Pearls of Hand Surgery by Don Lalonde

Pearls of Hand Surgery
Don Lalonde MD
Saint John, Canada
Professor Surgery
Dalhousie University

Tree sign
Don’t show me a forest, show me a
tree De Quervain

Tree sign
Don’t show me a forest, show
me a tree
• Torn PIP joint
• Any kind of pain anywhere

I rarely close a fasciotomy defect with
STSG for over 10 years
use the creep principle wide awake
• VAC as outpatient till limb soft and skin moves -
then close with creep in clinic under WALANT
(wide awake local anesthesia no tourniquet)
110cc of 0.25% lido with 1:400,000 adrenaline

2 weeks and 4 years post
op closure of fasciotomy
with creep sutures

Infectious flexor synovitis
Surgical drainage became dogma
before penicillin was even available!!!
• Penicillin invented by Fleming 1928
• 1938 Foley isolates penicillin
• 1942 they start saving lives with penicillin
• Kanavel described 4 signs (published
1928) and Bunnel put them into the first
American book on hand surgery published
in 1944
100 surgeon years experience in our unit -
Most of these to antibiotics without surgery

Hand infections
The following are probably more
important than antibiotics
• Immobilization (splint)
• Elevation
• Listen to your pain and take no pain
killers
• Tell patients the terrorist analogy

Coban the
world’s best
finger
bandage

Alqahtani M, Lalonde DH. Sterile vs non-
sterile clean dressings. Can J Plast Surg
2006;14(1):25.
• Cultured Coban, panti liners, sanitary
napkins, diapers and they are almost
sterile
• Not all patients can afford sterile
dressings
• Clean is fine
• T shirt with vaseline

1 week and 6 weeks patient impression of
secondary healing thumb

Secondary healing is a
problem when it crosses
joints

The same secondary healing for lawn
mower toes and heels brings normal
dermis, fat nerves and blood vessels
over the wound with contraction

The mighty
myofibroblast my
friend

Early protected movement for K
wired finger fractures
• Please send these to your therapist at 2-5
days after K wiring
• They can do early protected movement of
non involved finger joints to improve your
results
• The hand therapists of New Zealand are
up to this task and you will be pleased

Mucous cysts
Many of these cure themselves if you
don’t operate and the nail groove goes
away

Osteoarthritis of the DIP Joint
• My father and aunt story
• The natural history is that they frequently
autofuse and the pain goes away
• If your patient does not want surgery…

Mallet fingers
• Immobilize those 8 weeks, not 6 weeks
• Surgery literature says 6 weeks
• Therapists say 8 weeks
• Some need longer than that to get a good
result
• Let the therapist call the splint time shots

Coban tape is our friend
• We use it in all finger fractures and soft
tissue injuries until the swelling stays gone
after the tape comes off
Banjo splint PIP dislocation

Standard Treatments for Chronic Paronychia
• Peter Carter: Keyser wedge resection
• Adrian Flatt: proximal nail resection
“Eponychial
Marsupialization”
…Green’s Textbook
Excision
Proximal
Fingernail
…Flatt’s Text

Gentian violet (kills MRSA and candida)
very effective for chronic paronychia
Wyndell Merritt
Apply with
Qtip at
bedtime for
2 weeks
put bandaid
over it
-messy!

Conclusions: Chronic Paronychia
…30 yr experience in over 150 patients
• Chronic paronychia patients will
usually respond to topical Gentian
Violet dye (1-2 applications/day for 7-10
days) without need for antibiotics or
surgery
• This inexpensive treatment method
should be considered prior to surgery

Treatment Cost Analysis for
Gentian Violet:
• Prescription fee=0 (available over-the-counter)
• Systemic antibiotics=0 (none used)
= $3.49

Good irrigation of dirty
hand wounds in ER
• Go wash the hand in the sink
after you numb it for good
irrigation
• Better than a few drops of holy
sterile saline

Final Suggestion
• Never do an operation on anyone’s hand if
you would not have that same operation
on your own hand, on your wife’s hand, on
your mother’s hand, or on your daughter’s
hand.
• If you are faced with a difficult case with
difficult decisions, always ask yourself:
“What would I want if this were my own
hand?”

AAHS Meeting in January in a warm
place every year (Hawaii 2014)

Still worried about epinephrine?
• Start without a tourniquet under general
anesthesia
• As soon as the patient is asleep, inject the
lidocaine with epinephrine, then stall (go to
the washroom, answer a page, prep and
drape slowly) to allow 15 minutes to pass
so the epinephrine can work
• Then do your surgery and you will see you
can tolerate a little blood and survive
• It WILL bleed a little in the beginning, but it
will stop

Its OK to have a little bleeding
when we do hand surgery
• We have bleeding when we have surgery
in most of the body and we manage just
fine
• We have just always done it that way with
a tourniquet
• That does not mean that we have to keep
doing it that way
• The only thing that is constant in surgery is
change

18 months post subtotal table saw
thumb amputation (skin scar
marked with blue) Repaired wide
awake in emerg battery k wire
• Primary fusion MP (saw through MP joint)
• Repair FPL, most of EPL, 1 digital nerve

In the
hand
• Manage
lower lid for
stability
• Manage
upper lid for
mobility
• Manage the
thumb MP
joint for
stability
• Manage
fingers PIP for
mobility
In the
eyelid

Wrist ganglion cysts
• I quit operating on those years ago as well
• If any of you actually figure out how to
cure these with surgery, please let me
know

Have started anterior
approach trapeziectomy 2012
RITCHIE J, A Comparison of Trapeziectomy Via
Anterior and Posterior Approaches J Hand Surg Eur
33: 137, 200820 hands in each group Level II
• anterior had better
outcomes for power,
scar tenderness and
satisfaction.
• Scar-related
complications 3X
more common in
posterior group.
49

50
From MacKinnon and Dellon JHS July 1985

Pearls of Hand Surgery by Don Lalonde

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