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James A. Masson, F.R.A.C.S.


The nail root is covered by an epithelium-lined
sheath, the eponychium. The dermal layer beneath
the nail is the nail bed. It consists of the germinal
matrix, which underlies the proximal one-third of
the nail from the nail fold to the distal lunula and
the sterile matrix, which occupies the distal two-
thirds of the nail from the lunula to the end of the
nail bed (Fig. 1). The hyponychium consists of the
area beneath the distal free margin of the nail, where
the sterile matrix and fingertip skin meet. This spe-
cialized area contains increased numbers of poly-
morphonuclear leukocytes and lymphocytes.1 The
surrounding soft tissue is called the perionychium.
The perionychium bordering the nail edges on the
sides is the paronychium.
Nail production occurs in three areas of the peri-
onychium. The germinal matrix produces approxi-
mately 90% of the nail volume by pushing cells
from the ventral floor upward and outward. As
Fig 1. Anatomy of the nail in the sagittal (A) and dorsal view.
they reach the surface, these specialized cells flat- (Reprinted with permission from Brucker MJ, Edstrom L: The use
ten, elongate, keratinize, and stream distally; at of grafts in acute and chronic fingernail deformities. J Am Soc Surg
approximately the level of the lunula, the cell nuclei Hand 2(1):14, 2002.)
disintegrate and the nail becomes clear.
The remainder of the nail substance is produced by 2-point discrimination tests1. Where fingernails
by the germinal layer in the dorsal roof of the are permanently absent, fingerprints tend to disap-
proximal nail fold and by the sterile matrix in vari- pear.
able amounts, as evidenced by a thicker nail at its The nail grows at an average rate of 3 to 4 mm a
distal edge than its proximal root.1 The dorsal roof month. Nail growth is faster in summer than in
of the nail also provides cells that add shine to winter, and is also accelerated in nail biters. The nail
intact nails. is not attached to its bed, but rather “is a continuum
of a single structure from the basilar cells into the
The fingernail protects the fingertip from trauma
and aids in gripping fine objects. The nail resists INJURIES
deformation of the digital skin, and in so doing, Fingertip injuries are the most common type of
increases the sensitivity of the fingertip, as shown hand trauma, and the nail bed itself is the most
SRPS Volume 9, Number 32

frequent site of injury.2,3 Destruction of the germi-

nal matrix usually results in permanent loss of the
fingernail or troublesome nail remnants.4
Prompt treatment of nail bed injuries is vital to
maintain function and cosmesis.5,6 The Louisville
group4 reviewed 3,000 nail bed and root injuries
treated over a 10-year period and formulated the
principles of management for these injuries, which
• remove the remaining nail plate to assess the
underlying nail bed injury
• minimal debridement of the nail bed Fig 2. Schematic drawing of the composite nail graft. (Reprinted
with permission from Brucker MJ, Edstrom L: The use of grafts in
• stabilize the distal phalanx, if required 7
acute and chronic fingernail deformities. J Am Soc Surg Hand
• accurate repair of the nail bed and any associ- 2(1):18, 2002.)
ated skin lacerations
• replace missing sterile matrix with sterile matrix with these two structures being separated by only
graft at the primary procedure 1.2 mm.14 Visualization of the insertion of the ter-
• replace the nail plate, if available, or use 0.02” minal extensor tendon represents the proximal limit
silastic sheet as a nail spacer of excision. Reardon et al15 recommend that exci-
sion of the nail matrix should be rectangular,
These principles apply equally to the management extending to the mid-lateral lines.
of nail bed injuries in children in whom good results Microvascular nail transfer is the definitive
can be anticipated in the majority of cases.8 method for replacing the entire nail matrix, but is a
When the nail root is not significantly damaged, com- major procedure for what is as much an esthetic as
plete regrowth of the nail is normally obtained in 4 a functional outcome.16,17
to 5 months.4 In the event of partial or total loss of
the sterile matrix, nail grafting from an uninvolved
finger or from a toe9,10 is a possibility in the acute DEFORMITIES
setting. Similarly, chronic deformities such as nail Post-traumatic retraction and deformity of the
plate nonadherence and minor nail splitting have eponychial fold can follow lacerations or burns.
been treated successfully with sterile matrix grafting One-stage flap options are possible for correction
procedures.11,12 Isolated, nonvascularized, germinal of this problem.18,19
matrix grafts have a far less predictable outcome
and are usually not recommended. If a germinal
matrix graft is going to have any chance of success,
a large composite must be taken, which has to
include the nail fold. The nail plate, dorsal roof, ger-
minal and sterile matrices are harvested along with Sixty percent of all hand infections are the result
some paronychial skin (Fig. 2).13 The donor site from of trauma, 30% of infections result from human
the great toe is covered with a split-thickness skin bites, and a further 10% from animal bites.20 Hand
graft. However, in their review of 10 composite grafts infections account for approximately 20% of all
over a 10 year period, Lille et al14 were only able to admissions to hand surgery units. These injuries
obtain good or excellent results in 50% of cases. are often accorded a lower level of significance
Where there is significant loss of germinal matrix, than they warrant. When treated appropriately,
consideration should also be given to primary nail the patient will be returned to optimal function in
bed ablation. When performing an ablation, the a short time. If treated inadequately, the patient
intimate relationship of the terminal extensor ten- will be resigned to pain, stiffness, and disability,
don to the germinal matrix must be appreciated, with the possibility of amputation in extreme cases.

SRPS Volume 9, Number 32

Empiric Antibiotic Treatment for Some Common Hand Infections

(Reprinted with permission from Moran GJ, Talan DA: Hand infections. Emerg Med Clin North Am 11:603, 1993).

MICROBES AND ANTIBIOTICS ated with a foul odor. These infections usually
The most frequent pathogen in hand infections require intravenous antibiotics as initial therapy.
is Staphylococcus aureus, accounting for 50& to Anaerobic bacteria are especially common in
80% of all isolates.20-25 However, specific aspects bite wounds, infections associated with intravenous
of the history or physical examination can implicate drug abuse, and in diabetics. In addition to the bac-
other organisms as the inciting agent. Careful teria already mentioned, Eikenella corrodens is
attention to these factors allows the physician to found in many human bite wounds,27-29 and Pas-
make an appropriate choice for an initial antibiotic(s) teurella multocida in many domestic animal bites.30-
to cover all reasonable pathogens (Table 1). Indis-
These are usually adequately covered by the
criminate use of excessively broad-spectrum anti- addition of penicillin to an agent effective against
biotics can expose the patient to unnecessary side the other gram positives.34-36
effects and complications as well as promote the Compared with adults, children are more sus-
development of resistant strains. ceptible to unusual pathogens and have a higher
If the infection is the result of a known traumatic incidence of oral flora, Pseudomonas aeruginosa,
event, the circumstances of that event can give and Haemophilus influenzae37,38 associated with
important clues as to the pathogens. Gram positive their infections. However, these associations are
organisms are the most frequent isolates in routine probably not frequent enough to warrant a change
home and industrial accidents.26 In farm accidents, in the initial therapy of routine infections. Never-
mixed cultures of gram positive and negative bac- theless, if suggested by gram stain, if there is a site
teria, as well as anaerobes, are present. Among the of distant infection where these pathogens are com-
common gram positive isolates, S. aureus usually mon, or if the infection does not respond promptly
results in a purulent infection 3-5 days after the to the standard antibiotics, additional coverage is
event. The pus is usually creamy white and without warranted in these patients. The presence of mul-
odor. Infections with Streptococcus species present tiple pathogens in hand infections is probably more
rapidly, with marked cellulitis and possibly lymphan- common than is appreciated.39
gitis. While an antistaphylococcal penicillin or first- Three independent studies40-42 demonstrate that
generation cephalosporin will cover S. aureus prophylactic antibiotics do not avert infection in
adequately, streptococci are better covered by peni- hand lacerations. Meticulous wound debridement
cillin. Gram negative infections may present with a and care is preferred over the routine use of antibi-
cellulitis or purulent infection. If purulence is present, otics in hand injuries.43 Fitzgerald26 recommends
it can have a variety of colors and is often associ- prophylactic antibiotics in cases of hand wounds of

SRPS Volume 9, Number 32

home or industrial origin, but not in farm wounds, of allergy) should be the first line with the addition of
which instead should be debrided thoroughly and an anti-staphylococcal agent if S. aureus is cultured.
cultured. Nylen and Carlsson44 found no correla-
tion between the severity of the infection and the
number of organisms present in the wound or time Paronychia
elapsed before treatment (up to 18 hours), and A paronychia is an infection of those structures
further emphasize the importance of wound debri- surrounding the proximal and lateral nail. Parony-
dement in the care of hand injuries. chia is initiated by the introduction of bacteria
between the nail and its surrounding structures.
This is usually caused by minor trauma such as nail
MANAGEMENT biting or manicures. It is frequently reported that S.
While the spectrum of acute bacterial hand aureus is the most frequent isolate in paronychia.
infections is quite broad, the management principles Recent studies have shown anaerobic bacteria to
are similar in all and can be summarized as: be present alone, or in combination, in a large
• Rest, elevation, and immobilization in a position percentage of cases of paronychia.46,47 This is felt
of function to be due to the frequency of contact of the oral
secretions with the inciting wound.
• Adequate drainage of all loculations of pus, and The paronychia initially begins as erythema, swell-
debridement of necrotic tissue ing, and discomfort at the nail fold, sometimes with
• Antibiotics, determined by sensitivities from aero- fluctuation and frank purulence. If detected early,
bic and anaerobic cultures (obtained prior to the warm soaks, elevation, and oral antibiotics may be
commencement of antimicrobial therapy) and sufficient treatment. If the infection has been present
special cultures—fungi, mycobacteria, viruses— for greater than 24 hours or if there is any fluctuance
where indicated under the nail, the nail fold must be drained by
• Penicillin plus a first-generation cephalosporin simple elevation (Fig 3).48
or dicloxacillin are appropriate until sensitivities
are known. Alternatively, a third-generation
cephalosporin such as cefamandole45 may be
used alone
• Tetanus prophylaxis for all penetrating wounds
• Early, aggressive hand therapy


Hand infections may be acute or chronic, but
the overwhelming majority are acute. Of these acute
infections, over 90% are due to bacterial patho- Fig 3. Drainage of paronychia. (Reprinted with permission from
Conolly WB: Infections. In: Conolly WB (ed), Atlas of Hand
gens. 20 Surgery. Churchill Livingstone, 1997. Ch 32, p. 256.)

Cellulitis If this initial attempt at drainage is inadequate, if

the infection extends significantly proximal to the
Cellulitis is a common superficial infection of the nail fold, or if the infection fails to resolve with the
hand that presents as erythema, swelling, pain, and above treatment, more aggressive drainage is indi-
occasional lymphangitis or vesicle formation. Cel- cated. The nail plate should be removed as it may
lulitis occurs most commonly on the dorsal aspect be acting as a foreign body by this stage. It might
of the fingers and metacarpals, and beta-hemolytic also be necessary to incise the dorsal nail fold. Two
streptococcus is the usual pathogen. incisions are made at right angles to the nail fold at
Treatment includes rest, elevation, splinting and the 5 o’clock and 7 o’clock positions to elevate it
antibiotics. Penicillin-G (or erythromycin in the event completely from the nail bed in the region of the

SRPS Volume 9, Number 32

antifungal-steroid cream, has also shown good


Pulp Space Infections (Felons)

A felon is an infection of the pulp of the distal
finger. The anatomy of the pulp is unique, with 15-
20 longitudinal septa anchoring the tip to the distal
phalanx (Fig 5). When infection is present, these
septa can compartmentalize an infection and pre-
clude adequate drainage if the septa are not fully
Fig 4. Incisions in eponychium. (Reprinted with permission from
Zook EG and Brown RE: The Perionychium. In: Green DP (ed.),
Operative Hand Surgery. 3rd ed. Churchill Livingstone, 1993. Ch.
34, p.1289)

infection (Fig 4). Accurate placement of these inci-

sions will minimize the chance of eponychial
retraction subsequently.
If the paronychia has been neglected or inad-
equately treated, purulence may extend around
the nail to its ventral surface overlying the nail matrix.
The pressure of the accumulating pus can perma-
nently damage the germinal matrix, and removal of
an appropriate section or all of the nail is indicated
to adequately drain this infection. Inadequate treat-
ment may allow the pus to spread under the nail
sulcus to the opposite side, resulting in a “run-
around” abscess.
Occasionally, paronychia may become a chronic Fig 5. Anatomy of the fingertip. (Reprinted with permission from
problem,49,50 perhaps from secondary mycobacte- Conolly WB: Surgical Anatomy. In: Conolly WB (ed), Atlas of
rial or fungal infections which are more commonly Hand Surgery. Churchill Livingstone, 1997. Ch1, p. 6.)
seen in immunosuppressed patients, diabetics, and
cancer patients. Chronic paronychia is also seen in Most felons are precipitated by some sort of
patients who have a frequent exposure to a moist penetrating trauma and x-rays should be carefully
environment. Candida albicans is the most com- evaluated for a foreign body in all felons. If a felon
monly identified organism in this infection.48 Infec- does not respond to therapy, or if there is strong
tion may also become chronic in the presence of evidence in the history that a nonradioopaque for-
vascular insufficiency, eg, Raynaud’s disease or scle- eign body is embedded in the pulp, ultrasound
roderma. These chronic infections may be treated might show a foreign body not seen on conven-
in several ways: (a) The nail fold may be marsupial- tional x-rays. S. aureus is the most common patho-
ized by excision of a crescent of tissue down to the gen in felons,55 but gram negative organisms have
germinal matrix, which is then left to close by sec- been reported. Gram negative organisms should
ondary infection.51,52 (b) Alternatively, the entire be considered in immunosuppressed patients. A
proximal nail fold, including the cuticle, can be number of cases have been reported in diabetics
excised.53 Once healed, this gives a very satisfac- who developed felons after checking their blood
tory cosmetic result, although as the dorsal roof of sugar level by fingerstick.56
the nail is ablated, the shiny surface layer of the nail If a pulp infection is seen quite early, there may
is no longer produced. (c) Complete removal of simply be a localized cellulitis or a small superficial
the nail, followed by treatment with a combined abscess. This can be treated with oral antibiotics,

SRPS Volume 9, Number 32

rest and elevation, or with local drainage as indi- Tenosynovitis

cated. In the true felon, a patient presents with the Tenosynovitis is an infection within the sheaths
entire pulp red, swollen and markedly tender. The which form the gliding surfaces around the ten-
patient usually complains of a severe throbbing dons in the hand. It is almost exclusively a disease
pain, particularly when the finger is dependent. of the flexor tendons, although extensor teno-
This is due to the increased tissue pressure caused synovitis at the level of the dorsal retinaculum has
by the unyielding septa—essentially a compartment also been described.58 While tenosynovitis is rarely
syndrome of the pulp. At this stage, adequate drain- life-threatening, delayed or inappropriate treatment
age, as well as antibiotics, are required for treat- can lead to devastating consequences. The deli-
ment.48,55 Late presentation or incomplete therapy cate gliding surfaces of the tendon sheaths can be
can result in a compromise of the blood flow to destroyed by infection, resulting in a stiff and pain-
the pulp, which can result in necrosis of the soft ful finger. Even more prolonged delay in treatment
tissues, tenosynovitis, septic arthritis, and even os- can allow the sheath to rupture, with spread of the
teomyelitis.557 infection to any of the spaces of the palm or to the
Many incisions have been recommended for adjacent bone. Prolonged infection can also lead
the drainage of felons. If it is pointing, the felon to ischemic rupture of the tendon itself.59,60
should be drained at this site. Careful palpation Most cases of tenosynovitis begin with penetrat-
with a small blunt probe can often determine a ing trauma, and in this event the most common
point of maximal tenderness and the incision infectious agent is S. aureus. Some cases are due to
should be made at this site. The pulp must be hematogenous dissemination, particularly of gono-
explored immediately volar to the phalanx but coccal infections, and this possibility should be con-
staying dorsal to the neurovascular structures. sidered if there is no history of antecedent trauma.61
The fibrous septa are ruptured to allow com- The hallmarks of flexor tenosynovitis were first
plete drainage of the infected space. Good re- established by Kanavel62 and constitute the four
sults are seen with a longitudinal midline palmar cardinal signs which bear his name. They are:
incision which does not cross the distal interpha- • fusiform swelling of the digit
langeal joint (Fig 6).48 These incisions heal well • partially flexed posture of the digit
and do not usually produce a hypersensitive scar
on the pulp.
• tenderness along the entire flexor sheath, and
• pain along the entire flexor sheath with passive
extension of the digit

In situations where there may be some uncer-

tainty as to the diagnosis, ultrasound may be of
benefit,63,64 as it can show swelling of the tendon as
well as peritendinous fluid.
The diagnosis of suppurative tenosynovitis should
be able to be made on clinical grounds alone. Once
the diagnosis of tenosynovitis has been made, treat-
ment must be instituted promptly. Very early cases
may undergo a trial of intravenous antibiotics, splint-
ing, and elevation. This mode of treatment, how-
ever, should be selected with caution. The patient
should be observed closely and if significant
improvement is not noted in 12-24 hours, treat-
ment should progress to surgical drainage.
Fig 6. Drainage of a felon. (Reprinted with permission from
When surgical drainage is deemed necessary by
Conolly WB: Infections. In: Conolly WB (ed), Atlas of Hand initial presentation or failure to improve, two meth-
Surgery. Churchill Livingstone, 1997. Ch 32, p. 258.) ods are available, as described by Neviaser.60,65 The

SRPS Volume 9, Number 32

majority of cases can be treated with a limited inci- pulley. A counter incision is then made just proxi-
sion and drainage followed by closed catheter irri- mal to the transverse wrist crease, where a drain is
gation65-67 (Fig. 7). If the patient fails to respond to placed in the bursa. This system is managed in a
this treatment, or if the sheath cannot be cleared of similar fashion to the digital system. Again, if the
purulence at the initial exploration, open drainage patient does not respond to this treatment, open
must be used. The sheath is opened widely via a drainage of the bursae is necessary.
midlateral incision, sparing the A-2 and A-4 pulleys,
and is copiously irrigated.59,60,68 The wound is closed
loosely or left open for a delayed closure. Active Deep Space Infections
range of motion exercises are begun with the first A variety of “spaces” has been described in the
dressing change on the ward.69 hand. In reality, these spaces are potential and only
become significant when infected, as they become
loculations of purulent material. They include the
thenar space, the midpalmar space, the subten-
dinous space, also known by the eponym Parona
(see above in “Tenosynovitis”), the dorsal subapo-
neurotic space, and the web spaces.71
Infection in these spaces begins most frequently
with a penetrating injury, and again the most com-
monly identified isolate is S. aureus. Initial antibiotic
therapy may be with an antistaphylococcal agent,
unless gram stain at the time of drainage suggests
another organism. As clearly described in the
preantibiotic era by Kanavel,62 the key to treatment
of these infections is precise drainage of the
abscess, guided by knowledge and respect for the
surrounding and involved structures.
The most important deep spaces of the hand
are the midpalmar space and the thenar space (Fig
Fig 7. Closed irrigation for flexor tenosynovitis. (Reprinted with
permission from Brown DM, Young VL: Hand infections. South 8). Thenar space infections are usually character-
Med J 86:64, 1993). ized by the thumb being held in an abducted posi-
tion, with pain over the adductor muscles and pain
In the event that the thumb or little finger are on extension or attempted opposition of the thumb.
involved with tenosynovitis, the infection can extend This is the only hand infection in which the thumb
proximally to involve either the ulnar or radial bur- is not adducted. Drainage of these abscesses must
sae. These two bursae communicate through the respect not only the proximity of neurovascular
space of Parona, deep to the flexor tendons in the structures, primarily the radial bundle to the index
distal forearm. A “horseshoe” abscess can form finger and the ulnar bundle to the thumb, but also
where a flexor tenosynovitis, beginning in either prevent scarring across the thumb-index web.
the thumb or little finger flexor sheath, spreads The palmar space, exclusive of the flexor ten-
proximally to the space of Parona and then passes don sheaths, allows free spread of infection along
retrogradely down either the little finger or thumb fascial planes to deeper areas in the hand. Treat-
flexor tendon sheath. Phillips et al,70 however, ment consists of incision and drainage with cath-
showed that many times the little finger flexor syn- eter irrigation for 2 to 3 days.71
ovial sheath ends at the level of the A1 pulley, so
that little finger tenosynovitis can usually be man-
aged by drainage of the finger alone. In instances Osteomyelitis
where an infection extends proximally closed cath- Osteomyelitis of the bony structures of the hand
eter drainage is indicated. The catheter is directed is a relatively infrequent infection.72 Osteomyelitis
proximally from the incision at the level of the A-1 can present as a spontaneous bone infection, usu-

SRPS Volume 9, Number 32

Septic Arthritis
Infection of the joint spaces of the hand can
cause a devastating loss of hand function, as it
threatens the cartilaginous surface of the joint.76
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 by hematog-
enous spread from a distant infection. Distant sites
of recent infection must be sought, particularly in
Fig 8. Deep spaces of the hand. (Reprinted with permission from
the patient with no history of trauma.77 In children,
Brown DM, Young VL: Hand infections. South Med J 86:62, 1993). monoarticular arthritis is often due to hemato-
genous spread from a distant infection. In addition
to Streptococcus and Staphylococcus species,
Haemophilus influenzae must be considered to be
ally by hematogenous seeding from a distant source.
a common potential pathogen and covered appro-
The most likely pathogens are Staphylococcus and priately. In the sexually-active patient, particularly
Streptococcus species as well as Haemophilus spe- those under 40 with no history of direct inocula-
cies in young children. It presents as a localized tion, a gonococcal arthritis must also be suspected.78
focus of erythema, pain, and swelling along the
Septic arthritis in the hand presents as a locally
course of one of the long bones of the hand. If the
tender, erythematous, and swollen joint. Due to
infection does not show clinical signs of improve-
the swelling and pain, the joint is held in the posi-
ment within 48 hours of commencing intravenous
tion which maximizes its volume, approximately 30
antibiotic treatment, bone biopsy should be per-
degrees of flexion in the interphalangeal joints, and
formed to obtain a specimen for culture. Any obvi- full extension in the metacarpophalangeal joints.
ously necrotic bone should be debrided at this The joint will be particularly tender with any passive
procedure. motion. Arthrocentesis of the joint can be per-
Osteomyelitis can also develop secondary to formed as a diagnostic maneuver. Treatment con-
local tissue conditions. This can be either the spread sists of elevation, parenteral antibiotics, and inci-
of another contiguous infection or direct injury to sion and drainage of the joint. Depending on the
the surrounding soft tissues and bone. The best severity of the infection, this might be followed by
test for diagnosing osteomyelitis under these cir- irrigation of the joint for 48 to 72 hours. Once the
cumstances is direct evaluation of the bone in an acute inflammation has abated, range of motion
operative setting, with a biopsy at the same proce- exercises should commence.
dure. The biopsy also provides a culture to guide
the antibiotic therapy. A superficial swabbing of the
wound is inadequate for diagnosis or culture, as BITE WOUNDS
the pathogens obtained by this technique may not
accurately reflect the microbiology of the infected Human Bite Wounds
bone.73 The initial antibiotics should be broad- Bites to the human hand account for 20% to
spectrum parenteral antibiotics until the results of 30% of all hand infections, and of these the major-
the cultures allow specification.74 ity are caused by human bites. The clenched-fist
In a review of 46 patients with osteomyelitis of injury is associated with a high incidence of compli-
the metacarpals or phalanges, Reilly et al75 noted cations, including stiff joints and even amputa-
an overall amputation rate of 39% despite aggres- tions.79,80 The injury is sustained as the clenched fist
sive surgery and intravenous antibiotic therapy. A strikes the mouth of another person, and the tooth
delay of more than 6 months from onset of symp- frequently impales the metacarpal heads. The key
toms to diagnosis and definitive treatment resulted point in understanding the potential of the underly-
in amputation in 6 of 7 patients. ing pathology is that the site of penetration of the

SRPS Volume 9, Number 32

various layers is relative to the position of the fist at The clenched-fist wound to the metacarpo-
the moment of impact.81-83 (Fig 9) The hand must phalangeal joint is a notoriously underestimated
be assessed in the clenched-fist position to allow and undertreated injury. All of these patients should
an accurate assessment of the depth of injury. be managed with splinting, elevation, antibiotics,
and surgical exploration.85,86 In grossly septic joints,
irrigation can be continued postoperatively for 48-
72 hours. Early motion (48-72 hours) should be
advocated,69 as stiffness is one of the more difficult
complications to treat.
Several studies have demonstrated that uncom-
plicated bite wounds (not involving the joint cap-
sule or articular surface), when seen early (<12
hours), may be adequately managed on an
outpatient basis.82,86 Treatment involves wound
exploration, vigorous irrigation, debridement, and
supplementation with oral antibiotics. It should only
be implemented in a reliable patient.
The mechanical effects of wound irrigation and
debridement will resolve the infection in almost
half of the cases seen. The addition of appropriate
intravenous or oral antibiotics is necessary to ensure
eradication of the causative organism. As the
majority of infections will be caused by staphylo-
Fig 9. (A) The tooth pierces the clenched fist penetrating skin, cocci, streptococci, or Eikenella corrodens, a rea-
tendon, joint capsule and the metacarpal head. (B) When the
finger is extended, the four puncture wounds do not corre- sonable first line therapy would be penicillin plus
spond. (Reprinted with permission from Lister G (ed), The Hand. dicloxacillin (penicillinase-resistant).35 Cephalexin or
Diagnosis and Indications. Churchill Livingstone. 3rd ed. 1993. erythromycin can be used in patients with a penicil-
Chapter 4, p. 332). lin allergy.

The patient presenting early with a laceration or

puncture will have minimal swelling or inflamma- Animal Bite Wounds
tion. An x-ray may show a fracture of the metacar- Domestic dogs are responsible for 90% of all
pal head, air within the joint, or occasionally a for- animal bites. More than half these dog attacks
eign body such as a broken tooth. In the late pre- involve young children, and of the resulting
sentation the patient has a red, swollen, painful wounds about half are to the hands and forearms.
hand, and may have associated lymphangitis and Dog bites become infected less often than human
regional lymphadenitis. Patients will be constitution- or cat bites. A dog’s jaws can exert a force of 150
ally unwell, with a fever and elevated white cell to 450 psi, which is sufficient to devitalize tissues.
count. These patients are in serious danger of The resulting wound can be a puncture, lacera-
osteomyelitis, septic arthritis, and a severely dam- tion, avulsion, crush, or combination of the afore-
aged joint.79 X-ray examination in these patients, mentioned.87,88 Like the human bite, the most com-
apart from looking for a chip fracture or foreign mon pathogens isolated will be a mixture of
body, will be directed at early signs of osteomyeli- aerobes (esp. S. aureus and Strep. viridans), anaer-
tis or abscess formation within the bone.84 obes (various Bacteroides species), and also Pas-
Cultures yield S. aureus and Strep. viridans in the teurella multocida.29-32 Pasteurella infection should
majority of cases.29,33 The other organisms com- be suspected if there is an acute onset of cellulitis,
monly encountered are anaerobic Bacteroides spe- lymphangitis and a serosanguinous or purulent
cies (found in 50% if specifically sought on culture) discharge from a hand wound within 24 hours of
and Eikenella corrodens.27-29 Eikenella corrodens a dog or cat bite. Fortunately, Pasteurella multocida
is sensitive to penicillin. is sensitive to penicillin.

SRPS Volume 9, Number 32

Unlike human bite wounds which should not be Infections with M. marinum follow a break in the
closed primarily, most dog bite wounds89,90 should integrity of the skin, often from an insignificant abra-
be thoroughly irrigated with normal saline, have sion on the dorsum of the hand or over the inter-
the margins sharply excised (especially over joints, phalangeal or metacarpophalangeal joints of the
tendons, vessels, and nerves), and have the edges fingers. Infection of the hand progresses through a
loosely approximated with sutures. Most of the spectrum of indolent skin ulcers through subcuta-
organisms commonly encountered in dog saliva neous granulomas with sinus tracts, tenosynovitis
are sensitive to penicillin, so a 5 day oral course (flexor and extensor), and septic arthritis or osteo-
should also be prescribed.36 The tetanus status of myelitis.109,110
the patient and the rabies status of the animal should Treatment of superficial disease may be success-
be verified and treated as appropriate. ful with chemotherapy alone, both minocycline and
Domestic cat bites account for only 5% of ani- co-trimoxazole having been shown to be effec-
mal bite wounds to the hand. The configuration of tive.111,112 The largest study to date from Hong Kong
the teeth of a cat is different from a dog’s. Cat’s suggests that chemotherapy alone may also be
teeth are long and sharp, and the injury subse- applicable to more extensive disease.111 Generally
quently inflicted tends to be a deep puncture with deeper disease treatment will also require sur-
wound.91 There is significantly less devitalization of gery with radical synovectomy and more specific
tissues, so wound debridement needs to be com- antimycobacterial therapy with rifampicin and
mensurably less. The wound should be irrigated ethambutol for up to 2 years.
and loosely approximated if sufficiently large to The early clinical diagnosis of mycobacterial
warrant suturing.92 An oral course of penicillin infections will only be made with a high index of
should be prescribed to cover Pasteurella. suspicion. When mycobacterial infection is sus-
Cat bites may also give rise to cat-scratch fever, pected, cultures should be performed both at 31°
an infection caused by an intracellular gram nega- and 37°C, or else M. marinum infections may be
tive rod. The primary lesion is a small pustule or missed. Positive cultures for mycobacterial strains
furuncle with surrounding edema at the site of a will take at least 6 weeks for identification, there-
cat scratch or bite. A similar lesion is seen at the fore treatment may be instituted on the basis of
regional lymph nodes. The course of the disease is granulomas seen on histology or acid-fast bacilli
benign and self-limiting, and treatment is symptom- seen on a smear.
atic. The incubation period is 1 to 2 weeks, and
symptoms last 1 to 3 weeks, although lymphaden-
opathy lasts 6 weeks and occasionally years. VIRAL INFECTIONS

Herpes Simplex Virus

ATYPICAL MYCOBACTERIAL INFECTIONS Herpes simplex virus infection of the hand may
The incidence of tuberculosis of the hand has be caused by a primary or recurrent infection
diminished at a rate commensurate with the decline with either HSV-1 or HSV-2. It tends to occur in
in pulmonary tuberculosis.93-95 In its place, however, three distinct patient subgroups. The first and
are infections caused by atypical mycobacteria, which largest group is adolescents with genital herpes,
increase yearly.96-98 The three major atypical myco- who tend to be infected with HSV-2. The remain-
bacteria involved in hand infection are M. marinum,99- ing groups tend to be infected with HSV-1. The
M. kansasii,103-105 and M. terrae.106-108 second group involves children with oral gingi-
M. marinum is the most common mycobacterial vostomatitis,113,114 while the third group is adult
species to infect the hand. It lives in warm water health care professionals who deal directly with
environments and has been cultured from con- potentially infected oral and respiratory secre-
taminated swimming pools, fish tanks, piers, boats, tions—ie, dentists, anesthesiologists, surgeons, and
and stagnant water. It is endogenous to fresh and nurses. 115
saltwater marine life. M. marinum survives best at Herpetic infection of the hand typically involves
31°C, and for this reason, produces infections on the fingers or thumb in the vast majority of
the extremities, rather than deep body cavities.96-101 cases.116 The infection initially declares itself with

SRPS Volume 9, Number 32

a prodromal phase of approximately 72 hours’ mycobacterial species is suspected, triple-agent

duration, with severe pain or tingling in the therapy (rifampicin, ethambutol, isoniazid) will be
affected digit, followed by erythema and swell- instituted.
ing. Over the ensuing hours to days vesicles
appear and coalesce, often around the epony-
Diabetes Mellitus
chium and lateral nail fold. It is at this stage that
the viral infection is most likely to be mistaken Candida albicans infections of the nails are com-
for a bacterial felon or paronychia. However, the mon in diabetics, so much so that a random blood
pulp is usually not tense as it would be in a bacte- glucose should be done as a baseline in any pa-
rial felon. There may be associated lymphangitis. tient presenting in this way. The same has been
This whole process takes about 2 weeks and suggested by some groups for a first presentation
then resolves again in another 7 to 10 days. with flexor tenosynovitis.121 Infections can com-
Reactivation of latent virus occurs in only about mence from relatively simple injuries (eg, felons
20% of hand patients.117 It is not normally as and suppurative flexor tenosynovitis following
severe as the primary infection and lasts for about finger-stick blood test for glucose levels).56,122 Mi-
7 to 10 days. crobiology often shows a mixed flora, and S. aureus,
It is possible to confirm the diagnosis by labora- so commonly encountered in “normal” patients
tory investigations, including viral cultures. The with suppurative hand infections, is often grossly
Tzanck smear is relatively inexpensive and rapid.118 outweighed by gram negative organisms.123 Dia-
Although not quite as sensitive as viral cultures, it is betics often present with advanced disease (bone,
still a useful adjunct in diagnosis, especially if per- tendon, or deep space infection), which may also
formed early in the course of the disease, during reflect a peripheral neuropathy as a causative fac-
the vesicular or pustular stages. tor.124-126 Finally, many will go onto amputation,
The treatment of herpetic infections of the hand either to control infection or because the function
is primarily nonsurgical. Rest, elevation and anti- in the remaining part is so poor as to be a hin-
inflammatory analgesia are the mainstays of treat- drance or danger to the patient.
ment. In immunocompromised patients, aggressive Treatment of hand infections in diabetics must
therapy with intravenous acyclovir may be war- be early and aggressive if useful function is to be
ranted in an attempt to prevent a life-threatening maintained and amputation avoided.123-126 Obvious
viremia.119,120 abscesses must be drained and appropriate speci-
mens taken for aerobic and anaerobic cultures. X-
rays should be performed and supplemented by
INFECTIONS IN IMMUNOCOMPROMISED bone scans, if indicated. Broad-spectrum intrave-
PATIENTS nous antibiotic cover should be instituted and
Immunocompromised patients can develop appropriately modified after cultures are returned.
hand infections from opportunistic organisms. Likewise, rehabilitation should be aggressive and
The management of these patients is identical instituted as soon as the acute manifestations of
irrespective of the underlying etiology. Many of the infection are on the wane.
the fungi, viruses, and mycobacteria will only be
cultured under very exacting laboratory condi-
tions. Diagnosis will almost certainly necessitate TUMORS
formal surgical tissue biopsy. Treatment will be
dictated by the organism cultured, but as many Several authors offer excellent reviews of the
of these unusual organisms can take several spectrum of hand neoplasms including their inci-
weeks to grow, therapy must be instituted “on dence, etiology, anatomic distribution, and man-
spec”. If a fungal etiology is most likely, intrave- agement, which almost always involves surgical
nous amphotericin B will be the first line treat- removal.127-133 Only the more common hand tumors
ment. Similarly, for a viral etiology, of which her- will be discussed here. The overwhelming majority
pes simplex is the most likely, intravenous of hand masses are benign, and true neoplasms
acyclovir will be administered. Finally, if a are rare in the hand (Table 2).

SRPS Volume 9, Number 32

Table 2 II. Volar wrist ganglion. The volar wrist location

Grading of bone and soft tissue tumors of the hand is the most frequent site of ganglia in children
under 10,145,146 but much less so in adults (15%-
20% of cases). The ganglion arises from the FCR
tendon sheath, the radioscaphoid, scapholunate
or STT joints. Ultrasonography can delineate the
origin pre-operatively. The ganglion is in close
proximity to the radial artery, which may cause it
to be bilocular.

III. Flexor tendon sheath ganglion. These ganglia

arise from the volar flexor tendon sheaths in the
vicinity of the MP joint. They often present through
the A1 or A2 pulleys or in the interval between
(Reprinted with permission from Mankin HJ: Principles of them. These ganglia are believed to be a direct
diagnosis and management of tumors of the hand. Hand Clin
result of pressure damage to the fibrous sheath
3:187, 1987).
and require excision only if symptomatic, taking a
small cuff of pulley as required.147

SOFT TISSUE TUMORS IV. Mucous cysts. Ganglia arising in association

with tendons and joints on the dorsal aspect of fin-
Ganglia gers may originate from the extensor tendon itself
Ganglia are the most common benign tumors in or, more commonly, from the joint capsule.148-150
the hand. 134-136 Although trauma is commonly They occur primarily in older women who have
thought to be implicated in the development of osteoarthritic changes of the underlying joint, usu-
ganglia, a traumatic antecedent has been docu- ally the DIP joint. Where an underlying arthritic
mented in only a small percentage of patients. The joint is the cause of the ganglion, the joint must be
pathogenesis is thought to be mucoid degenera- debrided or the ganglion will recur.
tion of fibrous connective tissue in joint capsules Mucous cysts can produce a deformity of the
or tendon sheaths occurring idiopathically or sec- nail plate from pressure on the nail bed. Brown
ondary to injury or irritation. Ganglia are 2-3X more and coworkers151 report their experience with 26
common in women than in men. The usual clinical nail deformities secondary to mucous cysts of the
presentation is that of a mass with or without pain. distal interphalangeal joint managed by excision
of the cyst and debridement of associated
Occasionally occult ganglia may present as
osteophytes. No recurrences were seen at fol-
paresthesias or weakness from nerve compres-
low-up, and residual nail deformity in 8 patients
sion.137-140 Occasionally ganglia may even arise
was negligible.
within tendon141 or bone.142
Ganglia in the wrist and hand are of five main
types: Pathologic Anatomy
Ganglions typically have a uni- or multilocular
I. Dorsal wrist ganglion. The dorsum of the wrist main cyst that communicates with smaller intra-
accounts for 70% of all ganglia in the hand and articular cysts through a tortuous, continuous,
wrist. In this location the ganglion usually overlies one-way valvular system of ducts.133 Microscopic
the scapholunate ligament. Clay and Clement143 examination of the ganglion wall typically reveals
noted the pedicle of the ganglion to arise from this compressed collagen fibers with no evidence of
site in 76% of patients. The etiology of dorsal wrist cells of epithelial or synovial origin.152,153 The cyst
ganglia is still uncertain, but there is some evidence contains viscous mucoid material consisting of
for an underlying periscaphoid ligamentous insta- glucosamine, albumin, globulin, and hyaluronic
bility.144 acid.

SRPS Volume 9, Number 32

Management The treatment of wrist ganglia is indicated only

Rosson and Walker reviewed the natural his-
146 in the event of significant discomfort or deformity.
tory of ganglions in children and note that 22 of 29 While surgery is the mainstay of treatment, various
nonoperative techniques have been advocated.
lesions resolved spontaneously. A conservative
Aspiration158,159 or injection of enzymes,160 scleros-
approach to ganglions is therefore advocated in
ing agents, or cortisone have been suggested, but
young patients.145,146 The management of wrist gan-
all have a significant recurrence rate. Arthroscopic
glions in adults is controversial. The literature sup-
resection of the ganglion may be associated with a
ports a spontaneous regression rate of 38%-58%,154
lower recurrence rate.161-163 It can also identify the
while treatment of all types is associated with recur-
exact origin of the ganglion as well as other intra-
rence rates from <1%136 to up to 50%155 (average
articular pathology.
24%). Incomplete excision of the cyst stalk com-
plex probably accounts for the high recurrence
rate.156 Prevention of recurrence depends on iden- Giant-Cell Tumor of Tendon Sheath
tification and excision of the involved segment of Giant-cell tumors are the second most frequent
joint capsule and deep attachments of the cyst hand tumor. They typically occur in the fingers of
pedicle to the scapholunate ligament, but only mini- 20- to 40-year-olds and are slightly more common
mal resection of the ligament itself to prevent future in women. Giant-cell tumors of tendon sheath are
scapholunate dissociation (Fig 10). Clay and Clem- also known as pigmented villonodular synovitis
ent143 noted only 3.2% recurrence with this proto- when they arise from the volar joint recess.164,165
col. More radical procedures pose a greater risk of There is no evidence that repeated hemorrhage,
subsequent stiffness, hypertrophic scar, wound friction, or cholesterol imbalance contributes sig-
infection, and nerve damage. nificantly to the development of these lesions, and
only about one-third of patients give a history of
previous trauma or surgery to the region. Pain and
tenderness are not prominent features, but pro-
longed unchecked tumor growth in time interferes
with mechanical function of the hand.
Clinical presentation is that of a lobulated, mottled,
yellow subcutaneous mass. Although the diagno-
sis is usually evident clinically, MRI has been
described as an adjunct in the preoperative assess-
ment of extensive tumors.166 Microscopically the
characteristic lobulation is seen, and a relatively
noncellular, collagenous connective tissue often
divides and partially envelops the lesion.167 Histo-
logical examination reveals the basic polyhedral
Fig 10. A representation of a ganglion with its pedicle attached cells of a fibrous xanthoma. In the more cellular
to the scapholunate ligament. (Reprinted with permission from areas mitotic figures are seen, but never in large
Minotti P, Taras JS: Ganglion cysts of the wrist. J Am Soc Surg Hand numbers. Also present are spindle cells, multinucle-
2(2):104, 2002.) ated giant cells, foam cells, and reticulin.167,168 The
tumor may erode bone by pressure169 and/or infil-
Herbert157 believes that symptomatic dorsal wrist trate the overlying dermis.170 Frank bony invasion
ganglia are the result of scaphoid instability which, has been documented.171
if present on clinical examination preoperatively, is Treatment is complete local excision, ensuring
treated by a dorsal capsulorrhaphy of the wrist com- total clearance of the volar joint recess. Recurrences
bined with ganglion excision. Of 7 patients oper- are unfortunately common, especially in the fin-
ated on for recurrent ganglia in whom a capsulor- gers, and are the result of inadequate resection for
rhaphy was performed, none had recurrence of which repeat excision is recommended.172 Exten-
ganglia at 12 months. sive recurrences often necessitate arthrodesis of

SRPS Volume 9, Number 32

the affected joint, as resection of violated ligaments may also be considered in cases with emboliza-
and joint capsule may be required. Very occasion- tion.201
ally amputation is needed. Despite infiltrative growth
patterns, rapid recurrence, and a frequently confus-
ing histological appearance, giant-cell tumors are Peripheral Nerve Tumors
considered benign.173 True neural cell tumors are rare in the hand (1%-
5% incidence)205. All lesions arise from Schwann
Vascular Lesions cells. 206-208 While no uniform classification of
Several authors offer excellent reviews of vascu- peripheral nerve tumors exists, most clinicians refer
lar tumors of the hand and upper extremity.174-178 to five general types:
Upton and Coombs discuss pediatric vascular
tumors.179 Neurilemmomas are the most common soli-
tary tumors of neural cell origin in the hand and are
particularly prevalent in the middle-aged.209,210 Neu-
Glomus Tumor rilemmomas begin as asymptomatic nodular swell-
Glomus tumors are benign hamartomas of the ings without associated sensory or motor abnor-
normal glomus apparatus, which consists of arte- malities. When exposed surgically, they are seen
riovenous anastomoses involved in the regulation to have a dumbbell shape and to lie extrinsic to the
of cutaneous circulation.180-183 Glomus tumors are nerve fiber proper. Histologically they are made up
usually less than 1 cm in diameter (often measuring almost exclusively of Schwann cells. Excision
only a few millimeters), and classically present with involves enucleation under magnification so as to
the triad of pain, pinpoint tenderness, and cold sen- preserve nerve fibers that fan out over the tumor.
sitivity. Transillumination is a simple and useful clini- Recurrences are rare and malignant degeneration
cal test.184 The most common site of presentation is not a clinical feature.
is subungual, but occasionally they may occur on Unlike neurilemmomas, neurofibromas can
the volar surface of a digit. Approximately one- intimately proliferate within nerve fibers, producing
quarter of all glomus tumors are multiple.185,186 functional abnormalities and making excision more
Ultrasound187-189 and MRI190-192 are used as aids in difficult without division of the nerve. Histologically
diagnosis and also to detect multiple tumors. they are difficult to differentiate from neurilemmo-
Treatment is by excision; if subungual, care mas, although they exhibit mast cells, lymphocytes,
should be taken to repair the nail bed after removal mucoid material, and xanthoma cells in addition to
of the tumor. The major problems after surgical Schwann cells.210 Solitary lesions are usually seen
treatment are a high recurrence rate and a residual before age 10. Neurofibromas can cause gigan-
nail deformity.193-195 tism of the affected part.211,212
Neurofibromatosis (von Recklinghausen’s dis-
ease) is an autosomal dominant condition charac-
Ulnar Artery Aneurysm
terized by multiple peripheral and central neurofi-
Ulnar artery aneurysms are almost always post- bromata (acoustic neuromas, meningiomas, optic
traumatic (“hypothenar hammer syndrome”196,197), gliomas). Temporal lobe involvement may erode
and occur predominantly in males.198,199 Typical clini- the greater wing of the sphenoid, producing pulsa-
cal features are a pulsatile mass accompanied by tile exophthalmos.212 Extremity involvement may
digital ischemic changes with or without distal produce gigantism of the limb.213 Diagnostic café
emboli.200,201 An ulnar nerve Tinel’s sign is often au lait spots, numbering more than six, occur on
present.202 An Allen’s test should be performed to the skin. The individual tumors manifest a plexiform
ascertain patency of the ulnar artery, and arterio- pattern. Sarcomatous degeneration has been
graphy will rule out thrombosis of the ulnar artery reported in 2%-3% of lesions.214
and embolic showering. Management consists of Neurofibrosarcomas (neurosarcomas or malig-
aneurysm resection and ligation of the ulnar artery, nant schwannomas) account for 2%-3% of malig-
with autogenous vein grafting in cases of inadequate nant hand tumors and are usually associated with
collateral circulation.203,204 Regional thrombolysis von Recklinghausen’s disease.215 Local extension

SRPS Volume 9, Number 32

and metastases are common, resulting in 90% mor- mended. SCC of the hand is an aggressive tumor
tality. Wide excision or amputation of the extremity prone to recurrence and metastasis. The metastatic
is the recommended treatment. rate for SCC of the hand is higher than elsewhere
Intraneural tumors of nonneural origin may on the body, particularly if the primary lesion
include lipofibromatous hamartomas, hemangio- involves the digital web space.222
mas, ganglion cysts, and lipomas.216 Lipofibromatous
hamartomas are commonly seen within the first Basal cell carcinoma (BCC) is a very uncom-
decade of life and usually involve the median nerve. mon tumor on the finger.232 Palmar variants are
They may result in macrodactyly, especially of the seen,233 especially in Gorlin’s syndrome (multiple
index and middle fingers.217 Treatment involves nevoid basal call carcinoma syndrome),234 and it has
release of the carpal tunnel after excision of the also been reported subungually235, where differen-
tumor under magnification. Malignant degenera- tiation from a subungual melanoma must be made.236
tion has not been reported. Although BCC do not metastasize, they are locally
aggressive. Excision is the usual form of treatment.
Epidermal Inclusion Cyst Melanoma of the hand can occur on the
Epidermal inclusion cysts commonly occur on palm237-246 or subungually.247-250 A recent study by
the palmar surface of the hand or digits of patients Ridgeway et al showed that the acral histological
whose work or leisure activities predispose them subtype does not affect the disease-free and over-
to penetrating hand injuries. The time from the all survival.246 Tumor thickness remains the only
traumatic incident to cyst development varies from prognostic indicator. Slingluff et al found that acral
months to years. Clinically the lesions are firm, melanoma has a strong racial predilection, carries a
spherical, and nontender. The cyst wall consists of grave prognosis, and arises from glabrous skin.243
squamous epithelium with laminated keratin and In their study there was no survival difference
the cyst material contains protein, cholesterol, fat, between volar and subungual sites. Amputation did
and fatty acids. not make a difference either. Melanoma requires
Spontaneous rupture is common, but the lesion wide excision or amputation of the digit or hand,
often persists unless the cyst lining, contents, and depending on location and depth.251-253 The appro-
overlying puckered skin are surgically removed. priate level of amputation has not been determined.
Local complications include infections and bone Papachristou247 advocates amputation through the
erosion. carpometacarpal joint, whereas Finley et al249 per-
formed 7 finger amputations distal to the metacar-
pophalangeal joint (4 just proximal to the DIP joint
Malignant Skin Tumors
and 3 just proximal to the PIP joint) with no local
Malignant tumors of the skin of the hand make recurrences. Quinn et al250 have shown no differ-
up a very small percentage of upper extremity neo- ence in local recurrence for subungual melanomas
plasms218-220 and are primarily squamous cell car- whether amputations are performed proximal or
cinomas (SCC).221-224 Squamous cell carcinomas distal to the IP joint of the thumb or the middle of
predominate among people with fair skin and light the middle phalanx in the fingers. Likewise there
hair colour. The usual origin of SCC is ionizing has been no prospective study to date to show a
solar radiation. Other less common causes of SCC survival or local control benefit for prophylactic
are previous irradiation,225 burn scars, exposure to lymph node dissection, regional perfusion, or
arsenic compounds, and inherited genetic disor- immunotherapy.254-256
ders.226 The dorsum of the hand, with the highest
actinic exposure, is the most common site for SCC,
although the tumor has also been reported on the BONY TUMORS
palms227 and subungually.228-231 Appropriate treat- Several authors offer excellent reviews of bony
ment consists of wide excision unless there is evi- tumors of the hand.257-259 Treatment is based on
dence of nodal metastasis or local recurrence, in accurate diagnosis and staging of the lesions
which case axillary lymphadenectomy is recom- (Table 3).

SRPS Volume 9, Number 32

Enneking’s Staging System for Bone and Soft-tissue Tumors and Their Indicated Excision

(Reprinted with permission from Mankin HJ: Principles of diagnosis and management of tumors of the hand. Hand Clin 3:185, 1987.)

Chondroma tumors distort, expand, and sometimes erode the

Chrondromas are the most common benign car- bony cortex, particularly in the diaphyses and meta-
tilaginous tumors of the hand.260,261 Chondromas physes; calcifications are seen in the translucent
that remain within the substance of the bone or areas on x-ray. Because 20% of multiple enchon-
cartilage are called enchondromas.262-264 Enchon- dromas go on to become chondrosarcomas, wide
dromas favor the tubular bones of the hand, espe- excision is the treatment of choice, with adjuvant
cially the middle and proximal phalanges. Congeni- radiotherapy to the malignant lesions.
tal cartilaginous rests are implicated in their origin, Osteochondromas are the most common car-
and the lesions are totally benign, with little ten- tilaginous neoplasm in the body overall , but are
dency toward malignant degeneration. Nelson et less common than enchondromas in the
al265 reviewed the literature and found only three hand.271,272 The lesions occur primarily in young
well-documented cases of chondrosarcoma aris- patients. Like enchondromas, osteochondromas
ing from enchondromas. arise from congenital cartilaginous foci, which
Enchondromas usually appear as well-demar- qualify them as manifestations of a congenital
cated, round or oval swellings. A pathologic frac- dysplasia. There is a very slight risk (1%) of ma-
ture is often the first indication of their presence. In lignant transformation. Radiographically osteo-
this instance the fracture should be allowed to heal chondromas appear as bony protuberances
before the enchondroma is treated. Radiographi- extending beyond the metaphyseal cortex of the
cally enchondromas appear as radiolucent, sym- involved bone on a narrow stalk.
metric, fusiform, expansile diametaphyseal lesions
that do not involve the epiphyses. Treatment usu-
ally consists of curettage of the tumor through a
window in the cortex, with or without cancellous Exostoses usually require no treatment.
bone grafting.266,267 Hasselgren et al268 question the Subungual lesions typically have a traumatic
need for bone grafting and report excellent bone antecedent, and are characterized by pain on
healing with curettage alone. They believe that pressure to the nail plate months after the
bone grafting should be reserved for the rare cir- injury.273,274 X-ray readily differentiates this lesion
cumstance in which “the tumor has so severely from other entities. If required, the deformed
damaged the bone stock that the bone is likely to nail can be removed and the mass excised from
collapse during surgery”.268 the distal phalanx.
Multiple enchondromas are rare in the hand
and always occur as part of a disseminated involve-
Bone Cysts
ment (Ollier’s dyschondroplasia). 269 Multiple
enchondromas associated with hemangiomas are Aneurysmal bone cysts tend to show an equal
part of Maffucci’s syndrome. The earliest clinical sex distribution and are more common in the sec-
manifestations of multiple enchondromatosis are ond decade of life, but still before closure of the
swelling and deformity of several bones.270 The epiphyseal plate. Aneurysmal bone cysts are

SRPS Volume 9, Number 32

eccentrically placed in the metaphysis or diaphysis, and 50, and is virtually unknown in the under-20
are expansile and lucent, and resemble a periosteal age group. Women outnumber men slightly.
blowout.275,276 Surgical resection or curettage with Clinically this is a solitary lesion, often well
bone grafting is usually curative unless the cyst has advanced by the time it is noticed. A dull, constant
been incompletely excised. pain heralds its presence, sometimes preceded by
swelling.282,283 Radiographically, it is seen to involve
the soft tissues. The epiphyseal end of the bone is
Osteoid Osteoma
affected, with extension to the adjacent metaphy-
Osteoid osteoma is a benign osteoblastic tumor sis. The tumor is translucent and the cortex of the
that is uncommon in the hand.277 The lesion affects bone is noticeably thin. The clinical course is long
male patients 2-3X times more often than females, but localized. Sarcomatous degeneration averages
and generally between the ages of 10 and 25 years. 10%, and the lesion metastasizes in approximately
Osteoid osteoma is most frequent in the distal pha- 15% of cases.284-287
langes.278,279 The etiology is unknown. Treatment consists of wide resection with
The nidus of an osteoid osteoma consists of autograft or allograft replacement.288-290 The recur-
richly vascularized osteoblastic osteoid tissue rarely rence rate is high (75%). Amputation is reserved
larger than 1 cm. Clinical presentation is that of a for recurrent or highly malignant tumors.
localized, painful area over a tubular bone. Typi-
cally the pain is worse at night, and is completely
relieved by aspirin. There may be an increase in SARCOMAS
size of the terminal digit. Radiographically, the lesion Sarcomas are very uncommon tumors in the
shows a central area of lucency that may be sur- hand. The pathological subtypes of soft-tissue
rounded by a zone of sclerotic bone. Bone scintig- sarcomas 291-293 and malignant primary bone
raphy with 99mTc is of benefit in locating the nidus tumors294,295 are reviewed by several authors. Cur-
and CT280 has also been used. Treatment involves rent treatment protocols for both bony and soft
complete excision of the lesion and packing of the tissue extremity sarcomas are also reviewed.296-304
cavity with cancellous bone. Combination therapy (wide excision, radiotherapy,
and chemotherapy) is now used for most high-
grade tumors, and produces excellent local con-
trol rates in some tumor types. Amputation is
Like osteoid osteoma, osteoblastomas are rare avoided and is saved for the management of local
in the hand, favor the tubular bones, and occur recurrences. When these sarcomas fail, they tend
primarily in young patients. Unlike osteoid osteo- to do so at distant sites. In this circumstance, a
mas, osteoblastomas exhibit no sex predilection functional hand provides a better quality of life.
and are usually larger than 1.5 to 2 cm. Because of
the bone destruction accompanying osteo-
blastomas, the differential diagnosis includes osteoid Skeletal sarcomas
osteoma, aneurysmal bone cyst, and malignant Ewing’s sarcoma accounts for approximately 6%
tumors. The entire bone must be removed for cure. to 10% of primary malignant tumors of bone and is
Radiotherapy is helpful in tumor cell control and rare in the hand.305-307 It affects males twice as often
may even aid in healing. as females and of a younger age group than any
other bone tumor. A focal mass is a frequent clini-
cal finding, and radiographically the lesion shows
Giant-Cell Tumor of Bone
permeation, soft-tissue mass, and often a sclerotic
Giant-cell tumors are uncommon anywhere. reaction.308 Angiography, CT and MRI are often
They represent about 5% or less of all primary used in treatment planning.309
malignant bone tumors, and only 2% to 5% of Ewing’s sarcoma generally has a poor progno-
giant cell tumors occur in the hand.281 The lesion sis, although the subset of patients with Ewing’s
affects patients primarily between the ages of 30 sarcoma of the hand can expect excellent local

SRPS Volume 9, Number 32

control and good function with combination Soft Tissue Sarcomas

therapy.298,304 Rosenberg and Schiller292 offer an excellent review
of soft tissue sarcomas of the hand. Soft tissue sar-
Osteosarcoma is a rare tumor in the hand, comas are an uncommon but important group of
accounting for only 0.18% of all osteosarcomas.310 hand tumors. They tend to occur in young patients,
Peak incidence is during the second decade of life, are innocuous in presentation, often leading to an
with a male-to-female ratio of 2:1. The presenting incorrect diagnosis, and have protracted clinical
complaint is persistent, increasing pain from a rap- courses. They are prone to local recurrence, have
idly growing mass. 311,312 The pathogenesis is an unusually high incidence of lymphatic spread and
unknown. The lesions may arise de novo or may regional node metastases, and often metastasize
be secondary to a benign process. Osteosarco- systemically late in their course. Deep tumors that
mas in general tend to occur more frequently in are firm and 5 cm or larger should be considered to
irradiated bone, Paget’s disease, fibrous dysplasia be possible sarcomas until proven otherwise.303 CT
of bone, giant cell tumor, solitary enchondroma, and MRI are often used to define the anatomy. Stan-
multiple enchondromatosis, and multiple osteo- dard treatment is wide surgical excision with or with-
chondromas. out adjunctive radiotherapy and/or chemotherapy.
Radiographically the borders of an osteosarcoma The prognosis is generally poor.
are indistinct, but the lesion invariably involves the
cortex and generally transgresses it. Often there is Epithelioid sarcoma is the most common soft
a large, contiguous soft tissue mass. A combination tissue sarcoma of the hand.319 A post-traumatic eti-
of destructive and proliferative new bone is usually ology has been proposed by some.320 Lesions are
present, showing a streaked texture and a charac- notoriously insidious, and often mistaken for a
teristic sunburst pattern. Histologically osteosar- benign inflammatory condition.321 Most lesions in
coma has a typical spindle-shaped cell pattern. Treat- the hand arise on the palm or volar surface of the
ment has changed from amputation to excision digits.322,323 Local recurrence is common, as is dis-
with a wide margin plus adjuvant therapy. In Okada’s tant metastasis. Treatment recommendations are
study311 local control was achieved in 5 of 6 patients radical excision (often necessitating a partial ampu-
using this protocol; 1 patient died from metastatic tation303) and node dissection.324 Adjuvant therapy
disease. may be of benefit.

Chondrosarcomas are uncommon in the hand, Malignant fibrous histiocytoma is one of the
where they are occasionally associated with more common soft tissue sarcomas in the adult
osteochondromas and, to a lesser degree, with upper extremity.303 Lesions may be superficial or
multiple enchondromatosis,313,314 although in the deep, single or multinodular. They extend along
vast majority of cases, there is no pre-existing tissue planes and metastasize via the lymphatics
lesion.315,316 Chondrosarcomas characteristically and bloodstream.325 Treatment is primarily surgical,
occur in older patients (60-80 years) in the epi- with radiotherapy added unless there has been a
physeal area of the proximal phalanx or metacar- generous margin. The value of chemotherapy has
pal. The clinical course is slow and metastasis is yet to be defined.
late.317,318 The tumors present as a progressively
painful large mass near the metacarpophalangeal Alveolar rhabdomyosarcoma tends to involve
joint. Treatment of choice is amputation or ray the thenar and hypothenar musculature.326,327 It is a
resection. Histological interpretation of cartilagi- highly malignant, devastating tumor that presents
nous lesions of the hand is difficult, and clinical as a rapidly-growing, deep mass in the palm of
and radiological appearance (bone expansion, children.303 Local recurrence is common, and it is
lytic areas of bone destruction, soft tissue swell- invariably fatal if not treated adequately. There is a
ing) are often more reliable indicators of malig- high incidence of nodal spread and distant
nancy. Prognosis is good if metastasis has not metastases. The prognosis for this disease has
occurred. 315,316 improved with multimodality therapy, but is still poor.

SRPS Volume 9, Number 32

Synovial sarcoma arises in the juxta-articular have a fatal outcome within 6 to 12 months of
soft tissues (tendon, tendon sheath, and bursa).328 It diagnosis, whereas slower-growing tumors are com-
presents as a slow-growing tumor on the volar patible with 20-year survival.
surface of the hand, and delay to presentation is
often measured in years. This tumor has a poor Metastatic Tumors
prognosis and a high incidence of metastases. Treat- Hand metastases are very uncommon and are
ment is usually surgery (often involving a partial usually associated with a primary carcinoma in the
amputation303), radiotherapy, and chemotherapy. lung336-338 or kidney. Despite their rarity, metastatic
tumors should be considered in the differential
Fibrosarcoma arises within the deep subcutane- diagnosis of inflammatory processes of the hand.
ous space, fascial septa, or muscle and presents as The distal phalanges are most often involved and
an insidiously growing deep mass.329,330 Lymph metastases in this location are often mistaken for a
node metastases are less common in this disease, felon or paronychia.339-341.
but hematogenous spread occurs frequently. Treat- Amadio and Lombardi342 recommend palliative
ment is wide excision or amputation when neu- treatment given the median survival of only 5
rovascular structures are compromised.331 Adjuvant months. Amputation of a phalanx, digit, or ray is
therapy may be of benefit. recommended for most solitary phalangeal or
metacarpal lesions when survival is expected to
Clear cell sarcoma (malignant melanoma of soft exceed a few months.338
parts) is an uncommon tumor. It presents as a slow-
growing, deep-seated mass attached to tendons,
aponeuroses, or fascia.332,333 Prognosis is poor, with
a very high rate of local recurrence and both lym-
phatic and hematogenous dissemination. Surgery
with node dissection is usually combined with FINGERTIPS
radiotherapy and chemotherapy.
The treatment objectives in fingertip amputations
are to:
Kaposi’s sarcoma is a malignant tumor that often
involves bone and may originate there. The hand • close the wound
and foot are the most common locations and where • maximize sensory return
it is noticed earliest.334 Patients of all ages may be • preserve length
affected, from very small children to the elderly,
with peaks in the fourth and fifth decades. Males • maintain joint function
outnumber females by a 10:1 ratio, and there is a • obtain a satisfactory cosmetic appearance343-346
strong association with AIDS.335
The first clinical signs are dark-blue to violaceous Many variables will affect the reconstructive
macules on the skin that are later replaced by infil- choice— mechanism of injury, size of the defect,
trative plaques and finally by nodules measuring location and status of the wound, associated inju-
0.5 to 3 cm in diameter. Some of the lesions may ries to other parts of the hand, and age, sex, gen-
heal while others coalesce and ulcerate. Initially eral health, and occupation of the patient.
the skin lesions correspond to the distal end of the
tumor in the bone, but in time the skin manifesta-
tions appear at progressively more proximal levels. Healing by Secondary Intention
On radiographic examination the affected bones If the skin loss is no larger than about 1.5 cm2, the
appear decalcified in a trabecular pattern, with cor- wound may be allowed to granulate and heal spon-
tical thinning as the tumor expands. Cystic erosion taneously.347-349 This type of treatment is especially
shows as bites taken out of the bone. well suited to children and the elderly. All devital-
Treatment is by a combination of radiotherapy ized tissue should be debrided and any exposed
and chemotherapy. The prognosis varies accord- bone trimmed to lie below the soft tissue level. The
ing to the behavior of the tumor. Fulminating lesions wound is covered with a semi-occlusive350 or algi-

SRPS Volume 9, Number 32

nate dressing which can be left intact for 5 to 7 days ment to support the distal nail. In these circum-
and can then be changed as necessary. Complete stances Beasley355 offers the following guidelines
healing is usually obtained in 3 to 4 weeks. for reconstruction:
Mennen350 treated extensive fingertip defects with • the replacement soft tissue must have good ulti-
this method and reports excellent functional and mate sensibility and be capable of tolerating nor-
cosmetic outcomes. The advantage of this treat- mal usage
ment is that as the wound contracts, it will pull
• the secondary disfigurement must be insignifi-
proximal innervated pulp skin over the exposed
bone, resulting in a very small area of residual scar cant, with no functional loss at the donor site
located off the pressure area of the finger. How- • the method must be safe, practical, reliable, eco-
ever, if this same technique is used to treat more nomical, and predictable in results
dorsal fingertip defects with involvement of the
distal nail bed, the subsequent wound contraction He further lists three indications for local flaps in
can lead to “parrot-beaking” of the nail, which can the repair of fingertip amputations: (1) a wound
be difficult to correct secondarily. bed unsuitable for revascularization of a skin graft;
(2) need for subcutaneous tissue replacement as
well as skin; (3) protection of a vital structure such
Skin Grafts
as a nerve.
Skin grafts are commonly used to repair finger- Flaps for soft tissue reconstruction of the finger-
tip defects. They may be used as a temporizing tip can be from the same finger (homodigital),
measure with a view to subsequent flap revision, another finger (heterodigital), local, regional, or dis-
or they may serve as the definitive wound closure. tant sources.356-359 An enormous number of flaps
In the former situation, split-thickness skin is more has been described and countless more will be
appropriate, as it has a more predictable “take”. published in the years ahead. For a flap to be useful
Likewise, large soft tissue defects are resurfaced clinically, it must fulfill the guidelines listed above,
with split skin because it tends to contract more but at the same time it must be reliable and simple
than full-thickness skin, thus keeping the resultant to perform. Only select flaps will be discussed in
insensitive area as small as possible.343 Split-thickness
the sections that follow.
skin from the hypothenar eminence or instep of
the foot has a papillary pattern which most closely
resembles native fingertip skin.351 Beasley suggests Homodigital Flaps
full-thickness donor sites from groin to minimize
The most immediate source of tissue for finger-
the cosmetic deformity of the donor site. 343
tip replacement is the same finger. The obvious
Hypothenar full-thickness skin grafts have an excel-
advantages are that it does not violate another nor-
lent texture match and do not hyperpigment as
mal finger or part of the body nor does it immobi-
groin skin tends to. Their size is limited by the
lize uninvolved joints. The tissue used must be out-
necessity to obtain primary closure of the donor
site. side the zone of injury. The neurovascular integrity
Although some spontaneous reinnervation of of the finger should be maintained.
full-thickness skin grafts has been demonstrated,352 The tissue directly adjacent to the wound is the
any insensitive or hyposensitive areas that remain closest source of flap tissue and forms the basis for
limit the application of skin grafts in the hand.353 many traditionally popular flaps. The volar V-Y
Braun et al found no difference in 2-point discrimi- advancement360,361 is useful for dorsal oblique to
nation between wounds covered by split-thickness transverse amputations where the defect does not
grafts and those covered by local flaps.354 exceed 1 cm (Fig 11). The usefulness of this flap is
vastly improved by extending the proximal part of
the “V” past the DIP joint crease and into the middle
Flap Reconstruction phalangeal segment and by elevating the flap as a
Loss of fingertip pulp greater than one-third the true bilateral neurovascular island flap on both
length of the phalanx requires soft tissue replace- pedicles.362

SRPS Volume 9, Number 32

and Watson370 preserve the dorsal perforating ves-

sels by using a “spreading-dissecting” technique
in which the volar flap is not cut free except at its
most distal area. They report no skin loss or joint
stiffness in 69 transfers and 2-point discrimination
values within 2 mm of the contralateral normal
Lateral advancement flaps have the potential
to offer the ideal fingertip reconstruction, replacing
“like with like” from the same digit. Ipsilateral
advancement flaps371-376 move tissue from directly
adjacent to the defect and maintain sensibility (Fig
12). As with all homodigital flaps, there is the
potential for flap embarrassment if damaged tis-
sues or pedicles are used.

Fig 11. V-Y advancement flap. (A) Skin incision and mobilization
of triangular flap. (B) Advancement of flap. (C) Closure with V-
Y technique. (Reprinted with permission from Chao JD et al:
Local hand flaps. J Am Soc Surg Hand 1(1):28, 2002.)

In 1964 Moberg described a rectangular volar

advancement flap from the base of the thumb
that can be used in thumb tip reconstruction.363
This is a true axial flap, as the incisions are placed Fig 12. Oblique triangular flap. (A) Volar oblique amputation.
dorsal to the neurovascular bundles so as to include (B) Design and raising of flap on a digital neurovascular bundle.
(C) Closure of flap with V-Y technique. (Reprinted with permis-
them with the flap and restore normal sensation to sion from Chao JD et al: Local hand flaps. J Am Soc Surg Hand
the tip. The tissue movement achieved in propor- 1(1):28, 2002.)
tion to the extent of the dissection is quite disap-
pointing, and if too large a defect is closed (>1cm), Reversed digital artery island flaps from the
flexion contracture of the interphalangeal joint will proximal finger necessitate sacrifice of one digital
occur. Several authors364-366 have subsequently artery and rely on retrograde flow through an intact
modified the method of mobilization, incorporating anastomosis with the contralateral normal artery.377-
a V-Y closure in the advancement to make the flap 380
They require neurorrhaphy of a dorsal branch
more reliable. Alternatively the flap can be con- to the contralateral digital nerve for optimal recov-
verted into a true island and the proximal defect ery of sensibility.381 A preoperative digital Allen’s
can be skin grafted.367 test is essential in these digits to assess the patency
Snow368,369 applied the Moberg flap to the repair of both arteries. Venous drainage of these flaps is
of fingertip amputations, but dorsal tip necrosis via the soft tissue around the arterial pedicle, so the
and an unstable pulp scar plagued the series. Macht pedicle should not be skeletonized.

SRPS Volume 9, Number 32

The dorsal middle phalangeal finger flap382-384 Many variations of the cross-finger flap have been
can be raised on a short or long antegrade or described. The dorsal sensory branch can be included
retrograde pedicle, and can be used as a free flap, in the flap and sutured to the digital nerve of the
an arterial and/or venous flow-through flap, or neu- injured fingertip,392 although this technique has not
rovascular flap. been shown to improve the ultimate sensibility of
the flap. The flap can be de-epithelialized and used
to resurface dorsal defects of adjacent fingers,
Heterodigital Flaps necessitating an additional skin graft on top of the
In 1951 Cronin first described the cross-finger flap.393-395
flap for fingertip reconstruction. 385 The cross- Advantages of the cross-finger flap technique
finger flap brings durable cover to exposed bone, are that it is easy to elevate and can carry ample
joint, or flexor tendons when homodigital flaps quantities of similar tissue. Disadvantages are that
it is a two-stage procedure, a skin graft is required
do not suffice.385-389 Blood supply of the cross-
for the donor site (which is obvious on the
finger flap is random and based upon the sub-
exposed dorsum of the finger), stiffness of the
dermal plexus of an adjacent digit. The flap may
involved digits is a possibility, and 2-point dis-
be based laterally, proximally, or distally depend-
crimination values average only 9 mm.396,397
ing on the most comfortable approximation of
In a study of 54 patients with cross-finger flaps,
donor digit to defect. The dorsum of the middle
Nishikawa397 found that despite recovery of pro-
phalanges of the index, middle, and ring fingers
tective sensation, no patient had recovered tac-
is the most appropriate donor site in terms of
tile gnosis. Maximal recovery of sensibility occurs
joint immobilization. Use of a cross-finger flap in those under 20 years, and 2-point discrimina-
from the volar aspect of the middle finger, rather tion plateaus at 1 year.396 Contraindications to
than the thinner dorsal finger skin, gives better the use of cross-finger flaps include arthritis,
tissue quality for resurfacing the pulp of the Dupuytren’s contracture, and generalized vasos-
thumb. 355,390 pastic syndromes.
Hoskins details the technical points of cross- Littler398 and Tubiana399 developed the technique
finger flap elevation and transfer (Fig 13).391 The of interdigital transfer of pedicled neurovascular
pedicle can be divided safely by the 8th or 9th island flaps. These flaps have found their greatest
day to lessen the risk of joint stiffness from joint application in reconstruction of the ulnar thumb
immobilization. pulp,4000,401 where median nerve-innervated skin can

Fig 13. Elevation and transfer of a dorsal

cross-finger flap. The full-thickness skin
graft should be sutured to the edge of the
defect adjacent to the donor finger before
the flap is inset so that a “closed” system
is created. (Reprinted with permission
from Lister GD: Skin flaps. IN: Green DP
(ed.), Operative Hand Surgery. 3rd Ed.
Churchill Livingstone, 1993. Ch. 49, p.1768)

SRPS Volume 9, Number 32

be transferred from the ulnar pulp of the middle

finger (less desirably, the radial pulp of the ring
finger). For the flap to reach the tip of the thumb,
the digital nerve must be dissected well back into
the median nerve and the proper digital artery to
the adjacent finger must be sacrificed. Cortical mis-
representation remains a problem, and the sensibil-
ity of the transferred skin has been variable in sev-
eral series.402,403
Holevich404 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. There is a problem
with cortical interpretation, and the skin is not pulp
skin. Several authors405-407 have since expanded the
applications of the first dorsal metacarpal artery
flap in hand resurfacing.

Regional Flaps
Gatewood408 first proposed a thenar flap in
1926 for resurfacing the tip of the index finger in
one patient. Thirty years later Flatt409 illustrated his
results with a similar “palmar flap” in a large series
of fingertip reconstructions.
Fig 14. Descriptive drawings of the surgical technique. (A) The
The classic thenar flap is based proximally to complex defect exposing the dorsal aspect of the distal inter-
ensure good venous return and minimize PIP phalangeal joint. (B) Design of the adipofascial flap. The base
joint flexion. Contracture can be controlled fur- of the flap is adjacent to the defect. (C) Development of the
ther by placing the thumb in full palmar abduc- distally based adipofascial flap. (D) The flap is turned over on
tion and bringing the MP joint of the involved itself to cover the defect. (E) Primary closure of the donor site.
The flap is covered with a split-thickness skin graft. (Reprinted
digit into full flexion.343,410 If designed properly,
with permission from Al-Qattan MM: The adipofascial turnover
the donor site can usually be closed prima- flap for coverage of the exposed distal interphalangeal joint of the
rily.410,411 Unlike the true palmar flap, the thenar fingers and interphalangeal joint of the thumb. J Hand Surg
flap is not likely to produce joint stiffness post- 26A:1117, 2001.
operatively provided the pedicle is divided in
about 10 days. Heterodigital flaps
Small defects of the hand can be resurfaced using
SMALL DEFECTS OF THE HAND OR DIGITS so-called venous flaps. These flaps consist of skin
islands raised on a single-vein pedicle from the dor-
Homodigital flaps sum of the hand over the proximal phalanx, and
are used to reconstruct either the dorsal or volar
Lai 412 described the adipofascial turn-over
surfaces of adjacent digits.413-416
flap, in which dorsal defects of the finger and
hand can be resurfaced by a flap of subcutaneous Earley417 detailed the anatomy of the second
tissue hinged on a pedicle which borders the dorsal metacarpal artery and reported various uses
defect. It is especially useful in abrasion injuries of for this neurovascular island flap hand reconstruc-
the DIP joint, with exposed terminal extensor ten- tion. He and others418-420 broadened the applica-
don. The donor site is closed primarily, and the tions of the second dorsal metacarpal artery
flap is grafted (Fig 14). flap.

SRPS Volume 9, Number 32

Regional flaps
Maruyama 421 and Quaba and Davidson 422
elevated skin islands from the dorsum of the hand,
based distally over the metacarpal head (Fig 15).
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. 423-425
Maruyama raised flaps on all five dorsal metacarpal Fig 16. The arterial basis of the distally based dorsal hand flap
arteries, and reports a largely successful experi- is a direct branch from the dorsal metacarpal artery that enters
the skin 0.5 to 1 cm proximal to the adjacent metacarpopha-
ence in 8 cases.421
langeal joint. (Reprinted with permission from Quaba AA,
Davison PM: The distally based dorsal hand flap. Br J Plast Surg
43:28, 1990.)


Regional Flaps
The regional flaps applicable for resurfacing the
hand are based on the three major arteries of the
forearm, viz. the radial, ulnar, and posterior
interosseous arteries.427
Yang428 described the territory of the radial
forearm flap in 1981. The skin on the flexor sur-
face of the forearm is relatively hairless, thin, and
pliable, which makes it ideal for resurfacing the
dorsum of the hand. The radial forearm unit may
be raised as a composite of fascia-skin,429-431 fas-
cia,432,433 bone-muscle-fascia-skin,434-436 or fascia-
In 1984 Lin and coworkers 440 noted ample
retrograde flow into the radial artery from the
ulnar artery via the deep palmar arch, and pro-
posed a “reverse” forearm flap. The flap is nour-
ished by this retrograde circulation, and can be
elevated on its long pedicle for reconstruction
Fig 15. Design of the reverse dorsal metacarpal flap and cross- anywhere in the hand. They described a cross-
section at distal flap. (Reprinted with permission from Maruyama over pattern of communicating branches between
Y: The reverse dorsal metacarpal flap. Br J Plast Surg 43:24, 1990.) the paired venae comitantes and identified small
superficial collateral branches of each vein, which
In contrast, Quaba and Davidson believe the effectively bypass the valves. This system enables
flaps are nourished by a direct cutaneous branch the flap to be drained despite competent valves.
of the dorsal metacarpal artery that enters the skin Even in significant hand trauma where the palmar
0.5 to 1 cm proximal to the adjacent metacarpopha- arches are in question, the flap has been raised
langeal joint422,426 (Fig 16). They raised reverse successfully, based on communications proximal
DMA flaps on the 2nd, 3rd, and 4th intermetacarpal to the wrist.441,442
spaces in 21 patients, and report one partial loss There are two main disadvantages of the radial
and one failure.422 Donor sites up to 2 cm wide can forearm flap. Foremost is that a major vessel to the
be closed primarily. hand is sacrificed, but Kleinman and O’Connell443

SRPS Volume 9, Number 32

found the only significant objective difference

between patients who had undergone flap trans-
fer and controls to be an 18% delay in reconstitu-
tion of normothermia after cold stress testing.
Reconstruction of the vessel is rarely neces-
sary.444,445 Weinzweig et al446 have described a
technique for elevating a distally-based fascio-
cutaneous flap with preservation of the radial
artery, while Braun et al447 have similarly elevated
a retrograde radial fascial turn-down flap based on
distal perforators of the radial artery, leaving the
main radial artery intact. Fig 17. Cross-section of the distally based posterior interosseous
island flap taken at the middle one-third of the forearm. The
The unesthetic and potentially unstable grafted posterior interosseous artery reaches the overlying skin in the
donor site of the radial forearm flap remains the space between the extensor carpi ulnaris (ECU) and extensor
major detractor of this otherwise excellent flap.448 digiti minimi proprius (EDMP). (Reprinted with permission from
Skin graft take is not usually a problem in flaps Landi A et al: The distally based posterior interosseous island flap
for the coverage of skin loss of the hand. Ann Plast Surg 27(6):529,
used for hand reconstruction, as the flap is based 1991).
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 a Distant Flaps
suprafascial dissection of the flap.449 Many meth-
Large flaps of skin can be transferred to the hand
ods have been proposed to improve the donor
from distant sites by means of traditional pedicled
site, including direct closure, full-thickness skin
techniques or microvascular free tissue transfer.
grafts, local flaps, and tissue expansion.450-455 Split-
thickness skin grafting remains the standard in most
centers. Pedicled Flaps
In 1984 Lovie et al456 described the ulnar artery
Flaps of skin from remote sites over the chest
island flap, and 4 years later reported their expe-
and abdomen were traditional methods for resur-
rience with this method in hand and forearm re-
construction.457 The skin territory of the flap over- facing large wounds of the upper extremity. The
lies the proximal ulnar aspect of the forearm, which most commonly used pedicled flap is the groin
is almost always hairless and less visible than the flap based on the superficial circumflex iliac artery473-
radial border. They and others458-461 found the ul-
or the superficial inferior epigastric artery.477
nar flap to be superior in terms of esthetics, easier Groin flaps are axial-pattern flaps with reliable vas-
harvesting of bone and muscle (flexor carpi cularity. However, they necessitate two surgical
ulnaris), direct closure of the donor site, and lower stages, the hand remains dependent during the
morbidity. initial period of flap attachment, encouraging edema
The posterior interosseous artery flap is based and stiffness. In addition, groin flaps are too bulky
on the communication between the anterior and for dorsal hand resurfacing and require subsequent
posterior interosseous arteries.462-467 The posterior revisional surgery.
interosseous artery runs in a fascial septum Chow et al478 offer their experience with 36 groin
between the extensor carpi ulnaris and extensor flaps used in delayed primary or elective second-
digiti minimi muscles (Fig 17). A segment of ulna ary hand resurfacing, while Arner and Moller479
can be taken as a composite flap.468 The advan- highlight potential complications.
tages of this flap are good pedicle length and pri-
mary closure of the donor site. Its disadvantages
are a relatively hairy donor site, an obvious scar on Microvascular Free Tissue Transfer
the visible dorsum of the forearm, limited size of Microvascular free tissue transfer allows a single-
the flap, and unreliability of the vascular communi- stage composite reconstruction of complex hand
cation.469-472 defects,480-488 obviating the need for cumbersome,

SRPS Volume 9, Number 32

two-stage pedicled procedures with their inherent

shortcomings. Free flaps can also be used to pro-
vide vascular conduits as well as soft tissue cover-
age.489,490 Free flaps are the definitive form of soft
tissue cover in emergency situations.491-496
Critical sensibility of the fingertip can be restored
by free neurosensory flaps497-503 or microvascular
toe-pulp transfer.504-506 Toe-to-hand transfers in
thumb reconstruction are discussed in the “Micro-
surgery: Free Tissue Transfer and Replantation” issue
of Selected Readings in Plastic Surgery. Protective
sensibility of the palm and dorsum of the hand is
usually achieved by thin muscle, fascial, or
fasciocutaneous flaps.507
The first web-space flap of the foot is the
“gold standard” of neurosensory flaps.498 It con-
sists of the lateral aspect of the great toe, and the
medial aspect of the second toe. The flap is sup-
plied by the first dorsal metatarsal artery (FDMA),
a branch of the dorsalis pedis artery, or the first
plantar metatarsal artery. Its innervation is through
both the deep peroneal nerve and the medial Fig 18. Innervation of the foot first web space and great toe.
plantar nerve (Fig 18). May and Lee503 found that (Reprinted with permission from May JW et al: Free neurovascular
the FDMA arose from the dorsalis pedis artery flap from the first web of the foot in hand reconstruction. J Hand
Surg 2:387, 1977.)
dorsal to the mid-metatarsal axis in 78% of 50
cadaver dissections. The authors usually obtain
preoperative angiography to determine the vas- The lateral arm flap is supplied by the posterior
cular anatomy. The main advantage of the first- radial collateral artery and innervated by the poste-
web space flap for sensory reconstruction in the rior cutaneous nerve of the arm.515-517 It may be
hand is replacement with similar thin glabrous skin raised as a fasciocutaneous flap or as combinations
with concentrated sensory receptors, allowing the of fascia,518 muscle, tendon,519,520 or bone.521 Do-
best 2-point discrimination of any neurosensory nor defects up to 6 cm wide can usually be closed
flap. primarily. Designs for extending the flap have been
The thin, malleable skin over the dorsum of the described,522,523 as well as techniques for extending
foot may also be transferred as an innervated free the length of the vascular pedicle.524 The flap has
flap,508-510 including the underlying extensor ten- the advantage of confining flap harvest to the same
dons511-514 and second metatarsal for composite extremity as the defect. However, this popular flap
reconstruction if required. The dorsalis pedis flap comes with a price. Graham et al525 reviewed 123
is raised on the dorsalis pedis artery, and venous lateral arm flaps and found that a significant number
drainage is via the venae comitantes and saphen- of patients complained of unsatisfactory appearance
ous vein. Its neural input is from the superficial and hypersensitivity of the donor site, elbow pain,
peroneal nerve. The donor site is unforgiving, so numbness in the forearm, and excessive flap bulk.
meticulous attention must be paid to flap dissec- For large defects of the upper extremity where
tion and wound care. sensibility is not as important, the scapular and
The free radial forearm flap and free ulnar parascapular flaps have found popularity. The
forearm flap can be used just as readily as the parascapular flap526-528 allows a larger skin paddle to
already discussed pedicled flaps. They have neuro- be harvested with primary closure of the secondary
sensory potential via the lateral and medial cutane- defect, and the resulting scar is less conspicuous
ous nerves of the forearm, respectively. than the horizontal scapular flap defect. The scapu-

SRPS Volume 9, Number 32

lar flap can be raised as a fascial flap529 or as an excellent for filling the three-dimensional defect
osteofascial flap.530 Both flaps have the disadvan- resulting from the extensive release of complex first
tage that they are bulky, even in thin individuals, web space contractures. The donor defect on the
and secondary defatting or liposuction is necessary scalp is insignificant. Potential complications of flap
for an optimal aesthetic contour. transfer include palsy of the frontal branch of the
The free groin flap gives an unsurpassed donor facial nerve and permanent alopecia.
site and allows the transfer of a large quantity of Another extremely thin fascial flap is the serratus
hairless skin. Like the pedicled groin flap, it is too anterior fascial flap.544-547 This flap consists of the
bulky for resurfacing the hand and requires loose areolar tissue between the latissimus dorsi and
revisional defatting and/or liposuction. serratus anterior muscles and is supplied by the
Recent interest in perforator flaps has led to the thoracodorsal vessels. It has a long, constant vascular
growing popularity of the anterolateral thigh pedicle; very thin, well-vascularized tissue; low donor
flap531,532 and the tensor fasciae latae perforator site morbidity; and allows simultaneous donor and
flap533,534 in dorsal hand reconstruction. Large flaps recipient site dissection. It can also be combined
of very thin skin can be raised with minimal donor with other flaps of the subscapular system.
site morbidity. As the flaps are based on perforat- Free muscle flaps can only provide crude protec-
ing vessels, the motor function of the underlying tive sensibility through pressure receptors, but their
TFL is preserved. malleability makes them well-suited to difficult con-
The anatomy of the temporal region has been tour problems in the hand, especially the palm. For
elucidated by several authors.535-537 Upton et al538 small defects the serratus anterior548,549 seems most
discuss the various applications of free temporo- useful, while for moderate-sized wounds the rec-
parietal fascial flaps in dorsal hand resurfacing. tus abdominis550,551 flap has been suggested. For
Temporoparietal fascia is most commonly used in very large wounds of the upper extremity, the latis-
the upper extremity to wrap exposed or contracted simus dorsi is the muscle of choice. All of these
tendons.538-543 The deep areolar surface of the flap flaps have large-diameter pedicles of very adequate
is turned toward the tendons to provide a smooth length with minimal donor site morbidity.
gliding surface. The overlying fascia is thin and pli- Functional free muscle transfers are discussed in
able for metacarpal contouring. A skin graft com- the “Microsurgery” issue of Selected Readings in
pletes the reconstruction. This fascial flap is also Plastic Surgery.

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54. Kilgore ES, Graham WP: The Hand. Philadelphia, Lea & 83. Faciszewski T, Coleman DA: Human bite wounds. Hand
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110. Jones MW et al: Septic arthritis of the hand due to 138. McDowell CL, Henceroth WD: Compression of the ulnar
Mycobacterium marinum. J Hand Surg 13B:333, 1988. nerve in the hand by a ganglion. Report of a case. J Bone
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163. Singh D, Culp RW: Arthroscopic ganglionectomy. J Am 188. Ogino T, Ohnishi N: Ultrasonography of a subungual
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215. Epstein MJ: Malignant schwannomas of the hand: a re- 240. Gutman M et al: Acral (volar-subungual) melanoma. Br J
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371. Hueston JT: Local flap repair in finger tip injuries. Plast 397. Nishikawa H, Smith PJ: The recovery of sensation and
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421. Maruyama Y: The reverse dorsal metacarpal flap. Br J Plast 446. Weinzweig N et al: The distally based radial forearm
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severe upper extremity injuries. J Hand Surg 20B:53, 1995. 1990.

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519. Gosain AK et al: The composite lateral arm free flap: 536. Kaplan IB et al: The vascularized fascia of the scalp. J
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Surg 77(1):17, 1986. 1999.

SRPS Volume 9, Number 32


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Brown DM, Young VL: Hand infections. South Med J 86(1):56, 1993.

Hoffman RD, Adams BD: The role of antibiotics in the management of elective and post-traumatic
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Quinn MJ, Thompson JE, Crotty K, McCarthy WH, Coates AS: Subungual melanoma in the hand.
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Glasson DW, Lovie MJ: The ulnar island flap in hand and forearm reconstruction. Br J Plast Surg
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Zancolli EA, Angrigiani C: Posterior interosseous island forearm flap. J Hand Surg 13B(2):130,

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Ninkovic MM, Schwabegger AH, Wechselberger G, Anderl H: Reconstruction of large palmar

defects of the hand using free flaps. J Hand Surg 22B(5):623, 1997.

Lee WPA, May JW Jr: Neurosensory free flaps to the hand. Indications and donor selection.
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