In-Service Exam
Hand - Tip - Amps - Dupuy - Vasc - 2001





Following split-thickness skin grafting, which of the following dressings can be used at the donor site to minimize discomfort, reduce the risk for infection, and decrease healing time?

(A) Bismuth tribromophenate-impregnated gauze (Xeroform)
(B) Heterograft
(C) Hydrocolloid polymer complex (DuoDerm)
(D) Silicone membrane-nylon fabric composite (Biobrane)
(E) o-Tolylazo-_-naphthol- (Scarlet Red-) impregnated gauze
The correct response is Option C.

An occlusive dressing consisting of a polyurethane foam and a hydrocolloid polymer complex (DuoDerm), or a semiocclusive dressing consisting of synthetic adhesive moisture vapor permeable films (eg, Op-Site, Tegaderm) will minimize patient discomfort, reduce the risk for infection, and decrease healing time.

Fine mesh gauzes (eg, Scarlet Red, Vaseline, Xeroform) use the semiopen technique of wound healing. Epithelialization and infection rates are favorable, but, when compared with other dressings, pain and discomfort are greater.

Another version of the semiopen wound-healing technique involves the use of a semipermeable silicone membrane and a knitted nylon fabric covalently bonded to porcine collagen (Biobrane). This method is more comfortable for the patient but is associated with a higher rate of infection following skin grafting.

Biologic dressings (eg, cadaveric skin homografts, heterografts, porcine xenografts, amniotic membranes) are frequently associated with marked inflammation of the wound, delayed epithelialization, and prolonged wound healing times.

References
1. Feldman DL. Which dressing for split thickness skin graft donor sites? Ann Plast Surg. 1991;27:288-291.
2. Michie DD, Hugill JV. Influence of occlusive and impregnated gauze dressings on incisional healing: a prospective, randomized, controlled study. Ann Plast Surg. 1994;32:57-64.
3. Smith DJ, Thomson PD, Bolton LL, et al. Microbiology and healing of the occluded skin-graft donor site. Plast Reconstr Surg. 1993;91:1094-1097.

PHOTO

The above photographs are of a 45-year-old man who sustained a crush injury to the right index finger when a 55-gallon drum fell on the finger eight days ago. On examination, there is significant compromise of the soft tissues and multiple stellate pattern injuries of the volar and ulnar aspects of the finger with marginal necrosis. There are gangrenous changes of the fingertip and only marginal vascularization of the finger to the level of the proximal interphalangeal (PIP) joint. The dense anesthesia in the distribution of the radial and ulnar digital nerves has worsened over time. The flexor and extensor tendons are intact. Radiographs show several areas of impacted debris; there is no evidence of fracture.

Which of the following is the most appropriate management?

(A) Healing by second intention
(B) Debridement and dressing changes
(C) Amputation at the PIP joint
(D) Amputation at the metacarpophalangeal joint
(E) Ray amputation

The correct response is Option E.

This 45-year-old man sustained a multilevel crush injury to his right index finger, resulting in gangrenous changes at the level of the midportion of the midphalanx. In most patients who have extensive soft-tissue and nerve damage, the affected digit should be shortened to a level at which ample soft tissue is available for primary closure of the wound. However, complete ray amputation is recommended instead in this patient because the soft-tissue injuries extend proximal to the level of the distal interphalangeal joint. This single-stage procedure will securely close the soft tissues, allowing the patient to return to work sooner. In addition, oblique osteotomy should be performed through the proximal
metacarpal flare, enhancing the curved web space. Hand function can be realized by allowing the middle finger to perform as an index finger during grasping.

Healing by second intention is typically reserved for fingertip amputations without exposed bone. In this patient who has an extensive area of injury with contamination, second intention healing may result in the development of wound sepsis. Although dressing changes can aid in wound debridement, they would be inadequate in a patient with a severely injured and possibly contaminated digit.

Staged reconstruction of the skin, tendons, nerves, and vessels would result in a stiff, insensitive digit that would be bypassed during hand activities.

Amputation at the PIP joint is rarely indicated for the index finger. Amputation through the metacarpophalangeal joint would result in a prominent, cumbersome amputation stump and would provide no advantage over ray amputation because the intrinsic and extrinsic tendons have already been sacrificed.

References
1. Louis DS, Jebson PJ, Graham TJ. Amputations. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1:48-94.
2. McKee NH. Amputation stump management and function preservation. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;7:4329-4339.

PHOTO

In the above diagram, the sterile matrix of the nail is best represented by

(A) A
(B) B
(C) C
(D) D
(E) E
The correct response is Option B.

Anatomically, A represents the hyponychium, B is the sterile matrix, C is the lunula, D is the eponychial fold, E is the germinal matrix, and F is the nail plate. The sterile matrix begins at the lunula and facilitates the adherence of the nail to the finger.

The germinal matrix lies proximal to the sterile matrix and has a component within the nail fold. It contributes to growth and development of the nail plate and the smooth, shiny surface of the nail.

The hyponychium is specialized tissue with a dense collection of keratin molecules. It is located under the distal aspect of the nail and helps to prevent infection.

The lunula denotes the endpoint of the germinal matrix and the starting point of the sterile matrix.

The eponychium is the edge of skin at the end of the nail; the nail plate is found beneath it.

References
1. Rockwell WB, Wray RC Jr. Nail bed injuries and reconstruction. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;2:1101-1111.
2. Zook EG, Brown RE. The perionychium. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1353-1380.

A 50-year-old woman has joint stiffness and shiny edema of both hands. She has had difficulty swallowing for the past several months. Examination shows ulcers on the distal tips of several fingers. These findings are most consistent with

(A) Raynaud's disease
(B) Raynaud's phenomenon
(C) reflex sympathetic dystrophy
(D) scleroderma
(E) systemic lupus erythematosus

The correct response is Option D.

The most likely diagnosis in this 50-year-old woman is scleroderma, or primary systemic sclerosis. Characteristic findings in patients with scleroderma include shiny edema of the skin and stiffness of the joints. Vasospasm of the digits may lead to ischemia and ultimately to the ulceration typically associated with Raynaud's phenomenon. These conditions may occur concomitantly as part of the CREST syndrome (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasias).

Raynaud's disease is a vasospastic disorder characterized by triphasic color changes of the skin. This disorder has no gender predilection and typically has its onset in patients age 30 to 50 years. Hand symptoms are bilateral and dysesthesias of the extremities are associated. Symptoms must be present for two years before a definitive diagnosis can be made.

In patients with Raynaud's phenomenon, there are episodic triphasic color changes of the digits following stress or cold exposure. Digital gangrene may result. This condition often occurs in patients with connective tissue disorders such as scleroderma.

Patients with reflex sympathetic dystrophy have the sudden onset of diffuse pain and hypersensitivity of one extremity following surgery or trauma to the extremity. Signs and symptoms of reflex sympathetic dystrophy include diminished hand function, joint stiffness, color changes, and vasomotor instability.

Systemic lupus erythematosus is an autoimmune disorder characterized by arthralgias of the hands, wrists, and feet and swelling of the joints. This condition typically affects women of child-bearing age. Neurologic involvement is common; a malar rash can also be seen.

References
1. Jones NF. Ischemia of the hand in systemic disease. Clin Plast Surg. 1989;16:547-556.
2. Matteucci BM, Schumacher HR. Systemic arthritic conditions of the upper extremities Ð inflammatory. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996.
3. Miller LM, Morgan RF. Vasospastic disorders: etiology, recognition and treatment. Hand Clin. 1993;9:171-187.

PHOTO

The above photograph is of a 25-year-old laborer who has sustained a crush injury of the thumb. Examination shows complete avulsion of the extensor pollicis longus tendon from its insertion as well as avulsion of the dorsal soft tissues from the germinal matrix to the midproximal phalanx. The patient wishes to maintain as much thumb function as possible.

Which of the following flaps is most appropriate for soft-tissue coverage of the wound?

(A) Dermal flap
(B) Flag flap
(C) Free flap
(D) Kite flap
(E) Muscle flap

PHOTO

The correct response is Option D.

A kite flap will provide reliable soft-tissue coverage of this patient's wound. This axially patterned flap is based on the first dorsal metacarpal artery; it can be elevated from the dorsal aspect of the proximal phalanx of the index finger. In order to reach distal defects of the dorsal thumb, the surgeon should dissect proximally to the origin of the first dorsal metacarpal artery, just proximal to the bifurcation of the dorsal radial artery and into the princeps pollicis artery and deep palmar arch. Although this flap is technically demanding, it will provide optimal results.

A dermal turnover flap from the index finger will not have a sufficient arc of rotation to cover this defect. A flag flap is best for coverage of defects involving the proximal phalanges or metacarpophalangeal joints of the fingers and should not be used for the thumb. A free flap should not be attempted when more simple options are available. A muscle flap is too bulky and would inhibit pinch strength, effectively limiting the use of the hand, which is unacceptable in a laborer.

References
1. Adani R, Busa R, Bathia A, et al. The "kite flap" for dorsal thumb reconstruction. Acta Chir Plast. 1995;37:63-66.
2. Edgerton BW, Beasley RW. Dorsal cross-finger flaps. In: Strauch B, Vasconez LO, Hall-Findlay EJ, eds. Grabb's Encyclopedia of Flaps. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 1998.
3. Foucher G, Van Genechten F. Neurovascular skin kite flap from the index finger. In: Strauch B, Vasconez LO, Hall-Findlay EJ, eds. Grabb's Encyclopedia of Flaps. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 1998.
4. Hynes DE. Neurovascular pedicle and advancement flaps for palmar thumb defects. Hand Clin. 1997;13:207-216.
5. Lister G, Pederson W. Skin flaps. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1973-1976.
6. Pakiam AI. Reversed dermis flap. In: Strauch B, Vasconez LO, Hall-Findlay EJ, eds. Grabb's Encyclopedia of Flaps. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 1998.
7. Tubiana R, Gilbert A, Masquelet AC, eds. An Atlas of Surgical Techniques of the Hand and Wrist. Baltimore, Md: Williams & Wilkins; 1999:38-39.

A 25-year-old construction worker sustains a crush amputation involving the distal third of the dominant right thumb. Examination shows exposed bone at the distal phalanx. Which of the following is most appropriate for coverage of the wound?

(A) Split-thickness skin graft from the hypothenar region
(B) Full-thickness skin graft from the medial upper arm
(C) Cross-finger flap from the index finger
(D) Thenar flap
(E) Volar advancement flap

The correct response is Option E.

In this patient who has sustained a crush amputation of the distal third of the dominant thumb, the most appropriate management is coverage of the wound using a volar advancement, or Moberg, flap. This flap is most effective for coverage of thumb amputations that occur distal to the interphalangeal joint. It is comprised entirely of palmar thumb skin, providing an excellent color and tissue match. In addition, both neurovascular bundles are included for stable, sensate wound coverage.

Split-thickness skin grafting alone over exposed bone will result in a painful thumb due to inadequate padding. A full-thickness skin graft provides a poor skin match. Sensory recovery is diminished with the use of this type of graft. The cross-finger flap should not be used in construction workers or other patients who require good hand function following repair. In addition, a large donor site defect would result. A thenar flap, which is based on the thenar eminence, is used to cover adjacent defects and cannot be used for the thumb.

References
1. Eaton CJ, Lister GD. Treatment of skin and soft-tissue loss of the thumb. Hand Clin. 1992;8:71.
2. Kleinman WB, Strickland JW. Thumb reconstruction. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:2068-2170.
3. Lister GD, Pederson WC. Skin flaps. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1783-1850.

A 54-year-old carpenter has the sudden onset of numbness, tingling, and a cold sensation in the ring and little fingers of his dominant left hand. On examination, he has an area of tenderness in the palm; a photograph is shown above. Two-point discrimination is 12 mm in the ring and little fingers. Temperature in the small finger is 26.7 %C (80%F).

Which of the following is the most appropriate next step in diagnosis?

(A) Radiograph of the carpal tunnel
(B) CT scan of the hand
(C) EMG and nerve conduction velocity studies
(D) Impedance plethysmography with cold temperature challenge
(E) Angiography of the upper extremity

The correct response is Option E.

In this patient who has findings consistent with hypothenar hammer syndrome, or thrombosis of the ulnar artery in Guyon's canal, the most appropriate next step in diagnosis is angiography of the upper extremity. Hypothenar hammer syndrome is characterized by pain in the region of the hook of the hamate bone as well as paresthesias and a decrease in digital temperature in the ring and little fingers. Because this condition is caused by repetitive trauma, it is often seen in carpenters who use the hypothenar eminence as a hammer-type device during their work.

The diagnosis of hypothenar hammer syndrome can be confirmed with Doppler ultrasonography or angiography of the upper extremity. If findings on either test are positive, management should include surgical exploration of the ulnar artery and resection of the thrombosed segment. The inflammation characteristically seen around the thrombus in patients with hypothenar hammer syndrome has been theorized to result in sympathetic hyperstimulation and irritation of the ulnar nerve; as a result, some surgeons have advocated the use of thrombolytic therapy. Although reconstruction of the ulnar artery with a vein graft is controversial, most surgeons agree that grafting can be used to prevent cold intolerance in certain patients. If the distal ulnar artery pressure is less than 0.7 times the proximal ulnar artery pressure, vein grafting can be beneficial.

Radiographs of the carpal tunnel can be performed to diagnose a fracture of the hook of the hamate bone, which is
nstability in patients with Raynaud's phenomenon.

References
1. Jones NF. Ischaemia of the hand. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;2:1705.
2. Koman LA, Ruch DS, Paterson Smith B, et al. Vascular disorders. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:2254-2302.
3. Wheatley MJ, Marx MV. The use of intra-arterial urokinase in the management of hand ischaemia secondary to palmar and digital arterial occlusion. Ann Plast Surg. 1996;37:356.

A 56-year-old man has a 30-degree flexion contracture of the proximal interphalangeal (PIP) joint of the right ring finger. He has had thickening in the palm at the base of the finger for the past five years. Which of the following structures are most likely involved in the PIP joint contracture?

(A) Central and spiral cords
(B) Lateral cord and knuckle pad
(C) Natatory and retrovascular cords
(D) Retrovascular and lateral cords
(E) Spiral cord and Cleland's ligament

The correct response is Option A.

The central, lateral, and spiral cords each contribute to recurrent contracture of the PIP joint; the little finger is affected most frequently. The central cord develops from fascia between the neurovascular bundles and is continuous proximally with the pretendinous cord. It attaches distally to the tendon sheath over the middle phalanx. The lateral cord is adherent to the skin, while the spiral cord can occur as a continuation of the pretendinous cord or can arise at the musculotendinous junction of the intrinsic muscle. This cord straightens and courses less obliquely over time.

The natatory cord passes across the palm at the level of the web spaces and attaches to each individual flexor tendon sheath. Contracture of this cord can contribute to contracture of the PIP joint. Cleland's ligaments are fascial structures located dorsal to the neurovascular bundle that help to hold the skin in position during flexion and extension of the finger. These structures are only an occasional cause of PIP joint contracture. The retrovascular cord most frequently causes contractures of the distal interphalangeal joint. This longitudinally oriented fascial cord lies dorsal to the neurovascular bundle and palmar to Cleland's ligament.

Knuckle pads are a manifestation of joint contracture and not a cause themselves.

References
1. McGrouther DA. Dupuytren's contracture. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1:563-591.
2. Starkweather KD, Lattuga S, Hurst LC, et al. Collagenase in the treatment of Dupuytren's disease: an in vitro study. J Hand Surg. 1996;21A:490-495.
3. Strickland JW, Leibovic SJ. Anatomy and pathogenesis of the digital cords and nodules. Hand Clin. 1991;7:645-657.
4. Watson HK, Paul H Jr. Pathologic anatomy. Hand Clin. 1991;7:661-668.

A 43-year-old man has moderate Dupuytren's contractures of the middle, ring, and little fingers. There is limited abduction of the ring and little fingers at the level of the metacarpophalangeal joints. This finding most likely results from Dupuytren's contracture of which of the following structures?

(A) Cleland's ligaments
(B) Grayson's ligaments
(C) Natatory ligaments
(D) Pretendinous bands
(E) Spiral band

The correct response is Option C.

This 43-year-old man has limited abduction of the ring and little fingers at the level of the metacarpophalangeal joints caused by Dupuytren's contracture of the natatory ligaments. These ligaments, which are found within the digital web spaces, primarily pass in a transverse manner but may run distally along the sides of the fingers to join with the lateral digital sheet. Patients with Dupuytren's contracture of the natatory ligaments have limited finger abduction and flexion contractures of the proximal interphalangeal joints. Although transverse fibers of the palmar aponeurosis are seen more proximally at the level of the metacarpal necks, they play no role in the Dupuytren's contractures.

Cleland's ligaments, which originate from the phalanges and pass dorsal to the digital neurovascular bundle into the lateral digital sheet, do not contribute to Dupuytren's contractures. Grayson's ligaments are thin structures that arise from the flexor tendon sheath and travel volar to the digital neurovascular bundle into the lateral digital sheet. These ligaments are frequently involved in Dupuytren's contractures. The mechanism of action of both Cleland's and Grayson's ligaments is stabilization of the skin during finger motion.

Most patients with Dupuytren's contractures have involvement of the pretendinous bands of the palmar aponeurosis. Progressive fibrosis and shortening of these bands results in the development of a pretendinous cord, which causes flexion contractures of the metacarpophalangeal joints in the disease state. This band continues distally into the fingers, where it divides into the radial and ulnar spiral bands. Although these bands ultimately contribute to the lateral digital sheet, they are not a cause of Dupuytren's contractures.

References
1. Hurst L, Starkweather KD, Badalamente MA. Dupuytren's disease. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;2:1601-1615.
2. McGrouther DA. Dupuytren's contracture. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1:563-591.

A 45-year-old computer programmer sustains a transverse guillotine amputation of the dominant thumb midway through the nail bed. The distal phalanx is exposed. Which of the following is the most appropriate management?

(A) Dressing changes
(B) Full-thickness skin grafting
(C) Coverage with a Moberg advancement flap
(D) Coverage with a neurovascular island flap
(E) Coverage with a thenar flap

The correct response is Option C.

This patient's wound is best covered with a Moberg advancement flap. This flap can be used to effectively preserve length in many patients who have palmar oblique amputations of the thumb. Harvest of the Moberg flap is possible because the thumb has a dual arterial supply. It is raised on its neurovascular pedicles and thus provides durable, sensate coverage of the pulp of the thumb. However, advancement greater than 1.5 cm is difficult; contractures of the interphalangeal joints can occur with the use of a Moberg flap. In addition, this flap should not be used in other digits because the digital arteries must be included with the flap. Vascular compromise is likely, resulting in dorsal skin necrosis. The V-Y flap is a useful variation of the Moberg flap.

Dressing changes are most appropriate for small wounds (less than 10 ( 10 mm) without exposure of bone or tendon. Full-thickness skin grafts are appropriate for large avulsion injuries; these grafts will regain at least protective sensibility when employed. The neurovascular island flap is a sensate flap harvested from the ulnar side of the middle or ring finger and transferred to the thumb. Venous congestion and absence of cortical reorientation may be noted following flap transfer. Thenar flaps are used for amputations of the index and middle fingertips with exposed bone to preserve finger length; they cannot be used in the thumb. Postoperative stiffness of the proximal interphalangeal joint and painful donor site scarring may be associated.

References
1. Carlton JM, McGrath MH, Goldberg NH. Skin grafts and pedicle flaps. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;3:1819-1843.
2. Goitz RJ, Westkaemper JG, Tomaino MM, et al. Soft-tissue defects of the digits: coverage considerations. Hand Clin. 1997;13:189-205.
3. Lister GD, Pederson WC. Skin flaps. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1783-1850.

A 30-year-old carpenter sustains an avulsion injury of the palmar skin of the dominant thumb from the tip to the interphalangeal joint. The palmar aspect of the distal phalanx is exposed; both digital nerves are absent. Which of the following is the most appropriate management?

(A) Dressing changes
(B) Split-thickness skin grafting
(C) Coverage with a kite flap
(D) Coverage with a Moberg advancement flap
(E) Coverage with a thenar flap

The correct response is Option C.

In this patient who has sustained an avulsion injury of the skin of the dominant thumb, the most appropriate management is coverage of the defect using a kite flap, a neurovascular flap harvested from the dorsal soft tissue of the proximal phalanx of the index finger. The vascular pedicle of this flap is the second dorsal metacarpal artery; two nerve branches, the superficial radial sensory nerve branch and dorsal proximal interphalangeal joint branch, can be used for digital nerve reconstruction (microneurorrhaphy). The kite flap can only be used if the paratenon has been preserved; in addition, skin grafting of the donor site must be performed following flap transfer.

Dressing changes are best for defects smaller than 10 ( 10 mm without exposed vital structures (eg, bone, tendons, nerves). A 1-cm wound may require as long as six weeks to heal.

Split-thickness skin grafts to the distal phalanx of the thumb cortex would not result in stable, durable, or sensate thumb padding.

The Moberg advancement flap is appropriate for palmar oblique thumb amputations in order to preserve as much length as possible. However, because the flap cannot be advanced more than 1.5 cm, its use would not be practical in this patient. In addition, contractures of the interphalangeal joints are associated, and sensibility would be poor in a patient with absence of both digital nerves.
The thenar flap is typically used for coverage of defects involving the index and middle fingers in which there is exposed bone in order to preserve much length as possible. Postoperative stiffness of the proximal interphalangeal joint and painful scarring are associated. The thenar flap cannot be used to cover thumb amputations.

References
1. Carlton JM, McGrath MH, Goldberg NH. Skin grafts and pedicle flaps. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;2:1819-1843.
2. Goitz RJ, Westkaemper JG, Tomaino MM, et al. Soft-tissue defects of the digits: coverage considerations. Hand Clin. 1997;13:189-205.
3. Lister GD, Pederson WC. Skin flaps. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1783-1850.

A 57-year-old man has a 15-degree flexion contracture of the metacarpophalangeal joint of the ring finger. Examination of the hand shows palmar nodules and a thick palmar cord. The patient does not wish to undergo surgery.

Which of the following is the LEAST appropriate nonoperative management?

(A) Application of dimethyl sulfoxide (DMSO)
(B) Injection of collagenase
(C) Injection of corticosteroids
(D) Continuous skeletal traction
(E) Static flexion splinting

The correct response is Option E.

In this patient who has a Dupuytren's contracture primarily involving the metacarpophalangeal (MP) joint of the ring finger, the least appropriate management is static flexion splinting, which would only worsen the flexion contracture. Static extension splinting should be used instead following surgical treatment of flexion contractures.

Collagenase injections have been used successfully in the treatment of Dupuytren's contracture. According to several studies, excellent results have been achieved in 90% of MP joint contractures and 60% of proximal interphalangeal joint contractures nine months after initiation of treatment.

Continuous skeletal traction has been shown to provide only a temporary resolution of flexion contractures. This technique, which results in continuous elongation, should be followed by limited fasciectomy.

Administration of triamcinolone and/or other corticosteroids has been shown to improve palmar nodules.

Other modalities, such as administration of dimethyl sulfoxide (DMSO), vitamin E, or medications used in the treatment of gout, as well as physical therapy and ultrasonography, have no demonstrated effect in patients with Dupuytren's contractures.

References
1. Hurst LC, Badalamente MA. Nonoperative treatment of Dupuytren's disease. Hand Clin. 1999;15:97-107.
2. Messina A, Messina J. The continuous elongation treatment by the TEC device for Dupuytren's contracture of the fingers. Plast Reconstr Surg. 1993;92:84-90.