2017-Surgical Exposures in Ortho

Figure 5-90 Identify the fibrous flexor sheath covering the flexor pollicis longus
tendon and incise it longitudinally just proximal to the tendon’s insertion into the
distal phalanx. Incise the synovium in the sheath to drain the pus and then pass a
probe proximally along the flexor sheath. Make a small longitudinal incision over
the probe at the level of the wrist to ensure complete drainage.
Drainage of the Ulnar Bursa

The synovial sheath surrounding the flexor tendons to the little finger
extends from the insertion of the profundus tendon on the distal phalanx of
the little finger to the volar aspect of the wrist, just proximal to the
proximal end of the flexor retinaculum. The flexor tendons to the index,
middle, and ring fingers also are invested by this layer of synovium as they
pass through the carpal tunnel. The distal extension of the synovial
compartment ends at the origin of the lumbrical muscle from the tendons
to the ring, middle, and index fingers. It is known as the ulnar bursa (see
Fig. 5-88).
Infection of the synovial sheath of the little finger may lead to infection
of the ulnar bursa. The physical signs include a tenosynovitis affecting the
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little finger, with active or passive extension producing extreme pain. In
addition, pain may be referred to the palm when the other fingers are
extended.
Position of the Patient
Place the patient supine on the operating table, with the arm extended on
an arm board. Use a nonexsanguinating tourniquet and either a general
anesthetic or a proximal local block (an axillary or brachial block).
Landmark and Incision
Landmark
The distal interphalangeal crease of the little finger is the surface marking
for the distal interphalangeal joint. It lies just proximal to the distal end of
the fibrous sheath of the little finger.
Incision
Make a short midline incision on the ulnar side of the little finger over the
distal end of the middle phalanx (Fig. 5-91, inset). The incision should be
just dorsal to the line connecting the dorsal termination of the proximal
and distal interphalangeal creases. Make a second longitudinal incision on
the lateral aspect of the hypothenar eminence at the level of the wrist.
Internervous Plane
There is no internervous plane. The finger skin incision lies between skin
that is supplied by the dorsal digital nerves and skin that is supplied by the
volar digital nerves.
Superficial Surgical Dissection
Deepen the approach in line with the incision, staying to the dorsal side of
the neurovascular bundle. Identify the fibrous flexor sheath and incise it
longitudinally. Next, incise the synovium to allow drainage of the pus.
Pass a probe gently along the tendon until it can be felt on the volar aspect
of the wrist, just proximal to the proximal end of the flexor retinaculum.
Carefully incise the skin longitudinally over the probe and dissect
down to it layer by layer. The probe should be just proximal to the
proximal end of the flexor retinaculum. It may be in the carpal tunnel,
however, in which case, the flexor retinaculum will have to be incised
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meticulously, taking care to avoid damage to the underlying median nerve.
If the probe is lying in the forearm, then take great care not to damage the
ulnar nerve and artery, which are very close to the flexor digitorum
superficialis tendon to the little finger (see Fig. 5-91).
As is true in the case of other tendon sheath infections, a small catheter
may be inserted in the distal wound to allow continuous or intermittent
irrigation of the tendon sheath.
Dangers
The digital nerve to the ulnar side of the little finger is in danger if the
skin incision on the finger is made too far in a volar direction. The distal
vessels run with the nerves.
How to Enlarge the Approach
The approach cannot be enlarged effectively by either local or extensile

measures.
Figure 5-91 Drainage of the ulnar bursa. Make a short midline incision on the
ulnar side of the little finger over the distal end of the middle phalanx. Make a
second longitudinal incision over the lateral aspect of the hypothenar eminence at
the level of the wrist. Pass a probe from the distal aspect to the proximal aspect,
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and cut down onto the probe at its proximal end, a point that marks the proximal
end of the ulnar bursa.
Anatomy of the Hand

Two characteristics of the normal hand reveal what happens when it is
damaged:
1. The hand has a natural resting position. At rest, both the
metacarpophalangeal and the interphalangeal joints normally hold a
position of slight flexion. The fingers all adopt a slightly different
degree of rotation, such that the volar surfaces of the terminal phalanges
face progressively more toward the thumb as one moves from the index
finger to the little finger. It is critical to appreciate the different degrees
of rotation in the finger when assessing displacement in phalangeal or
metacarpal fractures. The degree of flexion increases as one passes from
the index finger to the little finger. This configuration is a result of
muscle balance; if one element is deficient or absent, the resting position
of the hand changes. In cases of acute trauma, a cut flexor tendon may
leave a finger extended. An abnormal resting position often is indicative
of tendon damage.
2. The concept of muscle balance also can be applied to chronic
conditions of the hand. In patients with long-standing ulnar nerve
lesions, in which the intrinsic muscles of the hand are paralyzed, the
hand develops an abnormal attitude because of muscle imbalance. The
intrinsic muscles normally flex the fingers at the metacarpophalangeal
joints and extend them at the proximal and distal interphalangeal joints.
The absence of intrinsic function leads to extension of the
metacarpophalangeal joints and flexion of the proximal and distal
interphalangeal joints of the affected fingers, resulting in an ulnar claw
hand.
Palm
Skin
The skin of the palm and the palmar aspect of the fingers is a tough
structure, characterized by flexure creases in the palm and fingerprints in
the fingers. The skin has very little laxity because of the series of tough
fibrous bands that tie it to the palmar aponeurosis. These bands divide the
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Figure 5-90 Identify the fibrous flexor sheath covering the flexor pollicis longus

Drainage of the Ulnar Bursa

Position of the Patient

Landmark and Incision

Superficial Surgical Dissection

How to Enlarge the Approach

The approach cannot be enlarged effectively by either local or extensile

Anatomy of the Hand

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