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294
MUCL
2
1
Valgus
2
LUCL
Fig. 11.18 Proposed order of ligamentous tearing from
lateral to medial during a traumatic elbow subluxation or
dislocation, also termed “Horii Circle.” Injury can be
thought of as a spectrum of involvement and severity,
typically starting with the 1. Lateral structures (LUCL); 2.
Anterior capsule structures (coronoid avulsion) /Posterior
capsule; followed by 3. Medial structures (MCL- anterior
bundle). Depending on the mechanism of injury, tearing
can be seen in any combined pattern, location, or in
isolation
3
athletes, often require surgical reconstruction, in
which a tendon graft (palmaris longus or gracilis
autograft/allograft) is used to reconstruct the
MCL (tommy john surgery). In selected patients,
where there is a small avulsion injury of the
medial epicondyle, MCL repair with suture aug-
K. W. Zittel and M. W. Kessler
mentation is a viable alternative with promising
results utilizing newer augmented techniques.
Complications after surgical management
include ulnar neuropraxia, medial antebrachial
cutaneous nerve injury, fracture of ulna or medial
epicondyle, elbow stiffness, and inability to
regain pre-injury level of activity.
Summary andConclusions
The elbow is the critical link between the highly
mobile shoulder joint and the precisely coordinated wrist and hand. Conditions that interfere
with the elbow’s normal motion can signicantly
compromise a patient’s ability to feed, dress, and
clean himself or herself. In the athlete, compromise in function often precludes the ability to
participate. Fortunately, most conditions affecting the elbow do not result in signicant limitations. The majority of elbow problems can be
readily diagnosed with a thorough history, physical, and basic radiographic examination. An
algorithmic approach to treatment facilitates resolution of most problems of the elbow.
Further Reading
Morrey BF, editor. The elbow and its disorders. 3rd ed.
WB Saunders: Philadelphia, PA; 2000.
Galatz LM, editor. Orthopaedic knowledge update: shoul-
der and elbow. 3rd ed. Rosemont, IL: Journal of the
American Academy of Orthopaedic Surgeons; 2008.
Cheung EV, Steinmann SP. Surgical approaches to the
elbow. J Am Acad Orthop Surg. 2009;17(5):325–33.
Karbach LE, Elfar J. Elbow instability: anatomy, bio-
mechanics, diagnostic maneuvers, and testing. J
Hand Surg Am. 2017;42(2):118–26. https://doi.
org/10.1016/j.jhsa.2016.11.025. PMID: 28160902;
PMCID: PMC5821063.
The Hand
EdwardFakhre andCurtisM.Henn
12
Introduction
The human hand is perhaps the most important
interface of a person’s body with the outside
world. It allows us to touch, feel, manipulate, and
modify our environment. Its cortical representation in the brain is nearly as large as the rest of the
musculoskeletal system combined. Loss of hand
function can have devastating effects on a person’s ability to work or perform activities of daily
living. Unfortunately, because of its constant use
and its position at the forefront of human activity,
it is frequently affected by trauma and other disease processes. Nearly all physicians, regardless
of specialty or subspecialty, will encounter a
wide variety of hand pathology. Hand problems
will affect their patients, their family members,
their friends, and their colleagues. Therefore,
familiarity with the basic hand evaluation, hand
pathology, and basic treatment is crucial.
E. Fakhre · C. M. Henn (*)
Georgetown University School of Medicine,
Washington, DC, USA
Department of Orthopedics, MedStar Georgetown
University Hospital, Washington, DC, USA
e-mail: Curtis.M.Henn@gunet.georgetown.edu
History
As in all elds of medicine, the history begins by
determining the patient’s chief complaint, which
at times can be surprisingly difcult. Asking the
patient to locate the point of maximal pain or what
is the primary reason they came to see you is often
helpful. Obtaining a detailed history of the present illness should then follow. Supplemental
information specic to hand function should be
obtained, including hand dominance, occupation,
sports involvement, and hobbies.
The history of present illness is tailored to the
patient’s chief complaint and requires an understanding of various pathologic processes in the
hand and upper extremity. For instance, in
patients with congenital hand differences or
birth-related injuries, one should obtain a careful
understanding of the gestational and birth history.
One must inquire about gestational diabetes, preeclampsia, and other maternal and fetal health
problems, including exposure to teratogens. A
family history of similar anomalies should also
be determined. This information allows for the
prediction and detection of other associated
anomalies and conditions. The physician should
also inquire if improvement in the condition has
occurred and seek to understand the parental
goals and expectations of treatment.
In nontraumatic situations, one should have
the patient focus closely on the exact site of the
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
W. F. Postma et al. (eds.), Essentials of Orthopedic Surgery,
https://doi.org/10.1007/978-3-031-66215-7_12
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296
E. Fakhre and C. M. Henn
problem and detail the history of onset, progression, and interventions. An understanding of
what helps relieve symptoms and what aggravates them can aid in determining the diagnosis
and tailoring the treatment. In patients who attribute their problems to repetitive activities, it is
further important to understand the length of time
it takes before symptoms begin, how long the
patient had been doing this activity before this
problem developed, and whether symptoms are
now present when the patient is not involved in
these activities.
When a traumatic injury is present, the exact
nature of the injury and the surrounding circumstances under which it occurred should be carefully noted and documented; this includes the
environment in which the injury occurred,
whether it was clean or dirty, and whether the
patient perceives that the injury was caused by
another person’s fault, their own error, or an
unavoidable circumstance. These injuries often
entail worker’s compensation claims or other
medicolegal litigation. By carefully determining
and recording the events that occurred, the treating physician can give the most accurate representation of the injury and avoid later difculties
in trying to reconstruct events from memory.
Often patients present late after having been
treated elsewhere or having avoided treatment
altogether. This was particularly true during the
COVID-19 pandemic. In these cases, one should
note the evolution of the patient’s problems, what
treatments have occurred, and the current functional limitations of the patient.
The remainder of the patient’s medical history
should be elicited. An understanding of the
patient’s diseases including the presence of diabetes, hypothyroidism, heart disease, or other problems can help determine factors contributing to a
hand problem. Previous surgical history, including complications of anesthetics, is also very
important in the treatment process. Medications
and allergies have obvious implications in the
treatment. Social history should include the
patient’s occupation and hobbies, as well as
tobacco, alcohol, and illicit drug use. Family history and review of systems then complete a thorough evaluation of the patient’s history.
Physical Examination
When examining the hand and upper extremity, it
is important to develop a systematic approach
that evaluates all joints and sensory and motor
function of all peripheral nerves. The exam is
then completed with specic provocative tests
tailored to the patient’s complaints. It is important to compare the injured or affected extremity
with the contralateral extremity, because there is
a wide variation in normal exams from person to
person.
One begins the evaluation with the observation
of both upper extremities, noting atrophy, deformity, or any other lesions. Active range of motion
is then assessed, including of the shoulders,
elbows, forearms, wrists, and digits. If there is limited or asymmetric active range of motion, passive
range of motion should then be assessed. Motor
function and strength can then be evaluated.
Typically, the extensor digitorum communis, the
rst dorsal interosseous, and the abductor pollicis
brevis muscles are tested to evaluate the radial,
ulnar, and median nerve motor function. Adding
strength testing of wrist extension, extensor pollicis longus, exor digitorum profundus to the small
and/or index nger can further localize the lesion.
Sensation is then tested. The radial aspect of the
index nger tip, ulnar aspect of the small ngertip
and rst dorsal webspace are the best places to test
for radial nerve, ulnar nerve, and median nerve
sensation. In evaluating the sensory function, it is
often helpful to obtain some measured data, such
as two-point discrimination or Semmes–Weinstein
monolament threshold testing. For young children, assessment of wrinkling after immersion
under water or the presence or absence of sweating
can be helpful, as they are functions of the autonomic nervous system and cease when a peripheral nerve function is absent. Finally, vascular
supply should be assessed by palpating the radial
artery at the wrist and/or assessing capillary rell
in the nger(s). A Doppler ultrasound can also be
used if a radial pulse is not palpable or there is
question about distal perfusion.
Palpation of the general area of the chief complaint should be performed next. In this section,
one should localize the patient’s pain or symp-
12 The Hand
297
toms as anatomically as possible, but it is also
important to start your palpation away from the
point of maximal pain. The hand is unique in that
many of the affected structures are easily palpated and distinguished from other structures,
which often allows the examiner to make the
diagnosis by determining the precise anatomic
structure that is symptomatic. Thus, an understanding of surface anatomy is critical. For example, one must know that the scaphoid waist
underlies the anatomic snuff box and that the A-1
pulley of the exor tendon sheath is at the level of
the metacarpophalangeal joint.
Specialized testing for specic injuries or
problems can help conrm a diagnosis, and these
tests are addressed under the sections describing
those specic disease processes. In the setting of
traumatic injury and or open wounds, strength
testing is often deferred and the examination then
seeks to determine if the function of the peripheral nerve or digital nerve is present or absent and
seeks to determine if a partial or complete tendon
laceration is present. Flexor and extensor tendon
function can be determined by evaluation of
active range of motion as well as the tenodesis
effect of the wrist. Normally, the digits should
ex upon passive wrist extension and extend with
passive wrist exion, and a digit not doing so
indicates a possible exor or extensor tendon
injury. Pain with resisted tendon function may
indicate a partial tendon injury. Following a thorough history and physical exam typically is
imaging of the hand. The exam may then be
repeated or further tailored following evaluation
of the imaging ndings.
Imaging
Imaging of the hand and upper extremity starts
with radiographs. The standard views of the hand
and wrist include anteroposterior (AP), lateral,
and oblique views, and further views can be
added depending on the specic area of concern
(Fig. 12.1). For example, an AP of the wrist in
ulnar deviation, also called a scaphoid view, provides an excellent view of the scaphoid in prole.
All physicians who will evaluate the hand should
have familiarity with the basic normal radiographic anatomy of the carpals, metacarpals, and
phalanges. The physician should evaluate the
overall alignment and relative relationships of the
carpal bones to avoid missing a dislocation in an
emergency room setting, such as commonly
abc
Fig. 12.1 AP (a), oblique (b), and lateral (c) radiographs of a normal wrist without any evident pathology or abnormality.
The line arrow on the AP and lateral views points to the scaphoid bone and the block arrow in both points to the lunate
298
ab
E. Fakhre and C. M. Henn
Fig. 12.2 AP (a) and lateral (b) radiographs of a perilu-
nate dislocation that was missed in the emergency department. Evaluation of the PA show subtle abnormalities of
the carpal alignment, and the lateral then shows the dorsal
occurs in the setting of a perilunate dislocation
(Fig.12.2). Any detection of abnormality should
prompt further three-dimensional imaging or
immediate evaluation by a hand surgeon.
Advanced imaging modalities are used for disease or injury processes that present with normal
radiographs and the diagnosis remains uncertain,
such as an occult scaphoid fracture. Advanced
imaging may also be used to further characterize
dislocation of the capitate from the lunate. The line arrow
points to the volar aspect of the lunate. Note that the
lunate is no longer articulating with the capitate, which is
dorsal and signied by the block arrow
which tendons or other soft tissue structures can
be evaluated while they are moving. It is a costeffective imaging modality but is highly operator
dependent in terms of performance and interpretation of the study. Bone scans can also be useful
for helping dene infection, reex sympathetic
dystrophy, and occult fractures, but utilization of
bone scan has largely been replaced by MRI,
except in unique situations.
a known abnormality, such asfurther evaluation
of a soft tissue tumor. Computed tomography
(CT) scans can evaluate precise bony anatomy
Arthroscopy
and are useful in dening fracture presence, fracture displacement, fracture healing, and bony
lesions. Magnetic resonance imaging (MRI) is the
modality of choice for soft tissue lesions and has
become the modality of choice for occult fractures of the scaphoid. MRI can also be used to
diagnose ligamentous injuries of the wrist such as
scapholunate or lunotriquetral ligament injuries.
Ultrasound is rapidly becoming a useful imaging
technique, especially to dene soft tissue lesions,
bony abnormalities, and ligamentous injuries. It
can be particularly helpful in differentiating
between rupture or scarring of a tendon repair and
for visualizing foreign bodies that are not radiopaque. Ultrasound allows for a dynamic study in
Arthroscopy has become a common and impor-
tant treatment modality in treating wrist
pathology. Wrist arthroscopy has signicant
diagnostic value and is the gold standard for
diagnosis of ligamentous injury, chondral dam-
age, and capsular tears. As a treatment modality,
arthroscopic debridement or repair is frequently
employed in the treatment of triangular brocar-
tilage complex (TFCC) tears, and arthroscopi-
cally assisted procedures are becoming more
common (Fig. 12.3). As indications and tech-
nique are rened, arthroscopy will likely play an
increasingly important role in the treatment of
other bony, ligamentous, and chondral injuries.
12 The Hand
ab
299
Fig. 12.3 (a) Arthroscopic image demonstrating a cen-
tral tear of the TFCC.The probe is inserted into the tear.
These tears generally require debridement. (b)
Arthroscopic image demonstrating a complete tear of the
Pathophysiology
Hand problems can be grouped into seven major
categories of disease: congenital, developmental/
acquired, infectious, traumatic, metabolic, vascular,
and neoplastic. There is tremendous overlap
between these divisions, and a given disease process may have origins in more than one category.
However, keeping these categories in mind and
eliminating those that do not t a patient’s complaint can help focus one’s differential diagnosis,
leading to the proper diagnosis and treatment protocol. The remainder of this section reviews the most
common disease entities within each category.
Congenital Hand Dierences
In the human embryo, the upper extremity begins
to develop as a limb bud at 4weeks after fertilization when a segment of mesoderm outgrows and
protrudes into the overlying ectoderm. A small
segment of ectoderm then condenses and forms
the apical ectodermal ridge, which guides further
longitudinal growth of the limb. A second area,
named the zone of polarizing activity, forms in
the posterior margin of the limb bud and controls
TFCC with the ulnar head visible through the torn TFCC
on the right side of the image. The shaver probe on the left
of the image is radial to the tear and resting on the lunate
facet of the radius
radial and ulnar growth and differentiation. A
third area in the dorsal ectoderm helps control
formation of volar and dorsal characteristics of
the limb. From weeks 4–8 after fertilization, this
small outgrowth of mesoderm becomes a fully
differentiated upper extremity with separate
joints and digits. It is during this time that most
congenital upper extremity anomalies originate.
Failure ofFormation
Failures of formation may be transverse or longi-
tudinal. Transverse failures are caused by injuries
to the apical ectodermal ridge. They result in
complete congenital amputation distal to the site
of injury, which can vary from loss of ngertips
to complete absence of the arm. The most com-
mon presentation is a congenital below-elbow
absence of the hand and distal two thirdsof the
forearm. Depending on the level of the congenital
absence, it is often treated by observation and
parental reassurance or prosthetic replacement.
Longitudinal failures of formation involve
loss of only part of the distal segment. They can
be divided into radial (preaxial), central, and
ulnar (postaxial). The most common of these are
300
ab c
E. Fakhre and C. M. Henn
Fig. 12.4 Congenital malformations. (a) Radial club-
hand produced by longitudinal absence of radius. (b and
c) Bilateral cleft hand with failure of formation of the cen-
the radial-sided deciencies such as congenital
absence of the thumb or radial clubhand
(Fig.12.4a). These problems are often associated
with visceral and bone marrow abnormalities
such as Holt–Oram (cardiac septal defects);
Fanconi anemia; thrombocytopenia absent radius
(TAR); and vertebral, anal, cardiac, tracheoesophageal, renal, and limb abnormalities
(VACTRL). These patients should undergo evaluation by the appropriate pediatric subspecialists.
Central defects are much less common and primarily include the cleft hand (Fig. 12.4b, c).
Ulnar-sided deciencies include ulnar clubhand
and its variations; these are often associated with
other orthopedic anomalies. A very uncommon
form of longitudinal growth arrest involves intrasegmental losses such as phocomelia, in which a
relatively normal hand is attached to either the
trunk or a very short segment of arm. Treatment
of longitudinal failures of formation varies
widely, as the severity and functional limitations
vary widely from patient to patient.
Failure ofDierentiation (Separation
ofParts)
Failure of differentiation occurs when the normal
programmed cell death between tissues fails to
occur and bones, joints, or individual digits fail to
tral digit. The patient has undergone a derotational osteotomy of the left middle metacarpal
form. The most common manifestation of this is
syndactyly, in which individual digits are still
linked together either by webs of skin or sometimes by continued fusion of the bones (Fig.12.5a,
b). These parts often require surgical separation
when the patient reaches the appropriate age.
Other common failures of separation include the
congenital lunotriquetral coalition; this is rarely
symptomatic and is often an incidental nding.
Synostosis, particularly of the proximal radius
and ulna, which restricts pronation and supination, and symphalangism, in which there is congenital fusion of the proximal interphalangeal
(PIP) joint, are other manifestations that can be
more functionally limiting and symptomatic.
Duplication
Duplication or polydactyly, another fairly common congenital hand difference, can range in
scope from a simple skin tag attached to the small
nger to a complete mirror hand. The very small
skin tags formed on the ulnar aspect of the hand
can sometimes be treated with suture ligation in
the nursery, but more complex polydactylies
require formal surgical resection and reconstruction (Fig.12.6). This is particularly true when a
joint is involved, as osteotomy to allow the joint
surfaces to maintain normal congruity and liga-
ab
cd
12 The Hand
a b
Fig. 12.5 (a and b) Syndactyly in an infant
301
Fig. 12.6 (a and b) Thumb polydactyly at the level of the metacarpophalangeal joint requiring removal of the duplicate
radial digit and reconstruction of the radial soft tissue (c and d)
ment reconstruction to reestablish stability may
be required. Often the individual duplicated segments are not equal in size to a normal part, and
function may not be completely normal after
reconstruction. Many of the thumb reconstructions, in particular, require later secondary operations to ne-tune the result or to make adjustments
for growth-induced deformities. Occasionally
302
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E. Fakhre and C. M. Henn
c
Fig. 12.7 (a, b, and c) 75-year-old woman with fully functioning polydactyly. The patient had presented to the ofce
with complaints related to the contralateral normal hand
patients and their parents forgo surgical correction and can live a normal life with an extra digit
(Fig.12.7).
look for an underlying cause such as a vascular
malformation or neurobromatosis. The problem
can be exceedingly difcult to treat, and when
debulking procedures fail, ray amputation of
affected digits often is required.
Other Congenital Anomalies
Undergrowth or hypoplasia also includes a
wide spectrum of problems including such minor
The remaining categories of congenital hand differences are less common. Overgrowth is a condition that can affect either an entire limb or an
individual digit or section of the upper extremity.
When this is encountered, the physician should
differences as brachymetacarpia (short metacarpals) or involving signicant hypoplasias of the
entire upper extremity. It is sometimes associated
with other syndromic conditions such as Poland
syndrome (pectus excavatum and other chest
12 The Hand
303
wall abnormalities, hypoplasia of the hand, syndactyly, and other associated abnormalities). The
treatment is patient specic, and often supportive
care is all that is needed.
Congenital constriction band syndrome is a
process in which it is thought that amniotic
bands form around segments of the extremities,
causing deep circumferential bands, fusions of
distal parts, and even amputation. In rare
instances, surgery very soon after birth is
required to prevent neurovascular compromise,
but most cases the bands can be treated in a
delayed fashion. Treatment often involves excision of the deep constriction band and multiple
Z-plasties for reconstruction. In some situations,
a separation of distal syndactyly of the digits can
be required.
Developmental or Acquired Disease
Arthritides
Arthritis of the hand and wrist is a common problem, and as it becomes progressively more severe,
patients can experience marked limitation in
hand function due to pain, deformity, or loss of
range of motion.
Nearly all types of arthritis affect the hand, but
osteoarthritis is by far the most common. The distal interphalangeal (DIP) joints of the ngers and
interphalangeal (IP) joints of the thumbs are the
most common joint in the hand affected, and
patients often notice painless nodules early in the
disease process. Mucous cysts, which are ganglion cysts arising from the arthritic distal interphalangeal joints, can develop at these joints as
well. The PIP joints can also become involved
and can develop signicant stiffness and/or angular deformity. The thumb carpometacarpal
(CMC) joint, also known as the basilar joint or
trapeziometacarpal joint, is a common site of
involvement as well, and it is the joint that most
commonly requires surgical intervention for
osteoarthritis in the hand. Arthritis in the basal
joint can be extremely painful and cause debilitating loss of pinch and grasp function. In the carpus itself, the scaphotrapeziotrapezoid (STT)
joint also has high rates of involvement and often
accompanies thumb CMC arthritis.
The diagnosis can often be made by the
patient’s description of their symptoms alone.
Patients will complain of pain at the base of the
thumb, particularly with opening jars or pinching
with any force. Physical examination often shows
a characteristic deformity with swelling about the
basal joint with or without adduction of the thumb
metacarpal and hyperextension of the thumb
metacarpophalangeal joint. The patient will also
have signicant tenderness at the affected joint.
Thumb CMC arthritis can further be diagnosed by
a positive thumb CMC grind test. The thumb
metacarpal is carefully grasped between the
examiner’s thumb and index nger. The remainder of the wrist is stabilized with the other hand,
and an axial load and circumduction force are
applied to the thumb metacarpal. This procedure
usually results in severe pain for patients who
have arthritis of this joint. Plain radiographs conrm the diagnosis in nearly all cases and advanced
imaging is rarely needed. Classic radiographic
ndings are joint space narrowing, subchondral
sclerosis, subchondral cyst formation, and osteophyte formation (Fig.12.8).
Treatment is dictated by the patient’s level of
symptoms and their radiographic staging. For
moderate pain and earlier radiographic stages,
simple rest and anti-inammatories can often
provide signicant relief. Splinting is often an
adjunct, particularly for the thumb CMC and
STT joints. Corticosteroid injections are a
second- line treatment that provides signicant
short to medium term relief, particularly at the
thumb CMC joint and the STT joint. If patients
have developed mucous cysts at the DIP joint
causing pain, skin breakdown, or nail deformities, surgical treatment with resection of the
mucous cysts and the underlying osteophytes is
indicated. Symptomatic PIP and DIP joint osteoarthritis refractory to conservative management
is usually treated by fusion. Arthroplasty is an
option for the treatment of MCP osteoarthritis as
well as select cases of PIP involvement. Isolated
STT joint arthritis can be treated with fusion or
resection arthroplasty by removing the trapezium
and proximal trapezoid. Arthritis of the CMC