Suruh B Jennings, RN
Reconstructive hand surgery Reconstructive hand surgery can alleviate pain, correct deformities, and restore function. In evaluating whether to perform a surgical procedure, the restoration of motion, strength, and stability of the involved part must be considered. The operating room nurse can function as an important member of the surgical team if she has basic knowledge of the anatomy of the hand and if she is acquainted with the problems that concern the sur-
Sarah B Jennings, R N , is a graduate of the University of Mississippi, Oxford. Mrs Jennings is clinical nurse specialist, orthopedics, division hand surgery, at Ochsner Clinic, New Orleans, La. She was a speaker at the 1974 AORN Congress.
gem. These problems fall into four categories that help the physician determine the best method of treatment. Skin. Whether a wound is closed by direct suturing or another method depends on the degree of skin loss. Skin loss must be assessed in a relative sense rather than in actual amount. Because of local reaction, some wounds without skin loss cannot be safely sutured without dangerous tension that would cause breakdown of the suture line and delayed healing; other wounds, despite some degree of skin loss, can be closed by direct suture. Skin grafting becomes necessary if there is significant skin loss; whether splitthickness graft, full-thickness graft, or pedicle flap is necessary is determined by the degree of skin loss. Soft tissue. The soft tissue of the hand includes not only the subcutaneous tissue but also tendons, nerves, and tumor masses. Palmar tissue is different from tissue on the dorsum of the hand. The palmar skin is held close to the subcutaneous tissue permitting little sliding movement of one upon the other. Skin on the dorsum of the hand is so lax that
AORN Journal, January 1975, Vol 21, No 1
71
Severe degloving injury to hand.
a skin fold grasped with the thumb and index finger can be elevated several centimeters from the underlying deep fascia. Tissue on the hand dorsum can be separated from the deep fascia by blunt dissection while palmar skin must be separated by sharp dissection.' Dupuytren's contracture, a common palm problem, is caused by proliferative fibroplasia of subcutaneous palmar tissue, first occurring as nodules and later as cords with resulting secondary contractures of the
fingers.2 The etiology remains unknown but there is some evidence that heredity is a factor. Trauma may be a factor, but this has not been proved. Surgical intervention of Dupuytren's contracture, a deIicate and detailed procedure, frequently involves the nerves and pulleys. Because the skin tears easily, it must be separated by sharp dissection and care taken while retracting. Injuries to the tendons of the fingers are serious and involve either flexor or extensor tendons or both.
Hand following split-thickness graft to dorsum of hand, reconstruction of thumb, and pedicle f l a p graft to widen web space.
72
AORN Journal, January 1975, Vol 21, N o 1
Factors that determine which tendons may be repaired are: elapsed time since injury, area of the hand affected, number of tendons divided, severity of wound contamination, presence or absence of fracture, and general condition of the surrounding tissue. Delayed tendon repair is done 1. when the injury is produced by severe crushing in which the tendon will be more edematous; 2. when the site of tendon division is near one or more fractures; 3. when the skin is avulsed or lost and skin grafting is necessary over the divided tendon^.^ Ideally, repair of lacerated tendons is done in the operating room with proper anesthesia. The area where most tendon injuries occur is packed with vital anatomical structures, and the surgeon must be concerned with healing, fibrosis, adhesions within the tendon sheaths, and limitation of function. Tendons can be repaired by end-to-end suture, free graft using palmaris longus or plantaris tendon, or by tendon transfers. Since nerve injury in the hand involves motor nerves, sensory nerves, or both, this injury is considered serious. Median, ulnar, and radial nerves supply the intrinsic and extrinsic muscles that enable a person to supinate, pronate, adduct, abduct, flex, and extend the hand. The median and ulnar nerves supply sensory nerves in the volar and dorsal aspects of the fingers. Exploration of the median and ulnar nerves is a common surgical procedure. Tenosynovitis or edema can cause the median nerve to become compressed where it passes through the carpal tunnel. Paresthesia in the fingers is caused by nerve anoxia produced by venous s t a ~ i sPrimary .~ repair is usually ad-
visable in a clean, incised nerve wound. Secondary nerve repair must be considered when the wound is dirty, when too much time has elapsed since injury, or when a severe crushing injury involves a segment of undetermined length. Tumors of the hand are common and varied, each having its own peculiar incidence, malignant potential, and symptoms. They are usually detected early because of pain, impairment of function, or obvious swelling and are treated surgically. Rarely is biopsy needed since complete local excision is usually indicated. Tumors most commonly found in the hand are (1) benign tumors, ie, lipoma, xanthoma, neuroma; (2) malignant tumors, ie, osteogenic sarcoma, chondrosarcoma; and (3) tumorous conditions such as ganglion, inclusion cysts, and mucous cysts. Bone. Mobility of the hand is of vital importance in the treatment of hand fractures. Actions of the flexor and extensor muscles are separated by the long bones; thus, when a long bone is fractured, the power of the tendons is altered and deformity results. Relatively minor degrees of deformity may produce significant disturbance of function. Since function position represents the balance of power of muscle forces acting over long bones, it follows that fractures can be held reduced by maintaining them in the functional position. Some fractures, however, are unstable and require direct internal fixation by sutures or K-wire. A frequent source of disability following a fracture of the hand is malunion with rotation. In some cases, osteotomy must be done so that proper realignment can be obtained. Frequently, in severe crush injury or
AORN Journal, January 1975, V o l 2 1 , N o 1
73
blast injury, there is enough bone loss to warrant bone grafting to prevent nonunion and bone defect. Joints. The basic problem in joint surgery is balancing the functional disturbance created by the joint disease against the degree of function that will be restored by the operation. Surgery is advised if a significant increase in function can be achieved or further destruction prevented. A large percentage of joint surgery is done on patients with rheumatoid disease, where the tissue under attack is the synovium. Secondary degenerative joint changes occur as synovitis invades the extrinsic tendons, intrinsic muscles, and at the wrist and digital joints. To prevent deformity, debridement and synovectomy are performed. Synovectomy is done a t the wrist, the metacarpophalangeal joints, and the proximal interphalangeal joints. Arthroplasty of the metacarpopha-
langeal joints is a common procedure in the surgical care of the rheumatoid hand. Arthroplasty may be defined as making an artificial joint or reconstructing a new and functioning joint from a destroyed one. Sometimes the only treatment available is arthrodesis, or fusion of a joint in a functional position. Implant surgery. Discussions of reconstructive hand surgery would be incomplete without including information on implants. For years resection, reconstruction, and arthroplasty were the treatments of choice used for rheumatoid arthritis. Now silicone rubber prostheses have been used with S U C C ~ S S . ~ Since 1959, several types of joint prostheses have been designed, the most widely used being the Swanson and Niebauer-Cutter designs. The Swanson silicone-rubber prosthesis is a one-piece flexible design with the hinge in the center and two intramedullary stems. The Niebauer-Cut-
Severe rheumatoid arthritis, both hands. The right hand is shown following Swanson's arthroplasfy of the metacarpophalangeal joinfs.
74
AORN Journal, January 1975, VoZ 21, No 1
ter silicone rubber, Dacron-covered prosthesis has Dacron weave around each stem and a biconcave hinge that is moderately more flexible than the stems. The Dacron weave becomes incorporated within and fixed to the medullary shaft; whereas the onepiece design stays smooth and nonfixed. The prosthesis becomes a flexible, internal splint. Implant surgery includes synovectomy of the metacarpophalangeal joint, resection of the metacarpal heads, recentralization of the extensor tendon, and stabilization OP the proximal phalanx. Results show that prosthetic implantation produces relief of pain, improvement in the range of motion, and maintenance of function. Other Silastic implants, such as Swanson greater multangular, radial head, etc, are used purely as spacers. Tendon implant has played a major role in salvaging severely injured tendons, When primary repair cannot be carried out because of crush injury or multiple tendon injury, a two-stage procedure using the Hunter tendon prosthesis may be considered.F In the first stage, the damaged flexor tendon and its scarred sheath are exposed, the pulley system preserved or reconstructed, and the implant inserted. The distal end is sutured beneath the stump of the profundus tendon. I t is then sutured a t the proximal end to the profundus tendon beneath the flexion crease of the wrist. A new tendon bed and sheath forms in response to the gliding tendon prosthesis. In stage two, the free tendon graft, usually the plantaris tendon, is passed through the new sheath and sutured distally with button and pullout wire
set. Proximally, the graft is anastomosed to the motor tendon. Research now is being done on a one-stage artificial tendon. One such tendon is made of woven monofilament Dacron. The distal end is inserted into bone; the mid-portion, made of multiple parallel fibers, goes through the pulleys and across the joints; the proximal end is attached to viable tendon. Early motion permits an ingrowth of fibrous tissue from the ends of the tendon which completely infiltrates the parallel fibers of the artificial tendon without adhesion to the pulleys and surrounding tissue. The ingrowth of fibrous tissue creates a functioning new tendon. Nurse’s ?*oZe. Since reconstructive hand operations are usually quite complex, considerable planning and preparation should be done by the supporting OR nurse. In any operation, the immediate availability of desired instruments is of prime importance. In hand operations, it is magnified by a time factor. Almost all hand operations are performed with a pneumatic tourniquet on the patient’s arm, and since the tourniquet can be inflated for only limited periods of time, the surgeon must be able to do as much work as possible during these intervals. The tourniquet provides a dry field for exact dissection and holds sponging and clamping of bleeders to a minimum. Wide Penrose drains may be used for fingers. A red rubber catheter should never be used because of pressure damage to nerves and vessels. Instruments and sutures should be available before the tourniquet is inflated. Some hospitals have their own standard hand setup. These sets
AORN Journal, January 1975, VoE 21, N o 1
75
should be arranged in consultation with the surgeons so that each will be satisfied with the instruments available. The soft tissue work is basically plastic in nature and selection of instruments should center around this fact. Very fine dissecting scissors and forceps, long-handled skin hooks, vein retractors for tendons and nerves, tendon passers and special instruments used for implant surgery are among the instruments needed. A selection of small bone instruments should be available as well as the means for applying and cutting fine Kirschner wires. Kirschner wires are used for fixation of fractures or osteotomies and to splint joints in desirable positions. Ideally, a pistol grip power driver is needed for K-wire driving. The position of the bone or joint can be held with one hand while the wire is placed with the other hand. Assisting the surgeon. Special care must be exercised in retracting skin. Gillie skin hooks should be used where possible. For rheumatoid patients having reconstructive metacarpophalangeal joint surgery, the proximal skin edge should be retracted in a seesaw fashion. Constant traction on the skin can cause venous damage and create excessive swelling and delayed wound healing. Because of tourniquet use, the bloodless field, and low humidity in the operating room, tissue tends to dry out. A moist sponge or a few drops of saline in the wound by the nurse will be helpful. Special care must be exercised in handling tendons and joint implants. Tendons should be handled with a moist, gloved hand, never a dry sponge. Some joint implants should
76
be moistened and care taken not to handle the implant with the gloved hand. Instruments without teeth are used because scratching may weaken the implant. Applying dressings. Nurses may be called on to help apply dressings after surgery. Proper positioning of fingers and wrist is imperative. Frequently the success of the surgery depends upon a good dressing and good position. Dressings should be laid on rather than wrapped tightly keeping in mind that the tourniquet is up, and when it comes down, there must be room for venous filling and postoperative swelling. Active nursing involvement in hand operations is of short duration as compared to other surgical problems. However, the nurse's contribution is important for a satisfactory outcome.'
0
Notes I. E W Lampe, "Surgical anatomy of the hand,"
clinics/ Symposia, 2 I ( 1969) 66- 109. 2. B K Rauk, A R Wakefield, Surgery of Repair as Applied fo H a n d lnjuries (Baltimore: Williams
& Wilkins Co, 1960).
3. W Campbell, Operative Orfhopaedics, 4th ed, A H Crenshaw, ed. (St Louis: C W Mosby Co, 1963) 191-220, 275. 4. A E Flatt, The Care of the Rheumdoid Hand, 2nd ed ( S t Louis: C V Mosby, 1968) 34, 43-70, 95-127. 5. J R Urbanialr, D E McCollum, J L Goldner, "Metacarpophalangeal and interphalangeal joint reconstruction: Use of silicone rubber Dacron prostheses for replacement of irreparable joints of the hand," Southern Medics/ Journal, 63 ( 1970) I28 I 1290. 6. J M Hunter, R E Salisbury, "Flexor-tendon reconstruction in severely damaged hands. A hvostage procedure using a silicone-Dacron reinforced gliding prosthesis prior t o tendon grafting," Journal of Bone and Joint Surgery, 53 [ 1971 1 829-858. 7. F B Kesslar, "The nurse in hand surgery," AORN Journal, 15 (1972) 44-46.
AORN Journal, January 1975, Vol 21, No 1
-
Reconstructive hand surgery Reconstructive hand surgery can alleviate pain, correct deformities, and restore function. In evaluating whether to perform a surgical procedure, the restoration of motion, strength, and stability of the involved part must be considered. The operating room nurse can function as an important member of the surgical team if she has basic knowledge of the anatomy of the hand and if she is acquainted with the problems that concern the sur-
Sarah B Jennings, R N , is a graduate of the University of Mississippi, Oxford. Mrs Jennings is clinical nurse specialist, orthopedics, division hand surgery, at Ochsner Clinic, New Orleans, La. She was a speaker at the 1974 AORN Congress.
gem. These problems fall into four categories that help the physician determine the best method of treatment. Skin. Whether a wound is closed by direct suturing or another method depends on the degree of skin loss. Skin loss must be assessed in a relative sense rather than in actual amount. Because of local reaction, some wounds without skin loss cannot be safely sutured without dangerous tension that would cause breakdown of the suture line and delayed healing; other wounds, despite some degree of skin loss, can be closed by direct suture. Skin grafting becomes necessary if there is significant skin loss; whether splitthickness graft, full-thickness graft, or pedicle flap is necessary is determined by the degree of skin loss. Soft tissue. The soft tissue of the hand includes not only the subcutaneous tissue but also tendons, nerves, and tumor masses. Palmar tissue is different from tissue on the dorsum of the hand. The palmar skin is held close to the subcutaneous tissue permitting little sliding movement of one upon the other. Skin on the dorsum of the hand is so lax that
AORN Journal, January 1975, Vol 21, No 1
71
Severe degloving injury to hand.
a skin fold grasped with the thumb and index finger can be elevated several centimeters from the underlying deep fascia. Tissue on the hand dorsum can be separated from the deep fascia by blunt dissection while palmar skin must be separated by sharp dissection.' Dupuytren's contracture, a common palm problem, is caused by proliferative fibroplasia of subcutaneous palmar tissue, first occurring as nodules and later as cords with resulting secondary contractures of the
fingers.2 The etiology remains unknown but there is some evidence that heredity is a factor. Trauma may be a factor, but this has not been proved. Surgical intervention of Dupuytren's contracture, a deIicate and detailed procedure, frequently involves the nerves and pulleys. Because the skin tears easily, it must be separated by sharp dissection and care taken while retracting. Injuries to the tendons of the fingers are serious and involve either flexor or extensor tendons or both.
Hand following split-thickness graft to dorsum of hand, reconstruction of thumb, and pedicle f l a p graft to widen web space.
72
AORN Journal, January 1975, Vol 21, N o 1
Factors that determine which tendons may be repaired are: elapsed time since injury, area of the hand affected, number of tendons divided, severity of wound contamination, presence or absence of fracture, and general condition of the surrounding tissue. Delayed tendon repair is done 1. when the injury is produced by severe crushing in which the tendon will be more edematous; 2. when the site of tendon division is near one or more fractures; 3. when the skin is avulsed or lost and skin grafting is necessary over the divided tendon^.^ Ideally, repair of lacerated tendons is done in the operating room with proper anesthesia. The area where most tendon injuries occur is packed with vital anatomical structures, and the surgeon must be concerned with healing, fibrosis, adhesions within the tendon sheaths, and limitation of function. Tendons can be repaired by end-to-end suture, free graft using palmaris longus or plantaris tendon, or by tendon transfers. Since nerve injury in the hand involves motor nerves, sensory nerves, or both, this injury is considered serious. Median, ulnar, and radial nerves supply the intrinsic and extrinsic muscles that enable a person to supinate, pronate, adduct, abduct, flex, and extend the hand. The median and ulnar nerves supply sensory nerves in the volar and dorsal aspects of the fingers. Exploration of the median and ulnar nerves is a common surgical procedure. Tenosynovitis or edema can cause the median nerve to become compressed where it passes through the carpal tunnel. Paresthesia in the fingers is caused by nerve anoxia produced by venous s t a ~ i sPrimary .~ repair is usually ad-
visable in a clean, incised nerve wound. Secondary nerve repair must be considered when the wound is dirty, when too much time has elapsed since injury, or when a severe crushing injury involves a segment of undetermined length. Tumors of the hand are common and varied, each having its own peculiar incidence, malignant potential, and symptoms. They are usually detected early because of pain, impairment of function, or obvious swelling and are treated surgically. Rarely is biopsy needed since complete local excision is usually indicated. Tumors most commonly found in the hand are (1) benign tumors, ie, lipoma, xanthoma, neuroma; (2) malignant tumors, ie, osteogenic sarcoma, chondrosarcoma; and (3) tumorous conditions such as ganglion, inclusion cysts, and mucous cysts. Bone. Mobility of the hand is of vital importance in the treatment of hand fractures. Actions of the flexor and extensor muscles are separated by the long bones; thus, when a long bone is fractured, the power of the tendons is altered and deformity results. Relatively minor degrees of deformity may produce significant disturbance of function. Since function position represents the balance of power of muscle forces acting over long bones, it follows that fractures can be held reduced by maintaining them in the functional position. Some fractures, however, are unstable and require direct internal fixation by sutures or K-wire. A frequent source of disability following a fracture of the hand is malunion with rotation. In some cases, osteotomy must be done so that proper realignment can be obtained. Frequently, in severe crush injury or
AORN Journal, January 1975, V o l 2 1 , N o 1
73
blast injury, there is enough bone loss to warrant bone grafting to prevent nonunion and bone defect. Joints. The basic problem in joint surgery is balancing the functional disturbance created by the joint disease against the degree of function that will be restored by the operation. Surgery is advised if a significant increase in function can be achieved or further destruction prevented. A large percentage of joint surgery is done on patients with rheumatoid disease, where the tissue under attack is the synovium. Secondary degenerative joint changes occur as synovitis invades the extrinsic tendons, intrinsic muscles, and at the wrist and digital joints. To prevent deformity, debridement and synovectomy are performed. Synovectomy is done a t the wrist, the metacarpophalangeal joints, and the proximal interphalangeal joints. Arthroplasty of the metacarpopha-
langeal joints is a common procedure in the surgical care of the rheumatoid hand. Arthroplasty may be defined as making an artificial joint or reconstructing a new and functioning joint from a destroyed one. Sometimes the only treatment available is arthrodesis, or fusion of a joint in a functional position. Implant surgery. Discussions of reconstructive hand surgery would be incomplete without including information on implants. For years resection, reconstruction, and arthroplasty were the treatments of choice used for rheumatoid arthritis. Now silicone rubber prostheses have been used with S U C C ~ S S . ~ Since 1959, several types of joint prostheses have been designed, the most widely used being the Swanson and Niebauer-Cutter designs. The Swanson silicone-rubber prosthesis is a one-piece flexible design with the hinge in the center and two intramedullary stems. The Niebauer-Cut-
Severe rheumatoid arthritis, both hands. The right hand is shown following Swanson's arthroplasfy of the metacarpophalangeal joinfs.
74
AORN Journal, January 1975, VoZ 21, No 1
ter silicone rubber, Dacron-covered prosthesis has Dacron weave around each stem and a biconcave hinge that is moderately more flexible than the stems. The Dacron weave becomes incorporated within and fixed to the medullary shaft; whereas the onepiece design stays smooth and nonfixed. The prosthesis becomes a flexible, internal splint. Implant surgery includes synovectomy of the metacarpophalangeal joint, resection of the metacarpal heads, recentralization of the extensor tendon, and stabilization OP the proximal phalanx. Results show that prosthetic implantation produces relief of pain, improvement in the range of motion, and maintenance of function. Other Silastic implants, such as Swanson greater multangular, radial head, etc, are used purely as spacers. Tendon implant has played a major role in salvaging severely injured tendons, When primary repair cannot be carried out because of crush injury or multiple tendon injury, a two-stage procedure using the Hunter tendon prosthesis may be considered.F In the first stage, the damaged flexor tendon and its scarred sheath are exposed, the pulley system preserved or reconstructed, and the implant inserted. The distal end is sutured beneath the stump of the profundus tendon. I t is then sutured a t the proximal end to the profundus tendon beneath the flexion crease of the wrist. A new tendon bed and sheath forms in response to the gliding tendon prosthesis. In stage two, the free tendon graft, usually the plantaris tendon, is passed through the new sheath and sutured distally with button and pullout wire
set. Proximally, the graft is anastomosed to the motor tendon. Research now is being done on a one-stage artificial tendon. One such tendon is made of woven monofilament Dacron. The distal end is inserted into bone; the mid-portion, made of multiple parallel fibers, goes through the pulleys and across the joints; the proximal end is attached to viable tendon. Early motion permits an ingrowth of fibrous tissue from the ends of the tendon which completely infiltrates the parallel fibers of the artificial tendon without adhesion to the pulleys and surrounding tissue. The ingrowth of fibrous tissue creates a functioning new tendon. Nurse’s ?*oZe. Since reconstructive hand operations are usually quite complex, considerable planning and preparation should be done by the supporting OR nurse. In any operation, the immediate availability of desired instruments is of prime importance. In hand operations, it is magnified by a time factor. Almost all hand operations are performed with a pneumatic tourniquet on the patient’s arm, and since the tourniquet can be inflated for only limited periods of time, the surgeon must be able to do as much work as possible during these intervals. The tourniquet provides a dry field for exact dissection and holds sponging and clamping of bleeders to a minimum. Wide Penrose drains may be used for fingers. A red rubber catheter should never be used because of pressure damage to nerves and vessels. Instruments and sutures should be available before the tourniquet is inflated. Some hospitals have their own standard hand setup. These sets
AORN Journal, January 1975, VoE 21, N o 1
75
should be arranged in consultation with the surgeons so that each will be satisfied with the instruments available. The soft tissue work is basically plastic in nature and selection of instruments should center around this fact. Very fine dissecting scissors and forceps, long-handled skin hooks, vein retractors for tendons and nerves, tendon passers and special instruments used for implant surgery are among the instruments needed. A selection of small bone instruments should be available as well as the means for applying and cutting fine Kirschner wires. Kirschner wires are used for fixation of fractures or osteotomies and to splint joints in desirable positions. Ideally, a pistol grip power driver is needed for K-wire driving. The position of the bone or joint can be held with one hand while the wire is placed with the other hand. Assisting the surgeon. Special care must be exercised in retracting skin. Gillie skin hooks should be used where possible. For rheumatoid patients having reconstructive metacarpophalangeal joint surgery, the proximal skin edge should be retracted in a seesaw fashion. Constant traction on the skin can cause venous damage and create excessive swelling and delayed wound healing. Because of tourniquet use, the bloodless field, and low humidity in the operating room, tissue tends to dry out. A moist sponge or a few drops of saline in the wound by the nurse will be helpful. Special care must be exercised in handling tendons and joint implants. Tendons should be handled with a moist, gloved hand, never a dry sponge. Some joint implants should
76
be moistened and care taken not to handle the implant with the gloved hand. Instruments without teeth are used because scratching may weaken the implant. Applying dressings. Nurses may be called on to help apply dressings after surgery. Proper positioning of fingers and wrist is imperative. Frequently the success of the surgery depends upon a good dressing and good position. Dressings should be laid on rather than wrapped tightly keeping in mind that the tourniquet is up, and when it comes down, there must be room for venous filling and postoperative swelling. Active nursing involvement in hand operations is of short duration as compared to other surgical problems. However, the nurse's contribution is important for a satisfactory outcome.'
0
Notes I. E W Lampe, "Surgical anatomy of the hand,"
clinics/ Symposia, 2 I ( 1969) 66- 109. 2. B K Rauk, A R Wakefield, Surgery of Repair as Applied fo H a n d lnjuries (Baltimore: Williams
& Wilkins Co, 1960).
3. W Campbell, Operative Orfhopaedics, 4th ed, A H Crenshaw, ed. (St Louis: C W Mosby Co, 1963) 191-220, 275. 4. A E Flatt, The Care of the Rheumdoid Hand, 2nd ed ( S t Louis: C V Mosby, 1968) 34, 43-70, 95-127. 5. J R Urbanialr, D E McCollum, J L Goldner, "Metacarpophalangeal and interphalangeal joint reconstruction: Use of silicone rubber Dacron prostheses for replacement of irreparable joints of the hand," Southern Medics/ Journal, 63 ( 1970) I28 I 1290. 6. J M Hunter, R E Salisbury, "Flexor-tendon reconstruction in severely damaged hands. A hvostage procedure using a silicone-Dacron reinforced gliding prosthesis prior t o tendon grafting," Journal of Bone and Joint Surgery, 53 [ 1971 1 829-858. 7. F B Kesslar, "The nurse in hand surgery," AORN Journal, 15 (1972) 44-46.
AORN Journal, January 1975, Vol 21, No 1
-
