Techniques in Hand & Upper Extremity Surgery

Techniques in Hand and Upper Extremity Surgery 9(2):67–68, 2005 Ó 2005 Lippincott Williams & Wilkins, Philadelphia E D...

281 downloads 1090 Views 6MB Size Report

This content was uploaded by our users and we assume good faith they have the permission to share this book. If you own the copyright to this book and it is wrongfully on our website, we offer a simple DMCA procedure to remove your content from our site. Start by pressing the button below!

Report copyright / DMCA form

DOWNLOAD PDF

Techniques in Hand and Upper Extremity Surgery 9(2):67–68, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

E D I T O R I A L

Treatment of Fractures of the Distal Radius in Adults: A Surgeon’s Forty-Five Year Perspective recently attended a combined meeting of the Japanese Society for Surgery of the Hand (JSSH) and the American Society for Surgery of the Hand (ASSH) in Honolulu. Many of the papers and ‘‘hands-on’’ workshops were about the management of fractures of the distal radius in adults. The major emphasis in these presentations was on the technical aspects of open reduction and internal fixation of these fractures. One presenter polled the audience to determine their personal preferences for the management of several complex fractures of the distal radius that he presented. The great majority of the audience indicated that their preference was for some form of open reduction and internal fixation of these fractures. Only a few participants (most had grey hair) favored less invasive and less aggressive methods of treatment. The following comments reflect the changes in treatment for distal radius fractures that have occurred over the last 45 years. They are to be taken as a brief, noncomprehensive review of some of the highlights in the evolution of the treatment of distal radius fractures. These comments are based on one surgeon’s experience and may contain information that some might consider apocryphal (or the result of a faulty memory) and may also have egregious omissions. My comments are not intended to be a comprehensive historical review but simply my observations of some trends that I have observed from the time I began my Orthopaedic training to the present.

I

n

Plaster Cast Techniques

I have treated my share of distal radius fractures during my career and the treatment first taught to me was a fracture hematoma block with local anesthesia followed by longitudinal traction and manipulative reduction to restore length and the anatomic angles in the anteriorposterior and lateral planes. Reduction was confirmed by a portable x-ray (no rapid film development or portable scanning devices that yielded quick results were available in those days). There was much energy expended by my mentors to teach me that the reduction more often than not could be maintained by appropriate molding of the cast to obtain ‘‘three point fixation’’. The three points of fixation were the palmar aspect of the distal radius, the dorsal aspect of the distal radius, carpus and base of the metacarpals and the dorsal and radial aspect of the index metacarpal. I was told that if these three fixation points

were properly molded into the cast that the normal length and appropriate angles would be maintained. The reduction was also said to be augmented and protected by palmar flexion and ulnar deviation of the wrist. Refinements in these techniques included minimal use of padding or ‘‘skin tight casts’’ and maintaining the forearm in supination to eliminate the deforming force of the brachioradialis muscle that inserts broadly on the distal radius and radial styloid. I assumed that my ‘‘three point fixation’’ technique was lacking in many instances since most of my reductions were associated with shortening of the radius and loss of the critical anatomical angles. It was a relief to learn later on that it was not my execution of the threepoint fixation technique that was faulty but a failure of the method itself that gave less than satisfactory results. The end result of this plaster technique was usually characterized by shortening of the radius and prominence (relative lengthening) of the distal ulna. The resultant deformity was considered to be more of a cosmetic than a functional problem and was treated by excision of the distal ulna with varying levels of success.

n

The Roger Anderson Device

During this era (the early 1960’s) I discovered a fixation device applied to the forearm of a skeleton in the back of one of the drawers in the Orthopedic Clinic at my training hospital. It had long been neglected and when queried about the device my training chief explained that it was called a Roger Anderson Device and that it was designed to treat fractures of the distal radius. I was told that it had been developed in the early 1940’s and that it was seldom if ever used because it either broke, came apart or otherwise failed. The device consisted of two threaded pins drilled into the index metacarpal and two similar pins drilled into the distal radius. Small bars that could be locked in place spanned the two pins that were proximal and distal and they in turn were connected by two other adjustable rods. This resulted in a type of cantilever system that would maintain length and the normal anatomic angles of the distal radius. This device was not strong enough to stand-alone and in my practice it was supported by a long arm cast to prevent breakage of the pins or disruption of the system. I used it with what I considered to be good results when compared to closed reduction and

Volume 9, Issue 2

67

Doyle

casting. It was the forerunner of other similar devices called external fixators that would be developed in the 1980’s.

n

Pins and Plaster Technique

n

Pins and plaster techniques were the next to appear on the scene in my practice and consisted of Kirschner wires or Steinman pins drilled at right angles to the long axis of the base of the index and middle finger metacarpals and the olecranon process. These pins were used for traction and the fracture reduced by appropriate manipulation followed by a long arm cast that incorporated the pins in the plaster. The Steinman pins were stiff enough for the job and did not flex or bend significantly but the K-wires had to be kept under tension with a traction bow that added weight and bulk to the construct. The long arm or sometimes-short arm cast effectively ‘‘locked’’ the pins and the reduction in place and was a useful technique.

n

External Fixators

These devices began to appear on the scene as answers to the problems and failures associated with earlier techniques. During this period it became appropriate to open and reduce and bone graft certain fractures of the distal radius and the ‘‘die punch’’ injury that represented an offset of the articular surface of the lunate fossa became well known. Fracture classifications began to appear that supplied guidelines and treatment options that began to make some sense for these complex fractures. Stable and anatomic reductions that restored joint surface congruity of the distal radius became the treatment goal, if not the ‘‘gold standard’’. Improved imaging techniques became available in this era including computed tomography that aided the surgeon in the evaluation of articular congruity. External fixators of various types were used and some were capable of allowing positional adjustments to fine tune the reduction. Other surgeons used the external fixator to maintain length and percutaneous K-wire fixation to achieve or maintain joint congruency. The external fixator was often left in place for 8 weeks. Finger motion

68

was permissible with the external fixator but wrist motion was not. Some surgeons noted incomplete recovery of wrist joint motion that they associated with this technique.

Open Reduction and Internal Fixation

Open reduction and rigid internal fixation of distal radius fractures has become more common due to a variety of reasons including the perceived desire and need to achieve better joint congruity and earlier active range of motion in the wrist joint to avoid joint stiffness. Surgical approaches have included dorsal, dorso-radial and palmar. All methods have their proponents and indications. Several manufacturers have developed devices in conjunction with surgeons and the technology involved has steadily improved. Plates, screws and pins of suitable material and configurations allow for permanent insertion of the devices in many instances. Innovations and applications will no doubt continue to evolve. The last issue of Techniques in Hand and Upper Extremity Surgery (March, 2005) described two innovative techniques for treatment of distal radius fractures: The first was by distraction plating and the second about the use of Kirschner wires for reduction and stabilization of distal radius fractures based on a modified Kapandji technique. This issue of Techniques in Hand and Upper Extremity Surgery includes an article on arthroscopically assisted reduction and fixation of distal radius fractures and a second presentation on an innovative device for fragment specific fixation of distal radius fractures. These four presentations are representative of the rapid evolution that is occurring in the surgical management of distal radius fractures and demonstrate innovative, useful and current techniques relative to a very common problem seen by upper extremity surgeons. l James R. Doyle, MD Co-Editor-in-Chief Emeritus Professor of Surgery (Orthopaedics) John A. Burns School of Medicine University of Hawaii Honolulu, Hawaii

Techniques in Hand and Upper Extremity Surgery

Techniques in Hand and Upper Extremity Surgery 9(2):69–73, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

T E C H N I Q U E

Intramedullary Nailing of Metacarpal Shaft Fractures Jorge Orbay, MD Miami Hand Center Miami, FL

n

ABSTRACT

Uncorrected bony deformity or stiffness resulting from a metacarpal shaft fracture can produce a significant functional or cosmetic deficit. Intramedullary fixation of metacarpal shaft fractures using small flexible rods can provide stable internal fixation while minimizing the extent of soft tissue trauma that is associated with more extensive surgical techniques such as plate or screw fixation. The flexible rod is usually introduced in a proximal to distal direction to avoid injury to the metacarpophalangeal joint and extensor mechanism. Closed reduction of the fracture and percutaneous insertion of the rod improve operative efficiency and allow what is truly a minimally invasive procedure. The use of a proximal locking pin greatly enhances fixation and has resulted in an expansion of the surgical indications to include spiral and comminuted fractures. Usually a single locked nail is used, although it is possible to insert multiple nails if necessary. A radiopaque plastic cap can be applied over the cut end of the nail to minimize irritation of the adjacent soft tissues during rehabilitation. Post-operatively, splint or cast immobilization is often unnecessary. The nails are routinely removed after the fracture has completely healed. Keywords: metacarpal fractures, intramedulary nailing, minimally invasive

n

open reduction and internal fixation with plate and screw fixation, a method that involves a trade-off between the restoration of normal bony anatomy and the consequences of exposure of the fracture site, specifically soft tissue irritation and scar formation. Intramedullary fixation of metacarpal shaft fractures has been advocated to simplify the surgical treatment of these common injuries and minimize the complications associated with more extensive surgical approaches. Lord3 and later Pfeiffer4 advocated closed retrograde pinning of metacarpal fractures by inserting K-wires through the flexed MP joint. This technique implied transfixing the MP joint and the extensor mechanism. In 1975, Foucher introduced the ‘‘bouquet’’ technique of closed anterograde nailing of metacarpal fractures using multiple small pre-bent K-wires.5 The technique avoided both opening the fracture site and injury to the soft tissues around the MP joint. A drawback of the ‘‘bouquet’’ technique was the need for a proximal surgical incision and the relative technical difficulties. More recently Gonzalez et al,6 Gonzalez and Hall,7 and Manueddu and Della Santa8 have reported similar success with surgical techniques that incorporate variations of the ‘‘bouquet’’ technique. Recently we described a technique for percutaneous insertion of small flexible locked nails using prefabricated instrumentation.9

n

HISTORICAL PERSPECTIVE

Metacarpal shaft fractures are common, representing approximately one third of all fractures encountered by the hand surgeon.1,2 It has been generally accepted that a severely displaced and unstable metacarpal shaft fracture requires operative treatment. This is commonly accomplished via Address correspondence and reprint requests to Jorge Orbay, MD, Miami Hand Center, 8905 SW 87 Avenue, Suite 100, Miami, FL 33176. E-mail: [email protected].

INDICATIONS/ CONTRAINDICATIONS

Flexible intramedullary nailing is indicated for any displaced or unstable fracture of the metacarpal shaft or neck in which nonoperative treatment would produce an unacceptable result including symptomatic malunion (Fig. 1). The technique is also indicated when ORIF is undesirable, specifically a fracture of the fifth metacarpal with more than 60 degrees of angulation or 45 degrees for the 4th metacarpal and 30 degrees for the 3rd and 2nd metacarpals, respectively. Spiral fractures and fractures

Volume 9, Issue 2

69

Orbay

FIGURE 1. A good indication for using the intramedullary ﬁxation technique is the presence of multiple metacarpal shaft fractures.

with rotational malalignment, excessive shortening (more than 5 mm), and moderate comminution defined as a single butterfly fragment are acceptable indications for this technique, but a proximal locking pin or the use of multiple nails is typically necessary. Fractures in those patients who are unwilling or unable to tolerate cast immobilization are also good candidates for the intramedullary nailing technique. Intraarticular involvement or fractures with severe diaphyseal comminution (more than 1 butterfly fragment) and those injuries with associated soft tissue loss in which the exposure for plate and screw fixation would not entail additional morbidity are not amenable to intramedullary nailing. Those patients presenting with a chronic fracture or nascent malunion may also be treated with flexible intramedullary nailing, provided that the fracture is exposed through a small incision and the callus mobilized or excised.

n

TECHNIQUE

Flexible, blunt, and pre-bent nails measuring 1.6 or 1.1 mm in diameter are inserted through a percutaneous approach, under manual power with the aid of a specially designed prefabricated awl (Small Bone Fixation System, Hand Innovations, LLC, Miami, FL). The procedure is performed under fluoroscopic guidance, and local anesthesia and sedation are frequently used. First, and most importantly, it is must be confirmed that the fracture can be easily reduced by closed manipulation. A small stab incision is then placed over the proximal base of

70

the fractured metacarpal (Fig. 2). Blunt soft tissue dissection is carried down to the dorsal cortex. Careful spreading of the soft tissues is particularly important with fractures of the long and ring metacarpals because the extensor tendons are in close proximity to the nail insertion site. The dorsal metaphyseal cortex is perforated manually using the awl, and the nail is deployed into the medullary canal (Fig. 3). The nail is then advanced to the level of the fracture site (Fig. 4). The fracture is gently manipulated and reduced under fluoroscopic guidance, and the nail is then advanced across the fracture and into the distal fragment (Fig. 5). The nail is finally advanced into the subchondral bone of the metacarpal head, where additional

FIGURE 2. A small stab incision is placed directly over the base of the fractured metacarpal.

Techniques in Hand and Upper Extremity Surgery

Intramedullary Nailing of Metacarpal Shaft Fractures

FIGURE 3. Using the awl, the surgeon perforates the dorsal cortex at the base of the metacarpal. Fluoroscopy is used to conﬁrm the correct entry point.

FIGURE 5. The fracture is reduced by closed manipulation with the assistance of ﬂuoroscopic imaging. The nail is then advanced across the fracture into the distal metacarpal.

careful manual rotation of the nail can assist in the final reduction. If necessary, the nail can be removed and the curvature modified as needed before reinsertion. This is usually performed to achieve greater stability of the fixation construct or to improve the final reduction. Once the surgeon is satisfied with the reduction and nail placement, the decision to lock the nail proximally is made. Locking the nail proximally greatly enhances rotational and longitudinal stability. Locking is desirable in the case of oblique, spiral, or comminuted fractures to prevent shortening and control rotation. If locking is not indicated, as in the case of a transverse or short oblique metacarpal shaft fracture, the surgeon simply cuts the handle off the nail, bends the proximal end to facilitate later retrieval, and cuts the remaining end off beneath the skin to prevent pin tract infection (Fig. 6). If locking of the nail is indicated, the nail handle is cut off, and the proximal end of

the nail is bent approximately 90 degrees with the assistance of a custom device (Fig. 7). A proximal locking sleeve is introduced over the cut end of the nail and is gently driven palmarward through the entrance portal into the proximal metaphysis (Fig. 8). Fluoroscopic guidance is recommended for this step. When the locking pin engages the volar cortex, resistance is encountered, indicating that the device is appropriately seated. A ratchet mechanism engaging the locking pin to the nail prevents component disengagement during rehabilitation. The locking sleeve is kept in place by means of small teeth that engage the nail through an interference effect. Next, the prominent ends of the locking pin and nail are cut below the skin (Fig. 9), and a radiopaque plastic cap is applied (Fig. 10). This is a very important step because the cap is designed to prevent soft tissue irritation and facilitate rehabilitation while avoiding attritional injury to the extensor digitorum communis tendons. For the majority of metacarpal fractures, a single intramedullary nail is

FIGURE 4. The nail is carefully introduced into the intramedullary canal before being separated from the awl.

FIGURE 6. The handle is cut off from the nail.

Volume 9, Issue 2

71

Orbay

FIGURE 7. A tool is used to bend the proximal end of the intramedullary nail approximately 90 degrees.

FIGURE 9. The locking pin is cut below the skin level.

usually sufficient (Fig. 11). Multiple nails may be inserted into a single metacarpal using the identical steps just described. Multiple nails are used if persistent instability of the fracture is encountered following the insertion of a single nail or if the patient has an excessively large intramedullary canal.

A bulky postoperative dressing is applied immediately postoperatively. The dressing should support the MP joints in a flexed position while allowing unimpeded interphalangeal (IP) joint motion. The patient is instructed to begin immediate active and passive IP joint motion while in the recovery room. The patient returns to clinic at approximately 1 week after surgery, and the dressing is

subsequently removed. The rehabilitation plan is individualized and is based on each patient’s circumstances. It is important to consider fracture location, stability achieved, patient compliance, and the range of digital motion encountered before deciding on a plan. Stable fractures may simply require encouraging the patient to perform a home program consisting of range-ofmotion exercises and edema management (Fig. 12). Unstable fractures may benefit from a dorsal hand–based splint with a MP flexion block. A well-designed splint will not only augment the fixation but will also assist in rotational alignment and the potential development of an MP joint extension contracture. The nail is routinely removed in the O/R as an outpatient procedure after complete fracture healing has been confirmed on plain radiographs. Local anesthesia augmented with intravenous sedation

FIGURE 8. The locking pin is introduced over the cut end of the nail and driven palmarward to engage the opposite cortex.

FIGURE 10. Applying the plastic soft tissue protection cap over the cut end of the locking pin prevents tendon or skin irritation during rehabilitation.

n

72

REHABILITATION

Techniques in Hand and Upper Extremity Surgery

Intramedullary Nailing of Metacarpal Shaft Fractures

FIGURE 11. Postoperative PA and oblique radiographic views of the hand demonstrating satisfactory reduction and ﬁxation of ring and small ﬁnger metacarpal shaft fractures.

FIGURE 12. Full digital motion is expected at the initial postoperative visit. Light functional activities are permitted, and splinting may be discontinued.

is suitable for these cases. A needle-nose pliers is used to remove the implant components. This usually occurs between 4 and 8 weeks postoperatively.

metacarpal head can occur in osteopenic bone, and this complication is treated by nail removal after the fracture is healed.

n

COMPLICATIONS

n

Penetration of the nail through the metacarpal head can occur in those fractures with small distal fragments and in patients with osteoporotic bone. Inserting the nail such that the tip is pointing down inside the metacarpal head and therefore placing the convexity of the nail against the subchondral bone or using multiple nails can help avoid this problem. Excessive distraction of the fracture can result in a delayed union. The surgeon must be careful to impact the fragments at the fracture site to prevent this problem after inserting the nail. Spiral fractures require particular attention to rotational alignment to prevent malunion. If malrotation is encountered and cannot be corrected, the surgeon must abandon the intramedullary technique. Comminuted and long oblique fractures are inherently unstable and tend to shorten. Therefore, proximal locking of the nail should be performed. In the case of a fracture of the long or ring finger metacarpal, the proximal end of the nail is located in the vicinity of the extensor tendons. Irritation can be prevented with the use of the plastic soft tissue protection cap. If the cap is not used and the patient develops tendon irritation, a custom fabricated dorsal hand splint with a MP joint flexion block can be used to minimize long extensor excursion. In our experience, there have been no tendon ruptures, infection, loosening, or migration with the use of the plastic cap. Penetration of the implant through the

REFERENCES

1. Wolfe SW, Elliot AJ. Metacarpal and carpometacarpal trauma. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York: McGraw-Hill, 1996, pp 883–920. 2. Greene TL. Metacarpal fractures. In: American Society for the Surgery of the Hand, eds. Hand Surgery Update. Rosemont, IL: American Academy of Orthopaedic Surgery, 1996, pp 11–15. 3. Lord RE. Intramedullary fixation of metacarpal fractures. JAMA. 1957;164:1746–1749. 4. Pfeiffer KM. [Advances in osteosynthesis of hand fractures]. Handchirurgie. 1976;8:17–22. 5. Foucher G. ‘‘Bouquet’’ osteosynthesis in metacarpal neck fractures: a series of 66 patients. J Hand Surg [Am]. 1995;20:S86–S90. 6. Gonzalez MH, Igram CM, Hall RF Jr. Flexible intramedullary nailing for metacarpal fractures. J Hand Surg [Am]. 1995;20:382–387. 7. Gonzalez MH, Hall RF Jr. Intramedullary fixation of metacarpal and proximal phalangeal fractures of the hand. Clin Orthop Rel Res. 1996;Jun:47–54. 8. Manueddu CA, Della Santa SD. Fasciculated intramedullary pinning of metacarpal fractures. J Hand Surg [Br]. 1996;21: 230–236. 9. Orbay JL, Indriago IR, Gonzalez E, et al. Percutaneous fixation of metacarpal fractures. Oper Tech Plast Reconstr Surg. 2002;9:138–142.

Volume 9, Issue 2

73

Techniques in Hand and Upper Extremity Surgery 9(2):74–83, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

T E C H N I Q U E

Fragment-Specific Fixation of Distal Radius Fractures Using the Trimed Device Evan D. Schumer, MD and Bruce M. Leslie, MD Newton-Wellesley Hospital Newton, MA

n

ABSTRACT

Fragment-specific fixation of the distal radius represents a new technique for addressing complex distal radius fractures. It signifies a substantial shift in the thought process of open reduction and internal fixation; each fracture fragment is addressed independently with small plates or wire forms, allowing comminuted fractures to be anatomically restored and early motion started. Although the system is at first daunting, its modularity provides flexibility for the surgeon to modify the fixation to the individual needs of the patient’s specific fracture pattern and the surgeon’s level of expertise. Once the technique has been learned, the surgeon will have in his or her armamentarium a powerful new tool to treat fractures that had before been difficult to address satisfactorily with conventional techniques. Keywords: fragment specific, wire forms, distal radius, modularity, comminuted

plished. Although this approach is certainly still valid in those fractures with a small number of sizable fragments that can be secured to the plate with distal screws, for the complex fracture with marked comminution and/or osteopenia that prevented distal screw purchase, it has not been entirely successful. Several revolutionary ideas were introduced through the Trimed system to address these problematic injuries. An array of low-profile plates and wire forms is used that can address each of the major fracture fragments. The system also uses plate-supported 0.045 pins, sharp tines on the wire forms, or buttress wire forms to engage the distal fragments of bone where screw fixation is suboptimal or impossible. Placing the hardware in an orthogonal configuration permits rigid fixation to be obtained, allowing early motion in the majority of these patients.1,2

n

TECHNIQUE

Approach

n

HISTORICAL PERSPECTIVE/ OVERVIEW

Introduction of the Trimed Fracture Fixation System in 1996 represented a novel approach in the fixation of complex distal radius fractures. Previously, open reduction and internal fixation had applied a single ‘‘one size fits all’’ plate to the dorsum or volar surface of the distal radius and then attempted to secure the multitude of fracture fragments to the plate as well as could be accomThe authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. Neither of the authors or any of their families have any ownership in the TriMed Corporation or any of its affiliate companies. Address correspondence and reprint requests to Evan D. Schumer, MD, 2000 Washington Street, Suite 343, Newton, MA 02462. E-mail: [email protected].

74

The patient is placed supine, and a hand table is used. General anesthesia or axillary block that allows muscle relaxation is helpful in reduction, particularly in muscular individuals or longstanding fractures. An assistant or end table traction is useful but not necessary to aid in gaining and holding reduction during parts of the procedure. A mini-C-arm is essential during the procedure and will be used often enough that if it is not readily available we do not recommend proceeding with this device. A modified Henry volar 6-cm incision is made proximal to the distal volar wrist crease.3 The dissection continues along the lateral border of the radial artery between the radial artery and brachioradialis and the volar aspect of the 1st dorsal compartment tendons. The interval between the pronator quadratus insertion onto the radius and the volar retinacular attachment of the 1st dorsal compartment is sharply incised (Fig. 1). This allows subperiosteal elevation of the pronator quadratus and the 1st dorsal compartment tendons for exposure of the volar radius and the radial column, respectively. Elevating

Techniques in Hand and Upper Extremity Surgery

Trimed Fixation of the Distal Radius

FIGURE 1. Line drawing depicting volar approach to the radius. The pronator quadratus is subperiosteally elevated, reﬂecting the radial artery and FCR out of harm’s way. The 1st dorsal compartment can be elevated next to allow exposure to the radial column of bone for application of the radial pin plate.

the 1st dorsal compartment exposes the anticipated location of the radial pin plate at the radial tuberosity. Despite careful subperiosteal dissection, the floor of the 1st dorsal compartment may be violated. This will not affect tendon gliding or cause subluxation of these tendons. The most distal aspect of the tuberosity should be visualized. A narrow Homan retractor can be placed along the lateral edge of the radius to facilitate this part of the exposure. The brachioradialis can be elevated off the radius if it is a significant deforming force. A standard 3rd dorsal compartment splitting approach is performed, exposing more of the metadiaphysis than the carpus.4 The EPL is identified and retracted. The dorsal radius is exposed by subperiosteal elevation of the 2nd through 4th compartments. Care must be exercised in the subperiosteal elevation because the dorsal fracture fragments are frequently bound to the undersurface of the retinaculum and need to be dissected free. The posterior interosseous nerve (PIN) can be neurectomized at this time if desired. Through these 2 approaches approximately 270 degrees of the distal radius is exposed for inspection and reduction of the fracture as well as the eventual application of the orthogonal fixation.

Volar Fracture Fixation Only after both of these approaches have been completed should fracture assessment commence, and our preference is to begin from the volar portion of the radius. The subperiosteal elevation of the pronator muscle is held in place by a Bennett retractor. Frequently there is an unappreciated rotational component of the fracture. The ulnar portion of the distal fracture fragment is

displaced dorsally, leading to pronation of the hand on the forearm. This can be corrected by careful elevation of the distal fragment with a Freer elevator. If there is excessive fragmentation volarly and/or poor bone stock, application of a volar buttress plate will prevent volar translation of the fracture late in the case. In most instances gentle finger manipulation with end-of-table traction is all that is required to gain volar apposition of the fracture fragments. If the volar reduction seems to be anatomic, the first 0.045 K-wire should be driven across the fracture site. The K-wire is inserted at the most distal portion of the radial tuberosity. Exposure is facilitated by the use of either a small retractor or a tissue protector at the most distal dorsal corner of the incision. Drill the K-wire in the coronal plane of the radius to allow it to engage the proximal cortex. Confirm the fracture reduction and the K-wire position with a mini-C-arm. Frequently the K-wire is more proximal to the radial styloid than suspected. If the reduction is satisfactory and the pin has good purchase, the initial K-wire does not usually need to be reinserted. This K-wire may be secured to the radial pin plate later in the case or may serve only as a provisional fixation that is removed. It is important, however, not to secure the pin to the radial pin plate at this juncture because this will lock the fracture in place and prevent further reduction from the dorsum in an effort to regain volar tilt of the articular surface.

Volar Wire Form The volar wire form is designed to address a displaced volar ulnar fragment. These bony fragments should be reduced and stabilized before proceeding with the dorsal fixation. This fragment can often be visualized through the modified Henry volar approach or though a second incision ulnar to the median nerve. The fragment is reduced with manual manipulation and held with a provisional small K-wire. The volar wire form is prebent to follow the contour of the volar ulnar cortex. Its 2 legs need to be inserted into the volar lip of the volar ulnar fragment in such a way that when the wire form is impacted, the proximal loop will rest on the volar ulnar cortex of the radius. The volar wire form is inserted by first drilling 2 holes into the volar lip approximately 5 to 7 mm apart. The 2 holes are for the legs of the implant. An imaginary line connecting the 2 drill holes should be roughly perpendicular to the long axis of the radius (Fig. 2). The holes should be drilled approximately 20 degrees from the perpendicular to avoid penetration of the concave articular surface. The legs of the wire form are then trimmed; 1 leg is cut shorter than the other to facilitate impaction. The longer leg is then inserted into the appropriate drill hole and impacted until the second leg is touching the volar cortex. The second leg is then manipulated until it too is in its

Volume 9, Issue 2

75

Schumer and Leslie

FIGURE 2. The appearance of the volar pin plate on a saw bones with screws and washers in place.

respective hole. By alternating impaction the proximal loop of the volar wire form will now rest on the volar ulnar cortex. If the proximal loop is angled ulnarly, then the drill holes were not placed perpendicular to the long axis of the radius, and the wire form may need to be withdrawn and 1 of the drill holes repositioned. Once the volar wire form is resting on the volar cortex, it should be secured with 2 separate screw-and-washer combinations.

Dorsal Fracture Fixation The configuration of the dorsal radial metaphyseal surface is akin to the underside of a boat hull, rising to its maximum height between the 2 facet surfaces just ulnar to the Lister tubercle. This affords 2 distinct surfaces for fracture reduction and application of fixation hardware. Frequently one will encounter 2 or more large dorsal fracture fragments. These fragments represent the supporting dorsal cortical surface proximal to the scaphoid and lunate facet respectively. One difference between the Trimed system and other plating systems is that one must regain near perfect reduction before applying the fixation devices because the components are small and cannot be relied on to provide significant fracture fragment reduction. By utilizing end-table traction, gentle fracture manipulation, and flexion of the wrist over several rolled towels, one can maneuver the ulnarmost fragment into position.

76

Gentle elevation of the dorsal cortical bony fragments will allow visualization of the metaphysis of the radius and the undersurface of the subchondral joint. Frequently there is extensive bone loss noted, and we have found it valuable to pack bone graft beneath the subchondral surface to both aid in reduction of the joint surface and support the fracture while it heals. Bone graft material is fitted under each facet separately as the reduction and fixation of each proceed. Care must be taken not to allow bone graft to enter into the joint through any fracture lines that may extend distally. One can now replace the dorsal metaphyseal plate of bone over the graft site. The cortical plate of bone should lock into anatomic position at the proximal and distal fracture margins. If it does not, then it may mean that the distal fracture margin is not fully out to length. This shortening of the fracture alignment represents dorsal tilt of the joint surface. Further traction and augmenting the bone graft may be necessary to obtain correct length, which is verified by the anatomic fit of the dorsal plate of bone. When both proximal and distal margins align, provisional K-wire fixation can be accomplished with a proximally directed 0.045 K-wire placed into the fracture fragment just proximal to the subchondral margin. Fluoroscopy is used to check articular alignment and pin placement at this time. The dorsal ulnar fracture can then be held in position with either the ulnar pin plate from the set or a combination of different wire forms. Once fixation of the ulnar side of the dorsal radius is completed, a similar approach to the radial-side fracture fragment is accomplished. Inspection of the metaphyseal bone loss, gentle manipulation of the subchondral bone surface back into position, packing with bone graft, and replacement of the dorsal cortical plate of bone, which serves to both hold the bone graft in place and support the dorsal subchondral rim of bone, is completed. Wire forms are typically used on the radial side for fracture fixation.

Ulnar Pin Plate The ulnar pin plate is designed to stabilize dorsal ulnar fractures of the distal radius (Fig. 3). The fracture is reduced and held with a proximally directed oblique K-wire. The location of the K-wire as well as the reduction should be checked with the mini-C-arm. If the location and reduction are acceptable, an ulnar pin plate can be slipped over the protruding end of the K-wire. Because the distal edge of the dorsal lip of the radius is generally visible, it is not necessary to confirm the position of the ulnar pin plate radiographically before securing it to the proximal cortex. The ulnar pin plate comes in 2 sizes (UPP-3 and UPP-5). Select a plate that allows 2 good screws to engage the proximal cortex. Try to insert the screws such that they engage the ulnar half of the radius.

Techniques in Hand and Upper Extremity Surgery

Trimed Fixation of the Distal Radius

easier. If the fracture line is deep to the ligaments, the mini-C-arm may be necessary to both guide and confirm the reduction. In some instances the ulnar pin plate can be used without the pin. In such situations the ulnar pin plate will function as a buttress holding the ulnar fragment down and preventing dorsal migration.

Wire Forms

FIGURE 3. Line drawing of an ulnar pin plate ﬁxing a small dorsal ulnar fracture fragment with 2 K-wires. The ulnar pin plate is ideal for small ulnar-sided fragments. Much like the radial pin plate, it acts as a cortical buttress and stabilizes the ulnar-sided pins.

If they are inserted perpendicular to the sloped angle of the dorsal cortex, the screws will end up engaging the volar radial half of the radius and possibly interfere with future component fixation. The plate will need to be twisted to fit the contour of the dorsal ulnar corner of the radius. The amount of twist will best be appreciated after the plate is slipped over the pin and the contour of the bone is compared with that of the plate. The plate can be twisted and bent with the plate holding clamps provided in the equipment tray. The pin plate is ideal for fixing the small dorsal ulnar lip fractures, which involve both the distal radial ulnar joint and the lunate facet. There will be times, however, when the fracture involves more of the distal radial–ulnar joint and less of the lunate facet; in such situations it is crucial that the dorsal distal radial–ulnar joint ligaments are not detached from the small fragment. When faced with such a fracture, one should place the ulnar pin plate superficial to the ligaments. If the fracture line is radial to the ligaments, the alignment of the fragments is a bit

There are 2 basic wire forms: the outer (dorsal) clip, which may or may not be combined with an inner clip (Figs. 4, 5), and a buttress clip, which may or may not be combined with an outer clip (Figs. 6, 7).All clips are secured to the proximal radial cortex with a 2.3-mm self-tapping screw and a washer. The washer allows the screw to grab the wire form and hold it in place. The wire forms are designed with a proximal loop; the wire form can be slid proximally or distally to adjust the amount of support provided until the screw is fully tightened. Because the wire form is held in place with only 1 screw, it is crucial that the screw have excellent bicortical purchase. If there is any doubt as to the integrity of the screw purchase, a longer wire form should be chosen, such that a more proximally located screw and washer is used. Occasionally 2 screws (and their accompanying washers) may be necessary to salvage a long wire form with inadequate screw purchase. Dorsal Clip. The dorsal clip is the easiest wire form both to conceptualize and to use. The dorsal clip is

FIGURE 4. Line drawing representing the application of an outer clip for the reduction and stabilization of a dorsal radial fragment.

Volume 9, Issue 2

77

Schumer and Leslie

FIGURE 5. Line drawing representing the application of an inner and outer clip combination for the reduction and stabilization of a dorsal radial fragment.

designed to hold a cortical fragment in place with a downward force. The clip can be used by itself if, on reduction, the displaced bony fragment is stabilized on at least 2 of 4 sides. If the reduced fragment is stabilized by only 1 intact piece of cortical bone, the bone fragment can rotate or shift; in such a situation, it is probably wiser to use

FIGURE 6. Line drawing representing the application of a buttress clip for the reduction and stabilization of an isolated die punch fracture fragment.

78

FIGURE 7. Line drawing representing the application of a buttress clip and outer clip combination for the reduction and stabilization of a die punch and dorsal radial fracture.

a combined inner and outer clip. The dorsal clip can be bent either in an anterior–posterior direction to provide greater downward force or in a medial–lateral direction to accommodate a cortical fragment that is either narrower or wider than the unmodified dorsal clip. The wire forms are best bent with the wire bender provided in the set. Combined Inner and Outer (Dorsal) Clip. Combining an inner and an outer clip holds an unstable piece of cortical bone. It is usually used for dorsal radial fractures but can also be used for dorsal ulnar fractures. To insert the inner clip, a small narrow opening needs to be made at the proximal aspect of the displaced bony fragment. Enough bone is removed to allow the inner clip to be slid under the displaced dorsal fragment; this is most easily accomplished by making 2 small notches in the cortex with a rongeur to allow insertion of the inner clip. The shoulder of the inner wire form should rest flush against the strong proximal cortical bone. If it does not, there is the potential for proximal migration of this inner wire form with subsequent loss of reduction. The length of the inner wire form depends on the size of the displaced bony fragment and the integrity of the proximal cortex. The smaller the distal fragment, the shorter the distal end of the inner wire form, and a weaker proximal cortex requires a longer proximal loop of the inner wire. The distal end of the outer clip should be a bit longer than

Techniques in Hand and Upper Extremity Surgery

Trimed Fixation of the Distal Radius

the distal end of the inner clip and long enough to encircle the proximal end of the inner clip (Fig. 8). If necessary, the outer clip can be bent either in an anterior– posterior or medial–lateral direction. Buttress Clip. The buttress clip, by itself, is the most infrequently used wire form. It is designed for a central die punch fragment when the dorsal cortex is intact (Fig. 9). Before insertion of the wire form, the radiocarpal joint is exposed, and the displaced die punch fragment is located. A narrow 2 mm 3 5 mm window is made in the dorsal cortex in line with and proximal to the displaced fragment. The window allows insertion of the legs of the wire form and supplementary bone graft. The window should be made such that the legs of the buttress clip, when inserted, will support the subchondral bone of the displaced articular fragment. The legs of the wire form will always need to be cut short because they do not need to engage the volar radial cortex. The legs of the wire form can be bent to change the volar tilt of the supported fragment. Once the wire form is secured, bone graft or bone substitute can be inserted through the previously created dorsal window.

FIGURE 8. Intraoperative photo of an inner outer wire form used to stabilize the dorsal ulnar component of a comminuted distal radius fracture. The outer clip’s loop extends proximal to the inner wire form, and both are captured together with a single screw and washer. Note that the dorsal fracture fragment has keyed back into place and is held by the clips.

FIGURE 9. Line drawing representing a buttress clip supporting the articular surface in an isolated die punch fracture.

Combined Inner Buttress Clip and Outer (Dorsal) Clip. The most typical fracture pattern we have encountered on the dorsal radial surface is a displaced articular fragment in conjunction with a displaced dorsal cortical fragment (Fig. 10). This type of fracture is well supported by use of an inner buttress clip behind the impacted articular fracture and an outer clip to hold the displaced dorsal fragment (Fig. 11). It is necessary to notch the

FIGURE 10. The ﬁngers are toward the top of the photograph. This intraoperative photograph represents the typical die punch fragment encountered; a large articular piece wedged into the metaphyseal bone with displaced dorsal fracture fragments.

Volume 9, Issue 2

79

Schumer and Leslie

FIGURE 11. Line drawing of an inner buttress clip and outer dorsal clip in place. This would be an appropriate treatment method for the displaced die punch fracture with associated dorsal fracture components, as seen in Figure 10.

cortical bone to allow the inner clip to be positioned under the dorsal fragment and behind the articular surface. Placing the distal bent edge of the inner buttress clip in the dorsal corner of the radius allows the legs to hug the subchondral bone behind the distal radial articular surface. Bending the legs of the inner buttress clip will provide more (or less) volar tilt. The proximal end of the inner buttress clip should be long enough to engage the strong cortical bone at the notches created by the rongeur to prevent proximal displacement of the wire form. The outer dorsal clip should be long enough to provide adequate dorsal support and still encircle the proximal loop of the inner buttress clip. Radial Pin Plate. The radial pin plate is used to stabilize the radial column (Fig. 12). It is applied to the distal radius deep to the first dorsal compartment through the volar modified Henry approach. If the provisional radial styloid K-wire is still in good position, then it can be secured to the radial pin plate. Determine which of the 3 radial pin plate lengths (RPP-3, RPP-5, RPP-7) will provide adequate support. The pin plate needs to be long enough to allow fixation proximal to the fracture line with at least 2 good screws. The choice of pin plates is determined by sliding the plate over the protruding end of the K-wire. If the K-wire is relatively proximal to the tuberosity, then the K-wire should be passed through 1 of the more proximal pin holes of the plate. This will allow the second pin to be placed more distally in both the plate and the tuberosity. Plate position should be confirmed with the mini-C-arm. For most fractures, the RPP-3 will suffice. The plate will almost always appear to be proud above the bone by several millimeters before screw

80

application; however, with good bicortical screw purchase the plate will snug down against the radial column and can usually be counted on to correct several millimeters of radial translation in the process. Usually only 2 screws are necessary, but be careful to keep the screws relatively perpendicular to the long axis of the radius. The contour of the bone and plate in this region will have a tendency to angle the screws, and the distal screw tip may end up in the DRUJ. The position of the first radial styloid pin will frequently determine the location of the radial pin plate. If the first radial styloid pin is proximal and volar, the plate will rest obliquely with the distal edge volar and the proximal edge dorsal. If the first pin is dorsally placed at the distal edge of the radial styloid, the plate will rest along the lateral aspect of the radius in the midaxial line. We have not noted any clinical difference in this regard. Before the K-wire is secured to the pin plate, a second K-wire should be inserted. The location of the second K-wire is determined by the position of the first K-wire. If the first K-wire was a bit too proximal, the second K-wire

FIGURE 12. Line drawing of the radial pin plate. We advocate bicortical screw purchase and placement of dorsal hardware before the radial pin plate hardware.

Techniques in Hand and Upper Extremity Surgery

Trimed Fixation of the Distal Radius

should be inserted through one of the distal holes in the pin plate, and vice versa. Once the second K-wire is in place, the pins can be secured to the plate. Each K-wire needs to be withdrawn, bent, cut, crimped, and impacted into the plate. Working with one K-wire at a time, drill back the K-wire while simultaneously leaning the wire into the plate. The combination of leaning into the plate while backing out the K-wire scores the K-wire with circumferential rings. The rings allow you to determine where to cut and crimp the K-wire. If the K-wire had originally just engaged the distal cortex, then the ring closest to the drill should be at the level of the pinhole once the pin has been impacted. An alternative method involves using the distinctive 0.045 K-wires with alternating black and silver stripes that are provided in the equipment set. By localizing a stripe location in relation to the plate edge, one can ascertain the correct pin length for bending, cutting, and impacting. The K-wire is backed out far enough to crimp the end. The bending/crimping tool is positioned such that the center of the tool is just distal to the ring closest to the drill or just distal to the appropriate zebra stripe. After bending, the pin is cut. The modified needle holders are used to narrow the U-shaped bend. The impacting tool is used to reinsert the pin, impacting the cut end into the previously open adjacent pinhole. The cut end can be inserted into the hole just distal or proximal in the pin

FIGURE 13. Intraoperative photo of the radial pin plate. The plate not only acts as a buttress to the radial column but also increases the stability provided by the radial styloid pins. In place it is low proﬁle and should not affect the tendons of the ﬁrst dorsal compartment.

plate. Once the K-wires and plate are secure, the tissues are allowed to fall back into place. Properly placed, the radial pin plate should not interfere with first dorsal compartment excursion (Fig. 13).

n

COMPLICATIONS

Displaced intraarticular Colles fractures may be associated with significant soft tissue trauma. Nerve and tendon injuries are not uncommon and need to be assessed before proceeding with an open reduction and internal fixation. The integrity of the skin and the degree of soft tissue swelling will dictate the timing of the surgery and the

FIGURE 14. Preoperative and postoperative radiographs demonstrating the use of the radial and ulnar pin plate. The lunate facet was elevated and temporarily held in place with a 0.045 Kwire. The K-wire was then supported and secured with an ulnar pin plate. Two K-wires were used with the ulnar pin plate.

Volume 9, Issue 2

81

Schumer and Leslie

location of the incisions. In most situations 2 incisions will be necessary to rigidly fix the radius; occasionally a third incision will be necessary to stabilize the ulnar styloid. In patients with marked swelling it may not be wise to make the third incision because it will be difficult to primarily close the additional incision. In such situations the ulnar fracture will need to be treated nonoperatively with a pronation/supination splint. Skin sloughs between the volar and dorsal incisions have not been seen. Although the TriMed Wrist Fixation System provides excellent fixation, the device itself can not always prevent collapse in the face of bone loss. Bone graft or bone substitute should be used in patients with osteoporotic bone, displaced articular fragments, and significant bone loss. The most commonly voiced concern among those who start using the TriMed Wrist Fixation System is the issue of tendon irritation or tendon rupture. Tendon problems do not generally occur with the wire forms. The wire forms have a low profile and are usually under the intact floor of the fourth dorsal compartment. Tendon

irritation can occur with either the radial or the ulnar pin plate. The irritation is not caused by the low-profile pin plate but rather by the associated pins, which may back out. Properly inserted, crimped and secured, the pin does not usually back out. Overcrimping allows the pins to close down like a clothespin on insertion into the bone, discouraging loosening and backing out. Pin migration is clinically associated with crepitus and pain. If the fracture is healed and the pin is no longer necessary for stabilization, a migrating pin should be removed; left in place, a migrating pin may fray or rupture an overlying tendon.

n

POSTOPERATIVE CARE

The arm is immobilized in a forearm-based splint. If rigid fixation was obtained, range of motion exercises are begun at 7 to 10 days in formal occupational therapy. A removable splint can be used for temporary support. Within 6 weeks the temporary removable splint should no longer be necessary. The buried hardware has been painful and

FIGURE 15. Preoperative and postoperative radiographs demonstrating a displaced intraarticular scaphoid facet fragment. The displaced fragment can be seen on the PA and lateral radiographs that were taken after application of an external ﬁxator. The intraoperative picture demonstrates both the size and displacement of the articular fragment. The fragment was elevated and supported with cancellous bone graft. Further support was provided by placing the distal end of the inner clip ﬁrmly against the subchondral surface of the (now) elevated fragment. The lateral postoperative radiograph shows how far distal the distal end of the inner clip was placed.

82

Techniques in Hand and Upper Extremity Surgery

Trimed Fixation of the Distal Radius

needed to be removed in fewer then 10% of our patients. This is generally related to 1 of the pins from the radial or ulnar pin plate backing out. With the more recent bending techniques our incidence of this problem has decreased significantly.

n

CLINICAL EXAMPLES

Case 1 A 42-year-old man sustained a displaced intraarticular Colles fracture. The fracture line is between the scaphoid and lunate facets. The fracture has collapsed dorsally and proximally. Rigid fixation was obtained with a radial and ulnar pin plate (the simplest of constructs and a good case as an introduction to the system). The ulnar pins are a bit too long, as can be seen on the lateral postoperative x-ray; however, anatomic alignment has been restored, and motion was begun on postoperative day (Fig. 14).

Case 2 A 27-year-old framer sustained a work related die-punch fracture. The initial treatment with an external fixator did not restore the articular alignment. Note the depressed articular fragment seen on both the AP preoperative x-ray and the intraoperative photo. This displaced fracture fragment was reduced and held in place with cancellous bone graft and supported with a combined inner and outer clip. Another option would have been to use a combined inner buttress clip and outer dorsal clip. The patient was able to return to work within 1 month wearing a removable wrist splint (Fig. 15).

n

CONCLUSION

At first glance, the TriMed Wrist Fixation System may seem a bit intricate, but the concept is quite simple: rigid fixation is obtained with a combination of wire forms and pin plates. The wire forms and pin plates come in different shapes and sizes. Different combinations of wire forms and pin plates will be used based on the fracture pattern and the experience of the surgeon. The variability of the wire forms and pin plates allows the operating surgeon to customize the device to the fracture rather than the fracture to the device. Properly used, the TriMed Wrist Fixation System provides excellent fracture stability and allows the patient to begin early wrist motion.

n

REFERENCES

1. Medoff RJ, Kopylov P. Immediate internal fixation and motion of comminuted distal radius fractures using a new fragment specific fixation system. Orthop Trans. 1998;22:165. 2. Medoff RJ, Kopylov P. Open reduction and immediate motion of intra-articular distal radius fractures with a fragment specific fixation system. Arch Am Acad Orthop Surg. 1999;2: 53–61. 3. Henry AK. Exposure of the whole shaft of radius from in front with extensions to median and ulnar nerves. In: Henry AK, ed. Extensile Exposure, 2nd ed. Edinburgh: E. & S. Livingstone, 1970:100–106. 4. Weil C, Ruby LK. The dorsal approach to the wrist revisited. J Hand Surg [Am]. 1986;11:911–912.

Volume 9, Issue 2

83

Techniques in Hand and Upper Extremity Surgery 9(2):84–90, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

T E C H N I Q U E

Arthroscopically Assisted Reduction and Immobilization of Intraarticular Fracture of the Distal End of the Radius: Several Options of Reduction and Immobilization Chen Guofen, MD Department of Orthopaedics & Traumatology Nanfang Hospital Guangzhou, China

Kazuteru Doi, MD, Yasunori Hattori, MD, and Izuru Kitajima, MD Department of Orthopedic Surgery Ogori Daiichi General Hospital Yamaguchi Prefecture, Japan

n

ABSTRACT

n

On the basis of preoperative computerized tomography scanning and newly developed 3-dimensional reconstruction technique, Doi classified intraarticular distal radial fracture to 2-, 3-, and 4-part type, according to the number of main fracture fragments in distal radial aspect. This classification system simply, as well as perspicuously, describes the status of joint surface, thereby providing an intuitionist and practical guideline for arthroscopy procedure. Between 1992 and 2003, 91 patients ranged from 21 to 79 years of age with intraarticular distal radius fracture were treated with an arthroscopically assisted operation at our department. Among these patients, 42, 34, and 15 cases were 2-, 3-, and 4-part type, accounting for 46%, 37%, and 17% respectively. Wrist arthroscopy was applied individually according to the different type, with the purpose of achieving ,1mm reduction. Role of arthroscopy was postreduction examination for 14 cases, as K-wire guider in 13 cases, assisting reduction, and immobilization in 61 cases. Four of the 61 cases changed to ORIF. Immobilization methods include external fixator combined with K-wire or plate combined with pullout wire or screw. K-wire without other implant was applied to 6 cases. In 1 case, ascrew was the only implant. Keywords: distal radius fracture, classification, arthroscopy Address correspondence and reprint requests to Chen Guofen, MD, Department of Orthopaedics & Traumatology, Nanfang Hospital, Guangzhou, 510515 China. E-mail: [email protected].

84

HISTORICAL PERSPECTIVE

Diagnostic techniques and treatment of distal radius fracture have developed greatly with the rapid advance of imaging techniques and new devices. A number of authors have proposed systems for the classification of fractures of the distal aspect of the radius, such as the Frykman,1 Mayo,2 Melone,3 and AO4 classification systems. A system will be most useful if it can describe the relative severity of the fracture and the corresponding treatment options.5 In other words, the principal significance of any classification is to provide guidelines for treatment as well as to facilitate evaluation and comparison of results. Complete understanding of the detailed status of distal radius surface such as direction and degree of displacement or comminution is of essential importance to any well-ordered reduction and immobilization. Unfortunately, most of the existing classification systems focus on the mechanism of injury or the geometry of the fracture. They are helpful for describing the fractures but may not correspond directly to the status of intraarticular fragments,6 which is the key information required for accurate reconstruction of the distal aspect of radius. It is important to note that the original systems were developed without the use of computerized tomography, which has become particularly important for the diagnosis of intraarticular fractures. Knirk and Jupiter reported that displacement of the distal radial articular surface $2.0 mm resulted in traumatic osteoarthritis.7 Other investigators have found that

Techniques in Hand and Upper Extremity Surgery

Intraarticular Fracture of the Distal Radius

displacement of even 1.0 mm resulted in pain and stiffness of the wrist.8,9 Less than 1 mm of displacement is an acceptable result after reduction. Closed reduction and cast immobilization is still the mainstay of treatment of nondisplaced, stable distal radius fractures. Over the past 20 years, more sophisticated internal and external fixation techniques and devices for the treatment of displaced fractures of the distal radius have been developed. The use of percutaneous pin fixation, external fixation devices that permit distraction and palmar translation, low-profile internal fixation plates, and implants all have contributed to improved fracture stability and outcome.10 However, these procedures are theoretically unable to restore a congruent articular surface because they are extraarticular techniques. Open reduction and internal fixation (ORIF) of intraarticular fractures of the distal end of the radius solely under fluoroscopic visualization appears in some instances to be inadequate to reestablish articular congruency.11–17 In our experience, fluoroscopic imaging can not meet the demand of accurate reconstruction (,1 mm) of the articular surface. Even under limited arthrotomy, it is not always possible to perform articular surface reduction in such a narrow space represented by the radiocarpal joint. When the mechanisms of conventional procedures are compared and summarized, 1 common denominator of them is to restore extraarticular configurations including radial inclination, radial height, volar tilt, as well as distal radioulnar joint alignment. Reconstruction of the articular surface is not directly taken into consideration. In our opinion, extraarticular alignment and metaphyseal continuity are very important, as is congruency of the articular surface. However, articular congruency is believed to represent a very significant contribution to the final outcome.18 Rogachefsky reported that anatomic restoration of the articular surface is a critical part of the operative treatment of AO type-C3 fractures and has a direct influence on the final outcome. It is well known that intraarticular malreduction contributes to rapid degenerative changes of the wrist joint.19–21 One reason many of the conventional treatment methods pay more attention to extraarticular alignment and metaphyseal continuity relates to the methods of evaluation used by the classification systems. Another reason is the technical ease of restoring continuity compared with restoring congruity.

n

INDICATIONS

Wrist function is dependent on the integrity and alignment of the radius with its carpal and ulnar articulations. Accurate reconstruction of the articular surface, with the goal of establishing anatomic congruency of that surface,

is important to minimize the risk of late osteoarthritis. Wrist arthroscopy provides the ability to directly assess the articular surface for step-offs or gaps as well as to evaluate the ligaments for tears.23 Reduction and immobilization of the intraarticular fragments performed under arthroscopy simplifies the surgical procedure and yields the best possible result. Furthermore, arthroscopy is associated with minimal capsular and adjacent soft-tissue scarring and thus reduces postoperative contracture and may contribute to the improvement of the overall functional results. This technique is especially indicated for 3-part and 4-part (fragment .1 cm3) types. In 1999, Doi et al reported that arthroscopically assisted reduction and immobilization of intraarticular fractures of the distal end of the radius, and their long-term outcome demonstrated better range of motion and grip strength than those treated by conventional procedures.22 However, as mentioned above, currently available classifications do not provide adequate descriptions of the status of the distal aspect of radius, which is necessary for operative planning and treatment. Fortunately, computerized tomography and a newly developed 3-dimensional reconstruction technique (3D CT) solve the limitation of plain radiography. However, because of the variable nature of the fracture pattern, degree of displacement of the fracture fragments, and stability of the fracture, it is necessary to apply this technique selectively based on our classification system. The role of arthroscopy in these procedures was postreduction examination for 14 cases, as a guide for Kirschner-wire insertion in 13 cases, and assisting reduction and immobilization in 61 cases. Four of the 61 cases changed to ORIF because of infeasibility of the arthroscopic technique.

n

FRACTURE CLASSIFICATION

On the basis of preoperative 3D CT scanning, Doi classified intraarticular distal radial fractures into 2-, 3-, and 4-part types, according to the number of main fracture fragments in the distal radial aspect. Two-part fractures had 3 subtypes, based on the direction of the fracture line (horizontal, vertical, or at the dorsal rim). Three-part fractures are composed of a significant radial styloid fragment and 2 main fragments in the lunate facet. A 4-part fracture involves 2 main fragments in both the lunate and scaphoid fossae. Severe comminuted cases, namely AO type C3 fractures, are categorized as 4-part fractures in this system. Compared with other classifications, this system simply and accurately describes the status of the joint surface, thereby providing an intuitive and practical guideline for the arthroscopy and reduction-fixation procedure (Fig. 1).

Volume 9, Issue 2

85

Guofen et al

FIGURE 1. Doi classiﬁcation.

n

TECHNIQUE OF ARTHROSCOPICALLY ASSISTED REDUCTION AND IMMOBILIZATION PROCEDURE

The detailed steps of our procedure were reported previously.22 Between 1992 and 2003, 91 patients ranging from 21 to 79 years old who suffered from intraarticular distal radius fracture were treated with arthroscopically assisted operation at our department. Among them, 42 cases were 2-part type, accounting for 46%; 34 cases were 3-part type, accounting for 37%; 15 cases were 4-part type, accounting for 17%. Generally, we prefer 3 arthroscopic portals for visualization of the reduction. These include a volar portal

FIGURE 2. Volar portal.

86

FIGURE 3. Dorsal portals.

between the flexor carpi radialis tendon and the radial artery (Fig. 2), the conventional dorsal 3–4 portal (between the extensor pollicis longus tendon and the extensor digitorum communis tendons,), and the dorsal 4–5 portal

FIGURE 4. Hematoma removal.

Techniques in Hand and Upper Extremity Surgery

Intraarticular Fracture of the Distal Radius

FIGURE 5. Reduction and ﬁxation of intraarticular fragments.

(between the extensor digitorum communis tendons and the extensor digiti minimi tendon; Fig. 3). After removal of the remaining hematoma from the volar portal, the degree of comminution, separation, and depression of the dorsal fracture fragments is assessed. From the dorsal 3–4 portal, the volar surface and the lunate fossa are examined. Under arthroscopic view, the degree of comminution was assessed, which can confirm the preoperative 3D CT diagnosis. In addition, gap separation and step-off displacement can be accurately evaluated with the tip of the probe. With a goal of less than 1 mm reduction, individual steps were applied to different types of fracture under a common principle.

Two-Part Type

FIGURE 6. Fixation of dorsal rim fragment with K-wire.

Most cases of the 2-part type can be easily reduced by simple traction and manual compression. In cases with 2-part type fracture having a horizontal fracture line, the volar fragment, in particular, tend to rotate dorsally during traction because of ligamentotaxis. Longitudinal traction is released slightly, and the wrist is placed in slight flexion. Following adjustment of traction force and manual compression, gap and step-off displacement were reduced to less than 1 mm. If a sagittal gap is present, manual lateral compression is effective for reduction. The fragments are gently compressed together and maintained with a tenaculum forceps. Transverse Kirschner wires are placed to provide interfragmentary fixation followed with oblique crossing Kirschner wires fixing intraarticular fragments to the radial shaft (Figs. 4, 5). The dorsal rim fragment is difficult to view from the dorsal portals. The arthroscope is therefore placed through the volar portal. It is not difficult to reduce a dorsal rim fragment by lateral compression with the wrist in flexion. In some cases, a single Kirschner-wire was used with the aim of immobilizing a dorsal die-punch fragment (Fig. 6). In case a big dorsal die-punch fragment is present, a mini cancellous screw is a good alternative (Fig. 7). In fact, the

Volume 9, Issue 2

87

Guofen et al

FIGURE 7. Fixation of dorsal fragment with miniscrew.

main role of arthroscope for a 2-part type fracture is prereduction and postimmobilization evaluation of the articular surface.

Three-Part Type Arthroscopically assisted reduction is especially indicated for a 3-part type fracture, as outcome from simple traction and manual reduction is always unsatisfactory. In these cases, the radial styloid fragment is usually reduced first. This provides an anatomic landmark to which remaining fragments can be reduced. A small incision is made in the anatomic snuffbox to avoid the radial artery and the superficial radial nerve. Usually, a 2-mm Kirschner wire is placed through the skin incision and is inserted through the styloid fragment into the radial shaft. Volar tilt and radioulnar inclination of the articular surface must be anatomically reduced at this stage, as the reduced

styloid fragment will be the control fragment for reduction of the medial die-punch fragment. Too much traction can overreduce the radioulnar inclination and cause dorsal tilt of the fragment. To prevent these deformities, the wrist should be placed in a position of slight flexion with reference to the preoperative plain radiographs made with the wrist in traction. If present, the lunate die-punch fragment then is reduced to the radial styloid fragment. With comminuted fractures, it is common to identify both a volar and a dorsal die-punch fragment. The depressed fragment can be elevated with use of a small periosteal elevator placed through the small skin incision into the metaphyseal bone proximal to the metaphyseal fracture line. The periosteal elevator can be used as a joystick to elevate and reduce the fracture fragment under arthroscopic control (Fig. 8). The volar die-punch fragment then can be fixed to the radial styloid fragment with a 1.5-mm Kirschner wire placed from the dorsal 4–5 portal under the control of the arthroscope in the dorsal 3–4 portal. In 1 case, besides sagittal gap, a tiny dorsal fragment was present. We applied a pullout technique with thin stainless steel smooth wire, which can produce interfragmentary compression and reliable fixation (Fig. 9). However, this technique requires special instrumentation to be used as a wire guide, as well as rather time consuming.

Four-Part Type In the 4-part type, namely a severe comminuted fracture, it is very difficult to restore the congruity of the distal radial joint surface. For some cases, under arthroscopy, the same principle as for a 3-part fracture is followed. Gap and step displacement of the die-punch fragment is reduced to less than 1 or 2 mm as possible. Multiple

FIGURE 8. Elevation of die-punch fragment with K-wire or trocar.

88

Techniques in Hand and Upper Extremity Surgery

Intraarticular Fracture of the Distal Radius

FIGURE 9. Pull-out wire technique.

Kirschner wires are applied for immobilization (Fig. 10). Nevertheless, in several severely comminuted cases, arthroscopic technique was infeasible, so we changed to ORIF. Iliac crest bone grafting is performed to provide support for the articular surface of an impacted fracture. As for the extraarticular metaphyseal fracture, we prefer an external fixator. In cases with a big distal metaphyseal fragment, a distal radius plate is a better choice, as it can provide rigid fixation and is beneficial to early rehabilitation. Immobilization methods include external fixator combined with Kirschner wire or plate, plate combined with pullout wire or screw. Kirschner wire without other implant was applied to 6 cases. In 1 case, a screw was the only implant.

n

DISCUSSION

As mentioned previously, improved diagnostic imaging with computerized tomography and 3-dimensional reconstruction techniques are helpful for assessing intraarticular displacement of the distal radius fracture as well as for classification of the fracture and operative planning. Combined with traditional classification systems,

our classification provides a detailed and clear description of the articular surface. Another advantage of this classification is its comprehensibility. Also, there were rare cases in which misdiagnosis of an extraarticular fracture was made based on plain radiographs. However, these intraarticular fractures were defined after CT scanning. Computerized tomography scanning and 3-dimensional reconstruction of the distal radius do add medical costs and prolong the diagnostic evaluation. Kirschner wires were commonly used for immobilization. Although Kirschner wires are technically easy to use, there are some obvious disadvantages such as absence of compression force, and the tip of a Kirschner wire may disturb tendon gliding. Superficial infection is another troublesome complication of Kirschner wires, although it seems easy to deal with. Pull-out wire techniques and screws were applied in some cases with the aim of overcoming the disadvantages of K-wires, but these methods require special instruments and may prolong the operative time. More practical methods are yet to be developed. In our opinion, 4-part comminuted fractures are challenging to treat. We applied multiple Kirschner wires in our cases, trying to replace and immobilize intraarticular fragments as much as possible. Anatomically, the distal end of the radius has 3 concave articular surfaces—the scaphoid fossa, the lunate fossa, and the sigmoid notch. Anatomic reduction of the lunate fossa is very important.24,25 Based on these facts, and because it is practically impossible to reconstruct the original congruency of the whole joint surface in severely comminuted cases, we prefer to pay more attention to restoring the contact area of the lunate and scaphoid fossae. For instance, in cases of dorsal rim fracture, because the fragment has no load contribution or articular function, we avoid ‘‘overoperating’’ or reducing these fragments. We believe an ‘‘intact’’ but rough surface is functionally worse than a partially deficient but smooth one. Therefore, I personally recommend resection of an articular fracture fragment if acceptable reduction cannot be achieved.

FIGURE 10. Multiple pinning combined with external ﬁxator.

Volume 9, Issue 2

89

Guofen et al

n

REFERENCES

1. Frykman G. Fracture of the distal radius including sequelae— shoulder-hand-finger syndrome, disturbances in the distal radial-ulnar joint and impairment of nerve function: a clinical and experimental study. Acta Orthop. Scandinavia, Supplementum 108, 1967. 2. Cooney WP. Fractures of the distal radius: a modern treatmentbased classification. Orthop Clin North Am. 1993;24:211–216. 3. Melone CP. Articular fractures of the distal radius. Orthop Clin North Am. 1984;15:217–236. 4. Mu¨ller ME, Allgo¨wer M, Schneider R, et al. Manual of Internal Fixation. Techniques Recommended by the AO-ASIF Group, ed 3. New York: Springer, 1991. 5. Trumble TE, Culp RW, Hanel DP, et al. Intra-articular fractures of the distal aspect of the radius. Instr Course Lect. 1999;48:465–480. 6. Waters PM, Mintzer CM, Hipp JA, et al. Noninvasive measurement of distal radius instability. J Hand Surg [Am]. 1997;22A:572–579. 7. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986;68:647–659. 8. Fernandez DL, Geissler WB. Treatment of displaced articular fractures of the radius. J Hand Surg [Am]. 1991;16: 375–384. 9. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intraarticular distal radius fractures. J Hand Surg [Am]. 1994;19:325–340.

14. Geissler WB. Arthoscopically assisted reduction of intraarticular fractures of the distal radius. Hand Clin. 1995; 11:19–29. 15. Geissler WB, Freeland AE. Arthroscopic management of intra-articular distal radius fractures. Hand Clin. 1999;15: 455–465. viii. 16. Hanker GJ. Diagnostic and operative arthroscopy of the wrist. Clin Orthop. 1991;263:165–174. 17. Wolfe SW, Easterling KJ, Yoo HH. Arthroscopic assisted reduction of distal radius fractures. Arthroscopy. 1995;11: 706–714. 18. Rogachefsky RA, Lipson SR, Applegate B, et al. Treatment of severely comminuted intra-articular fractures of the distal end of the radius by open reduction and combined internal and external fixation. J Bone Joint Surg Am. 2001; 83-A:509–519. 19. Martini AK. Secondary arthritis of the wrist joint in malposition of healed and uncorrected fracture of the distal radius[German]. Aktuelle Traumatol. 1986;16:143–148. 20. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986;68:647–659. 21. Catalano LW 3rd, Cole RJ, Gelberman RH, et al. Displaced intra-articular fractures of the distal aspect of the radius. Long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg Am. 1997;79: 1290–1302.

10. Simic PM, Weiland AJ. Fractures of the distal aspect of the radius: changes in treatment over the past two decades. Instr Course Lect. 2003;52:185–195. Review.

22. Doi K, Hattori Y, Otsuka K, et al. Intra-articular fractures of the distal aspect of the radius: arthroscopically assisted reduction compared with open reduction and internal fixation. J Bone Joint Surg Am. 1999;81: 1093–1110.

11. Duncan S, Weiland AJ. Minimally invasive reduction and osteosynthesis of articular fractures of the distal radius. Injury. 2001;32(suppl 1):SA14–SA24.

23. Gupta R, Bozentka DJ, Osterman AL. Wrist arthroscopy: principles and clinical applications. J Am Acad Orthop Surg. 2001;9:200–209.

12. Cooney WP, Berger RA. Treatment of complex fractures of the distal radius. Combined use of internal and external fixation and arthroscopic reduction. Hand Clin. 1993;9:603–612.

24. Mekhail AO, Ebraheim NA, McCreath WA, et al. Anatomic and x-ray film studies of the distal articular surface of the radius. J Hand Surg [Am]. 1996;21:567–573.

13. Auge WK 2nd, Velazquez PA. The application of indirect reduction techniques in the distal radius: the role of adjuvant arthroscopy. Arthroscopy. 2000;16:830–835.

25. Wagner WF Jr, Tencer AF, Kiser P, et al. Effects of intraarticular distal radius depression on wrist joint contact characteristics. J Hand Surg [Am]. 1996;21:554–560.

90

Techniques in Hand and Upper Extremity Surgery

Techniques in Hand and Upper Extremity Surgery 9(2):91–95, 2005

2005 Lippincott Williams & Wilkins, Philadelphia

T E C H N I Q U E

The Reverse Heterodigital Neurovascular Island Flap for Digital Pulp Reconstruction Roberto Adani, MD, Ignazio Marcoccio, MD, Luigi Tarallo, MD, and Umberto Fregni, MD Department of Orthopaedic Surgery University of Modena and Reggio Emilia Modena, Italy

n

ABSTRACT

A heterodigital neurovascular reverse-flow flap island flap for extensive pulp defects is described. A dorsolateral flap from the middle phalanx, based on the digital artery, is harvested from the adjacent uninjured finger. The common digital artery between the injured finger and the donor finger is ligated and transected just before its bifurcation. At this point the 2 converging branches of the digital arteries can be entirely mobilized as a continuous vascular pedicle for the flap. The vascularization is now supplied by reverse flow through the proximal transverse digital palmar arch of the injured finger; to provide sensation, the dorsal branch of the digital nerve from the donor finger must be included in the flap. This technique is indicated for large pulp defects with bone exposure of index and middle finger pulps, which are important for sensation. Keywords: finger pulp reconstruction, neurovascular island flap, microsurgery, heterodigital island flap, reverse flow

n

HISTORICAL PERSPECTIVE

Loss of digital pulp or cutaneous sensibility of the fingertip is a common problem in hand surgery involving both cosmetic and functional aspects. Most often these lesions can be repaired using simple advancement flaps.1–3 However, when a greater part of the pulp is involved with bone exposure, it is necessary to resort to neurovascular flaps. Traditional techniques, such as the thenar flap4 and the cross-finger flap5,6 need, in fact, 2 surgical procedures immobilizing the finger in unnatural positions with resultant joint stiffness. Direct homodigital neurovascular island flaps can cover limited defects not exceeding 2 3 2.5 cm in size.7–11 Reverse homodigital island flaps require the integrity of the middle transverse digital palmar arch,12,13 which may be damaged in extensive Address correspondence and reprint requests to Roberto Adani, MD, Department of Orthopaedic Surgery, University of Modena and Reggio Emilia, Policlinico, Largo del Pozzo 71, Modena, Italy. E-mail: adani. [email protected].

pulp injuries. As an alternative to microsurgical reconstruction for large pulp defects14–18 involving the index and middle finger, we proposed a heterodigital island flap, which can be considered as a reverse-flow flap.19 The idea of raising a flap distally on a branch of a Y-like vascular bifurcation and turning the Y into a V is not new; this concept was introduced by Martin et al20 and was subsequently used in hand surgery for dorsal finger reconstruction, employing the dorsal digital network.21–24

n

INDICATIONS/ CONTRAINDICATIONS

The heterodigital reverse-flow neurovascular island flap is indicated for large losses of pulp from the index and middle fingers in situations where a homodigital island flap, with direct or reversed flow, would have presented risks and as an alternative to microsurgical reconstruction. We do not recommend this procedure in case of severe crushing injury involving multiple finger pulp losses because of the possible damage to the vascular network including the proximal or middle transverse digital palmar arches.

n

PREOPERATIVE PLANNING

Before surgery, performance of an Allen test and a Doppler examination is advisable for correct evaluation of the digital arteries of the injured and adjacent donor finger. The procedure is carried out under axillary plexus anesthesia, tourniquet control, and loupe magnification. The flap is designed on the dorsolateral aspect of the middle phalanx of the adjacent uninjured finger according to the shape and size of the defect (Fig. 1A). We prefer to use donor skin from the lateral side of the middle phalanx with the vascular pedicle located to the ventral side of the flap. In this way the grafted donor area is esthetically acceptable, and scar contracture can be prevented because the donor defect is not extended over the flexor aspect of the finger. An innervated flap can be harvested: the dorsal branch of the digital nerve is constant in all digital nerves and can be used to innervate the flap.25

Volume 9, Issue 2

91

Adani et al

FIGURE 1. A, Anatomic dissection after latex injection: the pedicle of the ﬂap is isolated up to its bifurcation in the palm, and the common digital artery is transacted (arrow) just before its division. B, The 2 converging branches of the digital arteries are mobilized as a continuous vascular pedicle, and the vascularization of the ﬂap is supplied by a ‘‘reverse ﬂow’’ system through the transverse palmar arches (usually the proximal transverse palmar arch); the ﬂap now reaches the defect.

n

SURGICAL TECHNIQUE

The skin incision starts from the proximal border of the flap and is prolonged to the palm by a Bruner design. The digital artery of the flap is first identified and then separated from the digital nerve, preserving as much fibrofatty tissue as possible around the vascular pedicle to ensure good venous drainage. The dorsal branch of the proper digital nerve from the donor finger can be included in the flap, to provide sensation. The flap is then raised from distal to proximal, and the pedicle is isolated up to its bifurcation in the palm. At this point the common digital artery between the injured finger and the flap-donor finger is dissected and transected just before its bifurcation (Fig. 1A). The Y-like vascular bifurcation is then turned into a V, and the two converging branches of the

92

digital arteries can be entirely mobilized as a continuous vascular pedicle for the flap; this expedient considerably increases the length of the flap pedicle (Fig. 1B). Thus, the vascularization is now supplied only by a ‘‘reverseflow’’ system through the proximal transverse digital palmar arch of the injured finger (if the middle transverse palmar arch has been damaged); the flap now can reach the defect (Fig. 1B). Because there is no accompanying vein, a thin cuff of soft tissue should be left around the digital artery to provide channels for venous drainage. Planning to leave the flap free of tension is important for its survival. The flap is transferred to the recipient finger via a subcutaneous tunnel in the palm to avoid another scar at the base of the reconstructed finger. The recipient digital nerve of the defect (usually the radial side) is dissected, and a microneurorraphy is done to the sensory

Techniques in Hand and Upper Extremity Surgery

Reverse Heterodigital Neurovascular Island Flap

nerve of the flap. The donor defect is covered with a fullthickness skin graft. At the end of operation, an aluminum splint is applied with the MP and IP joints in slight flexion: mobilization is started after 15 days.

n

RESULTS AND COMPLICATIONS

Between June 1995 and June 2003, 22 reverse heterodigital island flaps were used in 22 patients: 14 men and 8 women with an average age of 34 years (range 16– 51 years). Six patients underwent surgery on an emergency basis, whereas in the remaining patients the flaps where performed electively (5–45 days after trauma). The right hand was injured 14 times, and the left hand 8 times. In all patients the flap was used as a neurovascular flap for

finger reconstruction: the defect occurred on the index finger in 13 cases, and the middle finger was injured in the remaining 9 cases. The size of the flaps ranged from 2 3 2.5 to 3 3 3.5 cm. There were 2 complications in 2 patients in the early postoperative period as a result of venous congestion, which was relieved by removal of a few sutures. All of the flaps survived completely. Good coverage with supple and well-vascularized skin was obtained in each patient (Figs. 2, 3). Regarding donor site quality, there was a hypertrophic scar along the margins of the donor defect in 3 cases, and scar contracture was recorded on the donor digit in 2 cases. Only 1 patient complained of a mild intolerance to cold (in both donor and reconstructed finger); however, this did not impair function in work and was partially relieved by time.

FIGURE 2. A, Skin necrosis of the pulp of the middle ﬁnger. Preoperative planing. B, The digital artery of the ﬂap is identiﬁed and separated from the digital nerve (the dorsal branch of the proper digital nerve is included). The common digital artery of the second space is ligated to increase the length of the pedicle. C, Final result with good esthetic reconstruction of the pulp of the middle ﬁnger.

Volume 9, Issue 2

93

Adani et al

FIGURE 3. A, Unstable and painful pulp scar of the index ﬁnger following direct healing; there is still some bone exposure. Preoperative planing. B, Flap dissection and nerve suture between the dorsal branch of the proper digital nerve from the donor ﬁnger and the ulnar digital nerve of the index ﬁnger. The ﬂap is transferred to the defect, and the donor site is covered with skin graft. C, Final esthetic result with acceptable donor site result.

There were no painful neuromas. Mean TAM (expressed in terms of total active movement of the metacarpophalangeal and interphalangeal joints of the involved fingers) in the donor digit was 250 degrees, and in the reconstructed finger it was 230 degrees. The mean static 2-point discrimination test (s2PD) over the reconstructed pulp was 9 mm, and the mean dynamic 2-point discrimination test (m2PD) was 7 mm.

n

There are 2 main disadvantages: • the flap is taken from a healthy finger • the common digital artery of the second space is killed with subsequent decrease of arterial flow during the first few months

CONCLUSIONS

The advantages of this procedure are: • the possibility of a 1-stage reconstruction of extensive pulp defects with supple and well-vascularized skin • a length of vascular pedicle that allows a wide arch of transposition of the flap for coverage of a defect located

94

in the middle and index fingers, without the need to flex the IP joint, with good recovery of range of digital motion (without a defect of extension of the IP-joint) • early postoperative mobilization • good cosmetic result • satisfactory sensory recovery

Numbness over the dorsum of the donor middle phalanx caused by sectioning of the dorsal branch is negligible compared with the sensory restoration of the involved

Techniques in Hand and Upper Extremity Surgery

Reverse Heterodigital Neurovascular Island Flap

finger pulp, and also the risk of painful neuroma is limited because the dorsal digital branch is localized in a deep layer after transection.

n

13. Adani R, Marcuzzi A, Busa R, et al. A propos du lambeau en ilot homodigital a contre-courant. Revision de 15 cas et de la literature. Ann Chir Main. 1995;14: 169–181. 14. Buncke HJ, Rose EM. Free toe-to-fingertip neurovascular flaps. Plast Reconstr Surg. 1979;63:607–612.

REFERENCES

1. Kutler W. A new method for fingertip amputation. JAMA. 1947;133:29–30. 2. Tranquilli-Leali E. Ricostruzione dell’apice delle falangi ungueali mediante autoplastica volare peduncolata per scorrimento. Infort Traum Lavoro. 1935;1:186–193. 3. Elliot D, Moiemen NS, Jigjinni VS. The neurovascular Tranquilli-Leali flap. J Hand Surg [Br]. 1995;20:815–823. 4. Quaba A. Thenar flap. In: Foucher G, ed. Fingertip and Nailbed Injuries. Edinburgh: Churchill Livingstone, 1991: 87–91. 5. Souquet R, Souquet JR. Les indications actualles des lambeaux digito-digitaux dans les plaines des doigts. Ann Chir Main. 1986;5:43–53. 6. Lassner F, Becker M, Berger A, et al. Sensory reconstruction of the fingertip using the bilaterally innervated sensory cross-finger flap. Plast Reconstr Surg. 2002;109:988–993. 7. Foucher G, Smith D, Pempinello C, et al. Homodigital neurovascular island flaps for digital pulp loss. J Hand Surg. 1989;14B:204–208. 8. Lanzetta M, Mastropasqua B, Chollet B, et al. Versatility of the homodigital triangular neurovascular island flap in fingertip reconstruction. J Hand Surg. 1995;20B:824–829. 9. Adani R, Busa R, Castagnetti C, et al. Homodigital neurovascular island flaps with ‘‘direct flow’’ vascularization. Ann Plast Surg. 1997;38:36–40. 10. Borman H, Maral T, Tancer M. Fingertip reconstruction using two variations of direct-flow homodigital neurovascular island flaps. Ann Plast Surg. 2000;45:24–30. 11. Smith K, Elliot D. The extended Segmu¨ller flap. Plast Reconstr Surg. 2000;105:1334–1346. 12. Adani R, Busa R, Pancaldi G, et al. Reverse neurovascular homodigital island flap. Ann Plast Surg. 1995;35:77–82.

15. Logan A, Elliot D, Foucher G. Free toe pulp transfer to restore traumatic digital pulp loss. Br J Plast Surg. 1985;38: 497–500. 16. Kamei K, Ide Y, Kimura T. A new free thenar flap. Plast Reconstr Surg. 1993;92:1380–1384. 17. Koshima I, Urushibara K, Inagawa K, et al. Free medial plantar perforator flaps for the resurfacing of finger and foot defects. Plast Reconstr Surg. 2001;107:1753– 1758. 18. Tsai F-C, Cheng M-H, Chen H-C, et al. Microsurgical medialis pedis flaps for reconstruction of soft tissue defects in the hand. Ann Plast Surg. 2002;48:41–47. 19. Adani R, Busa R, Scagni R, et al. The heterodigital reversed flow neurovascular island flap for fingertip injuries. J Hand Surg. 1999;24B:431–436. 20. Martin D, Legaillard P, Bakhach J, et al. L’allongement pediculaire en Y–V a flux retrograde: un moyen puor doubler l’arc de rotation d’un lambeau sous certaines conditions. Ann Chir Plast Est. 1994;39:403–414. 21. Legaillard P, Grangier Y, Casoli V, et al. Le lambeau boomerang. Ann Chir Plast Est. 1996;41:251–258. 22. Karakalar A, Ozcan M. U-I flap. Plast Reconstr Surg. 1998; 102:741–747. 23. Pelissier P, Casoli V, Bakhach J, et al. Reverse dorsal digital and metacarpal flaps: a review of 27 cases. Plast Reconstr Surg. 1999;103:159–165. 24. Chen S-L, Chou T-D, Chen S-G, et al. The boomerang flap in managing injuries of the dorsum of the distal phalanx. Plast Reconstr Surg. 2000;106:834–839. 25. Tellioglu AT, Sensoz O. The dorsal branch of the digital nerve: an anatomic study and clinical applications. Ann Plast Surg. 1998;40:145–148.

Volume 9, Issue 2

95

Techniques in Hand and Upper Extremity Surgery 9(2):96–104, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

T E C H N I Q U E

Principalization of Pollicization of the Index Finger in Congenital Absence of the Thumb Guy Foucher and Jose Medina University of Las Palmas Gran Canaria, Spain

Patrick Lorea SOS Main Strasbourg, France

Giorgio Pivato Centro Studi Mano Milan, Italy

n

ABSTRACT

After reviewing our experience with pollicization in congenital cases of thumb hypoplasia or aplasia, we found that classic techniques have several weak points concerning function and appearance. Abduction is frequently inadequate, and adduction is quite weak. Esthetically the thumb has a slender aspect, the web fold is absent, and the commissure looks more like a cleft. We tried to prioritize the issues to propose some technical modifications for improvement of function and appearance. Keywords: pollicization, congenital differences, malformations, thumb hypoplasia

n

HISTORICAL PERSPECTIVE

Pollicization, the moving of a finger (partially or totally) into the thumb position, is a time-honored procedure for traumatic and congenital conditions. Littler has provided, in addition to personal contributions,1,2 a comprehensive historical review3 on thumb reconstruction. Anecdotal commentaries on pollicization in congenital differences have gone from overwhelming pessimism with Brooks, who said that, ‘‘at best, pollicization gives a hand that is cosmetically distasteful and functionally disappointing,’’4 to overenthusiasm with some authors such as Buck Gramcko.5 Few studies have provided detailed functional results,6–10 and the majority of authors concur concerning the difficulty of such assessment in a young population.6,11,12 Address correspondence and reprint requests to Guy Foucher, 6 Boulevard Edwards, Strasbourg 67000, France. E-mail: [email protected].

96

Many authors have contributed to technical improvement of function and appearance.1,5,13,14 Despite numerous contributions, many issues remain unsolved for reconstruction of the thumb in congenital deficiencies. Many published series mixed pollicization of a quite normal thumb in isolated hypoplasia or aplasia and more extensive radial dysplasia.7,10 On reviewing our own experience of 82 cases, we realized that the situation is too complex in extensive radial deficiencies to allow comparison with pollicization of a quite normal index in isolated thumb hypo- or aplasia. Even in the best cases, we found15 that the results of pollicization, even if rewarding, are far from perfect. If sensibility, mobility, growth, and integration were good, the bad news concerned power grip, which was only 55%, and pinch, which was only 42% of the opposite side (or of the standard values in bilateral cases). These results are close to those of Kosin et al12 (14 hands, 67% and 60%), Roper and Turnbull9 (9 cases, 63% and 56%), or Manske et al7 (28 cases, 21% and 26%). Such variations could be explained partly by the number of cases of radial dysplasia included. Finally, an independent surgeon assessed appearance (ranked excellent by the relatives in 85%) based on scar visibility, aspect of the first web space, and appearance of the thumb (length from the web and position). On a 10-point scale, the average score was 6.5. In October 2000 the senior author restricted his surgical activity to congenital differences, operating in 11 countries in a pro bono program. He then began a prospective series, which included 38 normal index pollicizations, and proposed some technical modifications after listing all the issues that he encountered.

Techniques in Hand and Upper Extremity Surgery

Congenital Pollicization

n

INDICATIONS/ CONTRAINDICATIONS

Timing and indications for pollicization in congenital abnormalities continue to be a matter of controversy.5–9,11 The majority of surgeons select early surgery,5,8 and Buck Gramcko stressed the hypertrophy of the thenar eminence as well as the remodeling of the new ‘‘carpometacarpal joint.’’ However, there is no limit on age when the index is used as a thumb: the operation is aimed not at the construction of a new pinch pattern but only at improving an existing one. Indeed, Manske et al,7 in a precise review of the functional results, was not able to find any difference. We prefer to operate around 1 year of age (mean 13 months in our series), at least for the social goals of creating a better appearance and relieving the anxiety of the family. We postpone the operation only when we must because of the presence of a syndrome (eg, Fanconi, Blackfan-Diamond, Holt Oram, Townes Brookes) or association (VACTERL). Thumb hypoplasia has been classified by Mu¨ller16 and Blauth,13 but many modifications were introduced17 rendering the comparison of series quite difficult (Table 1). Indeed, we demonstrate that except for types IV (pouce flottant) and V (aplasia), thumb hypoplasia is a spectrum of transitional forms, and it remains better to describe and correct each hypoplastic structure.18 Indications of pollicization are generally accepted in these 2 last groups. And if reconstruction is the accepted technique in groups I and II (except for Egloff and Verdan,11 who extended their indications of pollicization to this group), controversy remains in so-called group III, which was divided by Manske into type A (with a first carpometacarpal joint) and type B (without). Many factors have to be taken into account in deciding between reconstruction and pollicization, not just the presence or absence of first carpometacarpal joint. Among these are age of the patient, degree of hypoplasia of the thumb, pattern of pinch and grasp (and integration of the thumb), cultural background, and opinion of the relative. We have found that if reconstruction is complex (free vascularized tarsometatarsal joint transfer, web flap, joint stabilization, reconstruction of intrinsic and extrinsic function), it is not TABLE 1. Classification of thumb hypoplasia by Muller16 and Blauth13 TI TII TIII TIV TV

Slimness (without thenar muscle hypoplasia?) Adducted thumb with thenar hypoplasia and occasionally MPJ laxity/joint dysplasia Partial aplasia of the first metacarpal; thenar muscles nearly absent; severe abnormalities of muscles First metacarpal absent with ‘‘pouce flottant’’ Thumb aplasia

the real issue because growth of the distal part of the thumb remains unpredictable.19–21 There is no doubt in our mind that pollicization is functionally and cosmetically superior to such multistage reconstruction, but we found it useless to try to convince some relatives from Asia or Arabic countries who just want the child to have 5 fingers. Except in such cases, we no longer try to perform very early reconstruction and wait until the child can give his or her own opinion and demonstrate some integration in grasp, and the degree of hypoplasia can be assessed. A second contraindication for index pollicization is an established ulnar pinch pattern. Such a fixed pattern could be seen in neglected or recurrent radial club hands or rare cases of ulnar or central longitudinal deficiencies. Few authors have performed a pollicization of the little finger on the ulnar side of the hand.22–25 We have not used this technique because we found the appearance unacceptable. However, we described18,26 a ‘‘pseudopollicization’’ that does not change the pattern of grip but improves the ability to manipulate small objects and to grasp large ones in the commissure. It consists in providing a wide web between the ring and fifth finger through a rotation flap from the dorsum of the hand (mirror image of a Buck Gramcko flap27) combined with rotationosteotomy of the fifth metacarpal. A limited metacarpal shortening facilitates rotation after division of the deep intermetacarpal ligament and separation of the intertendinous connection. In fact, it is an ulnar transposition of the osteotomy of the first metacarpal bone described by Hentz and Littler28 but without any angulation in such a way that when the patient adducts the fifth finger, the result of the operation is easily concealed (except for the rotation of the nail). In this review, we do not discuss pollicization in radial polydactyly, transitional forms of triphalangeal thumb, mirror hand, or amniotic band amputation. In thumb hypo- or aplasia, we differentiate 2 different techniques of pollicization even if the basic operation remains the same, according to the mobility of the index finger. Stiffness of the index (including camptodactyly deformity) is not a contraindication for pollicization. Some authors have found a relationship with the degree of radial dysplasia. 7 In such cases the course of the tendons, tested by traction, is extremely limited with frequent adhesions of the extensors and flexors. Sometimes correction of the radial club hand with or without previous distraction aggravates finger stiffness. If we use the same technique that we will describe later, we do not attempt to ‘‘balance’’ the thumb but only ‘‘position’’ it as a post in front of the middle finger with sufficient pronation. On the other hand, MPJ hyperextension has to be avoided because the usual stiffness of this joint could prevent abduction and opposition to the fifth finger.

Volume 9, Issue 2

97

Foucher et al

The length of the new thumb (and the extent of metacarpal resection) is calculated according to the mobility of the middle finger and the possibility of tip contact between the new thumb and the middle finger. However we try to improve the overall appearance by raising the first web distally to decrease the otherwise slender appearance of too long a thumb.

n

TECHNIQUE

We describe here the technique of pollicization of a normal index.29 As in all surgery of congenital conditions, loupe magnification is mandatory as well as partial exsanguination with an elastic band combined with elevation. Many incisions have been described,2,5,11,13,14,30,31 but none was based on ordered priorities of the functional and cosmetic requirements. After we analyzed our previous results some issues were clear, and some solutions were proposed and evolved in the last 38 cases.

The Flaps, the Web Fold, and the Scar First, all current proposed incisions leave a too conspicuous scar on the ‘‘visible’’ dorsal aspect of the hand. With the most frequently used one, the Buck Gramko design,5 the dorsal flap for the web is often insufficient and leads to some adduction of the thumb as well as some supination and retropulsion. The web is not high enough, and it does not produce a fold but rather a sort of cleft with thumb, which looks long and slender. We successively modify the drawing until we obtain a good exposure of all anatomic structures to make their dissection easy, a huge dorsal flap to allow full opposition, a limited (but not circular) scar at the base of the thumb, and a ‘‘high’’ web with a fold reaching the base of the new thumb on the anteroulnar aspect at the previous PIPJ level (Fig. 1). Indeed, the fold of the normal first web extends from the

base of the index (8 o’clock on the left hand and 5 o’clock on the right) to the thumb (4 o’clock on the left and 9 o’clock on the right) (Fig. 2). It reaches the thumb distal to the MPJ. We use a distally based flap on the palmar aspect of the index extending in an L shape on the anterior aspect of the palm in front of the MP joint of the middle finger. This flap, ABCDEF, is lifted from the volar aspect of the neurovascular bundles laterally and flexor sheath centrally until the PIPJ is reached (Fig. 1). AB is situated on the midlateral line, DE is on the volar aspect of the web, and EF is volar to the midlateral line in prolongation of the web incision (at 9 o’clock and 4 o’clock on a left index). Through this part of the approach, opening of the A1 and part of the A2 pulley is easy, as is checking the course of the flexor tendons. A longitudinal incision is drawn on the palm in front of the second metacarpal (GHI), down to the volar wrist crease. The oblique dorsal incision on the index crosses the PIPJ (AF, F being more distal than A). The only alteration of incisions concerns the cases with a hypoplastic thumb. The modification depends on the level of insertion of this remnant. When it is distally implanted, part of the dorsal skin is kept with the volar index finger flap. If the thumb has a more proximal base, it is simply excised, and usually the scar remains on the thenar eminence. The dissection is begun volarly to allow refilling of the dorsal veins and simplify the dorsal dissection. The classic steps are elevation of both arteries and nerves. Sometimes the radial artery could be absent or very tiny. It could also start from the artery of the hypoplastic thumb very close to its base. The radial artery of the middle finger is divided, and the accompanying nerve is freed with care about the frequent Hartmann boutonniere, in which part of the nerve makes a loop around the artery. Then both bundles need to be entirely free

FIGURE 1. Proposed incisions for pollicizations.

98

Techniques in Hand and Upper Extremity Surgery

Congenital Pollicization

metacarpal head to control the absence of any kinking, compression, or tension of the vessels.

The New Carpometacarpal Joint

FIGURE 2. Schematic representation of the ﬁrst web fold position.

for elevation, maintaining some fat around them to preserve the surrounding veins. Then section of the intermetacarpal ligament is performed as well as resection of the lumbrical. Indeed, proximal migration of the lumbrical in the carpal tunnel could impede the function of the flexor profundus, as we noticed in our published series using classic technique. The next step is the dissection of the first dorsal interosseous muscle from distal to proximal and from radial to ulnar. The muscle is elevated from the second metacarpal bone to avoid any proximal dissection on the anterior aspect and not to jeopardize its innervation. Indeed, using this technique, a secondary opposition transfer was never necessary in our experience. Only then is the dorsal dissection begun because refilling of the venous network is usually sufficient. The dorsal skin flap is elevated from the dorsal aspect of the proximal phalanx. This step is difficult near the PIP joint where the skin is thin, but this part is not necessary and partially excised at the end of the operation even if Riordan has demonstrated its safety.32 The veins and the preserved radial nerve branches are elevated from the extensor plan to allow transverse section of the extensor mechanism at the base of the proximal phalanx and separation of the extensor indicis communis (EIC) and extensor indicis proprius (EIP). This last tendon could be absent or have no effect when pulled. The extensors need to be freed all the way to the dorsal retinacular ligament, with the intertendinous connections cut. Distally, the extensor is cut longitudinally in its middle (without injury to the periosteum) along the entire length of the proximal phalanx, to form 2 bands separated as far as the PIP joint. We found it useful to cut the metacarpal head through the growth plate with a knife before dissecting the palmar interosseous muscle in the second space. The growth plate is carefully curetted to destroy any potential growth. Then the metacarpal shaft is circularly freed to the base, where it is cut obliquely with a volar slope. The metacarpal head is shifted to the

Two points are important: maintain 1 cm of the base of the second metacarpal to save the insertions of the wrist extensor and flexor (FCR and ECRL) and destroy a potential pseudoepiphysis of the metacarpal base (not always visible on the x-rays). We favor opening the metacarpal base as a flower by simply breaking bone fragments, which remain attached to the periosteum. This increases the stability of the basal joint of the thumb. A good dorsal cortical bone is maintained to allow good anchorage of a MitekÒ resorbable minianchor (Fig. 3). The hole is formed in a precise position in the metacarpal base (at 2 o’clock for the left hand and 10 o’clock for the right), but, in fact, the perforator has the direction of a normal first metacarpal bone. We found the point of Buck Gramcko quite difficult to insert, and 2 points do not allow any more total rotation. The MitekÒ anchor simplifies this fixation greatly. Concerning hyperextension of the MP joint, which was stressed by Buck Gramcko, it is misleading to give a fixed angle, and it has to be adjusted to the preoperative hyperextension of the joint. Too much hyperextension in a stiff preoperative

FIGURE 3. Insertion of the metacarpal head at the metacarpal base with the use of a bone anchor.

Volume 9, Issue 2

99

Foucher et al

joint could lead to lack of abduction. The hyperextension is limited by the bite taken with the MitekÒ in the volar plate, which is detached when the section is through the growth plate. At this stage full range of motion is checked including axial rotation. The advantage is that the thumb is entirely ‘‘balanced’’ by tendon transfers and skin suture. Indeed when a K-wire is used, sometimes the thumb moves to adduction and supination when the K wire is removed.

‘‘Balancing’’ the New Thumb Two major anatomic points need to be stressed from the beginning. In a normal thumb, intrinsic extension allow for full interphalangeal extension (but no hyperextension). The other major issue is that the EIC and EIP are adductors (as well as the EPL in a normal thumb). They also act as supinators, destabilizing the position of the new thumb when classically fixed. On the other hand, 1 of the main flaws of pollicization is the weakness of adduction (pinch 42% of normal in our series of classic pollicizations15). The adductor of the thumb is among the strongest muscles of the body. We found that the adductor is frequently present even in a very hypoplastic thumb, and when present it has to be dissected and reinserted very carefully. To reinforce adduction we transfer the EIC on the ulnar half of the extensor hood as well as the second palmar interosseous muscle (Fig. 4). When this muscle is of small diameter we perform a cross-intrinsic transfer using the second dorsal interosseous muscle to have a stronger adductor with a more oblique direction. Indeed, in a quite rare anatomic variation this muscle is inserted on the ulnar side of the index finger. At this stage the new thumb is adducted and supinated. The next step is to provide abduction and pronation through fixation of the EIP (or the EIC when EIP is absent). However, the extensor, coming from the fourth extensor compartment, provides adduction and retroposition. To provide abduction this tendon has to be rerouted through a prefabricated first compartment, which could be formed from the fibrous tissue of the proximoradial insertion of the first dorsal interosseous muscle. Pronation is provided by fixation to the periosteum of the dorsum of the proximal phalanx. The last step is fixation of the first dorsal interosseous on the radial band of the extensor (usually very close to the previous PIPJ). We have not transferred this interosseous more ulnarly as proposed by Zancolli31 for fear of injuring its innervation, but it is true that the direction is not optimal. At this stage the thumb has to rest in a physiological position with 135 degrees of pronation, in some abduction (around 45 degrees), in front of the middle finger.

100

FIGURE 4. Transfers of tendons and muscles to balance the new thumb.

Skin Suture The skin is then sutured, maintaining some tension on the web fold formed from the dorsal flap. The scar is on the palmar side of the web but close to the distal border to allow for progressive retraction and constitution of a real fold (Fig. 5). None of our cases has evolved toward web restriction. A Z-plasty is cut on the radial aspect of the

FIGURE 5. Situation of the scar after skin sutures.

Techniques in Hand and Upper Extremity Surgery

Congenital Pollicization

new thumb in a place where it remains quite invisible to avoid any tendency to circular scar at the base of the thumb. The dorsal flap is wrapped around the new thenar muscles with the suture lying on the palmar aspect. Then only a linear skin scar is visible on the exposed dorsal aspect of the hand.

n

POSTOPERATIVE COURSE AND REHABILITATION

A fluffy dressing is passed in the first web to maintain it open, and a nonsterile drop of SuperglueÒ maintains contact between the pulp of the new thumb and the middle finger. A shell of plaster protects the dorsum of the hand from any impact, and the dressing is undisturbed until the

end of the third postoperative weeks. We found that passing an ElastoplastÒ around the elbow in 2 straps, 1 volar and 1 dorsal, ensures that the child does not escape from the dressing. A hole in the distal part of the band facilitates elevation of the hand for the first night. When this dressing is removed, the pulps are always spontaneously separated, and the baby is allowed to use the thumb freely, encouraging bimanual games (Fig. 6. ). No formal rehabilitation is used. An opposition splint is worn at night with full opening of the web in opposition during the next 2 months. At 6 weeks, if passive flexion at IP and/or MPJ level is limited, a splint in flexion is worn 1 hour in the morning and the evening until full active flexion is noticed (around 4 to 5 months postoperatively). Scar compression is frequently necessary if surgery is performed

FIGURE 6. Appearance of the ‘‘thumb’’ at 3 months postoperatively.

Volume 9, Issue 2

101

Foucher et al

early because scar hypertrophy is more often the rule than the exception.

n

COMPLICATIONS

We listed in Table 2 the numerous possible complications of this quite sophisticated operation. Some could happen during the operation, but we have not seen a single case of absent artery rendering the pollicization impossible. In case of absent palmar interdigital artery, or in case of unique ulnar artery, the dorsal metacarpal artery of the second space and the deep metacarpal artery could be dissected out. Any lesion of a major vessel could be microsurgically repaired. Postoperatively, hematoma and skin necrosis are a major concern and could be linked. Careful perioperative hemostasis is of maximum importance. Concerning skin vascularization, the only jeopardized skin flap is the distal part of the dorsum of the index. This part is lifted according to the technique of Riordan,32 leaving all the fat on the finger. However, necrosis of this part occurred once in our cases. We currently favor excision of this skin because it is not necessary for web reconstruction and skin closure. Some long-term complications need to be discussed. Absent (previous) DIP flexion was observed in several cases before we excised the lumbrical. This complication does not seem to be related to a pseudoquadriga syndrome with lack of muscle independence of the flexor profundus and, for us, contraindicated any surgical shortening33 with the risk of adhesions. It is also a reason for us not to disturb the flexor superficialis that could otherwise be used as a potential transfer. Unbalance of the thumb is also a potential complication. A ‘‘Z’’ deformity could be a complication according to Buck Gramcko, but fixing the previous MPJ in hyperextension is very effective (Fig. 7). But it is necessary to avoid the opposite pitfall, which consist of too much hyperextension in an already quite stiff joint TABLE 2. Possible complications of pollicization Insufficient artery for pollicization Perioperative arterial or nerve lesions (including first dorsal interosseous muscle denervation) Necrosis of the finger Skin flap necrosis Hematoma Scar contraction ‘‘Z’’ deformity of the finger (flexion of the former MPJ) Limited passive abduction caused by fixation in too much hyperextension of the previous MPJ Insufficient opposition (adduction retroposition deformity) Tendon adhesion or lumbrical obstruction Overgrowth from insufficient growth plate destruction or proximal metacarpal pseudoepiphysis Aseptic necrosis of the metacarpal head Ossification around the former MPJ Instability of the new first carpometacarpal joint

102

FIGURE 7. X-ray aspect of a bilateral pollicization using a nonresorbable anchor.

because it could limit abduction. A more frequent problem is a tendency of the thumb to stay in the same plane as the other fingers in some adduction retroposition. This was not unusual with the classic transfers because the pull of the extensors is in adduction retroposition. Only a transfer in the axis of the first extensor compartment could mimic the function of the abductor pollicis longus. Finally insufficient opposition is quite frequently mentioned in the literature, and the authors allude to the hypoplasia of the first dorsal interosseous muscle. We have not found it necessary to perform a secondary Huber Littler transfer for insufficient opposition. In the series of Oberlin and Gilbert,34 5 of the 14 cases of opponensplasty were after pollicizations, and Manske et al7 had to perform 8 opponensplasties on his 28 published pollicizations. Four other complications concern the new first carpometacarpal joint: 3 are clinical and include instability, progressive range limitation by ossification, and overgrowth; 1 is radiologic—aseptic necrosis. This last complication is only a transitory aspect in our experience. Instability and periarticular ossification were not seen in our experience, but opening the base as a flower could avoid the first but could also promote the second. However, as we have not seen the problem, we hypothesize that it could be related to preservation of the periosteum of the second metacarpal bone with the transferred muscles. Overgrowth has been a cause of reoperation in 3 cases of our published series of classic pollicization, and 2 explanations are possible. One is insufficient distal metacarpal growth plate destruction. The second concerns the growth of a proximal pseudoepiphysis, which is avoided by the current technique because introduction of the perforator for inserting the anchor destroys it. One word about functional exclusion, which is a major issue. It could be related to a mistake in indication if the index was not used as a thumb preoperatively or to a bad postoperative position of the thumb (adducted). More

Techniques in Hand and Upper Extremity Surgery

Congenital Pollicization

frequently it is only a temporary exclusion, and full integration occurs in a few months with use of bimanual games. Finally, we could include weakness of the thumb as a complication. Indeed, with a classic technique the strength of pinch at 7-year follow-up was only 42%, and the grasp 55%, of normal.15 Its is too early to assert in a small series with short follow-up (2.4 years) that our modifications have improved strength, but we can already say that extension is complete, abduction and opposition are satisfactory, and clearly the cosmetic score is better (8.5/10) because of the shorter appearance of the thumb (related to the more distally located web), better resting position of the thumb, and reduction of visible scar on the dorsal aspect of the hand.

n

11. Egloff DV, Verdan C. Pollicization of the index finger for reconstruction of the congenitally hypoplastic or absent thumb. J Hand Surg. 1983;8A:839–848. 12. Kozin SH, Weiss AA, Webber JB, et al. Index finger pollicization for congenital aplasia or hypoplasia of the thumb. J Hand Surg. 1992;17A:880–884. 13. Blauth W. Principles of pollicisation with special emphasis on new incision methods. Handchirurgie. 1970;2:117–121. 14. Malek R, Grossman JAI. The skin incision in pollicization. J Hand Surg. 1984;9A:305–306. 15. Foucher G, Navarro R, Medina J, et al. Pollicization, remains of the past or current operation. Bull Acad Natl Med. 2000;184:1241–1253. 16. Mu¨ller W. Die angeborenen Fehlbildungen der menschlichen Hand. Leipzig: Thieme, 1937.

CONCLUSION

We proposed some modifications of the technique of pollicization based on prioritizing of the surgical requirements. Our propositions are not definitive and are presented only as an encouragement for surgeons involved in the treatment of congenital differences to look for improvement and not consider the current procedure as necessarily providing ‘‘ideal’’ results functionally and cosmetically.

n

10. Sykes PJ, Chandraprakasam T, Percival NJ. Pollicisation of the index finger in congenital anomalies. A retrospective analysis. J Hand Surg. 1991;16B:144–147.

REFERENCES

1. Littler JW. The neurovascular pedicle method of digital transposition for reconstruction of the thumb. Plast Reconstr Surg. 1952;12:303–319. 2. Littler JW. Principles of reconstructive surgery of the hand. In: Converse JM, ed. Reconstructive Plastic Surgery. Philadelphia: WB Saunders, 1964:1620–1624. 3. Littler JW. On making a thumb: one hundred years of surgical effort. J Hand Surg. 1976;1:35–51. 4. Brooks D. Reconstruction of the injured hand. In: Wynn Parry CB, ed. Rehabilitation of the Hand, 2nd ed. London: Butterworths, 1966:341. 5. Buck-Gramcko D. Pollicization of the index finger. Method and results in aplasia and hypoplasia of the thumb. J Bone Joint Surg Am. 1971;53:1605–1617.

17. Manske PR, McCaroll HR. Type IIIA hypoplastic thumb. J Hand Surg. 1995;20A:246–253. 18. Foucher G, Medina J, Navarro R. Thumb hypoplasia. In: Hovius S, ed. The Pediatric Upper Limb. London: Martin Dunitz, 2002:133–152 19. Foucher G. Vascularized joint transfers. In: Green D, ed. Operative Hand Surgery, 2nd ed. New York: Churchill Livingstone, 1988:1271–1293. 20. Foucher G, Gazarian A, Pajardi G. La chirurgie reconstructive dans les hypoplasies type III de Blauth. Ann Chir Main. 1999;1:191–196. 21. Foucher G, Medina J, Navarro R. Microsurgical reconstruction of the hypoplastic thumb type IIIB. J Reconstr Surg. 2001;17:9–15. 22. Harrison SH. Pollicisation in children. Hand. 1971;3:204– 210. 23. Ipsen T, Barfred T. Ulnar thumb in cleft-hand-type congenital deformity: case report. Scand J Plast Reconstr Surg. 1988;22:257–259. 24. Segalman KA, McClinton MA, Anthony MS. Reconstruction of an ulnar-sided thumb in central deficiency: a case report. J Hand Surg. 2001;26A:40–43. 25. Wood VE. Small finger pollicization in the radial club hand. J Hand Surg. 1988;13A:96–99.

6. Clark DI, Chell J, Davis TR. Pollicisation of the index finger. A 27-year follow-up study. J Bone Joint Surg. 1988;80B:631–635.

26. Foucher G, Lorea P, Pivato G, et al. Technical note: ulnar ‘‘pseudo-pollicisation’’ in congenital hand differences. Chir Main. 2004;23:289–293.

7. Manske PR, Rotman MB, Dailey LA. Long-term functional results after pollicization for the congenitally deficient thumb. J Hand Surg. 1992;17A:1064–1072.

27. Buck-Gramcko D. Syndactyly between the thumb and index finger. In: Buck-Gramcko D, ed. Congenital Malformations of the Hand and Forearm. London: Churchill Livingstone, 1998:141–147.

8. Ogino T, Ishii S. Long-term results after pollicization for congenital hand deformities. Hand Surg. 1997;2:79–85. 9. Roper BA, Turnbull TJ. Functional assessment after pollicisation. J Hand Surg. 1986;11B:399–403.

28. Hentz VR, Littler JW. Abduction-pronation and recession of second (index) metacarpal in thumb agenesis. J Hand Surg. 1977;2:113–116.

Volume 9, Issue 2

103

Foucher et al 29. Foucher G, Medina J, Lore´a P, et al. Pollicization in congenital differences. Handchir Mikrochir Plast Chir. 2004; 36:146–151.

32. Riordan DC. The hand. Campbell’s Operative Orthopaedics, 5th ed. St Louis: CV Mosby, 1971:278–279.

30. Lister G. Reconstruction of the hypoplastic thumb. Clin Orthop Rel Res. 1985;195:52–65.

33. Bartlett GR, Coombs CJ, Johnstone BR. Primary shortening of the pollicized long flexor tendon in congenital pollicization. J Hand Surg. 2001;26A:595–598.

31. Zancolli E. Transplantation of the index finger in congenital absence of the thumb. J Bone Joint Surg. 1960;42A: 658–660.

34. Oberlin C, Gilbert A. Transfer of the abductor digiti minimi (quinti) in radial deformities of the hand in children. Ann Chir Main. 1984;3:215–220.

104

Techniques in Hand and Upper Extremity Surgery

Techniques in Hand and Upper Extremity Surgery 9(2):105–112, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

T E C H N I Q U E

Anconeus Muscle Transposition for Chronic Lateral Epicondylitis, Recurrences, and Complications Riccardo Luchetti, MD, Andrea Atzei, MD, Francesco Brunelli, MD, and Tracy Fairplay, LPT Hand Surgery Ancona University Department of Plastic and Reconstructive Surgery and Hand Surgery Torrette Hospital Ancona, Italy

n

ABSTRACT

The use of the anconeus muscle in the treatment of chronic lateral epicondylitis (CLE), recurrences, and infection is presented. In chronic lateral epicondylitis, a wide degenerative area of epicondyle tendon is not frequently found, but when it occurs, its treatment is quite difficult. Recurrences of CLE and superficial or articular infections of the radiohumeral joint after surgical treatment or cortisone infiltrations are 2 more major conditions in which the use of anconeus muscle transposition demonstrated to be a promising technique. The procedure is widely described based on personal experience of 13 cases, 8 of which were CLE (group 1), and 5 recurrences and infection (group 2). Rotation of this muscle close to the epicondyle makes it possible to cover the epicondyle bone and the exposed radiohumeral joint in all cases. Additional surgical time usually requires only an extra 15 minutes. At the mean follow-up of 74 and 55 months, all the patients of the first group were painless, and the patients of the second group showed a decrease in pain from 9 to 3. Patients of the 2 groups returned to their previous work with a complete recovery of elbow range of motion and grip strength. Keywords: chronic lateral epicondylitis, anconeus muscle, recurrence, infection

n

HISTORICAL PERSPECTIVE

The use of the anconeus muscle as a cutaneous covering in an exposed elbow region was first described by Cardany et al1 in 1981, who referred to its use as a myocutaneous flap for posteriorly exposed cutaneous elbow Address correspondence and reprint requests to Dr. Riccardo Luchetti, Ancona University, Department of Plastic and Reconstructive Surgery and Hand Surgery Torrette Hospital, Ancona, Italy. E-mail: rluc@ adhoc.net.

coverage. This technique was later described by Mathes and Nahai,2 Lamberty and Cormack3 and Vasconez.4 The same muscle flap was used and interposed to prevent proximal radioulnar synostosis by Bell and Benger in 19995 and later used as a spacer in radial–capitular resection by Morrey and Schneeberg.6 The use of this same muscle flap for epicondylar region coverage in chronic lateral epicondylar (CLE) syndromes was first presented at the 47th Annual ASSH meeting in 19927 and more recently has been published in 1998.8 This study reported its comparative results in 3 surgical procedures for the treatment of chronic epicondylitis, for a total of 61 surgical patients and 42 followups, with a 4-year follow-up control. The first chronic epicondylitis group was treated by conventional means: resection of the epicondyle tendons and partial resection of the epicondyle itself. The second chronic epicondylitis group was treated by an anconeus muscle transfer in association with the traditional method. The third chronic epicondylitis residual group, was treated with an anconeus muscle transfer only after they had undergone a traditional treatment program. For the most part, the follow-up control parameters that were taken into consideration were pain and return to work. The 3 groups rendered positive results for the pain parameters in 62%, 87%, and 52%, respectively, and for the return to work parameters in 84%, 96%, and 88%. The only limiting factors reported occurred in the third group, in which there was a lack of complete elbow extension. When the first 2 groups were compared, it was evident that the anconeus muscle transposition, in association with an epicondyle resection, renders positive percentile results in comparison to the use of only traditional surgical techniques. The use of this muscle flap in successive surgical treatments permits a discrete recovery for painful symptoms (52% pain reduction) and an optimal percentage for return to work (88% cases). In the second group, where these

Volume 9, Issue 2

105

Luchetti et al

cases were immediately treated with this technique, pain reduction was 87%, and return to work was 96% of the cases. This technique has been adopted by other authors9–12 and used for the same surgical indications that have been proposed by Almquist et al.8

n

INDICATIONS/ CONTRAINDICATIONS

The appropriate surgical candidate for the application of this technique usually has chronic (longstanding) epicondylitis in which various physical therapy treatments and pharmaceutical treatments have not been successful. The majority of patients had already undergone a series of cortisone infiltrations with progressive onset of symptoms after treatment. These patients have constant lateral elbow pain that is exacerbated with activity. Whatever type of medical therapy that they have tried has not reduced their painful symptoms. These patients also have a reduction in wrist extension and elbow extension strength when a resistance is applied at the wrist level. In addition, they usually present with dyschromia and muscle atrophy around the elbow extensor muscles as a result of repetitive cortisone infiltrations into the elbow area. Other surgical candidates that are appropriate for undergoing this procedure are patients who have residual epicondylar symptoms that have not responded to conventional surgery and have had an increase in painful symptoms without responding to any conservative therapy treatment. The most important surgical indication for this technique is the presence of a fistula or an articular infection postoperatively or postinfiltration. This clinical condition requires an ample area for surgical exposure and thus necessitates nearby muscle or cutaneous-muscle flap coverage. In summary, the indications for muscle flap use are reported below and can be divided into major and minor indications. Major indications include the following:

n

TECHNIQUE

The operation consists of the transfer of the anconeus muscle (Figs. 1, 2) onto the lateral epicondyle and/or the radiohumeral articulation to cover and protect the joint (Fig. 3) or the epicondyle bone. Anconeus muscle has recently been studied by Almquist et al8 and Schmidt et al.12 It has 2 pedicle vessels, the more important of which is the distal one, the recurrent posterior interosseous artery (RPIA); the proximal one is the medial collateral artery (MCA) (Figs. 4, 5). The innervation is derived from a branch of the radial nerve that follows the lateral portion of the medial head of the triceps muscle. Surgery is performed under brachial plexus anesthesia with a tourniquet placed most proximally on the arm to guarantee ischemia of the entire extremity. The elbow is placed in a flexed position, and the epicondyle is the reference point. A skin incision is made 3 cm proximal to the epicondyle, passing anteriorly and extending distally for 8–10 cm along the anterior border of the anconeus muscle (Fig. 6). The dorsal antibrachial fascia must be longitudinally sectioned to expose the epicondyle tendons, which are transversally sectioned about 1 cm from their insertion. The type of tendon injury and its severity must be well documented in association with the eventual exposure of the radiohumeral articulation after the removal of pathologic tendon tissue (Fig. 7). Continuing on, a tangent resection of the epicondyle is performed up until the point where there is evidence of good bone vascularization, which can also be checked by perforating the bone itself. The anconeus muscle transfer is done by sectioning its compartment fascia and isolating the distal portion

1. wide excision of degenerative extensor tendon pathology with or without radiohumeral joint exposure 2. recurrence of CLE 3. chronic articular fistula 4. superficial or deep infection after traditional surgery for CLE A minor indication would be dystrophic and/or hypotrophic subcutaneous skin caused by steroid injection. It must be mentioned that a predominant contraindication to this procedure is an absent or devitalized anconeus muscle, which may occur during surgical dissection.

106

FIGURE 1. Anatomic dissection of anconeus muscle (AM). White and black arrows show the anterior and dorsal distal proﬁles of the muscle. Black asterisk shows the lateral epicondyle.

Techniques in Hand and Upper Extremity Surgery

Anconeus Muscle Transfer for Epicondilitys

FIGURE 2. Schematic of the elbow location of the anconeus muscle. The distal pedicle vessel (RPIA) was legated to permit its rotation.

of the muscle (Fig. 8). The flap is raised up in a distal– proximal and ulnoradial direction until the vascular pedicle is exposed and its distal pedicle vessel (RPIA) is identified proximal to the surgical site (Fig. 4). This pedicle vessel is always sacrified (Fig. 2) because it is otherwise impossible for the muscle to be transferred. The arterial pedicle on the deep surface of the anconeus muscle must be carefully preserved. The muscle flap remains vascularized by the anastomosis that come from the proximal pedicle vessel (MCA). The anconeus muscle must be mobilized in order to rotate it 90 degrees onto the epicondyle and to cover the treated area (Fig. 9). The proximal part of the muscle should not be mobilized, nor should the nerve pedicle that comes off the radial nerve. As soon as the muscle is thoroughly mobilized, one can see its ample capacity to cover the epicondyle site where it is being transferred and positioned via reabsorbable sutures (Fig. 10). The flap should not be pulled or excessively tensioned; otherwise, damage could occur to the vascular pedicle. Accurate hemostasis is performed at

FIGURE 3. Schematic of the rotation of the anconeus muscle on the radiohumeral joint.

FIGURE 4. Anatomic dissection of anconeus muscle (AM). Proximal (black arrow) and distal (white arrows) vascular pedicles of the muscle.

the harvest site, and an aspiration drain is inserted prior to flap closure to aid in the drainage of hematic liquids (Fig. 11). The fascia will be used to cover the donor anconeus muscle site, but it should never be completely sutured above the transferred muscle to avoid development of secondary iatrogenic compartment syndromes.13 A primary skin closure is always possible. The elbow must be immobilized in a flexed position and the wrist in a neutral position, leaving the fingers free to move, for 15 days. Medication changes should be performed daily, and the aspiration drain is removed 48 hours from the time of surgery.

n

PERSONAL EXPERIENCE

From 1992 to 2003, 13 patients affected by CLE (8 cases: 6 male and 2 female) (group 1) or recurrence and

FIGURE 5. Dissection of the anconeus muscle with their vascular pedicle. MCA, medial collateral artery; RPIA, recurrent posterior interosseous artery.

Volume 9, Issue 2

107

Luchetti et al

FIGURE 6. Surgical approach to the lateral aspect of the elbow. Skin incision starts 3 cm proximal to the epicondyle and continues distally for 8–10 cm.

FIGURE 8. The anconeus muscle is harvested from distal to proximal, and the distal vascular pedicle is sacriﬁced.

complications (5 cases: 2 male and 3 female) (group 2) were operated on by the same surgeon (L.R.). The mean age of the patients of the first group was 45 years (range 33–59 years) and 48 years (range 37–60 years) for group 2. All the patients were clinically evaluated both preand postoperatively according to pain, elbow ROM, grip strength, and work status. Patient’s pain perception was evaluated by using a Visual Analogue Scale (VAS) (0 to 10), elbow ROM using a goniometer, and grip strength using a Jamar dynamometer. Work status and return to work after surgery were documented both in the preand postoperative evaluation. The instrumental evaluations, pre- and postoperatively, were comprised of an elbow x-ray and an epicondylar ultrasound. An electromyography (EMG) evaluation of

the transferred anconeus muscle was performed only postoperatively to verify its functional activity.

FIGURE 7. Exposure of the radiohumeral articulation after excision of the lateral fascia and the degenerative epicondyle tendon.

108

n

RESULTS

All the patients were reviewed at a mean follow-up of 74 months in group 1 (7–102 months) and 55 months in the group 2 (12–89 months). In the first group, the dominant side was affected in 65% of the cases. In the group 2 the affected side was always dominant (Table 1). In the first group, pain was absent in all cases. Elbow ROM was almost normal without any differences from the contralateral side (Fig. 12A–H). Grip strength increased from 26 kg to 32 kg postoperatively. In group 2 (Fig. 13A–I) there was an average decrease in pain from 9 preoperatively to 3 postoperatively (VAS). One of the fistula patients was satisfied with

FIGURE 9. The anconeus muscle ﬂap is rotated proximally to cover the radiohumeral articulation.

Techniques in Hand and Upper Extremity Surgery

Anconeus Muscle Transfer for Epicondilitys

FIGURE 10. The anconeus muscle ﬂap is positioned and sutured over the joint.

FIGURE 11. The skin is sutured, and a drain is positioned to prevent hematoma at the level of the donor site.

postoperative results but referred to their pain as being at level 8 because of radiohumeral instability. Elbow ROM and grip strength recovered without significant difference from the contralateral side. All the patients of group 1 and group 2 returned to their previous work 47 and 81 days after operation, respectively. The x-ray evaluation demonstrated tangent signs of the resected epicondyle in all cases and the disappearance of intratendinous calcifications. The ultrasound evaluation confirmed the presence of normal echogenic muscle tissue and normal contractile function in 91% of the cases. In these same cases, the EMG demonstrated normal contractile function. The reduction of grip strength remained in 1 of the cases of residual pain (group 2). In this same case the ultrasound evaluation demonstrated the presence of abnormal echogenic muscle, and the EMG demonstrated a partial reduction of muscle contractile function in addition to the presence of denervation potential with a trace of single waves voluntary muscle fiber reclutment. The subjective results were optimal in 12 cases (92%). Even the patient whose outcome was not considered satisfactory was able to return to the previous work. In 1 case a hypertrophic surgical scar was present, but the patient did not report functional disability that compromised work activities.

n

COMPLICATIONS

Possible complications (Table 2) from this type of surgery can be caused by muscular necrosis from the vascular pedicle injury (RPIA) and from injury to the nerve branch of the anconeus muscle with muscle atrophy. Loss of anconeus muscle does not represent a functional problem for the elbow because it assists the triceps muscle in extension of the elbow.6,14 In our experience, the abovementioned complication has occurred only once, and the functional recovery was sufficient for the patient to return to work. Postoperative infections or residual epicondylitis have not occurred among our operated cases. The loss of range of motion or reduction in complete elbow extension that has been cited by Necking and Almquist,7 Almquist et al,8 and Mackenney et al11 are quite possible. In our experience, this never occurred. Hypertrophic scarring can be cited as one of the minor complications that can occur in association with this surgery, although rare in its occurrence, many times it depends on the subject’s predisposition. Cutaneous dyschromia from previous steroid infiltrations is another minor complication that occurs with this type of surgical patients. Usually its improvement is seen over time. Muscle bulging also can occur from the presence of the transferred anconeus muscle around the epicondyle,

TABLE 1. Summary of patient characteristics Parameters Pain (VAS) Elbow ROM (deg) Grip strength (kg) Return to work (days)

Chronic lateral epicondylitis Preop (mean) Postop (mean) 8 140 26

0 142 32 47

Volume 9, Issue 2

Recurrences and complications Preop (mean) Postop (mean) 9 132 19

3 133 24 81

109

Luchetti et al

FIGURE 12. Clinical case (female, 45 years old, right dominant) with recurrence of chronic lateral epicondylitis at the right elbow. A, Incomplete elbow extension 2 months after operation. B, Elbow ﬂexion is complete. C, Scar of the previous surgery and painful area of the lateral aspect of the elbow. D and E, X-ray images of the elbow. F, Ultrasonographic image of the epicondyle tendon showing lack of normal tissue density. Surgery corresponds to Figures 6 to 10. Clinical result 6 months after operation. G and H, Patient was completely pain-free with normal ﬂexion–extension ROM of the elbow, and she returned to previous heavy work a month after surgery.

but this too diminishes with time. This minor complication is much more evident in male patients and has been found and confirmed by ultrasound and EMG. On the contrary, there usually is a slight superficial muscle indentation at the site where the anconeus muscle has been harvested. This indentation permanently remains over time.

110

n

REHABILITATION

The elbow should be immobilized for only 15 days, and rehabilitation should be initiated immediately afterward to recuperate entire upper extremity function. Passive elbow and wrist mobilization is initiated immediately and performed for both flexion/extension and pronosupination

Techniques in Hand and Upper Extremity Surgery

Anconeus Muscle Transfer for Epicondilitys

FIGURE 13. Clinical case (male, 60 years old, right dominant) with infection of the radiohumeral articulation following previous treatment of chronic lateral epicondylitis. As the infection became evident, patient was operated on to clean the joint infection. A, Scar incision with ﬁstula. B, Exposition of the radiohumeral joint after removal of the degenerated and infected tissues. Anconeus muscle ﬂap is distally harvested (C) and rotated to cover the joint (D). Radiologic (E and F) and clinical result (G) after a year; patient was pain-free, and his elbow had complete ﬂexion–extension ROM (H and I).

movements during the daily medication changes. In cases in which there is a significant amount of edema, the patient is sent to a physical therapist to perform lymphdrainage massage to increase venous return. The elbow TABLE 2. Complications 1. 2. 3. 4. 5. 6. 7. 8.

Elbow stiffness Residual epicondylitis Infection Muscle necrosis Muscle paralysis Cutaneous dyschromia Hypertrophic scar Bulging muscle

splint is removed after 15 days, and the patient is educated on performing flexion/extension and pronosupination exercises autonomously. Both elbow and wrist exercises can be performed either in or out of water. Progressive resistive grasping exercises are performed to increase forearm muscle strength and can be introduced into the rehabilitation program once range of motion exercises are performed without pain. The entire rehabilitation program should last about 20 days. Both return to work and sports activities are dependent on the type and physical intensity of the activity performed. In our experience, it is advisable that the patient who has undergone an anconeus muscle transfer for chronic lateral epicondylitis should wait 40 days from the time of

Volume 9, Issue 2

111

Luchetti et al

surgery to begin moderate to heavy labor or sports activities, and patients who have had residual problems that required second surgeries, fistulas, or infections wait at least 80 days before beginning resistive forearm muscle activities. Additional or secondary surgical procedures for associated epicondylar pathologies can easily be performed without ulterior contraindications. In 3 cases the posterior interosseous nerve at Fro¨hse arch was decompressed, without minimally affecting the immobilization time, clinical improvement, or final surgical results. Other procedures that have been performed are carpal tunnel release in 2 cases and a palmar fasciectomy for Dupuytren syndrome.

n

CONCLUSIONS

Based on our obtained results, we feel that this surgical technique that can render enormous help in treating conditions where the radiohumeral articulation is exposed after removal of severely degenerated tendinous structures, residual epicondylitis is present because of osteoarticular pathologies that have not been treated, subcutaneous adhesions at a capsular-articular level, and cutaneous and subcutaneous tissue atrophy conditions are present because of repetitive cortisone infiltrations associated with chronic epicondylitis. Additional surgical time can be well managed and usually requires only an extra 15 minutes. Microvascular surgical experience is not required to perform this technique, but the surgeon should not underestimate that the muscle dissection requires an extreme amount of caution specifically in regard to the vascular pedicle.

n

4. Vasconez LO. Personal communication, quoted in Cormack GC. The antecubital forearm flap. In: Gilbert A, Masquelet AC, Hentz VR, eds. Pedicle Flaps of the Upper Limb. New York: Martin Dunitz, 1992. 5. Bell SN, Benger D. Management of radioulnar synostosis with mobilization, anconeus interposition, and a forearm rotation assist splint. J Shoulder Elbow Surg. 1999;8: 621–624. 6. Morrey BF, Schneeberg AG. Anconeus arthroplasty. In: Morrey BF, ed. The Elbow. Master Techniques in Orthopaedic Surgery, 2nd ed. Philadelphia: Lippincott William & Wilkins, 2002:409–424. 7. Necking L, Almquist EE. Results of epicondilar resection with anconeous muscle transfer in chronic lateral epicondylitis. Presented at: 47th Annual Meeting of ASSH, Phoenix, AZ, 1992. 8. Almquist EE, Necking L, Bach AW. Epicondilar resection with anconeous muscle transfer in chronic lateral epicondylitis. J Hand Surg. 1998;23A:723–731. 9. Fuller DA, Culp RW. The anconeus muscle flap in revision surgery for lateral epicondylitis. Atlas Hand Clinics. 1999; 1:87–93. 10. Luchetti R, Alfarano M, Montagna G, et al. Chronic lateral epicondylitis: treatment by anconeous muscle transposition. Riv Chir Riab Mano Arto Sup. 1994;31:103–113. 11. Mackenney E, Aguirre R, Sanchez MA, et al. Recalcitrant epicondylitis and chronic epicondylitis treated by anconeous transfer. Presented at: 9th Congress of IFSSH, Budapest, Hungary, June 13–17, 2004. 12. Schmidt CC, Kohut GN, Greenberg JA, et al. The anconeus muscle flap: its anatomy and clinical application. J Hand Surg. 1999;24A:359–369.

REFERENCES

1. Cardany C, Maxwell P, Gilbert A. Personal communication, quoted in Cormack GC. The antecubital forearm flap. In: Gilbert A, Masquelet AC, Hentz VR, eds. Pedicle Flaps of the Upper Limb. New York: Martin Dunitz, 1992. 2. Mathes S, Nahai F. Clinical Applications for Muscle and Musculocutaneous Flaps. St Louis: CV Mosby, 1982: 631.

112

3. Lamberty BGH, Cormack GC. The arterial anatomy of upper-limb skin flaps. In: Gilbert A, Masquelet AC, Hentz VR, eds. Pedicle Flaps of the Upper Limb. New York: Martin Dunitz, 1992:20.

13. Abrahamson SO, Sollerman C, Soderberg T, et al. Lateral elbow pain caused by anconeous compartment syndrome. Acta Orthop Scand. 1987;58:589–591. 14. Gleason T, Goldstein WM, Ray RD. The function of the anconeous muscle. Clin Orthop Rel Res. 1983; Jan-Feb: 147–148.

Techniques in Hand and Upper Extremity Surgery

Techniques in Hand and Upper Extremity Surgery 9(2):113–119, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

T E C H N I Q U E

Combined Glenohumeral Arthrodesis and Above-Elbow Amputation for the Flail Limb Following a Complete Posttraumatic Brachial Plexus Injury Asheesh Bedi, MD and Bruce Miller, MD Department of Orthopaedic Surgery University of Michigan Medical Center Ann Arbor, MI

Peter J. L. Jebson, MD Division of Hand & Upper Extremity Surgery Department of Orthopaedic Surgery University of Michigan Medical Center Ann Arbor, MI

n

ABSTRACT

n

The treatment of a severe traction injury resulting in complete, posttraumatic brachial plexus palsy remains a daunting challenge to the upper extremity surgeon. Operative intervention must address painful glenohumeral instability while optimizing functional rehabilitation. Glenohumeral arthrodesis has been shown to reliably alleviate pain from shoulder instability and place the extremity in a functional posistion for activities of daily living. An above the elbow amputation has also been advocated to remove the flail insensate extremity and create a stable stump for prosthetic training and rehabilitation. We describe the technique of a combined glenohumeral arthrodesis and above elbow amputation to address the flail insensate limb following a severe posttraumatic brachial plexus injury. In our clinical experience, the combination of procedures results in an improved pain level, enhances shoulder stability, encourages functional rehabilitation via prosthetic fitting, and is associated with high patient satisfaction. Keywords: brachial plexus palsy, glenohumeral arthrodesis, above elbow amputation

Address correspondence and reprint requests to Peter J. L. Jebson, MD, Chief, Division of Hand & Upper Extremity Surgery, Department of Orthopaedic Surgery, 2098 South Main Street, Ann Arbor, MI 48103. E-mail: [email protected].

HISTORICAL PERSPECTIVE

A severe brachial plexus injury results in a significant loss of upper extremity function and painful glenohumeral instability that is a substantial rehabilitation challenge. A complete posttraumatic plexopathy results in a flail shoulder and upper extremity that makes independent positioning of the hand in space difficult or impossible. Furthermore, deficiency of the rotator cuff and deltoid muscles results in painful glenohumeral subluxation.1–5 Treatment is directed at both pain relief and acceptable functional rehabilitation. Glenohumeral arthrodesis is a well-established treatment approach for upper extremity paralysis secondary to a traumatic brachial plexus injury.1–7 Shoulder arthrodesis eliminates symptomatic instability and places the extremity in a functional position. Some range of motion is still preserved via the scapulothoracic articulation. An above-elbow amputation has also been advocated to address the flail extremity, allowing for early prosthetic training and functional rehabilitation.1–5 A combination of glenohumeral arthrodesis and aboveelbow amputation was first recommended by Yeoman and Seddon in 1971.3 Arthrodesis helps to stabilize the residual limb for simple daily activities and is believed to result in more reliable prosthetic use. We describe the surgical technique of combining a glenohumeral arthrodesis and an above-elbow amputation in the patient with a flail insensate functionless painful limb following a traumatic brachial plexus injury.

Volume 9, Issue 2

113

Bedi et al

n

INDICATIONS

1. Flail upper extremity, including the hand, following a severe brachial plexus injury with a poor prognosis for additional recovery. 2. Failed prior operative treatment, including nerve grafting and nerve and/or muscle transfers, for complete brachial plexus injury. 3. Patient dissatisfaction with lack of useful function and/or discomfort of the flail limb. The patient should be willing to attempt prosthetic use. 4. Pain or discomfort secondary to inferior glenohumeral subluxation.

n

FIGURE 1. Intraoperative positioning of the patient on an inﬂatable beanbag in the lateral decubitus position.

CONTRAINDICATIONS

1. Paralysis of the trapezius, levator scapulae, latissimus dorsi, serratus anterior, or rhomboid muscles. These muscle groups are essential for stabilization of the scapula and for compensatory scapulothoracic motion following glenohumeral arthrodesis.6–9 2. An active infection in the proximal humerus or glenohumeral joint is also a contraindication. 3. Although unusual, a contralateral glenohumeral arthrodesis is a contraindication because bilateral shoulder arthrodeses severely limit the patient’s functional abilities.6,9

n

PREOPERATIVE EVALUATION

Careful physical examination is essential to evaluate the function of the serratus anterior, latissimus dorsi, trapezius, levator scapulae, and rhomboid muscles, which are essential for scapular stabilization and to maintain scapulothoracic motion after the arthrodesis. In difficult cases, it may be necessary to obtain preoperative electromyographic (EMG) studies to confirm normal muscle function and strength. Preoperative plain radiographs are important to assess the glenoid and humeral head bone stock. Anteroposterior (AP), lateral, and axillary views provide important information about bone quality and the presence of any deformity that may affect the surgical technique and fixation technique.

n

OPERATIVE TECHNIQUE

Anesthesia A general anesthetic is preferred, although a long-acting regional axillary block may be adequate for patients with multiple medical comorbidities.

114

Patient Positioning The patient is placed in the lateral decubitus position on the operating table with the uninvolved side down (Fig. 1). An inflatable, padded bean bag is helpful for stabilization of the patient. An axillary roll is used, and the lower extremities are carefully padded and protected with pillows between the legs. The entire limb is prepped and draped up to the base of the neck and to the anterior and posterior midlines. The operative field should include the entire limb and the chest and back from the midline. A sterile stockinette or ACE bandage is applied over the forearm and hand.

Surgical Exposure An incision is made from the midaspect of the scapular spine extending over the anterior aspect of the acromion and longitudinally down the lateral aspect of the proximal humeral shaft for 5 to 8 cm (Fig. 2). The acromion and spine of the scapula are exposed subperiosteally. The deltoid is elevated, and its fibers are split distally to expose the glenohumeral capsule and the humeral shaft. The atrophied rotator cuff and capsule is elevated off the greater tuberosity, and the articular surfaces of the humeral head and glenoid are exposed. The articular cartilage is then carefully removed with a burr while preserving the convexity of the humeral head and concavity of the glenoid fossa. Subchondral bone is perforated on both the glenoid and humeral head to achieve bleeding cancellous surfaces.6,8,9 The position of the arthrodesis is then determined. The trunk is used as a reference as the scapula is manually stabilized in an anatomic position. The final position of the limb should permit the arm to hang in a comfortable position without associated winging or deformity of the scapula. We favor a position of approximately

Techniques in Hand and Upper Extremity Surgery

Above-Elbow Amputation for Flail Limb

FIGURE 2. The skin incision is placed over the spine of the scapula and continued over the anterior acromion and laterally down the proximal humerus.

30 degrees of abduction, 30 degrees of forward flexion, and 40 degrees of internal rotation. We estimate this position by having an assistant hold the limb with the hand positioned at the mouth and the humeral head reduced to the glenoid. A malleable aluminum pelvic reconstruction plate template is contoured precisely to the desired fusion position. A combination of meticulous bending and twisting of the plate is usually required. A 10-hole, 4.5-mm pelvic reconstruction plate (Synthes, Paoli, PA) is selected and contoured to the template, allowing flush positioning over the scapular spine, acromion, and proximal humeral shaft. We have found the pelvic reconstruction plate to be less prominent and more easily contoured than a standard dynamic compression plate (DCP). The plate is secured to the acromion with 4.5-mm cortical screws inserted in bicortical fashion. If adequate screw purchase cannot be achieved because of osteopenia, 6.5-mm screws may be inserted without tapping the osteoporotic bone. After stabilizing the plate to the acromion with a minimum of 2 screws, and with the humeral head reduced into the glenoid, the plate is secured to the humeral shaft. Again, 4.5-mm screws are preferred, but 6.5-mm screws may be used to optimize fixation. The final screws are then inserted in the remaining holes of the

plate on the acromion and scapular spine. To further enhance stability of the plate on the scapula, a carefully angled 4.5- or 6.5-mm screw(s) may be inserted through the acromion through the superior glenoid and into the humeral head. If it is elected to insert a screw into the humeral head, the screw itself must not interfere with the subsequent insertion of a 6.5-mm screw between the humeral head and the glenoid. The partially threaded 6.5-mm cancellous screw is carefully placed through one of the holes in the plate to compress and stabilize the denuded surfaces of the humeral head and glenoid (Fig. 3). We try to obtain 8 cortices of fixation within the scapula and humeral shaft, respectively. Plain radiographs are obtained intraoperatively to confirm satisfactory fixation (Fig. 4). The wound is irrigated before closure. We prefer pulsatile lavage with 3 L of normal saline combined with an antibiotic such as 50,000 units of bacitracin. We prefer this approach to wound lavage because of the prolonged duration of wound exposure associated with the procedure and the subsequent risk of contamination and wound infection. The deltoid is then reapproximated over the plate and repaired with 0-Vicryl suture in a figure-of-8 fashion. The subcutaneous layer is also closed with absorbable suture over a deep drain. The skin incision is closed with nonabsorbable suture, and a sterile dressing is applied. The entire wound is then covered with an IOBAN drape (3M, Saint Paul, MN) in preparation for the above-elbow amputation. The beanbag is deflated, and the patient is carefully placed into the supine position. A hand table is then attached to the operating room table. The entire upper extremity is prepped and draped into the operative field. A sterile pneumatic tourniquet over webril padding is applied on the upper arm. The extremity is exsanguinated with an Esmarch bandage. In those

FIGURE 3. A 10-hole 4.5-mm pelvic reconstruction plate is contoured and secured with a combination of 4.5- and 6.5-mm screws.

Volume 9, Issue 2

115

Bedi et al

proximally, ligated, and then transected several centimeters proximal to the anticipated humeral cut. The brachialis muscle is transected at the same level as the biceps. The radial nerve is identified, ligated, and transected proximally. Attention is then turned to the posterior aspect of the elbow. The triceps is transected at a level just distal to the biceps. An oscillating saw is used to resect 10 to 12 cm of the distal humerus in a transverse fashion. Sharp bone edges are smoothed with a rasp. The median and ulnar nerves are folded back on themselves and tunneled beneath the biceps muscle belly. The radial and musculocutaneous nerves are similarly protected proximally beneath the triceps and brachialis muscles, respectively. The wound is copiously irrigated in the same fashion as the shoulder wound, followed by deflation of the tourniquet. Meticulous hemostasis is obtained. Closure is completed initially with approximation of the biceps to the triceps fascia with absorbable fascia. The deep dermal and skin layers are then closed in a standard, interrupted fashion. A bulb-suction drain may be placed deep to the fascial layer if significant, persistent bone bleeding is noted. A sterile, well-padded compressive dressing is placed.

Rehabilitation

FIGURE 4. (A) Preoperative AP radiograph of left shoulder in patient with painful glenohumeral subluxation after traumatic, complete bracial plexus palsy. (B) Postoperative radiograph after fusion. Note the partially threaded 6.5-mm screw placed through the plate and humeral head into the glenoid and scapular body.

patients with short limbs, the procedure may be performed without a tourniquet. The humeral shaft is typically transected 10 to 12 cm proximal to the elbow joint. A fishmouth skin incision is placed, and the anterior and posterior skin flaps are developed and elevated. The incision for the anterior and posterior flaps is placed 3 to 4 cm distal to the anticipated level of the bone cut. The brachial and cephalic veins are identified and ligated. The biceps muscle is transected, and the underlying lateral antebrachial cutaneous nerve is mobilized proximally. The nerve is ligated with nonabsorbable suture, sharply transected, and then translocated proximally beneath the biceps muscle belly. The medial antebrachial, ulnar, and median nerves are similarly identified with the brachial artery. The artery is ligated prior to transection. Each of the nerves is mobilized

116

A custom-fabricated brace is used immediately postoperatively (Fig. 5) for stump stabilization and immobilization until complete fusion has been confirmed on follow-up radiographs. The skin sutures are removed 2 weeks postoperatively. Stump shrinkage dressings for edema control are initiated by the prosthetist at this time. Plain radiographs are routinely obtained at 6 and 12 weeks postoperatively to assess for a successful fusion defined as obliteration of the glenohumeral joint space and trabeculation between the glenoid and humeral head. Limb mobilization and functional use out of the brace are then permitted. Prosthetic fitting and training are also initiated at this time in coordination with the physical medicine and rehabilitation specialist.

n

COMPLICATIONS

Wound Infection The surgical wound for glenohumeral arthrodesis is at risk for infection because of the prolonged duration of exposure associated with the procedure. Infection can be minimized by meticulous handling of the soft tissues, preoperative prophylactic antibiotics, and pulsatile irrigation of the wound with antibiotic saline solution. Treatment of a postoperative wound infection involves a thorough debridement followed by wound irrigation and suppressive intravenous antibiotics until a solid fusion

Techniques in Hand and Upper Extremity Surgery

Above-Elbow Amputation for Flail Limb

closure and the use of a deep drain to successfully prevent the formation of a large wound hematoma postoperatively.

Nonunion Fortunately, nonunion is rare, and we have not experienced this complication in our clinical series. Careful decortication and preparation of the glenoid and humeral head surfaces with maximal contact area between them is essential. Achieving satisfactory fixation and compression across the glenohumeral joint are extremely important. Preoperative counseling of the patient to discontinue smoking for a minimum of 6 weeks preoperatively and for a minimum of 3 months postoperatively is critical before proceeding with surgical intervention. If a nonunion does occur, treatment usually consists of a revision arthrodesis with supplemental autogenous bone grafting.6,9

Prominent Hardware Those patients with a severe posttraumatic brachial plexus palsy injury involving the upper trunk develop significant rotator cuff atrophy. As a result, an often tenuous soft tissue envelope is present over the prominent scapular spine. We use a low-profile pelvic reconstruction plate to allow for careful contouring to minimize hardware prominence and soft tissue tension.8 However, we inform the patient preoperatively that subsequent removal of symptomatic, prominent hardware is not uncommon and may be necessary after solid fusion is achieved.

Malpositioning of the Arthrodesis

FIGURE 5. Front (A) and back (B) views of postoperative custom-fabricated, adjustable abduction orthosis.

is achieved. All of the hardware is removed promptly after radiographic confirmation of a successful fusion.6,8,9

There is no concensus in the literature regarding the ideal position of a glenohumeral arthrodesis.6 The goal is to optimize the functional position of the limb without precipitating periscapular pain and discomfort. Excessive abduction and forward flexion can result in malpositioning of the scapula and scapulothoracic muscle fatigue.6,9 We carefully position the limb intraoperatively so that there is enough abduction to clear the axilla, enough forward flexion to permit prosthetic reach to the face, and enough internal rotation to reach the midline of the body. Using this technique rather than a strict angled measurement permits the scapula to be maintained in a neutral, anatomic position without compromising the functional outcome. Extreme malpositioning with scapular winging or rotation may require a reconstructive osteotomy of the fusion mass.6,7

Hematoma Formation Hematoma formation with a subsequent wound dehiscence can also occur postoperatively. Wound dehiscence may be caused by excessive soft tissue tension over a prominent plate at the level of the scapular spine. Careful contouring and use of the low-profile pelvic reconstruction plate help to minimize this complication. Similarly, we have found meticulous hemostasis before wound

Complications of the Above-Elbow Amputation The above-elbow amputation is not without risk of significant complications. A high incidence of phantom limb pain has been reported in the literature.3,4,10 Even with meticulous technique to protect and bury proximal nerve endings beneath the soft tissues, a painful neuroma may develop and limit prosthetic use. A lack of careful

Volume 9, Issue 2

117

Bedi et al

preoperative planning may result in inadequate or excessive resection of the distal humerus, creating problems with prosthetic fit and use.

Lack of Predictable Pain Relief The paucity of outcome studies regarding patients who have undergone a combined glenohumeral arthrodesis and above-elbow amputation for a severe brachial plexus injury has made the accurate prediction of pain relief difficult. Rorabeck et al reported that painful causalgia is not reliably relieved with an amputation, especially when it requires narcotic analgesics or is present for more than a year.4 Thus, the surgeon is obligated to discuss candidly the expected postoperative course. A number of small series have documented improved function and pain relief following the procedure.1–5 In our experience, pain secondary to inferior glenohumeral subluxation is reliably improved. We have observed that the patients are usually relieved following removal of a functionally useless limb that they perceive as an impediment. The patients are also consistently satisfied with the appearance of the limb (Fig. 6).

n

RESULTS

Glenohumeral arthrodesis has been shown to improve function and provide considerable pain relief in those patients with a severe, posttraumatic brachial plexus injury.1–7 Rouholamin et al studied 13 patients after shoulder fusion and found all to have improved limb function.2 Three of the patients had an associated above-elbow amputation, all of whom reported a significant benefit from stump stabilization.2 Richards et al retrospectively reviewed 14 patients with a brachial plexus injury who underwent glenohumeral arthrodesis.1 At a mean follow-up of 3 years, all patients noted improved extremity function.1 Compliance and reliability of prosthetic use after an above-elbow amputation, however, remains a significant concern. Wright et al assessed prosthetic use in those patients with a major upper extremity amputation at an average follow-up of 12 years postoperatively.10 Approximately half of all of the patients with an above-elbow amputation reported a discontinuation of prosthetic use. Furthermore, a stiff shoulder or an associated brachial plexus injury was found to be an independent predictor of poor prosthetic usage.10 The compliance rate for prosthetic use in the patient with a combined glenohumeral arthrodesis and above-elbow amputation remains poorly defined. Richards et al and Rouholamin et al both noted that only 1 of the 3 patients who underwent the procedures became a good prosthetic user.1,2 We have similarly noted inconsistent prosthetic usage in our clinical series.

118

FIGURE 6. Front (A) and back (B) views of a 47-year-old man 10 weeks postoperatively following a left glenohumeral arthrodesis and above-elbow amputation for a complete, posttraumatic brachial plexus injury that occurred 11 years previously following a motorcycle accident.

No large series exists in the literature that evaluates the clinical outcome of a combined glenohumeral arthrodesis and above-elbow amputation for a posttraumatic brachial plexus injury. Rorabeck et al retrospectively compared 3 subgroups of 23 patients with a complete plexus injury that underwent (1) no intervention, (2) an above-elbow amputation, or (3) an above-elbow amputation with a glenohumeral arthrodesis.6 Return to employment and prosthetic usage was best achieved following an above-elbow amputation. Performing an arthrodesis with a glenohumeral arthrodesis did not improve on the results. However, only 3 patients were included in the combined treatment group, and the follow-up was limited.4 We are currently completing a retrospective review of a large series of patients with a posttraumatic brachial plexus injury who have undergone an arthrodesis in conjunction with an above-elbow amputation. Our preliminary findings and clinical experience suggest that an appropriately performed glenohumeral arthrodesis

Techniques in Hand and Upper Extremity Surgery

Above-Elbow Amputation for Flail Limb

and above-elbow amputation can result in considerable pain relief, limb stability, and improved functional rehabilitation in the carefully selected patient with a severe posttraumatic brachial plexus injury.

n

5. Chammas M, Goubier JN, Coulet B, et al. Glenohumeral arthrodesis in upper and total brachial plexus palsy. Analysis of functional results. J Bone Joint Surg. 2004;86B: 692–695. 6. Clare DJ, Wirth MA, Groh GI, et al. Shoulder arthrodesis. J Bone Joint Surg. 2001;83-A:593–600.

REFERENCES

1. Richards RR, Waddell JP, Hudson AR. Shoulder arthrodesis for the treatment of brachial plexus palsy. Clin Orthop. 1985;198:250–258. 2. Rouholamin E, Wootton JR, Jamieson AM. Arthrodesis of the shoulder following brachial plexus injury. Injury. 1991; 22:271–274. 3. Yeoman PM, Seddon HJ. Brachial plexus injuries: treatment of the flail arm. J Bone Joint Surg. 1961;43B:493. 4. Rorabeck CH. The management of the flail upper extremity in brachial plexus injuries. J Trauma. 1998;20:491–493.

7. Cofield RH, Briggs BT. Glenohumeral arthrodesis. Operative and long-term functional results. J Bone Joint Surg. 1979;61:668–677. 8. Richards RR, Sherman RM, Hudson AR, et al. Shoulder arthrodesis using a pelvic reconstruction plate. J Bone Joint Surg. 1988;70A:416–421. 9. Rowe CR, Leffert RD. Advances in Arthrodesis of the Shoulder. New York: Mosby, 1988, pp 507–519. 10. Wright TW, Hagen AD, Wood MB. Prosthetic usage in major upper extremity amputations. J Hand Surg. 1995;20A: 619–622.

Volume 9, Issue 2

119

Techniques in Hand and Upper Extremity Surgery 9(2):120–121, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

T E C H N I Q U E

DAREJD Simple Technique of Draining Acute Paronychia Johnson D. Ogunlusi, FMCS (Ortho) State Specialist Hospital Ado-Ekiti Formerly Department of Orthopaedics and Traumatology Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife, Nigeria

Lawrence M. Oginni, FMCS, FWACS College of Health Sciences, Obafemi Awolowo University Ile-Ife, Nigeria

Olugbemisola O. Ogunlusi, FMCP (Paed) State Specialist Hospital Ado-Ekiti Formerly Department of Paediatrics Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife, Nigeria

n

ABSTRACT

The severe deformities of the fingers seen in poorly treated or late presenting cases of paronychia stimulated this prospective study. The aim was to make early diagnosis and to find a simple method of draining the pus in the paronychia. This was a prospective hospital based study at the Wesley Guild Hospital (WGH) Ilesa for 9 months. Using simple materials like 23G or 21G needle, cotton wool, chlorohexidine solution, methlylated spirit and zinc oxide plaster, abscess in acute paronychia was drained by lifting the nail fold with the tip of the needle. Ten cases of paronychia in 8 patients were drained with the method. Combination of the early drainage and antibiotics showed that all the patients were relieved of pain and could use their fingers normally within 2 days. There was no need of anesthesia and daily dressing. The drainage technique is simple and effective. The early drainage prevents the occurrence of any form of complication. Keywords: acute paronychia, draining, technique

n

BACKGROUND

Paronychia, an infection of the epidermis bordering the nail, is commonly precipitated by localized trauma.1–3 In United States it is the most common hand infection, representing approximately 35% of all infections of the Address correspondence and reprint requests to Dr. J. D. Ogunlusi, c/o Dr. L. M. Oginni, Department of Orthopaedic Surgery and Traumatology, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria. E-mail: [email protected].

120

hands.4 The traumatized site provides a portal of entry for bacteria. Clinically, it presents as an acute or a chronic condition. It is a localized, superficial infection or abscess of the paronychial tissues of the hands or, less commonly, the feet.3 The most commonly cultured organism in acute paronychia is Staphylococcus aureus.4,5 Immunosuppressive states and systemic diseases such as diabetes can alter the action and the causative organisms as well as the intensity of treatment that a patient will require.6 Paronychia is more common in women than in men, with female-to-male ratio of 3:1.4 Early diagnosis and prompt treatment are important to avoid complications such as chronic paronychia, osteomyelitis, nail deformity, felon, and septic tenosynovitis. If the paronychia is neglected, pus may spread under the nail sulcus to the opposite side, resulting in what is known as a ‘‘run-around abscess.’’ Pus may also accumulate beneath the nail itself and lift the plate off the underlying matrix. These advanced cases may require more complex treatment, including removal of the nail to allow adequate drainage.3,6

n

METHOD

This was a controlled prospective study done at Wesley Guild Hospital Ilesa. Patients with features of acute paronychia with symptoms and signs present for 2–8 days were recruited; in those presenting beyond this period, chronic paronychia were excluded. Drainage of the abscess was done using the simple technique described below.

Techniques in Hand and Upper Extremity Surgery

Draining of Acute Paronychia

draining technique healed within 2 days, and the fingers could be used normally. Follow-up for more than 6 months did not show any recurrence or complication.

n

FIGURE 1. The DAREJD simple technique of drainage of acute paronychia.

Procedure of Drainage 1. The procedure was explained to the patient, who was reassured that the procedure would be painless. Aneasthesia was not required. 2. The finger was cleaned with chlorohexidine solution and methylated spirit. 3. The nail fold of the infected nail bed was gently lifted off the nail with the tip of 23G/21G needle (Fig. 1). This was followed immediately by passive oozing of pus from the nail bed. 4. A sample was taken for microscopy culture and sensitivity. 5. A gentle pressure was applied close to the nail bed to complete the drainage. 6. The little wound made was dressed with cotton wool soaked with TBC, and a firm zinc oxide plaster was applied. There was no need of daily dressing subsequently.

Other Treatment Antibiotics were given for 5 days. No further dressing was required for any of the 8 patients because there was no wound to be dressed.

n

DISCUSSION

In the study, the women were more involved than men (female:male ratio was 1.7:1), which supports the earlier findings.4 All the patients were right-handed, and it was noted that the right hand was involved in 7 cases (70%); the regular usage of the hand could account for this. The continuous use of the dominant hand may predispose the fingers and the nail folds to injuries, thereby providing a portal of entry for bacteria. Patient occupations included housewife, student, housemaid, and an orthopedic surgeon, all of whom are prone to develop paronychia. The best form of treatment is to prevent the injury to the nail folds, especially the self- or iatrogencically inflicted injuries during nail biting, manicuring, and wearing of artificial nails. Prompt diagnosis and nonoperative methods of treatment have a place when abscess has not developed. These methods include antibiotics and soaks in warm water.3,4 When an abscess has developed, drainage must be done. The methods described in previous studies include the nonincision technique using either the tip of an 18G needle or blunt instrument for dissection followed with excision of the proximal nail bed and packing of the wound for 2 days.3,4,7 These methods required digital block, application of a digital tourniquet, and use of a surgical blade.3,4,7 However in this present study, digital block and tourniquet were not used in any of the patients including a 3-year-old boy, and the procedure was well tolerated by all. The little wounds healed well within 2 days, and the patients were able to use their hands and fingers subsequently. It is concluded that the described technique is effective, painless, required no subsequent dressing, and can be arranged quickly and cheaply. It can thus be used as drainage procedure and part of management of acute paronychia.

n

REFERENCES

1. Clark DC. Common acute hand infections. Am Fam Physician. 2003;68:2167–2176.

RESULTS

In 8 patients, 10 cases of paronychia were diagnosed. Two female patients had involvement of 2 different fingers at different occasions during the study period. Male: female ratio was 1:1.7, and the age ranged between 3 and 49 years with mean of 24.1 ± 14.7 years. All the patients were right-handed, and the right hand was involved in 7 cases compared to 3 cases in the left hand. Duration of the symptoms was 2–7 days. The involvement of the fingers is as follows: thumb (3), index (1), middle (4), ring (2) and little (1). Staphylococcus aureus was cultured in 7 cases, E. coli in 1, no growth in 1, and culture was not done in 1. All the little wounds created by the simple

2. Daniel CR 3rd. Paronychia. Dermatol Clin. 1985;3:461–464. 3. Rockwell PG. Acute and chronic hand infections. Am Fam Physician. 2001;63:1113–1116. 4. Lee S. http://www.samragroup.com. Paronychia. eMedicine last updated October 24, 2004. 5. Whitehead SM, Eykyn SJ, Philips I. Anaerobic paronychia. Br J Surg. 1981;68:420–422. 6. Canales FL, Newmeyer WL 3rd, Kilgore ES Jr. The treatment of felon and paronychia. Hand Clin. 1989;5:515–523. 7. Buttaravoli PM, Stair TO. Paroncyhia. In: Common Simple Emergencies. Washington, DC: Longwood Information LLC.

Volume 9, Issue 2

121

Techniques in Hand and Upper Extremity Surgery 9(2):122–123, 2005

L E T T E R

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

T O

T H E

E D I T O R

Milking Technique for Reimplanted Digits With Insufficient Venous Drainage ¨ zgenel, MD Abdullah Eto¨z, MD, Kemal Karaca, MD, and Yesxim O Uludag˘ University Faculty of Medicine Department of Plastic, Reconstructive and Hand Surgery Bursa, Turkey

n

ABSTRACT

The most common problem after finger replantation is congestion because of insufficient venous drainage. A simple method—milking technique—is described as an additional method for the treatment of venous congestion. Keywords: milking technique, venous insufficiency digital replantation

fter reimplantation of digits, the most common problem is insufficient venous drainage.1 Amelioration of venous congestion in the tissues takes a few months. Medicinal leeches have been used in reimplantation surgery.2 Gordon et al reported that partial removal of the nail plate and heparinization improve venous drainage.3 According to another study, an automatic milking apparatus can also be used to increase the venous drainage after reimplantation of digits.4 Venous congestion that occurs in the early postoperative period after finger reimplantation would be an indication for the use of such a milking approach. Because venous congestion occurs after reimplantation surgery, it is critical to warm up the patient as well as the operated extremity. The patient is sedated with intravenous analgesics and medications. The wound dressings are opened, and only the incision lines are left loosely dressed. Milking of the reimplanted digit is performed

A

Address correspondence and reprint requests to Abdullah Eto¨z, MD, Asil Sok Balkar Apt 1/4, Ataevler 16140 Bursa, Turkey. E-mail: [email protected].

122

to increase the venous drainage. The milking can be performed in a circular fashion starting from pulp to the distal palmar crease, almost 10 times per hour (Fig. 1). The tip of the reimplanted finger is surrounded by the pulps of our first 3 fingers to achieve a circular grasp. The milking should be performed quite slowly and gently. However, the pressure should be high enough to cause a whitish discoloration in the skin that lasts a second. This sign helps us to control the applied pressure. Unless the milking procedure improves drainage of the venous blood within the first 24 hours, the patient should be operated again, and venous reanastomosis performed urgently. We do not suggest waiting until the end of the first 24 hours to revise the anostomosis. However, we apply the milking procedure to decide on the need for reoperation. We continue the milking procedure 5 times per hour in the second day until 48 hours after the operation. According to our experience in 8 cases, milking technique has been so effective that no additional treatment with medicinal leeches or nail plate removal was needed. Bleeding the pulp of the reimplanted finger using a needle may be beneficial as well. The milking procedure is performed quite slowly with gentle pressure. We did not encounter any reinjury to vascular anostomosis during this procedure. The milking technique does not cause additional trauma during the pulp bleeding and eliminates the need for additional surgical interventions for reanastomosis. The most common problem after reimplantation is congestion from insufficient venous drainage. The milking technique appears to be an alternative method that can be applied easily. To our knowledge, a standard milking procedure has not been reported to date. In this report, we presented the results of our experience with a milking technique that is applied after reimplantation of digits to improve insufficient venous drainage.

Techniques in Hand and Upper Extremity Surgery

Letter to the Editor

FIGURE 1. The milking technique is performed in a circular fashion from pulp to the level of the distal palmar crease.

n

REFERENCES

1. Sanders WE. Principles of microvascular surgery. In: Green DP, Hotchkiss RN, eds. Operative Hand Surgery, 3rd ed. London: Churchill Livingstone, 1993:1061. 2. Brody GA, Maloney WJ, Hentz VR. Digit replantation applying the leech Hirudo medicinalis. Clin Orthop. 1989;245:133–137.

3. Gordon L, Leither DW, Buncke HJ, et al. Partial nail plate removal after digital replantation as an alternative method of venous drainage. J Hand Surg. 1985;10a:360– 364. 4. Kotani H, Kawai S, Doi K, et al. Automatic milking apparatus for the insufficient venous drainage of the replanted digit. Microsurgery. 1984;5:90–94.

Volume 9, Issue 2

123

Volume 9(2)

June 2005

(C) 2005 Lippincott Williams & Wilkins, Inc.

ISSN: 1089-3393

Viewing 1-10 of 10 Results pg. 67-68

01 Treatment of Fractures of the Distal Radius in Adults: A Surgeon's Forty-Five Year Perspective. Doyle, James R MD [EDITORIAL] pg. 69-73

02 Intramedullary Nailing of Metacarpal Shaft Fractures. Orbay, Jorge MD [TECHNIQUE] pg. 74-83

03 Fragment-Specific Fixation of Distal Radius Fractures Using the Trimed Device. Schumer, Evan D MD; Leslie, Bruce M MD [TECHNIQUE] pg. 84-90

04 Arthroscopically Assisted Reduction and Immobilization of Intraarticular Fracture of the Distal End of the Radius: Several Options of Reduction and Immobilization. Guofen, Chen MD 1; Doi, Kazuteru MD 2; Hattori, Yasunori MD 2; Kitajima, Izuru MD 2 [TECHNIQUE] pg. 91-95

05 The Reverse Heterodigital Neurovascular Island Flap for Digital Pulp Reconstruction. Adani, Roberto MD; Marcoccio, Ignazio MD; Tarallo, Luigi MD; Fregni, Umberto MD [TECHNIQUE] pg. 96-104

06 Principalization of Pollicization of the Index Finger in Congenital Absence of the Thumb. Foucher, Guy 1; Medina, Jose 1; Lorea, Patrick 2; Pivato, Giorgio 3 [TECHNIQUE] pg. 105-112

07 Anconeus Muscle Transposition for Chronic Lateral Epicondylitis, Recurrences, and Complications. Luchetti, Riccardo MD; Atzei, Andrea MD; Brunelli, Francesco MD; Fairplay, Tracy LPT

[TECHNIQUE]

pg. 113-119

08 Combined Glenohumeral Arthrodesis and Above-Elbow Amputation for the Flail Limb Following a Complete Posttraumatic Brachial Plexus Injury. Bedi, Asheesh MD 1; Miller, Bruce MD 1; Jebson, Peter J. L MD 2 [TECHNIQUE] pg. 120-121

09 DAREJD Simple Technique of Draining Acute Paronychia. Ogunlusi, Johnson D FMCS (Ortho) 1; Oginni, Lawrence M FMCS, FWACS 2; Ogunlusi, Olugbemisola O FMCP (Paed) 3 [TECHNIQUE] pg. 122-123

10 Milking Technique for Reimplanted Digits With Insufficient Venous Drainage. Etoz, Abdullah MD; Karaca, Kemal MD; Ozgenel, Yesim MD [LETTER TO THE EDITOR]