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Of the carpometacarpal joints other than the thumb, the fifth metacarpal hamate joint is probably most subject to arthritic changes. This is probably because of its mobility and its border position, similar in some ways to characteristics of the thumb. The fifth metacarpal is probably not subject to the repetitive traumas of pinch and grasp that affect and amict the trapeziometacarpal joint, and it is rarely involved in rheumatoid arthritis to the point of operative intervention. More often, the problem is due to degenerative or posttraumatic changes (Figs. 46-1 A Figs. 46-1 B Fig. 46-1 C- D and 46-2 A-G). Injuries to the carpometacarpal joints of the index, middle, and ring fingers are usually due to direct trauma from crush, blast, or missile, and are much less likely to occur through repetitive trauma or from rheumatoid arthritis (Figs. 46-3 A-G). Joints can be tailored for arthrodesis by parallel saw cuts, sculpturing with a dental burr, or by slotted bone graft. Fixation may be either by plate and screws or by tension band wiring techniques.

Transverse metacarpal shaft fractures often result from crush or high-velocity injuries and are accompanied by severe swelling and soft tissue damage even when the fracture is closed (Figs. 16-1 A and 16-2 A). Even though the fracture configuation is stable, satisfactory reduction may not be possible because of soft tissue swelling (Fig. 16-1 B). Open reduction (Figs. 16-1 C, D) may be necessary. The surgeon must decide whether the additional dissection necesary for plate fixation is justified by the considerably increased stability achieved at the fracture site (Figs. 16-1 E-G). With less dissection, a tension band wire with or without neutralizing Kirschner wires may be considered for stabilization of a transverse or short oblique metacarpal diaphyseal fracture (Figs. 16-2 A-C).

Two patients of 56 who were reconstructed with polyurethane-coated implants developed breast pain as a late complication and eventually required implant removal for relief. Although the cause of pain was not proven, it may have been due to contracture of the fibrous capsule which formed between the polyurethane and the shell of the implant. The complication of late pain has not been stressed previously in the literature on reconstruction.

Reconstruction of acquired traumatic amputations at the level of the middle third of the thumb may be accomplished by pollicization of an injured or partially amputated digit, the cocked-hat flap, metacarpal lengthening, or osteoplastic reconstruction techniques that involve a bone graft covered by a tubed pedicle flap and an island pedicle flap. Particularly in the absence of another injured or partially amputated digit, metacarpal lengthening followed by a second-stage bone grafting procedure and deepening of the web space with phalangization of the remaining thumb at the same time provides an excellent method of managing this devastating injury (Figs. 57-1 A Figs. 57-1 B Figs. 571-1 C Figs. 571-1 D-N). The purpose of this operation is to restore length and mobility to oppose other digits. In addition, the reconstructed thumb should have adequate sensation, stability to allow strong resistance without collapse, and freedom from pain.

The lag screw is the basic implant for stable interfragmental fixation. A 1.5 mm (0.062 or 1/16) cortical screw has the same thread diameter as the largest Kirschner wire used in the United States. The thread diameter of a 2.0 mm cortical screw is equal to the diameter of the largest Kirschner wire used in Europe. From this, it can be seen that cortical screws designed for the hand are only slightly larger, in general, than Kirschner wires that might be chosen for the same fixation. Whereas Kirschner wires can only splint the fracture and provide coaptive fixation, screws can provide firm fixation by compression. Screws, in addition, can be measured precisely for the desired length required and do not protrude through the bone.

Radial styloid fractures occur following forced radial deviation. They were called “backfire fractures” in the period when they were sustained by turning the crankshafts of old cars to ignite the sparkplugs. Most radial styloid fractures are isolated injuries, are undisplaced, and require only protection until they heal. If displacement occurs in this intraarticular fracture, it must be restored in order to preserve joint congruity. If such a fracture requires open reduction, screw fixation is an excellent means of stabilization (Fig. 36-1 A Fig. 36-1 B Fig. 36-1 C Fig. 36-1 D E-Q and 36-2 A-D).

The most common secondary phalangeal deformity in our experience results from a long oblique or spiral phalangeal diaphyseal fracture. Deformities may include shortening, rotation, angulation, and combinations of these. There may be compromised digital motion as a result of blocking of the proximal interphalangeal joint by the distal portion of the proximal fragment or as a result of tendon or capsular adhesions (Figs. 55-1 A-K).

An axial force applied to the digit with a slight volar vector can cause an oblique shear and a displaced intraarticular fracture of the dorsal lip of the proximal portion of the middle phalanx, with subluxation of the remaining portion of the middle phalanx volar to the proximal phalanx (Figs. 30-1 A, Figs. 30-1 B). Again, joint congruity and stability must be restored for an optimal result. A dorsal approach provides optimal exposure. The joint can be inspected by incising on either side of the extensor slip adjacent to the lateral bands. Inspection of the fracture site allows one to clean it of debris and elevate displaced fragments and is often necessary to obtain a congruent reduction. One or more 1.5 mm cortical lag screws provide excellent stability in such cases (Figs. 30-1 C, Figs. 30-1 D).

Marginal fractures at the base of the proximal phalanx result from avulsion of the collateral ligament or from direct impact of the phalangeal base against the metacarpal head. Such fractures may also occur with hyperextension forces at the metacarpophalangeal joint, such as those that cause complex dislocation.

Arthroplasty has not been refined sufficiently to achieve a predictably good result in the distal interphalangeal joint of the fingers. Furthermore, distal interphalangeal motion plays a relatively small role in the overall function of a reconstructed hand. Arthrodesis has been predictable and effective for salvaging those situations with instability, destruction, or deformity of the distal interphalangeal joint (Figs. 54-1 A Figs. 54-1 B Figs. 54-1 C Figs. 54-1 D-E).

Index metacarpophalangeal joint arthrodesis may be a valuable method of reconstruction and salvage for a damaged or deformed joint. This is particularly true if the other interphalangeal joints are not involved. Of the four fingers, the index contributes the least to grip, as anyone who swings a hammer or tennis racquet can attest, and functions primarily as an opposer of the thumb in pulp, lateral, and chuck pinch. It can accomplish all these tasks with a minimum of metacarpophalangeal joint motion. The advantages of metacarpophalangeal joint arthrodesis over arthroplasty are stability, strength, and power. Fusion will actually improve pinch and grip for the unstable index finger, provided the proximal interphalangeal joint is normal. An additional advantage of arthrodesis of the metacarpophalangeal joint of the index finger is that it will protect arthroplasties of the remaining fingers from ulnarly directed forces during pinch and grasp. This shielding by the index metacarpophalangeal joint may prolong the life of the metacarpophalangeal joint arthroplasties of the remaining fingers.

Whenever more than one metacarpal is fractured and displaced, each fracture compounds the instability, deformity, and muscular imbalance created by the other. In such injuries, it is particularly important to restore anatomy and stability to avoid permanent deformity, dysfunction, and stiffness (Figs. 20-1 A Figs. 20-1 A Figs. 20-1 C Figs. 20-1 D, 20-2 A-E, 20-3 A-G, 20-4 A-H). If the fractures are not adequately reduced, as the metacarpals shorten, the metacarpophalan-geal joints creep into extension and gradually stiffen there, with loss of the longitudinal arch. The surrounding soft tissue becomes indurated and edematous, and fracture disease, as described in Chapter 3, can occur. Whenever there is marked dorsal angulation of a metacarpal fracture, the adjacent metacarpal bases should be inspected for fracture or dislocation (Figs. 20-3 A-G).

Bennett described the fracture-dislocation of the thumb metacarpal that bears his name in 1882 and again in 1886 (Fig. 10-1 A). When this injury occurs, the abductor pollicis longus pulls the thumb metacarpal proximally, dislocating it and causing an adducted posture of the thumb and consequent narrowing of the thumb-web space. Should the fracture-dislocation remain in this position or be inadequately reduced, circumduction of the trapeziometacarpal joint will be compromised, and painful posttraumatic arthritis can be anticipated later. Each of these unfortunate conditions will compromise pinch, grasp, and grip. Accurate restoration of the joint surface of the metacarpal is necessary if one is to avoid these troublesome consequences.

The main blood supply of the sternocleidomastoid muscle enters it above from branches of the superior thyroid, posterior auricular and occipital arteries. The lower third is supplied by a branch from the transverse cervical artery and at this level there are few if any musculocutaneous branches. Long skin flaps with or without the underlying muscle should be checked with fluorescein before transfer.

Fresh cadaver nerves were examined by serial cross-sections and microdissection with the operating microscope. The findings are compared with those of previous authors, primarily Sydney Sunderland. Our study confirms and amplifies Sunderland's findings: although it is true that funicular plexus formation and interchange takes place in the nerves of the human forearm, these connections are not of such a degree as to preclude operative procedures such as intraneural neurolysis, fascicular nerve repair, and interfascicular nerve grafting. Individual branches and bundles can be identified and traced within the main nerve trunk for considerable distances without significant trauma to conducting fibers. This arrangement lends itself to the application of modern microneurosurgical techniques. Clinical applications of these findings in the repair, lysis, and grafting of the major nerves of the forearm are described. The possibility of using such branches as the dorsal cutaneous branch of the ulnar nerve (if irreparably damaged) as a donor nerve for grafting is noted.

The vast majority of hand fractures can and should be managed by simple protection, closed reduction and protection, or closed reduction and internal fixation with percutaneous Kirschner wires. Nevertheless, some fractures will require open reduction because of unstable configuration, unsatisfactory reduction, or both. Traditionally, Kirschner wires have been the most common form of internal fixation when open reduction is performed in the hand. Methods using Kirschner wires remain the benchmark by which all other techniques of fracture fixation should be measured.

In 1837, John Rhea Barton of Philadelphia described both the dorsal and volar (Fig. 35-1) radiocarpal fracture-dislocations. Thomas later included the volar radiocarpal fracture- dislocation in his classification of Smith's fractures as a Smith Type II injury. This fracture can be very unstable and intraarticular and often must be fixed to achieve optimal stability and restoration of joint congruity. If the fracture associated with this carpal dislocation is a single or major fragment, it may be secured with lag screws (Fig. 35-2 A Fig. 35-2 C-F). Insertion of a T-plate or two one-quarter semitubular plates is also an excellent method of firmly securing an anatomic reduction of this fracture (Figs. 35-3 A-J and 35-4 A-L).

In 1847, Robert William Smith, Colles' protege, described the less common analog of the Colles' fracture (Fig. 34-1). A classic Smith's fracture usually is managed by closed reduction, with dorsiflexion of the wrist and supination of the forearm. Occasionally, open reduction and internal fixation may be necessary if an adequate reduction cannot be achieved or maintained by closed methods ((Fig. 34-2 A) (Fig. 34-2 B) (Fig. 34-2 C) (Fig. 34-2 D)).

Transverse phalangeal fractures result from direct blows to the digits or severe flexion-extension forces. Not infrequently, there is an open wound and an accompanying tendon injury. Transverse phalangeal shaft fractures may be completely displaced and accompanied by severe swelling, and closed reduction becomes difficult if not impossible. This situation is an indication for open reduction and internal fixation. Angulation is volar and may be quite deceptive and, therefore, easy to underestimate as the transverse fracture approaches the metacarpophalangeal joint. It is extremely important in such injuries to obtain a true lateral x-ray of the digit and to measure the actual angulation.

Our experiences with the reconstruction of lips by the use of innervated myocutaneous flaps is described. We present the technique and some illustrative cases.

When the flexor pronator origins are transplanted proximally on the humerus, Campbell's modification of Steindler's flexorplasty may be used. In this modification, the medial epicondyle is excised with the flexor pronator origin and secured to a prepared portion of the anterior surface of the distal humerus (Figs. 62-1 A Figs. 62-1 B Figs. 62-1 C-G).

Rupture of the flexor digitorum profundus occurs because of forceful extension of the distal interphalangeal joint while the flexor digitorum profundus is actively contracting. This is a frequent football injury and is usually caused by grabbing an opponent's jersey. The ring finger is most often involved and is in special jeopardy because the small finger easily slips from the grasp and fully flexes, causing the ring finger to absorb all of the force applied to the ulnar innervated profundi.

When there are more than one fracture in the hand that are either unstable, displaced, or both, the hand is in particular jeopardy of becoming stiff, deformed, and dysfunctional. Occasionally, this can occur with closed injuries, and, in such instances, it is more common with crush and blast type injuries. We showed examples of multiple metacarpal fractures in Chapter 20, and in Chapter 28 we showed an example of a bicondylar phalangeal fracture along with another proximal phalanx fracture of an adjacent finger. Polyfractures in the hand and wrist are more common in open injuries, which are demonstrated in Chapter 39. Anatomic restoration and stabilization of bony architecture in these instances are important not only in securing bony union but also as an adjunct in soft tissues healing and healing of other deep structures that require repair or reconstruction. In this chapter, we show examples of both a metacarpal and a phalanx being fractured in the same hand in a closed injury. Stable fixation leading to good stability and pain control is certainly an advantage for implementation of early and aggressive active range of motion and institution of measures against swelling, such as the Jobst pump, isotoner glove, and Coban wrapping (Fig. 37-1 A Fig. 37-1 B Fig. 37-1 C Fig. 37-1 D and 37-2 A-D).>

In 1910, Kienbock, an Austrian radiologist, described the disease of the lunate that bears his name. It is thought to be caused most often by continuing microtrauma which interrupts the circulation and causes avascular necrosis. In most instances, the lunate receives sufficient blood supply both dorsally and volarly so that if one of these sources of blood supply is interrupted, the other will still provide adequate circulation. In some patients, however, either one or the other of the sources of blood supply is predominant, and if that one is interrupted, avascular necrosis of the lunate results.

In 1910, Rolando described a T-pattern or Y-pattern fracture at the base of the thumb metacarpal that involved both a volar lip and a large dorsal lip fragment. The fracture configuration still bears his name and can be considered a type of comminuted Bennett's fracture (Fig. 12-1 A).

When a butterfly fragment is present, a three-part fracture exists, and the problems of reduction and fixation become more challenging than with the spiral oblique fracture only. Each side of the butterfly must be fixed to its adjacent fragment before the reduction will be stable. Occasionally, it is possible to get more than one screw into each side of the butterfly fragment (Figs. 26-1 A-G), but this is not common in such small bones as the phalanges. If possible when only one screw can be inserted, it should be positioned to bisect a perpendicular to the fracture and a perpendicular to the long axis of the bone. A neutralization plate is used to protect the two screws from rotational forces (Figs. 26-2 A-K). Where there is more comminution and fragments are small, the ideal fixation techniques cannot be used. The ingenuity of the surgeon is taxed by such situations, and this is where interosseous wiring and tension band techniques may save the day. Although compression may be impossible, fixation may be stable and the overall result may be correspondingly improved.

Condylar fractures result from jammed fingers and may involve one or both condyles of the distal portion of either the proximal or middle phalanx. The patient may often have very little loss of motion, and a high Degree of suspicion is necessary to make the diagnosis (Figs. 27-1 A, B). Oblique roentgenographs of the finger must be obtained to properly demonstrate the fracture and its Degree of displacement (Fig. 27-1 C).

Spiral and oblique metacarpal shaft fractures are caused by torquing forces. These fractures tend to shorten and rotate but, on occasion, may angulate (Figs. 17-1 A, B). The border metacarpals are less stable and become deformed more than the internal metacarpals when fractured individually because the internal metacarpals are protected on either side by an intact metacarpal pillar whose deep transverse metacarpal ligaments tether the distal fragment. Five Degrees of malrotation in a metacarpal fracture can cause 1.5 cm of digital overlap. Malrotation causing digital overlap must be corrected (Fig. 17-1 C).

Occasionally, a dorsal oblique hamate fracture will occur in association with a dorsal dislocation of the fifth metacarpal base. This fracture configuration renders the fracture- dislocation unstable. Routine posteroanterior, lateral, and oblique x-ray views of the hand should be obtained ((Figs. 14-1 A) (Figs. 14-1 B) Figs. 14-1 C). An anteroposterior full supination view and oblique views, especially a 30 Degrees pronated lateral view (Fig. 14-1 C), may better delineate the fracture and the amount of displacement. Ulnar nerve motor function should be assessed carefully before and after surgery because of the proximity of the deep motor branch to the ulnar side of the hamate. A dorsal incision is used over the metacarpal hamate joint.

Although most attention to the harmful effects of finger sucking by infants has been on the potential dental deformities, finger deformities also occur. The three cases presented in this article describe radial rotation of the index finger as a result of persistent finger sucking. In the majority of cases rotational deformities spontaneously resolve once finger sucking ceases. In a few cases, particularly when the habit is unduly prolonged, deformities may persist and cause functional impairment. In these patients surgical intervention is indicated. In our cases the rotational digital deformities were treated successfully by rotational osteotomy of either the metacarpal or the proximal phalanx.

Arthrodesis of the trapeziometacarpal joint of the thumb may be indicated for posttraumatic arthritis, osteoarthritis, rheumatoid arthritis, or chronic subluxation or dislocation. The advantages of arthrodesis of this joint over arthroplasty are stability, strength, power, and endurance. There should be satisfactory function of the two distal joints of the thumb, since their motion must compensate for the loss at the proximal fused joint. Marked trapezioscaphoid arthritis is a contraindication to the procedure, although mild arthritis is not.

Thumb adduction contractures result from a variety of conditions that cause either direct scarring or scarring secondary to ischemia and subsequent contracture in the thumb-web space. Severe or prolonged edema and reflex sympathetic dystrophy can generate or contribute to the problem.

Arthrodesis is an excellent and effective way to reconstruct the deformed, destroyed, or unstable interphalangeal joint of the thumb. Position can be from 0 to 30 degrees of flexion and is adjusted to suit the needs of the individual patient. Methods of stable fixation of thumb interphalangeal joint arthrodesis include screw (Figs. 51-1 A Figs. 51-1 B Figs. 51-1 C Figs. 51-1 D) and tension band wire techniques. Tension band wire technique was demonstrated in Figures 50-2 A-K. When the screw is inserted retrograde, it is important to countersink the distal portion of the distal phalanx in order to better accommodate the screw head.

Fixing the thumb in a position of palmar abduction is an operation of last resort. It is reserved for those cases of paralysis in which there are no transferable muscles, where there are spastic paralysis and adduction contracture, and where there is severely scarred thumb-web space but in which there is still some chance for useful hand function if the thumb can be placed in an abducted position (Figs. 48-1 A Figs. 48-1 B Figs. 48-1 C-I).

Occasionally, internal fixation may be appropriate in securing reconstructive procedures in children. As in fractures, it is important to avoid disturbing the epiphyseal growth plate either during the dissection of soft tissues or during the application of fixation (Figs. 60-1 A Figs. 60-1 B Figs. 60-1 C Figs. 60-1 D Figs. 60-1 E-F and 60-2 A-F).

An unstable dorsal fracture-dislocation of the proximal interphalangeal joint is caused by a linear longitudinal compression force on the finger with a simultaneous hyperextension stress at the proximal interphalangeal joint. Although a variety of injuries may produce this fracture, the most common cause in our practice is catching a ball. If the fracture involves 40 percent of the articular surface or more, the middle phalanx loses not only the support of the volar margin of the middle phalanx but also that of the collateral ligaments and the volar plate complex, which are attached to this fragment. The middle phalanx, therefore, loses its buttressing effect and becomes dorsally displaced, unstable, and difficult if not impossible to reduce by closed methods (Fig. 29-1 A).

The tension band principle states that if a column is subjected to eccentric loading, there are not only axial compressive forces but also additional bending forces that give rise to further compressive stresses and tensile stresses. In our example, the resultant compressive stresses equal 110 kilopounds/cm2 and the tensile stresses equal 90 kilopounds/cm2 (Fig. 7-1 A). These bending stresses can be neutralized by a chain, which represents a tension band. The resultant compression on the column now corresponds to the pressure exerted by the tension band placed on the tension side of the column at an equal distance from the center of the column as the 100 kilopound weight on the compression side. The compression forces have now been neutralized by the tension forces, and the compression on the column equals 200 kilopounds/ cm2 (Fig. 7-1 B). Therefore eccentric bending or compressive stresses can be neutralized by similar tension forces eccentrically placed on the opposite side. The result is a summation of the forces in compression on the column or structure involved. In this case, we are talking about bone.

Displaced spiral or oblique metaphyseal metacarpal base fractures are often unstable, displaced, and dorsally angulated. They often require internal fixation in order to obtain and maintain reduction. An open procedure may be preferred over a percutaneous procedure to avoid penetration of extensor tendons and other deep structures. Small lag screws may be placed with little or no more dissection than necessary for Kirschner wires and provide more secure fixation. A single screw may be sufficient to secure the reduction, particularly in an internal third or fourth metacarpal, which is protected by adjacent intact or reconstructed metacarpal pillars. When possible, two screws are preferred to one, particularly in the border second and fifth metacarpals, where rotational stresses are greater than those of the internal metacarpals (Figs. 15-1 A Figs. 15-1 B Figs.C-D and 15-2 A-C). A plate may be used in the tension band (compression) mode for a transverse or short oblique fracture or in the neutralization mode to protect an interfragmentary lag screw (Figs. 15-3 A, B). Fig. 15-1 A 27-year-old haberdasher sustained spiral oblique fractures at the bases of his second and third metacarpals sliding into second base while playing softball. (Figs. A-D are reproduced with permission from Freeland, A.E. and Jabaley, M.E.: Management of Hand Fractures by Stable Fixation, in Habal, M.B., et al (Eds.): Advances in Plastic and Reconstructive Surgery, Vol. 2, copyright © 1986 by Year Book Medical Publishers, Inc., Chicago.) Figs

The AO/ ASIF group developed the principles of internal fixation advanced by Lambotte and Danis that ultimately revolutionized internal fixation of the skeleton. Their choices of design, metals, and methods of application are based upon sound engineering and biomechanical principles, physical laws, and metallurgical biocompatibility, and much of the basic scientific research was performed at their Laboratory for Experimental Research in Davos, Switzerland. The AO/ ASIF group defined the principles discussed in Chapter 3. They emphasized preoperative planning as a method of achieving optimal operative results and documentation so that results could be analyzed.

The arc of flexion of the thumb is such that it normally opposes most easily to the long finger. In mutilating injuries of the hand in which the thumb and small finger are the only remaining normal or functional digits, a rotational osteotomy performed at the base of the fifth metacarpal may considerably improve pinch and grasp by allowing the remaining digital tips to oppose more easily. This osteotomy is done through a dorsal longitudinal incision, which may be curved or darted at the surgeon's discretion. The osteotomy is performed at the junction of the proximal metaphysis and the diaphysis, where secure fixation may be provided by a T-plate placed in the tension band (compression) mode (Figs. 59-1 A Figs. 59-1 B Figs. 59-1 C Figs. 59-1 D Figs. 59-1 E-L).