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Operative Techniques:
Hand and Wrist Surgery
Third Edition
Kevin C. Chung, MD, MS

Chief of Hand Surgery, University of Michigan Health System
Charles B. G. de Nancrede Professor of Plastic Surgery and Orthopaedic Surgery
Assistant Dean for Faculty Affairs
Associate Director of Global REACH
University of Michigan Medical School
Ann Arbor, Michigan
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
OPERATIVE TECHNIQUES: HAND AND WRIST SURGERY,

THIRD EDITION ISBN: 978-0-323-40191-3
Copyright © 2018 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further informa-
tion about the Publisher’s permissions policies and our arrangements with organizations such as the
Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.
elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of p roducts
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
Previous editions © 2012, 2008
Library of Congress Cataloging-in-Publication Data
Names: Chung, Kevin C., editor.

Title: Hand and wrist surgery / [edited by] Kevin C. Chung.
Other titles: Operative techniques.
Description: 3rd edition. | Philadelphia, PA : Elsevier, [2018] | Series:
Operative techniques | Includes bibliographical references and index.
Identifiers: LCCN 2016046027 | ISBN 9780323401913 (hardcover : alk. paper)
Subjects: | MESH: Hand--surgery | Orthopedic Procedures--methods | Atlases
Classification: LCC RD559 | NLM WE 17 | DDC 617.5/75059--dc23
LC record available at https://lccn.loc.gov/2016046027
Content Strategist: Kayla Wolfe

Senior Content Development Manager: Taylor Ball
Publishing Services Manager: Catherine Jackson
Project Manager: Kate Mannix
Design Direction: Amy Buxton
Illustrations Manager: Lesley Frazier
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

To Chin-Yin and William
and
in memory of my mother-in-law, Chun-Huei
v
Contributors
Joshua M. Adkinson, MD Aviram M. Giladi, MD, MS Taichi Saito, MD, PhD

Assistant Professor of Surgery Resident International Research Fellow
Division of Plastic Surgery Section of Plastic Surgery Section of Plastic Surgery
Riley Children’s Hospital Department of Surgery Department of Surgery
Indiana University School of Medicine University of Michigan University of Michigan
Indianapolis, Indiana Ann Arbor, Michigan Ann Arbor, Michigan;
Orthopaedic Surgery Section
Matthew Brown, MD Steven C. Haase, MD, FACS Okayama University
Hand Fellow Associate Professor of Surgery Okayama, Japan
Section of Plastic Surgery Section of Plastic Surgery
Department of Surgery Associate Professor of Orthopaedic Erika Davis Sears, MD, MS
University of Michigan Surgery Assistant Professor of Surgery
Ann Arbor, Michigan University of Michigan Medical School Section of Plastic Surgery
Ann Arbor, Michigan Department of Surgery
Kevin C. Chung, MD, MS University of Michigan Medical School
Chief of Hand Surgery Sirichai Kamnerdnakta, MD Ann Arbor, Michigan
University of Michigan Health System International Research Fellow
Charles B. G. de Nancrede Section of Plastic Surgery Jennifer F. Waljee, MD, MPH, MS
Professor of Plastic Surgery and Department of Surgery Assistant Professor
Orthopaedic Surgery University of Michigan Section of Plastic Surgery
Assistant Dean for Faculty Affairs Ann Arbor, Michigan; Department of Surgery
Associate Director of Global REACH Division of Plastic Surgery University of Michigan Medical School
University of Michigan Medical School Department of Surgery Ann Abor, Michigan
Ann Arbor, Michigan Faculty of Medicine
Siriraj Hospital Guang Yang, MD
Yuki Fujihara, MD Mahidol University Associate Professor
International Research Fellow Salaya, Thailand Department of Hand Surgery
Section of Plastic Surgery China-Japan Union Hospital of
Department of Surgery Brian P. Kelley, MD Jilin University
University of Michigan Resident Changchun, Jilin Province, Peoples’
Ann Abor, Michigan; Section of Plastic Surgery Republic of China
Department of Hand Surgery Department of Surgery
Nagoya University Graduate School University of Michigan
of Medicine Ann Arbor, Michigan
Nagoya, Japan
Brett Michelotti, MD
Nasa Fujihara, MD Hand Fellow
International Research Fellow Section of Plastic Surgery
Section of Plastic Surgery Department of Surgery
Department of Surgery University of Michigan
University of Michigan Ann Arbor, Michigan
Ann Arbor, Michigan;
Department of Hand Surgery
Nagoya University Graduate School of
Medicine
Nagoya, Japan
vi
Preface
Welcome to the third edition of this classic treatise on hand and wrist operative
techniques. There is a general view that new editions are simply updating current infor-
mation without structurally changing a textbook. However, this third edition is different
because every chapter is rewritten and augmented with new pictures and videos to
provide a strong foundation for carrying out operations in a safe and efficient manner.
For the past two years, my team and I have meticulously collected pictures and videos
in anticipation of refurbishing this entire textbook so that it will be consistently high qual-
ity in lieu of a multiauthor textbook that may not have a uniform effort. All the operations
were done by me and my colleagues at the University of Michigan and organized by my
team of international scholars and staff members. I am certain that this textbook will
meet your high expectations of my team’s work.
As I travel around the world as a visiting professor, I see this textbook on a number of
bookshelves and book stores. Many of you have approached me to share your enthu-
siasm for this book. With such encouragement and fervor to leverage this textbook to
provide the best care for our patients, I have worked intensely for several years to pro-
duce this book, which sets the standard for meticulous illustrations and pictures, clear
scientific writing, and a dazzling array of more than 100 operative videos to cover all
procedures in hand surgery. Even though you may have purchased the first and second
editions, this third edition provides incremental knowledge to previous editions that
makes all three editions a seamless encyclopedic collection of hand surgical proce-
dures. I hope you will treasure this textbook as much as I do. Ultimately, this textbook
was made through your prodding and your enthusiasm.
A textbook like this requires many hours of intense effort by everyone involved. I
would like to acknowledge my trusted assistants Brianna Maroukis and Helen Huette-
man, who worked together to make this book a reality. Furthermore, my international
scholars Nasa Fujihara, Yuki Fujihara, Sirichai Kamnerdnakta, Taichi Saito, and Michiro
Yamamoto have meticulously captured every picture and video and spent countless
hours to organize the pictures and illustrations, as well as editing the videos to ensure
the highest quality possible. I would also like to acknowledge Taylor Ball from Elsevier,
who has worked with me on all three editions of this textbook. Without his dedication,
the book would not be able to be produced on time and presented to you seamlessly.
My thanks go to Elsevier’s Dolores Meloni, who vouched to the Elsevier leadership
that this third edition represents the most creative and comprehensive product in the
publishing world. Finally, my tribute to my patients, who are my best mentors; I learned
so much by their entrustment of themselves and their family members under my care.
Every patient in my practice has had preoperative, intraoperative, and postoperative
pictures taken so that I can review their treatment course to reflect and learn from their
outcomes. Someone asked me who my best mentor is. Without hesitation, I responded:
my patients.
I am eternally grateful to you for your interest and your support of this textbook
series. I look forward to seeing this textbook on your shelves. Please do seek me out at
national and international meetings so that I can thank you personally for your friendship
and encouragement.
Kevin C. Chung, MD, MS
vii
Foreword
It is with great honor and pleasure that I write the foreword for the third edition of Opera-
tive Techniques: Hand and Wrist Surgery, written by my friend and colleague Dr. Kevin
C. Chung. Current readers of hand surgery and plastic surgery texts all know Dr. Chung,
the Charles BG de Nancrede Professor of Surgery, Plastic Surgery, and Orthopae-
dic Surgery at the University of Michigan. Although he has published more than 400
peer-reviewed papers, 200 book chapters, and 18 textbooks, this may be the prolific
Dr. Chung’s best work. Why? Because it is consistent, concise, comprehensive, and
contemporary—four critical attributes of a classic textbook.
The format and prose are consistent. Although there are excellent coauthors, this
is essentially a single author textbook. Dr. Chung’s expert voice is present throughout.
With prior experience as an editor of the Journal of Hand Surgery and Plastic & Recon-
structive Surgery, Dr. Chung’s style of writing is crisp and clear.
A well-used surgical textbook should be concise. The chapters have bullet point
sections on Indications, Clinical Examination, and Surgical Anatomy. This is a proce-
dure-based textbook, and each key procedure is outlined as a step-by-step technique
guide. I agree with Dr. Chung that operations are best taught in this manner. The exten-
sive video library complements each chapter brilliantly. The figures have been carefully
presented with just the key anatomic points, and only the classic articles are referenced
for collateral reading.
Most importantly, this textbook is comprehensive and contemporary. The 105
chapters are based on Dr. Chung’s vast experience in all aspects of hand surgery.
Although many hand surgeons have chosen to focus on one specialized area, Dr. Chung
is known at his institution and internationally as adept at “doing it all”—from congenital
hand to complex distal radius fractures and microsurgical reconstruction. His practice
is dynamic; therefore, this third edition is up-to-date with new techniques such as per-
cutaneous needle aponeurotomy and nerve transfers.
Only a select few have the breadth and depth of clinical experience to present a
single primary author textbook of hand surgery. Dr. Kevin Chung has done so in out-
standing fashion. This third edition has refined an already classic textbook, one that I
have always recommended to my own trainees.
James Chang, MD
Chief, Division of Plastic & Reconstructive Surgery
Johnson & Johnson Distinguished Professor of Surgery & Orthopedic Surgery
Stanford University Medical Center
72nd President of the American Society for Surgery of the Hand (2017-2018)
viii
PROCEDURE 1
Anesthesia of the Hand

Aviram M. Giladi and Kevin C. Chung
Indications
• Postoperative pain control
• Aid in functional evaluation of traumatic injuries
• Bedside procedures in the emergency department
• Minor hand surgery procedures (“wide awake” hand surgery)
• Avoidance/reduction of sedation or airway instrumentation in higher risk patients
• Performing procedures that benefit from testing intraoperative movement (tenolysis,
trigger finger release, etc.)
Clinical Examination
Anesthetic Agents
• Lidocaine is most widely used—onset approximately 3 to 5 minutes, duration of ac-
tion 60 to 120 minutes.
• Bupivacaine (Marcaine) is also commonly used for longer durations of pain control
(∼400–450 minutes); however, onset takes up to 15 minutes or more.
• Use of epinephrine mixed in with the local anesthetic (1:200,000 or even 1:100,000)
is not contraindicated in the hand or fingers and may increase duration of anesthetic
action while aiding in minimizing blood loss.
Surgical Anatomy
• Fig. 1.1 shows the sensory distribution of the dorsal hand.
• Fig. 1.2 shows the location of the radial, median, and ulnar nerves. The radial nerve
crosses the wrist in the area of the radial styloid. The purely sensory nerve arbo-
rizes proximal to the radial styloid and crosses the wrist divided into a few major
branches that travel in subcutaneous tissues anywhere from just volar to the sty-
loid and as far dorsal/ulnar as the area in line with the middle finger metacarpal
(Fig. 1.3A and B).
• The median nerve crosses the wrist within the carpal tunnel, and the palmar cutane-
ous branch crosses in a similar region of the wrist but more superficially. The nerve
runs between the palmaris longus (PL) and the flexor carpi radialis (FCR) tendons,
and for patients with PL this tendon can be used to help landmark for injections.
• To identify PL, have patient pinch thumb to ring/small finger and see tendon bulge
in wrist (Fig. 1.4A and B).
• If not present or identifiable, the ulnar border of FCR tendon can be used as the
landmark.
• The ulnar nerve crosses the wrist in the area of the flexor carpi ulnaris tendon, proxi-
mal to its insertion on the pisiform (prior to nerve entering Guyon canal).
• The ulnar artery is radial to the nerve and to the flexor carpi ulnaris (FCU) tendon.
• The dorsal sensory branch also runs ulnar to FCU at the level of the wrist, more
superficial to the major ulnar nerve trunk (Fig. 1.5).
• Common digital nerves travel between the metacarpals. Injection site to perform
a block of the common digital nerve to anesthetize multiple fingers at once is at
the level of the distal palmar crease, approximately 1 cm proximal to the metacar-
pophalangeal joint.
• Each finger has a volar and dorsal nerve on the ulnar and radial sides (total four
digital nerves). The volar branches are larger, and within the finger will be volar to the
corresponding digital artery. The volar branches pass from the common digital nerve
proximal to each webspace and enter the finger (Fig. 1.6).
3
4 PROCEDURE 1 Anesthesia of the Hand
Superficial radial nerve
Dorsal cutaneous branch of ulnar nerve
Median nerve
Ulnar nerve
FIGURE 1.1
Ulnar
nerve
Median
nerve
Radial
nerve
FIGURE 1.2
Positioning
Blocks are most easily performed with patient supine and arm extended out on a hand
table with dorsum down. This is especially true for the median nerve block. However,
as long as the wrist and elbow are free to be moved, these blocks can generally be
performed in a variety of hand and arm positions.
PROCEDURE 1 Anesthesia of the Hand 5
Extensor pollicis longus
Superficial radial nerve
Styloid process
of radius
Scaphoid
Abductor pollicis longus

B
FIGURE 1.3
Procedure: Radial Nerve Block RADIAL NERVE BLOCK: STEP 1 PEARLS

• The radial nerve block at the wrist is, in
Step 1 essence, a superficial field block in the area
Begin with volar injection radial to the radial artery (along the radial border of the fore- around the radial styloid (Fig. 1.8).
arm/wrist), proximal to the radial styloid. Inject in the subcutaneous plane, being sure • Block is performed superficial to the first and
to aspirate before injecting to confirm no violation of the radial artery that could result second extensor compartment as well as the
anatomic snuffbox.
in an intraarterial injection (Fig. 1.7).
Step 2 RADIAL NERVE BLOCK: STEP 1

PITFALLS
Adjust position and move the needle along the radial border of the radius and then
The nerve branches travel in the subcutaneous
dorsally, to the area of the radial styloid, and inject again into the subcutaneous plane. plane; there is no need for deep injection with this
block.
Step 3
• Continue these subcutaneous injections along the dorsum, beyond the styloid, as far
ulnar as the area inline with the middle finger metacarpal.
Flexor carpi radialis
Median nerve
B Palmaris longus
FIGURE 1.4
Ulnar nerve
FIGURE 1.5
Dorsal sensory nerve Dorsal branch of the volar digital nerve
Volar digital nerve
FIGURE 1.6
Range of infiltration
Styloid process
1% Lidocaine + 0.5% Marcain

FIGURE 1.8
FIGURE 1.7
RADIAL NERVE BLOCK: STEP 3 PEARLS

• This technique often requires multiple needle
insertion points to cover adequate territory
around the curvature of the wrist without
injecting too deeply.
• This injection requires more anesthetic than
the others, with upwards of 10 mL needed for
adequate infiltration of the entire area.
FIGURE 1.9 MEDIAN NERVE BLOCK: STEP 1 PEARLS

• The injection is performed at the level of the
• One can also move slightly more proximal to confirm adequate anesthesia of the proximal wrist crease, in line with the ulnar
carpus (Fig. 1.9). styloid (Fig. 1.10).
• Flex or extend the fingers to see if the needle
“bobs.” This confirms localization at the
Procedure: Median Nerve Block entrance to the carpal tunnel.
Step 1
Identify the nerve between PL and FCR (or just ulnar to FCR). Enter approximately MEDIAN NERVE BLOCK: STEP 1
PITFALLS
1 cm deep, through the flexor retinaculum, and infiltrate with approximately 5 mL of
local anesthetic. • The median nerve block is done with injections
in a deep as well as superficial plane. The
landmarks described in the anatomy section
Step 2 are critical to proper localization of the nerve.
Slowly withdraw, and inject another small aliquot superficial to the retinaculum to
block the palmar cutaneous branch.
Flexor carpi radialis
FIGURE 1.11
Palmaris longus
FIGURE 1.10
ULNAR NERVE BLOCK: STEP 1 PEARLS

The ulnar nerve block can be done radial or ulnar Procedure: Ulnar Nerve Block
to FCU; however, we prefer the ulnar approach to
minimize risk of injection into the ulnar artery. Step 1
Identify FCU, and move ulnar and dorsal to the tendon (Fig. 1.11).
INTERMETACARPAL BLOCK: STEP 1
PEARLS
Step 2
• Injection site is at the distal palmar crease,
• At the level of the distal ulna, insert the needle and slide under the area of FCU (dor-
proximal to the metacarpophalangeal joint.
• Approach can be volar or dorsal, many report sal and ulnar to the tendon).
less patient discomfort with a dorsal approach. • Inject approximately 5 mL of anesthetic solution in this plane.
SUBCUTANEOUS DIGITAL BLOCK: Step 3

STEP 1 PEARLS
Withdraw slowly, and inject again in the subcutaneous tissues to block the dorsal
• If dorsal anesthesia is not required, a single- sensory branch as well.
injection volar technique is preferred by some.
This is done with a single injection over the Procedure: Digital Nerve Block
volar aspect, just proximal to the palmodigital
crease. The needle can be moved to the Blocking digital nerves can be done with a variety of techniques.
radial border webspace and then withdrawn
slowly and redirected to the ulnar side to allow Step 1: Intermetacarpal Block
injection of both sides with one needlestick. • If the goal is to block multiple adjacent fingers, an intermetacarpal block (also known
• However, our preferred technique is to inject a
as a transmetacarpal block) technique can be used (Figs. 1.12 and 1.13).
subcutaneous wheal dorsally, and then enter
vertically into that anesthetized wheal area • Inject alongside the metacarpal neck to block the common digital nerves to the fin-
to then drive the needle ulnar and then radial gers on either side of the corresponding webspaces (Fig. 1.14).
from that position (similar to the “single-
injection” technique), minimizing the need for Step 1: Subcutaneous Digital Block
additional skin injection sites.
• To block just one finger, the subcutaneous digital block technique can be used.
SUBCUTANEOUS DIGITAL BLOCK:
• One must infiltrate along the radial and ulnar border of the digit proximally, at the
STEP 1 PITFALLS webspace (Fig. 1.15).
• There is a debate on dorsal versus volar
approach, with many preferring dorsal Step 1: Intrathecal Block
because it is reportedly less painful. • Alternatively, a digital block can be performed using an intrathecal block technique,
• Volar-only techniques often still require a injecting into the flexor tendon sheath.
subcutaneous wheal injected on the dorsum of
• Injection is performed at the level of the palmodigital crease (Fig. 1.16).
the finger to block the dorsal digital nerves
Step 2: Intrathecal Block
INTRATHECAL BLOCK: STEP 1 PEARLS
Can insert needle until contact with bone is made; then pull back slowly while inject-
Intrathecal block offers anesthesia with one injec- ing until a loss of resistance is felt—this is the plane between periosteum and tendon
tion and reportedly has a faster onset.
within the sheath (Fig. 1.17).
INTRATHECAL BLOCK: STEP 1
PITFALLS
Some patients report more and prolonged discom-
fort with intrathecal block technique.
INTRATHECAL BLOCK: STEP 2 PEARLS

Also, needing to contact the bone can be avoided
by slowly approaching with the volar injection until
the sheath is entered and injecting superficial to
the tendon; similarly here, injection plunger pres-
Flexor tendon sure on the syringe will have a loss of resistance
when the injection is entering the tendon sheath
space rather than the subcutaneous tissues or the
Common tendon substance itself.
digital nerve
Distal
palmar crease INTRATHECAL BLOCK: STEP 2
PITFALLS
Injection superficial to the tendon is often less
accurate, and in some cases no intrathecal injec-
tion occurs, because the injection is all performed
in the subcutaneous space.
FIGURE 1.12
Common
digital nerve
FIGURE 1.13
Flexor tendon
Common
digital nerve
Distal
palmar crease
FIGURE 1.14
A B
FIGURE 1.15
Digital crease
Flexor tendon
FIGURE 1.16
Flexor tendon sheath

Flexor digitorum
profundus Volar digital nerve
Flexor digitorum Volar digital artery
superficialis
Proximal
phalangeal bone
FIGURE 1.17
Postoperative Care and Expected Outcomes

• Most of these blocks can be expected to provide adequate reduction of pain and POSTOPERATIVE PITFALLS
sharp sensation for the areas targeted. • Neuropraxia is uncommon, especially with
• Duration of block is based on which anesthetic agent was used, as outlined earlier. these distal nerve blocks. However, should
they occur, they will often resolve within
See also Video 1.1, Anesthesia of the Hand, on ExpertConsult.com 4 weeks. Patient support and reassurance is
usually the only necessary treatment. In the
EVIDENCE rare event of complete or near-complete palsy,
additional evaluation is warranted to rule out
Bas H, Kleinert JM. Anatomic variations in sensory innervation of the hand and digits. J Hand Surg Am
new sources of compression.
1999;24:1171-84.
• Toxicity from the local anesthetic, although
Thirty fresh cadaver hand dissections were performed to investigate the course and interconnec-
incredibly uncommon with these small
tion of the sensory nerves. The authors found interconnecting nerves between the median and
doses, should always be considered if patient
ulnar nerve just distal to the transverse carpal ligament. The dorsal branch of the volar digital nerve
experiences central neurologic or cardiac
branched out at the proximal level of the A1 pulley in 62% of the specimens. The dorsal sensory
changes.
nerve extended to the nail level in the thumb and little fingers. (Level IV evidence)
Gebhard RE, Al-Samsam T, Greger J, Khan A, Chelly JE. Distal nerve blocks at the wrist for outpatient
carpal tunnel surgery offer intraoperative cardiovascular stability and reduce discharge time. Anesth
Analg 2002;95:351-5.
This retrospective study of 62 consecutive patients compared Bier block, peripheral nerve (median
and ulnar nerve) block, and general anesthesia for carpal tunnel surgery. Peripheral nerve blocks
had greater intraoperative cardiovascular stability and earlier postoperative discharge from postan-
esthesia care unit. (Level IV evidence)
Hung VS, Bodavula VKR, Dubin NH. Digital anesthesia: comparison of the efficacy and pain associated
with three digital nerve block techniques. J Hand Surg Br 2005;30:581-4.
This is a randomized, controlled, single-blind study of 50 healthy volunteers, comparing time
of onset, pain from block, and method of preference of three different digital blocks. The meta-
carpal block took significantly longer to block the digital nerves than the other two methods.
Forty percent of subjects felt discomfort for 24 to 72 hours after the transthecal digital block.
Forty-three percent of subjects chose the subcutaneous block as the preferred method. (Level
I evidence)
Low CK, Vartany A, Engstrom JW, Poncelet A, Diao E. Comparison of transthecal and subcutaneous
single-injection digital block techniques. J Hand Surg 1997;22:901-5.
Randomized double-blind study on 142 patients comparing transthecal digital block and subcuta-
neous digital block. No difference was found in effectiveness, distribution, onset, and duration of
action. (Level I evidence)
Sonmez A, Yaman M, Ersoy B, Numanodlu A. Digital blocks with and without adrenalin: a randomised-
controlled study of capillary blood parameters. J Hand Surg Eur 2008;33:515-8.
Twenty patients were randomized to digital block with 2% lidocaine and 2% lidocaine with 1:80,000
adrenalin. PO2 and SaO2 in the digits were not significantly different between the groups. No con-
cerning issues with digital perfusion were reported. Return of sensation in digits without adrena-
lin returned an average of 4.8 hours later, and with adrenaline occurred 8.1 hours later. (Level II
evidence)
PROCEDURE 2
Fasciotomy for Compartment Syndrome of the

Hand and Forearm
Indications
• Compartment syndrome—when pressure within a fibroosseous space increases to a
level that results in a decreased perfusion gradient across tissues
• Reperfusion after prolonged ischemia time, including tourniquet, wraps, casts, com-
pression, and others
• Crush injury with resultant edema, causing increased pressure in the closed muscle
space
• Other high-risk causes of compartment syndrome: injection injury, extravasation in-
jury, electrical injury, penetrating trauma, circumferential burns, snake or insect bites
• Certain injection injuries (air, water, other hydrophilic liquids) can potentially be
observed depending on volume, clinical presentation, etc.
• Injection of paint or other oil-based liquid requires early decompression and
additional exploration/debridement as needed. These injection injuries tend
to develop ischemia as well as deep space infections and worsen rather than
improve with time (Fig. 2.1A and B).
• The ischemia caused by compartment syndrome affects nerves and then muscle;
irreversible damage can occur within 6 hours for muscle or even less for nerves.
• The diagnosis is generally a clinical one, based on findings of nerve or muscle injury.
• Pain (out of proportion to injury, especially on passive stretch), paresthesia, paralysis,
pallor, pulselessness, and inability to regulate limb temperature (poikilothermia).
• Pain out of proportion to injury and paresthesias are the two earliest findings, where-
as pulselessness and pallor are often (too) late of findings; they may not occur at all.
• The limb/compartment is often firm to palpation, and overlying skin may become
shiny and even develop blisters (Figs. 2.2A and B and 2.3).
A B
FIGURE 2.1
13
14 PROCEDURE 2 Fasciotomy for Compartment Syndrome of the Hand and Forearm
A B
FIGURE 2.2
FIGURE 2.3
FIGURE 2.4
Imaging
• Often the diagnosis is clinically apparent, and therefore no additional imaging or
other workup is needed.
• Most commonly, the diagnosis in less clinically apparent cases is made by measuring
compartment pressures. Although many techniques have been described, the Stryker
system has been found to be quite accurate, with an arterial line manometer as a more
easily accessible secondary option that is quite accurate if used properly (Fig. 2.4).
PROCEDURE 2 Fasciotomy for Compartment Syndrome of the Hand and Forearm 15
Median nerve
Flexor carpi radialis muscle

Palmaris longus muscle
Brachioradialis muscle
Flexor digitorum
Radial artery
superficialis muscle
Superficial branch of radial nerve Ulnar artery
Extensor carpi radialis muscle Ulnar nerve

and tendon
Flexor carpi ulnaris muscle
Flexor pollicis longus muscle Flexor digitorum profundus
Anterior interosseous artery muscle
Radius Anterior interosseous nerve

Extensor carpi radialis brevis Interosseous membrane
muscle and tendon Extensor pollicis longus
muscle
Abductor pollicis longus muscle
Antebrachial fascia
Extensor digitorum muscle
Ulna
Posterior interosseus artery
Extensor carpi ulnaris muscle
Extensor digiti minimi muscle
Posterior interosseus nerve
FIGURE 2.5
• Normal tissue pressures range from 0 to 8 mm Hg. Any reading over 30 mm Hg

is an indication for urgent fasciectomy, and readings of 20 or above warrant very
close monitoring if not early surgical intervention based on the clinical scenario. Ad-
ditionally, some consider a difference of >20 mm Hg between diastolic pressure and
compartment pressure as an indication for fasciotomy as well (hypotensive/septic
patients).
• Slit catheters and side port needles are more accurate than straight needles when
measuring compartment pressures.
Surgical Anatomy
• The forearm has three major compartments—volar, dorsal, and lateral (mobile wad).
Within the volar and dorsal compartments, there are superficial and deep subcom-
partments. Some consider there to be a third separate volar subcompartment around
the pronator quadratus. The deep volar compartment is most susceptible and most
often affected by compartment syndrome, whereas the mobile wad is least com-
monly involved (Fig. 2.5 and Table 2.1).
• The carpal tunnel is susceptible to compressive pressures and is often released
when other upper extremity fasciectomies are performed.
• The hand is reported to have as many as 10 compartments, but the clinical sig-
nificance of each compartment is debated, and most surgeons do not release all
compartments in the setting of hand compartment syndrome. The compartments
that may need release include thenar, hypothenar, adductor pollicis, dorsal interos-
seous (4), and volar interosseous (3).
• Digital compartments are also described, bound by Cleland ligament and Grayson
ligaments, although the clinical significance of these compartments in the setting of
compartment syndrome is debated.
• For high-pressure injection injuries, the surgical approach may need to be adjusted
in order to allow for adequate debridement of ischemic tissue in the area of injection
(Fig. 2.1A and B).
Table
2.1 Myofascial Compartments of the Upper Extremity and Their Contents
Compartment Muscle Artery Nerve

Arm Anterior Biceps, brachialis, coracobrachialis Brachial Musculocutaneous
Posterior Triceps Profunda brachii Radial
Deltoid Deltoid — Axillary
Forearm Volar Radial and ulnar Median, ulnar, and
anterior interosseous
Superficial Pronator teres, flexor carpi radialis, palmaris longus,
flexor digitorum superficialis, flexor carpi ulnaris
Deep Flexor pollicis longus, flexor digitorum profundus,
pronator quadratus
Dorsal Pos. interosseous Pos. interosseous
Superficial Extensor digitorum communis, extensor digiti minimi,
extensor carpi ulnaris
Deep Abductor pollicis longus, extensor pollicis brevis,
extensor pollicis longus, extensor indicis proprius,
supinator
Mobile wad Brachioradialis, extensor carpi radialis longus, extensor — Radial
carpi radialis brevis
Hand Thenar Abductor pollicis brevis, opponens pollicis, flexor Digital Recurrent motor
pollicis brevis
Hypothenar Abductor digiti minimi, opponens digiti minimi, flexor — Ulnar
digiti minimi
Adductor Adductor pollicis — Ulnar
Interosseous Four dorsal and three palmar interosseous muscles — Ulnar
Carpal tunnel Flexor digitorum profundus, flexor digitorum — Median
superficialis, flexor pollicis longus
Digit Digital Digital
Exposures
• Forearm
• Volar release is traditionally done via a curvilinear incision from the medial epicon-
dyle to the proximal wrist crease. However, this places the distal flexor tendons
and median nerve at risk for exposure and dehiscence, and we disagree with us-
ing this approach.
• We advocate using two longitudinal incisions—one over the volar radial aspect
(over the flexor muscles) and the other over the dorsal ulnar aspect of the exten-
sor muscles. This approach decompresses the volar and dorsal compartments
without exposing the median nerve or distal forearm tendons (Figs. 2.6 and 2.7).
• The more traditional dorsal release is performed via a single longitudinal inci-
sion along a line between Lister tubercle and an area 4 cm distal to the lateral
epicondyle (incision is made in the space between extensor digitorum and
extensor carpi radialis brevis; Fig. 2.8). This is an acceptable approach for dorsal
release; however, we have found success with the more limited incision shown in
Figs. 2.6 and 2.7.
• Hand
• The carpal tunnel is approached via a single incision between the thenar and
hypothenar spaces, in line with the webspace between the middle finger and ring
finger (Figs. 2.9–2.11).
• The thenar compartment is approached via an oblique longitudinal incision along
the radial margin of the thenar eminence (Figs. 2.9 and 2.10).
• The hypothenar compartment is released via a longitudinal incision along the ulnar
aspect of the palm (Fig. 2.9).
Arm incision
Volar radial Dorsal ulnar

Forearm incision
FIGURE 2.6
FIGURE 2.7
Skin incision, dorsal forearm
FIGURE 2.8
Thenar release
Carpal tunnel release
Hypothenar release
FIGURE 2.9
FIGURE 2.10
EXPOSURES PEARLS
• Hypothenar compartment release should
not be done directly on the ulnar border, but
instead should be slightly radial to the border,
so that the scar is not on a direct pressure
area of the hand.
• If carpal tunnel decompression is also
warranted, there is no reason to use an
incision that crosses the wrist, as this
increases risk of an open wound exposing the
medial nerve and flexor tendons.
FIGURE 2.11
EXPOSURES PITFALLS
Making release incisions distal in the midvolar • Dorsal hand compartments are released by two longitudinal incisions parallel and
forearm that result in exposure of the median radial to the index and ring finger metacarpals (Figs. 2.12–2.14).
nerve or distal flexor tendons is not necessary and • Finger
risks desiccation and necrosis of these vital struc- • Decompression can be done with a midaxial incision along the noncontact
tures. Avoid these exposure approaches whenever (radial for index and thumb, ulnar for middle, ring, and small) side of the finger
possible (Fig. 2.16A and B).
(Fig. 2.15).
Dorsal hand release
FIGURE 2.12
FIGURE 2.13
FIGURE 2.14
Skin incision, finger
FIGURE 2.15
FIGURE 2.16
STEP 1 PEARLS
• If the muscle still appears white after opening Procedure: Fasciotomy of the Forearm
fascia, divide the epimysium as well.
• Prior to approaching deep flexor muscles, Step 1: Volar Forearm Release
identify the median nerve and stay ulnar to
it to avoid injury to the palmar cutaneous • The incision (Fig. 2.17) is made through skin and subcutaneous tissues, and the deep
branch. fascia investing the muscles of the forearm is divided.
• After electrical injury, even if the superficial • Subcutaneous flaps can be elevated allowing for mobilization of the incision site and
volar forearm is soft, exposure and release improved exposure in all directions.
of the deep compartment is often performed • Dissect between flexor carpi radialis and palmaris longus to expose the deep flex-
because this compartment can be injured from
the electrical energy conducted through bone ors (pronator quadratus, flexor pollicis longus, and flexor digitorum profundus) and
with sparing of the superficial compartment. decompress as needed with fascial incisions.
• It is critical to visualize deep compartment flexor muscles.
• Visualizing the deeper compartment is especially important after electrical injury.
STEP 1 PITFALLS
• Avoid exposure of median nerve and distal
Step 2: Dorsal Forearm Release
flexor tendons (Fig. 2.16A and B). • For approaching the dorsal forearm compartment, our preferred incision is longitudi-
• Traditional teaching of wide extensile nal along the dorsoulnar forearm (Fig. 2.6).
exposure for forearm fasciotomy is shown • Alternatively, the incision can safely be made along a line between extensor digito-
in Fig. 2.16A.
rum and extensor carpi radialis brevis.
• Fig. 2.16B shows the risk of this approach
for volar fasciotomy, a nonhealing wound • The incision is made through skin and subcutaneous tissues and the deep fascia is
with resulting exposure and desiccation of exposed and divided (Fig. 2.18).
flexor tendons (black arrow pointing to flexor • Via the same incision, approach the muscles of the mobile wad (brachioradialis,
carpi radialis [FCR] tendon) and median nerve extensor carpi radialis longus, and extensor carpi radialis brevis) and divide the
(white arrow); patient required amputation.
investing fascia to release that compartment.
FIGURE 2.17
FIGURE 2.18
STEP 4 PEARLS
FIGURE 2.19 • Most of the incision sites should be left open,
but closure over vital structures should be
done. Although using our approach should not
put these structures at risk, if median nerve
Step 3 and flexor carpi radialis tendons are exposed,
Release tourniquet (if one was used) and obtain hemostasis. Proceed with debride- place a few tacking sutures to secure soft
ment of nonviable soft tissues back to healthy bleeding tissue. tissue over them.
• Closure of the wounds immediately post-
Step 4: Postrelease release risks additional ischemia, and is
technically difficult due to the edema causing
• Place any other soft tissue retention system as appropriate. large gaps between wound edges; however,
• Place bulky moist dressing over any open wounds and fit removable splint in retention systems can be used (e.g., staples
functional position. and vessel loops; Fig. 2.19) to minimize wound
• Initiate regular dressing changes to prevent desiccation of exposed muscles and gaps spreading and making reconstruction
more challenging.
tendons.
Procedure: Fasciotomy of the Hand

Step 1: Carpal Tunnel Release
STEP 1 PEARLS • The incision is made between the thenar and hypothenar spaces in line with the
After releasing the carpal tunnel, close skin to pre- webspace between middle finger and ring finger.
vent desiccation and necrosis of tunnel structures. • Dissect down to and through the longitudinal aponeurotic fibers and identify the
transverse fibers of the transverse carpal ligament.
• Divide the transverse carpal ligament across the full distal and proximal extent of the
STEP 2 PITFALLS ligament to completely free the carpal tunnel.
Use caution with the distal extension of the incision
so as not to expose metacarpophalangeal joint. Step 2: Thenar Decompression
• Deepen incision until abductor pollicis brevis is encountered.
• Divide fascia over abductor pollicis brevis.
STEP 3 PITFALLS
Step 3: Hypothenar Decompression
Be careful not to divide the ulnar digital nerve to
the small finger. • Deepen the incision until abductor digiti minimi is visualized.
• Divide fascia over abductor digiti minimi.
Step 4: Dorsal Decompression

STEP 4 PEARLS • Incision along index finger metacarpal is used to decompress the first dorsal interos-
To fully decompress the dorsal interossei, one seous, adductor pollicis, as well as second dorsal interosseous.
must incise the overlying muscle fascia, which • Incision along the ring finger metacarpal is used to decompress the third and fourth
requires the extensor tendons be mobilized and
dorsal interossei.
retracted to adequately access this fascia in each
intermetacarpal space.
Step 5
Release tourniquet (if one was used) and obtain hemostasis. Proceed with debride-
STEP 4 PITFALLS ment of nonviable soft tissues back to healthy bleeding tissue.
Be cautious of the branches of the superficial radial
nerve and dorsal branches of the ulnar nerve.
Step 6: Postrelease
• Place a few tacking sutures to secure soft tissue over the carpal tunnel and other
exposed critical structures.
• Place bulky moist dressing over remaining open wounds, and fit a removable splint
in functional position.
• Initiate regular dressing changes to prevent desiccation of exposed muscles and tendons.
Postoperative Care and Expected Outcomes

• Elevation of the extremity postoperatively is critical in reducing edema and improving
pain control.
• Reexamine the extremity within 12 to 24 hours to evaluate need for additional
debridement.
• If there is any concern for muscle viability, plan on return to OR approximately 48
hours after initial surgery for examination and additional debridement.
• Wound care with regular moist gauze dressing changes (or petroleum-based dress-
ings) is important in preventing dessication of any open wounds.
POSTOP PEARLS • Attempt closure of open wounds (whether primary wound closure or skin graft) within
If the patient can tolerate it, one may elevate the 3 to 5 days when tissues are still somewhat pliable and in order to limit infection risk.
area by putting a stockinette on the arm and sling- • If fasciotomy was performed within 4 to 6 hours of compartment syndrome onset,
ing the arm on an IV pole. If this is attempted, be patient may regain full function and sensation; however, any delay beyond 3 to 4
sure to support the elbow with pillows. hours may result in some degree of permanent nerve and/or muscle damage.
See also Video 2.1, Fasciotomy for Compartment Syndrome of the Hand and Forearm,
on ExpertConsult.com.
EVIDENCE
Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis,
treatment, and outcome. J Pediatr Orthop 2001;21:680–8.
Retrospective study of 33 pediatric patients. Seventy-five percent developed compartment
syndrome due to fracture. “Traditional” signs and symptoms of pain, pallor, paresthesia, paralysis,
and pulselessness were not reliable for early diagnosis. However, with early diagnosis and
intervention, >90% achieved full restoration of function (Level IV evidence).
Chan PSH, Steinberg DR, Pepe MD, Beredjiklian PK. The significant of the three volar spaces in forearm
compartment syndrome: A clinical and cadaveric correlation. J Hand Surg 1998;23A:1077–81.
On seven arms, all three volar spaces (superficial, deep, pronator quadratus) were evaluated for
relief of pressure after compartment release. In six arms, superficial release was adequate to relieve
pressure in deep and PQ spaces; in the seventh arm the PQ space needed independent release.
Authors advocate release of superficial volar compartment and rechecking pressures in deep and
PQ before additional dissection and release (Level V evidence).
Ouellette EA, Kelly R. Compartment syndromes of the hand. J Bone Joint Surg 1996;78:1515–22.
This is a retrospective review of 17 patients after fasciotomy for compartment syndrome of the hand. All
patients were diagnosed based on tense, swollen hand and pressure elevation in at least one interos-
seous compartment. Full hand decompression as well as carpal tunnel release was performed for all 17
patients; 13 of 17 had satisfactory results, 4 patients had poor results (Level IV evidence).
Prasarn ML, Ouellette EA. Acute compartment syndrome of the upper extremity. J Am Acad Orthop
Surg 2011;19:49–58.
This is a review of the pathophysiology of compartment syndrome, pertinent surgical anatomy,
surgical approaches, and care recommendations based on up-to-date evidence (Level III
evidence).
Verhoeven N, Hierner R. High-pressure injection injury of the hand: an often underestimated trauma.
Case report with study of the literature. Strat Traum Limb Recon 2008;3:27–33.
This article is a case report and discussion on management of oil and paint gun injection injuries
in the hand. The authors discuss the need for early debridement due to the ischemia and in some
cases infection that results from delayed treatment.
PROCEDURE 3
Finger Amputations
Indications
• Amputation does not indicate failure of salvage; rather, it is part of the treatment algo-
rithm for helping patients return to optimal function after extensive traumatic injuries.
• Injury that damages a digit to a degree that vascularity and function cannot be re-
stored (unsuccessful or unfeasible revascularization).
• Complete amputation of digit(s) that cannot successfully be replanted—either due
to degree of injury to the digit, or to the likely impairment that a poorly functioning
replanted digit would cause for the rest of the hand.
• Finger injury that substantially destroys structural and/or functional integrity beyond
ability to adequately reconstruct—this includes multisegment injuries, avulsions that
cause traction injury to the vessels and nerves, and loss of bone segment(s).
• Patient preference after substantial trauma to digit(s). For injuries in which the prog-
nosis for return of function is poor (joint destruction, need for extensive soft tissue
reconstruction, etc.), patients may prefer amputation to prolonged therapy with only
moderate return of function.
• Ischemic necrosis of the finger(s)
• Malignancy requiring adequate resection margins
• Goal is to preserve functional length with durable soft tissue coverage.
• For the thumb, it is important to preserve the carpometacarpal joint so that a toe
transfer remains an available option.
• In multidigit injuries, it is important to consider using tissues from a digit requiring
amputation to provide coverage for an adjacent digit or hand wound.
• Create soft tissue flaps for viable and potentially sensate coverage of other injured
sites.
• Use bone, tendon, vessel, or nerve for grafting in reconstruction of other injured digits.
• Check perfusion of the finger, looking at capillary refill, color, and turgor (Fig. 3.1).
Note the color difference between the pink, vascularized finger (upper finger) and the
white devascularized finger (lower finger).
• Check that refill takes approximately 2 seconds. This is most easily done by compres-
sion and release at the nail bed if available (especially in patients with darker skin tone).
• If the finger feels soft and compressible, vascular inflow may have been lost result-
ing in this loss of turgor.
FIG. 3.1
24
PROCEDURE 3 Finger Amputations 25
• Evaluate sensation.
• Check response to sharp stimulus at fingertip—use a sterile needle to test sharp
sensation.
• Examine two-point discrimination (although often difficult in the recently injured
patient). Can be done using a premade device if available, or by opening up a
paper clip to the desired prong width. Can also gently press using the tips of
sharp iris scissors opened to various widths. The objective is to test at what width
between the two points the patient is able to distinguish two points from feeling
like one point of pressure.
• Examine the structural integrity of each involved finger—test the function of flexion
(superficialis and profundus) and extension against gravity and resistance.
Imaging
• X-ray is generally the only modality used to evaluate traumatized digits when decid-
ing about structural integrity and potential for long-term function if salvaged.
Surgical Anatomy
In general, revision finger amputations are done through the bony shaft, rather than at
joint level. Knowing the anatomy of the fingers is important for maintaining attach-
ments of flexor and extensor tendons if possible, as well as contouring bone appro-
priately for the revision stump (Fig. 3.2A and B).
For metacarpal amputations, one must decide between a transmetacarpal amputation
and a ray amputation.
• For border digits, one often can do a transmetacarpal (neck or shaft) amputation, with the
distal remaining bone cut at a 45-degree angle to preserve hand curvature and shape.
• For central digits, and for border digits in patients unhappy with hand function/ap-
pearance after border amputation, one often will do complete ray amputation with
removal of the metacarpal.
• For index and middle fingers, one must keep the metacarpal base to preserve the
extensor carpi radialis longus (ECRL)/extensor carpi radialis brevis (ECRB) attach-
ments (respectively).
Although some advocate leaving cartilage in place, it is our general practice to denude EXPOSURES PEARLS
cartilage at the amputation site. Denuding cartilage has remained standard teaching
• Peroxide soak/wash can be helpful in cleaning
in hand surgery; however, there is no clear evidence to support leaving the cartilage
off dried blood.
cap versus denuding it. • Use of a finger tourniquet facilitates operating
Identify the neurovascular bundles on radial and ulnar sides of digit. Ligate/cauterize in a dry field. An extra glove can be used if
the vessel for hemostasis and appropriately manage the nerve to prevent neuroma no prefabricated finger tourniquet option is
(discussed later) (Fig. 3.3). available (Fig. 3.5).
• Put a clamp on the finger tourniquet so
In a ray amputation, identify and protect the common (palmar) digital vessel and nerve
that the surgeon has a reminder to remove
so as not to injure inflow or sensation to the bordering digit (Fig. 3.4). the tourniquet after surgery. In the chaotic
The A1 pulley must be divided to identify the flexor tendons during transmetacarpal/ray environment of the emergency room, the
amputation (Fig. 3.4). surgeon may forget the tourniquet is still on
without a reminder. In the anesthetized finger,
Positioning the patient may not feel tourniquet pain until it
is too late.
With an adequate digital block, a revision finger amputation can often be performed in the
emergency department or in a small procedure room rather than the operating room.
EXPOSURES PITFALLS
Exposures
One should not stop active bleeding from the
Thoroughly clean the hand during examination and evaluation. This will aid in visu- injured finger before the examination has been
alization of skin color and perfusion, as well as the extent of deformity and soft performed, as tourniquet/pressure on the digital
tissue injury. Often, once the sensory examination has been completed, it is easi- bundles can potentially alter sensory examina-
est to place the digital block and then thoroughly clean the anesthetized finger(s) tion—attempt to use direct pressure on the bleed-
ing site if necessary.
(see Chapter 1).
26 PROCEDURE 3 Finger Amputations
DIP joint Terminal tendon
Lateral band
Middle phalanx
Central slip
PIP joint
Proximal phalanx
Sagittal bands
MP joint
Juncturae tendineae
Extensor tendon
FDP
FDS
FIG. 3.2
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She gave a gasp, and quickly put her hand to her mouth to smother a cry.
She sat bolt upright now, her two hands clutching the arms of her chair, her
eyes—wide open, glowing, scared—fixed upon her guardian. He, obtuse
and matter-of-fact, mistook the gasp and the tense expression of her face.
'No wonder you are aghast, my dear,' he said cheerily. 'Not unpleasantly,
I hope. More than once it seemed to your old guardian that Monsieur's
martial presence was not altogether distasteful to you. He hath sharper eyes,
hath the old man, than you gave him credit for—what? Ah, well! I was
young too, once, and I still like to bask in the sunshine of romance. 'Twas a
pretty conceit on Monsieur's part, methinks, to pay his court to you under a
disguise—to win your love by the charm of his personality, ere you realized
the great honour that a Prince of the Royal House of France was doing to
our poor country, by wooing her fairest maid.'
Monseigneur continued to ramble on in the same strain. Jacqueline

hardly heard what he said. She was striving with all her might to appear
composed, to understand what the old man was saying, and to reply to him
with some semblance of coherence. Above all, she was striving to get the
mastery over her voice, for presently she would have to speak, to say
something which would shake her guardian's complacency, open his eyes to
the truth, the whole hideous, abominable truth; without ... without ...
Heavens above, this must be a hideous dream!
'It was all arranged with de Montigny, you remember?' Monseigneur

continued, still engrossed in his own rhetoric, too blind to see that
Jacqueline was on the verge of a collapse. 'Monsieur was so fanciful, and
we had to give in to him. We all desired the alliance with our whole hearts,
and Madame la Reyne de Navarre did approve of our schemes. I must say
that de Lalain and I were against the masquerade at first, but Monsieur's
soldierlike personality soon won our approval. And imagine our joy when
we realized that our dear Jacqueline was not wholly indifferent to him
either. He came to us this afternoon and made formal demand for your hand
in marriage.... So de Lalain and I have taken measures that our poor people
do have a holiday to-morrow, when Madame Jacqueline de Broyart,
duchesse et princesse de Ramèse, will solemnly plight her troth to Monsieur
Duc d'Anjou. So, my dear Jacqueline, I entreat you to wear your loveliest
gown. Flanders is proud of her fairest flower. Monsieur desired to rejoin his
armies to-day and leave the ceremony of betrothal waiting for happier
times; but de Lalain and I would not hear of it. Everything is prepared for a
festive holiday. Of a truth, to-morrow's forenoon will see the happiest hour
which our sadly-afflicted province hath seen these many years.'
He paused; I think, for want of breath: he certainly had been talking

uninterruptedly for the past ten minutes, going over the whole ground of de
Montigny's mission, Monsieur's romantic desire and the final demand in
marriage, till Jacqueline could have screamed to him to cease torturing her.
The hideousness of the mystery appalled her: some dark treachery lurked
here somewhere and she was caught in a net of odious intrigues, out of
which for the moment she could see no issue. A feeling of indescribable
horror came over her—a nameless, unspeakable terror, as in the face of a
yawning, bottomless abyss, on the brink of which she stood and into which
an unseen and mighty hand would presently hurl her.
Something of that appalling state of mind must have been reflected in

her face, despite the almost superhuman effort which she made not to allow
Monseigneur to guess at what was going on in her mind; for presently he
looked at her more keenly, and then said gently:
'Jacqueline, my dear, you look so strange. What is it? Hath my news so

gravely startled you?'
She shook her head, and when he reiterated his question, and leaned
forward in order to take her hand, she contrived to say, moderately calmly,
even though every word came with an effort from her parched throat:
'The man with the mask? ... The Prince de Froidmont? ... You are sure?'
'Sure of what, my dear?' he riposted.
'That he is the Duc d'Anjou?'
Monseigneur laughed loudly and long, apparently much relieved.

'Oh! is that what troubles you, my child?' he said gaily. 'Well then, let me
assure you that I am as sure of that as that I am alive. Why!' he added,
evidently much surprised, 'how could you ask such a funny thing?'
'I did not know,' she murmured vaguely. 'Sometimes an exalted prince
will woo a maid by proxy ... so I thought...'
But evidently the idea of Jacqueline's doubts greatly tickled

Monseigneur's fancy.
'What a strange conceit, my child!' he said with condescending

indulgence. 'By proxy, forsooth! His Highness came himself, not more than
three days after Messire de Montigny completed negotiations with him at
La Fère. He desired to remain incognito and chose to lodge in a poor
hostelry; but Madame la Reyne de Navarre begged us in a letter writ by her
own august hand, to make Monsieur Duc d'Anjou, her dear brother, right
welcome in Cambray. By proxy!' and Monseigneur laughed again, highly
amused. 'Why, His Highness was in my study but two hours ago, and made
formal proposal for your hand in marriage!'
Then, as the door behind him was thrown open and old Nicolle, shuffling
in, announced M. le Comte de Lalain, d'Inchy turned to his old friend and
said, highly delighted with what he regarded as a good joke:
'Ah, my good de Lalain! You could not have come at a more opportune
moment. Here is our ward, so bewildered at the news that she asks me
whether I am sure that it is truly Monsieur Duc d'Anjou who has been
masquerading as the Prince de Froidmont. Do reassure the child's mind, I
pray you; for in truth she seems quite scared.'
De Lalain, always a great stickler for etiquette, had in the meanwhile

advanced into the room, and was even now greeting Jacqueline with all the
ceremonial prescribed by Maître Calviac. Then only did he reply soberly:
'Sure, Madame? Of course we are sure! Why, 'tis not two hours since he
was standing before us and asking for the hand of Madame Jacqueline de
Broyart in marriage. We knelt before him and kissed his hand, and to-
morrow we'll present him to the people as the future Sovereign Lord of the
Netherlands.'
'And so, my dear Jacqueline——' concluded d'Inchy. But he got no

further, gave a loud call to Nicolle and the women; for Madame had uttered
a pitiful moan, slid out of her chair, and was now lying on the floor in a
swoon.
CHAPTER XXII
WHILE OTHERS FAILED
Of a truth, Monseigneur the governor was not gravely perturbed by his

ward's sudden attack of faintness. He knew that women were subject to
megrims and sundry other fancies, and he was willing to admit that in his
excitement he had, perhaps, been too abrupt with her and too brusque. She
had been scared, bewildered, no doubt, and lost consciousness in her
agitation. But old Nicolle had quickly come to the rescue with restoratives;
and with the prerogative of an old and trusted servant, she had bundled
Monseigneur and Monsieur de Lalain incontinently out of the room.
Madame would soon be well, she said, only needed rest. She was
overwrought and over fatigued with so many banquets and public functions
—such late hours, too; and Madame not twenty! Young people needed
plenty of sleep, and Madame, after a good and peaceful night, would be
quite well on the morrow.
So Monseigneur, fully reassured, went back to his apartments and to his

own business. There was still a great deal to be done, a great deal to see to
—many people to interview and many more orders to give, to ensure that
to-morrow's ceremony should be conducted not only with perfect
smoothness, but also that the preparations for it be concluded with perfect
secrecy.
M. de Lalain, d'Inchy's old friend, was an invaluable helpmate, and de

Landas too had for the occasion thrown off that supercilious manner which
he had adopted of late, and had entered fully into the spirit of the affair.
There was no fear that the wily Valois fox would slip from out the trap
which was being so skilfully laid for him.
Already messengers, dressed in Monseigneur the governor's livery, were

flying all over the town, carrying letters and sign-manuals. Directly these
were delivered, extraordinary bustle and activity came at once into being in
the official and municipal centres of the city. The Provosts could be seen,
wearing their chain of office and hurrying to the Town Hall, where they
were received by the Chief Magistrate. Orders and counter-orders flew from
one end of the town to the other, from the Citadel to the Palace and from
Cantimpré to the Château, while, by special command of M. le Marquis de
Landas, the entire garrison, which manned the forts, was under arms during
the whole of that night.
The humbler folk, scared by this unwonted turmoil, shut themselves up

with their families inside their houses, until a persistent rumour reassured
them that no fresh assault on the part of the besieging army was expected,
but rather that a happy, joyful and hopeful proclamation would be made by
Monseigneur the governor on the morrow, from the balcony of the Town
Hall. Whereupon fear and trouble were for the moment put resolutely away.
The people were beginning to suffer so acutely, that they were abjectly
thankful for any ray of hope, which gleamed through the darkness of their
ever-present misery. With the Duke of Parma's armies at their gates, they
were still clinging to the thought that some mighty Power would take
compassion on them, and come to their rescue with a force strong enough to
inflict a severe defeat upon the Spaniard. They had not yet reached the final
stages of despair. They were still ready to seize every opportunity for
forgetfulness, for enjoyment even, whenever it was offered or allowed
them. Rumour had been persistent about the help which was to come from
France. Messire de Balagny's presence in the city had confirmed the hopes
which had rested upon those rumours. Now, with the knowledge that
Monseigneur had a joyful announcement to make, mercurial temperaments
rose for awhile—especially among the young. The older people had been
too often deluded with flowery promises to believe in any good fortune for
their unfortunate city. They had seen the fate of others—of Mons and of
Mechlin and of Gand. The might of the Spanish armies always conquered in
the end, and the rebellious cities had been made to suffer untold brutalities,
as a punishment for their heroic resistance.
Fortunately for the morale of Cambray, these older people, these

wiseacres, were still in the minority, and hope is of all human attributes the
strongest and the most persistent. So, despite the prognostications and fear
of pessimists, people rose early on the following morning, in order betimes
to decorate their houses. Soon after dawn, activities began; flags were
dragged out of old, disused coffers and hung out of windows and balconies;
the women sought, in their worm-eaten dower chests, for any scraps of
finery that may have survived from the happy olden days, before their
Spanish tyrants had made of this prosperous land a forlorn wilderness.
By eight o'clock the beleaguered city looked almost gay. The shops were
closed; soldiers paraded the streets; the city guilds, their masters and their
'prentices, came out with banners flying, to stand in groups upon the Grand'
Place. If a stranger could have dropped into Cambray from the skies on that
fine April morning, he would of a truth have doubted if any Spanish army
was encamped around these walls.
II
Even Gilles de Crohin, absorbed as he was in his own affairs, could not
fail to notice the generally festive air which hung about the place. In the
quarter where he lodged, it is true that very little of that holiday mood had
found its way down the narrow streets and into the interior of squalid
houses, where the pinch of cold and hunger had already made itself
insistently felt. But as soon as he was past the Place aux Bois, he began to
wonder what was in the wind. The populace had been at obvious pains to
put aside for the moment every outward sign of the misery which it
endured. The women had donned their best clothes, the men no longer hung
about at street corners, looking hungry and gaunt. They did not even scowl
in the wake of the masked stranger, so lately the object of their ire, as the
latter hurried along on his way to the Palace.
And then there were the flags, and the open windows, the draped
balconies and pots of bright-coloured early tulips—all so different to the
dreary, drab appearance which Cambray had worn of late.
But, nevertheless, Gilles himself would have told you afterwards that no
suspicion of Monseigneur d'Inchy's intentions crossed his mind. Vaguely he
thought that Messire de Balagny's arrival had been announced to the
townfolk, and that the promise of help from France had been made the
occasion of a public holiday. And he himself was in too much of a fume to
pay serious heed to anything but his own affairs—to anything, in fact, but
his own departure, which had been so provokingly delayed until this
morning.
And this veracious chronicle has all along put it on record that Messire
Gilles de Crohin was not a man of patience. Imagine his choler, his fretting
rage when, fully prepared for his journey, mounted upon the same horse
which had brought him into Cambray a month ago, and duly accompanied
by Maître Jehan, who had a pack-horse on the lead, he had presented
himself on the previous afternoon at the Porte Notre Dame with his original
safe-conduct, and was incontinently refused exit from the city, owing to
strict orders issued by the commandant of the garrison that no one should be
allowed to pass out of the gates under any pretext whatsoever.
Gilles had argued, persuaded, demanded; but he himself was too

thorough a soldier not to have realized from the first that every argument
would be futile. The captain of the guard assured him that he could do
nothing in the face of the strict and uncompromising orders which he had
received. Gilles was of course quite certain that some one had blundered—a
mere matter of formality, which Monseigneur the governor could put right
with a stroke of the pen—but it was obviously not for a subordinate officer
to question his orders, or to take any revision thereto upon himself; and
Gilles, after receiving the captain's courteous regrets, had no option but to
ride away.
It was then six o'clock of the afternoon, and the brilliance of the early
spring day was quickly fading into dusk. A boisterous wind had sprung up,
which brought heavy banks of cloud along, threatening rain. But, rain or
shine, Gilles had no thought as yet of giving up his purpose. There were
other gates within the city walls, and wrapping his mantle closely round his
shoulders, he gave spur to his horse and started on a new quest, closely
followed by Maître Jehan. It is on record that he went the round of every
gate, armed with his safe-conduct and with as much patience as he could
muster. Alternately he tried bribery, persuasion, stealth; but nothing availed.
The town garrison was everywhere under arms; orders had been given, and
no one, be he the highest in the land, was allowed to leave.
Had the matter been vital or the adventure worth the trial, I doubt not but
what Messire would have endeavoured to get through at all costs—have
scaled the city walls, swam the river, challenged the Spanish lines and run
the gauntlet of archers and gunners, in order to accomplish what he wanted,
if he had wanted it badly. But a few hours' delay in his journey could make
no matter, and truth to tell he was in no mood for senseless adventure.
In the meanwhile, however, several hours had been wasted on fruitless

errands. It was late evening. The heavy gale had brought along its due
complement of rain. It were certainly not seemly to disturb Monseigneur
the governor in the Palace at this hour, so Gilles and Jehan returned, sorely
disappointed, to their lodgings, there to spend a sleepless night, waiting for
the first reasonable hour in the morning wherein Monseigneur the governor
might be expected to transact business. And I can confidently affirm that no
suspicion of what was in contemplation for the confusion of the fickle
Prince, crossed Gilles' mind, as he lay half the night, staring into the
darkness, with the image of Jacqueline haunting his tortured brain.
III
At eight o'clock the next morning, he was once more at the
Archiepiscopal Palace, demanding to see Monseigneur. Not wishing to
challenge any comparison at this eleventh hour between his two entities, he
had elected to present himself under his disguise and his mask, and to send
in a greeting to Monseigneur with the message that Messire le Prince de
Froidmont desired to speak with him immediately.
But it seems that Monseigneur had been very ill all night and had not yet
risen. A leech was in attendance, who, ignorant of the true rank of this early
visitor, strictly forbade that the sick man should be disturbed. No doubt if
Messire le Prince de Froidmont would present himself a couple of hours
later—the leech added suavely—Monseigneur would be prepared to see
him.
It was in very truth a trial of patience, and I marvel how Gilles' temper
stood the strain. The fact that he was a stranger in the city, without a friend,
surrounded too by a goodly number of enemies, may be accountable for his
exemplary patience. Certain it is that he did once again return to his
lodgings, anathematizing in his heart all these stodgy and procrastinating
Flemings, but otherwise calm and, I repeat, wholly unsuspecting.
At ten o'clock, a runner came to him with a message that Monseigneur

had been unexpectedly summoned to the Town Hall, but, not wishing to
disappoint M. le Prince de Froidmont, he begged the latter to go forthwith
to see him there. So Gilles left horses and baggage in Maître Julien's charge
and, accompanied by Jehan, he proceeded on foot to the Town Hall. He had
much difficulty in forcing his way through the crowd, which had become
very dense, especially in and about the Grand' Place.
Gilles, indeed, could not help but notice the festive appearance of the
town, the flags, the flowers, the banners of the guilds. Above all, the good-
humour of the crowd was in such strange contrast to their habitual surliness.
Instead of uttering insults against the masked stranger, as he jostled them
with his elbows and a rapid 'By your leave!' they chaffed and teased him,
laughed and joked among themselves in perfect good-humour.
In and about the Town Hall there was a large concourse of people, city
fathers and high dignitaries in official attire. The perron steps were
decorated with huge pots of Dutch earthenware, placed at intervals all the
way up as far as the entrance doors and filled with sheaves of white
Madonna lilies, produced at great cost at this season of the year in the
hothouses of the Archiepiscopal Palace. Pots containing the same priceless
flowers could also be seen up on the huge balcony above the entrance, and
showing through the interstices of the stonework of the splendid balustrade.
There was also a guard of honour—halbardiers in their gorgeous attire—
who lined the hall and the grand staircase as far as the upper floor.
When Gilles appeared outside the huge entrance gates, an usher in sober
black came forward from some hidden corner of the hall, and approached
him with marked deference. Monseigneur the governor had given orders
that directly M. le Prince de Froidmont presented himself at the Town Hall
he was to be shown up to the Council Room.
Gilles, having ordered Jehan to wait for him below, followed the usher
up the grand staircase, noting with the first gleam of suspicious surprise that
the guard presented arms as he went by.
But even then he did not guess.
IV
The Council Room was crowded when Gilles entered. At first he felt
quite dazed. The whole scene was so ununderstandable, so different to what
he had expected. He had thought of finding Monseigneur the governor
alone in a small apartment; and here he was ushered into a magnificent hall,
harmoniously ornamented with priceless Flemish tapestry above the rich
carving of the wainscoting. The hall was crowded with men, some of whom
he had vaguely seen on the night of the banquet at the Archiepiscopal
Palace. There was the Chief Magistrate, a venerable old man, gorgeously
decorated with a massive gold chain and other insignia of authority; there
were the Mayors of the City guilds, each recognizable by their robes of
state and the emblems of their trades; there were the Provosts and the
Captains of the guard and the Chiefs of the Guild of Archers, with their
crimson sashes, and there was also Monseigneur the governor, looking
more pompous and solemn than he had ever done before.
Gilles was once more deeply thankful for the mask which covered his
face, together with its expression of boundless astonishment, amounting to
consternation, which must inevitably have betrayed him. Already he would
have retreated if he could; but even as the swift thought crossed his mind,
the ushers closed the doors behind him, the guard fell in, and he was—there
was no mistaking it—a virtual prisoner.
Dressed for the journey, booted and spurred, with leather jerkin and
heavy belt, he stood for a moment, isolated, at the end of the room, a
magnificent and picturesque figure, mysterious and defiant—yes, defiant!
For he knew in one instant that he had been trapped and that he, the
gambler, had been set to play a losing game.
His quick, keen glance swept over the dignified assembly. Monseigneur,
in the centre, was advancing to greet him, bowing almost to the ground in
the excess of his deference. Every head was bared, the captains of the guard
had drawn their swords and held them up to the salute. Through the wide-
open, monumental windows, the pale April sun came peeping in, throwing
a glint of gold upon the rich robes of the Provosts and the Mayors. A
murmur of respectful greeting went round the room, followed immediately
by loud and prolonged cheering; and Gilles—suddenly alive to the whole
situation—took his plumed hat from off his head and, with a splendidly
insolent gesture, made a sweeping bow to the assembled dignitaries. His
life, his honour, his safety, were hanging by a thread. He stood like a
trapped beast before a number of men who anon would be clamouring
perhaps for his blood; but the whole situation suddenly struck him as so
boundlessly humorous, the solemnity of all these worthy Flemings would
presently be so completely ruffled, that Gilles forgot the danger he was in,
the precariousness of the position in which he stood, only to remember its
entirely ludicrous aspect.
'Long live His Highness le Duc d'Anjou et d'Alençon!' came in rousing

cheers, which woke the echoes of the old Town Hall.
And outside, on the Grand' Place, the people heard the cheering. They
did not know yet what it was about, but they had come out on this fine April
morning to enjoy themselves, to forget their troubles, their danger, their
miseries; and when they heard the cheering, they responded with full throat
and heart, and acclaimed not what they knew but what they hoped.
'You have beaten me, Messire,' Gilles said in a good-humoured whisper

to Monseigneur the governor, as the latter bent one knee to the ground and
kissed the gracious hand of the Valois Prince. 'Never was game so skilfully
trapped! All my compliments, Messire. You are a born——' 'liar' he would
have said, but checked himself just in time and used the smoother word
—'diplomatist.'
'Your Highness will not grudge us our little ruse,' d'Inchy riposted under
his breath with a suave smile. 'It is all for your glorification and the
exaltation of our promised union with France.'
'Take care, Messire!' retorted Gilles, 'that your want of trust in me doth
not receive the punishment it deserves.'
He had still the thought that he might run away. The only time in the
whole course of his life that Gilles de Crohin had the desire to show a clean
pair of heels to the enemy! If he could only have seen the slightest chance
of getting away, he would have taken it—through door or window, up the
chimney or the side of a house—any way, in fact, out of this abominable
trap which these astute Flemings had so skilfully laid for him. And this,
despite the fact that he had spied his arch-enemy, de Landas, at the far end
of the room—de Landas, who was gazing on him, not only in mockery but
also in triumph.
Nevertheless, Gilles was ready to turn his back even on de Landas—

anything, anything, in fact, to get away; for the situation, besides being
ludicrous, was tragic too, and desperate. One false move on his part, one
unconsidered word, and the whole fabric of Madame la Reyne's schemes
would totter to the ground. He seemed to see her now, with her gracious
hand extended towards him and the tears streaming down her cheeks, while
she said with solemn earnestness: 'When a prince of the house of Valois
breaks his word, the shame of it bears upon us all!' He seemed to see
himself with his hand upon the crosshilt of his sword, swearing by all that
he held most sacred and most dear that he would see this business through
to the end. Indeed, the end was in sight, and he felt like a soldier who has
been left all alone to defend a citadel and ordered to hold it at all costs.
That citadel was the honour of France.
And the soldier-nature in him not only refused to give in, but at this
supreme hour rejoiced in the task. He would hold on at all costs for the
honour of Monsieur, his master; but, above all, for the honour of France. If
contumely, disgrace or shame was to fall, in consequence of this gigantic
hoax, then it must fall entirely on him—Gilles de Crohin, the penniless
adventurer—not upon a Prince of the Royal House of France. Either he
would be able to extricate himself from this desperate position with the
mask still upon his face and Monsieur's secret still inviolate before these
assembled Flemings, or the whole burden of knavery and imposture must
fall upon him alone—the shameless rogue who had impersonated his master
for some unavowable purpose, and perpetrated this impudent fraud for the
sake of some paltry gain.
It only took him a few seconds thus to pass the whole situation, present
and future, in a brief review before his mind. Having done it, he felt
stronger and keener for the fight and ready for any eventuality. The honour
of France!—and he left here to guard it! ... Ye gods! but he felt prouder than
any king! Contumely, disgrace, exposure, an ignominious flight—mayhap a
shameful death. Bah! what mattered anything so long as the honour of
France and of her Royal House remained untarnished before the world?
Fortunately Jacqueline was not here! Perhaps she would not come!
Perhaps these wily fools, when they had set their trap, had left her out of
their reckoning. In which case, all might be well; the chances of exposure
remained remote. A little more impudence, a brief half-hour still of this
abominable rôle, and the curtain must fall at last upon the farcical tragedy
and he, Gilles, would be free to become an honest man once more.
A little luck!! And, remember that he was a gambler, and staking his all
upon the last throw!
And as, one by one, the city dignitaries came up to be presented by the
governor to His Highness, and as the minutes sped away, hope once more
knocked at the gateway of the adventurer's heart. One by one they came,
these solemn Flemings. They bent the knee and kissed the hand of the
Prince who was to be their Sovereign Lord. And some of them were old and
others very rheumatic; most of them appeared to Gilles highly ridiculous in
this homage rendered to an impostor. The desire to laugh aloud became
positive torture after awhile, and yet nothing but self-possession could carry
the day, now that every second rendered Gilles' position more hopeful.
For still Jacqueline did not come! Jacqueline! the only person inside this
city who could betray him, and she the one being in the entire world before
whom he would have wished to remain deserving and unimpeached. She of
a truth would know him amongst a thousand; her loving, searching eyes
would laugh at masks and disguises! Her finger alone could, at sight of him,
point at him with scorn; her voice, like that of an avenging angel, could be
raised against him, saying:
'That man is a liar and a cheat! He is not the Duc d'Anjou!'
Monseigneur the governor acted throughout as the Master of

Ceremonies. Obsequious and suave, he seemed to have no wish save to
please His Highness in all things, and to make him forget the want of trust
that the present ceremony implied. He hovered round Gilles, executing a
manoeuvre which the latter was certainly too guileless to notice. It was a
case of: 'On this side, I entreat Your Highness!' and 'Here is Messire de
Haynin, who craves the honour...' or 'If Your Highness would deign to speak
with Messire d'Anthoin.' All very subtle and unnoticeable, but it meant that
every time a city father came to kiss hands, Gilles, in order to greet him,
had to take a step or two forward, and that each step brought him a trifle
nearer to the open window. That window gave directly on La Bretèque, the
vast terrace-like balcony which overlooked the Grand' Place and which had
so often been the scene of historic proclamations. Suddenly Gilles found
himself there, in the open, with a huge concourse of people down below at
his feet.
He had Monseigneur the governor on his left, and the company of city
fathers and dignitaries had followed him out on La Bretèque. They were
standing in a compact group around him; and all down the length of the
balcony, at the foot of the balustrade, there were huge pots filled with those
Madonna lilies, which seemed like the very emblem of Jacqueline.
Time had gone on; the crowd had cheered at sight of him, and Gilles had
gradually been lulled into a semblance of security. Then suddenly, from the
far end of the balcony, some fifty paces away, there came the sound of an
usher's voice calling in stentorian tones:
'Make room for Madame Jacqueline de Broyart, Duchesse et Princesse

de Ramèse, d'Espienne et de Wargny! Make room!'
And down the vista of the long terrace, he caught sight of Jacqueline
advancing towards him between the avenue of lilies. She was dressed in a
white satin gown, and she had pearls round her neck and in her hair. The
April sun fell full upon her, and the soft breeze blew the tendrils of her hair,
like strands of gold, about her face. With a sinking of the heart, Gilles saw
that she walked with a weary and listless step; but she held herself very
erect, with head slightly thrown back, looking straight out before her as she
came. A mask of black satin hid her face, but even though he could not see
those heavenly blue eyes of hers, Gilles had realized in a moment that his
beloved knew everything.
An access of wellnigh savage rage sent the hot blood up to his head. For
the space of one second everything around him took on a blood-red hue,
and he turned on d'Inchy with convulsed fingers, prepared to grip him by
the throat. Already the cry 'You miserable scoundrel!' hovered on his lips....
Then he checked himself. What was the good? D'Inchy had acted rightly, in
accordance with his own lights. He wished to make sure that the Valois
Prince, who had broken so many promises in his life, should at least on this
one occasion be irrevocably fettered. The assembled dignitaries, the crowd
down below, the whole city of Cambray should witness the solemn
plighting of his troth. And Jacqueline—the unfortunate, innocent pawn in
all these intrigues—should be the one whose weak, small hands would hold
him indissolubly to his bond.
There was a moment of tense silence. Gilles could hear his own heart
beating in his breast. He had of a truth ceased to feel and to think. The
situation was so hopeless now, so stupendous, that it was beyond human
power to grapple with. He hardly felt that he was alive; a kind of greyish
veil had interposed itself between his eyes and that group of solemn
Flemish worthies around him. And through that veil he could see their
podgy faces, red and round, and grinning at him with great cavern-like
mouths, and eyes that darted fierce flames upon him. Of a truth, he thought
that he was going mad, had a wild desire to throw back his head and to
laugh—laugh loudly and long; laugh for ever at the discomfiture of some
fool who was standing there in his—Gilles de Crohin's—shoes; at that fool
who had thought to carry through a long farce unchecked, and who
presently would be unmasked by the very woman whom he loved, and
driven forth under opprobrium and ignominy into an outer world, where he
could never look an honest man in the face again.
Perhaps he would have laughed—for the muscles round his mouth were
itching till they ached—only that, just then, in the very midst of the crowd
below, he caught sight of de Landas' mocking glance—de Landas, who had
been in the Council Room awhile ago, and who apparently had since mixed
with the crowd for the sole purpose of witnessing his successful rival's
discomfiture. This seemed to stiffen him suddenly, to drag him back from
out that whirlpool of wild sensations wherein he was floundering, and
which was bowling him along, straight to dementia.
'No, my friend Gilles!' he said to himself. 'Since you are to die

dishonoured, at least die like a man. Not before all these people; not before
that man who hates you, not before that woman who loves you, shall you
flinch in the face of Destiny. You have played many ignoble parts these
days; do not now play that of a coward!'
And he stood quietly there, still picturesque and magnificent, still

defying Fate which had played him this last, desperate trick, while
Monseigneur advanced to Jacqueline, took her hand and said aloud in
measured tones of ceremony, so that every one there might hear:
'My dear Jacqueline, it is with inexpressible joy that mine old eyes
behold this happy hour. Monsieur Duc d'Anjou et d'Alençon, Prince of the
House of France, hath asked your hand in marriage. We, your guardians, do
but await your consent to this union which we had planned for the great
good of our beloved country. Say the word, my dear Jacqueline, and I
myself will proclaim to our poor, sorrowing people the joyful news that a
Liberator hath come to them at last, and that the United Provinces of the
Netherlands may look to him as their Sovereign Lord and King.'
Jacqueline had listened to Monseigneur's peroration with perfect

composure. She stood then not ten paces away from Gilles—the only
woman in the midst of all these men who were gambling with her destiny.
Through her mask she was looking on Gilles, and on him only, feeling that
the whole abyss of loathing, which filled her soul for him, would be
conveyed to him through her look.
She had believed in him so completely, trusted him so implicitly, that

now that she knew him to be both a liar and a cheat, she felt that the very
well-spring of her love had turned to bitter hate. And hate in a strong and
sensitive nature is at least as potent as love. What the mystery was
wherewith he chose to surround himself, she did not know. What the object
of the hideous comedy which he had played could be, she hardly cared. All
that she knew was that he had cheated her and played her false, stolen her
love from her to suit some political intrigue of which he held the threads—
helped in any case in a hideous and clumsy deception which would leave
her for ever shamed.
But now she knew just what she had to do. She might have unmasked
the deception last night, told Monseigneur the truth and opened his eyes to
the stupid fraud that was perpetrated upon him. What stopped her from
doing that she did not know. Perhaps she still hoped that something would
occur that would give a simple explanation of the difficult puzzle. Perhaps
she thought that when she would be brought face to face with the man who
was impersonating the Duc d'Anjou, that man would prove to be some low
impostor, but not her knight—not the man who had held her in his arms and
sworn that his love for her was as pure as that of the lark for the sun. And if,
indeed, she had been so hideously deceived, if her idol prove to have not
only feet of clay but heart of stone and soul of darkness, then she would
unmask him, publicly, daringly, before the entire people of Cambray,
humiliate him so utterly that his very name would become a by-word for all
that was ignominious and base, and find some solace for her misery in the
satisfaction of seeing him brought to shame.
Therefore Jacqueline had said nothing last night to Monseigneur—

nothing this morning. When requested by her guardian to prepare for this
day's ceremony, she had obeyed without a word. Now she listened to his
speech until the end. After which, she said calmly:
'Like yourself, Monseigneur, I am covered with confusion at thought of

the great honour which a Prince of the House of France will do to our poor
country. I would wish, with your permission, to express my deep respect for
him ere I place my hand in his.'
Whereupon Monseigneur stood a little to one side, so that Jacqueline and

Gilles remained directly facing one another. Every one was watching the
young pair, and kindly murmurs of approval at the beauty of the girl, and
the martial bearing of the man, flew from mouth to mouth.
Jacqueline, stately and dignified as was her wont, advanced a step or

two. Then she said slowly:
'And is it of a truth Monsieur Duc d'Anjou et d'Alençon who stands

before me now?'
She looked straight at him, and he in imagination saw beneath the mask
which hid the expression of her face—saw those blue eyes which had
looked on him yesterday with such ineffable tenderness; saw those exquisite
lips which had murmured words of infinite love. An utter loathing
overcame him of the part which he had to play, of the fraud which was to
deliver his beloved into the keeping of a worthless reprobate. He was
conscious only of a wild desire to throw himself at her feet in an agony of
remorse and repentance, to kiss her gown, the tips of her velvet shoes; and
then to proclaim the truth, to put it for ever out of that profligate Prince's
power to claim this exquisite woman as his bride—to proclaim the truth,
and then to run away like a second Cain, from the scene of an unforgivable
crime; to flee like the treacherous soldier who hath deserted the citadel; to
flee, leaving behind him the tattered rag of France's honour lying for ever
soiled in the dust, beneath the feet of a duped and credulous nation.
Just then she put out her hand—that perfect hand, which he had held in
his and which to his touch had seemed like the petal of a flower, and she
said, with the same solemn deliberation:
'Is it in truth to the Duc d'Anjou himself that I herewith plight my troth?'
The avowal was on Gilles' lips.
'Madame——' he began, and looked unflinchingly, straightforwardly at

her.
But before he could speak another word, a cry suddenly rang out—shrill
and terrifying—out of the crowd.
'Do not touch him, Madame! Do not touch him! He is not the Duc
d'Anjou! He is an impostor and a liar! A Spanish spy! Beware!!'
Monseigneur, the city fathers, the Mayor—every one on La Bretèque, in

fact—gasped with horror. How dared these abominable agitators mar the
beauty of this affecting ceremony? Monseigneur went forward, leaned over
the balustrade in order to try and ascertain who it was who was trying to
create a disturbance. He saw de Landas down below in the midst of the
throng, vaguely wondered what the young commandant was doing there,
when his place was up on La Bretèque amongst those of his own rank.
Anyway, he spoke to de Landas, shouted himself hoarse to make the young
man hear, for an unpleasant turmoil had followed that first cry of 'Spanish
spy'—people were shouting and gesticulating and the call 'Down with him!'
came repeatedly from several points in the rear of the crowd.
De Landas looked up, but he pretended not to hear, laughed and

shrugged his shoulders, as if the matter did not concern him. And yet there
was no mistaking the persistence with which that ominous cry 'Spanish
spy!' was taken up again and again, nor the disturbing effect which it had
upon the crowd.
Monseigneur then tried to harangue the mob, to point out to them the
evil of their ways. Had they forgotten that they were out to enjoy
themselves, to forget their troubles, to forget the very fact that the words
'Spaniard' and 'Spanish' existed in their lexicon. But Messire de Landas'
paid agents would not let him speak. They had been paid to create a
disturbance, not to let the people stand about placidly, listening to windy
harangues.
So, the moment Monseigneur opened his mouth, the whole gang of them
took up the provocative cry: 'A Spanish spy! Take care, Madame
Jacqueline!' until it was repeated over and over again by numberless voices,
hoarse with excitement and with spite. The crowd oscillated as if driven by
a sudden blast; ominous murmurs came from those points where women
and men stood in compact and sullen groups.
'Spanish spy! Beware!' rang out again and again.
Monseigneur the governor was in a wild state of agitation. He could not

understand what it was that had set some rowdy malcontents to disturb the
peaceful serenity of this eventful morning. Unable to make himself heard,
he turned in helpless bewilderment to Gilles.
'Monseigneur,' he began, in a voice quivering with consternation. 'I do

entreat you...'
But he got no further. Above this peroration, above the shuffling and the
mutterings of his friends on the balcony, above the cries and murmurs down
below, there had suddenly resounded the dull boom of distant cannon. The
crowd gave one terrific, full-throated roar of terror:
'The Spaniards! They are on us!'
And in the seething mass of humanity on the Grand' Place could be seen
just that awful, ominous swaying which precedes a stampede. Already the
women screamed and some men shouted: 'Sauve qui peut!'
'The Spanish spy!' cried a voice. 'What did I tell you, citizens? He hath
taken advantage of this holiday to bring the Spaniards about your ears!'

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Operative Techniques : Hand and Wrist

Surgery 3rd. Edition Chung - eBook

Green's operative hand surgery Seventh Edition Cohen -

Operative Techniques: Spine Surgery. A volume in

(eBook PDF) Operative Techniques: Shoulder and Elbow

(eBook PDF) Operative Techniques in Gynecologic

(eBook PDF) Operative Techniques in Plastic Surgery

Operative Techniques: Knee Surgery 2nd Edition Edition

Operative Techniques: Orthopaedic Trauma Surgery 2nd

(eBook PDF) Reconstructive Surgery of the Hand and

Kevin C. Chung, MD, MS

OPERATIVE TECHNIQUES: HAND AND WRIST SURGERY,

Previous editions © 2012, 2008

Library of Congress Cataloging-in-Publication Data

Names: Chung, Kevin C., editor.

Content Strategist: Kayla Wolfe

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Joshua M. Adkinson, MD Aviram M. Giladi, MD, MS Taichi Saito, MD, PhD

Kevin C. Chung, MD, MS

Anesthesia of the Hand

Superficial radial nerve

Dorsal cutaneous branch of ulnar nerve

Extensor pollicis longus

Superficial radial nerve

Abductor pollicis longus

Procedure: Radial Nerve Block RADIAL NERVE BLOCK: STEP 1 PEARLS

Step 2 RADIAL NERVE BLOCK: STEP 1

Flexor carpi radialis

Dorsal sensory nerve Dorsal branch of the volar digital nerve

Volar digital nerve

1% Lidocaine + 0.5% Marcain

RADIAL NERVE BLOCK: STEP 3 PEARLS

FIGURE 1.9 MEDIAN NERVE BLOCK: STEP 1 PEARLS

Flexor carpi radialis

1% Lidocaine + 0.5% Marcain

ULNAR NERVE BLOCK: STEP 1 PEARLS

SUBCUTANEOUS DIGITAL BLOCK: Step 3

INTRATHECAL BLOCK: STEP 2 PEARLS

Flexor tendon sheath

Postoperative Care and Expected Outcomes

Fasciotomy for Compartment Syndrome of the

Flexor carpi radialis muscle

Extensor carpi radialis muscle Ulnar nerve

Radius Anterior interosseous nerve

Posterior interosseus nerve

• Normal tissue pressures range from 0 to 8 mm Hg. Any reading over 30 mm Hg

Compartment Muscle Artery Nerve

Volar radial Dorsal ulnar

Skin incision, dorsal forearm

Carpal tunnel release

Dorsal hand release

Skin incision, finger

Procedure: Fasciotomy of the Hand

Step 4: Dorsal Decompression

Postoperative Care and Expected Outcomes

DIP joint Terminal tendon

Monseigneur continued to ramble on in the same strain. Jacqueline

'It was all arranged with de Montigny, you remember?' Monseigneur

He paused; I think, for want of breath: he certainly had been talking

Something of that appalling state of mind must have been reflected in

'Jacqueline, my dear, you look so strange. What is it? Hath my news so

'Sure of what, my dear?' he riposted.

'That he is the Duc d'Anjou?'

Monseigneur laughed loudly and long, apparently much relieved.

• Normal tissue pressures range from 0 to 8 mm Hg. Any reading over 30 mm Hg