Which of the following is most appropriate for reconstruction of the index finger?

(A) Skin graft
(B) Moberg advancement flap
(C) Reverse cross-finger flap
(D) Thenar flap
(E) Volar V-Y advancement flap

The correct response is Option D.

The thenar flap is most appropriate for reconstruction of this patient’s defect. This flap can be used to effectively reconstruct defects of the tips of the index and long fingers, which flex comfortably into the thenar eminence. In contrast, because the ring and small fingers have difficulty reaching the thenar crease, defects of these fingertips can be covered instead using a hypothenar flap from the ulnar side of the hand.

Split-thickness or full-thickness skin grafting is inappropriate over exposed bone, and padding is required for coverage of any fingertip defect.

Moberg flaps are recommended for coverage of soft-tissue defects of the volar pad of the thumb. The dorsal circulation of the thumb allows for the extensive soft-tissue mobilization required with this flap. The neurovascular bundles are elevated with the Moberg flap.

A reverse cross-finger flap is used to cover defects of the dorsal aspect of the finger. With this flap, subcutaneous tissue is harvested from the dorsal and not the volar aspect of the finger; therefore, the neurovascular bundles are not disrupted. A cross-finger flap cannot be used in this patient because the dorsal skin of the long finger is avulsed.
Likewise, a volar V-Y advancement flap is not possible because the volar skin pad of the index finger has also been avulsed. Although the dorsal skin is intact, it should not be used for coverage because the patient would like to preserve finger length, and because the risk for development of a hook nail deformity would be increased if the dorsal skin were transferred.

References
1. Browne EZ Jr. Skin grafts. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1759-1782.
2. 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 63-year-old man has the deformity of the left small finger shown in the photographs above. It has worsened over the past two years, and he has limited passive and active extension of the proximal interphalangeal (PIP) joint of the finger. The most likely cause is contracture of which of the following cords?

(A) Central and lateral
(B) Central and pretendinous
(C) Natatory and lateral
(D) Natatory and pretendinous
(E) Natatory and spiral

The correct response is Option A.

In this 63-year-old man who has limited extension of the proximal interphalangeal (PIP) joint of the left small finger that has occurred as a result of a Dupuytren contracture, the central and lateral cords are the most likely cause. Diseased cords evolve from the normal fascial bands of the hand in patients with Dupuytren disease, leading to flexion deformities of the affected joints. Fascial structures of the hand that may contribute to Dupuytren contracture include Grayson’s and Cleland’s ligaments, the lateral digital sheath, the natatory ligament, the pretendinous and spiral bands, and the superficial transverse ligament.

The central, lateral, and spiral cords cause flexion contractures of the PIP joint. The central cord arises from the pretendinous band, and the lateral cord is formed from the central digital sheath. The spiral cord is composed of the pretendinous and spiral bands, lateral digital sheath, and Grayson’s ligament. Contraction of the spiral cord results in medial and superficial displacement of the neurovascular bundle.

In addition to the contracture of the PIP joint caused by the central and lateral cords, this patient’s hand posture results from contracture of the metacarpophalangeal joint caused by the action of the pretendinous cord. The pretendinous cord does not contribute to contractures of the PIP joint.

The natatory cord is formed from the natatory ligament as it passes transversely across the palm at the level of the web spaces. It causes adduction, not flexion, contractures of the digits.

References
1. McFarlane R. Patterns of diseased fascia in the fingers of Dupuytren’s contracture. Plast Reconstr Surg. 1974;54:31.
2. McFarlane RM. The anatomy of Dupuytren's disease. Bulletin Hosp Jt Dis Orthop Inst. 1984;44:318-337.
3. McFarlane RM. Dupuytren’s contracture. In: Green DP, ed. Operative Hand Surgery. 3rd ed. New York, NY: Churchill Livingstone, Inc; 1982:563-591.
4. Strickland JW, Leibovic SJ. Anatomy and pathogenesis of the digital cords and nodules. Hand Clin. 1991;7:645-671.

Six months after sustaining a traumatic amputation of the right index finger at the level of the distal interphalangeal joint, a 27-year-old machinist has extension of the proximal interphalangeal joint of the index finger when he attempts to make a fist. Revision amputation and primary closure were performed at the time of the initial injury, and the patient has undergone occupational therapy for the past six months.

Which of the following is the most appropriate management?

(A) Osteotomy of the middle phalanx
(B) Release of the sagittal bands
(C) Sectioning of the lumbrical muscle
(D) Tenolysis of the profundus tendon
(E) Transfer of the interosseous muscle

The correct response is Option C.

In this 27-year-old machinist who has a lumbrical-plus deformity secondary to release of the flexor digitorum profundus tendon to the index finger, the most appropriate management is sectioning or division of the lumbrical muscle. Because the profundus tendon to the index finger is independent, proximal retraction causes proximal retraction of lumbrical tendon, leading to increased tension. With attempted flexion of the proximal interphalangeal (PIP) joint (ie, to make a full fist), the lumbrical muscle migrates more proximally, exerting tension on the extensor mechanism through the lateral band. Paradoxical extension of the interphalangeal joints results. Sectioning of the muscle can be performed as an outpatient procedure using a local anesthetic.

Osteotomy of the middle phalanx will not correct the muscle-tendon imbalance. Release of the sagittal bands is most likely to result in subluxation of the extensor tendons across the metacarpophalangeal joint. Tenolysis of the profundus tendon is appropriate for management of flexion contractures with adhesions, and transfer of the interosseous muscle is performed for correction of ulnar drift in patients with rheumatoid arthritis.

References
1. Failla JM. Differential diagnosis of hand pain: tendinitis, ganglia, and other syndromes. In: Peimer CA, ed. Surgery of The Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;1:1223-1249.
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 5-year-old girl sustains a stellate laceration of the sterile matrix of the nail bed of the left long finger when she closes a door on the finger. Which of the following is the most appropriate management?

(A) Allowing the nail bed to heal by second intention
(B) Primary repair of the nail bed
(C) Debridement of the nail bed and split-thickness skin grafting
(D) Debridement of the nail bed and split germinal matrix nail grafting
(E) Coverage of the nail bed with a free flap from the great toe

The correct response is Option B.

In this patient who has sustained a stellate laceration of the nail bed of the long finger, the most appropriate management is primary repair of the nail bed. Lacerations of the nail bed are common injuries that most frequently occur in the long finger, as it is typically the last digit to be moved during a situation of potential trauma to the hand. Injury to the nail bed can be classified as simple laceration, stellate laceration, avulsion, crush injury, or amputation.

The most appropriate management of simple and stellate lacerations of the sterile matrix is primary repair. These injuries are associated with the best prognosis; the nail typically has a normal appearance after healing.

In patients with avulsion and crush injuries, the outcome is often variable, as fracture of the distal phalanx may be associated. Any fracture that occurs must be reduced initially to eliminate irregular bone contours, which often result in a nail deformity. If there is contamination of the nail bed, the necrotic tissue is debrided. Split matrix grafting, using sterile grafts obtained from an adjacent portion of uninjured nail bed, can be performed for reconstruction. A split nail bed graft can be harvested also from the great toe.

Healing by second intention would result in deformity of the nail bed.

Germinal matrix grafts are appropriate for repair of trauma to the germinal matrix of the nail. These are full-thickness grafts that leave a deformity at the donor site following harvest.

Reconstruction of the nail bed with a free flap is reserved for management of chronic deformities of the nail and is not considered in patients with acute injuries.

References
1. Shepard GH. Nail grafts for reconstruction. Hand Clin. 1990;6:79-102.
2. Zook EG. Anatomy and physiology of the perionychium. Hand Clin. 2002;18:553-559.
3. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and prognosis. J Hand Surg. 1984;9A:247-252.
4. Zook EG, Van Beek AL, Russell RC, et al. Anatomy and physiology of the perionychium: a review of the literature and anatomic study. J Hand Surg. 1980;5:528-536.

A 46-year-old woman sustains a ring avulsion injury to the long finger when the finger becomes caught in a machine. Emergent revascularization is performed; on examination 10 days later, the patient has the findings shown in the photographs above. Which of the following techniques is most likely to provide optimal function?

(A) Resection of all nonviable soft tissue and coverage with a full-thickness skin graft
(B) Resection of all nonviable soft tissue and coverage with a neurovascular island flap from the ring finger
(C) Resection of all nonviable soft tissue and reconstruction with a toe-to-hand transfer
(D) Revision amputation at the level of the mid proximal phalanx, with trimming of the bone to a level at which it can be covered primarily by viable skin
(E) Ray amputation of the long finger, leaving the base of the metacarpal in place

The correct response is Option E.

Ring avulsion injuries are typically associated with the highest failure rates following replantation, most likely because of the mechanism of injury, which involves destruction of the intimal layer of the supporting vasculature. In this patient, revascularization has failed, leaving a necrotic digit.

The most appropriate next step in management of this patient is ray amputation, which involves removal of the entire digit and most or all of the metacarpal. Completely removing the digit eliminates the segmental loss and greatly improves both function and aesthetic appearance, as shown in the photographs above.

Resection of nonviable soft tissue results in exposure of the phalanges and tendons. A full-thickness skin graft will not take over these exposed structures.

The Littler neurovascular island flap is based on the digital neurovascular bundle of either the long or ring finger. This flap provides sensate coverage of smaller digital defects, particularly the thumb, but would not cover the entire defect in this patient.

Replacing the long finger with a toe-to-hand transfer is impractical, as the transferred digit would be significantly shorter than the adjacent digits and would ultimately impair their function. This technique is appropriate for patients who have sustained amputations of the thumb or of multiple digits.

Simple revision amputation is the easiest method of skin closure but leaves a large gap between the long and small fingers, allowing an area through which small objects can fall, and thus limiting hand function.

References
1. Concannon MJ, Hurov J, eds. Hand Pearls. Philadelphia, Pa: Hanley & Belfus; 2002;141-145.
2. Levy HJ. Ring finger ray amputation: a 25-year follow-up. Am J Orthop. 1999;28:359-360.
3. Louis DL. Amputations. In: Green DP, ed. Operative Hand Surgery. 3rd ed. New York, NY: Churchill Livingstone, Inc; 1982:62-72.
4. Peimer CA, Wheeler DR, Barrett A, et al. Hand function following single ray amputation. J Hand Surg. 1999;24:1245-1248.

A 60-year-old mechanic is brought to the emergency department 12 hours after sustaining a amputation of the nondominant left thumb at the level of the metacarpophalangeal joint. At the time of injury, the amputated part was immediately placed in a plastic bag over an ice slush. He underwent arthroplasty of the carpometacarpal joint of the left hand five years ago.

Which of the following factors is most likely to influence the success of replantation in this patient?

(A) Age of the patient
(B) Hematocrit of the patient
(C) Length of ischemia time
(D) Mechanism of injury
(E) Previous hand surgery

The correct response is Option D.

In addition to the experience of the surgeon, the mechanism of injury is most likely to influence the success of replantation in any patient who has sustained an amputation of a digit. Because the vessels of the amputated part are damaged in patients who sustain avulsion and crush amputations, perfusion will be impeded, decreasing the likelihood of successful replantation. In addition, cooling of the amputated part contributes to the success of the replantation, as the amputated part can be replanted as late as 24 hours after injury if it is well preserved.

The age of the patient does not affect the success rate of replantation in the absence of other comorbid conditions or a history of cigarette smoking. Likewise, hematocrit and a history of hand surgery generally do not influence the outcome of replantation significantly. Because digits do not contain muscle, the length of ischemia time is not an influential factor.

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;1:1139-1157.
2. Soucacos PN. Indications and selection for digital amputation and replantation. J Hand Surg. 2001;26B:572-581.

A 22-year-old woman has the split nail deformity shown in the photograph above. On physical examination, the deformity involves the sterile and germinal matrices. The patient does not want to lose the nail. Which of the following is the most appropriate management?

(A) Excision of the scar and primary closure of the nail bed
(B) Split nail grafting from the same nail bed
(C) Split nail grafting from the toe
(D) Full-thickness nail grafting from the finger
(E) Full-thickness nail grafting from the toe

The correct response is Option E.

In this patient who has a split nail deformity, the most appropriate management is full-thickness nail grafting from the toe. This deformity is caused by injury to the nail bed, leading to scarring of the bed. The nail plate does not grow in the scarred area, resulting in a split in the nail plate.

Because the deformity involves both the sterile and germinal matrices, only a full-thickness nail will provide the sterile and germinal matrix components required for reconstruction. Harvest of a full-thickness nail produces a significant cosmetic defect at the donor site; therefore, a graft from the second toe is thought to provide the least unsightly result.

In patients who have a small scar affecting the sterile matrix only, appropriate management may include excision of the scar and re-approximation of the sterile matrix; however, the sterile matrix is not usually mobilized and re-approximated unless the affected area is narrow. In addition, the germinal matrix cannot tolerate re-approximation.

As mentioned above, a split nail graft from either the same nail bed or another nail bed will not provide the components needed for reconstruction of this defect. In addition, using another finger as a donor will result in an unsightly donor defect in the hand.

References
1. 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;1:1353-1380.
2. Zook EG. Surgically treatable problems of the perionychium. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;8:4499-4515.

A 57-year-old man has a flexion contracture involving the ring and small fingers of the left hand. A photograph is shown on page 178. During partial fasciectomy in this patient, the neurovascular bundle to these fingers is at risk for injury. Each of the following structures is a normal component of the fascia surrounding the neurovascular bundle EXCEPT

(A) Cleland’s ligament
(B) Grayson’s ligament
(C) lateral digital sheet
(D) pretendinous band
(E) retrovascular band

The correct response is Option D.

Fascial structures that encase the neurovascular bundles include Cleland’s and Grayson’s ligaments, the lateral digital sheet, and the retrovascular band. Cleland’s ligament is a thick fascial structure that lies deep to the neurovascular bundle; it arises from the side of the phalanges and courses obliquely toward the skin. Grayson’s ligament is thinner and more sheet-like than Cleland’s ligament, and is positioned superficial to the neurovascular bundle; it arises from the tendon sheath and extends to the skin. The lateral digital sheet is comprised of superficial fascia on either side of the phalanges. It receives fibers from the natatory ligament and the spiral band, and is found lateral to the neurovascular bundle. The retrovascular band is a longitudinal structure situated dorsomedial to the neurovascular bundle.

The pretendinous cord is a pathologic component of Dupuytren disease. It is an extension of the pretendinous band in the midline of the phalanges. The pretendinous band is not a component of the fascia surrounding the neurovascular bundles.