Compartment Syndromes

Upper limb fasciotomyForearm Fasciotomy Closure


1.  Antebrachial Compartment Syndrome




Supracondylar fracture of humerus

Both bone forearm fractures




Tense compartments

Pain +++

Passive extension of the digits or wrist increases pain

Paresthesias in median nerve distribution


Forearm Fasciotomy 


Decompression extending from elbow to wrist


Compartments (3)

- mobile wad

- volar

- dorsal



- medial arm

- across elbow

- continue as Henry approach into forearm

- can continue into palm as CTD incision



- lacertus fibrosus  (releases median nerve at elbow)

- fascia of forearm (releases superficial volar)

- deep fascial compartments (FCU / FDP / FPL)

- mobile wad


Remeasure dorsal compartment

- often decompression of volar compartment will reduce dorsal pressures




Volkmann's ischemic contracture

- result of delayed diagnosis

- severe muscle fibrosis & neuropathy 

- clawing of fingers


Muscles most commonly affected





- BR to FPL



Compartment Syndrome of Hand




Iatrogenic injuries

- arterial line or infiltration of IV medications

Crushing trauma

IV drug abuse

High pressure injections

- i.e. paint guns




Hand compartment syndromes lack abnormalities in sensory nerves

- no nerves are found within compartment

- non specific aching of the hand


Increased pain, loss of digital motion, continued swelling 

- tight swollen hand in a intrinsic minus position

- MP extension and PIP flexion

- intrinsic tightness (increased PIPJ motion with MCPJ flexion v extension)


Pressure measurement 


Should have a lower threshold than in leg compartments 

- pressures greater than 15-20 mmHg is a relative indication for release




10 separate osteofascial compartments 

- dorsal interossei (4) 

- palmar interossei (3) 

- adductor pollicis (1)

- thenar and hypothenar  (2)





- release thenar / hypothenar / adductor pollicis

- 2 x dorsal incisions over MC 2 and 4



Dupuytren's Disease


Definition Dupuytrens


Palmar Fibromatosis 




AD with variable penetration




Murrell's Theory of Pathogenesis


1. Microvascular ischaemia


2. Leads to conversion of 

- ATP to Hypoxanthine

- Endothelial Xanthine Hydrogenase to Xanthine Oxidase


3. Xanthine Oxidase converts Hypoxanthine to Uric Acid

- gives off OH-


4 OH- releases Free Radicals 

- stimulate fibroblast proliferation & increased Type III Collagen


5  Fibroblasts strangle microvessels

- Vicious Cycle  


Luck's three stages of Dupuytren's contracture 


1st stage (proliferative) stage 

- increased cellularity

- number of large myofibroblasts


2nd (involutional) stage 

- dense myofibroblast network aligned to long axis of collagen bundles

- the ratio of Type III collagen to Type I collagen is inc


3rd (residual) stage 

- myofibroblasts disappear 

- fibrocytes are dominant cell type

- dense collagen cord remains




Cell of origin for the nodular myofibroblast is unknown 

- fibroblast / smooth muscle cell / pericyte

- Contractile cell

- nodules composed of myofibroblasts 

- No myofibroblasts in cords


Dupuytren's diathesis 


Aggressive early-onset form of the disease which involves the multiple areas

- usually have family history

- disease recurs rapidly following treatment


Feet (Ledderhose, 1897)

Penis (Peyronie) 

Garrod knuckle pads on dorsum PIPJs




Chronic alcoholism 

- ? metabolic effect on fat and prostaglandin metabolism


Diabetes mellitus 

- may be related to the diabetic microangiopathy



- likely effect of antiepileptic drugs on collagen metabolism




Chronic pulmonary disease


Occupational hand trauma 

- controversial 

- probably only aggravation due to traumatizing an early nodule




Age 50-70

Male 7:1



- especially celtics / vikings heritage

- rare in blacks & asians




A.  Involved anatomy


1.  Pre-tendinous Bands

- part of the palmar aponeurosis in palm

- common site of disease

- palpable nodule is pathognomonic of Dupuytren's


2.  Spiral Band

- continuation of pre-tendinous band into finger

- spirals deep to NV bundle then becomes superficial to bundle


3.  Natatory Ligament

- pass between the web spaces

- frequently diseased and prevents abduction


4.  Lateral Digital Sheet

- condensation of superficial fascia on either side of the finger

- receives fibres from the natatory ligament, spiral band, Grayson's and Cleland's ligaments


5.  Grayson's Ligaments

- hold skin during flexion and extension

- pass from fibrous tendon sheath to the lateral digital sheet

- volar to the NV bundle

- almost always involved in Dupuytren's


B.  Not involved anatomy


Skoog's fibres 

- transverse palmar fibres 

- run from flexor sheath to flexor sheath at the level of the A1 pulley

- the nerve is always deep to the fibres

- part of palmar aponeurosis

- deep to pre-tendinous band

- don't become diseased


Cleland's Ligaments

- hold skin during flexion and extension

- firm fascial structures 

- pass from the side of the phalanges to the skin

- dorsal to the neurovascular bundle

- involved in Dupuytren's only through mingling with the lateral digital sheet


MEM: Dave Christie Goes Volar

(Dorsal Cleland's, Grayson's Volar)




LF / RF most commonly affected

MF / IF are sometimes affected

1st web sometimes affected




5 Major Pathological cords


1.  Pretendinous cord


In palm / other 4 in finger

- diseased pretendinous band

- causes MCPJ deformity


2.  Central cord 


Diseased central fibrofatty tissue

- large nodule often present in cord just proximal to PIPJ

- causes PIPJ deformity


3.  Spiral cord 


Pathological spiral band

- usually connects to the P2 (bone and tendon sheath)

- displaces neurovascular bundle volarly


Difficult to predict presence

- associated with more severe contractures


4. Lateral Cord 


Diseased lateral digital sheath

- intimately adherent to skin (sharp dissection required)

- contributes to DIPJ +/- PIPJ


5. Natatory Cord 


Diseased Natatory ligament

- causes web contracture


3 Minor Cords


1.  Retrovascular Cord 


Involves longitudinal fibers dorsal to the bundle

- commonly seen in combination with other cords

- causes DIPJ extension with lateral cord


2.  Abductor Digiti Minimi Cord 


Cord arises from abductor digiti minimi

- from MT junction 

- to ulnar side of the base of P2

- commonly adheres to the lateral skin


3.  Intercommissural Cords / 1st Web 


Pathological changes in 

- pre-tendinous band (radial longitudinal fiber)

- superficial transverse fibers of the palm (proximal transverse commissural ligament)

- the first web natatory ligaments (Grapow's ligament)




1.  PIPJ Contracture 


4 components

- Central cord 

- Spiral cord 

- Lateral cord 

- Retrovascular cord


Correction sequence

- resection pathological cords

- capsulotomy, release check rein ligaments

- release of accessory collateral ligaments performed

- release of volar plate 


2.  MCPJ Contracture


Always correctable by removal of central band

- Flexion deformity does not lead to collateral shortening 


3.  DIPJ Hyperextension

Occurs in advanced disease

- contracture of retro-vascular + lateral cord




Usually mildly painful nodules to begin

- palm of RF and LF rays

- very short lived


Severe night pain

- suspect fibrosarcoma


Progressive contracture of MCP, then PIPJ

- nodule over PIPJ warning of impending PIPJ contracture


Difficulty putting hands in pockets

- difficult gripping

- poke themselves in the eye



- foot, penis




Nodules / dimples / pits

- palm, fingers





- DIPJ extension

- web space contractures / natatory cords


PIPJ Contracture

- Examine PIPJ with MCPJ flexed

- eliminate effect of cord

- establish if any joint contracture



- feet, Garrod's pads


Hueston Table Top Test

- Royal Melbourne hospital

- palm down on table

- positive if can slide pen under

- MCPJ contracture 30-40o





1. Significant functional impairment


2. PIPJ contracture

- originally thought to intervene early

- Macfarlane showed residual FFD always about 30o

- may need to release  check rein ligaments / accessory collateral ligaments


3. MCPJ contracture >30o


4. Trigger fingers

- must do limited fasciectomy 

- otherwise may get exacerbation


5. CTS 

- treat dupuytren's 1st then carpal tunnel if doesn't settle




Advanced RA

Trophic changes due to vascular insufficiency

Unfit for GA


Risk for Recurrence



- Garrod's pads highest risk

- foot and penis involvement

Family History

Bilateral / Radial and ulna involvement / multiple digits


Young patients and patients > 75





Partial Fasciectomy

Complete Fasciectomy

Dermatofasciectomy and STSG





Division of fascial cord

- Temporary method to relieve a severe MCPJ contracture

- not definitive therapy

- not in digits because high risk of neurovascular injury

- useful in elderly patients 

- results are better with dense mature cords 


Partial Fasciectomy


Dupuytrens surgery


Most common procedure


Recurrence rates of 50%

- need for repeat surgical procedure is only 15%




Longitudinal incision with Z plasty at end of case

- probably better with severe contracture as allows skin closure

- easier to protect NV bundles

- z at 60o


Careful flap elevation

- easy to button hole through skin


Dissection of NV bundles

- under then over spiral bands


Resection of diseased tissue


PIPJ  contracture > 30o


- released check rein / accessory collateral / volar plate /  capsulotomy / flexor sheath

- note that a extended finger which does not flex is more debilitating than a FFD


Skin gaps

- due to large contractures


- McCash open technique (secondary healing)



- let down tourniquet for haemostasis

- consider drain

- check finger vascularity




POP backslab in POSI

Wound check at 7 days

ROS 2 weeks

Night splint in extension for 3/12


Complete Fasciectomy 


Abandoned due high complication rate

- does not completely prevent recurrence of the disease


Dermatofasciectomy & FTSG



- recurrent disease

- young with diathesis / aggressive disease

- Recurrence under grafts very rare (Hueston)

- the FTSG as a fire break




Rarely necessary

- may be indicated if severe PIPJ flexion 

- skin from involved finger may be used to cover palmar skin defect

- finger is filleted & skin folded into palm as pedicle with neurovascular bundles


Adjunctive Procedures


Trigger Fingers 


Excise diseased fascia with release of the A1 pulley


Pulley release without local diseased fascial excision

- may instigate a rapid progression of the Dupuytren's disease


Carpal Tunnel Syndrome 


Prophylactic CTD at time of fasciectomy is unwise

- accelerated scar formation may cause poor result


Partial Fasciectomy with CTD at later date





- can be a problem for the skin

- lead to necrosis


Vascular Impairment/ Flap Necrosis

- finger white at end of procedure

- often due to vessel stretched after significant release

- bend fingers, leave tourniquet down

- papaverine on vessels as antispasmodic

- warm hand

- inspect vessels for damage

- wait


Nerve Injury


Reflex sympathetic dystrophy 


Finger Fractures



1 / 1000 per year female

1.5 / 1000 per year male


Phalangeal fractures

- represent more than half of all hand fractures


Goals of Treatment


Restore normal function of the finger


1.  Restoration of bony anatomy


2.  Early motion

- inherent fracture stability

- splinting

- adequate internal fixation

- dynamic external fixation




Obvious swelling / bruising / deformity


Compound injuries


Rotational alignment

1.  With active flexion, all fingers point towards scaphoid tuberosity

2.  Evidence digital overlap (see below)

3.  Plane of nail beds all in same plane

- LF often slightly different rotation


Finger MalrotationFinger rotation normal


Tendon avulsion




3 planes centred on MCPJ  middle finger

- AP

- lateral

- oblique


Care to look for subtle evidence joint subluxation


Principles Closed Treatment


POSI (Position of Safe Immobilisation)

- 20o wrist extension

- flexion of MCPJ to 60 - 70o

- IP joints in extension

- thumb in abduction


Acceptable alignment


Pun etal JBJS Am 1989

- 10o angulation in both planes

- no rotation

- 50% overlay


Surgical approaches


A.  Midaxial

- dorsal to NV bundle

- make dots on flexion creases with finger flexed

- this marks incision

- approach P1 by excision of one sagittal band

- less tendon disruption

- more difficult visualisation / access


B.  Midlateral

- volar to NV bundle


C.  Dorsal approach

- direct doral incision

- divide extensor hood over P1

- between lateral bands P2

- repair extensor mechanism at end

- risks scarring down of extensor tendon to implant


Types of injuries


1.  Extra-articular fractures


A.  Distal phalanx tuft fractures

B.  Shaft fractures of the distal, middle and proximal phalanges


2.  Joint injuries



- dislocations

- mallet

- Pilon fractures

- Flexor tendon avulsion           



- dorsal dislocations

- dorsal fracture dislocations

- volar dislocations

- Pilon fractures

- Condylar fractures


MCPJ dislocations


Tuft fractures


Most common hand injury

- usually crush mechanism



- trephination of subungal haematoma (relieves pain)

- repair nail bed disruption

- irrigation and washout of open injuries


Distal phalangeal shaft fractures


Distal Phalanx Fracture 1Distal Phalanx Fracture 2


Non displaced fractures

– splint DIPJ for 2-3 weeks



- higher energy fractures

- washout open wounds

- repair nail bed

- bony reduction with percutaneous K wire

- distal phalanx just under nail bed


Shaft fractures middle / proximal phalanges



- usually stable

- buddy strap 3-4 weeks


Finger Fracture Undisplaced




Finger Phalangeal Shaft FractureProximal Phalanx Shaft Fracture


Unstable fractures

- oblique, spiral, comminuted fractures


Transverse fractures P1 / characteristic deformity

- insertion of intrinsics at base PP flex fragment

- insertion of central slip to MP extend fragment


Finger Phalangeal Shaft Fracture Lateral


Fractures of P2 distal to insertion FDS / characteristic deformity

- FDS will flex fragment

- extensor tendon will extend fragment


Closed reduction

- relaxation of intrinsics

- axial traction

- reduction of deformity / POSI




A.  Transverse fractures

- cross K wire

- Lister’s intra-osseous wire fixation

- plating


Hand Phalange Circular WireFinger Cross K Wires


B.  Long oblique / spiral fractures



- fracture must be at lease 2 x diameter bone

- can treat with 2 x lag screws

- one perpedicular to fracture to lag

- one perpendicular to shaft to resist shear



- percutaneous K wires / screw fixation / plating


FInger Lag Screws


DIPJ Dislocations



- most common

- closed reduction with dorsal traction

- failed closed reduction – volar plate, FDP

- 60% injuries open

- splint joint in flexion 2- 3/52 weeks

- ROM at 1/52



- rare

- failed closed reduction – extensor tendon

- DIPJ extension splint 6-8/52


Mallet fractures


Mallet Finger



- axial load

- extensor tendon attached to bony fragment


Closed treatment

- mallet splint (Stack)

- expect 10o extensor lag with mild loss ROM

- good results with non – op management


Bony Mallet Thumb





- volar subluxation of distal phalanx

- fragment > 50% joint surface

- chronic > 12 weeks old


Open treatment

- high incidence of complications

- percutaneous K wire recommended



1.  Reduce and axial K wire

2.  Dorsal blocking K wire / axial K wire


Wehbe and Schneider JBJS Am 1984

- 21 patients with intra-articular fractures

- 15 treated non operatively

- 6 treated operatively

- nil improvement in outcome

- worsened surgical morbidity


Pilon fractures base distal phalanx


Impaction injuries



- ORIF very difficult

- all attempts at closed reduction +/- percutaneous pinning should be made

- fallback of arthrodesis / arthroplasty


FDP avulsions


Leddy and Packer classification

I   Vinculae are ruptured, tendon retracts to palm

II  Vinculae intact, tendon remains at PIPJ

III Large bony fragment, ensnared beyond A4 pulley


Type 1

- must be operated within 10 days to avoid contractures

- otherwise 2 stage reconstruction


Type 2 / 3

- can operate within 6 weeks

- ORIF large fragments


Condylar fractures of head of P1 / P2



- torsional and valgus impaction


London classification

Type 1  Unicondylar, undisplaced

Type 2  Unicondylar, displaced

Type 3  Bicondylar


Displaced unicondylar

- percutaneous K wire

- ORIF with screw


Finger Unicondylar Displaced FractureFinger Unicondylar Fracture ORIF APFinger Unicondylar Fracture ORIF Lateral


Open reduction

- P1 – between central slip and lateral band

- P2 – lateral to terminal extensor tendon

- must preserve collateral ligament which supplies blood


Type III bicondylar fractures

- difficult fractures

- 90 degree condylar plate

- lag screw and plate

- high risk of joint stiffness


PIPJ Dislocations



- Dorsal

- Lateral

- Volar




Proper collateral ligaments

- primary stabilisers

- insert volar third of the base of PP


Accessory collateral ligaments

- inserts on and stabilises lateral margin of volar plate


Volar plate

- thick distally

- thin proximally, allowing collapse during flexion


Dorsal dislocations PIPJ


Most common joint injury of the hand

- hinge joint permitting 110o ROM

- volar plate fails distally

- collateral ligaments may be intact

- may be a fracture



- hyperextension

- axial loading of the flexed fingertip



- dependant on integrity of the collateral ligaments

- if fragment is > 40 – 50%, the attachment of the true collateral ligament is lost

- unstable


Eaton Classification


I Simple hyperextension

- buddy strap, early ROM


II Dorsal dislocation

- reduced and assess stability

- buddy strap if stable

- extension splint 10o further than instability

- each week extend further by 10o

- early aggressive ROM program


Dorsal Dislocation Simple


IIIA  fracture < 40% volar articular surface

- closed treatment with extension block


Finger Dorsal Dislocation Extension Blocking Splint


IIIB fracture > 40% + Pilon fractures

- inherently unstable

- extension blocking requires extreme flexion for stability, so risk of flexion contracture is high

- aim for congruent articular surface and early ROM


PIPJ Dislocation and Large Bony Fragment


IIIB Treatment Options


1.  Dorsal Blocking K wire

2.  Slade Dynamic Distraction External Fixator

3.  Compass Hinge

4.  Volar Plate Arthroplasty


Dorsal Blocking K wire



- flexion P2

- dorsal entry into P1

- 40o flexion

- early removal at 3/52

- Improvement compared to extension blocking


Suzuki / Slade Dynamic Distraction external fixator



- closed reduction through ligamentotaxis

- early motion of PIPJ



- transverse K wire in rotational centre / head P1

- transverse K wire distal P2

- attached by rubber bands

- third K wire mid-diaphysis P2,  prevents dorsal translation of MP


Deshmuhk S etal JBJS Br July 2004

- 12 patients complex fracture dislocations PIPJ

- treated with modified pin / rubber band system

- average 84o ROM

- nil radiological osteolysis or clinical osteomyelitis

- all returned to occupation


Hotchkiss designed PIP compass hinge



- K wire to centre head of P1 to set centre rotation

- 2 x  K wires each in P1 / P2

- barrel over centre of rotation

- options of active motion, passive ROM, locked


Bain I JBJS Br 1998

- 12 patients

- mean range of motion 12 – 86o

- only half presented within 2 week of injury

- combined operation with ORIF and volar plate arthroplasty

- nil osteomyelitis

- hinge on for 6 weeks


Volar plate arthroplasty / Volar plate advancement



- incise accessory collaterals to release volar plate

- excise bony fragment

- suture proximal volar plate into defect

- pass sutures through drill holes in base P2

- tie over button dorsally

- dorsal blocking splint 4 - 6 / 52


Finger Volar Plate Arthroplasty


Volar PIPJ dislocations


Finger Volar DislocationFinger Post Volar Dislocation


A.  Straight volar dislocation


Assessment of central slip post reduction critical

- if can active extend to within 30o, splint extended

- if nil active, surgical repair to prevent boutonniere


B.  Volar rotary subluxation

- condyle button holes between central slip and lateral band

- irreducible dislocation


Lateral PIPJ dislocations


Rupture of one collateral ligament and volar plate

- may be bony avulsion



- reduce and hold in extension 2/52, then protected ROM

- can perform primary repair or reconstruct


MCPJ Dislocation



- volar plate not interposed

- MCPJ 90o hyper-extended

- reduce via wrist flexion and volar translation of PP

- avoid hyperextension and axial distraction which may convert this injury to a complex dislocation

- extension blocking splint 3-4 weeks



- volar plate / lumbrical tendon / flexor tendons interposed

- joint space widened

- requires open reduction, dorsal or volar

- volar more direct but risk NV bundles

- protected motion post operatively


MCPJ Destruction



- infection

- trauma



- joint replacement

- fusion


MCPJ DestructionMCPJ Fusion APMCPJ Fusion Lateral


MCPJ Replacement


Finger Soft Tissue Injuries

Detipping Injury




Distal to insertion of flexor and extensor tendons




Thick skin

- fibrofatty tissue

- fibrous septa from dermis to periosteum of skin


Nail complex


1.  Nail Plate


2.  Nail Bed

- adherent to thin periosteum of P3


A.  Proximal germinal matrix

- proximal part

- limit is semilunar lunula

- produces 90% thickness of nail plate


B.  Sterile matrix

- adherent to nail plate

- contributes little to thickness


3.  Paronychium

- surrounding skin on dorsum of fingertip


4.  Eponychium 

- covers nail plate proximally


5.  Hyponychium

- thick skin below distal edge of nail




A Oblique facing up

B Transverse

C Oblique facing down

D Oblique facing laterally


Tissue involved

- Pulp only

- Nail bed

- Bone




1.  Preserve functional length 

2.  Preserve useful sensibility

3.  Prevent Neuromas

4.  Prevent joint contractures

5.  Short morbidity with early return to work


Management Pulp Loss


Pulp loss Finger




1.  Primary healing

- best option


2.  Secondary healing

- < 1 cm2 area to cover

- 90% 5 year satisfaction


3.  Skin grafting

- 50% 5 year satisfaction

- most are painful


4.  Flaps


Local flaps / VY flaps

- Atasoy single volar

- Kutlers lateral flaps


Regional Flaps

- Cross-finger

- Thenar flap


4.  Formalisation


If bone on view and patient doesn't want flap

- take bone to level distal to extensor / flexor tendons

- remove nail bed in full (bilateral eponychial incisions)


Bone on View




1.  Shorten and cover

2.  Preserve length and flap

3.  Secondary intention

- rarely a good option except in children


Soft tissue defects Finger


Local Flaps


1.  Atasoy  VY flap



- local



- often tender and sensitive long term

- can advance only 1 cm

- suitable for defects < 1 cm



- nibble bone back

- incise skin in V

- must release all fibrous septa form distal phalanx

- attempt to leave small vessels

- check is bleeding

- if avascular is usually because have not released all fibrous septa

- leaves too much tension on vessels


2.  Kutler's bilateral VY flap


Similar concept

- on both sides of digit


3.  Modified Kleinert flap


Lateral VY flap

- based on digital pedicle

- more volar VY flap than Kutler's


Regional Flaps


de-puplped finger injury



- 2 stage procedure 

- Often result in finger stiffness

- Contra-indicated if diabetes / vascular disorders

- age relative contra-indication > 40 years


1.  Cross finger flap


Rectangle of donor skin from dorsum of P2

- Hinge is mid-axial line

- Must preserve paratenon over extensor tendon


Full-thickness skin graft to donor site from forearm

- transversely across bicipital groove

- must remove all fat from FT graft


Graft sutured 75% onto dorsum of donor finger

- flap crossed onto distal finger pulp


Divide flap under GA 3 weeks later



- Obtain 10mm 2 point discrimination of flap


2.  Thenar flap



- source of good quality skin

- very similar to finger pulp

- 2 cm defect

- IF / MF / RF

- often difficult to oppose LF


Most important point is site of flap

- Position it high and parallel to MP crease

- If low or palmar can get debilitating donor site tenderness


Make skin 1.5 x defect size to reconstruct pulp

- donor site closed primarily or FTG


3.  Abdominal Flap


Suture finger to border between chest / abdomen

- release 3 weeks later

- primary closure of chest wound


4.  Formalisation



B.  Soft Tissue Defects Thumb




1.  Moberg advancement Flap



- only for thumb

- Cover 2cm defect



- mid-axial incisions from injury site to MPJ

- entire volar skin flap with both NV bundles

- flex IPJ, suture

- can do VY at base, or transverse incision and FTG at base


2.  Cross Finger Flap from Index Finger


3.  Littler Neurovascular Island flap


Ulna side of ring or little finger

- take on just one side

- significant secondary defect

- put a skin graft into secondary defect

- rarely first choice


3.  First dorsal Metacarpal Artery Flap



- skin over dorsum of P1 of IF

- 4-sided cut and mobilise on pedicle

- With art vein and nerve

- subcutaneous tunnel


4.  Free tissue transfer of great toe pulp


5.  Abdominal Flap




Gamekeeper's Thumb



Injury to ulnar collateral ligament of thumb MCPJ




Initial description

- chronic laxity of British gamekeeper's thumb's 

- no specific trauma

- secondary to breaking pheasant's neck


Acute trauma

- snow ski

- ball games


Valgus / forced abduction





- origin medial condyle metacarpal

- passes obliquely volarly 

- inserts on volar 1/3 of P1 and volar plate


Adductor aponeurosis 

- superficial to UCL

- inserts into ulna border thumb extensor mechanism

- via the ulna sesamoid




Painful, swollen MCPJ


Tenderness along UCL


Abduction Stress Test

- in full extension and 30° 

- loss of end point or 30o > other side

- indicates complete rupture




3 types Bony avulsion


1. Small fragment pulled away from P1


Thumb Bony Gamekeepers


2. Large intra-articular fracture involving >1/4 articular surface


3. S-H III in paediatric population




Look for stenar lesion

- when distal end of UCL

- flipped superficially over adductor aponeurosis

- will not be able to heal


A.  Undisplaced


MRI UCL Proximal Undisplaced InjuryTorn UCL Minimally Displaced MRI


B.  Displaced UCL




Non operative



- partial tear

- undisplaced complete tear

- undisplaced bony fragment




6/52 thumb spica




Indications for surgery

- complete tear with stener lesion

- large or small displaced bony fragment

- SH III in paediatrics

- chronic injury


Displaced Complete tear / Stener Lesion



- 18 - 43%




1.   Interposition of the adductor aponeurosis

- between a completely avulsed proximal ulnar collateral ligament injury

- and the proximal phalanx ligament insertion site


2.  Interposition between two ends of a mid-substance ligament tear




Difficult clinically

- may be able to palpate displaced UCL






Dorsal incision along ulna border MCPJ

- Divide Adductor pollicis aponeurosis

- leave cuff for lateral repair

- Identify and repair UCL



- direct suture if able to

- bony anchors

- through drill holes and over lateral button

- cerclage wire


Post op

- 6/52 thumb spica


Gamekeepers Thumb Repair


Bony Avulsion


ORIF Indications

1.   > 25% articular surface

2.   Small avulsion fracture displaced > 5mm

3.   SH III


Chronic Injuries


1.  Dynamic tendon transfer 


Adductor pollicis

- release adductor pollicis from ulnar sesamoid

- attach to base P1


2.  Free tendon graft


Graft options

- palmaris longus

- fourth toe tendon



- figure of 8 through drill holes

- transverse drill hole base P1

- drill hole head MC

- 6/52 POP


3.  Static tendon transfer



- leave attached distally

- weave through drill holes


Hand Arthritis






CREST (scleroderma)


RA (rare form)

Other seronegative arthropathies


Reactive arthropathy





Finger Osteoarthritis

EpidemiologyHeberden's Nodes


Male & Females > 60 years

- X-ray evidence of OA



- 25% females

- 15% males


Affected joints


Base thumb

PIPJ / Bouchard's nodes

DIPJ / Heberden's nodes


Finger OA


3 Groups


1.  Heberden's nodes

2.  Basilar thumb & Heberden's 

3.  Heberden's and Bouchard's




Joint space narrowing

Subchondral sclerosis

Osteophyte formation











DIPJ Arthrodesis





- 15 - 20o flexion



- transverse incision over DIPJ / H

- split / divide extensor tendon

- resect with small bone cutters and nibbles




A.  Headless compression screw


DIPJ Fusion ScrewDIPJ Fusion Screw 2


B.  K wire and TBW

- single intra-axial K wire

- pass retrograde first, reduce, anterograde

- Circular wire

- small drill holes and pass 25 or 26 gauge wire

- tension


DIPJ FusionDIPJ Fusion TBW Lateral


PIPJ Arthrodesis


Best in RF / LF





- 25 - 35o



- 45 - 50o




Longitudinal incision




A.  Reflect central slip

- leave attached distally

- lateral bands remain 

- suture repair at end


B.  Interval between central slip and lateral band

- reflect central slip laterally


Release collateral ligaments

- leave volar plate intact

- create two opposable surfaces

- saw or bone nibbler




A.  Headless compression screw


B.  Crossed K wires


C.  Longitudinal K wire and TBW figure 8

- pass wire retrograde 

- reduce, pass distally into P2


PIPJ Fusion TBWPIPJ Fusion TBW 2




Fusion rates about 90%




See rheumatoid hand discussion



Inflammatory Arthritis












Absorption of distal tuft of phalanx





Scleroderma / Raynauds

Frost Bite





RA rarely







Similar hand appearances to RA

- no joint destruction even in setting gross deformity




Autoimmune disorder


Distension of joint from synovitis rather than destruction of joint


Pannus not as aggressive as RA




Migratory poly arthralgia

Flexor tenosynovitis

MP and PIP arthritis


AVN of carpus



- butterfly rash

- lymphadenopathy

- pleuritis / pericarditis / Glomerulonephritis

- haemolytic anaemias





Juxtacortical osteopenia

Subluxation / dislocation

Bone infarction and abnormal calcification


Joint destruction = Co-existent RA









Aimed at rebalancing soft tissues

- may be inadequate

- may have to resort to fusion






Hand Sclerodermad Scleroderma Occluded Superficial Palmar Arch


Autoimmune disease

Unknown aetiology

Small vessel disease

Fibrosis in multiple organ systems





- 40% patients have RF




Patients female and middle ages


CREST Syndrome


1. Calcinosis

2. Raynaud's

3. Esophageal Strictures

4. Sclerodactyly

5, Telangiectasia




Stiff shiny digits

Loss of creases

Acral tapering of digits

Autoamputation (acro-osteolysis)


Calcium nodules




Lung fibrosis





1.  Calcium subcutaneous / extra - articular / occasionally intra-articular 

2.  Acro-osteolysis of the tufts of DP (80% patients)




Joint erosion

- RA part of DDx


Resorption of thumb CMC

- subsequent radial subluxation of the thumb MC




Psoriatic arthritis




Autoimmune disease

- seronegative arthritis


5-10% of RA have psoriasis


DDx from RA


Asymmetrical distribution


Psoriatic rash

Nail changes / pitting


Often less aggressive

- typically DIPJ more involved

- may have less synovitis but bone and soft tissue destruction still occur




1.  Classic - involvement of DIPJ joints of hands

2.  Deforming - with ankylosis & arthritis mutilans

3.  RA - Like - similar to RA but without RF

4.  Monarthritis

5.  Ankylosing Spondylitis - like


Hand X-ray


Periarticular phalangeal erosions

- asymmetrical

- no periarticular osteopenia


Periosteal new bone formation along MC / MT shafts



- typical 'Pencil in cup' deformity of DIPJ

- P3 tuft resorption & whittling


DIPJ Pencil in Cup


Juvenile Rheumatoid Arthritis


Differences from Adult RA


Usually much milder course

- 50-70% achieves remission


Deformity often opposite of Adult

- short ulna

- ulna hand / MC's

- radial deviation of fingers




Boutonniere deformity common

Intrinsic tightness uncommon


Extensor tenosynovitis signs uncommon

First sign is usually rupture of tendons with dropped wrist



Hand Infection



Human / Tooth Knuckle Injuries




Clenched knuckle

- tooth often penetrates capsule of MCPJ (60%)

- can injure the bone (58%)

- usually 3 / 4 th MCPJ


Associated Injury


Boxer's fracture

- 4th / 5th metacarpal head


Extensor tendon Laceration




Up to 50% rate of infection

- septic arthritis

- tenosynovitis

- osteomyelitis





- streptococci

- Staphylococci

- Eikenella

- anaerobes


Eikenella corrodens

- seen in 1/4 TKI

- gram negative rod / facultative anaerobe

- acts synergistically with strept and contributes to morbidity

- can be resistant to dicloxacillin

- usually sensitive to




Intial treatment

- povidone-iodine + copious irrigation



- augmentin oral

- IV penicillin



- best to debrige and washout all wounds

- open skin

- inspect extensor tendon

- open capsule, washout +++

- closure capusle

- leave skin open

- day 2 steristrip skin close


Await cultures

- change antibiotics accordingly



- failure of treatment with cephalosporin

- may be due to eikenella

- change to penicillin


Dog bites 




Mixed growth

- Streptococci

- Staphylocci

- Pasteurella




Washout & debride


TMP-SMX if allergic to penicillin


Cat Bites




More often become infected



- 50% Pasturella multocida




Incision and drainage



-  Augmentin / penicillin

- 2nd or 3rd generation Cephalosporin






Abscess of terminal pulp




Puncture wound

Paronychia or subungual abscess


S. aureus most common




Early Antibiotics and elevation


Usually requires incision and drainage



- lateral aspect of pulp

- unilateral longitudinal incision

- non-contact side of digit

- not too volar otherwise knocks out vessels

- must divide fibrous septa




Flexor Tendon Sheath Infections



S. aureus / Strept

- usually a history of trauma




IF / MF / RF

- extend from DP to distal crease



- extends to mid palm

- communicates with ulna bursa



- distal phalanx to volar wrist crease

- communicates with radial bursa




Kanavel's 4 signs


1.  Tenderness along course of flexor tendon

2.  Fusiform swelling

3.  Flexed attitude to finger

4.  Pain on passive extension of finger





- may settle with antibiotics if get early

- want improvement in 12 - 24 hours

- risk adhesions / tendon necrosis




Distal incision

- distal finger crease


Proximal incision

- distal palmar crease


Will see pus

- take swab for MCS


Pass infant feeding catheter

- into flexor sheath

- irrigate +++


IV ABx 48 hours


Occupational / hand therapy to prevent adhesions





Radial & Ulnar Bursal Infections


Bursal Anatomy


Enclose flexor tendons


Ulnar bursa is extension of little finger synovial sheath


Radial is extension of thumb synovial sheath


Coalesce in carpal tunnel to envelope all flexors

- 50% of time radial and ulna bursa communicate

- can get horse shoe collections


Deep Space Infections




Palmar pain and swelling


Dorsal pain and swelling




Midpalmar septum

- to MF Metacarpal


Hypothenar septum

- to LF Metacarpal


Potential Spaces

- thenar space

- midpalmar space


Thenar space

- ulnarly by midpalmar septum

- dorsally by Adductor Pollicis

- palmarly by index finger flexor tendon



- dorsal incision (can spread to involve 1st dorsal interossei)

- palmar incision


Midpalmar Space 

- Radial border midpalmar septum

- Ulnar hypothenar septum

- Dorsally 3-5 metacarpals

- palmar flexor tendons and lumbricals



- transverse incision across palm


Web Space Infection



- dorsally web skin

- Volar by transverse palmar fascia

- Radially and Ulnarly by fibrous septa



- both dorsal and volar incisions to ensure adequate drainage

- Avoid transverse incisions --> Contracture


Herpetic Whitlow




Cut on finger

- exposed to oral secretions




Often extremely painful




Oral antivirals

Recurrence 30 - 50%


Atypical Mycobacterium




Mycobacterium marinum

- aquatic trauma




Abundant tenosynovitis or joint synovitis


May take 8 weeks to culture on LJ medium





3-6 months ABx






Paronychia is skin around nail plate


Eponychia is skin covering base of nail plate




1.  Due to foreign material between nail plate and paronychium 


2.  By hang nail traumatising paronychium





- typically polymicrobial 

- aerobes and anaerobes

- Staph aureus, group A Strep, Eikinella corrodens

- Bacteroides, gram positive cocci and Fusobacterium nucleatum


Chronic paronychia

- atypical mycobacterium

- fungal infection

- gout

- carcinoma




Non operative

- warm soaks

- splinting 

- antibiotics (Augmentin)




Decompress and drainage of abscess may be necessary

- lift nail fold off plate +/- wedge resection

- avoid eponychial nail fold incision


Metacarpal Fractures



1.  Neck of 5th Metacarpal

2.  Metacarpal Shaft

3.  Metacarpal Head

4.  Base of Metacarpal Fracture Dislocations

5.  Base of Thumb Fractures / Bennett's / Rolanda


1.  Neck of 5th Metacarpal Fracture


Non operative Management


Accept 45o angulation

- will have finger extensor lag, but will recover

- can ring block and manipulate in POSI cast to improve position


Neck of Fifth Metacarpal Fracture


Operative Treatment



- K wire across MC head into 4th MC


2.  Metacarpal Shaft Fracture


Acceptable Deformity


Rotation < 5o

10o / 20o / 30o / 40o in IF / MF / RF / LF

< 5 mm shortening


Metacarpal Fracture Minimally Displaced


Operative Management



- plate

- lag screws (if spiral fracture)

- intramedullary wires


Metacarpal Intramedullary Wires


3.  Metacarpal Head Fracture



- uncommon

- usually in index finger


Indication for surgery

- > 2mm angulation



- T plate

- headless compression screws / intra-articular


4.  Base of Metacarpal Fracture Dislocations


Can be missed

- may need CT to diagnose



- reduce joint closed +/- open 

- dorsal approach

- K wire


Metacarpal Base Fracture Dislocation APMetacarpal Base Fracture Dislocation LateralBase of Metacarpal Dislocation CT


5.  Base of Thumb Metacarpal



A.  Bennett's

B.  Rolando

- Y shaped intra-articular


A.  Bennett's Fracture


Bennetts Fracture APBennetts Fracture LateralBennetts CT



- oblique intra-articular fracture

- small volar fragment remains in situ as attached to beak ligament

- metacarpal displaces proximally and dorsally due to APL

- inherently unstable



- closed reduction

- longitudinal traction on metacarpal

- use thumb to reduce metacarpal shaft

- use 2 x K wires to pin metacarpal to trapezium / trapezoid

- 6 weeks in thumb spica cast


Bennetts FractureBennetts K wireBennetts ORIF


Bennett K wires


B.  Rolando Fracture



- 2 small intra-articular fragments

- poor prognosis


Operative management

- for significant displacement

- dorsal approach

- protect superficial radial nerves

- between APL / EPB and EPL

- attempt to anatomically reduce and fix with plate

Nail Bed Lacerations

Subungual haematoma 



- < 50% of nail bed -> Decompress with needle

- > 50% -> remove nail and repair bed


Nail bed lacerations




1.  > 50% nail lost

- will get hook nail

- ablate nail bed


2.  < 50 % nail lost

- repair bed under magnification

- 6.0 chromic cat gut

- reduce nail plate back into fold to prevent adherence of dorsal and ventral folds


3.  Matrix defects

- can place nail bed material in place without sutures

- can use split thickness free nail bed graft

(i.e. from amputated digit)


4.  Proximal avulsion of nail plate

- always have germinal matrix laceration

- should always have 3 x horizontal mattress sutures




Hook Nail


Hook NailHook Nail




Replant 4 FingersReplant 4 fingers post





- reattachment of body part that has been completely severed


Revascularisation of incomplete Amputation

- vascular repair is necessary to prevent necrosis of the extremity

- retains some venous and lymphatic drainage albeit small

- revascularisation easier, quicker and better results


Mechanism of injury






Indications - Urbaniak 1987



Multiple digits

Individual digit distal to FDS insertion

Partial hand / through palm


Almost any body part in child


Wrist or forearm


Above or below Elbow 

- only if sharply demarcated




Adult single digit proximal to FDS insertion

- poor results / stiffness


Ischaemic time distal to carpus

- > 12 hours warm ischaemia time

- > 24 hours cold ischaemia time


Ischaemic time proximal to carpus

- > 6 hours warm ischaemia time

- > 12 hours cold ischaemia time


Severe crush or mangled



- through elbow

- high arm


Multiple level / segmental injury


Other serious injuries/diseases


Vessels atherosclerotic


Mentally unstable patient




Chinese red line sign 

- red streak along arterial course

- due to severe traction


Ribbon sign

- elongated tortuous arteries with pigtail appearance






Thumb has first priority

- a successfully replanted thumb is always better than any reconstruction

- thumb provides 40% of hand function

- a fixed stump / post is very useful


Detipped thumb can be successful

- need dorsal veins in stump

- need 4mm of skin proximal to nail plate

- all efforts should be made to preserve thumb length even up to nail base


Multiple amputations


Replant best digit to most useful stump

When thumb intact goal is to restore palm width


Single digit


Does well if FDS intact

- allows immediate mobilisation of digit


P1 replants


Useful function does not occur

- patient will bypass finger


Mid-palm amputations 


Absolute indication for replant 

- replant far superior to prosthesis as lose sensation and power grasp


Proximal injuries


Proximal forearm, EJ and Arm 

- usually avulsion types with extensive muscle injury

- infection and muscle necrosis very common 

- usually replant not indicated


Patient factors


High demand professionals 

- may push indications eg at P1


Age is not a barrier 


Patient must be aware of chance at viability, function, time off work etc


Premorbid conditions must be taken into account 

- DM, Smoking, HTN, peripheral vascular disease

- patient compliance




Key factor in success


Duration of allowed ischaemia varies from tissue to tissue


Recommended maximum


1.  Distal to carpus 

- 12 hours warm, 24 hours cool


Digits consist of skin, bone and subcutaneous tissue

- no muscle

- warm ischaemia tolerated for long periods

- freezing not tolerated

- digits have survived for 12 hours or longer of warm ischaemia

- when cooled replants have been performed at 36 hours


2.  Proximal to carpus 

- 6 hours warm, 12 hours cool


Major limb replants contain large volume of muscle

- only tolerate 4-6 hours of ischaemia

- because of the size of the extremity only its outer part is adequately cooled 

- the deep muscle remains relatively warm

- the allowable 6 hours can't be extended


Transport of part

4oC ideal


2 Methods


1. Wrapping the part in a moistened cloth of Ringer's or Saline

- placing in plastic bag and placing the bundle in ice water


2. Immersing the part in one of these solutions in a plastic bag 

- then putting on ice


No difference in outcome


Most important is to give clear and precise instructions to referring doctors




Dedicated replant team


Should be able to consistently achieve 90% patency rate in 1mm vessels in labratory


Operating theatre not the setting for practice


Surgical management


Operative Sequence for single digit


1. Locate and tag vessels and nerves

2. Debride

3. Shorten and fix the bone

4. Repair extensors

5. Repair flexors

6. Anastomose the arteries

7. Repair the nerves

8. Anastomose the veins

9. Obtain skin coverage


Set up

- maintain body temperature by warming the patient

- axillary block to block sympathetics

- ABx, tetanus prophylaxis




- longitudinal mid-lateral incisions for digital replants


Shorten bone

- get out of zone of injury 

- must have no tension on the grafts

- minimum 0.5 - 1cm each side

- alternative is to vein graft but is easier to shorten bone

- Shortening also helps with skin coverage


- K wire fusion DIPJ / P2


Extensor Tendons

- primary repair

- if inadequate extensor tendon for primary repair perform delayed repair


Flexor tendons 

- repaired primarily if at all possible

- otherwise 2 stage 



- 10/0 nylon interrupted

- key is repair normal intima to normal intima

- adventitia is intensely thrombogenic so ensure none in repair

- strip adventitia for 1-2mm

- repair both arteries if possible otherwise vein graft

- tourniquet acceptable

- micro-clips / bulldog clips should not be applied > 30min due to intimal damage

- heparin boluses to maintain patency (5000IU in 500 mls)

- papaverine antispasmodics

- 2 veins for every artery


Nerve repair

- 10/0 interrupted epineural repair

- primary repair if possible

- primary nerve graft if not 

- use medial cutaneous nerve of forearm 



- skin closed under no tension

- digital incisions often left open to decompress repairs

- fasciotomies in larger replants

- bulky above EJ dressing with volar slab unless flexor tendon repair then dorsal slab


Replant at level of nail bed



- No dorsal veins 



1.   Repair of volar veins (smaller and more flimsy)

2.   Anastomose one distal artery to proximal vein (AV anastomoses)

3.   Backbleeding by removing nail plate and scrapping every 2 hrs with cotton applicator and heparin dressings

4.   Medical grade leeches




Elevate gallows

- high dependency area

- high fluids

- anticoagulation controversial

- smoking strictly prohibited

- no caffeine

- warm ambient temperature

- colour, pulp, turgor, cap refill, and warmth all used as aids in monitoring the replant

- observations hourly for 72h then q4h

- if concern re myoglobinuria then maintain urine output high and alkalinise the urine



- if surface temperature <30°C poor perfusion of replant is certain


Reversal of failing patient


If appears threatened immediate action necessary

1. Relieve dressings or sutures

2. Either elevate or dependant position

3. Regional block for sympathetics

4. Relieve pain, fear and anxiety

5. Ensure patient warm and adequately hydrated

6. If return to OT necessary then must be within 4-6 hours of ischaemia




80-85% survivability


Urbaniak 1985

- 51/55 survived

- ROM 82o distal to FDS

- 35o proximal to FDS


Ring Avulsions


Urbaniak Classification


I - circulation adequate

II - circulation inadequate

III - complete degloving / amputation


Major limb replantation




Amputations proximal to metacarpal level have significant muscle bulk

- to prevent myonecrosis immediate arterial inflow is necessary

- following rapid skeletal stabilisation at least one artery must be stabilised then follow sequence for digit

- extensive fasciotomies always indicated

- any exposed vessels must be covered by rotation flap etc

- return to OT at 72 hrs for inspection and DPC


2 most common causes of failure in major limb replants 


1.  Myonecrosis with subsequent infection


2.  Failure to adequately decompress the restored vessels


Rheumatoid Hand

Hand RA Exam

Screening of Joints



-  ROM



- behind head / to mouth

- to back pocket 



- flexion / extension elbows 

- pronation / supination with thumb up & elbows by side



- flexion / extension



- make fist with thumb in and out 

- spread fingers


Functional Assessment of Hand


Power Grip 

Precision Grip 

Hook Grip 

Lateral Pinch Grip 

Tip Pinch


1.  Tip to Tip Pinch Grip

- pick up coin 


2. Lateral pinch grip

- turn key


3. Precision grip

- write with pen


4.  Power Grip

- turn knob 


5.  Hook Grip

- hold suitcase / fingers


Look at Hands / Place on Pillow


Palms up



- CTD / flexor tendon synovectomy


- flexor sheath synovium

Thenar & Hypothenar eminences


Thumb up


Thenar wasting

Swan neck / Boutonniere deformity


Rheumatoid thumb Boutonneire


Palms down


Rheumatoid Hand



- synovitis / synovectomy

- wrist fusion

- caput ulna

- radial drift 



- ulna drift / replacement / synovitis

- tendon subluxation



- Swan neck / Boutonniere deformity

- rheumatoid nodules


Rheumatoid Nodules





- median nerve / CTS

- ulnar nerve




Extensor tendons

- drop fingers

- DDx - locked trigger, tendon subluxation, joint subluxation, PIN palsy



- ruptures over Listers

- IPJ is extended by intrinsics also


Flexor tendons

- rupture IF & thumb (synovitis)

- rupture FPL alone over trapezial ridge (Mannerfelt)

- triggering



- ? subluxed


Boutonniere deformity

- degree of lag

- passively correctable

- ? arthritic changes


Swan neck deformity

- passively correctable

- intrinsic tightness / Bunnell test

- arthritic changes


Swan Neck Finger 1Rheumatoid Swan Neck Finger 1


Bunnell Test

- test with MCP extended and flexed

- correct ulna deviation

- invalidated by MCPJ dislocation

- with tight interossei will have reduced PIPJ flexion with MCPJ extension

Management Summary

Rheumatoid Hands Xray


Rheumatoid Arthritis Diagnostic Criteria


1987 American College of Rheumatology 


Need 4/7 (MAX RANS)

1. Morning Stiffness

2. Arthritis of 3 areas > 6/52

3. Xray changes

4. Rh factor

5. Arthritis of Hand > 6/52

6. Nodules

7. Symmetric Arthritis > 6/52


Types of Surgery


5 basic Groups


1. Synovectomy / Capsulorrhaphy

2. Tenosynovectomy

3. Tendon surgery & soft tissue balancing

4. Arthroplasty

5. Arthrodesis


General Principles


Replace all MCPJs


Replace RF/LF PIPJs

Fuse DIPJs

Correct wrist deformity at same time or risk recurrence


Caput Ulnae Syndrome 



- volar subluxation of ulnar carpus 

- supination of carpus on wrist 

- apparent dorsal subluxation of distal ulna 


Nalebuff Classification MCPJ


Stage I - Synovitis

- medical Rx and splinting

- synovectomy


Stage II - Synovitis + Ulna deviation

- medical treatment and splinting

- synovectomy + soft tissue reconstruction


Stage III - Moderate joint destruction

- volar subluxation and ulnar drift

- soft tissue reconstruction possible

- arthroplasty gives more reliable results


Stage IV - Advanced joint destruction

- fixed joint deformities

- arthroplasty with soft tissue releases


Causes of MCPJ Deformity


Ulna Drift / Ulna Dislocation


1.  Physiological

- gravity

- lateral pinch pressure


2.  Anatomic

- shape of MC heads

- collateral ligament length & orientation

- intrinsics to LF asymmetric (hypothenars strong)


3.  Pathological

- joint / capsule instability due to bony erosions

- collateral ligament stretching due to synovitis

- ulna/volar dislocation flexor tendons due to stretching pulleys

- ulna dislocation extensor tendons due to stretching sagittal bands

- intrinsic contracture

- radial deviation of wrist (Landsmere) redirecting line of pull of tendons

- volar / ulna carpal subluxation


Nalebuff Classification Thumb


Note: Type II now removed as Nalebuff later said doesn't exist


Type I - Boutonniere

- the commonest

- MCPJ flexion, IPJ hyperextension


Type II - Boutonniere & Swan Neck


Type III - Swan Neck

- second most common

- deformity is at CMC / Dorsal & radial subluxation

- hyperextension MPJ / flexion IPJ


Type IV - Gamekeepers


Type V - Stretched Volar Plate MCPJ


Type VI - Arthritis Mutilans


Swan Neck





- terminal extensor tendon rupture or attenuated

- entrapped FDP



- volar capsule stretching / FDS rupture

- contracted central extenor slip



- intrinsic tightness 

- extrinsic weakness / MCPJ subluxation and subluxation extensor apparatus





- FDS tenodesis / Lateral band transfer

- DIPJ arthrodesis (mallet)


Intrinsic tightness

- above +

- intrinsic release


Fixed deformity

- PIPJ dorsal release

- then above



- arthrodesis (20/30/40/50)

- arthroplasty (LF / RF)


Boutonniere Finger



- rupture of central slip



- flexible - Matev's central slips reconstruction

- radial lateral band to central slip

- ulna lateral band to radial lateral band insertion


Rheumatoid Fingers

ConditionsBoutonniere Fingers


1.  PIPJ Synovitis

- synovectomy via dorsomedial approach

2.  Flexor tenosynovitis

- may cause trigger finger

- trial HCLA

- remove synovits but don't release A1 pulley

- will worsen ulna drift

3.  DIPJ

- rarely affects

- may get mallet

- arthrodesis

4.  Ankylosis

- arthrodesis / arthroplasty

5.  Unstable / flail

- arthrodesis usually best option

6.  Swan neck deformity

7.  Boutonnière deformity




Boutonnière deformity

- usually good function

- often don't need surgical treatment


Hand Boutonniere Finger


Swan Neck

- much more debilitating

- usually need treatment


Swan Neck Deformity (Intrinsic Plus Deformity)




Hyperextended PIPJ / MCPJ + DIPJ flexion

- Bunnell calls this "Intrinsic plus deformity"


Rheumatoid Boutonniere FingerRheumatoid Boutonniere Finger


Rheumatoid Finger Swan Neck XrayFinger Swan Neck




Primary process is usually synovitis

- starts at either MCPJ / PIPJ / DIPJ





- terminal tendon ruptured or attenuated



- may also be due to stuck FDP





- rupture of FDS due to synovitis

- volar capsule stretches due to synovitis 



- contracted central extensor slip





- relative shortening of long extensors



- relative intrinsic tightness

- also seen in CP / CVA



- destruction or deformity


Rheumatoid Swan Neck secondary to MCPJ


Nalebuff Classification


Function depends upon PIPJ flexion


Bunnell Test


Assess Interossei Tightness


Positive test 

- PIPJ flexion less in MCPJ extension than with MCPJ flexion

- interossei are tighter in extension

- invalidated by MCPJ dislocation



- hand dorsum up

- correct ulna deviation

- extend MCPJ & comment on active PIPJ range

- flex MCPJ & comment on active PIPJ range


Type I

- PIPJ passively correctable / regardless of MCPJ position

- Bunnell Test negative


Type II

- PIPJ flexion limited with extension of MCPJ

- Bunnell Test positive

- intrinsic tightness


Type III

- fixed PIPJ flexion regardless of MCPJ position 

- joint problem

- lateral bands dislocated dorsal to axis of rotation


Type IV

- joint destruction / X-ray arthritis


RA Swan Neck Fingers XrayRheumatoid PIPJ Destruction




Aim is to create FFD

- many techniques described


Type 1


A.  Create FFD by FDS tenodesis

- use slip of FDS

- detach proximally

- pass through A2 pulley and attach to bone or on itself

- producing 20° FFD


+ DIPJ fusion


B.  Zancoli lateral band transfer


Lateral bands mobilised volar to axis of PIPJ

- raise flap of flexor retinaculum

- suture over lateral band to fix in place

- dorsal blocking splint / K wire


+ DIPJ fusion


Type II


Above +


Intrinsic release

- division of intrinsic oblique fibres



- oblique fibres which extend IPJ /  interossei

- transverse fibres flex the IPJ / lumbricals


Type III


PIPJ release first / Lateral band tenolysis / K wire

- release central slip / dorsal capsule / collateral ligs to allow flexion to >90o

- manipulate joint to flexed position

- fix with K-wire

- often stiff due to flexor synovitis

- often need flexor sheath synovectomy to get moving


Type IV


Arthroplasty RF / LF for grasp 

- arthroplasty has highest failure rate for Swan Neck 

- high recurrence and poor range

- 80% survival at 9 years


Fusion IF / MF for strength 

- angle of fusion a cascade 

- 20 30 40 50 (IF MF RF LF)


Rheumatoid Fusion PIPJ LF RF


Boutonniere's Deformity (Intrinsic Minus Deformity)


Boutonnierre Finger 1Boutonnierre Finger 2




PIPJ flexed / DIPJ hyperextended /  MCPJ hyperextended


Often well tolerated & treatment not needed




1.  Central slip dysfunction

- always starts with PIPJ flexion 


2.  Lateral bands displace volar 

- secondary to triangular ligament stretching


3.  DIPJ hyperextends secondary to PIPJ flexion

- contracted oblique retinacular ligament

- becomes fixed

- examination finds limited DIPJ flexion with PIPJ in extended position


Nalebuff Classfication


Stage 1 

- mild extensor lag 10-15°

- passively correctable


Lateral band reconstruction

- reduce lateral bands dorsally

- suture together


Stage 2

- moderate 30-40° lag

- passively correctable


Lateral band reconstruction + Central slip shortening / reconstruction


Dorso-Medial Incision & Synovectomy

A. Reduce lateral bands dorsally & Suture together

B. Tenotomy Terminal slip

C. Central slip options

i)   Shorten 5 mm

ii)  Reconstruct with lateral bands (take inside half of each and suture together)

iii) Reconstruct with PL

iv) Matev central slip reconstruction


Matev Central Slip Reconstruction

- radial lateral band divided at level of P2 

- proximal stump rerouted through central slip 

- attached to base P2 at central slip insertion

- ulnar lateral band divided distally

- passed dorsally over P2 and attached to distal radial lateral band stump


Stage 3 

- severe 

- fixed with x-ray arthritic changes


Arthrodesis / arthroplasty


PIPJ replacement


Rheumatoid Arthritis PIPJ OA




A. Pyrocarbon implants

- partially constrained press fit components

- relatively high failure rate

- can fracture when inserting and need cerclage wire


B.  Swanson spacer





Non reconstructable / irreparable

- extensor and flexor tendons

- collateral ligaments




Does not have same stability of MCPJ

- can dislocate




Dorsal incision

- straight or curved dorsomedially

- enter between central slip and lateral band

- can detach central slip proximally and reflect distally 


Release contractures

- balance soft tissues

- retain collaterals


Broach distally and proximally

- avoid extension at all times


Implant must achieve full extension

- no buckling, and no impingement


Repair central slip


Post op

- immobilise for 1 week

- dynamic extension splint 0 - 30o (Capner)

- active flexion


Arthrodesis PIPJ


Approach as above

- resect collaterals

- position as appropriate

- cross K wires / screw

Rheumatoid MCPJ



Ulna drift & volar dislocation


Rheumatoid MCPJRheumatoid MCPJ Ulnar Deviation


Causes of MCPJ Deformity


Ulna Drift / Ulna Dislocation


1.  Physiological

- gravity

- lateral pinch pressure

- power grip


2.  Anatomic

- shape of MC heads

- collateral ligament length & orientation

- intrinsics to LF asymmetric (hypothenars strong)


3.  Pathological

- joint / capsule instability due to bony erosions

- collateral ligament stretching due to synovitis

- ulna/volar dislocation flexor tendons due to stretching pulleys

- ulna dislocation extensor tendons due to stretching sagittal bands

- intrinsic contracture

- radial deviation of wrist (Landsmere) redirecting line of pull of tendons

- volar / ulna carpal subluxation


Nalebuff Classification MCPJ


Stage I - Synovitis

- medical treatment and splinting

- synovectomy


Stage II - Synovitis + Ulna deviation

- medical treatment and splinting

- synovectomy + soft tissue reconstruction


Stage III - Moderate joint destruction / Volar subluxation

- soft tissue reconstruction possible

- arthroplasty gives more reliable results


Rheumatoid Dislocated MCPJRheumatoid Dislocated MCPJ


Stage IV - Advanced joint destruction

- fixed joint deformities

- arthroplasty with soft tissue releases




Stage I Synovectomy MCPJ



- marked synovial proliferation not responding to medical treatment

- 6/12 non-operative

- painful

- concern regarding progression to deformity



- joint destruction with articular erosion

- instability

- fixed deformity or dislocation



- incise hood on Ulna side extensor tendon

- make sure clear under volar plate & collaterals


Stage II Synovitis / Ulna Deviation / Preserved MCPJ  


Synovectomy + Soft Tissue Reconstruction


1.  Ulna side release 

- divide transverse, oblique & sagittal bands


2.  Crossed Intrinsic Transfer

- corrects ulna drift

- ulna side intrinsics are released 

- transferred to the Ulna neighbour radial intrinsics

- reinsert through radial lateral band

- use EI for Index attach to radial side

- release EDM at little


3.  Extensor Tendon Relocation

- ulna sagittal band release

- radial sagittal band tightening


Stage III / IV Destroyed MCPJ


RA MCPJ Arthritis


Arthroplasty + ST Reconstruction as above


Swanson Joint Replacement


Swanson's Indications

- fixed or stiff MCPJs

- x-ray shows destruction or subluxation

- ulnar drift not reconstructable

- contracted intrinsic and extrinsics

- associated stiff IPJs


Swanson's contraindications

- infection

- inadequate skin coverage

- poor NV status

- irreparable intrinsic/extrinsic system

- insufficient bone stock



- painless joint with useful arc of motion





- usually > 40°

- get about 10° improvement



- > 80% pain relief

- no increase in strength


Deformity correction

- up to 40% loss over time

- loss of correction often due to inadequate soft tissue balancing



- 90% 10 year survival

- silicon synovitis uncommon unlike for wrist or trapezial implants


Technique MCPJ Swanson Arthroplasty



- transverse incision dorsum

- full thickness flaps preserving dorsal veins 



- incise extensor hood on ulna aspect each joint

- may need formal intrinsic release but bony cuts may be enough

- incise and remove capsule and synovitis


MC head

- excise MC head with osteotome or nibbler sufficiently to accept implant

- with final cut at 90° to shaft

- this often means removing collaterals

- ream MC with awl or drill



- do not resect P1 base

- just ream with awl



- resection of bone should allow no buckling of implant 

- no impingement of MC on P1

- insert prosthesis proximal then distally

- should have passive motion of 90°


Soft tissue balancing

- ulnar intrinsic release

- crossed intrinsic transfer

- extensor tendon relocation






Rheumatoid Thumb

Nalebuff Classification


Type I - Boutonniere 

- commonest

- MP flexion /  IP hyperextension

- usually EPB rupture with EPL subluxation


Rheumatoid Boutonniere Thumb


Type II

- Boutonniere & Swan Neck

- doesn't exist according to Nalebuff


Type III - Swan Neck

- second most common

- primary deformity is OA and dorsal subluxation of CMC

- hyperextension MPJ / IPJ flex


Rheumatoid Thumb Swan Neck


Type IV - Gamekeepers

- due to MCPJ synovitis

- stretches UCL

- either synovectomy / UCL reconstruction

- or fusion


Rheumatoid Gamekeepers Thumb


Type V - Stretched Volar Plate MCPJ

- differentiated from Swan Neck by no CMC disease

- fusion of MCPJ


Type VI - Arthritis Mutilans

- destruction and instability MCPJ / IPJ

- arthrodesis only option


RA Thumb Destruction IPJ


Boutonniere Deformity


RA Thumb Boutonniere's




Synovitis of MCPJ

- extensor Hood stretched

- EPB ruptures

- EPL tendon displaced Ulnarward & Volarly

- becomes flexor 




1.  Flexible MCPJ


A.  Synovectomy of MCPJ


B.  EI to EPB / EPL Centralisation


C.  EPL transfer + fusion IPJ

- divide EPL over P2 and reattach to base P1

- good correction early 

- but 66% recurrence


2.  Fixed MCPJ / Flexible IPJ


Arthrodesis / Arthroplasty MCPJ

- arthrodesis better suited for young, high demand

- arthroplasty better suited to low demand


Rheumatoid MCPJ Fusion


3.   Fixed IPJ and MPCPJ


A.  Fuse both 

- best option 


B.  IPJ fusion / MCPJ arthroplasty

- with arthroplasty have to balance soft tissues

- reroute EPL as above


Swan Neck




RA Thumb Swan NeckRA Swan Neck Deformity


Disease at CMCJ

- leads to dorsal subluxation of CMCJ 

- beak ligament is not functional

- result is adduction contracture


MCPJ hyperextension

- ? volar plate stretches


IJP flexion

- ? Mallet rupture 




A.  Trapeziectomy and LRTI


Rheumatoid Swan Thumb Trapeziectomy


B.  +/- MCPJ fusion


Thumb MCPJ Fusion


Tendon Injuries

Extensor Tendon Injuries




II Middle Phalanx


IV Proximal Phalanx


VI Metacarpal

VII Dorsal Wrist Retinaculum

VIII Distal Forearm

IX Mid & Proximal Forearm


MRI Wrist Extensor Compartments




Sagittal bands

- stabilise EDC

- extend MCPJ


Lateral bands

- lumbricals extended PIPJ


Zone 1 Mallet Finger



- loss of extension of DIPJ

- +/- Swan neck deformity

- hyperextension of PIPJ due to unopposed central slip action 




Avascular region of tendon at insertion into DIPJ

- explains poor surgical results






1.  Forced flexion of extended digit

- Rupture of tendon

- Avulsion of tendon ± small fragment of bone


2.  Forced hyperextension of DIPJ

- fracture of dorsal base of P3



- Laceration over dorsum of DIPJ




Type I    

- closed trauma

- no bone or < 1/3


Type II  

- laceration


Type III  

- deep abrasion


Type IV  

A) Transepiphyseal plate fracture in children

B) > 1/3 of joint surface

C) > 1/3 + Volar Subluxation of P3




1.  No or small Bony Lesion


Extension splint (Stack splint) for 6 to 8 weeks

- night splinting further 6 weeks

- 80% good results if treated early

- direct repair should be avoided (poor blood)


2.  Bony lesion > 50% with volar subluxation


A.  Extension splint


- poor skin, high risk of breakdown

C. Dorsal blocking K wire / second K wire across joint


3.  Chronic Mallet Finger 


1.  Arthrodesis 

- joint incongruent, arthritic or fixed


2.  Reconstruction possible if supple


4.  Open


Suture skin and tendon together


Zone 3 Boutonniere Lesion



- disruption of central slip at PIPJ





- forced flexion of PIPJ

- causes avulsion of central slip ± bony fragment



- laceration over central slip

- similar progressive deformity




Deformity usually not present at time of injury

- develops after 2-3/52


1. Flexion of PIPJ

- due to loss of central slip

- unopposed action of FDS


2. Stretching of expansion between central & lateral slips 

- transverse retinacular / triangular ligaments


3. Lateral bands migrate volar

- position volar to axis of rotation


4. Pull of lateral bands exclusively directed to DIPJ

- DIPJ hyperextends


5. MCPJ also hyperextends because of pull of long extensor




1.  Hold wrist and MCPJ fully flexed

- relaxes lateral bands

- unable to actively extend PIPJ


2.  Elson's test

- flex PIPJ to 90o over edge of table

- unable to actively extend PIPJ against resistance, will hyperextend DIPJ






1.   Splint PIP in Extension 4/52

- Leave DIPJ free and allow ROM


2.  Capener Splint 4/52



- central slip & lateral bands sutured with 5/0 nylon

- ff close to insertion, pull-out suture used

- PIPJ splinted in full extension for 6/52

- replaced with Capener splint when wound healed & sutures removed




Palmaris longus weave


Extensor Tendon Repairs Zone 5 - 9




Excellent results of repair 5 proximal zones

Only 50% excellent results 4 distal zones




Lacerations >50% zones V-VIII should be repaired

- modified Bunnell or Kessler best

- try to maintain length


Dynamic splinting 


Greatly improves results and is key 

- need 5mm excursion to prevent adhesions for flexors (Unknown for extensors)

- typical repairs shorten tendon


Outrigger with passive extension by rubber bands

- WJ 30o extension, MP's 10-15o flexion, IP's 0o

- allow 5mm excursion of tendon



Flexor Pulley Ruptures



5 Annular pulleys

3 Cruciate pulleys




A1 and A5 expendable


Loss of other annular pulleys can lead to bowstringing

- A2 & A4 +/- A3




Rock climbers

- usually when slipping


May hear or feel a pop


Develop swelling / tenderness / pain



- usually only with multiple pulley rupture





- exclude fracture



- very good



- if US inconclusive




Grade 1

- strain

- A4 tear (has good prognosis)


Grade 2

- partial tear A2 or A3


Grade 3

- complete A2 or A3 rupture


Grade 4

- multiple pulley rupture

- +/- lumbrical avulsion or collateral ligament damage




Non operative


Single complete pulley ruptures

- no climbing for 6 weeks

- gradual return to climbing with pulley taping

- full return to sport at 3 months




Multiple pulley ruptures

- repair techniques poor

- reconstruction required

- A2 with palmaris longus graft

- A3 with extensor retinaculum graft




Flexor Tendon Background



Fascicles of long, spiraling bundles

- tenocytes & Type I collagen

- synovial cells & fibroblasts present



- surrounds the individual collagen bundles



- fine fibrous outer layer, highly cellular, continuous with endotenon

- contains most of the blood vessels & capillaries



- thin visceral layer of adventitia on tendon

- provides nutrition & allows gliding


Synovial Sheaths

 - in distal palm & fingers, visceral synovial layer enclosing FDS/FDP

- parietal layer continuous with the pulleys

- tendons attached via long & short vinculae




Thickenings of the synovial sheath

- 5 strong annular pulleys interposed by 3 collapsible cruciate pulleys 

- allow the annular pulleys to approximate in flexion


A2 & A4 

- fibro-osseous annular pulleys

- arise from periosteum of the phalanx

- maintain short moment arm of tendon from joint, greatest joint rotation for least excursion

- most important


A1, A3, A5 

- arise from the volar plates 

- MCPJ, PIPJ & DIPJ respectively


Palmar Aponeurosis Pulley 

- important additional pulley

- transverse fibres of palmar fascia


Thumb Pulleys

- A1 (MCPJ) and A2 (IPJ)

- Oblique pulley in between and is most important

- can be excised if A1 intact


Flexor Tendons


Excursion can exceed 8cm

- in pulley area flexor tendons have segments that are avascular  





- arises from single muscle belly

- volar aspect of humerus, radius and ulna

- separates into 4 tendons in forearm

- IF and LF deep, RF and MF superficial in carpal tunnel

- LF may be absent (20%)

- bifurcates at level A1 pulley

- 2 slips rotate around and insert volar aspect base of P2 and radial / ulna sides



- has independent action

- FDS & interossei combine for forceful flexion

- 200N achieved in power grip



- has common muscle origin

- arises volar aspect ulna and interosseous membrane

- deep to FDS

- several digits have simultaneous action

- acts as primary digital flexor 



- arise from FDP

- lateral 2 (ulna n) bipennate, medial 2 arise from 1 tendon only (median n)

- insert on radial side of extensor expansion

- flex MCPJ and extend IPJ's


Vascular Supply


Blood vessels


1. Longitudinal vessels enter tendons in palm

-  Vessels enter at proximal synovial fold in distal palm


2. Vessels enter at osseous insertions


3. Segmental branches of digital arteries enter via long & short vinculae

- VBP vinculae brevis profundus 

- VLP vinculae longus profundus

- VBS vinculae brevis superficialis 

- VLS vinculae longus superficialis


Flexor tendons have highest vascularity dorsally


Synovial Fluid Diffusion


May function better than vascular perfusion

- composition similar to joint fluid

- imbibition process

- fluid is pumped into interstices of tendon through ridges oriented at 90° to each other during flexion and extension

- synovial sheath is critical to this process

- lacerations disrupt this mechanism


Avascular segments


1.  FDS & FDP have avascular segments over proximal phalanx under A2


2.  FDP has 2nd avascular segment over middle phalanx under A4


Tendon Biochemical Composition 



- Type I collagen 95%

- Type III & V collagen 5%


Dense, parallel collagen fibres

- Highest tensile strength of all soft tissues 

- Collagen in triple helix of tropocollagen molecules 


Age and immobilization

- increases collagen content 

- loss of water content, glycosaminoglycan concentration & strength


Exercise training

- increases collagen fibril size

- increases strength & stiffness


Tendon Healing  


Both Intrinsic & Extrinsic factors

- extrinsic - fibroblasts and inflammatory cells from periphery

- intrinsic - fibroblasts and inflammatory cells from epitenon


Aim is to optimize intrinsic healing and minimize extrinsic healing which may lead to development of adhesions


3 Phases

- inflammatory

- fibroblastic

- remodelling


Inflammatory Phase Day 1-4


Clot fills defect

- Epitenon cells migrate into & bridge the gap

- Peritendinous cells proliferate & migrate into laceration site


Fibroblastic Phase Day 5-28


Collagen secretion begins by day 5

- fibres formed in random fashion

- Fibroblasts become the predominant cell type

- Synovium is reconstituted by day 21 

- Vascularisation increases with penetration of avascular zones by new blood vessels

- Increased strength by 2 - 3 weeks

- Collagen content increases for first 4 weeks

- Collagen reorientation complete by day 28


Remodelling Phase Day 28-112


By day 28 fibroblasts longitudinally oriented 

- progressive remodeling & realignment of collagen fibrils

- By 6 weeks gap is completely filled

- By 8 weeks collagen is mature & realigned


By 4 months

- maturation complete 

- fibroblasts now quiescent tenocytes

- Full tensile strength only reached after physiologic loading




Dense adhesive scar 

- results from ingrowth of fibroblasts from the digital sheath & epitenon proliferation


More severe 

- immobilized tendons

- increased severity of synovial sheath injury /crush

- gaps > 3mm





Flexor Tendon Complications



1.  Flexor Tendon Rupture

2.  Adhesions

3.  PIPJ contractures

4.  Triggering

5.  Pulley failure

6.  Quadrigia


1.  Flexor Tendon Repair Rupture






Management Options


FDS only

- usually minimal impairment


FDP only

- may be better to fuse DIPJ

- passing tendon through FDS may give poor result



- repair / graft FDP


One Stage repair



1. Minimal scarring

2. Pliable joints

3. Adequate retinacular pulley system

4. Not Zone 2


2 Stage repair  




1.  Severe adhesions or scarred tendon bed

2.  Contractures

3.  Disruption of pulley system

4.  Missed injuries

5.  Injuries not suitable for primary repair

- usually gross contamination


Technique 2 Stage



- all anastomosis in Zone 1 and Zone 3 (not Zone 2)


Technique Stage 1 


Long Brunner incision finger

- Scarred tendon remnants excised, contractures released 

- A2/4 pulleys reconstructed if necessary

- Silastic implant sutured distally to FDP Zone 1

- proximal end zone 5 free

- need incision in palm to pass through to forearm 


Mobilisation regime post-op

- get finger moving / passive exercises +++

- minimise adhesions

- recreate synovial sheath for second stage


Pulley reconstruction

- use FDS, extensor retinaculum, PL free tendon

- A2: passed dorsal to NV bundles between phalanx and extensor tendons

- A4: superficial to extensor tendons


Technique Stage 2 


Graft options

- Palmaris longus (absent 25%)

- Plantaris (absent 20%)

- Long toe extensor (IV)



- performed at 3 months 

- Early, protected Post-op mobilisation

- active motion at 4 weeks


2.  Flexor Tenolysis


Diagnosis Flexor Tendon Adhesions


Limited active ROM > passive ROM

- tendon adhesions


Limited passive ROM = active ROM

- joint contracture


If there is a marked difference between active and passive ROM

- adhesions likely but

- need to ensure repair is intact

- feel for tendon / ultrasound




Up to 20% of patients require tenolysis

- therapy +++ for 3 - 6 months

- need to assess the amount of functional deficit of the patient

- subcutaneous tissues must be state of equilibrium (i.e. soft and supple)




Must be prepared to go on to 2-stage repair

- long brunner incision

- access tendon through sheath via less important pulleys

- early active ROM critical


3.  PIPJ Contractures


Non Operative



- static night time extension splints

- dynamic external fixators






Access between A2 and A3 pulley

- remove cruciform pulleys

- flexor tenolysis

- release check rein ligaments

- release accessory collateral / collaterals / volar plate





Improve extension 20 - 30o

- lose equivalent amount of flexion

- change functional arc


4.  Triggering


May be triggering on A2 or A4 pulley

- Non operative treatment


5.  Pulley Failure and Bowstringing


6.  Quadriga




FDP of MF / RF / LF linked

- will only extend as much as of shortest tendon

- if limited excursion of one FDP due to repair etc

- present with limitation of all finger flexion




Release adhesions of the shortened tendon



Flexor Tendon Repair



1. Core suture


Strength of repair proportional to

A.  Number of strands crossing the gap (not suture type)

B.  Suture size (usually non absorbable braided suture 3/0 or 4/0)


2. Repair strength increases more rapidly with early motion stress


3. Dorsal sutures are stronger but may interfere with blood supply


4. Repairs usually rupture at knots


5. Locking loops decrease pull out and increase strength


7. Peripheral Circumferential Suture 

- increases repair strength by 10-50%

- reduces gapping and bulk of repair significantly

- closure of epitenon with 6/0 suture


Partial Tendon Lacerations


< 25%

- debride


25 - 25%

- epitenon repair


> 50%

- core and epitenon repair


Early ROM Rehabilitation


1.  Load at failure at 3 weeks 

- immediately mobilised tendons 3 x > immobilised tendons

- more rapid collagen realignment

- histological exam increased healing response with decreased scar response


2.  Early mobilization decreases adhesions


Early Active ROM Protocol 


Position in extension blocking splint

- wrist and MCPJ flexed

- DIPJ and PIPJ in extension


Stage 1

- passive flexion using the other hand (5 times per hour)

- active extension of finger in splint

- splint never removed


Stage 2

- once full passive motion gained (each hour)

- 5 x passive finger flexion & active extension

- 5 x active finger flexion & 5 active finger extension

- splint never removed


6 Weeks

- splint removed & active wrist movement

- no resistance


8 weeks 

- resistive work (sponge squeezing)


12 Weeks 

- normal activity




Brunner incisions

- incorporate laceration

- avoid sharp angles <60o

- longitudinal incisions over flexor creases avoided


Identify and protect NV bundles


Expose synovial sheath

- preserve A2 and A4

- can remove other pulleys


Zones of Injury


Zone 1 

- distal to FDS (FDP only)


Zone 2 

- between A1 pulley and FDS insertion (2 tendons in sheath)


Zone 3 

- in palm, lumbrical origin


Zone 4 

- in carpal tunnel


Zone 5 

- proximal to carpal tunnel




Zone 1




1.  Open / laceration


2.  Rugger jersey finger

- most common RF

- caught in jersey whilst grasping

- RF forcibly extended at DIPJ while FDP is contracting maximally

- due to common muscle belly for FDP to LF, RF, MF




Avulsion FDP Type 1

- FDP retracts into palm

- vinculum ruptured

- tender swelling in palm 

- may need separate palmar incision

- need to pass under A2 and A4 pulley

- suture tendon to paediatric feeding catheter

- must be repaired in 7-10 days


Avulsion FDP Type 2 

- most common type

- retracts to PIPJ level

- vinculum intact

- swelling at PIPJ level

- early reinsertion best

- can be repaired up to 3 months after injury 

- may progress to type 1 injury if vinculae give way


Avulsion FDP Type 3 

- large bony fragment

- A4 pulley catches fragment & prevents retraction

- early reattachment




1.  Tendon to tendon repair

- if possible


2.  Insufficient distal tendon

- prepare bony insertion

- modified Kessler into tendon

- pass suture ends through distal phalanx and nail plate

- tie over button

- use 4.0 monofilament i.e. prolene

- need to remove button and sutures at 8/52


3.  Bony avulsion

- ORIF / button repair


Zone 2 / Bunnell No Man's Land



- both tendons injured

- high risk of bulky repairs / adhesions / poor function




Tendon laceration

- usually distal to skin cut

- need to retrieve tendons from palm

- A2 & A4 pulleys need preservation

- FDS & FDP both repaired if possible

- may only need one limb of FDS


Core Suture

- 2 x modified Kessler

- can use 2 x loop sutures to create 4 strand modified Kessler

- best to use prolene as will run easier than polyfilament suture


Peripheral suture

- 6.0 prolene running suture

- do dorsal aspect of tendon first, then core, then complete volar aspect

- very important for strength and allowing smooth glide


Zone 3


Delayed repair up to 3 weeks possible 

- lumbrical holds tendon 

- relatively good prognosis


Zone 4


Rigid compartment

- good result more difficult to achieve

- often complicated by median nerve injury

- should repair within 3 weeks to avoid myostatic muscle contraction


Zone 5 


Loose compartment

- good prognosis but associated nerve injuries important prognostically

- quality of repair not so important

- should repair within 3 weeks otherwise muscle contraction occurs






Thumb Radial Collateral Ligament

DefinitionRadial Collateral Ligament Avulsion


Also known as Chauffeur's Thumb




Much less common than UCL injuries




Rarely get soft tissue interposition




Chronic Instability


1.  Repair scarred ligament


2.  Reconstruct with graft


3.  Advance Abductor pollicis

- reinsert 10mm more distally on P1



Tumours of the Hand




Most common bony tumour of hand


Risk malignant transformation isolated lesion is < 2%

- more likely in long bones than hands




Proximal phalanx > middle





- multiple enchondromatosis

- risk of transformation 10 - 25%



- enchondromas and hemangiomas

- risk transformation close to 100%




Observation unless

- pain

- aggressive X-ray changes

- increased uptake on bone scan


Biopsy to exclude malignancy


Pathological fracture


Allow fracture to heal

- enchondroma does not resolve


Curette and bone graft at a later date


Epidermal Inclusion Cyst



Most frequent tumour around distal phalanx


M>F 2:1


Mean age 3rd decade




Likely traumatic 

- subcutaneous implantation of keratinising epithelium that continues to grow and produce keratin




Painless firm swellings

Most common volar aspect P3 index / middle




Round / oval lesion in P3

- thinning of cortex


Epidermal Inclusion Cyst




Fibrous capsule with keratin filled space

Squamous epithelium




Foreign Body Granuloma




Curettage and bone grafting (if bony)


Excision of lump

- recurrence very unusual







Most common tumour of hand

F > M

2nd - 4th decade







Mucoid degeneration of collagen tissue

Synovial herniation




1.  Dorsal

- scapho-lunate ligament 

- radial to EDC


2. Dorsal



3.  Volar

- scapho-trapezial joint 

- between FCR and APL


4. Retinacular

- along flexor sheaths 

- A1 / A2 pulley


5. Mucoid cyst

- associated with DIPJ OA and osteophyte


Recurrence rate


Dorsal 5%


Volar 20%




Most asymptomatic

- soft to firm

- 1-3 cm

- transilluminate


Mucoid cyst can groove nail bed

- important to remove osteophyte as well to prevent recurrence


McKeon J Hand Surg Am 2013

- association with ligamentous laxity and positive scaphoid shift test





- cavity lined by epithelium

- viscous mucin

- hyaluronic acid




Non - operative


Aspiration + HCLA injection

- usually needs multiple attempts


Khan J Hand Micosurg 2011

- aspiration plus steroid sucessful in 60%




Excision of ganglion

- find neck and dissect down to capsule

- remove capsular window


1.  Dorsal SLL



- radial side EDC

- protect SRN

- follow down

- excise neck and capsule




Edwards J Hand Surg Am 2009

- arthroscopic excision in 55 patients

- no recurrence


Kang J Hand Surg Am 2008

- RCT of 72 patients

- open v arthroscopic

- recurrence in 3/28 in arthroscopic

- recurrence in 2/23 in open


2.  Volar STJ



- between FCR and radial artery

- protect palmar branch median nerve





Nerve injury


Tendon damage



Giant cell tumour of tendon sheath



Benign tumour that arises from synovial tissues

- found near synovial-lined tendon sheaths


? Localised PVNS




2nd most common tumour of the hand


Age 40 - 60




Unknown origin

- theorized to be localized form PVNS

- similar histology

- however, lacks the inflammatory component of PVS 

- is considered by most to be a benign neoplasm

- may be a reactive process to minor trauma




Usually found near flexor tendons of hands & feet

- painless, firm and multi-lobulated mass

- usually on volar surface of finger


May present with

- lump

- loss of function




Can cause bone invasion and remodelling




Low signal on T1 and T2 and arising from the flexor sheath differentiates from sarcoma






Arise from synovial tissue

1. Well-circumscribed & discrete

2. Nodular & encapsulated


Doesn't invade surrounding tissues


Diagnostic colour

- yellow (cholesterol)

- brown (haemosiderin)

- grey (fibrous tissue)




Giant cell tumours prominent

- hyalinised CT

- sheets of round, oval & spindle cells

- focal collections of foam cells - xanthoma cells

- scattered haemosiderin




Marginal excision + bone currettage


Recurrence rate

- 10% - 20%

- to due to incomplete excision or spillage

- higher with bony involvement








Glomus Tumour







Hypertrophied glomus 

- coiled AV structure involved in temperature regulation

- > 50% in subungual region

- hand is the most common site

- usually under the nail plate





- pain

- exquisite tenderness

- cold intolerance




Ridging of nail bed

Blue spot at base of nail




Well defined radiolucent eccentric lesion

- base of P3

- < 1cm




Dark on T1 / Bright on T2




Remove nail plate

Longitudinal incision in nail bed

Excise tumour and repair nail bed

Replace nail







3rd - 6th decade




More frequent proximal


Most frequent

- thenar eminence 

- proximal phalanx




Non tender, mobile, soft


Does not transilluminate




Radiolucent on X ray

- Bufolini's sign




Negligible recurrence rate


Other Hand Tumours

1.  Foreign Body Granuloma




Curettage and bone graft (if bony)

Excision of lump 

- recurrence very unusual


2.  Osteochondroma




Cortical flow evident


3.  Brown's tumour




Primary hyperparathyroidism

Secondary hyperparathyroidism





Lytic lesion

- often seen in distal phalanx


4.  Nora's lesion


Bizarre parosteal osteochondroma


5.  Neurofibroma


Not possible to dissect free

- need to excise

- end to end anastomoses


6.  Synovial Chondromatosis


Diffuse swelling


May have calcification


7.  Juvenile Aponeurotic Fibroma


Benign fibrous tumour 

- occurs in the hands of children and young adults

- no gender predeliction 

- no tendency to involve ulnar digits as with Dupuytren's disease


Calcification is distinguishing feature

- locally infiltrative




Requires wide local excision without sacrifice of function

- local recurrence common


Metastatic fibrosarcoma after local recurrence of JAF reported

- careful follow up required


8.  Recurring Digital Fibrous Tumor of Childhood


Benign fibrous tumour that develops in fingers and toes in infants and children

- distinguished histologically by intracytoplasmic inclusion bodies within proliferating fibroblasts


Probable viral aetiology

- usually on several digits and intradermal

- recurrence rate up to 60%


Marginal excision if function compromised


No malignant potential 

- spontaneous regression described


9.  Malignant Tumours



- very rare 

- 50% lung cancer



- most common 

- chemo and radio insensitive

- only treatment is surgery


Osteosarcoma and Ewings

- quite rare


Dermatofibrosarcoma / Epitheloid Sarcoma / Synovial Sarcoma


Sarcoma Hand0001Sarcoma Hand0001





Benign tumour of Schwann cells




May have a positive Tinel's




Eccentrically located in nerve

- fascicles are splayed over it



- Malignant degeneration rare


Part of NF syndrome

- malignant degeneration may be as high as 15%




Surgical excision using microscope

- dissect fascicles off Schwannoma




Vascular Malformation



Dull ache and heaviness

- when arm dependent




Non operative


Compression garments




Nil recurrence with complete excisions


Not always possible

- multiple debulking +/- amputation