HAND I: FINGERNAILS, INFECTIONS, TUMORS

AND SOFT-TISSUE RECONSTRUCTION

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

FINGERNAILS

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

2

TABLE 1
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
The most frequent pathogen in hand infections
is Staphylococcus aureus, accounting for 50& to
80% of all isolates.20-25 However, specific aspects
of the history or physical examination can implicate
other organisms as the inciting agent. Careful
attention to these factors allows the physician to
make an appropriate choice for an initial antibiotic(s)
to cover all reasonable pathogens (Table 1). Indis-
criminate use of excessively broad-spectrum anti-
biotics can expose the patient to unnecessary side
effects and complications as well as promote the
development of resistant strains.
If the infection is the result of a known traumatic
event, the circumstances of that event can give
important clues as to the pathogens. Gram positive
organisms are the most frequent isolates in routine
home and industrial accidents.26 In farm accidents,
mixed cultures of gram positive and negative bac-
teria, as well as anaerobes, are present. Among the
common gram positive isolates, S. aureus usually
results in a purulent infection 3-5 days after the
event. The pus is usually creamy white and without
odor. Infections with Streptococcus species present
rapidly, with marked cellulitis and possibly lymphan-
gitis. While an antistaphylococcal penicillin or first-
generation cephalosporin will cover S. aureus
adequately, streptococci are better covered by peni-
cillin. Gram negative infections may present with a
cellulitis or purulent infection. If purulence is present,
it can have a variety of colors and is often associ-
SRPS Volume 9, Number 32
ated with a foul odor. These infections usually
require intravenous antibiotics as initial therapy.
Anaerobic bacteria are especially common in
bite wounds, infections associated with intravenous
drug abuse, and in diabetics. In addition to the bac-
teria already mentioned, Eikenella corrodens is
found in many human bite wounds,27-29 and Pas-
teurella multocida in many domestic animal bites.30-
33
These are usually adequately covered by the
addition of penicillin to an agent effective against
the other gram positives.34-36
Compared with adults, children are more sus-
ceptible to unusual pathogens and have a higher
incidence of oral flora, Pseudomonas aeruginosa,
and Haemophilus influenzae37,38 associated with
their infections. However, these associations are
probably not frequent enough to warrant a change
in the initial therapy of routine infections. Never-
theless, if suggested by gram stain, if there is a site
of distant infection where these pathogens are com-
mon, or if the infection does not respond promptly
to the standard antibiotics, additional coverage is
warranted in these patients. The presence of mul-
tiple pathogens in hand infections is probably more
common than is appreciated.39
Three independent studies40-42 demonstrate that
prophylactic antibiotics do not avert infection in
hand lacerations. Meticulous wound debridement
and care is preferred over the routine use of antibi-
otics in hand injuries.43 Fitzgerald26 recommends
prophylactic antibiotics in cases of hand wounds of
3
SRPS Volume 9, Number 32
home or industrial origin, but not in farm wounds,
which instead should be debrided thoroughly and
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
elapsed before treatment (up to 18 hours), and
further emphasize the importance of wound debri-
dement in the care of hand injuries.
MANAGEMENT
While the spectrum of acute bacterial hand
infections is quite broad, the management principles
are similar in all and can be summarized as:
• Rest, elevation, and immobilization in a position
of function
• Adequate drainage of all loculations of pus, and
debridement of necrotic tissue
• Antibiotics, determined by sensitivities from aero-
bic and anaerobic cultures (obtained prior to the
commencement of antimicrobial therapy) and
special cultures—fungi, mycobacteria, viruses—
where indicated
• Penicillin plus a first-generation cephalosporin
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
COMMON BACTERIAL INFECTIONS
Hand infections may be acute or chronic, but
the overwhelming majority are acute. Of these acute
infections, over 90% are due to bacterial patho-
gens. 20
Cellulitis
Cellulitis is a common superficial infection of the
hand that presents as erythema, swelling, pain, and
occasional lymphangitis or vesicle formation. Cel-
lulitis occurs most commonly on the dorsal aspect
of the fingers and metacarpals, and beta-hemolytic
streptococcus is the usual pathogen.
Treatment includes rest, elevation, splinting and
antibiotics. Penicillin-G (or erythromycin in the event
4
of allergy) should be the first line with the addition of
an anti-staphylococcal agent if S. aureus is cultured.
Paronychia
A paronychia is an infection of those structures
surrounding the proximal and lateral nail. Parony-
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
biting or manicures. It is frequently reported that S.
aureus is the most frequent isolate in paronychia.
Recent studies have shown anaerobic bacteria to
be present alone, or in combination, in a large
percentage of cases of paronychia.46,47 This is felt
to be due to the frequency of contact of the oral
secretions with the inciting wound.
The paronychia initially begins as erythema, swell-
ing, and discomfort at the nail fold, sometimes with
fluctuation and frank purulence. If detected early,
warm soaks, elevation, and oral antibiotics may be
sufficient treatment. If the infection has been present
for greater than 24 hours or if there is any fluctuance
under the nail, the nail fold must be drained by
simple elevation (Fig 3).48
Fig 3. Drainage of paronychia. (Reprinted with permission from
Conolly WB: Infections. In: Conolly WB (ed), Atlas of Hand
Surgery. Churchill Livingstone, 1997. Ch 32, p. 256.)
If this initial attempt at drainage is inadequate, if
the infection extends significantly proximal to the
nail fold, or if the infection fails to resolve with the
above treatment, more aggressive drainage is indi-
cated. The nail plate should be removed as it may
be acting as a foreign body by this stage. It might
also be necessary to incise the dorsal nail fold. Two
incisions are made at right angles to the nail fold at
the 5 o’clock and 7 o’clock positions to elevate it
completely from the nail bed in the region of the

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
problem,49,50 perhaps from secondary mycobacte-
rial or fungal infections which are more commonly
seen in immunosuppressed patients, diabetics, and
cancer patients. Chronic paronychia is also seen in
patients who have a frequent exposure to a moist
environment. Candida albicans is the most com-
monly identified organism in this infection.48 Infec-
tion may also become chronic in the presence of
vascular insufficiency, eg, Raynaud’s disease or scle-
roderma. These chronic infections may be treated
in several ways: (a) The nail fold may be marsupial-
ized by excision of a crescent of tissue down to the
germinal matrix, which is then left to close by sec-
ondary infection.51,52 (b) Alternatively, the entire
proximal nail fold, including the cuticle, can be
excised.53 Once healed, this gives a very satisfac-
tory cosmetic result, although as the dorsal roof of
the nail is ablated, the shiny surface layer of the nail
is no longer produced. (c) Complete removal of
the nail, followed by treatment with a combined
SRPS Volume 9, Number 32
antifungal-steroid cream, has also shown good
results.54
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
ruptured.
Fig 5. Anatomy of the fingertip. (Reprinted with permission from
Conolly WB: Surgical Anatomy. In: Conolly WB (ed), Atlas of
Hand Surgery. Churchill Livingstone, 1997. Ch1, p. 6.)
Most felons are precipitated by some sort of
penetrating trauma and x-rays should be carefully
evaluated for a foreign body in all felons. If a felon
does not respond to therapy, or if there is strong
evidence in the history that a nonradioopaque for-
eign body is embedded in the pulp, ultrasound
might show a foreign body not seen on conven-
tional x-rays. S. aureus is the most common patho-
gen in felons,55 but gram negative organisms have
been reported. Gram negative organisms should
be considered in immunosuppressed patients. A
number of cases have been reported in diabetics
who developed felons after checking their blood
sugar level by fingerstick.56
If a pulp infection is seen quite early, there may
simply be a localized cellulitis or a small superficial
abscess. This can be treated with oral antibiotics,
5
SRPS Volume 9, Number 32
rest and elevation, or with local drainage as indi-
cated. In the true felon, a patient presents with the
entire pulp red, swollen and markedly tender. The
patient usually complains of a severe throbbing
pain, particularly when the finger is dependent.
This is due to the increased tissue pressure caused
by the unyielding septa—essentially a compartment
syndrome of the pulp. At this stage, adequate drain-
age, as well as antibiotics, are required for treat-
ment.48,55 Late presentation or incomplete therapy
can result in a compromise of the blood flow to
the pulp, which can result in necrosis of the soft
tissues, tenosynovitis, septic arthritis, and even os-
teomyelitis.557
Many incisions have been recommended for
the drainage of felons. If it is pointing, the felon
should be drained at this site. Careful palpation
with a small blunt probe can often determine a
point of maximal tenderness and the incision
should be made at this site. The pulp must be
explored immediately volar to the phalanx but
staying dorsal to the neurovascular structures.
The fibrous septa are ruptured to allow com-
plete drainage of the infected space. Good re-
sults are seen with a longitudinal midline palmar
incision which does not cross the distal interpha-
langeal joint (Fig 6).48 These incisions heal well
and do not usually produce a hypersensitive scar
on the pulp.
Fig 6. Drainage of a felon. (Reprinted with permission from
Conolly WB: Infections. In: Conolly WB (ed), Atlas of Hand
Surgery. Churchill Livingstone, 1997. Ch 32, p. 258.)
6
Tenosynovitis
Tenosynovitis is an infection within the sheaths
which form the gliding surfaces around the ten-
dons in the hand. It is almost exclusively a disease
of the flexor tendons, although extensor teno-
synovitis at the level of the dorsal retinaculum has
also been described.58 While tenosynovitis is rarely
life-threatening, delayed or inappropriate treatment
can lead to devastating consequences. The deli-
cate gliding surfaces of the tendon sheaths can be
destroyed by infection, resulting in a stiff and pain-
ful finger. Even more prolonged delay in treatment
can allow the sheath to rupture, with spread of the
infection to any of the spaces of the palm or to the
adjacent bone. Prolonged infection can also lead
to ischemic rupture of the tendon itself.59,60
Most cases of tenosynovitis begin with penetrat-
ing trauma, and in this event the most common
infectious agent is S. aureus. Some cases are due to
hematogenous dissemination, particularly of gono-
coccal infections, and this possibility should be con-
sidered if there is no history of antecedent trauma.61
The hallmarks of flexor tenosynovitis were first
established by Kanavel62 and constitute the four
cardinal signs which bear his name. They are:
• fusiform swelling of the digit
• partially flexed posture of the digit
• 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.
When surgical drainage is deemed necessary by
initial presentation or failure to improve, two meth-
ods are available, as described by Neviaser.60,65 The

majority of cases can be treated with a limited inci-
sion and drainage followed by closed catheter irri-
gation65-67 (Fig. 7). If the patient fails to respond to
this treatment, or if the sheath cannot be cleared of
purulence at the initial exploration, open drainage
must be used. The sheath is opened widely via a
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
range of motion exercises are begun with the first
dressing change on the ward.69
Fig 7. Closed irrigation for flexor tenosynovitis. (Reprinted with
permission from Brown DM, Young VL: Hand infections. South
Med J 86:64, 1993).
In the event that the thumb or little finger are
involved with tenosynovitis, the infection can extend
proximally to involve either the ulnar or radial bur-
sae. These two bursae communicate through the
space of Parona, deep to the flexor tendons in the
distal forearm. A “horseshoe” abscess can form
where a flexor tenosynovitis, beginning in either
the thumb or little finger flexor sheath, spreads
proximally to the space of Parona and then passes
retrogradely down either the little finger or thumb
flexor tendon sheath. Phillips et al,70 however,
showed that many times the little finger flexor syn-
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
where an infection extends proximally closed cath-
eter drainage is indicated. The catheter is directed
proximally from the incision at the level of the A-1
SRPS Volume 9, Number 32
pulley. A counter incision is then made just proxi-
mal to the transverse wrist crease, where a drain is
placed in the bursa. This system is managed in a
similar fashion to the digital system. Again, if the
patient does not respond to this treatment, open
drainage of the bursae is necessary.
Deep Space Infections
A variety of “spaces” has been described in the
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
8). Thenar space infections are usually character-
ized by the thumb being held in an abducted posi-
tion, with pain over the adductor muscles and pain
on extension or attempted opposition of the thumb.
This is the only hand infection in which the thumb
is not adducted. Drainage of these abscesses must
respect not only the proximity of neurovascular
structures, primarily the radial bundle to the index
finger and the ulnar bundle to the thumb, but also
prevent scarring across the thumb-index web.
The palmar space, exclusive of the flexor ten-
don sheaths, allows free spread of infection along
fascial planes to deeper areas in the hand. Treat-
ment consists of incision and drainage with cath-
eter irrigation for 2 to 3 days.71
Osteomyelitis
Osteomyelitis of the bony structures of the hand
is a relatively infrequent infection.72 Osteomyelitis
can present as a spontaneous bone infection, usu-
7
SRPS Volume 9, Number 32
Fig 8. Deep spaces of the hand. (Reprinted with permission from
Brown DM, Young VL: Hand infections. South Med J 86:62, 1993).
ally by hematogenous seeding from a distant source.
The most likely pathogens are Staphylococcus and
Streptococcus species as well as Haemophilus spe-
cies in young children. It presents as a localized
focus of erythema, pain, and swelling along the
course of one of the long bones of the hand. If the
infection does not show clinical signs of improve-
ment within 48 hours of commencing intravenous
antibiotic treatment, bone biopsy should be per-
formed to obtain a specimen for culture. Any obvi-
ously necrotic bone should be debrided at this
procedure.
Osteomyelitis can also develop secondary to
local tissue conditions. This can be either the spread
of another contiguous infection or direct injury to
the surrounding soft tissues and bone. The best
test for diagnosing osteomyelitis under these cir-
cumstances is direct evaluation of the bone in an
operative setting, with a biopsy at the same proce-
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
the pathogens obtained by this technique may not
accurately reflect the microbiology of the infected
bone.73 The initial antibiotics should be broad-
spectrum parenteral antibiotics until the results of
the cultures allow specification.74
In a review of 46 patients with osteomyelitis of
the metacarpals or phalanges, Reilly et al75 noted
an overall amputation rate of 39% despite aggres-
sive surgery and intravenous antibiotic therapy. A
delay of more than 6 months from onset of symp-
toms to diagnosis and definitive treatment resulted
in amputation in 6 of 7 patients.
8
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
the patient with no history of trauma.77 In children,
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
a common potential pathogen and covered appro-
priately. In the sexually-active patient, particularly
those under 40 with no history of direct inocula-
tion, a gonococcal arthritis must also be suspected.78
Septic arthritis in the hand presents as a locally
tender, erythematous, and swollen joint. Due to
the swelling and pain, the joint is held in the posi-
tion which maximizes its volume, approximately 30
degrees of flexion in the interphalangeal joints, and
full extension in the metacarpophalangeal joints.
The joint will be particularly tender with any passive
motion. Arthrocentesis of the joint can be per-
formed as a diagnostic maneuver. Treatment con-
sists of elevation, parenteral antibiotics, and inci-
sion and drainage of the joint. Depending on the
severity of the infection, this might be followed by
irrigation of the joint for 48 to 72 hours. Once the
acute inflammation has abated, range of motion
exercises should commence.
BITE WOUNDS
Human Bite Wounds
Bites to the human hand account for 20% to
30% of all hand infections, and of these the major-
ity are caused by human bites. The clenched-fist
injury is associated with a high incidence of compli-
cations, including stiff joints and even amputa-
tions.79,80 The injury is sustained as the clenched fist
strikes the mouth of another person, and the tooth
frequently impales the metacarpal heads. The key
point in understanding the potential of the underly-
ing pathology is that the site of penetration of the

various layers is relative to the position of the fist at
the moment of impact.81-83 (Fig 9) The hand must
be assessed in the clenched-fist position to allow
an accurate assessment of the depth of injury.
Fig 9. (A) The tooth pierces the clenched fist penetrating skin,
tendon, joint capsule and the metacarpal head. (B) When the
finger is extended, the four puncture wounds do not corre-
spond. (Reprinted with permission from Lister G (ed), The Hand.
Diagnosis and Indications. Churchill Livingstone. 3rd ed. 1993.
Chapter 4, p. 332).
The patient presenting early with a laceration or
puncture will have minimal swelling or inflamma-
tion. An x-ray may show a fracture of the metacar-
pal head, air within the joint, or occasionally a for-
eign body such as a broken tooth. In the late pre-
sentation the patient has a red, swollen, painful
hand, and may have associated lymphangitis and
regional lymphadenitis. Patients will be constitution-
ally unwell, with a fever and elevated white cell
count. These patients are in serious danger of
osteomyelitis, septic arthritis, and a severely dam-
aged joint.79 X-ray examination in these patients,
apart from looking for a chip fracture or foreign
body, will be directed at early signs of osteomyeli-
tis or abscess formation within the bone.84
Cultures yield S. aureus and Strep. viridans in the
majority of cases.29,33 The other organisms com-
monly encountered are anaerobic Bacteroides spe-
cies (found in 50% if specifically sought on culture)
and Eikenella corrodens.27-29 Eikenella corrodens
is sensitive to penicillin.
SRPS Volume 9, Number 32
The clenched-fist wound to the metacarpo-
phalangeal joint is a notoriously underestimated
and undertreated injury. All of these patients should
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-
cocci, streptococci, or Eikenella corrodens, a rea-
sonable first line therapy would be penicillin plus
dicloxacillin (penicillinase-resistant).35 Cephalexin or
erythromycin can be used in patients with a penicil-
lin allergy.
Animal Bite Wounds
Domestic dogs are responsible for 90% of all
animal bites. More than half these dog attacks
involve young children, and of the resulting
wounds about half are to the hands and forearms.
Dog bites become infected less often than human
or cat bites. A dog’s jaws can exert a force of 150
to 450 psi, which is sufficient to devitalize tissues.
The resulting wound can be a puncture, lacera-
tion, avulsion, crush, or combination of the afore-
mentioned.87,88 Like the human bite, the most com-
mon pathogens isolated will be a mixture of
aerobes (esp. S. aureus and Strep. viridans), anaer-
obes (various Bacteroides species), and also Pas-
teurella multocida.29-32 Pasteurella infection should
be suspected if there is an acute onset of cellulitis,
lymphangitis and a serosanguinous or purulent
discharge from a hand wound within 24 hours of
a dog or cat bite. Fortunately, Pasteurella multocida
is sensitive to penicillin.
9
SRPS Volume 9, Number 32
Unlike human bite wounds which should not be
closed primarily, most dog bite wounds89,90 should
be thoroughly irrigated with normal saline, have
the margins sharply excised (especially over joints,
tendons, vessels, and nerves), and have the edges
loosely approximated with sutures. Most of the
organisms commonly encountered in dog saliva
are sensitive to penicillin, so a 5 day oral course
should also be prescribed.36 The tetanus status of
the patient and the rabies status of the animal should
be verified and treated as appropriate.
Domestic cat bites account for only 5% of ani-
mal bite wounds to the hand. The configuration of
the teeth of a cat is different from a dog’s. Cat’s
teeth are long and sharp, and the injury subse-
quently inflicted tends to be a deep puncture
wound.91 There is significantly less devitalization of
tissues, so wound debridement needs to be com-
mensurably less. The wound should be irrigated
and loosely approximated if sufficiently large to
warrant suturing.92 An oral course of penicillin
should be prescribed to cover Pasteurella.
Cat bites may also give rise to cat-scratch fever,
an infection caused by an intracellular gram nega-
tive rod. The primary lesion is a small pustule or
furuncle with surrounding edema at the site of a
cat scratch or bite. A similar lesion is seen at the
regional lymph nodes. The course of the disease is
benign and self-limiting, and treatment is symptom-
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.
ATYPICAL MYCOBACTERIAL INFECTIONS
The incidence of tuberculosis of the hand has
diminished at a rate commensurate with the decline
in pulmonary tuberculosis.93-95 In its place, however,
are infections caused by atypical mycobacteria, which
increase yearly.96-98 The three major atypical myco-
bacteria involved in hand infection are M. marinum,99-
102
M. kansasii,103-105 and M. terrae.106-108
M. marinum is the most common mycobacterial
species to infect the hand. It lives in warm water
environments and has been cultured from con-
taminated swimming pools, fish tanks, piers, boats,
and stagnant water. It is endogenous to fresh and
saltwater marine life. M. marinum survives best at
31°C, and for this reason, produces infections on
the extremities, rather than deep body cavities.96-101
10
Infections with M. marinum follow a break in the
integrity of the skin, often from an insignificant abra-
sion on the dorsum of the hand or over the inter-
phalangeal or metacarpophalangeal joints of the
fingers. Infection of the hand progresses through a
spectrum of indolent skin ulcers through subcuta-
neous granulomas with sinus tracts, tenosynovitis
(flexor and extensor), and septic arthritis or osteo-
myelitis.109,110
Treatment of superficial disease may be success-
ful with chemotherapy alone, both minocycline and
co-trimoxazole having been shown to be effec-
tive.111,112 The largest study to date from Hong Kong
suggests that chemotherapy alone may also be
applicable to more extensive disease.111 Generally
with deeper disease treatment will also require sur-
gery with radical synovectomy and more specific
antimycobacterial therapy with rifampicin and
ethambutol for up to 2 years.
The early clinical diagnosis of mycobacterial
infections will only be made with a high index of
suspicion. When mycobacterial infection is sus-
pected, cultures should be performed both at 31°
and 37°C, or else M. marinum infections may be
missed. Positive cultures for mycobacterial strains
will take at least 6 weeks for identification, there-
fore treatment may be instituted on the basis of
granulomas seen on histology or acid-fast bacilli
seen on a smear.
VIRAL INFECTIONS
Herpes Simplex Virus
Herpes simplex virus infection of the hand may
be caused by a primary or recurrent infection
with either HSV-1 or HSV-2. It tends to occur in
three distinct patient subgroups. The first and
largest group is adolescents with genital herpes,
who tend to be infected with HSV-2. The remain-
ing groups tend to be infected with HSV-1. The
second group involves children with oral gingi-
vostomatitis,113,114 while the third group is adult
health care professionals who deal directly with
potentially infected oral and respiratory secre-
tions—ie, dentists, anesthesiologists, surgeons, and
nurses. 115
Herpetic infection of the hand typically involves
the fingers or thumb in the vast majority of
cases.116 The infection initially declares itself with

a prodromal phase of approximately 72 hours’
duration, with severe pain or tingling in the
affected digit, followed by erythema and swell-
ing. Over the ensuing hours to days vesicles
appear and coalesce, often around the epony-
chium and lateral nail fold. It is at this stage that
the viral infection is most likely to be mistaken
for a bacterial felon or paronychia. However, the
pulp is usually not tense as it would be in a bacte-
rial felon. There may be associated lymphangitis.
This whole process takes about 2 weeks and
then resolves again in another 7 to 10 days.
Reactivation of latent virus occurs in only about
20% of hand patients.117 It is not normally as
severe as the primary infection and lasts for about
7 to 10 days.
It is possible to confirm the diagnosis by labora-
tory investigations, including viral cultures. The
Tzanck smear is relatively inexpensive and rapid.118
Although not quite as sensitive as viral cultures, it is
still a useful adjunct in diagnosis, especially if per-
formed early in the course of the disease, during
the vesicular or pustular stages.
The treatment of herpetic infections of the hand
is primarily nonsurgical. Rest, elevation and anti-
inflammatory analgesia are the mainstays of treat-
ment. In immunocompromised patients, aggressive
therapy with intravenous acyclovir may be war-
ranted in an attempt to prevent a life-threatening
viremia.119,120
INFECTIONS IN IMMUNOCOMPROMISED
PATIENTS
Immunocompromised patients can develop
hand infections from opportunistic organisms.
The management of these patients is identical
irrespective of the underlying etiology. Many of
the fungi, viruses, and mycobacteria will only be
cultured under very exacting laboratory condi-
tions. Diagnosis will almost certainly necessitate
formal surgical tissue biopsy. Treatment will be
dictated by the organism cultured, but as many
of these unusual organisms can take several
weeks to grow, therapy must be instituted “on
spec”. If a fungal etiology is most likely, intrave-
nous amphotericin B will be the first line treat-
ment. Similarly, for a viral etiology, of which her-
pes simplex is the most likely, intravenous
acyclovir will be administered. Finally, if a
SRPS Volume 9, Number 32
mycobacterial species is suspected, triple-agent
therapy (rifampicin, ethambutol, isoniazid) will be
instituted.
Diabetes Mellitus
Candida albicans infections of the nails are com-
mon in diabetics, so much so that a random blood
glucose should be done as a baseline in any pa-
tient presenting in this way. The same has been
suggested by some groups for a first presentation
with flexor tenosynovitis.121 Infections can com-
mence from relatively simple injuries (eg, felons
and suppurative flexor tenosynovitis following
finger-stick blood test for glucose levels).56,122 Mi-
crobiology often shows a mixed flora, and S. aureus,
so commonly encountered in “normal” patients
with suppurative hand infections, is often grossly
outweighed by gram negative organisms.123 Dia-
betics often present with advanced disease (bone,
tendon, or deep space infection), which may also
reflect a peripheral neuropathy as a causative fac-
tor.124-126 Finally, many will go onto amputation,
either to control infection or because the function
in the remaining part is so poor as to be a hin-
drance or danger to the patient.
Treatment of hand infections in diabetics must
be early and aggressive if useful function is to be
maintained and amputation avoided.123-126 Obvious
abscesses must be drained and appropriate speci-
mens taken for aerobic and anaerobic cultures. X-
rays should be performed and supplemented by
bone scans, if indicated. Broad-spectrum intrave-
nous antibiotic cover should be instituted and
appropriately modified after cultures are returned.
Likewise, rehabilitation should be aggressive and
instituted as soon as the acute manifestations of
the infection are on the wane.
TUMORS
Several authors offer excellent reviews of the
spectrum of hand neoplasms including their inci-
dence, etiology, anatomic distribution, and man-
agement, which almost always involves surgical
removal.127-133 Only the more common hand tumors
will be discussed here. The overwhelming majority
of hand masses are benign, and true neoplasms
are rare in the hand (Table 2).
11
SRPS Volume 9, Number 32
Table 2
Grading of bone and soft tissue tumors of the hand
(Reprinted with permission from Mankin HJ: Principles of
diagnosis and management of tumors of the hand. Hand Clin
3:187, 1987).
SOFT TISSUE TUMORS
Ganglia
Ganglia are the most common benign tumors in
the hand. 134-136 Although trauma is commonly
thought to be implicated in the development of
ganglia, a traumatic antecedent has been docu-
mented in only a small percentage of patients. The
pathogenesis is thought to be mucoid degenera-
tion of fibrous connective tissue in joint capsules
or tendon sheaths occurring idiopathically or sec-
ondary to injury or irritation. Ganglia are 2-3X more
common in women than in men. The usual clinical
presentation is that of a mass with or without pain.
Occasionally occult ganglia may present as
paresthesias or weakness from nerve compres-
sion.137-140 Occasionally ganglia may even arise
within tendon141 or bone.142
Ganglia in the wrist and hand are of five main
types:
I. Dorsal wrist ganglion. The dorsum of the wrist
accounts for 70% of all ganglia in the hand and
wrist. In this location the ganglion usually overlies
the scapholunate ligament. Clay and Clement143
noted the pedicle of the ganglion to arise from this
site in 76% of patients. The etiology of dorsal wrist
ganglia is still uncertain, but there is some evidence
for an underlying periscaphoid ligamentous insta-
bility.144
12
II. Volar wrist ganglion. The volar wrist location
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
them. These ganglia are believed to be a direct
result of pressure damage to the fibrous sheath
and require excision only if symptomatic, taking a
small cuff of pulley as required.147
IV. Mucous cysts. Ganglia arising in association
with tendons and joints on the dorsal aspect of fin-
gers may originate from the extensor tendon itself
or, more commonly, from the joint capsule.148-150
They occur primarily in older women who have
osteoarthritic changes of the underlying joint, usu-
ally the DIP joint. Where an underlying arthritic
joint is the cause of the ganglion, the joint must be
debrided or the ganglion will recur.
Mucous cysts can produce a deformity of the
nail plate from pressure on the nail bed. Brown
and coworkers151 report their experience with 26
nail deformities secondary to mucous cysts of the
distal interphalangeal joint managed by excision
of the cyst and debridement of associated
osteophytes. No recurrences were seen at fol-
low-up, and residual nail deformity in 8 patients
was negligible.
Pathologic Anatomy
Ganglions typically have a uni- or multilocular
main cyst that communicates with smaller intra-
articular cysts through a tortuous, continuous,
one-way valvular system of ducts.133 Microscopic
examination of the ganglion wall typically reveals
compressed collagen fibers with no evidence of
cells of epithelial or synovial origin.152,153 The cyst
contains viscous mucoid material consisting of
glucosamine, albumin, globulin, and hyaluronic
acid.

Management
Rosson and Walker reviewed the natural his-
146
tory of ganglions in children and note that 22 of 29
lesions resolved spontaneously. A conservative
approach to ganglions is therefore advocated in
young patients.145,146 The management of wrist gan-
glions in adults is controversial. The literature sup-
ports a spontaneous regression rate of 38%-58%,154
while treatment of all types is associated with recur-
rence rates from <1%136 to up to 50%155 (average
24%). Incomplete excision of the cyst stalk com-
plex probably accounts for the high recurrence
rate.156 Prevention of recurrence depends on iden-
tification and excision of the involved segment of
joint capsule and deep attachments of the cyst
pedicle to the scapholunate ligament, but only mini-
mal resection of the ligament itself to prevent future
scapholunate dissociation (Fig 10). Clay and Clem-
ent143 noted only 3.2% recurrence with this proto-
col. More radical procedures pose a greater risk of
subsequent stiffness, hypertrophic scar, wound
infection, and nerve damage.
Fig 10. A representation of a ganglion with its pedicle attached
to the scapholunate ligament. (Reprinted with permission from
Minotti P, Taras JS: Ganglion cysts of the wrist. J Am Soc Surg Hand
2(2):104, 2002.)
Herbert157 believes that symptomatic dorsal wrist
ganglia are the result of scaphoid instability which,
if present on clinical examination preoperatively, is
treated by a dorsal capsulorrhaphy of the wrist com-
bined with ganglion excision. Of 7 patients oper-
ated on for recurrent ganglia in whom a capsulor-
rhaphy was performed, none had recurrence of
ganglia at 12 months.
SRPS Volume 9, Number 32
The treatment of wrist ganglia is indicated only
in the event of significant discomfort or deformity.
While surgery is the mainstay of treatment, various
nonoperative techniques have been advocated.
Aspiration158,159 or injection of enzymes,160 scleros-
ing agents, or cortisone have been suggested, but
all have a significant recurrence rate. Arthroscopic
resection of the ganglion may be associated with a
lower recurrence rate.161-163 It can also identify the
exact origin of the ganglion as well as other intra-
articular pathology.
Giant-Cell Tumor of Tendon Sheath
Giant-cell tumors are the second most frequent
hand tumor. They typically occur in the fingers of
20- to 40-year-olds and are slightly more common
in women. Giant-cell tumors of tendon sheath are
also known as pigmented villonodular synovitis
when they arise from the volar joint recess.164,165
There is no evidence that repeated hemorrhage,
friction, or cholesterol imbalance contributes sig-
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
cells of a fibrous xanthoma. In the more cellular
areas mitotic figures are seen, but never in large
numbers. Also present are spindle cells, multinucle-
ated giant cells, foam cells, and reticulin.167,168 The
tumor may erode bone by pressure169 and/or infil-
trate the overlying dermis.170 Frank bony invasion
has been documented.171
Treatment is complete local excision, ensuring
total clearance of the volar joint recess. Recurrences
are unfortunately common, especially in the fin-
gers, and are the result of inadequate resection for
which repeat excision is recommended.172 Exten-
sive recurrences often necessitate arthrodesis of
13
SRPS Volume 9, Number 32
the affected joint, as resection of violated ligaments
and joint capsule may be required. Very occasion-
ally amputation is needed. Despite infiltrative growth
patterns, rapid recurrence, and a frequently confus-
ing histological appearance, giant-cell tumors are
considered benign.173
Vascular Lesions
Several authors offer excellent reviews of vascu-
lar tumors of the hand and upper extremity.174-178
Upton and Coombs discuss pediatric vascular
tumors.179
Glomus Tumor
Glomus tumors are benign hamartomas of the
normal glomus apparatus, which consists of arte-
riovenous anastomoses involved in the regulation
of cutaneous circulation.180-183 Glomus tumors are
usually less than 1 cm in diameter (often measuring
only a few millimeters), and classically present with
the triad of pain, pinpoint tenderness, and cold sen-
sitivity. Transillumination is a simple and useful clini-
cal test.184 The most common site of presentation
is subungual, but occasionally they may occur on
the volar surface of a digit. Approximately one-
quarter of all glomus tumors are multiple.185,186
Ultrasound187-189 and MRI190-192 are used as aids in
diagnosis and also to detect multiple tumors.
Treatment is by excision; if subungual, care
should be taken to repair the nail bed after removal
of the tumor. The major problems after surgical
treatment are a high recurrence rate and a residual
nail deformity.193-195
Ulnar Artery Aneurysm
Ulnar artery aneurysms are almost always post-
traumatic (“hypothenar hammer syndrome”196,197),
and occur predominantly in males.198,199 Typical clini-
cal features are a pulsatile mass accompanied by
digital ischemic changes with or without distal
emboli.200,201 An ulnar nerve Tinel’s sign is often
present.202 An Allen’s test should be performed to
ascertain patency of the ulnar artery, and arterio-
graphy will rule out thrombosis of the ulnar artery
and embolic showering. Management consists of
aneurysm resection and ligation of the ulnar artery,
with autogenous vein grafting in cases of inadequate
collateral circulation.203,204 Regional thrombolysis
14
may also be considered in cases with emboliza-
tion.201
Peripheral Nerve Tumors
True neural cell tumors are rare in the hand (1%-
5% incidence)205. All lesions arise from Schwann
cells. 206-208 While no uniform classification of
peripheral nerve tumors exists, most clinicians refer
to five general types:
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-
rilemmomas begin as asymptomatic nodular swell-
ings without associated sensory or motor abnor-
malities. When exposed surgically, they are seen
to have a dumbbell shape and to lie extrinsic to the
nerve fiber proper. Histologically they are made up
almost exclusively of Schwann cells. Excision
involves enucleation under magnification so as to
preserve nerve fibers that fan out over the tumor.
Recurrences are rare and malignant degeneration
is not a clinical feature.
Unlike neurilemmomas, neurofibromas can
intimately proliferate within nerve fibers, producing
functional abnormalities and making excision more
difficult without division of the nerve. Histologically
they are difficult to differentiate from neurilemmo-
mas, although they exhibit mast cells, lymphocytes,
mucoid material, and xanthoma cells in addition to
Schwann cells.210 Solitary lesions are usually seen
before age 10. Neurofibromas can cause gigan-
tism of the affected part.211,212
Neurofibromatosis (von Recklinghausen’s dis-
ease) is an autosomal dominant condition charac-
terized by multiple peripheral and central neurofi-
bromata (acoustic neuromas, meningiomas, optic
gliomas). Temporal lobe involvement may erode
the greater wing of the sphenoid, producing pulsa-
tile exophthalmos.212 Extremity involvement may
produce gigantism of the limb.213 Diagnostic café
au lait spots, numbering more than six, occur on
the skin. The individual tumors manifest a plexiform
pattern. Sarcomatous degeneration has been
reported in 2%-3% of lesions.214
Neurofibrosarcomas (neurosarcomas or malig-
nant schwannomas) account for 2%-3% of malig-
nant hand tumors and are usually associated with
von Recklinghausen’s disease.215 Local extension

and metastases are common, resulting in 90% mor-
tality. Wide excision or amputation of the extremity
is the recommended treatment.
Intraneural tumors of nonneural origin may
include lipofibromatous hamartomas, hemangio-
mas, ganglion cysts, and lipomas.216 Lipofibromatous
hamartomas are commonly seen within the first
decade of life and usually involve the median nerve.
They may result in macrodactyly, especially of the
index and middle fingers.217 Treatment involves
release of the carpal tunnel after excision of the
tumor under magnification. Malignant degenera-
tion has not been reported.
Epidermal Inclusion Cyst
Epidermal inclusion cysts commonly occur on
the palmar surface of the hand or digits of patients
whose work or leisure activities predispose them
to penetrating hand injuries. The time from the
traumatic incident to cyst development varies from
months to years. Clinically the lesions are firm,
spherical, and nontender. The cyst wall consists of
squamous epithelium with laminated keratin and
the cyst material contains protein, cholesterol, fat,
and fatty acids.
Spontaneous rupture is common, but the lesion
often persists unless the cyst lining, contents, and
overlying puckered skin are surgically removed.
Local complications include infections and bone
erosion.
Malignant Skin Tumors
Malignant tumors of the skin of the hand make
up a very small percentage of upper extremity neo-
plasms218-220 and are primarily squamous cell car-
cinomas (SCC).221-224 Squamous cell carcinomas
predominate among people with fair skin and light
hair colour. The usual origin of SCC is ionizing
solar radiation. Other less common causes of SCC
are previous irradiation,225 burn scars, exposure to
arsenic compounds, and inherited genetic disor-
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
palms227 and subungually.228-231 Appropriate treat-
ment consists of wide excision unless there is evi-
dence of nodal metastasis or local recurrence, in
which case axillary lymphadenectomy is recom-
SRPS Volume 9, Number 32
mended. SCC of the hand is an aggressive tumor
prone to recurrence and metastasis. The metastatic
rate for SCC of the hand is higher than elsewhere
on the body, particularly if the primary lesion
involves the digital web space.222
Basal cell carcinoma (BCC) is a very uncom-
mon tumor on the finger.232 Palmar variants are
seen,233 especially in Gorlin’s syndrome (multiple
nevoid basal call carcinoma syndrome),234 and it has
also been reported subungually235, where differen-
tiation from a subungual melanoma must be made.236
Although BCC do not metastasize, they are locally
aggressive. Excision is the usual form of treatment.
Melanoma of the hand can occur on the
palm237-246 or subungually.247-250 A recent study by
Ridgeway et al showed that the acral histological
subtype does not affect the disease-free and over-
all survival.246 Tumor thickness remains the only
prognostic indicator. Slingluff et al found that acral
melanoma has a strong racial predilection, carries a
grave prognosis, and arises from glabrous skin.243
In their study there was no survival difference
between volar and subungual sites. Amputation did
not make a difference either. Melanoma requires
wide excision or amputation of the digit or hand,
depending on location and depth.251-253 The appro-
priate level of amputation has not been determined.
Papachristou247 advocates amputation through the
carpometacarpal joint, whereas Finley et al249 per-
formed 7 finger amputations distal to the metacar-
pophalangeal joint (4 just proximal to the DIP joint
and 3 just proximal to the PIP joint) with no local
recurrences. Quinn et al250 have shown no differ-
ence in local recurrence for subungual melanomas
whether amputations are performed proximal or
distal to the IP joint of the thumb or the middle of
the middle phalanx in the fingers. Likewise there
has been no prospective study to date to show a
survival or local control benefit for prophylactic
lymph node dissection, regional perfusion, or
immunotherapy.254-256
BONY TUMORS
Several authors offer excellent reviews of bony
tumors of the hand.257-259 Treatment is based on
accurate diagnosis and staging of the lesions
(Table 3).
15
SRPS Volume 9, Number 32
TABLE 3
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
Chrondromas are the most common benign car-
tilaginous tumors of the hand.260,261 Chondromas
that remain within the substance of the bone or
cartilage are called enchondromas.262-264 Enchon-
dromas favor the tubular bones of the hand, espe-
cially the middle and proximal phalanges. Congeni-
tal cartilaginous rests are implicated in their origin,
and the lesions are totally benign, with little ten-
dency toward malignant degeneration. Nelson et
al265 reviewed the literature and found only three
well-documented cases of chondrosarcoma aris-
ing from enchondromas.
Enchondromas usually appear as well-demar-
cated, round or oval swellings. A pathologic frac-
ture is often the first indication of their presence. In
this instance the fracture should be allowed to heal
before the enchondroma is treated. Radiographi-
cally enchondromas appear as radiolucent, sym-
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
bone grafting.266,267 Hasselgren et al268 question the
need for bone grafting and report excellent bone
healing with curettage alone. They believe that
bone grafting should be reserved for the rare cir-
cumstance in which “the tumor has so severely
damaged the bone stock that the bone is likely to
collapse during surgery”.268
Multiple enchondromas are rare in the hand
and always occur as part of a disseminated involve-
ment (Ollier’s dyschondroplasia). 269 Multiple
enchondromas associated with hemangiomas are
part of Maffucci’s syndrome. The earliest clinical
manifestations of multiple enchondromatosis are
swelling and deformity of several bones.270 The
16
tumors distort, expand, and sometimes erode the
bony cortex, particularly in the diaphyses and meta-
physes; calcifications are seen in the translucent
areas on x-ray. Because 20% of multiple enchon-
dromas go on to become chondrosarcomas, wide
excision is the treatment of choice, with adjuvant
radiotherapy to the malignant lesions.
Osteochondromas are the most common car-
tilaginous neoplasm in the body overall , but are
less common than enchondromas in the
hand.271,272 The lesions occur primarily in young
patients. Like enchondromas, osteochondromas
arise from congenital cartilaginous foci, which
qualify them as manifestations of a congenital
dysplasia. There is a very slight risk (1%) of ma-
lignant transformation. Radiographically osteo-
chondromas appear as bony protuberances
extending beyond the metaphyseal cortex of the
involved bone on a narrow stalk.
Exostoses
Exostoses usually require no treatment.
Subungual lesions typically have a traumatic
antecedent, and are characterized by pain on
pressure to the nail plate months after the
injury.273,274 X-ray readily differentiates this lesion
from other entities. If required, the deformed
nail can be removed and the mass excised from
the distal phalanx.
Bone Cysts
Aneurysmal bone cysts tend to show an equal
sex distribution and are more common in the sec-
ond decade of life, but still before closure of the
epiphyseal plate. Aneurysmal bone cysts are

eccentrically placed in the metaphysis or diaphysis,
are expansile and lucent, and resemble a periosteal
blowout.275,276 Surgical resection or curettage with
bone grafting is usually curative unless the cyst has
been incompletely excised.
Osteoid Osteoma
Osteoid osteoma is a benign osteoblastic tumor
that is uncommon in the hand.277 The lesion affects
male patients 2-3X times more often than females,
and generally between the ages of 10 and 25 years.
Osteoid osteoma is most frequent in the distal pha-
langes.278,279 The etiology is unknown.
The nidus of an osteoid osteoma consists of
richly vascularized osteoblastic osteoid tissue rarely
larger than 1 cm. Clinical presentation is that of a
localized, painful area over a tubular bone. Typi-
cally the pain is worse at night, and is completely
relieved by aspirin. There may be an increase in
size of the terminal digit. Radiographically, the lesion
shows a central area of lucency that may be sur-
rounded by a zone of sclerotic bone. Bone scintig-
raphy with 99mTc is of benefit in locating the nidus
and CT280 has also been used. Treatment involves
complete excision of the lesion and packing of the
cavity with cancellous bone.
Osteoblastoma
Like osteoid osteoma, osteoblastomas are rare
in the hand, favor the tubular bones, and occur
primarily in young patients. Unlike osteoid osteo-
mas, osteoblastomas exhibit no sex predilection
and are usually larger than 1.5 to 2 cm. Because of
the bone destruction accompanying osteo-
blastomas, the differential diagnosis includes osteoid
osteoma, aneurysmal bone cyst, and malignant
tumors. The entire bone must be removed for cure.
Radiotherapy is helpful in tumor cell control and
may even aid in healing.
Giant-Cell Tumor of Bone
Giant-cell tumors are uncommon anywhere.
They represent about 5% or less of all primary
malignant bone tumors, and only 2% to 5% of
giant cell tumors occur in the hand.281 The lesion
affects patients primarily between the ages of 30
SRPS Volume 9, Number 32
and 50, and is virtually unknown in the under-20
age group. Women outnumber men slightly.
Clinically this is a solitary lesion, often well
advanced by the time it is noticed. A dull, constant
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
affected, with extension to the adjacent metaphy-
sis. The tumor is translucent and the cortex of the
bone is noticeably thin. The clinical course is long
but localized. Sarcomatous degeneration averages
10%, and the lesion metastasizes in approximately
15% of cases.284-287
Treatment consists of wide resection with
autograft or allograft replacement.288-290 The recur-
rence rate is high (75%). Amputation is reserved
for recurrent or highly malignant tumors.
SARCOMAS
Sarcomas are very uncommon tumors in the
hand. The pathological subtypes of soft-tissue
sarcomas 291-293 and malignant primary bone
tumors294,295 are reviewed by several authors. Cur-
rent treatment protocols for both bony and soft
tissue extremity sarcomas are also reviewed.296-304
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
avoided and is saved for the management of local
recurrences. When these sarcomas fail, they tend
to do so at distant sites. In this circumstance, a
functional hand provides a better quality of life.
Skeletal sarcomas
Ewing’s sarcoma accounts for approximately 6%
to 10% of primary malignant tumors of bone and is
rare in the hand.305-307 It affects males twice as often
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
permeation, soft-tissue mass, and often a sclerotic
reaction.308 Angiography, CT and MRI are often
used in treatment planning.309
Ewing’s sarcoma generally has a poor progno-
sis, although the subset of patients with Ewing’s
sarcoma of the hand can expect excellent local
17
SRPS Volume 9, Number 32
control and good function with combination
therapy.298,304
Osteosarcoma is a rare tumor in the hand,
accounting for only 0.18% of all osteosarcomas.310
Peak incidence is during the second decade of life,
with a male-to-female ratio of 2:1. The presenting
complaint is persistent, increasing pain from a rap-
idly growing mass. 311,312 The pathogenesis is
unknown. The lesions may arise de novo or may
be secondary to a benign process. Osteosarco-
mas in general tend to occur more frequently in
irradiated bone, Paget’s disease, fibrous dysplasia
of bone, giant cell tumor, solitary enchondroma,
multiple enchondromatosis, and multiple osteo-
chondromas.
Radiographically the borders of an osteosarcoma
are indistinct, but the lesion invariably involves the
cortex and generally transgresses it. Often there is
a large, contiguous soft tissue mass. A combination
of destructive and proliferative new bone is usually
present, showing a streaked texture and a charac-
teristic sunburst pattern. Histologically osteosar-
coma has a typical spindle-shaped cell pattern. Treat-
ment has changed from amputation to excision
with a wide margin plus adjuvant therapy. In Okada’s
study311 local control was achieved in 5 of 6 patients
using this protocol; 1 patient died from metastatic
disease.
Chondrosarcomas are uncommon in the hand,
where they are occasionally associated with
osteochondromas and, to a lesser degree, with
multiple enchondromatosis,313,314 although in the
vast majority of cases, there is no pre-existing
lesion.315,316 Chondrosarcomas characteristically
occur in older patients (60-80 years) in the epi-
physeal area of the proximal phalanx or metacar-
pal. The clinical course is slow and metastasis is
late.317,318 The tumors present as a progressively
painful large mass near the metacarpophalangeal
joint. Treatment of choice is amputation or ray
resection. Histological interpretation of cartilagi-
nous lesions of the hand is difficult, and clinical
and radiological appearance (bone expansion,
lytic areas of bone destruction, soft tissue swell-
ing) are often more reliable indicators of malig-
nancy. Prognosis is good if metastasis has not
occurred. 315,316
18
Soft Tissue Sarcomas
Rosenberg and Schiller292 offer an excellent review
of soft tissue sarcomas of the hand. Soft tissue sar-
comas are an uncommon but important group of
hand tumors. They tend to occur in young patients,
are innocuous in presentation, often leading to an
incorrect diagnosis, and have protracted clinical
courses. They are prone to local recurrence, have
an unusually high incidence of lymphatic spread and
regional node metastases, and often metastasize
systemically late in their course. Deep tumors that
are firm and 5 cm or larger should be considered to
be possible sarcomas until proven otherwise.303 CT
and MRI are often used to define the anatomy. Stan-
dard treatment is wide surgical excision with or with-
out adjunctive radiotherapy and/or chemotherapy.
The prognosis is generally poor.
Epithelioid sarcoma is the most common soft
tissue sarcoma of the hand.319 A post-traumatic eti-
ology has been proposed by some.320 Lesions are
notoriously insidious, and often mistaken for a
benign inflammatory condition.321 Most lesions in
the hand arise on the palm or volar surface of the
digits.322,323 Local recurrence is common, as is dis-
tant metastasis. Treatment recommendations are
radical excision (often necessitating a partial ampu-
tation303) and node dissection.324 Adjuvant therapy
may be of benefit.
Malignant fibrous histiocytoma is one of the
more common soft tissue sarcomas in the adult
upper extremity.303 Lesions may be superficial or
deep, single or multinodular. They extend along
tissue planes and metastasize via the lymphatics
and bloodstream.325 Treatment is primarily surgical,
with radiotherapy added unless there has been a
generous margin. The value of chemotherapy has
yet to be defined.
Alveolar rhabdomyosarcoma tends to involve
the thenar and hypothenar musculature.326,327 It is a
highly malignant, devastating tumor that presents
as a rapidly-growing, deep mass in the palm of
children.303 Local recurrence is common, and it is
invariably fatal if not treated adequately. There is a
high incidence of nodal spread and distant
metastases. The prognosis for this disease has
improved with multimodality therapy, but is still poor.

Synovial sarcoma arises in the juxta-articular
soft tissues (tendon, tendon sheath, and bursa).328 It
presents as a slow-growing tumor on the volar
surface of the hand, and delay to presentation is
often measured in years. This tumor has a poor
prognosis and a high incidence of metastases. Treat-
ment is usually surgery (often involving a partial
amputation303), radiotherapy, and chemotherapy.
Fibrosarcoma arises within the deep subcutane-
ous space, fascial septa, or muscle and presents as
an insidiously growing deep mass.329,330 Lymph
node metastases are less common in this disease,
but hematogenous spread occurs frequently. Treat-
ment is wide excision or amputation when neu-
rovascular structures are compromised.331 Adjuvant
therapy may be of benefit.
Clear cell sarcoma (malignant melanoma of soft
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
radiotherapy and chemotherapy.
Kaposi’s sarcoma is a malignant tumor that often
involves bone and may originate there. The hand
and foot are the most common locations and where
it is noticed earliest.334 Patients of all ages may be
affected, from very small children to the elderly,
with peaks in the fourth and fifth decades. Males
outnumber females by a 10:1 ratio, and there is a
strong association with AIDS.335
The first clinical signs are dark-blue to violaceous
macules on the skin that are later replaced by infil-
trative plaques and finally by nodules measuring
0.5 to 3 cm in diameter. Some of the lesions may
heal while others coalesce and ulcerate. Initially
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.
On radiographic examination the affected bones
appear decalcified in a trabecular pattern, with cor-
tical thinning as the tumor expands. Cystic erosion
shows as bites taken out of the bone.
Treatment is by a combination of radiotherapy
and chemotherapy. The prognosis varies accord-
ing to the behavior of the tumor. Fulminating lesions
SRPS Volume 9, Number 32
have a fatal outcome within 6 to 12 months of
diagnosis, whereas slower-growing tumors are com-
patible with 20-year survival.
Metastatic Tumors
Hand metastases are very uncommon and are
usually associated with a primary carcinoma in the
lung336-338 or kidney. Despite their rarity, metastatic
tumors should be considered in the differential
diagnosis of inflammatory processes of the hand.
The distal phalanges are most often involved and
metastases in this location are often mistaken for a
felon or paronychia.339-341.
Amadio and Lombardi342 recommend palliative
treatment given the median survival of only 5
months. Amputation of a phalanx, digit, or ray is
recommended for most solitary phalangeal or
metacarpal lesions when survival is expected to
exceed a few months.338
SOFT TISSUE RECONSTRUCTION
FINGERTIPS
The treatment objectives in fingertip amputations
are to:
• close the wound
• maximize sensory return
• preserve length
• maintain joint function
• obtain a satisfactory cosmetic appearance343-346
Many variables will affect the reconstructive
choice— mechanism of injury, size of the defect,
location and status of the wound, associated inju-
ries to other parts of the hand, and age, sex, gen-
eral health, and occupation of the patient.
Healing by Secondary Intention
If the skin loss is no larger than about 1.5 cm2, the
wound may be allowed to granulate and heal spon-
taneously.347-349 This type of treatment is especially
well suited to children and the elderly. All devital-
ized tissue should be debrided and any exposed
bone trimmed to lie below the soft tissue level. The
wound is covered with a semi-occlusive350 or algi-
19
SRPS Volume 9, Number 32
nate dressing which can be left intact for 5 to 7 days
and can then be changed as necessary. Complete
healing is usually obtained in 3 to 4 weeks.
Mennen350 treated extensive fingertip defects with
this method and reports excellent functional and
cosmetic outcomes. The advantage of this treat-
ment is that as the wound contracts, it will pull
proximal innervated pulp skin over the exposed
bone, resulting in a very small area of residual scar
located off the pressure area of the finger. How-
ever, if this same technique is used to treat more
dorsal fingertip defects with involvement of the
distal nail bed, the subsequent wound contraction
can lead to “parrot-beaking” of the nail, which can
be difficult to correct secondarily.
Skin Grafts
Skin grafts are commonly used to repair finger-
tip defects. They may be used as a temporizing
measure with a view to subsequent flap revision,
or they may serve as the definitive wound closure.
In the former situation, split-thickness skin is more
appropriate, as it has a more predictable “take”.
Likewise, large soft tissue defects are resurfaced
with split skin because it tends to contract more
than full-thickness skin, thus keeping the resultant
insensitive area as small as possible.343 Split-thickness
skin from the hypothenar eminence or instep of
the foot has a papillary pattern which most closely
resembles native fingertip skin.351 Beasley suggests
full-thickness donor sites from groin to minimize
the cosmetic deformity of the donor site. 343
Hypothenar full-thickness skin grafts have an excel-
lent texture match and do not hyperpigment as
groin skin tends to. Their size is limited by the
necessity to obtain primary closure of the donor
site.
Although some spontaneous reinnervation of
full-thickness skin grafts has been demonstrated,352
any insensitive or hyposensitive areas that remain
limit the application of skin grafts in the hand.353
Braun et al found no difference in 2-point discrimi-
nation between wounds covered by split-thickness
grafts and those covered by local flaps.354
Flap Reconstruction
Loss of fingertip pulp greater than one-third the
length of the phalanx requires soft tissue replace-
20
ment to support the distal nail. In these circum-
stances Beasley355 offers the following guidelines
for reconstruction:
• the replacement soft tissue must have good ulti-
mate sensibility and be capable of tolerating nor-
mal usage
• the secondary disfigurement must be insignifi-
cant, with no functional loss at the donor site
• the method must be safe, practical, reliable, eco-
nomical, and predictable in results
He further lists three indications for local flaps in
the repair of fingertip amputations: (1) a wound
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
as a nerve.
Flaps for soft tissue reconstruction of the finger-
tip can be from the same finger (homodigital),
another finger (heterodigital), local, regional, or dis-
tant sources.356-359 An enormous number of flaps
has been described and countless more will be
published in the years ahead. For a flap to be useful
clinically, it must fulfill the guidelines listed above,
but at the same time it must be reliable and simple
to perform. Only select flaps will be discussed in
the sections that follow.
Homodigital Flaps
The most immediate source of tissue for finger-
tip replacement is the same finger. The obvious
advantages are that it does not violate another nor-
mal finger or part of the body nor does it immobi-
lize uninvolved joints. The tissue used must be out-
side the zone of injury. The neurovascular integrity
of the finger should be maintained.
The tissue directly adjacent to the wound is the
closest source of flap tissue and forms the basis for
many traditionally popular flaps. The volar V-Y
advancement360,361 is useful for dorsal oblique to
transverse amputations where the defect does not
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
phalangeal segment and by elevating the flap as a
true bilateral neurovascular island flap on both
pedicles.362

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
dorsal to the neurovascular bundles so as to include
them with the flap and restore normal sensation to
the tip. The tissue movement achieved in propor-
tion to the extent of the dissection is quite disap-
pointing, and if too large a defect is closed (>1cm),
flexion contracture of the interphalangeal joint will
occur. Several authors364-366 have subsequently
modified the method of mobilization, incorporating
a V-Y closure in the advancement to make the flap
more reliable. Alternatively the flap can be con-
verted into a true island and the proximal defect
can be skin grafted.367
Snow368,369 applied the Moberg flap to the repair
of fingertip amputations, but dorsal tip necrosis
and an unstable pulp scar plagued the series. Macht
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
finger.
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 12. Oblique triangular flap. (A) Volar oblique amputation.
(B) Design and raising of flap on a digital neurovascular bundle.
(C) Closure of flap with V-Y technique. (Reprinted with permis-
sion from Chao JD et al: Local hand flaps. J Am Soc Surg Hand
1(1):28, 2002.)
Reversed digital artery island flaps from the
proximal finger necessitate sacrifice of one digital
artery and rely on retrograde flow through an intact
anastomosis with the contralateral normal artery.377-
380
They require neurorrhaphy of a dorsal branch
to the contralateral digital nerve for optimal recov-
ery of sensibility.381 A preoperative digital Allen’s
test is essential in these digits to assess the patency
of both arteries. Venous drainage of these flaps is
via the soft tissue around the arterial pedicle, so the
pedicle should not be skeletonized.
21
SRPS Volume 9, Number 32
The dorsal middle phalangeal finger flap382-384
can be raised on a short or long antegrade or
retrograde pedicle, and can be used as a free flap,
an arterial and/or venous flow-through flap, or neu-
rovascular flap.
Heterodigital Flaps
In 1951 Cronin first described the cross-finger
flap for fingertip reconstruction. 385 The cross-
finger flap brings durable cover to exposed bone,
joint, or flexor tendons when homodigital flaps
do not suffice.385-389 Blood supply of the cross-
finger flap is random and based upon the sub-
dermal plexus of an adjacent digit. The flap may
be based laterally, proximally, or distally depend-
ing on the most comfortable approximation of
donor digit to defect. The dorsum of the middle
phalanges of the index, middle, and ring fingers
is the most appropriate donor site in terms of
joint immobilization. Use of a cross-finger flap
from the volar aspect of the middle finger, rather
than the thinner dorsal finger skin, gives better
tissue quality for resurfacing the pulp of the
thumb. 355,390
Hoskins details the technical points of cross-
finger flap elevation and transfer (Fig 13).391 The
pedicle can be divided safely by the 8th or 9th
day to lessen the risk of joint stiffness from joint
immobilization.
22
Many variations of the cross-finger flap have been
described. The dorsal sensory branch can be included
in the flap and sutured to the digital nerve of the
injured fingertip,392 although this technique has not
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,
necessitating an additional skin graft on top of the
flap.393-395
Advantages of the cross-finger flap technique
are that it is easy to elevate and can carry ample
quantities of similar tissue. Disadvantages are that
it is a two-stage procedure, a skin graft is required
for the donor site (which is obvious on the
exposed dorsum of the finger), stiffness of the
involved digits is a possibility, and 2-point dis-
crimination values average only 9 mm.396,397
In a study of 54 patients with cross-finger flaps,
Nishikawa397 found that despite recovery of pro-
tective sensation, no patient had recovered tac-
tile gnosis. Maximal recovery of sensibility occurs
in those under 20 years, and 2-point discrimina-
tion plateaus at 1 year.396 Contraindications to
the use of cross-finger flaps include arthritis,
Dupuytren’s contracture, and generalized vasos-
pastic syndromes.
Littler398 and Tubiana399 developed the technique
of interdigital transfer of pedicled neurovascular
island flaps. These flaps have found their greatest
application in reconstruction of the ulnar thumb
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.
The classic thenar flap is based proximally to
ensure good venous return and minimize PIP
joint flexion. Contracture can be controlled fur-
ther by placing the thumb in full palmar abduc-
tion and bringing the MP joint of the involved
digit into full flexion.343,410 If designed properly,
the donor site can usually be closed prima-
rily.410,411 Unlike the true palmar flap, the thenar
flap is not likely to produce joint stiffness post-
operatively provided the pedicle is divided in
about 10 days.
SMALL DEFECTS OF THE HAND OR DIGITS
Homodigital flaps
Lai 412 described the adipofascial turn-over
flap, in which dorsal defects of the finger and
hand can be resurfaced by a flap of subcutaneous
tissue hinged on a pedicle which borders the
defect. It is especially useful in abrasion injuries of
the DIP joint, with exposed terminal extensor ten-
don. The donor site is closed primarily, and the
flap is grafted (Fig 14).
Fig 14. Descriptive drawings of the surgical technique. (A) The
complex defect exposing the dorsal aspect of the distal inter-
phalangeal joint. (B) Design of the adipofascial flap. The base
of the flap is adjacent to the defect. (C) Development of the
distally based adipofascial flap. (D) The flap is turned over on
itself to cover the defect. (E) Primary closure of the donor site.
The flap is covered with a split-thickness skin graft. (Reprinted
with permission from Al-Qattan MM: The adipofascial turnover
flap for coverage of the exposed distal interphalangeal joint of the
fingers and interphalangeal joint of the thumb. J Hand Surg
26A:1117, 2001.
Heterodigital flaps
Small defects of the hand can be resurfaced using
so-called venous flaps. These flaps consist of skin
islands raised on a single-vein pedicle from the dor-
sum of the hand over the proximal phalanx, and
are used to reconstruct either the dorsal or volar
surfaces of adjacent digits.413-416
Earley417 detailed the anatomy of the second
dorsal metacarpal artery and reported various uses
for this neurovascular island flap hand reconstruc-
tion. He and others418-420 broadened the applica-
tions of the second dorsal metacarpal artery
flap.

23
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
arteries, and reports a largely successful experi-
ence in 8 cases.421
Fig 15. Design of the reverse dorsal metacarpal flap and cross-
section at distal flap. (Reprinted with permission from Maruyama
Y: The reverse dorsal metacarpal flap. Br J Plast Surg 43:24, 1990.)
In contrast, Quaba and Davidson believe the
flaps are nourished by a direct cutaneous branch
of the dorsal metacarpal artery that enters the skin
0.5 to 1 cm proximal to the adjacent metacarpopha-
langeal joint422,426 (Fig 16). They raised reverse
DMA flaps on the 2nd, 3rd, and 4th intermetacarpal
spaces in 21 patients, and report one partial loss
and one failure.422 Donor sites up to 2 cm wide can
be closed primarily.
24
Fig 16. The arterial basis of the distally based dorsal hand flap
is a direct branch from the dorsal metacarpal artery that enters
the skin 0.5 to 1 cm proximal to the adjacent metacarpopha-
langeal joint. (Reprinted with permission from Quaba AA,
Davison PM: The distally based dorsal hand flap. Br J Plast Surg
43:28, 1990.)
LARGE DEFECTS OF THE HANDS OR DIGITS
Regional Flaps
The regional flaps applicable for resurfacing the
hand are based on the three major arteries of the
forearm, 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-
tendon-skin.437-439
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
anywhere in the hand. They described a cross-
over pattern of communicating branches between
the paired venae comitantes and identified small
superficial collateral branches of each vein, which
effectively bypass the valves. This system enables
the flap to be drained despite competent valves.
Even in significant hand trauma where the palmar
arches are in question, the flap has been raised
successfully, based on communications proximal
to the wrist.441,442
There are two main disadvantages of the radial
forearm flap. Foremost is that a major vessel to the
hand is sacrificed, but Kleinman and O’Connell443

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.
The unesthetic and potentially unstable grafted
donor site of the radial forearm flap remains the
major detractor of this otherwise excellent flap.448
Skin graft take is not usually a problem in flaps
used for hand reconstruction, as the flap is based
proximally over the muscle bellies. If the flap needs
to be raised in the distal forearm over the flexor
tendons, graft take can be improved by a
suprafascial dissection of the flap.449 Many meth-
ods have been proposed to improve the donor
site, including direct closure, full-thickness skin
grafts, local flaps, and tissue expansion.450-455 Split-
thickness skin grafting remains the standard in most
centers.
In 1984 Lovie et al456 described the ulnar artery
island flap, and 4 years later reported their expe-
rience with this method in hand and forearm re-
construction.457 The skin territory of the flap over-
lies the proximal ulnar aspect of the forearm, which
is almost always hairless and less visible than the
radial border. They and others458-461 found the ul-
nar flap to be superior in terms of esthetics, easier
harvesting of bone and muscle (flexor carpi
ulnaris), direct closure of the donor site, and lower
morbidity.
The posterior interosseous artery flap is based
on the communication between the anterior and
posterior interosseous arteries.462-467 The posterior
interosseous artery runs in a fascial septum
between the extensor carpi ulnaris and extensor
digiti minimi muscles (Fig 17). A segment of ulna
can be taken as a composite flap.468 The advan-
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
the visible dorsum of the forearm, limited size of
the flap, and unreliability of the vascular communi-
cation.469-472
SRPS Volume 9, Number 32
Fig 17. Cross-section of the distally based posterior interosseous
island flap taken at the middle one-third of the forearm. The
posterior interosseous artery reaches the overlying skin in the
space between the extensor carpi ulnaris (ECU) and extensor
digiti minimi proprius (EDMP). (Reprinted with permission from
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,
1991).
Distant Flaps
Large flaps of skin can be transferred to the hand
from distant sites by means of traditional pedicled
techniques or microvascular free tissue transfer.
Pedicled Flaps
Flaps of skin from remote sites over the chest
and abdomen were traditional methods for resur-
facing large wounds of the upper extremity. The
most commonly used pedicled flap is the groin
flap based on the superficial circumflex iliac artery473-
476
or the superficial inferior epigastric artery.477
Groin flaps are axial-pattern flaps with reliable vas-
cularity. However, they necessitate two surgical
stages, the hand remains dependent during the
initial period of flap attachment, encouraging edema
and stiffness. In addition, groin flaps are too bulky
for dorsal hand resurfacing and require subsequent
revisional surgery.
Chow et al478 offer their experience with 36 groin
flaps used in delayed primary or elective second-
ary hand resurfacing, while Arner and Moller479
highlight potential complications.
Microvascular Free Tissue Transfer
Microvascular free tissue transfer allows a single-
stage composite reconstruction of complex hand
defects,480-488 obviating the need for cumbersome,
25
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-

26

lar flap can be raised as a fascial flap529 or as an
osteofascial flap.530 Both flaps have the disadvan-
tage that they are bulky, even in thin individuals,
and secondary defatting or liposuction is necessary
for an optimal aesthetic contour.
The free groin flap gives an unsurpassed donor
site and allows the transfer of a large quantity of
hairless skin. Like the pedicled groin flap, it is too
bulky for resurfacing the hand and requires
revisional defatting and/or liposuction.
Recent interest in perforator flaps has led to the
growing popularity of the anterolateral thigh
flap531,532 and the tensor fasciae latae perforator
flap533,534 in dorsal hand reconstruction. Large flaps
of very thin skin can be raised with minimal donor
site morbidity. As the flaps are based on perforat-
ing vessels, the motor function of the underlying
TFL is preserved.
The anatomy of the temporal region has been
elucidated by several authors.535-537 Upton et al538
discuss the various applications of free temporo-
parietal fascial flaps in dorsal hand resurfacing.
Temporoparietal fascia is most commonly used in
the upper extremity to wrap exposed or contracted
tendons.538-543 The deep areolar surface of the flap
is turned toward the tendons to provide a smooth
gliding surface. The overlying fascia is thin and pli-
able for metacarpal contouring. A skin graft com-
pletes the reconstruction. This fascial flap is also
SRPS Volume 9, Number 32
excellent for filling the three-dimensional defect
resulting from the extensive release of complex first
web space contractures. The donor defect on the
scalp is insignificant. Potential complications of flap
transfer include palsy of the frontal branch of the
facial nerve and permanent alopecia.
Another extremely thin fascial flap is the serratus
anterior fascial flap.544-547 This flap consists of the
loose areolar tissue between the latissimus dorsi and
serratus anterior muscles and is supplied by the
thoracodorsal vessels. It has a long, constant vascular
pedicle; very thin, well-vascularized tissue; low donor
site morbidity; and allows simultaneous donor and
recipient site dissection. It can also be combined
with other flaps of the subscapular system.
Free muscle flaps can only provide crude protec-
tive sensibility through pressure receptors, but their
malleability makes them well-suited to difficult con-
tour problems in the hand, especially the palm. For
small defects the serratus anterior548,549 seems most
useful, while for moderate-sized wounds the rec-
tus abdominis550,551 flap has been suggested. For
very large wounds of the upper extremity, the latis-
simus dorsi is the muscle of choice. All of these
flaps have large-diameter pedicles of very adequate
length with minimal donor site morbidity.
Functional free muscle transfers are discussed in
the “Microsurgery” issue of Selected Readings in
Plastic Surgery.
27
SRPS Volume 9, Number 32

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SRPS Volume 9, Number 32
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SRPS Volume 9, Number 32
421. Maruyama Y: The reverse dorsal metacarpal flap. Br J Plast
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446. Weinzweig N et al: The distally based radial forearm
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495. Sundine M, Scheker LR: A comparison of immediate and
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37
SRPS Volume 9, Number 32
519. Gosain AK et al: The composite lateral arm free flap:
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522. Kuek LB, Chuan TL: The extended lateral arm flap: a new
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538. Upton J et al: Clinical applications of free temporopari-
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540. Chowdary RP: Use of temporoparietal fascia free flap in
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550. Press BH et al: The rectus abdominis muscle in difficult
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551. Horch RE, Stark GB: The rectus abdominis free flap as
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 SRPS Volume 9, Number 32

RECOMMENDED READING

Zook EG: Anatomy and physiology of the perionychium. Hand Clin 6(1):1,1990.

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
hand surgery. Hand Clin 14(4):657, 1998.

Mankin HJ: Principles of diagnosis and management of tumors of the hand. Hand Clin 3(2):185,
1987.

Quinn MJ, Thompson JE, Crotty K, McCarthy WH, Coates AS: Subungual melanoma in the hand.
J Hand Surg 21A(3):506, 1996.

Al-Qattan MM: The adipofascial turnover flap for coverage of the exposed distal interphalangeal
joint of the fingers and the interphalangeal joint of the thumb. J Hand Surg 26A(6):116,
2001.

Small JO, Brennen MD: The first dorsal metacarpal artery neurovascular island flap. J Hand Surg
13B(2):136, 1988.

Quaba AA, Davison PM: The distally-based dorsal hand flap. Br J Plast Surg 43(1):28, 1990.

Cavanagh S, Pho RWH: The reverse radial forearm flap in the severely injured hand: an
anatomical and clinical study. J Hand Surg 17B(5):501, 1992.

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