Skin incisions in hand surgery


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Skin incisions in hand surgery

  1. 1. Skin Incisions in Hand Surgery Dr. Bhaskaranand Kumar Professor and Head Division of Hand and Microsurgery Department of Orthopaedics, KMC Manipal, Manipal University
  2. 2. Sterling Bunnel – Father of Hand surgery• The primary purpose of surgical reconstruction - restore enough function to allow the patient to be self- sufficient• Surgical reconstruction of the hand requires careful technique to minimize the formation of adhesions and scars
  3. 3. Correct Incisions• A correct incision provides – a large area to easily permit dissection – Repair of lesions – Heal Rapidly – Without scars limiting mobility – Preserve sensation Dupuytren’s contracture release – Avoid painful scars – post op healing
  4. 4. Incorrectincisions• They are responsible for – An Insufficient access – Necrosis – Contractures – Anaesthetic areas – Painful scars
  5. 5. Pre – operative Planning• In no place is sound knowledge of surface and deep anatomy more relevant than in the surgical approaches of the Hand• Design of every incision must take into account the structure and mobility of area it crosses
  6. 6. Pre – operative Planning• Arrangements made before surgery – Instruments, – Sutures, – Implants – Microscope, loupes – Imaging, – Power instruments
  7. 7. Pre – operative Planning• Positioning • Tourniquet – Supine – Pneumatic – Lateral – Exsanguination – Dorsal• Hand table • Cautery• Stool – Bipolar
  8. 8. Immobility of theIncision area• Incisions are made in areas of relative immobility – Lateral midline – Along diagonals traversing volar surface – Remain within the limits of functional cutaneous units
  9. 9. Potentially damaging incisionsLongitudinal incisions crossing Incisions close and parallel to flexion creases vertically in the the web palmar area
  10. 10. Potentially damaging incisionsLongitudinal anterolateral incisions Incisions crossing thenar creasedamages the Neurovascular vertically in the hollow of thebundles palm
  11. 11. Potentially damaging incisionsIncisions on the palmar pulp Circumferential / spiral incisions
  12. 12. Potentially damaging incisionsFishmouth opening of pulp Incisions directly on theleaves a painful scar creases leads to maceration, delayed healing ,
  13. 13. Deeper structures awareness about the level of joints• 3rd, 4th and 5th MP joints - at distal palmar crease• 2nd MP joint - at Proximal Palmar crease
  14. 14. Deeper structures level of tendons• Incisions to expose tendons – Not directly over it – Nor along its longitudinal axis – Skin flaps adequately planned – Tendons must glide freely later
  15. 15. Vascular Supply• Centre of the palm – Poorly vascularised• Extensive undermining is to be avoided• This becomes important in Dupuytren’s contracture release•
  16. 16. Vascular Supply – dorsum• Dorsal skin is – thinner – Poorer blood supply• Main venous and lymphatic drainage of hand• Avoid acute angled flaps
  17. 17. VascularSupplyDorsum• Transverse incisions going through all the subcutaneous tissue should be avoided• If necessary only the transverse communicating veins should be ligated
  18. 18. Previous wounds and scars• Incisions should be modified if a wound already exists• Surgical extension of wounds always a difficult problem• Draw in ink on the proposed extension
  19. 19. Previous wounds and scars Common Mistakes • Incisions should never branch off from the middle of wound • Produces ischaemic skin flaps • Converts linear scars to stellate scars which are more disabling
  20. 20. Woundenlargedonly at itsextremitiesin a “Bayonetlike” fashion
  21. 21. Correct option
  22. 22. Correct optiond Convert a linear longitudinal scar to a zig-zag scar
  23. 23. Where should weplace our incision ?
  24. 24. Poor options • Produces stellate scars• In the line of Excursion of tendons • Ischaemic skin flaps
  25. 25. Better options • Incisionplaced well awayfrom line of excursion • Viable skin flaps
  26. 26. Incisions in common use • Fingers –Palmar –Dorsal • Palm / dorsum • Web space • Thumb • Proximal palm / wrist
  27. 27. Palmar approaches• Midlateral • Mid-axial • Zig – zag incisions incisions Incision –A –B —C
  28. 28. Mid-axial incisions• Incision determined by – Connect apex of flexor crease – Note point of change between dorsal and palmar surface
  29. 29. Mid-axial incisions• Dorsal to Cleland’s ligaments• No change in the length of incision line with flexion/extension• No skin tethering• Outside the region of Littler’s diamond
  30. 30. Mid-axial incisions• Pitfall – division of Dorsal branch of digital nerve
  31. 31. Mid-lateralincisions• Logitudinal line at mid portion of the palmar and dorsal surface• Dorsal to Cleland’s ligaments
  32. 32. Mid-lateral incisions• Dorsal branch of digital nerve preserved• Risk of scar > as line runs through Littler’s Diamond
  33. 33. Littler’s Diamonds• 3 diamond shaped areas formed as shown• Length of boundary lines does not change with flexion
  34. 34. Littler’s Diamonds• Incisions permitted – Transverse within diamond – Longitudinal in between the diamond and midaxial lines
  35. 35. Zigzag incisions1. Bruner’s2. Littler’s3. Diagonal lateral mixed4. Mixed diagonal5. Diagonal for thumb
  36. 36. Comparision between palmar incisions Anatomical parameters Mid- Midaxial Zigzag lateral Location of NVB and Cleland’s Palmar Dorsal Palmar ligaments Dividing Cleland’s Ligaments No Yes No Potential for contractures + - -Convenience in access to palmar aspect + ++ +++ Neurovascular bundle stays with Dorsal Palmar Dorsal Risk of damage to dorsal branch of No Yes No digital nerve
  37. 37. Dorsalincisions• Note the distribution radial and ulnar nerve in between the knuckles• Radial nerve at anatomical snuff box• Dorsal branch of ulnar nerve near ulnar head
  38. 38. Dorsalincisionsa . Bayonet for PIP Jtb. For DIP Jtc. PIP jt. and Central slipd. Extensive approache. Phalangeal exposuref. I and D for MP Jt.g. Dorsum of 1st rayh. Ulnar side of wristi. Dorsum of hand , wrist
  39. 39. Palm (transverse Incisions)• Digital , palmar, and wrist creases are // to Digital, MP and Wrist joints.• Incisions // to these lines will not cause scarring• Pitfall – Only limited exposure possible – Eg . Trigger finger release
  40. 40. Palm (transverse Incisions) • Extensive transverse incisions may result in central skin necrosis • Inadequate for tendon / nerve exploration
  41. 41. Littler’s diamonds in Palm • Principles of incisions for Littlers diamonds are very much applicable here also • Longitudinal incisions in these diamonds will cause scarring
  42. 42. PalmLongitudinal incisions• Oblique palmar axis – Midpoint of 2nd/3rd metacarpal head to Pisiform• Incisions // to this will not cause scar contracture• Angulate incisions at the creases when extending
  43. 43. Webspaces• Incisions here should never cross // to the crest of the webspace• 450 angle with /without Z- Plasty is preferable
  44. 44. Volar wrist• 3 rules followed – Topographical – Pal. Longus divides it into 2 portions • Radial / FPL / scaphoid • Ulnar / flexor tendons / ulnar NVB • Median nerve in the midline
  45. 45. Volarwrist– Flexion crease is transverse • Incisions must cross at an angle
  46. 46. Volar wrist• Incision must avoid damage to the sensory branches of the 3 nerves of the hand
  47. 47. To summarise• Thorough knowledge of the surface anatomy essential• Avoid –Palmar vertical incisions in the digits –Acute angled flaps –// incisions at the web• Preferable – lazy S / zig-zag( >900 )
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