- Email: [email protected]
Longitudinal incision for trigger finger release
The Journal of HAND SURGERY
Botte, Cooney, and Linscheid
capitateandscaphocapitate andlunocapitate articulation will come into view. Sweeping radially along the scaphocapitate joint, the STT joint will become visible. Sweeping ulnarly, the scapholunate, lunocapitate, lunotriquetral, and capitohamate intervals can be examined. At the completion of the examinations, the tourniquet is deflated and hemostasis is secured. The portal incisions are closed with skin sutures. A bulky hand dressing and supportive splint is applied. Helpful hints 1. Multiple portals can be used to provide better visualization of different parts of the wrist. Portal 5, located radial to the extensor carpi ulnaris, allows additional visualization of the triangular fibrocartilage or palmar ulnocarpal ligaments. Portal 2, located between the second and third dorsal compartments, provides excellent additional visualization of the radial palmar ligaments. A probe through portal 1 can be helpful in evaluating the articular surface of the distal radius. 2. Use of a 20-gauge or 22-gauge needle (Fig. 2, B) directed into the various portals before either probe or arthroscopic shaver insertion provides helpful direction and selection of the best portal for both diagnostic and therapeutic procedures. 3. A blunt trocar introduced into the joint instead of a sharp trocar protects joint surfaces during initial or repeat scope insertion and is preferred.
4. Thelargerscopes provide a greaterfieldofvision. However, these larger scopes are difficult to manipulate and it is best to use a 30 degree or 70 degree offset angled scope that can be rotated within the joint. 5. If continuous inflow irrigation is used, an adequate outflow system must be provided to prevent fluid extravasation into the forearm. A compartment syndrome is a potential complication of wrist arthroscopy. 6. A continuous fluid infusion technique with gravity drainage plus keeping the scope inclined upward (tip downward) will help prevent troublesome air bubbles, which obscure visualization. 7. Triangulation with a probe allows actual tactile examination of ligaments and cartilage surfaces. 8. Patience and practice with this procedure will lead to a better understanding of the indications and potentials of this relatively new method of carpal examination and treatment. REFERENCES Bora FW. Wrist arthroscopy. J HAND SURG1985;3OA:308. Chen YC. Arthroscopy of the wrist joint. In: Masaki, Watanabe, eds. Arthroscopy of small joints. New York: Igaku-shoin Medical Pub, 1985:85-90. Roth JH, Haddad RG. Radiocarpal arthroscopy and arthrography in the diagnosis of ulnar wrist pain. Arthroscopy 1986;2:234-43. Whipple TL, Marotta JJ, Powell JH. Techniques of wrist arthroscopy. Arthroscopy 1986;2:244-52.
Longitudinal incision for trigger finger release Raymond J. Stefanich,
MD, and Clayton A. Peimer, MD, Bz@zlo, N.Y.
From the Hand Surgery Service of the Department of Grthopaedic Surgery, affiliated hospitals of the University at Buffalo, State University of New York, Buffalo, N.Y. Received for publication May 23, 1988.
April 18, 1988; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subjects of this article. Reprint requests: Clayton A. Peimer, MD, Hand Center of Western New York, Millard Fillmore Hospital, 3 Gates Circle, Buffalo, NY 14209.
The classic operative approach to release a trigger finger is through a transverse skin incision at the Al pulley parallel to the distal palmar crease.14 Division of the Al pulley is then accomplished longitudinally once the neurovascular bundles are retracted. The operation can sometimes be a real struggle, since the principle of using an extensile exposure’ is not followed when using a transverse incision to operate on a longitudinally running structure. Since 1978 we have uniformly used a longitudinal
Vol. 14A, No. 2, Part 1 March 1989
Longitudinal incision for trigger finger release
317
Fig. 1. A-B, Proposed longitudinal incision for release of ring trigger digit is marked in line with the underlying metacarpal. C, The probe lies underneath the proximal portion of the first annular pulley. D, Postoperative scar in another patient 6 months after index and long releases.
skin incision to release trigger fingers. Although this approach is not new,4-8 it is rarely described and is
usually unrecognized; we find it most useful and worth reemphasizing. The palmar skin always has several longitudinal creases. We place our 1.5 cm incision in a crease over the Al pulley, but terminating proximal to the proximal digital crease (Fig. 1). Retractors hold back the skin edges; subcutaneous fat is sharply dissected with scalpel to expose the pulley. The advantages of this technique include less dissection to reach the Al pulley, complete and easy visualization of the pulley, and sure visual identification of the demarcation between Al and A2 pulleys. The approach through subcutaneous fat is made with impunity, since digital nerves and vessels lie well to either side of the actual dissection. After operation, the scar becomes nearly invisible with maturation. This longitudinal approach has never resulted in a contracture in any of more than 500 cases. It will not, as long as the palmar and digital creases are avoided.
REFERENCES Bunnell S. Surgery of the hand. Philadelphia:JB Lippincott 1944:498-9. Boyes JH. Bunnell’s surgery of the hand. 4th ed. Philadelphia: JB Lippincott, 1964:473-4. Froimson AI. Tenosynovitis and tennis elbow. In: Green DP, ed. Operative hand surgery. 2nd ed. New York: Churchill Livingstone, 1988:2123. 4. Conklin JE, White WL. Stenosing tenosynovitis and its possible relation to the carpal tunnel syndrome. Surg Clin 1960;40:531-40. Henry AK. Extensile exposure. 2nd ed. Edinburg: Churchill Livingstone, 1973. Lapidus PW. Stenosing tenovaginitis. Surg Clin North Am 1953;33:1317-47. Bruner JM. Optimum skin incisions for the surgical relief of stenosing tenosynovitis in the hand, Plast Reconstr Surg 1966;38:197-201. 8. Kilgore ES Jr, Graham WP III, eds. The hand. Surgical and non-surgical management. Philadelphia: Lea & Febiger, 1977:65.
Botte, Cooney, and Linscheid
capitateandscaphocapitate andlunocapitate articulation will come into view. Sweeping radially along the scaphocapitate joint, the STT joint will become visible. Sweeping ulnarly, the scapholunate, lunocapitate, lunotriquetral, and capitohamate intervals can be examined. At the completion of the examinations, the tourniquet is deflated and hemostasis is secured. The portal incisions are closed with skin sutures. A bulky hand dressing and supportive splint is applied. Helpful hints 1. Multiple portals can be used to provide better visualization of different parts of the wrist. Portal 5, located radial to the extensor carpi ulnaris, allows additional visualization of the triangular fibrocartilage or palmar ulnocarpal ligaments. Portal 2, located between the second and third dorsal compartments, provides excellent additional visualization of the radial palmar ligaments. A probe through portal 1 can be helpful in evaluating the articular surface of the distal radius. 2. Use of a 20-gauge or 22-gauge needle (Fig. 2, B) directed into the various portals before either probe or arthroscopic shaver insertion provides helpful direction and selection of the best portal for both diagnostic and therapeutic procedures. 3. A blunt trocar introduced into the joint instead of a sharp trocar protects joint surfaces during initial or repeat scope insertion and is preferred.
4. Thelargerscopes provide a greaterfieldofvision. However, these larger scopes are difficult to manipulate and it is best to use a 30 degree or 70 degree offset angled scope that can be rotated within the joint. 5. If continuous inflow irrigation is used, an adequate outflow system must be provided to prevent fluid extravasation into the forearm. A compartment syndrome is a potential complication of wrist arthroscopy. 6. A continuous fluid infusion technique with gravity drainage plus keeping the scope inclined upward (tip downward) will help prevent troublesome air bubbles, which obscure visualization. 7. Triangulation with a probe allows actual tactile examination of ligaments and cartilage surfaces. 8. Patience and practice with this procedure will lead to a better understanding of the indications and potentials of this relatively new method of carpal examination and treatment. REFERENCES Bora FW. Wrist arthroscopy. J HAND SURG1985;3OA:308. Chen YC. Arthroscopy of the wrist joint. In: Masaki, Watanabe, eds. Arthroscopy of small joints. New York: Igaku-shoin Medical Pub, 1985:85-90. Roth JH, Haddad RG. Radiocarpal arthroscopy and arthrography in the diagnosis of ulnar wrist pain. Arthroscopy 1986;2:234-43. Whipple TL, Marotta JJ, Powell JH. Techniques of wrist arthroscopy. Arthroscopy 1986;2:244-52.
Longitudinal incision for trigger finger release Raymond J. Stefanich,
MD, and Clayton A. Peimer, MD, Bz@zlo, N.Y.
From the Hand Surgery Service of the Department of Grthopaedic Surgery, affiliated hospitals of the University at Buffalo, State University of New York, Buffalo, N.Y. Received for publication May 23, 1988.
April 18, 1988; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subjects of this article. Reprint requests: Clayton A. Peimer, MD, Hand Center of Western New York, Millard Fillmore Hospital, 3 Gates Circle, Buffalo, NY 14209.
The classic operative approach to release a trigger finger is through a transverse skin incision at the Al pulley parallel to the distal palmar crease.14 Division of the Al pulley is then accomplished longitudinally once the neurovascular bundles are retracted. The operation can sometimes be a real struggle, since the principle of using an extensile exposure’ is not followed when using a transverse incision to operate on a longitudinally running structure. Since 1978 we have uniformly used a longitudinal
Vol. 14A, No. 2, Part 1 March 1989
Longitudinal incision for trigger finger release
317
Fig. 1. A-B, Proposed longitudinal incision for release of ring trigger digit is marked in line with the underlying metacarpal. C, The probe lies underneath the proximal portion of the first annular pulley. D, Postoperative scar in another patient 6 months after index and long releases.
skin incision to release trigger fingers. Although this approach is not new,4-8 it is rarely described and is
usually unrecognized; we find it most useful and worth reemphasizing. The palmar skin always has several longitudinal creases. We place our 1.5 cm incision in a crease over the Al pulley, but terminating proximal to the proximal digital crease (Fig. 1). Retractors hold back the skin edges; subcutaneous fat is sharply dissected with scalpel to expose the pulley. The advantages of this technique include less dissection to reach the Al pulley, complete and easy visualization of the pulley, and sure visual identification of the demarcation between Al and A2 pulleys. The approach through subcutaneous fat is made with impunity, since digital nerves and vessels lie well to either side of the actual dissection. After operation, the scar becomes nearly invisible with maturation. This longitudinal approach has never resulted in a contracture in any of more than 500 cases. It will not, as long as the palmar and digital creases are avoided.
REFERENCES Bunnell S. Surgery of the hand. Philadelphia:JB Lippincott 1944:498-9. Boyes JH. Bunnell’s surgery of the hand. 4th ed. Philadelphia: JB Lippincott, 1964:473-4. Froimson AI. Tenosynovitis and tennis elbow. In: Green DP, ed. Operative hand surgery. 2nd ed. New York: Churchill Livingstone, 1988:2123. 4. Conklin JE, White WL. Stenosing tenosynovitis and its possible relation to the carpal tunnel syndrome. Surg Clin 1960;40:531-40. Henry AK. Extensile exposure. 2nd ed. Edinburg: Churchill Livingstone, 1973. Lapidus PW. Stenosing tenovaginitis. Surg Clin North Am 1953;33:1317-47. Bruner JM. Optimum skin incisions for the surgical relief of stenosing tenosynovitis in the hand, Plast Reconstr Surg 1966;38:197-201. 8. Kilgore ES Jr, Graham WP III, eds. The hand. Surgical and non-surgical management. Philadelphia: Lea & Febiger, 1977:65.