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-
seling 23;  Surgical Steps 24;  Postoperative Protocol 26

6. Posterior Interosseous Artery Flap 27

Indications 27;  Advantages 27;  Disadvantages 27;  Presurgical Coun-
seling 27;  Surgical Steps 28;  Postoperative Protocol 31

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

Presurgical Counseling  61;  Surgical Steps  61;  Postoperative Protocol  66

14. Staged Flexor Tendon Reconstruction 67

Presurgical Counseling  67;  Surgical Steps  68

15. Flexor Tenolysis 74

Presurgical Counseling  74;  Surgical Steps  74;  Postoperative Protocol  76

16. Extensor Tendon Reconstruction 77

Presurgical Counseling  77;  Surgical Steps  77;  Postoperative Protocol  79

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

Presurgical Counseling  80;  Surgical Steps  80;  Postoperative Protocol  82

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

Presurgical Counseling  83;  Surgical Steps  83;  Postoperative Protocol  85

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

Presurgical Counseling  91;  Surgical Steps  91;  Postoperative Protocol  93
 Contents xiii

21. Bone Grafting 94

Presurgical Counseling  94;  Surgical Steps  94;  Postoperative Protocol  95

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

Presurgical Counseling  105;  Surgical Steps  105;  Postoperative Protocol  107

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

Presurgical Counseling  178;  Surgical Steps  178;  Postoperative Protocol  180

41. Opponensplasty with Abductor Digiti Minimi Muscle (Huber’s Transfer) 181
Presurgical Counseling  181;  Surgical Steps  181;  Postoperative Protocol  183
 Contents xv

42. Claw Correction—Lasso Procedure 184

Presurgical Counseling  184;  Surgical Steps  184;  Postoperative Protocol  186

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

Transfer (Ef4t) Procedure 187
Presurgical Counseling  187;  Surgical Steps  187;  Postoperative Protocol  190

44. Claw Correction—Fowler Procedure 191

Presurgical Counseling  191;  Surgical Steps  191;  Postoperative Protocol  193

45. Tendon Transfer for Radial Nerve Palsy 194

Presurgical Counseling  194;  Surgical Steps  194;  Postoperative Protocol  197

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
When the patient presents in the outpatient
clinic, there is a set protocol to be followed.
Seating the Patient
• If the patient is an adult, he is first asked to be
seated comfortably, preferably on the right
side of the examiner. This position is more
comfortable for conducting the examination.
• If the patient is a child, the child can be
more comfortably examined if he is on his
mother’s or grandmother’s lap.
• If the patient is an infant, he can be made to
lie on the examination couch with adequate
protective pillows on either side. If the baby
is fidgety, he can be held by his mother or
grandparent on the shoulder and the child’s
hands can be examined from behind. The
complete examination of the baby may not
be possible in one consultation, especially
in cases like birth palsy. This is because, this
condition will show changes with time, and
these changes should be tracked religiously.
It will require serial consultations before a
definite diagnosis and plan of management
may be made.
Communicating with the Patient
• Developing a rapport with the patient
is a very important part of the initial
examination. Hand surgery is a specialty
1
where the patient-doctor relationship is
significant for many reasons:
• Deciding the management depends on
multivarious factors ranging from the
age, occupation, needs of the patient
and sometimes even what the patient
wants. The surgeon can get a clear idea
about the patient only if the patient is
able to communicate freely and without
fear or apprehension.
• Many of the procedures require a long
follow-up period. Only if the patient is
able to communicate with the surgeon
and vice-versa, this may be possible.
• Some of the surgical procedures
require multiple stages and the entire
reconstruction may take several months.
It is important that the patient trusts the
surgeon and attends each surgical stage.
• Some of the procedures like micro­
surgical toe transfers require the
transfer of one normal part of the
body to another part which has been
lost. Hence, there exists a small risk
of failure and the consequence is that
the patient loses another part of his
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
trust in the surgeon if he agrees for the
procedure.
• Some procedures like neurotization
procedures for brachial plexus injury
may have a long period before any
4 SECTION 1  GENERAL CONSIDERATIONS
change can be manifest. This should be
informed to the patient and the patient
will be able to understand this only if
the bond with the surgeon is strong.
• Legible language should be used when
communicating with the patient. It is ideal
that the conversation takes place in the
patient’s native language. This is because
the patient must be able to understand
correctly what is required of him. When the
hand is being tested for specific movements
and the action of specific muscles, surgeon
should give clear instructions as to how
the movement should be done, and if
necessary, demonstrate it on his own
hand, before the patient is asked to do it.
• If the patient is a child, the pros and cons of
the treatment options must be discussed
with the parents of the child if possible, or
the guardians of the child.
Eliciting the History
As in any medical examination, the history
plays an important role. In patients with hand
injury, there are a few points to be emphasized
while eliciting the history. The general points
are discussed here, but there are specific
details required in different conditions which
will be dealt with in the relevant sections.
• Nature of complaints
• Duration of complaints
• Exact date of injury if any
• History of previous treatment
Examination of the Patient
This book has described in detail, the
examination of the different tissues of the
hand, such as skin, bone, tendon, nerve, etc.
So it is mandatory that a preliminary diagnosis
be made of the tissue involved before the
appropriate examination is conducted.
Sometimes, the involvement is not restricted
to one tissue alone like tendon or bone. It
may encompass different tissues and all
these should be identified in the preliminary
examination. There are a few pointers which
will help surgeon to identify the problem.
Then the assessment of the problem is
made as described in the appropriate chapter:
• If there is a raw area → go to chapter on raw
areas on skin
• If there is evidence of adherent skin or scar
→ go to chapter on other problems of skin
• If there are no movements in parts of the
hand or movements of the finger are not
full → go to chapter on tendons and nerves
to identify the problem
• If movements lost and sensation lost → go
to chapter on nerves
• 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
chapter on joints
• If there is a postburn contracture → go to
chapter on contractures
• If there is a paralysis/weakness of the hand
alone → go to chapter on Hansens
• If there is a history of injury in the neck
or shoulder area, and there is some loss
of movements in the upper limb → go to
the section on traumatic brachial plexus
injuries
• If there is a history of no movements of the
upper limb noticed immediately after birth
→ go to the chapter on obstetric brachial
plexus injuries to help in evaluation and
management.
• If there is evidence of involvement of
multiple tissues like skin and tendon,
or tendon and bone, the sequence of
management is described in the chapter
on complex post-traumatic problems.
• If there is a problem of the thumb, it
is dealt with in the chapter on thumb
reconstruction.

And, based on the assessment, the plan of
surgery can be made. This is also described in
the same chapter as the assessment.
No clinical diagnosis is complete without
making a plan of the sequence of management.
There are many modalities of management, like
CHAPTER 1  EXAMINATION OF THE HAND 5
physiotherapy, splints, and surgical procedures
either in multiple stages or in a single stage.
A logical sequence of management should
be made which should suit the needs of the
patient, and which will result in a useful
function on the involved hand.
 SECTION

Skin Reconstruction
 Assessment of
Skin Loss on the Hand
Introduction
This chapter refers to skin loss and raw areas
that are not seen in the emergency situation,
but at a time that is beyond the stage of
primary reconstruction.
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.
Other causes include burns including electrical
burns and infections. There are other situations
like tumors, burn contractures and congenital
anomalies where skin loss becomes apparent
after the condition is operated on. Such
conditions will be dealt with later. This chapter
deals with apparent raw areas that need skin
cover.
Before planning for treatment of a raw
area on the hand, a systematic assessment
is required. Only a correct evaluation of the
problem can lead to a suitable surgical option
being chosen as management. Achieving a
good skin cover on the hand is not the goal,
but achieving good function in the hand is
the ultimate aim. All our efforts in choosing
a skin cover must be focused on the issue of
achieving function.
Qualities of an ideal skin cover for a defect on
the hand:
• Must be durable skin
• Must be cosmetically pleasing
• Must be sensate
• Must be pain-free.
2
The surgical procedure that is planned for the
patient ideally:
• Must be a single-staged procedure
• Must have minimal or no donor site
morbidity
• Must have only a negligible risk factor
• Should be easy to perform.
Assessment of the Raw Area
Site of the defect: The exact location of the
defect must be noted. Defects in different
areas require different types of skin cover. A
defect on the pulp of the thumb requires a
skin cover that is sensate to allow the thumb
to function normally. However, there are
certain flaps that are designed for typical
defects. Raw areas on the volar aspect of the
fingers can be covered with cross-finger flaps
from the adjoining finger.
Size of the defect: The size of the defect is
important for planning a skin cover. Small
defects may be covered with local flaps. If,
however, the defect is larger, other flaps may
have to be thought of.
Shape of the defect: The direction and shape of
the defect can also influence the plan.
Floor of the defect: If the floor of the defect
exposes bone or tendon, a vascularized skin
cover is required.
Edges of the defect: The edges of the defect
are important in deciding on the plan of skin
cover. If the edges are unhealthy or macerated,
10 SECTION 2  SKIN RECONSTRUCTION

the skin cover planned should be larger than
the actual defect itself as the debridement of
unhealthy tissues is of paramount import­
ance. If the edges are everted or rolled out,
suggesting a malignancy, the total plan may
be different.
Distal deficit: A careful assessment of the
distal finger or hand must be made.
1. Associated tendon injury or loss: If there
is an associated injury or loss of tendon;
either flexor or extensor, the skin flap
should be given first and the tendon
reconstruction can be done later when
the skin flap has settled and become soft
and supple. Simultaneous reconstruction
of the tendons also along with the skin
cover is done only in situations where the
skin flap that has been planned is a free
flap like the anterolateral thigh flap where
100 percent inset is given, i.e. the flap
completely covers the defect and no area is
exposed to the environment. Simultaneous
reconstruction of the tendons can also
be done if a pedicled island flap like the
radial artery forearm flap or a posterior
interosseous artery flap is used for skin
cover as these flaps also provide total inset.
2. Associated bone fracture with or without
loss: Skeletal stability is essential before
planning a skin cover. However, if there is
a fracture, internal fixation through a raw
area is not prescribed. But stability must
be achieved and this can be done by the
use of external fixators that can stabilize
the skeleton when the skin cover is given.
When there is a bone loss, primary bone
grafting is not advised and must be done at
a later date after the skin reconstruction is

Table 2.2.1 Assessment of raw area and surgical plan

Site of raw area
Single finger
Multiple fingers
Thumb
Loss of thumb or circumfer-
ential loss on the fingers
Skin loss on the dorsum of
hand
Skin loss on the palm
End-on defect
Large defects on the hand
Degloving injury of the
entire hand and fingers
Characteristic
Defect on volar aspect alone
Defect on dorsal aspect alone
Defect on dorsum of PPX alone
Defect on volar aspect alone
Defect on dorsal aspect alone
Skin loss on the pulp
Skin loss on the dorsum up to the
interphalangeal (IP) joint
With less expertise
With more expertise
With less expertise
With more expertise
On the thumb
On multiple fingers
With less expertise
With microsurgical expertise
Surgical plan
Cross-finger flap (CFF)
Reverse dorsal cross-finger flap (RDCFF)
Reverse dorsal metacarpal artery flap
Abdominal flap-superiorly based
Abdominal flap-inferiorly based
Neurovascular island flap of littler
First dorsal metacarpal artery flap
Groin flap
Abdominal flap-inferiorly based
Posterior interosseous artery flap
Abdominal flap-superiorly based
Reverse flow radial artery flap
Staged island flap of Professor R
Venkataswami
End-on groin flap
Quadrant flap
Free anterolateral thigh flap
Buried abdominal flap
 CHAPTER 2  ASSESSMENT OF SKIN LOSS ON THE HAND
over. In the meantime, to achieve stability,
external fixators can be applied. Primary
reconstruction of the skin and bone can be
done if a free flap or pedicled island flap is
planned as skin cover.
3. Associated nerve injury or loss: This should be
reconstructed after the skin reconstruction
is over unless a free or pedicled island flap is
used as skin cover.
Table 2.2.1 shows the assessment of raw
area and surgical planning.
The commonly used flaps like the cross finger flap,
abdominal flap and groin flap are not discussed in
this manual.
Assessment of the Patient
Certain points are to be remembered when
deciding on skin cover:
11
• Very anxious patients: Select a safe and
time-tested flap. Leave very little margin
for failure or complications.
• Mentally unsound patients: Select a single-
staged flap. Choosing a staged flap like
the groin or abdominal flap may result in
complications as the patient will not be
compliant.
• Children: Usually are very compliant for
even pedicled flaps like groin or abdominal
flaps.
• Elderly patients: Avoid staged procedures.
These may cause stiffness of joints. Select
the simplest procedure.
Always talk to the patient about the procedure,
the postoperative period and possible out­
come. Get their full consent before embarking
on the surgery. Even if the patient is a child
of school going age, talk with him. Their level
of understanding will sometimes surprise
surgeon!
 Littler’s Island Flap
Introduction
The flap of choice for the reconstruction of
a defect on the pulp region of the thumb is a
neurovascular island flap described by Littler.
Advantages
• It brings partly glabrous skin to the pulp of
thumb which is well padded, durable and
cosmetically appealing.
• It is sensate and hence the function of the
thumb is not interfered with.
• It is a single staged procedure.
Disadvantages
• It requires a surgical expertise in performing
this procedure.
• It entails significant donor site morbidity—
there is loss of sensation on the ulnar half
of the middle finger, there is a significant
scarring on the middle finger.
• Sensory re-education is necessary to get
appreciable sensation on the flap.
Presurgical Counseling
• This procedure is planned to cover the raw
area on the thumb with skin and tissues
with sensation.
3
• This procedure will be done under axillary
block anesthesia or GA in children.
• This procedure will take about 3 hours to
perform.
• Skin will be removed along with soft
tissues from the middle finger and placed
on the raw area of the thumb. This will
entail making incisions on the palm also.
A skin graft will be taken from the medial
side of the upper arm and applied over the
secondary raw area on the middle finger.
There will be a loss of sensation on one
side of the middle finger and there will be a
scar on the finger. There will also be a scar
on the medial side of the arm.
• Admission will be necessary for a mini-
mum period of 3 days
• A dressing will be applied and a plaster
of Paris (POP) will be applied, which
will be retained for 10 days, following
which, physiotherapy will be started.
At the beginning, when the thumb is
touched, it will feel as if the middle finger
is being touched. During the period of
physiotherapy, techniques will be taught
to make the sensation more natural. The
sensation that returns may not be equal to
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
after­­­ward.
• In some instances, the flap may not be
possible because of anatomical variations.
In such cases, other surgery like a cross-
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
14 SECTION 2  SKIN RECONSTRUCTION
• From the proximal border of the flap,
make a marking on the ulnar neutral
line till the web area to reach point “B”.
• Now draw the axis of the flap, i.e. from
point “A” to point “B”. However, this
should not be a straight incision, as
it will lead to a straight line scar that
may lead to a contracture. It should
be a zigzag line marked with two
considerations: (1) the axis of the flap
and (2) the transverse creases on the
palm. From point “B”, move at an angle
of 30° to the nearest transverse crease,
run along the crease till you cross the
axis line. Now, again move to the next
proximal transverse crease and when
you reach it, run along the crease till
you cross the axis line. Then move
directly to point “A”. This is the marking
for the incision.
8. First make the incisions marked from “A”
to “B”. This incision should go through
the skin and the subcutaneous tissue, till
the palmar aponeurosis is seen. Lift up
this thick fascia with a forceps and open
it with a knife. The neurovascular bundle
is directly below this fascia, hence this
step must be done carefully. This should
be done along the entire length of the
marked axis of the flap. Remember that
the distal 2 to 3 cm of the palm will not
have a palmar aponeurosis. When this
step is over, the neurovascular bundle
will be exposed in the proximal 2/3 of the
wound. Place a small gauze soaked in 1
percent xylocaine over the neurovascular
bundle to prevent the vessels from going
into spasm. There will be about 4 to 6
triangular flaps that must be raised and
anchored with 3.0 ethilon to enhance the
exposure and facilitate further dissection.
9. The dissection of the vascular pedicle
begins here. Gently hold the soft tissues
around the neurovascular bundle with
a Jeweler’s forceps and examine the
anatomy. One digital nerve and one digital
artery will be seen. The digital nerve will
be seen to divide into two branches to
supply the middle and ring fingers. Gently
tease the tissues between the two branches
of the common digital nerve and keep
separating them proximally. Never dissect
between the digital artery and the nerves.
Dissect only to separate the ring finger
digital nerve away from the bundle. Again
it is reiterated that dissection should never
be done between the digital artery and
the digital nerve to the middle finger as
it damages the minute veins that serve as
venous drainage for the flap. Stop when
the digital nerve of the ring finger has
been separated up to the pivot point. Now
cauterize gently the small branches from
the digital artery to the deeper tissues.
Now the neurovascular bundle has been
dissected free in the palm. The pad of fat in
the web space must be carefully teased to
expose the bifurcation of the proper digital
artery into the branches to the middle and
ring fingers. Ligate and cut the branch to
the ring finger a few millimeters from the
bifurcation.
Take great care in preventing damage to the vessel
or excessive handling of the vessels as it may lead
to spasm of the vessel.
10. Now the flap can be raised. Make the
first incision on the mid-volar side. This
incision must be down to the fibrous
flexor sheath. There are a few transversely
oriented subcutaneous volar veins at this
area which must be cauterized. The volar
portion of the flap can be raised now, up to
the neutral line. The next incision should
be made on the dorsal side down to the
extensor paratenon and the dorsal portion
of the flap raised. Now the distal margin
of the flap incised and the neurovascular
bundle ligated with 3.0 vicryl and cut. The
flap is now attached by the Grayson’s and
Cleland’s ligaments. To divide these, the
flap must be lifted up, the neurovascular
bundle confirmed to enter the flap and
the ligaments must be divided close to the
bone. This will free the flap some more.
 CHAPTER 3  LITTLER’S ISLAND FLAP 15

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
16 SECTION 2  SKIN RECONSTRUCTION
through the tunnel. Grasp the 3.0 vicryl
stitches that have 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 number 13. After
delivering the flap in the wound site,
confirm the viability of the flap. If there
is reduced bleeding from the edges of the
flap, the tunnel is most probably tight at
the proximal edge which can be vented
with a small incision of about 2 to 3 mm.
This flap is usually a robust flap and there will be
very brisk bleeding from the edges, especially after
transfer. This is because the venous drainage takes
time to regularize. So, get hemostasis on the edges
of the flap before applying the insetting sutures!
19. Flap inset: After confirming the hemostasis
and the viability of the flap, inset can be
done with 4.0 ethilon using half buried
horizontal mattress suturing (Fig. 2.3.5).
Fig. 2.3.5  After final flap inset and donor site
closure with skin graft
20. Management of the donor area: After
confirming hemostasis, the palmar flaps
should be replaced and sutured with
4.0 ethilon. The residual raw area on the
middle finger should be covered with a
split thickness skin graft. At the points
where the defect crosses the proximal
interphalangeal (PIP) and DIP joint
creases, back cuts should be given for
3 mm. to avoid skin graft contractures
later on. Now raise the hand and prepare
the arm with betadine solution. The skin
graft should be harvested from the medial
side of the arm. Sterile dressings should be
applied over the skin graft donor site before
moving back to the hand. The graft should
be applied over the raw area and tie over
sutures applied with 3.0 ethilon. Drainage
tubes should be kept below the suture line
on the palm of the hand. The preferred
drainage tube would be Segmüller tube
which consists of segments of the scalp
vein set tubing.
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
or after complete recovery if under general
anesthesia

• Clinical monitoring of the flap once every
6 hours
• 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
removal of donor site dressing on the arm
• Removal of the POP slab on the 14th day
and advice the following:
CHAPTER 3  LITTLER’S ISLAND FLAP 17
• Refer to physiotherapy for active and
passive mobilization of the thumb and
fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil.
• Compression garment for scar softening
after a further 2 weeks
• Sensory re-education exercises by
physiotherapist.
 First Dorsal
Metacarpal Artery Flap
Introduction
First dorsal metacarpal artery flap is the flap
of choice for defects on the dorsum of the
thumb not extending beyond the level of the
interphalangeal (IP) joint. The flap is based on
the first dorsal metacarpal artery that usually
arises from the radial artery at the level of the
anatomical snuffbox.
Advantages of the Flap
• It is a single-staged procedure
• It is a sensate flap (because it is neurotized
by the branches of the superficial branch
of the radial nerve)
• Minimal morbidity in terms of donor site
scarring.
Disadvantages of the Flap
• It is not very reliable (because of
inconsistent anatomy)
• It requires expertise to raise this flap
• An alternate plan must always be ready.
Presurgical Counseling
• This procedure is planned to cover the raw
area on the thumb with skin and tissues
with sensation.
4
• This procedure will be done under axillary
block anesthesia or GA in children.
• This procedure will take about 3 hours to
perform.
• Skin will be removed along with soft
tissues from the index finger and placed on
the raw area of the thumb. This will entail
making incisions on the back of the hand
also. A skin graft will be taken from the
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
finger, but there will be a scar on the finger.
There will also be a scar on the medial side
of the arm.
• Admission will be necessary for a
minimum period of 3 days.
• A dressing will be applied and a plaster
of Paris (POP) will be applied, which
will be retained for 10 days, following
which, physiotherapy will be started. The
sensation that returns may not be equal to
the sensation on the normal thumb.
• A splint will have to be applied on the index
finger for a period of 3 to 4 weeks afterward.
• In some instances, the flap may not be
possible because of anatomical variations.
In such cases, other surgery like an
abdominal flap may be done.
• 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.
 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.
20 SECTION 2  SKIN RECONSTRUCTION

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
and the pivot point of the flap. This tunnel
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.
18. When good bleeding is seen from the
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
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 number 14. After delivering the flap
in the wound site, confirm the viability of
the flap. If there is reduced bleeding from
the edges of the flap, the tunnel is most
probably tight at the proximal edge which
can be vented with a small incision of about
2 to 3 mm.
20. Flap inset: After confirming the hemostasis
and the viability of the flap, inset can be
done with 4.0 ethilon using half-buried
horizontal mattress suturing.
21. Management of the donor area: After
confirming hemostasis, the gap in the
extensor expansion should first be
repaired primarily with 4.0 polypropylene
materials using horizontal mattress
suture. The dermal flaps should be
replaced and sutured with 4.0 ethilon.
The residual raw area on the dorsum of
the index finger should be covered with a
split thickness skin graft (Fig. 2.4.3). Now
Fig. 2.4.3  After flap inset
raise the hand and prepare the arm with
betadine solution. The skin graft should
be harvested from the medial side of the
arm. Sterile dressings should be applied
over the skin graft donor site before
moving back to the hand. The graft should
be applied over the raw area and tie over
sutures applied with 3.0 ethilon. Drainage
tubes should be kept below the suture line
on the dorsum of the hand. The preferred
drainage tube would be Segmüller tube,
which consists of segments of the scalp
vein set tubing.
22. Sterile dressings should be applied over
the index finger, dorsum of hand and
the thumb. Care must be taken to avoid
compression of the pedicle at any point
of its course. A volar POP slab should be
applied for the thumb keeping it in palmar
abduction and another slab for the hand
keeping the MCP joints of the fingers in
flexion of 90º and IP joints in extension.
A window must be made in the dressings
22 SECTION 2  SKIN RECONSTRUCTION
to allow inspection and monitoring of the
flap.
If there is evidence of reduced blood flow in
the flap postoperatively, the sutures should be
removed immediately and all tension released
from the suture line.
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
or after complete recovery if under general
anesthesia
• Clinical monitoring of the flap once every
6 hours
• 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 removal
of donor site dressing on the arm
• Removal of the POP slab on the 14th day
and advise 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
after a further 2 weeks.
 Reverse Dorsal
Metacarpal Artery Flap
Introduction
This flap is a useful flap in the armamentarium
of the hand surgeon. It serves as an ideal skin
cover for defects on the dorsum of the fingers
on the proximal phalangeal region alone.
The flap cannot cover defects that extend
beyond the proximal interphalangeal (PIP)
joint. Three dorsal metacarpal artery flaps
are possible from the dorsum of the hand: the
second, third and fourth dorsal metacarpal
artery flaps. The second dorsal metacarpal
artery flap can cover defects on the dorsum
of the index or middle fingers. Similarly, the
third dorsal metacarpal artery flap can cover
defects on the dorsum of the middle or ring
fingers, and the fourth dorsal metacarpal
artery flap can be used for defects on the ring
or little fingers.
This flap can be planned only if two criteria
are met:
1. The width of the flap should be such that
primary closure of the defect must be
possible on the dorsum of the hand. This
can be assessed by pinching up a fold of
skin on the dorsum of the hand.
2. The length of the flap should not extend
beyond the dorsal wrist crease.
Advantages of the Flap
• It is a single stage procedure
5
Disadvantages of the Flap
• It is not a very reliable flap as there are
many anatomic variations
• It is a reverse flow flap and hence, like all
reverse flow flaps, is prone for venous
congestion.
• There is considerable donor site morbidity.
Presurgical Counseling
• This procedure is planned to cover the raw
area on the finger with skin and tissues.
• This procedure will be done under axillary
block anesthesia.
• This procedure will take about 3 hours to
perform.
• Skin will be removed along with soft
tissues from the back of the hand and
placed on the raw area on the finger. There
will be a scar on the back of the hand.
• Admission will be necessary for a minimum
period of 3 days.
• A dressing will be applied and a plaster
of Paris (POP) will be applied, which will
be retained for 10 days, following which,
physiotherapy will be started
• In some instances, the flap may not be
possible because of anatomical variations.
In such cases, other surgery like a cross-
finger flap may be done
• The general complications of local
anesthetic infiltration like hypersensitivity
24 SECTION 2  SKIN RECONSTRUCTION
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. 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 (Fig. 2.5.1):
• Mark the two knuckle prominences
corresponding to the flap that has
been chosen. If the second dorsal
metacarpal artery flap has been
chosen, the knuckles of the index and
middle fingers are the landmarks. If
the third dorsal metacarpal artery flap
7. Now, make the incision “DCE”. This
8. Now, make the incisions “EBD” and “BA”.
Fig. 2.5.1  Flap markings
has been decided on, the middle and
ring finger knuckle prominences form
the landmarks. Similarly, the knuckle
prominences of the ring and little
fingers are the landmarks if the fourth
dorsal metacarpal artery flap has been
chosen.
• Mark a point “A” about 1 cm proximal
to the knuckle prominences. This point
forms the pivot point of the dorsal
metacarpal artery flap.
• Measure the distance between the
points “A” and the proximal border of
the defect. This distance is the length of
the pedicle
• Transpose this distance proximal to
the point “A” on the dorsum of the hand
and mark this point as “B”. Place the
lint pattern with its proximal border
at point “B” and make the marking of
the flap. When this is done, the distal
end of the flap marking “C” must not
extend beyond the wrist joint line
• Mark two parallel lines on either side
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”.
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.
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
a few subcutaneous veins. These veins
 CHAPTER 5  REVERSE DORSAL METACARPAL ARTERY FLAP
Fig. 2.5.2  Flap after elevation
are important to ensure good venous
drainage for the flap. Incise the fascia at
the marked area. Now, lift the distal edge
of the flap with skin hooks and elevate the
flap off the bed. This dissection should
stop at point “A”. The flap has now been
elevated (Fig. 2.5.2).
9. 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. This tunnel should be
wide enough to hold the flap as it passes
through, without traumatizing it.
10. Apply a stitch with 3.0 nylon on the
leading edge of the flap.
11. 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.
12. 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
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
hemostasis on the bed of the flap and the
primary defect.
13. When good bleeding is seen from the
edges of the flap, it is ready for transfer.
14. Pass a heavy curved hemostat from the
proximal edge of the 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
sometimes undergoes vascular compromise are
the following reasons:
• Tightness of the tunnel as mentioned
• Tight inset of the flap edges to the edges of the
defect
• If there is tightness of the tunnel, the tunnel is
most probably tight at the proximal edge which
can be vented with a small incision of about 2–3
mm
• If there is tightness of the suture line of the inset,
remove the sutures on one side—either the
radial or ulnar side and cover this exposed area
with a skin graft.
15. Flap inset: After confirming the hemostasis
and the viability of the flap, inset can be
done with 4.0 ethilon using half buried
horizontal mattress suturing.
16. Management of the donor area: After
confirming hemostasis, the defect
should first be closed primarily with 4.0
polypropylene materials using vertical
mattress suture. The dermal flaps should
be replaced and sutured with 4.0 ethilon
(Fig. 2.5.3). Drainage tubes should be
kept below the suture line on the dorsum
of the hand. The preferred drainage tube
would be Segmüller tube which consists
of segments of the scalp vein set tubing.
26 SECTION 2  SKIN RECONSTRUCTION
Fig. 2.5.3  After flap inset and management of the donor site
17. Sterile dressings should be applied over
the index finger, dorsum of hand. Care
must be taken to avoid compression of
the pedicle at any point of its course. A
volar POP slab should be applied for the
hand keeping the metacarpophalangeal
(MCP) joints of the fingers in flexion of
90° and interphalangeal (IP) joints in
extension. A window must be made in
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.
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
or after complete recovery if under general
anesthesia
• Clinical monitoring of the flap once every
6 hours
• 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
removal of donor site dressing on the arm
• Removal of the POP slab on the 14th day
and advise 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
after a further 2 weeks.
 Posterior Interosseous
Artery Flap
Introduction
The posterior interosseous flap is a reverse
flow flap based on the posterior interosseous
artery.
Indications
• Defects on the dorsum of hand with no
tendon injury
• Defects on the dorsum of hand and a single
finger not extending beyond the proximal
interphalangeal (PIP) joint
• Defects on the ulnar border of the hand
• Defect on the thumb web or dorsum of the
thumb
• Defects on the flexor aspect of the wrist.
Advantages
• It is a single-staged procedure
• Reliable flap
• Same field of regional block anesthesia.
Disadvantages
• Brings hair bearing skin to the hand
• Donor site morbidity is high
• Requires expertise.
6
Presurgical Counseling
• This procedure is planned to cover the raw
area with skin and tissues
• This procedure will be done under axillary
block anesthesia (except for children,
in whom general anesthesia may be
required) with a short general anesthesia
while harvesting a skin graft from the thigh
• This procedure will take about 3 hours to
perform
• Skin will be removed along with soft
tissues from the back of the forearm and
placed on the raw area. A skin graft will
be taken from the medial side of the thigh
and applied over the secondary raw area
on the forearm. There will be no deficit on
the forearm, but there will be a scar on the
forearm. There will consequently be a scar
on the thigh also
• Admission will be necessary for a
minimum period of 3 days
• A dressing will be applied and a plaster
of Paris (POP) will be applied, which will
be retained for 10 days, following which,
physiotherapy will be started
• In some instances, the flap may not be
possible because of anatomical variations.
In such cases, other surgery like an
abdominal/groin flap may have to be done.
• In rare instances, after the flap has been
done, there may be a problem to the
vascularity and the flap may necrose. In
such cases, other surgery like an abdominal
28 SECTION 2  SKIN RECONSTRUCTION
or groin flap may be required to be done
later
• 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.
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.
7. Markings for the flap (Fig. 2.6.1): Mark the
following points on the extensor aspect of
the forearm (the markings must be made
before the tourniquet is raised):
• Point “A”—radial styloid
• Point “B”—head of ulna
• Join points “A” and “B”
• Mark a point “C” at the junction of
ulnar one-third and radial two-thirds
of line AB. This represents the point
where the posterior interosseous artery
anastomoses with the terminal end of
the anterior interosseous artery.
• Mark a point “D” exactly over the
lateral epicondyle.
Fig. 2.6.1  Preliminary markings
• Join the points “C” and “D”. This
represents the axis of the flap, i.e. the
course of the posterior interosseous
artery, even though the origin of the
artery is about 8 cm distal to point “D”.
• Mark a point “E” about 2 cm proximal
to point “C”, on the line CD. This will
represent the distal most point of our
dissection
• Mark the mid-point “F” of the line CD.
Mark another point “X, 1 cm distal to
the point “F”. This point “X” represents
the point at which the central
cutaneous perforator of the posterior
interosseous artery appears. This point
must be included in the flap (Fig. 2.6.2).
• Now, measure the distance between
the point “E” and the proximal edge
of the defect. This will represent the
length of the pedicle. Transpose this
distance on the line ED and mark the
point as “G”. Place the lint pattern of
the defect centered on the axis DE,
with its proximal edge at the point “G”.
Make sure that the flap covers the point
“X”. Also make sure that the proximal
border is at least 6 cm distal to point
“D”.
• Draw a transverse line 2 cm proximal
to the point “X” to meet the radial and
ulnar sides of the marked flap at “H”
and “I” respectively. Draw two lines
2 cm parallel to the line CG, one on
the radial side and one on the ulnar
side. These lines represent the limit
of dissection on the radial and ulnar
sides. These lines will cut the marking
of the flap at the points “J” and “K” on
the radial and ulnar sides respectively.
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)
30 SECTION 2  SKIN RECONSTRUCTION
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.
11. Lift-up the flap and divide the inter­
muscular septum deep to the level of the
posterior interosseous vessels. As you
keep advancing, make sure to cauterize or
ligate the muscular branches.
  Keep ensuring that no damage occurs to
the vascular pedicle. When we encounter
some small branches to the ulna bone, it
means we have come close to the pivot
point. In this way, the flap can be raised
up to the level of the point “D”. At this
level, the vessels will lie between the ECU
and EDM tendons.
  Transpose the flap to the defect to
approximately see whether the flap covers
the defect (Fig. 2.6.4). If it does not do so,
elevate the pedicle a little more.
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
pedicle tissue. Hence, the chances of injury to
the vessel are high. The way to avoid injury to the
vessels at this level is to raise the pedicle tissue very
close to the ulna bone which lies underneath.
12. 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. This tunnel should be
wide enough to hold the flap as it passes
through, without traumatizing it.
13. Apply a stitch with 3.0 vicryl on the leading
edge of the flap.
Fig. 2.6.4  Checking the reach of the flap
14. 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.
15. 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.
This flap is usually a robust flap and there will be
good bleeding from the edges. Before transferring
the flap, turn the flap raw side up and get
hemostasis on the pedicle carefully!
16. When good bleeding is seen from the
edges of the flap, it is ready for transfer.
17. Pass a heavy curved hemostat from the
proximal edge of the 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
 CHAPTER 6  POSTERIOR INTEROSSEOUS ARTERY FLAP
flap in the wound site, confirm the viability
of the flap. If there is reduced bleeding
from the edges of the flap, the tunnel is
most probably tight at the proximal edge
which can be vented with a small incision
of about 2 to 3 mm.
18. Flap inset: After confirming the hemostasis
and the viability of the flap, inset can be
done with 4.0 ethilon using half buried
horizontal mattress suturing.
19. Management of the donor area: After
confirming hemostasis, the dermal flaps
should be replaced and sutured with
4.0 ethilon. The residual raw area on the
extensor aspect of the forearm should be
narrowed with 3.0 vicryl. Now prepare the
thigh with betadine solution. The skin graft
should be harvested from the medial side
of the thigh. Sterile dressings should be
applied over the skin graft donor site before
moving back to the hand. The graft should
be applied over the raw area and tie over
sutures applied with 3.0 ethilon. Drainage
tubes should be kept below the suture line
on the forearm. The preferred drainage tube
would be Segmüller tube which consists of
segments of the scalp vein set tubing.
20. 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 volar
POP slab should be applied for the hand
keeping the wrist in 30° extension, and the
metacarpophalangeal (MCP) joints of the
fingers in flexion of 90° and interphalangeal
(IP) joints in extension. A window must be
made in the dressings to allow inspection
and monitoring of the flap.
31
Inspect the flap after 6 hours. This is a critical period
in the phase of the flap when the venous drainage
has become established. However, there may be a
hematoma due to bleeding in the interim period,
and this may compress the vascular pedicle. If
so, removal of one or two sutures and gentle
compression to evacuate the hematoma will
restore equilibrium in 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
or after complete recovery if under general
anesthesia
• Clinical monitoring of the flap once every
6 hours
• 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
removal of donor site dressing on the arm
• Removal of the POP slab on the 14th 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
after a further 2 weeks.
 Radial Artery Forearm Flap
Introduction
Radial artery forearm flap is one of the
versatile flaps being used in hand surgery
ever since it was described by the Chinese.
It can be used as a pedicled flap or as a free
flap. In this chapter, its use as a pedicled flap
is described. When used as a pedicled flap, it
is a reverse flow flap.
Advantages
• 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
hand.
Disadvantages
• It involves the sacrifice of a major artery of
the upper limb
• It leaves a very bad scar on the forearm.
Presurgical Counseling
• This procedure is planned to cover the raw
area with skin and tissues.
• This procedure will be done under axillary
block anesthesia, with a short general
anesthesia while harvesting a skin graft
from the thigh.
• This procedure will take about 3 hours to
perform.
7
• Skin will be removed along with soft tissues
from the forearm and placed on the raw
area. A skin graft will be taken from the
medial side of the thigh and applied over
the secondary raw area on the forearm.
There will be no deficit on the forearm, but
there will be a scar on the forearm. There
will consequently be a scar on the thigh also.
• Admission will be necessary for a minimum
period of 3 days.
• A dressing will be applied and a plaster
of Paris (POP) will be applied, which will
be retained for 10 days, following which,
physiotherapy will be started.
sible because of anatomical variations. In
such cases, other surgery like an abdomi-
nal or groin flap may be done.
• In rare instances, after the flap has been
done, there may be a problem to the
vascularity and the flap may necrose. In
such cases, other surgery like an abdominal
or groin flap may be done later.
• The general complications of local anes-
thetic 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.
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.
7. Markings for the flap (Fig. 2.7.1):
• Draw a point “A” on the distal most
palpable pulsation of the radial artery
proximal to the wrist.
• Mark a point “B” on the palpable biceps
tendon in front of the elbow.
• Join the points “A” and “B”. This forms
the axis of the flap.
• Mark a point “C” about 2 cm proximal
to point “A” on the line AB. This will
represent the distal most point of our
dissection.
• Now measure the distance between
the point “C” and the proximal edge
of the defect. This will represent the
length of the pedicle. Transpose this
distance on the line AB and mark the
point as “D”. Place the lint pattern of
the defect centered on the axis AB, with
its proximal edge at the point “D”. Mark
the flap. Mark the distal most point on
the flap as “G”.
• Draw two lines 2 cm parallel to the line
CD, one on the radial side and one on
the ulnar side. These lines represent the
limit of dissection of the subcutaneous
cuff on the radial and ulnar sides. These
lines will cut the marking of the flap at
the points “E” and “F” respectively on
the radial and ulnar sides.
Fig. 2.7.1  Markings for the flap
CHAPTER 7  RADIAL ARTERY FOREARM FLAP 33
8. Make the incision on the ulnar border
of the flap from “G” to “F”. This incision
should be down to the level of the deep
fascia of the forearm. Raise the flap
superficial to the deep fascia, till the ulnar
border of the flexor carpi radialis muscle
is seen below the fascia. Now, deepen
the incision and divide the deep fascia.
Now continue raising the flap over the
muscle, while applying gentle radialward
and upward traction on the flap. Along
the radial border of the muscle, the radial
vascular bundle can be seen lying in a
septum. Do not dissect on this septum
now. Keep dissecting close to the muscle
only. Apply a retractor on the radial border
of the flexor carpi radialis muscle and
retract it toward the ulnar side. This will
expose the small branches of the radial
artery to the flexor muscles. Carefully
divide them away from the radial artery
and secure hemostasis.
9. Now make the incision on the radial side
from “G” to “E”. Raise this flap superficial
to the deep fascia. In this way we can avoid
injury to the superficial branch of the
radial nerve. Deepen the incision when
the ulnar border of the brachioradialis
muscle is seen beneath the fascia. Now
raise the flap off the muscle by applying
gentle ulnarward and upward traction on
the flap. The radial vascular bundle can
now be seen on the radial border of the
muscle and its tendon. Apply a retractor
on the ulnar border of the brachioradialis
muscle and retract it toward the radial
side. This will expose the small branches of
the radial artery to the muscles. Carefully
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
the ulnar side till the marked area. Apply
34 SECTION 2  SKIN RECONSTRUCTION
anchoring sutures with 3.0 ethilon. You
will be able to see fibrofatty tissue in the
bed, containing a few subcutaneous veins
including the cephalic vein. These veins
are important to ensure good venous
drainage for the flap. Make the incisions
on this fatty subcutaneous tissue at the
radial and ulnar ends (along the marked
limits of dissection). These incisions
can go deep to the fascia. Retract the
brachioradialis tendon radially and the
flexor carpi radialis tendon ulnarly and
the entire course of the radial vessels can
be seen.
11. Now go to the point “G” of the flap. Apply
2 ligatures with 3.0 vicryl at the proximal
most point of the exposed radial vessels.
Divide the vessels between the ligatures.
Lift-up the flap gently and divide the
septum deep to the level of the radial
vessels, taking care to cauterize the deeper
branches from the vessels.
12. Continue this dissection up to the point
“C”. Now the flap has been mobilized.
13. Now develop a subcutaneous tunnel
between the proximal edge of the defect
and the pivot point “C” of the flap. This
tunnel should be created with the help of
a tendon tunneller. This tunnel should be
wide enough to hold the flap as it passes
through, without traumatizing it.
It may not be possible to tunnel the palmar skin
because this skin is thicker and more anchored to
the subcutaneous tissues than the dorsal skin. In
such situations, it may be ideal to make an incision
on the palmar skin along the proposed track of the
flap. This incision will be made through the skin and
subcutaneous tissues, and both edges of the skin
retracted to accommodate the pedicle. This will
cause an unsightly scar on the palm. This may have
to be excised later and the skin closed primarily to
minimize the scar.
14. Apply a stitch with 3.0 nylon 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.
17. When good bleeding is seen from the
edges of the flap, it is ready for transfer.
18. Pass a heavy curved hemostat from the
proximal edge of the 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. After
delivering the flap in the wound site,
confirm the viability of the flap. If there
is reduced bleeding from the edges of the
flap, the tunnel is most probably tight at
the proximal edge which can be vented
with a small incision of about 2 to 3 mm.
19. Flap inset: After confirming the hemostasis
and the viability of the flap, inset can be
done with 4.0 ethilon using half buried
horizontal mattress suturing.
20. Management of the donor area (Fig. 2.7.2):
After confirming hemostasis, the dermal
flaps should be replaced and sutured with
4.0 ethilon. The residual raw area on the
extensor aspect of the forearm should be
narrowed with 3.0 vicryl. Now prepare
the thigh with betadine solution. The skin
graft should be harvested from the medial
side of the thigh. Sterile dressings should
be applied over the skin graft donor site
before moving back to the hand. The graft
should be applied over the raw area and
tie over sutures applied with 3.0 ethilon.

Fig. 2.7.2  Management of donor site
Drainage tubes should be kept below
the suture line on the forearm. The preferred
drainage tube would be Segmüller tube which
consists of segments of the scalp vein set tubing.
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 volar
POP slab should be applied for the hand
keeping the wrist in 30° extension, and the
metacarpophalangeal (MCP) joints of the
fingers in flexion of 90° and interphalangeal
(IP) joints in extension. A window must be
made in the dressings to allow inspection
and monitoring of the flap.
CHAPTER 7  RADIAL ARTERY FOREARM FLAP 35
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
or after complete recovery if under general
anesthesia.
• Clinical monitoring of the flap once every
6 hours.
• 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 removal
of donor site dressing on the arm
• Removal of the POP slab on the 14th 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
after a further 2 weeks.
 Buried Abdominal Flap
Introduction
Buried abdominal flap is the flap of choice for
degloving injuries of the entire hand. Routinely
used abdominal flaps and groin flaps are not
enough to resurface such large areas and
hence a different technique will have to be
employed. The technique of using the buried
abdominal flap refers to the method where
the entire hand is buried in a pocket in the
abdominal wall and then removed for further
reconstruction. When the hand is buried in
this manner in the abdominal wall, skin will
still not be available to cover the entire hand.
After the removal of the hand from the buried
status in the abdominal wall, the further
reconstruction may be of two types:
1. Partial Crane technique: The abdominal
skin can be retained on the dorsal aspect
of the hand and the residual raw area on
the palmar aspect can be covered with
skin graft, applied over the soft tissues
(Crane principle).
2. Full Crane technique: An alternative
method is to retain the abdominal skin in
the abdomen and remove the hand with
only the soft tissues covering it. This raw
area is subsequently skin grafted.
Both these techniques have been described
here:
Presurgical Counseling
• This procedure is planned to cover the
entire raw area on the hand.
8
• This procedure will be done under axillary
block anesthesia for the hand and either
spinal anesthesia or general anesthesia.
• This procedure will take about 3 hours to
perform.
• Incisions will be made on the abdominal
wall and the entire hand bereft of skin will
be buried in a pocket in the abdominal
wall. This will be retained for a period of 2
weeks.
• After a period of 2 weeks, a delay procedure
may have to be done under local anesthesia
or spinal anesthesia.
• Admission will be necessary for a minimum
period of 1 month.
• After the hand is removed from its buried
position in the abdomen, a skin grafting
will be required.
• There will be a scar in the abdominal wall.
• Splints and physiotherapy in the form of
exercises will be required afterward
• The general complications of local anes­
thetic 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. Complications of general
anesthesia or spinal anesthesia may occur.
Surgical Steps
1. The preferred anesthesia is axillary block
and regional block or general anesthesia.
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.
6. If all the fingers have been degloved, it is
useful to disarticulate the fingers at the
distal interphalangeal (DIP) joints, as the
reconstruction and rehabilitation will be
quicker and better.
7. Markings for the flap:
• There are usually two types of total
degloving injuries of the hand: (1)
involves the thumb and (2) spares the
thumb. The degloving usually extends
up to the wrist crease or on to the
forearm. The planning of the incision
in the abdominal wall depends on the
type of degloving.
• The hand is going to be buried in the
abdominal wall. So the hand is first
placed over the abdomen to plan the
area of the abdominal wall which is
going to be used for the reconstruction
(Fig. 2.8.1).
• If the thumb is spared from the deglov­
ing, the infraumbilical segment of the
Fig. 2.8.1  Marking the area on the abdomen which is to
be used for the buried flap
CHAPTER 8  BURIED ABDOMINAL FLAP 37
abdomen is enough. But if the thumb
is also degloved, the supraumbilical
segment of the abdominal wall will
­
also be required.
• The method of planning consists of
the incision and the area for creating
a pocket. The incision length will be
decided by the length of the skin on the
proximal edge of the defect.
• The incision is made through the skin
and subcutaneous tissues. It is not
necessary to make the incision down
to the fascia.
8. The abdominal pocket must be created
carefully (Fig. 2.8.2) with blunt dissection
to avoid injuring the multiple paraum­
bilical perforators.
9. The degloved hand can be inserted off
and on to ensure a comfortable lie within
its pocket.
10. Once the pocket created is of adequate
size, and the hand lies comfortably in
the pocket, the skin can be sutured at the
proximal edge.
11. This position must be maintained for a
period of 3 weeks.
Fig. 2.8.2  Showing the abdominal pocket created for
burying the degloved hand
38 SECTION 2  SKIN RECONSTRUCTION
Postoperative Protocol
after Flap Stage I
• Admission in the ward
• The affected hand should be kept elevated
• Patient can take normal diet immediately
if the procedure was under regional block
or after complete recovery if under general
anesthesia.
• Clinical monitoring of the flap once every
6 hours.
• Analgesics and antibiotics for 5 days.
• Sedation sos for 1 day.
• Inspection of the dressing after 48 hours.
• Removal of sutures on the 10th postoper­
ative day.
The further procedure will depend on
whether partial Crane technique or full Crane
technique is planned:
Partial Crane technique: Here, at the end of 2
weeks, a delay procedure is planned.
12. This surgery can be done under local
anesthesia, or regional block anesthesia.
13. The outline of the hand that has been
buried in the abdominal wall is palpated
carefully. A marking is made about 2 to 3
cm beyond the margins of the palpated
hand and thumb. All the fingers are taken
a single unit. When marking around the
thumb, the proximity to the umbilicus
must be considered. It is ideal to spare
Fig. 2.8.3  Delay of the flap
the umbilicus and plan the markings
around the umbilicus. Hence the marking
will now be as shown in the diagram
(Fig. 2.8.3). This marking will be the
planned incision for the delay procedure.
14. An incision is made along the markings,
through the skin and subcutaneous tissues.
Hemostasis is achieved and the wound is
sutured with 3.0 polyamide suture.
15. A sterile dressing is done.
16. Division of the flap: This is done at the
end of 3 weeks—1 week after the delay
procedure was done.
17. This surgery is done under regional block
anesthesia with supraclavicular block
anesthesia or general anesthesia.
18. The same incision is made as was used for
the delay procedure. First the sutures of the
delay procedure are removed and a wash
given with povidone-iodine solution.
19. The incision is made down to the fascia
and the hand is removed along with the
overlying abdominal skin flap which
covers the dorsum of the hand (Fig. 2.8.4).
20. The bed will now consist of the fascia
of the abdominal wall. Now the hand is
examined. Hemostasis is achieved. Both
the raw area in the abdominal wall (Fig.
2.8.5) and the palmar surface of the hand
(Fig. 2.8.6) are covered with skin graft
harvested from the thigh.
Fig. 2.8.4  Dorsal side of reconstructed hand

Fig. 2.8.5  Donor site with skin graft
Fig. 2.8.6  Volar view of the reconstructed hand
21. Anchoring sutures are applied with 3.0
polyamide sutures and sterile dressings
are applied after applying paraffin gauze.
22. On the hand, a volar plaster of Paris (POP)
slab must be applied with the wrist in 30°
CHAPTER 8  BURIED ABDOMINAL FLAP 39
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
on the palmar aspect.
28. Hemostasis is achieved on the abdominal
wall. The wounds are closed primarily
(Fig. 2.8.8) after keeping drainage tubes
and sterile dressings are applied.
29. Now the hand wound is thoroughly
washed with a solution of povidone-iodine,
hydrogen peroxide and saline.
40 SECTION 2  SKIN RECONSTRUCTION

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.

Postoperative Protocol
after Flap Stage II
Fig. 2.8.8  Suture line after explantation of the buried hand
• The affected hand should be kept elevated.
• 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.
• Removal of the POP slab on the 14th 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
Introduction
The inclusion of a free flap in this book signi-
fies the important role that the flap plays in
reconstruction of skin defects on the hand.
Primarily used as a skin flap, the anterolateral
thigh flap is slowly becoming one of the work-
horse flaps in this regard.
This flap has proved to be proving its
versatility due to different reasons:
• It is a robust and dependable flap
• It has got a fairly standard anatomy
• Raising the flap is simple
• It provides a large area of good quality skin
• The caliber of the vessels is adequate for an
easy vascular anastomosis
• A hidden donor site and hence less
morbidity.
It has a few disadvantages too:
• Requires microsurgical expertise
• Rare anatomical variations may preclude
the use of the flap.
Presurgical Counseling
• This procedure is planned to cover the raw
area with skin and tissues.
• This procedure will be done under axillary
block anesthesia, with general anesthesia
or spinal anesthesia.
• This procedure will take about 5 to 6 hours
to perform.
• Skin will be removed along with soft tissues
from the thigh and placed on the raw area.
9
A skin graft will be taken from the back side
of the thigh and applied over the secondary
raw area on the thigh. There will be no
deficit on the thigh, but there will be a scar
on the thigh.
• Admission will be necessary for a mini-
mum period of 3 days.
• A dressing will be applied and a plaster of
Paris (POP) will be applied on the hand,
which will be retained for 10 days, following
which, physiotherapy will be started.
• In some instances, the flap may not be pos-
sible because of anatomical variations. In
such cases, other surgery like an abdomi-
nal or groin flap may be done.
• In rare instances, after the flap has been
done, there may be a problem to the
vascularity and the flap may necrose. In
such cases, other surgery like an abdominal
or groin flap may be done later.
• The general complications of local anes-
thetic 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
Preparation on the Hand
• The surgery of free anterolateral flap cover
for a defect on the hand can be done under
general anesthesia or under regional
block; a combination of axillary block for
42 SECTION 2  SKIN RECONSTRUCTION
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.
• An incision is made to expose the recipient
vessel. The vessels commonly used are
the radial artery, cephalic vein, other
subcutaneous veins, venae comitantes
of the radial artery, and rarely, the digital
arteries and ulnar artery. The classical
incision for the exposure of the radial artery
is a “C-shaped” incision convex to the
ulnar side, on the distal 5 cm of the flexor
aspect of the forearm. The “C-shaped” flap
is raised and anchored with 3.0 ethilon.
The radial artery is found between the
tendons of the flexor carpi radialis and
the brachioradialis. The artery is dissected
along with both its venae comitantes
and the same exposure can be used to
dissect the cephalic vein. Once the vessels
are dissected, gauze pledgets soaked in
1 percent xylocaine is placed over them.
• Now the bandage around the raw area is
removed and the wound debrided. The
exact dimensions of the defect are noted
and a lint pattern is taken of the defect.
• The tourniquet is released and removed.
• The pulsations in the dissected artery
are noted. If there are good pulsations,
sterile gauze pledgets soaked in 1 percent
xylocaine is again placed over the vessels,
and a sterile pad applied. Hemostasis is
achieved.
Preparation on the Thigh
The thigh chosen as donor for the flap is
usually chosen for convenience to allow two
teams to simultaneously operate. Markings
for the flap should be made before the thigh
is prepared and draped (Fig. 2.9.1).
• Mark a point on the anterior superior
iliac spine. Mark another point on the
Fig. 2.9.1  Markings for the anterolateral thigh flap
superolateral border of the patella. Join
these two points with a straight line. This
forms the axis of the flap.
• Mark a point “A” on the center of this
line. Around this point, mark a circle
with diameter of 4 cm. Divide this circle
into four quadrants. The lower and outer
quadrant is the approximate site of the
musculocutaneous perforator from the
descending branch of the lateral circumflex
artery. This can be confirmed with a hand-
held Doppler probe that will show the exact
site of the perforator.
• Mark another point at the junction of the
proximal-third and middle-third of the axis
line ‘B’. Doppler this area. If a good signal
is picked up from this area, it signifies
a septocutaneous perforator from the
descending branch of the lateral circumflex
artery.
• These two points should be marked
with indelible ink as they are the points
around which the flap is going to be
marked.
1. The thigh is prepared and draped, exposing
the entire length from the anterosuperior
iliac spine to the patella.
2. The lint piece is placed on the thigh
centered on the axis line, with its proximal
end just proximal to the junction of the
proximal and mid-third of the axis line.
On the proximal end, an incision can be
marked along the axis line for about 5 cm
to allow for dissection of the pedicle.
3. The incision is first made on the medial
border of the flap marking. The incision
should go down to the deep fascia
 CHAPTER 9  VASCULARIZED FREE ANTEROLATERAL THIGH FLAP
covering the muscles. This deep fascia is
then incised along the entire length of the
medial border. Muscle will be seen in the
wound. This is the rectus femoris muscle.
This must be confirmed by the anatomical
relations.
4. The flap must now be raised from the
medial side by gently teasing the epimysial
layer of the rectus femoris muscle. The
lateral border of the rectus muscle will
come in to view as also the intermuscular
septum between the rectus femoris and
the vastus lateralis muscles. Now, apply
a deep retractor on the rectus femoris
muscle and retract the muscle medially.
This will expose the intermuscular septum.
5. Examine this septum to identify the
vascular pattern.
This area may have some anatomical anomalies.
Sometimes, there may not be a good musculocu-
taneous or septocutaneous perforator. Sometimes,
there may be a perforator, but the branch supply-
ing the skin may be very small and may not be
reliable. In such situations, there are a few options
available. Either explore the other thigh for a more
favorable anatomy for a flap, or abandon the proce-
dure and select another procedure.
6. The commonest pattern is the presence of
a single musculocutaneous perforator that
runs in the septum and one septocutaneous
perforator that is more proximal.
7. The skin flap must be lifted up and laterally
to expose fully and put the intermuscular
septum into tension. At the point where
the musculocutaneous perforator seems to
end, the soft tissue between that point and
the skin should be examined carefully. First
confirm by the marking that was previously
made on the skin, that this perforator is
the one that we had Dopplered. Then
check for the fine vessels that connect the
musculocutaneous perforator to this point.
This should be noted. Let this point be “A”.
Similarly, look for the terminal portion of
43
the septocutaneous perforator entering
the skin flap. This point is marked as “B”.
8. That two perforators have been identified,
we must now dissect them. First make
two incisions on the intermuscular
septum about 1 cm on either side of the
musculocutaneous perforator. The vessels
lie sandwiched between two layers of the
septum. The nerve to the muscle will be
seen along with the vascular pedicle. So
when incisions are made on either side
of the vessel, it is possible to gently do a
blunt dissection deep to the plane of the
vessels and free the vessels posteriorly.
Now, a hemostat passed through one
incision deep to the plane of the vessels
will exit at the other incision without
damaging the vessels. This can be done
for almost the entire length of the vessels
except proximally. As we dissect more
proximally, we will find one or two deep
branches that go to the muscle. These
should be carefully ligated with 4.0 vicryl
and then divided.
9. If a septocutaneous perforator is present,
this should also be included in the flap.
Just like how the musculocutaneous perfo-
rators were dissected, the septocutaneous
perforator is also dissected proximally up
to the origin from the descending branch
of the lateral circumflex femoral artery.
10. Now, apply a deep Langenbeck retractor
to the rectus femoris muscle and retract
it medially. This step will expose the
descending branch of the lateral circumflex
femoral artery, from which the perforators
arise. The perforators should be dissected
up to their origin from the descending
branch of the lateral circumflex femoral
artery. If a greater length of the pedicle
is required, the required length of the
descending branch can be dissected.
Remember again that there will be one
or two deeper branches arising exactly at
the point where the perforator originates.
Hence, these vessels should be carefully
ligated and divided while mobilizing the
44 SECTION 2  SKIN RECONSTRUCTION
pedicle. Now the pedicle is ready. Apply
pledgets of gauze soaked in 1 percent
xylocaine solution over the vessels.
11. Now, draw an imaginary line between
the points “A” and the distal point of
the musculocutaneous perforator. This
imaginary line represents the approximate
course of the perforator through the vastus
lateralis muscle. Now make an incision
about 1 cm caudal to this imaginary
line and parallel to it. This incision will
go down to the muscle after dividing
the deep fascia. Incise the muscle also
carefully, cauterizing the three to four
vascular branches from our perforator.
Similarly, draw an imaginary line between
the point “B” and the distal point of the
septocutaneous perforator. This imaginary
line represents the approximate course of
the perforator through the intermuscular
septum. Now make an incision about 1 cm
cephalad to this imaginary line and parallel
to it. This incision goes through the septum
and divides it.
12. Draw an imaginary line connecting
the points “A” and “B”. This represents
the vascular hilum of the flap. On the
undersurface of the flap that we have so far
raised, we can see the deep fascia as a dense
white layer. Make a marking on this layer, 1
cm medial to the line “AB”. So the only fascia
we require in our flap is the fascia required
to protect the vascular hilum. Continue this
line distally and proximally for 2 cm. Make
the incisions on the markings.
During the entire procedure of dissection of the
pedicle, the vessels must be constantly bathed
with 1 percent solution of xylocaine. This will
prevent spasm of the vessels.
13. Replace the flap back. Make the remaining
incisions of the proximal, lateral and distal
borders of the flap. The flap should be
raised from these sides superficial to the
deep fascia. There will be a number of small
perforators to the skin. These should be
cauterized while raising the flap. Stop the
dissection when the point of the vascular
hilum is reached. Make an incision on
the deep fascia about 1 cm lateral to the
vascular hilum. So now the entire hilum
is protected by fascia. With gentle lateral
retraction of the flap, the remaining muscle
fibers are separated, thus freeing the entire
pedicle.
14. The flap is replaced back and two to
three anchoring sutures are placed with
3.0 ethilon to the medial skin edge to
prevent the flap from shearing. Bleeding
is checked from the edges of the flap. A
small streak is made on the distal most
portion of the skin flap to confirm the slow
and steady ooze of bright-red blood.
15. Flap thinning: The anchoring suture
should be removed and the flap freed. It
should be turned over and the flap thinned
with heavy curved scissors passed parallel
to the surface of the skin. The area around
the vascular hilum should not be thinned.
16. The pedicle should be divided only after
the vessels have been dissected and kept
ready on the hand.
17. Division of the pedicle: Usually, there are
two veins and one artery at the point of
origin of the vessels from the descending
branch of the lateral circumflex vessels.
The artery and veins should be dissected
free. 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 with the
raw area facing upward and taken to the
recipient site for vascular anastomosis.
18. Management of the donor site: After
securing hemostasis, the secondary defect
should be narrowed with 3.0 vicryl and
the proximal end closed primarily with 3.0
ethilon. There will be a residual raw area if
the flap has been a big one. This should be
covered with a split skin graft harvested
 CHAPTER 9  VASCULARIZED FREE ANTEROLATERAL THIGH FLAP
from the posterior aspect of the same
thigh. The graft should be applied over the
raw area and tie over sutures applied with
3.0 ethilon. Sterile dressings should be
applied and elastocrépe bandage applied
over it.
Vascular Anastomosis
19. The flap is brought to the hand defect.
First the flap is held up and the pedicle
allowed hanging down. This step will
make sure that there is no inadvertent
twisting of the vascular pedicle. The
45
flap is then placed over the defect with
the correct orientation and the end of
the pedicle should be placed over the
recipient vessels. A few sutures should be
applied to inset the flap.
20. The recipient vessels should be divided,
blood flow checked from the divided
artery and approximator clamps applied.
The soft clamps must be released from
the donor vessels. Vascular anastomosis
should be done. (The technique of vascular
anastomosis is beyond the scope of this
manual).
 SECTION

Other Post-traumatic
Sequelae on the Skin
 Adherent Scars
and Contractures
Introduction
Even if there are no raw areas on the upper
limb, the condition of the skin is the most
important point to be assessed. There are
certain features to be examined and evaluated
before the deeper structures can be assessed.
The nature of the skin on the upper limb
may be consisted of any one of the following
types:
• Soft and supple skin
• No scars but indurated skin
• Linear scars following healing by primary
intention
• Linear scars following healing by secondary
intention
• Hypertrophic scars
• Pigmented scars
• Depigmented scars
• Atrophic scars
• Adherent scars
• Contracted scars.
Examination of the Scar
• The site of the scar: It gives an idea about the
probable injury to the underlying tissues.
For example, if there is a scar on the flexor
aspect of the forearm, it indicates possible
injury to the flexor tendons and median
and ulnar nerves.
• The length of the scar: It will also give an
idea about the possible structures injured.
10
A scar on the flexor aspect of the forearm
that is limited to the ulnar side is most
likely to have involved only the ulnar side
structures such as the ulnar nerve and the
flexors of the ring and little fingers.
• The width of the scar: A scar that has healed
by primary intention is usually thin,
while a scar that has healed by secondary
intention is wider.
• Shape of the scar: In some situations the
shape of the scar will give a clue about the
cause. For example, if the patient has made
an attempt to camouflage a tattoo on the
forearm with chemicals, the pattern of the
burn and the site of the burn will point
toward a self-inflicted injury.
• The color of the scar: Some scars are
hyperpigmented, especially the scars
that have been caused by very superficial
flame burns that have not been adequately
protected during the healing phase. Scars
that have formed from healing of superficial
abrasions also tend to behave in the same
way. The other types of scars that are
hyperpigmented are grafted skin scars,
which become hyperpigmented with time.
• The thickness of the scar: This will indicate
the nature of the lesion that caused the
scar. If the scar is wide and hypertrophic,
it may have been caused by secondary
healing of a wound, or if it is broad and
hypertrophic, it might have been caused
by flame burns.
• The relationship of the scar to the underlying
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
• Duration of injury: Apart from primary
Introduction
When a patient presents at the outpatient
department with a tendon injury, reconstruction
must be planned with the following aims:
• To evaluate which tendons have been
injured
• To evaluate the plan of reconstruction.
The following points should be noted:
• History: The nature of injury and the
duration of injury
• Nature of injury
• If the injury has been a blunt injury
with a forceful extension of a finger
or a forceful flexion of a finger against
resistance, there is most probably a
tendon avulsion.
• If the injury was by a penetration
injury, most probably, a single tendon
has been injured, but other injuries
like nerve injuries should be ruled out.
• If the injury was by a sharp instru­
ment, it is likely that many tendons
are injured along with nerves. Hence,
a thorough assessment is necessary.
• If the injury was by a heavy object,
leading to skin loss, the tendons
injured also have segmental loss,
which must be taken into account
during assessment.
• If the injury was by avulsion, it is
most likely that the entire tendon and
muscle have been lost and this will
require special attention in planning
the treatment.
11
management of tendon injuries which
have not been dealt with in this manual,
patients may present later and require
treatment:
• Less than 10 days: In such a situation,
the tendon repair can be done at the
end of 10 days when the sutures have
been removed and the wound is dry.
• Between 10 days and 3 weeks: If the
patient has presented during this
period, it is ideal not to plan for any
surgical management immediately,
but to wait till 3 weeks are over
after the injury. This is because the
tissues are in the inflammatory
phase and any surgical management
will result in more scar formation
and subsequently, more adhesions
between the tendons and other
tissues. Moreover, when the patient
is taken up for surgery by the end of
3 weeks, the tendons are so retracted
that it may be impossible to do
primary repair of the tendons. In such
situations, a tendon grafting is ideal
for all the flexor tendons and extensor
tendons of the fingers except the
flexor pollicis longus (FPL) tendon
and the extensor pollicis longus
(EPL) tendon of the thumb. If there is
a segmental loss of these two tendons
or the proximal ends have retracted,
it is ideal to do a tendon transfer for
these tendons, rather than a tendon
54 SECTION 4  TENDON RECONSTRUCTION
grafting. However, this waiting period
can be utilized to mobilize the fingers
and hand to keep the joints supple
and to strengthen muscles.
• More than 1 year after injury: Some­
times, patients turn-up even a year
after the injury, to have reconstruction
done. In such patients, since primary
repair of the tendons will not be
possible, tendon grafting will have
to be done. However, the bulk of the
muscle should be assessed before
planning the tendon graft. This is
because the muscle might have
undergone atrophy by this time,
and may not be able to move the
tendon after grafting. Hence, in such
situations, a tendon transfer is better
suited for such patients.
• The nature of the skin over the affected
area:
• If there has been an avulsion of the
tendon as in case of flexor digitorum
profundus (FDP) avulsion, the skin
will grossly appear normal, but tell-tale
signs of bruising and contusion can be
made out in the early few days after
injury.
• If there was a penetrating injury, a very
small scar may be seen that may belie
the magnitude of injury.
• In case of an assault or an injury with a
sharp instrument, the scar will indicate
the structures that are most probably
injured. This scar should be soft and
supple before any surgical management
is planned.
• If there was a skin loss which has
already been treated with a skin cover,
this should also be noted. The quality of
the skin cover is very important:
• If the skin over the injured tendon is a
skin graft, it is necessary to resurface
this area with a skin flap before
tendon surgery can be done. This
is because the skin grafted area will
not withstand incisions and wound
healing will be poor.
• If the skin over the area is a skin flap,
which is thin and soft, surgery can
be done for the tendons through this
skin.
• If the skin flap is bulky, it is ideal to
do the first stage of thinning the flap
and making it more cosmetically
acceptable, before the stage of tendon
reconstruction.
• In long standing problems, the skin
may have been contracted over the
area of tendon injury as happens in
cases of tendon injuries in children. In
such situations, a contracture release
is done before tendon reconstruction
is attempted.
• The finger or fingers affected by the tendon
injury should be noted.
• The status of the joints of the hand and of
the affected fingers in particular must be
noted. This assessment must include the
active range of movement and the passive
range of movement. This is particularly
useful in patients who are presenting late
for treatment, as the joints become stiff
if regular physiotherapy has not been
done.
• Any concomitant injury: It is important
to look for other injuries which are likely
to have happened along with the tendon
injury.
• Nerve injury: If this is the case,
reconstruction of the nerve should also be
planned when the tendon reconstruction
is done.
• Bone injury: If there has been a fracture
along with the tendon damage at the
time of injury, the bony status should
be assessed.
• If good union: No bony work is
required.
• If fracture malunited but in acceptable
position: Tendon reconstruction can
be carried out right away and it is not
 CHAPTER 11  TENDON RECONSTRUCTION—ASSESSMENT 55

Table 4.11.1 Clinical examination

Tendon tested
Flexor digitorum profundus of the
finger
Flexor digitorum superficialis (FDS)
of the finger-middle, ring and little
Flexor digitorum superficialis of
index finger
Flexor pollicis longus
Extensor digitorum communis
(EDC) of the fingers
Extensor indicis proprius (EIP) of
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)
Palmaris longus
Extensors of fingers
Flexors of the wrist
Instructions for the patient
Hold the middle phalangeal segment of the finger and ask the patient
to flex the distal interphalangeal (DIP) joint
Place the palm flat on the table with the fingers straight. Place the
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
Hold the DIP joint of index finger in hyperextension and ask patient to
flex PIP joint
Hold the proximal phalangeal segment of the thumb and ask the
­patient to flex the interphalangeal (IP) joint of the thumb
Ask the patient to place the palm flat on the table. Ask the patient to
lift-up the finger being tested
Ask the patient to make a fist. Now, ask the patient to lift and point the
index finger
Hold the proximal phalangeal segment of the thumb and ask the
­patient to extend the IP joint of the thumb
Oppose the tip of the thumb to the tip of the little finger and flex the
wrist. The tendon can be palpated
Make a fist and then extend 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
56 SECTION 4  TENDON RECONSTRUCTION

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
Introduction
The condition of an avulsed flexor tendon
can present either at the emergency theater
or in the outpatient clinic. Recognition of the
condition is by the following features:
• History of blunt injury by a hyperextension
of the finger—may occur after a fall on the
hand, or by a forceful flexion of the finger
when the finger is locked in extension—as
in a sports injury when the finger is caught
in the shirt of another player.
• Total inability to flex both interphalangeal
(IP) joints of the finger, even though only
the flexor profundus tendon is avulsed.
This is because the retracted flexor tendon
recedes in the pulley and may get caught
in the chiasma of the flexor superficialis.
Hence, the superficialis tendon may also
get locked.
• Tell-tale signs of bruising on the finger on
the volar aspect at the terminal phalanx
level may be present.
• An X-ray may reveal the proximal end
of the avulsed tendon, if there has been
an associated fracture of the volar lip of
the terminal phalanx, where the flexor
profundus tendon is inserted.
The treatment of this condition consists of
exploration and reattachment of the avulsed
flexor tendon.
12
Presurgical Counseling
• This procedure will be done under axillary
block anesthesia or general anesthesia (in
children)
• The procedure consists of reattaching the
avulsed tendon
• This procedure will take about 1½ to 2
hours to perform
• A dressing will be applied and a plaster of
Paris (POP) slab will be applied at the end
of surgery
• Admission will be necessary for a
minimum period of 3 days
• Postoperatively, no movements of the
fingers should be attempted. If it is done,
the sutured tendon may rupture
• Postoperatively, the POP slab will be
continued for a period of 3 weeks. After this
period, physiotherapy will be started and
this should be done for another 5 weeks
• In some instances, even if the movements
of the finger improve, further surgery may
be required to release the scars that may
form
• The general complications of 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.
58 SECTION 4  TENDON RECONSTRUCTION
Surgical Steps
1. First, the hand is prepared for surgery as
described in Appendix I.
2. Marking the incisions:
• First, make a marking on the neutral
line of the noncontact surface of the
finger from the web region to the distal
interphalangeal (DIP) joint crease.
This means that the incision should be
made on the ulnar side for the index,
middle and ring finger and the radial
side for the little finger.
• From the DIP joint crease level, extend
the incision distally across the volar
aspect of the terminal phalangeal
segment (pulp region) in an oblique
manner to reach the opposite side of
the finger near the tip.
• From the point on the web region,
extend the incision proximally in an
oblique manner to reach the distal
palmar crease. This marking may have
to be extended proximally later, but
this is the preliminary marking for the
exploration of the flexor tendon of the
finger and palm.
3. Now, the tourniquet is raised and the
incisions are made. Make the incisions
down to the subcutaneous 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
tendon sheath will be visible on the bed.
5. 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.
6. Now, the entire flexor sheath is exposed.
Examine the sheath to look for signs of the
proximal end of the avulsed and retracted
tendon.
7. Hematoma under the tendon sheath that
is visible.
8. Swelling in the flexor sheath at the level
of the proximal phalanx segment of the
finger.
9. If the tendon end seems to be lying in
the tunnel distal to the middle of the
proximal phalangeal region (distal to A2
pulley), make a small incision about 1 cm
long transversely across this site, and try
to retrieve the avulsed tendon from this
opening in the sheath. If this is difficult, a
proximal extension of the incision of the
tendon sheath can be made on one side,
parallel to the underlying tendon.
10. If the tendon end seems to be lying in the
tunnel in the level of A2 pulley, do not
make any incision on the tendon sheath,
as the A2 pulley is very important for
function and flexor tendon movement,
and any scarring in this area will
compromise movement. So, go proximal
to the A1 pulley which is seen in the palm
level. If it is possible, retrieve the tendon
proximally from the A1 pulley level. If this
is not possible, as happens when there is
a segment of bone attached to the end of
the avulsed tendon, make an incision over
the tendon sheath as described in step 9.
11. Now, dissect the terminal segment of the
flexor tendon sheath. Make an incision
on one side of the tendon sheath at this
level and reflect the flap of the sheath
to expose the point of insertion of the
flexor profundus tendon into the base of
the terminal phalanx. This place will be
empty due to the avulsed tendon. Identify
the volar aspect of the base of the terminal
phalanx and debride this area. There must
 CHAPTER 12  REPAIR OF AVULSED FLEXOR TENDON
be a small raw area of the bone into which
the tendon is going to be reattached.
12. Take a polyethylene tube—a scalp vein set
tube with the needle end cut-off (retain
this needle end for use later). Thread
the free end of the tube into the tendon
sheath from the distal end. Try to reach
the point where the opening has been
made in the tendon sheath to retrieve
the proximal end. Deliver the free end of
the tube in this point. Attach the avulsed
end of the flexor tendon to the polye­
thylene tube with 3.0 polypropylenes
suture using horizontal suture technique
(Fig. 4.12.1).
13. Now, gently pull on the distal end of the
polyethylene tube to railroad the tendon
through the remaining segment of the
intact flexor sheath, to the point of insertion
at the terminal phalanx.
14. Now, the entire flexor tendon has been
repositioned in the flexor sheath, and
the reattachment must be done. Take a
stitch in the free end of the tendon with
3.0 polypropylenes using Kessler Mason
technique, and keep it ready. Cut-off the
needle of the suture material and leave
both ends of the suture material long. It
does not matter if there is a small segment
Fig. 4.12.1  Retrieving the proximal retracted flexor digitorum
profundus (FDP) tendon
Fig. 4.12.2  Attaching the FDP tendon to the bone
59
of bone in this, the suturing of the tendon
will be enough to jam the bone segment
into the raw area that has been created in
the volar aspect of the terminal phalanx.
15. Make two drill holes from the volar aspect
of the base of the terminal phalanx to exit
on the nail plate (Fig. 4.12.2). The two holes
must be at a distance of a minimum of 2
to 3 mm. Thread the two free ends of the
suture material that are on the end of the
tendon through the two drill holes, to exit
on the nail plate. If this is difficult, it can
be done by passing an 18G needle from
the nail plate end and then threading the
suture material ends through the needle
bore.
16. Now, the tendon has been replaced at
its insertion and the two free ends of the
suture material are exiting through the
holes on the nail plate. Take the needle
end of the scalp vein set that had been
cut-off earlier. It has two polyethylene
wings. Cut one of these wings, make two
holes in it about 2 to 3 mm apart with an
18G needle. Thread the two free ends of
the suture material through these holes,
hold the “button” close to the nail plate
and tie the suture securely with surgical
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
tendon sheath with 5.0 polypropylenes
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.
60 SECTION 4  TENDON RECONSTRUCTION
19. Apply sterile dressings, and apply a dorsal
below elbow POP slab, extending till the
tips of the fingers, with the wrist in neutral
position, metacarpophalangeal (MCP)
joints of the fingers in 90° position and the
IP joints straight.
Postoperative Protocol
The postoperative follow-up protocol of this
surgery is very important.
• Admission in the ward
• The affected hand should be kept elevated
• Patient can take normal diet immediately
if the procedure was under regional block
or after complete recovery if under general
anesthesia
• Inspection of the suture line after 48 hours
without disturbing the position of the POP
slab
• Discharge of the patient by third day
• Suture removal on the 10th day. Do not
remove the dorsal button suture
• Patient to retain the POP slab
• Removal of the POP slab on the 21st day
and advise the following:
• Refer to physiotherapy for active mobi-
lization of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Review the patient after another 1 week
and remove the dorsal button suture.
Advise the patient to continue:
• Active mobilization of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Review the patient again after another 2 weeks
(total of 6 weeks after surgery), assess the
movements and advise
• Passive mobilization and passive stretch-
ing of the finger
• To apply straightening splint for the
finger at night and to continue active
and passive mobilization of the fingers
during the day. This should be done for
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).
• A dressing will be applied and a plaster of
• 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
• Admission will be necessary for a minimum
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.
infiltration like hypersensitivity may occur
If the flexor digitorum superficialis (FDS)
in spite of test dose application. This
tendon is not available, the palmaris longus
complication will cause dryness of mouth
tendon can be harvested and used as a tendon
and apprehension, which can be corrected
graft.
immediately.

Presurgical Counseling
Surgical Steps
• This procedure will be done under axillary
block anesthesia or general anesthesia (in 1. First, the hand is prepared for surgery as
children) described in Appendix I.
62 SECTION 4  TENDON RECONSTRUCTION
Fig. 4.13.1  Incision markings
2. Marking the incisions (Fig. 4.13.1):
• First make a marking “A” on the neutral
line of the noncontact surface of the
finger from the web region to the distal
interphalangeal (DIP) joint crease. This
means that the incision should be made
on the ulnar side for the index, middle
and ring fingers and the radial side for
the little finger.
• From the distal IP joint crease level,
extend the incision distally across the
volar aspect of the terminal phalangeal
segment (pulp region) in an oblique
manner “B” to reach the opposite side
of the finger near the tip.
• From the point on the web region,
extend the incision “C” proximally in
an oblique manner to reach the distal
palmar crease. This marking will have
to be extended proximally to reach the
proximal part of the hollow between
the thenar and hypothenar eminences.
• A longitudinal incision “D” on the
forearm measuring about 5 to 6 cm,
about 2 cm proximal to the wrist
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
tendon sheath will be visible on the bed.
5. 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.
6. 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 like
a book, by making an incision on the side
of the flexor sheath at the level of the distal
part of the middle phalanx and the terminal
phalanx. This will expose the insertion of
the FDP on the terminal phalanx.
7. Usually, there will be about 2 to 2.5 cm
of the tendon remaining inserted to
bone. Only 2 cm should be retained for
good attachment of the tendon graft.
The longer this insertion is left, the less
will be the leverage of the tendon, and
hence, lesser will be the movement. Once
the inserting tendon has been dissected,

it should be pulled to see if full range of
movement of the distal IP joint is present.
If there is a restriction of either the flexion
or extension, further dissection must be
done to free the adhesions with the volar
plate and surrounding tissues. Only when
the full range of passive movement is
achieved at the distal IP joint, can the next
step be done.
8. Now, consider the remaining segment of
the flexor tendon sheath. This tunnel will
usually be collapsed, and will contain:
• The insertion of the flexor superficialis
tendon (about 1–1.5 cm)
• The proximal cut ends of the flexor
superficialis and flexor profundus ten­
dons may be present in the proximal
part of the tunnel. Even if these
tendons are present, they will be stuck
by dense adhesions to the sides of the
flexor tunnel.
  The flexor sheath also will be weakened
at some places and may not withstand
dissection. The most important pulleys
that must be preserved are the A2
pulley and the A4 pulley: that is, the
pulley segment over the proximal part
of the proximal phalanx region, and the
pulley segment over the proximal part
of the middle phalanx region. These two
pulleys are essential for achieving good
movements after reconstruction. Hence,
sparing these two pulley segments, the
other segments may be opened up to
allow access to the tunnel. Through the
approaches possible, a hemostat should
be passed gently to dilate the space in
the tunnel that has collapsed and also to
release some of the adhesions that are
holding the walls together. By this method,
most of the tunnel can be recreated.
However, the proximal part may be
difficult to clear, because it contains the
densely adherent proximal edges of the
tendons.
9. Proximal tendon dissection: The proximal
cut end of the tendon will be found in one
of these two places:
CHAPTER 13  FLEXOR TENDON GRAFTING 63
• The proximal portion of the flexor sheath
as described in the previous step
• It may be found buried in the lumbrical
muscle, almost at the distal edge of the
flexor retinaculum.
  If it is present in the former position,
dissection in the palm will show the FDP
and FDS tendons. These can be held up
with a retractor to make them taut and
the cut portion that is found adherent in
the proximal end of the A2 pulley can be
divided as far as possible. Dissection of
the adherent tendon is usually not done
as it may damage the A2 pulley. If it is
possible to extricate the cut end of the
FDP and FDS tendons without damaging
the pulley, it would help to recreate the
entire tunnel. If the tendons are not found
at this level, dissection must be done
proximally. An easy method is to identify
the corresponding lumbrical tendon of
the finger, and dissect within the fibers of
this muscle. The cut ends of the tendons
of the FDP and FDS will be found as
rounded ends within the muscle. They
can be dissected free and gentle traction
will release the tendons. The FDP tendon
can be identified the area of origin of the
lumbrical muscle. The FDS tendon can
sometimes be identified by its flattened
end. Now, the proximal end of the tendon
FDP and the tunnel is also ready.
10. Harvesting the tendon graft: If only one
finger is involved, the cut tendon of the
FDS of the involved finger is usually
used as a graft to reconstruct the FDP. If
it is damaged beyond use, the palmaris
longus is used as a graft. If the FDS is
intact and palmaris longus is absent, FDS
of the neighboring finger can be used
as a tendon graft. If multiple fingers are
involved, the choice is between the FDS
of the respective fingers or the fascia lata
graft.
• Harvesting the FDS as a graft:
• A transverse or longitudinal incision
about 3 cm is made on the flexor
64 SECTION 4  TENDON RECONSTRUCTION
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
which has already been identified
and dissected in the palm is pulled
and cut
• It is retrieved from the wrist wound
by pulling on the FDS tendon
• Another transverse incision 3.0
cm is made about 6 to 7 cm more
proximally on the forearm after
applying traction on the cut end of
the tendon and palpating the taut
tendon under the skin
• The FDS is retrieved through this
wound, and divided to close to the
musculotendinous junction
• The tendon is placed in a cup of
normal saline till its use.
• Harvesting the Palmaris longus tendon
as a graft: It has been described in
Appendix (VII)
• Harvesting the fascia lata graft: It is
described in Appendix (VIII).
11. Fixing the tendon graft:
• Distal tendon anastomosis: Once the
tendon graft has been harvested, the
tendon grafting can be done. First the
distal tendon anastomosis is done.
Before that, the tunnel for the tendon
graft to be routed is made ready
• Take a polyethylene tube—a scalp vein
set tube with the needle end cut-off.
Thread the free end of the tube into
the tendon sheath from the distal end.
Retrieve the proximal end of the tube in
the palm, proximal to the flexor tendon
sheath. Deliver the free end of the tube
in this point. Attach the distal end of
the tendon graft to the polyethylene
Fig. 4.13.2  Method of distal tendon repair of equal size
tube with 3.0 polypropylenes suture
using horizontal suture technique
• Now, gently pull on the distal end of
the polyethylene tube to railroad the
tendon through the entire length of
the flexor sheath, to the point of distal
tendon edge at the terminal phalanx
• Now, the entire flexor tendon graft has
been repositioned in the flexor sheath
• The distal end of the tendon graft is
attached to the distal cut end of the FDP
tendon by one of these two methods:
a. If the size of the cut end of the tendon
graft is equal to the size of the distal
FDP tendon, the suturing is done
with 3.0 polypropylenes using modi­
fied Kessler Mason Allen suture (Fig.
4.13.2)
b. If the size of the cut end of the tendon
graft is smaller than the distal cut end
of the FDP tendon, the following
technique is used. The distal FDP
tendon is split into two longitudinally
for about 1 cm. The distal end of the
tendon graft is inserted in between
the two parts. A stitch is taken with
3.0 polypropylenes from the side,
through one part of the FDP tendon,
then through the tendon graft, and
again through the second part of
the FDP tendon. This stitch is then
turned back through the same layers
in reverse and the knot is tied (Fig.
4.13.3) Another stitch of the same
type can be applied distal to the first,

Fig. 4.13.3  Method of tendon repair if tendon graft is smaller
to reinforce the distal attachment.
This suturing should be secured.
It should be remembered that the
common cause of tendon dehiscence
occurs at the distal anastomosis
• The extralength of the tendon graft
should be excised and stored in saline
as mentioned above, and can be used
as material for pulley reconstruction
• Once the distal suturing is over, the
free end of the tendon graft that is at
the palm level should be gently pulled
and the movement pattern of the finger
at the IP joints noted. The finger-tip
should touch the palm. If this does
not happen, or, the movement is not
satisfactory, the pulley system should
be examined
• If there is a deficit at the A2 or A4
pulleys, they should be reconstructed
• Pulley reconstruction: The excess ten­
don graft should be applied over the
area where the pulley is to be recon­
structed. One end should be sutured to
the remnant of the original pulley with
5.0 polypropylenes using horizontal
suture technique with the knot com­
ing outside. The tendon graft is then
laid transversely over the tendon graft
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
the free end of the tendon graft, should
again be confirmed
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.
12. Proximal tendon anastomosis: The proxi­
mal end of the tendon graft is now sutured
to the cut end of the FDP tendon which
has been dissected and kept ready (step
9). The important consideration in this
step is the adjustment of tension in the
tendon graft:
• Pull the cut end of the FDP tendon.
It should glide freely forward and
backward. If it does not do so, further
mobilization should be done until
it does so. Pull the tendon to the
maximum. Make a mark on the tendon
at the point where it just becomes
visible in the wound. Mark this point
as “A”. Now, relax the tendon and it
will glide back into the forearm for a
certain distance. Now, mark the point
where the tendon just becomes visible
at the edge of the wound. Mark this
point as “B”. So, the distance “AB” is
the amplitude of movement of the
66 SECTION 4  TENDON RECONSTRUCTION
Fig. 4.13.4  Pulvertaft technique of tendon suturing
FDP tendon. Mark 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 visible at the
edge of the wound. This should be the
position of the FDP while it is being
sutured to the tendon graft, with the
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
the cascade of the finger. Now, freshen
the two ends of the tendons and repair
them in one of the following methods:
• If the size of the cut end of the
tendon graft is equal to the size of
the cut end of FDP, the suturing
is done with 3.0 polypropylenes
using modified Kessler Mason Allen
suture
• If the size of the cut end of the tendon
graft is smaller than the distal cut end
of the FDP tendon, the Pulvertaft
technique (Fig. 4.13.4) is used
• Hold the FDP tendon taut with a
hemostat applied on the end and
pulling distally
• About 1 cm proximal to the end of
the tendon, make a cut in a volar to
dorsal direction with a number 11
blade, with just enough length to
allow the tendon graft through. Pull
the tendon graft through and adjust
the tension so that the finger lies in
the normal cascade. Apply a suture
with 3.0 polypropylenes using hori­
zontal mattress suture
• About 1 cm proximal to the first cut,
make another cut with number 11
blade, from a radial to ulnar direction.
Thread the free end of the tendon
graft through this opening also and
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
tendon.
13. Suture the skin with 4.0 Ethilon after
keeping Segmüller drains.
14. Apply sterile dressings, and apply a dorsal
below elbow POP slab, extending till the
tips of the fingers, with the wrist in neutral
position, metacarpophalangeal (MCP)
joints of the fingers in 90° position and the
IP joints straight.
Postoperative Protocol
The postoperative follow-up protocol of this
surgery is very important.
• Admission in the ward
• The affected hand should be kept elevated
• Patient can take normal diet immediately
if the procedure was under regional block
or after complete recovery if under general
anesthesia
• Inspection of the suture line after 48 hours
without disturbing the position of the POP
slab
• Discharge of the patient by third day
• Suture removal on the 10th day
• Patient to retain the POP slab
• Removals of the POP slab on the 21st day
and advise the following:
• Refer to physiotherapy for active mobiliz­
ation of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Review the patient again after another
2 weeks (total of 6 weeks after surgery),
assess the movements and advice passive
mobilization and passive stretching of the
finger
• To apply straightening splint for the finger
at night and to continue active and passive
mobilization of the fingers during the day.
This should be done for 2 weeks.
 Staged Flexor
Tendon Reconstruction
Introduction
In some cases where a tendon graft is required,
the procedure should not be done as described
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.
Presurgical Counseling
This procedure will consist of two stages.
Both stages will be done under axillary block
anesthesia or general anesthesia:
Stage I • This procedure will take about 1½ to 2
• The first stage consists of inserting the
silastic implant in the finger. • A dressing will be applied and a POP slab
• This procedure will take about 1½ to 2
hours to perform. • Admission will be necessary for a
• A dressing will be applied and a plaster of
Paris (POP) slab will be applied at the end • Postoperatively, no movements of the
of surgery.
• Admission will be necessary for a minimum
period of 3 days.
• Postoperatively, no movements of the
fingers should be attempted. If it is done,
the sutured tendons may rupture.
• Postoperatively, the POP slab will be
continued for a period of 3 weeks. After this
period, physiotherapy will be started and
this should be done for another 3 weeks.
14
• Only after 3 months, the next stage will be
done.
• In some rare instances, the implant may
extrude. In this situation, the procedure
will have to be redone with a new implant.
• The general complications of 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.
Stage II
• The procedure consists of harvesting a
tendon graft from either the forearm (in
case of one or two fingers) and from the
thigh (in case of more than two fingers).
hours to perform.
will be applied at the end of surgery.
minimum period of 3 days.
fingers should be attempted. If it is done,
the sutured tendons may rupture.
• Postoperatively, the POP slab will be
continued for a period of 3 weeks. After this
period, physiotherapy will be started and
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.
68 SECTION 4  TENDON RECONSTRUCTION
• The general complications of 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
Stage I
• First the hand is prepared for surgery as
described in Appendix I
• Marking the incisions (Fig. 4.14.1):
• First make a marking “A” on the neutral • Make the incisions down to the sub­
line of the noncontact surface of the
finger from the web region to the distal
interphalangeal (DIP) joint crease. This
means that the incision should be made
on the ulnar side for the index, middle
and ring fingers and the radial side for
the little finger.
• From the DIP joint crease level, extend
the incision distally across the volar
aspect of the terminal phalangeal
segment (pulp region) in an oblique
• Now, raise the palmar portion of the flap
• Anchor the raised skin flaps with 3.0 Ethilon
• Distal tendon dissection: The first step is to
Fig. 4.14.1  Incision markings for stage I
manner “B” to reach the opposite side
of the finger near the tip.
• From the point on the web region,
extend the incision “C” proximally in
an oblique manner to reach the distal
palmar crease. This marking will have
to be extended proximally to reach the
proximal part of the hollow between the
thenar and hypothenar eminences.
• A longitudinal incision “D” on the
forearm measuring about 5 to 6 cm,
about 2 cm proximal to the wrist crease.
This incision should be on the ulnar half
of the distal forearm.
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
fibrous flexor sheath. This dissection stops
when the digital neurovascular bundle of
the opposite side of the finger comes into
view.
along with the fat pad (superficial to the
palmar aponeurosis). The noncontact
side neurovascular bundle and the flexor
tendon sheath will be visible on the bed.
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.
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
like a book, by making an incision on the
 CHAPTER 14  STAGED FLEXOR TENDON RECONSTRUCTION
side of the flexor sheath at the level of
the distal part of the middle phalanx and
the terminal phalanx. This will expose
the insertion of the flexor digitorum
profundus (FDP) on the terminal phalanx.
• Usually, there will be about 2 to 2.5 cm
of the tendon remaining inserted to
bone. Only 2 cm should be retained for
good attachment of the tendon graft. The
longer this insertion is left, the less will
be the leverage of the tendon, and hence,
lesser will be the movement. Once the
inserting tendon has been dissected, it
should be pulled to see if full range of
movement of the DIP joint is present. If
there is a restriction of either the flexion or
extension, further dissection must be done
to free the adhesions with the volar plate
and surrounding tissues. Only when the
full range of passive movement is achieved
at the DIP joint, can the next step be done.
• Now, consider the remaining segment of
the flexor tendon sheath. This tunnel will
usually be collapsed, and will contain:
• The insertion of the flexor superficialis
tendon (about 1–1.5 cm).
• The proximal cut ends of the flexor
superficialis and flexor profundus
tendons may be present in the proximal
part of the tunnel. Even if these tendons
are present, they will be stuck by dense
adhesions to the sides of the flexor
tunnel.
• The flexor sheath also will be weakened
at some places and may not withstand
dissection. The most important pulleys
that must be preserved are the A2
pulley and the A4 pulley: that is, the
pulley segment over the proximal part
of the proximal phalanx region, and the
pulley segment over the proximal part
of the middle phalanx region. These two
pulleys are essential for achieving good
movements after reconstruction. Hence,
sparing these two pulley segments, the
other segments may be opened up to
allow access to the tunnel. Through the
approaches possible, a hemostat should
be passed gently to dilate the space
69
in the tunnel that has collapsed and
also to release some of the adhesions
that are holding the walls together. By
this method, most of the tunnel can
be recreated. However, the proximal
part may be difficult to clear, because it
contains the densely adherent proximal
edges of the tendons.
• Now, a longitudinal incision should be
made on the forearm measuring about
5 to 6 cm, about 2 cm proximal to the
wrist crease. This incision should be on
the ulnar half of the distal forearm.
• The flexor digitorum superficialis (FDS)
and FDP tendons of the fingers should
be dissected through this incision. Care
should be taken to avoid injury to the
median nerve at this area.
• Take a polyethylene tube—a scalp vein
set tube with the needle end cut-off.
Thread the free end of the tube in to the
carpal tunnel from the palm. Retrieve
the tube in the proximal end in the
forearm and retain it with a hemostat.
Route this palmar end of the tube
further distally through the remaining
flexor tendon sheath to the insertion of
the FDP tendon. The polyethylene tube
now lies in the proposed course of the
tendon implant
• Change the gloves, wash with normal
saline and open the tendon implant
packet.
Make sure that glove powder does not come
in contact with the implant material. If so, talc
granuloma may form and cause adhesions.
• Now, attach the tendon implant to the
proximal end of this polyethylene tube
with 4.0 polypropylenes using horizontal
mattress suture. Now, gently pull on the
distal end of the polyethylene tube to
railroad the tendon implant through the
entire length, to the point of distal tendon
edge at the terminal phalanx. Now, the
entire tendon implant has been positioned
(Fig. 4.14.2).
70 SECTION 4  TENDON RECONSTRUCTION
Fig. 4.14.2  Positioned silastic implant in the flexor sheath
• Suture the distal end of the tendon implant
to the stump of the FDP tendon insertion as
follows. Place the distal end of the tendon
implant under the stump of the FDP. Apply
horizontal mattress sutures to anchor the
implant to the tendon.
• The proximal end of the tendon implant
should be left free in the forearm wound
• 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
wounds are closed with 4.0 Ethilon after
placing Segmüller drains.
Postoperative Protocol for Stage I
• Admission in the ward
• The affected hand should be kept elevated
• Patient can take normal diet immediately
if the procedure was under regional block
or after complete recovery if under general
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
and advise the following:
• Refer to physiotherapy for active mobi­
lization of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
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.
If an ulcer develops at the incision line or at any
other point on the finger, it indicates that:
•  There is an infection
•  The implant is beginning to extrude. The patient
must be given a course of strong antibiotics. If
the ulcer fails to heal, the patient must be taken
to surgery as soon as possible and the implant
removed, a thorough wash given and the
wounds closed. Reconstruction of the tendons
will have to be planned again.
Stage II
• First the hand is prepared for surgery as
described in Appendix I.
• Marking the incisions (Fig. 4.14.3):
• In this stage only the distal most
and proximal forearm incisions are
required. This is to expose the sites of
the proposed tendon anastomoses only.
• From the DIP joint crease level, extend
the incision “A” distally across the volar
aspect of the terminal phalangeal
segment (pulp region) in an oblique
manner to reach the opposite side of
 CHAPTER 14  STAGED FLEXOR TENDON RECONSTRUCTION
Fig. 4.14.3  Incision markings for stage II
the finger near the tip. If necessary, the
incision can be extended proximally
from the level of the DIP joint along the
neutral line for about 2 cm to afford good
exposure of the insertion of the FDP
tendon.
• The second incision “B” that should
be marked is the forearm incision
as described in stage I. This incision
should be marked in such a way that the
previous scar can be excised.
• The tourniquet can be raised and the
incisions made. First the distal incision
is made. The flap of skin that is raised is
anchored with 4.0 Ethilon. The insertion
of the FDP tendon is exposed along with
the distal end of the tendon implant. The
scar tissue is excised around the tendon
and the DIP joint is mobilized passively to
achieve full range of motion.
• A saline soaked gauze piece is placed over
this area and the proximal incision on the
forearm is made.
• The forearm incision is made and the flexor
tendons identified along with the proximal
71
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
end incision, remove the suture between
the distal end of the tendon implant and
the FDP tendon. Carefully pull the tendon
implant out and monitor the tendon graft
that is moving inside along with it. Do
not lose sight of the proximal end of the
tendon graft.
• Once the suture between the tendon
implant and the tendon graft is visible at
the terminal phalangeal level, remove the
suture between them. Discard the tendon
implant.
• Fixing the tendon graft:
• Distal tendon anastomosis: The distal
end of the tendon graft is attached to
the distal cut end of the FDP tendon by
one of the following methods:
• If the size of the cut end of the
tendon graft is equal to the size of
the distal FDP tendon, the suturing is
done with 3.0 polypropylenes using
modified Kessler Mason Allen suture
(See Fig. 4.13.2)
• If the size of the cut end of the tendon
graft is smaller than the distal cut
end of the FDP tendon, the following
technique is used. The distal FDP
72 SECTION 4  TENDON RECONSTRUCTION
tendon is split into two longitudinally
for about 1 cm.
• The distal end of the tendon graft is
inserted in between the two parts. A
stitch is taken with 3.0 polypropylene
from the side, through one part of
the FDP tendon, then through the
tendon graft, and again through the
second part of the FDP tendon. This
stitch is then turned back through the
same layers in reverse and the knot is
tied. Another stitch of the same type
can be applied distal to the first, to
reinforce the distal attachment. This
suturing should be secure. It should
be remembered that the common
cause of tendon dehiscence occurs at
the distal anastomosis.
• Once the distal suturing is over,
the free end of the tendon graft
that is at the distal forearm level
should be gently pulled and the
movement pattern of the finger
at the interphalangeal (IP) joints
noted. The finger-tip should touch
the palm.
• The skin wound on the finger should
now be sutured with 4.0 Ethilon. The
passive movement of the finger on
pulling on the free end of the tendon
graft, should again be confirmed.
• Proximal tendon anastomosis: The
proximal end of the tendon graft
is now sutured to the cut end of
the FDP tendon which has been
dissected and kept ready. The
important consideration in this step
is the adjustment of tension in the
tendon graft.
• Pull the cut end of the FDP tendon.
It should glide freely forward and
backward. If it does not do so, further
mobilization should be done until
it does so. Pull the tendon to the
maximum. Make a mark on the tendon
at the point where it just becomes
visible in the wound. Mark this point
as “A”. Now, relax the tendon and it will
glide back into the forearm for a certain
distance. Now mark the point where
the tendon just becomes visible at the
edge of the wound. Mark this point as
“B”. So, the distance AB is the amplitude
of movement of the FDP tendon. Mark
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
visible at the edge of the wound. This
should be the position of the FDP while
it is being sutured to the tendon graft.
• Pull the free end of the tendon graft so that
the finger is held in a position of the cascade
of the finger. Now, freshen the two ends of
the tendons and repair them in one of the
following methods:
• The Pulvertaft technique is used for
tendon anastomosis at this level.
• Hold the FDP tendon taut with a
hemostat applied on the end and
pulling distally.
• About 1 cm proximal to the end of the
tendon, make a cut in a volar to dorsal
direction with a number 11 blade, with
just enough length to allow the tendon
graft through. Pull the tendon graft
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.
• About 1 cm proximal to the first cut,
make another cut with number 11 blade,
from a radial to ulnar direction. Thread
the free end of the tendon graft through
this opening also and suture with 3.0
polypropylene using horizontal mattress
suture.
• Trim the excess length of the tendon
graft and the FDP. Apply sutures with
4.0 polypropylene to attach the cut ends
to the surface of the tendon.
• Suture the skin with 4.0 Ethilon after
keeping Segmüller drains.
• Apply sterile dressings, and apply a dorsal
below elbow POP slab, extending till the
tips of the fingers, with the wrist in neutral
position, metacarpophalangeal (MCP)
 CHAPTER 14  STAGED FLEXOR TENDON RECONSTRUCTION
joints of the fingers in 90° position and the
IP joints straight.
Postoperative Protocol for Stage II
The postoperative follow-up protocol of this
surgery is very important.
• Admission in the ward
• The affected hand should be kept elevated
• Patient can take normal diet immediately
if the procedure was under regional block
or after complete recovery if under general
anesthesia
• Inspection of the suture line after 48 hours
without disturbing the position of the POP
slab
• Discharge of the patient by third day
• Suture removal on the 10th day
73
• Patient to retain the POP slab
• Removal of the POP slab on the 21st day
and advise the following:
• Refer to physiotherapy for active
mobilization of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Review the patient again after another
2 weeks (total of 6 weeks after surgery),
assess the movements and advise passive
mobilization and passive stretching of the
finger
• To apply straightening splint for the finger
at night and to continue active and passive
mobilization of the fingers during the day.
This should be done for 2 weeks.
 Flexor Tenolysis
Introduction
One of the most rewarding surgeries of the
tendons is flexor tenolysis. This surgery is done
when the passive range of motion is more than
the active range of motion.
Presurgical Counseling
• This procedure will be done under wrist
block anesthesia as patient cooperation will
be required in the course of the procedure.
• A tourniquet will be applied and raised,
but will be released before pain starts.
• This procedure will take about 30 to 45
minutes to perform if it involves a single
finger and more if more fingers are
involved.
• 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.
• A dressing will be applied and no plaster of
Paris (POP) will be applied.
• A catheter will be placed in the wrist (like
an IV cannula), through which, anesthetic
solution will be injected if there is pain.
• Admission will be necessary for a
minimum period of 3 days.
• Postoperatively, gentle active mobilization
of the finger should be continued. If it is
stopped, the finger will get back to the
original state before surgery.
15
• In some instances, if the tendon is very
grossly stuck and devoid of blood supply, a
staged reconstruction may have to be done.
This involves inserting a tendon implant,
harvesting a tendon graft, and two surgical
stages.
• In some instances, in the postoperative
period, the tendon may rupture due to
reduced blood supply. In such situations,
the aforementioned staged procedure will
have to be done after the wounds heal.
• In some instances, even if the movements
of the finger improve, further surgery may
be required to reconstruct the pulleys.
• 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
• This procedure should be done under
wrist block anesthesia. However, if more
than one finger is involved, the procedure
is better done under axillary block
anesthesia, as the patient cannot tolerate
the tourniquet for a prolonged time under
local anesthesia.
• First prepare the hand as described in
Appendix I.
• Marking the incisions (Fig. 4.15.1):

Fig. 4.15.1  Markings for exposure of the flexor
tendons for tenolysis
• First make a marking ‘A’ on the neutral
line of the noncontact surface of the
finger from the web region to the distal
interphalangeal (DIP) joint crease. This
means that the incision should be made
on the ulnar side for the index, middle
and ring fingers and the radial side for
the little finger.
• From the DIP joint crease level, extend
the incision distally across the volar
aspect of the terminal phalangeal
segment (pulp region) in an oblique
manner to reach the opposite side of
the finger near the tip ‘B’.
• From the point on the web region, extend
the incision proximally ‘C’ in an oblique
manner to reach the distal palmar crease.
This marking will have to be extended
proximally to reach the proximal part
of the hollow between the thenar and
hypothenar eminences.
• If multiple fingers are involved,
multiple ‘C’ incisions cannot be made
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
fibrous flexor sheath. This dissection stops
when the digital neurovascular bundle of
the opposite side of the finger comes into
view.
• 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
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.
• All the adhesions between the tendons and
the surrounding tissues must be divided.
Care must be taken to avoid injuring the
pulley system.
• When all the adhesions have been divided,
the tendons must be pulled proximally
and the movement of the finger noted.
The finger must flex fully and the tip of the
finger should touch the palm. If not, a few
more adhesions will have to be released till
this is achieved. Then ask the patient to flex
the finger. He may not be able to isolate the
finger to move due to the local anesthesia,
so he must be instructed to flex all the
fingers at once, slowly. This will flex the
finger that is involved. The range of motion
must be noted again. If all adhesions have
been achieved, full range of active motion
will be present. This must be shown to
76 SECTION 4  TENDON RECONSTRUCTION
the patient, so that it will serve as an
impetus for postoperative physiotherapy.
If full range is not achieved, two things are
possible. Either there are more adhesions
proximally, that should be released, or,
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,
which cannot be implemented if pulley
reconstruction is done.
• 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.
• For giving postoperative analgesia for
the thumb, index and middle fingers, a
Venflon catheter should be inserted in
the volar aspect of the wrist, about 1 cm
proximal to the wrist crease. The needle
must be inserted to the ulnar side of the
palmaris longus tendon, the needle being
aimed deeply, pointing to the knuckle of
the middle finger. This cannula will deliver
anesthetic solution in the area surrounding
the median nerve. If the ring or little fingers
have been involved, the Venflon catheter is
placed to the radial side of the flexor carpi
ulnaris (FCU) tendon about 1 cm proximal
to the wrist crease. This cannula must be
fixed with plaster after the wounds are
sutured.
• Suture the skin with 4.0 Ethilon after
keeping Segmüller drains and apply sterile
dressings.
Postoperative Protocol
The postoperative follow-up protocol of this
surgery is very important.
• Admission in the ward.
• The affected hand should be kept elevated.
• Patient can take normal diet immediately
if the procedure was under regional block
or after complete recovery if under general
anesthesia.
• Four milliliter of 1 percent solution of
Bupivacaine must be injected into the
cannula once every 6 hours. The patient
must be attended to by a physiotherapist
and both active and passive mobilization
of the fingers must be done.
• Inspection of the suture line after 48 hours.
• Discharge of the patient by third day.
• Suture removal on the 10th day.
• Refer to physiotherapy for active mobiliz­
ation of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil.
 Extensor Tendon
Reconstruction
Introduction
In situations where there is a loss of extensor
tendons on the dorsum of the hand,
reconstruction with grafting is ideal since the
extensor muscles are intact. If the extensor
muscles are lost or deservated, tendon transfer
is ideal and has been described in chapter 45.
Presurgical Counseling
• This procedure will be done under axillary
block anesthesia or general anesthesia.
• The procedure consists of harvesting a
tendon graft from either the forearm (in
case of one or two fingers) and from the
thigh (in case of more than two fingers).
• This procedure will take about 1½–2 hours
to perform.
• A dressing will be applied and a plaster of
Paris (POP) slab will be applied at the end
of surgery.
• Admission will be necessary for a minimum
period of 3 days.
• Postoperatively, no movements of the
fingers should be attempted. If it is done,
the sutured tendons may rupture.
• Postoperatively, the POP slab will be
continued for a period of 3 weeks. After this
period, physiotherapy will be started and
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.
16
• The general complications of 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
• First the hand is prepared as described in
Appendix I.
• Markings for the incisions will depend on
the situation.
• There are two situations in which extensor
tendon grafts are commonly done:
• An injury to the extensor tendons on
the dorsum of the hand with scars
running across the dorsum of the hand
or the forearm. These patients have
presented late for treatment (more than
3 months). Hence, a secondary repair of
the tendons will not be possible and a
tendon grafting is done.
• An injury with loss of extensor tendons
on the dorsum of the hand with
concomitant skin loss, which has been
corrected by a skin flap surgery done
at the time of injury. In such situations,
the tendon reconstruction is done as a
secondary procedure.
• In the former situation (Fig. 4.16.1), the
incision is a longitudinally oriented lazy
“S” shaped incision extending from about
4 cm distal to the scar to 4 cm proximal to
the scar. The original scar is usually not
78 SECTION 4  TENDON RECONSTRUCTION

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
• Tendon anastomoses using the palmaris
longus tendon graft: the proximal tendon
anastomosis is done first. The tendon graft
is woven into the proximal cut ends of the
extensor tendons with 4.0 polypropylene
suture using horizontal mattress suture.
After the tendon graft is woven through
the ends of the tendons, the tendon graft
is sutured to itself to make the anastomosis
secure. Now, the distal end of the tendon
graft is taken to the distal incision site. If
the tendon graft is intended for two fingers,
the tendon graft is split longitudinally. If
this surgery is being done on a patient who
has had a skin flap applied on the dorsum
of the hand, the entire skin bridge need
not be opened up. A subcutaneous tunnel
can be created under the skin flap from
the proximal incision to the distal incision.
The tendon graft can be routed through
this tunnel to the distal incision.
• If the fascia lata has been harvested as a
tendon graft, the graft must be prepared
before the proximal tendon anastomosis.
The graft should be tubed with the external
surface of the fascia lata graft going inside
and the deeper surface of the graft forming
the surface of the tube. The tubing is done
after the formed tube is placed around the
proximal ends of the cut extensor tendons.
The seam line of the tube is sutured with
4.0 polypropylene using continuous
buried suture technique. The tubing is
not done for the entire length of the graft.
The distal half of the tendon graft is split
into slips depending on the number of
fingers for which the extensors are to
be reconstructed. The distal ends of the
tendon graft are taken to the distal incision.
• Distal tendon anastomoses: The slips of the
tendon graft are sutured to the distal ends
of extensor tendons. The suturing is done
with 4.0 polypropylene using horizontal
mattress suture. At this juncture, the most
important thing to consider is adjusting
the tension of suturing. Each finger
extensor must be sutured and the position
of the finger checked. The tenodesis effect
must be present. This means that when
79
the wrist is flexed passively, the finger
whose extensor has been repaired must
extend passively. Similarly, when the wrist
is extended, the finger must extend at the
metacarpophalangeal (MCP) joint. Thus,
the extensor tendons must be anastomosed
for all the fingers after checking this effect.
• After all the extensors have been
anastomosed, moist gauze is placed over
the incisions, gentle compression applied
and the hand elevated. The tourniquet is
released, and the elevation of the hand is
maintained for 3 minutes.
• The hand is then placed back on the table
and hemostasis achieved. The wounds
are sutured with 4.0 Ethilon after keeping
Segmüller drains. Sterile dressings are
applied.
• A volar slab POP is applied keeping the
wrist in 30° extensions, the MCP joints in
60º flexion and the interphalangeal (IP)
joints extended.
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
or after complete recovery if under general
anesthesia
• Inspection of the suture line after 48 hours
without disturbing the position of the POP
slab
• 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
and advise the following:
• Refer to physiotherapy for active
mobilization of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Patient is advised to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
 17
Extensor Indicis Proprius to
Extensor Pollicis Longus
Tendon Transfer

• The general complications of anesthetic

Introduction infiltration like hypersensitivity may occur
in spite of test dose application. This
As described earlier, the loss of a segment of
complication will cause dryness of mouth
EPL tendon or delayed presentation of EPL
and apprehension, which can be corrected
tendon injury warrants reconstruction with a
immediately.
tendon transfer using EIP tendon.

Surgical Steps
Presurgical Counseling
• First the hand is prepared as described in
• 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.
• A dressing will be applied and a plaster of
Paris (POP) slab will be applied at the end
of surgery.
• Admission will be necessary for a
minimum period of 3 days.
• Postoperatively, no movements of the
fingers should be attempted. If it is done,
the sutured tendons may rupture.
• Postoperatively, the POP slab will be
continued for a period of 3 weeks. After this
period, physiotherapy will be started and
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
• Incision A: An incision is marked over • Now, a subcutaneous tunnel is created
the area where the distal cut end of the
extensor pollicis longus (EPL) tendon is
present
• Incision B: Now, an S-shaped incision is
marked over the dorsum of the proximal
phalanx of the index finger, starting on
the ulnar side of the proximal phalanx,
extending proximally across the
knuckle of the metacarpophalangeal
(MCP) joint and the dorsum of the hand
• Incision C: Another incision about 2 cm
is marked over the dorsal aspect of the
wrist.
• The tourniquet is raised. First the incision
to expose the EPL is made and the skin
flaps are raised. The distal cut end of the
EPL tendon is identified, and dissected
free from the surrounding scar tissue. The
EPL tendon is now pulled proximally after
grasping with a hemostat. The passive
movement of the thumb interphalangeal
(IP) joint must be full. If it is not so, a
further dissection must be done to release
the tendon from the scar. The distance
from the radial styloid to the dorsum of
the IP joint of the thumb is measured. This
will be the length of the extensor indicis
proprius (EIP) tendon required beyond
the wrist.
• Now, the incision is made to harvest the
EIP tendon. The skin flaps are raised and
anchored with 4.0 Ethilon sutures. The
extensor tendons to the index finger are
exposed. Now, the EIP tendon is isolated.
Of the two extensor tendons to the index
finger, the ulnar side tendon is the EIP
tendon. The tendons are separate from
each other till they reach the knuckle of the
index. An incision is made over the middle
of the extensor expansion, and extended
distally for as much length of the tendon is
required.
• Now, the tendon of EIP is harvested. It is
pulled distally to confirm that there are
no more attachments of the EIP. Now, the
incision “C” is made and the EIP tendon
pulled out through this wound.
81
between the incision “A” and incision
“C”. A tendon retriever is inserted from
the incision “A” and passed through the
subcutaneous tunnel to the incision “C”.
Here, the free end of the EIP tendon is
grasped, pulled and delivered at incision
“A”.
• Moist gauze is placed over the wounds and
gentle compression is applied. The hand
is raised and the tourniquet released. The
elevation of the hand is maintained for
3 minutes and then the hand is placed
back on the table. Hemostasis is achieved.
• The gap that has been created in the
extensor apparatus by the removal of the EIP
tendon is sutured with 4.0 polypropylenes
using continuous suture. The skin wounds
at incision “B” are sutured with 4.0 Ethilon.
• The skin wounds at incision “C” are also
sutured with 4.0 Ethilon after securing
hemostasis.
• Now, the distal end of the EIP tendon
must be sutured to the EPL tendon. The
mechanical advantage is more if the EIP
tendon is sutured as distally as possible. If
a long length of the EPL tendon is available,
it is advantageous to excise a portion of this
tendon up to the level of the MCP joint of
the thumb and then suture the EIP tendon
to the remaining stump of the EPL tendon.
A trial stitch with 4.0 polypropylenes is
applied and the tension is checked. The
tenodesis effect is now checked as an
indicator of the tension adjustment in the
tendon anastomosis. The wrist is passively
flexed. This movement should cause
extension of the thumb IP joint. Similarly,
passive flexion of the wrist should cause a
flexion of the thumb joints. If this happens,
the tension on the tendon transfer is correct.
If there is too much tension, or too little
tension, it should be corrected by redoing
the tendon anastomosis.
• The tendon anastomosis is done by
Pulvertaft weave. Hold the EPL tendon
taut with a hemostat applied on the end
and pulling proximally.
82 SECTION 4  TENDON RECONSTRUCTION

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.

Postoperative Protocol
Fig. 4.17.2  Completed tendon transfer • Admission in the ward
• The affected hand should be kept elevated
• Patient can take normal diet immediately
if the procedure was under regional block
• About 1 cm proximal to the end of the
or after complete recovery if under general
tendon, make a cut in a volar to dorsal
anesthesia
direction with a number 11 blade, with
just enough length to allow the tendon
• Inspection of the suture line after 48 hours
without disturbing the position of the POP
graft through. Pull the tendon graft
slab
through and adjust the tension so that
the finger lies in the normal cascade.
• Discharge of the patient by third day
Apply a suture with 3.0 polypropylene
• Suture removal on the 10th day
using horizontal mattress suture (Fig.
• Patient to retain the POP slab
4.17.2).
• Removal of the POP slab on the 21st day
and advise the following:
• 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
• Daily wash with soap and water
through this opening also and suture
• Massage of scar and grafted skin with
coconut oil
with 3.0 polypropylenes using horizontal
mattress suture.
• Patient is advised to continue the
mobilization of the fingers; both active
• 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

in spite of test dose application. This

Introduction complication will cause dryness of mouth
and apprehension, which can be corrected
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
• First the hand is prepared as described in
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.
• A dressing will be applied and a plaster of
Paris (POP) slab will be applied at the end
of surgery.
• Admission will be necessary for a minimum
period of 3 days.
• Postoperatively, no movements of the fingers
should be attempted. If it is done, the sutured
tendons may rupture.
• Postoperatively, the POP slab will be
continued for a period of 3 weeks. After this
period, physiotherapy will be started and
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.
• The general complications of anesthetic
infiltration like hypersensitivity may occur Fig. 4.18.1  Markings for the incisions
84 SECTION 4  TENDON RECONSTRUCTION
• 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
FPL tendon is now pulled proximally after
grasping with a hemostat. The passive
movement of the thumb interphalangeal
(IP) joint must be full. If it is not so, a
further dissection must be done to release
the tendon from the scar.
• Now, the incision “B” is made to harvest
the FDS tendon. The skin on the volar
side is raised superficial to the digital
neurovascular bundle. The flexor tendon
heath is identified. An incision is made
in the flexor tendon sheath to isolate the
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 blade until both slips are
free. The vincular attachment will also
have to be divided to achieve total release
of the FDS slips.
Fig. 4.18.2  Harvested FDS tendon ready for transfer
• Now, the tendon of FDS is ready for
harvest. It is pulled distally to confirm that
there are no more attachments of the FDS.
Now, the incision “C” is made and the FDS
tendon pulled out through this wound
(Fig. 4.18.2).
• A subcutaneous tunnel is created between
the incision “A” and incision “C”. A tendon
retriever is inserted from the incision “A”
and passed through the subcutaneous
tunnel to the incision “C”. Here, the free
end of the FDS tendon is grasped, pulled
and delivered at incision “A”.
• Moist gauze is placed over the wounds and
gentle compression is applied. The hand
is raised and the tourniquet released. The
elevation of the hand is maintained for
3 minutes and then the hand is placed
back on the table. Hemostasis is achieved.
• The skin wounds at incision “B” are sutured
with 4.0 Ethilon.
• The skin wounds at incision “C” are also
sutured with 4.0 Ethilon after securing
hemostasis.
• Now, the distal end of the FDS tendon
must be sutured to the FPL tendon. The
mechanical advantage is more if the FDS
tendon is sutured as distally as possible.
If a long length of the FPL tendon is
 CHAPTER 18  FLEXOR DIGITORUM SUPERFICIALIS TO FLEXOR POLLICIS LONGUS...
available, it is advantageous to excise a
portion of this tendon up to the level of
the IP joint of the thumb and then suture
the FDS tendon to the remaining stump
of the FPL tendon. A trial stitch with 4.0
polypropylenes is applied and the tension
is checked. The tenodesis effect is now
checked as an indicator of the tension
adjustment in the tendon anastomosis.
The wrist is passively flexed. This
movement should cause extension of the
thumb IP joint. Similarly, passive flexion
of the wrist should cause a flexion of the
thumb joints. If this happens, the tension
on the tendon transfer is correct. If there
is too much tension, or too little tension, it
should be corrected by redoing the tendon
anastomosis. The tendon anastomosis is
done by modified Kessler Mason suture
using 3.0 polypropylene suture materials.
• When the tendon anastomosis is over,
the extra length of the EIP and EPL are
trimmed. Wound closed with 4.0 Ethilon
sutures.
• 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.
• Sterile dressings are applied and a dorsal
POP slab should be applied for the hand
keeping the wrist in neutral, and the
metacarpophalangeal (MCP) joints of
the fingers in flexion of 90° and IP joints
in extension and a dorsal POP slab for
85
the thumb keeping the IP joints in 15º
flexion and the MCP joint in 15º flexion
and the carpometacarpal joint in palmar
abduction.
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
or after complete recovery if under general
anesthesia
• Inspection of the suture line after 48 hours
without disturbing the position of the POP
slab
• 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
and advise the following:
• Refer to physiotherapy for active mobiliz­
ation of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Patient is advised to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
The procedure done has transferred a powerful
tendon to do a relatively light work.
Hence, the movement of the thumb may be
seen quite early into the physiotherapy!
 SECTION

Bone Reconstruction
 Bone Reconstruction—
Assessment
Introduction
When there is an evidence of bone problem, the
evaluation of the patient will be directed to find
the nature of the problem and deciding on a plan
of management. It must be remembered that a
problem of the bone may result in alteration
of the function of the other structures like
the tendons and joints. Hence, an evaluation
should assess not only the bone problem per se,
but also the effects of the problem affecting the
other structures in the hand.
History
Nature of Injury
The nature of injury will give a clue about
the magnitude of the problem. A low-energy
injury may cause a fracture but the effect may
be negligible on the surrounding structures
like tendons and joints.
Duration
If an injury has occurred more than 2 weeks
earlier, the bone is probably beginning to
unite and the callus has formed. If the fracture
had been sustained less than 2 weeks back, it
may need to support and immobilization.
19
Nature of Previous Management
This must be recorded. Any previous
management, whether operative or otherwise,
should be noted.
Skin
Presence of scars, protruding K-wires from
previous treatment should also be noted.
Deformity
When there is a deformed part of the finger
or hand, the cause is usually a malunited
fracture. The points to be recorded are:
• Site of the deformity: It will point to the
bone that has been injured
• Angulation at the deformity: This must be
measured and recorded. Some fractures
develop characteristic angulation due to
the forces that act on the proximal and
distal segments
• Rotation at the deformity: Some displaced
fractures also get rotated and united in this
deformed position. This deformity will be
manifested by an altered orientation of the
affected fingers with respect to the other
fingers. This is recorded as an ulnar or
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
Introduction
Unacceptable position of union of fractures
of the bones of hand require open reduction
and fixation, such position leads to gross
shortening of the finger/rotation leading
to scissoring of the fingers while making a
fist, or gross deformity. Such deformities
lead to biomechanical disturbances that
compromise function of the hand.
Presurgical Counseling
• This procedure will be done under axillary
block anesthesia or under GA (in children).
• This procedure will take about 2 hours to
perform.
• Wires will have to be introduced into the
bone to fix it in the correct position.
• A dressing and a plaster of Paris (POP) will
be applied.
• Admission will be necessary for a
minimum period of 3 days.
• Postoperatively, no movements of the
fingers should be attempted. The POP slab
must be retained for a minimum period of
3 weeks. After the period of 3 weeks, the
wires will be removed from the hand after
confirming the healing with appropriate
X-rays. Even before the wires are removed,
physiotherapy may be required. After
the wires are removed, it is necessary to
20
undergo a period of physiotherapy till
good movements are achieved.
• During the period of physiotherapy, splints
may have to be applied as considered to
appropriate by the surgeon/physiatrist.
• This surgical procedure aims only at
getting the deformity/fracture corrected.
Any injury of the surrounding structures
will be dealt with later.
• 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
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
• Prepare the hand as described in Appendix
I.
• Mark a cross finger flap like incision on the
dorsum of the proximal phalanx (PPX) or
middle phalanx (MPX) region of the finger
(Fig. 5.20.1). If there is already a scar on
the finger, it can be incorporated in to the
incision. If a metacarpal bone is involved,
the incision is made on the dorsum of the
hand over the metacarpal.
92 SECTION 5  BONE RECONSTRUCTION
Fig. 5.20.1  Exposures for fracture fixation in the
hand and fingers
• The tourniquet is raised and the incisions
are made.
• The incision is made through the skin and
subcutaneous tissues and the skin flap is
elevated. It is anchored with 3.0 Ethilon
after keeping the dorsal tissues exposed.
• The extensor tendon is identified and
dissected. It is usually found to have
adhesions with the underlying bone and
fracture. These adhesions are released.
A retractor is placed under the extensor
tendon to retract the tendon and expose
the underlying bone (PPX or MPX).
• Now, the curved hemostat is passed under
the bone to the flexor side, deep to the
flexor tendons. The flexor tendons will also
have multiple adhesions to the bone and
fracture site. These adhesions are released
totally.
• Now, the segment of bone bearing the
fracture site is totally dissected.
• 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
a healthy look and not sclerotic. The
sclerotic bone ends must be nibbled and
healthy bone exposed.
• Now, the freshened bone ends must be
aligned. Any protruding cortex must be
nibbled to allow complete bone-to-bone
contact. There should be no angulation of
the bone on trial alignment.
• The orientation of the tip of the finger
should also be noted and it must be oriented
normally to its neighboring finger.
• Now, the fixation of the fracture is done
with cross K-wires.
• 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 wounds are closed with 4.0 Ethilon
after keeping Segmüller drains.
• A volar slab POP is applied keeping the
wrist in 30° extensions, the metacarpo­
phalangeal (MCP) joints in 60º flexion and
the interphalangeal (IP) joints extended.
 CHAPTER 20  OPEN REDUCTION INTERNAL FIXATION OF FRACTURES
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
or after complete recovery if under general
anesthesia
• Inspection of the suture line after 48 hours
without disturbing the position of the POP
slab
• Discharge of the patient by third day
93
• Suture removal on the 10th day
• Patient to retain the POP slab
• Removal of the POP slab on the 21st day
and advise the following:
• Refer to physiotherapy for active mobiliz­
ation of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Patient is advised to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
 Bone Grafting
Introduction
When a segment of either middle phalanx/
proximal phalanx or metacarpal is lost, it can
be reconstructed with a bone graft harvested
from the ulna. This is advantageous as it falls
in the same field of regional anesthesia, and
there is negligible donor site morbidity.
Presurgical Counseling
• This procedure will be done under axillary
block anesthesia.
• This procedure will take about 2 hours to
perform.
• This procedure will entail removing a
piece of bone from the elbow and putting
it inside the injured finger to make the
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
be applied.
• Admission will be necessary for a
minimum period of 3 days.
• Postoperatively, no movements of the
fingers should be attempted. The POP slab
must be retained for a minimum period
of 3 weeks. After the period of 3 weeks, the
wires will be removed from the hand after
confirming the healing with appropriate
X-rays. Even before the wires are removed,
physiotherapy may be required. After
the wires are removed, it is necessary to
21
undergo a period of physiotherapy till good
movements are achieved.
• During the period of physiotherapy, splints
may have to be applied as considered to
appropriate by the surgeon/physiatrist.
• This surgical procedure aims only at
getting the deformity/fracture corrected.
Any injury of the surrounding structures
will be dealt with later.
• 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 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
• The hand is prepared as described in
Appendix I.
• The exposure is planned according to the
bone that is involved. For the proximal
phalanx (PPX) or middle phalanx (MPX) of
the fingers, or PPX of the thumb, the cross-
finger flap like incision described in the
previous chapter is used. For exposure of the
metacarpal bones, a longitudinal incision
is made over the involved metacarpal as
described in the earlier chapter.

• The tourniquet is raised and the incisions
are made.
• The incision is made through the skin and
subcutaneous tissues and the skin flap is
elevated. It is anchored with 3.0 Ethilon
after keeping the dorsal tissues exposed.
• The extensor tendon is identified and
dissected. It is usually found to have
adhesions with the underlying bone and
fracture. These adhesions are released.
A retractor is placed under the extensor
tendon to retract the tendon and expose
the underlying bone (PPX or MPX).
• Now, the curved hemostat is passed under
the bone to the flexor side, deep to the flexor
tendons. The flexor tendons will also have
multiple adhesions to the bone and fracture
site. These adhesions are released totally.
• Now, the segment of bone bearing the
fracture site is totally dissected.
• The proximal and distal bone ends must
have a healthy look and not sclerotic. The
sclerotic bone ends must be nibbled and
healthy bone exposed. Now, the bone
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
requirement of bone graft will be about 2
cm more than the measured gap between
the bone ends.
• The bone graft is harvested from the ulna,
if a single phalanx or metacarpal has a
non-union of a fracture. If more than one
bone has a fracture, it is preferable to use
an iliac bone graft.
• The method of harvesting an ulnar bone
graft is described in Appendix VI.
• The bone graft is sculpted in the form of a
“ladle” or a “roti belan”, with a “handle” on
either end.
• The bone graft is brought to the involved
finger and inserted between the ends of
the bone. The handles on either side of the
graft are used to peg into the proximal and
distal ends of the fractured bone.
CHAPTER 21  BONE GRAFTING 95
• The stability of the bone graft pegging is
confirmed. If there is some evidence of
instability, the graft fixation is reinforced
with a straight K-wire. The orientation of
the finger is confirmed to be normal and
it is also ascertained that the length of the
finger is normal.
• 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 wounds are closed with 4.0 Ethilon
after keeping Segmüller drains.
• A volar slab POP is applied keeping the wrist
in 30° extensions, the metacarpophalangeal
(MCP) joints in 60° flexion and the
interphalangeal (IP) joints extended.
When applying the POP in such patients, make
sure that the proximal interphalangeal (PIP) joints
are kept extended. Failure to ensure this may result
in minimal flexion contracture of the IP joints
(especially of the operated finger).
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
or after complete recovery if under general
anesthesia
• Inspection of the suture line after 48 hours
without disturbing the position of the POP
slab
• 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.
Take an X-ray of the part to confirm the
healing of the bone. If the X-ray shows a
good healing, the K-wire can be removed
in the operation theater after infiltrating
96 SECTION 5  BONE RECONSTRUCTION
the point of entry of the wire with local
anesthetic solution. Now, advise the
following:
• Refer to physiotherapy for active mobiliz­
ation of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Patient is advised to continue the mobiliz­
ation of the fingers; both active and
passive and review once every month for
evaluation.
 Vascularized Fibula Transfer
Introduction
Reconstructive surgery on the hand can
never be completed without the vascularized
fibula flap in surgeons armamentarium. The
use of this technique is wide and the main
indications are:
• Traumatic segmental loss
• Osteomyelitis
• Low grade malignant bone tumors
• Locally aggressive bone tumors
• Epiphyseal arrest due to trauma/infection.
Presurgical Counseling
• This procedure will be done under axillary
block anesthesia and general or spinal
anesthesia.
• This procedure will take about 6 hours to
perform.
• This procedure will entail removing a piece
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
anastomosis procedure. There will be no
deficit due to removal of the bone graft
from the leg.
• A dressing and a plaster of Paris (POP) will
be applied both on the hand and the leg.
• Admission will be necessary for a minimum
period of 1 week.
• Postoperatively, no movements of the fingers
should be attempted. The POP slab must be
retained for a minimum period of 3 weeks.
22
After the period of 3 weeks, the wires will
be removed from the hand after confirming
the healing with appropriate X-rays. After
the wires are removed, it is necessary to
undergo a period of physiotherapy till good
movements are achieved.
• During the period of physiotherapy, splints
may have to be applied as considered to
appropriate by the surgeon/physiatrist.
• This surgical procedure aims only at
getting the deformity/fracture corrected.
Any injury of the surrounding structures
will be dealt with later.
• 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
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
• The preferred anesthesia is either general
anesthesia or combined regional block—
continuous epidural anesthesia with supra-
clavicular block (if the surgery is for finger
or hand motorization).
• Prepare for the procedure as outlined in
the Appendix II.
• Prepare the involved upper limb, including
the shoulder, neck, front of chest.
98 SECTION 5  BONE RECONSTRUCTION
Fig. 5.22.1  Markings for raising the flap
• Prepare the opposite side thigh and leg
and foot regions.
• Markings for the flap (Fig. 5.22.1):
• Mark a point “A” on the fibular head.
Mark a point “B” on the lateral malleolus.
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
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
encountered, going from the muscle to the
skin flap (Fig. 5.22.2).
  These perforators can also be ligated
and divided. The dissection stops when
the posterior surface of the posterior
intermuscular septum is reached.
• Now, go back to the anterior surface of
the intermuscular septum. Divide the
Fig. 5.22.2  Perforators entering the skin flap

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
will now be opened and the tibialis
posterior muscle encountered. When this
muscle is retracted, the peroneal vascular
bundle will be seen. The entire length of
the peroneal vessels must be dissected.
The branches from the artery to the fibula
and the nutrient vessel can be seen. This
dissection should be done in a plane deep
to the peroneal vessels and not between
the fibula and vascular bundle. The plane
of the vessels is shown in Figure 5.22.3.
• The posterior dissection along the soleus
muscle should be continued now. Keep
dividing the soleus muscle fibers and
freeing the muscle from the fibula and the
intermuscular septum. Now, the entire
length of the posterior intermuscular
septum can be dissected. The proximal
and distal osteotomies can be done now.
Further dissection can be completed after
the osteotomy.
• Mark the site of the proximal osteotomy.
Make the incision in the periosteum about
2 cm proximal to this site. Elevate the
periosteum up to the site of the proposed
osteotomy. Carry out the osteotomy.
• Mark the site of distal osteotomy. Make
an incision on the periosteum and then
perform the osteotomy.
• Now, the osteotomized bone segment
and the skin paddle will be attached by
CHAPTER 22  VASCULARIZED FIBULA TRANSFER 99
Fig. 5.22.3  Cross-section of leg showing the relative anatomy
Key: 3. Flexor digitorum longus; 4. Tibialis posterior; 5. Flexor hallucis
longus; 6. Tibialis anterior; 7. Extensor hallucis longus; 8. Extensor
digitorum longus; 9. Peroneus brevis; 10. Peroneus longus; 14. Fibula;
15. Transverse intermuscular septum; 16. Interosseous membrane;
17. Anterior intermuscular septum
the posterior intermuscular septum, the
peroneal vascular bundle and a few fibers
of the flexor hallucis longus muscle. These
fibers can be retained along with the
pedicle to prevent injury to the vessels.
• The fibular osteocutaneous flap is now
ready for transfer. The division of pedicle
should be done only after the completion
of the dissection in the recipient site.
• Division of the pedicle: Usually, there are
two veins and one artery at the vascular
pedicle and the nerve. 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 recipient site for vascular
anastomosis.
• Management of the donor site: After securing
hemostasis, the secondary defect should be
closed with a skin graft from the thigh. Sterile
dressings should be applied and elastocrépe
bandage applied over it. A posterior below
knee slab is applied.
100 SECTION 5  BONE RECONSTRUCTION

• Patient can take normal diet immediately

Vascular Anastomosis if the procedure was under regional block
or after complete recovery if under general
• The flap is brought to the hand defect. First anesthesia
the flap is held up and the pedicle allowed
• Inspection of the suture line after 48 hours
to hang down. This step will make sure
without disturbing the position of the POP
that there is no inadvertent twisting of the
slab
vascular pedicle. The flap is then placed
• Suture removal on the 10th day
over the defect with the correct orientation
• Patient to retain the POP slab
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
• Daily wash with soap and water
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
Introduction
When a patient presents with a problem of the
joint, assessment of the situation should lead
to the cause of the problem. The assessment
of a joint is twofold. The joint could either
have been injured per se or it could have
become involved after an injury which is not
directly on the joint.
This section deals mainly with post-
traumatic sequelae affecting the joints.
Conditions like tumors, degenerative diseases
like rheumatoid disease, and congenital
anomalies can also affect the joints, but such
problems are not highlighted in this chapter.
Clinical Examination
The examination of the patient should follow
the steps outlined below:
• Cause of the injury:
• Blunt injuries are likely to cause
dislocations and closed fractures. It
should be noted whether this type of
injury has caused an injury to the joint.
Even an injury at a remote site can result
in a stiffness of the joint of the hand.
This should also be recorded.
• Open injuries are more likely to cause
soft tissue disruption which may cause
instability of the joint.
• Duration of the injury: This is very
important. When a dislocation of the
proximal interphalangeal (PIP) joint
23
occurs, and the patient presents within a
week to 10 days, the chances of achieving
a good reduction and hence good function
are high. However, if the patient presents
later than this period, it is more likely that
the function of the joint may have been lost
forever.
• Local symptoms: Like pain or swelling
can occur in situations where there is
inflammation
• Infection of the joint can occur after
penetrating injuries like human bite.
• Inflammation can occur following
vigorous, unsupervised physiotherapy.
• The management of both these con-
ditions is different and hence the
correct diagnosis is essential.
• Constitutional symptoms: Like fever
and malaise may occur when there is a
hematogenous spread of infection from a
joint.
• Position of the joint: It is important to
record the resting position of the joint as
it gives a clue to the underlying pathology.
• Associated fracture: As mentioned
earlier, the fracture of the proximal
phalanx can cause a stiffness of the PIP
joint, even if the fracture has not been
intra-articular. This is caused mainly by
improper position of the joints during
immobilization at the time of treatment
of the fracture.
• The range of movements of the joint must
be recorded. This will include both active
and passive range of movement. This
recording has two uses:
104 SECTION 6  JOINT RECONSTRUCTION
• It is diagnostic, e.g. in a condition
where the PIP joint is kept in a position
of flexion, a study of the range of
movement will indicate whether the
condition is caused by boutonniere
deformity or a stiffness of the PIP joint
caused by an intra-articular fracture.
• It serves as an indicator of progress or
deterioration after starting a course
of physiotherapy or after surgical
procedure.
• Investigations:
• X-ray findings:
• Nature of articular surfaces
• Congruity of articular spaces
• Joint space
• Status of bones proximal and distal
to the joint.
Planning the Management
• Role of physiotherapy—as soon as the • Common surgeries done on the joints in
patient is seen with a joint problem, it is
imperative that basic investigations are
done to study the status of the joint. Once
the study of the joint is completed, the
patient must be seen by the physiotherapist
for two reasons:
• The patient must meet the physio-
therapist who is going to play an
important role in bringing back the
movement in a stiff joint. Sometimes,
if the stiffness is minimal, the physio-
therapy itself is the treatment and good
function can be achieved.
• If the stiffness is severe, or the joint
requires surgical management, even
then, the physiotherapist must develop
a good rapport with the patient, who
needs the help of the physiotherapist
after the surgery.
• Indications for surgery:
• If the joint does not become supple
after a course of physiotherapy.
• If the injury has been directly on the
joint and has caused either:
• A dislocation or subluxation
• A loss of joint surfaces
• Incongruity of joint surfaces.
• Timing of surgery—in case of the multiply
injured hand, surgery on multiple
structures can be done at the same stage to
reduce the number of stages done. In such
a situation, it is important to remember
that some surgeries on the hand require
immobilization and some procedures
require immediate mobilization. These two
types of procedures should not be done
together for obvious reasons.
the hand:
• Reduction of chronic dislocation of
metacarpophalangeal (MCP) joint of
the finger.
• Release of a stiff joint especially. PIP
joint and MCP joint (arthrolysis).
• Arthrodesis of PIP joint of the finger,
MCP joint of the thumb.
• Replacement of a destroyed joint (PIP
and MCP) with an implants.
• Replacement of a joint with a vascularized
metatarsophalangeal (MTP) joint of the
toe.

Chronic
Metacarpophalangeal Joint
Dislocation Reduction
Introduction
Dislocation of the metacarpophalangeal joint
of the fingers, especially the index finger is not
amenable for closed reduction. When such a
condition presents late, open reduction of the
dislocation is one method of management
that yields good results. Explaining to the
patient what is going to be done and what
is expected of him is very important in
determining the outcome.
Presurgical Counseling
• This procedure will be done under axillary
block anesthesia/general anesthesia.
• This procedure will take about 1 to 1½ • In some instances, in the postoperative
hours to perform.
• An incision will be made on the palm, and if
necessary, on the dorsum of the hand. The
scar on the palm will be as inconspicuous
as possible.
• Postoperative physiotherapy is a must
and should be started immediately after
surgery.
• A dressing will be applied and a plaster of
Paris (POP) slab will be applied.
• 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.
• Admission will be necessary for a minimum
period of 3 days, after which review will be
on the instructions of the surgeon.
24
• Postoperatively, gentle active and passive
mobilization of the interphalangeal (IP)
joints of the finger should be continued. If
it is not done, the finger will get back to the
original state before surgery.
• The POP and postoperative physiotherapy
should be continued for a minimum period
of 3 weeks. This should be followed by a
period of wearing a detachable splint for a
further 3 weeks. The wearing of the splint
beyond this period will depend upon the
progress achieved, and the reaction of
the tissues, which will be assessed by the
surgeon.
• In some instances, if the dislocation is
severe, full movements may not be achieved
after one surgery.
period, the movements may be achieved
fully, but if physiotherapy is neglected,
recurrence of the dislocation can occur,
which will require a surgery again.
• 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
• The hand is first prepared as describe in
Appendix I.
106 SECTION 6  JOINT RECONSTRUCTION
Fig. 6.24.1  Volar incisions to approach the MCP
joints of the fingers
• Incision (Fig. 6.24.1): A transverse
incision is made on the palm at
the distal palmar crease, over the
metacarpophalangeal (MCP) joint of
the finger. The incision must be made
about 4 to 5 cm long. Care must be taken
to keep this incision skin deep only, as
the digital neurovascular bundle may
be very superficial over the projecting
head of metacarpal.
• Retractors are applied on both the edges
and the skin flaps retracted. The structures
are exposed and the box mechanism is
identified by applying gentle traction. The
flexor tendons are on the ulnar side. The
neurovascular bundle is on the radial side
along with the lumbrical muscle. Retract
the flexor tendons toward the ulnar side to
expose the base of the proximal phalanx.
By inserting a number 15 blade between
the base of proximal phalanx and the
head of metacarpal, the deep transverse
metacarpal ligament is released.
• The scar tissue between the head of the
metacarpal and the base of the proximal
phalanx must also be excised. Along with
this step, the A1 pulley of the flexor sheath
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
fully from the scar, or the flexor tendon has
not been released fully from the scar. These
structures should be released from the scar
and the joint reduced.
• Once reduced the entire volar plate can be
seen on the volar aspect of the joint. It will
be seen usually to have a tear transversely.
By keeping the flexor tendon retracted
this tear in the volar plate is repaired by
a continuous suture of 5–0 polypropylene
with knots on either end. The tourniquet
is released and hemostasis obtained. The
flexor tendon is then repositioned and
suturing of the wound is done with 4.0
Ethilon.
• For giving postoperative analgesia for
the thumb, index and middle fingers, a
Venflon catheter should be inserted in
the volar aspect of the wrist, about 1 cm
proximal to the wrist crease. The needle
must be inserted to the ulnar side of the
palmaris longus tendon, the needle being
aimed deeply, pointing to the knuckle of
the middle finger. This cannula will deliver
anesthetic solution in the area surrounding
the median nerve. If the ring or little fingers
have been involved, the Venflon catheter is
placed to the radial side of the flexor carpi
ulnaris (FCU) tendon about 1 cm proximal
to the wrist crease. This cannula must be
 CHAPTER 24  CHRONIC METACARPOPHALANGEAL JOINT DISLOCATION REDUCTION
fixed with plaster after the wounds are
sutured.
• Vaseline gauze is applied over suture line
and dressing done. A dorsal slab POP is
applied with the wrist in neutral position,
MCP joints in 90° flexion and IP joints
extended.
Since a Venflon catheter has been introduced in
the wrist, clear instructions should be given to the
ward nurse that it is not a portal for IV fluid infusion!
If possible, the patient can also be told to warn the
nurse about the special catheter!
Postoperative Protocol
The postoperative follow-up protocol of this
surgery is very important:
• Admission in the ward.
• The affected hand should be kept elevated.
• Patient can take normal diet immediately
if the procedure was under regional block
or after complete recovery if under general
anesthesia.
• Four milliliters of 1 percent solution of
Xylocaine must be injected into the cannula
once every 6 hours. The dressing is opened
107
on the volar aspect and suture line is
inspected after 48 hours. If it is clean, active
and passive mobilization of the IP joints of
the finger is started within the POP slab.
• The patient must be attended by a physio­
therapist and both active and passive
mobilization of the fingers must be done
within the POP. The MCP joint will be kept
flexed but the IP joints mobilized.
• Discharge of the patient by third day.
• Suture removal on the 10th day. Retain the
POP slab
• Refer to physiotherapy for continuing
active and passive mobilization of the
fingers.
• Review at the end of 3 weeks. Remove
the POP slab.
• Daily wash with soap and water.
• Massage of scar and grafted skin with
coconut oil.
• Prescribe a dynamic knuckle bender
splint to be worn 24 hours a day for a
further 3 weeks.
• Review after this period. If the active
range of movement is full, discard the
splint. If the range of movement is not
full, to continue wearing the splint at
night for a further 3 weeks.
 Arthrolysis
Introduction
Stiffness of the hand joints, especially the IP
joints and MCP joint can occur due to many
causes including direct or indirect injuries or
infection. Achieving good movements of the
fingers is important for the return of normal
function and movements can be achieved
by prudent arthrolysis which may have to be
combined with tenolysis also.
Arthrolysis of the Proximal
Interphalangeal Joint
of the Finger
Presurgical Counseling • The general complications of local anes­
• This procedure will be done under wrist
block anesthesia as patient cooperation
will be required in the course of the
procedure.
• A tourniquet will be applied and raised,
but will be released before pain starts.
• This procedure will take about 30 to 45
minutes to perform if it involves a single
finger and more if more fingers are
involved.
• The return of full movement will be shown
to the patient on the table. If this movement
is to be maintained, postoperative physio­
therapy is a must.
• A dressing will be applied and no plaster of
Paris (POP) will be applied.
25
• A catheter will be placed in the wrist (like
a IV cannula), through which, anesthetic
solution will be injected if there is pain.
• Admission will be necessary for a
minimum period of 3 days.
• Postoperatively, gentle active mobilization
of the finger should be continued. If it is
stopped, the finger will get back to the
original state before surgery.
• 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
some loss of power of the finger, but there
will be no loss of movements.
• In some instances, even if the movements
of the finger improve, further surgery may
be required to reconstruct the pulleys.
thetic 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
• This procedure should be done under
wrist block anesthesia. However, if more
than one finger is involved, the procedure
had better be done under axillary block
anesthesia, as the patient cannot tolerate
the tourniquet for a prolonged time under
local anesthesia.
• The incision is made on the noncontact
side of the involved finger, i.e. the ulnar

side of the index, middle and ring fingers
and the radial side of the little finger. The
incision should be about 4 to 5 cm on the
neutral line, centered on the point where
the proximal interphalangeal (PIP) joint
crease touches the neutral line.
• The incision goes down through the skin,
to the subcutaneous tissue. Care should
be taken to avoid damage to the digital
neurovascular bundle, which will be only
slightly volar to the neutral line.
• A retractor applied on the volar skin will
expose the side of the flexor sheath. An
incision should be made with a knife on
the side of the flexor sheath, and the flexor
tendons exposed. The flexor tendons are
now retracted volarward to expose the
volar structures, especially the volar plate,
in front of the PIP joint capsule.
• It is this volar plate that is the usual cause of
the PIP joint deformity. This volar plate is
divided transversely about 0.5 cm from its
attachment on the proximal phalanx. Small
arterial branches are usually encountered
here which should be cauterized.
• Now, the release of the PIP joint should be
assessed. The passive range of movement
at the PIP joint must be full and free. If it is
not so, the collateral ligaments will have to
be divided next.
• With the careful use of the blade, the
collateral ligaments should be divided
on both sides of the PIP joint. If the blade
goes deeper while doing this, the joint
capsule will also be damaged. The amount
of postoperative swelling will be more in
such a situation and if more of the joint
capsule is injured, the joint may become
unstable.
• Again the release of the PIP joint should be
reassessed. If there is still a volar tightness,
palpate the flexor tendons. The flexor
digitorum superficialis (FDS) is usually
tight. If so, confirm the intactness of the
flexor digitorum profundus (FDP) tendon
and divide the FDS tendon, about 1 cm
CHAPTER 25  ARTHROLYSIS 109
proximal to the insertion. This will release
the PIP joint totally.
• Now, ask the patient to flex the PIP joint
of the finger. He may find it difficult
to localize the single finger due to the
wrist block. Hence, the patient must be
instructed to flex all the fingers together.
This will demonstrate the movements at
the PIP joint of the involved finger also.
The extension of the finger should also be
demonstrated to the patient. There may
be some lag in extension due to the wrist
block. Hence, a full range of passive flexion
and extension will be enough.
• 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.
• For giving postoperative analgesia for
the thumb, index and middle fingers, a
Venflon catheter should be inserted in
the volar aspect of the wrist, about 1 cm
proximal to the wrist crease. The needle
must be inserted to the ulnar side of the
palmaris longus tendon, the needle being
aimed deeply, pointing to the knuckle of
the middle finger. This cannula will deliver
anesthetic solution in the area surrounding
the median nerve. If the ring or little fingers
have been involved, the Venflon catheter is
placed to the radial side of the flexor carpi
ulnaris (FCU) tendon about 1 cm proximal
to the wrist crease. This cannula must be
fixed with plaster after the wounds are
sutured.
• Suture the skin with 4.0 Ethilon after
keeping Segmüller drains and apply sterile
dressings.
Postoperative Protocol
The postoperative follow-up protocol of this
surgery is very important:
• Admission in the ward.
• The affected hand should be kept elevated.
110 SECTION 6  JOINT RECONSTRUCTION
• Patient can take normal diet immediately
if the procedure was under regional block
or after complete recovery if under general
anesthesia.
• Four milliliters of 1 percent solution
of Xylocaine must be injected into the
cannula once every 6 hours. The patient
must be attended to be a physiotherapist
and both active and passive mobilization
of the fingers must be done.
• Inspection of the suture line after 48 hours.
• Discharge of the patient by third day.
• Suture removal on the 10th day
• Refer to physiotherapy for active mobili-
zation of the fingers.
• Daily wash with soap and water.
• Massage of scar and grafted skin with
coconut oil.
• To apply a straightening splint at night
for the involved finger alone for a period
of 3 weeks thereafter.
Arthrolysis of the
Metacarpophalangeal
Joint of the Finger
Presurgical Counseling
• 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
procedure.
• A tourniquet will be applied and raised,
but will be released before pain starts.
• This procedure will take about 30 to 45
minutes to perform if it involves a single
finger and more if more fingers are
involved.
• The return of full movement will be shown
to the patient on the table. If this movement
is to be maintained, postoperative physio­
therapy is a must.
• A dressing will be applied and a POP will
be applied, which will be retained for
10 days, following which, a detachable
splint will be applied. This splint should
be worn at night for a further 3 weeks and
physiotherapy should be continued during
the day for this period also.
• A catheter will be placed in the wrist (like
a IV cannula), through which, anesthetic
solution will be injected if there is pain.
• Admission will be necessary for a
minimum period of 3 days.
• Postoperatively, gentle active mobilization
of the finger should be continued. If it is
stopped, the finger will get back to the
original state before surgery.
• In some instances, if the joint is very
grossly stuck, release may accuse to return
of movement, but there may be some
instability, which may have to be corrected
at a later surgery.
• In some instances, if the extensor tendon is
also damaged beyond repair, it may have to
be sacrificed to achieve a good movement
at the joint. However, the tendon will have
to be reconstructed at a later surgery.
• 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.
wrist block anesthesia. However, if more
than one finger is involved, the procedure
had better be done under axillary block
anesthesia, as the patient cannot tolerate
the tourniquet for a prolonged time under
local anesthesia.
• The incision is made on the dorsum of
the hand over the knuckle of the involved
joint. The incision will be longitudinally
oriented, in the shape of a lazy “S” about 5
cm long, with the transverse portion lying
exactly over the knuckle prominence.
• The incision goes down through the skin,
to the subcutaneous tissue. Care should be
taken to avoid damage to the subcutaneous
veins.

• The extensor tendons should be retracted
to expose the joint capsule of the
metacarpophalangeal (MCP) joint.
• An incision should be made with a knife on
the dorsum of the capsule and a segment
of the dorsal capsule about 3 cm × 0.5 cm
should be excised. This portion of the joint
capsule should extend from one neutral
line to the other. This will release the
collateral ligaments on the radial and ulnar
sides of the joint. The articular surfaces of
the proximal phalanx and the head of the
metacarpal will be exposed.
• Now, the release of the MCP joint should be
assessed. The passive range of movement
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
to localize the single finger due to the
wrist block. Hence, the patient must be
instructed to flex all the fingers together.
This will demonstrate the movements at
the MCP joint of the involved finger also.
The extension of the finger should also be
demonstrated to the patient. There may
be some lag in extension due to the wrist
block. Hence, a full range of passive flexion
and extension will be enough.
• 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.
• For giving postoperative analgesia for
the thumb, index and middle fingers, a
Venflon catheter should be inserted in
the volar aspect of the wrist, about 1 cm
proximal to the wrist crease. The needle
must be inserted to the ulnar side of the
palmaris longus tendon, the needle being
aimed deeply, pointing to the knuckle of
the middle finger. This cannula will deliver
anesthetic solution in the area surrounding
the median nerve. If the ring or little fingers
have been involved, the Venflon catheter is
placed to the radial side of the FCU tendon
about 1 cm proximal to the wrist crease.
CHAPTER 25  ARTHROLYSIS 111
This cannula must be fixed with plaster
after the wounds are sutured.
• Suture the skin with 4.0 Ethilon after
keeping Segmüller drains and apply sterile
dressings.
• A dorsal slab POP is applied with the
wrist in neutral position, MCP joints in
90º flexion and interphalangeal (IP) joints
extended.
Since a Venflon catheter has been introduced in
the wrist, clear instructions should be given to the
ward nurse that it is not a portal for IV fluid infusion!
If possible, the patient can also be told to warn the
nurse about the special catheter!
Postoperative Protocol
The postoperative follow-up protocol of this
surgery is very important:
• Admission in the ward.
• The affected hand should be kept elevated.
• Patient can take normal diet immediately
if the procedure was under regional block
or after complete recovery if under general
anesthesia.
• Four milliliters of 1% solution of Xylocaine
must be injected into the cannula once
every 6 hours. The dressing is opened
on the volar aspect and suture line is
inspected after 48 hours. If it is clean, active
and passive mobilization of the IP joints of
the finger is started within the POP slab.
• The patient must be attended to be a
physiotherapist and both active and
passive mobilization of the fingers must be
done within the POP.
• Discharge of the patient by third day.
• Suture removal on the 10th day. Retain the
POP slab:
• Refer to physiotherapy for continuing
active and passive mobilization of the
fingers.
• Review at the end of 3 weeks. Remove
the POP slab.
• Refer to physiotherapy for continuing
active and passive mobilization of the
fingers.
112 SECTION 6  JOINT RECONSTRUCTION
• Daily wash with soap and water.
• Massage of scar and grafted skin with
coconut oil.
• Prescribe a dynamic knuckle bender
splint to be worn 24 hours a day for a
further 3 weeks.
• Review after this period. If the active
range of movement is full, discard the
splint. If the range of movement is not
full, to continue wearing the splint at
night for a further 3 weeks.

Vascularized Toe
Metatarsophalangeal
Joint Transfer
Introduction
When the joint of a finger has been destroyed,
the resulting function in the finger is
compromised. Replacement of the joint by
biological, vascularized tissue is perhaps
the ideal reconstruction in such cases.
Disadvantages that are seen for artificial joint
replacement are not seen in this method of
microvascular reconstruction.
Presurgical Counseling
• This procedure will be done under axillary
block anesthesia for the hand and general
or spinal anesthesia.
• This procedure will take about 6 hours to
perform.
• This procedure will entail removing a joint
from the second toe of the leg on the same
side as the hand injured, along with its
blood supply and fixing it inside the injured
finger to make the new joint heal properly.
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
no deficit in walking due to removal of the
joint and loss of toe.
• A dressing and a plaster of Paris (POP) will
be applied both on the hand and the leg.
• Admission will be necessary for a minimum
period of 1 week.
• Postoperatively, no movements of the fingers
should be attempted. The POP slab must be
26
retained for a minimum period of 3 weeks.
After the period of 3 weeks, the wires will
be removed from the hand after confirming
the healing with appropriate X-rays. After
the wires are removed, it is necessary to
undergo a period of physiotherapy till good
movements are achieved.
• During the period of physiotherapy, splints
may have to be applied as considered
appropriate by the surgeon/physiatrist.
• This surgical procedure aims only at
getting the deformity/fracture corrected.
Any injury of the surrounding structures
will be dealt with later.
• 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 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.
Preparation
• Palpate the dorsalis pedis artery 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.
• Mark a point “A” at the level of the distal
edge of the inferior extensor retinaculum,
114 SECTION 6  JOINT RECONSTRUCTION
halfway between the dorsalis pedis artery
marking and the great saphenous system
marking.
• Draw a curvilinear line between the point
“A” and the web space between the great
toe and the second toe.
• Similarly, from the web space between the
great toe and second toe, on the plantar
aspect, make a marking that extends from
the apex proximally along the second
metatarsal to the midsole.
• If a skin flap is needed, it can be planned
on the dorsum of the metatarsophalangeal
(MTP) joint of the second toe. The flap
should not extend distal to the level of the
proximal interphalangeal (PIP) joint.
Surgical Steps
• Prepare for the surgery as described in the
Appendix I and II.
• Make the dorsal incision down to the
dermis only.
• Raise medial and lateral flaps for about
2 to 3 cm on either side.
• The following should be dissected now—
the great saphenous vein, other dorsal
veins, fat and subcutaneous tissue.
• 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.
• Dissect the deep peroneal nerve and divide
it at the level of the MTP joint of the second
toe. It is not required in the flap.
• At the distal part of the first dorsal
metacarpal artery, identify the deep
communicating branch going to the
plantar side. This branch will join with
the first plantar metatarsal artery to form
the plantar digital artery. And this plantar
digital artery will divide into two, 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.
• Now, surgeons go to the plantar side
dissection. Make the plantar incisions.
The plantar incision is needed only if the
vessels cannot be clearly dissected from
the dorsal approach.
• The medial plantar digital artery (branch
to the great toe) is divided.
• The transverse metatarsal ligament is
divided on the lateral aspect of the MTP
joint of the second toe. This should be done
as close to the joint as possible without
injuring the capsule.
• Now, retractors should be applied to the
second metatarsal and retracted laterally
and the first metatarsal retracted medially.
The arterial system is now exposed. The
system should be carefully dissected, taking
into account the dominance of the vessel
system. This can be assisted by carefully
dividing the interosseous muscles and
further exposing the arterial system.
• Now, disarticulate the second toe at the
level of the PIP joint. Now, the MTP joint
of the second toe is almost completely
dissected and is held only by the intact
metatarsal bone and the artery and veins.
The osteotomy of the metatarsal can be
done. This should be done depending
on the length that surgeons have already
calculated in the preoperative work-up.
• The osteotomy should be done in an
oblique manner. This is because of the
nature of the MTP joint of the toe. This
joint is basically an extension joint. The
range of motion of this joint is 0–550 of
extension and 0–50 of flexion. If this joint
is used to replace any of the small joints
of the hand, it will not be physiological,
because the joints of the hand should
have more amount of flexion and lesser
amount of extension for good function.
Hence, the MTP joint of the toe must be
modified, if it is to become a flexion joint
 CHAPTER 26  VASCULARIZED TOE METATARSOPHALANGEAL JOINT TRANSFER
Fig. 6.26.1  Harvested second toe MTP joint, ready for transfer
in the hand. The easiest way to do this is to
do an oblique osteotomy at the neck of the
metatarsal bone.
• The next step is to make transverse drill
holes on the metatarsal and the proximal
phalanx adjoining the joint. Stainless steel
wire (24G) are threaded through these drill
holes and kept ready.
• Once the osteotomy is over, the remaining
soft tissues can be divided, so that the
second toe joint is now held only by the
arteries and veins (Fig. 6.26.1).
• Now, release the tourniquet, apply warm,
moist pads over the second toe and the
vascular pedicle. Take care to prevent
the toe from falling down and shearing
the vessels! Raise the foot for about 5
minutes. Then place the foot on the table.
It usually takes about 15 to 20 minutes
for the circulation to be re-established in
the dissected skin flap. By the end of this
time, the flap becomes pink and warm and
ready for 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
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 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 and elastocrépe bandage
applied over it. A posterior below knee POP
slab should be applied.
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
• One percent of Xylocaine gauze is applied
over the dissected vessels
• A volar incision is made on the stump of the
thumb proximally up to the thenar area.
Raise the medial and lateral skin flaps,
116 SECTION 6  JOINT RECONSTRUCTION
apply anchoring sutures with 3.0 Ethilon
and dissect the following structures:
• Prepare the ends of the bony stumps to
which the MTP joint of the second toe
is going to be fixed. Pass transverse drill
holes through both ends of the bone
which will lie proximal and distal to the
position of the joint
• 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.
Fixation of the Toe
Metatar­sophalangeal Joint Flap
• Bring the toe flap to the recipient site.
Place the MTP joint of the toe in position,
a position in which good function can be
achieved with the fingers.
• A subcutaneous tunnel is created between
the recipient site vessels and the summit of
the stump. This tunnel is for the vessels of
the toe to be passed through to reach the
recipient vessels—the radial artery.
• The structures to be passed through the
tunnel are:
• The arteries
• The veins
• Bone fixation—fix the bones, both
proximally and distally with the stainless
steel wires that had already been passed.
This can be done by using square knot of
the wire without causing damage to the
vessels.
• Tendon repair—this may be required, in
conditions of trauma only. In congenital
conditions, the tendons will be intact
and tendon reconstruction may not be
necessary.
• Vascular anastomosis—the recipient
vessels should be divided, blood flow
checked from the divided artery and
approximator clamps applied. The soft
clamps must be released from the donor
vessels. Vascular anastomosis should
be done (the technique of vascular
anastomosis is beyond the scope of this
manual).
Postoperative Protocol
• Admission in the ward for a minimum
period of 1 week.
• The affected hand and the leg should be
kept elevated.
• Patient can take normal diet immediately
if the procedure was under regional block
or after complete recovery if under general
anesthesia.
• Inspection of the suture line after 48 hours
without disturbing the position of the POP
slab.
• Suture removal on the 10th day. Patient to
retain the POP slab.
• Removal of the POP slab on the 21st day.
Take an X-ray of the part to confirm the
healing of the bone. If the X-ray shows a
good healing, the K-wire can be removed
in the operation theater after infiltrating
the point of entry of the wire with local
anesthetic solution. Now, advise the
following:
• Refer to physiotherapy for active
mobilization of the fingers.
• Daily wash with soap and water.
• Massage of scar and grafted skin with
coconut oil.
• Patient is advised to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
 SECTION

Nerve Reconstruction
 Nerve Reconstruction—
Assessment
When the patient has an injury to the nerves,
the diagnosis may sometimes be quite
obvious. When assessing such an injury,
the effects of injury to the nerve can be
seen in the hand, where, the neural deficit
will be seen. This includes motor, sensory
and autonomic neural deficits that must be
assessed. The assessment of the deficits has
been outlined in the chapter on Hansen’s
disease—assessment.
The injuries to the median, ulnar and
radial nerves will be considered, and the
methods of reconstruction will be dealt with.
The functional deficit associated with each
nerve is different. When the ulnar nerve is
involved, the deficit is mainly in the power
of the hand, and when the involvement is of
the median nerve, it is more of a precision
and fine work deficit that is noted. So, when
a manual labourer presents with an ulnar
nerve involvement, he is more likely to be
incapacitated by the problem, than a person
27
who is a sedentary worker with the same
nerve involvement.
The next assessment should be of the
specific motor or sensory deficit, because the
treatment protocol will be aimed at correcting
the particular problem. In a case of ulnar
nerve injury, who has had a previous surgery,
or has had a partial involvement only, there
may be a sparing of some of the innervated
muscles. In such a situation, it is not prudent
to carry out the routinely described tendon
transfers blindly.
All hands are not alike. We are likely to
come across some patients with thin and
fragile hands, and sometimes some patients
with short stubby and thick hands. So it is
obvious that any described tendon transfer
will not have the same results in all types of
hands. Hence, the assessment of the habitus
of the hand must also be made, before
planning the treatment protocol.
 Nerve Reconstruction—
Management
Approaches and Exploration
Points to be remembered when exploration is
planned for nerve injury:
• It is not advisable to approach the deeper
tissues through the scar that is present.
This is because, the tissues will be grossly
adherence at this area and it may be very
difficult to identify the injured nerve in
this scar tissue. The chances of inadvertent
injury to the nerve are also possible.
• Hence, the incision should incorporate the
scar in the standard prescribed incision for
exploration of the particular nerve.
• The dissection of the nerve should
commence in the area distal to the zone of
injury and in the area proximal to the zone
of injury, so that, the healthy nerve can be
identified first and can then be traced to
the area of injury.
• A liberal incision always helps in the
following ways:
• Tissue handling is more gentle and
rough retraction is not required.
• The exposure offered is better and gives
an idea about the relative anatomy in
the zone of exploration.
• Thus, both time and energy are saved in
this technique.
The markings for nerve exploration depend
on the site of injury of the nerve. However,
there are some standard incisions that are
used when the nerves are explored.
28
In the arm:
• Radial nerve is approached by a longitudinal
incision on the lateral aspect of the entire
arm, over the palpable border of the
humerus.
• Median nerve and ulnar nerve are
approached by a longitudinal incision on
the medial side of the entire length of the
arm.
In the forearm:
• Median nerve and the ulnar nerve are
approached by a lazy “S” incision on the
flexor aspect of the forearm, from the elbow
to the wrist crease.
In the palm:
• Median nerve and ulnar nerve: The incision
should be made on the thenar crease.
• Digital nerves in the palm: Zig zag incisions
on the palm.
• Digital nerves in the fingers: Neutral line
incision on the appropriate side to expose
the digital nerves.
Nerve Repair
• The hand is prepared as described in
Appendix I
• The markings are made as described above.
• The tourniquet is raised and the skin
incisions are made as planned.
• The incision is made down through the
skin and subcutaneous tissues to the deep
fascia of the forearm. This fascia is incised
and the compartment of the flexor muscles
 CHAPTER 28  NERVE RECONSTRUCTION—MANAGEMENT
is reached. The muscles are dissected
carefully and the median nerve is looked for
in the plane between the flexor digitorum
superficialis (FDS) and the flexor digitorum
profundus (FDP). If there is any difficulty in
locating the median nerve, it can be traced
in a retrograde manner from the distal part
of the forearm, where it is relatively easily
identified among the tendons. The nerve
lies deep to the palmaris longus tendon
and to the radial side of the FDS and FDP
tendons to the fingers. In the distal part of
the forearm, opening the deep fascia will
give access to the tendons.
• When the nerve has been dissected, the
ends of the nerve are examined under
microscope. There is usually a rounded
swelling of the proximal end of the nerve
which consists of the neuroma. There is
a swelling on the distal end of the nerve
constituting a glioma. Both these swellings
must be excised before reconstruction of
the nerve can be done.
• The excision of the neuroma should be
done under the microscope. A scalpel
handle is taken and totally wound with
moist gauze piece over a length of about 5
cm. This part of the handle is then placed
under the end of the nerve and the excision
of the neuroma begins. With a number
11 blade, the neuroma is cut transversely
across. The proximal end of the cut
neuroma is examined under microscope, to
look for evidence of fascicles. The fascicles
will appear clearly only in the intact portion
of the nerve. In other areas, the nerve
fascicles will appear hazy and surrounded
by homogenous scar tissue. The proximal
end of the nerve should again be cut at a
distance of 1 mm from the end. This end
should again be examined for determining
the integrity of the fascicles as described
above. This process should be continuously
done until anatomically intact fascicles are
encountered. There should be absolutely
no scar tissue in the end of the nerve now.
On examining the epineurial covering of
the nerve, blood vessels should be seen
121
running on the surface till the cut end of the
nerve. The nerve should feel soft and supple
to the palpating finger. Now, the proximal
end of the nerve is ready for reconstruction.
• This procedure should be repeated for the
distal end also. By this, the distal end of the
nerve will also be ready for reconstruction.
• Now, the process of mobilization of the
nerve ends should be done. This is done to
free the proximal and distal nerve segments
from any scars that have formed with the
surrounding soft tissues. This is done gently
teasing the tissues around the proximal
and distal nerve segments and freeing
the nerves. It should be remembered that
this process of mobilization should not be
extended for more than 5 to 8 cm from both
ends, as this may lead to devascularization
of the nerve segments.
• The nerve ends should be placed loosely
on their bed and the reconstruction plan
should be made:
• Ends of the nerves are close to each
other or gap less than 2 cm: primary
repair of the nerve.
• Gap between nerve ends between 2 and
10 cm: free nerve graft.
• Gap between nerves ends greater than
10 cm: vascularized nerve graft.
• Primary repair of the nerve—the nerve
ends are placed closing to each other
and a background material is placed
under the proposed site of nerve repair
(this background material is available
commercially). The ends of the nerve
should fall in contact with each other
when left lax. Hemostasis is achieved and
then the orientation of the nerve ends is
matched.
• The orientation of the fascicles is matched
on the proximal and distal ends of the
nerve.
• If blood vessels are seen running on the
epineurial surface, these are matched
between the proximal and distal ends.
• Now, the epineurial repair (Fig. 7.28.1) is
done after orienting the cut ends correctly.
The repair is done under microscope. In no
122 SECTION 7  NERVE RECONSTRUCTION
Fig. 7.28.1  Epineurial repair
part of the surgery should the nerve tissue
be held with the forceps. The microsurgery
instruments set is opened now and only
these instruments are used. The suturing
is done between the epineurium of the
proximal end and the epineurium of the
distal end with 8.0 Ethilon using simple
interrupted sutures. This suturing is done
around the circumference of the nerve.
Nerve Grafting
• The gap between the nerve ends is
measured. The surface area of the cut ends
of the nerve is assessed. Usually, about 3
cables of nerve graft will be required for
the reconstruction of median nerve in the
forearm and 2 cables for the ulnar nerve
in the forearm. Hence, the requirement of
nerve graft should be assessed carefully
before harvesting the graft. The sural
nerve is commonly harvested as a nerve
graft and the procedure is described in
Appendix IV.
• Nerve graft anastomosis: The first step
done is to reverse the nerve graft. This is
easily done by the following steps:
• The nerve graft has a stitch of 7.0
polypropylene on the distal end (the
end from the calf region of the leg). The
other end of the graft is the proximal
end.
• Place the proximal end of the nerve
graft at the cut end of the distal segment
of the nerve. Place the entire length of
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
segment of the nerve. Align them and
suture by applying epineurial sutures as
described above.
• Cut the remaining nerve graft at the
level of the proximal cut end of the
nerve. Bring the remaining nerve graft
to the cut distal end and repeat the
process described above.
• At the end of this step, the distal end
of the nerve would have been sutured
to three cables of the nerve graft, and
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
will still be showing the stay suture of
7.0 polypropylene.
• Now, these three cables should be
sutured to the proximal cut end of
the nerve with 8.0 Ethilon epineurial
sutures, starting with the deepest cable.
• The skin wound is now closed with 4.0
Ethilon after keeping Segmüller drainage
tubes.
• Sterile dressings are applied and a
plaster of Paris (POP) slab is applied,
keeping the wrist in neutral position, and
metacarpophalangeal (MCP) joints of
fingers in flexion, the interphalangeal (IP)
joints straight.
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
or after complete recovery if under general
anesthesia.
 CHAPTER 28  NERVE RECONSTRUCTION—MANAGEMENT 123

• Analgesics and antibiotics for 5 days.
• Sedation sos for 1 day.
• Inspection of the dressing after 48 hours.
• Discharge of the patient by third day.
• Suture removal on the 10th day.
• Removal of the POP slab on the 14th day
and advise 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
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.
Now, the different plans have been made
for the individual problems, they have to be
integrated into a total solution and the timing
has to be decided.
Classify According to
Postoperative Regimen
• Procedures that require immobilization:
Some procedures require immobilization
after surgery, like reconstruction with
nerve grafts, bone fixation, tendon grafts
and tendon transfers, etc.
• Procedures that require mobilization: Some
procedures require that mobilization be
started immediately after the surgical
procedure. Examples are procedures like
arthrolysis and tenolysis.
Classify According to
Time Schedule
• Procedures that can be done immediately:
Some procedures have to be done imme­
diately, like resurfacing of raw areas. These
procedures should be planned as soon as
possible after the required investigations
are done and the raw area is fitted for
surgical resurfacing
• Procedures that have to be done later:
Some procedures like reconstruction of
the tendons and nerves can be done as
elective procedures after investigations are
done and after the patient is adequately
counseled about the various reconstructive
options
• Procedures that have to be done after the
environment becomes conducive in the
hand: THere are some procedures for which
the timing can be planned only when the
tissues are conducive. For example, tendon
reconstruction cannot be done unless the
joints of the hand and fingers are made
adequately supple, either by physiotherapy
or surgical maneuvers.
not, which hand to be operated first
• If multiple fingers are involved, can all
fingers be operated together? If not, which
finger to be operated on first
• When multiple tissues are involved, which
tissue reconstruction gets priority?
Priority Lists
If Both Upper Limbs are Involved
The priority is to be decided depending on
the nature of involvement, age of the patient,
disability in the patient.
• According to the nature of involvement:
• The upper limb with raw areas, ulcers
get priority
• Then comes nerve involvement; the
limb with nerve involvement should be
treated first.
• According to the age of the patient:
• In adults, both upper limbs are not
usually operated on together, because
then, the patient becomes dependent
and may cause inconvenience
• In children, both hands can be operated
on together.
• According to the disability in the patient:
• If one upper limb is so involved that it
does not participate in the activities of
daily living, this limb must be operated
on first
• If both limbs are equally involved, it
is better to operate on the nondomi­
nant side first, so that the patient can
get used to the routine of surgery and
the postoperative protocols. Pati­ ent
will thus be better prepared when the
dominant hand is operated upon
• If both upper limbs have been involved
so badly that both are not used for
activities of daily living, the dominant
hand should be operated on first.
 CHAPTER 29  COMPLEX POST-TRAUMATIC PROBLEMS—ASSESSMENT 129

If Multiple Fingers are Involved
The priority is to be decided based on the
fingers involved, the nature of the involve­
ment and the nature of surgical management
requ­ired.
• According to the finger involved: If the
fingers and the thumb are involved, it is
ideal to reconstruct the fingers first and
then plan the reconstruction on the thumb.
• According to nature of involvement:
• The finger with raw areas, ulcers gets
priority
• Then comes nerve involvement; the
limb with nerve involvement should be
treated first
• When there is a contracture, adherent
scar on one finger, this finger gets priority
and gets operated on before the other
fingers are operated on.
• According to the surgical management
required:
• When one finger requires a surgical pro­
cedure which need immediate mobiliz­
ation in the postoperative period, this
finger is operated on first. The fingers that
need immobilization in the postoperative
period are dealt with at a later stage.
• When all fingers require surgical pro­
ced­ures needing immobilization in the
postoperative period, the finger requi­
ring a bone surgery is operated on first
(deformity correction first).
If Multiple Tissues are Involved
(Table 8.29.1)
• The first priority is the skin problem;
whether it is a raw area or contracture or
adherent scar. This should be corrected first
before the other structures are dealt with.
• Then, this should be the correction of
deformity and the achievement of stability.
Hence, the bony reconstruction must be
planned next.
• Once stability is achieved, surgeons should
now achieve full passive mobility. So, the
next priority is getting the full range of
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
mobility. However, getting active move­
ments in anesthetic hand is very dang­
erous as it may lead to the develop­ment of
trophic ulcers. Hence, the recon­stru­ction
of the nerves must be done prior to the
reconstruction of the tendons.
• If both the extensor and flexor tendons
need reconstruction, the extensor tendon
reconstruction is planned to be done first
and the flexor tendon reconstruction is
done at a later stage.
• In reconstructing the hand to achieve
active movements, the reconstruction of
the extrinsic tendons must be achieved
before the reconstruction of intrinsic
motors with tendon transfers.
 SECTION

Thumb Reconstruction

Principles and
Decision Making in Thumb
Reconstruction
Principles
Loss of a thumb is a debilitating condition
that results in loss of function and hence
earning capacity, especially for a manual
laborer. Considering the fact that loss of
thumb amounts to 40 percent disability;
there are various procedures to reconstruct
the thumb. However, a hand surgeon must
consider various factors before deciding on a
particular method.
Characters that an ideal thumb must have:
1. Length
2. Stability
3. Mobility
4. Sensation
5. Cosmesis
6. Free from pain.
These characteristics are discussed in the
following:
1. Length: The optimum length for a fun­
ctioning thumb when all the fingers are
intact is up to the neck of the proximal
phalanx. This will ensure that there is
functional contact between the tips of
the fingers and the reconstructed thumb.
If the length is less than that, function
will be compromised and useful function
will not result. So, when planning for
reconstruction of a thumb, it should be
planned for a length up to the neck of the
proximal phalanx of the intact thumb.
When planning for a thumb in a hand
30
where all the fingers are missing or short, a
thumb equal in length to that of a normal
thumb should be planned.
2. Stability: The reconstructed thumb should
be stable and able to maintain its position
in status quo. The position of the thumb
must be physiological and not in the way
of the moving fingers. This depends on the
stability provided by the bones that make
up the reconstructed thumb. Obviously,
when a thumb is being reconstructed,
it will have to comprise an underlying
foundation of bones, which may be as
free grafts or vascularized graft. For the
reconstructed thumb to be stable, the
bones that make up the thumb must be:
• Stably fixed to the underlying stump
• Fixed in a correct position for function.
  This is more relevant when there is a total
loss of thumb, without a carpometacarpal
joint. In such a situation, when a toe
transfer is done, the position of fixation is
very important at the radius or stump of
the carpus.
3. Mobility: The normal thumb has three
joints: (1) Carpometacarpal (CMC) joint
(2) Metacarpophalangeal (MCP) joint
and (3) Interphalangeal (IP) joint of
the thumb. So, mobility of the thumb is
normally dependent on the movement
at these three joints. Among these joints,
the most important is the CMC joint of
the thumb. If surgeons plan to reconstruct
a thumb, it would be ideal to have the
movements at all three joints and hence
134 SECTION 9  THUMB RECONSTRUCTION
ideal to reconstruct all three joints. Since,
it may be difficult to reconstruct all three
joints, the order of priority is to have a
functioning and mobile CMC joint, or
if that is not possible, a functioning and
mobile MCP joint.
4. Sensation: For a thumb to function
normally, the grips of the hand involving
the thumb should be intact. This means
that the reconstructed thumb should
be capable of taking part in two types
of activities: (1) power grips and (2)
precision grips. When precision grips are
involved, it is important that the pulp of
the thumb be sensate. Only then, grip
strength can be assessed by the thumb.
The other reason is that, the thumb, being
involved in most of the movements of
the hand, if the tip is insensate, it will be
prone for trophic ulceration. So, when a
thumb is reconstructed, it is imperative
that sensation is provided for at least the
pulp region and the tip to achieve the goal
of providing a functioning thumb.
5. Cosmesis: The thumb occupies a very
large space in the cortex of the brain. The
thumb, being an important part of the
hand is always in the vision field of the
patient and that of the observer. Hence, it
is important that the reconstructed thumb
look like a thumb with all the components,
like quality of dorsal skin, quality of
pulp skin and nail complex. Although a
meticulously reconstructed thumb can
bring back function to the patient’s hand,
the patient may not be totally satisfied if it
does not look cosmetically acceptable. If
this happens, the patient may slowly stop
using the reconstructed thumb as he may
be ashamed of it, and gradually, even a
moving thumb may become useless to the
patient just because it is cosmetically not
accepted.
6. Freedom from pain: If a thumb were to
be reconstructed that is totally stable and
without any movement, there would be
no pain at all. On the other hand, such a
thumb would be useless to the patient.
Only if there is movement, there will be
function. And if there is movement, there
are bound to be reconstructed moving
joints and ligaments which will be prone
for strain and wear and tear, leading
to pain and ultimately, disuse. Hence,
reconstruction of a thumb must not
provide mobility at the cost of pain. This
will totally defeat surgeons’ purpose of
providing a useful and functioning thumb.
Decision Making
There are certain set protocols in deciding
about what method to use for thumb
reconstruction in a particular case. However,
there are many factors to consider, before
deciding the method of reconstruction for a
patient.
General Factors
1. Sex: The method of reconstruction differs
for males and females in certain aspects.
The requirements for the male thumb are
the capability for manual labor and lifting
heavy weights, especially in a country
like India, where the manual laborers are
usually the victims of industrial accidents
who lose their thumb. Hence, a stable post
is required, with minimal movements, to
allow for the power grips. However, for
males who are pursuing white collar jobs,
or those who work as typists or musicians,
or females, the requirement is the recon­
struction of a fairly mobile thumb, which
should provide the precision grips like
pulp-to-pulp pinch, tip-to-tip pinch, etc.
2. Age: The requirement in children is almost
the same as adults with a few differences:
• When the reconstruction is done early
in life, the reconstructed thumb gets
incorporated in the body image faster
• The reconstructed thumb must have a
potential for growth in chil­dren. A good
example is the use of vascularized wrap
around great toe flap in amputation at
 CHAPTER 30  PRINCIPLES AND DECISION MAKING IN THUMB RECONSTRUCTION
the level of the MCP joint. In adults, it
provides an excellent reconstruction
method and cosmesis. Even in chil­
dren, it provides good results, but the
biggest disadvantage in the use of this
flap in children is its lack of growth
potential. Hence, a flap that can grow
along with the child is chosen, like a
vascularized second toe transfer.
3. Occupation: As mentioned earlier, man­
ual laborers require a more stable recon­
struction with the ability for power grips,
whereas sedentary laborers require more
mobile reconstruction. An example would
be the choice of vascularized wraps around
great toe flap in amputation at the level of
the MCP joint for manual laborers. This may
not be an ideal method of reconstruction
for sedentary workers, due to the lack of
IP and MCP joint movements. Thus, more
movements can be provided by the choice
of vascularized trimmed toe transfer that
can provide both mobility and cosmesis.
4. Socioeconomic status: A developing nat­
ion like India, financial constraints pose
a problem when deciding on the choice
of thumb reconstruction. When there has
been an amputation at the level of the
MCP joint, and carpometacarpal joint
mobility has been preserved, the choice
rests between osteoplastic reconstruction
and vascularized wrap around great
toe flap. Both the procedures provide a
functioning thumb. The former procedure
may prove financially viable for a patient
who is more worried about the cost factor
than the cosmetic factor. Thus, the option
of classical staged method must also be
offered to the patient before a decision
can be arrived at.
5. Other medical illnesses: For mentally
uns­table patients and elderly indivi­duals,
clas­sical methods of reconstruction
may not be ideal. Single staged proce­
dures like free flaps are preferred in such
situ­ations.
135
Local Factors
1. Hand dominance: A similar type ampu­
tation on both the thumbs of a patient may
warrant different methods of recon­struction
on the dominant hand and nondominant
hand. This may be a controversial topic,
but it is generally more practical to decide
for a more elaborate reconstruction on the
dominant hand.
2. Other fingers: When all the fingers are
absent or shortened, the method of recon­
struction may be totally different. Other
ancillary procedures like thumb web dee­
pen­ing may have to be combined with the
prescribed methods of reconstruction to
create a useful thumb.
3. Condition of the rest of the upper limb: This
is applicable in a situation like the con­
genital condition of radial club hand. The
thumb may be hypoplastic and may require
reconstruction. The preferred method
of reconstruction will be the procedure
of pollicization. However, the procedure
should not be done if there is no movement
at the elbow, which is sometimes the
associated symptom in such a condition.
This is because a moving thumb cannot
produce function if it cannot move to the
rest of the body where it has to act.
4. Remaining stump of thumb: The pre­scri­­
bed method of reconstruction depends
also on the level of amputation of the
thumb. For purposes of simplicity, sur­
geons can divide the thumb into levels as
follows:
Type I
Amputation at tip of the thumb to the proxi­
mal third of the nail complex:
• Requisites of reconstruction: Sensate tip
• Preferred methods:
• For Transverse amputation: Lateral
advancement flaps of Kütler
• For volar oblique amputation: Inner­
vated cross finger flap
136 SECTION 9  THUMB RECONSTRUCTION

• For dorsal oblique amputation: Volar
advancement flap of Atasoy–Kleinert
• For radial/ulnar oblique amputation
Type I: Oblique triangular flap
• For radial/ulnar oblique amputation
Type II: Dorsal transposition flap
Type II
Amputation proximal to the proximal third of
the nail complex to the neck of the proximal
phalanx:
• Requisites of reconstruction:
• Preservation of length
• Sensate tip
• Cosmesis
• Preferred methods:
• Transverse amputations: Staged Island
flap of Professor R Venkataswamy.
• Amputations with more dorsal loss:
First dorsal metacarpal artery flap
• Amputations with more volar loss:
Littler’s neurovascular Island flap
Type III
Amputation proximal to the neck of the
proximal phalanx, up to the MCP joint:
• Requisites of reconstruction:
• Provide length
• Stability
• Sensate tip
• Cosmesis.
• Preferred methods:
• Osteoplastic reconstruction
• Vascularized wrap around great toe
transfer

Table 9.30.1 Levels of amputation, characteristic and their surgical options

Level of amputation
Amputation at tip of the thumb
to the proximal third of the nail
complex
Amputation proximal to the
proximal third of the nail complex
to the neck of the proximal
phalanx
Amputation proximal to the neck
of the proximal phalanx, up to the
metacarpophalangeal (MCP) joint
Amputation proximal to the MCP
joint to the base of the metacarpal
bone with intact carpometacarpal
joint
Amputation through the
carpometacarpal joint with
destroyed joint
Characteristic
Transverse amputation
Volar oblique amputation
Dorsal oblique amputation
Radial/ulnar oblique amputation
Type I
Radial/ulnar oblique amputation
Type II
Transverse amputations
Amputations with more dorsal loss
Amputations with more volar loss
Patient not willing for toe transfer
Expertise not available for
microsurgery
Patient willing for microsurgery
In children
Expertise not available for
microsurgery
Microsurgical expertise available
Expertise not available for
microsurgery
Microsurgical expertise available
Surgical option
Lateral advancement flaps of Kütler
Lateral advancement flaps of Kütler
Volar advancement flap of Atasoy–
Kleinert
Oblique triangular flap
of Professor R Venkataswami
Dorsal transposition flap
Staged Island flap of Professor R
Venkataswami
First dorsal metacarpal artery flap
Littler’s neurovascular Island flap
Osteoplastic reconstruction
Vascularized wrap around great
toe transfer
Vascularized second toe transfer
Pollicization + opponensplasty
Vascularized second toe transfer +
opponensplasty
Pollicization
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.

Procedures for
Reconstruction of
Type I Amputations
Transverse and Volar Oblique
Amputations
Lateral Advancement
Flaps of Kütler
When there has been a transverse amputation
on the thumb at any point between the
proximal third of the nail complex tip and
reconstruction of the thumb should be done
 
after the following considerations:
• Length is not necessary as optimum length
of the thumb is already available. Hence,
retaining the available length of the thumb
is important and further shortening should  
not be thought of, to preserve the nail
complex.
• The closure of the stump should be done
in such a way that sensate, glabrous skin
covers the tip.  
• The above criteria will be filled by the use
of the lateral advancement flaps, originally
described by Kütler.
Surgical Steps
 1. Axillary block anesthesia is given. A
tourniquet is applied on the arm.
  2. The hand is painted and draped. The tourni­  
quet is raised. The wound is debrided and
defect measurement is taken (Figs 9.31.1A
and B).  
  3. The defect will be in the form of a circle or
transverse oval, with the amputated end
of the bone protruding in the center of the
31
defect. Mark the midpoint of the volar half
of the defect and mark this point as “A”.
Mark the points on the lateral edges where
the neutral lines cut the defect and name
these points “B” and “C” on the ulnar and
radial sides respectively. Mark the neutral
lines on the radial and ulnar sides. These
lines will touch the interphalangeal (IP)
joint crease at the points “D” and “E” on
the radial and ulnar sides respectively.
4. First the three points “A”, “B” and “E” are
joined together to form a triangle, the
base being formed by the volar radial half
of the edge of the defect, the apex being
pointed proximally.
5. The two sides of the flap are incised with a
number 15 blade down to the dermis only,
and the incision is completed by turning
around the apex at the distal interphalan­
geal (DIP) joint.
6. Now, the incision is gently deepened till
the fat globules protrude through the
incision site. A skin hook is applied on the
leading edge of the flap, i.e. the edge of the
defect and mild traction applied. While
maintaining traction, the knife is used to
gently incise the fibrous septae one by
one. As this is being done, the flap can be
felt and seen to advance slowly.
7. When the flap covers the radial half of the
defect, mobilization of the flap should be
stopped.
8. A similar procedure should be done on
the ulnar side by joining the points “C”, “A”
and “D” and the ulnar side flap is raised as
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
of the flaps confirmed, and hemostasis
achieved.
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,
using 4.0 polyamide sutures. The dorsal
and volar edges should be sutured using
4.0 polyamides in a “Y” fashion. The longi­
tudinal limb of the “Y’ is representative of
the amount of movement achieved by the
flap.
11. Vaseline gauze is applied. Sterile dress­
ing done. Below elbow dorsal slab thumb
plaster of Paris (POP) is applied with a
wrist in neutral position, metacarpo­
phalangeal (MCP) joint of thumb flexed
at 20°, and inter­phalangeal (IP) joint in
neutral posi­­tion.
Postoperative Regimen
• Day 2: Inspection of flap and suture line
• Day 10: Suture removal, removal of POP
slab, scar massage and mobilization of
thumb.
Dorsal Oblique Amputations
Volar Advancement Flap of Atasoy
When there has been a dorsal oblique ampu­
tation on the thumb at any point between the
proximal third of the nail complex and the neck
of the proximal phalanx, reconstruction of the
thumb should be done after the following
considerations:
• Length is not necessary as optimum length
of the thumb is already available. Hence,
retaining the available length of the thumb
is important and further shortening should
not be thought of
• The closure of the stump should be done
in such a way that sensate, glabrous skin
covers the tip
140 SECTION 9  THUMB RECONSTRUCTION

• 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
described by Atasoy.
Surgical Steps
1. Axillary block anesthesia is given. A
tourniquet is applied on the arm.
2. The hand is painted and draped. The
tourniquet is raised. The wound is debrided
and defect measurement is taken (Figs
9.31.2A and B).
3. The defect will be in the form of a circle or
transverse oval, with the amputated end
of the bone protruding in the center of
the defect. Mark the two edges of the nail
stump as “A1” and “B1”.
4. Now, on the free edge of the defect on the
volar skin, mark two points “A” and “B”
corresponding to the points “A1” and “B1”.
Mark a point “C” in the midvolar aspect
of the IP joint crease of the thumb. The 3
points “A”, “B” and “C” are joined together
to form a triangle, the base being formed
by the volar edge of the defect, the apex
being pointed proximally.
number 15 blade down to the dermis only,
and the incision completed by turning
around the apex at the DIP joint.
6. Now, the incision is gently deepened till
the fat globules protrude through the
incision site. A skin hook is applied on the
leading edge of the flap, i.e. the edge of the
defect and mild traction applied. While
maintaining traction, the knife is used to
gently incise the fibrous septae one by
one. As this is being done, the flap can be
felt and seen to advance slowly.
7. When the flap covers the defect, and the
advancing edge AB reaches the point “A”
and “B”, mobilization of the flap should be
stopped (Figs 9.31.3A and B).
8. The tourniquet should be released, viability
of the flaps confirmed, and hemostasis
achieved.
9. The leading edge of the flap should be
sutured to the nail bed on the dorsal aspect,
using 4.0 polyamide sutures. The sides of
the flap should be sutured using 4.0 poly­
amides in a “Y” fashion. The longitudinal

A B

Figs 9.31.2A and B  Defect and the markings for the flap
 CHAPTER 31  PROCEDURES FOR RECONSTRUCTION OF TYPE I AMPUTATIONS 141

limb of the “Y” is representative of the
amount of movement achieved by the flap.
10. Vaseline gauze is applied. Sterile dressing
done. Below elbow dorsal slab thumb POP
is applied with wrist in neutral position,
MCP joint of thumb flexed at 20º, and IP
joint in neutral position.
Postoperative Regimen
• Day 2: Inspection of flap and suture line
• Day 10: Suture removal, removal of POP
slab, scar massage and mobilization of
thumb.
Oblique Amputation Type “A”
Oblique Triangular Flap of
Professor R Venkataswami
Oblique amputations on the thumb at Type I
can be of two types. The classification depends
on the angle of the obliquity. An oblique
amputation means that there is more loss of
one side, either the radial side or the ulnar
side. Thus, one edge, either the radial or ulnar
edge is more proximal. When the proximal
edge of the amputation does not cross the
level of the nail fold, the obliquity is minimal
and is called oblique amputation type “A”.
Surgical Steps
1. Axillary block anesthesia is given. A
tourni­quet to be tied on the arm.
2. Hand to be painted and draped. Tourni­
quet to be raised.
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
marked. It will be seen that one point is
more proximal than the other due to the
obliquity of the defect. Mark this proximal
point as “A”. The distal point is marked “B”.
Now, a point “C” is marked on neutral
line at the PIP joint on the side of point
“B”. These two points are joined by a line.
Similarly “A” and “C” are joined. This line
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
142 SECTION 9  THUMB RECONSTRUCTION
marked as an oblique triangle with base
on the edge of defect.
4. Make skin incision along BC and AC with
number 15 blade. The incision is turned
around the apex and completed.
5. Skin hooks are placed on the edge of the
defect, and the flap is raised superficial
to the fibrous flexor sheath. By doing this,
the neurovascular bundle goes along with
the flap. As it nears the apex, care should
be taken not to injure the neurovascular
bundle. When the flap is totally raised,
it will be seen to be attached only by the
neurovascular bundle. Now, the skin hooks
are used to give gentle traction on the flap
to advance it and the reach of the flap is
checked.
6. Now, release the tourniquet, and secure
hemostasis. Then inset the flap at the
leading edge by using 4–0 polypropylene.
Then the sides are sutured. It will be seen
that the suture line is in the form of a “Y”,
the vertical limb of the “Y” denoting the
amount of advancement of the flap.
7. Dressings are applied with vaseline gauze,
dry gauze and finger dressings. Pad and
bandage are applied on the hand and
forearm.
8. Below elbow dorsal slab thumb POP is
applied with wrist in neutral position,
MCP joint of thumb flexed at 20°, and IP
joint in neutral position.
Postoperative Regimen
• Day 2: Inspection of flap, and suture line
• Day 10: Suture removal is done, POP slab
is discarded.
Advise: Wash with soap and water, massage
scar and mobilize the thumb.
Oblique Amputation Type “B”
Dorsal Transposition Flap
As described, an oblique amputation may be
of two types and will now discuss the optimal
management of the second type. This type
involves an obliquity in such a way that one
end extends beyond the nail fold. Thus, the
obliquity in this type of amputation is more
than the obliquity in the first type.
Use of the dorsal skin as a transposition
flap can be done by the following method.
Surgical Steps
1. Axillary block anesthesia is given. A
tourniquet is applied on the arm.
2. The hand is painted and draped. The
tourniquet is raised. The wound is debrided
and defect measurement is taken (Figs
9.31.4A and B).
3. One edge of the oblique oval will be
proximal to the nail fold, either on the
radial side or on the ulnar side. Mark this
point as “A”. Mark the opposite end of the
oval defect as “B”. Measure the distance
from “A” to “B”. Measure the volar-dorsal
distance at the widest point of the defect.
Mark these points as “C” and “D” on the
volar and dorsal sides respectively.
4. Mark this distance transversely on the
dorsum of the terminal phalanx region,
about 3 mm proximal to the nail fold, to
protect the underlying hyponychium.
This line may be at the point “A” or it may
be 1 to 2 mm proximal to “A”. This does not
matter. It only means that there will be an
intact skin bridge about 2 mm between
the base of the flap and the defect, which
has to be excised later. Name this line as
AE.
5. Mark another point “F” proximal to the
point “A” at a distance equal to CD. This
will form the base of the flap. Mark a line
FG parallel to AE. Join the points “G” and
“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.
7. The tourniquet should be released, viabil­
ity of the flap confirmed, and hemostasis
achieved.
8. The leading edge of the flaps should be
sutured to the distal edge of the defect
and the sides of the flap should be sutured
 CHAPTER 31  PROCEDURES FOR RECONSTRUCTION OF TYPE I AMPUTATIONS 143

A B

Figs 9.31.4A and B  Markings for the dorsal transposition flap

to the volar and dorsal edges of the defect
using 4.0 polyamide sutures.
9. Management of the donor area: After con­
firming hemostasis, the raw area on the
dorsum should be covered with a split
thickness skin graft. Now, raise the hand
and prepare the arm with betad­ine solu­
tion. The skin graft should be harvested
from the medial side of the arm. Sterile
dressings should be applied over the skin
graft donor site before moving back to the
hand. The graft should be applied over the
raw area and tie over sutures applied with
3.0 Ethilon.
10. Vaseline gauze is applied. Sterile dressing
done. Below elbow dorsal slab thumb
POP is applied with wrist in neutral posi­
tion, MCP joint of thumb flexed at 20°, and
IP joint in neutral position.
Postoperative Regimen
• Day 2: Inspection of flap and suture line
• Day 10: Suture removal, removal of POP slab,
scar massage and mobilization of fin­­gers.

Procedures for
Reconstruction of
Type II Amputations
Introduction
There are three standard procedures for the
reconstruction of such defects:
1. Staged Island flap described by Professor
R Ven­­­­ka­ta­swami.
2. First dorsal metacarpal artery flap.
3. Littler’s neurovascular Island flap.
The procedures 2 and 3 have already been
described in Chapters 4 and 3 respectively.
The procedure of staged Island flap of
Professor R Venkataswami is described here.
Staged Island Flap of
Professor R Venkataswami
The flap of choice for the reconstruction
of a defect on the stump of the thumb is a
staged Island flap described by Professor R
Venka­taswami.
Advantages
• It brings partly glabrous skin to the tip
of thumb stump which is well padded,
durable and cosmetically appealing
• It is sensate, retains the sensation of the
native thumb, and hence the function of
the thumb is not interfered with. Sensory
re-education is not necessary to get appre­
ciable sensation on the flap
• It is a relatively easy procedure when com­
pared to the Littler’s neurovascular Island
flap.
32
Disadvantages
• It requires two stages of surgery
• It entails significant donor site morbidity:
There is a loss of sensation on the ulnar half
of the middle finger, there is a significant
scarring on the middle finger.
Presurgical Counseling
• This procedure is planned to cover the raw
area on the thumb with skin and tissues
with sensation
• This procedure will be done under axillary
block anesthesia
• This procedure will take about 3 hours to
perform
• Skin will be removed along with soft
tissues from the middle finger and placed
on the raw area of the thumb. There will be
a bridge of skin connecting the thumb with
the middle finger from where the skin is
going to be taken. A skin graft will be taken
from the medial side of the upper arm and
applied over the secondary raw area on
the middle finger. There will be a loss of
sensation on one side of the middle finger,
and there will be a scar on the finger. There
will also be a scar on the medial side of the
arm
• Admission will be necessary for a minimum
period of 3 days
• A dressing will be applied and a plaster
of Paris (POP) will be applied, which will
be retained for 14 days, following which,
another stage of surgery will be done to dis-
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
• In some instances, the flap may not be
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
occur in spite of test dose application. This
com­plication will cause dryness of mouth
and apprehension, which can be corrected
immediately.

Surgical Steps
• Stage I: Debriding the wound, tagging the
ulnar side digital nerve to thumb, raising
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
the flap.
Stage I
  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. The elbow area must also be
prepared and kept exposed.
  4. Raise the tourniquet and note the time.
  5. Debride the defect and measure it. Dissect
the stump of the ulnar side digital nerve
and tag it with 7.0 polypropylenes for
coaptation in the second stage of surgery.
Make sure that the edges consist of intact
and healthy skin. Take a lint pattern of the
defect.
 6. Markings for the flap (Fig. 9.32.1):
• The basis of this flap is the neurovas­  
cular bundle to the ulnar side of the
middle finger. Cut a lint pattern accor­
ding to the defect on the stump of the
thumb. Holding the lint at the base of
the middle finger on the ulnar side,
transpose the lint of the defect to the
middle finger on the ulnar side. It
Fig. 9.32.1  Markings for the staged neurovascular flap
should not go beyond the DIP crease of
the middle finger
• The flap can now be marked on the
middle finger ulnar side keeping in
mind the following criteria; the flap
should not go beyond the mid volar line
or the mid dorsal line. The base of this
flap “AB” will be on the ulnar side of the
middle finger at the level of the volar
metacarpophalangeal (MCP) crease.
The point “A” will be represented by the
mid volar line cutting the volar MCP
crease and “B” will be the mid dorsal
line at the midpoint of the proximal
phalangeal segment. Distally, surgeons
should remember that the nail bed
extends for 3 to 4 mm proximal to the
nail fold; hence, the flap should not go
beyond this area.
7. Now, the flap can be raised. Make the first
incision on the mid volar side. This incision
must be drawn to the fibrous flexor sheath.
There are a few transversely oriented subcu­
taneous volar veins at this area which must
be cauterized. The volar portion of the flap
can be raised now up to the neutral line.
The next incision should be made on the
146 SECTION 9  THUMB RECONSTRUCTION
dorsal side down to the extensor paratenon
and the dorsal portion of the flap raised.
Now, the distal margin of the flap incised
and the neurovascular bundle ligated with
3.0 Vicryl and cut. The flap is now attached
by the Grayson’s and Cleland’s ligaments.
To divide these, the flap must be lifted up,
the neurovascular bundle confirmed to
enter the flap and the ligaments must be
divided closing to the bone. This will free
the flap some more.
 8. As the base of the flap is reached, care
should be exercised, as the neurovascular
bundle is deep to this area. Gently free the
neurovascular bundle from the deeper
fibrous attachments and the multiple small
branches coursing into the web. Now, the
flap is free, attached only at the base “AB”.
 9. Gently move the flap to the defect over
the skin to check whether it reaches the
defect comfortably. If it does not, a little
more dissection of the base of the flap is
in order.
10. 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.
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.
12. When good bleeding is seen from the
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
the flap “AB”. Allow the flap to lie freely
over the defect. When it does so, there is
a raw area on the undersurface of the flap.
It is not necessary to tube this flap and it is
also dangerous to do so.
13. Flap inset (Fig. 9.32.2): After confirming
the hemostasis and the viability of the flap,
inset can be done with 4.0 Ethilon using
half buried horizontal mattress suturing.
14. Management of the donor area: After
confirming hemostasis, the residual
raw area on the middle finger should be
covered with a split thickness skin graft.
At the points where the defect crosses the
proximal interphalangeal (PIP) and distal
interphalangeal (DIP) joint creases, back
cuts should be given for 3 mm to avoid
skin graft contractures later on. Now,
raise the hand and prepare the arm with
betadine solution. The skin graft should
be harvested from the medial side of the
arm. Sterile dressings should be applied
over the skin graft donor site before
moving back to the hand. The graft should
be applied over the raw area and tie over
sutures applied with 3.0 Ethilon.
15. Sterile dressings should be applied over
the hand and the forearm. Care must
Fig. 9.32.2  After final flap inset
 CHAPTER 32  PROCEDURES FOR RECONSTRUCTION OF TYPE II AMPUTATIONS
be taken to avoid compression of the
pedicle at any point of its course. A finger
dressing must be applied on the middle
finger. A sterile gauze must be placed
under the flap which is bridging the base
of the middle finger with the stump of
the thumb. A dorsal POP slab should be
applied for the thumb keeping the wrist in
neutral, and the MCP joint of the thumb
in flexion of 20° and interphalangeal (IP)
joints 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
or after complete recovery if under general
anesthesia
• Clinical monitoring of the flap once every
6 hours
• Analgesics and antibiotics for 5 days
• Sedation SOS for 1 day
• Inspection of the dressing after 48 hours
• Discharge of the patient by third day
• Suture removal on the 10th day and
removal of donor site dressing on the arm
• Removal of the POP slabs on the 14th day
and execute the second stage of surgery.
Stage II
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. The elbow area must also be
prepared and kept exposed
4. Raise the tourniquet and note the time
5. Divide the base of the flap close to the place
where it is attached to the middle finger.
147
The digital vessel to the middle finger will
now be cut and must be ligated
6. The stump of the flap must now be sutured
to the skin grafted edge on the middle
fin­­ger
7. On the thumb, through the exposure
provided by the divided flap, the stump of
the ulnar side digital nerve to the thumb
must be identified and dissected. Since
surgeons have already tagged this nerve end
with 7.0 polypropylene suture materials,
it may be easily identifiable. Now, on the
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
2 to 3 mm, to allow for nerve coaptation
8. The two nerve ends are coapted with 7.0
polypropylenes
9. The tourniquet is released and hemostasis
is achieved
10. The final inset is now done with 4.0
Ethilon. Sterile dressings are done and a
thumb dressing is provided.
Postoperative Protocol
• Patient can be treated as an outpatient
• The affected hand should be kept elevated
• Patient can take normal diet immediately
if the procedure was under regional block
or 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
• Suture removal on the 10th day. 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
after a further 2 weeks.

Procedures for
Reconstruction of
Type III Amputations
Osteoplastic Reconstruction
One of the methods of staged reconstruction
of a thumb that has been amputated at
the level between the neck of the proximal
phalanx and the metacarpophalangeal (MCP)
joint (type III amputation) is the osteoplastic
reconstruction.
The requirements for a thumb amputated at
this level are:
• To provide length with soft tissues and skin
cover
• To provide stability with bone
• To provide sensation on the pulp region of
the reconstructed thumb
• To provide for the lost movement at the
lost interphalangeal (IP) joint region
• To provide for good cosmetic appearance
with a nail complex.
However, the method of reconstruction that
surgeons are going to consider now, does not
provide all the above. However, this method
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
skills
• Provides adequate length to the thumb
• Excellent stability is provided by the use of
the bone graft
• Preserves the already available movement
at the carpometacarpal (CMC) joint, and
hence, coarse movements of the thumb are
preserved
33
• Provides good sensation on the tip and pulp
– provided by the Littler’s neurovascular
Island flap component of this method of
reconstruction.
Disadvantages
• Does not provide the lost movement at the
level of an IP joint
• Is a staged procedure and hence, takes
time
• Does not provide cosmesis, as the nail
complex is not restored.
The components of this method of recon­struc­
tion are as follows:
• Stage I: Tubed groin flap to augment the
length with a skin envelope followed by
division and inset of the flap
• Stage II: Free bone graft to provide stability
to the skin tube
• Littler’s neurovascular Island flap to pro­
vide sensation to the tip and pulp of the
reconstructed thumb.
3. Component III: Littler’s neurovascular
Is­land flap
Surgical Procedure of Component I
(Tubed Groin Flap)
1. Debridement of the hand wound can
be done under axillary block anesthesia
and spinal anesthesia or tumescent local
 CHAPTER 33  PROCEDURES FOR RECONSTRUCTION OF TYPE III AMPUTATIONS
anesthetic for raising the flap. In children,
general anesthesia may be used.
2. The patient should be placed in a supine
position. A rolled up towel should be
placed under the gluteal region on the
side that the flap is going to be raised. This
position makes raising the flap easy.
3. Now, the groin region is prepared, from
the subcostal margin to the groin region
and from the midline to the mid-axillary
line on the same side of the injured hand.
If the flap planned is large, the ipsilateral
thigh is also prepared. The hand is also
prepared and draped.
4. Now, debridement of the hand wound is
done. After debriding the wound, a lint
pattern is taken of the defect on the hand.
The tourniquet is released and hemostasis
is achieved. The tourniquet is removed
and the site of application on the arm is
massaged by the theater assistant.
5. Markings are now made on the groin
region. The first marking is the anterior
sup­erior iliac spine. Next the pubic tub­ercle
is marked. These two points are joined by
a curvilinear line convex downward. The
femoral artery is palpated and marked for
about 3 cm from the inguinal ligament
distally. Now, a point is marked on this
femoral artery line, about 2.5 cm (2 finger
breadths) distal to the inguinal ligament.
Another point is marked 2.5 cm (2 finger
breadths) lateral to this point. This point is
where the axial artery of the flap-superficial
circumflex iliac artery enters the flap.
Now, draw a line from this point parallel
to the inguinal ligament up to the anterior
superior iliac spine. This is the course of
this artery.
6. Place the lint pattern of the defect with the
pedicle at the marked pivot point of the
flap. The flap can be marked with equal
breadth superior and inferior to the axis
of the flap. When the flap extends beyond
the anterior superior iliac spine, it has
restricted dimensions. If, at the level of the
anterior superior iliac spine, the width of
the flap is 6 cm, the flap can only extend
149
for 6 cm beyond the anterior superior iliac
spine. This is because this portion of the
flap is a random portion and must follow
the 1:1 ratio. The flap is now marked foll­
ow­ing the above principles.
7. The first incision is made on the distal
portion of the flap with a number 22 blade
down to the skin, subcutaneous tissue
up to fascia. Incision is then made on the
superior margin up to the membranous
layer of the superficial fascia. The inferior
incision is made up to the deep fascia.
Now, incisions have been completed on
3 sides. By placing two skin hooks on the
distal portion of the flap, and applying
gentle traction, the flap is raised from the
bed in the plane of loose areolar tissue
superficial to the deep fascia. The flap is
raised thus till the marked pivot point. The
viability of the flap can be confirmed by
noting the bleeding from the edges of the
flap.
8. The donor site of the flap should now
be covered. If it is small, it can be closed
primarily in layers, with 2.0 Vicryl subcu­
taneous sutures, and 3.0 polypro­pylenes
for skin. This can be facilitated by flexing at
the hip to ease the suture line till closure of
the skin. If the defect is large, it should first
be narrowed by suturing the edge of the
skin to the deep fascia with 3.0 Vicryl and
making the residual raw area smaller. The
residual raw area should then be covered
with a split thickness skin graft harvested
from the thigh. The donor site of the graft
should be covered with vaseline gauze
and dressing with pads and bandage.
The skin graft should be applied on the
raw area in the groin and anchored with
3.0 silk. Sterile vaseline gauze and pad is
applied.
9. Now, the hand is brought to the groin
region and insetting of the flap is done, i.e.
the suturing of the flap to the edges of the
defect. This is done with 3.0 polyamide
suture material.
10. After the flap inset is done, vaseline gauze
is applied over the suture line. Arm and
150 SECTION 9  THUMB RECONSTRUCTION
elbow restraints are applied with pad and
sticking plaster, to maintain the position
of the hand in a comfortable position for
the patient.
Stage of flap division: This is done on Day 14.
• Local anesthetic or tumescent solution is
injected in the base of the flap. It is then
incised with a number 15 blade and the
hand separated from the groin region
• Hemostasis is achieved and the groin wound
is closed with 3.0 polypropylene sut­ures.
Sterile dressings are applied on the groin
and hand wound.
Stage of final flap inset: This is done on Day 16
(2 days after flap division)
• Axillary block anesthesia is given
• The hand is painted and draped. The flap
edges are looked for necrosis. Any necrosed
portion is excised. If there is no necrosis the
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
supple and the joint of thumb to become active
again (after the period of immobilization
in the groin flap), the second stage of the
reconstruction is done. This comprises of two
components, both done in the same stage.
Surgical Procedure of Component II
(Ulnar Bone Graft Application)
• Preparation and draping are done as • Removal of the POP slab on the 14 day and
described in Appendix I.
• The scar on the volar aspect of the groin flap
skin is excised and the volar seam line of the
groin flap is opened. This will expose the
stump of the bone, which may be either the
base of the proximal phalanx or the head of
the metacarpal bone. The exposed stump of
bone must be freshened by nibbling away
the sclerotic layer. If the remaining base
of the proximal phalanx is very small (less
than 0.5 cm), it can be excised.
• Now, a hole must be drilled in the end of
the bone to receive the bone graft. This is
because, the ulnar bone graft which is a
corticocancellous graft is going to be used
and the most effective method of fixation
would be to peg the bone graft into a hole in
the stump of bone.
• The procedure of harvesting the ulnar
bone graft is described in the Appendix VI.
Surgical Procedure of Component III
(Littler’s Neurovascular Island Flap)
Once the bone graft has been pegged into
place, the opening that was made in the volar
aspect of the groin flap must be resurfaced
with the neurovascular flap. The defect is
mea­sured and the neurovascular Island flap
done as described in chapter 3.
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
or after complete recovery if under general
anesthesia
• Clinical monitoring of the flap once every
6 hours
• Analgesics and antibiotics for 5 days
• Sedation sos for 1 day
• Inspection of the dressing after 48 hours
• Discharge of the patient by third day
• Suture removal on the 10th day and remo­
val of donor site dressing on the arm
advise 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
after a further 2 weeks
• Straightening splint for the middle fin­
ger to be worn for 3 weeks at night.
 CHAPTER 33  PROCEDURES FOR RECONSTRUCTION OF TYPE III AMPUTATIONS
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
the circumference of the ipsilateral great
toe at the metatarsophalangeal (MTP)
joint.
• Measure the length of the normal thumb
and the length of the thumb to be recon­
structed. The difference between the two
values will give the measurement of the
ipsilateral great toe required as a flap (Fig.
9.33.1). The difference between the two
values represents the width of the flap of
skin on the medial side of the great toe. This
flap is marked on the medial side of the
great toe and this flap extends distally to the
tip of the great toe with a tapering tip.
• Next, the marking of the flap (Fig. 9.33.2)
is made. If the circumference of the thumb
is 7.5 cm, a 7.5 cm circumferential line
is drawn at the base of the ipsilateral
great toe. Now, the medial flap must be
outlined, which is necessary to protect the
remaining portion of the great toe. A line is
drawn on the dorsum of the great toe from
Fig. 9.33.1  Showing the amount of skin on the great toe to
be harvested as a flap
151
Fig. 9.33.2  Marking for the dissection of the pedicle
the tip to the circumferential base line on
the medial side including the medial nail
fold. From the medial eponychium, this
line is extended laterally, about 2 to 3 mm
beneath the nail. A similar line is marked
on the plantar aspect of the great toe to
meet the above line at the level of the
lateral toe tip.
• Mark a point “A” at the level of the distal
edge of the inferior extensor retinaculum,
halfway between the dorsalis pedis artery
marking and the great saphenous system
marking.
• Draw an “S” shaped line between the point
“A” and the marked circumferential base
line adjacent to the first web space.
Surgical Steps
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,
where it will divide into two branches to
the great toe and the second toe.
152 SECTION 9  THUMB RECONSTRUCTION
7. Dissect the deep peroneal nerve which
lies deep to the dorsalis pedis artery. Diss­
ect 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 great toe
as proximally as possible and tag with
7.0 polypropylene. This nerve should be
anastomosed to the superficial radial
nerve branches on the dorsal aspect of the
thumb.
8. Start the dissection on the great toe on the
medial side and elevate the flap toward
the lateral side. This should contain the
nail plate, nail bed and the part of the
terminal phalanx bone to which the nail
bed is adherent. As the dissection moves
proximally, elevate only the skin flap
superficial to the extensor hallucis longus
tendon. Dissect over the extensor hallucis
longus tendon and take care to retain the
paratenon over it as a skin graft must be
applied over it later.
9. At the distal part of the dorsalis pedis artery,
identify the deep communicating branch
going to the plantar side. This branch will
join with the first plantar metatarsal artery
to form the plantar digital artery. And this
plantar digital artery will divide into two,
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
the great toe are identified. They are cut as
proximal as possible and tagged with 7.0
polypropylenes.
11. The lateral plantar digital artery (branch
to the second toe) is divided.
12. The transverse metatarsal ligament is
divided on the medial aspect of the MTP
joint of the second toe. Great care should
be taken at this level to avoid injury to the
vessels at this level.
13. Now, retractors should be applied to the
second metatarsal and retracted later­
ally and the first metatarsal retracted
medially. The arterial system is now
exposed (Fig. 9.33.3). The system should
be carefully dissected, taking into account
the dominance of the vessel system. This
can be assisted by carefully dividing
the interosseous muscles and further
exposing the arterial system.
14. Now, the wrap around toe is almost
completely dissected and is held only by
the artery and veins.
15. Now, release the tourniquet, apply warm,
moist pads over the dissected wrap around
great toe and the vascular pedicle. Take
care to prevent the toe from falling down
and shearing the vessels! Raise the foot
for about 5 minutes. Then place the foot
on the table. It usually takes about 15 to
20 minutes for the circulation to be re-
established in the dissected toe. By the
end of this time, the toe becomes pink and
warm and ready for transfer.
16. The vessels can be divided when the
recipient site dissection is over (Fig. 9.33.4).
Fig. 9.33.3  Showing relevant vascular anatomy
of the great toe
Key: 1. First dorsal metacarpal artery; 2. Common Dorsal digital artery;
3. Proper dorsal digital artery to II toe; 4. Proper dorsal digital artery to
great toe; 5. First plantar metatarsal artery; 6. Distal communicating
artery; 7. Common plantar digital artery; 8. Proper digital artery
to medial side great toe; 9. Proper digital artery to II toe; 10. Proper
digital artery to lateral side great toe; 11. Deep transverse metatarsal
ligament
 CHAPTER 33  PROCEDURES FOR RECONSTRUCTION OF TYPE III AMPUTATIONS
Fig. 9.33.4  Harvested wrap-around great toe flap
17. 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
recipient site for vascular anastomosis.
18. Management of the donor site: After secur­
ing hemostasis, the secondary defect on
the great toe should be dealt with. The
plantar side should be covered with a cross
toe flap harversted from the dorsal aspect
of the second toe and the flap should be
inset to the edge of the medial flap that has
been planned and retained on the medial
side of the big toe. The dorsal aspect should
be covered with a skin graft harvested from
the ipsilateral thigh and applied over the
paratenon covering the extensor hallucis
tendon. The incision on the dorsum of the
foot should be closed primarily 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 and elastocrépe bandage app­
lied over it. A posterior below knee POP
slab should be applied.
153
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
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:
• The digital nerves—the ends should be
tagged with 7.0 polypropylene
• Prepare the end of the bony stump to
which the great toe wrap around flap is
going to be fixed.
Harvesting the Ulnar Bone Graft
• An ulnar bone graft should be harvested
from the proximal part of the ulna which is
subcutaneous and close to the olecranon.
Lengths of up to 8 cm of bone graft and up
to 1 of 3 the circumference of the ulna can
be harvested without morbidity
• A gentle “S” shaped incision is marked
over the subcutaneous border of the ulna
just distal to the olecranon. This incision
should be about 8 cm long. The incision is
made deeply down to the bone
• The incision is made on the periosteum
and the periosteum elevated on both sides
to expose the ulna for a width of about 3 cm
• The required dimensions of the bone are
now marked on the ulna. The length of the
bone required is the length of the thumb
with 1 cm extra. The width should be 2 cm
• Perform the osteotomy to raise the cortico
cancellous bone graft. Sculpt the graft into
154 SECTION 9  THUMB RECONSTRUCTION
the shape of a “cricket bat”, to enable the
“handle” end to be pegged into the head of
the metacarpal bone. 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
• Now, peg the bone graft into the stump of
the bone that has been prepared. This must
be done in such a way that the cancellous
side faces the dorsal aspect
• 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.
Fixation of the Toe Flap
• Bring the wrap around great toe flap to
the recipient site. Place the toe over the
pegged bone graft and get a good position,
a position in which good opposition can be
achieved with the fingers and is a functional
position
• A subcutaneous tunnel is created between
the recipient site vessels and the summit of
the stump. This tunnel is for the vessels of
the toe to be passed through to reach the
recipient vessels—the radial artery
• The structures to be passed through the
tunnel are:
• The arteries
• The veins
• The deep peroneal nerve.
• Nerve repair—the digital nerves are sutured
to the two plantar digital nerves of the toe
and the deep peroneal nerve is sutured to
the superficial branch of the radial nerve at
the anatomical snuff box. The nerve repairs
are done with 7.0 polypropylene using
epineurial sutures
• Vascular anastomosis—the recipient vessels
should be divided, blood flow checked
from the divided artery and approximator
clamps applied. The soft clamps must be
released from the donor vessels. Vascular
anastomosis should be done (the technique
of vascular anastomosis is beyond the scope
of this manual).
• Bulky sterile dressings and above elbow
POP are applied with the elbow in 90°
flexion, forearm in mid prone position. A
bulky dressing is applied on the leg and foot
with a posterior below knee POP slab.
Postoperative Protocol
• Admission in the ward
• The affected hand and the donor foot
should be kept elevated
• Patient is kept on nil oral for 24 hours in
case of need for exploration if there is a
vascular problem in the flap
• Clinical monitoring of the flap once every
hour
• Analgesics and antibiotics for 5 days
• Sedation SOS for 1 day
• Inspection of the dressing after 48 hours
• Suture removal on the 10th day
• Removal of the POP slab on the 21st day. If
across toe flap has been done for coverage
of the donor site, the flap has to be divided
at this time
• Refer to physiotherapy for active and pas­
sive 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
after a further 2 weeks.

Procedures for
Reconstruction of
Type IV Amputations
Vascularized Second
Toe Transfer
Preparation
• Palpate the dorsalis pedis artery 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
• Mark a dorsal triangle on the dorsum of
the foot (Fig. 9.34.1) 2 cm length and 1 cm
base at the second toe. Mark the plantar
Fig. 9.34.1  Markings for the second toe harvest
34
triangle about 1.5 cm and 1.0 cm (in adults,
this triangle measures 4 cm by 2.5 cm on
the dorsum and 3 cm by 2 cm)
• Mark a point “A” at the level of the distal
edge of the inferior extensor retinaculum,
halfway between the dorsalis pedis artery
marking and the great saphenous system
marking
• Draw a curvilinear line between the point
“A” and the apex of the marked triangle
• Similarly, from the apex of the triangle on
the plantar aspect, make a marking that
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
polypropylenes.
156 SECTION 9  THUMB RECONSTRUCTION
6. Dissect the extensor hallucis longus ten­
don and divide it at the level of the distal
edge of the inferior extensor retinaculum.
Divide the tendon of the extensor brevis at
the level of the metatarsal base.
7. At the distal part of the dorsalis pedis ar­
tery, identify the deep communicating
branch going to the plantar side. This
branch will join with the first plantar
metatarsal artery to form the plantar digi­
tal artery. And this plantar digital artery
will divide into two, the medial plantar
digital artery going to the lateral side of
great toe and the lateral plantar digital and veins.
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.
8. Now, surgeons go to the plantar side dis­
sec­tion. Make the plantar incisions. The
medial and lateral plantar digital nerves
are identified. The fascicles to the great
toe and the fascicles to the third toe teased
from the medial and plantar digital nerves
respectively. The fascicles going to the
second toe are cut as proximal as possible
and tagged with 7.0 polypropylenes.
9. The flexor digitorum brevis muscle is cut
at the midsole level, where it joins the
tendon of the long flexor. The long flexor
tendon is divided at the midsole level.
10. The medial plantar digital artery (branch
to the great toe) is divided.
11. The transverse metatarsal ligament is
divided on the medial and lateral aspect
of the metatarsophalangeal (MTP) joint of
the second toe. Great care should be taken
at this level to avoid injury to the vessels at
this level.
12. Now, retractors should be applied to the
second metatarsal and retracted laterally
and the first metatarsal retracted medially.
The arterial system is now exposed. The
sys­tem should be carefully dissected,
tak­ing into account the dominance of
the vessel system. This can be assisted
by carefully dividing the interosseous
muscles and further exposing the arterial
system.
13. Now, the second toe is almost completely
dissected and is held only by the intact
metatarsal bone and the artery and veins.
The osteotomy of the metatarsal can be
done. This should be done depending
on the length that surgeons have already
calculated in the preoperative work-up.
14. Once the osteotomy is over, the remaining
soft tissues can be divided, so that the
second toe is now held only by the arteries
15. Now, release the tourniquet, apply warm,
moist pads over the second toe and the
vascular pedicle. Take care to prevent
the toe from falling down and shearing
the vessels. Raise the foot for about 5
minutes. Then place the foot on the table.
It usually takes about 15 to 20 minutes for
the circulation to be re-established in the
dissected toe. By the end of this time, the
toe becomes pink and warm and ready for
transfer.
16. The vessels can be divided when the
recipient site dissection is over.
17. 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
recipient site for vascular anastomosis.
18. Management of the donor site—after
securing hemostasis, the secondary defect
should be closed primarily 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 and elastocrépe bandage applied
over it. A posterior below knee plaster of
Paris (POP) slab should be applied.
Recipient Site Dissection
• The hand is prepared as described in
Appendix I
 CHAPTER 34  PROCEDURES FOR RECONSTRUCTION OF TYPE IV AMPUTATIONS
• 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 comi- tension should be adjusted, so that, the
­tantes
• 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
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:
• The flexor pollicis longus tendon
• The digital nerves—the ends should be
tagged with 7.0 polypropylene
• The extensor pollicis longus tendon
• Prepare the end of the bony stump to
which the second toe is going to be fixed.
• 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 ot 5 minutes.
Rest the hand on the table and secure
he­m­o­stasis.
Fixation of the Toe Flap
• Bring the toe flap to the recipient site. Place
the toe over the stump and get a good
position, a position in which good opposition
can be achieved with the fingers and is a
functional position.
• A subcutaneous tunnel is created between
the recipient site vessels and the summit of
the stump. This tunnel is for the vessels of
the toe to be passed through to reach the
recipient vessels—the radial artery.
• The structures to be passed through the
tunnel are:
• The arteries
• The veins
• The deep peroneal nerve.
• Bone fixation—is done with K-wires without
causing damage to the vessels.
• Tendon repair—the flexor longus tendon
of the toe is sutured to the flexor pollicis
157
longus tendon end and the extensor longus
tendon of the toe is sutured to the end of
the extensor pollicis longus tendon. The
toe is stable and in a functional position.
The repair is done with 3.0 polypropylenes
using modified KM suture technique.
• Nerve repair—the digital nerves are sutured
to the two plantar digital nerves of the toe
and the deep peroneal nerve is sutured to
the superficial branch of the radial nerve at
the anatomical snuff box. The nerve repairs
are done with 7.0 polypropylene using epi­
n­eu
­ rial sutures.
• Joint repair—the MTP joint of the toe is
primarily in a position of hyperextension.
When this toe is transferred to become
a thumb, if it retains this position, the
reconstructed thumb may not be functional
as it may be away from the fingers. So, it
is important that the MTP joint be made
more physiological. To do this, the volar
capsule of the MTP joint is plicated with 4.0
polypropylenes.
• Vascular anastomosis—the recipient vessels
should be divided, blood flow checked
from the divided artery and approximator
clamps applied. The soft clamps must be
released from the donor vessels. Vascular
anastomosis should be done (the technique
of vascular anastomosis is beyond the scope
of this manual).
• Bulky sterile dressings and above elbow
POP are applied with the elbow in 90° flex­
ion, forearm in mid prone position. A bulky
dressing is applied on the leg and foot with
a posterior below knee POP slab.
Postoperative Protocol
• Admission in the ward
• The affected hand and the donor foot
should be kept elevated
• Patient is kept on nil oral for 24 hours in
case of need for exploration if there is a
vascular problem in the flap
• Clinical monitoring of the flap once every
hour
158 SECTION 9  THUMB RECONSTRUCTION
• Analgesics and antibiotics for 5 days
• Sedation SOS for 1 day
• Inspection of the dressing after 48 hours
• Suture removal on the 10th day
• Removal of the POP slab on the 21st day. If
across toe flap has been done for coverage
of the donor site, the flap has to be divided
at this time
• Refer to physiotherapy for active and pas­
sive 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
after a further 2 weeks.

Procedures for
Reconstruction of
Type V Amputations
Pollicization
Presurgical Counseling
• This procedure will be done under axillary
block anesthesia or general anesthesia
• 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 to 2
hours to perform
• A dressing will be applied and a plaster of
Paris (POP) slab will be applied at the end
of surgery
• Admission will be necessary for a minimum
period of 3 days
• Postoperatively, no movements of the fin­
gers should be attempted. If it is done, the
sutured tendons may rupture
35
• Postoperatively, the POP slab will be
con­tinued for a period of 3 weeks. After
this period, physiotherapy will be started
and 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
• The general complications of anesthetic
infiltration like hypersensitivity may occur
in spite of test dose application. This com­
plication will cause dryness of mouth and
apprehension, which can be corrected
immediately.
Surgical Steps
Described in Chapter on Hypoplastic thump
pollicization.
 SECTION

10

Tumors
 Ganglion Excision
Introduction
One of the most common tumors occurring
on the hand is the ganglion, which can occur
on the volar side or the dorsal aspect of the
wrist. The surgical management of both these
conditions is described here.
Salient Features of the
Condition
1. Is believed to occur due to degenerative
changes in the joint capsule.
2. Is prone for recurrence after surgery
due to incomplete removal of the intra-
articular portion of the ganglion.
3. Complete removal and prevention of
recurrence is dependent on following the
principles of hand surgery, i.e. regional
block anesthesia (axillary or supra­clavi­
cular block), use of tourniquet, use of
magni­ fi­
cation, bipolar cautery and a
liberal incision to expose and excise the
tumor.
The surgical steps for the excision of volar and
dorsal ganglions are the same and they are
discussed here.
Surgical Steps
1. Apply a pneumatic tourniquet on the
upper arm.
36
2. Prepare and drape the involved upper
limb from the elbow to the tip of the hand.
3. Mark a transverse incision over the summit
of the tumor (volar or dorsal). The incision
should extend beyond the circumference
of the tumor by about 3 to 4 mm.
4. Raise the tourniquet.
5. Make the incision as marked down through
the dermis.
6. Apply skin hooks on one of the edges and lift
the skin flap off the surface of the ganglion.
Elevate this flap till the corresponding
edge of the ganglion is visible. Repeat this
procedure on the opposite edge of the flap.
So, now the entire circumference of the
ganglion will be visible on retracting both
skin edges.
7. The ganglion will have a narrow stalk as it
arises from the intra-articular area. This
must be dissected by gently elevating the
circumference of the ganglion from the
bed, formed by the surface of the joint
capsule. The points to be noted when
doing this step are:
• The tendons on either side should be
retracted carefully to the radial and
ulnar sides to avoid injury to them
• The ganglion should not be grasped
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
retaining some soft tissues over the
surface to enable surgeons to hold it, or
by atraumatic retraction with a piece of
saline gauze
164 SECTION 10  TUMORS
• In the case of volar ganglion, the radial
artery and its venae comitantes may
course close to the edge of the tumor.
Care should be exercised to avoid
injury to these vessels by appropriate
retraction.
8. Once the ganglion has been raised off
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
stalk and the intra-articular area exposed.
By this incision, the stalk of the ganglion
can be traced over the articular surfaces of
the carpal bones down to the intercarpal
ligaments.
9. The entire stalk of the ganglion can be
removed by gentle blunt dissection to free
it from the intercarpal ligament. Thus, the
entire ganglion can be excised in-toto.
10. The tourniquet should be released and
hemostasis achieved. The rent in the joint
capsule should not be closed. A Segmüller
drain (tubing of the scalp vein set) kept
and the wound closed in layers with 4.0
Vicryl for the subcutaneous tissues and
skin closed with 3.0 polypropylene sub-
cuticular sutures, with the drainage tube
coming out from one end of the suture
line. Non-adherent dressings applied
and plaster of Paris (POP) slab should be
­applied to immobilize the wrist. For the
dorsal ganglion, a volar POP slab should
be applied with the wrist in 20° extension,
and for the volar ganglion, a dorsal POP
slab should be applied with the wrist in
10° flexion.
Postoperative Protocol
• The patient may be treated as an outpatient
with the advise to keep the hand elevated,
oral antibiotics for 3 days, analgesics and
anti-inflammatory agents
• The suture line must be examined at the
end of 48 hours and the drainage tube
removed. Dressings must be applied again
and the POP slab retained
• On the 10th day, the suture can be remo­
ved, and the POP slab removed
• Patient may be advised the following:
• Wash with soap and water
• Scar massage with coconut oil
• Active and passive movements of the
wrist and fingers at physiotherapy
• Compression garment after 2 weeks
to soften the scar, to be worn for a
minimum of 3 weeks.
 SECTION

11

Degenerative
Conditions
 Dupuytren’s Contracture—
Assessment
Introduction
Dupuytren’s contracture is a relatively un­
co­mmon condition that surgeons see in the
outpatient department in South India, but
when a patient does present, management
should be perfect to relieve the patient of his
distress and make his hand a useful one.
The points to be noted in the assessment
are described below:
History
• History of diabetes mellitus, alcohol in­
take or epilepsy, or family history of the
disorder. These are important findings not
only for the diagnosis of the problem, but
also to prognosticate the results
• Though patients with diabetes present
mai­nly with a mild form of the disease
con­sisting of palmar nodules, the rate of
recur­rence after surgical management of
contractures, if they develop, are quite high
• Similarly, patients who give history of alcohol
intake are also prone for complications
after surgical management of Dupuytren’s
disease
• Eliciting a history of trauma, however
trivial, may also be significant, because, in
such situations, the prognosis is very good
and recurrence rates are very minimal.
37
Symptoms
• Tightness in the palm on extension
• Nodules or callus like formation in the palm
• Gradually increasing contracture of the
fin­­gers
• Maceration of skin within contracture folds
and secondary infection.
Clinical Examination
• Nodules—usually present in the area of the
distal palm particularly at the level of the
palmar creases. Usually non-tender and
painless
• Skin pits—are sometimes seen in the
plamar region
• Sometimes, there is just a distortion of the
palmar creases; either deepening of the
creases or widening of the creases. These
are significant, since they denote the early
stages of the disease. However, it is not
essential for these lesions to progress and
lead to contractures
• Palpable cords—different types of cord
formation which lead to different types
of contractures and need different sur­
gi­cal management plans. If the cord is
palpable, the extent of the cord should
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

Planning of management of Dupuytren’s
con­tracture—assessment are given in Table
11.37.2.
Planning the Timing of the Surgery
When the contracture involves only the
MCP joint, the surgery need not be done
before fasciectomy
imm­e­diately as there is no risk of involvement
of the joint. However, in cases of mainly PIP
joint, it is important to schedule the surgery
as early as possible to avoid irreversible con­
tracture of the joint.
 Dupuytren’s Contracture—
Management
Fasciectomy
Surgical Steps
• Prepare the hand as described in App­
endix I
• Marking the incisions (Fig. 11.38.1):
• The zig-zag incisions of Bruner are
mar­ked on the palm and affected fin­
ger rays, beginning proximally from
the hollow of the palm between the
thenar and hypothenar eminences. The
incisions follow the course of the flexor
tendons of each finger.
Fig. 11.38.1  Marking the incisions for fasciectomy
38
• The tourniquet is raised and the inci­
sions are made
• The incision is made down through the
skin and subcutaneous tissues only and
the skin flaps are raised on either side
• The contracted and thickened fascia is
carefully dissected and isolated. It is very
important to keep the neurovascular bun­
dles in sight throughout the dissection
procedure. This is to avoid inadvertent
injury to the neurovascular bundles
• Once the entire length of the fascia is
dissected, it is excised
• 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.
Postoperative Protocol
• Admission in the ward
• The affected hand should be kept elevated
170 SECTION 11  DEGENERATIVE CONDITIONS
• Patient can take normal diet immediately
if the procedure was under regional block
or after complete recovery if under general
anesthesia
• Inspection of the suture line after 48 hours
without disturbing the position of the POP
slab
• Discharge of the patient by third day
• Suture removal on the 10th day
• Plaster of Paris is also removed on the 10th
day
• Advise the following:
• Refer to physiotherapy for active mobi­
lization of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Application of a detachable straighten­
ing splint for the affected fingers
through­out the day for 3 weeks. Inter­
mittently, the splint should be removed
and active and passive mobilization
of fingers should be done. The splint
should be worn for another 3 weeks at
night
• The unaffected fingers should be mobi­
lized from the day of POP removal
• Patient is advised to continue the mobi­
lization of the fingers; both active and
passive and review once every month
for evaluation.
• It is practical to advise the patient to
carry a brief case or portfolio, which
keeps the MCP joints in extended posi­
tion and stretched to the maximum.
 SECTION

12

Infection
 Hansen’s Disease
and Sequelae
History
• Duration of complaints—will indicate the
progress of the lesion
• History of treatment—both medical and
surgical
• Occupation of the patient—this is impor­
tant for deciding the surgical recon­stru­ction
• A patient who does manual labor will need
powerful tendon transfers, while patients
doing sedentary type of labor will require
the transfer of less powerful muscles. In
such patients, even static procedures will
sometimes suffice
• Episodes of drug reactions—a history of
lepra reaction and the time of the reaction
will be important in deciding the timing of
surgical reconstruction.
Clinical Examination
Type of Hand
Some people have soft hands with hypermobile
joints. The force required to move these joints
is very little, as the joints are very supple and
the skin and soft tissues are also very supple.
Hence, when tendon transfers are planned
for such patients, care should be exercised in
cho­osing the donor tendon [avoid removing
the flexor digitorum superficialis (FDS) of
the finger] and in choosing the type of ten­
don transfer (avoid using powerful tendon
transfers like Brand’s procedure). Procedures
39
like Fowler’s procedure may well suit such
patients. On the other hand, patients with
bulky hands with thickened skin will require
more powerful transfers.
Attitude of the Hand
The following positions of the hand may be
seen:
• Total claw of the hand—the metacarpo­
phalangeal (MCP) joints are hyperextended,
interphalangeal (IP) joints are flexed in all
the fingers. This signifies combined low
ulnar and median nerve palsy
• Ulnar fingers alone in clawed position—
may denote that there is a low ulnar nerve
palsy. However, the involvement of the
median nerve also cannot be ruled out
• 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
• Fingers appear to be in cascade—ask the
patient to extend all the fingers. This will
show the claw if it is present
• Thumb and index finger are kept extended,
while the other fingers are in cascade—will
indicate a high level median nerve lesion
• All the fingers, thumb and the wrist are in
flexed position, with inability to extend any
of them—indicates a radial nerve lesion
• “Z” deformity of the thumb indicates a
combined low median and ulnar palsy
• A flat palm, with the metacarpal arch
obliteration points to the combined low
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
ges—indicates a combined median and
ulnar nerve lesion
• Absorption of the fingertip and defor­
mities of the nail will denote long standing
disease
• Wasting of the thenar eminence on the
palm—indicates a median nerve lesion.
This lesion can be either low level or high
level lesion
• Wasting of the hypothenar eminence indi­
cates an ulnar nerve lesion
• Hollowing of the intermetacarpal spaces
on the dorsum of the hand also signifies
ulnar nerve lesion
• Presence of ulcers—are significant and
usually found on typical areas like over
the heads of the metacarpals, tips of the
fingers, and on the volar aspect of the wrist
ulcers. In some patients, scars may give
a clue about the previously done recon­
structive procedures, if any.
By now, there will be a clue about which nerve
has been involved in the disease process. So,
the next step consists of testing the individual
nerve territory separately for the three nerves.
There are many standard tests described in
textbooks, and a few of them are mentioned
here.
For the Ulnar Nerve
Ulnar nerve of Hansen’s disease and sequelae
are shown in Table 12.39.1.
For the Median Nerve
Median nerve of Hansen’s disease and sequ­
elae are shown in Table 12.39.2.

Table 12.39.1 Ulnar nerve of Hansen’s disease and sequelae

Method of doing
Finger closing Ask the patient to keep
pattern the fingers straight on the
table with the palm facing
upward. He is then asked to
very slowly flex the fingers
to bring the tips of the
fingers to the palm.
Unassisted angle Ask the patient to make a
fist. Then ask him to slowly
extend the IP joints alone
and bring the IP joints to
neutral position, without
extending the MCP joints.
To make it clear, the surgeon
can demonstrate first on his
own hand, and then ask the
patient to do it on his unin-
volved hand if possible.
Finding
Normally, the MCP joints
start moving first and
then the IP joints flex to
complete the flexion. If the
ulnar nerve is involved, the
IP joints flex fully and then
move the MCP joints.
The patient with ulnar
nerve injury will not be able
to achieve the lumbrical
position. If only the ulnar
nerve is involved, the index
and middle fingers will
come to lumbrical position,
but not the ring and little.
Now, measure the angle
at the PIP joints of the ring
and little fingers. This is the
unassisted angle.
Significance
Denotes paralysis of the
primary flexors of the MCP
joints. So, the long flexors
have to flex the MCP joint
and they can do this only
after they have fully flexed
the IP joints.
Denotes paralysis of the
primary extensors of the
IP joints and flexors of the
MCP joints.

Contd...

Contd...
Assisted angle Now, support the MCP
joints of the involved
fingers at 90º with your
hands and ask the patient
to extend the IP joints as
above.
Contracture angle If there is an assisted angle,
try to passively extend the
proximal interphalangeal
(PIP) joints of the involved
fingers.
Latent clawing When the patient is asked
to keep the involved hand
in lumbrical position, he
may be able to do it. Test
the power of this MCP joint
flexion, by giving a short
upward push on the volar
side of the prophylaxis
(PPX) level of the involved
fingers.
Adduction of the Ask the patient keep all
fingers the fingers extended, and
insert a card between the
fingers. Ask him to grip the
card tightly with the sides
of his fingers, while the
examiner tries to withdraw
the card.
Adduction of little Ask the patient to adduct
finger the extended little finger to
the extended ring finger.
Froment’s sign A book is held by the
examiner and the patient is
asked to hold it with both
hands. The examiner now
gently tries to pull the book
away, necessitating the
patient to apply more pres-
sure with the thumb.
CHAPTER 39  HANSEN’S DISEASE AND SEQUELAE
The patient may be able to
now extend the IP joints
and bring them to neutral
position. This is because
the long extensors of the
fingers can extend the IP
joints when the MCP joints
are stabilized.
Sometimes, it may not be
possible to extend beyond
a certain angle. This is the
contracture angle.
If the ulnar nerve is
involved, the involved
fingers will buckle under
the pressure and the claw
will be revealed.
In a case of ulnar nerve
palsy, the patient will not
be able to grip the card
properly or not at all.
This will not be possible in
a patient with ulnar nerve
palsy (Wartenberg’s sign).
If the ulnar nerve is
involved, the involved hand
will show increased flexion
at the IP joint of the thumb
– positive Froment’s sign.
175
If the patient is not able to
extend the IP joints fully,
it signifies that the long
extensors and central slip
have become attenuated,
most probably due to long
standing claw deformity.
This signifies that the joint
has become stiff due to
long standing claw. Hence,
it must be corrected either
by physiotherapy or surgi-
cal means to achieve a full
passive range of motion.
This signifies that the ulnar
nerve is involved, but the
soft tissues surrounding
the MCP joints are strong
enough to stabilize the
joint weakly. There is no
need to wait for an obvious
claw to develop before
planning a correction.
Indicates paralysis of the
adductors of the fingers
– the palmar interossei
muscles.
This is because the third
palmar interosseous muscle
which must adduct the
little finger is paralyzed
and only the extensor digiti
minimi are acting.
If the adductor pollicis
muscle, which must act to
grip the book is weak, the
flexor pollicis longus (FPL)
tendon tries to compen-
sate and this manifests as
increasing flexion at the IP
joint of thumb.
176 SECTION 12  INFECTION

Table 12.39.2 Median nerve of Hansen’s disease and sequelae

Method of doing
Testing for abductor Patient is asked to keep his
pollicis brevis (APB) hand flat on the table, with
muscle the palm facing upward.
The examiner then holds a
pen parallel to the plane of
the palm at a distance. He
is then asked to lift-up only
the thumb to touch the pen.
When the patient attempts
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
fundus (FDP) of index individually only the distal
and mid interphalangeal (DIP) joints
of the index and middle
fingers when the middle
phalanx (MPX) segments
of the fingers are stabilized
by the examiner. When the
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
on index finger both hands. The position of
the index finger is assessed
in this position.
Testing the FPL action Patient is asked to flex the IP Will not be possible in high
joint of the thumb against re- involvement of the median
sistance, while supporting the nerve.
PPX segment of the thumb.
Thumb web angle A line is drawn on the dorsal The normal thumb web
aspect of the hand over the angle is 40°.
first metacarpal and the
second metacarpal bones.
The angle between these
two lines (the thumb web
angle) is measured.
Finding Significance
Sometimes, the patient may
be able to weakly touch the
pen, only when the level of
the pen is brought closer
to the palm. Even then, the
weakness or absence of
muscle tone in APB denotes
the involvement of the
median nerve.
Patient will not be able to Indicates high median
do so individually in a case nerve palsy.
of high median nerve palsy.
There may be some move-
ment of flexion, but this
may be by the contiguous
movements at the FDP of
the ring and little fingers.
When the median nerve Indicates high median
is involved at a high level nerve palsy.
(in the proximal forearm or
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).
Indicates high median
nerve palsy.
If the angle is less than
normal, it indicates tight-
ening of the underlying
adductors/stiffness of the
carpometacarpal (CMC)
joint of thumb and/or
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
to the tips of the index,
middle, ring and little
fingers. The grading of the
range of movements is
done as shown.
patient touches the tips of
the fingers with the tip of
the thumb. All other pinches
are not representative of
true opposition.

Table 12.39.3 Radial nerve of Hansen’s disease and sequelae

Method of doing Finding Significance
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

Radial nerve of Hansen’s disease and sequ­
elae are shown in Table 12.39.3.
Position of the joints—should be checked
and recorded. This will show any stiffness or
contractures and will play an important role
should include both active and passive range
of movements. Reversal of the metacarpal
arch must also be recorded.
Sensation—the pain, touch sensation should
be recorded and the two point discri­mi­n­ation
should also be recorded.

Opponensplasty with Flexor
Digitorum Superficialis
of Ring Finger
Introduction
Though there are many procedures for opp­
on­ensplasty this procedure is a standard one
that is commonly used, when the thumb web
is tight, and a powerful muscle is needed to
overcome this tightness.
Presurgical Counseling
• This procedure is planned to correct only
the weak thumb. This surgery will not
correct the other problems that may exist
on the hand like wasting of the muscles
or loss of sensation. These problems need
to separate sittings of surgery and cannot
usually be combined with the procedure
planned at present
• This procedure will be done under axillary
block anesthesia
• This procedure will take about 1 hour to
perform
• A tendon from the ring finger will be
removed and taken to the thumb to make
the thumb move in a useful direction. There
will be no obvious deficit on the ring finger,
but there may be some weakness of the
finger
• Admission will be necessary for a minimum
period of 3 days
• A dressing will be applied and a plaster
of Paris (POP) will be applied, which will
be retained for 3 weeks, following which,
40
physiotherapy will be started. This should
be continued for a further 3 weeks. During
this period of physiotherapy, exercises will
be taught to make the tendon of the ring
finger move the thumb
• In some instances, the movement that
returns on the thumb may be weak and may
not be powerful enough for useful work. In
some other instances, the tendon may not
work at all. This will require another sitting
of surgery to correct the problem
• In some instances, the ring finger may
develop a minimal deformity on the
proximal interphalangeal (PIP) joint. This
will require a small surgery to correct the
problem
• 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. Prepare the hand as described in
Appendix I.
2. Mark the incisions as follows (Fig. 12.40.1):
• Incision “A”—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 PIP joint crease
• Incision “B”—an incision 2 cm long
mar­ ked transversely over the distal
 CHAPTER 40  OPPONENSPLASTY WITH FLEXOR DIGITORUM SUPERFICIALIS OF RING FINGER
Fig. 12.40.1  Markings for opponensplasty using flexor
digitorum superficialis (FDS) of ring finger
palmar crease proximal to the ring
finger
• Incision “C”—an incision 2 cm long
marked transversely over the flexor
aspect of the forearm about 3 cm
proximal to the wrist crease
• Incision “D”—an incision 2 cm long
marked transversely over the palm just
distal and radial to the pisiform bone
• Incision “E”—an incision 2 cm long
marked longitudinally over the radial
aspect of the thumb at the level of the
metacarpophalangeal (MCP) joint just
volar to the midpoint
• Incision “F”—an incision 2 cm long
marked transversely over the dorsum
of the proximal phalanx of the thumb,
just proximal to the interphalangeal (IP)
joint crease on the thumb.
• Incision “G”—an incision on the ulnar
side of the MCP joint of the thumb,
about 2 cm long.
3. The tourniquet is raised and the incisions
are made.
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
blade until both slips are free. The vincular
attachment will also have to be divided to
achieve total release of the FDS slips.
5. Incision “B” is made and the synovium over
the FDS and FDP tendons just proximal
to the A1 pulley is incised to expose the
tendons. Identify the FDS tendon and pull
so that the tendon is now delivered in this
wound. Suture wound “A” now.
6. The incision “C” is made and the FDS
tendon identified among the tendons to
the fingers. The FDS of the ring finger is
pulled and delivered in the wound.
7. Now, incision “D” is made through the
skin and subcutaneous tissues. The
subcutaneous fat consisting of fine fat
globules is seen. The incision is gently
deepened till large fat globules protrude
out. Now, a tendon retriever is passed
through this wound proximally to exit at
the forearm wound. The free end of the
FDS tendon is grasped and the tendon
delivered at the incision “D”.
8. Incision “E” is made through the skin
and subcutaneous tissues to expose the
insertion of the abductor pollicis brevis
tendon. The tendon retriever is passed
from this wound to the incision “D”. The
180 SECTION 12  INFECTION
free end of the FDS tendon is grasped and
retrieved in incision “E”. The incisions “B”,
“C” and “D” are sutured with 4.0 Ethilon.
9. The tendon anchoring is done under
correct tension. The wrist is placed in
neutral position and the thumb positioned
at prone position and abducted position.
The thumb should now be facing the
middle finger. Now, the free end of the FDS
tendon is pulled distally and the excursion
of the tendon is recorded. The midpoint of
this excursion range is marked and placed
close to the tendon of abductor pollicis
brevis (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
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.
10. The above method of tendon suturing
is done for a case of pure median nerve
lesion or injury. If there is a combined
median and ulnar nerve injury, the
following method of tendon anchorage is
done. The anchoring of the tendon is not
done only at the APB tendon as discussed
above. Two more incisions are made.
11. Incision “F” is made and the extensor
pollicis longus (EPL) tendon is identified
just proximal to the IP joint.
12. Incision “G” is made and the adductor
incision is identified and dissected.
13. At the incision “E”, the free end of the FDS
tendon is now split into two slips. One
slip is passed through a tunnel over the
dorsum of the MCP joint of the thumb
and attached to the adductor insertion
at incision “G” with 4.0 polypropylenes
using horizontal mattress suture, under
minimal tension as described above. The
other slip is passed subcutaneously to
incision “F” where it is anchored to the
EPL tendon with 4.0 polypropylenes using
horizontal mattress suture with neutral
tension on the anastomosis.
14. Now, the suturing of the wounds must be
done with 4.0 Ethilon.
15. Sterile dressings are applied and a POP slab
is applied on the thumb, maintaining the
wrist in (10°) flexions, and the thumb kept
in a position of abduction – opposition.
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
or after complete recovery if under general
anesthesia
• The POP slabs must not be disturbed at all
for 3 weeks
• Discharge of the patient by third day
• Patient to retain the POP slab till the end
of 3 weeks
• Removal of the POP slab on the 21st day
and advise the following:
• Refer to physiotherapy for active mobili­
zation of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Patient is advised to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
• To continue wearing a short opponens
splint at night for 3 weeks after removal
of POP.

Opponensplasty with
Abductor Digiti Minimi
Muscle (Huber’s Transfer)
Introduction
This method of tendon transfer is ideal for
children with weakness of the thenar muscles
due to congenital hypoplasia, either of the
musculature only, or hypoplasia of the thumb
which may occur alone or with hypoplasia of
the radius (radial club hand).
Presurgical Counseling
• This procedure is planned to correct only
the weak thumb. This surgery will not
correct the other problems that may exist
on the hand like wasting of the muscles
or loss of sensation. These problems need
to separate sittings of surgery and cannot
usually be combined with the procedure
planned at present
• This procedure will be done under axillary
block anesthesia
• This procedure will take about 1 hour to
perform
• A muscle from the little finger will be
removed and taken to the thumb to make
the thumb move in a useful direction. There
will be no obvious deficit on the little finger,
but there may be some weakness of the
finger
• Admission will be necessary for a mini­
mum period of 3 days
• A dressing will be applied and a plaster
of Paris (POP) will be applied, which will
41
be retained for 3 weeks, following which,
physiotherapy will be started. This should
be continued for a further 3 weeks. During
this period of physiotherapy, exercises will
be taught to make the muscle of the little
finger move the thumb
• In some instances, the movement that
returns on the thumb may be weak and may
not be powerful enough for useful work. In
some other instances, the muscle may not
work at all. This will require another sitting
of surgery to correct the problem
• There will be a scar on the palm and the
little finger
• The general complications of local anes­
thetic 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. Prepare the hand as described in App­
endix I.
2. Mark the incisions (Fig. 12.41.1) as follows:
• First the incision “A” is marked to
harvest the abductor digiti minimi
(ADM) tendon. First the midpoint on
the ulnar neutral line on the proximal
phalanx (PPX) segment of the little
finger is marked point “P”. The point
where the neutral line cuts the volar
meta­carpophalangeal (MCP) joint crease
182 SECTION 12  INFECTION
Fig. 12.41.1  Marking the incisions
on the little finger is marked point
“Q”. Another point is marked over the
palpated hook of the hamate point “R”.
A “C” shaped marking is made from
point “Q” to “R”, along the radial border
of the hypothenar prominence. When
crossing the palmar creases, a zig-zag
shape should be incorporated to avoid
scar contractures later.
3. The tourniquet is raised and the incisions
are made.
4. First the incision “A” is made to harvest
the abductor digiti minimi (ADM) tendon.
The palmar portion of the incision is
made and the skin flap is raised on the
ulnar side over the hypothenar area.
The flap is raised superficial to the fascia
covering the ADM muscle. The ADM is the
most radial and prominent muscle seen
among the hypothenar muscles. Usually,
the digital neurovascular bundles to the
little fingers will not be encountered by
this incision in the palm. Now, the distal
portion of the incision is made on the
little finger. The neurovascular bundle to
Fig. 12.41.2  Reach of the harvested ADM muscle checked
the ulnar side of the little finger must be
protected while raising the flaps of skin
on this part of the incision. Stay sutures
with 3.0 Ethilon are made to restrain the
raised flaps of skin. The insertion of the
ADM muscle is now dissected. It usually
has two insertions one into the base of
the ulnar side of the PPX or MCP joint of
the little finger, and the other insertion on
the extensor apparatus on the ulnar side
of the little finger in the distal portion of
the proximal phalangeal segment of the
finger. Both these insertions are divided
and the muscle is gently raised taking care
to cauterize the small branches entering
the muscle in the distal and middle-thirds.
5. The neurovascular supply to this muscle
must be preserved. It enters the muscle
in the proximal third from the radial side.
The muscle can be elevated till this point.
6. The tendon and muscle is now swung
toward the thumb (Fig. 12.41.2) to make
sure that it reaches the incision “B”, a
point on the radial border of the MCP
joint of the thumb. Usually, it is sufficient
 CHAPTER 41  OPPONENSPLASTY WITH ABDUCTOR DIGITI MINIMI MUSCLE (HUBER’S TRANSFER)
to dissect the muscle till the point
described. However, in some situations,
the muscle may not reach the incision
“B”. In such situations, the origin of the
muscle can be carefully divided on the
ulnar side till the tendon reaches the
desired point, taking care to protect the
neurovascular hilum to the muscle which
enters the radial side.
7. Now, a saline gauze is wrapped around
the muscle and the next incision is made.
8. Incision “B” is made through the skin
and subcutaneous tissues to expose the
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
and retrieved in incision “B”.
9. The tourniquet is now released and
hemostasis achieved. The incision “A” are
sutured with 4.0 Ethilon.
10. The tendon anchoring is done under
correct tension. The wrist is placed in
neutral position and the thumb positioned
at prone position and abducted position.
The thumb should now be facing the
middle-finger. Now, the free end of the
ADM tendon is pulled distally and the
excursion of the tendon is recorded.
The midpoint of this excursion range is
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
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.
11. Sometimes, it may not be possible to
identify the APB tendon at its insertion
because it may be very hypoplastic. In this
situation, the suturing of the transferred
ADM tendon should be made with 3.0
polypropylene using horizontal mattress
183
sutures, to the MCP joint capsule of the
thumb. While making this attachment,
a point must be chosen just dorsal to
the axis of the joint. If the attachment
becomes volar, the transferred tendon
begins to flex the MCP joint of the thumb,
which is not useful in such cases.
12. Now, the suturing of the incision “B” must
be done with 4.0 Ethilon.
13. Sterile dressings are applied and a POP slab
is applied on the thumb, maintaining the
wrist in 10° extensions, and the thumb kept
in a position of abduction – opposition.
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
or after complete recovery if under general
anesthesia
• The POP slabs must not be disturbed at all
• Discharge of the patient by third day
• Patient to retain the POP slab till the end
of 3 weeks
• Removal of the POP slab on the 21st day
and advise the following:
• Refer to physiotherapy for active
mobilization of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Patient is advised to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation
• To aid in keeping the thumb in a correct
position of abduction at rest, a short
opponens splint must be applied at night
during the period of physiotherapy. In
children, they must be encouraged to
use the new movement of the thumb.
 Claw Correction—
Lasso Procedure
Introduction
Lasso procedure is a standard procedure
used in claw correction. The results obtained
are usually quite predictable and satisfactory.
Presurgical Counseling
• This procedure is planned to correct only the
clawing of the fingers. This surgery will not
correct the other problems like flattening
of the hand, or wasting of the muscles or
loss of sensation. These problems need
to separate sittings of surgery and cannot
usually be combined with the procedure
planned at present
• This procedure will be done under axillary
block anesthesia
• This procedure will take about 1 hour to
perform
• A tendon from the ring finger will be
removed and used to provide useful fun­
ction in all the fingers. There will be no
obvious deficit on the ring finger, but there
may be some weakness of the finger
• Admission will be necessary for a mini­
mum period of 3 days
• A dressing will be applied and a plaster
of Paris (POP) will be applied, which will
be retained for 3 weeks, following which,
physiotherapy will be started. This should
be continued for a further 3 weeks. During
this period of physiotherapy, exercises will
42
be taught to make the tendon of the ring
finger flex the fingers
• In some instances, the movement that
returns on the fingers may be weak and may
not be powerful enough for useful work. In
some other instances, the tendon may not
work at all. This will require another sitting
of surgery to correct the problem
• In some instances, the ring finger may
develop a minimal deformity on the
proximal interphalangeal (PIP) joint. This
will require a small surgery to correct the
problem
• The general complications of local anes­
thetic 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. Prepare the hand as described in App­
endix I.
2. Mark the incisions as follows (Fig. 12.42.1):
• Incision “A”—a transverse incision is
marked from the radial border of the
hand to the ulnar border of the hand
along the distal palmar crease
• 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 PIP
joint crease. This incision is to divide
 CHAPTER 42  CLAW CORRECTION—LASSO PROCEDURE
Fig. 12.42.1  Marking of incisions
the insertion of the flexor digitorum
superficialis (FDS) of the ring finger
• Incision “C”—a 2 cm incision is marked
on the thenar crease in the groove
between the thenar and hypothenar
eminences.
3. The tourniquet is raised and the incision
“A” is made. The incision goes down
through the skin and subcutaneous tissues
to the palmar aponeurosis. This layer is also
carefully incised, because just under this
layer lie the digital neurovascular bundles.
4. Gently retract the distal skin flap to expose
the A1 pulleys of all the fingers.
5. Now, the incision “B” 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.
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
avoid injuring the vascular arch. Identify
the FDS tendon of the ring finger and
deliver it in this wound. Split the tendon
into 4 equal slips. Pass a tendon retriever
from incision “A” to incision “C” from
the index finger along the route of the
flexor tendons and deep to the superficial
palmar arch. Grasp the radial most slip
of the FDS and deliver it in incision “A”
proximal to the index finger. Similarly,
deliver the remaining slips of the FDS
(Figs 12.42.2A and B) proximal to the
corresponding fingers on incision “A”.
8. About 7 mm distal to the free edge of the
A1 pulley of the index finger, make a nick
in the flexor sheath. Pass a tendon retriever
through this nick, proximally and grasp the
free end of the FDS slip to the index finger.
Pull the tendon slip through. Now, suture
the free end of the slip to itself over the part
of A1 pulley under correct tension. This
is done by holding the wrist and all the
finger joints in neutral position, pulling
the tendon slip to maximum tension and
suturing it to itself with 4.0 polypropylenes
(Fig. 12.42.3).
186 SECTION 12  INFECTION

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.

Postoperative Protocol
Fig. 12.42.3  Suturing of the tendons after
adjusting the tension • Admission in the ward
• The affected hand should be kept elevated
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.

Claw Correction—Extensor
to Flexor 4-Tailed Tendon
Transfer (EF4T) Procedure
Introduction
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
tougher.
Presurgical Counseling
• This procedure is planned to correct only the
clawing of the fingers. This surgery will not
correct the other problems like flattening
of the hand, or wasting of the muscles or
loss of sensation. These problems need
to separate sittings of surgery and cannot
usually be combined with the procedure
planned at present
• This procedure will be done under axillary
block anesthesia
• This procedure will take about 1½ to 2
hours to perform
• A tendon from the extensor aspect of the
wrist will be removed and taken to the
fingers to make them move in a useful
direction. There will be no obvious deficit on
the wrist, but there may be some weakness
• A tendon graft will be harvested from the
side of the thigh under local anesthesia
and used as a graft. There will be no deficit
as a result of removing this tendon
• Admission will be necessary for a mini­
mum period of 3 days
43
• A dressing will be applied and a plaster
of Paris (POP) will be applied, which will
be retained for 3 weeks, following which,
physiotherapy will be started. This should
be continued for a further 3 weeks. During
this period of physiotherapy, exercises will
be taught to make the rerouted tendon
move the fingers in a useful manner
• In some instances, the movement that
returns on the fingers may be too powerful
or too weak to produce useful work. In
some other instances, the tendon may not
work at all. This will require another sitting
of surgery to correct the problem
• 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. Prepare the hand as described in App­
endix I.
2. Mark the incisions as follows (Figs 12.43.1A
and B):
• Incisions 1, 2, 3, 4—each 3 cm long on
the dorsolateral aspect of the proximal
phalanx region of the index, middle,
ring and little fingers, on the ulnar
side on the index finger, and on the
radial side on the middle, ring and little
fingers
188 SECTION 12  INFECTION
A B
Figs 12.43.1A and B  Marking of incisions
• Incision 5—two centimeter trans­
versely on the dorsoradial aspect of the
wrist over the insertion of the extensor
carpi radialis longus (ECRL) tendon.
When the hand is made into a fist and
the wrist is extended, two tendons can
be palpated on the radial side of the
dorsum of the wrist and the ECRL is the
radial of the two
• Incision 6—two centimeter transverse,
made on the dorsal aspect of the mid
fore­arm about 10 cm proximal to the
radial styloid
• Incision 7—two centimeter transverse,
made on the volar aspect of the distal
third fore­arm
• Incision 8—two centimeter on the
thenar crease in the mid palm.
3. The tourniquet is raised and the incisions
1, 2, 3 and 4 are made one by one.
The extensor tendon is exposed in the
wounds. The portions of the tendon that
are exposed are the lateral bands and the
central tendon. This can be confirmed by
grasping the selected portion of the tendon
with a tissue forceps and applying traction
proximally. This traction should produce
extension of the proximal interphalangeal
(PIP) and distal interphalangeal (DIP)
joints. This must be done on all the
fingers. A moist gauze piece is placed over
the incisions.
4. Incision 5 is now made. The ECRL tendon
must be identified. The extensor pollicis
longus (EPL) tendon runs obliquely
across it and the extensor carpi radialis
brevis (ECRB) tendon is on the ulnar side.
The ECRL tendon should be held with
a hemostat and divided to close to the
insertion with a number 11 blade.
5. Gentle traction to the ECRL is applied in a
distal direction by pulling on the hemostat.
This will confirm the position of the muscle
proximally and the incision “6” is made
now. The muscle/musculotendinous unit
of the ECRL is exposed in this incision and
confirmed by traction on the hemostat.
6. Make incision 7 through the skin and
subcutaneous tissues, and then through
the deep fascia. Now, the hemostat is
removed at the end of the ECRL tendon.
The tendon is exteriorized at incision 6.
 CHAPTER 43  CLAW CORRECTION—EXTENSOR TO FLEXOR 4-TAILED TENDON TRANSFER…
Then a hemostat is passed from incision
7 to incision 6 and the end of the ECRL
tendon is caught. Now, this tendon is
delivered in incision 7.
7. Now, the tendon graft of fascia lata
should be harvested. The harvest of this
tendon graft can be done as described in
Appendix VIII.
8. The tendon graft should now be attached to
the ECRL tendon by the technique shown.
First make one end of the fascia lata graft
pointed. Protect the fascia lata graft with
moist gauze pieces throughout its length. A
small longitudinal incision is made on the
deeper aspect of the end of ECRL tendon.
The pointed end of the fascia lata graft
is inserted inside by a hemostat passed
through the opening. This is now sutured
to the ECRL tendon with 4.0 polypropylene
using simple interrupted sutures. Now, the
fascia lata graft is tubed around the end of
the ECRL tendon, with 4.0 polypropylene
using simple interrupted sutures. Then,
the part of the ECRL tendon is also tubed
around the fascia lata tendon graft entering
on the deep surface of the tendon. Now,
the proximal tendon anastomosis is
completed.
9. Make incision 8 in the palm. Take care
to avoid the superficial palmar arch and
the digital nerves. Pass a tendon retriever
proximally just deep to the palmar
aponeurosis. It must go through the carpal
tunnel and come out at incision 7. Here,
the free end of the fascia lata graft should
be grasped and pulled to be delivered in
wound number 8. Apply a wet gauze piece
over the tendon graft and suture incisions
5, 6 and 7.
10. Now, split the free end of the tendon graft
into four slips of equal width using number
11 blade. Flex the metacarpophalangeal
(MCP) joint of the index finger to 90°
and pass the tendon retriever through
incision 1 to exit at incision 8. While doing
this, the retriever must be advanced very
gently, making probing maneuvers to find
the path of least resistance. The retriever
189
must not be forced into any path. It must
be remembered that this route must be
volar to the deep transverse metacarpal
ligament. Grasp the radial most slip of the
fascia lata and pull it gently to deliver it in
incision 1. Similarly, the other slips must
be delivered into the respective incisions
2, 3 and 4. Suture incision 8.
11. The distal tendon anastomosis is done
now, by suturing the free end of the fascia
lata 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.
12. First, the index finger is dealt with. The
hand is placed in a position with rolled
up towels of 30° flexion at wrist, 60º
flexion at MCP joints of all fingers and
fingers straight. Now, the free end of the
fascia lata graft slip is pulled gently at
the incision 1 and the movement of the
tendon is assessed. Usually, there will
be about 2 cm of excursion. Suture the
midpoint of this excursion to the portion
of the extensor tendon that has already
been dissected and kept ready. Check
whether this suturing is too tight or lose by
the tenodesis effect and adjust the tension
as necessary.
13. Next, repeat the procedure for the little
finger, suturing the tendons at a point just
distal to the midpoint of the excursion of
the fascia lata. This is to provide slightly
more traction on the little finger to correct
the metacarpal arch reversal to a certain
extent.
14. Now, the suturing must be done on the
middle and ring fingers. Then, all the
incisions 1, 2, 3 and 4 must be closed with
4.0 Ethilon, and the tourniquet released.
15. 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, MCP joints of
fingers in 90º flexion and interphalangeal
(IP) joints of the fingers straight.
190 SECTION 12  INFECTION

• Removal of the POP slab on the 21st day

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
if the procedure was under regional block
co­conut oil
or after complete recovery if under general
• 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
• Discharge of the patient by third day
evaluation.
• Patient to retain the POP slab till the end
of 3 weeks
 Claw Correction—
Fowler Procedure
Introduction
This is a procedure that is ideally suited for
post-traumatic sequelae with injury to the
ulnar nerve.
Presurgical Counseling
• This procedure is planned to correct only the • In some instances, the movement that
clawing of the fingers. This surgery will not
correct the other problems like flattening
of the hand, or wasting of the muscles or
loss of sensation. These problems need
to separate sittings of surgery and cannot
usually be combined with the procedure
planned at present
• This procedure will be done under axillary
block anesthesia
• This procedure will take about 1 hour to
perform
• 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
little fingers to correct the deformity and
also to make the movements of the fingers
more useful. If the index and middle
fingers are also involved, a tendon from
the backside of the index finger will also be
removed and taken to the front side of the
index and mid fingers to make them also
move in a useful direction. There will be
no obvious deficit on the index and little
fingers, but there may be some weakness
of the fingers
44
• Admission will be necessary for a
minimum period of 3 days
• A dressing will be applied and a plaster
of Paris (POP) will be applied, which will
be retained for 3 weeks, following which,
physiotherapy will be started. This should
be continued for a further 3 weeks. During
this period of physiotherapy, exercises will
be taught to make the rerouted tendons
move the fingers
returns on the fingers may be weak and may
not be powerful enough for useful work. In
some other instances, the tendon may not
work at all. This will require another sitting
of surgery to correct the problem
• The general complications of local ane­
sthetic 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. Prepare the hand as described in App­
endix I.
2. Mark the incisions as follows (Fig. 12.44.1):
• Incision “1”, “2”, “3”, “4”—each 3 cm
long on the dorsolateral aspect of the
proximal phalangeal region of the
index, middle, ring and little fingers, on
the ulnar side on the index finger, and
on the radial side on the middle, ring
and little fingers
192 SECTION 12  INFECTION
Fig. 12.44.1  Mark the incisions
• Incision “5”—a longitudinally oriented
lazy “S” incision over the dorsum of the
meta­ carpophalangeal (MCP) joint of
the index finger, extending proximally
from incision 1
• Incision “6”—similar to incision 5, but
on the dorsal aspect of the MCP joint
of the little finger, starting on the radial
side of the little finger
• Incision “7”—two centimeter transverse
incisions on the dorsum of the hand
just distal to the wrist crease, over the
base of II MC.
3. The tourniquet is raised and the incisions
“1”, “2”, “3”, and “4” are made one by one.
The extensor tendon is exposed in the
wounds. The portions of the tendon that
are exposed are the lateral bands and the
central tendon. This can be confirmed by
grasping the selected portion of the tendon
with a tissue forceps and applying traction
proximally. This traction should produce
extension of the proximal interphalangeal
(PIP) and distal interphalangeal (DIP)
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.
5. The incision “6” is made similar to incision
“5”, but over the little finger. The extensor
digiti minimi (EDM) tendon is harvested
just as the EIP was harvested. The EDM
tendon is the more ulnar tendon of the
two extensor tendons to the little finger.
A hemostat is applied over the free end of
the EDM tendon.
6. Now, incision “7” is made, after confirming
the position of the marking by applying
traction on the hemostats holding the
free ends of the EIP and EDM tendons,
and palpating the movement of the
tendons beneath the skin of the marking.
The EIP and EDM tendons are identified
and isolated. They are pulled and this
maneuver delivers the two tendons at
incision “7”.
7. Each tendon is divided longitudinally into
two slips. This is done by holding the two
corners of the free ends with hemostats
and using a number 11 blade to split the
tendon. Remember to keep bathing the
tendon with normal saline while doing
this. Thus, there are now four tendon
slips; two from splitting the EIP and two
from the EDM. The radial and ulnar slips
 CHAPTER 44  CLAW CORRECTION—FOWLER PROCEDURE
from the EIP tendon will be used for the
index and middle fingers respectively.
The radial and ulnar slips from the EDM
tendon will be used for the ring and little
fingers respectively. The splitting should
stop proximally at the site of incision “7”.
Now, incisions “5” and “6” can be closed
with 4.0 Ethilon.
8. Flex the MCP joint of the index finger to
90° and pass the tendon retriever through
incision “1” to exit at incision “7”. While
doing this, the retriever must be advanced
very gently, making probing maneuvers
to find the path of least resistance. The
retriever must not be forced into any
path. It must be remembered that this
route must be volar to the deep transverse
metacarpal ligament. Grasp the radial
most slip of the four tendon slips and
pull it gently to deliver it in incision “1”.
Similarly, the other slips must be delivered
into the respective incisions “2”, “3” and
“4”. Suture incision “8”.
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
hand is placed in a position with rolled
up towels of 30° flexion at wrist, 60º
flexion at MCP joints of all fingers and
fingers straight. Now, the free end of the
fascia lata graft slip is pulled gently at the
incision “1” and the movement of the
tendon is assessed. Usually, there will
be about 2 cm of excursion. Suture the
midpoint of this excursion to the portion
of the extensor tendon that has already
been dissected and kept ready. Check
whether this suturing is too tight or lose by
the tenodesis effect and adjust the tension
as necessary.
11. Next, repeat the procedure for the little
finger, suturing the tendons at a point just
193
distal to the midpoint of the excursion of
the tendon slip of EDM. This is to provide
slightly more traction on the little finger to
correct the metacarpal arch reversal to a
certain extent.
12. Now, the suturing must be done on the
middle and ring fingers. The ulnar slip
of the divided EIP tendon is used for the
middle finger and the radial slip of the
divided EDM is used for the ring finger.
Then all the incisions “1”, “2”, “3” and “4”
must be closed with 4.0 Ethilon, and the
tourniquet released.
13. 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, MCP joints of
fingers in 90º flexion and interphalangeal
(IP) joints of the fingers straight.
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
or after complete recovery if under general
anesthesia
• The POP slabs must not be disturbed at all
• Discharge of the patient by third day
• Patient to retain the POP slab till the end
of 3 weeks
• Removal of the POP slab on the 21st day
and advise the following:
• Refer to physiotherapy for active mobi­
li­zation of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Patient is advised to continue the mobi­
lization of the fingers; both active and
passive and review once every month
for evaluation.
 Tendon Transfer for
Radial Nerve Palsy
Introduction
Tendon transfers for radial nerve palsy are
standard procedures. Understanding the bio­
me­chanics is very important before emban­
king on these transfers.
Presurgical Counseling
• This procedure is planned to correct only
the inability to extend the wrist, fingers and
thumb. This surgery will not correct the
other problems like wasting of the muscles
or loss of sensation. These problems need
to separate sittings of surgery and cannot
usually be combined with the procedure
planned at present
• This procedure will be done under axillary
block anesthesia
• This procedure will take about 1 hour to
perform
• Tendons from the forearm will be removed
and taken to the thumb, wrist and fingers
to make it possible to lift them afterward.
There will be no obvious deficit on the
forearm, but there may be some weakness
• Admission will be necessary for a minimum
period of 3 days
• A dressing will be applied and a plaster
of Paris (POP) will be applied, which will
be retained for 3 weeks, following which,
physiotherapy will be started. This should
be continued for a further 3 weeks. During
45
this period of physiotherapy, exercises
will be taught to make the tendons of the
forearm lift the wrist, fingers and thumb
• In some instances, the movements that
return may be weak and may not be
powerful enough for useful work. In some
other instances, the tendon may not work
at all. This will require another sitting of
surgery to correct the problem
• The general complications of local anes­
thetic 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. Prepare the hand as described in App­
endix I.
2. Mark the incisions as follows (Figs 12.45.1A
and B):
• Incision “A”—a curved incision is
marked 10 cm long on the middle-third
of the forearm on the radial border
• Incision “B”—mark an incision 5 cm
longitudinally on the middle of the
dorsal aspect of the forearm in the distal-
third, extending proximally from the
radial styloid
• Incision “C”—incision “C” is made
transversely on the flexor aspect of the
forearm about 2 cm proximal to the
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
about 8 cm proximal to the wrist crease
• Incision “E”—this incision is a
transverse incision about 2 cm long,
made transversely on the dorsum
of the thumb, just proximal to the
metacarpophalangeal (MCP) joint
• Incision “F”—is 3 cm long and made
longitudinally on the radial border of
the forearm about 3 cm proximal to the
wrist.
3. The tourniquet is raised and first, incision “A”
is made through the skin and subcutaneous
tissues. The pronator teres insertion is
dissected. This is done by identifying the
muscle and then following the fibers distally
till the insertion on the middle-third of the
radius bone. When the tendon of insertion
is identified, an extension is made on the
periosteum for about 3 cm, and then the
tendon is elevated from the bone along with
the periosteal extension. When the tendon
has been raised, make sure that the muscle
is totally free.
skin and subcutaneous tissues and then
open the deep fascia. This will expose the
extensor muscles in the various com­
partments. First the extensor carpi radialis
longus (ECRL) and extensor carpi radialis
brevis (ECRB) tendons are dissected in the
second compartment and isolated.
5. Now, a tendon retriever is passed from this
incision to incision “A” in a plane created
superficial to the brachioradialis muscle.
The end of the pronator teres tendon is
grasped in the retriever and is delivered in
incision “B”.
6. The free end of the pronator teres tendon
along with its periosteal extension is now
sutured to the ECRB tendon. The ECRB
tendon is on the ulnar side of the ECRL
tendon. These two tendons are crossed by
the extensor pollicis longus (EPL) tendon
distally.
7. Adjustment of tension: The wrist is placed
in 45° extension. A point is selected on
the ECRB tendon, which is the distalmost
point on it, where the posterior tibial (PT)
196 SECTION 12  INFECTION
tendon end reaches. The free end of the
PT tendon is pulled maximally and then
released. The amount of excursion of the
tendon is noted. The midpoint of this
excursion range is noted. The PT tendon
is now slightly pulled and the tendon
anastomosis is now done. The technique
of tendon anastomosis is as follows:
• The tendon anastomosis is done by
Pulvertaft weave. Hold the ECRB
tendon taut with a hemostat applied on
the end and pulling proximally
• About 1 cm proximal to the end of the
tendon, make a cut in a volar to dorsal
direction with a number 11 blade, with
just enough length to allow the PT
tendon end through. Pull the tendon
end through. Apply a suture with
3.0 polypropylene using horizontal
mattress sutures
• About 1 cm proximal to the first cut,
make another cut with number 11
blade, from a radial to ulnar direction.
Thread the free end of the PT tendon
end through this opening also and
suture with 3.0 polypropylene using
horizontal mattress sutures.
8. When the tendon anastomosis is over, the
extra length of the PT tendon is trimmed.
9. It must be made that the wrist can be
passively flexed and the tendon anasto­
mosis is not too tight as to prevent it.
10. Now, incision “C” is made and the palmaris
longus (PL) 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
hemostat applied on the cut end.
11. Incision “D” is made after applying traction
on the cut end of the tendon and palpating
the taut tendon under the skin. The tendon
is dissected in this wound.
12. The PL is retrieved through this wound,
and the hemostat reapplied at the cut end.
Moist gauze is placed over the length of
the tendon lying outside.
13. Incision “F” is made. Care must be taken
to avoid injury to the radial artery and the
superficial branch of the radial nerve at
this area. A tendon retriever is passed from
this incision, proximally to the incision “D”,
the end of the PL is grasped and pulled to
be delivered in incision “F”. Moist gauze is
placed around the free end of the tendon.
14. Now, in incision “B”, the EPL tendon is
identified as proximal as possible. This
tendon lies in the third compartment and
can be identified by the extension pro­
duced on the thumb interphalangeal (IP)
joint by traction proximally. The tendon is
divided.
15. Now, incision “E” is made. The EPL tendon
is identified on the dorsal aspect of the
thumb and dissected from the extensor
pollicis brevis (EPB) tendon which lies to
the radial side. Now, traction is applied
and the EPL tendon is delivered into the
incision “E”. The exposed length of the
tendon is covered with saline gauze.
16. From incision “F”, a tendon retriever is
passed through to incision “E” and the
free end of the EPL tendon is grasped and
pulled to be delivered in incision “F” itself.
The incision “E” is closed primarily with 4.0
Ethilon.
17. The tendon anastomosis between the PL
and the EPL tendon is done now in the
site of incision “F”. The tendon anasto­
mosis is done by the Pulveraft weave
as described above. The PL tendon’s
free end is woven into the pro­ximal end
of the EPL tendon after adjusting the
tension. With the wrist maintained at 45°
extensions, a trial stitch is made between
the ends of the PL and the EPL. When
the wrist is gently passively flexed, the
thumb must extend.
18. Now, the incision “C” is explored again
and the tendon of flexor carpi radialis
(FCR) is identified. This tendon is radial
to the PL tendon that has already been
divided. Now, the FCR tendon is divided
as distally as possible.
 CHAPTER 45  TENDON TRANSFER FOR RADIAL NERVE PALSY
19. Through the incision “D”, the FCR tendon
is identified and pulled so that the free
end is delivered in incision “D” itself.
20. In incision “B”, the tendons of the extensor
digitorum are identified and dissected. This
includes the extensor digitorum communis
(EDC) to index, middle, ring, little, the
extensor indicis proprius (EIP) tendon and
the extensor digiti minimi (EDM) tendon. A
tendon retriever is passed from this wound
to the incision “D” around the radial border
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
hemostasis achieved. Except incision “B”,
all the other wounds are closed primarily
with 4.0 Ethilon.
22. Now, the tension adjustment is done.
Each tendon of the extensor to the finger
is pulled to note the movement. The
tendon is now pulled enough to hold the
finger in a position of extension at the
MCP joints (not hyperextension). The
free end of FCR tendon is now woven
through the extensors of the fingers after
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
the fingers is ascertained. After the FCR
passes through each tendon, an anchoring
stitch is made with 3.0 polypropylene. In
this way all the tendons are woven to the
FCR tendon. Now, the tenodesis effect is
checked. On wrist flexion, there must be
hyperextension of the MCP joints of the
fingers.
197
23. Incision “B” is closed primarily with 4.0
Ethilon.
24. Sterile dressings are applied and a volar
POP slab is applied, keeping the wrist in
45° extension, the finger MCP joints in
30° flexion and the IP joints of the fingers
straight. Another POP slab is applied on
the volar aspect of the thumb, holding it in
palmar abduction at the carpometacarpal
(CMC) joint, and extension at the MCP
and IP joints.
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
or after complete recovery if under general
anesthesia
• The POP slabs must not be disturbed at all
• Discharge of the patient by third day
• Patient to retain the POP slab till the end
of 3 weeks
• Removal of the POP slab on the 21st day
and advise the following:
• Refer to physiotherapy for active
mobilization of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Patient is advised to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
 SECTION

13

Congenital Disorders
 Congenital Disorders—
Assessment
Introduction
Dealing with the classification, assessment
and the surgical management of all the con-
genital anomalies is beyond the scope of this
manual. However, the most common condi-
tions will be dealt here, so that the beginner
will be able to do the basic surgical proce-
dures. As it has been stressed earlier, reading
this manual will not be enough knowledge to
perform the surgery straightaway. A thorough
study of the classification, nomenclature and
altered anatomy are essential before surgery
can be attempted.
The following chapters will deal with
six different congenital anomalies seen
commonly:
• Syndactyly
• Radial club hand
• Trigger finger and trigger thumb
• Macrodactyly
• Polydactyly
• Cleft hand.
Congenital anomalies as a whole have some
features that should be assessed. In addition,
each condition has peculiar assessment
criteria, which are also mentioned here.
46
Assessment Criteria—
General
The Details that Must be
Collected are:
• Consanguinity: This is particularly relevant
in our country where marriage between
uncles and nieces and between first cousins
is allowed, and sometimes even encouraged.
• Antenatal history: Any relevant antenatal
history must be obtained like history of
exanthematous fevers, ingestion of drugs,
exposure to radiation and smoking. The
outbreak of phocomelia, a severe congenital
deformity occurring in the babies born
of mothers who had taken the drug
thalidomide, is well known.
• Family history: Congenital anomalies like
syndactyly are known to occur in families.
Assessment Criteria—Specific
These will be dealt with under the specific
conditions.
 Syndactyly
Assessment (Syndactyly)
• Fingers involved: Commonly involves the
middle and ring fingers, but any of the
fingers and any number of fingers may be
involved. This is important especially in
planning the management protocol.
• Whether both upper limbs are involved
• Whether the lower limbs are involved
• Any other congenital anomalies: The
type of syndactyly will be typical if it is
a part of a congenital syndrome. For
example, in apert syndrome, all the
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
particular syndrome.
• Type of the syndactyly (length):
• If the entire length of the fingers is
involved, it denotes complete syndactyly.
• If only part of the length of the finger
is involved, it denotes incomplete
syndactyly.
• Type of syndactyly (involvement of bones):
• If there is no fusion of the skeletal
components between the syndactylized
fingers, it is referred to as simple
syndactyly.
• If there is a fusion of even a part of the
skeleton of the fingers, it is referred to as
complex syndactyly.
• Special types of syndactyly:
• Acrosyndactyly: This is a slightly differ­
ent condition, even though the fingers
47
are in syndactyly. The pathogenesis of
this condition is different, in that, the
fingers have usually developed normal­
ly, but due to some intrauterine prob­
lem, parts of the fingers have got ampu­
tated and have healed in utero.
• Typically, there will be gaps between
the syndactylized fingers that run
through from the palmar to the dorsal
side.
• There will be irregular tips of the
fingers.
• Apert syndrome: The syndactyly of the hand
in this condition has been described above.
Management Schedule
Factors to be considered while planning the
treatment:
• Age of the child: There is no specific age
limit for surgery on syndactyly. It can be
done as early as 6 months also. It is also
important that the surgery should not be
delayed beyond 4 years, when the child
enters school. So, it must be planned in
such a way that all surgery is over for the
hand by the age of 4 years.
• Bilateral involvement: If both hands are
involved, both can be operated on at the
same time; especially if two operating
teams are available. This is to minimize
the period of anesthesia and to reduce the
number of surgical stages. However, if the
patient is an adult (which is sometimes

possible), it is ideal that bilateral syndactyly
is operated on in two stages, because it will
avoid making the patient totally dependent
on others following plaster of Paris (POP)
slabs on both hands.
• Fingers involved: If the thumb or little
fingers are involved, they must be released
first. If the index finger and ring finger are
involved together with the middle finger,
the index finger must be released first. So,
the priority of importance of the fingers
release is as follows:
• Thumb
• Little finger
• Index finger
• Middle finger
• Ring finger.
Principles of planning for syndactyly surgery:
• If the thumb, little or index fingers are
involved, surgery must be done as early as
possible after 6 months age.
• Do not operate on adjacent sides of a finger
at the same time. For example, if there is a
syndactyly between the index, middle and
ring finger, do not release all the fingers at
the same time. Only one can be released,
either the index and middle or the ring
and middle fingers. According to principle
A, the index and middle fingers should be
released first.
• The timing between two stages must be a
minimum of 6 months.
Surgery (Syndactyly)
Presurgical Counseling
• The surgery will be done under general
anesthesia. Both hands will be operated on
at the same time (in children).
• A POP slab will be applied from the elbow
to the fingers after the surgery on the
operated upper limb.
• If necessary, a skin graft will be harvested
from the groin region. There will be a small
scar on the groin region, but there will be
no other deficit.
CHAPTER 47  SYNDACTYLY 203
• Admission will be necessary for a minimum
of 3 days.
• The child can take fluids 4 hours after the
surgery.
• There may be minimal pain in the first post­
operative night. Analgesics and sedatives
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.
• After the POP is removed, splints will be
required for as long as the surgeon feels
necessary.
• In some instances, there may be small
problems, like creeping forward of the web,
contracture of the finger. This will need
surgical correction at a later date.
Surgical Steps
1. After the anesthesia is administered and
patient put in supine position, the hand is
prepared as described in Appendix I.
2. The markings are now made (Figs 13.47.1A
and B):
• The fingers are flexed at the meta­
carpophalangeal (MCP) joints and
the knuckles of the two fingers are
marked. Similarly, the dorsum of the
proximal interphalangeal (PIP) joints
is also marked with a single point in
the midline.
• The midline of the dorsum and the
midline of the volar aspect of the fin­
gers are marked.
• With the markings on the MCP joints
as base, the dorsal flap “D” is marked.
The length of this flap should be two-
thirds of the distance between the
MCP joint and the PIP joint. This flap
should have a lesser length on the side
of the “important finger” (between the
middle and ring, it is the ring finger;
between the middle and index, it is the
index finger). Thus, the advancing edge
of the dorsal flap will be sloping.
• The palmar rectangular flap will be
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
of the involved fingers. There will be a
flexion crease at a particular point. This
is the level of the proximal limb of the
rectangular flap. The rectangular flap
should be based on the “important
finger”. The length of the flap should be
the width of the dorsal flap “D”.
• Now, the dorsal zig-zag incisions
can be marked on the fingers. The
first dorsal triangular flap is marked
based on the “nonimportant finger”.
The flaps should not cross the marked
midline on the dorsum or on the
volar aspect of the fingers. Beyond the
distal interphalangeal (DIP) joints, the
incision becomes straight and ends on
the tip of the finger.
• Draw dotted lines from the tips of the
dorsal flaps backward over the middle
of the flap in a horizontal line to the
point on the volar midline. This is the
point where the tip of the dorsal flap
will reach. At this point, it should be
the apex of the palmar triangular flaps.
• The first palmar triangular flap is
based on the “important finger”. All the
palmar triangular flaps are then drawn
as dictated by the dotted lines.
3. Now, the tourniquet can be raised.
4. The incisions are made in the following
order. First the dorsal flap is raised. This is
raised after making the incisions up to the
skin and subcutaneous tissues and raising
the flap with a layer of subcutaneous fat.
The other dorsal incisions are made and
the respective dorsal triangular flaps
raised in the same plane.
5. Now, the palmar aspect is exposed and
the rectangular flap is raised first. The
other palmar triangular flaps are raised.
6. Now, the soft tissues between the
two fingers are dissected. The digital
neurovascular bundle is identified. There
are usually two bundles, one for each
finger. Occasionally, there may be only
one bundle. This can be allocated for one
of the fingers and the two fingers now
divided. The proximal extent of the division
between the fingers is determined by
the point of division of the proper digital
artery. If the division of the digital nerve
is very distal, it can be separated by gently
teasing the epineurium between the
two digital branches. The viability of the
fingers is ascertained before proceeding
to the next step.
7. The soft tissues can be defatted by excising
the fat globules, while carefully preserving

the neurovascular bundles. This step
helps to reduce the bulk on the finger
and thus ensures a tensionless suturing of
the flaps and avoids complications in the
postoperative period.
8. 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.
9. The suturing of the flaps is now done.
First the dorsal rectangular flap “D” is
sutured to the volar aspect to create the
commissure. Next the palmar rectangular
flap is brought round the side of the
finger and sutured to the skin edge on
the dorsum. All the dorsal and palmar
triangular flaps are thus sutured using 4.0
vicryl. There will be one or two small areas
without skin cover. A full thickness skin
graft should be harvested from the lateral
end of the groin crease and applied over
the raw areas. Anchoring of the skin graft
is done with 4.0 vicryl.
10. The hand and fingers are cleaned
thoroughly and nonadherent dressings
CHAPTER 47  SYNDACTYLY 205
applied. Fluffy gauze pieces are applied
between the fingers and sterile dressings
applied. An above elbow POP slab is
applied.
Postoperative Protocol
• Admission in the ward.
• The affected hand should be kept elevated.
• Patient can take normal diet after complete
recovery if under general anesthesia.
• Discharge of the patient by third day.
• Inspection of the suture line after 10
days only. If necessary, a short general
anesthesia may be required if the child is
very anxious. Suture removal can be done
on the same day. The POP slab can also be
removed. The following are advised:
• Refer to physiotherapy for active
mobiliz­ation of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Patient is advised to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
 Cleft Hand
Assessment (Cleft Hand)
In addition to the general assessment criteria
outlined in the earlier chapter, there are
certain criteria to be assessed specifically in
a cleft hand. The first assessment is to analyze
the type of cleft.
Typical Cleft
There is no middle finger ray. So, the index
and thumb fingers stay on the radial side and
the ring and little fingers are on the ulnar
side.
48
• Web contracture between the thumb and
index fingers
• Syndactyly between the ring and little
fingers
• Sometimes defect of middle finger ray
• Sometimes defect of index finger ray
• Sometimes even the thumb is absent.
There are certain bony deformities that
may be seen:
• Loss of one metacarpal—usual
• Bifid metacarpal—supporting two fingers
• Two metacarpals—supporting one finger
• Sometimes transverse orientation of meta-
carpal is seen.

Atypical Cleft Functional Problems

There is absence of more than one ray.
There are certain characteristics to help
and differentiate between the two types of
cleft (Table 13.48.1).
Features to look for that indicate the
severity of the problem:
• Deficiency of middle finger ray
There are usually not many functional
problems; this condition is more of a cosmetic
problem. Surgery may be indicated only in
certain situations.
Management Protocol
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
Presurgical Counseling
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.
• Admission will be necessary for a
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.
208 SECTION 13  CONGENITAL DISORDERS

• 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
Contracture of Thumb
and Closure of the Cleft
(Method of Littler)
Presurgical Counseling
• The surgery will be done under general
anesthesia. Both hands can be operated
on at the same time (in children).
• This surgery is only to separate the thumb
and index fingers and also to bring the
two deviated fingers together. Hence,
this surgery is mainly for the cosmetic
correction of the deformity. There is some
chance that the already present function
may be compromised to some extent in
the beginning due to the scars of surgery.
If there are already some other deformities
like contracture of fingers or syndactyly of
fingers, they will be dealt with at a different
stage.
• There may be need for skin grafting to
cover some raw areas. If so, the graft
will be harvested from the thigh, and a
dressing applied over this area, which will
heal spontaneously in a period of about 2
weeks. Sometimes, if the requirement of
graft is small, the graft will be taken from
the groin crease, and in this situation, the
wound will be closed leading to a scar that
will settle in the groin crease line.
• A 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.
• Admission will be necessary for a
minimum 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.
CHAPTER 48  CLEFT HAND 209
• After the POP is removed, splints will be
required for as long as the surgeon feels
necessary.
• In some instances, there may be small
problems, like creeping forward of the
web, contracture of the finger. This will
need surgical correction at a later date.
Surgical Steps
• This surgery is usually done under general
anesthesia.
• The hand is first prepared as described in
Appendix I.
• The markings are made now (Figs 13.48.3A
and B).
• Mark the mid-dorsal line, neutral line and
the mid-volar line on the index finger and
the ring fingers. The neutral line will travel
on the margins of the cleft. Now, mark a
point at the junction of the proximal third
and middle third of the proximal phalanx
region on the neutral line on the ulnar side
of the index finger (A) and the radial side of
the ring finger (B). Mark another point “C”
about 1 cm proximal to the edge of the cleft
on the dorsum of the hand.
• Join the points AC and BC, running
between the mid-dorsal line and the
neutral lines of the corresponding fingers.
• At the point A, make a longitudinal incision
distally along the neutral line up to the
middle of the proximal phalanx. Similarly
on the ring finger, mark a distally based
flap YBZ of sides measuring equal to the
distance AX.
• On the volar aspect, mark a line from the
point “A” that travels in between the mid-
volar line and the neutral line of the index
finger up to a point “D” that does not
extend beyond the volar apex of the cleft.
Similarly draw another line from the point
“B” that travels between the mid-volar line
of the ring finger and its neutral line to a
point “E” that extends slightly beyond the
volar apex of the cleft.
210 SECTION 13  CONGENITAL DISORDERS
A B
Figs 13.48.3A and B  Marking of the incisions
The blood supply of this flap is from the skin
bridge formed by DE. Hence, it is safer to make the
lines AD and BE diverging slightly rather than run
strictly parallel.
• Now, a marking is made to release the
thumb web. Mark the point “G” where
the index finger and the thumb meet at
the web. From this point, a line is marked
extending proximally on the dorsal aspect
of the hand up to the point “H” at the
junction between the bases of the first and
second metacarpal bones. Now, a marking
is made on the volar aspect from the point
“G” to a point “J” on the midpoint of the
already marked line AD. This creates a
triangular flap of skin on the volar aspect
of the index finger.
• The tourniquet is raised up to 200 mm Hg
and the incisions are made down through
the skin and subcutaneous tissues in the
space between the index and ring fingers.
The flap is raised carefully, taking care to
avoid injury to the neurovascular bundles
of the index and ring fingers. In this way,
the flap DCE is based only on the volar
skin and soft tissues and this flap of skin is
being planned to resurface thumb web that
is going to be created. Sometimes the third
metacarpal bone may be present, either
fully, or as a stump. It is ideal to remove
the metacarpal at the base, so that the
index metacarpal can be transposed onto
this stump while reconstructing the finger.
Any remnants of abnormal bone, either
bifid metacarpal or double metacarpal or
transversely oriented bone is also dealt
with now.
• Now, the incisions GH and GJ are made
through skin and subcutaneous tissues.
As the incision is deepened, care must be
taken to avoid injury to the neurovascular
bundles on the thumb and index fingers.
The adductor pollicis muscle comes into
view on the volar side of the wound now.
This must be erased from the second
metacarpal to get a good release. The
first dorsal interosseous muscle also
must be divided near the base of the first
metacarpal. Care must be taken at this
dissection to avoid injuring the radial
artery that passes between the two heads
of the adductors. These steps alone may
not achieve a good thumb web, as the
index metacarpal may still be tilted toward
the thumb.
• At this point, the index finger is held only by
the metacarpal, long flexors and extensors
and neurovascular bundles. The base of the

second metacarpal can be osteotomized
to free the index finger, so that it can be
moved radially over the stump of the third
metacarpal bone. It can be fixed at its new
position with short K-wires.
• When the finger is shifted in this way,
there is a high chance that it scissors with
the ring finger. Hence, it is necessary while
fixing the second metacarpal, to rotate it
slightly to face the volar aspect.
• This alone may not be necessary to
retain the position of the index finger in
alignment with the ring finger. 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 polypropylene. This is
done to replace the transverse metacarpal
ligament and bring the two fingers together.
• The flap DCE is now transposed to the
newly created thumb web. 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.
A B
Figs 13.48.4A and B  Suturing of the skin flaps
CHAPTER 48  CLEFT HAND 211
• The flap DCE is now sutured with 4.0
polyamide suture. This flap may not be
adequate to cover the entire raw area in the
thumb web, but it is important to resurface
the raw area adjacent to the thumb to
ensure that the web does not undergo any
contracture. The raw area if any on the
radial side of the index finger side can be
covered with a full thickness graft from the
groin, or a thick split thickness graft from
the thigh.
• The wound is now sutured with 4.0
polyamide on the space between the index
finger and the ring finger (Figs 13.48.4A and
B). The commissural flap YBZ is sutured to
the defect created by the incision AX, to
form a healthy finger commissure.
• Drainage tubes are kept at strategic
positions.
• The hand and fingers are cleaned thor-
oughly 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.
212 SECTION 13  CONGENITAL DISORDERS
Postoperative Protocol
• Admission in the ward.
• The affected hand should be kept elevated.
• Patient can take normal diet after complete
recovery if under general anesthesia.
• Discharge of the patient by third day.
• Inspection of the suture line after 10
days only. If necessary, a short general
anesthesia may be required if the child is
very anxious. Suture removal can be done
on the same day. The POP slab needs to be
retained for another 2 weeks.
• After a further 2 weeks, the POP is removed.
The following are advised:
• Refer to physiotherapy for active mobi­
lization of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• A splint must be applied to maintain the
index and ring fingers in approximated
position and a static thumb web spacer
must be incorporated in the splint.
This splint must be maintained for a
minimum of a further 3 weeks.
• Child is encouraged to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
 Trigger Thumb Release
Introduction
One of the most common congenital con-
ditions affecting the hand is the congenital
trigger thumb. This may be commonly a bilat-
eral condition. The treatment of this affliction
consists of surgical release. The release of this
trigger thumb should be done as early as pos-
sible to preserve the function of the thumb.
Surgical Steps
• Bilateral release of the trigger thumb can
be done simultaneously. The preferred
anesthesia is general anesthesia, or sedation
with infiltration of local anesthetic solution.
The combination of local anesthesia and
sedation is preferred, but done when the
patient is a little older and can cooperate for
the procedure.
• The affected hand is painted and prepared
as in Appendix I. If surgery is planned on
both hands, both hands are prepared and
draped and kept ready.
• The tourniquet is raised up to 200 mm Hg.
• The volar aspect of the thumb is palpated.
There will be a nodular swelling at the level
of the metacarpophalangeal (MCP) joint.
A transverse incision is marked at the level
of the volar MCP crease of the thumb,
measuring about 1.0 cm in length. The
incision need not go from one neutral line
to the other.
49
• Make the incision on the marking with a
No. 15 blade. The incision must be made
very gently and should be superficial.
This is because the digital nerves are very
superficial in this condition and may be
injured by an inadvertent deep incision.
Once the incision goes through the skin to
the underlying fat, skin hooks are applied
to both edges and the skin edges lifted up.
• Dissection is now done in a longitudinal
direction on either side of the flexor
tendon sheath which runs in the mid-volar
line. This dissection aims at mobilizing
both neurovascular bundles the lie on
both sides of the flexor tendon sheath and
run parallel to it. Once they are dissected,
they can be retracted to either side, so that
they can be prevented from getting
injured during the surgery on the tendon
sheath.
• Now, the tendon sheath has been dissected
free from the neurovascular bundles.
Palpate the sheath and find the nodular
swelling at the level of the A1 pulley.
• Make an incision with a No. 15 blade
on one side of the tendon sheath. This
incision must also be made carefully as
the tendon of flexor pollicis longus (FPL)
lies immediately below the sheath and
should not be injured. The incision must
be extended both proximally and distally
as far as possible. When this incision is
completed, the roof of the tendon sheath
can be opened out like a book, exposing
the FPL tendon underneath.
214 SECTION 13  CONGENITAL DISORDERS
• Now, with the tendon sheath opened out,
make the second incision on the sheath,
parallel to the first. This incision is made
on the other side of the tendon. When
this incision is completed, the roof of the
tendon sheath at the A1 pulley will be
totally excised.
• Now, the tightness at the interphalangeal
(IP) joint will have been released. Check
the free and full passive range of flexion
and extension at the IP joint. If there is an
obstruction to the full range, excise more
of the pulley either proximally or distally as
outlined in steps.
• Release the tourniquet, secure hemostasis.
Wound suturing can be done with
absorbable suture material. Sterile dressings
are applied only to the thumb base. There is
no need for immobilization.
• If the other thumb is also involved, the
surgery can be done in a similar fashion on
that side.
Postoperative Protocol
• The child is reviewed after 48 hours and
the suture line inspected. Dressings are
reapplied. Gentle passive mobilization of the
IP joint by the parent/grandparent is advised
when the child is asleep. Active movements
of the thumb are also encouraged.
• At the end of 10 days, the dressing is
discarded.
• Wash with soap and water is advised.
• Scar massage is advised with coconut oil.
 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.
216 SECTION 13  CONGENITAL DISORDERS

• 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.
• Admission will be necessary for a minimum
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.
• After the POP is removed, splints will be
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.

Postoperative Protocol
• 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
218 SECTION 13  CONGENITAL DISORDERS
Suture removal can be done on the same day.
The POP slab needs to be retained for 3 weeks.
• At the end of 3 weeks, the POP is removed.
If any K-wires have been applied, they are
removed now. The following are advised:
• Refer to physiotherapy for active mobi­
liz­ation of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• A compression garment must be applied
to the operated fingers and maintained
for a minimum of 3 months.
• Child is encouraged to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
 Hypoplastic Thumb—
Pollicization
Assessment
(Hypoplastic Thumb)
Hypoplasia of the thumb can occur in varying
degrees (Fig. 13.51.1).
• Grade I: Normal thumb, but smaller in size
• Grade II: Smaller than normal, weakness
of the thenar muscles may be present
• Grade III: Short thumb with complete
absence of thenar muscles
• Grade IV: Floating thumb—only a nubbin
is present
• Grade V: Absent thumb.
Fig. 13.51.1  Grades of hypoplasia thumb
51
In Grade I hypoplasia, no treatment is essential.
In Grade II, the individual case must
be examined carefully to evaluate the
function of the muscles moving the thumb.
Appropriate tendon transfers will improve
the function. In some neglected cases, the
thumb web may be contracted. This must be
addressed first, before any tendon surgery is
planned.
In Grade III hypoplasia, the existing
thumb may be too small to be able to do the
normal work of the thumb even after tendon
transfers. The option of pollicization may be
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
Presurgical Counseling
• This procedure will be done under general
or spinal anesthesia.
• This procedure will take about 2 hours to
perform.
220 SECTION 13  CONGENITAL DISORDERS
• This procedure is being done to transfer Surgical Steps
the existing index finger to the position of
thumb.
• If there is already a small thumb that is
present, it may have to be sacrificed so
that the new thumb can function well.
The transferred index finger will not look
exactly like the thumb, but it will have a
length almost equal to a normal thumb.
• Admission will be necessary for a minimum
period of 1 week.
• Postoperatively, the affected upper limb will
be immobilized in a plaster of Paris (POP)
slab and movements will be prevented.
• The result of this surgery will become
obvious only after a few months of
physiotherapy to train the transferred
index finger to work like a thumb.
• There may be some deficit in the working
of the thumb, in which case minor surgical
procedures may be required later.
• During the period of physiotherapy, splints
may have to be applied as considered
appropriate by the surgeon/physiatrist.
• The general complications of general
anesthesia can occur.
A B
Figs 13.51.2A and B  Markings for pollicization on dorsal and palmar aspects
For ease of understanding, this procedure has
been divided into two stages:
1. Steps of finger dissection.
2. Steps of musculoskeletal stabilization.
Steps of Finger Dissection
• First the hand is prepared as described in
Appendix I.
• Marking the incisions (Figs 13.51.2A and B).
• Planning of the incisions is paramount.
• Dorsal side: First mark a point “X” on the
knuckle of the index finger. Mark another
point “Y” on the dorsum of the finger over
the proximal interphalangeal (PIP) joint.
Join these two points. From point “X” draw
two lines: (1) on the ulnar side to the web
space between the index and middle finger
and (2) on the radial side to the radial
aspect of the metacarpophalangeal (MCP)
joint of the index finger. Mark these points
as “E” and “F” respectively.
• Palmar side: Mark the midpoint of the
volar MCP joint crease on the index finger
as “B”. Mark another point “A” on the palm
 CHAPTER 51  HYPOPLASTIC THUMB—POLLICIZATION 221

at approximately the site of the base of the
second metacarpal bone. Join these two
points “A” and “B” with a gentle “S”-shaped
curve. The proximal curve must have an
ulnar facing convexity and the distal curve
must have a radial facing convexity.
• Now, the tourniquet can be raised and the
surgery started.
• Dorsal flaps: Make the incisions as
planned on the dorsal aspect and raise the
two dorsal flaps “G” and “H”. These flaps
are raised in a subdermal plane, avoiding
injury to the underlying subcutaneous
veins.
• Veins: Free the veins from the skin, at
least two of them. Dissect the veins to as
proximal as possible. The further dissection
can be done when the final incisions are
made on the dorsum at a later stage in the
procedure. It is important to dissect the
dorsal nerves also along with the veins.
• Extensors: Under the subcutaneous veins
is the extensor system of the finger. It is
formed by four structures: (1) the extensor
indicis proprius (EIP) and the extensor
digitorum to the index finger, (2) on the
radial side the insertion of the first dorsal
interosseous, (3) the lumbrical and (4)
on the ulnar side the insertion of the
palmar interosseous. Divide the extensor
digitorum communis (EDC) tendon.
Divide the remaining extensor mechanism
into three, i.e. separate the lateral bands
of the dorsal aponeurosis from the central
band (Figs 13.51.3A and B). The division of
the lateral bands must be done about 1 cm
distal to the musculotendinous junction
of the first dorsal interosseous and the
palmar interosseous respectively.
Now, the dissection proceeds to the
palmar side. Incisions are made as shown in
Figures 13.51.2A and B.
• Neurovascular pedicle: By gentle dissection,
the digital neurovascular bundles are
identified and mobilized. The radial side
digital artery is used. The branch to the
middle finger is ligated and the vessels
mobilized. The vessels must be visualized

A B

Figs 13.51.3A and B  Dividing the radial and ulnar lateral bands
222 SECTION 13  CONGENITAL DISORDERS

fully before the next step is taken as there
may be anatomical anomalies which should
be identified and considered.
• There may be a common digital artery
between index and mid finger. Along with
the vessels, it is important to dissect the
digital nerves too.
• Flexor tendons and interossei: The flexor
tendons must be mobilized fully in the
palm. The flexor sheath must be released
from proximally, up to the base of the
proximal phalanx (PPX) bone. Dissect the
flexor tendons and the A1 and proximal
part of A2 pulley. Divide A1 and A2 pulleys,
so that A3 will become the A1 pulley of the
newly created thumb.
• The palmar and dorsal interossei tendons
must be elevated subperiosteally from
the metacarpal shaft, taking care to
preserve the neurovascular supply. Divide
lumbrical at its insertion into radial slip of
the dorsal aponeurosis.
• Elevate the first dorsal interosseous
(FDI) muscle along with its innervation.
The muscle dissected proximally up to the
base of second metacarpal.
• 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
• Dorsal veins
• Dorsal nerves.
Steps of Musculoskeletal Stabilization
• Step of skeletal readjustment
• Position
• The head of the metacarpal is now
fixed in the position of the thumb (Fig.
13.51.4). This can be done by attaching
the head of the second metacarpal bone
to a point just palmar to the stump of
the second metacarpal bone. It must
be kept in rotation of the digit at about
140°. The new “trapezium” has been
positioned now. But before fixing it,
another point must be considered. The
normal MCP joint of the index finger has
got some hyperextension movements.
This is not required when this joint
becomes the carpometacarpal (CMC)
joint of the thumb. Hence, to counteract
this hyperextension nature, the head of
the metacarpal is flexed and fixed in its
position. The fixation can be done with
a suture of 4.0 ethilon.
• Step of muscular realignment (Fig.
13.51.5).
• Now that the new thumb has been
positioned and fixed, the muscular
Fig. 13.51.4  Positioning the new carpometacarpal
joint of thumb
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.
224 SECTION 13  CONGENITAL DISORDERS
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.
Postoperative Protocol
• Admission in the ward.
• The affected hand should be kept elevated.
• Patient can take normal diet after complete
recovery if under general anesthesia.
• Discharge of the patient by third day.
• Inspection of the suture line after 10
days only. If necessary, a short general
anesthesia may be required if the child is
very anxious. Suture removal can be done
on the same day. The POP slab needs to be
retained for another 2 weeks.
• After a further 2 weeks, the POP is removed.
The following are advised:
• Refer to physiotherapy for active mobi­
lization of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• A splint must be applied to maintain the
index and ring fingers in approximated
position and a static thumb web spacer
must be incorporated in the splint.
This splint must be maintained for a
minimum of a further 3 weeks.
• Child is encouraged to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
 SECTION

14

Common
Clinical Conditions
 Contractures on the
Upper Limb—Assessment
Introduction
Contractures on the upper limb occurring as
sequelae to either trauma, burns or congenital
conditions form a major chunk of patients
attending the hand surgery outpatient
department in a developing country like
India. Planning a treatment schedule for such
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
are dealt in other sections.
When a patient presents with a contracture
in any part of the upper limb, evaluation and
planning the management is done based on
various factors. The first criteria are the site of
the contracture.
Examination of the
Contracture
When there is a contracture on the upper
limb, examination must show:
• Part involved
• Associated contractures
• Longitudinal extent of the contracture
• Quality of the skin over the contracture
and the surrounding segment
• Nature of the scar—whether soft or
hypertrophic, hyperemic
• Presence of any sinuses, ulcers
52
• Description of the attitude, position of the
joints
• Active and passive movements of the joints
• Assessment of the apparent defect and the
true defect.
In addition to the generalized examination
steps outlined above, there may be certain
criteria unique to some contractures, which
will be described in the particular sections.
Contracture of the Finger
Additional Examination Criteria
• Involvement of the web spaces
• Involvement of the nail complex
Thumb
A thumb contracture must also be evaluated
in the same way with a few points to be
emphasized:
• Any associated thumb web contracture
and measurement of thumb web angle
• Any associated bony problems.
Palm
Palmar contractures rarely occur alone,
except in the rare condition called camphor
burn, which is unique to our part of the
country (India). Here, there is an isolated
contracture on the palm, which may or may
not cause a secondary contracture of the
fingers.
228 SECTION 14  COMMON CLINICAL CONDITIONS
The most important evaluation in a case
of palmar contracture in the common criteria
discussed above (points 1–8) is the estimation
of the true defect.
Dorsum
Contractures on the dorsum of the hand very
frequently involve the fingers and the thumb.
Evaluation must proceed in the manner
described above. In this site, assessment of
the scar is very important, as it will decide
the involvement of the underlying extensor
tendons.
Wrist
The wrist contractures usually have under­
lying joint problems that must be corrected
when the surgery is done. Hence, the evalu­
ation of a wrist contracture must concentrate
on the passive and active range of movements
at the joint.
Elbow
Evaluation of elbow contractures is like the
general evaluation of any contracture on the
upper limb. Emphasis will have to be laid
on assessing the quality of the normal skin
around the contracture. This is because this
skin can be used in reconstruction, when the
contracture is released.
Axilla
Axillary contractures must be evaluated as
critically as possible. This is because the release
of the contracture must be planned based on
the clinical evaluation. The examination of the
scar will show whether the contracture is by
bands of skin on the anterior axillary fold, or
posterior axillary fold or involves the both folds
of skin, and whether the axillary dome is intact.
General Examination
• Other contractures—neck, lower limbs,
bilateral:
• If neck contracture is also present, the
management of the neck contracture
gains precedence over the management
of the other contractures. This is mainly
for purposes of anesthesia, which may
be difficult in the presence of a neck
contracture.
• If lower limb contractures are present,
these also are more important than
upper limb contractures, because with
lower limb contractures, the patient
may not be able to walk normally.
• It is also important to note if there is
a contracture on the opposite upper
limb also, and the nature of this
contracture.
• Other scars: Other parts of the body should
be examined for presence of scars. This is
important for two reasons:
• Skin cannot be used from the scarred
site when the contracture is released
on the upper limb. For example, a thick
hypertrophic scar on the abdomen may
preclude the use of abdominal flap for
resurfacing the defect after contracture
release.
• This scar also may have to be treated
when the surgery is being done for the
upper limb contracture.
Factors Affecting the
Surgical Management
Age
In younger age group, the points to be
remembered are:
• Skeletal growth is not complete, hence, a
contracture when it is released, should be
resurfaced with good skin that can grow
with the affected part. Hence, the plan
should be more for a flap cover than skin
grafting.
• Even bilateral contractures can be released
at the same sitting, since the patient will
anyway be dependent on the guardian or
parent.
 CHAPTER 52  CONTRACTURES ON THE UPPER LIMB—ASSESSMENT 229

• In planning a major surgery for a child, the
probable blood loss should be estimated
beforehand to avoid complications.
Associated Neck Contracture
If there is an associated neck contracture, this
should be released at the first stage. No limb
surgery should be done at the time of neck
contracture release if it is felt that the blood
loss may exceed the permissible levels or
patient compliance may not be good.
Bilateral Upper Limb Contracture
Usually not released at the same sitting as
this may make the patient totally dependent
on his attender and this may prove difficult,
especially for adult patients.
Contractures on Two Sites of the
Same Upper Limb
When there are two or more contractures on
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
Finger—single
*Finger—single
Finger—multiple
*Finger—multiple
*Thumb
Thumb web contracture
*Thumb web contracture
Palm contracture
*Dorsal contracture
*Dorsal contracture
*Dorsal contracture with
thumb web contracture
*Volar wrist contracture
*Dorsal wrist contracture
Elbow contracture
Axilla contracture
Axilla contracture
Qualifying criteria
Skin band contracture
Scar
Skin band contractures
Scar
Scar
Supple skin in web
Scarred skin
Scarred skin
Scarred skin with mobile metacarpo-
phalangeal (MCP) joints of fingers
Scarred skin with fixed/subluxated
MCP joints of fingers
Scarred skin with fixed/subluxated
MCP joints of fingers
Skin band contracture
Scarred skin
Plan of surgery
Z-plasty
Release and cross finger flap
Z-plasty
Release and superiorly based
abdominal flap cover
Release and inferiorly based
abdominal flap cover
Five flap release
Square flap
Release and groin flap cover
Release and superiorly based
abdominal flap cover/pedicled
radial artery flap cover
Release and skin grafting
Release and inferiorly based
abdominal flap cover
Release and groin flap cover
Release and superiorly based
abdominal flap cover
Release and inferiorly based
abdominal flap cover
Release and skin grafting
Z-plasty
Release and skin grafting

* Indicates that adjuvant techniques will be required like:

230 SECTION 14  COMMON CLINICAL CONDITIONS
released together because of the blood loss
that may occur. In such situations, the release
of contractures will have to be done one after
the other.
Priority of Contracture Release
Proximal contractures should be released
first. When the resurfaced skin—whether
graft or flap, has settled well, and the full
range of movements has been achieved at the
released joint, the surgery of the next distal
joint is undertaken.
Cause of the Contracture
If the contracture has been caused by flame
burns, release of the skin contracture may
suffice to achieve good function. However,
if the contracture has been caused by
trauma, or a congenital condition like flexion
contracture, just release of the skin and
resurfacing with skin tissue may not suffice,
and good function may not be achieved
without management of any underlying
problem like tendon contracture.
Protocols for Resurfacing after
Contracture Release on the
Upper Limb
There are generalized protocols for resurfacing
defects after contracture release. These pro­
tocols are not absolute and the surgery can
be tailored to the needs of the patient (Table
14.52.1).
• Bone surgery: Arthrodesis of the inter­
phalangeal joint of the thumb in severe
contractures.
• Joint surgery: Release of the subluxated/
ankylosed joint may be required in
conditions like contracture release of the
PIP joint or MCP joint of the finger.
• Fixation with K-wire: This may be required
in conditions like release of a wrist
contracture.
• Muscle release surgery: It will be required in
conditions like thumb web release, where
the contracted and fibrosed adductor
muscles should be released along with the
skin release.
 Contractures on the
Upper Limb—Management
Introduction
This segment on operative surgery will deal
with the following surgical procedures only,
since the other procedures mentioned have
already been discussed in other chapters.
• Release of contracture
• Z-plasty
• Square flap method of thumb contracture
release
• Five flap method of thumb web release.
Release of Contracture
The most important things to remember
when a burn contracture is being released are
the following points:
• Complete release of the contracture must
be aimed at and should be the primary
goal. Hence, return of function is prime.
• Excision of surrounding scar is a secondary
consideration and should be contemplated
only if total release of contracture has been
achieved and excision of further scar will
not compromise the hemodynamic status
of the patient.
• Even if the primary plan is a contracture
release and skin grafting, the surgeon must
be prepared for a situation where there is
an exposure of tendon or bone and a flap
cover becomes mandatory.
The basic procedure for the release of a
contracture is the same and the finer details
are described here.
53
Surgical Steps
• First prepare the hand and the upper limb
as described in the Appendix I.
• Marking the incisions:
• The release incision should be marked
on the contracture, in a transverse
direction from one neutral line to the
other. This pattern of release will reduce
the chances of a recontracture.
• At both ends of the marked incision,
fish tailing incisions should be marked.
These are “V”-shaped cuts extending
medially and laterally from both ends
of the incision. The length of these cuts
depends on the amount of contracture
release and can be extended, if release
is not fully achieved.
• If the scar is hypertrophic, like the
dorsum of the hand and the elbow,
tumescent solution can be injected
under the scar in the plane between the
normal tissues and the scar, to help in
dissection (hydrodissection).
• If the contracture is in areas like the
axilla, where a tourniquet cannot be
applied during the surgery, tumescent
solution can be injected under the scar,
to control the bleeding at surgery, due to
the effect of the adrenaline component.
• The tourniquet should be raised and the
surgery started.
• The skin incision should be made through
the entire thickness of the scar, down to
the subcutaneous tissue. Care should be
exercised when incising thick, hypertrophic
232 SECTION 14  COMMON CLINICAL CONDITIONS
scars, as the force required to go through
the scar may be high, and the subcutaneous
tissues may be injured in the sudden
release.
• Once the subcutaneous tissue is reached,
it can be identified by the presence of
subcutaneous veins (especially in the
elbow and wrist and dorsum of hand).
On the fingers, these veins may not be
prominent, but the yielding of the skin
edges after incision, will indicate that the
subcutaneous plane has been reached.
• Fibrous bands may sometimes be seen in
the subcutaneous tissues. These should be
incised totally or excised to achieve a full
release.
• To aid in the release, the fish tail incisions
as described above can be extended
carefully.
• Full release may not be obtained in the
following situations:
• If there is a subluxation of the joint and
a contracture of the capsule—here, the
capsule of the joint should be released
and the joint fixed with K-wires as
necessary.
• If there is a bony block or ankylosed
joint, it should be osteotomized,
the contracture released and formal
arthrodesis of the joint should be done.
• If there is a tendon contracture, like
in the case of longstanding elbow
contracture, where the biceps tendon
gets contracted, total release may not
be possible. In this situation, either the
tendon can be lengthened by Z-plasty
or the residual contracture can be
accepted and dealt with later by wedging
techniques.
• Sometimes there may be a total release,
but the joint may be springing back to
the contracted position, like in the case of
release of a contracture on the wrist. Thus,
the released joint should be maintained
in neutral position by means of a K-wire
passed either obliquely or longitudinally.
• Once the release is complete, the bed of
the raw area must be examined. If there is
any area of exposed tendon or bone, a flap
cover must be given as per the protocol
described above. If there is no exposure
of tendon, a skin graft can be planned to
resurface the raw area.
• Apply wet gauze on the raw area. 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.
• Now set the hand on the table. Assess
the viability of the tip of the finger. It
may take a few minutes for the tip of the
finger to become pink. This is because of
the fact that the vessels which were in a
shortened length in the contracted finger
are now stretched with the release of the
contracture, and may hence go into spasm.
If this occurs, apply xylocaine soaked gauze
pieces over the vessels and wait for the
spasm to be relieved. If the tip of the finger
is still pale, remove any K-wires that have
been applied. Wait for the viability of the
tip of the finger to be confirmed and then
secure hemostasis. Apply a wet pad over
the raw area and prepare for the skin cover
(whether skin graft or flap).
• The method of harvesting a skin graft has
been described in Appendix VI. If a skin
flap is planned, the flap may be raised as
described in the relevant section.
Z-plasty
This procedure is done when there is no scar
over the contracted area, but contracture
bands. These bands have skin on their sides
which can be redistributed to cover the area
when the contracture is released. In executing
a Z-plasty, planning is very important.
This procedure is ideal for contracture
release of contracture bands on the fingers and
axilla, where the joints are soft and supple.
Surgical Steps
• Prepare the hand as described in
Appendix I.
 CHAPTER 53  CONTRACTURES ON THE UPPER LIMB—MANAGEMENT
• Markings for the procedure (Figs 14.53.1A
and B):
• Mark the ends of the contracture band
as points “A” and “B”. Draw the line AB.
This line will run on the summit of the
contracture band.
• The contracture band will have two
surfaces. From point “A”, draw a line at an
angle of 60° to line AB on one of the sides
of the contracture band. This line should
not cross the neutral line of the part. This
means that this line should not cross the
neutral line of the finger in a contracture
of the finger and should not extend
beyond the walls of the contracture band
in the case of an axillary contracture.
Mark the point where this line cuts the
neutral line as “C”. Measure the length of
line AC.
• Mark the length of AC on the line AB
measured from the point “A”. Mark
this point on the line AB as “D”. From
the point “D”, draw a line at an angle
of 60º to line AB on the other side of
the contracture band. This line, again,
should not cross the neutral line of the
part.
• Thus, one Z-plasty has been designed.
Thus, further flaps should be marked so
that the entire contracture band AB is
covered. Sometimes, it is possible that
a single Z-plasty will cover the entire
length AB.
A B
Figs 14.53.1A and B  Marking the contracture release with Z-plasty on the finger
233
• The tourniquet should be raised and the
incisions made. First the summit of the
band, i.e. AB should be incised. Then, the
incisions should be made on the sides of
the contracture band.
• Using skin hooks to hold up the tips of
the flaps, they should be raised in the
subcutaneous plane. When this is done
on the finger care should be taken to avoid
injury to the neurovascular bundles of the
fingers.
• When the flaps are raised, apply wet
gauze on the finger. 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.
• Now set the hand on the table. Assess
the viability of the tips of the flaps. It may
take a few minutes for the tips of the flaps
to become pink. Transpose the flaps to
achieve the lengthening of the contracture
band. If some confusion exists as to which
flap goes where, just stretch the finger and
the flaps will fall in place.
• Suture the tips of the flaps with 4.0 ethilon
using the corner stitch (half-buried
horizontal mattress). Suture the edges of the
flap with 4.0 ethilon using simple sutures.
• Apply a paraffin gauze and sterile dressings.
In case of axillary contracture release
with Z-plasty, it is not necessary to apply
a plaster of Paris (POP). In case of finger
234 SECTION 14  COMMON CLINICAL CONDITIONS
contracture release, a volar POP slab
should be applied for the hand keeping
the metacarpophalangeal (MCP) joints of
the fingers in flexion of 90° and IP joints in
extension.
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
or after complete recovery if under general
anesthesia.
• Analgesics and antibiotics for 5 days.
• Sedation optimization strategy (SOS) for
1 day.
• Inspection of the dressing after 48 hours.
• Discharge of the patient by third day.
• Suture removal on the 10th day and
removal of the POP slab and advice the
following:
• Refer to physiotherapy for active and
passive mobilization of the fingers
during the day
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Straightening splints to the affected
finger/fingers to be worn at night for a
period of 3 weeks.
A B
Figs 14.53.2A and B  Marking the flaps
• Compression garment for scar softening
after a further 2 weeks.
Square Flap Method
This procedure is a preferred technique when
a release of a contracture is required in the
upper limb, especially a contracture of the
thumb web or axilla. The requirement for this
procedure to be done is a good quality skin on
either side of the contracture.
Surgical Steps
• Prepare the hand as described in
Appendix I.
• Markings for the procedure (Figs 14.53.2A
and B):
• Mark the ends of the contracture band
as points “A” and “B”. Draw the line AB.
This line will run on the summit of the
contracture band.
• The contracture band will have two
surfaces. From point “A”, draw a line
“AC” at 90° on one surface of the
contracture. The length of this line
must be equal to the distance ‘’AB”.
Draw another line “BD” parallel to this
line, from the point “B” on the same
contracture surface.
 CHAPTER 53  CONTRACTURES ON THE UPPER LIMB—MANAGEMENT 235

• Now the markings can be made on the • Now, the dorsal incisions can be made
other contracture surface.
• From the point “A”, a line “AE” is marked
at 45° on the second surface of the
contracture. The length of this line must
be equal to the distance “AB”. From the
point “E”, another line “EF” is marked at
45º to the line “AE”.
• Now surgeons have one square flap
CABD and two triangular flaps FEA and
EAB.
When a contracture on the thumb web is released
by this method, the square flap CABD is usually
planned on the palmar surface of the contracture.
The zig-zag flaps FEA and EAB are planned on the
dorsal surface of the contracture.
• 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 AC and BD 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 on the finger or thumb
web, care should be taken to avoid injury
to the neurovascular bundles. Now the
contracture will slowly start getting released.
as follows. First the incision AE is made
through skin and subcutaneous tissue. The
flap EAB is raised holding the tip of the
flap with a skin hook. Then the incision EF
can be made and the triangular flap FEA is
raised similarly. The flaps must be raised
fully, based on the subcutaneous pedicles.
When the flaps are raised, transpose the
triangular flaps and advance the square
flap as shown in the diagram. Thus, the
leading edge of the square flap AB will get
sutured to the line EF, the tip of the flap
EAB will transpose and the tip “A” of this
flap will get sutured to the point “D”, and
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
areas. 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.
• Now set the hand on the table. Assess the
viability of the tips of the flaps. Secure
hemostasis. It may take a few minutes
for the tips of the flaps to become pink.
Transpose the flaps as described above.
• Suture the tips of the flaps with 4.0 ethilon
using the corner stitch (half-buried
horizontal mattress). Suture the edges
of the flap with 4.0 ethilon using simple
sutures.

A B

Figs 14.53.3A and B  Principle of the square flap method

236 SECTION 14  COMMON CLINICAL CONDITIONS
• Apply a paraffin gauze and sterile dressings.
In case of axillary contracture release with
square flap plasty, it is not necessary to
apply a POP. In case of finger contracture
release, a volar POP slab should be
applied for the hand keeping the MCP
joints of the fingers in flexion of 90º and
interphalangeal (IP) joints in extension. In
case of a thumb web contracture release,
a good bulky padding must be applied
over the freshly released thumb web and
a volar POP slab must be applied with
the wrist in 30° extensions, thumb kept in
palmar abduction and the POP slab over
the thumb web region.
Postoperative Protocol • Markings for the procedure (Figs 14.53.4A
• Admission in the ward.
• The affected hand should be kept elevated.
• Patient can take normal diet immediately
if the procedure was under regional block
or after complete recovery if under general
anesthesia.
• Analgesics and antibiotics for 5 days.
• Sedation optimization strategy (SOS) for
1 day.
• Inspection of the dressing after 48 hours.
• Discharge of the patient by third day.
• Suture removal on the 10th day and removal
of the POP slab and advise the following:
• Refer to physiotherapy for active and
passive mobilization of the fingers and
thumb during the day
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Dynamic thumb web spacer splints to
the affected thumb web to be worn at
night for a period of 3 weeks. In case
of finger contracture release, finger
straightening splints must be worn for
the same period.
• Compression garment for scar softening
after a further 2 weeks.
Five Flap Method of
Thumb Web Release
This procedure is a preferred technique
when a release of a contracture is required
in the thumb web. The requirement for this
procedure to be done is a good quality skin
on either side of the contracture. There are
five flaps involved in this procedure. This
technique is otherwise called a double
opposing Z-plasty with Y-V advancement.
Surgical Steps
• Prepare the hand as described in
Appendix I.
and B):
• Mark the ends of the contracture band
as points “A” and “B”. Draw the line AB.
This line will run on the summit of the
contracture band. Mark the midpoint of
this line “C”.
• Measure the distance AC. Mark a line
“AD” equal in length to AC on one
surface of the contracture at an angle
of 60º. From the point C, mark another
line CE equal in length to AC at an
angle of 60º the line AC on the opposite
surface of the contracture. Thus, two
flaps of a Z-plasty (CAD and ACE)
have been designed. Similarly mark
two flaps for the segment CB as shown
in Figures 14.53.4A and B. Since these
Z-plasties are parallel Z-plasties and not
in—series, care should be taken in the
planning now. A line BF equal in length
to CB is dropped at 60º from the point
“B” on the same surface as the line AD.
Another line CG equal in length to CB is
dropped from the point “C” at an angle
of 60º to the line CB. Now, two opposing
Z-plasties have been designed and
marked.
 CHAPTER 53  CONTRACTURES ON THE UPPER LIMB—MANAGEMENT 237

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
238 SECTION 14  COMMON CLINICAL CONDITIONS
tourniquet. Maintain the hand in elevated
position for about 3 minutes and ask for
the tourniquet to be removed entirely.
• Now set the hand on the table. Assess the
viability of the tips of the flaps. Secure
hemostasis. It may take a few minutes
for the tips of the flaps to become pink.
Transpose the flaps as described above.
• Suture the tips of the flaps with 4.0 ethilon
using the corner stitch (half-buried hori­
zontal mattress). Suture the edges of the
flap with 4.0 ethilon using simple sutures.
• Apply a paraffin gauze and sterile dressings.
A good bulky padding must be applied over
the freshly released thumb web and a volar
POP slab must be applied with the wrist
in 30º extension, thumb kept in palmar
abduction and the POP slab over the thumb
web region.
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
or after complete recovery if under general
anesthesia.
• Analgesics and antibiotics for 5 days.
• Sedation optimization strategy (SOS) for
1 day.
• Inspection of the dressing after 48 hours.
• Discharge of the patient by third day.
• Suture removal on the 10th day and
removal of the POP slab and advise the
following:
• Refer to physiotherapy for active and
passive mobilization of the fingers and
thumb during the day.
• Daily wash with soap and water.
• Massage of scar and grafted skin with
coconut oil.
• Dynamic thumb web spacer splints to
the affected thumb web to be worn at
night for a period of 3 weeks.
• Compression garment for scar softening
after a further 2 weeks.
 SECTION

15

Adult Brachial
Plexus Injuries
 Adult Brachial Plexus
Injuries—Assessment
Introduction
When the patient presents at the outpatient
department, surgeons aim is threefold and to
identify the following three points:
1. What is the “level” of the lesion?
2. What is the “nature” of the lesion?
3. What is the “plan” of management?
54
them closer to the aims of determining “level,
nature and plan”.
Clinical Examination
Clinical examination of adult brachial plexus
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
244 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES
Fig. 15.54.1  Sensory examination
observer at the next visit. Hence, the record
will help to chart the patient’s progress.
See Appendix VI for the proforma that is
routinely used.
Decision Making: What
is to be Done?
Whatever surgeons plan to do must have the
following aims to make the involved upper
limb functional. And to do this, the following
bare minimum must be achieved.
• Elbow flexion
• Shoulder stabilization
• Brachiothoracic pinch
• Sensation below elbow
• Wrist extension and finger flexion.
Now that the level of the lesion and the most
probable nature of the injury have been made
out, the decision to formulate the management
must be made. Before making the decision,
there are certain points to be remembered.
• 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
exploration of the brachial plexus in such
patients. However, an exploration can
be done if there is associated pain, in an
attempt to alleviate the pain.
• Contraindications for “exploration” sur­­gery:
• 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
of injury, exploration of the brachial
plexus is contraindicated.
• If the patient is elderly.
• If the surgeon does not have enough
experience.
• Surgical plans when the patient presents
more than a year after the injury or when
the exploration and nerve surgery fail:
• Muscle surgery
• Latissimus dorsi transfer for elbow
flexion
• Free gracilis muscle transfer for
elbow flexion, wrist extension, finger
flexion
• Bone surgery
• Arthrodesis of shoulder if all the
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.
• In our country, one more consideration—
all patients do not come immediately and
hence, the regular protocols may not be
possible.
• Priority wise—first attempt exploration
and nerve surgery
• Then, muscle/tendon surgery
• Then, lastly, bone surgery.
• The results of nerve transfer are inferior to
nerve repair.
Decision Making: When is it to
be Done?
The plan has been made as to what procedure
is to be done. Now, what remains to be
decided, is, when to carry out the procedure.
There are different time periods in which the
different surgeries are planned.
• Immediate surgery:
• When there has been a penetrating
injury?
injury?
• When exploration has already been
planned by the vascular surgeon for
the subclavian artery, concomitant
exploration and assessment of the
brachial plexus injury can be done.
• Waiting period: If immediate surgery is not
indicated, it is better to wait for a period of
about 6 weeks.
• If the patient has an incomplete lesion,
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
done and he will have time to experience
the flail limb or disability.
• Surgery at 6 weeks to 3 months: It is the
ideal period for exploration surgery to be
done in patients with total or near total
palsy? The period of inflammation is over
and the tissues are soft and exploration
will be fruitful.
• Surgery at 3 to 6 months: It is the ideal
period for surgery for the following:
• Partial palsy of upper levels
246 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES

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
• Cases of incomplete palsy who have
recovered only the distal group of
muscles over the period of 3 to 6
months.
Management Protocol After
Clinical Examination
Management protocol after clinical examin­
ation is described in Table 15.54.4.
 Adult Brachial Plexus
Injuries—Exploration
Presurgical Counseling
• This procedure will be done under general
or spinal anesthesia.
• This procedure will take about 4 hours to
perform.
• This procedure is being done primarily to • The result of this surgery will become
assess the injury to the nerves. The definitive
treatment for the injury has already been
made, but may have to be changed,
depending on the findings that are seen.
• If the nerves appear to be intact, but
surrounded by scar tissue, it is most
probably an injury around the nerves. The
scar tissue will be excised to release the
nerves and recovery may be expected.
• 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
bridged with nerve grafts from the legs.
Taking nerves from the legs will cause
some loss of sensation on the lateral aspect
of the sole of the feet. It will also cause a
scar on the legs.
• If there is no nerve to supply the cut nerve
as may occur when the nerve has been
pulled away from the spinal cord, another
nerve will be taken to supply the involved
nerve(s). This will entail using a part of an
intact nerve to try to bring back function to
the affected nerve. By taking away a part of
a nerve from another muscle will not cause
any major deficit. The nerves that can be
55
taken are the spinal accessory nerve or the
intercostal nerves.
• Admission will be necessary for a minimum
period of 1 week.
• Postoperatively, the affected upper limb will
be immobilized in a sling and movements
will be prevented.
obvious only after a few months of intensive
physiotherapy and electrical stimulation
and other supportive measures as will be
required.
• During the period of physiotherapy, splints
may have to be applied as considered
appropriate by the surgeon/physiatrist.
• The general complications of general
anesthesia can occur.
Position of the Patient
The patient is placed in the following position:
• Patient is placed in supine position on the
operation table.
• A small pillow is placed below the space
between the scapulae. This puts the neck
in an extended position.
• The head is placed on a head ring. The
head is turned to the side opposite to that
of the lesion.
• The ipsilateral shoulder is depressed
caudalward
• The anesthetist is requested to turn the
endotracheal tube away from the side of the
248 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES
lesion, so that the field for the surgeon and
his assistant are free from protuberances.
Preparation
The surgical preparation is done on the neck,
mastoid area, shoulder, ipsilateral chest and
entire upper limb. The drapings are applied
and the prepared upper limb is placed on
the operation table, parallel to the patient’s
position.
Markings
• Segment “A” of the incision (for the
supraclavicular dissection). The incision
starts from a point just below the mastoid
process. It then runs parallel to the
sternomastoid muscle up to the junction
between the middle third and lower third
of the muscle. Here, the incision turns away
from the muscle and runs parallel to the
clavicle and runs about 1 cm parallel to it
(Fig. 15.55.1).
Fig. 15.55.1  Markings for the exploratory incision
• Segment “B” of the incision (for the
infraclavicular dissection). At the lateral end
of the clavicle, the incision turns downward
over the clavicle at the level of the coracoid
process to enter the deltopectoral groove.
The incision then runs in the deltopectoral
groove to the anterior axillary fold, which
it crosses to reach the medial side of the
upper arm. Here, it runs parallel to the
brachial artery, up to the midpoint of the
arm.
• 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
infraclavicular area.
Tumescent Infiltration
The markings are infiltrated with tumescent
solution. The infiltration is done in the sub­
cutaneous layer to control the bleed on
making the incision. After a waiting period of
about 6 to 7 minutes, the incision is made.
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
cervical fat pad. Dissection in this area will
 CHAPTER 55  ADULT BRACHIAL PLEXUS INJURIES—EXPLORATION 249

reveal the omohyoid muscle. This muscle is
divided. The fat pad is retracted downward
to reveal the underlying structures.
• First the transverse cervical artery will
be seen along with its venae comitantes.
This must be ligated. The deep layer of the
cervical fascia is seen and now opened.
• The scalene muscles (Fig. 15.55.2) will be
seen in the medial border of the exposed
area. This can be confirmed by the
presence of the phrenic nerve running on
the surface of the anterior scalene muscle.
These are retracted medially to further
enhance the exposure of the area for the
brachial plexus. The first structure that
should be identified now is the superior
trunk, either directly, or after identifying
the C5 root.
• The roots of the plexus should be identified
now. This can be done in one of the
following methods.
• If there has not been much scarring, the
superior trunk of the plexus will be seen
in the center of the exposed field.
• If there has been some scarring, and the
superior trunk is not easily visualized,
identify the phrenic nerve again and
then, this can be traced proximally to
find the root of the C5.
• Alternatively, the cervical rami which
exit from the posterior border of the
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
250 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES
proximally to find the C4 root. This will
serve as a guide to identify C5 root also.
• If the C5 root has been avulsed, the root
will not be seen. It will be lying near the
clavicular area.
• If C5 root has been identified, next the
C6 root should be looked for immedi­
ately inferior and posterior to C5 root.
• The C7 root is inferior to C6 root and is
related to the transverse cervical artery.
• The C8 root is inferior to C7 root.
• The T1 root is identified immediately
posterior to the subclavian artery.
• The anatomical identification of the
trunks and divisions can be made in
this dissection field itself. The avulsed
segments of the upper roots will be found
in the area behind the clavicle. The distal
segments of ruptured upper trunks will
also be found at this level only.
• The Erb’s point can be identified by the three
“divisions”: (1) the suprascapular nerve,
(2) the anterior division of the superior
trunk and (3) the posterior division of the
superior trunk.
• If the distal segments of the avulsed of
ruptured roots cannot be seen in the
surgical exposure afforded till now, the
infraclavicular extension must be made.
• The incision is made as described (segment
“B”) of the marking. The incision is made
through the skin and subcutaneous tissues
down to the groove between the deltoid and
pectoralis major muscles. The two muscles
are separated and the clavipectoral fascia
is reached. This is divided and when this is
done, it may be necessary to divide some
of the fibers of insertion of the pectoralis
major muscle also. Retractors are applied
medially and the insertion of the pectoralis
minor muscle is identified deep to the
pectoralis major muscle. This will be just
medial to the coracobrachialis muscle.
• The pectoralis minor muscle is dissected,
and divided between clamps. Retractors
are applied both medially and laterally and
the infraclavicular portion of the plexus is
exposed.
• Identification points for the structures
seen at this level:
• The lateral cord will usually be seen in
the center of this field.
• The medial cord will be seen inferior
and medial to the subclavian/axillary
artery.
• The posterior cord will be identified
easier on the posterior aspect of the
subclavian/axillary axis.
• Now, the findings are noted. There are
some characteristic findings that are
described below:
• The plexus may appear intact, but for
some appearance of thickened portions
which suggest a neuroma-in-continuity.
• There may be avulsion; the roots may
not be available at the foramina and
the avulsed segments may be lying
distally.
• There may be rupture of the nerve
segments; roots may appear intact, but
on following them, there may be a loss
of continuity.
The brachial plexus has been dissected
and the findings recorded. Now is the time to
make decisions.
Decision Making
Neurolysis
When on exploration, the nerve plexus
appears to be intact, but evidence of scarring
is seen at different levels, neurolysis is
planned. This procedure aims at clearing
the scar tissues around the plexus that are
probably causing compression to the neural
elements. This scar may be either around the
plexal elements or within the epineurium of
the nerves.
The process of freeing the plexus from
the scar tissue around the nerves is called
“external neurolysis” and the process of
freeing of the fascicles of the nerves from the
scar within the epineurium is called “internal
neurolysis”.
 CHAPTER 55  ADULT BRACHIAL PLEXUS INJURIES—EXPLORATION
The technique of neurolysis is described
in the Chapter on “Nerve Surgery”.
Nerve Repair—Primary
When the exploration of the neck is done, the
altered anatomy is studied in detail. When
there has been an injury to the nerve or the
cord, and there is no loss of tissue, primary
repair is done as described in the Chapter on
“Nerve Surgery”.
Nerve Grafting
In the process of exploration, when loss of
part of a nerve continuity is seen, it is ideal to
reconstruct this defect with a nerve graft. As
discussed earlier, the primary requirements
before doing a nerve graft procedure are:
• A good source of nerve to grow into the
graft. The donor nerve that is available
should be of good quantity and quality.
• A good nerve graft source that can be used
without any residual morbidity.
Sources of grafts:
• Sural nerve: Most commonly used nerve
graft source.
• Medial/lateral cutaneous nerve of arm
and forearm
• Superficial radial cutaneous nerve
• Lateral femoral nerve
• Superficial peroneal nerve/saphenous
nerve
• Split/whole ulnar nerve.
• Good conditions for the growth of the
nerve into the graft:
• The length of the defect should not be more
than 10 cm. This is because a graft more
than 10 cm long will be nonvascularized
and hence the recovery will be poor. In such
situations, there are two choices available:
• A vascularized nerve grafting can be
done.
• A nerve transfer can be done to avoid a
grafting.
• The bed of the grafting area should be
free of scar and hematoma. Hemostasis
should be perfect.
251
• The duration of the brachial plexus injury
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
achieve good resultant function in the
upper limb.
The technique of suturing of nerve grafts is
described in the Chapter on “Nerve Surgery”.
Nerve Transfer
There are situations like the following, where,
nerve repair or grafting cannot be done.
• Avulsion of roots.
• Multiple level lesions with no continuity
of the proximal nerve segment with the
spinal cord.
• Ruptured nerve in which the proximal
nerve segment does not appear healthy,
or is heavily scarred and cannot supply
enough neurons.
• Delayed cases beyond 6 to 8 months,
where the slow growth of nerve in a graft
may not be conducive to achieving good
function.
• Cases with long segmental loss of nerve
(> 10 cm).
In such situations, it is ideal to achieve
neurotization of the important nerves with
another nerve that can supply neurons and
hence achieve function. The prerequisites for
nerve transfer are the following:
• A good source of nerve to grow into the
graft. The donor nerve that is available
should be of good quantity and quality.
There should be no residual morbidity as a
result of use of this nerve donor.
• A valid nerve into which the nerve must be
attached, so as to get useful function. This
is particularly important in multiple level
lesions, when not all segmental losses
are made good, but only the important
nerves for achieving useful function. This
is because the availability of nerve graft
source is limited.
Good conditions for the growth of the
transferred nerve.
• A good source of nerve to transfer: The
following are the nerves that can be used
252 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES
Table 15.55.1 Management protocol of adult brachial plexus injuries—exploration
Finding Characteristics
All components of the plexus
appear intact
Both ends of ruptured nerve available
Part of the plexus ruptured Gap between nerve ends
Duration > 6 months
C7 ruptured
C7 also avulsed
Part of the plexus avulsed
All roots avulsed
> 8 months
to neurotize segments of the injured
plexus. The sources may be from within the
plexus like the ipsilateral C7 transfer or the
Oberlin transfer. These are “intraplexal”
transfers. The nerve sources may be from
other areas like the spinal accessory
nerve or intercostals nerves. These are
“extraplexal” transfers.
• Accessory nerve transfer
• Intercostal nerve transfers
• Commonly used nerve transfers
• Ipsilateral and contralateral C7 transfer
• Distal intraplexal transfer(Oberlin)
• Cervical plexus
• Phrenic nerve
• Medial pectoral nerves
• Hypoglossal nerve
• Nerve into which the nerve graft must be
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.
• Upper trunk: To achieve shoulder and
elbow stability and mobility.
• Lateral cord: To achieve shoulder
stability, elbow flexion and hand
sensation.
Plan
Internal and external neurolysis
Primary nerve repair
Nerve grafting
Nerve transfer
Intraplexal C7 transfer
Extraplexal nerve transfer
Contralateral C7 transfer
Distal intraplexal nerve transfers
• Suprascapular nerve: To achieve shoul­
der mobility.
• Musculocutaneous nerve: To achieve
elbow flexion and hand sensation.
• Medial cord: To achieve finger flexion.
• Nerve to biceps and brachialis: To
achieve elbow flexion.
• Median nerve: To achieve sensation in
the hand.
• Good conditions for the growth of the
transferred nerve:
• A healthy bed with minimal scarring,
which can be achieved by ensuring
careful tissue handling and perfect
hemostasis.
• Good technique of nerve anastomosis.
• Use of the microscope and fine suture
materials.
Management Protocol After
Exploration
Management protocol of adult brachial
plexus injuries after exploration is given in
the Table 15.55.1.
 Adult Brachial Plexus
Injuries—Nerve Surgery
Spinal Accessory Nerve Transfer
The spinal accessory nerve is a good donor
nerve readily available in the field of surgery.
If the nerve is divided as far as possible, there
is hardly any motor deficit. This nerve can be
used in any of the following ways:
• To neurotize the suprascapular nerve for
shoulder abduction
• To neurotize the free vascularized gracilis
muscle transfer being used for elbow
flexion and finger extension.
• It may also be used to neurotize other
nerves like the musculocutaneous nerve,
using long nerve grafts.
Surgical Steps
• First, the suprascapular nerve is prepared
to receive the spinal accessory nerve. The
proximal end of the suprascapular nerve
is trimmed under the microscope. The
fascicular elements are looked for. The
nerve is further trimmed in increments of
1 mm till normal appearing nerve is seen
under microscope.
• The spinal accessory nerve is now identified.
The posterior border of the exposed field
is now examined. The plane between the
sternomastoid and the anterior border of
the trapezius is dissected and the nerve
looked for. When the nerve is found, it is
first confirmed to be the spinal accessory,
by stimulating with a nerve stimulator,
56
and noting the contraction in the trapezius
muscle.
• The nerve is dissected as distally as
possible. It will be seen that there are many
small branches from the main nerve to the
muscle at different levels. These branches
must be spared to avoid totally denervating
the trapezius muscle.
• The nerve is divided as far as possible. The
cut end is now brought to the prepared
proximal end of the suprascapular nerve.
There should be no tension between the
two ends. If there is evidence of tension,
some more mobilization of the nerves can
be attempted by releasing them from soft
tissues. If this maneuver is not successful,
a nerve graft may have to be interposed
between the ends of the nerve. The
procedure of harvesting the sural nerve
graft is described in Appendix IV. Usually,
this will not be necessary, as the length of
the spinal accessory nerve will be sufficient
for a primary repair with the suprascapular
nerve.
• Under microscope, the nerve suturing is
done with 10.0 ethilon epineural sutures
using simple interrupted suturing technique.
• The wounds are then closed after keeping
drainage tubes.
• Sterile dressings are applied.
• A layer of padding is kept between the arm
and the chest and the arm is strapped to
the chest with adherent plaster. The elbow
support sling is also applied.
254 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES

caudally, in the anterior axillary line up to

Intercostal Nerve Transfer
The intercostal nerves serve as good donors of
both motor and sensory nerves. These donors
can be used in the following ways:
• To neurotize the musculocutaneous nerve
for elbow flexion.
• To neurotize the median nerve for hand
and finger flexion and sensation.
• To neurotize the triceps muscle to achieve
stabilization of the elbow.
• To neurotize the free vascularized functional
gracilis muscle transfer for finger flexion.
When it is decided to use the intercostal
nerves to neurotize some elements, the
third to sixth intercostal nerves are usually
harvested.
Contraindications
The intercostal nerve transfer is not planned
when there are multiple rib fractures or there
is evidence of phrenic nerve injury as seen by
elevation of the ipsilateral hemidiaphragm.
Surgical Steps
• At the point where the original marked
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.
the seventh rib. The incision then curves
gently transversely along the lower border of
the seventh rib up to the mid-clavicular line.
• The incision is made down through the
skin and subcutaneous tissues and the
flap of skin on the anterior chest is raised.
• The pectoralis major muscle is retracted.
• The neurovascular bundle runs on the
inferior surface of the corresponding
rib. The nerve is extraperiosteal.
• The nerve is dissected gently from the
mid-axillary line distally along the
curvature of the rib. The nerve is very
thin and must not be held with forceps
at any time during the dissection.
Gentle retraction with a skin hook will
be enough.
• The sensory branches also should be
dissected and tagged.
• Cautery must be avoided close to the
nerve.
• After the nerve is harvested, it can be
grouped along with the other intercostal
nerves (Fig. 15.56.2) that has been
harvested and taken to the decided
recipient.
Hemostasis should be achieved and

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.

Presurgical Counseling
• 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
Fig. 15.56.2  Grouping together of the intercostal nerves
• This procedure will take about 3 hours to
perform.
• This procedure will entail using a part of an
intact nerve that goes to the hand to try to
bring back function to the elbow. By taking
away a part of a nerve from the normal
nerve will not cause any major deficit.
• Admission will be necessary for a minimum
period of 1 week.
• Postoperatively, the affected upper limb
will be immobilized in a plaster of Paris
(POP) slab and sling.
• The result of this surgery will become
obvious only after a few months of intensive
physiotherapy and electrical stimulation
and other supportive measures as will be
required.
• During the period of physiotherapy, splints
may have to be applied as considered
appropriate by the surgeon/physiatrist.
• The general complications of general
anesthesia can occur.
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
both sides.
The biceps muscle is identified and
retracted laterally.
• The brachial artery is now identified by the
pulsation and will serve as a landmark for
the identification of the nerves.
• The musculocutaneous nerve is closest to
the biceps muscle. The branch from the
musculocutaneous nerve entering the
biceps muscle is identified and divided
close to the hilum. The branch entering
the brachialis muscle is also identified and
divided.
• The ulnar nerve is dissected. At about the
level where the nerve to biceps has been
identified, the epineurium over the ulnar
nerve is opened by sharp dissection and
the fascicles are separated without causing
damage (Fig. 15.56.4). The fascicles are
stimulated individually to identify the
fascicles going to the FCU tendon. These
fascicles are divided and transposed to
be coapted to the nerve to biceps. The
coaptation is done with 10.0 ethilon or
nerve glue. Similarly, the fascicles of the
256 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES
Fig. 15.56.4  Plan of nerve transfer
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
median nerve are separated at the level
where the nerve to brachialis has been
divided. The fascicles are stimulated
indivi­
dually and the fascicle supplying
the FDS muscles is divided. This fascicle is
transposed and coapted with the divided
nerve to brachialis muscle.
• The wounds are then closed after keeping
drainage tubes.
• Sterile dressings are applied.
A layer of padding is kept between the
arm and the chest and the arm is strapped
to the chest with adherent plaster. The elbow
support sling is also applied.
Contralateral C7 Transfer
The contralateral C7 provides an excellent
source of healthy neurons that can be spared.
Presurgical Counseling
• This procedure will be done under general
or spinal anesthesia.
• This procedure will take about 3 hours to
perform.
• This procedure will entail using a part of
an intact nerve from the opposite side to
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.
• Admission will be necessary for a minimum
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
obvious only after a few months of intensive
physiotherapy and electrical stimulation
and other supportive measures as will be
required.
• During the period of physiotherapy, splints
may have to be applied as considered
appropriate by the surgeon/physiatrist.
• The general complications of general
anesthesia can occur.
Position of the Patient
The patient is placed in the following position:
• Patient is placed in supine position on the
operation table.
• A small pillow is placed below the space
between the scapulae. This puts the neck
in an extended position.
• 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
side, so that the field for the surgeon and
his assistant are free to work on the normal
side brachial plexus.
Preparation
The surgical preparation is done on the neck,
mastoid area, shoulder, ipsilateral chest and
entire upper limb. The drapings are applied
and the prepared upper limb is placed on
the operation table, parallel to the patient’s
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.
The dissection is started in the wrist,
where the ulnar nerve is easily identified.
Incision deepened through skin and
subcutaneous tissues. Retraction of the FCU
tendon ulnarward is done to expose the ulnar
neurovascular bundle. The ulnar nerve is not
divided until the entire length of the nerve up
to the arm has been dissected.
The ulnar artery and the ulnar venae
comitantes are identified and protected.
Dissection of the ulnar nerve is done,
preserving the epineural covering and the
blood vessels coursing in the epineurium.
At the level of the elbow, the ulnar nerve is
dissected in the cubital tunnel and freed
completely. The nerve is then dissected
into the upper thirds of the arm. The vessels
running along with the ulnar nerve should
be carefully preserved. Now, the nerve is
tunneled to the opposite side neck by a
subcutaneous tunnel created with a tendon
tunneler.
Dissecting the contralateral brachial plexus
and identifying the C7 root: The steps of this
surgery have been described in the chapter
on brachial plexus exploration. Once the C7
has been identified, it must be dissected as far
Fig. 15.56.5  Markings for the harvest of the vascularized
ulnar nerve
as possible. The C7 divides into the anterior
and posterior divisions. The anterior division
contains the fibers for pectoralis major
innervation. The posterior division contains
fibers for neurotization of the latissimus dorsi
muscle and triceps. These fibers can be used
for transfer and will not cause any obvious
deficit.
Nerve suturing to C7 root: Distal end of the
vascularized ulnar nerve is first tunneled
across in a subcutaneous route to the neck
incision on the contralateral side (Fig. 15.56.6)
coapted with the selected fibers of the C7 root
with 10.0 ethilon under microscope or with
nerve glue.
Recipient nerve surgery: This can be done
immediately or as a staged procedure. If
done immediately, the recipient nerve is first
dissected and kept ready. The recipient nerves
are usually the musculocutaneous nerve, the
nerve to triceps or sometimes to neurotize a
functional muscle transfer, in which case it is
done as a staged procedure.
• The epineurium of the ulnar nerve is
carefully incised.
258 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES

• 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
 Adult Brachial Plexus
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.
• Admission will be necessary for a minimum
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
physiotherapy and electrical stimulation
and other supportive measures as will be
required.
• During the period of physiotherapy, splints
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
260 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES
of the muscle is the point where the
neurovascular bundle enters the muscle.
• A skin ellipse is marked about 5 cm × 12 cm,
about 4 cm lateral to the marked border of
the LD muscle and oriented parallel to the
border. The cephalic apex of the ellipse
is marked as “B”. The caudal apex of the
ellipse is marked as “C”.
• Join the points “A” and “B”.
• Extend the incision caudally for about 8
cm from the point “C”, parallel to the lateral
border of the muscle.
Surgical Steps
• The surgery is done under general
anesthesia.
• The patient is placed in lateral decubitus
position and the arm is kept in an abducted
position.
• The entire back, neck, shoulder, half of
the chest, entire arm up to the elbow is
prepared and sterile drapings are applied.
• The incision is made first on the lateral
border of the skin paddle ellipse. This
incision is made down through the skin
and subcutaneous tissues, till the surface
of the LD muscle is seen.
• Now, the proximal incision “AB” is made
only through skin and subcutaneous
tissues. Then the caudal extension from
“C” is also made down to the surface of the
muscle.
• Now only the lateral skin flap is raised,
superficial to the surface of the muscle.
This is done till the lateral border of
the muscle. From here, the dissection
proceeds deep to the muscle, and the
muscle is raised from the chest wall. There
are usually many perforators from the
chest wall to the muscle, which should be
cauterized as the dissection proceeds. This
dissection should be done almost under
the entire span of the muscle.
• The lateral border of the skin paddle
is now incised and dissected up to the
surface of the LD muscle. Care should
be taken to avoid dissecting between the
muscle and the skin paddle. This can be
ensured by applying stay sutures with 3.0
vicryl, between the surface of the muscle
and the dermis of the skin flap. Now
the medial skin flap is elevated over the
surface of the muscle, till the origin from
the paravertebral fascia. There are many
perforators to the skin from the muscle,
which must also be cauterized during the
dissection. Now, the muscle is divided as
far as the dissection limits.
• Now the vascular pedicle is identified. The
vascular pedicle lies parallel to the lateral
border of the muscle and runs 2 cm on the
undersurface of the muscle. The branches
to the Serratus anterior and Teres major
are ligated and divided.
• Now the muscle has been totally dissected
and is now attached only by the vascular
pedicle and the tendinous insertion into
the neck of the humerus.
• The tendon of insertion into the neck of
the humerus is dissected and divided. The
LD muscle has been totally raised on its
vascular pedicle. The viability of the muscle
and the skin paddle must be confirmed.
• The muscle is exteriorized and most of
the incision is closed primarily with 3.0
polypropylenes after placing a vacuum
suction drain in the wound and bringing
out the free end in the mid axillary line.
Preparation of the
Recipient Area on the Arm
• The patient is placed in supine position
and the preparation of the arm is done.
• An incision “E” is made on the medial
surface of the arm from the anterior
axillary fold to the front of the elbow
(Fig. 15.57.2). The incision is made through
the skin and subcutaneous tissues and the
atrophic biceps muscle is identified. The
biceps tendon is dissected and isolated.
• An incision “F” about 5 cm is made
transversely over the coracoid process. The
bone is dissected and bared of periosteum.
• Now, the harvested LD muscle is now
tunneled to the incision “E” on the arm.
 CHAPTER 57  ADULT BRACHIAL PLEXUS INJURIES—MUSCLE TRANSFER
Fig. 15.57.2  Markings on the arm
Care should be taken to maintain the
orientation of the muscle and care should
also be taken to avoid kinking or torsion
of the vascular pedicle. The viability of
the muscle and the skin paddle must be
confirmed again. If there is any problem
in the muscle bleed, the vascular pedicle
must be checked for signs of compression
or torsion and corrected immediately.
• The tendinous insertion of the LD muscle
must be oriented cephalad in the arm. This
tendinous portion should be tunneled to
the incision “F”. Now, the suturing on the
back can be completed.
• The tendinous insertion of the LD muscle
must now be attached to the coracoid
process to give a new origin for the muscle.
This is done using 3.0 polypropylene with
horizontal mattress sutures. Now, the
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.
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
or after complete recovery if under general
anesthesia.
• The POP slabs must not be disturbed at all.
• Discharge of the patient by third day.
Patient to retain the POP slab till the end
of 4 weeks.
• Removal of the POP slab on the 21st day
and advise the following:
• Refer to physiotherapy for active
mobilization of the elbow and fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• To wear the elbow sling at all times for a
further 3 weeks
• Patient is advised to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
 Obstetric Brachial Plexus
Palsy—Assessment
Introduction
In a case of brachial plexus birth injury, it
is not always that the hand surgeon gets to
see the patient soon after the baby is born.
Sometimes, it takes a few months before the
baby is referred. In some instances, it may
even take a few months or a year before
the hand surgeon sees the patient. Hence,
assessment of a brachial plexus birth injury
must be accurately assessed at varying stages
of the child’s growth with the problem.
Eliciting the history is one of the first
priorities in a case of brachial plexus birth
palsy. Among the details to be found out are
the following:
• Specific antenatal history: Whether there
was occurrence of maternal diabetes.
• Details of the delivery—which include:
• Venue of delivery: Whether in the hospital
or at home.
• Method of delivery: Whether by natural
labor or cesarean section.
• If by cesarean section, the indication,
was it cephalo-pelvic disproportion?
• If the delivery was by natural labor, was
it a breech or cephalic presentation?
• Was the labor assisted—with vacuum/
forceps?
• What was the birth weight?
• Attitude of the limb:
• If the affected limb lies flail by the side
and there is no movement at all, it
denotes a total palsy.
58
• If the limb lies in a position of internal
rotation at the shoulder and pronation
of the forearm, and flexion of the wrist,
it is most probably an upper trunk
lesion, which is the most common type
of presentation.
• Signs of Horner’s syndrome:
• Ptosis
• Miosis
• Is evidence of avulsion of the lower
roots and carries a poor prognosis?
The grading of the muscle power should be
made and recorded. It may not be possible to
test each muscle individually in babies and
children. What can be tested are the muscle
groups as mentioned below:
• Shoulder abductors
• Shoulder external and internal rotators
• Shoulder flexors
• Elbow flexors and extensors
• Wrist flexors and extensors
• Finger flexors and extensors.
Muscle Power Grading
• M0: No contraction
• M1: Contraction without movement
• M2: Slight movement with weight of arm
supported against gravity
• M3: Complete movement against gravity.
Sometimes, the grading of the muscle
power may not be possible. In such
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
Introduction
The surgical management of obstetric brachial
plexus palsy consists of exploration and nerve
surgery at the earliest. The procedure is the
same as described earlier in Chapter “Adult
Brachial Plexus Injuries of Exploration and
Nerve Surgery”.
Mod Quad Procedure
In obstetric brachial plexus palsy, muscle
imbalances develop as some group of muscles
overact and some muscles are paralyzed.
This imbalance of action on the growing
bones and joints creates deformities of which
a few are common. When there is a palsy of
shoulder abductors and external rotators,
the shoulder goes in for internal rotation
and adduction. With time, if this deformity
is left uncorrected, the internal rotators and
adductors—the subscapularis and pectoralis
major muscle go in for contracture. If this
happens, not only the child will not be able
to actively abduct the shoulder, but even
passive abduction also will not be possible.
In such sequelae, the Mod Quad procedure
is done which consists of four steps:
1.  Release of the contracted pectoralis
major and subscapularis.
2. Reconstitution of the internal rotators by
attaching the muscle of pectoralis major
to the distal cut end of subscapularis
tendon.
59
3. Transfer of the latissimus dorsi muscle to
supraspinatus for shoulder abduction.
4. Transfer of teres major muscle to teres
minor for external rotation.
It is not essential that all these steps be
performed for all the patients with obstetric
brachial plexus palsy. Some children have
good abduction, and no internal rotation
contracture. But, they have no external rotation
and this is a deficit that must be corrected.
Hence, the surgery must be tailored to the
need of the individual patient.
Presurgical Counseling
• This procedure will be done under general
anesthesia.
• This procedure will take about 3 hours to
perform.
• This procedure will entail using two muscles
from the back to bring back function of
flexion of the elbow in the affected side.
By taking away these muscles, there will
be no major deficit in the limb. There will
also be a procedure done on the front of the
shoulder where a release of the contracted
muscles will be done.
• There will be a scar on the front and back
of the shoulder.
• Admission will be necessary for a
minimum 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
physiotherapy and electrical stimulation
 CHAPTER 59  OBSTETRIC BRACHIAL PLEXUS PALSY—MANAGEMENT
and other supportive measures as will be
required.
• During the period of physiotherapy, splints
may have to be applied as considered
appropriate by the surgeon/physiatrist.
• The general complications of general
anesthesia can occur.
Position of the Patient
The patient is placed in the following position:
• Patient is placed in lateral position on
the operation table with the involved side
uppermost with the provision to make
the patient in supine position during the
early phase of surgery for release of the
pectoralis major and subscapularis.
• A small pillow is placed in front of the
chest, and the child rests on the pillow
with a slightly pronated torso.
• The involved upper limb is placed in a
position of abduction of 90° at the shoulder
and elbow in 90° flexion with internal
rotation of the shoulder. This limb is placed
over sterile drapes applied over a hand rest.
• The head is placed on a head ring.
• The anesthetist is requested to turn the
endotracheal tube away from the side of the
lesion, so that the field for the surgeon and
his assistant are free from protuberances.
A B
Figs 15.59.1A and B  Marking of the incisions for the different components of the procedure
265
Preparation
The surgical preparation is done on the neck,
mastoid area, shoulder, ipsilateral chest and
back up to the midline on the respective sides,
entire involved upper limb. The drapings
are applied and the prepared upper limb is
placed on the hand rest as described above.
Markings
• Segment “A” of the incision (for the release
of the internal rotators). The incision
starts from a point just below the coracoid
process (Figs 15.59.1A and B). It then runs
in the deltopectoral groove caudally and
cuts the anterior axillary fold.
• Segment “B” and “C” of the incision (for the
tendon transfer). At the posterior aspect of
the shoulder, two incisions are made. First
the spine of scapula is palpated and above
this spine lies the supraspinatus muscle. A
transverse incision “B” parallel to the spine
of the scapula is marked. Another incision
“C” is marked over the posterior axillary fold,
palpating the free margin of the latissimus
dorsi muscle. This incision is made to dissect
the insertion of the latissimus dorsi muscle.
• It is not essential to make all the incisions
that have been marked.
266 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES
Tumescent Infiltration
The markings are infiltrated with tumescent
solution. The infiltration is done in the
subcutaneous layer to control the bleed on
making the incision. After a waiting period of
about 6 to 7 minutes, the incision is made.
Step 1
• Through the incision “A”, the deltoid fibers
are split and the pectoralis major muscle
is identified. This is dissected distally to
identify the insertion. The muscle is divided
as close to the insertion as possible.
• Through the cephalad part of the same
incision, the insertion of the subscapularis
tendon is identified. This can easily be
done by viewing the anterior aspect
of the shoulder capsule. The tendon
of the subscapularis is in the form of
an aponeurotic sheet. This is divided
proximally to retain as much of the insertion
as possible. Now, passive abduction and
external rotation of the shoulder will be
smooth and free.
Step 2
To reconstruct the internal rotation, the
divided pectoralis major muscle is sutured to
the distal cut end of the subscapularis tendon
with 3.0 polypropylene.
Step 3
• By the incision “C”, the latissimus dorsi • On the 21st day:
muscle is identified and dissected up to the
insertion. The muscle is divided close to the
insertion and the muscle is held with an
Allis tissue forceps. The teres major muscle
is now dissected. It lies just cephalad to the
latissimus dorsi muscle. This muscle is also
dissected up to its insertion and divided
near the insertion. The teres minor muscle
lies deep to the teres major muscle. This
muscle is identified and dissected free.
• Through the incision “B”, the supraspinatus
muscle is dissected and the insertion is
also identified.
Step 4
• The divided muscle of the teres major is
sutured to the teres minor, close to the
insertion, keeping the shoulder in a position
of 90° abduction and external rotation. A
subcutaneous tunnel is created connecting
incision “B” and “C”. The divided muscle
of latissimus dorsi which is held by Allis
tissue forceps is tunneled through this
subcutaneous tunnel to reach incision
“B”. Here, it is sutured to the supraspinatus
muscle close to its insertion.
Hemostasis is achieved and wounds
closed primarily. Sterile dressings are done.
The involved upper limb is immobilized in an
airplane spline, with 100° of abduction at the
shoulder and full external rotation, so that the
palm faces upward.
Postoperative Protocol
• Admission in the ward.
• The affected hand should be kept elevated.
• Patient can take normal diet after complete
recovery from general anesthesia.
• The POP slabs must not be disturbed at all.
• Discharge of the patient by third day.
Patient to maintain immobilization of the
upper limb in the POP slab till the end of
3 weeks.
• After 3 weeks, mobilization of the shoulder
will be started retaining the POP. Hence,
the child will be encouraged to abduct the
shoulder above the level of the POP slab or
splint.
• Refer to physiotherapy for active mobiliz­
ation of the elbow and fingers.
• Daily wash with soap and water.
• Massage of scar and grafted skin with
coconut oil.
• To wear the splint at all times for a
further 3 weeks.
• Patient is advised to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
• The POP slab will be discarded at the
end of 6 weeks.
 Volkmann’s Ischemic
Contracture—Assessment
Introduction
In our part of the country, Volkmann’s ische­
mic contracture (VIC) is a condition that
can be seen quite often in different stages
of its development. The mainstay of the
management of such a condition and attain­ing
a good useful hand from a hand that has been
affected by this condition depends on one
main factor—correct and accurate assess­ment
of the problem and the stages of involvement
of almost all the structures of the hand.
Assessment of such a condition is aimed
at:
• Determining the stages of involvement
of the structures in the hand and the
involvement of the structures that deter­
mine function in the hand.
• Determining the treatment plan which is
basically dependent on the diagnosis.
Not all the cases of VIC that surgeons see
will fall exactly into one of the types men-
tioned in Table 15.60.1. But, there will be a
general trend that will categorize the type
of lesion in a particular patient. As far as the
treatment options are concerned, manage­
ment will depend on the condition of the
different structures in the hand (Table 15.60.2).
Planning the Sequence of
Surgical Procedures
• Physiotherapy: As soon as the patient
is seen in the outpatient department,
60
especially if it is a mild type, the patient
must be subjected to physiotherapy. This
consists of mobilization of the fingers and
splints to straighten out joints that are
minimally stiff. This will even lengthen the
minimally contracted tendons.
• Exploration: The first surgical procedure
that is planned is usually an exploration.
This procedure achieves the following:
• It demonstrates the damaged structures.
• It gives an opportunity to excise muscle
infarcts.
• The nerves can be assessed and the
nerve surgery can be planned and done.
The timing of the exploration depends on
the severity of lesion. In more severe types
(Type II and Type III), early exploration is
advised because it is important to bring
back sensation to the hand. In mild type
(Type I), the nerve is usually not involved. The
exploration should not be done too early, as
it may interfere with the healing of muscles
after the trauma. Hence, this surgery can be
planned after 6 months in Type I when the
muscles have healed well.
• Skin: It is imperative that the skin on the
forearm is of good quality and not scarred/
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
on exploration.
• Skeletal problems: Any deformities of the
forearm bones or contractures of the joints
must be corrected before planning any soft
tissue surgery on the nerve or tendons.
268 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES

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
Power of Good Weak Contracture
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
tion on the hand is an essential requisite
before contemplating reanimation
pro­ce­dures.
• Joint: The joints of the hand and fingers
must be made soft and supple before
any tendon surgery can be planned. This
principle must be followed in keeping with
the principles of tendon surgery.
• Tendon: The tendon procedures should
be done after the other procedures are
complete.
 Volkmann’s Ischemic
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
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.
• 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
be engulfed in a scar. If it is possible, the
adhesions may be released and tenolysis
done. If the scar is very dense and involves
the muscle portion of the tendons also, the
scar must be excised along with involved
tendons. If any tendon transfer is planned
along with, it can also be done, provided
the sensation of the hand was clinically
normal.
Examination of the nerves:
• The nerves—median and ulnar nerves
must be examined now. The entire length
of the median and ulnar nerves must be
dissected free from the surrounding scars,
exposed and examined in detail. The
median nerve is more important as far
as the function of the hand is concerned.
Normally, an artery can be visualized on
the surface of the median nerve, running
along the entire length of the nerve. This
is the median artery, representing the
embryological axis artery during the
development of the upper limb. There are
four grades of involvement of the nerves
(Fig. 15.61.2) based on the appearance of
this artery and the diameter of the median
nerve in the involved segment.
271
Fig. 15.61.2  Grading of involvement of the nerves
• Grade I—No reduction in caliber of median
nerve and the median artery appears to be
visualized fully.
• Grade II—Minimal reduction in the
diameter of the median nerve and the
median artery is of smaller caliber and
absent in some segments.
• Grade III—Up to 50 percent reduction in
the diameter of the median nerve.
• Grade IV—More than 50 percent reduc­
tion in the caliber of the median nerve
with total loss of some segments of the
nerve.
• If the nerve comes under grade I, releasing
the surrounding scar by neurolysis is
enough. If the involvement of the nerve
is either grade II, III or IV, reconstruction
of the nerve is necessary for restoration
of sensation on the hand. This can be
done by any of the following methods.
First the length of the segment involved is
considered.
• If the segment is less than 6 cm—
nonvascularized reversed sural nerve
graft from the leg.
• If the segment involved is more than
6 cm, either a vascularized pedicled
nerve graft or vascularized micro­
surgical nerve transfer is done.
272 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES
Examination of the blood vessels:
• The caliber of the radial artery and the
ulnar artery must also be examined. The
hand may already be viable, but it is ideal
to have a good vasculature to the hand to
ensure optimum healing of the tissues
and function. If the vessels are obliterated,
appropriate vein grafts to bridge the
gaps and restore good blood flow to the
hand must be done by microvascular
anastomosis using reversed saphenous
vein grafts from the leg.
• The tourniquet must be released and
gentle pressure with a saline pad should
be applied and the hand kept elevated
for two minutes. Next, the hand must
be placed on the table and hemostasis
achieved. Skin suturing is done with 3.0
ethilon and drainage tubes kept in the
proximal portion of the suture line. Sterile
dressings are applied and dorsal plaster
of Paris (POP) slab is applied with wrist
in neutral position and fingers in position
appropriate with the surgical procedure
that has been done (nerve or tendon
surgery).
Postoperative Protocol
• Admission in the ward.
• The affected hand should be kept
elevated.
• Patient can take normal diet after comp­
lete recovery if he was under general
anesthesia.
• Discharge of the patient by 3rd day.
• Inspection of the suture line on the 2nd
day. If necessary, a short general anesthesia
may be required if the child is very serious.
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:
• Refer to physiotherapy for active
mobilization of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Child is encouraged to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
Tendon Lengthening
Surgical Steps
• The involved tendon is identified and
dissected.
• The excursion of the tendon is confirmed
by a passive mobilization.
• It is divided with a No. 11 blade as shown
in the diagram (Fig. 15.61.3).
• The suturing of the tendon is now done
with 3.0 polypropylene, as shown in the
diagram (Fig. 15.61.3).
• The tourniquet must be released and gentle
pressure with a saline pad should be applied
and the hand kept elevated for two minutes.
Next, the hand must be placed on the table
and hemostasis achieved. Skin suturing is
done with 3.0 ethilon and drainage tubes
kept in the proximal portion of the suture
line. Sterile dressings are applied and dorsal
POP slab is applied with wrist in neutral
position and fingers in position appropriate
with the surgical procedure that has been
done (nerve or tendon surgery).
Postoperative Protocol
• Admission in the ward.
• The affected hand should be kept elevated.
• Patient can take normal diet after complete
recovery if he was under general anesthesia.
• Discharge of the patient by the 3rd day.
Fig. 15.61.3  Technique of tendon lengthening
 CHAPTER 61  VOLKMANN’S ISCHEMIC CONTRACTURE—MANAGEMENT
• Inspection of the suture line on the
2nd day. If necessary, a short general
anesthesia may be required, if the child is
very serious. 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:
• Refer to physiotherapy for active mobili­
zation of the fingers
• Daily wash with soap and water
• Massage of scar and grafted skin with
coconut oil
• Child is encouraged to continue the
mobilization of the fingers; both active
and passive and review once every month
for evaluation.
Muscle Slide Operation
Surgical Steps
• Incision on the forearm must extend from
the wrist on the radial side to allow access
to the flexor pollicis longus (FPL) tendon
if necessary to the arm, proximal to the
elbow joint.
• Identify the median nerve, which is just
ulnar to the biceps tendon. Identify the
brachialis muscle that is posterior to the
median nerve. Identify the pronator teres
muscle, which is immediately ulnar to the
median nerve.
• Identify the ulnar nerve as it enters the
forearm between the two heads of the FCU
muscle. Palpate the ulna bone.
• Pass a retractor and retract to the radial
side, the median nerve along with the
brachialis and biceps. Pass another retrac­
tor to retract the pronator teres ulnarward.
Palpate the medial epicondyle of the
humerus in the valley between the two
retrac­tors. Incise the periosteum, and with
a periosteal elevator, release the pronator
and flexors muscle origin from the
epicondyle, subperiosteally. This can be
done from the radial side toward the ulnar
side. It will have to stop when the ulnar
nerve is encountered.
273
• Now, make incision on the ulna for the
distance of the origin of the FCU muscle.
Raise the FCU muscle subperiosteally. The
ulnar nerve is still seen entering the FCU
muscle. This need not be disturbed. As the
FCU muscle is being erased from its origin,
the ulnar nerve can be brought anterior
to the medial epicondyle, to reduce the
tension on the nerve. As this is being done,
the elbow joint capsule and the tuberosity
of the ulna will get exposed. When this
procedure is done carefully, the muscle
will be erased along with the periosteum.
• After the FCU is raised from the ulna, the
interosseous membrane comes into view
and the anterior interosseous artery, and
its perforating branches and nerve and
veins will be seen. These must be protected.
• Gentle traction must be given on the
fingers to extend them. As the muscles are
being released, the fingers will be able to be
passively extended. The end point of this
muscle elevation is the full, free passive
extension of all the fingers and thumb.
• The thumb may not get released by the
procedure described above. From the
middle and distal segments of the incision,
the FPL muscle is exposed and released
subperiosteally from the radius to achieve
full extension of the thumb.
• Now, the ulnar and median nerves must
be released from all scars distally also.
• The tourniquet must be released and
gentle pressure with a saline pad should be
applied and the hand kept elevated for two
minutes. Next, the hand must be placed
on the table and hemostasis achieved.
Skin suturing is done with 3.0 ethilon
and drainage tubes kept in the proximal
portion of the suture line. Sterile dressings
are applied and dorsal POP slab is applied
with wrist in neutral position and fingers
in position appropriate with the surgical
procedure that has been done (nerve or
tendon surgery).
Postoperative Protocol
• Admission in the ward.
• The affected hand should be kept elevated.
274 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES
• Patient can take normal diet after complete • The FDS tendons of all the fingers are
recovery if he was under general anesthesia.
• Discharge of the patient by the 3rd day.
• Inspection of the suture line on the
2nd day. If necessary, a short general
anesthesia may be required if the child is
very serious. 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:
• Refer to physiotherapy for active
mobilization of the fingers.
• Daily wash with soap and water.
• Massage of scar and grafted skin with
coconut oil.
• Child is encouraged to continue the
mobilization of the fingers; both active
and passive and review once every
month for evaluation.
Tendon Transfer—FDS to FDP
Surgical Steps
Through the exposure described above, the
following steps are carried out (Figs 15.61.4A
and B).
A B
Figs 15.61.4A and B  Technique of FDS to FDP transfer
identified and dissected. The FDP tendons
to all the fingers are identified and dissected.
• The FDS tendons are divided as distally as
possible in the palm at Zone III level for all
the fingers. The FDP tendons are divided
close to the musculotendinous junction
for all the fingers.
• The excursion of the FDP tendons is
confirmed by passive mobilization. The
proximal FDS tendon of the index finger
and the distal FDP tendon of the finger
are now kept in proximity. They cannot
be sutured directly as the tension has not
yet been adjusted. Too tight suturing or
too loose suturing will result in a useless
finger. The method of adjusting the tension
is as follows:
• The wrist is kept in neutral position. The
FDS muscle is now going to move the
FDP tendon of the corresponding finger.
The proximal FDS tendon is pulled and
relaxed alternatively to confirm the
supple muscle. The distal cut end of
the FDP tendon is also moved passively
to confirm that there are no adhesions
distally.
• With the wrist in neutral position, the
distal FDP tendon of the index finger
 CHAPTER 61  VOLKMANN’S ISCHEMIC CONTRACTURE—MANAGEMENT 275

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
• Admission in the ward.
mobilization should be done until
• The affected hand should be kept elevated.
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
removed. The following are advised:
mark this point as “C”. Hold the tendon
• Refer to physiotherapy for active
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
• Massage of scar and grafted skin with
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.
276 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES
Fig. 15.61.5  Marking for the incisions for harvesting
ECRL tendon
• Incision for extensor carpi radialis
longus (ECRL) must be made as follows
(Fig. 15.61.5):
• Incision “A” is now made. The ECRL
tendon must be identified. The extensor
pollicis longus (EPL) tendon runs
obliquely across it and the extensor
carpi radialis brevis (ECRB) tendon
is on the ulnar side. The ECRL tendon
should be held with a hemostat and
divided closely to the insertion with a
No. 11 blade.
• Gentle traction to the ECRL is applied
in a distal direction by pulling on the
hemostat. This will confirm the position
of the muscle proximally and the
incision “B” is made now. The muscle/
musculotendinous unit of the ECRL is
exposed in this incision and confirmed
by traction on the hemostat.
• The FDP tendons for all the fingers are
divided as proximally as possible and
tagged.
Fig. 15.61.6  After tendon suturing
Tension adjustment: The tendons of the
BR must be sutured to the FPL tendon
with the wrist in neutral position, thumb
kept in a position of palmar abduction and
interphalangeal (IP) joint in 10° flexion
(Fig. 15.61.6).
• The tendon of the ECRL is sutured to the
tendons of all the FDP tendons of the
fingers, keeping the wrist in neutral position
and fingers in a position of natural cascade:
MCP—10º, PIP—70º and DIP—20º. The
technique of suturing the tendons is
described in the previous chapter.
• The tourniquet must be released and
gentle pressure with a saline pad should be
applied and the hand kept elevated for two
minutes. Next, the hand must be placed
on the table and hemostasis achieved.
Skin suturing is done with 3.0 ethilon
and drainage tubes kept in the proximal
portion of the suture line. Sterile dressings
are applied and dorsal POP slab is applied
with wrist in neutral position and fingers
 CHAPTER 61  VOLKMANN’S ISCHEMIC CONTRACTURE—MANAGEMENT
in position appropriate with the surgical
procedure that has been done (nerve or
tendon surgery).
Postoperative Protocol
• Admission in the ward.
• The affected hand should be kept elevated.
• Patient can take normal diet after complete
recovery if he was under general anesthesia.
• Discharge of the patient by the 3rd day.
• Inspection of the suture line on the
2nd day. If necessary, a short general
anesthesia may be required if the child is
very serious. Suture removal can be done
277
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:
• Refer to physiotherapy for active mobi­
lization of the fingers.
• Daily wash with soap and water.
• Massage of scar and grafted skin with
coconut oil.
• Patient is encouraged to continue the
active mobilization of the fingers for
three weeks from removal of the POP.
• After three weeks from removal of the
POP, gentle passive stretching is started.
 Vascularized Gracilis
Muscle Transfer
Introduction
The transfer of the functioning gracilis
muscle is the only answer to situations
like some cases of brachial plexus injuries
and Volkmann’s ischemic contracture. The
indications for such a muscle transfer have
already been discussed in the previous
chapters.
Advantages
• This is an easy muscle to harvest and has a
pedicle of length even up to 6 to 7 cm.
• The donor site morbidity is minimal.
• It may even be possible to split the muscle
for different functions like for motorizing
the thumb and fingers, due to the unique
anatomy of the gracilis muscle. This
muscle has a dual nerve supply and the
muscle fibers can be split according to the
nerve fascicles supplying it.
• The muscle has a length almost equal
to the length of the arm (when using the
muscle as elbow flexor), and also equal to
the length of the forearm (when using the
muscle as finger flexor or extensor).
• The cross section of the muscle is such that
it appears physiological when contracting
and does not appear grotesque.
• There is no motor deficit in the lower limb
after removal of the gracilis muscle.
62
Disadvantage
The skin paddle of this flap is not very reliable.
Surgical Steps
Donor Site Dissection
• The preferred anesthesia is either general
anesthesia or combined regional block—
continuous epidural anesthesia with
supraclavicular block (if the surgery is for
finger or hand motorization).
• Prepare for the procedure as outlined in
the Appendix II.
• Prepare the involved upper limb,
including the shoulder, neck and front of
chest.
• Prepare the opposite side thigh and
groin regions.
Markings (Fig. 15.62.1)
• Flex the hip to 90° and the knee to 90°. Now
abduct the hip to the maximum possible.
On the medial side of the thigh, the
prominence of the adductor longus muscle
can be seen from the pubic tubercle.
Immediately posterior/inferior to this
prominence, there is a small groove and
within this groove is the gracilis muscle.
Sometimes, it may be obvious as a small
prominence in the depth of the groove;
 CHAPTER 62  VASCULARIZED GRACILIS MUSCLE TRANSFER
Fig. 15.62.1  Markings for the harvest of gracilis muscle
sometimes it may only be palpable in the
groove. Now, mark a point on the pubic
tubercle “A” and another point on the
medial femoral condyle “B”. Join these two
lines. This forms the superior border of
the gracilis muscle. It does not represent
the axis of the flap. The muscle is about
2 cm inferior or behind this axis. The skin
paddle can be marked now. At the proximal
end of the axis, an ellipsoid skin paddle
can be marked “E” about 5 cm distal to the
pubic tubercle with its superior surface on
the marked line. Hence, the skin paddle
will lie over the muscle. The maximum size
of the skin paddle can be 5 cm/8 cm.
• Mark the incision about 2 cm parallel to
and inferior to the line AB. This line will
start proximally at the distal tip “C” of the
skin paddle and end at a point “D” on the
medial side of the knee, posterior to the
medial femoral condyle.
• Make the incision CD. First make the
middle third of this incision. Go through
the skin, superficial fascia and the deep
fascia. By applying retractors on both
sides of the wound, the gracilis muscle
can be seen surrounded by loose areolar
tissue. The adductor longus muscle can be
seen superiorly and the adductor magnus
inferiorly.
• The gracilis muscle can be dissected free
from the loose areolar tissue. There will
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
should be raised now.
• The adductor longus muscle will come
into view (Fig. 15.62.2). A retractor must
be placed and the adductor longus
muscle retracted superiorly, to expose
the undersurface of this muscle. Now,
the vascular pedicle can be seen entering
the undersurface of the gracilis muscle.
There will be one or two branches from
the pedicle to the adductor longus muscle
that should be carefully ligated and cut.
Similarly, the branches to the adductor
magnus muscle can also be ligated and
divided. This will allow further retraction
of the adductor longus muscle and further
expose the vascular pedicle.
• About 3 cm proximal to the vascular hilum,
the nerve can be seen and dissected. This is
the anterior branch of the obturator nerve.
This must be gently dissected proximally as
the nerve lies on the surface of the adductor
magnus muscle. The greater the length of
the nerve that is dissected, the easier is the
nerve anastomosis at the recipient site.
• When the entry point of the vascular
pedicle is made out on the medial/
undersurface of the gracilis muscle, the
incision on the inferior edge of the skin
paddle can be made. Anchoring sutures
should be placed again between the deep
fascia and the dermis of the skin paddle.
Now, the dissection should go on the
undersurface of the gracilis muscle and
any branches to the adductor magnus
muscle should be ligated and divided. This
280 SECTION 15  ADULT BRACHIAL PLEXUS INJURIES
Fig. 15.62.2  Dissection of the vascular pedicle
will totally free the circumference of the
muscle, which will now be attached by the
vascular pedicle and the nerve only.
• Identify the origin of the gracilis muscle
from the pubic tubercle and dissect it.
• Now, complete the distal third of the
incision. Go through the superficial and
deep fascia. The muscle can be followed
up to its insertion on the medial femoral
condyle as a thin tendon. This tendon will
lie between the sartorius superiorly and
the semitendinosus inferiorly.
• Mark every 5 cm on the muscle with a 3.0
silk suture. This step is to ensure that when
the muscle is transplanted, the optimal
length will be maintained and will neither
be lengthened nor shortened.
• Now, divide the origin of the gracilis
muscle, as close to the pubic tubercle as
possible. This may be tendinous at some
areas. The division of the origin can be
done using cautery.
• Divide the tendinous insertion.
• Observe the bleeding from the edges of
the skin paddle. Make a streak on the
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
postoperative period.
• Now, the muscle lies free, attached only by
the vascular pedicle and the nerve. These
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
recipient site for vascular anastomosis.
• Management of the donor site: After securing
hemostasis, the secondary defect should be
closed in layers with subcutaneous suturing
with 3.0 vicryl and the skin closed primarily
with 3.0 ethilon after keeping a suction
drain. Sterile dressings should be applied
and elastocrépe bandage applied over it.
Vascular Anastomosis
• The flap is brought to the hand defect.
First, 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 vascular pedicle. The flap is then
placed over the defect with the correct
orientation and the end of the pedicle
should be placed over the recipient
vessels. A few sutures should be applied to
inset the flap.
• The recipient vessels should be divided,
blood flow checked from the divided artery
and approximator clamps applied. The soft
clamps must be released from the donor
vessels. Vascular anastomosis should be
done (The technique of vascular anastomosis
is beyond the scope of this manual).
Recipient Site Dissection
It depends on whether the gracilis is being
used to bring about (I) elbow flexion or
(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
Introduction
Mutilated hands are those in which there has
been a loss of composite tissues which may
be either skin, soft tissues, bones, tendons
or fingers themselves. Thus, mutilated hands
result in disability of varying degrees. A
minimum of three structures should be lost
before it can be called a mutilated hand.
Mutilated hands can present in the
emergency situation or can present in the
outpatient clinic after many attempts have
been made at reconstruction. When such
patients present to surgeons, it is very essential
to do what is best for him, as the disability with
which the patient presents may be extreme.
To simplify the method of assessing the
defect, hand mutilations can be classified as
follows:
Surface Mutilation
• Dorsal
• Palmar
• Ulnar
• Radial.
The basic work-up of such patients is
threefold:
• Assess what is lost.
(THE DEFECT)
• How to reconstruct the defect?
(THE PLAN)
• When to carry out the plan?
(THE TIMING)
63
Terminal Mutilation
The basic requirements for a functioning
hand are the following:
• Ulnar post: Consisting of a minimum of
two fingers.
• Radial post: Consisting of a thumb.
• Thumb web: The connecting structure
between the radial post and the ulnar post.
Radial Post
Though, it quantifies that there must be at least
two fingers, there are also some qualifying
criteria:
• The fingers that are available must have
a critical length up to the middle of the
middle phalanx (MPX) of the finger.
• The metacarpophalangeal (MCP) joints of
the available fingers must be mobile.
• They must have sensate tips.
• The two fingers that are available can be:
• The index and middle fingers: In which
case the power grips of the hand may
not be effective?
• The middle and ring fingers: In which
most of the function in the hand can be
achieved?
• The ring and little fingers: In which case,
not only precision grips on the hand are
impaired, but the total power of the hand
is also impaired, because the motors of
the little finger are not powerful enough.
• Hence, if no fingers are available and
reconstruction is planned, it would be
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
ulnar post is described in Table 16.63.1.
Radial post: This is represented by the thumb.
The thumb must be of critical length, up
to the neck of the proximal phalanx. If this
length is not available, the thumb must be
reconstructed up to this level at least.
Surgical option, characteristics, level of
amputation of radial post is described in
Table 16.63.2.
Thumb Web Absent
Surgical option and characteristic of thumb
web is described in Table 16.63.3.

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
Amputation proximal to the
neck of the proximal phalanx,
up to the metacarpophalan-
geal joint
Amputation proximal to the
metacarpophalangeal joint
to the base of the metacarpal
bone with intact carpometa-
carpal joint
Characteristic
•  Patient not willing for toe transfer
•  Not willing for microsurgery
•  Expertise not available for
microsurgery
In children
Expertise not available for
microsurgery
Microsurgical expertise available
Surgical option
Osteoplastic reconstruction
Vascularized wrap around great toe
transfer
Vascularized second toe transfer
Pollicization and opponensplasty
Vascularized second toe transfer
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

Table 16.63.3 Surgical option and characteristic of thumb web
Thumb web not present Characteristic
Contracted thumb web—moderate
Contracted thumb web—severe
Sequence of Surgery
When all three components: (1) the radial
post, (2) the ulnar post and (3) the thumb web
are not available, reconstruction of all the
three components is prescribed as discussed
above.
• First the ulnar post must be reconstructed.
• Next the thumb web must be reconstructed.
• Finally, the thumb must be reconstructed.
There must be a minimum period of three
months between two procedures.
Prosthetics
Training Prosthesis
When the patient presents with a loss of
fingers or thumb, the remaining digits
usually lose their useful function because
CHAPTER 63  THE MUTILATED HAND 287
Surgical option
Release by:
•  Z plasty
•  Square flap
Release and flap cover:
•  Groin flap
•  Posterior interosseous artery flap
they have nothing to act against. For
example, when the fingers are not present,
the thumb loses its capacity to pronate. This
will lead to a functionless hand even after the
reconstruction of the fingers, because the
thumb is not useful. To make such thumbs
to be trained, it is advisable to attach a
prosthesis to the ulnar post that the thumb
can act against.
Functional Prosthesis
These are usually prescribed for more
proximal amputations, to achieve basic
function.
Cosmetic Prosthesis
Cosmetic prosthesis can be prescribed for
loss of tips of fingers.
 Vascularized Double
Toe Transfer
Indications
A double toe transfer of the contralateral
second and third toes on a single pedicle
is indicated for loss of contiguous fingers
of the hand. Typically, the stumps must be
at the level of the metacarpal heads, so that
the metacarpophalangeal joints can be
reconstructed.
If the amputation of the fingers is more
proximal, i.e. at the level of mid-metacarpals,
it is ideal to augment the stump with a
nonvascularized bone graft and skin flap,
before the double toe transfer is done. This is
because, the double toe harvest should only be
done at the level of the metatarsophalangeal
joints of the second and third toes. If the toes
are cut proximally, the stability of the foot will
be lost.
Preparation
• Palpate the dorsalis pedis artery and mark • Prepare the ipsilateral lower limb from the
the course on the opposite foot.
• Put the leg in a dependent position and
mark the main dorsal veins, the transverse
arch and the great saphenous system.
• Mark a dorsal triangle on the dorsum of the
foot, encircling the second and third toes
(Figs 16.64.1A and B). The medial limit of
the base of this dorsal triangle should not
cross the midpoint of the first web space
between the great toe and the second toe.
64
Similarly, the lateral limit of the dorsal
triangle should not cross the midpoint of
the third web space between the third and
fourth toes. The apex of the triangle should
be about 1.5 cm proximal to the web space
between the second and third toes. Mark
the plantar triangle slightly smaller than
the dorsal triangle.
• Mark a point “A” at the level of the distal
edge of the inferior extensor retinaculum,
halfway between the dorsalis pedis artery
marking and the great saphenous system
marking.
• Draw a curvilinear line between the point
“A” and the apex of the marked triangle.
• Similarly, from the apex of the triangle on
the plantar aspect, make a marking that
extends from the apex proximally along
the second metatarsal to the midsole.
Surgical Steps
knee distally and apply the drapings.
• The tourniquet can be raised and the time
noted.
• Make the dorsal incision down to the
dermis only.
• Raise medial and lateral flaps for about 2 to
3 cm on either side.
• The following should be dissected now—
the great saphenous vein, other dorsal
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
distal part of the intermetatarsal space,
where it will divide into two branches to
the great toe and the second toe.
• 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 tag with 7.0
polypropylene.
• Dissect the extensor hallucis longus ten-
don of both the second and third toes and
divide it at the level of the distal edge of the
inferior extensor retinaculum. Divide the
tendon of the extensor brevis at the level of
the metatarsal base.
• At the distal part of the dorsalis pedis artery,
identify the deep communicating branch
going to the plantar side. This branch will
join with the first plantar metatarsal artery
to form the plantar digital artery. And this
plantar digital artery will divide into two:
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.
• Now surgeons go to the plantar side
dissection. Make the plantar incisions.
The medial and lateral plantar digital
nerves are identified. The fascicles to the
great toe and the fascicles to the second
toe teased from the second medial digital
nerve. The fascicles going to the second
toe are cut as proximal as possible and
tagged with 7.0 polypropylenes. Similarly,
the plantar digital nerve to the second and
290 SECTION 16  DIFFICULT HAND PROBLEMS
third toes is dissected and the nerve is cut
as proximal as possible and tagged with 7.0
polypropylenes.
• The flexor digitorum brevis muscle is cut at
the midsole level, where it joins the tendon
of the long flexor. The long flexor tendons
of the second and third toes are divided at
the midsole level.
• The medial plantar digital artery (branch
to the great toe) is divided.
• The transverse metatarsal ligament is
divided on the medial aspect of the
metatarsophalangeal joint of the second
toe. Great care should be taken at this
level to avoid injury to the vessels at this
level.
• Now, retractors should be applied to the
second metatarsal and retracted laterally
and the first metatarsal retracted medially.
The arterial system is now exposed. The
system should be carefully dissected,
taking into account the dominance of the
vessel system. This can be assisted by care­
fully dividing the interosseous muscles
and further exposing the arterial system.
• 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
second and third toe metatarsophalangeal
joints are now incised proximally, near
the attachment to the metatarsal bone.
This incision should be taken on the
volar aspect and both joints disarticulated
from their respective metatarsals. Thus, a
cuff of capsule and volar plate should be
harvested along with the two toes.
• Once the disarticulation is over, the
remaining soft tissues can be divided. This
includes the third plantar artery system, so
that the double toe flap is now held only by
the arteries and veins.
• Now release the tourniquet, apply warm,
moist pads over the double toes and the
vascular pedicle. Take care to prevent
the toe from falling down and shearing
the vessels. Raise the foot for about 5
minutes. Then place the foot on the table.
It usually takes about 15 to 20 minutes for
the circulation to be re-established in the
dissected toes. By the end of this time, the
toes become pink and warm and ready for
transfer.
• 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
recipient site for vascular anastomosis.
• Management of the donor site: After
securing hemostasis, the secondary defect
should be closed primarily 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 and elastocrépe bandage applied
over it. A posterior below knee plaster of
Paris (POP) slab should be applied.
Recipient Site Dissection
• The hand is prepared as described in
Appendix I and Appendix II.
• 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 palm of the
hand proximal to the stumps of the middle
and ring fingers. Raise the medial and
lateral skin flaps, apply anchoring sutures
 CHAPTER 64  VASCULARIZED DOUBLE TOE TRANSFER
with 3.0 ethilon and dissect the following
structures:
• The flexor digitorum profundus tendons
of the middle and ring fingers.
• The digital nerves to the middle and
ring fingers—the ends should be tagged
with 7.0 polypropylenes.
• Similarly, make an incision on the dorsum
of the hand proximal to the stumps of
the middle and ring fingers. Dissect the
following structures and keep ready:
• The extensor digitorum tendons of the
middle and ring fingers.
• Prepare the heads of the metacarpals
of the middle and ring fingers, to
which double toe flap is going to be
attached.
• 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.
Fixation of the Double Toe Flap
• Bring the double toe flap to the recipient
site. Place the toes over the stumps of
the middle and ring fingers and get a
good position, a position in which good
opposition can be achieved with the
fingers and is a functional position.
• A subcutaneous tunnel is created between
the recipient site vessels and the summit
of the stump. This tunnel is for the vessels
of the double toe flap to be passed through
to reach the recipient vessels—the radial
artery.
291
• The structures to be passed through the
tunnel are:
• The arteries
• The veins
• The deep peroneal nerve.
• Fixation: It is done by repairing the joint
capsule of the second and third toes with
the joint capsules/soft tissues around
the heads of the middle and ring fingers
respectively. The reconstruction of the joint
capsules is done with 4.0 polypropylenes.
• If the toes still appear unstable, they can
be stabilized with short oblique K-wires
without causing damage to the vessels.
• Tendon repair: The flexor longus tendons of
the toes are sutured to the flexor digitorum
profundus tendons of the middle and ring
fingers, and the extensor longus tendons
of the toes are sutured to the ends of the
extensor digitorum tendons of the middle
and ring fingers. The tension should be
adjusted, so that, the toes are stable and
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
to the two plantar digital nerves of the toes
and the deep peroneal nerve is sutured to
the superficial branch of the radial nerve
at the anatomical snuff box. The nerve
repairs are done with 7.0 polypropylenes
using epineural sutures.
• Vascular anastomosis: The recipient vessels
should be divided, blood flow checked
from the divided artery and approximator
clamps applied. The soft clamps must be
released from the donor vessels. Vascular
anastomosis should be done (The technique
of vascular anastomosis is beyond the scope
of this manual).
 SECTION

17

Appendices
 Preparation for
Hand Surgery
Introduction
When the patient is put on the table for
surgery, the position of the patient is
important. For any standard hand surgical
procedure, supine position of the patient
is ideal. Even if surgery is planned on both
the hands, they can be performed with the
patient in the supine position.
Before the actual surgery is performed,
there are certain things to be made ready.
• Getting the electrocautery equipment
ready: Usually, only the bipolar cautery
is used in hand surgical procedures.
However, in procedures like the use of
pedicled latissimus dorsi muscle flap
and some procedures on the upper arm,
monopolar cautery may be used. Hence,
these equipments must be made ready.
• Getting the tourniquet ready: The
recommended tourniquet for use in hand
surgery is the pneumatic tourniquet, where
the calibration of the pressure used is clear.
The tourniquet cuff must be applied at the
level of the upper arm of the side that is
going to be operated.
• Applying the monitors: Like the pulse
oximeter and noninvasive blood pressure
(BP) monitors.
• Setting up the intravenous line: Called
traditionally the “life-line”, this IV line will
serve as a portal for drug delivery and for
I
resuscitation if there is a fall in the general
condition of the patient.
• Catheterizing the urinary bladder: This is
particularly important when the surgery
may take a long time, or if the condition
of the patient must be monitored closely.
• Giving the prophylactic antibiotic: A dose
of antibiotic is given as soon as the patient
is put on the table. This is followed up with
one dose after 12 hours and the next after
another 12 hours.
• Checking required materials for the
procedure: Like the silastic rods or silastic
materials which may be needed in cases
like staged tendon reconstruction, external
fixators and autoclaved set of plates and
screws along with AO instruments which
may be needed in bone surgery on the
hand.
• Getting drugs ready for use during the
surgical procedure: Some drugs may be
required to be given during the course
of the procedure. For example, during a
replantation procedure, a bolus dose of
injection heparin may be required to be
given intravenously just before release of
clamps. Hence, it is important to have the
required drugs ready for use.
• Wearing the surgical loupe: The basic
requirements for a good hand surgery are:
• Good lighting
• Good anesthesia
• 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
Preparation Before the
Patient is Brought to the
Operation Theater
Before the patient is brought to the operation
theater, the following should already have
been done. These should not be done on the
table or after anesthesia has been given.
• Doppler: A Doppler study to analyze the
vascular pattern in the patient and an
appropriate plan must be ready.
• Markings: When the Doppler study has
been done, the appropriate markings for
the flap should be made preoperatively
and the plan explained to the patient
immediately. Any alternate plan if made
should also be informed to the patient and
consent obtained for the same.
• Lint: Once the marking for the flap has
been made, a lint pattern must be cut,
given to the operating room personnel for
autoclaving and to be kept ready for use
during surgery.
• Measurements: The accurate measure­
ments must be made before the patient
is wheeled into the operating room. For
example, the length of the second toe
required for a toe transfer must be made
preoperatively, with the help of relevant
X-rays of the foot, the opposite hand for an
X-ray of the normal thumb, etc.
• Photographs: Clinical photographs are
a must. But, they must be taken pre­
operatively, with appropriate positioning of
II
the patient. Sometimes, movement videos
may be required, which may not be possible
if the patient has been anesthetized.
Only after the above conditions have been
fulfilled, the patient may be put on the
operating table. Once the patient is on the
table, he is under the care of an anesthesio­
logist, who should be given freedom of space
and time to decide on the anesthesia.
Preparation While Anesthesia is
Being Delivered
While anesthesia is being delivered, the
following should be arranged:
• Microsurgery chart: This is a form that
records the main events of the microsurgical
procedure. A sample of this form is shown
in the section on proformas. It is the duty
of the surgeon to allocate the duty of filling
out this form to a responsible person.
• Instruments: The microinstruments that
are required, any special instruments that
may be required, should be arranged on a
tray.
Preparation After the
Anesthesia has been
Delivered
• Positioning of patient: Once the anesthesia
has been given, the patient can be put
298 SECTION 17  APPENDICES
into position for surgery. This may be
determined by the procedure that is being
done, or the number of teams that are
going to operate.
• Tourniquets to be applied: Tourniquets
should be applied at the appropriate parts.
• Setting up of the various equipment: Before
the surgeon can go to wash up, the following
equipment must be positioned in such a
way that it is convenient for the surgeon,
convenient for monitoring of the patient
by the anesthetist, convenient for the staff
nurses and the paramedical personnel to
carry out their duties.
• Microscope
• Bipolar and unipolar cautery machine
• Patient vitals monitoring machine
• Tourniquet machines
• Compressed air sources
• Video monitor from the microscope.
• Earthpad for cautery: Appropriate place­
ment of the earthpad for cautery should be
done now, after the position of the patient
has been determined.
• Bladder catheterization: The next step to
be done is catheterization of the bladder.
This step is very important for monitoring
of the patient, especially in this surgery
which may be prolonged. When this has
been done, the surgeon can wash up.
• Preparation and draping: Now, the pre­
paration and draping of the patient can be
done. Only after the draping, the following
can be procured and placed in the surgical
field.
• Bipolar cautery leads and wires
• Unipolar cautery leads and wires
• Start of surgery: Now the surgery can be
started. Apart from all the above, one more
thing is very important, especially when
a microsurgery procedure is being done.
This is decorum in the theater.
 Preparing Instrument Sets
for Use in Hand Surgery
Preparing Instrument Sets
Following are the preparing instrument sets
for use in hand surgery:
• Axillary block pack
• Basic set
• Tendon set
• Bone set
III
• Mosquito-straight artery forceps—two pairs
• one pair—skin hooks
• one pair—cats paw retractors
• One needle holder—7”
• One sponge holding forceps
• One kidney tray
• One stainless steel cup
• One towel clip
• 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).
300 SECTION 17  APPENDICES

• 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
The sural nerve graft is quite commonly used
in hand surgery in the following situations:
• In brachial plexus injuries where nerve
gaps have to be reconstructed.
• Conditions where loss of nerve occurs
following trauma or tumors.
Surgical Steps
• First prepare and drape the entire leg
and foot from which the nerve is to be
harvested.
• Mark the course of the nerve:
• Mark the lateral malleolus and the
lateral border of the tendo-achilles
at the level of the lateral malleolus.
Mark the midpoint “A” of the distance
between the lateral malleolus and the
lateral border of the tendo-achilles.
• Now consider the calf region of the leg
and note the level of maximum convexity
of this region. Mark the midpoint “B” of
the maximal convexity on the calf region
(Fig. 17.IV.1).
Fig. 17.IV.1  Markings for harvesting a sural nerve graft
IV
• Draw the line AB. This marks the course
of the sural nerve.
• The surgery can be done under local
anesthetic infiltration.
• The incision is made over the point “A” and
extended proximally for about 5 cm along
the marked line AB, through the skin and
subcutaneous tissues.
• The skin edges are retracted and the sural
nerve is dissected. It runs alongside the
lesser saphenous vein and this vein should
not be mistaken for the nerve.
• A skin hook is applied on the nerve and
lifted up. Gentle traction is applied to
make the nerve taut. The proximal course
of the taut nerve can be palpated under
the skin along the marked line AB. The skin
incision is extended further proximally for
another 5 cm and the nerve is dissected.
• This step is repeatedly done with the
help of retraction of the skin hook, till the
point “B”, with where the nerve may be
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
of normal saline till it is used.
 Harvesting a Skin Graft
A skin graft is required in many of the
reconstructive procedures in hand surgery.
It is therefore essential that the hand surgeon
be adept in taking skin grafts of varying
thickness according to the situation.
The materials required for harvesting a
skin graft can be prepared in the form of a
packed set that can be used when required.
The preparation of this skin graft set has been
outlined in the Appendix on preparation of
sets for surgery.
The requirement of skin graft is of two
categories in hand surgery:
• The first type is the small graft required for
a part of a single finger alone. An example
would be the donor site of a cross finger
flap. This small skin graft can be harvested
from the medial side of the upper arm.
The advantage of harvesting a small graft
in this site is that it is done in the same
field of anesthesia (axillary block), it is not
cosmetically disfiguring as it is hidden and
it does not require many dressings in the
form of Gamgee pads and bandages as
would be required for a dressing on the
thigh.
• The second type is the requirement of a
large sheet or sheets of skin graft to cover
extensive raw areas on the forearms or
hand, or to cover the donor site of a large
flap like the radial artery forearm flap or
posterior interosseous flap. This will have
to be harvested from the thigh/thighs.
V
The first type is described in the section on
cross finger flap. The method of harvesting
a skin graft from the thigh will be discussed
here.
Surgical Steps
• This surgery requires an anesthesia of the
lower limbs and this must be informed
to the anesthetist at the beginning of the
procedure on the hand.
• Ask a theater assistant to hold up the
opposite side leg and prepare the thigh
with antiseptic solution from the inguinal
region to just below the knee.
• Apply two sterile sheets on the table,
covering also the unprepared lower limb.
Now place a sterile towel lengthwise on the
sterile sheets and receive the unprepared
leg. Drape this part securely and apply a
sterile bandage to secure it. Then a sterile
sheet can be placed over the abdomen.
• Paint the thigh again with antiseptic
solution.
• Apply a disposable skin graft blade in the
graft handle and adjust the thickness.
• Harvest a graft from the thigh, preferring
the medial side, for cosmetic reasons.
• Place the skin graft in normal saline
solution. Apply a moist abdominal pad
over the area where the skin graft has been
taken and apply gentle pressure. Wait for
2 minutes and then gently remove the

pad. Apply paraffin gauze over the site in a
single layer to cover the entire area.
• Place gauze pieces that have been soaked
in betadine solution over the paraffin
gauze, to again cover the entire area. Apply
Gamgee pads over the betadine gauze and
APPENDIX V  HARVESTING A SKIN GRAFT 303
the circumference of the thigh and roll
sterile bandages over the entire thigh. The
bandaging should be secure and should
apply gentle compression. This can be
enhanced by applying a crepe bandage over
the dressing.
 Harvesting an
Ulnar Bone Graft
Surgical Steps
• The upper limb is prepared up to above the
elbow.
• A gentle “S”-shaped incision is marked
over the subcutaneous border of the ulna
just distal to the olecranon. This incision
should be about 8 cm long. The incision
is made deeply, down to the bone (Fig.
17.VI.1).
• The incision is made on the periosteum
and the periosteum elevated on both sides
to expose the ulna for a width of about 3
cm.
• The required dimensions of the bone are
now marked on the ulna. The length of the
Fig. 17.VI.1  Markings for harvesting an ulnar bone graft
VI
bone required is the length of the thumb
with 1 cm extra. The width should be 2 cm.
• Perform the osteotomy to raise the cortico
cancellous bone graft. If the bone graft is
going to be pegged into a single bone, the
graft should be sculpted into the shape of
a “cricket bat”, to enable the “handle” end
to be pegged into the head of the bone. If
the bone graft is to be inserted between
two ends of bone, as is done when doing
a surgery for nonunion, the bone graft
should be sculpted in the form of a “ladle”
or a “roti belan”, with a “handle” on either
end (Figs 17.VI.2A and B).
• 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.
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
described in Appendix I.
• 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
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
anesthetic infiltration or infiltration of
tumescent solution.
• The thigh is prepared from the level of the
inguinal ligament to the knee.
• Markings: The thigh is flexed and adducted
to expose the lateral surface. This position
will make the fascia lata taut. It extends
from the anterior superior iliac spine to
the knee. The width of the fascia is about 10
cm and the anterior limit is the imaginary
line drawn from the anterior superior iliac
spine to the lateral femoral condyle.
• A longitudinal incision AB is marked
about 4 cm posterior to the marking of
the anterior limit of the fascia lata. The
length of this incision should be about 4
cm longer than the requirement of tendon
graft. The proximal limit of the incision
is 10 cm from the anterior superior iliac
spine (Fig. 17.VIII.1).
• The marked incision line is infiltrated with
tumescent solution to provide analgesia.
• The incision is made through the skin and
subcutaneous tissues. When this is done,
VIII
Fig. 17.VIII.1  Markings for harvesting a fascia lata graft
the fascia lata will be exposed as a shiny
white layer and will feel thick.
• The anterior and posterior skin flaps are
raised superficial to the fascia lata for
about 4 cm in either direction, to expose
the fascia lata for harvest.
• The fascia lata is now ready for harvest.
Usually, a width of about 4 cm and a length
according to requirement is harvested.
The required dimensions of the fascia lata
is marked and incised all around with no.
15 blade. The harvested graft is placed in
normal saline solution.
• If it is possible, the defect in the fascia
lata is repaired with 3.0 polypropylene
continuous sutures. If it is not possible,
the defect is left as such and the wound is
closed in layers: subcutaneous tissues with
3.0 vicryl, and skin with 3.0 polypropylenes
subcuticular sutures.
• Sterile dressings and elastocrepe compres­
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:
Suture material used:
Vein 2: Vessels anastomosed:
Team:
Suture material used:
Other: Vessels anastomosed:
Team:
Suture material used:
Other: Vessels anastomosed:
Team:
Suture material used:
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:
Duration since injury:
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:
 Volkmann’s Ischemic
Contracture Evaluation V
Evaluated by:
P.S. Number: Date:
Name: Age/Sex:
Side involved:
Date of accident:
Duration since injury:
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
Power of Good Weak Contracture
flexion of fingers
Power of Good Weak Contracture
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:
Duration since injury:
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:

MCP joint PIP joint DIP joint

Active Passive Active Passive Active Passive
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:
Duration since injury:
Cause of injury:
Local symptoms: Pain/Swelling

Constitutional symptoms: Fever/malaise:

Position of the joints of the fingers:

MCP joint PIP joint DIP joint

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

MCP joint PIP joint DIP joint

Active Passive Active Passive Active Passive
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:

MCP joint PIP joint DIP joint

Active Passive Active Passive Active Passive
Index finger
Middle finger
Ring finger
Little finger
Thumb

Plan:
Physiotherapy evaluation:

Page numbers followed by f refer to figure and t refer to table, respectively.
A Anterolateral thigh flap,
Abdominal
pocket created for burying
degloved hand 37f
wall 36
Abductor
digiti minimi 181, 182
pollicis brevis 223
Abnormal mobility bone
reconstruction 90
Acrosyndactyly 202
Adherent scars and contractures
49
Adult brachial plexus injuries
239
assessment 241
clinical examination of 242t
exploration 247
investigations of 245t
muscle transfer 259
nerve surgery 253
of exploration and nerve
surgery 264
Advancement of flap and final
suture line 141f
Advantages
Littler island flap 12
posterior interosseous flap
27
radial artery forearm flap 32
of flap 18, 23
After final flap inset 146f
and donor site closure with
skin graft 16f
After flap inset 21f
and management of donor
site 26f
After tendon suturing 276f
Amount of skin on great toe to
be harvested flap 151f
Anterior scalene muscle 249
Index
injury evaluation 310
markings for 42f Brachialis muscle 256f
Anxious patients 11 Branch to
Appearance of hand 174 great toe 114
Arthrolysis 108 second toe 152
of metacarpophalangeal Brand’s procedure 173
joint of finger 110 Buried abdominal flap 36
of proximal interphalangeal introduction 36
joint of finger 108
Associated C
bone fracture
with loss 10 Calf region of leg 122
Carpometacarpal joint 133
without loss 10
neck contracture 229 Cause
dryness of mouth 24
nerve injury or loss 11
tendon injury or loss 10 of contracture 230
Cephalic vein 42, 157
Attaching FDP tendon to bone
59f Characteristics to help and
differentiate between
Attitude of hand 173
Atypical cleft 206 typical cleft and
atypical cleft 206t
Axilla 228
Axillary Checking reach 15f
block anesthesia 41, 57 of flap 30f
or supraclavicular block 163 Chronic metacarpophalangeal
joint dislocation
B reduction 105
Clavicular fibers of pectoralis
Biceps muscle 256f
major muscle 249f
Bilateral upper limb contracture
Claw correction
229
extensor to flexor 4-tailed
Bone 127, 128, 129
assessment 4 tendon transfer
fixation 116, 157 procedure 187
grafting 94 Fowler procedure 191
injury 54 Lasso procedure 184
problem evaluation 316 Cleft hand 206
reconstruction 87 assessment 206
introduction 89 Cleland’s ligaments 14, 146
assessment 89 Coapting vascularized ulnar
surgery 230, 244 nerve to donor
Brachial plexus fascicles 258f
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
324 MANUAL OF RECONSTRUCTIVE HAND SURGERY

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

with abductor digiti minimi
muscle 181
with flexor digitorum
superficialis of ring
finger 178
P reconstruction, nature
Palm 227
Palmar
aponeurosis 58
interosseous muscle 223f
Palmar side 220
Palmaris longus tendon graft 79
Palpable cords 167
Partial crane technique 36, 38
Pedicled latissimus muscle
transfer for elbow
flexion 259
Perforators entering skin flap
98f
Peroneus
brevis 99f
longus 99f
Piece of saline gauze 163
Plan of
nerve transfer 256f
skin cover 9
Plantar digital arteries 152
Plaster of Paris 12, 18, 77, 220
Plicated EIP tendon 223f
Pollicization on dorsal and
palmar aspects,
markings for 220f
Polyethylene tube 59, 69
Position of joint 103
Positioned silastic implant in
flexor sheath 70f
Positioning new
carpometacarpal joint
of thumb 222f
Posterior interosseous
artery flap 27
flap, introduction 27
Postoperative protocol 22
after flap stage 38, 40
for stage 70, 73
Preparation
for free flap 297
for hand surgery 295
of recipient area on arm 260
on hand 41
on thigh 42
Preparing instrument sets for
use in hand surgery
299
Presurgical counseling 18, 41,
191
Previous management bone
of 89
Principle of
flap movement in five flap
method 237f
square flap method 235f
Priority of contracture release
230
Problems of skin 4
Procedures for reconstruction of
type amputations 138,
144, 148, 155, 159
Proper dorsal digital artery to
great toe 152f
II toe 152f
Prosthetics 287
Protocols for resurfacing after
contracture release on
upper limb 229t, 230
Proximal
Border
dermal flaps 20
of flap 14
end of nerve graft 122
interphalangeal 16, 23, 95
joint 19, 27, 103, 109, 114,
178, 184, 188, 203, 220
phalanx 181
tendon
anastomosis 65, 72
dissection 63
Pulley reconstruction 65
Pulp region 58, 62, 68
Pulvertaft technique of tendon
suturing 66f
R Seating patient 3
Radial artery 42
forearm flap 32
forearm flap, introduction
32
Radial
club hand 181
nerve 119, 177
of Hansen’s disease and
sequelae 177t
INDEX 325
post 285
absent 286
ulnar oblique amputation
136
Railroading tendon graft 71
Raising flap, markings for 98f
Range of motion joints 90
Raw
area and surgical plan,
assessment of 10t
areas on skin 4
Reach of harvested ADM
muscle 182f
Recipient
nerve surgery 257
vessel 42
Reduction of tip of finger 216f
Regional block anesthesia 38
Relevant
anatomy on brachial plexus
exploration 249f
vascular anatomy of great toe
152f
Removal of pop slab 82
Repair of avulsed flexor tendon
57
Replacement of joint 113
Retrieving proximal retracted
flexor digitorum
profundus tendon 59f
Reverse dorsal metacarpal
artery flap 23
Role of physiotherapy joint
reconstruction 104
Rotation at deformity 89
Roti belan 95
Roximal phalanx 91
S
Scalene muscles 249
Scalenus anterior muscle 249f
Scalp vein set 164
Second toe
harvest, markings for 155f
transfer, vascularized 155
Sedation optimization strategy
236
Segmüller
drains 59, 66, 164
tube 21, 25, 35
Sensory examination 244f
326 MANUAL OF RECONSTRUCTIVE HAND SURGERY

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