spoon nail: a central depression of the nail with raised sides.

  
  
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  subungual exostosis: a bone spur emanating from the distal phalanx dorsally under the nail bed, causing pressure pain, necrosis, and possible infection of the nail bed. Also called Dupuytren exostosis.

  
  
• 
  

  subungual hematoma: usually posttraumatic with nail bed laceration under an intact nail. A collection of blood under the nail plate.

  
  
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  turtle-back nail: a distorted fingernail, being more convex than normal.

  
  
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  unguis incarnatus: ingrown nail.

  
  
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  watch crystal nail: a nail as broad as it is long and convex lengthwise and crosswise; seen in pulmonary osteoarthropathy.

Other Specific Terms

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  aponeurotic fibroma: fibrous lesions of the hands commonly seen in childhood and adolescence. They are benign, but can be locally aggressive.

  
  
• 
  

  Bouchard node: thick nodular swelling caused by bone spurs in the PIP joints, not necessarily associated with systemic arthritis.

  
  
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  carpal bossing: prominence seen particularly at the dorsal index or middle CMC joint; may be painful but usually causes no symptoms.

  
  
• 
  

  cheirospasm: spasms of the muscles of the hand; also called writers cramps.

  
  
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  Dietrich disease: avascular necrosis of the metacarpal head.

  
  
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  flexor origin syndrome: tendonitis of pronator teres and wrist and finger flexor muscle origin on medial epicondyle of elbow; also called medial epicondylitis and golfer’s elbow.

  
  
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  ganglion: a clear, viscid, fluid-filled sac found near the wrist joints or fingers, arising from capsuloligamentous structures; rarely associated with other diseases; most commonly found on dorsum of wrist.

  
  
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  glomus tumor: small vascular lesion that is usually very painful and associated with hypersensitivity to pressure or temperature; usually in fingertip.

  
  
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  hamartoma: unusual tumors of the peripheral nerves most commonly involving the median nerve of the hand. It starts as a slowly progressive swelling in the distal forearm of the palm; common symptoms of nerve compression may be present.

  
  
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  hand-foot syndrome: swelling in hands and feet as seen in sickle cell disease.

  
  
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  Heberden node: a thick nodular swelling caused by bone spurs in the DIP joints; not necessarily associated with systemic arthritis.

  
  
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  inclusion cyst: a noninfectious process following healing of laceration or puncture wound; germinal matrix of dermal growth, causing mass composed of desquamated dermal cells.

  
  
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  Kienbock’s disease: spontaneous loss of blood supply and collapse and fragmentation of lunate, usually seen in young adults.

  
  
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  Luck classification of Dupuytren disease divided into three phases: proliferative phase, involutional phase, and residual phase, based on the histologic behavior of Dupuytren fibroblast.

  
  
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  mucous cyst: a misnomer; this is a ganglion of the DIP joint, which makes a cyst under the skin in the eponychial area.

  
  
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  nodular fasciitis: an uncommon reactive lesion that may simulate a sarcoma usually seen on the volar surface of the forearm, usually a rapidly growing small nodule. This has been confused with fibrosarcoma or myxoid liposarcoma leading to overtreatment.

  
  
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  overlap syndrome: seen in scleroderma patients with associated findings characteristic of lupus, dermatomyositis, or rheumatoid arthritis.

  
  
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  pillar pain: pain that may occur following carpal tunnel release, believed to be due to minor destabilization of the wrist carpal bones following transection of the transcarpal ligament.

  
  
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  Preiser disease: spontaneous loss of blood supply and collapse of scaphoid, usually seen in young adults.

  
  
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  Raynaud disease: a condition characteristic of color changes in the tip of the fingers, either blanching or cyanosis in both hands, and may not be involved with vasospastic disease and not lead to ulceration of the fingertips.

  
  
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  Raynaud phenomenon: a clinical sign describing intermittent color changes that occur after exposure to cold or stress. A condition characteristic of color changes in the tip of the fingers, either blanching or cyanosis in both hands; may not be involved with vasospastic disease and not lead to ulceration of the fingertips.

  
  
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  stenosing tenosynovitis: a bulbous swelling of the tendon, causing the tendon to catch as it passes through the pulley (the thick fibrous tunnel that holds the tendon in place); sometimes caused by rheumatoid arthritis; also called trigger fingers and snapping tendons.

Infections

The hand has many structures that are vulnerable to infections. When edema and swelling place pressure on muscles, tendons, blood vessels, and nerves, function is disrupted and compartmental ischemia could result. Adhesions or fibrosis following infection may reduce hand function temporarily or permanently. Terms related to infections are the following.

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  barber’s interdigital pilonidal sinus: a foreign body granuloma usually caused by a reaction to hair implanted in the intradigital skin of the hand; first described in barbers; also called interdigital pilonidal sinus.

  
  
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  collar-button abscess: a digital webspace infection usually in the subdermal fatty layers. Surgical drainage is usually required; also called shirt-stud abscess.

  
  
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  dactylitis: nonsuppurative insidious chronic infections of the hands and fingers commonly seen in syphilis and tuberculosis.

  
  
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  deep space infection: refers to infection of the thenar, Parona’s, or midpalmar spaces; also called palmar space infection.

  
  
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  ecthyma contagiosum: a chronic infection causing large tumorlike lesions in immunodeficient host; believed to be contracted from exposure to sheep and goats.

  
  
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  eponychia: a nail-fold infection involving the entire eponychial fold and lateral nail fold. These are relatively rare.

  
  
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  fasciitis: a rapidly advancing necrotizing infection affecting the skin and subcutaneous tissue sparing the underlying muscle associated with high morbidity and mortality, seen commonly in group A streptococcus infections.

  
  
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  felon: a subcutaneous abscess involving the tissue of the distal fingertip. These may be under great pressure and require surgical drainage, usually through a midlateral approach.

  
  
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  Hansen disease: commonly involves the hands; caused by Mycobacterium leprae. Peripheral neuropathy predominates with intrinsic atrophy and clawing. Later, soft tissue necrosis can result in actual loss of digits. Also called leprosy.

  
  
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  herpetic whitlow: a fascicular outbreak with an erythematous rim seen usually in fingertips of health care workers. These are commonly misdiagnosed and mistakenly drained. Supportive treatment is the mainstay. These are usually self-limited.

  
  
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  hockey-stick incisions: incisions placed at the lateral and distal aspects of the finger to facilitate drainage of felons (abscesses) of the fingertips.

  
  
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  horseshoe abscess: in those hands in which radial and ulnar bursae are interconnected, an abscess may spread to both sides of the hand in the shape of a horseshoe. The infection can also spread to a palmar space infection involving the thenar and midpalmar spaces. The deep spaces of the hand may fill with purulent material. Drainage is the key.

  
  
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  interdigital granuloma: small pyogenic granulomas found in the hand of cow milkers resulting from penetration of bovine hairs into the skin of the hand causing a foreign body reaction.

  
  
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  Kanavel sign: for pyogenic flexor tenosynovitis; there is a flexed position of the finger, symmetrical enlargement of the finger, excessive tenderness over the course of the tendon sheath, and extreme pain on passive extension of the digit.

  
  
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  Meleney infection: life- or limb-threatening infection with anaerobic bacteria or microaerophilic streptococcus. Amputation is usually required to save the patient’s life; also called gas gangrene.

  
  
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  paronychia: infection in the soft tissue folds around the nail that usually results from Staphylococcus aureus by a sliver of nail tissue, a manicure instrument, or a tooth. Drainage is mandatory.

  
  
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  pyogenic flexor tenosynovitis: a closed space infection of the flexor tendon sheath of the fingers and thumb generally caused by Staphylococcus aureus, Streptococcus, or Pasteurella presented with Kanavel signs, which are semiflexed position of the fingers, symmetrical enlargement of the whole digit, excessive tenderness limited to the flexor tendon sheath, and excruciating pain on passively extending the finger.

  
  
• 
  

  pyogenic granuloma: a skin growth that is small, round, and usually bloody red in color. They are usually friable due to the presence of a large number of blood vessels. They’re also known as lobular capillary hemangioma or granuloma telangiectaticum, an exophytic friable growth over the surface of the skin. They are not due to an infectious agent. They may be self-limiting or may require shaving, cauterizing, or freezing. Some may require complete excision to effect a cure.

  
  
• 
  

  shooter’s abscess: infections caused by parenteral drug abuse involving accessible sites on the hand and forearm. These appear as raised ulcers with cellulitis.

  
  
• 
  

  subungual abscess: a collection of pus under the nail plate or over the nail bed.

  
  
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  tenosynovitis: inflammation of the tendon sheath. Causes are multifactorial and include overuse, rheumatoid arthritis, infection, and nonspecific onset.

  
  
• 
  

  verruca vulgaris: a viral wart involving the nail or skin tissue. A carbon dioxide laser is usually curative.

Arthrodeses of the Fingers

• 
  

  chevron a.: a rigid stable construction for IP joint fusion; a precise, chevron-shaped fitting of the bone cuts of the joint to be fused with resection of the joint surface.

  
  
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  Goldfarb and Stern a.: thumb CMC arthrodesis.

  
  
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  Haddad and Riordan a.: method of arthrodesis of wrist.

  
  
• 
  

  interphalangeal a.: cup and cone technique useful for MCP or IP fusion, allows for fine adjustment of angles and rotatory alignment after joint surfaces have been prepared.

  
  
• 
  

  Millender and Nalebuff a.: for a variety of painful conditions, subtotal arthrodesis of wrist.

  
  
• 
  

  Moberg dowel graft: for an IP arthrodesis in which there has been bone loss or nonunion. A finger joint fusion using a small, squared, bone peg.

  
  
• 
  

  Potenza a.: a finger joint fusion using bone peg taken from the adjacent phalanx or metacarpal.

  
  
• 
  

  Stern a.: tension band interphalangeal and metacarpophalangeal joint arthrodesis.

  
  
• 
  

  trapeziometacarpal fusion: for advanced trapeziometacarpal disease in the thumb in young, active patients.

Arthrodeses of the Wrist

• 
  

  intercarpal a.: for wrist instability or collapse patterns, Kienböck disease, rheumatoid arthritis, localized degenerative changes in the carpus. These include triscaphe (scaphotrapeziotrapezoid), scaphocapitate, capitolunate, scapholunate, lunatotriquetral capitohamate (four-poster fusion). Moberg dowel grafts are useful in securing these fusions.

  
  
• 
  

  radiocarpal a.: commonly a total wrist fusion with or without autogenous graft. Useful for (1) a heavy laborer with posttraumatic arthritis, (2) failed RC arthroplasty, (3) rheumatoid arthritis, (4) tetraplegia with deformity of the wrist, and (5) tendon transfer surgery to stabilize the wrist.

  
  
• 
  

  radioulnar a.: for the creation of a one-bone forearm for advanced disease of the distal radioulnar joint.

  
  
• 
  

  scaphoid excision and 4 corner fusion: for the common combination of radioscaphoid and MC arthritis often seen in chronic nonunions of the scaphoid; a capitolunate with triquetralhamate arthrodesis with excision of scaphoid.

  
  
• 
  

  total wrist a.: fusion of the distal radius and proximal and distal carpal rows. Useful salvage procedure for severe carpal arthritis.

  
  
• 
  

  triscaphe a.: of the scaphotrapeziotrapezoid articulation. Useful for localized arthritis and for rotatory subluxation of the scaphoid.

Arthroplasties

An arthroplasty is the reconstruction of joints to restore motion and stability. It involves the MCP, CMC, and PIP joints of the fingers and wrist, often with implants. The hand specialist frequently treats joint destruction commonly found in rheumatoid arthritis.

An implant arthroplasty involves a prosthetic replacement of joints by metallic or silicone-rubber parts, usually for arthritic conditions or traumatic ankylosis. Swanson silicone-rubber arthroplasty is a popular choice. (Volz prosthesis, Steffe prosthesis, Swanson prosthesis.)

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  anchovy procedure (Carroll p.): rolled PL graft placed into the space that remains after trapezium excision for pantrapezial arthritis.

  
  
• 
  

  Blatt capsulodesis: for prevention of dynamic rotatory subluxation of the scaphoid. A proximally based flap of dorsal wrist capsule is attached to the dorsal distal pole of the scaphoid; this will prevent downward (or flexion) movement of the distal pole during radial deviation of the wrist; also called dorsal capsulodesis.

  
  
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  Broadbent and Woolf p.: four-flap Z-plasty in adducted thumb.

  
  
• 
  

  Brunelli and Brunelli p.: carpal ligament reconstruction, for scapholunate injury.

  
  
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  Burton and Pellegrini p.: CMC thumb tendon interposition arthroplasty with ligament reconstruction using FCR tendon.

  
  
• 
  

  capsulectomy: PIP joint flexion contractures unresponsive to conservative treatment; proximal release of the joint capsule (volar plate) will improve movement.

  
  
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  Carroll a.: an interposition rolled tendon (palmaris longus) used as a spacer when the trapezium is removed for pantrapezial arthritis; also called Froimson a.

  
  
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  Curtis p.: capsulotomy of PIP joint.

  
  
• 
  

  Darrach resection: resection of the distal 1 to 1.5 cm of distal ulna at the wrist. Once considered as the standard procedure for the treatment of a myriad of distal radioulnar joint problems; now useful primarily in older adults and for severe rheumatoid arthritis. Also called Albright and Chase p.

  
  
• 
  

  dorsal capsulectomy: the removal of the dorsal joint capsule; for example, in the treatment of distal radial ulnar joint fracture.

  
  
• 
  

  Eaton p.: for thumb carpometacarpal arthritis, tendon interposition arthroplasty with ligament reconstruction.

  
  
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  Eaton volar plate a.: a chronic subluxation of the PIP joint after a displaced large volar lip fracture of the proximal end of the middle phalanx, greater than 50% of the articular surface. If left untreated, a chronic subluxation results. The volar plate is then advanced into the fracture site and tightened to prevent subluxation.

  
  
• 
  

  flexible hinge implant: a design for silastic implant arthroplasty that essentially functions as a flexible spacer rather than a specific joint developed by Swanson used in MP and PIP arthroplasties.

  
  
• 
  

  Fowler metacarpophalangeal a.: for arthritis of the MCP joint. The metacarpal is cut in the form of a chevron at the base of the proximal phalanx and then cut into a V shape, with an interposition of extensor tendon fusion.

  
  
• 
  

  hemiresection interposition arthroplasty: for distal radioulnar joint arthritis, resection of the articular surface of the distal ulna and interposition of a rolled tendon graft. Also called Bowers arthroplasty.

  
  
• 
  

  matched ulnar resection: popularized by Watson; resection of the articular surface of the distal ulna to match the shape of the radial styloid notch. This is useful for the treatment of distal radioulnar joint instability and arthritis.

  
  
• 
  

  Neibauer prosthesis: silicone hinge joints with built-in ties; useful in MCP joint arthroplasty.

  
  
• 
  

  perichondral autografts: use of osteocartilaginous grafts (from ribs) to resurface the injured articular surface of a small joint in the hand.

  
  
• 
  

  proximal row carpectomy: a salvage procedure whereby the scaphoid, lunate, and triquetrum are excised. This is useful in treating advanced arthritis involving the RC joint with a relatively intact capitolunate joint where wrist motion is still desired by the patient.

  
  
• 
  

  radial styloidectomy: excision of the tip of the radial styloid; useful in isolated radioscaphoid arthritis or as part of the scapholunate advanced collapse wrist reconstruction.

  
  
• 
  

  Sauvé-Kapanji p: for the treatment of distal radial ulnar joint arthritis, arthrodesis and creating a pseudoarthrosis of the ulna just proximal to the arthrodesis to preserve forearm pronation and supination. Also called Lauenstein p.

  
  
• 
  

  Schneider p.: technique, proximal interphalangeal joint arthroplasty through an anterior approach.

  
  
• 
  

  Stefee thumb a.: a cemented metal polyethylene prosthesis useful in thumb MCP arthroplasty.

  
  
• 
  

  suspensionplasty p.: for advanced trapeziometacarpal arthritis, removal of the trapezium, and placement of half of the flexor carpi radialis as an anchor to the metacarpal and as a spacer. An improvement on the classic anchovy procedure. Also called ligament reconstruction tendon interposition (LRTI) p. and Burton p.

  
  
• 
  

  Swanson a.: complete array of silicone implants for all digital articula, joints, carpal bones, total wrist arthroplasty, distal ulna, and proximal radius. This is most useful in rheumatoid arthritis for the reconstruction of MCP joints. Its use in the carpus had to be discontinued because of concerns regarding silicone synovitis.

  
  
• 
  

  Swanson prosthesis (silicone): most useful for MCP and PIP arthroplasty in rheumatoid arthritis. In selected situations, a total wrist arthroplasty is useful (i.e., in bilateral involvement). Carpal silicone arthroplasty is now falling out of favor because of silicone synovitis.

  
  
• 
  

  trapezial hemiarthroplasty: resection of the distal half of the trapezium, sparing the scaphotrapezial joint; useful for trapeziometacarpal arthritis.

  
  
• 
  

  Tupper a.: in MCP joint arthritis, the volar plate may be used as an interpositional material after excision arthroplasty.

  
  
• 
  

  Vainio metaphalangeal interposition: MCP joint resectional arthroplasty with interposition of the extensor tendon and collateral ligaments.

  
  
• 
  

  Voltz a.: a metal-polyethylene cemented total wrist arthroplasty useful in selected cases of end-stage degenerative or rheumatoid arthritis.

  
  
• 
  

  Zancholli capsuloplasty: a volar plate advancement of the MCP joint of the thumb to treat congenital hyperextension.

  
  
• 
  

  Zancholli-Lasso p.: transfer of the flexor digitorum sublimus tendon to the lateral band or the A2 pulley to prevent metaphalangeal hyperextension and clawing; found in low ulnar nerve palsy.

  
  
• 
  

  Zancholli static-lock p.: a volar plate advancement (plication) for the treatment of metaphalangeal hyperextension; seen in claw deformities in low ulnar nerve palsy.

Neurologic Procedures

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  Boyes p.: repair of deep branch of ulnar nerve; tendon transfers for radial nerve palsy; tendon transfers to restore thumb adduction.

  
  
• 
  

  cable nerve grafts: a method of uniting strands of nerve graft and interposing them into a gap to repair a polyfascicular nerve discontinuity (of historic interest).

  
  
• 
  

  epineural repair: repair of lacerated nerve segments by repairing the epineurium. This is useful in digital nerves or in oligofascicular proximal nerves.

  
  
• 
  

  epineurotomy: the opening of the epineurium during a neurolysis procedure. This can be useful in certain cases of chronic nerve compression.

  
  
• 
  

  funiculectomy: for chronic end neuromas; peeling back the epineurium and resecting nerve fascicles, with reclosure and ligation of the epineurium. May aid in the treatment of end neuromas.

  
  
• 
  

  group fascicular repair: a perineural repair; useful in treating laceration of mixed motor and sensory nerves. Presumably, exact anatomic reapproximation will facilitate maximal functional return.

  
  
• 
  

  hemi-pulp flap: neurosensory free flaps from the great or second toe indicated for large single pulp defect. This is indicated when sensory function is essential for proper hand function and protection. This is best indicated for thumb reconstruction.

  
  
• 
  

  hetero-digital flaps: a cross-finger flap of dorsal skin to cover a significant palmar surface defect in an adjacent defect. Digital island transfer of pedicle flaps that are lifted with its neurovascular bundle and transferred to a defect on an adjacent digit.

  
  
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  internal neurolysis: presumably, internal dissection of intraneural scarring will facilitate return of nerve function. Originally thought to be useful in the treatment of carpal tunnel syndrome but now found to be harmful in many cases. This technique, however, is useful in the removal of intraneural neurilemmoma.

  
  
• 
  

  medial epicondylectomy: one method to decompress the ulnar nerve in the cubital tunnel by removing its bony floor, the medial epicondyle of the distal humerus.

  
  
• 
  

  Moberg p.: for tetraplegia; to restore the ability of key pinch in group II or III level tetraplegia. This includes CMC thumb arthrodesis, extensor pollicis longus tenodesis, and FPL tenodesis or transfer. Also called key pinch p.

  
  
• 
  

  neurectomy: the resection of a portion of nerve of an end neuroma (and presumed buried in bone or muscle).

  
  
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  neurotization: in patients with a profound brachial plexus injury with a flare anesthetic arm, the use of a live intercostal nerve grafted to a distal neural segment of the brachial plexus has restored some upper extremity function in select patients.

Trauma Procedures

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  Belsky-Eaton p.: pinning of proximal phalangeal fracture

  
  
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  Bentzon p.: attempt to convert a painful scaphoid nonunion to a painless pseudarthrosis by soft tissue (capsular flap) interposition; of historic interest.

  
  
• 
  

  Bevin Aurglass p.: a digital web-deepening procedure for the correction of burn syndactyly.

  
  
• 
  

  Buchler p.: open reduction and fixation of a Rolando base of thumb metacarpal fracture.

  
  
• 
  

  Burke and Singer p.: distraction plate fixation of distal radial fracture.

  
  
• 
  

  Cooney p.: open repair of triangular fibrous cartilage complex for class 1D injury.

  
  
• 
  

  Culp p.: open repair of triangular fibrous cartilage complex class 1C injury.

  
  
• 
  

  distal finger amputation revision: procedure performed following traumatic amputation involving the distal phalanx (fingertip) by the following techniques: healing by secondary intention, reamputation, V-Y flap (Kutler or Atasoy), volar flap advancement (Moberg), Bipedicle dorsal flap, crossfinger flap, and thenar flap.

  
  
• 
  

  Doyle p.: for displaced mallet fracture, open reduction and fixation with pull-out wire.

  
  
• 
  

  Eaton and Littler p.: for recurrent dislocation of thumb CMC joint, ligament reconstruction; also called trapeziometacarpal ligament reconstruction.

  
  
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  Eaton and Malerich p.: open reduction of PIP joint fracture-dislocation.

  
  
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  Fernandez p.: grafting for scaphoid nonunion; also called opening-wedge free graft.

  
  
• 
  

  finger flaps: to preserve sensation.

  
  
  
  
  • 
    

    Atosoy p.: volar single V-Y advancement.

    
    
  • 
    

    cross-finger flap: a section of skin with its blood supply intact from a neighboring finger used to cover open area.

    
    
  • 
    

    Kutler p.: lateral double V-Y advancement.

    
    
  • 
    

    thenar flap: one raised from the thumb side of the base of the palm.

    
    
  • 
    

    Wolfe graft: free skin (pinch) graft; a section of full-thickness skin placed on the open area.

  
  
  
  
• 
  

  Fisk-Fernandez volar wedge: anterior cortical cancellous bone graft for the correction of scaphoid nonunion or malunion.

  
  
• 
  

  Foster and Hastings p.: open reduction and internal fixation of Rolando fracture.

  
  
• 
  

  Gibraiel flap: a form of rotational skin flap using moving skin from the lateral aspect of the digit to the flexor surface with little or no movement of the pivot point.

  
  
• 
  

  Glickel p.: closed reduction and percutaneous pinning of distal radial fracture; graft reconstructions of chronic thumb ulnar collateral ligament injuries.

  
  
• 
  

  Herbert screw osteosynthesis: the use of a dumbbell-shaped bone screw with variable pitch to affect rigid compressive internal fixation of a scaphoid fracture or nonunion. This can be used with or without bone graft.

  
  
• 
  

  Jantes p.: arthroscopic repair of triangular fibrocartilage complex.

  
  
• 
  

  Kapandji fixation: for distal radius fracture; use of two K-wires inserted at 90 degrees at fracture site lateral and posterior and then angled 45 degrees anteriorly.

  
  
• 
  

  Kaplan p.: open reduction of finger MCP dislocation.

  
  
• 
  

  Kawai and Yamamoto p.: for scaphoid nonunion, vascularized bone graft.

  
  
• 
  

  Kirschner (K) wire fixation: small threaded or nonthreaded wires are used to transfix fractures or to produce traction with the use of an external appliance.

  
  
• 
  

  Lamey and Fernandez p.: for distal ulnar pseudarthrosis, distal radial-ulnar joint arthrodesis.

  
  
• 
  

  Matti-Russe p.: for scaphoid non-union iliac crest bone graft.

  
  
• 
  

  Melendez p.: for distal radius malunion osteotomy and bone graft.

  
  
• 
  

  metacarpal lengthening: useful for irretrievable thumb amputation at the MCP joint level; metacarpal osteotomy, application of a distraction device, slow distraction, and later bone grafting will partially restore length of the thumb ray. Secondary first web deepening may be required. Also called Matevp p.

  
  
• 
  

  Milford p.: tendon transfer for correction of old mallet finger.

  
  
• 
  

  Morrison p.: for traumatic thumb amputation, great toe wraparound flap transfer.

  
  
• 
  

  Orbay p.: volar plate fixation of distal radial fracture.

  
  
• 
  

  Peacock p.: little finger transposition to fourth ray, or long finger to index.

  
  
• 
  

  Ruch p.: for highly comminuted distal radius fracture, plate bridges proximal radius to second metacarpal .

  
  
• 
  

  Ruland p.: for unstable proximal interphalangeal fracture dislocation, dynamic distraction external fixation.

  
  
• 
  

  Russe bone graft: for scaphoid nonunion fracture; cortical cancellous graft placed by a volar approach through a longitudinal trough in the volar surface of the scaphoid that will enhance bony union.

  
  
• 
  

  Sagerman and Short p.: for tear triangular fibrocartilage complex, arthroscopic repair of class 1D injury.

  
  
• 
  

  Scheker p.: reconstruction of dorsal ligament of TFCC.

  
  
• 
  

  Shea p.: for distal radial malunion, volar osteotomy.

  
  
• 
  

  Stark p.: for scaphoid nonunion, grafting with screw fixation.

  
  
• 
  

  Steichen p.: for traumatic amputation thumb, great toe wraparound flap transfer.

  
  
• 
  

  Wagner p. : for Bennett fracture either a closed pin fixation or open fixation.

  
  
• 
  

  Zaidemberg p.: for scaphoid nonunion, vascularized bone graft.

Microvascular Procedures

• 
  

  anastomosis: term used for the direct repair of nerves and blood vessels.

  
  
• 
  

  back wall first technique: a microsurgical procedure in which the vessel wall away from the surgeon is sutured first, most useful in vessels of approximately equal size when one or both of the presenting ends cannot be rotated within a double clamp.

  
  
• 
  

  Chinese flap (radial forearm flap): a radial forearm rotation flap based on the radial artery to repair radial and hand defects.

  
  
• 
  

  cross-arm flaps: random flaps using tissue from random pedicle flap using tissue from the patient’s upper arm to cover a large defect on the patient’s contralateral hand.

  
  
• 
  

  denervation: the accidental or intentional removal of sensory or motor nerve input to a distal site in the hand or arm.

  
  
• 
  

  dorsalis pedis flap: a microvascular free flap using the dorsalis pedis artery of the foot as the donor artery used to cover small defects in the upper extremity.

  
  
• 
  

  fibrin clot glue: a method of augmenting nerve apposition by using fibrin clot glue to cement the suture line.

  
  
• 
  

  flipping technique: used in microsurgery repairing a small vessel that is freely mobile. One can flip the vessel to repair the back wall. Used in vein grafting and free-tissue transfer technique.

  
  
• 
  

  four-flap Z-plasty: a double Z-plasty used commonly in the reconstruction of the first webspace.

  
  
• 
  

  free flaps: a method of free tissue transfer using skin, muscle, bone, or all three. Tissue is transferred using its vascular pedicle and microsurgical anastomotic technique.

  
  
• 
  

  interposition graft: generally used for either nerve or vascular (vein) grafts to bridge a gap for direct microanastomosis of nerves and vessels.

  
  
• 
  

  laser Doppler fluximetry: this evaluates cutaneous microvascular perfusion. This evaluates the motion of the red blood cells in the area directly beneath the probe.

  
  
• 
  

  lateral arm flap: a free flap based on the posterior radial collateral artery; useful for covering large, full-thickness defects in the dorsum of the hand.

  
  
• 
  

  no reflow phenomenon: a microvascular anastomosis with arterial anastomosis. Disruption of the neurovascular tree may result in no venous return into the field.

  
  
• 
  

  sympathectomy: a method to improve peripheral blood flow by ablating the central or peripheral sympathetic innervation to arteries in treatment of chronic regional pain syndrome by surgery.

  
  
• 
  

  toe-thumb transfer: complete transfer of a toe with its full complement of neurovascular, tendinous, and bone structures to the hand to add to a digit or thumb on a posttraumatic or congenitally deficient hand.

  
  
• 
  

  wraparound procedure: the medial aspect of the great toe with its neurovascular bundles is removed from the toe and wrapped around a free bone graft at the tip of an amputation stump. This is then reattached using microvascular techniques. The donor site is secondarily grafted to close its defect.

Congenital Deformity Repairs

• 
  

  Barsky macrodactyly reduction: (1) filleting out of the distal phalanx, then placing all distal structures on to the end of the middle phalanx (this will shorten the macrodactylous digit); (2) hemiresection of the middle phalanx and DIP joint fusion.

  
  
• 
  

  Bayne and Klug p.: centralization of hand with transfer of flexor carpi ulnaris.

  
  
• 
  

  Bilhaut-Cloquet p.: for Wassel II thumb duplication (bifid thumb). The narrow half of each thumb tip is united with the other, discarding the central units and allowing the thumb to become one phalanx.

  
  
• 
  

  Bonola p.: a dorsally based closing wedge osteotomy of the distal phalanx to correct a Kirner deformity.

  
  
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  Bora p.: for radial club hand, a wrist centralization procedure.

  
  
• 
  

  Bracket resection: epiphyseal resection of the apex of a delta phalanx accompanied by fat grafting.

  
  
• 
  

  Buck-Gramcko p.: centralization of hand lengthening brachymetacarpia in hypoplastic hand; pollicization of another finger.

  
  
• 
  

  callotasis: technique of one-stage bone lengthening by placement of an external fixator on both sides of osteotomy and stretching the bone out to lengthen short digits. Also called distraction lengthening.

  
  
• 
  

  Carstan reverse wedge osteotomy: for the treatment of a delta phalanx; a central wedge is reversed and turned 180 degrees to straighten a digit.

  
  
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  Cronin technique: a technique for separating syndactylized digit using a combination of palmar and dorsal triangular flaps.

  
  
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  House p.: for thumb-in-palm deformity, contracture release; for flexion and key pinch capacity, reconstruction of index finger.

  
  
• 
  

  Kato p.: for congenitally short metacarpal, callotasis metacarpal lengthening.

  
  
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  Kessler p.: for partial thumb amputations or other defects, metacarpal lengthening.

  
  
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  Krukenberg p.: in the congenital absence of a hand, the radius and ulna are surgically separated and covered with soft tissue so that the two bones will act as a claw.

  
  
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  Lamb p.: for surgical correction of congenital bifid thumbs.

  
  
• 
  

  Manske and McCarroll opponensplasty: for congenital radial dysplasia, abductor digiti minimi opponensplasties.

  
  
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  Miura and Komada p.: for cleft hand closure, closure with release of thumb adduction contracture.

  
  
• 
  

  physiolysis: the selective obliteration of the growth plate and area of uneven bone growth such as seen in Madelung deformity. This is frequently accompanied by fat grafting to inhibit further bone growth.

  
  
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  radialization, centralization: an attempt to rebalance the hand and wrist on to the distal forearm in radial clubbed hand.

  
  
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  Ranawat p.: for Madelung deformity, closing wedge osteotomy combined with Darrach excision of distal ulnar head.

  
  
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  Ueba p.: for congenital palmar cleft, V shaped closure.

  
  
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  Van Heest p.: for radial longitudinal deficiency, centralization of hand with dorsal rotation flap.

  
  
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  Vickers and Nielsen p.: For Madelung deformity, resection of dyschondrosteosis lesion.

  
  
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  Watson p.: for Madelung deformity, balanced radial osteotomy.

  
  
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  Whitey p.: open finger syndactyly release.

  
  
• 
  

  Woolf and Broadbent p.: butterfly flap technique for release of syndactyly.

Skin, Nails, and Fascia Procedures

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  advancement flaps: flaps cut either from the volar pad or from the radial and ulnar pad of the distal fingertip for the reconstruction of fingertip injuries with skin and subcutaneous loss; also called V-Y flaps and Kleinert-Atosoy.

  
  
• 
  

  axial cutaneous flaps: free or island flap on a subscapular artery pedicle for medium-sized defect coverage in the hand; also called scapular flap.

  
  
• 
  

  axial flag flaps: a rotational skin flap based on a dorsal digital artery used for digital skin and subcutaneous defects.

  
  
• 
  

  axial pattern skin flap: a long skin flap possible because of an underlying vascular supply running along its long axis underneath.

  
  
• 
  

  Bednar and Lane p.: advancement of skin to cover base of a fingernail.

  
  
• 
  

  cocked-half flap: reconstruction of a thumb amputation at the MCP joint level with a local skin graft, iliac crest graft, and skin graft; also called Gillies flap.

  
  
• 
  

  composite nail bed flap: a full-thickness nail bed graft from a toe to cover a defect in a fingernail bed.

  
  
• 
  

  cross-finger flap: the dorsal skin of one digit is flapped over itself to create coverage for a volar skin defect of an adjacent digit.

  
  
• 
  

  cryotherapy: a method of using extreme cold to freeze skin lesions such as actinic keratosis.

  
  
• 
  

  escharotomy: in the management of deep thermal burns, burned and contracted skin is incised to decompress deeper tissues and prevent further necrosis.

  
  
• 
  

  fasciectomy: generic term used to describe excision of the palmar fascia, usually when involved in Dupuytren disease.

  
  
• 
  

  fasciotomy: (1) opening of muscle compartments and decompressing intrinsic muscle spaces in compartment syndrome; spaces to be decompressed are interosseus muscles (through dorsal incisions or volar thenar and hypothenar compartments); (2) incision into a Dupuytren central cord to release contracture; this is useful in older and debilitated patients, but contracture recurrence is common.

  
  
• 
  

  flag flap: a rotational pedicle flap harvested on the dorsum of the finger and used to cover defects on adjacent fingers or over the MCP joint. The same can be performed as a volar flap as well.

  
  
• 
  

  Jacobsen flap: for Dupuytren’s contracture, L-shaped incision leaving proximal end open for granulation.

  
  
• 
  

  Macindo procedure: a form of palmar fasciectomy for Dupuytren contracture when the palmar skin is left open to granulate.

  
  
• 
  

  marsupialization: a technique used to expose the germinal matrix of a nail in patients with chronic paronychia in which a crescent of the eponychial fold is removed to uncover chronic fungal infection. Also called Keyser p.

  
  
• 
  

  Moberg flap: useful in thumb tip reconstruction; the volar half of the thumb soft tissue is elevated with its neurovascular structures, and by flexing the IP joint of the thumb, the flap is then stretched over the thumb tip.

  
  
• 
  

  neurovascular island transfer: a method of transferring sensibility to an important part of the hand such as the thumb tip from a less important part of the hand, whereby a portion of skin is left connected to its neurovascular structures and passed subcutaneously to a different part of the hand.

  
  
• 
  

  onychectomy: removal of a fingernail.

  
  
• 
  

  onychotomy: the method of cutting into a nail, usually to remove a mass under the nail.

  
  
• 
  

  pedicle flap: a procedure that permits an island of skin and subcutaneous tissue to be transferred from one place to another on its own vascular supply, using multiple operative stages.

  
  
• 
  

  pedicle grafts: a term used for pedicle flaps but also includes pedicle bone grafts. Island pedicle grafts and neurovascular pedicle grafts are pedicle, skin, or subcutaneous tissue containing blood and nerve supply, thus providing sensation for the skin graft.

  
  
• 
  

  thenar flap: for fingertip coverage, an H-flap is raised on the thenar eminence and the digit tip is flexed down to it. By 10 to 14 days, the flap provides a good skin and soft tissue coverage to the distal digit tip. However, digital stiffness is common.

Muscle Transfers and Procedures for the Hand

There are two types of tendon procedures: (1) restoration of tendon function by direct repair of a tendon, its advancement, or its transfer, and (2) freeing of tendon from scar tissue, restrictive bands, or abnormal lining tissues. In some cases muscle attachments are transferred or used as a cover for soft tissue defects.

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  Bateman p.: indicated in axillary and suprascapular nerve palsy, which involves an acromial fragment to the humerus to facilitate shoulder abduction.

  
  
• 
  

  Chen p.: posterior interosseous muscle flap.

  
  
• 
  

  deltoid flap: a muscular-free flap using the deltoid to cover small to moderate deficits in the upper extremity.

  
  
• 
  

  Hammond p.: multiple muscle transfers for reconstruction of the paralyzed shoulder in brachial plexus injuries. Transfer of the posterior third of the deltoid to the lateral aspect of the clavicle and from the tendinous origins of the long head of the triceps and the short head of the biceps to the lateral aspect of the acromion to aid in shoulder abduction. Transfer of the latissimus dorsi to teres major tendons.

  
  
• 
  

  House reconstruction: complete array of reconstructions to facilitate hand function in patients with varying degrees of quadriplegia (tetraplegia) depending on the level of the lesion in the cervical spine.

  
  
• 
  

  McFarlane p.: for wrist extensor motor loss, transfer of flexor superficialis tendon to extensor apparatus.

  
  
• 
  

  Steindler flexorplasty: in brachial plexus injury causing paralysis of elbow flexion (biceps and brachialis) with sparing of distal forearm musculature, the flexor pronator mass with the medial epicondyle of the distal humerus is transferred anteriorly and proximally on the humerus to effect elbow flexion.

  
  
• 
  

  Williams p.: hemi-hamate autograft.

  
  
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  Williams and Haddad p.: for spastic paralysis, extensive release of flexor pronator origin.

Tendon Suture Repair Techniques

Numerous techniques and types of sutures are used in repairing tendons. A tendon repair is any reapproximation of a partially or completely severed tendon. The specific technique is directed at gaining maximal strength with minimal scarring.

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  Adelaide tendon repair: for flexor tendon repair, suture anchored in four places on each end of lacerated tendon such that a total of eight suture strands cross the repair site.

  
  
• 
  

  Becker p.: multiple cross-stitching technique for approximation of fresh tendon edges.

  
  
• 
  

  Bunnell opponensplasty: the use of the flexor digitorum sublimis IV as a donor motor for thumb opposition, using the pulley in the region of the flexor carpi ulnaris and the pisiform.

  
  
• 
  

  Kleinert p.: modification of Bunnell technique, burying suture knot at tendon edge.

  
  
• 
  

  modified Kessler suture: a direct end-to-end grafting suture for flexor tendon lacerations, especially in zone II. These are usually augmented with epitendinous sutures.

  
  
• 
  

  Pulver-Taft weave: the strongest method of reattaching two tendons where space is not at a premium. It involves weaving tendon ends in and out of each other.

  
  
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  Tsuge: multiple cross-stitching technique for tendon reapproximation.

  
  
• 
  

  Verdan suture: multiple cross-stitching technique for tendon reapproximation.

Other specific techniques include four-strand cruciate p., Tajima p., Halsted p., Salvage p., and Silfverskiöld p.

Tendon Grafts and Transfers

A tendon transfer is the relocation of a tendon from one place to another. The tendon retains attachment to its muscle. By contrast, free tendon graft requires complete excision of a tendon and its repositioning in a new location. Tendon transfers may be static or dynamic.

Tendon transfers are commonly required to replace or assist voluntary muscle function that is lost because of nerve injury, nerve disease, or direct and indirect sequelae of trauma to the muscle. Substantial numbers of transfers are used in central nervous system paralyses such as those caused by strokes and polio. Transfers are listed by categories that define function.

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  Aichef technique: a method of central slip reconstruction in Boutonnière deformity by designing a tendon flap using the central half of the lateral bands and bringing them toward the midline to recreate a central slip in which the central slip has been irreparably damaged by trauma.

  
  
• 
  

  Brand p.: hand web deepening with sliding flap; ring finger sublimis tendon used as motor; transfer of extensor carpi radialis longus or brevis tendon; transfer of sublimis tendon.

  
  
• 
  

  Brent-Moberg tenodesis: thumb flexor tenodesis to restore key pinch in quadriplegics. A technique using flexor or extensor tendon graft to restore and treat functions in ulnar nerve palsy.

  
  
• 
  

  Burkhalter p.: transfer of extensor indicis proprius tendon.

  
  
• 
  

  Burkhalter transfer: threading digital flexors through the proximal phalanx to facilitate MCP flexion in low ulnar nerve palsy with claw deformities.

  
  
• 
  

  Camitz p.: the palmaris longus, with its distal attachment tubularized, is passed under the thenar eminence and attached to the radial aspect of the base of the proximal phalanx of the thumb to act as an opponensplasty. This is useful in chronic carpal tunnel syndrome.

  
  
• 
  

  Carlson p.: for swan neck deformity in cerebral palsy, intrinsic lengthening.

  
  
• 
  

  central slip repair and reconstruction: procedure designed to repair the common extensor insertion into the proximal dorsal end of the middle phalanx, thus restoring active PIP extension.

  
  
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  Clark pectoralis major transfer: transfer of the sternocostal portion of the pectoralis major muscle for the restoration of elbow flexion in brachial plexus injury.

  
  
• 
  

  crossed intrinsic transfer: in rheumatoid arthritis, with ulnar deviation of the digits at the metaphalangeal joint, a conjoined ulnar intrinsic tendon is released from one digit and placed into the radial conjoined intrinsic tendon of the adjacent digit on its ulnar side.

  
  
• 
  

  dynamic tendon transfer: one that brings about motion by direct action of muscle contraction.

  
  
• 
  

  finger extension p.: Boyes procedure.

  
  
• 
  

  finger flexion p.: for flexion of the MCP joint (intrinsic transfer); Boyes, Fowler, Bunnell, Stiles-Bunnell, Riordan, and Pulver-Taft procedures, and Brand I and Brand II procedures.

  
  
• 
  

  flexor pronator slide: release of the flexor pronator muscle group origin allowing the muscle to slide distally. This helps correct wrist and digital flexion deformity and forearm pronation deformity in cerebral palsy.

  
  
• 
  

  flexor tenolysis: method used to free flexor tendon from its surrounding scars approximately 4 months after flexor tendon repair with secondary tendon adherence.

  
  
• 
  

  Fowler tenodesis: static tendon grafts originating in the extensor retinaculum, passing volarly to the deep transverse metacarpal ligament, and inserting it into the radial lateral bands. A procedure to prevent hyperextension of the MCP joint as seen in the claw deformity of low ulnar nerve palsy.

  
  
• 
  

  Green transfer: flexor carpi ulnaris to extensor carpi radialis brevis transfer to correct a wrist flexion deformity in cerebral palsy. Overcorrection is common.

  
  
• 
  

  Groves and Goldner transfer: transfer of flexor carpi ulnaris combined with sublimis tendon.

  
  
• 
  

  Huber transfer: a procedure designed to restore thumb opposition based on a transfer into the thenar eminence of the abductor digiti minimi, that is, a neurovascular pedicle.

  
  
• 
  

  Hui-Linscheid p.: a tenodesis procedure designed to reconstruct the volar ulnar carpal ligament using a strip of flexor carpi ulnaris tendon particularly useful in primary ulnar-carpal instability or secondary distal radial ulnar joint instability.

  
  
• 
  

  Jones transfer: in radial nerve palsy, tendon transfer designed to restore thumb, digital, and wrist extension.

  
  
• 
  

  Jupiter and Breen p.: for unstable distal ulna, combination tenodesis of flexor carpi ulnaris and extensor carpi ulnaris.

  
  
• 
  

  Lasso p.: flexor digitorum superficialis in a tenodesis mode to flex the MCP joint used commonly in tetraplegia and patients with hyperextension deformities of the MCP joint and with hyperextension of the PIP joint.

  
  
• 
  

  Lennox Fritschi technique: a palmaris longus motored four-tail transfer used in ulnar palsy to correct claw deformities to promote MCP flexion and PIP extension.

  
  
• 
  

  Littler-Eaton ligament reconstruction: method of stabilizing the base of the thumb metacarpal in stage I basal joint arthritis by using local tendon graft reconstruction.

  
  
• 
  

  Littler boutonnière reconstruction: includes dorsal transposition of the lateral bands and repair of the central SLIP to the base of the middle phalanx.

  
  
• 
  

  Mennen opponensplasty: the extensor pollicis longus is passed through the interosseous membrane to the volar aspect of the forearm and backed out along the thenar eminence to the dorsal surface of the MCP joint, thus creating opponens function.

  
  
• 
  

  Oishi and Ezaki p.: for Volkmann contracture, two-staged free gracilis transfer to recover extrinsic finger flexion.

  
  
• 
  

  Omer and Capen p.: for cerebral palsy, carpectomy and muscle transfers.

  
  
• 
  

  opponensplasty: the use of any of the intrinsic or extrinsic muscle tendon units to restore thumb opposition (i.e., in median nerve palsy); also called Brand, Burkhalter, Groves, Goldner, Riordan, Phalen-Miller, Littler, Huber, and Fowler procedures.

  
  
• 
  

  Parke tenodesis: static tenodesis using wrist extensors as grafts to treat claw deformities to promote MP flexion.

  
  
• 
  

  Ranney technique: an extensor digiti minimi transfer to the neck of the fifth metacarpal to restore the transverse metacarpal arch in ulnar nerve palsy.

  
  
• 
  

  Riordan technique: a flexor carpi radialis transfer using a free graft passing from the flexor to the extensor side of the forearm, radial lateral bands of the fingers involved in claw deformity in low ulnar nerve palsy; sublimis transfers for a variety of conditions.

  
  
• 
  

  Smith p.: flexor pollicis longus abductorplasty; release of severe intrinsic contractures with muscle fibrosis; transfer of extensor carpi radialis brevis tendon to restore thumb adduction.

  
  
• 
  

  static tendon transfer: transfer of a free tendon graft attached to two or more bony locations, such that the active movement of one joint will cause the passive movement of some other joint. For example, a tendon appropriately inserted proximal to the wrist and in the fingers will cause flexion of the fingers if the wrist is extended.

  
  
• 
  

  Strickland p.: flexor tendon repair in zone II.

  
  
• 
  

  tendolysis: a tendon release. It describes two different types of procedures: (1) one in which the tendon is freed from scar tissue or entrapment so that it may move properly, and (2) tenosynovectomy, whereby all or part of the sheath of a functioning tendon is excised. Also called tenolysis.

  
  
• 
  

  tendon advancement: done when the damage segment of a tendon is so near its insertion that a direct tendon-to-bone rather than tendon-to-tendon repair is necessary. One such technique is the Wagner advancement of the profundus tendon.

  
  
• 
  

  tenodesis: the fixation of a tendon onto two bony locations to keep a joint from flexing or extending beyond a selected range. This procedure lends itself to prevention of hyperextension of the MCP joints in ulnar claw deformity. Two commonly done are the Fowler and Riordan procedures.

  
  
• 
  

  tenorrhaphy: the repair of a lacerated tendon, either immediate or delayed.

  
  
• 
  

  tenotomy: a procedure in which a tendon, either flexor or extensor, is sectioned purposely to correct a deformity to bring back the position or function of the hand or wrist.

  
  
• 
  

  thumb abduction p.: pulling thumb away from the side of the hand; also called Boyes p.

  
  
• 
  

  thumb adduction p.: pulling the thumb to side of index finger; also called Boyes p., Bunnell p., Edgarton-Grand p., and Royle-Thompson p.

  
  
• 
  

  wrist extension p.: Boyes p. using pronator teres to the extensor carpi radialis brevis muscle.

Tenosynovectomy

Tenosynovectomy refers to the excision of thickened tendon sheath and other tissue surrounding a tendon, commonly seen in infection, chemical irritation, and rheumatoid arthritis (synovectomy). It also refers to the following procedures in hand surgery.

• 
  

  abductor pollicis longus release: a release of the fibrous canal surrounding the abductor pollicis longus at the wrist for symptoms of de Quervain syndrome (pain on abduction of the thumb). Also called de Quervain release.

  
  
• 
  

  Howard p.: freeing of adherent flexor tendon.

  
  
• 
  

  Inglis p.: for early thumb metacarpophalangeal disease in rheumatoid arthritis, thumb metacarpophalangeal synovectomy, and dorsal reconstruction.

  
  
• 
  

  tenosynovectomy: a procedure whereby the tenosynovium surrounding the tendon sheaths are removed such as in rheumatoid arthritis to prevent tendon rupture or to treat tendon entrapment.

  
  
• 
  

  tenovaginotomy: procedure designed to release stenosing tenosynovitis by incising a retinaculum or flexor pulley.

  
  
• 
  

  trigger finger release: a release of fibrous covering of tendon (pulley) at the base of the finger to prevent a tendon with nodular changes from snapping with motion of the finger. Also called snapping tendon release.

Other Tendon Procedures

• 
  

  boutonnière reconstruction: a classic extensor tendon reconstruction for boutonnière deformity, designed to restore active extension of the PIP joint and to prevent its flexion posturing. This procedure is fraught with difficulty, and prognosis is guarded; also called Littler, Matev, and Fowler procedures.

  
  
• 
  

  Hunter rod: a silicone-rubber tendon spacer or rod that is used to form a new synovium-filled channel. It is removed during a second-stage procedure, and a tendon graft is threaded through. Useful as a two-stage procedure when the tendon bed is extremely scarred and a direct tendon graft is impossible. Also called passive tendon implant.

  
  
• 
  

  Kortzeborn p.: a lengthening of the extensor tendons of the thumb and formation of a fascial attachment of the thumb to the ulnar side of the hand to relieve ape hand deformity.

  
  
• 
  

  Matsuo p.: for swan-neck deformity, intrinsic lengthening.

  
  
• 
  

  Moberg p.: to restore normal pinch ability, tenodesis of flexor pollicis longus to distal radius. Also called key grip tenodesis .

  
  
• 
  

  swan-neck revision: surgery designed to eliminate a swan-neck deformity in the fingers by revision of tendons; also called Swanson revision and Littler modified tendon revision.

  
  
• 
  

  tenodermodesis: for chronic mallet finger deformity, delayed repair of tendon using old tendon edges, scar, and skin to reestablish distal joint extension.

Other Hand and Wrist Procedures

• 
  

  Adams and Berger technique: anatomic reconstruction of distal radioulnar ligaments.

  
  
• 
  

  Agee p.: single-incision endoscopic carpal tunnel release.

  
  
• 
  

  Almquist p.: carpal ligament reconstruction.

  
  
• 
  

  Atasoy VY flap advancement: for distal finger tip amputation a flap of skin created to cover dital tip.

  
  
• 
  

  Baker and Cummings techniques: for arthroscopic bursectomy or tennis elbow release.

  
  
• 
  

  Beckenbaugh p.: correction of hyperextension deformity of PIP joint.

  
  
• 
  

  Beskin p.: proximal phalangeal osteotomy.

  
  
• 
  

  Brand p.: hand web deepening with sliding flap; ring finger sublimis tendon used as motor; transfer of extensor carpi radialis longus or brevis tendon; transfer of sublimis tendon.

  
  
• 
  

  Broadbent and Woolf p.: four-flap Z-plasty in adducted thumb

  
  
• 
  

  Broudy and Smith p.: rotational osteotomy of first metacarpal.

  
  
• 
  

  capsular release: an incision of a joint capsule done to regain lost motion caused by contractures; also called capsulectomy.

  
  
• 
  

  capsulodesis: in hand surgery, the capsule, which may include the dorsal or volar plate, may be tightened to help hold an affected joint in a position that can no longer be held voluntarily. This is done often for nerve injuries and is commonly called the Zancolli procedure (for clawhand deformity); also called volar capsular reefing and Blatt dorsal capsulodesis.

  
  
• 
  

  carbon implant: a new form of resurfacing arthroplasty for the MCP and PIP joints used commonly in osteoarthritis; also called pyrocarbon implant.

  
  
• 
  

  carpal tunnel release: a division of the strong ligamentous band (transverse carpal ligament) that covers the median nerve and flexor tendons of the finger and thumb. This is usually done to relieve pressure on the median nerve that may result from arthritis, trauma, or unknown causes. A tenosynovectomy, if necessary, may be done through the same incision.

  
  
• 
  

  carpectomy: the removal of the proximal row of carpal bones, usually indicated in some forms of arthritis or severe spastic contractures.

  
  
• 
  

  Chow p: two-incision carpal tunnel release.

  
  
• 
  

  Chun and Palmer p.: an ulnar shortening osteotomy

  
  
• 
  

  Cowen and Loftus p.: metacarpal lengthening with distraction.

  
  
• 
  

  dermodesis: the removal of a segment of skin and then closure of the skin margins to shorten skin and restrict motion of a joint. It is frequently done in conjunction with a Zancolli capsulodesis for ulnar clawhand.

  
  
• 
  

  Dupuytren contracture release: named after a French surgeon, this surgical procedure is the excision of the contracted fibrotic bands of the palmar fascia. However, the skin is often adherent and recurrent deformity is a problem. Specific techniques for resection of these bands are:

  
  
  
  
  • 
    

    Luck p.: percutaneous transection of fibrotic bands without removal of tissue.

    
    
  • 
    

    McCash p.: transverse skin incision with transection of bands and then passive stretch dressing applied, leaving the wounds open.

  
  
  
  
• 
  

  fishmouth incision: a wraparound incision over the distal end of the finger to facilitate drainage.

  
  
• 
  

  Foucher technique: a procedure for internal fixation of metacarpal neck fractures using multiple prebent Kirschner wires in a wire-stacking technique.

  
  
• 
  

  ganglionectomy: the excision of a ganglion, which usually occurs on the dorsum of the wrist or the base of the fingers.

  
  
• 
  

  Hammond procedure : multiple muscle transfers for reconstruction of the paralyzed shoulder in brachial plexus injuries. Transfer of the posterior third of the deltoid to the lateral aspect of the clavicle, and from the tendinous origins of the long head of the triceps and the short head of the biceps, to the lateral aspect of the acromion, to aid in shoulder abduction. Transfer of the latissimus dorsi to teres major tendons.

  
  
• 
  

  Illarramendi and De Carlit p.: radial decompression for loss of blood supply to the lunate bone.

  
  
• 
  

  infiltration technique: a method of axillary block for regional anesthesia in upper extremity surgery. The anesthetic is injected around the axillary artery inside the sheath of the neurovascular bundle spreading local anesthetic around the brachial plexus.

  
  
• 
  

  interscalene block: a brachial plexus block using a needle in the interscalene space to numb the brachial plexus to effect regional anesthetic commonly used in shoulder surgery.

  
  
• 
  

  island flaps: either pedicle or free flaps of small amounts of tissue either skin, bone, muscle, or a combination of both for the reconstruction of small area defects.

  
  
• 
  

  joint leveling procedures with ulnar lengthening and radial shortening: used to restore the anatomic relationship between the distal radius and ulna (generally, the ulnar variance seen on the contralateral normal side).

  
  
• 
  

  Kanaya procedure: for limited pronation and supination of the wrist caused by distal radial ulnar joint disorders; interposition of vascularized fascia-fat graft with corrective osteotomy of the radius.

  
  
• 
  

  kite flap: an island pedicle of flap proximally based on the first dorsal metacarpal artery designed on the radial side of the distal portion of the second metacarpal and MCP joint; used to reconstruct defects on the dorsum of the hand usually on the radial side.

  
  
• 
  

  Kleinman and Eckenrode p.: for trapezial arthritis, tendon interposition arthroplasty with ligament reconstruction,

  
  
• 
  

  Kleinman and Greenberg p.: for failure of Darrach procedure, tenodesis of extensor carpi ulnaris and transfer of pronator quadratus.

  
  
• 
  

  Kozin and Ezaki p.: for forearm hypoplasia, ring sublimis opponensplasty with ulnar collateral ligament reconstruction.

  
  
• 
  

  latissimus dorsi flap: a form of myocutaneous pedicle or free flap in which blood supply derives from the thoracodorsal artery and is used to cover large soft tissue defects.

  
  
• 
  

  Luchetti p.: arthroscopic technique for resection of dorsal wrist ganglion.

  
  
• 
  

  mallet finger revision: designed to regain active extension of the DIP joints of the finger.

  
  
  
  
  • 
    

    Fowler release: technique used at the PIP joint for a mallet finger.

  
  
  
  
• 
  

  Marx and Axelrod p.: anatomically corrective osteotomy for intraarticular malunion of distal radius.

  
  
• 
  

  Millesi p.: interfascicular nerve grafting; tension-free nerve graft; thumb shortening.

  
  
• 
  

  Nalebuff and Millender p.: for swan neck deformity in rheumatoid arthritis, lateral band mobilization and skin release.

  
  
• 
  

  Osterman and Raphael p.: arthroscopic resection of dorsal wrist ganglion.

  
  
• 
  

  palmar advancement flaps: a proximally based flap used to cover distal soft tissue defects; most commonly used in the thumbs. Also called Moberg flap.

  
  
• 
  

  palmar fasciectomy, fasciotomy: the release, with or without resection of tissues, of shortened, thickened, and contracted fasciae in the palm or finger in flexion deformities resulting from Dupuytren contracture.

  
  
• 
  

  phalangectomy: the excision of a part or all of a phalanx because of trauma or arthritis. Rarely performed in the hand; more commonly done in the foot.

  
  
• 
  

  pollicization: any operation replacing a congenitally or traumatically missing thumb by reconstruction of the index, long, ring, or little finger such that it acts or functions as a thumb; also called Buck-Gramko p., Riordan p., Littler p., Gillies p., and Verdan p.

  
  
• 
  

  random pattern flaps: skin flaps that are generally quadrilateral in shape and are raised by incising three of the four sides and depends on the minute vessels of the subdermal and subcutaneous plexus.

  
  
• 
  

  RASL p.: acronym referring to the reduction association of the scapholunate joint. This consists of an open reduction of the scapholunate articulation, repair of the ligamentous remnants, and protection of the repair by internally blocking the scapholunate joint with a transverse Herbert screw for a year to provide intercarpal fibrosis.

  
  
• 
  

  ray amputation: a procedure to remove a metacarpal and all phalangeal segments of a finger distal to that metacarpal.

  
  
• 
  

  regional flaps: those derived from tissues not immediately adjacent to the primary defect but in its vicinity. They can be random or axial pattern flaps depending on their blood supply.

  
  
• 
  

  replantation: a microsurgical procedure that requires the reattachment of nerves, veins, and arteries to attempt restoration of function to a freshly severed part such as a finger.

  
  
• 
  

  revision polydactyly: polydactyly usually affects the thumb and little finger. Revision requires reattachment of specific tendons or ligaments; also called Marks and Bayne p.

  
  
• 
  

  saphenous flap: a myocutaneous flap based on the saphenous artery and nerve. This is used to cover small- to medium-sized defects.

  
  
• 
  

  Snow and Littler p.: for cleft hand deformity, combined cleft closure and release of thumb adduction contracture may be combined with other procedures.

  
  
• 
  

  synovectomy: removal of synovium in joints. The procedure is done frequently for rheumatoid arthritis.

  
  
• 
  

  tendinocutaneous flaps: vascularized tendon graft that can be transferred with a dorsalis pedis or radial forearm flap. This is indicated for one-stage reconstruction of degloving injury to the dorsum of the hand with loss of skin and extensor tendons for example.

  
  
• 
  

  Tomaino p.: for scaphoid nonunion, grafting and stabilization.

  
  
• 
  

  Tomaino and Weiser p.: for triangular fibrocartilage tears with positive ulnar variance, wafer distal ulnar resection and TFCC debridement.

  
  
• 
  

  Tonkin p.: for swan neck deformity, lateral band translocation.

  
  
• 
  

  transposition flaps: skin flaps used to cover small deficits. These may be axial pattern or random pattern.

  
  
• 
  

  trapeziectomy: removal of the trapezium bone in the treatment of basal joint arthritis, which may be done alone or in concert with an interposition arthroplasty.

  
  
• 
  

  Trumble p.: for triangular fibrocartilage injury, arthroscopic repair.

  
  
• 
  

  ulnar forearm flap: a fascial cutaneous flap that is based on the ulnar artery and is harvested from the ulnar aspect of the forearm; used to cover deficits of the ulnar side of the hand or used as a free flap for distal defect.

  
  
• 
  

  wafer p.: for ulnar plus wrist; resection of the distal 2 to 3 mm of the ulnar head, leaving the styloid intact.

  
  
• 
  

  Wei p.: for thumb absence, a trimmed-toe transfer.

  
  
• 
  

  Weiss p.: arthroscopic proximal row carpectomy.

Approaches

Hand

Surgical approaches are too numerous and complicated to describe here. Refer to Canale ST, Beaty J, 2013.

Type I: PIP joint flexible in all positions of MP joint.

Type II: PIP joint is limited in certain positions.

Type III: PIP joint is limited in all positions.

Type IV: stiff PIP with gross articular destruction.

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