Soft tissue coverage in devastating hand injuries

Clinical Application of a Modified Local Transposition Flap (Parallelogram Flap) Surgery in Repairing Fingertip Defects

OBJECTIVE

Parallelogram flap was performed for transverse finger amputation with the loss of distal pulp, nails, and bone. This study aimed to compare the clinical effects of parallelogram flap, antegrade homodigital island flaps, and reverse digital artery island flaps in fingertip reconstruction.

PATIENTS AND METHODS

From January 2017 to January 2021, clinical patient data with parallelogram flaps (78 cases), antegrade homodigital island flaps (78 cases), and reverse digital artery island flaps (78 cases) to repair fingertip defects were collected and analyzed. Two hundred thirty-four cases (234 fingers) were included in our study. All operations were performed by one surgical team. The operation time, 2-point discrimination, total active movement, and the Michigan Hand Questionnaire (MHQ) of the injured fingers were recorded to evaluate the therapeutic effect.

RESULTS

Parallelogram flaps (group A), antegrade homodigital island flaps (group B), and reverse digital artery island flaps (group C) had survived postoperatively. The operative duration of group A is the shortest (A < B < C, P < 0.05). At the last 6-month follow-up, there was no difference with the 2-point discrimination of the palmar part of the flaps in group A and group B but better than group C (P < 0.05). There was no difference with the total active movement of injured figures in 3 groups (P > 0.05). The MHQ summary scores in group A were much higher than those in group B and group C (P < 0.05). Evaluation of the MHQ subscale performance showed that the overall hand function, activities of daily living, work performance, and pain score had no differences (P > 0.05), but aesthetics and satisfaction score was the highest in group A (A > B > C, P < 0.05).

CONCLUSIONS

The reconstruction of transverse finger amputation using parallelogram flaps can achieve a shorter operation time, a more satisfying appearance. Parallelogram flaps and antegrade homodigital island flaps can both achieve a better sensory recovery. Parallelogram flaps is a better choice for reconstruction of transverse finger amputation with the loss of distal pulp, nails, and bone.

Parallelogram flap versus homodigital island flap in the treatment of fingertip defects with bone exposure: a prospective controlled study

Purpose

A modified local transposition flap (we call it “parallelogram flap”) surgery was performed for fingertip injuries. This study aimed to compare the clinical effects of parallelogram flap and homodigital island flaps in fingertip reconstruction.

Methods

The study collected patients who underwent parallelogram transposition flaps and homodigital island flaps to repair fingertip defects from 2019 to 2021. 150 cases (150 fingers) were included in our study. All operations were performed by one surgical team. Record the operation time, two-point discrimination (2PD), Total Active Movement (TAM) and the MHQ (Michigan Hand Questionnaire) of the injured fingers to evaluate the therapeutic effect.

Results

All parallelogram (Group A) and homodigital island flap (Group B) had survived postoperatively. The operative duration of Group A (31.2 ± 3.3 min) is shorter than Group B (97.8 ± 6.1 min) (P < 0.05). At the 6-month follow-up, there was no difference with the two-point discrimination (2PD) of the palmar part of the flaps and the Total Active Movement (TAM) of injured figures in Group A and Group B. The MHQ summary scores in Group A (94.29 ± 3.14) were much higher than in Group B (91.73 ± 3.41) (P < 0.05). Evaluation of the MHQ subscale performance showed that the overall hand function, activities of daily living, work performance and pain score had no differences(P > 0.05), but aesthetics (92.15 ± 7.16) and satisfaction (92.45 ± 5.61) score in Group A was higher than aesthetics (86.56 ± 5.60) and satisfaction (86.72 ± 8.21) score in Group B (P < 0.05 for both).

Conclusions

The reconstruction using parallelogram flaps is a easier and more versatile treatment with better functions, less morbidity and better aesthetics. This method is a better choice for reconstruction of fingertip injury.

Second dorsal metacarpal artery-based index finger dorsal island flap for the management of thumb defects

Index finger dorsal island flaps were frequently utilized by hand surgeons to reconstruct thumb defects. However, the blood supply of the traditional index finger dorsal island flap comes from the first dorsal metacarpal artery, which has a smaller diameter, more anatomical variation, and can be injured in conjunction with thumb injuries. Therefore, we design an alternative index finger dorsal island flap based on the second dorsal metacarpal artery to treat thumb skin defects. From August 2015 to October 2018, we used the index finger dorsal island flaps with the second dorsal metacarpal artery to treat 11 patients with thumb skin defects. All the flaps and skin grafts survived completely without complications. At the last follow-up, the mean 2PD of the flap was 6.4 mm (45.5% for excellent, 54.5% for good), the mean ROM of the injured thumbs was 115.9° (72.7% for excellent, 27.3% for good), and the mean cosmetics score was 8.6. Our results demonstrate that the index finger dorsal island flap with the second dorsal metacarpal artery is suitable for the reconstruction of thumb skin defects. The flap has an excellent survival rate and good coverage with satisfactory results and represents a promising treatment for the selected patients. Level of Evidence: Therapeutic, level IV.

Customized reconstruction of complex soft tissue defects in the upper extremities with variants of double skin paddle anterolateral thigh perforator flap

BACKGROUND

Complex soft tissue defects in the upper extremities are challenging to reconstruct. The purpose of this study was to share our experience with using four variants of double skin paddle Anterolateral Thigh Perforator (ALT) flap to achieve the customized reconstruction of the complex defects.

PATIENTS AND METHODS

From January 2007 to December 2019, 15 patients (14 male and 1 female) aged 15-61 years underwent double skin paddle ALT flap reconstruction of the upper extremities. 10 wounds were located in the wrist or hand, while four wounds were located in the forearm, and one wound in the elbow. All the wounds were large with non-adjacent defects and with or without a dead space. Four variants of double skin paddle anterolateral thigh perforator flaps were harvested according to the patient's needs.

RESULTS

The flaps received were consisted of 7 classic double skin paddle ALT flap, 4 vastus lateralis muscle-chimeric double skin paddle ALT flap, 2 microdissected thin double skin paddle ALT flap, and 2 flow-through double skin paddle ALT flap. The size of the skin flap ranged from 6 × 6 cm² to 26 × 7 cm², and the size of the muscle segment ranged from 5 × 2 × 1 cm³ to 16× 6 × 2 cm³. Flap necrosis related to the pedicle kinking was observed in one patient, while the rest of the flaps survived without complications. The follow-up period ranged from 7 to 54 months, with a median of 15.6 months. The mean value of the qDASH scores at the last follow-up was 27.12 ± 16.51 (range, 11.4-59.1). None of the patients showed wrist flexion deformity. Postoperatively, three patients developed finger joint stiffness, which correlated with the severity of the injury.

CONCLUSIONS

Variants of double skin paddle ALT flaps provide versatile design and allow customized reconstruction of complex soft tissue defects in the upper extremities with limited donor site morbidity. We believe that the algorithm provided will help the surgeons with deciding among variants of double skin paddle ALT flap.

Fingertip injuries managed by a thenar flap: Follow-up and long-term outcomes of 32 cases

While various techniques are used for the reconstruction of fingertip injuries, the main goals remain the same: preserve finger length, sensation, and function. The thenar flap is a well-described technique and simple procedure in fingertip amputations. This study aimed to evaluate the long-term functional and esthetic outcomes along with patient satisfaction of thenar flaps done for fingertip defects. Thenar flaps used in 32 patients operated between January 2010 and December 2016 were analyzed retrospectively to assess sensory recovery, range of motion, cold intolerance, pain relief, appearance, patient satisfaction, and QuickDASH score. All flaps survived, without adverse events. The flap was detached after 10-14 days (mean 12.5 days). The mean follow-up was 31 months (range, 20-45 months). According to Semmes-Weinstein monofilament test results, protective sensation was achieved in 25 patients (78%). The mean static 2-point discrimination was 6.1 mm. There were no functionally significant finger flexion contractures at the final follow-up. Complications such as pain, donor site morbidity and cold intolerance were not encountered. The thenar flap is an excellent technique for coverage of total or subtotal tissue loss of radial-side fingertips that is not accessible to local flaps. It provides good sensory function and appearance when fundamental technical principles (flap design, timing of division, and early mobilization) are respected.

Evaluation of Primary and Secondary Free Flap Desyndactylization Techniques in Hand and Digit Reconstruction: A Systematic Review

Objective Injuries of the hand often require free flap reconstruction. To minimize flap loss, evidence exists to surgically syndactylize digits when repairing multiple injuries, with delayed flap division, or desyndactylization. However, evidence suggests that division of the flap at the time of inset can be accomplished with minimal negative effect. The purpose of this study was to evaluate outcomes, following hand reconstruction with free flaps utilizing either acute or staged desyndactylization techniques.

Methods A systematic review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Articles that described the use of a free flap for surgically syndactylized digits or multilobed flaps for coverage of multiple digits were included.

Results One hundred sixty-one articles were reviewed with 34 fulfilling inclusion criteria. One hundred seventeen patients underwent 145 free flap reconstructions. Traumatic avulsions (49%) were the most common injuries, followed by burns (11%). Twenty-one (62%) papers described surgical syndactylization of digits, which were later desyndactylized and five (15%) papers included reconstruction of more than one digit with multilobed free flaps. Eight papers (24%) described both techniques. Overall, 100% of included flaps survived. Total complication rate was 6%, with six complications (67%) occurring in flaps with primary syndactylization.

Conclusion Hand defects often require free flaps for reconstruction. Although free flaps for the reconstruction of digital defects is technically demanding, they result in better outcomes. With available evidence indicating complications rates less than those of staged desyndactylization, multidigit reconstruction with multilobed free flaps may be a more desirable technique.

Reconstructive microsurgery in upper limb reconstruction: 30 years' experience of a single surgeon

The reconstruction of compound tissue defects in upper extremity injuries often represents a challenge. The goal of reconstruction is to obtain not only a good cosmetic result, but also the best possible function. Microsurgery highly contributes to the management of upper limb simple or complex defects by offering a large number of surgical possibilities. Due to advances in understanding of blood supply to tissues and microsurgical techniques in the last 50 years, microsurgeons have renounced more and more to the use of traditional flaps in favour of the more reliable perforator flaps. This article presents the experience of a single surgeon performing post-traumatic upper limb reconstructive microsurgery over the last 30 years.

Comparison of Fasciocutaneous and Muscle-based Free Flaps for Soft Tissue Reconstruction of the Upper Extremity

Soft tissue free flap reconstruction of upper extremities has proven to be reliable and essential for limb salvage and function. Nevertheless, comparative data regarding flap outcome are still lacking. The present study aimed to compare procedural features and individual complication rates of different free flaps used for upper extremity reconstruction.

Methods

The authors evaluated retrospectively the results of 164 free flaps in 149 patients with upper extremity defects. Chart reviews were performed from April 2000 to June 2014, analyzing flap choices, complication, and success rate assessment for patients >18 years old, with a soft tissue defect of the upper extremity. Chosen flap types were classified as fasciocutaneous (including adipocutaneous) and muscle-based, respectively. We comparatively analyzed total flap loss, flap survival after microsurgical revisions, and susceptibility rates for thromboses rates and partial flap necrosis.

Results

Defect size was larger when muscle-based flaps were used (231 ± 38.6 versus 164 ± 13.7 cm², P < 0.05). Outcome analysis revealed a tendency towards higher arterial thrombosis rates for muscle flaps (10.2% versus 4.3%) and venous thrombosis rates for fasciocutaneous flaps (2% versus 7%). Total flap loss (6.1% versus 7.8%) and flap survival after vascular revisions (75% versus 70.6%) showed comparable rates. Partial flap necrosis was generally higher in muscle-based flaps (22.4% versus 8.6%, P = 0.02) with impact on patients' hospital stay (37.2 ± 4.69 and 27.11 ± 1.62 days, n = 115, P = 0.01), while no differences in partial necrosis rates were noted in flaps larger than 300 cm² (25% versus 10%, P = 0.55). There was a trend over time towards using fasciocutaneous-based flaps more frequently with a final overall percentage of 83.7% between 2012 and 2014.

Conclusions

Microsurgical tissue transfer to the upper extremity is safe and reliable, but flap-type specific procedural and measures should be taken into consideration. Total flap loss as well as flap survival after microsurgical revisions are not altered between these flaps. They differ, however, in their susceptibilities for thromboses rates, partial flap necrosis and thus require individual risk stratification and flap placement.

Free Serratus Fascia Flap for Reconstruction of Soft Tissue Defects Involving the Distal Upper and Lower Extremity

BACKGROUND

Free fascial flaps are widely used for the reconstruction of defects located on the distal extremities as they provide thin yet durable soft tissue coverage. The serratus anterior fascia flap stands out from other fascial flap alternatives as it has optimal anatomical properties that can provide ideal coverage in a wide range of reconstructive challenges. The purpose of this study was to present our experience with the serratus anterior fascia flap in a variety of complex soft tissue defects.

METHODS

A retrospective review was conducted on patients who underwent reconstruction with the free serratus anterior fascia flap for complex soft tissue defects involving the distal extremities.

RESULTS

Complex soft tissue defects of 13 patients were reconstructed using the free serratus fascia flap. No major postoperative complications such as flap loss, dehiscence, infection, or hematoma were encountered in any of the patients. All of the patients demonstrated durable and harmonious long-term flap coverage that facilitated movement without any signs of scar contractures and tendon adhesions at the site of reconstruction.

CONCLUSIONS

The serratus anterior fascia flap demonstrates versatility and stability for the closure of complex distal extremity defects. It creates thin yet durable coverage that facilitates underlying tendon gliding while providing harmony with the natural contours of these anatomic areas and has low donor site morbidity, making it a primary choice in the reconstruction complex soft tissue defects involving the hands and feet.

Treatment of fingertip avulsion injuries using two periposition pedicled flaps

We described a treatment of fingertip avulsion injury by two periposition pedicled flaps, the reversed pedicle island flap of dorsal branch of proper digital artery and the cross-finger flap. From February 2009 to January 2017, 22 patients (22 fingers) with fingertip avulsion injury were treated with two periposition pedicled flaps, 14 male and 8 female, aged from 17 to 47 years (mean 32 ± 9 years). All of the patients were followed up more than 6 months after operations (mean 9.6 ± 2.6 months). All flaps survived completely. Compared with the traditional abdominal flaps, two periposition pedicled flaps had less pedicle division time. At last follow-up, the 2PD of the palmar part of the flaps, the TAM of the injured finger and the MHQ summary score of the two periposition pedicled flaps were much better than the traditional abdominal flaps. The reconstruction using two periposition pedicled flaps is a versatile treatment with better functions, less morbidity and better aesthetics. Level of evidence: Therapeutic, level III.

Anastomosis to the common and proper digital vessels in free flap soft tissue reconstruction of the hand

OBJECTIVE

This study seeks to demonstrate the safety of anastomosing free flaps to the common or proper digital artery, and to the volar or dorsal digital vein in soft tissue reconstruction of the hand; as well, as to discuss the advantages of this technique.

METHODS

Retrospective review of all patients who underwent free flap reconstruction of the hand in two institutions over a period of 5 years.

RESULTS

A total of 29 free flaps (9 great toe pulp, 7 anterolateral thigh, 6 second toe pulp, 4 radial artery perforator, 2 partial medial rectus, 1 lateral arm) in 28 patients met our inclusion criteria. All recipient vessels were the proper or common digital artery and the volar or dorsal digital vein. There was one case of venous congestion that resolved with leeching. There was no partial or total loss of any of the flaps.

CONCLUSION

Anastomosing soft tissue free flaps to the common or proper digital artery, and the volar or dorsal digital vein is a safe and effective approach with numerous advantages that should be considered in the reconstruction of soft tissue defects of the hand. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:21-25, 2018.

Colgajo microquirúrgico de músculo gracilis para cobertura de palma y dorso de mano tras revascularización

Presentamos el caso de un varón de 28 años de edad que sufrió el atrapamiento y la avulsión cutánea de la palma y dorso de la mano izquierda con arrancamiento de todos los pedículos vasculo-nerviosos a la altura del canal carpiano. Presentaba una fractura metafisaria de la falange proximal del quinto dedo, fractura diafisaria del tercer metacarpiano y avulsión de la piel del pulgar a la altura de la articulación trapeciometacarpiana. Las fracturas se fijaron con agujas. Tras la revascularización del pulgar y reparación microquirúrgica de los pedículos avulsionados, el 5.° dedo y la piel de la palma y del dorso, evolucionaron a la necrosis. Una semana después se realizó el desbridamiento de la necrosis y la cobertura con un colgajo microvascular de músculo gracilis, anastomosado a la arteria cubital termino-lateralmente. Cinco días después el colgajo se cubrió con un injerto de piel de espesor parcial.

El postoperatorio trascurrió sin complicaciones. El paciente comenzó la rehabilitación a la 4.a semana tras revascularización. 28 meses tras la intervención presenta un rango de movimiento de los dedos trifalángicos y muñeca completos, rigidez en pulgar (IF 30°-90°, MCF 20-60°). La sensibilidad era de 20 mm en el test de discriminación a los dos puntos en los dedos trifalángicos y, anestesia en el pulgar. La fuerza de prensa era del 79,6% (43 kg/54 kg) respecto a la mano sana.

El colgajo microquirúrgico del músculo gracilis constituye una excelente opción para cobertura en mano, al permitir el deslizamiento de los tendones. Además, mediante el uso de presoterapia, se consigue un excelente resultado estético, en un único tiempo, muy superior al conseguido con colgajos fasciocutáneos.

Soft tissue coverage of the upper extremity: an overview

Prehension is a complex function of the hand that gives it mechanical precision combined with a standard sensory pattern. The priority in soft tissue reconstruction for the upper extremity is to restore function. Significant injury to the upper extremity may result after trauma because of various etiologies. The timing and choice of soft tissue coverage for upper extremity defects warrant special consideration to avoid prolonged immobilization, which can result in joint stiffness, tendon adhesions, scar contractures, and ultimately, loss of function. This article reviews the various reconstructive options and considerations involved in providing coverage for upper extremity soft tissue defects.

Free skin flap coverage of the upper extremity

Successful soft tissue reconstruction of the upper extremity must provide stable coverage and restore function to the injured hand. To ensure the best possible outcome after traumatic upper extremity injuries, early radical debridement and early flap coverage that restores all missing tissue components is critical to allow early mobilization. Free flaps provide extraordinary versatility in reconstructing defects of soft tissue, muscle, tendon, and bone.

Optimizing functional and aesthetic outcomes of upper limb soft tissue reconstruction

This article highlights reconstructive principles in flap selection, use, and insetting to optimize functional and aesthetic outcomes after upper extremity reconstruction. The concept of respecting the aesthetic units of the hand during reconstruction is discussed. A current literature review of the aesthetic outcomes using various flaps, such as fasciocutaneous, fascia only, and muscle flaps, is provided. An approach based on aesthetic unit principles to upper extremity reconstruction is also highlighted to help optimize outcomes.

Free muscle flaps for reconstruction of upper limb defects

Restoration of structure, function, and sensation are critical after trauma or tumor resection of the hand. Thorough debridement, reconstruction of functional structures, and immediate soft tissue coverage are most effectively performed in a single stage within approximately 24 hours of the injury. Skin flaps provide robust, pliable, and cosmetically appropriate tissue that is not prone to contracture and that facilitates secondary reconstructive work. Muscle flaps retain indications for complex defects with substantial initial contamination or dead space, or for reanimation. In this article, the indications, options, and surgical techniques for free muscle flap reconstruction of upper limb defects are reviewed.

Local flaps of the hand

A local flap consists of skin and subcutaneous tissue that is harvested from a site near a given defect while maintaining its intrinsic blood supply. Local skin flaps can be a used as a reliable source of soft tissue replacement that replaces like with like. Flaps are categorized based on composition, method of transfer, flap design, and blood supply, but flap circulation is considered the most critical factor for the flap survival. This article reviews the classification of local skin flaps of the hand and offers a practical reconstructive approach for several soft tissue defects of the hand and digits.

The biophysical characteristics of human composite flexor tendon allograft for upper extremity reconstruction

INTRODUCTION

Devastating volar hand injuries with significant damage to the skin and soft tissues, pulley structures and fibro-osseous sheath, flexor tendons, and volar plates pose a major problem to the reconstructive hand surgeon. Despite advances in tendon handling, operative technique, and postoperative hand rehabilitation, patients who have undergone flexor tendon reconstruction are often plagued by chronic pain, stiffness, and decreased range of motion with resultant decreased ability to work and poor quality of life. In this article, we expand the technique of human composite flexor tendon allografts (CFTAs), pioneered by Dr E.E. Peacock, Jr, which consist of both the intrasynovial and extrasynovial flexor digitorum superficialis and flexor digitorum profundus tendons and their respective fibro-osseous sheath consisting of the digital pulley structures, periosteum, and volar plates procured from cadaveric donors with the use of modern tissue processing techniques.

METHODS

Human cadaveric CFTAs were procured and divided into 2 groups-unprocessed CFTAs and processed CFTAs, which are cleansed and sterilized to a sterility assurance level of 10(-6). Physical length and width relationships as well as tensile strength and gliding resistance assessments were recorded pre-tissue and post-tissue processing. The histologic properties of the composite allografts were assessed before and after tissue processing.

RESULTS

There was no significant difference with respect to physical properties of the composite allografts before or after tissue processing. The processed composite allografts demonstrated equivalent maximum load to failure and elastic modulus compared to unprocessed tendons. The gliding resistance of the composite tendon allografts was not significantly different between the 2 groups.

CONCLUSIONS

The use of CFTAs addresses the issues of adhesion formation and lack of suitable donor material by providing a source of intrasynovial tendon in its unaltered fibro-osseous sheath without donor morbidity. This approach represents an important step toward designing an ideal material for complex flexor tendon reconstruction, which takes advantage of an intrasynovial flexor tendon in its native fibro-osseous sheath without the need for additional donor morbidity using a construct which can be engineered to have minimal tissue reactivity, negligible potential for disease transmission, and improved tendon healing properties versus standard tendon allograft.

Open fractures of the hand with soft tissue loss

The evaluation, initial treatment, and definitive reconstruction of open fractures of the hand with associated soft tissue loss are reviewed. Specific attention is given to the literature on open fracture antibiotic prophylaxis in the hand; the timing of bone and soft tissue reconstruction; and options for soft tissue coverage, including local, regional, and distant tissue transfer. Factors that have shown association with outcomes in these injuries are also discussed, and the authors' preferred management is summarized.

Composite anterolateral thigh perforator flaps in the management of complex hand injuries

The anterolateral thigh (ALT) fasciocutaneous flap has been well described for hand skin cover, however its use in its composite (multiple tissue) form incorporating bone, muscle and/or fascia has been less well described. We report the usefulness of the composite ALT flap in six complex hand trauma cases, four male and two female (age range 14-46 years). The palm of the hand was affected by injury in three cases, the dorsum in two cases, and the radial side in one case. The first web formed part of the injury in three cases. There was variable involvement of the tendons, nerves and bones. Fascia lata was included in the flap to provide a gliding surface in four cases, part of the vastus lateralis muscle was included to obliterate dead space in two cases and to create a first web in one case, and a bone block from the iliac crest was included to reconstruct the lost metacarpals in one case. All flaps survived with minimal complications. This work shows that the anterolateral thigh composite flap is a reliable option when multiple tissue types are required in hand reconstruction.

Current management of the mangled upper extremity

Mangled describes an injury caused by cutting, tearing, or crushing, which leads to the limb becoming unrecognizable; in essence, there are two treatment options for mangled upper extremities, amputation and salvage reconstruction. With advances in our understanding of human physiology and basic science, and with the development of new fixation devices, modern microsurgical techniques and the possibility of different types of bony and soft tissue reconstruction, the clinical and functional outcomes are often good, and certainly preferable to those of contemporary prosthetics. Early or even immediate (emergency) complete upper extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. Before any reconstruction is attempted, injuries to other organs must be excluded. Each step in the assessment and treatment of a mangled extremity is of utmost importance. These include radical tissue debridement, prophylactic antibiotics, copious irrigation with a lavage system, stable bone fixation, revascularization, nerve repair, and soft tissue coverage. Well-planned and early rehabilitation leads to a better functional outcome. Despite the use of scoring systems to help guide decisions and predict outcomes, the decision to reconstruct or to amputate still ultimately lies with the surgical judgment and experience of the treating surgeon.

Scar contractures of the hand

This article discusses scar contracture of the hand. It contains a brief outline of the anatomy of the hand and upper extremities and the types of injuries involved. Hand reconstruction, including examination, nonoperative treatment, surgery, excision and skin grafting, flaps, postoperative management, and complications, are covered.

Principles in the management of a mangled hand

Mangling hand injuries are high energy complex conditions that are challenging to manage. They require careful planning and meticulous execution of treatment. A clear set of anatomical and functional goals at the outset guides the planning. The first surgery is crucial to ensure good vascularity to the salvaged tissue, prevent infection and achieve bony stabilization. Re-look surgery and definitive reconstruction can then follow. Post-operative therapy is an important component of treatment. Despite best efforts, outcomes are variable in these devastating injuries. Secondary procedures and provision of prostheses will do much to improve the patient's body image and limb function. This article provides a set of principles that will guide the assessment and treatment of such injuries.

[Algorithms for treatment of complex hand injuries]

BACKGROUND

The primary treatment strongly influences the course and prognosis of hand injuries. Complex injuries which compromise functional recovery are especially challenging. Despite an apparently unlimited number of injury patterns it is possible to develop strategies which facilitate a standardized approach to operative treatment. In this situation algorithms can be important guidelines for a rational approach.

MATERIAL AND METHODS

The following algorithms have been proven in the treatment of complex injuries of the hand by our own experience. They were modified according to the current literature and refer to prehospital care, emergency room management, basic strategy in general and reconstruction of bone and joints, vessels, nerves, tendons and soft tissue coverage in detail.

CONCLUSIONS

Algorithms facilitate the treatment of severe hand injuries. Applying simple yes/no decisions complex injury patterns are split into distinct partial problems which can be managed step by step.

Early management of ballistic hand trauma

Complex hand wounds are an unfortunate consequence of conflict. Increased battlefield survival rates have resulted in an evolving range of ballistic hand trauma encountered by deployed surgical teams, requiring increased knowledge and understanding of these injuries. In the civilian setting, the combined threats of gun crime and acts of terrorism warrant appreciation for such injury among all surgeons. Surgeons often have to relearn the management of ballistic hand trauma and other aspects of war surgery under difficult circumstances because the experiences of their predecessors may be forgotten. Current evidence regarding these injuries is scarce. Ballistic hand trauma is rarely isolated. The demand on surgical resources from combat injury is significant, and it is imperative that a phased strategy be followed in this setting. Minimal, accurate débridement and decompression with early stability are crucial. Delayed primary closure and an awareness of future reconstructive options are fundamental.

Immediate emergency free anterolateral thigh flap transfer for the mutilated upper extremity

BACKGROUND

Immediate emergency free flaps are defined as flaps performed directly following emergency surgery due to the exposure of major reconstructed arteries, major nerves, bones, and tendons. The authors document their experience in using free anterolateral thigh flaps in the immediate reconstruction of complex upper extremity injuries.

METHODS

From January of 2000 to October of 2006, 12 patients ranging from 10 to 59 years old with complicated upper extremity traumatic injuries were treated with immediate emergency free anterolateral thigh flap transfers. These flaps were performed to cover the exposed vital structures. Flap sizes ranged from 30 x 15 to 8 x 6 cm. A variety of flap designs were used, including six flow-through flaps for upper limb revascularization and three tensor fasciae latae components for gliding planes of exposed repaired tendons. The operative times ranged from 7.2 to 12.1 hours, with an average operative time of about 9.6 hours. The hospital stay was from 13 to 34 days, with average stay of about 27.7 days.

RESULTS

All of the flaps survived. No re-exploration was required. Partial flap necrosis occurred in only one case. Traumatized wound infection occurred in three patients.

CONCLUSIONS

The anterolateral thigh flap has been popularized as the versatile flap for soft-tissue reconstruction. It has many advantages, including long pedicle length, large skin territory, flow-though and chimeric concept design, a two-team approach, and no need for changing the position. Thus, it is suitable as the immediate emergency flap for upper extremity salvage.

Forked finger fillet flap for segmental extensor tendon coverage of an adjacent digit

Finger fillet flaps have been used to treat a variety of complex hand deformities providing stable soft tissue coverage and preventing pathologic contractures. Fillet flaps have not been reported in the coverage of segmental extensor tendon deficit in an adjacent digit. A 20-year-old man involved in a motor vehicle crash sustaining a 30% total body surface area burn, primarily to left arm and bilateral lower extremities. In particular, his left index finger extensor mechanism was disrupted with exposure of the proximal interphalangeal (PIP) joint. In addition, the middle finger had a segmental exposure of the extensor tendon. The nonfunctional index finger was sacrificed to provide coverage, via a forked fillet finger flap, of the exposed extensor tendon at the PIP and metacarpophalangeal (MCP) joints. Total active motion of left fingers at 12 months consisted of the third digit 0 to 86 degrees at the MCP joint, 0 to 88 degrees at the PIP joint and 0 to 33 degrees at the distal interphalangeal joint. Gross grip strength improved to 26 lb at 1 year follow-up. Adequate soft tissue coverage of extensor tendons can be challenging in the traumatic hand. With this novel approach of a forked finger fillet flap we were able to provide adequate soft tissue coverage of exposed tendons and joints improving the patient's strength and active range of motion especially in the middle finger. Prevention of postburn boutonnière deformity was an additional benefit.

Primary bone grafting with pedicled flap cover for dorsal combined injuries of the digits

Twenty digits in 15 patients with dorsal combined tissue loss were treated by radical debridement, primary non-vascularised iliac crest bone graft and immediate lower abdominal flap cover between 1996 and 2006. The average length of the bone grafts was 3.3 (range 2.5-5) cm. No extensor tendon reconstruction was carried out. The flaps were divided at 3 weeks without delay. Permissible thinning of the flap was done at the time of division of flaps. No secondary procedure was done. All patients were retrospectively reviewed and X-rays obtained. Radiological union was achieved in 18 of 20 digits. One bone graft was removed because of infection. One bridging bone graft united with the distal phalanx but had a painless non-union with the proximal phalanx. There were no flap complications. Bone graft length resorptions of 20% and 15% occurred in two terminal bone grafts. We recommend this protocol as a solution to this challenging problem.

Defektdeckung durch lokoregionäre Lappenplastiken an der Hand

Soft tissue defects in the hand with exposed tendons, bones, or joints present difficult reconstructive challenges. A wide variety of highly sophisticated intrinsic flaps offer a wide range of therapeutic options of locoregional soft tissue coverage to achieve acceptable aesthetic and functional results. This article gives an overview of the various groups of flaps, indication, and their use in clinical situations based on the experience with more than 100 flaps over a 4-year period.

Evaluation of moving and static two point discriminations of volar forearm skin before and after transfer as a sensate radial forearm island flap in reconstruction of degloving injury of the thumb

In degloving injury of the thumb the large skin defect needs cover with sensate, glabrous and pliable skin. Although coverage of this defect with a sensate free flap from the foot is the best choice, most commonly, cover is achieved using a non-sensate distant pedicle flap. Between 2001 and 2003, degloving injuries of the thumb in eight patients were reconstructed using a sensate radial forearm flap in the sensory territory of the lateral ante-brachial nerve of the forearm which was repaired to the digital nerve of the thumb (six cases) or to a branch of the sensory radial nerve (two cases). Follow-up period ranged from 17 to 41 months (mean: 29.9 months). Sensory evaluation was performed using the moving two point discrimination (M-2PD) and static two point discrimination (S-2PD) of the volar forearm skin. These altered significantly after transfer and their values approached those of the contra-lateral thumb but never reached normal sensation (p<0.01). Sensate radial forearm island flap is a reliable option to cover a large defect of the thumb such as degloving injury and the sensation produced is acceptable.

Indications and selection of free flaps for soft tissue coverage of the upper extremity

The advantages of free flap coverage of the upper extremity following trauma or tumor resection have been acknowledged by several authors. Most importantly, these benefits include the ability to provide early coverage with composite reconstruction of all damaged or missing tissues and early mobilization to restore function. The purpose of this article is to review the indications and options for selection of free flaps for soft tissue coverage of the upper extremity.

Funktionelle und ästhetische Gesichtspunkte bei der Defektdeckung der Streckseite an Hand und distalem Unterarm mit freien Lappenplastiken

INTRODUCTION

Free coverage of exposed functional structures of the hand and distal forearm can be achieved using a variety of free flaps. However, there is a lack of data in the literature which tissue components are best used for defect coverage of this specific area regarding aspects such as tendon gliding and tissue elasticity. The purpose of this retrospective study was to compare and to evaluate the functional and aesthetical results using free cutaneous, fascial and muscle flaps.

PATIENTS AND METHODS

Between 1994 and 2002, a total of 56 patients underwent free flap coverage at the dorsal side of the hand and forearm at our institution. Of these patients, 20 with 21 free flaps met the study criteria and were available for follow-up examination. Depending on the tissue component used patients were allocated into three different groups. In group 1 eight patients received a fascial flap, in group 2 eight a cutaneous flap and in group 3 five a muscle flap. The mean follow-up was 50 months (range: 4-103 months). At follow-up examination the patients answered the Client Satisfaction Questionnaire (CSQ 8) and the DASH questionnaire.

RESULTS

Regarding range of motion of the wrist and fingers, fascial flaps clearly showed the best results. Concerning grip strength and pinch grip, fascial and cutaneous flaps demonstrated the same results. Patients with cutaneous flaps showed the best DASH score. Regarding the overall aesthetical outcome, fascial and cutaneous flaps were far better than muscle flaps. Donor site morbidity was lowest for fascial flaps followed by muscle flaps and was highest for cutaneous flaps.

CONCLUSION

Cutaneous and fascial flaps had the best functional and aesthetical results. Fascial flaps achieved the best aesthetical outcome of the donor site. We recommend free fascial flaps and cutaneous flaps as the first choice due to their advantages in the specific area of the dorsal site of the hand and distal forearm which requires pliable and thin tissue coverage.

Die akzidentelle thermische Verletzung der Hand

Hands are most frequently involved in severe burns. The treatment of the burned hand is one of the most challenging problems in plastic surgery. The success of therapy is determined by the severity of the initial injury, the first aid provided, and the correct balance between mobilization, splinting and plastic surgery. In this respect, it is vital to have a highly qualified interdisciplinary team approach consisting of plastic surgeons, well-trained physical therapists, psychologists and a highly motivated patient.

Coverage of soft-tissue defects of the hand with free fascial flaps

Coverage of exposed functional structures such as tendons, bones, vessels, or nerves at the dorsal and palmar surface of the hand requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result. The purpose of this retrospective study was to evaluate the functional and aesthetic results after coverage of the hand with free fascial flaps. From 1994-2002, 14 patients underwent free fascial flap coverage of the hand with 4 tempo-parietal fascia flaps and 11 serratus fascia flaps. Eight patients could be reexamined and answered a questionnaire about their satisfaction with the functional and aesthetic results. The mean follow-up was 41.7 months. Average active range of motion of the hand, functional improvement, and the aesthetic result were satisfying in all follow-up patients. No secondary debulking or other contouring procedures were required. We recommend the use of free fascial flaps as a valuable alternative to fasciocutaneous or muscle flaps, since the functional results are excellent, no additional procedures were necessary, and the aesthetic results are appealing.