Tip to Overcome Oversized Finger Traps in Wrist Arthroscopy Distraction

Abstract

Wrist arthroscopy has become a common procedure for examination and treatment of wrist pathologies in recent years. An essential part of the wrist arthroscopy setup involves finger suspension over the traction tower to provide a wider space, which is usually achieved via Chinese finger traps. Nowadays, nylon finger traps are favored over metal finger traps because of the risk of skin lesions. Nylon finger traps usually come in 3 to 4 standard sizes, which can accommodate most patients undergoing the procedure. However, at times, we encounter patients whose fingers happen to be between 2 sizes or are too small for the smallest size. Under such circumstances, trying to find the optimal fit is frustrating, time-consuming and increases costs. We propose a method using small Tegaderm dressings to wrap around the bases of the fingers (1 for each finger) to be distracted and then applying the oversized finger traps. The increased friction between the dressing layer and the finger traps helps stabilize the finger traps and, thus, they will not slip under traction. This simple, safe, and cost-efficient method has helped us overcome the problem of oversized finger traps in almost all the cases we have encountered.

Since its introduction in 1979 by Chen,¹ wrist arthroscopy has become a common procedure that enables minimally invasive examination and treatment of a wide range of wrist and hand pathologies.² The standard setup for wrist arthroscopy involves placement of the patient in the supine position with the arm abducted 70° to 90° on an extended hand table with or without a tourniquet. Traction is applied to 2 to 3 fingers using Chinese finger traps, suspended on a traction tower. The fingers to be suspended depend on the designated area of arthroscopic examination and treatment, and generally, the index and ring fingers are suspended to obtain a well-balanced view of the radiocarpal and midcarpal joints. The selection of specific brands of traction towers and arthroscopic instruments is widely variable among different facilities. However, the designs of the Chinese finger traps are similar among different manufacturers.

Presently, nylon finger traps are preferred over metal finger traps because of the risk of skin lesions in elderly patients and patients with autoimmune diseases taking corticosteroids. Each brand of finger trap usually includes 3 to 4 standard sizes that could fit most patients undergoing arthroscopic procedures. However, patients’ fingers often may be between 2 sizes or may be too small to fit even the smallest size. Certain manufacturers have developed circular band designs at the bases of the finger traps to fasten the finger traps to the finger. This concentrates pressure at the site of the band and could potentially cause pressure ulcers or neurapraxia. Moreover, searching for the correct size of finger trap can be frustrating and can increase costs or delay surgery. In our practice, we have devised a simple technique that helps overcome oversized finger traps in almost all cases.

Surgical Technique

When we encounter oversized finger traps, we use a simple technique that requires only 2 small Tegaderm dressings, sized 6 cm × 7 cm (Transparent Film Dressing, Frame Style; 3M, Maplewood, MN). We gently wrap 1 piece of dressing each around the bases of the fingers to be distracted, usually the index finger and the ring finger. There is no need to apply additional tension or an additional layer while wrapping the dressing. After wrapping, the oversized finger traps are applied. The increased friction, rather than the increased finger width due to the layer of dressing, helps stabilize the finger traps; thus, they will not slip away from the fingers under adequate traction. The stepwise procedure is shown in Figure 1.

Fig 1.

(A) The author’s left hand lies horizontally on a hand table with a set of oversized finger traps originally applied over the index and ring fingers, which could not withstand manual horizontal traction for 5 lb and thus slid out of place. (B) Small Tegaderm dressings, sized 6 cm × 7 cm (Transparent Film Dressing, Frame Style), are used for the described method (1 piece for each finger to be distracted). (C) The dressings are wrapped around the bases of the fingers to be distracted. The yellow arrows indicate the dressings around the index and ring fingers. No tension is applied to the dressing while wrapping it around the finger. (D) Proper traction can now be applied with the same finger traps. The red arrow indicates the scale at 12 lb of traction, which is usually required for wrist arthroscopy surgery, and the black arrows show the dressings applied to the fingers, which are now under the finger traps. The friction between the dressings and the finger traps prevents the oversized finger traps from slipping away. This is a simple, effective, and noninvasive method to overcome oversized finger traps in wrist arthroscopy.

This technique has been effective in our practice even when the discrepancy between the finger traps and the finger width has been relatively large. In addition, the dressing adds an extra protection layer to the skin and, as a result, prevents minor abrasions. No complication has been noted with this method in our practice. Video 1 demonstrates the technique on one of the authors, followed by one of our patients.

Discussion

There has not been much discussion about the designs of finger traps or alternative apparatuses for finger traction in the past literature. However, finger traction is the cornerstone of wrist arthroscopy, and every wrist surgeon has encountered the dilemma of oversized finger traps. Davies et al.³ proposed a method in which a large sheet of Steri-Drape (3M) is wrapped around the fingers up to the metacarpophalangeal joints a few times and the free end is tied into a knot, after which the hand is suspended for traction. They reported excellent outcomes and no concern regarding the size and sterility of the finger traps. Their technique also has a unique advantage in addressing patients with very large fingers for which all the finger traps are too small. However, this method limits the potential to distract specific fingers for the examination of specific joints. In addition, it is more difficult to examine the fingers directly during the surgical procedure, for instance, if tendon injury is suspected. Likewise, Diaz et al.⁴ proposed a method of trans-metacarpophalangeal traction using K-wires to avoid finger-related complications. However, given the invasive nature of this method, it may be more helpful in some particularly difficult cases such as patients with amputation of several fingers, congenital deformity, or rheumatoid arthritis with poor skin condition.

Our technique, requiring only 2 pieces of transparent dressing, is a reliable solution for oversized finger traps in wrist arthroscopy. When this technique is performed in the clinical setting, pearls and pitfalls include choosing oversized finger traps that are closest in size to the patient’s fingers and not applying additional tension or extra layers of dressing when wrapping the dressing. Our technique has the advantages of easy application, high cost-efficiency, and noninvasiveness, and most importantly, it does not change the surgeon’s routine for surgical setup. However, there are some limitations to this technique. We have only attempted this technique using the aforementioned brand of dressing; although this product is widely available commercially and used internationally, it still may not be available in some parts of the world. Moreover, the efficacy of similar products is yet to be explored. In addition, although we believe the dressing provides an extra layer of protection for the skin, we would still be very cautious when the patient is receiving corticosteroid treatment or has fragile skin. Furthermore, we have used the described technique in cases with a relatively large discrepancy between finger trap size and finger width; however, the exact limit for this technique has not been determined in this study. Pearls and pitfalls of this technique are summarized in Table 1, and advantages and disadvantages are summarized in Table 2. In conclusion, we present a simple, effective, and cost-efficient solution to overcome oversized finger traps for wrist arthroscopy distraction.

Table 1.

Pearls and Pitfalls of Technique for Overcoming Oversized Finger Traps

Pearls

When no properly fitting finger traps are available, choose oversized finger traps that are closest in size to the patient’s fingers.

Evenly apply the Tegaderm dressing around the fingers to be distracted, with 1 piece of dressing per finger.

Pitfalls

Avoid additional tension while applying the Tegaderm dressing.

Note that 1 layer should be sufficient for maintaining the traction force.

Apply cautious use in patients with fragile skin.

Table 2.

Advantages and Disadvantages or Potential Risks of Technique for Overcoming Oversized Finger Traps

Advantages

The technique is easy to apply.

The technique is cost-efficient.

There is no need to change the surgeon’s routine for setup.

Individual fingers can be examined during surgery.

The technique provides an additional layer of protection for the skin.

Disadvantages or potential risks

We have only tried this technique using Tegaderm dressing; whether similar dressing brands will work is yet to be determined.

The exact limit the technique is capable of overcoming is yet to be determined.

Cautious use is required in patients with fragile skin.

Disclosures

All authors (I-N.L., C-Y.Y., J-P.W., Y-C.H.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

Technique to overcome oversized finger traps in wrist arthroscopy distraction. First, the technique is demonstrated on one of the authors. Two oversized finger traps applied over the author’s left index and ring fingers were first tested under manual horizontal traction, both of which failed within 6 and 5 lb of traction. After 1 piece of Tegaderm dressing was applied to the base of each finger to be distracted, 12 lb of traction could be achieved with the same oversized finger traps. Next, an actual case is presented. The designated finger traps were clearly oversized for the patient. After the Tegaderm dressings were evenly applied to the bases of the index and ring fingers, with care taken not to apply additional tension, 15 lb of traction could easily be achieved, as shown by manual traction. The wrist was then properly set up with the traction tower with vertical traction of at least 12 lb. The finger traps remained stable throughout 45 minutes of surgery. The skin of the fingers was examined after the operation and was intact and free of pressure marks; this shows that the increased friction between the dressings and the finger traps was sufficient to hold the finger traps under traction. This is a simple, effective, cost-efficient, and noninvasive technique to overcome oversized finger traps. It should be noted although the selected finger traps come with black tightening straps at the base, they were not used in this case, as shown at the end of the video.