The Thumb: A Guide to Surgical Management

Description

In this book, globally renowned orthopedic, plastic, and hand surgeons provide the knowledge required in order to understand and resolve the full range of problems associated with diseases, anomalies, deformities, and trauma of the thumb. The opening section describes the history of “making a thumb” and covers the fundamentals of anatomy, embryology, and functional dynamics. After careful presentation of the surgical procedures for various developmental anomalies of the thumb, subsequent sections focus on the treatment of bone and joint, tendon, and nerve problems encountered in patients with different diseases and injuries. All aspects of the surgical management of benign and malignant tumors of the thumb are then described. The final section is devoted to current and emerging treatments for trauma, including amputation and microsurgical and non-microsurgical reconstruction. The text is supported by superb clinical photographs as well as high-quality schematic drawings and video clips. The book will be of value not only to practicing surgeons but also to residents and medical students. Preface Contents Part I: Introduction 1: History of “Making a Thumb” Traumatic Thumb Defect Congenital Thumb Anomaly Thumb Duplication Thumb Hypoplasia Thumb Agenesis References 2: Anatomy and Biomechanics Skin Vascular Structures Bones of the Thumb Trapezium First Metacarpal The Proximal Phalanx The Distal Phalanx Joints of the Thumb Trapeziometacarpal Joint (TM Joint) Metacarpophalangeal Joint (MP Joint) Interphalangeal Joint (IP Joint) Functional Anatomy of the Muscles and Tendons of the Thumb Intrinsic Muscles Abductor Pollicis Brevis (APB) Flexor Pollicis Brevis (FPB) Opponens Pollicis (OPP) Adductor Pollicis (ADP) First Palmar Interosseous Muscle Extrinsic Muscles Flexor Pollicis Longus (FPL) Extensor Pollicis Longus (EPL) Extensor Pollicis Brevis (EPB) Abductor Pollicis Longus (APL) Dynamics of Opposition Summary References Part II: Developmental Anomalies 3: Duplicated Thumb and Secondary Deformity Introduction Classification Preoperative Considerations: Operation Timing and Anesthesia Operative Principles Flatt Types I and II Flatt Type III Flatt Type IV Flatt Types V and VI Secondary Deformity and Its Reconstruction References 4: Thumb Hypoplasia Blauth Classification Type I Type II Type III Type III-A Type III-B Type IV Type V Surgical Approaches to the Hypoplastic Thumb Blauth Type I Opponensplasty Blauth Type II Blauth Type III Pollicization References 5: Other Developmental Anomalies Clasped Thumb Clinical Features Treatment Treatment Considerations in Cases of Arthrogryposis Trigger Thumb Incidence and Etiological Findings Natural History Treatment Triphalangeal Thumb Treatment Symphalangism References Part III: Bone and Joint Problems 6: Fractures and Dislocations Basic Anatomy of the Thumb Thumb Phalangeal Fractures Distal Phalanx Fractures Extra-articular Fractures Intra-articular Fractures and Avulsions Mallet Thumb Extension Block Technique Open Reduction and Fixation Avulsion Fractures of the Volar Lip Proximal Phalanx Fractures Metacarpal Fractures Extra-articular Fractures Intra-articular Metacarpal Fractures Metacarpal Head Fractures Articular Fractures and Dislocations of Thumb Metacarpal Base Bennett’s Fracture Rolando Fracture Dislocations Thumb IP Dislocations Thumb MCP Dislocations Thumb TM Joint Dislocations Summary References 7: Collateral Ligament Injuries Collateral Ligament Injuries of the Metacarpophalangeal Joint of the Thumb Anatomy Pathologic Anatomy Diagnosis Physical Examination Radiographic Examination Treatment Acute Injuries Operative Approaches Surgical Technique of Open Repair of the Collateral Ligament Using a Suture Anchor Chronic Injuries Operative Approaches Surgical Technique of Anatomical Collateral Ligament Reconstruction Using Suture Anchors and a Free Tendon Graft Technical Tip Dislocation of the Metacarpophalangeal Joint of the Thumb Treatment References 8: Arthritis of the Interphalangeal Joint and Metacarpophalangeal Joint Rheumatoid Arthritis Type 1 (Boutonniere Deformity) Type 2 Type 3 (Swan Neck Deformity) Type 4 (Gamekeeper Thumb) Type 5 Degenerative Arthritis Arthrodesis of Thumb Joints IPJ Arthrodesis MPJ Arthrodesis Bibliography 9: Arthritis of the Carpometacarpal Joint Introduction Pathophysiology Clinical and Radiologic Findings Treatment for Early Arthritis Treatment for Advanced Arthritis Simple Trapeziectomy Ligament Reconstruction Operative Technique of Ligament Reconstruction (Fig. 9.2) Prosthetic Arthroplasty Carpometacarpal Arthrodesis Comparison of Clinical Results Conclusions References Part IV: Tendon Problems 10: Flexor Tendon Introduction Trigger Thumb In Children In Adults Injury Acute Injury Surgical Technique for FPL Tenorrhaphy Chronic Problems Secondary Reconstruction of FPL Complications of Primary and Delayed FPL Tenorrhaphy Postoperative Care Outcomes After FPL Reconstruction Other Problems References 11: Extensor Tendon Extensor Tendon Extensor Mechanism of the Thumb Diagnostic Imaging Classification of Extensor Tendon Injuries of the Thumb General Principles Exposures Sutures Surgical Management Zones T1 and T2 Mallet Thumb Tenodermodesis Zones T3 and T4 Zone T5 Acute Injuries Chronic Injuries or Segmental Tendon Loss of EPL Tendon EIP Transfer Interpositioning Tendon Graft Palmaris Longus Tendon Graft Procedure Complicated Injury Partial Tendon Injury References 12: Wide-Awake Tendon Surgery Introduction Dosage of Local Anesthesia in Wide–Awake Surgery of the Thumb Minimal Pain Injection Tumescent Local Anesthesia Technique for Injecting Local Anesthesia Advantages of WALANT Flexor Pollicis Longus (FPL) Repair of the Thumb Extensor Pollicis Longus (EPL) Tendon Repair of the Thumb Tenolysis of the Thumb Extensor Indicis Proprius (EIP) to Extensor Pollicis Longus (EPL) Tendon Transfer Flexor Digitorum Superficialis (FDS) of the Long or Ring Finger to Flexor Pollicis Longus (FPL) Tendon Transfer Complications and Limitations Improved Results with Tendon Surgery Conclusion References Part V: Nerve Problems 13: Sensory Loss Introduction Nerve Anatomy Sensory Nerve from the Median Nerve and Radial Nerve Sensory Receptor Sensory Representation of the Human Thumb in Cortex Sensory Physical Examination Two-Point Discrimination (2PD) Semmes-Weinstein Test Tactile Gnosis Symptoms and Cause Treatment Nerve Repair Pedicled Flap Third Finger Ulnar Side Cutaneous Island Flap Using Proper Digital Artery Second Finger Dorsal Side Cutaneous Flap Using Dorsal Interosseous Artery Free Flap Toe Pulp Free Flap Radial Artery Perforator Flap Nerve Graft/Nerve Conduit Nerve Transfer Superficial Radial Nerve to First and Second Proper Digital Nerve of Median Nerve Dorsal Ulnar Nerve to First and Second Proper Digital Nerve of Median Nerve Fourth Web Space Proper Digital Nerve to the First and Second Proper Digital Nerve of the Median Nerve Sensory Recovery, Education, and Rehabilitation Sensory Recovery and Education Sensory Rehabilitation References 14: Motor Loss Principles of Restoration of Thumb Motor Function Planning Tendon Transfer Evaluation of Donor Muscles Timing of Tendon Transfer Restoration of Thumb Opposition Correction of Thumb Deformity Donor for Transfer Surgical Techniques Restoration of Thumb Pinch Restoration of Thumb Adduction and Index Abduction Surgical Procedures of Thumb Adduction Surgical Techniques of Index Abduction References 15: Reconstruction of the Spastic Thumb Spasticity of the Thumb Deformities in Spastic Thumb House Classification of Spastic Thumb Patient Assessment Nonoperative Treatment Surgical Treatment Principle of Surgical Treatment Surgical Methods Based on House Classification Weakening of Deforming Muscles Augmentation of Weak Muscles Stabilization of the Joint Techniques Release of the Origin of Spastic Thumb Intrinsic Muscles Release or Proximal Advancement of the Insertion of the Spastic Thumb Adductor Lengthening of FPL EPL Rerouting BR to EPB Transfer FPL Abductorplasty MP Joint Volar Capsulodesis MP Joint Arthrodesis Outcomes of Treatment References Part VI: Tumors 16: Benign Tumors Introduction Evaluation and Staging Bone and Cartilage Tumors Enchondroma Aneurysmal Bone Cyst Giant Cell Tumor Osteochondroma Osteoid Osteoma Soft Tissue Tumors Ganglion Epidermal Inclusion Cyst Giant Cell Tumor of Tendon Sheath Lipoma Angiolipoma Nerve Tumor Vascular Tumors Pyogenic Granuloma Glomus Tumor Hemangioma Vascular Malformation Angioleiomyoma References 17: Malignant Tumors Basal Cell Carcinoma Introduction Clinical Manifestations Classification Differential Diagnosis Treatment Prognosis Squamous Cell Carcinoma Introduction Clinical Presentation Risk Factors Treatment Prognosis Malignant Melanoma Incidence Clinical Presentation Diagnosis Staging Treatment Subungual Melanoma References Part VII: Bone and Soft Tissue Reconstruction 18: Soft Tissue Reconstruction Palmar Advancement Flap Operative Technique Reverse Homodigital Dorsal Radial Flap Operative Technique Cross-Finger Flap Operative Technique First Dorsal Metacarpal Artery Island Flap Operative Technique Free Pulp Flap Operative Technique Recipient Site Preparation Donor Site Design and Flap Dissection Complications Flap Necrosis Flap Bulkiness Delayed Donor Site Healing Radial Artery Superficial Palmar Branch Free Flap: Modified Free Thenar Flap Operative Technique Complications Wrist Pain Donor Site Scar Flap Bulkiness Nail Reconstruction with Partial Toe Transfer Operative Technique References 19: Replantation and Revascularization Introduction General Considerations in Replantation Emergency Management Patient Selection Mechanism of Injury Ischemic Time Other Preoperative Preparatory Evaluation Surgical Techniques of Thumb Replantation Surgical Anatomy Surgical Procedure Positioning Debridement and Preparation Bone Shortening and Fixation Tendon Repair Arterial Anastomosis and Nerve Coaptation Venous Anastomosis Skin Closure and Dressing Postoperative Care Special Conditions Distal Amputation Avulsion and Degloving Amputation Segmental Amputation Transpositional Replantation Rehabilitation Outcomes References 20: Non-microsurgical Reconstruction Classification Reconstruction Methods No Reconstruction First Web Deepening Method Osteoplastic Reconstruction (Fig. 20.3a, b) On-Top Plasty Distraction Osteogenesis Pollicization Skin Incision Soft Tissue Dissection Skeletal Manipulation Extrinsic Tendon Rebalancing Intrinsic Tendon Balancing Skin Closure Other Factors Affecting Selection Reconstruction Options Summary References 21: Microsurgical Reconstruction Introduction Indications Preoperative Considerations Reconstruction According to Amputation Level Level I. Reconstruction at Very Distal Defects Distal to or at IP Joint Operative Procedure Postoperative Management and Secondary Procedures Reconstruction Options of the Very Distal Amputation of the Thumb Level II. Reconstruction at Distal Subtotal Defect Level III. Reconstruction at Proximal Subtotal Defect at MP Joint Level IV. Reconstruction for Total Defect of the Thumb Complications Donor Site Problems Flap Failure Emergency Reconstruction of the Thumb Rehabilitation and Functional Outcomes References 22: Miscellaneous Infection of the Thumb General Principles Pathophysiology Clinical Evaluation Imaging Studies Laboratory Studies Complete Blood Cell Count with Differential White Blood Cell Acute-Phase Protein Erythrocyte Sedimentation Rate Nonoperative Management of Hand Infections Surgical Management of Hand Infections Infections Paronychia Felon Septic Arthritis Osteomyelitis Onychomycosis Mycobacterial Infection Complication Seymour Fracture Burned Thumb Thumb Amputation Chronic Sesamoiditis of the Thumb Introduction and Anatomy Diagnosis Sesamoid Provocation Test [62] Case Presentation Treatment References Index