In-Service Exam
Hand - Tip - Amps - Dupuy - Vasc - 2003





A 35-year-old man has had worsening pain in the nail bed of the nondominant left thumb for the past two years. He says that the pain intensifies with pressure to the thumb pad. There is swelling and tenderness of the paronychia when the hand is immersed in water. Physical examination shows a distorted, curled thumbnail with deep impingement of the medial and lateral margins of the nail plate into the soft tissues; a photograph is shown above.

Which of the following is the most appropriate management?

(A) Topical application of podophyllin
(B) Removal of the nail plate and healing by second intention
(C) Lateral elevation of the nail matrix and dermal autografting
(D) Split matrix grafting from the great toe
(E) Toenail transplantation

The correct response is Option C.

In this patient who has a pincer or trumpet nail deformity, the most appropriate management is lateral elevation of the nail matrix and dermal autografting. This deformity of unknown cause is characterized by excess transverse curvature of the nail and progressive pinching of the soft tissue of the distal fingertip, resulting in a painful, unattractive deformity. To correct this, the nail plate is removed, the nail bed is elevated from the sides of the distal phalanx, and dermal grafts are placed under the lateral and medial portions of the nail bed. Another management option is surgical ablation of the nail matrix and full-thickness skin grafting.

Topical application of podophyllin is appropriate for treatment of digital or plantar warts. Removal of the nail plate or toenail transplantation would not correct the underlying distorted matrices, and the new nail would continue to grow in the same pattern. Split matrix grafting is used for nail reconstruction in patients who have bifid nails or eponychial or hyponychial pterygium, in which the nail bed is scarred or the nail plate does not adhere to the nail bed.

References
1. Zaias N, ed. The Nail in Health and Disease. 2nd ed. Stamford, Conn: Appleton & Lange, 1990:67-85.
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;2:1353-1372.

Which of the following are the most likely findings in a patient with Dupuytren's diathesis?

(A) Heberden's nodes and flexor tenosynovitis
(B) Hypersensitivity and skin discoloration
(C) Knuckle pads and plantar fascia involvement
(D) Thrombophlebitis and sclerodactyly
(E) Trophic changes in the fingers and decreased temperature

The correct response is Option C.

Dupuytren's diathesis is an aggressive form of Dupuytren's contracture associated with knuckle pads, involvement of the plantar fascia, and Peyronie's disease, or thickening of the tunica albuginea of the penis. Dupuytren's diathesis has an earlier age of onset and a more rapid progression than Dupuytren's contractures, and is more likely to be bilateral and to involve the radial side of the hand. In contrast, Dupuytren's contractures typically affect the ulnarmost digits.

Heberden's (DIP) and Bouchard (PIP) nodes, which affect the distal interphalangeal and proximal interphalangeal joints, respectively, occur in association with osteoarthritis of the hand.

Patients with Dupuytren's diathesis who undergo surgery have been shown to be at increased risk for development of a flare response with early recurrence or extension of the condition. A flare response is a type of extreme, focal reflex sympathetic dystrophy or complex regional pain syndrome that occurs after surgery for Dupuytren's contracture and is associated with hypersensitivity and skin discoloration.

Flexor tenosynovitis occurs in patients with trigger finger or rheumatoid arthritis.

Thrombophlebitis, sclerodactyly, trophic changes in the fingers, and decreased temperature in the fingers and/or hand are symptomatic of vascular conditions such as ischemia, scleroderma, or Raynaud's disease.

References
1. Lubahn JD. Dupuytren's fasciectomy: open palm technique. In: Blair WF, ed. Techniques in Hand Surgery. Baltimore, Md: Williams & Wilkins; 1996.
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 right-handed, 40-year-old construction worker has episodes of severe vasospasm in the right ring and small fingers after he uses a heavy wrench to forcibly loosen a nut. He does not smoke and is otherwise healthy. Physical examination shows decreased temperature in the long, ring, and small fingers. Doppler ultrasonography shows complete occlusion of the ulnar artery at the distal aspect of the wrist; the pulsation in the superficial arch disappears completely with manual occlusion of the radial artery. Plain radiographs show normal findings. An arteriogram is shown above.

Which of the following is the most likely diagnosis?

(A) Hypothenar hammer syndrome
(B) Maffucci syndrome
(C) Raynaud's phenomenon
(D) Thoracic outlet syndrome
(E) Thromboangiitis obliterans

The correct response is Option A.

The findings in this 40-year-old construction worker are consistent with hypothenar hammer syndrome. In this condition, there is increased pressure caused by significant trauma to the hand, resulting in crushing of the ulnar artery at Guyon's canal. This produces a true aneurysm that can shower emboli to the digits. The ischemic symptoms in the long, ring, and small fingers are caused by an incomplete superficial arch and excessive sympathetic activity resulting from localized inflammation in the region of Guyon's canal, adjacent to the ulnar nerve. Doppler
ultrasonography shows occlusion of the ulnar artery at that location and patency of the radial artery and the superficial arch. Following arteriography, the thrombosed segment of the ulnar artery is excised. The success of arterial reconstruction using a reverse saphenous vein graft depends on the vascularity of the digits. In this patient, reverse saphenous vein grafting was successful, immediately restoring pulsatile flow to the three ulnarmost digits.

Maffucci syndrome is a rare disorder that is characterized by multiple enchondromas associated with vascular hemangiomas. Because the risk for chondrosarcoma is increased, frequent follow-up examination is required.

Raynaud's phenomenon is a progressive vasospastic condition that typically occurs in middle-age women. Affected patients develop nonhealing ulcers and gangrenous changes of the fingertips due to inadequate tissue perfusion. Cold stress vascular testing can be used in diagnosis.

Patients with thoracic outlet syndrome have sensorimotor findings in the distribution of C8-T1 resulting from compression of the subclavian artery and lower trunk of the brachial plexus. Symptoms include occipital headaches, numbness in the fingers (especially the small finger), and pain in the shoulder and chest that is exacerbated when the arm is lifted above the level of the shoulder. Occlusion of peripheral arteries is not associated.

Thromboangiitis obliterans, or Buerger's disease, manifests as gangrene of the fingertips. This condition typically occurs in middle-age patients who smoke. Arteriography shows diffuse atherosclerotic plaques in the digital arteries. Management includes cessation of smoking.

References
1. Jones KJ, Henry MH. Thoracic outlet syndrome. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1448-1465.
2. Koman LA, Ruch DS, Smith BP, et al. Vascular disorders. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:2254-2297.
3. Koman LA. Venous grafts for ulnar artery thrombosis. In: Blair WF, ed. Techniques in Hand Surgery. Baltimore, Md: Williams & Wilkins; 1996:1155-1163.

A 34-year-old woman sustains a traumatic amputation of all digits. The digits have been preserved. Photographs are shown above. Which of the following is the most appropriate sequence for replantation?

(A) Digit by digit, initially long finger
(B) Digit by digit, initially thumb
(C) Structure by structure, initially artery
(D) Structure by structure, initially bone
(E) Structure by structure, initially flexor tendon

The correct response is Option D.

When contemplating replantation of multiple digits, it is important to choose a management plan that maximizes the potential for survival of each replanted digit. For instance, in patients with sharp amputations, there is a better prognosis for replantation than in patients with avulsion-type amputations or crush amputations. The level of injury also helps determine the usefulness of the digit. In a patient who has sustained amputations of all digits, the relative importance of replantation is guided by the contribution of each digit to overall hand function.

Because the thumb is generally believed to be the most important digit, its preservation is a priority. Although the index finger is generally important for fine motor pinch, the long finger can perform its functions in its absence. The two ulnarmost digits provide power grasping functions of the hand. In a five-digit replantation, the thumb is thought to be the most important digit, followed by either the long or ring finger, with replantation of the index finger being least important. Optimal repair has been shown to occur with a structure-by-structure approach, rather than a digit-by-digit approach. Most surgeons agree that bone and tendons should be repaired initially, followed by either vein or artery repair. The nerves should be repaired last.

The AMA Guides to the Evaluation of Permanent Impairment are used to assign an impairment percentage to each amputated digit. Impairment can be calculated based on the level of amputation and the involved digit; each digit is given a value relative to the whole hand. The thumb is given a value of 40%, the index and long fingers values of 20% each, and the ring and small fingers values of 10% each. In addition, amputation through each portion of a digit is assigned a relative value of loss to the entire digit. Amputation through the metacarpophalangeal joint of a digit is assigned a value of 100%, and amputation through the proximal interphalangeal joint has a value of 80%. Amputation through the interphalangeal joint of the thumb is given a value of 50%. Amputation through the distal interphalangeal joint has a value of 45%.

References
1. Goldner RD, Urbaniak JR. Replantation. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1139-1158.
2. Guides to the Evaluation of Permanent Impairment. 4th ed. Chicago, Ill: American Medical Association; 1995:18-20.
3. Moy OJ, Ablove RH. Microsurgical methods and replantation. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996:1845-1874.

Three months after sustaining a traumatic amputation of the long finger at the level of the proximal phalanx, a 45-year-old banker says that he has problems with coins dropping between his fingers. Primary closure and disarticulation at the metacarpophalangeal joint were performed at the time of injury. Transposition of the index finger to the long finger is to be performed.

Which of the following is the most appropriate level for transposition?

(A) Carpometacarpal joint
(B) Metacarpal base
(C) Metacarpal head
(D) Metacarpal shaft
(E) Metacarpophalangeal joint

The correct response is Option B.

Transposition of the index finger to the long finger is best accomplished at the level of the metacarpal base. This provides a greater volume of cancellous bone at the metaphyseal flare, resulting in a higher rate of bony union. There is an increased incidence of nonunion if the osteotomy is performed too distally.

Ray resection of the metacarpal of the long finger can also be performed in this patient, and the deep transverse metacarpal ligaments between the index and ring fingers can be sutured to close the web space. However, the width of the palm decreases following ray amputation, and grip strength may be diminished. In contrast, preservation of the metacarpal also preserves palmar width, but leaves a functional midhand gap in the areas of the missing digits.

If transposition were performed at the level of the carpometacarpal (CMC) joint, CMC arthrodesis would be required. Transposition of the index finger at the metacarpal head will stretch the neurovascular bundle, increasing the risk for injury to the nerves and/or vessels. Transposition at the level of the metacarpophalangeal joint will result in a stiff joint.

References
1. Adamson GJ, Palmer RE. Amputations. In: Achauer BM, Erikson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby Ð Year Book, Inc; 2000;4:1831-1843.
2. Louis DS, Jebson PJ, Graham T. Amputations. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1:48-94.

A 67-year-old farmer sustains an amputation of the volar soft tissue of the thumb. Physical examination shows a 2 * 1.5-cm defect with loss of 50% of the tactile surface of the thumb. There is exposure of 0.5 cm of the distal phalanx. Which of the following is the most appropriate management?

(A) Healing by second intention
(B) Full-thickness skin grafting
(C) Coverage with a Moberg flap
(D) Coverage with a neurovascular island flap from the long finger
(E) Second toe pulp transfer

The correct response is Option C.

The most appropriate management is coverage with a palmar advancement flap, also known as a Moberg flap. This flap provides durable and sensate skin to the pulp of the thumb and preserves length. Although it can be used to cover defects as large as 2 * 2 cm, it is more typically used for defects that have a length of 1 to 1.5 cm. Flap transfer involves mobilization of both digital arteries and nerves and advancement of volar skin, resulting in a minimal flexion deformity.

Healing by second intention is contraindicated in a patient who has a defect involving exposed bone.

Full-thickness skin grafts can be used for reconstruction of small defects but would result in an insensate thumb. In addition, grafting over exposed bone does not provide adequate coverage for pinch functions.

Although transfer of pulp from the second toe may be indicated for thumb reconstruction, it is not the procedure of choice in a 67-year-old farmer.

Coverage with a neurovascular island skin flap derived from the long finger is appropriate for reconstruction of large defects that involve sensate pinch on the radial aspect of the thumb. This technique is often performed secondarily if other first-line methods fail to restore satisfactory sensation.

References
1. Bang H, Kojima T, Hayashi H. Palmar advancement flap with V-Y closure for thumb tip injuries. J Hand Surg. 1992;17A:933-941.
2. Hynes DE. Neurovascular pedicle and advancement flaps for palmar thumb defects. Hand Clin. 1997;13:207-216.

A 10-year-old boy has venous congestion of the thumb eight hours after undergoing replantation. Which of the following is the most appropriate next step in management?

(A) Removal of the splint and dressings
(B) Application of leeches
(C) Operative exploration of the veins
(D) Operative exploration of the arteries
(E) Amputation

The correct response is Option A.

In this 10-year-old boy who has developed venous congestion after undergoing thumb replantation, it is important to remove all dressings and splints initially and examine the thumb. If improvement does not occur following removal of the dressings, suture removal is indicated because the closure may be constricting the digit and obstructing venous outflow. Other potential causes of venous obstruction include development of a hematoma or bleeding onto the dressing, which may cause the dressing to harden into a "blood cast." If these measures fail to resolve the congestion, intravenous administration of heparin, leech therapy, or heparin-induced matrix bleeding may be considered. If symptoms do not improve or worsen instead, repeat operative exploration of the venous and in some cases arterial anastomoses is warranted.

Amputation of the thumb in a child is only indicated if all other measures have failed.

References
1. Goldner RD, Urbaniak JR. Replantation. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1139-1157.
2. Lim B, Tan B, Peng Y. Digital replantations including fingertip and ring avulsions. Hand Clin. 2001;17:419-431.

A 32-year-old man sustains an avulsion injury involving the volar soft tissue of the left thumb. Physical examination shows exposure of the flexor pollicis longus tendon. The first dorsal metacarpal artery flap is to be used for closure of the defect.

Which of the following best describes the location of the first dorsal metacarpal artery during flap harvest?

(A) Adjacent to the common digital artery to the thumb
(B) At the deep palmar arch
(C) Over the periosteum of the first metacarpal
(D) Within the fascia of the first dorsal interosseous muscle
(E) Within the subcutaneous tissue over the first dorsal interosseous muscle

The correct response is Option D.

The correct response is Option D.

The first dorsal metacarpal artery courses within the fascia of the first dorsal interosseous muscle; in rare cases, it may lie within the muscle itself. It communicates with the perforators from the superficial palmar arch at the level of the metacarpophalangeal joint.

The first dorsal metacarpal artery flap is axially patterned and based on a terminal branch of the radial artery after it exits the region known as the anatomic snuff box. This region is bordered volarly by the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons (first dorsal compartment) and dorsally by the extensor pollicis longus (EPL) tendon (third dorsal compartment). The skin paddle of this flap is obtained from the dorsal aspect of the index finger over the proximal phalanx, and the venae comitantes and superficial veins provide venous drainage.

References
1. Earley MJ. The arterial supply of the thumb first web space and index finger in its surgical application. J Hand Surg. 1986;11B:163-170.
2. Foucher G, Bishop A. Island flaps based on the first and second dorsal metacarpal artery. In: Levin E, Gerrmann G, eds. Local Flaps about the Hand: Atlas of the Hand Clinics. Philadelphia, Pa: WB Saunders Co; 1998.
3. Walton RL, Neumeister MW. Pedicled flaps and grafts. In: Achauer BM, Erikson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby Ð Year Book, Inc; 2000;4:1793-1817.

A 54-year-old man has 40-degree contractures of the proximal interphalangeal (PIP) joints of the left ring and small fingers. Physical examination shows soft-tissue thickening in the left palm. Which of the following structures is NOT involved in the development of the PIP joint contractures?

(A) Grayson's ligament
(B) Lateral digital sheath
(C) Natatory ligament
(D) Pretendinous band
(E) Spiral band

The correct response is Option C.

Dupuytren's disease is an autosomal dominantly inherited disorder of unknown etiology that involves benign fibroproliferation of the palmar fascia. This condition occurs almost exclusively in Caucasian persons and is rare in African American and Asian American persons. It is most likely to develop in patients between 40 and 60 years of age, and men are seven to 15 times more likely to require surgery than women. Patients with diabetes mellitus are at greater risk for development of Dupuytren's disease.

Contractures of the metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints have been shown to result from distinct fascial elements. The central, lateral, retrovascular, and spiral cords cause contractures of the PIP joint. Grayson's ligament and the lateral digital sheath, pretendinous band, spiral band, and vertical band contribute to the spiral cord. The natatory ligament is the only web coalescence structure that is not involved in a contracture of the PIP joint.

Division or resection of the involved cords is indicated in patients with joint or web space contractures that inhibit hand function. Surgery should be considered in patients who have MP joint contractures of more than 30 degrees or any type of flexion contracture involving the interphalangeal joints.

Reference
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.