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Treatment of extraarticular phalangeal fractures

Indications Reduction and fixation should be performed for all fractures that cannot be reduced with closed methods or for those that remain unstable with loss of reduction after successful closed reduction. Fractures with angulation more than 10 degrees or shortening greater than 2 mm and significantly comminuted fractures are best treated with reduction and fixation. Fractures with any rotational deformity or fingers that cross over each…

Kirschner wire fixation of mallet fractures

Seymour fractures and nail bed repair Indications Seymour fracture is defined as a displaced physeal fracture of the distal phalanx with an associated nail bed injury. This pediatric fracture pattern is typically caused by a crush injury and can be classified as a Salter-Harris I or II fracture. The Seymour fracture is considered to be an open fracture because a nail bed laceration is present. Therefore…

Principles of bone fixation and healing

The essential components of fracture healing Fracture healing is a complex and dynamic process that restores injured bones to prefracture conditions. Fracture healing requires coordinated interactions among multiple cell types, cytokines, and growth factors. The healing process is influenced by the local mechanical and biologic environment, the surgical fixation device, and the reduction method. Maintaining adequate blood flow to the affected site is the primary determinant…

Splints and orthoses

Introduction This textbook describes over 120 surgical procedures of the finger, hand, wrist, and forearm. For many of these procedures, splints or orthoses are used to immobilize or support the operative sites. The goal of this chapter is to introduce the basic tenets of upper extremity splinting and to present the common orthoses that can be used during postoperative recovery. Basic principles of orthoses Think critically…

Finger infections (paronychia, felons, pyogenic flexor tenosynovitis)

Indications Paronychia, felons, and flexor tenosynovitis (FTS) are some of the most common infectious pathologies seen among hand surgeons. They are most often bacterial in origin—with Staphylococcus aureus as the most common pathogen—and can be pyogenic (pus-forming). Paronychia is an infection of the lateral or proximal nail fold and soft tissue, which can also extend to the germinal and sterile matrix beneath the nail. A felon…

Proximal upper extremity amputation

Indications The goal of upper extremity amputation is to provide a stable, functional limb with durable soft-tissue coverage to facilitate the use of a prosthesis. Upper extremity amputation is most common after unsalvageable trauma, such as a crushed/mangled extremity, amputation with prolonged ischemic time, electrical burns, complex vascular injury, or cold injury Amputation is also used to remove unresectable sarcoma, such as tumors with extensive vascular…

Finger amputations

Indications Digit amputation should be considered for any injury that damages a digit to the degree that vascularity, function, or soft tissue coverage cannot be restored. If at all possible, revascularization or replantation should be considered first. Amputation should also be considered after finger injuries that substantially destroy structural and/or functional integrity beyond the ability to adequately reconstruct. Ring avulsions or other traction injuries may leave…

Fasciotomy for compartment syndrome of the hand and forearm

Indications Compartment syndrome occurs when pressure within a fibroosseous space increases beyond a level that is suitable for perfusion across tissues. The most common cause of forearm compartment syndrome is fracture, especially distal radius fracture. Other causes of compartment syndrome include an injection injury, an extravasation injury, a penetrating trauma, circumferential burns, and snake or insect bites. Injection injuries involving air, water, or other hydrophilic liquids…

Anesthesia of the hand

Indications Local anesthesia has many practical uses and is straightforward to administer because of the superficial nature and consistent anatomic course of the sensory nerves surrounding the hand and wrist. It is increasingly used as the sole anesthetic in the outpatient setting for WALANT (wide awake, local anesthesia, no tourniquet) procedures. Local anesthetics can be administered to individual digits (digital block) along named sensory nerves, such…

Anterior Compartment Fasciotomy for Exertional Compartment Syndrome

Chronic exertional compartment syndrome (CECS) has been described in the upper extremities, spine, thigh, and most commonly, in the lower leg. The incidence of CECS in athletes with exercise-induced lower leg pain is reportedly as high as 27%. There is a roughly equal distribution of CECS between male and female athletes. Most information regarding the physiology of exertional compartment syndrome comes from the acute compartment syndrome…

Proximal Tibia Bone Graft

Indications Fusions and complex fractures in the foot and ankle often require cancellous bone graft. Ample bone (≤30 cc) is available from the proximal tibia. Bone harvest from the proximal tibial is less painful then from the iliac crest. The tibial site can easily be draped into the operative field. Treatment Options Iliac crest, distal tibia, or calcaneal autograft Allograft Bone graft substitutes Surgical Anatomy The…

Calf (Gastrocnemius) Release for Equinus Contracture

Acknowledgments Andrew K. Sands would like to acknowledge the assistance of Edmund Choi, MD, with this chapter. Indications Equinus contracture/tight calf is typically an associated condition of a primary diagnosis of a bunion and may exacerbate the bunion problem. In general orthopedic practice it is most commonly seen in flat or cavus feet. Associated with diabetes mellitus (DM) and has been shown to be an important…