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Tetraplegia

Synopsis ■ Suffering a spinal cord injury causes a huge life transition, where simple everyday tasks become a challenge. Patients with tetraplegia rank hand and arm control as their top functional restoration priotity. The primary goal for people with tetraplegia is increased independence. ■ There is no cure for spinal cord injuries, but highly specialized care can rehabilitate and partially restore some lost functions. ■ Restoration…

Brachial plexus injuries: adult and pediatric

Synopsis ■ Brachial plexus injuries (BPI) are characterized by many complex problems and remain a dilemma to many reconstructive microsurgeons. These complexities include: (1) diverse injury patterns; (2) disrupted anatomy; (3) unpredictable nerve degeneration and regeneration; (4) difficult physical examination and diagnosis; (5) challenging nerve surgery; (6) long rehabilitation; (7) different palliative surgeries for sequelae deformity; (8) no consensus of outcome evaluation; and (9) difficult pain…

Peripheral nerve repair and reconstruction

Synopsis ■ Nerve regeneration after injury is orchestrated by delicate processes in neurons, non-neural cells, and other cells at various levels from the periphery to the central nervous system. ■ The clinical effects of a nerve injury include not only impaired sensory and motor function, but also symptoms such as impaired dexterity, sensitivity to cold, and pain. Therefore, they have a severe impact on activities of…

Nerve entrapment syndromes

Synopsis ■ Chronic nerve entrapment syndromes in the upper extremity are common and their occurrence is only likely to increase as risk factors such as diabetes, obesity, and advanced age become more prevalent in the general population. ■ In most cases, the diagnosis is based on a good history and a proper physical examination. ■ A proper physical examination should include a clinical triad of muscle…

Occupational disorders of the hand

Synopsis Upper extremity problems that are attributed to the workplace require experience, a knowledge base, and skill set that set them aside from non-occupational injuries. A careful history, physical examination, and knowledge of current evidence is required to evaluate causation. The workers’ compensation environment creates external forces on the provider and patient that can adversely affect patient management and recovery. Management of work-related upper extremity disorders…

Rheumatologic conditions of the hand and wrist

Synopsis ■ Rheumatoid arthritis is a systemic autoimmune inflammatory disease that affects the joints of the hand and wrist. Rheumatoid arthritis also affects the soft tissues and can cause disease processes such as trigger finger and carpal tunnel syndrome. ■ The diagnosis of rheumatoid arthritis is primarily clinical and is supported by radiographic and laboratory studies. Although symptoms can usually be managed effectively with newer biologic…

Osteoarthritis in the hand and wrist

Synopsis ■ Osteoarthritis is characterized by a loss of articular cartilage. ■ The development of osteoarthritis is a dynamic process that represents an imbalance between destruction and repair of the articular cartilage. It can result from trauma, such as an intra-articular fracture, or a ligamentous injury that results in abnormal load-bearing characteristics or it can be idiopathic without an identifiable cause. ■ Osteoarthritis can affect the…

Dupuytren’s disease

Access video content for this chapter online at Elsevier eBooks+ Basic science and disease process Dupuytren’s disease (DD) is a primary fibroproliferative disorder of the palmar and digital fasciae of the hand. A similar disease process known as Ledderhose and Peyronie’s disease affects the feet and penis, respectively. Recent studies indicate that the condition occurs as a result of a complex interplay between genetic, epigenetic, immunologic,…

Tumors of the hand

Synopsis ■ Benign and malignant tumors of the hand arise from distinct tissue types. ■ The majority of these tumors are benign. ■ Accurate assessment, diagnosis, and treatment will optimize clinical outcomes. ■ Reconstructive procedures of the hand and upper extremity should be performed only after the diagnosis is confirmed and appropriate surgical margins are achieved. Introduction ■ Most tumors of the hand are benign, recognized…

Infections of the hand

Synopsis ■ Hand infections are common, with diverse etiologies. It is important to have a high index of suspicion to allow expeditious diagnosis and treatment in order to prevent morbidity and maximize outcomes. ■ A thorough understanding of hand anatomy and the pathophysiology of hand infections is necessary to adequately provide treatment and improve functional outcomes. ■ The treatment of hand infections includes the combination of…

Thumb reconstruction: Microsurgical techniques

Synopsis ■ Microsurgical toe-to-hand transplantation allows “like-with-like” reconstruction, achieving the best functional and aesthetic results. ■ Preservation of neurovascular bundles, flexor and extensor tendons, mobile joints, and viable skin with minimal bone shortening in the amputation stump ensures optimal functional results and less morbidity at the recipient and donor site, respectively. ■ Retrograde dissection of the vascular pedicle at the first webspace during toe harvest is…

Thumb reconstruction: Non-microsurgical techniques

Synopsis ■ Thumb reconstruction should aim to restore the cardinal thumb actions: mobility, stability, sensibility, length, and appearance. ■ Level of thumb loss is divided into thirds: distal (tip to interphalangeal joint), middle (interphalangeal joint to metacarpal neck), and proximal (metacarpal neck to carpometacarpal joint). ■ Distal-­third reconstruction typically warrants only soft-­tissue restoration. ■ Numerous options exist for middle-­third reconstruction, including increasing thumb ray length (metacarpal…

Replantation

Synopsis ■ Replantation has evolved through the development of advanced optics and microsurgical techniques. Every patient should be carefully evaluated and considered a candidate for replantation unless the patient declines or is unable to tolerate surgery. ■ The steps for replantation proceeds from a deep to superficial pattern, and in multiple digit amputations, using a structure-by-structure approach to maximize efficiency. ■ K-wires should be considered the…

Extensor tendon injuries

Synopsis ■ A thorough understanding of the complex anatomy is crucial for successful treatment of extensor tendon injuries. ■ Injuries are classified into nine anatomic zones. Treatment strategies vary considerably according to the location of the lesion, ranging from splinting to tendon grafting. ■ Minimal variations in tendon length may result in considerable alteration in range of motion. ■ As in flexor tendon injuries, postoperative care…

Flexor tendon injuries and reconstruction

Synopsis ■ Tendons transmit forces generated by muscles to move joints or to create action power. Flexor tendon injuries are common, but recovery of satisfactory function, particularly after injuries within the digital sheath, is sometimes difficult. Lacerated flexor tendons should be treated by primary surgical repair whenever possible. ■ The current trend of end-to-end surgical tendon repairs is to use multistrand core sutures (four-strand repairs such…

Fractures and dislocations of the wrist and distal radius

Synopsis ■ Wrist injuries are common, and proper management relies on an understanding of normal anatomy, alignment, and kinematics. ■ Scaphoid fractures can be subtle, and due to the precarious blood ­supply to this bone, may go on to non-union if not properly managed. ■ Indications for scapholunate ligament repair and/or reconstruction depend on the patient's symptoms and on the chronicity of the injury. ■ For…

Hand fractures and joint injuries

Synopsis ■ Diagnosis of hand fractures and joint injuries requires history, examination, and adequate imaging studies. ■ Treatment decisions are based on fracture geometry, stability, and individual patient needs. ■ Nonoperative principles include reduction, maintenance of reduction through casting, splinting or buddy taping, followed by protected motion. ■ Operative treatment includes closed reduction with or without percutaneous pinning, external fixation, and open reduction and internal fixation…

Nail and fingertip reconstruction

Synopsis ■ Fingertip and nail bed injuries are the most common injuries of the hand. ■ Large subungual hematomas should be drained to relieve pressure and pain; small and asymptomatic hematomas (<50%) can be observed. Trephination of a subungual hematoma is performed to relieve the throbbing pain associated with this injury. ■ When the nail plate is intact, not all nail bed lacerations need to be…

Principles of internal fixation

Synopsis Careful preoperative planning facilitates safe and expeditious surgery. ■ Ligamentotaxis relies on the intact soft-tissue envelope. By applying linear traction, it indirectly reduces fragments via the intact periosteum, ligaments, and soft tissues. ■ The most appropriate method of fracture fixation depends on a careful assessment of the fracture characteristics and patient-related factors. ■ Postoperative care should aim for early mobilization if fixation permits in order…