Volume 11 Issue R9

HAND: FINGERNAILS, INFECTIONS, TUMORS,

AND SOFT-TISSUE RECONSTRUCTION

Bridget Harrison, MD
Michael Dolan, MD
Michel Saint-Cyr, MD, FRCS(C)

Reconstructive
 www.SRPS.org

Editor-in-Chief Jeffrey M. Kenkel, MD

30 Topics
Editor Emeritus Fritz E. Barton, Jr, MD
Reconstruction
Contributing Editors Breast Reconstruction
Cleft Lip and Palate
R. S. Ambay, MD, DDS J. E. Leedy, MD Craniofacial Anomalies
R. G. Anderson, MD J. A. Lemmon, MD Eyelid Reconstruction
S. J. Beran, MD A. H. Lipschitz, MD Facial Fractures
S. M. Bidic, MD J. H. Liu, MD, MSHS Hand: Congenital Anomalies
G. Broughton II, MD, PhD R. A. Meade, MD Hand: Extensor Tendons
J. L. Burns, MD M. Morales, MD Hand: Flexor Tendons
J. S. Chatterjee, MRCS D. L. Mount, MD Hand: Peripheral Nerves
A. Cheng, MD K. Narasimhan, MD Hand: Soft Tissues
J. Cheng, MD A. T. Nguyen, MD Hand: Wrist, Joints, Rheumatoid Arthritis
C. P. Clark III, MD J. C. OBrien, MD Head and Neck Reconstruction
H. J. Desai, MD J. K. Potter, MD, DDS Lip, Cheek, Scalp, and Hair Restoration
M. Dolan, MD R. J. Rohrich, MD Lower Extremity Reconstruction
R. W. Ellison, MD S. Rozen, MD Microsurgery
R. Ghaiy, MD M. Saint-Cyr, MD Nasal Reconstruction
D. L. Gonyon, Jr, MD T. Schaub, MD Plastic Surgery of the Ear
A. A. Gosman, MD M. Schaverien, MRCS Trunk Reconstruction
J. R. Griffin, MD M. C. Snyder, MD Vascular Anomalies
K. A. Gutowski, MD M. Swelstad, MD Wounds and Wound Healing
R. Y. Ha, MD J. F. Thornton, MD
F. Hackney, MD, DDS M. J. Trovato, MD Cosmetic
B. Harrison, MD A. P. Trussler, MD Blepharoplasty
L. H. Hollier, MD J. G. Unger, MD Body Contouring
R. E. Hoxworth, MD M. Vucovich, MD Breast Augmentation
B. A. Hubbard, MD R. I. Zbar, MD Brest Reduction and Mastopexy
J. E. Ireton, MD Brow Lift
K. Itani, MD Facelift
J. E. Janis, MD Neuromodulators and Injectable Fillers
R. K. Khosla, MD Lasers and Light Therapy
C. J. Langevin, MD Rhinoplasty
Skin Care
Senior Manuscript Editor Dori Kelly
Business Manager Becky Sheldon
Corporate Sponsorship Barbara Williams

Selected Readings in Plastic Surgery (ISSN 0739-5523) is a series of monographs

published by Selected Readings in Plastic Surgery, Inc. For subscription
information, please visit our web site: www.SRPS.org.
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 SRPS Volume 11 Issue R9 2016

HAND: FINGERNAILS, INFECTIONS, TUMORS, AND

SOFT-TISSUE RECONSTRUCTION

Bridget Harrison, MD*

Michael Dolan, MD
Michel Saint-Cyr, MD, FRCS(C)

*Department of Plastic Surgery, University of Texas Southwestern

Medical Center at Dallas, Dallas, Texas
West Tennessee Bone and Joint Clinic, Jackson, Tennessee
Department of Plastic Surgery, Mayo Clinic, Rochester, Minnesota

FINGERNAILS or weight but can be stunted by poor nutrition.3

Extending to the most distal point of the mobile digit,
the fingernail is exposed to a variety of injuries: traumatic,
infectious, and vascular. Their treatment frequently is
devalued compared with the reconstruction of proximal
structures, but neglect or carelessness can result in long-
term aesthetic and functional difficulties.
Anatomy and Physiology
Nail anatomy is closely linked with the physiology
and pathology of the nail unit. The nail plate
provides substantial aesthetic and functional
importance, serving to protect the underlying
sterile and germinal matrix and aid in gripping
fine objects. The nail plate is made of a keratinous
material produced as cells of the germinal matrix
die and are pressed upward.1 In its absence, 2-point
discrimination and sensation tend to decrease.
However, Jansen et al.2 found that nails longer than
0.5 cm beyond the tip of the finger decrease grip
strength and limit finger flexion.
Underlying the nail plate are the sterile and
germinal matrices. The germinal matrix produces
90% of the nail by volume. On average, fingernails
grow 3 mm per month (or 0.1 mm per day) and
toenails grow approximately 1 mm per month.
Growth generally is not affected by climate, height,
The germinal matrix is composed of dividing germ
cells from the proximal nail fold to the lunula and
extends down to periosteum. The cells retain their
nuclei to the level of the lunula, which produces the
white color of that area. Distal to the lunula is the
sterile matrix, which is responsible for nail adherence
and thickening of the distal nail. At this level, the
cell nuclei disintegrate and the nail becomes clear.
The loss of nuclei is why it is referred to as the sterile
matrix. Rugae of the sterile matrix run longitudinally
and increase surface area and adherence.4
Distal to the sterile matrix and the free nail
margin is the hyponychium. The surrounding soft
tissue is referred to as the perionychium, and the
perionychium bordering the lateral nail edges is the
paronychium (Fig. 1).5 An infection of this area,
discussed later, is termed paronychia. Proximally, the
nail fold is covered by a layer of epidermis commonly
referred to as the cuticle, or eponychium. Loss of this
protective layer can result in irregularities of the nail
plate and loss of nail shine.
Injuries
Fingertip injuries are exceedingly common, and
the nail bed itself is a frequent site of injury. Injury
or destruction of the matrices can result in nail
deformation, abnormal growth, or complete nail

1
 SRPS Volume 11 Issue R9 2016

Eponychium
Nail fold
Lunula (dorsal roof and ventral floor) Pulp

0 No injury

1 Laceration

2 Crush
Hyponychium
3 Lossdistal transverse
Ventral (sterile) matrix
A Intermediate (germinal) matrix
4 Losspalmar oblique partial
Eponychium
5 Lossdorsal oblique
Lunula

6 Losslateral

7 Losscomplete

Nail

0 No injury

1 Sterile matrix laceration

Ventral Intermediate
2 Germinal + sterile matrix laceration
(sterile) (sterile)
B matrix matrix 3 Crush

Figure 1. Anatomy of the nail shown in sagittal (A) and 4 Proximal nailbed dislocation
dorsal (B) views. (Modified from Brucker and Edstrom.5)
5 Lossdistal third

6 Lossdistal two thirds

loss. Acute injury to the nail plate or bed requires
7 Losslateral
determination of the mechanism of injury and
evaluation of the underlying structures. Fingertip 8 Losscomplete
injuries have also been classified by Allen6, Tamai,7 Bone
and Evans and Bernardis.8 Evan and Bernardis
reported using the Pulp Nail Bone classification, 0 No injury
which classifies injuries based on those three 1 Tuft
components of the fingertip (Fig. 2).8 Crush injuries
result in compression of the nail bed between the 2 Comminuted non-articular
hard distal phalanx and nail plate, often producing 3 Articular
stellate lacerations and subungual hematomas.
Avulsion injuries can result in removal of the nail 4 Displaced basal
plate and/or nail bed.69 5 Tip exposure
Bleeding underneath the nail bed results in 6 Lossdistal half
a subungual hematoma, which can be managed by
observation, trephination, or removal of the nail 7 Losssubtotal (tendon insertions intact)
plate and laceration repair. Although traditional 8 Losscomplete
thought recommended removal of the nail plate
for any hematoma exceeding 50% of the nail bed,
a systematic review of the literature found no Figure 2. The Pulp Nail Bone classification of fingertip
randomized controlled trial comparing nail bed injuries. (Modified from Evans and Bernardis.8)

2

exploration with trephination and no evidence for any
difference in final nail cosmesis or complication rate
between the techniques.10 If nail bed repair is elected,
the nail plate is removed and the nail bed typically
is repaired with 6.0 chromic suture. Replacement of
the nail plate beneath the fold is another common
practice, but its replacement has not been found to
affect nail regrowth or final appearance.11
Promising results have also been observed with
the use of dermal adhesives in nail bed repair. In a
randomized controlled trial comparing repair with
6-0 chromic sutures versus 2-octylcyanoacrylate
(Dermabond; Ethicon, Somerville, NJ), Strauss
et al.12 found no difference in cosmesis. However,
Dermabond significantly decreased the time required
for nail bed repair. Its use in children has also been
successful, although 27 of 30 pediatric patients
experienced simple transverse lacerations.13
When nail bed injury is extensive or involves
partial or total loss of the sterile matrix, split-
thickness matrix grafting from an uninvolved finger
or toe can be performed. If the avulsed part has been
retained, it can be replaced as a graft. This technique
can be successful even with exposed bone of the
distal phalanx.14 Split-thickness sterile matrix grafts
generally perform better than grafts of the germinal
matrix.15 Germinal matrix grafts must be of full
thickness to include the basilar layer of proliferative
cells. Higher success is obtained when the germinal
matrix is grafted in conjunction with other nail
elements as a composite graft.16 The donor site is then
covered with a split-thickness skin graft.
In cases with substantial loss of germinal matrix,
consideration should be given to primary nail bed
ablation. When performing an ablation, the intimate
relationship of the terminal extensor tendon to
the germinal matrix must be appreciated, with the
two structures being separated by only 1.2 mm.17
Visualization of the insertion of the terminal extensor
tendon represents the proximal limit of excision.
Microvascular nail transfer is the definitive method
for replacing the entire nail matrix, but to obtain
improved cosmesis at the recipient site, a notable
defect is created from the donor. Artificial dermis has
been described to improve donor site morbidity,18
SRPS Volume 11 Issue R9 2016
but the indications for this challenging procedure are
limited and patients must be well versed on the risks
and potential complications.19,20
Nail Deformities
Although a variety of systemic disorders can result in
nail abnormalities, the plastic surgeon is most likely
to be presented with posttraumatic deformities such
as a hook nail, pincer nail, or split nail (Fig. 3). A
hook nail arises when the nail curves volarly during
growth. This can occur after fingertip amputation
when the remaining nail bed is sutured to volar skin
or granulation tissue results in contraction. For this
reason, the nail bed should not be used to cover an
amputated tip. A hook nail can also arise secondary
to a malpositioned distal phalanx fracture with volar
angulation.21 Correction might require scar release
and full-thickness skin graft, V-Y flap, or shortening
of the nail bed to the length of the bone to provide
support.
Lateral hooking, when severe and progressive,
is known as a pincer nail. The cause of a pincer nail is
not always known, but its progression can cause pain
and discomfort. Treatment methods include wedge
resection of the midportion of the phalanx, lateral
dermal grafts, or surgical extirpation and nail bed
ablation.
A split nail can occur as a result of a
longitudinal scar in the germinal matrix or injury to
the sterile matrix. If the split is narrow, scar excision
and primary closure might be possible. Larger splits
require grafting for correction.
C
A B
Figure 3. Hook (A), pincer (B), and split (C) nails.
3
 SRPS Volume 11 Issue R9 2016
INFECTIONS
Sixty percent of all hand infections are the result of
trauma, 30% result from human bites, and 10%
result from animal bites.22 Hand infections account
for approximately 20% of all admissions to hand
surgery units and often are accorded a lower level
of significance than warranted. When the infection
is appropriately treated, the patient returns to
optimal function in a short time. If the infection is
inadequately treated, the patient is resigned to pain,
stiffness, and disability. Amputation is sometimes
required in extreme cases.
Microbes and Antibiotic Selection
The most frequent pathogen involved in hand
infections is Staphylococcus aureus, with an increasing
trend toward methicillin-resistant species.23,24 Current
recommendations do not require prophylaxis for
methicillin-resistant S. aureus (MRSA) in all patients,
but individual factors and local antibiograms should
be considered. In a retrospective review of 159 hand
infections treated in the operating room during an
11-year period, Imahara and Friedrich25 identified
intravenous drug use as the only independent risk
factor for community-acquired MRSA infections.
However, the Centers for Disease Control
recommend empiric coverage of MRSA infections
if the local rate of MRSA exceeds 15%,26 a rate that
is not uncommonly exceeded in recent reports.
Outpatient coverage can reasonably be obtained with
trimethoprim-sulfamethoxazole, clindamycin, or a
long-acting tetracycline.
When selecting an antibiotic, one needs to
consider the severity of the infection, suspected
organism, and patient characteristics. High-level
resistance to clindamycin has been reported, especially
in patients with antibiotic exposure within 3 months
and in those who have recently undergone surgery.27
Rifampin frequently is added to antibiotic regimens
to cover MRSA, but little evidence supports this
practice.28 Rifampin has been found to be effective
when combined with Linezolid for implant-associated
infections,29 but the extension of this practice to all
MRSA infections has not been established. Bactrim
4
is effective in treating MRSA30 but does not provide
adequate coverage of group A streptococci (Table 1).
Infections with Streptococcus species present rapidly,
with marked cellulitis and possibly lymphangitis.
Although an antistaphylococcal penicillin or first-
generation cephalosporin adequately covers S. aureus,
streptococci are better covered by penicillin.
Infections associated with intravenous drug use,
diabetes mellitus, bites, and farm injuries are more
frequently polymicrobial with gram-negative, gram-
positive, and anaerobic species.3133 Although alpha-
hemolytic streptococcus and S. aureus are the most
commonly isolated pathogens in human bite wounds,
Eikenella corrodens is found in up to one-third of
cases.34 Pasteurella multocida can be found in domestic
animal bite wounds and scratches.35 These wounds
usually are adequately covered by the addition of
penicillin to an agent effective against the other gram-
positive organisms36 or amoxicillin-clavulanic acid.37
Prophylactic Antibiotics
Five independent studies have shown that
prophylactic antibiotics are not useful for
uncomplicated hand lacerations,3842 and they are
not recommended for routine hand trauma. Even
among mutilating injuries sustained on the farm,
Fitzgerald et al.31 failed to identify improvement
from prophylactic parenteral antibiotics. In cases of
open fractures, an orthopaedic study43 identified a
benefit of the use of a short course of first-generation
cephalosporins and appropriate fixation. Antibiotics
should be administered within 6 hours of injury.44,45
For elective hand surgery, the role of
prophylactic antibiotics is limited. Hoffman and
Adams46 recommended antibiotics for the following
procedures: 1) soft-tissue reconstructive procedures with
large flaps, 2) total elbow or wrist implant arthroplasty,
3) procedures of long duration, 4) complex open hand
trauma with wound contamination and extensive soft-
tissue and bony injury, and 5) procedures longer than
2 hours in duration. A common factor of the above
procedures is prolonged operative time, which has
repeatedly been shown to significantly increase infection
rates (P < 0.0001).47,48 Still, although Bykowski et al.49
 SRPS Volume 11 Issue R9 2016

Empiric Antibiotic Treatment for Some Common Hand Infections
Infection
Cellulitis/lymphangitis
Paronychium/felon
Flexor tenosynovitis
Deep space infection
Human bite wound
Dog or cat bite wound
Table 1
Antibiotic Likely Organisms
First-generation cephalosporin Streptococcus pyrogenes,
or antistaphylococcal penicillin Staphylococcus aureus
Dicloxacillin S. aureus, anaerobes
or first-generation cephalosporin
b-Lactamase inhibitor S. aureus, streptococci,
anaerobes;
or first-generation cephalosporin
and penicillin; consider ceftriaxone Neisseria gonorrhoeae
b-Lactamase inhibitor S. aureus, streptococci, gram-
negative bacilli, anaerobes
or first-generation cephalosporin
and penicillin
b-Lactamase inhibitor S. aureus, streptococci,
or first-generation cephalosporin Eikenella corrodens, anaerobes
and penicillin
b-Lactamase inhibitor S. aureus, streptococci,
or first-generation cephalosporin Pasteurella multocida
and penicillin

associated surgical site infections with longer procedure
times, smoking status, and diabetes mellitus in a review
of 8850 patients, prophylactic antibiotics did not affect
infection rates in those subgroups.
Antibiotics have been shown to reduce infection
rates in large joint replacements,50,51 although Shapiro52
argued that smaller, non-metallic prostheses, such as
those used in the hand, might be more resistant to seeding.
Because of the marked morbidity associated with implant
infection, prophylaxis is commonly used when
implanting prostheses.
Management
Although the spectrum of acute bacterial hand
infections is broad, the management principles are
similar for all and can be summarized as follows:
rest, elevation, and immobilization in
position of function
adequate drainage of all loculations of
pus and dbridement of necrotic tissue
antibiotics, determined by sensitivities
from aerobic and anaerobic cultures
and special culturesfungi,
mycobacteria, virusesas indicated
treatment with broad-spectrum
antibiotics until cultures are available
tetanus prophylaxis for all
penetrating wounds
early, aggressive hand therapy
Common Bacterial Infections
Hand infections can be acute or chronic, but the
overwhelming majority of them are acute. Of the
acute infections, the overwhelming majority are
bacterial in origin.
Cellulitis
Cellulitis is a common superficial infection of the
hand that presents as erythema, swelling, pain,
and occasional lymphangitis or vesicle formation.
Cellulitis occurs most commonly on the dorsal aspect

5
 SRPS Volume 11 Issue R9 2016
of the fingers and metacarpals, and beta-hemolytic
streptococcus is the usual pathogen. Treatment
includes rest, elevation, splinting, and antibiotics.
Paronychia
Paronychia is an infection of the lateral soft-tissue
fold surrounding the fingernail. Paronychia is
initiated by the introduction of bacteria between
the nail and its surrounding structures. This usually
is caused by minor trauma, such as nail biting and
manicures. It frequently is reported that S. aureus
is the most frequent isolate in paronychia. Studies
have shown anaerobic bacteria to be present alone
or in combination in a large percentage of cases of
paronychia,53 likely because of the frequency
of contact of the oral secretions with the
inciting wound.
Paronychia initially begins as erythema,
swelling, and discomfort at the nail fold, sometimes
with fluctuation and frank purulence. If paronychia
is detected early, warm soaks, elevation, and
oral antibiotics can be sufficient treatment. Oral
cephalexin, clindamycin, and amoxicillin-clavulanate
are effective against most pathogens isolated from
paronychia.54 Although no trials have compared
antibiotic therapy alone versus surgical drainage, in
the presence of an obvious abscess, drainage generally
is recommended.55
Different methods for drainage have been
described.56,57 Superficial infections can be drained
easily with an 11 blade or elevation of the nail fold
with the tip of a 21- or 23-gauge needle. If pus is
present underneath the nail, however, most hand
surgeons remove a portion or all of the nail plate
(Fig. 4).58 If nail plate removal is indicated, incision
of the dorsal nail fold can facilitate removal and
drainage. Two incisions are made at right angles to
the nail fold, at the 5 oclock and 7 oclock positions,
to elevate it completely from the nail bed in the
region of the infection (Fig. 5).59,60 Accurate placement
of the incisions minimizes the chance of subsequent
eponychial retraction.
6
Occasionally, paronychia becomes a chronic
problem, perhaps from secondary mycobacterial or
fungal infections, which more commonly occur in
immunosuppressed patients, diabetics, and patients
with cancer. Chronic paronychia also occurs in patients
with frequent exposure to irritants and allergens.61
With this condition, the cuticle separates from the
nail plate exposing the region to potential bacterial
and fungal pathogens. Although chronic paronychia
was previously thought to be a predominantly fungal
infection caused by Candida albicans, the role of this
pathogen has recently been questioned.62
Before initiating treatment, alternative diagnoses
must be considered. Considering the chronicity of
the lesion, entities such as squamous cell carcinoma
(SCC), malignant melanoma, and metastatic lesions
should be considered.63,64 Treatment should begin
with avoidance of contact irritants. Although Candida
has been targeted in the past, topical steroids have
been shown to be more efficacious than systemic
antifungals.62 Refractory chronic paronychia might
require marsupialization or excision of the proximal
nail fold. The nail fold can be marsupialized by
excision of a crescent of tissue down to the germinal
matrix, which is then left to close by secondary
intention.65 Alternatively, the entire proximal nail fold,
including the cuticle, can be excised.66
Pulp Space Infection (Felons)
A felon is an infection of the pulp of the distal finger.
The anatomy of the pulp is unique, with hundreds
of longitudinal septa anchoring the tip to the distal
phalanx (Fig. 6).58 When infection is present, the
septa can compartmentalize an infection and preclude
adequate drainage if the septa are not fully ruptured.
Most felons are precipitated by some sort
of penetrating trauma, and radiographs should be
obtained of all felons and carefully evaluated for
foreign bodies. If a felon does not respond to therapy
or if strong evidence indicates that a non-radiopaque
foreign body is embedded in the pulp, ultrasonography
might reveal a foreign body not seen on conventional
radiographs. S. aureus is the most common pathogen
in felons,67 but gram-negative organisms have also
 SRPS Volume 11 Issue R9 2016

been reported. Gram-negative organisms should be

considered in immunosuppressed patients. Cases of
pulp space infection have also been reported to occur
in diabetics who developed felons after checking their
blood sugar level by fingerstick.68
Paronychia If a pulp infection is observed early, it might
simply be a case of localized cellulitis or a small
superficial abscess. Localized cellulitis and small
Figure 4. Drainage of paronychia. (Modified from
superficial abscesses can be treated with orally
Conolly.58)
administered antibiotics, rest, and elevation or
with local drainage as indicated. In a case of true
felon, the patient presents with the entire pulp red,
swollen, and markedly tender. The patient usually
complains of a severe throbbing pain, particularly
when the finger is dependent. The pain is caused
by increased tissue pressure, which is caused by
the unyielding septa (essentially a compartment
syndrome of the pulp). At that stage, adequate
drainage and antibiotics are required for treatment.
Late presentation or incomplete therapy can result in
a compromise of the blood flow to the pulp, which
Figure 5. Incisions in eponychium. (Modified from Zook can result in necrosis of the soft tissues, tenosynovitis,
and Brown.60) septic arthritis, and even osteomyelitis.69
Many incisions have been recommended for
the drainage of felons. If it is pointing, the felon
should be drained at that site. Careful palpation
Germinal matrix Dorsal roof
Nail plate with a small blunt probe often determines a point of
Eponychium

Hyponychium
maximal tenderness, and the incision should be made
at that site. The pulp must be explored immediately
volar to the phalanx but dorsal to the neurovascular
Sterile matrix structures. The fibrous septa are ruptured to allow
Periosteum complete drainage of the infected space. Good results
are achieved with a longitudinal midline palmar
Fat pad and fascial septa Sterile matrix
incision that does not cross the distal interphalangeal
Paronychium
(DIP) joint (Fig. 7).58,70 The incision heals well and
Artery usually does not produce a hypersensitive scar on the
Nerve
pulp. A dorsal mid-axial hockey stick incision can be
used but should be placed on the noncontact side of
Fascial septa
the digit and should not extend around the tip of the
Figure 6. Anatomy of the fingertip. (Modified from finger. If this incision is used, care must be taken to
Conolly.58) preserve the neurovascular bundles.

7
 SRPS Volume 11 Issue R9 2016
Pus pocket
Digital artery
and nerve
Figure 7. Drainage of a felon. (Modified from Conolly.58)
Tenosynovitis
Tenosynovitis is an infection within the sheaths that
form the gliding surfaces around the tendons in the
hand. It is almost exclusively a disease of the flexor
tendons, although extensor tenosynovitis has also
been described. Reports of extensor tenosynovitis
more commonly involve atypical organisms, such
as tuberculosis or blastomyces.7173 Although
tenosynovitis rarely is life-threatening, delayed or
inappropriate treatment can lead to devastating
consequences. The delicate gliding surfaces of the
tendon sheaths can be destroyed by infection,
resulting in a stiff and painful finger. Even more
prolonged delay in treatment can allow the sheath
to rupture, with spread of the infection to any of the
spaces of the palm or to the adjacent bone. Prolonged
infection increases pressure in the sheath and can
thereby lead to ischemic rupture of the tendon via
inhibition of extrinsic blood flow.74
Most cases of tenosynovitis begin with
penetrating trauma, and in such cases, the most
common infectious agent is S. aureus. Some cases are
caused by hematogenous dissemination, particularly
of gonococcal infections, and this possibility should
be considered in cases with no history of antecedent
trauma.75
8
The hallmarks of flexor tenosynovitis were
first established by Kanavel76 and constitute the four
cardinal signs that bear his name:
fusiform swelling of the digit
partially flexed posture of the digit
tenderness along the entire flexor sheath
pain along the entire flexor sheath with
passive extension of the digit
The sensitivity and specificity of these signs
have not been validated, and authors7780 have
reported variations in the most commonly seen
sign. In a study of 75 patients with purulent flexor
tenosynovitis, Pang et al.77 found that fusiform
swelling was most common (97%). All patients in
a report by Dailiana et al.78 experienced tenderness
along the flexor tendon sheath and pain with passive
extension. Diagnosis is first and foremost clinical, but
in situations of uncertainty, ultrasonography might
be of benefit.79,80 Ultrasonography can show swelling
of the tendon and peritendinous fluid.
Michon81 classified flexor tenosynovitis
into three stages that can be used to describe and
document the clinical presentation. In the first stage,
the tendon sheath becomes distended with exudative
fluid. In the second stage, further distension occurs
with purulent fluid. In the third stage, the tendon
becomes nonviable and necrosis of the tendon and
pulleys is present.
Once the diagnosis of tenosynovitis has been
made, treatment must be instituted promptly. Very
early cases can undergo a trial of intravenously
administered antibiotics, splinting, and elevation.
That mode of treatment, however, should be selected
with caution. The patient should be observed closely,
and if marked improvement is not noted within
12 to 24 hours, treatment should progress to
surgical drainage.
When surgical drainage is deemed necessary
based on initial presentation or failure to improve,
two methods are available. Early cases can be
irrigated through incisions in the sheath just
proximal to the A1 pulley and at the distal flexor
sheath. A small catheter is then placed (Fig. 8).8284
In general, irrigation does not need to continue
 SRPS Volume 11 Issue R9 2016

postoperatively. Lille et al.85 found no difference in

functional outcomes with continued irrigation. If the
patient fails to respond to treatment or if the sheath
cannot be cleared of purulence at initial exploration,
open drainage must be performed. The sheath is
opened widely via a midlateral incision to maintain
coverage of the tendon sheath and is copiously
irrigated.86 The wound is closed loosely or left open
for delayed closure. Active range-of-motion exercises
are begun with the first dressing change on the ward.87
In the event that the thumb or little finger is
involved with tenosynovitis, the infection can extend
proximally to involve either the ulnar or radial bursa.
The two bursae communicate through the space of
Parona, between the pronator quadratus and flexor
digitorum profundus tendons. When infection spreads
through this communicating space, a horseshoe
abscess can form. This will cause proximal pain and
swelling and might necessitate incisions in the ulnar
and radial bursa and carpal tunnel release.88

Deep Space Infection

A variety of spaces have been described in the hand.
In reality, the spaces are potential and become notable
only when infected, as they become loculations of
purulent material. They include the thenar space,
midpalmar space, hypothenar space, subtendinous
space or Parona space, dorsal subcutaneous space, Figure 8. Closed irrigation for flexor tenosynovitis.
dorsal subaponeurotic space, and interdigital web
spaces (Fig. 9).59,84 The spaces often are confused (Modified from Brown and Young.84)
with the compartments of the hand, which are the
four dorsal interossei, three volar interossei, thenar,
hypothenar, and adductor pollicis compartments.
Thenar space Midpalmar space
Infection in the deep spaces begins most
frequently with a penetrating injury, the most Midpalmar septum Hypothenar septum
commonly identified isolate being S. aureus. An
antistaphylococcal agent can be used for initial
antibiotic therapy unless gram stain at the time of
drainage suggests another organism. Nonsurgical
management has no place in the treatment of deep
space infections. As clearly described in the pre-
antibiotic era by Kanavel,89 the key to treatment of
deep space infections is precise drainage of the abscess,
Figure 9. Deep spaces of the hand. (Modified from
guided by knowledge and respect for the surrounding
and involved structures. Brown and Young.84)

9
 SRPS Volume 11 Issue R9 2016
Both thenar and midpalmar space infections
usually present with diffuse hand swelling, especially
on the dorsum. This is because the volar skin is
more limited by tight fascial attachments, whereas
dorsally, there is room for expansion. Thenar space
infections usually are characterized by the thumb
being held in an abducted position, with pain over the
adductor muscles and pain on extension or attempted
opposition of the thumb. Drainage of the abscesses
must not only respect the proximity of neurovascular
structures, primarily the radial bundle to the index
finger and the ulnar bundle to the thumb, but also
must prevent scarring across the thumb-index web
(Fig. 10).84
A midpalmar infection causes loss of palmar
concavity, with fingers often held in flexion. The
midpalmar space, exclusive of the flexor tendon
sheaths, allows free spread of infection along fascial
planes to deeper areas in the hand. Its boundaries
are the fascia over the second and third interosseous
muscles, the oblique midpalmar septum radially, the
hypothenar septum ulnarly, and the flexor sheaths of
the long, ring, and small fingers volarly. The fingers
might be held in a semi-flexed posture with pain
during passive extension. Hypothenar space infections
are less common and are localized to an area defined
by the hypothenar septum ulnarly, the periosteum of
the fifth metacarpal dorsally, and the palmar fascia and
fascia of the hypothenar muscles volarly.
Osteomyelitis
Osteomyelitis of the bony structures of the hand
is a relatively infrequent infection because of the
extensive blood supply to the region,90 but its effects
can be devastating. Nearly half of all fingers with
osteomyelitis ultimately require amputation, with
many more remaining stiff or nonfunctional.91
Osteomyelitis can present after penetrating or crush
wounds or can spread from an adjacent infection,
hematogenous seeding, or treatment of fractures.
The incidence of osteomyelitis after internal
fixation of open hand fractures is reportedly 0 to
2.5%.92 For osteomyelitis in this setting, Balaram
and Bednar93 recommended implant removal and
surgical cultures from the affected bone and soft
10
tissue. Dbridement of infected soft tissue and bone
is performed. Antibiotic spacers are placed in the
defect, and external fixation can be applied before
wound closure.94 Positive cultures are treated with 4
to 6 weeks of antibiotic treatment. After successful
treatment, spacers can be removed and autologous
grafting can be performed.
Overall, S. aureus is the most common
infecting organism, but polymicrobial infections are
common after penetrating trauma or open injuries.
Hematogenous osteomyelitis and postoperative
infections are more likely to be caused by a single
organism.95 The best test for diagnosing osteomyelitis
under such circumstances is direct evaluation of the
bone in an operative setting, with a biopsy performed
during the same procedure. The biopsy also
provides a culture to guide the antibiotic therapy. A
superficial swabbing of the wound is inadequate for
diagnosis or culture, because the pathogens obtained
by that technique might not accurately reflect
the microbiology of the infected bone. Although
conventional radiographs should be obtained to
identify foreign bodies and other pathological
conditions, they are unreliable in the diagnosis of
osteomyelitis.96 Three-phase bone scans and tagged
white blood cell scans are more accurate but are
expensive, time-consuming, and limited by acuity of
the infection and other local inflammatory processes.
Magnetic resonance imaging (MRI) is frequently
used for diagnosis, but sensitivity and specificity
have been reported to range from 60% to 100%
and from 50% to 90%, respectively.97 Diagnosis
can be confused with noninfectious inflammatory
conditions, bone contusion, healing fractures,
osteonecrosis, and metastasis.
Septic Arthritis
Infection of the joint spaces of the hand can
cause a devastating loss of hand function because
it can quickly lead to joint degeneration or
osteomyelitis.98,99 Septic arthritis can present as a
primary site of infection or as a complication of
another hand infection, the most common of which
is an acute flexor tenosynovitis. Isolated septic
arthritis can occur either by direct inoculation or
 SRPS Volume 11 Issue R9 2016

C D

Figure 10. Incisions for drainage of deep space infections. A, Thenar space. B, Mid-palmar space. C, Hypothenar
space. D, Collar button abscess. (Modified from Brown and Young.84)

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 SRPS Volume 11 Issue R9 2016
by hematogenous spread from a distant infection.
Distant sites of recent infection must be sought,
particularly in the patient with no history of
trauma.100 In children, monoarticular arthritis
often is caused by hematogenous spread from a
distant infection. In addition to Streptococcus and
Staphylococcus species, Haemophilus influenzae must be
considered to be a common potential pathogen and
covered appropriately. In the sexually active patient,
particularly those younger than 40 years with no
history of direct inoculation, gonococcal arthritis
must be suspected.101
Septic arthritis in the hand presents as a locally
tender, erythematous, and swollen joint. Because
of the swelling and pain, the joint is held in the
position that maximizes its volume, approximately
30 degrees of flexion in the interphalangeal joints
and full extension in the metacarpophalangeal
(MCP) joints. The joint is particularly tender with
any passive motion. Arthrocentesis of the joint can
be performed as a diagnostic maneuver. Treatment
consists of elevation, parenteral antibiotics, and
incision and drainage of the joint.102 Treatment
with open irrigation and dbridement is standard,
but arthroscopic approaches in the wrist have been
described as achieving good results.103 Depending on
the severity of the infection, irrigation of the joint
for 48 to 72 hours might also be required. Based on
a review of 40 consecutive cases of septic arthritis in
the hand or wrist, Kowalski et al.104 recommended
a short course (<1 week) of parenteral antibiotics
supplemented with oral therapy for an additional 2
to 3 weeks.
Views differ on the subject of immobilization
versus mobilization. Wittels et al.105 showed the
benefits of early mobilization in a study of septic
arthritis in 40 hand joints. Boustred et al.106 also
reported achieving good results with mobilization
with 24 hours of surgical drainage but suggested
primary arthrodesis for patients who present after
10 days of onset of symptoms. The recommendation
was supported by data from Curtiss,107 Roy and
Bhawan,108 and Smith et al.,109 who found irreversible
changes in the articular cartilage by 7 days of sepsis
and chondrocyte death within 24 to 48 hours.
12
Bite Wounds
Human Bite Wounds
Bites to the human hand account for 20% to 30%
of all hand infections, and the majority are human
bites. The clenched-fist injury is associated with a
high incidence of complications, including stiff joints
and even amputations.110,111 The injury is sustained as
the clenched fist strikes the mouth of another person,
and the tooth frequently impales the metacarpal
heads. The key point in understanding the potential
of the underlying pathological condition is that the
site of penetration of the various layers is relative to
the position of the fist at the moment of impact (Fig.
11).112 The hand must be assessed in the clenched-fist
position to allow accurate assessment of the depth
of injury.
The patient presenting early with a laceration
or puncture has minimal inflammation. Radiography
might reveal a fracture of the metacarpal head, air
within the joint, or, occasionally, a foreign body such
as a broken tooth.113 The patient presenting late has
a red, swollen, painful hand and can have associated
lymphangitis and regional lymphadenitis. The
patients are constitutionally unwell, with fever and
elevated white cell count, and are in serious danger
of osteomyelitis, septic arthritis, and severe joint
damage.114 Radiographic examination of the patients,
in addition to looking for a chip fracture or foreign
body, is directed at early signs of osteomyelitis or
abscess formation within the bone.115
In the majority of cases, cultures yield S.
aureus,116 but early reports were limited by failure
to include anaerobic cultures. With adequate
cultures, other organisms commonly encountered
include alpha- and beta-hemolytic streptococci,
Eikenella corrodens, Bacteroides gracilis, Prevotella, and
Peptostreptococcus.117
The clenched-fist wound to the MCP joint
is a notoriously underestimated and undertreated
injury. All patients with clenched-fist wounds should
be managed with splinting, elevation, antibiotics,
and wound exploration.118,119 In grossly septic joints,
irrigation can be continued postoperatively for 48
to 72 hours. Early motion (4872 hours) should be
advocated considering that stiffness is one of the more
difficult complications to treat.

A the most common pathogens isolated are a mixture
B excised (especially over joints, tendons, vessels, and
Figure 11. A, Tooth pierces clenched fist, penetrating
skin, tendon, joint capsule, and metacarpal head. B,
When finger is extended, four puncture wounds do not
align. (Modified with permission from Lister.112)
Studies120,121 have shown that uncomplicated
bite wounds (not involving the joint capsule or
articular surface), when seen within 12 hours, can
be adequately managed on an outpatient basis.
Treatment involves wound exploration, vigorous
irrigation, dbridement, and supplementation with
orally administered antibiotics to be implemented
only for compliant patients. The addition of
appropriate intravenously or orally administered
antibiotics is necessary to ensure eradication of the
causative organism. Amoxicillin and clavulanic
acid have been shown to be effective in treating
human and animal bites.122 Tetanus vaccination and
immunoglobulin should be administered as indicated.
If the aggressors hepatitis B status is unknown,
consider an accelerated course of the hepatitis
B vaccine.123
SRPS Volume 11 Issue R9 2016
Animal Bite Wounds
Domestic dogs are responsible for 90% of all animal
bites. More than half the dog attacks involve young
children, and of the resulting wounds, approximately
half are to the hands and forearms. Dog bites become
infected less often than do human or cat bites.117
A dogs jaws can exert a force of 150 to 450 psi,
which is sufficient to devitalize tissues. The resulting
wound can be a puncture, laceration, avulsion,
crush, or combination. As with the human bite,
of aerobes (including Pasteurella multocida) and
anaerobes.124 Pasteurella infection should be suspected
in cases of acute onset of cellulitis, lymphangitis,
and serosanguineous or purulent discharge from a
hand wound within 24 hours of a dog or cat bite.125
Fortunately, P. multocida is sensitive to penicillin.
Most dog bite wounds can be thoroughly
irrigated with normal saline, have the margins sharply
nerves), and have the edges loosely approximated
with sutures. Paschos et al.126 found no difference in
infection rate between primary suturing and non-
suturing, whereas the cosmetic appearance of the
sutured wounds was notably better. Most of the
organisms commonly encountered in dog saliva are
sensitive to penicillin, so a 5-day course of orally
administered penicillin should be prescribed.127
Penicillin-allergic patients can be treated with
clindamycin and a fluoroquinolone or clindamycin
and trimethoprim-sulfamethoxazole.128 The tetanus
status of the patient and the rabies status of the
animal should be verified and treated as appropriate.
Domestic cat bites account for only 5%
of animal bite wounds to the hand but are more
likely to become infected than dog bites. This can
be attributed to the configuration of the animals
dentition. Cat teeth are long and sharp, and the
injury subsequently inflicted tends to be a deep
puncture wound, which can inoculate deep structures
and lead to delay in diagnosis.129 Markedly less
devitalization of tissues occurs with a cat bite
compared with a dog bite, but location over a joint
or tendon sheath should increase concern.130 Wound
closure is controversial, and although primary
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closure has been reported without subsequent
complications,131 deep wounds, noncompliant
patients, and late-presenting injuries might be better
managed open. Antibiotic choices are similar to those
used for dog bites.
Atypical Mycobacterial Infections
The three major atypical mycobacteria involved
in hand infection are Mycobacterium marinum,132
Mycobacterium kansasii,133135 and Mycobacterium
terrae.136,137 M. marinum is the most common
mycobacterial species to infect the hand. It lives in
warm water environments and has been cultured
from contaminated swimming pools, fish tanks, piers,
boats, and stagnant water. It is endogenous to fresh
and saltwater marine life. M. marinum survives best
at 31C, and for that reason, it produces infections on
the extremities rather than deep body cavities.138 M.
kansasii infection is associated with exposure to soils,
whereas M. terrae infection should be suspected with
patients involved in farming. These organisms can
cause infection even in immunocompetent patients.
Infections with Mycobacterium occur after
a break in the integrity of the skin, often from a
mild abrasion on the dorsum of the hand or over
the interphalangeal or MCP joints of the fingers.
Infection of the hand progresses through a spectrum
of indolent skin ulcers through subcutaneous
granulomata with sinus tracts, tenosynovitis (flexor
and extensor), and septic arthritis or osteomyelitis.
Remote exposure must be identified because lesions
appear after an incubation period of 2 to 4 weeks.139
Early clinical diagnosis of mycobacterial
infections is made only with a high index of
suspicion. When mycobacterial infection is suspected,
cultures should be obtained at both 31C and 37C;
otherwise, M. marinum infections can be missed.
Positive cultures for mycobacterial strains take at least
6 weeks for identification; therefore, treatment can
be instituted on the basis of granulomata shown by
histological examination or on the basis of acid-fast
bacilli seen on a smear.
Treatment of superficial disease can be
successful with chemotherapy alone. No single or
combination of agents has been shown to be the
treatment of choice. Success has been reported with
tetracycline,140 ciprofloxacin,141 and clarithromycin.142
The largest study to date,143 from Hong Kong,
suggested that chemotherapy alone might be
applicable to more extensive disease; the authors
reported a worse prognosis with severe disease
regardless of the treatment option. Generally, deeper
disease treatment also requires surgery with radical
synovectomy and more specific antimycobacterial
therapy with rifampicin and ethambutol for up to 2
years. The optimal duration of treatment, however,
is unknown. If surgery is indicated, physiotherapy
should begin promptly.
Viral Infections
Herpetic Whitlow
Herpes simplex virus (HSV) infection of the hand
was first described by H. G. Adamson in 1909. It can
be caused by a primary or recurrent infection with
either HSV-1 or HSV-2, but subtypes are clinically
indistinguishable. It tends to occur in three distinct
patient subgroups. The first group is adolescents
with genital herpes, who tend to be infected with
HSV-2.144 The remaining groups tend to be infected
with HSV-1. The second group is children with
oral gingivostomatitis,145 and the third group is
adult health care professionalsincluding dentists,
anesthesiologists, surgeons, and nurseswho deal
directly with potentially infected oral and respiratory
secretions.146
Herpetic infection of the hand initially declares
itself with a prodromal phase of approximately 72
hours duration, with severe pain or tingling in the
affected digit, and then erythema and swelling.
This is called herpetic whitlow. During the ensuing
hours to days, vesicles appear and coalesce, often
around the eponychium and lateral nail fold. It is
at that stage that the viral infection is most likely
to be mistaken for a bacterial felon or paronychia.
However, the pulp usually is not tense, as it would be
in a case of bacterial felon. Associated lymphangitis
can be present. The natural history of untreated,
uncomplicated herpetic whitlow is complete
resolution within 3 weeks. Viral shedding, however,

14

occurs during the first 12 days and corresponds
with the peak of infectivity.147 Reactivation of latent
virus occurs in only approximately 20% of hand
patients.148,149 It is not normally as severe as the
primary infection and lasts for 7 to 10 days.
Diagnosis is primarily clinical but can be
confirmed by viral culture, serum antibody titers,
Tzanck smear, and viral polymerase chain reaction.
Viral culture is the most sensitive diagnostic test but
can require 1 to 4 days for results. The Tzanck smear
is easily performed by unroofing a vesicle and taking
scrapings with a scalpel but identifies only 50% to
60% of culture-proven herpetic infections.150
The treatment of herpetic infections of the
hand is primarily nonsurgical. Of note, surgical
intervention can both delay diagnosis and expose
the patient to other pathogens.151 Rest, elevation,
and anti-inflammatory analgesia are the mainstays
of treatment. A total daily dose of 1600 to 2000
mg of orally administered acyclovir can prevent
or shorten symptom duration and viral shedding
if administered at the onset of the prodrome, but
optimal treatment duration is unknown.152,153 For
immunocompromised patients, aggressive therapy
with intravenously administered acyclovir might be
warranted in an attempt to prevent life-threatening
viremia or meningitis.154
Verruca Vulgaris
The most frequent viral infection of the hand
is caused by human papillomavirus. Human
papillomavirus subtypes 2 and 4 cause verruca
vulgaris, or common warts. Warts occur in up to
10% of children and young adults, most commonly
between the ages of 12 and 16.155 Forty percent of
warts can be expected to clear without treatment,156
but pain and aesthetic appearance can prompt
consultation.
Many over-the-counter preparations contain
salicylic acid, and evidence exists for a better cure rate
(75%) over placebo (48%).157 Higher concentrations
can be prescribed by a physician, but improved
efficacy compared with over-the-counter preparations
has not been proven. Cryotherapy is also an effective
SRPS Volume 11 Issue R9 2016
treatment, but multiple treatments usually are
required for resolution. Imiquimod, bleomycin,
and systemic retinoids have all been used to treat
warts, but side effects are notable and limit
widespread application.
TUMORS
Several authors158162 have presented excellent reviews
of the spectrum of hand neoplasms, including
their incidence, causes, anatomic distribution, and
management, which almost always involves surgical
remova1. Only the more common hand tumors are
discussed herein. The overwhelming majority of hand
masses are benign, and true neoplasms are rare in the
hand (Table 2).158
Soft-Tissue Tumors
Ganglia
Ganglia are the most common benign tumors in the
hand.163,164 Although trauma is commonly thought
to be implicated in the development of ganglia, a
traumatic antecedent has been documented in only
a small percentage of patients. The pathogenesis
is thought to be mucoid degeneration of fibrous
connective tissue in joint capsules or tendon sheaths
occurring idiopathically or secondary to injury
or irritation. Ganglia are two to three times more
common in women than in men. The usual clinical
presentation is that of a mass with or without pain.
Occasionally, occult ganglia present as paresthesias or
weakness from nerve compression.165167
Dorsal wrist gangliaThe dorsum of the
wrist accounts for 70% of all ganglia in the hand
and wrist. In the dorsum of the wrist, the ganglion
usually overlies the scapholunate ligament. Clay
and Clement168 noted the pedicle of the ganglion to
arise from that site in 76% of patients. The cause of
dorsal wrist ganglia is still uncertain. Some attribute
underlying peri-scaphoid ligamentous instability,169
but this might be a sequelae of surgical treatment of
the ganglion.
Volar wrist gangliaVolar wrist ganglia arise
from the flexor carpi radialis tendon sheath or the
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 SRPS Volume 11 Issue R9 2016

Table 2
Grading of Bone and Soft-tissue Tumors of the Hand158

Benign (G0) Low-grade Sarcomas (G1) High-grade Sarcomas (G2)

Bone
Enchondroma Giant-cell tumor Osteosarcoma
Osteochondroma Desmoplastic fibroma Ewings sarcoma
Fibrous dysplasia Chondrosarcoma (low-grade) Lymphoma
Osteoid osteoma Parosteal osteosarcoma Chondrosarcoma
Bone cysts Angiosarcoma
Hemangioma Myeloma
Osteoblastoma
Soft Tissue
Ganglion Desmoid Synovioma
Giant cell tumor Liposarcoma (low-grade) Malignant fibrous histiocytoma
(tendon sheath) Fibrosarcoma (low-grade) Liposarcoma (high-grade)
Lipoma Kaposis sarcoma Rhabdomyosarcoma
Neurolemmoma Epithelioid sarcoma
Chondromatosis Clear cell sarcoma
Glomus tumor Angiosarcoma
Hemangiopericytoma
Malignant schwannoma

radioscaphoid, scapholunate, or scaphoid-trapezium-
trapezoid joint. Ultrasonography can delineate
the origin preoperatively. The ganglion is in close
proximity to the radial artery, which can cause it to
be bilocular.
Flexor tendon sheath gangliaFlexor tendon
sheath ganglia arise from the volar flexor tendon
sheaths in the vicinity of the MCP joint. They
present as small, hard, tender tumors on the volar
aspect of the MCP joint or proximal phalanx but do
not move with the tendon. Etiology is unknown, and
they require excision only if symptomatic, excising a
small cuff of the tendon sheath.170 Recurrence rates
are lower with direct excision, but the most cost-
effective treatment for flexor tendon sheath ganglia is
two aspirations before excision.171
Mucous cystsGanglia arising in association
with tendons and joints on the dorsal aspect of
fingers can originate from the extensor tendon itself
or from the joint capsule. Mucous cysts can produce
a deformity of the nail plate from pressure on the
nail bed. The etiology of these cysts is unclear, and
various surgical approaches have been successful.
Brown et al.172 reported their experience with 26
nail deformities occurring secondary to mucous
cysts of the DIP joint managed by excision of the
cyst and dbridement of associated osteophytes. No
recurrences occurred during the follow-up period,
and residual nail deformity in eight patients was
negligible. However, cyst excision and osteophyte
removal might not be necessary for treatment
considering that success has been reported with
simple osteophyte removal,173 raising and resiting
a flap over a suspected leakage point from the DIP
joint without cyst or osteophyte excision,174 and
simple dorsal capsulectomy.175

16

Pathological anatomyDepending on its
origin, a ganglion typically has a uni- or multilocular
main cyst that communicates with smaller intra-
articular cysts through a tortuous, continuous,
one-way valvular system of ducts. Microscopic
examination of the ganglion wall typically reveals
compressed collagen fibers with no evidence of cells
of epithelial or synovial origin.176,177 The cyst contains
viscous mucoid material consisting of glucosamine,
albumin, globulin, and hyaluronic acid.
ManagementCalif et al. reviewed the
178
natural history of wrist ganglia in children and noted
that 27 of 29 lesions resolved spontaneously within
an average of 9 months. A conservative approach to
ganglia is therefore advocated for young patients,
unless the ganglion is atypical or does not resolve
within a year. Management of wrist ganglia in adults
is controversial. The literature supports a spontaneous
regression rate of 58%,179 whereas treatment of all
types is associated with recurrence rates from less than
1% to 64%.180
Treatment of wrist ganglia is indicated only
in the event of substantial discomfort or deformity.
Although surgery is the mainstay of treatment,
various nonoperative techniques have been advocated.
Zubowicz and Ishii181 reported 85% success rates
with up to three aspirations; however, with each
subsequent aspiration, failure is more likely. Varley et
al.182 reported less promising results, with only 33%
success with either aspiration or aspiration combined
with steroid injection. Injection of hyaluronidase has
also been proposed, with the theoretical advantage of
making the cyst permeable to the concurrent injection
of steroid. Despite good results reported by Paul and
Sochart,183 a prospective, randomized clinical trial
comparing hyaluronidase injection and aspiration
with surgical excision found a recurrence rate of 77%
with injection and aspiration compared with 24%
after surgery.184 Sclerotherapy with phenol,185 OK-
432, and hypertonic saline186 has been described, but
benefit over surgical excision has not been proven and
sclerotherapy carries risks associated with sclerosant
injections.179,187
Arthroscopic resection of wrist ganglia has been
associated with a lower188 or equivalent189 recurrence
SRPS Volume 11 Issue R9 2016
rate compared with open resection. It can also
identify the exact origin of the ganglion and other
intra-articular pathological conditions.190 Previously,
excision of the cyst stalk was thought to be necessary
to prevent recurrence,191 but this is not a universally
accepted risk factor.192
Giant Cell Tumors of Tendon Sheath
Giant cell tumors are the second most frequent
type of hand tumor after the ganglion cyst. They
typically occur in the fingers of 30- to 50-year-
old patients and are slightly more common in
women.193 They have many names and have been
variably referred to as pigmented villonodular
tenosynovitis, myeloplax tumors, fibrous xanthoma,
xanthosarcoma, and localized nodular synovitis.
No evidence has shown that repeated hemorrhage,
friction, or cholesterol imbalance contributes
substantially to the development of giant cell tumors,
and only approximately one-third of patients provide
histories of trauma or surgery to the region. Pain and
tenderness are not prominent features, but prolonged
unchecked tumor growth interferes with mechanical
function of the hand. Approximately 5% of patients
experience associated sensory disturbances.194
The clinical presentation of a giant cell tumor
of the tendon sheath is that of a lobulated, mottled,
yellow subcutaneous mass. Although the diagnosis
usually is evident clinically, MRI and ultrasonography
have been described as adjuncts in the preoperative
assessment of extensive tumors.195,196 Histological
examination reveals stromal cells, multinucleated giant
cells, and lipid laden foam cells. Cell proliferation is
polyclonal and non-neoplastic.197 Giant cell tumors of
the tendon sheath are considered benign but can erode
bone by pressure and/or can infiltrate the overlying
dermis. Bony invasion has been described and requires
enucleation and curretage.198
Treatment is complete local excision, ensuring
total clearance of the volar joint recess. Recurrences
unfortunately are common, especially in the fingers.
Reported recurrence rates vary from 4% to 44%.199,200
The lowest recurrence rate was reported by Kotwal et
al.,201 who applied radiation after excision. Extensive
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 SRPS Volume 11 Issue R9 2016
recurrences can necessitate arthrodesis of the affected
joint in that resection of violated ligaments and joint
capsule might be required. Despite infiltrative growth
patterns, rapid recurrence, and a frequently confusing
histological appearance, no report of metastases of
a giant cell tumor of the tendon sheath has been
presented.202
Glomus Tumors
Glomus tumors are benign hamartomas of the normal
glomus apparatus, which consists of neuromyoarterial
structure involved in the regulation of cutaneous
circulation.203 Glomus tumors usually are smaller
than 1 cm in diameter (often measuring only a few
millimeters) and classically present with the triad
of pain, pinpoint tenderness, and cold sensitivity.
Transillumination is a simple and useful clinical test.
Other clinical tests include the Love test (exquisite
localized pain with pinpoint pressure), the Hildreth
test (reduction of pain and tenderness with application
of a proximal tourniquet),204 and the cold test (pain
with application of cold water or an ice cube).205 The
most common site of presentation is subungual, but
glomus tumors occasionally occur on the volar surface
of a digit. Approximately one-fourth of all glomus
tumors are multiple206 and have been associated with
neurofibromatosis.207 Ultrasonography208,209 and
MRI210,211 aid in diagnosis and can detect
multiple tumors.
Treatment is by excision. A balance between
exposure to examine for multiple lesions and
complete tumor removal must be achieved with the
minimization of iatrogenic nail bed injury. The surgical
approach can be transungual, with removal of the nail
plate, or lateral subperiosteal. The major problems
after surgical treatment are a high recurrence rate and
residual nail deformity.212214
Peripheral Nerve Tumors
True neural cell tumors in the hand are rare (2%5%
incidence),215 which can result in their neglect or
inappropriate management. They typically are slow
growing and sometimes asymptomatic.
18
NeurilemomasNeurilemomas, or schwannomas,
are the most common solitary tumors of neural cell
origin in the hand and are particularly prevalent
in middle-aged patients.216 Neurilemomas begin
as asymptomatic nodular swellings without
associated sensory or motor abnormalities. Patients
with neurofibromatosis type I can suffer from
multiple schwannomas. When surgically exposed,
neurilemomas are seen to have a dumbbell shape and
to lie eccentric to the nerve fiber proper. Histologically,
they are made up of spindle cells with large nuclei
called Antoni type A. Less cellular regions are termed
Antoni type B areas. Excision involves enucleation
under magnification so as to preserve nerve fibers
that fan out over the tumor. Recurrences are rare, and
malignant degeneration is not a clinical feature.
NeurofibromasUnlike neurilemomas,
neurofibromas can intimately proliferate within nerve
fibers, producing functional abnormalities and making
excision more difficult without division of the nerve.
They occur in three forms: localized, dermal, and
plexiform. Clinically, they are indistinguishable from
schwannomas.217 Histologically, neurofibromas show
weaker S-100 and Leu-7 staining compared with
schwannomas. Malignant degeneration in the absence
of NF-1 is rare. Plexiform neurofibromas, seen more
commonly in NF-1, have a high risk for progression
to malignancy.218220 Consequently, a mass in this
patient population that changes rapidly in size, causes
an associated neurological deficit, or becomes painful
should undergo incisional biopsy.
Granular cell tumorsAlthough most
commonly reported to occur in the tongue, 10%
to 20% of granular cell tumors are found in the
upper extremity.221 They present as small, non-
tender, subcutaneous masses that can cause pain or
pruritus and are more common in women and blacks.
Histologically, they are composed of large, elongated
cells with periodic acid-Schiff-positive granules.222
Complete excision usually is curative. Recurrence and
malignancy are rare but have been reported.223,224
Malignant peripheral nerve sheath tumors
Previously referred to as neurofibrosarcoma or malignant
schwannoma, malignant peripheral nerve sheath tumors
arise from the Schwann cell and account for 2% to 3%

of malignant hand tumors.225 Half are associated with
von Recklinghausen disease.226 Local extension and
hematogenous spread are common, resulting in a
poor prognosis. Wide excision or amputation of the
extremity is the recommended treatment.
Intraneural tumors of non-neural origin
Intraneural tumors of non-neural origin include
lipofibromatous hamartomas, hemangiomas, ganglion
cysts, and lipomas.227 Lipofibromatous hamartomas
commonly occur within the 1st decade of life
and usually involve the median nerve. They can
result in macrodactyly, especially of the index and
middle fingers.228 Treatment involves carpal tunnel
release with or without neurolysis. Radial excision
is not recommended because severe sensory and
functional impairments can result. Macrodactyly
can be treated with amputation, wedge osteotomy,
or epiphysiodesis.229 Malignant degeneration has not
been reported.
Epidermal Inclusion Cysts
Epidermal inclusion cysts commonly occur on the
palmar surface of the hand or digits of patients
whose work or leisure activities predispose them
to penetrating hand injuries.230 The time from the
traumatic incident to cyst development varies from
months to years. Clinically, the lesions are firm,
spherical, and non-tender, but they can cause pain
from direct pressure or secondary infection. The cyst
wall consists of squamous epithelium with laminated
keratin, and the cyst material contains protein,
cholesterol, fat, and fatty acids.
Spontaneous rupture is common, but the lesion
often persists unless the cyst lining, contents, and
overlying puckered skin are surgically removed. Local
complications include infections and bone erosion.
Malignant Skin Tumors
SCCAlthough basal cell carcinomas (BCC) are
the most common cutaneous malignancy overall,
squamous cell cancer is more common in the upper
extremity.231 SCC predominate among people with
fair skin and light hair color. The usual origin of
SRPS Volume 11 Issue R9 2016
SCC is ionizing solar radiation. Other less common
causes of SCC are previous irradiation,232 burn scars,
exposure to arsenic compounds, and inherited genetic
disorders.233 The dorsum of the hand, with the highest
actinic exposure, is the most common site for SCC,
although the tumor has been reported to also occur
on the palms and subungually.234,235 Most textbooks
recommend excision with 1- to 2-cm margins, but
a recent trial236 of marginal excision for 32 patients
reported no recurrences at a follow-up of 31 months.
One case of possible metastasis was identified. Until
further information is available, however, margins
of 4 mm for lesions <2 cm and 6 mm for lesions >2
cm are recommended.237 If nodal metastasis or local
recurrence is evidenced, axillary lymphadenectomy
is recommended. The role of sentinel node biopsy in
cases of SCC is not yet defined in the literature. SCC
of the hand is an aggressive tumor prone to recurrence
and metastasis.238 The metastatic rate for SCC of
the hand is higher than elsewhere on the body,
particularly if the primary lesion involves the digital
web space.239
BCCBCC are very uncommon tumors in
the upper extremity.240,241 Palmar variants have been
observed,242 especially in cases of Gorlin syndrome
(multiple nevoid BCC syndrome).243 BCC has been
reported to also occur subungually, in which case
differentiation from a subungual melanoma must be
made.244,245 Although BCC do not metastasize, they
are locally aggressive. Excision is the usual form of
treatment, although low-risk BCC can be treated with
topical immunomodulators, intralesional treatments,
or electrodessication and curettage.246
MelanomasOf all cutaneous melanomas,
approximately 2% present on the hand.247 They are
palmar, dorsal, or subungual in location. Longitudinal
melanonychia or pigmented streaking of the nail plate
might warrant biopsy, particularly when >3 mm or
extending into the nail fold (Hutchinson sign).248
A study by Ridgeway et al.249 showed that the acral
histological subtype does not affect the disease-free
and overall survival. Tumor thickness remains the
only prognostic indicator. Slingluff et al.250 found that
acral melanoma has a strong racial predilection, carries
a grave prognosis, and arises from glabrous skin. In
that study, no survival difference was shown between
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 SRPS Volume 11 Issue R9 2016
volar and subungual sites, nor did amputation make
a difference. Poor prognosis is likely related to later
diagnosis in the extremity.251
Melanoma requires wide excision or amputation
of the digit or hand, depending on location and
depth.252 The appropriate level of amputation has
not been determined, but there is a trend toward
more conservative resection. In 1982, Papachristou
and Fortner253 advocated amputation through the
carpometacarpal joint. In 1984, Finley et al.254
reported seven finger amputations distal to the MCP
joint (four just proximal to the DIP joint and three
just proximal to the proximal interphalangeal joint),
with no local recurrences. Quinn et al.255 showed
no difference in local recurrence for subungual
melanomas whether amputations were performed
proximal or distal to the interphalangeal joint of
the thumb or the middle of the middle phalanx
in the fingers. Similarly, no prospective study to
date has shown a survival or local control benefit
to prophylactic lymph node dissection, regional
perfusion, or immunotherapy.256,257 A recent
retrospective study, however, did suggest improvement
in long-term survival with lymph node dissection in
advanced stages.258 The use of sentinel lymph node
biopsy has grown markedly in recent years.259
Bony Tumors
Several authors260263 have presented excellent reviews
of bony tumors of the hand. Treatment is based on
accurate diagnosis and staging of the lesions
(Table 3).158
Chondromas
Chondromas are the most common benign
cartilaginous tumors of the hand.264 Chondromas
that remain within the substance of the bone or
cartilage are called enchondromas. Enchondromas
favor the tubular bones of the hand, especially the
middle and proximal phalanges.265 Congenital
cartilaginous rests are implicated in their origin, and
the lesions are totally benign, with little tendency
toward malignant degeneration. Nelson et al.266
reviewed the literature and found only three well-
documented cases of chondrosarcoma arising from
enchondromas.
20
Enchondromas usually appear as well-
demarcated round or oval swellings. A pathological
fracture often is the first indication of their presence.
In such cases, the fracture should be allowed to heal
before the enchondroma is treated. Radiographically,
enchondromas appear as radiolucent, symmetric,
expansile diametaphyseal lesions that do not involve
the epiphyses.
Treatment usually consists of curettage of the
tumor through a window in the cortex, with or
without cancellous bone grafting. Injectable calcium
phosphate bone cement has also been described for
healed fractures or enchondromas without fractures267
and provides increased strength compared with
curettage alone.268 According to a retrospective review
of 102 enchondromas in 82 patients, Sassoon et
al.269 found that most patients achieve bony healing
regardless of the graft material used.
Multiple enchondromasMultiple
enchondromas are rare in the hand and always
occur as part of a disseminated involvement (Ollier
dyschondroplasia).270 Multiple enchondromas
associated with hemangiomas are part of Maffucci
syndrome. The earliest clinical manifestations
of multiple enchondromatosis are swelling and
deformity of several bones.271 The tumors distort,
expand, and sometimes erode the bony cortex,
particularly in the diaphyses and metaphyses;
calcifications are seen in the translucent areas on
radiographs. Because at least 20% of multiple
enchondromas go on to become chondrosarcomas,272
wide excision is the treatment of choice, with
adjuvant radiotherapy to the malignant lesions.
OsteochondromasOsteochondromas are the
most common cartilaginous neoplasm in the body
overall but are less common than enchondromas in
the hand.273 They are thought to arise secondary to a
defect within the periosteum and present as a bony
prominence.261 Radiographically, osteochondromas
appear as bony protuberances extending beyond
the metaphyseal cortex of the involved bone on a
narrow stalk. Management consists of observation or,
if symptomatic, surgical excision. The prominence
can result in tendon rupture or restricted range of
motion,274276 and some authors recommend early
excision. Of distinct histology and clinical behavior
 SRPS Volume 11 Issue R9 2016

Table 3
Enneking Staging System for Bone and Soft-tissue Tumors
and Their Indicated Excision158

Stage Grade (G) Anatomic Location (T) Metastases (M)

0 Benign (G0) Any (T1 or T2) None (M0)

IA Low (G1) Intracompartmental (T1) None (M0)

IB Low (G1) Extracompartmental (T2) None (M0)

IIA High (G2) Intracompartmental (T1) None (M0)

IIB High (G2) Extracompartmental (T2) None (M0)

III Any grade Any (T1 or T2) Metastasis (M1)

is the Nora lesion, a parosteal osteochondromatous Osteoid Osteomas

proliferation with a high recurrence rate.
Consequently, more extensive resection is often
required.277
Bone Cysts
Aneurysmal bone cysts tend to show an equal sex
distribution and are more common during the 2nd
decade of life but before closure of the epiphyseal
plate. Aneurysmal bone cysts are eccentrically
placed in the metaphysis or diaphysis, are expansile
and lucent, and resemble a periosteal blowout.278,279
Curettage and bone grafting comprise the standard
treatment, but recurrence rates are high. Cryotherapy
and high-speed burring have been described to
decrease rates of recurrence.280 MRI findings of
aneurysmal bone cysts include a double-density fluid
level, septations, and low signal on T1-weighted
images, which are less frequent with unicameral bone
cysts.281 Unicameral, or simple, bone cysts rarely
occur in the hand. When they do occur, they can
be observed or, if the bone is at risk of pathological
fracture, treated with curettage and bone grafting.282
Osteoid osteomas are benign osteoblastic tumors
that are uncommon in the hand.283 The lesion affects
male patients two to three times more often than
female patients, generally between the ages of 10 and
25 years. In the hand, osteoid osteoma occurs most
frequently in the distal phalanges.284,285 The cause
is unknown.
The nidus of an osteoid osteoma consists of
richly vascularized osteoblastic osteoid tissue rarely
larger than 1 cm. Clinical presentation is that of a
localized painful area over a tubular bone. Typically,
the pain is worse at night and is completely relieved
by aspirin. An increase in the size of the terminal
digit might occur. Radiographically, the lesion shows
a central area of lucency that can be surrounded by
a zone of sclerotic bone. Bone scintigraphy with
technetium 99 is of benefit in locating the nidus, and
Cp80 has also been used. Treatment involves complete
excision of the lesion or curettage.286
Osteoblastomas
Like osteoid osteomas, osteoblastomas rarely occur
in the hand and occur primarily in young patients.

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 SRPS Volume 11 Issue R9 2016
Whereas large bone osteoblastomas typically are
distinguished by their larger size, in the small bones of
the hand, size might not be a distinguishing factor.287
Because of the bone destruction accompanying
osteoblastomas, the differential diagnosis includes
osteoid osteoma, aneurysmal bone cyst, and malignant
tumors. Although curettage has been described, high
recurrence rates and malignant transformation suggest
the need for complete excision.288,289 Radiotherapy is
helpful in tumor cell control and might even aid
in healing.
Giant Cell Tumors of Bone
Giant cell tumors are uncommon anywhere. They
represent approximately 5% or fewer of all primary
malignant bone tumors, and only 2% to 5% of giant
cell tumors occur in the hand.290 The lesion affects
patients primarily between the ages of 30 and 50
years and is virtually unknown in patients younger
than 20 years. Women with giant cell tumors slightly
outnumber men.
Clinically, the giant cell tumor is a solitary
lesion, often well advanced by the time it is noticed.
A constant dull pain heralds its presence, sometimes
preceded by swelling.291 Radiographically, it is seen
to involve the soft tissues. The epiphyseal end of
the bone is affected, with extension to the adjacent
metaphysis. The tumor is translucent, and the cortex
of the bone is noticeably thin. The clinical course is
long but localized. Sarcomatous degeneration averages
10%, but the lesion metastasizes in fewer than 15% of
cases.292,293
Treatment consists of curettage with adjuvant
phenol, cryotherapy, or polymethylmethacrylate to
reduce the recurrence rate. When soft-tissue extension
is present, en bloc resection is advised.294 The
recurrence rate depends on location and method of
treatment, ranging from a reported 0% with resection
to 65% with curettage alone.295,296 Amputation is
reserved for recurrent or highly malignant tumors.
Sarcomas
Sarcomas are very uncommon tumors in the hand.
22
The pathological subtypes of soft-tissue sarcomas297,298
and bone tumors299,300 have been reviewed by several
authors. Treatment protocols for both bony and soft-
tissue extremity sarcomas have been reviewed.301303
Combination therapy (wide excision, radiotherapy,
and chemotherapy) is now used for most high-grade
tumors and produces excellent local control rates
in some tumor types. Amputation is avoided and is
saved for the management of local recurrences. When
sarcomas fail, they tend to do so at distant sites. In
that circumstance, a functional hand provides a better
quality of life.
Skeletal Sarcomas
Ewing sarcomasEwing sarcomas of the hand
or foot are not common, representing only 4% of all
Ewing sarcoma cases.304 The thumb and long finger
are most frequently affected.305 Ewing sarcomas
affect male patients twice as often as female patients,
usually in the 2nd decade. Radiographically, lytic
bone destruction with variably sclerotic matrix
and periosteal reaction is seen. A soft-tissue mass
often is present.306 Ewing sarcoma generally has a
poor prognosis, with metastasis present in 25% of
presenting cases.307 Still, neoadjuvant or adjuvant
chemotherapy improves survival and is recommended
nearly universally for this malignancy.308 Radiation
alone is not indicated, because it cannot control the
lesion. It is used when wide margins are not obtained
and when chemotherapy response is incomplete.309
OsteosarcomasOsteosarcomas in the hand
are rare tumors, accounting for only 0.18% of all
osteosarcomas.310 Peak incidence is during the 2nd
decade of life, with a male-to-female ratio of 2:1. The
presenting complaint often is persistent, increasing
pain from a rapidly growing mass. The pathogenesis is
unknown. The lesions can arise de novo or can occur
secondary to a benign process. Osteosarcomas in
general tend to occur more frequently in association
with irradiated bone, Pagets disease, fibrous dysplasia
of bone, giant cell tumor, solitary enchondroma,
multiple enchondromatosis, and multiple
osteochondromas.

Radiographically, the borders of an osteosarcoma
are indistinct, but the lesion invariably involves the
cortex and generally transgresses it. Often, a large
contiguous soft-tissue mass is present. A combination
of destructive and proliferative new bone usually is
present, showing a streaked texture and a characteristic
sunburst pattern. Histologically, osteosarcoma has
a typical spindle-shaped cell pattern. Treatment has
changed from amputation to excision with a wide
margin plus adjuvant therapy. The 5-year overall
survival rate associated with osteosarcomas of the
upper extremity is approximately 67%.311
ChondrosarcomasChondrosarcomas are the
most common primary malignant bone tumors to
occur in the hand.312 They occasionally are associated
with osteochondromas and, to a lesser degree, with
multiple enchondromatosis,313,314 although the vast
majority of cases include no preexisting lesion.315,316
Chondrosarcomas characteristically occur in older
patients (age, 6080 years) in the epiphyseal area
of the proximal phalanx or metacarpal. The clinical
course is slow, and metastasis is late.317,318 The tumor
presents as a progressively painful large mass near the
MCP joint. Treatment of choice is amputation or ray
resection. Histological interpretation of cartilaginous
lesions of the hand is difficult, and clinical and
radiological appearance (bone expansion, lytic areas of
bone destruction, soft-tissue swelling) often are more
reliable indicators of malignancy. Prognosis is good if
metastasis has not occurred.
Soft-Tissue Sarcomas
Soft-tissue sarcomas are an uncommon but important
group of hand tumors. They tend to occur in young
patients, are innocuous in presentation, often leading
to an incorrect diagnosis, and have protracted clinical
courses. They are prone to local recurrence, have
an unusually high incidence of lymphatic spread
and regional node metastases, and often metastasize
systemically late in their course. Deep tumors that
are firm and are 5 cm or larger should be considered
to be possible sarcomas until proven otherwise.319
Workup should include plain radiography and
MRI of the hand and computed tomography of the
chest. Standard treatment is wide surgical excision
SRPS Volume 11 Issue R9 2016
or amputation, depending on the size and location
of the tumor. Radiation has been shown to reduce
local recurrence in randomized trials, but it does not
improve patient survival.320,321 Chemotherapy also
reduces recurrence rates and can improve overall
survival in selected tumors.322 The prognosis generally
is poor.
Epithelioid sarcomasEpithelioid sarcomas are
the most common soft-tissue sarcomas of the hand.323
They have been associated with trauma in one-third
of cases.324 Lesions are notoriously insidious and often
mistaken for a benign inflammatory condition.325
Most lesions in the hand arise on the palm or volar
surface of the digits.326 Local recurrence is common,
as is distant metastasis. Treatment recommendations
are radical excision (often necessitating partial
amputation) and node dissection.327 Adjuvant therapy
can be of benefit, particularly in the setting of
metastatic disease.328
Malignant fibrous histiocytomasMalignant
fibrous histiocytomas are the most common soft-tissue
sarcomas overall, often presenting in the 6th to 8th decade
of life.329 Lesions can be superficial or deep, single or
multinodular. Like epithelioid sarcomas, malignant
fibrous histiocytomas often are painless and slow
growing. Metastasis has been observed in 35% of
patients, with a 5-year survival rate of 65% overall.330
Treatment primarily is surgical resection, with
radiotherapy added unless a generous margin has been
excised. Neoadjuvant chemotherapy can be useful for
high-grade lesions.331,332
RhabdomyosarcomasRhabdomyosarcomas
tend to involve the thenar eminence or interosseous
spaces. The alveolar subtype predominates in the
upper extremity, over the embryonal, botryoid, and
pleomorphic subtypes. An alveolar rhabdomyosarcoma is
a highly malignant, devastating tumor that presents as
a rapidly growing, deep mass in the palm of a child.319
Local recurrence is common, and it invariably is fatal
if not adequately treated. Metastatic involvement has
been noted in up to 50% of cases at presentation.333
Total excision of the tumor should be attempted, even
at the cost of function or cosmesis.334 The prognosis
for alveolar rhabdomyosarcoma has improved with
multi-modality therapy but is still poor because of its
marked tendency to spread.333
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 SRPS Volume 11 Issue R9 2016
Synovial sarcomasSynovial sarcomas arise in the
juxta-articular soft tissues (tendon, tendon sheath,
and bursa).335 A synovial sarcoma presents as a slow-
growing tumor on the volar surface of the hand, and
delay to presentation often is measured in years. Local
recurrence and/or metastatic disease is found in nearly
80% of patients.336 Surgical resection is the treatment
of choice, but it often is combined with radiation and
chemotherapy.337
FibrosarcomasFibrosarcomas arise within the
deep subcutaneous space, fascial septa, or muscle
and present as insidiously growing deep masses.338,339
They primarily are adult malignancies, but infantile
fibrosarcomas can present at birth.340 Although the
adult and infantile fibrosarcomas are histologically
similar, they differ in a more rapid growth phase.
Treatment is wide excision or, when neurovascular
structures are compromised, amputation.341
Chemotherapy is recommended for locally extensive
disease, high-grade tumors, and metastatic disease.342
Clear cell sarcomasClear cell sarcomas, also
known as malignant melanomas of soft parts, are
uncommon tumors. A clear cell sarcoma presents as a
slow-growing, deep-seated mass attached to tendons,
aponeuroses, or fascia.343 Prognosis is poor, with a very
high rate of local recurrence and both lymphatic and
hematogenous dissemination.344 Complete surgical
resection is the standard of care for this tumor, which
often is chemoresistant.345
Kaposi sarcomas Kaposi sarcoma presents as
a palpable, pigmented, non-painful lesion. The first
clinical signs are dark blue to violaceous macules on
the skin that are later replaced by infiltrative plaques
and finally by nodules measuring 0.5 to 3 cm in
diameter. Some of the lesions heal, and others coalesce
and ulcerate.346 The classic form is associated with
elderly men of Jewish and Mediterranean descent,
but a more aggressive form has been associated with
acquired immunodeficiency syndrome and human
T-lymphotropic virus type 3.
Kaposi sarcoma might respond to surgical
excision, radiation, and chemotherapy.347 The
prognosis varies according to the behavior of the
tumor. Fulminating lesions have a fatal outcome
within 6 to 12 months of diagnosis, whereas slower
growing tumors are compatible with 20-year survival.
24
Metastatic Tumors
Hand metastases are very uncommon and usually
are associated with a primary carcinoma in the lung,
gastrointestinal tract, or kidney.348 Despite their rarity,
metastatic tumors should be considered in the differential
diagnosis of inflammatory processes of the hand. The
distal phalanges are most often involved,349 and metastases
in those locations often are mistaken for felons or
paronychia.350352
Amadio and Lombardi352 recommended palliative
treatment considering the median survival time of only
5 months. Amputation of a phalanx, digit, or ray is
recommended for most solitary phalangeal or metacarpal
lesions when survival is expected to exceed a few
months.353
SOFT-TISSUE RECONSTRUCTION
Fingertips
Because of their distal, unprotected location, fingertips
often are the subject of trauma and tissue loss. Goals in
fingertip reconstruction should include wound closure,
length preservation, optimization of sensory return, joint
preservation, and cosmesis.
Healing by Secondary Intention
Some authors suggest a cutoff of 1.0 cm2 for nonsurgical
management of fingertip injuries.354,355 Such treatment
is especially well suited to children and the elderly. The
wound is covered with a semi-occlusive or alginate
dressing, which can be left intact for 5 to 7 days and can
then be changed as necessary. Complete healing usually is
achieved in 1 to 2 months.356 Mennen and Wiese357 treated
extensive fingertip defects by using this method and
reported excellent functional and cosmetic outcomes. The
advantage of this treatment is that as the wound contracts,
it pulls proximal innervated pulp skin over the exposed
bone, resulting in a very small area of residual scar located
off the pressure area of the finger. However, if the same
technique is used to treat more dorsal fingertip defects
with involvement of the distal nail bed, the subsequent
wound contraction can lead to parrot beaking of the
nail, which can be difficult to correct secondarily.

Even small amounts of exposed bone can be
managed conservatively. In a retrospective study
comparing conservatively treated fingertip amputations
with bone exposure with surgical intervention, results
were equivalent.358 However, when used for exposure of
more than a small bony tuft, secondary healing risks bony
desiccation and osteomyelitis.
Skin Grafts
Skin grafts commonly are used to repair fingertip defects.
They can be used as a temporizing measure with a view to
subsequent flap revision, or they can serve as the definitive
wound closure. In the former situation, split-thickness
skin is more appropriate because it has a more predictable
take. Similarly, large soft-tissue defects are resurfaced
with split skin because it tends to contract more than
full-thickness skin, thus keeping the resultant insensitive
area as small as possible.359 Split-thickness skin from the
hypothenar eminence or instep of the foot has a papillary
pattern that most closely resembles native fingertip skin.360
Beasley359 suggested full-thickness donor sites from the
groin to minimize the cosmetic deformity of the donor
site. Thenar or hypothenar full-thickness skin grafts have
an excellent texture match and do not hyperpigment as
groin skin tends to.361 Their size is limited by the necessity
to obtain primary closure of the donor site.
Although some spontaneous reinnervation of full-
thickness skin grafts has been observed, any insensitive
or hyposensitive areas that remain theoretically limit the
application of skin grafts to the hand.362 However, Braun
et al.363 found no difference in functional outcomes or
2-point discrimination when comparing split-thickness
skin grafting with primary closure with skin flaps.
Flap Reconstruction
Loss of fingertip pulp greater than one-third the
length of the phalanx requires replacement of soft
tissue to support the distal nail. Beasley364 offered the
following guidelines for reconstruction in such cases:
Replacement soft tissue must have
good ultimate sensibility and be
capable of tolerating normal usage.
Secondary disfigurement must be
SRPS Volume 11 Issue R9 2016
insignificant, with no functional loss
at the donor site.
The method must be safe, practical,
reliable, economical, and predictable
in results.
Beasley further listed three indications for local
flaps in the repair of fingertip amputations: 1) wound
bed unsuitable for revascularization of skin graft; 2)
need for subcutaneous tissue replacement in addition
to skin; 3) protection of vital structure, such as nerve.
Flaps for reconstruction of soft tissue of the
fingertip can be obtained from the same finger
(homodigital) or another finger (heterodigital)
or from local, regional, or distant sources.365367
For a flap to be clinically useful, it must fulfill the
guidelines listed above and must be reliable and
simple to create. Common reliable flaps are discussed
in the sections that follow.
Homodigital Flaps
The most immediate source of tissue for fingertip
replacement is the same finger. The obvious
advantages are that it does not violate another normal
finger or part of the body nor does it immobilize
uninvolved joints. The tissue used must be outside
the zone of injury. The neurovascular integrity of the
finger should be maintained.
The tissue directly adjacent to the wound is the
closest source of flap tissue and forms the basis for
many traditionally popular flaps. The Atasoy volar V-Y
advancement is useful for dorsal oblique-to-transverse
amputations in cases in which the defect does not
exceed 1 cm (Fig. 12).368 After application of a volar
V-Y flap, 2-point sensitivity is decreased to approximately
75% of normal.369,370 The usefulness of the flap is vastly
improved by extending the proximal part of the
V past the DIP joint crease and into the middle
phalangeal segment and by elevating the flap as a true
bilateral neurovascular island flap on both pedicles,
which is known as the Tranquilli-Leali flap.371
In 1964, Moberg372 described a rectangular volar
advancement flap from the base of the thumb that can
be used in thumb tip reconstruction for defects <1.5
cm in axial length. The volar advancement flap is a
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 SRPS Volume 11 Issue R9 2016
true axial flap in that the incisions are placed dorsal to
the neurovascular bundles so as to include them with
the flap and restore normal sensation to the tip. The
tissue movement achieved in proportion to the extent
of the dissection is disappointing, and if too large a
defect is closed (>1 cm), flexion contracture of the
interphalangeal joint can occur. Several authors373,374
subsequently modified the method of mobilization,
incorporating a V-Y closure in the advancement to
make the flap more reliable. Alternatively, the flap
can be converted into a true island and the proximal
defect can be skin grafted.375
Snow376 applied the Moberg flap to the repair
of fingertip amputations, but dorsal tip necrosis and
an unstable pulp scar plagued the series. Macht and
Watson377 preserved the dorsal perforating vessels by
using a spreading-dissecting technique with which
the volar flap is not cut free except at its most distal
area. They reported no skin loss or joint stiffness
occurring in 69 transfers and 2-point discrimination
values within 2 mm of the contralateral normal finger.
Lateral advancement flaps have the potential to
offer the ideal fingertip reconstruction, replacing
like with like from the same digit. Unilateral
advancement flaps move tissue from directly adjacent
to the defect and maintain sensibility. The unilateral
V-Y flap was first described by Geisserndrfer378
in 1943 but has little cover potential. Bilateral
advancement flaps can also be used, as described by
Kutler379 in 1944 (Fig. 13).380 As with all homodigital
flaps, the potential exists for flap embarrassment if
damaged tissues or pedicles are used.
Reversed digital artery island flaps from the
proximal finger necessitate sacrifice of one digital
artery and rely on retrograde flow through an intact
anastomosis with the contralateral normal artery.381
These flaps require neurorrhaphy of a dorsal branch
to the contralateral digital nerve for optimal recovery
of sensibility.382 A preoperative digital Allen test is
essential to assess the patency of both arteries. Venous
drainage of the flaps is via the soft tissue around
the arterial pedicle, so the pedicle should not be
skeletonized.
The dorsal middle phalangeal finger flap, or flag
flap, can be raised on a short or long antegrade or
26
retrograde pedicle and can be used as a free flap,
an arterial and/or venous flow-through flap, or a
neurovascular flap.383,384 It was originally described by
Iselin385 in France but is now probably more useful in
coverage of thumb tip defects when harvested from
the proximal phalanx of the index finger.
Heterodigital Flaps
In 1951, Cronin386 first described the cross-finger flap
for fingertip reconstruction. The cross-finger flap
brings durable cover to exposed bone, joint, or flexor
tendons when homodigital flaps do not suffice.387
Blood supply of the cross-finger flap is random and
based on the subdermal plexus of an adjacent digit.
The flap can be based laterally, proximally, or distally,
depending on the most comfortable approximation
of donor digit to defect. The dorsum of the middle
phalanges of the index, middle, and ring fingers is
the most appropriate donor site in terms of joint
immobilization. Use of a cross-finger flap from the
volar aspect of the middle finger, rather than from
the thinner dorsal finger skin, provides better tissue
quality for resurfacing the pulp of the thumb.388
The technical points of cross-finger flap
elevation and transfer were detailed in 1960389 and
were illustrated by Lister390 in 1993 (Fig. 14). The
pedicle can be divided by the 8th or 9th day to lessen
the risk of joint stiffness from joint immobilization,
but many wait 2 to 3 weeks to ensure graft take.
Many variations of the cross-finger flap have
been described. The dorsal sensory branch can be
included in the flap and sutured to the digital nerve
of the injured fingertip, although that technique has
not been shown to improve the ultimate sensibility
of the flap.391 Dorsal defects can be repaired with the
reverse cross-finger flap, described by Pakiam392 (Fig.
15). Dorsal skin is elevated, exposing full-thickness
subcutaneous tissue. This fascial flap is then elevated
off the peritenon and transposed to the adjacent
dorsal defect. The method requires a full-thickness
skin graft to cover the recipient site. The originally
elevated donor skin is replaced in situ and sewn back
into place.
 SRPS Volume 11 Issue R9 2016

A B

Figure 12. Atasoy V-Y advancement flap. A, Skin incision and mobilization of triangular flap. B, Advancement of
flap. C, Closure with V-Y technique. (Modified from Atasoy et al.368)

27
 SRPS Volume 11 Issue R9 2016
A B
Figure 13. Kutler lateral V-Y advancement flaps. (Reprinted with permission from Lee et al.380)
Advantages of the cross-finger flap technique are
that the flap is easy to elevate and can include ample
quantities of similar tissue. Disadvantages are that it is
a two-stage procedure, a skin graft is required for the
donor site (which is obvious on the exposed dorsum
of the finger), stiffness of the involved digits is a
possibility, and 2-point discrimination values average
only 9 mm.393
In a study of 54 patients with cross-finger flaps,
Nishikawa and Smith394 found that despite recovery
of protective sensation, no patient had recovered
tactile gnosis. Maximal recovery of sensibility
occurs in those younger than 20 years, and 2-point
discrimination plateaus at 1 year. Contraindications
to the use of cross-finger flaps include arthritis,
Dupuytrens contracture, and generalized
vasospastic syndromes.
Littler395and Tubiana et al.396 developed
the technique of interdigital transfer of pedicled
neurovascular island flaps. Pedicled neurovascular
island flaps have found their greatest application in
reconstruction of the ulnar thumb pulp, with median
nerve-innervated skin being transferred from the
ulnar pulp of the middle finger (less desirably, the
radial pulp of the ring finger).397,398 For the flap to
reach the tip of the thumb, the digital nerve must
be dissected well back and the proper digital artery
28
C D
to the adjacent finger must be sacrificed. Cortical
misrepresentation remains a problem, and the
sensibility of the transferred skin has been variable in
several series.399,400
Holevich401 reported a pedicled island flap
from the dorsum of the index finger that is based
on the first dorsal metacarpal artery. It includes a
terminal branch of the radial nerve and can be used
to resurface a shortened thumb. A problem exists
with cortical interpretation, and the skin is not pulp
skin. Indications for the first dorsal metacarpal artery
flap have expanded, and it is reliably used for thumb
reconstruction, contracture release, and web space
reconstruction.402,403
Regional Flaps
In 1926, Gatewood404 first proposed a thenar flap for
resurfacing the tip of the index finger in one patient.
Thirty years later, Flatt405 presented his results with
a similar palmar flap in a large series of fingertip
reconstructions.
The classic thenar flap is based proximally to
ensure good venous return and to minimize proximal
interphalangeal joint flexion. Contracture can be
further controlled by placing the thumb in full
palmar abduction and bringing the MCP joint of the
 SRPS Volume 11 Issue R9 2016

Figure 14. Elevation and transfer of dorsal cross-finger flap. Full-thickness skin graft should be sutured to edge of
defect adjacent to donor finger before flap is inset so that a closed system is created. (Modified from Lister.390)

A B C D
Figure 15. Reverse cross-finger flap. A, Dorsal aspect of index finger has exposed tendon. Reverse cross-finger
flap is designed. Dorsal skin of long finger is de-epithelialized. B, Flap is elevated at level of paratenon and trans-
posed, like a page in a book, over dorsal aspect of index finger. C, Both digits are covered with full-thickness skin
graft. Flaps are inset 2 to 3 weeks later. D, Representation of final outcome. (Modified from Pakiam.392)

29
 SRPS Volume 11 Issue R9 2016
involved digit into full flexion.406 If designed properly,
the donor site usually can be closed primarily.407
Unlike the true palmar flap, the thenar flap is not
likely to produce joint stiffness postoperatively,
provided the pedicle is divided in approximately
10 days.
Small Defects of the Hand or Digits
Homodigital Flaps
Lai et al.408 described the adipofascial turn-over flap
with which dorsal defects of the finger and hand
can be resurfaced by a flap of subcutaneous tissue
hinged on a pedicle that borders the defect. This flap
is especially useful in cases of abrasion injuries of the
DIP joint with exposed terminal extensor tendon.
The donor site is closed primarily, and the flap is
grafted (Fig. 16).409 Advantages include a one-stage
procedure, minimal donor-site morbidity, and avoidance
of damage to the volar digital arteries.410
Heterodigital Flaps
In addition to the flaps previously described, small
defects of the hand can be resurfaced by applying so-
called venous flaps. Venous flaps consist of skin islands
raised on a single-vein pedicle from the dorsum of
the hand and are used to reconstruct either the dorsal
or volar surfaces of adjacent digits.411,412 When based
on the dorsum of the hand, the flap contains a dorsal
vein, perivenous areolar tissue, and the fascia of the
interosseous muscle.413
Earley414 detailed the anatomy of the second
dorsal metacarpal artery and reported various uses for
this neurovascular island flap hand reconstruction.
He and others415,416 broadened the applications of the
second dorsal metacarpal artery flap. Its main use involves
repair of radio-palmar and thumb defects or release of
first web space contractures. Distal flap necrosis can
occur if the flap extends beyond the proximal
interphalangeal joint.
Regional Flaps
Maruyama417 and Quaba and Davison418 elevated
skin islands from the dorsum of the hand, based
30
distally over the metacarpal head (Fig. 17). These
reverse dorsal metacarpal artery flaps are sustained by
interconnections between terminal branches of the
dorsal metacarpal arteries and the deep digital and
palmar arterial systems. Maruyama raised flaps on all
five dorsal metacarpal arteries and reported a largely
successful experience in eight cases.
The flap now known as the Quaba flap is based
on a perforator from the dorsal metacarpal artery 0.5
to 1 cm proximal to the adjacent MCP joint (Fig.
18).418 The arc of rotation allows coverage of the dorsal
metacarpal, web, and phalangeal areas. Long flaps can
also reach volar web spaces.419
Large Defects of the Hands or Digits
Regional Flaps
The regional flaps applicable for resurfacing
the hand are based on the three major arteries of the
forearm: the radial, ulnar, and posterior interosseous
arteries.420 Yang et al.421 described the territory of the
radial forearm flap in 1981, and it was subsequently
used as a free flap by Song et al.422 in 1982. The
skin on the flexor surface of the forearm is relatively
hairless, thin, and pliable, which makes it ideal
for resurfacing the dorsum of the hand. It avoids a
contralateral donor site or need for attachment to
the groin. The radial forearm unit can be raised as
a composite of fascia-skin,423,424 fascia,425,426 bone-
muscle-fascia-skin,427429 or fascia-tendon-skin.430,431
Although initially used for contralateral hand
injuries, in 1984, Lin et al.432 noted ample retrograde
flow into the radial artery from the ulnar artery
via the deep palmar arch and proposed a reverse
forearm flap. The flap is nourished by this retrograde
circulation and can be elevated on its long pedicle for
reconstruction anywhere in the hand. The authors
described a crossover pattern of communicating
branches between the paired venae comitantes and
identified small superficial collateral branches of each
vein, which effectively bypass the valves. This system
enables the flap to be drained despite competent
valves. Even in cases of substantial hand trauma in
which the palmar arches are in question, the flap has
been successfully raised, based on communications
proximal to the wrist.433,434

Flap base
Flap
Defect
Incision
A B C D
Figure 16. Surgical technique. A, Complex defect exposing dorsal aspect of distal interphalangeal joint. B, Design
of adipofascial flap. Base of flap is adjacent to defect. C, Development of distally based adipofascial flap. D, Flap is
turned over on itself to cover defect. E, Primary closure of donor site. Flap is covered with split-thickness skin graft.
(Modified from Al-Qattan.409)
The radial forearm flap has two main
disadvantages. Foremost is that a major vessel to the
hand is sacrificed, but Kleinman and OConnell435
found that the only marked objective difference
between patients who had undergone flap transfer and
control patients was an 18% delay in reconstitution of
normothermia after cold stress testing. Reconstruction
of the vessel rarely is necessary.436,437 Even so,
Weinzweig et al.438 described a technique for elevating
a distally based fasciocutaneous flap with preservation
of the radial artery if ischemia is a concern and Braun
et al.439 similarly elevated a retrograde radial fascial
turn-down flap based on distal perforators of the
radial artery, leaving the main radial artery intact.
The unaesthetic and potentially unstable grafted
donor site of the radial forearm flap remains the major
detractor of this otherwise excellent flap.440 Skin graft
take usually is not a problem with flaps used for hand
reconstruction, because the flap is based proximally
over the muscle bellies. If the flap needs to be raised
in the distal forearm over the flexor tendons, graft
take can be improved by suprafascial dissection of
the flap.441 Many methods of improving the donor
site have been proposed, including direct closure,
full-thickness skin grafts, local flaps, acellular dermal
SRPS Volume 11 Issue R9 2016
Turned-over flap
Flap base
Skin graft
Closure
E
matrix, and tissue expansion.442446 Split-thickness skin
grafting remains the standard at most centers.
Failure of the flap is most commonly related to
technical error in elevation or insetting. Care must be
taken to avoid kinking or compression of the pedicle
after its transposition.
In 1984, Lovie et al.447 described the ulnar
artery island flap, and 4 years later, they reported their
experience with this method for hand and forearm
reconstruction. The skin territory of the flap overlies
the proximal ulnar aspect of the forearm, which is
almost always hairless and less visible than the radial
border. The authors and others447449 found that the
advantages of the ulnar flap were superiority in terms
of aesthetics, easier harvesting of bone and muscle
(flexor carpi ulnaris), direct closure of the donor site,
and less morbidity.
The posterior interosseous artery flap is based
on the communication between the anterior and
posterior interosseous arteries.450,451 The posterior
interosseous artery runs in a fascial septum between
the extensor carpi ulnaris and extensor digiti minimi
muscles, ulnar to the posterior interosseous nerve
(Fig. 19).452 Markings for exposure are made on a line
31
 SRPS Volume 11 Issue R9 2016

Anterior
Ulna interosseus
artery

Radius

Posterior
interosseus
artery
Extensor
carpi Extensor digiti
ulnaris minimi proprius

Figure 19. Cross-section of distally based posterior

interosseous island flap taken at middle one-third
of forearm. Posterior interosseous artery reaches
II Dorsal metacarpal artery
overlying skin in space between extensor carpi ulnaris
and extensor digiti minimi proprius. (Modified from
Extensor
Landi et al.452)

Extensor

drawn between the lateral epicondyle and the inferior

II III
II Dorsal interosseus muscle
Figure 17.Design of reverse dorsal metacarpal flap and
cross-section at distal flap.(Modified from Maruyama.417)
radioulnar joint. A segment of ulna can be taken as a
composite flap. The advantages of this flap are good
pedicle length and primary closure of the donor site.
It also preserves the principal arteries of the forearm.
It generally is raised as a distally based flap to cover
small defects on the dorsum of the hand, web space,
or thumb.453 If an innervated flap is desired, the flap
can be raised with the posterior antebrachial nerve.
Its disadvantages are a relatively hairy donor site, an
obvious scar on the visible dorsum of the forearm,
limited size of the flap, and unreliability of the
vascular communication.454,455

1
3
2
Figure 18. Arterial basis of distally based dorsal hand
flap is direct branch from dorsal metacarpal artery that
enters skin 0.5 to 1 cm proximal to adjacent MCP joint.
1, Dorsal carpal arch; 2, Deep palmar arch; 3, Superficial
palmar arch. (Modified from Quaba and Davison.418)
Distant Flaps
Large flaps of skin can be transferred to the hand
from distant sites by means of traditional pedicled
techniques or microvascular free tissue transfer.
Pedicled flapsHistorically, flaps of skin from
remote sites over the chest and abdomen traditionally
were used for resurfacing large wounds of the
upper extremity. These included flaps from the
abdomen, lower chest, thigh, and buttocks. The most
commonly used pedicled flap is the groin flap based

32
 SRPS Volume 11 Issue R9 2016

on the superficial circumflex iliac artery456458 or the both the deep peroneal nerve and the medial plantar
superficial inferior epigastric artery.459 The superficial nerve (Fig. 20).468 Lee and May469 found that the
circumflex iliac artery (SCIA) arises from the femoral first dorsal metatarsal artery arose from the dorsalis
artery 2 cm below the inguinal ligament or from a pedis artery dorsal to the mid-metatarsal axis in
common trunk with the superficial inferior epigastric 78% of 50 cadaver dissections. The authors usually
artery. Chuang et al.460 described a rule of two finger obtain preoperative angiography to determine the
widths, which relies on locating the SCIA two finger
vascular anatomy. The main advantage of the first
widths below the junction of the inguinal ligament
web space flap for sensory reconstruction in the hand
and the femoral artery. Two finger widths medial to
is replacement with similar thin glabrous skin with
the anterior superior iliac spine, the SCIA emerges
from beneath the deep fascia to become superficial. concentrated sensory receptors, allowing the best
The upper flap border is defined two finger widths 2-point discrimination of any neurosensory flap.
above the inguinal ligament parallel to the SCIA, and
the lower flap border is two finger widths below the
SCIA origin.460
Groin flaps are axial-pattern flaps with reliable
vascularity. However, they necessitate two surgical
stages and the hand remains dependent during the
Branch of
initial period of flap attachment, encouraging edema superficial
and stiffness. In addition, groin flaps are too bulky peroneal nerve

for dorsal hand resurfacing and require subsequent

Extensor
revision surgery. hallucis
longus
Microvascular Free Tissue Transfer tendon

Microvascular free tissue transfer allows single-stage

composite reconstruction of complex hand defects,
Extensor
obviating the need for two-stage pedicled procedures hallucis Inferior
and dependent immobilization.461 Successful brevis extensor
retinaculum
reconstruction of soft tissue of the upper extremity
with free flaps must be approached with the goals Deep
of providing stable coverage and, more importantly, peroneal
nerve
restoring function. Radical dbridement and
restoration of all tissue components at the time of
coverage encourage early mobilization.462
Critical sensibility of the fingertip can be
restored by free neurosensory flaps463 or microvascular
toe-pulp transfer.464,465 The glabrous skin and pulp
from the great toe might offer slightly improved
sensibility over the second toe.466 Static 2-point
discrimination of 5 mm has been reported.467 The
first web space flap of the foot is the gold standard of
neurosensory flaps.468 It consists of the lateral aspect
of the great toe and the medial aspect of the second
toe. The flap is supplied by the first dorsal metatarsal
artery, a branch of the dorsalis pedis artery, or the first Figure 20. Innervation of the foot first web space and
plantar metatarsal artery. Its innervation is through great toe. (Modified from May et al.468)

33
 SRPS Volume 11 Issue R9 2016
The thin, malleable skin over the dorsum of
the foot can also be transferred as an innervated free
flap,470,471 including the underlying extensor tendons472
and second metatarsal for composite reconstruction,473
if required. The dorsalis pedis flap is raised on the
dorsalis pedis artery, and venous drainage is via the
venae comitantes and saphenous vein. Neural input is
from the superficial peroneal nerve. The donor site is
unforgiving, so meticulous attention must be paid to
flap dissection and wound care.
The free radial forearm flap and free ulnar forearm
flap can be used just as readily as the already discussed
pedicled flaps. They have neurosensory potential
via the lateral and medial cutaneous nerves of the
forearm, respectively.
The lateral arm flap, originally described by Song
et al.474 in 1982, is supplied by the posterior radial
collateral artery and innervated by the posterior
cutaneous nerve of the arm. Pedicle length can be up
to 11 cm. It can be raised as a fasciocutaneous flap or
as combinations of fascia,475 muscle, tendon,476 and
bone.477,478 Donor defects up to 6 cm wide usually can
be closed primarily. The cutaneous territory of the flap
can be extended to the lateral epicondyle479 and the
pedicle lengthened by splitting the triceps between its
lateral and long heads.480The flap has the advantage
of confining flap harvest to the same extremity as the
defect. However, this popular flap comes with a price.
Graham et al.481 reviewed 123 lateral arm flaps and
found a high rate of complications and morbidities.
Seventeen percent of the patients complained of
hypersensitivity at the donor site, 19% had elbow
pain, 59% reported numbness in the forearm, and
83% complained of excessive flap bulk.
For large defects of the upper extremity,
where sensibility is not as important, scapular and
parascapular flaps often are applied.482,483 Vascular
supply is based on the circumflex scapular vessels, off
the subscapular system. The parascapular flap allows
a larger skin paddle to be harvested with primary
closure of the secondary defect, and the resulting
scar is less conspicuous than that of the horizontal
scapular flap defect.484 The scapular flap can be raised
as a fascial flap or as an osteofascial flap.485,486 Both
flaps have the disadvantage of being bulky, even in
thin patients, and secondary defatting or liposuction is
34
necessary for an optimal aesthetic contour.
The free groin flap constitutes an unsurpassed
donor site and allows the transfer of a large quantity
of hairless skin. Like the pedicled groin flap, it is too
bulky for resurfacing the hand and requires revision
defatting and/or liposuction.
Recent interest in perforator flaps has led to the
growing popularity of the anterolateral thigh flap487,488
and the tensor fasciae latae perforator flap489 in dorsal
hand reconstruction, but perforator flaps based on
nearly all the standard pedicled flaps have also been
described.490492 Large flaps of very thin skin can be
raised with minimal donor site morbidity. Because
the flaps are based on perforating vessels, the motor
function of the underlying tensor fascia latae is
preserved.
The temporoparietal fascia flap offers a thin,
well-vascularized gliding surface. It is supplied by
the superficial temporal artery and vein.493 It is
advantageous in the upper extremity to wrap exposed
or contracted tendons. The deep areolar surface of the
flap is turned toward the tendons to provide a smooth
gliding surface. The overlying fascia is thin and pliable
for metacarpal contouring. A skin graft completes
the reconstruction. This fascial flap is also excellent
for filling the three-dimensional defect resulting
from the extensive release of complex first web space
contractures. Upton et al.494 reported favorably on
their upper extremity reconstruction using this flap,
expressing preference over radial forearm fascia for its
superior donor site scar and preservation of a principal
artery to the hand. Potential complications of flap
transfer include palsy of the frontal branch of the
facial nerve and permanent alopecia.
Another extremely thin fascial flap is the
serratus anterior fascial flap. The serratus anterior fascial
flap consists of the loose areolar tissue between the
latissimus dorsi and serratus anterior muscles and
is supplied by the thoracodorsal vessels.495,496 It has
a long constant vascular pedicle, very thin well-
vascularized tissue, and low donor site morbidity,
and it allows simultaneous donor and recipient site
dissection. It can also be combined with other flaps of
the subscapular system or can incorporate the lower
slips of serratus muscle.497,498

Free muscle flaps can provide only crude
protective sensibility through pressure receptors, but
their malleability makes them well suited to difficult
contour problems in the hand, especially the palm.
They are sometimes favored for complex contaminated
wounds and to fill dead space.499,500 For small defects,
the serratus anterior497,498 seems most useful, and for
moderate-sized wounds, the rectus abdominis501,502 or
SRPS Volume 11 Issue R9 2016
gracilis flap have been suggested.503 For very large,
degloving-type wounds of the upper extremity, the
latissimus dorsi is the muscle of choice. These three
flaps have large-diameter pedicles of adequate length
with minimal donor site morbidity. Functional free
muscle transfers are discussed in the Microsurgery
issue of Selected Readings in Plastic Surgery.504
35
 SRPS Volume 11 Issue R9 2016
REFERENCES
1. Zook EG. Anatomy and physiology of the perionychium.
Clin Anat 2003;16:1-8.
2. Jansen CW, Patterson R, Viegas SF. Effects of fingernail
length on finger and hand performance. J Hand Ther
2000;13:211-217.
3. de Berker DA, Andr J, Baran R. Nail biology and nail
science. Int J Cosmet Sci 2007;29:241-275.
4. de Berker D. Nail anatomy. Clin Dermatol 2013;
31:509-515.
5. Brucker MJ, Edstrom L. The use of grafts in acute
and chronic fingernail deformities. J Am Soc Surg Hand
2002;2:14-20.
6. Allen MJ. Conservative management of finger tip injuries
in adults. Hand 1980;12:257-265.
7. Tamai S. Twenty years experience of limb replantation:
Review of 293 upper extremity replants. J Hand Surg Am
1982;7:549-556.
8. Evans DM, Bernardis C. A new classification for fingertip
injuries. J Hand Surg Br 2000;25:58-60.
9. Brown RE. Acute nail bed injuries. Hand Clin 2002;18:
561-575.
10. Dean B, Becker G, Little C. The management of the acute
traumatic subungual haematoma: A systematic review.
Hand Surg 2012;17:151-154.
11. OShaughnessy M, McCann J, OConnor TP, Condon KC.
Nail re-growth in fingertip injuries. Ir Med J 1990;
83:136-137.
12. Strauss EJ, Weil WM, Jordan C, Paksima N. A prospective,
randomized, controlled trial of 2-octylcyanoacrylate
versus suture repair for nail bed injuries. J Hand Surg Am
2008;33:250-253.
13. Langlois J, Thevenin-Lemoine C, Rogier A, Elkaim M,
Abelin-Genevois K, Vialle R. The use of 2-octylcyanoacrylate
(Dermabond()) for the treatment of nail bed injuries in
children: Results of a prospective series of 30 patients. J
Child Orthop 2010;4:61-65.
14. Shepard GH. Perionychial grafts in trauma and
reconstruction. Hand Clin 2002;18:595-614.
15. Pessa JE, Tsai TM, Li Y, Kleinert HE. The repair of nail
deformities with the nonvascularized nail bed graft:
Indications and results. J Hand Surg Am 1990;15:466-470.
16. McCash CR. Free nail grafting. Br J Plast Surg 1955;
8:19-33.
17. Lille S, Brown RE, Zook EE, Russell RC. Free
nonvascularized composite nail grafts: An institutional
experience. Plastic Reconstr Surg 2000;105:2412-2415.
18. Hiras Y, Kojima T, Matsui M. Aesthetic fingertip
reconstruction with a free vascularized nail graft: A review
of 60 flaps involving partial toe transfers. Plast Reconstr Surg
36
1997;99:774-784.
19. Valenti P. Secondary microsurgical reconstruction of nail
problems in musicians. Hand Clin 2003;19:273-278.
20. Morrison WA. Microvascular nail transfer. Hand Clin
1990;6:69-76.
21. Rai A, Jha MK, Makhija LK, Bhattacharya S, Sethi N,
Baranwal S. An algorithmic approach to posttraumatic
nail deformities based on anatomical classification. J Plast
Reconstr Aesthet Surg 2014;67:540-547.
22. Linscheid RL, Dobyns JH. Common and uncommon
infections of the hand. Orthop Clin North Am 1975;
6:1063-1104.
23. Fowler JR, Greenhill D, Schaffer AA, Thoder JJ, Ilyas
AM. Evolving incidence of MRSA in urban hand infections.
Orthopedics 2013;36:796-800.
24. OMalley M, Fowler J, Ilyas AM. Community-acquired
methicillin-resistant Staphylococcus aureus infections of the
hand: Prevalence and timeliness of treatment. J Hand Surg
Am 2009;34:504-508.
25. Imahara SD, Friedrich JB. Community-acquired
methicillin-resistant Staphylococcus aureus in surgically
treated hand infections. J Hand Surg Am 2010;35:97-103.
26. Wilson PC, Rinker B. The incidence of methicillin-
resistant Staphylococcus aureus in community-acquired
hand infections. Ann Plast Surg 2009;62:513-516.
27. Cadena J, Sreeramoju P, Nair S, Henao-Martinez A,
Jorgensen J, Patterson JE. Clindamycin-resistant methicillin-
resistant Staphylococcus aureus: Epidemiologic and
molecular characteristics and associated clinical factors.
Diagn Microbiol Infect Dis 2012;74:16-21.
28. Tremblay S, Lau TT, Ensom MH. Addition of rifampin
to vancomycin for methicillin-resistant Staphylococcus
aureus infections: What is the evidence? Ann Pharmacother
2013;47:1045-1054.
29. Baldoni D, Haschke M, Rajacic Z, Zimmerli W, Trampuz
A. Linezolid alone or combined with rifampin against
methicillin-resistant Staphylococcus aureus in experimental
foreign-body infection. Antimicrob Agents Chemother
2009;53:1142-1148.
30. Pappas G, Athanasoulia AP, Matthaiou DK, Falagas ME.
Trimethoprim-sulfamethoxazole for methicillin-resistant
Staphylococcus aureus: A forgotten alternative? J Chemother
2009;21:115-126.
31. Fitzgerald RH Jr, Cooney WP III, Washington JA II, Van
Scoy RE, Linscheid RL, Dobyns JH. Bacterial colonization of
mutilating hand injuries and its treatment. J Hand Surg Am
1977;2:85-89.
32. Mann RJ, Peacock JM. Hand infections in patients with
diabetes mellitus. J Trauma 1977;17:376-380.
33. Reyes FA. Infections secondary to intravenous drug
abuse. Hand Clin 1989;5:629-633.

34. Goldstein EJ, Citron DM, Wield B, Blachman U, Sutter VL,
Miller TA, Finegold SM. Bacteriology of human and animal
bite wounds. J Clin Microbiol 1978;8:667-672.
35. Arons MS, Fernando L, Polayes IM. Pasteurella multocida:
The major cause of hand infections following domestic
animal bites. J Hand Surg Am 1982;7:47-52.
36. Guba AM Jr, Mulliken JB, Hoopes JE. The selection of
antibiotics for human bites of the hand. Plast Reconstr Surg
1975;56:538-541.
37. Paul K, Patel SS. Eikenella corrodens infections in
children and adolescents: Case reports and review of the
literature. Clin Infect Dis 2001;33:54-61.
38. Grossman JA, Adams JP, Kunec J. Prophylactic antibiotics
in simple hand lacerations. JAMA 1981;245:1055-1056.
39. Haughey RE, Lammers RL, Wagner DK. Use of antibiotics
in the initial management of soft tissue hand wounds. Ann
Emerg Med 1981;10:187-192.
40. Roberts AH, Teddy PJ. A prospective trial of prophylactic
antibiotics in hand lacerations. Br J Surg 1977;64:394-396.
41. Beesley JR, BowdenG, Hardy RH, Reynolds TD.
Prophylactic antibiotics in minor hand injuries. Injury
1975;6:366.
42. Whittaker JP, Nancarrow JD, Sterne GD. The role of
antibiotic prophylaxis in clean incised hand injuries: A
prospective randomized placebo controlled double blind
trial. J Hand Surg Br 2005;30:162-167.
43. Hauser CJ, Adams CA Jr, Eachempati SR; Council of
the Surgical Infection Society. Surgical Infection Society
guideline: Prophylactic antibiotic use in open fractures: An
evidence-based guideline. Surg Infect (Larchmt) 2006;
7:379-405.
44. Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz
M, Leake B, Kay RM, Flynn JM. The effect of surgical delay on
acute infection following 554 open fractures in children. J
Bone Joint Surg Am 2005;87:8-12.
45. Penn-Barwell JG, Murray CK, Wenke JC. Early antibiotics
and debridement independently reduce infection in an
open fracture model. J Bone Joint Surg Br 2012;94:107-112.
46. Hoffman RD, Adams BD. The role of antibiotics in the
management of elective and post-traumatic hand surgery.
Hand Clin 1998;14:657-666.
47. Garibaldi RA, Cushing D, Lerer T. Risk factors for
postoperative infection. Am J Med 1991;91:158S-163S.
48. Haley RW, Culver DH, Morgan WM, White JW, Emori
TG, Hooton TM. Identifying patients at high risk of surgical
wound infection: A simple multivariate index of patient
susceptibility and wound contamination. Am J Epidemiol
1985;121:206-215.
49. Bykowski MR, Sivak WN, Cray J, Buterbaugh G,
Imbriglia JE, Lee WP. Assessing the impact of antibiotic
prophylaxis in outpatient elective hand surgery: A single-
SRPS Volume 11 Issue R9 2016
center, retrospective review of 8,850 cases. J Hand Surg Am
2011;36:1741-1747.
50. Burnett JW, Gustilo RB, Williams DN, Kind AC.
Prophylactic antibiotics in hip fractures: A double-blind,
prospective study. J Bone Joint Surg Am 1980;62:457-462.
51. Boyd RJ, Burke JF, Colton T. A double-blind clinical trial
of prophylactic antibiotics in hip fractures. J Bone Joint Surg
Am 1973;55:1251-1258.
52. Shapiro DB. Postoperative infection in hand surgery:
Cause, prevention, and treatment. Hand Clin 1998;
14:669-681, x.
53. Brook I. Paronychia: A mixed infection: Microbiology
and management. J Hand Surg Br 1993;18:358-359.
54. Ritting AW, OMalley MP, Rodner CM. Acute paronychia.
J Hand Surg Am 2012;37:1068-1070.
55. Shaw J, Body R. Best evidence topic report: Incision and
drainage preferable to oral antibiotics in acute paronychial
nail infection? Emerg Med J 2005;22:813-814.
56. Rockwell PG. Acute and chronic paronychia. Am Fam
Physician 2001;63:1113-1116.
57. Ogunlusi JD, Oginni LM, Ogunlusi OO. DAREJD simple
technique of draining acute paronychia. Tech Hand Up
Extrem Surg 2005;9:120-121.
58. Conolly WB. Infections. In, Conolly WB (ed): Atlas of Hand
Surgery. New York: Churchill
59. Livingstone; 1997:256.
60. Green DP, Hotchkiss RN, Pederson WC, Wolfe SW
(ed): Greens Operative Hand Surgery. 5th ed. Philadelphia:
ElsevierHealth Sciences; 2005.
61. Zook EG, Brown RE. The perionychium. In, Green DP
(ed): Operative Hand Surgery. 3rd ed. New York: Churchill
Livingstone; 1993:12831297.
62. Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute
and chronic paronychia. Am Fam Physician 2008;77:339346.
63. Tosti A, Piraccini BM, Ghetti E, Colombo MD. Topical
steroids versus systemic antifungals in the treatment of
chronic paronychia: An open, randomized double-blind and
double dummy study. J Am Acad Dermatol 2002;47:7376.
64. Kuschner SH, Lane CS. Squamous cell carcinoma of the
perionychium. Bull Hosp Jt Dis 1997;56:111112.
65. Gorva AD, Mohil R, Srinivasan MS. Aggressive digital
papillary adenocarcinoma presenting as a paronychia of the
finger. J Hand Surg Br 2005;30:534.
66. Bednar MS, Lane LB. Eponychial marsupialization and
nail removal for surgical treatment of chronic paronychia. J
Hand Surg Am 1991;16:314317.
67. Grover C, Bansal S, Nanda S, Reddy BS, Kumar V. En
bloc excision of proximal nail fold for treatment of chronic
paronychia. Dermatol Surg 2006;32:393398.
68. Kilgore ES Jr, Brown LG, Newmeyer WL, Graham WP III,
37
 SRPS Volume 11 Issue R9 2016
Davis TS. Treatment of felons. Am J Surg 1975;130:194198.
69. Perry AW, Gottlieb LJ, Zachary LS, Krizek TJ. Fingerstick
felons. Ann Plast Surg 1988;20:249251.
70. Watson PA, Jebson PJ. The natural history of the
neglected felon. Iowa Orthop J 1996;16:164166.
71. Canales FL, Newmeyer WL III, Kilgore ES Jr. The
treatment of felons and paronychias. Hand Clin
1989;5:515523.
72. Mrabet D, Ouenniche K, Mizouni H, Ounaies M, Khmiri
C, Sahli H, Sellami S. Tuberculosis tenosynovitis of the
extensor tendons of the wrist. BMJ Case Rep 2011;31:2011.
73. Lall H, Nag SK, Jain VK, Khare R, Mittal D. Tuberculous
extensor tenosynovitis of the wrist with extensor pollicis
longus rupture: A case report. J Med Case Rep 2009;3:142.
74. Popa MA, Jebson PJ, Condit DP. Blastomycotic extensor
tenosynovitis of the hand: A case report. Hand (N Y)
2012;7:323326.
75. Schnall SB, Vu-Rose T, Holtom PD, Doyle B, Stevanovic
M. Tissue pressures in pyogenic flexor tenosynovitis of the
finger: Compartment syndrome and its management. J Bone
Joint Surg Br 1996;78:793795.
76. Ogiela DM, Peimer CA. Acute gonococcal flexor
tenosynovitis: Case report and literature review. J Hand Surg
Am 1981;6:470472.
77. Kanavel AB. Infections of the Hand: A Guide to the Surgical
Treatment of Acute and Chronic Suppurative Processes in the
Fingers, Hand, and Forearm. Philadelphia:
Lea & Febiger: 1912.
78. Pang HN, Teoh LC, Yam AK, Lee JY, Puhaindran ME,
Tan AB. Factors affecting the prognosis of pyogenic flexor
tenosynovitis. J Bone Joint Surg Am 2007;89:17421748.
79. Dailiana ZH, Rigopoulos N, Varitimidis S, Hantes M,
Bargiotas K, Malizos KN. Purulent flexor tenosynovitis:
Factors influencing the functional outcome. J Hand Surg Eur
Vol 2008;33:280285.
80. Jeffrey RB Jr, Laing FC, Schechter WP, Markison RE,
Barton RM. Acute suppurative tenosynovitis of the hand:
Diagnosis with US. Radiology 1987;162:741742.
81. Schecter WP, Markison RE, Jeffrey RB, Barton RM, Laing
F. Use of sonography in the early detection of suppurative
flexor tenosynovitis. J Hand Surg Am 1989;14:307310.
82. Michon J. Phlegmon of the tendon sheaths [in French].
Ann Chir 1974;28:277280.
83. Gutowski KA, Ochoa O, Adams WP Jr. Closed-
catheter irrigation is as effective as open drainage for
treatment of pyogenic flexor tenosynovitis. Ann Plast Surg
2002;49:350354.
84. Harris PA, Nanchahal J. Closed continuous irrigation
in the treatment of hand infections. J Hand Surg Br
1999;24:328333.
38
85. Brown DM, Young VL. Hand infections. South Med J
1993;86:5666.
86. Lille S, Hayakawa T, Neumeister MW, Brown RE, Zook
EG, Murray K. Continuous postoperative catheter irrigation
is not necessary for the treatment of suppurative flexor
tenosynovitis. J Hand Surg Br 2000;25:304307.
87. Neviaser RJ. Tenosynovitis. Hand Clin 1989;5:525531.
88. Glass KD. Factors related to the resolution of treated
hand infections. J Hand Surg Am 1982;7:388394.
89. Young-Afat DA, Dayicioglu D, Oeltjen JC, Garrison AP.
Fishing-injury-related flexor tenosynovitis of the hand: A
case report and review. Case Rep Orthop 2013;2013:587176.
90. Kanavel AB. Infections of the Hand: A Guide to the Surgical
Treatment of Acute and Chronic Suppurative Processes in
the Fingers, Hand, and Forearm. 7th ed. Philadelphia: Lea &
Febiger; 1939.
91. Szabo RM, Spiegel JD. Infected fractures of the hand
and wrist. Hand Clin 1988;4:477489.
92. Reilly KE, Linz JC, Stern PJ, Giza E, Wyrick JD.
Osteomyelitis of the tubular bones of the hand. J Hand Surg
Am 1997;22:644649.
93. Barbieri RA, Freeland AE. Osteomyelitis of the hand.
Hand Clin 1998;14:589603, ix.
94. Balaram AK, Bednar MS. Complications after the
fractures of metacarpal and phalanges. Hand Clin
2010;26:169177.
95. Ashmead D IV, Rothkopf DM, Walton RL, Jupiter JB.
Treatment of hand injuries by external fixation. J Hand Surg
Am 1992;17:954964.
96. Honda H, McDonald JR. Current recommendations in
the management of osteomyelitis of the hand and wrist. J
Hand Surg Am 2009;34:11351136.
97. Termaat MF, Raijmakers PG, Scholten HJ, Bakker
FC, Patka P, Haarman HJ. The accuracy of diagnostic
imaging for the assessment of chronic osteomyelitis: A
systematic review and meta-analysis. J Bone Joint Surg Am
2005;87:24642471.
98. Malcius D, Jonkus M, Kuprionis G, Maleckas A,
Monastyreckiene E, Uktveris, Rinkevicius S, Barauskas V.
The accuracy of different imaging techniques in diagnosis
of acute hematogenous osteomyelitis. Medicina (Kaunas)
2009;45:624631.
99. Cooper C, Cawley MI. Bacterial arthritis in an
English health district: A 10 year review. Ann Rheum Dis
1986;45:458463.
100. Nade S. Septic arthritis. Best Pract Res Clin Rheumatol
2003;17:183200.
101. Bayer AS. Nongonococcal bacterial septic arthritis:
An update on diagnosis and management. Postgrad Med
1980;67:157165.

102. Bayer AS. Gonococcal arthritis syndromes: An
update on diagnosis and management. Postgrad Med
1980;67:200204, 207208.
103. Murray PM. Septic arthritis of the hand and wrist. Hand
Clin 1998;14:579587, viii.
104. Sammer DM, Shin AY. Arthroscopic management of
septic arthritis of the wrist. Hand Clin 2011;27:331334.
105. Kowalski TJ, Thompson LA, Gundrum JD. Antimicrobial
management of septic arthritis of the hand and wrist.
Infection 2014;42:379384.
106. Wittels NP, Donley JM, Burkhalter WE. A functional
treatment method for interphalangeal pyogenic arthritis. J
Hand Surg Am 1984;9:894898.
107. Boustred AM, Singer M, Hudson DA, Bolitho GE. Septic
arthritis of the metacarpophalangeal and interphalangeal
joints of the hand. Ann Plast Surg 1999;42:623628.
108. Curtiss PH Jr. The pathophysiology of joint infections.
Clin Orthop Relat Res 1973;96:129135.
109. Roy S, Bhawan J. Ultrastructure of articular cartilage in
pyogenic arthritis. Arch Pathol 1975;99:4447.
110. Smith RL, Merchant TC, Schurman DJ. In vitro cartilage
degradation by Escherichia coli and Staphylococcus aureus.
Arthritis Rheum 1982;25:441446.
111. Mennen U, Howells CJ. Human fight-bite injuries of the
hand: A study of 100 cases within 18 months. J Hand Surg Br
1991;16:431435.
112. Iyidobi EC, Nwokocha AU, Nwadinigwe CU, Ugwoke
KI. Above-elbow amputation and death following human
bite mismanaged by quacks: A case report and review of
literature. Nigerian J Med 2012;21:249251.
113. Lister G. The Hand: Diagnosis and Indications.
Edinburgh: Churchill Livingstone; 1993:331332.
114. Staiano J, Graham K. A tooth in the hand is
worth a washout in the operating theater. J Trauma
2007;62:15311532.
115. Dunbar JD. Serious infection following wounds and
bites of the hand. N Z Med J 1988;101:368369.
116. Resnick D, Pineda CJ, Weisman MH, Kerr R.
Osteomyelitis and septic arthritis of the hand following
human bites. Skeletal Radiol 1985;14:263266.
117. Chadaev AP, Jukhtin VI, Butkevich AT, Emkuzhev VM.
Treatment of infected clench-fist human bite wounds in
the area of metacarpophalangeal joints. J Hand Surg Am
1996;21:299303.
118. Griego RD, Rosen T, Orengo IF, Wolf JE. Dog,
cat, and human bites: A review. J Am Acad Dermatol
1995;33:10191029.
119. Kelly IP, Cunney RJ, Smyth EG, Colville J. The
management of human bite injuries of the hand. Injury
1996;27:481484.
SRPS Volume 11 Issue R9 2016
120. Patzakis MJ, Wilkins J, Bassett RL. Surgical
findings in clenched-fist injuries. Clin Orthop Relat Res
1987;220:237240.
121. Malinowski RW, Strate RG, Perry JF Jr, Fischer RP. The
management of human bite injuries of the hand. J Trauma
1979;19:655-659.
122. Zubowicz VN, Gravier M. Management of early human
bites of the hand: A prospective randomized study. Plast
Reconstr Surg 1991;88:111-114.
123. Goldstein EJ, Citron DM. Comparative activities of
cefuroxime, amoxicillin-clavulanic acid, ciprofloxacin,
enoxacin, and ofloxacin against aerobic and anaerobic
bacteria isolated from bite wounds. Antimicrob Agents
Chemother 1988;32:1143-1148.
124. Shoji K, Cavanaugh Z, Rodner CM. Acute fight bite. J
Hand Surg Am 2013;38:1612-1614.
125. Talan DA, Citron DM, Abrahamian FM, Moran GJ,
Goldstei EJ. Bacteriologic analysis of infected dog and cat
bites: Emergency Medicine Animal Bite Infection Study
Group. New Engl J Med 1999;340:85-92.
126. Lucas GL, Bartlett DH. Pasteurella multocida infection
in the hand. Plast Reconstr Surg 1981;67:49-53.
127. Paschos NK, Makris EA, Gantsos A, Georgoulis AD.
Primary closure versus non-closure of dog bite wounds: A
randomised controlled trial. Injury 2014;45:237-240.
128. Rosen RA. The use of antibiotics in the initial
management of recent dog-bite wounds. Am J Emerg Med
1985;3:19-23.
129. Presutti RJ. Prevention and treatment of dog bites. Am
Fam Physician 2001;63:1567-1572.
130. Kwo S, Agarwal JP, Meletiou S. Current treatment of cat
bites to the hand and wrist. J Hand Surg Am 2011;
36:152-153.
131. Babovic N, Cayci C, Carlsen BT. Cat bite infections of
the hand: Assessment of morbidity and predictors of severe
infection. J Hand Surg Am 2014;39:286-290.
132. Philipsen TE, Molderez C, Gys T. Cat and dog bites:
What to do? Guidelines for the treatment of cat and dog
bites in humans. Acta Chir Belg 2006;106:692-695.
133. Hurst LC, Amadio PC, Badalamente MA, Ellstein JL,
Dattwyler RJ. Mycobacterium marinum infections of the
hand. J Hand Surg Am 1987;12:428-435.
134. Kaplan H, Clayton M. Carpal tunnel syndrome
secondary to Mycobacterium kansasii infection. JAMA
1969;208:1186-1188.
135. Gunther SF, Elliott RC. Mycobacterium kansasii infection
in the deep structures of the hand: Report of two cases. J
Bone Joint Surg Am 1976;58:140-142.
136. Dillon J, Millson C, Morris I. Mycobacterium kansasii
infection in the wrist and hand. Br J Rheumatol 1990;
39
 SRPS Volume 11 Issue R9 2016
29:150-153.
137. Halla JT, Gould JS, Hardin JG. Chronic tenosynovial
hand infection from Mycobacterium terrae. Arthritis Rheum
1979;22:1386-1390.
138. Deenstra W. Synovial hand infection from
Mycobacterium terrae. J Hand Surg Br 1988;13:335-336.
139. Collins CH, Grange JM, Noble WC, Yates MD.
Mycobacterium marinum infections in man. J Hyg (Lond)
1985;94:135-149.
140. Bhatty MA, Turner DP, Chamberlain ST. Mycobacterium
marinum hand infection: Case reports and review of
literature. Br J Plast Surg 2000;53:161-165.
141. Kozin SH, Bishop AT. Atypical Mycobacterium infections
of the upper extremity. J Hand Surg Am 1994;19:480-487.
142. Parent LJ, Salam MM, Appelbaum PC, Dossett
JH. Disseminated Mycobacterium marinum infection
and bacteremia in a child with severe combined
immunodeficiency. Clin Infect Dis 1995;21:1325-1327.
143. Bonnet E, Debat-Zoguereh D, Petit N, Ravaux I, Gallais
H. Clarithromycin: A potent agent against infections due to
Mycobacterium marinum. Clin Infect Dis 1994;18:664-666.
144. Cheung JP, Fung BK, Ip WY. Mycobacterium marinum
infection of the deep structures of the hand and wrist: 25
years of experience. Hand Surg 2010;15:211-216.
145. Dragavon J, Peterson E, Ashley R, Lafferty W, Corey
L. Routine typing of herpes simplex virus isolates. Diagn
Microbiol Infect Dis 1985;3:269-270.
146. Amir J, Harel L, Smetana Z, Varsano I. The natural
history of primary herpes simplex type 1 gingivostomatitis
in children. Pediatr Dermatol 1999;16:259-263.
147. Amir J, Nussinovitch M, Kleper R, Cohen HA, Varsano
I. Primary herpes simplex virus type 1 gingivostomatitis in
pediatric personnel. Infection 1997;25:310-312.
148. Rubright JH, Shafritz AB. The herpetic whitlow. J Hand
Surg Am 2011;36:340-342.
149. Fowler JR. Viral infections. Hand Clin 1989;5:613-627.
150. Feder HM Jr, Long SS. Herpetic whitlow: Epidemiology,
clinical characteristics, diagnosis, and treatment. Am J Dis
Child 1983;137:861-863.
151. Solomon AR, Rasmussen JE, Varani J, Pierson CL. The
Tzanck smear in the diagnosis of cutaneous herpes simplex.
JAMA 1984;251:633-635.
152. Patel R, Kumar H, More B, Patricolo M. Paediatric
recurrent herpetic whitlow. BMJ Case Rep 2013 [Epub ahead
of print, July 31].
153. Gill MJ, Bryant HE. Oral acyclovir therapy of recurrent
herpes simplex virus type 2 infection of the hand.
Antimicrob Agents Chemother 1991;35:382-383.
154. Schwandt NW, Mjos DP, Lubow RM. Acyclovir and
the treatment of herpetic whitlow. Oral Surg Oral Med Oral
40
Pathol 1987;64:255-258.
155. Karpathios T, Moustaki M, Yiallouros P, Sarifi F,
Tzanakaki G, Fretzayas A. HSV-2 meningitis disseminated
from a herpetic whitlow. Paediatr Int Child Health
2012;32:121-122.
156. Bacelieri R, Johnson SM. Cutaneous warts: An
evidence-based approach to therapy. Am Fam Physician
2005;72:647-652.
157. Massing AM, Epstein WL. Natural history of warts: A
two-year study. Arch Dermatol 1963;87:306-310.
158. Gibbs S, Harvey I, Sterling J, Stark R. Local treatments
for cutaneous warts: Systematic review. BMJ 2002;325:461.
159. Mankin HJ. Principles of diagnosis and management of
tumors of the hand. Hand Clin 1987;3:185-195.
160. Froimson AI. Benign solid tumors. Hand Clin
1987;3:213-217.
161. Shenaq SM. Benign skin and soft-tissue tumors of the
hand. Clin Plast Surg 1987;14:403-412.
162. Henderson MM, Neumeister MW, Bueno RA Jr. Hand
tumors: I. Skin and soft-tissue tumors of the hand. Plast
Reconstr Surg 2014;133:154e-164e.
163. Henderson M, Neumeister MW, Bueno RA Jr. Hand
tumors: II. Benign and malignant bone tumors of the hand.
Plast Reconstr Surg 2014;133:814e-821e.
164. Barnes WE, Larsen RD, Posch JL. Review of ganglia of
the hand and wrist with analysis of surgical treatment. Plast
Reconstr Surg 1964;34:570-578.
165. Butler ED, Hamill JP, Seipel RS, De Lorimier AA. Tumors
of the hand: A ten-year survey and report of 437 cases. Am J
Surg 1960;100:293-302.
166. Ly JQ, Barrett TJ, Beall DP, Bertagnolli R. MRI
diagnosis of occult ganglion compression of the posterior
interosseous nerve and associated supinator muscle
pathology. Clin Imaging 2005;29:362-363.
167. Nakamichi K, Tachibana S, Kitajima I. Ultrasonography
in the diagnosis of ulnar tunnel syndrome caused by an
occult ganglion. J Hand Surg Br 2000;25:503-504.
168. Steiger R, Vgelin E. Compression of the radial nerve
caused by an occult ganglion: Three case reports. J Hand
Surg Br 1998;23:420-421.
169. Clay NR, Clement DA. The treatment of dorsal wrist
ganglia by radical excision. J Hand Surg Br 1988;13:187-191.
170. Watson HK, Rogers WD, Ashmead D IV. Reevaluation
of the cause of the wrist ganglion. J Hand Surg Am
1989;14:812-817.
171. Finsen V, Hberg O, Borchgrevink GE. Surgery for
ganglia of the flexor tendon sheath. Orthop Rev (Pavia)
2013;5:e6.
172. Bittner JG IV, Kang R, Stern PJ. Management of flexor
tendon sheath ganglions: A cost analysis. J Hand Surg Am

2002;27:586-590.
173. Brown RE, Zook EG, Russell RC, Kucan JO, Smoot EC.
Fingernail deformities secondary to ganglions of the distal
interphalangeal joint (mucous cysts). Plast Reconstr Surg
1991;87:718-725.
174. Lee HJ, Kim PT, Jeon IH, Kyung HS, Ra IH, Kim TK.
Osteophyte excision without cyst excision for a mucous cyst
of the finger. J Hand Surg Eur Vol 2014;39:258-261.
175. Lawrence C. Skin excision and osteophyte removal
is not required in the surgical treatment of digital myxoid
cysts. Arch Dermatol 2005;141:1560-1564.
176. Kanaya K, Wada T, Iba K, Yamashita T. Total dorsal
capsulectomy for the treatment of mucous cysts. J Hand
Surg Am 2014;39:1063-1067.
177. Psaila JV, Mansel RE. The surface ultrastructure of
ganglia. J Bone Joint Surg Br 1978;60:228-233.
178. Loder RT, Robinson JH, Jackson WT, Allen DJ. A surface
ultrastructure study of ganglia and digital mucous cysts. J
Hand Surg Am 1988;13:758-762.
179. Calif E, Stahl S, Stahl S. Simple wrist ganglia in children:
A follow-up study. J Pediatr Orthop B 2005;14:448-450.
180. Dias J J, Dhukaram V, Kumar P. The natural history
of untreated dorsal wrist ganglia and patient reported
outcome 6 years after intervention. J Hand Surg Eur Vol
2007;32:502-508.
181. Nelson CL, Sawmiller S, Phalen GS. Ganglions of the
wrist and hand. J Bone Joint Surg Am 1972;54:1459-1464.
182. Zubowicz VN, Ishii CH. Management of ganglion
cysts of the hand by simple aspiration. J Hand Surg Am
1987;12:618-620.
183. Varley GW, Needoff M, Davis TR, Clay NR. Conservative
management of wrist ganglia: Aspiration versus steroid
infiltration. J Hand Surg Br 1997;22:636-637.
184. Paul AS, Sochart DH. Improving the results of ganglion
aspiration by the use of hyaluronidase. J Hand Surg Br
1997;22:219-221.
185. Jagers Op Akkerhuis M, Van Der Heijden M, Brink
PR. Hyaluronidase versus surgical excision of ganglia:
A prospective, randomized clinical trial. J Hand Surg Br
2002;27:256-258.
186. Park S, Iida T, Yoshimura K, Kawasaki Y. Phenol
cauterization for ganglions of the hand, wrist, and foot: A
preliminary report. Ann Plast Surg 2002;48:582-585.
187. Dogo D, Hassan AW, Babayo U. Treatment of ganglion
using hypertonic saline as sclerosant. West Afr J Med
2003;22:13-14.
188. Jalul M, Humphrey AR. Radial artery injury caused by a
sclerosant injected into a palmar wrist ganglion. J Hand Surg
EurVol 2009;34:698-699.
189. Aslani H, Najafi A, Zaaferani Z. Prospective outcomes of
SRPS Volume 11 Issue R9 2016
arthroscopic treatment of dorsal wrist ganglia. Orthopedics
2012;35:e365-e370.
190. Edwards SG, Johansen JA. Prospective outcomes
and associations of wrist ganglion cysts resected
arthroscopically. J Hand Surg Am 2009;34:395-400.
191. Bienz T, Raphael JS. Arthroscopic resection of the
dorsal ganglia of the wrist. Hand Clin 1999;15:429-434.
192. Janzon L, Niechajev IA. Wrist ganglia: Incidence and
recurrence rate after operation. Scand J Plast Reconstr Surg
1981;15:53-56.
193. Kim JP, Seo JB, Park HG, Park YH. Arthroscopic excision
of dorsal wrist ganglion: Factors related to recurrence and
postoperative residual pain. Arthroscopy 2013;
29:1019-1024.
194. Fotiadis E, Papadopoulos A, Svarnas T, Akritopoulos P,
Sachinis AP, Chalidis BE. Giant cell tumour of tendon sheath
of the digits: A systematic review. Hand (N Y) 2011;6:244-
249.
195. Di Grazia S, Succi G, Fragetta F, Perrotta RE. Giant cell
tumor of tendon sheath: Study of 64 cases and review of
literature. G Chir 2013;34:149-152.
196. Middleton WD, Patel V, Teefey SA, Boyer MI. Giant
cell tumors of the tendon sheath: Analysis of sonographic
findings. AJR Am J Roentgenol 2004;183:337-339.
197. Karasick D, Karasick S. Giant cell tumor of tendon
sheath: Spectrum of radiologic findings. Skeletal Radiol
1992;21:219-224.
198. Vogrincic GS, OConnell JX, Gilks CB. Giant cell tumor
of tendon sheath is a polyclonal cellular proliferation. Hum
Pathol 1997;28:815-819.
199. Uriburu IJ, Levy VD. Intraosseous growth of giant
cell tumors of the tendon sheath (localized nodular
tenosynovitis) of the digits: Report of 15 cases. J Hand Surg
Am 1998;23:732-736.
200. Lanzinger WD, Bindra R. Giant cell tumor of the tendon
sheath. J Hand Surg Am 2013;38:154-157.
201. Reilly KE, Stern PJ, Dale JA. Recurrent giant cell tumors
of the tendon sheath. J Hand Surg Am 1999;24:1298-1302.
202. Kotwal PP, Gupta V, Malhotra R. Giant-cell tumour of
the tendon sheath. Is radiotherapy indicated to prevent
recurrence after surgery? J Bone Joint Surg Br 2000;
82:571-573.
203. Glowacki KA, Weiss AP. Giant cell tumors of tendon
sheath. Hand Clin 1995;11:245-253.
204. Barre JA, Masson PV. Anatomy-clinical study of certain
painful subungual tumors: Tumors of neuromyoarterial
glomus of the extremities. Bull Soc Fr Dermatol Syph
1924;31:148-159.
205. Giele H. Hildreths test is a reliable clinical sign for the
diagnosis of glomus tumours. J Hand Surg Br 2002;
41
 SRPS Volume 11 Issue R9 2016
27:157-158.
206. Bhaskaranand K, Navadgi BC. Glomus tumour of the
hand. J Hand Surg Br 2002;27:229-231.
207. Maxwell GP, Curtis RM, Wilgis EF. Multiple digital
glomus tumors. J Hand Surg Am 1979;4:363-367.
208. Harrison B, Moore AM, Calfee R, Sammer DM. The
association between glomus tumors and neurofibromatosis.
J Hand Surg Am 2013;38:1571-1574.
209. Baek HJ, Lee SJ, Cho KH, Choo HJ, Lee SM, Lee YH,
Suh KJ, Moon TY, Cha JG, Yi JH, Kim MH, Jung SJ, Choi JH.
Subungual tumors: Clinicopathologic correlation with US
and MR imaging findings. Radiographics 2010;30:1621-
1636.
210. Fornage BD. Glomus tumors in the fingers: Diagnosis
with US. Radiology 1988;167:183-185.
211. Theumann NH, Goettmann S, Le Viet D, Resnick D,
Chung CB, Bittoun J, Chevrot A, Drap JL. Recurrent glomus
tumors of fingertips: MR imaging evaluation. Radiology
2002;223:143151.
212. Matloub HS, Muoneke VN, Prevel CD, Sanger JR, Yousif
NJ. Glomus tumor imaging: Use of MRI for localization of
occult lesions. J Hand Surg Am 1992;17:472-475.
213. Lin YC, Hsiao PF, Wu YH, Sun FJ, Scher RK. Recurrent
digital glomus tumor: Analysis of 75 cases. Dermatol Surg
2010;36:1396-1400.
214. Gandhi J, Yang SS, Hurd J. The anatomic location
of digital glomus tumor recurrences. J Hand Surg Am
2010;35:986-989.
215. Lee IJ, Park DH, Park MC, Pae NS. Subungual glomus
tumours of the hand: Diagnosis and outcome of the
transungual approach. J Hand Surg Eur Vol 2009;34:685-688.
216. Forthman CL, Blazar PE. Nerve tumors of the hand and
upper extremity. Hand Clin 2004;20:233-242, v.
217. Phalen GS. Neurilemmomas of the forearm and hand.
Clin Orthop Relat Res 1976;219-222.
218. Holdsworth BJ. Nerve tumours in the upper limb: A
clinical review. J Hand Surg Br 1985;10:236-238.
219. Ferner RE, Gutmann DH. International consensus
statement on malignant peripheral nerve sheath tumors in
neurofibromatosis. Cancer Res 2002;62:1573-1577.
220. McCarron KF, Goldblum JR. Plexiform neurofibroma
with and without associated malignant peripheral
nerve sheath tumor: A clinicopathologic and
immunohistochemical analysis of 54 cases. Mod Pathol
1998;11:612-617.
221. Crist P, Wilcox BL, McCarron K. Transitional portfolios:
Orchestrating our professional competence. Am J Occup
Ther 1998;52:729-736.
222. Maher DP. Granular cell tumor in the hand. J Hand Surg
Am 1987;12:800-803.
42
223. Apisarnthanarax P. Granular cell tumor: An analysis of
16 cases and review of the literature. J Am Acad Dermatol
1981;5:171-182.
224. Lack EE, Worsham GF, Callihan MD, Crawford BE,
Klappenbach S, Rowden G, Chun B. Granular cell tumor:
A clinicopathologic study of 110 patients. J Surg Oncol
1980;13:301-316.
225. Fanburg-Smith JC, Meis-Kindblom JM, Fante R,
Kindblom LG. Malignant granular cell tumor of soft tissue:
Diagnostic criteria and clinicopathologic correlation. Am J
Surg Pathol 1998;22:779-794.
226. Epstein MJ. Malignant schwannomas of the hand: A
review. Bull Hosp Joint Dis 1971;32:136-147.
227. Nambisan RN, Rao U, Moore R, Karakousis CP.
Malignant soft tissue tumors of nerve sheath origin. J Surg
Oncol 1984;25:268-272.
228. Terzis JK, Daniel RK, Williams HB, Spencer PS. Benign
fatty tumors of the peripheral nerves. Ann Plast Surg
1978;1:193-216.
229. Al-Qattan MM. Lipofibromatous hamartoma of the
median nerve and its associated conditions. J Hand Surg Br
2001;26:368-372.
230. Tahiri Y, Xu L, Kanevsky J, Luc M. Lipofibromatous
hamartoma of the median nerve: A comprehensive review
and systematic approach to evaluation, diagnosis, and
treatment. J Hand Surg Am 2013;38:2055-2067.
231. Lucas GL. Epidermoid inclusion cysts of the hand. J
South Orthop Assoc 1999;8:188-192.
232. Schiavon M, Mazzoleni F, Chiarelli A, Matano P.
Squamous cell carcinoma of the hand: Fifty-five case
reports. J Hand Surg Am 1988;13:401-404.
233. Bunkis J, Mehrhof AI, Stayman JW III. Radiation-
induced carcinoma of the hand. J Hand Surg Am 1981;
6:384-387.
234. Mauro JA, Maslyn R, Stein AA. Squamous-cell
carcinoma of nail bed in hereditary ectodermal dysplasia. N
Y State J Med 1972;72:1065-1066.
235. Eibel P. Squamous cell carcinoma of the nail bed: A
report of two cases and a discussion of the literature. Clin
Orthop Relat Res 1971;74:155-160.
236. Lai CS, Lin SD, Tsai CW, Chou CK. Squamous cell
carcinoma of the nail bed. Cutis 1996;57:341-345.
237. Joyner KS, Wilson B, Wagner RF, Viegas SF. Marginal
excision of squamous cell carcinomas of the hand.
Orthopedics 2008;31:79.
238. Brodland DG, Zitelli JA. Surgical margins for excision
of primary cutaneous squamous cell carcinoma. J Am Acad
Dermatol 1992;27:241-248.
239. Askari M, Kakar S, Moran SL. Squamous cell
carcinoma of the hand: A 20-year review. J Hand Surg Am

2013;38:2124-2133.
240. Rayner CR. The results of treatment of two hundred
and seventy-three carcinomas of the hand. Hand
1981;13:183-186.
241. TerKonda SP, Perdikis G. Non-melanotic skin tumors of
the upper extremity. Hand Clin 2004;20:293-301, vi.
242. Oriba HA, Tauscheck A, Snow SN. Basal-cell carcinoma
of the finger: A case report and review of the literature. J
Hand Surg Am 1997;22:1103-1106.
243. Schnall SB, Gentry JF, Woll LM, Rohrer PA. Palmar basal
cell carcinoma. J Hand Surg Am 1987;12:1125-1127.
244. Golitz LE, Norris DA, Luekens CA Jr, Charles DM.
Nevoid basal cell carcinoma syndrome: Multiple basal
cell carcinomas of the palms after radiation therapy. Arch
Dermatol 1980;116:1159-1163.
245. Mikhail GR. Subungual basal cell carcinoma. J Dermatol
Surg Oncol 1985;11:1222-1223.
246. Mehregan AH. Subungual basal cell carcinoma
versus acral lentiginous melanoma. J Am Acad Dermatol
1987;17:511-513.
247. Ilyas EN, Leinberry CF, Ilyas AM. Skin cancers of the
hand and upper extremity. J Hand Surg Am 2012;
37:171-178.
248. Quinn MJ, Wikramanayake R, Thompson JF, McCarthy
WH. Non-subungual melanomas of the hand. J Hand Surg Br
1992;17:433-436.
249. Levit EK, Kagen MH, Scher RK, Grossman M, Altman E.
The ABC rule for clinical detection of subungual melanoma.
J Am Acad Dermatol 2000;42:269-274.
250. Ridgeway CA, Hieken TJ, Ronan SG, Kim DK, Das Gupta
TK. Acral lentiginous melanoma. Arch Surg 1995;130:88-92.
251. Slingluff CL Jr, Vollmer R, Seigler HF. Acral melanoma:
A review of 185 patients with identification of prognostic
variables. J Surg Oncol 1990;45:91-98.
252. Durbec F, Martin L, Derancourt C, Grange F. Melanoma
of the hand and foot: Epidemiological, prognostic and
genetic features: A systematic review. Br J Dermatol
2012;166:727-739.
253. Yang Z, Xie L, Huang Y, Sun H, Yuan T, Ma X, Jing C, Liu
P. Clinical features of malignant melanoma of the finger and
therapeutic efficacies of different treatments. Oncol Lett
2011;2:811-815.
254. Papachristou DN, Fortner JG. Melanoma arising under
the nail. J Surg Oncol 1982;21:219-222.
255. Finley RK III, Driscoll DL, Blumenson LE, Karakousis CP.
Subungual melanoma: An eighteen-year review. Surgery
1994;116:96-100.
256. Quinn MJ, Thompson JE, Crotty K, McCarthy WH,
Coates AS. Subungual melanoma of the hand. J Hand Surg
Am 1996;21:506-511.
SRPS Volume 11 Issue R9 2016
257. Eggermont AM, Gore M. Randomized adjuvant therapy
trials in melanoma: Surgical and systemic. Semin Oncol
2007;34:509-515.
258. Heaton KM, el-Naggar A, Ensign LG, Ross MI, Balch CM.
Surgical management and prognostic factors in patients
with subungual melanoma. Ann Surg 1994;219:197-204.
259. Cho K, Jung ST. Treatment outcomes of advanced
stage malignant melanoma in hand and foot after
amputation in Korean patients. Clin Orthop Surg 2013;
5:314-320.
260. Eggermont AM. Adjuvant therapy of malignant
melanoma and the role of sentinel node mapping. Recent
Results Cancer Res 2000;157:178-189.
261. Feldman F. Primary bone tumors of the hand and
carpus. Hand Clin 1987;3:269-289.
262. Payne WT, Merrell G. Benign bony and soft tissue
tumors of the hand. J Hand Surg Am 2010;35:1901-1910.
263. Puhaindran ME, Athanasian EA. Malignant
and metastatic tumors of the hand. J Hand Surg Am
2010;35:1895-1900.
264. Putnam MD, Cohen M. Malignant bony tumors of the
upper extremity. Hand Clin 1995;11:265-286.
265. Floyd WE III, Troum S. Benign cartilaginous lesions of
the upper extremity. Hand Clin 1995;11:119-132.
266. Eiken O, Carstam N. Enchondroma in the hand. Acta
Chir Scan Suppl 1966;357:148-153.
267. Nelson DL, Abdul-Karim FW, Carter JR, Makley JT.
Chondrosarcoma of small bones of the hand arising from
enchondroma. J Hand Surg Am 1990;15:655-659.
268. Yasuda M, Masada K, Takeuchi E. Treatment of
enchondroma of the hand with injectable calcium
phosphate bone cement. J Hand Surg Am 2006;31:98-102.
269. Pianta TJ, Baldwin PS, Obopilwe E, Mazzocca AD,
Rodner CM, Silverstein EA. A biomechanical analysis of
treatment options for enchondromas of the hand. Hand (N
Y) 2013;8:86-91.
270. Sassoon AA, Fitz-Gibbon PD, Harmsen WS, Moran SL.
Enchondromas of the hand: Factors affecting recurrence,
healing, motion, and malignant transformation. J Hand Surg
Am 2012;37:1229-1234.
271. Miyawaki T, Kinoshita Y, Iizuka T. A case of Olliers
disease of the hand. Ann Plast Surg 1997;38:77-80.
272. Goto T, Motoi T, Komiya K, Motoi N, Okuma T, Okazaki
H, Takatori Y, Tange T, Nakamura K. Chondrosarcoma of the
hand secondary to multiple enchondromatosis: Report of
two cases. Arch Orthop Trauma Surg 2003;123:42-47.
273. Muramatsu K, Kawakami Y, Tani Y, Taguchi T. Malignant
transformation of multiple enchondromas in the hand: Case
report. J Hand Surg Am 2011;36:304-307.
274. Ganzhorn RW, Bahri G, Horowitz M. Osteochondroma
43
 SRPS Volume 11 Issue R9 2016
of the distal phalanx. J Hand Surg Am 1981;6:625-626.
275. Yoshioka S, Hamada Y, Takata S, Takai H, Yasui N.
An osteochondroma limiting flexion of the proximal
interphalangeal joint in hereditary multiple exostosis: A case
report. Hand (N Y) 2010;5:299-302.
276. Shah NR, Wilczynski M, Gelberman R. Osteochondroma
of the capitate causing rupture of the extensor digiti minimi:
Case report. J Hand Surg Am 2009;34:46-48.
277. Katayama T, Ono H, Furuta K. Osteochondroma of the
lunate with extensor tendons rupture of the index finger: A
case report. Hand Surg 2011;16:181-184.
278. Joseph J, Ritchie D, MacDuff E, Mahendra A.
Bizarre parosteal osteochondromatous proliferation: A
locally aggressive benign tumor. Clin Orthop Relat Res
2011;469:2019-2027.
279. Johnston AD. Aneurysmal bone cyst of the hand. Hand
Clin 1987;3:299-310.
280. Basarir K, Saglik Y, Yildiz Y, Tezen E. Aneurysmal
bone cyst of the hand: A report of four cases. Hand Surg
2006;11:35-41.
281. Athanasian EA, McCormack RR. Recurrent aneurysmal
bone cyst of the proximal phalanx treated with cryosurgery:
A case report. J Hand Surg Am 1999;24:405-412.
282. Sullivan RJ, Meyer JS, Dormans JP, Davidson RS.
Diagnosing aneurysmal and unicameral bone cysts
with magnetic resonance imaging. Clin Orthop Relat Res
1999;366:186-190.
283. Pretell-Mazzini J, Murphy RF, Kushare I, Dormans
JP. Unicameral bone cysts: General characteristics and
management controversies. J Am Acad Orthop Surg
2014;22:295-303.
284. Jackson RP, Reckling FW, Mants FA. Osteoid osteoma
and osteoblastoma: Similar histologic lesions with different
natural histories. Clin Orthop Relat Res 1977;128:303-313.
285. Foucher G, Lemarechal P, Citron N, Merle M. Osteoid
osteoma of the distal phalanx: A report of four cases and
review of the literature. J Hand Surg Br 1987;12:382-386.
286. Brown RE, Russell JB, Zook EG. Osteoid osteoma of the
distal phalanx of the finger: A diagnostic challenge. Plast
Reconstr Surg 1992;90:1016-1021.
287. Marcuzzi A, Acciaro AL, Landi A. Osteoid osteoma of
the hand and wrist. J Hand Surg Br 2002;27:440-443.
288. Afshar, A. Osteoblastoma of the capitate bone. J Hand
Microsurg 2012;4:34-38.
289. Morton KS, Quenville NF, Beauchamp CP. Aggressive
osteoblastoma: A case previously reported as a recurrent
osteoid osteoma. J Bone Joint Surg Br 1989;71:428-431.
290. van Dijk M, Winters HA, Wuisman PI. Recurrent
osteoblastoma of the hamate bone: A two-stage
reconstruction with a free vascularized iliac crest flap. J Hand
44
Surg Br 1999;24:501-505.
291. Athanasian EA, Wold LE, Amadio PC. Giant cell tumors
of the bones of the hand. J Hand Surg Am 1997;22:91-98.
292. Biscaglia R, Bacchini P, Bertoni F. Giant cell tumor of the
bones of the hand and foot. Cancer 2000;88:2022-2032.
293. Wold LE, Swee RG. Giant cell tumor of the small bones
of the hands and feet. Semin Diagn Pathol 1984;1:173-184.
294. Averill RM, Smith RJ, Campbell CJ. Giant-cell tumors of
the bones of the hand. J Hand Surg Am 1980;5:39-50.
295. Oliveira VC, van der Heijden L, van der Geest IC,
Campanacci DA, Gibbons CL, van de Sande MA, Dijkstra PD.
Giant cell tumours of the small bones of the hands and feet:
Long-term results of 30 patients and a systematic literature
review. Bone Joint J 2013;95:838-845.
296. Errani C, Ruggieri P, Asenzio MA, Toscano A, Colangeli
S, Rimondi E, Rossi G, Longhi A, Mercuri M. Giant cell
tumor of the extremity: A review of 349 cases from a single
institution. Cancer Treat Rev 2010;36:1-7.
297. Balke M, Schremper L, Gebert C, Ahens H, Streitbuerger
A, Koehler G, Hardes J, Gosheger G. Giant cell tumor of
bone: Treatment and outcome of 214 cases. J Cancer Res Clin
Oncol 2008;134:969-978.
298. Rosenberg AE, Schiller AL. Soft tissue sarcomas of the
hand. Hand Clin 1987;3:247-261.
299. Terek RM, Brien EW. Soft-tissue sarcomas of the hand
and wrist. Hand Clin 1995;11:287-305.
300. Frassica FJ, Amadio PC, Wold LE, Dobyns JH, Linscheid
RL. Primary malignant bone tumors of the hand. J Hand Surg
Am 1989;14:1022-1028.
301. Dick HM, Angelides AC. Malignant bone tumors of the
hand. Hand Clin 1989;5:373-381.
302. Yang JC, Chang AE, Baker AR, Sindelar WF, Danforth
DN, Topalian SL, DeLaney T, Glatstein E, Steinberg SM,
Merino MJ, Rosenberg SA. Randomized prospective study of
the benefit of adjuvant radiation therapy in the treatment
of soft tissue sarcomas of the extremity. J Clin Oncol
1998;16:197-203.
303. Keus RB, Rutgers EJ, Ho GH, Gortzak E, Albus-Lutter
CE, Hart AA. Limb-sparing therapy of extremity soft tissue
sarcomas: Treatment outcome and long-term functional
results. Eur J Cancer 1994;30A:1459-1463.
304. Rosenberg SA, Tepper J, Glatstein E, Costa J, Baker A,
Brennan M, DeMoss EV, Seipp C, Sindelar WF, Sugarbaker
P, Wesley R. The treatment of soft-tissue sarcomas of the
extremities: Prospective randomized evaluations of (1)
limb-sparing surgery plus radiation therapy compared with
amputation and (2) the role of adjuvant chemotherapy. Ann
Surg 1982;196:305-315.
305. Pritchard DJ, Dahlin DC, Dauphine RT, Taylor WF,
Beabout JW. Ewings sarcoma: A clinicopathological and
statistical analysis of patients surviving five years or longer. J

Bone Joint Surg Am 1975;57:10-16.
306. Baccari S, Hamdi MF, Mabrouki Z, Daghfous M,
Tarhouni L. Ewings sarcoma of the finger: Report of two
cases and literature review. Orthop Traumatol Surg Res
2012;98:233-237.
307. Rajiah P, Ilaslan H, Sundaram M. Imaging of primary
malignant bone tumors (nonhematological). Radiol Clin
North Am 2011;49:1135-1161, v.
308. Gorlick R, Janeway K, Lessnick S, Randall RL, Marina N;
COG Bone Tumor Committee. Childrens Oncology Groups
2013 blueprint for research: Bone tumors. Pediatr Blood
Cancer 2013;60:1009-1015.
309. Parida L, Fernandez-Pineda I, Uffman J, Navid
F, Davidoff AM, Neel M, Krasin MJ, Rao BN. Clinical
management of Ewing sarcoma of the bones of the hands
and feet: A retrospective single-institution review. J Pediatr
Surg 2012;47:1806-1810.
310. Anakwenze OA, Parker WL, Wold LE, Amrami KK,
Amadio PC. Ewings sarcoma of the hand. J Hand Surg Eur Vol
2009;34:35-39.
311. Okada K, Wold LE, Beabout JW, Shives TC.
Osteosarcoma of the hand: A clinicopathologic study of 12
cases. Cancer 1993;72:719-725.
312. Pradhan A, Reddy KI, Grimer RJ, Abudu A, Tillman
RM, Carter SR, Jeys L. Osteosarcomas in the upper distal
extremities: Are their oncological outcomes similar to other
sites? Eur J Surg Oncol 2015;41:407412.
313. Block RS, Burton RI. Multiple chondrosarcomas in a
hand: A case report. J Hand Surg Am 1977;2:310-313.
314. Gargan TJ, Kanter W, Wolfort FG. Multiple
chondrosarcomas of the hand. Ann Plast Surg
315. 1984;12:542-546.
316. Roberts PH, Price CH. Chondrosarcoma of the bones of
the hand. J Bone Joint Surg Br 1977;59:213221.
317. Palmieri TJ. Chondrosarcoma of the hand. J Hand Surg
Am 1984;9:332-338.
318. Justis EJ Jr, Dart RC. Chondrosarcoma of the hand with
metastasis: A review of the literature and case report. J Hand
Surg Am 1983;8:320-324.
319. Karabela-Bouropoulou V, Patra-Malli F, Agnantis N.
Chondrosarcoma of the thumb: An unusual case with lung
and cutaneous metastases and death of the patient 6 years
after treatment. J Cancer Res Clin Oncol 1986;112:71-74.
320. Fleegler EJ. An approach to soft tissue sarcomas of the
hand and upper limb. J Hand Surg Br 1994;19:411-419.
321. Al-Refaie WB, Habermann EB, Jensen,EH, Tuttle TM,
Pisters PW, Virnig BA. Surgery alone is adequate treatment
for early stage soft tissue sarcoma of the extremity. Br J Surg
2010;97;707713.
322. Beane JD, Yang JC, White D, Steinberg SM, Rosenberg
SRPS Volume 11 Issue R9 2016
SA, Rudloff U. Efficacy of adjuvant radiation therapy in the
treatment of soft tissue sarcoma of the extremity: 20-year
follow-up of a randomized prospective trial. Ann Surg Oncol
2014;21:24842489.
323. Pervaiz N, Colterjohn N, Farrokhyar F, Tozer R,
Figueredo A, Ghert M. A systematic meta-analysis of
randomized controlled trials of adjuvant chemotherapy
for localized resectable soft-tissue sarcoma. Cancer
2008;113:573581.
324. Steinberg BD, Gelberman RH, Mankin HJ, Rosenberg
AE. Epithelioid sarcoma in the upper extremity. J Bone Joint
Surg Am 1992;74:28-35.
325. Herr MJ, Harmsen WS, Amadio PC, Scully SP. Epithelioid
sarcoma of the hand. Clin Orthop Relat Res 2005;
431:193-200.
326. Chase DR, Enzinger FM. Epithelioid sarcoma: Diagnosis,
prognostic indicators, and treatment. Am J Surg Pathol
1985;9:241-263.
327. Bryan RS, Soule EH, Dobyns JH, Pritchard DJ, Linscheid
RL. Primary epithelioid sarcoma of the hand and forearm: A
review of thirteen cases. J Bone Joint Surg Am 1974;
56:458-465.
328. Fong Y, Coit DG, Woodruff JM, Brennan MF. Lymph
node metastasis from soft tissue sarcoma in adults: Analysis
of data from a prospective database of 1772 sarcoma
patients. Ann Surg 1993;217:72-77.
329. Ross HM, Lewis JJ, Woodruff JM, Brennan MF.
Epithelioid sarcoma: Clinical behavior and prognostic
factors of survival. Ann Surg Oncol 1997;4:491-495.
330. Murray PM. Soft tissue sarcoma of the upper extremity.
Hand Clin 2004;20:325-333, vii.
331. Salo JC, Lewis JJ, Woodruff JM, Leung DL, Brennan MF.
Malignant fibrous histiocytoma of the extremity. Cancer
1999;85:1765-1772.
332. Bacci G, Picci P, Mercuri M, Bertoni F, Ferrari S.
Neoadjuvant chemotherapy for high grade malignant
fibrous histiocytoma of bone. Clin Orthop Relat Res
1998;346:178-189.
333. Guo J, Cui Q, Liu C, Sui J, Jiang N, Zhou J, Li D, Zeng Y.
Clinical report on transarterial neoadjuvant chemotherapy
of malignant fibrous histiocytoma in soft tissue. Clin Transl
Oncol 2013;15:370-375.
334. Casanova M, Meazza C, Favini F, Fiore M, Morosi C,
Ferrari A. Rhabdomyosarcoma of the extremities: A focus on
tumors arising in the hand and foot. Pediatr Hematol Oncol
2009;26:321-331.
335. Xarchas K, Papavassiliou N, Tsoutseos N, Burke FD.
Rhabdomyosarcoma of the hand: Two case reports and a
review of the literature. J Hand Surg Br 1996;21:325-329.
336. Dick HM. Synovial sarcoma of the hand. Hand Clin
1987;3:241-245.
45
 SRPS Volume 11 Issue R9 2016
337. Casal D, Ribeiro AI, Mafra M, Azeda C, Mavioso
C, Mendes MM, Mouzinho MM. A 63-year-old woman
presenting with a synovial sarcoma of the hand: A case
report. J Med Case Rep 2012;6:385.
338. Ferrari A, Gronchi A, Casanova M, Meazza C, Gandola
L, Collini P, Lozza L, Bertulli R, Olmi P, Casali PG. Synovial
sarcoma: A retrospective analysis of 271 patients of all ages
treated at a single institution. Cancer 2004;101:627-634.
339. Pritchard DJ, Soule EH, Taylor WF, Ivins JC.
Fibrosarcoma: A clinicopathologic and statistical study of
199 tumors of the soft tissues of the extremities and trunk.
Cancer 1974;33:888-897.
340. Widgerow AD, Murray J. Fibrosarcoma of the hand: A
case report. S Afr J Surg 1988;26:118-120.
341. Pousti TJ, Upton J, Loh M, Grier H. Congenital
fibrosarcoma of the upper extremity. Plast Reconstr Surg
1998;102:1158-1162.
342. Castro EB, Hajdu SI, Fortner JG. Surgical therapy
of fibrosarcoma of extremities: A reappraisal. Arch Surg
1973;107:284-286.
343. Di Martino L, Dessena M, Demontis B, Grosso LP,
Murenu G. Clinical management of soft tissue sarcomas. Chir
Ital 2000;52:343-349.
344. Chung EB, Enzinger FM. Malignant melanoma of soft
parts: A reassessment of clear cell sarcoma. Am J Surg Pathol
1983;7:405-413.
345. Andrew TA. Clear cell sarcoma of the hand. Hand
1982;14:200-203.
346. Hocar O, Le Cesne A, Berissi S, Terrier P, Bonvalot S,
Vanel D, Auperin A, Le Pechoux C, Bui B, Coindre JM, Robert
C. Clear cell sarcoma (malignant melanoma) of soft parts:
A clinicopathologic study of 52 cases. Dermatol Res Pract
2012;2012:984096.
347. Witt JD, Jupiter JB. Kaposis sarcoma in the hand
seen as an arteriovenous malformation. J Hand Surg Am
1991;16:607-609.
348. Keith JE Jr, Wilgis EF. Kaposis sarcoma in the hand of an
AIDS patient. J Hand Surg Am 1986;11:410-413.
349. Afshar A, Farhadnia P, Khalkhali H. Metastases to the
hand and wrist: An analysis of 221 cases. J Hand Surg Am
2014;39:923-932.
350. Kerin R. The hand in metastatic disease. J Hand Surg Am
1987;12:77-83.
351. Henderson JJ. Metastatic carcinoma in the hand
presenting as an acute paronychia. Br J Clin Pract
1987;41:805-806.
352. Levack B, Scott G, Flanagan JP. Metastatic carcinoma
presenting as a pulp space infection. Hand 1983;
15:341-342.
353. Moss AL. Secondary carcinoma simulating a pulp
46
infection. Injury 1984;16:196-197.
354. Amadio PC, Lombardi RM. Metastatic tumors of the
hand. J Hand Surg Am 1987;12:311-316.
355. Flynn CJ, Danjoux C, Wong J, Christakis M, Rubenstein
J, Yee A, Yip D, Chow E. Two cases of acrometastasis to the
hands and review of the literature. Curr Oncol 2008;
15:51-58.
356. Chang J, Vernadakis AJ, McClellan WT. Fingertip
injuries. Clinics Occup Environ Med 2006;5:413-422, ix.
357. Martin C, Gonzlez del Pino J. Controversies in the
treatment of fingertip amputations: Conservative versus
surgical reconstruction. Clin Orthop Relat Res 1998;
353:63-73.
358. Fox JW IV, Golden GT, Rodeheaver G, Edgerton MT,
Edlich RF. Nonoperative management of fingertip pulp
amputation by occlusive dressings. Am J Surg 1977;
133:255-256.
359. Mennen U, Wiese A. Fingertip injuries management
with semi-occlusive dressing. J Hand Surg Br 1993;
18:416-422.
360. Sderberg T, Nystrm A, Hallmans G, Hultn J.
Treatment of fingertip amputations with bone exposure:
A comparative study between surgical and conservative
treatment methods. Scand J Plast Reconstr Surg
1983;17:147-152.
361. Beasley RW. Reconstruction of amputated fingertips.
Plast Reconstr Surg 1969;44:349-352.
362. Nakamura K, Namba K, Tsuchida H. A retrospective
study of thick split-thickness plantar skin grafts to resurface
the palm. Ann Plast Surg 1984;12:508-513.
363. Milner CS, Thirkannad SM. Resurfacing glabrous skin
defects in the hand: The thenar base donor site. Tech Hand
Up Extrem Surg 2014;18:89-91.
364. Terzis JK. Functional aspects of reinnervation of free
skin grafts. Plast Reconstr Surg 1976;58:142-156.
365. Braun M, Horton RC, Snelling CF. Fingertip amputation:
Review of 100 digits. Can J Surg 1985;28:72-75.
366. Beasley RW. Principles of soft tissue replacement for
the hand. J Hand Surg Am 1983;8:781-784.
367. Lister G. Local flaps to the hand. Hand Clin 1985;
1:621-640.
368. Rose EH. Small flap coverage of hand and digit defects.
Clin Plast Surg 1989;16:427-442.
369. Foucher G, Boulas HJ, Braga Da Silva J. The use of
flaps in the treatment of fingertip injuries. World J Surg
1991;15:458-462.
370. Atasoy E, Ioakimidis E, Kasdan ML, Kutz JE, Kleinert HE.
Reconstruction of the amputated finger tip with a triangular
volar flap: A new surgical procedure. J Bone Joint Surg Am
1970;52:921-926.

371. Tupper J, Miller G. Sensitivity following volar V-Y plasty
for fingertip amputations. J Hand Surg Br 1985;10:183-184.
372. Foucher G, Dallaserra M, Tilquin B, Lenoble E, Sammut
D. The Hueston flap in reconstruction of fingertip skin
loss: Results in a series of 41 patients. J Hand Surg Am
1994;19:508-515.
373. Elliot D, Moiemen NS, Jigjinni VS. The neurovascular
Tranquilli-Leali flap. J Hand Surg Br 1995;20:815-823.
374. Moberg E. Aspects of sensation in reconstructive
surgery of the upper extremity. J Bone Joint Surg Am
1964;46:817-825.
375. Dellon AL. The extended palmar advancement flap. J
Hand Surg Am 1983;8:190-194.
376. Elliot D, Wilson Y. V-Y advancement of the entire volar
soft tissue of the thumb in distal reconstruction. J Hand Surg
Br 1993;18:399-402.
377. OBrien B. Neurovascular island pedicle flaps for
terminal amputations and digital scars. Br J Plast Surg
1968;21:258-261.
378. Snow JW. The use of a volar flap for repair of fingertip
amputations: A preliminary report. Plast Reconstr Surg
1967;40:163-168.
379. Macht SD, Watson HK. The Moberg volar advancement
flap for digital reconstruction. J Hand Surg Am 1980;
5:372-376.
380. Geissendrfer H. Beitrag zur Fingerkuppenplastik.
Zentral Chir 1943;70:1107-1108.
381. Kutler W. A new method for finger tip amputation. J
Am Med Assoc 1947;133:29.
382. Lee JY, Teoh LC, Seah VW. Extending the reach of the
heterodigital arterialized flap by cross-finger transfer. Plast
Reconstr Surg 2006;117:2320-2328.
383. Lai CS, Lin SD, Chou CK, Tsai CW. A versatile method for
reconstruction of finger defects: Reverse digital artery flap.
Br J Plast Surg 1992;45:443-453.
384. Lai CS, Lin SD, Chou CK, Tsai CW. Innervated reverse
digital artery flap through bilateral neurorrhaphy for pulp
defects. Br J Plast Surg 1993;46:483-488.
385. Leupin P, Weil J, Buchler U. The dorsal middle
phalangeal finger flap: Mid-term results of 43 cases. J Hand
Surg Br 1997;22:362-371.
386. Hirase Y, Kojima T, Matsuura S. A versatile one-stage
neurovascular flap for fingertip reconstruction: The
dorsal middle phalangeal finger flap. Plast Reconstr Surg
1992;90:1009-1015.
387. Iselin M. Modified Z plastic operations [in French]. Ann
Chir Plast 1962;7:295-298.
388. Cronin TD. The cross finger flap: A new method of
repair. Am Surg 1951;17:419-425.
389. Curtis RM. Cross-finger pedicle flap in hand surgery.
SRPS Volume 11 Issue R9 2016
Ann Surg 1957;145:650-655.
390. Vlastou C, Earle AS, Blanchard JM. A palmar cross-
finger flap for coverage of thumb defects. J Hand Surg Am
1985;10:566-569.
391. [No authors listed]. The versatile cross-finger pedicle
flap. Can Med Assoc J 1960;83:1020.
392. Lister GD. Skin flaps. In, Operative Hand Surgery. 3rd
ed. New York: Churchill Livingstone; 1993:17411822.
393. Cohen BE, Cronin ED. An innervated cross-finger
flap for fingertip reconstruction. Plast Reconstr Surg
1983;72:688-697.
394. Pakiam AI. The reversed dermis flap. Br J Plast Surg
1978;31:131-135.
395. Nicolai JP, Hentenaar G. Sensation in cross-finger flaps.
Hand 1981;13:12-16.
396. Nishikawa H, Smith PJ. The recovery of sensation and
function after cross-finger flaps for fingertip injury. J Hand
Surg Br 1992;17:102-107.
397. Littler JW. Neurovascular skin island transfer in
reconstructive hand surgery. In, Transactions of the Second
International Congress of Plastic and Reconstructive Surgery
London: E&S Livingstone; 1960:175.
398. Tubiana R, Duparc J, Moreau C. Restoration of
sensibility at the level of the hand by transfer of a
heterodigital cutaneous transplant possessing its vasculo-
nervous pedicle [in French]. Rev Chir Orthop Reparatrice
Appar Mot 1960;46:163-178.
399. Reid DA. The neurovascular island flap in thumb
reconstruction. Br J Plast Surg 1966;19:234-244.
400. Thompson JS. Reconstruction of the insensate thumb
by neurovascular island transfer. Hand Clin 1992;8:99-105.
401. Markley JM Jr. The preservation of close two-point
discrimination in the interdigital transfer of neurovascular
island flaps. Plast Reconstr Surg 1977;59:812-816.
402. Stice RC, Wood MB. Neurovascular island skin flaps
in the hand: Functional and sensibility evaluations.
Microsurgery 1987;8:162-167.
403. Holevich J. A new method of restoring sensibility to
the thumb. J Bone Joint Surg Br 1963;45:496-502.
404. Foucher G, Braun JB. A new island flap transfer from
the dorsum of the index to the thumb. Plast Reconstr Surg
1979;63:344-349.
405. Muyldermans T, Hierner R. First dorsal metacarpal
artery flap for thumb reconstruction: A retrospective clinical
study. Strategies Trauma Limb Reconstr 2009;4:27-33.
406. Gatewood MA. Plastic repair of finger defects without
hospitalization. 1926;87:1479.
407. Flatt AE. The thenar flap. J Bone Joint Surg Br
1957;39:80-85.
408. Melone CP Jr, Beasley RW, Carstens JH Jr. The thenar
47
 SRPS Volume 11 Issue R9 2016
flap: An analysis of its use in 150 cases. J Hand Surg Am
1982;7:291-297.
409. Dellon AL. The proximal inset thenar flap for fingertip
reconstruction. Plast Reconstr Surg 1983;72:698-704.
410. Lai CS, Lin SD, Yang CC, Chou CK. The adipofascial turn-
over flap for complicated dorsal skin defects of the hand
and finger. Br J Plast Surg 1991;44:165-169.
411. Al-Qattan MM. De-epithelialized cross-finger flaps
versus adipofascial turnover flaps for the reconstruction of
small complex dorsal digital defects: A comparative analysis.
J Hand Surg Am 2005;30:549-557.
412. Silva JB, Faloppa F, Albertoni W, Gazzalle A, Cunha GL.
Adipofascial turnover flap for the coverage of the dorsum
of the thumb: An anatomic study and clinical application. J
Hand Surg Eur Vol 2013;38:371-377.
413. Baek SM, Weinberg H, Song Y, Park CG, Biller HF.
Experimental studies in the survival of venous island flaps
without arterial inflow. Plast Reconstr Surg 1985;75:88-95.
414. Fukui A, Maeda M, Tamai S, Inada Y. The pedicled
venous flap: Clinical applications. Br J Plast Surg 1993;
46:68-71.
415. Murata K, Inada Y, Fukui A, Tamai S, Takakura Y. Clinical
application of the reversed pedicled venous flap containing
perivenous areolar tissue and/or nerve in the hand. Br J Plast
Surg 2001;54:615-620.
416. Earley MJ. The arterial supply of the thumb, first web
and index finger and its surgical application. J Hand Surg Br
1986;11:163-174.
417. Earley MJ. The second dorsal metacarpal artery
neurovascular island flap. J Hand Surg Br 1989;14:434-440.
418. Small JO, Brennen MD. The second dorsal metacarpal
artery neurovascular island flap. Br J Plast Surg 1990;
43:17-23.
419. Maruyama Y. The reverse dorsal metacarpal flap. Br J
Plast Surg 1990;43:24-27.
420. Quaba AA, Davison PM. The distally-based dorsal hand
flap. Br J Plast Surg 1990;43:28-39.
421. Koch H, Bruckmann L, Hubmer M, Scharnagl E.
Extended reverse dorsal metacarpal artery flap: Clinical
experience and donor site morbidity. J Plast Reconstr Aesthet
Surg 2007;60:349-355.
422. Martin D, Bakhach J, Casoli V, Pellsier P, Ciria-Llorens
G, Khouri RK, Baudet J. Reconstruction of the hand with
forearm island flaps. Clin Plast Surg 1997;24:33-48.
423. Yang GF, Chen PJ, Gao YZ, Liu XY, Li J, Jiang SX, He SP.
Forearm free skin flap transplantation: A report of 56 cases:
1981. Br J Plast Surg 1997;50:162-165.
424. Song R, Gao Y, Song Y, Yu Y, Song Y. The forearm flap.
Clin Plast Surg 1982;9:21-26.
425. Mhlbauer W, Herndl E, Stock W. The forearm flap. Plast
48
Reconstr Surg 1982;70:336-344.
426. Soutar DS, Tanner NS. The radial forearm flap in the
management of soft tissue injuries of the hand. Br J Plast
Surg 1984;37:18-26.
427. Jin YT, Guan WX, Shi TM, Quian YL, Xu LG, Chang TS.
Reversed island forearm fascial flap in hand surgery. Ann
Plast Surg 1985;15:340-347.
428. Reyes FA, Burkhalter WE. The fascial radial flap. J Hand
Surg Am 1988;13:432-437.
429. Foucher G, Van Genechten F, Merle M, Michon J. Single
stage thumb reconstruction by a composite forearm island
flap. J Hand Surg Br 1984;9:245-248.
430. Matev I. The osteocutaneous pedicle forearm flap. J
Hand Surg Br 1985;10:179-182.
431. Brotherston T M, Banerjee A, Lamberty BG.
Digital reconstruction using the distally based
osteofasciocutaneous radial forearm flap. J Hand Surg Br
1987;12:93-95.
432. Reid CD, Moss LH. One-stage flap repair with
vascularised tendon grafts in a dorsal hand injury using the
Chinese forearm flap. Br J Plast Surg 1983;36:473-479.
433. Podlewski J, Opolski M, Jankiewicz L. Dorsal hand
injury repair with vascularized tendon graft using a radial
forearm flap: Case report. Acta Chir Plast 1988;30:58-62.
434. Lin SD, Lai CS, Chiu CC. Venous drainage in the reverse
forearm flap. Plast Reconstr Surg 1984;74:508-512.
435. Naasan A, Quaba AA. Successful transfer of two reverse
forearm flaps despite disruption of both palmar arches. Br J
Plast Surg 1990;43:476-479.
436. Cavanagh S, Pho RW. The reverse radial forearm flap in
the severely injured hand: An anatomical and clinical study.
J Hand Surg Br 1992;17:501-503.
437. Kleinman WB, OConnell SJ. Effects of the
fasciocutaneous radial forearm flap on vascularity of the
hand. J Hand Surg Am 1993;18:953-958.
438. Meland NB, Core GB, Hoverman VR. The radial
forearm flap donor site: Should we vein graft the artery? A
comparative study. Plast Reconstr Surg 1993;91:865-870.
439. Jones BM, OBrien CJ. Acute ischaemia of the hand
resulting from elevation of a radial forearm flap. Br J Plast
Surg 1985;38:396-397.
440. Weinzweig N, Chen L, Chen ZW. The distally based
radial forearm fasciosubcutaneous flap with preservation of
the radial artery: An anatomic and clinical approach. Plast
Reconstr Surg 1994;94:675-684.
441. Braun RM, Rechnic M, Neill-Cage DJ, Schorr RT. The
retrograde radial fascial forearm flap: Surgical rationale,
technique, and clinical application. J Hand Surg Am
1995;20:915-922.
442. Timmons MJ, Missotten FE, Poole MD, Davies DM.

Complications of radial forearm flap donor sites. Br J Plast
Surg 1986;39:176-178.
443. Lutz BS, Wei FC, Chang SC, Yang KH, Chen IH. Donor
site morbidity after suprafascial elevation of the radial
forearm flap: A prospective study in 95 consecutive cases.
Plast Reconstr Surg 1999;103:132-137.
444. Fenton OM, Roberts JO. Improving the donor site of
the radial forearm flap. Br J Plast Surg 1985;38:504-505.
445. McGregor, AD. The free radial forearm flap: The
management of the secondary defect. Br J Plast Surg
1987;40:83-85.
446. Elliot D, Bardsley AF, Batchelor AG, Soutar DS. Direct
closure of the radial forearm flap donor defect. Br J Plast Surg
1988;41:358-360.
447. Hallock GG. Refinement of the radial forearm flap
donor site using skin expansion. Plast Reconstr Surg
1988;81:21-25.
448. Wirthmann A, Finke JC, Giovanoli P, Lindenblatt N.
Long-term follow-up of donor site morbidity after defect
coverage with Integra following radial forearm flap
elevation. Eur J Plast Surg 2014;37:159-166.
449. Lovie MJ, Duncan GM, Glasson DW. The ulnar artery
forearm free flap. Br J Plast Surg 1984;37:486-492.
450. Grobbelaar AO, Harrison DH. The distally based ulnar
artery island flap in hand reconstruction. J Hand Surg Br
1997;22:204-211.
451. Brown EN, Chaudhry A, Mithani SK, Bluebond-Langner
RO, Feiner JM, Shaffer CK, Call D, Rodriguez ED. Long-term
vascular, motor, and sensory donor site outcomes after ulnar
forearm flap harvest. J Reconstr Microsurg 2014;30:115-120.
452. Penteado CV, Masquelet AC, Chevrel JP. The anatomic
basis of the fascio-cutaneous flap of the posterior
interosseous artery. Surg Radiol Anat 1986;8:209-215.
453. Bayon P, Pho RW. Anatomical basis of dorsal forearm
flap: Based on posterior interosseous vessels. J Hand Surg Br
1988;13:435-439.
454. Landi A, Luchetti R, Soragni O, De Santis G, Sacchetti
GL. The distally based posterior interosseous island flap
for the coverage of skin loss of the hand. Ann Plast Surg
1991;27:527-536.
455. Costa H, Smith R, McGrouther DA. Thumb
reconstruction by the posterior interosseous
osteocutaneous flap. Br J Plast Surg 1988;41:228-233.
456. Tonkin MA, Stern H. The posterior interosseous artery
free flap. J Hand Surg Br 1989;14:215-217.
457. Brunelli F, Valenti P, Dumontier C, Panciera P, Gilbert A.
The posterior interosseous reverse flap: Experience with 113
flaps. Ann Plast Surg 2001;47:25-30.
458. Schlenker JD. Important considerations in the design
and construction of groin flaps. Ann Plast Surg 1980;
SRPS Volume 11 Issue R9 2016
5:353-357.
459. Wray RC, Wise DM, Young VL, Weeks PM. The groin flap
in severe hand injuries. Ann Plast Surg 1982;9:459-462.
460. Freedlander E, Dickson WA, McGrouther DA. The
present role of the groin flap in hand trauma in the light of a
long-term review. J Hand Surg Br 1986;11:187-190.
461. Chow JA, Bilos ZJ, Hui P, Hall RF, Seyfer AE, Smith
AC. The groin flap in reparative surgery of the hand. Plast
Reconstr Surg 1986;77:421-426.
462. Chuang DC, Colony LH, Chen HC, Wei FC. Groin flap
design and versatility. Plast Reconstr Surg 1989;84:100-107.
463. Pederson WC. Upper extremity microsurgery. Plast
Reconstr Surg 2001;107:1524-1537.
464. Saint-Cyr M, Gupta A. Indications and selection of free
flaps for soft tissue coverage of the upper extremity. Hand
Clin 2007;23:37-48.
465. Morrison WA, OBrien BM, MacLeod AM, Gilbert A.
Neurovascular free flaps from the foot for innervation of the
hand. J Hand Surg Am 1978;3:235-242.
466. Rui Y, Mi J, Shi H, Zhang Z, Yan H. Free great toe wrap-
around flap combined with second toe medial flap for
reconstruction of completely degloved fingers. Microsurgery
2010;30:449-456.
467. Lee DC, Kim JS, Ki SH, Roh SY, Yang JW, Chung KC.
Partial second toe pulp free flap for fingertip reconstruction.
Plast Reconstr Surg 2008;121:899-907.
468. Halbert CF, Wei FC. Neurosensory free flaps: Digits and
hand. Hand Clin 1997;13:251-262.
469. Gu JX, Pan JB, Liu HJ, Zhang NC, Tian H, Zhang WZ, Xu
T, Feng SM, Wang JC. Aesthetic and sensory reconstruction
of finger pulp defects using free toe flaps. Aesthetic Plast
Surg 2014;38:156-163.
470. May JW Jr, Chait LA, Cohen BE, OBrien BM. Free
neurovascular flap from the first web of the foot in hand
reconstruction. J Hand Surg Am 1977;2:387-393.
471. Lee WP, May JW Jr. Neurosensory free flaps to the hand:
Indications and donor selection. Hand Clin 1992;8:465-477.
472. Zuker RM, Manktelow RT. The dorsalis pedis free flap:
Technique of elevation, foot closure, and flap application.
Plast Reconstr Surg 1986;77:93-104.
473. Takami H, Takahashi S, Ando M. Use of the dorsalis
pedis free flap for reconstruction of the hand. Hand
1983;15:173-178.
474. Caroli A, Adani R, Castagnetti C, Pancaldi G, Squarzina
PB. Dorsalis pedis flap with vascularized extensor tendons
for dorsal hand reconstruction. Plast Reconstr Surg
1993;92:1326-1330.
475. Ju J, Hou R. Reconstruction of penetrating injuries of
the hand with dorsalis pedis composite free flaps: A series of
23 patients. J Plast Reconstr Aesthet Surg 2012;65:1368-1376.
49
 SRPS Volume 11 Issue R9 2016
476. Katsaros J, Schusterman M, Beppu M, Banis JC Jr,
Acland RD. The lateral upper arm flap: Anatomy and clinical
applications. Ann Plast Surg 1984;12:489-500.
477. Song R, Song Y, Yu Y, Song Y. The upper arm free flap.
Clin Plast Surg 1982;9:2735.
478. Yousif NJ, Warren R, Matloub HS, Sanger JR. The lateral
arm fascial free flap: Its anatomy and use in reconstruction.
Plast Reconstr Surg 1990;86:1138-1145.
479. Hou SM, Liu TK. Vascularized tendon graft using
lateral arm flap: 5 microsurgery cases. Acta Orthop Scand
1993;64:373-376.
480. Arnez ZM, Kersnic M, Smith RW, Godina M. Free
lateral arm osteocutaneous neurosensory flap for thumb
reconstruction. J Hand Surg Br 1991;16:395-399.
481. Windhofer C, Michlits W, Karlbauer A, Papp C.
Treatment of segmental bone and soft-tissue defects of
the forearm with the free osteocutaneous lateral arm flap. J
Trauma 2011;70:1286-1290.
482. Kuek LB. The extended lateral arm flap: A detailed
anatomical study. Ann Acad Med Singapore 1992;
21:169-175.
483. Moffett TR, Madison SA, Derr JW Jr, Acland RD. An
extended approach for the vascular pedicle of the lateral
arm free flap. Plast Reconstr Surg 1992;89:259-267.
484. Graham B, Adkins P, Scheker LR. Complications and
morbidity of the donor and recipient sites in 123 lateral arm
flaps. J Hand Surg Br 1992;17:189-192.
485. Fissette J, Lahaye T, Colot G. The use of the free
parascapular flap in midpalmar soft tissue defect. Ann Plast
Surg 1983;10:235-238.
486. Burns JT, Schlafly B. Use of the parascapular flap in
hand reconstruction. J Hand Surg Am 1986;11:872-875.
487. Nassif TM, Vidal L, Bovet JL, Baudet J. The parascapular
flap: A new cutaneous microsurgical free flap. Plast Reconstr
Surg 1982;69:591-600.
488. Datiashvili RO, Shibaev EYu, Chichkin VG, Oganesian
AR. Reconstruction of a complex defect of the hand with
two distinct segments of the scapula and a scapular fascial
flap transferred as a single transplant. Plast Reconstr Surg
1992;90:687-694.
489. Masaki F, Takehiro D, Ryuuichi M, Kumi M. Late
reconstruction of two total metacarpal bone defects using
lengthening devices and a double-barrel osteocutaneous
free parascapular flap. Plast Reconstr Surg 2000;106:102-106.
490. Peng F, Chen L, Han D, Xiao C, Bao Q, Wang T.
Reconstruction of two separate defects in the upper
extremity using anterolateral thigh chimeric flap.
Microsurgery 2013;33:631-637.
491. Yang X, Zhang G, Liu Y, Yang J, Ding M, Tang M. Vascular
anatomy and clinical application of anterolateral leg
perforator flaps. Plast Reconstr Surg 2013;131:534e-543e.
50
492. Koshima I, Urushibara K, Inagawa K, Moriguchi T. Free
tensor fasciae latae perforator flap for the reconstruction
of defects in the extremities. Plast Reconstr Surg
2001;107:1759-1765.
493. Yoon CS, Noh HJ, Malzone G, Suh HS, Choi DH, Hong JP.
Posterior interosseous artery perforator-free flap: Treating
intermediate-size hand and foot defects. J Plast Reconstr
Aesthet Surg 2014;67:808-814.
494. Appleton SE, Morris SF. Anatomy and physiology of
perforator flaps of the upper limb. Hand Clin 2014;
30:123-135, v.
495. Kim SW, Lee HJ, Kim JT, Kim YH. Multiple-digit
resurfacing using a thin latissimus dorsi perforator flap. J
Plast Reconstr Aesthet Surg 2014;67:74-80.
496. Kaplan IB, Gilbert DA, Terzis JK. The vascularized fascia
of the scalp. J Reconstr Microsurg 19895:7-15.
497. Upton J, Rogers C, Durham-Smith G, Swartz WM.
Clinical applications of free temporoparietal flaps in hand
reconstruction. J Hand Surg Am 1986;11:475-483.
498. Fassio E, Laulan J, Aboumoussa J, Senyuva C, Goga D,
Ballon G. Serratus anterior free fascial flap for dorsal hand
coverage. Ann Plast Surg 1999;43:77-82.
499. Schwabegger AH, Hussl H, Rainer C, Anderl H,
Ninkovic MM. Clinical experience and indications of the free
serratus fascia flap: A report of 21 cases. Plast Reconstr Surg
1998;102:1939-1946.
500. Brody GA, Buncke HJ, Alpert BS, Hing DN. Serratus
anterior muscle transplantation for treatment of soft tissue
defects in the hand. J Hand Surg Am 1990;15:322-327.
501. Gordon L, Levinsohn DG, Finkemeier C, Angeles A,
Deutch H. The serratus anterior free-muscle transplant for
reconstruction of the injured hand: An analysis of the donor
and recipient sites. Plast Reconstr Surg 1993;92:97-101.
502. Chang N, Mathes SJ. Comparison of the effect of
bacterial inoculation in musculocutaneous and random-
pattern flaps. Plast Reconstr Surg 1982;70:1-10.
503. Richards RR, Orsini EC, Mahoney JL, Verschuren R.
The influence of muscle flap coverage on the repair of
devascularized tibial cortex: An experimental investigation
in the dog. Plast Reconstr Surg 1987;79:946-958.
504. Press BH, Chiu DT, Cunningham BL. The rectus
abdominis muscle in difficult problems of hand soft tissue
reconstruction. Br J Plast Surg 1990;43:419-425.
505. Horch RE, Stark GB. The rectus abdominis free flap as
an emergency procedure in extensive upper extremity soft-
tissue defects. Plast Reconstr Surg 1999;103:1421-1427.
506. Schaverien MV, Hart AM. Free muscle flaps
for reconstruction of upper limb defects. Hand Clin
2014;30:165-183, v, vi.
507. Griffin JR, Thornton JF. Microsurgery: Free tissue
transfer and replantation. Selected Readings in Plastic
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