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Create a Free AccountSurgical Techniques
The Surgical Techniques section provides step-by-step details of various surgical procedures relevant to clinical practice. Articles discuss indications and contraindications, surgical anatomy, surgical technique, postoperative management, pearls and pitfalls, and complications; many articles also provide a case illustration.
Clarification of Extensor Tenotomy for Finger Deformities
This article clarifies the terminology and different applications of proximal Fowler extensor tenotomy and distal Dolphin extensor tenotomy. Although Fowler is a popular eponym for all finger extensor tenotomies, proximal Fowler tenotomy is specifically indicated for swan neck deformities, whereas distal Dolphin tenotomy is indicated for boutonniere deformities. For swan neck deformities with a distal interphalangeal joint extensor lag of greater than 40°, central slip tenotomy can be combined with terminal tendon imbrication or reinsertion.Surgical Management of Spastic Shoulder Deformities in Adult Patients
Spastic shoulder deformity in patients with upper motor neuron syndrome results from an imbalance of muscle forces about the shoulder girdle. In typical spastic deformities, the shoulder assumes an adducted and internally rotated posture. The severity of the deformity can range over a spectrum depending on the involved muscle groups, degree of spasticity, and presence of myostatic and/or joint contractures. Surgical options to correct the spastic shoulder deformity can be broadly classified as procedures for the functional versus nonfunctional shoulder or, in other words, preserved versus absent volitional motor control, respectively.Wide Awake Local Anesthesia No Tourniquet Endoscopic Cubital Tunnel Release
As demands for faster return to function, improvement in surgical scarring, and minimal disruption to personal schedule have increased, so also have the demands increased for minimally invasive procedures under the wide awake, local anesthetic, no tourniquet method. However, owing to the subcutaneous yet constrained position of the ulnar nerve at the elbow, wide-awake endoscopic cubital tunnel release has remained a technical challenge. We describe a 2-stage local anesthetic injection method that safely introduces local anesthetic within the cubital tunnel and simultaneously achieves comfort, sufficient visualization, and the ability to decompress multiple compression sites through a minimal incision.Kickstand Technique for Intraoperative Reduction of Fifth Metacarpal Neck Fractures
This article reports a novel intraoperative technique for the reduction of angulated metacarpal neck fractures undergoing retrograde headless intramedullary screw fixation. This technique is a useful reduction maneuver, especially for hand surgeons operating without a first assistant, because it eliminates the need to hold manual reduction during implant placement.The Iliac Crest Top Hat Bone Graft for Challenging Metacarpal Nonunion
Metacarpal nonunion is a rare outcome of metacarpal injury, and little has been published about its management. Care typically includes open reduction and internal fixation with a possible bone graft, similar to the treatment of other nonunions. However, there is no literature guidance if traditional methods do not lead to union. To improve the treatment of these recalcitrant metacarpal diaphyseal nonunions, we proposed a new surgical technique using a “top hat” bone graft harvested from the iliac crest.Long Arm Double Asymmetrical Sliding Flaps: A Technique to Treat Flexion Contractures of Digits
Contracture involving flexor aspect of the fingers is one of the common sequelae encountered after burns, infection, and trauma. In the treatment of contractures, the surgeon is often challenged by the paucity of skin flaps to cover the joint area. It is then covered with skin grafts, leading to recurrence. When there is a large discrepancy between the required and the available length of skin, traditional Z-plasty techniques fail to overcome this deficiency of the skin. We employ 2 long skin flaps to cover the joint, using all the available skin around the contracture and leaving areas on the sides of the digit that are covered by full-thickness skin grafts.Triangular Vascularized Free Fibula Flap for Massive Carpal Reconstruction
Massive carpal loss following trauma, tumor, or infection poses a difficult reconstructive challenge. There are limited reconstructive options for such cases, particularly when the metacarpal bases are also lost. We describe a method of carpal reconstruction using closing wedge osteotomies in a triangular vascularized free fibular flap, and a proposed algorithm for the management of metacarpal instability in this setting.Infantile Flexor Tendon Lacerations: Surgical Technique and Illustrative Case
Infantile flexor tendon lacerations are rare, with few cases reported. Surgical intervention in this age group is favorable, but there are several factors that add to the complexity of these injuries, such as small hand anatomy, frequent delays in diagnosis, and difficulties with postoperative rehabilitation. This article describes a 2-strand flexor tendon repair technique in a 10-month-old female infant.Transradial Amputation With Pedicled Pronator Quadratus Interposition and Advanced Neuroma-Prevention Techniques
Transradial amputation is a reconstructive option for upper-extremity trauma, infection, malignancy, and ischemia. The possible postoperative complications include residual radioulnar impingement and the development of a painful neuroma. In this report, a pedicled pronator quadratus flap interposition between the distal radius and ulna has been described. Additionally, various techniques to mitigate the development of symptomatic neuromas have been described.Fourth Dorsal Interosseous Muscle Transfer to Treat an Abducted Little Finger
A patient presented with an abducted little finger due to the avulsion of the third volar interosseous muscle. For treatment, we transferred the fourth dorsal interosseous muscle arising from the ulnar side of the fourth metacarpal bone to the lateral band of the little finger.Variant Plantaris Anatomy During Tendon Harvest
The plantaris tendon is commonly used in upper extremity reconstruction as a tendon graft. Variations in plantaris anatomy are described as terminating proximally into the calcaneal tendon or gastrocnemius in certain cases, making the tendon an unusable length as a graft. A case of anomalous attachment of the gastrocnemius muscle to the plantaris tendon is described. After division of this attachment through a counterincision, complete harvest of the plantaris tendon was possible. Further exploration when resistance is encountered in standard plantaris tendon harvest is recommended to avoid unnecessary abandonment of a plantaris harvest.Continuous External Tissue Expansion Closure Technique for Management of Forearm Compartment Syndrome Releases and Simple Upper-Extremity Wounds
Upper-extremity wounds from various etiologies such as trauma and fasciotomies can prove to be problematic for the upper-extremity surgeon. These defects can result in considerable morbidity often requiring prolonged wound care and the eventual use of skin grafting from a separate painful donor site. Tissue expansion takes advantage of the viscoelastic properties of skin to provide additional tissue for reconstruction. The authors present a technique using a continuous external tissue expansion device for closure of upper-extremity wounds.The Original Anatomic Reconstruction of Palmar and Dorsal Radioulnar Ligaments for Distal Radioulnar Joint Instability
Thirty years ago, the first anatomic reconstruction of the palmar and dorsal radioulnar ligaments for chronic distal radioulnar joint (DRUJ) instability was proposed by Sanders. In this surgical technique, the midpoint of a free tendon autograft is firmly secured in a bony tunnel at the ulnar fovea. The 2 graft limbs anchored at the fovea traverse the DRUJ and are securely woven into the periarticular soft tissues radially, reproducing the ligamentous anatomy while not overconstraining the joint.Open Reduction of Neglected Dislocations of the Proximal Interphalangeal Joint
Chronic unreduced dislocations of the proximal interphalangeal joint are uncommon and management principles for these injuries have not been defined. The dislocation can be volar or dorsal and closed reduction is rarely successful owing to soft tissue contractures. We describe an extensile midaxial approach to the proximal interphalangeal joint for release of contractures, open reduction, and repair of critical structures. A smaller contralateral incision can be made if needed for additional soft tissue release.Using Skin of the Cleft as Bipedicle flap for Release of the First Web Space in Congenital Central Deficiency
We are describing a new technique to utilize the skin of the cleft as a bipedicle flap to reconstruct and to widen the narrow first web space in congenital central deficiency. The skin of the cleft maintains its attachments on the dorsal and palmar aspects of the hand and the index finger is passed (tunneled) underneath it so that the skin of the cleft comes to occupy the first web space. This technique ensures maintenance of good blood supply of the skin of the cleft and a rounded edge of the first web without scars across it.Two-Screw Fixation of Scaphoid Waist Fractures
Optimal fixation strategy for scaphoid waist fractures remains a contentious topic with options including using a single screw, 2 screws, or a scaphoid plate. Biomechanical studies favor 2-screw fixation with regards to higher load to failure, load to 2-mm displacement, energy absorbed, rotational stability, and stiffness. Furthermore, recent retrospective studies found increased union rate with 2 screws. Although conclusive clinical data are lacking, 2-screw fixation of a scaphoid waist fracture may theoretically allow the patient to start earlier range of motion and strengthening with greater confidence.The Use of a Vascularized Distal Ulna Autograft for Complex Distal Radius Fracture Nonunions
In patients with segmental nonunion of the distal radius, the distal ulna and distal radioulnar joint may not be salvageable. As an alternative to a vascularized free fibula, a pedicled distal ulna vascularized graft is a useful salvage technique. The procedure relies on the vascular bundle of the pronator quadratus and the dorsal oblique arterial anastomosis between the anterior and posterior interosseous arteries running along the interosseous membrane as the pedicle. We present 3 patients who received a distal ulna vascularized graft with concomitant wrist arthrodesis for distal radius segmental nonunion after complex distal radius fracture.A Loop-Wiring Technique for Volarly Displaced Distal Radius Fractures With Small Thin Volar Marginal Fragments
Volarly displaced distal radius fractures (VD-DRFs) with small thin volar marginal fragments (VMFs) are challenging to treat with conventional volar locking plates (VLPs) alone. Several alternative surgical options have been reported to treat these fractures, including wire-loop fixation, spring-wire fixation, hook plates, headless compression screws, and tension-band wiring, but the optimal method is yet to be determined. We have devised a surgical treatment for these fractures, entitled the “loop-wiring method” in which VMFs are anatomically reduced and 2 0.043-inch K-wires are drilled through the volar tip of the fragment and introduced into the dorsal cortex.A Modified Surgical Approach Through Guyon’s Canal and the Proximal Ulnar Border of the Carpal Tunnel Allows for Safe Excision of the Hook of the Hamate
Hook of the hamate fractures can be treated by various methods including cast immobilization, open reduction, and internal fixation and excision. Usually, those individuals who elect for excision have acute fractures and need to return to sporting activity or work quickly or have nonunions with persistent symptoms. There is a paucity of descriptions in the literature and textbooks of a technique to safely excise the hook of the hamate. The authors present a method of safely exposing and removing the hook of the hamate by visualizing the potential structures at risk: the motor branch of the ulnar nerve, the ulnar digital nerve to the little finger, and the flexor tendons to the ring and little fingers by an approach through Guyon’s canal and the proximal ulnar border of the carpal tunnel.Pedicled Serratus Anterior Flap as an Alternative Muscle Target for Targeted Muscle Reinnervation in Transhumeral Amputees
Upper limb amputation is a universally devastating injury that results in substantial loss of function. Myoelectric prostheses represent a new generation of battery-powered programmable prostheses controlled by EMG signals. The aim of upper limb targeted muscle reinnervation (TMR) is to enhance the control of a myoelectric prosthesis by improving the number and quality of EMG signals that can be used to control prosthetic elbow, wrist, and hand movements. Current TMR techniques rely on preservation of parts of biceps and triceps to be used as reinnervated muscle targets.The Use of a Lumbrical Muscle Flap for Treatment of Chronic Tenocutaneous Fistula
Tenocutaneous fistulas after trauma or open release of the A1 pulley provide a unique reconstructive challenge. We describe the use of a lumbrical muscle turnover flap as a novel technique for managing these wounds and present its successful use in a patient with a tenocutaneous fistula after A1 pulley release of the middle finger. This flap provides a simple, local reconstructive option in patients with an array of palmar wounds that have failed conservative management.Zone II Flexor Tendon Repair by Modified Brunelli Pullout Technique and Very Early Active Mobilization
Numerous surgical methods and hand therapy protocols have been described in attempts to improve the functional outcome after flexor tendons repair in zone II. It is generally accepted that the best functional results can be obtained by combining a surgical technique, which provides enough strength of the repair, with very early postoperative mobilization. One of the methods to achieve these goals seems to be the Brunelli pullout technique, which moves the tension from the suture level to the finger pulp.Intermediate Cuneiform Resurfacing Arthroplasty for Combined Defects of the Sigmoid Notch and the Lunate Fossa of the Distal Radius
Posttraumatic comminution and bone loss at the sigmoid notch and the lunate fossa of the distal radius result in substantial impairment. Established salvage methods do not meet the physical demands of young patients. Replacement of the articular cartilage is challenging owing to the loss of 2 articular surfaces in different planes and the lack of a defined autogenous source to replace them simultaneously. The use of an intermediate cuneiform osteoarticular autograft to reconstruct the sigmoid notch and the lunate fossa is a new surgical technique that restores joint congruity and stability while allowing early active motion.Cerclage Fusion Technique for 4-Corner Arthrodesis
Four-corner arthrodesis is commonly performed for symptomatic scapholunate advanced collapse and scaphoid nonunion advanced collapse. Potential complications associated with current techniques include nonunion, hardware issues, and dorsal impingement. A method for achieving 4-corner arthrodesis with strong internal fixation and effective compression while avoiding dorsal and cartilage-bearing surfaces can maximize the benefits of the fusion while minimizing the aforementioned complications. We present a cerclage fusion technique for achieving 4-corner arthrodesis.Technique of Tendon Interposition Arthroplasty for Chronic Volar Dislocation of the Distal Radioulnar Joint
Volar distal radioulnar joint (DRUJ) dislocations are uncommon wrist injuries. Failed diagnosis or treatment can result in irreversible damage to the articulating surfaces and ultimately lead to chronic degenerative arthritis. When the DRUJ is reducible, and the cartilage is preserved, ligament reconstruction and ulnar osteotomy are surgical options for residual wrist instability or pain. When destruction of the native DRUJ has already occurred, surgical treatment options are salvage procedures.
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