Ten Tips to Simplify the Spaghetti Wrist

Abstract

Hand surgeons refer to deep lacerations of the volar distal forearm as "spaghetti wrists." Given that multiple tendons, vessels, and nerves often require repair, this injury may be intimidating. We review management of spaghetti wrists and summarize with 10 simplifying tips.

Fig. 1.

The tip of the Doppler probe should be placed on the center of the fingertip whorl.

Fig. 2.

Flexor tendon lacerations cause involved digits to fall into extension, and the injured hand may lose its resting half-fist digit cascade.

Fig. 3.

The FDS tendons to any single finger may be tested by holding the other fingers out to length. This eliminates the action of the single FDP muscle belly and makes any observed active flexion the result of an intact FDS tendon. Only the FDP crosses the distal interphalangeal joint and the presence of active flexion here implies an intact profundus tendon. FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis.

Fig. 4.

Pressure on the volar forearm shortens the tendons and will flex digits with intact myotendinous units.

Fig. 5.

The FDP myotendinous junction is a tendinous sheet rather than individual tendons, although the tendon to the index finger is usually independent.

Fig. 6.

The FDS tendons are separate and coplanar in the forearm. They overlap one another in the carpal tunnel, however, so that the slips to the ring and long fingers are immediately superficial to the index and small finger tendons. This relationship can be demonstrated by holding the fingers as shown.

Fig. 7.

A transverse incision should be extended radially and ulnarly to the borders of the forearm. This incision may be then made into a “T” or an “H” by adding an ulnar longitudinal limb or ulnar and radial limbs, respectively.

Fig. 8.

Many surgeons are familiar with a forearm fasciotomy incision that creates a large, rounded, ulnarly based flap of forearm skin. We favor a more ulnar, longitudinal incision when possible.

Fig. 9.

In joining a carpal tunnel incision to the patient’s laceration, the palmar cutaneous branch of the median nerve should be avoided.

Fig. 10.

Careful documentation is valuable for the surgeon and hand therapist postoperatively.