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Surgery_Schwartz_12802 | Surgery_Schwartz | even before degenerative disease sets in. Also, many corticosteroid injections are suspensions, not solutions; injected corticosteroid will remain in the joint space and can be seen as a white paste if surgery is performed on a joint that has been previously injected.Small Joints (Metacarpophalangeal and Interphalangeal)When conservative measures fail, two principal surgical options exist: arthrodesis and arthroplasty. The surgeon and patient must decide together as to whether conservative measures have failed. Surgery for arthritis, whether arthrodesis or arthroplasty, is performed for the purpose of relieving pain. Arthrodesis, fusion of a joint can be performed with a tension band or axial compression screw techniques.54 Both methods provides excel-lent relief of pain and is durable over time. However, it comes at the price of total loss of motion.Silicone implant arthroplasty has been available for over 40 years.55 Rather than a true replacement of the joint, the silicone implant | Surgery_Schwartz. even before degenerative disease sets in. Also, many corticosteroid injections are suspensions, not solutions; injected corticosteroid will remain in the joint space and can be seen as a white paste if surgery is performed on a joint that has been previously injected.Small Joints (Metacarpophalangeal and Interphalangeal)When conservative measures fail, two principal surgical options exist: arthrodesis and arthroplasty. The surgeon and patient must decide together as to whether conservative measures have failed. Surgery for arthritis, whether arthrodesis or arthroplasty, is performed for the purpose of relieving pain. Arthrodesis, fusion of a joint can be performed with a tension band or axial compression screw techniques.54 Both methods provides excel-lent relief of pain and is durable over time. However, it comes at the price of total loss of motion.Silicone implant arthroplasty has been available for over 40 years.55 Rather than a true replacement of the joint, the silicone implant |
Surgery_Schwartz_12803 | Surgery_Schwartz | time. However, it comes at the price of total loss of motion.Silicone implant arthroplasty has been available for over 40 years.55 Rather than a true replacement of the joint, the silicone implant acts as a spacer between the two bones adja-cent to the joint. This allows for motion without bony contact that would produce pain. Long-term studies have shown that all implants fracture over time, but usually continue to preserve motion and pain relief.56In the past 15 years, resurfacing implant arthroplasties have become available for the small joints of the hand. Multiple different materials have been used to fabricate such implants. These are designed to behave as a true joint resurfacing (as knee and hip arthroplasty implants are) and have shown promising outcomes in shortand intermediate-term studies.56 Neither the silicone nor the resurfacing arthroplasties preserve (or restore) full motion of the MP or PIP joints.WristThe CMC joint of the thumb, also called the basilar joint, is | Surgery_Schwartz. time. However, it comes at the price of total loss of motion.Silicone implant arthroplasty has been available for over 40 years.55 Rather than a true replacement of the joint, the silicone implant acts as a spacer between the two bones adja-cent to the joint. This allows for motion without bony contact that would produce pain. Long-term studies have shown that all implants fracture over time, but usually continue to preserve motion and pain relief.56In the past 15 years, resurfacing implant arthroplasties have become available for the small joints of the hand. Multiple different materials have been used to fabricate such implants. These are designed to behave as a true joint resurfacing (as knee and hip arthroplasty implants are) and have shown promising outcomes in shortand intermediate-term studies.56 Neither the silicone nor the resurfacing arthroplasties preserve (or restore) full motion of the MP or PIP joints.WristThe CMC joint of the thumb, also called the basilar joint, is |
Surgery_Schwartz_12804 | Surgery_Schwartz | studies.56 Neither the silicone nor the resurfacing arthroplasties preserve (or restore) full motion of the MP or PIP joints.WristThe CMC joint of the thumb, also called the basilar joint, is another common location of arthritis pain. Pain in this joint par-ticularly disturbs function because the CMC joint is essential for opposition and cylindrical grasp. Patients will typically com-plain of pain with opening a tight jar or doorknob and strong pinch activities such as knitting. Conservative management is used first, as described earlier. Prefabricated, removable thumb spica splinting can provide excellent relief of symptoms for many patients.Multiple surgical options exist for thumb CMC arthritis. Many resurfacing implants have been used in the past; often they have shown good shortand intermediate-term results and poor long-term results. Resection of the arthritic trapezium provides excellent relief of pain; however, many authors feel that stabi-lization of the thumb metacarpal base | Surgery_Schwartz. studies.56 Neither the silicone nor the resurfacing arthroplasties preserve (or restore) full motion of the MP or PIP joints.WristThe CMC joint of the thumb, also called the basilar joint, is another common location of arthritis pain. Pain in this joint par-ticularly disturbs function because the CMC joint is essential for opposition and cylindrical grasp. Patients will typically com-plain of pain with opening a tight jar or doorknob and strong pinch activities such as knitting. Conservative management is used first, as described earlier. Prefabricated, removable thumb spica splinting can provide excellent relief of symptoms for many patients.Multiple surgical options exist for thumb CMC arthritis. Many resurfacing implants have been used in the past; often they have shown good shortand intermediate-term results and poor long-term results. Resection of the arthritic trapezium provides excellent relief of pain; however, many authors feel that stabi-lization of the thumb metacarpal base |
Surgery_Schwartz_12805 | Surgery_Schwartz | results and poor long-term results. Resection of the arthritic trapezium provides excellent relief of pain; however, many authors feel that stabi-lization of the thumb metacarpal base is necessary to prevent shortening and instability.57 Some surgeons have demonstrated excellent long-term results from resection of the trapezium without permanent stabilization of the metacarpal base.58 For both of these operations, the thumb base may not be sufficiently stable to withstand heavy labor. For these patients, fusion of the thumb CMC in mild opposition provides excellent pain relief and durability. The patient must be warned preoperatively that he will not be able to lay his hand flat after the surgery. This loss of motion can be problematic when the patient attempts to tuck in clothing or reach into a narrow space.59Degenerative change of the radiocarpal and midcarpal joints is often a consequence of scapholunate ligament injury. Often the initial injury goes untreated, with the patient | Surgery_Schwartz. results and poor long-term results. Resection of the arthritic trapezium provides excellent relief of pain; however, many authors feel that stabi-lization of the thumb metacarpal base is necessary to prevent shortening and instability.57 Some surgeons have demonstrated excellent long-term results from resection of the trapezium without permanent stabilization of the metacarpal base.58 For both of these operations, the thumb base may not be sufficiently stable to withstand heavy labor. For these patients, fusion of the thumb CMC in mild opposition provides excellent pain relief and durability. The patient must be warned preoperatively that he will not be able to lay his hand flat after the surgery. This loss of motion can be problematic when the patient attempts to tuck in clothing or reach into a narrow space.59Degenerative change of the radiocarpal and midcarpal joints is often a consequence of scapholunate ligament injury. Often the initial injury goes untreated, with the patient |
Surgery_Schwartz_12806 | Surgery_Schwartz | into a narrow space.59Degenerative change of the radiocarpal and midcarpal joints is often a consequence of scapholunate ligament injury. Often the initial injury goes untreated, with the patient believ-ing it is merely a “sprain”; the patient is first diagnosed with the initial injury when he presents years later with degenerative changes.Degenerative wrist changes associated with the scaph-olunate ligament follow a predictable pattern over many years, called scapholunate advanced collapse or SLAC wrist.60 Because of this slow progression (Fig. 44-17A), patients can usually be treated with a motion-sparing procedure. If there is truly no arthritic change present, the scapholunate ligament can be reconstructed.If arthritis is limited to the radiocarpal joint, two motion-sparing options are available. The proximal carpal row (scaphoid, lunate, and triquetrum) can be removed (proximal row carpectomy [PRC]). The lunate facet of the radius then Brunicardi_Ch44_p1925-p1966.indd | Surgery_Schwartz. into a narrow space.59Degenerative change of the radiocarpal and midcarpal joints is often a consequence of scapholunate ligament injury. Often the initial injury goes untreated, with the patient believ-ing it is merely a “sprain”; the patient is first diagnosed with the initial injury when he presents years later with degenerative changes.Degenerative wrist changes associated with the scaph-olunate ligament follow a predictable pattern over many years, called scapholunate advanced collapse or SLAC wrist.60 Because of this slow progression (Fig. 44-17A), patients can usually be treated with a motion-sparing procedure. If there is truly no arthritic change present, the scapholunate ligament can be reconstructed.If arthritis is limited to the radiocarpal joint, two motion-sparing options are available. The proximal carpal row (scaphoid, lunate, and triquetrum) can be removed (proximal row carpectomy [PRC]). The lunate facet of the radius then Brunicardi_Ch44_p1925-p1966.indd |
Surgery_Schwartz_12807 | Surgery_Schwartz | are available. The proximal carpal row (scaphoid, lunate, and triquetrum) can be removed (proximal row carpectomy [PRC]). The lunate facet of the radius then Brunicardi_Ch44_p1925-p1966.indd 194520/02/19 2:49 PM 1946SPECIFIC CONSIDERATIONSPART IIarticulates with the base of the capitate, whose articular surface is similar in shape to that of the base of the lunate. Studies have shown maintenance of approximately 68% of the wrist flexion-extension arc and 72% of hand strength compared to the con-tralateral side.61 Alternatively, the scaphoid can be excised, and four-bone fusion (lunate, capitate, hamate, and triquetrum) can be performed. This maintains the full length of the wrist and the lunate in the lunate facet of the radius. Some series have shown better strength but less mobility with this technique, oth-ers have shown equivalent results to the PRC.62 The four-bone fusion does appear to be more durable for younger patients and/or those who perform heavy labor.If the patient | Surgery_Schwartz. are available. The proximal carpal row (scaphoid, lunate, and triquetrum) can be removed (proximal row carpectomy [PRC]). The lunate facet of the radius then Brunicardi_Ch44_p1925-p1966.indd 194520/02/19 2:49 PM 1946SPECIFIC CONSIDERATIONSPART IIarticulates with the base of the capitate, whose articular surface is similar in shape to that of the base of the lunate. Studies have shown maintenance of approximately 68% of the wrist flexion-extension arc and 72% of hand strength compared to the con-tralateral side.61 Alternatively, the scaphoid can be excised, and four-bone fusion (lunate, capitate, hamate, and triquetrum) can be performed. This maintains the full length of the wrist and the lunate in the lunate facet of the radius. Some series have shown better strength but less mobility with this technique, oth-ers have shown equivalent results to the PRC.62 The four-bone fusion does appear to be more durable for younger patients and/or those who perform heavy labor.If the patient |
Surgery_Schwartz_12808 | Surgery_Schwartz | with this technique, oth-ers have shown equivalent results to the PRC.62 The four-bone fusion does appear to be more durable for younger patients and/or those who perform heavy labor.If the patient presents with pancarpal arthritis or motion-sparing measures have failed to alleviate pain, total wrist fusion is the final surgical option. The distal radius is fused, through the proximal and distal carpal rows to the third metacarpal, typi-cally with a dorsal plate and screws. Multiple long-term studies have shown excellent pain relief and durability; this comes at the cost of total loss of wrist motion. This is surprisingly well tolerated in most patients, especially if the other hand/wrist is unaffected. The only activity of daily living that cannot be done with a fused wrist is personal toileting.Rheumatoid ArthritisRheumatoid arthritis (RA) is an inflammatory arthritis that can affect any joint in the body. Inflamed synovium causes articular cartilage breakdown with pain and | Surgery_Schwartz. with this technique, oth-ers have shown equivalent results to the PRC.62 The four-bone fusion does appear to be more durable for younger patients and/or those who perform heavy labor.If the patient presents with pancarpal arthritis or motion-sparing measures have failed to alleviate pain, total wrist fusion is the final surgical option. The distal radius is fused, through the proximal and distal carpal rows to the third metacarpal, typi-cally with a dorsal plate and screws. Multiple long-term studies have shown excellent pain relief and durability; this comes at the cost of total loss of wrist motion. This is surprisingly well tolerated in most patients, especially if the other hand/wrist is unaffected. The only activity of daily living that cannot be done with a fused wrist is personal toileting.Rheumatoid ArthritisRheumatoid arthritis (RA) is an inflammatory arthritis that can affect any joint in the body. Inflamed synovium causes articular cartilage breakdown with pain and |
Surgery_Schwartz_12809 | Surgery_Schwartz | toileting.Rheumatoid ArthritisRheumatoid arthritis (RA) is an inflammatory arthritis that can affect any joint in the body. Inflamed synovium causes articular cartilage breakdown with pain and decreased range of motion. The goals of hand surgery for the RA patient are relief of pain, improvement of function, slowing progression of disease, and improvement in appearance.63 In addition, swelling of the joint due to the inflammation can cause laxity and even failure of the collateral ligaments supporting the joints. Recent advances in the medical care of RA have made the need for surgical care of these patients far less common than in previous decades.MP joints of the fingers are commonly affected. The base of the proximal phalanx progressively subluxates and eventu-ally dislocates volarly with respect to the metacarpal head. The collateral ligaments, particularly on the radial side, stretch out and cause the ulnar deviation of the fingers characteristic of the rheumatoid hand. In more | Surgery_Schwartz. toileting.Rheumatoid ArthritisRheumatoid arthritis (RA) is an inflammatory arthritis that can affect any joint in the body. Inflamed synovium causes articular cartilage breakdown with pain and decreased range of motion. The goals of hand surgery for the RA patient are relief of pain, improvement of function, slowing progression of disease, and improvement in appearance.63 In addition, swelling of the joint due to the inflammation can cause laxity and even failure of the collateral ligaments supporting the joints. Recent advances in the medical care of RA have made the need for surgical care of these patients far less common than in previous decades.MP joints of the fingers are commonly affected. The base of the proximal phalanx progressively subluxates and eventu-ally dislocates volarly with respect to the metacarpal head. The collateral ligaments, particularly on the radial side, stretch out and cause the ulnar deviation of the fingers characteristic of the rheumatoid hand. In more |
Surgery_Schwartz_12810 | Surgery_Schwartz | with respect to the metacarpal head. The collateral ligaments, particularly on the radial side, stretch out and cause the ulnar deviation of the fingers characteristic of the rheumatoid hand. In more advanced cases, the joint may not be salvageable (Fig. 44-17B). For these patients, implant arthro-plasty is the mainstay of surgical treatment. Silicone implants have been used for over 40 years with good results.64 The sili-cone implant acts as a spacer between proximal and distal bone, rather than as a true resurfacing arthroplasty. The radial col-lateral ligament must be repaired to appropriate length to cor-rect the preoperative ulnar deviation of the MP joint. Extensor tendon centralization is then performed, as needed, at the end of the procedure.For MP joint and PIP joint disease, fusion is an option. However, since RA usually affects multiple joints, fusion is typically avoided due to impaired function of adjacent joints, which would leave a severe motion deficit to the | Surgery_Schwartz. with respect to the metacarpal head. The collateral ligaments, particularly on the radial side, stretch out and cause the ulnar deviation of the fingers characteristic of the rheumatoid hand. In more advanced cases, the joint may not be salvageable (Fig. 44-17B). For these patients, implant arthro-plasty is the mainstay of surgical treatment. Silicone implants have been used for over 40 years with good results.64 The sili-cone implant acts as a spacer between proximal and distal bone, rather than as a true resurfacing arthroplasty. The radial col-lateral ligament must be repaired to appropriate length to cor-rect the preoperative ulnar deviation of the MP joint. Extensor tendon centralization is then performed, as needed, at the end of the procedure.For MP joint and PIP joint disease, fusion is an option. However, since RA usually affects multiple joints, fusion is typically avoided due to impaired function of adjacent joints, which would leave a severe motion deficit to the |
Surgery_Schwartz_12811 | Surgery_Schwartz | fusion is an option. However, since RA usually affects multiple joints, fusion is typically avoided due to impaired function of adjacent joints, which would leave a severe motion deficit to the finger.Failure of the support ligaments of the distal radioulnar joint (DRUJ) leads to the caput ulnae posture of the wrist with the ulnar head prominent dorsally. As this dorsal prominence becomes more advanced, the ulna head, denuded of its cartilage to act as a buffer, erodes into the overlying extensor tendons. Extensor tenosynovitis, followed ultimately by tendon rupture, begins ulnarly and proceeds radially. Rupture of the ECU ten-don may go unnoticed due to the intact ECRL and ECRB ten-dons to extend the wrist. EDQ rupture may go unnoticed if a sufficiently robust EDC tendon to the small finger exists. Once the fourth compartment (EDC) tendons begin to fail, the motion deficit is unable to be ignored by the patient.Surgical solutions must address the tendon ruptures as well as the DRUJ | Surgery_Schwartz. fusion is an option. However, since RA usually affects multiple joints, fusion is typically avoided due to impaired function of adjacent joints, which would leave a severe motion deficit to the finger.Failure of the support ligaments of the distal radioulnar joint (DRUJ) leads to the caput ulnae posture of the wrist with the ulnar head prominent dorsally. As this dorsal prominence becomes more advanced, the ulna head, denuded of its cartilage to act as a buffer, erodes into the overlying extensor tendons. Extensor tenosynovitis, followed ultimately by tendon rupture, begins ulnarly and proceeds radially. Rupture of the ECU ten-don may go unnoticed due to the intact ECRL and ECRB ten-dons to extend the wrist. EDQ rupture may go unnoticed if a sufficiently robust EDC tendon to the small finger exists. Once the fourth compartment (EDC) tendons begin to fail, the motion deficit is unable to be ignored by the patient.Surgical solutions must address the tendon ruptures as well as the DRUJ |
Surgery_Schwartz_12812 | Surgery_Schwartz | exists. Once the fourth compartment (EDC) tendons begin to fail, the motion deficit is unable to be ignored by the patient.Surgical solutions must address the tendon ruptures as well as the DRUJ synovitis and instability and ulna head break-down that led to them.65 Excision of the ulna head removes the bony prominence. The DRUJ synovitis must also be resected. Figure 44-17. Arthritis of the hand and wrist. A. This patient injured her scapholunate ligament years prior to presentation. The scapholunate interval is widened (double arrow), and the radioscaphoid joint is degenerated (solid oval), but the radiolunate and lunocapitate joint spaces are well preserved (dashed ovals). B. This patient has had rheumatoid arthritis for decades. The classic volar subluxation of the metacarpophalangeal joints of the fingers (dashed oval) and radial deviation of the fingers are apparent.Brunicardi_Ch44_p1925-p1966.indd 194620/02/19 2:49 PM 1947SURGERY OF THE HAND AND WRISTCHAPTER 44Alternatively, | Surgery_Schwartz. exists. Once the fourth compartment (EDC) tendons begin to fail, the motion deficit is unable to be ignored by the patient.Surgical solutions must address the tendon ruptures as well as the DRUJ synovitis and instability and ulna head break-down that led to them.65 Excision of the ulna head removes the bony prominence. The DRUJ synovitis must also be resected. Figure 44-17. Arthritis of the hand and wrist. A. This patient injured her scapholunate ligament years prior to presentation. The scapholunate interval is widened (double arrow), and the radioscaphoid joint is degenerated (solid oval), but the radiolunate and lunocapitate joint spaces are well preserved (dashed ovals). B. This patient has had rheumatoid arthritis for decades. The classic volar subluxation of the metacarpophalangeal joints of the fingers (dashed oval) and radial deviation of the fingers are apparent.Brunicardi_Ch44_p1925-p1966.indd 194620/02/19 2:49 PM 1947SURGERY OF THE HAND AND WRISTCHAPTER 44Alternatively, |
Surgery_Schwartz_12813 | Surgery_Schwartz | of the fingers (dashed oval) and radial deviation of the fingers are apparent.Brunicardi_Ch44_p1925-p1966.indd 194620/02/19 2:49 PM 1947SURGERY OF THE HAND AND WRISTCHAPTER 44Alternatively, the DRUJ can be fused and the ulna neck resected to create a pseudoarthrosis to allow for rotation. For both pro-cedures, the remaining distal ulna must be stabilized. Multiple techniques have been described using portions of FCU, ECU, wrist capsule, and combinations thereof.The ruptured extensor tendons are typically degenerated over a significant length. Primary repair is almost never pos-sible, and the frequent occurrence of multiple tendon ruptures makes repair with graft less desirable due to the need for mul-tiple graft donors.Strict compliance with postoperative therapy is essential to maximizing the surgical result. Due to the chronic inflam-mation associated with RA, tendon and ligament repairs will be slower to achieve maximal tensile strength. Prolonged night-time splinting, usually | Surgery_Schwartz. of the fingers (dashed oval) and radial deviation of the fingers are apparent.Brunicardi_Ch44_p1925-p1966.indd 194620/02/19 2:49 PM 1947SURGERY OF THE HAND AND WRISTCHAPTER 44Alternatively, the DRUJ can be fused and the ulna neck resected to create a pseudoarthrosis to allow for rotation. For both pro-cedures, the remaining distal ulna must be stabilized. Multiple techniques have been described using portions of FCU, ECU, wrist capsule, and combinations thereof.The ruptured extensor tendons are typically degenerated over a significant length. Primary repair is almost never pos-sible, and the frequent occurrence of multiple tendon ruptures makes repair with graft less desirable due to the need for mul-tiple graft donors.Strict compliance with postoperative therapy is essential to maximizing the surgical result. Due to the chronic inflam-mation associated with RA, tendon and ligament repairs will be slower to achieve maximal tensile strength. Prolonged night-time splinting, usually |
Surgery_Schwartz_12814 | Surgery_Schwartz | the surgical result. Due to the chronic inflam-mation associated with RA, tendon and ligament repairs will be slower to achieve maximal tensile strength. Prolonged night-time splinting, usually for months, helps prevent recurrence of extensor lag. Finally, the disease may progress over time. Reconstructions that were initially adequate may stretch out or fail over time. Medical management is the key to slowing dis-ease progression and maximizing the durability of any surgical reconstruction.DUPUYTREN’S CONTRACTUREIn 1614, a Swiss surgeon named Felix Plater first described con-tracture of multiple fingers due to palpable, cord-like structures on the volar surface of the hand and fingers. The disease state he described would ultimately come to be known as Dupuytren’s contracture. Dupuytren’s name came to be associated with the disease after he performed an open fasciotomy of a contracted cord before a class of medical students in 1831.66The palmar fascia consists of collagen bundles in | Surgery_Schwartz. the surgical result. Due to the chronic inflam-mation associated with RA, tendon and ligament repairs will be slower to achieve maximal tensile strength. Prolonged night-time splinting, usually for months, helps prevent recurrence of extensor lag. Finally, the disease may progress over time. Reconstructions that were initially adequate may stretch out or fail over time. Medical management is the key to slowing dis-ease progression and maximizing the durability of any surgical reconstruction.DUPUYTREN’S CONTRACTUREIn 1614, a Swiss surgeon named Felix Plater first described con-tracture of multiple fingers due to palpable, cord-like structures on the volar surface of the hand and fingers. The disease state he described would ultimately come to be known as Dupuytren’s contracture. Dupuytren’s name came to be associated with the disease after he performed an open fasciotomy of a contracted cord before a class of medical students in 1831.66The palmar fascia consists of collagen bundles in |
Surgery_Schwartz_12815 | Surgery_Schwartz | name came to be associated with the disease after he performed an open fasciotomy of a contracted cord before a class of medical students in 1831.66The palmar fascia consists of collagen bundles in the palm and fingers. These are primarily longitudinally oriented and reside as a layer between the overlying skin and the underlying tendons and neurovascular structures. There are also connections from this layer to the deep structures below and the skin above. Much is known about the progression of these structures from their normal state (called bands) to their contracted state (called cords), but little is known on how or why this process begins.Increased collagen deposition leads to a palpable nodule in the palm. Over time, there is increased deposition distally into the fingers. This collagen becomes organized and linearly ori-ented. These collagen bundles, with the aid of myofibroblasts, contract down to form the cords, which are the hallmark of the symptomatic patient. Detail of | Surgery_Schwartz. name came to be associated with the disease after he performed an open fasciotomy of a contracted cord before a class of medical students in 1831.66The palmar fascia consists of collagen bundles in the palm and fingers. These are primarily longitudinally oriented and reside as a layer between the overlying skin and the underlying tendons and neurovascular structures. There are also connections from this layer to the deep structures below and the skin above. Much is known about the progression of these structures from their normal state (called bands) to their contracted state (called cords), but little is known on how or why this process begins.Increased collagen deposition leads to a palpable nodule in the palm. Over time, there is increased deposition distally into the fingers. This collagen becomes organized and linearly ori-ented. These collagen bundles, with the aid of myofibroblasts, contract down to form the cords, which are the hallmark of the symptomatic patient. Detail of |
Surgery_Schwartz_12816 | Surgery_Schwartz | becomes organized and linearly ori-ented. These collagen bundles, with the aid of myofibroblasts, contract down to form the cords, which are the hallmark of the symptomatic patient. Detail of the molecular and cell biology of Dupuytren’s disease is beyond the scope of this chapter but is available in multiple hand surgery texts.67Most nonoperative management techniques will not delay the progression of disease. Corticosteroid injections may soften nodules and decrease the discomfort associated with them but are ineffective against cords. Splinting has similarly been shown not to retard disease progression.Recently, several minimally invasive treatment approaches have been described for the treatment of Dupuytren’s disease.68 Disruption of the cord with a needle is an effective means of releasing contractures, particularly at the MP joint level. Long-term studies have demonstrated more rapid recovery from needle fasciotomy, as the procedure is called, but more durable results with | Surgery_Schwartz. becomes organized and linearly ori-ented. These collagen bundles, with the aid of myofibroblasts, contract down to form the cords, which are the hallmark of the symptomatic patient. Detail of the molecular and cell biology of Dupuytren’s disease is beyond the scope of this chapter but is available in multiple hand surgery texts.67Most nonoperative management techniques will not delay the progression of disease. Corticosteroid injections may soften nodules and decrease the discomfort associated with them but are ineffective against cords. Splinting has similarly been shown not to retard disease progression.Recently, several minimally invasive treatment approaches have been described for the treatment of Dupuytren’s disease.68 Disruption of the cord with a needle is an effective means of releasing contractures, particularly at the MP joint level. Long-term studies have demonstrated more rapid recovery from needle fasciotomy, as the procedure is called, but more durable results with |
Surgery_Schwartz_12817 | Surgery_Schwartz | releasing contractures, particularly at the MP joint level. Long-term studies have demonstrated more rapid recovery from needle fasciotomy, as the procedure is called, but more durable results with fasciectomy.69 Injectable clostridial collagenase was approved by the U.S. Food and Drug Administration in 2009, and although it has shown good early results, treatment costs remain high.70For patients with advanced disease including contrac-tures of the digits that limit function, surgery is the mainstay of therapy. Although rate of progression should weigh heavily in the decision of whether or not to perform surgery, general guidelines are MP contractures greater than or equal to 30° and/or PIP contractures greater than or equal to 20°.71Surgery consists of an open approach through the skin down to the involved cords. Skin is elevated off of the under-lying cords. Great care must be taken to preserve as much of the subdermal vascular plexus with the elevated skin flaps to minimize | Surgery_Schwartz. releasing contractures, particularly at the MP joint level. Long-term studies have demonstrated more rapid recovery from needle fasciotomy, as the procedure is called, but more durable results with fasciectomy.69 Injectable clostridial collagenase was approved by the U.S. Food and Drug Administration in 2009, and although it has shown good early results, treatment costs remain high.70For patients with advanced disease including contrac-tures of the digits that limit function, surgery is the mainstay of therapy. Although rate of progression should weigh heavily in the decision of whether or not to perform surgery, general guidelines are MP contractures greater than or equal to 30° and/or PIP contractures greater than or equal to 20°.71Surgery consists of an open approach through the skin down to the involved cords. Skin is elevated off of the under-lying cords. Great care must be taken to preserve as much of the subdermal vascular plexus with the elevated skin flaps to minimize |
Surgery_Schwartz_12818 | Surgery_Schwartz | skin down to the involved cords. Skin is elevated off of the under-lying cords. Great care must be taken to preserve as much of the subdermal vascular plexus with the elevated skin flaps to minimize postoperative skin necrosis. All nerves, tendons, and blood vessels in the operative field should be identified. Once this is done, the involved cord is resected while keeping the critical deeper structures under direct vision. The skin is then closed, with local flap transpositions as needed, to allow for full extension of the fingers that have been released (Fig. 44-18).Alternative cord resection techniques include removal of the skin over the contracture (dermatofasciectomy). This requires a skin graft to the wound and should only be done if skin cannot be separated from the cords and local tissue cannot be rearranged with local flaps to provide closure of the wound.Complications of surgical treatment of Dupuytren’s dis-ease occur in as many as 24% of cases.72 Problems include digi-tal | Surgery_Schwartz. skin down to the involved cords. Skin is elevated off of the under-lying cords. Great care must be taken to preserve as much of the subdermal vascular plexus with the elevated skin flaps to minimize postoperative skin necrosis. All nerves, tendons, and blood vessels in the operative field should be identified. Once this is done, the involved cord is resected while keeping the critical deeper structures under direct vision. The skin is then closed, with local flap transpositions as needed, to allow for full extension of the fingers that have been released (Fig. 44-18).Alternative cord resection techniques include removal of the skin over the contracture (dermatofasciectomy). This requires a skin graft to the wound and should only be done if skin cannot be separated from the cords and local tissue cannot be rearranged with local flaps to provide closure of the wound.Complications of surgical treatment of Dupuytren’s dis-ease occur in as many as 24% of cases.72 Problems include digi-tal |
Surgery_Schwartz_12819 | Surgery_Schwartz | tissue cannot be rearranged with local flaps to provide closure of the wound.Complications of surgical treatment of Dupuytren’s dis-ease occur in as many as 24% of cases.72 Problems include digi-tal nerve laceration, digital artery laceration, buttonholing of the skin, hematoma, swelling, and pain, including some patients with CRPS (see earlier section on CRPS). Digital nerve injury can be quite devastating, producing annoying numbness at best or a painful neuroma in worse situations.Hand therapy is typically instituted within a week of sur-gery to begin mobilization of the fingers and edema control. The therapist can also identify any early wound problems because he or she will see the patient more frequently than the surgeon. Extension hand splinting is maintained for 4 to 6 weeks, with nighttime splinting continued for an additional 6 to 8 weeks. After this point, the patient is serially followed for evidence of recurrence or extension of disease.INFECTIONSTrauma is the most common | Surgery_Schwartz. tissue cannot be rearranged with local flaps to provide closure of the wound.Complications of surgical treatment of Dupuytren’s dis-ease occur in as many as 24% of cases.72 Problems include digi-tal nerve laceration, digital artery laceration, buttonholing of the skin, hematoma, swelling, and pain, including some patients with CRPS (see earlier section on CRPS). Digital nerve injury can be quite devastating, producing annoying numbness at best or a painful neuroma in worse situations.Hand therapy is typically instituted within a week of sur-gery to begin mobilization of the fingers and edema control. The therapist can also identify any early wound problems because he or she will see the patient more frequently than the surgeon. Extension hand splinting is maintained for 4 to 6 weeks, with nighttime splinting continued for an additional 6 to 8 weeks. After this point, the patient is serially followed for evidence of recurrence or extension of disease.INFECTIONSTrauma is the most common |
Surgery_Schwartz_12820 | Surgery_Schwartz | nighttime splinting continued for an additional 6 to 8 weeks. After this point, the patient is serially followed for evidence of recurrence or extension of disease.INFECTIONSTrauma is the most common cause of hand infections. Other predisposing factors include diabetes, neuropathies, and immu-nocompromised patients. Proper treatment consists of incision and drainage of any collections followed by debridement, obtain-ing wound cultures, antibiotic therapy, elevation, and immobi-lization. Staphylococcus and Streptococcus are the offending pathogens in about 90% of hand infections. Infections caused by intravenous drug use or human bites and those associated with diabetes will often be polymicrobial, including gram-positive and gram-negative species. Heavily contaminated injuries require anaerobic coverage. Although α-hemolytic Streptococcus and Staphylococcus aureus are the most commonly encountered pathogens in human bites, Eikenella corrodens is isolated in up to one-third of cases | Surgery_Schwartz. nighttime splinting continued for an additional 6 to 8 weeks. After this point, the patient is serially followed for evidence of recurrence or extension of disease.INFECTIONSTrauma is the most common cause of hand infections. Other predisposing factors include diabetes, neuropathies, and immu-nocompromised patients. Proper treatment consists of incision and drainage of any collections followed by debridement, obtain-ing wound cultures, antibiotic therapy, elevation, and immobi-lization. Staphylococcus and Streptococcus are the offending pathogens in about 90% of hand infections. Infections caused by intravenous drug use or human bites and those associated with diabetes will often be polymicrobial, including gram-positive and gram-negative species. Heavily contaminated injuries require anaerobic coverage. Although α-hemolytic Streptococcus and Staphylococcus aureus are the most commonly encountered pathogens in human bites, Eikenella corrodens is isolated in up to one-third of cases |
Surgery_Schwartz_12821 | Surgery_Schwartz | coverage. Although α-hemolytic Streptococcus and Staphylococcus aureus are the most commonly encountered pathogens in human bites, Eikenella corrodens is isolated in up to one-third of cases and should be considered when choosing antimicrobial therapy. Ziehl-Neelsen staining and cultures at 28°C to 32°C in Lowenstein-Jensen medium must be performed if there is a suspicion for atypical mycobacteria.73CellulitisCellulitis is characterized by a nonpurulent diffuse spreading of inflammation characterized by erythema, warmth, pain, swell-ing, and induration. Skin breakdown is a frequent cause, but Brunicardi_Ch44_p1925-p1966.indd 194720/02/19 2:49 PM 1948SPECIFIC CONSIDERATIONSPART IIFigure 44-18. Dupuytren’s disease. A. This patient has cords affecting the thumb, middle, ring, and small fingers. B. The resected specimens are shown. C. Postoperatively, the patient went on to heal all his incisions and, with the aid of weeks of hand therapy, recover full motion.often no inciting factor | Surgery_Schwartz. coverage. Although α-hemolytic Streptococcus and Staphylococcus aureus are the most commonly encountered pathogens in human bites, Eikenella corrodens is isolated in up to one-third of cases and should be considered when choosing antimicrobial therapy. Ziehl-Neelsen staining and cultures at 28°C to 32°C in Lowenstein-Jensen medium must be performed if there is a suspicion for atypical mycobacteria.73CellulitisCellulitis is characterized by a nonpurulent diffuse spreading of inflammation characterized by erythema, warmth, pain, swell-ing, and induration. Skin breakdown is a frequent cause, but Brunicardi_Ch44_p1925-p1966.indd 194720/02/19 2:49 PM 1948SPECIFIC CONSIDERATIONSPART IIFigure 44-18. Dupuytren’s disease. A. This patient has cords affecting the thumb, middle, ring, and small fingers. B. The resected specimens are shown. C. Postoperatively, the patient went on to heal all his incisions and, with the aid of weeks of hand therapy, recover full motion.often no inciting factor |
Surgery_Schwartz_12822 | Surgery_Schwartz | B. The resected specimens are shown. C. Postoperatively, the patient went on to heal all his incisions and, with the aid of weeks of hand therapy, recover full motion.often no inciting factor is identified. Group A α-hemolytic Streptococcus is the most common offending pathogen and causes a more diffuse spread of infection. S aureus is the second most common offending pathogen and will cause a more local-ized cellulitis. The diagnosis of cellulitis is clinical. Septic arthritis, osteomyelitis, an abscess, a deep-space infection, and necrotizing fasciitis are severe infectious processes that may initially mimic cellulitis. These must be ruled out appropriately before initiating treatment, and serial exams should be con-ducted to ensure proper diagnosis. Treatment of cellulitis con-sists of elevation, splint immobilization, and antibiotics that cover both Streptococcus and Staphylococcus. Intravenous antibiotics are usually initiated for patients with severe comorbidities and those who | Surgery_Schwartz. B. The resected specimens are shown. C. Postoperatively, the patient went on to heal all his incisions and, with the aid of weeks of hand therapy, recover full motion.often no inciting factor is identified. Group A α-hemolytic Streptococcus is the most common offending pathogen and causes a more diffuse spread of infection. S aureus is the second most common offending pathogen and will cause a more local-ized cellulitis. The diagnosis of cellulitis is clinical. Septic arthritis, osteomyelitis, an abscess, a deep-space infection, and necrotizing fasciitis are severe infectious processes that may initially mimic cellulitis. These must be ruled out appropriately before initiating treatment, and serial exams should be con-ducted to ensure proper diagnosis. Treatment of cellulitis con-sists of elevation, splint immobilization, and antibiotics that cover both Streptococcus and Staphylococcus. Intravenous antibiotics are usually initiated for patients with severe comorbidities and those who |
Surgery_Schwartz_12823 | Surgery_Schwartz | elevation, splint immobilization, and antibiotics that cover both Streptococcus and Staphylococcus. Intravenous antibiotics are usually initiated for patients with severe comorbidities and those who fail to improve on oral antibiotics after 24 to 48 hours. Failure to improve after 24 hours indicates a need to search for an underlying abscess or other infectious cause.735AbscessAn abscess will present much like cellulitis, but they are two clinically separate entities. The defining difference is an area of fluctuance. Skin-puncturing trauma is the most common cause. S aureus is the most common pathogen, followed by Streptococcus. Treatment consists of incision and drainage with appropriate debridement, wound cultures, wound packing, elevation, immo-bilization, and antibiotics. The packing should be removed in 12 to 24 hours or sooner if there is clinical concern, and warm soapy water soaks with fresh packing should be initiated. Most should be allowed to heal secondarily. Delayed | Surgery_Schwartz. elevation, splint immobilization, and antibiotics that cover both Streptococcus and Staphylococcus. Intravenous antibiotics are usually initiated for patients with severe comorbidities and those who fail to improve on oral antibiotics after 24 to 48 hours. Failure to improve after 24 hours indicates a need to search for an underlying abscess or other infectious cause.735AbscessAn abscess will present much like cellulitis, but they are two clinically separate entities. The defining difference is an area of fluctuance. Skin-puncturing trauma is the most common cause. S aureus is the most common pathogen, followed by Streptococcus. Treatment consists of incision and drainage with appropriate debridement, wound cultures, wound packing, elevation, immo-bilization, and antibiotics. The packing should be removed in 12 to 24 hours or sooner if there is clinical concern, and warm soapy water soaks with fresh packing should be initiated. Most should be allowed to heal secondarily. Delayed |
Surgery_Schwartz_12824 | Surgery_Schwartz | should be removed in 12 to 24 hours or sooner if there is clinical concern, and warm soapy water soaks with fresh packing should be initiated. Most should be allowed to heal secondarily. Delayed primary clo-sure should only be performed after repeat washouts for larger wounds where complete infection control has been achieved.Collar-Button AbscessThis is a subfascial infection of a web space and is usually caused by skin trauma that becomes infected; it often occurs in Brunicardi_Ch44_p1925-p1966.indd 194820/02/19 2:49 PM 1949SURGERY OF THE HAND AND WRISTCHAPTER 44laborers. The adherence of the palmar web space skin to the pal-mar fascia prevents lateral spread, so the infection courses dor-sally, resulting in both palmar web space tenderness and dorsal web space swelling and tenderness. The adjacent fingers will be held in abduction with pain on adduction (Fig. 44-19). Incision and drainage, often using separate volar and dorsal incisions, is mandatory, and follows the same | Surgery_Schwartz. should be removed in 12 to 24 hours or sooner if there is clinical concern, and warm soapy water soaks with fresh packing should be initiated. Most should be allowed to heal secondarily. Delayed primary clo-sure should only be performed after repeat washouts for larger wounds where complete infection control has been achieved.Collar-Button AbscessThis is a subfascial infection of a web space and is usually caused by skin trauma that becomes infected; it often occurs in Brunicardi_Ch44_p1925-p1966.indd 194820/02/19 2:49 PM 1949SURGERY OF THE HAND AND WRISTCHAPTER 44laborers. The adherence of the palmar web space skin to the pal-mar fascia prevents lateral spread, so the infection courses dor-sally, resulting in both palmar web space tenderness and dorsal web space swelling and tenderness. The adjacent fingers will be held in abduction with pain on adduction (Fig. 44-19). Incision and drainage, often using separate volar and dorsal incisions, is mandatory, and follows the same |
Surgery_Schwartz_12825 | Surgery_Schwartz | The adjacent fingers will be held in abduction with pain on adduction (Fig. 44-19). Incision and drainage, often using separate volar and dorsal incisions, is mandatory, and follows the same treatment as for any abscess or deep-space infection.OsteomyelitisOsteomyelitis in the hand usually occurs due to an open fracture with significant soft tissue injury. The presence of infected hard-ware, peripheral vascular disease, diabetes, and alcohol or drug abuse are also predisposing factors. Presentation includes per-sistent or recurrent swelling with pain, erythema, and possible drainage. It will take 2 to 3 weeks for periosteal reaction and osteopenia to be detected on radiographs. Bone scans and MRI Figure 44-19. Collar-Button abscess A. The fingers surround-ing the involved (second) web space rest in greater abduction than the other fingers. B. Dorsal and volar drainage incisions are made, separated by a bridge of intact web skin; a Penrose drain prevents the skin from closing too | Surgery_Schwartz. The adjacent fingers will be held in abduction with pain on adduction (Fig. 44-19). Incision and drainage, often using separate volar and dorsal incisions, is mandatory, and follows the same treatment as for any abscess or deep-space infection.OsteomyelitisOsteomyelitis in the hand usually occurs due to an open fracture with significant soft tissue injury. The presence of infected hard-ware, peripheral vascular disease, diabetes, and alcohol or drug abuse are also predisposing factors. Presentation includes per-sistent or recurrent swelling with pain, erythema, and possible drainage. It will take 2 to 3 weeks for periosteal reaction and osteopenia to be detected on radiographs. Bone scans and MRI Figure 44-19. Collar-Button abscess A. The fingers surround-ing the involved (second) web space rest in greater abduction than the other fingers. B. Dorsal and volar drainage incisions are made, separated by a bridge of intact web skin; a Penrose drain prevents the skin from closing too |
Surgery_Schwartz_12826 | Surgery_Schwartz | space rest in greater abduction than the other fingers. B. Dorsal and volar drainage incisions are made, separated by a bridge of intact web skin; a Penrose drain prevents the skin from closing too early.are useful modalities to aid in diagnosis. Erythrocyte sedimenta-tion rate (ESR) and C-reactive protein (CRP) have low specific-ity but are useful for monitoring the progress of treatment, with CRP being more reliable. Treatment consists of antibiotics alone in the early stage as long as there is favorable response. All necrotic bone and soft tissue, if present, must be debrided. Initial intravenous antibiotic therapy should cover S aureus, the most common pathogen, and should then be adjusted according to bone cultures. Antibiotic therapy is continued for 4 to 6 weeks once the patient clinically improves and there is no further need for debridement. For osteomyelitis in the setting of an acute fracture with internal fixation in place, the hardware should be left in place as long as | Surgery_Schwartz. space rest in greater abduction than the other fingers. B. Dorsal and volar drainage incisions are made, separated by a bridge of intact web skin; a Penrose drain prevents the skin from closing too early.are useful modalities to aid in diagnosis. Erythrocyte sedimenta-tion rate (ESR) and C-reactive protein (CRP) have low specific-ity but are useful for monitoring the progress of treatment, with CRP being more reliable. Treatment consists of antibiotics alone in the early stage as long as there is favorable response. All necrotic bone and soft tissue, if present, must be debrided. Initial intravenous antibiotic therapy should cover S aureus, the most common pathogen, and should then be adjusted according to bone cultures. Antibiotic therapy is continued for 4 to 6 weeks once the patient clinically improves and there is no further need for debridement. For osteomyelitis in the setting of an acute fracture with internal fixation in place, the hardware should be left in place as long as |
Surgery_Schwartz_12827 | Surgery_Schwartz | improves and there is no further need for debridement. For osteomyelitis in the setting of an acute fracture with internal fixation in place, the hardware should be left in place as long as it is stable and the fracture has not yet healed. If the hardware is unstable, it must be replaced. An external fixation device may be useful in this setting. If osteo-myelitis occurs in a healed fracture, all hardware and necrotic bone and soft tissue must be removed.74Pyogenic ArthritisInfection of a joint will progress quickly to severe cartilage and bony destruction if not addressed quickly. Direct trauma and local spread of an infection are the most common causes. Hema-togenous spread occurs most commonly in patients who are immunocompromised. S aureus is the most common pathogen, followed by Streptococcus species. Neisseria gonorrhoeae is the most common cause of atraumatic septic arthritis in an adult less than 30 years of age. Presentation includes exacerbation of pain with any joint | Surgery_Schwartz. improves and there is no further need for debridement. For osteomyelitis in the setting of an acute fracture with internal fixation in place, the hardware should be left in place as long as it is stable and the fracture has not yet healed. If the hardware is unstable, it must be replaced. An external fixation device may be useful in this setting. If osteo-myelitis occurs in a healed fracture, all hardware and necrotic bone and soft tissue must be removed.74Pyogenic ArthritisInfection of a joint will progress quickly to severe cartilage and bony destruction if not addressed quickly. Direct trauma and local spread of an infection are the most common causes. Hema-togenous spread occurs most commonly in patients who are immunocompromised. S aureus is the most common pathogen, followed by Streptococcus species. Neisseria gonorrhoeae is the most common cause of atraumatic septic arthritis in an adult less than 30 years of age. Presentation includes exacerbation of pain with any joint |
Surgery_Schwartz_12828 | Surgery_Schwartz | Streptococcus species. Neisseria gonorrhoeae is the most common cause of atraumatic septic arthritis in an adult less than 30 years of age. Presentation includes exacerbation of pain with any joint movement, severe pain on axial load, swell-ing, erythema, and tenderness. Radiographs may show a foreign body or fracture, with widened joint space early in the process and decreased joint space late in the process due to destruc-tion. Joint aspiration with cell count, Gram stain, and culture is used to secure the diagnosis. Treatment of nongonococcal septic arthritis includes open arthrotomy, irrigation, debridement, and packing the joint or leaving a drain in place. Intravenous antibi-otics are continued until there is clinical improvement, followed by 2 to 4 weeks of additional oral or intravenous antibiotics. Gonococcal septic arthritis is usually treated nonoperatively. Intravenous ceftriaxone is first-line therapy. Joint aspiration may be used to obtain cultures and decrease joint | Surgery_Schwartz. Streptococcus species. Neisseria gonorrhoeae is the most common cause of atraumatic septic arthritis in an adult less than 30 years of age. Presentation includes exacerbation of pain with any joint movement, severe pain on axial load, swell-ing, erythema, and tenderness. Radiographs may show a foreign body or fracture, with widened joint space early in the process and decreased joint space late in the process due to destruc-tion. Joint aspiration with cell count, Gram stain, and culture is used to secure the diagnosis. Treatment of nongonococcal septic arthritis includes open arthrotomy, irrigation, debridement, and packing the joint or leaving a drain in place. Intravenous antibi-otics are continued until there is clinical improvement, followed by 2 to 4 weeks of additional oral or intravenous antibiotics. Gonococcal septic arthritis is usually treated nonoperatively. Intravenous ceftriaxone is first-line therapy. Joint aspiration may be used to obtain cultures and decrease joint |
Surgery_Schwartz_12829 | Surgery_Schwartz | antibiotics. Gonococcal septic arthritis is usually treated nonoperatively. Intravenous ceftriaxone is first-line therapy. Joint aspiration may be used to obtain cultures and decrease joint pressure.75Necrotizing InfectionsNecrotizing soft tissue infections occur when the immune system is unable to contain an infection, leading to extensive spread with death of all involved tissues. This is different from an abscess, which forms when a functioning immune system is able to “wall off” the infectious focus. Necrotizing infections can result in loss of limb or life, even with prompt medical care.Bacteria spread along the fascial layer, resulting in the death of soft tissues, which is in part due to the extensive blood vessel thrombosis that occurs. An inciting event is not always identified. Immunocompromised patients and those who abuse drugs or alcohol are at greater risk, with intravenous drug users having the highest increased risk. The infection can by monoor polymicrobial, with | Surgery_Schwartz. antibiotics. Gonococcal septic arthritis is usually treated nonoperatively. Intravenous ceftriaxone is first-line therapy. Joint aspiration may be used to obtain cultures and decrease joint pressure.75Necrotizing InfectionsNecrotizing soft tissue infections occur when the immune system is unable to contain an infection, leading to extensive spread with death of all involved tissues. This is different from an abscess, which forms when a functioning immune system is able to “wall off” the infectious focus. Necrotizing infections can result in loss of limb or life, even with prompt medical care.Bacteria spread along the fascial layer, resulting in the death of soft tissues, which is in part due to the extensive blood vessel thrombosis that occurs. An inciting event is not always identified. Immunocompromised patients and those who abuse drugs or alcohol are at greater risk, with intravenous drug users having the highest increased risk. The infection can by monoor polymicrobial, with |
Surgery_Schwartz_12830 | Surgery_Schwartz | Immunocompromised patients and those who abuse drugs or alcohol are at greater risk, with intravenous drug users having the highest increased risk. The infection can by monoor polymicrobial, with group A β-hemolytic Streptococcus being the most common pathogen, followed by α-hemolytic Streptococcus, S aureus, and anaerobes. Prompt clinical diag-nosis and treatment are the most important factors for salvag-ing limbs and saving life. Patients will present with pain out of proportion with findings. Appearance of skin may range from normal to erythematous or maroon with edema, induration, and blistering. Crepitus may occur if a gas-forming organism Brunicardi_Ch44_p1925-p1966.indd 194920/02/19 2:49 PM 1950SPECIFIC CONSIDERATIONSPART IIis involved. “Dirty dishwater fluid” may be encountered as a scant grayish fluid, but often there is little to no discharge. There may be no appreciable leukocytosis. The infection can progress rapidly and can lead to septic shock and disseminated | Surgery_Schwartz. Immunocompromised patients and those who abuse drugs or alcohol are at greater risk, with intravenous drug users having the highest increased risk. The infection can by monoor polymicrobial, with group A β-hemolytic Streptococcus being the most common pathogen, followed by α-hemolytic Streptococcus, S aureus, and anaerobes. Prompt clinical diag-nosis and treatment are the most important factors for salvag-ing limbs and saving life. Patients will present with pain out of proportion with findings. Appearance of skin may range from normal to erythematous or maroon with edema, induration, and blistering. Crepitus may occur if a gas-forming organism Brunicardi_Ch44_p1925-p1966.indd 194920/02/19 2:49 PM 1950SPECIFIC CONSIDERATIONSPART IIis involved. “Dirty dishwater fluid” may be encountered as a scant grayish fluid, but often there is little to no discharge. There may be no appreciable leukocytosis. The infection can progress rapidly and can lead to septic shock and disseminated |
Surgery_Schwartz_12831 | Surgery_Schwartz | as a scant grayish fluid, but often there is little to no discharge. There may be no appreciable leukocytosis. The infection can progress rapidly and can lead to septic shock and disseminated intravas-cular coagulation. Radiographs may reveal gas formation, but they must not delay emergent debridement once the diagnosis is suspected. Intravenous antibiotics should be started imme-diately to cover gram-positive, gram-negative, and anaerobic bacteria. Patients will require multiple debridements, and the spread of infection is normally wider than expected based on initial assessment.73Necrotizing myositis, or myonecrosis, is usually caused by Clostridium perfringens due to heavily contaminated wounds. Unlike necrotizing fasciitis, muscle is universally involved and found to be necrotic. Treatment includes emergent debride-ment of all necrotic tissue along with empirical intravenous antibiotics.Wet gangrene is most common in diabetics with renal failure and an arteriovenous shunt. It is | Surgery_Schwartz. as a scant grayish fluid, but often there is little to no discharge. There may be no appreciable leukocytosis. The infection can progress rapidly and can lead to septic shock and disseminated intravas-cular coagulation. Radiographs may reveal gas formation, but they must not delay emergent debridement once the diagnosis is suspected. Intravenous antibiotics should be started imme-diately to cover gram-positive, gram-negative, and anaerobic bacteria. Patients will require multiple debridements, and the spread of infection is normally wider than expected based on initial assessment.73Necrotizing myositis, or myonecrosis, is usually caused by Clostridium perfringens due to heavily contaminated wounds. Unlike necrotizing fasciitis, muscle is universally involved and found to be necrotic. Treatment includes emergent debride-ment of all necrotic tissue along with empirical intravenous antibiotics.Wet gangrene is most common in diabetics with renal failure and an arteriovenous shunt. It is |
Surgery_Schwartz_12832 | Surgery_Schwartz | includes emergent debride-ment of all necrotic tissue along with empirical intravenous antibiotics.Wet gangrene is most common in diabetics with renal failure and an arteriovenous shunt. It is usually polymicrobial. Patients will present with a necrotic digit that is purulent and very malodorous, with rapidly evolving pain, swelling, skin discoloration, and systemic collapse. Emergent treatment is the same as for other necrotizing infections, and amputation of the involved digit or extremity must often be performed.Infectious Flexor TenosynovitisFlexor tenosynovitis (FTS) is a severe pathophysiologic state causing disruption of normal flexor tendon function in the hand. A variety of etiologies are responsible for this process. Most acute cases of FTS are due to purulent infection. FTS also can occur secondary to chronic inflammation as a result of diabetes, RA, crystalline deposition, overuse syndromes, amyloidosis, psoriatic arthritis, systemic lupus erythematosus, and | Surgery_Schwartz. includes emergent debride-ment of all necrotic tissue along with empirical intravenous antibiotics.Wet gangrene is most common in diabetics with renal failure and an arteriovenous shunt. It is usually polymicrobial. Patients will present with a necrotic digit that is purulent and very malodorous, with rapidly evolving pain, swelling, skin discoloration, and systemic collapse. Emergent treatment is the same as for other necrotizing infections, and amputation of the involved digit or extremity must often be performed.Infectious Flexor TenosynovitisFlexor tenosynovitis (FTS) is a severe pathophysiologic state causing disruption of normal flexor tendon function in the hand. A variety of etiologies are responsible for this process. Most acute cases of FTS are due to purulent infection. FTS also can occur secondary to chronic inflammation as a result of diabetes, RA, crystalline deposition, overuse syndromes, amyloidosis, psoriatic arthritis, systemic lupus erythematosus, and |
Surgery_Schwartz_12833 | Surgery_Schwartz | FTS also can occur secondary to chronic inflammation as a result of diabetes, RA, crystalline deposition, overuse syndromes, amyloidosis, psoriatic arthritis, systemic lupus erythematosus, and sarcoidosis.The primary mechanism of infectious FTS usually is penetrating trauma. Most infections are caused by skin flora, including both Staphylococcus and Streptococcus species. Bac-teria involved vary by etiology of the infection: bite wounds (Pasteurella multocida—cat, E corrodens—human); diabetic patients (Bacteroides, Fusobacterium, Haemophilus species, gram-negative organisms); hematogenous spread (Mycobacte-rium tuberculosis, N gonorrhoeae); or water-related punctures (Vibrio vulnificus, Mycobacterium marinum). Infection in any of the fingers may spread proximally into the wrist, carpal tun-nel, and forearm, also known as Parona’s space.76Suppurative FTS has the ability to rapidly destroy a finger’s functional capacity and is considered a surgical emer-gency. Suppurative FTS results | Surgery_Schwartz. FTS also can occur secondary to chronic inflammation as a result of diabetes, RA, crystalline deposition, overuse syndromes, amyloidosis, psoriatic arthritis, systemic lupus erythematosus, and sarcoidosis.The primary mechanism of infectious FTS usually is penetrating trauma. Most infections are caused by skin flora, including both Staphylococcus and Streptococcus species. Bac-teria involved vary by etiology of the infection: bite wounds (Pasteurella multocida—cat, E corrodens—human); diabetic patients (Bacteroides, Fusobacterium, Haemophilus species, gram-negative organisms); hematogenous spread (Mycobacte-rium tuberculosis, N gonorrhoeae); or water-related punctures (Vibrio vulnificus, Mycobacterium marinum). Infection in any of the fingers may spread proximally into the wrist, carpal tun-nel, and forearm, also known as Parona’s space.76Suppurative FTS has the ability to rapidly destroy a finger’s functional capacity and is considered a surgical emer-gency. Suppurative FTS results |
Surgery_Schwartz_12834 | Surgery_Schwartz | and forearm, also known as Parona’s space.76Suppurative FTS has the ability to rapidly destroy a finger’s functional capacity and is considered a surgical emer-gency. Suppurative FTS results from bacteria multiplying in the closed space of the flexor tendon sheath and culture-rich synovial fluid medium causing migration of inflammatory cells and subsequent swelling. The inflammatory reaction within the closed tendon sheath quickly erodes the paratenon, leading to adhesions and scarring, as well as increase in pressures within the tendon sheath that may lead to ischemia. The ultimate con-sequences are tendon necrosis, disruption of the tendon sheath, and digital contracture.Patients with infectious FTS present with pain, redness, and fever (Fig. 44-20). Physical examination reveals Kanavel’s “cardinal” signs of flexor tendon sheath infection: finger held in slight flexion, fusiform swelling, tenderness along the flexor ten-don sheath, and pain over the flexor sheath with passive | Surgery_Schwartz. and forearm, also known as Parona’s space.76Suppurative FTS has the ability to rapidly destroy a finger’s functional capacity and is considered a surgical emer-gency. Suppurative FTS results from bacteria multiplying in the closed space of the flexor tendon sheath and culture-rich synovial fluid medium causing migration of inflammatory cells and subsequent swelling. The inflammatory reaction within the closed tendon sheath quickly erodes the paratenon, leading to adhesions and scarring, as well as increase in pressures within the tendon sheath that may lead to ischemia. The ultimate con-sequences are tendon necrosis, disruption of the tendon sheath, and digital contracture.Patients with infectious FTS present with pain, redness, and fever (Fig. 44-20). Physical examination reveals Kanavel’s “cardinal” signs of flexor tendon sheath infection: finger held in slight flexion, fusiform swelling, tenderness along the flexor ten-don sheath, and pain over the flexor sheath with passive |
Surgery_Schwartz_12835 | Surgery_Schwartz | “cardinal” signs of flexor tendon sheath infection: finger held in slight flexion, fusiform swelling, tenderness along the flexor ten-don sheath, and pain over the flexor sheath with passive exten-sion of the digit.77 Kanavel’s signs may be absent in patients who are immunocompromised, have early manifestations of Figure 44-20. Suppurative flexor tenosynovitis of the ring finger. A. The finger demonstrates fusiform swelling and flexed posture. B. Proximal exposure for drainage. C. Distal drainage incision.Brunicardi_Ch44_p1925-p1966.indd 195020/02/19 2:49 PM 1951SURGERY OF THE HAND AND WRISTCHAPTER 44infection, have recently received antibiotics, or have a chronic, indolent infection.If a patient presents with suspected infectious FTS, empiric intravenous antibiotics should be initiated. Prompt medical ther-apy in early cases may prevent the need for surgical drainage. For healthy individuals, empiric antibiotic therapy should cover Staphylococcus and Streptococcus. For | Surgery_Schwartz. “cardinal” signs of flexor tendon sheath infection: finger held in slight flexion, fusiform swelling, tenderness along the flexor ten-don sheath, and pain over the flexor sheath with passive exten-sion of the digit.77 Kanavel’s signs may be absent in patients who are immunocompromised, have early manifestations of Figure 44-20. Suppurative flexor tenosynovitis of the ring finger. A. The finger demonstrates fusiform swelling and flexed posture. B. Proximal exposure for drainage. C. Distal drainage incision.Brunicardi_Ch44_p1925-p1966.indd 195020/02/19 2:49 PM 1951SURGERY OF THE HAND AND WRISTCHAPTER 44infection, have recently received antibiotics, or have a chronic, indolent infection.If a patient presents with suspected infectious FTS, empiric intravenous antibiotics should be initiated. Prompt medical ther-apy in early cases may prevent the need for surgical drainage. For healthy individuals, empiric antibiotic therapy should cover Staphylococcus and Streptococcus. For |
Surgery_Schwartz_12836 | Surgery_Schwartz | be initiated. Prompt medical ther-apy in early cases may prevent the need for surgical drainage. For healthy individuals, empiric antibiotic therapy should cover Staphylococcus and Streptococcus. For immunocompromised patients (including diabetics) or infections associated with bite wounds, empiric treatment should include coverage of gram-negative organisms as well.78Adjuncts to antibiotics include splint immobilization (intrinsic plus position preferred) and elevation until infec-tion is under control. Hand rehabilitation (i.e., range-of-motion exercises and edema control) should be initiated once pain and inflammation are under control.If medical treatment alone is attempted, then initial inpa-tient observation is indicated. Surgical intervention is necessary if no obvious improvement has occurred within 12 to 24 hours.Several surgical approaches can be used to drain infectious FTS. The method used is based on the extent of the infection. Michon developed a classification scheme | Surgery_Schwartz. be initiated. Prompt medical ther-apy in early cases may prevent the need for surgical drainage. For healthy individuals, empiric antibiotic therapy should cover Staphylococcus and Streptococcus. For immunocompromised patients (including diabetics) or infections associated with bite wounds, empiric treatment should include coverage of gram-negative organisms as well.78Adjuncts to antibiotics include splint immobilization (intrinsic plus position preferred) and elevation until infec-tion is under control. Hand rehabilitation (i.e., range-of-motion exercises and edema control) should be initiated once pain and inflammation are under control.If medical treatment alone is attempted, then initial inpa-tient observation is indicated. Surgical intervention is necessary if no obvious improvement has occurred within 12 to 24 hours.Several surgical approaches can be used to drain infectious FTS. The method used is based on the extent of the infection. Michon developed a classification scheme |
Surgery_Schwartz_12837 | Surgery_Schwartz | has occurred within 12 to 24 hours.Several surgical approaches can be used to drain infectious FTS. The method used is based on the extent of the infection. Michon developed a classification scheme that can be use-ful in guiding surgical treatment (Table 44-1).79 Figure 44-20 (B and C) demonstrates drainage of a stage II FTS. A Brunner incision allows better initial exposure but may yield difficul-ties with tendon coverage if skin necrosis occurs. A 16-gauge catheter or 5-French pediatric feeding tube then is inserted into the tendon sheath through the proximal incision. The sheath is copiously irrigated with normal saline. Avoid excessive fluid extravasation into the soft tissue because the resulting increase in tissue pressure can lead to necrosis of the digit. The catheter is removed after irrigation. The incisions are left open. Some surgeons prefer a continuous irrigation technique for a period of 24 to 48 hours. The catheter is sewn in place, and a small drain is placed at the | Surgery_Schwartz. has occurred within 12 to 24 hours.Several surgical approaches can be used to drain infectious FTS. The method used is based on the extent of the infection. Michon developed a classification scheme that can be use-ful in guiding surgical treatment (Table 44-1).79 Figure 44-20 (B and C) demonstrates drainage of a stage II FTS. A Brunner incision allows better initial exposure but may yield difficul-ties with tendon coverage if skin necrosis occurs. A 16-gauge catheter or 5-French pediatric feeding tube then is inserted into the tendon sheath through the proximal incision. The sheath is copiously irrigated with normal saline. Avoid excessive fluid extravasation into the soft tissue because the resulting increase in tissue pressure can lead to necrosis of the digit. The catheter is removed after irrigation. The incisions are left open. Some surgeons prefer a continuous irrigation technique for a period of 24 to 48 hours. The catheter is sewn in place, and a small drain is placed at the |
Surgery_Schwartz_12838 | Surgery_Schwartz | after irrigation. The incisions are left open. Some surgeons prefer a continuous irrigation technique for a period of 24 to 48 hours. The catheter is sewn in place, and a small drain is placed at the distal incision site. Continuous or intermittent irrigation every 2 to 4 hours with sterile saline can then be per-formed through the indwelling catheter.After surgery, an intrinsic plus splint is applied, the hand is elevated, and the appropriate empiric antibiotic coverage is instituted while awaiting culture results. The hand is reexamined the following day. Whirlpool therapy and range of motion are begun. Drains are removed before discharge from the hospital. The wounds are left open to heal by secondary intention. In severe cases, repeat irrigation and operative debridement may be required.Antibiotic therapy is guided by culture results as well as clinical improvement. Once there is no further need for debride-ment, a 7to 14-day course of oral antibiotics is generally prescribed. | Surgery_Schwartz. after irrigation. The incisions are left open. Some surgeons prefer a continuous irrigation technique for a period of 24 to 48 hours. The catheter is sewn in place, and a small drain is placed at the distal incision site. Continuous or intermittent irrigation every 2 to 4 hours with sterile saline can then be per-formed through the indwelling catheter.After surgery, an intrinsic plus splint is applied, the hand is elevated, and the appropriate empiric antibiotic coverage is instituted while awaiting culture results. The hand is reexamined the following day. Whirlpool therapy and range of motion are begun. Drains are removed before discharge from the hospital. The wounds are left open to heal by secondary intention. In severe cases, repeat irrigation and operative debridement may be required.Antibiotic therapy is guided by culture results as well as clinical improvement. Once there is no further need for debride-ment, a 7to 14-day course of oral antibiotics is generally prescribed. |
Surgery_Schwartz_12839 | Surgery_Schwartz | therapy is guided by culture results as well as clinical improvement. Once there is no further need for debride-ment, a 7to 14-day course of oral antibiotics is generally prescribed. Consultation with an infectious disease specialist should be considered early in order to maximize efficiency and efficacy of therapy.FelonA felon is a subcutaneous abscess of the fingertip and is most commonly caused by penetrating trauma. S aureus is the most common pathogen. The fingertip contains multiple septa con-necting the distal phalanx to the skin. These septa are poorly compliant, and presence of an abscess will increase pressure and lead to severe pain and tissue death. Patients will experience erythema, swelling, and tenderness of the volar digital pad. Oral antibiotics may resolve the infection if diagnosed very early, but incision and drainage is indicated when fluctuance is identified. A digital block should be performed, followed by a longitudi-nal incision over the point of maximal | Surgery_Schwartz. therapy is guided by culture results as well as clinical improvement. Once there is no further need for debride-ment, a 7to 14-day course of oral antibiotics is generally prescribed. Consultation with an infectious disease specialist should be considered early in order to maximize efficiency and efficacy of therapy.FelonA felon is a subcutaneous abscess of the fingertip and is most commonly caused by penetrating trauma. S aureus is the most common pathogen. The fingertip contains multiple septa con-necting the distal phalanx to the skin. These septa are poorly compliant, and presence of an abscess will increase pressure and lead to severe pain and tissue death. Patients will experience erythema, swelling, and tenderness of the volar digital pad. Oral antibiotics may resolve the infection if diagnosed very early, but incision and drainage is indicated when fluctuance is identified. A digital block should be performed, followed by a longitudi-nal incision over the point of maximal |
Surgery_Schwartz_12840 | Surgery_Schwartz | if diagnosed very early, but incision and drainage is indicated when fluctuance is identified. A digital block should be performed, followed by a longitudi-nal incision over the point of maximal fluctuance (Fig. 44-21). Transverse and lateral incisions should be avoided, and the incision should never extend across the distal phalangeal joint crease. Deep incision should not be performed as this may cause seeding of bacteria into the flexor tendon sheath. The wound is irrigated and packed, with warm soapy water soaks and packing changes initiated within 24 hours and performed two to three times daily until secondarily healed. Antibiotic coverage should cover for Staphylococcus and Streptococcus species.73ParonychiaParonychia is an infection beneath the nail fold. The nail plate can be viewed as an invagination into the dorsal skin extend-ing down to the distal phalanx periosteum. Predisposing factors include anything that causes nail trauma, such as manicures, artificial nails, or nail | Surgery_Schwartz. if diagnosed very early, but incision and drainage is indicated when fluctuance is identified. A digital block should be performed, followed by a longitudi-nal incision over the point of maximal fluctuance (Fig. 44-21). Transverse and lateral incisions should be avoided, and the incision should never extend across the distal phalangeal joint crease. Deep incision should not be performed as this may cause seeding of bacteria into the flexor tendon sheath. The wound is irrigated and packed, with warm soapy water soaks and packing changes initiated within 24 hours and performed two to three times daily until secondarily healed. Antibiotic coverage should cover for Staphylococcus and Streptococcus species.73ParonychiaParonychia is an infection beneath the nail fold. The nail plate can be viewed as an invagination into the dorsal skin extend-ing down to the distal phalanx periosteum. Predisposing factors include anything that causes nail trauma, such as manicures, artificial nails, or nail |
Surgery_Schwartz_12841 | Surgery_Schwartz | as an invagination into the dorsal skin extend-ing down to the distal phalanx periosteum. Predisposing factors include anything that causes nail trauma, such as manicures, artificial nails, or nail biting. The infection may spread around Table 44-1Michon’s stages of suppurative flexor tenosynovitis and appropriate treatmentSTAGEFINDINGSTREATMENTIIncreased fluid in sheath, mainly a serous exudateCatheter irrigationIIPurulent fluid, granulomatous synoviumMinimal invasive drainage ± indwelling catheter irrigationIIINecrosis of the tendon, pulleys, or tendon sheathExtensive open debridement and possible amputationBAFigure 44-21. Felon. A. Lateral view of the digit showing fluctu-ance between the skin of the pad and the underlying distal phalanx bone. B. The authors prefer to drain felons with a longitudinal inci-sion (dashed line) directly over the area of maximal fluctuance.Brunicardi_Ch44_p1925-p1966.indd 195120/02/19 2:49 PM 1952SPECIFIC CONSIDERATIONSPART IIthe nail plate from | Surgery_Schwartz. as an invagination into the dorsal skin extend-ing down to the distal phalanx periosteum. Predisposing factors include anything that causes nail trauma, such as manicures, artificial nails, or nail biting. The infection may spread around Table 44-1Michon’s stages of suppurative flexor tenosynovitis and appropriate treatmentSTAGEFINDINGSTREATMENTIIncreased fluid in sheath, mainly a serous exudateCatheter irrigationIIPurulent fluid, granulomatous synoviumMinimal invasive drainage ± indwelling catheter irrigationIIINecrosis of the tendon, pulleys, or tendon sheathExtensive open debridement and possible amputationBAFigure 44-21. Felon. A. Lateral view of the digit showing fluctu-ance between the skin of the pad and the underlying distal phalanx bone. B. The authors prefer to drain felons with a longitudinal inci-sion (dashed line) directly over the area of maximal fluctuance.Brunicardi_Ch44_p1925-p1966.indd 195120/02/19 2:49 PM 1952SPECIFIC CONSIDERATIONSPART IIthe nail plate from |
Surgery_Schwartz_12842 | Surgery_Schwartz | a longitudinal inci-sion (dashed line) directly over the area of maximal fluctuance.Brunicardi_Ch44_p1925-p1966.indd 195120/02/19 2:49 PM 1952SPECIFIC CONSIDERATIONSPART IIthe nail plate from one side to the other, or it may extend into the pulp and result in a felon. An acute paronychia is usually caused by S aureus or Streptococcal species. Patients report pain, ery-thema, swelling, and possibly purulent drainage involving the periungual tissue. Treatment consists of warm water soaks and oral antibiotics if diagnosed early. If purulence or fluctu-ance is present, then a freer elevator or 18-gauge needle can be passed along the involved nail fold to decompress the collection (Fig. 44-22). If the infection involves the eponychial fold, a small proximally based flap of eponychium is created by using a scalpel, followed by irrigation and packing. The nail plate must be removed if the infection extends beneath the nail plate. Packing is kept in place for 24 to 48 hours, followed by | Surgery_Schwartz. a longitudinal inci-sion (dashed line) directly over the area of maximal fluctuance.Brunicardi_Ch44_p1925-p1966.indd 195120/02/19 2:49 PM 1952SPECIFIC CONSIDERATIONSPART IIthe nail plate from one side to the other, or it may extend into the pulp and result in a felon. An acute paronychia is usually caused by S aureus or Streptococcal species. Patients report pain, ery-thema, swelling, and possibly purulent drainage involving the periungual tissue. Treatment consists of warm water soaks and oral antibiotics if diagnosed early. If purulence or fluctu-ance is present, then a freer elevator or 18-gauge needle can be passed along the involved nail fold to decompress the collection (Fig. 44-22). If the infection involves the eponychial fold, a small proximally based flap of eponychium is created by using a scalpel, followed by irrigation and packing. The nail plate must be removed if the infection extends beneath the nail plate. Packing is kept in place for 24 to 48 hours, followed by |
Surgery_Schwartz_12843 | Surgery_Schwartz | by using a scalpel, followed by irrigation and packing. The nail plate must be removed if the infection extends beneath the nail plate. Packing is kept in place for 24 to 48 hours, followed by warm water soaks and local wound care. Usually, the wound cannot be repacked once the dressing is removed.73A chronic paronychia is most commonly caused by Can-dida species and is most often found in patients who perform jobs involving the submersion of their hands in water or other moist environments. These develop into thickened nails with callus-like formation along the nail folds and may occasion-ally become red and inflamed. They do not respond to antibi-otic treatment, and nail plate removal with marsupialization of the skin proximal to the eponychial fold will allow the wound to heal secondarily. The environmental factors leading to the chronic paronychia must also be corrected in order for treatment to be successful.All hand infections other than cellulitis will require surgi-cal | Surgery_Schwartz. by using a scalpel, followed by irrigation and packing. The nail plate must be removed if the infection extends beneath the nail plate. Packing is kept in place for 24 to 48 hours, followed by warm water soaks and local wound care. Usually, the wound cannot be repacked once the dressing is removed.73A chronic paronychia is most commonly caused by Can-dida species and is most often found in patients who perform jobs involving the submersion of their hands in water or other moist environments. These develop into thickened nails with callus-like formation along the nail folds and may occasion-ally become red and inflamed. They do not respond to antibi-otic treatment, and nail plate removal with marsupialization of the skin proximal to the eponychial fold will allow the wound to heal secondarily. The environmental factors leading to the chronic paronychia must also be corrected in order for treatment to be successful.All hand infections other than cellulitis will require surgi-cal |
Surgery_Schwartz_12844 | Surgery_Schwartz | The environmental factors leading to the chronic paronychia must also be corrected in order for treatment to be successful.All hand infections other than cellulitis will require surgi-cal management. Clinical examination, particularly noting the area of greatest tenderness and/or inflammation, is the single most useful diagnostic tool to localize any puru-lence requiring drainage. Specific recommendations for differ-entiating among the possible locations of hand infection are included in the diagnostic algorithm shown in Fig. 44-23.TUMORSTumors of the hand and upper extremity can be classified as benign soft tissue tumors; malignant soft tissue tumors (subclas-sified into cutaneous and noncutaneous malignancies); benign bony tumors; malignant bony tumors; and secondary metastatic tumors. Initial investigation for any mass starts with a complete 6ABAFigure 44-22. Paronychia. A. Fluctuance in the nail fold is the hallmark of this infection. B. The authors prefer to drain a paro-nychia | Surgery_Schwartz. The environmental factors leading to the chronic paronychia must also be corrected in order for treatment to be successful.All hand infections other than cellulitis will require surgi-cal management. Clinical examination, particularly noting the area of greatest tenderness and/or inflammation, is the single most useful diagnostic tool to localize any puru-lence requiring drainage. Specific recommendations for differ-entiating among the possible locations of hand infection are included in the diagnostic algorithm shown in Fig. 44-23.TUMORSTumors of the hand and upper extremity can be classified as benign soft tissue tumors; malignant soft tissue tumors (subclas-sified into cutaneous and noncutaneous malignancies); benign bony tumors; malignant bony tumors; and secondary metastatic tumors. Initial investigation for any mass starts with a complete 6ABAFigure 44-22. Paronychia. A. Fluctuance in the nail fold is the hallmark of this infection. B. The authors prefer to drain a paro-nychia |
Surgery_Schwartz_12845 | Surgery_Schwartz | Initial investigation for any mass starts with a complete 6ABAFigure 44-22. Paronychia. A. Fluctuance in the nail fold is the hallmark of this infection. B. The authors prefer to drain a paro-nychia using the bevel of an 18-gauge needle inserted between the nail fold and the nail plate at the location of maximal fluctuance.NondiagnosticFractureForeign bodyCellulitisadmit, IV Abxserial examSite of fluctuanceEntire fingerseYoNPyogenic FTSKanavel’ssigns presentMRI if nofluctuanceSubcutaneousabscessThenarabscessMidpalmabscessHypothenarabscessDistalLoss ofpalmarconcavityRadial toIF MCUlnar toSF MCWeb spaceabscessPalmPain withaxial loadingof jointPyogenic vs.crystallinearthritisConsiderarthrocentesisNo improvementin 48 hoursHand inflammationPlain X-raysPartial fingerDorsalCenteredon jointBetweendigitsLocalized fluctuanceFigure 44-23. Diagnostic algorithm. Diagnostic workup for a patient with hand inflammation to evaluate for infection. See text for details about particular infectious | Surgery_Schwartz. Initial investigation for any mass starts with a complete 6ABAFigure 44-22. Paronychia. A. Fluctuance in the nail fold is the hallmark of this infection. B. The authors prefer to drain a paro-nychia using the bevel of an 18-gauge needle inserted between the nail fold and the nail plate at the location of maximal fluctuance.NondiagnosticFractureForeign bodyCellulitisadmit, IV Abxserial examSite of fluctuanceEntire fingerseYoNPyogenic FTSKanavel’ssigns presentMRI if nofluctuanceSubcutaneousabscessThenarabscessMidpalmabscessHypothenarabscessDistalLoss ofpalmarconcavityRadial toIF MCUlnar toSF MCWeb spaceabscessPalmPain withaxial loadingof jointPyogenic vs.crystallinearthritisConsiderarthrocentesisNo improvementin 48 hoursHand inflammationPlain X-raysPartial fingerDorsalCenteredon jointBetweendigitsLocalized fluctuanceFigure 44-23. Diagnostic algorithm. Diagnostic workup for a patient with hand inflammation to evaluate for infection. See text for details about particular infectious |
Surgery_Schwartz_12846 | Surgery_Schwartz | fluctuanceFigure 44-23. Diagnostic algorithm. Diagnostic workup for a patient with hand inflammation to evaluate for infection. See text for details about particular infectious diagnoses. Abx = antibiotics; FTS = flexor tenosynovitis; IF MC = index finger metacarpal; MRI = magnetic resonance imaging; SF MC = small finger metacarpal.Brunicardi_Ch44_p1925-p1966.indd 195220/02/19 2:49 PM 1953SURGERY OF THE HAND AND WRISTCHAPTER 44history and physical exam. Hand and/or wrist X-rays should be obtained in every patient presenting with a mass unless clearly not indicated (e.g., a superficial skin lesion with no aggressive/malignant features). The workup proceeds in an orderly fashion until a diagnosis is obtained. Once a benign diagnosis is secured (by strong clinical suspicion in an experienced hand surgeon, radiographic evidence, or tissue biopsy), further workup is not needed; this may occur at any point in the workup of a mass.Most hand masses are benign and can be readily diagnosed | Surgery_Schwartz. fluctuanceFigure 44-23. Diagnostic algorithm. Diagnostic workup for a patient with hand inflammation to evaluate for infection. See text for details about particular infectious diagnoses. Abx = antibiotics; FTS = flexor tenosynovitis; IF MC = index finger metacarpal; MRI = magnetic resonance imaging; SF MC = small finger metacarpal.Brunicardi_Ch44_p1925-p1966.indd 195220/02/19 2:49 PM 1953SURGERY OF THE HAND AND WRISTCHAPTER 44history and physical exam. Hand and/or wrist X-rays should be obtained in every patient presenting with a mass unless clearly not indicated (e.g., a superficial skin lesion with no aggressive/malignant features). The workup proceeds in an orderly fashion until a diagnosis is obtained. Once a benign diagnosis is secured (by strong clinical suspicion in an experienced hand surgeon, radiographic evidence, or tissue biopsy), further workup is not needed; this may occur at any point in the workup of a mass.Most hand masses are benign and can be readily diagnosed |
Surgery_Schwartz_12847 | Surgery_Schwartz | hand surgeon, radiographic evidence, or tissue biopsy), further workup is not needed; this may occur at any point in the workup of a mass.Most hand masses are benign and can be readily diagnosed without advanced imaging or tissue biopsy. When necessary, additional workup may include baseline laboratory studies, CT and/or MRI of the involved region, and a bone scan or positron emission tomography (PET) scan. Staging of a malignant tumor may occur before biopsy if a malignancy is strongly suspected, or it may occur after formal biopsy. Staging includes a chest X-ray and CT with intravenous contrast of the chest, abdomen, and pelvis to detect possible metastasis. Biopsy of the mass is always the last step of a workup and should occur only after all other available information has been gathered. Any mass that is over 5 cm in size, is rapidly increasing in size (as judged by an experienced surgeon or oncologist), is symptomatic or painful, or has an aggressive clinical or radiographic | Surgery_Schwartz. hand surgeon, radiographic evidence, or tissue biopsy), further workup is not needed; this may occur at any point in the workup of a mass.Most hand masses are benign and can be readily diagnosed without advanced imaging or tissue biopsy. When necessary, additional workup may include baseline laboratory studies, CT and/or MRI of the involved region, and a bone scan or positron emission tomography (PET) scan. Staging of a malignant tumor may occur before biopsy if a malignancy is strongly suspected, or it may occur after formal biopsy. Staging includes a chest X-ray and CT with intravenous contrast of the chest, abdomen, and pelvis to detect possible metastasis. Biopsy of the mass is always the last step of a workup and should occur only after all other available information has been gathered. Any mass that is over 5 cm in size, is rapidly increasing in size (as judged by an experienced surgeon or oncologist), is symptomatic or painful, or has an aggressive clinical or radiographic |
Surgery_Schwartz_12848 | Surgery_Schwartz | Any mass that is over 5 cm in size, is rapidly increasing in size (as judged by an experienced surgeon or oncologist), is symptomatic or painful, or has an aggressive clinical or radiographic appearance war-rants workup and biopsy to rule out malignancy.CT scans are useful for detecting bony tumor extension across planes and identifying tumors of small bones, such as the carpal bones. MRI is useful for evaluating soft tissue tumor involvement (e.g., which muscle compartments are involved) as well as intramedullary lesions. Most soft tissue tumors will appear dark on T1-weighted images and bright on T2-weighted images. Hematomas, hemangiomas, lipomas, liposarcomas, and adipose tissue will appear bright on T1-weighted images and dark on T2-weighted images. Scintigraphy uses methylene diphosphonate attached to technetium-99m. This complex will attach to hydroxyapatite. Immediate uptake is seen in areas of increased vascularity, such as infection, trauma, and neoplasia. Increased uptake 2 | Surgery_Schwartz. Any mass that is over 5 cm in size, is rapidly increasing in size (as judged by an experienced surgeon or oncologist), is symptomatic or painful, or has an aggressive clinical or radiographic appearance war-rants workup and biopsy to rule out malignancy.CT scans are useful for detecting bony tumor extension across planes and identifying tumors of small bones, such as the carpal bones. MRI is useful for evaluating soft tissue tumor involvement (e.g., which muscle compartments are involved) as well as intramedullary lesions. Most soft tissue tumors will appear dark on T1-weighted images and bright on T2-weighted images. Hematomas, hemangiomas, lipomas, liposarcomas, and adipose tissue will appear bright on T1-weighted images and dark on T2-weighted images. Scintigraphy uses methylene diphosphonate attached to technetium-99m. This complex will attach to hydroxyapatite. Immediate uptake is seen in areas of increased vascularity, such as infection, trauma, and neoplasia. Increased uptake 2 |
Surgery_Schwartz_12849 | Surgery_Schwartz | attached to technetium-99m. This complex will attach to hydroxyapatite. Immediate uptake is seen in areas of increased vascularity, such as infection, trauma, and neoplasia. Increased uptake 2 to 3 hours later is seen in “pooled” areas where new bone formation has occurred. This modality is useful for detecting areas of tumor invasion or metastases not other-wise seen on prior CT, MRI, or radiographs.Biopsy is reserved for masses that cannot be diagnosed as benign based on prior clinical and radiographic exams. Needle biopsy is not reliable for primary diagnosis, but it can be use-ful for recurrent or metastatic disease. Open excisional (if mass is less than 5 cm in size) or incisional (if mass is greater than 5 cm in size) biopsy is the most common biopsy method. Proper surgical oncologic technique is strictly adhered to in order to prevent tumor spread into uninvolved tissues or compartments. This includes making all incisions longitudinally using sharp dissection and meticulous | Surgery_Schwartz. attached to technetium-99m. This complex will attach to hydroxyapatite. Immediate uptake is seen in areas of increased vascularity, such as infection, trauma, and neoplasia. Increased uptake 2 to 3 hours later is seen in “pooled” areas where new bone formation has occurred. This modality is useful for detecting areas of tumor invasion or metastases not other-wise seen on prior CT, MRI, or radiographs.Biopsy is reserved for masses that cannot be diagnosed as benign based on prior clinical and radiographic exams. Needle biopsy is not reliable for primary diagnosis, but it can be use-ful for recurrent or metastatic disease. Open excisional (if mass is less than 5 cm in size) or incisional (if mass is greater than 5 cm in size) biopsy is the most common biopsy method. Proper surgical oncologic technique is strictly adhered to in order to prevent tumor spread into uninvolved tissues or compartments. This includes making all incisions longitudinally using sharp dissection and meticulous |
Surgery_Schwartz_12850 | Surgery_Schwartz | technique is strictly adhered to in order to prevent tumor spread into uninvolved tissues or compartments. This includes making all incisions longitudinally using sharp dissection and meticulous hemostasis; carrying the incision directly down to the tumor with no development of tissue planes (i.e., making a straight-line path from skin to tumor); incising through the fewest number of muscle compartments; and avoid-ing critical neurovascular structures. The CT or MRI images will help determine the best surgical approach for biopsy or resection in order to avoid uninvolved compartments and criti-cal structures.80Benign Soft Tissue TumorsGanglion Cyst. This is the most common soft tissue tumor of the hand and wrist, comprising 50% to 70% of all soft tis-sue tumors in this region. They can occur at any age but are most common in the second to fourth decades with a slight predilection toward females. Patients may report a slowgrowing soft mass that may fluctuate in size and can sometimes | Surgery_Schwartz. technique is strictly adhered to in order to prevent tumor spread into uninvolved tissues or compartments. This includes making all incisions longitudinally using sharp dissection and meticulous hemostasis; carrying the incision directly down to the tumor with no development of tissue planes (i.e., making a straight-line path from skin to tumor); incising through the fewest number of muscle compartments; and avoid-ing critical neurovascular structures. The CT or MRI images will help determine the best surgical approach for biopsy or resection in order to avoid uninvolved compartments and criti-cal structures.80Benign Soft Tissue TumorsGanglion Cyst. This is the most common soft tissue tumor of the hand and wrist, comprising 50% to 70% of all soft tis-sue tumors in this region. They can occur at any age but are most common in the second to fourth decades with a slight predilection toward females. Patients may report a slowgrowing soft mass that may fluctuate in size and can sometimes |
Surgery_Schwartz_12851 | Surgery_Schwartz | at any age but are most common in the second to fourth decades with a slight predilection toward females. Patients may report a slowgrowing soft mass that may fluctuate in size and can sometimes be associated with mild pain. Compressive neuropathies may be seen if they occur in Guyon’s canal or the carpal tunnel, but they are uncommon. There are no reports of malignant degeneration. History and physical exam are usually sufficient to establish a diagnosis. Occurrence by location is as follows: 60% to 70% occur on the dorsal wrist between the third and fourth exten-sor compartments and are connected by a stalk to the scaph-olunate ligament (Fig. 44-24); 18% to 20% occur on the volar wrist; and 10% to 12% occur in the digits as volar retinacular or flexor tendon sheath cysts. The cyst transilluminates. There is always a stalk that communicates with the underlying joint or tendon sheath. The cyst wall is composed of compressed col-lagen fibers with no epithelial or synovial cells | Surgery_Schwartz. at any age but are most common in the second to fourth decades with a slight predilection toward females. Patients may report a slowgrowing soft mass that may fluctuate in size and can sometimes be associated with mild pain. Compressive neuropathies may be seen if they occur in Guyon’s canal or the carpal tunnel, but they are uncommon. There are no reports of malignant degeneration. History and physical exam are usually sufficient to establish a diagnosis. Occurrence by location is as follows: 60% to 70% occur on the dorsal wrist between the third and fourth exten-sor compartments and are connected by a stalk to the scaph-olunate ligament (Fig. 44-24); 18% to 20% occur on the volar wrist; and 10% to 12% occur in the digits as volar retinacular or flexor tendon sheath cysts. The cyst transilluminates. There is always a stalk that communicates with the underlying joint or tendon sheath. The cyst wall is composed of compressed col-lagen fibers with no epithelial or synovial cells |
Surgery_Schwartz_12852 | Surgery_Schwartz | transilluminates. There is always a stalk that communicates with the underlying joint or tendon sheath. The cyst wall is composed of compressed col-lagen fibers with no epithelial or synovial cells present. Clear viscous mucin fills the cyst and is composed of glucosamine, albumin, globulin, and hyaluronic acid. The etiology is unclear. The most accepted theory currently is Angelides’ who proposed that repeated stress of a joint, ligament, or tendon sheath causes an increase of mucin-producing cells and subsequent mucin pro-duction. The increased mucin production dissects superficially and coalesces into a cyst. The successful treatment of dorsal ganglion cysts by excising only the stalk supports this theory.80Treatment consists of observation if asymptomatic. If symptoms exist or the patient desires removal for cosmetic appearance, aspiration of the cyst may be performed with a Figure 44-24. Dorsal wrist ganglion cyst. These typically occur between the third and fourth dorsal | Surgery_Schwartz. transilluminates. There is always a stalk that communicates with the underlying joint or tendon sheath. The cyst wall is composed of compressed col-lagen fibers with no epithelial or synovial cells present. Clear viscous mucin fills the cyst and is composed of glucosamine, albumin, globulin, and hyaluronic acid. The etiology is unclear. The most accepted theory currently is Angelides’ who proposed that repeated stress of a joint, ligament, or tendon sheath causes an increase of mucin-producing cells and subsequent mucin pro-duction. The increased mucin production dissects superficially and coalesces into a cyst. The successful treatment of dorsal ganglion cysts by excising only the stalk supports this theory.80Treatment consists of observation if asymptomatic. If symptoms exist or the patient desires removal for cosmetic appearance, aspiration of the cyst may be performed with a Figure 44-24. Dorsal wrist ganglion cyst. These typically occur between the third and fourth dorsal |
Surgery_Schwartz_12853 | Surgery_Schwartz | the patient desires removal for cosmetic appearance, aspiration of the cyst may be performed with a Figure 44-24. Dorsal wrist ganglion cyst. These typically occur between the third and fourth dorsal extensor compartments and have a stalk connecting the base of the cyst to the scapholunate ligament.Brunicardi_Ch44_p1925-p1966.indd 195320/02/19 2:49 PM 1954SPECIFIC CONSIDERATIONSPART IIsuccessful cure rate ranging from 15% to 89%. The benefit of injected steroids is inconclusive. Aspiration of a volar wrist ganglion cyst can be dangerous due to the potential of injur-ing neurovascular structures. Open excision and arthroscopic excision of the cyst stalk are surgical options for cysts that are not amendable to aspiration. A recent meta-analysis reported recurrence rates after either needle aspiration, open excision, and arthroscopic excision as 59%, 21%, and 6%, respectively.81Mucous Cyst. A mucous cyst is a ganglion cyst of the DIP joint. They occur most commonly in the fifth to | Surgery_Schwartz. the patient desires removal for cosmetic appearance, aspiration of the cyst may be performed with a Figure 44-24. Dorsal wrist ganglion cyst. These typically occur between the third and fourth dorsal extensor compartments and have a stalk connecting the base of the cyst to the scapholunate ligament.Brunicardi_Ch44_p1925-p1966.indd 195320/02/19 2:49 PM 1954SPECIFIC CONSIDERATIONSPART IIsuccessful cure rate ranging from 15% to 89%. The benefit of injected steroids is inconclusive. Aspiration of a volar wrist ganglion cyst can be dangerous due to the potential of injur-ing neurovascular structures. Open excision and arthroscopic excision of the cyst stalk are surgical options for cysts that are not amendable to aspiration. A recent meta-analysis reported recurrence rates after either needle aspiration, open excision, and arthroscopic excision as 59%, 21%, and 6%, respectively.81Mucous Cyst. A mucous cyst is a ganglion cyst of the DIP joint. They occur most commonly in the fifth to |
Surgery_Schwartz_12854 | Surgery_Schwartz | aspiration, open excision, and arthroscopic excision as 59%, 21%, and 6%, respectively.81Mucous Cyst. A mucous cyst is a ganglion cyst of the DIP joint. They occur most commonly in the fifth to seventh decades, and the underlying cause is associated osteoarthritis of the DIP joint. They are slow growing and usually occur on one side of the ter-minal extensor tendon between the DIP joint and the eponych-ium. The earliest clinical sign is often longitudinal grooving of the involved nail plate followed by a small enlarging mass and then attenuation of overlying skin. X-rays will show signs of osteoarthritis within the DIP joint. Heberden nodes (osteophytes within the DIP joint) are often seen on X-ray.Possible treatment includes observation, aspiration, or excision. If the cyst is not draining and the overlying skin is intact, the patient may be offered reassurance. A draining cyst poses risk of DIP joint infection due to the tract communicating with the DIP joint and should be excised. | Surgery_Schwartz. aspiration, open excision, and arthroscopic excision as 59%, 21%, and 6%, respectively.81Mucous Cyst. A mucous cyst is a ganglion cyst of the DIP joint. They occur most commonly in the fifth to seventh decades, and the underlying cause is associated osteoarthritis of the DIP joint. They are slow growing and usually occur on one side of the ter-minal extensor tendon between the DIP joint and the eponych-ium. The earliest clinical sign is often longitudinal grooving of the involved nail plate followed by a small enlarging mass and then attenuation of overlying skin. X-rays will show signs of osteoarthritis within the DIP joint. Heberden nodes (osteophytes within the DIP joint) are often seen on X-ray.Possible treatment includes observation, aspiration, or excision. If the cyst is not draining and the overlying skin is intact, the patient may be offered reassurance. A draining cyst poses risk of DIP joint infection due to the tract communicating with the DIP joint and should be excised. |
Surgery_Schwartz_12855 | Surgery_Schwartz | and the overlying skin is intact, the patient may be offered reassurance. A draining cyst poses risk of DIP joint infection due to the tract communicating with the DIP joint and should be excised. If the cyst is symp-tomatic, painful, or the patient desires removal for cosmetic pur-poses, excision should be performed. Any osteophytes in the DIP joint must be removed to reduce recurrence. Aspiration is an option for treatment, but this poses the risk of DIP joint infec-tion through seeding of bacteria into the joint or by the devel-opment of a draining sinus tract. It is generally not performed.Giant Cell Tumor of the Tendon Sheath. Also known as a xanthosarcoma, fibrous xanthoma, localized nodular synovitis, sclerosing hemangioma, or pigmented villonodular tenosynovi-tis, giant cell tumor of the tendon sheath is the second most com-mon soft tissue mass of the hand and wrist. It is a benign lesion with no clear pathogenesis. The tumor is a growth of polyclonal cells with no risk of | Surgery_Schwartz. and the overlying skin is intact, the patient may be offered reassurance. A draining cyst poses risk of DIP joint infection due to the tract communicating with the DIP joint and should be excised. If the cyst is symp-tomatic, painful, or the patient desires removal for cosmetic pur-poses, excision should be performed. Any osteophytes in the DIP joint must be removed to reduce recurrence. Aspiration is an option for treatment, but this poses the risk of DIP joint infec-tion through seeding of bacteria into the joint or by the devel-opment of a draining sinus tract. It is generally not performed.Giant Cell Tumor of the Tendon Sheath. Also known as a xanthosarcoma, fibrous xanthoma, localized nodular synovitis, sclerosing hemangioma, or pigmented villonodular tenosynovi-tis, giant cell tumor of the tendon sheath is the second most com-mon soft tissue mass of the hand and wrist. It is a benign lesion with no clear pathogenesis. The tumor is a growth of polyclonal cells with no risk of |
Surgery_Schwartz_12856 | Surgery_Schwartz | of the tendon sheath is the second most com-mon soft tissue mass of the hand and wrist. It is a benign lesion with no clear pathogenesis. The tumor is a growth of polyclonal cells with no risk of malignant transformation. Despite the simi-larity in name, it is not histopathologically related to giant cell tumor of the bone.82Giant cell tumor of the tendon sheath occurs as a firm slow-growing painless mass over months to years and will often feel bumpy or nodular, which is a distinguishing characteristic helpful for diagnosis. It has a predilection for occurring in close proximity to joints along flexor surfaces of the wrist, hands, and digits (especially the PIP joints of the radial digits) and occurs most commonly between the second and fifth decades (Fig. 44-25A). These tumors do not transilluminate. Direct extension into joints and ligaments can make complete exci-sion difficult. Gross appearance of the tumor will show a wellcircumscribed nodular firm mass with a deep brown color | Surgery_Schwartz. of the tendon sheath is the second most com-mon soft tissue mass of the hand and wrist. It is a benign lesion with no clear pathogenesis. The tumor is a growth of polyclonal cells with no risk of malignant transformation. Despite the simi-larity in name, it is not histopathologically related to giant cell tumor of the bone.82Giant cell tumor of the tendon sheath occurs as a firm slow-growing painless mass over months to years and will often feel bumpy or nodular, which is a distinguishing characteristic helpful for diagnosis. It has a predilection for occurring in close proximity to joints along flexor surfaces of the wrist, hands, and digits (especially the PIP joints of the radial digits) and occurs most commonly between the second and fifth decades (Fig. 44-25A). These tumors do not transilluminate. Direct extension into joints and ligaments can make complete exci-sion difficult. Gross appearance of the tumor will show a wellcircumscribed nodular firm mass with a deep brown color |
Surgery_Schwartz_12857 | Surgery_Schwartz | Direct extension into joints and ligaments can make complete exci-sion difficult. Gross appearance of the tumor will show a wellcircumscribed nodular firm mass with a deep brown color due to the large amount of hemosiderin content, which is easily detected on histologic staining (Fig. 44-25B). Multinucleated giant cells and hemosiderin-laden macrophages are characteristic.80This tumor is not visible on radiographs. Approximately 20% will show extrinsic cortical erosion on X-ray. This is a risk factor for recurrence, and removal of the cortical shell should be considered. MRI is useful for delineating involvement with tendons, ligaments, and joints.The standard treatment is marginal excision. These tumors will often grow next to or around neurovascular bundles, and an Allen’s test should always be performed preoperatively to con-firm adequate blood supply by both ulnar and radial arteries as Figure 44-25. Giant cell tumor of tendon sheath. A. The mass pro-duces lobulated enlargement of | Surgery_Schwartz. Direct extension into joints and ligaments can make complete exci-sion difficult. Gross appearance of the tumor will show a wellcircumscribed nodular firm mass with a deep brown color due to the large amount of hemosiderin content, which is easily detected on histologic staining (Fig. 44-25B). Multinucleated giant cells and hemosiderin-laden macrophages are characteristic.80This tumor is not visible on radiographs. Approximately 20% will show extrinsic cortical erosion on X-ray. This is a risk factor for recurrence, and removal of the cortical shell should be considered. MRI is useful for delineating involvement with tendons, ligaments, and joints.The standard treatment is marginal excision. These tumors will often grow next to or around neurovascular bundles, and an Allen’s test should always be performed preoperatively to con-firm adequate blood supply by both ulnar and radial arteries as Figure 44-25. Giant cell tumor of tendon sheath. A. The mass pro-duces lobulated enlargement of |
Surgery_Schwartz_12858 | Surgery_Schwartz | be performed preoperatively to con-firm adequate blood supply by both ulnar and radial arteries as Figure 44-25. Giant cell tumor of tendon sheath. A. The mass pro-duces lobulated enlargement of the external finger. B. The excised giant cell tumor has a multilobulated, tan-brown appearance.ABwell as dual blood supply to an involved digit via the ulnar and radial proper digital arteries. It is important to completely excise the stalk because this will greatly reduce tumor recurrence even in the setting of residual tumor. If tumor is suspected to have extended into the joint, the joint must be opened and all tumor removed. Despite this being a benign lesion, local recurrence is varies widely from 4% to 44%. Some variants can mimic more aggressive processes, and malignancy must be considered if aggressive features are identified, such as direct bony invasion.82Lipoma. Lipomas of the hand and wrist may occur in multiple anatomic locations, including subcutaneous tissues; intramus-cularly | Surgery_Schwartz. be performed preoperatively to con-firm adequate blood supply by both ulnar and radial arteries as Figure 44-25. Giant cell tumor of tendon sheath. A. The mass pro-duces lobulated enlargement of the external finger. B. The excised giant cell tumor has a multilobulated, tan-brown appearance.ABwell as dual blood supply to an involved digit via the ulnar and radial proper digital arteries. It is important to completely excise the stalk because this will greatly reduce tumor recurrence even in the setting of residual tumor. If tumor is suspected to have extended into the joint, the joint must be opened and all tumor removed. Despite this being a benign lesion, local recurrence is varies widely from 4% to 44%. Some variants can mimic more aggressive processes, and malignancy must be considered if aggressive features are identified, such as direct bony invasion.82Lipoma. Lipomas of the hand and wrist may occur in multiple anatomic locations, including subcutaneous tissues; intramus-cularly |
Surgery_Schwartz_12859 | Surgery_Schwartz | if aggressive features are identified, such as direct bony invasion.82Lipoma. Lipomas of the hand and wrist may occur in multiple anatomic locations, including subcutaneous tissues; intramus-cularly (especially thenar or hypothenar muscles); deep spaces; carpal tunnel or Guyon’s canal; and rarely bone or nerve. They typically present as a painless, slow-growing, soft, and mobile mass over a period of months to years. Painful findings sug-gest close approximation to a neurovascular structure or, less commonly, a malignant lesion such as liposarcoma. Lipomas do not transilluminate. They resemble mature fat histologically. X-rays typically reveal no abnormality. MRI is a helpful imag-ing modality to evaluate a lipoma and will show signal charac-teristics that are suggestive of adipose tissue.80Asymptomatic lesions with no aggressive findings may be observed. Marginal excision is recommended for symptomatic, painful, or enlarging lipomas or those that cause dysfunction. MRI is recommended | Surgery_Schwartz. if aggressive features are identified, such as direct bony invasion.82Lipoma. Lipomas of the hand and wrist may occur in multiple anatomic locations, including subcutaneous tissues; intramus-cularly (especially thenar or hypothenar muscles); deep spaces; carpal tunnel or Guyon’s canal; and rarely bone or nerve. They typically present as a painless, slow-growing, soft, and mobile mass over a period of months to years. Painful findings sug-gest close approximation to a neurovascular structure or, less commonly, a malignant lesion such as liposarcoma. Lipomas do not transilluminate. They resemble mature fat histologically. X-rays typically reveal no abnormality. MRI is a helpful imag-ing modality to evaluate a lipoma and will show signal charac-teristics that are suggestive of adipose tissue.80Asymptomatic lesions with no aggressive findings may be observed. Marginal excision is recommended for symptomatic, painful, or enlarging lipomas or those that cause dysfunction. MRI is recommended |
Surgery_Schwartz_12860 | Surgery_Schwartz | lesions with no aggressive findings may be observed. Marginal excision is recommended for symptomatic, painful, or enlarging lipomas or those that cause dysfunction. MRI is recommended for deep lipomas to evaluate proxim-ity or involvement of critical structures, followed by marginal excision if MRI findings are consistent with a lipoma. If MRI findings are not consistent with a lipoma, incisional biopsy is warranted. Recurrence after marginal excision is rare.80Brunicardi_Ch44_p1925-p1966.indd 195420/02/19 2:50 PM 1955SURGERY OF THE HAND AND WRISTCHAPTER 44Schwannoma. A schwannoma, also known as a neurilem-moma, is a type of benign peripheral nerve sheath tumor. It is the most common benign peripheral nerve sheath tumor of the upper extremity.83 The majority occur as single solitary masses. Patients with neurofibromatosis type 1 (NF1) or 2 (NF2) may develop multiple schwannomas involving large peripheral nerve trunks or bilateral acoustic schwannomas, respectively. These tumors | Surgery_Schwartz. lesions with no aggressive findings may be observed. Marginal excision is recommended for symptomatic, painful, or enlarging lipomas or those that cause dysfunction. MRI is recommended for deep lipomas to evaluate proxim-ity or involvement of critical structures, followed by marginal excision if MRI findings are consistent with a lipoma. If MRI findings are not consistent with a lipoma, incisional biopsy is warranted. Recurrence after marginal excision is rare.80Brunicardi_Ch44_p1925-p1966.indd 195420/02/19 2:50 PM 1955SURGERY OF THE HAND AND WRISTCHAPTER 44Schwannoma. A schwannoma, also known as a neurilem-moma, is a type of benign peripheral nerve sheath tumor. It is the most common benign peripheral nerve sheath tumor of the upper extremity.83 The majority occur as single solitary masses. Patients with neurofibromatosis type 1 (NF1) or 2 (NF2) may develop multiple schwannomas involving large peripheral nerve trunks or bilateral acoustic schwannomas, respectively. These tumors |
Surgery_Schwartz_12861 | Surgery_Schwartz | masses. Patients with neurofibromatosis type 1 (NF1) or 2 (NF2) may develop multiple schwannomas involving large peripheral nerve trunks or bilateral acoustic schwannomas, respectively. These tumors arise from the Schwann cell and occur most often in the middle decades of life. They grow as painless, slow-growing, firm, round, well-encapsulated masses with a predilection toward flexor surfaces of the forearm and palm (given their presence of large nerves). Schwannomas grow from the peripheral nerve sheath and are usually connected by a pedicled stalk. The tumor is well demar-cated and can be readily separated from the nerve fascicles (Fig. 44-26). Unlike neurofibromas, they do not grow within the nerve. Paresthesias or other neurologic findings may occur, but they are usually absent, as is the Tinel’s sign. Findings such as pain, paresthesias, or numbness should raise concern for a tumor causing a compressive neuropathy or a tumor that is malignant.83Histologic exam reveals Antoni | Surgery_Schwartz. masses. Patients with neurofibromatosis type 1 (NF1) or 2 (NF2) may develop multiple schwannomas involving large peripheral nerve trunks or bilateral acoustic schwannomas, respectively. These tumors arise from the Schwann cell and occur most often in the middle decades of life. They grow as painless, slow-growing, firm, round, well-encapsulated masses with a predilection toward flexor surfaces of the forearm and palm (given their presence of large nerves). Schwannomas grow from the peripheral nerve sheath and are usually connected by a pedicled stalk. The tumor is well demar-cated and can be readily separated from the nerve fascicles (Fig. 44-26). Unlike neurofibromas, they do not grow within the nerve. Paresthesias or other neurologic findings may occur, but they are usually absent, as is the Tinel’s sign. Findings such as pain, paresthesias, or numbness should raise concern for a tumor causing a compressive neuropathy or a tumor that is malignant.83Histologic exam reveals Antoni |
Surgery_Schwartz_12862 | Surgery_Schwartz | is the Tinel’s sign. Findings such as pain, paresthesias, or numbness should raise concern for a tumor causing a compressive neuropathy or a tumor that is malignant.83Histologic exam reveals Antoni type A palisades of spindle cells with large oval nuclei with interlacing fascicles. Less cellular regions appear as Antoni type B areas. Mutations of the schwanomin gene on chromosome 22 are found in 50% of sporadic cases and 100% of acoustic schwannomas in patients with NF2.84Surgical treatment is reserved for symptomatic tumors and those that require biopsy to rule out a malignant process. An MRI should be obtained prior to surgery to confirm that the tumor is not located within the nerve (i.e., a neurofibroma) and that it is consistent with a schwannoma. Operative treatment involves excisional biopsy. If the tumor is adherent to adjacent soft tissue or not encapsulated, incisional biopsy is performed and excision is delayed pending pathology results. Malignant degeneration is | Surgery_Schwartz. is the Tinel’s sign. Findings such as pain, paresthesias, or numbness should raise concern for a tumor causing a compressive neuropathy or a tumor that is malignant.83Histologic exam reveals Antoni type A palisades of spindle cells with large oval nuclei with interlacing fascicles. Less cellular regions appear as Antoni type B areas. Mutations of the schwanomin gene on chromosome 22 are found in 50% of sporadic cases and 100% of acoustic schwannomas in patients with NF2.84Surgical treatment is reserved for symptomatic tumors and those that require biopsy to rule out a malignant process. An MRI should be obtained prior to surgery to confirm that the tumor is not located within the nerve (i.e., a neurofibroma) and that it is consistent with a schwannoma. Operative treatment involves excisional biopsy. If the tumor is adherent to adjacent soft tissue or not encapsulated, incisional biopsy is performed and excision is delayed pending pathology results. Malignant degeneration is |
Surgery_Schwartz_12863 | Surgery_Schwartz | excisional biopsy. If the tumor is adherent to adjacent soft tissue or not encapsulated, incisional biopsy is performed and excision is delayed pending pathology results. Malignant degeneration is exceedingly rare.83Malignant Soft Tissue Tumors—CutaneousSquamous Cell Carcinoma. Squamous cell carcinoma (SCC) is the most common primary malignant tumor of the hand, accounting for 75% to 90% of all malignancies of the hand. Eleven percent of all cutaneous SCC occurs in the hand.85 It is the most common malignancy of the nail bed. Risk factors include sun exposure, radiation exposure, chronic ulcers, immu-nosuppression, xeroderma pigmentosa, and actinic keratosis. Marjolin’s ulcers represent malignant degeneration of old burn or traumatic wounds into an SCC and are a more aggressive type. Transplant patients on immunosuppression have a fourfold increased risk, and patients with xeroderma pigmentosa have a 65 to 200–fold increased risk of developing an SCC.86 They often develop as small, | Surgery_Schwartz. excisional biopsy. If the tumor is adherent to adjacent soft tissue or not encapsulated, incisional biopsy is performed and excision is delayed pending pathology results. Malignant degeneration is exceedingly rare.83Malignant Soft Tissue Tumors—CutaneousSquamous Cell Carcinoma. Squamous cell carcinoma (SCC) is the most common primary malignant tumor of the hand, accounting for 75% to 90% of all malignancies of the hand. Eleven percent of all cutaneous SCC occurs in the hand.85 It is the most common malignancy of the nail bed. Risk factors include sun exposure, radiation exposure, chronic ulcers, immu-nosuppression, xeroderma pigmentosa, and actinic keratosis. Marjolin’s ulcers represent malignant degeneration of old burn or traumatic wounds into an SCC and are a more aggressive type. Transplant patients on immunosuppression have a fourfold increased risk, and patients with xeroderma pigmentosa have a 65 to 200–fold increased risk of developing an SCC.86 They often develop as small, |
Surgery_Schwartz_12864 | Surgery_Schwartz | patients on immunosuppression have a fourfold increased risk, and patients with xeroderma pigmentosa have a 65 to 200–fold increased risk of developing an SCC.86 They often develop as small, firm nodules or plaques with indistinct margins and surface irregularities ranging from smooth to ver-ruciform or ulcerated (Fig. 44-27). They are locally invasive, with 2% to 5% lymph node involvement. Metastasis rates of up to 20% have been reported in radiation or burn wounds. Stan-dard treatment is excision with 0.5to 1.0-cm margins. Other treatment options include curettage and electrodessication, cryotherapy, and radiotherapy.85Basal Cell Carcinoma. Basal cell carcinoma (BCC) is the sec-ond most common primary malignancy of the hand, accounting for 3% to 12%; 2% to 3% of all BCCs occur on the hand. Risk fac-tors are similar for SCC and include chronic sun exposure, light complexion, immunosuppression, inorganic arsenic exposure, and Gorlin’s syndrome. Presentation includes a small, | Surgery_Schwartz. patients on immunosuppression have a fourfold increased risk, and patients with xeroderma pigmentosa have a 65 to 200–fold increased risk of developing an SCC.86 They often develop as small, firm nodules or plaques with indistinct margins and surface irregularities ranging from smooth to ver-ruciform or ulcerated (Fig. 44-27). They are locally invasive, with 2% to 5% lymph node involvement. Metastasis rates of up to 20% have been reported in radiation or burn wounds. Stan-dard treatment is excision with 0.5to 1.0-cm margins. Other treatment options include curettage and electrodessication, cryotherapy, and radiotherapy.85Basal Cell Carcinoma. Basal cell carcinoma (BCC) is the sec-ond most common primary malignancy of the hand, accounting for 3% to 12%; 2% to 3% of all BCCs occur on the hand. Risk fac-tors are similar for SCC and include chronic sun exposure, light complexion, immunosuppression, inorganic arsenic exposure, and Gorlin’s syndrome. Presentation includes a small, |
Surgery_Schwartz_12865 | Surgery_Schwartz | on the hand. Risk fac-tors are similar for SCC and include chronic sun exposure, light complexion, immunosuppression, inorganic arsenic exposure, and Gorlin’s syndrome. Presentation includes a small, well-defined nodule with a translucent, pearly border and overlying telangi-ectasias (Fig. 44-28). Metastasis is very rare. Standard treatment is excision with 5-mm margins. Other treatment options include curettage and electrodessication, cryotherapy, and radiotherapy.Melanoma. Melanoma accounts for approximately 4% of skin cancers and is responsible of 80% of all deaths from skin cancer. Approximately 2% of all cutaneous melanomas occur in the hand.87 Risk factors include sun exposure (especially blis-tering sunburns as a child), dysplastic nevi, light complexion, family history of melanoma, immunosuppression, and congenital Figure 44-26. Schwannomas grow as a firm, round, well-encapsulated mass within the epineurium of a peripheral nerve. Schwannomas are able to be separated from the | Surgery_Schwartz. on the hand. Risk fac-tors are similar for SCC and include chronic sun exposure, light complexion, immunosuppression, inorganic arsenic exposure, and Gorlin’s syndrome. Presentation includes a small, well-defined nodule with a translucent, pearly border and overlying telangi-ectasias (Fig. 44-28). Metastasis is very rare. Standard treatment is excision with 5-mm margins. Other treatment options include curettage and electrodessication, cryotherapy, and radiotherapy.Melanoma. Melanoma accounts for approximately 4% of skin cancers and is responsible of 80% of all deaths from skin cancer. Approximately 2% of all cutaneous melanomas occur in the hand.87 Risk factors include sun exposure (especially blis-tering sunburns as a child), dysplastic nevi, light complexion, family history of melanoma, immunosuppression, and congenital Figure 44-26. Schwannomas grow as a firm, round, well-encapsulated mass within the epineurium of a peripheral nerve. Schwannomas are able to be separated from the |
Surgery_Schwartz_12866 | Surgery_Schwartz | immunosuppression, and congenital Figure 44-26. Schwannomas grow as a firm, round, well-encapsulated mass within the epineurium of a peripheral nerve. Schwannomas are able to be separated from the nerve fascicles relatively easily because they do not infiltrate between them (unlike neurofibromas).Figure 44-27. Squamous cell carcinoma involving the nail fold and nail bed. Note the wart-like and ulcerated appearance.Brunicardi_Ch44_p1925-p1966.indd 195520/02/19 2:50 PM 1956SPECIFIC CONSIDERATIONSPART IInevi. Pigmented lesions with irregular borders, color changes, increase in growth, or change in shape are suggestive of mela-noma. Breslow thickness is the most important factor in predicting survival for a primary melanoma. Melanoma in situ lesions should be surgically excised with 0.5 cm margins. For lesions up to 1 mm in thickness, 1-cm margins should be used. Two centimeter mar-gins should be used for lesions over 1 mm in thickness.88 Sentinel lymph node biopsy is done for lesions | Surgery_Schwartz. immunosuppression, and congenital Figure 44-26. Schwannomas grow as a firm, round, well-encapsulated mass within the epineurium of a peripheral nerve. Schwannomas are able to be separated from the nerve fascicles relatively easily because they do not infiltrate between them (unlike neurofibromas).Figure 44-27. Squamous cell carcinoma involving the nail fold and nail bed. Note the wart-like and ulcerated appearance.Brunicardi_Ch44_p1925-p1966.indd 195520/02/19 2:50 PM 1956SPECIFIC CONSIDERATIONSPART IInevi. Pigmented lesions with irregular borders, color changes, increase in growth, or change in shape are suggestive of mela-noma. Breslow thickness is the most important factor in predicting survival for a primary melanoma. Melanoma in situ lesions should be surgically excised with 0.5 cm margins. For lesions up to 1 mm in thickness, 1-cm margins should be used. Two centimeter mar-gins should be used for lesions over 1 mm in thickness.88 Sentinel lymph node biopsy is done for lesions |
Surgery_Schwartz_12867 | Surgery_Schwartz | margins. For lesions up to 1 mm in thickness, 1-cm margins should be used. Two centimeter mar-gins should be used for lesions over 1 mm in thickness.88 Sentinel lymph node biopsy is done for lesions over 1 mm in thickness or for any lesion that is over 0.76 mm in thickness and exhibits ulcer-ation or high mitotic rate.89 Any clinically palpable lymph node requires a formal lymph node dissection of the involved basin, as do sentinel lymph nodes positive for melanoma. Lymph node dis-section has not been shown to offer any long-term survival ben-efit, but the information gained from sentinel lymph node biopsy (or lymph node dissection) does offer valuable staging informa-tion that is important for prognosis. For cases of subungual mela-nomas, DIP amputation is the current standard of care. A recent study reported similar recurrence and survival rates when com-paring patients treated with either DIP amputations or wide local excision; however, there was insufficient evidence to conclude | Surgery_Schwartz. margins. For lesions up to 1 mm in thickness, 1-cm margins should be used. Two centimeter mar-gins should be used for lesions over 1 mm in thickness.88 Sentinel lymph node biopsy is done for lesions over 1 mm in thickness or for any lesion that is over 0.76 mm in thickness and exhibits ulcer-ation or high mitotic rate.89 Any clinically palpable lymph node requires a formal lymph node dissection of the involved basin, as do sentinel lymph nodes positive for melanoma. Lymph node dis-section has not been shown to offer any long-term survival ben-efit, but the information gained from sentinel lymph node biopsy (or lymph node dissection) does offer valuable staging informa-tion that is important for prognosis. For cases of subungual mela-nomas, DIP amputation is the current standard of care. A recent study reported similar recurrence and survival rates when com-paring patients treated with either DIP amputations or wide local excision; however, there was insufficient evidence to conclude |
Surgery_Schwartz_12868 | Surgery_Schwartz | A recent study reported similar recurrence and survival rates when com-paring patients treated with either DIP amputations or wide local excision; however, there was insufficient evidence to conclude if one treatment was superior to another.90Malignant Soft Tissue Tumors—NoncutaneousPrimary soft tissue sarcomas of the upper extremity are very rare. Approximately 12,000 new cases of sarcomas are diag-nosed each year and of those, only 15% occur in upper extremity.80 Statistical inference is limited due to the rare occur-rence of these tumors, but mortality rate is very high despite the aggressive treatments. Fewer than 5% of soft tissue sarcomas of the upper extremity will develop lymph node metastasis. Cutaneous malignancies must be considered in the differential diagnosis for any patient with palpable lymph nodes in the setting of any upper extremity mass. Any lesion of the upper extremity that is over 5 cm in diameter, rapidly enlarges, or is painful should be considered malignant | Surgery_Schwartz. A recent study reported similar recurrence and survival rates when com-paring patients treated with either DIP amputations or wide local excision; however, there was insufficient evidence to conclude if one treatment was superior to another.90Malignant Soft Tissue Tumors—NoncutaneousPrimary soft tissue sarcomas of the upper extremity are very rare. Approximately 12,000 new cases of sarcomas are diag-nosed each year and of those, only 15% occur in upper extremity.80 Statistical inference is limited due to the rare occur-rence of these tumors, but mortality rate is very high despite the aggressive treatments. Fewer than 5% of soft tissue sarcomas of the upper extremity will develop lymph node metastasis. Cutaneous malignancies must be considered in the differential diagnosis for any patient with palpable lymph nodes in the setting of any upper extremity mass. Any lesion of the upper extremity that is over 5 cm in diameter, rapidly enlarges, or is painful should be considered malignant |
Surgery_Schwartz_12869 | Surgery_Schwartz | with palpable lymph nodes in the setting of any upper extremity mass. Any lesion of the upper extremity that is over 5 cm in diameter, rapidly enlarges, or is painful should be considered malignant until proven otherwise.91Treatment for soft tissue sarcomas can range from pallia-tive debulking to attempted curative resection. Many muscles of the upper extremity and their compartments cross joints (e.g., forearm flexors). Any malignancy within a compartment mandates complete resection of that compartment, and there-fore, amputations must often be performed at levels much more proximal than the level of the actual tumor. Many soft tissue sarcomas are not responsive to radiation or chemotherapy, and use of these adjuvant treatments must be decided upon after discussion with medical and radiation oncologists in a multi-disciplinary team. Several studies have shown higher mortality rates in patients who undergo initial tumor biopsy of sarcomas at institutions from which they do not | Surgery_Schwartz. with palpable lymph nodes in the setting of any upper extremity mass. Any lesion of the upper extremity that is over 5 cm in diameter, rapidly enlarges, or is painful should be considered malignant until proven otherwise.91Treatment for soft tissue sarcomas can range from pallia-tive debulking to attempted curative resection. Many muscles of the upper extremity and their compartments cross joints (e.g., forearm flexors). Any malignancy within a compartment mandates complete resection of that compartment, and there-fore, amputations must often be performed at levels much more proximal than the level of the actual tumor. Many soft tissue sarcomas are not responsive to radiation or chemotherapy, and use of these adjuvant treatments must be decided upon after discussion with medical and radiation oncologists in a multi-disciplinary team. Several studies have shown higher mortality rates in patients who undergo initial tumor biopsy of sarcomas at institutions from which they do not |
Surgery_Schwartz_12870 | Surgery_Schwartz | radiation oncologists in a multi-disciplinary team. Several studies have shown higher mortality rates in patients who undergo initial tumor biopsy of sarcomas at institutions from which they do not ultimately receive treatment. These studies recommend biopsy be performed at the institution at which definitive treatment will be provided.92 Institutions best suited for such treatment should have pathologists familiar with soft tissue sarcomas, medical and radiation oncologists, surgical oncologists, and a multidisciplinary tumor board.An in-depth review of each type of soft tissue sarcoma is beyond the scope of this chapter. Epithelioid sarcoma is the most common primary soft tissue sarcoma of the upper extremity and usually presents as a benign-like slow-growing mass during the third or fourth decades. It has a propensity for the forearm, palm, and digits. Spread to lymph nodes has been reported. It typically spreads along fascial planes.80 Synovial sarcoma is argued by some to be the | Surgery_Schwartz. radiation oncologists in a multi-disciplinary team. Several studies have shown higher mortality rates in patients who undergo initial tumor biopsy of sarcomas at institutions from which they do not ultimately receive treatment. These studies recommend biopsy be performed at the institution at which definitive treatment will be provided.92 Institutions best suited for such treatment should have pathologists familiar with soft tissue sarcomas, medical and radiation oncologists, surgical oncologists, and a multidisciplinary tumor board.An in-depth review of each type of soft tissue sarcoma is beyond the scope of this chapter. Epithelioid sarcoma is the most common primary soft tissue sarcoma of the upper extremity and usually presents as a benign-like slow-growing mass during the third or fourth decades. It has a propensity for the forearm, palm, and digits. Spread to lymph nodes has been reported. It typically spreads along fascial planes.80 Synovial sarcoma is argued by some to be the |
Surgery_Schwartz_12871 | Surgery_Schwartz | decades. It has a propensity for the forearm, palm, and digits. Spread to lymph nodes has been reported. It typically spreads along fascial planes.80 Synovial sarcoma is argued by some to be the most common primary soft tissue sarcoma of the hand and wrist, but the paucity of case reports is inconclusive. It is a high-grade malignancy that is painless and slow-growing and usually occurs adjacent to, but not involving, joints. It is most common in the second to fifth decades of life. Tumor size (greater than 5 cm) is positively correlated with mortality. Other sarcomas include malignant fibrous histiocytoma, liposarcoma, fibrosarcoma, dermatofibrosarcoma protuberans, and malignant peripheral nerve sheath tumors, and more information can be found in further selected reading.93 The majority of metastases to the hand involve secondary bone tumors and are discussed later in the section, “Secondary Metastatic Tumors.”Benign Bone TumorsPrimary benign bone tumors of the hand and wrist make up | Surgery_Schwartz. decades. It has a propensity for the forearm, palm, and digits. Spread to lymph nodes has been reported. It typically spreads along fascial planes.80 Synovial sarcoma is argued by some to be the most common primary soft tissue sarcoma of the hand and wrist, but the paucity of case reports is inconclusive. It is a high-grade malignancy that is painless and slow-growing and usually occurs adjacent to, but not involving, joints. It is most common in the second to fifth decades of life. Tumor size (greater than 5 cm) is positively correlated with mortality. Other sarcomas include malignant fibrous histiocytoma, liposarcoma, fibrosarcoma, dermatofibrosarcoma protuberans, and malignant peripheral nerve sheath tumors, and more information can be found in further selected reading.93 The majority of metastases to the hand involve secondary bone tumors and are discussed later in the section, “Secondary Metastatic Tumors.”Benign Bone TumorsPrimary benign bone tumors of the hand and wrist make up |
Surgery_Schwartz_12872 | Surgery_Schwartz | metastases to the hand involve secondary bone tumors and are discussed later in the section, “Secondary Metastatic Tumors.”Benign Bone TumorsPrimary benign bone tumors of the hand and wrist make up a total of 7% of all primary benign bone tumors in the body. Benign tumors of cartilage origin comprise 79% of all primary benign bone tumors of the hand and wrist.94Enchondroma. This is the most common primary benign bone tumor of the hand and wrist and is of cartilage origin. Up to 90% of all bone tumors in the hand and wrist are enchondromas, with 35% to 54% of all enchondromas occurring in the hand and wrist. They are often found incidentally on X-rays taken for other reasons (e.g., hand trauma). They are usually solitary and favor the diaphysis of small tubular bones and are most com-mon in the second and third decades of life. The most common location is in the proximal phalanges, followed by the metacar-pals and then middle phalanges. Enchondroma has never been reported in the | Surgery_Schwartz. metastases to the hand involve secondary bone tumors and are discussed later in the section, “Secondary Metastatic Tumors.”Benign Bone TumorsPrimary benign bone tumors of the hand and wrist make up a total of 7% of all primary benign bone tumors in the body. Benign tumors of cartilage origin comprise 79% of all primary benign bone tumors of the hand and wrist.94Enchondroma. This is the most common primary benign bone tumor of the hand and wrist and is of cartilage origin. Up to 90% of all bone tumors in the hand and wrist are enchondromas, with 35% to 54% of all enchondromas occurring in the hand and wrist. They are often found incidentally on X-rays taken for other reasons (e.g., hand trauma). They are usually solitary and favor the diaphysis of small tubular bones and are most com-mon in the second and third decades of life. The most common location is in the proximal phalanges, followed by the metacar-pals and then middle phalanges. Enchondroma has never been reported in the |
Surgery_Schwartz_12873 | Surgery_Schwartz | in the second and third decades of life. The most common location is in the proximal phalanges, followed by the metacar-pals and then middle phalanges. Enchondroma has never been reported in the trapezoid. Presentation is usually asymptomatic, but pain may occur if there is a pathologic fracture or impending fracture. The etiology is believed to be from a fragment of carti-lage from the central physis. Histology shows well-differentiated hyaline cartilage with lamellar bone and calcification.94Figure 44-28. Basal cell carcinoma of the dorsal hand with sur-rounding telangiectasia.Brunicardi_Ch44_p1925-p1966.indd 195620/02/19 2:50 PM 1957SURGERY OF THE HAND AND WRISTCHAPTER 44Figure 44-29. Enchondroma. A. X-ray of the phalanx demon-strates a well-defined central lucency. Surrounding cortex may thin or thicken. Thinning of the cortex contributes to risk of pathologic fracture. B. Intraoperative fluoroscopy after curettage of the tumor. A radiopaque ribbon is used to occupy the defect | Surgery_Schwartz. in the second and third decades of life. The most common location is in the proximal phalanges, followed by the metacar-pals and then middle phalanges. Enchondroma has never been reported in the trapezoid. Presentation is usually asymptomatic, but pain may occur if there is a pathologic fracture or impending fracture. The etiology is believed to be from a fragment of carti-lage from the central physis. Histology shows well-differentiated hyaline cartilage with lamellar bone and calcification.94Figure 44-28. Basal cell carcinoma of the dorsal hand with sur-rounding telangiectasia.Brunicardi_Ch44_p1925-p1966.indd 195620/02/19 2:50 PM 1957SURGERY OF THE HAND AND WRISTCHAPTER 44Figure 44-29. Enchondroma. A. X-ray of the phalanx demon-strates a well-defined central lucency. Surrounding cortex may thin or thicken. Thinning of the cortex contributes to risk of pathologic fracture. B. Intraoperative fluoroscopy after curettage of the tumor. A radiopaque ribbon is used to occupy the defect |
Surgery_Schwartz_12874 | Surgery_Schwartz | may thin or thicken. Thinning of the cortex contributes to risk of pathologic fracture. B. Intraoperative fluoroscopy after curettage of the tumor. A radiopaque ribbon is used to occupy the defect to help ensure that there is no tumor (similarly radiolucent to the defect after curettage) left behind prior to bone grafting.BATwo variants of enchondroma include Ollier’s disease (multiple enchondromatosis) and Maffucci’s syndrome (multi-ple enchondromatosis associated with multiple soft tissue hem-angiomas). Malignant transformation is very rare in the solitary form, but there is a 25% incidence by age 40 in Ollier’s patients and a 100% life-time incidence in Maffucci’s patients. When malignant transformation does occur, it is almost uniformly a chondrosarcoma with pain and rapid growth.95Diagnosis is usually made based on history, physical exam, and X-rays. There is a well-defined, multilobulated cen-tral lucency in the metaphysis or diaphysis that can expand caus-ing cortical thinning | Surgery_Schwartz. may thin or thicken. Thinning of the cortex contributes to risk of pathologic fracture. B. Intraoperative fluoroscopy after curettage of the tumor. A radiopaque ribbon is used to occupy the defect to help ensure that there is no tumor (similarly radiolucent to the defect after curettage) left behind prior to bone grafting.BATwo variants of enchondroma include Ollier’s disease (multiple enchondromatosis) and Maffucci’s syndrome (multi-ple enchondromatosis associated with multiple soft tissue hem-angiomas). Malignant transformation is very rare in the solitary form, but there is a 25% incidence by age 40 in Ollier’s patients and a 100% life-time incidence in Maffucci’s patients. When malignant transformation does occur, it is almost uniformly a chondrosarcoma with pain and rapid growth.95Diagnosis is usually made based on history, physical exam, and X-rays. There is a well-defined, multilobulated cen-tral lucency in the metaphysis or diaphysis that can expand caus-ing cortical thinning |
Surgery_Schwartz_12875 | Surgery_Schwartz | is usually made based on history, physical exam, and X-rays. There is a well-defined, multilobulated cen-tral lucency in the metaphysis or diaphysis that can expand caus-ing cortical thinning or, sometimes, thickening (Fig. 44-29A). Further imaging is seldom needed, but a CT would be the study of choice.Observation is indicated for asymptomatic enchondromas with no risk of impending fracture, followed by annual X-rays for 2 years. If a pathologic fracture is found, it is treated with immobilization until fracture union and then surgically treated. If there is any uncertainty as to whether it is an enchondroma, incisional biopsy is indicated, and definitive treatment is postponed pending final pathology. Symptomatic lesions and those with impending fracture are treated surgically. Surgical treatment consists of an open incisional biopsy and confirmation by frozen section that it is well-differentiated hyaline cartilage. Curettage and high-speed burring are used to ablate the tumor. | Surgery_Schwartz. is usually made based on history, physical exam, and X-rays. There is a well-defined, multilobulated cen-tral lucency in the metaphysis or diaphysis that can expand caus-ing cortical thinning or, sometimes, thickening (Fig. 44-29A). Further imaging is seldom needed, but a CT would be the study of choice.Observation is indicated for asymptomatic enchondromas with no risk of impending fracture, followed by annual X-rays for 2 years. If a pathologic fracture is found, it is treated with immobilization until fracture union and then surgically treated. If there is any uncertainty as to whether it is an enchondroma, incisional biopsy is indicated, and definitive treatment is postponed pending final pathology. Symptomatic lesions and those with impending fracture are treated surgically. Surgical treatment consists of an open incisional biopsy and confirmation by frozen section that it is well-differentiated hyaline cartilage. Curettage and high-speed burring are used to ablate the tumor. |
Surgery_Schwartz_12876 | Surgery_Schwartz | treatment consists of an open incisional biopsy and confirmation by frozen section that it is well-differentiated hyaline cartilage. Curettage and high-speed burring are used to ablate the tumor. Intraoperative fluoroscopy is used to confirm complete ablation (Fig. 44-29B). The defect is then packed with bone graft or bone substitute. Recurrence ranges from 2% to 15%. X-rays should be obtained serially after surgery.94Periosteal Chondroma. Periosteal chondromas are benign bone tumors of cartilage origin that arise most commonly within or adjacent to periosteum at the metaphyseal-diaphyseal junc-tion in phalanges. They occur usually in the second or third decade as solitary lesions with pain, swelling, deformity, and possible pathologic fracture. X-rays reveal a subperiosteal lytic, unilobular lesion with erosion into adjacent cortex. There is often a rim of sclerosis. Histologically, they appear as aggres-sive cartilage with atypia, and it can be difficult to differentiate these from | Surgery_Schwartz. treatment consists of an open incisional biopsy and confirmation by frozen section that it is well-differentiated hyaline cartilage. Curettage and high-speed burring are used to ablate the tumor. Intraoperative fluoroscopy is used to confirm complete ablation (Fig. 44-29B). The defect is then packed with bone graft or bone substitute. Recurrence ranges from 2% to 15%. X-rays should be obtained serially after surgery.94Periosteal Chondroma. Periosteal chondromas are benign bone tumors of cartilage origin that arise most commonly within or adjacent to periosteum at the metaphyseal-diaphyseal junc-tion in phalanges. They occur usually in the second or third decade as solitary lesions with pain, swelling, deformity, and possible pathologic fracture. X-rays reveal a subperiosteal lytic, unilobular lesion with erosion into adjacent cortex. There is often a rim of sclerosis. Histologically, they appear as aggres-sive cartilage with atypia, and it can be difficult to differentiate these from |
Surgery_Schwartz_12877 | Surgery_Schwartz | lesion with erosion into adjacent cortex. There is often a rim of sclerosis. Histologically, they appear as aggres-sive cartilage with atypia, and it can be difficult to differentiate these from chondrosarcomas.94Diagnosis involves X-rays with incisional biopsy to con-firm the benign diagnosis and avoid unnecessary amputation. Treatment includes en bloc resection of periosteum and cortico-cancellous bone. Recurrence is less than 4%.Osteoid Osteoma. This is a tumor of bone origin. Approxi-mately 5% to 15% of all osteoid osteomas occur in the hand and wrist and are most often found in the proximal phalanx or car-pus. They usually occur in the second or third decade and pres-ent with a deep, dull ache that is classically worse at night and relieved by nonsteroidal anti-inflammatory drugs (NSAIDs). X-rays reveal a central lucency that is usually less than 1 cm in diameter surrounded by reactive sclerosis. Bone scan or CT is helpful to secure the diagnosis.96Treatment consists of NSAID | Surgery_Schwartz. lesion with erosion into adjacent cortex. There is often a rim of sclerosis. Histologically, they appear as aggres-sive cartilage with atypia, and it can be difficult to differentiate these from chondrosarcomas.94Diagnosis involves X-rays with incisional biopsy to con-firm the benign diagnosis and avoid unnecessary amputation. Treatment includes en bloc resection of periosteum and cortico-cancellous bone. Recurrence is less than 4%.Osteoid Osteoma. This is a tumor of bone origin. Approxi-mately 5% to 15% of all osteoid osteomas occur in the hand and wrist and are most often found in the proximal phalanx or car-pus. They usually occur in the second or third decade and pres-ent with a deep, dull ache that is classically worse at night and relieved by nonsteroidal anti-inflammatory drugs (NSAIDs). X-rays reveal a central lucency that is usually less than 1 cm in diameter surrounded by reactive sclerosis. Bone scan or CT is helpful to secure the diagnosis.96Treatment consists of NSAID |
Surgery_Schwartz_12878 | Surgery_Schwartz | (NSAIDs). X-rays reveal a central lucency that is usually less than 1 cm in diameter surrounded by reactive sclerosis. Bone scan or CT is helpful to secure the diagnosis.96Treatment consists of NSAID therapy only, and resolu-tion occurs at an average of 33 months. If the patient does not wish to undergo prolonged discomfort with conservative ther-apy, curettage or percutaneous ablation of the nucleus may be performed.96Giant Cell Tumor of Bone. Giant cell tumors of bone make up only 4% to 5% of all benign bone tumors in the body, and only 12% of these occur in the hand or wrist. Although its name is similar to that of “giant cell tumor of tendon sheath,” they are two separate tumors and do not share the same clinical or histo-pathologic characteristics. Approximately 2% occur in the hand and 10% occur in the distal radius; those within the distal radius are more aggressive. They usually occur in the fourth decade with pain and swelling and possibly pathologic fracture.97Giant cell | Surgery_Schwartz. (NSAIDs). X-rays reveal a central lucency that is usually less than 1 cm in diameter surrounded by reactive sclerosis. Bone scan or CT is helpful to secure the diagnosis.96Treatment consists of NSAID therapy only, and resolu-tion occurs at an average of 33 months. If the patient does not wish to undergo prolonged discomfort with conservative ther-apy, curettage or percutaneous ablation of the nucleus may be performed.96Giant Cell Tumor of Bone. Giant cell tumors of bone make up only 4% to 5% of all benign bone tumors in the body, and only 12% of these occur in the hand or wrist. Although its name is similar to that of “giant cell tumor of tendon sheath,” they are two separate tumors and do not share the same clinical or histo-pathologic characteristics. Approximately 2% occur in the hand and 10% occur in the distal radius; those within the distal radius are more aggressive. They usually occur in the fourth decade with pain and swelling and possibly pathologic fracture.97Giant cell |
Surgery_Schwartz_12879 | Surgery_Schwartz | and 10% occur in the distal radius; those within the distal radius are more aggressive. They usually occur in the fourth decade with pain and swelling and possibly pathologic fracture.97Giant cell tumor of the bone is unique in that it is benign on histology but does have metastatic potential and can cause death. It should be considered a low-grade malignancy.97 Workup includes a CT of the chest and total-body scintigra-phy to evaluate for metastases and multifocal lesions and MRI to evaluate the extent of local tissue involvement. The recom-mended treatment consists of surgical resection of the involved phalanges or metacarpals and wide excision of entire carpal rows. Treatment with curettage and adjuvant treatments only results in a high rate of recurrence. Local and systemic surveil-lance must be done for at least 10 years because metastasis has been reported to occur as late as 10 years postoperatively.97,98Malignant Bone TumorsMalignant primary and secondary bone tumors of the | Surgery_Schwartz. and 10% occur in the distal radius; those within the distal radius are more aggressive. They usually occur in the fourth decade with pain and swelling and possibly pathologic fracture.97Giant cell tumor of the bone is unique in that it is benign on histology but does have metastatic potential and can cause death. It should be considered a low-grade malignancy.97 Workup includes a CT of the chest and total-body scintigra-phy to evaluate for metastases and multifocal lesions and MRI to evaluate the extent of local tissue involvement. The recom-mended treatment consists of surgical resection of the involved phalanges or metacarpals and wide excision of entire carpal rows. Treatment with curettage and adjuvant treatments only results in a high rate of recurrence. Local and systemic surveil-lance must be done for at least 10 years because metastasis has been reported to occur as late as 10 years postoperatively.97,98Malignant Bone TumorsMalignant primary and secondary bone tumors of the |
Surgery_Schwartz_12880 | Surgery_Schwartz | must be done for at least 10 years because metastasis has been reported to occur as late as 10 years postoperatively.97,98Malignant Bone TumorsMalignant primary and secondary bone tumors of the hand, like soft tissue malignancies, are exceedingly rare. An in-depth Brunicardi_Ch44_p1925-p1966.indd 195720/02/19 2:50 PM 1958SPECIFIC CONSIDERATIONSPART IIreview is beyond the scope of this chapter. The same principles for soft tissue sarcomas of the upper extremity apply here with regard to evaluation, biopsy, and treatment.Chondrosarcoma comprises 41% of all primary malignant bone tumors of the hand and wrist but only 1.5% of all chon-drosarcomas overall. It is most likely to occur from malignant degeneration from a preexisting lesion, with enchondromatosis and osteochondromatosis being the most common. It usually presents as a slow-growing, painless mass in the fourth to sixth decades and can be difficult to differentiate from its benign counterparts. X-ray reveals endosteal erosion, | Surgery_Schwartz. must be done for at least 10 years because metastasis has been reported to occur as late as 10 years postoperatively.97,98Malignant Bone TumorsMalignant primary and secondary bone tumors of the hand, like soft tissue malignancies, are exceedingly rare. An in-depth Brunicardi_Ch44_p1925-p1966.indd 195720/02/19 2:50 PM 1958SPECIFIC CONSIDERATIONSPART IIreview is beyond the scope of this chapter. The same principles for soft tissue sarcomas of the upper extremity apply here with regard to evaluation, biopsy, and treatment.Chondrosarcoma comprises 41% of all primary malignant bone tumors of the hand and wrist but only 1.5% of all chon-drosarcomas overall. It is most likely to occur from malignant degeneration from a preexisting lesion, with enchondromatosis and osteochondromatosis being the most common. It usually presents as a slow-growing, painless mass in the fourth to sixth decades and can be difficult to differentiate from its benign counterparts. X-ray reveals endosteal erosion, |
Surgery_Schwartz_12881 | Surgery_Schwartz | most common. It usually presents as a slow-growing, painless mass in the fourth to sixth decades and can be difficult to differentiate from its benign counterparts. X-ray reveals endosteal erosion, cortical expan-sion, cortical destruction, and calcification. Metastasis has never been reported for chondrosarcomas of the hand. Chondrosarco-mas are not responsive to chemotherapy or radiation.99Osteosarcoma of the hand is exceedingly rare; only 0.18% of osteosarcomas occur in the hand. It usually presents as a painful swelling with pathologic fracture in the fifth to eighth decades of life. Radiation exposure is believed to be a possible risk factor. X-ray findings vary widely, with 90% of tumors occurring at a metaphyseal location. Findings include an osteo-blastic or osteolytic lesion, cortical breakthrough with soft tissue extension, a “sunburst” pattern radially, or periosteal elevation (Codman’s triangle). The presence or absence of metastasis is the most important prognostic | Surgery_Schwartz. most common. It usually presents as a slow-growing, painless mass in the fourth to sixth decades and can be difficult to differentiate from its benign counterparts. X-ray reveals endosteal erosion, cortical expan-sion, cortical destruction, and calcification. Metastasis has never been reported for chondrosarcomas of the hand. Chondrosarco-mas are not responsive to chemotherapy or radiation.99Osteosarcoma of the hand is exceedingly rare; only 0.18% of osteosarcomas occur in the hand. It usually presents as a painful swelling with pathologic fracture in the fifth to eighth decades of life. Radiation exposure is believed to be a possible risk factor. X-ray findings vary widely, with 90% of tumors occurring at a metaphyseal location. Findings include an osteo-blastic or osteolytic lesion, cortical breakthrough with soft tissue extension, a “sunburst” pattern radially, or periosteal elevation (Codman’s triangle). The presence or absence of metastasis is the most important prognostic |
Surgery_Schwartz_12882 | Surgery_Schwartz | cortical breakthrough with soft tissue extension, a “sunburst” pattern radially, or periosteal elevation (Codman’s triangle). The presence or absence of metastasis is the most important prognostic factor, with a 5-year survival of 70% in the absence of metastases and a 5-year survival of 10% if present. Preoperative chemotherapy is usually given, but radi-ation therapy plays no role.100Secondary Metastatic TumorsMetastases to the hand or wrist are rare, with only 0.1% of skel-etal metastases occurring in the hand. The majority of metas-tases to the hand are bone lesions, but soft tissue metastases have been reported. The most common primary site is the lung (40%), followed by the kidney (13%) and the breast (11%). Approximately 16% will have no known diagnosis of cancer.101 The most common sites are the distal phalanges, followed by the proximal and middle phalanges, metacarpals, and carpus. Patients will present with pain, swelling, and erythema. Dif-ferential diagnosis includes | Surgery_Schwartz. cortical breakthrough with soft tissue extension, a “sunburst” pattern radially, or periosteal elevation (Codman’s triangle). The presence or absence of metastasis is the most important prognostic factor, with a 5-year survival of 70% in the absence of metastases and a 5-year survival of 10% if present. Preoperative chemotherapy is usually given, but radi-ation therapy plays no role.100Secondary Metastatic TumorsMetastases to the hand or wrist are rare, with only 0.1% of skel-etal metastases occurring in the hand. The majority of metas-tases to the hand are bone lesions, but soft tissue metastases have been reported. The most common primary site is the lung (40%), followed by the kidney (13%) and the breast (11%). Approximately 16% will have no known diagnosis of cancer.101 The most common sites are the distal phalanges, followed by the proximal and middle phalanges, metacarpals, and carpus. Patients will present with pain, swelling, and erythema. Dif-ferential diagnosis includes |
Surgery_Schwartz_12883 | Surgery_Schwartz | sites are the distal phalanges, followed by the proximal and middle phalanges, metacarpals, and carpus. Patients will present with pain, swelling, and erythema. Dif-ferential diagnosis includes felon, gout, osteomyelitis, trauma, RA, or skin cancer. Treatment of a hand or wrist metastatic lesion must not interfere with treatment of the primary cancer. Treatment is usually palliative (simple excision or amputa-tion). The average life expectancy for these patients is less than 6 months.101BURNSThe palm of the hand makes up approximately 1% of the total body surface area. A burn involving the entire hand and digits is unlikely to cause life-threatening injury or shock, but seem-ingly small burns to the hand may cause severe permanent loss of function if not treated appropriately. Burns to the hand can cause serious shortand long-term disability. All burns to the hand are considered severe injuries that warrant transfer to a dedicated burn center for specialized treatment. This | Surgery_Schwartz. sites are the distal phalanges, followed by the proximal and middle phalanges, metacarpals, and carpus. Patients will present with pain, swelling, and erythema. Dif-ferential diagnosis includes felon, gout, osteomyelitis, trauma, RA, or skin cancer. Treatment of a hand or wrist metastatic lesion must not interfere with treatment of the primary cancer. Treatment is usually palliative (simple excision or amputa-tion). The average life expectancy for these patients is less than 6 months.101BURNSThe palm of the hand makes up approximately 1% of the total body surface area. A burn involving the entire hand and digits is unlikely to cause life-threatening injury or shock, but seem-ingly small burns to the hand may cause severe permanent loss of function if not treated appropriately. Burns to the hand can cause serious shortand long-term disability. All burns to the hand are considered severe injuries that warrant transfer to a dedicated burn center for specialized treatment. This |
Surgery_Schwartz_12884 | Surgery_Schwartz | to the hand can cause serious shortand long-term disability. All burns to the hand are considered severe injuries that warrant transfer to a dedicated burn center for specialized treatment. This manage-ment will include a multidisciplinary team consisting of hand surgeons, burn surgeons, burn-specialized nurses, occupational therapists, case managers, and social workers.Superficial burns involve damage to the epidermis only and present with erythema, no blistering, and full sensation with blanching of skin. These will heal without scarring. Super-ficial partial-thickness burns involve damage to the papillary dermis; all skin appendages are preserved, and therefore, these readily reepithelialize with minimal to no scarring. Superficial partial-thickness burns are sensate and present with pain, ery-thema, blistering, and blanching of skin. Topical dressings are the mainstay of treatment. Deep partial-thickness burns involve damage to the reticular dermis with damage to skin appendages, | Surgery_Schwartz. to the hand can cause serious shortand long-term disability. All burns to the hand are considered severe injuries that warrant transfer to a dedicated burn center for specialized treatment. This manage-ment will include a multidisciplinary team consisting of hand surgeons, burn surgeons, burn-specialized nurses, occupational therapists, case managers, and social workers.Superficial burns involve damage to the epidermis only and present with erythema, no blistering, and full sensation with blanching of skin. These will heal without scarring. Super-ficial partial-thickness burns involve damage to the papillary dermis; all skin appendages are preserved, and therefore, these readily reepithelialize with minimal to no scarring. Superficial partial-thickness burns are sensate and present with pain, ery-thema, blistering, and blanching of skin. Topical dressings are the mainstay of treatment. Deep partial-thickness burns involve damage to the reticular dermis with damage to skin appendages, |
Surgery_Schwartz_12885 | Surgery_Schwartz | ery-thema, blistering, and blanching of skin. Topical dressings are the mainstay of treatment. Deep partial-thickness burns involve damage to the reticular dermis with damage to skin appendages, as well as the dermal plexus blood vessels and nerves. These have decreased sensation and no cap refill and appear pale or white. Blistering may be present. Damage to the skin append-ages and blood supply in the dermal plexus precludes spontane-ous healing without scar. Excision with skin grafting is needed. Third-degree burns involve full-thickness damage through the dermis and are insensate with no blistering. They appear dry, leathery, and even charred.Acute ManagementAdvanced trauma life support guidelines should be followed. After primary survey, circulation to the hand should be assessed. Palpation and Doppler ultrasound should be used to evaluate blood flow within the radial and ulnar arteries, the pal-mar arches, and digital blood flow at the radial and ulnar aspect of each volar | Surgery_Schwartz. ery-thema, blistering, and blanching of skin. Topical dressings are the mainstay of treatment. Deep partial-thickness burns involve damage to the reticular dermis with damage to skin appendages, as well as the dermal plexus blood vessels and nerves. These have decreased sensation and no cap refill and appear pale or white. Blistering may be present. Damage to the skin append-ages and blood supply in the dermal plexus precludes spontane-ous healing without scar. Excision with skin grafting is needed. Third-degree burns involve full-thickness damage through the dermis and are insensate with no blistering. They appear dry, leathery, and even charred.Acute ManagementAdvanced trauma life support guidelines should be followed. After primary survey, circulation to the hand should be assessed. Palpation and Doppler ultrasound should be used to evaluate blood flow within the radial and ulnar arteries, the pal-mar arches, and digital blood flow at the radial and ulnar aspect of each volar |
Surgery_Schwartz_12886 | Surgery_Schwartz | Palpation and Doppler ultrasound should be used to evaluate blood flow within the radial and ulnar arteries, the pal-mar arches, and digital blood flow at the radial and ulnar aspect of each volar digital pad. A sensorimotor exam should be per-formed. Objective evidence of inadequate perfusion (i.e., deteri-orating clinical exam with changes in or loss of pulse or Doppler signal) indicates the need for escharotomy, especially in the set-ting of circumferential burns. Escharotomy may be performed at bedside with scalpel or electrocautery under local anesthesia or intravenous sedation. In the forearm, axially oriented midra-dial and midulnar incisions are made for the entire extent of the burn. Escharotomy should proceed as distally as necessary into the wrist and hand to restore perfusion. Digital escharotomies are made via a midaxial (the middle of the longitudinal axis on sagittal view) incision over the radial aspects of the thumb and small finger and the ulnar aspects of the index, | Surgery_Schwartz. Palpation and Doppler ultrasound should be used to evaluate blood flow within the radial and ulnar arteries, the pal-mar arches, and digital blood flow at the radial and ulnar aspect of each volar digital pad. A sensorimotor exam should be per-formed. Objective evidence of inadequate perfusion (i.e., deteri-orating clinical exam with changes in or loss of pulse or Doppler signal) indicates the need for escharotomy, especially in the set-ting of circumferential burns. Escharotomy may be performed at bedside with scalpel or electrocautery under local anesthesia or intravenous sedation. In the forearm, axially oriented midra-dial and midulnar incisions are made for the entire extent of the burn. Escharotomy should proceed as distally as necessary into the wrist and hand to restore perfusion. Digital escharotomies are made via a midaxial (the middle of the longitudinal axis on sagittal view) incision over the radial aspects of the thumb and small finger and the ulnar aspects of the index, |
Surgery_Schwartz_12887 | Surgery_Schwartz | Digital escharotomies are made via a midaxial (the middle of the longitudinal axis on sagittal view) incision over the radial aspects of the thumb and small finger and the ulnar aspects of the index, middle, and ring fingers.102 These locations for digital escharotomies avoid pain-ful scars on the heavy-contact surfaces of each respective digit. After primary survey, vascular, and sensorimotor exams are complete, careful documentation should be made of all burns. This is best done with a Lund and Browder chart and includes location, surface area, and initial depth of burn.The burns should be dressed as soon as examination is complete. Gauze moistened with normal saline is a good initial dressing because it is easy, readily available, and will not leave ointment or cream on the wounds, which can hinder frequent examinations in the initial period. It is critical that no dressing is wrapped in a circumferential manner around any body part. Edema and swelling can lead to extremity | Surgery_Schwartz. Digital escharotomies are made via a midaxial (the middle of the longitudinal axis on sagittal view) incision over the radial aspects of the thumb and small finger and the ulnar aspects of the index, middle, and ring fingers.102 These locations for digital escharotomies avoid pain-ful scars on the heavy-contact surfaces of each respective digit. After primary survey, vascular, and sensorimotor exams are complete, careful documentation should be made of all burns. This is best done with a Lund and Browder chart and includes location, surface area, and initial depth of burn.The burns should be dressed as soon as examination is complete. Gauze moistened with normal saline is a good initial dressing because it is easy, readily available, and will not leave ointment or cream on the wounds, which can hinder frequent examinations in the initial period. It is critical that no dressing is wrapped in a circumferential manner around any body part. Edema and swelling can lead to extremity |
Surgery_Schwartz_12888 | Surgery_Schwartz | which can hinder frequent examinations in the initial period. It is critical that no dressing is wrapped in a circumferential manner around any body part. Edema and swelling can lead to extremity ischemia if a circum-ferential dressing is in place. It is important to maintain body temperature above 37°C, especially in burn patients who have lost thermoregulatory function of the skin and now have moist dressings in place. The hands should be elevated above heart level to decrease edema formation, which can hinder motion and lead to late scar contracture. The hand should be splinted in the intrinsic plus position with the MPs flexed to 90° (placing MP collateral ligaments under tension), the IPs in straight extension (prevents volar plate adhesion), and the wrist in approximately 15° of extension.103 In rare cases, Kirschner wires or heavy steel wires/pins are needed to keep a joint in proper position. These are placed percutaneously through the involved joint and serve as a temporary | Surgery_Schwartz. which can hinder frequent examinations in the initial period. It is critical that no dressing is wrapped in a circumferential manner around any body part. Edema and swelling can lead to extremity ischemia if a circum-ferential dressing is in place. It is important to maintain body temperature above 37°C, especially in burn patients who have lost thermoregulatory function of the skin and now have moist dressings in place. The hands should be elevated above heart level to decrease edema formation, which can hinder motion and lead to late scar contracture. The hand should be splinted in the intrinsic plus position with the MPs flexed to 90° (placing MP collateral ligaments under tension), the IPs in straight extension (prevents volar plate adhesion), and the wrist in approximately 15° of extension.103 In rare cases, Kirschner wires or heavy steel wires/pins are needed to keep a joint in proper position. These are placed percutaneously through the involved joint and serve as a temporary |
Surgery_Schwartz_12889 | Surgery_Schwartz | In rare cases, Kirschner wires or heavy steel wires/pins are needed to keep a joint in proper position. These are placed percutaneously through the involved joint and serve as a temporary joint stabilizer.After the primary and secondary surveys are complete, the wound should be evaluated again. Devitalized tissue should be Brunicardi_Ch44_p1925-p1966.indd 195820/02/19 2:50 PM 1959SURGERY OF THE HAND AND WRISTCHAPTER 44debrided. Wounds should be cleansed twice daily, typically with normal saline. Second-degree superficial burns may be dressed with Xeroform gauze and bacitracin. Silver sulfadiazine cream is another option for any secondor third-degree wound. It cov-ers gram-positive and gram-negative microbes, but it does not penetrate eschar. It should be applied at least one-sixteenth of an inch thick. Sulfamylon can be used in conjunction with silver sulfadiazine or alone. It deeply penetrates eschar and tissues and has good gram-positive coverage.Surgical ManagementAny burn | Surgery_Schwartz. In rare cases, Kirschner wires or heavy steel wires/pins are needed to keep a joint in proper position. These are placed percutaneously through the involved joint and serve as a temporary joint stabilizer.After the primary and secondary surveys are complete, the wound should be evaluated again. Devitalized tissue should be Brunicardi_Ch44_p1925-p1966.indd 195820/02/19 2:50 PM 1959SURGERY OF THE HAND AND WRISTCHAPTER 44debrided. Wounds should be cleansed twice daily, typically with normal saline. Second-degree superficial burns may be dressed with Xeroform gauze and bacitracin. Silver sulfadiazine cream is another option for any secondor third-degree wound. It cov-ers gram-positive and gram-negative microbes, but it does not penetrate eschar. It should be applied at least one-sixteenth of an inch thick. Sulfamylon can be used in conjunction with silver sulfadiazine or alone. It deeply penetrates eschar and tissues and has good gram-positive coverage.Surgical ManagementAny burn |
Surgery_Schwartz_12890 | Surgery_Schwartz | of an inch thick. Sulfamylon can be used in conjunction with silver sulfadiazine or alone. It deeply penetrates eschar and tissues and has good gram-positive coverage.Surgical ManagementAny burn wound will eventually heal with proper wound care. However, this may involve unacceptable scarring, deformity, contractures, pain, and unstable wounds that are prone to breakdown. The goal is to restore preinjury function as much as possible with a wound that is durable, supple, nonpainful, and allows the patient to return to society as an active member. Local wound care is the ideal treatment for wounds that can heal completely within 14 days while not sacrificing function. For deep partial-thickness or full-thickness burns, early surgical excision and skin grafting is necessary.103Considerable controversy surrounds the need, timing, and method of grafting burns. Careful consideration must be given to the patient’s overall status, their preinjury state, and the type of work and recreational | Surgery_Schwartz. of an inch thick. Sulfamylon can be used in conjunction with silver sulfadiazine or alone. It deeply penetrates eschar and tissues and has good gram-positive coverage.Surgical ManagementAny burn wound will eventually heal with proper wound care. However, this may involve unacceptable scarring, deformity, contractures, pain, and unstable wounds that are prone to breakdown. The goal is to restore preinjury function as much as possible with a wound that is durable, supple, nonpainful, and allows the patient to return to society as an active member. Local wound care is the ideal treatment for wounds that can heal completely within 14 days while not sacrificing function. For deep partial-thickness or full-thickness burns, early surgical excision and skin grafting is necessary.103Considerable controversy surrounds the need, timing, and method of grafting burns. Careful consideration must be given to the patient’s overall status, their preinjury state, and the type of work and recreational |
Surgery_Schwartz_12891 | Surgery_Schwartz | controversy surrounds the need, timing, and method of grafting burns. Careful consideration must be given to the patient’s overall status, their preinjury state, and the type of work and recreational activities they enjoyed in order to have a better understanding of which issues should be addressed. Tangential excision of the wounds should be performed under tourniquet to minimize blood loss and is carried down to viable tissue. Avoid excising through fascia (epimysium) overlying muscles or exposing tendons, bone, joint capsules, or neurovascular structures. Tissues capable of receiv-ing a skin graft include well-vascularized fat, muscle, perineu-rium, paratenon, perichondrium, and periosteum. Exposure of deep structures without an adequately graftable bed mandates further coverage before skin grafting can occur (discussed later in “Reconstruction”).Once there is an adequate bed, grafting is the next step. If there is any doubt as to whether the wound bed can support a skin graft, a | Surgery_Schwartz. controversy surrounds the need, timing, and method of grafting burns. Careful consideration must be given to the patient’s overall status, their preinjury state, and the type of work and recreational activities they enjoyed in order to have a better understanding of which issues should be addressed. Tangential excision of the wounds should be performed under tourniquet to minimize blood loss and is carried down to viable tissue. Avoid excising through fascia (epimysium) overlying muscles or exposing tendons, bone, joint capsules, or neurovascular structures. Tissues capable of receiv-ing a skin graft include well-vascularized fat, muscle, perineu-rium, paratenon, perichondrium, and periosteum. Exposure of deep structures without an adequately graftable bed mandates further coverage before skin grafting can occur (discussed later in “Reconstruction”).Once there is an adequate bed, grafting is the next step. If there is any doubt as to whether the wound bed can support a skin graft, a |
Surgery_Schwartz_12892 | Surgery_Schwartz | skin grafting can occur (discussed later in “Reconstruction”).Once there is an adequate bed, grafting is the next step. If there is any doubt as to whether the wound bed can support a skin graft, a temporary dressing such as Allograft (human cadaver skin) should be placed and the patient reexamined fre-quently for signs of granulation tissue and wound bed viability. It can remain in place for up to 14 days before rejection and can serve as a way of “testing” if a wound is ready to receive a skin graft. Skin grafts to the dorsum of the hand are typi-cally split-thickness sheet grafts (not meshed), as sheet grafts have a superior aesthetic appearance. Skin grafts to the palmar aspects of the hand should be full-thickness in order to provide the dermal durability needed for daily functions. Skin grafts are secured with staples, sutures, fibrin glue, or even skin glue. It is important to bolster every skin graft. This prevents shearing loss and also keeps the skin graft in contact with | Surgery_Schwartz. skin grafting can occur (discussed later in “Reconstruction”).Once there is an adequate bed, grafting is the next step. If there is any doubt as to whether the wound bed can support a skin graft, a temporary dressing such as Allograft (human cadaver skin) should be placed and the patient reexamined fre-quently for signs of granulation tissue and wound bed viability. It can remain in place for up to 14 days before rejection and can serve as a way of “testing” if a wound is ready to receive a skin graft. Skin grafts to the dorsum of the hand are typi-cally split-thickness sheet grafts (not meshed), as sheet grafts have a superior aesthetic appearance. Skin grafts to the palmar aspects of the hand should be full-thickness in order to provide the dermal durability needed for daily functions. Skin grafts are secured with staples, sutures, fibrin glue, or even skin glue. It is important to bolster every skin graft. This prevents shearing loss and also keeps the skin graft in contact with |
Surgery_Schwartz_12893 | Surgery_Schwartz | Skin grafts are secured with staples, sutures, fibrin glue, or even skin glue. It is important to bolster every skin graft. This prevents shearing loss and also keeps the skin graft in contact with the wound bed, preventing fluid collections that can lead to graft loss. A bol-ster may consist of a tie-over bolster and a splint or a negativepressure dressing. The hand should be splinted in intrinsic plus for 7 days after skin grafting. Once the graft is adherent, hand therapy should begin, consisting of active and passive range-of-motion exercises and modalities.103ReconstructionReconstruction of burn wounds can begin as early as the acute setting and continue into the subacute and late stages. Burns may initially be superficial but later convert to deep burns (especially with grease, oil, and alkali burns) due to infection, tissue desiccation, or continued trauma, or they may be deep from the outset of injury. Debridement or excision of burns may result in exposure of viable muscle, | Surgery_Schwartz. Skin grafts are secured with staples, sutures, fibrin glue, or even skin glue. It is important to bolster every skin graft. This prevents shearing loss and also keeps the skin graft in contact with the wound bed, preventing fluid collections that can lead to graft loss. A bol-ster may consist of a tie-over bolster and a splint or a negativepressure dressing. The hand should be splinted in intrinsic plus for 7 days after skin grafting. Once the graft is adherent, hand therapy should begin, consisting of active and passive range-of-motion exercises and modalities.103ReconstructionReconstruction of burn wounds can begin as early as the acute setting and continue into the subacute and late stages. Burns may initially be superficial but later convert to deep burns (especially with grease, oil, and alkali burns) due to infection, tissue desiccation, or continued trauma, or they may be deep from the outset of injury. Debridement or excision of burns may result in exposure of viable muscle, |
Surgery_Schwartz_12894 | Surgery_Schwartz | and alkali burns) due to infection, tissue desiccation, or continued trauma, or they may be deep from the outset of injury. Debridement or excision of burns may result in exposure of viable muscle, bone, tendon, cartilage, joints, and neurovascular structures, as well as loss of fascial layers that are required for overlying soft tissue to glide during movement. Simply skin grafting these exposed structures will result in unstable wounds that are prone to chronic breakdown. Soft tissue contractures will develop as the skin grafts adhere to the structures, effectively anchoring them in static position. This is especially true for tendons, where gliding capability is paramount for function. Flap coverage is required in these situ-ations. The reversed radial forearm flap is a local flap and is often the first choice for flap coverage of the hand. If the zone of injury or size of defect precludes its use, other skin and fat flaps, including the free lateral arm, free anterolateral thigh, | Surgery_Schwartz. and alkali burns) due to infection, tissue desiccation, or continued trauma, or they may be deep from the outset of injury. Debridement or excision of burns may result in exposure of viable muscle, bone, tendon, cartilage, joints, and neurovascular structures, as well as loss of fascial layers that are required for overlying soft tissue to glide during movement. Simply skin grafting these exposed structures will result in unstable wounds that are prone to chronic breakdown. Soft tissue contractures will develop as the skin grafts adhere to the structures, effectively anchoring them in static position. This is especially true for tendons, where gliding capability is paramount for function. Flap coverage is required in these situ-ations. The reversed radial forearm flap is a local flap and is often the first choice for flap coverage of the hand. If the zone of injury or size of defect precludes its use, other skin and fat flaps, including the free lateral arm, free anterolateral thigh, |
Surgery_Schwartz_12895 | Surgery_Schwartz | is often the first choice for flap coverage of the hand. If the zone of injury or size of defect precludes its use, other skin and fat flaps, including the free lateral arm, free anterolateral thigh, or even free parascapular flaps, may be useful, provided the patient can tolerate a free tissue transfer (see Chapter 45) operation (Fig. 44-30). The digits may also be buried subcutaneously in the lower abdominal skin or groin crease. Vascular ingrowth from the digits into the abdominal or groin skin occurs over 2 to 3 weeks, allowing division of the flap(s) and achieving full-thickness coverage of the wounds.104An acellular dermal regenerative substitute (e.g., Integra) may be used for wounds that have exposed structures and require more durability than is offered by a skin graft such as full-thickness loss overlying the extensor tendons of the wrist and hand.105 Dermal substitute is a good option for wounds that are not extensive enough to warrant a flap and for patients who are poor | Surgery_Schwartz. is often the first choice for flap coverage of the hand. If the zone of injury or size of defect precludes its use, other skin and fat flaps, including the free lateral arm, free anterolateral thigh, or even free parascapular flaps, may be useful, provided the patient can tolerate a free tissue transfer (see Chapter 45) operation (Fig. 44-30). The digits may also be buried subcutaneously in the lower abdominal skin or groin crease. Vascular ingrowth from the digits into the abdominal or groin skin occurs over 2 to 3 weeks, allowing division of the flap(s) and achieving full-thickness coverage of the wounds.104An acellular dermal regenerative substitute (e.g., Integra) may be used for wounds that have exposed structures and require more durability than is offered by a skin graft such as full-thickness loss overlying the extensor tendons of the wrist and hand.105 Dermal substitute is a good option for wounds that are not extensive enough to warrant a flap and for patients who are poor |
Surgery_Schwartz_12896 | Surgery_Schwartz | loss overlying the extensor tendons of the wrist and hand.105 Dermal substitute is a good option for wounds that are not extensive enough to warrant a flap and for patients who are poor candidates for an extensive surgery. Integra is com-posed of acellular cross-linked bovine tendon collagen and gly-cosaminoglycan with an overlying silicone sheet. It is applied much like a skin graft. After incorporation in 14 to 21 days, it is capable of accepting a skin graft (after removing the silicone sheet). Conceptually, it works by replacing the lost dermis and adds durability to a wound bed. It may be reapplied multiple times to the same area if thicker neodermis is desired. Although cultured autologous keratinocytes have been used, they are expensive, time-consuming, and do not provide prompt or durable coverage.Web space contractures are the most common deformity resulting after hand burns. They may occur late despite the best efforts. In the normal web space, the leading edge of the volar | Surgery_Schwartz. loss overlying the extensor tendons of the wrist and hand.105 Dermal substitute is a good option for wounds that are not extensive enough to warrant a flap and for patients who are poor candidates for an extensive surgery. Integra is com-posed of acellular cross-linked bovine tendon collagen and gly-cosaminoglycan with an overlying silicone sheet. It is applied much like a skin graft. After incorporation in 14 to 21 days, it is capable of accepting a skin graft (after removing the silicone sheet). Conceptually, it works by replacing the lost dermis and adds durability to a wound bed. It may be reapplied multiple times to the same area if thicker neodermis is desired. Although cultured autologous keratinocytes have been used, they are expensive, time-consuming, and do not provide prompt or durable coverage.Web space contractures are the most common deformity resulting after hand burns. They may occur late despite the best efforts. In the normal web space, the leading edge of the volar |
Surgery_Schwartz_12897 | Surgery_Schwartz | durable coverage.Web space contractures are the most common deformity resulting after hand burns. They may occur late despite the best efforts. In the normal web space, the leading edge of the volar Figure 44-30. Free anterolateral thigh flap reconstruction of a large dorsal hand wound. Once wound coverage is stable, this flap will need to be surgically revised to achieve proper contour.Brunicardi_Ch44_p1925-p1966.indd 195920/02/19 2:50 PM 1960SPECIFIC CONSIDERATIONSPART IIaspect of the web is distal to the dorsal aspect. This is reversed in web space contractures and limits digit abduction. Local modified Z-plasty (double-opposing Z-plasty) is the preferred treatment (Fig. 44-31).Special ConsiderationsChemical burns pose a risk to healthcare providers and should be considered hazardous material. They must also be removed from the patient or continued burn injury will occur. A complete discussion of all chemicals causing burns is beyond the scope of this chapter. Hydrofluoric acid | Surgery_Schwartz. durable coverage.Web space contractures are the most common deformity resulting after hand burns. They may occur late despite the best efforts. In the normal web space, the leading edge of the volar Figure 44-30. Free anterolateral thigh flap reconstruction of a large dorsal hand wound. Once wound coverage is stable, this flap will need to be surgically revised to achieve proper contour.Brunicardi_Ch44_p1925-p1966.indd 195920/02/19 2:50 PM 1960SPECIFIC CONSIDERATIONSPART IIaspect of the web is distal to the dorsal aspect. This is reversed in web space contractures and limits digit abduction. Local modified Z-plasty (double-opposing Z-plasty) is the preferred treatment (Fig. 44-31).Special ConsiderationsChemical burns pose a risk to healthcare providers and should be considered hazardous material. They must also be removed from the patient or continued burn injury will occur. A complete discussion of all chemicals causing burns is beyond the scope of this chapter. Hydrofluoric acid |
Surgery_Schwartz_12898 | Surgery_Schwartz | material. They must also be removed from the patient or continued burn injury will occur. A complete discussion of all chemicals causing burns is beyond the scope of this chapter. Hydrofluoric acid produces a slow onset of severe pain and continues to penetrate deeper structures. It avidly binds tissue and circulating calcium and can lead to hypocalcemia and cardiac arrest. The wound should be irrigated copiously with water followed by topical or intra-arterial injection of calcium gluconate. Chromic acid burns should be treated with immediate lavage, phosphate buffer soaks and immediate surgical excision. Cement can result in chemical burns and should be treated with immediate irrigation and topical antibacterial ointments. Alka-line and acid burns require copious irrigation with water, with alkali burns often requiring hours of irrigation. Phenol burns should be irrigated with dilute polyethylene glycol wash fol-lowed by high-flow water lavage.106VASCULAR DISEASEVascular disease | Surgery_Schwartz. material. They must also be removed from the patient or continued burn injury will occur. A complete discussion of all chemicals causing burns is beyond the scope of this chapter. Hydrofluoric acid produces a slow onset of severe pain and continues to penetrate deeper structures. It avidly binds tissue and circulating calcium and can lead to hypocalcemia and cardiac arrest. The wound should be irrigated copiously with water followed by topical or intra-arterial injection of calcium gluconate. Chromic acid burns should be treated with immediate lavage, phosphate buffer soaks and immediate surgical excision. Cement can result in chemical burns and should be treated with immediate irrigation and topical antibacterial ointments. Alka-line and acid burns require copious irrigation with water, with alkali burns often requiring hours of irrigation. Phenol burns should be irrigated with dilute polyethylene glycol wash fol-lowed by high-flow water lavage.106VASCULAR DISEASEVascular disease |
Surgery_Schwartz_12899 | Surgery_Schwartz | with alkali burns often requiring hours of irrigation. Phenol burns should be irrigated with dilute polyethylene glycol wash fol-lowed by high-flow water lavage.106VASCULAR DISEASEVascular disease encompasses a broad spectrum of disorders leading to compromised perfusion to the hand and digits and may potentially cause ischemia and necrosis. Chronic vascular disorders tend to develop slowly and are typically seen in older patients. This includes progressive thrombosis, aneurysms, sys-temic vasculopathy, and vasospastic disorders. Disorders unique or common to the hand are discussed in the following sections.Progressive Thrombotic DiseaseHypothenar hammer syndrome involves occlusion of the ulnar artery at the wrist and is the most common occlusive vascular disorder of the upper extremity. The etiology is believed to be chronic trauma to the ulnar artery as it exits Guyon’s canal. The classic example is a construction worker who frequently uses heavy equipment, such as jackhammers, that | Surgery_Schwartz. with alkali burns often requiring hours of irrigation. Phenol burns should be irrigated with dilute polyethylene glycol wash fol-lowed by high-flow water lavage.106VASCULAR DISEASEVascular disease encompasses a broad spectrum of disorders leading to compromised perfusion to the hand and digits and may potentially cause ischemia and necrosis. Chronic vascular disorders tend to develop slowly and are typically seen in older patients. This includes progressive thrombosis, aneurysms, sys-temic vasculopathy, and vasospastic disorders. Disorders unique or common to the hand are discussed in the following sections.Progressive Thrombotic DiseaseHypothenar hammer syndrome involves occlusion of the ulnar artery at the wrist and is the most common occlusive vascular disorder of the upper extremity. The etiology is believed to be chronic trauma to the ulnar artery as it exits Guyon’s canal. The classic example is a construction worker who frequently uses heavy equipment, such as jackhammers, that |
Surgery_Schwartz_12900 | Surgery_Schwartz | etiology is believed to be chronic trauma to the ulnar artery as it exits Guyon’s canal. The classic example is a construction worker who frequently uses heavy equipment, such as jackhammers, that cause prolonged vibration and repetitive impact on the ulnar aspect of the palm. This causes periadventitial arterial damage that results in scar-ring and eventual compression, as well as medial and intimal damage.107 The artery then becomes weakened and prone to aneurysm and/or thrombosis. If a thrombus forms, it may embo-lize, producing digital ischemia. Symptoms may be chronic or acute and include pain, numbness and tingling, weakness of grip, discoloration of the fingers, and even gangrene or ulcers of the fingertips.If acute in onset, proximal occlusions may be extracted with a balloon catheter or, sometimes, under direct vision via an arteriotomy. Very distal embolism may require infusion of thrombolytics to dissolve clots and allow reperfusion. Large-vessel acute embolism and | Surgery_Schwartz. etiology is believed to be chronic trauma to the ulnar artery as it exits Guyon’s canal. The classic example is a construction worker who frequently uses heavy equipment, such as jackhammers, that cause prolonged vibration and repetitive impact on the ulnar aspect of the palm. This causes periadventitial arterial damage that results in scar-ring and eventual compression, as well as medial and intimal damage.107 The artery then becomes weakened and prone to aneurysm and/or thrombosis. If a thrombus forms, it may embo-lize, producing digital ischemia. Symptoms may be chronic or acute and include pain, numbness and tingling, weakness of grip, discoloration of the fingers, and even gangrene or ulcers of the fingertips.If acute in onset, proximal occlusions may be extracted with a balloon catheter or, sometimes, under direct vision via an arteriotomy. Very distal embolism may require infusion of thrombolytics to dissolve clots and allow reperfusion. Large-vessel acute embolism and |
Surgery_Schwartz_12901 | Surgery_Schwartz | catheter or, sometimes, under direct vision via an arteriotomy. Very distal embolism may require infusion of thrombolytics to dissolve clots and allow reperfusion. Large-vessel acute embolism and reperfusion may result in edema and compartment syndrome, requiring fasciotomy. A high index of suspicion must be maintained.For the more common scenario of chronic, progres-sive occlusion, the involved segment of ulnar artery should be resected. There is disagreement in the literature regarding whether simple ligation and excision is sufficient for patients with sufficient distal flow or if all patients should undergo vas-cular reconstruction.108 The authors’ personal preference is to reconstruct all patients.Systemic VasculopathyBuerger’s disease (thromboangiitis obliterans) is an inflamma-tory occlusive disease affecting small and medium-sized arter-ies and veins. It is strongly influenced by smoking and will often resolve upon smoking cessation. The disease is classified into acute, | Surgery_Schwartz. catheter or, sometimes, under direct vision via an arteriotomy. Very distal embolism may require infusion of thrombolytics to dissolve clots and allow reperfusion. Large-vessel acute embolism and reperfusion may result in edema and compartment syndrome, requiring fasciotomy. A high index of suspicion must be maintained.For the more common scenario of chronic, progres-sive occlusion, the involved segment of ulnar artery should be resected. There is disagreement in the literature regarding whether simple ligation and excision is sufficient for patients with sufficient distal flow or if all patients should undergo vas-cular reconstruction.108 The authors’ personal preference is to reconstruct all patients.Systemic VasculopathyBuerger’s disease (thromboangiitis obliterans) is an inflamma-tory occlusive disease affecting small and medium-sized arter-ies and veins. It is strongly influenced by smoking and will often resolve upon smoking cessation. The disease is classified into acute, |
Subsets and Splits