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CONGENITAL

 * Absent and Hypoplastic Disorders
 * Brachial Plexus Birth Injury
 * Cerebral Palsy
 * Embryology and Classification
 * Finger and Thumb Anomalies
 * Hand and Wrist Fractures and Dislocations
 * Physeal Injury (Traumatic and Acquired)
 * Polydactyly
 * Syndactyly and Symbrachydactyly
 * Wrist and Upper Limb Anomalies


GENERAL PRINCIPLES

 * Anesthesia (including WALANT)
 * Compartment Syndrome
 * Imaging
 * Infections
 * Medical Conditions
 * Principles of Hand and Wrist Arthroscopy


HAND AND WRIST: BONE AND JOINT

 * Carpal Fractures (including Malunion and Nonunion)
 * Distal Radius and Ulna Fractures (including Malunion and Nonunion)
 * DRUJ Arthritis
 * DRUJ Injury and Reconstruction
 * Intercarpal and Radiocarpal Arthritis
 * Metacarpal Injuries (including Malunion and Nonunion)
 * Osteoarthritis of Fingers (including Arthroplasty)
 * Osteoarthritis of the Thumb (including Arthroplasty)
 * Phalangeal Injuries (including Malunion and Nonunion)
 * PIP Dislocations and Fracture Dislocations
 * Scaphoid Fractures
 * Scaphoid Fractures (Nonunion)
 * Scapholunate Ligament Injuries and Reconstruction
 * Thumb Fractures and Ligament Injuries
 * Wrist Dislocations and Instability (not including SL)


HAND AND WRIST: SOFT TISSUE

 * Acute Flexor Tendon Injuries
 * Burns
 * Extensor Tendon Injury
 * Fingertip and Nail Bed Injuries
 * Flexor Tendon Reconstruction
 * Free Tissue Transfer
 * Local and Regional Flaps for Hand Reconstruction
 * Replantation
 * Tendinopathies
 * The Mangled Hand and Amputation


NERVE

 * Adult Brachial Plexus Injuries (Reconstruction, Nerve Transfers, Late
   Reconstruction)
 * Median Nerve Compression
 * Median Nerve Injury, Repair and Tendon Transfers
 * Nerve Injury and Repair
 * Radial Nerve Compression
 * Radial Nerve Injury, Repair and Tendon Transfers
 * Ulnar Nerve Compression
 * Ulnar Nerve Injury, Repair and Tendon Transfers


DISORDERS AND DISEASES

 * AVN of Hand and Wrist
 * Complex Regional Pain Syndrome (CRPS)
 * Dupuytren Disease
 * Primary Bone Tumors
 * Psychological Aspects of Arm Illness
 * Rheumatoid and Inflammatory Arthropathies
 * Soft Tissue Tumors
 * Tetraplegia and Stroke
 * Upper Limb Amputation, TMR, Prosthetics
 * Vascular Disorders

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Hand and Wrist: Soft Tissue


REPLANTATION

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ISCHEMIA TIME

 * Acceptable ischemia time major amputations <6 hours and digit amputation(s)
   <12 hours
 * Cooling can extend ischemia time to 12 hours for a major limb and >24 hours
   for a digit

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PREOPERATIVE ASSESSMENT

 * Prehospital care—Amputated part is cooled immediately, wrapped in a
   saline-soaked sponge and placed in a plastic bag with bag placed in ice slush
 * Note occupation, hand dominance, mechanism of injury, and any past injury to
   the area
 * Record past medical history including history of CVD, PVD, DM, and smoking
 * Assess the condition of the patient—complete trauma evaluation—and the
   amputated part—ischemia time, level of injury, poor prognostic signs such as
   red line or ribbon sign
 * Imaging—three-view X-rays of the amputated part and residual limb

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SURGICAL TECHNIQUE FOR DIGIT REPLANTATION

 * Debridement of all nonviable tissue and foreign material
 * Sequence of repair includes bone, extensor tendon, flexor tendon, artery,
   nerve, and veins
 * Bone shortening and fixation
   * Bone shortening of 0.5–1 cm will help limit tension on repair of
     neurovascular structures
   * Fixation with K-wires is most common, but other options include
     interosseous wiring, K-wire and interosseous wire (hybrid method),
     intramedullary fixation, and plate/screws
 * Extensor tendon is repaired primarily with a braided 3–0 or 4–0 suture
 * Flexor tendon is repaired primarily using at least a 4-strand core suture
   repair
   * Repair of one artery is often sufficient
     * Inadequate arterial inflow proximally is addressed by:
       * Dissecting the vessel proximally to healthy tissue
       * Warming and volume-repleting patient
       * Irrigating the vessel with warm saline and a vasodilator such as
         papaverine
       * Liberal use of vein grafts
   * Nerves are ideally repaired primarily, but allografts can be used when
     necessary
   * Two veins are anastomosed for each repaired artery
   * Loose skin closure; liberal use of skin grafts is encouraged to prevent
     tension

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DISTAL DIGITAL REPLANTATION

 * Injuries distal to DIPJ can be replanted but present difficulties in venous
   outflow
 * Ideally, 1 cm of dorsal skin exists proximal to nail fold to find a vein of
   adequate caliber
 * If no dorsal vein is available, other methods for venous outflow may be tried
   such as repair of volar vein, AV shunting, surface bleeding, leeching,
   subcutaneous pocketing, pulp reduction, and intramedullary drainage

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ADDITIONAL CONSIDERATIONS FOR MAJOR LIMB REPLANTATION

 * Ischemia time is critical
 * Sequence of repair includes debridement/fasciotomies (forearm/hand), arterial
   shunting, bone shortening and fixation, arterial anastomoses, venous
   anastomoses, nerve repair, muscle repair, and skin coverage.
 * Arterial shunting—catheter is temporarily used to bridge a proximal artery in
   the residual limb to an artery in the amputated part to re-perfuse the
   amputated part
 * Approximately 4 cm of bone shortening is performed at the forearm level. Fix
   with plate and screws in the forearm vs. crossed K-wires in the carpus.
 * Arterial repairs are performed before venous repairs to flush out toxic
   metabolites
   * Prepare for blood loss and transfusion
   * Intermittent use of tourniquet or recovery system (e.g., cell saver) can
     limit blood loss
 * Venous repairs should include deep and superficial systems
 * Neurorrhaphy is performed using an epineural repair
 * Muscle and tendon repair is completed from deep to superficial
 * Skin closure over the neurovascular bundles with open areas for drainage
 * Repeat debridement is often performed 48–72 hours postoperatively

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POSTOPERATIVE CARE

 * Noncompressive dressing and plaster splint is applied
 * The arm is elevated to heart level
 * The patient is kept well hydrated
 * The room and limb are maintained warm
 * Anticoagulation such as aspirin, heparin, and lovenox can be instituted,
   although there is not sufficient data to make specific recommendations
 * Perform frequent assessment for color, skin turgor, temperature, and
   capillary refill
 * Venous congestion algorithm includes ensuring a non-compressive dressing, OR
   takeback, and leeches

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PEDIATRIC REPLANTATION

 * Almost any amputated part in a healthy child is considered for replantation
 * With an open epiphysis, the replanted part will continue to grow
 * Bone shortening should be limited to prevent epiphysis injury
 * Longitudinal growth will be ~80% of normal
 * Sensory recovery is similar to that of an isolated digital nerve repair
 * Cold intolerance is uncommon in a child

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COMPLICATIONS

 * Arterial insufficiency (pale appearance)
 * Venous insufficiency manifests as congestion (rapid capillary refill)
 * Infection including osteomyelitis
 * Cold intolerance (adults). Symptoms often improve in 1–2 years, or never
   resolve.
 * Stiffness requiring tenolysis and contracture release
 * Nonunion
 * Abnormal sensation




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