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Fig. 31.2 Toe transfer in U4R1 hand Post op
small nger positions to allow three-point
pinch. Rarely, if the parents are willing to
accept the appearance of the donor foot,
combined second and third toes can be
transferred into the middle—ring or ring—
small nger positions. The range of motion
of a toe transfer used for reconstruction of a
nger depends on whether there is an existing metacarpophalangeal (MCP) joint in the
hand. If the proximal phalanx of a toe transfer can be xed to a remnant of the proximal
phalanx of a nger, excellent motion can be
expected at the existing metacarpophalangeal joint, whereas if the metatarsal of the
toe transfer has to be xed to a metacarpal
in the hand, the motion achieved at the
metatarsophalangeal and proximal interphalangeal joints is signicantly less.
2. Complete absence of all ve digits (R5).
This is usually seen in the adactylic type IV
symbrachydactyly [69] or transverse failure
of formation. Reconstruction may be accomplished using two second toe transfers into the
thumb and ring or small nger positions to
provide grasp and tip-to-tip pinch. This can be
performed simultaneously but is probably better performed sequentially, so that positioning
of the second transfer into a nger position
can be adjusted to the position and mobility of
the rst transfer into the thumb position
(Fig.31.3).
N. Jones and C. Parolo
Fig. 31.3 Double Toe transfer in R5 hand Post op
31.8 Timing ofToe Transfers
forCongenital Hand
Dierences
The optimal age for performing a toe transfer to
reconstruct a congenital hand difference has not
been dened. Generally, the earlier that a toe
transfer is performed, the better the chance of
cortical integration. Children with a unilateral
congenital hand difference should probably be
reconstructed at an earlier age, before the use of
the contralateral normal hand dominates.
However, the real limiting factor in pediatric toe
transfers is the size of the donor and recipient
vessels, which must be of adequate size to facilitate the microsurgical anastomoses. Gilbert [57,
58] and Lister [62] have performed toe transfers
in children as young as 6–12 months of age, but
toe transfers have also been successful in older
children between 11 and 17 years of age [71].
The author usually performs toe transfers
between two and three years of age.
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31.9 Evaluation ofaChild
foraToe-to-Hand Transfer
After a traumatic injury to a child’s hand, there is
always some blame, either attached to or accepted
by one of the parents. The parental response to a
child born with a congenital hand difference resembles the bereavement response. Each parent must
deal with their own sense of loss, as well as the obligation to direct the treatment of their child. Listening
to the child’s parents and allowing them to express
their understanding of their child’s condition and
their hopes and expectations for reconstruction are
vitally important. Some surgeons have recommended that the parents and child meet with a clinical psychologist prior to considering a toe-to-hand
transfer, and it has been documented that psychological counseling may play an integral role in decision-making in pediatric hand surgery [72].
Rather than just showing pre- and postoperative
photographs or videos or fabricating moulages,
the author’s practice is to arrange for prospective
parents to meet the parents of a child with a similar
congenital hand difference who has previously
undergone a toe transfer, so that the parents can
see for themselves the potential function and
appearance of the reconstructed hand and speak
with the other parents about their concerns [60].
The parents should be prepared psychologically for the signicant amount of time and
energy that will be required during the pre- and
postoperative period. In addition, they must
understand and accept the fact that a toe transfer
can fail, leaving the child with the same decit in
the hand but also, now, missing a toe in the foot.
If the parents and/or child cannot accept the time
commitment and the potential risk of failure, toeto- hand surgery should not be considered.
The child with a congenital hand difference
will usually have been examined by a pediatrician
for other congenital anomalies and possibly even
by a geneticist to exclude a syndromic association.
A detailed examination of the involved upper
extremity should be performed, or if the child is
very young, he/she should be observed while playing. More proximal shoulder or elbow abnormalities should be excluded such as Poland’s syndrome
or radioulnar synostosis. The presence or absence
of a radiocarpal joint as well as the number and
length of any metacarpal bones should be determined. The presence or absence of a thumb and
whether there is a thumb carpometacarpal joint is
important if a toe-to- thumb transfer is being considered. Dimpling of the skin in symbrachydactyly
may indicate the presence of exor tendons in the
vicinity of the nubbins.
One or other of the child’s feet may be positioned close enough to the affected hand, so that
the parents and/or child can visualize what the
transferred toe might look like. Occasionally,
congenital differences of the lower extremities
may co-exist with upper extremity differences
and especially with bilateral congenital hand differences; the availability of donor toes may be
limited because of associated foot abnormalities.
Plain radiographs of both hands and both feet
should be obtained to determine the presence of
metacarpals and whether a carpometacarpal joint of
the thumb is present or absent. In children where the
carpal or metacarpal bones have not yet ossied, an
MRI scan may occasionally be considered.
The necessity for preoperative angiography of
either the upper or lower extremity remains controversial. Greenberg [73] found a preoperative
lateral angiogram of the foot to be helpful in
identifying the location and size of the rst dorsal
metatarsal artery (FDMA) and rst plantar metatarsal artery (FPMA). The author no longer
obtains angiograms but listens to the dorsalis
pedis and rst dorsal metatarsal artery in both
feet with a handheld Doppler probe. The dorsalis
pedis artery can be traced distally into the rst
dorsal metatarsal artery lying between the great
toe and second toe metatarsals using an 8 mHz
pencil Doppler ultrasound probe. The dominance
of the FDMA can be assessed from the presence
or absence of a Doppler signal, and the potential
depth of the FDMA (supercial, within or deep
to the interosseous muscles) can be assessed from
the intensity of the signal.
31.10 Anatomy oftheGreat Toe
andSecond Toe
The arterial anatomy of both the great toe and the
second toe is based on either the rst dorsal metatarsal artery (FDMA), a continuation of the dor-
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salis pedis artery, or the rst plantar metatarsal
artery (FPMA) [74]. Supercial veins drain to the
medial side of the dorsum of the foot and then
into the greater saphenous vein. Sensibility to the
plantar surface of the great toe or second toe is
provided by the tibial (medial) and bular (lateral) digital nerves and to the dorsal surface by
the deep peroneal nerve.
31.11 Surgical Technique
The child is positioned supine with the arm and
hand on a hand table and the donor foot at the end
of the operating table. General anesthesia is occasionally supplemented with an axillary block or
continuous brachial plexus infusion. A Foley
catheter is used to monitor urine output and uid
status, but central venous catheters are not used
routinely. A regular tourniquet is applied to the
upper arm, and a sterile tourniquet is applied to
the thigh, since a skin graft may need to be harvested later from the thigh or groin.
Two surgical teams are utilized to dissect the
hand and foot simultaneously, but dissection
should usually start with the hand in congenital
cases to conrm that recipient tendons and nerves
are available. If only one team is available, the
dissection usually commences with the hand to
conrm that the specic tendons and digital
nerves are available for subsequent tendon and
nerve repairs.
31.11.1 Dissection oftheDonor
Foot
Preoperatively, the 8 mHz Doppler ultrasound
probe is used to mark the location of the dorsalis
pedis artery and/or the posterior tibial artery,
depending on the local anatomy and the needs of
the recipient hand. The location of suitable dorsal
veins may be marked by inating the thigh tourniquet to 100 mmHg after the draping but prior to
the start of the surgery. The leg is then elevated but
not exsanguinated in order to leave some blood
within the venous system. A racquet- shaped incision is used to harvest the great toe. A V-shaped
incision is used to harvest the second toe. The mid-
point of the web space between the great toe and
the second toe and the midpoint of the web space
between the second and third toes are marked, and
dorsal and plantar triangular aps are designed
from these two points proximally to their apex at
the level of the metatarsophalangeal joint. The
dorsal incision is extended proximally in either a
longitudinal fashion or a lazy S-shape to the level
of the extensor retinaculum. Draining veins from
the apex of the dorsal ap are dissected in a distalto-proximal direction to a dominant dorsal vein,
which is dissected further proximally to its origin
from the greater saphenous vein at the level of the
extensor retinaculum.
Either the extensor hallucis longus (EHL)
tendon to the great toe or the extensor digitorum
communis tendon (EDC) to the second toe is
dissected in a distal-to-proximal direction and
transected at the level of the extensor
retinaculum.
The deep peroneal nerve is identied proximally by dividing the extensor hallucis brevis
tendon and traced in a proximal-to-distal direction to the proximal margin of the V-shaped dorsal ap. The fascicles supplying either the great
toe or the second toe are divided from the main
trunk of the deep peroneal nerve.
In the original technique of harvesting a toe
transfer, the dorsalis pedis artery was identied
proximally and dissected in a proximal-to-distal
direction into the rst dorsal metatarsal artery
(FDMA). However, it is faster to identify the
FDMA distally in the web space between the
great toe and second toe [75]. The FDMA may
lie in a supercial dorsal, intramuscular, or
plantar position in relation to the interosseous
muscles. A communicating branch between the
FDMA and the rst plantar metatarsal artery
(FPMA) may be visualized passing over and
distal to the intermetatarsal ligament. The ligament is divided and the FPMA may be dissected
further proximally through the plantar incision.
If the second toe is being transferred, the bular
digital artery to the great toe is ligated and
divided. If the great toe is being transferred, the
tibial digital artery to the second toe is ligated
and divided. The surgeon can then decide
whether the dorsal or plantar arterial system is
dominant. If the FDMA is considered to be large
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enough and in a supercial position, the FDMA
is dissected in a distal-to- proximal direction to
its origin from the dorsalis pedis artery, which is
itself dissected further proximally to the level of
the extensor retinaculum by dividing the extensor hallucis brevis tendon. If the FDMA is very
small in caliber or lies deeply intramuscularly,
the FPMA is chosen as the dominant arterial
system but has to be extended with an interposition vein graft, anastomosed on a back table
[76]. If both the FDMA and FPMA are absent or
hypoplastic, the great toe may still be transferred using the medial plantar arterial system
[77]. In children with congenital cleft feet, the
great toe is usually transferred on the posterior
tibial artery pedicle which can be traced distally
to the medial plantar arterial system.
The exor hallucis longus tendon to the great
toe or the exor digitorum longus and exor digitorum brevis tendons to the second toe are identied through the plantar incision and are divided as
far proximally as possible. The exor tendons may
be difcult to harvest without creating a long incision on the plantar surface of the foot. In order to
gain more length, the exor tendons may be
divided through the dorsal incision after the metatarsal osteotomy.
The tibial and bular plantar digital nerves are
traced proximally to their bifurcation from the
common digital nerves. The common digital
nerves to the great toe-second toe web space and
the second-third toe web space are split more
proximally using micro-forceps and microscissors before transecting the tibial and bular digital nerves to either the great toe or second toe.
Each nerve is tagged with a small micro clip to
facilitate later identication.
Harvest of a second toe transfer is completed
by osteotomy of the second toe metatarsal at the
level of the metaphyseal are with a short, thin,
narrow oscillating saw blade. The great toe is
usually harvested at the level of the base of the
proximal phalanx, as a more proximal osteotomy
through the metatarsal head may interfere with
gait. The tourniquet is then deated and the vascular pedicles irrigated with 1:20 papaverine
solution to relieve any vasospasm, and the foot is
wrapped in a laparotomy pad bathed with warm
irrigating solution.
Prior to transfer to the hand, the toe transfer
should be pink with normal capillary rell and
should have an excellent Doppler signal. The
toe transfer should be allowed to reperfuse for at
least 20min before reinating the tourniquet on
the leg. The arterial and venous pedicles to the
toe are ligated with 4-0 silk ties and reinforced
with small micro-clips. The toe transfer is
wrapped in a moist laparotomy pad and handed
to the surgical team operating on the hand.
31.11.2 Dissection oftheRecipient
Hand
This may be performed simultaneously with the
foot dissection if two teams are available or primarily before the foot is dissected, especially in
congenital cases to ensure that there are adequate
nerves and tendons present in the hand. Even
though the external morphological appearance
and a plain radiograph of the hand are reliable
indications for consideration of a toe-to-hand
transfer, they do not imply availability of internal
recipient structures. In general, the anatomic
structures (tendons and nerves) are more developed in children with congenital constriction ring
syndrome compared to those children with symbrachydactyly, hypoplasia, and transverse deciency. Several authors [56–58, 60, 61, 78] have
observed that tendons and nerves are more likely
to be normal proximal to a constriction ring compared with symbrachydactyly. However, with
increasing experience of the surgeon, the lack of
suitable recipient tendons and nerves, which may
be encountered in symbrachydactyly, can be circumvented by using tendon grafts or tendon
transfers and nerve grafts or nerve transfers.
The dorsal aspect of the hand is explored rst,
either through a transverse incision at the level of
the wrist or through a longitudinal incision
extending proximally from the proposed metacarpal stump. The extensor tendons in a congenital hand are almost universally present, and a
recipient extensor tendon is selected which has
satisfactory gliding and excursion. A large dorsal
vein is identied and tagged with vessel loops. A
branch of the supercial radial nerve is also identied for later coaptation to the deep peroneal
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nerve or as a nerve transfer to the plantar digital
nerves of the toe transfer. For a toe-to-thumb
transfer, the dorsal branch of the radial artery
passing through the anatomical snuff box is dissected and tagged with vessel loops.
The palmar aspect of the hand is explored
through a Bruner zigzag incision. Either the
median or ulnar nerve is identied at the level of
the wrist and dissected in a proximal-to-distal
direction to identify common digital nerves or
proper digital nerves for later coaptation to the
plantar digital nerves of the toe transfer. The
exor tendons are dissected either proximal or
distal to the transverse carpal ligament, but a portion of the transverse carpal ligament should
always be left intact to prevent bowstringing.
One exor tendon should be selected which has
satisfactory gliding and excursion. For a toe-tonger transfer, the ulnar artery is dissected
through Guyon’s canal and tagged with vessel
loops. The periosteum over the stump of the
selected metacarpal is elevated, and dorsalpalmar and radial-ulnar drill holes are made with
a 0.035 inch K-wire for subsequent 90–90 interosseous wiring. The incisions in the hand are
temporarily closed with staples to prevent excessive swelling and the tourniquet deated.
31.11.3 Transfer oftheToe
totheHand
Before reinating the arm tourniquet, the relevant
structures in the toe transfer are reidentied—the
dorsal vein, extensor tendon, deep peroneal
nerve, exor tendons, and tibial and bular digital nerves—and either the dorsalis pedis artery,
FDMA or the FPMA system. The position and
length of the toe transfer are then determined by
placing the base of the metatarsal of a second toe
or the proximal phalanx of a great toe at the proposed site of osteosynthesis with the selected
metacarpal, checking the length and relationship
of the toe transfer to the remaining digits in the
hand or to the proposed location of a future additional toe transfer. Excess length of the metatarsal of a second toe transfer is removed with an
oscillating saw. Dorsal-palmar and radial-ulnar
drill holes are made in the metatarsal or proximal
phalanx of the toe transfer using a 0.035 inch
K-wire, and osteosynthesis between the toe metatarsal or proximal phalanx and the recipient
metacarpal or proximal phalanx is accomplished
using 90–90 interosseous wiring with 26 gauge
stainless steel dental wire. Alternatively, osteosynthesis can be accomplished using crossed
K-wires or a longitudinal K-wire or even a small
plate and screws. Any propensity for hyperextension at the metatarsophalangeal joint of the toe
transfer is prevented by suturing the volar plate
more proximally to soft tissues or to the metatarsal itself to limit extension to a neutral 0°.
The extensor hallucis longus tendon of a great
toe transfer or the extensor digitorum communis
tendon of a second toe transfer is repaired to the
selected extensor tendon in the hand. The toe
transfer is positioned in full extension at the MCP
(metacarpophalangeal) and interphalangeal joints
and the selected recipient tendon at its resting
tension. The extensor tendon repair is performed
with multiple 4-0 clear nylon mattress sutures
and a running locked suture to allow early motion.
If a toe-to-thumb reconstruction is being performed, the extensor indicis proprius (EIP) tendon to the index nger may need to be transferred
as a donor tendon transfer. When reconstructing a
nger, the “quadriga” effect, due to tethering of
adjacent extensor tendons with a common muscle belly to the absent digits, must be prevented
by releasing adjacent extensor tendons.
Usually only one exor tendon, the exor hallucis longus of a great toe transfer or the exor digitorum longus tendon of a second toe transfer, is
repaired to the selected recipient exor tendon in
the hand or at the wrist level. The exor tendon
repair is accomplished using several 4-0 nylon mattress sutures supplemented with a running locked
suture. To prevent any “quadriga” effect, adjacent
exor tendons that may tether the newly reconstructed exor tendon to the toe transfer are divided.
Occasionally, an interposition exor tendon graft
may be necessary to make up for any discrepancy in
length between the exor tendon of the toe transfer
and the selected exor tendon at the wrist. If a exor
tendon with adequate excursion cannot be identied, a primary tendon transfer may be required.
Neurorrhaphies of the tibial and bular digital
nerves of the toe transfer to recipient common or
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proper digital nerves in the hand are performed
using an end-to-end epineurial technique with 10-0
nylon microsutures under the operating microscope.
Digital nerve neurorrhaphies can occasionally be
facilitated using brin glue. Neurorrhaphy of a
branch of the deep peroneal nerve of the toe transfer
to a branch of the supercial radial nerve in the hand
is similarly performed. If there is a gap between the
digital nerves of the toe transfer and recipient nerves
in the hand, interposition nerve grafts may be necessary, using either the supercial or deep peroneal
nerves harvested as a nerve graft from the donor
foot. If recipient digital nerves are unavailable in a
toe-to-thumb transfer, end-to-side neurorrhaphies
may be required, or a nerve transfer can be performed using a branch of the supercial radial nerve
coapted to the ulnar digital nerve of the toe
transfer.
Osteosynthesis, extensor and exor tendon
repairs, and neurorrhaphies of the digital nerves
and deep peroneal nerve should hopefully be performed within a 2 h period of tourniquet ination.
The tourniquet is then deated for the arterial and
venous anastomoses. The venous anastomosis is
usually performed rst before the arterial anastomosis. The draining vein of the toe transfer is anastomosed end to end under the operating microscope
using standard microsurgical techniques using
10-0 nylon microsutures to the selected vein on the
dorsal aspect of the wrist. The recipient vein is
then occluded just proximal to the anastomosis
with a small microvascular clamp. The site of the
arterial anastomosis depends on whether the dorsal or plantar arterial system of the toe transfer has
been harvested and the location of the recipient
radial or ulnar artery. If a “long” dorsalis pedis—
FDMA arterial pedicle—has been harvested, endto-end or end-to- side anastomosis to the ulnar
artery at the wrist or the dorsal branch of the radial
artery in the anatomical snuff box can be performed. If the “short” FPMA pedicle has been harvested, it can occasionally be anastomosed to the
supercial palmar arch or to a common digital
artery, but it is usually better to elongate the FPMA
with an interposition vein graft anastomosed on a
back table prior to osteosynthesis [76]. The vein
graft can then be anastomosed end to end to the
dorsal branch of the radial artery in the anatomical
snuff box or the ulnar artery at the wrist. After
completion of the arterial anastomosis, the double
approximator clamp is removed, but the single
microvascular clamp on the proximal side of the
venous anastomosis is maintained to create a highpressure column of blood owing through the toe
transfer to expand any collapsed vessels due to
vasospasm. The anastomoses are irrigated with
1:20 papaverine solution. The toe transfer should
rapidly turn pink and have excellent capillary
rell. After removal of the microvascular clamp
from the proximal side of the venous anastomosis,
the patency of the arterial and venous anastomoses
can be conrmed by the Acland “milking test.”
The incisions are loosely closed with interrupted 4-0 or 5-0 chromic sutures. Split thickness or full thickness skin grafts are liberally
used to prevent any tension on the underlying
anastomoses. A sterile pulse oximeter probe is
applied to the nail plate of the toe transfer
before the dressings are applied for continuous
postoperative monitoring of the patency of the
arterial and venous anastomoses [79]. The pulse
rate of the toe transfer should correspond
exactly to the pulse oximeter on the opposite
hand and monitors the patency of the arterial
anastomosis. Any decrease in the pulse rate
compared to the systemic heart rate may indicate that the arterial anastomosis is compromised. The oxygen saturation (SaO2) monitors
the patency of the venous anastomosis, and any
decrease in the oxygen saturation for an
extended period of time when compared to the
systemic oxygen saturation may indicate
thrombosis of the venous anastomosis. The
incisions are covered with antibiotic ointment
and nonadherent gauze dressings and the hand,
wrist, forearm, and elbow immobilized in a
loose plaster of Paris sugar-tong splint.
31.11.4 Closure oftheDonorFoot
The thigh tourniquet is deated and hemostasis
achieved in the donor foot. If necessary, a small
Jackson-Pratt drain is placed. After harvesting the
second toe, the gap between the great toe and the
third toe is closed by repairing the intermetatarsal
ligament using 2-0 or 3-0 Ethibond sutures. The
skin is loosely closed with interrupted 4-0 or 5-0
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chromic sutures. After harvesting the great toe, the
dorsal and plantar skin can usually be approximated or the remaining defect covered with a skin
graft. After harvesting the Morrison “wraparound”
or “trimmed toe” variations of a great toe transfer,
the proximal-based ap on the medial aspect of the
foot is used to cover any remnant of the proximal
phalanx of the great toe, and any remaining soft
tissue defect is covered with a skin graft. The
donor foot is immobilized in a posterior plaster of
Paris splint with the foot in neutral position.
31.12 Postoperative Care
Both the hand and foot are elevated and the hand
kept warm with a heating blanket. The child is monitored in a pediatric intensive care unit for up to
three days postoperatively. The child is kept sedated
using opiates and benzodiazepines as necessary,
and a rst-generation cephalosporin is administered
intravenously for 5–7 days postoperatively.
Anticoagulation with dextran 40 (0.36 ml/kg/h) is
continued for ve days, and low-dose aspirin 81mg
is started on the rst postoperative day and continued for four weeks. The dextran infusion is reduced
to half on postoperative day 6 and discontinued on
day 7. If the clinical appearance of the toe transfer
or the differential pulse oximetry monitoring indicates compromised perfusion to the toe transfer, the
child should be returned to the operating room
immediately for exploration and possible revision
of the microsurgical anastomoses.
The splints on the hand and foot are removed
10–14 days postoperatively and the “take” of any
skin graft is assessed. The child can then begin to
ambulate with a bulky sock in a slipper or sneaker.
The hand is protected with a removable thermoplast splint for two more weeks when passive and
active range of motion exercises of the toe transfer are begun.
These children may require secondary tenolyses, tendon transfers, bone grafting, arthrodeses,
osteotomies, or scar revisions to reach their optimal functional and aesthetic outcome.
31.13 Conclusions
Microsurgical toe-to-hand transfers for posttraumatic reconstruction in children and for reconstruc-
tion of congenital hand differences will hopefully
continue to evolve to become accepted into the
armamentarium of pediatric hand surgeons,
although it will continue to remain a technical challenge requiring a high level of microsurgical skill on
the part of the hand surgeon and the ultimate trust of
the child’s parents. Preoperative counseling of the
parents with the opportunity to meet and speak with
other families and children who have undergone a
toe transfer is absolutely vital. Most importantly, the
parents should fully understand the small potential
for failure of the procedure with consequent loss of
the toe transfer. While the indications for toe transfers are now better dened [60], the optimal age for
toe transfers remains unknown. Just like other congenital hand surgeries, most experienced surgeons
believe that toe transfers between two and three
years of age have the best chance of cortical integration, although toe transfers have been successfully
reported in older children between the ages of 11
and 17 years [71].
It will always be very difcult to prove conclusively that microsurgical reconstruction of
congenital hand differences is superior to either
no surgical intervention or conventional reconstruction, but a child who is able to write his/her
name for the rst time, or who can pick up a cup
singlehandedly and hold an utensil or who can
now ride a bicycle, provides the hand surgeon
with far greater conrmation than the most
sophisticated outcome instruments. In the future,
parental assessment of their child’s functional
outcome and even the child’s own assessment
will be important validation of these techniques
[80, 81].
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Compartment Syndromes (CS)
https://t.me/medicina_free
and Volkmann’s and Upper Limb
Vascular Pathology in the Peri-
and Neonatal Period
AntonioLandi, GiuesppeCaserta,
AndreaGiorgini, SilvanaSartini, andScottOishi
32
Abstract
The borderline between perinatal compartment syndrome (CS), Volkmann’s contracture
and vascular lesion appears to be very subtle.
As regards CS, a new pathophysiological
classication has been introduced. Location,
clinical symptoms and complementary investigations vary signicantly from adults. The
overlying area of skin necrosis, “the sentinel
lesion”, usually accompanies the intrauterine
and CS and Volkmann’s syndrome.
Treatment consists of early fasciotomy
which has exceptionally carried out as the
newborn already presents at birth with an
established Volkmann’s contracture.
A. Landi (*)
Hand Unit Casa di Cura Toniolo, Bologna, Italy
e-mail: landi_antonio@virgilio.it
G. Caserta
Hand Surgery Unit, Policlinico di Modena,
Modena, Italy
A. Giorgini
Orthopaedic and Traumathology Unit, Policlinico di
Modena, Modena, Italy
S. Sartini
Hand Rehabilitation Service, Policlinico di Modena,
Modena, Italy
e-mail: ssartini@gruppociemme.it
S. Oishi
Department of Upper Extremity and Microsurgery,
Scottish Rite Hospital for Children, Dallas, TX, USA
e-mail: Scott.Oishi@tsrh.org
Ideal treatment consists of early escharotomy
followed by skin grafting, early removal of the
scar and neurolysis of the main nerves. Tendon
or free muscle transfer will be subsequently performed according to the severity of the lesion.
Vascular lesions in the newborn are also
very rare but must be distinguished from CS
and Volkmann’s syndrome as treatment must
be urgently addressed due to the fact that
thrombosis of the main vessels might lead to
necrosis followed by amputation of the upper
limb. During the growing phase, residual
problems such as joint stiffness, rst web contracture and bone non-union should be dealt
with. Surprising in spite of signicant residual
limb discrepancy, favourable long-term outcomes might be obtained.
Keywords
Perinatal compartment syndrome
Volkmann’s classication · Fasciotomy
Tendon transfer · Free muscle transfer · Limb
discrepancy · Perinatal vascular lesion
Sentinel lesion
32.1 Introduction
The pathology of CS and of Volkmann’s syndrome, especially in relation to the associated
skin lesion of the upper limb in the peri- and neonatal period, was initially conned within the
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