Hand incisions

• As long as certain principles are observed, skin incisions can be made anywhere on the hand and not
only in or near major skin creases.
• Incisions within deep creases should be avoided.
– Here subcutaneous fat is sparse, and moisture tends to accumulate, macerating the skin edges.
• An incision should be long enough to expose the deep structures without excessive stretching of
the skin edges;
– greater exposure is possible if the skin and subcutaneous fat are dissected from the underlying fascia.
• The tissue beneath the skin incision usually is converted into a mobile oval or elliptical opening.
• The placement of an incision applies only to the skin;
– entries into deeper structures are made according to their anatomy and may be opposite in direction to
those made in the skin.
• Although the skin incision over the radial surface of the wrist for de Quervain stenosing tenosynovitis
may be transverse, the underlying incision in the stenosed sheath is longitudinal
• Generally, shorter incisions may suffice on the dorsum of the hand because here
the skin is more mobile.
• Through a 7.5-cm, lazy-S longitudinal incision on the middorsum of the wrist,
structures can be exposed from the extreme radial side of the wrist to the
extreme ulnar side or from the tendons of the extensor pollicis brevis and
abductor pollicis longus to that of the extensor carpi ulnaris.
• In many situations, straight-line incisions are avoided; the dorsal approach to the
wrist in a rheumatoid patient is an exception.
• If gently curved, the scar is less noticeable and usually conforms better to natural
lines.
• A curved incision also can be extended later with freer choice of direction.
• Exposure usually is better on the concave side of a semicircular incision; an S-
shaped incision provides even more exposure.
• Parallel or nearly parallel incisions that are too close together or
too long should be avoided because healing may be slow, or skin
necrosis may occur because of impairment of the blood supply.
• Scars that adhere to the underlying structures, especially bone,
should be avoided if possible.
• The offset incision is helpful: the first incision is carried through the
skin and subcutaneous fat, and after a flap is undermined on one
side, the deep approach is made through the fascia and muscle
parallel with but offset from the skin incision.
• The plane of motion of a part is approximately
perpendicular to the long axis of skin creases.
• An incision should not cross a crease at or near a right
angle because the resulting scar, being in the line of
tension created by motion, hypertrophies;
– it may limit motion because a mature scar would not stretch
like skin.
– Although true elsewhere in the body, this principle is more
important when dealing with the hand, especially the fingers,
because the development of contractures results in significant
impairment of function.
• Sometimes incisions should be outlined on the skin with a
sterile skin pencil, especially if multiple incisions are
needed.
• They can be made without hesitation, saving time after the
tourniquet has been inflated.
• Finger Incisions
• A basic and versatile finger incision, the midlateral incision
sometimes has been misunderstood.
• With this incision, the neurovascular bundle can be carried
volarward with the volar flap of the incision, or it can be left in
place by carrying the dissection superficial to it.
• If the dissection is taken superficial to the neurovascular
bundle, care must be taken to avoid making the skin flaps too
thin.
• To carry the neurovascular bundle volarward, begin the incision on the midlateral aspect of
the finger at the level of the proximal finger crease, and carry it distally to the proximal
interphalangeal joint just dorsal to the flexor skin crease; continue it distally along the
middle phalanx, dorsal to the distal flexor skin crease, and proceed toward the lateral edge
of the fingernail.
• Because flexor skin creases extend slightly over halfway around the finger, the incision is
slightly posterolateral.
• Develop the dorsal flap a little to aid in closure of the incision.
• On the radial sides of the index and middle fingers and the ulnar side of the little finger is a
dorsal branch of the digital nerve that should be preserved when possible.
• Develop the volar flap by continuing into the subcutaneous fat over the proximal and middle
phalanges, but because fat is scanty over the proximal interphalangeal joint, be careful not
to enter it by mistake.
• Immediately after incising the fat, carry the dissection volarward
deep to the neurovascular bundle, and expose the tendon sheath.
• The sheath can be incised, or the neurovascular bundle can be
exposed by further dissection.
• The opposite neurovascular bundle also can be exposed because
of its anterolateral position.
• For the second basic midlateral incision, the skin flap is developed
superficial to the neurovascular bundle
• Make the same midlateral skin incision, but just distal to the distal
flexor skin crease carry the incision obliquely into the pulp of the
finger.
• As the volar skin flap is developed through the subcutaneous fat,
carefully isolate the neurovascular bundle; it can best be found at
the middle of the middle phalanx
• Expose the bundle by dissecting the fat from its volar surface, and
expose the flexor tendon sheath by carrying the dissection toward
the bone
• If necessary, the skin flap can be developed further by dissecting
into the depths of the pulp distally, being careful not to disturb the
nerves and arteries, and by extending the incision into the palm
proximally.
Midlateral skin incision in finger extending from metacarpophalangeal joint to
lateral edge of nail. To avoid flexor skin creases, it is placed slightly posterolateral.
Midlateral approach especially to expose flexor tendon sheath. On radial sides of index and
middle fingers and on ulnar side of little finger is dorsal branch of digital nerve that should
be preserved if possible. Volar flap containing neurovascular bundle has been developed
and reflected. Window has been cut in sheath to show relationships of flexor tendons.
• Using the principles just outlined and illustrated, many, less extensive
exposures of the finger are possible.
• New incisions and approaches are still being described that allow more
direct access to deep structures.
• The popular volar zigzag finger incision does not require mobilizing
either neurovascular bundle and directly exposes the volar surface of the
flexor tendon sheath.
• When used on a contracted skin surface, however, it tends to straighten
out and result in a more linear scar than is desirable; here multiple Z-
plasty incisions are more satisfactory.
• In either type of incision, the neurovascular bundles must be protected.
• The volar midline oblique incision is useful for a variety of
procedures and often can be used instead of a volar zigzag
incision.
• It generally is safe and easily closed.
• In the approach to the flexor sheath, the incision crosses the
flexion creases obliquely in the midline of the finger between
the neurovascular bundles.
• Thumb Incisions
• Midlateral incisions described for the fingers also are suitable for
the thumb; the radial side is more accessible, and an incision here
can be extended by curving its proximal end at the midmetacarpal
area and creating a flap on the palmar surface of the thumb.
• Care should be taken to avoid the dorsal branch of the superficial
radial nerve to the radial side of the thumb.
• This incision can be used for tendon grafts without an additional
palmar incision because the flap can be developed sufficiently to
expose most of the flexor surface of the thumb.
• Fat is scanty on the lateral aspects of the distal joint of the thumb,
and the volar plate of the capsule may be opened by mistake when
seeking the flexor tendon sheath.
• When a transverse incision for trigger thumb is made at the level of
the metacarpophalangeal joint, the two digital nerves of the thumb,
located to either side of the flexor tendon as in the fingers, must
be carefully avoided
• Palmar Incisions
– As a rule, distal palmar incisions are transverse; in the proximal palm,
they tend to be more longitudinal, with the distal end curving radially
and paralleling the closest major skin crease, but at any desired
distance from it.
– An incision of any desired length can be made across the palm, provided
that the underlying digital nerves and other vital structures are
protected.
– After the skin and underlying fat have been incised, the latter is
dissected from the palmar fascia and is carried with the skin flaps.
– It may be desirable, although tedious, to preserve small vessels
perforating the palmar fascia if wide undermining of the skin flaps is
necessary; otherwise, most of the vital structures are deep to the
palmar fascia.
– In the distal palm, structures lying between the metacarpal heads are
not protected by the palmar fascia.
– After the skin flaps have been retracted, the fascia can be incised in
any direction necessary for ample exposure; excision of the fascia may
be desirable.
– The tendons and, parallel to them, the neurovascular bundles can then
be seen.
• The superficial volar vascular arch can be ligated and cut at one
end if deeper exposure is required.
• Incisions in the more proximal palm should parallel the thenar
crease; however, when extended proximal to the wrist, they
should not cross the flexor wrist creases at a right angle.
• The most important structure in the thenar area is the recurrent
branch (motor) of the median nerve, which should be exposed and
protected if its exact location is in doubt.
• In addition, care should be taken to avoid injury to the palmar
cutaneous branches of the median and ulnar nerves.
• There is no single longitudinal incision in the proximal palm that
completely avoids the palmar cutaneous branches of the median
and ulnar nerves.
• Care is recommended to minimize damage to these branches
during procedures in the midproximal palm and procedures around
the palmar base of the thumb.
Correct skin incisions in hand. A, Midlateral incision in finger. B, Incision for draining
felon. C, Midlateral incision in thumb. D, Incision to expose central slip of extensor
tendon. E, Inverted V incision for arthrodesis of distal interphalangeal joint. F,
Incision to expose metacarpal shaft. G, Incision to expose palmar fascia distally. H,
Incision to expose structures in middle of palm. I, L incision of base of finger. J, Short
transverse incision to expose flexor tendon sheath. K, S incision in base of finger. L,
Incision to expose proximal end of flexor tendon sheath of thumb. M, Incision to
expose structures in thenar eminence. N, Extensive palmar and wrist incision. O,
Incisions in dorsum of wrist. P, Transverse incision in volar surface of wrist. Q,
Incision in base of thumb. R, Alternative incision to drain a felon.
• Additional correct skin incisions in hand.
A, Z-plasty incision often used in
Dupuytren contracture (McGregor).
• B and C, Zigzag incisions for Dupuytren
contracture or exposure of flexor tendon
sheath.
• D, Volar flap incision. E, Incision to
expose structures in volar side of thumb
and thenar area. F, Incision in distal palm
for trigger finger or other affections of
proximal tendon sheath.
• G, Incision to form flap over hypothenar
area. H, Incision to expose structures in
middle of palm; it may be extended
proximally into wrist.
• I, Short transverse incision in volar
surface of wrist. J, Short transverse
incision to release trigger thumb.
• K, Digital palmar oblique incision.
• Basic Skin Closure Techniques
– Early closure of all hand wounds lessens the chance of infection and
excessive scarring, which may destroy the gliding mechanism essential
to hand movements.
– Immediate coverage is imperative when bone, cartilage, or tendon are
exposed because without it these structures would not survive.
Whenever possible, direct suture of the skin without tension is the
best method of closure.
– On the dorsum of the hand or wrist, this is sometimes possible even
after considerable loss of the mobile skin by extending the wrist to
relieve tension; care should be taken, however, not to hyperextend the
metacarpophalangeal joints.
– When a large defect here is closed in this manner, flexion of the wrist
and fingers is limited, and replacement of skin by grafting may be
necessary later.
– The advantages of primary closure by direct suture are jeopardized,
unless each suture is accurately and patiently placed because not only
the epidermis, but also each plane of tissue should meet its
corresponding plane.
• In the digits, palm, and dorsum of the hand, subcutaneous sutures
are almost never necessary.
• Placing too few sutures, or placing them too close to the skin edges
jeopardizes satisfactory wound closure: the underlying tissues heal
poorly, the skin edges tend to separate between the sutures, and
necrosis occurs around the sutures.
• The apical stitch is extremely useful for suturing a sharp angle in a
laceration or in an elective flap because it holds effectively without
embarrassing the circulation at the apex.
• Sometimes a “dog ear” of redundant tissue is left after closure of a
wound with uneven edges.
• This “dog ear” can be excised one side at a time after splitting it
down the middle to create two triangles; each triangle is then
excised at its base.
• The line of excision of one side is used to mark the line of excision
of the other.
• Another method of excising a “dog ear”
• When closure without excessive tension by direct suture is
impossible, some type of skin graft must be chosen without
prolonged delay, usually within about 5 days.
A, Skin closed by insufficient number of sutures placed too superficially
and too close to skin edges. B, Skin closed by sufficient number of sutures
placed more deeply and well away from skin edges.
Apical stitch is useful for suturing sharp angle
in laceration or in elective flap.
Method of excising “dog ear.” A, Fold of skin is caught at its apex by hook. B, Fold is retracted
to one side, and skin is incised along base of fold on opposite side; point X forms apex of
flap. C, Skin is unfolded, and resulting flap is excised. D, Skin closure has been completed.
• Z-plasty
• Z-plasty is an application of the transposition type of local
flap; suitably constructed skin flaps are brought from
adjacent areas to release a contracture.
• Typically, Z-plasty produces a gain in length along the
central limb, which undergoes a change in orientation.
• Its primary use is in the release of a long, narrow
contracture surrounded by tissue mobile enough to allow
some shifting and manipulation without the danger of
necrosis from impaired blood supply.
• Z-plasty should not be used in attempting to close a wide
fusiform defect.
• Z-plasty should not be used in the primary closure of a
wound, unless the wound consists only of a laceration
similar to a surgical incision.
• Make the central limb of the Z along the line of the
contracture to be released.
• Make the other two limbs of the Z equal in length to that
of the central limb; the angle between each limb and the
central limb must be equal to each other and should be
about 60 degrees or less.
• An increase in this angle would not allow transposition of
the flap without severe tension; a decrease makes the Z
less effective in releasing tension and impairs the blood
supply to each flap.
• Handle the points of the flaps with care because they are
most likely to undergo necrosis; suture each point with an
apical stitch.
• Multiple Z-plasties can be used when a scar is too long to
allow correction with one Z-plasty, and when the scars
resulting from the rotation of the flaps would be in a more
desirable position.
Angles permissible in performing Z-plasties. Angle that central limb of Z
makes with each of the other two limbs should be 45 to 60 degrees. When
angle is less than 45 degrees, blood supply to flap is impaired; when angle is
more than 60 degrees, flaps cannot be transposed without severe tension.
Simple Z-plasty to release long, narrow contracture. 1, Central limb of Z is made along line of
contracture, and other two limbs are to be made where shown. 2, Incisions are made, and
flaps are shifted. 3, Flaps are sutured in their new positions. Note apical stitches at A and B.
Multiple Z-plasties to release scar too long to be released by single Z-plasty.
• McGregor modified the standard multiple Z-plasty for use in
the fixed palmar skin of the hand and fingers (see Fig. 61-14 A).
• The length of its limbs may vary, making adjoining flaps larger
or smaller as desired; however, the length of the limbs of each
individual Z must be equal.
• The oblique limbs are curved to broaden the tips of the flaps,
increasing their blood supply.
• A three-flap arrangement of skin can be useful for relieving
web contractures in the second, third, or fourth webs
To correct linear contracture of second, third, or fourth web caused only by narrow
scar, dorsal flap may be fashioned using technique shown. A, Web contracture. B,
Flaps are outlined. C, Flaps are rotated in place. Inset, Flaps are sutured.
 From master surgery
• SKIN INCISION PRINCIPLES
• There are a great number of skin incisions in the hand and the fingers. Certain
basic
• principles should be followed at all instances. The skin incisions should never be
• placed within deep skin creases. The subcutaneous fat is very thin under these
creases
• and moisture tends to accumulate leading to maceration of the skin edges. The
• incisions should be long enough to expose the underlying deep structures
without
• stretching the skin edges, since the mobility of the volar skin in the hand is
limited.
• The reflected skin edges should be thick involving the underlying fat in
order to avoid
• devascularization of the skin edges. The direction of the dissection in the
deeper
• tissues can follow a different orientation than the direction of the skin
incision.
• Straight-line incisions should be avoided; gently curved or angled incisions
provide
• better exposure and are less noticeable cosmetically. Furthermore, they
can be
• extended with freer choice of direction.
• The plane of motion of the different parts of the hand is perpendicular to the
long axis
• of the skin creases. Therefore, an incision should not cross a crease at or near a
right
• angle since the resulting scar being in the line of tension during early motion will
• hypertrophy resulting in function impairment.
• Parallel or nearly parallel incisions should be avoided because necrosis or
delayed
• healing can occur due to limited blood supply of the bridged skin flap, especially
if the
• incisions are too close to each other or too long.
• SURGICAL EXPOSURE TO THE FLEXOR TENDONS IN THE FINGERS
• Based on the principles mentioned above there are many different finger incisions.
• The most popular are the zigzag incision and the midlateral incision.
• The Zigzag Incision
• The concept of zigzag incisions was introduced by Brunner and consists of several oblique
incisions between the different skin creases meeting each other exactly over the creases.
• The angle between the different creases should be about 90 degrees
• Angles of less than 90 degrees can lead to skin necrosis of the corners.
• The apex of the angles is located at the edges of the creases and should not extend more
posteriorly since the neurovascular bundles could be injured during mobilization of the
skin flaps.
The different finger skin incisions from right to left: Thum midlateral incision, the Brunner
zigzag incision, volar midline oblique incision, the midlateral incisionextending on the volar
surface of the distal phalanx, and the midlateral incision. All the incisions have beenextended
proximally within the palm.
• A variation of this incision is the volar midline oblique incision in
which the whole skin incision is performed volarly, along the
midline of the finger.
• It is relatively safe and easily closed.
• The incision crosses the skin creases transversely and slightly
obliquely allowing exposure of the flexor tendon sheath in the
midline of the finger between the two neurovascular bundles.
• Both zigzag incisions can be extended to the palmar region using
the same principles and following a zigzag pattern to the distal
palmar crease.
• The Midlateral Incision
– Important landmarks in this approach are the proximal and the distal
interphalangeal creases, which tend to extend slightly more to the
dorsal surface of the finger.
– These creases may disappear in a swollen finger.
– Another important landmark is the junction between the smooth
volar skin and the dorsal wrinkled skin on the side of the finger.
– The incision is not a true lateral incision but rather dorsolateral.
– A straight incision is performed connecting the more dorsal points of
the finger creases.
• The incision can reach up to the lateral end of the fingernail
distally and up to the web space proximally.
• An alternative way to find the connecting points for the skin
incision is to flex the fingers and connect the most dorsal points of
the interphalangeal creases
• This approach can be performed on radial or ulnar side of a finger
but never on both sides.
• The ulnar side of the index, middle, and ring fingers and the radial
side of the small finger are usually preferred, since the incisions
will not interfere with normal hand function postoperatively.
The midlateral finger skin incision with extension in the palm.
A-C: Deeper dissection of the midlateral approach of the finger. The flexor tendon sheath has
been approached raising a skin flap volar to the neurovascular bundle of the finger.
• Thumb Incisions
– The incisions that can be performed in the thumb are similar to the finger
incisions described previously.
– The midlateral incision in the radial side is easier and can be extended by
curving its proximal end at the midmetacarpal area and creating a flap on
the palmar surface of the thumb.
– Care should be taken to avoid injury of the dorsal radial branch of the
superficial radial nerve which is located exactly under the skin.
– The lateral surface of the thumb does not contain a lot of fat, especially at
the interphalangeal joint, so care should be taken to avoid incising the
joint or the volar plate.
• Another alternative incision is the volar zigzag incision.
• The two digital nerves at the level of the metacarpophalangeal
joint are very superficial on either side of the flexor tendons and
care should be taken to avoid injury of them.
• In FPL lacerations within the thumb, the proximal stump of the
tendon retracts, usually under the thenar eminence.
• It is advisable not to extend the thumb incisions in the thenar
eminence and retrieve the tendon with an open approach
through the thenar musculature, but rather to retrieve the tendon
through a separate approach in the distal forearm and pass it
under the thenar musculature to the thumb.
• Transverse incisions along the proximal thumb crease can be
performed to access the flexor tendon at the level of the
metacarpophalangeal joint as well as the A1 pulley.
• The digital nerves are located on either side of the tendon and
should always be identified and protected throughout the
operative procedure.
• SURGICAL EXPOSURE TO THE FLEXOR TENDONS IN THE PALM
– All the principles that apply to the fingers concerning the skin and the
skin creases apply to palmar incisions too.
– As a general principle, the incisions in the palm tend to be more
transverse in the distal part and more longitudinal curving radially
and parallel to the closest skin crease in the proximal part.
– There is a great variability of skin incisions in the palm, especially in the
distal part.
– The most common incisions in the distal part of the palm are the
transverse incisions used in trigger fingers.
– The location of these incisions is exactly over the midpalmar crease in
most of the patients, although they may be located slightly more
distally in case of the middle, ring, and small fingers.
– All these transverse incisions can be extended more proximally towards
the thenar crease keeping in mind that the flexor tendon course is
towards the midline from distal to proximal as they exit from the
carpal tunnel
• After the dissection of skin and subcutaneous fat, the latter is dissected from the
• palmar fascia trying to preserve any perforating small vessels that may supply the
• more superficial layers. The palmar fascia is incised in any desired orientation keeping
• in mind that the vital structures are under it. If wider exposure is desired, part of the
• palmar fascia can be excised. The tendons and the longitudinally oriented
• neurovascular bundles can be seen. It is advisable to always locate the neurovascular
• bundles at this level and protect them at all times during the flexor tendon surgical
• procedure.
• Most of the vital structures like arteries or nerves lie under the palmar
fascia in the
• proximal part of the palm. In the distal palm, these structures are lying
between the
• metacarpals heads and are not protected by the palmar fascia. In the very
distal part
• of the palm the arteries and nerves are oriented longitudinally. In the
proximal part of
• the palm there are some structures with a transverse orientation, like the
superficial
• palmar arch and the thenar motor branch of the median nerve.
The different palmar skin incisions.
NB
The skin creases of the human hand. a, distal digital crease; b,proximal digital crease; c,
palmar digital crease; d, thumb interphalangeal crease; e, proximal thumb crease; f, distal
palmar crease; g, transverse or midpalmar crease; h, proximal palmar or thenar crease
 Hand best
• PRINCIPLES OF INCISIONS IN THE HAND AND WRIST
• THE INCISION SHOULD
• Provide good exposure of the underlying anatomy and the pro- posed surgical procedure.
• Preserve the blood supply of the skin. Note that there are certain difficult areas (e.g., on the
volar part of the wrist on the radial side).
• Be extendable.
• Be along the neutral lines of ten- sion and not become complicated by contracture.
• Avoid being made directly over ten- dons, nerves, or vesselsto be sutured.
• If possible include previous scarsand incisions to protect the blood supply.
• Be adjacent to skin creases, since these incisions are easier to close than those actually in
the crease, where subcutaneous fat is absent.
• NOTE: Note the anatomic differences between the palmar and
dorsal skin.
• DORSAL INCISIONS
• The dorsal skin is relatively thin and
• the blood supply not as good as volar skin. Aim at curvilinear
incisions to protect the longitudinal running veins and infatics.
Dorsal incisions. (A) For exposure of the distal interphalangeal (DIP) joint.
(B) For exposure of terminal ex- tensor tendon. (C) For exposure of proximal interphalangeal (PIP) joint. (0)
For exposure of exten- sor apparatus over PIP joint and for extension to DIP joint.
(E) For exposure of metacarpo- phalangeal (MCP) joint. (F) For exposure of all finger (MCP) joints. (G) For
exposure of all ulnar lateral ligaments of thumb. (H) For exposure of scapho- trapezial trapezoid (SIT) joint. (I)
For exposure of dorsal wrist ganglion. (J) For exposure of first carpometacarpal joint. (K) For exposure of wrist