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Home , Hand surgery, Trigger finger

2.0 ANCC Contact Disorders of the Hours A Case Study Approach

Mary C. Kamienski

Using a case study approach, 2 disorders of the are Anatomy of the Hand presented. Dupuytren’s and bilateral trigger The hand is an intricate mechanism and consists of fi nger are described with a discussion of the interventions, multiple , ligaments, and (see Figure 1). including injection and surgical repair. Dupuytren’s disease is Twenty-seven bones make up the basic skeleton of the a of the connective tissue in the hand. It is also and hand. It is innervated by three nerves: the me- known as palmar fi bromatosis and can occur bilaterally. This dian, ulnar, and radial nerves. There are 14 phalanges in is a progressive disorder and causes deformity of the hands the fi ngers of the hand; the fi ve metacarpal bones are and eventually results in a decrease of functionality. Trigger found in the middle of the hand and the eight carpal fi nger is a common fi nger ailment that also causes deform- bones create the wrist. The fi rst metacarpal ity of the hand. This disorder is often referred to as stenos- () is the shortest and most mobile (Wilhelmi ing and can occur in several fi ngers bilaterally. et al., 2011). The infl ammation and hypertrophy of the sheath restricts There are numerous muscles, ligaments, and sheaths the motion of the fl exor that results in triggering of in the hand. The muscles contract and allow the hand to move the bones, while the fi brous ligaments bind the the affected fi nger. It is painful and disabling. The etiology, and the sheaths are tubes that surround parts of prevalence, incidence, diagnosis, treatment, and the fi nger. Tendons fl ex the interphalangeal , while care of these disorders are discussed. digit extension occurs from the extensor tendons. The pulley system is essential for fl exion of the fi nger. an alone has a hand” (Alpenfels, 1955). The thumb has two annular pulleys and one oblique Hands represent a vital part of our anat- pulley, while in the fi ngers the second and fourth annu- “ omy. We use them for expression, to offer lar pulleys are critical. Disorders of the pulley system comfort, perform basic tasks of daily liv- can result in less-active fl exion of the digit for some ten- ing, M conduct professional activities, communicate, and don excursion. be creative. They are used as tools and weapons and can Considering the complexity of the muscle, bones, be seen as representative of the meaning of a whole per- ligaments, and tendons in the hand, it becomes obvious son. Hands allow us to perform intricate tasks or heavy why even a minor problem can cause disability or a de- labor. Hands are a sensory organ used to feel heat or crease in functionality. The most common dysfunctions cold or rough surfaces or smooth or to communicate of the hand include osteoarthritis and rheumatoid ar- our feelings with a touch. Many individuals use hands thritis. These disorders result in mild to severe pain and when talking to emphasize or enhance speech, and some limitations in function to major deformities and hands are literally used to communicate when a person an inability to use the hands at all. Diagnosis and treat- uses sign language. Hands are used to gesture a greeting ment of these two disorders are a specialty in itself. or a sign of farewell. However, even less-common disorders can lead to per- Hands need to be fl exible and pain free to function at manent disability if not diagnosed and treated appropri- maximum capacity. They can offer much information ately. The following case scenarios are examples of these about an individual’s ability to be functional ranging disorders. from the simple activities of daily living to performing Dupuytren’s contractures: Case Study 1 intricate activities such as . An inability to have full function of hands can alter a life in profound ways. Joseph is a 48-year-old electrical lineman in good Consider a retired, 80-year-old woman who can no health with no chronic health problems. He presented longer crochet or embroider and struggles to button her Mary C. Kamienski, PhD, APRN, FAEN, FAAN, Professor, Chair Primary clothing. The inability of a plastic surgeon to hold a Care Department, School of Nursing, University of and scalpel or a needle holder can have a far-reaching effect. of New Jersey, Montville. Even when hands remain fl exible, the pain associated The author has disclosed that she has no fi nancial interests to any com- with neuropathies and other disorders can preclude mercial company related to this educational activity. using hands in a meaningful way. DOI: 10.1097/NOR.0000000000000003

© 2013 by National Association of Orthopaedic Nurses Orthopaedic Nursing • November/December 2013 • Volume 32 • Number 6 299 Copyright © 2013 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

OONJ591R1.inddNJ591R1.indd 299299 112/11/132/11/13 10:1110:11 PMPM Ligaments of Right Hand (Palmar View)

1 8 Key: Ligaments of Right Hand 2 9 Palmar View 3 10 1. Radius 11 2. Palmar radiocarpal l. 5 4 12 3. Flexor carpi radialis t. 13 4. Flexor retinaculum 14 5. Trapezium 6. Palmar ll. 15 7. Articular capsule 6 8. Ulna 9. Flexor carpi ulnaris t. 10. Pisiform 11. Pisohamate l. 7 12. Pisometacarpal l. 13. Hamate 14. Palmar metacarpal ll. 15. Deep transverse metacarpal ll.

F IGURE 1. Ligaments of the right hand. From Anatomical Chart Company/Lippincott Williams & Wilkins.

to his primary care provider with a complaint that of the same symptoms, and only 3% stated that the fam- some fi ngers on both hands were starting to bend and ily member had been diagnosed with Dupuytren’s dis- he couldn’t straighten them. He was concerned that he ease (Dibenedetti, Nguyen, Zogrqafox, Ziemiecki, & had arthritis. He stated his mother had severe arthritis Zhou, 2011). in both hands and knees with major joint deformities. Dupuytren’s disease is a progressive genetic disorder He was referred to an orthopedic surgeon who also specialized in . The surgeon quickly diag- that occurs as a result of pathologic collagen production nosed Dupuytren’s disease and recommended surgical and deposition. The resulting contractures most com- repair. On examination, it was determined that Joseph monly affect the metacarpophalangeal joint, the proxi- had progression in the small (fi fth fi nger) of both hands mal interphalangeal joint, or both. The most commonly and the beginning of contractures in both ring fi ngers. affected are the ring and little fi ngers. It occurs in all Bilateral regional fasciotomies were performed with racial and ethnic groups but the incidence is highest in mixed results. Both ring fi ngers were repaired success- those of European descent. It is more common in men fully and regained full fl exibility. Both small fi ngers than in women and the incidence increases with age. It were not successfully repaired and remained fl exed at has been associated with smoking, alcoholism, diabe- a 90-degree angle in his right, dominant hand and tes, epilepsy, and HIV (Hurst et al., 2009). 45-degree angle in his left hand. Follow-up revealed that Joseph was able to return to work after an une- Bowere, Nelson, and Gazzard (1990) conducted a ventful 3-month postoperative period. The disease did comparison study of 50 males with HIV stage IV and not progress over time after the surgery. stage III and a control group of males who were nega- tive for HIV antibody. Eighteen of the HIV patients had Dupuytren’s disease or contractures are also known bilateral Dupuytren’s contractures. None of the control as palmar fi bromatosis. The connective tissue under the subjects had Dupuytren’s contractures. The prevalence skin of the palm contracts while collagen cords form, of Dupuytren’s contracture in the general population is thicken, and fi nally shorten. This can cause permanent 4% to 5%–6%. The prevalence in this study was 36%. A fl exion contractures of the fi nger joints and progressive more recent review of the literature indicates that there fl exion of one or more fi ngers (Figure 2). has been no further evidence reported of a link between This disease usually occurs in one hand fi rst and may HIV + , , tuberculosis, syphilis, and high or may not appear in the other hand at a later time. An serum lipids (Mafi , Hindocha, & Khan, 2012). epidemiological study conducted of 23,104 individuals Regional palmar fasciectomy is the most commonly revealed that 61% of the 165 individuals with a diagno- performed surgical procedure for this disorder. Only the sis of Dupuytren’s disease sought care when a bump de- diseased parts of the superfi cial fascial aponeurosis are veloped on the palm or at the base of the fi ngers. A much excised. Good results have been reported with this pro- lower percentage (30%) indicated that a rope-like cedure. Bulstrode, Jemec, and Smith. (2005) reported growth was the fi rst symptom they noticed followed by that regional fasciectomy, also called a modifi ed Skoog’s fi nger fl exion or dimpling, 82% indicated that the fi rst procedure, does correct the deformity but does not pre- symptom occurred in only one hand, 18% of the pa- vent recurrence of the disease. Recurrence occurred in tients reported that a family member had one or more 23 of 75 patients after a 9-year follow-up.

300 Orthopaedic Nursing • November/December 2013 • Volume 32 • Number 6 © 2013 by National Association of Orthopaedic Nurses Copyright © 2013 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

OONJ591R1.inddNJ591R1.indd 300300 112/11/132/11/13 10:1110:11 PMPM A

B

F IGURE 2. (A and B) Preoperative clinical photographs F IGURE 3. (A) Intraoperative photograph of the fi nger prior to demonstrating a Dupuytren’s contracture. surgery. (B) Preoperative demonstration of the surgical incision for Dupuytren’s contracture.

Closed fasciotomy is a surgical technique that is suc- cessful when the metacarpal (MCP) is contracted but is Percutaneous needle fasciotomy is an outpatient not as useful for proximal interphalangeal joint (PIP) procedure that can be done in the offi ce under local an- contractures. This technique also involves some risk of esthesia. It involves making multiple puncture sites and neurovascular injury. This procedure is performed sectioning the Dupuytren cord. In a study of 211 older under local in an outpatient setting. Crean, patients (mean of 65 years old) although there was only Gerber, Graverand, Boyd, and Cappelleri, (2011) re- one digital nerve injury, no , and no tendon ported that this procedure is useful for patients who injuries, the recurrence (58%) and disease progression may not be candidates for local fasciectomy. In a 10- (69%) were high at a 3-year follow-up (Foucher, Medine, year follow-up of 160 patients treated with closed fas- & Navarro, 2003). ciectomy, 34% of patients required no further surgery Distraction and passive extension techniques have while 66% of the patients required additional surgery in been successfully utilized in conjunction with fasciecto- an average of 5 years. mies that offer gradual passive extension. A device A radical fasciectomy with a complete removal of the called the Proximal Interphalangeal Skeletal Traction palmar aponeurosis and natatory ligaments was thought Extendor was introduced by Hodgkinson (1994) for out- to be a cure for Dupuytren’s disease (McIndoe & Beare, patient preoperative use and may facilitate successful 1958) (see Figures 3a and 3b ). Satisfactory results were surgery. A staged extension device technique was uti- obtained in more than 200 cases; however, recurrent dis- lized with 38 fi ngers in 27 patients with Dupuytren’s ease was not eliminated by the more extensive surgery. contractures. Sixty-nine percent of the results were re- Hueston (1961) found an equal recurrence rate at 5- to ported as good to excellent ( White et al., 2012). 15-year follow-up in a comparison study of limited fas- Finally, if complete extension is not obtained by care- ciectomy (regional) and this more radical procedure. ful digital fasciectomy, the PIP joint may need to be re- More recently, Crean et al. (2011) report that 61%–97% leased. Alternative procedures also include of patients achieved a mean improvement in contracture that includes implants and ; however, these angle from 58% to 79%. About 20% of the patients expe- procedures increase a functional angle at the joint but rienced an adverse event with a 39% recurrence rate. limit fi nger function.

© 2013 by National Association of Orthopaedic Nurses Orthopaedic Nursing • November/December 2013 • Volume 32 • Number 6 301 Copyright © 2013 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

OONJ591R1.inddNJ591R1.indd 301301 112/11/132/11/13 10:1110:11 PMPM The injection of collagenase (Xiapex) into the cords Dupuytren’s disease cannot be cured; however, there has been approved for use. This enzyme can break down are many interventions that can decrease the loss of the cords that are pulling the fi ngers into fl exion. This is functionality of the hand and can halt or delay the pro- an outpatient procedure that does not require anesthesia gression of the disease. but does require frequent follow-up to have the fi ngers manipulated by the surgeon (Badalmente & Hurst, 2007). Palmar Tenosynovitis (): Case 2 A three-step approach to the management of Dupuytren’s contracture has been proposed ( Denkler, Susan K. is a 64-year-old working registered nurse. 2012 ). Needle fasciotomy has been suggested as a fi rst She has presented for her fourth surgical procedure step with reports of long-standing excellent results. for stenosing tenosynovitis (trigger fi nger) in the past 10 years. Susan has a 9-year history of Type 2 diabe- Xiafl ex injections are a possible second approach with tes. Her blood sugar has been maintained at a Hgb positive results reported after one treatment. Finally, A1C of 6.0–6.3 for many years on a daily dose of met- fasciectomy has been recommended with recurrent dis- formin 500 mg twice a day. She has no other comor- ease; however, there are reports of high complication bidities. She continues to practice patient care while rates associated with this procedure. working as the nurse manager of a busy emergency Physical may be helpful in the early stages of department. The management job involves frequent the disease by applying heat and ultrasonographic computer use. Susan states that the ring fi nger on her waves. The patient may also be advised to wear a splint left hand has become stiff and she can hear and feel a or brace to stretch the fi ngers and perform range-of- popping sensation when she moves that fi nger. The motion exercises daily. Following surgical correction, fi nger will often catch in a bent position and she can no longer actively extend it but must passively physical and occupational therapy may be recom- straighten the fi nger. Susan states that she has de- mended. Patients who have not achieved full extension creased direct patient care recently as the trigger fi n- of the affected fi ngers may need to learn adaptive tech- ger has gotten worse and she is concerned she will niques and use assistive devices to enhance function drop anything held in the left hand if the fi nger be- (Balaguer, David, Ihrai, Daideri, & Lebreton, 2009). comes locked. She also reports that the pain is severe Postoperative care requires careful attention to (8 on a 0–10 scale) when the fi nger locks and she at- maintaining extension with fl exion of the MCP and ex- tempts to straighten it. Susan has had surgical re- tension of the PIP. This is achieved with the use of a lease of the middle fi nger of her left hand, the middle dorsal splint to avoid pressure on the incision. Splinting fi nger of her right hand, and the thumb on her right may be maintained for at least 6 weeks and some require hand. When the condition was fi rst presented, she had a local injection of the left middle 3 months of immobility to minimize scar contractures. fi nger and later for the middle fi nger of her right Rehabilitation is a progressive process of increasing hand. In both cases, the condition returned after ap- activity and decreasing splinting. Return to normal ac- proximately 6 months and seemed to be worsened. tivity is usually in 2–3 months. The performed to release the The risks and of surgical and other treat- in all of the affected fi ngers have been successful and ment for Dupuytren’s disease include joint stiffness and she states she has been pain free and has full function loss of preoperative fl exion, hematoma, skin loss, infec- of both hands with the exception of the ring fi nger of tion, nerve injury, vascular injury, prolonged edema, the left hand. The condition began with fi nger stiff- and refl ex sympathetic dystrophy. Signifi cant hand ar- ness and the popping sensation and has rapidly thritis is a contraindication to surgery because of the progressed to frequent locking. Surgical release was performed under local anesthesia and light sedation high risk of worsened hand function after surgery in an outpatient surgical setting. At a 6-month follow- ( Denkler, 2010; Skoff, 2004). With successful surgery, up, Susan reported a successful outcome with no ad- patients may be able to carry objects, play tennis, or verse side effects and has regained full fl exion and even type on keyboards, but fi ne motor activity may be extension of the affected fi nger. even more diffi cult than before the surgery. Activities such as handwriting, crafting, playing music, or holding Trigger fi nger or stenosing tenosynovitis is an infl am- items securely may be diffi cult or impossible. mation of the fl exor tendon A1 pulley, which becomes Nursing implications for patients pre- and postoper- irritated as it slides through the tendon sheath tunnel. If atively need to focus on patient education and helping untreated, the tendon may thicken and nodules may the patient understand the disease, its progression, and form that increase the diffi culty of moving the tendon the realistic outcomes that can be expected from inter- through the tunnel. The tunnel itself may thicken, which vention. Patients must be encouraged to perform physi- further increases the problem. The most commonly af- cal and occupational therapy exercises on a regular fected is the ring fi nger followed by the thumb, long, basis. index, and small fi ngers. The cause is unknown; how- Hand infections can cause severe problems and must ever, it is six times more common in women than in men be identifi ed and treated very aggressively. Patients and individuals who are between the ages of 40 and 60 should understand the need to maintain the dressings years. There is also some evidence that there is a rela- postoperatively, avoid getting the area wet, and report tionship with and . In dia- any signs of infection such as increased pain at the op- betes, the incidence seems to be related to the duration erative site immediately. The potential for a decreased of the disease and not glycemic control. There is also ability to hold items securely is a safety concern and evidence that there is a correlation with carpal tunnel patients should be reminded that this can cause acci- syndrome, de Quervain’s disease, hypothyroidism, renal dents such as dropping a hot pot of boiling water. disease, and amyloidosis. Although there have been

302 Orthopaedic Nursing • November/December 2013 • Volume 32 • Number 6 © 2013 by National Association of Orthopaedic Nurses Copyright © 2013 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

OONJ591R1.inddNJ591R1.indd 302302 112/11/132/11/13 10:1110:11 PMPM suggestions that trigger fi nger is associated with occu- A compression dressing is applied after surgery to pations that require gripping and hand fl exion, this protect the incision. Nonabsorbable sutures are used to relationship has not been supported with evidence and close the site that should be removed about 14 days the relationship is questionable. The evidence suggests after the surgery. Patients are instructed to apply ice to that the causes of trigger fi nger are multifactorial and the palmar surface of the hand and keep the affected very individualized (Makkouk, Oetgen, Swigart, & hand elevated for several days. The dressings can be re- Dodds, 2008). moved in 3–5 days, and the patient can be instructed The diagnosis of trigger fi nger does not require imag- that they may shower but to apply a light covering such ing. The patient’s report of popping and locking of the as a band aid until the sutures are removed. If a splint fi nger is usually all that is needed for a diagnosis. Prior has been applied during surgery, patients are instructed to surgical intervention, the fi nger is fl exed or “trig- to continue to use the splint until the follow-up visit. gered” to confi rm the diagnosis (see Figure 3). Patients are offered analgesia that ranges from oxyco- Treatment for trigger fi nger can begin with activity done to nonsteroidal anti-infl ammatory drugs or Tordol modification accompanied by nonsteroidal anti- (ketorolac). Most patients, however, report a very low infl ammatory drugs for pain control. Splinting is done level of pain or discomfort and seldom report pain to prevent the friction caused by fl exor tendon move- greater than 4 on a scale ranging from 0 to 10. ment through the tendon sheath tunnel (Akhtar, Bradley, There is a very low incidence of infection (1:1000) fol- Quinton, & Burke, 2005). Splinting has been used as a lowing this surgery; however, patients should be in- conservative treatment option. The splint is used to structed to report any symptoms such as an increase in maintain the MCP joint at 10° –15 ° of fl exion for about 6 pain, swelling, warmth, and/or redness of the hand, wrist weeks. This appears to be effective for mild triggering or forearm, fever, chills, or night sweats (Denkler, 2010). (Ryzewicz & Wolf, 2006). Splinting has not been suc- cessful in patients with severe disease or long-term du- Implications for Nursing ration of symptoms. With careful attention to postoperative care for any The injection of is recommended be- hand surgery, infections can be avoided. However, hand fore surgical intervention. It has been found to be 93% infections can be very serious and cause problems that effective especially in nondiabetic patients (Green et al., persist even after the infection has been cleared. Most 2005). It has been less successful in patients with a long infections, if diagnosed early, can be treated with antibi- history of the disease, diabetes mellitus, and multiple otics, rest, elevation, and other noninvasive methods. In digit involvement. If the condition does not resolve after some cases, even after only 1–2 days, the infection can the fi rst injection, or if symptoms recur, a second evolve quickly and require a combination of antibiotics, injection is one-half as likely to succeed (Benan, surgical drainage, and debridement of infected or dead Nakhdjevani, Loyd, & Schreuder, 2012). Patients report tissues. Treatment may require the intravenous use of that the injection is extremely painful and are reluctant antibiotics and hospitalization. Deep tissue infections to allow a second injection or an initial injection if the may spread to the wrist and forearm ( Denkler, 2012). A condition occurs in another digit. relatively minor, usually very successful surgical proce- Surgical treatment is very successful and is regarded dure can progress into a serious problem that requires as the gold standard of treatment for complete resolu- hospitalization to resolve and may permanently alter tion of trigger fi nger. Operative intervention can be the outcomes from the original surgery. percutaneous or an open release. Surgical intervention Patients may have a tendency to discount the seri- is generally offered after failure of conservative treat- ousness of this surgical procedure and return to all ac- ment that includes splinting and corticosteroid injec- tivities because the fi nger is fully mobile and the pain tions (Benson & Ptaszek, 1997). from the condition is gone. Percutaneous trigger release is done as an offi ce pro- Nursing intervention should be focused on careful cedure with the use of lidocaine as a local anesthesia. patient education with feedback to determine whether Success rates have been more than 90% with this proce- the patient understands the signifi cance of attention to dure (Ryzewicz & Wolf, 2006). However, there is a risk self-care and the need to follow up for suture removal of digital nerve or artery injury. and assessment of the surgical site. An emphasis should Open release of trigger fi nger has been the treatment be placed on the need to call immediately if symptoms for more than 100 years. The procedure involves full sec- occur or worsen. tioning of the A1 pulley with a greater exposure that is In conclusion, conditions that affect the functional- thought to be safer. Surgery is done through a small inci- ity of the hand should be diagnosed and treated. The sion in the palm of the hand at the base of the affected tendency to minimize disorders of the hands can lead to fi nger (see Figure 3b ). Complications may include refl ex progression of the disease and have a major impact on sympathetic dystrophy, infection, stiffness, nerve tran- activities of daily living. In some cases, a curable or fi x- section, incision pain, fl exion deformity, fl exor tendon able problem becomes a major disability. bowstringing, and recurrence (Akhtar et al., 2005). Most patients are able to move the fi nger immediately. There REFERENCES is usually minimal pain and swelling and complete re- Akhtar , S. , Bradley , M. , Quinton , D. , & Burke , F. (2005 ). covery can be expected in 2–3 weeks. If the condition Management and referral for trigger fi nger/thumb. was severe before the surgery and the affected fi nger British Medical Journal , 331 ( 7507 ), 30 – 33 . was very stiff, recovery might take up to 6 months and Alpenfels , E. ( 1955 ). The anthropology and social signifi - required some and fi nger exercises. cance of the human hand. Artifi cial Limbs , 2 ( 2 ), 4 – 21 .

© 2013 by National Association of Orthopaedic Nurses Orthopaedic Nursing • November/December 2013 • Volume 32 • Number 6 303 Copyright © 2013 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

OONJ591R1.inddNJ591R1.indd 303303 112/11/132/11/13 10:1110:11 PMPM Badalmente , M. , & Hurst , L. ( 2007 ). Effi cacy and safety of Hodgkinson , P. (1994 ). The use of skeletal traction to cor- injectable mixed collagenase subtypes in the treat- rect the fl exed PIP joint in Dupuytren’s disease. A pilot ment of Dupuytren’s contracture . The Journal of Hand study to assess the use of the Pipster. The Journal of Surgery , 32 ( 6 ), 767 – 774 . Hand Surgery British , 19 ( 4 ), 534 – 537 . Balaguer , T. , David , S. , Ihrai , T. , Cardot , N. , Daideri , G. , & Hueston , J. (1961 ). Limited fasciectomy for Dupuytren’s Lebreton , E. ( 2009). Histological staging and contracture . Plastic Reconstructive Surgery Transplant Dupuytren’s disease recurrence or extension after sur- Bulletin , 27 , 569 – 585 . gical treatment: a retrospective study of 124 patients. Hurst , L. , Badalamente , M. , Hentz , V. , Hotchkiss , R. , The Journal of Hand Surgery European , 34 ( 4 ), 493 – 496 . Kaplan , T. , Meals , R. , & … Rodzvilla , J. (2009 ). Benan , M. , Nakhdjevani , A. , Lloyd, M. , & Schreuder , F. (2012 ). Injectable collagenase Clostridium histolyticum for The effi cacy of steroid injection in the treatment of trig- Dupuytren’s contracture . The New England Journal of ger fi nger. in , 4 ( 4 ), 263 – 268 . Medicine , 361 , 968 – 979 . Benson , L. & Ptaszek , A. (1997 ). Injection versus surgery in Mafi , R. , Hindocha , S. , & Khan , W. (2012 ). Recent surgical the treatment of trigger fi nger. Journal of Hand Surgery and medical advances in the treatment of Dupuytren’s American , 22 , 138 – 144 . disease: a systematic review of the literature. The Open Bowere , M. , Nelson , M. , & Gazzard , B. ( 1990 ). Dupuytren’s Orthopaedics Journal , 6 ( Suppl. 1: M9), 77 – 82 . contractures in patients infected with HIV. British Makkouk , A. , Oetgen , M. , Swigart , C. , & Dodds , S. ( 2008 ). Medical Journal , 300 , 164 – 165 . Trigger fi nger: etiology, evaluation, and treatment. Bulstrode , N. , Jemec , B. , & Smith , P. (2005 ). The complica- Current Reviews in Musculoskeletal Medicine , 1 , tions of Dupuytren’s contracture surgery. Journal of 92 – 96 . Hand Surgery , 30 ( 5 ), 1021 – 1025 . McIndoe , A. , & Beare , R. ( 1958 ). The surgical management Crean , S. , Gerber , R. , LeGraverand , M. , Boyd , D. , & of Dupuytren’s contracture . American Journal of Cappelleri , J. (2011 ). The effi cacy and safety of fasciec- Surgery , 95 ( 2 ), 197 – 203 . tomy and fasciotomy for Dupuytren’s contracture in Ryzewicz , M. , & Wolf , J. ( 2006 ). Trigger digits: principles, European patients: a structured review of published management, and complications. The Journal of Hand studies. The Journal of Hand Surgery (European Surgery , 31 ( 1 ), 135 – 146 . Volume) , 36 ( 5 ), 396 – 407 . Skoff , H. (2004 ). The surgical treatment of Dupuytren’s Denkler , K. ( 2010 ). Surgical complications associated with fas- contracture: a synthesis of techniques . Plastic and ciectomy for Dupuytren’s disease: a 20-year review of the Reconstructive Surgery , 113 ( 2 ), 540 – 544 . English literature. Journal of , 10 , 116–133. White , J. , Kang , S. N. , Nancoo , T. , Floyd , D. , Kambhampati , Denkler , K. ( 2012 ). Options for severe proximal inter- S. , & McGrouther , D. ( 2012 ). Management of severe phalangeal joint contractures in Dupuytren contrac- Dupuytren’s contracture of the proximal interphalan- ture . Plastic & Reconstructive Surgery , 130 ( 1 ), 205 – 206 . geal joint with use of a central slip facilitation device . DiBenedetti , D. , Nguyen , D. , Zografos , L. , Zlemiecki , R. , & The Journal of Head Surgery (European Volume) , 37 ( 8 ), Zhou , X. ( 2011 ). Prevalence, incidence, and treat- 728 – 732 . ments of Dupuytren’s disease in the United States: re- Wilhelmi , B. , Marrero , I. , Bunyamin , S. , Talavera , F. , sults from a population study. Hand , 6 , 149 – 158 . Chang , D. , Slenkovich , N. , & Gest , T. ( 2011 ). Hand Foucher , G. , Medine , J. , & Navarro , R. (2003 ). Percutaneous anatomy. Medscape . Retrieved February 28, 2013, needle aponeurotomy: complications and results. from http://emedicine.medscape.com/article/1285060- Journal of Hand Surgery Britain , 28 ( 5 ), 427 – 431 . overview#aw2aab6b9

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304 Orthopaedic Nursing • November/December 2013 • Volume 32 • Number 6 © 2013 by National Association of Orthopaedic Nurses Copyright © 2013 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

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