Practical Plastic Surgery

depends on its persistence in the injection site, and its continued anti-inflammatory effect on the tendon within the canal. Recent reports suggest better efficacy when injected around the tendon sheath rather than directly into it, although the reasons for this are not well established.

Percutaneous Treatment

Higher grade or persistent lesions can be treated by percutaneous release. Involving local anesthesia and an 18 gauge needle, percutaneous intervention has been advocated by some authors for moderate (grade 2 or 3) lesions. The needle tip is inserted, cutting edge oriented longitudinally, to avoid nerve injury, and used to divide the fibers of the A1 pulley. A history of consistent triggering is key to this approach as it allows for immediate identification of complete release, since the pulley cannot be visualized by this technique. Because the digital nerves cross the path of the tendon sheath for the thumb and border digits, many surgeons restrict this treatment to long and ring digit release, in order to minimize the risk of nerve injury. Others have reported its use safely in all digits. After release, steroid injection is often given as an adjunct treatment. Detractors of this technique suggest that the blind movement of the needle during attempts to cut the pulley can be more traumatic than a carefully controlled open release.

Open Release

For lesions in border digits with refractory triggering, an open release should be considered. These can be approached by a variety of volar incisions over the MCP joints: transverse, longitudinal or oblique. Also feasible under local anesthesia, open release involves blunt dissection to the level of the sheath and sharp division of the A1 pulley under direct visualization. Usually traction is applied to deliver both flexor tendons through the wound, ensuring that they are no longer constrained by the pulley.

Pearls and Pitfalls

Although recommended injection amounts are variable, the senior author favors a reduced steroid load—0.2 ml of 10 mg Kenalog, which has not changed its efficacy in his hands. This decreases the adverse effects of steroids including fat atrophy, discoloration and hyperglycemia, which can be seen with traditional doses.

As a rule, axial incisions should be made in an inter-nervous plane whenever possible. In the case of the thumb, where the digital nerves run as close as 1 mm beneath the skin of the proximal digital crease, this may provide a valuable safety net for the surgeon especially in the context of resident teaching. Triggering in the thumb is also

95noteworthy for its peculiar presentation of pain which can radiate up the forearm. Moreover, the principal pulley to preserve for normal thumb flexion is the oblique pulley, which bears careful scrutiny given its proximity to the release site in the thumb.

While most triggering is manageable using these techniques, triggering in the context of rheumatoid arthritis usually requires tendon debulking to restore a more normal ratio of tendon to sheath, rather than pulley releases. Occasionally, even a slip of flexor digitorum sublimis must be excised to restore more normal functional relations in these patients.

Suggested Reading

1.Carlson Jr CS, Curtis RM. Steroid injection for flexor tenosynovitis. J Hand Surg [Am] 1984; 9:286.

2.Newport ML, Lane LB, Stuchin SA. Treatment of trigger finger by steroid injection. J Hand Surg [Am] 1990; 15:748.

symptomatic without an appreciable mass may have an occult cyst, which can be diagnosed by MRI.

Common Sites of Occurrence

The most common site of occurrence is in the wrist, where up to 80% of cysts will occur. In order of frequency, ganglion cysts present on the dorsal wrist, volar wrist, volar hand and distal digit.

Dorsal Wrist (80%)

The common form of the most frequent mass off the wrist, these lesions tend to be pedunculated off a stalk extending from the distal edge of the scapholunate ligament.

Volar Wrist (20%)

Second most frequent, these can be radiocarpal (65%), scaphotrapezial (34%) or radial artery adherent (54%) originating from between the radial artery and flexor carpi radialis.

Volar Retinaculum (5%)

Significantly rarer, these are found at the proximal digital crease or the volar side of the MP joint. They can be mistaken for tendon sheath tumors; however they mostly (80%) originate from the A1 or A2 pulley and are not mobile with tendon sliding.

Distal Digit (5%)

Also known as a mucous cyst, these masses typically extend from a degenerative spur off an arthritic DIP joint in an older patient. They cause a slow growing, nontender nodule over the dorsal distal phalanx, eventually producing a characteristic grooving of the nail bed. Occasionally, these become infected through a tract from the nail distally and then present as a paronychia, even though chronic nail grooving hints at the chronicity of the true underlying diagnosis.

Treatment

Management of ganglion cysts can be divided into closed, percutaneous, open and endoscopic treatment.

Closed Treatment

Presentation is usually characteristic enough that observation is an option. Since

96activity has been thought to exacerbate this condition, splinting and reduction in active use may result in improvement in some cases. Treatment can usually be delayed until the patient’s symptoms are aggravating enough to warrant intervention. Given the waxing and waning in the size of these cysts, the patient may elect to wait until it is clear that things will not resolve or improve. Unfortunately, observation may reveal improvement or spontaneous resolution, but this is frequently followed by recurrence at a later date. Closed treatment by traumatic rupture (so-called “Bible therapy”) is mentioned largely for historical purposes.

Percutaneous Treatment

Many authors advocate aspiration, which involves percutaneous needle drainage, usually with a large enough bore needle to permit withdrawal of the viscous

contents (20 gauge or greater). This has the side effect of leaving a sufficient drainage tract for remaining contents to be directly expressed by compression. Some surgeons include compression as a significant component of this approach to prevent reaccumulation of the cyst contents. Aspiration alone has a high reported recurrence rate (50-85%).

1.Angelides AC, Wallace PF. The dorsal ganglion of the wrist: Its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg 1976; 1(3):228.

2.Minotti, Taras. J Am Soc Surg Hand May 2002; 2(2).

3.Nahra ME, Bucchieri JS. Ganglion cysts and other tumor related conditions of the hand and wrist. Hand Clin 2004; 20(3):249.

•The first dorsal compartment usually has more than just two tendon slips (i.e., APL and EPB) and may even have two or more distinct fibroosseus tunnels. Each of the two tendons can have multiple slips. During surgery, each separate compartment should be identified and the intervening septae divided. The various tendon slips should be inspected one at a time to ensure proper gliding free of excess synovium.

•Stenosing tenosynovitis is a common finding in patients with rheumatoid arthritis, and tendon rupture is one of the worst complications that can result. Treatment if these patients should focus on prevention of rupture. NSAIDs and

infrequent steroid injections are the mainstay of medical therapy, and surgical tenosynovectomy is reserved for patients who fail conservative management.

•The diagnosis of gout should always be ruled out (by joint aspiration and microscopic fluid examination) in any patient presenting with tenosynovitis of multiple sites in the hand or in whom a history of trauma or repetitive motion is not present.

Suggested Reading

1.Anderson BC, Manthey R, Brouns MC. Treatment of DeQuervain’s tenosynovitis with corticosteroids: A prospective study of the response to local injection. Arthritis Rheum 1991; 34:793.

2.Froimson AF. Tenosynovitis and tennis elbow. In: Green, ed. Operative Hand Surgery. New York: Churchill Livingstone, 1993:1989-2000.

3.Moore SJ. De Quervain’s tenosynovitis: Stenosing tenosynovitis of the first dorsal compartment. J Occup Environ Med 1997; 39(10):990.

4.Richie III CA, Briner Jr WW. Corticosteroid injection for treatment of de Quervain’s tenosynovitis: A pooled quantitative literature evaluation. J Am Board Fam Pract 2003; 16:102.

5.Weiss AP, Akelman E, Tabatabai M. Treatment of de Quervain’s disease. J Hand Surg 1994; 19(4):595.

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bicipital aponeurosis to avoid injury to the brachial and ulnar arteries and median nerve. The artery continues down the length of the forearm, running deep to the brachioradialis muscle. Exposure of the artery is best achieved with lateral retraction of this muscle. As it travels more distally, the artery is sandwiched by the brachioradialis laterally and the superficial flexor compartment medially. It travels over the pronator teres, flexor digitorum superficialis and flexor pollicus longus (FPL)—in that order. In the mid forearm, care must be taken to avoid injury to the superficial radial nerve by minimizing lateral traction of the brachioradialis. The lateral antebrachial cutaneous nerve must also be avoided in the mid forearm by retracting it laterally along with the brachioradialis and the short and long extensor carpi muscles during exposure of the artery. In the distal forearm, the radial artery becomes very superficial. It is bounded by the tendon of brachioradialis and radius bone laterally, the flexor carpi radialis (FCR) tendon medially, and FPL dorsally. Most of the perforating branches of the radial artery emerge in the distal forearm and are at risk for avulsion if care is not taken.

Operative Technique

The arm is positioned extended and supinated. The incision extends from a fingerbreadth lateral to the biceps tendon to a point just medial to the radial styloid at the wrist crease. The fascia between brachioradialis and FCR is divided. Some surgeons will administer a loading dose of a calcium-channel blocker followed by continuous infusion in order to prevent radial artery spasm. Initial dissection should begin in the mid forearm where the artery is best visualized. The artery should be retracted upward lightly with a vessel loop. All branches should be clipped and divided. From this point, the dissection should progress both proximally and distally. The distal artery is ligated using suture ligation at the level of the radial styloid. The proximal artery is both suture ligated and tied off using a 2-0 silk tie. After the artery is divided and removed from the patient, it is placed in papaverine-soaked gauze. Closure of the wound should be done in two layers. Some surgeons will leave a flat Jackson-Pratt drain in for 1-2 days. For dressings, only gauze and gentle ACE wrap compression is required.

Endoscopic Technique

In the past few years, endoscopic harvest of the radial artery has been performed at a number of centers. The artery is harvested through a 3 cm wrist incision with the aid of a Harmonic Scalpel. Some surgeons perform a counter incision at the elbow to divide and ligate the artery, although this can be done endoscopically. The complication rate from this procedure is somewhat higher than in the traditional open approach. Most of the complications are related to bleeding, such as conver-

98sion to an open procedure and postoperative hematoma. Patient satisfaction with the endoscopic technique is high (80-90%), and it is likely that this technique will gain popularity in the future.

Postoperative Considerations

Removal of the radial artery is extremely well-tolerated. Surgical site infection rate is low (4%) compared to the saphenous vein harvest site (18%). Radial sensory neuropathy is reported in 10-20% of patients, manifested by dorsal hand numbness. Noninvasive vascular tests demonstrate no difference between the operated and nonoperated hands after radial artery harvest. Cold intolerance, hand

claudication, neuropathies, grip strength, and sensory discrimination are also no different between the two hands after surgery. Nevertheless, some patients report more disability, pain and physical limitations of the operated hand; however these findings are not supported by objective measurements. The lack of postoperative complications can be explained by the fact that the caliber and flow rate of the ulnar artery increases after radial artery harvest. Blood flow in the brachial artery remains constant. In summary, removal of the radial artery does not decrease blood flow to the hand, and does not result in any clinically evident detrimental changes.

Pearls and Pitfalls

In the well selected patient with preserved blood flow to the hand with radial artery compression, the major source of morbidity is injury to small nerves at the distal aspect of the incision. A tourniquet helps to visualize these small antebrachial cutaneous nerves for preservation. The arm with the best vascularity should be used, rather than the nondominant limb.

Suggested Reading

1.Abu-Omar Y, Mussa S, Anastasiadis K et al. Duplex ultrasonography predicts safety of radial artery harvest in the presence of an abnormal Allen test. Ann Thorac Surg 2004; 77:116.

2.Allen RH, Szabo RM, Chen JL. Outcome assessment of hand function after radial artery harvesting for coronary artery bypass. J Hand Surg 2004; 29A:628.

3.Casselman FP, La Meir M, Cammu G et al. Initial experience with an endoscopic radial artery harvesting technique. J Thorac Cardiovasc Surg 2004; 128(3):463.

4.Dumanian GA, Segalman K, Mispireta LA et al. Radial artery use in bypass grafting does not change digital blood flow or hand function. Ann Thorac Surg 1998; 65:1284.

5.Dumanian GA, Segalman K, Buehner JW et al. Analysis of digital pulse-volume recordings with radial and ulnar artery compression. Plast Reconstr Surg 1998; 102(6):1993.

6.Reyes AT, Frame R, Brodman RF. Technique for harvesting the radial artery as a coronary artery bypass graft. Ann Thorac Surg 1995; 59:118.

7.Royse AG, Royse CF, Maleskar A et al. Harvest of the radial artery for coronary artery surgery preserves maximal blood flow of the forearm. Ann Thorac Surg 2004; 78(2):539.

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