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500 Cummings CenterSuite 4550Beverly, MA 01915(978) 927-8330www.handsurgery.org

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A publication of theAmerican Association for Hand Surgery

Fall/Winter2011

Steve McCabe, MD

MESSAGE FROM THE PRESIDENTHello everyone. While at

the ASSH meeting Dr.Bindra and I slipped out toRed Rock for a site visit. Thehotel and conference facilityat Red Rock are well suitedto our meeting. The guestrooms, conference rooms,exhibitor hall, and instruc-tional courses are all in closeproximity. The ubiquitouscasino is adjacent, close butavoidable.

The hotel has activitiesfor families and includes abowling alley. We decidedagainst changing the annualgolf outing to a bowlingtournament however. If youare coming to Red Rockplease remember it is aboutfifteen miles from the Vegasstrip. If you want to take insome shows or go down tothe strip please consideryour transportation. Al-though there are plenty ofactivities at the Red Rocklocation, if you plan to comeand go a lot it may be worthconsidering a car rental.

The program for RedRock looks good. We haveinvited the Brazilian Societyas our guests and have someexcellent scientific presenta-tions from Brazil. Nervetransfers, implant arthro-plasties, treatment ofDupuytren’s, and transplan-tation are some of the “hottopics” in hand that will beexplored.

I have invited a profes-sor from MIT as the presi-dential guest lecturer. Dr.Srinivasan is the director ofthe “touch lab” and will talkto us about the science ofhaptics. This is a fascinatinglook at sensibility from anengineering perspective andwill not disappoint you.

Terry Light is the Danyoinvited guest lecturer andwill speak about the switchfrom books to digitaleducation. The combinedguest lecturer is StevenLevitt, the author ofFreakonomics who willspeak on Saturday morning.

Georgette Fogg hasorganized the specialty dayfor Wednesday around thetopic of hand trauma. Shehas put together a series ofpanels with James Changgiving an invited address.Sheel Sharma has organizedthe review course for Fridayafternoon.

The meeting is wellsupported by industry and Ibelieve it will live up toyour expectations regardingthe scientific and socialprogram. Please come toRed Rock to teach and learnand to have some fun withyour colleagues.

Steve McCabe

INSIDE THIS ISSUE

From the Editor’s Desk

2012 Keynote Speaker

Hand Therapist’s Profile:Lisa M. Cyr

Coding Corner

AAHS Calendar

Board of Directors

Panel Discussion:Peripheral Nerve

2012 Annual MeetingSchedule at a Glance

Recruit a Member

Hand Therapists Corner

PSEN

Hand SurgeryEndowment

AAHS Website

14th Annual PhiladelphiaHand Surgery Symposium

2013 AAHS Annual Meeting

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2

FROM THE EDITOR’S DESK

HAND SURGERY Quarterly

PresidentSteve McCabe, MD, FACSEditorThomas Hughes, MDManaging EditorLorraine M. O’GradyHand Surgery Quarterly is a publicationof the American Association for HandSurgery and is published strictly forthe members of AAHS. This publica-tion is designed as a forum for opendiscussion and debate among theAAHS membership. Opinions dis-cussed are those of the authors orspeakers and are not necessarily theposition, posture or stance of the As-sociation.Copyright ©2011, American Associa-tion for Hand Surgery. All rights re-served. No portion of this newslettermay be printed without express writ-ten permission from the publisher, 500Cummings Center, Suite 4550, Beverly,

MA 01915, 978-927-8330.

Thomas Hughes,MD

Balancing ActAs the AAHS prepares for the

upcoming annual meeting, we areexcited about the upcoming event.Registration numbers are up with alarge contingent from our interna-tional partner, Brazil. It is going tobe an exciting meeting with a greatopportunity to learn, exchangeideas, and socialize with yourcolleagues.

In addition to preparations forthe annual meeting, we are comingto the end of the year. A time of

significant activity. Whether it ispreparation for the holidays,closing out the fiscal year, orpreparing a talk for the upcomingannual meeting, there is no short-age of activities to consume ourfree-time. As we continue to moveahead with health care reform itmay mean implementing a newelectronic medical record, learninghow “meaningful use criteria”applies to our practices, or gearingup for ICD-10.

As I work through the end ofmy year, it seems more difficult tostay focused on the issues thatmatter most. In an effort to get myyear concluded, it is easiest toeliminate those activities that haveno obvious deadline. Spending timewith my family, teaching myresidents and fellows, and spendingmore time with my patients are allitems that seem to suffer this timeof year, probably when it is most

important todedicate moretime to theseendeavors.

So for thismonth’s col-umn, I amproposing improved balance in ourpractices and our lives. Takingmore time for family and friendswill always be a better choice thandoing another case. Taking moretime for introspection and educa-tion will enhance your ability tocare for your patients.

Maintaining this balance can bedifficult. It requires constantawareness of the choices we aremaking and how they affect thisbalance. It requires constant vigi-lance to repeatedly reassess priori-ties. We have to make it a priorityto have balance. If we do not, thescales will quickly tip toward theside of work, stress and chaos.

We have tomake it apriority tohave balance.

If we do not, the scaleswill quickly tip towardthe side of work, stressand chaos.

2012 Annual MeetingKeynote Speaker

Professor Steven Levitt has agreedto be our distinguished keynotespeaker at the 2012 Annual Meet-ing. Professor Steven Levitt is theauthor of the bestselling book,Freakonomics, andSuperfreakonomics and is theWilliam Ogden Professor of Eco-nomics at the University of Chicago. He is also a contribut-ing author to the NY Times with his weekly blog,Freakonomics which has also been turned into a movie.

Saturday, January 14, 201210am – 11am

Red Rock Casino and ResortLas Vegas, NV

HandSurgeryQuarterly

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3

HAND THERAPISTS PROFILE: Lisa M. Cyr, OTR/L, CHT

PERSONALI grew up in Massachusetts

then headed west to college. After Igraduated, I moved to Connecticutwhere I live with my husband, step-son and two dogs. I’m very activeand spend my non- working hourshiking, bike riding kayaking anddoing Zumba. I also love to go forlong rides on the back of myhusband’s motorcycle.

EDUCATIONI graduated from Colorado

State University with a BS inOccupational Therapy, and becamea CHT in 1996. I am currentlyenrolled in a Doctorate of OTprogram at Rocky MountainUniversity of Health Professionswith an anticipated graduation datein the summer of 2012.

EMPLOYERI have been employed at the

Center for Orthopaedics since 2000.I was initially hired as the sole

hand therapist to shadow our handsurgeon at three of our four sites. In2004 I also became the therapymanager of a staff of 18. I stillspend the majority of my timetreating patients among the threeoffices. This affords me the oppor-tunity to provide direct and indirectsupervision to most of the staffwhile they are working in theirnormal routines. This seems to be a

beneficial set up to promote consis-tency among front desk personnel,and continuity of care among thetherapy staff.

AAHS INVOLVEMENTI became a member of AAHS in

2009 when I realized ‘all the coolkids’ were members.

In January of 2010, I wasnominated to be one of the two newAffiliates on the NominatingCommittee. My involvement withAAHS was part of the impetus forme to return to school for anadvanced degree.

BEST PART OF MY JOBI’ve been a hand therapist for

over 16 years. I am still over-whelmed with emotion when I seepatients’ faces light up when theydiscover that they can do some-thing with their injured extremitiesthat they never thought they’d beable to do again.

I love the intimacy, creativityand therapeutic relationships thatdevelop and evolve as I work withsomeone with a potentially devas-tating injury and assist them in theprocess of restoring range ofmotion and function in whatevercapacity they are capable.

MAJOR AC-COMPLISH-MENTS

Becoming aCHT was the oneof my greatestprofessionalachievements.

I have beenincrediblyfortunate to crosspaths withseveral peoplewho haveenabled me topublish in boththe Journal ofHand Therapy

and in a chapter in a book onsplinting (or fabricating orthoses asit is now called).

I am also incredibly blessed tobe a part of the Guatemala HealingHands Foundation team and havetravelled to Guatemala on twohand therapy/ surgery missionswith the team.

CLINICAL SPECIALTIESOrthopedic trauma. I work very

closely with my hand surgeon andam fortunate to see most patientssoon after their injuries beforesecondary complications develop.

I believe that it’s critical to be intune with the psychosocial aspectsof an injury to help patients copewith the trauma they have sus-tained. This can greatly influencethe healing process. I also love tofabricate custom orthoses. Thisgives me an opportunity to expressmy creative side.

GREATEST PROFES-SIONAL CHALLENGE

Getting the courage to volun-teer to speak at an AAHS confer-ence.

THREE WORDS THATDESCRIBE ME:

LIVE 4 2DAY

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4

CODING CORNER

Eon K. Shin, MD

This issue of Hand SurgeryQuarterly focuses on nerve injuriesand repair. To reflect this focus,coding guidelines for a variety ofnerve procedures will be covered.We will not cover carpal tunnelsurgery or other neuroplastyprocedures.

For digital nerve injuries in thehand, two codes are utilized: CPT64831 describes the first digitalnerve that is repaired, while CPT64832 describes each additionalnerve repair. Repair of majorperipheral nerves, like the mediannerve, is similarly reported: CPT64856 or 64857 is used to describethe first nerve repaired. Though64856 includes transposition of thenerve as part of the procedure, itappears that 64857 reimburses morewithout the nerve transposition.CPT 64859 is utilized for eachadditional major peripheral nerverepair.

When coding for nerve grafts,distinctions are made for the lengthof the grafts obtained, the numberof strands used to span a defect,and the location of the nervereconstruction. For single strandrepairs in the hand or arm, CPT64890-64893 are used. For cable ormultiple grafts up to 4 cm in length,CPT 64895 is used. For cable graftsgreater than 4 cm in length, CPT64896 should be listed.

CPT 64910 is defined as a nerverepair using a synthetic conduit. Itis important to note that the syn-thetic conduit must be used to span

a defect between cut ends of a nerveand not simply as a nerve wrap.When using conduits as a nervewrap such as in cases of carpaltunnel revision surgery, for ex-ample, CPT 64999 (unlisted proce-dure, nervous system) can be listedbut is subject to review by thepayer.

Unfortunately, no code exists todescribe nerve repair with allograft.For now, surgeons are encouragedto use CPT 64910 (nerve repair;with synthetic conduit) or CPT64911 (nerve repair; with autog-enous vein graft). However, thesecodes do not accurately describe thework of allograft nerve reconstruc-tion and may not be reimbursed.

Keep in mind that wounddebridement codes (CPT 11042-11047) may be applicable to claimsassociated with nerve injuries.When performing debridement of a

single wound, report the depthusing the deepest level of tissueremoved and the surface area of thewound.

Use of Operating Microscope(CPT 69990)

CPT 69990 is a designated add-on code and may be separatelyreported when using an operatingmicroscope for microscopic repairs.Do not append modifier 51. Thiscode should be listed immediatelyfollowing the primary procedure onthe claim form. While CPT 64831(suture repair of digital nerve) ispaid 19.92 Relative Value Units(RVUs), 69990 reimburses anadditional 6.48 RVUs. Medicareallows reimbursement for modifier80 (assistant surgeon) on 69990.

An important caveat: Whenrepairing nerves with syntheticconduits, 69990 cannot be used in

(continued on next page)

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5

CODING CORNER (continued from previous page)

2011-2012 Board of Directors

President: Steven McCabe, MD

President-Elect: Jesse B. Jupiter, MD

Vice President: Donald H. Lalonde, MD

Secretary: Brian D. Adams, MD

Treasurer: Michael W. Neumeister, MD

Treasurer-Elect: Peter Murray, MD

Past President: A. Lee Osterman, MD

Penultimate Past President: Nicholas B. Vedder, MD, FACS

Historian: Miguel A. Pirela-Cruz, MD

Parliamentarian: Jaiyoung Ryu, MD

Senior Directors at Large: Randip R. Bindra, MD, FRCS

Steven L. Moran, MD

Junior Directors at Large: Thomas B. Hughes, MD

Jeffrey B. Friedrich, MD

Past Sr. Affiliate Director: Susan Michlovitz, PT, PhD, CHT

Sr. Affiliate Director at Large: Georgette A. Fogg, OTR/L, CHT

Jr. Affiliate Director at Large: Sharon Andruskiwec, PT, CHT

Calendar2012January 11-14AAHS 42nd Annual MeetingRed Rock Casino Resort & SpaLas Vegas, NV

January 18The Philadelphia HandSociety Mid-Winter MeetingVisiting Lecturer: Jorge L. Orbay,MD

March 3-5 (Surgery)Hand Rehabilitation Foundation2012 Surgery and TherapySymposia, Loews PhiladelphiaPhiladelphia, PA

March 3-6 (Therapy)Hand Rehabilitation Foundation2012 Surgery and TherapySymposia, Sheraton City CenterHotel, Philadelphia, PA

March 25-29The 2012 Upper ExtremityTutorial, Snowmass Village, CO

June 21-23XVII FESSH Congress, Antwerp,Belgium

October 18-21ASHT 35th Annual Meeting,Sandiego, CA

November 15-17American Society for Reconstruc-tive Transplantation 3rd Biennial

Meeting, Chicago, IL

2013January 9-12, 2013AAHS 43rd Annual MeetingNaples Grande Resort & ClubNaples, FL

2014January 8-11, 2014AAHS 44th Annual MeetingGrand Hyatt Kauai Resort & Spa

Kauai, HI

500 CUMMINGS CENTER, SUITE 4550BEVERLY, MA 01915

PHONE: (978) 927-8330 / FAX: (978) 524-8890EMAIL: contact@handsurgery.org

conjunction with 64910 (nerve repair with synthetic conduit) or 64911(nerve repair with autogenous vein graft). Of course, 69990 cannot bereported for the use of magnifying loupes.

CPT 69990 may only be reported one time per operative session andcannot be listed more than once on a claim form, even if the operatingmicroscope is used for multiple vessel or nerve procedures. There are anumber of procedures that “bundle” use of the operating microscope andwill not allow separate reporting of 69990. These procedures include:

15756-15757 Free myo/skin/microvascular procedures20955-20962 Bone graft with microvascular anastomosis20969-20973 Free graft with microvascular anastomosis26551-26554 Toe to hand with microvascular anastomosis26556 Free toe transfer with microvascular anastomosis64727 Neuroplasty requiring use of operating microscope64910-64911 Nerve conduit

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6

AROUND THE HAND TABLE

(continued on next page)

MODERATOR:

Warren Hammert, MDAssociate Professor, Department ofOrthopaedicsAssociate Professor, Department ofSurgery, PlasticUniversity of Rochester

PANELISTS:

Jeffrey B. Friedrich, MDAssistant Professor, Plastic SurgeryDivisionAdjunct Assistant Professor, Depart-ment of OrthopedicsUniversity of Washington

Jonathan E. Isaacs, MDAssociate Professor and Chair,Division of Hand SurgeryVirginia Commonwealth University

Robert A. Kaufmann, MDAssistant Professor of OrthopaedicSurgeryDivision of Hand and Upper ExtremitySurgeryUniversity of Pittsburgh

Heather C. Smith, MS, PT, CHT, Cert.MDTSenior Therapist-Hand RehabilitationDepartment of OrthopaedicsUniversity of Rochester Medical Center

Dean Sotereanos, MDProfessor, Orthopaedic SurgeryDrexel University College of MedicineVice Chairman, Orthopaedic NetworkDevelopment, Department of Ortho-paedic Surgery

Warren: I appreciate everyone tak-ing time to participate in thisroundtable discussion regarding pe-ripheral nerve conditions. I thoughtwe would start off and talk aboutdigital nerve injury because that issomething common that all hand sur-geons treat. So, starting off with Jeff,when you have an isolated digitalnerve injury, what are your thoughtson repairing them primarily versususing a conduit or something else?

Jeff: As my practice has evolved, Ihave a lower and lower threshold forusing either a conduit or a nervegraft. I used to try to repair most ofthese injuries primarily, includingsaw injuries, which I think has provento be ill-advised because I think withthe kerf of a saw, that zone of injuryis probably bigger than I appreciated.So currently, I trim the digital nerveinjuries back to very good lookingnerve, and I almost always have touse something for those rather thandoing a primary repair. I just feel likeI can no longer justify keeping thosedigits down in a flexed position dur-ing the early healing. Regarding theconduits and grafts, I would say thatI do a mix. It is probably a 50-50. Ilike the PIN for digital nerves but Ihave been very happy with the con-duits also. A lot of it has to do withresident and fellow education andmaking sure they are exposed to dif-ferent methods. So, for me it is usu-ally one or the other. The only pri-mary repairs that I find that I am do-ing are sharp knife lacerations, butmost of what I see in my practice isnot the sharp injury amenable to pri-mary repair.

Warren: Okay. Rob, any otherthoughts or anything different thatyou do with isolated digital nerveinjuries?

Rob: I couldn’t have echoed his sen-timents more. I agree that the zone

of injury is generally underestimatedat the initial time and I normally getto these problems quite soon. I havebeen using mostly nerve conduits butI also use autografts for longer de-fects. When the gap is greater than2.5 cm, I will use the posterior in-terosseous nerve and I have beenhappy with that nerve.

Warren: What type of conduit do youprefer? In your opinion, is there a dif-ference in the collagen conduits ver-sus the PGA/ PLA conduits or any ofthe others that are out on the market?

Rob: I use the collagen conduits pri-marily because that is what I have themost experience with. I know thatthere is literature support for thePGA, which is perhaps even favor-able in comparison to the collagen,but in my hands I have been veryhappy with the collagen. It is just theease of use- I know how it handlesand I feel quite comfortable with it.

Warren: When you irrigate these af-ter repairing the nerve, do you thinkwe need to use heparinized saline orjust saline by itself? There is a not aconsensus opinion as some surgeonsadvocate using heparinized saline toirrigate to try to prevent clots fromforming inside the tube that mayblock or impede axonal regeneration,while other surgeons use saline.What is your preference?

Rob: I use saline. I have read aboutthe need for heparinized saline but Idon’t know if it really matters if thereis a little clot inside the tube. I don’tthink it is truly going to prevent thenerve from regenerating through thatconduit and in my experience ithasn’t mattered.

Warren: Does anybody think there isa benefit to irrigating with heparin-ized saline?

PANEL DISCUSSION: PERIPHERAL NERVE

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7

(continued on page 10)

Hand Table(continued from previous page)

- Warren Hammert , MD

I see a lot of neuromaswhich are symptom-atic early, but it is notcommon that I have togo back and do any-thing for these.

Participants: Probably not. I wouldagree with that as well.

Warren: Jonathan, I know you havesome experience working with al-lograft nerves. What is your thoughton the role for allograft nerve versusconduit for repair of isolated digitalnerve injuries?

Jonathan: First off, I don’t think weknow the answer to that question,which is why we are putting togethera multi-center clinical trial. However,my current feeling from my own in-terpretation of the literature and myown observations is that conduits aregreat but only for relatively short dis-tances…. I believe shorter distancesthan what most people are usingthem for. I think a conduit probablyis a good option for defects less than15 mm, but after that I think it be-comes unpredictable. So, once thedefect is greater than 15 mm, I usu-ally turn towards the allograft. Thebenefit of the allograft being that itmaintains an internal structure toguide the axons as opposed to count-ing on a stable fibrin clot (like youwould see inside a nerve conduit).The fibrin clot becomes less stablewith greater distances and can makethe results less predictable. Of coursethe disadvantage of the allograft isthat you have to have two suturelines. So, I think there is a balance.They both have a place in digitalnerve reconstruction and I generallymake my decision based on thelength of the defect.

I would add with regards to thenerve tubes, I think that when youtalk about the choice of differenttypes of nerve tubes that theNeurolac, which is poly-caprolactone, has a hard surface andthere is a risk of these erodingthrough the skin. So, I think that thoseprobably don’t have a great role indigital nerve reconstruction.

Warren: I agree the stiffness of theNeurolac tubes can be problematic

and I have had soft tissue breakdownover those tubes, so I prefer the col-lagen tubes. Do you have a distancewhere you think that there is nolonger an advantage to allograft andyou prefer to use autograft? Does itmatter if the defect is 2.5, 3, or 4 cen-timeters?

Jonathan: For a digital nerve injury,my cut off would be 5 cm, but this isbased on the fact that it is currentlythe longest available allograft. Youknow, it bothers me to harvest a nerveand create a defect to reconstruct asensory nerve. But, I think it dependson which nerve you were talkingabout replacing. I would be morelikely to consider an autograft for theulnar aspect of the thumb or radialaspect of the index finger.

Warren: What are your thoughts orexperience taking MABC or LABCfor nerve grafts as opposed to thePINs? Obviously, the PIN is easy be-cause it is in the same extremity andthere is minimal, if any donor sitemorbidity - any experience with theMABC or LABC nerves autografts?

Jonathan: Well, I have been gettingaway from autografts, but in the past,I have had patients develop painfulneuromas after using the MABC as adonor nerve. You never have a pa-tient who is going to say, “I couldn’tdo such and such activity because Ihad numbness on the inside of myforearm”, but what you do have ispeople that say, “Boy, it sure hurtswhen I lean on this part of my elbow.”So, that has been one of my main rea-sons for avoiding the MABC. Inter-estingly, I have not had very manyproblems with sural nerve grafts.

Warren: Okay, we previously men-tioned problems with stiffness insome of the conduits and the poten-tial for soft tissue problems and thisleads me to the next point I wouldlike to discuss. Dean, considering thatmany times digital nerve injuries arecombined with flexor tendon lacera-tions and / or fractures and more sig-nificant soft tissue injuries, or the so-called combined injuries, often the

nerve injury is a secondary thoughtand the primary concern is the ten-don or osseous injury. In those situa-tions where you may require specificrehabilitation program, do you doanything different with your nerverepairs?

Dean: Well, at least my thought inregards to that Warren are that obvi-ously if there is a tendon injury, youwant to mobilize that tendon, particu-larly for zone 2 injuries. A primarynerve repair is certainly not amend-able to that, so I certainly would usea conduit or an allograft to enablemoving the finger at the same time,and not having to come back and doa tenolysis because of the nerve in-jury. I think that is a perfect indica-tion to do a conduit or a graft of sometype. I personally never use an au-tograft for anything anymore. I havejust preferred not to risk the morbid-ity of harvesting an autograft, be itfrom the MABC/LABC or PIN forthat matter. Why risk any additionalmorbidity? So I tend to stick with ei-ther conduits or allografts. I do use

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10

(continued on next page)

Hand Table(continued from page 7)

- Heather C. Smith MS

conduits, but generally for shorterdefects, a centimeter or less. Thereare also porcine mucosal conduitsavailable, which are about a centime-ter long and I find them great for digi-tal nerves.

Warren: Do you have a preference inthese combined injuries along withtendons or fractures when the defectis too long for the submucosal con-duit (2 to 3 cm), conduit versus al-lografts?

Dean: My preference is that it de-pends on the size and the length ofthe defect and how much tensionthere is. If it is two centimeters or less,I would probably use a conduit,which would be the vast majority ofwhat I use. If it were a longer defectthen I would use an allograft of sometype. I think most hand surgeonsknow is that the longer the defect,especially in a traumatic situation, theless likely they are going to get any-thing other than protective sensation.So, once again, why risk an autograftin that situation? I personally thinkthat a conduit or a allograft wouldgive you the same result, whichwould be protective sensation, insomething longer than say three cen-

timeters, but in someone who isyoung, less than 20 years old, inwhich I have seen excellent resultswith long defects.

Warren: Okay, Heather, when it comes to rehabilitation following thesetypes of injuries, any trick or tech-niques that you found useful for ei-ther the isolated or the combined in-juries as far as improving the nervegliding and desensitized patientsduring their recovery?

Heather: I definitely think that earlypost-op follow-up is important, as faras edema control and early range andmotion. Definitely, with the com-bined injuries as you both are saying,it is important to mobilize them andif they have the conduit and no ten-sion on the repair, you can start thenerve gliding sooner. You really wantto start to maximize the excursion orthe gliding of the nerve, not causingany strain or over-stretching of thenerve at that point. So, the key thingsfor me are just seeing the patientearly, early and often, and gettingthem moving.

Warren: Any specific tricks on mobi-lizing the nerve and getting it glid-ing that you can suggest or recom-mend?

Heather: With the nerve gliding, youdon’t want to put any strain on therepair so you hold the adjacent jointand you are either going to glideproximal or distal to where the repairis located, but you are not going todo both. You want to use a slow os-cillatory motion to start gliding andyou don’t want to put any tension onthe repair. It can be a challenge toteach patients that it should not bepainful because they always thinkthat everything we do in therapy ispainful. So, it is really important toteach them how to minimize the strainwhen they are doing their exercises.

Warren: Once the patient is comfort-able with nerve gliding, and beginsto recover often they have sensitivityin the area. Any tricks for desensiti-zation?

Heather: Yes, usually we start earlyscar tissue massage and sensorytraining. Usually we start them withrubbing different textures along theirincision and along the distribution ofthe nerve that was repaired. I usuallystart that on the first visit and encour-age them to continue to do this athome.

Warren: Rob, what are your thoughtson symptomatic, painful neuromas ofdigital nerves following amputa-tions?

Rob: Well, neuroma pain is very realand it can be quite debilitating. Forthe digital nerve in particular, mypreferred technique for terminal neu-romas is to drill little holes usuallyinto the middle or proximal phalanx.It can be anywhere in these bones andobviously as distal as possible. I drilla little hole and then I place the digi-tal nerve into the hole and that hasbeen predictable for me in prevent-ing neuroma pain. Not having sensi-bility can be overcome with relativeease. Enduring a painful neuroma,particularly if it affects gripping, canbe quite troubling. Another option formore proximal neuromas iS place-ment into muscle, but in my experi-ence, putting them into bone hasworked out quite well. Do any of thepanelists perform primary neuromasurgeries for a revision amputation?I do because I just feel like that’s myway of preventing neuroma symp-toms. I take care of a lot of these, butusually not from my own revisionamputations. Is that the standard oram I, maybe, doing more than Ishould?

Dean: What do you mean, Rob, byprimary neuroma surgeries? Do youtrim the nerve back or what is it thatyou do?

Rob: I actually try not to trim thenerve back. I try to leave the injurednerve as long as possible and then Idrill little holes in an appropriate lo-cation on the medial and lateral sidesof the middle or the proximal pha-lanx of the affected digit, and then I

I definitely think thatearly post-op follow-upis important, as far asedema control and earlyrange and motion.

HandSurgeryQuarterly

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11

Hand Table(continued from previous page)

(continued on next page)

tuck those nerves into the bone sothat hopefully, they don’t developsymptomatic neuromas.

Warren: I see a lot of neuromas,which are symptomatic early, but it isnot common that I have to go back anddo anything for these. If I need to doan amputation revision, I will identifythe nerves and resect them, allowingthem to retract proximally away fromthe scar. Maybe it’s because I havegood therapists I work with...but a lotof these are desensitized and don’tneed to do something down the line.

Warren: Anybody else have anythoughts on that?

Jonathan: I’m going to say that myexperience has not been the same asRob’s. I have found that burying thenerve in bone has created almost apotential for traction neuritis— whenthe patient moves that digit it pullson the neuroma and causes pain. SoI’ve gone away from that.

And when you think aboutwhat’s causing a neuroma, it’s that theaxons don’t have anywhere to go,they can’t find their path distally. Sowhen you get a neuroma with a nerverepair, it’s because your axons weren’table to advance along theendoneurial tubes so this may needto be addressed.

But I totally agree with thepremise that I think Warren was get-ting at earlier that they should havea good course of therapy and conser-vative treatment. You know, one ofthe issues is that, as we all know, do-ing surgery for pain, which is whatoften neuromas are, has a certainlevel of unpredictability. Since wecan’t see pain, we often are not ableto “cut” it out.

Dean: I generally simply trim thenerve back and typically that workspretty well. Sometimes they do de-velop a neuroma but that is not com-mon. Terminal neuromas can be re-located very nicely as well. It’s some-

thing that’s well described in the lit-erature in the finger. The neuroma isrelocated in the interosseous spacebetween the metacarpals. That’s beenpublished in several textbooks. Iagree with Jonathon in that I veryrarely ever bury a neuroma into bone,either primarily or secondarily, espe-cially if it’s distal to a joint. As thefinger moves, there is traction on theneuroma and I’ve seen some prob-lems with that, so that’s not a tech-nique that I typically use, although Iknow that it is described.

Warren: Heather, along those linesfor amputation revisions, any tech-niques or tricks that you think froma therapy standpoint are beneficial totry to prevent patients that are be-coming symptomatic and painful?

Heather: I have them start using theamputated digit as soon as possibleso I have them doing sensory re-train-ing. I have them do things they wouldtypically do every day. The more func-tional activities I can have them doearly on, the less chance they are todevelop sensitivity of that neuroma.We also do things where we have themactually submerge their hand into dif-ferent particles, which can also be verybeneficial in desensitization.

Warren: So, moving on to the nextarea. We know that nerve repairs donot always work, so when you havea digital nerve repair that has clearlyfailed, the patient is not getting re-turn of sensation, has a painful neu-roma, and no evidence of recovery oradvancing Tinel’s sign. Rob - Do youthink there’s a role for revision of thenerve repair? For example, a failedrepair along the ulnar aspect of thethumb or radial aspect of the indexfinger? Do you think that there’s arole to go back and try to re-repairthat? Or do you typically just usesomething that may be more predict-able and try to get the symptomaticneuroma out of the way?

Rob: I have, so far, always done thelatter, which is not try to re-do a nerverepair. And I haven’t really beenfaced with a younger person that has

a border digit neuroma in a locationthat would benefit from a revisionnerve repair. But I would have noproblem doing that in the correct set-ting. It is, however, important not tosubject someone to a procedure thathas a low likelihood of truly givingthem improved sensation.

Warren: Jeff, do you have any differ-ent experience or any other thoughtson revision of nerves that have notbeen successful from a repair stand-point?

Jeff: No I do not. I haven’t encoun-tered the situation where there’s beena symptomatic neuroma, say on theindex or the thumb, to even discusswith the patient about a revision pro-cedure. Even when they do not re-cover sensation, I find many patientslearn to live with it. I have had a fewpatients that I think have had somebenefit from neurolysis when it’sdone in conjunction with a tenolysis,but I haven’t done a neurolysis on itsown. I don’t think I could justify thatas a stand-alone procedure. So, likeRob, I don’t have a problem trying are-repair, especially in those two dig-its, but I just haven’t encountered thesituation yet.

- Jonathan E. Isaacs, MD

...one of the issues is

...doing surgery for painhas a certain level ofunpredictability. Sincewe can’t see pain, weoften are not able to“cut” it out.

HandSurgeryQuarterly

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12

Hand Table(continued from previous page)

(continued on next page)

- Jeffery B. Friedrich, MD

I tend to go with suralnerve grafts so I can getenough cables for themedian or the ulnarnerve.

Warren: Okay, Jonathan, do you haveany different thoughts?

Jonathan: If somebody has a clearlydysfunctional or nonfunctioningnerve repair and pain, then I assumethe axons were not able to advancedown the endoneurial tube. And myfirst choice in treatment for that is togive those axons a place to go and Iwill revise that as my primary treat-ment and redo that nerve repair.

Warren: And when you do that,would you use a nerve tube again, orare you more apt to go to an allograftnerve for a revision.

Jonathan: When a nerve repair doesnot work, I think usually the prob-lem is you haven’t resected back tonormal nerve fasicles out of yourzone of injury more than anythingelse— but I would still step it up anotch. So if I used a conduit I mightuse an allograft. I’ve not been in thissituation but I think that if I had an al-lograft I might go back and do it withan autograft, trying not to do the exactsame thing that was done before.

Dean: This situation, a neuroma incontinuity is much different than aterminal neuroma. I would treat afailed repair of a digital nerve injurywith a neuroma in continuity withresection of the neuroma and a con-duit. I think that works very well andit’s very simple to do.

Warren: Okay. Let’s move proximal.Jeff - If a patient has an injury of themedian or ulnar nerve in the forearmand you have a small defect, a 10millimeter gap, would you use an al-lograft or conduit for a mixed nerveor do you prefer an autograft?

Jeff: When the allografts initially be-came available, I used it for at leastfor one ulnar and one median nerveat the wrist and I think others havedescribed this at least anecdotally, butfor mixed nerves, I think this is still

an unanswered question. I don’tthink an allograft can approach theresults we get with autogenous cablegrafting. I mention that I use conduitsand autografts for digital nerves, andI certainly use allografts to, but forthose mixed nerves at wrist level, asI said, I have drifted away from al-lografts based on what is admittedlya limited experience. So, I tend to gowith sural nerve grafts so I can getenough cables for the median or theulnar nerve. I think for me the bigchallenge is getting the topographylined up both proximally and distallybecause, as you said, if you have agap, your surface indicators of thetopography can be limited. So, Ispend a lot of time trying to line upeach cable with what I think is a cor-responding fascicle.

Warren: Dean, anything you wouldlike to add or anything different withyour experience for that?

Dean: For someone with a mixednerve injury proximally, it is obvi-ously a very difficult situation and Iam not sure anecdotally in my ownexperience that doing cable grafts isany better than using a short conduitin a short defect. I think in a longerdefect with a mixed nerve, you aregoing to be better off either doing acable graft with either autogenoussural nerve or allograft nerve versussome type of neurotization proce-dure. I guess my first option, in a pri-mary reconstruction in a short defect,is to use a conduit or allograft. In alonger defect, I would probably stilluse autograft.

Warren: What is your definition of ashort defect for this?

Dean: I would say 2 centimeters orless.

Warren: Jonathan, what is your ex-perience with allografts on mixednerves?

Jonathan: Minimal. When we aretalking about really importantnerves, the median or ulnar, as op-posed to a digital nerve, there is not

enough data to convince me to useallograft. If it were my median orulnar nerve, I would have it repairedwith autograft. As Dean pointed out,there is always some sort of risk andmorbidity with taking a nerve, but Ifeel this is the best available graftmaterial and when you start talkingabout a really important nerve, Ithink that you use the best avail-able—- as long as the person is will-ing to accept the donor site morbidity.

Rob: I have used exclusively suralcable grafting for those types of prob-lems and I have had probably thesame success or failure. It is a verytough problem. I feel like autograftsare the best. It is important to line upthe topography and ensure a repairaway from the zone of injury.

Warren: Heather, anything from arehabilitation standpoint when youhave more proximal nerve injuries?There is obviously less ability to mo-bilize the nerves and help them glide.Is there anything different that youwould do from a rehab standpoint?

Heather: Yes, they usually are insome type of protective splinting forthe first three to four weeks and youare working on protective range ofmotion. Then, you are going to start

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13

(continued on next page)

Hand Table(continued from previous page)

- Robert A. Kaufmann, MD

I very much want to re-pair injuries to the sen-sory branch of the radialnerve as neuromas areusually quite painful.

looking for recovery. So you are go-ing to start looking for advancingTinel’s sign, and the return of motorfunction or sensory function. Theywill often benefit from an orthosis atthat point to facilitate function, so ifit were a median nerve injury, I mightbe looking at giving the patient anopponens splint to help with oppo-sition or if it was an ulnar nerve in-jury, I might be making them an anti-clawing splint to prevent MP hyper-extension and help with IP extension.Then basically the same things wetalked about before as far as the sen-sory education and then eventuallynerve gliding.

Warren: Okay, I think those are somegood points and things that oftensurgeons don’t think about, particu-larly with early splinting.

Jeff: If I can ask a question before wemove on to the next topic. What arethe thoughts about reversing an au-tograft with the theory being that ifyou reverse it, there is less chancethose axons become misdirected, par-ticularly the small branches? Doesanybody else routinely do that?

Dean: I did a study published in TheJournal of Reconstruction Microsur-gery. I am probably older than a lotof you guys so, about 20 years agowe took a rat sciatic nerve and flippedit. We did this in three differentgroups. One group was cut and in-terposed. Another group was re-versed, trying to align the topogra-phy and the third group was resectedand repaired without effort to alignthe topography. They all did thesame. There was no difference in thefootprint. We did walking trackanalysis, PNGs and everything. So,reversing the polarity makes no dif-ference. I think that is well proven.

Warren: Thanks Dean. That was veryhelpful! Let’s talk about radial sen-sory nerve injuries. These seem to befairly common, in the past from ex-

ternal fixation devices for distal ra-dius fractures, but we still see themfollowing sharp injuries and occa-sionally following deQuervain’s re-lease. Any thoughts on doing any-thing different with this as opposedto digital nerves? It is obviously alarger diameter nerve and this nerveseems to be more susceptible to devel-opment of symptomatic neuromas’s.

Dean: No, I approach them in thesame way that I do the digital nerves,with regards again to my philosophybeing that those are not real func-tional deficits by not having sensa-tion on the dorsum of your first webspace, but that it is a functional deficitto have the pain associated with theneuroma. So, I do repair these and myalgorithm is pretty much the same:direct repair if possible, conduit if shortgap or allograft if longer defect.

Jonathan: One thing that I have beendoing differently in this particulararea, however, is if I am doing a pri-mary repair, I will take a conduit andwrap it around the repair and I thinkactually that you told me that it wasa good idea and that you were doingit. I don’t want to falsely give youcredit for something that I am copy-ing now, but I think that you told methat it would decrease the potentialof axons escaping and causing painat the suture site. After dealing witha couple of repaired superficial radialnerves, the patients just reallystruggle with this comfort. So, I havedone that and anecdotally I do thinkit helps, but I don’t have any real sci-entific data behind that. Am I rightthat you were the one that told me todo that?

Warren: I am not the one. I can’t takecredit for that, good or bad. I thinkthis, like a lot of other things seem tomake sense, but I have not seen anyscientific evidence that convinces methis really helps. I think it may makethe surgeon feel better, but I don’tknow if it does anything for the pa-tient other than increase the cost ofthe procedure. I understand the con-cept behind it and hopefully, some-one will be able to do a study, at least

in an animal model to look at this is-sue. I also know several surgeons thatuse this technique. Rob, what areyour thoughts on the sensory branchradial nerve? Would you be more aptto resect this and try to get it out ofthe way, or would you try to repairthis specific nerve?

Rob: I very much want to repair in-juries to the sensory branch of the ra-dial nerve as neuromas are usuallyquite painful. Failed deQuervain’ssurgery due to injury or aggravationof the dorsal radial sensory nerve,particularly in the work compensa-tion population, can drag on forever.Patients present with a lidodermpatch and I think these injuries are aCRPS creator. So, I try to repair thisnerve. If it comes to me and is injured,I do all the same sort of neuroma typeefforts that we discussed earlier.

Warren: If you have done a repair andit has failed, then do you try to revisethe repair, doing something differentthe second time, or is your plan to tryto move the painful neuroma out ofthe way, resecting and implantationinto a proximal location?

Rob: I am not a big re-repairer. Iwould then go for the neuroma sur-gery. In maybe three instances, I have

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14

Hand Table(continued from previous page)

(continued on next page)

had success with simply drilling ahole in the radial styloid and dissect-ing proximally and placing this nervewith very little tension into the holebecause the whole traction neuritisissue that was brought up earlier. Ifeel this is very real phenomenon. Ithink that is a little bit dependent onhow you do this technically. If thenerve is under any tension when it isplaced in the bone, any motion acrossthat site will pull on the nerve andtraction neuritis will result, causingyour neuroma procedure to fail. Ifyou place the finger in full extensionfor instance and you very gingerly putthe nerve in and you have a lot of lax-ity there still, then I think it will onlybecome more lax as you flex the fin-ger – same situation with the radialsensory nerve at the wrist. So, I thinkthat traction neuritis problems areavoidable through technical efforts.

Warren: Jeff, any additional thoughtson that?

Jeff: The radial sensory nerves inju-ries that I have treated, at least lately,are associated with zone 9 extensortendon injuries, so they are a littlemore proximal. I have tended to re-pair all of those because I worry thatespecially with that brachioradalistendon, at that point that it is justgoing to be a recipe for scarring. I amalso worried that it is going to getstuck to one of those tendon repairs.I think nerve gliding in that proximalforearm is more challenging whencompared to the wrist or a digit. So, Ihave repaired these and I have occa-sionally used a nerve-wrap on thesealso. I just have my anecdotal experi-ence to go on, but I think if I cansomehow attempt to protect thatfrom the scarring, it seems to help.That is a fairly limited experience.

Dean: Warren, I have had quite a bitof experience with radial sensorynerve neuromas and a lot of them arerecalcitrant. I often see patients whohave had two or three operationswith nerve wraps or putting them inbone and they still have significantpain. I have basically gone to relocat-ing the entire nerve. I tell the patientthat they are going to have numbnessin the radial sensory distribution andthat will be in exchange for the painthat they are currently having. So, Ifind all three branches and I resect theneuromas and transfer the nervesomewhere deep between thesuperficialis and the profoundus inthe forearm and that gets rid of thepain. I have not had anybody comeback and say they still have symp-toms, and the vast majority of thesepatients are happy in not having thatneuroma pain.

Warren: Any tricks for identifying ordo you do anything with the LABC?Obviously if you see a neuroma thereyou are going to deal with it, but doyou just go straight to the radial sen-sory nerve proximally or do you ex-plore and see if there is anything else,maybe contributions from a neuromaof the LABC?

Dean: I find the radial sensory nerveas it comes up from under thebrachioradiolis and trace it distally. I

trace each branch of that nerve and Idon’t really look for the LABC in thatsituation. If I do encounter anotherneuroma, I will take care of it, butgenerally I find the radial nerve andtrace it into the dorsum of the hand,finding the branches, which are gen-erally extremely scared. As I men-tioned, my preferred technique is toresect all three of the branches andmove it into the mid forearm.

Warren: Do you do diagnostic blockson them before to see if that is goingto relieve their pain? Or do you baseyour decision process on history andyour clinical exam?

Dean: Generally I do a Tinel’s test andmost of them can’t tolerate that testover the nerve. They jump when yousimply tap or percuss over the nerve.They usually come with EMG stud-ies that describe radial sensory defi-cits. So, like I said, I have tried all ofthe techniques that we have men-tioned and at this point in my career,my favorite technique is to relocate theentire nerve into the mid forearm, un-less it is a simple, isolated branch neu-roma that is from a small lacerationand then I would try a conduit. How-ever, if it is intractable pain in some-one who has had several operations, Iwould plan to relocate it.

Warren: Let’s move on to anothertopic now. Dean, you have a lot ofexperience with recurrent and persis-tent carpal tunnel syndrome. Theseare two different problems, with re-current being the patient who has hada carpal tunnel release, was better fora period of time and then developssymptoms again as opposed to some-one who never had relief of symp-toms after their primary operation.How do you manage the person withthe persistent carpal tunnel, and thenwhat is your current opinion as to therole for vein wraps or a conduit wrapas opposed to a hypothenar fat flapor something else?

Dean: That is a very, very good ques-tion. In someone with persistent car-pal tunnel or carpal tunnel syndrome

- Dean Sotereanos, MD

...my favorite techniqueis to relocate the entirenerve into the mid fore-arm, unless it is asimple, isolated branchneuroma that is from asmall laceration andthen I would try a con-duit.

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15

Hand Table(continued from previous page)

(continued on next page)

that does not remit after primary sur-gery, I assume that this is an incom-plete release. In that particular case,I will not do a vein wrap. I will re-re-lease the carpal tunnel. However, Ialways do something to augment thesoft tissue coverage. I almost alwaysuse a hypothenar fat flap. I find that isa very easy flap to do and in the past,have used it in any revision carpal tun-nel release for a second operation.

Recently, I started wrapping thenerve with porcine submucosa wrapand sometimes I do both. I will doboth to create a belt and suspenderseffect. That has worked out prettywell. I would not advise simply to doa revision carpal tunnel release be-cause of the risk of recurrent scaringfollowing the second operation. Inyour scenario regarding recurrentcarpal tunnel syndrome, or someonewho was better for a while and thenhad recurrent symptoms, I wouldtreat that patient the same way. Iwould probably start with the hy-pothenar fat flap and maybe augmentwith the porcine submucosal wrap.

Someone who has had two pre-vious operations, however, is a dif-ferent story. In this patient, my as-sumption is now that they have hada good release already. The secondoperation certainly has released thetransverse carpal ligament, and inthis case, I would tend to do a veinwrap, as well as an additional hy-pothenar fat flap just to add a layerof tissue under the skin. It more orless desensitizes that area because ofthe padding from the thickness of thefat flap. So, the vein wrap would bein someone who has failed two pre-vious surgeries. The hypothenar fatflap and/or the porcine submucosalwrap in someone who has failed oneprevious surgery.

Warren: Have you ever use collagenor other type of conduit as a wrap,perhaps even in the first revision be-fore the porcine wraps were available?

Dean: The conduit, or collagen tubes

that are used for nerve repair are ex-actly the same material as the wrapthat is made commercially, so youcould get a tube and basically cut thetube and wrap it around the nerve,or you could use one of their com-mercially available wraps. So, that isan option, along with the porcinesubmucosal wrap, but I would stilluse a hypothenar fat flap in a primarysetting and the nerve wrap in addition,but not in place of the fat flap.

Warren: Okay, well, Jeff, Jonathan, orRob, do you have any additionalthoughts or approaches to either per-sistent or recurrent carpal tunnel syn-drome?

Rob: I couldn’t have said it better.That pretty much is exactly my algo-rithm and almost universally when Ihave somebody that did not get bet-ter from a prior carpal tunnel releaseit is because the surgeon didn’t feelcomfortable dissecting distally to thelevel of superficial arch and on revi-sion surgery there was persistentcompression in this area. There is a14-millimeter variability in the loca-tion of the superficial palmar archwithin the palm. There may exist asubset of surgeons that don’t want todissect around it which may result inincomplete releases. I also alwaysperform a hypothenar fat flap duringrevisions. Only with the second revi-sion do I use a vein wrap. I have alsodone this with the ulnar nerve, butthat is not as common of a procedurein my practice. In addition during re-vision carpal tunnel surgery, I try todebulk the carpal tunnel by remov-ing the inflammatory tissue aroundflexor tendons and I have had goodsuccess with that algorithm - basi-cally Dean’s algorithm.

Jonathan: We have been using ultra-sound to try to look at the nerve tosee if we see areas of ongoing com-pression. As we know, nerve conduc-tion studies are difficult to interpretfollowing nerve decompression asthey likely do not return to normal,so we have started incorporating ul-trasound as a new and exiting diag-nostic tool. In some situations, par-

ticularly with injuries or compressionof the nerves around the elbow, ul-trasound has been very helpful.

I like to have a staged plan whenwe go to the OR, so depending onwhat I find, it may be procedure A,B, or C. One maneuver I find usefulduring the clinical exam is simulta-neous extension of the wrist and fin-gers. If the patient has a sharp in-crease in pain when I do the maneu-ver, I feel it is a traction neuritis and Ianticipate I am going to find a lot ofscar tissue around the nerve. In thatscenario, I generally do a vein wrap.I have found that the vein wrap pro-cedure works very well, but of courseit has the morbidity of vein harvest.If I encounter a lot of scar, I will do avein wrap even if it is the first revi-sion and I have the patient preparedfor this. If I look at the nerve and itdoesn’t look like there is that muchscar, I agree with putting some sortof interposition but in that situation Iam not sure it is worth the morbidityof the fat flap, so I use an off the shelfproduct – either a conduit or nervewrap. I only use the hypothenar fatflap if it seems like there is a lack oftissue between the nerve and the skin.So, if there is plenty of fat between theskin and the nerve, I only use the wrap.

Warren: I find the median nerve isoften adherent to the deep surface ofthe radial leaf of the transverse carpalligament, and I find that the hypoth-enar fat flap can be released and if yousuture it to the floor along the radialaspect of the carpal tunnel, it provides

As we know, nerve con-duction studies are diffi-cult to interpret follow-ing nerve decompressionas they likely do notreturn to normal, so wehave started incorporat-ing ultrasound as a newand exiting diagnostictool. - Dr. Isaacs

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16

Hand Table(continued from previous page)

tissue the nerve can glide under and itis less likely to become adherent anddevelop a traction neuritis.

A couple other points before wewrap things up here. Jeff, what areour thoughts on revision ulnar nervesurgery? For example, someone thathas had an in situ ulnar nerve decom-pression at the elbow and continuesto be symptomatic. Do you transposethem in a subcutaneous or sub-mus-cular position or do you do some-thing else.

Jeff: I would say the caveat of my ex-perience has been that unlar nervedecompressions that fail have beenrelated to subluxation over the me-dial epicondyle, and I have done asubcutaneous transposition for thoseand they have been happy with theresults. So, like Jonathan, I tend tohave a plan A, B, and C and I tend tolike to keep the submuscular trans-position in my back pocket if I can’tmake the subcutaneous transpositionwork. Thus far, I have had prettygood results with the subcutaneoustransposition after the failed in situdecompression. I think another prob-lem with treatment of ulnar nervecompressions around the elbow aresymptomatic neuromas of the medialbrachial and the medial antebrachialcutaneous nerves. I spend some timeat the initial exposure trying to finda neuroma and when located, I trans-pose the branch of the nerve into

muscle. I don’t attempt to put it intoa bone, but I really work for a whileto get it into a muscle like the tricepsbecause I have seen a few patientswith symptoms form the ulnar nerveand neuroma of the MABC and theywere fairly miserable.

Warren: Heather, any concepts orthoughts in treating the patient fol-lowing revision ulnar nerve surgery?And any tricks for radial sensorynerve problems?

Heather: Usually as far as a subcuta-neous transposition, I look at howthey are feeling symptom wise. I mayimmobilize them in a post-operativebrace for a short period of time, andcontinue with gentle nerve glidingand range of motion, but I usuallysave immobilization for submusculartransposition patients. Nerve mobi-lization, early scar tissue massage,and the sensory reeducation is reallyimportant because the ulnar nerveespecially along the medial elbow, issensitive.

The ulnar nerve patients usuallydo quite well, particularly in com-parison to the patients with sensorybranch of the radial nerve problems.I think those patients often do not dowell as others have stated. Oftenthese are from failed deQuervain’ssurgery and are workers compensa-tion patients, so there may be issuesof secondary gain.

Warren: Dean, do you or Jonathan orRob have any other thoughts on re-vision ulnar nerves surgery?

Dean: I think that most hand sur-geons believe, based on the literature,that a sub-muscular transposition isthe way to go with some of the diffi-cult ulnar nerve procedures. I person-ally have gone away from doing asubmuscular transposition, espe-cially in the patients that have alreadyhad submuscular transpositions thathave failed, which is the most diffi-cult ulnar nerve revision. I find thatoften times when the nerve is reposi-tioned anteriorly, it becomes tetheredto the medial epicondyle. So, the wayI approach this now involves a verygood neurolysis of the nerve and Ialways do a minimal medialepicondilectomy in these patients toeliminate the anterior tethering of thenerve. You always see a “V”-shapeddeformity in the failed submuscular,and in the failed subcutaneous usu-ally it is a “Z”-shaped deformity. Thatis how I teach my fellows. Byresecting a portion of the medial epi-condyle, it decompresses that sitevery nicely and it leaves the nerve ina deeper yet subcutaneous position.I find that that works pretty well. Imay then put some type of wraparound the nerve as I have evolvedinto doing that fairly routinely for allof my revision nerve procedures.

Warren: Jonathan, do you or Robhave anything additional?

Jonathan: Well, I tend to approachthis similarly to how I approach thecarpal tunnel releases in that I go andI look for what the problem is beforeI decide what I am going to do. Gen-erally, if there is an area of ongoingimpingement that is fairly easy torecognize, I will just decompress it,but often there is a problem with scartissue and so I will usually addressthat with a vein wrap for larger ar-eas or if it is a small area, sometimeswith a conduit. If it is an in situ, I willusually revise it to an anterior sub-cutaneous transposition. I agree withDean that I do not like submusculartranspositions. I only do those inpeople who are really thin and haveminimal subcutaneous fat and Iworry they will be bothered by the

(continued on next page)

I would say the caveat of my experience has beenthat unlar nerve decompressions that fail havebeen related to subluxation over the medial epi-condyle, and I have done a subcutaneous trans-position for those and they have been happy withthe results. So, like Jonathan, I tend to have aplan A, B, and C and I tend to like to keep thesubmuscular transposition in my back pocket if Ican’t make the subcutaneous transposition work.

- Dr. Friedrich

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17

sub-q location of the nerve, but ingeneral, I have not seen that as an is-sue. I know that many surgeons dosubmuscular transpositions withgreat results, but to me you are tak-ing the nerve and putting it against ahard surface – the elbow joint andsurrounding ligaments. I have notbeen doing the medial epicon-dylectomy. One additional thing youhave to be careful about is the poten-tial problem of kinking as the nerveshifts directions and crosses the el-bow joint or when it goes into theflexor carpi ulnaris—whether it issubcutaneous or submuscular, so youhave to be very careful.

Warren: I think that a straight path-way for the nerve may be more im-portant than whether it is in asubmuscular or subcutaneous posi-tion, so I agree with that. Rob, wereyou going to say something?

Rob: What I do is actually a sub-fas-cial transposition. So, that is sort of

Hand Table Conclusion

the in between, as Susan MacKinnonhas described. You make that stepcut in the fascia and then create atrough for the nerve. As the yearshave gone on, I have made a moreand more generous trough to reallycreate that almost perfect straight linefor the ulnar nerve and I have beenvery aggressive in making sure thereis no kinking. So, I will go as far dis-tal as necessary to make sure thereare no fascial bands within the flexorcarpi ulnaris muscle.

I personally don’t really like thesubcutaneous position as much, butmy partner does and he is very happywith that. I have revised a couple ofthose in thin and younger people thatwere symptomatic and I have donethis sub-fascial transposition. I thinkit has a relatively vascular bed andyet, if it fails, it is not quite thesubmuscular position where it is insuch a deep location that it is verydifficult to expose. So, I think I havebeen a hybrid. One of the issues Ihave is whether to do an in situ de-

compression for the primary proce-dure or to do a transposition. I dothe in situ decompression and flex theelbow intraoperatively and see whatthe ulnar nerve wants to do. If itsubluxes a little bit, I will leave it, butif it subluxes more than I am comfort-able with, and particularly if the pa-tient is relatively young, then I willhave a very low threshold to trans-pose the nerve. If it is rock solid, thenI generally tend to keep the nerve inplace, particularly if the nerve is hor-ribly compromised. If there is veryslow conduction across the elbow, forexample 23 meters per second, then Iwill try not to disrupt the blood sup-ply. I will try to avoid moving thenerve and try to keep it in place.

Warren: Okay, we have covered allthe points that I was hoping to covertonight.

I appreciate everybody takingtheir time out of their schedule toparticipate in this valuable andeducational panel discussion.

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ACCURATE SURGICAL & SCIENTIFIC INSTRUMENTS®

HandSurgeryQuarterly

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18

HAND THERAPISTS’ CORNER

Middle Phalangeal Fractures: Early Mobilization with SplintingShrikant J. Chinchalkar, OTR, CHT, Chelsea A. Barker, MScOT, , Joey G. Pipicelli, MScOT, CHT

Hand Therapy, Hand & Upper Limb Centre, St. Joseph’s Health Care, London, Ontario, Canada

Middle phalangeal shaftfractures account for 10-15% of allfractures in the hand. The manage-ment of volar and dorsal lip frac-tures has been well documented inthe literature; however, literatureon shaft fractures of the middlephalanx is limited.

The anatomy of the middlephalanx consists of the extensordigitorum communis, central slipand conjoined lateral bands. Theconjoined lateral bands are helddorsally by the triangular ligament.These bands reunite across themiddle phalanx before insertingonto the base of the distal phalanxforming the terminal tendon. On

the volar surface, the flexordigitorum superficialis (FDS) andflexor digitorum profundus (FDP)are intimately aligned. At theproximal phalanx, the FDS dividesto pass around the FDP and insertsonto the shaft of the middle pha-lanx. This division creates anopening called Camper’s Chiasmthat allows the FDP to emerge andinsert onto the base of the distalphalanx. The transverse retinacularligament attaches to the conjoinedlateral bands volarly. The spiraloblique retinacular ligament arisesfrom the proximal phalanx andinserts onto the distal phalanx,volarly crossing the PIP joint.

Shaft fractures of the middlephalanx are relatively slower toheal because of the vascularity ofthe cortical bone. Clinical manage-ment is dependent upon fractureclassification. An undisplacedfracture typically entails closedreduction and immobilization,whereas a displaced fracturerequires open reduction andinternal fixation (ORIF) withimmobilization.

Complications associated withshaft fractures of the middlephalanx have not been well de-scribed. In our experience immobi-lization has lead to tendon adhe-sions as well as PIP and DIP joint

Online AAHS membership applications are now available on the AAHS Website:

www.handsurgery.org

All AAHS members should consider sponsoring an associate, colleague, protégé, trainee, or fellow formembership in the American Association for Hand Surgery. Over the last several years the AAHS hasincreased its membership and continues outreach in this area. Because an application for membershiprequires support by an AAHS member, you are likely to be asked by a prospective applicant to serve as hisor her sponsor. We know that there are a number of hand surgeons, hand therapists, and allied healthprofessionals who have much to offer the Association. Please help us identify them.

To apply for AAHS Membership, applicants can begin the online application process themselves atwww.handsurgery.org or AAHS members may initiate an application for a new applicant in the MembersOnly area of the AAHS website.

Please feel free to contact the Membership Committee chairs if you have any questions regarding apotential candidate or the application process.

Jeffrey B. Friedrich, MD, Active Membership Committee ChairRebecca von der Heyde, PhD, OTR/L, CHT

Affiliate Membership Committee Chair

Recruit an AAHS Member

(continued on next page)

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19

stiffness. Other complicationsidentified included quadriga andlumbrical plus sign. Consideringthe anatomical location of tendonsand ligaments, these complicationshave compromised functional useof the hand by reducing grip andpinch strength.

Besides protecting the fracture,it is imperative that a controlledmobilization program is imple-mented to restore digital motionand tendon gliding. To protect thefracture, a volar finger gutterorthosis is fabricated for continualwear (Figure 1). Mobilizationorthoses are used to allow PIP andDIP motion respectively. Theseorthoses consist of a volar fingerorthotic stabilizing the proximaland middle phalanx, leaving theDIP free for motion (Figure 2); anda circumferential orthotic stabiliz-ing the distal and middle phalanxallowing PIP motion (Figure 3). It isrecommended that patients per-form 10-15 repetitions, severaltimes during the day. Upon radio-graphic confirmation of fracturehealing, the frequency of exercisesmay be increased. Standard edemaand pain control measures are usedas necessary. Finally, contracturecontrol consisting of flexion orextension orthotics may be utilizedonce the fracture healing is con-firmed. Figure four (Figure-4 a & b)and five demonstrates middlephalanx fracture and final digitalflexion following the managementas described above (Figure 5).

Figure 4 - a) Middle phalanx shaftfracture; b) Healing fracture

Figure 5 - Active digital motion

Figure 1 - Finger gutter orthosis Figure 2 - Mobilization orthosisallowing DIP joint motion

Figure 3 - Mobilization orthosisallowing PIP joint motion

As mentioned, literaturediscussing the clinical managementfor shaft fractures of the middlephalanx is currently limited. Agreater emphasis is placed onproximal phalangeal fracturemanagement and complications.This article presents a controlledmobilization guideline to minimizethe complications commonlyassociated with middle phalangealfractures.

ReferencesPratt, NE. Anatomy and kinesiol-ogy of the hand. In: Skirven TM,Osterman, AL, Fedorczyk, JM,Amadio, PC, 6th eds. Rehabilitationof the Hand and Upper Extremity.Mosby, Philidelphia, PA: 2011: 361-385.

Dean BJ, Little, C. Fractures of themetacarpals and phalanges. OrthopTraum 2010; 25: 43-56.

Hardy MA, Freeland AE. Handfracture fixation and healing:Skeletal stability and digital mobil-ity. In: Skirven TM, Osterman, AL,Fedorczyk, JM, Amadio, PC, 6th eds.Rehabilitation of the Hand andUpper Extremity. Mosby,Philidelphia, PA: 2011: 361-385.

Day, CS, Stern, PJ. Fractures of themetacarpals and phalanges. In:Wolfe, SW, Hotchkiss, RN,Pederson, WC, Kozin, SH, 6th eds.Green’s Operative Hand Surgery.Churchill Livingstone, Philidelphia,PA: 2011: 239-290.

HAND THERAPISTS’ CORNER (continued from previous page)

a) b)

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20

Lifelong learning...AM

ERIC

AN S

OCIE

TY OF MAXILLOFACIAL SUR

GEONS

FOUND E D 1947

SUPPORTED BY:

P S E N E T W O R K . O R G

Procedural Videos CME Courses Case Reports

Self Assessment Tools Community

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21

Members Only Website Access:http://handsurgery.org/members/

AAHS Members have exclusive access to the Members Only area of the AAHS website. Toaccess, simply log-in with your individual Username and Password. Contact the AAHSAdministrative Office if you need your login infor-mation.

Access HAND, the official Journal of the AAHS - This is the best way to gain full access.

Go Green and receive electronic-only access toHAND

Search the AAHS Membership database byname, geographic area, or specialty to find yourcolleagues.

Sign up to receive Table of Contents alerts fromHAND.

Update and verify your Member Record for efficient and effective communication.Please be sure to note your specialty so your colleagues can find you!

The mission of the Hand Surgery Endowment is to foster and promote the

highest quality of hand care through development and sponsorship of educa-

tional programs related to the hand and the upper extremity, through commu-

nications with health care professionals and the public, and through the

endowment of research.

The Hand Surgery Endowment depends greatly upon thegenerosity of AAHS members and affiliates for support. Contributions support current andfuture initiatives:

Guatemala Healing Hands Foundation

Health Volunteers Overseas Missions

Partnerships with International Federation ofSocieties for Surgery of the Hand (IFSSH),Orthopaedic Research & Education Foundation (OREF), and many other organizations forinternational outreach and volunteer missions to improve global hand care

Vargas International Hand Therapist Teaching Award*

Research Grants, including the AAHS Annual Research Grant and the HSE/AAHS/PSFCombined Pilot Research Grant

DONADONADONADONADONATE TO HSETE TO HSETE TO HSETE TO HSETE TO HSEClick here to DONATE ONLINE

HandSurgeryQuarterly

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Fall/Winter2011

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22

O

F

F

I

C

E

T

W

I

T

T

E

R

Strategies for Success in

Hand and Upper Extremity Care

A. Lee Osterman, MD

Randall W. Culp, MD

Sidney M. Jacoby, MD

Alejandro Badia, MD

Charles J. Eaton, MD

Joseph E. Imbriglia, MD

Donald H. Lalonde, MD

»»HONORED

PROFESSORS

CHAIRMEN

CONTACT INFORMATION

URL: www.handfoundation.org

EMAIL: hrf@handfoundation.org

PHONE: 610.768.5958

CME Credits available

Endorsed by: Sponsored by: Supported by: Jefferson

Health SystemHand & Rehabilitation Foundation

American Association of Hand Surgery POSNAUniversity of Colorado

Denver School of Medicine

http://meeting.handsurgery.org/past-future-meetings.cgi