Hand Clinics

Published by WB Saunders
Print ISSN: 0749-0712
Publications
The pathogenesis of hypertrophic scars following thermal injury remains a complex and incompletely understood process but recent investigations into the composition of the tissue itself, the activities of the scar fibroblasts, and the effects of various cytokines and growth factors, have all contributed to the emergence of an increasingly clear picture. Although it may be considered just one example of a broad range of fibroproliferative disorders that afflict many different organs, often in response to diverse environmental insults, the nature of the burn injury and the special properties of skin probably play important roles in promoting the development of this especially troublesome variety of excessive connective tissue. This knowledge has provided the rationale for a number of experimental therapies that, individually or in some combination, may augment or one day supplant the more commonly employed surgical or physical treatments.
 
Although a substantial amount of molecular and cellular data have been generated in an effort to understand the process of wound contraction and scar contracture formation, questions remain. What seems apparent is that the myofibroblast is not the only cell that generates contractile forces within wounds, but it does appear to be intrinsically linked to the development of hypertrophic scars. The supposition that the formation of scar contractures is solely the result of a continuation of wound contraction is an oversimplification. Figure 4 provides a model of the possible evolution of contractile forces during the wound healing process and their role in the development of scar contractures. Migration of fibroblasts into and through the extracellular matrix during the initial phase of wound healing, prior to the expression of alpha-SMA, appears to be a fundamental component of wound contraction. During this migration, the pulling of collagen fibrils into a streamlined pattern in their wake, and the associated production of collagenase, may facilitate a more normal arrangement of collagen. Once the wound has been repopulated and the chemotactic gradient that was established by inflammatory cells is decreased, fibroblast migration will cease. It is at this point that myofibroblasts appear and play a key role in the production of hypertrophic scars, given that their prolonged presence and over-representation are hallmarks of this pathology. One of the pivotal differences between wounds that proceed to normal scar compared with those that develop hypertrophic scars and scar contractures may be a lack (or late induction) of myofibroblast apoptotic cell death. The combined contribution of fibroblasts and myofibroblasts to abnormal extracellular matrix protein production results in an excessive and rigid scar. The isometric application of contractile forces by myofibroblasts probably contributes to the formation of the whorls, nodules, and scar contractures characteristic of hypertrophic scars. Because the prolonged presence of myofibroblasts, producing an imbalance in extracellular matrix proteins and proteases, probably exacerbates hypertrophic scars and wound contraction, accelerating the rate of apoptotic cell death to reduce the cell number to that seen in normal scar may be a useful strategy for providing effective and efficient treatment of scar contracture.
 
The author investigates the complex anatomic relationship between the ulnar head and adjacent osseous structures (radius and carpus). Special attention is directed to the orientation and shape of the articular surfaces the constraining effects of specific membranes and ligaments (radio-ulnar and ulnocarpal), the shock-absorbing function of the triangular fibrocartilage, and the dynamic action of specific muscles (pronator quadratus and extensor carpi ulnaris) The anatomy of other nonstabilizing structures (meniscus homologue and prestyloid recess) is also discussed.
 
Speculating on the possible advances of microsurgery in the 1990s has encompassed discussion of transplantation technique, biochemistry, monitoring, and nerve and motor reconstruction. This article, however, is by no means exhaustive, and many other discoveries and innovations may come from areas not discussed here. The only clearly incorrect possibility concerning microsurgery in the 1990s is that nothing exciting will happen.
 
The triangular fibrocartilage complex (TFCC) is the key structure at the wrist that facilitates the rotation of the radius and the carpus on the distal ulnar. The radial or type 1D tears of the TFCC are uncommon, but they pose a major disruption of the articular contact between the carpus and the distal ulna. The tears can heal by arthroscopically repairing the TFCC back to the radius using sutures through bone tunnels. This procedure allows patients to return to their work and sports activities with significant recovery of strength and range of motion.
 
This is a report of the first prosthetic hemiarthroplasty and full arthroplasty, designed and implanted for the distal radioulnar joint in 1988. Two case reports are presented, with follow-up of 24 years. Experience and problems in the design of both a hemiarthroplasty and total prosthetic arthroplasty are described, in the hope that future developments may avoid past failures.
 
Ganglion cysts, foreign bodies and vascular malformations are some of the most common causes of a palpable mass in the pediatric hand. There are other rarer tumors, such as digital fibromas, which are unique to the pediatric population. Malignant tumors are exceedingly rare. An awareness of both the common and unusual tumors seen in the pediatric population is essential for the hand surgeon evaluating these patients.
 
One of the few muscles or myocutaneous flaps in the hand available to cover soft-tissue defects without compromising significantly the hand's function and appearance is the abductor digiti minimi muscle. A technique that harvests the abductor digiti minimi flap with a small skin island from the hypothenar eminence allows direct closure of the skin following ADM transposition and makes it possible to directly monitor the blood supply to the muscle. This skin island is much smaller than others previously reported.
 
Matricectomy refers to the complete extirpation of the nail matrix, resulting in permanent nail loss. Usually however, matricectomy is only partial, restricted to one or both lateral horns of the matrix. Nail ablation is the definitive removal of the entire nail organ. The most important common denominator in the successful matricectomy is the total removal or destruction of the matrix tissue. Matricectomy may be indicated for the management of onychauxis, onychogryphosis, congenital nail dystrophies, and chronic painful nail, such as recalcitrant ingrown toenail or split within the medial or lateral one-third of the nail.
 
Several ablative procedures exist for the treatment of distal radio-ulnar joint arthritis. This article describes the indications, techniques, pitfalls, and outcomes for the four most popular procedures: Darrach, hemiresection-interposition, Sauvé-Kapandji, and matched ulnar resection. The authors explain their personal algorithm for treatment selection, emphasizing patient requirements versus the physiologic characteristics of each procedure.
 
Microsurgical reconstruction offers unique opportunities for improving function and appearance in children's hands affected by congenital anomalies or following trauma. Strong parallels exist between the surgery for congenital and post-traumatic defects. This article defines some of the methods used in replacement of skin, the creation of new digits, and the transfer of muscles.
 
Given the complexity and diversity of congenital differences, a separate and broad category of generalized skeletal abnormalities was proposed to include all conditions that are unable to be neatly packaged into the other categories. Some of the conditions included in this category are obscure, whereas others are more common. Some conditions listed in this section may fit into other categories but may be considered as part of the overall classification scheme. This article presents congenital trigger finger, congenital clasped thumb, Madelung's deformity, and other skeletal hand deformities that are characteristic of generalized bone and connective tissue disorders, including achondroplasia and Marfan syndrome.
 
The distal radioulnar joint plays an intricate part in the function of the wrist and thus in the function of the entire upper extremity. The radius and hand move in relation to and function about the distal ulna. Significant loads are transmitted to the forearm unit through the distal ulna via the triangular fibrocartilage complex. The anatomic relationships between the distal radius and ulna and ulnar carpus are precise, and even minor modification in these relationships leads to significant load changes and resultant pain syndromes. Evaluation of a patient with ulnar wrist pain is, at best, difficult. Despite a careful and thorough history and physical examination and the use of sophisticated ancillary diagnostic studies, some patients with distal radioulnar joint and ulnar carpal complex problems remain diagnostic and therapeutic mysteries. These patients are best followed; exploratory surgery is rarely satisfying to either the patient or the surgeon. Armed with an understanding of the normal anatomy and biomechanics, the examination of such a patient and subsequent treatment should become a challenge that is rewarding for both patient and treating physician.
 
Because of the improved predictability, relative lack of donor morbidity, and excellent cosmetic appearance associated with the various forms of toe-to-hand transfers, these operations have become the procedure of choice in the reconstruction of a traumatically amputated thumb. However, a transfer from the foot may not always be available. If severe injuries, such as burns, have occurred to the feet, although a transfer may be technically feasible, it should be avoided. Occasionally, a patient will refuse to sacrifice a portion of his or her foot for either cosmetic or cultural reasons. If the presence of significant peripheral vascular disease is documented in the patient, the anatomy and suitability of the vessels supplying the toes becomes entirely unpredictable, and alternative methods for thumb reconstruction should be considered. In the acute trauma setting, first consideration as a source of donor tissue for thumb reconstruction should be given to any other digits, either ipsilateral or contralateral. Any digit amputated or severely injured at or proximal to the proximal interphalangeal joint may be considered as a possible donor digit. Careful examination of the neurovascular structures in this situation is essential to demonstrate that the zone of injury does not prohibit an appropriate repair at the recipient thumb bed. In the nonacute setting, occasionally, digits on the same or opposite hand are a valuable donor source for thumb reconstruction. Any digit found to be nonfunctional for reasons related to its location may be available for amputation and transfer to the thumb. Procedures to be performed in individuals who have a contralateral nerve palsy with severe functional loss, who have undergone previous proximal tendon surgery with poor functional digital range of motion, or who have other factors resulting in nonfunctional digits represent the ideal indications for the use of these digits in thumb reconstruction. On rare occasions, it is possible and desirable to transfer a normal digit from the same or opposite hand for thumb reconstruction. In sporadic case reports, one-stage, free microvascular transfers of normal, injured, or useless digits have been performed for reconstruction of the thumb. In patients in whom another digit, injured or uninjured, is not available or appropriate for transfer to the thumb and in whom the foot is not available as a donor site as well, then other techniques of an osteocutaneous reconstruction may be performed. This method of thumb reconstruction is generally predictable, may supply limited sensation through nerve repair and imparts little loss of a body part to the patient. The major disadvantages of this reconstructive technique are the cosmetic appearance of the reconstructed thumb, the relatively diminished sensory potential of the reconstruction when compared with that in an adjacent digit or toe transfer, and the poor mobility present in the reconstructed thumb because the osseous component is essentially a single strut of bone. However, in several situations an osteocutaneous reconstruction of a traumatically absent thumb may provide a predictable method for success with the least morbidity to the patient. This technique should be considered in any patient who has an abnormal microvascular supply to either the donor tissue region or the recipient bed. The use of alternative methods to reconstruct a thumb relies heavily on the creativity of the surgeon examining the particular factors involved in the reconstruction. Microvascular surgery has reached a level of sophistication at which the technical aspects, which previously represented the main barrier in most transfers, are a relatively minor consideration when possible donor sites for thumb reconstruction are examined.
 
Amputation of the thumb is a severe handicap. In an emergency situation, thumb amputation must be treated by means of reimplantation when possible. If reimplantation cannot be performed or fails, several methods of thumb reconstruction can be used according to various factors. These include the number of surviving fingers and the level of the thumb amputation. Pollicization is the first choice for amputations proximal to the metacarpophalangeal joint when four and even three fingers are present. It is the easiest and safest operation that supplies the best results both from the motor and sensory points of view. Pollicization can be done even in an emergency situation in selected patients. The index finger is preferred because it can be pollicized without palmar scar or tendons, vessels, or nerves crossing over. If a damaged finger is present, it is preferred to the index finger to leave one more sound finger; a damaged finger can frequently be used, because the thumb is shorter than the other fingers, and although its mobility is very important at the trapeziometacarpal joint, it is less important at the metacarpophalangeal and interphalangeal joint levels. It is preferable to take as much second metacarpal bone as necessary to place the transferred second metacarpophalangeal joint at the position of the thumb metacarpophalangeal joint so that the tendons of the index interosseous muscles can be sutured to the intrinsic muscles of the thumb. According to this concept, the distal phalanx of the transferred finger should be amputated. In this manner, the new thumb will have a normal size, only two phalanges, only one extrinsic flexor, and normal insertion of the muscles of the thumb.
 
The development of microvascular surgical techniques during the last quarter century has advanced the ability of the hand surgeon to reconstruct the traumatically amputated thumb. The use of tissue from the foot has become the mainstay of therapy for this previously exceedingly difficult reconstructive problem. Although numerous minor variations of thumb reconstruction with use of the toes from the foot are available, three main techniques—the complete great toe transfer, wraparound flap, and second toe transfer—provide a predictable outcome. With multiple donor sites available, the surgeon can choose a procedure based on the needs of the patient as well as the particular preferences of the individual surgeon involved. The uniform goal in thumb reconstruction is to provide a cosmetically acceptable, stable, mobile, and sensible thumb that can be used in opposition and pinch maneuvers. Transfer of the great toe can provide excellent reconstruction in the selected patient. This transfer may be the procedure of choice in the child who requires continued epiphyseal growth of the transferred digit. The esthetic appeal of this transfer is somewhat dependent on individual patient variation and the appearance of the toe relative to that of the contralateral uninjured thumb. In patients with a narrow great toe, the transfer can provide an ideal esthetic result. Disadvantages of this transfer are that it is less esthetic when the toe is very bulbous in appearance and that the resultant defect and morbidity in the donor foot may be significant, possibly affecting activities of daily living. The wraparound flap provides the unique ability to customize the thumb reconstruction. The final esthetic outcome of the thumb can be altered in nail size, circumference, and length. Use of the wraparound flap permits a greater portion of the great toe to be left with the foot in an attempt to preserve more normal gait and function postoperatively.³⁵ This type of transfer does not permit interphalangeal joint motion and may not permit metacarpophalangeal joint motion. Therefore, the requirements of a normal carpometacarpal joint with excellent thenar musculature so that the postoperative thumb can be put through a functional arc of motion are essential. Transferring a portion of the distal phalanx in the wraparound flap permits the intercalary iliac crest graft to have viable bone on both the distal and proximal aspects, thereby reducing postoperative osteopenia of the iliac crest graft itself.1, 31 The second toe transfer, in general, provides the least esthetic thumb reconstruction; however, it permits customized bony lengthening of the reconstructed thumb, which may be essential in patients with certain traumatic defects, and significant motion at its interphalangeal and metacarpophalangeal joints. A second advantage of second toe transfer is that the donor defect in the foot is acceptable cosmetically and provides little, if any, diminution of function postoperatively.17, 18 The second toe transfer may perform better as a digital replacement than as a thumb replacement. Regardless of the type of transfer used in thumb reconstruction, it is essential that the recipient hand provides a healthy, well-vascularized, and noncontracted recipient bed. If resurfacing of the recipient bed is necessary, the thumb reconstruction should be accomplished in a staged procedure. Careful adherence to the basic principles of microvascular surgery combined with thoughtful techniques can result in an extremely useful new thumb for the patient.
 
The author describes his experience in a Miami hospital, where an average of three to five cases per week of infections to the hand related to intravenous drug abuse were seen. The infections are classified along with the appropriate treatment techniques.
 
Ulnocarpal abutment presents a significant clinical challenge. In the last two decades, the anatomy of the ulnar side of the wrist and the pathophysiology of ulnocarpal abutment have been defined more clearly. Based on this greater understanding, a variety of treatments have been devised. This article reviews the current methods of treatment of ulnocarpal abutment.
 
Ulnar-sided wrist pain is a frequent cause for loss of practice time and competitive play for athletes. Ulnocarpal abutment, a common source of ulnar-sided pain, typically burdens athletes who participate in gymnastics, racket sports, and baseball. Although many athletes respond to nonoperative management, surgical intervention should be considered when symptoms persist. Surgical options include arthroscopic debridement, arthroscopic wafer, open wafer, or ulnar-shortening osteotomy. Treatment should be tailored to the athletes' level of function, expectations, and goals. The timing of interventions also influences the treatment algorithm. A successful outcome can be anticipated when appropriate treatment is rendered.
 
The TMC joint is an articulation with special articular surfaces adapted to produce simple (nonrotatory) and complex (rotatory) metacarpal movements. Its articular anatomy and biomechanics are closely related to the pathogenesis of osteoarthritis. The joint works under high transarticular compressive-shearing forces. In osteoarthritic thumbs, the articular forces are increased because of the constant presence of accessory APL tendons, almost exclusively of the digastric type. Other factors should be considered in the pathogenesis of TMC joint osteoarthritis, such as repetitive use of the thumb under unfavorable patterns of function) strong side-to-side pinch grips, thumb with the tendency to maintain in reposition), cartilage aging, hormonal disturbances in women, and general osteoarthritic disease. Osteoarthritic thumbs in stages I and II that have failed to respond to conservative treatment are candidates to unload the joint by tenotomy of the transarticular accessory tendons. Long-term results have been very satisfactory (97%), eliminating or substantially reducing pain and returning patients to their activity. The procedure is contraindicated in severe (stage III) TMC joint osteoarthritis and in primary articular instability.
 
The first successful hand transplant in the modern era of reconstructive transplantation was performed in 1998. Since then, more than 65 hand and upper limb transplantations have been performed around the globe, with encouraging results. The main goal of all upper limb transplantations is to enhance the patient's quality of life. The transplant must be successfully integrated into the patient's body and self-image and the recipient should be satisfied with the recovery of sensitivity and muscle function of the new limb. To achieve these goals, a proper and thorough design of the rehabilitation regimen is of critical importance.
 
Revision amputation is one of the most commonly performed operations in hand surgery. Despite being considered, a relatively straightforward procedure, it demands the full skills of the operating surgeon. Appropriate management is dependent upon a comprehensive understanding of hand anatomy and function, the ability to communicate clearly with the patient, and a repertoire of technical skills that allows the surgeon to select the most appropriate line of management.
 
Pain in the ulnar aspect of the pediatric wrist is an uncommon problem; however, when pain does occur it is usually the result of antecedent bony trauma or an underlying skeletal abnormality, which may lead to ulnar-sided wrist pain of varying etiology. The clinician must to be able to identify these entities within the pediatric wrist in order to make the appropriate diagnosis and plan for surgical intervention to prevent ongoing damage to the distal radioulnar joint (DRUJ). This article reviews the etiology, clinical presentation, and treatment strategies for the management of the unique problems that can affect the pediatric and adolescent DRUJ.
 
Metastatic lesions to the hand are rare, accounting for approximately 0.1% of all skeletal metastases. Various primary malignancies have been identified with a known metastasis to the hand or wrist. The most common primary sites are the lung, kidney, and breast. The phalanges are involved more frequently than the metacarpals and carpus. The distal phalanx is the most common site overall. Most patients have a prior diagnosis of a primary carcinoma, so the new onset of symptoms, such as a mass, swelling, or pain in the hand should be regarded as suspicious for a metastatic lesion. Because an acrometastasis may mimic other common hand conditions, such as an infectious or inflammatory process or a benign tumor or cyst, the clinician must have a high index of suspicion, because occult cancers have been reported. Diagnostic evaluation includes plain radiographs with CT scan and MRI. Intralesional needle biopsy or an incisional or excisional biopsy is the essential step in making a diagnosis. Treatment of the metastasis is usually palliative and consists of wide resection of the tumor or an amputation. Unfortunately the overall prognosis is poor and most patients reportedly expire within a year of developing a hand metastasis. On rare occasions a long disease-free interval can occur following wide excision of the metastasis and medical management of the primary tumor. Patients who exhibit an acral manifestation of a paraneoplastic syndrome depend directly on the treatment of the underlying malignancy, with some patients demonstrating a marked improvement following a reduction in tumor load.
 
Internal fixation of acute scaphoid fractures has significant advantages over conservative treatment, using cast immobilization. Healing rates are improved, functional recovery is accelerated, and morbidity is reduced. Percutaneous fixation has become the treatment of choice for the majority of acute fractures, since it is an out-patient procedure, which produces virtually no scarring and enables an extremely-rapid recovery; however, in those cases where a stable and anatomical reduction cannot be achieved by closed means, open volar repair remains the best method of treatment. With careful attention to technique, and the avoidance of postoperative immobilization, excellent results can be achieved, even in the case of transscaphoid fracture-dislocation of the carpus.
 
To date, 78 upper extremity transplants have been performed in 55 recipients around the world. The purpose of this article is to provide an overview of acute and chronic rejection (CR) and to summarize collective insights in upper extremity transplantation. To date, almost all patients experienced AR that is pathophysiologically similar to that in solid organs. The spectre of chronic rejection is just emerging. Upper extremity transplantation has significant potential as a reconstructive option only if efforts are invested in strategies to reduce risks of prolonged immunosuppression and in approaches to better diagnose, monitor and treat AR and CR.
 
Scaphoid fractures in the athlete present a dilemma to the treating clinician. Diagnosis of scaphoid fractures should be suspected in any athlete, especially those participating in contact sports, presenting with radial wrist pain. Appropriate imaging studies should be obtained to make a timely and complete diagnosis. Treatment alternatives for acute scaphoid fractures in the athlete include casting and staying out of sports, casting with use of a playing cast, and internal fixation. Displaced unstable fractures and proximal pole fractures should be treated by open reduction and internal fixation. Nondisplaced mid-third fractures are the most common type seen in the athlete. Alternatives of treatment should be carefully explained to the patients and family and the most appropriate treatment employed.
 
Acute injuries of the distal radioulnar joint are common. They often are not treated aggressively owing to a failure to diagnose or the misconception that there is little functional impairment if left untreated. Early aggressive treatment with restoration of anatomic alignment and stability will yield optimum results. Acute treatment usually produces a better functional outcome than late reconstructive procedures.
 
The results of acute repair of the extensor tendons proximal to the metacarpophalangeal joint vary with the degree of associated injuries. Shortening should be kept to a minimum at the time of repair. The Kleinert modification of the Bunnell technique affords the greatest tensile strength. A 3-0 or 4-0 nonabsorbable sutur e on a small tapered needle should be used. The extensor retinaculum should be resected or transposed for injuries in zones VII and TV. Sensory branches of the ulnar and radial nerves should be repaired primarily, if possible. The most frequent complication is loss of metacarpophalangeal joint flexion secondary to tendon adhesions. The more complex the wound, the greater the indication for controlled mobilization.
 
Although the carpal tunnel is open at both ends, it has the physiologic properties of a closed compartment bounded by synovium proximally and distally. When the intracarpal canal interstitial pressure rises above a critical threshold pressure, capillary blood flow is reduced below the level required for median nerve viability. Acute carpal tunnel syndrome is recognized frequently as occurring secondary to wrist trauma and infrequently due to a variety of infectious, rheumatologic, and hematologic disorders. This condition warrants prompt recognition and the treatment is early carpal tunnel release.
 
Burns of the upper extremity occur frequently in children. Because of differences in development and anatomy, patterns of burn injury are different in children compared to adults. Immediate goals after these injuries are to prevent compartment syndromes and minimize progressive damage. The second decision is whether the burn requires conservative care or grafting. If the injury heals within 2 weeks, then scarring is minimized. If the wound has not healed in that time period, then grafting should be considered. Grafting techniques that optimize function and cosmetic appearance are outlined.
 
Flexor tendon repair in zone II is still a technically demanding procedure, but the outcomes have become more predictable and satisfying. Of keystone importance for obtaining the goals of normal strength and gliding of repaired flexor tendons are an atraumatic surgical technique, an appropriate suture material, a competent pulley system, and the use of early motion rehabilitation protocols. The overall goal of hand and finger function also implies timely addressing of neurovascular injuries. New devices such as the TenoFix (Ortheon Medical; Winter Park, Florida) have shown adequate strength in the laboratory but are bulky and untested for work of flexion. Insufficient clinical data and high cost may prevent widespread use.
 
Scaphoid fractures are a common problem encountered in clinical practice. This manuscript provides an algorithm for the diagnosis, evaluation, and treatment of acute scaphoid fractures.
 
This article reviews acute dislocations of the distal radioulnar joint (DRUJ) and distal ulna fractures. Acute dislocations can occur in isolation or in association with a fracture to the distal radius, radial metadiaphysis (Galeazzi fracture), or radial head (Essex-Lopresti injury). Distal ulna fractures may occur in isolation or in combination with a distal radius fracture. Both injury patterns are associated with high energy. Outcomes are predicated on anatomic reduction and restoration of the stability of the DRUJ.
 
Distal radioulnar joint injuries can occur in isolation or in association with distal radius fractures, Galeazzi fractures, Essex-Lopresti injuries, and both-bone forearm fractures. The authors have classified DRUJ/TFCC injuries into stable, partially unstable (subluxation), and unstable (dislocation) patterns based on the injured structures and clinical findings. Clinical findings and plain radiographs are usually sufficient to diagnose the lesion, but axial CT scans are pathognomonic. Diagnostic arthroscopy is the next test of choice to visualize stable and partially unstable lesions. Stable injuries of the DRUJ/TFCC unresponsive to conservative measures require arthroscopic debridement of the TFCC tear, along with ulnar shortening if there is ulnar-positive variance. Partially unstable injuries, on the other hand, are treated with direct arthroscopic or open repair of the TFCC tear, once again, along with ulnar shortening if ulnar-positive variance is present. Unstable injuries include simple and complex DRUJ dislocations. A simple DRUJ dislocation is easily reducible but may be stable or unstable. In complex dislocation, reduction is not possible because there is soft tissue interposition or a significant tear. After the associated injury is dealt with, treatment for complex injuries requires exploration of the DRUJ, extraction of the interposed tissue, repair of the soft tissues, and open reduction and internal fixation of the ulnar styloid fracture (if present and displaced). The early recognition and appropriate treatment of an acute DRUJ injury are critical to avoid progression to a chronic DRUJ disorder, the treatment of which is much more difficult and much less satisfying.
 
The management of flexor tendon injuries continues to evolve as our knowledge of tendon biology and physiology improves. The concept of early motion after tendon repair is a key part of this evolutionary process. This section has provided a brief review of the history of early motion and presented a postoperative therapy program for flexor tendon repairs. Patient education, splinting (protective and corrective) and an exercise and activity program have been stressed. It must be emphasized that if early motion is used postoperatively, it must be done in conjunction with a closely supervised hand therapy program.
 
The forearm is the most common site for compartment syndrome in the upper extremity. The three compartments of the forearm include the volar (anterior or flexor), the dorsal (posterior or extensor), and the mobile wad. Both-bone forearm fractures and distal radius fractures are common initial injuries in adults that lead to acute forearm compartment syndrome. Supracondylar fractures, especially those with associated vascular injuries, are frequent causes of compartment syndrome in children. The flexor digitorum profundus and flexor pollicis longus are among the most severely affected muscles because of their deep location, adjacent to bone. Initial treatment consists of removal of occlusive dressings or splitting or removal of casts. If symptoms do not resolve rapidly, fasciotomy is indicated. Decompression fasciotomy of the forearm is performed through volar or dorsal approaches. The medial nerve is decompressed throughout its course, including high-risk areas deep to the lacertus fibrosus; between the humeral and ulnar heads of the pronator teres, the proximal arch, and deep fascial surface of the flexor digitorum superficialis; and the carpal tunnel.
 
Acute thermal hand burns require a systematic approach to obtain optimal results. Much has been written about the care of hand burns and the significant studies have been summarized here. Discussion still remains concerning the most appropriate treatment of the second-degree burn injury. Despite the residual controversies, a planned algorithm for treatment should help the hand surgeon decide the best approach when faced with a significant hand burn. Our algorithm for the acute thermal hand burn covers the spectrum of care with the ultimate goal of returning normal hand function.
 
In conclusion, the authors believe that younger high-demand patients should be offered the option of surgical repair; can be performed through the preferred single anterior incision with two suture anchors. Chronic tears, even with retraction, may be successfully reconstructed using a free tendon graft, often the flexor carpi radialis. Complications, including radial nerve palsy and proximal radioulnar synostosis, can be avoided with the single-incision technique. Older, low-demand patients can be rehabilitated and have excellent function without acute repair. Partial tendon injuries, for the most part, may be treated with rest and rehabilitation and explored only for chronic, urnemitting pain. The authors believe that the single anterior approach should be used over the previously popularized two-incision technique.
 
Many of the principles of flexor tendon repair and rehabilitation can be applied to zones III-V. Injuries in zones III-V are rarely isolated and neurovascular involvement is common. Because of the often extensive and unknown degree of injury, there should be a low threshold for surgical wound exploration. Primary repair of injured tendons and neurovascular structures is recommended by way of a systematic approach. Good to excellent outcomes in range of motion and tendon function can be expected; however, functional outcomes of associated nerve injuries are varied, with younger patients generally demonstrating the best results (Fig. 2E).
 
Methods of treatment of nail bed avulsions, both historic and modern, are described. A description is given of the technical aspects of replacement of amputated parts, full and partial thickness nail matrix grafts, composite grafts, and rotation of nail matrix flaps. Results of treatment with currently available techniques are successful in minimizing nail deformities.
 
Hand burns, in particular, are one of the leading causes of hand injury in children and can result in significant impairment of hand function. Appropriate initial management of hand burns in children is imperative to optimize function and minimize long-term scarring, and it is for this reason that the American Burn Association advocates referral of pediatric hand burns to a verified burn center.
 
Heightened awareness of the pathologic conditions resulting in acute vascular trauma will govern the success of management. A thorough examination with appropriate vascular studies followed by meticulous surgical intervention and a carefully monitored postoperative course avoids the associated complications of these challenging injuries.
 
Top-cited authors
Arthur Lee Osterman
  • Thomas Jefferson University
Steven Z Glickel
  • New York University
Andrew K Palmer
  • State University of New York Upstate Medical University
Jesse Jupiter
  • Harvard Medical School
Arnold Peter C Weiss
  • Brown University