Hand Clinics

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Infections of the upper extremity can be challenging to diagnose and treat because of the complex anatomy and range of offending pathogens. Early recognition of infections that require an emergent surgical intervention, such as necrotizing fasciitis and septic joints, is imperative for good clinical outcomes. In addition, prompt diagnosis and intervention for deep closed space infections, such as deep abscesses or flexor tenosynovitis, is necessary to avoid chronic pain and dysfunction. Complicating factors such as underlying osteomyelitis, atypical pathogens, and immunocompromised states of patients should always be considered when treating upper-extremity infections...

Dupuytren disease is a common pathologic condition that can be especially challenging to hand surgeons in recurrent or severe contractures. Recurrence risk may be reduced with a variety of techniques, including skin grafting, external fixator application, radiation, and many others described in this article. Management of recurrence requires special attention to anatomy at risk. Adjuvant therapy may help to prevent the progression or recurrence of severe disease.

Outcomes after tendon transfer to restore upper extremity function can be optimized using a standardized, multidisciplinary approach to the patient preoperatively, augmented intraoperative decision-making, and an early postoperative mobilization therapy protocol.

Extensor tendon repair can be technically challenging and can lead to suboptimal outcomes and complications even if managed perfectly. This article describes the pertinent clinical anatomy of the extensor mechanism, reviews outcomes and complications following extensor tendon repair, and provides guidance on how to avoid and manage complications when they occur.

The proper technique for flexor tendon repair has been well established through numerous bench science and clinical studies. However, less is known about strategies to avoid and manage postoperative complications. This article discusses the common complications after flexor tendon repair, such as repair site rupture and adhesion formation. This article also addresses strategies to prevent and manage these complications. The foundation for preventing many of these complications is ensuring a strong repair without gapping at time zero, which will enable the accrual of tensile strength through early initiation of motion...

Tendinopathies are some of the most common diagnoses treated by hand surgeons. Diagnoses such as trigger digit, de Quervain tenosynovitis, extensor carpi ulnaris tendinitis, and epicondylitis often resolve with nonoperative treatment and/or a single ambulatory procedure. When symptoms persist or worsen after surgery, patients are disappointed and treatment can be challenging. This article reviews practical points in evaluation of such cases, and surgical options that work in revision scenarios.

Peripheral nerve injuries may substantially impair a patient's function and quality of life. Despite appropriate treatment, outcomes often remain poor. Direct repair remains the standard of care when repair is possible without excessive tension. For larger nerve defects, nerve autografting is the gold standard. However, a considerable challenge is donor site morbidity. Processed nerve allografts and conduits are other options, but evidence supporting their use is limited to smaller nerves and shorter gaps. Nerve transfer is another technique that has seen increasing popularity...

Most compression neuropathies can be reliably treated with surgical decompression; however, in approximately 25% of the cases, this release fails, requiring revision surgery. Defining the correct diagnosis after a failed nerve decompression (ie, persistent, recurrent, or new symptoms) is of the utmost importance and guides toward the optimal treatment. This article describes the clinical categorization of secondary carpal tunnel syndrome and cubital tunnel syndrome, intraoperative principles of revision surgery and treatment options that are currently available...

Scapholunate and lunotriquetral instability are common causes of chronic, debilitating wrist pain and functional impairment. In the setting of subacute or chronic injuries with predynamic or dynamic instability, the ideal surgical approach remains unclear. In January 2020 the authors started enrolling patients with predynamic and dynamic instability in an Institutional Review Board-approved prospective study, aimed at meticulously studying outcomes using the all-dorsal InternalBrace reconstruction technique...

Ligamentous injuries in the hand and wrist are often underdiagnosed and can present with significant functional limitations if there is untimely recognition of injury. Adequate repair or reconstruction is critical in restoring joint stability and mobility. The purpose of this review is to provide an overview of the metacarpophalangeal joint, scapholunate interosseous ligament (SLIL), and non-SLIL carpal ligament anatomy, diagnosis, imaging, treatment consideration and options, as well as surgical techniques encompassing repair, reconstruction, and fusion...

Wrist arthritis is a common condition with numerous causes and presentations. Several management options exist, and treatment should be individualized based on patient age, comorbidities, occupation, duration of symptoms, and failed treatment modalities. Arthroscopy and denervation are appealing because of shorter recovery time and preservation of motion, but duration of effectiveness varies between patients. Patients who fail these smaller procedures or those with pancarpal arthrosis are treated effectively with total wrist arthrodesis or total wrist arthroplasty in lower-demand patients...

Compared with hip and knee arthroplasty, total elbow arthroplasty (TEA) has a higher complication rate and lower survivorship. Modern TEA implants most commonly require revision due to implant loosening, infection, and periprosthetic fracture. Concerns with revision TEA include handling of the soft tissues and possible necessity of flap coverage, triceps management, preservation of bone stock, and management of concurrent infection or fracture. In this review, we will discuss preoperative evaluation of the failed elbow arthroplasty, surgical approaches, techniques for revision, outcomes, and complications following revision total elbow arthroplasty...

Traditional management of wrist arthritis consists of proximal row carpectomy, partial carpal fusions, or, in the event of pancarpal arthritis, total wrist fusion. Although proximal row carpectomy and partial wrist fusions preserve some motion at the wrist while relieving pain symptoms, the quality of results obtained from these procedures is not predictable or optimal in many instances. Management of hip, knee, ankle, and shoulder joints has evolved from arthrodesis to arthroplasty. The wrist joint is following the same pattern of evolution with the advent of reliable designs...

Thumb carpometacarpal arthroplasty with complete trapeziectomy with or without suspensionplasty, ligament reconstruction, and/or tendon interposition is largely considered equivalent techniques in providing pain relief and improving function for patients with thumb carpometacarpal arthritis. In cases of continued pain, instability, and dysfunction following an index surgery, one must first identify the cause of failure. Any options for revision surgery depend on addressing the specific cause of persistent symptoms with awareness of available options...

Small joint arthroplasty of the hand has been an established means of joint preservation and pain relief for over a half a century. Despite this, metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint arthroplasty has not achieved the long-term success seen with hip and knee arthroplasty. Problems following MCP, PIP, and carpometacarpal (CMC) joint arthroplasty can include intraoperative fracture, postoperative dislocation, recurrent pain, limitation of motion, and instability. The hand surgeon needs to be prepared for these problems and their management...

Nonunion or malunion of forearm fractures may result in restricted range of motion or persistent pain, leading to limitations in activities of daily living. Complications may also present in the form of ectopic bone growth or persistent infections. A systematic method to evaluate complications resulting from forearm fractures is helpful to both determine the cause for the failure and plan for adequate reconstruction.

An unstable distal radius fracture is one that is not capable of resisting displacement after initial closed reduction. The challenge in managing distal radius fractures is identifying which fractures are prone to displacement. Currently, there are no standard criteria for assessing the stability of distal radius fractures. The fracture pattern and patient characteristics should be taken into consideration when treating distal radius fractures. This article discusses how to recognize and manage distal radius fractures that are prone to displacement...

Scaphoid and carpal bone fractures are challenging injuries to manage and have significant functional implications. Prompt diagnosis is important and relies on systematic evaluation via history, examination, and imaging. Cross-sectional imaging is often helpful for diagnosis and treatment planning. Treatment for nondisplaced fractures is often closed but these injuries typically require prolonged immobilization and may still result in nonunion or avascular necrosis. Displaced carpal bone fractures, and those associated with carpal instability, typically require open reduction internal fixation...

Phalangeal and metacarpal fractures that require operative treatment have documented complications in around 50% of patients. The most common of these complications are stiffness and malunion. These can be highly challenging problems for the hand surgeon. In this article, we discuss complications after phalangeal and metacarpal fractures and treatment strategies for these complications.