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Digital nerve repair

Indications The major mechanisms of nerve injury include crush/compression, tension/traction, and laceration of the digits. From superficial to deep, the layers of a peripheral nerve include the epineurium, perineurium, and endoneurium. Nerve injury can occur at any or all of these layers. The classification of nerve injuries has been described by Seddon and Sunderland ( Table 60.1 ). Neuropraxia describes a temporary nerve conduction block. The…

Radial nerve decompression

Introduction Radial neuropathy can result from direct trauma or compression anywhere along the radial nerve’s course, from the brachial plexus through the spiral groove, radial tunnel, posterior interosseous nerve (PIN), or superficial branch of the radial sensory nerve. Three types of radial nerve decompression may arise in the forearm: PIN syndrome, radial tunnel syndrome, and compression of the radial sensory nerve in the distal forearm, otherwise…

Procedures for ulnar compressive neuropathy

Introduction The ulnar nerve is a mixed motor and sensory nerve. Compression leads to a constellation of symptoms that vary depending on the location. The two most common areas of compression include the elbow (the “cubital tunnel”) and the wrist/palm (the “Guyon canal”). Because the area of compression determines the surgical approach, it is critical to use the physical examination in conjunction with nerve conduction studies…

Revision carpal tunnel release and coverage using a hypothenar fat pad flap

Indications The indications for revision carpal tunnel release (CTR) include persistent, recurrent, or new symptoms after initial release. Persistent carpal tunnel syndrome Incomplete release of the transverse carpal ligament or secondary site of median nerve compression is the most common indication, accounting for around 43% of patients who undergo revision CTR. Incomplete release is associated with an acute worsening of carpal tunnel symptoms secondary to a…

Endoscopic carpal tunnel release

Indications Indications are similar to those described for open carpal tunnel release ( Chapter 55 ). Clinical examination The clinical examination is similar to that described for open carpal tunnel release ( Chapter 55 ). EXAMINATION PEARLS The wrist is examined for stiffness, specifically with extension, because the wrist must be extended for correct cannula placement ( Fig. 56.1 ). Imaging Preoperative testing, including electrodiagnostic testing…

Open carpal tunnel release

Indications Signs and symptoms of carpal tunnel syndrome (CTS) include paresthesias, pain or numbness in the median nerve distribution (volar thumb, index, middle and radial one-half of ring finger), nocturnal neuropathic symptoms, and/or thenar muscle weakness or wasting. Carpal tunnel release is indicated for those who have failed to achieve improvement with respect to the duration or distribution of finger/thumb numbness using conservative measures such as…

Wrist denervation

Indications Wrist denervation is indicated in patients with chronic pain but preserved motion after exhausting nonoperative treatments. Patients are candidates for denervation if they have pain from primary degenerative or inflammatory arthritis, osteonecrosis (Kienböck or Preiser disease), or traumatic conditions, such as scaphoid nonunion advanced collapse (SNAC) or scapholunate advanced collapse (SLAC) wrist, ligamentous instability, or sequelae of distal radius fractures. Transecting articular nerve branches reduces…

Total wrist fusion

Indications Total wrist fusion is indicated in patients with pain or instability after failure of nonoperative management and motion-preserving procedures. Wrist fusion is preferred when multiple joints (i.e., the radiocarpal and midcarpal joints) are involved. If disease is isolated to a single joint, motion-preserving procedures, such as a proximal row carpectomy or partial wrist arthrodesis, can be considered ( Fig. 53.1 ). Total wrist fusion is…

Total wrist arthroplasty

Indications Total wrist arthroplasty (TWA) is indicated in low-demand patients with severe wrist pain who require some motion. Potential candidates include patients with osteoarthritis (OA), posttraumatic arthritis, and sometimes rheumatoid arthritis (RA). Although new implant designs show promise, TWA is fraught with complications including stiffness, infection, tendon attenuation, and hardware loosening, dislocation, or failure. Fastidious precision is mandatory in placing the current implant design because of…

Hemiresection ulnar arthroplasty

Indications Matched hemiresection ulnar arthroplasty is indicated in patients with distal radioulnar joint (DRUJ) pain from posttraumatic arthritis, osteoarthritis (OA), or inflammatory arthritis with an intact triangular fibrocartilaginous complex (TFCC). The premise of hemiresection arthroplasty is that the DRUJ articulation is eliminated, but the TFCC and ulnocarpal ligaments are maintained. The procedure is technically simple, maintains ulnar length, preserves ulnar-sided wrist stability, and permits full pronation…

Sauvé-Kapandji procedure

Indications The Sauvé-Kapandji procedure consists of fusion of the distal radioulnar joint (DRUJ) and resection of a short segment of ulna proximal to the joint to preserve forearm motion. It eliminates the painful articulation between the ulna and sigmoid notch and maintains normal anatomic alignment of the wrist. When intact, triangular fibrocartilage complex (TFCC) function is preserved. The Sauvé-Kapandji procedure is indicated in patients with DRUJ…

Distal ulnar resection (Darrach procedure)

Indications The goal of surgical treatment of distal radioulnar joint (DRUJ) arthritis is to eliminate the articulation between the distal ulna and the sigmoid notch. Options include distal ulna resection (Darrach procedure) or hemi-resection (Bowers procedure; see Chapter 51 ), DRUJ arthrodesis (Sauvé-Kapandji procedure; see Chapter 50 ), and ulna head replacement. The Darrach procedure is indicated in low-demand patients with chronic DRUJ pain or instability…

Revision carpometacarpal joint arthroplasty

Indications Carpometacarpal (CMC) joint arthroplasty with trapeziectomy with or without ligament reconstruction provides predictable pain relief for most patients. Revision CMC arthroplasty is indicated in patients with persistent or recurrent basilar thumb pain or instability who are at least 1 year out from their primary procedure and have failed symptomatic management. Patients must be counseled that revision procedures are less predictable than primary CMC arthroplasty. Multiple…

Trapeziectomy and abductor pollicis longus suspensionplasty

Indications Carpometacarpal (CMC) arthritis is one of the most common conditions treated by hand surgeons. Surgery is indicated in patients who continue to have severe pain or thumb dysfunction despite nonoperative management. Patients with Eaton stage III or IV trapeziometacarpal (TM) disease have damage to the articular cartilage (see Chapter 46 , Table 46.1 ). Joint salvage procedures do not provide predictable pain relief for these…

Reconstruction for thumb carpometacarpal joint instability using flexor carpi radialis (Littler procedure)

Indications Anterior oblique ligament reconstruction (Littler procedure) is indicated in patients with Eaton-Littler stage I or early stage II trapeziometacarpal (TM) disease with painful instability or diminished thumb function who have failed nonoperative management ( Table 46.1 ). TABLE 46.1 Eaton-Littler Classification System Stage Radiographic Characteristics Stage I Normal or slightly widened trapeziometacarpal (TM) joint; TM subluxation up to one-third of articular surface; Normal articular contours…

Carpometacarpal joint fusion for basilar arthritis

Indications Initial management options for thumb basilar joint arthritis include activity modification, nonsteroidal antiinflammatory drugs (NSAIDs), splinting, therapy, and corticosteroid injections. Surgery is indicated in patients who continue to have severe pain or poor function despite nonoperative management. The Eaton-Littler classification describes four stages of arthritis based on a true lateral radiograph of the trapeziometacarpal (TM) joint ( Fig. 45.1A–D ). This classification system is helpful…

Joint fusion for thumb metacarpophalangeal instability

Indications Thumb metacarpophalangeal (MCP) joint fusion is indicated in patients with symptomatic arthritis or instability. Clinical examination Patients may complain of pain, swelling, stiffness, or decreased grip strength. Patients with carpometacarpal joint destruction often have compensatory hyperextension of the thumb MCP joint and will have pain with gripping, twisting, and key pinch. A normal thumb has a subtle degree of passive hyperextension at the MCP joint…

Distal interphalangeal joint arthrodesis

Indications Distal interphalangeal (DIP) joint arthrodesis is indicated in patients with intractable pain or instability after failure of nonoperative management. Many patients with DIP arthritis present with mucous cysts. Cyst excision may correct a nail deformity, skin changes, or a draining wound, but it will not improve joint pain. Fusion is a reliable option when pain causes functional limitations. Clinical examination Patients may present with stiffness,…