Chapman’s Orthopaedic Surgery
3rd Edition

CHAPTER 37
PRINCIPLES OF HAND SURGERY AND SURGICAL APPROACHES TO THE HAND AND WRIST
Michelle Gerwin Carlson
Robert M. Szabo
Paul R. Lipscomb
M. G. Carlson: Department of Orthopaedics, The Hospital for Special Surgery, New York, NY, 10021.
R. M. Szabo: Professor of Orthopaedics, Professor of Surgery, Division of Plastic Surgery, Chief, Hand and Upper Extremity Service, University of California—Davis, School of Medicine, Sacramento, CA, 95817.
P. R. Lipscomb: Professor Emeritus of Orthopaedics, School of Medicine, University of California—Davis, Davis California, 95817.
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A. BASIC PRINCIPLES OF HAND SURGERY
Robert M. Szabo
Paul R. Lipscomb
Sterling Bunnell (1882 to 1957), the father of modern hand surgery, said, “Next to the brain, the hand is man’s greatest asset and to it is due the development of man’s handiwork. The hand begins in the opposite cerebral cortex and extends from there to the tips of the nails” (5,6). He emphasized the importance of a detailed knowledge of structural and functional anatomy of the hand and a basic comprehension of the entire upper extremity (10). He also stressed the importance of atraumatic surgical technique in reconstructive hand surgery. Reconstruction of the hand is often a composite problem, requiring knowledge of orthopaedic, plastic, microvascular, and neurologic surgical techniques. The hand surgeon must be trained to handle all of the tissues in the extremity. Surgical reconstruction of the hand requires careful technique to minimize the formation of adhesions, which tend to bind together the nicely adjusted movable parts. Although cosmesis is important, the primary purpose of surgical reconstruction is to restore enough function to allow the patient to be self-sufficient (2,5,6,7,10,12,13,14,15 and 16).
PREOPERATIVE PLANNING
Even in emergency surgery, the surgeon usually has time to examine the extremity carefully to determine the severity of involvement of the skin, vessels, nerves, tendons, and skeleton. He or she can then plan the anticipated surgical procedure, which, after cleansing and debridement, might call for a skin graft or repair of lacerated radial, ulnar, and digital arteries and nerves. Through clinical examination and radiographs, the physician can evaluate the skeletal structures and plan for reduction and internal fixation of subluxations, dislocations, and fractures.
For severe injuries, paralytic conditions, and some disease entities, staged surgical repair and reconstructive procedures may be indicated. In these cases, a sequence of
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surgical procedures can be planned and, in most cases, can be discussed with the patient and relatives before surgery.
The primary requirement in hand surgery is the restoration of the position of function, nutrition, sensibility, motion, and good skin cover. The ends of the digits should have noncicatricial touch surfaces. The thumb should oppose the fingers, and the hand should open and close for the functions of pinch, hook, and grasp. The wrist should usually be in an extended position or occasionally in a straight position, and the fingers should be flexed partially at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints. The priorities of reconstruction are, in order of their importance, artery, skin, bone and nerve, and tendon.
For elective surgical procedures, advise patients to discontinue any medications (aspirin, nonsteroidal antiinflammatory drugs) that may increase perioperative bleeding at least 4 days before surgery. Patients on warfarin should be under supervision by an internist, who should be consulted regarding management.
OPERATING ROOM SETUP
Position a standard operating table so that a hand table can be attached to it. The distal end should have a stable, perpendicular appendage that extends to the floor. When fluoroscopy is needed, use a radiolucent table without legs that interfere with positioning of the fluoroscope. Always choose a table supported by legs when using a microscope, otherwise the operative field will drift out of focus as weight is placed on and taken off the table. With the patient in a comfortable supine position, abduct the extremity to 90° and place it on the table. Arrange the overhead lights opposite each other in line with the hand table so that neither surgeons’ nor nurses’ heads obstruct the focused light. The stools on which the surgeon and the assistant sit opposite from each other should be firm and stable, and their height should be adjustable. Both the surgeon and the assistant must be comfortably erect, with their forearms resting on the hand table.
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TOURNIQUETS
A tourniquet is mandatory for almost all hand surgery. As Bunnell said, “A jeweler can’t repair a watch in a bottle of ink, and neither can we repair a hand in a pool of blood” (6). A bloodless field allows very small vessels and nerves to be seen and dissected with accuracy and minimal trauma.
Formerly, Esmarch bandages were used as tourniquets, and tourniquet palsy was not uncommon. Likewise, with the use of blood pressure cuffs that were not monitored by a mercury manometer or equipped with protective safety devices, false pressure readings, which sometimes masked extremely high pressures, remained undetected. The tourniquet gauge should, therefore, be checked and calibrated at least daily and the figures recorded (24). The calibration of many newer tourniquets is more stable and reliable. Become familiar with the one you are using and be confident that the pressure readings are accurate. Until a time of 2 hours was established by Wilgis as a safe period for a tourniquet to remain in place, tourniquet palsy was common (25).
UPPER ARM TOURNIQUET
  • Properly position the patient and the extremity, then smoothly wrap several layers of sheet wadding or Webril-type soft cast padding around the upper arm and into the lower axilla.
  • Apply the pneumatic cuff snugly and as high as is comfortably possible over the padding.
  • Securely attach the cuff to the tubing that leads from a nitrogen source, and inflate the tourniquet briefly to ensure that the system is operating properly.
  • During skin preparation, take care to avoid seepage of solutions onto the cast padding and tourniquet cuff. Accomplish this by placing a vinyl drape around the tourniquet with an adhesive border sticking to the upper arm. Be careful that this drape is not completely circumferential because when the tourniquet is inflated, a shearing force is applied to the skin that could result in injury.
  • After preparation and draping, mark the skin with a methylene blue pen to outline the proposed incisions.
  • Elevate and exsanguinate the extremity with a snugly wrapped 4-inch rubber or elastic bandage. In most adults, inflate the tourniquet to a pressure of 250 mm Hg; occasionally, in patients with heavily muscled arms or significant hypertension, inflate the tourniquet to 300 mm Hg.
In children, the pressure generally need not exceed 200 mm Hg. Exsanguination is contraindicated in patients with infections or tumors. However, in these patients, elevate the extremity for a few minutes before inflating the tourniquet.
  • In most surgical procedures requiring more than 2 hours of operating time, deflate the tourniquet for 10 to 15 minutes at the end of the first 1 to 1.5 hour. During this period, apply pressure to the wound with a soft pad for the first 5 minutes.
  • Then gently remove the pad and secure hemostasis with electrocautery and ligatures. Elevate the extremity again and reinflate the tourniquet.
  • Following application of the dressing, splint, or cast (if required), immediately remove the tourniquet and underlying padding to avoid venous congestion.
FOREARM AND FINGER TOURNIQUETS
Forearm tourniquets are safe, effective, and well tolerated for surgery in the distal forearm, wrist, and hand (11). The optimal tourniquet pressure for this technique is 75 to 100 mm Hg above the patient’s systolic pressure (11).
  • Wrap several layers of Webril-type soft cast padding circumferentially around the proximal forearm and apply a pneumatic tourniquet approximately 5 cm below the medial epicondyle.
  • Protect with a vinyl drape (as described under upper arm tourniquet) to keep the Webril dry.
  • Exsanguinate with an Esmarch bandage before tourniquet inflation.
A relatively minor procedure on the digit can be performed using a digital tourniquet.
  • Apply an encircling rubber tourniquet (Penrose drain 1.25 mm, or 1/2 inch, in diameter) at the base of the digit.
  • Wrap the drain once around the base of the digit without tension, then mark and clamp with a hemostat the points at which the surfaces of the drain meet on the circumference.
  • Remove the loop. Shorten the distance between the two marks by 20 mm.
  • Reposition the Penrose drain around the base of the digit.
  • As the assistant elevates and compresses the finger, stretch the drain around the finger so that the length is shortened by 20 mm. Then clamp the drain with the hemostat.
The pressure thus generated produces a bloodless field; the risk of digital nerve and arterial damage secondary to this pressure is minimal.
As an alternative, Salem described a method of simultaneous exsanguination of the finger and application of a digital tourniquet (21).
  • Cut a finger from a sterile rubber glove and roll it onto the finger.
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  • Cut the tip from it and roll the remaining portion proximally to form a rubber ring at the base of the finger.
This technique is contraindicated in the presence of infection or tumors. There is no good way to standardize or measure pressure beneath a digital tourniquet, and there have been cases of ischemia from the surgeon forgetting to remove the digital tourniquet before applying the dressing. For these reasons, an arm or forearm tourniquet is preferable.
ANESTHESIA
The choice of anesthesia for each procedure, other than a local block, is made by the anesthesiologist (17,23). Discuss with the anesthesiologist the patient’s concerns and wishes, the estimated length of the operation, and the length of time the tourniquet will be in place. For most children, for apprehensive adults, and for extensive procedures and patients requiring surgery elsewhere on the body, general anesthesia is usually preferable. A general anesthetic may also be necessary because infection or neoplasm may contraindicate regional anesthesia.
Regional anesthesia in the form of supraclavicular, axillary, brachial, and peripheral nerve blocks is very satisfactory for many procedures involving the upper extremity. Preoperative and, if necessary, intraoperative sedation may be used to keep the patient from moving and to lessen discomfort from the tourniquet.
Intravenous anesthesia using 1% lidocaine solution and two tourniquets on the arm, when administered by a competent anesthesiologist, is satisfactory for many surgical procedures on the hand that take no longer than 1 ½ hours. The three main problems with this technique are tourniquet pain, oozing at the surgery site, and risk of systemic anesthetic toxicity from cuff failure. Re-exsanguination 15 to 20 minutes after injection of the local anesthetic by firm reapplication of a sterile Esmarch bandage, followed by complete release and immediate reinflation of the double cuff tourniquet provides a better surgical field with improved tourniquet tolerance (18).
With proper preoperative sedation and, if necessary, intravenous sedation, an arm tourniquet is generally well tolerated for half an hour or longer. Many procedures can be performed simply with local anesthesia or a digital block. Some clinical anesthesia is produced almost immediately with a 1% solution of plain lidocaine hydrochloride, but the full effect takes 3 to 7 minutes and lasts about an hour (20). Avoid local anesthetics with epinephrine for procedures on the hand. Injection in or close to an artery can result in ischemic necrosis of digits.
DIGITAL NERVE BLOCK
  • Keep the position of the neurovascular bundles in mind.
  • Insert a 26-gauge needle dorsally between the metacarpal heads and just proximal to the finger web space.
  • Make a small skin wheal and advance the needle to the palmar aspect of the web space.
  • Aspirate to make sure that you are not in the digital artery or vein. Then inject 2 to 3 ml of 1% lidocaine.
  • Rotate the needle 90° and advance it subcutaneously to the opposite side of the finger and repeat the injection of 2 to 3 ml lidocaine into the other web space.
When active movement of the patient’s fingers is desirable during surgery, a block of the superficial branch of the radial nerve above the styloid process of the radius, as well as of the ulnar and median nerves on the palmar aspect of the wrist, is indicated
WRIST BLOCK
  • Block the median nerve between the palmaris longus and flexor carpi radialis tendon. In this interval at the proximal wrist crease, insert a 22-gauge needle directed 45° distally and 45° dorsally toward the floor of the carpal tunnel. If paresthesias are elicited, withdraw slightly and redirect the needle. Inject 5 ml of 1% lidocaine.
  • Block the radial sensory nerve three fingerbreadths proximal to the radial styloid.
  • Inject about 5 ml of 1% lidocaine evenly distributed dorsally and palmarly.
  • Block the ulnar nerve at the level of the proximal wrist crease, just radial to the flexor carpi ulnaris.
  • Using a 26-gauge needle, inject about 5 ml of 1% lidocaine after aspirating to be certain that you are not in the ulnar artery.
  • Block the dorsal cutaneous branch of the ulnar nerve by injecting 5 ml of 1% lidocaine subcutaneously beginning at the intersection of the flexor carpi ulnaris and the proximal wrist flexion crease, and ending at the midpoint of the dorsal wrist.
INSTRUMENTS
The hand surgeon requires special instruments that are often more delicate than those required for most other surgical procedures. Small knife blades, such as Bard-Parker #15 and #11; small Adson forceps; pointed, curved, and straight scissors; osteotomes and chisels; ronguers and small bone cutters; probes; hemostats; curets; gouges; tendon strippers; sharp hook and blade retractors; needles; sutures; and ligatures are indispensable for hand surgery. Other special instruments, various hand holders (including those made of malleable lead), hand and motorized
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drills, special sutures, and small needles should be available in the operating suite before starting a procedure.
MAGNIFICATION
Many hand surgeons routinely use 2.5 × to 4.5 × magnifying glasses or loupes when dissecting. With magnification, the planes between diseased and normal tissue are immediately apparent. Likewise, the small branches of the digital nerves and arteries are seen and protected easily. Operating loupes have been designed on one of three basic types of magnification systems: simple, compound (galilean), and prismatic. For discussion of the fundamental optical principles and terminology, and a concise description of various loupes available on the market, the reader is referred to Baker and Meals’ article (1).
Those who perform microvascular surgery need a variety of microsurgical instruments, as well as a double-headed or triple-headed binocular microscope with electric foot controls that allows 6 × to 15 × magnification. Learn, practice, and develop the technical skills of operating with microscopic magnification in the microsurgery laboratory; only after gaining this experience can the skill be applied to patients.
GLOVES, SKIN PREPARATION, AND DRAPING
Although vaccination against hepatitis B virus is now available, there is no vaccination against either the hepatitis C virus or the human immunodeficiency virus (HIV). Take care to avoid injury to the surgical team by needle sticks (27). Although the incidence of glove puncture varies with the type of surgery, it is suggested that, on average, 5.6 injuries occur per 100 procedures (9). Double surgical gloves significantly protect the surgeon against needle perforations, but they impair comfort, sensitivity, and dexterity (instrument and tissue handling) during operations (26). Each surgeon must individually deliberate whether the price of perceived impairment of sensation and dexterity is worth the benefit of extra protection against injury.
Each hand surgeon and operating facility should establish a standardized routine for preparation of the skin and draping, thereby ensuring that each patient receives the same careful attention to detail that is necessary for successful hand surgery. If the surgical procedure is an elective one, caution the patient at the time of scheduling to avoid scratches and abrasions to the hand and the entire extremity for 2 weeks before surgery. Advise patients who are manual laborers and who are accustomed to having grease and dirt on their hands to scrub their hands with a detergent solution twice daily for several days before surgery.
Formerly, it was customary to shave the entire extremity, but it has been shown that this is unnecessary and, in fact, may do more harm than good. Shaving should be limited to the site of the proposed incisions and is done in the operating room immediately before final skin preparation. The nails should be cleansed and trimmed, and polish should be removed before the patient enters the operating room.
After the patient and the extremity are properly positioned, scrub the hand and forearm for 10 minutes with a sterile povidone-iodine solution from the tips of the nails to the upper arm, where the pneumatic tourniquet is in position. Then dry the extremity with sterile towels and paint it with povidone-iodine. Povidone-iodine stains the digits and obscures the evaluation of capillary flow in patients whom the vascular status must be assessed intraoperatively (e.g., replants, revascularizations). Consider an alternative scrub solution like chlorhexidine or hexachlorophene, particularly in these situations. Next, apply sterile drapes and stockinette to the hand and forearm. Cover the hand table with a waterproof drape to prevent contamination of the drapes should they become wet during the procedure. Then exsanguinate or elevate the extremity and request that the tourniquet be inflated. Take a seat, usually on the axillary side of the patient, and cut the stockinette to expose the hand.
BASIC SURGICAL TECHNIQUE
The basic aim of hand surgery is to restore function and cosmesis to the greatest extent possible within the shortest, safest period of time. In acute injuries, this can often be done by thorough cleansing and debridement of the wound, followed by primary repair of nerve, bone, and tendon injuries. However, in some severe and mutilating injuries, the primary object of treatment is to obtain healing of the skin and subcutaneous tissues and skeletal stabilization without intercurrent wound infection. These injuries often mandate delayed wound closure and a further delay in the repair of tendons and nerves. For each injury or reconstructive procedure, formulate a basic plan, which may consist of one or more stages (12,13).
The time required for the induration of tissues that follows each injury and surgical procedure to subside is variable and must be anticipated. It is best to wait until all inflammatory signs have subsided, the danger of infection is past, the tissues are soft and supple, and the joints are flexible. During this waiting period, proper positioning, encouragement of active motion, and the use of corrective splinting help to prevent permanent stiffness.
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Make surgical incisions so that they offer the best possible exposure, protection of important structures, and healing with minimal scar. For some conditions, they should parallel the flexion creases in the fingers, palm, and wrist. Zigzag incisions described by Bruner or the traditional Bunnell incision in a midlateral location are often most appropriate (4,5). On the dorsum, curved and S-shaped incisions are often appropriate for the fingers, metacarpal area, and wrist. Transverse incisions are often used at the level of the wrist. See Table 37.1 and Table 37.2 and the approaches described later in this chapter.
Table 37-1. Surgical Approaches in the Hand and Wrist
Table 37.2. Structures at Risk in Hand and Wrist Exposures
Sharp dissection with the aid of loupes or magnifying glasses, Bard-Parker #15 and #11 blades, and small curved Littler scissors is essential for the atraumatic technique that has been championed by Bunnell and his disciples.
Obtain hemostasis with small hemostats and a bipolar cautery unit, both during the surgical procedure and just before wound closure, when the tourniquet is deflated. Then, irrigate the wound with Ringer’s or normal saline solution before you close the skin. Injections of 0.25% bupivacaine (Marcaine) into the subcutaneous as well as deep tissues at this point decreases the amount of analgesics needed for immediate postoperative pain control.
Primary skin closure is appropriate for most surgical procedures and some sharp traumatic wounds. Interrupted 5-0 nylon sutures are usually used for closure of surgical wounds of the hand. An occasional subcutaneous absorbable suture allows removal of the skin sutures at the end of 1 week. If necessary, Steri-Strips can then be applied, thereby eliminating cross-hatch suture scars. For young children, always use small absorbable sutures to obviate the need for suture removal.
POSTOPERATIVE CARE
DRESSINGS
After most surgical procedures, the hand can be placed in the position of function in a large, bulky dressing (Fig. 37.1) (22). Plaster of Paris splints are incorporated in the well-padded dressing, which usually extends from the proximal level of the nails to above the elbow. Circumferential casting should be avoided, but in some situations (e.g., tendon transfers in a patient with cerebral palsy), strong rigid support is essential. If flexor tendons or nerves are repaired, the wrist and involved digit are immobilized in a semiflexed position to remove tension but are never positioned in full flexion. In extensor tendon injuries, the wrist and fingers are immobilized in extension.
Figure 37.1. Bulky well-padded compression dressing. A: Use fourteen 4 × 4 inch fluffs; six 2 × 2 inch gauze; three combines; three rolls of 4-inch cast padding; two rolls of 6-inch bias stockinette; 1 yard of 4-inch stockinette; twenty-one 4 × 15 inch plaster splints; one ½ and one 1-inch tape; rope. B: Place three 2 × 2 inch gauze squares between the fingers. C: Distribute fluffs evenly about the hand. D: Place a combine dorsally and palmarly around the wrist, and wrap the hand with 4-inch cast padding. E: Place an additional combine around the elbow, which is maintained at 90°. F: Place plaster slabs (4 × 15 inches) dorsally and (G) around the elbow. H: Cover plaster with cast padding. I: Wrap the dressing with 6-inch bias. J,K: Place a tubular stocking and overwrap with 6-inch bias. L: Apply tape, and cut a slot posteriorly. M: Secure rope into the slot with tape. N: Elevate the extremity with the rope. (Reprinted with permission from Szabo RM.. Upper extremity emergency problems. In: Kravis TC, Warner CG, Jacobs LM, eds. Emergency Medicine, 3rd ed. New York: Raven Press, Ltd., 1993:164.)
In most cases, the dressing and splints should be applied with the forearm in slight supination. This is especially important if the splints or cast extend above the elbow. Sometimes, the forearm should be in a midposition, but rarely should it be immobilized in pronation.
GENERAL CARE
On removal of the drapes and tourniquet, evaluate and record the status of circulation in the exposed fingertips. Keep the hand elevated on pillows that are appreciably higher than the shoulder. Evaluate the neurovascular status at regular intervals if the procedure was extensive enough to warrant hospitalization. If there is any question about adequacy of circulation, loosen the bandages and splints; if a cast has been applied, it should be split and spread along its full length.
When the patient becomes ambulatory, the extremity should be held in an elevated position at shoulder level or above. This position is often easiest to maintain if the patient places the operated hand on the opposite shoulder. Caution the patient not to place the hand in a dependent position. If the extremity is placed in a sling, more dependent edema and postoperative stiffness occurs than when cooperative patients keep the extremity elevated by use of their own muscles.
On discharge from the hospital or outpatient facility, patients and their relatives are instructed to check circulation in the fingertips by the blanch test and to observe for any numbness or tingling that was not previously present. Patients are advised to return immediately should there be any concern about changes in sensibility or the adequacy of circulation.
SPLINTING
The correct use of splints is an important aspect of hand surgery. Splinting is used to prevent deformity, immobilize the operated part, protect joints and tendons, change or correct the position of joints, substitute for paralyzed muscles, and move joints passively.
The wrist is the key joint in the mechanics and function of the hand, whereas the metacarpophalangeal joint is of primary importance in the mechanical balance of a finger. Splinting the wrist in extension and the metacarpophalangeal joints in flexion is of fundamental importance unless specifically contraindicated.
Temporary splinting or immobilization is used before and after many surgical procedures. Splints may be made with plaster of Paris, fiberglass, plastic, or malleable metal. They are usually padded with sheet wadding, cotton, or felt, and are fastened to the extremity with web straps and buckles or Velcro fasteners.
Immobilization is used for treating infection, holding fractured bones in place, and facilitating healing after trauma or surgery. A limb is held in a certain position to protect against separation of newly repaired tissues, such as tendons, nerves, ligaments, and arteries; to keep paralyzed muscles in a relaxed position; and in some cases, to allow tissues to grow until they adapt to the desired position. Joints are gradually pulled into increased flexion or
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extension to correct deformities, to place the limb in the position of function, or to produce more motion in a joint.
Splints should not only maintain the position of function but should also allow function of all uninjured parts. Dynamic splinting is used to draw joints into flexion or extension gradually, as in changing the position from one of nonfunction to that of function. Rubber bands, spring wire, or flat blue spring steel produce tension that is controllable yet insufficient to injure the joints or to cause ischemia.
Internal splinting using K-wires, pins, screws, or plates is used to pin and immobilize fractured bones or joints. Special internal removable sutures can be used to pull the proximal ends of severed tendons distally, thereby eliminating or diminishing tension at the site of repair where individual sutures are used (3,8).
Various hand splints, fabricated for different purposes, are advertised in orthopaedic periodicals and can be obtained from surgical supply houses or manufacturers. Hospitals and outpatient facilities should maintain a supply of commonly used hand splints in several sizes.
CONCLUSION
The following article, entitled “Who Should Do Surgery of the Hand?” was published as an editorial in 1961 and is as relevant today as it was then (14). It is reprinted by permission of Surgery, Gynecology & Obstetrics.
Approximately one third of all injuries requiring the services of a physician or a surgeon, whether in the emergency department of a metropolitan hospital or the office of a rural practitioner, involve the hand. The physician administering the primary treatment for such injuries has a great responsibility, since his treatment determines, to a large extent, the final outcome.
All physicians must be taught the basic principles that should govern the treatment of an injury to the hand. They must know that it is important to protect wounds from contamination and infection and that adequate help, facilities, and proper instruments must be available before one starts to care for the injured hand. The traumatized hand must be cleansed thoroughly but gently. When compared with injuries of the arm, leg, or abdomen, the involved tissue of the hand should be sparingly debrided. Whereas many wounds of the arms and legs should be treated by delayed closure, almost all wounds of the hand should be closed primarily and this closure must be without tension. In some instances, the use of skin grafts is necessary to avoid tension. When possible, fractures should be reduced and immobilized at the time of the primary treatment. However, if the physician is not trained to care adequately for the bone injury, less harm will be done if the skin is closed, the hand is placed in a position of moderate dorsiflexion of the wrist, moderate flexion of the fingers, and moderate abduction and opposition of the thumb, and a bulky dressing is applied to prevent edema. In such selected instances, the fractures can be dealt with after the cutaneous wound has healed. Even more important is the necessity to realize that severed nerves and tendons do not require primary repair; less harm will be done under unfavorable conditions by secondary repair of nerves and tendons after the initial wound has healed. A surgeon who attempts primary suture of a flexor tendon in its digital sheath should have had considerable education, training, and experience in reconstructive surgical treatment of the hand and should be capable of performing a tendon graft.
Extensive, reparative, restorative, reconstructive, and rehabilitative surgery of the hand should be carried out in hospitals by surgeons well qualified and dedicated to this field of surgery. The surgeon interested in treatment of the severely injured hand must be educated to work in orthopedic surgery, plastic surgery, and neurosurgery. He should have knowledge of dermatologic, circulatory, paralytic and arthritic diseases which are prone to affect the hand. He must be well versed in the most minute details of the surgical and functional anatomy of the entire upper extremity. He must be versed in rehabilitative procedures and trained in splinting and bracing. He must be capable of teaching the patient how to prevent and overcome stiffness of joints and how to co-ordinate muscles which formerly had one function but after a tendon transfer have another function.
Above all, the surgeon who devotes much of his time to surgery of the hand must teach medical students, interns, and residents how to care properly for injuries which affect the hand. Many of the principles established by such pioneers as Allen Kanavel, Sterling Bunnell, and Sumner Koch are still basic and pertinent. It is important that these principles be learned if crippling of the hand is to be minimized.
Always think and strive to avoid being in the predicament that results in pondering to yourself “if there were only an operation that could undo the results of my last operation!”
REFERENCES
Each reference is categorized according to the following scheme: *, classic article; #, review article; !, basic research article; and +, clinical results/outcome study.
# 1. Baker JM, Meals RA. A Practical Guide to Surgical Loupes. J Hand Surg 1997;22A:967.
* 2. Boyes J. Bunnell’s Surgery of the Hand, 4th ed. Philadelphia: J.B. Lippincott, 1964.
+ 3. Brown C, McGrouther D. Excursion of the Tendon of Flexor Pollicis Longus and its Relation to Dynamic Splinting. J Hand Surg 1984;9A:787.
* 4. Bruner J. The Zig Zag Volar-digital Incision for Flexor Tendon Surgery. Plast Reconstr Surg 1967;40:571.
* 5. Bunnell S. Surgery of the Hand, 3rd ed. Philadelphia: J.B. Lippincott, 1948.
* 6. Bunnell S. Splinting the Hand. Instr Course Lect 1952;9:233.
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# 7. Green D. General Principles. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery, 4th ed, Vol 1. New York: Churchill Livingstone, 1999:1.
+ 8. Hester RJ, Foad N.. Early Mobilization of Repaired Flexor Tendons within Digital Sheath Using an Internal Profundus Splint: Experimental and Clinical Data. Ann Plastic Surg 1984;12:187.
+ 9. Hussain S, Latif A, Choudhary A. Risk to Surgeons: A Survey of Accidental Injuries during Operations. Br J Surg 1988;75:314.
* 10. Kaplan E. Anatomy and Kinesiology of the Hand. In: Flynn J, ed. Hand Surgery, 3rd ed. Baltimore: Williams & Wilkins, 1982:33.
+ 11. Khuri S, Uhl RL, Martino J, Whipple R. Clinical Application of the Forearm Tourniquet. J Hand Surg 1994;19A:861.
# 12. Lipscomb P. Management of Recent Injuries of the Hand. Minn Med 1955;38:299.
# 13. Lipscomb P. Treatment of Acute Injuries of the Hand. J Med Pharmacol 1958;11:447.
* 14. Lipscomb P. Who Should do Surgery of the Hand? Surg Gynecol Obstet 1961;113:233.
# 15. Lynch A, Lipscomb P. Management of Fractures of the Hand. Am Surg 1963;29:277.
# 16. Milford L. The Hand. In Edmonson CA AS, ed. Campbell’s Operative Orthopaedics, 6th ed. St. Louis: Mosby, 1980.
# 17. Ramamurthy S. Anesthesia. In G. DP, ed. Operative Hand Surgery. New York: Churchill-Livingstone, 1982.
+ 18. Rawal N, Hallén J, Amilon A, Hellstrand P. Improvement in I.V. Regional Anaesthesia by Re-exsanguination before Surgery. Br J Anaesth 1993;70:280.
# 19. Ritchie JM, Cohen PJ, Dripps RD. Cocaine, Procaine and Other Synthetic Local Anesthetics 388. In: Goodman LS, Gilman A, eds. The Pharmacological Basis of Therapeutics, 4th ed. New York: The Macmillan Company, 1970:388.
# 20. Rohrer TE, Leslie B, Grande DJ. Dermatologic Surgery of the Hand. General Principles and Avoiding Complications. J Dermatol Surg Oncol 1994;20:19; quiz 36.
+ 21. Salem M. Simple Finger Tourniquet. Br Med J 1973;1:779.
# 22. Szabo RM. Upper Extremity Emergency Problems. In: Kravis TC, Warner CG, Jacobs LM, eds. Emergency Medicine, 3rd ed. New York: Raven Press, Ltd, 1993:195.
# 23. Vandam L. Anesthesia for Hand Surgery. In: F. JE, ed. Hand Surgery, 3rd ed. Baltimore: Williams & Wilkins, 1982:74.
! 24. Wheeler D, PR L. A Safety Device for a Pneumatic Tourniquet. J Bone Joint Surg 1964;46:870.
+ 25. Wilgis E. Observations on the Effects of Tourniquet Ischemia. J Bone Joint Surg 1971;53A:1343.
+ 26. Wilson SJ, Sellu D, Uy A, Jaffer MA. Subjective Effects of Double Gloves on Surgical Performance. Ann R Coll Surg Engl 1996;78:20.
+ 27. Wright KU, Moran CG, Briggs PJ. Glove Perforation during Hip Arthroplasty. A Randomised Prospective Study of a New Taperpoint Needle. J Bone Joint Surg Br 1993;75B:918.
B. SURGICAL APPROACHES TO THE HAND AND WRIST
Michelle Gerwin Carlson
There are several factors that are important to consider when choosing the surgical approach to the hand and wrist. An ideally planned incision will give the maximum exposure of the pathology with the minimum necessary length of incision and risk of injury to the surrounding structures. If possible, the incision should fall within Langer’s lines to produce the most cosmetically pleasing scar and avoid hypertrophy (i.e., a transverse incision rather than a longitudinal one for excision of a dorsal ganglion). Injury to surrounding structures includes not only intraoperative injury but postoperative fibrosis that may limit range of motion. For instance, the dorsal approach to a metacarpal fracture avoids the dissection of the neurovascular bundles and flexor tendons necessary in a palmar approach. The dorsal approach is not only more facile but decreases the chance of postoperative fibrosis of the flexor tendons that may hamper rehabilitation and ultimately decrease range of motion. Cutaneous nerves should always be preserved whenever possible to decrease the risk of neuroma formation and painful scars. Loupe magnification is recommended for visualization of all the small structures of the wrist and hand. Microscope magnification is often necessary for repair of nerves and vessels.
APPROACHES TO THE DIGITS
There are essentially three approaches to the digit: the dorsal approach, the midaxial approach, and the palmar approach. The midaxial approach and the midlateral approach are similar, except that the midaxial incision is dorsal to the midlateral. The midlateral incision is made at the anatomic midpoint of the finger. The midaxial incision is made at the connection of the centers of rotation of the respective joints and is slightly dorsal to the midlateral because the joints are dorsal to the rest of the soft tissues in the digit (flexor tendons). The midaxial incision is more often used because it is right over the bone and, on deep dissection, leaves the neurovascular structures safely in the palmar flap.
DORSAL APPROACH
Indications
The dorsal approach is effective for the exposure of the extensor mechanism and bone of the proximal and middle phalanx, proximal interphalangeal (PIP) joint and metacarpophalangeal (MP) joints.
Contraindications
The dorsal approach does not allow for visualization of palmar articular fractures of the joints,
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for which a palmar approach is usually more effective. A transverse or H-type incision may be more appropriate for the exposure of the distal interphalangeal (DIP) joint for excision of a mucous cyst or arthrodesis. A longitudinal incision over the DIP joint may extend into the germinal matrix of the nail bed and cause nail deformity with growth.
Technique (Fig. 37.2)
Figure 37.2. The dorsal approach to the digit. The dorsal sensory branch of the digital nerve and the dorsal veins have been retracted.
  • Make a longitudinal incision over the dorsum of the digit in the midline. Take care with deep dissection to protect the dorsal veins when possible and the dorsal sensory branches of the digital nerves.
  • The extensor mechanism is well visualized. For exposure of the middle phalanx, incise the extensor mechanism between the two lateral bands. For exposure of the proximal phalanx, make an incision between the central slip and lateral band, being careful to preserve the insertion of the central slip on the base of the middle phalanx. If an arthrodesis of the PIP joint is to be performed, the central slip is divided longitudinally and is elevated off the base of the middle phalanx, along with subperiosteal dissection of the proximal and middle phalanx. In the thumb, make the exposure on one side of the extensor pollicis longus tendon. Expose the MP joint with proximal extension of the incision. Incise the dorsal hood 2 mm radial or ulnar to the extensor tendon, leaving a rim of hood attached to the extensor tendon for later repair.
MIDAXIAL APPROACH
Indications
The midaxial approach is indicated for exposure of the neurovascular bundle, the proximal, middle or distal phalanx, and the flexor sheath. Because the incision lies in the axis of the finger, it heals very well despite early mobilization and is often barely visible when healed. It provides excellent visualization of phalangeal fractures for placement of internal fixation (either screws or plates) on the radial or ulnar aspect of the bone. In this position, they are less likely to interfere with gliding of the adjacent tendon than in the dorsal or palmar position. The radial or ulnar midaxial incision may be favored based on the fracture anatomy, and this decision should be made preoperatively. Visualization of the neurovascular bundles is excellent through this incision, and it is ideal for isolated digital nerve repair. Visualization of the flexor tendons is sufficient to allow for debridement of tenosynovitis, but flexor tendon repair may be difficult.
Contraindications
Visualization of the flexor tendons for repair is limited through this approach and is better accomplished through a palmar approach.
Technique (Fig. 37.3)
Figure 37.3. The midaxial approach to the digit. A: The incision is made by connecting the flexion creases of the digits. B: The phalanges, fibrous sheath, and neurovascular bundles are visualized. The extensor hood is retracted or incised proximally, and the dorsal sensory branch is retracted dorsally. C: Axial schematic demonstrating midaxial approach.
  • Flex the digit completely at the MP, PIP, and DIP joints. Mark the dorsal aspect of the flexion creases at these joints. Then extend the digit and connect these marks by a longitudinal line. It can be extended distally along the distal phalanx palmar to the nail. Proximally, it can be extended up dorsally over the MP joint except on the radial aspect of the index and ulnar aspect of the little finger, where it may be extended radially and ulnarly, respectively. Similarly, the incision can be extended palmarly proximal to the MP joint in a zigzag fashion to increase palmar exposure.
  • Carry the incision down through the deep tissues dorsal to the neurovascular bundles. Divide Clelands’ ligaments to expose the neurovascular bundle. With the neurovascular bundle in the palmar flap, the periosteum of the phalanges can be visualized. Palmarly, the flexor tendon sheath can be identified.
  • Proximal dissection of the proximal phalanx will encounter two structures that limit exposure. The first is the dorsal branch of the digital nerve. This nerve lies dorsal over the middle phalanx but travels palmar to dorsal over the proximal phalanx and needs to be identified and protected. The second is the lateral band. This can be incised longitudinally to allow for excellent exposure of the proximal phalanx. Repair is optional if the contralateral lateral band is intact.
  • Palmarly, the flexor sheath can be incised between the
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    A2 and A4 pulleys for debridement of the flexor tendons.
PALMAR APPROACH
Indications
The palmar approach is ideal for exposure of the digital flexor tendons for repair, tenosynovectomy, or tumor excision. It is extensile into the hand. It also provides excellent visualization of the neurovascular bundles and is frequently used for the excision of Dupuytren’s disease. It is the exposure of choice for a volar plate arthroplasty or the palmar articular fracture (2).
Contraindications
The palmar approach is not ideal for the repair of phalangeal shaft fractures or the extensor mechanism.
Technique (Fig. 37.4)
Figure 37.4. A and B: The palmar approach to the digit and palm. With incision of the A3 or A1 and palmar pulley with retraction of the flexor tendons, the volar plate of the PIP and MP joints can be visualized respectively. C: Axial schematic demonstrating palmar approach.
  • Plan a zigzag Brunner incision across the digit, extending from the distal phalanx into the palm. Cross the digital flexion creases at 45° angles to create a flap with a 90° corner. Any portion of this incision can be used.
  • Dissect the subcutaneous tissue carefully to expose the
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    flexor sheath and neurovascular bundles by division of Grayson’s ligaments.
  • Now incise the flexor sheath by creating an L with a radially or ulnarly based flap to allow access to the flexor tendons. This should be done between, proximal, or distal to the A2 and A4 pulleys. Take care to preserve these pulleys to prevent bowstringing of the flexor tendons postoperatively.
  • If access to the PIP joint is desired, create a flap in the sheath over the joint, retract the flexor tendons, and expose the volar plate of the joint. Dissect the flexor plate from the middle phalanx to expose the joint.
APPROACHES TO THE HAND
There are two approaches to the hand: dorsal and palmar. The dorsal approach exposes the extensor tendons, metacarpals (MP), and carpometacarpal (CMC) joints, and the intrinsic muscle compartments. The palmar approach exposes the flexor tendons and lumbricals, neurovascular bundles, and Dupuytren’s disease.
DORSAL APPROACH
Indications
The dorsal approach exposes the extensor tendons, and the metacarpal, MP, and CMC joints.
Contraindications
The dorsal approach is contraindicated for exposure of palmar articular fractures of the MP joint. It also does not provide visualization of the neurovascular bundles or flexor tendons.
Technique (Fig. 37.5)
Figure 37.5. The dorsal approach to the hand. A: The longitudinal incision is centered over the desired metacarpal. B: Deep dissection reveals the extensor tendon, which can be retracted, and the juncturae, which can be transected, to visualize the metacarpal.
  • Make a longitudinal incision over the desired metacarpal. Extend it proximally or distally to expose the MP or CMC joint. Perform subcutaneous dissection to avoid injury to the cutaneous nerves, which are branches of the radial or ulnar nerve. The extensor tendons are visualized and may consist of multiple slips and multiple juncturae (8,11,12 and 13).
  • If deeper exposure is desired, make an incision in the investing fascia of the extensor tendons and retract the extensor tendons. Occasionally, it will be necessary to divide the juncturae tendinae to provide exposure of the metacarpal or MP joint. These can be later repaired if desired.
  • Subperiosteal dissection of the metacarpal is then possible to complete the exposure. The interosseous muscles are evident on either side of the metacarpal. In the thumb, the deep dissection is in the interval between the extensor pollicis longus and extensor pollicis brevis.
  • Distal extension exposes the MP joint. Divide the extensor hood on either the radial or ulnar side, then incise the capsule to expose the MP joint. Proximal extension exposes the capsule of the CMC joint, which can be incised longitudinally and elevated subperiosteally.
Occasionally, when only a small incision is necessary, such as for repair of a lacerated extensor tendon or harvesting of the extensor indicis proprius tendon, make a transverse incision directly over the site of repair. This gives a more cosmetic scar because the incision falls within Langer’s lines.
PALMAR APPROACH
Indications
The palmar approach to the hand is used for visualization of flexor tendons, neurovascular bundles, lumbricals, or Dupuytren’s disease. It is also recommended for palmar articular fractures of the MP joint.
Contraindications
The palmar approach is relatively contraindicated in the internal fixation of fractures of the
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metacarpals because it is more likely to cause adhesions between the flexor tendons and the bone.
Technique (Fig. 37.4)
  • Make a zigzag Brunner incision in the palm over the desired area of exposure, usually over the flexor tendon. This can be extended to a Brunner incision of the digit and across the carpal tunnel.
  • Incise the palmar fascia longitudinally. Careful dissection reveals the flexor tendon and common digital arteries and nerves on either side.
  • The A1 pulley is visualized over the MP joint, and a palmar pulley can be identified proximally (7). The arteries can be traced proximally to the superficial palmar arch.
  • Accomplish visualization of the MP joint with incision of the A1 pulley and detachment of the volar plate from the base of the proximal phalanx.
  • In the thumb, care must be taken when dissecting over the flexor tendon because the radial neurovascular bundle originates ulnar to the flexor tendon and crosses to its radial side at the metacarpal level.
  • For surgical release of trigger fingers, center a single longitudinal incision over the A1 pulley for the index through little fingers. A transverse incision for the thumb may be used (Fig. 37.6). Alternatively, the incision can be placed in the distal palmar crease transversely for the little, ring and long finger, and the proximal palmar crease for the index finger. If the longitudinal incision is used, do not cross any palmar creases or a scar contracture can form.
    Figure 37.6. Planned incision for release of trigger fingers (A1 pulleys).
APPROACHES TO THE WRIST
DORSAL APPROACH
The dorsal approach to the wrist is an extensile longitudinal incision with a few exceptions. It can be extended proximally to include the distal radius and ulna, and it can be extended distally into the hand as already described. Depending on the exposure desired, make the incision in the midline or displaced slightly radially or ulnarly. In certain situations, such as the approach to the scapholunate joint, the approach to the scaphoid, or for a proximal row carpectomy, a transverse incision may be used for a more cosmetic result.
Approach to the Distal Radius and Extensor Tendons
Indications
This approach is indicated to expose the distal radius for internal fixation of fractures or wrist fusion, or to expose the extensor tendons for tenosynovectomy.
Contraindications
The dorsal approach to the distal radius is not effective in exposing the palmar aspect of the radius for fractures with palmar displacement or palmar articular fractures.
Technique (Fig. 37.7)
Figure 37.7. The dorsal approach to the distal radius and extensor tendons. A: The incision is usually placed in the midline. B: Exposure of the extensor tendons. Axial schematic demonstrating incision of the dorsal retinaculum over the second dorsal compartment with radial and ulnar dissection of the extensor retinaculum. C: Exposure of the distal radius. Axial schematic demonstrating incision of the dorsal retinaculum over the third dorsal compartment with subperiosteal radial and ulnar dissection of the extensor tendons.
  • Make a longitudinal incision over the digital extensor tendons. It may be midline or displaced slightly radially or ulnarly, depending on the location of the pathology.
  • Use blunt dissection through the subcutaneous tissue to prevent injury to cutaneous nerves and the dorsal veins, when possible. Expose the extensor retinaculum and make deep skin flaps just superficial to the retinaculum if an extensor tenosynovectomy is planned. For the approach to the distal radius, skin flaps are not necessary.
Exposure of the Extensor Tendons
  • Incise the dorsal retinaculum longitudinally over the index or fifth dorsal compartment. Then dissect radially and ulnarly cutting the intercompartmental septa to expose all six dorsal compartments as desired. Do not dissect the compartments superiosteally and avoid damage to the adjacent extensor tendons. This procedure can be aided by placing a small elevator in the next compartment to be exposed. This method easily identifies the intercompartmental septum for division.
  • The retinaculum is particularly difficult to dissect between the second and third compartment. Here, subperiosteal dissection is necessary on Lister’s tubercle to maintain continuity of the retinaculum. This approach is easily extensile into the hand and up the forearm.
  • Often in closing the retinaculum after tenosynovectomy, it is split transversely, with half placed below the tendons and half above. Repair of the dorsal retinaculum is necessary to prevent bowstringing of the tendons.
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Exposure of the Distal Radius
  • Incise the dorsal retinaculum over the third dorsal compartment and retract the extensor pollicis longus tendon radially from the compartment.
  • Perform subperiosteal dissection of the remaining compartments radially and ulnarly to expose the distal radius. Subperiosteal dissection of the fourth compartment decreases the likelihood of postoperative adhesion of the extensor digitorum communis tendons.
  • This exposure can be extended distally to the carpus or proximally up the forearm to the extensor pollicis brevis muscles.
  • After internal fixation of the radius, often the third dorsal compartment can be closed over the plate. The extensor pollicis longus tendon does not need to be replaced in its compartment.
Approach to the Distal Radioulnar Joint
  • To include the distal radioulnar joint, continue ulnar dissection using the above-mentioned technique. If only the distal radioulnar joint needs to be approached, then a smaller skin incision can be made directly over the fifth dorsal compartment.
  • Incise the extensor retinaculum over the fifth dorsal compartment and retract the extensor digitorum quinti tendon radially. The capsule of the distal radioulnar joint is immediately beneath this compartment and can be incised longitudinally. A synovectomy of the joint
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    can then be performed, the distal ulna excised, or the triangular fibrocartilage complex (TFCC) repaired.
  • After synovectomy or TFCC repair, repair the dorsal capsule primarily. After distal ulnar excision, reattach the dorsal capsule of the distal radioulnar joint to the palmar capsule over the end of the distal ulna with several nonabsorbable sutures to prevent subluxation of the distal ulna. Repair the extensor retinaculum with nonabsorbable sutures and close the skin as usual.
Approach to the Radiocarpal Joint
Indications
The approach to the radiocarpal joint can be an extension of the previously described approach to the distal radius, with the dissection continued distally to dissect the carpal bones subperiosteally. This approach is useful for radiocarpal fusions. When a limited exposure of the wrist is known to be needed preoperatively, a transverse incision may be used with a more cosmetically appealing result. Often the scar, when healed, is barely visible within Langer’s lines. If a later radiocarpal fusion is necessary, a longitudinal incision can be made at a right angle to this incision without complication. It is possible to excise the terminal branch of the posterior interosseous nerve through this transverse incision, if desired. Carry out the dissection proximally with incision of the third dorsal compartment under the proximal skin flap. The terminal branch of the posterior interosseous nerve is then evident between the third and fourth compartments and can be excised.
Contraindications
A transverse incision is not extensile and should be avoided when exposure of the hand or distal radius is desired.
Technique
Make a transverse incision over the proximal row approximately 1.5 cm distal to Lister’s tubercle. The length of the incision is dependent on the pathology to be explored. (Fig. 37.8).
Figure 37.8. The dorsal approach to the radiocarpal joint. A transverse incision is made over the radiocarpal joint distal to Lister’s tubercle. After longitudinal incision of the extensor retinaculum and T-incision of the dorsal capsule, the radiocarpal joint is exposed.
Proximal Row Carpectomy
The incision will need to be over the entire carpus, approximately 3 to 4 cm in length.
  • Carry the incision down through the subcutaneous tissue, taking care to identify and protect the cutaneous branches of the radial and ulnar nerves.
  • Incise transversely the capsule overlying the proximal row. Make a T over the lunate. Then expose the scaphoid, lunate, and triquetrum subperiosteally.
  • After removal of the carpus, repair the capsule with nonabsorbable suture and close the skin.
Scaphoid and Scapholunate Joint
  • Make a dorsal transverse incision 2 to 3 cm in length centered over the scaphoid or scapholunate joint, respectively. The scapholunate joint can be palpated 1 to 1.5 cm directly distal to Lister’s tubercle.
  • After the cutaneous nerves are dissected free, incise the capsule over the scapholunate joint, and dissect radially and ulnarly along the radiocarpal joint as necessary. Take care to avoid damage to the dorsal vessels entering the waist of the scaphoid.
  • After repair of the scapholunate ligament or fixation of the scaphoid fracture, repair the capsule with nonabsorbable suture and close the wound with a subcuticular suture.
PALMAR APPROACH
The palmar approach to the wrist provides excellent visualization of the distal radius, carpal tunnel, digital flexor tendons, palmar aspect of the carpus, median and ulnar nerve, and the radial and ulnar arteries. One of two incisions can be used. The more radial incision centered over the flexor carpi radialis exposes the distal radius, radial artery, and scaphoid. The more midline incision exposes the carpal tunnel, median and ulnar nerve, ulnar artery, digital flexor tendons, carpus and distal radius, ulna, and palmar distal radioulnar joint. For the isolated exposure of the distal radius, the radial incision is preferred because it does not involve dissection around the digital flexor tendons and thereby decreases the chance of postoperative adhesions.
Approach to the Distal Radius and Scaphoid
Indications
The palmar radial approach to the distal radius and scaphoid is indicated when the only structures that are necessary to be exposed are the distal radius, scaphoid, and radial artery. It has the advantage of not
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dissecting around the flexor tendons, therefore minimizing postoperative adhesions. It can be extended to include exposure of the scaphotrapezial joint distally and the palmar radius proximally.
Contraindications
The carpal tunnel is not visualized through this incision but can be visualized through a separate incision. The flexor tendons, median and ulnar nerves, and ulnar artery, as well as the remainder of the carpus, are not visualized either and are better exposed through the midline palmar approach.
Technique
  • Make a longitudinal incision over the flexor carpi radialis tendon, extending proximally as far as necessary (Fig. 37.9). Distally, end the incision at the proximal palmar wrist flexion crease if only the radius is to be exposed. If exposure of the scaphoid is necessary, the incision begins 2 cm proximal to and then extends just past the distal wrist flexion crease to the scaphoid tubercle. This approach is known as the Russe approach to the scaphoid. Carry the incision down through subcutaneous tissue in line with the flexor carpi radialis. It is important not to deviate ulnar to the flexor carpi radialis because injury to the palmar cutaneous branch of the median nerve can occur (6).
    Figure 37.9. The palmar approach to the distal radius and scaphoid. The incision is based over the flexor carpi radialis tendon and is curved radially distal to the distal wrist flexion crease.
  • Incise the sheath overlying the flexor carpi radialis and retract the flexor carpi radialis ulnarly.
  • Expose the radial artery along the radial border of the sheath and protect it.
  • Incise the sheath deep to the flexor carpi radialis and retract the flexor tendons ulnarly. Identify the pronator quadratus on the palmar radius and incise it longitudinally on its radial aspect, leaving a small portion radially for reattachment.
  • Then subperiosteally expose the radius ulnarly to the distal radioulnar joint.
  • If exposure of the scaphoid is desired, incise the palmar capsule longitudinally to the scaphoid tubercle and expose the scaphoid.
  • Close with repair of the palmar capsule and reattachment of the pronator, if possible. Then repair the skin with interrupted or running subcuticular sutures as desired.
Approach to the Carpal Tunnel and Guyon’s Canal
Indications
This approach is indicated for exposure of the median nerve in the carpal tunnel and ulnar nerve in Guyon’s canal. Limited visualization of the flexor tendons and palmar aspect of the carpus is afforded (4,10).
Contraindications
Exposure of the distal radius, and flexor tendons for rheumatoid flexor tenosynovectomy for rheumatoid arthritis requires proximal extension of this incision.
Technique (Fig. 37.10)
Figure 37.10. Palmar approach to the carpal tunnel and Guyon’s canal. A: The skin incision is made in line with the radial aspect of the fourth finger. Care should be taken not to stray radial to this line because injury of the palmar cutaneous branch of the median nerve may result. B: The palmar fascia fibers are noted to run longitudinally and are transected. After transection of the transverse carpal ligament, the median nerve and flexor tendons are identified within the wound and can be retracted for exposure of the palmar carpus. C: The location of Guyon’s canal, which can be identified in the ulnar aspect of the wound.
  • Make a longitudinal incision in the palm in line with the radial border of the ring finger. The distal extent of the incision intersects Kaplan’s cardinal line (a line determined by abducting the thumb and drawing a horizontal line from the first web space parallel to the proximal transverse palmar crease). The proximal extent of the incision is the distal wrist flexion crease. Then incise sharply down through the subcutaneous tissue because the palmar cutaneous nerve is out of potential harm.
  • Incise the palmar fascia longitudinally, and identify the ulnar nerve and artery beneath the palmar fascia in the ulnar aspect of the wound. Remember that the ulnar artery can be palmar to the palmaris brevis, and other anomalies have been reported as well (5,9). The ulnar artery and sensory branch of the ulnar nerve continue distally and may cross radial to the hook of the hamate (3).
  • Then incise the transverse carpal ligament longitudinally, ensuring that the proximal aspect of the ligament
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    is transected. Often, a tenotomy scissors is necessary to complete the proximal release. For further details, see Chapter 52 on compression neuropathies.
Approach to the Digital Flexor Tendons, Radiocarpal Joint, and Distal Radius
Indications
This exposure provides the best access to the flexor tendons, median and ulnar nerves, and radiocarpal joint. The distal radius can also be exposed through this incision.
Contraindications
If the distal radius alone is to be exposed, it is better to approach it through the radial palmar incision. This midline approach has an increased incidence of flexor tendon adherence owing to the dissection necessary around the tendons.
Technique (Fig. 37.11)
Figure 37.11. Palmar approach to the digital flexor tendons, radiocarpal joint, and distal radius. Extension radial to the palmaris may produce injury to the palmar cutaneous branch of the median nerve. Deep dissection allows visualization of the digital flexor tendons, which may be retracted radially to expose the palmar distal radius and pronator. Subperiosteal dissection of the pronator exposes the distal radius. The radiocarpal joint is exposed through a longitudinal or T-incision.
  • The incision is a proximal extension of the incision made for exposure of the carpal tunnel. Cross the wrist flexion creases at 45° angles. Proximal to the proximal wrist flexion crease, the incision can be a straight line, ulnar to the palmaris tendon.
  • Divide the antebrachial fascia. Identify the median nerve and flexor tendons, and the ulnar nerve in the ulnar aspect of the wound.
  • Retract the flexor tendons to expose the distal radius and distal radioulnar joint. To expose the distal radius, incise the pronator along its radial margin, leaving a small cuff of tissue to which to repair it. Expose the radius subperiosteally. The distal radioulnar joint can be visualized by longitudinal incision into the palmar capsule. Take care distally not to incise the triangular fibrocartilage complex (TFCC).
  • Close the wound with repair of the pronator and the capsule. Close the skin with interrupted or subcuticular sutures.
Radial Approach to the Scaphoid
Indications
The radial approach to the scaphoid provides excellent visualization of the proximal pole, waist, and distal pole of the scaphoid. It useful in procedures in which a dorsal extensile exposure of the scaphoid is desired, such as for vascularized bone grafting of the scaphoid, and provides excellent exposure of the radial styloid for radial styloidectomy.
Contraindications
If the palmar aspect of the radius or flexor tendons need to be exposed, then the palmar approach to the scaphoid provides better visualization of the palmar wrist structures.
Technique (Fig. 37.12)
Figure 37.12. The radial approach to the scaphoid. A: The curvilinear incision is made over the anatomic snuffbox, between the extensor pollicis longus and extensor pollicis brevis. B: A longitudinal incision is made in the radiocarpal joint capsule, and the radial artery is retracted distally. The scaphoid is visualized.
  • Make a curvilinear incision over the anatomic snuffbox. Extend it proximally over the dorsal or radial aspect of the wrist as needed. Then proceed between the extensor pollicis longus dorsally and the extensor pollicis brevis palmarly. These tendons are easily identified because traction on the extensor pollicis longus produces extension of the thumb IP joint and traction on the extensor pollicis brevis produces extension and abduction of the thumb ray without extension of the IP joint.
  • Take care to avoid injury to the superficial branches of the radial nerve, which may be multiple (1).
  • Retraction of the tendons allows visualization of the radial artery and its dorsal branches, which must be preserved to maintain the vascularity of the scaphoid. Incise the joint capsule longitudinally and expose the scaphoid with distal and palmar retraction of the radial artery. It is important when exposing the scaphoid not to disrupt the dorsal blood supply to the bone by stripping the vessels that enter the scaphoid through the dorsal waist.
Ulnar Approach to the Distal Ulna
Indications
The ulnar approach to the distal ulna is useful for distal ulnar excision or internal fixation, exposure of the extensor carpi ulnaris tendon, or open visualization of the TFCC.
Contraindications
This exposure does not provide visualization of the distal radius, or the extensor or flexor tendons.
Technique (Fig. 37.13)
Figure 37.13. The ulnar approach to the distal ulna. A: The longitudinal incision is made along the palmar aspect of the extensor carpi ulnaris tendon. B: The sheath over the extensor carpi ulnaris tendon is incised, and the extensor carpi ulnaris is retracted dorsally. Care must be taken to avoid injury to the dorsal sensory branch of the ulnar nerve, which travels from palmar to dorsal in this region. Subperiosteal dissection may be performed on the distal ulna and the ulnocarpal joint may be incised longitudinally to expose the TFCC.
  • Make a longitudinal straight incision over the ulnar aspect of the distal ulna, just palmar to the extensor carpi
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    ulnaris tendon. Center it over the ulnar head and extend it distally across the ulnocarpal joint and proximally as far as necessary.
  • Perform deep dissection in a blunt fashion because the dorsal sensory branch of the ulnar nerve runs from palmar to dorsal across the distal ulna in this region.
  • Incise the retinaculum over the extensor carpi ulnaris tendon longitudinally and retract the tendon dorsally.
  • Incise the ulnocarpal joint capsule longitudinally along its ulnar aspect to visualize the TFCC. Start the incision distally and do not cut into the TFCC. Proximally, the distal radioulnar joint capsule and ulnar periosteum may similarly be elevated off the distal ulna to allow its exposure.
  • Closure of the wound may include repair of the distal radioulnar joint capsule and the retinaculum over the extensor carpi ulnaris tendon if it is noted to sublux palmarly.
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+ 9. Richards RS, Dowdy P, Roth JH. Ulnar Artery Palmar to Palmaris Brevis: Cadaveric Study and Three Case Reports. J Hand Surg 1993;18:888.
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+ 10. Rotman MB, Manske PR. Anatomic Relationships of an Endoscopic Carpal Tunnel Device to Surrounding Structures. J Hand Surg 1993;18:442.
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