SRPS PS - Plastic Surgery Internal

SRPS 

SELECTED READINGS 

IN PLASTIC SURGERY 

HAND 

MICHAEL DOLAN MD 

MICHEL SAINT-CYR MD 

VOLUME 10: NUMBER 25 

2 0 0 9

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Jeffrey M. Kenkel, MD 

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R. S. Ambay, MD 

R. G. Anderson, MD 

S. J. Beran, MD 

S. M. Bidic, MD 

G. Broughton II, MD, PhD 

J. L. Burns, MD 

J. J. Cheng, MD 

C. P. Clark III, MD 

D. L. Gonyon, Jr, MD 

A. A. Gosman, MD 

K. A. Gutowski, MD 

J. R. Griffin, MD 

R. Y. Ha, MD 

F. Hackney, MD, DDS 

L. H. Hollier, MD 

R. E. Hoxworth, MD 

J. E. Janis, MD 

R. K. Khosla, MD 

J. E. Leedy, MD 

J. A. Lemmon, MD 

A. H. Lipschitz, MD 

R. A. Meade, MD 

D. L. Mount, MD 

J. C. O’Brien, MD 

J. K. Potter, MD, DDS 

R. J. Rohrich, MD 

M. Saint-Cyr, MD 

M. Schaverien, MRCS 

M. C. Snyder, MD 

M. Swelstad, MD 

J. F. Thornton, MD 

A. P. Trussler, MD 

R. I. S. Zbar, MD 

Dori Kelly 

Grafts and Flaps 

Wound Healing, Scars, and Burns 

Skin Tumors: Basal Cell Carcinoma, Squamous Cell 

Carcinoma, and Melanoma 

Implantation and Local Anesthetics 

Head and Neck Tumors and Reconstruction 

Microsurgery and Lower Extremity Reconstruction 

Nasal and Eyelid Reconstruction 

Lip, Cheek, and Scalp Reconstruction 

Ear Reconstruction and Otoplasty 

Facial Fractures 

Blepharoplasty and Brow Lift 

Rhinoplasty 

Rhytidectomy 

Skin Care and Cosmetic Injectables 

Lasers 

Facial Nerve Disorders 

Cleft Lip and Palate and Velopharyngeal Insufficiency 

Craniofacial I: Cephalometrics and Orthognathic Surgery 

Craniofacial II: Syndromes and Surgery 

Vascular Anomalies 

Breast Augmentation 

Breast Reduction and Mastopexy 

Breast Reconstruction 

Body Contouring and Liposuction 

Trunk Reconstruction 

Hand: Soft Tissues 

Hand: Peripheral Nerves 

Hand: Flexor Tendons 

Hand: Extensor Tendons 

Hand: Wrist, Joints, Congenital Anomalies, and 

Rheumatoid Arthritis 

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HAND: 

FINGERNAILS, INFECTIONS, TUMORS, AND 

SOFT-TISSUE RECONSTRUCTION 

Michael Dolan, MD 

Michel Saint-Cyr, MD 

FINGERNAILS 

Anatomy 

The nail root is covered by an epithelium-lined sheath 

called the eponychium. The dermal layer beneath the 

nail is the nail bed. It consists of the germinal matrix, 

which underlies the proximal one-third of the nail 

from the nail fold to the distal lunula, and the sterile 

matrix, which occupies the distal two-thirds of the nail 

from the lunula to the end of the nail bed (Fig. 1). 1 The 

area beneath the distal free margin of the nail, where 

the sterile matrix and fingertip skin meet, is called the 

hyponychium. This specialized area contains increased 

numbers of polymorphonuclear leukocytes and 

lymphocytes. 2 The surrounding soft tissue is called the 

perionychium. The perionychium bordering the nail 

edges on the sides is called the paronychium. 

Nail production occurs in three areas of the 

perionychium. The germinal matrix produces 

approximately 90% of the nail volume by pushing cells 

from the ventral floor upward and outward. As they 

reach the surface, the specialized cells flatten, elongate, 

keratinize, and stream distally. At approximately the 

level of the lunula, the cell nuclei disintegrate and the 

nail becomes clear. The loss of nuclei is why it is 

referred to as the sterile matrix. 

The remainder of the nail substance is produced 

by the germinal layer in the dorsal roof of the proximal 

nail fold and by the sterile matrix in variable amounts, 

as evidenced by a thicker nail at its distal edge than at 

Department of Plastic Surgery, 

University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 

Figure 1. Anatomy of the nail shown in sagittal (A) and 

dorsal (B) views. (Reprinted with permission from Brucker and 

Edstrom. 1 ) 

its proximal root. 2 The dorsal roof of the nail also 

provides cells that add shine to intact nails.

SRPS Volume 10, Issue 25, 2009 

Physiology 

The fingernail protects the fingertip from trauma and 

aids in gripping fine objects. The nail resists 

deformation of the digital skin and, in so doing, 

increases the sensitivity of the fingertip, as shown by 

2-point discrimination tests. 2 Where fingernails are 

permanently absent, fingerprints tend to disappear 

and 2-point discrimination worsens. 

The nail grows at an average rate of 3 to 4 mm a 

month. Nail growth is faster during the summer than 

during the winter and is accelerated in nail biters. The 

nail is not attached to its bed but rather “is a 

continuum of a single structure from the basilar cells 

into the nail”. 2 

Injuries 

Fingertip injuries are the most common type of hand 

trauma, and the nail bed itself is the most frequent site 

of injury. 3,4 Destruction of the germinal matrix usually 

results in permanent loss of the fingernail or 

troublesome nail remnants. 5 

Prompt treatment of nail bed injuries is vital to 

maintain function and cosmesis. 6,7 Ashbell et al. 5 

reviewed 3000 nail bed and root injuries treated during 

a 10-year period and formulated the principles of 

management for the injuries, as follows: 

remove remaining nail plate to assess underlying 

nail bed injury 

perform minimal débridement of nail bed 

stabilize distal phalanx, if required 8 

achieve accurate repair of nail bed and any 

associated skin lacerations 

replace missing sterile matrix with sterile matrix 

graft at primary procedure 

replace nail plate, if available, or use 0.02-inch 

silastic sheet as nail spacer 

These principles apply equally to the management 

of nail bed injuries in children, in whom good results 

can be anticipated in the majority of cases. 9 When 

repairing a nail bed in a child in the emergency 

department, conscious sedation often is needed to 

facilitate accurate nail bed repair. In cases in which the 

nail plate is recovered, it can be used to splint the nail 

fold but it is recommended that it first be trephinated 

to allow for the inevitable hematoma to drain. 

Application of Xeroform gauze (Invacare Supply 

2 

Group, Holliston, MA) under the nail fold can also be 

used for this purpose. 

When the nail root is not significantly damaged, 

complete regrowth of the nail normally is obtained in 4 

to 5 months. 5 In the event of partial or total loss of the 

sterile matrix, nail grafting from an uninvolved finger 

or from a toe 10,11 is possible in the acute setting. 

Similarly, chronic deformities such as nail plate 

nonadherence and minor nail splitting have been 

successfully treated with sterile matrix grafting 

procedures. 12,13 Isolated, nonvascularized, germinal 

matrix grafts have far less predictable outcomes and 

usually are not recommended. If a germinal matrix 

graft is to have any chance of success, a large 

composite must be taken, which has to include the nail 

fold. The nail plate, dorsal roof, and germinal and 

sterile matrices are harvested along with a small rim of 

paronychial skin (Fig. 2). 1 The donor site from the great 

toe is covered with a split-thickness skin graft. 

However, in their review of 10 composite grafts 

performed during a 10-year period, Lille et al. 14 were 

able to obtain good or excellent results in only 50% of 

the cases. 

Figure 2. Composite nail graft. (Reprinted with permission from 

Brucker and Edstrom. 1 ) 

In cases with significant loss of germinal matrix, 

consideration should be given to primary nail bed 

ablation. When performing an ablation, the intimate 

relationship of the terminal extensor tendon to the 

germinal matrix must be appreciated, with the two 

structures being separated by only 1.2 mm. 14 

Visualization of the insertion of the terminal extensor

tendon represents the proximal limit of excision. 

Reardon et al. 15 recommend that excision of the nail 

matrix should be rectangular, extending to the midlateral 

lines. Microvascular nail transfer is the 

definitive method for replacing the entire nail matrix 

but is a major procedure for what is as much an 

aesthetic as a functional outcome. 16,17 

Deformities 

Posttraumatic retraction and deformity of the 

eponychial fold can occur after lacerations or burns. 

One-stage flap options are possible for correction of 

this problem. 18,19 

In cases in which the nail fold is not properly 

stented open, the patient might develop a synechia 

and skin pterygium, which can lead to secondary nail 

deformities. Prevention by appropriate nail fold 

splinting is recommended to avoid the problem. 

INFECTIONS 

Sixty percent of all hand infections are the result of 

trauma, 30% result from human bites, and 10% result 


from animal bites. 20 Hand infections account for 

approximately 20% of all admissions to hand surgery 

units and often are accorded a lower level of 

significance than warranted. When the infection is 

treated appropriately, the patient returns to optimal 

function in a short time. If the infection is inadequately 

treated, the patient is resigned to pain, stiffness, and 

disability. Amputation is sometimes required in 

extreme cases. 

Microbes and Antibiotics 

The most frequent pathogen involved in hand 

infections is Staphylococcus aureus, accounting for 50% 

to 80% of all isolates. 20–25 The microbes, unfortunately, 

are likely to be resistant, as shown in multiple 

studies. 26,27 However, specific aspects of the history 

and/or physical examination findings can implicate 

other organisms as the inciting agent. Careful attention 

to the aspects and findings allows the physician to 

make an appropriate choice of initial antibiotic(s) to 

cover all reasonable pathogens (Table 1). 

Indiscriminate use of excessively broad-spectrum 

Table 1 

Empiric Antibiotic Treatment for Some Common Hand Infections24 Infection Antibiotic Likely Organisms 

Cellulitis/lymphangitis First-generation cephalosporin 

or 

antistaphylococcal penicillin 

Paronychium/felon Dicloxacillin 

or 

fi rst-generation cephalosporin 

Flexor tenosynovitis β-Lactamase inhibitor 

or 


and penicillin; 

consider ceftriaxone 

Deep space infection β-Lactamase inhibitor 

or 


and penicillin 

Human bite wound β-Lactamase inhibitor 

or 



Dog or cat bite wound β-Lactamase inhibitor 

or 



Streptococcus pyrogenes, 

S. aureus 

S. aureus, anaerobes 

S. aureus, streptococci, anaerobes; 

Neisseria gonorrhoeae 

S. aureus, streptococci, 

gram-negative bacilli, anaerobes 


E. corrodens, anaerobes 


P. multocida 

3


antibiotics can expose the patient to unnecessary side 

effects and complications and can promote the 

development of resistant strains. 

Infections with Streptococcus species present 

rapidly, with marked cellulitis and possibly 

lymphangitis. Although an antistaphylococcal 

penicillin or first-generation cephalosporin adequately 

cover S. aureus, streptococci are better covered by 

penicillin. Gram-negative infections might present with 

a cellulitis or purulent infection. Anaerobic bacteria are 

especially common in bite wounds, infections 

associated with intravenous drug abuse, and diabetics. 

In addition to the bacteria already mentioned, Eikenella 

corrodens is found in many human bite wounds 28–30 and 

Pasteurella multocida in many domestic animal bite 

wounds. 31–34 These usually are adequately covered by 

the addition of penicillin to an agent effective against 

the other gram-positive organisms. 35–37 

Compared with adults, children are more 

susceptible to unusual pathogens and have a higher 

incidence of oral flora, Pseudomonas aeruginosa, and 

Haemophilus influenzae 38,39 associated with infections. 

However, the associations probably are not frequent 

enough to warrant a change in the initial therapy for 

routine infections. Nevertheless, if suggested by gram 

stain, if a site of distant infection is present where the 

pathogens are common, or if the infection does not 

respond promptly to the standard antibiotics, 

additional coverage is warranted. The presence of 

multiple pathogens in hand infections is probably 

more common than is appreciated. 40 

If the patient is receiving recalcitrant to 

conventional antibiotic therapy, methicillin-resistant S. 

aureus (MRSA) must be considered. Cultures should be 

obtained, and an antibiotic that covers MRSA should 

be initiated. 27,41 

Prophylactic Antibiotics 

Three independent studies 42–44 showed that 

prophylactic antibiotics do not avert infection in cases 

of hand lacerations. Meticulous wound débridement 

and care are preferred over the routine use of 

antibiotics in cases of hand injuries. 45 Fitzgerald et al. 46 

recommend prophylactic antibiotics for hand wounds 

of home or industrial origin but not for farm wounds, 

which instead should undergo thorough débridement 

4 

and culture. Nylén and Carlsson 47 found no correlation 

between severity of infection and number of organisms 

present in wound or time elapsed before treatment (up 

to 18 hours) and further emphasized the importance of 

wound débridement in the care of hand injuries. 

Prophylactic antibiotics do have a role in cases 

undergoing the following procedures: 1) soft-tissue 

reconstructive procedures with large flaps, 2) total elbow 

or wrist implant arthroplasty, 3) procedures of long 

duration, 4) complex open hand trauma with wound 

contamination and extensive soft-tissue and bony injury, 

and 5) procedures longer than 2 hours in duration. 45 

For routine surgical cases in which more than 2 

hours of time elapses and prophylactic antibiotics are 

recommended, the choice of antibiotic typically is a 

first-generation cephalosporin. This typically is 

administered as cephalexin four times a day, but new 

evidence shows that administering the same total 

dosage in two doses is equally effective. 48 The duration 

of the administration of the antibiotics is unclear, but 

the literature does show that if the time period exceeds 

4 days, the antimicrobial resistance is altered. 49 

Management 

Although the spectrum of acute bacterial hand 

infections is broad, the management principles are 

similar for all and can be summarized as follows: 

rest, elevation, and immobilization in position of 

function 

adequate drainage of all loculations of pus and 

débridement of necrotic tissue 

antibiotics, determined by sensitivities from 

aerobic and anaerobic cultures (obtained before 

commencement of antimicrobial therapy) and 

special cultures—fungi, mycobacteria, viruses— 

as indicated 

treatment with broad-spectrum antibiotics that 

cover for MRSA 

tetanus prophylaxis for all penetrating wounds 

early, aggressive hand therapy 

Common Bacterial Infections 

Hand infections can be acute or chronic, but the 

overwhelming majority are acute. Of the acute 

infections, more than 90% are caused by 

bacterial pathogens. 20

Cellulitis 

Cellulitis is a common superficial infection of the hand 

that presents as erythema, swelling, pain, and 

occasional lymphangitis or vesicle formation. Cellulitis 

occurs most commonly on the dorsal aspect of the 

fingers and metacarpals, and beta-hemolytic 

streptococcus is the usual pathogen. Treatment 

includes rest, elevation, splinting, and antibiotics. 

Paronychia 

Paronychia is an infection of those structures 

surrounding the proximal and lateral nail. Paronychia 

is initiated by the introduction of bacteria between the 

nail and its surrounding structures. This usually is 

caused by minor trauma, such as nail biting and 

manicures. It frequently is reported that S. aureus is the 

most frequent isolate in paronychia. Studies have 

shown anaerobic bacteria to be present alone or in 

combination in a large percentage of cases of 

paronychia, 50,51 likely because of the frequency of 

contact of the oral secretions with the inciting wound. 

Paronychia initially begins as erythema, swelling, 

and discomfort at the nail fold, sometimes with 

fluctuation and frank purulence. If paronychia is 

detected early, warm soaks, elevation, and oral 

antibiotics can be sufficient treatment. If the infection 

has been present for longer than 24 hours or if any 

fluctuance is present under the nail, the nail fold must 

be drained by simple elevation (Fig. 3). 52,53 

If the initial attempt at drainage is inadequate, if 

the infection extends significantly proximal to the nail 

fold, or if the infection fails to resolve with the above 

treatment, more aggressive drainage is indicated. The 

Figure 3. Drainage of paronychia. (Reprinted with permission 

from Conolly. 53 ) 


nail plate should be removed because it might be 

acting as a foreign body by that stage. It might also be 

necessary to incise the dorsal nail fold. Two incisions 

are made at right angles to the nail fold, at the 5 

o’clock and 7 o’clock positions, to elevate it completely 

from the nail bed in the region of the infection (Fig. 

4). 54 Accurate placement of the incisions minimizes the 

chance of subsequent eponychial retraction. 

Figure 4. Incisions in eponychium. (Reprinted with permission 

from Zook and Brown. 54 ) 

If the paronychia has been neglected or 

inadequately treated, purulence might extend around 

the nail to its ventral surface overlying the nail matrix. 

The pressure of the accumulating pus can permanently 

damage the germinal matrix, and removal of an 

appropriate section or the entire nail is indicated to 

adequately drain the infection. Inadequate treatment 

might allow the pus to spread under the nail sulcus to 

the opposite side, resulting in a “runaround” abscess. 

Occasionally, paronychia becomes a chronic 

problem, 55,56 perhaps from secondary mycobacterial or 

fungal infections, which more commonly occur in 

immunosuppressed patients, diabetics, and cancer 

patients. Chronic paronychia also occurs in patients 

who have frequent exposure to moist environments. 

Candida albicans is the most commonly identified 

organism in paronychia. 52 Infection can become chronic 

in the presence of vascular insufficiency, such as in 

cases of Raynaud disease or scleroderma. The chronic 

infections can be treated in several ways. The nail fold 

can be marsupialized by excision of a crescent of tissue 

5


down to the germinal matrix, which is then left to 

close by secondary intention. 57,58 Alternatively, the 

entire proximal nail fold, including the cuticle, can be 

excised. 59 Once healed, a very satisfactory cosmetic 

result is achieved, although as the dorsal roof of the 

nail is ablated, the shiny surface layer of the nail is no 

longer produced. Complete removal of the nail and 

then treatment with a combined antifungal-steroid 

cream has also shown good results. 60 In cases of 

nonhealing chronic infection, malignancy should be 

ruled out considering that subungual melanoma often 

is unpigmented and mistaken for fungal infection. 61 

Pulp Space Infection (Felons) 

A felon is an infection of the pulp of the distal finger. 

The anatomy of the pulp is unique, with 1520 

longitudinal septa anchoring the tip to the distal 

phalanx (Fig. 5). 53 When infection is present, the septa 

can compartmentalize an infection and preclude 

adequate drainage if the septa are not fully ruptured. 

Figure 5. Anatomy of the fingertip. (Reprinted with permission 

from Conolly. 53 ) 

Most felons are precipitated by some sort of 

penetrating trauma, and radiographs should be 

obtained of all felons and carefully evaluated for 

foreign bodies. If a felon does not respond to therapy 

or if strong evidence indicates that a non-radiopaque 

foreign body is embedded in the pulp, 

6 

ultrasonography might reveal a foreign body not seen 

on conventional radiographs. S. aureus is the most 

common pathogen in felons, 62 but gram-negative 

organisms have also been reported. Gram-negative 

organisms should be considered in immunosuppressed 

patients. A number of cases have been reported in 

diabetics who developed felons after checking their 

blood sugar level by fingerstick. 63 

If a pulp infection is observed early, it might 

simply be a case of localized cellulitis or a small 

superficial abscess. Localized cellulitis and small 

superficial abscesses can be treated with orally 

administered antibiotics, rest, and elevation or with 

local drainage as indicated. In a case of true felon, the 

patient presents with the entire pulp red, swollen, and 

markedly tender. The patient usually complains of a 

severe throbbing pain, particularly when the finger is 

dependent. The pain is caused by increased tissue 

pressure, which is caused by the unyielding septa 

(essentially a compartment syndrome of the pulp). At 

that stage, adequate drainage and antibiotics are 

required for treatment. 52,62 Late presentation or 

incomplete therapy can result in a compromise of the 

blood flow to the pulp, which can result in necrosis of 

the soft tissues, tenosynovitis, septic arthritis, and 

even osteomyelitis. 64 

Many incisions have been recommended for the 

drainage of felons. If it is pointing, the felon should be 

drained at that site. Careful palpation with a small 

blunt probe often determines a point of maximal 

tenderness, and the incision should be made at that 

site. The pulp must be explored immediately volar to 

the phalanx but dorsal to the neurovascular structures. 

The fibrous septa are ruptured to allow complete 

drainage of the infected space. Good results are 

achieved with a longitudinal midline palmar incision 

that does not cross the distal interphalangeal joint (Fig. 

6). 52,53 The incision heals well and usually does not 

produce a hypersensitive scar on the pulp. 

Tenosynovitis 

Tenosynovitis is an infection within the sheaths that 

form the gliding surfaces around the tenons in the 

hand. It is almost exclusively a disease of the flexor 

tendons, although extensor tenosynovitis at the level of 

the dorsal retinaculum has also been described. 65

Figure 6. Drainage of a felon. (Reprinted with permission from 

Conolly. 53 ) 

Although tenosynovitis rarely is life-threatening, 

delayed or inappropriate treatment can lead to 

devastating consequences. The delicate gliding 

surfaces of the tendon sheaths can be destroyed by 

infection, resulting in a stiff and painful finger. Even 

more prolonged delay in treatment can allow the 

sheath to rupture, with spread of the infection to any 

of the spaces of the palm or to the adjacent bone. 

Prolonged infection can also lead to ischemic rupture 

of the tendon itself. 66,67 

Most cases of tenosynovitis begin with penetrating 

trauma, and in such cases, the most common infectious 

agent is S. aureus. Some cases are caused by 

hematogenous dissemination, particularly of gonococcal 

infections, and this possibility should be considered in 

cases with no history of antecedent trauma. 68 

The hallmarks of flexor tenosynovitis were first 

established by Kanavel 69 and constitute the four 

cardinal signs that bear his name: 

fusiform swelling of the digit 

partially flexed posture of the digit 

tenderness along the entire flexor sheath 

pain along the entire flexor sheath with passive 

extension of the digit 

In situations of uncertainty regarding the 

diagnosis, ultrasonography might be of benefit 70,71 in 


that it can show swelling of the tendon and 

peritendinous fluid. It is likely that the diagnosis of 

suppurative tenosynovitis can be made on clinical 

grounds alone. 

Once the diagnosis of tenosynovitis has been 

made, treatment must be instituted promptly. Very 

early cases can undergo a trial of intravenous 

antibiotics, splinting, and elevation. That mode of 

treatment, however, should be selected with caution. 

The patient should be observed closely, and if 

significant improvement is not noted within 12 to 24 

hours, treatment should progress to surgical drainage. 

When surgical drainage is deemed necessary based 

on initial presentation or failure to improve, two 

methods are available, as described by Neviaser. 67,72 

The majority of cases can be treated with limited 

incision and drainage and then closed catheter 

irrigation (Fig. 7). 21,72–74 If the patient fails to respond to 

that treatment or if the sheath cannot be cleared of 

purulence at initial exploration, open drainage must be 

used. The sheath is opened widely via a midlateral 

incision, sparing the A2 and A4 pulleys, and is 

copiously irrigated. 66,67,75 The wound is closed loosely or 

left open for delayed closure. Active range-of-motion 

exercises are begun with the first dressing change on 

the ward. 76 

Figure 7. Closed irrigation for flexor tenosynovitis. (Reprinted 

with permission from Brown and Young. 21 ) 

7


In the event that the thumb or little finger is 

involved with tenosynovitis, the infection can extend 

proximally to involve either the ulnar or radial bursa. 

The two bursae communicate through the space of 

Parona, deep to the flexor tendons in the distal 

forearm. A “horseshoe” abscess can form where a 

flexor tenosynovitis, beginning in either the thumb or 

little finger flexor sheath, spreads proximally to the 

space of Parona and then passes distally down either 

the little finger or thumb flexor tendon sheath. Phillips 

et al., 77 however, showed that the little finger flexor 

synovial sheath often ends at the level of the A1 pulley, 

so that little finger tenosynovitis usually can be 

managed by drainage of the finger alone. In instances 

in which an infection extends proximally, closed 

catheter drainage is indicated. The catheter is directed 

proximally from the incision at the level of the A1 

pulley. A counter incision is then made just proximal to 

the transverse wrist crease, where a drain is placed in 

the bursa. This system is managed in a similar fashion 

to the digital system. Again, if the patient does not 

respond to this treatment, open drainage of the bursae 

is necessary. 

Deep Space Infection 

A variety of “spaces” have been described in the hand. 

In reality, the spaces are potential and become 

significant only when infected, as they become 

loculations of purulent material. They include the 

thenar space, the midpalmar space, the subtendinous 

space, also known by the eponym Parona space, the 

hypothenar space, the dorsal subcutaneous space, the 

dorsal subaponeurotic space, and the interdigital web 

spaces. 78 The spaces often are confused with the 

compartments of the hand, which are the four dorsal 

interossei, three volar interossei, thenar, hypothenar, 

and adductor pollicis compartments. 

Infection in the spaces begins most frequently with 

a penetrating injury, the most commonly identified 

isolate being S. aureus. An antistaphylococcal agent can 

be used for initial antibiotic therapy unless gram stain 

at the time of drainage suggests another organism. As 

clearly described in the pre-antibiotic era by Kanavel, 69 

the key to treatment of deep space infections is precise 

drainage of the abscess, guided by knowledge and 

respect for the surrounding and involved structures. 

8 

The most important deep spaces of the hand are 

the midpalmar space and the thenar space (Fig. 8). 21 

Thenar space infections usually are characterized by 

the thumb being held in an abducted position, with 

pain over the adductor muscles and pain on extension 

or attempted opposition of the thumb. Thenar space 

infection is the only hand infection with which the 

thumb is not adducted. Drainage of the abscesses must 

not only respect the proximity of neurovascular 

structures, primarily the radial bundle to the index 

finger and the ulnar bundle to the thumb, but also 

must prevent scarring across the thumb-index web. 

Figure 8. Deep spaces of the hand. (Reprinted with permission 

from Brown and Young. 21 ) 

The midpalmar space, exclusive of the flexor 

tendon sheaths, allows free spread of infection along 

fascial planes to deeper areas in the hand. Treatment 

consists of incision and drainage with catheter 

irrigation for 2 to 3 days. 78 

Osteomyelitis 

Osteomyelitis of the bony structures of the hand is a 

relatively infrequent infection. 79 Osteomyelitis can 

present as a spontaneous bone infection, usually by 

hematogenous seeding from a distant source. The most 

likely pathogens are Staphylococcus and Streptococcus 

species and, in young children, Haemophilus species. 

Osteomyelitis presents as a localized focus of 

erythema, pain, and swelling along the course of one 

of the long bones of the hand. If the infection does not 

show clinical signs of improvement within 48 hours of 

commencing intravenously administered antibiotic 

treatment, bone biopsy should be performed to obtain

a specimen for culture. Any obviously necrotic bone 

should undergo débridement during that procedure. 

Osteomyelitis can also develop secondary to local 

tissue conditions, either the spread of another 

contiguous infection or direct injury to the 

surrounding soft tissues and bone. The best test for 

diagnosing osteomyelitis under such circumstances is 

direct evaluation of the bone in an operative setting, 

with a biopsy performed during the same procedure. 

The biopsy also provides a culture to guide the 

antibiotic therapy. A superficial swabbing of the 

wound is inadequate for diagnosis or culture, because 

the pathogens obtained by that technique might not 

accurately reflect the microbiology of the infected 

bone. 80 The initial antibiotics should be broad-spectrum 

parenteral antibiotics until the results of the cultures 

allow specification. 81 

In a review of 46 patients with osteomyelitis of the 

metacarpals or phalanges, Reilly et al. 82 noted an 

overall amputation rate of 39% despite aggressive 

surgery and intravenously administered antibiotic 

therapy. A delay of more than 6 months from onset of 

symptoms to diagnosis and definitive treatment 

resulted in amputation in six of seven patients. 

Septic Arthritis 

Infection of the joint spaces of the hand can cause a 

devastating loss of hand function because it threatens 

the cartilaginous surface of the joint. 83 Septic arthritis 

can present as a primary site of infection or as a 

complication of another hand infection, the most 

common of which is an acute flexor tenosynovitis. 

Isolated septic arthritis can occur either by direct 

inoculation or by hematogenous spread from a distant 

infection. Distant sites of recent infection must be 

sought, particularly in the patient with no history of 

trauma. 84 In children, monoarticular arthritis often is 

caused by hematogenous spread from a distant 

infection. In addition to Streptococcus and 

Staphylococcus species, H. influenzae must be considered 

to be a common potential pathogen and covered 

appropriately. In the sexually active patient, 

particularly those younger than 40 years with no 

history of direct inoculation, gonococcal arthritis must 

be suspected. 85 

Septic arthritis in the hand presents as a locally 


tender, erythematous, and swollen joint. Because of the 

swelling and pain, the joint is held in the position that 

maximizes its volume, approximately 30 degrees of 

flexion in the interphalangeal joints and full extension 

in the metacarpophalangeal joints. The joint is 

particularly tender with any passive motion. 

Arthrocentesis of the joint can be performed as a 

diagnostic maneuver. Treatment consists of elevation, 

parenteral antibiotics, and incision and drainage of the 

joint. Depending on the severity of the infection, 

irrigation of the joint for 48 to 72 hours might also be 

required. Once the acute inflammation has abated, 

range-of-motion exercises should commence. 

Bite Wounds 

Human Bite Wounds 

Bites to the human hand account for 20% to 30% of all 

hand infections, and the majority are human bites. The 

clenched-fist injury is associated with a high incidence 

of complications, including stiff joints and even 

amputations. 86,87 The injury is sustained as the clenched 

fist strikes the mouth of another person, and the tooth 

frequently impales the metacarpal heads. The key 

point in understanding the potential of the underlying 

Figure 9. A, Tooth pierces clenched fist, penetrating skin, 

tendon, joint capsule, and metacarpal head. B, When finger is 

extended, four puncture wounds do not align. (Reprinted with 

permission from Lister. 91 ) 

9


pathological condition is that the site of penetration of 

the various layers is relative to the position of the fist 

at the moment of impact (Fig. 9). 88–91 The hand must be 

assessed in the clenched-fist position to allow an 

accurate assessment of the depth of injury. 

The patient presenting early with a laceration or 

puncture has minimal inflammation. Radiography 

might reveal a fracture of the metacarpal head, air 

within the joint, or, occasionally, a foreign body such as 

a broken tooth. The patient presenting late has a red, 

swollen, painful hand and can have associated 

lymphangitis and regional lymphadenitis. The patients 

are constitutionally unwell, with fever and elevated 

white cell count, and are in serious danger of 

osteomyelitis, septic arthritis, and severe joint 

damage. 86 Radiographic examination of the patients, in 

addition to looking for a chip fracture or foreign body, 

is directed at early signs of osteomyelitis or abscess 

formation within the bone. 92 

In the majority of cases, cultures yield S. aureus and 

Streptococcus viridans. 30,34 The other organisms 

commonly encountered are anaerobic Bacteroides 

species (found in 50% if specifically sought on culture) 

and E. corrodens. 28–30 E. corrodens is sensitive to penicillin. 

The clenched-fist wound to the metacarpophalangeal 

joint is a notoriously underestimated and 

undertreated injury. All patients with clenched-fist 

wounds should be managed with splinting, elevation, 

antibiotics, and surgical exploration. 93,94 In grossly 

septic joints, irrigation can be continued 

postoperatively for 48 to 72 hours. Early motion (48–72 

hours) should be advocated, 76 considering that stiffness 

is one of the more difficult complications to treat. 

Several studies 89–94 have shown that uncomplicated 

bite wounds (not involving the joint capsule or articular 

surface), when seen early (within 12 hours), can be 

adequately managed on an outpatient basis. Treatment 

involves wound exploration, vigorous irrigation, 

débridement, and supplementation with orally 

administered antibiotics, to be implemented only for 

reliable patients. The addition of appropriate 

intravenously or orally administered antibiotics is 

necessary to ensure eradication of the causative 

organism. Considering that the majority of infections are 

caused by staphylococci, streptococci, or E. corrodens, a 

reasonable first-line therapy is penicillin plus dicloxacillin 

10 

(penicillinase-resistant). 36 Cephalexin or erythromycin can 

be used in patients with allergy to penicillin. 

Animal Bite Wounds 

Domestic dogs are responsible for 90% of all animal 

bites. More than half the dog attacks involve young 

children, and of the resulting wounds, approximately 

half are to the hands and forearms. Dog bites become 

infected less often than do human or cat bites. A dog’s 

jaws can exert a force of 150 to 450 psi, which is 

sufficient to devitalize tissues. The resulting wound 

can be a puncture, laceration, avulsion, crush, or 

combination. 95,96 As with the human bite, the most 

common pathogens isolated are a mixture of aerobes 

(especially S. aureus and S. viridans), anaerobes 

(various Bacteroides species), and also P. multocida. 30–33 

Pasteurella infection should be suspected in cases of 

acute onset of cellulitis, lymphangitis, and 

serosanguineous or purulent discharge from a hand 

wound within 24 hours of a dog or cat bite. 

Fortunately, P. multocida is sensitive to penicillin. 

Unlike human bite wounds, which should not be 

closed primarily, most dog bite wounds 97,98 should be 

thoroughly irrigated with normal saline, have the 

margins sharply excised (especially over joints, 

tendons, vessels, and nerves), and have the edges 

loosely approximated with sutures. Most of the 

organisms commonly encountered in dog saliva are 

sensitive to penicillin, so a 5-day course of orally 

administered penicillin should be prescribed. 37 The 

tetanus status of the patient and the rabies status of the 

animal should be verified and treated as appropriate. 

Domestic cat bites account for only 5% of animal 

bite wounds to the hand. The configuration of the teeth 

of a cat is different from that of a dog. Cat teeth are long 

and sharp, and the injury subsequently inflicted tends 

to be a deep puncture wound. 99 Significantly less 

devitalization of tissues occurs with a cat bite compared 

with a dog bite, so commensurably less wound 

débridement is needed. The wound should be irrigated 

and loosely approximated if sufficiently large to 

warrant suturing. 100 An orally administered course of 

penicillin should be prescribed to cover Pasteurella. 

Cat bites can also give rise to cat-scratch fever, an 

infection caused by an intracellular gram-negative rod. 

The primary lesion is a small pustule or furuncle with

surrounding edema at the site of a cat scratch or bite. 

A similar lesion is seen at the regional lymph nodes. 

The course of the disease is benign and self-limiting, 

and treatment is symptomatic. The incubation period 

is 1 to 2 weeks, and symptoms last 1 to 3 weeks, 

although lymphadenopathy lasts 6 weeks and 

occasionally years. 

Atypical Mycobacterial Infections 

The incidence of tuberculosis of the hand has 

diminished at a rate commensurate with the decline in 

pulmonary tuberculosis. 20,101,102 In its place, however, are 

infections caused by atypical mycobacteria, which 

increase yearly. 103–105 The three major atypical 

mycobacteria involved in hand infection are 

Mycobacterium marinum, 106–109 Mycobacterium kansasii, 110–112 

and Mycobacterium terrae. 113–115 

M. marinum is the most common mycobacterial 

species to infect the hand. It lives in warm water 

environments and has been cultured from 

contaminated swimming pools, fish tanks, piers, boats, 

and stagnant water. It is endogenous to fresh and 

saltwater marine life. M. marinum survives best at 

31°C, and for that reason, it produces infections on the 

extremities rather than deep body cavities. 103–108 

Infections with M. marinum occur after a break in 

the integrity of the skin, often from an insignificant 

abrasion on the dorsum of the hand or over the 

interphalangeal or metacarpophalangeal joints of the 

fingers. Infection of the hand progresses through a 

spectrum of indolent skin ulcers through subcutaneous 

granulomas with sinus tracts, tenosynovitis (flexor and 

extensor), and septic arthritis or osteomyelitis. 116,117 

Treatment of superficial disease can be 

successful with chemotherapy alone, both 

minocycline and co-trimoxazole having been shown 

to be effective. 118,119 The largest study to date, from 

Hong Kong, suggests that chemotherapy alone 

might also be applicable to more extensive disease. 118 

Generally, deeper disease treatment also requires 

surgery with radical synovectomy and more specific 

antimycobacterial therapy with rifampicin and 

ethambutol for up to 2 years. 

Early clinical diagnosis of mycobacterial infections 

is made only with a high index of suspicion. When 

mycobacterial infection is suspected, cultures should 


be performed at both 31 and 37°C; otherwise, 

M. marinum infections can be missed. Positive cultures 

for mycobacterial strains take at least 6 weeks for 

identification; therefore, treatment can be instituted on 

the basis of granulomas shown by histological 

examination or on the basis of acid-fast bacilli seen 

on a smear. 

Viral Infections 

Herpes Simplex Virus 

Herpes simplex virus (HSV) infection of the hand can be 

caused by a primary or recurrent infection with either 

HSV-1 or HSV-2. It tends to occur in three distinct 

patient subgroups. The first and largest group is 

adolescents with genital herpes, who tend to be infected 

with HSV-2. The remaining groups tend to be infected 

with HSV-1. The second group is children with oral 

gingivostomatitis, 120,121 and the third group is adult health 

care professionals—including dentists, anesthesiologists, 

surgeons, and nurses—who deal directly with 

potentially infected oral and respiratory secretions. 122 

Herpetic infection of the hand typically involves 

the fingers or thumb in the vast majority of cases. 123 

The infection initially declares itself with a prodromal 

phase of approximately 72 hours’ duration, with 

severe pain or tingling in the affected digit, and then 

erythema and swelling. This is called herpetic whitlow. 

During the ensuing hours to days, vesicles appear and 

coalesce, often around the eponychium and lateral nail 

fold. It is at that stage that the viral infection is most 

likely to be mistaken for a bacterial felon or 

paronychia. However, the pulp usually is not tense, as 

it would be in a case of bacterial felon. Associated 

lymphangitis can be present. The whole process takes 

approximately 2 weeks and then resolves in another 7 

to 10 days. Reactivation of latent virus occurs in only 

approximately 20% of hand patients. 124 It is not 

normally as severe as the primary infection and lasts 

for 7 to 10 days. 

It is possible to confirm the diagnosis by 

conducting laboratory investigations, including viral 

cultures. The Tzanck smear is relatively inexpensive 

and rapid. 125 Although not as sensitive as viral cultures, 

it is a useful adjunct in diagnosis, especially if 

performed early in the course of the disease, during 

the vesicular or pustular stages. 

11


The treatment of herpetic infections of the hand is 

primarily nonsurgical. Rest, elevation, and antiinflammatory 

analgesia are the mainstays of 

treatment. For immunocompromised patients, 

aggressive therapy with intravenously administered 

acyclovir might be warranted in an attempt to prevent 

a life-threatening viremia. 126,127 

Infections in Immunocompromised Patients 

Immunocompromised patients can develop hand 

infections from opportunistic organisms. The 

management of hand infections in 

immunocompromised patients is identical, irrespective 

of the underlying causes. Many of the fungi, viruses, 

and mycobacteria can be cultured only under very 

exacting laboratory conditions. Diagnosis almost 

certainly requires formal surgical tissue biopsy. 

Treatment is dictated by the organism cultured, but 

considering that many of the unusual organisms can 

take several weeks to grow, therapy must be instituted 

“on spec.” If a fungal origin is most likely, 

intravenously administered amphotericin B is the first 

line treatment. Similarly, for a viral origin, of which 

herpes simplex is the most likely, acyclovir is 

intravenously administered. Finally, if a mycobacterial 

species is suspected, triple-agent therapy (rifampicin, 

ethambutol, isoniazid) is instituted. 

Diabetes Mellitus 

C. albicans infections of the nails are common in 

diabetics, so much so that a random blood glucose 

level should be obtained as a baseline for any patient 

presenting with an infection of the nail complex. The 

same has been suggested by some groups for a first 

presentation with flexor tenosynovitis. 128 Infections can 

commence from relatively simple injuries (e.g., felons 

and suppurative flexor tenosynovitis occurring after 

fingerstick blood test for glucose levels). 63,129 

Microbiology often shows a mixed flora, and S. aureus, 

so commonly encountered in “normal” patients with 

suppurative hand infections, often is grossly 

outweighed by gram-negative organisms. 130 Diabetics 

often present with advanced disease (bone, tendon, or 

deep space infection), which can also reflect a 

peripheral neuropathy as a causative factor. 130–133 

Finally, many undergo amputation, either to control 

12 

infection or because the function in the remaining part 

is so poor as to be a hindrance or danger to the patient. 

Treatment of hand infections in diabetics must be 

early and aggressive if useful function is to be 

maintained and amputation avoided. 130–133 Obvious 

abscesses must be drained and appropriate specimens 

obtained for aerobic and anaerobic cultures. 

Radiographs should be obtained and supplemented 

with bone scans, if indicated. Broad-spectrum 

intravenous antibiotic cover should be instituted and 

appropriately modified after cultures are returned. 

Rehabilitation should be aggressive and instituted as 

soon as the acute manifestations of the infection are on 

the wane. 

TUMORS 

Several authors offer excellent reviews of the spectrum 

of hand neoplasms, including their incidence, causes, 

anatomic distribution, and management, which almost 

always involves surgical remova1. 134–140 Only the more 

common hand tumors are discussed herein. The 

overwhelming majority of hand masses are benign, 

and true neoplasms are rare in the hand (Table 2). 

Soft-Tissue Tumors 

Ganglia 

Ganglia are the most common benign tumors in the 

hand. 141–143 Although trauma is commonly thought to be 

implicated in the development of ganglia, a traumatic 

antecedent has been documented in only a small 

percentage of patients. The pathogenesis is thought to 

be mucoid degeneration of fibrous connective tissue in 

joint capsules or tendon sheaths occurring 

idiopathically or secondary to injury or irritation. 

Ganglia are two to three times more common in 

women than in men. The usual clinical presentation is 

that of a mass with or without pain. Occasionally, 

occult ganglia present as paresthesias or weakness 

from nerve compression. 144–147 Ganglia sometimes even 

arise within tendon 148 or bone. 149 

Dorsal wrist ganglia—The dorsum of the wrist 

accounts for 70% of all ganglia in the hand and wrist. 

In the dorsum of the wrist, the ganglion usually 

overlies the scapholunate ligament. Clay and Clement 150 

noted the pedicle of the ganglion to arise from that site 

in 76% of patients. The cause of dorsal wrist ganglia is

Bone 

Soft Tissue 

still uncertain, but some evidence indicates underlying 

peri-scaphoid ligamentous instability. 151 

Volar wrist ganglia—Volar wrist ganglia arise from 

the flexor carpi radialis tendon sheath or the 

radioscaphoid, scapholunate, or scaphoid-trapeziumtrapezoid 

joint. Ultrasonography can delineate the 

origin preoperatively. The ganglion is in close proximity 

to the radial artery, which can cause it to be bilocular. 

Flexor tendon sheath ganglia—Flexor tendon sheath 

ganglia arise from the volar flexor tendon sheaths in the 

vicinity of the metacarpophalangeal joint. They often 

present through the A1 or A2 pulleys or in the interval 

between them. Flexor tendon sheath ganglia are thought 

to be a direct result of pressure damage to the fibrous 

sheath and require excision only if symptomatic, taking 

a small cuff of pulley as required. 152 

Mucous cysts—Ganglia arising in association with 

tendons and joints on the dorsal aspect of fingers can 

originate from the extensor tendon itself or, more 

commonly, from the joint capsule. 153–155 They occur 

primarily in older women who have osteoarthritic 

changes of the underlying joint, usually the distal 

interphalangeal joint. When an underlying arthritic 

joint is the cause of the ganglion, the joint must 

undergo débridement or the ganglion will recur. 

Mucous cysts can produce a deformity of the nail plate 

Table 2 

Grading of Bone and Soft-tissue Tumors of the Hand134 SRPS Volume 10, Issue 25, 2009 

Benign (G0) Low-grade Sarcomas (G1) High-grade Sarcomas (G2) 

Enchondroma 

Osteochondroma 

Fibrous dysplasia 

Osteoid osteoma 

Bone cysts 

Hemangioma 

Osteoblastoma 

Ganglion 

Giant cell tumor 

(tendon sheath) 

Lipoma 

Neurolemmoma 

Chondromatosis 

Glomus tumor 

Giant-cell tumor 

Desmoplastic fi broma 

Chondrosarcoma (low-grade) 

Parosteal osteosarcoma 

Desmoid 

Liposarcoma (low-grade) 

Fibrosarcoma (low-grade) 

Kaposi’s sarcoma 

Osteosarcoma 

Ewing’s sarcoma 

Lymphoma 

Chondrosarcoma 

Angiosarcoma 

Myeloma 

Synovioma 

Malignant fi brous histiocytoma 

Liposarcoma (high-grade) 

Rhabdomyosarcoma 

Epithelioid sarcoma 

Clear cell sarcoma 

Angiosarcoma 

Hemangiopericytoma 

Malignant schwannoma 

from pressure on the nail bed. Brown et al. 156 reported 

their experience with 26 nail deformities secondary to 

mucous cysts of the distal interphalangeal joint 

managed by excision of the cyst and débridement of 

associated osteophytes. No recurrences occurred 

during the follow-up period, and residual nail 

deformity in eight patients was negligible. 

Pathologic anatomy—A ganglion typically has a 

uni- or multilocular main cyst that communicates with 

smaller intra-articular cysts through a tortuous, 

continuous, one-way valvular system of ducts. 140 

Microscopic examination of the ganglion wall typically 

reveals compressed collagen fibers with no evidence of 

cells of epithelial or synovial origin. 157,158 The cyst 

contains viscous mucoid material consisting of 

glucosamine, albumin, globulin, and hyaluronic acid. 

Management—Rosson and Walker 159 reviewed the 

natural history of ganglia in children and noted that 

22 of 29 lesions resolved spontaneously. A 

conservative approach to ganglia is therefore 

advocated for young patients. 159,160 The management of 

wrist ganglia in adults is controversial. The literature 

supports a spontaneous regression rate of 38% to 

58%, 161 whereas treatment of all types is associated 

with recurrence rates from less than 1% 143 to 50% 162 

(average 24%). Incomplete excision of the cyst stalk 

13


complex probably accounts for the high recurrence 

rate. 163 Prevention of recurrence depends on 

identification and excision of the involved segment of 

joint capsule and deep attachments of the cyst pedicle 

to the scapholunate ligament but only minimal 

resection of the ligament itself to prevent future 

scapholunate dissociation (Fig. 10). 164 Clay and 

Clement 150 noted only 3.2% recurrence when using 

that protocol. More radical procedures pose a greater 

risk of subsequent stiffness, hypertrophic scar, wound 

infection, and nerve damage. 

Figure 10. Ganglion with pedicle attached to scapholunate 

ligament. (Reprinted with permission from Minotti and Taras. 164 ) 

Filan and Herbert 165 think that symptomatic dorsal 

wrist ganglia are the result of scaphoid instability that, 

if present at the preoperative clinical examination, is 

treated by a dorsal capsulorrhaphy of the wrist 

combined with ganglion excision. Of seven patients 

who underwent surgery for recurrent ganglia in whom 

capsulorrhaphy was performed, none had experienced 

recurrence of ganglia at 12 months. 

The treatment of wrist ganglia is indicated only in 

the event of significant discomfort or deformity. 

Although surgery is the mainstay of treatment, 

various nonoperative techniques have been 

advocated. Aspiration 166,167 or injection of enzymes, 168 

sclerosing agents, or cortisone have been suggested, 

but all are associated with a significant recurrence 

rate. Arthroscopic resection of the ganglion might be 

associated with a lower recurrence rate. 169–171 It can also 

14 

identify the exact origin of the ganglion and other 

intra-articular pathological conditions. 

Giant Cell Tumors of Tendon Sheath 

Giant cell tumors are the second most frequent type of 

hand tumor. They typically occur in the fingers of 20to 

40-year-old patients and are slightly more common 

in women. Giant cell tumors of the tendon sheath are 

also known as pigmented villonodular synovitis when 

they arise from the volar joint recess. 172,173 No evidence 

has shown that repeated hemorrhage, friction, or 

cholesterol imbalance contributes significantly to the 

development of giant cell tumors, and only 

approximately one-third of patients provide histories 

of previous trauma or surgery to the region. Pain and 

tenderness are not prominent features, but prolonged 

unchecked tumor growth interferes with mechanical 

function of the hand. 

The clinical presentation of a giant cell tumor of 

the tendon sheath is that of a lobulated, mottled, 

yellow subcutaneous mass. Although the diagnosis 

usually is evident clinically, magnetic resonance 

imaging (MRI) has been described as an adjunct in the 

preoperative assessment of extensive tumors. 174 The 

characteristic lobulation is seen microscopically, and a 

relatively noncellular, collagenous connective tissue 

often divides and partially envelops the lesion. 175 

Histological examination reveals the basic polyhedral 

cells of a fibrous xanthoma. In the more cellular areas, 

mitotic figures are seen, but never in large numbers. 

Also present are spindle cells, multinucleated giant 

cells, foam cells, and reticulin. 175,176 The tumor can erode 

bone by pressure 177 and/or infiltrate the overlying 

dermis. 178 Frank bony invasion has been documented. 179 

Treatment is complete local excision, ensuring 

total clearance of the volar joint recess. Recurrences 

unfortunately are common, especially in the fingers, 

and are the result of inadequate resection, for which 

repeat excision is recommended. 180 Extensive 

recurrences often necessitate arthrodesis of the 

affected joint in that resection of violated ligaments 

and joint capsule might be required. Very occasionally, 

amputation is necessary. Despite infiltrative growth 

patterns, rapid recurrence, and a frequently confusing 

histological appearance, giant cell tumors are 

considered benign. 181

Vascular Lesions 

Several authors offer excellent reviews of vascular 

tumors of the hand and upper extremity. 182–186 Upton 

and Coombs 187 discussed pediatric vascular tumors. 

Glomus tumors—Glomus tumors are benign 

hamartomas of the normal glomus apparatus, which 

consists of arteriovenous anastomoses involved in the 

regulation of cutaneous circulation. 188–191 Glomus tumors 

usually are smaller than 1 cm in diameter (often 

measuring only a few millimeters) and classically 

present with the triad of pain, pinpoint tenderness, and 

cold sensitivity. Transillumination is a simple and useful 

clinical test. 192 The most common site of presentation is 

subungual, but glomus tumors occasionally occur on the 

volar surface of a digit. Approximately one-fourth of all 

glomus tumors are multiple. 193,194 Ultrasonography 195–197 

and MRI 198–200 are used as aids in diagnosis and also to 

detect multiple tumors. 

Treatment is by excision. If subungual, care should 

be taken to repair the nail bed after removal of the 

tumor. The major problems after surgical treatment are 

a high recurrence rate and a residual nail deformity. 201–203 

Ulnar artery aneurysms—Ulnar artery aneurysms 

are almost always posttraumatic (“hypothenar hammer 

syndrome” 204,205 ) and occur predominantly in male 

patients. 206,207 Typical clinical features are a pulsatile 

mass accompanied by digital ischemic changes, with or 

without distal emboli. 208,209 An ulnar nerve Tinel sign 

often is present. 210 An Allen’s test should be performed 

to ascertain patency of the ulnar artery, and 

arteriography can rule out thrombosis of the ulnar 

artery and embolic showering. Management consists of 

aneurysm resection and ligation of the ulnar artery, 

with autogenous vein grafting in cases of inadequate 

collateral circulation. 211,212 Regional thrombolysis can 

also be considered in cases with embolization. 209 

Peripheral Nerve Tumors 

True neural cell tumors in the hand are rare (1%–5% 

incidence). 213 All lesions arise from Schwann cells. 214–216 

Although no uniform classification of peripheral nerve 

tumors exists, most clinicians refer to five general types. 

Neurilemmomas—Neurilemmomas are the most 

common solitary tumors of neural cell origin in the 

hand and are particularly prevalent in middle-aged 

patients. 217,218 Neurilemmomas begin as asymptomatic 


nodular swellings without associated sensory or motor 

abnormalities. When exposed surgically, they are seen to 

have a dumbbell shape and to lie extrinsic to the nerve 

fiber proper. Histologically, they are made up almost 

exclusively of Schwann cells. Excision involves 

enucleation under magnification so as to preserve nerve 

fibers that fan out over the tumor. Recurrences are rare, 

and malignant degeneration is not a clinical feature. 

Neurofibromas—Unlike neurilemmomas, 

neurofibromas can intimately proliferate within nerve 

fibers, producing functional abnormalities and making 

excision more difficult without division of the nerve. 

Histologically, neurofibromas are difficult to differentiate 

from neurilemmomas, although they exhibit mast cells, 

lymphocytes, mucoid material, and xanthoma cells in 

addition to Schwann cells. 218 Solitary lesions usually 

occur before age 10 years. Neurofibromas can cause 

gigantism of the affected part. 219,220 

Neurofibromatosis—Neurofibromatosis (von 

Recklinghausen disease) is an autosomal dominant 

condition characterized by multiple peripheral and 

central neurofibromata (acoustic neuromas, 

meningiomas, optic gliomas). Temporal lobe 

involvement can erode the greater wing of the 

sphenoid, producing pulsatile exophthalmos. 220 

Extremity involvement can produce gigantism of the 

limb. 221 Diagnostic café au lait spots, numbering more 

than six, occur on the skin. The individual tumors 

manifest a plexiform pattern. Sarcomatous degeneration 

has been reported in 2% to 3% of lesions. 222 

Neurofibrosarcomas—Neurofibrosarcomas 

(neurosarcomas or malignant schwannomas) account 

for 2% to 3% of malignant hand tumors and usually 

are associated with von Recklinghausen disease. 223 

Local extension and metastases are common, resulting 

in 90% mortality. Wide excision or amputation of the 

extremity is the recommended treatment. 

Intraneural tumors of non-neural origin— 

Intraneural tumors of non-neural origin include 

lipofibromatous hamartomas, hemangiomas, ganglion 

cysts, and lipomas. 224 Lipofibromatous hamartomas 

commonly occur within the 1st decade of life and 

usually involve the median nerve. They can result in 

macrodactyly, especially of the index and middle 

fingers. 225 Treatment involves release of the carpal 

tunnel after excision of the tumor under magnification. 

15


Malignant degeneration has not been reported. 

Epidermal Inclusion Cysts 

Epidermal inclusion cysts commonly occur on the 

palmar surface of the hand or digits of patients whose 

work or leisure activities predispose them to 

penetrating hand injuries. The time from the traumatic 

incident to cyst development varies from months to 

years. Clinically, the lesions are firm, spherical, and 

nontender. The cyst wall consists of squamous 

epithelium with laminated keratin, and the cyst material 

contains protein, cholesterol, fat, and fatty acids. 

Spontaneous rupture is common, but the lesion 

often persists unless the cyst lining, contents, and 

overlying puckered skin are surgically removed. Local 

complications include infections and bone erosion. 

Malignant Skin Tumors 

Malignant tumors of the skin of the hand make up a 

very small percentage of upper extremity neoplasms226- 228 and are primarily squamous cell carcinomas 

(SCC). 229–232 SCC predominate among people with fair 

skin and light hair color. The usual origin of SCC is 

ionizing solar radiation. Other less common causes of 

SCC are previous irradiation, 233 burn scars, exposure to 

arsenic compounds, and inherited genetic disorders. 234 

The dorsum of the hand, with the highest actinic 

exposure, is the most common site for SCC, although 

the tumor has been reported to also occur on the 

palms235 and subungually. 236–239 Appropriate treatment 

consists of a 4-mm margin for tumors with a diameter 

of less than 2 cm. When the size of the tumor exceeds 

those dimensions, a margin of 6 mm is necessary. 240 If 

evidence exists of nodal metastasis or local recurrence, 

axillary lymphadenectomy is recommended. The role 

of sentinel node biopsy in cases of SCC is not yet 

defined in the literature. SCC of the hand is an 

aggressive tumor prone to recurrence and metastasis. 

The metastatic rate for SCC of the hand is higher than 

elsewhere on the body, particularly if the primary 

lesion involves the digital web space. 230 

Basil cell carcinomas—Basal cell carcinomas (BCC) 

are very uncommon tumors on the finger. 241 Palmar 

variants have been observed, 242 especially in cases of 

Gorlin’s syndrome (multiple nevoid BCC syndrome), 243 

and BCC has been reported to also occur 

16 

subungually, 244 in which case differentiation from a 

subungual melanoma must be made. 245 Although BCC 

do not metastasize, they are locally aggressive. 

Excision is the usual form of treatment. 

Melanomas—Melanomas of the hand can occur on 

the palm 246–255 or subungually. 256–259 A study by Ridgeway 

et al. 255 showed that the acral histological subtype does 

not affect the disease-free and overall survival. Tumor 

thickness remains the only prognostic indicator. 

Slingluff et al. 252 found that acral melanoma has a 

strong racial predilection, carries a grave prognosis, 

and arises from glabrous skin. In that study, no 

survival difference was shown between volar and 

subungual sites, nor did amputation make a difference. 

Melanoma requires wide excision or amputation of the 

digit or hand, depending on location and depth. 260–262 

The appropriate level of amputation has not been 

determined. Papachristou and Fortner 256 advocated 

amputation through the carpometacarpal joint, 

whereas Finley et al. 258 performed seven finger 

amputations distal to the metacarpophalangeal joint 

(four just proximal to the distal interphalangeal joint 

and three just proximal to the proximal interphalangeal 

joint), with no local recurrences. Quinn et al. 259 showed 

no difference in local recurrence for subungual 

melanomas whether amputations are performed 

proximal or distal to the interphalangeal joint of the 

thumb or the middle of the middle phalanx in the 

fingers. Similarly, no prospective study to date has 

shown a survival or local control benefit to prophylactic 

lymph node dissection, regional perfusion, or 

immunotherapy. 263–265 The use of sentinel lymph node 

biopsy has grown significantly in recent years. 266,267 

Bony Tumors 

Several authors have presented excellent reviews of 

bony tumors of the hand. 268–270 Treatment is based on 

accurate diagnosis and staging of the lesions (Table 3). 

Chondromas 

Chondromas are the most common benign 

cartilaginous tumors of the hand. 271,272 Chondromas that 

remain within the substance of the bone or cartilage 

are called enchondromas. 273–275 Enchondromas favor the 

tubular bones of the hand, especially the middle and 

proximal phalanges. Congenital cartilaginous rests are

implicated in their origin, and the lesions are totally 

benign, with little tendency toward malignant 

degeneration. Nelson et al. 276 reviewed the literature 

and found only three well-documented cases of 

chondrosarcoma arising from enchondromas. 

Enchondromas usually appear as well-demarcated 

round or oval swellings. A pathological fracture often 

is the first indication of their presence. In such cases, 

the fracture should be allowed to heal before the 

enchondroma is treated. Radiographically, 

enchondromas appear as radiolucent, symmetric, 

fusiform, expansile diametaphyseal lesions that do not 

involve the epiphyses. Treatment usually consists of 

curettage of the tumor through a window in the cortex, 

with or without cancellous bone grafting. 277,278 

Hasselgren et al. 279 questioned the need for bone 

grafting and reported excellent bone healing with 

curettage alone. They think that bone grafting should 

be reserved for the rare circumstance in which “the 

tumor has so severely damaged the bone stock that the 

bone is likely to collapse during surgery”. 279 

Multiple enchondromas—Multiple enchondromas 

are rare in the hand and always occur as part of a 

disseminated involvement (Ollier dyschondroplasia). 280 

Multiple enchondromas associated with hemangiomas 

are part of Maffucci syndrome. The earliest clinical 

manifestations of multiple enchondromatosis are 

swelling and deformity of several bones. 281 The tumors 

distort, expand, and sometimes erode the bony cortex, 

particularly in the diaphyses and metaphyses; 

calcifications are seen in the translucent areas on 

radiographs. Because 20% of multiple enchondromas 


Table 3 

Enneking Staging System for Bone and Soft-tissue Tumors and Their Indicated Excision134 Stage Grade (G) Anatomic Location (T) Metastases (M) 

0 Benign (G0) Any (T1 or T2) None (M0) 

IA Low (G1) Intracompartmental (T1) None (M0) 

IB Low (G1) Extracompartmental (T2) None (M0) 

IIA High (G2) Intracompartmental (T1) None (M0) 

IIB High (G2) Extracompartmental (T2) None (M0) 

III Any grade Any (T1 or T2) Metastasis (M1) 

go on to become chondrosarcomas, wide excision is 

the treatment of choice, with adjuvant radiotherapy to 

the malignant lesions. 

Osteochondromas—Osteochondromas are the most 

common cartilaginous neoplasm in the body overall but 

are less common than enchondromas in the hand. 282,283 Like 

enchondromas, osteochondromas arise from congenital 

cartilaginous foci, which qualify them as manifestations of 

congenital dysplasia. A very slight risk (1%) of malignant 

transformation is associated with osteochondromas. 

Radiographically, osteochondromas appear as bony 

protuberances extending beyond the metaphyseal cortex 

of the involved bone on a narrow stalk. 

Exostoses 

Exostoses usually require no treatment. Subungual 

lesions typically have a traumatic antecedent and are 

characterized by pain on pressure to the nail plate 

months after the injury. 284,285 Radiography readily 

differentiates exostosis from other entities. If required, 

the deformed nail can be removed and the mass 

excised from the distal phalanx. 

Bone Cysts 

Aneurysmal bone cysts tend to show an equal sex 

distribution and are more common during the 2nd 

decade of life but before closure of the epiphyseal 

plate. Aneurysmal bone cysts are eccentrically placed 

in the metaphysis or diaphysis, are expansile and 

lucent, and resemble a periosteal blowout. 286,287 Surgical 

resection or curettage with bone grafting usually is 

curative unless the cyst has been incompletely excised. 

17


Osteoid Osteomas 

Osteoid osteomas are benign osteoblastic tumors that 

are uncommon in the hand. 288 The lesion affects male 

patients two to three times more often than female 

patients, generally between the ages of 10 and 25 

years. Osteoid osteoma occurs most frequently in the 

distal phalanges. 289,290 The cause is unknown. 

The nidus of an osteoid osteoma consists of richly 

vascularized osteoblastic osteoid tissue rarely larger 

than 1 cm. Clinical presentation is that of a localized, 

painful area over a tubular bone. Typically, the pain is 

worse at night and is completely relieved by aspirin. 

An increase in the size of the terminal digit might 

occur. Radiographically, the lesion shows a central area 

of lucency that can be surrounded by a zone of 

sclerotic bone. Bone scintigraphy with technetium 99m 

is of benefit in locating the nidus, and Cp80 has also 

been used. Treatment involves complete excision of the 

lesion and packing of the cavity with cancellous bone. 

Osteoblastomas 

Like osteoid osteomas, osteoblastomas are rare in the 

hand, favor the tubular bones, and occur primarily in 

young patients. Unlike osteoid osteomas, osteoblastomas 

exhibit no sex predilection and usually are larger than 

1.5 to 2 cm. Because of the bone destruction 

accompanying osteoblastomas, the differential diagnosis 

includes osteoid osteoma, aneurysmal bone cyst, and 

malignant tumors. The entire bone must be removed for 

cure. Radiotherapy is helpful in tumor cell control and 

might even aid in healing. 

Giant Cell Tumors of Bone 

Giant cell tumors are uncommon anywhere. They 

represent approximately 5% or less of all primary 

malignant bone tumors, and only 2% to 5% of giant 

cell tumors occur in the hand. 291 The lesion affects 

patients primarily between the ages of 30 and 50 years 

and is virtually unknown in patients younger than 20 

years. Women with giant cell tumors slightly 

outnumber men. 

Clinically, the giant cell tumor is a solitary lesion, 

often well advanced by the time it is noticed. A dull, 

constant pain heralds its presence, sometimes preceded 

by swelling. 292,293 Radiographically, it is seen to involve 

the soft tissues. The epiphyseal end of the bone is 

18 

affected, with extension to the adjacent metaphysis. The 

tumor is translucent, and the cortex of the bone is 

noticeably thin. The clinical course is long but localized. 

Sarcomatous degeneration averages 10%, and the lesion 

metastasizes in approximately 15% of cases. 294–297 

Treatment consists of wide resection with autograft 

or allograft replacement. 298–300 The recurrence rate is 

high (75%). Amputation is reserved for recurrent or 

highly malignant tumors. 

Sarcomas 

Sarcomas are very uncommon tumors in the hand. The 

pathological subtypes of soft-tissue sarcomas 301–303 and 

malignant primary bone tumors 304,305 have been 

reviewed by several authors. Treatment protocols for 

both bony and soft-tissue extremity sarcomas have 

been reviewed. 306–314 Combination therapy (wide 

excision, radiotherapy, and chemotherapy) is now used 

for most high-grade tumors and produces excellent 

local control rates in some tumor types. Amputation is 

avoided and is saved for the management of local 

recurrences. When sarcomas fail, they tend to do so at 

distant sites. In that circumstance, a functional hand 

provides a better quality of life. 

Skeletal Sarcomas 

Ewing sarcomas—Ewing sarcomas account for 

approximately 6% to 10% of primary malignant 

tumors of bone and are rare in the hand. 315–317 They 

affects male patients twice as often as female patients, 

and they affect a younger age group than any other 

bone tumor. A focal mass is a frequent clinical finding, 

and radiographically, the lesion shows permeation, 

soft-tissue mass, and often a sclerotic reaction. 318 

Angiography, computed tomography (CT), and MRI 

often are used in treatment planning. 319 Ewing sarcoma 

generally has a poor prognosis, although the subset of 

patients with Ewing sarcoma of the hand can expect 

excellent local control and good function with 

combination therapy. 308,314 

Osteosarcomas—Osteosarcomas in the hand are 

rare tumors, accounting for only 0.18% of all 

osteosarcomas. 320 Peak incidence is during the 2nd 

decade of life, with a male-to-female ratio of 2:1. The 

presenting complaint is persistent, increasing pain 

from a rapidly growing mass. 321,322 The pathogenesis is

unknown. The lesions might arise de novo or might 

occur secondary to a benign process. Osteosarcomas in 

general tend to occur more frequently in association 

with irradiated bone, Paget’s disease, fibrous dysplasia 

of bone, giant cell tumor, solitary enchondroma, 

multiple enchondromatosis, and multiple 

osteochondromas. 

Radiographically, the borders of an osteosarcoma 

are indistinct, but the lesion invariably involves the 

cortex and generally transgresses it. Often, a large 

contiguous soft-tissue mass is present. A combination 

of destructive and proliferative new bone usually is 

present, showing a streaked texture and a 

characteristic sunburst pattern. Histologically, 

osteosarcoma has a typical spindle-shaped cell pattern. 

Treatment has changed from amputation to excision 

with a wide margin plus adjuvant therapy. In a study 

presented by Okada et al., 320 local control was achieved 

in five of six patients by using this protocol; one 

patient died as a result of metastatic disease. 

Chondrosarcomas—Chondrosarcomas are 

uncommon in the hand, where they occasionally are 

associated with osteochondromas and, to a lesser 

degree, with multiple enchondromatosis, 323,324 although 

the vast majority of cases include no preexisting 

lesion. 325,326 Chondrosarcomas characteristically occur in 

older patients (60–80 years) in the epiphyseal area of 

the proximal phalanx or metacarpal. The clinical 

course is slow, and metastasis is late. 327,328 The tumor 

presents as a progressively painful large mass near the 

metacarpophalangeal joint. Treatment of choice is 

amputation or ray resection. Histological interpretation 

of cartilaginous lesions of the hand is difficult, and 

clinical and radiological appearance (bone expansion, 

lytic areas of bone destruction, soft-tissue swelling) 

often are more reliable indicators of malignancy. 

Prognosis is good if metastasis has not occurred. 325,326 

Soft-Tissue Sarcomas 

Rosenberg and Schiller 302 have provided an excellent 

review of soft-tissue sarcomas of the hand. Soft-tissue 

sarcomas are an uncommon but important group of 

hand tumors. They tend to occur in young patients, are 

innocuous in presentation, often leading to an incorrect 

diagnosis, and have protracted clinical courses. They 


are prone to local recurrence, have an unusually high 

incidence of lymphatic spread and regional node 

metastases, and often metastasize systemically late in 

their course. Deep tumors that are firm and are 5 cm or 

larger should be considered to be possible sarcomas 

until proven otherwise. 313 CT and MRI often are used 

to define the anatomy. Standard treatment is wide 

surgical excision with or without adjunctive 

radiotherapy and/or chemotherapy. The prognosis 

generally is poor. 

Epithelioid sarcomas—Epithelioid sarcomas are the 

most common soft-tissue sarcomas of the hand. 329 A 

posttraumatic origin has been proposed by some. 330 

Lesions are notoriously insidious and often mistaken 

for a benign inflammatory condition. 331 Most lesions in 

the hand arise on the palm or volar surface of the 

digits. 332,333 Local recurrence is common, as is distant 

metastasis. Treatment recommendations are radical 

excision (often necessitating a partial amputation 313 ) and 

node dissection. 334 Adjuvant therapy can be of benefit. 

Malignant fibrous histiocytomas—Malignant 

fibrous histiocytomas are among the more common 

soft-tissue sarcomas in the adult upper extremity. 313 

Lesions can be superficial or deep, single or 

multinodular. They extend along tissue planes and 

metastasize via the lymphatics and bloodstream. 335 

Treatment primarily is surgical, with radiotherapy 

added unless there has been a generous margin. The 

value of chemotherapy has yet to be defined. 

Alveolar rhabdomyosarcomas—Alveolar 

rhabdomyosarcomas tend to involve the thenar and 

hypothenar musculature. 336,337 An alveolar 

rhabdomyosarcoma is a highly malignant, devastating 

tumor that presents as a rapidly growing, deep mass in 

the palm of a child. 313 Local recurrence is common, and 

it is invariably fatal if not adequately treated. The 

incidence of nodal spread and distant metastases is 

high. The prognosis for alveolar rhabdomyosarcoma has 

improved with multi-modality therapy but is still poor. 

Synovial sarcomas—Synovial sarcomas arise in the 

juxta-articular soft tissues (tendon, tendon sheath, and 

bursa). 338 A synovial sarcoma presents as a slowgrowing 

tumor on the volar surface of the hand, and 

delay to presentation often is measured in years. 

Synovial sarcoma has a poor prognosis and a high 

19


incidence of metastases. Treatment usually consists of 

surgery (often involving a partial amputation 313 ), 

radiotherapy, and chemotherapy. 

Fibrosarcomas—Fibrosarcomas arise within the 

deep subcutaneous space, fascial septa, or muscle and 

present as insidiously growing deep masses. 339,340 

Lymph node metastases are less common with 

fibrosarcoma, but hematogenous spread frequently 

occurs. Treatment is wide excision or amputation when 

neurovascular structures are compromised. 341 Adjuvant 

therapy can be of benefit. 

Clear cell sarcomas—Clear cell sarcomas 

(malignant melanomas of soft parts) are uncommon 

tumors. A clear cell sarcoma presents as a slowgrowing, 

deep-seated mass attached to tendons, 

aponeuroses, or fascia. 342,343 Prognosis is poor, with a 

very high rate of local recurrence and both lymphatic 

and hematogenous dissemination. Surgery with node 

dissection usually is combined with radiotherapy 

and chemotherapy. 

Kaposi sarcomas—Kaposi sarcomas are 

malignant tumors that often involve bone and can 

originate in bone. The hand and foot are the most 

common locations of occurrence and early 

detection. 344 Patients of all ages can be affected, from 

very small children to the elderly, with peaks in the 

4th and 5th decades. The male-to-female ratio is 10:1, 

and Kaposi sarcoma is strongly associated with 

acquired immunodeficiency syndrome. 345 

The first clinical signs are dark blue to violaceous 

macules on the skin that are later replaced by 

infiltrative plaques and finally by nodules measuring 

0.5 to 3 cm in diameter. Some of the lesions heal, and 

others coalesce and ulcerate. Initially, the skin lesions 

correspond to the distal end of the tumor in the bone, 

but in time, the skin manifestations appear at 

progressively more proximal levels. Radiographic 

examination reveals the affected bones to be 

decalcified in a trabecular pattern, with cortical 

thinning as the tumor expands. Cystic erosion shows 

as bites taken out of the bone. 

Treatment is by a combination of radiotherapy 

and chemotherapy. The prognosis varies according to 

the behavior of the tumor. Fulminating lesions have a 

fatal outcome within 6 to 12 months of diagnosis, 

20 

whereas slower growing tumors are compatible with 

20-year survival. 

Metastatic Tumors 

Hand metastases are very uncommon and usually are 

associated with a primary carcinoma in the lung 346–348 or 

kidney. Despite their rarity, metastatic tumors should be 

considered in the differential diagnosis of inflammatory 

processes of the hand. The distal phalanges are most 

often involved, and metastases in those locations often 

are mistaken for felons or paronychia. 349–351 

Amadio and Lombardi 352 recommend palliative 

treatment considering the median survival time of only 

5 months. Amputation of a phalanx, digit, or ray is 

recommended for most solitary phalangeal or 

metacarpal lesions when survival is expected to exceed 

a few months. 348 

SOFT-TISSUE RECONSTRUCTION 

Fingertips 

The treatment objectives of fingertip amputations are 

as follows: 

close the wound 

maximize sensory return 

preserve length 

maintain joint function 

obtain a satisfactory cosmetic appearance 353–356 

Many variables affect the reconstructive choice: 

mechanism of injury; size of defect; location and status 

of wound; associated injuries to other parts of hand; 

and age, sex, general health, and occupation of patient. 

Healing by Secondary Intention 

If the skin loss is no larger than approximately 1.5 cm 2 , 

the wound can be allowed to granulate and heal 

spontaneously. 357–359 Such treatment is especially well 

suited to children and the elderly. All devitalized tissue 

should undergo débridement, and any exposed bone 

should be trimmed to lie below the level of the soft 

tissue. The wound is covered with a semi-occlusive 360 

or alginate dressing, which can be left intact for 5 to 7 

days and can then be changed as necessary. Complete 

healing usually is achieved in 3 to 4 weeks. Mennen 

and Wiese 360 treated extensive fingertip defects by 

using this method and reported excellent functional

and cosmetic outcomes. The advantage of this 

treatment is that as the wound contracts, it pulls 

proximal innervated pulp skin over the exposed bone, 

resulting in a very small area of residual scar located 

off the pressure area of the finger. However, if the 

same technique is used to treat more dorsal fingertip 

defects with involvement of the distal nail bed, the 

subsequent wound contraction can lead to “parrot 

beaking” of the nail, which can be difficult to correct 

secondarily. 

Skin Grafts 

Skin grafts commonly are used to repair fingertip 

defects. They can be used as a temporizing measure 

with a view to subsequent flap revision, or they can 

serve as the definitive wound closure. In the former 

situation, split-thickness skin is more appropriate 

because it has a more predictable “take.” Similarly, 

large soft-tissue defects are resurfaced with split skin 

because it tends to contract more than full-thickness 

skin, thus keeping the resultant insensitive area as 

small as possible. 353 Split-thickness skin from the 

hypothenar eminence or instep of the foot has a 

papillary pattern that most closely resembles native 

fingertip skin. 361 Beasley 353 has suggested full-thickness 

donor sites from the groin to minimize the cosmetic 

deformity of the donor site. Hypothenar full-thickness 

skin grafts have an excellent texture match and do not 

hyperpigment as groin skin tends to. Their size is 

limited by the necessity to obtain primary closure of 

the donor site. 

Although some spontaneous reinnervation of fullthickness 

skin grafts has been observed, 362 any 

insensitive or hyposensitive areas that remain limit the 

application of skin grafts in the hand. 363 Braun et al. 364 

found no difference in 2-point discrimination between 

wounds covered by split-thickness grafts and those 

covered by local flaps. 

Flap Reconstruction 

Loss of fingertip pulp greater than one-third the length 

of the phalanx requires replacement of soft tissue to 

support the distal nail. Beasley 365 has offered the 

following guidelines for reconstruction in such cases: 

replacement soft tissue must have good 

ultimate sensibility and be capable of tolerating 


normal usage 

secondary disfigurement must be insignificant, 

with no functional loss at donor site 

method must be safe, practical, reliable, 

economical, and predictable in results 

Beasley further lists three indications for local flaps in 

the repair of fingertip amputations: 1) wound bed 

unsuitable for revascularization of skin graft; 2) need 

for subcutaneous tissue replacement in addition to 

skin; 3) protection of vital structure, such as nerve. 

Flaps for reconstruction of soft tissue of the 

fingertip can be from the same finger (homodigital) or 

another finger (heterodigital) or from local, regional, or 

distant sources. 366–369 An enormous number of flaps 

have been described, and countless more descriptions 

will be published in the years ahead. For a flap to be 

useful clinically, it must fulfill the guidelines listed 

above, but at the same time, it must be reliable and 

simple to create. Only select flaps are discussed in the 

sections that follow. 

Homodigital Flaps 

The most immediate source of tissue for fingertip 

replacement is the same finger. The obvious 

advantages are that it does not violate another normal 

finger or part of the body nor does it immobilize 

uninvolved joints. The tissue used must be outside the 

zone of injury. The neurovascular integrity of the 

finger should be maintained. 

The tissue directly adjacent to the wound is the 

closest source of flap tissue and forms the basis for 

many traditionally popular flaps. The Atasoy volar V-Y 

advancement 369-371 is useful for dorsal oblique to 

transverse amputations in cases in which the defect 

does not exceed 1 cm (Fig. 11). The usefulness of the 

flap is vastly improved by extending the proximal part 

of the “V” past the distal interphalangeal joint crease 

and into the middle phalangeal segment and by 

elevating the flap as a true bilateral neurovascular 

island flap on both pedicles. 372 

In 1964, Moberg 373 described a rectangular volar 

advancement flap from the base of the thumb that can 

be used in thumb tip reconstruction. The volar 

advancement flap is a true axial flap in that the 

incisions are placed dorsal to the neurovascular 

bundles so as to include them with the flap and restore 

21


Figure 11. V-Y advancement flap. A, Skin incision and 

mobilization of triangular flap. B, Advancement of flap. C, 

Closure with V-Y technique. (Reprinted with permission from 

Chao et al. 369 ) 

normal sensation to the tip. The tissue movement 

achieved in proportion to the extent of the dissection is 

disappointing, and if too large a defect is closed (>1 

cm), flexion contracture of the interphalangeal joint will 

occur. Several authors 374–376 subsequently modified the 

method of mobilization, incorporating a V-Y closure in 

the advancement to make the flap more reliable. 

Alternatively, the flap can be converted into a true 

island and the proximal defect can be skin grafted. 377 

Snow 378,379 applied the Moberg flap to the repair of 

fingertip amputations, but dorsal tip necrosis and an 

unstable pulp scar plagued the series. Macht and 

Watson 380 preserved the dorsal perforating vessels by 

using a “spreading-dissecting” technique with which 

the volar flap is not cut free except at its most distal 

22 

area. They reported no skin loss or joint stiffness 

occurring in 69 transfers and 2-point discrimination 

values within 2 mm of the contralateral normal finger. 

Lateral advancement flaps have the potential to 

offer the ideal fingertip reconstruction, replacing “like 

with like” from the same digit. Ipsilateral advancement 

flaps 369,381–386 move tissue from directly adjacent to the 

defect and maintain sensibility (Fig. 12). Bilateral 

advancement flaps can also be used, as described by 

Kutler 387 in 1944. As with all homodigital flaps, the 

potential exists for flap embarrassment if damaged 

tissues or pedicles are used. 

Figure 12. Oblique triangular flap. A, Volar oblique 

amputation. B, Design and raising of flap on digital 

neurovascular bundle. C, Closure of flap with V-Y technique. 

(Reprinted with permission from Chao et al. 369 ) 

Reversed digital artery island flaps from the 

proximal finger necessitate sacrifice of one digital 

artery and rely on retrograde flow through an intact 

anastomosis with the contralateral normal artery. 388–391 

They require neurorrhaphy of a dorsal branch to the 

contralateral digital nerve for optimal recovery of 

sensibility. 392 A preoperative digital Allen’s test is 

essential to assess the patency of both arteries. 

Venous drainage of the flaps is via the soft tissue 

around the arterial pedicle, so the pedicle should not 

be skeletonized.

The dorsal middle phalangeal finger flap 393–395 can be 

raised on a short or long antegrade or retrograde 

pedicle and can be used as a free flap, an arterial and/or 

venous flow-through flap, or a neurovascular flap. 

Heterodigital Flaps 

In 1951, Cronin first described the cross-finger flap for 

fingertip reconstruction. 396 The cross-finger flap brings 

durable cover to exposed bone, joint, or flexor tendons 

when homodigital flaps do not suffice. 396–400 Blood 

supply of the cross-finger flap is random and based on 

the subdermal plexus of an adjacent digit. The flap can 

be based laterally, proximally, or distally, depending on 

the most comfortable approximation of donor digit to 

defect. The dorsum of the middle phalanges of the 

index, middle, and ring fingers is the most appropriate 

donor site in terms of joint immobilization. Use of a 

cross-finger flap from the volar aspect of the middle 

finger, rather than from the thinner dorsal finger skin, 

provides better tissue quality for resurfacing the pulp 

of the thumb. 365,401 

Hoskins details the technical points of cross-finger 

flap elevation and transfer (Fig. 13). 91,402 The pedicle can 

be divided safely by the 8th or 9th day to lessen the 

risk of joint stiffness from joint immobilization. 

Many variations of the cross-finger flap have been 

described. The dorsal sensory branch can be included in 

the flap and sutured to the digital nerve of the injured 

fingertip, 403 although that technique has not been shown 


to improve the ultimate sensibility of the flap. The flap 

can be de-epithelialized and used to resurface dorsal 

defects of adjacent fingers, necessitating an additional 

skin graft on top of the flap. 404,405 

Advantages of the cross-finger flap technique are 

that it is easy to elevate and can carry ample quantities 

of similar tissue. Disadvantages are that it is a two-stage 

procedure, a skin graft is required for the donor site 

(which is obvious on the exposed dorsum of the finger), 

stiffness of the involved digits is a possibility, and 2point 

discrimination values average only 9 mm. 406,407 

In a study of 54 patients with cross-finger flaps, 

Nishikawa and Smith 407 found that despite recovery of 

protective sensation, no patient had recovered tactile 

gnosis. Maximal recovery of sensibility occurs in those 

younger than 20 years, and 2-point discrimination 

plateaus at 1 year. 406 Contraindications to the use of 

cross-finger flaps include arthritis, Dupuytren’s 

contracture, and generalized vasospastic syndromes. 

Littler 408 and Tubiana and Duparc 409 developed the 

technique of interdigital transfer of pedicled 

neurovascular island flaps. Pedicled neurovascular 

island flaps have found their greatest application in 

reconstruction of the ulnar thumb pulp, 410,411 with 

median nerve-innervated skin being transferred from 

the ulnar pulp of the middle finger (less desirably, the 

radial pulp of the ring finger). For the flap to reach the 

tip of the thumb, the digital nerve must be dissected 

well back into the median nerve and the proper digital 

Figure 13. Elevation and transfer of dorsal 

cross-finger flap. Full-thickness skin graft 

should be sutured to edge of defect adjacent 

to donor finger before flap is inset so that a 

“closed” system is created. (Reprinted with 

permission from Lister. 91 ) 

23


artery to the adjacent finger must be sacrificed. 

Cortical misrepresentation remains a problem, and the 

sensibility of the transferred skin has been variable in 

several series. 412,413 

Holevich 414 reported a pedicled island flap from the 

dorsum of the index finger that is based on the first 

dorsal metacarpal artery. It includes a terminal branch 

of the radial nerve and can be used to resurface a 

shortened thumb. A problem exists with cortical 

interpretation, and the skin is not pulp skin. Several 

authors 415–417 later expanded the applications of the first 

dorsal metacarpal artery flap in hand resurfacing. 

Regional Flaps 

In 1926, Gatewood 418 first proposed a thenar flap 

for resurfacing the tip of the index finger in one 

patient. Thirty years later, Flatt 419 presented his results 

with a similar “palmar flap” in a large series of 

fingertip reconstructions. 

The classic thenar flap is based proximally to 

ensure good venous return and to minimize proximal 

interphalangeal joint flexion. Contracture can be 

further controlled by placing the thumb in full palmar 

abduction and bringing the metacarpophalangeal joint 

of the involved digit into full flexion. 353,420 If designed 

properly, the donor site usually can be closed 

primarily. 420,421 Unlike the true palmar flap, the thenar 

flap is not likely to produce joint stiffness 

postoperatively, provided the pedicle is divided in 

approximately 10 days. 

Small Defects of the Hand or Digits 

Homodigital Flaps 

Lai et al. 422 described the adipofascial turn-over flap 

with which dorsal defects of the finger and hand can 

be resurfaced by a flap of subcutaneous tissue hinged 

on a pedicle that borders the defect. This flap is 

especially useful in cases of abrasion injuries of the 

distal interphalangeal joint with exposed terminal 

extensor tendon. The donor site is closed primarily, 

and the flap is grafted (Fig. 14). 423 

Heterodigital Flaps 

Small defects of the hand can be resurfaced using socalled 

venous flaps. Venous flaps consist of skin islands 

raised on a single-vein pedicle from the dorsum of the 

24 

Figure 14. Surgical technique. A, Complex defect exposing 

dorsal aspect of distal interphalangeal joint. B, Design of 

adipofascial flap. Base of flap is adjacent to defect. C, 

Development of distally based adipofascial flap. D, Flap is 

turned over on itself to cover defect. E, Primary closure of 

donor site. Flap is covered with split-thickness skin graft. 

(Reprinted with permission from Al-Qattan. 423 ) 

hand over the proximal phalanx and are used to 

reconstruct either the dorsal or volar surfaces of 

adjacent digits. 424–427 

Earley 428 detailed the anatomy of the second dorsal 

metacarpal artery and reported various uses for this 

neurovascular island flap hand reconstruction. He and 

others 428–431 broadened the applications of the second 

dorsal metacarpal artery flap. 


Maruyama 432 and Quaba and Davison 433 elevated skin 

islands from the dorsum of the hand, based distally 

over the metacarpal head (Fig. 15). These reverse 

dorsal metacarpal artery flaps are sustained by

Figure 15. Design of reverse dorsal metacarpal flap and 

cross-section at distal flap (Reprinted with permission from 

Maruyama. 432 ) 

interconnections between terminal branches of the 

dorsal metacarpal arteries and the deep digital and 

palmar arterial systems. 434–436 Maruyama raised flaps on 

all five dorsal metacarpal arteries and reported a 

largely successful experience in eight cases. 

Figure 16. Arterial basis of distally based dorsal hand flap is 

direct branch from dorsal metacarpal artery that enters skin 

0.5 to 1 cm proximal to adjacent metacarpophalangeal joint. 

(Reprinted with permission from Quaba and Davison. 433 ) 


In contrast, several authors 433,437 reported that the 

flaps are nourished by a direct cutaneous branch of the 

dorsal metacarpal artery that enters the skin 0.5 to 1 

cm proximal to the adjacent metacarpophalangeal joint 

(Fig. 16). The authors raised reverse dorsal metacarpal 

artery flaps on the second, third, and fourth 

intermetacarpal spaces in 21 patients and reported one 

partial loss and one failure. 433 Donor sites up to 2 cm 

wide can be closed primarily. 

Large Defects of the Hands or Digits 


The regional flaps applicable for resurfacing the hand 

are based on the three major arteries of the forearm: 

the radial, ulnar, and posterior interosseous arteries. 438 

Yang et al. 439 described the territory of the radial 

forearm flap in 1981. The skin on the flexor surface of 

the forearm is relatively hairless, thin, and pliable, 

which makes it ideal for resurfacing the dorsum of the 

hand. The radial forearm unit can be raised as a 

composite of fascia-skin, 440–442 fascia, 443,444 bone-musclefascia-skin, 

445–447 or fascia-tendon-skin. 448–450 

In 1984, Lin et al. 451 noted ample retrograde flow 

into the radial artery from the ulnar artery via the deep 

palmar arch and proposed a “reverse” forearm flap. 

The flap is nourished by this retrograde circulation and 

can be elevated on its long pedicle for reconstruction 

anywhere in the hand. The authors described a crossover 

pattern of communicating branches between the paired 

venae comitantes and identified small superficial 

collateral branches of each vein, which effectively bypass 

the valves. This system enables the flap to be drained 

despite competent valves. Even in cases of significant 

hand trauma in which the palmar arches are in question, 

the flap has been successfully raised, based on 

communications proximal to the wrist. 452,453 

The radial forearm flap has two main 

disadvantages. Foremost is that a major vessel to the 

hand is sacrificed, but Kleinman and O’Connell 454 

found the only significant objective difference between 

patients who had undergone flap transfer and controls 

to be an 18% delay in reconstitution of normothermia 

after cold stress testing. Reconstruction of the vessel 

rarely is necessary. 455,456 Weinzweig et al. 457 described a 

technique for elevating a distally based 

fasciocutaneous flap with preservation of the radial 

25


artery, and Braun et al. 458 similarly elevated a 

retrograde radial fascial turn-down flap based on 

distal perforators of the radial artery, leaving the main 

radial artery intact. 

The unesthetic and potentially unstable grafted 

donor site of the radial forearm flap remains the 

major detractor of this otherwise excellent flap. 459 Skin 

graft take usually is not a problem with flaps used for 

hand reconstruction, because the flap is based 

proximally over the muscle bellies. If the flap needs 

to be raised in the distal forearm over the flexor 

tendons, graft take can be improved by a suprafascial 

dissection of the flap. 460 Many methods have been 

proposed to improve the donor site, including direct 

closure, full-thickness skin grafts, local flaps, and 

tissue expansion. 461–466 Split thickness skin grafting 

remains the standard at most centers. 

In 1984, Lovie et al. 467 described the ulnar artery 

island flap and 4 years later reported their experience 

with this method for hand and forearm 

reconstruction. 468 The skin territory of the flap overlies 

the proximal ulnar aspect of the forearm, which is 

almost always hairless and less visible than the radial 

border. The authors and others 469–472 found the ulnar 

flap to be superior in terms of esthetics, easier 

harvesting of bone and muscle (flexor carpi ulnaris), 

direct closure of donor site, and lower morbidity. 

The posterior interosseous artery flap is based on 

the communication between the anterior and posterior 

interosseous arteries. 473–478 The posterior interosseous 

artery runs in a fascial septum between the extensor 

carpi ulnaris and extensor digiti minimi muscles (Fig. 

17). 479 A segment of ulna can be taken as a composite 

flap. 480 The advantages of this flap are good pedicle 

length and primary closure of the donor site. Its 

disadvantages are a relatively hairy donor site, an 

obvious scar on the visible dorsum of the forearm, 

limited size of the flap, and unreliability of the 

vascular communication. 481–484 

Distant Flaps 

Large flaps of skin can be transferred to the hand from 

distant sites by means of traditional pedicled 

techniques or microvascular free tissue transfer. 

Pedicled flaps—Flaps of skin from remote sites 

over the chest and abdomen traditionally were used 

26 

Figure 17. Cross-section of distally based posterior 

interosseous island flap taken at middle one-third of forearm. 

Posterior interosseous artery reaches overlying skin in space 

between extensor carpi ulnaris and extensor digiti minimi 

proprius. (Reprinted with permission from Landi et al. 479 ) 

for resurfacing large wounds of the upper extremity. 

The most commonly used pedicled flap is the groin 

flap based on the superficial circumflex iliac artery 485–488 

or the superficial inferior epigastric artery. 489 Groin 

flaps are axial-pattern flaps with reliable vascularity. 

However, they necessitate two surgical stages and the 

hand remains dependent during the initial period of 

flap attachment, encouraging edema and stiffness. In 

addition, groin flaps are too bulky for dorsal hand 

resurfacing and require subsequent revision surgery. 

Chow et al. 490 presented their experience with 36 

groin flaps used in delayed primary or elective 

secondary hand resurfacing. Arner and Möller 491 

highlighted potential complications. 

Microvascular Free Tissue Transfer—Microvascular 

free tissue transfer allows a single-stage composite 

reconstruction of complex hand defects, 492–500 obviating 

the need for cumbersome, two-stage pedicled 

procedures and their inherent shortcomings. Free flaps 

can also be used to provide vascular conduits and soft 

tissue coverage. 501,502 Free flaps are the definitive form 

of soft-tissue cover in emergency situations. 503–508 

Successful reconstruction of soft tissue of the upper 

extremity with free flaps must be approached with the 

goals of providing stable coverage and, more 

importantly, restoring function. The hand does not 

tolerate prolonged immobilization. Radical débridement 

and restoration of all tissue components at the time of 

coverage encourages early mobilization. 509

Critical sensibility of the fingertip can be restored by 

free neurosensory flaps 510–516 or microvascular toe-pulp 

transfer. 517–519 Toe-to-hand transfers in cases of thumb 

reconstruction are discussed in the “Microsurgery: Free 

Tissue Transfer and Replantation” issue of Selected 

Readings in Plastic Surgery. Protective sensibility of the 

palm and dorsum of the hand usually is achieved by 

thin muscle, fascial, or fasciocutaneous flaps. 520 

The first web space flap of the foot is the “gold 

standard” of neurosensory flaps. 513 It consists of the 

lateral aspect of the great toe and the medial aspect of 

the second toe. The flap is supplied by the first dorsal 

metatarsal artery, a branch of the dorsalis pedis artery, 

or the first plantar metatarsal artery. Its innervation is 

through both the deep peroneal nerve and the medial 

plantar nerve (Fig. 18). 511 Lee and May 516 found that the 

first dorsal metatarsal artery arose from the dorsalis 

pedis artery dorsal to the mid-metatarsal axis in 78% 

of 50 cadaver dissections. The authors usually obtain 

preoperative angiography to determine the vascular 

anatomy. The main advantage of the first web space 

flap for sensory reconstruction in the hand is 

replacement with similar thin glabrous skin with 

concentrated sensory receptors, allowing the best 2point 

discrimination of any neurosensory flap. 

The thin, malleable skin over the dorsum of the 

foot can also be transferred as an innervated free 

flap, 521–523 including the underlying extensor tendons 524–527 

and second metatarsal for composite reconstruction, if 

required. The dorsalis pedis flap is raised on the 

dorsalis pedis artery, and venous drainage is via the 

venae comitantes and saphenous vein. Its neural input 

is from the superficial peroneal nerve. The donor site is 

unforgiving, so meticulous attention must be paid to 

flap dissection and wound care. 

The free radial forearm flap and free ulnar forearm 

flap can be used just as readily as the already 

discussed pedicled flaps. They have neurosensory 

potential via the lateral and medial cutaneous nerves 

of the forearm, respectively. 

The lateral arm flap is supplied by the posterior 

radial collateral artery and innervated by the posterior 

cutaneous nerve of the arm. 528–530 It can be raised as a 

fasciocutaneous flap or as combinations of fascia, 531 

muscle, tendon, 532,533 and bone. 534 Donor defects up to 6 

cm wide usually can be closed primarily. Designs for 


Figure 18. Innervation of the foot first web space and great 

toe. (Reprinted with permission from May et al. 511 ) 

extending the flap have been described, 535,536 as have 

techniques for extending the length of the vascular 

pedicle. 537 The flap has the advantage of confining flap 

harvest to the same extremity as the defect. However, 

this popular flap comes with a price. Graham et al. 538 

reviewed 123 lateral arm flaps and found that a 

significant number of patients complained of 

unsatisfactory appearance and hypersensitivity of the 

donor site, elbow pain, numbness in the forearm, and 

excessive flap bulk. 

For large defects of the upper extremity, where 

sensibility is not as important, the scapular and 

parascapular flaps have found popularity. The 

parascapular flap 539–541 allows a larger skin paddle to be 

harvested with primary closure of the secondary 

defect, and the resulting scar is less conspicuous than 

that of the horizontal scapular flap defect. The scapular 

flap can be raised as a fascial flap 542 or as an 

osteofascial flap. 543 Both flaps have the disadvantage of 

being bulky, even in thin individuals, and secondary 

defatting or liposuction is necessary for an optimal 

aesthetic contour. 

27


The free groin flap constitutes an unsurpassed 

donor site and allows the transfer of a large quantity of 

hairless skin. Like the pedicled groin flap, it is too 

bulky for resurfacing the hand and requires revision 

defatting and/or liposuction. 

Recent interest in perforator flaps has led to the 

growing popularity of the anterolateral thigh flap 544,545 

and the tensor fasciae latae perforator flap 546,547 in 

dorsal hand reconstruction. Large flaps of very thin 

skin can be raised with minimal donor site 

morbidity. Because the flaps are based on perforating 

vessels, the motor function of the underlying tensor 

fascia latae is preserved. 

The anatomy of the temporal region has been 

elucidated by several authors. 548–550 Upton et al. 551 

discussed the various applications of free 

temporoparietal fascial flaps in dorsal hand 

resurfacing. Temporoparietal fascia most commonly is 

used in the upper extremity to wrap exposed or 

contracted tendons. 551–556 The deep areolar surface of the 

flap is turned toward the tendons to provide a smooth 

gliding surface. The overlying fascia is thin and pliable 

for metacarpal contouring. A skin graft completes the 

reconstruction. This fascial flap is also excellent for 

filling the three-dimensional defect resulting from the 

extensive release of complex first web space 

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RECOMMENDED READING 

Al-Qattan MM. The adipofascial turnover flap for coverage 

of the exposed distal interphalangeal joint of the 

fingers and the interphalangeal joint of the thumb. J 

Hand Surg [Am] 2001;26:1116-1119. 

Brown DM, Young VL. Hand infections. South Med J 

1993;86:56-66. 

Cavanagh S, Pho RW. The reverse radial forearm flap 

in the severely injured hand: An anatomical and clinical 

study. J Hand Surg [Br] 1992;17:501-503. 

Chuang DC, Colony LH, Chen HC, Wei FC. Groin flap 

design and versatility. Plast Reconstr Surg 1989;84:100- 

107. 

Glasson DW, Lovie MJ. The ulnar island flap in hand 

and forearm reconstruction. Br J Plast Surg 1988;41:349- 

353. 

Hoffman RD, Adams BD. The role of antibiotics in the 

management of elective and post-traumatic hand surgery. 

Hand Clin 1998;14:657-666. 

Lee WP, May JW Jr. Neurosensory free flaps to the 

hand: Indications and donor selection. Hand Clin 

1992;8:465-477. 

Mankin HJ. Principles of diagnosis and management 

of tumors of the hand. Hand Clin 1987;3:185-195. 

Ninkovic M, Deetjen H, Ohler K, Anderl H. 

Emergency free tissue transfer for severe upper 

extremity injuries. J Hand Surg [Br] 1995;208:53-58. 

Ninkovic MM, Schwabegger AH, Wechselberger G, 

Anderl H. Reconstruction of large palmar defects of 

the hand using free flaps. J Hand Surg [Br] 1997;22:623- 

630. 

Quaba AA, Davison PM. The distally-based dorsal 

hand flap. Br J Plast Surg 1990;43:28-39. 


Quinn MJ, Thompson JE, Crotty K, McCarthy WH, 

Coates AS. Subungual melanoma in the hand. J Hand 

Surg [Am] 1996;21:506-511. 

Small JO, Brennen MD. The first dorsal metacarpal 

artery neurovascular island flap. J Hand Surg [Br] 

1988;138:136-145. 

Zancolli EA, Angrigiani C. Posterior interosseous 

island forearm flap. J Hand Surg [Br] 1988;13:130-135. 

Zook EG. Anatomy and physiology of the perionychium. 

Hand Clin 1990;6:1-7. 

49


50

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