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Surgery of the Injured Hand
R Venkataswami
1:
History of Hand Surgery
2:
Structural Basis of Functioning of the Hand
HAND AS A SENSORY ORGAN1
Palmar Skin of Human Finger as Sensory Organ
Sensory Apparatus of Hand
Proximal Part of the Peripheral Neural Apparatus
Clinical Implications
HAND AS MOTOR PREHENSILE ORGAN
Working Space of the Hand
Variety of Grips
Power Grip
Precision Grip
Hook Grip
Key Grip
Syringe Grip
Some Postures of The Hand
Position of Rest
Position of Function
“Intrinsic” Position
Finger Mechanism
Basic Plan
Soft Tissue Adaptations
Terminal Pad
Skin Anchorage Systems
THE MOTOR APPARATUS
Finger Joint Mechanism
The IP Joints
MCP Joint
Muscles Activating Finger
Long Extensor Muscles of Fingers
The Long Flexor Muscles
Finger Posture Control
PIP–DIP Joint Co-ordination
Bi-articular Bi-muscular Tendon-displacement Model
Information from Electromyographic Studies of the Finger
THE THUMB
Nomenclature of Movements and Postures of the Thumb
Motor Apparatus of Thumb
The Carpo-metacarpal (CMC) Joint
The Metacarpo-phalangeal (MCP) Joint
The Interphalangeal (IP) Joint
Muscles Moving the Thumb
Extrinsic Muscles
Intrinsic Muscles
Muscle Activity during Thumb Movements
Assessment of Working Space of Fingers
Finger Dynamography
3:
Organisation of Hand Injury Services
INTRODUCTION
ORGANIZATION
ADEQUATE SPACE
THE MANPOWER
4:
Basic Techniques and Instrumentation in Hand Surgery
INTRODUCTION
INSTRUMENTS AND EQUIPMENTS
Basic Instruments
Other Instruments
EQUIPMENTS
Tourniquet
Magnifying Loupes and Microscope
C-arm
Bipolar Coagulator
Power Drill and Saw
EXAMINATION OF WOUND IN CASUALTY IN ACUTE TRAUMA
ASEPSIS, CLEANING AND DRAPING
POSITIONING
DEBRIDEMENT, EXPLORATION AND PLANNING
Debridement
Establishment of Vascularity and Stabilisation of Skeleton
Recognition of Skin Loss and Type of Cover
AMPUTATIONS
EXPLORATION OF TENDON AND NERVE REPAIR
INCISIONS, EXTENSION OF WOUND AND EXPOSURE
Adequacy of Exposure
Blood Supply of Skin: Altered Sensation following Extensive Dissection of Flaps
Avoidance of Scar Contracture
Relationship of Repaired Structures to the Suture Line in Skin
Direction of Existing Wound or Scar
Children with Expected Subsequent Growth
SKIN CLOSURE
Suture Materials
Suturing Techniques
Types of Sutures
Z–Plasty
SKIN GRAFTS
Donor Sites
FLAPS
Classification
Depending on the Area from which the Flap is Raised
Depending on the Blood Supply
Depending on the Composition of Tissues
COMMON FLAPS USED IN HAND SURGERY
LOCAL FLAPS
Transposition Flap
Increasing the Length of the Flap
Extension of Length of one Side
Back Cut
Limberg Flap and Dufourmentel Flap
Limberg Flap
Dufourmentel Flap (Fig. 4.18)
Rotation Flap
Advancement Flaps
Flag Flap
Regional Flaps
Random Regional Flaps
Cross Finger Flap
Thenar Flap
Axially Oriented Regional Flaps
First Dorsal Metacarpal Artery Flap
Neurovascular Island Flaps from Fingers
Other Regional Flaps
Distant Flaps
5:
Examination of the Hand
POSITION OF HAND
Position at Rest (Fig. 5.1)
Position of Function (Fig. 5.2)
CLASSIFICATION OF HAND INJURIES
Skin
Compartment Syndrome
Tendons
Flexor Tendons
Extensor Tendons
Nerve Injuries
Injury to Skeleton
Joint Injuries
Vascular Injuries
POST-TRAUMATIC SEQUELAE
Movements
Long Flexors
Long Extensors
Small Muscles of the Hand
Nerve Function
Sensory Function
Stereognosis
Sweating
BRACHIAL PLEXUS INJURY
Vascular Status
Bone and Joints
Investigations in the Diagnosis in Hand Trauma
X-Rays
6:
Aesthetic Prosthesis in Hand Injuries
INTRODUCTION
INDICATIONS AND TIMING OF PROSTHETIC FITTING
FACTORS INFLUENCING CHOICE OF PROSTHESIS FOR EACH LEVEL OF AMPUTATION
Thimble-type Prostheses Versus Full-finger Prostheses
Finger Prostheses Versus Partial Hand Prostheses
Total and Partial Hand Prothesis
Transradial and Transhumeral Aesthetic Prostheses
OVERVIEW OF MATERIALS AND TECHNIQUES
Making of Finger and Hand Models
Making the Master Impression Mould
Colour Matching and Moulding of the Multilayered Prosthesis
Fitting Methodology
IMPACT OF AESTHETIC PROSTHESES ON PATIENT REHABILITATION
Psychological Impact
Early Impact: Psychological
Late Impact: Psychosocial
Functional Impact
COMPLICATIONS AND MANAGEMENT
LONG-TERM USE OF PROSTHESES
CONCLUSION
7:
Anaesthesia for Hand Injuries
EMERGENCY HAND INJURIES
History
General Anaesthesia
Regional Anaesthesia
ELECTIVE HAND SURGERIES
General Anaesthesia
Possible Complications under General Anaesthesia
Regional Anaesthesia
Brachial Plexus Block
Interscalene Technique (Figs 7.1A and B)
Subclavian Perivascular Block (Figs 7.2A and B)
Supraclavicular Block
Infraclavicular Approach (Fig. 7.3)
Axillary Approach (Fig. 7.4)
Catheter Technique
Nerve Blocks around the Elbow
Nerve Blocks at Wrist
Intravenous Regional Anaesthesia
8:
Treatment of Fingertip and Nail Injuries
ACUTE TREATMENT OF FINGERTIP LOSS
TECHNIQUES
Techniques Using an Available Distal Fragment
Distal Replantation
Reposition and Reposition-flap
Delayed Healing
Terminalisation
Grafts
The “V-Y” Flaps
The Moberg Flap
The Hueston Flap
Islanded Homodigital Flaps
The Hetero-digital Island Flap
The Cross Finger Flap
The Thenar Flap
Distant Flaps
INDICATIONS
ACUTE MANAGEMENT OF THE NAIL
9:
Avulsion Injuries in the Fingers
10:
Refinements of Pedicle Flaps for Soft Tissue Cover in the Upper Limb
INTRODUCTION
RELEVANT ANATOMY
TECHNICAL CONSIDERATIONS IN PLANNING FLAP COVER
ROLE OF DELAY PRIOR TO FLAP DIVISION
POSTOPERATIVE CARE AND REHABILITATION
SECONDARY THINNING OF A PEDICLE FLAP
COMPLICATIONS
Flap Necrosis
Flap Edge Dehiscence
Flap Oedema
Unsatisfactory Donor Site
Joint Stiffness
11:
Primary Composite Reconstruction of the Hand
INTRODUCTION
PATIENT EVALUATION
WOUND MANAGEMENT: ADEQUATE DEBRIDEMENT IS ESSENTIAL
TECHNICAL ASPECTS
OSTEOSYNTHESIS
Vascular Reconstruction
Tendon Reconstruction
Nerve Reconstruction
ADVANTAGES OF IMMEDIATE RECONSTRUCTION
DISADVANTAGES
DEFINITION OF EMERGENCY FREE FLAP
INDICATIONS FOR EMERGENCY FREE FLAPS
ONE STAGE RECONSTRUCTION
CASE REPORTS
COMPLICATIONS
POSTOPERATIVE CARE
CONCLUSION
12:
Management of Complex Injuries of the Upper Extremity Proximal to the Wrist
BENEFITS OF UPPER LIMB SALVAGE
STEPS IN THE SALVAGE OF A COMPLEX UPPER LIMB INJURY
Step 1: Arrest Bleeding and Do a Complete Survey
Step 2: Pain Relief and Assessment of Injury—The Concept of “On Arrival Block”’
Step 3: Make a Complete Plan
Step 4: Debridement
Step 5: Skeletal Fixation
Step 6: Revascularisation
Step 7: Repair of Tendons and Nerves
Step 8: Soft Tissue Cover
SOFT TISSUE CONSIDERATIONS IN SPECIAL SITUATIONS
POSTOPERATIVE CARE
SUMMARY
13:
Osteoplastic Reconstruction of Thumb
INTRODUCTION
HISTORICAL BACKGROUND
Requisites of a Normal Thumb
Clinical Assessment
Osteoplastic Method of Reconstruction
First Stage
Second Stage
POSTOPERATIVE CARE
COMPLICATIONS
DISCUSSION
14:
Pollicization in Hand Mutilations
INTRODUCTION
TECHNIQUE
TECHNICAL VARIATIONS
DISCUSSION
INDICATIONS
CONTRAINDICATIONS
15:
Microsurgical Reconstruction of the Thumb
INTRODUCTION
HISTORICAL PERSPECTIVES ON THUMB RECONSTRUCTION
FUNCTIONAL ANATOMY OF THE THUMB
Bones and Joints
Carpometacarpal Joint
Metacarpophalangeal Joint
Interphalangeal Joint
Motor Control
Sensation
Blood Supply
Skin
Aesthetics
CLASSIFICATION OF ACQUIRED POST-TRAUMATIC THUMB DEFICIENCIES
MICROSURGICAL RECONSTRUCTION OF ACQUIRED POST-TRAUMATIC THUMB DEFICIENCIES
Replantation
Reconstruction
Common Dissection for Toe Segment Transfers37
Hallux
Trimmed Toe35
Whole Second Toe Transfer28
Toe Joint Transfers from the 2nd Toe
Wrap-around Flap31,37
Preoperative Evaluation
Markings
Operative Technique
Foot Dissection
Hand Dissection
Bone Graft
Thumb Reconstruction
Foot Closure
Postoperative Care
Dressings
Results
Toe Pulp Transfers33,39–42
Nail Flaps43
Other Microsurgical Flaps for Thumb Reconstruction
Free Flaps
Venous Flaps
RECOMMENDED MICROSURGICAL PROCEDURES
SUMMARY
16:
Trimmed Great Toe Transplantation (TTT) for Thumb Reconstruction
INTRODUCTION
HISTORICAL PERSPECTIVES
TRIMMED GREAT TOE TRANSPLANTATION (TTT)
INDICATIONS
PREOPERATIVE PLANNING
RELEVANT SURGICAL ANATOMY AND FLAP DESIGN
SURGICAL TECHNIQUE/PROCEDURE
Recipient Site Preparation
Flap Insetting
Skeletal Fixation
Tendon Repair
Nerve Repair
Skin Closure
Vascular Anastomoses
DONOR SITE MANAGEMENT
POSTOPERATIVE MANAGEMENT
EARLY/LATE COMPLICATIONS AND MANAGEMENT
REHABILITATION
Motor Rehabilitation
Sensory Rehabilitation
CONCLUSION
17:
Microsurgical Finger Reconstruction with Toe Transfers
INTRODUCTION
GENERAL CONSIDERATIONS
Initial Care
Bone and Joint
Tendon
Vessels
Nerve
Skin
Primary Versus Secondary Toe to Finger Transplantation
Reconstructive Options
Single Finger Amputation
Multiple Finger Amputation
ANATOMY
SURGICAL TECHNIQUES
Second Toe Partial or Total Transplantation
Indications
Flap Design and Elevation
Author's Method
Second Toe Wrap-around Flap
Indications
Flap Design
Pulp and Hemipulp Flaps
Indications
Flap Design and Elevation
First Web Neurosensory Flap
Indications
Flap Design and Elevation
Vascularised Nail Graft
Indications
Flap Design and Elevation
Third Toe Transplantation
Indications
Author's Method
Combined Second and Third Toe Transplantation
Indications
Flap Design and Elevation
Recipient Site Preparation
Skin Incision
Bone and Joint Preparation
Tendon and Pulley Preparation
Nerve Preparation
Vessel Preparation
Toe Fixation Technique
Skeletal Fixation
Tendon Repair
Nerve Repair
Skin Closure
Vascular Anastomoses
POSTOPERATIVE MANAGEMENT
Complications
Secondary Procedures
Donor Site Morbidity and Gait Analysis
Rehabilitation
18:
Reconstruction of Hand Loss after Wrist and Distal Forearm Amputation
INTRODUCTION
HISTORY
ANATOMICAL FEATURES
Forearm Stump
Foot as a Donor Site
INDICATIONS
TIMING OF THE PROCEDURE
PREOPERATIVE REHABILITATION
PREOPERATIVE INVESTIGATIONS AND PLANNING
OPERATIVE TECHNIQUE6–9
NEO-THUMB RECONSTRUCTION
POSTOPERATIVE MANAGEMENT
RESULTS8,10,11
DISCUSSION
19:
Primary Flexor Tendon Surgery
INTRODUCTION
HISTORICAL BACKGROUND
CLINICAL EVALUATION
SURGICAL ANATOMY
TECHNIQUES OF REPAIR
POSTOPERATIVE MANAGEMENT
THE ST ANDREW'S EARLY ACTIVE MOBILISATION REGIMEN (2004)
DISCUSSION
20:
Secondary Flexor Tendon Surgery
INTRODUCTION
EXTENSOR TENDON TETHERING
FLEXOR TENDON RUPTURE AFTER PRIMARY REPAIR
THE ‘STUCK’ OR ADHERENT PRIMARY TENDON REPAIR
THE OPTIONS OF TREATMENT IF PRIMARY REPAIR IS IMPOSSIBLE OR FAILS
Doing Nothing
Delayed Primary Repair
Tendon Grafting
BOW-STRINGING AND PULLEY RECONSTRUCTION
DISCUSSION
AVOIDING SECONDARY SURGERY
SIMPLIFYING SECONDARY SURGERY
21:
Complications of Flexor Tendon Injuries and their Management
INTRODUCTION
OVERVIEW OF THE ACUTE MANAGEMENT OF TENDON INJURIES
COMMON COMPLICATIONS
Adhesions Prevention
Adhesions Treatment
Joint Contractures
Tendon Rupture
Reflex Sympathetic Dystrophy
Triggering and Partial Tendon Injuries
Pulley Failure/Tendon Bowstringing
Infection
Cold Intolerance
Less Common Complications
Quadriga
Swan Neck Deformity
Lumbrical Plus
SUMMARY
22:
Repair and Reconstruction of Extensor Tendons
INTRODUCTION
ANATOMY AND DYNAMIC OF THE EXTENSOR SYSTEM
ZONES OF INJURY
Evaluation of Extensor Tendon Results
Dargan Criteria22
Miller System70
RESULTS FOLLOWING EXTENSOR TENDON INJURIES
SPLINTING AND REHABILITATION FOLLOWING EXTENSOR TENDON INJURIES
Zones I and II Injuries
Zones III and IV Injuries
Static Immobilisation
Evan's Active Short Arch Motion (SAM) Protocol
Zones V to VII Injuries
Early Passive Motion in a Dynamic Splint
Extensor Carpi Radialis Longus (ECRL), Extensor Carpi Radialis Brevis (ECRB) and Extensor Carpi Ulnaris. (ECU) Tendon Injuries (Zone VII)
Zone VIII Injuries
SPECIFIC EXTENSOR TENDON INJURIES
Zone I Injuries–Mallet Finger, DIP Joint
TREATMENT OF ACUTE MALLET FINGER INJURIES
Nonoperative Treatment
Operative Treatment
Zone I Thumb Injuries—Mallet Thumb, IP Joint
Zone II Injuries—Finger Middle Phalanx and Thumb Proximal Phalanx Injuries
Zone III Injuries— Boutonnière Lesion, PIP Joint
TREATMENT OF ACUTE BOUTONNIÈRE DEFORMITIES
Nonoperative Treatment
Operative Treatment
Zone III Thumb Injuries—MP Joint
Zone IV Injuries—Proximal Phalanx
Zone IV Thumb Injuries—Metacarpal
Zone V Injuries—MCP Joint
Zone V Thumb Injuries—CMC Joint
Zone VI Injuries—Metacarpal
Zone VII Injuries—Wrist
Zone VIII and Zone IX Injuries—Forearm
EXTENSOR TENDONS DEFICIT SECONDARY TO INFECTION
EXTENSOR TENDONS—LATE REPAIR AND TENDON RECONSTRUCTION
General Principles
CLINICAL EVALUATION AND INDICATIONS FOR SURGICAL PROCEDURE
Preoperative Planning
INTRODUCTION TO SPECIFIC OPERATIVE PROCEDURES
Chronic Extrinsic Extensor Tendon Deficit Proximal to MCP Joint
Operative Technique of Tendon Transfer
Chronic Subluxation of the Extrinsic Extensors at the MCP Joint Level
Operative Technique
Extrinsic Extensor Tendon Tightness (Dorsal Tenodesis)
Operative Technique
SWAN-NECK DEFORMITY
Operative Technique
Lateral Band Tenodesis
Oblique Retinacular Ligament Reconstruction
BOUTONNIÈRE DEFORMITY
Preoperative Planning
Nonoperative Treatment
Operative Treatment for Boutonnière Deformity
Secondary Repair
Established Boutonnière Deformity
Complications of Surgical Treatment
23:
Principles and Practice of Nerve Repair
ANATOMY OF A PERIPHERAL NERVE
Fascicular Patterns
Nerve Vascularisation
BIOLOGY OF NERVE INJURY AND REGENERATION
Classification of Peripheral Nerve Injury
Mode of Nerve Injury
Degenerative Changes
Role of Vascularisation
Principles of Nerve Repair
Method of Repair
Orientation and Fascicular Matching
Tension
Nerve transfers
Areas of Current Research Interest
Alternative Conduits
End to Side Coaptation
Pharmacological Agents
Nerve Allograft
24:
Clinical Aspects of Peripheral Nerve Injuries
EPIDEMIOLOGY OF PERIPHERAL NERVE LESIONS
CLINICAL ASSESSMENT OF THE PERIPHERAL NERVES
History
Examination: General Principles
Inspection
Motor Examination
Sensation and Autonomic Functions
Radiological Studies
Electrophysiological Studies
Muscle Biopsy
ANATOMY, CLINICAL FINDINGS AND OPERATIVE APPROACH TO THE NERVES OF THE UPPER LIMB
General Principles
Median Nerve
Anatomy
Median Nerve Injury
Approach to the Median Nerve
Ulnar Nerve
Anatomy
Martin-Gruber Connection
Connections in the Hand
Ulnar Nerve Injury
Approach to the Ulnar Nerve
Radial Nerve
Anatomy
Radial Nerve Injury
Approach to the Radial Nerve
Musculocutaneous Nerve
Anatomy
Musculocutaneous Nerve Injury
Approach to the Musculocutaneous Nerve
Axillary nerve
Anatomy
Axillary Nerve Injury
Approach to the Axillary Nerve
Sural Nerve
POSTOPERATIVE MANAGEMENT
Splinting and Wound Management
Sensory Re-education of Peripheral Nerves
RESULTS OF PERIPHERAL NERVE REPAIRS
Epineurial vs. Grouped Fascicular Repairs
Epineurial vs. Fascicular Repairs
Digital Nerves
Median Nerve
Ulnar Nerve
Radial Nerve
Musculocutaneous Nerve
Axillary Nerve
25:
Tendon Transfers– Principles and Techniques
INTRODUCTION
BIOMECHANICS
PRINCIPLES—THE RECIPIENT
PRINCIPLES—THE DONOR
PRINCIPLES—THE SURGICAL METHOD
SPECIFIC TENDON TRANSFERS
Low Median Nerve Palsy
Surgical Techniques
High Median Nerve Palsy
Surgical Techniques
Radial Nerve Palsy
Surgical Techniques
Postoperative Management
Ulnar Nerve Palsy
Surgical Techniques
Preferred Combinations for Restoration of Finger Intrinsic Function and Thumb/Index Power Pinch
CONCLUSION
26:
The Management of Painful Nerves
INTRODUCTION
THE AETIOLOGY OF NERVE PAIN
ASSESSMENT OF NERVE PAIN
NERVE PAIN MANAGEMENT
The Implication of Distal Nerve Function to Pain Management
Treatment of End-neuromas by Relocation
Treatment of the Neuroma Bulb
CLASSIFICATION OF SITES OF END-NEUROMAS
Suitable Relocations of Zone I End-neuromas
Relocation of the Dorsal Innervation of the Digits
Relocation in Ray Amputations
Suitable Relocations of Zone II End-neuromas
Suitable Relocations of Zone III End-neuromas
HYPERSENSITIVITY
DOCUMENTATION AND ASSESSMENT OF THE RESULTS OF RELOCATION OF END-NEUROMAS
FAILURE TO RELIEVE END-NEUROMA PAIN
TREATMENT OF END-NEUROMAS BY RECONNECTION
NEUROMAS-IN-CONTINUITY AND SCARRED NERVES
NERVE WRAPPING
POSTOPERATIVE MANAGEMENT
CONCLUSION
27:
Management of Adult Brachial Plexus Injuries
INTRODUCTION
SURGICAL ANATOMY
Spinal Nerves
CLASSIFICATIONS
Anatomical
CLINICAL EXAMINATION
Diagnostic Studies
Imaging Studies
NEUROPHYSIOLOGICAL EXAMINATION
Sensory Nerve Action Potentials (SNAP)
Somatosensory Evoked Potentials (SEP)
MANAGEMENT
THERAPEUTIC OPTIONS
Results
Results of the Grafts from a C5 Root Nerve Stump
Results of the Transfers of the Intercostal Nerves
Results of the Cross-chest C7 Transfer
PERSONAL SERIES
Partial Palsy by Radicular Lesion
C5 C6 Palsy
THERAPEUTIC TRENDS
Late Repair
The Choice of the Free Muscle
Which Nerve Transfer ?
SECONDARY SURGERY
Late Surgery at the Shoulder
COMPLEMENTARY SURGERY AT THE HAND
Functional Classification of the Long Fingers
Functional Classification of the Thumb
CONCLUSION
28:
Rehabilitation Following Primary Surgery in Adult Brachial Plexus Lesion
INTRODUCTION
POSTOPERATIVE CARE
THE ROLE OF PHYSIOTHERAPY
PRESERVATION OF MUSCULAR BULK AND STRENGTH
ERGOTHERAPY
Treatment of Pain in Brachial Plexus Lesions
RESULTS OF THIÉBAUD'S SERIES
EVALUATION OF THE REHABILITATION PROGRAMME
BRAIN PLASTICITY AND BRAIN MAPPING
29:
Pain Following Brachial Plexus Injury and its Management
BACKGROUND
PRACTICAL MANAGEMENT
Indications for Surgical Exploration and Repair
Intractable Pain after Nerve and Brachial Plexus Injury
Antidepressants
Anticonvulsants and Anti-arrhythmic Agents
Other Agents
Other Therapies
30:
Obstetric Brachial Plexus Palsy
HISTORICAL BACKGROUND
AETIOLOGY
EPIDEMIOLOGY
ANATOMOPHYSIOLOGY OF THE BRACHIAL PLEXUS
TYPE A
TYPE B
TYPE C
PATHOLOGICAL ANATOMY
Type 1
Type 2
Type 3
SPONTANEOUS RECOVERY AND PROGNOSIS
PREOPERATIVE EXAMINATION AND CARE
INSTRUMENTAL INVESTIGATION
EMG
Imaging
SURGICAL TREATMENT
TYPES OF LESIONS
REPAIR TECHNIQUES
Repair Strategies
Postoperative Care
Rehabilitation
Results
CONCLUSION
31:
Secondary Surgery in Obstetrical Palsies
INTRODUCTION
PALLIATIVE SURGERY OF THE SHOULDER
SUBSCAPULAR RELEASE SURGICAL TECHNIQUE
Muscle Transfer
Levator Scapulae Transfer
Trapezius Transfer
Latissimus Dorsi Transfer
LD transfer: Anterior approach Technique
LD transfer: Posterior Approach
RESULTS
Results in Shoulder 0
Late Shoulder Deformities
PALLIATIVE SURGERY AT THE ELBOW
LATISSIMUS DORSI TRANSFER
Technique
PECTORALIS MAJOR TRANSFER
Technique
EPITROCHLEAR MUSCLE TRANSFER (STEINDLER OP)
Technique
PALLIATIVE SURGERY AT THE FOREARM: PRONOSUPINATION DEFICIT
SURGICAL CORRECTION OF SUPINATION DEFORMITY
Rotating Osteotomy of the Radius
Rerouting of Biceps Tendon
PALLIATIVE SURGERY IN THE HAND
REHABILITATION IN SECONDARY SURGERY
32:
Nonoperative Management of Fractures of the Hand Skeleton–Metacarpals and Phalanges
INTRODUCTION
FRACTURES OF THE METACARPALS
Surgical and Functional Anatomy
Classification of Metacarpal Fractures
Carpometacarpal Region
Shaft Fractures
Subcapital Fractures
Technique of Closed Reduction of Metacarpal Fractures
Fractures of the Thumb
BENNETT'S FRACTURE2
Basal Fractures
Shaft Fractures
Fractures of the Thumb Phalanges
FRACTURES OF THE PHALANGES
Stiffness3
Tendons and Muscles
The Indication for Nonoperative Management4,5
Clinical Examination
Technique of Nonoperative Management
CONCLUSION
33:
Operative Fixation of Fractures of the Hand
INTRODUCTION
INDICATIONS FOR OPERATIVE FIXATION
ASSESSMENT OF THE FRACTURES
Fracture Character and Fixation Technique
PRINCIPLES OF OPERATIVE FIXATION
The Metacarpal Fractures
The Proximal Phalanx Fracture
The Middle Phalanx Fracture
The Distal Phalanx Fracture
The Metacarpal Base Fractures
The PIP Fracture Dislocations
The Mallet Fractures
POSTOPERATIVE REHABILITATION
34:
Scaphoid Fracture
INTRODUCTION
SURGICAL ANATOMY
CLINICAL EVALUATION
ACUTE WAIST FRACTURE
Non-surgical Treatment
Type of Cast
Position of the Wrist
Duration of Immobilisation
Determination of Union
Return to Activity
Surgical Treatment
Indication for Surgery
Unstable Fracture
Transcaphoid Perilunate Dislocation
Proximal Pole Fracture <25 per cent
Multitrauma
Avoid Prolonged Immobilisation
Preoperative Planning
Fracture Factors
Patient Factor
Surgeon Factor
Implants
Volar Approach
Dorsal Approach
Percutaneous Screw Insertion
DISTAL THIRD FRACTURE
PROXIMAL POLE FRACTURE
COMPLICATION OF SCAPHOID FRACTURE
Nonunion of Scaphoid
Stable Undisplaced Scaphoid Nonunion without Degenerative Changes
Unstable Displaced Scaphoid Nonunion without Degenerative Change
Avascular Necrosis
Pronator Quadratus Graft
Dorsal Distal Radius Vascularised Grafts (Zaidemberg)
Complex Fracture and Fracture Dislocation
Malunion
Osteoarthritis
Stage I
Stage II
Stage III
Stage IV
35:
Scapholunate Ligament Injury
INTRODUCTION
FUNCTIONAL ANATOMY
PATHOMECHANICS
DIAGNOSIS
HISTORY
PHYSICAL EXAMINATION
INVESTIGATION
TREATMENT
Acute Scapholunate Dissociation
Subacute Scapholunate Dissociation
Chronic Scapholunate Dissociation
Degenerative Changes
Stage I
Stage II
Stage III
Stage IV
36:
Distal Radioulnar Joint Problems and Solutions
INTRODUCTION
HISTORY
ANATOMY
The TFCC
DRUJ Motion
The Interosseous Membrane
The Shape of the Radius
THE FUNCTION OF THE FOREARM
DESCRIPTION OF DRUJ PROBLEMS
DRUJ Instability
The Stages of DRUJ Instability
Ulnocarpal Abutment
DRUJ Incongruity
EXAMINATION AND EVALUATION
Radiographs
Computed Tomography (CT) Scan
Arthrography
MRI
Arthroscopy
MANAGEMENT OF DRUJ PROBLEMS
DRUJ Instability Treatment Techniques
Reconstruction of the DRUJ Ligaments with a Tendon Graft46,47
Postoperative Treatment
Treatment of Ulnocarpal Abutment
Treatment for DRUJ Incongruity
Ulnar Shortening Osteotomy
Distal Ulnar Prosthetic Replacement60,61
CONCLUSION
37:
Primary and Secondary Reconstruction in Thermal Burn Injuries
INTRODUCTION
AETIOLOGY
Typical Distribution of a Hand Burn
STRUCTURE OF SKIN
PATHOLOGY
PRIMARY TREATMENT OF BURN WOUND
First Aid
Physical Examination
Circumferential Burns
Escharotomy Technique
Burn Wound Care
Tangential Excision and Skin Grafting
Technique of Tangential Excision and Skin Grafting
REHABILITATION—PHYSIOTHERAPY
Post-burn Sequelae
Scar
Finger and Palmar Contractures
Nail Deformity
Web Space Contractures
Axillary Contracture
Elbow Contracture
Pathology of Joint Stiffness
PIP Joint
MP Joint
Role of Distraction Devices
Arthrodesis
CONCLUSION
38:
Management of Vascular Injuries of the Upper Limb
INTRODUCTION
MECHANISM OF INJURY
PATHOPHYSIOLOGY OF ACUTE ISCHAEMIA
DIAGNOSIS
MANAGEMENT
Nonoperative Management
Endovascular Management
Operative Management
Adjunct Measures
Vasodilatation
Soft Tissue Coverage
Fasciotomy
Anticoagulation
SUBCLAVIAN AND AXILLARY ARTERY INJURY
BRACHIAL ARTERY INJURY
FOREARM ARTERIAL INJURIES
COMPLICATIONS
PRIMARY AMPUTATION
39:
Organisation of a Microsurgery Service
INTRODUCTION
GETTING STARTED: THE THREE ARMS OF ORGANISATION OF MICROSURGERY SERVICE (FIG. 39.1)
Creation of Infrastructure
Development of Team
Ensuring the Utilisation of Microsurgery Service
ORGANISATION IN THE GROWTH PHASE
CONCLUSION
40:
Replantation Upper Limb and Rehabilitation
INTRODUCTION
DECISION TO REPLANT
Clinical Examination
Type of Injury
Duration of Anoxia
Level of Amputation
Anticipated Results of Replantation
Preservation of the Amputated or Dismembered Part
Interaction with the Patient and Relatives
Socioeconomic Factors
Replantation Team
Blood Transfusion
Nursing Staff
Avulsion Amputations
Debridement and Assessment for Salvage
SEQUENCE OF REPLANTATION
DRESSING
TO SUMMARISE
Salvage Replantation
Fasciotomy
Medication
POSTOPERATIVE CARE
Monitoring
COMPLICATIONS
Early
Renal Failure
Mobilisation
Late Complications
Success or Failure
POSTOPERATIVE PHYSIOTHERAPY
SECONDARY PROCEDURES
FOLLOW-UP AND SECONDARY PROCEDURES
REHABILITATION
SPLINTS
DIGITAL REPLANTATION
SOCIOECONOMIC FACTORS
41:
Major Upper Limb Replantation
HISTORY AND INTRODUCTION
LIMB PRESERVATION AND REFERRAL
Management of the Amputation Victim
Preserving the Amputated Limb and Referral
PREOPERATIVE PREPARATION AND DECISION MAKING
Injury Factors
Tissue Damage and Condition of the Wound
Level of Amputation
Ischaemia Time
Role of Preservative Solutions
Bilateral Upper Limb Amputation
Multiple Level Amputations
Salvage Options in Multi-level Amputations and Other Unfavourable Cases
Patient Factors
Age
Associated Injuries
Associated Co-morbidities
Psychological Factors and Patient's Desire
ORGANISING THE REPLANTATION OPERATION
POSTOPERATIVE CARE
Positioning and Immediate Care1,7,9,11
Analgesia
Vascular Monitoring
General Management and Monitoring
Wound Inspection and Re-debridement
Re-exploration for Vascular Insufficiency
Reperfusion Injury
Local Wound Complications
Psychological Aspects
REHABILITATION, FOLLOW-UP AND RESULTS
42:
Free Mini Groin Flap for Digit Reconstruction
INTRODUCTION
FLAP TECHNIQUES
COMPLICATIONS
POSTOPERATIVE REHABILITATION
DISCUSSION
CONCLUSION
43:
Radial Forearm Flap in Hand Reconstruction
INTRODUCTION
ANATOMY
FLAP DISSECTION
Indications
Advantages
Disadvantages
Management of the Donor Site
Tips and Pitfalls
DISCUSSION
44:
Coverage of the Hand with Fascial Flaps
INTRODUCTION
ANATOMY
FLAP DISSECTION
Indications
Advantages
Disadvantages
MANAGEMENT OF DONOR SITE
Tips in Execution and Pitfalls
DISCUSSION
45:
Anterolateral Thigh Flap
INTRODUCTION
ANATOMY
Arterial Anatomy
Type I – LCFA
Type II
Type III – LCFA
Type IV – LCFA
Venous Anatomy
Neural Anatomy
Surface Anatomy
FLAP DIMENSION
OPERATIVE TECHNIQUE
Subfascial Dissection
Suprafascial Dissection
FLAP THINNING
Applications
Advantages
Disadvantages
CONCLUSION
46:
Lateral Arm Flap in Resurfacing of the Hand
INTRODUCTION
RESURFACING FOR COMPLEX AND MUTILATING INJURIES OF THE HAND
THE LATERAL ARM FLAP
The Pedicled Lateral Arm Flap
Assessment of the Recipient Requirement
The Harvesting of the Lateral Arm Flap
Flap Design
Harvesting of the Flap
Harvesting of the Distal Humeral Bone
Division of the Pedicle
Pedicled Transfer
Closure of Donor Defect
COMPLICATIONS
47:
Finger Joint Reconstruction by Toe Joint Transfer
INTRODUCTION
HISTORICAL BACKGROUND
RELEVANT SURGICAL ANATOMY
CLINICAL EVALUATION AND INDICATIONS FOR THE SURGICAL PROCEDURE
Clinical Evaluation
Indications
INVESTIGATION AND PREOPERATIVE PLANNING
Surgical Procedure
Recipient Site Preparation
Donor Site Preparation for Single-joint Transfer
Donor Site Preparation for Double-joint Transfer
Fixation of the Joint
Closure of the Donor Defect
POSTOPERATIVE MANAGEMENT
Complications
Acute Complication
Other Complications
Late Complications
Results
OTHER COMMON METHODS
Arthrodesis
Resectional Arthroplasty
Soft Tissue Interposition
Perichondrial Arthroplasty
Implant Arthroplasty
Allograft Reconstruction
DISCUSSION
CONCLUSION
48:
Surgical Opportunism in the Primary Repair of the Injured Hand
INTRODUCTION
CLINICAL EVALUATION AND PREOPERATIVE PLANNING
DIGITAL SKIN
DIGITAL REPLANTATION AND AVULSION INJURIES
SKIN FLAPS—FILLET FLAPS
CONTRALATERAL DIGIT AND LIMB TRANSFERS AND TRANSPLANTATIONS
CONCLUSION
INDEX
TOC
Index
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