Manual of Reconstructive Hand Surgery

Manual of
Reconstructive Hand Surgery

Manual of
Reconstructive Hand Surgery
G Karthikeyan MBBS MS MCh (Plastic Surgery)

Assistant Professor
Institute for Research and Rehabilitation of Hand and
Department of Plastic Surgery
Stanley Medical College and
Government Hospital
Chennai, Tamil Nadu, India
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Manual of Reconstructive Hand Surgery
First Edition: 2013

ISBN: 978-93-5090-512-8
Printed at
Dedicated to
My Gurus and patients
Preface
Hand surgery is more an art form. This is because we are dealing with living, moving and gliding
delicate tissues that respond positively to gentle dissection and react violently to unsure steps,
rough handling and disregard for hemostasis. I remember reading somewhere that a hand
surgeon must be in and out of the tissues before the tissues are even aware of the intrusion.
This, I suppose, was said, because the lesser the tissue handling, the better will be the results,
as the postoperative inflammation and edema will be minimal. To achieve this, speed is of
prime importance, and must be accompanied by gentle tissue handling.
Such tissue handling can be minimized if the surgeon is aware of what to do, how to do
and when to do. Avoiding unnecessary steps, circumventing potential problems in dissection,
undoing mistakes, and taking extra care at strategic points are some of the ways in which a
smooth conduct of the surgical procedure can be achieved.
At the beginning of my career in hand surgery, I was lucky to be guided by experts in the
field, as they led me step by step through the many procedures. However, elaborate textbooks
may be on the descriptive aspects of the surgical procedures, but they may not suffice for a
beginner who is attempting for the first time, even a well-described procedure.
So, I envisaged Manual of Reconstructive Hand Surgery, which will play the role of a coach
and also be able to guide the surgeon throughout the procedure. This book is written with this
intention.
I hope, this book will help surgeons to carry out their procedures with ease. After all, the
ultimate beneficiary should be the patient.
The procedures have been described in practical and easy way, and may not be the original
description.
G Karthikeyan
Acknowledgments
I thank my mother Kuppammal, and father Gomathinayagam, who taught me the path of duty
and righteousness. Thank you Amma and Appa, for showing me the right path.
My aunt Meenakshi, who cared for me, especially during my days of ill health. Thank you
Chithi.
I am indebted to my wife Venkatalakshmi, whose time I have borrowed mercilessly to be
with my patients. I know I cannot replace that time, but I thank her for understanding.
I thank my daughter Abinaya for always remaining a pillar of strength and support.
The late Flt Lt Professor J Rajappa, who in his own inimitable way, showed me the path of
discipline in surgery. I shall always remember you Sir, and the guidance that you gave me.
I thank Professor R Venkataswami, who has created a world class Institution at Government
Stanley Hospital, Chennai, Tamil Nadu, India, where devotees of hand surgery can serve.
I thank Professor Nirmala Subramaniam for introducing and giving the basic knowledge
about hand surgery, Professor G Balakrishnan for his lively advice and infusing the skills for
performing various procedures and Professor R Krishnamoorthy for nurturing the correct
attitude towards surgery, patients and life in general.
I also thank Professor J Jaganmohan, who has always remained a moral support in all my
endeavors.
I thank Professor V Nagaswamy, who proved to me that anesthesiologists are indispensable
to surgeons, can be better than surgeons and can sometimes even inspire surgeons.
My friends of batch of 1982 for their constant encouragement and gentle cajoling.
My students who still remain as friends and provide suggestions at appropriate times.
I thank each and every one of them. I have learnt more from them, than they from me.
I thank my patients who willingly gave their hands to me in the hope that I would completely
restore function in them. I have failed many times, but I assure all my patients that the lessons
learned during operation of their hands, will always be in my mind while operating on other
patients.
I thank God for putting me in the right place at the right times. I also thank the Almighty for
healing the wounds that I suture, moving the tendons that I repair, and giving life to the vessels
and nerves that I anastomose.
Contents
Section 1  General Considerations
1. Examination of the Hand 3

Seating the Patient 3; Communicating with the Patient 3; Eliciting the
History 4; Examination of the Patient 4
Section 2  Skin Reconstruction
2. Assessment of Skin Loss on the Hand 9

Assessment of the Raw Area 9; Assessment of the Patient 11
3. Littler’s Island Flap 12

Advantages 12; Disadvantages 12; Presurgical Counseling 12; Surgical
Steps 13; Postoperative Protocol 16
4. First Dorsal Metacarpal Artery Flap 18

Advantages of the Flap 18; Disadvantages of the Flap 18; Presurgical Coun-
seling 18; Surgical Steps 19; Postoperative Protocol 22
5. Reverse Dorsal Metacarpal Artery Flap 23

Advantages of the Flap 23; Disadvantages of the Flap 23; Presurgical Coun-
6. Posterior Interosseous Artery Flap 27

Indications 27; Advantages 27; Disadvantages 27; Presurgical Coun-
7. Radial Artery Forearm Flap 32

Advantages 32; Disadvantages 32; Presurgical Counseling 32; Surgical
Steps 32; Postoperative Protocol 35
8. Buried Abdominal Flap 36

Presurgical Counseling 36; Surgical Steps 36; Postoperative Protocol after
Flap Stage I 38; Postoperative Protocol after flap stage II 40
xii Manual of Reconstructive Hand Surgery
9. Vascularized Free Anterolateral Thigh Flap 41

Presurgical Counseling 41; Surgical Steps 41
Section 3  Other Post-traumatic Sequelae on the Skin
10. Adherent Scars and Contractures 49

Examination of the Scar 49; Management Protocol 50
Section 4  Tendon Reconstruction
11. Tendon Reconstruction—Assessment 53

Clinical Examination 56
12. Repair of Avulsed Flexor Tendon 57

Presurgical Counseling 57; Surgical Steps 58; Postoperative Protocol 60
13. Flexor Tendon Grafting 61

14. Staged Flexor Tendon Reconstruction 67

Presurgical Counseling 67; Surgical Steps 68
15. Flexor Tenolysis 74

16. Extensor Tendon Reconstruction 77

17. Extensor Indicis Proprius to Extensor Pollicis Longus Tendon Transfer 80

18. Flexor Digitorum Superficialis to Flexor Pollicis Longus Tendon Transfer 83

Section 5  Bone Reconstruction
19. Bone Reconstruction—Assessment 89

History 89; Deformity 89; Sinus 90; Abnormal Mobility 90
20. Open Reduction Internal Fixation of Fractures 91

Contents xiii
21. Bone Grafting 94

22. Vascularized Fibula Transfer 97

Presurgical Counseling 97; Surgical Steps 97; Vascular Anastomosis 100;
Postoperative Protocol 100
Section 6  Joint Reconstruction
23. Joint Reconstruction—Assessment 103

Clinical Examination 103; Planning the Management 104
24. Chronic Metacarpophalangeal Joint Dislocation Reduction 105

25. Arthrolysis 108

Arthrolysis of the Proximal Interphalangeal Joint of the Finger 108;
Arthrolysis of the Metacarpophalangeal Joint of the Finger 110
26. Vascularized Toe Metatarsophalangeal Joint Transfer 113

Presurgical Counseling 113; Preparation 113; Surgical Steps 114;
Recipient Site Dissection 115; Fixation of the Toe Metatarsophalangeal Joint
Flap 116; Postoperative Protocol 116
Section 7  Nerve Reconstruction
27. Nerve Reconstruction—Assessment 119
28. Nerve Reconstruction—Management 120

Approaches and Exploration 120; Nerve Repair 120; Nerve Grafting 122;
Postoperative Protocol 122
Section 8  Complex Post-traumatic Problems
29. Complex Post-traumatic Problems—Assessment 127

Priority of Management 127; Priority Lists 128
Section 9  Thumb Reconstruction
30. Principles and Decision Making in Thumb Reconstruction 133

Principles 133; Decision Making 134
xiv Manual of Reconstructive Hand Surgery
31. Procedures for Reconstruction of Type I Amputations 138

Transverse and Volar Oblique Amputations 138; Dorsal Oblique Amputations 139;
Oblique Amputation Type “A” 141; Oblique Amputation Type “B” 142
32. Procedures for Reconstruction of Type II Amputations 144

Staged Island Flap of Professor R Venkataswami 144
33. Procedures for Reconstruction of Type III Amputations 148

Osteoplastic Reconstruction 148; Vascularized Wrap-Around
Great Toe Transfer 151
34. Procedures for Reconstruction of Type IV Amputations 155

Vascularized Second Toe Transfer 155
35. Procedures for Reconstruction of Type V Amputations 159

Pollicization 159
Section 10  Tumors
36. Ganglion Excision 163

Salient Features of the Condition 163; Surgical Steps 163; Postoperative
P
rotocol 164
Section 11  Degenerative Conditions
37. Dupuytren’s Contracture—Assessment 167

History 167; Symptoms 167; Clinical Examination 167;
Staging 168; Planning The Management 168
38. Dupuytren’s Contracture—Management 169

Fasciectomy 169
Section 12  Infection
39. Hansen’s Disease and Sequelae 173

History 173; Clinical Examination 173
40. Opponensplasty with Flexor Digitorum Superficialis of Ring Finger 178

41. Opponensplasty with Abductor Digiti Minimi Muscle (Huber’s Transfer) 181
Contents xv
42. Claw Correction—Lasso Procedure 184

43. Claw Correction—Extensor to Flexor 4-Tailed Tendon

Transfer (Ef4t) Procedure 187
44. Claw Correction—Fowler Procedure 191

45. Tendon Transfer for Radial Nerve Palsy 194

Section 13  Congenital Disorders
46. Congenital Disorders—Assessment 201

Assessment Criteria—General 201; Assessment Criteria—Specific 201
47. Syndactyly 202

Assessment (Syndactyly) 202; Management Schedule 202;
Surgery (Syndactyly) 203
48. Cleft Hand 206

Assessment (Cleft Hand) 206; Simple Closure of the Cleft—Method of
Barsky 206; Release of Adduction Contracture of Thumb and Closure
of the Cleft (Method of Littler) 209; Postoperative Protocol 212
49. Trigger Thumb Release 213

Surgical Steps 213; Postoperative Protocol 214
50. Macrodactyly 215

Assessment (Macrodactyly) 215
51. Hypoplastic Thumb—Pollicization 219

Assessment (Hypoplastic Thumb) 219; Pollicization 219
Section 14  Common Clinical Conditions
52. Contractures on the Upper Limb—Assessment 227

Examination of the Contracture 227; Contracture of the Finger 227;
General Examination 228; Factors Affecting the Surgical Management 228;
Protocols for Resurfacing after Contracture Release on the Upper Limb 230
xvi Manual of Reconstructive Hand Surgery
53. Contractures on the Upper Limb—Management 231

Release of Contracture 231: z-plasty 232; Square Flap Method 234;
Five Flap Method of Thumb Web Release 236
Section 15  Adult Brachial Plexus Injuries
54. Adult Brachial Plexus Injuries—Assessment 241

Clinical Examination 241; Motor Examination 241; Sensory Examination 241;
Investigations 241; Documentation 241; Decision Making: What is to be
Done? 244; Decision Making: When is it to be Done? 245; Management Protocol
After Clinical Examination 246
55. Adult Brachial Plexus Injuries—Exploration 247

Presurgical Counseling 247; Position of the Patient 247; Preparation 248;
Markings 248; Tumescent Infiltration 248; Surgical Steps 248;
Decision Making 250; Management Protocol after Exploration 252
56. Adult Brachial Plexus Injuries—Nerve Surgery 253

Spinal Accessory Nerve Transfer 253; Intercostal Nerve Transfer 254;
Oberlin Transfer 254; Contralateral C7 Transfer 256
57. Adult Brachial Plexus Injuries—Muscle Transfer 259

Pedicled Latissimus Muscle Transfer for Elbow Flexion 259
58. Obstetric Brachial Plexus Palsy—Assessment 262

Muscle Power Grading 262
59. Obstetric Brachial Plexus Palsy—Management 264

Mod Quad Procedure 264
60. Volkmann’s Ischemic Contracture—Assessment 267

Planning the Sequence of Surgical Procedures 267
61. Volkmann’s Ischemic Contracture—Management 270

Exploration 270; Tendon Lengthening 272; Muscle Slide Operation 273;
Tendon Transfer—FDS to FDP 274; Tendon Transfer— Brachioradialis to
FPL and ECRL to FDP 275
62. Vascularized Gracilis Muscle Transfer 278

Advantages 278; Disadvantage 278; Surgical Steps 278
Contents xvii
Section 16  Difficult Hand Problems
63. The Mutilated Hand 285

Terminal Mutilation 285; Sequence of Surgery 287
64. Vascularized Double Toe Transfer 288

Indications 288; Preparation 288; Surgical Steps 278; Recipient Site
Dissection 290; Fixation of the Double Toe Flap 291
Section 17  Appendices
Appendix I: Preparation for Hand Surgery 295

Preparation and Draping of the Hand 296
Appendix Ii: Preparation for a Free Flap 297

Preparation Before the Patient is brought to the Operation Theater 297;
Preparation While Anesthesia is being Delivered 297; Preparation after
the Anesthesia has been Delivered 297
Appendix Iii: Preparing Instrument Sets for Use in Hand Surgery 299
Preparing Instrument Sets 299; Microsurgery Instruments Tray 300
Appendix Iv: Harvesting a Sural Nerve Graft 301
Appendix V: Harvesting a Skin Graft 302
Appendix Vi: Harvesting an Ulnar Bone Graft 304
Appendix Vii: Harvesting a Palmaris Longus Tendor Graft 305
Appendix Viii: Harvesting a Fascia Lata Graft 306
Section 18  Proformas
I: Microsurgery Recording Chart 309
II: Brachial Plexus Injury Evaluation 310
III: Contracture of Upper Limb 312

Proforma for Assessment of Contracture on Upper Limb
xviii Manual of Reconstructive Hand Surgery
IV: Dupuytren’s Contracture Evaluation 314
V: Volkmann’s Ischemic Contracture Evaluation 315
VI: Bone Problem Evaluation 316
VII: Joint Problem Evaluation 318
VIII: Tendon Injury Evaluation 320
Index 321
Introduction
When the patient presents in the outpatient room and seeks consultation, he is harboring a lot
of hopes and aspirations; expects his hand to get back to normal after treatment.
It is the bounden duty of the hand surgeon to fulfill the expectations of the patient as far as
possible. At the same time, the practical outcomes should be explained to the patient.
The diagnosis is obvious. For example, the diagnosis of brachial plexus injury may be made
quite easily within a minute of meeting the patient. Similarly, conditions, such as post burn
contractures can be diagnosed even by just looking at the patient. So, it is not the diagnosing
that is required or important in the hand surgery. What is required is the workup of the patient
that will lead surgeons to make a plan for management. This plan should take into account a lot
of factors, such as sex of the patient, occupation, side involved, and even the age of the patient.
This book is compiled with these aims.
This is not a textbook, but a practical guide for the nascent hand surgeons. The book will
help the hand surgeons to conduct a rehearsal in the mind the day before the surgery.
In making assessment of hand-injured patients, a lot depends on the type of tissue injured,
such as skin, bone or tendon. So, the main part of the book is devoted to the management of
such conditions involving the different tissues in different sections.
This book contains 18 sections. Each section has three segments:
1. The first segment is on assessment of the problem, so that a correct understanding of the
situation can be made. Based on this, the decision can be made about the management
protocol.
2. The second segment deals with presenting a simplified management protocol, which will
be deduced from the needs of the patient and the findings made on assessment of the
problem in the previous segment. It will not give all the options, but the one that is most
useful and what is routinely used.
3. The third segment describes the main surgical procedures enumerated in the management
protocol. Just reading through this segment will not be enough qualification to perform the
procedure. The surgeon must know the technique by reading about it first from a standard
textbook, then watching, and then assisting at the surgical procedures being performed by
a qualified surgeon. When the surgical procedure is being done, this manual will help:
• By giving a simplified description of the steps of the surgery
• By listing out the steps and thus avoiding missed steps
• By giving useful tips at various steps
• By suggesting troubleshooting measures in cases of probable difficulties
• By giving warning about difficult steps.
xx Manual of Reconstructive Hand Surgery
The section 15 deals with common hand conditions faced by the hand surgeons and also
pose problems in both assessment and planning. Examples are brachial plexus injuries and
Volkmann’s ischemic contractures. Such conditions are also dealt with in three segments.
At the end, there are two useful sections: Appendices and Proformas.
The section on appendices gives instructions on useful day-to-day procedures. Starting
from how to prepare for the hand surgery and how to set up the infrastructure before a
microsurgical procedure. This section also gives a list of instruments and equipment required
in an operation theater to start the hand surgery and microsurgery. These are used in various
hand surgery procedures, and include harvesting skin grafts, nerve grafts, etc.
The section on proformas gives many forms that can be used in the outpatient block when
the patient is being examined. These forms are based on the assessment parameters of the
individual conditions and ensure that all the parameters are assessed without missing any
detail. They may also serve as databases containing all the relevant details that can be used in
any retrospective study.
So, this is a cook book!

• Starting from the patient entering the outpatient block—practical steps to deal with the
situations
}
• How to diagnose
• How to decide what to do in the section Assessment
• How to decide time for doing procedure
• Preoperative counseling
• How to prepare for the procedure
• How to do the procedure
• How to follow-up the patient } in the section on Procedure
Knowing all the procedures described here will not make a complete hand surgeon. He/she
must know all the other procedures and the methods of doing them.
SECTION
General
Considerations
Examination of the Hand
1
When the patient presents in the outpatient where the patient-doctor relationship is
clinic, there is a set protocol to be followed. significant for many reasons:
• Deciding the management depends on
multivarious factors ranging from the
Seating the Patient age, occupation, needs of the patient
and sometimes even what the patient
• If the patient is an adult, he is first asked to be wants. The surgeon can get a clear idea
seated comfortably, preferably on the right about the patient only if the patient is
side of the examiner. This position is more able to communicate freely and without
comfortable for conducting the examination. fear or apprehension.
• If the patient is a child, the child can be • Many of the procedures require a long
more comfortably examined if he is on his follow-up period. Only if the patient is
mother’s or grandmother’s lap. able to communicate with the surgeon
• If the patient is an infant, he can be made to and vice-versa, this may be possible.
lie on the examination couch with adequate • Some of the surgical procedures
protective pillows on either side. If the baby require multiple stages and the entire
is fidgety, he can be held by his mother or reconstruction may take several months.
grandparent on the shoulder and the child’s It is important that the patient trusts the
hands can be examined from behind. The surgeon and attends each surgical stage.
complete examination of the baby may not • Some of the procedures like micro
be possible in one consultation, especially surgical toe transfers require the
in cases like birth palsy. This is because, this transfer of one normal part of the
condition will show changes with time, and body to another part which has been
these changes should be tracked religiously. lost. Hence, there exists a small risk
It will require serial consultations before a of failure and the consequence is that
definite diagnosis and plan of management the patient loses another part of his
may be made. body due to the surgical procedure. It
is the responsibility of the surgeon to
talk to the patient about this and it is
also important for the patient to have
Communicating with the Patient trust in the surgeon if he agrees for the
procedure.
• Developing a rapport with the patient • Some procedures like neurotization
is a very important part of the initial procedures for brachial plexus injury
examination. Hand surgery is a specialty may have a long period before any
4 SECTION 1 GENERAL CONSIDERATIONS
change can be manifest. This should be appropriate examination is conducted.

informed to the patient and the patient Sometimes, the involvement is not restricted
will be able to understand this only if to one tissue alone like tendon or bone. It
the bond with the surgeon is strong. may encompass different tissues and all
• Legible language should be used when these should be identified in the preliminary
communicating with the patient. It is ideal examination. There are a few pointers which
that the conversation takes place in the will help surgeon to identify the problem.
patient’s native language. This is because Then the assessment of the problem is
the patient must be able to understand made as described in the appropriate chapter:
correctly what is required of him. When the • If there is a raw area → go to chapter on raw
hand is being tested for specific movements areas on skin
and the action of specific muscles, surgeon • If there is evidence of adherent skin or scar
should give clear instructions as to how → go to chapter on other problems of skin
the movement should be done, and if • If there are no movements in parts of the
necessary, demonstrate it on his own hand or movements of the finger are not
hand, before the patient is asked to do it. full → go to chapter on tendons and nerves
• If the patient is a child, the pros and cons of to identify the problem
the treatment options must be discussed • If movements lost and sensation lost → go
with the parents of the child if possible, or to chapter on nerves
the guardians of the child. • If there is a deformity of bone, or abnormal
mobility is present in the area of bone → go
to chapter on bone assessment
• If there is no movement at a joint → go to
Eliciting the History chapter on joints
• If there is a postburn contracture → go to
As in any medical examination, the history chapter on contractures
plays an important role. In patients with hand • If there is a paralysis/weakness of the hand
injury, there are a few points to be emphasized alone → go to chapter on Hansens
while eliciting the history. The general points • If there is a history of injury in the neck
are discussed here, but there are specific or shoulder area, and there is some loss
details required in different conditions which of movements in the upper limb → go to
will be dealt with in the relevant sections. the section on traumatic brachial plexus
• Nature of complaints injuries
• Duration of complaints • If there is a history of no movements of the
• Exact date of injury if any upper limb noticed immediately after birth
• History of previous treatment → go to the chapter on obstetric brachial
plexus injuries to help in evaluation and
management.
• If there is evidence of involvement of
Examination of the Patient multiple tissues like skin and tendon,
or tendon and bone, the sequence of
This book has described in detail, the management is described in the chapter
examination of the different tissues of the on complex post-traumatic problems.
hand, such as skin, bone, tendon, nerve, etc. • If there is a problem of the thumb, it
So it is mandatory that a preliminary diagnosis is dealt with in the chapter on thumb
be made of the tissue involved before the reconstruction.
CHAPTER 1 EXAMINATION OF THE HAND 5
And, based on the assessment, the plan of physiotherapy, splints, and surgical procedures
surgery can be made. This is also described in either in multiple stages or in a single stage.
the same chapter as the assessment. A logical sequence of management should
No clinical diagnosis is complete without be made which should suit the needs of the
making a plan of the sequence of management. patient, and which will result in a useful
There are many modalities of management, like function on the involved hand.
SECTION
Skin Reconstruction
Assessment of
Skin Loss on the Hand 2
The surgical procedure that is planned for the
Introduction patient ideally:
• Must be a single-staged procedure
This chapter refers to skin loss and raw areas
• Must have minimal or no donor site
that are not seen in the emergency situation,
morbidity
but at a time that is beyond the stage of
• Must have only a negligible risk factor
primary reconstruction.
• Should be easy to perform.
Resurfacing an area of skin loss is a
common problem for a hand surgeon. The
causes leading to skin loss on the hands are
very much, the most common being trauma.
Assessment of the Raw Area
Other causes include burns including electrical Site of the defect: The exact location of the
burns and infections. There are other situations defect must be noted. Defects in different
like tumors, burn contractures and congenital areas require different types of skin cover. A
anomalies where skin loss becomes apparent defect on the pulp of the thumb requires a
after the condition is operated on. Such skin cover that is sensate to allow the thumb
conditions will be dealt with later. This chapter to function normally. However, there are
deals with apparent raw areas that need skin certain flaps that are designed for typical
cover. defects. Raw areas on the volar aspect of the
Before planning for treatment of a raw fingers can be covered with cross-finger flaps
area on the hand, a systematic assessment from the adjoining finger.
is required. Only a correct evaluation of the Size of the defect: The size of the defect is
problem can lead to a suitable surgical option important for planning a skin cover. Small
being chosen as management. Achieving a defects may be covered with local flaps. If,
good skin cover on the hand is not the goal, however, the defect is larger, other flaps may
but achieving good function in the hand is have to be thought of.
the ultimate aim. All our efforts in choosing
a skin cover must be focused on the issue of Shape of the defect: The direction and shape of
achieving function. the defect can also influence the plan.
Qualities of an ideal skin cover for a defect on Floor of the defect: If the floor of the defect
the hand: exposes bone or tendon, a vascularized skin
• Must be durable skin cover is required.
• Must be cosmetically pleasing Edges of the defect: The edges of the defect
• Must be sensate are important in deciding on the plan of skin
• Must be pain-free. cover. If the edges are unhealthy or macerated,
10 SECTION 2 SKIN RECONSTRUCTION
the skin cover planned should be larger than 100 percent inset is given, i.e. the flap
the actual defect itself as the debridement of completely covers the defect and no area is
unhealthy tissues is of paramount import exposed to the environment. Simultaneous
ance. If the edges are everted or rolled out, reconstruction of the tendons can also
suggesting a malignancy, the total plan may be done if a pedicled island flap like the
be different. radial artery forearm flap or a posterior
Distal deficit: A careful assessment of the interosseous artery flap is used for skin
distal finger or hand must be made. cover as these flaps also provide total inset.
1. Associated tendon injury or loss: If there 2. Associated bone fracture with or without
is an associated injury or loss of tendon; loss: Skeletal stability is essential before
either flexor or extensor, the skin flap planning a skin cover. However, if there is
should be given first and the tendon a fracture, internal fixation through a raw
reconstruction can be done later when area is not prescribed. But stability must
the skin flap has settled and become soft be achieved and this can be done by the
and supple. Simultaneous reconstruction use of external fixators that can stabilize
of the tendons also along with the skin the skeleton when the skin cover is given.
cover is done only in situations where the When there is a bone loss, primary bone
skin flap that has been planned is a free grafting is not advised and must be done at
flap like the anterolateral thigh flap where a later date after the skin reconstruction is
Table 2.2.1 Assessment of raw area and surgical plan

Site of raw area Characteristic Surgical plan
Single finger Defect on volar aspect alone Cross-finger flap (CFF)
Defect on dorsal aspect alone Reverse dorsal cross-finger flap (RDCFF)
Defect on dorsum of PPX alone Reverse dorsal metacarpal artery flap
Multiple fingers Defect on volar aspect alone Abdominal flap-superiorly based
Defect on dorsal aspect alone Abdominal flap-inferiorly based
Thumb Skin loss on the pulp Neurovascular island flap of littler
Skin loss on the dorsum up to the First dorsal metacarpal artery flap
interphalangeal (IP) joint
Loss of thumb or circumfer- Groin flap
ential loss on the fingers
Skin loss on the dorsum of With less expertise Abdominal flap-inferiorly based
hand
With more expertise Posterior interosseous artery flap
Skin loss on the palm With less expertise Abdominal flap-superiorly based
With more expertise Reverse flow radial artery flap
End-on defect On the thumb Staged island flap of Professor R
Venkataswami
On multiple fingers End-on groin flap
Large defects on the hand With less expertise Quadrant flap
With microsurgical expertise Free anterolateral thigh flap
Degloving injury of the Buried abdominal flap
entire hand and fingers
CHAPTER 2 ASSESSMENT OF SKIN LOSS ON THE HAND 11
over. In the meantime, to achieve stability, • Very anxious patients: Select a safe and
external fixators can be applied. Primary time-tested flap. Leave very little margin
reconstruction of the skin and bone can be for failure or complications.
done if a free flap or pedicled island flap is • Mentally unsound patients: Select a single-
planned as skin cover. staged flap. Choosing a staged flap like
3. Associated nerve injury or loss: This should be the groin or abdominal flap may result in
reconstructed after the skin reconstruction complications as the patient will not be
is over unless a free or pedicled island flap is compliant.
used as skin cover. • Children: Usually are very compliant for
Table 2.2.1 shows the assessment of raw even pedicled flaps like groin or abdominal
area and surgical planning. flaps.
• Elderly patients: Avoid staged procedures.
The commonly used flaps like the cross finger flap, These may cause stiffness of joints. Select
abdominal flap and groin flap are not discussed in the simplest procedure.
this manual. Always talk to the patient about the procedure,
the postoperative period and possible out
come. Get their full consent before embarking
Assessment of the Patient on the surgery. Even if the patient is a child
of school going age, talk with him. Their level
Certain points are to be remembered when of understanding will sometimes surprise
deciding on skin cover: surgeon!
Littler’s Island Flap
3
• This procedure will be done under axillary
Introduction block anesthesia or GA in children.
• This procedure will take about 3 hours to
The flap of choice for the reconstruction of
perform.
a defect on the pulp region of the thumb is a
• Skin will be removed along with soft
neurovascular island flap described by Littler.
tissues from the middle finger and placed
on the raw area of the thumb. This will
entail making incisions on the palm also.
Advantages A skin graft will be taken from the medial
side of the upper arm and applied over the
• It brings partly glabrous skin to the pulp of secondary raw area on the middle finger.
thumb which is well padded, durable and There will be a loss of sensation on one
cosmetically appealing. side of the middle finger and there will be a
• It is sensate and hence the function of the scar on the finger. There will also be a scar
thumb is not interfered with. on the medial side of the arm.
• It is a single staged procedure. • Admission will be necessary for a mini-
mum period of 3 days
• A dressing will be applied and a plaster
Disadvantages of Paris (POP) will be applied, which
will be retained for 10 days, following
• It requires a surgical expertise in performing which, physiotherapy will be started.
this procedure. At the beginning, when the thumb is
• It entails significant donor site morbidity— touched, it will feel as if the middle finger
there is loss of sensation on the ulnar half is being touched. During the period of
of the middle finger, there is a significant physiotherapy, techniques will be taught
scarring on the middle finger. to make the sensation more natural. The
• Sensory re-education is necessary to get sensation that returns may not be equal to
appreciable sensation on the flap. the sensation on the normal thumb.
• A splint will have to be applied on the
ring finger for a period of 3 to 4 weeks
Presurgical Counseling afterward.
• In some instances, the flap may not be
• This procedure is planned to cover the raw possible because of anatomical variations.
area on the thumb with skin and tissues In such cases, other surgery like a cross-
with sensation. finger flap may be done.
CHAPTER 3 LITTLER’S ISLAND FLAP 13
• The general complications of local anesthetic

infiltration like hypersensitivity may occur
in spite of test dose application. This
complication will cause dryness of mouth
and apprehension, which can be corrected
immediately.
Surgical Steps
1. The preferred anesthesia is either axillary
block or general anesthesia (in children).
2. Apply the tourniquet and keep ready.
3. Preparation and draping as described in
Appendix I.
4. The elbow area must also be prepared and
kept exposed. Fig. 2.3.1 Markings for the flap
5. Raise the tourniquet and note the time.
6. Debride the defect and measure it. Make
sure that the edges consist of intact and
healthy skin. Take a lint pattern of the
defect.
Take the marking of the flap about 0.25 cm more

on all sides as this is a thick flap and may be too
tight if measurements are taken exactly.
7. Markings for the flap:

• Draw a line from the ulnar border of
the radially abducted thumb exten
ding into the palm. Draw another
longitudinal line from the web between
middle and ring fingers proximally into
the palm. The point at which these two
lines intersect is point “A”, the pivot
point of the flap
• Place the lint piece of the defect over
the defect and cut a lint pedicle up to
point “A” (Fig. 2.3.1).
Fig. 2.3.2 Markings on the dorsum of finger
• Holding the lint at point “A”, transpose
the lint of the defect to the middle
finger on the ulnar side. It should not should not go beyond the mid volar
go beyond the distal interphalangeal line or the mid dorsal line (Fig. 2.3.2).
(DIP) crease of the middle finger Distally, surgeon should remember
• The flap can now be marked on the that the nail bed extends for 3 to 4 mm
middle finger ulnar side keeping in proximal to the nail fold, hence the flap
mind the following criteria: the flap should not go beyond this area
• From the proximal border of the flap, supply the middle and ring fingers. Gently
make a marking on the ulnar neutral tease the tissues between the two branches
line till the web area to reach point “B”. of the common digital nerve and keep
• Now draw the axis of the flap, i.e. from separating them proximally. Never dissect
point “A” to point “B”. However, this between the digital artery and the nerves.
should not be a straight incision, as Dissect only to separate the ring finger
it will lead to a straight line scar that digital nerve away from the bundle. Again
may lead to a contracture. It should it is reiterated that dissection should never
be a zigzag line marked with two be done between the digital artery and
considerations: (1) the axis of the flap the digital nerve to the middle finger as
and (2) the transverse creases on the it damages the minute veins that serve as
palm. From point “B”, move at an angle venous drainage for the flap. Stop when
of 30° to the nearest transverse crease, the digital nerve of the ring finger has
run along the crease till you cross the been separated up to the pivot point. Now
axis line. Now, again move to the next cauterize gently the small branches from
proximal transverse crease and when the digital artery to the deeper tissues.
you reach it, run along the crease till Now the neurovascular bundle has been
you cross the axis line. Then move dissected free in the palm. The pad of fat in
directly to point “A”. This is the marking the web space must be carefully teased to
for the incision. expose the bifurcation of the proper digital
8. First make the incisions marked from “A” artery into the branches to the middle and
to “B”. This incision should go through ring fingers. Ligate and cut the branch to
the skin and the subcutaneous tissue, till the ring finger a few millimeters from the
the palmar aponeurosis is seen. Lift up bifurcation.
this thick fascia with a forceps and open
it with a knife. The neurovascular bundle Take great care in preventing damage to the vessel
is directly below this fascia, hence this or excessive handling of the vessels as it may lead
step must be done carefully. This should to spasm of the vessel.
be done along the entire length of the
marked axis of the flap. Remember that 10. Now the flap can be raised. Make the
the distal 2 to 3 cm of the palm will not first incision on the mid-volar side. This
have a palmar aponeurosis. When this incision must be down to the fibrous
step is over, the neurovascular bundle flexor sheath. There are a few transversely
will be exposed in the proximal 2/3 of the oriented subcutaneous volar veins at this
wound. Place a small gauze soaked in 1 area which must be cauterized. The volar
percent xylocaine over the neurovascular portion of the flap can be raised now, up to
bundle to prevent the vessels from going the neutral line. The next incision should
into spasm. There will be about 4 to 6 be made on the dorsal side down to the
triangular flaps that must be raised and extensor paratenon and the dorsal portion
anchored with 3.0 ethilon to enhance the of the flap raised. Now the distal margin
exposure and facilitate further dissection. of the flap incised and the neurovascular
9. The dissection of the vascular pedicle bundle ligated with 3.0 vicryl and cut. The
begins here. Gently hold the soft tissues flap is now attached by the Grayson’s and
around the neurovascular bundle with Cleland’s ligaments. To divide these, the
a Jeweler’s forceps and examine the flap must be lifted up, the neurovascular
anatomy. One digital nerve and one digital bundle confirmed to enter the flap and
artery will be seen. The digital nerve will the ligaments must be divided close to the
be seen to divide into two branches to bone. This will free the flap some more.
11. Now make the incision marked on the

ulnar neutral line and the marked proximal
border of the flap. Care should be exercised,
as the neurovascular bundle is deep to this
area. Gently free the neurovascular bundle
from the fibrous attachments and the
multiple small branches coursing into the
web. Now the flap is totally free, attached
only at the pivot point “A” (Fig. 2.3.3).
12. Gently move the flap to the defect over the
skin to check whether it reaches the defect
comfortably (Fig. 2.3.4). If it does not, a
little more dissection of the pedicle is in
order.
13. Now develop a subcutaneous tunnel
between the proximal edge of the defect
and the pivot point of the flap. This tunnel
should be created with the help of a tendon
tunneller. The plane of the tunnel should
be superficial to the palmar aponeurosis.
This tunnel should be wide enough to Fig. 2.3.3 Dissected flap
hold the flap as it passes through, without
traumatizing it.
14. Apply a stitch with 3.0 vicryl on the leading
edge of the flap.
15. Apply wet gauze on the bed of the flap,
xylocaine soaked gauze on the pedicle of
the flap. Raise-up the hand and release the
tourniquet. Maintain the hand in elevated
position for about 3 minutes and ask for
the tourniquet to be removed entirely.
16. Now set the hand on the table and examine
the edges of the flap. There should be a
slow and sustained subdermal bleed. This
may not be evident immediately. It may
take a few minutes for the spasm of the
vessel to be relieved. In the meantime,
continue to bathe the pedicle with
1 percent xylocaine solution and achieve
hemostasis on the bed of the flap and the
primary defect.
Fig. 2.3.4 Checking the reach

If there is no bleeding from the flap edges, look for
the following problems and correct them:
• Any twist or kink in the vascular pedicle
17. When good bleeding is seen from the
• Any ligature of a branch that is too close to the edges of the flap, it is ready for transfer.
vessel. 18. Pass a heavy curved hemostat from the
proximal edge of the primary defect
through the tunnel. Grasp the 3.0 vicryl 20. Management of the donor area: After
stitches that have been applied on the confirming hemostasis, the palmar flaps
leading edge of the flap. Gently pull the should be replaced and sutured with
hemostat with fine rocking movements 4.0 ethilon. The residual raw area on the
and deliver the flap at the site of the defect. middle finger should be covered with a
If it is difficult, redo step number 13. After split thickness skin graft. At the points
delivering the flap in the wound site, where the defect crosses the proximal
confirm the viability of the flap. If there interphalangeal (PIP) and DIP joint
is reduced bleeding from the edges of the creases, back cuts should be given for
flap, the tunnel is most probably tight at 3 mm. to avoid skin graft contractures
the proximal edge which can be vented later on. Now raise the hand and prepare
with a small incision of about 2 to 3 mm. the arm with betadine solution. The skin
graft should be harvested from the medial
side of the arm. Sterile dressings should be
This flap is usually a robust flap and there will be
applied over the skin graft donor site before
very brisk bleeding from the edges, especially after
transfer. This is because the venous drainage takes moving back to the hand. The graft should
time to regularize. So, get hemostasis on the edges be applied over the raw area and tie over
of the flap before applying the insetting sutures! sutures applied with 3.0 ethilon. Drainage
tubes should be kept below the suture line
on the palm of the hand. The preferred
19. Flap inset: After confirming the hemostasis drainage tube would be Segmüller tube
and the viability of the flap, inset can be which consists of segments of the scalp
done with 4.0 ethilon using half buried vein set tubing.
horizontal mattress suturing (Fig. 2.3.5). 21. Sterile dressings should be applied over
the hand and the forearm. Care must be
taken to avoid compression of the pedicle
at any point of its course. A finger dressing
must be applied on the middle finger
and a short straightening splint should
be applied on the volar side of the finger.
A dorsal POP slab should be applied for
the thumb keeping the wrist in neutral,
and the metacarpophalangeal (MCP)
joint of the thumb in flexion of 20º and
interphalangeal (IP) joint in extension.
A window must be made in the dressings
to allow inspection and monitoring of the
flap.
Postoperative Protocol
• Admission in the ward
• The affected hand should be kept elevated
• Patient can take normal diet immediately
if the procedure was under regional block
Fig. 2.3.5 After final flap inset and donor site or after complete recovery if under general
closure with skin graft anesthesia
• Clinical monitoring of the flap once every • Refer to physiotherapy for active and
6 hours passive mobilization of the thumb and
• Analgesics and antibiotics for 5 days fingers
• Sedation sos for 1 day • Daily wash with soap and water
• Inspection of the dressing after 48 hours • Massage of scar and grafted skin with
• Discharge of the patient by 3rd day coconut oil.
• Suture removal on the 10th day and • Compression garment for scar softening
removal of donor site dressing on the arm after a further 2 weeks
• Removal of the POP slab on the 14th day • Sensory re-education exercises by
and advice the following: physiotherapist.
First Dorsal
Metacarpal Artery Flap 4
Introduction block anesthesia or GA in children.
First dorsal metacarpal artery flap is the flap
perform.
of choice for defects on the dorsum of the
• Skin will be removed along with soft
thumb not extending beyond the level of the
tissues from the index finger and placed on
interphalangeal (IP) joint. The flap is based on
the raw area of the thumb. This will entail
the first dorsal metacarpal artery that usually
making incisions on the back of the hand
arises from the radial artery at the level of the
also. A skin graft will be taken from the
anatomical snuffbox.
medial side of the upper arm and applied
over the secondary raw area on the index
finger. There will be no deficit on the index
Advantages of the Flap finger, but there will be a scar on the finger.
There will also be a scar on the medial side
• It is a single-staged procedure of the arm.
• It is a sensate flap (because it is neurotized • Admission will be necessary for a
by the branches of the superficial branch minimum period of 3 days.
of the radial nerve) • A dressing will be applied and a plaster
• Minimal morbidity in terms of donor site of Paris (POP) will be applied, which
scarring. will be retained for 10 days, following
which, physiotherapy will be started. The
sensation that returns may not be equal to
Disadvantages of the Flap the sensation on the normal thumb.
• A splint will have to be applied on the index
• It is not very reliable (because of finger for a period of 3 to 4 weeks afterward.
inconsistent anatomy) • In some instances, the flap may not be
• It requires expertise to raise this flap possible because of anatomical variations.
• An alternate plan must always be ready. In such cases, other surgery like an
abdominal flap may be done.
• The general complications of local
Presurgical Counseling anesthetic infiltration like hypersensitivity
may occur in spite of test dose application.
• This procedure is planned to cover the raw This complication will cause dryness of
area on the thumb with skin and tissues mouth and apprehension, which can be
with sensation. corrected immediately.
CHAPTER 4 FIRST DORSAL METACARPAL ARTERY FLAP 19
Surgical Steps
1. The preferred anesthesia is either axillary
block or general anesthesia (in children).
2. Apply the tourniquet and keep ready.
3. Preparation and draping as described in
Appendix I.
4. Raise the tourniquet and note the time.
5. Debride the defect and measure it. Make
sure that the edges consist of intact and
healthy skin. Take a lint pattern of the
defect.
6. Markings for the flap:
• Take the lint pattern and mark the
flap on the dorsum of the proximal
phalanx region of the index finger, just
beyond the level of the knuckle. This
is the “business end” of the flap. This
flap is marked like a cross-finger flap.
The distal limit of this flap is the dorsal Fig. 2.4.1 Markings for the flap
proximal interphalangeal (PIP) joint
line, the radial and ulnar limits are the reduces the distance between the pivot
respective neutral lines. point and the defect.
• Mark a point exactly at the junction of 7. Make the incision over the S-shaped line
the I metacarpal and the II metacarpal from “A” to “B”. This incision should be
on the dorsum of the hand distal to the only up to the dermis level, i.e. the incision
anatomical snuffbox. This is point A— should be made only to the depth where
the pivot point. This is the point where the underlying fat is just seen. Apply two
the first dorsal metacarpal artery arises skin hooks on the same side and elevate the
from the radial artery. dermal flaps on the radial side and then on
• Now mark the line of the II metacarpal the ulnar side. The flap should be raised on
bone on the skin. the radial side almost till the free margin of
• Now mark a point on the radial side of the thumb web and the I metacarpal bone.
the knuckle of the index finger. This is The flap on the ulnar side should be raised
point B (Fig. 2.4.1) This point should lie up to the entire length of the II metacarpal
on the proximal border of the marked bone. Remember that the surgeon will not
flap and should also be radial to the encounter the extensor tendons by this
distal end of the II metacarpal bone. dissection. Anchor the dermal flaps with
• Join the points “A” and “B” with a 3.0 nylon.
gentle S-shaped line. This S-shaped 8. Now, what is exposed will be the
line will have two curves: (1) a curve subcutaneous tissue between the I and II
convex toward the radial side and (2) metacarpal bones with the subcutaneous
a curve convex toward the ulnar side. veins and the branches of the superficial
When marking the S-shaped line from radial nerve. Make an incision on the
the point “A” to “B”, make sure that ulnar border of this tissue right over the
the curve convex to the radial side II metacarpal bone, extending along
is proximal and the curve convex to the entire length of the bone. Raise this
the ulnar side is distal. This method “flap” of subcutaneous tissue gently.
Underneath, the fascia covering the first dorsal interosseous tendon and the fascia
dorsal interosseous muscle can be seen. over this muscle with the first dorsal
Incise this fascia at its attachment to the metacarpal artery on its undersurface
II metacarpal bone. When this fascia is and subcutaneous tissue containing the
raised, the first dorsal metacarpal artery subcutaneous veins and the branches of
can be seen coursing on its undersurface the superficial radial nerve. Now, the flap
and the first dorsal interosseous muscle has been raised totally (Fig. 2.4.2).
belly can be seen. 14. Now, develop a subcutaneous tunnel
between the proximal edge of the defect
Try to include as many veins in the flap as possible. should be created with the help of a
This will ensure good venous drainage of the flap. tendon tunneller. This tunnel should be
wide enough to hold the flap as it passes
through, without traumatizing it.
9. Make an incision on the radial border of the 15. Apply a stitch with 3.0 vicryl on the leading
subcutaneous “flap” of tissue at the radial edge of the flap.
border of the first dorsal interosseous 16. Apply wet gauze on the bed of the flap,
muscle. xylocaine soaked gauze on the pedicle of
10. Now, make the incisions on the proximal the flap. Raise-up the hand and release the
phalangeal region of the index finger as tourniquet. Maintain the hand in elevated
marked. The distal, radial and ulnar edges position for about 3 minutes and ask for
should be incised down to the extensor the tourniquet to be removed entirely.
paratenon (as is done for a cross-finger 17. Now, set the hand on the table and examine
flap). When this is done, the flap will the edges of the flap. There should be a slow
be attached only by the entire proximal and sustained subdermal bleed. This may
border which has not been incised.
11. Make the incision of the proximal border
as dermal flaps. Anchor these flaps too
with 3.0 nylon.
12. Now, continue the incision made on
the radial border of the first dorsal
interosseous fascia in a distal direction.
In this way, the radial side extensor
expansion of the index finger will be
encountered. Incise through this structure
distally till the metacarpophalangeal
(MCP) joint is crossed. This step ensures
that the terminal end of the first dorsal
metacarpal artery is not damaged during
the dissection, as the tongue of extensor
expansion protects it.
13. Now, the flap is lifted with skin hooks
and raised off the bed. It will be noted
that the distal portion of the flap contains
only skin and subcutaneous tissue,
proximally, it contains a segment of the
extensor expansion and even further
proximally, the superficial part of the first Fig. 2.4.2 Flap being raised
CHAPTER 4 FIRST DORSAL METACARPAL ARTERY FLAP 21
not be evident immediately. It may take a

few minutes for the spasm of the vessel to
be relieved. In the meantime, continue to
bathe the pedicle with 1 percent xylocaine
solution and achieve hemostasis on the
bed of the flap and the primary defect.
edges of the flap, it is ready for transfer.
18. When
If there good
is no bleeding
bleeding from the is edges
seen offrom the
the flap
even afterof
edges the waiting
the flap, itperiod,
is readymostforprobably,
transfer.the
flap may not survive. Now, the decision must be
made whether to retain the flap and wait for a few
days (which can be done if there is some bleed
from the edges) or totally excise the flap, cover
the donor site with a skin graft and plan for an
abdominal flap cover for the primary raw area on
the thumb.
19. Pass a heavy curved hemostat from the

proximal edge of the primary defect through
the tunnel. Grasp the 3.0 vicryl stitch that Fig. 2.4.3 After flap inset
has been applied on the leading edge of
the flap. Gently pull the hemostat with fine
rocking movements and deliver the flap at raise the hand and prepare the arm with
the site of the defect. If it is difficult, redo betadine solution. The skin graft should
step number 14. After delivering the flap be harvested from the medial side of the
in the wound site, confirm the viability of arm. Sterile dressings should be applied
the flap. If there is reduced bleeding from over the skin graft donor site before
the edges of the flap, the tunnel is most moving back to the hand. The graft should
probably tight at the proximal edge which be applied over the raw area and tie over
can be vented with a small incision of about sutures applied with 3.0 ethilon. Drainage
2 to 3 mm. tubes should be kept below the suture line
20. Flap inset: After confirming the hemostasis on the dorsum of the hand. The preferred
and the viability of the flap, inset can be drainage tube would be Segmüller tube,
done with 4.0 ethilon using half-buried which consists of segments of the scalp
horizontal mattress suturing. vein set tubing.
21. Management of the donor area: After 22. Sterile dressings should be applied over
confirming hemostasis, the gap in the the index finger, dorsum of hand and
extensor expansion should first be the thumb. Care must be taken to avoid
repaired primarily with 4.0 polypropylene compression of the pedicle at any point
materials using horizontal mattress of its course. A volar POP slab should be
suture. The dermal flaps should be applied for the thumb keeping it in palmar
replaced and sutured with 4.0 ethilon. abduction and another slab for the hand
The residual raw area on the dorsum of keeping the MCP joints of the fingers in
the index finger should be covered with a flexion of 90º and IP joints in extension.
split thickness skin graft (Fig. 2.4.3). Now A window must be made in the dressings
to allow inspection and monitoring of the • Clinical monitoring of the flap once every
flap. 6 hours
• Analgesics and antibiotics for 5 days
• Sedation sos for 1 day
If there is evidence of reduced blood flow in • Inspection of the dressing after 48 hours
the flap postoperatively, the sutures should be
removed immediately and all tension released
• Discharge of the patient by 3rd day
from the suture line.
• Suture removal on the 10th day and removal
of donor site dressing on the arm
• Removal of the POP slab on the 14th day
and advise the following:
Postoperative Protocol • Refer to physiotherapy for active and
passive mobilization of the fingers and
• Admission in the ward thumb
• The affected hand should be kept elevated • Daily wash with soap and water
• Patient can take normal diet immediately • Massage of scar and grafted skin with
if the procedure was under regional block coconut oil
or after complete recovery if under general • Compression garment for scar softening
anesthesia after a further 2 weeks.
Reverse Dorsal
Metacarpal Artery Flap 5
Introduction Disadvantages of the Flap
This flap is a useful flap in the armamentarium • It is not a very reliable flap as there are
of the hand surgeon. It serves as an ideal skin many anatomic variations
cover for defects on the dorsum of the fingers • It is a reverse flow flap and hence, like all
on the proximal phalangeal region alone. reverse flow flaps, is prone for venous
The flap cannot cover defects that extend congestion.
beyond the proximal interphalangeal (PIP) • There is considerable donor site morbidity.
joint. Three dorsal metacarpal artery flaps
are possible from the dorsum of the hand: the
second, third and fourth dorsal metacarpal Presurgical Counseling
artery flaps. The second dorsal metacarpal
artery flap can cover defects on the dorsum • This procedure is planned to cover the raw
of the index or middle fingers. Similarly, the area on the finger with skin and tissues.
third dorsal metacarpal artery flap can cover • This procedure will be done under axillary
defects on the dorsum of the middle or ring block anesthesia.
fingers, and the fourth dorsal metacarpal • This procedure will take about 3 hours to
artery flap can be used for defects on the ring perform.
or little fingers. • Skin will be removed along with soft
This flap can be planned only if two criteria tissues from the back of the hand and
are met: placed on the raw area on the finger. There
1. The width of the flap should be such that will be a scar on the back of the hand.
primary closure of the defect must be • Admission will be necessary for a minimum
possible on the dorsum of the hand. This period of 3 days.
can be assessed by pinching up a fold of • A dressing will be applied and a plaster
skin on the dorsum of the hand. of Paris (POP) will be applied, which will
2. The length of the flap should not extend be retained for 10 days, following which,
beyond the dorsal wrist crease. physiotherapy will be started
possible because of anatomical variations.
In such cases, other surgery like a cross-
Advantages of the Flap finger flap may be done
• It is a single stage procedure anesthetic infiltration like hypersensitivity
may occur in spite of test dose application. has been decided on, the middle and
This complication will cause dryness of ring finger knuckle prominences form
mouth and apprehension, which can be the landmarks. Similarly, the knuckle
corrected immediately. prominences of the ring and little
fingers are the landmarks if the fourth
dorsal metacarpal artery flap has been
Surgical Steps chosen.
• Mark a point “A” about 1 cm proximal
1. The preferred anesthesia is either axillary to the knuckle prominences. This point
block or general anesthesia (in children) forms the pivot point of the dorsal
2. Apply the tourniquet and keep ready metacarpal artery flap.
3. Preparation and draping as described in • Measure the distance between the
Appendix I points “A” and the proximal border of
4. Raise the tourniquet and note the time the defect. This distance is the length of
5. Debride the defect and measure it. Make the pedicle
sure that the edges consist of intact and • Transpose this distance proximal to
healthy skin. Take a lint pattern of the defect the point “A” on the dorsum of the hand
6. Markings for the flap (Fig. 2.5.1): and mark this point as “B”. Place the
• Mark the two knuckle prominences lint pattern with its proximal border
corresponding to the flap that has at point “B” and make the marking of
been chosen. If the second dorsal the flap. When this is done, the distal
metacarpal artery flap has been end of the flap marking “C” must not
chosen, the knuckles of the index and extend beyond the wrist joint line
middle fingers are the landmarks. If • Mark two parallel lines on either side
the third dorsal metacarpal artery flap of the line “AB”, about 1 cm away. This
will be the width of the subcutaneous
pedicle. The distal ends of these lines
will cut the proximal border of the flap
at points “D” and “E”.
7. Now, make the incision “DCE”. This
incision must go through the skin and
subcutaneous tissue to the level of the
extensor paratenon, which is the thin
filmy layer over the extensor tendon.
Do not injure this paratenon. Raise the
flap superficial to this structure. The
subcutaneous veins that cross the incision
should be divided and ligated.
8. Now, make the incisions “EBD” and “BA”.
These incisions should be superficial
just through the epidermis and dermis,
to expose the fat underneath. Place skin
hooks and raise the dermal flaps on the
radial side and on the ulnar side till the
marked area. Apply anchoring sutures
with 3.0 ethilon. You will be able to see
fibrofatty tissue in the bed, containing
Fig. 2.5.1 Flap markings a few subcutaneous veins. These veins
CHAPTER 5 REVERSE DORSAL METACARPAL ARTERY FLAP 25
may take a few minutes for the spasm of

the vessel to be relieved. In the meantime,
continue to bathe the pedicle with 1
percent xylocaine solution and achieve
primary defect.
through the tunnel. Grasp the 3.0 vicryl
stitch that has been applied on the leading
edge of the flap. Gently pull the hemostat
with fine rocking movements and deliver
the flap at the site of the defect. If it is
difficult, redo step 14. After delivering
the flap in the wound site, confirm the
viability of the flap.
The most common reasons why this flap

Fig. 2.5.2 Flap after elevation sometimes undergoes vascular compromise are
the following reasons:
• Tightness of the tunnel as mentioned
are important to ensure good venous • Tight inset of the flap edges to the edges of the
drainage for the flap. Incise the fascia at defect
the marked area. Now, lift the distal edge • If there is tightness of the tunnel, the tunnel is
of the flap with skin hooks and elevate the most probably tight at the proximal edge which
flap off the bed. This dissection should can be vented with a small incision of about 2–3
stop at point “A”. The flap has now been mm
elevated (Fig. 2.5.2). • If there is tightness of the suture line of the inset,
9. Now, develop a subcutaneous tunnel remove the sutures on one side—either the
between the proximal edge of the defect radial or ulnar side and cover this exposed area
with a skin graft.
should be created with the help of a
tendon tunneller. This tunnel should be 15. Flap inset: After confirming the hemostasis
wide enough to hold the flap as it passes and the viability of the flap, inset can be
through, without traumatizing it. done with 4.0 ethilon using half buried
10. Apply a stitch with 3.0 nylon on the horizontal mattress suturing.
leading edge of the flap. 16. Management of the donor area: After
11. Apply wet gauze on the bed of the flap, confirming hemostasis, the defect
xylocaine soaked gauze on the pedicle of should first be closed primarily with 4.0
the flap. Raise-up the hand and release the polypropylene materials using vertical
tourniquet. Maintain the hand in elevated mattress suture. The dermal flaps should
position for about 3 minutes and ask for be replaced and sutured with 4.0 ethilon
the tourniquet to be removed entirely. (Fig. 2.5.3). Drainage tubes should be
12. Now, set the hand on the table and kept below the suture line on the dorsum
examine the edges of the flap. There should of the hand. The preferred drainage tube
be a slow and sustained subdermal bleed. would be Segmüller tube which consists
This may not be evident immediately. It of segments of the scalp vein set tubing.
the dressings to allow inspection and

monitoring of the flap, extending from
the distal most point of the flap to the
pivot point of the flap.
or after complete recovery if under general
anesthesia
• Clinical monitoring of the flap once every
6 hours
• Inspection of the dressing after 48 hours
• Discharge of the patient by 3rd day
Fig. 2.5.3 After flap inset and management of the donor site • Suture removal on the 10th day and
removal of donor site dressing on the arm
17. Sterile dressings should be applied over and advise the following:
the index finger, dorsum of hand. Care • Refer to physiotherapy for active and
must be taken to avoid compression of passive mobilization of the fingers and
the pedicle at any point of its course. A thumb
volar POP slab should be applied for the • Daily wash with soap and water
hand keeping the metacarpophalangeal • Massage of scar and grafted skin with
(MCP) joints of the fingers in flexion of coconut oil
90° and interphalangeal (IP) joints in • Compression garment for scar softening
extension. A window must be made in after a further 2 weeks.
Posterior Interosseous
Artery Flap 6
Introduction Presurgical Counseling
The posterior interosseous flap is a reverse • This procedure is planned to cover the raw
flow flap based on the posterior interosseous area with skin and tissues
artery. • This procedure will be done under axillary
block anesthesia (except for children,
in whom general anesthesia may be
required) with a short general anesthesia
Indications while harvesting a skin graft from the thigh
• Defects on the dorsum of hand with no perform
tendon injury • Skin will be removed along with soft
• Defects on the dorsum of hand and a single tissues from the back of the forearm and
finger not extending beyond the proximal placed on the raw area. A skin graft will
interphalangeal (PIP) joint be taken from the medial side of the thigh
• Defects on the ulnar border of the hand and applied over the secondary raw area
• Defect on the thumb web or dorsum of the on the forearm. There will be no deficit on
thumb the forearm, but there will be a scar on the
• Defects on the flexor aspect of the wrist. forearm. There will consequently be a scar
on the thigh also
• Admission will be necessary for a
Advantages minimum period of 3 days
• It is a single-staged procedure of Paris (POP) will be applied, which will
• Reliable flap be retained for 10 days, following which,
• Same field of regional block anesthesia. physiotherapy will be started
possible because of anatomical variations.
In such cases, other surgery like an
Disadvantages abdominal/groin flap may have to be done.
• In rare instances, after the flap has been
• Brings hair bearing skin to the hand done, there may be a problem to the
• Donor site morbidity is high vascularity and the flap may necrose. In
• Requires expertise. such cases, other surgery like an abdominal
or groin flap may be required to be done • Join the points “C” and “D”. This
later represents the axis of the flap, i.e. the
• The general complications of local anesthetic course of the posterior interosseous
infiltration like hypersensitivity may occur artery, even though the origin of the
in spite of test dose application. This artery is about 8 cm distal to point “D”.
complication will cause dryness of mouth • Mark a point “E” about 2 cm proximal
and apprehension, which can be corrected to point “C”, on the line CD. This will
immediately. represent the distal most point of our
dissection
• Mark the mid-point “F” of the line CD.
Surgical Steps Mark another point “X, 1 cm distal to
the point “F”. This point “X” represents
1. The preferred anesthesia is either axillary the point at which the central
block or general anesthesia (in children). cutaneous perforator of the posterior
2. Apply the tourniquet and keep ready. interosseous artery appears. This point
3. Preparation and draping as described in must be included in the flap (Fig. 2.6.2).
Appendix I. • Now, measure the distance between
4. The elbow area must also be prepared and the point “E” and the proximal edge
kept exposed. of the defect. This will represent the
5. Raise the tourniquet and note the time. length of the pedicle. Transpose this
6. Debride the defect and measure it. Make distance on the line ED and mark the
sure that the edges consist of intact and point as “G”. Place the lint pattern of
healthy skin. Take a lint pattern of the the defect centered on the axis DE,
defect. with its proximal edge at the point “G”.
7. Markings for the flap (Fig. 2.6.1): Mark the Make sure that the flap covers the point
following points on the extensor aspect of “X”. Also make sure that the proximal
the forearm (the markings must be made border is at least 6 cm distal to point
before the tourniquet is raised): “D”.
• Point “A”—radial styloid • Draw a transverse line 2 cm proximal
• Point “B”—head of ulna to the point “X” to meet the radial and
• Join points “A” and “B” ulnar sides of the marked flap at “H”
• Mark a point “C” at the junction of and “I” respectively. Draw two lines
ulnar one-third and radial two-thirds 2 cm parallel to the line CG, one on
of line AB. This represents the point the radial side and one on the ulnar
where the posterior interosseous artery side. These lines represent the limit
anastomoses with the terminal end of of dissection on the radial and ulnar
the anterior interosseous artery. sides. These lines will cut the marking
• Mark a point “D” exactly over the of the flap at the points “J” and “K” on
lateral epicondyle. the radial and ulnar sides respectively.
Fig. 2.6.1 Preliminary markings Fig. 2.6.2 Final markings of the flap
CHAPTER 6 POSTERIOR INTEROSSEOUS ARTERY FLAP 29
8. Make the incision from “J” to “K” on the opened to facilitate dissection. Dissect the
proximal border. This incision should be posterior interosseous artery and ligate
down to the deep fascia only. Do not incise the branches to the muscles. Now, ligate
the deep fascia. Secure hemostasis as there and divide the posterior interosseous
are many veins crossing the incision. After artery and veins proximal to the central
making the incision, raise this flap as a skin perforator, making sure that the nerve has
flap, superficial to the thick white layer been safeguarded.
of the deep fascia. The deeper muscles
can be visualized at this stage under the
This dissection is easily carried out on the radial
fascia. Starting from the ulna, the first
side (Fig. 2.6.3), i.e. from the EDM muscle side by
compartment (not to be confused with
retracting the muscle, rather than the ECU side.
extensor compartments at the dorsum of Avoid injuring the posterior interosseous nerve at
the wrist) seen is the extensor carpi ulnaris this juncture.
(ECU) muscle. The next big compartment is
the extensor digitorum communis (EDC).
Between these two compartments, a new 10. Now make the incision on the line GD.
compartment starts forming at about 6 to This must be a superficial incision, just
8 cm from the lateral epicondyle. This is through the epidermis and dermis, to
the extensor digiti minimi (EDM) muscle. expose the fat underneath. Place skin
Stop at the marked line HI. Now, raise the hooks and raise the dermal flaps on the
remaining portion of the flap first from the radial side and on the ulnar side till the
ulnar side (IK). As it is raised superficial marked area. Apply anchoring sutures
to the deep fascia, stop when you cross with 3.0 ethilon. You will be able to see
the ulna bone. Once the ulna is crossed, fibrofatty tissue in the bed, containing
deepen the incision by incising the deep a few subcutaneous veins. These veins
fascia. The ECU muscle will be seen. With are important to ensure good venous
gentle radialward retraction of the flap, drainage for the flap. Make the incisions
identify the radial border of the muscle and on this tissue at the radial and ulnar ends
stop. Similarly, raise the radial portion (HJ) (along the marked limits of dissection).
till the muscle compartment of the EDM These incisions can go deep to the fascia.
muscle is identified underneath the deep
fascia. Deepen the incision through the
deep fascia at the radial edge of the muscle.
With gentle ulnarward traction on the flap
identifies the ulnar border of the muscle
and retracts the muscle radialward. Now
the posterior interosseous vascular pedicle
along with the terminal branches of the
posterior interosseous nerve will be seen
at the depth of the intermuscular septum
between the EDM and ECU muscles. The
perforator from the posterior interosseous
artery to the skin can also be seen reaching
the skin at the level of our marking “X”.
9. Identify the posterior interosseous nerve
and separate it from the vascular pedicle.
There is usually a thin fascia covering the
neurovascular bundle. This will have to be Fig. 2.6.3 View of the raised flap (from the radial side)
Retract the EDM muscle radially and the

ECU muscle ulnarly and the entire course
of the posterior interosseous vessels can
be seen.
Try to get as many veins in the subcutaneous

tissues. It does not matter if the veins have been
accidentally damaged or cauterized. It is only the
venous channels that serve to drain the flap by the
help of intervenous channels.
Fig. 2.6.4 Checking the reach of the flap

11. Lift-up the flap and divide the inter
muscular septum deep to the level of the
posterior interosseous vessels. As you 14. Apply wet gauze on the bed of the flap,
keep advancing, make sure to cauterize or xylocaine soaked gauze on the pedicle of
ligate the muscular branches. the flap. Raise-up the hand and release
Keep ensuring that no damage occurs to the tourniquet. Maintain the hand in
the vascular pedicle. When we encounter elevated position for about 3 minutes
some small branches to the ulna bone, it and ask for the tourniquet to be removed
means we have come close to the pivot entirely.
point. In this way, the flap can be raised 15. Now, set the hand on the table and
up to the level of the point “D”. At this examine the edges of the flap. There should
level, the vessels will lie between the ECU be a slow and sustained subdermal bleed.
and EDM tendons. This may not be evident immediately. It
Transpose the flap to the defect to may take a few minutes for the spasm of
approximately see whether the flap covers the vessel to be relieved. In the meantime,
the defect (Fig. 2.6.4). If it does not do so, continue to bathe the pedicle with
elevate the pedicle a little more. 1 percent xylocaine solution and achieve
primary defect.
This is fondly called the “heart attack point” (for the
surgeon). This is because the vessel becomes so
small, that it is no longer visualized in the dissected This flap is usually a robust flap and there will be
pedicle tissue. Hence, the chances of injury to good bleeding from the edges. Before transferring
the vessel are high. The way to avoid injury to the the flap, turn the flap raw side up and get
vessels at this level is to raise the pedicle tissue very hemostasis on the pedicle carefully!
close to the ulna bone which lies underneath.

12. Now, develop a subcutaneous tunnel edges of the flap, it is ready for transfer.
between the proximal edge of the defect 17. Pass a heavy curved hemostat from the
and the pivot point of the flap. This tunnel proximal edge of the primary defect
should be created with the help of a through the tunnel. Grasp the 3.0 vicryl
tendon tunneller. This tunnel should be stitch that has been applied on the leading
wide enough to hold the flap as it passes edge of the flap. Gently pull the hemostat
through, without traumatizing it. with fine rocking movements and deliver
13. Apply a stitch with 3.0 vicryl on the leading the flap at the site of the defect. If it is
edge of the flap. difficult, redo step 14. After delivering the
CHAPTER 6 POSTERIOR INTEROSSEOUS ARTERY FLAP 31
flap in the wound site, confirm the viability

of the flap. If there is reduced bleeding Inspect the flap after 6 hours. This is a critical period
from the edges of the flap, the tunnel is in the phase of the flap when the venous drainage
has become established. However, there may be a
most probably tight at the proximal edge
hematoma due to bleeding in the interim period,
which can be vented with a small incision
and this may compress the vascular pedicle. If
of about 2 to 3 mm. so, removal of one or two sutures and gentle
18. Flap inset: After confirming the hemostasis compression to evacuate the hematoma will
and the viability of the flap, inset can be restore equilibrium in the flap.
done with 4.0 ethilon using half buried
horizontal mattress suturing.
19. Management of the donor area: After
confirming hemostasis, the dermal flaps Postoperative Protocol
should be replaced and sutured with
4.0 ethilon. The residual raw area on the • Admission in the ward
extensor aspect of the forearm should be • The affected hand should be kept elevated
narrowed with 3.0 vicryl. Now prepare the • Patient can take normal diet immediately
thigh with betadine solution. The skin graft if the procedure was under regional block
should be harvested from the medial side or after complete recovery if under general
of the thigh. Sterile dressings should be anesthesia
applied over the skin graft donor site before • Clinical monitoring of the flap once every
moving back to the hand. The graft should 6 hours
be applied over the raw area and tie over • Analgesics and antibiotics for 5 days
sutures applied with 3.0 ethilon. Drainage • Sedation sos for 1 day
tubes should be kept below the suture line • Inspection of the dressing after 48 hours
on the forearm. The preferred drainage tube • Discharge of the patient by 3rd day
would be Segmüller tube which consists of • Suture removal on the 10th day and
segments of the scalp vein set tubing. removal of donor site dressing on the arm
20. Sterile dressings should be applied over • Removal of the POP slab on the 14th day
the hand and the forearm. Care must and advice the following:
be taken to avoid compression of the • Refer to physiotherapy for active and
pedicle at any point of its course. A volar passive mobilization of the fingers and
POP slab should be applied for the hand thumb
keeping the wrist in 30° extension, and the • Daily wash with soap and water
metacarpophalangeal (MCP) joints of the • Massage of scar and grafted skin with
fingers in flexion of 90° and interphalangeal coconut oil
(IP) joints in extension. A window must be • Compression garment for scar softening
made in the dressings to allow inspection after a further 2 weeks.
and monitoring of the flap.
Radial Artery Forearm Flap
7
• Skin will be removed along with soft tissues
Introduction from the forearm and placed on the raw
area. A skin graft will be taken from the
Radial artery forearm flap is one of the
medial side of the thigh and applied over
versatile flaps being used in hand surgery
the secondary raw area on the forearm.
ever since it was described by the Chinese.
There will be no deficit on the forearm, but
It can be used as a pedicled flap or as a free
there will be a scar on the forearm. There
flap. In this chapter, its use as a pedicled flap
will consequently be a scar on the thigh also.
is described. When used as a pedicled flap, it
• Admission will be necessary for a minimum
is a reverse flow flap.
period of 3 days.
of Paris (POP) will be applied, which will
Advantages be retained for 10 days, following which,
physiotherapy will be started.
• It is a single staged procedure • In some instances, the flap may not be pos-
• It brings a large amount of skin on to the sible because of anatomical variations. In
hand. such cases, other surgery like an abdomi-
nal or groin flap may be done.
• In rare instances, after the flap has been
Disadvantages done, there may be a problem to the
vascularity and the flap may necrose. In
• It involves the sacrifice of a major artery of such cases, other surgery like an abdominal
the upper limb or groin flap may be done later.
• It leaves a very bad scar on the forearm. • The general complications of local anes-
thetic infiltration like hypersensitivity may
occur in spite of test dose application. This
Presurgical Counseling complication will cause dryness of mouth
• This procedure is planned to cover the raw immediately.
area with skin and tissues.
block anesthesia, with a short general Surgical Steps
anesthesia while harvesting a skin graft
from the thigh. 1. The preferred anesthesia is either axillary
• This procedure will take about 3 hours to block or general anesthesia (in children).
perform. 2. Apply the tourniquet and keep ready.
CHAPTER 7 RADIAL ARTERY FOREARM FLAP 33
3. Preparation and draping as described in 8. Make the incision on the ulnar border
Appendix I. of the flap from “G” to “F”. This incision
4. The elbow area must also be prepared and should be down to the level of the deep
kept exposed. fascia of the forearm. Raise the flap
5. Raise the tourniquet and note the time. superficial to the deep fascia, till the ulnar
6. Debride the defect and measure it. Make border of the flexor carpi radialis muscle
sure that the edges consist of intact and is seen below the fascia. Now, deepen
healthy skin. Take a lint pattern of the the incision and divide the deep fascia.
defect. Now continue raising the flap over the
7. Markings for the flap (Fig. 2.7.1): muscle, while applying gentle radialward
• Draw a point “A” on the distal most and upward traction on the flap. Along
palpable pulsation of the radial artery the radial border of the muscle, the radial
proximal to the wrist. vascular bundle can be seen lying in a
• Mark a point “B” on the palpable biceps septum. Do not dissect on this septum
tendon in front of the elbow. now. Keep dissecting close to the muscle
• Join the points “A” and “B”. This forms only. Apply a retractor on the radial border
the axis of the flap. of the flexor carpi radialis muscle and
• Mark a point “C” about 2 cm proximal retract it toward the ulnar side. This will
to point “A” on the line AB. This will expose the small branches of the radial
represent the distal most point of our artery to the flexor muscles. Carefully
dissection. divide them away from the radial artery
• Now measure the distance between and secure hemostasis.
the point “C” and the proximal edge 9. Now make the incision on the radial side
of the defect. This will represent the from “G” to “E”. Raise this flap superficial
length of the pedicle. Transpose this to the deep fascia. In this way we can avoid
distance on the line AB and mark the injury to the superficial branch of the
point as “D”. Place the lint pattern of radial nerve. Deepen the incision when
the defect centered on the axis AB, with the ulnar border of the brachioradialis
its proximal edge at the point “D”. Mark muscle is seen beneath the fascia. Now
the flap. Mark the distal most point on raise the flap off the muscle by applying
the flap as “G”. gentle ulnarward and upward traction on
• Draw two lines 2 cm parallel to the line the flap. The radial vascular bundle can
CD, one on the radial side and one on now be seen on the radial border of the
the ulnar side. These lines represent the muscle and its tendon. Apply a retractor
limit of dissection of the subcutaneous on the ulnar border of the brachioradialis
cuff on the radial and ulnar sides. These muscle and retract it toward the radial
lines will cut the marking of the flap at side. This will expose the small branches of
the points “E” and “F” respectively on the radial artery to the muscles. Carefully
the radial and ulnar sides. divide them away from the radial artery
and secure hemostasis.
10. Now make the incision on the lines flexor
digitorum communis (FDC) and extensor
digitorum communis (EDC). These must
be superficial incisions, just through the
epidermis and dermis, to expose the fat
underneath. Place skin hooks and raise
the dermal flaps on the radial side and on
Fig. 2.7.1 Markings for the flap the ulnar side till the marked area. Apply
anchoring sutures with 3.0 ethilon. You 15. Apply wet gauze on the bed of the flap,
will be able to see fibrofatty tissue in the xylocaine soaked gauze on the pedicle of
bed, containing a few subcutaneous veins the flap. Raise-up the hand and release the
including the cephalic vein. These veins tourniquet. Maintain the hand in elevated
are important to ensure good venous position for about 3 minutes and ask for
drainage for the flap. Make the incisions the tourniquet to be removed entirely.
on this fatty subcutaneous tissue at the 16. Now set the hand on the table and examine
radial and ulnar ends (along the marked the edges of the flap. There should be a
limits of dissection). These incisions slow and sustained subdermal bleed. This
can go deep to the fascia. Retract the may not be evident immediately. It may
brachioradialis tendon radially and the take a few minutes for the spasm of the
flexor carpi radialis tendon ulnarly and vessel to be relieved. In the meantime,
the entire course of the radial vessels can continue to bathe the pedicle with
be seen. 1 percent xylocaine solution and achieve
11. Now go to the point “G” of the flap. Apply hemostasis on the bed of the flap and the
2 ligatures with 3.0 vicryl at the proximal primary defect.
most point of the exposed radial vessels. 17. When good bleeding is seen from the
Divide the vessels between the ligatures.
Lift-up the flap gently and divide the
septum deep to the level of the radial
through the tunnel. Grasp the 3.0 vicryl
vessels, taking care to cauterize the deeper
stitch that has been applied on the leading
branches from the vessels.
edge of the flap. Gently pull the hemostat
12. Continue this dissection up to the point
with fine rocking movements and deliver
“C”. Now the flap has been mobilized.
the flap at the site of the defect. After
13. Now develop a subcutaneous tunnel delivering the flap in the wound site,
between the proximal edge of the defect confirm the viability of the flap. If there
and the pivot point “C” of the flap. This is reduced bleeding from the edges of the
tunnel should be created with the help of flap, the tunnel is most probably tight at
a tendon tunneller. This tunnel should be the proximal edge which can be vented
wide enough to hold the flap as it passes with a small incision of about 2 to 3 mm.
through, without traumatizing it. 19. Flap inset: After confirming the hemostasis
and the viability of the flap, inset can be
done with 4.0 ethilon using half buried
It may not be possible to tunnel the palmar skin horizontal mattress suturing.
because this skin is thicker and more anchored to 20. Management of the donor area (Fig. 2.7.2):
the subcutaneous tissues than the dorsal skin. In After confirming hemostasis, the dermal
such situations, it may be ideal to make an incision flaps should be replaced and sutured with
on the palmar skin along the proposed track of the
4.0 ethilon. The residual raw area on the
flap. This incision will be made through the skin and
subcutaneous tissues, and both edges of the skin
extensor aspect of the forearm should be
retracted to accommodate the pedicle. This will narrowed with 3.0 vicryl. Now prepare
cause an unsightly scar on the palm. This may have the thigh with betadine solution. The skin
to be excised later and the skin closed primarily to graft should be harvested from the medial
minimize the scar. side of the thigh. Sterile dressings should
be applied over the skin graft donor site
before moving back to the hand. The graft
14. Apply a stitch with 3.0 nylon on the leading should be applied over the raw area and
edge of the flap. tie over sutures applied with 3.0 ethilon.
CHAPTER 7 RADIAL ARTERY FOREARM FLAP 35
• The affected hand should be kept elevated.
anesthesia.
Fig. 2.7.2 Management of donor site • Clinical monitoring of the flap once every
6 hours.
Drainage tubes should be kept below • Sedation sos for 1 day
the suture line on the forearm. The preferred • Inspection of the dressing after 48 hours
drainage tube would be Segmüller tube which • Discharge of the patient by 3rd day
consists of segments of the scalp vein set tubing. • Suture removal on the 10th day and removal
21. Sterile dressings should be applied over of donor site dressing on the arm
the hand and the forearm. Care must • Removal of the POP slab on the 14th day
be taken to avoid compression of the and advice the following:
pedicle at any point of its course. A volar • Refer to physiotherapy for active and
POP slab should be applied for the hand passive mobilization of the fingers and
keeping the wrist in 30° extension, and the thumb.
metacarpophalangeal (MCP) joints of the • Daily wash with soap and water.
fingers in flexion of 90° and interphalangeal • Massage of scar and grafted skin with
(IP) joints in extension. A window must be coconut oil.
made in the dressings to allow inspection • Compression garment for scar softening
and monitoring of the flap. after a further 2 weeks.
Buried Abdominal Flap
8
Introduction block anesthesia for the hand and either
Buried abdominal flap is the flap of choice for spinal anesthesia or general anesthesia.
degloving injuries of the entire hand. Routinely • This procedure will take about 3 hours to
used abdominal flaps and groin flaps are not perform.
enough to resurface such large areas and • Incisions will be made on the abdominal
hence a different technique will have to be wall and the entire hand bereft of skin will
employed. The technique of using the buried be buried in a pocket in the abdominal
abdominal flap refers to the method where wall. This will be retained for a period of 2
the entire hand is buried in a pocket in the weeks.
abdominal wall and then removed for further • After a period of 2 weeks, a delay procedure
reconstruction. When the hand is buried in may have to be done under local anesthesia
this manner in the abdominal wall, skin will or spinal anesthesia.
still not be available to cover the entire hand. • Admission will be necessary for a minimum
After the removal of the hand from the buried period of 1 month.
status in the abdominal wall, the further • After the hand is removed from its buried
reconstruction may be of two types: position in the abdomen, a skin grafting
1. Partial Crane technique: The abdominal will be required.
skin can be retained on the dorsal aspect • There will be a scar in the abdominal wall.
of the hand and the residual raw area on • Splints and physiotherapy in the form of
the palmar aspect can be covered with exercises will be required afterward
skin graft, applied over the soft tissues • The general complications of local anes
(Crane principle). thetic infiltration like hypersensitivity may
2. Full Crane technique: An alternative occur in spite of test dose application. This
method is to retain the abdominal skin in complication will cause dryness of mouth
the abdomen and remove the hand with and apprehension, which can be corrected
only the soft tissues covering it. This raw immediately. Complications of general
area is subsequently skin grafted. anesthesia or spinal anesthesia may occur.
Both these techniques have been described
here:
Surgical Steps
Presurgical Counseling
1. The preferred anesthesia is axillary block
• This procedure is planned to cover the and regional block or general anesthesia.
entire raw area on the hand. 2. Apply the tourniquet and keep ready.
CHAPTER 8 BURIED ABDOMINAL FLAP 37
3. Preparation and draping as described in abdomen is enough. But if the thumb

Appendix I. is also degloved, the supraumbilical
4. Raise the tourniquet and note the time. segment of the abdominal wall will

5. Debride the defect and measure it. Make also be required.
sure that the edges consist of intact and • The method of planning consists of
healthy skin. the incision and the area for creating
6. If all the fingers have been degloved, it is a pocket. The incision length will be
useful to disarticulate the fingers at the decided by the length of the skin on the
distal interphalangeal (DIP) joints, as the
proximal edge of the defect.
reconstruction and rehabilitation will be
quicker and better.
• The incision is made through the skin
7. Markings for the flap: and subcutaneous tissues. It is not
• There are usually two types of total necessary to make the incision down
degloving injuries of the hand: (1) to the fascia.
involves the thumb and (2) spares the 8. The abdominal pocket must be created
thumb. The degloving usually extends carefully (Fig. 2.8.2) with blunt dissection
up to the wrist crease or on to the to avoid injuring the multiple paraum
forearm. The planning of the incision bilical perforators.
in the abdominal wall depends on the 9. The degloved hand can be inserted off
type of degloving. and on to ensure a comfortable lie within
• The hand is going to be buried in the its pocket.
abdominal wall. So the hand is first
10. Once the pocket created is of adequate
placed over the abdomen to plan the
size, and the hand lies comfortably in
area of the abdominal wall which is
the pocket, the skin can be sutured at the
going to be used for the reconstruction
(Fig. 2.8.1). proximal edge.
• If the thumb is spared from the deglov 11. This position must be maintained for a
ing, the infraumbilical segment of the period of 3 weeks.
Fig. 2.8.1 Marking the area on the abdomen which is to Fig. 2.8.2 Showing the abdominal pocket created for
be used for the buried flap burying the degloved hand
the umbilicus and plan the markings

Postoperative Protocol around the umbilicus. Hence the marking
after Flap Stage I will now be as shown in the diagram
(Fig. 2.8.3). This marking will be the
• Admission in the ward planned incision for the delay procedure.
• The affected hand should be kept elevated 14. An incision is made along the markings,
• Patient can take normal diet immediately through the skin and subcutaneous tissues.
Hemostasis is achieved and the wound is
sutured with 3.0 polyamide suture.
anesthesia.
15. A sterile dressing is done.
6 hours. 16. Division of the flap: This is done at the
• Analgesics and antibiotics for 5 days. end of 3 weeks—1 week after the delay
• Sedation sos for 1 day. procedure was done.
• Inspection of the dressing after 48 hours. 17. This surgery is done under regional block
• Removal of sutures on the 10th postoper anesthesia with supraclavicular block
ative day. anesthesia or general anesthesia.
The further procedure will depend on 18. The same incision is made as was used for
whether partial Crane technique or full Crane the delay procedure. First the sutures of the
technique is planned: delay procedure are removed and a wash
Partial Crane technique: Here, at the end of 2 given with povidone-iodine solution.
weeks, a delay procedure is planned. 19. The incision is made down to the fascia
12. This surgery can be done under local and the hand is removed along with the
anesthesia, or regional block anesthesia. overlying abdominal skin flap which
13. The outline of the hand that has been covers the dorsum of the hand (Fig. 2.8.4).
buried in the abdominal wall is palpated 20. The bed will now consist of the fascia
carefully. A marking is made about 2 to 3 of the abdominal wall. Now the hand is
cm beyond the margins of the palpated examined. Hemostasis is achieved. Both
hand and thumb. All the fingers are taken the raw area in the abdominal wall (Fig.
a single unit. When marking around the 2.8.5) and the palmar surface of the hand
thumb, the proximity to the umbilicus (Fig. 2.8.6) are covered with skin graft
must be considered. It is ideal to spare harvested from the thigh.
Fig. 2.8.3 Delay of the flap Fig. 2.8.4 Dorsal side of reconstructed hand
CHAPTER 8 BURIED ABDOMINAL FLAP 39
Fig. 2.8.5 Donor site with skin graft Fig. 2.8.7 Marking of incisions to explant the buried hand
extension, taking care to place adequate

padding in the thumb web. The thumb must
be kept in a position of palmar abduction.
Full Crane technique: When this technique
has been planned, flap division is planned
at the end of 3 weeks.
23. The anesthesia required for the procedure
of flap division is general anesthesia or
a regional block with a supraclavicular
block anesthesia.
24. The abdominal wall and the involved
upper limb is prepared and draped.
25. Incisions are made over the palpated hand
which has been buried in the abdominal
wall (Fig. 2.8.7).
26. The skin flaps are raised on the abdominal
wall superficial to the hand. In this way, the
entire buried hand is exposed, retaining a
coating of soft tissues acquired from the
abdominal wall.
27. The hand is now removed from its bed.
The soft tissue cover can also be noticed
Fig. 2.8.6 Volar view of the reconstructed hand on the palmar aspect.
28. Hemostasis is achieved on the abdominal
wall. The wounds are closed primarily
21. Anchoring sutures are applied with 3.0 (Fig. 2.8.8) after keeping drainage tubes
polyamide sutures and sterile dressings and sterile dressings are applied.
are applied after applying paraffin gauze. 29. Now the hand wound is thoroughly
22. On the hand, a volar plaster of Paris (POP) washed with a solution of povidone-iodine,
slab must be applied with the wrist in 30° hydrogen peroxide and saline.
30. Skin graft is harvested from the thigh and

applied over the raw areas on the hand
and fingers (Fig. 2.8.9). Anchoring sutures
are applied. Paraffin gauze is applied and
sterile dressings done. Care must be taken
to provide adequate fluffed gauze between
the fingers in the finger webs and in the
thumb web.
31. A volar POP slab is applied with wrist
in 30° extensions and thumb in palmar
abduction.
after Flap Stage II
Fig. 2.8.8 Suture line after explantation of the buried hand
• Patient can take normal diet after complete
recovery if under general anesthesia.
• Analgesics and antibiotics for 5 days.
• Sedation sos for 1 day.
• Inspection of the dressing after 48 hours.
• Discharge of the patient by 3rd day.
• Suture removal on the 10th day.
and advice the following:
• Refer to physiotherapy for active and
passive mobilization of the fingers and
thumb.
• Daily wash with soap and water.
• Massage of scar and grafted skin with
coconut oil.
• Compression garment for scar softening
Fig. 2.8.9 Volar and dorsal views of the reconstructed hand after a further 2 weeks.
Vascularized Free
Anterolateral Thigh Flap 9
A skin graft will be taken from the back side
Introduction of the thigh and applied over the secondary
raw area on the thigh. There will be no
The inclusion of a free flap in this book signi-
deficit on the thigh, but there will be a scar
fies the important role that the flap plays in
on the thigh.
reconstruction of skin defects on the hand.
• Admission will be necessary for a mini-
Primarily used as a skin flap, the anterolateral
mum period of 3 days.
thigh flap is slowly becoming one of the work-
• A dressing will be applied and a plaster of
horse flaps in this regard.
Paris (POP) will be applied on the hand,
This flap has proved to be proving its
which will be retained for 10 days, following
versatility due to different reasons:
which, physiotherapy will be started.
• It is a robust and dependable flap • In some instances, the flap may not be pos-
• It has got a fairly standard anatomy sible because of anatomical variations. In
• Raising the flap is simple such cases, other surgery like an abdomi-
• It provides a large area of good quality skin nal or groin flap may be done.
• The caliber of the vessels is adequate for an • In rare instances, after the flap has been
easy vascular anastomosis
done, there may be a problem to the
• A hidden donor site and hence less vascularity and the flap may necrose. In
morbidity.
such cases, other surgery like an abdominal
It has a few disadvantages too:
or groin flap may be done later.
• Requires microsurgical expertise • The general complications of local anes-
• Rare anatomical variations may preclude thetic infiltration like hypersensitivity may
the use of the flap.
Presurgical Counseling immediately.
• This procedure is planned to cover the raw

area with skin and tissues.
Surgical Steps
block anesthesia, with general anesthesia
or spinal anesthesia. Preparation on the Hand
• This procedure will take about 5 to 6 hours • The surgery of free anterolateral flap cover
to perform. for a defect on the hand can be done under
• Skin will be removed along with soft tissues general anesthesia or under regional
from the thigh and placed on the raw area. block; a combination of axillary block for
the upper limb and an epidural block for

the donor site.
• A tourniquet is applied on the upper arm.
• The hand is prepared and draped as
described in Appendix I.
• The raw area is covered with a sterile pad
and bandaged.
• The tourniquet is raised. Fig. 2.9.1 Markings for the anterolateral thigh flap
• An incision is made to expose the recipient
vessel. The vessels commonly used are
the radial artery, cephalic vein, other superolateral border of the patella. Join
subcutaneous veins, venae comitantes these two points with a straight line. This
of the radial artery, and rarely, the digital forms the axis of the flap.
arteries and ulnar artery. The classical • Mark a point “A” on the center of this
incision for the exposure of the radial artery line. Around this point, mark a circle
is a “C-shaped” incision convex to the with diameter of 4 cm. Divide this circle
ulnar side, on the distal 5 cm of the flexor into four quadrants. The lower and outer
aspect of the forearm. The “C-shaped” flap quadrant is the approximate site of the
is raised and anchored with 3.0 ethilon. musculocutaneous perforator from the
The radial artery is found between the descending branch of the lateral circumflex
tendons of the flexor carpi radialis and artery. This can be confirmed with a hand-
the brachioradialis. The artery is dissected held Doppler probe that will show the exact
along with both its venae comitantes site of the perforator.
and the same exposure can be used to • Mark another point at the junction of the
dissect the cephalic vein. Once the vessels proximal-third and middle-third of the axis
are dissected, gauze pledgets soaked in line ‘B’. Doppler this area. If a good signal
1 percent xylocaine is placed over them. is picked up from this area, it signifies
• Now the bandage around the raw area is a septocutaneous perforator from the
removed and the wound debrided. The descending branch of the lateral circumflex
exact dimensions of the defect are noted artery.
and a lint pattern is taken of the defect. • These two points should be marked
• The tourniquet is released and removed. with indelible ink as they are the points
• The pulsations in the dissected artery around which the flap is going to be
are noted. If there are good pulsations, marked.
sterile gauze pledgets soaked in 1 percent 1. The thigh is prepared and draped, exposing
xylocaine is again placed over the vessels, the entire length from the anterosuperior
and a sterile pad applied. Hemostasis is iliac spine to the patella.
achieved. 2. The lint piece is placed on the thigh
centered on the axis line, with its proximal
Preparation on the Thigh end just proximal to the junction of the
The thigh chosen as donor for the flap is proximal and mid-third of the axis line.
usually chosen for convenience to allow two On the proximal end, an incision can be
teams to simultaneously operate. Markings marked along the axis line for about 5 cm
for the flap should be made before the thigh to allow for dissection of the pedicle.
is prepared and draped (Fig. 2.9.1). 3. The incision is first made on the medial
• Mark a point on the anterior superior border of the flap marking. The incision
iliac spine. Mark another point on the should go down to the deep fascia
CHAPTER 9 VASCULARIZED FREE ANTEROLATERAL THIGH FLAP 43
covering the muscles. This deep fascia is the septocutaneous perforator entering
then incised along the entire length of the the skin flap. This point is marked as “B”.
medial border. Muscle will be seen in the 8. That two perforators have been identified,
wound. This is the rectus femoris muscle. we must now dissect them. First make
This must be confirmed by the anatomical two incisions on the intermuscular
relations. septum about 1 cm on either side of the
4. The flap must now be raised from the musculocutaneous perforator. The vessels
medial side by gently teasing the epimysial lie sandwiched between two layers of the
layer of the rectus femoris muscle. The septum. The nerve to the muscle will be
lateral border of the rectus muscle will seen along with the vascular pedicle. So
come in to view as also the intermuscular when incisions are made on either side
septum between the rectus femoris and of the vessel, it is possible to gently do a
the vastus lateralis muscles. Now, apply blunt dissection deep to the plane of the
a deep retractor on the rectus femoris vessels and free the vessels posteriorly.
muscle and retract the muscle medially. Now, a hemostat passed through one
This will expose the intermuscular septum. incision deep to the plane of the vessels
5. Examine this septum to identify the will exit at the other incision without
vascular pattern. damaging the vessels. This can be done
for almost the entire length of the vessels
except proximally. As we dissect more
This area may have some anatomical anomalies.
proximally, we will find one or two deep
Sometimes, there may not be a good musculocu-
taneous or septocutaneous perforator. Sometimes, branches that go to the muscle. These
there may be a perforator, but the branch supply- should be carefully ligated with 4.0 vicryl
ing the skin may be very small and may not be and then divided.
reliable. In such situations, there are a few options 9. If a septocutaneous perforator is present,
available. Either explore the other thigh for a more this should also be included in the flap.
favorable anatomy for a flap, or abandon the proce- Just like how the musculocutaneous perfo-
dure and select another procedure. rators were dissected, the septocutaneous
perforator is also dissected proximally up
to the origin from the descending branch
6. The commonest pattern is the presence of of the lateral circumflex femoral artery.
a single musculocutaneous perforator that 10. Now, apply a deep Langenbeck retractor
runs in the septum and one septocutaneous to the rectus femoris muscle and retract
perforator that is more proximal. it medially. This step will expose the
7. The skin flap must be lifted up and laterally descending branch of the lateral circumflex
to expose fully and put the intermuscular femoral artery, from which the perforators
septum into tension. At the point where arise. The perforators should be dissected
the musculocutaneous perforator seems to up to their origin from the descending
end, the soft tissue between that point and branch of the lateral circumflex femoral
the skin should be examined carefully. First artery. If a greater length of the pedicle
confirm by the marking that was previously is required, the required length of the
made on the skin, that this perforator is descending branch can be dissected.
the one that we had Dopplered. Then Remember again that there will be one
check for the fine vessels that connect the or two deeper branches arising exactly at
musculocutaneous perforator to this point. the point where the perforator originates.
This should be noted. Let this point be “A”. Hence, these vessels should be carefully
Similarly, look for the terminal portion of ligated and divided while mobilizing the
pedicle. Now the pedicle is ready. Apply perforators to the skin. These should be
pledgets of gauze soaked in 1 percent cauterized while raising the flap. Stop the
xylocaine solution over the vessels. dissection when the point of the vascular
11. Now, draw an imaginary line between hilum is reached. Make an incision on
the points “A” and the distal point of the deep fascia about 1 cm lateral to the
the musculocutaneous perforator. This vascular hilum. So now the entire hilum
imaginary line represents the approximate is protected by fascia. With gentle lateral
course of the perforator through the vastus retraction of the flap, the remaining muscle
lateralis muscle. Now make an incision fibers are separated, thus freeing the entire
about 1 cm caudal to this imaginary pedicle.
line and parallel to it. This incision will 14. The flap is replaced back and two to
go down to the muscle after dividing three anchoring sutures are placed with
the deep fascia. Incise the muscle also 3.0 ethilon to the medial skin edge to
carefully, cauterizing the three to four prevent the flap from shearing. Bleeding
vascular branches from our perforator. is checked from the edges of the flap. A
Similarly, draw an imaginary line between small streak is made on the distal most
the point “B” and the distal point of the portion of the skin flap to confirm the slow
septocutaneous perforator. This imaginary and steady ooze of bright-red blood.
line represents the approximate course of 15. Flap thinning: The anchoring suture
the perforator through the intermuscular should be removed and the flap freed. It
septum. Now make an incision about 1 cm should be turned over and the flap thinned
cephalad to this imaginary line and parallel with heavy curved scissors passed parallel
to it. This incision goes through the septum to the surface of the skin. The area around
and divides it. the vascular hilum should not be thinned.
12. Draw an imaginary line connecting 16. The pedicle should be divided only after
the points “A” and “B”. This represents the vessels have been dissected and kept
the vascular hilum of the flap. On the ready on the hand.
undersurface of the flap that we have so far 17. Division of the pedicle: Usually, there are
raised, we can see the deep fascia as a dense two veins and one artery at the point of
white layer. Make a marking on this layer, 1 origin of the vessels from the descending
cm medial to the line “AB”. So the only fascia branch of the lateral circumflex vessels.
we require in our flap is the fascia required The artery and veins should be dissected
to protect the vascular hilum. Continue this free. Soft clamps should be applied over
line distally and proximally for 2 cm. Make the artery and veins. The proximal ends of
the incisions on the markings. the artery and veins should be ligated with
3.0 vicryl. The vessels should be divided
and the time noted. The flap should be
During the entire procedure of dissection of the
placed on a moist abdominal pad with the
pedicle, the vessels must be constantly bathed
raw area facing upward and taken to the
with 1 percent solution of xylocaine. This will
prevent spasm of the vessels. recipient site for vascular anastomosis.
18. Management of the donor site: After
securing hemostasis, the secondary defect
13. Replace the flap back. Make the remaining should be narrowed with 3.0 vicryl and
incisions of the proximal, lateral and distal the proximal end closed primarily with 3.0
borders of the flap. The flap should be ethilon. There will be a residual raw area if
raised from these sides superficial to the the flap has been a big one. This should be
deep fascia. There will be a number of small covered with a split skin graft harvested
CHAPTER 9 VASCULARIZED FREE ANTEROLATERAL THIGH FLAP 45
from the posterior aspect of the same flap is then placed over the defect with
thigh. The graft should be applied over the the correct orientation and the end of
raw area and tie over sutures applied with the pedicle should be placed over the
3.0 ethilon. Sterile dressings should be recipient vessels. A few sutures should be
applied and elastocrépe bandage applied applied to inset the flap.
over it. 20. The recipient vessels should be divided,
blood flow checked from the divided
Vascular Anastomosis artery and approximator clamps applied.
19. The flap is brought to the hand defect. The soft clamps must be released from
First the flap is held up and the pedicle the donor vessels. Vascular anastomosis
allowed hanging down. This step will should be done. (The technique of vascular
make sure that there is no inadvertent anastomosis is beyond the scope of this
twisting of the vascular pedicle. The manual).
SECTION
Other Post-traumatic
Sequelae on the Skin
Adherent Scars
and Contractures 10
A scar on the flexor aspect of the forearm
Introduction that is limited to the ulnar side is most
likely to have involved only the ulnar side
Even if there are no raw areas on the upper
structures such as the ulnar nerve and the
limb, the condition of the skin is the most
flexors of the ring and little fingers.
important point to be assessed. There are
• The width of the scar: A scar that has healed
certain features to be examined and evaluated
by primary intention is usually thin,
before the deeper structures can be assessed.
while a scar that has healed by secondary
The nature of the skin on the upper limb
intention is wider.
may be consisted of any one of the following
• Shape of the scar: In some situations the
types:
shape of the scar will give a clue about the
• Soft and supple skin cause. For example, if the patient has made
• No scars but indurated skin an attempt to camouflage a tattoo on the
• Linear scars following healing by primary forearm with chemicals, the pattern of the
intention
burn and the site of the burn will point
• Linear scars following healing by secondary toward a self-inflicted injury.
intention
• The color of the scar: Some scars are
• Hypertrophic scars hyperpigmented, especially the scars
• Pigmented scars that have been caused by very superficial
• Depigmented scars flame burns that have not been adequately
• Atrophic scars protected during the healing phase. Scars
• Adherent scars that have formed from healing of superficial
• Contracted scars. abrasions also tend to behave in the same
way. The other types of scars that are
hyperpigmented are grafted skin scars,
Examination of the Scar which become hyperpigmented with time.
• The thickness of the scar: This will indicate
• The site of the scar: It gives an idea about the the nature of the lesion that caused the
probable injury to the underlying tissues. scar. If the scar is wide and hypertrophic,
For example, if there is a scar on the flexor it may have been caused by secondary
aspect of the forearm, it indicates possible healing of a wound, or if it is broad and
injury to the flexor tendons and median hypertrophic, it might have been caused
and ulnar nerves. by flame burns.
• The length of the scar: It will also give an • The relationship of the scar to the underlying
idea about the possible structures injured. tissues: This is an indicator of the pliability
50 SECTION 3 OTHER POST-TRAUMATIC SEQUELAE ON THE SKIN
of the skin. Even when there is no scar, unacceptable scars on these areas may
the skin may appear edematous and may damage the body image.
not move passively over the underlying
tissues when it is indurated. Sometimes
grafted skin also becomes adherent to the Management Protocol
underlying tissues.
• Contracture bands: May also develop The set of management protocol is given in
following trauma. The essential manage Table 3.10.1.
ment of such contractures is similar to the
management of contractures following
burns. However, the treatment of post-
Table 3.10.1 Management protocol
traumatic contractures does not end with
the management of the contracture as in Nature of skin or scar Management
burns. The underlying problem must also Edematous skin Hand elevation
be dealt with accordingly. Anti-inflammatory drugs
There are certain problems caused by scars: Indurated skin Compression garments
• Functional problems Scar massage
• Hypertrophic scars can cause functional
Linear scar with no Compression
problems like contractures and limit
tissue problem
ation of movements on the upper limb.
Linear scar with Excision of scar during
• Contractures on the skin can also cause underlying tissue tissue reconstruction
deformities and hence functional deficit. problem requiring
• Problems in later reconstruction Contracture skin Release contracture as in
• When scars are thin and atrophic, chapter on contractures
underlying problems of structures like
Hypertrophic scar with Compression
tendon or bone cannot be accessed no functional deficit If no response after 6
by incisions over this type of skin as months—plan for
wound healing may be poor. Similarly, excision and grafting
adherent scars and hypertrophic scars Hypertrophic scar with Excision and flap cover
have also to be corrected before any functional deficit (flap cover planned
reconstructive surgery can be planned Thin atrophic scar according to area as in
on the underlying tissues. previous segment)
Adherent scar
• Cosmetic problems
• Are also important, because hands Depigmented scar Excision and skin
grafting
are exposed parts of the body and
SECTION
Tendon Reconstruction
Tendon Reconstruction—
Assessment 11
• Duration of injury: Apart from primary
Introduction management of tendon injuries which
have not been dealt with in this manual,
When a patient presents at the outpatient
patients may present later and require
department with a tendon injury, reconstruction
treatment:
must be planned with the following aims:
• To evaluate which tendons have been • Less than 10 days: In such a situation,
the tendon repair can be done at the
injured
end of 10 days when the sutures have
• To evaluate the plan of reconstruction.
been removed and the wound is dry.
The following points should be noted:
• History: The nature of injury and the • Between 10 days and 3 weeks: If the
duration of injury patient has presented during this
• Nature of injury period, it is ideal not to plan for any
• If the injury has been a blunt injury surgical management immediately,
with a forceful extension of a finger but to wait till 3 weeks are over
or a forceful flexion of a finger against after the injury. This is because the
resistance, there is most probably a tissues are in the inflammatory
tendon avulsion. phase and any surgical management
• If the injury was by a penetration will result in more scar formation
injury, most probably, a single tendon and subsequently, more adhesions
has been injured, but other injuries between the tendons and other
like nerve injuries should be ruled out. tissues. Moreover, when the patient
• If the injury was by a sharp instru is taken up for surgery by the end of
ment, it is likely that many tendons 3 weeks, the tendons are so retracted
are injured along with nerves. Hence, that it may be impossible to do
a thorough assessment is necessary. primary repair of the tendons. In such
• If the injury was by a heavy object, situations, a tendon grafting is ideal
leading to skin loss, the tendons for all the flexor tendons and extensor
injured also have segmental loss, tendons of the fingers except the
which must be taken into account flexor pollicis longus (FPL) tendon
during assessment. and the extensor pollicis longus
• If the injury was by avulsion, it is (EPL) tendon of the thumb. If there is
most likely that the entire tendon and a segmental loss of these two tendons
muscle have been lost and this will or the proximal ends have retracted,
require special attention in planning it is ideal to do a tendon transfer for
the treatment. these tendons, rather than a tendon
54 SECTION 4 TENDON RECONSTRUCTION
grafting. However, this waiting period not withstand incisions and wound
can be utilized to mobilize the fingers healing will be poor.
and hand to keep the joints supple • If the skin over the area is a skin flap,
and to strengthen muscles. which is thin and soft, surgery can
• More than 1 year after injury: Some be done for the tendons through this
times, patients turn-up even a year skin.
after the injury, to have reconstruction • If the skin flap is bulky, it is ideal to
done. In such patients, since primary do the first stage of thinning the flap
repair of the tendons will not be and making it more cosmetically
possible, tendon grafting will have acceptable, before the stage of tendon
to be done. However, the bulk of the reconstruction.
muscle should be assessed before • In long standing problems, the skin
planning the tendon graft. This is may have been contracted over the
because the muscle might have area of tendon injury as happens in
undergone atrophy by this time, cases of tendon injuries in children. In
and may not be able to move the such situations, a contracture release
tendon after grafting. Hence, in such is done before tendon reconstruction
situations, a tendon transfer is better is attempted.
suited for such patients. • The finger or fingers affected by the tendon
• The nature of the skin over the affected injury should be noted.
area: • The status of the joints of the hand and of
• If there has been an avulsion of the the affected fingers in particular must be
tendon as in case of flexor digitorum noted. This assessment must include the
profundus (FDP) avulsion, the skin active range of movement and the passive
will grossly appear normal, but tell-tale range of movement. This is particularly
signs of bruising and contusion can be useful in patients who are presenting late
made out in the early few days after for treatment, as the joints become stiff
injury. if regular physiotherapy has not been
• If there was a penetrating injury, a very done.
small scar may be seen that may belie • Any concomitant injury: It is important
the magnitude of injury. to look for other injuries which are likely
• In case of an assault or an injury with a to have happened along with the tendon
sharp instrument, the scar will indicate injury.
the structures that are most probably • Nerve injury: If this is the case,
injured. This scar should be soft and reconstruction of the nerve should also be
supple before any surgical management planned when the tendon reconstruction
is planned. is done.
• If there was a skin loss which has • Bone injury: If there has been a fracture
already been treated with a skin cover, along with the tendon damage at the
this should also be noted. The quality of time of injury, the bony status should
the skin cover is very important: be assessed.
• If the skin over the injured tendon is a • If good union: No bony work is
skin graft, it is necessary to resurface required.
this area with a skin flap before • If fracture malunited but in acceptable
tendon surgery can be done. This position: Tendon reconstruction can
is because the skin grafted area will be carried out right away and it is not
CHAPTER 11 TENDON RECONSTRUCTION—ASSESSMENT 55
Table 4.11.1 Clinical examination

Tendon tested Instructions for the patient
Flexor digitorum profundus of the Hold the middle phalangeal segment of the finger and ask the patient
finger to flex the distal interphalangeal (DIP) joint
Flexor digitorum superficialis (FDS) Place the palm flat on the table with the fingers straight. Place the
of the finger-middle, ring and little examining hand on the fingers except the one that is being tested and
restrain the fingers. Ask the patient to flex only the finger that is being
tested
Flexor digitorum superficialis of Hold the DIP joint of index finger in hyperextension and ask patient to
index finger flex PIP joint
Flexor pollicis longus Hold the proximal phalangeal segment of the thumb and ask the
patient to flex the interphalangeal (IP) joint of the thumb
Extensor digitorum communis Ask the patient to place the palm flat on the table. Ask the patient to
(EDC) of the fingers lift-up the finger being tested
Extensor indicis proprius (EIP) of Ask the patient to make a fist. Now, ask the patient to lift and point the
index finger index finger
Extensor digiti minimi (EDM) of the Ask the patient to make a fist. Now, ask the patient to lift and point the
little finger little finger
Extensor pollicis longus (EPL) Hold the proximal phalangeal segment of the thumb and ask the
patient to extend the IP joint of the thumb
Palmaris longus Oppose the tip of the thumb to the tip of the little finger and flex the
wrist. The tendon can be palpated
Extensors of fingers Make a fist and then extend the wrist
Flexors of the wrist Make a fist and flex the wrist
Table 4.11.2 Diagnosis and management plan

Diagnosis Management plan
Injury to flexor or extensor tendon Delayed primary tendon repair
less than 10 days duration
Injury to flexor or extensor tendon of the finger less Tendon grafting
than 3 months duration
Or segmental loss of flexor or extensor tendon of the
finger
Segmental loss of flexor tendon with injury to pulley Staged flexor tendon reconstruction
system as evidenced by long duration (> 1 year)
extensive scarring over the fingers
Injury to flexor or extensor tendon of the thumb Tendon transfer
greater than 3 months duration
Or segmental loss of flexor or extensor tendon of the
thumb
Avulsion of the flexor tendon of the finger Reattachment of the flexor tendon/flexor tendon
grafting with pull-out suture
Repaired or reconstructed tendon with no active Tendon transfer
movement
Repaired or reconstructed tendon with less than full Flexor tenolysis
active movement, but full passive movement
essential to correct trivial malunion

unless it interferes with function. Clinical Examination
• If malunion and not acceptable:
The details of clinical examinations has been
Osteotomy is required and refixation
given in Table 4.11.1:
should be done in a first stage before
tendon reconstruction can be taken
up. Deciding on the Plan of
• If nonunion is present, this should Management
be dealt with appropriately, and the The diagnosis and management plan is
stage of tendon reconstruction should explained in Table 4.11.2.
be done later when the bone problem
has been settled.
Repair of Avulsed
Flexor Tendon 12
Introduction Presurgical Counseling
The condition of an avulsed flexor tendon • This procedure will be done under axillary
can present either at the emergency theater block anesthesia or general anesthesia (in
or in the outpatient clinic. Recognition of the children)
condition is by the following features: • The procedure consists of reattaching the
• History of blunt injury by a hyperextension avulsed tendon
of the finger—may occur after a fall on the • This procedure will take about 1½ to 2
hand, or by a forceful flexion of the finger hours to perform
when the finger is locked in extension—as • A dressing will be applied and a plaster of
in a sports injury when the finger is caught Paris (POP) slab will be applied at the end
in the shirt of another player. of surgery
• Total inability to flex both interphalangeal • Admission will be necessary for a
(IP) joints of the finger, even though only minimum period of 3 days
the flexor profundus tendon is avulsed. • Postoperatively, no movements of the
This is because the retracted flexor tendon fingers should be attempted. If it is done,
recedes in the pulley and may get caught the sutured tendon may rupture
in the chiasma of the flexor superficialis. • Postoperatively, the POP slab will be
Hence, the superficialis tendon may also continued for a period of 3 weeks. After this
get locked. period, physiotherapy will be started and
• Tell-tale signs of bruising on the finger on this should be done for another 5 weeks
the volar aspect at the terminal phalanx • In some instances, even if the movements
level may be present. of the finger improve, further surgery may
• An X-ray may reveal the proximal end be required to release the scars that may
of the avulsed tendon, if there has been form
an associated fracture of the volar lip of • The general complications of anesthetic
the terminal phalanx, where the flexor infiltration like hypersensitivity may occur
profundus tendon is inserted. in spite of test dose application. This
The treatment of this condition consists of complication will cause dryness of mouth
exploration and reattachment of the avulsed and apprehension, which can be corrected
flexor tendon. immediately.
5. Anchor the raised skin flaps with 3.0

Surgical Steps Ethilon after applying gentle traction on
the skin flaps to afford maximal exposure
1. First, the hand is prepared for surgery as
of the entire flexor tendon sheath of the
finger.
2. Marking the incisions:
6. Now, the entire flexor sheath is exposed.
• First, make a marking on the neutral Examine the sheath to look for signs of the
line of the noncontact surface of the
proximal end of the avulsed and retracted
finger from the web region to the distal
tendon.
interphalangeal (DIP) joint crease.
7. Hematoma under the tendon sheath that
This means that the incision should be
is visible.
made on the ulnar side for the index,
8. Swelling in the flexor sheath at the level
middle and ring finger and the radial
of the proximal phalanx segment of the
side for the little finger.
finger.
• From the DIP joint crease level, extend
9. If the tendon end seems to be lying in
the incision distally across the volar
the tunnel distal to the middle of the
aspect of the terminal phalangeal
proximal phalangeal region (distal to A2
segment (pulp region) in an oblique
pulley), make a small incision about 1 cm
manner to reach the opposite side of
the finger near the tip. long transversely across this site, and try
• From the point on the web region, to retrieve the avulsed tendon from this
extend the incision proximally in an opening in the sheath. If this is difficult, a
oblique manner to reach the distal proximal extension of the incision of the
palmar crease. This marking may have tendon sheath can be made on one side,
to be extended proximally later, but parallel to the underlying tendon.
this is the preliminary marking for the 10. If the tendon end seems to be lying in the
exploration of the flexor tendon of the tunnel in the level of A2 pulley, do not
finger and palm. make any incision on the tendon sheath,
3. Now, the tourniquet is raised and the as the A2 pulley is very important for
incisions are made. Make the incisions function and flexor tendon movement,
down to the subcutaneous tissue. On the and any scarring in this area will
neutral line segment and the terminal compromise movement. So, go proximal
phalanx region, take care to avoid injuring to the A1 pulley which is seen in the palm
the digital neurovascular bundle. Raise level. If it is possible, retrieve the tendon
the entire skin and soft tissues of the proximally from the A1 pulley level. If this
volar aspect of the finger. Thus, the digital is not possible, as happens when there is
neurovascular bundle on the noncontact a segment of bone attached to the end of
surface of the finger will be retained on the the avulsed tendon, make an incision over
finger and the flap will be raised superficial the tendon sheath as described in step 9.
to it. The flap continues to be raised 11. Now, dissect the terminal segment of the
superficial to the fibrous flexor sheath. flexor tendon sheath. Make an incision
This dissection stops when the digital on one side of the tendon sheath at this
neurovascular bundle of the opposite side level and reflect the flap of the sheath
of the finger comes into view. to expose the point of insertion of the
4. Now, raise the palmar portion of the flap flexor profundus tendon into the base of
along with the fat pad (superficial to the the terminal phalanx. This place will be
palmar aponeurosis). The noncontact empty due to the avulsed tendon. Identify
side neurovascular bundle and the flexor the volar aspect of the base of the terminal
tendon sheath will be visible on the bed. phalanx and debride this area. There must
CHAPTER 12 REPAIR OF AVULSED FLEXOR TENDON 59
be a small raw area of the bone into which of bone in this, the suturing of the tendon
the tendon is going to be reattached. will be enough to jam the bone segment
12. Take a polyethylene tube—a scalp vein set into the raw area that has been created in
tube with the needle end cut-off (retain the volar aspect of the terminal phalanx.
this needle end for use later). Thread 15. Make two drill holes from the volar aspect
the free end of the tube into the tendon of the base of the terminal phalanx to exit
sheath from the distal end. Try to reach on the nail plate (Fig. 4.12.2). The two holes
the point where the opening has been must be at a distance of a minimum of 2
made in the tendon sheath to retrieve to 3 mm. Thread the two free ends of the
the proximal end. Deliver the free end of suture material that are on the end of the
the tube in this point. Attach the avulsed tendon through the two drill holes, to exit
end of the flexor tendon to the polye on the nail plate. If this is difficult, it can
thylene tube with 3.0 polypropylenes be done by passing an 18G needle from
suture using horizontal suture technique the nail plate end and then threading the
(Fig. 4.12.1). suture material ends through the needle
13. Now, gently pull on the distal end of the bore.
polyethylene tube to railroad the tendon 16. Now, the tendon has been replaced at
through the remaining segment of the its insertion and the two free ends of the
intact flexor sheath, to the point of insertion suture material are exiting through the
at the terminal phalanx. holes on the nail plate. Take the needle
14. Now, the entire flexor tendon has been end of the scalp vein set that had been
repositioned in the flexor sheath, and cut-off earlier. It has two polyethylene
the reattachment must be done. Take a wings. Cut one of these wings, make two
stitch in the free end of the tendon with holes in it about 2 to 3 mm apart with an
3.0 polypropylenes using Kessler Mason 18G needle. Thread the two free ends of
technique, and keep it ready. Cut-off the the suture material through these holes,
needle of the suture material and leave hold the “button” close to the nail plate
both ends of the suture material long. It and tie the suture securely with surgical
does not matter if there is a small segment knots.
17. Apply gentle compression with moist
gauze and padding over the wound.
Release the tourniquet. Hold the hand in
an elevated position for a period of 4 to 5
minutes. Rest the hand on the table and
secure hemostasis. The finger will now
be seen in its attitude of normal cascade.
Repair the wound made on the flexor
Fig. 4.12.1 Retrieving the proximal retracted flexor digitorum tendon sheath with 5.0 polypropylenes
profundus (FDP) tendon using horizontal mattress suture, with the
knots lying outside the sheath.
18. Suture the skin with 4.0 Ethilon after
keeping Segmüller drains.
It is important to get good hemostasis before

suturing the skin. Hematomas are bad in any
surgery and more so in this type of tendon surgery
because, along with problems in wound healing,
there is a compromise in function of the tendon.
Fig. 4.12.2 Attaching the FDP tendon to the bone
19. Apply sterile dressings, and apply a dorsal • Patient to retain the POP slab
below elbow POP slab, extending till the • Removal of the POP slab on the 21st day
tips of the fingers, with the wrist in neutral and advise the following:
position, metacarpophalangeal (MCP) • Refer to physiotherapy for active mobi-
joints of the fingers in 90° position and the lization of the fingers
IP joints straight. • Daily wash with soap and water
coconut oil
• Review the patient after another 1 week
Postoperative Protocol and remove the dorsal button suture.
Advise the patient to continue:
The postoperative follow-up protocol of this • Active mobilization of the fingers
surgery is very important. • Daily wash with soap and water
• Admission in the ward • Massage of scar and grafted skin with
• The affected hand should be kept elevated coconut oil
• Patient can take normal diet immediately • Review the patient again after another 2 weeks
if the procedure was under regional block (total of 6 weeks after surgery), assess the
or after complete recovery if under general movements and advise
anesthesia • Passive mobilization and passive stretch-
• Inspection of the suture line after 48 hours ing of the finger
without disturbing the position of the POP • To apply straightening splint for the
slab finger at night and to continue active
• Discharge of the patient by third day and passive mobilization of the fingers
• Suture removal on the 10th day. Do not during the day. This should be done for
remove the dorsal button suture 2 weeks.
Flexor Tendon Grafting
13
• The procedure consists of harvesting a
Introduction tendon graft from either the forearm (in
case of one or two fingers) and from the
The most common indications for flexor
thigh (in case of more than two fingers)
tendon grafting are:
• This procedure will take about 2½ to
• Neglected injuries of flexor tendons 3 hours to perform or depends on the
presenting after a period of 3 weeks after
number of fingers involved
injury (especially at Zone II level).
• Segmental loss of flexor tendons due to Paris (POP) slab will be applied at the end
trauma, electrical burns.
of surgery
Flexor tendon grafting can be done only in
situations where the native muscle of the
period of 3 days
particular tendon is intact. For example, if
• Postoperatively, no movements of the
there is a segmental loss of flexor tendon in
fingers should be attempted. If it is done,
the fingers, and another burn on the forearm
the sutured tendons may rupture
in which all the muscles have been lost, a
• Postoperatively, the POP slab will be
flexor tendon graft cannot be done. In such
continued for a period of 3 weeks. After this
situations, tendon transfers are preferable
period, physiotherapy will be started and
from the tendons of healthy muscles.
this should be done for another 3 weeks
Considering the example of a flexor ten
• In some instances, even if the movements
don graft planned for a finger flexor, it can be
of the finger improve, further surgery may
planned to use the flexor superficialis tendon
be required to release the scars that may
as a graft for the flexor digitorum profundus
form
(FDP). Hence, only the FDP tendon is going
• The general complications of anesthetic
to be reconstructed.
If the flexor digitorum superficialis (FDS)
tendon is not available, the palmaris longus
tendon can be harvested and used as a tendon
graft.
immediately.
Surgical Steps
block anesthesia or general anesthesia (in 1. First, the hand is prepared for surgery as
children) described in Appendix I.
crease. This incision should be on the

ulnar half of the distal forearm.
3. Make the incisions down to the subcuta
neous tissue. On the neutral line segment
and the terminal phalanx region, take care
to avoid injuring the digital neurovascular
bundle. Raise the entire skin and soft
tissues of the volar aspect of the finger.
Thus, the digital neurovascular bundle
on the noncontact surface of the finger
will be retained on the finger and the flap
will be raised superficial to it. The flap
continues to be raised superficial to the
fibrous flexor sheath. This dissection stops
when the digital neurovascular bundle of
the opposite side of the finger comes into
view.
4. Now, raise the palmar portion of the flap
along with the fat pad (superficial to the
palmar aponeurosis). The noncontact
side neurovascular bundle and the flexor
Fig. 4.13.1 Incision markings
tendon sheath will be visible on the bed.
5. Anchor the raised skin flaps with 3.0
2. Marking the incisions (Fig. 4.13.1): Ethilon after applying gentle traction on
• First make a marking “A” on the neutral the skin flaps to afford maximal exposure
line of the noncontact surface of the of the entire flexor tendon sheath of
finger from the web region to the distal the finger. Surgeons must look for any
interphalangeal (DIP) joint crease. This associated injury like that of a digital nerve
means that the incision should be made which should be managed along with.
on the ulnar side for the index, middle 6. Distal tendon dissection: The first step is to
and ring fingers and the radial side for dissect the distal part of the tendon. This
the little finger. is the distal end of the flexor profundus
• From the distal IP joint crease level, tendon, as it is this tendon that surgeons
extend the incision distally across the are going to reconstruct. The distal part
volar aspect of the terminal phalangeal of the flexor tendon sheath is opened like
segment (pulp region) in an oblique a book, by making an incision on the side
manner “B” to reach the opposite side of the flexor sheath at the level of the distal
of the finger near the tip. part of the middle phalanx and the terminal
• From the point on the web region, phalanx. This will expose the insertion of
extend the incision “C” proximally in the FDP on the terminal phalanx.
an oblique manner to reach the distal 7. Usually, there will be about 2 to 2.5 cm
palmar crease. This marking will have of the tendon remaining inserted to
to be extended proximally to reach the bone. Only 2 cm should be retained for
proximal part of the hollow between good attachment of the tendon graft.
the thenar and hypothenar eminences. The longer this insertion is left, the less
• A longitudinal incision “D” on the will be the leverage of the tendon, and
forearm measuring about 5 to 6 cm, hence, lesser will be the movement. Once
about 2 cm proximal to the wrist the inserting tendon has been dissected,
CHAPTER 13 FLEXOR TENDON GRAFTING 63
it should be pulled to see if full range of • The proximal portion of the flexor sheath
movement of the distal IP joint is present. as described in the previous step
If there is a restriction of either the flexion • It may be found buried in the lumbrical
or extension, further dissection must be muscle, almost at the distal edge of the
done to free the adhesions with the volar flexor retinaculum.
plate and surrounding tissues. Only when If it is present in the former position,
the full range of passive movement is dissection in the palm will show the FDP
achieved at the distal IP joint, can the next and FDS tendons. These can be held up
step be done. with a retractor to make them taut and
8. Now, consider the remaining segment of the cut portion that is found adherent in
the flexor tendon sheath. This tunnel will the proximal end of the A2 pulley can be
usually be collapsed, and will contain: divided as far as possible. Dissection of
• The insertion of the flexor superficialis the adherent tendon is usually not done
tendon (about 1–1.5 cm) as it may damage the A2 pulley. If it is
• The proximal cut ends of the flexor possible to extricate the cut end of the
superficialis and flexor profundus ten
FDP and FDS tendons without damaging
dons may be present in the proximal
the pulley, it would help to recreate the
part of the tunnel. Even if these
entire tunnel. If the tendons are not found
tendons are present, they will be stuck
at this level, dissection must be done
by dense adhesions to the sides of the
proximally. An easy method is to identify
flexor tunnel.
the corresponding lumbrical tendon of
The flexor sheath also will be weakened
at some places and may not withstand the finger, and dissect within the fibers of
dissection. The most important pulleys this muscle. The cut ends of the tendons
that must be preserved are the A2 of the FDP and FDS will be found as
pulley and the A4 pulley: that is, the rounded ends within the muscle. They
pulley segment over the proximal part can be dissected free and gentle traction
of the proximal phalanx region, and the will release the tendons. The FDP tendon
pulley segment over the proximal part can be identified the area of origin of the
of the middle phalanx region. These two lumbrical muscle. The FDS tendon can
pulleys are essential for achieving good sometimes be identified by its flattened
movements after reconstruction. Hence, end. Now, the proximal end of the tendon
sparing these two pulley segments, the FDP and the tunnel is also ready.
other segments may be opened up to 10. Harvesting the tendon graft: If only one
allow access to the tunnel. Through the finger is involved, the cut tendon of the
approaches possible, a hemostat should FDS of the involved finger is usually
be passed gently to dilate the space in used as a graft to reconstruct the FDP. If
the tunnel that has collapsed and also to it is damaged beyond use, the palmaris
release some of the adhesions that are longus is used as a graft. If the FDS is
holding the walls together. By this method, intact and palmaris longus is absent, FDS
most of the tunnel can be recreated. of the neighboring finger can be used
However, the proximal part may be as a tendon graft. If multiple fingers are
difficult to clear, because it contains the involved, the choice is between the FDS
densely adherent proximal edges of the of the respective fingers or the fascia lata
tendons. graft.
9. Proximal tendon dissection: The proximal • Harvesting the FDS as a graft:
cut end of the tendon will be found in one • A transverse or longitudinal incision
of these two places: about 3 cm is made on the flexor
aspect of the ulnar half of the

forearm, about 3 cm proximal to the
wrist crease. The incision is made
through the skin and subcutaneous
tissues, to expose the flexor tendons
of the fingers
• The tendon of the FDS to the involved
finger is identified by applying traction
on the tendons and noting the
movements
• The cut end of the FDS tendon Fig. 4.13.2 Method of distal tendon repair of equal size
which has already been identified
and dissected in the palm is pulled
and cut tube with 3.0 polypropylenes suture
• It is retrieved from the wrist wound using horizontal suture technique
by pulling on the FDS tendon • Now, gently pull on the distal end of
• Another transverse incision 3.0 the polyethylene tube to railroad the
cm is made about 6 to 7 cm more tendon through the entire length of
proximally on the forearm after the flexor sheath, to the point of distal
applying traction on the cut end of tendon edge at the terminal phalanx
the tendon and palpating the taut • Now, the entire flexor tendon graft has
tendon under the skin been repositioned in the flexor sheath
• The FDS is retrieved through this • The distal end of the tendon graft is
wound, and divided to close to the attached to the distal cut end of the FDP
musculotendinous junction tendon by one of these two methods:
• The tendon is placed in a cup of a. If the size of the cut end of the tendon
normal saline till its use. graft is equal to the size of the distal
• Harvesting the Palmaris longus tendon FDP tendon, the suturing is done
as a graft: It has been described in with 3.0 polypropylenes using modi
Appendix (VII) fied Kessler Mason Allen suture (Fig.
• Harvesting the fascia lata graft: It is 4.13.2)
described in Appendix (VIII). b. If the size of the cut end of the tendon
11. Fixing the tendon graft: graft is smaller than the distal cut end
• Distal tendon anastomosis: Once the of the FDP tendon, the following
tendon graft has been harvested, the technique is used. The distal FDP
tendon grafting can be done. First the tendon is split into two longitudinally
distal tendon anastomosis is done. for about 1 cm. The distal end of the
Before that, the tunnel for the tendon tendon graft is inserted in between
graft to be routed is made ready the two parts. A stitch is taken with
• Take a polyethylene tube—a scalp vein 3.0 polypropylenes from the side,
set tube with the needle end cut-off. through one part of the FDP tendon,
Thread the free end of the tube into then through the tendon graft, and
the tendon sheath from the distal end. again through the second part of
Retrieve the proximal end of the tube in the FDP tendon. This stitch is then
the palm, proximal to the flexor tendon turned back through the same layers
sheath. Deliver the free end of the tube in reverse and the knot is tied (Fig.
in this point. Attach the distal end of 4.13.3) Another stitch of the same
the tendon graft to the polyethylene type can be applied distal to the first,
CHAPTER 13 FLEXOR TENDON GRAFTING 65
and sutured to the other side remnant

of the pulley with 5.0 polypropylenes
using horizontal suture technique with
the knot coming outside. Care should
be taken that the reconstructed pulley
is not so tight as to prevent the flexor
tendon from moving, nor so loose that
the tendon bowstrings on moving
• Apply gentle compression with moist
gauze and padding over the wound.
Release the tourniquet. Hold the hand
in an elevated position for a period of
4 to 5 minutes. Rest the hand on the
table and secure hemostasis. Now, the
skin wound on the finger should be
sutured with 4.0 Ethilon. The passive
movement of the finger on pulling on
Fig. 4.13.3 Method of tendon repair if tendon graft is smaller the free end of the tendon graft, should
again be confirmed
to reinforce the distal attachment.
This suturing should be secured. It is important to get good hemostasis before
It should be remembered that the suturing the skin. Hematomas are bad in any
common cause of tendon dehiscence surgery and more so in this type of tendon surgery
because, along with problems in wound healing,
occurs at the distal anastomosis
there is a compromise in function of the tendon.
• The extralength of the tendon graft
should be excised and stored in saline
as mentioned above, and can be used 12. Proximal tendon anastomosis: The proxi
as material for pulley reconstruction mal end of the tendon graft is now sutured
• Once the distal suturing is over, the to the cut end of the FDP tendon which
free end of the tendon graft that is at has been dissected and kept ready (step
the palm level should be gently pulled 9). The important consideration in this
and the movement pattern of the finger step is the adjustment of tension in the
at the IP joints noted. The finger-tip tendon graft:
should touch the palm. If this does • Pull the cut end of the FDP tendon.
not happen, or, the movement is not It should glide freely forward and
satisfactory, the pulley system should backward. If it does not do so, further
be examined mobilization should be done until
• If there is a deficit at the A2 or A4 it does so. Pull the tendon to the
pulleys, they should be reconstructed maximum. Make a mark on the tendon
• Pulley reconstruction: The excess ten at the point where it just becomes
don graft should be applied over the visible in the wound. Mark this point
area where the pulley is to be recon as “A”. Now, relax the tendon and it
structed. One end should be sutured to will glide back into the forearm for a
the remnant of the original pulley with certain distance. Now, mark the point
5.0 polypropylenes using horizontal where the tendon just becomes visible
suture technique with the knot com at the edge of the wound. Mark this
ing outside. The tendon graft is then point as “B”. So, the distance “AB” is
laid transversely over the tendon graft the amplitude of movement of the
suture with 3.0 polypropylenes using

horizontal mattress suture
• Trim the excess length of the tendon
graft and the FDP. Apply sutures
with 4.0 polypropylenes to attach
the cut ends to the surface of the
Fig. 4.13.4 Pulvertaft technique of tendon suturing tendon.
13. Suture the skin with 4.0 Ethilon after
FDP tendon. Mark the midpoint of keeping Segmüller drains.
the distance “AB” and mark this point 14. Apply sterile dressings, and apply a dorsal
as “C”. Hold the tendon in such a way below elbow POP slab, extending till the
that the point “C” is just visible at the tips of the fingers, with the wrist in neutral
edge of the wound. This should be the position, metacarpophalangeal (MCP)
position of the FDP while it is being joints of the fingers in 90° position and the
sutured to the tendon graft, with the IP joints straight.
finger in a position of normal cascade.
• Pull the free end of the tendon graft so
that the finger is held in a position of Postoperative Protocol
the cascade of the finger. Now, freshen
the two ends of the tendons and repair The postoperative follow-up protocol of this
them in one of the following methods: surgery is very important.
• If the size of the cut end of the • Admission in the ward
tendon graft is equal to the size of • The affected hand should be kept elevated
the cut end of FDP, the suturing • Patient can take normal diet immediately
is done with 3.0 polypropylenes if the procedure was under regional block
using modified Kessler Mason Allen or after complete recovery if under general
suture anesthesia
• If the size of the cut end of the tendon • Inspection of the suture line after 48 hours
graft is smaller than the distal cut end without disturbing the position of the POP
of the FDP tendon, the Pulvertaft slab
technique (Fig. 4.13.4) is used • Discharge of the patient by third day
• Hold the FDP tendon taut with a • Suture removal on the 10th day
hemostat applied on the end and • Patient to retain the POP slab
pulling distally • Removals of the POP slab on the 21st day
• About 1 cm proximal to the end of and advise the following:
the tendon, make a cut in a volar to • Refer to physiotherapy for active mobiliz
dorsal direction with a number 11 ation of the fingers
blade, with just enough length to • Daily wash with soap and water
allow the tendon graft through. Pull • Massage of scar and grafted skin with
the tendon graft through and adjust coconut oil
the tension so that the finger lies in • Review the patient again after another
the normal cascade. Apply a suture 2 weeks (total of 6 weeks after surgery),
with 3.0 polypropylenes using hori assess the movements and advice passive
zontal mattress suture mobilization and passive stretching of the
• About 1 cm proximal to the first cut, finger
make another cut with number 11 • To apply straightening splint for the finger
blade, from a radial to ulnar direction. at night and to continue active and passive
Thread the free end of the tendon mobilization of the fingers during the day.
graft through this opening also and This should be done for 2 weeks.
Staged Flexor
Tendon Reconstruction 14
• Only after 3 months, the next stage will be
Introduction done.
• In some rare instances, the implant may
In some cases where a tendon graft is required,
extrude. In this situation, the procedure
the procedure should not be done as described
will have to be redone with a new implant.
in the previous chapter in a single stage. It
should be done in a staged procedure consisting
of two stages. This is usually prescribed when
the duration is more than a year, or there are
multiple scars on the involved fingers.
immediately.
Stage II
This procedure will consist of two stages. • The procedure consists of harvesting a
Both stages will be done under axillary block tendon graft from either the forearm (in
anesthesia or general anesthesia: case of one or two fingers) and from the
thigh (in case of more than two fingers).
Stage I • This procedure will take about 1½ to 2
• The first stage consists of inserting the hours to perform.
silastic implant in the finger. • A dressing will be applied and a POP slab
• This procedure will take about 1½ to 2 will be applied at the end of surgery.
hours to perform. • Admission will be necessary for a
• A dressing will be applied and a plaster of minimum period of 3 days.
Paris (POP) slab will be applied at the end • Postoperatively, no movements of the
of surgery. fingers should be attempted. If it is done,
• Admission will be necessary for a minimum the sutured tendons may rupture.
period of 3 days. • Postoperatively, the POP slab will be
• Postoperatively, no movements of the continued for a period of 3 weeks. After this
fingers should be attempted. If it is done, period, physiotherapy will be started and
the sutured tendons may rupture. this should be done for another 3 weeks.
• Postoperatively, the POP slab will be • In some instances, even if the movements
continued for a period of 3 weeks. After this of the finger improve, further surgery may
period, physiotherapy will be started and be required to release the scars that may
this should be done for another 3 weeks. form.
• The general complications of anesthetic manner “B” to reach the opposite side
infiltration like hypersensitivity may occur of the finger near the tip.
in spite of test dose application. This • From the point on the web region,
complication will cause dryness of mouth extend the incision “C” proximally in
and apprehension, which can be corrected an oblique manner to reach the distal
immediately. palmar crease. This marking will have
to be extended proximally to reach the
proximal part of the hollow between the
Surgical Steps thenar and hypothenar eminences.
• A longitudinal incision “D” on the
Stage I forearm measuring about 5 to 6 cm,
about 2 cm proximal to the wrist crease.
• First the hand is prepared for surgery as
This incision should be on the ulnar half
described in Appendix I
of the distal forearm.
• Marking the incisions (Fig. 4.14.1):
• First make a marking “A” on the neutral • Make the incisions down to the sub
cutaneous tissue. On the neutral line
line of the noncontact surface of the
segment and the terminal phalanx region,
finger from the web region to the distal
take care to avoid injuring the digital
interphalangeal (DIP) joint crease. This
neurovascular bundle. Raise the entire
means that the incision should be made
skin and soft tissues of the volar aspect of
on the ulnar side for the index, middle
the finger. Thus, the digital neurovascular
and ring fingers and the radial side for
bundle on the noncontact surface of the
the little finger.
finger will be retained on the finger and
• From the DIP joint crease level, extend
the flap will be raised superficial to it. The
the incision distally across the volar
flap continues to be raised superficial to the
aspect of the terminal phalangeal
segment (pulp region) in an oblique
view.
• Now, raise the palmar portion of the flap
side neurovascular bundle and the flexor
tendon sheath will be visible on the bed.
• Anchor the raised skin flaps with 3.0 Ethilon
after applying gentle traction on the skin
flaps to afford maximal exposure of the entire
flexor tendon sheath of the finger. Surgeons
must look for any associated injury like that
of a digital nerve which should be managed
along with.
• Distal tendon dissection: The first step is to
dissect the distal part of the tendon. This
is the distal end of the flexor profundus
tendon, as it is this tendon that surgeons
are going to reconstruct. The distal part
of the flexor tendon sheath is opened
Fig. 4.14.1 Incision markings for stage I like a book, by making an incision on the
CHAPTER 14 STAGED FLEXOR TENDON RECONSTRUCTION 69
side of the flexor sheath at the level of in the tunnel that has collapsed and
the distal part of the middle phalanx and also to release some of the adhesions
the terminal phalanx. This will expose that are holding the walls together. By
the insertion of the flexor digitorum this method, most of the tunnel can
profundus (FDP) on the terminal phalanx. be recreated. However, the proximal
• Usually, there will be about 2 to 2.5 cm part may be difficult to clear, because it
of the tendon remaining inserted to contains the densely adherent proximal
bone. Only 2 cm should be retained for edges of the tendons.
good attachment of the tendon graft. The • Now, a longitudinal incision should be
longer this insertion is left, the less will made on the forearm measuring about
be the leverage of the tendon, and hence, 5 to 6 cm, about 2 cm proximal to the
lesser will be the movement. Once the wrist crease. This incision should be on
inserting tendon has been dissected, it the ulnar half of the distal forearm.
should be pulled to see if full range of • The flexor digitorum superficialis (FDS)
movement of the DIP joint is present. If and FDP tendons of the fingers should
there is a restriction of either the flexion or be dissected through this incision. Care
extension, further dissection must be done should be taken to avoid injury to the
to free the adhesions with the volar plate median nerve at this area.
and surrounding tissues. Only when the • Take a polyethylene tube—a scalp vein
full range of passive movement is achieved set tube with the needle end cut-off.
at the DIP joint, can the next step be done. Thread the free end of the tube in to the
• Now, consider the remaining segment of carpal tunnel from the palm. Retrieve
the flexor tendon sheath. This tunnel will the tube in the proximal end in the
usually be collapsed, and will contain: forearm and retain it with a hemostat.
• The insertion of the flexor superficialis Route this palmar end of the tube
tendon (about 1–1.5 cm). further distally through the remaining
• The proximal cut ends of the flexor flexor tendon sheath to the insertion of
superficialis and flexor profundus the FDP tendon. The polyethylene tube
tendons may be present in the proximal now lies in the proposed course of the
part of the tunnel. Even if these tendons tendon implant
are present, they will be stuck by dense • Change the gloves, wash with normal
adhesions to the sides of the flexor saline and open the tendon implant
tunnel. packet.
• The flexor sheath also will be weakened
at some places and may not withstand
Make sure that glove powder does not come
dissection. The most important pulleys
in contact with the implant material. If so, talc
that must be preserved are the A2 granuloma may form and cause adhesions.
pulley and the A4 pulley: that is, the
pulley segment over the proximal part
of the proximal phalanx region, and the • Now, attach the tendon implant to the
pulley segment over the proximal part proximal end of this polyethylene tube
of the middle phalanx region. These two with 4.0 polypropylenes using horizontal
pulleys are essential for achieving good mattress suture. Now, gently pull on the
movements after reconstruction. Hence, distal end of the polyethylene tube to
sparing these two pulley segments, the railroad the tendon implant through the
other segments may be opened up to entire length, to the point of distal tendon
allow access to the tunnel. Through the edge at the terminal phalanx. Now, the
approaches possible, a hemostat should entire tendon implant has been positioned
be passed gently to dilate the space (Fig. 4.14.2).

anesthesia
• Inspection of the suture line after 48 hours
without disturbing the position of the POP
slab. Start gentle passive movements of the
fingers
• Discharge of the patient by third day
• Suture removal on the 10th day
• Patient to retain the POP slab
• Removal of the POP slab on the 21st day
• Refer to physiotherapy for active mobi
lization of the fingers
• Daily wash with soap and water
coconut oil
• Patient is advised to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
The next stage of surgery is done after a period
of 3 months.
Fig. 4.14.2 Positioned silastic implant in the flexor sheath
If an ulcer develops at the incision line or at any
other point on the finger, it indicates that:
• Suture the distal end of the tendon implant • There is an infection
to the stump of the FDP tendon insertion as • The implant is beginning to extrude. The patient
must be given a course of strong antibiotics. If
follows. Place the distal end of the tendon
the ulcer fails to heal, the patient must be taken
implant under the stump of the FDP. Apply to surgery as soon as possible and the implant
horizontal mattress sutures to anchor the removed, a thorough wash given and the
implant to the tendon. wounds closed. Reconstruction of the tendons
• The proximal end of the tendon implant will have to be planned again.
should be left free in the forearm wound
• Moist saline gauze is placed over the
entire length of the wound and gentle Stage II
compression applied. The hand is • First the hand is prepared for surgery as
elevated and the tourniquet released. described in Appendix I.
After 3 minutes, the hand is kept back on • Marking the incisions (Fig. 4.14.3):
the table and hemostasis achieved. The • In this stage only the distal most
wounds are closed with 4.0 Ethilon after and proximal forearm incisions are
placing Segmüller drains. required. This is to expose the sites of
the proposed tendon anastomoses only.
Postoperative Protocol for Stage I • From the DIP joint crease level, extend
• Admission in the ward the incision “A” distally across the volar
• The affected hand should be kept elevated aspect of the terminal phalangeal
• Patient can take normal diet immediately segment (pulp region) in an oblique
if the procedure was under regional block manner to reach the opposite side of
end of the tendon implant. The proximal

end of the FDP of the injured finger is also
identified and tagged. This tendon will be
anastomosed to the proximal end of the
tendon graft later in the procedure.
• The tendon graft should now be harvested.
Measure the tendon graft required, by
measuring the distance between the tip
of the finger and the forearm incision. The
usual tendon used in this procedure is the
palmaris longus tendon. The method of
harvesting this tendon is described in the
Appendix VII.
• Railroading the tendon graft: At the
proximal forearm incision site, retrieve the
proximal end of the tendon implant. Take
the tendon graft and determine which the
thinner end is. To this thinner end, attach
the proximal end of the tendon implant
loosely with 4.0 polypropylene using
horizontal mattress suture. At the distal
Fig. 4.14.3 Incision markings for stage II end incision, remove the suture between
the distal end of the tendon implant and
the finger near the tip. If necessary, the the FDP tendon. Carefully pull the tendon
incision can be extended proximally implant out and monitor the tendon graft
from the level of the DIP joint along the that is moving inside along with it. Do
neutral line for about 2 cm to afford good not lose sight of the proximal end of the
exposure of the insertion of the FDP tendon graft.
tendon. • Once the suture between the tendon
• The second incision “B” that should implant and the tendon graft is visible at
be marked is the forearm incision the terminal phalangeal level, remove the
as described in stage I. This incision suture between them. Discard the tendon
should be marked in such a way that the implant.
previous scar can be excised. • Fixing the tendon graft:
• The tourniquet can be raised and the • Distal tendon anastomosis: The distal
incisions made. First the distal incision end of the tendon graft is attached to
is made. The flap of skin that is raised is the distal cut end of the FDP tendon by
anchored with 4.0 Ethilon. The insertion one of the following methods:
of the FDP tendon is exposed along with • If the size of the cut end of the
the distal end of the tendon implant. The tendon graft is equal to the size of
scar tissue is excised around the tendon the distal FDP tendon, the suturing is
and the DIP joint is mobilized passively to done with 3.0 polypropylenes using
achieve full range of motion. modified Kessler Mason Allen suture
• A saline soaked gauze piece is placed over (See Fig. 4.13.2)
this area and the proximal incision on the • If the size of the cut end of the tendon
forearm is made. graft is smaller than the distal cut
• The forearm incision is made and the flexor end of the FDP tendon, the following
tendons identified along with the proximal technique is used. The distal FDP
tendon is split into two longitudinally glide back into the forearm for a certain
for about 1 cm. distance. Now mark the point where
• The distal end of the tendon graft is the tendon just becomes visible at the
inserted in between the two parts. A edge of the wound. Mark this point as
stitch is taken with 3.0 polypropylene “B”. So, the distance AB is the amplitude
from the side, through one part of of movement of the FDP tendon. Mark
the FDP tendon, then through the the midpoint of the distance AB and
tendon graft, and again through the mark this point as “C”. Hold the tendon
second part of the FDP tendon. This in such a way that the point “C” is just
stitch is then turned back through the visible at the edge of the wound. This
same layers in reverse and the knot is should be the position of the FDP while
tied. Another stitch of the same type it is being sutured to the tendon graft.
can be applied distal to the first, to • Pull the free end of the tendon graft so that
reinforce the distal attachment. This the finger is held in a position of the cascade
suturing should be secure. It should of the finger. Now, freshen the two ends of
be remembered that the common the tendons and repair them in one of the
cause of tendon dehiscence occurs at following methods:
the distal anastomosis. • The Pulvertaft technique is used for
• Once the distal suturing is over, tendon anastomosis at this level.
the free end of the tendon graft • Hold the FDP tendon taut with a
that is at the distal forearm level hemostat applied on the end and
should be gently pulled and the pulling distally.
movement pattern of the finger • About 1 cm proximal to the end of the
at the interphalangeal (IP) joints tendon, make a cut in a volar to dorsal
noted. The finger-tip should touch direction with a number 11 blade, with
the palm. just enough length to allow the tendon
• The skin wound on the finger should graft through. Pull the tendon graft
now be sutured with 4.0 Ethilon. The through and adjust the tension so that
passive movement of the finger on the finger lies in the normal cascade.
pulling on the free end of the tendon Apply a suture with 3.0 polypropylene
graft, should again be confirmed. using horizontal mattress suture.
• Proximal tendon anastomosis: The • About 1 cm proximal to the first cut,
proximal end of the tendon graft make another cut with number 11 blade,
is now sutured to the cut end of from a radial to ulnar direction. Thread
the FDP tendon which has been the free end of the tendon graft through
dissected and kept ready. The this opening also and suture with 3.0
important consideration in this step polypropylene using horizontal mattress
is the adjustment of tension in the suture.
tendon graft. • Trim the excess length of the tendon
• Pull the cut end of the FDP tendon. graft and the FDP. Apply sutures with
It should glide freely forward and 4.0 polypropylene to attach the cut ends
backward. If it does not do so, further to the surface of the tendon.
mobilization should be done until • Suture the skin with 4.0 Ethilon after
it does so. Pull the tendon to the keeping Segmüller drains.
maximum. Make a mark on the tendon • Apply sterile dressings, and apply a dorsal
at the point where it just becomes below elbow POP slab, extending till the
visible in the wound. Mark this point tips of the fingers, with the wrist in neutral
as “A”. Now, relax the tendon and it will position, metacarpophalangeal (MCP)
joints of the fingers in 90° position and the • Patient to retain the POP slab
IP joints straight. • Removal of the POP slab on the 21st day
Postoperative Protocol for Stage II • Refer to physiotherapy for active
The postoperative follow-up protocol of this mobilization of the fingers
surgery is very important. • Daily wash with soap and water
• Admission in the ward • Massage of scar and grafted skin with
• The affected hand should be kept elevated coconut oil
• Patient can take normal diet immediately • Review the patient again after another
if the procedure was under regional block 2 weeks (total of 6 weeks after surgery),
or after complete recovery if under general assess the movements and advise passive
anesthesia mobilization and passive stretching of the
• Inspection of the suture line after 48 hours finger
without disturbing the position of the POP • To apply straightening splint for the finger
slab at night and to continue active and passive
• Discharge of the patient by third day mobilization of the fingers during the day.
• Suture removal on the 10th day This should be done for 2 weeks.
Flexor Tenolysis
15
• In some instances, if the tendon is very
Introduction grossly stuck and devoid of blood supply, a
staged reconstruction may have to be done.
One of the most rewarding surgeries of the
This involves inserting a tendon implant,
tendons is flexor tenolysis. This surgery is done
harvesting a tendon graft, and two surgical
when the passive range of motion is more than
stages.
the active range of motion.
• In some instances, in the postoperative
period, the tendon may rupture due to
reduced blood supply. In such situations,
Presurgical Counseling the aforementioned staged procedure will
have to be done after the wounds heal.
• This procedure will be done under wrist • In some instances, even if the movements
block anesthesia as patient cooperation will of the finger improve, further surgery may
be required in the course of the procedure. be required to reconstruct the pulleys.
• A tourniquet will be applied and raised, • The general complications of local anesthetic
but will be released before pain starts. infiltration like hypersensitivity may occur
• This procedure will take about 30 to 45 in spite of test dose application. This
minutes to perform if it involves a single complication will cause dryness of mouth
finger and more if more fingers are and apprehension, which can be corrected
involved. immediately.
• The return of full movement will be shown to
the patient on the table. If this movement is to
be maintained, postoperative physiotherapy
is a must. Surgical Steps
• A dressing will be applied and no plaster of
Paris (POP) will be applied. • This procedure should be done under
• A catheter will be placed in the wrist (like wrist block anesthesia. However, if more
an IV cannula), through which, anesthetic than one finger is involved, the procedure
solution will be injected if there is pain. is better done under axillary block
• Admission will be necessary for a anesthesia, as the patient cannot tolerate
minimum period of 3 days. the tourniquet for a prolonged time under
• Postoperatively, gentle active mobilization local anesthesia.
of the finger should be continued. If it is • First prepare the hand as described in
stopped, the finger will get back to the Appendix I.
original state before surgery. • Marking the incisions (Fig. 4.15.1):
CHAPTER 15 FLEXOR TENOLYSIS 75
as the intervening skin flap may be

jeopardized. Hence, a single ‘C’ incision
to afford exposure of all the finger
flaxors in the palm is advised.
• Make the incisions down to the sub
cutaneous tissue. On the neutral line
segment and the terminal phalanx region,
take care to avoid injuring the digital
neurovascular bundle. Raise the entire
skin and soft tissues of the volar aspect of
the finger. Thus, the digital neurovascular
bundle on the noncontact surface of the
finger will be retained on the finger and the
flap will be raised superficial to it. The flap
continues to be raised superficial to the
view.
• Now, raise the palmar portion of the flap
Fig. 4.15.1 Markings for exposure of the flexor side neurovascular bundle and the flexor
tendons for tenolysis tendon sheath will be visible on the bed.
• Anchor the raised skin flaps with 3.0
• First make a marking ‘A’ on the neutral Ethilon after applying gentle traction on
line of the noncontact surface of the the skin flaps to afford maximal exposure
finger from the web region to the distal of the entire flexor tendon sheath of the
interphalangeal (DIP) joint crease. This finger.
means that the incision should be made • All the adhesions between the tendons and
on the ulnar side for the index, middle the surrounding tissues must be divided.
and ring fingers and the radial side for Care must be taken to avoid injuring the
the little finger. pulley system.
• From the DIP joint crease level, extend • When all the adhesions have been divided,
the incision distally across the volar the tendons must be pulled proximally
aspect of the terminal phalangeal and the movement of the finger noted.
segment (pulp region) in an oblique The finger must flex fully and the tip of the
manner to reach the opposite side of finger should touch the palm. If not, a few
the finger near the tip ‘B’. more adhesions will have to be released till
• From the point on the web region, extend this is achieved. Then ask the patient to flex
the incision proximally ‘C’ in an oblique the finger. He may not be able to isolate the
manner to reach the distal palmar crease. finger to move due to the local anesthesia,
This marking will have to be extended so he must be instructed to flex all the
proximally to reach the proximal part fingers at once, slowly. This will flex the
of the hollow between the thenar and finger that is involved. The range of motion
hypothenar eminences. must be noted again. If all adhesions have
• If multiple fingers are involved, been achieved, full range of active motion
multiple ‘C’ incisions cannot be made will be present. This must be shown to
the patient, so that it will serve as an fixed with plaster after the wounds are
impetus for postoperative physiotherapy. sutured.
If full range is not achieved, two things are • Suture the skin with 4.0 Ethilon after
possible. Either there are more adhesions keeping Segmüller drains and apply sterile
proximally, that should be released, or, dressings.
the pulley system is damaged and needs
to be reconstructed. This reconstruction
should be done at a later procedure, since
mobilization is needed after tenolysis, Postoperative Protocol
which cannot be implemented if pulley
reconstruction is done. The postoperative follow-up protocol of this
• Moist saline gauze is placed over the surgery is very important.
entire length of the wound and gentle • Admission in the ward.
compression applied. The hand is elevated • The affected hand should be kept elevated.
and the tourniquet released. After 3 • Patient can take normal diet immediately
minutes, the hand is kept back on the table if the procedure was under regional block
and hemostasis achieved. or after complete recovery if under general
• For giving postoperative analgesia for anesthesia.
the thumb, index and middle fingers, a • Four milliliter of 1 percent solution of
Venflon catheter should be inserted in Bupivacaine must be injected into the
the volar aspect of the wrist, about 1 cm cannula once every 6 hours. The patient
proximal to the wrist crease. The needle must be attended to by a physiotherapist
must be inserted to the ulnar side of the and both active and passive mobilization
palmaris longus tendon, the needle being of the fingers must be done.
aimed deeply, pointing to the knuckle of • Inspection of the suture line after 48 hours.
the middle finger. This cannula will deliver • Discharge of the patient by third day.
anesthetic solution in the area surrounding • Suture removal on the 10th day.
the median nerve. If the ring or little fingers • Refer to physiotherapy for active mobiliz
have been involved, the Venflon catheter is ation of the fingers
placed to the radial side of the flexor carpi • Daily wash with soap and water
ulnaris (FCU) tendon about 1 cm proximal • Massage of scar and grafted skin with
to the wrist crease. This cannula must be coconut oil.
Extensor Tendon
Reconstruction 16
Introduction infiltration like hypersensitivity may occur
In situations where there is a loss of extensor
tendons on the dorsum of the hand,
reconstruction with grafting is ideal since the
immediately.
extensor muscles are intact. If the extensor
muscles are lost or deservated, tendon transfer
is ideal and has been described in chapter 45.
Surgical Steps
• First the hand is prepared as described in
Presurgical Counseling Appendix I.
• Markings for the incisions will depend on
• This procedure will be done under axillary the situation.
block anesthesia or general anesthesia. • There are two situations in which extensor
• The procedure consists of harvesting a tendon grafts are commonly done:
tendon graft from either the forearm (in • An injury to the extensor tendons on
case of one or two fingers) and from the the dorsum of the hand with scars
thigh (in case of more than two fingers). running across the dorsum of the hand
• This procedure will take about 1½–2 hours or the forearm. These patients have
to perform. presented late for treatment (more than
• A dressing will be applied and a plaster of 3 months). Hence, a secondary repair of
Paris (POP) slab will be applied at the end the tendons will not be possible and a
of surgery. tendon grafting is done.
• Admission will be necessary for a minimum • An injury with loss of extensor tendons
period of 3 days. on the dorsum of the hand with
• Postoperatively, no movements of the concomitant skin loss, which has been
fingers should be attempted. If it is done, corrected by a skin flap surgery done
the sutured tendons may rupture. at the time of injury. In such situations,
• Postoperatively, the POP slab will be the tendon reconstruction is done as a
continued for a period of 3 weeks. After this secondary procedure.
period, physiotherapy will be started and • In the former situation (Fig. 4.16.1), the
this should be done for another 3 weeks. incision is a longitudinally oriented lazy
• In some instances, even if the movements of “S” shaped incision extending from about
the finger improve, further surgery may be 4 cm distal to the scar to 4 cm proximal to
required to release the scars that may form. the scar. The original scar is usually not
opened up and the new incision usually

cuts across the previous scar.
• In the latter situation, where there is a
skin flap over the area of tendon loss, the
incisions are made as follows (Fig. 4.16.2):
• The distal edge of the flap is marked “A”
from the lateral side to the medial side.
• The proximal edge of the flap is also
marked “B” from the lateral side to the
medial side.
• From the center point of the proximal
edge, an “S” shaped incision is marked
“C”, extending proximally for about 4 cm.
• The tourniquet is raised and the incisions
are made as depends on the nature of
injury as described above.
• First the distal incision is made. The skin
flaps are dissected to afford good exposure
of the distal ends of the extensor tendons.
These tendons are isolated and all the
scar tissues around them are excised.
Fig. 4.16.1 Incision for extensor reconstruction The tendons are pulled proximally with
hemostats to determine whether the full
range of passive movement has been
achieved. If the finger movement is not
full, further tenolysis must be done and
the scars that attach the tendons to the bed
must be released.
• Now, the proximal incision is made and the
skin flaps reflected as marked. The proximal
cut end of the extensor tendons are
identified and dissected. The scars adherent
to the proximal cut end of the tendons is
excised. The tendons should be totally freed
from scars and then the tendons should
be pulled distally to evaluate the mobility
of the extensor muscles. If the muscles are
good, the tendon grafting can be done.
• The distance between the proximal end of
the extensor tendons and the distal end is
measured and the tendon graft harvested.
If the tendon graft is planned for one or
two fingers, the palmaris longus can be
harvested as a graft. If the tendon graft is
planned for more than two fingers, the
palmaris longus may not be sufficient, and
the fascia lata must be harvested as a graft.
• The method of harvesting the tendon grafts
Fig. 4.16.2 Incisions in case of flap reconstruction is described in Appendix VII and VIII.
CHAPTER 16 EXTENSOR TENDON RECONSTRUCTION 79
• Tendon anastomoses using the palmaris the wrist is flexed passively, the finger
longus tendon graft: the proximal tendon whose extensor has been repaired must
anastomosis is done first. The tendon graft extend passively. Similarly, when the wrist
is woven into the proximal cut ends of the is extended, the finger must extend at the
extensor tendons with 4.0 polypropylene metacarpophalangeal (MCP) joint. Thus,
suture using horizontal mattress suture. the extensor tendons must be anastomosed
After the tendon graft is woven through for all the fingers after checking this effect.
the ends of the tendons, the tendon graft • After all the extensors have been
is sutured to itself to make the anastomosis anastomosed, moist gauze is placed over
secure. Now, the distal end of the tendon the incisions, gentle compression applied
graft is taken to the distal incision site. If and the hand elevated. The tourniquet is
the tendon graft is intended for two fingers, released, and the elevation of the hand is
the tendon graft is split longitudinally. If maintained for 3 minutes.
this surgery is being done on a patient who • The hand is then placed back on the table
has had a skin flap applied on the dorsum and hemostasis achieved. The wounds
of the hand, the entire skin bridge need are sutured with 4.0 Ethilon after keeping
not be opened up. A subcutaneous tunnel Segmüller drains. Sterile dressings are
can be created under the skin flap from applied.
the proximal incision to the distal incision. • A volar slab POP is applied keeping the
The tendon graft can be routed through wrist in 30° extensions, the MCP joints in
this tunnel to the distal incision. 60º flexion and the interphalangeal (IP)
• If the fascia lata has been harvested as a joints extended.
tendon graft, the graft must be prepared
before the proximal tendon anastomosis.
The graft should be tubed with the external Postoperative Protocol
surface of the fascia lata graft going inside
and the deeper surface of the graft forming • Admission in the ward
the surface of the tube. The tubing is done • The affected hand should be kept elevated
after the formed tube is placed around the • Patient can take normal diet immediately
proximal ends of the cut extensor tendons. if the procedure was under regional block
The seam line of the tube is sutured with or after complete recovery if under general
4.0 polypropylene using continuous anesthesia
buried suture technique. The tubing is • Inspection of the suture line after 48 hours
not done for the entire length of the graft. without disturbing the position of the POP
The distal half of the tendon graft is split slab
into slips depending on the number of • Discharge of the patient by third day
fingers for which the extensors are to • Suture removal on the 10th day
be reconstructed. The distal ends of the • Patient to retain the POP slab
tendon graft are taken to the distal incision. • Removal of the POP slab on the 21st day
• Distal tendon anastomoses: The slips of the and advise the following:
tendon graft are sutured to the distal ends • Refer to physiotherapy for active
of extensor tendons. The suturing is done mobilization of the fingers
with 4.0 polypropylene using horizontal • Daily wash with soap and water
mattress suture. At this juncture, the most • Massage of scar and grafted skin with
important thing to consider is adjusting coconut oil
the tension of suturing. Each finger • Patient is advised to continue the
extensor must be sutured and the position mobilization of the fingers; both active
of the finger checked. The tenodesis effect and passive and review once every
must be present. This means that when month for evaluation.
17
Extensor Indicis Proprius to
Extensor Pollicis Longus
Tendon Transfer

Introduction infiltration like hypersensitivity may occur
As described earlier, the loss of a segment of
EPL tendon or delayed presentation of EPL
tendon injury warrants reconstruction with a
immediately.
tendon transfer using EIP tendon.
Surgical Steps
• This procedure will be done under axillary Appendix I.
block anesthesia or general anesthesia.
• Markings for the incisions (Fig. 4.17.1):
• The procedure consists of harvesting a
tendon graft from the index finger. There
will be no deficit on the index finger as a
result of this.
• This procedure will take about 1½–2 hours
to perform.
Paris (POP) slab will be applied at the end
of surgery.
minimum period of 3 days.
• Postoperatively, no movements of the
fingers should be attempted. If it is done,
the sutured tendons may rupture.
this should be done for another 3 weeks.
• In some instances, even if the movements
of the finger improve, further surgery may
be required to release the scars that may
form. Fig. 4.17.1 Markings for the tendon transfer
CHAPTER 17 EXTENSOR INDICIS PROPRIUS TO EXTENSOR POLLICIS LONGUS TENDON TRANSFER 81
• Incision A: An incision is marked over • Now, a subcutaneous tunnel is created

the area where the distal cut end of the between the incision “A” and incision
extensor pollicis longus (EPL) tendon is “C”. A tendon retriever is inserted from
present the incision “A” and passed through the
• Incision B: Now, an S-shaped incision is subcutaneous tunnel to the incision “C”.
marked over the dorsum of the proximal Here, the free end of the EIP tendon is
phalanx of the index finger, starting on grasped, pulled and delivered at incision
the ulnar side of the proximal phalanx, “A”.
extending proximally across the • Moist gauze is placed over the wounds and
knuckle of the metacarpophalangeal gentle compression is applied. The hand
(MCP) joint and the dorsum of the hand is raised and the tourniquet released. The
• Incision C: Another incision about 2 cm elevation of the hand is maintained for
is marked over the dorsal aspect of the 3 minutes and then the hand is placed
wrist. back on the table. Hemostasis is achieved.
• The tourniquet is raised. First the incision • The gap that has been created in the
to expose the EPL is made and the skin extensor apparatus by the removal of the EIP
flaps are raised. The distal cut end of the tendon is sutured with 4.0 polypropylenes
EPL tendon is identified, and dissected using continuous suture. The skin wounds
free from the surrounding scar tissue. The at incision “B” are sutured with 4.0 Ethilon.
EPL tendon is now pulled proximally after • The skin wounds at incision “C” are also
grasping with a hemostat. The passive sutured with 4.0 Ethilon after securing
movement of the thumb interphalangeal hemostasis.
(IP) joint must be full. If it is not so, a • Now, the distal end of the EIP tendon
further dissection must be done to release must be sutured to the EPL tendon. The
the tendon from the scar. The distance mechanical advantage is more if the EIP
from the radial styloid to the dorsum of tendon is sutured as distally as possible. If
the IP joint of the thumb is measured. This a long length of the EPL tendon is available,
will be the length of the extensor indicis it is advantageous to excise a portion of this
proprius (EIP) tendon required beyond tendon up to the level of the MCP joint of
the wrist. the thumb and then suture the EIP tendon
• Now, the incision is made to harvest the to the remaining stump of the EPL tendon.
EIP tendon. The skin flaps are raised and A trial stitch with 4.0 polypropylenes is
anchored with 4.0 Ethilon sutures. The applied and the tension is checked. The
extensor tendons to the index finger are tenodesis effect is now checked as an
exposed. Now, the EIP tendon is isolated. indicator of the tension adjustment in the
Of the two extensor tendons to the index tendon anastomosis. The wrist is passively
finger, the ulnar side tendon is the EIP flexed. This movement should cause
tendon. The tendons are separate from extension of the thumb IP joint. Similarly,
each other till they reach the knuckle of the passive flexion of the wrist should cause a
index. An incision is made over the middle flexion of the thumb joints. If this happens,
of the extensor expansion, and extended the tension on the tendon transfer is correct.
distally for as much length of the tendon is If there is too much tension, or too little
required. tension, it should be corrected by redoing
• Now, the tendon of EIP is harvested. It is the tendon anastomosis.
pulled distally to confirm that there are • The tendon anastomosis is done by
no more attachments of the EIP. Now, the Pulvertaft weave. Hold the EPL tendon
incision “C” is made and the EIP tendon taut with a hemostat applied on the end
pulled out through this wound. and pulling proximally.
and the tourniquet released. After 3 minutes,

the hand is kept back on the table and
hemostasis achieved.
• Sterile dressings are applied and a volar
POP slab should be applied for the hand
keeping the wrist in 30° extension, and
the MCP joints of the fingers in flexion of
90º and IP joints in extension and a POP
slab for the thumb keeping the IP joints in
extension.
Fig. 4.17.2 Completed tendon transfer • Admission in the ward
• About 1 cm proximal to the end of the
tendon, make a cut in a volar to dorsal
anesthesia
direction with a number 11 blade, with
just enough length to allow the tendon
graft through. Pull the tendon graft
slab
through and adjust the tension so that
the finger lies in the normal cascade.
Apply a suture with 3.0 polypropylene
using horizontal mattress suture (Fig.
4.17.2).
• About 1 cm proximal to the first cut,
make another cut with number 11
• Refer to physiotherapy for active mobiliz
ation of the fingers
blade, from a radial to ulnar direction.
Thread the free end of the tendon graft
through this opening also and suture
coconut oil
with 3.0 polypropylenes using horizontal
mattress suture.
• Patient is advised to continue the
• When the tendon anastomosis is over,
and passive and review once every month
the extra length of the EIP and EPL are
for evaluation.
trimmed. Wound closed with 4.0 Ethilon
sutures.
• Moist saline gauze is placed over the During the physiotherapy regime, concentrate first
entire length of the wound and gentle on getting back full range of active movements at
compression applied. The hand is elevated the index finger (donor finger)!
18
Flexor Digitorum Superficialis
to Flexor Pollicis Longus
Tendon Transfer

Introduction complication will cause dryness of mouth
The loss of a segment of FPL tendon or
immediately.
delayed presentation of FPL tendon injury
are best managed with a tendon transfer of
the FDS of ring finger. Surgical Steps
Presurgical Counseling Appendix I.
• Markings for the incisions (Fig. 4.18.1):
• This procedure will be done under axillary • Incision A: A zig-zag incision is marked
block anesthesia or general anesthesia. over the volar aspect of the proximal
• The procedure consists of harvesting a phalanx region of the thumb, where the
tendon graft from the ring finger. There will flexor pollicis longus (FPL) tendon can
be minimal deficit on the ring finger as a be dissected
result of this.
• This procedure will take about 1½–2 hours
to perform.
Paris (POP) slab will be applied at the end
of surgery.
period of 3 days.
• Postoperatively, no movements of the fingers
should be attempted. If it is done, the sutured
tendons may rupture.
this should be done for another 3 weeks.
• In some instances, even if the movements of
the finger improve, further surgery may be
required to release the scars that may form.
infiltration like hypersensitivity may occur Fig. 4.18.1 Markings for the incisions
• Incision B: Now, an incision is marked

over the neutral line on the ulnar border
of the ring finger about 4 cm long,
centered at the level of the proximal
interphalangeal (PIP) joint crease. This
incision is to divide the insertion of the
flexor digitorum superficialis (FDS) of
the ring finger
• Incision C: Another incision about
2 cm is marked over the palm in the
proximal part of the hollow between the
hypothenar and thenar eminences.
• The tourniquet is raised. First the incision
to expose the FPL is made and the skin
flaps are raised. The distal cut end of the
FPL tendon is identified, and dissected
free from the surrounding scar tissue. The Fig. 4.18.2 Harvested FDS tendon ready for transfer
FPL tendon is now pulled proximally after
grasping with a hemostat. The passive • Now, the tendon of FDS is ready for
movement of the thumb interphalangeal harvest. It is pulled distally to confirm that
(IP) joint must be full. If it is not so, a there are no more attachments of the FDS.
further dissection must be done to release Now, the incision “C” is made and the FDS
the tendon from the scar. tendon pulled out through this wound
• Now, the incision “B” is made to harvest (Fig. 4.18.2).
the FDS tendon. The skin on the volar • A subcutaneous tunnel is created between
side is raised superficial to the digital the incision “A” and incision “C”. A tendon
neurovascular bundle. The flexor tendon retriever is inserted from the incision “A”
heath is identified. An incision is made and passed through the subcutaneous
in the flexor tendon sheath to isolate the tunnel to the incision “C”. Here, the free
FDP and FDS tendons. The FDP tendon is end of the FDS tendon is grasped, pulled
usually seen first and it must be retracted and delivered at incision “A”.
volarward to expose the FDS tendon slips. • Moist gauze is placed over the wounds and
The ulnar slip is first seen. A hemostat gentle compression is applied. The hand
is applied about 1 cm proximal to the is raised and the tourniquet released. The
insertion. The tendon slip is now cut distal elevation of the hand is maintained for
to the hemostat. Now, traction is applied to 3 minutes and then the hand is placed
this cut slip with the hemostat and this will back on the table. Hemostasis is achieved.
expose the radial slip of the FDS tendon. • The skin wounds at incision “B” are sutured
This slip is also divided 1 cm proximal to with 4.0 Ethilon.
the insertion and another hemostat is • The skin wounds at incision “C” are also
applied on the proximal cut end. Both sutured with 4.0 Ethilon after securing
hemostats are pulled distally to expose hemostasis.
the decussation of the FDS tendon. It is • Now, the distal end of the FDS tendon
divided with a blade until both slips are must be sutured to the FPL tendon. The
free. The vincular attachment will also mechanical advantage is more if the FDS
have to be divided to achieve total release tendon is sutured as distally as possible.
of the FDS slips. If a long length of the FPL tendon is
CHAPTER 18 FLEXOR DIGITORUM SUPERFICIALIS TO FLEXOR POLLICIS LONGUS... 85
available, it is advantageous to excise a the thumb keeping the IP joints in 15º

portion of this tendon up to the level of flexion and the MCP joint in 15º flexion
the IP joint of the thumb and then suture and the carpometacarpal joint in palmar
the FDS tendon to the remaining stump abduction.
of the FPL tendon. A trial stitch with 4.0
polypropylenes is applied and the tension
is checked. The tenodesis effect is now Postoperative Protocol
checked as an indicator of the tension
adjustment in the tendon anastomosis. • Admission in the ward
The wrist is passively flexed. This • The affected hand should be kept elevated
movement should cause extension of the • Patient can take normal diet immediately
thumb IP joint. Similarly, passive flexion if the procedure was under regional block
of the wrist should cause a flexion of the or after complete recovery if under general
thumb joints. If this happens, the tension anesthesia
on the tendon transfer is correct. If there • Inspection of the suture line after 48 hours
is too much tension, or too little tension, it without disturbing the position of the POP
should be corrected by redoing the tendon slab
anastomosis. The tendon anastomosis is • Discharge of the patient by third day
done by modified Kessler Mason suture • Suture removal on the 10th day
using 3.0 polypropylene suture materials. • Patient to retain the POP slab
• When the tendon anastomosis is over, • Removal of the POP slab on the 21st day
the extra length of the EIP and EPL are and advise the following:
trimmed. Wound closed with 4.0 Ethilon • Refer to physiotherapy for active mobiliz
sutures. ation of the fingers
• Moist saline gauze is placed over the • Daily wash with soap and water
entire length of the wound and gentle • Massage of scar and grafted skin with
compression applied. The hand is elevated coconut oil
and the tourniquet released. After 3 • Patient is advised to continue the
minutes, the hand is kept back on the table mobilization of the fingers; both active
and hemostasis achieved. and passive and review once every
• Sterile dressings are applied and a dorsal month for evaluation.
POP slab should be applied for the hand
keeping the wrist in neutral, and the The procedure done has transferred a powerful
metacarpophalangeal (MCP) joints of tendon to do a relatively light work.
the fingers in flexion of 90° and IP joints Hence, the movement of the thumb may be
in extension and a dorsal POP slab for seen quite early into the physiotherapy!
SECTION
Bone Reconstruction
Bone Reconstruction—
Assessment 19
Introduction Nature of Previous Management
This must be recorded. Any previous
When there is an evidence of bone problem, the management, whether operative or otherwise,
evaluation of the patient will be directed to find should be noted.
the nature of the problem and deciding on a plan
of management. It must be remembered that a Skin
problem of the bone may result in alteration
of the function of the other structures like Presence of scars, protruding K-wires from
the tendons and joints. Hence, an evaluation previous treatment should also be noted.
should assess not only the bone problem per se,
but also the effects of the problem affecting the
other structures in the hand. Deformity
When there is a deformed part of the finger
History or hand, the cause is usually a malunited
fracture. The points to be recorded are:
Nature of Injury • Site of the deformity: It will point to the
bone that has been injured
The nature of injury will give a clue about • Angulation at the deformity: This must be
the magnitude of the problem. A low-energy measured and recorded. Some fractures
injury may cause a fracture but the effect may develop characteristic angulation due to
be negligible on the surrounding structures the forces that act on the proximal and
like tendons and joints. distal segments
• Rotation at the deformity: Some displaced
Duration fractures also get rotated and united in this
If an injury has occurred more than 2 weeks deformed position. This deformity will be
earlier, the bone is probably beginning to manifested by an altered orientation of the
unite and the callus has formed. If the fracture affected fingers with respect to the other
had been sustained less than 2 weeks back, it fingers. This is recorded as an ulnar or
may need to support and immobilization. radial rotation
90 SECTION 5 BONE RECONSTRUCTION
Table 5.19.1 Planning the management schedule

Fracture Characteristic Management
Fracture of finger proximal Good position Immobilize in plaster of Paris (POP)
phalanx (PPX) or middle phalanx slab
(MPX) or metacarpal less than 2
Unacceptable position Open reduction internal fixation
weeks old
(ORIF)
With loss Bone grafting
Fracture of finger PPX or MPX or Good position Mobilize the finger
metacarpal 2–4 weeks old
Unacceptable position ORIF
With loss Bone grafting
Fracture of finger PPX or MPX or Good position Mobilization
metacarpal greater than 4 weeks
Unacceptable position Mobilize to make the proximal and
old
distal joints supple
Then take up for refracturing and
fixation
Loss involving segment of single Bone graft from ulna
bone
Loss involving greater than one Vascularized bone graft from fibula
bone
• Tenderness/signs of inflammation: These

may be present in addition to deformity Sinus
when there is an evidence of infection in • Location of the sinus: It will indicate the
the involved bone bone involved
• Range of motion (ROM) at the joints: The • Type of discharge: A serous discharge may
problem of the bone can affect the joints indicate an inflammatory reaction within
and tendons of the affected finger or the bone. A purulent discharge will indicate
hand. These problems can be diagnosed a frank infection
by measuring and recording the active • Surrounding skin: Inflammatory changes/
and passive range of movements at the eczema may be seen in the surrounding
various joints. When the active range of skin.
movement is less than the passive range of
movements, it indicates that the tendons
have become adherent to the fracture site. Abnormal Mobility
If the passive range of motion is restricted,
it indicates that the joint itself may be • Site of abnormal mobility
involved by stiffness or ankylosis • Tenderness.
• Shortening of the hand/fingers: The
deformity of the bone, apart from producing Management
angulation and rotation, can also produce Planning the management schedule is given
shortening of the finger. in Table 5.19.1:
Open Reduction Internal
Fixation of Fractures 20
undergo a period of physiotherapy till
Introduction good movements are achieved.
Unacceptable position of union of fractures • During the period of physiotherapy, splints
of the bones of hand require open reduction may have to be applied as considered to
and fixation, such position leads to gross appropriate by the surgeon/physiatrist.
shortening of the finger/rotation leading • This surgical procedure aims only at
to scissoring of the fingers while making a getting the deformity/fracture corrected.
fist, or gross deformity. Such deformities Any injury of the surrounding structures
lead to biomechanical disturbances that will be dealt with later.
compromise function of the hand. • In some instances, if the movements of the
fingers do not return fully, a minor surgery
may have to be done to release the stuck
flexor or extensor tendons.
• The general complications of local anesthetic
• This procedure will be done under axillary infiltration like hypersensitivity may occur
block anesthesia or under GA (in children). in spite of test dose application. This
• This procedure will take about 2 hours to complication will cause dryness of mouth
perform. and apprehension, which can be corrected
• Wires will have to be introduced into the immediately.
bone to fix it in the correct position.
• A dressing and a plaster of Paris (POP) will
be applied. Surgical Steps
minimum period of 3 days. • Prepare the hand as described in Appendix
• Postoperatively, no movements of the I.
fingers should be attempted. The POP slab • Mark a cross finger flap like incision on the
must be retained for a minimum period of dorsum of the proximal phalanx (PPX) or
3 weeks. After the period of 3 weeks, the middle phalanx (MPX) region of the finger
wires will be removed from the hand after (Fig. 5.20.1). If there is already a scar on
confirming the healing with appropriate the finger, it can be incorporated in to the
X-rays. Even before the wires are removed, incision. If a metacarpal bone is involved,
physiotherapy may be required. After the incision is made on the dorsum of the
the wires are removed, it is necessary to hand over the metacarpal.
• The site of fracture is identified by the:

• Point of angulation
• The scar and callus around the fracture
site.
• A circumferential incision is made on the
bone at the site of fracture with a number
11 blade, through the periosteum. The
periosteum is raised both proximally and
distally for about 1 cm each.
• Now, the bone is refractured. This is done
by one of the following ways:
• If the callus is soft, scraping on it with
the periosteal elevator will refracture
the bone
• If the callus is hard, multiple drill holes
are passed with a 0.8 mm K-wire and
then the bone is refractured.
• After the bone has been refractured,
the ends of the bone are examined. The
proximal and distal bone ends must have
Fig. 5.20.1 Exposures for fracture fixation in the
a healthy look and not sclerotic. The
hand and fingers
sclerotic bone ends must be nibbled and
healthy bone exposed.
• Now, the freshened bone ends must be
• The tourniquet is raised and the incisions aligned. Any protruding cortex must be
are made. nibbled to allow complete bone-to-bone
• The incision is made through the skin and contact. There should be no angulation of
subcutaneous tissues and the skin flap is the bone on trial alignment.
elevated. It is anchored with 3.0 Ethilon • The orientation of the tip of the finger
after keeping the dorsal tissues exposed. should also be noted and it must be oriented
• The extensor tendon is identified and normally to its neighboring finger.
dissected. It is usually found to have • Now, the fixation of the fracture is done
adhesions with the underlying bone and with cross K-wires.
fracture. These adhesions are released. • Moist saline gauze is placed over the
A retractor is placed under the extensor entire length of the wound and gentle
tendon to retract the tendon and expose compression applied. The hand is elevated
the underlying bone (PPX or MPX). and the tourniquet released. After 3
• Now, the curved hemostat is passed under minutes, the hand is kept back on the table
the bone to the flexor side, deep to the and hemostasis achieved.
flexor tendons. The flexor tendons will also • The wounds are closed with 4.0 Ethilon
have multiple adhesions to the bone and after keeping Segmüller drains.
fracture site. These adhesions are released • A volar slab POP is applied keeping the
totally. wrist in 30° extensions, the metacarpo
• Now, the segment of bone bearing the phalangeal (MCP) joints in 60º flexion and
fracture site is totally dissected. the interphalangeal (IP) joints extended.
CHAPTER 20 OPEN REDUCTION INTERNAL FIXATION OF FRACTURES 93

Postoperative Protocol • Patient to retain the POP slab
• Admission in the ward and advise the following:
• The affected hand should be kept elevated • Refer to physiotherapy for active mobiliz
• Patient can take normal diet immediately ation of the fingers
if the procedure was under regional block • Daily wash with soap and water
or after complete recovery if under general • Massage of scar and grafted skin with
anesthesia coconut oil
• Inspection of the suture line after 48 hours • Patient is advised to continue the
without disturbing the position of the POP mobilization of the fingers; both active
slab and passive and review once every
• Discharge of the patient by third day month for evaluation.
Bone Grafting
21
undergo a period of physiotherapy till good
Introduction movements are achieved.
When a segment of either middle phalanx/ • During the period of physiotherapy, splints
proximal phalanx or metacarpal is lost, it can may have to be applied as considered to
be reconstructed with a bone graft harvested appropriate by the surgeon/physiatrist.
from the ulna. This is advantageous as it falls • This surgical procedure aims only at
in the same field of regional anesthesia, and getting the deformity/fracture corrected.
there is negligible donor site morbidity. Any injury of the surrounding structures
will be dealt with later.
• In some instances, if the movements of the
Presurgical Counseling fingers do not return fully, a minor surgery
• This procedure will be done under axillary flexor or extensor tendons.
block anesthesia. The general complications of local
• This procedure will take about 2 hours to anesthetic infiltration like hypersensitivity
perform. may occur in spite of test dose application.
• This procedure will entail removing a This complication will cause dryness of
piece of bone from the elbow and putting mouth and apprehension, which can be
it inside the injured finger to make the corrected immediately.
fractured bone heal properly. There will be
no deficit due to removal of the bone graft
• A dressing and a plaster of Paris (POP) will Surgical Steps
be applied.
• Admission will be necessary for a • The hand is prepared as described in
minimum period of 3 days. Appendix I.
• Postoperatively, no movements of the • The exposure is planned according to the
fingers should be attempted. The POP slab bone that is involved. For the proximal
must be retained for a minimum period phalanx (PPX) or middle phalanx (MPX) of
of 3 weeks. After the period of 3 weeks, the the fingers, or PPX of the thumb, the cross-
wires will be removed from the hand after finger flap like incision described in the
confirming the healing with appropriate previous chapter is used. For exposure of the
X-rays. Even before the wires are removed, metacarpal bones, a longitudinal incision
physiotherapy may be required. After is made over the involved metacarpal as
the wires are removed, it is necessary to described in the earlier chapter.
CHAPTER 21 BONE GRAFTING 95
• The tourniquet is raised and the incisions • The stability of the bone graft pegging is
are made. confirmed. If there is some evidence of
• The incision is made through the skin and instability, the graft fixation is reinforced
subcutaneous tissues and the skin flap is with a straight K-wire. The orientation of
elevated. It is anchored with 3.0 Ethilon the finger is confirmed to be normal and
after keeping the dorsal tissues exposed. it is also ascertained that the length of the
• The extensor tendon is identified and finger is normal.
dissected. It is usually found to have • Moist saline gauze is placed over the
adhesions with the underlying bone and entire length of the wound and gentle
fracture. These adhesions are released. compression applied. The hand is elevated
A retractor is placed under the extensor and the tourniquet released. After 3
tendon to retract the tendon and expose minutes, the hand is kept back on the table
the underlying bone (PPX or MPX). and hemostasis achieved.
• Now, the curved hemostat is passed under • The wounds are closed with 4.0 Ethilon
the bone to the flexor side, deep to the flexor after keeping Segmüller drains.
tendons. The flexor tendons will also have • A volar slab POP is applied keeping the wrist
multiple adhesions to the bone and fracture in 30° extensions, the metacarpophalangeal
site. These adhesions are released totally. (MCP) joints in 60° flexion and the
• Now, the segment of bone bearing the interphalangeal (IP) joints extended.
fracture site is totally dissected.
• The proximal and distal bone ends must When applying the POP in such patients, make
have a healthy look and not sclerotic. The sure that the proximal interphalangeal (PIP) joints
sclerotic bone ends must be nibbled and are kept extended. Failure to ensure this may result
in minimal flexion contracture of the IP joints
healthy bone exposed. Now, the bone
(especially of the operated finger).
segments must be placed back, and the
orientation of the finger realigned. This will
show the gap between the two ends of the
bone. This gap should be measured. The Postoperative Protocol
requirement of bone graft will be about 2
cm more than the measured gap between • Admission in the ward
the bone ends. • The affected hand should be kept elevated
• The bone graft is harvested from the ulna, • Patient can take normal diet immediately
if a single phalanx or metacarpal has a if the procedure was under regional block
non-union of a fracture. If more than one or after complete recovery if under general
bone has a fracture, it is preferable to use anesthesia
an iliac bone graft. • Inspection of the suture line after 48 hours
• The method of harvesting an ulnar bone without disturbing the position of the POP
graft is described in Appendix VI. slab
• The bone graft is sculpted in the form of a • Discharge of the patient by third day
“ladle” or a “roti belan”, with a “handle” on • Suture removal on the 10th day
either end. • Patient to retain the POP slab
• The bone graft is brought to the involved • Removal of the POP slab on the 21st day.
finger and inserted between the ends of Take an X-ray of the part to confirm the
the bone. The handles on either side of the healing of the bone. If the X-ray shows a
graft are used to peg into the proximal and good healing, the K-wire can be removed
distal ends of the fractured bone. in the operation theater after infiltrating
the point of entry of the wire with local • Massage of scar and grafted skin with
anesthetic solution. Now, advise the coconut oil
following: • Patient is advised to continue the mobiliz
• Refer to physiotherapy for active mobiliz ation of the fingers; both active and
ation of the fingers passive and review once every month for
• Daily wash with soap and water evaluation.
Vascularized Fibula Transfer
22
After the period of 3 weeks, the wires will
Introduction be removed from the hand after confirming
the healing with appropriate X-rays. After
Reconstructive surgery on the hand can
the wires are removed, it is necessary to
never be completed without the vascularized
undergo a period of physiotherapy till good
fibula flap in surgeons armamentarium. The
movements are achieved.
use of this technique is wide and the main
• During the period of physiotherapy, splints
indications are:
may have to be applied as considered to
• Traumatic segmental loss appropriate by the surgeon/physiatrist.
• Osteomyelitis • This surgical procedure aims only at
• Low grade malignant bone tumors getting the deformity/fracture corrected.
• Locally aggressive bone tumors Any injury of the surrounding structures
• Epiphyseal arrest due to trauma/infection. will be dealt with later.
• In some instances, if the movements of the
Presurgical Counseling may have to be done to release the stuck
• This procedure will be done under axillary • The general complications of local anesthetic
block anesthesia and general or spinal infiltration like hypersensitivity may occur
anesthesia. in spite of test dose application. This
• This procedure will take about 6 hours to complication will cause dryness of mouth
perform. and apprehension, which can be corrected
• This procedure will entail removing a piece immediately.
of bone from the leg along with its blood
supply and fixing it inside the hand to
replace the bone. This will entail a vascular Surgical Steps
anastomosis procedure. There will be no
deficit due to removal of the bone graft • The preferred anesthesia is either general
from the leg. anesthesia or combined regional block—
• A dressing and a plaster of Paris (POP) will continuous epidural anesthesia with supra-
be applied both on the hand and the leg. clavicular block (if the surgery is for finger
• Admission will be necessary for a minimum or hand motorization).
period of 1 week. • Prepare for the procedure as outlined in
• Postoperatively, no movements of the fingers the Appendix II.
should be attempted. The POP slab must be • Prepare the involved upper limb, including
retained for a minimum period of 3 weeks. the shoulder, neck, front of chest.
deep fascia, incise it and stop when the

peroneal muscles are seen. Now, elevate
the flap from anterior to posterior over the
peroneal muscles. As you do this, you may
find a few musculocutaneous perforators
from the muscle to the skin. These
perforators can be ligated and divided.
The elevation of the flap should stop at the
posterior edge of the peroneal muscles or
when the intermuscular septum is reached.
This is the posterior intermuscular septum
between the peroneal muscles and the
soleus muscle, and it is this septum that
contains the septocutaneous perforators to
supply the skin paddle.
• Now, make the posterior incision. This
incision should also go through the deep
fascia and stop on the surface of the soleus
muscle. Raise the skin paddle from the
posterior to the anterior direction over the
soleus muscle. A few perforators will be
Fig. 5.22.1 Markings for raising the flap encountered, going from the muscle to the
skin flap (Fig. 5.22.2).
These perforators can also be ligated
• Prepare the opposite side thigh and leg and divided. The dissection stops when
and foot regions. the posterior surface of the posterior
• Markings for the flap (Fig. 5.22.1): intermuscular septum is reached.
• Mark a point “A” on the fibular head. • Now, go back to the anterior surface of
Mark a point “B” on the lateral malleolus. the intermuscular septum. Divide the
Join these two lines. This line AB forms
the axis of the flap. It represents the
underlying fibula position
• Mark the midpoint “C” of the line AB.
This point “C” represents approximately
the area where the nutrient artery enters
the fibula
• Mark the skin paddle of the flap. This
should be in the form of an ellipse, with
the proximal and distal ends “D” and
“E” lying on the axis AB. The maximum
dimensions of the flap can be up to
15 cm × 8 cm.
• Positioning of the patient—flex the hip to
about 60°, flex the knee to about 135°, and
internally rotate the leg.
• First make the incision on the anterior
border of the flap, from the points “D” to
“E”. This incision should go down to the Fig. 5.22.2 Perforators entering the skin flap
CHAPTER 22 VASCULARIZED FIBULA TRANSFER 99
peroneal muscles from the fibula bone

along the entire length from “D” to “E”.
Do not divide too close to the bone, but
leave a cuff of muscle on the bone. As
this is being done, the dissection will go
anteriorly on the anterolateral surface
of the fibula. This dissection will stop at
another intermuscular septum. This is the
anterior intermuscular septum between
the peroneal muscles and the extensor
muscle compartment.
• This septum can also be divided and the
extensor compartment will be reached.
If the extensor muscles are retracted, the
anterior tibial vascular bundle can be
seen. Now, continue to dissect closing to
the fibula. The interosseous membrane Fig. 5.22.3 Cross-section of leg showing the relative anatomy
will now be opened and the tibialis Key: 3. Flexor digitorum longus; 4. Tibialis posterior; 5. Flexor hallucis
posterior muscle encountered. When this longus; 6. Tibialis anterior; 7. Extensor hallucis longus; 8. Extensor
muscle is retracted, the peroneal vascular digitorum longus; 9. Peroneus brevis; 10. Peroneus longus; 14. Fibula;
15. Transverse intermuscular septum; 16. Interosseous membrane;
bundle will be seen. The entire length of
17. Anterior intermuscular septum
the peroneal vessels must be dissected.
The branches from the artery to the fibula
and the nutrient vessel can be seen. This the posterior intermuscular septum, the
dissection should be done in a plane deep peroneal vascular bundle and a few fibers
to the peroneal vessels and not between of the flexor hallucis longus muscle. These
the fibula and vascular bundle. The plane fibers can be retained along with the
of the vessels is shown in Figure 5.22.3. pedicle to prevent injury to the vessels.
• The posterior dissection along the soleus • The fibular osteocutaneous flap is now
muscle should be continued now. Keep ready for transfer. The division of pedicle
dividing the soleus muscle fibers and should be done only after the completion
freeing the muscle from the fibula and the of the dissection in the recipient site.
intermuscular septum. Now, the entire • Division of the pedicle: Usually, there are
length of the posterior intermuscular two veins and one artery at the vascular
septum can be dissected. The proximal pedicle and the nerve. Soft clamps should
and distal osteotomies can be done now. be applied over the artery and veins. The
Further dissection can be completed after proximal ends of the artery and veins should
the osteotomy. be ligated with 3.0 Vicryl. The vessels should
• Mark the site of the proximal osteotomy. be divided and the time noted. The flap
Make the incision in the periosteum about should be placed on a moist abdominal pad
2 cm proximal to this site. Elevate the and taken to the recipient site for vascular
periosteum up to the site of the proposed anastomosis.
osteotomy. Carry out the osteotomy. • Management of the donor site: After securing
• Mark the site of distal osteotomy. Make hemostasis, the secondary defect should be
an incision on the periosteum and then closed with a skin graft from the thigh. Sterile
perform the osteotomy. dressings should be applied and elastocrépe
• Now, the osteotomized bone segment bandage applied over it. A posterior below
and the skin paddle will be attached by knee slab is applied.

Vascular Anastomosis if the procedure was under regional block
• The flap is brought to the hand defect. First anesthesia
the flap is held up and the pedicle allowed
to hang down. This step will make sure
that there is no inadvertent twisting of the
slab
vascular pedicle. The flap is then placed
over the defect with the correct orientation
and the end of the pedicle should be
• Removal of the POP slab from leg on
placed over the recipient vessels. A few
the 21st day. Take an X-ray of the part to
sutures should be applied to inset the flap.
confirm the healing of the bone on hand. If
• The recipient vessels should be divided,
the X-ray shows a good healing, the K-wire
blood flow checked from the divided artery
can be removed in the operation theater
and approximator clamps applied. The soft
after infiltrating the point of entry of the
clamps must be released from the donor
wire with local anesthetic solution. Now,
vessels. Vascular anastomosis should be
advise the following:
done (the technique of vascular anastomosis
• Refer to physiotherapy for active
is beyond the scope of this manual).
mobilization of the fingers
Postoperative Protocol • Massage of scar and grafted skin with
coconut oil
• Admission in the ward for a minimum • Patient is advised to continue the
period of 1 week mobilization of the fingers; both active
• The affected hand and the leg should be and passive and review once every
kept elevated month for evaluation.
SECTION
Joint Reconstruction
Joint Reconstruction—
Assessment 23
occurs, and the patient presents within a
Introduction week to 10 days, the chances of achieving
a good reduction and hence good function
When a patient presents with a problem of the
are high. However, if the patient presents
joint, assessment of the situation should lead
later than this period, it is more likely that
to the cause of the problem. The assessment
the function of the joint may have been lost
of a joint is twofold. The joint could either
forever.
have been injured per se or it could have
• Local symptoms: Like pain or swelling
become involved after an injury which is not
can occur in situations where there is
directly on the joint.
inflammation
This section deals mainly with post-
• Infection of the joint can occur after
traumatic sequelae affecting the joints.
penetrating injuries like human bite.
Conditions like tumors, degenerative diseases
• Inflammation can occur following
like rheumatoid disease, and congenital
vigorous, unsupervised physiotherapy.
anomalies can also affect the joints, but such
• The management of both these con-
problems are not highlighted in this chapter.
ditions is different and hence the
correct diagnosis is essential.
• Constitutional symptoms: Like fever
Clinical Examination and malaise may occur when there is a
hematogenous spread of infection from a
The examination of the patient should follow joint.
the steps outlined below: • Position of the joint: It is important to
• Cause of the injury: record the resting position of the joint as
• Blunt injuries are likely to cause it gives a clue to the underlying pathology.
dislocations and closed fractures. It • Associated fracture: As mentioned
should be noted whether this type of earlier, the fracture of the proximal
injury has caused an injury to the joint. phalanx can cause a stiffness of the PIP
Even an injury at a remote site can result joint, even if the fracture has not been
in a stiffness of the joint of the hand. intra-articular. This is caused mainly by
This should also be recorded. improper position of the joints during
• Open injuries are more likely to cause immobilization at the time of treatment
soft tissue disruption which may cause of the fracture.
instability of the joint. • The range of movements of the joint must
• Duration of the injury: This is very be recorded. This will include both active
important. When a dislocation of the and passive range of movement. This
proximal interphalangeal (PIP) joint recording has two uses:
104 SECTION 6 JOINT RECONSTRUCTION
• It is diagnostic, e.g. in a condition • If the stiffness is severe, or the joint

where the PIP joint is kept in a position requires surgical management, even
of flexion, a study of the range of then, the physiotherapist must develop
movement will indicate whether the a good rapport with the patient, who
condition is caused by boutonniere needs the help of the physiotherapist
deformity or a stiffness of the PIP joint after the surgery.
caused by an intra-articular fracture. • Indications for surgery:
• It serves as an indicator of progress or • If the joint does not become supple
deterioration after starting a course after a course of physiotherapy.
of physiotherapy or after surgical • If the injury has been directly on the
procedure. joint and has caused either:
• Investigations: • A dislocation or subluxation
• X-ray findings: • A loss of joint surfaces
• Nature of articular surfaces • Incongruity of joint surfaces.
• Congruity of articular spaces • Timing of surgery—in case of the multiply
injured hand, surgery on multiple
• Joint space structures can be done at the same stage to
• Status of bones proximal and distal reduce the number of stages done. In such
to the joint.
a situation, it is important to remember
that some surgeries on the hand require
immobilization and some procedures
require immediate mobilization. These two
Planning the Management
types of procedures should not be done
together for obvious reasons.
• Role of physiotherapy—as soon as the • Common surgeries done on the joints in
patient is seen with a joint problem, it is
the hand:
imperative that basic investigations are • Reduction of chronic dislocation of
done to study the status of the joint. Once metacarpophalangeal (MCP) joint of
the study of the joint is completed, the the finger.
patient must be seen by the physiotherapist • Release of a stiff joint especially. PIP
for two reasons: joint and MCP joint (arthrolysis).
• The patient must meet the physio- • Arthrodesis of PIP joint of the finger,
therapist who is going to play an MCP joint of the thumb.
important role in bringing back the • Replacement of a destroyed joint (PIP
movement in a stiff joint. Sometimes, and MCP) with an implants.
if the stiffness is minimal, the physio- • Replacement of a joint with a vascularized
therapy itself is the treatment and good metatarsophalangeal (MTP) joint of the
function can be achieved. toe.
24
Chronic
Metacarpophalangeal Joint
Dislocation Reduction
• Postoperatively, gentle active and passive

Introduction mobilization of the interphalangeal (IP)
joints of the finger should be continued. If
Dislocation of the metacarpophalangeal joint
it is not done, the finger will get back to the
of the fingers, especially the index finger is not
original state before surgery.
amenable for closed reduction. When such a
• The POP and postoperative physiotherapy
condition presents late, open reduction of the
should be continued for a minimum period
dislocation is one method of management
of 3 weeks. This should be followed by a
that yields good results. Explaining to the
period of wearing a detachable splint for a
patient what is going to be done and what
further 3 weeks. The wearing of the splint
is expected of him is very important in
beyond this period will depend upon the
determining the outcome.
progress achieved, and the reaction of
the tissues, which will be assessed by the
Presurgical Counseling surgeon.
• In some instances, if the dislocation is
• This procedure will be done under axillary severe, full movements may not be achieved
block anesthesia/general anesthesia. after one surgery.
• This procedure will take about 1 to 1½ • In some instances, in the postoperative
hours to perform. period, the movements may be achieved
• An incision will be made on the palm, and if fully, but if physiotherapy is neglected,
necessary, on the dorsum of the hand. The recurrence of the dislocation can occur,
scar on the palm will be as inconspicuous which will require a surgery again.
as possible. • The general complications of local anesthetic
• Postoperative physiotherapy is a must infiltration like hypersensitivity may occur
and should be started immediately after in spite of test dose application. This
surgery. complication will cause dryness of mouth
• A dressing will be applied and a plaster of and apprehension, which can be corrected
Paris (POP) slab will be applied. immediately.
• A catheter will be placed in the wrist (like
an IV cannula), through which, anesthetic
solution will be injected if there is a pain.
This cannula will be removed after 3 days. Surgical Steps
period of 3 days, after which review will be • The hand is first prepared as describe in
on the instructions of the surgeon. Appendix I.
may also have to be released. Once this is

released it will be possible to reduce this
dislocation in the method described above.
• To check whether this reduction is a true
reduction, the knuckle of the finger must
be palpated on the dorsal aspect. If the
knuckle is not palpable, the reduction is
not completed.
• Another method of confirming the
reduction is to passively flex the IP joints of
the finger. If the reduction is completed, full
passive range of motion will be achieved
without any tension in the joints. If the
reduction is incomplete, the intrinsics will
be tight, and passive flexion of the IP joint
will not be possible. If this happens, either
the lumbrical muscle has not been released
Fig. 6.24.1 Volar incisions to approach the MCP
fully from the scar, or the flexor tendon has
joints of the fingers
not been released fully from the scar. These
structures should be released from the scar
• Incision (Fig. 6.24.1): A transverse and the joint reduced.
incision is made on the palm at • Once reduced the entire volar plate can be
the distal palmar crease, over the seen on the volar aspect of the joint. It will
metacarpophalangeal (MCP) joint of be seen usually to have a tear transversely.
the finger. The incision must be made By keeping the flexor tendon retracted
about 4 to 5 cm long. Care must be taken this tear in the volar plate is repaired by
to keep this incision skin deep only, as a continuous suture of 5–0 polypropylene
the digital neurovascular bundle may with knots on either end. The tourniquet
be very superficial over the projecting is released and hemostasis obtained. The
head of metacarpal. flexor tendon is then repositioned and
• Retractors are applied on both the edges suturing of the wound is done with 4.0
and the skin flaps retracted. The structures Ethilon.
are exposed and the box mechanism is • For giving postoperative analgesia for
identified by applying gentle traction. The the thumb, index and middle fingers, a
flexor tendons are on the ulnar side. The Venflon catheter should be inserted in
neurovascular bundle is on the radial side the volar aspect of the wrist, about 1 cm
along with the lumbrical muscle. Retract proximal to the wrist crease. The needle
the flexor tendons toward the ulnar side to must be inserted to the ulnar side of the
expose the base of the proximal phalanx. palmaris longus tendon, the needle being
By inserting a number 15 blade between aimed deeply, pointing to the knuckle of
the base of proximal phalanx and the the middle finger. This cannula will deliver
head of metacarpal, the deep transverse anesthetic solution in the area surrounding
metacarpal ligament is released. the median nerve. If the ring or little fingers
• The scar tissue between the head of the have been involved, the Venflon catheter is
metacarpal and the base of the proximal placed to the radial side of the flexor carpi
phalanx must also be excised. Along with ulnaris (FCU) tendon about 1 cm proximal
this step, the A1 pulley of the flexor sheath to the wrist crease. This cannula must be
CHAPTER 24 CHRONIC METACARPOPHALANGEAL JOINT DISLOCATION REDUCTION 107
fixed with plaster after the wounds are on the volar aspect and suture line is
sutured. inspected after 48 hours. If it is clean, active
• Vaseline gauze is applied over suture line and passive mobilization of the IP joints of
and dressing done. A dorsal slab POP is the finger is started within the POP slab.
applied with the wrist in neutral position, • The patient must be attended by a physio
MCP joints in 90° flexion and IP joints therapist and both active and passive
extended. mobilization of the fingers must be done
within the POP. The MCP joint will be kept
Since a Venflon catheter has been introduced in flexed but the IP joints mobilized.
the wrist, clear instructions should be given to the • Discharge of the patient by third day.
ward nurse that it is not a portal for IV fluid infusion! • Suture removal on the 10th day. Retain the
If possible, the patient can also be told to warn the POP slab
nurse about the special catheter!
• Refer to physiotherapy for continuing
active and passive mobilization of the
fingers.
Postoperative Protocol • Review at the end of 3 weeks. Remove
the POP slab.
The postoperative follow-up protocol of this • Daily wash with soap and water.
surgery is very important: • Massage of scar and grafted skin with
• Admission in the ward. coconut oil.
• The affected hand should be kept elevated. • Prescribe a dynamic knuckle bender
• Patient can take normal diet immediately splint to be worn 24 hours a day for a
if the procedure was under regional block further 3 weeks.
or after complete recovery if under general • Review after this period. If the active
anesthesia. range of movement is full, discard the
• Four milliliters of 1 percent solution of splint. If the range of movement is not
Xylocaine must be injected into the cannula full, to continue wearing the splint at
once every 6 hours. The dressing is opened night for a further 3 weeks.
Arthrolysis
25
• A catheter will be placed in the wrist (like
Introduction a IV cannula), through which, anesthetic
Stiffness of the hand joints, especially the IP solution will be injected if there is pain.
joints and MCP joint can occur due to many • Admission will be necessary for a
causes including direct or indirect injuries or minimum period of 3 days.
infection. Achieving good movements of the • Postoperatively, gentle active mobilization
fingers is important for the return of normal of the finger should be continued. If it is
function and movements can be achieved stopped, the finger will get back to the
by prudent arthrolysis which may have to be original state before surgery.
combined with tenolysis also. • In some instances, if the joint is very grossly
stuck and one of the tendons to the finger
may have to be removed. This may result in
Arthrolysis of the Proximal some loss of power of the finger, but there
will be no loss of movements.
Interphalangeal Joint • In some instances, even if the movements
of the Finger of the finger improve, further surgery may
be required to reconstruct the pulleys.
Presurgical Counseling • The general complications of local anes
• This procedure will be done under wrist thetic infiltration like hypersensitivity may
block anesthesia as patient cooperation occur in spite of test dose application. This
will be required in the course of the complication will cause dryness of mouth
procedure. and apprehension, which can be corrected
• A tourniquet will be applied and raised, immediately.
but will be released before pain starts.
• This procedure will take about 30 to 45 Surgical Steps
minutes to perform if it involves a single • This procedure should be done under
finger and more if more fingers are wrist block anesthesia. However, if more
involved. than one finger is involved, the procedure
• The return of full movement will be shown had better be done under axillary block
to the patient on the table. If this movement anesthesia, as the patient cannot tolerate
is to be maintained, postoperative physio the tourniquet for a prolonged time under
therapy is a must. local anesthesia.
• A dressing will be applied and no plaster of • The incision is made on the noncontact
Paris (POP) will be applied. side of the involved finger, i.e. the ulnar
CHAPTER 25 ARTHROLYSIS 109
side of the index, middle and ring fingers proximal to the insertion. This will release
and the radial side of the little finger. The the PIP joint totally.
incision should be about 4 to 5 cm on the • Now, ask the patient to flex the PIP joint
neutral line, centered on the point where of the finger. He may find it difficult
the proximal interphalangeal (PIP) joint to localize the single finger due to the
crease touches the neutral line. wrist block. Hence, the patient must be
• The incision goes down through the skin, instructed to flex all the fingers together.
to the subcutaneous tissue. Care should This will demonstrate the movements at
be taken to avoid damage to the digital the PIP joint of the involved finger also.
neurovascular bundle, which will be only The extension of the finger should also be
slightly volar to the neutral line. demonstrated to the patient. There may
• A retractor applied on the volar skin will be some lag in extension due to the wrist
expose the side of the flexor sheath. An block. Hence, a full range of passive flexion
incision should be made with a knife on and extension will be enough.
the side of the flexor sheath, and the flexor • Moist saline gauze is placed over the
tendons exposed. The flexor tendons are entire length of the wound and gentle
now retracted volarward to expose the compression applied. The hand is elevated
volar structures, especially the volar plate, and the tourniquet released. After 3
in front of the PIP joint capsule. minutes, the hand is kept back on the table
• It is this volar plate that is the usual cause of and hemostasis achieved.
the PIP joint deformity. This volar plate is • For giving postoperative analgesia for
divided transversely about 0.5 cm from its the thumb, index and middle fingers, a
attachment on the proximal phalanx. Small Venflon catheter should be inserted in
arterial branches are usually encountered the volar aspect of the wrist, about 1 cm
here which should be cauterized. proximal to the wrist crease. The needle
• Now, the release of the PIP joint should be must be inserted to the ulnar side of the
palmaris longus tendon, the needle being
assessed. The passive range of movement
aimed deeply, pointing to the knuckle of
at the PIP joint must be full and free. If it is
the middle finger. This cannula will deliver
not so, the collateral ligaments will have to
anesthetic solution in the area surrounding
be divided next.
the median nerve. If the ring or little fingers
• With the careful use of the blade, the
have been involved, the Venflon catheter is
collateral ligaments should be divided
placed to the radial side of the flexor carpi
on both sides of the PIP joint. If the blade
ulnaris (FCU) tendon about 1 cm proximal
goes deeper while doing this, the joint
to the wrist crease. This cannula must be
capsule will also be damaged. The amount
fixed with plaster after the wounds are
of postoperative swelling will be more in sutured.
such a situation and if more of the joint • Suture the skin with 4.0 Ethilon after
capsule is injured, the joint may become keeping Segmüller drains and apply sterile
unstable. dressings.
• Again the release of the PIP joint should be
reassessed. If there is still a volar tightness,
palpate the flexor tendons. The flexor Postoperative Protocol
digitorum superficialis (FDS) is usually The postoperative follow-up protocol of this
tight. If so, confirm the intactness of the surgery is very important:
flexor digitorum profundus (FDP) tendon • Admission in the ward.
and divide the FDS tendon, about 1 cm • The affected hand should be kept elevated.
• Patient can take normal diet immediately be worn at night for a further 3 weeks and
if the procedure was under regional block physiotherapy should be continued during
or after complete recovery if under general the day for this period also.
anesthesia. • A catheter will be placed in the wrist (like
• Four milliliters of 1 percent solution a IV cannula), through which, anesthetic
of Xylocaine must be injected into the solution will be injected if there is pain.
cannula once every 6 hours. The patient • Admission will be necessary for a
must be attended to be a physiotherapist minimum period of 3 days.
and both active and passive mobilization • Postoperatively, gentle active mobilization
of the fingers must be done. of the finger should be continued. If it is
• Inspection of the suture line after 48 hours. stopped, the finger will get back to the
• Discharge of the patient by third day. original state before surgery.
• Suture removal on the 10th day • In some instances, if the joint is very
• Refer to physiotherapy for active mobili- grossly stuck, release may accuse to return
zation of the fingers. of movement, but there may be some
• Daily wash with soap and water. instability, which may have to be corrected
• Massage of scar and grafted skin with at a later surgery.
coconut oil. • In some instances, if the extensor tendon is
• To apply a straightening splint at night also damaged beyond repair, it may have to
for the involved finger alone for a period be sacrificed to achieve a good movement
of 3 weeks thereafter. at the joint. However, the tendon will have
to be reconstructed at a later surgery.
anesthetic infiltration like hypersensitivity
Arthrolysis of the may occur in spite of test dose application.
Metacarpophalangeal This complication will cause dryness of
Joint of the Finger mouth and apprehension, which can be
corrected immediately.
• This procedure will be done under wrist Surgical Steps
block anesthesia as patient cooperation • This procedure should be done under
will be required in the course of the wrist block anesthesia. However, if more
procedure. than one finger is involved, the procedure
• A tourniquet will be applied and raised, had better be done under axillary block
but will be released before pain starts. anesthesia, as the patient cannot tolerate
• This procedure will take about 30 to 45 the tourniquet for a prolonged time under
minutes to perform if it involves a single local anesthesia.
finger and more if more fingers are • The incision is made on the dorsum of
involved. the hand over the knuckle of the involved
• The return of full movement will be shown joint. The incision will be longitudinally
to the patient on the table. If this movement oriented, in the shape of a lazy “S” about 5
is to be maintained, postoperative physio cm long, with the transverse portion lying
therapy is a must. exactly over the knuckle prominence.
• A dressing will be applied and a POP will • The incision goes down through the skin,
be applied, which will be retained for to the subcutaneous tissue. Care should be
10 days, following which, a detachable taken to avoid damage to the subcutaneous
splint will be applied. This splint should veins.
CHAPTER 25 ARTHROLYSIS 111
• The extensor tendons should be retracted This cannula must be fixed with plaster
to expose the joint capsule of the after the wounds are sutured.
metacarpophalangeal (MCP) joint. • Suture the skin with 4.0 Ethilon after
• An incision should be made with a knife on keeping Segmüller drains and apply sterile
the dorsum of the capsule and a segment dressings.
of the dorsal capsule about 3 cm × 0.5 cm • A dorsal slab POP is applied with the
should be excised. This portion of the joint wrist in neutral position, MCP joints in
capsule should extend from one neutral 90º flexion and interphalangeal (IP) joints
line to the other. This will release the extended.
collateral ligaments on the radial and ulnar
sides of the joint. The articular surfaces of Since a Venflon catheter has been introduced in
the proximal phalanx and the head of the the wrist, clear instructions should be given to the
metacarpal will be exposed. ward nurse that it is not a portal for IV fluid infusion!
• Now, the release of the MCP joint should be If possible, the patient can also be told to warn the
assessed. The passive range of movement nurse about the special catheter!
at the MCP joint must be full and free.
• Now, ask the patient to flex the MCP
joint of the finger. He may find it difficult Postoperative Protocol
to localize the single finger due to the The postoperative follow-up protocol of this
wrist block. Hence, the patient must be surgery is very important:
instructed to flex all the fingers together. • Admission in the ward.
This will demonstrate the movements at • The affected hand should be kept elevated.
the MCP joint of the involved finger also. • Patient can take normal diet immediately
The extension of the finger should also be if the procedure was under regional block
demonstrated to the patient. There may or after complete recovery if under general
be some lag in extension due to the wrist anesthesia.
block. Hence, a full range of passive flexion • Four milliliters of 1% solution of Xylocaine
and extension will be enough. must be injected into the cannula once
• Moist saline gauze is placed over the every 6 hours. The dressing is opened
entire length of the wound and gentle on the volar aspect and suture line is
compression applied. The hand is elevated inspected after 48 hours. If it is clean, active
and the tourniquet released. After 3 and passive mobilization of the IP joints of
minutes, the hand is kept back on the table the finger is started within the POP slab.
and hemostasis achieved. • The patient must be attended to be a
• For giving postoperative analgesia for physiotherapist and both active and
the thumb, index and middle fingers, a passive mobilization of the fingers must be
Venflon catheter should be inserted in done within the POP.
the volar aspect of the wrist, about 1 cm • Discharge of the patient by third day.
proximal to the wrist crease. The needle • Suture removal on the 10th day. Retain the
must be inserted to the ulnar side of the POP slab:
palmaris longus tendon, the needle being • Refer to physiotherapy for continuing
aimed deeply, pointing to the knuckle of active and passive mobilization of the
the middle finger. This cannula will deliver fingers.
anesthetic solution in the area surrounding • Review at the end of 3 weeks. Remove
the median nerve. If the ring or little fingers the POP slab.
have been involved, the Venflon catheter is • Refer to physiotherapy for continuing
placed to the radial side of the FCU tendon active and passive mobilization of the
about 1 cm proximal to the wrist crease. fingers.
• Daily wash with soap and water. • Review after this period. If the active
• Massage of scar and grafted skin with range of movement is full, discard the
coconut oil. splint. If the range of movement is not
• Prescribe a dynamic knuckle bender full, to continue wearing the splint at
splint to be worn 24 hours a day for a night for a further 3 weeks.
further 3 weeks.
26
Vascularized Toe
Metatarsophalangeal
Joint Transfer
retained for a minimum period of 3 weeks.

Introduction After the period of 3 weeks, the wires will
When the joint of a finger has been destroyed, be removed from the hand after confirming
the resulting function in the finger is the healing with appropriate X-rays. After
compromised. Replacement of the joint by the wires are removed, it is necessary to
biological, vascularized tissue is perhaps undergo a period of physiotherapy till good
the ideal reconstruction in such cases. movements are achieved.
Disadvantages that are seen for artificial joint • During the period of physiotherapy, splints
replacement are not seen in this method of may have to be applied as considered
microvascular reconstruction. appropriate by the surgeon/physiatrist.
• This surgical procedure aims only at
getting the deformity/fracture corrected.
Presurgical Counseling Any injury of the surrounding structures
will be dealt with later.
• This procedure will be done under axillary • In some instances, if the movements of the
block anesthesia for the hand and general
or spinal anesthesia.
perform.
• This procedure will entail removing a joint
anesthetic infiltration like hypersensitivity
from the second toe of the leg on the same
may occur in spite of test dose application.
side as the hand injured, along with its
This complication will cause dryness of
blood supply and fixing it inside the injured
mouth and apprehension, which can be
finger to make the new joint heal properly.
corrected immediately.
This will entail a vascular anastomosis
procedure. After the joint is removed, the
second toe will have to be shortened and
the wound closed primarily. There will be Preparation
no deficit in walking due to removal of the
joint and loss of toe. • Palpate the dorsalis pedis artery and mark
• A dressing and a plaster of Paris (POP) will the course.
be applied both on the hand and the leg. • Put the leg in a dependent position and
• Admission will be necessary for a minimum mark the main dorsal veins, the transverse
period of 1 week. arch and the great saphenous system.
• Postoperatively, no movements of the fingers • Mark a point “A” at the level of the distal
should be attempted. The POP slab must be edge of the inferior extensor retinaculum,
halfway between the dorsalis pedis artery is dominant—the first dorsal metatarsal
marking and the great saphenous system artery and the dorsal digital arteries or the
marking. first plantar metatarsal arteries and the
• Draw a curvilinear line between the point plantar digital arteries.
“A” and the web space between the great • Now, surgeons go to the plantar side
toe and the second toe. dissection. Make the plantar incisions.
• Similarly, from the web space between the The plantar incision is needed only if the
great toe and second toe, on the plantar vessels cannot be clearly dissected from
aspect, make a marking that extends from the dorsal approach.
the apex proximally along the second • The medial plantar digital artery (branch
metatarsal to the midsole. to the great toe) is divided.
• If a skin flap is needed, it can be planned • The transverse metatarsal ligament is
on the dorsum of the metatarsophalangeal divided on the lateral aspect of the MTP
(MTP) joint of the second toe. The flap joint of the second toe. This should be done
should not extend distal to the level of the as close to the joint as possible without
proximal interphalangeal (PIP) joint. injuring the capsule.
• Now, retractors should be applied to the
second metatarsal and retracted laterally
Surgical Steps and the first metatarsal retracted medially.
The arterial system is now exposed. The
• Prepare for the surgery as described in the system should be carefully dissected, taking
Appendix I and II. into account the dominance of the vessel
• Make the dorsal incision down to the system. This can be assisted by carefully
dermis only. dividing the interosseous muscles and
• Raise medial and lateral flaps for about further exposing the arterial system.
2 to 3 cm on either side. • Now, disarticulate the second toe at the
• The following should be dissected now— level of the PIP joint. Now, the MTP joint
the great saphenous vein, other dorsal of the second toe is almost completely
veins, fat and subcutaneous tissue. dissected and is held only by the intact
• Dissect the dorsalis pedis artery up to the metatarsal bone and the artery and veins.
distal part of the intermetatarsal space, The osteotomy of the metatarsal can be
where it will divide into two branches to done. This should be done depending
the great toe and the second toe. on the length that surgeons have already
• Dissect the deep peroneal nerve and divide calculated in the preoperative work-up.
it at the level of the MTP joint of the second • The osteotomy should be done in an
toe. It is not required in the flap. oblique manner. This is because of the
• At the distal part of the first dorsal nature of the MTP joint of the toe. This
metacarpal artery, identify the deep joint is basically an extension joint. The
communicating branch going to the range of motion of this joint is 0–550 of
plantar side. This branch will join with extension and 0–50 of flexion. If this joint
the first plantar metatarsal artery to form is used to replace any of the small joints
the plantar digital artery. And this plantar of the hand, it will not be physiological,
digital artery will divide into two, the because the joints of the hand should
medial plantar digital artery going to the have more amount of flexion and lesser
lateral side of great toe and the lateral amount of extension for good function.
plantar digital artery going to the second Hence, the MTP joint of the toe must be
toe. Examine this system to see which modified, if it is to become a flexion joint
CHAPTER 26 VASCULARIZED TOE METATARSOPHALANGEAL JOINT TRANSFER 115
It is very important to ensure the wait till the toe

becomes pink and warm. It may take quite some
time (half an hour even) before this happens.
During this time, the surgeon can prepare the
recipient site, or if it has already been done, can go
for a coffee break and prayer!
• The vessels can be divided when the

recipient site dissection is over.
• Division of the pedicle: Soft clamps should
be applied over the artery and veins. The
proximal ends of the artery and veins
should be ligated with 3.0 Vicryl. The
vessels should be divided and the time
noted. The flap should be placed on a
moist abdominal pad and taken to the
Fig. 6.26.1 Harvested second toe MTP joint, ready for transfer recipient site for vascular anastomosis.
• Management of the donor site: After securing
hemostasis, the second toe must be
shortened and the wound closed primarily
in the hand. The easiest way to do this is to in layers with 3.0 Vicryl for the subcutaneous
do an oblique osteotomy at the neck of the tissues and 4.0 Ethilon for skin. Drainage
metatarsal bone. tubes should be placed. Sterile dressings
• The next step is to make transverse drill should be applied and elastocrépe bandage
holes on the metatarsal and the proximal applied over it. A posterior below knee POP
phalanx adjoining the joint. Stainless steel slab should be applied.
wire (24G) are threaded through these drill
holes and kept ready.
• Once the osteotomy is over, the remaining Recipient Site Dissection
soft tissues can be divided, so that the
second toe joint is now held only by the • The hand is prepared as described in
arteries and veins (Fig. 6.26.1). Appendix I
• Now, release the tourniquet, apply warm, • A curvilinear incision is made over the
moist pads over the second toe and the anatomical snuff box area and the following
vascular pedicle. Take care to prevent structures are identified and dissected:
the toe from falling down and shearing • The radial artery and both venae
the vessels! Raise the foot for about 5 comitantes
minutes. Then place the foot on the table. • The cephalic vein
It usually takes about 15 to 20 minutes • One percent of Xylocaine gauze is applied
for the circulation to be re-established in over the dissected vessels
the dissected skin flap. By the end of this • A volar incision is made on the stump of the
time, the flap becomes pink and warm and thumb proximally up to the thenar area.
ready for transfer. Raise the medial and lateral skin flaps,
apply anchoring sutures with 3.0 Ethilon • Vascular anastomosis—the recipient

and dissect the following structures: vessels should be divided, blood flow
• Prepare the ends of the bony stumps to checked from the divided artery and
which the MTP joint of the second toe approximator clamps applied. The soft
is going to be fixed. Pass transverse drill clamps must be released from the donor
holes through both ends of the bone vessels. Vascular anastomosis should
which will lie proximal and distal to the be done (the technique of vascular
position of the joint anastomosis is beyond the scope of this
• Apply gentle compression with moist gauze manual).
and padding over the wound. Release the
tourniquet. Hold the hand in an elevated
position for a period of 4 to 5 minutes. Postoperative Protocol
Rest the hand on the table and secure
hemostasis. • Admission in the ward for a minimum
period of 1 week.
• The affected hand and the leg should be
Fixation of the Toe kept elevated.
Metatarsophalangeal Joint Flap • Patient can take normal diet immediately
• Bring the toe flap to the recipient site. or after complete recovery if under general
Place the MTP joint of the toe in position, anesthesia.
a position in which good function can be • Inspection of the suture line after 48 hours
achieved with the fingers. without disturbing the position of the POP
• A subcutaneous tunnel is created between slab.
the recipient site vessels and the summit of • Suture removal on the 10th day. Patient to
the stump. This tunnel is for the vessels of retain the POP slab.
the toe to be passed through to reach the • Removal of the POP slab on the 21st day.
recipient vessels—the radial artery. Take an X-ray of the part to confirm the
• The structures to be passed through the healing of the bone. If the X-ray shows a
tunnel are: good healing, the K-wire can be removed
• The arteries in the operation theater after infiltrating
• The veins the point of entry of the wire with local
• Bone fixation—fix the bones, both anesthetic solution. Now, advise the
proximally and distally with the stainless following:
steel wires that had already been passed. • Refer to physiotherapy for active
This can be done by using square knot of mobilization of the fingers.
the wire without causing damage to the • Daily wash with soap and water.
vessels. • Massage of scar and grafted skin with
• Tendon repair—this may be required, in coconut oil.
conditions of trauma only. In congenital • Patient is advised to continue the
conditions, the tendons will be intact mobilization of the fingers; both active
and tendon reconstruction may not be and passive and review once every
necessary. month for evaluation.
SECTION
Nerve Reconstruction
Nerve Reconstruction—
Assessment 27
When the patient has an injury to the nerves, who is a sedentary worker with the same
the diagnosis may sometimes be quite nerve involvement.
obvious. When assessing such an injury, The next assessment should be of the
the effects of injury to the nerve can be specific motor or sensory deficit, because the
seen in the hand, where, the neural deficit treatment protocol will be aimed at correcting
will be seen. This includes motor, sensory the particular problem. In a case of ulnar
and autonomic neural deficits that must be nerve injury, who has had a previous surgery,
assessed. The assessment of the deficits has or has had a partial involvement only, there
been outlined in the chapter on Hansen’s may be a sparing of some of the innervated
disease—assessment. muscles. In such a situation, it is not prudent
The injuries to the median, ulnar and to carry out the routinely described tendon
radial nerves will be considered, and the
transfers blindly.
methods of reconstruction will be dealt with.
All hands are not alike. We are likely to
The functional deficit associated with each
come across some patients with thin and
nerve is different. When the ulnar nerve is
fragile hands, and sometimes some patients
involved, the deficit is mainly in the power
of the hand, and when the involvement is of with short stubby and thick hands. So it is
the median nerve, it is more of a precision obvious that any described tendon transfer
and fine work deficit that is noted. So, when will not have the same results in all types of
a manual labourer presents with an ulnar hands. Hence, the assessment of the habitus
nerve involvement, he is more likely to be of the hand must also be made, before
incapacitated by the problem, than a person planning the treatment protocol.
Nerve Reconstruction—
Management 28
In the arm:
Approaches and Exploration • Radial nerve is approached by a longitudinal
incision on the lateral aspect of the entire
Points to be remembered when exploration is arm, over the palpable border of the
planned for nerve injury: humerus.
• It is not advisable to approach the deeper • Median nerve and ulnar nerve are
tissues through the scar that is present. approached by a longitudinal incision on
This is because, the tissues will be grossly the medial side of the entire length of the
adherence at this area and it may be very arm.
difficult to identify the injured nerve in In the forearm:
this scar tissue. The chances of inadvertent • Median nerve and the ulnar nerve are
injury to the nerve are also possible. approached by a lazy “S” incision on the
• Hence, the incision should incorporate the flexor aspect of the forearm, from the elbow
scar in the standard prescribed incision for to the wrist crease.
exploration of the particular nerve. In the palm:
• The dissection of the nerve should • Median nerve and ulnar nerve: The incision
commence in the area distal to the zone of should be made on the thenar crease.
injury and in the area proximal to the zone • Digital nerves in the palm: Zig zag incisions
of injury, so that, the healthy nerve can be on the palm.
identified first and can then be traced to • Digital nerves in the fingers: Neutral line
the area of injury. incision on the appropriate side to expose
• A liberal incision always helps in the the digital nerves.
following ways:
• Tissue handling is more gentle and
rough retraction is not required.
Nerve Repair
• The exposure offered is better and gives • The hand is prepared as described in
an idea about the relative anatomy in Appendix I
the zone of exploration. • The markings are made as described above.
• Thus, both time and energy are saved in • The tourniquet is raised and the skin
this technique. incisions are made as planned.
The markings for nerve exploration depend • The incision is made down through the
on the site of injury of the nerve. However, skin and subcutaneous tissues to the deep
there are some standard incisions that are fascia of the forearm. This fascia is incised
used when the nerves are explored. and the compartment of the flexor muscles
CHAPTER 28 NERVE RECONSTRUCTION—MANAGEMENT 121
is reached. The muscles are dissected running on the surface till the cut end of the
carefully and the median nerve is looked for nerve. The nerve should feel soft and supple
in the plane between the flexor digitorum to the palpating finger. Now, the proximal
superficialis (FDS) and the flexor digitorum end of the nerve is ready for reconstruction.
profundus (FDP). If there is any difficulty in • This procedure should be repeated for the
locating the median nerve, it can be traced distal end also. By this, the distal end of the
in a retrograde manner from the distal part nerve will also be ready for reconstruction.
of the forearm, where it is relatively easily • Now, the process of mobilization of the
identified among the tendons. The nerve nerve ends should be done. This is done to
lies deep to the palmaris longus tendon free the proximal and distal nerve segments
and to the radial side of the FDS and FDP from any scars that have formed with the
tendons to the fingers. In the distal part of surrounding soft tissues. This is done gently
the forearm, opening the deep fascia will teasing the tissues around the proximal
give access to the tendons. and distal nerve segments and freeing
• When the nerve has been dissected, the the nerves. It should be remembered that
ends of the nerve are examined under this process of mobilization should not be
microscope. There is usually a rounded extended for more than 5 to 8 cm from both
swelling of the proximal end of the nerve ends, as this may lead to devascularization
which consists of the neuroma. There is of the nerve segments.
a swelling on the distal end of the nerve • The nerve ends should be placed loosely
constituting a glioma. Both these swellings on their bed and the reconstruction plan
must be excised before reconstruction of should be made:
the nerve can be done. • Ends of the nerves are close to each
• The excision of the neuroma should be other or gap less than 2 cm: primary
done under the microscope. A scalpel repair of the nerve.
handle is taken and totally wound with • Gap between nerve ends between 2 and
moist gauze piece over a length of about 5 10 cm: free nerve graft.
cm. This part of the handle is then placed • Gap between nerves ends greater than
under the end of the nerve and the excision 10 cm: vascularized nerve graft.
of the neuroma begins. With a number • Primary repair of the nerve—the nerve
11 blade, the neuroma is cut transversely ends are placed closing to each other
across. The proximal end of the cut and a background material is placed
neuroma is examined under microscope, to under the proposed site of nerve repair
look for evidence of fascicles. The fascicles (this background material is available
will appear clearly only in the intact portion commercially). The ends of the nerve
of the nerve. In other areas, the nerve should fall in contact with each other
fascicles will appear hazy and surrounded when left lax. Hemostasis is achieved and
by homogenous scar tissue. The proximal then the orientation of the nerve ends is
end of the nerve should again be cut at a matched.
distance of 1 mm from the end. This end • The orientation of the fascicles is matched
should again be examined for determining on the proximal and distal ends of the
the integrity of the fascicles as described nerve.
above. This process should be continuously • If blood vessels are seen running on the
done until anatomically intact fascicles are epineurial surface, these are matched
encountered. There should be absolutely between the proximal and distal ends.
no scar tissue in the end of the nerve now. • Now, the epineurial repair (Fig. 7.28.1) is
On examining the epineurial covering of done after orienting the cut ends correctly.
the nerve, blood vessels should be seen The repair is done under microscope. In no
122 SECTION 7 NERVE RECONSTRUCTION
the graft on the nerve gap and the bed.

Suture the nerve graft to the distal cut
end of the nerve as described above.
• Now, cut the nerve graft at the point
where it reaches the proximal end of
the nerve and let this cut end of the
graft stay near the proximal end of
the nerve. Bring the remaining nerve
graft again to the cut end of the distal
Fig. 7.28.1 Epineurial repair segment of the nerve. Align them and
suture by applying epineurial sutures as
described above.
part of the surgery should the nerve tissue • Cut the remaining nerve graft at the
be held with the forceps. The microsurgery level of the proximal cut end of the
instruments set is opened now and only nerve. Bring the remaining nerve graft
these instruments are used. The suturing to the cut distal end and repeat the
is done between the epineurium of the process described above.
proximal end and the epineurium of the • At the end of this step, the distal end
distal end with 8.0 Ethilon using simple of the nerve would have been sutured
interrupted sutures. This suturing is done to three cables of the nerve graft, and
around the circumference of the nerve. the free ends of the three cables will be
lying near the proximal cut end of the
nerve. The free end of the third cable
Nerve Grafting will still be showing the stay suture of
7.0 polypropylene.
• The gap between the nerve ends is • Now, these three cables should be
measured. The surface area of the cut ends sutured to the proximal cut end of
of the nerve is assessed. Usually, about 3 the nerve with 8.0 Ethilon epineurial
cables of nerve graft will be required for sutures, starting with the deepest cable.
the reconstruction of median nerve in the • The skin wound is now closed with 4.0
forearm and 2 cables for the ulnar nerve Ethilon after keeping Segmüller drainage
in the forearm. Hence, the requirement of tubes.
nerve graft should be assessed carefully • Sterile dressings are applied and a
before harvesting the graft. The sural plaster of Paris (POP) slab is applied,
nerve is commonly harvested as a nerve keeping the wrist in neutral position, and
graft and the procedure is described in metacarpophalangeal (MCP) joints of
Appendix IV. fingers in flexion, the interphalangeal (IP)
• Nerve graft anastomosis: The first step joints straight.
done is to reverse the nerve graft. This is
easily done by the following steps:
• The nerve graft has a stitch of 7.0 Postoperative Protocol
polypropylene on the distal end (the
end from the calf region of the leg). The • Admission in the ward.
other end of the graft is the proximal • The affected hand should be kept elevated.
end. • Patient can take normal diet immediately
• Place the proximal end of the nerve if the procedure was under regional block
graft at the cut end of the distal segment or after complete recovery if under general
of the nerve. Place the entire length of anesthesia.
CHAPTER 28 NERVE RECONSTRUCTION—MANAGEMENT 123
• Analgesics and antibiotics for 5 days. • Refer to physiotherapy for active and
• Sedation sos for 1 day. passive mobilization of the fingers and
• Inspection of the dressing after 48 hours. thumb.
• Discharge of the patient by third day. • Daily wash with soap and water.
• Suture removal on the 10th day. • Massage of scar and grafted skin with
• Removal of the POP slab on the 14th day coconut oil.
and advise the following: • Compression garment for scar softening
after a further 2 weeks.
SECTION
Complex Post-traumatic
Problems
Complex Post-traumatic
Problems—Assessment 29
Tendon:
Introduction • Flexor/extensor
• Injury/segmental loss
The assessment and management of different
• How many fingers are involved?
structures of the hand have been discussed in
the earlier segments. However, in practice, it is
Nerve:
not always a problem of only the tendon, or only
• Which nerve/nerves?
the joint and so on. It is usually a combination
• What is the level of injury?
of problems that is present in a single hand.
• What is the deficit?
There may be an adherent scar on the dorsum
of the hand and there may be a loss of extensor
Bone:
tendons on the fingers, along with malunited
• Which bone?
fractures of multiple metacarpal bones.
• Which finger?
When such a patient presents, it may be
• Nature of problem: Malunion/nonunion.
difficult to go through each single chapter and
then come to a diagnosis and form a plan of
Joint:
management. This chapter tries to consolidate
• Which joint/joints?
the findings in the previous chapters in a
• Which finger/fingers?
single chart, to simplify evaluation.
• Nature of problem: Stiffness/ankylosis/
In such situations, there are important goals
instability.
to be achieved.
• The exact problem, i.e. the tissue problem
must be assessed
• The nature of the problem must be assessed, Priority of Management
i.e. whether there is a loss of tissue
• The management protocol must be decided First Make a Plan According
• The sequence of management must also to Diagnosis
be charted.
• Skin: First the plan for the skin recon
Skin: struction can be made according to the
• Presence of raw areas discussion in the Chapter 10
• Presence of chronic ulcers/trophic ulcers • Tendon: THe plan is made according
• Presence of scars to the assessment done as described in
• Presence of grafted skin Chapter 11
• Presence of flaps • Nerve: THe plan is made as described in
• Presence of contractures. Chapter 27
128 SECTION 8 COMPLEX POST-TRAUMATIC PROBLEMS
• Bone: THe plan is made as described in Classify According to Priority Lists

Chapter 19 • If both upper limbs are involved, can both
• Joint: THe plan is made as described in upper limbs be operated on together? If
Chapter 23. not, which hand to be operated first
Now, the different plans have been made • If multiple fingers are involved, can all
for the individual problems, they have to be fingers be operated together? If not, which
integrated into a total solution and the timing finger to be operated on first
has to be decided. • When multiple tissues are involved, which
tissue reconstruction gets priority?
Classify According to
Postoperative Regimen
• Procedures that require immobilization: Priority Lists
Some procedures require immobilization
after surgery, like reconstruction with If Both Upper Limbs are Involved
nerve grafts, bone fixation, tendon grafts
The priority is to be decided depending on
and tendon transfers, etc.
the nature of involvement, age of the patient,
• Procedures that require mobilization: Some
disability in the patient.
procedures require that mobilization be
started immediately after the surgical • According to the nature of involvement:
procedure. Examples are procedures like • The upper limb with raw areas, ulcers
arthrolysis and tenolysis. get priority
• Then comes nerve involvement; the
Classify According to limb with nerve involvement should be
treated first.
Time Schedule
• According to the age of the patient:
• Procedures that can be done immediately: • In adults, both upper limbs are not
Some procedures have to be done imme
usually operated on together, because
diately, like resurfacing of raw areas. These
then, the patient becomes dependent
procedures should be planned as soon as
and may cause inconvenience
possible after the required investigations
are done and the raw area is fitted for
• In children, both hands can be operated
on together.
surgical resurfacing
• Procedures that have to be done later: • According to the disability in the patient:
Some procedures like reconstruction of • If one upper limb is so involved that it
the tendons and nerves can be done as does not participate in the activities of
elective procedures after investigations are daily living, this limb must be operated
done and after the patient is adequately on first
counseled about the various reconstructive • If both limbs are equally involved, it
options is better to operate on the nondomi
• Procedures that have to be done after the nant side first, so that the patient can
environment becomes conducive in the get used to the routine of surgery and
hand: THere are some procedures for which the postoperative protocols. Pati ent
the timing can be planned only when the will thus be better prepared when the
tissues are conducive. For example, tendon dominant hand is operated upon
reconstruction cannot be done unless the • If both upper limbs have been involved
joints of the hand and fingers are made so badly that both are not used for
adequately supple, either by physiotherapy activities of daily living, the dominant
or surgical maneuvers. hand should be operated on first.
CHAPTER 29 COMPLEX POST-TRAUMATIC PROBLEMS—ASSESSMENT 129
If Multiple Fingers are Involved finger is operated on first. The fingers that
The priority is to be decided based on the need immobilization in the postoperative
fingers involved, the nature of the involve period are dealt with at a later stage.
ment and the nature of surgical management • When all fingers require surgical pro
required. cedures needing immobilization in the
• According to the finger involved: If the postoperative period, the finger requi
fingers and the thumb are involved, it is ring a bone surgery is operated on first
ideal to reconstruct the fingers first and (deformity correction first).
then plan the reconstruction on the thumb.
• According to nature of involvement: If Multiple Tissues are Involved
• The finger with raw areas, ulcers gets (Table 8.29.1)
priority
• Then comes nerve involvement; the • The first priority is the skin problem;
limb with nerve involvement should be whether it is a raw area or contracture or
treated first adherent scar. This should be corrected first
• When there is a contracture, adherent before the other structures are dealt with.
scar on one finger, this finger gets priority • Then, this should be the correction of
and gets operated on before the other deformity and the achievement of stability.
fingers are operated on. Hence, the bony reconstruction must be
• According to the surgical management planned next.
required: • Once stability is achieved, surgeons should
• When one finger requires a surgical pro now achieve full passive mobility. So, the
cedure which need immediate mobiliz next priority is getting the full range of
ation in the postoperative period, this movements in the joints with arthrolysis.
Table 8.29.1 Involvement of different tissues

Tissue involved Problem Plan Points to remember
Raw area Resurfacing with skin graft/ As soon as possible
flap
Adherent scar Excision and flap cover Elective
Skin
Contracture Release and split skin graft- Elective
ing (SSG)/flap cover
Cosmetic deformity only Correction Elective
Malunion Refixation of fracture First priority after skin raw
areas management
Bone
Nonunion Bone grafting First priority after skin raw
areas management
Stiff joint Arthrolysis Needs postoperative
Joint mobilization
Ankylosed joint Arthrodesis To give stability
Injury Exploration and nerve To be done before tendon
Nerve
reconstruction reconstruction
Loss Tendon reconstruction
Tendon Adhesions Tenolysis Needs postoperative
mobilization
130 SECTION 8 COMPLEX POST-TRAUMATIC PROBLEMS
• The next on the list is achievement of active reconstruction is planned to be done first
mobility. However, getting active move and the flexor tendon reconstruction is
ments in anesthetic hand is very dang done at a later stage.
erous as it may lead to the development of • In reconstructing the hand to achieve
trophic ulcers. Hence, the reconstruction active movements, the reconstruction of
of the nerves must be done prior to the the extrinsic tendons must be achieved
reconstruction of the tendons. before the reconstruction of intrinsic
• If both the extensor and flexor tendons motors with tendon transfers.
need reconstruction, the extensor tendon
SECTION
Thumb Reconstruction
30
Principles and
Decision Making in Thumb
Reconstruction
where all the fingers are missing or short, a

Principles thumb equal in length to that of a normal
thumb should be planned.
Loss of a thumb is a debilitating condition
that results in loss of function and hence 2. Stability: The reconstructed thumb should
earning capacity, especially for a manual be stable and able to maintain its position
laborer. Considering the fact that loss of in status quo. The position of the thumb
thumb amounts to 40 percent disability; must be physiological and not in the way
there are various procedures to reconstruct of the moving fingers. This depends on the
the thumb. However, a hand surgeon must stability provided by the bones that make
consider various factors before deciding on a up the reconstructed thumb. Obviously,
particular method. when a thumb is being reconstructed,
it will have to comprise an underlying
Characters that an ideal thumb must have: foundation of bones, which may be as
1. Length free grafts or vascularized graft. For the
2. Stability reconstructed thumb to be stable, the
3. Mobility bones that make up the thumb must be:
4. Sensation • Stably fixed to the underlying stump
5. Cosmesis • Fixed in a correct position for function.
6. Free from pain. This is more relevant when there is a total
loss of thumb, without a carpometacarpal
These characteristics are discussed in the joint. In such a situation, when a toe
following: transfer is done, the position of fixation is
1. Length: The optimum length for a fun very important at the radius or stump of
ctioning thumb when all the fingers are the carpus.
intact is up to the neck of the proximal 3. Mobility: The normal thumb has three
phalanx. This will ensure that there is joints: (1) Carpometacarpal (CMC) joint
functional contact between the tips of (2) Metacarpophalangeal (MCP) joint
the fingers and the reconstructed thumb. and (3) Interphalangeal (IP) joint of
If the length is less than that, function the thumb. So, mobility of the thumb is
will be compromised and useful function normally dependent on the movement
will not result. So, when planning for at these three joints. Among these joints,
reconstruction of a thumb, it should be the most important is the CMC joint of
planned for a length up to the neck of the the thumb. If surgeons plan to reconstruct
proximal phalanx of the intact thumb. a thumb, it would be ideal to have the
When planning for a thumb in a hand movements at all three joints and hence
134 SECTION 9 THUMB RECONSTRUCTION
ideal to reconstruct all three joints. Since, Only if there is movement, there will be
it may be difficult to reconstruct all three function. And if there is movement, there
joints, the order of priority is to have a are bound to be reconstructed moving
functioning and mobile CMC joint, or joints and ligaments which will be prone
if that is not possible, a functioning and for strain and wear and tear, leading
mobile MCP joint. to pain and ultimately, disuse. Hence,
4. Sensation: For a thumb to function reconstruction of a thumb must not
normally, the grips of the hand involving provide mobility at the cost of pain. This
the thumb should be intact. This means will totally defeat surgeons’ purpose of
that the reconstructed thumb should providing a useful and functioning thumb.
be capable of taking part in two types
of activities: (1) power grips and (2)
precision grips. When precision grips are Decision Making
involved, it is important that the pulp of
the thumb be sensate. Only then, grip There are certain set protocols in deciding
strength can be assessed by the thumb. about what method to use for thumb
The other reason is that, the thumb, being reconstruction in a particular case. However,
involved in most of the movements of there are many factors to consider, before
the hand, if the tip is insensate, it will be deciding the method of reconstruction for a
prone for trophic ulceration. So, when a patient.
thumb is reconstructed, it is imperative
that sensation is provided for at least the
pulp region and the tip to achieve the goal
General Factors
of providing a functioning thumb. 1. Sex: The method of reconstruction differs
5. Cosmesis: The thumb occupies a very for males and females in certain aspects.
large space in the cortex of the brain. The The requirements for the male thumb are
thumb, being an important part of the the capability for manual labor and lifting
hand is always in the vision field of the heavy weights, especially in a country
patient and that of the observer. Hence, it like India, where the manual laborers are
is important that the reconstructed thumb usually the victims of industrial accidents
look like a thumb with all the components, who lose their thumb. Hence, a stable post
like quality of dorsal skin, quality of is required, with minimal movements, to
pulp skin and nail complex. Although a allow for the power grips. However, for
meticulously reconstructed thumb can males who are pursuing white collar jobs,
bring back function to the patient’s hand, or those who work as typists or musicians,
the patient may not be totally satisfied if it or females, the requirement is the recon
does not look cosmetically acceptable. If struction of a fairly mobile thumb, which
this happens, the patient may slowly stop should provide the precision grips like
using the reconstructed thumb as he may pulp-to-pulp pinch, tip-to-tip pinch, etc.
be ashamed of it, and gradually, even a 2. Age: The requirement in children is almost
moving thumb may become useless to the the same as adults with a few differences:
patient just because it is cosmetically not • When the reconstruction is done early
accepted. in life, the reconstructed thumb gets
6. Freedom from pain: If a thumb were to incorporated in the body image faster
be reconstructed that is totally stable and • The reconstructed thumb must have a
without any movement, there would be potential for growth in children. A good
no pain at all. On the other hand, such a example is the use of vascularized wrap
thumb would be useless to the patient. around great toe flap in amputation at
CHAPTER 30 PRINCIPLES AND DECISION MAKING IN THUMB RECONSTRUCTION 135
the level of the MCP joint. In adults, it Local Factors

provides an excellent reconstruction 1. Hand dominance: A similar type ampu
method and cosmesis. Even in chil tation on both the thumbs of a patient may
dren, it provides good results, but the warrant different methods of reconstruction
biggest disadvantage in the use of this on the dominant hand and nondominant
flap in children is its lack of growth hand. This may be a controversial topic,
potential. Hence, a flap that can grow but it is generally more practical to decide
along with the child is chosen, like a for a more elaborate reconstruction on the
vascularized second toe transfer. dominant hand.
3. Occupation: As mentioned earlier, man 2. Other fingers: When all the fingers are
ual laborers require a more stable recon absent or shortened, the method of recon
struction with the ability for power grips, struction may be totally different. Other
whereas sedentary laborers require more ancillary procedures like thumb web dee
mobile reconstruction. An example would pening may have to be combined with the
be the choice of vascularized wraps around prescribed methods of reconstruction to
great toe flap in amputation at the level of create a useful thumb.
the MCP joint for manual laborers. This may 3. Condition of the rest of the upper limb: This
not be an ideal method of reconstruction is applicable in a situation like the con
for sedentary workers, due to the lack of genital condition of radial club hand. The
IP and MCP joint movements. Thus, more thumb may be hypoplastic and may require
movements can be provided by the choice reconstruction. The preferred method
of vascularized trimmed toe transfer that of reconstruction will be the procedure
can provide both mobility and cosmesis. of pollicization. However, the procedure
4. Socioeconomic status: A developing nat should not be done if there is no movement
ion like India, financial constraints pose at the elbow, which is sometimes the
a problem when deciding on the choice associated symptom in such a condition.
of thumb reconstruction. When there has This is because a moving thumb cannot
been an amputation at the level of the produce function if it cannot move to the
MCP joint, and carpometacarpal joint rest of the body where it has to act.
mobility has been preserved, the choice 4. Remaining stump of thumb: The prescri
rests between osteoplastic reconstruction bed method of reconstruction depends
and vascularized wrap around great also on the level of amputation of the
toe flap. Both the procedures provide a thumb. For purposes of simplicity, sur
functioning thumb. The former procedure geons can divide the thumb into levels as
may prove financially viable for a patient follows:
who is more worried about the cost factor
than the cosmetic factor. Thus, the option
of classical staged method must also be Type I
offered to the patient before a decision Amputation at tip of the thumb to the proxi
can be arrived at. mal third of the nail complex:
5. Other medical illnesses: For mentally • Requisites of reconstruction: Sensate tip
unstable patients and elderly individuals, • Preferred methods:
classical methods of reconstruction • For Transverse amputation: Lateral
may not be ideal. Single staged proce advancement flaps of Kütler
dures like free flaps are preferred in such • For volar oblique amputation: Inner
situations. vated cross finger flap
• For dorsal oblique amputation: Volar • Amputations with more dorsal loss:
advancement flap of Atasoy–Kleinert First dorsal metacarpal artery flap
• For radial/ulnar oblique amputation • Amputations with more volar loss:
Type I: Oblique triangular flap Littler’s neurovascular Island flap
• For radial/ulnar oblique amputation
Type II: Dorsal transposition flap Type III
Type II Amputation proximal to the neck of the
proximal phalanx, up to the MCP joint:
Amputation proximal to the proximal third of
the nail complex to the neck of the proximal • Requisites of reconstruction:
phalanx: • Provide length
• Requisites of reconstruction: • Stability
• Preservation of length • Sensate tip
• Sensate tip • Cosmesis.
• Cosmesis • Preferred methods:
• Preferred methods: • Osteoplastic reconstruction
• Transverse amputations: Staged Island • Vascularized wrap around great toe
flap of Professor R Venkataswamy. transfer
Table 9.30.1 Levels of amputation, characteristic and their surgical options

Level of amputation Characteristic Surgical option
Amputation at tip of the thumb Transverse amputation Lateral advancement flaps of Kütler
to the proximal third of the nail
Volar oblique amputation Lateral advancement flaps of Kütler
complex
Dorsal oblique amputation Volar advancement flap of Atasoy–
Kleinert
Radial/ulnar oblique amputation Oblique triangular flap
Type I of Professor R Venkataswami
Radial/ulnar oblique amputation Dorsal transposition flap
Type II
Amputation proximal to the Transverse amputations Staged Island flap of Professor R
proximal third of the nail complex Venkataswami
to the neck of the proximal
Amputations with more dorsal loss First dorsal metacarpal artery flap
phalanx
Amputations with more volar loss Littler’s neurovascular Island flap
Amputation proximal to the neck Patient not willing for toe transfer Osteoplastic reconstruction
of the proximal phalanx, up to the Expertise not available for
metacarpophalangeal (MCP) joint microsurgery
Patient willing for microsurgery Vascularized wrap around great
toe transfer
In children Vascularized second toe transfer
Amputation proximal to the MCP Expertise not available for Pollicization + opponensplasty
joint to the base of the metacarpal microsurgery
bone with intact carpometacarpal
Microsurgical expertise available Vascularized second toe transfer +
joint
opponensplasty
Amputation through the Expertise not available for Pollicization
carpometacarpal joint with microsurgery
destroyed joint
Microsurgical expertise available Vascularized transmetatarsal
second toe transfer
CHAPTER 30 PRINCIPLES AND DECISION MAKING IN THUMB RECONSTRUCTION 137
• Vascularized second toe transfer (in Type V

children) Amputation through the carpometacarpal
• On-top plasty joint with destroyed joint:
• Distraction lengthening.
• Requisites of reconstruction:
Type IV • Provide length
Amputation proximal to the MCP joint to • Mobility
the base of the metacarpal bone with intact • Stability
carpometacarpal joint: • Sensate tip
• Requisites of reconstruction: • Cosmesis.
• Provide length • Preferred methods:
• Mobility
• Stability • Pollicization
• Sensate tip • Vascularized transmetatarsal second
• Cosmesis. toe transfer.
• Preferred methods: Ancillary procedures like phalangization and
• Vascularized transmetatarsal second toe deepening of thumb web are discussed under
transfer the management of mutilated hand.
• Pollicization. Levels of amputation, characteristic and
• Any of the above + Tendon transfer for their surgical options have been discussed in
opponensplasty. details in Table 9.30.1.
31
Procedures for
Reconstruction of
Type I Amputations
defect. Mark the midpoint of the volar half

Transverse and Volar Oblique of the defect and mark this point as “A”.
Amputations Mark the points on the lateral edges where
the neutral lines cut the defect and name
Lateral Advancement these points “B” and “C” on the ulnar and
Flaps of Kütler radial sides respectively. Mark the neutral
lines on the radial and ulnar sides. These
When there has been a transverse amputation
lines will touch the interphalangeal (IP)
on the thumb at any point between the
joint crease at the points “D” and “E” on
proximal third of the nail complex tip and
the radial and ulnar sides respectively.
reconstruction of the thumb should be done
4. First the three points “A”, “B” and “E” are
after the following considerations:
joined together to form a triangle, the
• Length is not necessary as optimum length base being formed by the volar radial half
of the thumb is already available. Hence, of the edge of the defect, the apex being
retaining the available length of the thumb pointed proximally.
is important and further shortening should 5. The two sides of the flap are incised with a
not be thought of, to preserve the nail number 15 blade down to the dermis only,
complex. and the incision is completed by turning
• The closure of the stump should be done around the apex at the distal interphalan
in such a way that sensate, glabrous skin geal (DIP) joint.
covers the tip. 6. Now, the incision is gently deepened till
• The above criteria will be filled by the use the fat globules protrude through the
of the lateral advancement flaps, originally incision site. A skin hook is applied on the
described by Kütler. leading edge of the flap, i.e. the edge of the
defect and mild traction applied. While
maintaining traction, the knife is used to
Surgical Steps gently incise the fibrous septae one by
1. Axillary block anesthesia is given. A one. As this is being done, the flap can be
tourniquet is applied on the arm. felt and seen to advance slowly.
2. The hand is painted and draped. The tourni 7. When the flap covers the radial half of the
quet is raised. The wound is debrided and defect, mobilization of the flap should be
defect measurement is taken (Figs 9.31.1A stopped.
and B). 8. A similar procedure should be done on
3. The defect will be in the form of a circle or the ulnar side by joining the points “C”, “A”
transverse oval, with the amputated end and “D” and the ulnar side flap is raised as
of the bone protruding in the center of the described in steps 4, 5, 6 and 7.
CHAPTER 31 PROCEDURES FOR RECONSTRUCTION OF TYPE I AMPUTATIONS 139
A B
Figs 9.31.1A and B Markings for the lateral advancement flaps
9. The tourniquet should be released, viability • Day 10: Suture removal, removal of POP
of the flaps confirmed, and hemostasis slab, scar massage and mobilization of
achieved. thumb.
10. The leading edge of the flaps should be
sutured to each other over the summit of
the defect, to the nail bed on the dorsal
aspect and the point “A” on the volar skin,
Dorsal Oblique Amputations
using 4.0 polyamide sutures. The dorsal
and volar edges should be sutured using Volar Advancement Flap of Atasoy
4.0 polyamides in a “Y” fashion. The longi When there has been a dorsal oblique ampu
tudinal limb of the “Y’ is representative of tation on the thumb at any point between the
the amount of movement achieved by the proximal third of the nail complex and the neck
flap. of the proximal phalanx, reconstruction of the
11. Vaseline gauze is applied. Sterile dress thumb should be done after the following
ing done. Below elbow dorsal slab thumb considerations:
plaster of Paris (POP) is applied with a • Length is not necessary as optimum length
wrist in neutral position, metacarpo of the thumb is already available. Hence,
phalangeal (MCP) joint of thumb flexed retaining the available length of the thumb
at 20°, and interphalangeal (IP) joint in is important and further shortening should
neutral position. not be thought of
• The closure of the stump should be done
Postoperative Regimen in such a way that sensate, glabrous skin
• Day 2: Inspection of flap and suture line covers the tip
• The above criteria will be filled by the use 5. The two sides of the flap are incised with a
of the volar advancement flap, originally number 15 blade down to the dermis only,
described by Atasoy. and the incision completed by turning
around the apex at the DIP joint.
Surgical Steps 6. Now, the incision is gently deepened till
1. Axillary block anesthesia is given. A the fat globules protrude through the
tourniquet is applied on the arm. incision site. A skin hook is applied on the
2. The hand is painted and draped. The leading edge of the flap, i.e. the edge of the
tourniquet is raised. The wound is debrided defect and mild traction applied. While
and defect measurement is taken (Figs maintaining traction, the knife is used to
9.31.2A and B). gently incise the fibrous septae one by
3. The defect will be in the form of a circle or one. As this is being done, the flap can be
transverse oval, with the amputated end felt and seen to advance slowly.
of the bone protruding in the center of 7. When the flap covers the defect, and the
the defect. Mark the two edges of the nail advancing edge AB reaches the point “A”
stump as “A1” and “B1”. and “B”, mobilization of the flap should be
4. Now, on the free edge of the defect on the stopped (Figs 9.31.3A and B).
volar skin, mark two points “A” and “B” 8. The tourniquet should be released, viability
corresponding to the points “A1” and “B1”. of the flaps confirmed, and hemostasis
Mark a point “C” in the midvolar aspect achieved.
of the IP joint crease of the thumb. The 3 9. The leading edge of the flap should be
points “A”, “B” and “C” are joined together sutured to the nail bed on the dorsal aspect,
to form a triangle, the base being formed using 4.0 polyamide sutures. The sides of
by the volar edge of the defect, the apex the flap should be sutured using 4.0 poly
being pointed proximally. amides in a “Y” fashion. The longitudinal
A B
Figs 9.31.2A and B Defect and the markings for the flap
limb of the “Y” is representative of the one side, either the radial side or the ulnar
amount of movement achieved by the flap. side. Thus, one edge, either the radial or ulnar
10. Vaseline gauze is applied. Sterile dressing edge is more proximal. When the proximal
done. Below elbow dorsal slab thumb POP edge of the amputation does not cross the
is applied with wrist in neutral position, level of the nail fold, the obliquity is minimal
MCP joint of thumb flexed at 20º, and IP and is called oblique amputation type “A”.
joint in neutral position.
Surgical Steps
Postoperative Regimen 1. Axillary block anesthesia is given. A
• Day 2: Inspection of flap and suture line tourniquet to be tied on the arm.
• Day 10: Suture removal, removal of POP 2. Hand to be painted and draped. Tourni
slab, scar massage and mobilization of quet to be raised.
thumb. 3. Debridement of the wound is done. The
marking of the flap are now made. The
points on the neutral line of the defect are
Oblique Amputation Type “A” marked. It will be seen that one point is
more proximal than the other due to the
obliquity of the defect. Mark this proximal
Oblique Triangular Flap of point as “A”. The distal point is marked “B”.
Professor R Venkataswami Now, a point “C” is marked on neutral
Oblique amputations on the thumb at Type I line at the PIP joint on the side of point
can be of two types. The classification depends “B”. These two points are joined by a line.
on the angle of the obliquity. An oblique Similarly “A” and “C” are joined. This line
amputation means that there is more loss of will cut across the IP joint crease. This is
A B
Figs 9.31.3A and B Showing the advancement of the flap and final suture line
marked as an oblique triangle with base involves an obliquity in such a way that one
on the edge of defect. end extends beyond the nail fold. Thus, the
4. Make skin incision along BC and AC with obliquity in this type of amputation is more
number 15 blade. The incision is turned than the obliquity in the first type.
around the apex and completed. Use of the dorsal skin as a transposition
5. Skin hooks are placed on the edge of the flap can be done by the following method.
defect, and the flap is raised superficial
to the fibrous flexor sheath. By doing this, Surgical Steps
the neurovascular bundle goes along with
1. Axillary block anesthesia is given. A
the flap. As it nears the apex, care should
tourniquet is applied on the arm.
be taken not to injure the neurovascular
2. The hand is painted and draped. The
bundle. When the flap is totally raised,
tourniquet is raised. The wound is debrided
it will be seen to be attached only by the
and defect measurement is taken (Figs
neurovascular bundle. Now, the skin hooks
9.31.4A and B).
are used to give gentle traction on the flap
3. One edge of the oblique oval will be
to advance it and the reach of the flap is
proximal to the nail fold, either on the
checked.
radial side or on the ulnar side. Mark this
6. Now, release the tourniquet, and secure
point as “A”. Mark the opposite end of the
hemostasis. Then inset the flap at the
oval defect as “B”. Measure the distance
leading edge by using 4–0 polypropylene.
from “A” to “B”. Measure the volar-dorsal
Then the sides are sutured. It will be seen
distance at the widest point of the defect.
that the suture line is in the form of a “Y”,
Mark these points as “C” and “D” on the
the vertical limb of the “Y” denoting the
volar and dorsal sides respectively.
amount of advancement of the flap.
4. Mark this distance transversely on the
7. Dressings are applied with vaseline gauze,
dorsum of the terminal phalanx region,
dry gauze and finger dressings. Pad and
about 3 mm proximal to the nail fold, to
bandage are applied on the hand and
protect the underlying hyponychium.
forearm.
This line may be at the point “A” or it may
8. Below elbow dorsal slab thumb POP is
be 1 to 2 mm proximal to “A”. This does not
applied with wrist in neutral position,
matter. It only means that there will be an
MCP joint of thumb flexed at 20°, and IP
intact skin bridge about 2 mm between
joint in neutral position.
the base of the flap and the defect, which
has to be excised later. Name this line as
Postoperative Regimen AE.
• Day 2: Inspection of flap, and suture line 5. Mark another point “F” proximal to the
• Day 10: Suture removal is done, POP slab point “A” at a distance equal to CD. This
is discarded. will form the base of the flap. Mark a line
Advise: Wash with soap and water, massage FG parallel to AE. Join the points “G” and
scar and mobilize the thumb. “E”. The line GE will form the leading edge
of the flap.
6. Raise the flap from the marking GE up to
the base AF.
Oblique Amputation Type “B” 7. The tourniquet should be released, viabil
ity of the flap confirmed, and hemostasis
Dorsal Transposition Flap achieved.
As described, an oblique amputation may be 8. The leading edge of the flaps should be
of two types and will now discuss the optimal sutured to the distal edge of the defect
management of the second type. This type and the sides of the flap should be sutured
A B
Figs 9.31.4A and B Markings for the dorsal transposition flap
to the volar and dorsal edges of the defect raw area and tie over sutures applied with
using 4.0 polyamide sutures. 3.0 Ethilon.
9. Management of the donor area: After con 10. Vaseline gauze is applied. Sterile dressing
firming hemostasis, the raw area on the done. Below elbow dorsal slab thumb
dorsum should be covered with a split POP is applied with wrist in neutral posi
thickness skin graft. Now, raise the hand tion, MCP joint of thumb flexed at 20°, and
and prepare the arm with betadine solu IP joint in neutral position.
tion. The skin graft should be harvested
from the medial side of the arm. Sterile Postoperative Regimen
dressings should be applied over the skin • Day 2: Inspection of flap and suture line
graft donor site before moving back to the • Day 10: Suture removal, removal of POP slab,
hand. The graft should be applied over the scar massage and mobilization of fingers.
32
Procedures for
Reconstruction of
Type II Amputations
Introduction Disadvantages
• It requires two stages of surgery
There are three standard procedures for the • It entails significant donor site morbidity:
reconstruction of such defects: There is a loss of sensation on the ulnar half
1. Staged Island flap described by Professor of the middle finger, there is a significant
R Venkataswami. scarring on the middle finger.
2. First dorsal metacarpal artery flap.
3. Littler’s neurovascular Island flap. Presurgical Counseling
The procedures 2 and 3 have already been • This procedure is planned to cover the raw
described in Chapters 4 and 3 respectively. area on the thumb with skin and tissues
The procedure of staged Island flap of with sensation
Professor R Venkataswami is described here. • This procedure will be done under axillary
block anesthesia
Staged Island Flap of perform
Professor R Venkataswami • Skin will be removed along with soft
tissues from the middle finger and placed
on the raw area of the thumb. There will be
The flap of choice for the reconstruction
a bridge of skin connecting the thumb with
of a defect on the stump of the thumb is a
the middle finger from where the skin is
staged Island flap described by Professor R
going to be taken. A skin graft will be taken
Venkataswami.
from the medial side of the upper arm and
applied over the secondary raw area on
Advantages the middle finger. There will be a loss of
• It brings partly glabrous skin to the tip sensation on one side of the middle finger,
of thumb stump which is well padded, and there will be a scar on the finger. There
durable and cosmetically appealing will also be a scar on the medial side of the
• It is sensate, retains the sensation of the arm
native thumb, and hence the function of • Admission will be necessary for a minimum
the thumb is not interfered with. Sensory period of 3 days
re-education is not necessary to get appre • A dressing will be applied and a plaster
ciable sensation on the flap of Paris (POP) will be applied, which will
• It is a relatively easy procedure when com be retained for 14 days, following which,
pared to the Littler’s neurovascular Island another stage of surgery will be done to dis-
flap. connect the thumb from the middle finger
CHAPTER 32 PROCEDURES FOR RECONSTRUCTION OF TYPE II AMPUTATIONS 145
• A splint will have to be applied on the

middle finger for a period of 3 to 4 weeks
afterward
possible due to anatomical variations. In
such cases, other surgery like a cross finger
flap may be done
• The general complications of local anesth
etic infiltration like hypersensitivity may
immediately.
Surgical Steps
• Stage I: Debriding the wound, tagging the
ulnar side digital nerve to thumb, raising
Fig. 9.32.1 Markings for the staged neurovascular flap
and insetting the flap from the middle finger
• Stage II: Dividing the flap, and coapting
the ulnar side digital nerve of thumb to the
segment of digital nerve of middle finger in
should not go beyond the DIP crease of
the flap.
the middle finger
• The flap can now be marked on the
Stage I middle finger ulnar side keeping in
1. The preferred anesthesia is either axillary mind the following criteria; the flap
block or general anesthesia (in children). should not go beyond the mid volar line
2. Apply the tourniquet and keep ready. or the mid dorsal line. The base of this
3. Preparation and draping as described in flap “AB” will be on the ulnar side of the
Appendix I. The elbow area must also be middle finger at the level of the volar
prepared and kept exposed. metacarpophalangeal (MCP) crease.
4. Raise the tourniquet and note the time. The point “A” will be represented by the
5. Debride the defect and measure it. Dissect mid volar line cutting the volar MCP
the stump of the ulnar side digital nerve crease and “B” will be the mid dorsal
and tag it with 7.0 polypropylenes for line at the midpoint of the proximal
coaptation in the second stage of surgery. phalangeal segment. Distally, surgeons
Make sure that the edges consist of intact should remember that the nail bed
and healthy skin. Take a lint pattern of the extends for 3 to 4 mm proximal to the
defect. nail fold; hence, the flap should not go
6. Markings for the flap (Fig. 9.32.1): beyond this area.
• The basis of this flap is the neurovas 7. Now, the flap can be raised. Make the first
cular bundle to the ulnar side of the incision on the mid volar side. This incision
middle finger. Cut a lint pattern accor must be drawn to the fibrous flexor sheath.
ding to the defect on the stump of the There are a few transversely oriented subcu
thumb. Holding the lint at the base of taneous volar veins at this area which must
the middle finger on the ulnar side, be cauterized. The volar portion of the flap
transpose the lint of the defect to the can be raised now up to the neutral line.
middle finger on the ulnar side. It The next incision should be made on the
dorsal side down to the extensor paratenon the flap “AB”. Allow the flap to lie freely
and the dorsal portion of the flap raised. over the defect. When it does so, there is
Now, the distal margin of the flap incised a raw area on the undersurface of the flap.
and the neurovascular bundle ligated with It is not necessary to tube this flap and it is
3.0 Vicryl and cut. The flap is now attached also dangerous to do so.
by the Grayson’s and Cleland’s ligaments. 13. Flap inset (Fig. 9.32.2): After confirming
To divide these, the flap must be lifted up, the hemostasis and the viability of the flap,
the neurovascular bundle confirmed to inset can be done with 4.0 Ethilon using
enter the flap and the ligaments must be half buried horizontal mattress suturing.
divided closing to the bone. This will free 14. Management of the donor area: After
the flap some more. confirming hemostasis, the residual
8. As the base of the flap is reached, care raw area on the middle finger should be
should be exercised, as the neurovascular covered with a split thickness skin graft.
bundle is deep to this area. Gently free the At the points where the defect crosses the
neurovascular bundle from the deeper proximal interphalangeal (PIP) and distal
fibrous attachments and the multiple small interphalangeal (DIP) joint creases, back
branches coursing into the web. Now, the cuts should be given for 3 mm to avoid
flap is free, attached only at the base “AB”. skin graft contractures later on. Now,
9. Gently move the flap to the defect over raise the hand and prepare the arm with
the skin to check whether it reaches the betadine solution. The skin graft should
defect comfortably. If it does not, a little be harvested from the medial side of the
more dissection of the base of the flap is arm. Sterile dressings should be applied
in order. over the skin graft donor site before
10. Apply wet gauze on the bed of the flap, moving back to the hand. The graft should
xylocaine soaked gauze on the pedicle of be applied over the raw area and tie over
the flap. Raise up the hand and release the sutures applied with 3.0 Ethilon.
tourniquet. Maintain the hand in elevated 15. Sterile dressings should be applied over
position for about 3 minutes and ask for the hand and the forearm. Care must
the tourniquet to be removed entirely.
11. Now, set the hand on the table and examine
the edges of the flap. There should be a slow
and sustained subdermal bleed. This may
not be evident immediately. It may take a
few minutes for the spasm of the vessel to
be relieved. In the meantime, continue to
bathe the pedicle with 1 percent xylocaine
solution and achieve hemostasis on the
bed of the flap and the primary defect.
If there is no bleeding from the flap edges, look

for any ligature of a branch that is too close to the
vessel.

edges of the flap, it is ready for insetting.
Bring the thumb to the middle finger, so
that the raw area is closed to the base of Fig. 9.32.2 After final flap inset
CHAPTER 32 PROCEDURES FOR RECONSTRUCTION OF TYPE II AMPUTATIONS 147
be taken to avoid compression of the The digital vessel to the middle finger will
pedicle at any point of its course. A finger now be cut and must be ligated
dressing must be applied on the middle 6. The stump of the flap must now be sutured
finger. A sterile gauze must be placed to the skin grafted edge on the middle
under the flap which is bridging the base finger
of the middle finger with the stump of 7. On the thumb, through the exposure
the thumb. A dorsal POP slab should be provided by the divided flap, the stump of
applied for the thumb keeping the wrist in the ulnar side digital nerve to the thumb
neutral, and the MCP joint of the thumb must be identified and dissected. Since
in flexion of 20° and interphalangeal (IP) surgeons have already tagged this nerve end
joints in extension. A window must be with 7.0 polypropylene suture materials,
made in the dressings to allow inspection it may be easily identifiable. Now, on the
and monitoring of the flap. cut edge of the flap, the digital vessel must
be ligated. The cut end of the digital nerve
entering the flap is now dissected for about
• Admission in the ward 2 to 3 mm, to allow for nerve coaptation
• The affected hand should be kept elevated 8. The two nerve ends are coapted with 7.0
• Patient can take normal diet immediately polypropylenes
if the procedure was under regional block 9. The tourniquet is released and hemostasis
or after complete recovery if under general is achieved
anesthesia 10. The final inset is now done with 4.0
• Clinical monitoring of the flap once every Ethilon. Sterile dressings are done and a
6 hours thumb dressing is provided.
• Sedation SOS for 1 day Postoperative Protocol
• Inspection of the dressing after 48 hours • Patient can be treated as an outpatient
• Discharge of the patient by third day • The affected hand should be kept elevated
• Suture removal on the 10th day and • Patient can take normal diet immediately
removal of donor site dressing on the arm if the procedure was under regional block
• Removal of the POP slabs on the 14th day or after complete recovery if under general
and execute the second stage of surgery. anesthesia
Stage II • Sedation SOS for 1 day
1. The preferred anesthesia is either axillary • Inspection of the dressing after 48 hours
block or general anesthesia (in children) • Suture removal on the 10th day. Refer
2. Apply the tourniquet and keep ready to physiotherapy for active and passive
3. Preparation and draping as described in mobilization of the fingers and thumb
Appendix I. The elbow area must also be • Daily wash with soap and water
prepared and kept exposed • Massage of scar and grafted skin with
4. Raise the tourniquet and note the time coconut oil
5. Divide the base of the flap close to the place • Compression garment for scar softening
where it is attached to the middle finger. after a further 2 weeks.
33
Procedures for
Reconstruction of
Type III Amputations
• Provides good sensation on the tip and pulp

Osteoplastic Reconstruction – provided by the Littler’s neurovascular
Island flap component of this method of
One of the methods of staged reconstruction reconstruction.
of a thumb that has been amputated at
the level between the neck of the proximal
phalanx and the metacarpophalangeal (MCP)
Disadvantages
joint (type III amputation) is the osteoplastic • Does not provide the lost movement at the
reconstruction. level of an IP joint
The requirements for a thumb amputated at • Is a staged procedure and hence, takes
this level are: time
• To provide length with soft tissues and skin • Does not provide cosmesis, as the nail
cover complex is not restored.
• To provide stability with bone The components of this method of reconstruc
• To provide sensation on the pulp region of tion are as follows:
the reconstructed thumb • Stage I: Tubed groin flap to augment the
• To provide for the lost movement at the length with a skin envelope followed by
lost interphalangeal (IP) joint region division and inset of the flap
• To provide for good cosmetic appearance • Stage II: Free bone graft to provide stability
with a nail complex. to the skin tube
However, the method of reconstruction that • Littler’s neurovascular Island flap to pro
surgeons are going to consider now, does not vide sensation to the tip and pulp of the
provide all the above. However, this method reconstructed thumb.
of reconstruction has its own advantages.
Surgical Steps
Advantages
1. Component I: Tubed groin flap
• A relatively simple method of reconstruc 2. Component II: Ulnar bone graft application
tion and does not require microsurgical
3. Component III: Littler’s neurovascular
skills
Island flap
• Provides adequate length to the thumb
• Excellent stability is provided by the use of
the bone graft Surgical Procedure of Component I
• Preserves the already available movement (Tubed Groin Flap)
at the carpometacarpal (CMC) joint, and 1. Debridement of the hand wound can
hence, coarse movements of the thumb are be done under axillary block anesthesia
preserved and spinal anesthesia or tumescent local
CHAPTER 33 PROCEDURES FOR RECONSTRUCTION OF TYPE III AMPUTATIONS 149
anesthetic for raising the flap. In children, for 6 cm beyond the anterior superior iliac
general anesthesia may be used. spine. This is because this portion of the
2. The patient should be placed in a supine flap is a random portion and must follow
position. A rolled up towel should be the 1:1 ratio. The flap is now marked foll
placed under the gluteal region on the owing the above principles.
side that the flap is going to be raised. This 7. The first incision is made on the distal
position makes raising the flap easy. portion of the flap with a number 22 blade
3. Now, the groin region is prepared, from down to the skin, subcutaneous tissue
the subcostal margin to the groin region up to fascia. Incision is then made on the
and from the midline to the mid-axillary superior margin up to the membranous
line on the same side of the injured hand. layer of the superficial fascia. The inferior
If the flap planned is large, the ipsilateral incision is made up to the deep fascia.
thigh is also prepared. The hand is also Now, incisions have been completed on
prepared and draped. 3 sides. By placing two skin hooks on the
4. Now, debridement of the hand wound is distal portion of the flap, and applying
done. After debriding the wound, a lint gentle traction, the flap is raised from the
pattern is taken of the defect on the hand. bed in the plane of loose areolar tissue
The tourniquet is released and hemostasis superficial to the deep fascia. The flap is
is achieved. The tourniquet is removed raised thus till the marked pivot point. The
and the site of application on the arm is viability of the flap can be confirmed by
massaged by the theater assistant. noting the bleeding from the edges of the
5. Markings are now made on the groin flap.
region. The first marking is the anterior 8. The donor site of the flap should now
superior iliac spine. Next the pubic tubercle be covered. If it is small, it can be closed
is marked. These two points are joined by primarily in layers, with 2.0 Vicryl subcu
a curvilinear line convex downward. The taneous sutures, and 3.0 polypropylenes
femoral artery is palpated and marked for for skin. This can be facilitated by flexing at
about 3 cm from the inguinal ligament the hip to ease the suture line till closure of
distally. Now, a point is marked on this the skin. If the defect is large, it should first
femoral artery line, about 2.5 cm (2 finger be narrowed by suturing the edge of the
breadths) distal to the inguinal ligament. skin to the deep fascia with 3.0 Vicryl and
Another point is marked 2.5 cm (2 finger making the residual raw area smaller. The
breadths) lateral to this point. This point is residual raw area should then be covered
where the axial artery of the flap-superficial with a split thickness skin graft harvested
circumflex iliac artery enters the flap. from the thigh. The donor site of the graft
Now, draw a line from this point parallel should be covered with vaseline gauze
to the inguinal ligament up to the anterior and dressing with pads and bandage.
superior iliac spine. This is the course of The skin graft should be applied on the
this artery. raw area in the groin and anchored with
6. Place the lint pattern of the defect with the 3.0 silk. Sterile vaseline gauze and pad is
pedicle at the marked pivot point of the applied.
flap. The flap can be marked with equal 9. Now, the hand is brought to the groin
breadth superior and inferior to the axis region and insetting of the flap is done, i.e.
of the flap. When the flap extends beyond the suturing of the flap to the edges of the
the anterior superior iliac spine, it has defect. This is done with 3.0 polyamide
restricted dimensions. If, at the level of the suture material.
anterior superior iliac spine, the width of 10. After the flap inset is done, vaseline gauze
the flap is 6 cm, the flap can only extend is applied over the suture line. Arm and
elbow restraints are applied with pad and • Now, a hole must be drilled in the end of
sticking plaster, to maintain the position the bone to receive the bone graft. This is
of the hand in a comfortable position for because, the ulnar bone graft which is a
the patient. corticocancellous graft is going to be used
and the most effective method of fixation
Stage of flap division: This is done on Day 14. would be to peg the bone graft into a hole in
• Local anesthetic or tumescent solution is the stump of bone.
injected in the base of the flap. It is then • The procedure of harvesting the ulnar
incised with a number 15 blade and the bone graft is described in the Appendix VI.
hand separated from the groin region
• Hemostasis is achieved and the groin wound Surgical Procedure of Component III
is closed with 3.0 polypropylene sutures.
Sterile dressings are applied on the groin (Littler’s Neurovascular Island Flap)
and hand wound. Once the bone graft has been pegged into
place, the opening that was made in the volar
Stage of final flap inset: This is done on Day 16 aspect of the groin flap must be resurfaced
(2 days after flap division) with the neurovascular flap. The defect is
• Axillary block anesthesia is given measured and the neurovascular Island flap
• The hand is painted and draped. The flap done as described in chapter 3.
edges are looked for necrosis. Any necrosed
portion is excised. If there is no necrosis the Postoperative Protocol
flap edge is trimmed for about 3 mm.
Suturing this edge to the edge of the defect
is done with 3.0 polyamide suture. Sterile
dressings are done.
After a period of about 3 months which is
needed for the skin flap to become soft and
anesthesia
supple and the joint of thumb to become active
again (after the period of immobilization
6 hours
in the groin flap), the second stage of the
reconstruction is done. This comprises of two
components, both done in the same stage.
• Inspection of the dressing after 48 hours
Surgical Procedure of Component II • Suture removal on the 10th day and remo
(Ulnar Bone Graft Application) val of donor site dressing on the arm
• Preparation and draping are done as • Removal of the POP slab on the 14 day and
described in Appendix I. advise the following:
• The scar on the volar aspect of the groin flap • Refer to physiotherapy for active and
skin is excised and the volar seam line of the passive mobilization of the fingers and
groin flap is opened. This will expose the thumb
stump of the bone, which may be either the • Daily wash with soap and water
base of the proximal phalanx or the head of • Massage of scar and grafted skin with
the metacarpal bone. The exposed stump of coconut oil
bone must be freshened by nibbling away • Compression garment for scar softening
the sclerotic layer. If the remaining base after a further 2 weeks
of the proximal phalanx is very small (less • Straightening splint for the middle fin
than 0.5 cm), it can be excised. ger to be worn for 3 weeks at night.
Vascularized Wrap-around Great

Toe Transfer
Preparation
• Palpate the dorsalis pedis artery, Doppler
it and mark the course.
• Put the leg in a dependent position and
mark the main dorsal veins, the transverse
arch and the great saphenous system.
• Measure the circumference of the normal
thumb at the level of the MCP joint. Measure Fig. 9.33.2 Marking for the dissection of the pedicle
the circumference of the ipsilateral great
toe at the metatarsophalangeal (MTP)
joint. the tip to the circumferential base line on
• Measure the length of the normal thumb the medial side including the medial nail
and the length of the thumb to be recon fold. From the medial eponychium, this
structed. The difference between the two line is extended laterally, about 2 to 3 mm
values will give the measurement of the beneath the nail. A similar line is marked
ipsilateral great toe required as a flap (Fig. on the plantar aspect of the great toe to
9.33.1). The difference between the two meet the above line at the level of the
values represents the width of the flap of lateral toe tip.
skin on the medial side of the great toe. This • Mark a point “A” at the level of the distal
flap is marked on the medial side of the edge of the inferior extensor retinaculum,
great toe and this flap extends distally to the halfway between the dorsalis pedis artery
tip of the great toe with a tapering tip. marking and the great saphenous system
• Next, the marking of the flap (Fig. 9.33.2) marking.
is made. If the circumference of the thumb • Draw an “S” shaped line between the point
is 7.5 cm, a 7.5 cm circumferential line “A” and the marked circumferential base
is drawn at the base of the ipsilateral line adjacent to the first web space.
great toe. Now, the medial flap must be
outlined, which is necessary to protect the
remaining portion of the great toe. A line is
Surgical Steps
drawn on the dorsum of the great toe from 1. Prepare the ipsilateral lower limb from the
knee distally and apply the drapings.
2. The tourniquet can be raised and the time
noted.
3. Make the dorsal incision down to the
dermis only.
4. Raise medial and lateral flaps for about 2
to 3 cm on either side.
5. The following should be dissected now
– the great saphenous vein, other dorsal
veins, fat and subcutaneous tissue.
6. Dissect the dorsalis pedis artery up to the
distal part of the intermetatarsal space,
Fig. 9.33.1 Showing the amount of skin on the great toe to where it will divide into two branches to
be harvested as a flap the great toe and the second toe.
7. Dissect the deep peroneal nerve which joint of the second toe. Great care should
lies deep to the dorsalis pedis artery. Diss be taken at this level to avoid injury to the
ect it till the divisions to the great toe and vessels at this level.
the second toe. Tease gently and separate 13. Now, retractors should be applied to the
the fascicles to the great toe and second second metatarsal and retracted later
toe. Divide the fascicles to the great toe ally and the first metatarsal retracted
as proximally as possible and tag with medially. The arterial system is now
7.0 polypropylene. This nerve should be exposed (Fig. 9.33.3). The system should
anastomosed to the superficial radial be carefully dissected, taking into account
nerve branches on the dorsal aspect of the the dominance of the vessel system. This
thumb. can be assisted by carefully dividing
8. Start the dissection on the great toe on the the interosseous muscles and further
medial side and elevate the flap toward exposing the arterial system.
the lateral side. This should contain the 14. Now, the wrap around toe is almost
nail plate, nail bed and the part of the completely dissected and is held only by
terminal phalanx bone to which the nail the artery and veins.
bed is adherent. As the dissection moves 15. Now, release the tourniquet, apply warm,
proximally, elevate only the skin flap moist pads over the dissected wrap around
superficial to the extensor hallucis longus great toe and the vascular pedicle. Take
tendon. Dissect over the extensor hallucis care to prevent the toe from falling down
longus tendon and take care to retain the and shearing the vessels! Raise the foot
paratenon over it as a skin graft must be for about 5 minutes. Then place the foot
applied over it later. on the table. It usually takes about 15 to
9. At the distal part of the dorsalis pedis artery, 20 minutes for the circulation to be re-
identify the deep communicating branch established in the dissected toe. By the
going to the plantar side. This branch will end of this time, the toe becomes pink and
join with the first plantar metatarsal artery warm and ready for transfer.
to form the plantar digital artery. And this 16. The vessels can be divided when the
plantar digital artery will divide into two, recipient site dissection is over (Fig. 9.33.4).
the medial plantar digital artery going to
the lateral side of great toe and the lateral
plantar digital artery going to the second
toe. Examine this system to see which
is dominant—the first dorsal metatarsal
artery and the dorsal digital arteries or the
first plantar metatarsal arteries and the
plantar digital arteries.
10. Now, surgeons go to the plantar side
dissection. Make the plantar incisions
on the medial side and dissect laterally.
Raise the entire pulp tissue and skin as
the flap. The two plantar digital nerves to Fig. 9.33.3 Showing relevant vascular anatomy
the great toe are identified. They are cut as of the great toe
Key: 1. First dorsal metacarpal artery; 2. Common Dorsal digital artery;
proximal as possible and tagged with 7.0
3. Proper dorsal digital artery to II toe; 4. Proper dorsal digital artery to
polypropylenes. great toe; 5. First plantar metatarsal artery; 6. Distal communicating
11. The lateral plantar digital artery (branch artery; 7. Common plantar digital artery; 8. Proper digital artery
to the second toe) is divided. to medial side great toe; 9. Proper digital artery to II toe; 10. Proper
12. The transverse metatarsal ligament is digital artery to lateral side great toe; 11. Deep transverse metatarsal
divided on the medial aspect of the MTP ligament
Recipient Site Dissection

• The hand is prepared as described in
Appendix I
• A curvilinear incision is made over the
anatomical snuff box area and the following
structures are identified and dissected:
• The radial artery and both venae
comitantes
• The cephalic vein
• The superficial branch of the radial
nerve.
• One percent of xylocaine gauze is applied
over the dissected vessels
• A volar incision is made on the stump of the
Fig. 9.33.4 Harvested wrap-around great toe flap thumb proximally up to the thenar area.
Raise the medial and lateral skin flaps,
apply anchoring sutures with 3.0 Ethilon
and dissect the following structures:
17. Division of the pedicle: Soft clamps should
be applied over the artery and veins. The
• The digital nerves—the ends should be
tagged with 7.0 polypropylene
proximal ends of the artery and veins
should be ligated with 3.0 Vicryl. The
• Prepare the end of the bony stump to
which the great toe wrap around flap is
vessels should be divided and the time
going to be fixed.
noted. The flap should be placed on a
moist abdominal pad and taken to the
recipient site for vascular anastomosis. Harvesting the Ulnar Bone Graft
18. Management of the donor site: After secur • An ulnar bone graft should be harvested
ing hemostasis, the secondary defect on from the proximal part of the ulna which is
the great toe should be dealt with. The subcutaneous and close to the olecranon.
plantar side should be covered with a cross Lengths of up to 8 cm of bone graft and up
toe flap harversted from the dorsal aspect to 1 of 3 the circumference of the ulna can
of the second toe and the flap should be be harvested without morbidity
inset to the edge of the medial flap that has • A gentle “S” shaped incision is marked
been planned and retained on the medial over the subcutaneous border of the ulna
side of the big toe. The dorsal aspect should just distal to the olecranon. This incision
be covered with a skin graft harvested from should be about 8 cm long. The incision is
the ipsilateral thigh and applied over the made deeply down to the bone
paratenon covering the extensor hallucis • The incision is made on the periosteum
tendon. The incision on the dorsum of the and the periosteum elevated on both sides
foot should be closed primarily in layers to expose the ulna for a width of about 3 cm
with 3.0 Vicryl for the subcutaneous tissues • The required dimensions of the bone are
and 4.0 Ethilon for skin. Drainage tubes now marked on the ulna. The length of the
should be placed. Sterile dressings should bone required is the length of the thumb
be applied and elastocrépe bandage app with 1 cm extra. The width should be 2 cm
lied over it. A posterior below knee POP • Perform the osteotomy to raise the cortico
slab should be applied. cancellous bone graft. Sculpt the graft into
the shape of a “cricket bat”, to enable the the anatomical snuff box. The nerve repairs
“handle” end to be pegged into the head of are done with 7.0 polypropylene using
the metacarpal bone. Place the bone graft epineurial sutures
in normal saline • Vascular anastomosis—the recipient vessels
• Close the donor site of the bone graft in should be divided, blood flow checked
layers with 3.0 Vicryl for the subcutaneous from the divided artery and approximator
tissues and 4.0 Ethilon for skin. Drainage clamps applied. The soft clamps must be
tubes should be placed. Sterile dressings released from the donor vessels. Vascular
should be applied anastomosis should be done (the technique
• Now, peg the bone graft into the stump of of vascular anastomosis is beyond the scope
the bone that has been prepared. This must of this manual).
be done in such a way that the cancellous • Bulky sterile dressings and above elbow
side faces the dorsal aspect POP are applied with the elbow in 90°
• Apply gentle compression with moist gauze flexion, forearm in mid prone position. A
and padding over the wound. Release the bulky dressing is applied on the leg and foot
tourniquet. Hold the hand in an elevated with a posterior below knee POP slab.
position for a period of 4 to 5 minutes.
Rest the hand on the table and secure Postoperative Protocol
hemostasis.
• The affected hand and the donor foot
Fixation of the Toe Flap should be kept elevated
• Bring the wrap around great toe flap to • Patient is kept on nil oral for 24 hours in
the recipient site. Place the toe over the case of need for exploration if there is a
pegged bone graft and get a good position, vascular problem in the flap
a position in which good opposition can be • Clinical monitoring of the flap once every
achieved with the fingers and is a functional hour
position • Analgesics and antibiotics for 5 days
• A subcutaneous tunnel is created between • Sedation SOS for 1 day
the recipient site vessels and the summit of • Inspection of the dressing after 48 hours
the stump. This tunnel is for the vessels of • Suture removal on the 10th day
the toe to be passed through to reach the • Removal of the POP slab on the 21st day. If
recipient vessels—the radial artery across toe flap has been done for coverage
• The structures to be passed through the of the donor site, the flap has to be divided
tunnel are: at this time
• The arteries • Refer to physiotherapy for active and pas
• The veins sive mobilization of the fingers and thumb
• The deep peroneal nerve. • Daily wash with soap and water
• Nerve repair—the digital nerves are sutured • Massage of scar and grafted skin with
to the two plantar digital nerves of the toe coconut oil
and the deep peroneal nerve is sutured to • Compression garment for scar softening
the superficial branch of the radial nerve at after a further 2 weeks.
34
Procedures for
Reconstruction of
Type IV Amputations
triangle about 1.5 cm and 1.0 cm (in adults,

Vascularized Second this triangle measures 4 cm by 2.5 cm on
Toe Transfer the dorsum and 3 cm by 2 cm)
• Mark a point “A” at the level of the distal
Preparation edge of the inferior extensor retinaculum,
• Palpate the dorsalis pedis artery and mark halfway between the dorsalis pedis artery
the course marking and the great saphenous system
• Put the leg in a dependent position and marking
mark the main dorsal veins, the transverse • Draw a curvilinear line between the point
arch and the great saphenous system “A” and the apex of the marked triangle
• Mark a dorsal triangle on the dorsum of • Similarly, from the apex of the triangle on
the foot (Fig. 9.34.1) 2 cm length and 1 cm the plantar aspect, make a marking that
base at the second toe. Mark the plantar extends from the apex proximally along the
second metatarsal to the midsole.
Surgical Steps
1. Make the dorsal incision down to the
dermis only.
2. Raise medial and lateral flaps for about
2 to 3 cm on either side.
3. The following should be dissected now
– the great saphenous vein, other dorsal
veins, fat and subcutaneous tissue.
4. Dissect the dorsalis pedis artery up to the
distal part of the intermetatarsal space,
where it will divide into two branches to
the great toe and the second toe.
5. Dissect the deep peroneal nerve which lies
deep to the dorsalis pedis artery. Dissect
it till the divisions to the great toe and the
second toe. Tease gently and separate the
fascicles to the great toe and second toe.
Divide the fascicles to the second toe as
proximally as possible and tagged with 7.0
Fig. 9.34.1 Markings for the second toe harvest polypropylenes.
6. Dissect the extensor hallucis longus ten by carefully dividing the interosseous
don and divide it at the level of the distal muscles and further exposing the arterial
edge of the inferior extensor retinaculum. system.
Divide the tendon of the extensor brevis at 13. Now, the second toe is almost completely
the level of the metatarsal base. dissected and is held only by the intact
7. At the distal part of the dorsalis pedis ar metatarsal bone and the artery and veins.
tery, identify the deep communicating The osteotomy of the metatarsal can be
branch going to the plantar side. This done. This should be done depending
branch will join with the first plantar on the length that surgeons have already
metatarsal artery to form the plantar digi calculated in the preoperative work-up.
tal artery. And this plantar digital artery 14. Once the osteotomy is over, the remaining
will divide into two, the medial plantar soft tissues can be divided, so that the
digital artery going to the lateral side of second toe is now held only by the arteries
great toe and the lateral plantar digital and veins.
artery going to the second toe. Examine 15. Now, release the tourniquet, apply warm,
this system to see which is dominant— moist pads over the second toe and the
the first dorsal metatarsal artery and the vascular pedicle. Take care to prevent
dorsal digital arteries or the first plantar the toe from falling down and shearing
metatarsal arteries and the plantar digital the vessels. Raise the foot for about 5
arteries. minutes. Then place the foot on the table.
8. Now, surgeons go to the plantar side dis It usually takes about 15 to 20 minutes for
section. Make the plantar incisions. The the circulation to be re-established in the
medial and lateral plantar digital nerves dissected toe. By the end of this time, the
are identified. The fascicles to the great toe becomes pink and warm and ready for
toe and the fascicles to the third toe teased transfer.
from the medial and plantar digital nerves 16. The vessels can be divided when the
respectively. The fascicles going to the recipient site dissection is over.
second toe are cut as proximal as possible 17. Division of the pedicle—soft clamps
and tagged with 7.0 polypropylenes. should be applied over the artery and
9. The flexor digitorum brevis muscle is cut veins. The proximal ends of the artery and
at the midsole level, where it joins the veins should be ligated with 3.0 Vicryl.
tendon of the long flexor. The long flexor The vessels should be divided and the
tendon is divided at the midsole level. time noted. The flap should be placed on
10. The medial plantar digital artery (branch a moist abdominal pad and taken to the
to the great toe) is divided. recipient site for vascular anastomosis.
11. The transverse metatarsal ligament is 18. Management of the donor site—after
divided on the medial and lateral aspect securing hemostasis, the secondary defect
of the metatarsophalangeal (MTP) joint of should be closed primarily in layers with
the second toe. Great care should be taken 3.0 Vicryl for the subcutaneous tissues and
at this level to avoid injury to the vessels at 4.0 Ethilon for skin. Drainage tubes should
this level. be placed. Sterile dressings should be
12. Now, retractors should be applied to the applied and elastocrépe bandage applied
second metatarsal and retracted laterally over it. A posterior below knee plaster of
and the first metatarsal retracted medially. Paris (POP) slab should be applied.
The arterial system is now exposed. The
system should be carefully dissected, Recipient Site Dissection
taking into account the dominance of • The hand is prepared as described in
the vessel system. This can be assisted Appendix I
CHAPTER 34 PROCEDURES FOR RECONSTRUCTION OF TYPE IV AMPUTATIONS 157
• A curvilinear incision is made over the longus tendon end and the extensor longus
anatomical snuff box area and the following tendon of the toe is sutured to the end of
structures are identified and dissected: the extensor pollicis longus tendon. The
• The radial artery and both venae comi- tension should be adjusted, so that, the
tantes toe is stable and in a functional position.
• The cephalic vein The repair is done with 3.0 polypropylenes
• The superficial branch of the radial nerve. using modified KM suture technique.
• One percent of Xylocaine gauze is applied • Nerve repair—the digital nerves are sutured
over the dissected vessels to the two plantar digital nerves of the toe
• A volar incision is made on the stump of the and the deep peroneal nerve is sutured to
thumb proximally up to the thenar area. the superficial branch of the radial nerve at
Raise the medial and lateral skin flaps, the anatomical snuff box. The nerve repairs
apply anchoring sutures with 3.0 Ethilon are done with 7.0 polypropylene using epi
and dissect the following structures: neu
rial sutures.
• The flexor pollicis longus tendon • Joint repair—the MTP joint of the toe is
• The digital nerves—the ends should be primarily in a position of hyperextension.
tagged with 7.0 polypropylene When this toe is transferred to become
• The extensor pollicis longus tendon a thumb, if it retains this position, the
• Prepare the end of the bony stump to reconstructed thumb may not be functional
which the second toe is going to be fixed. as it may be away from the fingers. So, it
• Apply gentle compression with moist gauze is important that the MTP joint be made
and padding over the wound. Release the more physiological. To do this, the volar
tourniquet. Hold the hand in an elevated capsule of the MTP joint is plicated with 4.0
position for a period of 4 ot 5 minutes. polypropylenes.
Rest the hand on the table and secure • Vascular anastomosis—the recipient vessels
hemostasis. should be divided, blood flow checked
from the divided artery and approximator
Fixation of the Toe Flap clamps applied. The soft clamps must be
released from the donor vessels. Vascular
• Bring the toe flap to the recipient site. Place anastomosis should be done (the technique
the toe over the stump and get a good
of vascular anastomosis is beyond the scope
position, a position in which good opposition
of this manual).
can be achieved with the fingers and is a
• Bulky sterile dressings and above elbow
functional position.
POP are applied with the elbow in 90° flex
• A subcutaneous tunnel is created between
ion, forearm in mid prone position. A bulky
the recipient site vessels and the summit of
dressing is applied on the leg and foot with
the stump. This tunnel is for the vessels of
a posterior below knee POP slab.
the toe to be passed through to reach the
recipient vessels—the radial artery.
• The structures to be passed through the Postoperative Protocol
tunnel are: • Admission in the ward
• The arteries • The affected hand and the donor foot
• The veins should be kept elevated
• The deep peroneal nerve. • Patient is kept on nil oral for 24 hours in
• Bone fixation—is done with K-wires without case of need for exploration if there is a
causing damage to the vessels. vascular problem in the flap
• Tendon repair—the flexor longus tendon • Clinical monitoring of the flap once every
of the toe is sutured to the flexor pollicis hour
• Analgesics and antibiotics for 5 days • Refer to physiotherapy for active and pas
• Sedation SOS for 1 day sive mobilization of the fingers and thumb
• Inspection of the dressing after 48 hours • Daily wash with soap and water
• Suture removal on the 10th day • Massage of scar and grafted skin with
• Removal of the POP slab on the 21st day. If coconut oil
across toe flap has been done for coverage • Compression garment for scar softening
of the donor site, the flap has to be divided after a further 2 weeks.
at this time
35
Procedures for
Reconstruction of
Type V Amputations

Pollicization continued for a period of 3 weeks. After
this period, physiotherapy will be started
Presurgical Counseling and this should be done for another
• This procedure will be done under axillary 3 weeks
block anesthesia or general anesthesia • In some instances, even if the movements
• The procedure consists of harvesting a of the finger improve, further surgery may
tendon graft from the index finger. There be required to release the scars that may
will be no deficit on the index finger as a form
result of this • The general complications of anesthetic
• This procedure will take about 1½ to 2 infiltration like hypersensitivity may occur
hours to perform in spite of test dose application. This com
• A dressing will be applied and a plaster of plication will cause dryness of mouth and
Paris (POP) slab will be applied at the end apprehension, which can be corrected
of surgery immediately.
period of 3 days
• Postoperatively, no movements of the fin Surgical Steps
gers should be attempted. If it is done, the Described in Chapter on Hypoplastic thump
sutured tendons may rupture pollicization.
SECTION
10
Tumors
Ganglion Excision
36
2. Prepare and drape the involved upper
Introduction limb from the elbow to the tip of the hand.
3. Mark a transverse incision over the summit
One of the most common tumors occurring
of the tumor (volar or dorsal). The incision
on the hand is the ganglion, which can occur
should extend beyond the circumference
on the volar side or the dorsal aspect of the of the tumor by about 3 to 4 mm.
wrist. The surgical management of both these 4. Raise the tourniquet.
conditions is described here. 5. Make the incision as marked down through
the dermis.
6. Apply skin hooks on one of the edges and lift
Salient Features of the the skin flap off the surface of the ganglion.
Condition Elevate this flap till the corresponding
edge of the ganglion is visible. Repeat this
1. Is believed to occur due to degenerative procedure on the opposite edge of the flap.
changes in the joint capsule. So, now the entire circumference of the
2. Is prone for recurrence after surgery ganglion will be visible on retracting both
due to incomplete removal of the intra- skin edges.
articular portion of the ganglion. 7. The ganglion will have a narrow stalk as it
3. Complete removal and prevention of arises from the intra-articular area. This
recurrence is dependent on following the must be dissected by gently elevating the
principles of hand surgery, i.e. regional circumference of the ganglion from the
block anesthesia (axillary or supraclavi bed, formed by the surface of the joint
cular block), use of tourniquet, use of capsule. The points to be noted when
magni fi
cation, bipolar cautery and a doing this step are:
liberal incision to expose and excise the • The tendons on either side should be
tumor. retracted carefully to the radial and
The surgical steps for the excision of volar and ulnar sides to avoid injury to them
dorsal ganglions are the same and they are • The ganglion should not be grasped
discussed here. with forceps as this may injure the
wall of the ganglion and lead to leak
of the mucoid material. The method
of retracting the ganglion is by either
Surgical Steps retaining some soft tissues over the
surface to enable surgeons to hold it, or
1. Apply a pneumatic tourniquet on the by atraumatic retraction with a piece of
upper arm. saline gauze
164 SECTION 10 TUMORS
• In the case of volar ganglion, the radial and plaster of Paris (POP) slab should be
artery and its venae comitantes may applied to immobilize the wrist. For the
course close to the edge of the tumor. dorsal ganglion, a volar POP slab should
Care should be exercised to avoid be applied with the wrist in 20° extension,
injury to these vessels by appropriate and for the volar ganglion, a dorsal POP
retraction. slab should be applied with the wrist in
8. Once the ganglion has been raised off 10° flexion.
the surface of the joint capsule, and
the extension into the joint identified,
an incision must be made on the joint
capsule up to the edge of the ganglion Postoperative Protocol
stalk and the intra-articular area exposed.
By this incision, the stalk of the ganglion • The patient may be treated as an outpatient
can be traced over the articular surfaces of with the advise to keep the hand elevated,
the carpal bones down to the intercarpal oral antibiotics for 3 days, analgesics and
ligaments. anti-inflammatory agents
9. The entire stalk of the ganglion can be • The suture line must be examined at the
removed by gentle blunt dissection to free end of 48 hours and the drainage tube
it from the intercarpal ligament. Thus, the removed. Dressings must be applied again
entire ganglion can be excised in-toto. and the POP slab retained
10. The tourniquet should be released and • On the 10th day, the suture can be remo
hemostasis achieved. The rent in the joint ved, and the POP slab removed
capsule should not be closed. A Segmüller • Patient may be advised the following:
drain (tubing of the scalp vein set) kept • Wash with soap and water
and the wound closed in layers with 4.0 • Scar massage with coconut oil
Vicryl for the subcutaneous tissues and • Active and passive movements of the
skin closed with 3.0 polypropylene sub- wrist and fingers at physiotherapy
cuticular sutures, with the drainage tube • Compression garment after 2 weeks
coming out from one end of the suture to soften the scar, to be worn for a
line. Non-adherent dressings applied minimum of 3 weeks.
SECTION
11
Degenerative
Conditions
Dupuytren’s Contracture—
Assessment 37
Introduction Symptoms
Dupuytren’s contracture is a relatively un • Tightness in the palm on extension
common condition that surgeons see in the • Nodules or callus like formation in the palm
outpatient department in South India, but • Gradually increasing contracture of the
when a patient does present, management fingers
should be perfect to relieve the patient of his • Maceration of skin within contracture folds
distress and make his hand a useful one. and secondary infection.
The points to be noted in the assessment
are described below:
Clinical Examination
History
• Nodules—usually present in the area of the
• History of diabetes mellitus, alcohol in distal palm particularly at the level of the
take or epilepsy, or family history of the palmar creases. Usually non-tender and
disorder. These are important findings not painless
only for the diagnosis of the problem, but • Skin pits—are sometimes seen in the
also to prognosticate the results plamar region
• Though patients with diabetes present • Sometimes, there is just a distortion of the
mainly with a mild form of the disease palmar creases; either deepening of the
consisting of palmar nodules, the rate of creases or widening of the creases. These
recurrence after surgical management of are significant, since they denote the early
contractures, if they develop, are quite high stages of the disease. However, it is not
• Similarly, patients who give history of alcohol essential for these lesions to progress and
intake are also prone for complications lead to contractures
after surgical management of Dupuytren’s • Palpable cords—different types of cord
disease formation which lead to different types
• Eliciting a history of trauma, however of contractures and need different sur
trivial, may also be significant, because, in gical management plans. If the cord is
such situations, the prognosis is very good palpable, the extent of the cord should
and recurrence rates are very minimal. be noted
168 SECTION 11 DEGENERATIVE CONDITIONS
• Sometimes, even the neurovascular bundles Staging of Dupuytren’s

on either side of thickened cords may be Table 11.37.1
contracture—assessment
palpable as soft fluffy swellings, especially
when they are deformed by the spiraling Contractures Description Stage
cords Nil 0
• Contractures—when there is a minimal < 45º I
contracture, the easy way to find it is to ask MCP contracture II
the patient to place the palm of the hand > PIP contracture
flat on the surface of the table. This will not 45º–90º
PIP contracture II D
be possible even in mild contractures of
> MCP contracture
the metacarpophalangeal (MCP) joint. The
contractures in the MCP joint, proximal MCP contracture III
interphalangeal (PIP) joint and the distal > PIP contracture
90º–135º
interphalangeal (DIP) joint should be PIP contracture III D
noted. The passive and active range of > MCP contracture
movements in these joints should also MCP contracture IV
be recorded. The angle of the contracture > PIP contracture
is also noted and will help to classify > 135º
PIP contracture IV D
the deformity according to the Tubiana- > MCP contracture
Michon system. The method of recording is
to measure the contracture angle from the
neutral line and add up the values of the Planning of management of
contractures on the MCP and PIP joints. Table 11.37.2 Dupuytren’s contracture—
This is applicable for fingers and thumb assessment
• Secondary problems of contractures—like
skin maceration, deformities of the nail Findings Plan
complexes should be noted. Stage 0: Only nodules Conservative management
or pits Stretching exercises, local
steroid injection
Stage I No surgery required
Staging
unless patient requests
Staging of Dupuytren’s contracture—assess Stage II: Only one or Fasciectomy

two rays
ment are given in Table 11.37.1.
Stage II: Multiple rays Open palm technique/
Stage III fasciectomy
Planning the Management Stage IV Distractor application

before fasciectomy
Planning of management of Dupuytren’s
contracture—assessment are given in Table
11.37.2.
immediately as there is no risk of involvement
of the joint. However, in cases of mainly PIP
Planning the Timing of the Surgery joint, it is important to schedule the surgery
When the contracture involves only the as early as possible to avoid irreversible con
MCP joint, the surgery need not be done tracture of the joint.
Dupuytren’s Contracture—
Management 38
• The tourniquet is raised and the inci
Fasciectomy sions are made
• The incision is made down through the
Surgical Steps skin and subcutaneous tissues only and
• Prepare the hand as described in App the skin flaps are raised on either side
endix I • The contracted and thickened fascia is
• Marking the incisions (Fig. 11.38.1): carefully dissected and isolated. It is very
• The zig-zag incisions of Bruner are important to keep the neurovascular bun
marked on the palm and affected fin dles in sight throughout the dissection
ger rays, beginning proximally from procedure. This is to avoid inadvertent
the hollow of the palm between the injury to the neurovascular bundles
thenar and hypothenar eminences. The • Once the entire length of the fascia is
incisions follow the course of the flexor dissected, it is excised
tendons of each finger. • Moist saline gauze pieces are placed
over the wound and the hand is raised.
Gentle compression is applied over the
gauze. The tourniquet is released and
the compression is maintained for 3
minutes. The hand is then placed back
on the table and hemostasis is secured.
The viability of the skin flaps is confirmed
• Suturing of the wounds is done with 4.0
Ethilon, after keeping Segmüller drai
nage tubes
• Sterile dressings are applied and a dorsal
plaster of Paris (POP) slab is applied
with the wrist in 30° extension, metacar
pophalangeal (MCP) joints of fingers in
40° flexion and interphalangeal (IP) joints
of the fingers kept straight.
Fig. 11.38.1 Marking the incisions for fasciectomy • The affected hand should be kept elevated
170 SECTION 11 DEGENERATIVE CONDITIONS
• Patient can take normal diet immediately • Application of a detachable straighten

if the procedure was under regional block ing splint for the affected fingers
or after complete recovery if under general throughout the day for 3 weeks. Inter
anesthesia mittently, the splint should be removed
• Inspection of the suture line after 48 hours and active and passive mobilization
without disturbing the position of the POP of fingers should be done. The splint
slab should be worn for another 3 weeks at
• Discharge of the patient by third day night
• Suture removal on the 10th day • The unaffected fingers should be mobi
lized from the day of POP removal
• Plaster of Paris is also removed on the 10th
• Patient is advised to continue the mobi
day
lization of the fingers; both active and
• Advise the following:
passive and review once every month
• Refer to physiotherapy for active mobi for evaluation.
lization of the fingers • It is practical to advise the patient to
• Daily wash with soap and water carry a brief case or portfolio, which
• Massage of scar and grafted skin with keeps the MCP joints in extended posi
coconut oil tion and stretched to the maximum.
SECTION
12
Infection
Hansen’s Disease
and Sequelae 39
like Fowler’s procedure may well suit such
History patients. On the other hand, patients with
bulky hands with thickened skin will require
• Duration of complaints—will indicate the more powerful transfers.
progress of the lesion
• History of treatment—both medical and
surgical Attitude of the Hand
• Occupation of the patient—this is impor The following positions of the hand may be
tant for deciding the surgical reconstruction seen:
• A patient who does manual labor will need • Total claw of the hand—the metacarpo
powerful tendon transfers, while patients phalangeal (MCP) joints are hyperextended,
doing sedentary type of labor will require interphalangeal (IP) joints are flexed in all
the transfer of less powerful muscles. In the fingers. This signifies combined low
such patients, even static procedures will ulnar and median nerve palsy
sometimes suffice • Ulnar fingers alone in clawed position—
• Episodes of drug reactions—a history of may denote that there is a low ulnar nerve
lepra reaction and the time of the reaction palsy. However, the involvement of the
will be important in deciding the timing of median nerve also cannot be ruled out
surgical reconstruction. • Fingers in cascade but the thumb is lying
in the plane of the palm—denotes the
involvement of the median nerve at the
level of the distal forearm
Clinical Examination • Fingers appear to be in cascade—ask the
patient to extend all the fingers. This will
Type of Hand show the claw if it is present
Some people have soft hands with hypermobile • Thumb and index finger are kept extended,
joints. The force required to move these joints while the other fingers are in cascade—will
is very little, as the joints are very supple and indicate a high level median nerve lesion
the skin and soft tissues are also very supple. • All the fingers, thumb and the wrist are in
Hence, when tendon transfers are planned flexed position, with inability to extend any
for such patients, care should be exercised in of them—indicates a radial nerve lesion
choosing the donor tendon [avoid removing • “Z” deformity of the thumb indicates a
the flexor digitorum superficialis (FDS) of combined low median and ulnar palsy
the finger] and in choosing the type of ten • A flat palm, with the metacarpal arch
don transfer (avoid using powerful tendon obliteration points to the combined low
transfers like Brand’s procedure). Procedures median and ulnar nerve palsy.
174 SECTION 12 INFECTION
Appearance of the Hand • Presence of scars—may indicate healed

• Skin appears shiny and bereft of skin rid ulcers. In some patients, scars may give
ges—indicates a combined median and a clue about the previously done recon
ulnar nerve lesion structive procedures, if any.
• Absorption of the fingertip and defor By now, there will be a clue about which nerve
mities of the nail will denote long standing has been involved in the disease process. So,
disease the next step consists of testing the individual
• Wasting of the thenar eminence on the nerve territory separately for the three nerves.
palm—indicates a median nerve lesion. There are many standard tests described in
This lesion can be either low level or high textbooks, and a few of them are mentioned
level lesion here.
• Wasting of the hypothenar eminence indi
cates an ulnar nerve lesion For the Ulnar Nerve
• Hollowing of the intermetacarpal spaces Ulnar nerve of Hansen’s disease and sequelae
on the dorsum of the hand also signifies are shown in Table 12.39.1.
ulnar nerve lesion
• Presence of ulcers—are significant and
usually found on typical areas like over For the Median Nerve
the heads of the metacarpals, tips of the Median nerve of Hansen’s disease and sequ
fingers, and on the volar aspect of the wrist elae are shown in Table 12.39.2.
Table 12.39.1 Ulnar nerve of Hansen’s disease and sequelae

Method of doing Finding Significance
Finger closing Ask the patient to keep Normally, the MCP joints Denotes paralysis of the
pattern the fingers straight on the start moving first and primary flexors of the MCP
table with the palm facing then the IP joints flex to joints. So, the long flexors
upward. He is then asked to complete the flexion. If the have to flex the MCP joint
very slowly flex the fingers ulnar nerve is involved, the and they can do this only
to bring the tips of the IP joints flex fully and then after they have fully flexed
fingers to the palm. move the MCP joints. the IP joints.
Unassisted angle Ask the patient to make a The patient with ulnar Denotes paralysis of the
fist. Then ask him to slowly nerve injury will not be able primary extensors of the
extend the IP joints alone to achieve the lumbrical IP joints and flexors of the
and bring the IP joints to position. If only the ulnar MCP joints.
neutral position, without nerve is involved, the index
extending the MCP joints. and middle fingers will
To make it clear, the surgeon come to lumbrical position,
can demonstrate first on his but not the ring and little.
own hand, and then ask the Now, measure the angle
patient to do it on his unin- at the PIP joints of the ring
volved hand if possible. and little fingers. This is the
unassisted angle.
Contd...
CHAPTER 39 HANSEN’S DISEASE AND SEQUELAE 175
Contd...
Assisted angle Now, support the MCP The patient may be able to If the patient is not able to
joints of the involved now extend the IP joints extend the IP joints fully,
fingers at 90º with your and bring them to neutral it signifies that the long
hands and ask the patient position. This is because extensors and central slip
to extend the IP joints as the long extensors of the have become attenuated,
above. fingers can extend the IP most probably due to long
joints when the MCP joints standing claw deformity.
are stabilized.
Contracture angle If there is an assisted angle, Sometimes, it may not be This signifies that the joint
try to passively extend the possible to extend beyond has become stiff due to
proximal interphalangeal a certain angle. This is the long standing claw. Hence,
(PIP) joints of the involved contracture angle. it must be corrected either
fingers. by physiotherapy or surgi-
cal means to achieve a full
passive range of motion.
Latent clawing When the patient is asked If the ulnar nerve is This signifies that the ulnar
to keep the involved hand involved, the involved nerve is involved, but the
in lumbrical position, he fingers will buckle under soft tissues surrounding
may be able to do it. Test the pressure and the claw the MCP joints are strong
the power of this MCP joint will be revealed. enough to stabilize the
flexion, by giving a short joint weakly. There is no
upward push on the volar need to wait for an obvious
side of the prophylaxis claw to develop before
(PPX) level of the involved planning a correction.
fingers.
Adduction of the Ask the patient keep all In a case of ulnar nerve Indicates paralysis of the
fingers the fingers extended, and palsy, the patient will not adductors of the fingers
insert a card between the be able to grip the card – the palmar interossei
fingers. Ask him to grip the properly or not at all. muscles.
card tightly with the sides
of his fingers, while the
examiner tries to withdraw
the card.
Adduction of little Ask the patient to adduct This will not be possible in This is because the third
finger the extended little finger to a patient with ulnar nerve palmar interosseous muscle
the extended ring finger. palsy (Wartenberg’s sign). which must adduct the
little finger is paralyzed
and only the extensor digiti
minimi are acting.
Froment’s sign A book is held by the If the ulnar nerve is If the adductor pollicis
examiner and the patient is involved, the involved hand muscle, which must act to
asked to hold it with both will show increased flexion grip the book is weak, the
hands. The examiner now at the IP joint of the thumb flexor pollicis longus (FPL)
gently tries to pull the book – positive Froment’s sign. tendon tries to compen-
away, necessitating the sate and this manifests as
patient to apply more pres- increasing flexion at the IP
sure with the thumb. joint of thumb.
Table 12.39.2 Median nerve of Hansen’s disease and sequelae

Testing for abductor Patient is asked to keep his Sometimes, the patient may
pollicis brevis (APB) hand flat on the table, with be able to weakly touch the
muscle the palm facing upward. pen, only when the level of
The examiner then holds a the pen is brought closer
pen parallel to the plane of to the palm. Even then, the
the palm at a distance. He weakness or absence of
is then asked to lift-up only muscle tone in APB denotes
the thumb to touch the pen. the involvement of the
When the patient attempts median nerve.
this, the examiner now
palpates the tone of the APB,
which is the first palpated
muscle on the radial side of
the first metacarpal bone.
Flexor digitorum pro- The patient is asked to flex Patient will not be able to Indicates high median
fundus (FDP) of index individually only the distal do so individually in a case nerve palsy.
and mid interphalangeal (DIP) joints of high median nerve palsy.
of the index and middle There may be some move-
fingers when the middle ment of flexion, but this
phalanx (MPX) segments may be by the contiguous
of the fingers are stabilized movements at the FDP of
by the examiner. When the the ring and little fingers.
patient does this, the exam-
iner tests the power of this
flexion and at the same time,
examines for movement of
the DIP joints of the ring and
little fingers also.
Testing the FDS action The patient is asked to clasp When the median nerve Indicates high median
on index finger both hands. The position of is involved at a high level nerve palsy.
the index finger is assessed (in the proximal forearm or
in this position. above), the patient will not
be able to flex the IP joints
of the index finger and it
will remain in extended
position (pointing index).
Testing the FPL action Patient is asked to flex the IP Will not be possible in high Indicates high median
joint of the thumb against re- involvement of the median nerve palsy.
sistance, while supporting the nerve.
PPX segment of the thumb.
Thumb web angle A line is drawn on the dorsal The normal thumb web If the angle is less than
aspect of the hand over the angle is 40°. normal, it indicates tight-
first metacarpal and the ening of the underlying
second metacarpal bones. adductors/stiffness of the
The angle between these carpometacarpal (CMC)
two lines (the thumb web joint of thumb and/or
angle) is measured. the skin. The suppleness
of the skin of the thumb
web, the free range of
movements at CMC joint
of thumb must be re-es-
tablished before planning
any tendon transfer.
Contd...
CHAPTER 39 HANSEN’S DISEASE AND SEQUELAE 177
Contd...
Grade of opposition The patient is asked to It is important that the

(Kapandji) touch the tip of his thumb patient touches the tips of
to the tips of the index, the fingers with the tip of
middle, ring and little the thumb. All other pinches
fingers. The grading of the are not representative of
range of movements is true opposition.
done as shown.
Table 12.39.3 Radial nerve of Hansen’s disease and sequelae

Extension of fingers Ask the patient to keep the The extension of the MCP
hand flat on the table with joints of the fingers is
the palm facing down- evaluated by this method.
wards. Then, the patient is
asked to lift the fingers one
by one and each finger is
evaluated individually.
Extension thumb The above test is repeated
for the thumb, and the
patient is asked to actively
extend the IP joint of the
thumb against resistance.
Wrist Patient is asked to make
a fist and then extend the
wrist against resistance.
For the Radial Nerve in planning the reconstruction. This recording

should include both active and passive range
Radial nerve of Hansen’s disease and sequ
of movements. Reversal of the metacarpal
elae are shown in Table 12.39.3.
arch must also be recorded.
Position of the joints—should be checked Sensation—the pain, touch sensation should
and recorded. This will show any stiffness or be recorded and the two point discrimination
contractures and will play an important role should also be recorded.
40
Opponensplasty with Flexor
Digitorum Superficialis
of Ring Finger
physiotherapy will be started. This should

Introduction be continued for a further 3 weeks. During
this period of physiotherapy, exercises will
Though there are many procedures for opp
be taught to make the tendon of the ring
onensplasty this procedure is a standard one
finger move the thumb
that is commonly used, when the thumb web
• In some instances, the movement that
is tight, and a powerful muscle is needed to
returns on the thumb may be weak and may
overcome this tightness.
not be powerful enough for useful work. In
some other instances, the tendon may not
work at all. This will require another sitting
Presurgical Counseling of surgery to correct the problem
• In some instances, the ring finger may
• This procedure is planned to correct only develop a minimal deformity on the
the weak thumb. This surgery will not proximal interphalangeal (PIP) joint. This
correct the other problems that may exist will require a small surgery to correct the
on the hand like wasting of the muscles problem
or loss of sensation. These problems need • The general complications of local anesthetic
to separate sittings of surgery and cannot infiltration like hypersensitivity may occur
usually be combined with the procedure in spite of test dose application. This
planned at present complication will cause dryness of mouth
• This procedure will be done under axillary and apprehension, which can be corrected
block anesthesia immediately.
• This procedure will take about 1 hour to
perform
• A tendon from the ring finger will be Surgical Steps
removed and taken to the thumb to make
the thumb move in a useful direction. There 1. Prepare the hand as described in
will be no obvious deficit on the ring finger, Appendix I.
but there may be some weakness of the 2. Mark the incisions as follows (Fig. 12.40.1):
finger • Incision “A”—an incision is marked over
• Admission will be necessary for a minimum the neutral line on the ulnar border of
period of 3 days the ring finger about 4 cm long, centered
• A dressing will be applied and a plaster at the level of the PIP joint crease
of Paris (POP) will be applied, which will • Incision “B”—an incision 2 cm long
be retained for 3 weeks, following which, mar ked transversely over the distal
CHAPTER 40 OPPONENSPLASTY WITH FLEXOR DIGITORUM SUPERFICIALIS OF RING FINGER 179
4. First the incision “A” is made to harvest

the FDS tendon. The skin on the volar
side is raised superficial to the digital
neurovascular bundle. The flexor tendon
sheath is identified. An incision is made
in the flexor tendon sheath to isolate the
flexor digitorum profundus (FDP) and FDS
tendons. The FDP tendon is usually seen
first and it must be retracted volarward to
expose the FDS tendon slips. The ulnar slip
is first seen. A hemostat is applied about 1
cm proximal to the insertion. The tendon
slip is now cut distal to the hemostat. Now,
traction is applied to this cut slip with the
hemostat and this will expose the radial
slip of the FDS tendon. This slip is also
divided 1 cm proximal to the insertion
and another hemostat is applied on the
proximal cut end. Both hemostats are
pulled distally to expose the decussation
of the FDS tendon. It is divided with a
Fig. 12.40.1 Markings for opponensplasty using flexor blade until both slips are free. The vincular
digitorum superficialis (FDS) of ring finger attachment will also have to be divided to
achieve total release of the FDS slips.
5. Incision “B” is made and the synovium over
palmar crease proximal to the ring the FDS and FDP tendons just proximal
finger to the A1 pulley is incised to expose the
• Incision “C”—an incision 2 cm long tendons. Identify the FDS tendon and pull
marked transversely over the flexor so that the tendon is now delivered in this
aspect of the forearm about 3 cm wound. Suture wound “A” now.
proximal to the wrist crease 6. The incision “C” is made and the FDS
• Incision “D”—an incision 2 cm long tendon identified among the tendons to
marked transversely over the palm just the fingers. The FDS of the ring finger is
distal and radial to the pisiform bone pulled and delivered in the wound.
• Incision “E”—an incision 2 cm long 7. Now, incision “D” is made through the
marked longitudinally over the radial skin and subcutaneous tissues. The
aspect of the thumb at the level of the subcutaneous fat consisting of fine fat
metacarpophalangeal (MCP) joint just globules is seen. The incision is gently
volar to the midpoint deepened till large fat globules protrude
• Incision “F”—an incision 2 cm long out. Now, a tendon retriever is passed
marked transversely over the dorsum through this wound proximally to exit at
of the proximal phalanx of the thumb, the forearm wound. The free end of the
just proximal to the interphalangeal (IP) FDS tendon is grasped and the tendon
joint crease on the thumb. delivered at the incision “D”.
• Incision “G”—an incision on the ulnar 8. Incision “E” is made through the skin
side of the MCP joint of the thumb, and subcutaneous tissues to expose the
about 2 cm long. insertion of the abductor pollicis brevis
3. The tourniquet is raised and the incisions tendon. The tendon retriever is passed
are made. from this wound to the incision “D”. The
free end of the FDS tendon is grasped and minimal tension as described above. The
retrieved in incision “E”. The incisions “B”, other slip is passed subcutaneously to
“C” and “D” are sutured with 4.0 Ethilon. incision “F” where it is anchored to the
9. The tendon anchoring is done under EPL tendon with 4.0 polypropylenes using
correct tension. The wrist is placed in horizontal mattress suture with neutral
neutral position and the thumb positioned tension on the anastomosis.
at prone position and abducted position. 14. Now, the suturing of the wounds must be
The thumb should now be facing the done with 4.0 Ethilon.
middle finger. Now, the free end of the FDS 15. Sterile dressings are applied and a POP slab
tendon is pulled distally and the excursion is applied on the thumb, maintaining the
of the tendon is recorded. The midpoint of wrist in (10°) flexions, and the thumb kept
this excursion range is marked and placed in a position of abduction – opposition.
close to the tendon of abductor pollicis
brevis (APB). It is pulled for 1 cm and the
tendon anastomosis is done. The free end Postoperative Protocol
of the tendon graft is used to wind around
the insertion of the APB tendon and then a
suture is applied with 3.0 polypropylenes.
The tenodesis effect is checked. When the
wrist is flexed, the thumb must open out
and when the wrist is flexed, the thumb
must oppose to the middle finger.
anesthesia
10. The above method of tendon suturing
is done for a case of pure median nerve • The POP slabs must not be disturbed at all
lesion or injury. If there is a combined for 3 weeks
median and ulnar nerve injury, the • Discharge of the patient by third day
following method of tendon anchorage is • Patient to retain the POP slab till the end
done. The anchoring of the tendon is not of 3 weeks
done only at the APB tendon as discussed • Removal of the POP slab on the 21st day
above. Two more incisions are made. and advise the following:
11. Incision “F” is made and the extensor • Refer to physiotherapy for active mobili
pollicis longus (EPL) tendon is identified zation of the fingers
just proximal to the IP joint. • Daily wash with soap and water
12. Incision “G” is made and the adductor • Massage of scar and grafted skin with
incision is identified and dissected. coconut oil
13. At the incision “E”, the free end of the FDS • Patient is advised to continue the
tendon is now split into two slips. One mobilization of the fingers; both active
slip is passed through a tunnel over the and passive and review once every
dorsum of the MCP joint of the thumb month for evaluation.
and attached to the adductor insertion • To continue wearing a short opponens
at incision “G” with 4.0 polypropylenes splint at night for 3 weeks after removal
using horizontal mattress suture, under of POP.
41
Opponensplasty with
Abductor Digiti Minimi
Muscle (Huber’s Transfer)
be retained for 3 weeks, following which,

Introduction physiotherapy will be started. This should
be continued for a further 3 weeks. During
This method of tendon transfer is ideal for
children with weakness of the thenar muscles
be taught to make the muscle of the little
due to congenital hypoplasia, either of the
finger move the thumb
musculature only, or hypoplasia of the thumb
which may occur alone or with hypoplasia of
returns on the thumb may be weak and may
the radius (radial club hand).
some other instances, the muscle may not
Presurgical Counseling of surgery to correct the problem
• There will be a scar on the palm and the
• This procedure is planned to correct only little finger
the weak thumb. This surgery will not • The general complications of local anes
correct the other problems that may exist thetic infiltration like hypersensitivity may
on the hand like wasting of the muscles occur in spite of test dose application. This
or loss of sensation. These problems need complication will cause dryness of mouth
to separate sittings of surgery and cannot and apprehension, which can be corrected
usually be combined with the procedure immediately.
planned at present
block anesthesia Surgical Steps
perform 1. Prepare the hand as described in App
• A muscle from the little finger will be endix I.
removed and taken to the thumb to make 2. Mark the incisions (Fig. 12.41.1) as follows:
the thumb move in a useful direction. There • First the incision “A” is marked to
will be no obvious deficit on the little finger, harvest the abductor digiti minimi
but there may be some weakness of the (ADM) tendon. First the midpoint on
finger the ulnar neutral line on the proximal
• Admission will be necessary for a mini phalanx (PPX) segment of the little
mum period of 3 days finger is marked point “P”. The point
• A dressing will be applied and a plaster where the neutral line cuts the volar
of Paris (POP) will be applied, which will metacarpophalangeal (MCP) joint crease
Fig. 12.41.1 Marking the incisions Fig. 12.41.2 Reach of the harvested ADM muscle checked
on the little finger is marked point the ulnar side of the little finger must be
“Q”. Another point is marked over the protected while raising the flaps of skin
palpated hook of the hamate point “R”. on this part of the incision. Stay sutures
A “C” shaped marking is made from with 3.0 Ethilon are made to restrain the
point “Q” to “R”, along the radial border raised flaps of skin. The insertion of the
of the hypothenar prominence. When ADM muscle is now dissected. It usually
crossing the palmar creases, a zig-zag has two insertions one into the base of
shape should be incorporated to avoid the ulnar side of the PPX or MCP joint of
scar contractures later. the little finger, and the other insertion on
3. The tourniquet is raised and the incisions the extensor apparatus on the ulnar side
are made. of the little finger in the distal portion of
4. First the incision “A” is made to harvest the proximal phalangeal segment of the
the abductor digiti minimi (ADM) tendon. finger. Both these insertions are divided
The palmar portion of the incision is and the muscle is gently raised taking care
made and the skin flap is raised on the to cauterize the small branches entering
ulnar side over the hypothenar area. the muscle in the distal and middle-thirds.
The flap is raised superficial to the fascia 5. The neurovascular supply to this muscle
covering the ADM muscle. The ADM is the must be preserved. It enters the muscle
most radial and prominent muscle seen in the proximal third from the radial side.
among the hypothenar muscles. Usually, The muscle can be elevated till this point.
the digital neurovascular bundles to the 6. The tendon and muscle is now swung
little fingers will not be encountered by toward the thumb (Fig. 12.41.2) to make
this incision in the palm. Now, the distal sure that it reaches the incision “B”, a
portion of the incision is made on the point on the radial border of the MCP
little finger. The neurovascular bundle to joint of the thumb. Usually, it is sufficient
CHAPTER 41 OPPONENSPLASTY WITH ABDUCTOR DIGITI MINIMI MUSCLE (HUBER’S TRANSFER) 183
to dissect the muscle till the point sutures, to the MCP joint capsule of the
described. However, in some situations, thumb. While making this attachment,
the muscle may not reach the incision a point must be chosen just dorsal to
“B”. In such situations, the origin of the the axis of the joint. If the attachment
muscle can be carefully divided on the becomes volar, the transferred tendon
ulnar side till the tendon reaches the begins to flex the MCP joint of the thumb,
desired point, taking care to protect the which is not useful in such cases.
neurovascular hilum to the muscle which 12. Now, the suturing of the incision “B” must
enters the radial side. be done with 4.0 Ethilon.
7. Now, a saline gauze is wrapped around 13. Sterile dressings are applied and a POP slab
the muscle and the next incision is made. is applied on the thumb, maintaining the
8. Incision “B” is made through the skin wrist in 10° extensions, and the thumb kept
and subcutaneous tissues to expose the in a position of abduction – opposition.
insertion of the abductor pollicis brevis
tendon. The tendon retriever is passed
from this wound to the incision “A”. The
free end of the ADM tendon is grasped Postoperative Protocol
and retrieved in incision “B”.
9. The tourniquet is now released and • Admission in the ward
hemostasis achieved. The incision “A” are • The affected hand should be kept elevated
sutured with 4.0 Ethilon. • Patient can take normal diet immediately
10. The tendon anchoring is done under if the procedure was under regional block
correct tension. The wrist is placed in or after complete recovery if under general
neutral position and the thumb positioned anesthesia
at prone position and abducted position. • The POP slabs must not be disturbed at all
The thumb should now be facing the • Discharge of the patient by third day
middle-finger. Now, the free end of the • Patient to retain the POP slab till the end
ADM tendon is pulled distally and the of 3 weeks
excursion of the tendon is recorded. • Removal of the POP slab on the 21st day
The midpoint of this excursion range is and advise the following:
marked and placed close to the tendon of
APB. It is pulled for 1 cm and the tendon
anastomosis is done. The free end of the
tendon graft is used to wind around the
insertion of the APB tendon and then a • Massage of scar and grafted skin with
suture is applied with 3.0 polypropylenes. coconut oil
The tenodesis effect is checked. When the • Patient is advised to continue the
wrist is flexed, the thumb must open out mobilization of the fingers; both active
and when the wrist is flexed, the thumb and passive and review once every
must oppose to the middle-finger. month for evaluation
11. Sometimes, it may not be possible to • To aid in keeping the thumb in a correct
identify the APB tendon at its insertion position of abduction at rest, a short
because it may be very hypoplastic. In this opponens splint must be applied at night
situation, the suturing of the transferred during the period of physiotherapy. In
ADM tendon should be made with 3.0 children, they must be encouraged to
polypropylene using horizontal mattress use the new movement of the thumb.
Claw Correction—
Lasso Procedure 42
be taught to make the tendon of the ring
Introduction finger flex the fingers
Lasso procedure is a standard procedure
returns on the fingers may be weak and may
used in claw correction. The results obtained
are usually quite predictable and satisfactory.
of surgery to correct the problem
Presurgical Counseling • In some instances, the ring finger may
develop a minimal deformity on the
• This procedure is planned to correct only the proximal interphalangeal (PIP) joint. This
clawing of the fingers. This surgery will not will require a small surgery to correct the
correct the other problems like flattening problem
of the hand, or wasting of the muscles or • The general complications of local anes
loss of sensation. These problems need thetic infiltration like hypersensitivity may
to separate sittings of surgery and cannot occur in spite of test dose application. This
usually be combined with the procedure complication will cause dryness of mouth
planned at present and apprehension, which can be corrected
• This procedure will be done under axillary immediately.
block anesthesia
perform Surgical Steps
• A tendon from the ring finger will be
removed and used to provide useful fun 1. Prepare the hand as described in App
ction in all the fingers. There will be no endix I.
obvious deficit on the ring finger, but there 2. Mark the incisions as follows (Fig. 12.42.1):
may be some weakness of the finger • Incision “A”—a transverse incision is
• Admission will be necessary for a mini marked from the radial border of the
mum period of 3 days hand to the ulnar border of the hand
• A dressing will be applied and a plaster along the distal palmar crease
of Paris (POP) will be applied, which will • Incision “B”—now, an incision is
be retained for 3 weeks, following which, marked over the neutral line on the
physiotherapy will be started. This should ulnar border of the ring finger about 4
be continued for a further 3 weeks. During cm long, centered at the level of the PIP
this period of physiotherapy, exercises will joint crease. This incision is to divide
CHAPTER 42 CLAW CORRECTION—LASSO PROCEDURE 185
The ulnar slip is first seen. A hemostat

is applied about 1 cm proximal to the
insertion. The tendon slip is now cut
distal to the hemostat. Now, traction is
applied to this cut slip with the hemostat
and this will expose the radial slip of the
FDS tendon. This slip is also divided 1
cm proximal to the insertion and another
hemostat is applied on the proximal cut
end. Both hemostats are pulled distally to
expose the decussation of the FDS tendon.
It is divided with a blade until both slips
are free. The vincular attachment will also
have to be divided to achieve total release
of the FDS slips.
6. Make an incision in the synovium over the
FDS and FDP tendons just proximal to the
A1 pulley. Identify the FDS tendon and
pull so that the tendon is now delivered in
this wound. Suture wound “B” now.
7. Make incision “C” and dissect carefully to
Fig. 12.42.1 Marking of incisions
avoid injuring the vascular arch. Identify
the FDS tendon of the ring finger and
the insertion of the flexor digitorum deliver it in this wound. Split the tendon
superficialis (FDS) of the ring finger into 4 equal slips. Pass a tendon retriever
• Incision “C”—a 2 cm incision is marked from incision “A” to incision “C” from
on the thenar crease in the groove the index finger along the route of the
between the thenar and hypothenar flexor tendons and deep to the superficial
eminences. palmar arch. Grasp the radial most slip
3. The tourniquet is raised and the incision of the FDS and deliver it in incision “A”
“A” is made. The incision goes down proximal to the index finger. Similarly,
through the skin and subcutaneous tissues deliver the remaining slips of the FDS
to the palmar aponeurosis. This layer is also (Figs 12.42.2A and B) proximal to the
carefully incised, because just under this corresponding fingers on incision “A”.
layer lie the digital neurovascular bundles. 8. About 7 mm distal to the free edge of the
4. Gently retract the distal skin flap to expose A1 pulley of the index finger, make a nick
the A1 pulleys of all the fingers. in the flexor sheath. Pass a tendon retriever
5. Now, the incision “B” is made to harvest through this nick, proximally and grasp the
the FDS tendon. The skin on the volar free end of the FDS slip to the index finger.
side is raised superficial to the digital Pull the tendon slip through. Now, suture
neurovascular bundle. The flexor tendon the free end of the slip to itself over the part
sheath is identified. An incision is made of A1 pulley under correct tension. This
in the flexor tendon sheath to isolate is done by holding the wrist and all the
the flexor digitorum profundus (FDP) finger joints in neutral position, pulling
and FDS tendons. The FDP tendon is the tendon slip to maximum tension and
usually seen first and it must be retracted suturing it to itself with 4.0 polypropylenes
volarward to expose the FDS tendon slips. (Fig. 12.42.3).
A B
Figs 12.42.2A and B Harvesting the FDS tendon from the ring finger
12. Sterile dressings are applied and two POP

slabs are applied, one on the volar aspect
and another on the dorsal aspect. The
position of the hand to be maintained is wrist
in neutral position, metacarpophalangeal
(MCP) joints of fingers in 90° flexion and
interphalangeal (IP) joints of the fingers
straight.
Fig. 12.42.3 Suturing of the tendons after
adjusting the tension • Admission in the ward
9. This procedure should be done for the • Patient can take normal diet immediately
middle, ring and little fingers also. When if the procedure was under regional block
the fingers and wrist are placed in relaxed or after complete recovery if under general
position, the normal cascade should be anesthesia
achieved. If not, suitable adjustments • The POP slabs must not be disturbed at all
must be made in the tension of suturing • Discharge of the patient by third day
the tendon slip to itself. Now, check the • Patient to retain the POP slab till the end
tenodesis effect to make sure that there is of 3 weeks
no triggering of the tendon slips and also • Removal of the POP slab on the 21st day
to make sure that the suturing is not too and advise the following:
tight. • Refer to physiotherapy for active mobili
10. Moist saline gauze is placed over the zation of the fingers
entire length of the wound and gentle • Daily wash with soap and water
compression applied. The hand is elevated • Massage of scar and grafted skin with
and the tourniquet released. After 3 coconut oil
minutes, the hand is kept back on the table • Patient is advised to continue the mobiliz
and hemostasis achieved. ation of the fingers; both active and pas
11. Now, the suturing of the wounds “A” and sive and review once every month for
“C” must be done with 4.0 Ethilon. evaluation.
43
Claw Correction—Extensor
to Flexor 4-Tailed Tendon
Transfer (EF4T) Procedure

Introduction of Paris (POP) will be applied, which will
The EF4T procedure is also a standard pro
cedure for claw correction which is ideally
suited for stubby hands, hands of manual
laborers, is whose hands, the soft tissues are
be taught to make the rerouted tendon
tougher.
move the fingers in a useful manner
returns on the fingers may be too powerful
Presurgical Counseling or too weak to produce useful work. In
• This procedure is planned to correct only the work at all. This will require another sitting
clawing of the fingers. This surgery will not of surgery to correct the problem
correct the other problems like flattening • The general complications of local
of the hand, or wasting of the muscles or anesthetic infiltration like hypersensitivity
loss of sensation. These problems need may occur in spite of test dose application.
to separate sittings of surgery and cannot This complication will cause dryness of
usually be combined with the procedure mouth and apprehension, which can be
planned at present corrected immediately.
block anesthesia
• This procedure will take about 1½ to 2 Surgical Steps
hours to perform
• A tendon from the extensor aspect of the 1. Prepare the hand as described in App
wrist will be removed and taken to the endix I.
fingers to make them move in a useful 2. Mark the incisions as follows (Figs 12.43.1A
direction. There will be no obvious deficit on and B):
the wrist, but there may be some weakness • Incisions 1, 2, 3, 4—each 3 cm long on
• A tendon graft will be harvested from the the dorsolateral aspect of the proximal
side of the thigh under local anesthesia phalanx region of the index, middle,
and used as a graft. There will be no deficit ring and little fingers, on the ulnar
as a result of removing this tendon side on the index finger, and on the
• Admission will be necessary for a mini radial side on the middle, ring and little
mum period of 3 days fingers
A B
Figs 12.43.1A and B Marking of incisions
• Incision 5—two centimeter trans proximally. This traction should produce

versely on the dorsoradial aspect of the extension of the proximal interphalangeal
wrist over the insertion of the extensor (PIP) and distal interphalangeal (DIP)
carpi radialis longus (ECRL) tendon. joints. This must be done on all the
When the hand is made into a fist and fingers. A moist gauze piece is placed over
the wrist is extended, two tendons can the incisions.
be palpated on the radial side of the 4. Incision 5 is now made. The ECRL tendon
dorsum of the wrist and the ECRL is the must be identified. The extensor pollicis
radial of the two longus (EPL) tendon runs obliquely
• Incision 6—two centimeter transverse, across it and the extensor carpi radialis
made on the dorsal aspect of the mid brevis (ECRB) tendon is on the ulnar side.
forearm about 10 cm proximal to the The ECRL tendon should be held with
radial styloid a hemostat and divided to close to the
• Incision 7—two centimeter transverse, insertion with a number 11 blade.
made on the volar aspect of the distal 5. Gentle traction to the ECRL is applied in a
third forearm distal direction by pulling on the hemostat.
• Incision 8—two centimeter on the This will confirm the position of the muscle
thenar crease in the mid palm. proximally and the incision “6” is made
3. The tourniquet is raised and the incisions now. The muscle/musculotendinous unit
1, 2, 3 and 4 are made one by one. of the ECRL is exposed in this incision and
The extensor tendon is exposed in the confirmed by traction on the hemostat.
wounds. The portions of the tendon that 6. Make incision 7 through the skin and
are exposed are the lateral bands and the subcutaneous tissues, and then through
central tendon. This can be confirmed by the deep fascia. Now, the hemostat is
grasping the selected portion of the tendon removed at the end of the ECRL tendon.
with a tissue forceps and applying traction The tendon is exteriorized at incision 6.
CHAPTER 43 CLAW CORRECTION—EXTENSOR TO FLEXOR 4-TAILED TENDON TRANSFER… 189
Then a hemostat is passed from incision must not be forced into any path. It must
7 to incision 6 and the end of the ECRL be remembered that this route must be
tendon is caught. Now, this tendon is volar to the deep transverse metacarpal
delivered in incision 7. ligament. Grasp the radial most slip of the
7. Now, the tendon graft of fascia lata fascia lata and pull it gently to deliver it in
should be harvested. The harvest of this incision 1. Similarly, the other slips must
tendon graft can be done as described in be delivered into the respective incisions
Appendix VIII. 2, 3 and 4. Suture incision 8.
8. The tendon graft should now be attached to 11. The distal tendon anastomosis is done
the ECRL tendon by the technique shown. now, by suturing the free end of the fascia
First make one end of the fascia lata graft lata slip to the portion of the extensor
pointed. Protect the fascia lata graft with tendon that has already been dissected
moist gauze pieces throughout its length. A and kept ready. While suturing, it is
small longitudinal incision is made on the important to adjust the tension correctly.
deeper aspect of the end of ECRL tendon. 12. First, the index finger is dealt with. The
The pointed end of the fascia lata graft hand is placed in a position with rolled
is inserted inside by a hemostat passed up towels of 30° flexion at wrist, 60º
through the opening. This is now sutured flexion at MCP joints of all fingers and
to the ECRL tendon with 4.0 polypropylene fingers straight. Now, the free end of the
using simple interrupted sutures. Now, the fascia lata graft slip is pulled gently at
fascia lata graft is tubed around the end of the incision 1 and the movement of the
the ECRL tendon, with 4.0 polypropylene tendon is assessed. Usually, there will
using simple interrupted sutures. Then, be about 2 cm of excursion. Suture the
the part of the ECRL tendon is also tubed midpoint of this excursion to the portion
around the fascia lata tendon graft entering of the extensor tendon that has already
on the deep surface of the tendon. Now, been dissected and kept ready. Check
the proximal tendon anastomosis is
whether this suturing is too tight or lose by
completed.
the tenodesis effect and adjust the tension
9. Make incision 8 in the palm. Take care
as necessary.
to avoid the superficial palmar arch and
13. Next, repeat the procedure for the little
the digital nerves. Pass a tendon retriever
finger, suturing the tendons at a point just
proximally just deep to the palmar
distal to the midpoint of the excursion of
aponeurosis. It must go through the carpal
the fascia lata. This is to provide slightly
tunnel and come out at incision 7. Here,
more traction on the little finger to correct
the free end of the fascia lata graft should
the metacarpal arch reversal to a certain
be grasped and pulled to be delivered in
extent.
wound number 8. Apply a wet gauze piece
over the tendon graft and suture incisions 14. Now, the suturing must be done on the
5, 6 and 7. middle and ring fingers. Then, all the
10. Now, split the free end of the tendon graft incisions 1, 2, 3 and 4 must be closed with
into four slips of equal width using number 4.0 Ethilon, and the tourniquet released.
11 blade. Flex the metacarpophalangeal 15. Sterile dressings are applied and two POP
(MCP) joint of the index finger to 90° slabs are applied, one on the volar aspect
and pass the tendon retriever through and another on the dorsal aspect. The
incision 1 to exit at incision 8. While doing position of the hand to be maintained is
this, the retriever must be advanced very wrist in neutral position, MCP joints of
gently, making probing maneuvers to find fingers in 90º flexion and interphalangeal
the path of least resistance. The retriever (IP) joints of the fingers straight.

Postoperative Protocol and advise the following:
• Refer to physiotherapy for active mobili
• Admission in the ward zation of the fingers
• The affected hand should be kept elevated • Daily wash with soap and water
• Patient can take normal diet immediately • Massage of scar and grafted skin with
coconut oil
• Patient is advised to continue the mobi
anesthesia
lization of the fingers; both active and
• The POP slabs must not be disturbed at all
passive and review once every month for
evaluation.
• Patient to retain the POP slab till the end
of 3 weeks
Claw Correction—
Fowler Procedure 44
Introduction minimum period of 3 days
This is a procedure that is ideally suited for
of Paris (POP) will be applied, which will
post-traumatic sequelae with injury to the
ulnar nerve.
Presurgical Counseling be taught to make the rerouted tendons
move the fingers
• This procedure is planned to correct only the • In some instances, the movement that
clawing of the fingers. This surgery will not returns on the fingers may be weak and may
correct the other problems like flattening not be powerful enough for useful work. In
of the hand, or wasting of the muscles or some other instances, the tendon may not
loss of sensation. These problems need work at all. This will require another sitting
to separate sittings of surgery and cannot of surgery to correct the problem
usually be combined with the procedure • The general complications of local ane
planned at present sthetic infiltration like hypersensitivity may
• This procedure will be done under axillary occur in spite of test dose application. This
block anesthesia complication will cause dryness of mouth
• This procedure will take about 1 hour to and apprehension, which can be corrected
perform immediately.
• A tendon will be removed from the
backside of the little finger will be removed
and taken to the front side of the ring and Surgical Steps
little fingers to correct the deformity and
also to make the movements of the fingers 1. Prepare the hand as described in App
more useful. If the index and middle endix I.
fingers are also involved, a tendon from 2. Mark the incisions as follows (Fig. 12.44.1):
the backside of the index finger will also be • Incision “1”, “2”, “3”, “4”—each 3 cm
removed and taken to the front side of the long on the dorsolateral aspect of the
index and mid fingers to make them also proximal phalangeal region of the
move in a useful direction. There will be index, middle, ring and little fingers, on
no obvious deficit on the index and little the ulnar side on the index finger, and
fingers, but there may be some weakness on the radial side on the middle, ring
of the fingers and little fingers
joints. This must be done on all the

fingers. A moist gauze piece is placed over
the incisions.
4. The incision “5” is now made through
skin, down through the subcutaneous
tissues to the extensor tendons. The
extensor indicis proprius (EIP) tendon is
identified. This is the more ulnar of the
two extensor tendons to the index finger.
The two extensor tendons together
form the extensor expansion. Surgeons
require a good length of the EIP tendon.
Hence, harvesting the tendon alone is
not enough, and an extension will have
to be taken from the extensor expansion.
This is done with a number 15 blade
and about 3 cm length is taken beyond
the MCP joint level. Now, a hemostat
is applied over the free end of the EIP
tendon, and a saline gauze is placed over
the tendon.
Fig. 12.44.1 Mark the incisions 5. The incision “6” is made similar to incision
“5”, but over the little finger. The extensor
digiti minimi (EDM) tendon is harvested
• Incision “5”—a longitudinally oriented just as the EIP was harvested. The EDM
lazy “S” incision over the dorsum of the tendon is the more ulnar tendon of the
meta carpophalangeal (MCP) joint of two extensor tendons to the little finger.
the index finger, extending proximally A hemostat is applied over the free end of
from incision 1 the EDM tendon.
• Incision “6”—similar to incision 5, but 6. Now, incision “7” is made, after confirming
on the dorsal aspect of the MCP joint the position of the marking by applying
of the little finger, starting on the radial traction on the hemostats holding the
side of the little finger free ends of the EIP and EDM tendons,
• Incision “7”—two centimeter transverse and palpating the movement of the
incisions on the dorsum of the hand tendons beneath the skin of the marking.
just distal to the wrist crease, over the The EIP and EDM tendons are identified
base of II MC. and isolated. They are pulled and this
3. The tourniquet is raised and the incisions maneuver delivers the two tendons at
“1”, “2”, “3”, and “4” are made one by one. incision “7”.
The extensor tendon is exposed in the 7. Each tendon is divided longitudinally into
wounds. The portions of the tendon that two slips. This is done by holding the two
are exposed are the lateral bands and the corners of the free ends with hemostats
central tendon. This can be confirmed by and using a number 11 blade to split the
grasping the selected portion of the tendon tendon. Remember to keep bathing the
with a tissue forceps and applying traction tendon with normal saline while doing
proximally. This traction should produce this. Thus, there are now four tendon
extension of the proximal interphalangeal slips; two from splitting the EIP and two
(PIP) and distal interphalangeal (DIP) from the EDM. The radial and ulnar slips
CHAPTER 44 CLAW CORRECTION—FOWLER PROCEDURE 193
from the EIP tendon will be used for the distal to the midpoint of the excursion of
index and middle fingers respectively. the tendon slip of EDM. This is to provide
The radial and ulnar slips from the EDM slightly more traction on the little finger to
tendon will be used for the ring and little correct the metacarpal arch reversal to a
fingers respectively. The splitting should certain extent.
stop proximally at the site of incision “7”. 12. Now, the suturing must be done on the
Now, incisions “5” and “6” can be closed middle and ring fingers. The ulnar slip
with 4.0 Ethilon. of the divided EIP tendon is used for the
8. Flex the MCP joint of the index finger to middle finger and the radial slip of the
90° and pass the tendon retriever through divided EDM is used for the ring finger.
incision “1” to exit at incision “7”. While Then all the incisions “1”, “2”, “3” and “4”
doing this, the retriever must be advanced must be closed with 4.0 Ethilon, and the
very gently, making probing maneuvers tourniquet released.
to find the path of least resistance. The 13. Sterile dressings are applied and two POP
retriever must not be forced into any slabs are applied, one on the volar aspect
path. It must be remembered that this and another on the dorsal aspect. The
route must be volar to the deep transverse position of the hand to be maintained is
metacarpal ligament. Grasp the radial wrist in neutral position, MCP joints of
most slip of the four tendon slips and fingers in 90º flexion and interphalangeal
pull it gently to deliver it in incision “1”. (IP) joints of the fingers straight.
Similarly, the other slips must be delivered
into the respective incisions “2”, “3” and
“4”. Suture incision “8”. Postoperative Protocol
9. The distal tendon anastomosis is done
now, by suturing the free end of the tendon
slip to the portion of the extensor tendon
that has already been dissected and kept
ready. While suturing, it is important to
adjust the tension correctly.
10. First, the index finger is dealt with. The
anesthesia
hand is placed in a position with rolled
up towels of 30° flexion at wrist, 60º • The POP slabs must not be disturbed at all
flexion at MCP joints of all fingers and • Discharge of the patient by third day
fingers straight. Now, the free end of the • Patient to retain the POP slab till the end
fascia lata graft slip is pulled gently at the of 3 weeks
incision “1” and the movement of the • Removal of the POP slab on the 21st day
tendon is assessed. Usually, there will and advise the following:
be about 2 cm of excursion. Suture the • Refer to physiotherapy for active mobi
midpoint of this excursion to the portion lization of the fingers
of the extensor tendon that has already • Daily wash with soap and water
been dissected and kept ready. Check • Massage of scar and grafted skin with
whether this suturing is too tight or lose by coconut oil
the tenodesis effect and adjust the tension • Patient is advised to continue the mobi
as necessary. lization of the fingers; both active and
11. Next, repeat the procedure for the little passive and review once every month
finger, suturing the tendons at a point just for evaluation.
Tendon Transfer for
Radial Nerve Palsy 45
this period of physiotherapy, exercises
Introduction will be taught to make the tendons of the
forearm lift the wrist, fingers and thumb
Tendon transfers for radial nerve palsy are
• In some instances, the movements that
standard procedures. Understanding the bio
return may be weak and may not be
mechanics is very important before emban
powerful enough for useful work. In some
king on these transfers.
other instances, the tendon may not work
at all. This will require another sitting of
surgery to correct the problem
Presurgical Counseling • The general complications of local anes
thetic infiltration like hypersensitivity may
• This procedure is planned to correct only occur in spite of test dose application. This
the inability to extend the wrist, fingers and complication will cause dryness of mouth
thumb. This surgery will not correct the and apprehension, which can be corrected
other problems like wasting of the muscles immediately.
or loss of sensation. These problems need
to separate sittings of surgery and cannot
usually be combined with the procedure Surgical Steps
planned at present
• This procedure will be done under axillary 1. Prepare the hand as described in App
block anesthesia endix I.
• This procedure will take about 1 hour to 2. Mark the incisions as follows (Figs 12.45.1A
perform and B):
• Tendons from the forearm will be removed • Incision “A”—a curved incision is
and taken to the thumb, wrist and fingers marked 10 cm long on the middle-third
to make it possible to lift them afterward. of the forearm on the radial border
There will be no obvious deficit on the • Incision “B”—mark an incision 5 cm
forearm, but there may be some weakness longitudinally on the middle of the
• Admission will be necessary for a minimum dorsal aspect of the forearm in the distal-
period of 3 days third, extending proximally from the
• A dressing will be applied and a plaster radial styloid
of Paris (POP) will be applied, which will • Incision “C”—incision “C” is made
be retained for 3 weeks, following which, transversely on the flexor aspect of the
physiotherapy will be started. This should forearm about 2 cm proximal to the
be continued for a further 3 weeks. During wrist crease, in the midline
CHAPTER 45 TENDON TRANSFER FOR RADIAL NERVE PALSY 195
A B
Figs 12.45.1A and B Mark the incisions
• Incision “D”—made 5 cm transversely 4. Now, make incision “B” down through the
on the flexor aspect of the forearm skin and subcutaneous tissues and then
about 8 cm proximal to the wrist crease open the deep fascia. This will expose the
• Incision “E”—this incision is a extensor muscles in the various com
transverse incision about 2 cm long, partments. First the extensor carpi radialis
made transversely on the dorsum longus (ECRL) and extensor carpi radialis
of the thumb, just proximal to the brevis (ECRB) tendons are dissected in the
metacarpophalangeal (MCP) joint second compartment and isolated.
• Incision “F”—is 3 cm long and made 5. Now, a tendon retriever is passed from this
longitudinally on the radial border of incision to incision “A” in a plane created
the forearm about 3 cm proximal to the superficial to the brachioradialis muscle.
wrist. The end of the pronator teres tendon is
3. The tourniquet is raised and first, incision “A” grasped in the retriever and is delivered in
is made through the skin and subcutaneous incision “B”.
tissues. The pronator teres insertion is 6. The free end of the pronator teres tendon
dissected. This is done by identifying the along with its periosteal extension is now
muscle and then following the fibers distally sutured to the ECRB tendon. The ECRB
till the insertion on the middle-third of the tendon is on the ulnar side of the ECRL
radius bone. When the tendon of insertion tendon. These two tendons are crossed by
is identified, an extension is made on the the extensor pollicis longus (EPL) tendon
periosteum for about 3 cm, and then the distally.
tendon is elevated from the bone along with 7. Adjustment of tension: The wrist is placed
the periosteal extension. When the tendon in 45° extension. A point is selected on
has been raised, make sure that the muscle the ECRB tendon, which is the distalmost
is totally free. point on it, where the posterior tibial (PT)
tendon end reaches. The free end of the 13. Incision “F” is made. Care must be taken
PT tendon is pulled maximally and then to avoid injury to the radial artery and the
released. The amount of excursion of the superficial branch of the radial nerve at
tendon is noted. The midpoint of this this area. A tendon retriever is passed from
excursion range is noted. The PT tendon this incision, proximally to the incision “D”,
is now slightly pulled and the tendon the end of the PL is grasped and pulled to
anastomosis is now done. The technique be delivered in incision “F”. Moist gauze is
of tendon anastomosis is as follows: placed around the free end of the tendon.
• The tendon anastomosis is done by 14. Now, in incision “B”, the EPL tendon is
Pulvertaft weave. Hold the ECRB identified as proximal as possible. This
tendon taut with a hemostat applied on tendon lies in the third compartment and
the end and pulling proximally can be identified by the extension pro
• About 1 cm proximal to the end of the duced on the thumb interphalangeal (IP)
tendon, make a cut in a volar to dorsal joint by traction proximally. The tendon is
direction with a number 11 blade, with divided.
just enough length to allow the PT 15. Now, incision “E” is made. The EPL tendon
tendon end through. Pull the tendon is identified on the dorsal aspect of the
end through. Apply a suture with thumb and dissected from the extensor
3.0 polypropylene using horizontal pollicis brevis (EPB) tendon which lies to
mattress sutures the radial side. Now, traction is applied
• About 1 cm proximal to the first cut, and the EPL tendon is delivered into the
make another cut with number 11 incision “E”. The exposed length of the
blade, from a radial to ulnar direction. tendon is covered with saline gauze.
Thread the free end of the PT tendon 16. From incision “F”, a tendon retriever is
end through this opening also and passed through to incision “E” and the
suture with 3.0 polypropylene using free end of the EPL tendon is grasped and
horizontal mattress sutures. pulled to be delivered in incision “F” itself.
8. When the tendon anastomosis is over, the The incision “E” is closed primarily with 4.0
extra length of the PT tendon is trimmed. Ethilon.
9. It must be made that the wrist can be 17. The tendon anastomosis between the PL
passively flexed and the tendon anasto and the EPL tendon is done now in the
mosis is not too tight as to prevent it. site of incision “F”. The tendon anasto
10. Now, incision “C” is made and the palmaris mosis is done by the Pulveraft weave
longus (PL) tendon is dissected at this level as described above. The PL tendon’s
by freeing it from the numerous fibrous free end is woven into the proximal end
strands that connect it to the overlying of the EPL tendon after adjusting the
skin and the surrounding structures. Once tension. With the wrist maintained at 45°
it is totally dissected, it is divided and a extensions, a trial stitch is made between
hemostat applied on the cut end. the ends of the PL and the EPL. When
11. Incision “D” is made after applying traction the wrist is gently passively flexed, the
on the cut end of the tendon and palpating thumb must extend.
the taut tendon under the skin. The tendon 18. Now, the incision “C” is explored again
is dissected in this wound. and the tendon of flexor carpi radialis
12. The PL is retrieved through this wound, (FCR) is identified. This tendon is radial
and the hemostat reapplied at the cut end. to the PL tendon that has already been
Moist gauze is placed over the length of divided. Now, the FCR tendon is divided
the tendon lying outside. as distally as possible.
CHAPTER 45 TENDON TRANSFER FOR RADIAL NERVE PALSY 197
19. Through the incision “D”, the FCR tendon 23. Incision “B” is closed primarily with 4.0
is identified and pulled so that the free Ethilon.
end is delivered in incision “D” itself. 24. Sterile dressings are applied and a volar
20. In incision “B”, the tendons of the extensor POP slab is applied, keeping the wrist in
digitorum are identified and dissected. This 45° extension, the finger MCP joints in
includes the extensor digitorum communis 30° flexion and the IP joints of the fingers
(EDC) to index, middle, ring, little, the straight. Another POP slab is applied on
extensor indicis proprius (EIP) tendon and the volar aspect of the thumb, holding it in
the extensor digiti minimi (EDM) tendon. A palmar abduction at the carpometacarpal
tendon retriever is passed from this wound (CMC) joint, and extension at the MCP
to the incision “D” around the radial border and IP joints.
of the forearm and the free end of the
FCR tendon is grasped and delivered into
incision “B”.
21. Now, the tourniquet is released and Postoperative Protocol
hemostasis achieved. Except incision “B”,
all the other wounds are closed primarily • Admission in the ward
with 4.0 Ethilon. • The affected hand should be kept elevated
22. Now, the tension adjustment is done. • Patient can take normal diet immediately
Each tendon of the extensor to the finger if the procedure was under regional block
is pulled to note the movement. The or after complete recovery if under general
tendon is now pulled enough to hold the anesthesia
finger in a position of extension at the • The POP slabs must not be disturbed at all
MCP joints (not hyperextension). The • Discharge of the patient by third day
free end of FCR tendon is now woven
• Patient to retain the POP slab till the end
through the extensors of the fingers after
of 3 weeks
making a longitudinal cut in the extensor
tendons in a radio ulnar direction with
number 11 blade. Before making the cut
in the extensor tendon, the position of • Refer to physiotherapy for active
the fingers is ascertained. After the FCR mobilization of the fingers
passes through each tendon, an anchoring • Daily wash with soap and water
stitch is made with 3.0 polypropylene. In • Massage of scar and grafted skin with
this way all the tendons are woven to the coconut oil
FCR tendon. Now, the tenodesis effect is • Patient is advised to continue the
checked. On wrist flexion, there must be mobilization of the fingers; both active
hyperextension of the MCP joints of the and passive and review once every
fingers. month for evaluation.
SECTION
13
Congenital Disorders
Congenital Disorders—
Assessment 46
Introduction Assessment Criteria—
General
Dealing with the classification, assessment
and the surgical management of all the con-
genital anomalies is beyond the scope of this
The Details that Must be
manual. However, the most common condi- Collected are:
tions will be dealt here, so that the beginner • Consanguinity: This is particularly relevant
will be able to do the basic surgical proce- in our country where marriage between
dures. As it has been stressed earlier, reading uncles and nieces and between first cousins
this manual will not be enough knowledge to is allowed, and sometimes even encouraged.
perform the surgery straightaway. A thorough • Antenatal history: Any relevant antenatal
study of the classification, nomenclature and history must be obtained like history of
altered anatomy are essential before surgery exanthematous fevers, ingestion of drugs,
can be attempted. exposure to radiation and smoking. The
The following chapters will deal with outbreak of phocomelia, a severe congenital
six different congenital anomalies seen deformity occurring in the babies born
commonly: of mothers who had taken the drug
• Syndactyly thalidomide, is well known.
• Radial club hand • Family history: Congenital anomalies like
• Trigger finger and trigger thumb syndactyly are known to occur in families.
• Macrodactyly
• Polydactyly
• Cleft hand.
Congenital anomalies as a whole have some Assessment Criteria—Specific
features that should be assessed. In addition,
each condition has peculiar assessment These will be dealt with under the specific
criteria, which are also mentioned here. conditions.
Syndactyly
47
are in syndactyly. The pathogenesis of
Assessment (Syndactyly) this condition is different, in that, the
fingers have usually developed normal
• Fingers involved: Commonly involves the ly, but due to some intrauterine prob
middle and ring fingers, but any of the
lem, parts of the fingers have got ampu
fingers and any number of fingers may be
tated and have healed in utero.
involved. This is important especially in
• Typically, there will be gaps between
planning the management protocol.
the syndactylized fingers that run
• Whether both upper limbs are involved
through from the palmar to the dorsal
• Whether the lower limbs are involved
side.
• Any other congenital anomalies: The • There will be irregular tips of the
type of syndactyly will be typical if it is
fingers.
a part of a congenital syndrome. For
• Apert syndrome: The syndactyly of the hand
example, in apert syndrome, all the
in this condition has been described above.
fingers are involved in the syndactyly
forming a spade like hand, and typically
involve both upper limbs. There are
also many features suggestive of the Management Schedule
particular syndrome.
• Type of the syndactyly (length): Factors to be considered while planning the
• If the entire length of the fingers is treatment:
involved, it denotes complete syndactyly. • Age of the child: There is no specific age
• If only part of the length of the finger limit for surgery on syndactyly. It can be
is involved, it denotes incomplete done as early as 6 months also. It is also
syndactyly. important that the surgery should not be
• Type of syndactyly (involvement of bones): delayed beyond 4 years, when the child
• If there is no fusion of the skeletal enters school. So, it must be planned in
components between the syndactylized such a way that all surgery is over for the
fingers, it is referred to as simple hand by the age of 4 years.
syndactyly. • Bilateral involvement: If both hands are
• If there is a fusion of even a part of the involved, both can be operated on at the
skeleton of the fingers, it is referred to as same time; especially if two operating
complex syndactyly. teams are available. This is to minimize
• Special types of syndactyly: the period of anesthesia and to reduce the
• Acrosyndactyly: This is a slightly differ number of surgical stages. However, if the
ent condition, even though the fingers patient is an adult (which is sometimes
CHAPTER 47 SYNDACTYLY 203
possible), it is ideal that bilateral syndactyly • Admission will be necessary for a minimum
is operated on in two stages, because it will of 3 days.
avoid making the patient totally dependent • The child can take fluids 4 hours after the
on others following plaster of Paris (POP) surgery.
slabs on both hands. • There may be minimal pain in the first post
• Fingers involved: If the thumb or little operative night. Analgesics and sedatives
fingers are involved, they must be released may be necessary.
first. If the index finger and ring finger are • The POP will be removed after 2 weeks. A
involved together with the middle finger, short anesthesia may be required when
the index finger must be released first. So, this is done, if the child is too small to
the priority of importance of the fingers cooperate.
release is as follows: • After the POP is removed, splints will be
• Thumb required for as long as the surgeon feels
• Little finger necessary.
• Index finger • In some instances, there may be small
• Middle finger problems, like creeping forward of the web,
• Ring finger. contracture of the finger. This will need
Principles of planning for syndactyly surgery: surgical correction at a later date.
• If the thumb, little or index fingers are
involved, surgery must be done as early as Surgical Steps
possible after 6 months age.
1. After the anesthesia is administered and
• Do not operate on adjacent sides of a finger patient put in supine position, the hand is
at the same time. For example, if there is a
prepared as described in Appendix I.
syndactyly between the index, middle and
2. The markings are now made (Figs 13.47.1A
ring finger, do not release all the fingers at
and B):
the same time. Only one can be released,
• The fingers are flexed at the meta
either the index and middle or the ring
carpophalangeal (MCP) joints and
and middle fingers. According to principle
the knuckles of the two fingers are
A, the index and middle fingers should be
marked. Similarly, the dorsum of the
released first.
proximal interphalangeal (PIP) joints
• The timing between two stages must be a is also marked with a single point in
minimum of 6 months.
the midline.
• The midline of the dorsum and the
midline of the volar aspect of the fin
Surgery (Syndactyly) gers are marked.
• With the markings on the MCP joints
as base, the dorsal flap “D” is marked.
Presurgical Counseling The length of this flap should be two-
• The surgery will be done under general thirds of the distance between the
anesthesia. Both hands will be operated on MCP joint and the PIP joint. This flap
at the same time (in children). should have a lesser length on the side
• A POP slab will be applied from the elbow of the “important finger” (between the
to the fingers after the surgery on the middle and ring, it is the ring finger;
operated upper limb. between the middle and index, it is the
• If necessary, a skin graft will be harvested index finger). Thus, the advancing edge
from the groin region. There will be a small of the dorsal flap will be sloping.
scar on the groin region, but there will be • The palmar rectangular flap will be
no other deficit. marked now. Expose the palm of the
204 SECTION 13 CONGENITAL DISORDERS
A B
Figs 13.47.1A and B Markings for syndactyly release
hand. Flex the fingers at the MCP joints 4. The incisions are made in the following
of the involved fingers. There will be a order. First the dorsal flap is raised. This is
flexion crease at a particular point. This raised after making the incisions up to the
is the level of the proximal limb of the skin and subcutaneous tissues and raising
rectangular flap. The rectangular flap the flap with a layer of subcutaneous fat.
should be based on the “important The other dorsal incisions are made and
finger”. The length of the flap should be the respective dorsal triangular flaps
the width of the dorsal flap “D”. raised in the same plane.
• Now, the dorsal zig-zag incisions 5. Now, the palmar aspect is exposed and
can be marked on the fingers. The the rectangular flap is raised first. The
first dorsal triangular flap is marked other palmar triangular flaps are raised.
based on the “nonimportant finger”.
6. Now, the soft tissues between the
The flaps should not cross the marked
two fingers are dissected. The digital
midline on the dorsum or on the
neurovascular bundle is identified. There
volar aspect of the fingers. Beyond the
are usually two bundles, one for each
distal interphalangeal (DIP) joints, the
incision becomes straight and ends on finger. Occasionally, there may be only
the tip of the finger. one bundle. This can be allocated for one
• Draw dotted lines from the tips of the of the fingers and the two fingers now
dorsal flaps backward over the middle divided. The proximal extent of the division
of the flap in a horizontal line to the between the fingers is determined by
point on the volar midline. This is the the point of division of the proper digital
point where the tip of the dorsal flap artery. If the division of the digital nerve
will reach. At this point, it should be is very distal, it can be separated by gently
the apex of the palmar triangular flaps. teasing the epineurium between the
• The first palmar triangular flap is two digital branches. The viability of the
based on the “important finger”. All the fingers is ascertained before proceeding
palmar triangular flaps are then drawn to the next step.
as dictated by the dotted lines. 7. The soft tissues can be defatted by excising
3. Now, the tourniquet can be raised. the fat globules, while carefully preserving
CHAPTER 47 SYNDACTYLY 205
the neurovascular bundles. This step applied. Fluffy gauze pieces are applied
helps to reduce the bulk on the finger between the fingers and sterile dressings
and thus ensures a tensionless suturing of applied. An above elbow POP slab is
the flaps and avoids complications in the applied.
postoperative period.
8. Moist saline gauze is placed over the
entire length of the wound and gentle
compression applied. The hand is elevated • Admission in the ward.
and the tourniquet released. After 3 • The affected hand should be kept elevated.
minutes, the hand is kept back on the table • Patient can take normal diet after complete
and hemostasis achieved. recovery if under general anesthesia.
9. The suturing of the flaps is now done. • Discharge of the patient by third day.
First the dorsal rectangular flap “D” is • Inspection of the suture line after 10
sutured to the volar aspect to create the days only. If necessary, a short general
commissure. Next the palmar rectangular anesthesia may be required if the child is
flap is brought round the side of the very anxious. Suture removal can be done
finger and sutured to the skin edge on on the same day. The POP slab can also be
the dorsum. All the dorsal and palmar removed. The following are advised:
triangular flaps are thus sutured using 4.0 • Refer to physiotherapy for active
vicryl. There will be one or two small areas mobilization of the fingers
without skin cover. A full thickness skin • Daily wash with soap and water
graft should be harvested from the lateral • Massage of scar and grafted skin with
end of the groin crease and applied over coconut oil
the raw areas. Anchoring of the skin graft • Patient is advised to continue the
is done with 4.0 vicryl. mobilization of the fingers; both active
10. The hand and fingers are cleaned and passive and review once every
thoroughly and nonadherent dressings month for evaluation.
Cleft Hand
48
• Web contracture between the thumb and
Assessment (Cleft Hand) index fingers
• Syndactyly between the ring and little
In addition to the general assessment criteria
fingers
outlined in the earlier chapter, there are
• Sometimes defect of middle finger ray
certain criteria to be assessed specifically in
• Sometimes defect of index finger ray
a cleft hand. The first assessment is to analyze
• Sometimes even the thumb is absent.
the type of cleft.
There are certain bony deformities that
may be seen:
Typical Cleft • Loss of one metacarpal—usual
There is no middle finger ray. So, the index • Bifid metacarpal—supporting two fingers
and thumb fingers stay on the radial side and • Two metacarpals—supporting one finger
the ring and little fingers are on the ulnar • Sometimes transverse orientation of meta-
side. carpal is seen.
Atypical Cleft Functional Problems

There is absence of more than one ray. There are usually not many functional
There are certain characteristics to help problems; this condition is more of a cosmetic
and differentiate between the two types of problem. Surgery may be indicated only in
cleft (Table 13.48.1). certain situations.
Features to look for that indicate the
severity of the problem: Management Protocol
• Deficiency of middle finger ray Management protocol of cleft hand is shown
in Table 13.48.2.
Characteristics to help and

Table 13.48.1 differentiate between typical
cleft and atypical cleft
Simple Closure of the Cleft—
Typical cleft Atypical cleft
Method of Barsky
“V”-shaped defect “U”-shaped defect
Bilateral Unilateral
• The surgery will be done under general
Involves feet Does not involve feet
anesthesia. Both hands can be operated
Inherited Sporadic on at the same time (in children).
CHAPTER 48 CLEFT HAND 207
Table 13.48.2 Management protocol of cleft hand

Finding Surgery indicated Method
Typical cleft Simple closure of the cleft Barsky method
Thumb web contracture Release of contracture and closure Littler method
of cleft
Syndactyly between ring and little Syndactyly release Discussed in earlier chapter
Bony deformities Relevant osteotomies
• A plaster of Paris (POP) slab will be applied

from the elbow to the fingers after the sur-
gery on the operated upper limb.
• This surgery is only to bring the two devi-
ated fingers together. If there are already
some other deformities like contracture of
fingers or syndactyly of fingers, they will be
dealt with at a different stage.
minimum of 3 days.
• The child can take fluids 4 hours after the
surgery.
• There may be minimal pain in the first
postoperative night. Analgesics and seda-
tives may be necessary.
• The POP will be removed after 2 weeks. A
short anesthesia may be required when
this is done, if the child is too small to
cooperate. Fig. 13.48.1 Markings for the flap
• After the POP is removed, splints will be
required for as long as the surgeon feels
necessary. the proximal phalanx. The dorsal midline
• In some instances, there may be small and the volar midline axes are marked.
problems, like creeping forward of the The flap is marked from mid-dorsal line
web, contracture of the finger. This will to mid-volar line. The length of the flap is
need surgical correction at a later date. equal to its width. The base is marked in
such a way that the volar point of the base
Surgical Steps “B” is more distal than the dorsal point “A”.
• The hand is first prepared as described in • On the opposing finger, a transverse line
Appendix I. FG is marked at the junction of proximal
• The markings are made now (Fig. 13.48.1). and distal half.
• The commissural flap is first marked. • The incision is marked on the cleft
This flap is diamond shaped and distally region.
based on the proximal phalanx region • The tourniquet is raised up to 200 mm Hg
of one of the fingers. The base of the flap and the incisions are made down through
AB is designed at the level of the junction the skin and subcutaneous tissues. The
between the proximal and distal half of diamond-shaped flap is raised.
• Any remnants of abnormal bone, either

bifid metacarpal, or double metacarpal
or transversely-oriented bone should be
dealt with now.
• Soft tissues are dissected around the neck
of the two metacarpals on either side of
the cleft. They are sutured together using
nonabsorbable suture material—3.0 poly
propylene. This is done to replace the
transverse metacarpal ligament and bring
the two fingers together. Sometimes, if the
second metacarpal bone does not yield, it
may be necessary to do an osteotomy on
the base of the second metacarpal to allow
the index finger to get approximated to the
ring finger.
• Moist saline gauze is placed over the
entire length of the wound and gentle
compression applied. The hand is elevated
and the tourniquet released. After 3
minutes, the hand is kept back on the table
and hemostasis achieved.
• The suturing of the diamond-shaped flap Fig. 13.48.2 Final suturing
is done first. This suturing is done in such
a way that the flap does not get anchored
transversely, but facing dorsally, so that anesthesia may be required if the child is
the newly created finger web has a gentle very anxious. Suture removal can be done
normal looking dorsal slope (Fig. 13.48.2). on the same day. The POP slab needs to be
• Suturing is done with 4.0 polyamide sutures. retained for another 2 weeks.
Drainage tubes are kept at strategic positions. • After a further 2 weeks, the POP is removed.
• The hand and fingers are cleaned thor- The following are advised:
oughly and nonadherent dressings applied. • Refer to physiotherapy for active mobili-
Fluffy gauze pieces are applied between the zation of the fingers
fingers and sterile dressings applied. An • Daily wash with soap and water
above elbow POP slab is applied with the • Massage of scar and grafted skin with
elbow in 90° flexion and the forearm kept in coconut oil
mid-prone position. • A splint must be applied to maintain the
index and ring fingers in approximated
Postoperative Protocol position and a static thumb web spacer
• Admission in the ward. must be incorporated in the splint.
• The affected hand should be kept elevated. This splint must be maintained for a
• Patient can take normal diet after complete minimum of a further 3 weeks.
recovery if under general anesthesia. • Child is encouraged to continue the
• Discharge of the patient by third day. mobilization of the fingers; both active
• Inspection of the suture line after 10 and passive and review once every
days only. If necessary, a short general month for evaluation.

Release of Adduction required for as long as the surgeon feels
Contracture of Thumb necessary.
and Closure of the Cleft • In some instances, there may be small
(Method of Littler) problems, like creeping forward of the
web, contracture of the finger. This will
Presurgical Counseling need surgical correction at a later date.
• The surgery will be done under general
anesthesia. Both hands can be operated Surgical Steps
on at the same time (in children).
• This surgery is usually done under general
• This surgery is only to separate the thumb
anesthesia.
and index fingers and also to bring the
• The hand is first prepared as described in
two deviated fingers together. Hence,
Appendix I.
this surgery is mainly for the cosmetic
• The markings are made now (Figs 13.48.3A
correction of the deformity. There is some
and B).
chance that the already present function
may be compromised to some extent in
• Mark the mid-dorsal line, neutral line and
the mid-volar line on the index finger and
the beginning due to the scars of surgery.
the ring fingers. The neutral line will travel
If there are already some other deformities
on the margins of the cleft. Now, mark a
like contracture of fingers or syndactyly of
fingers, they will be dealt with at a different point at the junction of the proximal third
stage. and middle third of the proximal phalanx
• There may be need for skin grafting to region on the neutral line on the ulnar side
cover some raw areas. If so, the graft of the index finger (A) and the radial side of
will be harvested from the thigh, and a the ring finger (B). Mark another point “C”
dressing applied over this area, which will about 1 cm proximal to the edge of the cleft
heal spontaneously in a period of about 2 on the dorsum of the hand.
weeks. Sometimes, if the requirement of • Join the points AC and BC, running
graft is small, the graft will be taken from between the mid-dorsal line and the
the groin crease, and in this situation, the neutral lines of the corresponding fingers.
wound will be closed leading to a scar that • At the point A, make a longitudinal incision
will settle in the groin crease line. distally along the neutral line up to the
• A POP slab will be applied from the elbow middle of the proximal phalanx. Similarly
to the fingers after the surgery on the on the ring finger, mark a distally based
operated upper limb. flap YBZ of sides measuring equal to the
• The child can take fluids 4 hours after the distance AX.
surgery. • On the volar aspect, mark a line from the
• There may be minimal pain in the first point “A” that travels in between the mid-
postoperative night. Analgesics and volar line and the neutral line of the index
sedatives may be necessary. finger up to a point “D” that does not
• Admission will be necessary for a extend beyond the volar apex of the cleft.
minimum of 3 days. Similarly draw another line from the point
• The POP will be removed after 2 weeks. A “B” that travels between the mid-volar line
short anesthesia may be required when of the ring finger and its neutral line to a
this is done, if the child is too small to point “E” that extends slightly beyond the
cooperate. volar apex of the cleft.
A B
Figs 13.48.3A and B Marking of the incisions
metacarpal bone may be present, either

The blood supply of this flap is from the skin fully, or as a stump. It is ideal to remove
bridge formed by DE. Hence, it is safer to make the the metacarpal at the base, so that the
lines AD and BE diverging slightly rather than run index metacarpal can be transposed onto
strictly parallel.
this stump while reconstructing the finger.
Any remnants of abnormal bone, either
• Now, a marking is made to release the bifid metacarpal or double metacarpal or
thumb web. Mark the point “G” where transversely oriented bone is also dealt
the index finger and the thumb meet at with now.
the web. From this point, a line is marked • Now, the incisions GH and GJ are made
extending proximally on the dorsal aspect through skin and subcutaneous tissues.
of the hand up to the point “H” at the As the incision is deepened, care must be
junction between the bases of the first and taken to avoid injury to the neurovascular
second metacarpal bones. Now, a marking bundles on the thumb and index fingers.
is made on the volar aspect from the point The adductor pollicis muscle comes into
“G” to a point “J” on the midpoint of the view on the volar side of the wound now.
already marked line AD. This creates a This must be erased from the second
triangular flap of skin on the volar aspect metacarpal to get a good release. The
of the index finger. first dorsal interosseous muscle also
• The tourniquet is raised up to 200 mm Hg must be divided near the base of the first
and the incisions are made down through metacarpal. Care must be taken at this
the skin and subcutaneous tissues in the dissection to avoid injuring the radial
space between the index and ring fingers. artery that passes between the two heads
The flap is raised carefully, taking care to of the adductors. These steps alone may
avoid injury to the neurovascular bundles not achieve a good thumb web, as the
of the index and ring fingers. In this way, index metacarpal may still be tilted toward
the flap DCE is based only on the volar the thumb.
skin and soft tissues and this flap of skin is • At this point, the index finger is held only by
being planned to resurface thumb web that the metacarpal, long flexors and extensors
is going to be created. Sometimes the third and neurovascular bundles. The base of the
second metacarpal can be osteotomized • The flap DCE is now sutured with 4.0
to free the index finger, so that it can be polyamide suture. This flap may not be
moved radially over the stump of the third adequate to cover the entire raw area in the
metacarpal bone. It can be fixed at its new thumb web, but it is important to resurface
position with short K-wires. the raw area adjacent to the thumb to
• When the finger is shifted in this way, ensure that the web does not undergo any
there is a high chance that it scissors with contracture. The raw area if any on the
the ring finger. Hence, it is necessary while radial side of the index finger side can be
fixing the second metacarpal, to rotate it covered with a full thickness graft from the
slightly to face the volar aspect. groin, or a thick split thickness graft from
• This alone may not be necessary to the thigh.
retain the position of the index finger in • The wound is now sutured with 4.0
alignment with the ring finger. Soft tissues polyamide on the space between the index
are dissected around the neck of the two finger and the ring finger (Figs 13.48.4A and
metacarpals on either side of the cleft. They B). The commissural flap YBZ is sutured to
are sutured together using nonabsorbable the defect created by the incision AX, to
suture material—3.0 polypropylene. This is form a healthy finger commissure.
done to replace the transverse metacarpal • Drainage tubes are kept at strategic
ligament and bring the two fingers together. positions.
• The flap DCE is now transposed to the • The hand and fingers are cleaned thor-
newly created thumb web. Moist saline oughly and nonadherent dressings applied.
gauze is placed over the entire length of the Fluffy gauze pieces are applied between the
wound and gentle compression applied. fingers and sterile dressings applied. An
The hand is elevated and the tourniquet above elbow POP slab is applied with the
released. After 3 minutes, the hand is kept elbow in 90° flexion and the forearm kept in
back on the table and hemostasis achieved. mid-prone position.
A B
Figs 13.48.4A and B Suturing of the skin flaps

• Refer to physiotherapy for active mobi

Postoperative Protocol lization of the fingers
• Admission in the ward. • Massage of scar and grafted skin with
• The affected hand should be kept elevated. coconut oil
• Patient can take normal diet after complete • A splint must be applied to maintain the
recovery if under general anesthesia.
index and ring fingers in approximated
• Discharge of the patient by third day. position and a static thumb web spacer
• Inspection of the suture line after 10 must be incorporated in the splint.
days only. If necessary, a short general
This splint must be maintained for a
anesthesia may be required if the child is
minimum of a further 3 weeks.
very anxious. Suture removal can be done
• Child is encouraged to continue the
on the same day. The POP slab needs to be
retained for another 2 weeks.
and passive and review once every
• After a further 2 weeks, the POP is removed.
The following are advised:
Trigger Thumb Release
49
• Make the incision on the marking with a
Introduction No. 15 blade. The incision must be made
very gently and should be superficial.
One of the most common congenital con-
This is because the digital nerves are very
ditions affecting the hand is the congenital
superficial in this condition and may be
trigger thumb. This may be commonly a bilat-
injured by an inadvertent deep incision.
eral condition. The treatment of this affliction
Once the incision goes through the skin to
consists of surgical release. The release of this
the underlying fat, skin hooks are applied
trigger thumb should be done as early as pos-
to both edges and the skin edges lifted up.
sible to preserve the function of the thumb.
• Dissection is now done in a longitudinal
direction on either side of the flexor
tendon sheath which runs in the mid-volar
Surgical Steps line. This dissection aims at mobilizing
both neurovascular bundles the lie on
• Bilateral release of the trigger thumb can both sides of the flexor tendon sheath and
be done simultaneously. The preferred run parallel to it. Once they are dissected,
anesthesia is general anesthesia, or sedation they can be retracted to either side, so that
with infiltration of local anesthetic solution. they can be prevented from getting
The combination of local anesthesia and injured during the surgery on the tendon
sedation is preferred, but done when the sheath.
patient is a little older and can cooperate for • Now, the tendon sheath has been dissected
the procedure. free from the neurovascular bundles.
• The affected hand is painted and prepared Palpate the sheath and find the nodular
as in Appendix I. If surgery is planned on swelling at the level of the A1 pulley.
both hands, both hands are prepared and • Make an incision with a No. 15 blade
draped and kept ready. on one side of the tendon sheath. This
• The tourniquet is raised up to 200 mm Hg. incision must also be made carefully as
• The volar aspect of the thumb is palpated. the tendon of flexor pollicis longus (FPL)
There will be a nodular swelling at the level lies immediately below the sheath and
of the metacarpophalangeal (MCP) joint. should not be injured. The incision must
A transverse incision is marked at the level be extended both proximally and distally
of the volar MCP crease of the thumb, as far as possible. When this incision is
measuring about 1.0 cm in length. The completed, the roof of the tendon sheath
incision need not go from one neutral line can be opened out like a book, exposing
to the other. the FPL tendon underneath.
• Now, with the tendon sheath opened out, • If the other thumb is also involved, the
make the second incision on the sheath, surgery can be done in a similar fashion on
parallel to the first. This incision is made that side.
on the other side of the tendon. When
this incision is completed, the roof of the
tendon sheath at the A1 pulley will be Postoperative Protocol
totally excised.
• Now, the tightness at the interphalangeal • The child is reviewed after 48 hours and
(IP) joint will have been released. Check the suture line inspected. Dressings are
the free and full passive range of flexion reapplied. Gentle passive mobilization of the
and extension at the IP joint. If there is an IP joint by the parent/grandparent is advised
obstruction to the full range, excise more when the child is asleep. Active movements
of the pulley either proximally or distally as of the thumb are also encouraged.
outlined in steps. • At the end of 10 days, the dressing is
• Release the tourniquet, secure hemostasis. discarded.
Wound suturing can be done with • Wash with soap and water is advised.
absorbable suture material. Sterile dressings • Scar massage is advised with coconut oil.
are applied only to the thumb base. There is
no need for immobilization.
Macrodactyly
50
Assessment (Macrodactyly) Table 13.50.1
Management protocol of
macrodactyly
In addition to the general assessment criteria Finding Surgery indicated
for congenital anomalies in the earlier Increased length Decrease the length
chapter, there are certain criteria to be
Deviation Osteotomy
assessed specifically in a case of macrodactyly
of the fingers. Increased girth Excise the soft tissues
and hypertrophied digital
The macrodactyly commonly involves the nerves on one side
index and middle fingers, but can involve any
Large nail complex Tip plasty
of the fingers or thumb.
and tip
There are certain deformities that may be
Continued growth Epiphysiolysis/epiphysiodesis
seen:
• Increased length Single involved fin- Amputation
• Deviation ger/recurrence/adults
• Increased girth
• Large nail complex
• Continued growth. of presentation. If the patient is less than a
year old, correction of the tip alone may be
Functional Problems enough. If the patient is older, correction of
the bone may be in order.
There are usually not many functional
problems; this condition is more of a cosmetic
problem. Surgery may be indicated only in Presurgical Counseling
certain situations. • The surgery will be done under general
anesthesia.
Management Protocol • This surgery is done to reduce the size
of the involved finger(s) and if possible
Management protocol of macrodactyly is
to correct the other problems like the
given in Table 13.50.1.
deviation, the rotation deformity and
nail problem. Sometimes it may not be
Decision Making possible to correct all the problems at the
The surgical correction may be planned same sitting, as the viability of the finger
according to the problems in the individual must be held in mind. In such situations,
patients. The age at which the surgical the further correction may be done at a
correction is planned depends on the age later stage.
• Some complications like skin necrosis be provided to apply continued compres

may occur. In such situations, the patient sion to the operated fingers.
may require a skin grafting from the thigh
to cover the raw areas that result. In such Surgical Steps
a situation there will be a resultant scar
• This surgery is usually done under general
on the thigh where the graft is taken. The
anesthesia.
patient may sometimes have numbness
• The hand is first prepared as described in
on one side of the finger, as the nerve
Appendix I.
supplying sensation has to be excised.
• The markings are made now.
This will usually get compensated by the
• The incision is marked on the contiguous
intact nerve on the other side. If that nerve
sides of the involved fingers which are
also has to be reduced to achieve good
diverging from each other. The marking is
reduction, a nerve graft will be required
made on the contiguous neutral lines of
to fill the gap in the nerve. This nerve graft
the corresponding fingers. If the fingers are
will be harvested from the leg, from a nerve
converging toward each other, the incision
called the sural nerve, and by removing
must be made on the noncontiguous
this nerve, the patient will have numbness
neutral lines. If the fingers are curving in
on the lateral aspect of the foot.
the same direction, the incisions are made
• Sometimes, surgery may have to be done
in the neutral lines of the fingers on the
on the involved bones. In such cases, the
convex side. When the tip and nail are
bones may have to be fixed with pins,
involved the incision is made as shown in
which need to be removed later at the end
the diagram (Fig. 13.50.1).
of 3 weeks.
• The tourniquet is raised to 200 mm Hg
• The chances of recurrence of the growth of
and the incision is made. The incision is
the finger are very high. Repeated surgery
may be required to achieve reduction.
• If the recurrence is very high and the
function of the other fingers is being
compromised by the large size of the
affected finger/fingers, amputation of the
involved fingers may be considered to
achieve rehabilitation.
• A plaster of Paris (POP) slab will be applied
from the elbow to the fingers after the
surgery on the operated upper limb.
• The child can take fluids 4 hours after the
surgery.
• There may be minimal pain in the first
postoperative night. Analgesics and sedatives
may be necessary.
of 3 days.
• The POP will be removed after 2 weeks. A
short anesthesia may be required when this
is done, if the child is too small to cooperate.
required for as long as the surgeon feels
necessary. A compression garment may also Fig. 13.50.1 Reduction of tip of finger
CHAPTER 50 MACRODACTYLY 217
deepened through the skin. The subcutane • Patient can take normal diet after complete
ous tissue is found to be hypertrophied. The recovery if under general anesthesia.
digital nerve is also found hypertrophied. • Discharge of the patient by third day.
The digital artery must be carefully dissect • Inspection of the suture line after 10 days
ed and protected. All the remaining soft tis only. If necessary, a short general anesthesia
sues extending from the mid-dorsal line to may be required if the child is very anxious.
the mid-volar line on the side of the incision
should be excised. This includes the digital
nerve which is excised. The digital artery
must be preserved.
• If osteotomy is planned, this can be done
as shown in Figure 13.50.2.
• The reduction of the length of the finger
along with maintaining the nail complex can
be done as shown in Figures 13.50.3A and B.
• Drainage tubes are kept at strategic
positions.
• The hand and fingers are cleaned thoroughly
and nonadherent dressings applied. Fluffy
gauze pieces are applied between the
fingers and sterile dressings applied. An
above elbow POP slab is applied with the
elbow in 90° flexion and the forearm kept in
mid-prone position.
• Admission in the ward. Fig. 13.50.2 Method of correcting the deviation
• The affected hand should be kept elevated. with osteotomy
A B
Figs 13.50.3A and B Methods for reduction of the length of the finger
Suture removal can be done on the same day. • Massage of scar and grafted skin with
The POP slab needs to be retained for 3 weeks. coconut oil
• At the end of 3 weeks, the POP is removed. • A compression garment must be applied
If any K-wires have been applied, they are to the operated fingers and maintained
removed now. The following are advised: for a minimum of 3 months.
• Refer to physiotherapy for active mobi • Child is encouraged to continue the
lization of the fingers mobilization of the fingers; both active
• Daily wash with soap and water and passive and review once every
Hypoplastic Thumb—
Pollicization 51
In Grade I hypoplasia, no treatment is essential.
Assessment In Grade II, the individual case must
(Hypoplastic Thumb) be examined carefully to evaluate the
function of the muscles moving the thumb.
Hypoplasia of the thumb can occur in varying Appropriate tendon transfers will improve
degrees (Fig. 13.51.1). the function. In some neglected cases, the
• Grade I: Normal thumb, but smaller in size thumb web may be contracted. This must be
• Grade II: Smaller than normal, weakness addressed first, before any tendon surgery is
of the thenar muscles may be present planned.
• Grade III: Short thumb with complete In Grade III hypoplasia, the existing
absence of thenar muscles thumb may be too small to be able to do the
• Grade IV: Floating thumb—only a nubbin normal work of the thumb even after tendon
is present transfers. The option of pollicization may be
• Grade V: Absent thumb. considered to provide a working thumb.
In Grade IV hypoplasia, the floating thumb
will not be useful. Hence, it must be excised
and pollicization done.
In Grade V, total absence of the thumb,
pollicization is a good option.
However, in all the conditions described
above with pollicization as a treatment option,
some parents may not prefer pollicization,
as it entails removing the index finger and
making it a thumb. If they prefer to add a
thumb, the option of vascularized second toe
transfer may be provided.
Pollicization
• This procedure will be done under general
Fig. 13.51.1 Grades of hypoplasia thumb perform.
• This procedure is being done to transfer Surgical Steps

the existing index finger to the position of For ease of understanding, this procedure has
thumb. been divided into two stages:
• If there is already a small thumb that is 1. Steps of finger dissection.
present, it may have to be sacrificed so 2. Steps of musculoskeletal stabilization.
that the new thumb can function well.
The transferred index finger will not look
exactly like the thumb, but it will have a Steps of Finger Dissection
length almost equal to a normal thumb. • First the hand is prepared as described in
• Admission will be necessary for a minimum Appendix I.
period of 1 week. • Marking the incisions (Figs 13.51.2A and B).
• Postoperatively, the affected upper limb will • Planning of the incisions is paramount.
be immobilized in a plaster of Paris (POP) • Dorsal side: First mark a point “X” on the
slab and movements will be prevented. knuckle of the index finger. Mark another
• The result of this surgery will become point “Y” on the dorsum of the finger over
obvious only after a few months of the proximal interphalangeal (PIP) joint.
physiotherapy to train the transferred Join these two points. From point “X” draw
index finger to work like a thumb. two lines: (1) on the ulnar side to the web
• There may be some deficit in the working space between the index and middle finger
of the thumb, in which case minor surgical and (2) on the radial side to the radial
procedures may be required later. aspect of the metacarpophalangeal (MCP)
• During the period of physiotherapy, splints joint of the index finger. Mark these points
may have to be applied as considered as “E” and “F” respectively.
appropriate by the surgeon/physiatrist. • Palmar side: Mark the midpoint of the
• The general complications of general volar MCP joint crease on the index finger
anesthesia can occur. as “B”. Mark another point “A” on the palm
A B
Figs 13.51.2A and B Markings for pollicization on dorsal and palmar aspects
CHAPTER 51 HYPOPLASTIC THUMB—POLLICIZATION 221
at approximately the site of the base of the indicis proprius (EIP) and the extensor
second metacarpal bone. Join these two digitorum to the index finger, (2) on the
points “A” and “B” with a gentle “S”-shaped radial side the insertion of the first dorsal
curve. The proximal curve must have an interosseous, (3) the lumbrical and (4)
ulnar facing convexity and the distal curve on the ulnar side the insertion of the
must have a radial facing convexity. palmar interosseous. Divide the extensor
• Now, the tourniquet can be raised and the digitorum communis (EDC) tendon.
surgery started. Divide the remaining extensor mechanism
• Dorsal flaps: Make the incisions as into three, i.e. separate the lateral bands
planned on the dorsal aspect and raise the of the dorsal aponeurosis from the central
two dorsal flaps “G” and “H”. These flaps band (Figs 13.51.3A and B). The division of
are raised in a subdermal plane, avoiding the lateral bands must be done about 1 cm
injury to the underlying subcutaneous distal to the musculotendinous junction
veins. of the first dorsal interosseous and the
• Veins: Free the veins from the skin, at palmar interosseous respectively.
least two of them. Dissect the veins to as Now, the dissection proceeds to the
proximal as possible. The further dissection palmar side. Incisions are made as shown in
can be done when the final incisions are Figures 13.51.2A and B.
made on the dorsum at a later stage in the • Neurovascular pedicle: By gentle dissection,
procedure. It is important to dissect the the digital neurovascular bundles are
dorsal nerves also along with the veins. identified and mobilized. The radial side
• Extensors: Under the subcutaneous veins digital artery is used. The branch to the
is the extensor system of the finger. It is middle finger is ligated and the vessels
formed by four structures: (1) the extensor mobilized. The vessels must be visualized
A B
Figs 13.51.3A and B Dividing the radial and ulnar lateral bands
fully before the next step is taken as there Steps of Musculoskeletal Stabilization
may be anatomical anomalies which should • Step of skeletal readjustment
be identified and considered. • Position
• There may be a common digital artery • The head of the metacarpal is now
between index and mid finger. Along with fixed in the position of the thumb (Fig.
the vessels, it is important to dissect the 13.51.4). This can be done by attaching
digital nerves too. the head of the second metacarpal bone
• Flexor tendons and interossei: The flexor to a point just palmar to the stump of
tendons must be mobilized fully in the the second metacarpal bone. It must
palm. The flexor sheath must be released be kept in rotation of the digit at about
from proximally, up to the base of the 140°. The new “trapezium” has been
proximal phalanx (PPX) bone. Dissect the positioned now. But before fixing it,
flexor tendons and the A1 and proximal another point must be considered. The
part of A2 pulley. Divide A1 and A2 pulleys, normal MCP joint of the index finger has
so that A3 will become the A1 pulley of the got some hyperextension movements.
newly created thumb. This is not required when this joint
• The palmar and dorsal interossei tendons becomes the carpometacarpal (CMC)
must be elevated subperiosteally from joint of the thumb. Hence, to counteract
the metacarpal shaft, taking care to this hyperextension nature, the head of
preserve the neurovascular supply. Divide the metacarpal is flexed and fixed in its
lumbrical at its insertion into radial slip of position. The fixation can be done with
the dorsal aponeurosis. a suture of 4.0 ethilon.
• Elevate the first dorsal interosseous • Step of muscular realignment (Fig.
(FDI) muscle along with its innervation. 13.51.5).
The muscle dissected proximally up to the • Now that the new thumb has been
base of second metacarpal. positioned and fixed, the muscular
• Divide the two insertions of the first palmar
interosseous muscle—into the ulnar slip of
dorsal aponeurosis and into the PPX.
• Metacarpal bone.
• Site of distal osteotomy: Preserve metacarpal
head of the index finger. Divide metacarpal
bone at level of epiphyseal plate. The
epiphyseal plate must be destroyed now by
crushing.
• Site of proximal osteotomy: The second
metacarpal bone is dissected. About 4 to 6
mm of base is retained. The bone is osteoto-
mized at this level. The intervening segment
of the second metacarpal is discarded.
Now, the finger is ready to be shifted. It
will now be attached only by the following
structures:
• Flexor tendons
• Extensor indicis proprius tendon
• Two palmar neurovascular bundles Fig. 13.51.4 Positioning the new carpometacarpal
• Dorsal veins joint of thumb
• Dorsal nerves. Key: 1. II metacarpal bone; 2. MCP joint capsule; 3. V–Volar; 4. D–Dorsal
CHAPTER 51 HYPOPLASTIC THUMB—POLLICIZATION 223
Fig. 13.51.5 Reconstructing the muscles of the new thumb

Key: 1. Extensor digitorum communis tendon attached to the base of
the PPX to act as APL tendon; 2. Palmar interosseous muscle; 2a. Ulnar
side lateral band; 3. Plicated EIP tendon; 4. First dorsal interosseous
muscle; 4a. Radial side lateral band
attachments must be made. The long flexor

tendons are already intact. The EIP tendon
is also intact. With time, the flexors contract
and act as a flexor pollicis longus (FPL)
tendon. However, the EIP tendon will have
to be plicated to help the thumb achieve a
normal attitude.
• The radial side lateral band will be sutured
to the dorsal interosseous to become the
abductor pollicis brevis (APB) and the
ulnar side lateral band will be sutured to the
palmar interosseous to become the future B
adductor pollicis of the reconstructed
Figs 13.51.6A and B Final suturing of the skin flaps
thumb.
• The method by which this suturing of
the tendons is by passing the free end
of the cut lateral bands into a hole made • The tourniquet is released and the hand is
in the musculotendinous junction of the covered with a saline gauze. The hand is
respective muscles and suturing them back kept elevated. Hemostasis is achieved and
onto themselves with 4.0 polypropylene skin wounds sutured as shown in Figures
sutures. 13.51.6A and B.
The hand and fingers are cleaned thoroughly on the same day. The POP slab needs to be
and nonadherent dressings applied. Fluffy retained for another 2 weeks.
gauze pieces are applied between the fingers • After a further 2 weeks, the POP is removed.
and sterile dressings applied. An above elbow The following are advised:
POP slab is applied with the elbow in 90° • Refer to physiotherapy for active mobi
flexion and the forearm kept in mid-prone lization of the fingers
position. • Daily wash with soap and water
coconut oil
Postoperative Protocol • A splint must be applied to maintain the
• Admission in the ward. index and ring fingers in approximated
• The affected hand should be kept elevated. position and a static thumb web spacer
• Patient can take normal diet after complete must be incorporated in the splint.
recovery if under general anesthesia. This splint must be maintained for a
• Discharge of the patient by third day. minimum of a further 3 weeks.
• Inspection of the suture line after 10 • Child is encouraged to continue the
days only. If necessary, a short general mobilization of the fingers; both active
anesthesia may be required if the child is and passive and review once every
very anxious. Suture removal can be done month for evaluation.
SECTION
14
Common
Clinical Conditions
Contractures on the
Upper Limb—Assessment 52
• Description of the attitude, position of the
Introduction joints
• Active and passive movements of the joints
Contractures on the upper limb occurring as
• Assessment of the apparent defect and the
sequelae to either trauma, burns or congenital
true defect.
conditions form a major chunk of patients
In addition to the generalized examination
attending the hand surgery outpatient
steps outlined above, there may be certain
department in a developing country like
criteria unique to some contractures, which
India. Planning a treatment schedule for such
will be described in the particular sections.
patients is important, since rehabilitation is of
immense importance. This chapter does not
deal with conditions like Volkmann’s ischemic
contracture or intrinsic contractures, which Contracture of the Finger
are dealt in other sections.
When a patient presents with a contracture Additional Examination Criteria
in any part of the upper limb, evaluation and • Involvement of the web spaces
planning the management is done based on • Involvement of the nail complex
various factors. The first criteria are the site of
the contracture.
Thumb
A thumb contracture must also be evaluated
in the same way with a few points to be
Examination of the emphasized:
Contracture • Any associated thumb web contracture
and measurement of thumb web angle
When there is a contracture on the upper
• Any associated bony problems.
limb, examination must show:
• Part involved Palm
• Associated contractures Palmar contractures rarely occur alone,
• Longitudinal extent of the contracture except in the rare condition called camphor
• Quality of the skin over the contracture burn, which is unique to our part of the
and the surrounding segment country (India). Here, there is an isolated
• Nature of the scar—whether soft or contracture on the palm, which may or may
hypertrophic, hyperemic not cause a secondary contracture of the
• Presence of any sinuses, ulcers fingers.
228 SECTION 14 COMMON CLINICAL CONDITIONS
The most important evaluation in a case • If neck contracture is also present, the
of palmar contracture in the common criteria management of the neck contracture
discussed above (points 1–8) is the estimation gains precedence over the management
of the true defect. of the other contractures. This is mainly
for purposes of anesthesia, which may
Dorsum be difficult in the presence of a neck
contracture.
Contractures on the dorsum of the hand very
• If lower limb contractures are present,
frequently involve the fingers and the thumb.
these also are more important than
Evaluation must proceed in the manner
upper limb contractures, because with
described above. In this site, assessment of
lower limb contractures, the patient
the scar is very important, as it will decide
may not be able to walk normally.
the involvement of the underlying extensor
• It is also important to note if there is
tendons.
a contracture on the opposite upper
limb also, and the nature of this
Wrist contracture.
The wrist contractures usually have under • Other scars: Other parts of the body should
lying joint problems that must be corrected be examined for presence of scars. This is
when the surgery is done. Hence, the evalu important for two reasons:
ation of a wrist contracture must concentrate • Skin cannot be used from the scarred
on the passive and active range of movements site when the contracture is released
at the joint. on the upper limb. For example, a thick
hypertrophic scar on the abdomen may
Elbow preclude the use of abdominal flap for
Evaluation of elbow contractures is like the resurfacing the defect after contracture
general evaluation of any contracture on the release.
upper limb. Emphasis will have to be laid • This scar also may have to be treated
on assessing the quality of the normal skin when the surgery is being done for the
around the contracture. This is because this upper limb contracture.
skin can be used in reconstruction, when the
contracture is released.
Factors Affecting the
Axilla Surgical Management
Axillary contractures must be evaluated as
critically as possible. This is because the release Age
of the contracture must be planned based on In younger age group, the points to be
the clinical evaluation. The examination of the remembered are:
scar will show whether the contracture is by • Skeletal growth is not complete, hence, a
bands of skin on the anterior axillary fold, or contracture when it is released, should be
posterior axillary fold or involves the both folds resurfaced with good skin that can grow
of skin, and whether the axillary dome is intact. with the affected part. Hence, the plan
should be more for a flap cover than skin
grafting.
General Examination • Even bilateral contractures can be released
at the same sitting, since the patient will
• Other contractures—neck, lower limbs, anyway be dependent on the guardian or
bilateral: parent.
CHAPTER 52 CONTRACTURES ON THE UPPER LIMB—ASSESSMENT 229
• In planning a major surgery for a child, the Bilateral Upper Limb Contracture
probable blood loss should be estimated Usually not released at the same sitting as
beforehand to avoid complications. this may make the patient totally dependent
on his attender and this may prove difficult,
Associated Neck Contracture especially for adult patients.
If there is an associated neck contracture, this
should be released at the first stage. No limb Contractures on Two Sites of the
surgery should be done at the time of neck
contracture release if it is felt that the blood
Same Upper Limb
loss may exceed the permissible levels or When there are two or more contractures on
patient compliance may not be good. the same upper limb, they are usually not
Table 14.52.1 Protocols for resurfacing after contracture release on the upper limb
Site of contracture Qualifying criteria Plan of surgery
Finger—single Skin band contracture Z-plasty
*Finger—single Scar Release and cross finger flap
Finger—multiple Skin band contractures Z-plasty
*Finger—multiple Scar Release and superiorly based
abdominal flap cover
*Thumb Scar Release and inferiorly based
Thumb web contracture Supple skin in web Five flap release
Square flap
*Thumb web contracture Scarred skin Release and groin flap cover
Palm contracture Scarred skin Release and superiorly based
abdominal flap cover/pedicled
radial artery flap cover
*Dorsal contracture Scarred skin with mobile metacarpo- Release and skin grafting
phalangeal (MCP) joints of fingers
*Dorsal contracture Scarred skin with fixed/subluxated Release and inferiorly based
MCP joints of fingers abdominal flap cover
*Dorsal contracture with Scarred skin with fixed/subluxated Release and groin flap cover
thumb web contracture MCP joints of fingers
*Volar wrist contracture Release and superiorly based
*Dorsal wrist contracture Release and inferiorly based
Elbow contracture Release and skin grafting
Axilla contracture Skin band contracture Z-plasty
Axilla contracture Scarred skin Release and skin grafting
* Indicates that adjuvant techniques will be required like:

released together because of the blood loss

that may occur. In such situations, the release Protocols for Resurfacing after
of contractures will have to be done one after Contracture Release on the
the other. Upper Limb
Priority of Contracture Release There are generalized protocols for resurfacing

defects after contracture release. These pro
Proximal contractures should be released
tocols are not absolute and the surgery can
first. When the resurfaced skin—whether
be tailored to the needs of the patient (Table
graft or flap, has settled well, and the full
14.52.1).
range of movements has been achieved at the
• Bone surgery: Arthrodesis of the inter
released joint, the surgery of the next distal
phalangeal joint of the thumb in severe
joint is undertaken.
contractures.
• Joint surgery: Release of the subluxated/
Cause of the Contracture ankylosed joint may be required in
If the contracture has been caused by flame conditions like contracture release of the
burns, release of the skin contracture may PIP joint or MCP joint of the finger.
suffice to achieve good function. However, • Fixation with K-wire: This may be required
if the contracture has been caused by in conditions like release of a wrist
trauma, or a congenital condition like flexion contracture.
contracture, just release of the skin and • Muscle release surgery: It will be required in
resurfacing with skin tissue may not suffice, conditions like thumb web release, where
and good function may not be achieved the contracted and fibrosed adductor
without management of any underlying muscles should be released along with the
problem like tendon contracture. skin release.
Contractures on the
Upper Limb—Management 53
Introduction Surgical Steps
• First prepare the hand and the upper limb
This segment on operative surgery will deal as described in the Appendix I.
with the following surgical procedures only, • Marking the incisions:
since the other procedures mentioned have • The release incision should be marked
already been discussed in other chapters. on the contracture, in a transverse
• Release of contracture direction from one neutral line to the
• Z-plasty other. This pattern of release will reduce
• Square flap method of thumb contracture the chances of a recontracture.
release • At both ends of the marked incision,
• Five flap method of thumb web release. fish tailing incisions should be marked.
These are “V”-shaped cuts extending
medially and laterally from both ends
Release of Contracture of the incision. The length of these cuts
depends on the amount of contracture
The most important things to remember release and can be extended, if release
when a burn contracture is being released are is not fully achieved.
the following points: • If the scar is hypertrophic, like the
• Complete release of the contracture must dorsum of the hand and the elbow,
be aimed at and should be the primary tumescent solution can be injected
goal. Hence, return of function is prime. under the scar in the plane between the
• Excision of surrounding scar is a secondary normal tissues and the scar, to help in
consideration and should be contemplated dissection (hydrodissection).
only if total release of contracture has been • If the contracture is in areas like the
achieved and excision of further scar will axilla, where a tourniquet cannot be
not compromise the hemodynamic status applied during the surgery, tumescent
of the patient. solution can be injected under the scar,
• Even if the primary plan is a contracture to control the bleeding at surgery, due to
release and skin grafting, the surgeon must the effect of the adrenaline component.
be prepared for a situation where there is • The tourniquet should be raised and the
an exposure of tendon or bone and a flap surgery started.
cover becomes mandatory. • The skin incision should be made through
The basic procedure for the release of a the entire thickness of the scar, down to
contracture is the same and the finer details the subcutaneous tissue. Care should be
are described here. exercised when incising thick, hypertrophic
scars, as the force required to go through any area of exposed tendon or bone, a flap
the scar may be high, and the subcutaneous cover must be given as per the protocol
tissues may be injured in the sudden described above. If there is no exposure
release. of tendon, a skin graft can be planned to
• Once the subcutaneous tissue is reached, resurface the raw area.
it can be identified by the presence of • Apply wet gauze on the raw area. Raise
subcutaneous veins (especially in the up the hand and release the tourniquet.
elbow and wrist and dorsum of hand). Maintain the hand in elevated position for
On the fingers, these veins may not be about 3 minutes and ask for the tourniquet
prominent, but the yielding of the skin to be removed entirely.
edges after incision, will indicate that the • Now set the hand on the table. Assess
subcutaneous plane has been reached. the viability of the tip of the finger. It
• Fibrous bands may sometimes be seen in may take a few minutes for the tip of the
the subcutaneous tissues. These should be finger to become pink. This is because of
incised totally or excised to achieve a full the fact that the vessels which were in a
release. shortened length in the contracted finger
• To aid in the release, the fish tail incisions are now stretched with the release of the
as described above can be extended contracture, and may hence go into spasm.
carefully. If this occurs, apply xylocaine soaked gauze
• Full release may not be obtained in the pieces over the vessels and wait for the
following situations: spasm to be relieved. If the tip of the finger
• If there is a subluxation of the joint and is still pale, remove any K-wires that have
a contracture of the capsule—here, the been applied. Wait for the viability of the
capsule of the joint should be released tip of the finger to be confirmed and then
and the joint fixed with K-wires as secure hemostasis. Apply a wet pad over
necessary. the raw area and prepare for the skin cover
• If there is a bony block or ankylosed (whether skin graft or flap).
joint, it should be osteotomized, • The method of harvesting a skin graft has
the contracture released and formal been described in Appendix VI. If a skin
arthrodesis of the joint should be done. flap is planned, the flap may be raised as
• If there is a tendon contracture, like described in the relevant section.
in the case of longstanding elbow
contracture, where the biceps tendon
gets contracted, total release may not Z-plasty
be possible. In this situation, either the
This procedure is done when there is no scar
tendon can be lengthened by Z-plasty
over the contracted area, but contracture
or the residual contracture can be
bands. These bands have skin on their sides
accepted and dealt with later by wedging
which can be redistributed to cover the area
techniques.
when the contracture is released. In executing
• Sometimes there may be a total release, a Z-plasty, planning is very important.
but the joint may be springing back to
This procedure is ideal for contracture
the contracted position, like in the case of
release of contracture bands on the fingers and
release of a contracture on the wrist. Thus,
axilla, where the joints are soft and supple.
the released joint should be maintained
in neutral position by means of a K-wire
passed either obliquely or longitudinally. Surgical Steps
• Once the release is complete, the bed of • Prepare the hand as described in
the raw area must be examined. If there is Appendix I.
CHAPTER 53 CONTRACTURES ON THE UPPER LIMB—MANAGEMENT 233
• Markings for the procedure (Figs 14.53.1A • The tourniquet should be raised and the
and B): incisions made. First the summit of the
• Mark the ends of the contracture band band, i.e. AB should be incised. Then, the
as points “A” and “B”. Draw the line AB. incisions should be made on the sides of
This line will run on the summit of the the contracture band.
contracture band. • Using skin hooks to hold up the tips of
• The contracture band will have two the flaps, they should be raised in the
surfaces. From point “A”, draw a line at an subcutaneous plane. When this is done
angle of 60° to line AB on one of the sides on the finger care should be taken to avoid
of the contracture band. This line should injury to the neurovascular bundles of the
not cross the neutral line of the part. This fingers.
means that this line should not cross the • When the flaps are raised, apply wet
neutral line of the finger in a contracture gauze on the finger. Raise up the hand and
of the finger and should not extend release the tourniquet. Maintain the hand
beyond the walls of the contracture band in elevated position for about 3 minutes
in the case of an axillary contracture. and ask for the tourniquet to be removed
Mark the point where this line cuts the entirely.
neutral line as “C”. Measure the length of • Now set the hand on the table. Assess
line AC. the viability of the tips of the flaps. It may
• Mark the length of AC on the line AB take a few minutes for the tips of the flaps
measured from the point “A”. Mark to become pink. Transpose the flaps to
this point on the line AB as “D”. From achieve the lengthening of the contracture
the point “D”, draw a line at an angle band. If some confusion exists as to which
of 60º to line AB on the other side of flap goes where, just stretch the finger and
the contracture band. This line, again, the flaps will fall in place.
should not cross the neutral line of the • Suture the tips of the flaps with 4.0 ethilon
part. using the corner stitch (half-buried
• Thus, one Z-plasty has been designed. horizontal mattress). Suture the edges of the
Thus, further flaps should be marked so flap with 4.0 ethilon using simple sutures.
that the entire contracture band AB is • Apply a paraffin gauze and sterile dressings.
covered. Sometimes, it is possible that In case of axillary contracture release
a single Z-plasty will cover the entire with Z-plasty, it is not necessary to apply
length AB. a plaster of Paris (POP). In case of finger
A B
Figs 14.53.1A and B Marking the contracture release with Z-plasty on the finger
contracture release, a volar POP slab • Compression garment for scar softening
should be applied for the hand keeping after a further 2 weeks.
the metacarpophalangeal (MCP) joints of
the fingers in flexion of 90° and IP joints in
extension. Square Flap Method
Postoperative Protocol This procedure is a preferred technique when

a release of a contracture is required in the
• Admission in the ward.
upper limb, especially a contracture of the
thumb web or axilla. The requirement for this
if the procedure was under regional block procedure to be done is a good quality skin on
either side of the contracture.
anesthesia.
• Analgesics and antibiotics for 5 days. Surgical Steps
• Sedation optimization strategy (SOS) for • Prepare the hand as described in
1 day. Appendix I.
• Inspection of the dressing after 48 hours. • Markings for the procedure (Figs 14.53.2A
• Discharge of the patient by third day. and B):
• Suture removal on the 10th day and • Mark the ends of the contracture band
removal of the POP slab and advice the as points “A” and “B”. Draw the line AB.
following: This line will run on the summit of the
• Refer to physiotherapy for active and contracture band.
passive mobilization of the fingers • The contracture band will have two
during the day surfaces. From point “A”, draw a line
• Daily wash with soap and water “AC” at 90° on one surface of the
• Massage of scar and grafted skin with contracture. The length of this line
coconut oil must be equal to the distance ‘’AB”.
• Straightening splints to the affected Draw another line “BD” parallel to this
finger/fingers to be worn at night for a line, from the point “B” on the same
period of 3 weeks. contracture surface.
A B
Figs 14.53.2A and B Marking the flaps

• Now the markings can be made on the • Now, the dorsal incisions can be made
other contracture surface. as follows. First the incision AE is made
• From the point “A”, a line “AE” is marked through skin and subcutaneous tissue. The
at 45° on the second surface of the flap EAB is raised holding the tip of the
contracture. The length of this line must flap with a skin hook. Then the incision EF
be equal to the distance “AB”. From the can be made and the triangular flap FEA is
point “E”, another line “EF” is marked at raised similarly. The flaps must be raised
45º to the line “AE”. fully, based on the subcutaneous pedicles.
• Now surgeons have one square flap When the flaps are raised, transpose the
CABD and two triangular flaps FEA and triangular flaps and advance the square
EAB. flap as shown in the diagram. Thus, the
leading edge of the square flap AB will get
When a contracture on the thumb web is released sutured to the line EF, the tip of the flap
by this method, the square flap CABD is usually
EAB will transpose and the tip “A” of this
planned on the palmar surface of the contracture.
The zig-zag flaps FEA and EAB are planned on the
flap will get sutured to the point “D”, and
dorsal surface of the contracture. similarly, the flap FEA will transpose and
get sutured to the point “C” (Figs 14.53.3A
and B). Apply wet gauze on the raw
• The tourniquet is raised and the surgery is areas. Raise up the hand and release the
begun. tourniquet. Maintain the hand in elevated
• The incisions are made. First the incision position for about 3 minutes and ask for
AB is made down through the skin and the tourniquet to be removed entirely.
subcutaneous tissues. The contracture will • Now set the hand on the table. Assess the
not get released by this incision alone. Now viability of the tips of the flaps. Secure
the incisions AC and BD are made through hemostasis. It may take a few minutes
skin and subcutaneous tissue. Using skin for the tips of the flaps to become pink.
hooks to hold up the tips of the flaps, they Transpose the flaps as described above.
should be raised in the subcutaneous plane. • Suture the tips of the flaps with 4.0 ethilon
When this is done on the finger or thumb using the corner stitch (half-buried
web, care should be taken to avoid injury horizontal mattress). Suture the edges
to the neurovascular bundles. Now the of the flap with 4.0 ethilon using simple
contracture will slowly start getting released. sutures.
A B
Figs 14.53.3A and B Principle of the square flap method

• Apply a paraffin gauze and sterile dressings.

In case of axillary contracture release with Five Flap Method of
square flap plasty, it is not necessary to Thumb Web Release
apply a POP. In case of finger contracture
release, a volar POP slab should be This procedure is a preferred technique
applied for the hand keeping the MCP when a release of a contracture is required
joints of the fingers in flexion of 90º and in the thumb web. The requirement for this
interphalangeal (IP) joints in extension. In procedure to be done is a good quality skin
case of a thumb web contracture release, on either side of the contracture. There are
a good bulky padding must be applied five flaps involved in this procedure. This
over the freshly released thumb web and technique is otherwise called a double
a volar POP slab must be applied with opposing Z-plasty with Y-V advancement.
the wrist in 30° extensions, thumb kept in
palmar abduction and the POP slab over Surgical Steps
the thumb web region. • Prepare the hand as described in
Appendix I.
Postoperative Protocol • Markings for the procedure (Figs 14.53.4A
• Admission in the ward. and B):
• The affected hand should be kept elevated. • Mark the ends of the contracture band
• Patient can take normal diet immediately as points “A” and “B”. Draw the line AB.
if the procedure was under regional block This line will run on the summit of the
or after complete recovery if under general contracture band. Mark the midpoint of
anesthesia. this line “C”.
• Analgesics and antibiotics for 5 days. • Measure the distance AC. Mark a line
• Sedation optimization strategy (SOS) for “AD” equal in length to AC on one
1 day. surface of the contracture at an angle
• Inspection of the dressing after 48 hours. of 60º. From the point C, mark another
• Discharge of the patient by third day. line CE equal in length to AC at an
• Suture removal on the 10th day and removal angle of 60º the line AC on the opposite
of the POP slab and advise the following: surface of the contracture. Thus, two
• Refer to physiotherapy for active and flaps of a Z-plasty (CAD and ACE)
passive mobilization of the fingers and have been designed. Similarly mark
thumb during the day two flaps for the segment CB as shown
• Daily wash with soap and water in Figures 14.53.4A and B. Since these
• Massage of scar and grafted skin with Z-plasties are parallel Z-plasties and not
coconut oil in—series, care should be taken in the
• Dynamic thumb web spacer splints to planning now. A line BF equal in length
the affected thumb web to be worn at to CB is dropped at 60º from the point
night for a period of 3 weeks. In case “B” on the same surface as the line AD.
of finger contracture release, finger Another line CG equal in length to CB is
straightening splints must be worn for dropped from the point “C” at an angle
the same period. of 60º to the line CB. Now, two opposing
• Compression garment for scar softening Z-plasties have been designed and
after a further 2 weeks. marked.
A B
Figs 14.53.4A and B Markings for the five flap method
• From the point C draw a line CH equal

to half the length of AC at 90º on the
contracture surface where the lines AD
and BF have been drawn. This line CH
represents the “Y” limb of the YV plasty.
• The tourniquet is raised and the surgery is
begun.
• The incisions are made. First the incision
AB is made down through the skin and
subcutaneous tissues. The contracture will
not get released by this incision alone. Now,
the incisions AD and CE are made through
skin and subcutaneous tissue. Using skin
hooks to hold up the tips of the flaps, they
should be raised in the subcutaneous
plane. When this is done, care should be
taken to avoid injury to the neurovascular
bundles. Similarly, incisions BF and CG can
be made and the flaps raised as described.
Now, the contracture will get released. The
incision CH can be made.
• The flaps now transpose as follows (Fig. Fig. 14.53.5 Principle of flap movement in five flap method
14.53.5). The point “C” of the flap ACE
gets sutured to the point “D”. The point
“A” of the flap DAC gets sutured to the the point “C” of this flap gets sutured to
point “E”. Similarly, the flaps CBF and BCG the point “H”. Apply wet gauze on the raw
transpose. The flap ECG advances and areas. Raise up the hand and release the
tourniquet. Maintain the hand in elevated • Patient can take normal diet immediately
position for about 3 minutes and ask for if the procedure was under regional block
the tourniquet to be removed entirely. or after complete recovery if under general
• Now set the hand on the table. Assess the anesthesia.
viability of the tips of the flaps. Secure • Analgesics and antibiotics for 5 days.
hemostasis. It may take a few minutes • Sedation optimization strategy (SOS) for
for the tips of the flaps to become pink. 1 day.
Transpose the flaps as described above. • Inspection of the dressing after 48 hours.
• Suture the tips of the flaps with 4.0 ethilon • Discharge of the patient by third day.
using the corner stitch (half-buried hori • Suture removal on the 10th day and
zontal mattress). Suture the edges of the removal of the POP slab and advise the
flap with 4.0 ethilon using simple sutures. following:
• Apply a paraffin gauze and sterile dressings. • Refer to physiotherapy for active and
A good bulky padding must be applied over passive mobilization of the fingers and
the freshly released thumb web and a volar thumb during the day.
POP slab must be applied with the wrist • Daily wash with soap and water.
in 30º extension, thumb kept in palmar • Massage of scar and grafted skin with
abduction and the POP slab over the thumb coconut oil.
web region. • Dynamic thumb web spacer splints to
the affected thumb web to be worn at
Postoperative Protocol night for a period of 3 weeks.
• Admission in the ward. • Compression garment for scar softening
• The affected hand should be kept elevated. after a further 2 weeks.
SECTION
15
Adult Brachial
Plexus Injuries
Adult Brachial Plexus
Injuries—Assessment 54
them closer to the aims of determining “level,
Introduction nature and plan”.
When the patient presents at the outpatient
department, surgeons aim is threefold and to
identify the following three points: Clinical Examination
1. What is the “level” of the lesion?
2. What is the “nature” of the lesion? Clinical examination of adult brachial plexus
3. What is the “plan” of management? injuries is given below (Table 15.54.1).
Level of the Lesion

• Whether supraganglionic or infraganglionic Motor Examination
• Whether at the root level or trunk level or
at any other level. Motor examination of adult brachial plexus
injuries is described in Table 15.54.2.
Nature of the Lesion
Is it a neuropraxia or rupture or avulsion?
Sensory Examination
Plan of Management
Figure 15.54.1 shows sensory examination.
Once the level of the lesion has been judged
and the probable nature of the lesion
diagnosed, a plan has to be made for manage
ment. This should be a comprehensive plan, Investigations
including the time of operation, the nature of
operation. Investigations of adult brachial plexus injuries
All surgeons exercises for evaluation of the are given in Table 15.54.3.
patient’s condition, like clinical examination
and investigations, will be aimed at the above
three results. Documentation
Surgeons will go through the evaluation of
the patient in a simplified way that will include It is very important to record the findings in
clinical examination and investigations. At a patient at the first visit. It is ideal that the
every step, surgeons will also see how it takes subsequent evaluation be done by the same
242 SECTION 15 ADULT BRACHIAL PLEXUS INJURIES
Table 15.54.1 Clinical examination of adult brachial plexus injuries

S. No. Parameter Level of lesion Nature of lesion Plan of management
1. History: A low energy injury A neurotmesis or
Is it a low energy injury usually will not cause neuropraxia will
or a high energy injury? rupture or avulsion, require a waiting
only varying degrees period to determine
of neuropraxia and the spontaneous
axonotmesis. recovery.
A high energy injury
will be likely to cause
avulsion and rupture.
2. History: If the neck was
Is there any history forcefully abducted, it
of how the injury is most likely to have
occurred—was caused injury to upper
the neck forcefully trunks. If the arm was
separated from the forcefully abducted,
shoulder or was it usually affects the
the arm forcefully lower trunks.
abducted at the
shoulder?
3. History: Deafferentation pain
Presence of severe pain suggests avulsion
injury
4. General examination:
Look for other injuries:
• Head
• Spine
• Lower limb trauma
• Fracture clavicle
5. General examination: Due to paralysis of Likely to be avulsion Poor prognosis
Shift of head away paraspinal muscles- injury
from injured side lesion at roots level
6. General examination: Suggests C8 T1 lesion Likely to be avulsion Poor prognosis
Horner’s syndrome injury
7. General examination: Avulsion at axillary
Posterior dislocation of nerve level
the shoulder
8. General examination: Lesion of upper trunks Most probably rup-
Palpable swelling in ture—the neuromas
the supraclavicular are palpable
region
9. General examination: Lesion of upper trunks If positive, most
Tinel’s sign at probably rupture—the
supraclavicular region neuromas are palpable.
If no Tinel’s, may
suggest avulsion injury.
CHAPTER 54 ADULT BRACHIAL PLEXUS INJURIES—ASSESSMENT 243
Table 15.54.2 Motor examination of adult brachial plexus injuries

S. No. Action tested Method of testing Inference
1. Trapezius Ask patient to shrug the shoulder
against resistance.
2. Rhomboids Ask patient to push both shoulders If working, means:
backward. Palpate the rhomboid • No avulsion
muscles and compare between the • Rupture distal to roots.
two sides.
3. Serratus anterior Push against a wall with both hands Winging indicates palsy of the
serrant
4. Shoulder Abduction Keep elbow extended and move the If not working, means: C5
arm away from the chest. Hold the involved.
lower end of scapula and note the
movements here (rotation).
Adduction Keep elbow extended and move arm If not working, means:
toward chest wall. C5 and C6 involved.
Flexion Patient stands with arm hanging by If not working, means: C5
the side, elbow extended and fore- involved.
arm supinated. Ask him to move arm
toward midline in front of chest.
Extension Ask patient to do the opposite of the If not working, means: C5 and
flexion. C6 involved.
External Patient stands with arm by the side of If not working, means: C5
rotation the chest, elbow at 90° flexion, fore- involved.
arm supinated, ask patient to move
the extended hand outward.
Internal In the above step, ask patient to move If not working, means:
rotation the hand inward. C5, C6, C7, and C8 involved.
Elbow Flexion Ask patient to flex the elbow with the If not working, means: C5
forearm supinated involved.
Extension If not working, means:
C6 involved.
Wrist Flexion If not working, means:
C6 and C7 involved.
Extension If not working, means:
C6, C7 and C8 involved.
Fingers Flexion If not working, means: C8, T1
of flexor involved
digitorum
profundus
(FDP) of index
and middle
fingers
Flexion of If not working, indicates C7, 8
FDP of index involved
and middle
fingers
• If there has been a diagnosis of neuropraxia

or axonotmesis, it is prudent to wait and
keep evaluating the patient. A plan for
surgery may have to be made in such
patients as the findings warrant.
• If there is a diagnosis of avulsion or
rupture, exploration of the brachial plexus
is necessary as spontaneous recovery can
never happen. Further procedure of nerve
grafting or nerve transfer should be decided
based on the findings at the exploration.
• It is very rare to have avulsion of all roots of
the plexus in a single patient. Hence, there
will definitely be some intact nerve which
can be used for neurotization.
• If the surgeon is reasonably careful,
exploration of the injured brachial plexus
will not cause further damage.
• If there has been a paralysis of the intrinsic
muscles of the hand, it is improbable that
they can be made functional by surgery
in the plexus. So, it is better not to do an
Fig. 15.54.1 Sensory examination exploration of the brachial plexus in such
patients. However, an exploration can
observer at the next visit. Hence, the record be done if there is associated pain, in an
will help to chart the patient’s progress. attempt to alleviate the pain.
See Appendix VI for the proforma that is • Contraindications for “exploration” surgery:
routinely used. • If the injury is more than 1-year-old, it
may not be useful to do an exploration
of the plexus and any subsequent nerve
surgery in the plexus. After 2 years
Decision Making: What of injury, exploration of the brachial
is to be Done? plexus is contraindicated.
• If the patient is elderly.
Whatever surgeons plan to do must have the • If the surgeon does not have enough
following aims to make the involved upper experience.
limb functional. And to do this, the following • Surgical plans when the patient presents
bare minimum must be achieved. more than a year after the injury or when
• Elbow flexion the exploration and nerve surgery fail:
• Shoulder stabilization • Muscle surgery
• Brachiothoracic pinch • Latissimus dorsi transfer for elbow
• Sensation below elbow flexion
• Wrist extension and finger flexion. • Free gracilis muscle transfer for
Now that the level of the lesion and the most elbow flexion, wrist extension, finger
probable nature of the injury have been made flexion
out, the decision to formulate the management • Bone surgery
must be made. Before making the decision, • Arthrodesis of shoulder if all the
there are certain points to be remembered. other procedures fail
CHAPTER 54 ADULT BRACHIAL PLEXUS INJURIES—ASSESSMENT 245
Table 15.54.3 Investigations of adult brachial plexus injuries

S. No Investigation Significance
1. X-ray cervical spine Number of transverse process of vertebrae suggests injury at root
level.
2. X-ray chest—in inspiration and To see function of phrenic nerve. If injured, suggests injury at root
in expiration level, probably avulsion.
3. X-ray shoulder To look for dislocations and shoulder instability in upper trunk lesions.
4. Computed tomography (CT) To look for pseudomeningocele if there has been an avulsion at root
myelography level.
5. Magnetic resonance imaging Same as above, but visualization of the avulsed nerve roots is better.
(MRI) scan
6. Electromyogram (EMG) First check for activity in rhomboids and serratus:
studies: • If it is present, lesion distal to roots
• In rhomboids • If it is not present, check activity in paraspinals
• In serratus anterior • If present in paraspinals, lesion distal to foramen
• In paraspinal muscles • If not present in paraspinals, lesion proximal to dorsal ramus—
probably avulsion.
7. Somatosensory evoked
potentials
• Should be done only if scapular • When there has been an iatrogenic

stabilizers are intact. injury?
• In our country, one more consideration— • When exploration has already been
all patients do not come immediately and planned by the vascular surgeon for
hence, the regular protocols may not be the subclavian artery, concomitant
possible. exploration and assessment of the
• Priority wise—first attempt exploration brachial plexus injury can be done.
and nerve surgery • Waiting period: If immediate surgery is not
• Then, muscle/tendon surgery indicated, it is better to wait for a period of
• Then, lastly, bone surgery. about 6 weeks.
• The results of nerve transfer are inferior to • If the patient has an incomplete lesion,
nerve repair. it allows surgeons time to re-evaluate
the progress of recovery
• If the patient has a total palsy, the patient
will have time to get all the investigations
Decision Making: When is it to
done and he will have time to experience
be Done? the flail limb or disability.
• Surgery at 6 weeks to 3 months: It is the
The plan has been made as to what procedure ideal period for exploration surgery to be
is to be done. Now, what remains to be done in patients with total or near total
decided, is, when to carry out the procedure. palsy? The period of inflammation is over
There are different time periods in which the and the tissues are soft and exploration
different surgeries are planned. will be fruitful.
• Immediate surgery: • Surgery at 3 to 6 months: It is the ideal
• When there has been a penetrating period for surgery for the following:
injury? • Partial palsy of upper levels
Table 15.54.4 Management protocol after clinical examination

Duration of lesion Findings Plan
< 48 hours Penetrating injury Immediate exploration
associated with vascular injury
All other lesions Conservative management till 6 weeks
to 3 months
6 weeks to 3 months Total palsy Exploration
Near total palsy
Incomplete palsy Conservative management till 3–6
Partial palsy of upper levels months
3–6 months • Total palsy Exploration
• Near total palsy
• Partial palsy of upper levels—with no
recovery
• Incomplete palsy with recovery only
distal muscles
Other lesions Conservative management
6 months to 1 year Total palsy Exploration
Near total palsy
Palsy of upper plexus Distal intraplexal nerve transfers
Incomplete palsy of lower plexus Tendon transfers
> 1 year Any lesion Muscle transfer
Distal nerve transfers
> 2 years Neglected injuries Bone surgery
Failures after surgical management Tendon transfers
• Cases of incomplete palsy who have no

recovery at all Management Protocol After
• Cases of incomplete palsy who have Clinical Examination
recovered only the distal group of
muscles over the period of 3 to 6 Management protocol after clinical examin
months. ation is described in Table 15.54.4.
Injuries—Exploration 55
taken are the spinal accessory nerve or the
Presurgical Counseling intercostal nerves.
• This procedure will be done under general period of 1 week.
• Postoperatively, the affected upper limb will
• This procedure will take about 4 hours to be immobilized in a sling and movements
perform.
will be prevented.
• This procedure is being done primarily to • The result of this surgery will become
assess the injury to the nerves. The definitive
obvious only after a few months of intensive
treatment for the injury has already been
physiotherapy and electrical stimulation
made, but may have to be changed,
and other supportive measures as will be
depending on the findings that are seen.
required.
• If the nerves appear to be intact, but
surrounded by scar tissue, it is most
may have to be applied as considered
probably an injury around the nerves. The
appropriate by the surgeon/physiatrist.
scar tissue will be excised to release the
• The general complications of general
nerves and recovery may be expected.
anesthesia can occur.
• If the nerves are found cut, they will be
repaired. Recovery depends on the length
of the nerve.
• If there is a gap in the nerves, it will be Position of the Patient
bridged with nerve grafts from the legs.
Taking nerves from the legs will cause The patient is placed in the following position:
some loss of sensation on the lateral aspect • Patient is placed in supine position on the
of the sole of the feet. It will also cause a operation table.
scar on the legs. • A small pillow is placed below the space
• If there is no nerve to supply the cut nerve between the scapulae. This puts the neck
as may occur when the nerve has been in an extended position.
pulled away from the spinal cord, another • The head is placed on a head ring. The
nerve will be taken to supply the involved head is turned to the side opposite to that
nerve(s). This will entail using a part of an of the lesion.
intact nerve to try to bring back function to • The ipsilateral shoulder is depressed
the affected nerve. By taking away a part of caudalward
a nerve from another muscle will not cause • The anesthetist is requested to turn the
any major deficit. The nerves that can be endotracheal tube away from the side of the
lesion, so that the field for the surgeon and • Segment “B” of the incision (for the
his assistant are free from protuberances. infraclavicular dissection). At the lateral end
of the clavicle, the incision turns downward
over the clavicle at the level of the coracoid
Preparation process to enter the deltopectoral groove.
The incision then runs in the deltopectoral
The surgical preparation is done on the neck, groove to the anterior axillary fold, which
mastoid area, shoulder, ipsilateral chest and it crosses to reach the medial side of the
entire upper limb. The drapings are applied upper arm. Here, it runs parallel to the
and the prepared upper limb is placed on brachial artery, up to the midpoint of the
the operation table, parallel to the patient’s arm.
position. • It is not essential to make all the incisions
that have been marked. The exploration
usually starts in the supraclavicular area.
If necessary, dissection can be done in the
Markings infraclavicular area.
• Segment “A” of the incision (for the

supraclavicular dissection). The incision
starts from a point just below the mastoid Tumescent Infiltration
process. It then runs parallel to the
sternomastoid muscle up to the junction The markings are infiltrated with tumescent
between the middle third and lower third solution. The infiltration is done in the sub
of the muscle. Here, the incision turns away cutaneous layer to control the bleed on
from the muscle and runs parallel to the making the incision. After a waiting period of
clavicle and runs about 1 cm parallel to it about 6 to 7 minutes, the incision is made.
(Fig. 15.55.1).
Surgical Steps
• Cross hatching marks are made on the
markings and then the incisions are made.
The incision is made on the sternomastoid
region and the area above the clavicle.
The incision goes through the skin and
subcutaneous tissues.
• The next layer encountered is the platysma
layer. This is also incised. Take care to avoid
injuring the external jugular vein.
• So, now a flap consisting of skin, sub
cutaneous tissues and platysma is raised. It
is anchored with 3.0 polypropylene.
• The sternomastoid muscle fibers are
identified and the muscle is retracted
medially to expose the superficial layer of
the cervical fascia. This fascia is incised.
• Now, the following structure is seen—the
Fig. 15.55.1 Markings for the exploratory incision cervical fat pad. Dissection in this area will
CHAPTER 55 ADULT BRACHIAL PLEXUS INJURIES—EXPLORATION 249
reveal the omohyoid muscle. This muscle is trunk, either directly, or after identifying
divided. The fat pad is retracted downward the C5 root.
to reveal the underlying structures. • The roots of the plexus should be identified
• First the transverse cervical artery will now. This can be done in one of the
be seen along with its venae comitantes. following methods.
This must be ligated. The deep layer of the • If there has not been much scarring, the
cervical fascia is seen and now opened. superior trunk of the plexus will be seen
• The scalene muscles (Fig. 15.55.2) will be in the center of the exposed field.
seen in the medial border of the exposed • If there has been some scarring, and the
area. This can be confirmed by the superior trunk is not easily visualized,
presence of the phrenic nerve running on identify the phrenic nerve again and
the surface of the anterior scalene muscle. then, this can be traced proximally to
These are retracted medially to further find the root of the C5.
enhance the exposure of the area for the • Alternatively, the cervical rami which
brachial plexus. The first structure that exit from the posterior border of the
should be identified now is the superior sternomastoid muscle can be traced
Fig. 15.55.2 Relevant anatomy on brachial plexus exploration

Key: 1. Sternomastoid muscle; 2. Trapezius muscle; 3. Scalenus anterior muscle; 4. Divided omohyoid muscle; 5. Clavicular fibers of pectoralis
major muscle; 6. Deltoid muscle; 7. Divided pectoralis minor muscle; 8. Subclavian artery; 9. Subclavian vein; 10. Phrenic nerve; 11. C5 root;
12. C6 root; 13. C7 root; 14. Median nerve; 15. Musculocutaneous nerve; 16. Ulnar nerve; 17. Brachial artery
proximally to find the C4 root. This will • Identification points for the structures
serve as a guide to identify C5 root also. seen at this level:
• If the C5 root has been avulsed, the root • The lateral cord will usually be seen in
will not be seen. It will be lying near the the center of this field.
clavicular area. • The medial cord will be seen inferior
• If C5 root has been identified, next the and medial to the subclavian/axillary
C6 root should be looked for immedi artery.
ately inferior and posterior to C5 root. • The posterior cord will be identified
• The C7 root is inferior to C6 root and is easier on the posterior aspect of the
related to the transverse cervical artery. subclavian/axillary axis.
• The C8 root is inferior to C7 root. • Now, the findings are noted. There are
• The T1 root is identified immediately some characteristic findings that are
posterior to the subclavian artery. described below:
• The anatomical identification of the • The plexus may appear intact, but for
trunks and divisions can be made in some appearance of thickened portions
this dissection field itself. The avulsed which suggest a neuroma-in-continuity.
segments of the upper roots will be found • There may be avulsion; the roots may
in the area behind the clavicle. The distal not be available at the foramina and
segments of ruptured upper trunks will the avulsed segments may be lying
also be found at this level only. distally.
• The Erb’s point can be identified by the three • There may be rupture of the nerve
“divisions”: (1) the suprascapular nerve, segments; roots may appear intact, but
(2) the anterior division of the superior on following them, there may be a loss
trunk and (3) the posterior division of the of continuity.
superior trunk. The brachial plexus has been dissected
• If the distal segments of the avulsed of and the findings recorded. Now is the time to
ruptured roots cannot be seen in the make decisions.
surgical exposure afforded till now, the
infraclavicular extension must be made.
• The incision is made as described (segment Decision Making
“B”) of the marking. The incision is made
through the skin and subcutaneous tissues
down to the groove between the deltoid and Neurolysis
pectoralis major muscles. The two muscles When on exploration, the nerve plexus
are separated and the clavipectoral fascia appears to be intact, but evidence of scarring
is reached. This is divided and when this is is seen at different levels, neurolysis is
done, it may be necessary to divide some planned. This procedure aims at clearing
of the fibers of insertion of the pectoralis the scar tissues around the plexus that are
major muscle also. Retractors are applied probably causing compression to the neural
medially and the insertion of the pectoralis elements. This scar may be either around the
minor muscle is identified deep to the plexal elements or within the epineurium of
pectoralis major muscle. This will be just the nerves.
medial to the coracobrachialis muscle. The process of freeing the plexus from
• The pectoralis minor muscle is dissected, the scar tissue around the nerves is called
and divided between clamps. Retractors “external neurolysis” and the process of
are applied both medially and laterally and freeing of the fascicles of the nerves from the
the infraclavicular portion of the plexus is scar within the epineurium is called “internal
exposed. neurolysis”.
CHAPTER 55 ADULT BRACHIAL PLEXUS INJURIES—EXPLORATION 251
The technique of neurolysis is described • The duration of the brachial plexus injury
in the Chapter on “Nerve Surgery”. should not be more than 6 months, in
which case, the rate of growth of the
nerve in the graft may not be enough to
Nerve Repair—Primary
achieve good resultant function in the
When the exploration of the neck is done, the upper limb.
altered anatomy is studied in detail. When The technique of suturing of nerve grafts is
there has been an injury to the nerve or the described in the Chapter on “Nerve Surgery”.
cord, and there is no loss of tissue, primary
repair is done as described in the Chapter on Nerve Transfer
“Nerve Surgery”.
There are situations like the following, where,
nerve repair or grafting cannot be done.
Nerve Grafting • Avulsion of roots.
In the process of exploration, when loss of
• Multiple level lesions with no continuity
of the proximal nerve segment with the
part of a nerve continuity is seen, it is ideal to
spinal cord.
reconstruct this defect with a nerve graft. As
discussed earlier, the primary requirements
• Ruptured nerve in which the proximal
nerve segment does not appear healthy,
before doing a nerve graft procedure are:
or is heavily scarred and cannot supply
• A good source of nerve to grow into the
enough neurons.
graft. The donor nerve that is available
should be of good quantity and quality.
• Delayed cases beyond 6 to 8 months,
where the slow growth of nerve in a graft
• A good nerve graft source that can be used
may not be conducive to achieving good
without any residual morbidity.
function.
Sources of grafts: • Cases with long segmental loss of nerve
• Sural nerve: Most commonly used nerve (> 10 cm).
graft source. In such situations, it is ideal to achieve
• Medial/lateral cutaneous nerve of arm neurotization of the important nerves with
and forearm another nerve that can supply neurons and
• Superficial radial cutaneous nerve hence achieve function. The prerequisites for
• Lateral femoral nerve nerve transfer are the following:
• Superficial peroneal nerve/saphenous • A good source of nerve to grow into the
nerve graft. The donor nerve that is available
• Split/whole ulnar nerve. should be of good quantity and quality.
• Good conditions for the growth of the There should be no residual morbidity as a
nerve into the graft: result of use of this nerve donor.
• The length of the defect should not be more • A valid nerve into which the nerve must be
than 10 cm. This is because a graft more attached, so as to get useful function. This
than 10 cm long will be nonvascularized is particularly important in multiple level
and hence the recovery will be poor. In such lesions, when not all segmental losses
situations, there are two choices available: are made good, but only the important
• A vascularized nerve grafting can be nerves for achieving useful function. This
done. is because the availability of nerve graft
• A nerve transfer can be done to avoid a source is limited.
grafting. Good conditions for the growth of the
• The bed of the grafting area should be transferred nerve.
free of scar and hematoma. Hemostasis • A good source of nerve to transfer: The
should be perfect. following are the nerves that can be used
Table 15.55.1 Management protocol of adult brachial plexus injuries—exploration

Finding Characteristics Plan
All components of the plexus Internal and external neurolysis
appear intact
Both ends of ruptured nerve available Primary nerve repair
Part of the plexus ruptured Gap between nerve ends Nerve grafting
Duration > 6 months Nerve transfer
C7 ruptured Intraplexal C7 transfer
C7 also avulsed Extraplexal nerve transfer
Part of the plexus avulsed
All roots avulsed Contralateral C7 transfer
> 8 months Distal intraplexal nerve transfers
to neurotize segments of the injured • Suprascapular nerve: To achieve shoul

plexus. The sources may be from within the der mobility.
plexus like the ipsilateral C7 transfer or the • Musculocutaneous nerve: To achieve
Oberlin transfer. These are “intraplexal” elbow flexion and hand sensation.
transfers. The nerve sources may be from • Medial cord: To achieve finger flexion.
other areas like the spinal accessory • Nerve to biceps and brachialis: To
nerve or intercostals nerves. These are achieve elbow flexion.
“extraplexal” transfers. • Median nerve: To achieve sensation in
• Accessory nerve transfer the hand.
• Intercostal nerve transfers • Good conditions for the growth of the
• Commonly used nerve transfers transferred nerve:
• Ipsilateral and contralateral C7 transfer • A healthy bed with minimal scarring,
• Distal intraplexal transfer(Oberlin) which can be achieved by ensuring
• Cervical plexus careful tissue handling and perfect
• Phrenic nerve hemostasis.
• Medial pectoral nerves • Good technique of nerve anastomosis.
• Hypoglossal nerve • Use of the microscope and fine suture
• Nerve into which the nerve graft must be materials.
attached—this usually depends upon the
priority that is before surgeons. Generally,
the following is the order of priority for the
distal end of the nerve graft. Management Protocol After
• Upper trunk: To achieve shoulder and Exploration
elbow stability and mobility.
• Lateral cord: To achieve shoulder Management protocol of adult brachial
stability, elbow flexion and hand plexus injuries after exploration is given in
sensation. the Table 15.55.1.
Injuries—Nerve Surgery 56
and noting the contraction in the trapezius
Spinal Accessory Nerve Transfer muscle.
• The nerve is dissected as distally as
The spinal accessory nerve is a good donor
possible. It will be seen that there are many
nerve readily available in the field of surgery.
small branches from the main nerve to the
If the nerve is divided as far as possible, there
muscle at different levels. These branches
is hardly any motor deficit. This nerve can be
must be spared to avoid totally denervating
used in any of the following ways:
the trapezius muscle.
• To neurotize the suprascapular nerve for • The nerve is divided as far as possible. The
shoulder abduction
cut end is now brought to the prepared
• To neurotize the free vascularized gracilis proximal end of the suprascapular nerve.
muscle transfer being used for elbow
There should be no tension between the
flexion and finger extension.
two ends. If there is evidence of tension,
• It may also be used to neurotize other some more mobilization of the nerves can
nerves like the musculocutaneous nerve,
be attempted by releasing them from soft
using long nerve grafts.
tissues. If this maneuver is not successful,
a nerve graft may have to be interposed
Surgical Steps between the ends of the nerve. The
• First, the suprascapular nerve is prepared procedure of harvesting the sural nerve
to receive the spinal accessory nerve. The graft is described in Appendix IV. Usually,
proximal end of the suprascapular nerve this will not be necessary, as the length of
is trimmed under the microscope. The the spinal accessory nerve will be sufficient
fascicular elements are looked for. The for a primary repair with the suprascapular
nerve is further trimmed in increments of nerve.
1 mm till normal appearing nerve is seen • Under microscope, the nerve suturing is
under microscope. done with 10.0 ethilon epineural sutures
• The spinal accessory nerve is now identified. using simple interrupted suturing technique.
The posterior border of the exposed field • The wounds are then closed after keeping
is now examined. The plane between the drainage tubes.
sternomastoid and the anterior border of • Sterile dressings are applied.
the trapezius is dissected and the nerve • A layer of padding is kept between the arm
looked for. When the nerve is found, it is and the chest and the arm is strapped to
first confirmed to be the spinal accessory, the chest with adherent plaster. The elbow
by stimulating with a nerve stimulator, support sling is also applied.
caudally, in the anterior axillary line up to

Intercostal Nerve Transfer the seventh rib. The incision then curves
gently transversely along the lower border of
The intercostal nerves serve as good donors of
the seventh rib up to the mid-clavicular line.
both motor and sensory nerves. These donors
• The incision is made down through the
can be used in the following ways:
skin and subcutaneous tissues and the
• To neurotize the musculocutaneous nerve flap of skin on the anterior chest is raised.
for elbow flexion.
• The pectoralis major muscle is retracted.
• To neurotize the median nerve for hand • The neurovascular bundle runs on the
and finger flexion and sensation.
inferior surface of the corresponding
• To neurotize the triceps muscle to achieve rib. The nerve is extraperiosteal.
stabilization of the elbow.
• The nerve is dissected gently from the
• To neurotize the free vascularized functional mid-axillary line distally along the
gracilis muscle transfer for finger flexion.
curvature of the rib. The nerve is very
When it is decided to use the intercostal
thin and must not be held with forceps
nerves to neurotize some elements, the
at any time during the dissection.
third to sixth intercostal nerves are usually
Gentle retraction with a skin hook will
harvested.
be enough.
• The sensory branches also should be
Contraindications dissected and tagged.
The intercostal nerve transfer is not planned • Cautery must be avoided close to the
when there are multiple rib fractures or there nerve.
is evidence of phrenic nerve injury as seen by • After the nerve is harvested, it can be
elevation of the ipsilateral hemidiaphragm. grouped along with the other intercostal
nerves (Fig. 15.56.2) that has been
Surgical Steps harvested and taken to the decided
recipient.
• At the point where the original marked
Hemostasis should be achieved and
incision crosses the anterior axillary fold,
wounds closed. Sterile dressings and dressing
the incision begins (Fig. 15.56.1). It runs
applied on the chest.
Oberlin Transfer
The Oberlin transfer is a method by which
a fascicle from the intact ulnar and median
nerves are used to neurotize the biceps and
brachialis muscles to achieve efficient elbow
flexion. Obviously, this nerve transfer can be
done only when the median and ulnar nerves
are totally intact. Hence, this option is used in
C5 and C6 lesions if primary nerve repair or
reconstruction is not possible in the brachial
plexus.
• This procedure will be done under general
Fig. 15.56.1 Markings for the incision or spinal anesthesia.
CHAPTER 56 ADULT BRACHIAL PLEXUS INJURIES—NERVE SURGERY 255
Fig. 15.56.3 Markings for the incision on the arm
Surgical Steps
Incision: It is made on the medial side of the
arm in the middle third (Fig. 15.56.3). This is
marked behind the palpated biceps muscle.
This incision may have to be extended
proximally or distally if it warrants.
Incision made through the skin, sub
cutaneous tissues and the skin flaps raised on
Fig. 15.56.2 Grouping together of the intercostal nerves
both sides.
The biceps muscle is identified and
retracted laterally.
• This procedure will take about 3 hours to • The brachial artery is now identified by the
perform. pulsation and will serve as a landmark for
• This procedure will entail using a part of an the identification of the nerves.
intact nerve that goes to the hand to try to • The musculocutaneous nerve is closest to
bring back function to the elbow. By taking the biceps muscle. The branch from the
away a part of a nerve from the normal musculocutaneous nerve entering the
nerve will not cause any major deficit. biceps muscle is identified and divided
• Admission will be necessary for a minimum close to the hilum. The branch entering
period of 1 week. the brachialis muscle is also identified and
• Postoperatively, the affected upper limb divided.
will be immobilized in a plaster of Paris • The ulnar nerve is dissected. At about the
(POP) slab and sling. level where the nerve to biceps has been
• The result of this surgery will become identified, the epineurium over the ulnar
obvious only after a few months of intensive nerve is opened by sharp dissection and
physiotherapy and electrical stimulation the fascicles are separated without causing
and other supportive measures as will be damage (Fig. 15.56.4). The fascicles are
required. stimulated individually to identify the
• During the period of physiotherapy, splints fascicles going to the FCU tendon. These
may have to be applied as considered fascicles are divided and transposed to
appropriate by the surgeon/physiatrist. be coapted to the nerve to biceps. The
• The general complications of general coaptation is done with 10.0 ethilon or
anesthesia can occur. nerve glue. Similarly, the fascicles of the
try to bring back function to the affected

side. By taking away a part of a nerve from
the normal side will not cause any major
deficit in that side of upper limb, except for
some numbness on the index and middle
fingers, which will improve with time.
period of 1 week.
• Postoperatively, there will be no restric-
tions on movements in the normal side.
However, the affected upper limb will be
immobilized in a sling and movements
will be prevented.
• The result of this surgery will become
Fig. 15.56.4 Plan of nerve transfer obvious only after a few months of intensive
Key: 1. Biceps muscle; 2. Brachialis muscle; 3. Nerve to biceps; 4. Nerve
to brachialis; 5. Musculocutaneous nerve; 6. Median nerve; 7. Ulnar
nerve; 8. Fascicle from ulnar nerve; 9. Fascicle from median nerve
required.
median nerve are separated at the level may have to be applied as considered
where the nerve to brachialis has been appropriate by the surgeon/physiatrist.
divided. The fascicles are stimulated • The general complications of general
indivi
dually and the fascicle supplying anesthesia can occur.
the FDS muscles is divided. This fascicle is
transposed and coapted with the divided
nerve to brachialis muscle.
Position of the Patient
• The wounds are then closed after keeping The patient is placed in the following position:
drainage tubes. • Patient is placed in supine position on the
• Sterile dressings are applied. operation table.
A layer of padding is kept between the • A small pillow is placed below the space
arm and the chest and the arm is strapped between the scapulae. This puts the neck
to the chest with adherent plaster. The elbow in an extended position.
support sling is also applied. • The head is placed on a head ring. The
head is turned to the side of the lesion.
• The anesthetist is requested to turn the
endotracheal tube away from the normal
Contralateral C7 Transfer
side, so that the field for the surgeon and
The contralateral C7 provides an excellent his assistant are free to work on the normal
source of healthy neurons that can be spared. side brachial plexus.
Presurgical Counseling Preparation

• This procedure will be done under general The surgical preparation is done on the neck,
or spinal anesthesia. mastoid area, shoulder, ipsilateral chest and
• This procedure will take about 3 hours to entire upper limb. The drapings are applied
perform. and the prepared upper limb is placed on
• This procedure will entail using a part of the operation table, parallel to the patient’s
an intact nerve from the opposite side to position.
CHAPTER 56 ADULT BRACHIAL PLEXUS INJURIES—NERVE SURGERY 257
Surgical Steps
The surgery consists of four components:
1. Harvesting the ulnar nerve from the
affected limb.
2. Dissecting the contralateral C7 root and
identifying the fascicles that are planned
to be used as donors.
3. Coapting the vascularized ulnar nerve to
the donor fascicles.
4. Planning the recipient nerves for the end
organ neurotization with the distal end of
the vascularized ulnar nerve.
Harvesting the Vascularized

Ulnar Nerve
Incision: On the medial side of the arm (Fig.
15.56.5), extending distally behind the medial
epicondyle on to the ulnar aspect of the
forearm, up to the flexor aspect of the wrist. Fig. 15.56.5 Markings for the harvest of the vascularized
The dissection is started in the wrist, ulnar nerve
where the ulnar nerve is easily identified.
Incision deepened through skin and as possible. The C7 divides into the anterior
subcutaneous tissues. Retraction of the FCU and posterior divisions. The anterior division
tendon ulnarward is done to expose the ulnar contains the fibers for pectoralis major
neurovascular bundle. The ulnar nerve is not innervation. The posterior division contains
divided until the entire length of the nerve up fibers for neurotization of the latissimus dorsi
to the arm has been dissected. muscle and triceps. These fibers can be used
The ulnar artery and the ulnar venae for transfer and will not cause any obvious
comitantes are identified and protected. deficit.
Dissection of the ulnar nerve is done,
preserving the epineural covering and the Nerve suturing to C7 root: Distal end of the
blood vessels coursing in the epineurium. vascularized ulnar nerve is first tunneled
At the level of the elbow, the ulnar nerve is across in a subcutaneous route to the neck
dissected in the cubital tunnel and freed incision on the contralateral side (Fig. 15.56.6)
completely. The nerve is then dissected coapted with the selected fibers of the C7 root
into the upper thirds of the arm. The vessels with 10.0 ethilon under microscope or with
running along with the ulnar nerve should nerve glue.
be carefully preserved. Now, the nerve is Recipient nerve surgery: This can be done
tunneled to the opposite side neck by a immediately or as a staged procedure. If
subcutaneous tunnel created with a tendon done immediately, the recipient nerve is first
tunneler. dissected and kept ready. The recipient nerves
are usually the musculocutaneous nerve, the
Dissecting the contralateral brachial plexus nerve to triceps or sometimes to neurotize a
and identifying the C7 root: The steps of this functional muscle transfer, in which case it is
surgery have been described in the chapter done as a staged procedure.
on brachial plexus exploration. Once the C7 • The epineurium of the ulnar nerve is
has been identified, it must be dissected as far carefully incised.
• The fascicles of the ulnar nerve are gently

separated by fine sharp dissection.
• Nerve suturing done with 10.0 ethilon
under microscope magnification.
• Skin wounds are sutures after securing
hemostasis and drainage tubes are kept.
• Sterile dressings applied and arm restraint
applied on both upper limbs.
Fig. 15.56.6 Coapting the vascularized ulnar nerve to the

donor fascicles
Injuries—Muscle Transfer 57
Markings
Pedicled Latissimus Muscle
Markings of the flap (Fig. 15.57.1) are made
Transfer for Elbow Flexion
with the patient in sitting position, with arm
held abducted at 90°.
Presurgical Counseling • The posterior axillary fold is identified and
• This procedure will be done under general an imaginary line is drawn to connect it
anesthesia. to the posterior surface of the iliac crest.
• This procedure will take about 3 hours to This represents the marking of the lateral
perform. border of the latissimus dorsi (LD) muscle.
• This procedure will entail using a muscle • The midpoint of the axillary cupola is
from the back to bring back function of marked as “A”. This represents the axillary
flexion of the elbow in the affected side. By artery in the axilla. Ten centimeter
taking away this muscle, there will be no below this point along the lateral border
major deficit in the limb.
• There will be a scar on the back and
sometimes a skin graft may have to be
applied on the back, if it is not possible to
close the wound.
period of 1 week.
• The upper limb will be immobilized in a
plaster of Paris (POP) slab and movements
will be prevented for a period of 4 weeks.
• The result of this surgery will become
obvious only after a few months of intensive
required.
may have to be applied as considered
appropriate by the surgeon/physiatrist.
• The general complications of general
anesthesia can occur. Fig. 15.57.1 Incisions for harvest of latissimus dorsi muscle
of the muscle is the point where the ensured by applying stay sutures with 3.0
neurovascular bundle enters the muscle. vicryl, between the surface of the muscle
• A skin ellipse is marked about 5 cm × 12 cm, and the dermis of the skin flap. Now
about 4 cm lateral to the marked border of the medial skin flap is elevated over the
the LD muscle and oriented parallel to the surface of the muscle, till the origin from
border. The cephalic apex of the ellipse the paravertebral fascia. There are many
is marked as “B”. The caudal apex of the perforators to the skin from the muscle,
ellipse is marked as “C”. which must also be cauterized during the
• Join the points “A” and “B”. dissection. Now, the muscle is divided as
• Extend the incision caudally for about 8 far as the dissection limits.
cm from the point “C”, parallel to the lateral • Now the vascular pedicle is identified. The
border of the muscle. vascular pedicle lies parallel to the lateral
border of the muscle and runs 2 cm on the
Surgical Steps undersurface of the muscle. The branches
• The surgery is done under general to the Serratus anterior and Teres major
anesthesia. are ligated and divided.
• The patient is placed in lateral decubitus • Now the muscle has been totally dissected
position and the arm is kept in an abducted and is now attached only by the vascular
position. pedicle and the tendinous insertion into
• The entire back, neck, shoulder, half of the neck of the humerus.
the chest, entire arm up to the elbow is • The tendon of insertion into the neck of
prepared and sterile drapings are applied. the humerus is dissected and divided. The
• The incision is made first on the lateral LD muscle has been totally raised on its
border of the skin paddle ellipse. This vascular pedicle. The viability of the muscle
incision is made down through the skin and the skin paddle must be confirmed.
and subcutaneous tissues, till the surface • The muscle is exteriorized and most of
of the LD muscle is seen. the incision is closed primarily with 3.0
• Now, the proximal incision “AB” is made polypropylenes after placing a vacuum
only through skin and subcutaneous suction drain in the wound and bringing
tissues. Then the caudal extension from out the free end in the mid axillary line.
“C” is also made down to the surface of the
muscle. Preparation of the
• Now only the lateral skin flap is raised,
superficial to the surface of the muscle.
Recipient Area on the Arm
This is done till the lateral border of • The patient is placed in supine position
the muscle. From here, the dissection and the preparation of the arm is done.
proceeds deep to the muscle, and the • An incision “E” is made on the medial
muscle is raised from the chest wall. There surface of the arm from the anterior
are usually many perforators from the axillary fold to the front of the elbow
chest wall to the muscle, which should be (Fig. 15.57.2). The incision is made through
cauterized as the dissection proceeds. This the skin and subcutaneous tissues and the
dissection should be done almost under atrophic biceps muscle is identified. The
the entire span of the muscle. biceps tendon is dissected and isolated.
• The lateral border of the skin paddle • An incision “F” about 5 cm is made
is now incised and dissected up to the transversely over the coracoid process. The
surface of the LD muscle. Care should bone is dissected and bared of periosteum.
be taken to avoid dissecting between the • Now, the harvested LD muscle is now
muscle and the skin paddle. This can be tunneled to the incision “E” on the arm.
CHAPTER 57 ADULT BRACHIAL PLEXUS INJURIES—MUSCLE TRANSFER 261
incision “F” should be sutured with 4.0

ethilon.
• Now, the LD muscle is given a new
insertion into the biceps muscle with 3.0
polypropylene. The elbow is kept in flexed
position at 90° and the forearm is kept
supinated.
• The wound is closed primarily except in
the portion where the skin paddle is inset
with 4.0 ethilon.
• An above elbow POP slab is applied with
the elbow in 90° flexion and full supination.
Gauze and pad dressings are applied on
the back and the axilla.
Fig. 15.57.2 Markings on the arm • The affected hand should be kept elevated.
Care should be taken to maintain the or after complete recovery if under general
orientation of the muscle and care should anesthesia.
also be taken to avoid kinking or torsion • The POP slabs must not be disturbed at all.
of the vascular pedicle. The viability of • Discharge of the patient by third day.
the muscle and the skin paddle must be Patient to retain the POP slab till the end
confirmed again. If there is any problem of 4 weeks.
in the muscle bleed, the vascular pedicle • Removal of the POP slab on the 21st day
must be checked for signs of compression and advise the following:
or torsion and corrected immediately. • Refer to physiotherapy for active
• The tendinous insertion of the LD muscle mobilization of the elbow and fingers
must be oriented cephalad in the arm. This • Daily wash with soap and water
tendinous portion should be tunneled to • Massage of scar and grafted skin with
the incision “F”. Now, the suturing on the coconut oil
back can be completed. • To wear the elbow sling at all times for a
• The tendinous insertion of the LD muscle further 3 weeks
must now be attached to the coracoid • Patient is advised to continue the
process to give a new origin for the muscle. mobilization of the fingers; both active
This is done using 3.0 polypropylene with and passive and review once every
horizontal mattress sutures. Now, the month for evaluation.
Obstetric Brachial Plexus
Palsy—Assessment 58
• If the limb lies in a position of internal
Introduction rotation at the shoulder and pronation
of the forearm, and flexion of the wrist,
In a case of brachial plexus birth injury, it
it is most probably an upper trunk
is not always that the hand surgeon gets to
lesion, which is the most common type
see the patient soon after the baby is born.
of presentation.
Sometimes, it takes a few months before the
• Signs of Horner’s syndrome:
baby is referred. In some instances, it may
• Ptosis
even take a few months or a year before
• Miosis
the hand surgeon sees the patient. Hence,
• Is evidence of avulsion of the lower
assessment of a brachial plexus birth injury
roots and carries a poor prognosis?
must be accurately assessed at varying stages
The grading of the muscle power should be
of the child’s growth with the problem.
made and recorded. It may not be possible to
Eliciting the history is one of the first
test each muscle individually in babies and
priorities in a case of brachial plexus birth
children. What can be tested are the muscle
palsy. Among the details to be found out are
groups as mentioned below:
the following:
• Shoulder abductors
• Specific antenatal history: Whether there • Shoulder external and internal rotators
was occurrence of maternal diabetes.
• Shoulder flexors
• Details of the delivery—which include: • Elbow flexors and extensors
• Venue of delivery: Whether in the hospital • Wrist flexors and extensors
or at home.
• Finger flexors and extensors.
• Method of delivery: Whether by natural
labor or cesarean section.
• If by cesarean section, the indication,
was it cephalo-pelvic disproportion? Muscle Power Grading
• If the delivery was by natural labor, was
it a breech or cephalic presentation? • M0: No contraction
• Was the labor assisted—with vacuum/ • M1: Contraction without movement
forceps? • M2: Slight movement with weight of arm
• What was the birth weight? supported against gravity
• Attitude of the limb: • M3: Complete movement against gravity.
• If the affected limb lies flail by the side Sometimes, the grading of the muscle
and there is no movement at all, it power may not be possible. In such
denotes a total palsy. situations, and also in older children, it is
CHAPTER 58 OBSTETRIC BRACHIAL PLEXUS PALSY—ASSESSMENT 263
Table 15.58.1 Shoulder recovery (Mallet’s classification) of muscle power grading

Score = 1 Score = 2 Score = 3
Active abduction < 30° 30°–90° > 90°
External rotation < 0° 0°–20° > 20°
Hand to head Not possible Difficult Easy
Hand to back Not possible Up to S1 spine Up to T12 spine
Hand to mouth Marked trumpet Partial trumpet < 40º abduction
ideal to classify as shown below. These tests Examination of the Baby

are simple to perform and demonstrate to at the End of 2 Days
the child/baby. These positions can also be
photographed/videographed for recording This should be done in cases of total palsy of
and assessment purposes. the upper limb seen immediately after birth.
In such babies, after 2 days, there may be
improvement seen and the real picture may
Shoulder Recovery be more apparent. This is because there is
(Mallet’s Classification) sometimes a conduction block immediately
Shoulder recovery (Mallet’s classification) of after birth, which is relieved by 48 hours.
muscle power grading is described in Table
15.58.1. Examination of the Baby
at the End of 1 Month
Elbow Recovery The following are the types of findings:
Elbow recovery of muscle power grading is • There is recovery evident in almost all the
described in Table 15.58.2. parts of the upper limb, like the shoulder,
elbow and hand.
Investigations • There is absolutely no recovery at all, and
this is usually the patient who has evidence
• Nerve action potentials (NAP) of Horner’s syndrome.
• Electromyography (EMG) • There is recovery only in the hand function.
There is no recovery of shoulder or elbow
muscles.
Elbow recovery of muscle Examination of the Baby
Table 15.58.2
power grading
at the End of 3 Months
Movement Finding Score
The following are the types of findings:
Flexion No contraction 1 • The biceps is recovering as evident by
Weak contraction 2 movements of flexion at the elbow.
Good contraction 3 • There is no recovery of the biceps.
Extension No extension 0 If there is recovery of the biceps and
shoulder muscles by the end of 3 months,
Weak extension 1
recovery of the entire limb may occur. But,
Good extension 2 if there is no recovery, or there is only a
Extension deficit 0–30° 0 recovery of the hand muscles, it is most likely
(fixed flexion 30°–50° –1 that shoulder and elbow recovery will not
deformity) occur normally. This is indication enough for
> 50° –2
exploration surgery and nerve surgery.
Obstetric Brachial Plexus
Palsy—Management 59
3. Transfer of the latissimus dorsi muscle to
Introduction supraspinatus for shoulder abduction.
4. Transfer of teres major muscle to teres
The surgical management of obstetric brachial
minor for external rotation.
plexus palsy consists of exploration and nerve
It is not essential that all these steps be
surgery at the earliest. The procedure is the
performed for all the patients with obstetric
same as described earlier in Chapter “Adult
brachial plexus palsy. Some children have
Brachial Plexus Injuries of Exploration and
good abduction, and no internal rotation
Nerve Surgery”.
contracture. But, they have no external rotation
and this is a deficit that must be corrected.
Hence, the surgery must be tailored to the
Mod Quad Procedure need of the individual patient.
In obstetric brachial plexus palsy, muscle Presurgical Counseling

imbalances develop as some group of muscles • This procedure will be done under general
overact and some muscles are paralyzed. anesthesia.
This imbalance of action on the growing • This procedure will take about 3 hours to
bones and joints creates deformities of which perform.
a few are common. When there is a palsy of • This procedure will entail using two muscles
shoulder abductors and external rotators, from the back to bring back function of
the shoulder goes in for internal rotation flexion of the elbow in the affected side.
and adduction. With time, if this deformity By taking away these muscles, there will
is left uncorrected, the internal rotators and be no major deficit in the limb. There will
adductors—the subscapularis and pectoralis also be a procedure done on the front of the
major muscle go in for contracture. If this shoulder where a release of the contracted
happens, not only the child will not be able muscles will be done.
to actively abduct the shoulder, but even • There will be a scar on the front and back
passive abduction also will not be possible. of the shoulder.
In such sequelae, the Mod Quad procedure • Admission will be necessary for a
is done which consists of four steps: minimum period of 1 week.
1. Release of the contracted pectoralis • The upper limb will be immobilized in a
major and subscapularis. plaster of Paris (POP) slab and movements
2. Reconstitution of the internal rotators by will be prevented for a period of 4 weeks.
attaching the muscle of pectoralis major • The result of this surgery will become
to the distal cut end of subscapularis obvious only after a few months of intensive
tendon. physiotherapy and electrical stimulation
CHAPTER 59 OBSTETRIC BRACHIAL PLEXUS PALSY—MANAGEMENT 265
and other supportive measures as will be Preparation

required. The surgical preparation is done on the neck,
• During the period of physiotherapy, splints mastoid area, shoulder, ipsilateral chest and
may have to be applied as considered back up to the midline on the respective sides,
appropriate by the surgeon/physiatrist. entire involved upper limb. The drapings
• The general complications of general are applied and the prepared upper limb is
anesthesia can occur. placed on the hand rest as described above.
Position of the Patient
The patient is placed in the following position: Markings
• Patient is placed in lateral position on • Segment “A” of the incision (for the release
the operation table with the involved side of the internal rotators). The incision
uppermost with the provision to make starts from a point just below the coracoid
the patient in supine position during the process (Figs 15.59.1A and B). It then runs
early phase of surgery for release of the in the deltopectoral groove caudally and
pectoralis major and subscapularis. cuts the anterior axillary fold.
• A small pillow is placed in front of the • Segment “B” and “C” of the incision (for the
chest, and the child rests on the pillow tendon transfer). At the posterior aspect of
with a slightly pronated torso. the shoulder, two incisions are made. First
• The involved upper limb is placed in a the spine of scapula is palpated and above
position of abduction of 90° at the shoulder this spine lies the supraspinatus muscle. A
and elbow in 90° flexion with internal transverse incision “B” parallel to the spine
rotation of the shoulder. This limb is placed of the scapula is marked. Another incision
over sterile drapes applied over a hand rest. “C” is marked over the posterior axillary fold,
• The head is placed on a head ring. palpating the free margin of the latissimus
• The anesthetist is requested to turn the dorsi muscle. This incision is made to dissect
endotracheal tube away from the side of the the insertion of the latissimus dorsi muscle.
lesion, so that the field for the surgeon and • It is not essential to make all the incisions
his assistant are free from protuberances. that have been marked.
A B
Figs 15.59.1A and B Marking of the incisions for the different components of the procedure
Tumescent Infiltration Step 4

The markings are infiltrated with tumescent • The divided muscle of the teres major is
solution. The infiltration is done in the sutured to the teres minor, close to the
subcutaneous layer to control the bleed on insertion, keeping the shoulder in a position
making the incision. After a waiting period of of 90° abduction and external rotation. A
about 6 to 7 minutes, the incision is made. subcutaneous tunnel is created connecting
incision “B” and “C”. The divided muscle
Step 1 of latissimus dorsi which is held by Allis
tissue forceps is tunneled through this
• Through the incision “A”, the deltoid fibers
subcutaneous tunnel to reach incision
are split and the pectoralis major muscle
“B”. Here, it is sutured to the supraspinatus
is identified. This is dissected distally to
muscle close to its insertion.
identify the insertion. The muscle is divided
Hemostasis is achieved and wounds
as close to the insertion as possible.
closed primarily. Sterile dressings are done.
• Through the cephalad part of the same
The involved upper limb is immobilized in an
incision, the insertion of the subscapularis
airplane spline, with 100° of abduction at the
tendon is identified. This can easily be
shoulder and full external rotation, so that the
done by viewing the anterior aspect
palm faces upward.
of the shoulder capsule. The tendon
of the subscapularis is in the form of Postoperative Protocol
an aponeurotic sheet. This is divided
proximally to retain as much of the insertion • Admission in the ward.
as possible. Now, passive abduction and • The affected hand should be kept elevated.
external rotation of the shoulder will be • Patient can take normal diet after complete
smooth and free. recovery from general anesthesia.
• The POP slabs must not be disturbed at all.
• Discharge of the patient by third day.
Step 2 Patient to maintain immobilization of the
To reconstruct the internal rotation, the upper limb in the POP slab till the end of
divided pectoralis major muscle is sutured to 3 weeks.
the distal cut end of the subscapularis tendon • After 3 weeks, mobilization of the shoulder
with 3.0 polypropylene. will be started retaining the POP. Hence,
the child will be encouraged to abduct the
shoulder above the level of the POP slab or
Step 3 splint.
• By the incision “C”, the latissimus dorsi • On the 21st day:
muscle is identified and dissected up to the • Refer to physiotherapy for active mobiliz
insertion. The muscle is divided close to the ation of the elbow and fingers.
insertion and the muscle is held with an • Daily wash with soap and water.
Allis tissue forceps. The teres major muscle • Massage of scar and grafted skin with
is now dissected. It lies just cephalad to the coconut oil.
latissimus dorsi muscle. This muscle is also • To wear the splint at all times for a
dissected up to its insertion and divided further 3 weeks.
near the insertion. The teres minor muscle • Patient is advised to continue the
lies deep to the teres major muscle. This mobilization of the fingers; both active
muscle is identified and dissected free. and passive and review once every
• Through the incision “B”, the supraspinatus month for evaluation.
muscle is dissected and the insertion is • The POP slab will be discarded at the
also identified. end of 6 weeks.
Volkmann’s Ischemic
Contracture—Assessment 60
especially if it is a mild type, the patient
Introduction must be subjected to physiotherapy. This
In our part of the country, Volkmann’s ische consists of mobilization of the fingers and
mic contracture (VIC) is a condition that splints to straighten out joints that are
can be seen quite often in different stages minimally stiff. This will even lengthen the
of its development. The mainstay of the minimally contracted tendons.
management of such a condition and attaining • Exploration: The first surgical procedure
a good useful hand from a hand that has been that is planned is usually an exploration.
affected by this condition depends on one This procedure achieves the following:
main factor—correct and accurate assessment • It demonstrates the damaged structures.
of the problem and the stages of involvement • It gives an opportunity to excise muscle
of almost all the structures of the hand. infarcts.
Assessment of such a condition is aimed • The nerves can be assessed and the
at: nerve surgery can be planned and done.
• Determining the stages of involvement The timing of the exploration depends on
of the structures in the hand and the the severity of lesion. In more severe types
involvement of the structures that deter (Type II and Type III), early exploration is
mine function in the hand. advised because it is important to bring
• Determining the treatment plan which is back sensation to the hand. In mild type
basically dependent on the diagnosis. (Type I), the nerve is usually not involved. The
Not all the cases of VIC that surgeons see exploration should not be done too early, as
will fall exactly into one of the types men- it may interfere with the healing of muscles
tioned in Table 15.60.1. But, there will be a after the trauma. Hence, this surgery can be
general trend that will categorize the type planned after 6 months in Type I when the
of lesion in a particular patient. As far as the muscles have healed well.
treatment options are concerned, manage • Skin: It is imperative that the skin on the
ment will depend on the condition of the forearm is of good quality and not scarred/
different structures in the hand (Table 15.60.2). contracted/adherent. If there are such
problem scars on the forearm, they should
be replaced with good quality skin cover as
a preliminary procedure before embarking
Planning the Sequence of on exploration.
Surgical Procedures • Skeletal problems: Any deformities of the
forearm bones or contractures of the joints
• Physiotherapy: As soon as the patient must be corrected before planning any soft
is seen in the outpatient department, tissue surgery on the nerve or tendons.
Table 15.60.1 Type of lesions of different structures in the hand

Criteria to assess Type I Type II Type III
Skin Supple Scarred Contracture
Intrinsic muscles Normal Palsy Contracture
Peripheral pulses Present +/– +/–
Position of the wrist Normal Flexion Flexion contracture
Position of the forearm Normal Fixed in pronation Fixed in pronation
Position of the thumb Normal Simian thumb Adduction contracture
Position of fingers Flexion Claw Intrinsic plus deformity
Sensation Normal Loss of sensation Loss
Finger flexion Volkmann’s sign Weak flexion Contracture
Fingers affected Not all the fingers All the fingers All the fingers
Joints Supple Stiff Stiff
Power of Good Weak Contracture
flexion of fingers
flexion of thumb
Extension of fingers Present +/– +/–
Table 15.60.2 Management protocol in Volkmann’s ischemic contracture

Structure tested Findings Management
Joints Stiff Physiotherapy and splints
Contracture Arthrodesis
Skin Thin skin Excision of the skin and skin flap cover
Grafted skin
Hypertrophic skin
Skin contracture
Flexor tendons Good power one or two fingers only involved Tendon lengthening
Good power—only the flexor digitorum Tendon transfer: Flexor digitorum superfi-
profundus (FDP) tendons involved cialis (FDS) → FDP
Good power—all the fingers involved Muscle slide operation
Weak power not acting in Type II VIC Tendon transfer: Brachioradialis (BR) →
Flexor pollicis longus (FPL), extensor
carpi radialis longus (ECRL) → FDP
Weak power not acting in type III VIC Free functioning gracilis muscle transfer for
finger flexion
Nerve Loss of sensation Exploration and nerve reconstruction
CHAPTER 60 VOLKMANN’S ISCHEMIC CONTRACTURE—ASSESSMENT 269
• Nerve surgery: Restoration of the sensa any tendon surgery can be planned. This
tion on the hand is an essential requisite principle must be followed in keeping with
before contemplating reanimation the principles of tendon surgery.
procedures. • Tendon: The tendon procedures should
• Joint: The joints of the hand and fingers be done after the other procedures are
must be made soft and supple before complete.
Contracture—Management 61
• Prepare for the procedure as outlined in
Exploration the Appendix I.
• Prepare the involved upper limb and the
Exploration must be planned only after a
legs.
complete examination of the hand has been
• Markings (Fig. 15.61.1): The incision extends
made. This procedure is not an alternative to
from the elbow to the wrist in a lazy “S”
the clinical examination.
fashion.
Exploration helps to see the problem in
• The incisions are made through the skin
the forearm and hand and to confirm the plan
to the deep fascia on the forearm. The skin
of management. It also allows to carry out a
flaps are raised at this plane in order to
part of the plan, if it follows the sequence as
preserve the vascularity of the flaps.
described above.
• The muscle plane is now opened. This is
This procedure must be done only if the
better done first over the proximal forearm,
skin on the forearm is of good quality. If the
where the muscle mass can be seen to be
skin has thin or adherent scars or even grafted
virgin, and the tissue planes can be well
skin, the wounds made for exploration are
made out. The next part of the incision can
likely to break down postoperatively, leading
be made distally over the distal end of the
to an emergency requirement of skin cover
forearm, sometimes extending on to the
to salvage the underlying soft tissues. In
palm as shown in Figure 15.61.1. When
such situations, where the scars are not of
the extension of the incision is made in
good quality, they must be replaced with
the palm, the flexor retinaculum must be
durable skin in the form of a flap—either
divided between the origins of the thenar
the conventional pedicled flaps like the
muscles and the hypothenar muscles. In
abdominal flap or the groin flap, or the
the center of the forearm, there is likely
microsurgical vascularized skin flap. However
in the setting of Volkmann’s ischemic
contracture (VIC), where the blood vessels
are likely to be involved or may be required
for later reanimation procedures, the pedicled
flaps are preferred.
Surgical Steps
• The preferred anesthesia is either general
anesthesia (in children) or regional block
(in adults). Fig. 15.61.1 Markings for the exploration on the forearm
CHAPTER 61 VOLKMANN’S ISCHEMIC CONTRACTURE—MANAGEMENT 271
to be a mass of scar and anatomical

identification of the individual structures
cannot be made out.
• Exploration of the structures.
Examination of the muscles and tendons:

• The first tendons that are encountered, are
the flexor carpi ulnaris (FCU), palmaris
longus (PL) and FCU tendons. In severe
cases, these muscles may be involved
and contracted leading to a deformity in
the wrist joint. In such situations, these
tendons must be divided as far away from
the insertion as possible to release the
contracture.
Fig. 15.61.2 Grading of involvement of the nerves
• Next, the flexor digitorum superficialis
(FDS) and flexor digitorum profundus
(FDP) muscles must be examined to look
for continuity. A part of the tendons may • Grade I—No reduction in caliber of median
be engulfed in a scar. If it is possible, the nerve and the median artery appears to be
adhesions may be released and tenolysis visualized fully.
done. If the scar is very dense and involves • Grade II—Minimal reduction in the
the muscle portion of the tendons also, the diameter of the median nerve and the
scar must be excised along with involved median artery is of smaller caliber and
tendons. If any tendon transfer is planned absent in some segments.
along with, it can also be done, provided • Grade III—Up to 50 percent reduction in
the sensation of the hand was clinically the diameter of the median nerve.
normal. • Grade IV—More than 50 percent reduc
tion in the caliber of the median nerve
Examination of the nerves: with total loss of some segments of the
• The nerves—median and ulnar nerves nerve.
must be examined now. The entire length • If the nerve comes under grade I, releasing
of the median and ulnar nerves must be the surrounding scar by neurolysis is
dissected free from the surrounding scars, enough. If the involvement of the nerve
exposed and examined in detail. The is either grade II, III or IV, reconstruction
median nerve is more important as far of the nerve is necessary for restoration
as the function of the hand is concerned. of sensation on the hand. This can be
Normally, an artery can be visualized on done by any of the following methods.
the surface of the median nerve, running First the length of the segment involved is
along the entire length of the nerve. This considered.
is the median artery, representing the • If the segment is less than 6 cm—
embryological axis artery during the nonvascularized reversed sural nerve
development of the upper limb. There are graft from the leg.
four grades of involvement of the nerves • If the segment involved is more than
(Fig. 15.61.2) based on the appearance of 6 cm, either a vascularized pedicled
this artery and the diameter of the median nerve graft or vascularized micro
nerve in the involved segment. surgical nerve transfer is done.
Examination of the blood vessels: • Child is encouraged to continue the

• The caliber of the radial artery and the mobilization of the fingers; both active
ulnar artery must also be examined. The and passive and review once every
hand may already be viable, but it is ideal month for evaluation.
to have a good vasculature to the hand to
ensure optimum healing of the tissues
and function. If the vessels are obliterated, Tendon Lengthening
appropriate vein grafts to bridge the
gaps and restore good blood flow to the
hand must be done by microvascular
Surgical Steps
anastomosis using reversed saphenous • The involved tendon is identified and
vein grafts from the leg. dissected.
• The tourniquet must be released and • The excursion of the tendon is confirmed
gentle pressure with a saline pad should by a passive mobilization.
be applied and the hand kept elevated • It is divided with a No. 11 blade as shown
for two minutes. Next, the hand must in the diagram (Fig. 15.61.3).
be placed on the table and hemostasis • The suturing of the tendon is now done
achieved. Skin suturing is done with 3.0 with 3.0 polypropylene, as shown in the
ethilon and drainage tubes kept in the diagram (Fig. 15.61.3).
proximal portion of the suture line. Sterile • The tourniquet must be released and gentle
dressings are applied and dorsal plaster pressure with a saline pad should be applied
of Paris (POP) slab is applied with wrist and the hand kept elevated for two minutes.
in neutral position and fingers in position Next, the hand must be placed on the table
appropriate with the surgical procedure and hemostasis achieved. Skin suturing is
that has been done (nerve or tendon done with 3.0 ethilon and drainage tubes
surgery). kept in the proximal portion of the suture
line. Sterile dressings are applied and dorsal
Postoperative Protocol POP slab is applied with wrist in neutral
position and fingers in position appropriate
• Admission in the ward. with the surgical procedure that has been
• The affected hand should be kept done (nerve or tendon surgery).
elevated.
• Patient can take normal diet after comp
lete recovery if he was under general
anesthesia. • Admission in the ward.
• Discharge of the patient by 3rd day. • The affected hand should be kept elevated.
• Inspection of the suture line on the 2nd • Patient can take normal diet after complete
day. If necessary, a short general anesthesia recovery if he was under general anesthesia.
may be required if the child is very serious. • Discharge of the patient by the 3rd day.
Suture removal can be done on the 10th
day. The POP slab needs to be retained for
another two weeks.
• After further two weeks, the POP is
removed. The following are advised:
coconut oil Fig. 15.61.3 Technique of tendon lengthening
• Inspection of the suture line on the • Now, make incision on the ulna for the
2nd day. If necessary, a short general distance of the origin of the FCU muscle.
anesthesia may be required, if the child is Raise the FCU muscle subperiosteally. The
very serious. Suture removal can be done ulnar nerve is still seen entering the FCU
on the 10th day. The POP slab needs to be muscle. This need not be disturbed. As the
retained for another two weeks. FCU muscle is being erased from its origin,
• After further two weeks, the POP is the ulnar nerve can be brought anterior
removed. The following are advised: to the medial epicondyle, to reduce the
• Refer to physiotherapy for active mobili tension on the nerve. As this is being done,
zation of the fingers the elbow joint capsule and the tuberosity
• Daily wash with soap and water of the ulna will get exposed. When this
• Massage of scar and grafted skin with procedure is done carefully, the muscle
coconut oil will be erased along with the periosteum.
• Child is encouraged to continue the • After the FCU is raised from the ulna, the
mobilization of the fingers; both active interosseous membrane comes into view
and passive and review once every month and the anterior interosseous artery, and
for evaluation. its perforating branches and nerve and
veins will be seen. These must be protected.
• Gentle traction must be given on the
Muscle Slide Operation fingers to extend them. As the muscles are
being released, the fingers will be able to be
Surgical Steps passively extended. The end point of this
• Incision on the forearm must extend from muscle elevation is the full, free passive
the wrist on the radial side to allow access extension of all the fingers and thumb.
to the flexor pollicis longus (FPL) tendon • The thumb may not get released by the
if necessary to the arm, proximal to the procedure described above. From the
elbow joint. middle and distal segments of the incision,
• Identify the median nerve, which is just the FPL muscle is exposed and released
ulnar to the biceps tendon. Identify the subperiosteally from the radius to achieve
brachialis muscle that is posterior to the full extension of the thumb.
median nerve. Identify the pronator teres • Now, the ulnar and median nerves must
muscle, which is immediately ulnar to the be released from all scars distally also.
median nerve. • The tourniquet must be released and
• Identify the ulnar nerve as it enters the gentle pressure with a saline pad should be
forearm between the two heads of the FCU applied and the hand kept elevated for two
muscle. Palpate the ulna bone. minutes. Next, the hand must be placed
• Pass a retractor and retract to the radial on the table and hemostasis achieved.
side, the median nerve along with the Skin suturing is done with 3.0 ethilon
brachialis and biceps. Pass another retrac and drainage tubes kept in the proximal
tor to retract the pronator teres ulnarward. portion of the suture line. Sterile dressings
Palpate the medial epicondyle of the are applied and dorsal POP slab is applied
humerus in the valley between the two with wrist in neutral position and fingers
retractors. Incise the periosteum, and with in position appropriate with the surgical
a periosteal elevator, release the pronator procedure that has been done (nerve or
and flexors muscle origin from the tendon surgery).
epicondyle, subperiosteally. This can be
done from the radial side toward the ulnar Postoperative Protocol
side. It will have to stop when the ulnar • Admission in the ward.
nerve is encountered. • The affected hand should be kept elevated.
• Patient can take normal diet after complete • The FDS tendons of all the fingers are
recovery if he was under general anesthesia. identified and dissected. The FDP tendons
• Discharge of the patient by the 3rd day. to all the fingers are identified and dissected.
• Inspection of the suture line on the • The FDS tendons are divided as distally as
2nd day. If necessary, a short general possible in the palm at Zone III level for all
anesthesia may be required if the child is the fingers. The FDP tendons are divided
very serious. Suture removal can be done close to the musculotendinous junction
on the 10th day. The POP slab needs to be for all the fingers.
retained for another two weeks. • The excursion of the FDP tendons is
• After further two weeks, the POP is confirmed by passive mobilization. The
removed. The following are advised: proximal FDS tendon of the index finger
• Refer to physiotherapy for active and the distal FDP tendon of the finger
mobilization of the fingers. are now kept in proximity. They cannot
• Daily wash with soap and water. be sutured directly as the tension has not
• Massage of scar and grafted skin with yet been adjusted. Too tight suturing or
coconut oil. too loose suturing will result in a useless
• Child is encouraged to continue the finger. The method of adjusting the tension
mobilization of the fingers; both active is as follows:
and passive and review once every • The wrist is kept in neutral position. The
month for evaluation. FDS muscle is now going to move the
FDP tendon of the corresponding finger.
The proximal FDS tendon is pulled and
Tendon Transfer—FDS to FDP relaxed alternatively to confirm the
supple muscle. The distal cut end of
the FDP tendon is also moved passively
Surgical Steps to confirm that there are no adhesions
Through the exposure described above, the distally.
following steps are carried out (Figs 15.61.4A • With the wrist in neutral position, the
and B). distal FDP tendon of the index finger
A B
Figs 15.61.4A and B Technique of FDS to FDP transfer

is gently pulled with an artery forceps done with 3.0 ethilon and drainage tubes
till the finger lies in the normal cascade kept in the proximal portion of the suture
position: metacarpophalangeal (MCP)— line. Sterile dressings are applied and dorsal
10º, proximal interphalangeal (PIP)—70º POP slab is applied with wrist in neutral
and distal inter phalangeal (DIP)—20º. position and fingers in position appropriate
This is the attitude of the fingers in with the surgical procedure that has been
complete relaxation. done (nerve or tendon surgery).
• Pull the cut end of the FDS tendon.
It should glide freely forward and Postoperative Protocol
backward. If it does not do so, further
mobilization should be done until
it does so. Pull the tendon to the
• Patient can take normal diet after
maximum. Make a mark on the tendon
complete recovery if he was under general
at the point, where it just becomes
anesthesia.
visible in the wound. Mark this point
• Discharge of the patient by the 3rd day.
as “A”. Now, relax the tendon and it will
• Inspection of the suture line on the 2nd
glide back into the forearm for a certain
day. If necessary, a short general anesthesia
distance. Now, mark the point where
may be required if the child is very serious.
the tendon just becomes visible at the
Suture removal can be done on the 10th
edge of the wound. Mark this point as
day. The POP slab needs to be retained for
“B”. So, the distance AB is the amplitude
another two weeks.
of movement of the FDS tendon. Mark
• After further two weeks, the POP is
the midpoint of the distance AB and
mark this point as “C”. Hold the tendon
in such a way that the point “C” is just
mobilization of the fingers.
visible at the edge of the wound. This
• Daily wash with soap and water.
should be the position of the FDS while
it is being sutured to the distal cut end
coconut oil.
of the FDP tendon.
• Patient is encouraged to continue the
• Pull the free end of the FDP tendon, so active mobilization of the fingers for
that the finger is held in a position of
three weeks from removal of the POP.
the cascade of the finger. Mark a point
• After three weeks from removal of the
“D” on this tendon which corresponds
POP, gentle passive stretching is started.
to the point “C” at this position of the
finger. The point “D” of the FDP must
now be sutured to the FDS tendon at
Tendon Transfer—Brachioradialis
the point “C”.
• Trim the excess length of the FDP to FPL and ECRL to FDP
tendon and the FDS tendons. Suturing
is done with 3.0 polypropylene using In a condition, where the muscles on the
modified Kessler-Mason-Allen suture. extensor side are acting well, these extensors
• The procedure is repeated for the can be used to provide flexion of the fingers
middle, ring and little fingers also. and thumb.
• The tourniquet must be released and gentle
pressure with a saline pad should be applied Surgical Steps
and the hand kept elevated for two minutes. • Incision to harvest brachioradialis (BR)
Next the hand must be placed on the table and FPL: These muscles can be harvested
and hemostasis achieved. Skin suturing is through the exploratory incisions.
Fig. 15.61.5 Marking for the incisions for harvesting Fig. 15.61.6 After tendon suturing
ECRL tendon
• Incision for extensor carpi radialis Tension adjustment: The tendons of the
longus (ECRL) must be made as follows BR must be sutured to the FPL tendon
(Fig. 15.61.5): with the wrist in neutral position, thumb
• Incision “A” is now made. The ECRL kept in a position of palmar abduction and
tendon must be identified. The extensor interphalangeal (IP) joint in 10° flexion
pollicis longus (EPL) tendon runs (Fig. 15.61.6).
obliquely across it and the extensor • The tendon of the ECRL is sutured to the
carpi radialis brevis (ECRB) tendon tendons of all the FDP tendons of the
is on the ulnar side. The ECRL tendon fingers, keeping the wrist in neutral position
should be held with a hemostat and and fingers in a position of natural cascade:
divided closely to the insertion with a MCP—10º, PIP—70º and DIP—20º. The
No. 11 blade. technique of suturing the tendons is
• Gentle traction to the ECRL is applied described in the previous chapter.
in a distal direction by pulling on the • The tourniquet must be released and
hemostat. This will confirm the position gentle pressure with a saline pad should be
of the muscle proximally and the applied and the hand kept elevated for two
incision “B” is made now. The muscle/ minutes. Next, the hand must be placed
musculotendinous unit of the ECRL is on the table and hemostasis achieved.
exposed in this incision and confirmed Skin suturing is done with 3.0 ethilon
by traction on the hemostat. and drainage tubes kept in the proximal
• The FDP tendons for all the fingers are portion of the suture line. Sterile dressings
divided as proximally as possible and are applied and dorsal POP slab is applied
tagged. with wrist in neutral position and fingers
in position appropriate with the surgical on the 10th day. The POP slab needs to be
procedure that has been done (nerve or retained for another two weeks.
tendon surgery). • After further two weeks, the POP is
Postoperative Protocol • Refer to physiotherapy for active mobi
• Admission in the ward. lization of the fingers.
• The affected hand should be kept elevated. • Daily wash with soap and water.
• Patient can take normal diet after complete • Massage of scar and grafted skin with
recovery if he was under general anesthesia. coconut oil.
• Discharge of the patient by the 3rd day. • Patient is encouraged to continue the
• Inspection of the suture line on the active mobilization of the fingers for
2nd day. If necessary, a short general three weeks from removal of the POP.
anesthesia may be required if the child is • After three weeks from removal of the
very serious. Suture removal can be done POP, gentle passive stretching is started.
Vascularized Gracilis
Muscle Transfer 62
Introduction Disadvantage
The transfer of the functioning gracilis The skin paddle of this flap is not very reliable.
muscle is the only answer to situations
like some cases of brachial plexus injuries
and Volkmann’s ischemic contracture. The Surgical Steps
indications for such a muscle transfer have
already been discussed in the previous
chapters.
Donor Site Dissection
• The preferred anesthesia is either general
anesthesia or combined regional block—
continuous epidural anesthesia with
Advantages supraclavicular block (if the surgery is for
finger or hand motorization).
• This is an easy muscle to harvest and has a • Prepare for the procedure as outlined in
pedicle of length even up to 6 to 7 cm.
the Appendix II.
• The donor site morbidity is minimal.
• Prepare the involved upper limb,
• It may even be possible to split the muscle
including the shoulder, neck and front of
for different functions like for motorizing
chest.
the thumb and fingers, due to the unique
• Prepare the opposite side thigh and
anatomy of the gracilis muscle. This
groin regions.
muscle has a dual nerve supply and the
muscle fibers can be split according to the
nerve fascicles supplying it. Markings (Fig. 15.62.1)
• The muscle has a length almost equal • Flex the hip to 90° and the knee to 90°. Now
to the length of the arm (when using the abduct the hip to the maximum possible.
muscle as elbow flexor), and also equal to On the medial side of the thigh, the
the length of the forearm (when using the prominence of the adductor longus muscle
muscle as finger flexor or extensor). can be seen from the pubic tubercle.
• The cross section of the muscle is such that Immediately posterior/inferior to this
it appears physiological when contracting prominence, there is a small groove and
and does not appear grotesque. within this groove is the gracilis muscle.
• There is no motor deficit in the lower limb Sometimes, it may be obvious as a small
after removal of the gracilis muscle. prominence in the depth of the groove;
CHAPTER 62 VASCULARIZED GRACILIS MUSCLE TRANSFER 279
be a few minor vascular pedicles entering

the muscle belly. These can be divided and
ligated.
• On the proximal third, the incision can be
made on the proximal part of the line CD
up to the point “C”. From here, the incision
will continue on the superior border of the
skin paddle. When the incision is deepened
through the deep fascia, anchoring sutures
must be made between the deep fascia and
the skin paddle to prevent shearing of the
myocutaneous perforator. Only the skin
flap on the superior edge of the incision
Fig. 15.62.1 Markings for the harvest of gracilis muscle should be raised now.
• The adductor longus muscle will come
into view (Fig. 15.62.2). A retractor must
sometimes it may only be palpable in the be placed and the adductor longus
groove. Now, mark a point on the pubic muscle retracted superiorly, to expose
tubercle “A” and another point on the the undersurface of this muscle. Now,
medial femoral condyle “B”. Join these two the vascular pedicle can be seen entering
lines. This forms the superior border of the undersurface of the gracilis muscle.
the gracilis muscle. It does not represent There will be one or two branches from
the axis of the flap. The muscle is about the pedicle to the adductor longus muscle
2 cm inferior or behind this axis. The skin that should be carefully ligated and cut.
paddle can be marked now. At the proximal Similarly, the branches to the adductor
end of the axis, an ellipsoid skin paddle magnus muscle can also be ligated and
can be marked “E” about 5 cm distal to the divided. This will allow further retraction
pubic tubercle with its superior surface on of the adductor longus muscle and further
the marked line. Hence, the skin paddle expose the vascular pedicle.
will lie over the muscle. The maximum size • About 3 cm proximal to the vascular hilum,
of the skin paddle can be 5 cm/8 cm. the nerve can be seen and dissected. This is
• Mark the incision about 2 cm parallel to the anterior branch of the obturator nerve.
and inferior to the line AB. This line will This must be gently dissected proximally as
start proximally at the distal tip “C” of the the nerve lies on the surface of the adductor
skin paddle and end at a point “D” on the magnus muscle. The greater the length of
medial side of the knee, posterior to the the nerve that is dissected, the easier is the
medial femoral condyle. nerve anastomosis at the recipient site.
• Make the incision CD. First make the • When the entry point of the vascular
middle third of this incision. Go through pedicle is made out on the medial/
the skin, superficial fascia and the deep undersurface of the gracilis muscle, the
fascia. By applying retractors on both incision on the inferior edge of the skin
sides of the wound, the gracilis muscle paddle can be made. Anchoring sutures
can be seen surrounded by loose areolar should be placed again between the deep
tissue. The adductor longus muscle can be fascia and the dermis of the skin paddle.
seen superiorly and the adductor magnus Now, the dissection should go on the
inferiorly. undersurface of the gracilis muscle and
• The gracilis muscle can be dissected free any branches to the adductor magnus
from the loose areolar tissue. There will muscle should be ligated and divided. This
should be divided only after the recipient

site has been prepared to shorten the
warm ischemia time.
• Division of the pedicle: Usually, there are
two veins and one artery at the vascular
pedicle and the nerve. The nerve should
be divided as proximally as possible after
tagging the end with 7.0 polypropylene
suture materials as a marker. Soft clamps
should be applied over the artery and
veins. The proximal ends of the artery and
veins should be ligated with 3.0 vicryl.
The vessels should be divided and the
time noted. The flap should be placed on
a moist abdominal pad and taken to the
Fig. 15.62.2 Dissection of the vascular pedicle
recipient site for vascular anastomosis.
• Management of the donor site: After securing
hemostasis, the secondary defect should be
will totally free the circumference of the
closed in layers with subcutaneous suturing
muscle, which will now be attached by the
with 3.0 vicryl and the skin closed primarily
vascular pedicle and the nerve only.
with 3.0 ethilon after keeping a suction
• Identify the origin of the gracilis muscle
drain. Sterile dressings should be applied
from the pubic tubercle and dissect it.
and elastocrépe bandage applied over it.
• Now, complete the distal third of the
incision. Go through the superficial and
deep fascia. The muscle can be followed Vascular Anastomosis
up to its insertion on the medial femoral • The flap is brought to the hand defect.
condyle as a thin tendon. This tendon will First, the flap is held up and the pedicle
lie between the sartorius superiorly and allowed to hang down. This step will make
the semitendinosus inferiorly. sure that there is no inadvertent twisting
• Mark every 5 cm on the muscle with a 3.0 of the vascular pedicle. The flap is then
silk suture. This step is to ensure that when placed over the defect with the correct
the muscle is transplanted, the optimal orientation and the end of the pedicle
length will be maintained and will neither should be placed over the recipient
be lengthened nor shortened. vessels. A few sutures should be applied to
• Now, divide the origin of the gracilis inset the flap.
muscle, as close to the pubic tubercle as • The recipient vessels should be divided,
possible. This may be tendinous at some blood flow checked from the divided artery
areas. The division of the origin can be and approximator clamps applied. The soft
done using cautery. clamps must be released from the donor
• Divide the tendinous insertion. vessels. Vascular anastomosis should be
• Observe the bleeding from the edges of done (The technique of vascular anastomosis
the skin paddle. Make a streak on the is beyond the scope of this manual).
surface of the skin paddle with a needle
tip and note the nature of the bleed. This
will serve as a monitoring skin flap in the Recipient Site Dissection
postoperative period. It depends on whether the gracilis is being
• Now, the muscle lies free, attached only by used to bring about (I) elbow flexion or
the vascular pedicle and the nerve. These (II) finger flexion (Table 15.62.1).
CHAPTER 62 VASCULARIZED GRACILIS MUSCLE TRANSFER 281
Table 15.62.1 Recipient site dissection of vascularized gracilis muscle transfer

Transfer I Transfer II
Aim To bring about elbow flexion and finger extension To bring about finger flexion
New origin Lateral aspect of clavicle and acromion process II, III and IV ribs
New insertion Into the finger extensors with the brachioradialis Into the finger flexors and flexor pollicis
as pulley longus (FPL) tendon
Donor vessels Thoracoacromial vessels/or transverse cervical Thoracodorsal vessels
vessels
Donor nerves Spinal accessory nerve/contralateral C7/intercos- Intercostal nerves 3–6
tal nerves 3–6
SECTION
16
Difficult Hand
Problems
The Mutilated Hand
63
Introduction Terminal Mutilation
Mutilated hands are those in which there has The basic requirements for a functioning
been a loss of composite tissues which may hand are the following:
be either skin, soft tissues, bones, tendons • Ulnar post: Consisting of a minimum of
or fingers themselves. Thus, mutilated hands two fingers.
result in disability of varying degrees. A • Radial post: Consisting of a thumb.
minimum of three structures should be lost • Thumb web: The connecting structure
before it can be called a mutilated hand. between the radial post and the ulnar post.
Mutilated hands can present in the
emergency situation or can present in the Radial Post
outpatient clinic after many attempts have Though, it quantifies that there must be at least
been made at reconstruction. When such two fingers, there are also some qualifying
patients present to surgeons, it is very essential criteria:
to do what is best for him, as the disability with • The fingers that are available must have
which the patient presents may be extreme. a critical length up to the middle of the
To simplify the method of assessing the middle phalanx (MPX) of the finger.
defect, hand mutilations can be classified as • The metacarpophalangeal (MCP) joints of
follows: the available fingers must be mobile.
• They must have sensate tips.
• The two fingers that are available can be:
Surface Mutilation • The index and middle fingers: In which
• Dorsal case the power grips of the hand may
• Palmar not be effective?
• Ulnar • The middle and ring fingers: In which
• Radial. most of the function in the hand can be
achieved?
The basic work-up of such patients is • The ring and little fingers: In which case,
threefold: not only precision grips on the hand are
• Assess what is lost. impaired, but the total power of the hand
(THE DEFECT) is also impaired, because the motors of
• How to reconstruct the defect? the little finger are not powerful enough.
(THE PLAN) • Hence, if no fingers are available and
• When to carry out the plan? reconstruction is planned, it would be
(THE TIMING) ideal to reconstruct middle and ring
fingers.
286 SECTION 16 DIFFICULT HAND PROBLEMS
Ulnar Post Absent Radial Post Absent

Surgical option and level of amputation of Surgical option, characteristics, level of
ulnar post is described in Table 16.63.1. amputation of radial post is described in
Table 16.63.2.
Radial post: This is represented by the thumb.
The thumb must be of critical length, up Thumb Web Absent
to the neck of the proximal phalanx. If this Surgical option and characteristic of thumb
length is not available, the thumb must be web is described in Table 16.63.3.
reconstructed up to this level at least.
Table 16.63.1 Surgical option and level of amputation of ulnar post

Level of amputation Surgical option
Index Middle Ring Little
– + + + Ray amputation of index finger
– – + + No surgery required:
There will be some loss of power
– – – + Augment with double toe transfer
– – – – Augment with double toe transfer—middle and ring fingers
+ – – – Augment with double toe transfer
+ + – – No surgery required:
There will be some loss of power
+ + + – Ray amputation of little finger
+ – + – Shift index finger ray to middle finger ray
– + – + Shift little finger ray to ring finger ray
Table 16.63.2 Surgical option, characteristics and level of amputation of radial post
Level of amputation Characteristic Surgical option
Amputation proximal to the • Patient not willing for toe transfer Osteoplastic reconstruction
neck of the proximal phalanx, • Not willing for microsurgery
up to the metacarpophalan- • Expertise not available for
geal joint microsurgery
Vascularized wrap around great toe
transfer
In children Vascularized second toe transfer
Amputation proximal to the Expertise not available for Pollicization and opponensplasty
metacarpophalangeal joint microsurgery
to the base of the metacarpal
bone with intact carpometa- Microsurgical expertise available Vascularized second toe transfer
carpal joint and opponensplasty
Amputation through the Expertise not available for Pollicization

carpometacarpal joint with microsurgery
destroyed joint
Microsurgical expertise available Vascularized transmetatarsal sec-
ond toe transfer
CHAPTER 63 THE MUTILATED HAND 287
Table 16.63.3 Surgical option and characteristic of thumb web

Thumb web not present Characteristic Surgical option
Contracted thumb web—moderate Release by:
• Z plasty
• Square flap
Contracted thumb web—severe Release and flap cover:
• Groin flap
• Posterior interosseous artery flap
they have nothing to act against. For

Sequence of Surgery example, when the fingers are not present,
the thumb loses its capacity to pronate. This
When all three components: (1) the radial
will lead to a functionless hand even after the
post, (2) the ulnar post and (3) the thumb web
reconstruction of the fingers, because the
are not available, reconstruction of all the
thumb is not useful. To make such thumbs
three components is prescribed as discussed
to be trained, it is advisable to attach a
above.
prosthesis to the ulnar post that the thumb
• First the ulnar post must be reconstructed. can act against.
• Next the thumb web must be reconstructed.
• Finally, the thumb must be reconstructed.
There must be a minimum period of three Functional Prosthesis
months between two procedures. These are usually prescribed for more
proximal amputations, to achieve basic
Prosthetics function.
Training Prosthesis
When the patient presents with a loss of Cosmetic Prosthesis
fingers or thumb, the remaining digits Cosmetic prosthesis can be prescribed for
usually lose their useful function because loss of tips of fingers.
Vascularized Double
Toe Transfer 64
Similarly, the lateral limit of the dorsal
Indications triangle should not cross the midpoint of
the third web space between the third and
A double toe transfer of the contralateral
fourth toes. The apex of the triangle should
second and third toes on a single pedicle
be about 1.5 cm proximal to the web space
is indicated for loss of contiguous fingers
between the second and third toes. Mark
of the hand. Typically, the stumps must be
the plantar triangle slightly smaller than
at the level of the metacarpal heads, so that
the dorsal triangle.
the metacarpophalangeal joints can be
• Mark a point “A” at the level of the distal
reconstructed.
edge of the inferior extensor retinaculum,
If the amputation of the fingers is more
halfway between the dorsalis pedis artery
proximal, i.e. at the level of mid-metacarpals,
marking and the great saphenous system
it is ideal to augment the stump with a
marking.
nonvascularized bone graft and skin flap,
• Draw a curvilinear line between the point
before the double toe transfer is done. This is
“A” and the apex of the marked triangle.
because, the double toe harvest should only be
• Similarly, from the apex of the triangle on
done at the level of the metatarsophalangeal
the plantar aspect, make a marking that
joints of the second and third toes. If the toes
extends from the apex proximally along
are cut proximally, the stability of the foot will
the second metatarsal to the midsole.
be lost.
Preparation Surgical Steps
• Palpate the dorsalis pedis artery and mark • Prepare the ipsilateral lower limb from the
the course on the opposite foot. knee distally and apply the drapings.
• Put the leg in a dependent position and • The tourniquet can be raised and the time
mark the main dorsal veins, the transverse noted.
arch and the great saphenous system. • Make the dorsal incision down to the
• Mark a dorsal triangle on the dorsum of the dermis only.
foot, encircling the second and third toes • Raise medial and lateral flaps for about 2 to
(Figs 16.64.1A and B). The medial limit of 3 cm on either side.
the base of this dorsal triangle should not • The following should be dissected now—
cross the midpoint of the first web space the great saphenous vein, other dorsal
between the great toe and the second toe. veins, fat and subcutaneous tissue.
CHAPTER 64 VASCULARIZED DOUBLE TOE TRANSFER 289
A B
Figs 16.64.1A and B Markings for the double toe transfer
• Dissect the dorsalis pedis artery up to the join with the first plantar metatarsal artery
distal part of the intermetatarsal space, to form the plantar digital artery. And this
where it will divide into two branches to plantar digital artery will divide into two:
the great toe and the second toe. the medial plantar digital artery going to
• Dissect the deep peroneal nerve which lies the lateral side of great toe and the lateral
deep to the dorsalis pedis artery. Dissect plantar digital artery going to the second
it till the divisions to the great toe and the toe. Examine this system to see which
second toe. Tease gently and separate the is dominant—the first dorsal metatarsal
fascicles to the great toe and second toe. artery and the dorsal digital arteries or the
Divide the fascicles to the second toe as first plantar metatarsal arteries and the
proximally as possible and tag with 7.0 plantar digital arteries.
polypropylene. • Now surgeons go to the plantar side
• Dissect the extensor hallucis longus ten- dissection. Make the plantar incisions.
don of both the second and third toes and The medial and lateral plantar digital
divide it at the level of the distal edge of the nerves are identified. The fascicles to the
inferior extensor retinaculum. Divide the great toe and the fascicles to the second
tendon of the extensor brevis at the level of toe teased from the second medial digital
the metatarsal base. nerve. The fascicles going to the second
• At the distal part of the dorsalis pedis artery, toe are cut as proximal as possible and
identify the deep communicating branch tagged with 7.0 polypropylenes. Similarly,
going to the plantar side. This branch will the plantar digital nerve to the second and
290 SECTION 16 DIFFICULT HAND PROBLEMS
third toes is dissected and the nerve is cut minutes. Then place the foot on the table.
as proximal as possible and tagged with 7.0 It usually takes about 15 to 20 minutes for
polypropylenes. the circulation to be re-established in the
• The flexor digitorum brevis muscle is cut at dissected toes. By the end of this time, the
the midsole level, where it joins the tendon toes become pink and warm and ready for
of the long flexor. The long flexor tendons transfer.
of the second and third toes are divided at • The vessels can be divided when the
the midsole level. recipient site dissection is over.
• The medial plantar digital artery (branch • Division of the pedicle: Soft clamps should
to the great toe) is divided. be applied over the artery and veins. The
• The transverse metatarsal ligament is proximal ends of the artery and veins
divided on the medial aspect of the should be ligated with 3.0 vicryl. The
metatarsophalangeal joint of the second vessels should be divided and the time
toe. Great care should be taken at this noted. The flap should be placed on a
level to avoid injury to the vessels at this moist abdominal pad and taken to the
level. recipient site for vascular anastomosis.
• Now, retractors should be applied to the • Management of the donor site: After
second metatarsal and retracted laterally securing hemostasis, the secondary defect
and the first metatarsal retracted medially. should be closed primarily in layers with
The arterial system is now exposed. The 3.0 vicryl for the subcutaneous tissues and
system should be carefully dissected, 4.0 ethilon for skin. Drainage tubes should
taking into account the dominance of the be placed. Sterile dressings should be
vessel system. This can be assisted by care applied and elastocrépe bandage applied
fully dividing the interosseous muscles over it. A posterior below knee plaster of
and further exposing the arterial system. Paris (POP) slab should be applied.
• Now, the second and third toes are almost
completely dissected as a single unit and
held only by the intact metatarsal bone
and the artery and veins. The capsule of the Recipient Site Dissection
second and third toe metatarsophalangeal
joints are now incised proximally, near • The hand is prepared as described in
the attachment to the metatarsal bone. Appendix I and Appendix II.
This incision should be taken on the • A curvilinear incision is made over
volar aspect and both joints disarticulated the anatomical snuff box area and the
from their respective metatarsals. Thus, a following structures are identified and
cuff of capsule and volar plate should be dissected:
harvested along with the two toes. • The radial artery and both venae
• Once the disarticulation is over, the comitantes
remaining soft tissues can be divided. This • The cephalic vein
includes the third plantar artery system, so • The superficial branch of the radial
that the double toe flap is now held only by nerve.
the arteries and veins. • One percent of xylocaine gauze is applied
• Now release the tourniquet, apply warm, over the dissected vessels.
moist pads over the double toes and the • A volar incision is made on the palm of the
vascular pedicle. Take care to prevent hand proximal to the stumps of the middle
the toe from falling down and shearing and ring fingers. Raise the medial and
the vessels. Raise the foot for about 5 lateral skin flaps, apply anchoring sutures
CHAPTER 64 VASCULARIZED DOUBLE TOE TRANSFER 291
with 3.0 ethilon and dissect the following • The structures to be passed through the
structures: tunnel are:
• The flexor digitorum profundus tendons • The arteries
of the middle and ring fingers. • The veins
• The digital nerves to the middle and • The deep peroneal nerve.
ring fingers—the ends should be tagged • Fixation: It is done by repairing the joint
with 7.0 polypropylenes. capsule of the second and third toes with
• Similarly, make an incision on the dorsum the joint capsules/soft tissues around
of the hand proximal to the stumps of the heads of the middle and ring fingers
the middle and ring fingers. Dissect the respectively. The reconstruction of the joint
following structures and keep ready: capsules is done with 4.0 polypropylenes.
• The extensor digitorum tendons of the • If the toes still appear unstable, they can
middle and ring fingers. be stabilized with short oblique K-wires
• Prepare the heads of the metacarpals without causing damage to the vessels.
of the middle and ring fingers, to • Tendon repair: The flexor longus tendons of
which double toe flap is going to be the toes are sutured to the flexor digitorum
attached. profundus tendons of the middle and ring
• Apply gentle compression with moist fingers, and the extensor longus tendons
gauze and padding over the wound. of the toes are sutured to the ends of the
Release the tourniquet. Hold the hand in extensor digitorum tendons of the middle
an elevated position for a period of 4 to 5 and ring fingers. The tension should be
minutes. Rest the hand on the table and adjusted, so that, the toes are stable and
secure hemostasis. in a functional position. The repair is done
with 3.0 polypropylenes using modified
Kessler-Mason-Allen suture technique.
• Nerve repair: The digital nerves are sutured
Fixation of the Double Toe Flap to the two plantar digital nerves of the toes
and the deep peroneal nerve is sutured to
• Bring the double toe flap to the recipient the superficial branch of the radial nerve
site. Place the toes over the stumps of at the anatomical snuff box. The nerve
the middle and ring fingers and get a repairs are done with 7.0 polypropylenes
good position, a position in which good using epineural sutures.
opposition can be achieved with the • Vascular anastomosis: The recipient vessels
fingers and is a functional position. should be divided, blood flow checked
• A subcutaneous tunnel is created between from the divided artery and approximator
the recipient site vessels and the summit clamps applied. The soft clamps must be
of the stump. This tunnel is for the vessels released from the donor vessels. Vascular
of the double toe flap to be passed through anastomosis should be done (The technique
to reach the recipient vessels—the radial of vascular anastomosis is beyond the scope
artery. of this manual).
SECTION
17
Appendices
Preparation for
Hand Surgery I
resuscitation if there is a fall in the general
Introduction condition of the patient.
• Catheterizing the urinary bladder: This is
When the patient is put on the table for
particularly important when the surgery
surgery, the position of the patient is may take a long time, or if the condition
important. For any standard hand surgical of the patient must be monitored closely.
procedure, supine position of the patient • Giving the prophylactic antibiotic: A dose
is ideal. Even if surgery is planned on both of antibiotic is given as soon as the patient
the hands, they can be performed with the is put on the table. This is followed up with
patient in the supine position. one dose after 12 hours and the next after
Before the actual surgery is performed, another 12 hours.
there are certain things to be made ready. • Checking required materials for the
• Getting the electrocautery equipment procedure: Like the silastic rods or silastic
ready: Usually, only the bipolar cautery materials which may be needed in cases
is used in hand surgical procedures. like staged tendon reconstruction, external
However, in procedures like the use of fixators and autoclaved set of plates and
pedicled latissimus dorsi muscle flap screws along with AO instruments which
and some procedures on the upper arm, may be needed in bone surgery on the
monopolar cautery may be used. Hence, hand.
these equipments must be made ready. • Getting drugs ready for use during the
• Getting the tourniquet ready: The surgical procedure: Some drugs may be
recommended tourniquet for use in hand required to be given during the course
surgery is the pneumatic tourniquet, where of the procedure. For example, during a
the calibration of the pressure used is clear. replantation procedure, a bolus dose of
The tourniquet cuff must be applied at the injection heparin may be required to be
level of the upper arm of the side that is given intravenously just before release of
going to be operated. clamps. Hence, it is important to have the
• Applying the monitors: Like the pulse required drugs ready for use.
oximeter and noninvasive blood pressure • Wearing the surgical loupe: The basic
(BP) monitors. requirements for a good hand surgery are:
• Setting up the intravenous line: Called • Good lighting
traditionally the “life-line”, this IV line will • Good anesthesia
serve as a portal for drug delivery and for • Good tourniquet
296 SECTION 17 APPENDICES
• Good magnification
• Good technique. Preparation and Draping
of the Hand
Hence, it is important for the surgeon and
• The upper limb is prepared from the elbow
the surgical assistant to wear surgical loupes.
downward in any hand procedure.
Magnification makes identifying structures
• Draping: Two towels on the hand table, one
easier, avoids excessive force on delicate
towel to cover the arm with the tourniquet,
tissues and ultimately benefits the patient.
and one sheet to cover the patient.
Preparation for a Free Flap
II
the patient. Sometimes, movement videos
Preparation Before the may be required, which may not be possible
Patient is Brought to the if the patient has been anesthetized.
Operation Theater Only after the above conditions have been
fulfilled, the patient may be put on the
Before the patient is brought to the operation operating table. Once the patient is on the
theater, the following should already have table, he is under the care of an anesthesio
been done. These should not be done on the logist, who should be given freedom of space
table or after anesthesia has been given. and time to decide on the anesthesia.
• Doppler: A Doppler study to analyze the
vascular pattern in the patient and an
appropriate plan must be ready.
Preparation While Anesthesia is
• Markings: When the Doppler study has
been done, the appropriate markings for Being Delivered
the flap should be made preoperatively
and the plan explained to the patient While anesthesia is being delivered, the
immediately. Any alternate plan if made following should be arranged:
should also be informed to the patient and • Microsurgery chart: This is a form that
consent obtained for the same. records the main events of the microsurgical
• Lint: Once the marking for the flap has procedure. A sample of this form is shown
been made, a lint pattern must be cut, in the section on proformas. It is the duty
given to the operating room personnel for of the surgeon to allocate the duty of filling
autoclaving and to be kept ready for use out this form to a responsible person.
during surgery. • Instruments: The microinstruments that
• Measurements: The accurate measure are required, any special instruments that
ments must be made before the patient may be required, should be arranged on a
is wheeled into the operating room. For tray.
example, the length of the second toe
required for a toe transfer must be made
preoperatively, with the help of relevant Preparation After the
X-rays of the foot, the opposite hand for an Anesthesia has been
X-ray of the normal thumb, etc. Delivered
• Photographs: Clinical photographs are
a must. But, they must be taken pre • Positioning of patient: Once the anesthesia
operatively, with appropriate positioning of has been given, the patient can be put
into position for surgery. This may be done now, after the position of the patient
determined by the procedure that is being has been determined.
done, or the number of teams that are • Bladder catheterization: The next step to
going to operate. be done is catheterization of the bladder.
• Tourniquets to be applied: Tourniquets This step is very important for monitoring
should be applied at the appropriate parts. of the patient, especially in this surgery
• Setting up of the various equipment: Before which may be prolonged. When this has
the surgeon can go to wash up, the following been done, the surgeon can wash up.
equipment must be positioned in such a • Preparation and draping: Now, the pre
way that it is convenient for the surgeon, paration and draping of the patient can be
convenient for monitoring of the patient done. Only after the draping, the following
by the anesthetist, convenient for the staff can be procured and placed in the surgical
nurses and the paramedical personnel to field.
carry out their duties. • Bipolar cautery leads and wires
• Microscope • Unipolar cautery leads and wires
• Bipolar and unipolar cautery machine • Start of surgery: Now the surgery can be
• Patient vitals monitoring machine started. Apart from all the above, one more
• Tourniquet machines thing is very important, especially when
• Compressed air sources a microsurgery procedure is being done.
• Video monitor from the microscope. This is decorum in the theater.
• Earthpad for cautery: Appropriate place
ment of the earthpad for cautery should be
Preparing Instrument Sets
for Use in Hand Surgery III
• Mosquito-straight artery forceps—two pairs
Preparing Instrument Sets • one pair—skin hooks
• one pair—cats paw retractors
Following are the preparing instrument sets
• One needle holder—7”
for use in hand surgery:
• One sponge holding forceps
• Axillary block pack • One kidney tray
• Basic set • One stainless steel cup
• Tendon set • One towel clip
• Bone set • One blood pressure (BP) handle
Axillary Block Set

It consists of the following:
Bone Set
• One sheet Bone set consists of the following:
• One kidney tray • Bone nibbler
• 20 ml glass syringe • Bone cutter
• 1 IV needle (20 g) • Autoclavable hand drill with chuck
• 2 IM needles (24 g) • K-wires set
• One sponge holder • Wire cutter
• One stainless steel cup • Periosteal elevator
• One towel • Gigli saw
• Chisel
Basic Set • Osteotome
• Mallet
It consists of the following: • Self-retaining retractor
• Two sheets
• Two towels
• Two aprons Skin Graft Set
• 5 ml syringe Skin graft set consists of the following:
• 1 IV needle (20 g) • One sheet
• 1 IM needle (24 g) • One stainless steel tray
• 6" fine dissecting scissors—one pair • Two Gamgee pads (size 15 cm × 10 cm)
• Toothed forceps—one pair • 10 bandage rolls
• Nontoothed forceps—one pair • Skin graft handle
• Mosquito-curved artery forceps—two pairs • Two wooden retractors (wooden plates).
• Fine dissecting scissors—curved

Microsurgery • Micro scissors—straight
Instruments Tray • Micro scissors—curved
• Micro forceps—two pairs
This is used only for microsurgical procedures • Micro-needle holder
and hence requires careful handling and • Vessel dilator
storage. This tray should not be autoclaved • Soft clamps—four numbers.
and is sterilized by formalin tablets. It contains • Approximator clamps—two numbers
the following instruments. • Background material
• Fine dissecting scissors—straight • Metal scale.
Harvesting a Sural
Nerve Graft IV
The sural nerve graft is quite commonly used • Draw the line AB. This marks the course
in hand surgery in the following situations: of the sural nerve.
• In brachial plexus injuries where nerve • The surgery can be done under local
gaps have to be reconstructed. anesthetic infiltration.
• Conditions where loss of nerve occurs • The incision is made over the point “A” and
following trauma or tumors. extended proximally for about 5 cm along
the marked line AB, through the skin and
Surgical Steps subcutaneous tissues.
• First prepare and drape the entire leg • The skin edges are retracted and the sural
and foot from which the nerve is to be nerve is dissected. It runs alongside the
harvested. lesser saphenous vein and this vein should
• Mark the course of the nerve: not be mistaken for the nerve.
• Mark the lateral malleolus and the • A skin hook is applied on the nerve and
lateral border of the tendo-achilles lifted up. Gentle traction is applied to
at the level of the lateral malleolus. make the nerve taut. The proximal course
Mark the midpoint “A” of the distance of the taut nerve can be palpated under
between the lateral malleolus and the the skin along the marked line AB. The skin
lateral border of the tendo-achilles. incision is extended further proximally for
• Now consider the calf region of the leg another 5 cm and the nerve is dissected.
and note the level of maximum convexity • This step is repeatedly done with the
of this region. Mark the midpoint “B” of help of retraction of the skin hook, till the
the maximal convexity on the calf region point “B”, with where the nerve may be
(Fig. 17.IV.1). embedded in the superficial layers of the
gastrocnemius muscle.
• Once the dissection of the nerve is com
plete, an identification stitch is made
with 7.0 polypropylenes on the end of the
nerve at the calf region. This is because the
nerve should be reversed when it is used
as a graft and the identification stitch will
identify the distal end.
• Both ends of the dissected nerve are divided
with no. 11 blade to ensure a clean cut.
• The harvested nerve graft is stored in cup
Fig. 17.IV.1 Markings for harvesting a sural nerve graft of normal saline till it is used.
Harvesting a Skin Graft
V
A skin graft is required in many of the The first type is described in the section on
reconstructive procedures in hand surgery. cross finger flap. The method of harvesting
It is therefore essential that the hand surgeon a skin graft from the thigh will be discussed
be adept in taking skin grafts of varying here.
thickness according to the situation.
The materials required for harvesting a
skin graft can be prepared in the form of a
Surgical Steps
packed set that can be used when required. • This surgery requires an anesthesia of the
The preparation of this skin graft set has been lower limbs and this must be informed
outlined in the Appendix on preparation of to the anesthetist at the beginning of the
sets for surgery. procedure on the hand.
The requirement of skin graft is of two • Ask a theater assistant to hold up the
categories in hand surgery: opposite side leg and prepare the thigh
• The first type is the small graft required for with antiseptic solution from the inguinal
a part of a single finger alone. An example region to just below the knee.
would be the donor site of a cross finger • Apply two sterile sheets on the table,
flap. This small skin graft can be harvested covering also the unprepared lower limb.
from the medial side of the upper arm. Now place a sterile towel lengthwise on the
The advantage of harvesting a small graft sterile sheets and receive the unprepared
in this site is that it is done in the same leg. Drape this part securely and apply a
field of anesthesia (axillary block), it is not sterile bandage to secure it. Then a sterile
cosmetically disfiguring as it is hidden and sheet can be placed over the abdomen.
it does not require many dressings in the • Paint the thigh again with antiseptic
form of Gamgee pads and bandages as solution.
would be required for a dressing on the • Apply a disposable skin graft blade in the
thigh. graft handle and adjust the thickness.
• The second type is the requirement of a • Harvest a graft from the thigh, preferring
large sheet or sheets of skin graft to cover the medial side, for cosmetic reasons.
extensive raw areas on the forearms or • Place the skin graft in normal saline
hand, or to cover the donor site of a large solution. Apply a moist abdominal pad
flap like the radial artery forearm flap or over the area where the skin graft has been
posterior interosseous flap. This will have taken and apply gentle pressure. Wait for
to be harvested from the thigh/thighs. 2 minutes and then gently remove the
APPENDIX V HARVESTING A SKIN GRAFT 303
pad. Apply paraffin gauze over the site in a the circumference of the thigh and roll
single layer to cover the entire area. sterile bandages over the entire thigh. The
• Place gauze pieces that have been soaked bandaging should be secure and should
in betadine solution over the paraffin apply gentle compression. This can be
gauze, to again cover the entire area. Apply enhanced by applying a crepe bandage over
Gamgee pads over the betadine gauze and the dressing.
Harvesting an
Ulnar Bone Graft VI
Surgical Steps bone required is the length of the thumb
• The upper limb is prepared up to above the with 1 cm extra. The width should be 2 cm.
elbow. • Perform the osteotomy to raise the cortico
• A gentle “S”-shaped incision is marked cancellous bone graft. If the bone graft is
over the subcutaneous border of the ulna going to be pegged into a single bone, the
just distal to the olecranon. This incision graft should be sculpted into the shape of
should be about 8 cm long. The incision a “cricket bat”, to enable the “handle” end
is made deeply, down to the bone (Fig. to be pegged into the head of the bone. If
17.VI.1). the bone graft is to be inserted between
• The incision is made on the periosteum two ends of bone, as is done when doing
and the periosteum elevated on both sides a surgery for nonunion, the bone graft
to expose the ulna for a width of about 3 should be sculpted in the form of a “ladle”
cm. or a “roti belan”, with a “handle” on either
• The required dimensions of the bone are end (Figs 17.VI.2A and B).
now marked on the ulna. The length of the • Place the bone graft in normal saline.
• Close the donor site of the bone graft in
layers with 3.0 vicryl for the subcutaneous
tissues and 4.0 ethilon for skin. Drainage
tubes should be placed. Sterile dressings
should be applied.
Fig. 17.VI.1 Markings for harvesting an ulnar bone graft Figs 17.VI.2A and B Sculpted shapes of the ulnar bone graft
Harvesting a Palmaris
Longus Tendon Graft VII
The palmaris longus (PL) is first tested
preoperatively by asking the patient to touch
the tips of the thumb and little finger and then
flexing the wrist. This will make two tendons
prominent on the central half of the flexor
aspect of the forearm near the wrist, if the PL
is present. The other tendon that becomes
prominent is the flexor carpi radialis tendon.
However, if the PL is absent, only the flexor
carpi radialis tendon will become prominent.
Surgical Steps
• The hand and forearm are prepared as
• The first incision is about 2.0 cm, made at
the level of the volar wrist crease over the
palpated PL tendon.
• The tendon is dissected at this level by
freeing it from the numerous fibrous
strands that connect it to the overlying
skin and the surrounding structures. Once
it is totally dissected, it is divided and a Fig. 17.VII.1 Markings for harvesting a PL tendon graft
hemostat applied on the cut end.
• Another incision about 2.0 cm is made
about 6 to 7 cm more proximally on the • Again another incision is made proximal
forearm after applying traction on the cut to the above incision and the PL tendon
end of the tendon and palpating the taut is divided close to the musculotendinous
tendon under the skin (Fig. 17.VII.1). junction.
• The PL is retrieved through this wound, • The tendon is placed in a cup of normal
and the hemostat reapplied at the cut end. saline till its use.
Harvesting a
Fascia Lata Graft VIII
When tendon grafts are required for flexor
tendon reconstruction of more than one
finger or extensor tendon reconstruction of
more than two fingers, the PL tendon graft
will not be enough. Hence, a larger tendon
graft is required. The alternate source of a
tendon graft is the fascia lata graft.
Surgical Steps
• This procedure can be done under local Fig. 17.VIII.1 Markings for harvesting a fascia lata graft
anesthetic infiltration or infiltration of
tumescent solution.
• The thigh is prepared from the level of the the fascia lata will be exposed as a shiny
inguinal ligament to the knee. white layer and will feel thick.
• Markings: The thigh is flexed and adducted • The anterior and posterior skin flaps are
to expose the lateral surface. This position raised superficial to the fascia lata for
will make the fascia lata taut. It extends about 4 cm in either direction, to expose
from the anterior superior iliac spine to the fascia lata for harvest.
the knee. The width of the fascia is about 10 • The fascia lata is now ready for harvest.
cm and the anterior limit is the imaginary Usually, a width of about 4 cm and a length
line drawn from the anterior superior iliac according to requirement is harvested.
spine to the lateral femoral condyle. The required dimensions of the fascia lata
• A longitudinal incision AB is marked is marked and incised all around with no.
about 4 cm posterior to the marking of 15 blade. The harvested graft is placed in
the anterior limit of the fascia lata. The normal saline solution.
length of this incision should be about 4 • If it is possible, the defect in the fascia
cm longer than the requirement of tendon lata is repaired with 3.0 polypropylene
graft. The proximal limit of the incision continuous sutures. If it is not possible,
is 10 cm from the anterior superior iliac the defect is left as such and the wound is
spine (Fig. 17.VIII.1). closed in layers: subcutaneous tissues with
• The marked incision line is infiltrated with 3.0 vicryl, and skin with 3.0 polypropylenes
tumescent solution to provide analgesia. subcuticular sutures.
• The incision is made through the skin and • Sterile dressings and elastocrepe compres
subcutaneous tissues. When this is done, sion bandage is applied.
SECTION
18
Proformas
Microsurgery
Recording Chart I
Name: Date:
Age: Sex: P. S. Number:
Diagnosis:
Procedure:
Step Time of starting Time of completing
Anesthesia:
Team:
Recipient site:
Team:
Donor site:
Team:
Time of division of pedicle
Vein 1: Vessels anastomosed:
Team:
Suture material used:
Artery: Vessels anastomosed:
Team:
Vein 2: Vessels anastomosed:
Team:
Other: Vessels anastomosed:
Team:
Other: Vessels anastomosed:
Team:
Time of release of clamps
Warm ischemia time
Brachial Plexus
Injury Evaluation II
P.S. Number: Date:
Name: Age/Sex:
Side involved:
Date of accident:
Duration since injury:
Mode of injury: Road traffic accidents (RTA)/Industrial/Fall from height/Birth
Nature of injury: Low energy/High energy
Mechanism of injury: Neck shoulder separation/arm shoulder separation
History of pain: Continuous/occasional/No pain
Other injuries: Head/spine/clavicle/lower limb
Shift of head away from injured side: Yes/No
Horner’s syndrome: Yes/No
Dislocation of shoulder: Yes/No
Swelling in supraclavicular region: Yes/No
Tinel’s sign at supraclavicular region: Yes/No
Peripheral pulses:
Muscles/groups tested Muscle power grading

(M0–M5)
Trapezius
Rhomboids
Serratus anterior
Shoulder abduction
Shoulder adduction
Shoulder flexion
Shoulder extension
Shoulder external rotation
Shoulder internal rotation
Elbow flexion
Elbow extension
PROFORMA II BRACHIAL PLEXUS INJURY EVALUATION 311
Investigation reports and findings:

X-ray cervical spine:
X-ray chest—in inspiration and in expiration:
X-ray shoulder:
Computed tomography (CT) myelography:
Magnetic resonance imaging (MRI) scan:
Electromyography (EMG) studies:
Probable level of lesion:
Probable site of lesion:
Probable nature of lesion:
Plan:
Contracture of Upper Limb
III
Proforma for Assessment of Contracture on Upper Limb
P.S. Number: Date:

Name: Age/Sex:
Side involved:
Part involved:
Associated contractures:
Longitudinal extent of the contracture:
Quality of the skin over the contracted segment:
If scar is present, nature of scar:
Presence of ulcers, sinuses on the contracted segment:
Attitude of the upper limb/hand:
Position of the joints:
Metacarpophalangeal Proximal interphalangeal Distal interphalangeal

(MCP) joint (PIP) joint (DIP) joint
Index finger
Middle finger
Ring finger
Little finger
Thumb
Position
Wrist
Elbow
Axilla
PROFORMA III CONTRACTURE OF UPPER LIMB 313
Range of motion at the joints:

MCP joint PIP joint DIP joint
Active Passive Active Passive Active Passive
Index finger
Middle finger
Ring finger
Little finger
Thumb
Flexion Extension
Wrist
Elbow
Axilla
Involvement of finger web spaces:

Involvement of nail complexes:
Involvement of thumb web:
Size of apparent defect:
Size of true defect:
Plan:
Dupuytren’s
Contracture Evaluation IV
Evaluated by:
P.S. Number: Date:
Name: Age/Sex:
Side involved:
Date of accident:
Cause of injury:
History of: Diabetes mellitus/alcohol intake/epilepsy
Family history: Yes/No
Symptoms: Tightness in the palm/Nodules/Contracture of the fingers/Maceration of skin
Nodules: Number and site
Palpable cords:
Extent:
Position of the joints:
Contracture on MCP joint (a) PIP joint (b) DIP joint (c) Total (a + b + c) Stage
the fingers
Index finger
Middle finger
Ring finger
Little finger
Thumb
Plan:
Contracture Evaluation V
Evaluated by:
P.S. Number: Date:
Name: Age/Sex:
Side involved:
Date of accident:
Nature of injury:
Criteria to assess Type I Type II Type III

Skin Supple Scarred Contracture
Intrinsic muscles Normal Palsy Contracture
Peripheral pulses Present +/– +/–
Position of wrist Normal Flexion Flexion contracture
Position of forearm Normal Fixed in pronation Fixed in pronation
Position of thumb Normal Simian thumb Adduction contracture
Position of fingers Flexion Claw Intrinsic plus
Sensation Normal Loss of sensation Loss
Finger flexion Volkmann’s sign Weak flexion Contracture
Fingers affected Not all fingers All the fingers All the fingers
Joints Supple Stiff Stiff
flexion of fingers
flexion of thumb
Extension of fingers Present +/– +/–
Plan:
Sequence of plan:
Bone Problem Evaluation
VI
Evaluated by:
P.S. Number: Date:
Name: Age/Sex:
Side involved:
Date of accident:
Cause of injury:
Position of the joints of the fingers: Position of the joints of the thumb:
MCP joint PIP joint DIP joint CMC joint MCP joint IP joint
Index finger
Middle finger
Ring finger
Little finger
Range of movements of the joints:

Index finger
Middle finger
Ring finger
Little finger
IP joint
Active Passive
Thumb
PROFORMA VI BONE PROBLEM EVALUATION 317
X-ray findings:
Malunion:
Nonunion:
Infection:
Sinus/scar:
Level of deformity:
Associated injuries:
Joint Problem Evaluation
VII
Evaluated by:
P.S. Number: Date:
Name: Age/Sex:
Side involved:
Date of accident:
Cause of injury:
Local symptoms: Pain/Swelling
Constitutional symptoms: Fever/malaise:
Position of the joints of the fingers:

Index finger
Middle finger
Ring finger
Little finger
Position of the joints of the thumb:

Carpometacarpal MCP joint Interphalangeal
(CMC) joint (IP) joint
Range of movements of the joints:

PROFORMA VII JOINT PROBLEM EVALUATION 319

Index finger
Middle finger
Ring finger
Little finger
IP joint
Active Passive
Thumb
X-ray findings:
Nature of articular surfaces:
Congruity of articular spaces:
Joint space:
Status of bones proximal and distal to the joint:
Plan:
Tendon Injury Evaluation
VIII
Evaluated by:
P.S. Number: Date:
Name: Age/Sex:
Side involved:
Date of accident:
Duration since injury: Less than 10 days/10 days–3 months/3 months–1 year/greater than
1 year
Nature of injury: Blunt/penetrating/assault/industrial/avulsion
Nature of scar: Soft and supple/indurated/hypertrophic/contracture
Fingers involved:
Tendons involved:
Sensation on the tips of fingers:
Associated fractures: No/united well/malunion/nonunion
Range of motion in the joints:

Index finger
Middle finger
Ring finger
Little finger
Thumb
Plan:
Physiotherapy evaluation:
Index
Page numbers followed by f refer to figure and t refer to table, respectively.
A Anterolateral thigh flap, injury evaluation 310

Abdominal markings for 42f Brachialis muscle 256f
pocket created for burying Anxious patients 11 Branch to
degloved hand 37f Appearance of hand 174 great toe 114
wall 36 Arthrolysis 108 second toe 152
Abductor of metacarpophalangeal Brand’s procedure 173
digiti minimi 181, 182 joint of finger 110 Buried abdominal flap 36
pollicis brevis 223 of proximal interphalangeal introduction 36
Abnormal mobility bone joint of finger 108
reconstruction 90 Associated C
Acrosyndactyly 202 bone fracture
with loss 10 Calf region of leg 122
Adherent scars and contractures Carpometacarpal joint 133
49 without loss 10
neck contracture 229 Cause
Adult brachial plexus injuries dryness of mouth 24
239 nerve injury or loss 11
tendon injury or loss 10 of contracture 230
assessment 241 Cephalic vein 42, 157
clinical examination of 242t Attaching FDP tendon to bone
59f Characteristics to help and
exploration 247 differentiate between
investigations of 245t Attitude of hand 173
Atypical cleft 206 typical cleft and
muscle transfer 259 atypical cleft 206t
nerve surgery 253 Axilla 228
Axillary Checking reach 15f
of exploration and nerve
block anesthesia 41, 57 of flap 30f
surgery 264
or supraclavicular block 163 Chronic metacarpophalangeal
Advancement of flap and final
joint dislocation
suture line 141f
Advantages B reduction 105
Clavicular fibers of pectoralis
Littler island flap 12 Biceps muscle 256f
major muscle 249f
posterior interosseous flap Bilateral upper limb contracture
Claw correction
27 229
extensor to flexor 4-tailed
radial artery forearm flap 32 Bone 127, 128, 129
of flap 18, 23 assessment 4 tendon transfer
After final flap inset 146f fixation 116, 157 procedure 187
and donor site closure with grafting 94 Fowler procedure 191
skin graft 16f injury 54 Lasso procedure 184
After flap inset 21f problem evaluation 316 Cleft hand 206
and management of donor reconstruction 87 assessment 206
site 26f introduction 89 Cleland’s ligaments 14, 146
After tendon suturing 276f assessment 89 Coapting vascularized ulnar
Amount of skin on great toe to surgery 230, 244 nerve to donor
be harvested flap 151f Brachial plexus fascicles 258f
Anterior scalene muscle 249 injuries 4 Color of scar 49
322 MANUAL OF RECONSTRUCTIVE HAND SURGERY
Common Dissection of vascular pedicle scar 49

dorsal digital artery 152f 280f Exploration on forearm 270f
plantar digital artery 152f Distal Exploratory incision, markings
Completed tendon transfer 82f communicating artery 152f for 248f
Complex post-traumatic deficit 10 Exposure of flexor tendons for
problems 4, 125, 127 interphalangeal 13, 37 tenolysis 75f
Concomitant injury 54 joints 58, 63, 188, 138 Exposures for fracture fixation
Congenital disorders— joint crease 62, 68, 192, in hand and fingers
assessment 201 204 92f
Contracture tendon Extension
bands 50 anastomoses 64, 79 of fingers 177
of upper limb 312 dissection 62, 68 thumb 177
on two sites of same upper Divided Extensor carpi radialis
limb 229 omohyoid muscle 249f brevis 195
on upper limb pectoralis minor muscle tendon 188
assessment 227 249f longus 195
management 231 Dividing radial and ulnar lateral tendon 188
Cosmetic bands 221f Extensor digiti minimi 55
problems 50 Division of pedicle 44, 99, 115, tendon 192, 197
prosthesis 287 153, 280 Extensor digitorum
Crane principle 36 Donor site with skin graft 39f communis 33, 55, 197
Cricket bat 154 Dorsal 222 tendon 221
digital arteries 114 tendon attached to base
D flaps 221 of PPX to act as APL
interosseous tendon 20 tendon 223f
Defect and markings for flap side of reconstructed hand longus 99f
140f 38f Extensor hallucis longus 99f
Deformity bone reconstruction transposition flap 142 tendon 156
89 markings for 143f Extensor indicis proprius 55,
Degenerative conditions 165 Dorsalis pedis artery 113, 152, 197
Delay of flap 38f 156 tendon 81, 192
Deltoid muscle 249f Dorsum 228 to extensor pollicis longus
Diabetes mellitus 167 Double toe transfer 289f tendon transfer 80
Difficult hand problems 283 vascularized 288 Extensor pollicis longus 53,
Digital Dupuytren’s contracture 167, 55, 81
arteries 42 168 tendon 195
nerves 145, 157 assessment 167 Extensor tendon reconstruction
in fingers 120 evaluation 314 77
in palm 120 management 169
neurovascular bundle 75 Dupuytren’s disease 167
Disadvantages F
Duration of injury 53
Littler island flap 12 Fascicle from
posterior interosseous flap median nerve 256f
27 E ulnar nerve 256f
radial artery forearm flap 32 Edematous skin 50 Fibula transfer, vascularized 97
of flap 18, 23 Elbow 228 Final suturing 208f
Dislocation of recovery 263 of skin flaps 223f
metacarpophalangeal of muscle power grading First dorsal
joint of fingers 105 263t interosseous 223f
Dissected flap 15f Epilepsy 167 muscle 20, 222
Dissecting contralateral brachial Epineurial repair 122f metacarpal artery 152f
plexus and identifying Examination of flap 18
C7 root 257 hand 3 metatarsal artery 114
INDEX 323
First plantar metatarsal artery complications of anesthetic Hypoplastic thumb

152f 80 assessment 219
Five flap method Good source of nerve to transfer pollicization 219
markings for 237f 251
of thumb web release 236 Gracilis muscle transfer, I
Fixation of toe vascularized 278
flap 154, 157 Grades of hypoplasia thumb Incision
metatarsophalangeal joint 219f for extensor reconstruction
flap 116 Grading of involvement of 78f
Fixation with k-wire 230 nerves 271f for harvest of latissimus dorsi
Fixing tendon graft 64 Grafted skin with coconut oil muscle 259f
Flap 112 in case of flap reconstruction
after elevation 25f Grayson’s ligaments 14, 146 78f
being raised 20f Great saphenous system 113 markings for 62f, 77f, 83f,
inset 16, 21 Grouping together of intercostal 254f
markings for 13f, 19, 19f, 24f, nerves 255f stage 68f, 71f
33f, 98, 207f on arm, markings for 255f
thinning 44 Index finger 159
H Indications posterior
Flexor carpi ulnaris 76, 109, 271
tendon 106 Hand interosseous flap 27
Flexor digitorum motorization 97 Indurated skin 50
communis 33 surgery 3 Infection 171
longus 99f Hansen’s disease and sequelae Injury
profundus 54, 61, 69, 109, 173 bone reconstruction, nature
121 Harvest of of 89
superficialis 55, 61, 69, 84, gracilis muscle, markings for to nerve 120
109, 121, 173, 271 279f Intercostal nerve transfer 254
to flexor pollicis longus vascularized ulnar nerve Interphalangeal joints 16, 72,
tendon transfer 83 257f 92, 105, 133, 193, 214,
Flexor Harvested 236
hallucis longus 99f FDS tendon ready for Involvement of
muscles 120 transfer 84f bones 202
pollicis longus 53, 83, 213 second toe MTP joint, ready different tissues 129t
tendon 223 for transfer 115f
wrap-around great toe flap
tendon J
and interossei 222 153f
Harvesting fascia lata graft 64, Joint 127-129, 269
grafting 61
306 of finger 113
tenolysis 74
markings for 306f problem evaluation 318
Fourth dorsal metacarpal artery
Harvesting reconstruction 101
flap 24
FDS graft 63 assessment 103
Fowler’s procedure 173
tendon from ring finger introduction 103
Free anterolateral thigh flap,
186f repair 157
vascularized 41
palmaris longus tendon graft supple and to strengthen
Freedom from pain 134
64, 305 muscles 54
Front of chest 97
skin graft 302 surgery 230
Full crane technique 36, 39
Functional prosthesis 287 sural nerve graft 301
tendon graft 63 K
ulnar bone graft 153, 304
G vascularized ulnar nerve 257 Kessler mason technique 59
Ganglion excision 163 History bone reconstruction 89 Knuckle
General Huber’s transfer 181 of index finger 19
anesthesia 19, 57, 105 Hydrodissection 231 prominences 24
L Marking flaps 234 Motor examination of adult

Marking for brachial plexus
Ladle 95
dissection of pedicle 151f injuries 243t
Lateral
incisions for harvesting Multiple fingers 10t
advancement flaps
ECRL tendon 276f Muscle 20
markings for 139f
Marking incisions 182f power grading 262
of Kütler 138
for fasciectomy 169f release surgery 230
circumflex femoral artery 43
Marking of slide operation 273
cord 252
incisions 185f, 188f, 210f surgery 244
Latissimus dorsi muscle 259
for different components Musculocutaneous nerve 252,
Length of scar 49
of procedure 265f 256f
Lesion, nature of 241
to explant buried hand Mutilated hand 285
Level of
amputation 136, 136t 39f
anatomical snuffbox 18 Markings on N
interphalangeal joint 18 arm 261f Nature of problem 127
lesion 241 dorsum of finger 13f Neck 97, 228
Linear scar with no tissue MCP joint capsule 183, 222 Nerves 4, 127, 129
problem 50 Medial graft anastomosis 122
Littler’s plantar digital artery 114 grafting 122, 251
island flap 12 skin edge 44 injury 54, 120
neurovascular island flap Median nerve 119, 120, 174, reconstruction
150 252, 256f assessment 119
Local anesthesia or spinal of Hansen’s disease and management 120
anesthesia 36 sequelae 176t repair 120, 154, 157
Location of sinus 90 Mentally unsound patients 11 primary 251
Loss of thumb or Metacarpal bone 222 surgery 269
circumferential loss on Metacarpophalangeal 79, 81 suturing to C7 root 257
fingers 10t joint 16, 20, 26, 35, 60, 92, 95, to biceps 256f
Lower limbs 228 133, 148, 173, 186, 192, to brachialis 256f
195, 203, 213, 220, 234 transfer 251
M of fingers 66 Neurolysis 250
Metatarsophalangeal joint 104, Neurovascular
Maceration of skin 167
114, 151, 156 bundles 205, 213
Macrodactyly 215
Method of pedicle 221
Macrodactyly, assessment 215
Barsky 206 Nodules 167
Mallet’s classification 263, 263t
Management of donor correcting deviation with
area 16, 21, 25 osteotomy 217f O
site 35f, 44, 99, 153, 280 distal tendon repair of equal Oberlin transfer 254
Management size 64f Oblique
of Dupuytren’s contracture Littler 209 amputation type 141, 142
assessment 168t tendon repair tendon graft triangular flap 141
protocol 50, 50t, 246 65f Obstetric brachial plexus palsy
after exploration 252 Methods for reduction of length assessment 262
in Volkmann’s ischemic of finger 217f management 264
contracture 268t Microsurgery recording chart Open reduction internal fixation
of adult brachial plexus 309 of fractures 91
injuries—exploration Middle Opponensplasty
252t finger 180 using flexor digitorum
of cleft hand 207t phalanx 91 superficialis of ring
of macrodactyly 215t Mod quad procedure 264 finger, markings for
Mark incisions 192f, 195 Moist saline gauze 85 179f
INDEX 325
with abductor digiti minimi Preparing instrument sets for post 285
muscle 181 use in hand surgery absent 286
with flexor digitorum 299 ulnar oblique amputation
superficialis of ring Presurgical counseling 18, 41, 136
finger 178 191 Railroading tendon graft 71
Previous management bone Raising flap, markings for 98f
P reconstruction, nature Range of motion joints 90
of 89 Raw
Palm 227 Principle of area and surgical plan,
Palmar flap movement in five flap assessment of 10t
aponeurosis 58 method 237f areas on skin 4
interosseous muscle 223f square flap method 235f Reach of harvested ADM
Palmar side 220 Priority of contracture release muscle 182f
Palmaris longus tendon graft 79 230 Recipient
Palpable cords 167 Problems of skin 4 nerve surgery 257
Partial crane technique 36, 38 Procedures for reconstruction of vessel 42
Pedicled latissimus muscle type amputations 138, Reduction of tip of finger 216f
transfer for elbow 144, 148, 155, 159 Regional block anesthesia 38
flexion 259 Proper dorsal digital artery to Relevant
Perforators entering skin flap great toe 152f anatomy on brachial plexus
98f II toe 152f exploration 249f
Peroneus Prosthetics 287 vascular anatomy of great toe
brevis 99f Protocols for resurfacing after 152f
longus 99f contracture release on Removal of pop slab 82
Piece of saline gauze 163 upper limb 229t, 230 Repair of avulsed flexor tendon
Plan of Proximal 57
nerve transfer 256f Border Replacement of joint 113
skin cover 9 dermal flaps 20 Retrieving proximal retracted
Plantar digital arteries 152 of flap 14 flexor digitorum
Plaster of Paris 12, 18, 77, 220 end of nerve graft 122 profundus tendon 59f
Plicated EIP tendon 223f interphalangeal 16, 23, 95 Reverse dorsal metacarpal
Pollicization on dorsal and joint 19, 27, 103, 109, 114, artery flap 23
palmar aspects, 178, 184, 188, 203, 220 Role of physiotherapy joint
markings for 220f phalanx 181 reconstruction 104
Polyethylene tube 59, 69 tendon Rotation at deformity 89
Position of joint 103 anastomosis 65, 72 Roti belan 95
Positioned silastic implant in dissection 63 Roximal phalanx 91
flexor sheath 70f Pulley reconstruction 65
Positioning new Pulp region 58, 62, 68
carpometacarpal joint S
Pulvertaft technique of tendon
of thumb 222f suturing 66f Scalene muscles 249
Posterior interosseous Scalenus anterior muscle 249f
artery flap 27 Scalp vein set 164
flap, introduction 27 R Seating patient 3
Postoperative protocol 22 Radial artery 42 Second toe
after flap stage 38, 40 forearm flap 32 harvest, markings for 155f
for stage 70, 73 forearm flap, introduction transfer, vascularized 155
Preparation 32 Sedation optimization strategy
for free flap 297 Radial 236
for hand surgery 295 club hand 181 Segmüller
of recipient area on arm 260 nerve 119, 177 drains 59, 66, 164
on hand 41 of Hansen’s disease and tube 21, 25, 35
on thigh 42 sequelae 177t Sensory examination 244f
Sequence of surgery 287 Superficial with skin and tissues 18

Sex 134 radial nerve 20 Tibialis
Shape of scar 49 to palmar aponeurosis 68 anterior 99f
Shortening of hand/fingers 90 Superolateral border of patella posterior 99f
Shoulder 97 42 Toe metatarsophalangeal joint
recovery 263 Supraclavicular dissection 248 transfer, vascularized
of muscle power grading Suprascapular nerve 252 113
263t Sural nerve 251 Transverse and volar oblique
Simple closure of cleft 206 Surgical option and amputations 138
Single finger 10t characteristic of thumb web Trapezius muscle 249f, 253
Sinus 90 287t Traumatic brachial plexus
Site of level of amputation of ulnar injuries 4
deformity 89 post 286t Trigger thumb release 213
distal osteotomy 222 Surgical procedure of Tubed groin flap 148
proximal osteotomy 222 component 150 Tumescent infiltration 266
scar 49 Suture line after explantation of Type of
Skeletal problems 267 buried hand 40 hand 173
Skin 54, 129 Suturing of lesions of different structures
flap 92 skin flaps 211f in hand 268t
graft 40 tendons after adjusting syndactyly 202
hooks 142 tension 186f Typical cleft 206
loss on Syndactyly 202, 203
hand, assessment of 9 assessment 202 U
palm 10t release, markings for 204f
Ulnar
or scar, nature of 50t artery 42
pits 167 T bone graft application 150
Spinal Technique of nerve 49, 119, 120, 174, 256f
accessory nerve transfer 253 FDS to FDP transfer 274f of Hansen’s disease and
anesthesia 41 tendon lengthening 272f sequelae 174t
Stage of vascular anastomosis 116 post absent 286
final flap inset 150 Tendons 4, 127, 129, 269 side lateral band 223f
flap division 150 injury evaluation 320 Under local anesthesia 38
Staged lengthening 272 Upper
flexor tendon reconstruction reconstruction 51 limb 97
67 assessment 53 trunk 252
neurovascular flap 145f repair 116, 157
Staging of Dupuytren’s transfer
contracture V
brachioradialis to FPL
assessment 168t and ECRL to FDP 275 Vascular
Steps of musculoskeletal FDS to FDP 274 anastomosis 45, 100, 157,
stabilization 222 for radial nerve palsy 194 280
Sternomastoid muscle 249f markings for 80f hilum of flap 44
Subclavian Testing for abductor pollicis Vascularized gracilis muscle
artery 249f brevis muscle 176 transfer 281t
vein 249f Thickness Vaseline gauze 107
Subcutaneous of scar 49 Veins 221
flap 20 skin graft 21 Venae comitantes of radial
tissues 195 Thumb 10t, 227 artery 42
tunnel 15, 25 reconstruction 4, 131 View of raised flap 29f
veins 42 web absent 286 Volar 222
INDEX 327
advancement flap of atasoy joint 181 W

139 plaster of Paris 39
Width of scar 49
and dorsal views of view of reconstructed hand
Wrap-around great toe transfer,
reconstructed hand 39f
vascularized 151
40f Volkmann’s ischemic
Wrist 177, 228
incisions to approach MCP contracture 267
crease 106, 179
joints of fingers 106f assessment 267
metacarpophalangeal evaluation 315
crease 145 management 270 Z
Z-plasty 232

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Manual of

Reconstructive Hand Surgery

G Karthikeyan MBBS MS MCh (Plastic Surgery)

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Jaypee Brothers Medical Publishers (P) Ltd.

© 2013, Jaypee Brothers Medical Publishers

Inquiries for bulk sales may be solicited at: [email protected]

Manual of Reconstructive Hand Surgery

First Edition: 2013

Section 1  General Considerations

1. Examination of the Hand 3

Section 2  Skin Reconstruction

2. Assessment of Skin Loss on the Hand 9

3. Littler’s Island Flap 12

4. First Dorsal Metacarpal Artery Flap 18

5. Reverse Dorsal Metacarpal Artery Flap 23

6. Posterior Interosseous Artery Flap 27

7. Radial Artery Forearm Flap 32

8. Buried Abdominal Flap 36

9. Vascularized Free Anterolateral Thigh Flap 41

Section 3  Other Post-traumatic Sequelae on the Skin

10. Adherent Scars and Contractures 49

Section 4  Tendon Reconstruction

11. Tendon Reconstruction—Assessment 53

12. Repair of Avulsed Flexor Tendon 57

13. Flexor Tendon Grafting 61

14. Staged Flexor Tendon Reconstruction 67

15. Flexor Tenolysis 74

16. Extensor Tendon Reconstruction 77

17. Extensor Indicis Proprius to Extensor Pollicis Longus Tendon Transfer 80

18. Flexor Digitorum Superficialis to Flexor Pollicis Longus Tendon Transfer 83

Section 5  Bone Reconstruction

19. Bone Reconstruction—Assessment 89

20. Open Reduction Internal Fixation of Fractures 91

21. Bone Grafting 94

22. Vascularized Fibula Transfer 97

Section 6  Joint Reconstruction

23. Joint Reconstruction—Assessment 103

24. Chronic Metacarpophalangeal Joint Dislocation Reduction 105

25. Arthrolysis 108

26. Vascularized Toe Metatarsophalangeal Joint Transfer 113

Section 7  Nerve Reconstruction

27. Nerve Reconstruction—Assessment 119

28. Nerve Reconstruction—Management 120

Section 8  Complex Post-traumatic Problems

29. Complex Post-traumatic Problems—Assessment 127

Section 9  Thumb Reconstruction

30. Principles and Decision Making in Thumb Reconstruction 133

31. Procedures for Reconstruction of Type I Amputations 138

32. Procedures for Reconstruction of Type II Amputations 144

33. Procedures for Reconstruction of Type III Amputations 148

34. Procedures for Reconstruction of Type IV Amputations 155

35. Procedures for Reconstruction of Type V Amputations 159

36. Ganglion Excision 163

Section 11  Degenerative Conditions

37. Dupuytren’s Contracture—Assessment 167

38. Dupuytren’s Contracture—Management 169

39. Hansen’s Disease and Sequelae 173

40. Opponensplasty with Flexor Digitorum Superficialis of Ring Finger 178

42. Claw Correction—Lasso Procedure 184