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THE MUTILATED HAND Copyright © 2005, Elsevier Inc. All rights reserved.
ISBN: 1-56053-446-X
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Notice Hand surgery is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the licensed prescriber, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the publisher nor the editors assume any liability for any injury and/or damage to persons or property arising from this publication.
Library of Congress Cataloging-in-Publication Data The mutilated hand/Norman Weinzweig, Jeffrey Weinzweig [editors]—1st ed. p. cm. ISBN 1-56053-446-X 1. Hand—Surgery 2. Hand—Wounds and injuries I. Weinzweig, Norman II. Weinzweig, Jeffrey RD559.M865 2005 617.5'75059—dc22 2003056597
Editor: Daniel Pepper Publishing Services Manager: Joan Sinclair Project Manager: Mary Stermel Design Manager: Karen O’Keefe Owens Marketing Manager: Lisa Damico
Printed in China Last digit is the print number:
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In memory of our father, for his immeasurable courage and uncompromising integrity. Our greatest inspiration. Our hero.
In honor of our mother, for her unwavering support and profound devotion.
To our mentors, our residents, and our patients, who have taught us, humbled us, and inspired us. JW / NW
To my wife and best friend, Amy, for her love and encouragement. To my son, Justin, for opening up a new and truly wondrous world. NW
Contributors Kimberly J. Anderson, PsyD Assistant Professor Department of Anesthesiology Medical College of Wisconsin Children’s Hospital of Wisconsin Clinical Psychologist Jane B. Pettit Pain and Palliative Care Center Milwaukee, Wisconsin Steffen Baumeister, MD Department of Hand, Plastic, and Reconstructive Surgery Burn Center The University of Heidelberg Heidelberg, Germany BG-Trauma Center Ludwigshafen, Germany Robert W. Beasley, MD, FACS Professor and Director of Hand Service Departments of Plastic Surgery New York University Medical Center Professor and Director of Hand Services Department of Plastic Surgery Bellevue Hospital New York, New York Consultant, Hand Surgery Department of Plastic Surgery Hackensack University Medical Center Hackensack, New Jersey Warren C. Breidenbach III, MD, MSc, FRCS(C) Assistant Clinical Professor Division of Plastic and Reconstructive Surgery University of Louisville School of Medicine Kleinert, Kutz and Associates Hand Care Center Louisville, Kentucky Michael P. Brunelli, MD Department of Surgery Metrowest Medical Center Framingham, Massachusetts
Linda K. Cendales, MD Former Senior Clinical Fellow Christine M. Kleinert Institute for Hand and Microsurgery Louisville, Kentucky James Chang, MD Associate Professor of Plastic Surgery Director, Residency Program, Plastic Surgery Director, Plastic and Hand Surgery Laboratory Stanford University Medical Center Attending Surgeon, Lucile Packard Children’s Hospital Chief, Section of Plastic Surgery Palo Alto Veterans Administration Health Care System Stanford, California I-Chen Chen, MD Attending Plastic Surgeon Taichung Veterans General Hospital Taiwan, Republic of China Former Hand Fellow Christine M. Kleinert Institute for Hand and Microsurgery Louisville, Kentucky Zhong-Wei Chen, MD* Chairman Department of Surgery Zhong Shan Hospital Fudan University Medical Center President Chinese Society for Reconstructive Microsurgery Shanghai, People’s Republic of China Byung Chae Cho, MD, PhD Professor and Director Department of Plastic and Reconstructive Surgery Kyungpook National University Hospital Kyungpook National University School of Medicine Taegu, Korea *Deceased
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CONTRIBUTORS
N. Della Rosa, MD Unit of Hand Surgery and Microsurgery Policlinico of Modena Modena, Emilia Romagna, Italy Lee E. Edstrom, MD Professor and Chief of Plastic Surgery Division of Plastic Surgery Department of Surgery Brown University Plastic Surgeon-in-Chief Department of Plastic Surgery Rhode Island Hospital Providence, Rhode Island Bassem Elhassan, MD Chief Resident in Orthopedic Surgery Department of Orthopedic Surgery University of Illinois at Chicago Chicago, Illinois Guy Foucher, MD Professor Department of Trauma University of Las Palmas Gran Canaria Hospital Insular Las Palmas, Spain Parham A. Ganchi, MD, PhD Assistant Professor Division of Plastic Surgery University of Medicine and Dentistry of New Jersey Newark, New Jersey Günter K. Germann, MD, PhD Professor of Surgery Chief, Department of Hand, Plastic, and Reconstructive Surgery, Burn Center Chair, Plastic and Hand Surgery The University of Heidelberg Heidelberg, Germany BG-Trauma Center Ludwigshafen, Germany Mark H. Gonzalez, MD, MEng Professor of Orthopedic Surgery Adjunct Professor of Mechanical Engineering University of Illinois at Chicago Chairman of Orthopedic Surgery John H. Stroger, Jr. Hospital of Cook County Chicago, Illinois Ruben N. Gonzalez, MD Hand Surgery Fellow Christine M. Kleinert Institute for Hand and Microsurgery Department of Surgery University of Louisville School of Medicine Louisville, Kentucky
Vijay S. Gorantla, MD, PhD Hand Surgery Fellow Christine M. Kleinert Institute for Hand and Microsurgery Department of Surgery University of Louisville School of Medicine Louisville, Kentucky Carl N. Graf, MD Chief Resident in Orthopedic Surgery Department of Orthopedic Surgery University of Illinois at Chicago Chicago, Illinois Brad K. Grunert, PhD Associate Professor of Psychology Department of Plastic Surgery Department of Psychiatry and Behavioral Medicine Medical College of Wisconsin Milwaukee, Wisconsin Robert Hagan, MD St. Louis University School of Medicine Department of Plastic Surgery St. John’s Mercy Medical Center St. Louis, Missouri Qing Huang, MD Associate Professor Department of Hand Surgery Ningbo Sixth Hospital Ningbo, Zhejiang Province, People’s Republic of China Vivek Jain, MCh Ortho Consultant, Trauma and Orthopaedics (LOCUM) Department of Trauma and Orthopaedics Lewisham University Hospital Lewisham, London, United Kingdom Neil F. Jones, MD, FRCS Professor Department of Orthopedic Surgery Division of Plastic and Reconstructive Surgery UCLA School of Medicine Chief of Hand Surgery UCLA Medical Center Los Angeles, California Jesse B. Jupiter, MD Hansjorg Wyss/AO Professor of Orthopaedic Surgery Harvard Medical School Chief, Orthopaedic Hand Surgery Massachusetts General Hospital Boston, Massachusetts Joseph E. Kutz, MD, FACS Clinical Professor of Surgery Department of Surgery University of Louisville School of Medicine Louisville, Kentucky
CONTRIBUTORS
Antonio Landi, MD Unit of Hand Surgery and Microsurgery Policlinico of Modena Modena, Emilia Romagna, Italy A. Leti Acciaro, MD Unit of Hand Surgery and Microsurgery Policlinico of Modena Modena, Emilia Romagna, Italy Scott Levin, MD, FACS Professor of Plastic and Orthopaedic Surgery Department of Surgery Divisions of Plastic and Orthopaedic Surgery Duke University School of Medicine Duke University Medical Center Durham, North Carolina Chih-Hung Lin, MD Department of Plastic Surgery Chang Gung Memorial Hospital Chang Gung Medical College and University Taipei, Taiwan, Republic of China William Lineaweaver, MD, FACS Professor and Chief, Division of Plastic Surgery Department of Surgery Professor, Department of Physiology and Biophysics University of Mississippi Medical Center Jackson, Mississippi J. William Littler, MD C. V. Starr Hand Surgery Center St. Lukes/Roosevelt Hospital Center New York, New York Susan E. Mackinnon, MD, FRCS(C) Shoenberg Professor and Chief Division of Plastic and Reconstructive Surgery Department of Surgery Washington University School of Medicine St. Louis, Missouri Ivan Matev, MD, DSc Consultant Hand Surgeon The University Hospital of Orthopaedics Sofia, Bulgaria Hani S. Matloub, MD Professor, Director of Hand Center Department of Plastic Surgery Medical College of Wisconsin Milwaukee, Wisconsin J. Medina, MD Associate Professor in Orthopaedics University of Las Palmas at Gran Canaria Assistant in Orthopaedics Service Hand and Upper Extremity Unit University Hospital Insular of Las Palmas Las Palmas, Spain
Elizabeth A. Mikola, MD Assistant Professor Hand and Microvascular Surgery Department of Orthopaedics University of New Mexico Health Sciences Center Albuquerque, New Mexico Moheb S. Moneim, MD, FRCS Professor and Chairman Department of Orthopaedics and Rehabilitation Chief, Division of Hand Surgery University of New Mexico Albuquerque, New Mexico Hanh H. Nguyen, MD Assistant Professor Department of Plastic Surgery Medical College of Wisconsin Milwaukee, Wisconsin Tanya Oswald, MD Department of Surgery University of Mississippi Medical Center Jackson, Mississippi G. Pajardi, MD Chair, Plastic and Hand Surgery Department Milan University MultiMedica Hospital Milan, Italy Stephen Pap, MD Staff Surgeon Division of Plastic Surgery Mount Auburn Hospital Cambridge, Massachusetts Jaewoo Park, MD Assistant Professor Department of Plastic and Reconstructive Surgery Kyungpook National University Hospital Kyungpook National University School of Medicine Taegu, Korea Julian J. Pribaz, MD Professor of Surgery Harvard Medical School Associate Plastic Surgeon Division of Plastic Surgery Brigham and Women’s Hospital Children’s Hospital Boston, Massachusetts Barbara E. Puddicombe, OTR/L, CHT Hand Therapy Associates Cranston, Rhode Island
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CONTRIBUTORS
David Ring, MD Instructor in Orthopaedics Harvard Medical School Hand and Upper Extremity Service Department of Orthopaedic Surgery Massachusetts General Hospital Boston, Massachusetts Deryl J. C. Robson, MS, OTR/L Hand Therapy Associates Cranston, Rhode Island Christian E. Sampson, MD Assistant Professor of Surgery (Plastic) Department of Surgery Division of Plastic Surgery Harvard Medical School Brigham and Women’s Hospital Children’s Hospital Boston, Massachusetts Luis R. Scheker, MD Assistant Clinical Professor Division of Plastic and Reconstructive Surgery University of Louisville School of Medicine Kleinert, Kutz and Associates Hand Care Center Louisville, Kentucky William H. Seitz, Jr., MD Executive Director Cleveland Orthopaedic and Spine Hospital at Lutheran Hospital Cleveland Clinic Health System Associate Clinical Professor of Orthopaedic Surgery Case Western Reserve University School of Medicine Cleveland, Ohio Jui-Tien Shih, MD Department of Orthopaedic Surgery Armed Forces Taoyuan General Hospital Taiwan, Republic of China Former Research Fellow Christine M. Kleinert Insitute for Hand and Microsurgery Louisville, Kentucky Dean G. Sotereanos, MD Human Motion Center Allegheny General Hospital Pittsburgh, Pennsylvania James W. Strickland, MD Clinical Professor of Orthopaedic Surgery Department of Orthopaedic Surgery Indiana University School of Medicine Indianapolis, Indiana Department of Orthopaedic Surgery St. Vincent Hospital Indianapolis, Indiana
Tsu-Min Tsai, MD Clinical Professor Department of Orthopaedic Surgery University of Louisville School of Medicine Christine M. Kleinert Institute for Hand and Microsurgery Louisville, Kentucky Raoul Tubiana, MD, Hon FRCS (Ed) Professor University of Paris Institut de la Main Centre Orthopedique Jouvenet Paris, France Thomas H. Tung, MD Assistant Professor of Surgery Division of Plastic and Reconstructive Surgery Department of Surgery Washington University School of Medicine St. Louis, Missouri Joseph Upton, MD Clinical Associate Professor of Surgery Harvard Medical School Department of Surgery, The Children’s Hospital Department of Surgery, Beth Israel Deaconess Medical Center Department of Surgery, Shriners Burns Institute Boston, Massachusetts Dimitris G. Vardakas, MD Fellow, Hand and Upper Extremity Surgery Department of Orthopaedic Surgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Huan Wang, MD, PhD Associate Professor Department of Hand Surgery Hua Shan Hospital Fudan University Shanghai, People’s Republic of China Former Research Fellow Division of Plastic Surgery, Department of Surgery University of Mississippi Medical Center Jackson, Mississippi Fu-Chan Wei, MD, FACS Professor of Plastic Surgery Dean Chang Gung Memorial Hospital Chang Gung Medical College and University Taipei, Taiwan, Republic of China
CONTRIBUTORS
Jeffrey Weinzweig, MD, FACS Chairman Department of Plastic and Reconstructive Surgery Director Plastic Surgery Residency Program Lahey Clinic Medical Center Burlington, Massachusetts Attending Surgeon Boston Children’s Hospital Boston, Massachusetts
Irvin M. Wiesman, MD Department of Surgery St. Elizabeth’s Hospital Department of Surgery St. John’s Hospital Chicago, Illinois
Norman Weinzweig, MD, FACS Professor Department of Plastic and Reconstructive Surgery Rush University Medical Center Senior Attending Surgeon Divisions of Plastic Surgery and Orthopedic Surgery Department of Surgery John H. Stroger, Jr. Hospital of Cook County Chicago, Illinois
Michael R. Zenn, MD, FACS Assistant Professor Department of Surgery Division of Plastic and Reconstructive Surgery Duke University School of Medicine Duke University Medical Center Durham, North Carolina
Jo M. Weis, PhD Assistant Professor Department of Psychiatry and Behavioral Medicine Medical College of Wisconsin Milwaukee, Wisconsin
Steven D. Young, MD Southern Orthopedic Associates Herrin, Illinois
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Foreword Although traumatic injuries to the upper limb are extremely common, mutilating wounds involving both soft tissue and skeletal parts are less frequent. When they do occur, however, the lives of these patients are inexorably altered. In older patients, we find that healing may be compromised by associated conditions, recovery may be prolonged, support systems may be deficient, and adaptation to the loss may be difficult at best. There are clear differences when these injuries involve children, whose sensory return is superior and adaptation to the loss can seem almost magical. Regardless of age, the major goal in treating these patients is to restore as much as possible normal function and appearance to severely injured thumbs, digits, hands, or other parts of the upper limb. As counterintuitive as it may seem to a novice, any damaged tissue that cannot be saved and utilized as a “spare part” for functional restoration should be discarded so that it does not interfere with function of the remainder of the hand. This decision to discard composite parts is often the most difficult at the time of initial debridement, but revascularization and salvage of the injured parts that have some functional potential should always be judicious. Without question, the individual surgeon’s experience, knowledge, and ability should be the primary determining factors in this decision-making process. Next in importance is a careful assessment of the severity and potential cutaneous loss in the injured extremity. Clearly, surgeons more familiar with the myriad options for skin resurfacing will feel much more comfortable treating the devastating injuries presented in this book. Once the initial wound has been surgically assessed and debrided and the usable parts have been salvaged, a long-term plan should be designed. Despite the many obstacles interposed by associated medical conditions, social constraints, and insurance companies, this plan should be followed as closely as possible. Of course, every plan must be tailored to each individual patient and followed until the best possible outcome has been achieved. Many of the remarkable cases presented in
this book are the result of not years but decades of careful follow-up and reconstruction. Advances in our knowledge of the cutaneous, muscular, and neural anatomy of the upper limb; breakthroughs in microsurgical techniques and instrumentation; and the creativity of reconstructive surgeons have dramatically changed this field over the past three decades. While thirty years ago complete amputation was the only option for a hand mutilated by a printing or punch press, today most of the injured parts can be isolated, carefully assessed, reattached or revascularized, and integrated into a functional hand or arm. There is no claim that these limbs will ever be normal, except possibly in a young child with a very isolated injury, but we no longer see the complete amputations that we once did. At present, the most difficult decision the surgeon may face is whether to sacrifice an injured part when he or she knows that the long-term outcome of not sacrificing the part may be more detrimental than beneficial. While remaining aware of all the breakthroughs in recent years, today’s reconstructive surgeons should not overlook proven traditional techniques of yesterday, such as skin grafting and pedicle flap transfers. The best surgeons will effectively integrate all eras of practice into current procedures. The young microvascular surgery tyro can easily get into trouble if he or she does not carefully assess all the options before progressing to a complicated free tissue transfer or multiple-digit reattachment effort. This comprehensive book illustrates well the effectiveness of old, predictable techniques— such as pedicle flaps, post-traumatic pollicizations, and staged thumb reconstructions—in contrast to newer innovations—such as immediate free tissue transfers and toe-to-hand transfers. The text is well organized and divided into sections devoted to replantation and revascularization, “spare parts” surgery, toe transfers, pediatric injuries, secondary reconstruction, complications, postoperative management, and every other facet involved in the care of these injuries. xv
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FOREWORD
From the start, it is essential to remember that these are not normal injuries and treating them involves many people—certainly more than simply the surgeon and the patient. Often surgeons find themselves treating an entire family pedigree and extended family of concerned friends. The work is labor-intensive, frequently involving other physicians, nurses, and potentially every type of health care provider within the system. Occupational and physical therapists, for example, offer critical services in the months and years following the initial recovery. A successful outcome can be achieved only if the injured person returns to his or her normal environment in an active and functional capacity, and this can require a team of practitioners and caregivers. Chapters focused on secondary reconstruction, occupational therapy, and the psychological impact and treatment of these injuries are particularly informative. The success of any reconstruction depends not only on the surgeon’s skill and the potential for a good sensory recovery. Perhaps of equal importance are the motivation and cooperation of the patient, both of which are unknown factors at the time of initial injury. These characteristics become critical because these injuries are never simple and favorable outcomes are achieved following months, often years, of hard work. While pain and psychological issues must be addressed early and treated effectively, the enduring will power of a strongly motivated patient will prevail. Children are not the only patients who achieve the remarkable, unexpected result. Hard-working adults who creatively adapt to their loss and find new ways to function often do not feel disabled following severe injuries. Even with all these odds stacked against complete recovery, it is important to remember that it can be done. Few members of our society can be as hard working and persistent as surgeons. I recently watched one of our young senior surgical residents perform an open colon resection. Following the completion of the procedure, I asked his general surgical attending if he had noticed anything wrong with the resident’s manual dexterity. As I expected, the attending responded, “No.” Then he added, “But, he could have tied his knots a little faster.” Just nitpicking, really. I nodded and smiled to myself. Twenty-
five years earlier, I had reattached three digits at the PIP joint level and revascularized that resident’s thumb following a July 4th “cherry bomb” explosion injury to his nondominant hand. We put the pieces back together, but our patient did the hard work and had the determination so characteristic of surgeons. Obviously, the successful treatment of a mutilation injury to the upper limb represents one of the most challenging, inspiring, and rewarding experiences for any hand surgeon. This comprehensive volume represents the largest collected work to date that focuses on mutilating injuries to the upper limb, and it offers hidden pearls of wisdom from surgeons with vast experience. Although all the surgical principles and concepts presented here have initially appeared in journals, they are now collected in this well-edited book, presented in full color, and written by an internationally recognized group of experts, most of whom have published seminal works on this subject. J. William Littler’s classic article on thumb reconstruction has been reproduced in addition to his cases presented in the chapter on index pollicization for post-traumatic deformities. This is the only volume in which Wei’s extensive experience with toe-to-hand transfer is summarized in more detail than in abbreviated journal articles. Landi’s chapter on the historical aspects of the mutilated hand and Hagan’s contribution on the mutilated pediatric hand are interesting, original contributions. Germann’s chapter on internal fixation is the most comprehensive in the hand literature and should be on the mandatory reading list for all plastic and orthopedic resident surgeons. Mackinnon’s chapter on nerve allografts and Breidenbach’s discussion of hand allotransplantation both offer clear insights into very difficult and controversial subjects. Who benefits from reading this book? Just about everyone from the interested lay person, the medical student, the resident surgeon, to the experienced senior surgeon. This volume offers a plethora of information for everyone interested in the subject of mutilating injuries of the upper extremity, and it will become an essential text for good treatment. Joseph Upton, MD
Preface Management of the mutilated hand is one of the most daunting challenges facing the reconstructive hand surgeon. Despite the development of newer safety measures in the workplace, modernization of machinery, and improved employee training, these injuries remain all too common. The ultimate functional outcome in each case depends on the initial care of the mutilated hand, including the method of preservation of any amputated parts, determination of what should and should not be preserved, “spare parts” surgery, and the use of “emergency” free flaps, as well as compliance with hand therapy and the surgeon’s experience in the secondary reconstructive efforts. The advent of microsurgery has ushered in a new era with remarkable innovations in surgical techniques and extended indications. However, expertise with the “classic” techniques, such as osteoplastic thumb reconstruction and pollicization, is mandatory. Optimal treatment demands a combination of both approaches. The key is not always the restoration of anatomic congruity but the restoration of maximal function in spite of irreparable anatomic incongruity. Functional goals, as in the patient with arthritis mutilans, must be individualized to each patient’s specific needs. There are roles for osteoplastic reconstruction, pollicization, phalangization, or even Krukenberg’s operation. With this in mind, we set out to accomplish a Herculean task—to edit a comprehensive textbook covering all facets of the management of mutilating injuries of the hand. Chapters are devoted to defining the mutilated hand, describing the etiologies of mutilating injuries, providing classification schemes for these injuries, and offering primary and secondary management strategies. The purpose of this book is to serve as the definitive resource, both as a reference text as well as a practical tool, for residents in plastic surgery and orthopedic surgery, hand fellows, hand therapists, trauma surgeons, and experienced surgeons of the hand and upper extremity. The Mutilated Hand highlights the vast collective experience of numerous luminaries who have advanced
the management of these devastating injuries. Antonio Landi takes us on an historical odyssey of the mutilated hand; J. William Littler, who inspired generations of hand surgeons by his clinical brilliance and da Vinci–like drawings, has recreated his classic work on the making of the thumb in chapters in collaboration with Joseph Upton and Jim Strickland; Fu-Chan Wei has distilled his tremendous clinical expertise on the phalangeal hand, the metacarpal hand, and the wraparound procedure for thumb reconstruction; Raoul Tubiana shares his enduring work on prehension and Krukenberg’s operation; Ivan Matev expounds his experience with distraction-lengthening. One section is devoted to reconstruction of the mutilated hand in children, with invaluable chapters by Joseph Upton and Julian Pribaz. Another section is devoted to bony reconstruction of the mutilated hand, with comprehensive chapters by Günter Germann and Steffen Baumeister. The experimental and clinical arena of limb allotransplantation is explored in superb chapters by Susan Mackinnon and Warren Breidenbach. We are profoundly indebted to the nationally and internationally renowned experts who have contributed their time and ingenuity to produce the 42 beautifully crafted chapters that comprise this volume. They were carefully selected for their outstanding technical skills, clinical experience, and personal insights. These surgeons have dedicated their lives to rehabilitation of the upper limb and have pioneered many of the approaches to the management of mutilating hand injuries described in this book. We are equally grateful to the prominent psychologists and hand therapists who have contributed outstanding chapters to this text, providing invaluable depth and insight into the management of patients with mutilating hand injuries. It is our expectation that the cumulative experience of these masters will greatly increase the chances of a favorable result by the rest of us. As we revel in the birth of this tome, we also mourn the untimely passing of one of its most revered contributors, Professor Zhong-Wei Chen, one of the great pioneers xvii
xviii PREFACE in the world of reconstructive microsurgery, who performed the first successful hand replantation more than 40 years ago. One of the editors (NW) has had the distinct privilege of operating with and coauthoring publications with Professor Chen, as well as participating in training his daughter, Lilly Chen, in plastic surgery. Professor Chen will be sorely missed by his friends and colleagues throughout the world. Our deepest sympathy is extended to his wife and family. The orchestration of scores of contributors from around the globe was no easy task. The compilation of a comprehensive text demands attention to thousands of details and microdetails that could only be accomplished by a dedicated team of highly talented individuals committed to producing a book of the
finest quality. We are extremely fortunate to have had just such a team involved in the gargantuan undertaking of producing The Mutilated Hand. Elsevier and Hanley & Belfus provided us with an editorial and production staff with open minds and a willingness to allow us to digress now and then from convention. For that, and our inclusion in virtually every decision and detail that contributed to the evolution of this volume, we are very grateful. We are especially thankful to our editors, Linda Belfus and Dan Pepper, whose efforts in bringing this project to fruition have been extraordinary. Norman Weinzweig, MD, FACS Jeffrey Weinzweig, MD, FACS
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1 The Historical Odyssey of the Mutilated Hand Antonio Landi, MD A. Leti Acciaro, MD N. Della Rosa, MD
To better understand the occurrence of hand mutilation around the world, one must consider the influence of numerous diverse cultures. Behavior is driven by underlying philosophy. Therefore, penal amputation or self-amputation, accidental amputation in the battlefield, and early attempts at compensating for upper limb injuries need to be interpreted within the appropriate cultural context. This truism also applies to reconstructive procedures and to the new frontiers of human hand transplantation and genetic engineering. Ethical evaluations depend on sensitivity to, and comprehension of, our surroundings.30 The Greek philosopher Aristotle maintained that each part of the body when separated from the living being is no longer a part of that body. Therefore, a hand amputated from its body becomes another entity, and its nature is no longer that of a hand. This concept was later reinforced by Saint Thomas Aquinas. It is obviously in conflict with the prevailing cultural sentiment that an amputated hand remains the same hand the person possessed before the tragic event.30 Islamic philosophers and theologists became aware that if living creatures were shed from the Creator, as the sun emits particles of light, they could no longer accept that God desired and loved them. They thus imagined God like Plato’s Demiourg, who molded his creatures. By equating reality to artifacts it was possible to guarantee divine liberty in creation and to satisfy creatures’ needs to be wanted and loved. The cost of this cultural exercise is that reality is considered in a mechanistic way, and the concepts of materialism and reductionism are promoted in our culture. As a result, our technical know-how makes us feel closer to the Supreme Creator and grants a license to interfere with and manipulate the physical world to our liking. The Eastern world has hundreds of Asian cultures that often have little or nothing in common. The Chinese culture is the oldest, from which so-called alternative medicine originated. The Japanese culture is the most Western-like, while the Khmer (Cambodian) culture has ties to the Indian and Pali cultures of Burma.6 Nevertheless, all share the concept of personal energy, which determines the physiologic essence of the human being. It is important to bear in mind that this energy may have existed for many years in the same being, and one must not ignore the different psychological, physical, and emotional energy that is experienced differently from one body to another. Rejection of a transplanted body part might therefore be considered not only on an organic basis, but also on a psychological and energetic basis. In Eastern cultures, the body is considered living even if it is that of a deceased person, and it is the exclusive property of the person. This gives us clues as to why the Japanese find it difficult to donate body organs and their physicians are wary of transplantation. Asians 3
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THE MUTILATED HAND
distance themselves from the mechanistic concept of Western culture, which considers replacement of a part that has worn out normal and appropriate.6 Remember that the Asian culture has been deeply influenced by Confucian philosophy (500 BC). Confucius considered the human body to be a gift from the parents that must never be damaged. When injury occurs, the afflicted person feels responsible, as he or she has dishonored parents and ancestors by failing to protect what had been handed down. A completely different attitude is encountered in the Taoists, who suggest a different concept of the universe by advocating a withdrawn lifestyle based on acceptance of misfortune as a gift from Nature. Nevertheless, the desire to restore body integrity when faced with mutilation remains a prevailing cultural prerogative even in modern China.25 On the basis of these considerations, we divided this chapter into the following sections: ritualistic and esoteric aspects, legal and penal amputation, self-mutilations, surgical techniques of amputation handed down from the Renaissance, compensation following amputation, and the chronology of the development of various reconstructive procedures. This long and fascinating journey starts in the Neolithic era and concludes with the “yesterday” of recent times.
RITUALISTIC AND ESOTERIC ASPECTS Ancient Evidence of Mutilation The image of the hand from prehistoric times has been preserved in caves on all continents.2,7,24 The 25 caves of Chauvet in southeast France, discovered in 1994, contain the most clearly preserved and ancient example of prehistoric art, dating back 35,000 years. In Brunel Hall, a cluster of 92 palmar hand prints are assembled to outline the profile of a bison. The collapse of the main entry wall of the caves created a stable microclimate, which almost perfectly preserved the pigments.7 As in the caves of Gargas, located in the Aventignan area of the high Pyrenean mountain chain,2 the printing technique differs between the positive and negative hands. In the latter, the pigment is diluted in water, and a mouthful of the liquid color is then blown directly from the mouth. The black color of the hands produces a distinct surrounding spray, and tiny spots are easily discernible. This is due to the pigment—finely ground manganese dioxide, which is insoluble. Conversely, the red-colored hands are made with pigments derived from ochre and hematite, which are soluble in water and give the color a more uniform appearance.18 The mutilated hands of the cave at Maltravieso (Estremadura) contain 24 red negative hands. All of the
discernible hands are mutilated at the little finger. The level of amputation is usually located at the proximal phalanx (Fig. 1-1) or at the level of the proximal interphalangeal joint. The thumb is always preserved. At Gargas, there are 236 hands: 136 are left hands, and 22 are right; 143 are black, and 80 are red; one hand is white (white powdered calcite).2 Mutilation is obvious at the middle and distal phalanx of the middle fingers of 114 hands. The little finger is still the most frequently affected finger (59 cases). A few hundred meters from Gargas is the cave at Tibiran, where Ali Sahly counted 10 red hands. All of these present different types of mutilation. Many theories have been advanced to attempt to explain the incomplete state of these hands. The theory of ritualistic mutilation is conceivable at Maltravieso, where the mutilated finger is always the little finger. However, according to André Leroi-Gourham, ethnologist and prehistorian, this theory does not provide a complete accounting, as the hunters should have severed all of their fingers to be even more fortunate in the hunt. Obviously, this would not be a successful economic policy in primitive communities.10 The theory of pathological mutilation also has been considered by Sahly, as such injuries could have been favored by the environmental conditions in the early upper Paleolithic period. However, Raynaud’s syndrome, leprosy, and severe frostbite rarely entail mutilations comparable to those seen at Gargas and Tibiran.34 According to Leroi-Gourham, our ancestors, like many subsequent hunters, are likely to have used a system of hand and finger signs to communicate the presence of wild animals. This cynegetic code classifies “mutilations” in order of frequency, possibly corresponding to the five animals most commonly seen on murals of caves in the Pyrenees (mainly bison and horses, followed by ibex and deer). Despite the aforementioned theories, the reason for prehistoric mutilations still remains a mystery.
FIGURE 1-1. An outline of a hand at a cave in Maltravieso showing the mutilation of the little finger.
Legends and Folklore Let us consider some well-documented traditions belonging to Irish and Italian legends and folklore.1,5,27,33
The Red Hand According to Irish legend, the red hand was associated with the savior of the Irish race. One such king was Cathal Crobhdhearg, or Cathal Mor of the Wine-Red Hand, who lived in the early 13th century. His father, Turlough Mor O’Connor, brother of Roderick, last high king of Ireland, having no heir by the queen, produced one with a concubine. The jealous queen arranged with her witches to cast a spell to prevent the birth. Before this became effective, the child’s arm had been born (prolapsed). After several days and nights of labor, the spell was broken, and a son was born to the king of Connaught, but with a wine-red hand. This, presumably, was a port-wine stain or a perinatal Volkmann’s ischemia.27
THE HISTORICAL ODYSSEY OF THE MUTILATED HAND
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the monasteries of Clonmacnoise and Lorrha about the time of the suppression of the monasteries, during the reign of Henry VIII.
The Dead Hand The dead hand was used to cure many diseases, according to the Irish folklore, for which purpose the sufferers were brought to wakes and executions. The hand of an unbaptized infant holding a candle was regarded as invaluable in casting out spells, and grave robbing for the purpose of obtaining such a hand was not uncommon.27
Hand Shrines In Ireland, Isle of Saints, the hand was frequently kept as a relic and encased in a shrine. Hands were used as objects of veneration, to emphasize solemnity, as objects on which an oath would be taken, and for cure of the sick. An example is the shrine of St. Patrick, a 15-inchlong silver case that is in the possession of the Ulster Museum. The fingers are in the posture of an episcopal blessing (thumb, index, and middle fingers extended). There is also the shrine of St. Lachtin’s arm. He was a native of Cork who established a monastery there in AD 622. The shrine itself is of bronze and silver, with gold and glass ornamentation. Other hand shrines, such as those of St. Ciaran and St. Ruadhan, disappeared from
The Sword in Italian Rocks Strictly linked to the vicissitudes of King Arthur throughout Europe, the adventures of the sword were assembled by Sir Thomas Malory around 1450, based on the epic cycle that was initiated by Cretien de Troyers (1130–1190), poet at the Court of the King of France, who identifies in Camelot the palace of King Arthur. The “Mass of the Sword” has been celebrated for centuries in Cividale of Friuli. Similarly, Grosseto preserves the sword by which Guglielmo of Malavalle, formerly William, Duke of Aquitania, who lived a short distance from Chiusdino, killed the local infesting dragon in the middle of the 12th century. Guglielmo might be the person who imported the myth of King Arthur into Tuscany, remnants of which include the Templar Cross painted at the entry of the Cistercensis Abbey (Fig. 1-2). Galgano Guidotti, who later became St. Galgano, lived in Chiusdino (1148–1181). After a rather licentious youth, he abandoned his weapons to become a hermit as a consequence of a vision. On Mount Siepi,
A
B
FIGURE 1-2. A, Templar cross painted at the entry of the Abbey in Tuscany. B, View of the Cistercensis Abbey.
1
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THE MUTILATED HAND
Koranic Law
FIGURE 1-3. Remnants of St. Galgano—part of the arm kept in the shrine of the chapel.
he ran his sword into the volcanic rock of the mountain as a symbol of the Cross and of his conversion. The legend states that during his pilgrimage to Rome to visit Pope Alexander III, three monks wanted to unmask his fictitious conversion of faith. The monks went to the mountain to destroy the sword and the hut (a scene that is also pictured in an altarpiece by Giovanni Di Paolo), but a wolf defended the sword by tearing the arms off the monk who tried to extract it. These arms are kept in the shrine of the chapel, and carbon-14 testing has effectively dated them to the 12th century (Fig. 1-3).1,5,33
LEGAL AND PUNITIVE AMPUTATIONS The first mention of a penal amputation comes from the Bible (Judges I:1–7) and concerns a Canaanite king, Adoni-bezek, who led a coalition against Joshua and was defeated by Judah and Simeon in nearby Gabaon. The defeated king was crippled by having his thumbs and great toes cut off, a torture that he himself had previously inflicted on 70 subjugated chieftains. Amputation of the thumbs caused a major disability by abolishing the capacity for fighting, since swords, vital weapons of the time, could no longer be handled. Cutting off the big toes made running impossible at a time when wars were waged barefoot. Adoni-bezek died soon after his mutilations. It was also customary for Pharaohs to order the amputations of the hands of thousands of prisoners following their battles.36 A similar type of amputation is mentioned by Montaigne (1580), and is quoted by Landi,14,22 as having occurred during the Greek period. The famous French philosopher does not quote specific sources but relates that after a naval battle, the thumbs of the defeated enemies were cut off so that they would no longer be able to row. Accordingly, the Athenians went on to amputate the thumbs of the Aeginetas to deprive them of their naval supremacy.
Laws based on the application of the Shari’a are applied in the United Emirate Republic, Bahrain, Saudi Arabia, Sudan, Syria, Oman, Qatar, Libya, and Yemen. Corporal punishment, such as that inflicted on thieves and plunderers, is indeed mentioned in the Koran with specific rules and regulations. The philosophy of the law of the Koran is that of establishing justice and guaranteeing the basic needs of all. Once society has achieved these levels of social justice and equity, appropriate sanctions can be mandated and implemented. A thief is defined according to the social context in which he or she lives. In the absence of ideal social conditions, one who breaks the law must face a penalty but not corporal punishment. The prerequisites for corporal punishment include exceptional violence of the crime committed and being a habitual criminal, in addition to exceeding the limits of certain parameters specific to respective societies. Two descriptions of primitive hand amputation as punishment are found in Sura 5 of the Koran: Verse 33: “The punishment for those who wage war with Allah and his Messenger and who seed corruption on Earth is to be put to death or crucified and that they be amputated of their hand and opposite leg or that they be exiled from the Earth. This is the dishonour they face in this world; in the other world they will receive an immense punishment.” Verse 38: “Cut the hand of the thieves to punish them for what they have done, as a sanction in the name of Allah. Allah is great and wise.” Excluding crimes driven by poverty or need, the law of Islam levies a severe punishment on thieves. Based on the Sunna of the Messenger of Allah, Islamic law establishes the rules for applying these punishments as well as a series of attenuating circumstances and justifications. For example, the caliph Umar would not allow amputation of the hand of a thief who did not possess at least a 3-month supply of food. These conditions were known since the beginning in the religion and philosophy of the Koran; indeed, no more than six hands were amputated in the first five centuries of Islam. These acts were already uncommon when the social structures were less disrupted than they are today. Corporal punishment was meant to be dissuasive but also to express the virtue of complying with civic and religious duties: “No hesitation in the face of indignity and injustice.” Inflicting corporal punishment outside this philosophy and context does not represent the model but a deviation that must be condemned, even for Islamism. Only one mention of corporal punishment is found in the Italian medical literature of the Renaissance
period. De Renzi reported that in the Republic of Venice, when the Lictors had to amputate the hand of offenders, they would adopt the best surgical technique of the times by retracting the skin as much as possible and avoiding amputations through the joints.12,13 This caution was probably a result of Venice’s ties with the Asian world and cultures.
Punitive Amputation in China Systems of punishment were unknown before the great kings of China (1760 BC); execution and physical punishment were started during the reign of the Chou kings (1120–256 BC). Execution was accomplished by decapitation, whereas physical punishment involved removal of fingers and sacrifice of individual muscles. Later, King Wu created the five punishments of suffocation, nose amputation, patella removal, genitalia resection, and decapitation. Subsequent types of punishment were all based on these, although the varieties and means of execution became increasingly colorful. The main justification for physical punishment was the belief that suffering should be either short term, as exemplified by whipping and crushing the extremities between boards, or permanent, like the five major punishments. The ancient rulers were also aware that further humiliation might be achieved by means other than physical punishment. External labels such as special tattoos and headgear offered constant humiliation. Some offenders were sentenced to a combination of bodily punishment and external labeling. All external organs might be removed, for example, the ears, eyes, fingers, and toes; or the whole hand or foot might be amputated. Disfiguring procedures were usually reserved for serious crimes, whereas amputation procedures were means of punishing thieves (the upper limbs) and gangsters (the lower limbs).25
Central and South American Cultures Amputation generally was dreaded more than death, because it affected the spirit of life after death for eternity. Therefore burial with all parts of the body was, and remains, important in many cultures, including that of the Australian aboriginals. In Perù, the Moche culture (300 BC to AD 600) was located on the North Coast. An unsettled argument exists as to which diseases caused deformity and amputations in ancient Peru, but these are more or less the same as those already reported in the section on ancient evidence of mutilation.29 Punishment was probably the major cause for amputation in Peru, and the magnitude of the mutilation was proportional to the significance of the fault. Theft was punished by amputation of one hand. The level of amputation was related to the punishment ordered.
THE HISTORICAL ODYSSEY OF THE MUTILATED HAND
7
These different types of amputation are represented in the pottery of the corresponding period. Punishment depended not only on the crime but also on the social class of the criminal. The figures that almost invariably have ear plugs and headdresses belong to the upper classes, for whom bilateral amputation was assigned for the criminal rebellion. In the mysterious Mayan culture, the different kingdoms achieved their peak splendor between the 6th and 9th centuries AD in Mexico, Guatemala, Belize, and Honduras. When one of the city-states conquered an opponent, the victorious king captured the scribes of the defeated court. At some stage, their fingers were broken and their nails avulsed to destroy their ability to record history, but before being subjected to this torture, the scribes were obliged to write or paint the celebrations of the victorious king. In the fresco of Bonampak in Mexico, one prisoner is shown painting and the others with amputated, bleeding fingers.15
SELF-AMPUTATIONS Self-amputations have been, and still are, performed as a result of psychiatric disorder; to establish a permanent stigma for mourning (a tradition that is still widely practiced by widows in Malaysia); to assert the right to choose conditions of life that are believed to be better than, for example, compulsory military service; and to affirm extreme courage. Finally, amputation of the self might be considered an extreme protest in regard to relevant social and political issues. Mutilations of the self occurred during the Roman age without any therapeutic purpose whatsoever. Indeed, these amputations were carried out to evade the pressure exercised by a relentless authority. For many centuries, this authority had been exclusively political: the State. However, in the 4th and 5th centuries AD, it was replaced by the religious authority of the Church. We find the oldest reference in Suetonius’ account of the age of Augustus. A short while before, the upheavals of the civil wars and of the “revolution” had ended, and Rome was transformed from a republic into a principate. Once Augustus had consolidated his authority, he set out to restore order in the State, trying to revive among the Romans the ethical values of the past. Among the reforms, he made many changes and innovations in the army. He sold a Roman knight (eques romanus) and his property at public auction because the knight had cut off the thumbs of two young sons to make them unfit for military service. But when he saw that some tax collectors (publicans) were intent on buying the knight, he instead demoted him to a freeman, with the understanding that he should be banished to the country districts but allowed to live in freedom.
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THE MUTILATED HAND
Augustus mitigated the sentence so as not to subject the knight to the humiliation of becoming the property of a tax collector, a profession that operated under the control of, or even within, the equestrian class.9 From the time of Marcus Aurelius (AD 161–180), border wars became more frequent and were no longer aimed at conquest but at defense against the attacks of barbarians—circumlatrantes, “who bark all round us”— along the frontiers, as noted by the anonymous author of the De rebus bellicis shortly after AD 350. The armies were increasingly composed of peasants from provinces more and more remote from Italy. In fact, the great Roman landowners were reluctant to give up the coloni, who cultivated their estates, to fill the recruitment quotas. They preferred to give money and to pay barbarian mercenaries. The sons of veterans (that is, soldiers dismissed from the army because of advanced age) were to replace their fathers in the military service. Thus, if we glance through the imperial constitutions of the 4th century gathered together in the Theodosian Code, we witness an abundance of measures designed to assert that military service had to pass from father to son and to put a stop to exemptions and evasions achieved with the most varied expedients. In the constitution of 313 addressed to Octavianus, the governor of the Lucania et Bruttii, Constantine decreed that “the veterans’ sons who are unfit for military service by mutilation of their own bodies” should be compelled in one way or another to be of service to the State. “If they should be judged useless for military service because their fingers have been cut off, we order them to be assigned to the performance of the compulsory public services and duties of decurions.”9 At the end of the 4th century, the practice of cutting off a thumb to escape conscription seems to have spread very widely. It was no longer restricted to the upper ranks of society (honestiores) who wished to avoid active military duty to embark on a career in the State bureaucracy, which was much more prestigious and remunerative. It was also practiced by ordinary soldiers with the collusion of their masters, who did not wish to lose peasant labor. Theodosius I, probably seeking punishments of greater benefit to the community as well as being moved by a Christian spirit, decreed that those who were guilty of amputation of their fingers for the purpose of avoiding military service should be branded with a stigma so that they would always be recognized (this was the practice with workers in certain State factories), and then they should be assigned to whatever public service needed them (“if any person by the disgraceful amputation of his fingers should evade the use of arms, he shall not escape that service which he seeks to avoid, but he shall be branded with a stigma, and he
shall perform military service imposed as a labor since he declined it as an honor”). Theodosius also decreed that the provincial taxpayers should provide “two mutilated recruits for one whole one.” In the centuries of the late empire, especially in the Latin West, the energies of the upper classes in society were directed toward the ecclesiastical hierarchies. Bishops of a high cultural level and dedicated to a severe ascetic discipline tenaciously implemented a policy that led to an increase in the number of priests and above all to their recruitment from the higher ranks of society. However, they were opposed by anchorites and monks who claimed absolute autonomy from any institutionalized earthly authority (including the Church). They held themselves to be subject to God alone. They refused and feared priesthood. The Church made every effort to control these variegated and disorderly centers of spiritual strength. In the end, the Church succeeded in imposing its authority, especially after the Council of Calcedonia in AD 451 had ratified the obligation for all monasteries to depend on the local bishops. In the hagiographic literature of the time, we read of ascetics who bit off a finger of the bishop who was attempting to place his hand on their head to ordain them. Still others are reduced to self-mutilation, as the body of a priest had to be intact, inasmuch as it was the image of Christ’s own body. In modern times, the deprivation of the thumb is still considered an obstacle to being ordained, even though it has been sometimes disputed by resorting to the example of St. Mark the Evangelist. In fact, with reference to St. Mark (who might have belonged to a Levitical family), at the very beginning of the third century, Hippolytus testifies to his curious nickname: ho kolobodaktulos, “with a finger cut off.” From this a legend arose, in which St. Mark mutilated himself to avoid the Levitical priesthood.9
The Red Hand of Ulster The Red Hand of Ulster was the crest of the O’Neill clan, and later it was adopted by the province as a whole. The story of its origin, which is also found in the Isles of Scotland, was that the leader of an invading force promised the largest parcel of land to the man who first touched the soil, whereupon a warrior cut off his hand and flung it from the ship to the shore.27
Political Protest in Korea The Prime Minister of Japan, Jumichiro Koizumi, visited South Korea in August 2001. In Japan, August is the month for the remembrance of the dead, and an official visit was paid to the temple of Yosukumi, where several Japanese who are considered war criminals in Korea
1
THE HISTORICAL ODYSSEY OF THE MUTILATED HAND
9
1
were honored. This was a clearly political act, and it triggered the auto-amputations of fingers as a sign of protest from some of the attending Koreans. In Asia, the act of amputating a little finger is an extreme protest bearing a precise significance, namely, “I reach the stage of self-mutilation to protest what I consider a grave injustice.” A macabre demonstration was seen when about 20 South Koreans made this extreme protest. The scene was broadcast, with the men, one by one, amputating their little fingers with a small guillotine. Each placed the amputated segment on a South Korean flag, folded it, and then tied it in a knot.
TECHNIQUES OF AMPUTATION Historical records and archaeological artifacts show that amputations have been performed since Neolithic times at least 43 thousand years BC. Some drastic methods have been recorded throughout history.29 Rev. H. Wollaston, assistant colonial surgeon, reported on an Australian aboriginal who had been involved in a tribal fight and received a spear injury to the leg that penetrated the bone. The aboriginal man and his companions made a fire and dug a hole to accommodate the leg. The limb was then surrounded with live coals, which were kept replenished until the leg burned off.26 In Western culture, the surgical technique of amputation can be traced only to the end of the Renaissance.19,31 The routinely adopted method of amputation of the hand originated with Joham Scultetus of Ulm32 (1595–1646) and the authors of the Armamentarium Chirurgicum (Fig. 1-4). This work, translated into various languages, made its influence felt throughout Europe for a considerable time.23 The technique of amputation and the related instruments are superbly described (Fig. 1-5): “XII—A hand is blocked by a laze; when lacking a saw it is placed onto a wood chuck and held with a chisel, at the healthy end of the radius bone and elbow; it is amputated with good success. The elbow above the body is blocked in a band, in order to reduce the sensitivity to pain but also to permit tamponade of the arteries against the great perfusion of blood after the amputation. XIII—A basin filled with water and vinegar, in which a bladder is floating, to be applied to the mutilated segment. XIV—Two wound dressing bands are used to tie and fasten the arm from which the hand was amputated.”32 Only a few selected instruments were used (Fig. 1-6). The stone knife (see IV in Fig. 1-6) resembles similar instruments, called tumi, that were routinely used by the Peruvians.26,29 Ligation of vessels also began to be routinely performed in that period (Fig. 1-7): “XI—A mutilated arm where the artery was extracted and tied off to prevent blood loss.”32 Probably the best drawing on the techniques of hand amputation is by N. H. Jacob, the expert designer
FIGURE 1-4. Part of the title page of the Armamentarium Chirurgicum.
FIGURE 1-5. Description of the techniques of amputation in the Armamentarium Chirurgicum.
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THE MUTILATED HAND
FIGURE 1-8. Some of the surgical procedures in hand amputation as described by Jacob in the Traité Complet de l’Anatomie de l’Homme.
FIGURE 1-6. The instruments used in amputations, as described in the Armamentarium Chirurgicum.
of the Traité Complet de l’Anatomie de l’Homme 3 by Bourgery and Claude Bernard published in Paris in 1870 (Fig. 1-8). Anesthesia was obtained by the same “pills” that were used in Roman times: opium, hyoscyamus niger, and mandragora officinalis.28
Analgesias were derived from plants containing salicylates. As an aid to amputation, compression of the principal nerves, as suggested by Scultetus, was detailed by James Moore in 1784.26 He devised a clamp for this purpose and advised that it be applied preoperatively for 20 minutes. Patients reported that they experienced very little pain except during bone rasping. Surgical technique flourished after the development of anesthesia,8 introduced in America by Dr. Crawford Long in 1842 and later publicized by Dr. Horace Well in 1844. Dr. Well implemented the use of nitrous oxide (laughing gas). We were getting closer to the antiseptic Listerian era, which contributed to the shift of surgery from empiricism to the domain of science.
ANCIENT LEGISLATION RELATED TO HAND MUTILATIONS The problems related to loss of hand function were already perceived; past and present compensation criteria can be traced back to the centuries before the common era.
The Brehon Laws
FIGURE 1-7. The techniques used for vessel ligation and for preventing blood loss during amputations.
The Brehon Laws of Ireland were first promulgated in pagan times several hundred years before the common era and were codified in the 5th century AD. They continued to provide a very comprehensive and practical guide to the social order of the country until the reign of James I in the early 17th century. The judges, who were given the title of Brehons, were educated in these laws and implemented them “in circuit.” The hand was singled out for special attention.27
Guidelines were provided so that the standards could be met in the houses of physicians where the sick and wounded were tended. Each soldier wounded in battle was entitled to a “bed and a physician.” Stipulations were made for the quality of food and drink and for the protection of those convalescing in the house, similar to Roman customs.28 In the 7th century book of Aicill, the topic of Brehon compensation, or eiric, for injuries is dealt with, and here the hand is addressed directly. Compensation for the whole hand was fixed at 36 screpalls (monetary units); 18 represented the thumb, and 9 the index finger of the right hand or middle finger of the left hand. The remaining fingers were rated at 3 screpalls each. Compensation was further subdivided according to how many joints were affected. Injuries to the tips of the fingers and the nails also were discussed in detail in the text, and the concept that such a loss might cause disproportionate suffering according to the occupation of the affected person was recognized. Loss of the upper limb was indemnified as for the hand, whether it be from the wrist, elbow, or shoulder.
Legum Regis Canuti Magni King Canute was a Danish king who ruled England from 1016 to 1035; he is buried in Winchester Cathedral. He also was sovereign of Denmark and Norway. Few people are aware that the name Canute is linked to a famous treaty, the Legum Regis Canuti Magni, which unified England, Denmark, and Norway in that period. The treaty is written both in the Latin of the Middle Ages and in ancient Anglo-Saxon; the original manuscript is preserved in the Colbert Museum in Paris.21,22 In this treaty, dictated by the king himself, we find the “Criteria of Indemnity” for accidents sustained by his subjects. It represents a genuine manual, among the first relating to medicolegal matters. In particular, this document details the various compensations awarded for different types of hand and finger injuries. Considering the detail of this section, one can suppose that finger amputation occurred frequently. The solidus was the correspondent currency, and as far as we know, one solidus was worth a considerable amount. One hundred solidi was the sum paid to a wife following the death of her husband, and the same amount was awarded to a man who was totally paralyzed after a neck injury. Fractures during this age were still a very serious injury: A man with fractures to both arms received 30 solidi. The loss of a thumb was also worth 30 solidi. King Canute, more than nine centuries before the establishment of a health service in the United Kingdom (1942), was aware of the extreme disability caused by thumb loss. It is possible to interpret these values in solidi in modern terms by comparing them with the British industrial scheme (Table 1-1).
THE HISTORICAL ODYSSEY OF THE MUTILATED HAND
TABLE 1-1 Lost Digit
11
Evaluation of Degree of Permanent Disability Following Industrial Accidents King Canute (solidi)
British Law (£)
Thumb
30
30
Index
15
14
Middle
12
12
Ring
18
7
Little
9
7
IMPORTANT EVENTS IN THE DEVELOPMENT OF TREATMENT FOR HAND OR FINGER LOSS The Byzantine Period An early miraculous event is recorded in the Byzantine period. The legendary vicissitudes relating to the restoration of the thumb take us to ancient Cusio (today’s Lake d’Orta in Italy). It was from the Orient, from Aegina in Greece to be exact, that two brothers— Julius, a seminarist, and Julian, a deacon—arrived around AD 350 to preach in the region. During their journey, they converted many people to the Christian faith and, as a lasting testimony, built 100 churches (according to the legend). The last two churches were constructed in the vicinity of Lake d’Orta. St. Julius performed many miracles during his travels, one of which was to reattach the left thumb of a worker who had accidentally amputated it with an axe. This miracle, the story of which has been handed down over the centuries, is represented in a 15th-century fresco situated to the left of the nave in the St. Julius Basilica (Fig. 1-9). According to Bollandus,21,22 writing in 1784, during the basilica’s construction, a worker extended his hand imprudently forward and severed his own thumb “with that metal implement that people call ‘axe’.” Blood spurted abundantly from the wound, and the man fell to the ground unconscious. Seeing this, his companions hurried to inform St. Julius. The saint came to the side of the injured man, saying, “Bring me the finger.” He took the severed thumb and held it in its place while making the Sign of the Cross, and the hand was restored (see Fig. 1-9).
The Renaissance During the Renaissance, Gabriele Fallopius was included among the most distinguished surgeons of the
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THE MUTILATED HAND
A
B
FIGURE 1-9. A, View of the Basilica dedicated to St. Julius. B, Part of the fresco representing the miracle of St. Julius.
time. His most famous work, entitled Libelli duo alter de ulceribus, alter de tumoribus praeter natura, was published in 156317 (Fig. 1-10). During his practice, he replaced a subtotally amputated ear and similarly achieved the survival of an amputated digit.12,13 He was inspired by a very modern principle of microsurgery: that the amputated part should be cooled.
The Role of the Horse in Hand Amputations The role of the horse in finger amputation is quite interesting and varied over the centuries. On the positive side, the horse was the driving force of the “flying horse ambulance” introduced by Barron Harrey, a surgeon to Napoleon Bonaparte, with the aim of accelerating the evacuation of the wounded from the battlefield.26 The horse also acted as a stimulus to introduce various reconstructive surgical procedures.11,35 On
the negative side, the horse has played an active role in amputation of parts of the human body in several circumstances.4 One of the clinical observations described by De Marchetti in 1665 concerns an avulsion injury of the thumb (Fig. 1-11) caused by a horse that was recalcitrant to the setting of the reins. Hemostasis at the proximal stump was accomplished by applying egg white and a local ointment containing snake blood. Secondary healing was successfully accomplished, adhering to the Avicenna principles of wound treatment. The patient was also put on diet and had to refrain from drinking wine. Obviously, no repositioning of the avulsed part was attempted! In 1852, in an inspiring accident for Huguier, a thumb was bitten off by a horse. After secondary healing was established, Huguier made the first attempt to restore some useful function of the thumb by phalangization of the thumb metacarpal. “When we
THE HISTORICAL ODYSSEY OF THE MUTILATED HAND
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The First Reconstructive Procedures of the 20th Century
FIGURE 1-10. Part of the title page from the famous work edited by Gabriel Fallopius in 1563.
observe,” he wrote, “that the functional superiority of the thumb essentially originates from its metacarpal, which is in reality the proximal phalanx, we may ask ourselves if it is possible to replace some of the functions of the thumb by isolating the distal half of the bone through deepening of the first interosseous space.”35
FIGURE 1-11. Part of an avulsion injury of the thumb described by De Marchetti.
Major advances in surgical reconstructive procedures were achieved in the 20th century, and we have had the privilege of witnessing these events. The world’s first replantation of a completely amputated thumb in a 28year-old man was accomplished in July 1965 by Shigeo Komatsu and Susumu Tamai at the Orthopaedic Clinic of the Nara Medical University Hospital, Kashihara, Japan, and was reported in Plastic and Reconstructive Surgery in 1968. Komatsu and Tamai had worked on replantation of amputated extremities since 1959. In 1964, they asked the members of the Nara Prefectural Medical Association to send them all patients with traumatically amputated hands or digits. On July 27, 1965, Komatsu and Tamai finally succeeded in replanting an amputated thumb. Undoubtedly, the success of this replant was related to the use of 8-0 monofilament suture that Professor Yukato Onji, Director of the Institute of Orthopaedics, had brought back with him after a visit to the United States.22 The first free vascularized toe transfer was performed in 1966 by Yang Dongyue, but the original paper, entitled “Free Second Toe Transplantation in Reconstruction of the Thumb,” was not published until 1977 in the Chinese Journal of Surgery.14,22 On September 24, 1998, the first cadaveric forearm and hand transplantation was successfully performed by a team of microsurgeons led by J.M. Dubernard of France and E. Owen from Australia.16,20 For a moment, one might consider that nothing else could possibly be added to these successes, but we all know too well that the odyssey of the mutilated hand is a continuing journey.
Acknowledgment We are grateful to Dr. John Pradelli for assisting in the English translation and to Tiziana Cuccagna for providing the Latin translations.
References 1. Albergo V: Die Abtei San Galgano und die Rundkirche von Monte Siepi. Pistoia, Italy, Tellini, 1986. 2. Barriere C, Sueres M: Le mani di gargas. Manovre 7(1):47–57, 1992. 3. Bourgery, BC: Traité complet de l’anatomie de l’homme. Paris, France, L Guerin et C, 1870. 4. Brighetti A: Chirurgia e infortunistica a Roma nel Seicento. Rivista di Storia della Medicina 14(2):157–166, 1968. 5. Cardini F: San Galgano e la Spada nella Roccia. In Cantagalli (ed): I Classici Cristiani, vol 254. Siena, Italy, Cantagalli, 1998, pp 97–111. 6. Chieregatti A: Replantation of the upper limb and surgery of the hand: Impact on Oriental culture. Rivista di
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Chirurgia e Riabilitazione della Mano e dell’Arto Superiore 36(2–3):331–336, 1999. Clottes J: Magie dell’era glaciale nella Grotta di Chauvet. National Geographic 8(2):96–113, 2001. Collect Medical Antiques: General surgery & amputation: Available at http://www.collectmedicalantiques/amputation. html. Cracco Ruggini L: Mutilation of the self: Cutting off fingers or ears as a protest in antiquity. Rend Mor Acc Lincei 5(9):375–385, 1998. Delluc B, Delluc B: Le rappresentazioni grafiche della mano nella preistoria. Manovre 7(1):23–46, 1992. De Marchettis P: Observatio LXII. In: Observationum Medico-Chirurgicarum Rariorum Sylloge. M. DC. LXV, 1665, Amstelodami, Ex Officina Petrile Grand, pp 140–143. De Renzi S: Storia della Medicina in Italia, vol 4. Napoli, Italy, Filiatre Sebezio, 1846, p 511. De Renzi S: Storia della Medicina in Italia, vol 3. Napoli, Italy, Filiatre Sebezio, 1846, pp 641–666. De Santis G, De Luca S, Bernabeo R: From the Roman age to the Renaissance. In Landi A (ed): Reconstruction of the Thumb. London, Chapman Hall Medical, 1989, pp 21–26. Domenici V: I Maya Spezzavano le Dita agli Scrittori di Regime. In Corriere della Sera of 18 November 26, 2001. Dubernard JM: Human hand allograft: Report on first 6 months. Rivista di Chirurgia e Riabilitazione della Mano e dell’Arto Superiore 36(2–3):265–278, 1999. Faloppii G: Libelli duo. Alter de ulceribus, alter de tumoribus preaeter natura. Venetijs, 1563. Garcia MA, Duday H: Le Impronte della mano dei preistorici nell’argilla delle Grotte Decorate. Manovre 7(1):63–68, 1992. Helling TS, McNabney WK: The role of amputation in the management of battlefield casualties: A history of two millennia. J Trauma 49:930–939, 2000. Jensen JN: Composite tissue allotransplantation: A comprehensive review of the literature. Rivista di Chirurgia e Riabilitazione della Mano e dell’Arto Superiore. 36(2–3): 203–224, 1999.
21. Landi A, De Santis G, Sacchetti GL, De Luca S: The history of the thumb from the Roman Age to the Renaissance. In Cavina C (ed): International Symposium on Plastic Surgery. Padova, Italy, La Garangola, 1988, pp 27–32. 22. Landi A, Facchini MC, Saracino A, Caserta G: Historical aspects. In Foucher G (ed): Reconstructive Surgery in Hand Mutilation. London, Martin Dunitz, 1997, pp 3–11. 23. Leonardo RA: History of Surgery. New York, 1943. 24. Le Quellec JL: Le Mani nelle Pitture Rupestri del Sahara Centrale (Fezzan, Tassili, Ahaggar). Manovre 7(1):69–90, 1992. 25. Leung PC: The Chinese culture and hand reconstruction. In Landi A (ed): Reconstruction of the Thumb. London, Chapman Hall Medical, 1989, pp 12–16. 26. Magee R: Amputation through the ages: The oldest major surgical operation. Aust N Z Surg 68:675–678, 1998. 27. Mooney EE, Prendiville JB: The hand in Irish legend and folklore. Plast Reconstr Surg 87(6):1131–1134, 1991. 28. Morelli E: From Athens to Rome. Riv Chir Mano Arto Sup 33(2):99–103, 1996. 29. Padula PA, Friedmann LW: Acquired amputation and prostheses before the sixteenth century. J Vasc Dis February: 133–141, 1987. 30. Parenti S: Hand transplantation: Issues from philosophy to theology. Rivista di Chirurgia e Riabilitazione della Mano e dell’Arto Superiore 36(2–3):323–328, 1999. 31. Robinson KP: Historical aspects of amputation. Ann Royal Coll Surg Engl 73:134–136, 1991. 32. Sculteti I: Armamentarium Chirurgicum. Combi e La Nou (ed). Venetiis, 1630. 33. Seniori Costantini G: Vita di San Galgano. Chiusdino, Italy, Compagnia di San Galgano, 1904. 34. Tardos R: Mani di Gargas: Studio critici delle ipotesi patologiche. Manovre 7(1):59–61, 1992. 35. Tubiana R: The French school. In Landi A (ed): Reconstruction of the Thumb. London, Chapman Hall Medical, 1989, pp 21–26. 36. Verdan C: Histoire de la chirurgie de la Main. Ann Chir 34(9):647–654, 1980.
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2 Evaluation, Management, and Reconstruction: An Overview Jaewoo Park, MD Byung Chae Cho, MD, PhD
GENERAL PRINCIPLES OF WOUND MANAGEMENT Mutilating injuries of the hand have the potential to produce significant, permanent hand impairment. Management of these devastating injuries is challenging and difficult work. Initial assessment is very important and begins when the patient arrives. Obtain a complete history and perform a thorough physical examination. A radiologic examination of both the stump and the amputated part is necessary. Complete assessment is performed during debridement in the operating room. Another team should assess and prepare the amputated part under an operating microscope or loupe magnification to reduce operating time. Even if the amputated part cannot be replanted at the original site, it should be wrapped in moist gauze for ectopic replantation or for bone, nerve, vessel, and skin harvest as “spare parts.”
Debridement and Fixation Perform adequate debridement to cleanse and decontaminate the wound. After vigorous irrigation, remove all foreign material and devitalized tissue. Immediate coverage with a well-vascularized flap seems to achieve better results than serial partial debridement. Because this aggressive approach leaves little scar tissue in the wound, early rehabilitation is facilitated. Serial debridement prolongs the healing time and increases the chance of infection and cicatricial contractures, thus worsening the final hand function. Viable structures may be desiccated by classic wet-to-dry dressings. Contaminated bone must be scrubbed, burred, and rongeured. If the wound is not closed, great care must be taken so that the tissue does not desiccate. Immediate coverage with well-vascularized tissue can prevent this and heal the partially devitalized tissue.1 The wound should be covered with a skin graft or flap within 2–3 days. Following complete and adequate debridement, perform a final assessment of the defect before reconstruction. Surgeons should consider the various reconstructive options and choose the operative method that will achieve the best ultimate hand function. Once debridement is complete, rigid skeletal fixation should be applied. Plates are used for metacarpal bones; K-wire fixation or interosseous wiring is used for phalanges. Where bony defects exist, external fixation can be used. Small defects can be filled with cancellous bone grafts; large defects can be reconstructed with a free bone flap. If the injured structures can be placed in a well-vascularized bed, it may be possible to spare them from additional damage caused by desiccation, infection, and fibrosis. Close 15
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contact between the flap and the wound eliminates any dead space that may become the site of later infection or fibrosis. After surgery, the wound is dressed and the hand is kept elevated. Three to five days after the operation, passive exercise is started. Rehabilitation should follow a standardized protocol to maximize the final outcome. However, this protocol should be modified according to the individual needs and the clinical situation.
Presurgical Considerations Adequate hydration is essential for optimal circulation preoperatively, intraoperatively, and postoperatively. For assessment of the vessels, preoperative angiography and Doppler monitoring may be performed prior to free tissue transfer. Arteriography delineates any alteration of the arterial anatomy and provides comprehensive information about the location and quality of the venous drainage. Previously, the authors used angiography to assess the vascular status of the hand. Currently, a threedimensional ultrasonic Doppler or magnetic resonance angiography may be used. These tests are not invasive, and surgeons can acquire information about total blood flow to the tissue unit as well as the size and the location of perforating vessels.
INITIAL RECONSTRUCTION OF INDIVIDUAL STRUCTURES Bones Rigid fixation is required, but prolonged immobilization should be avoided. Small bony defects can be satisfactorily filled with cancellous bone, either as a block or as chips. Large bony defects in the metacarpal bones should be replaced with autogenous free or vascularized bone grafts. A vascularized bone graft is superior to a free bone graft. However, in a well-vascularized bed, a free bone graft may be adequate. If conditions do not support a free bone graft, it should be delayed, and a spacer should be inserted (e.g., bone cement or silicone). Available osteocutaneous free flaps include the ilium with the groin flap, the fibula with the skin flap, the metatarsus with the dorsalis pedis flap, the humerus with the lateral arm flap, the rib with the serratus anterior muscle flap, the radius with the radial forearm flap, the ulna with the ulnar forearm flap, and the scapula with the scapular skin flap. A joint injury can significantly impair hand function, especially when the metacarpophalangeal (MCP) joint or
interphalangeal (IP) joints are involved. In such cases, reconstruction with an autogenous vascularized joint transfer is recommended.
Tendons If there is a tendon injury, perform primary tenorrhaphy followed by early passive motion. If tendon defects occur, with a well-vascularized bed and an adequate pulley system, a primary tendon graft from the amputated discarded part or from typical tendon donor sites is considered. If a severely contaminated or inadequate recipient wound exists, a tendon transfer or staged tendon reconstruction should be performed.
Arteries For arterial anastomosis, adequate debridement of the injured artery is required. If there is any sign of arterial damage, such as an ecchymotic arterial wall or a torn intima, laminated media should be excised up to the intact vascular area. After that, it should be reconstructed with an artery from the discarded part or superficial veins. If there are palmar arch injuries, they should be reconstructed. When a vein graft is required, preserve the dorsal vein of the foot for later reconstruction with the dorsalis pedis flap or toe transfer.
Veins Venous reconstruction is rarely necessary. However, if there is a circumferential injury around the wrist, venous reconstruction is an option. In such cases, perform debridement and well-vascularized flap coverage. Debridement of the veins should occur in the zone of injury. Connect the proximal and distal ends using vein grafts.
Nerves If there are any signs of compartment syndrome, decompression is necessary. After careful examination of the nerve, undertake conservative debridement. Primary neurorrhaphy is ideal, when possible. However, if there is excessive tension or a gap between the nerve ends, perform a primary nerve graft. If conditions are unfavorable for nerve grafting, consider a nerve conduit or a delayed nerve reconstruction.
Soft Tissue Defect With a skin defect of the fingertip, a step-advancement island flap10 (Fig. 2-1) or V-Y advancement flap on the same finger is useful. A skin defect of the hand can be
EVALUATION, MANAGEMENT, AND RECONSTRUCTION: AN OVERVIEW
17
FIGURE 2-1. Step-advancement island flap. A, Preoperative view shows soft tissue defect of the little finger tip. B, One year after the reconstruction.
A
B
covered with a skin graft, local flap, distant flap, or free tissue transfer. For dorsal wounds with intact areolar tissue covering the tendons, full-thickness skin grafts are preferred for coverage. Protective sensation often is achieved as a result of ingrowth of the dorsal sensory nerves into the graft. If the condition for later reconstruction exists for the tendon, the pulley system, and the bone, consider flap surgery. Particularly with dorsal defects of extensor injuries, skin grafts will prevent excursion of the tendons. There are many local flaps for the hand and fingers. However, these flaps are generally used for small defects because they are limited in size and location. The distallybased radial forearm flap,12 the reverse posterior interosseous flap,27 and the dorsal ulnar artery flap can be transferred easily to the hand to provide stable coverage. Among the regional flaps, the posterior interosseous island flap (Fig. 2-2) is far superior to the radial or ulnar arterial flap. It resurfaces the hand defect without sacrifice of the major arterial system to the hand. The adipofascial turnover flap14,15 is also useful to cover soft tissue defects of the dorsal or the ulnar column (Fig. 2-3). Distant flaps such as the groin flap and abdominal flap are sometimes useful for degloving injuries of the fingers or hand (Figs. 2-4 to 2-6). They have many advantages for coverage of the hand. They are simple, safe, and straightforward procedures. However, prolonged immobilization of the injured part and positional discomfort are pitfalls. In addition, a defatting procedure is needed. Consider distant flaps when later reconstruction is a factor, for multiple degloving injuries, or when other locations for free flaps are unavailable.
For defects that are not suitable for local flap coverage, there are several fascial and fasciocutaneous free flaps that can be used to fulfill the tissue requirements. The lateral arm flap4 is a fasciocutaneous flap that is a good choice to cover dorsal or palmar defects because it is relatively thin, easy to dissect, and associated with few complications. The temporoparietal fascial flap22 is the preferred free flap for large dorsal hand defects. This flap provides very thin vascular fascia that can be covered with a full-thickness skin graft to provide excellent coverage of large hand wounds. It can be split between the arborizations of the frontal and parietal branches of the superficial temporal arteries to cover separate components of a complex defect independently. In addition, the flap can be taken as a double-layered flap, incorporating both the superficial and deep temporal vessels. The scapular fascial flap9 and the serratus anterior fascial flap11 are also alternative techniques. The dorsalis pedis flap7,18,23 provides a thin, pliable soft-tissue coverage that is well suited for dorsal hand defects. It is also possible to transfer the dorsalis pedis flap as a sensate cutaneous flap by including the superficial peroneal cutaneous nerve. The overlying tendons, the second metatarsal bone, and the metatarsophalangeal joint can be raised with this flap, enabling a wide range of reconstruction options. The main disadvantage of this flap is the donor site morbidity. If a tendon defect exists, the dorsalis pedis flap with extensor tendon is superior to other flaps. In cases of pulp defects, joint destruction, and finger loss, the dorsalis pedis flap incorporating toe tissue is the optimal method.
2
2
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FIGURE 2-2. The posterior interosseous island flap. A, Preoperative design. The location of the island flap is the line between the lateral epicondyle and the distal radioulnar joint. The width of the flap depends on the size of the defect of the hand. B, Anatomy of the interosseous arteries. The common interosseous artery divides into the anterior interosseous artery, running volar to the interosseous membranous, and into the posterior interosseous artery. Distally, the anterior interosseous artery approaches the posterior compartment of the forearm and gives branches to the dorsal aspect of the wrist and forearm, which anastomose with the cutaneous branches of the posterior interosseous artery.
Distal radio-ulnar joint
A
Lateral epicondyle
Interosseous membrane Common interosseous artery
Posterior interosseous artery
B
Anterior interosseous artery
If immediate coverage is not possible, such as in heavily contaminated wounds or poor general conditions, consider delayed coverage. The wound should be appropriately managed, followed by coverage with a graft or flaps within 2–3 days.
AMPUTATION INJURY Stump Revision In the past, a single finger amputation of the hand was not an indication for replantation. Presently, however, a patient with any finger amputation is a candidate for replantation for functional and cosmetic reasons. Microsurgical replantation should first be attempted. If replantation is impossible or unsuccessful, the finger can then be amputated. During stump revision, the bony ends should be shortened minimally but sufficiently to close without tension; the nerve endings should be ligated to avoid painful neuroma formation. A stump revision is indicated when the amputation is confined to one or two fingers distal to the proximal interphalangeal (PIP) joint, because the remaining portion of the amputated finger(s) can be useful for grasping and pinching,
wearing an artificial prosthesis, or later finger reconstruction. If it is not possible to close the wound with the remaining skin, cover it with a local or distant flap. It is crucial that an opposable stump for the thumb remain. If only a proximal phalanx stump remains, it is better than nothing, especially with multiple-finger amputations.
Ray Amputation A ray amputation is usually indicated for patients with single-digit trauma proximal to the PIP joint of the central three fingers. Some hand surgeons do not like this operation because it narrows the palm and thereby decreases grasping power. However, it has many advantages, including improved appearance and more coordinated hand function. Ray amputation is usually undertaken as an elective procedure; it is not performed at the time of the initial trauma. In later reconstruction, residual metacarpal bone is a good source of bone graft or can be used for phalangization. In multiple-finger amputations, with inability to replant at the original site (e.g., severe crushing injury to the index MCP joint with other finger mutilations), ray amputation and ectopic replantation are preferred.
EVALUATION, MANAGEMENT, AND RECONSTRUCTION: AN OVERVIEW
19
2
2
A
B
C
FIGURE 2-3. The adipofascial turnover flap. A, The preoperative view shows a soft tissue defect on the little finger MCP joint area dorsum of the hand. B, The adipofascial flap was elevated and transposed. The full-thickness skin graft was placed on the adipofascial flap. C, Six months postoperative view.
In little finger amputations, the remnant is essentially useless when it is lost at the level of the proximal phalanx. As an unsightly nub on the ulnar side of the hand, it has a tendency to catch on pockets, table tops, and drawers. An incision is planned to remove the fourth webspace starting at the base of the ring finger
on the ulnar side (Fig. 2-7). A curved incision on the dorsum of the hand, adequate in length to expose the proximal portion of the fifth metacarpal, is marked out.3 A similar incision on the palm is outlined. The dorsal branch of the ulnar nerve is identified during dissection so that branches to the ring finger can be preserved, FIGURE 2-4. The groin flap. A, The preoperative view shows a degloving injury of the little finger. B, Six months postoperative view.
A
B
20
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THE MUTILATED HAND
B
C
FIGURE 2-5. The abdominal flap. A, Preoperative view shows a degloving injury of the fingers and hand. B, The defect was covered with the abdominal flap. C, One year after the division of the abdominal flap.
thus avoiding anesthesia over the residual ulnar aspect of the hand. Elevation of the triangular dorsal flap exposes the dorsal interossei and the subcutaneous portion of the fifth metacarpal. The periosteum is incised and elevated from the proximal half of the metacarpal.
A
B
An oblique osteotomy is performed so that the bone ends fit the new hand contour. The extensor digiti minimi and extensor digitorum communis tendons are cut after being retracted distally. The extensor digitorum slip to the little finger frequently crosses over to the ring
C
FIGURE 2-6. The abdominal flap. A, Preoperative view shows a degloving injury of the fingers and hand. B, Coverage. C, One month after the division of the flap.
EVALUATION, MANAGEMENT, AND RECONSTRUCTION: AN OVERVIEW
21
FIGURE 2-7. Fifth ray amputation. A, Preoperative design. A curved incision is marked on the dorsum of the hand, adequate in length to expose the proximal portion of the fifth metacarpal. B, An oblique osteotomy is performed. The flexor tendons are individually pulled distally, cut short, and allowed to retract. C, The abductor digiti minimi tendon is sutured to the lateral band on the ulnar side of the ring finger. A
B
C
finger just proximal to the MCP joint. The intrinsic muscles are preserved. The insertions of the abductor digiti minimi into the lateral band and proximal phalanx of the little finger are cut sharply and preserved for transfer to the ulnar lateral band of the ring finger. The flexor tendons are individually retracted distally, cut short, and allowed to retract. The abductor digiti minimi tendon is then sutured to the lateral band on the ulnar side of the ring finger. Closure of the space left by removal of the metacarpal and MCP joint is achieved by shifting the abductor digiti minimi radially and suturing it to the fourth dorsal interosseous. Revision of the skin edges is best achieved by starting the suture closure on the palmar aspect and progressing around to the dorsum. The mobile, thin dorsal skin can be tailored to ensure smooth closure.
Second-Toe Transfer Reconstruction of the ulnar fingers with a second-toe transfer is not important to function of a hand when there is an intact thumb and index finger. A second-toe transfer is considered in patients requiring fine manipulation, such as musicians and typists, and (in Korea) in unmarried young women. The second toe is shorter than the finger; in a patient with an amputation of the middle and ring fingers at the PIP joint, it might be indicated. For preoperative identification, preoperative angiography or Doppler might be necessary. For the noninvasive identification of the arterial system, three-dimensional ultrasonography or magnetic resonance angiography can be used for first dorsal metatarsal artery (FDMA) imaging. After elevation of the foot without exsanguination of the venous blood, inflate the tourniquet to fill the venous channel. Doing so makes it easier to dissect the venous system. The second-toe flap is designed a little larger than the defect size of the finger. In the case of fingertip reconstruction with partial-toe transfer, two triangular flaps are designed on both lateral sides of the second toe to prevent any linear scar contracture and to avoid the exposure
of the neurovascular pedicle without skin tension during skin closure (Fig. 2-8). For partial or total length transfer of the second toe, triangular flaps are designed on the plantar and dorsal sides of the foot. At first, through a dorsal incision, dissect the venous channel to the toe. There are two venous systems in the foot; one is superficial, the other is deep. Because the superficial vein is so small and very close to the skin, it is very difficult to dissect. The deep vein located in the intermetatarsal space is thicker and easier to dissect, so it typically is used for the finger transfer. After venous dissection, the artery is dissected from distal to proximal. Through the incision at the first web, the digital artery and nerve are isolated from adjacent tissue. The dissection is extended to the first webspace, and the continuation of the artery to the FDMA is confirmed. If the plantar system is dominant, the dominant plantar system is used. If the FDMA is dominant and located above or in the transmetatarsal ligament, the dissection is continued to acquire the adequate length of vascular pedicles. After ligation of the branch to the great toe and plantar system, it is traced proximally. The
A
Partial toe transfer
B
Total toe transfer
V A N
N
N V
A T
FIGURE 2-8. Operative technique: A, Partial transfer of the second toe. B, Total transfer of the second toe. (A ⫽ artery, V ⫽ vein, N ⫽ digital nerve, T ⫽ tendon.)
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THE MUTILATED HAND
extensor hallucis brevis crosses it on the dorsum of the foot, which can be divided for further dissection. During this dissection, the digital nerve and deep peroneal nerve are dissected for neural repair. If the plantar artery is used in absence of the FDMA, a vein graft might be needed. An extensor tendon of adequate length is harvested through the same incision, and the flexor tendons are cut through an additional plantar incision. Subsequently, the bony segment is acquired by osteotomy at the phalangeal or metacarpal bone or at the disarticulation of the MTP joint, depending on the defect level of the hand. After complete dissection, the tourniquet is released, adequate hemostasis is obtained, and the circulation to the elevated toe flap is checked. If there is no blood flow to the flap due to vascular spasm, 2% xylocaine or 10% papaverine may be used for vascular dilatation. For patients with defects of the distal part of the PIP joint, only a partial length of the second toe is transferred, whereas in patients with more proximal defects of the PIP joint, transfer of the total length of the second toe is required. The bone fixation is performed using K-wires or interosseous wiring. The extensor digitorum longus of the second toe is sutured to the central band of the extensor tendon of the finger. The extensor digitorum brevis of the second toe is split into two parts and sutured to the lateral bands to reinforce the extensor function of the transferred second toe. The flexor digitorum longus of the second toe is sutured to the flexor digitorum profundus of the finger at the distal
A
B
palmar crease, and the suture tension is adjusted to avoid any flexion deformity of the transferred second toe. The FDMA and superficial foot dorsal vein are anastomosed to either the digital artery of the ulnar side of the finger or the common digital artery and dorsal vein of the hand. There is much to consider when the second toe is used for finger reconstruction. The IP joint of the toe is more flexed than that of the finger. The MCP joint of the toe is more hyperextended than that of the finger. In addition, the toe has less range of motion, a smaller nail, and shorter digital length than the fingers. Also, the shape of the toe is different from the fingers, with a bulky plantar pad on the tip and metacarpal head. The webspace of the toe is located at the midportion of the proximal phalanx, which is required for the additional skin coverage after the transfer. When harvesting the toe, enough tissue should be left for primary donor site closure. If it is transferred for a midphalangeal amputation, it creates a “cobra head” deformity because the smaller toe is on top of the larger finger stump. On the basis of the authors’ experience,6 partial reconstruction of a finger with a second-toe transfer is a very useful method for patients with a defect of the distal part of the PIP joint (Figs. 2-9 and 2-10). However, the results of the total reconstruction of the finger using a second-toe transfer, as in patients with defects of proximal parts of the PIP joint, were disappointing owing to inadequate length, a narrow shape, and limited motion of the reconstructed finger.
C
FIGURE 2-9. The single second-toe transfer. A, Preoperative view shows absence of the ring finger at the PIP joint level. B, Intraoperative design. C, Six months after the operation.
EVALUATION, MANAGEMENT, AND RECONSTRUCTION: AN OVERVIEW
23
2
2
A
B
FIGURE 2-10. The single second-toe transfer. A, Preoperative view shows absence of the little finger on the left hand. B, One year after the operation.
METACARPAL HAND The definition of a metacarpal hand is a hand that has lost all prehensile hand function owing to the amputation of all fingers, with or without thumb amputation. Mutilating hand injuries with multiple amputations at the proximal digital level result in the loss of prehensile ability. In particular, amputation through the middle of the proximal phalanx makes it difficult to handle an object. The goal of functional reconstruction is to allow the finger to oppose the remaining thumb. Ray amputation of central metacarpal bones, distraction skeletal lengthening, and microvascular toe transfer can achieve this goal. Reconstruction of the metacarpal hand should be planned as the initial emergency care for the mutilated hand. Adequate debridement and soft tissue coverage are necessary. Preserve vital structures such as bones, tendons, and neurovascular bundles for later reconstruction. The essential component of hand function is prehension. This requires opposition of the thumb and fingers, which allows a coordinated pinch necessary for control and manipulation of an object. For precise prehension, two opposable elements on the hand are necessary. The elements must have adequate length, stable skeletal mobile joints, pain-free contact surfaces, and protective sensibility. Ulnar positioning is believed to give the best power grip and is often given priority in heavy laborers who need a broad-based strong grasp. Radial (secondand third-ray) reconstructions have the greatest cosmetic appeal and generally provide more precise prehension for fine manipulation. Central (third- and fourth-ray) reconstructions are an acceptable choice but should be combined with a second-ray amputation to maximize grasp and prehension. Collins and Khouri8 proposed that the
extent and pattern of the injury should be analyzed in each case, and transfers should be placed on the most functional contiguous bases regardless of location (Fig. 2-11). The best reconstruction method for the mutilated hand depends on the level of amputation and the remaining MCP joint remnants.21,25 For example, if an articular surface of the MCP joint remains, it can be reconstructed with a second-toe transfer disarticulated from the MCP joint level of the toe. However, if the amputation level is proximal to the MCP joint, a secondtoe transfer with the metatarsophalangeal joint will be necessary for joint reconstruction. The range of motion of the toe is about 55°, less than that of the finger. With an oblique osteotomy, the joint surface must be in a neutral position in relation to the transferred joint. In the case of midmetacarpal-level amputation, metacarpal lengthening should be augmented with a metatarsal transfer, adjacent metacarpal bone transposition, and vascularized or nonvascularized bone graft. Be sure to acquire enough length of the metacarpal bone by proximal transmetatarsal osteotomy for donor site closure. For both fine manipulation and power grip, the optimal position for toe transfer in the metacarpal hand is on the third and fourth metacarpal bones. It is sometimes necessary to remove the second metacarpal bone by ray amputation to widen the first webspace. For powerful pinching and gripping, more than two fingers are necessary. Two-toe transfer is possible from one side or both sides of the feet. If two toes are taken from the same foot, the functional deficit on that side is substantial. Therefore, it is better to harvest from both feet. However, Wei et al.24 proposed that amputations of adjacent digits proximal to the digital webs are suitable for combined second- and third-toe reconstructions.
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THE MUTILATED HAND
FIGURE 2-11. Approach to reconstruction in relation to pattern of digital loss. METACARPAL HAND
Central reconstruction
Ulnar reconstruction
RADIAL OBLIQUE AMPUTATION
Ulnar reconstruction
ULNAR OBLIQUE AMPUTATION
Radial reconstruction
Distal to this, combined toe units produce an unnaturally conspicuous, long palm-short finger reconstruction. These reconstructions allow useful chuck pinching and strong gripping with wider webspace. For reconstruction of the bilateral metacarpal hand, there are several factors to consider, such as sufficient soft tissue coverage, individual functional requirement, donor site selection, and morbidity.26 It is possible to do single-toe or two-toe transfers to each hand. Because of total loss of prehensile function of all fingers, a free toe transfer can yield better results than the conventional reconstruction method. In such cases, multiple toes are required for prehensile hand functions such as pinching and gripping.
Distraction Osteogenesis Distraction osteogenesis has been widely used for long bones. It is also applied to increase the functional length of the deficient bony hand to enhance mechanical length, prehension, and grip. To accomplish this, the injured hand should be covered with adequate soft
tissue. It takes a long time to achieve satisfactory results, and regular follow-up is required. Educate patients and their families about the procedure, that is, the duration of the procedure, the necessity of daily monitoring, daily care of the pin sites, the potential for complications, and limitation in daily activities. The technique includes preinsertion of pins, local skin incision for osteotomy, careful partial elevation of the periosteum, controlled osteotomy, periosteal repair, wound closure, and device assembly. A latent period after the operation is needed for primary callus formation. After that, delayed slow distraction at a rate of 1 mm per day is started. Premature consolidation or early bony union of the bony gap limits the ability to obtain adequate length. This is usually due to inadequate patient education or noncompliance, which causes a delay in lengthening and results in premature healing. Possible causes of failure in bony formation of the distracted area are (1) damage to the periosteum and surrounding tissue with decreased blood supply at the site of new bone formation, (2) a rapid distraction rate, (3) inadequate maintenance of distraction devices, such
EVALUATION, MANAGEMENT, AND RECONSTRUCTION: AN OVERVIEW
as pin loosening, and (4) an unstable fixator or a fracture of the lengthened bony segment. In the case of failure of bone formation, an intercalating bone graft is necessary.
25
replantation (Fig. 2-12). For the metacarpal hand, the third and fourth metacarpal bones are usually used as the recipient bones. The second metacarpal bone can be managed with ray amputation, yielding a wide first webspace and improved cosmetic result.
Toe Transfer There are many factors to consider before performing toe-to-finger transfers in a metacarpal hand. Because it is not clear how much function remains, the surgeon should check the remaining hand function and level of amputation and also decide which method is best in any given case. If there are no ulnar posts against the thumb, as with a metacarpal hand, second-toe transfer can increase grip strength and the ability to manipulate objects. To preserve grip strength and palm breadth, second-toe transfer might be better than transpositional
B
A
FIGURE 2-12. Two second-toe transfers. A, Preoperative view shows absence of the middle and ring fingers at the middle phalanx level. B, Intraoperative design. C, One month after the operation.
C
SECONDARY PROCEDURES Functional Muscle Transfer for Gripping In the paralytic extremity, especially one involving the ulnar three fingers, functional muscle transfer is useful for functional recovery. The most common application of muscle transfer has been to replace the forearm flexor musculature. The candidate for forearm flexor
2
2
26
THE MUTILATED HAND
muscle transfer lacks finger flexion subsequent to a loss of the profundus and sublimis muscles. The hand must have mobile joints, good sensibility, and some intrinsic function or the capability to restore this function. A motor nerve or branch that normally supplies the finger flexor musculature will provide the most appropriate neural messages. Suitable nerves include the anterior interosseous nerve, median nerve motor branches to the bellies of the flexor digitorum superficialis tendons, and ulnar nerve motor branches to the bellies of the flexor digitorum profundus tendons. Good skin coverage will allow muscle and tendon gliding and a tenolysis, should it be necessary at a later date. Predictable vascular anatomy in location and diameter is necessary for microsurgical transfer. The gracilis muscle is suitable for these requirements. It has a long, thin muscle belly and a good neurovascular bundle for transfer.16 The muscle runs from the inferior ramus to the medial condyle of the knee and is bound anteriorly by the sartorius and posteriorly by the semimembranosus and semitendinosus. The vascular system of the gracilis consists of one artery from the medial circumflex vessels and two accompanying veins. The nerve branch from the obturator nerve accompanies the vessels. The recipient nerve of the forearm is usually used with the motor branch of the median nerve to the short superficialis and long profundus flexor tendons. The ulnar nerve to the two ulnar profundus tendons may also be used. With hip flexion and abduction and knee flexion, anatomic landmarks are marked to identify the critical structures. After identification of the adductor longus from the pubis to the medial knee, the anterior border of the gracilis should be marked parallel about 3 cm inferior to the palpated adductor longus inferior margin. The muscle width is about 6 cm from the anterior border. During dissection, the greater saphenous vein crosses the subcutaneous tissue to the anterior border of the gracilis. The adductor magnus and the semimembranosus lie posterior to the gracilis, while the sartorius lies anterior to the gracilis. The dominant vascular pedicle to the gracilis from the medial circumflex vessels is located about 10–12 cm from the pubic tubercle and runs superiorly between the adductor longus and adductor magnus. The motor branch from the obturator nerve to the gracilis is located about 2 cm proximal to the vessels. There are always two minor pedicles—one at the midpoint and the other at the distal portion of the gracilis. Approximately 40% of the time, the minor pedicle is located near the muscular origin, higher toward the dominant pedicle. For optimal muscular function, it should be marked with multiple sutures placed at regular intervals. When the gracilis is attached to the profundus tendons at the correct tension, there will be a 5-cm distance between each pair of muscle markers when the
5 cm
A
B
FIGURE 2-13. Gracilis muscle transfer. A, The gracilis muscle is stretched to maximal physiologic length by abducting the thigh and extending the knee. Suture markers are then applied every 5 cm on the surface of the muscle. B, The distal muscle and tendon have been divided into two separate components for separate thumb and finger flexion.
fingers and wrist are placed in full extension (Fig. 2-13). Determine this tension by pulling the gracilis tendon distally until the distance between each pair of markers on the muscle is 5 cm. While holding the fingers and wrist in full extension, locate and mark the position of the flexor tendon stumps on the tendon of the stretched gracilis. In this position, the muscle will be stretched to the maximum length in which it will be required to function in the arm, which is the same maximum length that was required to function in the leg. The flexor tendon stumps should be sutured to the gracilis muscle tendon in the marked position. With the wrist and fingers in flexion, the tension is not excessive for tendon repair. Connect the tendons by weaving each of the profundus tendons through the gracilis and the gracilis tendon through each profundus into a smooth and solid tendon “knot.”
Vascularized Free Bone Transfer Because the vascularized free bone transfer has intact circulation, it can be used to reconstruct a long bone defect in a hostile bed, such as a scarred or infectious bed. Furthermore, it resists infection, so it can heal faster without bone absorption and atrophy. Since Taylor et al.20 first reported the free vascularized fibular transfer, it has been used for intractable nonunions such as infected nonunions, congenital pseudoarthroses, significant bone defects after tumor resection, and traumatic bone defects. The vascularized
EVALUATION, MANAGEMENT, AND RECONSTRUCTION: AN OVERVIEW
bone graft allows reliable bony union. Donors of the vascularized bone flap are the fibula with the peroneal artery, the rib bone with the intercostal artery, the iliac bone with the deep circumflex iliac artery, and the scapula with the descending branch of the circumflex scapular artery. The fibula has been widely used because it is a long, straight cortical bone with minimal donor site morbidity (Fig. 2-14). In addition, it can be transferred with a skin flap, muscle, or nerve. For children, longitudinal growth can be expected using a vascularized fibular epiphyseal
A
B
27
transfer. The fibular flap has many advantages: It is a straight tubular bone that is suitable for early weightbearing; it is long enough to make a double strut using a single vascular pedicle; it can be used to construct a constant, large vascular pedicle that is easy to elevate and anastomose; and it allows a composite flap with muscle and skin and minor donor deformity. Also, it can grow if it is transferred with the epiphysis in children. Be careful to avoid injury to the common peroneal nerve. The entry of the nutrient vessel is variable but is close to the junction of the proximal and middle thirds of the
C
FIGURE 2-14. The vascularized fibular osteocutaneous flap. A, Preoperative view shows a soft tissue defect involving the ulnar column. B, An X-ray shows the absence of the fifth metacarpal bone. C, The osteocutaneous fibular free flap was harvested. D, E, One year after the operation. D
E
2
2
28
THE MUTILATED HAND
fibula. It supplies the medulla and inner one-third of the cortical bone. The outer one-third of the cortical bone is supplied by periosteal branches. Because the common peroneal nerve runs above the fibular neck, 3 cm below the lateral femoral condyle, it must be left about 5 cm from the condyle to avoid nerve injury. Deep to the soleus, the posterior tibial artery bifurcates and forms the peroneal artery. There are several perforating cutaneous branches along the posterior border of the midfibula; therefore the skin paddle must be located along the posterior border of the fibula. There are several approaches to harvesting the fibular bone, including the anterior, lateral, and posterior approaches. After the outline of the entire fibular bone is marked, the skin paddle and bone that will be transferred should be designed. At this time, 5 cm of the proximal and distal fibular bone should be preserved on each side. Under tourniquet control, a skin incision is made along the skin paddle. The incision should be deep to the muscular fascia that accompanies the skin flap. After skin flap elevation with identification of the perforating cutaneous vessels, the posterior dissection is deepened into the soleus muscle and flexor hallucis longus posteriorly, continuing along the posterior border of the fibular bone. The anterior dissection is continued along the
anterior edge of the fibula, including a small muscle cuff of the peroneus and the extensor digitorum longus. The interosseous membrane and the tibialis posterior muscle should be separated from the fibular bone. The distal end of the fibula is cut with a saw, and the vascular pedicle is identified and ligated. From distal to proximal, the flap is elevated, tracing the vascular pedicle. At the bifurcating portion from the posterior tibial artery, the flap should be separated. For safe elevation of the osteocutaneous free fibular flap, the authors conducted a prospective study on the course of the perforators of the peroneal artery.5 On the basis of our, and another author’s, study,5,19 musculocutaneous and septocutaneous perforators are more numerous 5–19 cm distal to the fibular head. Septocutaneous perforators are more numerous 20–31 cm distal to the fibular head, with greatest numbers at 25 cm distal. Therefore, in designing the osteocutaneous free fibular flap 10–20 cm from the fibular head, it is recommended that a cuff of soleus and flexor hallucis longus muscles be included to incorporate these perforators. However, in designing the flap 20–30 cm from the fibular head, it is possible to elevate the flap without incorporating the soleus or the flexor hallucis muscles (Fig. 2-15).
FIGURE 2-15. Anatomy of the perforators of the peroneal artery. Musculocutaneous and septomusculocutaneous perforators are more numerous 5–19 cm distal to the fibular head; septocutaneous perforators are more numerous 20–31 cm distal to the fibular head.
Musculocutaneous perforator
Septomusculocutaneous perforator
Soleus Flexor hallucis longus Peroneus
Septocutaneous perforator
EVALUATION, MANAGEMENT, AND RECONSTRUCTION: AN OVERVIEW
Guelinckx and Sinsel13 used the seventh rib with cartilage and the serratus muscle for reconstruction of complex injuries. They reconstructed the carpometacarpal joint with costal cartilage, the fourth metacarpal bone with rib, and the extensor tendon and first webspace with the serratus muscle. These “all-in-one” reconstructions allow good functional recovery for mutilated hands and are accepted as guidelines for treatment. Vascularized scapular transfer is widely used for bone defects with accompanying wide skin defects. Masaki et al.17 reported late reconstruction of two total metacarpal bone defects using lengthening devices and a double-barrel osteocutaneous free parascapular flap. This procedure has many advantages, including a long, constant large pedicle and an available large skin flap with muscle. However, this flap is too thick for the hand. Vascularized radius grafts can be used for hand defects but are not commonly employed. Chacha et al.2 used them for a one-stage reconstruction of a thumb defect.
CONCLUSION The patient with a mutilated hand has suffered a complex injury with composite tissue loss and significant functional disability. After surgical debridement of the devitalized tissue, all viable structures should be preserved to retain as much function as possible. Ideally, similar tissue is used for coverage of soft tissue defects of the hand. Local or free flaps may provide excellent soft tissue coverage. However, they must provide sufficient subcutaneous tissue for deep gliding structures; supply subcutaneous tissue for the coverage of vital neural, vascular, bone, and joint structures; and be esthetically pleasing. Finally, the surgeon should choose the proper composite flap for reconstruction of the complex multiple tissue defect.
References 1. Browne Jr EZ: General principles of wound management in hand injury. In McCarthy JG (ed): Plastic Surgery, vol 3. Philadelphia, WB Saunders, 1990. 2. Chacha B, Soin K, Tan KC: One-stage reconstruction of intercalated defect of the thumb using the osteocutaneous radial forearm flap. J Hand Surg 12B:86, 1987. 3. Chase RA: Fifth ray amputation. In: Atlas of Hand Surgery. Philadelphia, WB Saunders, 1986, pp 158–161. 4. Chen HC, El-Gammal A: The lateral arm fascial free flap for resurfacing of the hand and finger. Plast Reconstr Surg 99:454, 1997. 5. Cho BC, Kim SY, Baik BS: The blood supply of the osteocutaneous free fibular flap and the peroneus longus muscle: A prospective anatomic study and clinical applications. Process Plast Reconstr Surg 108:1963, 2001.
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6. Cho BC, Lee DH, Park JW, et al: Second toe to index transfer. Br J Plast Surg 53:324, 2000. 7. Cho BC, Lee JH, Weinzweig N, Baik BS: Use of the free innervated dorsalis pedis tendocutaneous flap in composite hand reconstruction. Ann Plast Surg 40:268, 1998. 8. Collins ED, Khouri R: Management of the mangled hand with polydigit loss: Reconstruction of the upper extremity. Probl Plast Reconstr Surg 3:356, 1993. 9. Datiashvili RO, Shibaev EY, Chichkin VG, Oganesian AR: Reconstruction of a complex defect of the hand with two distinct segments of scapula and a scapular fascial flap transferred as a single transplant. Plast Reconstr Surg 90:687, 1992. 10. Evans DM, Martin DL: Step-advancement island flap for fingertip reconstruction. Br J Plast Surg 41:105, 1988. 11. Fassio E, Laulan J, Aboumoussa J, et al: Serratus anterior free fascial flap for dorsal hand coverage. Ann Plast Surg 43:77, 1999. 12. Foucher G, Genechten F, Merle N, Michon, J: A compound radial artery forearm flap in hand surgery: An original modification of the Chinese forearm flap. Br J Plast Surg 37:139, 1984. 13. Guelinckx PJ, Sinsel NK: The “Eve” procedure: The transfer of vascularized seventh rib, fascia, cartilage, and serratus muscle to reconstruct difficult defects. Plast Reconstr Surg 97:527, 1996. 14. Lai CS, Lin SD, Yang CC, Chou CK: The adipofascial turnover flap for complicated dorsal skin defects of the hand and finger. Br J Plast Surg 44:165, 1991. 15. Koshima I, Moriguchi T, Etoh H, et al: The radial artery perforator-based adipofascial flap for dorsal hand coverage. Ann Plast Surg 35:474, 1995. 16. Manktelow RT: Functioning muscle transplantation: Microvascular reconstruction. Berlin, Springer-Verlag, 1986, pp 151–164. 17. Masaki F, Takehiro D, Ryuuichi M, Kumi M: Late reconstruction of two total metacarpal bone defects using lengthening devices and a double-barrel osteocutaneous free parascapular flap. Plast Reconstr Surg 106:102, 2000. 18. McCraw JB: On the transfer of a free dorsalis pedis sensory flap to the hand [letter]. Plast Reconstr Surg 59:738, 1977. 19. Schusterman MA, Reece GP, Miller MJ, Harris S: The osteocutaneous free fibula flap: Is the skin paddle reliable? Plast Reconstr Surg 90:787, 1992. 20. Taylor GI, Miller G, Ham F: The free vascularized bone graft: A clinical extension of microvascular techniques. Plast Reconstr Surg 54:274, 1974. 21. Tsai TM, Jupiter JB, Wolff TW, Atasoy E: Reconstruction of severe transmetacarpal mutilating hand injuries by combined second and third toe transfer. J Hand Surg 6:319, 1981. 22. Ueda K, Harashina T, Inoue T, Ohba S: Temporoparietal sandwich technique in acute avulsion injury of the hand. J Reconstr Microsurg 12:19, 1996. 23. Vila-Rovira R, Ferreira BJ, Guinot A: Transfer of vascularized extensor tendons from the foot to the hand with a dorsalis pedis flap. Plast Reconstr Surg 76:421, 1985.
2
2
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THE MUTILATED HAND
24. Wei FC, Colony LH, Chen HC, et al: Combined second and third toe transfer. Plast Reconstr Surg 84:651, 1989. 25. Wei FC, El-Gammal TA, Lin CH, et al: Metacarpal hand: Classification and guidelines for microsurgical reconstruction with toe transfers. Plast Reconstr Surg 99:122, 1997.
26. Wei FC, Lutz BS, Cheng SL, Chuang DCC: Reconstruction of bilateral metacarpal hands with multiple-toe transplantations. Plast Reconstr Surg 104:1698, 1999. 27. Zancolli EA, Angrigiani C: Posterior interosseous island forearm flap. J Hand Surg 13B:130, 1988.
3
3 Classification Systems for Mutilating Injuries Jeffrey Weinzweig, MD, FACS Norman Weinzweig, MD, FACS
Tubiana defined prehension as “a complex function of the hand that gives it a mechanical precision combined with a standard sensory pattern,”14 enabling the hand to oppose the fingers to grip or grasp. Reid defined the mutilated hand as one that “has suffered a severe injury involving loss of substance, and has been left . . . lacking in prehension.”9 Such complex injuries with resultant composite tissue loss and significant functional compromise often require reestablishment of the bony architecture and soft tissue reconstruction.1,3,6,10,13,15 Without such intervention, the mutilated hand would remain virtually functionless. Because mutilated hands can assume a myriad of forms, it is crucial that they be precisely described. A useful classification system should permit accurate description of any mutilating injury, demonstrate user-friendliness, enable description based on progression of injury complexity, and facilitate communication between clinicians. Furthermore, a classification system should ideally direct treatment, predict functional outcome, and ultimately allow us to derive a staging system based on functional outcome. This system should allow the examining surgeon to accurately and reproducibly describe any mutilating injury of the hand. Several classifications of mutilating hand injuries exist in the literature; unfortunately, they provide a categorization that is “arbitrarily grouped according to the part of the hand predominantly involved.”9 Reid’s classification groups mutilating injuries into six categories: dorsal injuries, palmar injuries, radial hemiamputations, ulnar hemiamputations, distal amputations, and degloving injuries.9 The modified Pulvertaft classification groups mutilating injuries into five categories: radial, ulnar, central, transverse, and other.8 Wei’s classification groups mutilating injuries into two categories: in type I, all fingers are amputated proximal to the proximal interphalangeal joint and the thumb is intact; in type II, at least three fingers are amputated proximal to the proximal interphalangeal joint and the thumb is amputated proximal to the interphalangeal joint (opposition is impossible in both cases).16 A devascularized hand with radial hemiamputation and ulnar degloving cannot be accurately described by any current classification. Because a mutilated hand may have sustained several different types of complex injuries, a comprehensive classification should incorporate the degree and precise location of soft-tissue and/or bony destruction and the vascular integrity, in addition to the predominantly involved part of the hand.
WEINZWEIG CLASSIFICATION A new classification of mutilating injuries of the hand is described that categorizes the injuries into seven types: type I, dorsal mutilation; type II, palmar mutilation; type III, ulnar mutilation; type IV, radial mutilation; type V, transverse amputations; type VI, degloving injuries; and 31
32
THE MUTILATED HAND
TABLE 3-1
“Tic-Tac-Toe” Classification System
Injury Types I. Dorsal mutilation II. Palmar mutilation III. Ulnar mutilation IV. Radial mutilation V. Transverse amputation VI. Degloving injury VII. Combination injury Injury Subtypes A. Soft tissue loss B. Bony loss C. Combined tissue loss
type VII, combination injuries.17 These injury types are subcategorized into three subtypes: subtype A, soft tissue loss; subtype B, bony loss; and subtype C, combined tissue loss. The vascular integrity of the hand and fingers is recorded as a subscript: O, vascularization intact, or 1, devascularization (Table 3-1). The hand is then systematically divided into nine numerical zones in tic-tac-toe fashion with radial, central, and ulnar columns and proximal, central, and distal rows (Table 3-2). Diagrammatic representation of this classification system allows easy identification of the various zones (Fig. 3-1). Clinical examples will illustrate the user-friendliness and practicality of the “Tic-Tac-Toe” classification system. Each injury is described by means of the following notation: type, subtype, vascular status (hand/digits devascularized), and zones (rows and columns).
Vascular Integrity 0. Vascularity intact 1. Devascularization
TABLE 3-2
“Tic-Tac-Toe” Classification Regions
Zone
Contents
1
Thumb phalanges
2
Index and middle finger phalanges
3
Ring and little finger phalanges
4
Thumb metacarpal
5
Index and middle finger metacarpals
6
Ring and little finger metacarpals
7
Scaphoid, trapezium, and trapezoid
8
Capitate and lunate
9
Hamate, triquetrum and pisiform
Row
Contents
Distal
Zones 1, 2, and 3 (phalanges)
Central
Zones 4, 5, and 6 (metacarpals)
Proximal
Zones 7, 8, and 9 (wrist)
Column
Contents
Radial
Zones 1, 4, and 7
Central
Zones 2, 5, and 8
Ulnar
Zones 3, 6, and 9
A
B
FIGURE 3-1. “Tic-tac-toe” classification zones.
3
CLASSIFICATION SYSTEMS FOR MUTILATING INJURIES
33
CASE 1 Type I: Dorsal Mutilation Type I: Dorsal Mutilation Dorsal injuries involve the dorsal skin, extensor tendons, and bones. The tactile surface (palmar skin) of the hand is preserved. Vascularization is intact.
Type I A0, Zones 4–9 (Proximal and Central Rows) A 41-year-old woman sustained a severe crush-avulsion injury to the dorsum of the left hand when her car overturned. There was significant dorsal soft tissue loss, avulsion of the extensor digitorum communis and extensor digiti quinti minimi tendons, shear and loss of the dorsal metacarpal cortices, and exposed carpus (Fig. 3-2). Comment Dorsal injuries are usually the least severe mutilations, often requiring soft tissue coverage of the dorsum of the hand and immediate or staged extensor tendon repairs and/or reconstruction.2,11 The most common mechanism is crush-avulsion in which the loose, mobile dorsal soft tissue is avulsed, often with the extensor tendons. Occasionally, bony injury may be associated with a crush or shear component, as is seen in this case. Note that the volar tissues such as the flexor tendons, neurovascular structures, and tactile soft tissue are preserved, thus minimizing functional losses. Functional outcome is relatively favorable and directly related to the extent of bony injury and the need for prolonged immobilization.
FIGURE 3-2. Dorsal mutilation. Type I A0, zones 4–9 (proximal and central rows).
3
CLASSIFICATION OF INJURY TYPES
34
THE MUTILATED HAND
CASE 2 Type II: Palmar Mutilation Type II: Palmar Mutilation Palmar injuries involve the palmar skin (tactile surface), flexor tendons, and bones. They often involve the radial and ulnar arteries, deep and superficial palmar arches, and common and proper digital arteries, with possible devascularization of one or more fingers and/or the entire hand. The median and ulnar nerves and the common and proper digital nerves may also be involved. The tactile surface of the hand is usually disrupted.
Type II A1(index), Zones 4–9 (Proximal and Central Rows) A 55-year-old woman sustained a roller-type injury to her left hand resulting in avulsion of the palmar soft tissue with exposure of the palmar aponeurosis and the flexor tendons to the index finger, devascularization of the index finger, and neuropraxia of the median and ulnar nerves. There was no bony involvement (Fig. 3-3).
FIGURE 3-3. Palmar mutilation. Type II A1(index), zones 4–9 (proximal and central rows).
CASE 3 Type II: Palmar Mutilation Type II A0, Zones 1–9 (Distal, Central and Proximal Rows) A 38-year-old man sustained a devastating multilating volar soft tissue injury to his right hand by an industrial rug-cutting machine. This patient sustained complete disruption of both flexor tendons (in zone 2) of the index and little fingers, lacerations of the neurovascular bundles, and sagittal transaction of the thumb extending into the thenar musculature of the hand, as well as an extensive degloving type of soft-tissue injury to the right hand. Despite the extensiveness of this palmar injury, neither devascularization nor fracture accompanied the soft tissue injury (Fig. 3-4).
A
Comment Palmar injuries are generally more severe and complex than are dorsal injuries. Palmar injuries disrupt the tactile surface of the hand, often necessitating resurfacing with regional or distant flaps. Additionally, they may require open or closed reductions and internal fixation of fractures and/or flexor tendon repair with or without staged reconstruction. Neurovascular compromise to one or more fingers is often seen, as in Case 2 (Fig. 3-3).
B
FIGURE 3-4. Palmar mutilation. Type II A0, zones 1–9 (proximal, central, and distal rows).
3
CLASSIFICATION SYSTEMS FOR MUTILATING INJURIES
35
CASE 4
Type III: Ulnar Mutilation Ulnar mutilations involve loss of the ulnar digits, destruction of the ulnar column (phalanges, metacarpals, and/or carpus), and interference with grasp or power grip mechanisms.
ring and little finger metacarpals and a midshaft metacarpal fracture of the middle finger.
A 35-year-old man sustained a shotgun injury resulting in a through-and-through soft-tissue and bony defect of the ulnar aspect of his hand (Fig. 3-5). There was destruction of the
Comment These injuries involve bone, tendon, soft tissue, and neurovascular structures along the ulnar aspect of the hand, resulting in significant functional disability due to interference with grip mechanisms. An objective of reconstructive surgery is to maintain the breadth of the hand.
A
B
Type III C0, Zones 5 and 6 (Central Row)
C
D
FIGURE 3-5. Ulnar mutilation. Type III C0, zones 5 and 6 (central row).
3
Type III: Ulnar Mutilation
36
THE MUTILATED HAND
CASE 5 Type IV: Radial Mutilation Type IV: Radial Mutilation
Type IV C1(thumb), Zone 1
Radial mutilations involve loss of the thumb, destruction of the radial column, and loss of opposition or pinch mechanisms.
A 36-year-old woman sustained a traumatic amputation of her right thumb at the level of the metacarpophalangeal joint by a bread-cutting machine (Fig. 3-6).
A
B
C
FIGURE 3-6. Radial mutilation. Type IV C1(thumb), zone 1.
3
CLASSIFICATION SYSTEMS FOR MUTILATING INJURIES
37
CASE 6
Type IV C1(thumb), Zone 1
Comment These are very serious injuries that directly affect opposition and the pinch mechanism. They may involve total or subtotal loss of the thumb and thenar musculature. Without
restoration, these injuries result in severe disability with loss of 50% or more of total hand function. Damage to the remainder of the hand plays a role in the choice of reconstructive options such as pollicization of the index finger or remnants of other injured fingers,18 osteoplasty, or toe-to-thumb transfer. When replantation or revascularization is successful, functional results are generally good depending on the status of the remainder of the hand. Replantation was possible in Case 5 (Fig. 3-6) owing to the mechanism of injury; it was not an option in this case owing to the avulsive nature of that injury.
A
B
A 22-year-old man sustained an avulsion injury of his right thumb distal to the interphalangeal joint. His entire flexor pollicis longus tendon was avulsed from its muscular origin (Fig. 3-7).
FIGURE 3-7. Radial mutilation. Type IV C1(thumb), zone 1. C
3
Type IV: Radial Mutilation
38
THE MUTILATED HAND
CASE 7 Type V: Transverse Amputation Type V: Transverse Amputation Transverse amputations result in loss of the hand or digits at different levels with corresponding functional losses. Restoration of functioning pinch depends on the level of loss. Amputations that are distal to the metacarpophalangeal joint level can result in a phalangeal hand (see Chapter 19), whereas amputations that are proximal to the metacarpophalangeal joint level can result in a metacarpal
A
C
hand (see Chapter 20). Complete hand amputations can also occur.
Type V C1(I, M, R, S), Zones 2 and 3 (Distal Row) This 28-year-old man sustained a table saw injury to his left hand resulting in amputation of the four fingers just distal to the proximal interphalangeal joints, sparing the thumb (Fig. 3-8).
B
D
FIGURE 3-8. Transverse amputation. Type V C1(I, M, R, S), zones 2 and 3 (distal row).
CASE 8 Type V: Transverse Amputation
3
Type V C1(I, M, R, S), Zones 2, 3, 5, and 6 (Central and Distal Rows) This 62-year-old man sustained an industrial paper-cutting injury to his left hand, resulting in amputation of the four fingers at the metacarpophalangeal joint level (Fig. 3-9).
A
B
FIGURE 3-9. Transverse amputation. Type V C1(I, M, R, S), zones 2, 3, 5, and 6 (central and distal rows).
CASE 9 Type V: Transverse Amputation Bilateral Type V C1(I, M, R, S), Zones 2, 3, 5, and 6 (Central and Distal Rows) This 19-year-old man sustained a punch-press injury to both hands resulting in amputation of all eight fingers through the metacarpophalangeal joints, sparing both thumbs (Fig. 3-10). Comment Transverse amputation injuries often occur at, or proximal to, the metacarpophalangeal joint of the fingers, involving at least three fingers, with possible involvement of the thumb. These are severe injuries resulting in significant functional losses based on the success of replantation or revascularization of the amputated part(s), including the fingers as a metacarpal unit (and possibly the thumb). Involvement of the thumb adds the component of radial mutilation to the equation, making this a combined injury (type VII). Successful replantations and revascularizations at the transmetacarpal level generally result in fair to poor functional results, even with guillotine-type amputations.19 This finding is probably due to the ischemic insult to the interosseous and lumbrical muscles as a result of either direct muscle injury or interruption of the delicate blood supply to these tiny muscles.20 There can often be an extensive zone of injury with destruction of the intrinsic muscles, flexor and extensor tendons, metacarpophalangeal joints, and neurovascular structures, requiring multiple reconstructive procedures in
staged fashion. Bilateral mutilations present a special circumstance with respect to functional outcome.12 On the basis of their experience with 59 cases of metacarpal hand reconstructed with toe-to-hand transfers, Wei and Loftus16 described a classification system that served as a guide to their treatment philosophy. They identified two major types of metacarpal hand depending on whether or not the thumb is injured.
FIGURE 3-10. Transverse amputations. Bilateral type V C1(I, M, R, S), zones 2, 3, 5, and 6 (central and distal rows).
39
40
THE MUTILATED HAND
CASE 10 Type V: Transverse Amputation Type V C1, Zones 1–9 This 42-year-old psychotic man sustained a self-inflicted hacksaw injury to his left hand resulting in complete amputation through the carpus. Note the hesitation cut across the dorsal wrist just distal to the level of amputation (Fig. 3-11).
A
Comment These injuries generally have a better prognosis than those at the transmetacarpal level. The flexor tendons are injured in zone 5, and the intrinsic muscles of the hand are spared.
B
FIGURE 3-11. Transverse amputation. Type V C1, zones 1–9.
3
CLASSIFICATION SYSTEMS FOR MUTILATING INJURIES
41
CASE 11
Type VI: Degloving Injury
This 45-year-old man sustained a roller-press injury to his left hand with complete degloving of the ring and little fingers and avulsion of the distal pulp and nail of the thumb (Fig. 3-12). Note the avulsed neurovascular bundle to the little finger.
Comment Degloving injuries are serious ones that are usually caused by avulsion of soft tissue by a roller-type mechanism. No local innervated skin is available to resurface important tactile areas of the hand. Soft tissue coverage can occasionally be achieved by harvesting a skin graft from the degloved part. Often, a groin flap or emergency free flap is required. Reconstruction is especially difficult for simultaneous provision of skin on both sides of the hand.4,5,7
A
B
Degloving injuries involve circumferential loss of innervated skin and the tactile surface of the hand. They are often associated with nerve, vessel, or tendon avulsion.
VI A1, Zones 3 and 6 (Ulnar Column)
FIGURE 3-12. Degloving injury. Type VI A1, zones 3 and 6 (ulnar column). C
3
Type VI: Degloving Injury
42
THE MUTILATED HAND
CASE 12 Type VII: Combination Injury Type VII: Combination Injury These injuries usually involve a combination of types I to VI as well as other injuries that do not fit the more rigid definitions of types I to VI. These injuries are usually the most severe, often caused by extreme forces such as punch presses and thermal or electrical burns.
Type VII C1(I, M, R, S), Zones 5–9 (Proximal and Central Rows) This 21-year-old man sustained a punch-press injury to his left hand resulting in devascularization of the four fingers, destruction of the ulnar metacarpals and carpal bones, and palmar soft tissue loss (Fig. 3-13).
A
B
FIGURE 3-13. Combination injury (punch-press). Type VII C1(I, M, R, S), zones 5–9 (proximal and central rows). C
3
CLASSIFICATION SYSTEMS FOR MUTILATING INJURIES
43
CASE 13
Type VII C1(T, I, M, R, S), Zones 1–6 (Central and Distal Rows) This 38-year-old man sustained a rotary saw injury resulting in an oblique amputation of his left hand extending from the distal portion of the proximal phalanges of the little and ring
A
C
fingers through the distal portion of the metacarpals of the middle and index fingers through the base of the thumb metacarpal (Fig. 3-14).
B
D
FIGURE 3-14. Combination injury (table saw). Type VII C1(T, I, M, R, S), zones 1–6 (central and distal rows).
3
Type VII: Combination Injury
44
THE MUTILATED HAND
CASE 14 Type VII: Combination Injury Type VII C1(hand), Zones 1–9 (Proximal, Central and Distal Rows) This 43-year-old man sustained a pipe bomb blast injury to his left hand with massive bone, soft tissue, and nerve destruction with palmar devascularization (Fig. 3-15).
FIGURE 3-15. Combination injury (bomb blast). Type VII C1(hand), zones 1–9.
CASE 15 Type VII: Combination Injury Type VII C1(I,M,R), Zones 1–6 (Central and Distal Rows) This 19-year-old man sustained a shotgun blast injury to his left hand with resultant palmar and dorsal soft tissue loss;
devascularization of the index, middle, and ring fingers; and multiple phalangeal and metacarpal fractures. The proximity of the blast is indicated by the limited radius of pellet scatter (Fig. 3-16).
FIGURE 3-16. Combination injury (shotgun blast). Type VII C1(I, M, R) , zones 1–6 (central and distal rows).
3
CLASSIFICATION SYSTEMS FOR MUTILATING INJURIES
45
CASE 16
Type VII C1, Zones 7–9 (Proximal Row) This 28-year-old woman sustained a conveyor belt injury of her left hand and forearm resulting in circumferential soft tissue loss at the level of the wrist, multiple carpal and distal
A
radius fractures, and carpometacarpal fracture-dislocations. The conveyor belt assembly can be seen within the wound (Fig. 3-17).
B
FIGURE 3-17. Combination injury (conveyor belt). Type VII C1, zones 7–9 (proximal row). C
3
Type VII: Combination Injury
CASE 17 Type VII: Combination Injury
This 34-year-old woman sustained severe frostbite of both hands when she fell from a snowmobile, lost consciousness, and was found in the snow 6 hours later. Severe blistering and ischemic changes were initially seen, although
there was no evidence of devascularization at that time (Figs. 3-18A and 3-18B). Demarcation ensued over the subsequent 2 weeks (Figs. 3-18C and 3-18D), necessitating multiple bilateral amputations. A three-phase bone scan revealed the degree of vascular compromise and lack of distal perfusion (Fig. 3-18E).
A
B
C
D
Bilateral Type VII C0, Zones 1–9 (Proximal, Central and Distal Rows)
FIGURE 3-18. Combination injury (frostbite). Bilateral type VII C0, zones 1–9 (proximal, central, and distal rows). A, B, Right hand initially. C, D, Two weeks later. E, Threephase bone scan. E
46
CONCLUSION A myriad of injury mechanisms result in a multitude of injury types. The importance of accurately classifying complex injuries of the hand for purposes of communication with other physicians, preoperative planning, and staging reconstruction outcomes cannot be overstated. While a number of classification systems exist in the literature, we favor the “Tic-TacToe” system that we have described, which represents a unique method that accurately and reproducibly categorizes any mutilating injury of the hand. Such injuries are always complex, and the majority invariably escape complete description by existing classifications. With brief notation, this system permits categorization of a hand injury by type, tissue
TABLE 3-3
CLASSIFICATION SYSTEMS FOR MUTILATING INJURIES
47
involvement, and vascular status of the hand and digits. With the hand divided into nine zones that are composed of three rows and columns, the tic-tac-toe system allows exact description of injury locations within the hand. A data worksheet has been designed that easily summarizes the system and permits classification of injuries as well as documentation of vital patient information on initial presentation (Table 3-3). It is anticipated that these data will contribute to the development of a staging system based on patient outcomes within each of the injury categories. This will ultimately assist the hand surgeon with management decisions when confronted with complex mutilating injuries of the hand.
“Tic-Tac-Toe” Classification Data Sheet Tic-Tac-Toe Classification Columns Radial
Central
Ulnar
Injury Type I. Dorsal mutilation
D i s t a l
R o w s
C e n t r a l P r o x i m a l
II. Palmar mutilation III. Ulnar mutilation Zone 1
Zone 2
Zone 3
IV. Radial mutilation V. Transverse amputation VI. Degloving injury VII. Combination injury
Zone 4
Zone 6
Zone 7
Subtype A. Soft tissue loss B. Bone loss C. Combined tissue loss 0. No vascular injury 1. Devascularization
Zone 7
Zone 8
Zone 9
Clinical Data Sheet Patient Name__________________________
Dominant Hand__________________
Classification__________________________
Age__________________________________
Injured Hand_____________________
Zone(s)_____________________________
Sex___________________________________
Mechanism______________________
Region(s)___________________________
Medical Record No._____________________
Description_______________________
Procedure____________________________
Hospital_______________________________
________________________________
______________________________________
Occupation____________________________
________________________________
Attending_____________________________ Resident______________________________
3
3
48
THE MUTILATED HAND
References 1. Brown HC, Williams HB, Woodhouse FM: Principles of salvage in mutilating hand injuries. J Trauma 8:319, 1968. 2. Cho BC, Lee JH, Weinzweig N, Baik BS: Use of the free innervated dorsalis pedis tendocutaneous flap in composite hand reconstruction. Ann Plast Surg 40:268–276, 1998. 3. Harris GD, Nagle DJ, Bell JL: Mutilating injuries. In Jupiter JB (ed): Flynn’s Hand Surgery. Baltimore, Williams & Wilkins, 1991, pp 103–114. 4. Kleinman WB, Dustman JA: Preservation of function following complete degloving injuries of the hand: Use of simultaneous groin flap, random abdominal flap, and partial-thickness skin graft. J Hand Surg Am 6:82, 1981. 5. Josh BB: Sensory flaps for the degloved mutilated hand. Hand 6:247, 1974. 6. Midgler RD, Entin, MA: Management of mutilating injuries of the hand. Clin Plast Surg 3:99, 1976. 7. Nicolle FV, Woodhouse FM: Restoration of sensory function in severe degloving injuries of the hand. J Bone Joint Surg Am 48:1511, 1966. 8. Pulvertaft G: Mutilating Hand Injuries (Videotape). San Francisco, Library of the American Society for Surgery of the Hand, 1971. 9. Reid DAC, Tubiana R: Mutilating Injuries of the Hand. Edinburgh, Churchill Livingstone, 1984. 10. Scheker LR: Salvage of a mutilated hand. In Cohen M (ed): Mastery of Plastic Surgery. Boston, Little, Brown, 1994, pp 1658–1681.
11. Sundine M, Scheker LR: A comparison of immediate and staged reconstruction of the dorsum of the hand. J Hand Surg Br 21:216, 1996. 12. Tubiana R: Repair of bilateral hand mutilations. Plast Reconstr Surg 44:323, 1969. 13. Tubiana R: Reconstruction after traumatic mutilations of the hand. Injury 2:127, 1970. 14. Tubiana R: Prehension in the mutilated hand. In Reid DAC, Tubiana R (eds): Mutilating Injuries of the Hand. Edinburgh, Churchill Livingstone, 1984, pp 61–92. 15. Tubiana R, Stack HG, Hakstian RW: Restoration of prehension after mutilations of the hand. J Bone Joint Surg Br 48:455, 1966. 16. Wei FC, Loftus JB: Metacarpal hand: A classification as a guide to reconstruction (Abstract). Paper presented at the Annual Meeting of the American Association for Hand Surgery, Cancun, Mexico, 1993, p 63. 17. Weinzweig J, Weinzweig N: The “Tic-Tac-Toe” classification system for mutilating injuries of the hand. Plast Reconstr Surg 100:1200–1211, 1997. 18. Weinzweig N, Chen L, Chen C-W: Pollicization in the severely injured hand by transfer of middle and ring finger remnants. Ann Plast Surg 34:523, 1995. 19. Weinzweig N, Sharzer L, Starker I: Replantation and revascularization at the transmetacarpal level: Long-term functional results. J Hand Surg Am 21:877, 1996. 20. Weinzweig N, Starker I, Sharzer LA, Fleegler EJ: Revisitation of the vascular anatomy of the lumbrical and interosseous muscles. Plast Reconstr Surg 99:785, 1997.
4
4 Management of the Dorsal Mutilating Injury Byung Chae Cho, MD, PhD
GENERAL PRINCIPLES OF WOUND MANAGEMENT The fundamentals for treating mutilating hand injuries include the surgical debridement of devitalized tissues, removal of foreign material, and stabilization of fractures. The primary objective of the surgeon must be to preserve as much function as possible of the injured parts by maintaining the length of the osseous structures, sparing any viable skin and subcutaneous tissue, and preserving the nerves, tendons, and vascular structures for subsequent reconstruction. An accurate diagnosis is facilitated by a complete history and a thorough physical examination. For example, physical agents such as heat, cold, oil, and grease will increase the extent of damage (e.g., in a steam press injury). Initial wound debridement should include generous irrigation and removal of all foreign material and devitalized tissue. The use of highpressure irrigation is recommended for most wounds, especially those resulting from industrial and farm accidents. Marginally viable tissue should be excised back to the bleeding edges under tourniquet control; otherwise, bleeding will obscure viability or ischemia of the tissues.2 Skin debridement should be minimal; only clearly nonviable tissue should be removed. Maintain any small, free-floating bony fragments with periosteal continuity, and, if possible, achieve skeletal stability. In the case of a grossly contaminated wound, defer bony stabilization for a few days until further definitive debridement can ensure that the wound is clean. Additional excision of viable but nonvital tissue is justified to create a flat wound surface. This permits close contact between the flap and the bed, thereby eliminating any dead space that might later become the site of infection or fibrosis. Preserve intact tendons, nerves, or major blood vessels. Contaminated bone can be cleansed by scrubbing vigorously and using burrs and rongeurs. If the wound is not closed, avoid dessication of the tissues. Further necrosis can be expected, especially in partially devitalized tissue, if desiccation takes place. Any exposed bone and tendon will desiccate and die and will have to be excised. Therefore consider early flap coverage in the case of exposure of vital but poorly vascularized structures. Once debridement is complete, apply rigid skeletal fixation. Miniplates are used for the metacarpals; Kirschner wires or interosseous wiring is used for the phalanges. Where bony defects exist, external fixation can be employed. Small defects can be filled with cancellous bone grafts, while large defects can be reconstructed with a free vascularized bone flap. In degloving injuries, partially or completely degloved skin might or might not be salvageable. A total degloving injury of the entire hand presents a difficult problem, and surgeons often attempt to salvage too much. Completely degloved skin generally is unsalvageable. Even with microsurgery, this skin cannot be salvaged because the blood vessels of the skin are severely damaged. Accordingly, in this case it is better to use a skin graft or a regional or distant flap. 51
52
THE MUTILATED HAND
SKIN GRAFT Note that the tissue on the dorsum of the hand is nonglabrous, hirsute, thin, and mobile to allow individual movements of the joints of the hand. The thin layer of areolar tissue covering the tendons permits motion and tendon gliding. For dorsal wounds with intact areolar tissue covering the tendons, full-thickness skin grafts are preferred for coverage. Occasionally, degloved skin can be used as a full-thickness skin graft after the underlying fat is removed. Protective sensation is often achieved as a result of the ingrowth of dorsal sensory nerves into the graft. However, in the case of a degloved finger, the use of a pedicle flap is preferable to a skin graft.
FLAP SELECTION The debridement of nonviable or infected bone and soft tissue followed by an immediate or staged flap transfer provides both stable coverage and well-vascularized tissue to restore local circulation. Flap coverage is required when vital structures such as vessels, nerves, tendons, or bone are exposed. Flaps are necessary if secondary surgery, such as bone grafts, nerve grafts, or tendon transfer, is to be performed. Early complete
A
B
wound coverage with well-vascularized tissue avoids the prolonged exposure of tendons and bone, thereby decreasing the potential for infection. The large size and reliability of flaps in the reconstructive surgeon’s armamentarium allow the surgeon to perform aggressive wound debridement followed by immediate coverage with a microvascular free flap (Fig. 4-1). A soft tissue flap provides durable coverage, including skin and subcutaneous tissue. Subsequent elevation of the flap for secondary procedures, such as tendon or bone grafts, can be readily accomplished. Although the thickness of the subcutaneous tissue in the skin flap is variable, the application of this flap to the upper extremity does not alter the normal contour of the recipient site. In contrast, the thickness of a musculocutaneous flap is often excessively bulky when used in the reconstruction of the dorsal hand. Similarly, the use of muscle and a skin graft eliminates the subcutaneous tissue, which might be excessive in an obese patient. For a small defect, a serratus anterior muscle or gracilis muscle flap is recommended. For a medium-sized defect, a rectus abdominis muscle flap is best. For a large defect, including the dorsum of the hand and forearm, a latissimus dorsi muscle flap is most useful. Application of a skin graft over vascularized fascia provides the thinnest coverage and is often desirable over the dorsal surface of the hand. The special needs of a defect that can be
C
FIGURE 4-1. A, This patient sustained a crushing injury to the dorsum of the hand that resulted in a degloving soft tissue defect. B, Copious saline irrigation, debridement of the devitalized tissue, and bone fixation were performed. The soft tissue defect was resurfaced with a dorsalis pedis free flap. C, One year later, the flap showed similar texture and good color match.
accommodated by flap selection include the bone, soft tissue, tendon(s), and nerve(s).
Local Flaps Local or regional flaps of the hand have the distinct advantages of bearing similar soft tissue and placing no other wounds on the body. However, they are limited in their availability. The larger the primary defect, the less local soft tissue is available for flap coverage. Additionally, elevation of a local flap inflicts additional injury to the traumatized upper extremity. The resulting compound wound can further impair hand function. A reverse-flow radial forearm flap can be based distally on the radial artery and venae comitantes, thereby permitting the transfer of volar forearm skin to the hand without the need for microvascular anastomoses.14,47 The forearm is a safe and reliable donor area for a variety of tissues, and these flaps are relatively easy to raise from the injured arm. The forearm can provide up to 8 ⫻ 10 cm of thin, hairless skin, which can be used to resurface the dorsum of the hand or palm. These procedures facilitate postural control of the hand edema, early physiotherapy, and mobilization. The disadvantages of these skin flaps are skin-grafted scars on the forearm, postoperative hypoesthesia or paresthesia on the dorsum of the hand, and sacrifice of the radial artery. A reverse-flow posterior interosseous flap, initially described by Zancolli and Angrigiani,54 has specific merits, including the preservation of the major vessels in the hand and a relatively good aesthetic result at the donor site with primary closure of 4 to 5 cm. The dorsal aspect of the forearm can provide an island flap with minimal subcutaneous fat; on a retrograde pedicle of the posterior interosseous vessels, it can be transferred to the dorsum of the hand or wrist (Fig. 4-2). A line is drawn between the lateral epicondyle and the distal radioulnar joint, representing the course of the posterior interosseous artery. The skin incision begins at the level of the distal anastomosis between the two interosseous arteries and continues along the radial side of the flap. Fascia is not included in the flap. As the flap is elevated toward the line, the cutaneous branches can be easily observed and dissected. The fascia is incised longitudinally over the extensor digiti minimi and extensor carpi ulnaris muscles. Gentle blunt dissection between these two muscles exposes the posterior interosseous artery with its venae comitantes. The posterior interosseous artery itself is divided at its proximal origin near the distal edge of the supinator muscle. The ulnar side of the flap is incised, elevated, and then dissected down to the distal anastomosis with the anterior interosseous artery. The vascular pedicle can be further developed for additional length. The main drawbacks of this flap are that (1) it involves a complex and time-consuming
MANAGEMENT OF THE DORSAL MUTILATING INJURY
53
dissection of the vascular pedicle, (2) there are anatomic variations, and (3) there are limits to the size allowed by the primary closure. A local adipofascial turnover flap has also been developed.25,37 However, since this flap basically depends on a “random” pattern of vascularity, it is limited in size (the base-to-length ratio is 1:1 to 1:1.5) and therefore is most suitable for repair of small defects. However, the use of a radial artery perforator-based fasciosubcutaneous flap (first described by Weinzweig and colleagues) obviates this drawback.23,51 This flap is a distally based fasciosubcutaneous flap that is supplied by perforators of the distal radial artery; the main radial artery is not sacrificed. This flap has several advantages, as the surgical procedure is straightforward and produces only slight donor scarring. The perforators of the radial artery nourish a wide and long territory of adipofascial tissue. There is no postoperative functional deficit in the donor arm. The forearm cutaneous veins and nerves can be preserved, because the perforating veins are sufficient to drain the venous blood of the flap through the venae comitantes. However, for patients with insufficient perforators, a preoperative Doppler evaluation or stereoscopic arteriography, or both, is recommended to estimate the location of the perforators.
Distant Flaps Distant flaps usually are harvested from the contralateral upper inner arm, thorax, groin, trunk, and flanks. These flaps are useful for large defects, including the dorsum of the hand and forearm (Fig. 4-3). McGregor and Jackson32 were the first to describe a groin flap in 1972. A groin flap is a medially based flap that can be of either axial or random vascularity, thereby allowing its donor site to be primarily closed. This flap is usually based on the superficial circumflex iliac vessels that arise from the femoral artery approximately 2 cm below the inguinal ligament. The superficial circumflex artery traverses laterally within the subcutaneous fat and then pierces the deep fascia to lie superficially lateral to the sartorius muscle. The vessel runs parallel and inferior to the inguinal ligament toward the anterior superior iliac spine, where the blood supply to the skin lateral to this point is random in nature. It is easier to raise this flap from distal to proximal from the superior iliac spine in the subcutaneous plane. If the lateral border of the sartorius muscle is encountered, the fascia of the sartorius and medial tissue must be taken with the flap. Generally, this flap will be approximately 10 ⫻ 15 cm in size. However, the hand must remain dependent during the attachment process, which can be uncomfortable and increase edema formation, and the lack of exercise can result in joint stiffness. This flap is often hair-bearing in males, which is not aesthetically ideal when used to resurface non-hair-bearing skin. Furthermore, this
4
4
54
THE MUTILATED HAND
A
B
C
FIGURE 4-2. A, Preoperative view of dorsal soft tissue defect following trauma. B, A reverse-flow posterior interosseous island flap was designed. C, The flap was elevated and transferred to the dorsum of the hand. The donor site was covered with a skin graft. D, One year post surgery. D
type of flap can be bulky and might contain much subcutaneous fat; however, this can be debulked if desired.
Free Flaps Free flaps are available in virtually any size and can also provide sensate glabrous skin. They permit the elevation of the hand and early mobilization. However, a free flap must be thin enough to provide good coverage and must include a gliding surface for tendon function.
Fascial Flaps Fascial flaps are thin, are well vascularized, and provide satisfactory gliding tissue, thereby facilitating mobilization of the fingers. Many donor sites are appropriate for free fascial flaps, including temporoparietal fascial flaps, antebrachial or radial forearm fascial flaps, lateral arm fascial flaps, scapular fascial flaps, and serratus anterior fascial flaps.7,46,53 The temporoparietal fascial flap is most commonly used; however, the drawback to this flap is the risk of alopecia, which is visible in short-haired or
4 A
B
C
D
FIGURE 4-3. A, This patient experienced extravasation of an anticancer drug resulting in wide necrosis of the soft tissue of the dorsal hand, wrist, and forearm. B, Following debridement, there was no local flap available to cover the defect. C, D, A 20 ⫻ 12 cm groin flap was designed and elevated. E, The groin flap was found to be too bulky. Six months later, a defatting procedure was performed (twice). F, Final result 6 months after the defatting procedures. E
F
55
56
THE MUTILATED HAND
balding men.1,19,41,45,49 The lateral arm fascial flap,53 pedicled by the posterior radial collateral artery, provides thin fascia and acceptable results (Fig. 4-4). The antebrachial fascial flap requires the sacrifice of the radial artery. The scapular fascia flap is often thick, especially in obese people.12,52 The serratus anterior fascial flap is as thin as the temporoparietal fascial flap, and its donor site morbidity is low, thereby resulting in a thin scar that can be easily hidden with clothes. Additionally, there is no functional disorder.13 It also offers longer and larger pedicle dimensions. Its main length is 15 cm, and the subscapular artery diameter increases the reliability
A
C
of the flap. The free scapular, temporoparietal, lateral arm, antebrachial, and serratus anterior fascial flaps can also all be transferred with bone.
Sensory Skin Flap Thin skin flaps are also useful for coverage of soft tissue defects of the dorsal hand. While glabrous skin donor sites are essential for critical sensibility restoration, these donor sites are generally too limited to provide sensate skin for dorsal resurfacing. The donor sites that are available for dorsal sensory free flap coverage include the dorsalis pedis flap, deltoid flap, lateral arm flap, and
B
D
FIGURE 4-4. A, Preoperative view showing necrosis of soft tissue due to a contact burn. After debridement of the necrotic tissue, the extensor tendons were exposed. B, The defect was covered with a thin lateral arm fascia flap and split-thickness skin graft. C, D, The flap was thin and pliable and provided good gliding for the tendons.
radial forearm flap. Each donor site is supplied by a named septocutaneous artery and cutaneous nerve. The skin and subcutaneous tissue overlying the deltoid muscle can be transferred as a sensory free flap based on the posterior circumflex humoral artery and lateral brachial cutaneous nerve.15 The artery emerges through the quadrangular space and can be located with a Doppler examination at the deltoid-triceps groove, where it becomes subcutaneous. When dissected beneath the triceps muscle, the vessel diameter reaches 2 to 4 mm, providing a pedicle length of 6 to 8 cm. The deltoid flap can also supply a fasciocutaneous flap of 10 ⫻ 15 cm with cutaneous sensitivity. The donor site can be closed primarily in patients with smaller flaps, whereas larger defects usually require skin grafts. When the flap is transferred to the hand, protective sensory recovery can be expected with a static and moving two-point discrimination of more than 20 mm. Located just below the territory of the deltoid flap, between the deltoid-triceps groove and the elbow, the lateral arm fasciocutaneous skin territory is vascularized by the posterior radial collateral artery, which emerges from behind the proximal humerus and courses along the lateral intermuscular septum.22 The artery is consistently 1.5 to 2.0 mm in diameter, providing a vascular pedicle 7 to 8 cm long. The flap is centered over the lateral intermuscular septum on a line that joins the deltoid insertion and the lateral epicondyle. A flap width up to 6 cm can be closed primarily; however, the vascular territory extends to 15 ⫻ 14 cm. The skin of the lateral arm is innervated by the posterior cutaneous nerve of the arm. This nerve arises from the radial nerve in the spiral groove and accompanies the artery and venae comitantes. During dissection, this nerve must be differentiated from the larger radial nerve and from the posterior cutaneous nerve of the forearm. This type of flap can be used as a neurosensory skin flap, fascial flap, or tendocutaneous flap including the triceps tendon.
Tendocutaneous Flap In the past, extensor tendon defects on the dorsum of the hand have been reconstructed secondarily by a combination of tendon transfers and tendon grafts, if necessary, passed beneath a flap that was previously placed to cover a soft tissue defect. The skin defect is resurfaced by local or distant flaps, such as a groin or subaxillary flap. Although these flaps offer the best results with respect to the donor site, they immobilize the hand in a nonfunctional position, thus limiting the excursion of both finger and wrist joints. It is difficult to assess the exact length for a grafted tendon because of myostatic contraction of the recipient muscle bellies due to prolonged immobilization. This results in tendon adhesions and associated extension and flexion deficits in both the repaired and grafted tendons. Moreover, a groin flap is
MANAGEMENT OF THE DORSAL MUTILATING INJURY
57
bulky and prohibits primary tendon reconstruction, thereby requiring multiple surgical procedures. Scheker and colleagues42 reported on nine patients with extensive soft tissue and bone losses who were treated with an emergency free flap for skin cover, primary bone grafts, and tendon grafts passed through individual tunnels in the free flap. The tendon grafts, harvested from the extensor digitorum longus or the plantaris, were passed through individual tunnels in the free skin flap, which was either a groin, lateral arm, or radial forearm flap, to avoid adhesions and improve gliding. The results were good in four cases, fair in four and poor in one. Vascularized tendon grafting offers several potential advantages. Vascularized tendons are less likely to induce adhesion formation, since they retain their vascularity after transfer. The early development of tensile strength at the junctures in these tendons permits safer and earlier active motion so that any adhesions are less likely to restrict gliding. Various donor sites for vascularized tendons have been reported in the literature for reconstruction of combined extensor tendon and softtissue defects. Reid and Moss38 reported on a radial forearm flap including the palmaris longus tendon with part of the tendinous portion of the brachioradialis. McGeorge and colleagues31 described a distally based brachioradialis muscle-tendon flap. These methods offer local one-stage reconstruction using only one or two strips of the tendon and no requirement for microvascular transfer. However, the donor site is not as well tolerated in females. Foucher and associates14 described a free radial forearm flap with tendons of the palmaris longus, flexor carpi radialis, and brachioradialis. Gosain and coworkers18 studied a composite lateral arm free flap with a triceps tendon supplied by the posterior radial collateral artery, which is the only composite flap for which perfusion of the tendon graft is not dependent on perfusion of the skin-fascial component. Independent orientation of the tendinous and fasciocutaneous components can be performed for optimal reconstruction of a specific defect. This flap provides a less conspicuous scar and a skin paddle 6 to 8 cm in width without requiring a skin graft for closure of the donor site. A groin-epigastric flap with external oblique aponeurosis is another potential area of skin and vascularized tendon. Although it is bulky, it has clinical applications in the lower limbs. Taylor and Townsend48 suggested the following prerequisites for an ideal composite graft: (1) Multiple tendons of adequate length should be available to repair the particular defects. These tendons should be surrounded by paratenon to reduce the risk of adhesions, and their blood supply should be predictable. (2) The skin flap should be thin, have a mobile relationship with the attached tendons, and (if necessary) have the
4
4
58
THE MUTILATED HAND
potential to include other structures in the flap design such as nerve or bone. (3) A single arteriovenous system should nourish both the flap and the tendons. Taylor and Townsend concluded that the extensor tendons of the toes seemed to be the only site with the potential of fulfilling the above-listed criteria. An island flap based on the dorsalis pedis artery was first introduced by O’Brien and Shanmugan35 and McCraw and Furlow.30 Robinson40 gives an account of the anatomy of the dorsalis pedis artery; the first dorsal metatarsal artery is described in detail by Gilbert17 and May and associates.29 Man and Acland28 clarified the microanatomic details of the cutaneous branches of the dorsalis pedis artery. Taylor and Townsend48 studied the dorsalis pedis–first dorsal metatarsal artery system that supplies the tendon of the extensor hallucis brevis and the communis tendon of the second toe. Ohmori and Harii36 reported that sensory recovery would seem to depend to a great extent on the condition of the recipient bed. When transferred to a favorable recipient bed, thin flaps tend to restore good sensation even without the coaptation of the sensory nerves. Vila-Rovira and colleagues50 reported that the tendinous portion of the tendocutaneous dorsalis pedis flap maintains its entire perfusion through the superior and inferior lateral tarsal branches and through small arteries emanating directly from the dorsalis pedis artery. The superior lateral tarsal artery provides the richest vascularization of the long and short extensor paratenon of the toes. The dorsalis pedis composite flap provides four vascularized tendons of adequate length for mass action reconstruction, sensory nerves, and bone; additionally, it is supplied by a single arteriovenous system: the dorsalis pedis–first dorsal metatarsal artery. The quality of the foot’s dorsal skin is similar to that of the dorsum of the hand because they both have thin pliable skin. VilaRovira and colleagues,50 Shen,44 and Caroli and coworkers5 reported promising results when using a dorsalis pedis–tendocutaneous flap for the loss of multiple tendons and dorsal hand skin. In contrast, O’Brien and Shanmugan35 excluded the overlying skin and used the extensor hallucis longus tendon as a vascularized flap to repair the profundus tendon. The first step in creating a dorsalis pedis tendocutaneous flap is preoperative Doppler tracing of the course of the dorsalis pedis–first dorsal metatarsal vascular axis. An outline of the flap is drawn on the basis of the dorsalis pedis–first dorsal metatarsal vascular axis (Fig. 4-5). It is helpful to outline the venous drainage on the foot. The flap elevation begins under tourniquet control. The dissection begins distally. The first dorsal metatarsal vessels are identified and included in the flap. The extensor hallucis brevis of the great toe and the extensor digitorum longus of the toes are then divided (according to the number of destroyed tendons) close to their insertions
and dissected proximally with the flap. The flap is elevated distally to proximally and laterally to medially below the level of the first dorsal metatarsal artery and the long extensors of the toes. The extensor hallucis brevis is included in the flap if only one tendon is needed; the extensor hallucis brevis and extensor digitorum longus II are included if two tendons are needed; and the extensor digitorum longus II to V are included if four tendons are needed. It is critical to preserve the paratenon over these tendons along with their vascular connections from the dorsalis pedis vessels. The key to vascularization of the extensor digitorum longus of the toes is the presence of a superficially situated first dorsal metatarsal artery and superior lateral tarsal artery. The short extensors of the toes, including their paratenon, are left intact. As dissection proceeds medially, the venous structures are maintained in continuity with the long saphenous vein. During elevation, the long saphenous vein or median dorsal vein is preserved. Perforators below the takeoff of the first dorsal
Extensor digitorum longus Extensor retinaculum Tibialis anterior tendon
Dorsalis pedis artery Extensor hallucis brevis Extensor hallucis longus tendon Deep peroneal nerve First dorsal metatarsal artery
FIGURE 4-5. Dorsalis pedis flap anatomy and design.
metatarsal artery are divided at the base of the second metatarsal bone. The superficial peroneal nerve is preserved. The extensor retinaculum is divided, and the anterior tibial vessels are dissected proximally to a point based on the needs of the recipient site. The anterior tibial artery and one of its venae comitantes are anastomosed to the radial artery and one of its venae comitantes, respectively, using 10-0 nylon in an end-to-end or end-to-side fashion. The long saphenous vein or the median dorsal vein is then anastomosed to either a dorsal vein in the hand or the cephalic vein in the forearm. The long extensors of the toes are sutured to both the proximal and distal ends of the recipient tendons with 4-0 nylon. An accurate assessment of the tendon graft length is obtained by placing the interphalangeal joint and the metacarpophalangeal joint in full extension and the wrist joint in 30° of extension. The superficial peroneal nerve is coapted to a branch of the superficial radial nerve. An intermediate-thickness split-skin graft and tieover dressing are then applied to the donor site and left in place for 5 days. A posterior plaster splint is applied for ankle immobilization until the graft take is complete. The hand is immobilized by placing the interphalangeal joint and metacarpophalangeal joint in full extension and the wrist joint in 30° of extension with a splint for 6 days postoperatively. After 1 week, active flexion and passive extension can commence. I use a dynamic splinting program with an outrigger splint that holds the fingers in extension while allowing full active flexion. Progressive resistance exercises should be performed for an additional 5 weeks.3 Take care to preserve the blood supply to the tendons to avoid the risk of tendon exposure by injuring the paratenon. To prevent extensor lag, it is important to excise the scarred proximal and distal ends of the recipient tendon; thus, the exact tendon length to be transferred can be assessed by keeping the interphalangeal and metacarpophalangeal joints in full extension and the wrist joint in 30° of extension. In the case of extensor lag, it is necessary to perform extensor tendon shortening. Vila-Rovira and colleagues50 used a dorsalis pedis tendocutaneous flap to transfer one tendon in one case and four tendons in another case of combined loss of skin and tendons on the dorsum of the hand. They reported subsequent full extension of the reconstructed fingers. Caroli and coworkers5 described promising results in three cases in which four tendons were transferred, which resulted in full recovery of range of motion. Lee and colleagues26 reported good results in 13 patients in whom the number of transferred tendons ranged from one to five. Furthermore, I have experience with seven patients in whom the number of transferred tendons ranged from one to four. The recovery rate for
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the range of motion in the metacarpophalangeal joint of the reconstructed finger averaged 91.4 % (Figs. 4-6 and 4-7). Two-point discrimination of the transferred flaps averaged 25 mm.10 A defatting procedure is not necessary. The drawbacks of this flap include the variable anatomy of the first dorsal metatarsal artery, tedious dissection, limitation of skin flap size, and donor site morbidity. The greatest disadvantage is the skin loss due to an incomplete take of the skin graft.34 Meticulous technique is required to close the foot defects. Ideally, it is desirable to preserve the paratenon of the short extensors of the toes to prevent any desiccation of the grafted bed during the flap dissection and avoid excessive pressure from the tie-over dressing. However, delayed healing of the donor site rarely produces a significant long-term functional deficit. There are no functional deficits or gait disturbances because the short extensors of the toes are completely intact and the long extensors are partially intact. Accordingly, this procedure offers mass action reconstruction with multiple tendons, the provision of similar color match and skin texture compared with the normal skin of the hand, a one-stage operation, faster healing with less adhesion and early mobilization, and good sensation. For bony reconstruction, this flap can also include the second metatarsal bone. Nakayama and colleagues33 first described an arterialized venous flap in 1981 and anticipated that the survival of arterialized venous flaps would increase with a high inflow of oxygen. However, after arterialization, congestion and edema occur for 3 to 6 weeks, resulting in partial or total necrosis. Normally, the survival of this type of flap is not uniform, and its application is limited to small defects.20,24 Lee suggested that two essential elements must exist for the successful perfusion of an arterialized venous flap27: (1) The flap must contain a rich venous network communicating with both afferent and efferent veins. (2) The flap should not have functional valves in the veins. Galumbeck and Freeman16 postulated that by arterializing the venous flap in an antegrade fashion, blood flow through the tissue becomes reversed. This then increases the pressure in the venous system and dilates the oscillating veins, which supply nutritive blood to the cutaneous tissues. With time, venous congestion and edema resolve, resulting in either microvascular shunts in the flap or neovascularization from the surrounding tissues. Byun and colleagues4 and Seo and associates43 suggested that transversely oriented venous networks delay procedures before the arterialization of the venous tree can enhance perfusion of the flap by increasing venoarterial communication and dilating the vascular trees after a 2-week delay. This type of surgical delay produces a uniform survival rate for arterialized venous flaps. Previously, Cho and colleagues11,39 suggested that the
4
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THE MUTILATED HAND
A
B
C
D
E
F
FIGURE 4-6. A, This patient sustained a severe avulsion injury to the dorsum of the hand by an electric saw. B, C, Harvesting of a 9 ⫻ 9.5 cm flap including four extensor digitorum longus tendons from the toes for transfer. D, Immediate postoperative view. E, F, Two years after separation of the individual fingers, the fingers could be flexed and extended very effectively.
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FIGURE 4-7. A, A 21-year-old man with a defect to the skin and four extensor tendons on the dorsum of the hand due to a machine injury. After the original skin grafting, there was incomplete extension of the fingers. A dorsalis pedis tendocutaneous flap, including four extensor digitorum longus tendons, was transferred. B, Twenty-six months postoperative, the fingers showed full extension.
A
B
combination of surgical and chemical delay procedures can shorten the length of the delay. Recently, Cho and colleagues9 reported on the clinical application of a delayed arterialized venous flap in 13 patients: nine with acute soft tissue defects and four with scar contractures. Koshima and coworkers24 reported a case of a skin defect involving osteomyelitis of the carpal bones in the hand. This patient underwent reconstruction with a free osteocutaneous arterialized venous flap taken from the medial aspect of the leg, including a segment of the tibia and its overlying skin. Chen and colleagues6 and Inoue and colleagues21 also described three cases of a tendocutaneous arterialized venous flap with the palmaris longus tendon used for dorsal finger reconstruction. However, the flap size was small and ranged from 1.5 to 2.2 cm ⫻ 1.5 to 6 cm. Cho and colleagues8 also previously reported two cases with large composite tissue defects, including two extensor tendons on the dorsum of the hand. These defects were reconstructed by using a dorsalis pedis tendocutaneous delayed arterialized venous flap. On the basis of a study of the vascular network in the dorsum of the foot, a venous flap should be designed with its main vein axially centered in the flap. It is important to have at least two efferent veins in the flap. The circumferential incision is made with preservation of the skin bridges.8 Four skin bridges, 1 cm in width, are made at the sites of the afferent and efferent veins (Fig. 4-8). The incision is carried deep to the fascia. The venous flap, including the veins, fascia, and extensor tendons of the toes, should be completely undermined from the bed to maximize the effect of the
surgical delay. Arterial inflow from the surrounding tissues is not preserved, except from the skin bridges. After complete hemostasis, the venous flap is sutured back into its bed. Arterialization of the venous flap is then performed after a 2-week surgical delay procedure. Sufficient length of an afferent and efferent vein should be obtained from the dorsum of the foot to perform microanastomosis without tension. The dorsalis pedis tendocutaneous venous flap is then raised from the dorsum of the foot and transferred to the hand. The tendons of the extensor digitorum longus are sutured to the appropriate tendons of the hand to maintain the extended position of the fingers. Patency of the veins from the afferent veins to the efferent veins can be confirmed by irrigation with a heparinized saline solution (1000 U/100 mL). The afferent vein of the venous flap is anastomosed to the radial artery using 10-0 nylon. After confirming the pulsating arterial outflow in the efferent veins, they are anastomosed to the cephalic veins to make an antegrade flow-through type venous flap. Two efferent veins are anastomosed to drain the arterial blood inflow effectively. Cho and coworkers8 have reported two such cases. Flap sizes were 6 ⫻ 6 cm and 10 ⫻ 10 cm, including two tendons of the extensor digitorum longus. Recovery rates for range of motion in the metacarpophalangeal joints of the operated fingers average 98% and 94%, respectively, compared to the contralateral nonoperated fingers (Fig. 4-9). Dorsalis pedis tendocutaneous delayed arterialized venous flaps can be larger than pure venous flaps or arterialized venous flaps; since they have a higher survival rate, this allows them to be
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THE MUTILATED HAND
Efferent vein
Cephalic vein
Skin bridge
Extensor digitorum longus tendons of the 2nd and 3rd toes
Afferent vein
A
Radial artery
B
FIGURE 4-8. Arterialization of venous flap. A, Surgical delay procedure. Four skin bridges, each 1 cm in width, are made at the site of the afferent and efferent veins. B, The delayed arterialized venous flap, including two extensor tendons, is elevated from the dorsum of the foot. One distal afferent vein is anastomosed to the radial artery. The two proximal efferent veins are then anastomosed to the cephalic veins of the forearm.
used as composite flaps. In the two cases mentioned above, angiograms showed a well-vascularized venous network without any arteriovenous shunts. However, the angiograms were unable to confirm whether the attached tendons in the venous flap were adequately perfused. It would appear that the attached tendons were perfused by a retrograde venous blood flow. These flaps have additional advantages, such as preservation of the main artery of the donor site, use of thin, nonbulky tissue, and easy elevation without deep dissection. Postoperative arterial insufficiency does not occur if the dorsalis pedis artery is not patent. However, a dorsalis pedis arterial flap should not be used in the presence of small vessel disease. This donor site cannot be used when the posterior tibial artery is absent. A dorsalis pedis delayed arterialized venous flap can be used
in the absence of the posterior tibial artery and can spare one major artery.
Osteocutaneous Flap Complex composite defects of the hand present both functional and aesthetic reconstructive challenges. Small bone defects can be suitably filled with cancellous bone, either as a block or as chips. Large defects in the metacarpal bones are best reconstructed with free bone flaps. Bone that can be vascularized by an overlying free flap includes segments of the ilium with a groin flap, fibula with a skin flap, metatarsus with a dorsalis pedis flap, humerus with a lateral arm flap, rib bone with a serratus anterior muscle flap (Fig. 4-10), radius with a radial forearm flap, ulna with an ulnar forearm flap, and scapula with a scapular skin flap.
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4
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B
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F
D
E
FIGURE 4-9. A, A 27-year-old man with a thermal compression injury to the dorsum of the hand. The ring and little fingers were amputated. The dorsum of the hand shows the soft tissue defect and the absence of the extensor digitorum communis tendons of the index and middle fingers. B, C, A venous flap, including two tendons, was elevated after the delay procedure. D, An angiogram taken 6 months after arterialization showed a well-vascularized venous network with no arteriovenous shunt. E, F, The range of motion in the index and middle fingers was nearly normal with good resurfacing 8 months after the operation.
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A
B
C
D
E
F
FIGURE 4-10. A, This patient sustained an avulsion injury to the first webspace and dorsum of the hand. B, X-ray view shows a partial loss of the metacarpal and proximal phalanx of the thumb. C, D, The serratus anterior muscle, including the sixth rib, was harvested and transferred to the defect. E, F, Six-month postoperative views demonstrate good bony stability and soft tissue volume in the reconstructed area.
CONCLUSION A mutilated hand suffers a complex injury with composite tissue loss and significant functional disability. Following surgical debridement of the devitalized tissue, the viable functional structures should be preserved to
retain as much function as possible. Ideally, soft tissue defects of the hand should be replaced with similar tissue. Local or free flaps are excellent options. However, they must provide sufficient subcutaneous tissue for deep gliding structures; supply subcutaneous tissue in
bulk for the coverage of vital neural, vascular, bone, and joint structures; and be aesthetically pleasing. Finally, surgeons should also choose the proper composite flap for reconstruction of a complex tissue defect.
References 1. Brent B, Upton J, Acland RD: Experience with the temporoparietal fascial free flap. Plast Reconstr Surg 76:177, 1985. 2. Browne Jr EZ: General principles of wound management in hand injury. In McCarthy JG (ed): Plastic Surgery, vol 3. Philadelphia, WB Saunders, 1990. 3. Browne EZ, Ribik CA: Early dynamic splinting for extensor tendon injuries. J Hand Surg [Am] 14:72, 1989. 4. Byun JS, Constantinescu MA, Lee WPA, May Jr JW: Effects of delay procedures on vasculature and survival of arterialized venous flaps: An experimental study in rabbits. Plast Reconstr Surg 34:88, 1995. 5. Caroli A, Adani R, Castagnetti C, et al: Dorsalis pedis flap with vascularized extensor tendons for dorsal hand reconstruction. Plast Reconstr Surg 92:1326, 1993. 6. Chen CL, Chiu HY, Lee JW, Yang JT: Arterialized tendocutaneous venous flap for dorsal finger reconstruction. Microsurgery 15:886, 1994. 7. Chen HC, El-Gammal A: The lateral arm fascial free flap for resurfacing of the hand and finger. Plast Reconstr Surg 99:454, 1997. 8. Cho BC, Byun JS, Baik BS: Dorsalis pedis tendocutaneous delayed arterialized venous flap in hand reconstruction. Plast Reconstr Surg 104:2138, 1999. 9. Cho BC, Lee JH, Byun JS, Baik BS: Clinical applications of the delayed arterialized venous flap. Ann Plast Surg 39:145, 1997. 10. Cho BC, Lee JH, Weinzweig N, Baik BS: Use of the free innervated dorsalis pedis tendocutaneous flap in composite hand reconstruction. Ann Plast Surg 40:268, 1998. 11. Cho BC, Lee MS, Lee JH, et al: The effects of surgical and chemical delay procedures on the survival of arterialized venous flaps in rabbits. Plast Reconstr Surg 102:1134, 1998. 12. Datiashvili RO, Shibaev EY, Chichkin VG, Oganesian AR: Reconstruction of a complex defect of the hand with two distinct segments of scapular and a scapular fascial flap transferred as a single transplant. Plast Reconstr Surg 90:687, 1992. 13. Fassio E, Laulan J, Aboumoussa J, Senyuva C, et al: Serratus anterior free fascial flap for dorsal hand coverage. Ann Plast Surg 43:77, 1999. 14. Foucher G, Genechten F, Merle N, Michon J: A compound radial artery forearm flap in hand surgery: An original modification of the Chinese forearm flap. Br J Plast Surg 37:139, 1984. 15. Franklin JD: The deltoid flap: Anatomy and clinical application. In Buncke HJ, Furnas DW (eds): Symposium on Clinical Frontiers in Reconstructive Microsurgery, vol 24. St Louis, CV Mosby, 1984. 16. Galumbeck MA, Freeman BG: Arterialized venous flaps for reconstructing soft-tissue defects of the extremities. Plast Reconstr Surg 94:997, 1994.
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17. Gilbert A: Composite tissue transfers from the foot: Anatomic basis and surgical technique. In Daniller A, Strauch B (eds): Symposium on Microsurgery, vol 15. St. Louis, Mosby, 1976. 18. Gosain AK, Matloub HS, Yousif NJ, Sanger JR: The composite lateral arm free flap: Vascular relationship to triceps tendon and muscle. Ann Plast Surg 29:6, 1992. 19. Hing D, Buncke HJ, Alpert BS: Use of the temporoparietal free fascial flap in the upper extremity. Plast Reconstr Surg 81:534, 1988. 20. Inoue G, Maeda N, Suzuki K: Resurfacing of skin defects of the hand using the arterialized venous flap. Br J Plast Surg 43:135, 1990. 21. Inoue G, Tamura Y, Suzuki K: One-stage repair of skin and tendon digital defects using the arterialized venous flap with palmaris longus tendon. J Reconstr Microsurg 12:93, 1996. 22. Katsaros J, Schusterman M, Bepper M: The lateral upper arm flap: Anatomy and clinical applications. Ann Plast Surg 12:489, 1984. 23. Koshima I, Moriguchi T, Etoh H, et al: The radial artery perforator-based adipofascial flap for the dorsal hand coverage. Ann Plast Surg 35:474, 1995. 24. Koshima I, Soeda S, Nakayama Y, et al: An arterialized venous flap using the long saphenous vein. Br J Plast Surg 44:23, 1991. 25. Lai CS, Lin SD, Yang CC, Chou CK: The adipofascial turnover flap for complicated dorsal skin defects of the hand and finger. Br J Plast Surg 44:165, 1991. 26. Lee KS, Park SW, Kim HY: Tendocutaneous free flap transfer from the dorsum of the foot. Microsurg 15:882, 1994. 27. Lee WPA: Arterialized venous flap for treating multiple skin defects of the hand (discussion). Plast Reconstr Surg 91:303, 1993. 28. Man D, Acland RD: The microarterial anatomy of the dorsalis pedis flap and its clinical applications. Plast Reconstr Surg 65:419, 1980. 29. May JW, Chait LA, Cohen BE, O’Brien BM: Free neurovascular flap from the first web of the foot in hand reconstruction. J Hand Surg [Am] 2:387, 1977. 30. McCraw JB, Furlow LT: The dorsalis pedis arterialized flap: A clinical study. Plast Reconstr Surg 55:177, 1975. 31. McGeorge DD, Arnstein PM, Stilwell JH: The distally-based brachioradialis muscle flap. Br J Plast Surg 44:30, 1991. 32. McGregor IA, Jackson IT: The groin flap. Br J Plast Surg 25:3, 1972. 33. Nakayama Y, Soeda S, Kasai Y: Flaps nourished by arterial inflow through the venous system: An experimental investigation. Plast Reconstr Surg 67:328, 1981. 34. O’Brien BM: Microvascular Reconstructive Surgery: Tendon, Muscle, and Nerve Reconstruction. Edinburgh, Churchill Livingstone, 1977. 35. O’Brien BM, Shanmugan N: Experimental transfer of composite free flaps with microvascular anastomoses. Aust N Z J Surg 43:285, 1973. 36. Ohmori K, Harii K: Free dorsalis pedis sensory flap to the hand, with microneurovascular anastomosis. Plast Reconstr Surg 58:546, 1976. 37. Penteado CV, Masquelet AC, Chevrel JP: The anatomic basis of the fasciocutaneous flap of the posterior interosseous artery. Surg Radiol Anat 8:209, 1986.
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38. Reid CD, Moss ALH: One-stage flap repair with vascularized tendon grafts in a dorsal hand injury using the “Chinese” forearm flap. Br J Plast Surg 36:473, 1983. 39. Rhyu HH, Cho BC, Byun JS, Baik BS: The role of chemical delay in the survival of the arterialized venous flap. J Korean Soc Plast Reconstr Surg 23:942, 1996. 40. Robinson DW: Microsurgical transfer of the dorsalis pedis neurovascular island flap. Br J Plast Surg 29:209, 1976. 41. Rose EH, Norris MS: The versatile temporoparietal fascial flap: Adaptability to a variety of composite defects. Plast Reconstr Surg 85:224, 1990. 42. Scheker LR, Langley SJ, Martin DL, Jullianrd KN: Primary extensor tendon reconstruction in dorsal hand defects requiring free flaps. J Hand Surg 18B:568, 1993. 43. Seo MS, Cho BC, Byun JS, Baik BS: The role of delay procedures in the survival of arterialized venous flap. J Korean Soc Plast Reconstr Surg 22:7, 1995. 44. Shen ZY: Vascularized tendon grafting from the dorsum of the foot: A functional anatomic study and clinical experience [abstract]. J Reconstr Microsurg 5:90, 1989. 45. Smith PJ, Ross DA: Tubed radial fascial flap and reconstruction of the apparatus in the forearm. J Hand Surg [Am] 18A:959, 1993. 46. Smith RA: The free fascial scalp flap. Plast Reconstr Surg 66:204, 1980.
47. Soutar DS, Tanner NSB: The radial forearm flap in the management of soft tissue injuries of the hand. Br J Plast Surg 37:18, 1984. 48. Taylor GI, Townsend P: Composite free flap and tendon transfer: An anatomical study and a clinical technique. Br J Plast Surg 32:170, 1979. 49. Ueda K, Harashina T, Inoue T, Ohba S: Temporoparietal sandwich technique in acute avulsion injury of the hand. J Reconstr Microsurg 12:19, 1996. 50. Vila-Rovira R, Ferreira BJ, Guinot A: Transfer of vascularized extensor tendons from the foot to the hand with a dorsalis pedis flap. Plast Reconstr Surg 76:421, 1985. 51. Weinzweig N, Chen L, Chen Z-W: The distally based forearm fasciosubcutaneous flap with preservation of the radial artery: An anatomical and clinical approach. Plast Reconstr Surg 94(5):675, 1994. 52. Yano H, Nishimura G, Kaji S, et al: A clinical and histologic comparison between free temporo-parietal and scapular fascial flap. Plast Reconstr Surg 95:452, 1995. 53. Youssif NJ, Warren R, Matloub H, et al: The lateral arm fascial free flap: Its anatomy and use in reconstruction. Plast Reconstr Surg 86:1138, 1990. 54. Zancolli EA, Angrigiani C: Posterior interosseous island forearm flap. J Hand Surg 13B:130, 1988.
5
5 Management of the Palmar Mutilating Injury Hanh H. Nguyen, MD Hani S. Matloub, MD
A mutilating injury involving the palmar aspect of the hand poses a very difficult challenge owing to the unique anatomy of the palm. The palm is the working surface of the hand. It is concave in shape and larger in surface area than the dorsum of the hand. It is composed of thick layers of skin, subcutaneous fat, and fascia overlying the neurovascular bundles, flexor tendons, and intrinsic muscles. The dermal-epidermal junction and fibrous septae form an extensive network by which the glabrous skin resists horizontal shearing stress. The aim of reconstruction is not only to provide a durable, tactile surface, but also to restore the function of the flexor tendons and to provide stable bony support.
ANATOMY The skin of the palm is glabrous, with a thick dermal layer, and heavily cornified. It has more sweat glands than the dorsum, and is devoid of pigment. It also contains a large number of sensory mechanoreceptors that provide sophisticated sensibility. The subcutaneous fat pad is composed of firm adherent lobules separated by the vertical septae and fibers that run between the palmar fascia and the dermis. These loculi of fat can change their shape, but not their volume, within this fascial framework. This soft pad allows the hand to conform to the contours of objects being grasped, allowing better interpretation of sensation and better grip. At the creases, the vertical fibrous tissue holds the skin tightly to the underlying fascia. While palmar skin provides the stability that is critical to hand function, the system of creases allows mobility of the fingers and palm. Two volar wrist creases are for the movement of the radiocarpal joint. There are two major creases in the palm: the proximal crease, which runs with the thenar crease at the radial border of the palm and travels toward the ulnar border of the hand, and the distal crease, which runs from the second webspace to the ulnar border. The thenar creases allow adduction and opposition of the thumb. The distal palmar crease lies over the midportion of the proximal phalanx at the limit of the proximal fat pad at the interdigital folds rather than overlying the metacarpophalangeal joints. Each of the volar creases attaches directly to the sheaths of the flexor tendons, dividing the volar subcutaneous fat of the finger into three distinct pads.22 The palmar fascia consists of strong fibrous tissue arranged in longitudinal, transverse, and oblique fibers. The palmar fascia serves as a strong anchoring system to the skin, resisting horizontal shearing forces. The longitudinal fibers are arranged in bundles corresponding to the 67
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THE MUTILATED HAND
four digital rays. In addition, there is a variable bundle crossing the thenar eminence toward the radial side of the thumb. The transverse fibers are concentrated in the distal palm, supporting the web skin, and in the midpalm as the transverse palmar ligament, which lies deep to the longitudinal fibers and is connected to the vertical fibers. The transversely oriented fibers have a role in maintaining the transverse arch of the hand by binding to the skeletal structures. The deep transverse intermetacarpal ligaments connect the metacarpophalangeal joint volar plate from one to another. The vertical fibers extend superficially into the dermis; the deep fibers coalesce into septae, forming tunnels for the flexor tendons and the neurovascular units (Fig. 5-1).11 Immediately under the palmar fascia are the superficial vascular arch and the volar digital nerves. Here the vessels of the superficial palmar arch lie volar to the nerves. However, at the distal palm, the nerves curve volarly around the arteries. The blood supply of the hand comes from the radial and ulnar arteries. It can be divided into two layers: the superficial palmar arch and the deep palmar arch. The superficial branch of the radial artery, which arises near the distal radius, forms the superficial palmar arch. This branch courses over or through the abductor pollicis brevis and anastomoses with the superficial branch of the ulnar artery under the midpalmar fascia. It rarely assumes a complete arch and varies in blood supply of the common digital arteries. It gives rise to three common digital arteries and multiple branches to the intrinsic muscles and the skin. The deep arch lies at the proximal ends of the metacarpals and deep to the flexor tendons. It receives its blood supply mainly from the branch of the radial artery. As the radial artery crosses the anatomic snuffbox under the abductor pollicis longus, extensor pollicis brevis, and extensor pollicis longus, it passes deep through an arcade in the first dorsal interosseous muscle into the palm. It anastomoses with the deep branch of the ulnar artery and then gives rise to four palmar metacarpal arteries, the first branch being the major source of blood supply to the thumb and the radial side of the index finger. After giving off the radial proper artery to the index finger, the artery becomes the princeps pollicis artery. The median and ulnar nerves are responsible for motion and sensation in the hand. The median nerve commonly gives rise to the recurrent motor branch just distal to the border of the transverse carpal ligament. It then passes forward and branches to the first four digits in a plane superficial to the flexor tendons and deep to the superficial palmar arch. On the palmar aspect of the hand, a midline passing longitudinally from the tip of the ring finger to the wrist indicates the distribution of the median nerve on the radial side of this line and the ulnar nerve on the ulnar side of the line. The median
nerve supplies the thumb, index, middle, and part of the ring finger. The radial digital nerve of the index finger is most often injured, as it is located most superficial. The pulps of these fingers are especially important in hand function, particularly in exploring and manipulating. The median nerve supplies the muscles of the thenar eminence except for the deep head of the flexor pollicis brevis and the two radial lumbricals. Damage to the recurrent branch of the median nerve results in an inability to position the thumb for pulp-and-pulp opposition with other digits. The ulnar nerve is far less important from the standpoint of hand sensation, but it is very important for its motor innervation of the intrinsic muscles of the hand.21 It runs on the ulnar side of the ulnar artery through an opening in the transverse carpal ligament (Guyon’s canal). It divides into the superficial sensory branch and the deep motor branch at the distal border of the ligament. The sensory branch supplies the ulnar aspect of the palm and the volar surface of only the little finger and half of the ring finger. The ulnar digital nerve to the little finger, like the radial digital nerve to the index finger, is most frequently injured owing to its superficial position. The deep branch dives between the abductor and the flexor muscles of the little finger and travels across the palm beneath the deep vascular arch. It supplies the hypothenar muscles, the two ulnar lumbricals, the interossei, the deep head of the flexor pollicis brevis, and the adductor of the thumb. There is variability in the division of nerve supply between the median and the ulnar nerves, in both their sensory and motor distribution.2 As the flexor tendons pass volarly from the wrist joint to the distal interphalangeal joint, their relationship to the joint axes is maintained by the retinacular system. The retinacular system holds the flexor tendons close to the bone and volar joint plate surfaces, thereby producing the maximal mechanical advantage for joint flexion. At the wrist, the transverse carpal ligament runs across from the pisiform and hook of hamate medially to the scaphoid tuberosity and trapezium laterally. It prevents bowstringing of the flexor tendons at the wrist. Each digit has five annular ligaments: A2 and A4 arise exclusively from the bone and are broad and rigidly fixed to the outer edge of the proximal phalanx and the middle phalanx. A1, A3, and A5 arise from the bone and the volar joint plate. They adjust with movement, holding the flexor tendons close to the joint. There are three cruciform pulleys, C1, C2, and C3, which serve as reinforcing extensions of the annular pulleys and preventing herniation of the sheath.28 The digital synovial sheaths are made up of two layers: the visceral layer on the tendon surface and the parietal layer on the fibrous surface. The thumb synovial sheath is continuous from the wrist to the tip of the tendon. The sheaths for the index, middle and ring fingers
69
C
A
B
FIGURE 5-1. Detailed anatomy of different layers of the soft tissue of the palm.
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usually start at the distal palmar crease and extend to the distal interphalangeal joints. The sheath of the little finger extends proximally to communicate with the common sheath around the tendons at the wrist level.
GENERAL CONSIDERATIONS Mutilating palmar injuries are uncommon, but they are complex injuries with significant damage not only to the specialized glabrous skin, but also to the important underlying tissues, including muscles, flexor tendons, neurovascular bundles, and bone. These injuries can result from industrial trauma, agricultural machinery, motor vehicle accidents, and burns. The causes of these injuries include crush, avulsion, blast, and thermal or electrical burns. Such injuries present difficulties in reconstruction, and the deficit can have severe functional and cosmetic consequences. An optimal outcome demands that the attending surgeon pay close attention to the problem in all its preoperative, intraoperative, and postoperative phases, at both the donor and recipient sites. The main priority in the acute management of palmar mutilating injuries is to restore vascularity to the hand and digits. Skeletal stabilization, musculotendinous and nerve repair, and soft tissue coverage are other important factors in restoring overall function to the hand.4
OPERATIVE ASSESSMENT The extent of damage to the soft tissue can be assessed adequately only in the operating room. Thoroughly irrigate the wound with the power irrigator under tourniquet control. Identify important vascular structures, and tag them with 7-0 Prolene so that they can be easily found later. Examine flexor tendons together with their pulley systems. Perform direct repair of the flexor tendons while the tourniquet is still inflated. If there is loss of length, the tendon can be marked for tendon graft. Metacarpal and carpal fractures should also be fixed while the hand is still under tourniquet control. The fixation method is dependent on the type of fracture and the degree of comminution or bone loss. Place the plate or wire away from the volar surface of the metacarpal. Avoid excessive stripping of the periosteum. External fixation may be required if there is significant comminution. It must be carefully placed so as not to interfere with subsequent soft tissue reconstruction. After thorough exploration of the wound, repair of flexor tendons, and skeletal stabilization, deflate the tourniquet. Completely excise the devitalized skin, fascia, and muscle back to the bleeding tissue. The extent of the defect can now be established for reconstruction. Document the list of deficient tissues, and consider them individually in planning reconstruction. As was previously indicated, flexor tendon repairs and skeletal stabilization should be performed under tourniquet control to employ the ischemic time efficiently.
PREOPERATIVE ASSESSMENT AND INITIAL MANAGEMENT
SKELETAL STABILIZATION
Preoperative assessment of the palmar mutilating injury should include a thorough history and physical examination. Time and mechanism of injury, age, hand dominance, occupational status, and general health of the patient are important factors in the management plan. Assess the hand and the digits with regard to vascular status, degree of contamination, and severity of soft tissue loss. Systematic examination of musculotendinous and nerve function is often difficult in such injuries; however, the general posture of the hand can reveal much about the involved underlying structures. Conduct skeletal assessment with plain X-rays of the wrist and hand. The degree of comminution, bone loss, and intra-articular damage could significantly affect the plan of reconstruction and the functional outcome. Determine the patient’s immunization status, and administer appropriate prophylaxis. Give all such patients prophylactic antibiotics to cover both aerobic and anaerobic organisms, as a significant degree of contamination and devitalized tissue accompanies this type of injury.
Rigid fixation of the fractures of the hand and digits is important in the postoperative rehabilitation period. Plating and interfragmentary screws are preferred if there is no bone loss. A small dorsal incision is made if there is no contraindication; however, in extensive palmar mutilation, fractures are often widely exposed palmarly. As was mentioned, the plate or interosseous wires should be placed laterally, avoiding the flexor surface of the bones. If there is significant bone loss, the bone should be held out to length by K-wires or an external fixator. Perform primary bone grafting in a well-vascularized bed if there is minimal wound contamination (Figs. 5-2 and 5-3). Delayed bone grafting is preferred in cases of severe contamination of the wound. It is important in these cases that the bones are held out to length and that the external fixator does not interfere with postoperative rehabilitation. The metacarpophalangeal and interphalangeal joints are often destroyed in severe mutilating injuries of the palm. These can be treated by using K-wire fixation and the distraction method with early mobilization to remodel the articular surface. In some cases of
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primary arthroplasty in other fingers in the absence of severe wound contamination.
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SPECIFIC REPAIRS Flexor Tendon We prefer to repair the flexor tendons primarily in the acute setting, using direct repair with a four-strand core suture and epitendinous suture. We perform primary tendon grafting if the pulleys are well preserved and there is an optimal gliding bed. Palmaris longus or plantaris tendons, as well as tendons from unsalvageable digits, are sources of donor tendons. If the pulleys are completely destroyed, Hunter silicone rods are placed for second-stage tendon grafting. Attempt to reconstruct the A2 and A4 pulleys when possible (Figs. 5-4 and 5-5). FIGURE 5-2. X-ray reveals multiple metacarpal and phalangeal fractures sustained after a tire explosion injury to the hand.
FIGURE 5-4. Reconstruction of the A2 and A4 pulleys using the extensor retinaculum.
FIGURE 5-3. Repair of these fractures with combined open reduction and internal fixation with bone grafting using interosseous K-wires.
unsalvageable joints, you can perform primary arthroplasty using Swanson prostheses for the metacarpophalangeal joints. For the proximal interphalangeal joints, arthrodese the joint of the index finger, and perform
FIGURE 5-5. The reconstructed A2 and A4 pulleys, showing flexion.
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Occasionally, it is necessary to reconstruct the flexor retinaculum to maintain the carpal arch and prevent severe bowing of the flexor tendons.
ery in the following 3 to 6 months, then explore, resect the neuroma, and reconstruct with cable nerve grafts.
Blood Vessels Nerves The median and ulnar nerves are vulnerable to injury at the wrist level (Fig. 5-6). Nerve transections are repaired acutely under no tension. Perform primary grafting if there is a segmental defect (Fig. 5-7). It is very important to trim the nerve ends back to healthy-appearing fascicles. You can send the cut ends for frozen sections to determine adequate resection. Sural nerves may be harvested endoscopically via a small horizontal incision distally. Several cables are often used for the median and ulnar nerves. The assessment of injury to nerves in continuity is difficult because the degree of nerve injury cannot be accurately determined at the time of initial evaluation. Allow the nerve to recover. If there is no sign of recov-
FIGURE 5-6. Crush injury to the hand with laceration of the common digital nerve to the index and middle fingers.
FIGURE 5-7. Nerve graft from the common digital nerve to the proper digital nerve to the adjacent digit.
Devascularization of digits is often caused by extensive soft tissue damage in palmar mutilating injuries. The main priority in the acute management of these cases is to restore vascularity. Interpositional vein grafts are often required. It is important to obtain a good forward flow from the proximal source. An example of such a repair is illustrated in Figures 5-8 to 5-16. Severe punch press injury to the hand resulted in amputation to the thumb, index, and middle fingers and devascularization of the ring and small fingers. The patient required interpositional vein grafts from the arch to the common digital arteries to the index, middle, and ring fingers. Soft tissue coverage in this case was accomplished with a free lateral arm flap. The patient also had multiple
FIGURE 5-8. Palmar view of a punch press injury to the right hand.
FIGURE 5-9. Lateral view of the same hand.
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FIGURE 5-10. Mangled amputated thumb and index finger.
FIGURE 5-13. Secondary reconstruction with toe-to-thumb transfer.
FIGURE 5-11. A lateral arm free flap was immediately placed for soft tissue coverage after revascularization of the hand using interposition vein grafts from the arch to the common digital arteries to the middle and ring fingers.
FIGURE 5-14. Palmar view of toe-to-thumb transfer.
FIGURE 5-12. Six months after the operation.
FIGURE 5-15. Dorsal view of toe-to-thumb transfer.
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FIGURE 5-16. Secondary procedures included flexor tenolysis, median nerve grafting, and iliac bone graft.
secondary procedures: toe-to-thumb transfer, flexor tenolysis, nerve graft to median nerve, and iliac bone graft. Free tissue transfer has been used to provide flowthrough vascular conduits for simultaneous coverage and revascularization of the hand or digit. Brandt, Khouri, and Upton described the use of fillet flaps from the nonreplantable tissue or free temporoparietal fascia flaps as flow-through conduits to bridge the gaps instead of the interpositional vein grafts.3
FIGURE 5-17. Partial avulsion of the palm required debridement and primary closure.
SOFT TISSUE COVERAGE The goals of soft tissue coverage include appropriate matching of the lost tissue for sensory potential, skin color and type (glabrous), functional potential, and appropriate contour in the palm. Other considerations that influence the choice of reconstructive technique include limiting donor site morbidity, choosing the simplest method with the highest success rate, and choosing procedures that facilitate postoperative therapy. Skin grafts, either split- or full-thickness, may be the appropriate choice if skin loss has occurred while vascularized tissue is being preserved. Full-thickness grafts provide better protection, better color match, less recipient site contraction, and better potential for sensory innervation; however, the donor site is limited. The split-thickness skin graft can be harvested from the nonweight-bearing plantar aspect of the foot, which offers hairless and glabrous skin similar to that of the palm. Proper immobilization of the upper extremity is important to ensure graft take. Do not apply skin grafts over the flexor tendons, as the adhesions will interfere with gliding of the tendons. Figures 5-17 to 5-20 show a partial avulsion injury of the palm in which the flap was primarily sutured but subsequently necrosed. It required split-thickness skin grafting. Local, regional, or free tissue transfer is a better choice for coverage over areas of exposed tendons, especially when secondary reconstruction or tendon grafting is anticipated.
FIGURE 5-18. Primary closure of the palm avulsion.
FIGURE 5-19. Partial necrosis of the palmar flap required a split-thickness skin graft.
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FIGURE 5-20. Long-term result of split-thickness skin grafting to cover an area of partial necrosis.
FIGURE 5-21. Soft tissue defect in the right hand, with exposure of the flexor tendons, blood vessels, and nerves. A reverse radial forearm flap was raised.
Palmar mutilating injuries are usually associated with significant skin and soft tissue loss, thus leaving a poorly vascularized bed or exposing important structures. Tissue transfer that imports its own blood supply is required. The following sections discuss specific flaps and their uses.
reversed flap is provided by a crossover or bridging between the two venae comitantes. For this reason, it is important to include at least one or two superficial veins. The disadvantage of the reverse flap is venous congestion. The radial forearm flap is known for its donor site morbidity with a visible skin-grafted donor site and for poor graft take. However, in these mutilating injuries, the palmar arterial arches can be damaged by a severe palmar injury, which prohibits application of a distally based pedicled reversed radial forearm flap. The radial artery forearm flap has been used as a distally based fascial flap to cover the palmar defect. This flap is raised from proximal to distal and is based on six to ten perforators found at the distal portion of the forearm. Hence, it can be raised without sacrificing the radial artery.25 Weinzweig suggested that the skin
Local Random Flaps Local random flaps include Z-plasties, local transposition, and other types of rotation and advancement flaps from around the hand. These flaps take skin from the surrounding tissues and transpose it while maintaining a wide base to perfuse the flap on a subdermal plexus. The disadvantages of random flaps include limited flap availability and potential size, inability to fill defects, and additional damage to an already traumatized extremity.12
Axial-Pattern Flaps The axial-pattern flap includes a named vessel along its axis. It has a better blood supply than the random flap, allowing the flap to be larger, with a greater length-to-width ratio. It is often raised on a pedicle as an island flap. The radial forearm flap can be used for coverage of soft tissue defects of the hand and the forearm. Figures 5-21 and 5-22 show a reverse radial forearm flap being raised and set into position. The flap is based on the radial artery and its venae comitantes. Perform an Allen’s test before elevating the flap to assess the completeness of the palmar arch and adequacy of the ulnar artery blood flow to the hand. The venous outflow in a
FIGURE 5-22. A reverse radial forearm flap inset into position, with a split-thickness skin graft applied to the donor site.
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graft should be delayed a few days to ensure that venous congestion is not present in the flap. Secondary reconstructive procedures, however, are more difficult beneath fascia covered with skin graft than beneath a flap consisting of normal skin and subcutaneous tissue. Other disadvantages of fascial flaps are their thickness and limited size. Other island flaps have been described to provide soft tissue coverage to the palm. The reversed ulnar artery flap provides less hair-bearing skin. However, this flap has a number of distinct disadvantages that do not support the wide use of the flap compared to the radial artery flap. These disadvantages are the bulkiness of the tissue, the smaller available skin territory, and the sacrifice of the ulnar artery, which may lead to transient ischemia of the ulnar nerve with paresthesias in up to 30% of cases.7 The posterior interosseous arterial flap has been used to cover the defect over the hypothenar region.18 The flap is based on the posterior interosseous artery. The vascular supply of the flap is variable with small skin territory.1 Dissection of the flap is relatively difficult, with the pivot point 2 cm proximal to the radial styloid. It is not the flap of choice for a palmar defect.
radial collateral artery. The skin overlying the lateral arm varies in thickness. The distal skin overlying the lateral humeral epicondyle and elbow in most individuals is quite thin. This portion is applicable for palmar resurfacing. A flap up to 9 cm in width can be harvested and still allow primary closure of the donor site. The flap vessels course in the lateral intermuscular septum between the triceps muscle posteriorly and the brachialis muscle anteriorly. Branches to the skin perforate the intermuscular septum and follow either a direct course to the dermis or a course as fascial branches, which perfuse both the fascia and the overlying skin.9 The flap artery originates from the profunda artery and has an external diameter ranging from 0.77 mm to 1.5 mm. The upper portion of the flap is innervated by the antebrachial cutaneous nerve of the arm, while the antebrachial cutaneous branch of the forearm provides innervation more distally. These nerves can be coapted to a recipient nerve in the hand.14 Figures 5-23 to 5-27 illustrate the anatomy of the lateral arm flap.
Distant Flaps Distant pedicle flaps that can be used to cover hand defects include groin flaps, cross-arm flaps, chest flaps, and abdominal flaps. The groin flap is an axial pattern flap based on the superficial circumflex femoral artery and is most commonly used. A large amount of tissue can be elevated, lengthening the flap laterally past the anterior superior iliac spine as a nonaxial random extension. The flap can be thinned at its distal portion to improve the contour at the recipient site.6 Primary donor site closure is possible, creating a well-hidden donor site scar in the groin. The major disadvantages of this flap are its bulk, poor color match, dependent position, and prolonged immobilization after the surgery. This flap is a poor soft tissue substitute for palmar surface reconstruction.
FIGURE 5-23. Anatomy of the lateral arm flap.
Microvascular Free Tissue Transfers Various kinds of free tissue transfers have been described that allow the surgeon to tailor the transferred tissue to the need of the recipient site.19,23 The cutaneous flaps that are most frequently used include the lateral arm, scapular, parascapular,5 first webspace,17 and instep of the sole.21
Lateral Arm Flap The lateral arm flap is our preferred free flap for reconstruction of large defects. It is based on the posterior
FIGURE 5-24. Marking of the lateral arm flap.
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The advantages of this flap are the reliable and long pedicle, primary donor site closure, and possible innervation. Figures 5-28 to 5-30 show a grinder injury to the palm, requiring tendon grafts and soft tissue coverage
FIGURE 5-25. Anatomy of the lateral arm flap.
FIGURE 5-28. A grinder injury to the palm and left thumb.
FIGURE 5-26. Intraoperative view of a section of the lateral arm flap, with a recurrent artery that supplies the triceps tendon as well as the muscles. FIGURE 5-29. Marking of a lateral arm flap, 29 cm by 9 cm.
FIGURE 5-27. Drawing showing the lateral arm flap and fascial extension.
FIGURE 5-30. Postoperative photo showing complete coverage at 6 months after the lateral arm flap.
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using a lateral arm flap. An additional advantage of the lateral arm flap is that because of separate vascular leashes, its component parts can be separated and combined as necessary. Fascial flaps alone can be harvested; a sandwich flap can be made by separating fascia from skin; or a portion of the triceps tendon can be used.8 Disadvantages of the lateral arm flaps are the small diameter of the pedicle and the thickness of the flap in some patients.13
Medial Arm Flap A medial arm flap is another option with possible innervation.15 The skin on the medial aspect of the upper arm in most patients is thin and quite mobile and allows primary closure of 6- to 8-cm deficits. This area is relatively hairless in most people. The flap can be innervated by using the brachial cutaneous nerve, which runs in the subcutaneous tissue along the posterior margin of the flap. The blood supply of the flap comes from a combination of vessels along the course of the brachial artery. The superior ulnar collateral artery is the dominant flap vessel in 80% of patients. This vessel accompanies the ulnar nerve along its course. In the remaining 20%, either a direct cutaneous or musculocutaneous branch from the brachial artery assumes the dominant role. The major disadvantages of the medial arm flap are the anatomic variations and the small and short pedicles. It is recommended that the artery or vein be tagged prior to division, as one is easily mistaken for the other owing to the small diameter of the vessels.10,16 First Webspace Flap The first webspace flap is another reliable neurosensory flap that is very useful in resurfacing a small (3- to 6-cm) palmar deficit. The blood supply of the flap is the first dorsal metacarpal artery and the dorsalis pedis system. The branches of the deep peroneal nerve accompanying the first dorsal metacarpal artery provide sensation to the flap. The flap can be extended distally to include the hemipulp of the great toe or second toe, or both. This is ideal for resurfacing the pulp deficit of the thumb and the index finger.17 Figures 5-31 to 5-38 show a patient who sustained an avulsion injury to all fingers. He required groin and abdominal flaps for immediate soft tissue coverage and subsequently had a first webspace neurosensory free flap transfer. Medial Plantar Flap The medial plantar flap, or sole instep flap, is usually reserved for a slightly larger palmar defect. The plantar fasciocutaneous flap can be based on the medial or
FIGURE 5-31. Avulsion injury of the index, middle, ring, and little fingers after debridement.
lateral plantar artery or both. It is a true neurosensory flap supplied by branches of the medial and lateral plantar nerves. It provides an optimal cosmetic, functional, and anatomic replacement of the palm with acceptable donor site morbidity. The pedicle is 3 to 5 cm in length and 1 to 2 cm in diameter. The disadvantages of the flap are the bulk of the flap, difficulty in separating the cutaneous fascicles, and marginal hyperkeratosis at the donor site. Another limitation is the relatively small size, with maximum dimensions of 7 cm in length and 6 cm in width.20,21
FIGURE 5-32. Combined groin and abdominal flap for immediate soft tissue coverage.
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FIGURE 5-33. Photo of the patient 3 months later after detachment of the flap.
FIGURE 5-35. First webspace flap, with its nerves, arteries, and veins.
FIGURE 5-34. First webspace neurosensory flap for coverage of the index and middle fingers.
FIGURE 5-36. Diagram of the first webspace flap.
Other Flaps Large fasciocutaneous flaps such as scapular, parascapular, or groin flaps can be used for large defects. However, these flaps are bulky and insensate and therefore are not ideal for palmar reconstruction. Figures 5-39 to 5-42 show a hand that had been caught in a printing press. In this case, a parascapular flap was used to cover both the palm and the dorsal aspect of the fingers. The flap was then divided 2 weeks later to separate the fingers.
Free fascial flaps with skin graft have been used for palmar resurfacing. Potential donor sites include the temporoparietal fascia, lateral thigh, and posterior calf. These flaps provide a thin vascularized flap for skin grafts and a fascia layer that allows the tendons to glide. They are useful when secondary reconstruction is unlikely. As was mentioned, it is more difficult to perform extensive secondary procedures beneath fascial flaps covered with skin graft.20 Several fascial flaps have also been used, including the serratus fascia and temporoparietal fascia.24,26
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FIGURE 5-40. Debridement of a grossly contaminated wound.
FIGURE 5-37. Flap in the early postoperative period.
FIGURE 5-41. The same hand after repair of the flexor tendons and nerves.
FIGURE 5-38. Flap in position 6 months after the operation.
FIGURE 5-39. A printing press injury to the right hand with partial amputation of the tip of the index and middle fingers.
FIGURE 5-42. A parascapular flap used to cover the palmar and the dorsal aspects of the finger. The flap was divided 2 weeks later to separate the ring and little fingers.
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Muscle flaps are not applicable for palmar reconstruction owing to extensive fibrosis to underlying tissues. The fibrosis makes secondary procedures difficult.
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CONCLUSION The palmar mutilating injury is a complex problem because it involves significant damage to a combination of tissues. Reconstruction should aim to replace all the structural and functional components of the hand. Such injuries require radical debridement of devitalized tissue and immediate soft tissue coverage.8 Almost all of these patients require secondary procedures to obtain optimal function of the hand. Figures 5-43 to 5-49 show a patient who sustained a punch press injury with
FIGURE 5-45. The donor great toe.
FIGURE 5-43. A punch press injury to the left hand.
FIGURE 5-46. Fixation of the great toe and enlargement of the webspace.
FIGURE 5-44. Preoperative X-rays of a punch press injury.
FIGURE 5-47. An islanded scapular flap.
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References
FIGURE 5-48. The scapular flap inset into the palmar aspect of the hand.
amputation of the thumb, index, and middle fingers. The patient underwent secondary procedures (toe-to-thumb transfer with scapular flap to provide both palmar and dorsal coverage) and achieved a good functional result.
1. Angrigiana C, Grilli D, Dominikow D, et al: Posterior interosseous reverse forearm flap: Experience with 80 consecutive cases. Plast Reconstr Surg 92:285–293, 1993. 2. Backhouse KM: Innervation of the hand. Hand 7:107–114, 1975. 3. Brandt K, Khouri RK, Upton J: Free flaps as flow-through vascular conduits for simultaneous coverage and revascularization of the hand and digit. Plast Reconstr Surg 98:321–327, 1996. 4. Bray PW, Boyer MI, Bowen CVA: Complex injuries of the forearm. Hand Clin 13:263–278, 1997. 5. Burns JT, Schlafy B: Use of the parascapular flap in hand reconstruction. J Hand Surg 11A:872–875, 1986. 6. Chow JA, Bilos ZJ, Hui P, et al: The groin flap in reparative surgery of the hand. Plast Reconstr Surg 77:421–425, 1986. 7. Glasson DW, Lovie MJ: The ulnar island flap in hand and forearm reconstruction. Br J Plast Surg 41:349–353, 1988. 8. Godina M: Early surgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 78:285–292, 1986. 9. Gosain AK, Matloub HS, Yousif NJ, Sanger JR: The composite lateral arm free flap: Vascular relationship to triceps tendon and muscle. Ann Plast Surg 29:496–507, 1992.
A
C
FIGURE 5-49. Postoperative functional results. A, Grasping grip. B, Writing. C, Gripping tools. B
10. Kaplan EN, Pearl RM: An arterial medial arm flap: Vascular anatomy and clinical applications. Ann Plast Surg 4:201–215, 1980. 11. Landsmeer JMF: Atlas of Anatomy of the Hand. New York, Churchill Livingstone, 1976. 12. Lister GD: Emergency free flaps. In Green DP (ed): Operative Hand Surgery, 2nd ed, vol 2. New York, Churchill Livingstone, 1988, pp 1127–1149. 13. Matloub HS, et al: The lateral arm flap in upper extremity reconstruction: An analysis of eighty cases. Plastic Surgical Forum 10:184, 1987. 14. Matloub HS, Sanger JR, Godina M: The lateral arm neurosensory flap. In Williams HB (ed): Transactions of the VIII International Plastic and Reconstructive Surgery, 1983, p 125. 15. Matloub HS, Trevisani TT, Eder E, Godina M: The medial arm neurosensory free flap. Paper presented at the Annual Meeting of the American Society for Plastic and Reconstructive Surgery, New York, October 20, 1981. 16. Matloub HS, Ye Z, Yousif NJ, Sanger JR: The medial arm flap. Ann Plast Surg 29:517–522, 1992. 17. May JW, Chait LA, Cohen BE, O’Brien BMcM: Free neurovascular flap from the first web of the foot in the hand reconstruction. J Hand Surg 2:387, 1977. 18. Mih AD: Pedicle flaps for coverage of the wrist and hand. Hand Clin 13:217–229, 1997. 19. Ninkovic MM, Schwabegger AH, Wechselberger G, Anderl H: Reconstruction of large palmar defects of the
20.
21.
22. 23.
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26. 27.
28.
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hand using free flaps. J Hand Surg (Br), 22B(5):623–630, 1997. Ninkovic M, Wechselberger G, Schwabegger A, Anderl H: The instep free flap to resurface palmar defects of the hand. Plast Reconstr Surg 97:1489–1493, 1996. Shaw WW, Hidalgo DA: Anatomic basis of the plantar flap designs: Clinical applications. Plast Reconstr Surg 78: 637–651, 1986. Spinner M (ed): Kaplan’s Functional and Surgical Anatomy of the Hand, 3rd ed. Philadelphia, JB Lippincott, 1984. Upton J, Havlik RJ, Khouri RK: Refinements in hand coverage with microvascular free flaps. Clin Plast Surg 19:841–857, 1992. Upton J, Rogers C, Durham-Smith G, Swartz WM: Clinical applications of free temporoparietal flaps in hand reconstruction. J Hand Surg 11A:475–483, 1986. Weinzweig N, Chen L, Chen ZW: The distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery: An anatomical and clinical approach. Plast Reconstr Surg 94:675–684, 1994. Wintsch K, Helaly P: Free flap of gliding tissue. J Reconstr Microsurg 2:143–151, 1986. Yousif NJ, Warren R, Matloub, et al: The lateral arm fascial free flap: Its anatomy and use in reconstruction. Plast Reconstr Surg 86:1138–1145, 1990. Zancolli EA, Cozzi EP: Atlas of Surgical Anatomy of the Hand. New York, Churchill Livingstone, 1992.
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6 Management of the Ulnar Mutilating Injury Mark H. Gonzalez, MD, MEng Norman Weinzweig, MD, FACS Carl N. Graf, MD Bassem Elhassan, MD
BIOMECHANICS Prehensile grasp in the human hand occurs through a combination of extension, abduction, and pronation, allowing the thumb to oppose the ulnar column of the hand. The ulnar column provides breadth to the palm, which allows a platform for grip. The ulnar column is thus critical to the development of power grip. The breadth of the palm is important for stability of grip. In gripping an object such as a broom or a tennis racket, the thumb is relatively narrow, and a wide palm is necessary to avoid rotational instability. In full opposition, the thumb points toward the ulnar column just distal to the ring and little finger metacarpophalangeal (MCP) joints. The curvature of the carpometacarpal (CMC) cascade rotationally directs these fingers toward the thumb. Consider the index and little fingers and the thumb as three-point fixation for a cylinder in power grasp. Loss of the ring and little finger columns causes the three-point fixation to occur between the index and middle fingers and the thumb. Narrowing of the space between two of the points decreases stability of the cylinder. If the thumb continues to provide an ulnar-dorsal–based force, the cylinder can actually rotate out of the grip. The thumb must redirect its force toward the index and middle fingers, out of its normal plane of function, thus limiting the development of force during grip. The index and middle finger CMC joints are rigid joints permitting virtually no flexion. This is useful in their role in a pincer grasp. The ring and little finger CMC joints, however, flex during tight grasp, allowing up to 30⬚ of motion in the sagittal plane. This flexion permits a tight grip on the ulnar side of the hand. The hypothenar eminence and the ring and little fingers, along with the thumb and thenar eminence, form a broad ring that is crucial to power grasp (Fig. 6-1). 87
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the ulnar side of the little finger. The common digital nerve then divides into proper digital nerves to the ulnar aspect of the ring finger and to the radial aspect of the little finger. The dorsal branch of the ulnar nerve arises approximately 4 to 6 cm proximal to the distal wrist crease. It passes volar to the ulnar styloid and then runs dorsally to provide innervation to the dorsum of the hand overlying the metacarpals and proximal phalanges of the ring and little fingers.
Arterial System of the Ulnar Column
FIGURE 6-1. Flexion of the ring and little finger CMC joints permits a tight grip on the ulnar aspect of the hand with the hypothenar muscles, ring, and little fingers and the thumb and the thenar muscles forming a broad ring crucial to power grasp.
ANATOMY
The ulnar artery enters the wrist just radial to the ulnar nerve and deep and radial to the flexor carpi ulnaris tendon. As the artery exits Guyon’s canal at the level of the pisiform, it gives off a small, deep palmar branch, while the main branch continues as the superficial arch. The superficial palmar arch then communicates with a branch of the radial artery radially. The superficial arch continues distally and radially as it penetrates the fascia separating the hypothenar muscles from the central palmar compartment. The superficial palmar arch courses the palm at about the level of the distal palmar crease. The superficial palmar arch gives off branches to the ulnar side of the little finger and three common digital arteries to the index, middle, ring, and little fingers.
Compartments of the Ulnar Column Ulnar Nerve The ulnar nerve enters the wrist on its volar aspect. The ulnar nerve and artery descend in the lower part of the forearm, radial and dorsal to the flexor carpi ulnaris tendon, with the ulnar nerve lying ulnar to the ulnar artery. The nerve and artery pass radial to the pisiform bone. The nerve resides in Guyon’s canal, which is a tunnel between the volar carpal ligament and the transverse carpal ligament. The transverse carpal ligament is the roof of the carpal tunnel and the floor of Guyon’s canal. Passing distally, the nerve emerges from under the volar carpal ligament and passes into the palm deep to the palmaris brevis muscle. The nerve then divides into motor and sensory components at approximately the level of the pisiform bone. The motor branch passes between the flexor digiti minimi and the abductor digiti minimi and then pierces the opponens digiti minimi before curving toward the ulnar side of the hand and innervating the interossei, the lumbricals to the ring and little fingers, the adductor pollicis, and one head of the flexor pollicis. The sensory component passes beneath the palmar aponeurosis and superficial to the flexor tendons. The nerve then splits into a common and a proper digital nerve. The proper digital nerve passes to
The ulnar column consists of three compartments: the hypothenar compartment, the dorsal interossei, and the volar interossei. The hypothenar compartment contains the short muscles of the little finger, while the volar and dorsal interosseous compartments contain their respective muscles. A crush injury of the ulnar column can therefore elevate the pressure within these separate compartments, leading to a compartment syndrome. Each compartment must be decompressed individually to prevent muscle necrosis and ischemic contracture.
RECONSTRUCTION OF THE ULNAR COLUMN Operative Planning: Staging of Reconstruction Initial evaluation of an injury to the ulnar column must include assessment of viability of the tissue in terms of vascularity and degree of injury. Lack of sufficient arterial inflow and venous return must be recognized
early because a delay significantly diminishes the success of revascularization and replantation. Once it is determined that blood supply is adequate, the viability of the affected tissues themselves must be determined. Crushed, necrotic, and severely contaminated tissue must be debrided as well as dark, noncontracting muscle.15 Tissue of questionable viability may be retained; however, repeat debridement is necessary in 24 to 48 hours. Once viability of the soft tissue envelope has been established, the surgeon can proceed with reconstruction of bone, nerve, and tendon. In cases in which the soft tissue envelope is inadequate, a local, regional, distant, or free flap might be required to reconstitute the soft tissue envelope. In situations such as this, reconstruction of bone, nerve, and tendon might have to be delayed.
Soft Tissue Reconstruction Soft tissue reconstruction must provide durable coverage to allow grip on the ulnar side of the hand and a cushion for resting the ulnar side of the hand on a surface. Adherent unyielding skin on the ulnar side of the hand can cause pain and breakdown and can limit hand function. Degloving of the skin with maintenance of sufficient underlying soft tissue can be treated with a full-thickness or partial-thickness skin graft. However, exposed bone will require flap coverage. A radial or ulnar forearm flap provides ideal coverage for the ulnar aspect of the hand.2,18,23,32 Both flaps are based on an arterial pedicle and require an intact palmar arch for retrograde flow. The flaps may be harvested as a fasciocutaneous flap or a fascial flap. The fasciocutaneous flap is cosmetically appealing but leaves a significant defect in the forearm that often has to be skin grafted. The fascial flap has to be skin grafted; however, there is a more aesthetic donor forearm. In mutilating injuries of the hand in which the palmar arch is incompetent, interrupting the ulnar or radial artery can place the vascularity of the hand at risk. Furthermore, retrograde flow to the flap may be diminished or nonexistent. Before contemplating either flap, perform an Allen’s test. If the test is equivocal, obtain an angiogram of the hand. Although the radial or ulnar artery theoretically can be reconstructed after division using a vein graft, if there is any question of adequate flow, we defer to a free flap. Various free flaps can be employed for the ulnar column. For the dorsal aspect of the hand, a free temporalis fascial,16 dorsalis pedis,19,22,34 or serratus anterior flap provides excellent coverage.1,14,28 The free temporalis fascial flap is very thin and requires a skin graft. The dorsalis pedis flap provides excellent coverage, and the skin quality is identical to that of the dorsal skin. The
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disadvantage of this flap is the donor site. A skin graft on the dorsum of the foot can break down with shoe wear or hypertrophy. The serratus anterior flap is a small muscle flap consisting of the superior three slips of the muscle. The lower slips should be preserved to prevent scapular winging. The advantage of the serratus is that it is a thin muscle that contours nicely and will not be too bulky on the dorsum of the hand. This flap also requires skin graft coverage. For defects of the volar surface of the ulnar column, we prefer a pedicled forearm flap or, if blood supply is questionable, a free flap. Free flaps may be lateral arm,10,20,30 scapular, or parascapular flaps.13,27,29 Good results have been obtained with the lateral arm flap (Fig. 6-2). The lateral arm free flap can be taken from the ipsilateral or contralateral arm. The donor site can be closed primarily if the flap is less than 6 cm wide. If a wider flap is necessary, it can be harvested but requires primary grafting. The flap can be taken from the deltoid insertion and can extend 1 to 2 cm distal to the elbow. The disadvantage of the lateral arm flap (and scapular/parascapular flaps) is that they are relatively thick and contain significant subcutaneous adipofascial tissue. Should a patient gain weight, the flap can actually enlarge. In this situation, liposuction of the flap can be performed (Fig. 6-2C–E), but the surgeon who performed the flap procedure should be present, if possible, or the operative report should be reviewed, to ensure that the vascular pedicle is adequately protected. Delay liposuction until 6 to 12 months after the flap is inset. Larger defects of the ulnar column (dorsal and volar) can be resurfaced with a gracilis,6,17 rectus abdominis,24,26 or latissimus dorsi4,21,31 free muscle flap. The gracilis muscle is approximately 6 cm wide. It is a relatively thin muscle that will conform to the ulnar side of the hand. The muscle can be spread slightly and oriented obliquely to cover volar dorsal defects. The rectus abdominis muscle is a flat, broad muscle that contours nicely. The muscle is thick and often, but not always, atrophies secondary to denervation. The latissimus dorsi muscle is a very large muscle. The flap can be tailored to fit smaller defects, but the muscle is quite thick, especially at its origin. Reserve the use of this flap for large combined palmar and dorsal defects. The arterial anastomosis for a free flap to the ulnar column of the hand can be performed to the ulnar artery end-to-end only if the ulnar artery has been previously divided and at the time of the original trauma. Care must be taken to perform the anastomosis outside the zone of injury, and a vein graft should be performed if necessary. If the ulnar artery is intact with normal flow to the hand, then the anastomosis should be performed in an end-to-side fashion. Again, it is advisable to do the anastomosis outside the zone of injury. The venous
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THE MUTILATED HAND
A
B
C
D
FIGURE 6-2. A, B, This patient presented with an avulsion injury involving the ulnar aspect of the hand. C, A lateral arm free flap provided coverage of the soft tissue defect. Liposuction was performed at a later date to debulk the flap and improve contour. D, E, The patient had a cosmetically and functionally good result. E
anastomosis can be performed to the venae comitantes to the ulnar artery or to another local vein. The available local veins are present both on the dorsum of the hand and on the volar and dorsal aspects of the wrist. The hypothenar muscles can be transposed for coverage of the ulnar nerve, artery, or tendon. This flap is also useful after repair or graft reconstruction of the
ulnar artery when there is a possibility of scarring about the ulnar nerve. Avoid the use of abdominal or groin flaps to the hand, if possible, because the period of immobilization can lead to stiffness of the hand. In some instances, the vascularity to the hand is tenuous. When there is risk of compromising vascularity to the hand by performing an end-to-side anastomosis
to an intact vessel or if the patient is too sick to undergo a prolonged microsurgical procedure, a groin or abdominal flap is indicated. The hand and fingers can be covered with the flap, separation of the flap and digits being delayed.
Bone Reconstruction Loss of height of the ring and little finger metacarpals decreases the power of flexion of these fingers. Shortening of the metacarpals more than 5 mm should therefore be avoided.9 Angulation of the ring and little finger metacarpals, however, is better tolerated than is angulation of the index and middle finger metacarpals because of the greater amount of compensatory flexion at the ring and little finger CMC joints. Dislocation or fracture-dislocation of the CMC joints should be treated with closed reduction and percutaneous pinning or, if necessary, open reduction and percutaneous pinning. If a near-anatomic reduction of the fracturedislocation cannot be achieved, then the open procedure should be performed. Chronic dislocation of the CMC joints can be treated with open reduction and fusion. Fractures of the metacarpals can be treated with closed reduction and percutaneous pinning. A disadvantage of percutaneous pinning is tethering of the soft tissues. Open or closed reduction and intramedullary rodding of the metacarpal has been described (Fig. 6-3).7,8 As an alternative, open reduction can also be performed with percutaneous pinning or plating of the fracture using 1.5- and 2.0-mm screws and plates. Open fractures are associated with a variable degree of soft tissue injury. Open fractures of the hand can be classified according to the nature of the soft tissue injury.9 The classification is modified from Gustilo:11,12 Grade 1—tidy wound less than 1 cm in length; Grade 2—tidy wound greater than 1 cm and no periosteal stripping (e.g., low-velocity gunshot wound); Grade 3— contaminated wound, fracture with significant comminution, and periosteal stripping (e.g., high-velocity gunshot wounds, farm injuries, blast injuries). Grade 1 injuries have a very low infection rate, comparable to that of closed fractures. These fractures can be treated with fixation as mandated by the fracture pattern. Grade 2 injuries have a higher rate of infection and are frequently associated with an increased degree of bony comminution. Immediate lavage and debridement are performed. The wounds are serially examined, and if they are infection free within 7 to 10 days of injury, bony reconstruction and wound closure are performed. Bone grafting, both cancellous and corticocancellous en bloc, can also be applied at this time. Intramedullary rods with plates or K-wires to control rotation or locked intramedullary rods are used to secure the bone ends and maintain length while the graft incor-
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porates. This strategy has proven to be effective in low-velocity gunshot wounds of the metacarpal and in similar fractures of varied mechanisms. Grade 3 injuries present a more difficult problem. Owing to the increased risk of infection, several authors recommend fixation with an external fixator or K-wires until the soft tissue is stabilized and proven free of infection. A wire spacer can be placed between bone ends to maintain length while the soft tissue heals adequately. In some cases, the initial fixation is adequate to effect bony union. Addition of an antibiotic bead pouch can be done after initial debridement to decrease the bacterial flora and increase the chance of future flap survival. Frequently, secondary procedures such as bone grafting and internal fixation are necessary and are performed after the soft tissue envelope is stable and infection free.5 Length of treatment is prolonged for open fractures. In the series of Peimer,25 the average treatment course lasted just under 2 years. Duncan and colleagues,3 in a study of recovery of motion after open fracture, showed that return of function correlates with the degree of initial soft tissue injury. This study also found that fractures of the metacarpal had better return of function than did fractures of the proximal phalanx. Fractures requiring wound extension by incision for reduction of the fracture showed a poorer return of function than those that did not. A patient who has undergone an amputation of the ulnar column will complain of weak grip as a result of a narrow palm and scarring. In this situation, an iliac crest bone graft ulnar to the middle finger will widen the palm, and the area can be resurfaced with a lateral arm flap. This will help to provide breadth and restore a stronger grip.
Nerve Reconstruction Evaluation of ulnar nerve injuries begins with a complete physical examination to quantify residual function, if any. Sensation to the ring and little fingers and to the volar and dorsal aspects of the hand must be evaluated. Motor function of the interossei and adductor pollicis must be checked. The presence of clawing and Wartenberg’s sign implies denervation as a result of an ulnar nerve injury. Gunshot wounds or crush injuries to the ulnar nerve often cause neuropraxia. In the case of a crush or gunshot wound with ulnar nerve dysfunction, an electromyogram and nerve conduction velocity is performed 2 to 3 weeks after injury. The failure of return of nerve function in 3 to 6 months, documented by clinical examination and electromyogram and nerve conduction velocity, mandates operative exploration. The nerve is examined, and intraoperative conduction velocities are performed. Intact fascicular groups are preserved, and
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A
THE MUTILATED HAND
B
C
FIGURE 6-3. A, B, This patient suffered a gunshot wound to the hand, with severe comminution of the ring finger metacarpal. C, D, A locked intramedullary rod with tricortical iliac crest bone grafting was performed. E, The functional outcome was excellent. D
E
a neurolysis is then performed. Nerve grafting is done to reconstruct divided fascicular groups. In the acute setting, sharp lacerations to the ulnar nerve or digital nerves should be repaired primarily. If the wound is badly contaminated, or in cases of questionable viability, definitive repair can be delayed several days. A severe ulnar nerve injury involving nerve division with significant antegrade or retrograde nerve damage presents several difficulties for the surgeon. Injuries of this
nature are usually associated with high-velocity gunshot wounds and crush injuries. Nerve grafting will be required, but delayed reconstruction is prudent for several reasons. First, the degree of nerve damage in both the proximal and distal ends of the nerve cannot be determined in the acute setting. Second, the viability of the wound and the possibility of infection make the placement of a nerve graft risky. In this situation, the nerve ends are tagged, and the nerve is reexplored in 4 to 6
6
Clawing Clawing is typically associated with an ulnar nerve injury. The mechanism is secondary to paralysis of the ulnar intrinsic and lumbrical muscles of the ring and little fingers, permitting the unopposed extensors to hyperextend the MCP joints. The excursion of the extensors is expanded at the MCP joints, and the proximal interphalangeal (PIP) joints, therefore, fall into flexion. Hyperextension at the MCP joints also places the flexor tendons under tension, exacerbating the flexed posture of the PIP joints. Surgical correction of clawing must address the hyperextension deformity of the MCP joint as well as the flexion deformity of the PIP joint. For tendon transfers to be performed, the joints must be completely supple, with a full or nearly full range of motion. Zancolli’s lasso procedure33 detaches the distal insertion of the flexor digitorum sublimus tendon and reattaches it to the A-2 pulley, creating flexion at the MCP joint. This procedure does not address the flexion deformity at the PIP joint, however. There are a number of tendon transfers that are appropriate for the treatment of clawing. The brachioradialis or wrist extensors with a tendon graft (palmaris longus or plantaris) can be used to power MCP flexion. One can decide on the insertion of the graft based on the preoperative examination. The examiner holds the MCP joints flexed and asks the patient to extend the PIP joints. If the patient has complete PIP extension, then the tendon transfer can be placed into the radial aspect of the proximal phalanx. If the patient lacks complete PIP extension, then the tendon transfer can be inserted into the radial aspect of the extensor hood so that the transfer will augment both MCP flexion and PIP extension. The tendon graft is performed by using a dorsal approach. The four-tailed graft is placed through the lumbrical canal passing deep to the intermetacarpal ligament. The insertion is then placed as described above, with the tension adjusted so that the MCP joints can reach within 5⬚ of full extension with the wrist in 60⬚ to 70⬚ of the extension. Wartenberg’s sign is ulnar deviation of the little finger with extension. This sign is associated with an ulnar nerve lesion. In approximately 44% of people, the extensor has an attachment to the adductor tubercle, or the center axis of the extensor tendons passes ulnar to the center of the little finger MCP joint. In these individuals, the unopposed action of the extensor tendon in the absence of a functioning interosseous muscle causes ulnar deviation with MCP extension.
93
Lister recommends transfer of the ulnar portion of the extensor digiti minimi (EDM) to the radial side of the proximal phalanx. If the joint hyperextends, it is advisable to attach the EDM to the volar plate. If there is no hyperextension, the EDM can be attached to the radial collateral attachment on the proximal phalanx.
Neuromas of the Ulnar Column Painful neuromas of the ulnar nerve or its branches can occur after laceration, amputation, or crush injury. Neuromas of a digital nerve after amputation can produce a tender stump and will require desensitization. Continued pain might require exploration of the stump and transposition of the neuroma to a nonscarred area proximal to the amputation site. A neuroma of the sensory branch of the ulnar nerve can create pain on the ulnar dorsal aspect of the hand. Failure of desensitization and medical therapy might mandate transposition of the neuroma. The nerve can be dissected back, and its fascicles can be separated from the ulnar nerve, allowing it to be transposed proximal to the wrist between the flexor digitorum sublimis (FDS) and flexor digitorum profundus muscles.
Reconstruction of Tendon Injuries Lacerations of the flexor tendons of the ulnar column are repaired primarily if the wound conditions permit. Wound viability or contamination might preclude this, making a delayed repair necessary. Prolonged delay or tendon loss might require a tendon graft or staged (Hunter) tendon reconstruction. Lacerations of the extensor digitorum communis (EDC) or extensor digiti minimi (EDM) should be repaired primarily. Delayed injuries or injuries with substance loss that are isolated to both the ring and little fingers are reconstructed with a tendon transfer from the radial side of the hand. The extensor indicis proprius tendon can be transferred to the little finger EDC tendon, and the ring finger EDC tendon can be sutured to the middle finger EDC tendon. A single laceration with substance loss of the ring or little finger EDC can be treated by suturing the distal tendon stump to the tendon of the adjacent digit. When all extensor tendons are lost, grafting of the tendons with intercalated grafts can be performed. With an avulsion injury to the dorsum of the hand and concomitant loss of the extensor tendons, a silastic implant (Hunter) is placed beneath a flap, and tendon grafting is performed at a later date. Options for reconstruction include free grafts with the native EDC, flexor carpi radialis, or FDS as a motor.
6
weeks. The nerve ends are resected back to normalappearing fascicles, and then the nerve gap is grafted.
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THE MUTILATED HAND
AMPUTATION OF THE ULNAR COLUMN Amputation of a stiff or painful digit can actually improve function of the hand. Isolated amputation of the little finger with preservation of the metacarpal will preserve the width of the palm. Isolated amputation of the ring finger will create a space between the ring and little fingers, which can be disabling for a patient who is attempting to pick up small objects, such as change. In this scenario, the patient should be offered a ray amputation of the ring finger. The entire ring finger metacarpal can be excised, and the gap between the middle and little finger metacarpals can be narrowed by suturing the deep intermetacarpal (volar) ligaments. Take care to reconstruct the intermetacarpal ligament to avoid radial migration of the little finger metacarpal. A second option is to transpose the little finger metacarpal. The base of the ring finger metacarpal is preserved, and the little finger metacarpal is transposed to it. The metacarpal is then fixed with crossed K-wires. Likewise, it is important to repair the intermetacarpal ligament. Amputation of the little finger metacarpal requires preservation of the metacarpal base where the flexor and extensor carpi ulnaris insert. Amputation of the ring or little finger at the level of the PIP joint leaves a proximal phalanx under control of the intrinsic musculature. The phalanx can be useful as long as there is an attachment of the EDC on the phalanx to permit extension. A proximal phalanx can enhance grip. A very short proximal phalanx has little function, and the space created between fingers in the case of a ring finger amputation can be disabling, mandating a ray resection and closure of the space.
References 1. Brody GA, Buncke H, Alpert BS, Hing DN: Serratus anterior muscle transplantation for treatment of soft tissue defects in the hand. J Hand Surg 15:322–327, 1990. 2. Christie DRH, Dunkin GM, Glasson DW: The ulnar artery free flap: The first 7 years. Plast Reconst Surg 93:547–551, 1994. 3. Duncan RW, Freeland AE, Jabley ME, Meydrech EF: Open hand fractures an analysis of the recovery of active motion and of complications. J Hand Surg 18A:387–394, 1993. 4. Elliott LF, Raffel B, Wade J: Segmental latissimus dorsi free flap: Clinical applications. Ann Plast Surg 23:231–238, 1989. 5. Freeland AE, Jabaley ME, Burkhalter WE, et al: Delayed primary bone grafting in the hand and wrist after traumatic bone loss. J Hand Surg 9A:22–28, 1987. 6. Giordano PA, Abbes M, Pequignot JP: Gracilis blood supply: Anatomical and clinical re-evaluation. Br J Plast Surg 43:266–272, 1990. 7. Gonzalez MH, Igram CM, Hall Jr RF: Flexible intramedullary nailing for metacarpal fractures. J Hand Surg 20A:382–387, 1995.
8. Gonzalez MH, Igram CM, Hall Jr RF: Intramedullary nailing of proximal phalangeal fractures. J Hand Surg 20A:808–812, 1995. 9. Gonzalez MH, Jablon M, Weinzweig N: Open fractures of the hand. J South Orthop Assoc 1999; 8:193–202, 1999. 10. Gosain AK, Matloub H, Yousif NJ, Sanger JR: The composite latereral arm free flap: Vascular relationship to triceps tendon and muscle. Ann Plast Surg 29:496–507, 1992. 11. Gustilo RB, Anderson JT: Prevention of infection in the treatment of 1025 open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg 58:453–458, 1976. 12. Gustilo RB, Anderson JT, Williams DN: Problems in management of type III (severe) open fractures: A new classification of type III fractures. J Trauma 24:742–746, 1984. 13. Hamilton SGL, Morrison W: The scapular free flap. Br J Plast Surg 35:2–7, 1982. 14. Harii K, Yamanda A, Ishihara K, et al: A free transfer of both latissimus dorsi and serratus anterior flaps with thoracodorsal vessel anastomoses. Plast Reconstr Surg 70:620–629, 1982. 15. Haury B, Vensko J, et al: Debridement: An essential component of traumatic wound care. Am J Surg 135:238–242, 1928. 16. Hirase Y, Kojima T: Use of the doubled-layered free temporal fascia flap for upper extremity coverage. J Hand Surg 19A:864–870, 1994. 17. Jones JW, Thorvaldsson S: Simplified gracilis harvesting. Plast Reconstr Surg 85:829–830, 1990. 18. Lovie MJ, Dunkin G, Glasson DW: The ulnar artery forearm free flap. Br J Plast Surg 37:486–492, 1984. 19. Man D, Acland R: The microarterial anatomy of the dorsalis pedis flap and its clinical applications. Plast Reconstr Surg 65:419–423, 1980. 20. Matloub HS, et al: The lateral arm flap: A neurosensory free flap. Transactions of the VIII International Congress of Plastic Surgery, Montreal, Canada, 1983. 21. May JW, Lukash FN, Gallico III GG: Latissimus dorsi free muscle flap in lower extremity reconstruction. Plast Reconstr Surg 68:603–607, 1981. 22. McCraw JB, Furlow LT: The dorsalis pedis arterialized flap. Plast Reconstr Surg 55:177–185, 1975. 23. Muhlbauer W, Stock W: The forearm flap. Plast Reconstr Surg 70:336–342, 1982. 24. Pennington DG, Lai MF, Pelly AD: The rectus abdominis myocutaneous free flap. Br J Plast Surg 33:277–282, 1980. 25. Peimer CA, Smith RJ, Leffert RD: Distraction fixation in the primary treatment of metacarpal bone loss. J Hand Surg 6:111–124, 1981. 26. Rao VK, Baertsch A: Microvascular reconstruction of the upper extremity with the rectus abdominis muscle. Microsurgery 15:746–750, 1994. 27. Santos LF: The scapular flap: A new microsurgical free flap. Rev Bras Cir 70:133–141, 1980. 28. Takayanagi S, Tsukie T: Free serratus anterior muscle and myocutaneous flaps. Ann Plast Surg 8:277–283, 1982. 29. Thoma A, Heddle S: The extended free scapular flap. Br J Plast Surg 43:709–712, 1990. 30. Waterhouse N, Healy C: The versatility of the lateral arm flap. Br J Plast Surg 43:398–402, 1990.
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33. Zancolli EA: Structural and Dynamic Bases of Hand Surgery. Philadelphia, Lippincott, 1979, pp 229–262. 34. Zuker RM, Manktelow RT: The dorsalis pedis free flap: Technique of elevation foot closure and flap application. Plast Reconstr Surg 77:93–104, 1986.
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31. Watson JS, Craig RDP, Orton CI: The free latissimus dorsi myocutaneous flap. Plast Reconstr Surg 64:299–305, 1979. 32. Yang G, Gao Y, Jiang S, He S: The forearm free skin flap transplantation. Natl Med J Chin 61:139, 1981.
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On Making a Thumb: A Century of Surgical Effort J. William Littler, MD James W. Strickland, MD*
Restoration of a functional thumb following agenesis or acquired loss has long challenged the hand surgeon’s ingenuity, creativity, and technical skills. Numerous procedures drawing from orthopedic, plastic, vascular, and neurosurgery techniques have been designed and implemented to restore thumb function. In his classic treatise “On Making a Thumb: One Hundred Years of Surgical Effort,”50 J. William Littler (Fig. 7-1) provides a lucid history of the methods of thumb reconstruction from 1874 to 1976 with particular attention given to several procedures and to the surgeons who originated and developed them (Fig. 7-2). Peacock,80 Matev58, and Foucher and colleagues22 have provided excellent historical reviews of thumb reconstruction. Significant developments in the techniques of thumb reconstruction will be described in chronological order in this chapter, and important new techniques, most of which utilize microvascular methods, will also be presented. The development of surgical techniques to provide or restore thumb function resulting from congenital absence or traumatic loss can be divided into three time periods. From 1874 until 1948, reasonably crude methods were employed that often failed to provide adequate sensibility, mobility, stability or length. From 1949 until 1968, the development of techniques for the transfer of local hand tissues sustained by their neurovascular pedicles greatly enhanced the ability to restore thumb function. The final period in the chronology of thumb reconstruction began in 1968 with the successful replantation of a severed thumb40 and the first free transfer of a toe to the hand to provide thumb function.16 These works represented the clinical application of an enormous amount of laboratory experimentation and were followed by a barrage of imaginative methods utilizing free microvascular tissue transfer for thumb reconstruction. The three time periods of thumb reconstruction will be considered separately in this chapter, although there has obviously been considerable refinement and modification of techniques originating within each of these periods. Many of the methods discussed here continue to be clinically useful.
*Dr. Littler kindly gave me permission to revise and update his original article. I have, with his advice and editorial assistance, rearranged the material in chronological order and added some of the more important recent contributions to this fascinating subject.
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1874 TO 1948
FIGURE 7-1. J. William Littler, M.D., shown illustrating the reconstruction of the basal ligament of the thumb in 1968.
Deepening of the first webspace to relatively increase the length of a partially amputated thumb was first described by Hugier in France in 1874.30 Although there have been a number of minor modifications of the method for producing a deepened first interosseous cleft, named phalangization by Klapp in 1912,37 the basic procedure was established by Hugier as a satisfactory technique for restoring thumb function. In 1887, Guermonprez, also a French surgeon, first suggested transferring an index or other finger of the same hand into the thumb position following traumatic loss.27 In 1897, the imaginative Carl Nicoladoni of Austria (Fig. 7-3) treated a patient who had an avulsion of the soft tissues of his thumb with a rolled pedicle skin graft from the left anterior pectoral region to resurface a totally divested but intact metacarpophalangeal unit.68 This procedure had apparently been carried out 6 years previously on a young factory worker, providing him with a rather bulbous and redundant thumb that
FIGURE 7-2. Chronology of thumb reconstruction from 1874 to 1976. (From Littler JW: On making a thumb: one hundred years of surgical effort. J Hand Surg 1:35, 1976, with permission.)
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FIGURE 7-3. Carl Nicoladoni.
contained a nipple (Fig. 7-4). In his paper, Nicoladoni also introduced the osteoplastic method for thumb reconstruction and recommended that a toe or finger from the opposite hand might be substituted for thumb loss. In 1900, he first reported three successful transfers of a toe to the thumb position (Fig. 7-5).69 His first toeto-thumb transfer was apparently carried out in 1898 and involved the movement of a second toe to the hand of a 5-year-old boy who had suffered traumatic thumb loss. The case was complicated by necrosis, but the result was satisfactory because of the retention of good basilar thumb joint motion. Nicoladoni’s second patient developed subluxation of the transferred toe and an interphalangeal joint contracture but is said to have done well. In 1903, Nicoladoni analyzed the results of his toe-to-thumb transfers and considered them to be satisfactory;70 however, there was apparently very little enthusiasm for the procedure among other surgeons of the time. Although his methods were somewhat crude by today’s standards, Nicoladoni was the first to envision and carry out osteoplastic reconstruction of the thumb and toe-to-hand transfer to restore thumb function.3 In 1903, Luksch, who was Nicoladoni’s assistant, described pollicization of the index and other damaged fingers,52 and a successful hallux-to-thumb transfer was reported by Crouse in 1906.17 In 1909, Noesske of Germany reported on thumb reconstruction using a tubed pedicle skin flap and bone graft requiring separate operations.71 He used tibial bone and, later, toe
FIGURE 7-4. Nicoladoni’s first case of thumb soft tissue avulsion (1897). The drawings are those of J. William Littler50 and depict an intact metacarpophalangeal unit that was resurfaced with a rolled pedicle skin flap from the left anterior pectoral region. The lower right sketch is from Nicoladoni68 showing the result with a retained nipple.
FIGURE 7-5. Second toe-to-hand transfer for traumatic thumb loss in a 5-year-old boy (1898). Terminal necrosis complicated this case; the result was good because the basal metacarpophalangeal unit was intact. A second patient (a 25-year-old man) did well despite subluxation of the toe and interphalangeal joint contracture.
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phalanges for osteoplastic reconstruction, apparently feeling that the phalanges did not undergo as much bone resorption. George H. Monks of Boston first shifted a vascularized skin island from the forehead to the lower eyelid in 1898,51 and in 1917, Esser expanded on the vascular island pedicle technique,20 which was to provide an important basis for later improvements in thumb restoration. World War I provided tremendous opportunities to develop new techniques of thumb reconstruction. Between 1918 and 1930, there was a concentrated endeavor to perfect pollicization of a finger, although some surgeons persisted with efforts to create thumbs from local or remote tissues in an attempt to overcome the unsatisfactory results of multistage procedures. In 1918, Joyce in England utilized a contralateral ring finger for thumb reconstruction in three cases.34 Additional contributions to early thumb reconstruction were also made by Albee in the United States in 1919; he implanted a bone graft subcutaneously and awaited its vascularization before transfer with skin investment to the thumb amputation stump.1 Verrall reported on three cases of thumb reconstruction by phalangization in 1919,87 and in 1920, Lambert described good results from toe transfer (Fig. 7-6).41 Noesske, also in 1920, attempted to transpose an index finger into thumb position utilizing two stages.72 The first consisted of mobilization of the
FIGURE 7-6. Restoration of the thumb by grafting the great toe. A plaster dressing maintains the left hand attached to the right foot. (Drawing by Littler from Lambert after Nicoladoni.50 Published with permission.)
radialmost finger and resulted in a cleft that was covered with a pedicle skin flap. The second stage was the fixation of the finger in the thumb position. A similar procedure was later refined by Tanzer and Littler in the United States in 1948 (Fig. 7-7).85 Perthes successfully demonstrated the transfer of an adjacent finger with intact sensation but without tendon repair in 1921.81 In 1922, Oudard described one case of finger transposition from the opposite hand,79 and Dunlop reported in 1923 on the use of the index finger for thumb restoration with the concomitant use of an abdominal pedicle flap.19 In 1925, Jepson successfully transferred a middle finger into thumb position.33 Pierce described a skin tube and bone graft reconstruction carried out as separate operations in 1927,82 and in 1929, Joyce reported on the transfer of a finger from the opposite hand in two cases with excellent results.35 In 1930, Gueullette of France compiled the reports of various thumb mutilations and reported the difficulties encountered in their treatment.28 He summarized all previously published papers and classified different techniques in an effort to determine the results that had been achieved and the value of each. He felt that phalangization contributed to prehension, particularly in the burned hand in which phalanges have been lost.
FIGURE 7-7. The procedure described by Noesske was used in the American hand centers. Two major stages were considered necessary: (1) mobilization of the radialmost finger, with the resulting cleft covered with a pedicle skin flap, and (2) fixation of the finger in the thumb position.
Although a simple operation, it was invaluable when sensation had been preserved on the adjacent borders of the newly established cleft. Gueullette determined that the early experience of staged autogenous greattoe-to-thumb transfers were disappointing, only five cases exhibiting active motion. The presence of occlusive annular scar and the lack of attention to accurate nerve and tendon suture technique resulted in poor nutrition. Gueullette reported poor function in nine pollicization operations, resulting in a finger roughly in the thumb position but too long and narrow for power and of an unacceptable appearance. He concluded that simple first interosseous cleft deepening and osteoplastic elongation were the best types of thumb restoration despite poor sensibility, problems of atrophy, limited power and movement, and the lack of skin fixation.28 In 1931, Sterling Bunnell of the United States (Fig. 7-8) published his important article, “Physiological Reconstruction of a Thumb After Total Loss,”10 in which he described a transfer of the index metacarpophalangeal remnant to the trapezium with concomitant basilar joint reconstruction and restoration of thumb motor systems utilizing those from the index finger. This effort at pollicization utilized a small skin bridge but preserved sensibility. The resulting thumb ray therefore had both independence and power. In 1937, Iselin of France published his opinions on reconstruction of the
FIGURE 7-8. Sterling Bunnell (1882–1967).
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thumb devoting special attention to the problem of traumatic thumb loss and the most desirable features of reconstruction.31 At that time, he favored the transfer of an independent index finger. He believed that toe-tohand transfer was undesirable because of the obligatory 3- to 6-week period of uncomfortable immobilization required by the attachment of the hand to the foot. In 1938, Zsulyevich achieved a very satisfactory thumb restoration by uniting the proximal phalanx of the transposed index finger to the thumb metacarpal remnant utilizing an intramedullary bone peg.89 During the early years of World War II, most thumb reconstructions were performed by osteoplastic techniques in military hospitals. Sterling Bunnell was appointed as the civilian surgical consultant to the Secretary of War, and his charge was to develop the specialty of hand surgery by integrating and coordinating the management of complex injuries of the upper extremity received in combat. Patients who sustained severe hand injuries were referred to nine centers for hand surgery, as designated by the Surgeon General. As a result of this concentration of the treatment of hand injuries, the years 1944 to 1947 have been considered by many to herald the Renaissance of hand surgery. During this short period, over 20,000 injured hands were reconstructed, providing military surgeons with an unprecedented opportunity to apply the elements of plastic, neurologic, and orthopedic surgery to mutilating injuries of the hand. It was during this period that techniques were developed for preserving and restoring sensation, intrinsic function, and tendon dynamics in thumb reconstruction. Dr. Bunnell’s first consulting visit was to the Cushing General Hospital, where Dr. Littler had also been assigned. Dr. Bunnell’s tireless devotion to hand surgery encouraged a cadre of younger and increasingly capable hand surgeons to develop skills in the management of many difficult problems, among them the surgical restoration of the amputated thumb. Two skillful surgeons at the Cushing General Hospital, Colonel Radford Tanzer and Major Michael Lewin,46 became especially interested in thumb reconstruction for the war injured. Colonel Walter C. Graham and Colonel Bradford Cannon26 achieved good results from thumb reconstruction by conventional techniques while serving at Valley Forge General Hospital. In general, however, this period was characterized by reasonably unsatisfactory results utilizing available procedures for thumb restoration. Phalangization appeared to be the simplest and most predictable operation, while transfer of the stump of an injured index finger was found to be effective in improving thumb performance. Techniques for osteoplastic reconstruction, pollicization, and toe transfer all had substantial disadvantages because of problems achieving stability, motion, and,
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After World War II, with the reopening of medical communication between previously hostile nations, it became apparent that the independent work of Gosset24 in France and Hilgenfeldt29 in Germany had resulted in the development of techniques for finger transfer into thumb position by mobilizing and preserving digital neurovascular pedicles. Such methods allowed monumental advances in the progress of thumb reconstruction and were quickly followed by important modifications
by Littler, Bunnell, and others in the United States.11 These new procedures permitted surgeons to move digits and composite tissues from their normal location in the hand to the exact anatomic site and configuration required to restore thumb function. The requirement for supplementary skin grafting was minimized, and both the required skeletal length and the position of transferred joints could be accurately predetermined. Gosset was perhaps the first surgeon to employ the neurovascular pedicle finger transfer method as reported in his paper “La Pollicisation de l’Index” (Fig. 7-9).24 He utilized the index finger to replace a missing thumb in two cases, as had been suggested earlier by his countryman, Iselin.31 Gosset’s method of transfer was completely free of any skin bridge and allowed the digit to be easily transferred into thumb position while preserving good circulation and sensibility. He apparently encountered problems with excessive length and reduced stability of the transferred finger and therefore adjusted length by amputating the terminal phalanx. During World War II, Hilgenfeldt had worked to develop a method of transposing a finger on its intact nerves and blood vessels beneath a small palmar skin bridge (Fig. 7-10) utilizing the middle-finger-forthumb reconstruction. His results were analyzed in his monograph of 1950, Operative Daumenersatz und Beseitigung von Greifstorungen bei Fingerverlusen,29 which detailed a variety of problems associated with digital amputation and procedures designed to restore hand function. Hilgenfeldt believed that the middle finger best fulfilled the essential requirements for thumb substitution, and he was able to precisely determine the phalangeal length necessary to return thumb function. He sutured the stump of the extensor pollicis longus to
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perhaps most important, sensibility to the reconstructed part. At the end of the war, Major S.B. Fowler of the Newton D. Baker General Hospital was forced to conclude:12 “In several instances, total reconstruction of the thumb (osteoplastic) was attempted but results were always discouraging. Skin tubes did not heal well and it might be many months . . . until the final application and healing of the bone graft. Sensation developed slowly in the reconstructed thumb and the epicritic sense was never normal. The experience of one patient subjected to this operation was typical: immediately after reconstruction was completed, he was thoroughly satisfied with the result; at the end of three months, he knew that the procedure had not proved worthwhile. That was also the opinion of the hand surgeons on the staff. Transplantation of a finger or toe to take the place of a missing thumb was never attempted.”
1949 TO 1969
FIGURE 7-9. Pollicization of the index finger as described by Gosset in 1949. Gosset preserved the index metacarpophalangeal joint by joining the index metacarpal to the thumb metacarpal with the thumb intrinsic muscles (adductor and abductor) sutured to those of the index (dorsal and volar interossei). (Drawn by J. William Littler.50 Published with permission.)
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FIGURE 7-10. Thumb substitution with the use of the middle finger as described by Hilgenfeldt in 1950. Note the retained palmar skin bridge. (Drawn by J. William Littler.50 Published with permission.)
the combined extensor digitorum communis and extensor indicis proprius and transferred the extensor pollicis longus motor to the deep flexor of the transferred finger in a subsequent operation. He reported excellent results with this technique. In the United States, Sterling Bunnell had been working on a method of neurovascular tissue transfer and summarized his thoughts in a publication in 1952.11 He made further technical modifications in the method of transfer of a finger and advocated the use of the intact or injured index finger. In 1952 and 1953, Littler made further modifications to the transfer of the finger on its neurovascular pedicle for either thumb agenesis or traumatic loss (Fig. 7-11).47,48 He also favored the use of the intact or injured index finger because of its relatively independent status and position adjacent to the thumb. He described a technique of rebalancing the transferred index finger by recession-abduction-pronation of the finger into thumb position with adjustments of the extensor system. During the Korean War, the Valley Forge General Hospital again served as a center for hand injuries; a number of excellent thumb reconstructions were done by Peacock80 and Chase,14 and in 1951, Peacock reported on 17 successful digital transfers.80 In 1954, Roger Letac of South Africa described a technique of ring finger pollicization,42 and in 1958, Kelleher and Sullivan of the United States described thumb reconstruction by fifth digit transposition.36 In 1964, Butler of the United States reported on a revised method of ring finger pollicization that involved amputation of the distal phalanx,13 and in the same year, Gosset and Sels of France described their preference for ring finger pollicization for the thumb amputated at or just distal to the metacarpophalangeal joint.
FIGURE 7-11. Technical considerations for index finger pollicization with the thumb amputated at the metacarpophalangeal joint or just beyond. A rudimentary but useful thumb digit is gained when the metacarpal is liberated by a deepening of the first interosseous space (phalangization) or by elongation through an osteoplastic reconstruction. These two procedures provide for only basic use. (Drawn by J. William Littler.50 Published with permission.)
From these important contributions, a number of additional imaginative techniques were developed. In 1955, Moberg of Sweden (Fig. 7-12), in discussing a paper on nerve grafting, introduced the concept of digital neurovascular pedicle skin island transfer to return sensibility to areas of the hand with particular emphasis on the thumb.65 This important concept allowed for the composite transfer of good corniferous skin with intact vascularity and sensibility, thus greatly improving the performance of techniques of osteoplastic thumb reconstruction, which had been all but abandoned because of their inability to return sensation. In 1961, Tubiana (Fig. 7-13) and Duparc of France further refined the restoration of sensibility by neurovascular skin island transfer,86 and this technique was incorporated into an excellent description of thumb reconstruction by osteoplastic methods by McGregor of Scotland and Simonetta of Switzerland.62 This technique utilized a
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FIGURE 7-12. Eric Moberg.
FIGURE 7-13. Raoul Tubiana.
composite skin bone flap from the clavicle with surrounding skin. In 1965, Lewin of the United States also reported on his use of the sensory island flap in osteoplastic thumb reconstruction.46 In 1966, Reid of England (Fig. 7-14) recommended formation of a tubed pedicle flap fashioned from thoracic skin; he felt that this had a number of advantages over abdominal skin and, when incorporated into a neurovascular skin island transfer, provided an excellent method of thumb restoration.83,84 Osteoplastic techniques were further refined by Morgan and Stein of the United States when in 1972 they reported on a “method for rapid and good thumb reconstruction” by the use of neurovascular skin island transfer incorporated into the reconstructed thumb at the time of tube pedicle detachment.66 The logical extension of the application of neurovascular tissue transfer techniques and pollicization was the ability to reconstruct a congenitally absent thumb. Particularly notable in this regard was the work of Matthews of England and Zancolli of Argentina, both of whom reported on their techniques in 1960.59,88 Littler and Riordan of the United States and Malek of France made additional refinements in the methods for index finger transfer for thumb agenesis.49,54,63 Dieter Buck-Gramcko in Germany (Fig. 7-15), drawing on his
FIGURE 7-14. D. A. C. Reid.
incredible experience with thalidomide-induced thumb agenesis, reported a series of 100 consecutive pollicization operations.4–7 These authors developed methods for providing muscle balance to the pollicized index finger with the correct length, motion, and stability to enable excellent recovery of thumb function in children born without thumbs. In 1967, Matev of Bulgaria (Fig. 7-16) first reported a technique for lengthening the first metacarpal after thumb amputation.56 Osteotomy of the metacarpal was followed by gradual distraction using a pair of endless screws and four Kirschner pins; a bone graft was interposed in the resulting gap. He later refined this technique,55–57 together with the distraction apparatus, to enable a 2- to 4-cm lengthening of the metacarpal. Matev subsequently published a superb monograph devoted to thumb reconstruction.58 It can be seen that the development of sophisticated techniques for the transfer of digits and tissues on their neurovascular pedicles added tremendously to the ability to return excellent thumb function to patients following congenital absence or traumatic loss. Pollicization of injured or normal digits into thumb position could be achieved, and the ability to provide sensation with osteoplastic techniques revived their
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FIGURE 7-16. Ivan Matev.
popularity among some surgeons. Nonetheless, these methods were limited to the obligatory use of tissues from the same hand, with the inevitable functional compromise that this represented.
1968 TO THE PRESENT DAY
FIGURE 7-15. Dieter Buck-Gramcko.
The report of Komatsu and Tamai in Japan in 1968 of a successful replantation of a completely severed thumb40 heralded the onset of microvascular reconstruction of the thumb. In the following year, Cobbett of England reported a case of free microvascular transfer of a great toe to replace the amputated thumb of a 31-year-old carpenter with an amputation of this thumb and the index and middle fingers.16 Since that time, the ability to carry out free tissue transfer utilizing microneurovascular anastomoses has enormously improved the potential to return useful thumb function following congenital absence or traumatic loss. Attention must be drawn to the tremendous amount of microvascular research that preceded the successful clinical employment of these techniques. In 1960, Jacobsen of the United States was apparently the first to describe microvascular methods for performing elective free tissue transfers.32 In 1963, Ch’en Chung-Wei of China utilized loupe magnification to successfully replant the
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severed hand of a worker in the Number Six People’s Hospital in Shanghai,15 and also in 1963, Kleinert of the United States and his associates described small vessel anastomoses for the reattachment of devascularized extremities.38 After one complete survival out of nine rhesus monkey free composite replants, Buncke of the United States (Fig. 7-17) concluded in 1966 that the use of microminiature vascular anastomoses now permitted the successful transfer of composite blocks of tissue.8 Shortly thereafter, there was a monumental increase in the research and clinical application of these techniques. Following the initial procedure by Cobbett, Buncke in 1973 reported successful great toe transfers for thumb replacement utilizing microvascular anastomoses.9 In 1975, O’Brien of Australia (Fig. 7-18) and his colleagues reported further experience with hallux-to-hand transfer,78 which he followed with additional descriptions of the clinical application of microvascular techniques in 1977,73 1978,74–76 and 1979.77 In 1976, Gilbert of France described the anatomic basis and surgical techniques for composite tissue transfer from the foot with particular reference to great- and second-toe transfer.23 In 1977, May of the United States, in conjunction with O’Brien and his colleagues, reported the use of a free neurovascular flap from the first web of the foot for thumb reconstruction.60 In 1980, a substantial addition was described by Morrison and O’Brien when they reported on thumb reconstruction utilizing a free neurovascular “wraparound flap” from the big toe. Also in 1980, Leung of
FIGURE 7-17. Harry Buncke.
FIGURE 7-18. Bernard O’Brien.
China described the restoration of thumb function by second-toe transfer,43–45 and in 1984, Foucher of France indicated his preference for this method over the use of the great toe.21 A significant contribution to osteoplastic thumb reconstruction was McGregor’s description of the axial pattern groin flap in 1972,61 and in 1981, Doi and colleagues from Japan described an improved technique utilizing a one-stage free neurovascular flap and iliac crest bone graft.18 In 1983, Minami of Japan described thumb reconstruction by the use of sensory flaps from the foot utilizing microvascular techniques,64 and numerous free sensory flaps for use in thumb reconstruction have subsequently evolved. Two methods of singlestage thumb reconstruction utilizing composite radial osteocutaneous forearm island flaps have been reported by Biemer and Stock2 and Foucher et al.22 and these appear to be extremely promising methods that do not require microsurgical techniques and avoid the necessity of multistage procedures. Biemer had first seen the flap in China, where it had been used as a free flap for postneck-burn contractures. A skin pedicle containing a segment of radius, a length of the lateral antebrachial cutaneous nerve, and two veins are turned 180°, and the segment of radius is fixed to the thumb metacarpal. The digital nerves of the thumb are sutured to the nerves in the flap; the vein anastomoses are optional. Foucher’s technique is similar and utilizes the radial forearm osteocutaneous flap with sensory restoration achieved by means of a neurovascular island pedicle flap.
The use of microneural coaptations and microvascular anastomoses greatly enhances the ability to return thumb function following agenesis or amputation. Not only have the methods of transfer of the great toe or the second toe proved to be excellent alternatives to the pollicization of a normal finger, but methods of osteoplastic reconstruction have been enhanced by the ability to transfer vascularized bone and sensate skin. Many of these techniques are still in their developmental stages, and the imagination of the reconstructive microvascular surgeon remains without limits. Certainly, many additional techniques will evolve in the near future.
CONCLUSION It can be seen from this brief historical chapter that there have been tremendous advances in the techniques used to return function to the thumb-deprived hand. Procedures have evolved from crude tissue transfers and ill-fated methods of osteoplastic restoration to refined techniques utilizing neurovascular pedicle flaps and free composite tissue transfers taken from remote sources around the body. The obvious extension of these methods would be to transplant a normal thumb from one human to another, as is now done successfully with organs such as the kidney, liver, and heart. The technical capability to carry out this procedure already exists, but its success awaits the refinement of immunologic suppression to prevent the rejection of the transplanted tissues. The crowning achievement of more than a century of enormous progress toward restoring the important function of the thumb would be the successful transplantation of a thumb.
References 1. Albee FH: Synthetic transplantation of tissue to form a new finger with restoration of function of the hand. Ann Surg 69:379, 1919. 2. Biemer E, Stock W: Total thumb reconstruction: A onestage reconstruction using an osteocutaneous forearm flap. Br J Plast Surg 36:52, 1983. 3. Boyes JH: On the Shoulders of Giants: Notable Names in Hand Surgery. Philadelphia, JB Lippincott, 1976, p 131. 4. Buck-Gramcko D: Indikation und technik der daumenbildung bei aplasie und hypoplasie. Chir Plast Reconstr 5:46, 1968. 5. Buck-Gramcko D: Pollicization of the index finger: Methods and results in aplasia and hypoplasia of thumb. J Bone Joint Surg [Am] 53:1605, 1971. 6. Buck-Gramcko D: Difficulties in technique of pollicization of the index finger in aplasia of the thumb. In Stack HG, Bolton H (eds): The Second Hand Club. London, British Society for Surgery of the Hand, 1975, pp 493–495.
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7. Buck-Gramcko D: Thumb reconstruction of digital transposition. Orthop Clin North Am 8:329, 1977. 8. Buncke HJ, Buncke CM, Schultz WP: Immediate Nicoladoni procedure in the rhesus monkey or hallux-to-hand transplantation, utilizing microminiature vascular anastomoses. Br J Plast Surg 19:332, 1966. 9. Buncke HJ, McLean DH, George PT, et al: Thumb replacement: Great toe transplantation by microvascular anastomosis. Br J Plast Surg 26:194, 1973. 10. Bunnell S: Physiological reconstruction of a thumb after total loss. Surg Gyncol Obstet 52:245, 1931. 11. Bunnell S: Digit transfer by neurovascular pedicle. J Bone Joint Surg [Am] 34:772, 1952. 12. Bunnell S (ed): Surgery in World War II: Hand Surgery. Washington, DC, U.S. Government Printing Office, 1995. 13. Butler B: Ring finger pollicization (with transplantation of nailbed and matrix on a volar flap). J Bone Joint Surg [Am] 46:1069, 1964. 14. Chase RA: An alternate to pollicization in subtotal thumb reconstruction. Plast Reconstr Surg 44:421, 1969. 15. Ch’en CW: Salvage of the forearm following complete traumatic amputation. China Med 82:632, 1963. 16. Cobbett JR: Free digital transfer: Report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg [Br] 51:677, 1969. 17. Crouse F: Ersatz des daumens aus der grossen zehn. Klin Wochenschr 48:1527, 1906. 18. Doi J, Hattori S, Kawai S, et al: New procedure on making a thumb one-stage reconstruction with free neurovascular flap and iliac bone graft. J Hand Surg 6:346, 1981. 19. Dunlop J: The use of the index finger for the thumb: Some interesting points in hand surgery. J Bone Joint Surg 5:99, 1923. 20. Esser JFS: Island flaps. New York J Med 106:264, 1917. 21. Foucher G, Van Genechten F, Merle M, et al: Toe-to-hand transfers in reconstructive surgery of the hand: Experience with seventy-one cases. Ann Chir Main 3:124, 1984. 22. Foucher G, Van Genechten M, Michon J: Single stage thumb reconstruction by a composite forearm island flap. J Hand Surg [Br] 9:245, 1984. 23. Gilbert A: Composite tissue transfers from the foot: Anatomic basis and surgical technique. In Daniller AJ, Strauch B (eds): Symposium on Microsurgery. St. Louis, CV Mosby, 1976, pp 230–242. 24. Gosset J: La pollicisation de l’index. J Chir 65:403, 1949. 25. Gosset J, Sels M: Technique, indications et resultats de la pollicisation du 4e doigt. Ann Chir 18:1005, 1964. 26. Graham WC, Brown JB, Cannon B, et al: Transposition of fingers in severe injuries of the hand. J Bone Joint Surg 29:998, 1947. 27. Guermonprez F: Notes sur Quelques Resection et Restaurations du Pouce. Paris, Passein, 1887. 28. Gueullette R: Etude critique des procedes de restauration du pouce. J Chir 36:1, 1930. 29. Hilgenfeldt O: Operative Daumenersatz und Beseitigung von Greifstorungen bei Fingerverlusen. Stuttgart Ferdinand Enke, 1950. 30. Hugier PC: Replacement du ponce par son metacarpien, par l’agrandissement du premier espace interosseux. Arch Gen Med 1:78, 1874.
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31. Iselin M: Reconstruction of the thumb. Surgery 2:619, 1937. 32. Jacobsen HJ, Suarez EL: Microsurgery in anastomosis of small vessels. Surg Forum 2:243, 1960. 33. Jepson PN: Transformation of a middle finger into a thumb. Minn Med 8:552, 1925. 34. Joyce JL: A new operation for the substitution of a thumb. Br J Plast Surg 5:499, 1917–18. 35. Joyce JL: The results of a new operation for substitution of a thumb. Br J Surg 16:362, 1929. 36. Kelleher JC, Sullivan JG: Thumb reconstruction by fifth digit transposition. Plast Reconstr Surg 21:470, 1958. 37. Klapp R: Uber einige kleinere plastiche: Operationen an fingern und hand. Dtsch Z Chir 188:479, 1912. 38. Kleinert HE, Kasdan ML, Romero JL: Small blood-vessel anastomosis for salvage of severely injured upper extremity. J Bone Joint Surg [Am] 45:788, 1963. 39. Kleinschmidt O: Ueber daumenplastik unter verwendung des unbrauchbaren mittel fingers. Bruns Beitr. Klin Chir 120:589, 1920. 40. Komatsu S, Tamai S: Successful reimplantation of a completely cut-off thumb. Plast Reconstr Surg 42:374, 1968. 41. Lambert O: Resultat eloigne d’une transplantation du gros orteil remplacement du pouce. Bull Mem Soc Chir Paris, May 5, 1920, p 689. 42. Letac R: Pollicization of the ring finger. J Int Coll Surg 22:649, 1954. 43. Leung PC: Transplantation of the second toe to the hand: A preliminary report of sixteen cases. J Bone Joint Surg [Am] 62:990, 1980. 44. Leung PC: Thumb reconstruction using second toe transfer. Hand 15:15, 1983. 45. Leung PC: Thumb reconstruction using second toe transfer. Hand Clin 1:285, 1985. 46. Lewin ME: Sensory island flap in osteoplastic reconstruction of the thumb. Am J Surg 109:226, 1965. 47. Littler JW: Subtotal reconstruction of the thumb. Plast Reconstr Surg 10:772, 1952. 48. Littler JW: Neurovascular pedicle method of digital transposition for reconstruction of the thumb. Plast Reconstr Surg 12:303, 1953. 49. Littler JW: Digital transposition. In Adams JP (ed): Current Practice in Orthopaedic Surgery, vol 3. St. Louis: CV Mosby, 1966. 50. Littler JW: On making a thumb: One hundred years of surgical effort. J Hand Surg 1:35, 1976. 51. Littler JW: Personal communication, 1985. 52. Luksch L: Uber eine nene methode zum ersatz des verlorenen daumens. Verh Dtsch Ges Chir 32:221, 1903. 53. Lyle HHM: The disabilities of the hand and their physiological treatment. Ann Surg 78:816, 1923. 54. Malek R, de la Caffiniere JY: Pollicisations de l’index chez l’enfant. Ann Chir Plast 16:198, 1971. 55. Matev IB: Gradual elongation of the first metacarpal as a method of thumb reconstruction. (Presented in 1967 at 23rd meeting in Lausanne and Vienna.) In Stack HG, Bolton H (eds): Proceedings of the Second Hand Club. London, British Society for Surgery of the Hand, 1975, pp 431–496.
56. Matev IB: First metacarpal lengthening for thumb reconstruction. Ortop Travmatol Protez 6:11, 1969. 57. Matev IB: Thumb reconstruction after amputation at the metacarpophalangeal joint by bone-lengthening: A preliminary report of three cases. J Bone Joint Surg [Am] 52:957, 1970. 58. Matev IB: Reconstructive Surgery of the Thumb. Brentwood, Essex, England: Pilgrims Press, 1983. 59. Matthews D: Congenital absence of functioning thumb. Plast Reconstr Surg 26:487, 1960. 60. May JW, Chait LA, Cohen BE, et al: Free neurovascular flap from the first web of the foot in hand construction. J Hand Surg 2:387, 1977. 61. McGregor IA, Jackson IT: The groin flap. Br J Plast Surg 25:3, 1972. 62. McGregor IA, Simonetta C: Reconstruction of the thumb by composite bone-skin flap. Br J Plast Surg 17:37, 1964. 63. Milford L: The Hand. St. Louis, CV Mosby, 1971, pp 139–142. 64. Minami A, Usui M, Kathoh H, et al: Thumb reconstruction by free sensory flaps from the foot using microsurgical techniques. J Reconstr Microsurg 1:239, 1984. 65. Moberg E: Discussion of paper by Brooks D: Nerve grafting in orthopaedic surgery. J Bone Joint Surg [Am] 37:305, 1955. 66. Morgan LR, Stein F: Method for a rapid and good thumb reconstruction. Plast Reconstr Surg 50:131, 1972. 67. Moutier G: Les procedes operatoires de restauration du pouce, J Chir (Paris) 19:225, 1922. 68. Nicoladoni C: Daumenplastick. Wein Klin Wochenschr 10:663, 1897. 69. Nicoladoni C: Daumenplastik fund organischer ersatz der fingerspitze (anticheiroplastik and daktyloplastik). Arch Klin Chir 61:606, 1900. 70. Nicoladoni C: Weitere erfahrungen uber daumenplastik. Arch Klin Chir 69:695, 1903. 71. Noesske K: Uber den plastischen ersatz von ganz oder teilweise verlorene finger, insbesondere des daumens, und uber handtellerplastik. Munch Med Wochenschr 56:1403, 1909. 72. Noesske K: Uber ersatz des samt metakarpus verlorenen daumens durch operative umstellung des zeigefingers. Munch Med Wochenschr 67:465, 1920. 73. O’Brien BM: Microvascular Reconstructive Surgery. London, Churchill Livingstone, 1977, pp 183–204. 74. O’Brien BM: Microvascular surgery: Its present place in reconstructive surgery. Handchirurgie 10:75, 1978. 75. O’Brien BM, Black MJM, Morrison WA, et al: Microvascular great toe transfer for congenital absence of the thumb. Hand 10:113, 1978. 76. O’Brien BM, Brenne MB, MacLeod AM: Microvascular free toe transfer. Clin Plast Surg 5:223, 1978. 77. O’Brien BM, MacLeod AM, Morrison WA: Digital replantation. In Reid DAC, Gosset J (eds): Mutilating Injuries of the Hand, GEM no. 3. New York, Churchill Livingstone, 1979. 78. O’Brien BM, MacLeod AM, Sykes PJ, et al:. Hallux-to-hand transfer. Hand 7:128, 1975. 79. Oudard JS: Greffe de doigts par transplantation. Rev Orthopaed, 1922.
80. Peacock EE: Reconstruction of the thumb. In Flynn JE (ed): Hand Surgery. Baltimore, Williams & Wilkins, 1966. 81. Perthes V: Uber plastischen daumenersatz insbesondere bei verlust des gonzen daumenstrahles. Arch Orthop U Unfall-Chir 19:1958, 1921. 82. Pierce GW: Reconstruction after total loss. Surg Gynecol Obstet 45:825, 1927. 83. Reid DAC: The neurovascular island flap in thumb reconstruction. Br J Plast Surg 19:234, 1966. 84. Reid DAC: Reconstruction of the thumb. In Pulvertaft RG (ed): Clinical Surgery: The Hand. Washington, DC, Butterworths, 1966, pp 296–307.
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85. Tanzer RC, Littler JW: Reconstruction of the thumb by transposition of adjacent digit. Plast Reconstr Surg 3:533, 1948. 86. Tubiana R, Duparc J: Restoration of sensibility in the hand by neurovascular skin island transfer. J Bone Joint Surg [Br] 43:474, 1961. 87. Verrall PJ: Three cases of reconstruction of the thumb. Brit Med J 2:775, 1919. 88. Zancolli E: Transplantation of the index finger in congenital absence of the thumb. J Bone Joint Surg [Am] 42:658, 1960. 89. Zsulyevich I: Ein fall von plastichem daumenersatz. Chir 10:433, 1938.
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Prehension in the Normal and Mutilated Hand Raoul Tubiana, MD, Hon FRCS (Ed)
Prehension may be defined as the combination of complex functions that are used when an object is grasped: intent, sensory control, and grip. Grip is the manual, mechanical component of prehension. Prehension is disturbed and sometimes lost following a traumatic amputation. This chapter emphasizes several points that explain the difference between prehension of the normal hand and of the mutilated hand. Prehension is not a purely motor act; it depends on the messages of tactile and proprioceptive sensibility and their utilization by the central nervous system.14 From the early days of life, a model of our own body image gradually develops in the parietal area of the brain. This image becomes the permanent cortical representation of the self. It is so deeply ingrained that it remains unchanged in the amputee. Because of their mutilation, patients have to adapt to their new functional capabilities. After traumatic amputation, established nerve pathways between the central nervous system and the hand are severely disturbed and can be very difficult to restore. The ability to control grip is restricted or lost, and sensory information is reduced, the degree depending on the extent of the injury. Knowledge of prehension in the normal hand helps with an understanding of prehension in the mutilated hand.
PREHENSION OF THE NORMAL HAND In the normal hand, humans have the ability to modify grip. They will choose and adapt their mode of prehension not only to the object grasped, but also to the purpose of the grip. To take is not simply to grasp. Like touch, prehension is intentional. This implies an awareness of utilization, and this is where prehension differs fundamentally from grip. The choice of the type of grip is preselected. Grip is not totally fixed at any particular moment; it is continually modified to retain maximum efficiency in relation to the objective sought in the grip.
Mechanics of Grip Grip consists of three stages: initially, opening of the hand; next, closing of the digits to grasp the object; and finally, regulation of the force of grip. Opening of the hand requires the simultaneous action of the long extensors and intrinsic muscles. It is proportional to the volume of the object grasped. Positioning the hand to grasp an object and adapt to its form takes into account forces: the forces to which a solid object is subjected, principally gravity and occasionally kinetic forces, and the forces generated by the hand itself. These forces are produced by contraction of the intrinsic and extrinsic muscles. 113
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When there is a possibility of the object slipping over the skin, a resistance—namely, friction—intervenes in proportion to the area of the surfaces that are in contact. It is different in several cutaneous areas and is more marked over palmar skin and over the pulp of the fingers. The pulp skin is characterized by small, concentric epidermal crests, the same papillary ridges as in fingerprints.4 These crests act on an object in the same way as the tread of a tire acts on the road. The sweat glands, by moistening the skin, tend to increase friction and make the skin more adhesive.
Types of Grip Grip can be defined as supporting or dynamic. Supporting grip is mainly static. The hand is only opposing the weight of the object without adapting to its form. The hand is usually kept flat, with the object resting on the whole or on part of the palmar surface. This hold does not fix the object, but it can be quite powerful, as all the muscles of the forearm and hand jointly oppose the weight of the object. Another type of supporting grip is used by a waiter holding up a tray. Here, the hand is extended, and all the fingers are semiflexed; the thumb and little finger are abducted to expand the supporting polygon. Dynamic grip occurs when the mobile elements of the hand adapt to the shape of the object. At least two sets of forces are applied to the object from different directions. These forces are regulated by the conscious mind in the cortex of the brain in association with memory. A cerebral pattern is created that can promote active and repetitive movement. The association of voluntary movement and memory produces experience. Applied experience is skill.6 The dynamic phase of the pinch is followed by a static phase of fixation on the object.
Thumb-Finger Pinch In the thumb-finger pinch, mobility of the thumb is essential. In opposition, its pulp surface comes into direct contact with the pulp of the fingers. Opposition is a combined movement involving all three segments of the thumb: The metacarpal segment moves in an anteposition plane and then in adduction, a movement that is accompanied by an “automatic” longitudinal rotation into pronation. The proximal phalanx flexes, pronates, and radially deviates. The distal phalanx flexes to a variable degree, and this flexion is accompanied by slight pronation adapted to the requirements of the grip. It is evident that the extensive movement of opposition requires an expansile, mobile webspace and that any contracture of the webbed areas (cutaneous, muscular, tendinous, aponeurotic, or capsuloligamentous) will impair the thumb’s mobility.
FIGURE 8-1. Thumb-finger termino-terminal pinch.
A consideration of the area of skin contact between the thumb and fingers is a useful way to appreciate the result of the oppositional movement. In these terms, it is possible to describe several types of thumb-finger pinch. The termino-terminal pinch (Fig. 8-1) brings the tip of the thumb into contact with the tip of an opposable finger. Thus the thumb and index finger, in contact at their tips, can precisely pinch a small object while all their joints are flexed to form a regular “O.” The grip is not a firm one, except for small objects. Terminal grips are far less commonly applied than subterminal pulp grips. The subterminal pulpar pinch (Fig. 8-2) brings the pulp of the pronated thumb into contact with that of the supinated opposed finger’s pulp, with the distal phalanges of both digits in almost complete extension. The plasticity and high sensibility of the pulps are thereby brought into play. The lateral pinch (Fig. 8-3) between the distal phalanx of the thumb and the lateral aspect of the index finger is quite strong but not precise. However, lateral pinch can be very useful because the restoration of
FIGURE 8-2. Subterminal pulpar pinch.
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FIGURE 8-3. Lateral pinch between the distal phalanx of the thumb and the lateral aspect of the index finger.
mobility is necessary only on one branch of the pincer, usually on the thumb ray. Lateral pinch can be subdivided into the lateral-proximal pinch with the proximal phalanx of the index finger, the lateral-middle pinch with the middle phalanx, and the lateral-distal pinch with the distal phalanx. The more distal the lateral pinch, the more useful it is. Kapandji proposed a numbered method for evaluation of thumb opposition using the hand itself as the reference system.8 This method is based on successive thumb-finger pinch during the wide course of opposition. Eleven stages are defined (Fig. 8-4): ❚ Stage 0: The tip of the thumb is in contact with the lateral aspect of the proximal phalanx of the index finger. ❚ Stage 1: The tip of the thumb is in contact with the lateral aspect of the middle phalanx of the index finger. ❚ Stage 2: The tip of the thumb is in contact with the lateral aspect of the distal phalanx of the index finger. ❚ Stage 3: Terminal pinch between the thumb and the index finger. ❚ Stage 4: Terminal pinch between the thumb and the middle finger. ❚ Stage 5: Terminal pinch between the thumb and the ring finger. ❚ Stage 6: Terminal pinch between the thumb and the little finger. ❚ Stage 7: The tip of the thumb is in contact with the distal interphalangeal crease of the little finger.
FIGURE 8-4. Kapandji’s numbered method for evaluation of thumb opposition. There are eleven successive stages.
❚ Stage 8: The tip of the thumb is in contact with the proximal interphalangeal joint crease of the little finger. ❚ Stage 9: The tip of the thumb is in contact with the proximal crease of the little finger. ❚ Stage 10: The tip of the thumb reaches the distal palmar crease at the base of the little finger. This opposition test is considered valid when stage 10 is reached after every stage of the “wide-course” has been passed through. In fact, stage 10 can be reached by passing the “restricted opposition motion,” with the thumb crawling in the palm.
Tripod Fixation The two ulnar digits customarily act together, especially in palmar grip, to provide support and static control. The radial digits have a rather dynamic action: The thumb, the index finger, and the middle finger work together to form the elements of the “dynamic tripod,”2 which could be better named the “dynamic tridactyl.” In reconstructive surgery of the hand, there is an enormous improvement in stability when bilateral pinch is advanced to three-point fixation (Figs. 8-5 and 8-6). Many of the normal functions of the hand are performed with three-point fixation, such as writing, lifting, holding a cup by the handle, and using a fork. Composite Grip The tripod may be supplemented by a fourth point of stability produced by the palm. As a rule, the grip is achieved by thumb and index finger or thumb and middle finger.
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cases of interosseous paralysis, the sequence of flexion is altered. Finger flexion is accomplished by the long flexors alone, which act first on the distal phalanges. With flexion, the pulps of the fingers approach the palm, and the hand cannot grasp large objects.
Hook Grip In the hook grip, the fingers are flexed at the proximal interphalangeal joints, and the thumb is adducted. This type of grip is used in carrying a bag or in lifting (Fig. 8-8). It is deliberately created in some forms of reconstruction, by arthrodesing the proximal interphalangeal joints in flexion; this is particularly applicable in burns when the extensor mechanism has been destroyed.
FIGURE 8-5. Tripod fixation. The thumb, index finger, and middle finger improve steadily by three-point fixation. Stages 0, 1, and 2 are indicated.
The two ulnar fingers are often used as a buttress to prevent ulnar drifting of the other fingers. Quite often, the object is pressed against the edge of the hand, either on the radial side inside the first cleft, with the index maintaining the contact between hand and object, or on the ulnar side, contact now being maintained by the little finger, which serves to lock the grip.
Digito-Palmar Grip Theoretically, this grip may exclude the thumb. The flexed fingers oppose the thenar eminence of the hand. These are the two main supporting zones. The thenar eminence or the thumb itself acts as a buttress (Fig. 8-7). Normally, finger flexion begins at the level of the proximal interphalangeal and metacarpophalangeal joints and is followed by distal interphalangeal joint flexion. In
FIGURE 8-6. Precision grip during surgical dissection using tripod fixation of both hands.
Interdigital Grip Mechanically, this grip is less efficient than the abovementioned types. The motor muscles involved are weaker, and abduction and adduction of the interossei are supplemented by the long flexors. This grip is used only for small, light objects and to compensate for a functional loss of the thumb (Fig. 8-9). Selection of Grip Positioning the mobile elements of the hand to grasp an object and adapt to its form is a complex process. For Napier, the diversity of the hand’s movement is more apparent than real if one forgets the multiplicity of grasped objects and remembers only the attitudes of the hand.11 The functional activities of prehension can be divided into power grips, in which the digits maintain the object against the palm, and precision grips, with or without participation of the palm. These two forms of grip depend less on the form of the object than on the reason for which the object is grasped. The thumb is absolutely indispensable for the precision of the grip. It provides both stability and control of direction, which are necessary for movements of precision. The thumb is also very useful in providing the power of the grip, forming a buttress against which an object is stabilized. The thumb is not indispensable for all forms of power grip (Fig. 8-10). Certain grips use only a simple hook formed by the fingers, which is controlled by the powerful digital long flexor and extensor muscles. They have more stamina than the intrinsic muscles, which control flexion of the metacarpophalangeal joints and adduction of the thumb but tire easily. Thus with fatigue, full closure of the hand around an object is transformed into a hook of the interphalangeal joints, and precision is lost. The role of the intrinsic muscles assumes increased importance when agility and precision are necessary; when emphasis is on power, the extrinsic muscles become more important. Landsmeer describes “precision
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FIGURE 8-7. Digito-palmar grip. A, Power digito-palmar grip along the transverse axis of the hand. B, Grip of an object along the oblique palmar axis, or palmar groove, has a longer area of contact, multiple pulp grip between the fingers and the thumb, and thus more precision.
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FIGURE 8-8. Hook grip.
FIGURE 8-9. Interdigital grip.
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FIGURE 8-10. Amputation of the thumb ray. Some forms of grip are still possible but without precision. A, Hook grip. B, Digito-palmar grip. C, Interdigital grip. C
handling,” which requires a continual adaptation between the thumb and the fingers without participation of the palm; this has a dynamic significance, whereas “precision grip” implies more stasis of activity.9 Regulation of the force of grip is essential. The force must be varied according to the weight, fragility, surface characteristics, and utilization of the object. Precise and continuous sensory information is indispensable for safety reasons in preventing premature release or excessive pressure. In particular, Pacinian corpuscles play the role of measuring grasping force to regulate them in a semiautomatic fashion. In first grasping an object of unknown weight, there is always an overshoot of the forces, whereas the second grasp automatically regulates the level of force required to ensure prehension.
The anesthetic hands of lepers, for example, have lost their sensory safety signals and are constantly subjected to wounds caused by excessive pressure.
PREHENSION OF THE MUTILATED HAND Prehension of the mutilated hand differs from prehension of the normal hand for these reasons: ❚ The range of grips is restricted or lost because of the mechanical deficit. ❚ Mutilating injuries are often associated with subsequent sequelae: Stiffness and diminution of
sensation, motor power, and vascularity that can considerably reduce the functional value of the remaining elements and compromise the chances of successful reconstruction. These sequelae must be taken into account in establishing a program of reconstruction. Traumatic amputations also differ from congenital ones, not only because of the abundance of scar tissue, but also because in a traumatic amputation, the patient has not adapted to his or her injury. Indeed, the older the patient, the more difficult will be the adaptation. Whereas the normal hand is a source of information and an agent of action, with multiple possibilities for dynamic adaptation, the mutilated hand falls to the level of a primitive tool. The physician’s role is to try to restore the more common forms of grip. Depending on the severity of the amputation, the clinician can hope at best to restore a precision grip or a power grip or simply the more rudimentary action of a vice, a pincer, a hook, a pusher, or a paperweight. The following section considers prehension in mutilations of increasing severity. In view of the importance of the thumb and first metacarpal, prehension is considered in the following lesions: ❚ Normal thumb ray with multidigital amputations ❚ Partial amputation of the thumb associated with partial or total amputation of one or several fingers ❚ Complete amputation of the thumb associated with partial or total amputations of one or several fingers ❚ The metacarpal hand ❚ Total amputations of the hand, which can be transmetacarpal or above the wrist ❚ The special problems of prehension raised by severe bilateral amputations.
Normal Thumb Ray with Multidigital Amputations This group can be subdivided according to the degree of severity of the fingers’ mutilation.17
Normal Thumb with Partial Amputation of the Middle Finger Precision grip is possible if there is a finger of sufficient length to oppose to the thumb pulp. A good digito-palmar grasp requires at least two fingers with sufficient length and mobility to reach the palm. As a general rule, pain must be relieved before any reconstructive procedure is attempted, since pain will prohibit the use of the digital stump. In cases of multidigital partial amputations, the length of the stumps that
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can oppose the normal thumb or the palm is an important prognostic factor for prehension. The more fingers that are involved, the greater must be the attempt to conserve all available length as well as the mobility of the joints of opposable digits. Stumps should have adequate length to control the direction of the grip. Translocation of the stumps, apart from lengthening short stumps, can ensure redistribution of functional units. Toe transfers are rarely indicated when the normal thumb can easily reach the finger stumps, except in wellmotivated patients (e.g., musicians) when the finger’s stump has a functional proximal interphalangeal joint.
Normal Thumb with Complete Amputation of One or More Fingers The functional value of each finger is determined by its position in the hand. The index finger is important for lateral pinch and distal precision handling, whereas the middle finger, with its median position, participates in precision and power grips. The ring and the little fingers are important for the digito-palmar power grip. Amputation of a central finger (middle or ring finger), in addition to the cosmetic problems and a marked reduction of grip strength, is accompanied by increasing convergence of the peripheral finger and loss of small objects from the palm. A toe transfer will avoid falling articles, but functionally, the range of motion is disappointing. It is preferable to perform a digital translocation. For amputation of the middle finger, the index ray can be translocated with a metacarpal osteotomy (Fig. 8-11).3 For amputation of the ring finger, a translocation of the little finger can be performed with osteotomy at its metacarpal or by intracarpal osteotomy (Fig. 8-12).10 In isolated amputations of the two radial fingers, pinch between the thumb and ring finger is adequate. In isolated amputation of the ulnar fingers (ring and little fingers), grip strength is considerably decreased, but the three-point pinch (chuck pinch) is useful for the primary functions of the hand (Fig. 8-13). In central hemiamputation (middle and ring fingers), reorientation of the little finger by a supination osteotomy at the base of the fifth metacarpal is useful. When three or four fingers are amputated with an intact thumb, indications include reorientation by osteotomy, phalangization, finger lengthening, toe transfer, and prosthesis (Fig. 8-14). When the ulnar metacarpals are amputated, it is necessary to build a post to oppose the thumb. The opposition post can be provided by a bone graft, usually iliac, covered by a sensate skin flap or a toe transfer.
Partial Amputation of the Thumb We must distinguish between cases in which the fingers are partially amputated, those in which they are totally
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FIGURE 8-11. A, Amputation of the middle finger. Adduction of the index finger. B, C, Translocation of the index finger on the third metacarpal.
amputated, and those in which there is injury to the metacarpals.
Partial Amputation of Thumb with Partial Amputation of Fingers This group covers a wide range of lesions. One must appreciate the functional value of the remaining elements. Which types of grips are still possible? Are there fingers or
parts of fingers that can reach the thumb or palm? Is the skin cover in the area of grip sensate and of good quality? The functional prognosis is favorable if many mobile segments remain. Contact between these segments of different lengths must be facilitated by means of reorientating osteotomies or transpositions. The primary aim is to make the movements of the thumb as useful as possible. This can be achieved by deepening the first webspace by phalangization of the thumb metacarpal (Fig. 8-15) and/or
FIGURE 8-12. A, Amputation of the ring finger. Convergence of the middle and little fingers. B, Translocation of the little finger.
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FIGURE 8-12 cont’d. C, D, Translocation of the little finger.
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by lengthening the stump of the thumb. Transfer of a healthy finger, if any remain, is out of the question because it must be preserved for palmar gripping. This is a good indication for pollicization of a mutilated finger.
Partial Amputation of Thumb with Amputation of All Fingers In these cases, all the metacarpals have been preserved with a fragment of phalanx of the thumb. You should strive to improve the function of the remaining mobile structures. A phalangization of the thumb and the little finger metacarpals can restore a useful grip (Fig. 8-16).16 It is certainly more effective now to use the possibilities offered by toe transfers on the thumb and on other finger rays, especially if it remains a functional metacarpophalangeal joint, which will improve the toe mobility. Phalangization of the mobile little finger, associated with an angulation osteotomy at the base of the little finger metacarpal, can be a useful support for a toe transfer.
Partial Amputation of Thumb Associated with Amputations of Metacarpals In these cases, do not expect enough mobility from the reconstructed finger for a digito-palmar grasp. A pincer must be constructed between a thumb lengthened by a toe transfer or any other procedure. A second “arm” must be constructed opposite the mobile thumb ray to create a pincer.
Complete Amputation of the Thumb FIGURE 8-13. Isolated amputation of the two ulnar fingers. Thumb-finger grip and digito-palmar grip are preserved, but the grip strength is considerably decreased.
The first aim will be thumb reconstruction. Here again, we distinguish between cases in which one or several fingers are intact or those in which they are partially or totally amputated. Complete amputation of the thumb
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FIGURE 8-14. Normal thumb with amputation of all fingers. A, Lateral grip can be strong but without precision. The patient cannot hold large objects. B, C, Phalangization with osteotomy at the base of the little finger metacarpal will transform a bilateral pinch into a tripod one and enhance the stability of the grip. A lengthening of the little finger metacarpal, using a toe transfer, will increase the capacity for gripping large objects. C
FIGURE 8-15. A, Partial amputation of the thumb with partial amputation of the fingers. B, Phalangization of the first metacarpal and reorientation of the fifth metacarpal.
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FIGURE 8-15 cont’d. C, Restoration of a large grip. D, Pinch of small objects between the thumb and the little finger.
with preservation of some fingers necessitates pollicization (Fig. 8-17).
Complete Amputation of Thumb with Partial Mutilation of Fingers Prehension in this group depends on the number of finger mutilations and the level of the amputations. A thumb must be constructed to oppose the remaining
fingers or finger stumps. The choice of procedure for thumb reconstruction is determined to a great extent by the importance of associated injuries on the other rays (Fig. 8-18). One must take into account the general architecture of the hand, the relative length of the thumb metacarpal, the transferable part, the opposable elements, and their mobility. If the index finger is partially amputated but still has at least a mobile joint plus good vascularity and sensibility, it should be pollicized. If the index finger is not usable, any other finger’s stump with its metacarpal and at least a mobile metacarpophalangeal joint can be used for thumb reconstruction. Transfer of a toe does not allow ideal reconstruction of a complete thumb ray amputation; the transferred toe is too short and has an insufficient range of movement. Reorientation of the stumps so that they are opposable to the new thumb will improve the grip. When the little finger is preserved up to the proximal interphalangeal joint, a supination osteotomy can be very useful.
Complete Amputation of Thumb with Complete Amputation of One or More Fingers
FIGURE 8-16. Partial amputation of the thumb with amputation of the fingers. Thumb-finger grip and digito-palmar grip are lost. Phalangization of the thumb and of the little finger metacarpal will improve the situation. Lengthening of the thumb and of the little finger metacarpal will increase the grasping ability.
Thumb-finger grip is lost. Restoration of prehension in this group depends on the number of finger amputations and on the level of the thumb metacarpal amputation (Fig. 8-19). If the thumb metacarpal is long enough and has some active mobility, a toe transfer may be used for thumb reconstruction. Pollicization of a remaining finger is another possibility (Fig. 8-20), as is an osteoplastic reconstruction (Fig. 8-21).
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FIGURE 8-17. A, Complete amputation of the thumb ray. B, Pollicization of the index finger.
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FIGURE 8-18. A, Amputation of the thumb with partial amputation of the fingers. B, Pollicization of the index finger stump.
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The Metacarpal Hand Loss of the thumb and all the fingers constitutes the “metacarpal hand.” All commissures are lost, and the hand is reduced to the state of a pusher or a hook if the wrist is mobile. However, when the thumb metacarpal has retained some mobility, prehensile function can be restored by deepening the first webspace with excision of the index metacarpal. An osteotomy of the base of the
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little finger metacarpal can be associated with its phalangization.12,15,16 Lengthening of the thumb metacarpal and sometimes of two other metacarpals increases the value of these phalangizations. The peripheral or border metacarpals, the thumb and the little finger, possess a well-developed intrinsic musculature of their own, the thenar and hypothenar muscles. The mobility of the thumb metacarpal is considerable. In the little finger
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FIGURE 8-19. A, Complete amputation of the thumb associated with amputation of the index, middle, and ring fingers. Pollicization of the little finger is possible. A toe transfer would be too short, with limited mobility. The decision was made to pollicize the ring finger metacarpal with a mobile metacarpophalangeal joint. The index and middle finger metacarpophalangeal joints are stiff. A tube flap was first utilized for the restoration of the first web. B, C, Pollicization of the stump of the ring finger with its metacarpal. D, The new thumb is short but has two mobile joints.
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FIGURE 8-20. A, Amputation of the thumb and index finger after a severe burn. B, Pollicization of the middle finger on the thumb metacarpal.
metacarpal, mobility is much less marked although extremely useful. The index and ring finger metacarpals are resected to deepen the “interdigital” spaces. The middle finger metacarpal is retained to preserve the insertions of the adductor pollicis muscle and because this central support enhances the precision of the grip (Fig. 8-22). Lengthening of the thumb metacarpal can be performed by various procedures. Transfer of one or more toes has considerably increased the grasping ability after phalangization of metacarpal hands. The benefit brought by phalangizations in cases of severe mutilation of the hand underlines the importance of preserving as much length as
possible in the thumb and little finger at the time of initial treatment.
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Transmetacarpal Amputation When the metacarpals are partially amputated, the possibility of restoration of a useful grip depends essentially on the survival of the proximal mobile part of the thumb metacarpal, which can be lengthened by any appropriate procedure. Some form of opposition posts are then constructed on the ulnar side of the hand. Use of a removable prosthetic opposition post constitutes another possibility. If the thumb metacarpal is destroyed
FIGURE 8-21. Complete amputation of the thumb and index finger. An osteoplastic post was constructed anterior to the remaining fingers. Some sensation on the post may be produced by a posterior interosseous skin flap.
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movement also can help to establish a sensitive grip against a toe transfer or a prosthesis.
Bilateral Hand Mutilations
When a carpal segment has survived, activated by the wrist flexors and extensors (inserted on the base of the metacarpals), the persistent mobility of the stump is used in creating a natural and powerful hook. This
The problems arising from severe bilateral mutilations differ from those of unilateral mutilation not only in the severity of the injury and its psychological effects, but also in the therapeutic approach. In the unilateral mutilated hand, surgery aims at providing the patient with a useful instrument to assist the contralateral intact hand; however, in cases of severe bilateral mutilation, the surgeon must try to restore the lost autonomy. The therapeutic approach involves difficult decisions that must take into account the site and extent of the lesions as well as the patient’s age, occupation, and psychological
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Total Amputation of the Hand
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FIGURE 8-22. A, Metacarpal hand. B, Phalangization of the thumb and little finger metacarpals with resection of the index and ring finger metacarpals. C, D, A useful metacarpal grip can be restored. C
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and useless, the opportunity for repair is much more limited. In these very severe amputations, one is tempted to transfer a finger from the other hand. This involves considerable risk that, in exceptional cases, might be worthwhile. Büchler has transferred the contralateral index finger;1 Morrison prefers transfer of the ring finger, considering this to be less functionally useful than the index finger for the donor hand.7 Foucher proposed a transfer of a mutilated contralateral finger when possible.5
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state. Microsurgical techniques have certainly enhanced the effectiveness of traditional procedures. However, patients with extensive burns, those with frostbite, and the victims of explosion injuries often have associated lesions of the hand and of the feet that limit the possibilities of toe transfers. However, motivated by sheer necessity, patients with bilateral mutilations often achieve remarkable functional results, comparatively superior to those with unilateral amputations. We have classified bilateral mutilations into three groups according to their severity and prognosis: (1) mutilations in which one can hope to restore good manual prehension on both sides (Fig. 8-23), (2) mutilations that are severe on at least one side, and (3) severe
bilateral mutilations.13 In these unfortunate patients, only a weak grip can be restored. A Krukenberg’s operation, which creates an active pincer with the two bones of the forearm covered with sensitive skin, can restore a broad, powerful, and sensitive grip (Fig. 8-24).
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PROSTHETIC APPLIANCES Despite remarkable progress made in the field of prosthetics, prostheses are devoid of sensation. In the absence of sensation, true prehension does not exist, and a prosthesis will not restore prehension. With the
FIGURE 8-23. Bilateral hand mutilations. A, Group 1: partial thumb and finger amputation on both sides. One can hope to restore prehension on both sides. B, Group 2: bilateral hand mutilations after frostbite. Very short thumb and finger stumps on the right hand, with much longer stumps on the left side. Toe transfer to the left thumb metacarpal and pollicization of the index stump on the right side were performed. The patient was able to resume his favorite sport: mountaineering. C, D, Group 3: severe bilateral mutilations after extensive burns. Metacarpal hand on the right side; midforearm amputation on the left side. A strong grip was restored to both sides owing to a phalangization on the right side and a Krukenberg’s procedure on the left side. The patient recovered total independence.
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FIGURE 8-24. Severe bilateral mutilations.
assistance of a prosthesis, the mutilated patient can perform movements resembling those of the articulated hand, but such appliances, although they allow some form of grip, remain insensitive. A sensitive grip that is capable of recognizing objects and adjusting the force of a grip is certainly superior to a prosthetic pincer, which must always be controlled by vision. Total hand prostheses are rarely used by manual laborers with mutilated hands, especially if they have a good contralateral hand. However, prosthetic appliances can be of great cosmetic and functional assistance. When they are designed for a precise function, they can improve certain specific grips in their attempt to restore prehension.
References 1. Büchler U: Proximal radial hemiamputation: Reconstruction of prehension by free cross-hand digital transplantation. In Tubiana R (ed): The Hand, vol 3. Philadelphia, WB Saunders, 1998, pp 1210–1215. 2. Capener N: The hand in surgery. J Bone Joint Surg 38B:128, 1956. 3. Carroll RE: Transposition of the index finger to replace the middle finger. Clin Orthopaed 15:27, 1959. 4. Cauna N: Nature and functions of the papillary ridges of the digital skin. Anat Rec 119–449, 1954. 5. Foucher G: Reconstructive Surgery in Hand Mutilation. London, Martin Dunitz, 1997.
6. Harrison SH: The functional relationship of the thumb to the fingers. In Tubiana R (ed): The Hand, vol 1. Philadelphia, WB Saunders, 1981, pp 481–487. 7. Morrison WA, O’Brien BM, MacLeod AM: Ring finger transfer in reconstruction of transmetacarpal amputations. J Hand Surg 9A:4–11, 1984. 8. Kapandji AI: Clinical evaluation of the thumb’s opposition. J Hand Ther 5:102–106, 1992. 9. Landsmeer JMF: Power grip and precision handling. Ann Rheum Dis 21:164–170, 1962. 10. Leviet D: Translocation of the fifth finger by intracarpal osteotomy. Ann Plast Surg 17:228–238, 1986. 11. Napier JR: Prehensile movements of the human hand. J Anat 89:564, 1955. 12. Tubiana R: Phalangisation du cinquième métacarpien. Acta Orthop Belg Suppl 3:120–121, 1958. 13. Tubiana R: Repair of bilateral hand mutilations. Plast Reconstr Surg 44:323–330, 1969. 14. Tubiana R: Architecture and functions of the hand. The Hand, vol 1. Philadelphia, WB Saunders, 1981, pp 82–86. 15. Tubiana R: Phalangization of the metacarpals. In Tubiana R (ed): The Hand, vol 3. Philadelphia, WB Saunders, 1988, pp 1190–1209. 16. Tubiana R, Roux J-P: Phalangization of the first and fifth metacarpals: Indications, operative technique, and results. J Bone Joint Surg 56A:447–457, 1974. 17. Tubiana R, Valenti P: Multidigital amputations. In Tubiana R, Gilbert A (eds): Surgery of the Hand and Lesions of the Upper Limb Affecting the Hand, vol 1: Skin and Skeleton. London, Martin Dunitz, 2001.
9 9
Distraction Lengthening for Thumb Reconstruction Ivan Matev, MD, DSc
HISTORY The ancient Greeks called the thumb antiheir or “opposing the fingers.” The Romans named the thumb pollex, which came from polleo, “to be strong.” The great Gaius Julius Caesar (100–44 BC) punished his war prisoners with bilateral thumb amputations, aware that by doing so, he condemned them to a horrible fate. In the late 1950s, while reading the Journal of the American Medical Association, I came across a 1921 publication by Vittorio Putti,9 the famous Italian orthopedic surgeon, reporting on several patients with leg-length discrepancy that had been successfully treated by gradual femoral lengthening. My interest was aroused with good reason, because I realized that an old idea of mine, namely, to create a thumb from the residual amputation stump through distraction, was indeed possible. At the Anglo-Scandinavian Symposium of Hand Surgery held in Lausanne and Vienna in May 1967, I presented a young patient with an amputation through the metacarpal head of the thumb that had been treated successfully by metacarpal lengthening, that is, distraction of the bone together with the soft tissues, resulting in a 2-cm stump elongation and creation of a new thumb. Until then, this type of thumb reconstruction had not been clinically implemented or published in the literature, a fact that has been duly confirmed by a number of authors, including Ulitzkii and Maligin,10 Kessler, Baruch, and Hecht,3 Cugola, Colognese, and Mercer,1 Vossmann and Zellner,11 Neff,7 Pollack,8 Foucher et al.,2 and Littler and Strickland.4 This chapter reflects personal experience I have had with 84 thumb amputations treated by the distraction method over a 30-year period (Fig. 9-1).
ESSENTIAL POINTS OF THE TECHNIQUE Skin of the Thumb Stump The skin of the stump should be soft and mobile. This point is most applicable to the stump end. If the skin is thickened and not pliable, a soft tissue coverage procedure should be performed prior to the osteotomy. A rotational flap from the vicinity, preferably a radiallyinnervated island flap from the dorsal surface of the index finger, is the coverage procedure I recommend. 131
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FIGURE 9-1. Schematic representation of the distractionlengthening method.
FIGURE 9-2. The minimum bone length needed for realization of thumb reconstruction through gradual metacarpal distraction.
Length of the Bone Stump
This is absolutely necessary to secure the exact alignment of the fragments when the device is set on the pins. A very important detail has to be attended to in children; the proximal pin should be driven at least 3–4 mm away from the metacarpal epiphyseal plate, because at a shorter distance, the distraction forces could damage the growth plate. At the completion of the operation, the pins are firmly fastened to the device by means of small screws. Adequate pin fixation may be achieved also by curving the end of the pins over the screws of the apparatus.
To be lengthened without difficulty, the metacarpal stump should have enough length. The best scenario is when the entire metacarpal is available, that is, in the case of an amputation through the metacarpal head. Normally, the length of the metacarpal in adults varies from 4.5 to 5.5 cm, which is a length that promotes the easy application of the distraction apparatus, with the proximal pair of pins piercing the proximal half of the metacarpal and the distal pins piercing the distal half. In this fashion, the middle of the metacarpal is free for the osteotomy. In my experience, the minimum length of the postamputation metacarpal remnant should be 3 cm (Fig. 9-2). At this length, mounting of the device, although extremely delicate, is still possible. Both distal pins of the apparatus go through the distal part of the metacarpal stump, while the most proximal ones are usually passed through the os trapezium.
Postoperative Period The postoperative period can be divided in two phases: (1) the period of gradual distraction and (2) the period of rest, when ossification of the interfragmental gap takes place.
The Distraction Phase How I Perform the Osteotomy The osteotomy is best done subperiosteally with a fine awl and chisel through a several-millimeters-long skin incision. Periosteum and bone are pierced with the awl several times transversally at different angles. Finally, the bone is fractured manually, that is, by osteoclasis. Prior to the osteotomy or osteoclasis, both pairs of pins, proximal and distal, are inserted into the metacarpal.
A full turn of the screws of the device corresponds to 1-mm distraction of the fragments, that is, lengthening of the metacarpal. Usually, this is the daily amount tolerated without complaint from patients, including children. Some ambitious patients insist on accelerated treatment and undertake two turns daily: one in the morning and one in the evening. I do not oppose this because, as shown by the results, if the distraction is
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hastened, spontaneous filling of the gap between the set-apart fragments is more likely to occur. A distraction period exceeding 25–30 days creates conditions for delayed ossification. Obviously, the constantly sustained and increased stress of periosteum and endosteum stimulates bone production. Usually, the distraction period lasts 1 month. In the meantime, a 3- to 4-cm metacarpal lengthening is accomplished. The patient should be checked on a weekly basis. If some loosening of the pins is seen, the small screws should be tightened. X-rays are done every other week to monitor the rate of the interfragment ossification. Gradual elongation of the skin, soft tissues, neurovascular bundles, and periosteum is well tolerated even when the initial length of the metacarpal bone is doubled (Fig. 9-3). Electromyography of the short muscles of the thumb during distraction may show slight quantitative alterations, returning to normal at the end of the lengthening period. When the lengthening of the metacarpal reaches 3–4 cm, that is, the bone is close to or doubled in length, some reduction of skin sensibility at the thumb tip may occur, but in the phase of rest, it subsides. Some patients, mainly young women, are willing to have the reconstructed thumb with length equal to that of the intact one. They turn the screws of the device until their goal is attained (Fig. 9-4). The optimal length of the newly formed thumb is taken to be the one that reaches the middle of the distal phalanx of the thumb. One should keep in mind that the new thumb lacks a new joint, and therefore from a functional point of view, the thumb should be shorter than its normal counterpart. After the postoperative pain subsides, the distraction begins. Lengthening is conducted on an
outpatient basis under direct supervision by the surgeon. Lengthening of the metacarpal stump up to 50% of its original length is readily achieved. Distraction of 70–80% or 2.5–3-cm length, equal to that of the thumb’s proximal phalanx, is accomplished without difficulty. In many patients of the series reviewed, a 100% lengthening was documented, and in three children, 110% distraction of the fragments relative to the initial length of the metacarpal was seen. I think that this is the limit of lengthening of an amputation stump in the hand through progressive distraction. In no other bone of the human skeleton is such a great percentage of lengthening possible.
A
B
The Rest Phase The rest phase usually lasts several months, the average being 3 months. In children and teenagers, ossification of a 3-cm interfragmental gap comes about within a shorter term, 2–3 months, whereas in adults, a longer period is needed. What the patient and the surgeon should know includes the following: ❚ The hand is to be maintained without additional immobilization. ❚ The device must be sufficient to keep both fragments stable. ❚ The pins should remain well fixed to the device. ❚ Every other week, X-rays should to be taken to monitor the rate of ossification of the gap between the fragments. The treatment is considered complete when full ossification of the interfragment space in length and width along the metacarpal is seen on the X-rays.
FIGURE 9-3. A 10-year-old boy. A, Before treatment. B, Elongation of the metacarpal to 108% of its initial length has been accomplished.
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A
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FIGURE 9-4. A 19-year-old female. A, The thumb at the end of the distraction phase. B, The small proximal phalanx remnant fell into a flexion contracture. MP joint capsulotomy and elongation of the short muscles of the thumb were done. The K-wire temporarily stabilized the MP joint in correction. C, D, Three years after completion of treatment. The metacarpal is lengthened 4.3 cm, that is, 100% of the initial length of the bone. The patient is very happy, but I am not. The functional capacity of the hand would be better if the reconstructed thumb was slightly shorter.
Stimulation of Osteogenesis During the rest period, consecutive X-rays show a gradual filling of the interfragment gap with bone substance. The central zone of the gap is the last to ossify. Whenever a gap persists between the two fragments, a slower thickening and consolidation is seen (Fig. 9-5). As a rule, the ossification process is limited to the frame of periosteum. The new bone slowly increases its density. In children
aged 8 to 12 years, a 3.5-cm gap fills spontaneously with bone within 2–3 months. In patients over age 20, spontaneous ossification of such a gap is seldom seen. Many surgeons wait 3, 4, or 5 months in the hope that the gap will consolidate spontaneously. I do not recommend such an approach, which gives rise to osteoporosis development in the separated fragments and needlessly prolongs the treatment.
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undertaken in three patients with an equivocal effect. In another two patients, aged 27 and 29, current produced by a battery pocket-size bonegrowth stimulator was employed, with an active needle electrode and an external electrode. The insulated conductive needle was inserted into the gap between the fragments, and the external electrode was attached to the skin of the ipsilateral forearm. The current magnitude that was used ranged from 2 to 4 A. Bone stimulation was carried out for 12 hours daily over a 3-week period. Enhanced bone production in the interfragment gap accelerating the metacarpal fusion was seen (Fig. 9-6).
Bone Grafting of the Interfragment Gap
FIGURE 9-5. A gap persists in the middle of the lengthened metacarpal. Do not remove the device. Let it stay for another month and then decide whether to graft or not.
In my clinical practice, I have seen several factors that contribute to the acceleration of ossification: 1. Vibration of the fragments through the device and the pins. Three of my patients continued to work on a vibration machine using the operated hand in a similar fashion as before the intervention. As a result, ossification of the gap occurred spontaneously in all three patients, who were over age 25. 2. A mild inflammatory process associated with edema of the thumb during the rest period. This developed in the channels of one or two pins owing to loosening. The X-rays of the two cases presenting inflammatory phenomena showed accelerated consolidation of the gap. 3. Electrostimulation of ossification. This was employed in a number of patients with delayed consolidation of the gap. A closed chain between the direct current source—a battery electrostimulator—and both Kirschner wires of the distraction device closest to the interfragment space was created. The wires were isolated from the skin and the rest of the distraction apparatus. The mode of current application was as follows: two to four sessions of 5- to 10-minute duration daily with a current magnitude of 15 A. Electrostimulation was carried out over 30 days. The type of bone electrostimulation described was
Delayed spontaneous consolidation of the gap between the separated fragments requires a bone graft to shorten the treatment period. If the osteogenic potential of periosteum, endosteum, and the other regenerating tissues of the fragments are exhausted, there is no other alternative but bridging the gap by a bone graft. During the first several years of application of the distraction-lengthening method for thumb reconstruction, I believed that the wait-and-see policy might bring about a successful outcome. Over the years, I have taken the position that it is preferable to adopt a more active approach, that is, to undertake an early bone-grafting procedure. It was evident that the rate of ossification during the first postosteotomy month, judged by the consecutive X-rays, points to the possibility of gap consolidation with or without using a bone graft. Early bone grafting, that is, in the first month after discontinuing the distraction-lengthening, which means during the second month after metacarpal osteotomy, considerably shortens the duration of treatment. It is by no means advisable to wait and lose valuable time. In my practice, the optimal graft is the one taken from the iliac crest, including the cortical layer, cancellous bone, and periosteum (Fig. 9-7). Fixation is performed by firmly wedging the graft into the longitudinal clefts of either fragment. Usually, additional fixation is unnecessary. The iliac crest graft affords stability and has a markedly expressed stimulating effect on fragments consolidation. The grafting procedure should be done without removal of the distraction device.
The Bone-Lengthening Device I use a one-piece distraction device. It has two screws to which two stainless steel arches are mounted, each of them fixed at both ends to quadrangular blocks. By means of small handles fixed to the screw ends,
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B
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FIGURE 9-6. A 27-year-old male patient. Because of delayed ossification of the interfragment gap, bone growth electrostimulation was used. A, Condition before treatment. B, There is no fusion of the fragments 3 months after the osteotomy. C, Stabilized pulsed current with a magnitude of 2–4 A was used. Metacarpal fusion occurred in 1 month. D, Condition 5 years after treatment. D
rotation of the screws is carried out, thus moving one of the arches in a direction opposite to the other arch. The two pairs of pins that pass across the proximal and distal half of the metacarpal are firmly fixed to the blocks by small screws (Fig. 9-8). Since 1967, when I described for the first time a simple distraction device for thumb reconstruction, various apparatuses have been proposed by many surgeons, including: unilateral,
bilateral, semicircular, and circular. It is my position that a universal distraction device for the hand does not exist. Each part of the hand has its own specific features and requires a specific device. I believe that the distraction device should be stable and lightweight, a one- or two-piece device, providing solid fixation of the K-wires, comfortable, easy to set, and easy to handle.
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A
B
FIGURE 9-7. Heavy laborer aged 45. The thumb was avulsed with the soft tissues. During the first operative stage, soft tissue coverage of the thumb stump was performed. A, Before the operation. B, The interfragment space was bridged by a cortico-cancellous-periosteal graft taken from the iliac crest. Note the wedging fixation of the graft in longitudinal clefts of the fragments. C, Two years after completion of treatment. C
The Response of the Carpometacarpal Joint to the Distraction Forces In the course of the distraction phase, and in the rest phase as well, the first carpometacarpal joint is subjected to continuous pressure by the distraction forces. It is difficult to estimate the amount of this pressure, which is altered during the two phases of treat-
ment (Fig. 9-9). In our series, X-ray evidence of changes in the carpometacarpal joint were not observed during the distraction phase. In three patients, I noted a certain narrowing of the articular space during the rest phase. Later, in the early post-treatment period, the joint space and the motion in the carpometacarpal joint became normal. In all three patients, the elongation had
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Deepening of the First Webspace As the result of amputation stump elongation, the first webspace is drawn together. Thus, a syndactyly results. If the web skin has a normal structure, it stretches enough for the interdigital web to prove adequately deepened. The problem is quite different in the presence of cicatricial changes in the web skin. In the latter case, the skin remains tense, with a crest displaced distally, and operative correction proves necessary. Usually, a Z-plasty procedure appears to be efficient for deepening the interdigital web. In a number of our cases, an innervated flap from the dorsal aspect of the index finger is used. During the operation, all thickened, scarred tissue that interferes with the abduction of the first metacarpal is released (Fig. 9-10).
FIGURE 9-8. The bone-lengthening device.
Distraction Lengthening of the Thumb Proximal Phalanx achieved over 90% of the original size of the metacarpal bone. Transient osteoporosis with isolated small cystic formation at the metacarpal base was observed on the X-rays of two adult patients. It is rather difficult to explain the cause of the changes in articular and para-articular bone structures: whether or not they are the consequence of pressure exerted on the articular cartilage by the distraction forces or result from the prolonged inactivity of the joint. Most likely, both factors are essential to the process.
A thumb that is amputated through the interphalangeal joint may be lengthened not only by metacarpal distraction but also by proximal phalanx elongation. The indications for such a reconstruction are disputable, since amputations through the interphalangeal joint or through the thumb distal phalanx are assigned under the heading “amputations compensated for,” where the function of the thumb is largely preserved (Fig. 9-11). In these cases, psychological factors prevail. In Figure 9-12, a young man aged 21 with an interphalangeal joint amputation of the thumb is shown. The indication for lengthening at the more distal amputation level is relative. In this case, psychological factors were of decisive importance.
The Distraction-Lengthening Method in Children
FIGURE 9-9. The tensiometer shows variation of the distraction forces during the distraction phase: occasionally approaching 5 kg.
My personal experience includes 12 children aged 8 to 14 years. As a rule, application of the distraction method in children does not differ significantly from that for adults. The devices used are of identical design but smaller in dimension.6 During the operation, special attention is paid to the transverse insertion of the two pairs of Kirschner wires. They should be placed as far as possible from the epiphyseal plate so they do not hamper the growth of the metacarpal (Fig. 9-13). The transverse osteotomy is done subperiosteally, across the middle third, through a small incision of the skin and a tiny opening in the periosteum.
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A
B
FIGURE 9-10. Deepening and resurfacing of the first webspace and palmar side of the lengthened metacarpal. A, Innervated flap from the dorsal side of the index finger including both neurovascular bundles is used, as well as an additional skin graft for the thumb base. B, The donor area is covered with a split-thickness skin graft.
The Nail Problem The new thumb has no joint or nail. The lack of the nail is very often a serious problem for young women. The simplest way to solve the problem is to polish the nail site, just as women normally do to their digital nails.
Expected Complications I have seen the following types of complications very rarely: ■ Drainage from the pintracts This happens when the pins are loose. Drainage never occurs if there is stable fixation of the four pins to the distraction device. ■ Angulation of the lengthened bone This happens when the distraction device is removed before complete ossification of the interfragment gap in length and width. In such a case one should reapply the device and wait an additional 6 weeks.
FIGURE 9-11. Schematic representation of the amputation levels: 1–compensated amputation zone, 2–partially compensated, 3–decompensated, 4–subtotal, 5–total amputation.
■ Contracture of the adjacent joint This is often seen in the metacarpophalangeal joint when the first metacarpal is excessively lengthened in the presence of a small proximal phalanx remnant. In this case, metacarpophalangeal capsulotomy and lengthening of the thumb muscles should be undertaken.
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B
A
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D
FIGURE 9-12. This 21-year-old male patient underwent an interphalangeal joint amputation. The proximal phalanx was lengthened by 2 cm. The indications for such treatment are relative; psychological factors usually dominate. A, B, Before and during treatment. C, D, Early result.
Disadvantages and Advantages Disadvantages of the bone-lengthening method are as follows: ❚ A full treatment course lasts several months. ❚ The reconstructed digit has no joint or nail. Advantages of the bone-lengthening method are as follows:
❚ Reconstruction of the thumb is performed by using the tissues available. ❚ The reconstructed thumb is covered by its own normally innervated skin. ❚ The reconstructed thumb is stable and free of osteolytic phenomena, which are often seen in other methods of reconstruction.
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FIGURE 9-13. This 10-year-old boy sustained a blast injury. The metacarpal was lengthened by 3.7 cm. The most proximal pin was placed too close to the epiphyseal plate. A, B, Condition prior to treatment. C, D, One year after removal of the device. D
References 1. Cugola L, Colognese L, Mercer M: L’allungamento del I. metacarpo per ricostruire una pinza pollice-digitale. Riv Ital Chir Mano 12:137–142, 1974. 2. Foucher G, Hultgren T, Merle M, Braun JM: L’allongement digital selon Matev: A propos de vingt cas. Ann Chir Main 7:210–216, 1988. 3. Kessler I, Baruch A, Hecht O: Experience with distraction lengthening of digital rays in congenital anomalies. J Hand Surg 2:394–401, 1977.
4. Littler JW, Strickland, JW: On Making a Thumb: A Decade of Surgical Effort, ed. by JW Strickland, London, Churchill Livingstone, 1994, pp 1–13. 5. Matev I: Gradual elongation of the first metacarpal as a method of thumb reconstruction. (Lausanne and Vienna, 1967). In: Stack G, Bolton H (eds): The Proceedings of the Second Hand Club. London, British Society for Surgery of the Hand. 1975, pp 431, 495–496. 6. Matev I: Thumb reconstruction in children through metacarpal lengthening. Plast Reconstr Surg 64:665–669, 1979.
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7. Neff G: Verlaengerung nach Matev bei Handfehlbildungen. Z Orthop 119:14–20, 1981. 8. Pollack H-J: Rekonstruktion des traumatisch amputierten Daumens durch kontinuierliche Distraktion nach Matev. Handchir Mikrochir Plast Chir 26:291–297, 1994. 9. Putti V: The operative lengthening of the femur. JAMA 77:934–935, 1921.
10. Ulitzkii GI, Maligin GD: Digital reconstruction by distraction of the metacarpals. Ortop Travmatologia Protezirane 32:55–60, 1971 (Russian). 11. Vossman H, Zellner P-R: Verlaengerunq des I. Mittelhandknochens bei Verlust des Daumens nach Matev. Plast Chir 3:49–54, 1979.
10 10
Digital Pollicization for Traumatic Thumb Loss Joseph Upton, MD J. William Littler, MD
“God put His stamp on each person so that not one man can be like another.” — Mishna of the Talmud
The thumb, called “pollex” for its strength, is the single most important component of the functioning hand. The evolution of thumb reconstruction closely parallels the development of the surgical subspecialty of hand reconstruction over the past 150 years, as imaginative surgeons have either embraced known principles from other surgical specialties or created new ones for the restoration of the injured thumb.42 Although the recent era of microvascular tissue transfer has replaced many of the traditional indications for pollicization, the creation of a functioning thumb by transposition of the index finger or other parts of the hand is still applicable in many clinical situations. In this chapter, the history, principles, and techniques of pollicization of the severely injured or mutilated hand are reviewed. Many of these operations are still very applicable to present day posttraumatic thumb losses and congenital differences.
HISTORY Phalangization The early surgical efforts to both salvage and utilize the remaining parts of a hand following a severe injury were best documented in Europe. The historian must be literate in both the German and French medical written languages to gain a full understanding of what European surgeons were doing independently of one another prior to World War II.6,60 The earliest attempt to reconstruct a functional thumb is credited to a French physician, Huguier, who in 1852 deepened the intermetacarpal space 25 days after the thumb and index finger of his patient had been bitten off by a horse. During his presentation to the Surgical Society of Paris, he noted that his patient had a 2.5-cm gap and was able to “grasp a medium-sized book.” Two years later, Huguier performed a similar procedure on a railroad mechanic.32 Over 30 years later, Guermonprez23 described the surgical efforts of Verodart, another Frenchman, who, for a similar injury, resected the index metacarpal in an effort to open the first webspace and to further isolate the thumb metacarpal.63 In 1887, Guermonprez wrote a monograph entitled “Some Resections and Reconstructions of the Thumb,” in which nonusable parts of a mutilated index finger were transferred to a thumb stump “without damaging 143
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the blood vessels.”24 Like most early surgical innovators of his era, he practiced the early digital transpositions on human cadavers and primates before he attempted them in a clinical setting.
osteoplasty usually created a longer, floppy, bulky thumb with no sensation (Figs. 10-3 and 10-4).
Toe Transfer Osteoplastic Reconstruction While the French surgeons were reconstructing the damaged thumb by creation of a first webspace with or without the transposition of parts from the injured hand, Carl Nicoladoni, Professor of Surgery in Innsbruck, Austria, was employing distant parts. His first osteoplastic reconstruction involved a patient with a degloved thumb that was covered with a distant pectoral pedicle flap, dramatically illustrated by Littler’s drawing, which shows the patient’s nipple on the radial border of the new thumb (Fig. 10-1).42,51,52 Refinements in osteoplastic techniques soon followed. Noesske, from Dresden, Germany, although not aware of Nicoladoni’s work, introduced the free bone graft into the tube pedicle (Fig. 10-2). He preferred toe phalanges because of their similarity to hand phalanges and lack of resorption54,55 but also reported his experience with free tibial corticocancellous bone grafts. Recognizing the limitations of these staged osteoplastic reconstructions, hand surgeons introduced many variations of flaps and grafts over the next 50 years.1,3,48,58 As more thumb reconstructions were attempted, both the anatomic and functional problems with phalangization of the metacarpal and osteoplastic reconstructions became well recognized. Phalangization often left a bizarre appearance with limited function, and multistaged
FIGURE 10-1. A, Nicoladoni’s first thumb avulsion case, in 1891, in the thumb with a contralateral pectoral tube pedicle flap. Skeletal structures, including the distal phalanx and interphalangeal joint, were intact. The nipple and areola were left on the flap. B, Carl Nicoladoni. (From Littler JW, On making a thumb: One hundred years of surgical effort, J Hand Surg 1:35–51, 1976; with permission.)
At the turn of the century, the resourceful Nicoladoni next introduced the concept of transferring the most likely substitute for the thumb—a toe—as a pedicle flap to the hand (Fig. 10-5).51–53 In 1903, he analyzed three patients with deformities he had reconstructed in 1900. In his discussion of the first case, he even suggested using an uninjured digit from the opposite hand. Prior to World War I, Joyce reported the use of a contralateral normal ring finger pedicle transfer for thumb reconstruction.34 Over the next 30 years, surgeons chronicled their experience with the use of pedicled greattoe,37,38,56 second-toe,13,35 and index finger31,36 transfers for thumb reconstruction. Collectively, these reports recognized the improved contour and appearance as well as potential for sensation while also providing detailed descriptions of congestion (treated with leeches), delayed wound healing, partial or complete loss, and extreme patient discomfort. Luksch, a student of Nicoladoni, was one of the first German surgeons to look for spare parts in the upper extremity. He described the transfer of a normal contralateral index finger in a staged thumb reconstruction. He is also credited with the second digital transposition after Guermonprez in 1903.46 Within three decades, critical evaluations of the three available methods of thumb reconstruction began to appear. Phalangization, which often sacrificed the
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FIGURE 10-2. Neurovascular myocutaneous osteoplastic transfer. A, Radiograph of a hand following a severe traumatic injury. The thumb CMC joint is intact; the index finger is the only remaining intact ray of the hand. B, Plan of the procedure shows an intact palmar skin bridge as the little finger metacarpal is transferred as a neurovascular island on top of the thumb CMC joint. The ulnar artery and its venae comitantes, the entire abductor digiti quinti including its origin on the pisiform, and the flexor carpi ulnaris will remain intact. C, The dorsoulnar skin over the little finger metacarpal will articulate with the index finger. D, An intramedullary pin provides stable fixation. The ring finger metacarpal was resected to permit easier closure. E, Location of the dorsal skin closure and rotation of skin over the dorsal surface of the index metacarpal. A split-thickness skin graft was needed to cover the donor site. F, The clinical appearance of the hand demonstrates a stable and effective thumb-to-index finger pinch. William Littler performed this procedure in 1952.
FIGURE 10-3. Phalangization versus osteoplastic reconstruction. Top, With a traumatic loss at the metacarpophalangeal joint level, a useful thumb can be gained either by deepening the first webspace (phalangization) or by lengthening through an osteoplastic reconstruction. These two procedures provide basic pinch and grasp, and neither provides the specialized features of the normal thumb terminal phalanx. The terminal ungual phalanx (neo 2.5) is the evolutionary product of a fusion of the second (m 2.0) and third (d 1.2) primitive phalanges (pr 2). These primitive thumb phalangeal lengths were determined from the thumb metacarpal length (5.2) by the finger phalangeal ratio, 1:1.618 (Fibonacci sequence). The 5.2 length of the middle and index PIP joints is comparable to that of the thumb metacarpal. (ip ⫽ interphalangeal, mp ⫽ metacarpophalangeal, neo ⫽ ungual terminal phalanx, I ⫽ thumb, II ⫽ index, III ⫽ middle, pip ⫽ proximal interphalangeal joint, dip ⫽ distal interphalangeal joint, d ⫽ distal phalanx, m ⫽ middle phalanx, tr ⫽ transverse head of adductor pollicis muscle, ob ⫽ oblique head of adductor pollicis muscle.) Bottom left, The length differential between a phalangization of the left thumb metacarpal compared to the uninjured side. The web has been lined with a full-thickness skin graft. Bottom right, Thumb length has been restored with an infraclavicular pedicle flap with clavicular bone. The coverage is unstable, bulky, and without sensation prior to defatting and a neurovascular island flap transfer from the ulnar side of the middle finger. (From Littler JW. On making a thumb: One hundred years of surgical effort. J Hand Surg 1:35–51, 1976; with permission.)
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FIGURE 10-4. Osteoplastic reconstruction and ring digital transposition. A, A crush injury to the thumb with total soft tissue avulsion and loss of the distal phalanx has been resurfaced with an abdominal pedicle flap. The extrinsic flexor and extensor tendons have been saved. B, The soft tissue coverage was bulky, unstable, and insensate. Index and middle fingers are intact, but the ring finger was damaged at the PIP level with intact neurovascular structures. The proximal third of the terminal phalanx has been lost. (FPL ⫽ flexor pollicis longus tendon, IV ⫽ ring finger, I ⫽ thumb) C, With its distal phalanx and terminal pulp intact, the ring finger is transposed as a neurovascular island to reconstruct the distal thumb, which has intact extrinsic and intrinsic tendons and MP joint. Dorsal veins were ligated, and venous drainage was maintained through venae comitantes. The donor site was closed primarily, and a new intermetacarpal ligament was constructed. D, The final result shows good contour and stability. The IP joint has been fused, and sensation within the reconstructed thumb is perceived in the ring digit. William Littler performed this digital transposition procedure in 1955. (From Littler JW. On making a thumb: One hundred years of surgical effort. J Hand Surg 1:35–51, 1976; with permission.)
first interosseous muscle, was the easiest to perform but produced limited mobility and diminished strength and sensibility.46,57 Pedicled toe transfer provided some surprisingly good outcomes but had limited sensation and maximal patient discomfort.14,42 Osteoplastic reconstructions provided desired elongation but yielded poor sensation, limited motion, atrophic changes, and poor skin fixation.14 In several published reports, digital
transposition outcomes were not endorsed by most hand surgeons because of limited motion, excessive length, and altered sensibility.
Digital Transposition Another option for thumb loss was to transfer either an intact or injured portion of the hand into the thumb
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FIGURE 10-5. Second-toe transfer to hand. A, Drawing depicting Nicoladoni’s first pedicled second-toe transfer in 1900.53 B, The little finger of this patient, is attached to the second toe of the right foot. J.W. Littler, MD, is in the middle reviewing a radiograph with a nurse. C, Six months post-transfer, the little finger has good contour, appearance, and protective sensation. D, The extrinsic flexor and extensor tendons of the toe have been joined to recipient tendons. Intramedullary bone placement has resulted in a solid skeletal union. (From Littler JW: On making a thumb: One hundred years of surgical effort. J Hand Surg 1:35–51, 1976; with permission.)
position. Before World War II, the fundamental techniques for digital transposition were described first by Noesske54,55 and 18 years later by Iselin,25 both of whom espoused the transfer of an independent index finger. Following Iselin’s suggestions, Zsulyevich presented an excellent reconstruction of an index-to-thumb transposition secured with an intramedullary bone peg.7 Bunnell from the United States presented a physiological thumb reconstruction by transfer to an index metacarpal and proximal phalanx.8 After the war, Bunnell directed the U.S. Army Hand Surgical Centers, where osteoplastic reconstructions (Nicoladoni) were initially popular for thumb loss. The unsatisfactory rigidity, poor sensation, poor circulation, bulk, and appearance stimulated many of Bunnell’s hand surgeons to refine pollicization techniques with an emphasis on reconstruction of the normal motor systems, basal joint mobility, and index finger sensibility.59 Early published reports often showed a cleft
that required pedicle graft coverage and unsatisfactory contours and scars.7 During this time, Hilgenfeldt, working independently in Germany, recognized the primal importance of sensation as he developed an extensive experience with digital transposition to the thumb, which was finally published in 1950 in German29,30 and (regrettably) many years later in English. He transferred any useful portion of an injured digit to the thumb but preferred the middle ray for reconstruction of subtotal thumb loss at the metacarpal level. Dorsal tendons and veins were detached if necessary, but in all cases, a palmar skin bridge was retained to ensure the viability of the transferred part (Fig. 10-6A). His first pollicization was performed in 1943, and in his case history, Hilgenfeldt noted that this adult patient was dissatisfied with the “thumb feeling” that was perceived on the middle finger.29,30
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FIGURE 10-6. Early digital transpositions. A, Otto Hilgenfeldt, MD, worked at the same time in Germany, where he accumulated a large series of digital transpositions. He initially preferred not to use an uninjured index ray, but rather employed transposition of the middle finger. Characteristic of his early reconstructions was the palmer skin bridge and his precise skeletal sculpting. B, Jean Gosset, MD, of France was one of the first to transpose the index ray into the thumb position following traumatic thumb loss. The index ray was isolated as a neurovascular island with ligation of the proper digital artery to the radial side of the middle finger. A palmar-based flap lines the first webspace, and bone fixation at the metacarpal level was stabilized with an intramedullary bone peg. This peg afforded adjustment of rotation with the proper attitude of a normal thumb. Note that the tip of the transferred index finger (now the new thumb) was amputated to make it the same length as a thumb. (From Littler JW. On making a thumb: One hundred years of surgical effort. J Hand Surg 1:35–51, 1976; with permission.)
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Gosset of Paris20,21 (Fig. 10-6B) and Bunnell7,8 were among the first to cut the palmar skin bridge during digital transpositions. They noted that the simple act of cutting this “umbilical cord” provided much greater versatility to the procedure. Gosset’s classic work described the transfer of any of the four fingers to the thumb position and also stressed the importance of tendon and/or muscle transfers to balance the reconstructed thumb. The British surgeons were better known for their efforts to lengthen the existing thumb with a bone peg and local flaps.17,33 A number of early pollicizations were performed,18 and emphasis was placed on the effectiveness of transferring digital stumps to the thumb position.9,11 By the midportion of the twentieth century, posttraumatic pollicization had became a well-recognized and frequently performed procedure (Fig. 10-7).
Neurovascular Island Perhaps the most important concept for thumb reconstruction occurred four decades earlier in related surgical specialties, as Gersuny,16 Monks,50 and Esser15 described the transfer of skin with and without hair for facial reconstruction using island flaps based on the superficial temporal artery and vein. Many series of postwar thumb reconstructions were reported, and the most important appraisal again focused on the critical importance of sensation.49 Through his elegant drawings and imaginative reconstructions, Littler39–41,43,44 described the anatomy of neurovascular island transfers and, with Tanzer59 and Tubiana61 among others, refined pollicization techniques to our present standards. Although he emphasized the importance of saving dorsal veins whenever possible, Littler demonstrated that with careful dissection the transposed digit could predictably survive on a digital artery and its venae comitantes.41,42 Over the next three decades, he refined the technique of digital pollicization to its present status.39,40,43,45 The American surgeons placed great emphasis on the importance of length sensibility and balance of biomechanical forces moving the new thumb. Controversy still existed across the Atlantic Ocean because many European surgeons still preferred to transfer one of the ulnar three fingers instead of the index. Guellette from France echoed early protests that would later be made by the Germans: “Has not the hand found its function diminished by the transplant of a healthy digit?”22 The thalidomide tragedy in Western Europe allowed Buck-Gramcko to apply these principles to the child with congenital absence or severe hypoplasia of the thumb.4,5 Influenced by both Bunnell and Littler, Chase
further refined osteoplastic techniques with the transfer of sensate neurovascular island flaps to the ulnar surface of the new thumb and by stabilizing the floppy palmar tissue with suture along the midaxial line of the thumb.12 Stabilization of palmar tissue and the introduction of sensation with the neurovascular island transfer from an adjacent digit revived osteoplastic methods of reconstruction. Biemer next introduced the distally based osteocutaneous island flap based on the radial artery and use of the antebrachial cutaneous nerve of the forearm as a single-stage reconstruction.2 During the past 40 years, creative hand surgeons from all over the globe have further refined both transposition and osteoplastic techniques. Paramount to all contributions was the importance of sensation; a mobile, unscarred first webspace; proper length; and mobility.43 The advent of sophisticated microvascular transfers during the last three decades has supplanted osteoplastic thumb reconstruction and pollicization for distal phalangeal loss. Digital pollicization for proximal traumatic thumb loss still has a place in primary reconstruction. Unquestionably, the most frequent use of these techniques is for children and adults with congenital differences (Table 10-1).
PRINCIPLES OF DIGITAL POLLICIZATION The ideal reconstruction of the amputated or severely traumatized thumb ray is to replace the amputated part if sufficiently intact or to reconstruct it with similar tissue, which usually involves an immediate microvascular transfer of amputated parts from the hand or an elective transfer of composite tissue from the foot. However, not all hand surgeons are skilled microsurgeons. The next best alternative is to reconstruct as normal a thumb as possible with available parts. In his many contributions Littler emphasized the unique characteristics of the thumb,15,39–41,43–45,49 which have evolved with time and cannot be duplicated despite our most elegant pollicizations or microvascular toe transfers. These include the dorsal curvature of the extended thumb; the larger radial condyle of the proximal phalanx, which provides a conjoint rotation in pronation of interphalangeal joint flexion; the depressed ulnar pulp surface, which perfectly matches the radial index pulp; the breadth of the distal phalanx with its septal connections; and the unique mobility provided by the basilar saddle joint.27,62 To function as a useful thumb following trauma, a reconstructed thumb ray must include (1) length equal to the opposite or uninjured thumb, (2) mobility and stability of the metacarpal remnant, (3) strength provided
10 FIGURE 10-7. Transposition of normal index finger to thumb. A, A radiograph showing the dominant hand of a young laborer following sharp amputation at the metacarpophalangeal joint level. B, The Littler incisions show dorsal (“D”) and volar (“V”) flaps and incisions around the base of the index finger, which will be transferred, as a vascular island. Point “X” on the index flap will lie at the base of the thumb metacarpal. This exposure will permit a careful dissection of skeletal, muscular, and neurovascular structures and avoid a contiguous scar across the first webspace. C, The “V” flap has been advanced, inset to create a broad new first webspace. D, The index ray has been recessed, rotated and stabilized to the thumb metacarpal with an intramedullary bone peg. Additional resection of the index metacarpal has broadened the first webspace. (dip ⫽ distal interphalangeal joint, pip ⫽ proximal interphalangeal joint, mp ⫽ metacarpophalangeal joint, I ⫽ thumb, II ⫽ index, III ⫽ middle metacarpal) E, F, The bone union is solid, and the clinical appearance mimics that of the normal thumb and first webspace.
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TABLE 10-1
Preferred Reconstructive Options for Traumatic Amputations and Congenital Differences of the Thumb
Level
Reconstruction
Trauma Distal phalanx
Nothing Pulp transfer Toe transfer
Interphalangeal joint
Nothing Modified (trimmed) toe transfer Distraction lengthening
Proximal phalanx
Same as IP joint
Metacarpophalangeal joint
Toe transfer (second or modified great toe)
Level of Amputation The level of amputation best defines thumb loss. Most classifications start with the obliquity and amount of soft tissue pulp loss and then extend down the axial skeleton from tuft of distal phalanx through metacarpal base. We prefer to categorize our reconstructions into one of two levels: phalangeal and metacarpal.27,62 Very few thumb losses at the phalangeal level will require a neurovascular island pedicle flap (Figs. 10-7 to 10-9) or complete or partial pollicization on a cutaneous pedicle flap (Fig. 10-10). Immediate reattachment of amputated parts (Fig. 10-11), rearrangement of injured parts (Figs. 10-12 and 10-13) or secondary toe transfers are preferred in all but the most unique circumstances. Distraction lengthening at the phalangeal or metacarpal level47 is very effective because the desired length is achieved with intact sensation.
Distraction lengthening Digital transposition of injured part Metacarpal
Digital transposition (pollicization) Toe transfer Prosthesis
Carpometacarpal joint
Index rotation-recession
Congenital Hypoplasia Blauth III B, C
Index pollicization
Blauth IV
Index pollicization
Congenital Absence Blauth V
Index pollicization
SHSF syndrome
No reconstruction Partial great or fifth toe (if present) transfer
Constriction ring syndrome
Same Distraction lengthening Digital transposition (pollicization)
IP joint: thumb interphalangeal joint. SHSF: split hand split foot syndrome.
by the cone of thenar intrinsic muscles and extrinsic flexors and extensors, (4) sensation, (5) proper position of the metacarpal for precise pinch and grip, and (6) an unscarred webspace between the thumb and its next digit or opposition post, lined by full-thickness tissue.39,45 The importance of sensation cannot be overemphasized. Although no thumb reconstruction will achieve all of these goals to perfection, plan each reconstruction to make as normal a thumb as possible. The preferred method of reconstruction at the different levels of thumb loss are outlined in Table 10-1.
Indications for Digital Pollicization There are clear differences in both the aesthetic and functional outcomes of thumbs reconstructed by toe transfer, pollicization of adjacent parts, or osteoplastic techniques.62 The method that is chosen depends on the level of amputation, the functional needs and desires of the patient, spare parts available, and experience and expertise of the surgeon. In general, pollicization by digital transposition provides a thin thumb with superior mobility. Toe transfers are very thin (second-toe, great-toe wraparound) or excessively thick and broad (great toe or trimmed great toe), with excellent stability and limited mobility. Osteoplastic reconstructions are very rarely performed today and result in a stiff, broad, floppy thumb with limited sensation. The sole indication might be the degloved thumb with an intact metacarpophalangeal joint and proximal phalanx. A pedicle flap combined with neurovascular island transfer12 is a good alternative when microvascular transfers are neither available nor practical. Phalangization of the thumb metacarpal (see Fig. 10-3) is a procedure of historical interest at this time but is a technique that can be used effectively in a rural setting where access to modern technology or rehabilitation is unavailable. At the present time, digital transposition (pollicization) is primarily indicated in posttraumatic injuries with thumb loss at the metacarpal level with partial or complete loss of the thenar muscle cone. Often a poorly functioning or damaged index or other digit is of better use to the hand if it is transferred to provide length, stability, and sensation to the injured thumb (see Figs. 10-8 to 10-10).
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FIGURE 10-8. Index finger to thumb transposition with secondary shortening. A, The thumb has been amputated through the base of the proximal phalanx. On the index finger, the radial neurovascular bundle and both flexor tendons have been severed. The index remains stiff following primary flexor repair of all structures. B, The planned incisions will isolate the index finger for transposition on top of the thumb metacarpophalangeal joint. The transfer is based on the ulnar neurovascular bundle. C, The excess length of the transposed digit is seen on lateral radiographs. The extensor tendon has been repaired with a zigzag stainless steel suture seen dorsal to the MP joint. D, A chevron-shaped skin excision is combined with skeletal shortening and arthrodesis at the DIP joint level of the transposed index digit. E, A 1-year postoperative photograph showing comparable length, healed incisions, and the narrow appearance of the new thumb.
No single method of thumb reconstruction serves all patients well. The method that is chosen should be carefully planned to achieve the proper marriage between patient and procedure. The basic principles of thumb reconstruction should guide the surgeon to what Hentz would term a “strategic redeployment”27 of available parts. Digital pollicization following traumatic thumb loss remains a valuable reconstructive option for the more proximal losses. Older procedures such as excessive deepening of the first webspace at the metacarpal level, the English “cocked hat” procedure,10,19 and the classic osteoplastic reconstructions are rarely indicated today. Because the variety of malformations in children with congenital differences is so varied, it is difficult to make broad generalizations. At the present time, we occasionally find a place for digital transposition in the constriction ring syndrome (CRS) and the chorionic vil-
lus sampling (CVS) thumb losses where the proximal anatomy is normal. We routinely perform modified index pollicizations5,12 for thumb absence and hypoplasias classified at the Blauth III B and C, and IV levels. In a few children, pollicization has been performed for a very small, unstable Blauth III A thumb. The sole exceptions for toe transfer are those with the syndromic or nonsyndromic cleft hand-foot syndrome with no thumbs and the occasional constriction ring syndrome child with a proximal thumb loss. In adults with congenital aplasia or severe hypoplasia, a rotationrecession osteotomy of the index metacarpal plus a rebalancing of the extrinsic extensors or intrinsic muscles is the treatment of choice (Fig. 10-14).26 The singular procedure of index pollicization for thumb absence or hypoplasia perhaps remains the most intricate, elegant and dramatic operation in the field of hand surgery.
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FIGURE 10-9. Normal ring finger transposition to thumb. A, A radiograph showing amputation of the thumb at the base of the proximal phalanx in a 7-year-old boy following a roping avulsion injury (he was trying to emulate his father, who was a fireman). B, Incisions are outlined for the phalangeal transfer of the ring finger to thumb. C, The ring finger flexor superficialis tendon has been severed and the profundus flexor saved before the digit is passed through a subfascial tunnel to the amputation site. D, Intramedullary wire fixation has been prepared for fixation of the transferred digit. E, Fixation of the new thumb has been secured. The ring finger proximal phalanx will be ablated and the webspace closed. F, A radiograph 3 years later showing narrowing of the third interdigital webspace. G, Hand function is excellent. The new thumb flexion is motored by the ring finger flexor digitorum superficialis. The thumb flexor digitorum profundus had been lost during the original avulsion injury. This boy later became a member of the U.S. Marine Corps. (From Littler JW. Finger pollicization for traumatic loss. In May JW, Littler JW (eds): McCarthy’s Plastic Surgery, vol 8: The Hand and Upper Extremity. Philadelphia, WB Saunders, 1990, pp 5143–5144; with permission.)
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FIGURE 10-10. Injured index finger to thumb transposition as pedicle flap. A, In a skill saw injury, a 32-year-old building manager amputated his thumb at the PIP level and severed both flexors and neurovascular bundles to the index finger and the radial bundle and deep flexor to the middle finger. The thumb tip was not reattachable. Primary repair of all other structures was performed the night of injury. B, Six months later, the index finger remains stiff but with good protective sensation. The middle finger is rotated owing to a malunion of the proximal phalanx. C, The distal half of the index finger was transferred as a pedicle flap to augment the thumb loss. Four weeks later, the pedicle was detached, and the unscarred portion of the digital nerves within the pedicle were joined to the thumb nerves proximal to the level of amputation. The new thumb interphalangeal joint was left tenodesed and the long finger malunion corrected. D, Five years later, the patient continues to have strong thumb-to-middle-finger pinch and grasp, a moving two-point discrimination of 7 mm, and intact metacarpophalangeal motion. His job performance has been unaffected.
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FIGURE 10-11. Microvascular transposition of multiple spare parts. A, Amputated potential spare parts are assembled after the right, dominant hand in this teenage girl was caught in an industrial machine, which assembled large boxes. B, The thumb has been amputated at the interphalangeal joint level with volar soft tissue loss; the index and middle fingers are detached at the proximal metacarpal level; and the ring finger ray is devascularized and incompletely amputated at the distal metacarpal level. The entire metacarpophalangeal joint of the little finger ray has been shredded with intact flexor tendons and neurovascular bundles. C, Postoperative radiograph shows the reallocation of parts: 1 ⫽ distal middle finger to thumb, 2 ⫽ proximal middle finger to little finger as a vascularized metacarpophalangeal joint, 3 ⫽ flexor tendon as radial collateral ligament to reconstructed middle finger, 4 ⫽ nonvascularized intercalated bone graft to reconstructed middle metacarpal, 5 ⫽ devascularized ring to middle ray transposition. D, Six months later, the patient returned to work with a mobile thumb; a broad, unscarred webspace; and full metacarpophalangeal and proximal interphalangeal joint flexion of the middle and little fingers. Two-point discrimination was 7 mm on both sides of the thumb and normal (4–5 mm) in both digits.
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FIGURE 10-12. Index finger transposition to partially lost thumb. A, The gloved hand of this experienced furniture maker became caught in a router machine. The thumb was severely mutilated, with soft tissue and skeletal loss at the phalangeal level. All tendons and neurovascular structures to the index, middle, and ring fingers were severed, and the palmar surface of the first webspace was lost. The ring finger tendons have been repaired. All structures to the middle finger have been repaired, along with both arteries and nerves to the index finger, which will be used to reconstruct the thumb. B, The thumb parts are viable with an intact neurovascular bundle. The tan template outlines the loss of tissue within the webspace, and the methylmethacrylate mold of the opposite thumb mimics perfectly the desired length and contour. The germinal matrix has been lost, and the distal half of the thumb ungual phalanx is viable. C, A radiograph of the thumb at the time of injury. D, A radiograph showing that the index proximal and distal interphalangeal joints will become the thumb metacarpophalangeal and interphalangeal joints. The step-cut within the bone combined with cortical screws provided stable fixation. E, Appearance at the time of index-finger-to-thumb transposition. Dorsal and palmar soft tissues were transferred, and index neurovascular bundles remained intact. At the same time, a free lateral arm fasciocutaneous flap was used to construct a new first webspace. F, Excellent extension was achieved following a flexor tenolysis 1 year after surgery. G, The patient needed strong flexion and a good power pinch to return to his work as a master furniture and cabinet maker. Continued
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FIGURE 10-12 cont’d. H, A broad, unscarred webspace remains after flap debulking. The contour and appearance are excellent. I, The index metacarpal has been shortened. The line of metallic hemoclips outlines the careful dissection of the lateral arm flap pedicle (posterior superior radial collateral artery) to the radial artery.
FIGURE 10-13. Elective index finger transposition to thumb. A, A 32-year-old left-handed man presented following an incomplete excisional biopsy of a soft tissue mass involving his left hand. Diagnosis was epithelioid sarcoma with positive margins. B, This radiograph outlines the planned skeletal resection. Parts from the normal index finger will be used to reconstruct the metacarpal and metacarpophalangeal joint of the thumb. C, The thumb and index rays have been ablated with all thenar intrinsic muscles contiguous to the tumor. The flexor tendons to the index finger were used to motor the thumb. D, Radiograph following transposition.
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FIGURE 10-13 cont’d. E, A free lateral arm flap was simultaneously transferred to construct a new webspace. F, Appearance 1 month after a full course of radiation to the reconstructed thumb and hand. The entire hand is swollen, stiff, and painful. G, H, Twelve years later, the hand remains very stiff with an immobile thumb, which does have protective sensation. A secondary flexor and extensor tenolysis combined with a metacarpophalangeal joint release was not effective in restoring motion following radiation. The patient uses it as a post and has transferred hand dominance to his right side.
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FIGURE 10-14. Index finger pollicization for a congenital hypoplasia in an adult patient. A, The right hand of an adult with bilateral radial dysplasia shows the autopronation of the index finger, which had been used as a substitute for the hypoplastic thumb. B, A radiograph showing a widening of the first webspace and a very hypoplastic thumb with intact metacarpals and phalanges. Resection of the nonfunctional thumb and repositioning of the index finger is planned. C, A rotation-recession osteotomy of the index metacarpal is a good alternative for the adult patient. The interosseous mitek anchor suture secures the tendon transfers for palmar abduction (palmaris longus) and adduction (ring flexor digitorum superficialis). The extensors were shortened and flexors left intact. D, Excellent contour and appearance of the webspace has been maintained. E, F, The new thumb is more strategically positioned for both strong pinch and grasp.
References 1. Albee F: Synthetic transplantation of tissue to form a new finger with restoration of the function of the hand. Ann Surg 69:379–385, 1919. 2. Biemer E, Stock W: Total thumb reconstruction: A onestage reconstruction using an osteocutaneous forearm flap. Brit J Plast Surg 36:512–555, 1983. 3. Broadbent TR, Woolf RD: Thumb reconstruction with contiguous skin-bone pedicle graft. Plast Reconstr Surg 25:494–501, 1960. 4. Buck-Gramcko D: Pollicization of the index finger: Method and results in aplasia and hypoplasia of the thumb. J Bone Joint Surg 53A:1605–1616, 1971. 5. Buck-Gramcko D: Thumb reconstruction by digital transposition. Orthop Clin North Am 8:329–342, 1977. 6. Buck-Gramcko D, Nicoladoni, and the Central European school: In Landi A (ed): Reconstruction of the Thumb. London, Chapman Hall, 1989, pp 27–34. 7. Bunnell S: Physiological reconstruction of a thumb after total loss. Surg Gynecol Obstet 52:245–248, 1931. 8. Bunnell S: Digit transfer by neurovascular pedicle. J Bone Joint Surg 34(A)772–774, 1952. 9. Campbell Reid DA: Reconstruction of the thumb. J Bone Joint Surg 42B:444–550, 1960. 10. Campbell Reid DA: Thumb lengthening by the Gilles method. Handchir 13:46–50, 1981. 11. Campbell Reid DA: Pollicization of stumps. In Landi A (ed): Reconstruction of the Thumb. London, Chapman Hall, 1989, pp 128–142. 12. Chase RA: An alternate to pollicization in sub-total thumb reconstruction. Plast Reconstr Surg 44:421–430, 1969. 13. Clarkson P: Reconstruction of hand digits by toe transfer. J Bone Joint Surg 37A:270–276, 1955. 14. Dial DE: Reconstruction of the thumb after traumatic amputation. J Bone Joint Surg 21:98, 1939. 15. Esser JFS: Island flaps. New York Med J 106:264–265, 1917. 16. Gersuny R: Plastischer Ersatz der Wangenschleimhaut. Zentrabl Chir 14:706–707, 1887. 17. Gilles HD: Autograft of amputated digit: A suggested operation. Lancet 1:1002, 1940. 18. Gilles HD, Cuthbert JB: Operation for pollicization of the index finger. In Medical Annual. Bristol, England, J Wright and Sons, 1943, pp 262–266. 19. Gilles JD, Millard DR: The Principles and Art of Plastic Surgery. London, Butterworths, 1957, p 486. 20. Gosset J: La pollicisation de l’index (technique chirurgicale). J Chir (Paris) 1949;65:403–411. 21. Gosset J, Sels M: Technique, indications et resultats de la pollicisation du 4e doight. Ann Chir 18:1005–1014, 1964. 22. Guellette R: Etude critique des precedes de restauration de pouce. J Chir (Paris) 36:1–23, 1930. 23. Guermonprez F: Essai de cheiroplastie: Tentative de restauration du pouce au moyen d’un debris de medius. Paris, Soc Chir Plast, 28 July, 1886. 24. Guermonprez F: Notes sur Quelques Resections et Restaurations de Pouce. Paris, P Asselin, 1887. 25. Iselin M: Reconstruction of the thumb. Surgery 2:427–429, 1938.
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26. Hentz VR, Littler JW: Abduction-pronation and recession of the second (index) metacarpal in thumb agenesis. J Hand Surg 2:113, 1977. 27. Hentz VR, Littler JW: Traditional techniques for thumb reconstruction: Guidelines for indications. In Landi A (ed): Reconstruction of the Thumb. London, Chapman Hall, 1989, pp 170–186. 28. Herndon J, Littler JW, Watson FM: Traumatic amputation of the thumb and three fingers; treatment by digital pollicization. J Bone Joint Surg 57A:708, 1975. 29. Hilgenfeldt O: Operativer Daumenersatz und Beseitigung von Greifstorungen bei Fingerverlusten. Ferdinand Enke. Stuttgart, Verlag, 1950. 30. Hilgenfeldt O: Fingerstumpfverlangerung und Daumenbildung durch Knockenvorverpflanzung. Handchir 1:38–45, 1969. 31. Horhammer C: Beitrag zur plastischen Operation des Daumenersatzes. Munchner Med Weschr 62:1681–1684, 1915. 32. Huguier PC: Remplacement du pouce par son metacarpien, par l’angrandissement du premier espace interosseux. Arch Gen Med 1:78–82, 1874. 33. Hughes NC, Moore FT: A preliminary report on the use of a local flap and peg bone graft for lengthening of a short thumb. Brit J Plast Surg 3:34, 1951. 34. Joyce JL: A new operation of the substitution of a thumb. Br J Plast Surg 5:499–504, 1918. 35. Kleinschmidt O: Zum ersatz des Daumens curch die zweite Zehe. Langenbecks Arch Klin Chir 164:809–811, 1931. 36. Klemm P: Ueber plastische Operationen an den Handen. Langenbecks Arch Klin Chir 96:181–196, 1911. 37. Krause F: Ersatz des Daumens aus der grossen Zehe. Berl Klin Wochenschr 43:1527–1528, 1906. 38. Lambert O: Resultat eloigne d’une transplantation de gros orteil remplacement du pouce. Bull Mem Soc Chir, Paris, 5 May 1920, p 689. 39. Littler JW: Subtotal reconstruction of the thumb. Plast Reconstr Surg 10:215–226, 1952. 40. Littler JW: The neurovascular pedicle method of digital transposition for reconstruction of the thumb. Plast Reconstr Surg 12:303–319, 1953. 41. Littler JW: Neurovascular skin island transfer in reconstructive hand surgery. In Trans Int Soc Plast Surg, 2nd Congress, London. Edinburgh, Livingstone, 1959. 42. Littler JW: On making a thumb: One hundred years of surgical effort. J Hand Surg 1(1):35–51, 1976. 43. Littler JW: Restoration of the amputated thumb. In Littler JW, Cramer LM, Smith LW (eds): Symposium on Reconstructive Hand Surgery, vol 9. St. Louis, CV Mosby, 1990. 44. Littler JW: Finger reconstruction for traumatic loss. In May J, Littler J (eds): McCarthy’s Plastic Surgery, vol 8: The Hand and Upper Extremity. Philadelphia, WB Saunders, 1990, pp 5135–5152. 45. Littler JW: Digital transposition. In Adams JP III (ed): Current Practice in Orthopedic Surgery, vol 3. St Louis, CV Mosby, 1964. 46. Luksch L: Ueber eine neue Methode zum Ersatz des verlorenen Daumens. Verb Dtsch Ges Chir 32:221–223, 1903.
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47. Matev I: Thumb reconstruction in children through metacarpal lengthening. Plast Reconstr Surg, 64:665–668, 1979. 48. McGregor I, Simonetta C: Reconstruction of thumb by composite bone-skin flap. Br J Plast Surg 17:37–48, 1964. 49. Moberg E: Discussion of paper, in Brooks D: Nerve grafting in orthopedic surgery. J Bone Joint Surg 37A:305, 1955. 50. Monks GH: The restoration of a lower eyelid by a new method. Boston Med Surg J 139:385–387, 1898. 51. Nicoladoni C: Daumenplastik. Wien Klin Wochenschr, 10:663–665, 1897. 52. Nicoladoni C: Daumenplastik und organischer Ersatz der Fingerspitze (Anticheiroplastik und Daktyloplastik). Arch Klin Chir 61:606–614, 1900. 53. Nicoladoni C: Weitere Erfahrungen uber Daumenplastic. Arch Klin Chir 69:695–703, 1903. 54. Noesske K: Ueber den plastischen Ersatz von ganz oder teilweise verlorenen Fingern, insbesondere des Daumens, und uber Hantellerplastik. Munch Med Wochenschr 56:1403–1404, 1909. 55. Noesske K: Ueber Ersatz des samt Metakarpus verlorenen Daumens durch operative Umstellung des Zeigefingers. Munch Med Wochenschr 67:465–466, 1920.
56. Oehlecker F: Endergebnis der Uberpflanzung der grossen Zehe als Daumener4satz. Langenbecks Arch Klin Chir 189:674–680, 1937. 57. Ombredanne ML: Constitution autoplastique d’un pouce prenant au moyen du le metacarpien. Bull Mem Soc Chir, Paris, 28 Jan 1920, p 158. 58. Shepelmann E: Das spatere Schicksal einer Daumenplastik. Z Orthop Chir 39:181–200, 1920. 59. Tanzer R, Littler JW: Reconstruction of the thumb by transposition of an adjacent digit. Plast Reconstr Surg 3:533–547, 1948. 60. Tubiana R: The French school. In Landi A (ed): Reconstruction of the Thumb. London, Chapman Hall, 1989, pp 21–26. 61. Tubiana R, Duparc J: Restoration of sensibility in the hand by neurovascular skin island transfer. J Bone Joint Surg 43B:474–480, 1961. 62. Upton J, Littler JW: Microsurgical thumb reconstruction with toe transfer: Selection of various techniques. Plast Reconstr Surg 93(2):352–357, 1994. 63. Verodart A: In F Guermonprez (ed): Pratique Chirurgicale des Etablissements Industriels. Paris-Lille, p 262. 64. Zsulyevich I: Ein Fall von plastischen Daumenersatz. Chirurgie 10:433–435, 1938.
11 Great-Toe to Thumb Transfer 11
William Lineaweaver, MD, FACS
Transfer of the great toe for thumb reconstruction is a remarkable operation because of its historical significance, its revolutionary effect on the concepts associated with the classical problem of thumb reconstruction, and its longevity as an effective, definitive reconstructive procedure. Historically, great-toe transfer was performed in primate models in the early 1960s at the time when microsurgical technique and instrumentation were in their infancies.1 Toe transfer demonstrated that microsurgery could be the basis of a complex procedure involving many tissue components and achieving an excellent functional outcome. The first clinical report of a thumb reconstruction by microsurgical great-toe transfer was published in 1969, preceding reports of microsurgical flap procedures.6 Toe transfer may therefore be regarded as the first elective microsurgical reconstructive transfer procedure, setting an elegant standard for the explosion of microsurgical reconstructive procedures to follow. The effects of toe transfer on the concepts of thumb reconstruction were a thorough transformation, setting a precedent for the ways in which microsurgery would redefine defects and reconstructive strategies throughout plastic surgery. Prior to microsurgical toe transfer, thumb reconstruction was achieved by combinations of local flaps, tubed pedicle flaps, neurosensory island flaps from other fingers, and bone grafts. These procedures were the basis for the definition of thumb reconstruction as a stable post, with durable soft tissue coverage and protective sensation. The transferred toe, with all its elements, redefined thumb reconstruction as a much closer approximation of an actual thumb, including appearance, sensation, and motion. The toe is an aesthetic unit and brings with it vascularized nerves, tendons, and joints. The toe therefore greatly expanded the concepts of flap function and how these functions can usefully make the definition of defects and reconstruction more complex. Similar conceptual revolutions based on microsurgery have dramatically changed the definition of reconstructive surgery in the mandible, breast, lower extremity, and other problem areas.14 Great-toe transfer for thumb reconstruction remains a definitive procedure 30 years after its first clinical application. Variant procedures, including subtotal toe units as well as specific utilization of joints and sensate cutaneous segments, have had successful clinical application.2,7,8,12,15,19 Great-toe transfer, however, remains a reliable procedure to create a strong, sensate, mobile thumb with an acceptable appearance and donor site defect.5,9,17,24
PATIENT SELECTION AND PREOPERATIVE EVALUATION In the author’s practice, a patient is considered an acceptable candidate for a great-toe to thumb procedure if he or she has an established thumb amputation and can articulate a need for thumb reconstruction. The author has been very unsuccessful in predicting which patients with traumatic thumb amputations will functionally adjust to their losses and which individuals will declare a need for thumb reconstruction. Therefore, the operation is not offered in the period 163
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immediately following injury. Tobacco use, neurologic disorders, and vasospastic disease are relative contraindications. Preoperative evaluation of the hand should include a clear survey of remaining hand function, clear definition of the level of amputation illustrated by X-rays, and review of any records of the initial injury and treatment to note special circumstances (e.g., avulsion of the digital nerve or flexor pollicis longus). If damage to the radial artery is suspected or if a tenuous blood supply to the hand is a possibility, obtain an angiogram to clarify the arterial anatomy at the wrist and in the hand.3,10 The ipsilateral great toe is the first choice for transfer because of the relationship of its dorsal blood supply to the recipient radial artery in the snuffbox.4,10 The toe should be inspected for infection, old injury, joint motion, and sensation. If any of these elements is problematic, consider the other great toe. In such cases, carefully plan the arterial anastomosis, as a longer arterial segment must be harvested with the toe to reach the recipient site. An arteriogram of the foot can be a useful map in the toe harvest.3,11 Ideally, the dominant arterial supply will be found dorsally as a continuation of the dorsalis pedis artery into the first webspace and toe. If the plantar blood supply is dominant, dissection of the arterial system should be the first part of the harvest to determine whether a perforating vessel can be traced to the dorsalis pedis artery or whether vein grafts will be necessary. In cases of severely mutilated hands, the great-toe obviously cannot function by itself and should be a part of a comprehensive reconstructive program to provide skeletal stability, stable soft tissue coverage, pinch, and grasp.18,20,25
PROCEDURE At the time of the operation, position the patient so that the donor lower extremity and recipient upper extremity are comfortably accessible to conventional operating and microscopic surgery as necessary. Apply tourniquets to both extremities. Prepare the donor sites for vein grafts, nerve grafts, and skin grafts. Ideally, two teams should perform coordinated maneuvers at the donor and recipient sites. The recipient site should define the donor site dissection by specifying dimensions for all components harvested for transfer. At the recipient site, all unstable skin should be resected and incisions extended for volar and dorsal exposures. The bone stump is then debrided to viable bone. Dorsally, the radial artery is skeletonized in the snuffbox. Associated or convenient subcutaneous veins are identified and looped. The dorsal radial sensory nerve is then identified as an alternative recipient nerve should the digital nerves be unusable. Finally, the extensor
pollicis longus is tagged. On the volar surface, the digital nerves are identified and tagged, as is the flexor pollicis longus. If the thumb tendons are not usable, immediate tendon transfer (such as flexor carpi radialis for flexion) can provide recipient motor units. The toe harvest proceeds on the basis of the needs of the recipient site. The skin incisions are designed to include necessary soft tissue for recipient site closure. Initial dissection is undertaken in the first webspace to identify the arterial supply.23 If a dorsal system is dominant, then its bifurcation to the great and second toe is identified, the branch to the second toe is divided, and the dorsal artery is mobilized as needed. If a plantar system is present, it is dissected either to a connection to the dorsal system or to a maximum accessible length from a plantar exposure. In this last circumstance, vein grafting will probably be necessary for the arterial inset. The remainder of the dorsal dissection consists of skeletonization of appropriate lengths of the extensor hallucis longus and one or two appropriate veins. The plantar dissection is completed with dissection of the determined lengths of digital nerves and the flexor hallucis longus. Completion of the harvest consists of division and tagging of the vessels and nerves, division of tendons, and finally, amputation at the determined bone level or joint. The recipient site is closed as an amputation. The harvested toe is brought to the recipient site, and careful identification of all parts is directly communicated to all concerned surgeons by the harvesting surgeon. Inset commences with bony fixation. Crossed K-wires, peg (recipient bone) and hole (toe bone) insertion reinforced by wires or screws, interosseous wiring, and plate fixation are all reliable methods of bone fixation.5,27 If the toe is placed as the distal component of an interphalangeal or metacarpophalangeal joint, a soft tissue capsule reconstruction reinforced by K-wires is performed. The tendons are then repaired. The microscope is used to establish the arterial connection between the radial artery and the toe. Good perfusion of the toe should be evident in the toe by the color of the pulp and nail bed as well as venous return. One or two venous anastomoses are then performed, and the digital nerves are connected. After removal of the microscope, skin insets are performed. Skin grafts should be freely employed whenever primary closure appears to compress the vascular repair. The new thumb is carefully splinted in a spica position with its tip exposed for monitoring. A soft dressing is applied to the foot. The surgeon may use the perioperative adjuncts of local papavarine, heparin, and lidocaine, as well as systemic aspirin, dextran, and heparin, secure in the knowledge that none of these agents has been shown to be harmful. Their efficacies, however, are arguable, and the surgeon should consider their use based on individual training, experience, and conviction.5
POSTOPERATIVE CARE, COMPLICATIONS, AND REHABILITATION In the immediate postoperative period, the transferred toe is watched closely for any evidence of venous or arterial insufficiency. Clinical observation, quantitative fluorimetry, and implantable Doppler probes have been specifically reported as being useful in monitoring circulation in transplanted toes.5,26 Any evidence of circulatory impairment should lead to the immediate removal of dressings and, if persistent, to operative exploration. The transferred toe has large, specific vascular connections, and the value of re-exploration is very high. Generally, toe transfers have the highest success rates of all microvascular transfers, and in most toe series, failure percentages are close to zero.13 Care of the foot includes dressing, support garments, and gait training. Complications at the donor site, including infection and incisional breakdown, may occur in up to 30% of patients.3 The great majority of patients eventually resume all activities, including sports.5,9
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Complications of the established transferred toe are rare but include skeletal nonunion, tendon adhesions or rupture, poor sensation, and soft tissue irregularities, especially bulkiness at the inset. Correct skeletal nonunion when it becomes obvious. Otherwise, perform secondary tendon, nerve, and soft tissue procedures as the deficits become stable and hand rehabilitation has reached a plateau.3,13,21,22 Specific hand therapy strategies are similar to the protocol used for replanted digits.16 Active range of motion of uninvolved joints and digits begins the first week following surgery. Passive range of motion of mobile toe joints begins during the second week. Protected active motion is initiated during the third week and is gradually increased until K-wires (if present) are removed. At 6–8 weeks following surgery, active motion and strengthening are started, and as sensation improves, the patient is guided toward complex activities. In uncomplicated cases, the patient should have a functional result in 3–6 months, although sensation may improve up to 18 months, and cold intolerance may persist indefinitely.5,21 The cases that follow illustrate a range of thumb defects to which great-toe transfer can be successfully applied. As a group, they also show how elements of
CASE 1 Distal Phalangeal Amputation his 20-year-old man suffered a high-pressure grease gun injury to his left thumb. Initial debridement included the Tdigital nerves to the level of the carpal tunnel (Fig. 11-1). Six months later, he had an unstable amputation stump with a recurrent infection of the nail remnant and no functional sensation (Fig. 11-2). X-ray showed an intact interphalangeal joint (Fig. 11-3).
FIGURE 11-2. Unstable amputation stump.
FIGURE 11-1. Grease gun injury to the left thumb.
The patient underwent transfer of the distal phalanx of his left great toe. At the time of surgery, sural nerve grafts were used to bridge the gaps in the digital nerves (Fig. 11-4). One year following surgery, the toe provided stable, sensate cover with good range of motion, effective pinch, and appearance similar to the normal thumb (Figs. 11-5 to 11-8). The donor site healed without complication (Fig. 11-9), and the patient went on to resume his usual activities, including jogging and basketball.
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FIGURE 11-5. Stable distal phalanx postoperatively.
FIGURE 11-3. Skeletal amputation level with intact interphalangeal joint.
FIGURE 11-6. Flexion at interphalangeal joint.
FIGURE 11-4. Incision showing exposure required for digital nerve grafting.
FIGURE 11-7. Pinch.
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FIGURE 11-8. Flexion of reconstructed and normal thumb.
FIGURE 11-9. Healed donor site.
CASE 2 Toe Transfer to the Proximal Phalanx 30-year-old oil field worker had his right thumb amputated and crushed by heavy machinery. Replantation was Aunsuccessful. Six months after this injury, he declared his wish for thumb reconstruction based on his work requirements (Fig. 11-10). The patient underwent transfer of the right great toe with matching of harvest components determined by the
FIGURE 11-10. Amputation stump of right thumb.
hand dissection (Figs. 11-13). Skeletal fixation consisted of fashioning a peg from the proximal phalanx of the thumb, inserting the peg into the proximal phalanx of the toe, and stabilizing the unit with a single screw (Fig. 11-14). A secondary revision of the nerve repair was done 6 months following transfer. One year following transfer, he had good sensation, motion, and appearance (Figs. 11-15 to 11-18). Cold intolerance precluded oil field work, but he otherwise obtained a good functional result and new employment. His foot healed without functional limitation (Fig. 11-19).
FIGURE 11-11. Harvest of right great toe.
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FIGURE 11-12. Components of toe harvest, including vessels, nerves, and tendons. FIGURE 11-14. Skeletal fixation by peg and screw.
FIGURE 11-15. Thumb in extension.
FIGURE 11-13. Transfer of toe to the hand field.
FIGURE 11-16. Thumb in flexion.
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FIGURE 11-17. Thumb in opposition to pinch the little finger.
FIGURE 11-19. Uncomplicated donor site.
FIGURE 11-18. Comparison of reconstructed right thumb to the normal left thumb.
CASE 3 Toe Transfer to a Thumb Metacarpal 28-year-old man suffered an unreplantable crushing of the radial 60% of his left hand (Fig. 11-20). TThehisamputation amputation site healed following skin grafting, leaving him with the metacarpal stump of his thumb (Fig. 11-21) and good function of his ring and little fingers (Figs. 11-22 and 11-23). Preoperative angiography showed good recipient sites on the radial artery and an uncomplicated dorsal arterial supply to the toe (Figs. 11-24 and 11-25). Transfer of the toe, including nerve repair and tendon repair, was tailored to
the recipient site structures (Fig. 11-26). A single K-wire secured skeletal fixation (Fig. 11-27). Six months following surgery, a webspace contracture was relieved with skin grafting and a dorsal rotation flap from the hand (Fig. 11-28). One year following secondary surgery, the patient had a sensate thumb with effective grip and pinch (Figs. 11-29 and 30). He returned to a full range of activity, including recreational softball (Fig. 11-31).
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FIGURE 11-20. Crush injury to left hand.
FIGURE 11-22. Healed amputation site.
FIGURE 11-21. Skeletal level of injury.
FIGURE 11-23. Flexion of ring and little finger.
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FIGURE 11-24. Angiogram of foot showing dominant dorsal artery.
FIGURE 11-26. Great toe brought to the recipient site.
FIGURE 11-25. Angiogram of the wrist and hand showing the radial artery.
FIGURE 11-27. K-wire fixation of the transfer.
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FIGURE 11-28. Release of webspace contracture.
FIGURE 11-30. Thumb flexion with pinch.
FIGURE 11-29. Thumb extension.
FIGURE 11-31. Play ball!
preoperative evaluation, surgical technique, and postoperative care (including secondary surgery) can be coordinated for maximization of functional outcome.
Acknowledgments The patients described in the cases were treated at the Davies Medical Center, between 1987 and 1991. Harry J. Buncke, MD, assisted in the planning of Case 1, and Suzanne Kerley, MD, a resident at the time, flawlessly
served as co-surgeon. Dr. Buncke was co-surgeon on Cases 2 and 3.
References 1. Buncke HJ, Bunche CM, Schulz WP: Immediate Nicoladoni procedure in the rhesus monkey. Br J Past Surg 19:332–337, 1966. 2. Buncke H, Rose E: Free toe-to-fingertip neurovascular flaps. Plast Reconstr Surg 63:607–612, 1979.
3. Buncke HJ, Valauri F, Buncke GM: Toe to hand. In Brunelli G (ed): Textbook of Microsurgery. Milano, Italy, Masson, 1988, pp 305–322. 4. Buncke HJ: Great toe transplantation. In Buncke HJ (ed): Microsurgery. Philadelphia, Lea and Febiger, 1991, pp 6–43. 5. Buncke HJ, Buncke GM, Kind G, et al: Thumb reconstruction. In Russel RC (ed): Plastic Surgery, vol 4: Hand Surgery. St. Louis, Mosby, 2000, pp 2183–2208. 6. Cobbett JR: Free digital transfer: A report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg 51B:677–679, 1969. 7. Foucher G: Custom-made free flaps from the toe. In Brunelli G (ed): Textbook of Microsurgery. Milano, Italy, Masson, 1988, pp 323–328. 8. Foucher G, Sammat D, Citron N: Free vascularized toejoint transfer in hand reconstruction. J Reconstr Microsurg 6:201–207, 1990. 9. Frykman G, O’Brian B, Morrison W, et al: Functional evaluation of the hand and foot after one-stage toe-to-hand transfer. J Hand Surg 11A:9–17, 1988. 10. Gordon L, Buncke HJ, Alpert B, et al: Indications and results in 41 cases. In Buncke HJ, Furnas D (eds): Symposium on Clinical Frontiers in Reconstructive Microsurgery. St. Louis, Mosby, 1984, pp 239–246. 11. Greenberg B, May J. Great toe-to-hand transfer: Role of the preoperative lateral arteriogram of the foot. J Hand Surg 13A:423–426, 1988. 12. Koshima I, Inagawa K, Urushibara K, et al: Fingertip reconstruction using partial toe transfers. Plast Reconstr Surg 105:1066–1074, 2000. 13. Lineaweaver W, Buncke HJ: Complications. In Buncke HJ (ed): Microsurgery. Philadelphia, Lea and Febiger, 1991, pp 722–728. 14. Lineaweaver W: The history of reconstructive microsurgery: A conceptual approach. Sing Gen Hosp Proc 7(1):31–40, 1998.
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15. Morrison W, O’Brian B, MacLeod A: Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg 5:575–583, 1980. 16. Petrelli J, Milne E, Nugent K, et al: Hand therapy. In Buncke HJ (ed): Microsurgery. Philadelphia, Lea and Febiger, 1991, pp 748–759. 17. Poppen NK, Norris T, Buncke HJ: Evaluation of sensibility and function with microsurgical free tissue transfer of the great toe to the hand for thumb reconstruction. J Hand Surg 8:516–531, 1983. 18. Wei F, Chen H, Chuang C, Noordhoff M: Simultaneous multiple toe transfer in hand reconstruction. Plast Reconstr Surg 81:366–377, 1988. 19. Wei F, Chen H, Chuang C, Noordhoff M: Reconstruction of the thumb with a trimmed toe transfer technique. Plat Reconstr Surg 82:506–513, 1988. 20. Wei F, Chen H, Chuang C, Chen S: Microsurgical thumb reconstruction with toe transfer: selection of various techniques. Plat Reconstr Surg 93:345–351, 1994. 21. Wei F, Ma H: Delayed sensory reeducation after toe to hand transfer. Microsurgery 16:583–585, 1995. 22. Wei F, Yim K: Pulp plasty after toe-to-hand transplantation. Plast Reconstr Surg 96:661–666, 1995. 23. Wei F, Silverman R, Hsu W: Retrograde dissection of the vascular pedicle in toe harvest. Plast Reconstr Surg 96:1211–1214, 1995. 24. Wei F, Abdalla El-Gammal T: Toe to hand transfer. Clin Plast Surg 23:103–116, 1996. 25. Whitney T, Lineaweaver W, Hing D, et al: Sequential multiple free flap transfer for reconstruction of devastating hand injuries. Ann Plast Surg 27:66–72, 1991. 26. Whitney T, Lineaweaver W, Billys J, et al: Improved salvage of complicated microvascular transplants monitored with quantitative fluorometry. Plast Reconstr Surg 90:105–111, 1992. 27. Yim K, Wei F: Interosseous wiring in toe-to-hand transplantation. Ann Plast Surg 35:66–69, 1995.
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12 Second-Toe Transfer in Post-traumatic Thumb Reconstruction 12
Guy Foucher, MD J. Medina, MD G. Pajardi, MD
Second-toe to thumb or finger transfer was first used in a pedicled fashion by Nicoladoni in a 5-year-old boy.31 With this technique, the hand remained attached to the foot for several weeks. Current microsurgery techniques allow a more elegant, one-step reconstruction. The first historical microsurgical transfer was a great-toe to thumb transfer by Cobbett in 1969,2 an operation based on the pioneering work of Harry Buncke.1 The second-toe to thumb transfer soon followed and is now more popular owing to its advantages at the donor site. Since then, many technical refinements with partial toe transfer have allowed us to fine-tune the indications for thumb reconstruction.3,24
TECHNIQUE This chapter does not provide all the technical details of second-toe transfer; however, the authors would like to emphasize several original points and some useful tips and tricks. Foot and hand dissection is performed under tourniquet control, using magnification. The authors have found it more efficient to work with only one team,4,7,8 allowing the donor site to perfuse during preparation of the recipient thumb. After completion of the transfer, the reconstructed thumb is revascularized during closure of the donor site. This sequential approach prevents loss of time and permits a more precise assessment of the necessary length of each transferred structure. Ideally, it will never be necessary to insert a nerve graft or a vein graft due to insufficient pedicle length. With respect to the donor site, the contralateral side is usually selected owing to better positioning of the vessels and having the larger nerve for the more important ulnar aspect of the thumb.4,7 A dorsal approach may be employed,8,9 without a plantar incision, except to harvest a small triangular skin flap. The longitudinal incision is centered over the first intermetatarsal space; the classic S-shaped incision is prone to marginal necrosis. A dorsal triangular flap is created to avoid a circular scar at the base of the thumb. Tributaries of the great saphenous vein are dissected out, preserving as many as possible. A communicating vein between the superficial and deep network is often present at the point where the dorsalis pedis artery dives into the first interosseous space. This artery (absent in five of 223 toe dissections in the authors’ clinical series) is easily found under 175
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the extensor hallucis brevis. Dissection then proceeds distally in the first webspace, exploring the arteries of the great and second toes. If the common artery is found dorsal to the intermetatarsal ligament, it is a dorsal metatarsal artery with either a superficial or deep course passing through the muscles.23 Proximally, a communicating vein between the superficial and deep networks usually denotes a change in the course of this first dorsal metatarsal artery. If there is no artery dorsal to the ligament, vascularization is through the plantar arteries. Regardless of the type of vessels encountered, it is better to harvest at least two or even three arteries, in continuity with the dorsalis pedis and the plantar arch, to nourish the toe. Indeed, postoperative vascular crisis is unlikely when at least two arteries are preserved.12,19 The next steps are the proximal division of the long and short extensor tendons, followed by osteotomy of the second metatarsal near its base. (Of note, a second dorsal metatarsal artery of sufficient diameter was found in only three of the authors’ 223 toe dissections.) The proximal bone cut has two advantages: (1) it facilitates dissection of all plantar anatomical structures, and (2) after reconstruction of the intermetatarsal ligament, it provides for an aesthetic closure of the space. When the metatarsal is elevated, it is possible to immediately see the plantar artery of the second webspace, a vessel that is overlooked in the classic anatomic descriptions.23,25,29 It runs under the metatarsal, tethered to the fibular aspect of the plantar plate giving rise to the arteries of the second webspace.7,8 Sectioning of the intermetatarsal ligament of the second webspace facilitates its dissection. If the metatarsophalangeal (MTP) joint is used for thumb reconstruction, it is not necessary to free it from the plantar plate. After sectioning of the intermetatarsal ligament of the first webspace, it is possible to dissect the plantar artery of the first webspace proximal and distal to the MTP joint. Indeed, at this level, one or two small vessels tether the artery to the plantar plate. Gentle traction on the proximal and distal segments allows for hemostasis and total freeing. The plantar arch is divided close to the third metatarsal bone, and all the dissected arteries are maintained in continuity with the dorsalis pedis artery. During this step, the plantar nerves are freed, and an endoneurolysis allows harvesting of as a long a segment as necessary. A similar nerve dissection is performed in the second intermetatarsal space. Here, endoneurolysis is more demanding due to the smaller diameter of the nerves. It is easier to perform a thorough defatting at the base of the toe before transecting the vessels and nerves of the neighboring toes in the distal webs. When these vessels are cut, the neurovascular bundles are at risk during defatting, which is mandatory to avoid a proximal
bulging and to improve appearance.4,7,9 When the intrinsic muscles are available at the recipient site, the intrinsic tendons of the second toe are cut at the musculotendinous junction for later repair. The last step consists of gently pulling on the isolated toe and retracting the adductor hallucis to harvest as long a segment as possible of the flexor profundus tendon. Sectioning of the superficialis is performed more distally, as it will not be repaired later on. In the case of an amputation proximal to the metacarpophalangeal (MCP) joint, it is necessary to transfer the MTP joint. Unfortunately, this joint moves more in hyperextension and has only a limited range of flexion. To avoid a distal “Z” deformity with hyperextension of the MCP and a flexion deformity of the interphalangeal (IP) joint, we tilt the metatarsal head palmarly about 45°.7,8 For this purpose, an oblique osteotomy is performed at the metaphysis level. When a hemijoint reconstruction is contemplated, the whole capsuloligamentous apparatus of the MTP joint is harvested for fixation to the recipient metacarpal bone, taking care to tighten the ulnar collateral ligament as well as the plantar plate. At the recipient stump of the thumb, two flaps are elevated, with the larger one to cover the more important defect on the fibular side of the toe. The authors favor an S-shaped incision that is elongated on the palmar aspect to approach the palmar nerves and the flexor tendon as well as to accommodate the plantar triangular flap. Dorsally, the incision is limited to the length of the dorsal triangular flap. The bone and the recipient extensor tendons are prepared. A separate incision, usually transverse, is performed at the “snuffbox” level to prepare the recipient vessels, most frequently the radial artery and the cephalic vein. Yoshimura33 has called this technique a “long transfer,” in comparison with a vascular suture performed on digital arteries of the thumb. A subcutaneous tunnel is created between the two incisions to allow delivery of the donor vessels. This tunnel has to be wide enough to accommodate the vessels without any compression. Precise measurement of the necessary artery and vein length is critical. The transfer usually begins with bone osteosynthesis. Many methods are available. When a segment of the proximal phalanx is present at the thumb level, the authors like to perform a “ball-and-socket” fit between the two bony segments and stabilize them with two crossed K-wires or one longitudinal K-wire combined with interosseous loop wiring. The longitudinal K-wire has the advantage of maintaining the IP joint in extension, avoiding the natural tendency toward a flexed attitude. A similar technique is used when the MTP joint is maintained and angulated volarly. A periosteal suture adds stability in young patients. The next step is the intrinsic repair by weaving the donor intrinsic tendons
SECOND-TOE TRANSFER IN POST-TRAUMATIC THUMB RECONSTRUCTION
to the thenar and adductor muscles. The extensor tendons are repaired with a “vest-over-pants” technique performed with sufficient tension to compensate for the flexor force. The vessels are then passed in the subcutaneous tunnel and delivered in the snuffbox, avoiding any kinking. The dorsal skin around the toe is closed. On the volar aspect the profundus tendon is repaired in a “fish-mouth” fashion with the smaller profundus tendon buried in the flexor pollicis longus. The microscope is brought into the field, and the two plantar nerves are carefully sutured to the recipient nerves at a level as distal as possible. The palmar skin is closed (the only remaining open incision is in the snuffbox where the tension on the vessels is adjusted). The arterial suture technique is variable. The authors typically interpose in end-to-end fashion the segment of the dorsalis pedis and plantar arch. This has the advantage of restoring physiologic flow to both the radial artery and the toe. In other cases, an end-to-side or end-to-end anastomosis is performed. Finally, the great saphenous vein is anastomosed in end-to-end fashion to the cephalic vein, and the incision is closed before removing the tourniquet. During revascularization of the thumb, the foot is closed after control of hemostasis. After reconstruction of the intermetatarsal ligament, the skin is sutured and a suction drainage is placed.
POSTOPERATIVE COURSE The patient is hospitalized for 4–5 days in an intensive care unit. The color and temperature of the reconstructed thumb are regularly monitored. Low-dose aspirin is administered during this time, as well as pain medication if necessary. Anticoagulant is not required. The dressing is not disturbed for 2 weeks, and the longitudinal K-wire is maintained for 5 weeks. The authors’ attempts at early motion have been disappointing; currently, motion is begun at 5 weeks and a dynamic splint is worn for several hours each day. An extension splint is maintained for several months at night to control the tendency for flexion deformity, especially in adult patients. At 5 months postoperatively, a formal home-based program of sensory reeducation is implemented. Occupational therapy is also begun for job retraining.
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reviewed at a mean follow-up of 6 years. Sixteen adults with a mean age of 26 years (19–47 years) and six children with a mean age of 11.5 years were included. The dominant hand was involved in 18 cases. Associated mutilation of middle finger was present in 14 adults and three children. Twelve were workers’ compensation injuries. The mean operative time was 250 minutes (with a maximum of 420 minutes and a minimum of 150 minutes). Ischemia time was 68 minutes (maximum 100 minutes and minimum 45 minutes). A purely dorsal vascularization was used in three cases, a plantar one in nine, and a mixed plantar and dorsal in ten. Osteosynthesis was done with K-wires in the majority of cases (21 cases). Intrinsic repair was performed in 16 cases. A distant flap preceded the toe transfer in six cases and twice was performed at the same time as the transfer. A split-thickness skin graft was necessary in six hands (and in no case on the foot). There were two postoperative complications of arterial thrombosis, which were successfully salvaged. Nine of the patients had additional surgery on the same hand; only Z-plasties or scar excision was performed on the thumb in five cases, and an IP joint arthrodesis was performed in two adults and deemed necessary in two others. Two tenolyses were performed with little benefit. The average time off work was 270 days. The average compensation fee was 34%, mainly due to multiplefinger amputations. Thirteen of the 15 patients who were working before the transfer were able to go back to work, eight to the same job. The average active range of motion of the toes was 34° in adults and 41° in children. In all children, passive range of motion exceeded active motion. The mean extension lag was 27° (from 5° to 45°) in adults but only 12° in children; however, the difference did not reach statistical significance owing to the small number of children. The Weber two-point discrimination test averaged 10 mm (4–15 mm in the oldest patient of the series). There was a significant correlation between two-point discrimination and age ( p ⬍ 0.01) and dominance of the hand (p ⬍ 0.05). All patients used the transfer, but two found it insufficient for fine pinch. Cold intolerance was present in 19 hands and in 17 feet. Grasp measured using the Jamar dynamometer was 33.1% that of the normal side. Pinch was 59.5% that of the normal side.
RESULTS In a personal series of 227 toe transfers performed between 1976 and 1999, the authors performed 27 second-toe to thumb transfers for traumatic losses and performed 47 “custom-made” reconstructions of the thumb. Twenty-two second-toe to thumb transfers were
INDICATIONS Many methods are available for thumb reconstruction. However, there are some basic requirements, including length, mobility, sensibility, and stability. In the authors’
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12
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A
B
FIGURE 12-1. A, Severe mutilation of the nondominant hand in a 17-year-old boy. B, C, Six-month postoperative result following second-toe transfer. C
experience,14,15,18 main requirements are absence of pain, good stability and sensibility, and preserved thumb carpometacarpal joint mobility with sufficient thenar muscles. Two-point discrimination better than 15 mm seems to be necessary. Length is critical but depends mainly on the mobility of the opposing fingers. Mobility at the IP level is less crucial; 30° is useful for fine pinch. Finally, appearance is not to be neglected, since a thumb that the patient considers to be ugly will be buried in the pocket most of the time, limiting its function. This problem is difficult to solve in the case of severe mutilation with multiple amputations, yet it is advisable to take it into account in a four- or five-fingered hand. The absence of one finger is easily concealed during motion when the gesture is natural. Microsurgery has found a place in posttraumatic thumb reconstruction mainly in well-motivated, young, and healthy patients. In a series of 75 toe transfers,12,18 the most successful were in patients under 35 years of age. In older patients, pollicization of a mutilated finger is the best approach. When phalangeal length is sufficient, progressive bone distraction-lengthening is the best option.14,18 Absence of the nail can be corrected by
a microsurgical nail transfer.21 For such cosmetic improvement, there is no age limit in a healthy patient, especially since nerve suture is unnecessary. Poorer sensory return is typical after avulsion injuries.12 The main advantage of a toe transfer is to add structural support to the hand that has sustained multiple finger amputations when pollicization of a stump simply shifts tissue from one place to the other;14,17 it does add some joint mobility, an opportunity that is rarely encountered in pollicization of a mutilated finger (except when the MCP is transferred in metacarpal amputations or a proximal interphalangeal [PIP] joint is intact). Compared to osteoplastic reconstruction,6 toe transfer provides a one-stage reconstruction with longterm preservation of bone stock (in the absence of resorption), good sensibility, some mobility, and better appearance. Progressive distraction-lengthening is a multistage procedure encompassing a period of soft tissue healing (around a week) and a long period for bone lengthening and healing (either spontaneous after callotasis or by secondary bone grafting).10,22,27,28 Finally, a first web deepening is usually necessary (at least when lengthening is performed at the metacarpal level). In the
SECOND-TOE TRANSFER IN POST-TRAUMATIC THUMB RECONSTRUCTION
B
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FIGURE 12-2. A, Amputation of the thumb and index finger in a 9-year-old boy. B, C, One-year postoperative result. D, E, Nine-year postoperative result. Thumb and donor foot.
absence of complications (quite frequent in the majority of series), the final result is a stiff thumb with preserved sensibility, no additional mobility, and a poor cosmetic aspect (in the absence of a nail). However, this problem can also be remedied with a free vascularized nail from the great toe.21 At the beginning of the microsurgical era, the choice was limited to great- and second-toe transfers. For surgeons who are faithful to the great toe,1 there is controversy about the definite advantages concerning sensibility, mobility, and strength compared to the second toe. In some cases, the appearance of the hand is better, but in others, the great toe is too large. Buncke has demonstrated the absence of functional foot problem (when the head of the first metatarsal is preserved). The success of the second toe lies in less morbidity at the donor site and the availability of unlimited length compared to the great toe. The second toe can be used in amputations ranging from proximal to the MCP to as far distal as the proximal centimeter
of the proximal phalanx. Functionally, the second toe commonly develops a flexion deformity, because it contains three phalanges.15,26 When severe, the deformity not only is unappealing but also hampers good fine pinch. This problem has been more relevant in adults than in children. A consequence of the flexion deformity is a poor aesthetic appearance, which is rarely acceptable. Even in the absence of this complication, the second toe remains slender with a bulky tip and a short nail. Because of these drawbacks, indications for secondtoe transfer are restricted to severe mutilations in which a four- or five-fingered hand cannot be salvaged (Fig. 12-1).14,15 However, note that the procedure has been satisfactory in children, even in isolated thumb mutilations, owing to the absence of flexion deformity and good potential growth (with three or four vascularized epiphyses) (Fig. 12-2). When the emphasis is placed on function as well as form, rely on “custommade” reconstructions.6
12
12
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In proximal amputation, consider the “twisted two toes,” which is a combination of components from the first and second toes.6,7,8,11 The skin envelope of the great toe is lifted en bloc with the nail complex, and a segment of vascularized bone is taken longitudinally on the distal phalanx. On a separate vascular bundle, the PIP joint of the second toe (with adjacent skeleton and tendons, flexor and extensor) is harvested and incorporated into the skin envelope of the great toe. The advantages are clear. Appearance is good, as the nail of the great toe curves around the narrow piece of bone, providing a symmetrical appearance for the thumb compared to the normal side.13 It is important to have distal vascularized bone to avoid bone resorption generally followed by a nail “hook deformity” and socket like skin mobility, which impedes fine pinch. This problem is a frequent complication of the classic wraparound technique, as described by Morrison.30 Preservation of the pulp septa gives stability to the tip. A “two-phalangeal” thumb, which is easier to balance, is reconstructed. In amputations proximal to the MCP joint, transfer of a MTP joint allows for more extension of the reconstructed thumb. The vascularized joint provides a mean 30° of motion. Growth is preserved in children with two (or even three, when the MCP is incorporated) vascularized epiphyses. The length of the great toe is preserved16 (as the piece of bone is longitudinally harvested), and the fillet of skin of the proximally amputated second toe provides stable cover with a small nail. In amputations that preserve the proximal part of the proximal phalanx, consider “bipolar lengthening”20 combining a partial transfer from the great toe (including bone, nail, and pulp) with a first web-deepening plasty (Ostrowski’s type32). This produces a short thumb that does not protrude excessively in making a fist.
2.
3. 4.
5.
6.
7.
8.
9. 10.
11.
12.
13.
14.
CONCLUSION There are limited indications for second-toe to thumb transfer, mainly for amputations at or proximal to the MCP. It provides useful functional results with good donor site morbidity and function but at the expense of appearance. Because of the absence of a flexion deformity and good growth potential, the indications are frequent in children. In adults, indications are restricted to multiple finger amputations where appearance is no longer a concern. Otherwise “custom-made” thumb reconstruction may provide a better appearance at the recipient site and preserves the great-toe length.
References 1. Buncke HJ, Buncke CM, Schultz WP: Immediate Nicoladoni procedure in the rhesus monkey as hallux to hand trans-
15. 16. 17.
18.
19.
20.
21.
plantation utilising microminiature vascular anastomosis. Br J Plast Surg 19:332–337, 1966. Cobbett JR: Free digital transfer: Report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg 51B:677–679, 1969. Dongyue Y: Free second toe transplantation in reconstruction of the thumb. Chinese J Surg 1977. Foucher G, Merle M, Maneaud M, Michon J: Microsurgical free partial toe transfer in hand reconstruction: A report of 12 cases. Plast Reconstr Surg 65:616–627, 1980. Foucher G: Indication du transfert osseux vascularisé en chirurgie de la main. Rev Chir Orthop 68(Suppl 2):38–39, 1982. Foucher G, Van Genechten F, Merle M, Michon J: Single stage thumb reconstruction by a composite forearm island flap. J Hand Surg 9B:245–248, 1984. Foucher G, Van Genechten F, Morrison WA: Composite tissue transfer to the hand from the foot. In Jackson IT, Sommerland BC (eds): Recent Advances in Plastic Surgery. London, Churchill Livingstone, 1985. Foucher G: Vascularized joint transfer. In Green DP, Hotchkiss RN, Pederson WC, Lampert R (eds): Green’s Operative Hand Surgery, 2nd ed. London, Churchill Livingstone, 1989, pp 1271–1293. Foucher G, Norris RW: The dorsal approach in harvesting the second toe. Intern J Microsurg 4:185–187, 1988. Foucher G, Hultgren T, Merle M, Braun JM: L’allongement digital selon Matev: A propos de vingt cas. Ann Chir Main 7:210–216, 1988. Foucher G, Van De Kar T. Twisted two toes technique in thumb reconstruction. In Lamb D (ed): Reconstruction of the Thumb. Chapman, London, 1989, 35:275–279. Foucher G, Moss ALH: Microvascular second toe to finger transfer: A statistical analysis of 55 transfers. Br J Plast Surg 44:87–90, 1991. Foucher G, Sammut D: Aesthetic improvement of the nail by illusion technique in partial toe transfer for thumb reconstruction. Ann Plast Surg 28:195–196, 1992. Foucher G: La reconstruction après amputation traumatique du pouce. Cahiers d’Enseignement du GEM Expansion 9:65–76, 1993. Foucher G, Binhammer P: Thumb reconstruction by micro-vascular techniques. Int Angiol 14(3):313–318, 1995. Foucher G, Binhammer P: Plea to save the great toe in total thumb reconstruction. Microsurgery 16:373–376, 1995. Foucher G, Rostane S, Chammas M, et al: Transfer of a severely damaged digit to reconstruct an amputated thumb. J Bone Joint Surg 78-A:1889–1896, 1996. Foucher G, Smith D: Indications in secondary reconstruction of the thumb. In Foucher G (ed): Reconstruction Surgery in Hand Mutilation. London, Martin Dunitz, 1997, pp 67–73. Foucher G, Binhammer P: Free vascularized toe transfer. In Foucher G (ed): Reconstruction Surgery in Hand Mutilation. London, Martin Dunitz, 1997, pp 57–65. Foucher G, Chabaud M: The “bipolar lengthening” technique: A modified partial toe transfer for thumb reconstruction. Plast Reconstr Surg 102(6):1981–1987, 1998. Foucher G, Nagel D, Briand E: Microvascular great toe nail transfers after conventional thumb reconstruction. Plast Reconstr Surg 103:570–576, 1999.
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22. Foucher G, Lamas C, Mir X: Reconstruccion digital segun tecnica de Matev: Estudio de 45 casos. Rev Iber Cir Mano 27:31–39, 2000. 23. Gilbert A: Composite tissue transfers from the foot: Anatomic basis and surgical technique. In Daniller AI, Strauch B (eds): Symposium on Microsurgery. St Louis, Mosby, 1976. 24. Harii K: Microvascular surgery and its applications. Clin Orthop 95:133–137, 1978. 25. Leung PC, Wong WL: The vessels of the first metatarsal web space. An operative and radiographic study. J Bone Joint Surg 65A:235–239, 1983. 26. Lister GD, Kalisman M, Tsu Min Tsai: Reconstruction of the hand with free microneurovascular toe to hand transfer: Experience with 54 toe transfers. Plast Reconstr Surg 71:372–384, 1983. 27. Matev IB: Thumb reconstruction after amputation at the metacarpophalangeal joint by bone lengthening. J Bone Joint Surg (Am) 52:957–965, 1970.
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28. Matev I: Thumb reconstruction through metacarpal bone lengthening. J Hand Surg 5:482–487, 1980. 29. May Jr JW, Chait LA, Cohen BE, O’Brien BM: Free neurovascular flap from the first web of the foot in hand reconstruction. J Hand Surg 2A:387–393, 1997. 30. Morrison WA, O’Brien BMC, MacLeod AM: Thumb reconstruction with a free neurovascular wraparound flap from the big toe. J Hand Surg 5A:575–583, 1980. 31. Nicoladoni C: Daumenplastik und organischer Ersatz der Fingerspitze. (Anticheiropastik und Daktyloplastik). Archiv Klin Chir 1:606–628, 1900. 32. Ostrowski DM, Feagin CA, Gould JS: A three-flap web-plasty for release of short congenital syndactyly and dorsal adduction contracture. J Hand Surg 16A:634–641, 1991. 33. Yoshimura M: Toe to hand transfer. Plast Reconstr Surg 73(5):851–852, 1984.
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13 Modified Great-Toe Wraparound Flap Fu-Chan Wei, MD, FACS
13
Vivek Jain, MCh Ortho
Traumatic loss of the thumb presents significant functional disability because of its essential role in hand function. The thumb is responsible for almost half of the functional capacity of the hand; without the thumb, object manipulation and prehension are significantly reduced. In opposition, the thumb is brought onto the pulp or radial aspect of the adjacent finger(s) to allow fine manipulation of small objects. The thumb can also aid in grasping and holding large objects more firmly. Thus, the patient with a thumbless hand may have great difficulty coping with activities of daily living. Reconstruction of the amputated thumb has remained a major challenge to the reconstructive surgeon. A large number of traditional techniques of thumb reconstruction have been employed, followed recently by microsurgical toe transfers. All of these procedures strive to provide a new thumb that is pain-free, stable, and sensate with sufficient length and mobility to oppose the fingers.13 Conventional techniques utilize rearrangement and transfer of bone, joint, and soft tissues for thumb reconstruction, including distraction-lengthening,6,15–17,22,23 phalangization,2,22,25 osteoplastic reconstruction,3,27 and pollicization.1,4,14 Microsurgical toe transfer techniques for thumb reconstruction include total greattoe8,18,29 and great-toe variants, such as trimmed great-toe11,30 and great-toe wraparound flaps.7,19,26 Among the lesser toe-to-thumb transfer techniques, options include second-toe, partial second-toe, second-toe wraparound, second-toe pulp, and second-toe nail transfers. Appearance and function following microsurgical reconstruction are superior to those of traditional methods, as all essential components for thumb reconstruction—such as glabrous innervated skin, nail, tendons, bone, and joint—can be harvested from the foot. Furthermore, careful preoperative planning minimizes functional loss at the donor foot. The total great toe8,18 is indicated for thumb reconstruction for amputations located between the interphalangeal joint and the base of the metacarpal. It should be employed for patients who request better hand function and appearance and are willing to accept possible mild functional disturbance of the foot. It is also indicated in the severely injured hand, as it provides strong grip and pinch when the size discrepancy between the thumb and great toe is acceptable. The total great toe provides the best sensibility, stability, grip strength, pinch power, grasp, and interphalangeal joint motion to the reconstructed thumb. However, the reconstructed thumb is big, and the appearance is not perfect. Trimmed great-toe transfer29,30 combines the better aesthetics of wraparound procedures and better function of the total great-toe transfer. This procedure involves trimming of the excess soft tissue, bone, and joint yet preserves the articulation of the interphalangeal joint. It is indicated for thumb amputations at or distal to the metacarpophalangeal joint when
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there is an obvious size discrepancy between the thumb and the great toe and when movement of the interphalangeal joint is desirable. It also can be employed in children, since careful trimming of the epiphysis does not hamper growth.11
RELEVANT SURGICAL ANATOMY The great toe is approximately 20% larger and longer than the thumb. Anatomic differences between the great toe and the thumb include circumference, nail width, and phalangeal and joint length and width. On the average, the transverse diameter of the great toe is 13 mm and 11 mm and the great-toe nail is 4 mm and 3 mm wider than the thumb in men and women, respectively.30 The arterial supply of the flap is via the dorsal or plantar metatarsal artery,7 and the venous drainage is via the dorsal venous system, a tributary of the great saphenous vein. The plantar digital nerves of the great toe and the terminal branches of the deep peroneal nerve in the first webspace are included for sensation.
ORIGINAL WRAPAROUND PROCEDURE FOR THUMB RECONSTRUCTION 19,26
As described by Morrison, in the original wraparound procedure, the skin envelope and nail complex were harvested from the great-toe and wrapped around a contoured iliac crest bone graft over the thumb stump. The final shape of the reconstructed thumb was similar to that of the contralateral one. There was no sacrifice of the great-toe skeleton, which was then covered with a cross-toe flap and skin graft.10 The cosmetic shortcomings of total great-toe transfer and preservation of the great toe helped to popularize this flap. The primary indication for this technique, as originally described, was thumb reconstruction in amputations proximal to the interphalangeal joint.19 The flap is harvested from ipsilateral foot so that the more important ulnar side of the reconstructed thumb has better innervation and remains free from surgical scar. The circumference and length of the contralateral normal thumb are measured and transposed to the great toe. A tibial skin bridge extending and tapering around the tip is outlined, the width being the difference between the thumb and great-toe circumferences. This strip is preserved and later used for donor site closure. The flap is a partial degloving of the great toe, which includes the nail and pulp without the skeleton and tendons. The neurovascular pedicle is identified,
and the flap is elevated dorsally, with dissection being subperiosteally beneath the nail. On the plantar aspect, dissection remains superficial to the tendons. The digital nerves are included in the flap. The iliac crest bone graft is harvested, crafted into proper shape, and fixed on the thumb phalangeal or metacarpal stump using crossed K-wires. This bone graft serves as structural support to the transferred great-toe wraparound flap. The neurovascular pedicle is then anastomosed. Donor site closure is performed with the tibial skin strip aided by a cross-toe flap from the second toe26 and skin grafting. This technique is a definitive forward step in terms of function and appearance of the recipient and donor sites. However, there are several drawbacks with respect to indications and flap design.
Drawbacks in Surgical Indications The original indication included amputations proximal to the interphalangeal joint. As there was no provision for interphalangeal joint movements in the reconstructed thumb, the functional results remain deficient, especially for fine pinch.
Drawbacks in Flap Design and Donor Site Management The flap includes skin and nail from the great-toe without bony elements or tendons that might be required for reconstruction. The nonvascularized iliac bone graft used for bone reconstruction can be resorbed or fractured, resulting in flap and nail instability,5,12 thus compromising function of the reconstructed thumb. Melting of bone graft can lead to cosmetic concern in the form of a hook nail deformity5 or a bottleneck deformity at the junction of the stump and bone graft. The great toe is partially preserved, but closure requires cross-toe flaps and skin grafts,19 which increases the number of surgical steps as well as foot morbidity and prolongs recovery time. Furthermore, it has been shown that there is no additional advantage to preserving more than 1 to 1.5 cm of the proximal phalanx for foot function.29 The absence of growth potential in nonvascularized bone grafts precludes the use of this technique in children, and a painful bone graft donor site in the groin area increases overall morbidity.
MODIFIED GREAT-TOE WRAPAROUND PROCEDURE 9,24
The purpose of these modifications is to overcome the drawbacks of the original procedure.
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MODIFIED GREAT-TOE WRAPAROUND FLAP
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Modified Flap Design and Donor Site Management
The best indication for the great-toe wraparound flap is soft tissue avulsion injuries of the thumb that leave the skeleton and tendons intact (Fig. 13-1). The reconstruction requirements in this situation are for skin flap and nail, without the need for bone graft. Thumb amputation distal to the interphalangeal joint is another good indication for modified great-toe wraparound, as it requires no joint reconstruction (Fig. 13-2).
One of the most important modifications of the greattoe wraparound procedure is the inclusion of a portion of the distal phalanx in the flap. This bone remains vascularized; hence, it does not get resorbed or fractured. Inclusion of tendons in the flap, if needed, has made this flap even more versatile. As there seems to be no obvious advantage of preserving the entire length of the proximal phalanx, which
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Revised Indications of Great-Toe Wraparound Flap
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FIGURE 13-1. Left thumbnail and skin sleeve avulsion amputation at the metacarpophalangeal joint level. A, Nail and skin sleeve avulsion. Note the intact tendons and skeleton. B, Coverage reconstruction achieved with a pedicled groin flap. C, Harvested modified left great-toe wraparound flap. Note the inclusion of the dorsal half of the distal phalanx. D, Appearance at 6-month follow-up.
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FIGURE 13-2. Right thumb amputation at the distal phalanx reconstructed with a modified great-toe wraparound flap. A, Right thumb amputated at the distal phalanx. B, Harvested modified left great-toe wraparound flap. C, D, Appearance at 6-year follow-up. E, Range of motion 25° at the interphalangeal joint.
requires subsequent complicated coverage reconstruction with cross-toe flaps and skin grafts, the distal phalanx of the great-toe is always included in the wraparound flap if bone reconstruction is needed. Preservation of the proximal phalanx is sufficient for weight-bearing, propulsion, and prevention of windlass effect.29
Preoperative Planning Planning for reconstruction begins with emergency management. All grossly viable tissues should be preserved.28 Adequate or even redundant skin cover might be required, especially to reconstruct the first webspace. This can be achieved with a pedicled groin flap. This additional skin will be of use during later reconstruc-
tion, as it will reduce the amount of skin that needs to be harvested from the foot and will allow direct closure of the donor site. It is not advisable to include web skin or skin from the dorsum of foot, though this is described in the original technique, because these can increase donor site problems. The cosmetic and functional requirements for both recipient and donor sites as well as patient preference must be considered. In the recipient hand, the level of amputation, preserved structures, extent of coverage defect, and range of motion should be evaluated in the stump of the thumb. Associated injuries or defects of the hand and the remaining function of the thenar muscles must be assessed. In selecting the donor tissue from the foot, the similarities and differences between the normal thumb and the great toe should be considered.
Procedure (Authors’ Preferred Technique) The left great toe is always considered to be the first choice as the donor site first unless it is not suitable, regardless of which thumb is to be reconstructed. The design of the skin flap is similar to the original one. After retrograde dissection31 of one sizable vein and the dominant artery in the first webspace, the toe is incised along the medial skin strip to the toe tip. The dorsal skin flap is elevated from the underlying tissue to the level of the proximal eponychial fold, deep to the dorsal veins, and over the paratenon of the extensor tendon insertion. It is important to preserve the interphalangeal joint capsule and not disrupt the tendon sheath. The germinal matrix is left attached to the distal phalanx. Attention is then directed to the plantar surface of the flap, which is elevated from medial to lateral. The medial proper digital nerve is identified, isolated, and included in the transfer. The flap is then elevated from the distal phalangeal segment and flexor tendon sheath; the plantar proper digital nerve and artery are identified and freed at the lateral aspect. The soft tissue is completely separated, and the distal phalanx is osteotomized longitudinally by one-third on its medial side to reduce the wide transverse diameter. Preservation of the vascularized distal phalanx on its lateral side protects the nail bed and helps to maintain normal nail growth.5 The plantar side of the distal phalanx is also burred to reduce the anteroposterior diameter. If required, the corners at each side of the germinal matrix are then excised, so when the nail grows again, it will be narrowed to the desired degree. In addition, the extensor hallucis longus and flexor hallucis longus may be included in the transfer if necessary. Since an advantage of this technical modification is the simplicity of wound closure and less morbidity at the donor site, reconstruction of the donor great toe should be performed with utmost care. If viability is questioned, the medial skin strip should be excised, even if this means further bone shortening for closure. The cartilagenous surface of the proximal phalanx or several millimeters of proximal phalanx can be removed to facilitate a tension-free donor site closure. The proximal portion of the medial skin strip is helpful in wound closure; skin grafts and cross-toe flaps should be avoided. Although shorter, a great toe with acceptable appearance and good function of the foot can still be achieved in this fashion.
Recipient Site Preparation and Toe Transfer Inset Bone, tendons, and neurovascular bundles are prepared at the recipient site through a cruciate incision of the stump. After verification of proper length, the phalanx of
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the transferred wraparound flap is fixed to the bone of the amputation stump with two interosseous wires.32 If the extensor and flexor tendons are included in the flap, they are repaired with proper tension to place the thumb in neutral position. All proper or common digital nerves are coapted in end-to-end fashion with 10-0 nylon suture. Both the deep and superficial peroneal nerves are also repaired, when recipient nerves are available. The artery and vein are tunneled to the corresponding recipient site. The transferred wraparound flaps are draped around the bone in such a way as to avoid wound closure adjacent to the contact surface of the pulp. Skin redundancy from either a wraparound flap or a recipient site is tailored, and all wounds are closed, leaving only those for vascular anastomosis. Arterial anastomosis is performed first, followed by the vein. The remaining wounds then are closed.
Postoperative Management Ideally, the patients can be cared for in a special microsurgery intensive care unit for several days, where specialized nurses are available for close monitoring of the transferred flap and the patient’s general condition. The proximal palm and wrist are gently wrapped; the reconstructed digits are left exposed for continuous observation. The hand and forearm are kept slightly elevated to reduce edema. Bulky dressings are not recommended, as blood clots can be retained around the wounds, and attempts to remove them may induce vasospasm. An initial bolus of 100 cc of Dextran 40 (low molecular weight) is rapidly administered intravenously, 10 minutes prior to completion of the arterial anastomosis, followed by continuous infusion (25 mL per hour) over the next 4 to 5 days. Aspirin (325 mg daily) is administered for 2 weeks to reduce platelet aggregation risk. Prophylactic antibiotics are not necessary in elective cases. However, in primary toe transfers, prolonged surgical cases, or dirty wounds, antibiotics against both Gram-positive and Gram-negative bacteria are given. The vascular conditions in the toe are subjectively monitored by direct observation of skin color, capillary refilling, and turgor and objectively by measuring the surface temperature in the toe in comparison to that in the adjacent normal finger and contralateral hand. Ultrasound or laser Doppler helps to assess vascular anastomosis patency. The donor foot is gently covered with gauze and a light fluff dressing. No splints are used in the donor foot or the recipient hand. The foot is uncovered 2 days later without further dressings. The patient is allowed to walk a few steps on the heel of the donor foot after the second week. It must be emphasized that any contact with the distal plantar weight-bearing surface should be
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avoided during this time. After 6 weeks, the patient is allowed to walk with a normal gait in shoes.
Immediate and Late Complications and Management Vasospasm is the most frequent vascular complication. It can occur intraoperatively or postoperatively. It is observed more often in distal digital reconstruction with partial toe transfer. Arterial vasospasm during the procedure can be relieved by topical instillation of lidocaine (Xylocaine 1–2%) or papaverine. Adventitiectomy helps in relieving the spasm and should be carried out under the operating microscope. Tension from the vascular anastomosis should be avoided. If necessary, vein grafts can be employed, although with adequate preoperative planning, they are rarely needed. The vessels should be kept moist during the procedure, and the skin closure should not be tight. Postoperative vasospasm may be precipitated by low room temperature, low blood pressure, anxiety in the patient, or excessive manipulation of the hand. Prevention consists of maintaining an optimal blood pressure, supplying adequate fluids, and avoiding oversedation. If vasospasm occurs, some skin sutures should be removed, and vasodilators such as lidocaine (Xylocaine) should be intermittently instilled into the partially opened wounds. Sublingual nitroglycerin or nifedipine21 and regional blocks20 may help to relieve vasospasm. However, if no improvement of circulation is noted after observation for a reasonable time (1 hour), prompt reexploration in the operation room is mandatory. In some cases, incomplete adventitiectomy or a small hematoma might be responsible for local vasospasm. Once the adventitial layer has been adequately excised or after draining the hematoma, the vasospasm may be relieved. Refractory vasospasm or a thrombosed artery is an indication for redoing the anastomosis, with or without an interposed vein graft. In contrast to arterial thrombosis, venous thrombosis is less common and is often related to incorrect positioning such as twisting or kinking or compression by tunnel, hematoma, or tight skin closure. In most instances of vascular compromise, it is possible to salvage the transferred flap after re-exploration. The attitude toward re-exploration and vein grafting (if necessary) should be aggressive. Other complications observed in the first 2 weeks usually involve skin coverage and wound-healing problems. In most cases, these are secondary to partial necrosis of thin skin flaps in the transferred toe or in the scarred recipient site. With exposure of important structures such as tendons, nerves, and vessels, immediate coverage reconstruction should be performed to prevent desiccation of these structures and subsequent sequelae.
CONCLUSION The modified great-toe wraparound flap is best indicated for reconstruction of the thumb amputated distal to the interphalangeal joint. It is also suitable for reconstruction of a thumb with only nail and skin sleeve avulsion. The inclusion of the dorsal half of the vascularized distal phalanx avoids pulp instability and problems related to resorption of a nonvascularized iliac bone graft. The simplified wound closure technique at the distal phalangeal or interphalangeal joint level allows minimal donor site morbidity. In summary, the modified great-toe wraparound flap eliminates the drawback of the original techniques and provides the most aesthetic and functional thumb reconstruction in indicated cases.
References 1. Brunelli GA, Brunelli GR: Reconstruction of the traumatic absence of thumb in the adult by pollicization. Hand Clin 8:41–45, 1992. 2. Bunnel S: Physiologic reconstruction of the thumb after total loss. Surg Obstet Gynaecol 52:245, 1931. 3. Chase RA: An alternative to pollicization in subtotal thumb reconstruction. Plast Reconstr Surg 44:421, 1969. 4. Cheng MH, Cheng SL, Tung TC, et al: A case report of pollicization of traumatized index finger for reconstruction of traumatic amputation of thumb. J Surg Assoc Rep China 30:134–139, 1992. 5. Foucher G, Binhammer P: Plea to save the great toe in total thumb reconstruction. Microsurgery 16:373–376, 1995. 6. Fultz FW, Lester DK, Hunter JM: Single-stage lengthening by intercalary bone graft in patients with congenital hand deformities. J Hand Surg 11B:40–46, 1986. 7. Gilbert A: Composite tissue transfer from the foot: Anatomic basis and surgical technique. In Daniller A, Strauch B (eds): Symposium on Microsurgery, vol 15. St Louis, CV Mosby, 1976. 8. Gordon L: Toe to thumb transplantation. In Green DP (ed): Operative Hand Surgery. Edinburgh, Churchill Livingstone, 1993, pp 1253–1282. 9. Govila A: Improvisation in wrap around toe to thumb transfer. Acta Chir Plast 35:101–110, 1993. 10. Hamilton RB, O’Brien B, Morrison WA: The cross toe flap. Br J Plast Surg 32:213–216, 1985. 11. Jain V, Wei FC, Yu CC, et al: Trimmed great toe to thumb transfer in children: Long-term results. Submitted to Plast Reconstr Surg. 12. Lee KS, Park JW, Chung WK: Thumb reconstruction with a wrap-around free flap according to the level of amputation. Microsurgery 20:25–31, 2000. 13. Lister G: The choice of procedure following thumb amputation. Clin Ortho Rel Res 195:45–51, 1985. 14. Littler JW: Reconstruction of the thumb in traumatic loss. In Converse JM (ed): Reconstructive Plastic Surgery, 2nd ed. Philadelphia, WB Saunders, 1977, pp 3350–3367. 15. Matev IB: Thumb reconstruction in children through metacarpal lengthening. Plast Reconstr Surg 64:665–669, 1979.
16. Matev IB: Reconstructive Surgery of the Thumb. Brentwood, Essex, England, Pilgrims Press, 1983. 17. Matev IB: The bone lengthening method in hand reconstruction: 20 years experience. J Hand Surg Am 14(2):376–378, 1989. 18. May JW: Microvascular great toe to hand transfer for reconstruction of amputated thumb. In McCarthy JG (ed): Plastic Surgery. Philadelphia, WB Saunders, 1990, pp 5153–5158. 19. Morrison WA, McLead AM: Thumb reconstruction with a free neurovascular wrap around flap from the big toe. J Hand Surg 5:575–583, 1980. 20. Neimkin RJ, May JW, Roberts J, Sunder N: Continuous axillary block trough an indwelling Teflon cathether. J Hand Surg 9A:830–833, 1984. 21. Nilsson H, Jonasson T, Ringquist I: Treatment of digital vasospastic disease with the calcium-entry blocker, nifedipine. Acta Med Scand 215:135–139, 1984. 22. Seitz Jr WH, Dobyns JH: Digital lengthening with emphasis on distraction osteogenesis in the upper limb. Hand Clin 9(4):699–706, 1993. 23. Smith RJ, Gumley GJ: Metacarpal distraction lengthening. Hand Clin 1:417–429, 1985.
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24. Tsu-Min Tsai, Falconer D: Modified great toe wrap for thumb reconstruction. Microsurg 7:193–198, 1986. 25. Tubiana R, Roux JP: Phalangisation of the first and fifth metacarpal. Indications, operative techniques and results. J Bone Joint Surg Am 56:447–457, 1974. 26. Urbaniak JR: Wrap-around procedure for thumb reconstruction. Hand Clin 1:259–269, 1985. 27. Verdan C: The reconstruction of the thumb. Surg Clin North Am 48:1033, 1968. 28. Wei FC: Tissue preservation in hand injury: The first step to toe-to-hand transplantation [Editorial]. Plast Reconstr Surg 102:2497–2501, 1998. 29. Wei FC, Chen HC, Chuang CC, Chen SH: Microsurgical thumb reconstruction: Selection of various techniques. Plast Reconstr Surg 93:345–351, 1994. 30. Wei FC, Chen HC, Chuang CC, Noordhoff MS: Reconstruction of thumb with a trimmed great toe transfer technique. Plast Reconstr Surg 82:506, 1988. 31. Wei FC, Silverman TS, Hsu WM: Retrograde dissection of the vascular pedicle in toe harvest. Plast Reconstr Surg 96:1211–1214, 1995. 32. Yim KK, Wei FC: Intraosseous wiring in toe-to-hand transplantation. Ann Plast Surg 35:66–69, 1995.
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14 Principles of Replantation and Revascularization Zhong-Wei Chen, MD
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Qing Huang, MD
Replantation and revascularization of severed limbs and digits with survival and functional recovery is a relatively recent laboratory and clinical proposition in the field of traumatology. In 1903, Höpfner attempted to replant three completely severed legs in dogs but was unsuccessful. In China, Du Kai-yuan et al., in their experimental replantation of completely amputated canine legs, achieved survival and partial functional recovery in several of their cases. Subsequently, laboratory and clinical replantation of completely severed limbs and digits has become a problem of common concern to surgeons all over the world.28–30 During the 1960s, consecutive successes in replanting completely amputated limbs and digits were reported by surgeons in many countries.2,3,8–10,12,15,20,23,31 In 1963, Zhong-Wei Chen and Chien Ying-Ching in China replanted a right hand that had been severed above the wrist, with complete success, accompanied by good functional recovery (Fig. 14-1).2 This was the first such case reported in the world’s medical literature. Thereafter, knowledge and technical development of replantation surgery have accumulated progressively through clinical trials.1 At the present time, it is possible to successfully replant not only freshly amputated limbs that are cleanly cut or avulsed with irregular surfaces at any level of the upper or lower extremity, but also those severed limbs with an ischemic period as long as 36 hours. Replantation has been rather widely adopted and practiced in China. The concomitant development of operating instruments, such as the designing and manufacturing of complete sets of microsurgical instruments and operating microscopes, provide an invaluable aid to replantation and the survival rate has greatly improved.5 The term severance of the digit is used to denote its detachment distal to the metacarpophalangeal joint but proximal to the distal interphalangeal joint.
MECHANISM AND CLASSIFICATION OF AMPUTATIONS OF LIMBS OR DIGITS Mechanism of Amputations The mechanisms of amputation injuries in limbs vary, and therefore the therapy for these injuries also varies. 193
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In multiple-blade injuries, such as those caused by a flywheel, saw, fan, tightwire, or reaping machine, tissue damage is not very serious; sometimes the limb is shattered by a blade or is severed into several segments. The injured or destroyed segments should be excised before the limb is replanted; sometimes multiple-level replantation surgery is required.
A
Crushing or Rolling Severances These injuries result from being crushed by a train wheel, automobile wheel, or gear wheel. Although tissues are ruptured at identical levels, the bone is splintered. Generally, the distal part is intact. Crushing amputations caused by automobile wheels often occur in the lower limb; most are incomplete severances. Usually, a large part of the skin is avulsed, and the wound surface is badly contaminated. When the severance is caused by a gear wheel, the width of the wheel should be examined in detail so that an appropriately wide debridement, extending to healthy tissue, is performed. Compression Severances This type of wound is caused by a heavy machine, stone, iron plank, kneader, or other heavy object. The wound is sectioned at different levels, tissue trauma is severe, and a significant amount of foreign material is often compressed into the area of tissue and is very difficult to remove completely. Furthermore, there are usually combined wounds in the distal part, such as fracture of a bone or rupture of blood vessels. Often, contusion of the superficial veins may occur, resulting in thrombosis, which may affect the venous return and lead to significant swelling of the replanted limb.
B FIGURE 14-1. Replantation of a completely severed hand. A, Before replantation. B, One year after the operation. The patient has resumed his original work.
Guillotine Severances In this type of severance, the limb was severed by a sharp object such as a milling machine, industrial scissors, lay cutter, or glass. Tissues in the limb are severed at identical levels. The extent of the tissue trauma is negligible, and the clean cut offers the best conditions for replantation.
Avulsion Severances Limbs are amputated by axes, straps, disks, or reels (e.g., a lathe, thresher, or electric motor). The skin is avulsed or has distinct contusions; superficial veins may be injured too. Muscles of the forearm are frequently avulsed at the juncture of the tendon and muscle belly. If anticoagulants are used in such patients, extensive blood oozing and hematoma formation may take place. Often severe vasospasm occurs at the proximal and distal ends of the severed blood vessel, which makes it difficult to reestablish circulation. Avulsion amputation injuries offer the most unfavorable conditions for replantation. The problem lies with the differing levels of injury of the different structures. For example, nerves may be avulsed at the neuromuscular junction or even within the intervertebral foramen. There is no effective treatment for the latter at present. When nerves are avulsed, the graft, fibers, and sheath are often disrupted at different levels, and the wound length may be greater than 20 cm.
Classification of Amputations There are two major categories of limb or digit severance: complete and incomplete.
Complete Severances This category includes those with the distal segment completely separated from the proximal stump with no soft tissue connection or with only a minimal amount of soft tissue attachment. Incomplete Severances In this category, there is fracture or dislocation at the disrupted skin surface, with soft tissue attachment of less than one-fourth of the cross-sectional area and disruption of the main blood vessels, or there is only tendinous continuity with a remnant skin connection of less than one-eighth of the total circumference while all other vascular tissues are disrupted. Total loss of circulation or severe ischemia exists in the distal segment that will lead to necrosis if the vessels are not anastomosed. During the period from January 1963 to September 1976, the Sixth People’s Hospital of Shanghai performed 438 replantations of various types of severances of limbs and digits. Of these, 330 cases were males, and 108 were females. The age distribution was between 1 and 74 years, the greatest incidence (151 cases) falling between 21 and 30 years. The youngest patient was 42
A
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days old (Fig. 14-2). Of the 438 cases, 301 had complete severances, and 137 had incomplete severances (all, however, were devascularized). There were 190 cases of severed limbs at different levels, with a survival rate of 83.2%, and 248 cases of severed digits (totaling 416 digits) at different levels, with a survival rate of 63.7%. If calculated with respect to the number of digits involved, the survival rate was 57.5%. Among these, 65 digits had been anastomosed since 1973, using operating microscopes, and the survival rate has been as high as 93.2%. This clearly shows the important role played by the operating microscope in the improvement of clinical results of replantation of severed digits.
OPERATIVE INDICATIONS The utmost effort should be made to preserve every useful limb or digit under the assumption that the life and safety of the patient are ensured. On the basis of our clinical experiences, of both successes and failures, we take as our guiding principle that replantation should be considered only when (1) the patient is able to withstand the operation and (2) the local conditions are suitable for such a procedure. It should be realized that the indications for replantation are relative. Each patient is different and should be analyzed and managed individually.13
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FIGURE 14-2. Complete traumatic amputation of the right wrist of a 42-day-old infant. Replantation was successful.
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In general, replantation may be carried out when the following conditions are met: 1. The patient is able to withstand the operation. Proper judgment of indications for replantation of severed limbs and digits is not only important to their survival, but also of great concern to the overall safety of the patient. Patients suffering from limb severance often have concomitant shock subsequent to trauma or serious blood loss or have accompanying intracranial, abdominal, or thoracic injuries. In such cases, prompt and resolute measures must be taken to deal with these life-threatening conditions. During the period from January 1963 to December 1972, of 114 limb transplantations, there were 23 cases in which amputation was combined with shock or other serious injury; 19 of these patients underwent successful replantation. Here are two examples: (a) complete amputation of the left arm combined with left epidural hematoma; after replantation of the limb and removal of the hematoma by craniotomy, the patient and the replanted limb survived. (b) right acromioclavicular joint amputation combined with fracture of ribs, contusion of the lung, and hemopneumothorax; after drainage of the hemopneumothorax replantation was performed with survival of the replanted limb. If the patient’s general status at the time of examination is unsatisfactory for replantation, the severed limb or digit should be stored temporarily at 0–4°C until the patient’s systemic condition improves to a state that will permit replantation. 2. The amputated limb or digit must maintain a certain degree of integrity; there should be no serious damage to the vascular bed. In comparison with severances caused by crushing, those resulting from cutting with their structures relatively clean and neat in general have better chances of successful treatment. However, in many cases of avulsive injury with partial destruction of the vascular bed, complicated by multiple fractures or with concomitant electric or thermal injuries, replantation may still be successfully carried out, provided that the traumatized tissues are adequately debrided and the limb or digit is shortened. Vascular repair and internal fixation of fracture may have to be performed when injured blood vessels and multiple fractures are present. Clinically, the incidence of digital amputations is higher than that of the limbs. Multiple-digit
amputations generally cause the greatest functional impairment of the hand and warrant the most diligent endeavors for replantation. If the thumb is crushed and its distal part cannot be replanted but the index finger, though severed, is in fairly good condition, it may be transferred to the stump of the amputated thumb. In severance of the thumb and four fingers, if the distal part of the thumb is severely comminuted and impossible to replant, it will be more advisable to transfer the better-preserved ring finger to the proximal segment of the thumb and to have the index and middle fingers replanted in situ. In this way, the manual function will have a maximal degree of recovery (Fig. 14-3). When serious disruption of the integrity of the severed part occurs, for example, with prolonged ischemia time, attempts to replant will often fail. If the avulsed blood vessels and nerves are not at the same level and revascularization is not feasible, replantation should be aborted. Lastly, the method of preservation of the amputated part is important. If the severed limb or digit is placed directly in hypotonic, hypertonic, or antiseptic solution, the solution will enter the blood vessels and cause endothelial damage. The result is loss of the opportunity for successful replantation of the severed part. 3. Replantation may be attempted if the time elapsed after severance is not too long and there is no irreversible degeneration of tissue cells. The longest time interval between severance and restoration of circulation is called the ischemia time. When a part of the limb or digit is totally detached, its circulation is suddenly and completely interrupted. Degenerative changes occur to varying degrees in different tissues successively with the passage of time, ultimately leading to death of the tissues. We performed in vitro experiments to observe the changes in energy metabolism and tissue decomposition, under normal temperatures and found that adenosine triphosphate, succinyl dehydrogenase, acid phosphatase, and glycogen content fell precipitously 5–10 hours after severance, while the lactic acid level rose rapidly and mild tissue lysis occurred. There was only a small amount of residual muscle glycogen 48 hours after amputation, but serious tissue decomposition had not yet occurred. Pathological examination showed that only slight tissue degeneration was present within 10 hours of amputation but became moderate to severe afterward. Cold storage reduces the speed of cellular metabolism
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C
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FIGURE 14-3. Ectopic replantation of digits. The severed ring finger was transferred to the stump of the thumb. The index and middle fingers were replanted in situ. A, Before replantation. B, After replantation. C, Opposition. D, Holding a fist.
and tissue degeneration. Thus, an amputated canine leg stored at 0–4°C for 108 hours was replanted with success and functional recovery (Fig. 14-4). The ischemia time is also related to the level of severance.27 If a limb is severed at more proximal levels, the distal portion will contain larger amounts of muscle tissue, and the tolerance to anoxia will be poorer and tissue degeneration more severe. These features are minimized when
the amputation is more distal. One unique aspect of the digits is that they contain primarily bones, tendons, and skin and therefore have the greatest tolerance to anoxia. The digits have little effect on the patient’s general status; even if the replanted digits do not survive, there is no danger to the patient’s life. Thus the ischemia time for digits is considerably longer than that for limbs. The ischemia time bears an important relationship to the survival rate. This is shown by
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FIGURE 14-4. Successful replantation of a dog’s leg with functional recovery. The limb had been cold stored for 108 hours.
the following data derived from cases of various types of limb amputation at different levels treated in the Sixth People’s Hospital of Shanghai between January 1963 and December 1972: 47 cases had an ischemia time of less than 6 hours, with a survival rate of 95.7%, and 37 cases had an ischemia time within 10 hours had a survival rate of 78.4%. Of the 30 cases with time intervals greater than 10 hours (among these, the severed parts of five cases were cold stored), the survival rate was 60%.26 We have recently performed another experiment to evaluate the DNA degradation in the nuclei of skeletal muscle and smooth muscle cells in rabbits during ischemia to estimate the status of tissue degradation. The results are as follows: (a) The DNA contents in nuclei of skeletal muscle cells decreased at 8 hours after warm (25°C) ischemia took place, and the decrease became significant at 16 hours after ischemia occurred. In the refrigerated (0–4°C) group, the DNA contents showed no change at 24 hours. (b) The DNA contents in the nuclei of smooth muscle cells decreased at 8 hours after ischemia took place, and the decrease became significant at 16 hours after ischemia occurred. In the refrigerated group, the DNA contents showed no change at 24 hours. Our conclusion is that the time limitation of replantation of a severed limb
is 8 hours at room temperature; for severed digits, it is 12 hours at room temperature. Preserved in a refrigerator (0–4°C), severed limbs or digits could be replanted when ischemic time is limited to 24 hours. The ischemia time can be relatively prolonged after restoration of circulation by the administration of hyperbaric oxygen, human albumin, energy mixture (adenosine triphosphate, coenzyme A, cytochrome C), which may reverse the microcirculatory compromise, thus making survival possible. Severe swelling and necrosis of the replanted part may still occur after reestablishment of the circulation, owing to such factors as protracted ischemia and anoxia, change in permeability of the cell membrane, and massive reperfusion toxin absorption. Life may be endangered in extreme cases. Therefore, replantation of limbs or digits should preferably not be performed in cases having prolonged ischemia time without cold storage of the severed parts and when tissue degeneration has already occurred. 4. Replantation should be carried out only when it is estimated that the part replanted can recover at least some function. The object of replantation is not merely survival of the limb or digit; more important still is its functional recovery. The probability of functional recovery must therefore be carefully considered before embarking on replantation. If it is estimated that replantation will be detrimental to functional recovery or that there is practically no chance of rehabilitation, then replantation is inadvisable. Replantation is also contraindicated in cases with severe avulsion of nerves and muscles that cannot be expected to have their functions restored through secondary tendon transfer or other tissue transfer using microsurgical techniques. There is no effective therapeutic means to treat those cases in which the nerve roots to the upper limbs are avulsed at the level of the intervertebral foramina. Even if the replantation is successful, there will be neither sensation nor recovery of other functions, and the replantation will be fruitless. However, in cases of peripheral nerve avulsion occurring at sites where the motor nerves enter the muscle bellies it was accepted that the muscle and nerve functions could not be restored. These injuries could also not be treated by tendon transfer, and therefore replantation was contraindicated. This is no longer true. With the development of microsurgical technique, transfer of free muscle together with its intact nerve and vascular supply or
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transfer of a combination of free bone, muscle, tendon, and skin with attached nerves and vessels to restore the function of the lost parts becomes possible.30 Therefore replantation should be considered in such cases, followed by secondstage microsurgical transfer of free combined tissues to restore function of the lost parts. Zhong-Wei Chen has treated the loss of part of the forearm by a multidimension-freedom electronic artificial hand, which is controlled by a reconstructed digit transferred from the second toe to the forearm stump; 100% accuracy rate of the electronic artificial hand can thus be achieved (Fig. 14-5).6
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DEBRIDEMENT General Management Debridement is the basis for the treatment of all kinds of open trauma. Thorough and meticulous debridement is an important prerequisite to ensure healing of the wound, patency of vascular anastomoses, and recovery of neural function. Such debridement not only reduces the tissue inflammatory reaction and the postoperative adhesions, but also minimizes infection, thus providing an important and advantageous condition for second-stage reconstruction. If the debridement is incomplete, necrotic tissue will interfere with the proper healing of wound surfaces and lead to an inflammatory reaction and swelling of the surrounding tissues. The latter will initially impede the venous return and later the arterial blood flow and will finally cause necrosis of the replanted part. In severe situations, toxic symptoms may be produced, endangering the life of the patient. It should be borne in mind that the process of debridement is not merely an important first step in the treatment of the patient, but also a procedure during which information is obtained regarding the nature and extent of damage done to the various tissues involved in the trauma. Severely damaged tissues at the amputation site should be removed (Fig. 14-6). Devitalized tissue should never be retained in an attempt to conserve the length of the limb. This often leads to failure of replantation, a situation that is often seen in clinical practice. To make the procedure less time consuming, debridement is performed by two teams: One deals with the proximal portion of the amputated part and the other with the distal portion. While carrying out the debridement, each team should keep the other informed of the conditions and the extensiveness of bone, nerve, blood vessel, muscle, and skin resection.
B
C FIGURE 14-5. Electronic artificial hand controlled by a reconstructed digit. A, Transfer of the toe onto the forearm stump. B, Electronic artificial hand. C, Demonstration of function.
This will aid in the planning and performance of the replantation. The whole of the limb or digit and margins of the wound are washed and scrubbed with sterile soap solution. Foreign bodies within the wound surface are
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removed, and the region is irrigated with large quantities of isotonic saline. After washing and scrubbing twice, the skin is sterilized with 3% tincture of iodine and 70% alcohol and draped with sterile towels. For multiple-digit amputations, debridement is carried out in the order of importance. The digits that are not being debrided are temporarily placed in a 0–4°C freezer to retard tissue degeneration.
Debridement of Skin, Muscles, Tendons, and Bone
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This can be done using the naked eyes or under the microscope; the badly contaminated wound surface is converted into a relatively clean one. Generally, the skin, muscles, tendons, and bones may all be debrided under direct vision, while the nerves and blood vessels should be debrided using an operating microscope. All parts of the skin that are badly avulsed and have a brownish-violet discoloration, have intradermal hemorrhage, or are thinned and detached from the subcutaneous tissue by a crushing or rolling injury should be excised because these are signs of devitalization. The uninjured superficial veins should be protected during skin excision. They may be utilized for venous anastomosis. In avulsive degloving injuries, the skin may be preserved after peeling off the subcutaneous fatty tissue and kept ready for skin grafting if necessary. If the skin is avulsed from the proximal part and has no obvious wound, it need not be removed. When extension of the wound is necessary, the incision should be made according to the principles of plastic surgery, using 60° Z-plasties; by this means, late-stage scar contracture is prevented. The extent of tendon excision is determined by observing whether the color, luster, or form remains normal and whether the paratenon is intact. Those tendons that are not indispensable for functional recovery should be excised to lessen postoperative adhesions. The viability of tissues proximal to the level of severance is judged by color, luster, and the presence or absence of bleeding and muscular contraction. When a limb or digit has been partially amputated, the soft tissues that remain attached should be conserved as much as possible, because the capillaries and lymphatics in various soft tissues may play a role in the survival of the replanted part.
B FIGURE 14-6. Replantation after extensive debridement of a badly traumatized segment. A, Right forearm severed by rolling into a lathe. Before transfer. B, Replantation after resection of a badly traumatized segment measuring about 10 cm, with functional recovery.
Assessment of the Vascular Bed Locating the Blood Vessels The blood vessels in a severed limb are larger in caliber and generally easy to find if sought along their anatomic paths. The digital vessels are tiny, especially
the veins, and often hidden beneath the skin and difficult to distinguish from other surrounding tissues. Therefore they should be dissected with care and precision, a time-consuming procedure. The digital arteries are situated dorsal to the digital nerves and deep to the Cleland’s ligament. Longitudinal incisions are made bilaterally through the skin and Cleland’s ligament for a length of about 0.5 cm. The palmar skin is then reflected away from the detached surface. The digital nerves are found first and the digital arteries are then identified (Fig. 14-7). Another way to locate the digital arteries is to observe their pulsations and the spurting of blood when the tourniquet is released. This is easier than the first method. These are used as markers when the vascular anastomosis is ready to be performed. The digital veins are situated beneath the dorsal skin of the digit—an anatomic feature of the digit. Some veins are situated beneath the palmar skin of the digit. Therefore two oblique incisions making an angle of 60° with the cut margin may be made on each side of the dorsum of the severed ends according to the Z-plasty principle, and the triangular skin flaps are then transposed toward their bases (Fig. 14-8). Care must be taken not to injure the veins on the deep side of the dermis. Another method to identify the digital veins is to perfuse the digital artery with 12.5 units/mL heparin in normal saline. The opening of the digital vein may then be identified by the outflow during perfusion.
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FIGURE 14-7. Bilateral longitudinal incisions are made about 0.5 cm in length on both ends of the severed finger. The palmar skin is reflected in a direction away from the cut surfaces. Digital arteries and nerves are exposed.
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FIGURE 14-8. Incisions forming a 60° angle with the cut edge are made over the dorsum of the finger. The triangular skin flaps are turned up to expose the veins.
Perfusion of the Vascular Bed Intravascular perfusion with 12.5 units/mL heparin in normal saline is useful for estimating (l) the integrity of the vascular bed of the severed part and (2) whether replantation is possible. Furthermore, thrombi within the small vessels as well as the products of metabolism may be eliminated through irrigation, thus reducing toxic absorption and intravascular thrombus formation. It is also useful for dilating the spastic, obliterated small vessels and capillary network and for restoring the siphon activity of the capillaries. For vascular perfusion, a main artery or other artery not intended for anastomosis is selected. A marker suture is placed at the vascular edge of the cut end. A blunt needle is then inserted, and perfusion is done with a solution of 12.5 units/mL heparin in normal saline. The needle should be carefully and gently inserted in the direction parallel to the longitudinal axis of the blood vessel. Care must be taken not to insert the needle obliquely, forming an angle with the longitudinal direction of the vessel, so as to avoid injuring the vascular intima. In general, 10–20 mL of the solution will be enough for the digital vessels. If no resistance is met during injection, the perfusing fluid will flow out from the communicating branches of the arteries, the medullary cavity, and the cut venous ends. Perfusion is continued until the outflow is clear. The amount of the venous outflow should be approximately equal to the irrigating inflow through the arterial end, and there should be no swelling of the distal segment of the limb or digit. These findings indicate patency of the vascular bed. Considerable resistance during perfusion or small venous outflow suggests vascular obstruction or disruption. The usual causes of vascular obstruction are spasm, obliteration by thrombi, or impaired patency of the capillary bed. Rupture of the vessel may occur in the artery, often distal to the level of
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severance, accompanied by fracture or skin contusion. The perfusing fluid will leak out and cause obvious swelling of the local tissues, or rupture may occur in the veins, and the irrigating fluid will then leak out and accumulate in the subcutaneous tissue. Rupture of the capillary bed caused by a crushing injury is accompanied by blotchy, bluish-violet discoloration and intradermal hemorrhage, and diffuse swelling occurs during vascular perfusion. Two different viewpoints exist regarding vascular perfusion. Some authors think that this process is unnecessary because it may be injurious to the microcirculation; others regard perfusion as a necessary step in replantation. We are of the opinion that for amputation of short duration and with rather clean-cut wound surfaces, irrigation is usually unnecessary. However, when the wounds are untidy with possible vascular damage and prolonged ischemia time, intravascular perfusion must be instituted.18
repair of muscles, tendons, and nerves is of prime importance in ensuring the reestablishment of function. Before proceeding with the replantation, an overall plan should be conceived for the reconstruction of the five basic structural components: bones, blood vessels, nerves, muscles, and skin.13 Mismanagement of any link may affect the entire process. The replantation can usually be carried out in accordance with the sequential principle of repairing deep tissues before the superficial ones. Therefore the first step is to reconstruct the bone framework. The second is to reestablish the circulation. The main muscles, tendons, and nerves are then repaired; lastly, the subcutaneous tissue and skin are sutured to complete the wound coverage. These procedures are described separately as follows.
Reconstitution of the Skeletal Framework Debridement of the Blood Vessels Thorough debridement of the wall of the blood vessels is a crucial step in vascular anastomosis. There may be some difficulty in judging the presence and degree of damage sustained by the vessel wall, for it may occur that intimal contusion is present while the adventitia remains intact. Relatively extensive vascular injury or latent intimal damage is frequently found and varies with the nature of the trauma. Usually, intimal contusion or disruption is shown by the presence of mural hematoma, roughening or visible rupture of the intima, or swelling of the vessel wall when 12.5 units/mL heparin in normal saline is injected into the lumen. All traumatized portions of the vessels should be excised. They should not be preserved for the purpose of conserving the length with the intention to perform direct anastomosis of the severed ends. Such anastomosis often leads to postoperative thrombosis and failure of replantation. If a vascular defect is present, an autogenous vessel graft may be used for repair. On the other hand, if the vessel is left too long and becomes redundant after anastomosis, twisting of the vessel and hemodynamic changes will result, particularly in the veins. Veins have low intravascular pressure, and the flow is slow; obstruction of the venous lumen is thus more liable to occur and in turn causes impairment of venous backflow, leading to swelling of the replanted part. Any redundancy of the vessel should therefore be excised.
REPLANTATION TECHNIQUE It may be briefly stated that debridement and skin covering form the basis of successful replantation. Anastomosis of blood vessels is critical to survival of the part, and the
Since some degree of soft tissue retraction of the severed part occurs, the bony ends will become relatively increased in length. Consequently, they should be shortened by an appropriate amount after consideration has been given to the following factors: (1) The length of the blood vessels and nerves should be such that no tension will be present after their anastomosis and coaptation; (2) an appropriate amount of tension should be present after suturing of muscles and tendons; and (3) the wound surface must be completely covered with skin. These factors should be analyzed in detail before internal fixation of the bone is performed. Bone shortening, of course, is not without limits. The main function of the upper extremity is manipulative in nature, so even when it is shortened significantly, postreplantation function will generally still be better than that of a prosthesis. When the lower extremities are shortened by more than 15–20 cm, they can no longer be used for weight bearing and walking; replantation in this case will be pointless. One exception is in children; since their epiphyseal plates are not closed, the disparity could be reduced by about 8 cm through autoadjustment. Also, the epiphyseal line of the contralateral femur can be blocked during development to a degree that is compatible with the shortened replanted limb (Fig. 14-9). For phalanges, the shortening is usually about 0.5 cm, not exceeding 2 cm even in serious injuries. Otherwise, it will make replantation very difficult or pointless. The necessary features of skeletal fixation are that it should be performed with simplicity, promptness, certainty, and stability and that it should heal rapidly with good functional recovery. Immobilization may also be obtained by using various kinds of intramedullary pins. In the case of amputation through the metaphysis, the shaft is driven into the metaphysis
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FIGURE 14-9. Traumatic amputation of the middle one-third of the left thigh by train wheels, replanted and survived. A, B, The extremity was 18 cm shorter than the normal one at completion of replantation. However, since the epiphyses had not closed, the disparity was reduced by 8 cm 5 years later through autoadjustment. Epiphyseal plate arrest of the normal knee was performed. The relative shortening is now about 6 cm. Recovery of function is shown 5 years after operation.
and fixed with one metal screw. Cross-fixing may be done with stainless steel pins, or plates and wires may be applied for fixation. In amputation through the joint with destruction of articular surfaces, primary arthrodesis or arthroplasty may be performed. For amputation of digits, if severance occurred in the phalangeal shaft, the most commonly used method is intramedullary fixation using Kirschner wires. The rounded circumference of the pin, however, makes rotation of the bone fragments possible, which may lead to avulsion or spasm of the blood vessels. Such rotational movements can be prevented by applying two sutures to the sheath of the flexor tendon. Flexion and extension of the digit during and after replantation may exert traction on the blood vessels that have already been anastomosed and may cause avulsion or spasm. Hence, fixation of the metacarpophalangeal joint is best done concomitantly with internal fixation of the fracture for the proximal phalangeal amputation. For digital amputations through the joints, primary arthrodesis is indicated.
Reestablishment of Circulation General Principles Restoration of circulation is vital to the survival of the replanted part. The arteries and veins should be anastomosed as soon as possible to provide adequate arterial blood supply to the tissues and to maintain a similar volume of venous return. If the arterial blood supply is insufficient, necrosis of the limb or digit at the distal part may occur in spite of survival of the replant. Inadequacy of venous return may lead to swelling of the replanted part and, in severe cases, may result in necrosis due to its effect on arterial blood flow. We feel that the sequence of vascular anastomosis should be decided mainly by the length of the ischemic period of the limb or digit. When the time interval between amputation and replantation is short and the trauma has been mild, the veins may be anastomosed first, followed by the artery. By so doing, most of the blood flowing through the operative area
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will return via the veins, the amount of bleeding is reduced, and the operative field will be relatively dry. For digital amputations, one or two dorsal digital veins are generally anastomosed first, followed by the digital artery. Some surgeons prefer to anastomose the digital artery first. Not only will this shorten the period of tissue ischemia and anoxia, but the earlier perfusion will also help to wash away toxic metabolites produced by ischemic tissues. Moreover, the restored arterial flow will distend the veins, making them easier to recognize and anastomose. However, blood loss is increased, and the operative field will be less clearly visualized. Another point is that after arterial anastomosis, the artery often needs to be temporarily occluded while carrying out venous anastomosis. Such interruption of blood flow may lead to thrombus formation at the anastomotic site and the capillary bed or to spasm of the anastomosed artery and ultimately cause failure of replantation. We therefore do not recommend the adoption of such procedures. The number of vessels that are anastomosed should be considered before vascular anastomosis. Normally, the number of veins is greater than that of the arteries at the same level of the limb so circulatory equilibrium between the arteries and veins is maintained. Swelling of the replanted limb will occur owing to inadequate venous return; subsequently, the arterial blood supply is adversely affected. If serious enough, this may lead to failure of replantation. Therefore, it is necessary when performing vascular anastomoses to consider the ratio between arteries and veins to be anastomosed to ensure hemodynamic equilibrium by equal flow in the arteries and veins. Clinical experiences have shown that when the ratio of arteries to veins is about 1:1.5, minimal swelling will occur. Thus, anastomosis of more veins than arteries is a good way to prevent swelling (Fig. 14-10). Generally, in replantation of amputated fingers, for each artery that is anastomosed, two veins should be anastomosed; if the digital arteries are bilaterally anastomosed, it is better to reestablish the continuity of three digital veins. Hemorrhagic shock of various degrees often accompanies major limb amputation, especially if the amputation is proximal. Adequate blood volume replacement should be given before vascular anastomosis to maintain the systolic pressure above 100 mm Hg. The vascular bed of the limb should be perfused by large quantities of blood after the vessels have been successfully anastomosed. If blood replacement has been inadequate, the blood volume relative to the total vascular bed will rapidly decline, and shock again appears. Insufficient perfusion of the vascular bed may cause vascular spasm or thrombo-
A
B FIGURE 14-10. Amputation of right thumb and index finger by an electric saw. There was no postoperative swelling owing to the proper ratio of the number of arteries and veins anastomosed during replantation. A, Before replantation. B, Demonstration of postreplantation functional recovery.
sis at the point of anastomosis and may lead to vascular crisis. The patency rate of small-vessel anastomosis relies mainly on the exquisiteness of the anastomotic technique; various anticoagulants and antispasmodics are merely supplementary. Six percent low-molecular-weight dextran (LMD) is used systemically as a routine adjunct for venoclysis; although its anticoagulant action is not as effective as heparin, it has fewer side effects. The operating microscope should be examined and adjusted, and all microinstruments should be ready for use before vascular anastomosis.
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FIGURE 14-11. Trimming of adventitial tissue.
Vascular Suturing Techniques Limbs may be amputated at any level. Anastomotic techniques should be applied according to the size of the vessels: 1. End-to-end anastomosis. Prior to anastomosis, a small segment of the blood vessel should be cut evenly so that a slight retraction of the adventitia occurs, while the media and intima protrude from the cut end (Fig. 14-11). The diameters of the vessels to be anastomosed should be similar. In general, if the difference in size of the vessel ends is one-fourth to one-fifth of their diameters, they can still be anastomosed directly, provided that mild dilatation of the smaller-caliber vessel is performed prior to the anastomosis. If the difference is more than one-fourth to one-fifth but does not exceed one-third to one-fourth of their diameters, it is better to have the smaller end cut at an angle 45° with its longitudinal axis to enlarge its opening (Fig. 14-12). End-to-end anastomosis is then performed. 2. End-to-side anastomosis. This is performed when the size of the two vessel ends is in obvious dis-
FIGURE 14-12. The end of smaller vessel is cut obliquely at an angle of 30–45° with the longitudinal axis of the vessel.
FIGURE 14-13. End-to-side anastomosis. A, B, Cutting a hole in the lateral wall of the vessel. C, Suturing the third stitch of the anterior wall anastomosis. D, Anterior wall anastomosis completed. E, Examination of the condition of the anterior wall anastomosis. F, Application of the middle stitch of the posterior wall anastomosis. G, Anastomosis completed.
parity, the difference reaching more than one-half of the diameter of the larger one (Fig. 14-13). If the blood vessels are of similar size, one of them must be kept intact and cannot be sectioned for an end-to-end anastomosis. 3. Invagination anastomosis. In 1978, almost simultaneously, Lauritzen14 and Mayer16 et al. achieved good results performing invagination anastomosis in rat femoral vessels whose calibers were less than 1 mm. In 1980, we studied invagination anastomosis in 100 rat femoral arteries between 0.6 and 0.8 mm in caliber. The immediate patency rate was 100%, and the long-term patency rate was 98%. Generally, this kind of suturing technique requires only three stitches. The operation is simple and quick, and there is no suture exposed in the intima (Fig. 14-14). However, the vessels that are to be anastomosed by invagination anastomosis must be long enough, and the diameters of the vessels should be similar. When blood vessels must be anastomosed in end-to-side fashion, invagination anastomosis should not be employed.
Venous Anastomosis In venous anastomosis, the adventitia of the cut vein ends is stripped for a distance of 2–3 mm to avoid falling into the lumen during anastomosis. Overstripping may cause vasospasm; if the stripping is carried too deeply to the media, the sutures may tear the vessel wall during
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FIGURE 14-14. Invagination anastomosis. A, The needle is inserted near the end of the proximal artery (the distance between the point of insertion of the suture and the edge of the divided vessel, which is known as the marginal distance, is about 0.8–1.2 mm) from the adventitia through part of tunica media but no intima with the longitudinal axis of the vessel, so the first stitch hangs on the vascular wall. B, The needle is then inserted from inside out through the vascular wall of the end of the distal artery (the marginal distance is 0.2–0.3 mm). C, The second stitch is at a distance of 120° from the first stitch. D, The lumen of the distal artery is exposed, and the proximal artery is inserted into it. E, The third stitch (that between the first and second stitch) can also be sewn before the insertion of the proximal artery into the lumen of the distal artery without tying. F, Tying of the third stitch.
anastomosis. Heparinized saline is used for irrigation, allowing the cut ends of the vein to gape, thus facilitating anastomosis. Interrupted sutures are generally used for venous anastomosis to avoid stenosis. An 8-0 to 11-0 atraumatic needle is passed through the vein walls. The first two guide sutures are placed either directly opposite each other (180° apart) or 120° apart. Intersuture and marginal distances are similar. Generally, the marginal distance is 0.1–0.2 mm, and the intersuture distance 0.2–0.3 mm. Six to eight stitches are sufficient for digital vein anastomosis.
Arterial Anastomosis It is not advisable to dissect the adventitia away from the cut vessel end, like rolling up a sleeve. The farther the dissection is carried, the more likely it is that kinking of the vessel will occur, which often leads to stenosis of the lumen and subsequent impairment of blood flow or vascular spasm. The arterial clamp is temporarily released after trimming of the adventitia. If blood
spurts freely from the cut arterial end, it can be assumed that the blood pressure is good and that no intraluminal thrombus or vasospasm is present. This predicts adequate perfusion of the amputated part after reestablishing arterial continuity. If the blood flows poorly from the cut end, the causative factor or factors should be sought and corrected. The most common cause is vascular spasm, which may be relieved by retrograde pressure irrigation with warm 2% procaine solution. Inadequate filling of the vascular bed due to blood volume deficit may also cause the poor flow. If the digit has been severely contused with marked traumatic swelling, the poor blood flow might be due to compression by Cleland’s ligament or lumbrical canal; the pressure should be relieved by a longitudinal incision of the compressing structure. When properly carried out, these measures will rapidly improve the blood flow of the artery that is to be anastomosed. After the arterial anastomosis is completed, the occluding clamps are removed. Arterial pulsation will be seen or felt distal to the anastomosis; the blood supply to the replanted digit or limb is observed to be good. The skin color changes from pale to red, and the cutaneous temperature increases. Adequate flow of the artery can be demonstrated by the patency test. Successful reestablishment of circulation is appreciated by good filling and free backflow of the anastomosed arteries and veins and by the oozing of fresh blood from the distal end of the replanted part when pricked by a pin.
Repair of Vascular Defects When an injured blood vessel is anastomosed after an inadequate debridement, there may be temporary restoration of blood flow; however, this is often followed by thrombus formation and impairment of circulation, necessitating complete resection of the traumatized segment of the vessel. This often results in inadequate length of the vessel for end-to-end anastomosis. If the artery or vein involved has a diameter greater than 2 mm and the length deficit is not more than 2 cm and is situated near a joint, the latter may be flexed to make end-to-end anastomosis feasible. However, for a large vascular deficit, it will be necessary to perform autogenous vein grafting. Fresh autogenous vein is the ideal material for vessel grafting. It is easily obtainable, it has a smooth intima, its survival rate is high, it will not cause foreign body reaction, it has a high resistance to infection, and the postanastomotic patency rate is high. For these reasons, autogenous vein graft is widely used clinically (Fig. 14-15). Veins are selected that have calibers similar in size to those of recipients and that lack pathological lesions. Subcutaneous veins with varicosities or veins that have been used for infusions should not be used.
FIGURE 14-15. Venous grafting to repair an arterial defect.
The donor vein is chosen in accordance with the length and branching of the defective segment. It is carefully dissected out, and the tributaries are tied off. The length of the graft should be slightly longer than that of the deficient segment. Usually, the adventitia at the ends of the venous segment is dissected first. The exact length needed is then measured and cut. Spasm often occurs in the segment taken out owing to surgical manipulation during dissection. Stenosis due to spasm should be completely relieved so as to prevent postanastomotic impairment of blood flow. The donor segment is placed in its original orientation for venous repair; for arterial repair, this orientation is reversed. When the digit is severed at the level of the proximal phalanx, anastomosis of a single artery and a single vein may result in progressive swelling. This may be prevented when an additional vein is not available locally, by transferring a neighboring digital vein of appropriate length and anastomosing its cut end to the digital vein of the severed digit. When postanastomotic swelling occurs in multiple digits, the guiding principle is to ensure the survival of the digits of greater functional importance. Veins from digits of less functional importance or those not planned to be replanted may be dissected out and used as free grafts. Two anastomoses are therefore needed for each replant. Digital artery deficits are frequently seen in clinical practice. When arterial defects occur bilaterally, the condition sometimes cannot be resolved by simple shortening of the phalanges. With severance of a single finger, the digital artery on one side may be harvested as a free graft for repairing the arterial defect of the other side, and two anastomoses with appropriate tension are performed for each graft. Alternatively, the normal digital artery of a neighboring digit may be utilized as a pedicle graft, to be anastomosed to the digital artery of the severed digit. In multiple-digit amputations, the digital arteries of digits that are not intended to be replanted may be taken as free arterial grafts. The postoperative crisis of arterial insufficiency may occur as a consequence of vascular spasm or stenosis of the anastomosis. This may be treated by applying a wet
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compress soaked with 2% lidocaine or 6% warm magnesium sulfate or by pressure dilatation with 2% procaine solution or heparin solution. The application of fluid pressure dilatation can relieve vasospasm and at the same time dilate the mildly stenosed anastomosis by forcing the solution to flow out between the intersuture vascular edges. The intima is everted slightly by this maneuver, rendering the inner surface of the anastomosis smoother. If all these measures fail to improve the circulation, it is necessary to resect the anastomosis, followed by reanastomosis or vascular grafting.
Muscle and Tendon Repair Early repair of muscles and tendons is critical for active range of motion of the joints, which in turn will prevent periarticular adhesion and contracture of the joints. It is also beneficial to the healing of fractures and better functional recovery of the replanted part. The corresponding muscle layers in the severed parts should be defined before suturing. The intermuscular septa or periosteum are repaired first to avoid inadvertent suturing of the flexors to the extensors. Primary repair of tendons of greater functional significance should be done. We usually perform primary repair of muscles and tendons at different levels of severance as described below.
The Upper Extremity 1. Digits. The extensor tendons possess paratenon without tendon sheaths, and their primary repair is feasible. This should be done before anastomosis of the dorsal digital veins. If severance occurs at the level of the proximal phalanx, suturing of the extensor tendon and lateral bands should be carried out at the same time. When the severance occurs at the level of the middle phalanx, the extensor tendon should be sutured at its expanded portion. The flexor tendon may be repaired at an early stage in clean-cut amputation. However, when trauma is severe and postoperative adhesions are likely, secondary repair by free tendon grafting is more suitable than primary suture. 2. Metacarpals. On the palmar side, the thenar and hypothenar muscles, the flexor pollicis longus tendon of the thumb, and the digitorum profundus tendon of the fingers are sutured; on the dorsal side, the extensor pollicis longus tendon of the thumb and the extensor tendons of the fingers are repaired. 3. Wrist or Distal Third of the Forearm. Thumb repair includes suturing of tendons of the long flexor muscle of the finger and cross-suturing of the distal portion of the deep flexor tendon of the fingers and proximal portion of the superficial
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flexor tendon of the finger. Dorsal repair includes tendons of the long extensor muscle of the thumb, long and short radial extensor muscles of the wrist, and extensor muscle of the finger. 4. Middle or Proximal Third of the Forearm. The tendons and bellies of flexors and bellies of the radial extensors of the wrist are sutured. 5. Elbow or Middle or Distal Third of the Arm. The biceps on the flexor side and triceps on the extensor side are sutured.
Nerve Repair Early repair of peripheral nerves forms the foundation of functional recovery in the late stage. Generally, one should strive to perform nerve repair during the primary replantation operation. Not only will the nerves be better exposed at that time, but they may also be more easily sutured without tension by skeletal shortening.25 Rerouting or transposition, if necessary, will be more easily done at this stage. When the nerve is severely contused and the length to be excised cannot be decided with certainty, early repair is inadvisable. It should instead be tagged and fixed in the subcutaneous tissue and thus be prepared for secondary repair. As most peripheral nerves are composed of mixed nerve fibers, no tension is tolerated during their repair, or there may be cross-suturing of motor to sensory nerve fibers leading to interference with recovery of both sensory and motor functions. It is generally possible to recognize the untwisted natural position of the nerve by its cross-sectional internal structure and by its external topography such as the position, course, and branching of the nutrient vessels on the nerve surface. The essential feature of nerve repair is suturing of the epineurium with 8-0 nylon suture (Fig. 14-16). There will occasionally be separation, overlapping, torsion, and branching of the ends of the fascicles. They may actually protrude through the epineurium or even form neuromas, which will adversely affect the functional recovery of the nerve. Connective tissue proliferation, as well as nerve edema due to excessive dissection, will be lessened by meticulous nerve repair. This will favorably
FIGURE 14-17. Endoneurium suture.
influence nerve regeneration and recovery of conductive function. The technique of perineural suturing is as follows. The epineurium of each of the cut ends of the peripheral nerve is incised longitudinally, separated, and then circumcised for a length of about 1 cm. The fascicles are then trimmed neatly, and the nutrient vessels are ligated. Finally, the nerve fascicles are repaired separately by suturing the perineurium with 9-0 atraumatic needles without tension. Usually, two stitches will suffice for each fascicle (Fig. 14-17). Neural coaptation must be carried out with no tension, and a good blood supply should be present in the surrounding soft tissues. If the nerve defect becomes too extensive after dissection and trimming, suturing may be rendered possible after rerouting or flexing of the joint. The extent of joint flexion should be limited; for example, the wrist joint should not be flexed more than 30°, and the elbow and knee joint no more than 90°. Nerves should never be sutured under tension; the stretch that is produced will cause fibrosis and impairment of nerve regeneration. In cases in which a relatively long nerve segment has been lost and end-to-end coaptation becomes impossible, interfascicular nerve grafting may be performed. Some cutaneous nerves may be used that, if absent, will not significantly affect limb sensation, for example, the medial cutaneous nerve of the forearm, the saphenous nerve of the leg, and the lateral cutaneous nerve of the thigh. The ultimate result is better than that of nerve transfer and the “cable type” of nerve repair. We had performed an experimental study of terminolateral neurorrhaphy in rats, which showed that nerve can be regenerated, but this method cannot be applied clinically at present.4 Digital nerves are pure sensory nerves and regenerate relatively rapidly. In bilateral nerve deficits, efforts should be directed toward repair of the nerves on the ulnar side of the thumb and little finger and that on the radial side of the index, middle, and ring fingers.
Skin Covering FIGURE 14-16. Epineurium suture.
The skin is sutured according to the basic principles of plastic surgery. Circumferential suturing around a
limb or digit must be avoided, since it will induce contracture and impairment of local circulation. The skin should be sutured without inversion of the edges. Great care must be taken that the dorsal digital veins are not involved while suturing the dorsal skin of the digits, and the sutures should be tied loosely to avoid compressing the vein. If tension exists, incisions can be made to relieve it. Skin defects may be covered with free skin grafts. Early skin covering prevents infection, increases the survival rate of replantation, and creates a favorable situation for secondary operations.
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Erythrocyte count, hematocrit level, and hemoglobin concentration are measured as frequently as deemed necessary. They may be used as guides in deciding the amounts of transfusion to be given.
Manifestations of systemic reaction include blood volume deficit, acute renal failure, fat embolism, hypoalbuminemia, disturbance of fluid and electrolyte balance, infection, and other visceral injuries. These may not only threaten the survival of the replanted part, but also endanger the life of the patient.17,29 The following is a brief account of the more important manifestations of systemic reaction.
Acute Renal Failure Proximal limb amputations, particularly traumatic amputation of a lower extremity, often lead to renal failure, and the patient may die of uremia.11 The more common causes of renal failure are prolonged hypotension, severe trauma of limb tissues, massive accumulation of metabolic products due to protracted ischemia, serious infection after inadequate debridement, and indiscriminant use of vasoconstrictors. Therefore, to prevent renal failure, thorough debridement should be performed. Replantation should not be performed if the limb is unsuitable for such a procedure. Blood volume must be replaced expeditiously to correct hypovolemic shock. Preventive fasciotomy of the replanted limb should be done to improve microcirculation when the limb has been ischemic for a relatively long period of time. If the blood volume is adequate, intravenous diuretics such as mannitol or 25% sorbitol may be administered. Hourly and 24-hour urine are observed closely. Urinalysis, CO2 levels, and blood urea nitrogen are examined frequently. If symptoms and signs of renal failure appear, prompt treatment is mandatory. Management includes water limitation, controlling hyperkalemia, eliminating acidosis, and azotemia. There could be a spontaneous cure after a critical stage of 10–21 days. The replanted limb might have to be reamputated to save the patient’s life, especially since toxins can be rapidly absorbed.
Blood Volume Deficit The amount of blood loss varies with the nature of the injury and the level of limb amputation. According to our data, the average transfused blood volume for amputation is 4000 mL at the upper arm, 3300 mL at the forearm, and 2100 mL at the wrist and palm. Whole blood should be transfused promptly, rapidly, and effectively, and blood pressure and pulse should be watched closely. The systolic pressure should be maintained above 100 mm Hg. After blood volume replacement, if the contralateral healthy fingers or toes become pink and warm, with a capillary filling time not exceeding 2 seconds, or the external jugular veins become visible above the clavicles, it may be assumed that the blood volume is near normal. The total volume and rate of blood transfusion may be regulated according to the observed central venous pressure. This is of great help in determining the blood volume of patient with limb or digit amputation complicated by serious traumatic shock.
Fat Embolism This condition is a rare but serious complication. The etiology of fat embolism is still controversial. Most investigators think that certain tissue factors are produced after trauma that can cause the suspended chylomicrons to aggregate and form fat droplets, leading to fat embolism. Others propose that the activity of plasma lipase is increased after trauma, resulting in alteration of plasma triglyceride distribution, and fat emboli are formed because of disruption of the suspended status of the plasma lipids. Mild or moderate pulmonary fat embolism is more commonly seen clinically but does not usually give rise to symptoms. A few serious cases may show respiratory symptoms or be accompanied by pneumonia, atelectasis, pulmonary infection, or other complications, finally resulting in death due to respiratory failure. Petechiae usually appear 2–3 days after trauma in the regions of the anterior chest wall, axillae, base of neck, or beneath the conjunctivae. The emboli may be carried to certain important viscera and give rise to related symptoms. When fat embolism occurs in the
POSTREPLANTATION MANAGEMENT Limb and digital amputations differ widely in nature. Patients with limb amputations often have accompanying injuries, resulting in complications that may have an impact on the ultimate outcome following replantation. If sufficient attention is not paid to the postoperative management, the replantation can fail.20,21
Systemic Reaction
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THE MUTILATED HAND
brain, impairment of consciousness, delirium, or coma may appear. If the fat embolism occurs in the kidneys, oliguria and renal ischemia often result. Patients who are suspected of fat embolism should have their blood, urine, and sputum examined to see whether free fat is present and whether there is elevation of plasma lipase. The diagnosis may also be made by taking chest X-rays and finding the presence of snowflake-like shadows or by an abnormal EKG. As soon as fat embolism occurs, emulsifying agents or detergents (e.g., Furonic F-68) should be administered to reduce the emboli in the bloodstream. Heparin (10–15 mg/g every 3–4 hours) may be given to maintain the bleeding time at or near 20 minutes. Chylomicrons are induced to enter tissues, and lipolysis is accelerated in the blood. Fat embolism may also be prevented by 6% LMD given by intravenous drip.
Local Circulatory Impairment Whenever local circulation is impaired, its etiology should be determined and treated promptly to halt further progression. Any delay may lead to an irreversible vascular crisis. The more common criteria for observing and assessing the circulatory status are as follows:19 1. Color of the skin and morphology of the fingers. Red, moist skin with adequate turgor and pink nails denote adequate digital circulation. Poor venous return may be diagnosed in the early stage by cyanotic skin color and diminution or absence of normal creases. In serious cases, it is indicated by the formation of blisters; venous stasis and necrosis may occur after 2–3 days. 2. Skin color with changing of limb or digit position. A simple test of adequate arterial supply is elevation of the limb or digit for 5–10 minutes and then return to a horizontal position. Normally, the limb or digit will turn red within 45–60 seconds. Delayed return of color should be regarded as signifying insufficient arterial blood supply, which may be due to hypotension, arterial spasm, anastomotic stenosis, or external compression of the artery. 3. Filling time of the subdermal venous plexus of the skin. Normal skin blanches when compressed but turns red within 2–3 seconds after release of the pressure. Blanching is prolonged in arterial insufficiency. In rare cases, however, the filling time is not delayed when arterial thrombosis is already present; sometimes, with precedent venous thrombosis and stasis, the filling time may even be shortened. Hence, the result of this test should be carefully analyzed, since normal venous filling time is not invariably indicative of normal circulation.
4. Measurement of cutaneous temperature. This is a relatively reliable method of assessing the circulatory status. Both inadequate arterial blood supply and impairment of venous return will soon reduce skin temperature. Measurements should be taken at symmetrical points on both limbs and under the same conditions. The limb with good circulation often has an elevation of skin temperature of about l–2°C (room temperature is 20°C) compared with the healthy limb as the blood vessels are dilated in the replanted limb owing to loss of nerve supply and the skin temperature is much more easily affected by the environment. When the skin temperature of the replanted limb is 5–6°C lower than that on the healthy side, circulatory impairment should be deemed present. 5. Needle prick. The digital tip of the affected limb is pricked with a needle; in the case of digit replantation, a 0.3- to 0.5-cm skin incision can also be made on the opposite side of the vascular anastomosis. The presence or absence of arterial thrombosis or impaired venous return is judged by the amount and color of the blood that oozes out. 6. Ultrasonic test for circulation. Using the Doppler method, the state of flow within an artery or vein can be measured and compared bilaterally by the volume and amplitude of the ultrasound signals received after its emission and reflection. This method is very sensitive and can be used to examine the flow in the terminal part of the digital artery. It can also be done repeatedly without further traumatizing the tissues. For these reasons, it is a rather new method that is worthy of wider adoption in estimating circulation in the replanted part. 7. Other methods. Circulation can be examined with the isotope 32P, and angiography can also be performed. These methods are used only infrequently, but they are effective in determining the causes of circulatory insufficiency when it cannot be ascertained by other means. Particularly in late-stage intraluminal obstruction, angiography is an efficient procedure for diagnosis. These criteria for evaluating patency and adequacy of arteries and veins are summarized in Table 14-1. Circulatory crisis may occur suddenly and is seen more often in arterial thrombosis; it may also develop gradually with manifestations of inadequate blood supply and is more commonly caused by vasospasm. As soon as the circulatory crisis is diagnosed, it should be promptly determined whether it is of arterial or venous origin. This is followed by further determination of its being caused by thrombosis or vasospasm (Table 14-2).
14
PRINCIPLES OF REPLANTATION AND REVASCULARIZATION
TABLE 14-1
Manifestation of Arterial and Venous Obstruction
Differential Points
Arterial Obstruction
Venous Obstruction
Color
Pale
Cyanotic
Finger pulp
Shrunken
Full, swollen
Creases
Deepened
Inconspicuous or lost
211
Skin
Limb (digit) elevation
Mottled
Not mottled
Temperature
Lowered
Lowered
Pulse
Weak or absent
Present
Capillary filling time
Prolonged
Shortened
Volume and amplitude reduced or lost
Volume and amplitude reduced or lost
Isotopic examination
Impulses of radiation diminished or absent
Pulses appear later, increased in number, disappearance delayed
Blood oozing from fingertip on pricking
Reduced or absent
Increased and purplish red in color
14
Ultrasonic Doppler signal
Vasospasm may occur repeatedly, giving rise to manifestations of arterial insufficiency. With such measures as blood transfusion; administration of 6% LMD, tolazoline, or other anticoagulants or antispasmodics; acupuncture; local heat application; or sympathetic nerve block, the spasm may improve gradually. Exploratory
TABLE 14-2
surgery may be necessary if doubt exists about the occurrence of thrombosis. If thrombosis is found during the operation, thrombectomy or resection and reanastomosis may effect a cure. Vascular grafting might be necessary when the vessels are too short for direct anastomosis.
Differentiation Between Small-Vessel Spasm and Thrombosis
Differential Points
Vasospasm
Thrombosis
Causative factors
Mechanical, chemical, cold irritation, etc.
Disruption of intima, slowing of blood flow, alterations in blood
Pathological changes
Narrowing of vascular lumen, partial or total obstruction
Occlusion of vascular lumen by thrombi
Antispasmodics
Effective
Ineffective
Cervical sympathetic block and acupuncture
Effective
Ineffective
Massage
May be effective
Harmful (thrombi may be pushed into distal vascular bed and become difficult to to extract)
Local heat
Helpful
Harmful (increases metabolism and oxygen consumption)
Incision of fingertip
Small amount of blood may ooze out
No bleeding
Angiography
Conical shadow of the vascular lumen
Sudden interruption of vascular lumen
Hyperbaric oxygen
Effective
Ineffective
Therapeutic management
Conservative initially, keep close observation
Early exploration indicated once thrombosis
Operative findings
Vascular narrowing both proximal and distal to the anastomosis; blood flows poorly from the central end
Darkened color and feeling of thrombus at the anastomotic site; dilatation of the vessel proximal to, and narrowing distal to the anastomosis without pulsation; thrombi found in the lumen; no bleeding when the vessel is cut distal to the thrombosis
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THE MUTILATED HAND
For replanted digits, if the venous anastomosis is compromised, the replanted part will be swollen and purplish, indications of a venous crisis. However, if more than one digital vein is anastomosed, that is ideal. If it is impossible to find appropriate digital veins for anastomosis, the surgeon can make a small skin incision at the fingertip, allowing blood to drain out, releasing the constriction of the replanted digit. If the replanted digit can survive 5 days after replantation, the collateral circulation through the capillary vessels will be reestablished.
As long as arterial perfusion and venous return remain normal, the swelling will be relieved gradually when lymphatic recanalization occurs 10–14 days later.
Postreplantation Infection Wound infection may lead to necrosis of the vascular wall, rupture of the vessel with hemorrhage, or septicemia in serious cases. For prophylaxis of postoperative infection, separate sets of instruments should be used for debridement and replantation. Debridement must be done thoroughly. Skin grafts may be applied to cover skin defects. Adequate drainage and appropriate antibiotics are crucial.
Swelling of the Replanted Limb or Digit One of the chief complications that may threaten the survival of the replanted part is postoperative progressive swelling. The swelling, which usually subsides gradually after 10–14 days, can be caused by the following: 1. Impairment of venous return due to intravascular or extravascular factors. Intravascular factors include deficiency in number or size of veins anastomosed, stenosis at the anastomotic site, venous spasm, thrombosis, and slowing of the blood flow due to twisting or kinking of the vessel. The chief extravascular factor is compression caused by suture, hematoma, fascial edges, supporting bands near the joints, swollen muscles, tight skin suturing, and excessive pressure from casts or bandages. 2. Tissue reaction due to trauma or inflammation resulting from incomplete debridement. 3. Pressure by hematoma formed after reestablishment of circulation. 4. Other factors, including prolonged ischemia and anoxia of the amputated part, local wound infection, improper positioning, and impairment of lymphatic flow. The degree of swelling can be estimated by the appearance of skin creases and changes in the contour and circumference of the replanted part, as well as by the rate of increase of the distance between two fixed points on the surface. The surgeon must be intent on finding and eliminating the etiologic factors of swelling during the operation and administer appropriate therapy in a timely fashion. Precisely anastomosing an adequate number of superficial and deep veins and maintaining their patency postoperatively are efficient measures in improving the survival rate and preventing and reducing progressive swelling. Prophylactic decompressive incisions of deep fascia should be performed if the part is severely traumatized and the ischemic period is protracted.
Anticoagulant Therapy The recent trend in arterial surgery is to avoid the use of anticoagulants because they do not improve the rate of success. On the contrary, many complications may occur, and anticoagulants are now used only in endarterectomy and arterial embolectomy. According to Salzman,24 heparin administration cannot diminish or abolish the adhesive and aggregating activities of platelets and therefore cannot preclude the formation of arterial thrombi. On the other hand, the general trend in venous surgery is to give anticoagulants because the venous flow is slow, and accumulation of coagulating factors is encouraged. Anticoagulants may eliminate the activities of thromboplastin and thrombin, thus preventing thrombosis. Whether anticoagulants are to be used in replantation should be judged on an individual basis. As was stated above, the key to achieving long-term patency in small-vessel anastomosis lies in precise and exquisite suturing technique, while the administration of various antispasmodics and anticoagulants plays only an adjunctive role. These drugs per se cannot increase the patency rate of vascular anastomosis. Thus, if the trauma is not very severe and the condition of the vessels is reasonably good, anticoagulant therapy is not deemed necessary. LMD has fewer side effects than heparin; however, its action as an anticoagulant is comparatively weaker. Anticoagulant therapy is considered only in cases of severe trauma and/or poor vascular condition or in the period immediately after embolectomy or vascular transplantation. Aspirin is another anticoagulant that is often used clinically. It reduces platelet adhesion and aggregation in the blood as well as decreasing the aggregation of red blood cells, thus improving the microcirculation.
Application of Hyperbaric Oxygen Hyperbaric oxygen may be of some therapeutic value in cases in which extremely protracted periods of ischemia have been sustained by the amputated limb or digit or
when postreplantation recovery of the circulatory status is poor.22 Hyperbaric oxygen increases the partial pressure of oxygen in plasma, reaching 22 times normal under 3 ATA (absolute atmospheric pressure). Physically dissolved oxygen in plasma increases from 0.3 vol % under normal atmospheric pressure to 4.5–6.0 vol %. An adequate oxygen supply is then obtained by the tissue cells, and the sodium pump resumes its activities. Microcirculation in tissues is improved, and edema subsides gradually. We consider the use of hyperbaric oxygen in replantation under the following circumstances: 1. When the warm ischemic period of the amputated part is relatively prolonged (e.g., 8–10 hours) or when microcirculatory derangements appear in spite of patency of the anastomosis. 2. When the ischemic interval is not necessarily long but the postreplantation circulatory status is poor, without thrombosis in the anastomosed vessels. 3. When there had been thrombosis or severe spasm of the anastomosed vessels, with the replanted part appearing pale and ischemic and such status was re-explored and corrected after a relatively long period of observation. 4. When thrombosis occurs 1 week after replantation, at which time there is already partial establishment of collateral circulation but not yet enough for adequate tissue oxygen supply. 5. When the replanted part is incompletely severed but the main vessels are injured and the reestablishment of circulation has been deferred or when the blood supply remains insufficient after vascular anastomosis and recovery of flow. 6. When the ischemic period has been comparatively long (more than 10–12 hours) and the vessels are patent postoperatively. Although immediate signs of microcirculatory deficiency, such as lowered skin temperature, do not appear, hyperbaric oxygen may be considered as a prophylactic measure. These indications are not absolute but should be considered along with other factors such as the level of traumatic amputation, the length of the ischemic interval, the ambient temperature, clinical manifestations, and,
TABLE 14-3
PRINCIPLES OF REPLANTATION AND REVASCULARIZATION
213
finally, the condition of the available hyperbaric oxygen chamber. We successfully applied this mode of therapy in a case of hand amputation with an ischemic period of 36 hours. However, when compartment syndrome appears, hyperbaric oxygen therapy alone cannot be depended on to attain the expected effect. In these cases, fasciotomy should be performed to relieve the pressure, and the tissue cells will then be able to obtain sufficient oxygen supply, resulting in improved microcirculation. There are as yet no definite criteria for deciding the length of time for giving hyperbaric oxygen therapy. According to our clinical experience, we think it is necessary to institute hyperbaric oxygen therapy for 7–14 days. The exact timing should be determined by the length of the ischemic period and other related conditions.
Function Restoration and Function Evaluation in the Latter Stages It is very important to restore the function of survived limbs or digits in the latter stages of therapy.
Physical Therapy Performing therapy early is beneficial in relieving swelling and vasospasm, avoiding infection, delaying muscle atrophy, preventing joint stiffness, and reducing adhesions (Table 14-3). Evaluation of Function There is no standard criterion for functional examination of replanted limbs at present. Here is a protocol we formulated for evaluation of function of the upper limb that has been adopted by many institutes in Europe and America: ❚ Patients resume working: their total joint range of motion (ROM) (one joint proximal to the replanted level is included) is more than 60% of that of the contralateral healthy limb; nerves function well and can resist cold; motor strength may be grade 4–5. ❚ Patients resume appropriate work: their total joint ROM is more than 40% of that of the contralateral healthy limb; function of the median
Physical Therapy Methods
Goal
Therapy
To accelerate wound cure
Ultraviolet, sunlamp
To improve circulation, relieve swelling and prevent adhesions
Sunlamp, microwave, short wave, ultrashort wave, massage
To prevent joint stiffness and delay muscle atrophy
Ultrasonic wave, sunlamp, warm bath, low-frequency pulse and massage
To remove adhesions and enhance muscle power
Ultrasonic wave, low-frequency pulse, swirl bath
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THE MUTILATED HAND
nerve and ulnar nerve is relatively normal, and they are able to resist cold; motor strength may be grade 3–4. ❚ Patients can carry out the activities of daily life; their joint ROM is more than 30% of that of the contralateral healthy limb; sensation is incomplete (e.g., only a single median nerve or ulnar nerve has good function or the median nerve and ulnar nerve just have protective sensation); motor strength may be grade 3. ❚ The replanted extremities survive without any practical function.
Ischemia-Reperfusion Injury In recent years, there has been experimental evidence to indicate that tissue injury occurs during ischemia as well as reperfusion, a phenomenon that is known as ischemia-reperfusion injury. This injury is believed to be caused by a free radical, which is produced through xanthine oxidase, NADPH oxidase, and myeloperoxidase enzyme systems. Some drugs, such as aspirin, are considered capable of preventing such injury.7
REPLANTATION OF THE DISTAL PORTION OF THE LIMB AFTER RESECTION OF A TUMOR-BEARING SEGMENT Over the past century, early proximal amputation of the limb has been the routine therapeutic procedure for malignant tumor of the extremity. Proximal amputation
TABLE 14-4
will remove the tumor; however, serious crippling occurs owing to the loss of the whole limb. In the early stages, the tumor frequently remains localized to a portion of the limb, and centrifugal spread is uncommon. The distal segment of the limb is often normal. If the tumor-bearing segment can be radically resected according to the basic principles of tumor surgery and the uninvolved distal segment is then replanted, would that be the solution to the very problem raised above: to remove the tumor while preserving limb function to a maximum extent? From 1966 to 1973, the senior author (Z-WC) treated 18 cases of malignant tumors of the upper extremities by segmental resection and limb replantation (Table 14-4). Of these cases, 66.1% were followed for more than 3 years without recurrence of tumors, and the patients were alive and well.
Indications for Segmental Resection and Replantation Low-Grade Malignant Bone Tumors of the Upper Extremity These include chondrosarcomas, giant cell tumors of the bone with malignant predisposition as manifested by pathological grading of II to III, cortical bone destruction, invasion of surrounding soft tissues, or recurrence after simple curettage and bone grafting. Malignant Soft Tissue Tumors Not Suitable for Local Excision Tumors of this group are synovial sarcomas, malignant hemangioendotheliomas, malignant neurilemmomas, and recurrent fibrosarcomas with extensive infiltration.
Summary of Clinical Observations in 18 Cases of Malignant Tumors of the Upper Extremities Treated with Segmental Resection and Replantation
Pathological Diagnosis
No. of Cases
Postoperative Recovery Died of Hematogenous of Limb Function Spread Within 3 years Local Recurrence
Others
Osteogenic sarcoma
4
—
2
—
Failure 1
Synovial sarcoma
5
3
2
—
—
Giant cell tumor of bone
4
4
—
—
—
Malignant neurilemmoma
2
1
—
1
Amputation at reoperation
Chondrosarcoma
1
1
—
—
—
Myxochondroma
1
1
—
—
—
Malignant hemangioendothelioma
1
1
—
—
—
18
11
4
1
2
Unknown 1
Total
Principles of the Operation The extent of resection should conform to the basic principles of surgery for malignant tumors. If the tumor has extended into the marrow cavity, the whole bone and its surrounding soft tissues should be resected. Low-grade malignant tumors with no pathological evidence of bone marrow invasion can be treated by resecting 5 cm proximal and distal to the margins of the tumors. Muscles that have been invaded by tumor should be totally excised from their origin to their insertion. The main neurovascular bundles that pass through or lie close to the tumor should be resected; if they are relatively distant from the tumors and found to be free of involvement by pathological sections, preservation of these structures may be considered.
Types of Segmental Resection and Replantation On the basis of the principles stated above, segmental resection of the tumor-bearing part of the upper extremity and replantation of the segment may be categorized into clinical types.
Total Resection of the Scapular Region and the Arm Followed by Replantation The entire arm is resected with the scapular region of the shoulder girdle; disarticulation is performed at the elbow joint. Replantation is begun by suspending the olecranon process of the ulna on the lateral aspect of the biceps tendon and the trapezius to the aponeurosis of the triceps near the olecranon process. The muscles of the forearm, arising from the lower end of the humerus, are left without further management following their resection. The components of the major neurovascular bundles are individually anastomosed in end-to-end fashion. Resection of the Scapular Region and Proximal Segment of the Arm Followed by Replantation The operative procedure is similar to the above type, except that the distal end of the humerus and the elbow joint are preserved, and the humerus is suspended on the clavicle. These types of operation are indicated for malignant tumors of the scapular and shoulder regions. Total Arm Resection and Replantation The arm is resected after disarticulation of the shoulder and elbow joints. The olecranon process is fixed to the acromion. The pectoralis major muscle is sutured to the tendon of the biceps, and the trapezius muscle is sutured to the aponeurosis of the triceps near the olecranon process of the ulna. This type of procedure is indicated for malignant tumors in the middle portion of the arm.
PRINCIPLES OF REPLANTATION AND REVASCULARIZATION
215
Segmental Resection of the Arm and Replantation After resection of the tumor-bearing segment of the arm, appropriate internal fixation is applied according to the part of the arm that was removed. For example, in proximal-segment resections, the proximal end of the humerus is suspended to the clavicle or the acromion; in middle-segment resections, step-cut ends of the humerus are produced that reciprocally fit to each other and are fixed by one or two screws; in distal-end resections, temporary fixation is done by inserting a Kirschner wire through the olecranon process into the medullary cavity of the humerus. Early exercise is encouraged so that a pseudojoint is formed. Resection of the Elbow and the Adjoining Segment of the Arm Followed by Replantation After the tumor-bearing segment is resected, the ulna is fixed to the humerus by screws. Since the muscle bellies of many of the flexors and extensors of the forearm have been resected, the extensor repair is achieved by suturing the extensor pollicis longus muscle of the thumb and the extensor muscle to the fingers to the triceps, and the flexor repair is achieved by suturing the flexor pollicis longus muscle of the thumb and the deep flexor muscle to the fingers to the biceps. Total Resection of the Forearm and Replantation The forearm is resected after disarticulation at the levels of the wrist and elbow joints. The distal end of the humerus and the proximal part of the carpal bones are cut into oblique surfaces that are adapted closely to each other and fixed together with one screw. The ulnar and radial arteries, basilic and median cubital veins, and ulnar and median nerves are individually resected and reanastomosed. The biceps is sutured to the flexor pollicis longus muscle of the thumb and the digitorum profundus to the fingers; the triceps is sutured to the extensor pollicis longus muscle of the thumb and the extensor muscles to the fingers; and the brachialis muscle is sutured to the tendons of the extensor pollicis brevis of the thumb and the abductor pollicis longus of the thumb. Segment Resection of the Forearm and Replantation After resection of the tumor-bearing segment, internal fixation of the ends of the bones of the forearm varies with the levels of resection. In distal-segment resection, the radius is fixed to the carpal bones by screws. In middle-segment resection, the bone ends are shaped into mutually fitting steplike surfaces and then fixed with screws. In proximal-segment resection, the lower end of the humerus is fixed to the ulna according to the existing condition either by an intramedullary pin or with screws after the ends are step-cut into
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THE MUTILATED HAND
reciprocally fitting surfaces. The repair of muscles and tendons varies with different sites and extents of resection. As a general rule, direct suturing is done in distaland middle-segment resection. In proximal-segment resection, the biceps and triceps may be utilized by suturing them to the flexors and extensors of the digits, respectively. In these types of segmental resection, the diameter and circumference of the proximal and distal stumps to be anastomosed together are usually unequal. Therefore the incision of skin and subcutaneous tissue should be made with rather large serrations so that suturing of these parts during replantation is facilitated and scar contracture after wound healing is avoided. Segmental resection and replantation is a new operative technique in the treatment of low-grade malignant tumors of the upper extremity. Although the rate of radical cure of the tumor is not increased, it provides the surgeon with a valuable means to better preserve the function of the affected limb with the prerequisite of not decreasing the ultimate cure rate and therefore is welcomed by the patients. Preoperative and postoperative chemotherapy and radiotherapy as a combined treatment will undoubtedly improve the management of patients suffering from these kinds of neoplasms.
References 1. Chen CW, Chien YC: Replantation of Severed Limbs. Peking, People’s Medical Publishing House, 1996. 2. Chen CW, Chien YC, Bao YS: Salvage of the forearm following complete traumatic amputation: Report of a case. Chin Med J 82:632, 1963. 3. Chen CW, Chien YC, Bao YS: Further experience in the restoration of amputated limbs. Chin Med J 84:255, 1965. 4. Chen TY, Zhao JZ, Chen ZW: The experimental study of terminolateral neurorrhaphy in rats. Chin J Microsurg 21(2):86–89, 1998. 5. Chen ZW: Some viewpoints on severed limbs replantation. Chin J Surg 16(1):5, 1978. 6. Chen ZW, et al: Electronic artificial hand controlled by reconstructed digit. Chin J Orthop Trauma 1(1):28–30, 1999. 7. Cho Y, Pang M, et al: Pharmacologic intervention in ischemia-induced reperfusion injury in the skeletal muscle. Microsurgery 14:176–182, 1993. 8. Christeas N: Replantation of amputated extremities. Am J Surg 118:68, 1969. 9. Cui ZY: Studies on the technique of small vessel anastomosis. Chin J Surg 13:268–276, 1965.
10. Department of Surgery, Shanghai Sixth People’s Hospital: Reattachment of traumatic amputations: A summing up of experiences. China’s Med 5:392, 1967. 11. Guo BF: Post-traumatic acute renal failure. Chin J Surg 12:545, 1964. 12. Inoue T: Replantation of severed limbs. J Cardiovasc Surg 8:31, 1967. 13. Kleinert HE: Digital replantation-selection, technique, and results. Orthop Clin North Am 8:309, 1977. 14. Lauritzen C: A new and easier way to anastomose microvessels. Scand J Plast Reconstr Surg 12:284–291, 1978. 15. Malt RA: Replantation of severed arm. JAMA 189:716, 1964. 16. Mayer VE, et al: Microvascular anastomosis using the telescope principle: Experimental study. Int J Microsurg 2(2):81–86, 1980. 17. McNeill IF: The problems of limb replacement. Br J Surg 57:365, 1970. 18. Mehl RL: Patency of the microcirculation in the traumatically amputated limb: A comparison of common perfusates. J Trauma 4:248–256, 1964. 19. Morrison W: Evaluation of digital replantation. Orthop Clin North Am 8:295, 1977. 20. Nursing Group of Orthopaedic Department, Shanghai Sixth People’s Hospital: Nursing care of a patient after replantation of the forearm following complete traumatic amputation. Clin J Nursing 1:6, 1964. 21. Research Laboratory for Replantation of Severed Limbs, Shanghai Sixth People’s Hospital: Current knowledge and development on replantation of severed limbs and digits. Natl Med J China 1:3, 1973. 22. Research Laboratory for Replantation of Severed Limbs, Shanghai Sixth People’s Hospital: Hyperbaric oxygen therapy in replantation of severed limbs: A report of 21 cases. Chin Med J 3:197, 1975. 23. Robert SS: Treatment of the extremity suffering near or total severance with special consideration of the vascular problem. Clin Orthop 29:56, 1963. 24. Salzman E: Limitation of heparin after arterial reconstructive surgery. Surgery 57:131, 1965. 25. Seddon HJ: Peripheral Nerve Injuries. London, 1963. 26. Shanghai Sixth People’s Hospital: Extremity replantation. Clin Med J 4:5, 1978. 27. Shaw W, Wilgis EF: Observations on the effects of tourniquet ischemia. J Bone Joint Surg 534:1343, 1971. 28. Tu KY: Animal Experimentations on replantation of severed limbs. Chin J Surg 10:1, 1962. 29. Wang SH: Some problems on salvaging traumatic amputated limbs. Clin J Surg 13:863, 1965. 30. William DE: Replantation of extremities (collective review). Surg Gyn Obstr 132:901, 1971. 31. William GR: Replantation of amputated extremities. Ann Surg 163:788, 1966.
15 Multiple-Digit Replantations Michael R. Zenn, MD, FACS
15
Scott Levin, MD, FACS
Management of the mutilated hand that sustains multiple-digit amputations presents one of the greatest challenges for the hand surgeon. Few other injuries require such immediate, complex decision making and technical excellence to succeed and maximize long-term function. Unlike single-digit amputations, multiple-digit amputations raise the level of complexity of repair and require creative thinking to optimize the outcome. There is no universal management protocol that is appropriate for all cases involving multiple-digital amputations, and many controversies remain. Nonetheless, by relying on basic hand surgery and reconstructive principles, a successful outcome can be achieved. The concept of a “replantation team” is critical to the management of the multiple-digit replantation patient. While one microsurgeon can have a high success rate for a single-digit replantation, multiple-digit replantations require several proficient microsurgeons to assist during these procedures, which often last more than 20 hours.* The team concept alleviates surgeon fatigue and allows simultaneous surgery on both hands and amputated parts.
THE DECISION TO REPLANT Whether to replant amputated parts in the mutilated hand is a judgment that is made at the time of surgery.3,10 The operating microscope is an invaluable diagnostic tool to aid in this decision. Multiple amputations are an often-cited indication for replantation due to the impact on overall hand function.4,8 Unless parts are severely crushed or otherwise unusable, replantation should be attempted. If straightforward replantation is not possible, creative uses of the “spare parts” should be considered. Banking of amputated parts for later replantation has also been described.16
OPERATIVE PROTOCOL In straightforward, orthotopic replantation, standard operative protocol should be followed to minimize ischemia time and blood loss (Table 15-1).24,35 This particular order of repair has been well documented in the literature with several reports of successful nine- and ten-digit replantations.1,18,21,26 Although there is agreement regarding the order of repair of bones, tendons, vessels, and nerves, some variations exist. Two acceptable ways to replant multiple digits are the synchronous and sequential techniques. The synchronous technique dictates that all structures in each digit be repaired at the same time (i.e., all bony fixation, then all *See references 1, 2, 13, 18, 21, 23, 27, 33, 36, 38.
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TABLE 15-1
Conduct of the Replantation
Bone fixation Flexor tendon repair Arterial repair Nerve repair Volar skin closure Extensor tendon repair Vein repair Dorsal skin closure/skin graft
tendons, etc.). This technique has the advantages of time efficiency and more effective use of the tourniquet, but these are often outweighed by prolonged warm ischemia time. The sequential method dictates complete repair of each digit in series. While this requires several changes in instrumentation, including additional movements of the operating microscope, certain benefits exist. Most important, digital ischemia is minimized, as parts may be effectively cooled awaiting reattachment. Priorities should be given to revascularizing the most important digits first, giving them the best chance of success. Thus when four or more digits are to be replanted, the sequential repair is our preference and the most commonly practiced today.35 In the situation in which not all digits are usable and only some digits will be replanted, the benefits of the synchronous technique might prevail. Since the overall ischemia time per digit is shorter (less to replant) and blood loss is less, the time savings by less instrumentation
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changes becomes the overriding factor. Ultimately, the decision as to use of the synchronous or sequential method will be dictated by the situation and the surgeon’s preference. The order of repair for orthotopic replantation starts with the most important digit, the thumb, and proceeds ulnarly. This allows the greatest amount of space to perform each digital replantation and allows an orderly progression to the procedure (Fig. 15-1). In cases of multiple-digit amputations in which skin bridges connect the digits, a different approach is taken (Fig. 15-2).7 This corresponds to Tamai’s zone V and adds the challenge of keeping the parts cooled while they are awaiting revascularization. Digits in this case should not be separated from each other, because the interconnection provides a valuable conduit for arterial inflow or venous egress. Some creative ideas and cooling techniques have arisen to keep parts cool in this situation.29 Blood loss in the multiple-digit replantation patient is an important issue. Some series report an excess of 40 units of packed red blood cells for a ten-digit replantation. This degree of exsanguination must be avoided, and judicious use of the tourniquet is important as well as early venous anastomoses. One argument for the sequential approach, alluded to earlier, is maximization of tourniquet time prior to microscopic anastomoses. There is a general concern about reapplying the tourniquet after the microvascular anastomoses have been performed for fear of thrombosis. This has been refuted by some with reliable clinical results.18 We routinely reapply the tourniquet when needed, especially since
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FIGURE 15-1. A, Four-digit amputation. Only the ring and little fingers were replantable. B, Sequential repair of the ring and little fingers in their normal positions. C, The patient has adequate length in the index finger for fine manipulation, while the replanted ring and little fingers provide grasp.
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FIGURE 15-2. A, Industrial injury, Tamai level V, attached only by a tendon. B, Postreplantation. In this situation, digits are attached en bloc, the part being cooled while replantation is performed.
patients are therapeutically heparinized after the first anastomosis is performed. Therefore, judicious reinflation of the tourniquet during the sequential replantation of multiple digits is a valuable tool for minimizing blood loss. It was once though that arterial anastomoses should precede venous anastomoses to reduce ischemia time and to allow for engorgement and identification of dorsal veins. This, however, exponentially increases blood loss. If identification of veins is possible, their anastomoses prior to arterial anastomoses will dramatically cut down on intraoperative blood loss. If identification of veins is not possible, reestablishment of inflow first should facilitate their repair.
BONE FIXATION Bone fixation is the first step in replantation, to build a solid base to support the remainder of the replantation surgery. Many types of fixation have been employed, all with good results.26,35 The best fixation is one that is both reliable in the hands of the operator and relatively straightforward and rapid in its application. Anatomy can dictate whether plating is possible or whether Kirschner wire fixation might be more applicable. Owing to ease of use and reliability, our preference is K-wires placed longitudinally or crossed. In the pediatric patient with open epiphyses, a single longitudinal K-wire should suffice to stabilize the replantation and avoid growth disturbance. Bony shortening should be considered for each replantation. Some advocate maintaining length at all cost, but this necessitates the use of vein grafts, which
complicates the replantation and should be avoided. Depending on the mechanism of injury, vein grafts might be unavoidable, and therefore, shortening can be minimized. If mechanism and anatomy allow shortening of up to 1 centimeter, this can allow revascularization without vein grafts and both simplify the replantation and reduce the ischemia time. Be cautious in the pediatric patient to minimize shortening, especially when epiphyses are involved. Growth considerations should take precedence.
TENDON REPAIR Repair of flexor tendons followed by extensor tendons is next in the protocol. There is a rich surgical history regarding tendon repair during replantation, ranging from immediate repair of all structures to delayed repair.31 While today it is acceptable to repair all structures injured, the mechanism of injury and level of division may dictate otherwise. In complicated procedures with severely crushed or avulsed structures, delayed repair may be acceptable.23 Primary use of a Hunter rod can be considered. Repair of the flexor tendons in Zone II (“no man’s land”) remains controversial, even during replantation. In clean, sharp injuries, repair of both the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons should be performed, with postoperative physical therapy aimed at reducing adhesion between tendons. Variations such as FDP-only repair and FDS-to-FDP repair also have been reported.31,36 Ultimately, the decision will be made on the basis of
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clinical judgment at the time of replantation, aided by the knowledge that reasonable options exist. Repair of flexor tendons is performed in standard fashion with a modified Kessler core suture and an epitendinous nylon suture. Extensor tendon repair usually entails a permanent external suture, without the need for an internal core suture.
the amputated part is reanastomosed to a recipient vein or vein graft. This has been shown to support the digit for the time required for successful vessel ingrowth.12 Venous flaps, which can provide coverage and outflow possibilities, are another option.11,34 Remember that a lack of vessels to revascularize an amputated part can be a contraindication to replantation in the first place.
VASCULAR REPAIR
NERVE REPAIR
Vascular repair in orthotopic replantation is straightforward but does require some decision making. Clinical acumen will dictate the need for vein grafting to achieve a tension-free repair. Most clinical series report better survival rate with more vessels anastomosed; thus, when possible, both arteries should be repaired. However, one arterial anastomosis—especially if it is the dominant artery—is usually enough to maintain viability of the digit. Cross-arterial grafting can obviate the need for vein grafts when adequate length exists radially on one side but ulnarly on the other side. Rerouting the vessels to achieve anastomosis without vein grafting is possible. Additionally, nonreplantable digits can be useful sources of arterial conduits, often preferable over vein grafts because of their lumen size match from proximal to distal.12 Reestablishment of venous outflow is not as straightforward as arterial inflow. Depending on the level of amputation, vein size and number might be small, and alternative sources of outflow might be required. When possible, multiple veins should be repaired. A minimum of two venous repairs per arterial repair is desirable, and as many as three or four have been described. It was once thought that more venous anastomoses would reduce venous flow in each, potentially encouraging thrombosis. This has not been observed clinically, and it is more likely that a process of natural selection is occurring.22 The better-draining vessels are selected, and excess capacitance exists in the system to ensure venous drainage despite a thrombosis. When no suitable veins can be localized on the amputated part, other maneuvers are required.11,34 Distal to the proximal interphalangeal joint, venous engorgement can be treated with either leech therapy or topical heparin therapy. Leech therapy is more costly but preferred, because it more effectively decompresses the congested digit. Three to five days of treatment are often required until vessel ingrowth can support the digit. Transfusion is usually required and should be discussed with the patient.19 Another successful strategy to deal with venous outflow without veins is creation of an arterial-venous anastomosis. While the dominant artery is used for inflow, the contralateral digital artery from
Nerve repair in replantation is often straightforward and is performed after revascularization while the microscope is in place and exposure is optimal. Mobilization of the nerve for a centimeter proximally and distally usually allows coaptation, especially if bony shortening has occurred. In crush or avulsion injuries, it is hard to determine the level or zone of injury within the nerve.14 Coaptation does expedite later dissection of the nerve for grafting and potentially limits the formation of painful neuroma. When the ends cannot be coapted, you must decide if immediate or delayed repair is in order. As was previously noted, it is difficult to ascertain the zone of injury acutely. This decision often can be made more easily in a delayed fashion as atrophy and neuroma formation declare themselves. If delayed repair is chosen, simply marking each end of the nerve with a dyed suture or clip is all that is required at the time of initial replantation. For nerve gaps up to 3 cm after debridement, consider the use of vein grafts or dexon tubes as conduits for nerve regeneration.37 This saves valuable nerve donor sites that might be required later if sensibility is not restored. There is some evidence that conduits might be superior in comparison with primary repair in short gaps, emphasizing the importance of neurotrophic factors. In clean, sharp lacerations, where immediate repair is chosen and coaptation is not possible owing to larger gaps, the posterior interosseous nerve is our graft of choice. Other choices include the medial antebrachial cutaneous nerves or, rarely, the sural nerves.25 As with other nerve repairs, adequate debridement and attention to detail are the keys to success. At the level of the digits, only epineural repair is required. In the case of frayed nerves, fibrin glue also may be employed.
DISTAL REPLANTATION It was once thought that replantation distal to the FDS insertion was not indicated and unnecessary. Many authors have looked at this question and have shown that for the correctly selected patient, replantation of the digit distal to the FDS insertion is well tolerated and straightforward when compared to replantation more
proximally.5,15 Since the FDS is present, flexion of the digit already exists, and FDP repair is not required. Arthrodesis of the distal interphalangeal joint or tenodesis of the profundus tendon can be performed, leaving only nerve repair, vascular anastomoses, and skin closure. Given the short operative time required, added length, and good sensibility gained, this is a replantation option that is to be strongly considered.
DIGITAL TRANSPOSITION Digital transposition is the most interesting aspect of multiple-digit amputations in the mutilated hand. Transposition of digits simply means placing the usable parts in the most effective position.6,9,28 It is not uncommon in a mutilating injury to have unusable tissues. It is important to critically evaluate these parts before committing them to waste, as components such as skin, tendon, or composite tissue can be utilized even if the entire digit cannot.
REPLANTATION PRIORITIES Once assessment is complete regarding evaluation of usable tissues and functional loss of the hand, decisions
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must be made regarding a realistic expected outcome for the hand. Although there are no absolute rules to guide the surgeon, some concepts are noteworthy, such as individualizing each case and being creative with available tissues to maximize the functional results. Consider the patient as a whole—his or her level of activity, occupation, and comorbidities—to arrive at a reasonable outcome expectation for the hand. Is the patient a white-collar company manager who would place a premium on pinch and fine manipulations for writing or computer use? Is the patient a blue-collar laborer who places a premium on functional grasp and grip strength so that he can return to work? Each of these scenarios would have different priorities and goals. These early considerations will set the stage for maximal hand function, individualized to the patient’s needs and desires. The highest priority is salvage of the thumb to allow for a functional hand in pinch, grasp, and most manipulative tasks. Even with poor range of motion at the interphalangeal and the metacarpophalangeal joints, the length gained by replantation is still useful (Fig. 15-3).17 If the thumb is not replantable, give high priority to consideration of another digit to replace the thumb. Transposition of another digit to the thumb position brings up unique issues. Problems with size discrepancy of components and location of vessels involved should
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FIGURE 15-3. A, Amputation of the thumb at the level of the metacarpophalangeal (MCP) joint. B, Recipient site for orthotopic replantation. C, After successful replantation. Although there is no motion at the metacarpophalangeal joint, carpometacarpal joint motion and the additional length provided by replantation improve function.
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be anticipated and planned for. If no digit is suitable for transposition to the thumb position, pollicization or toe-to-thumb transfer should be planned in delayed fashion (Fig. 15-4). Priority for the replantation of digits will depend on functional priority. Many series emphasize thumbindex finger pinch, three-point pinch, and fine manipulations; therefore make index and middle finger repair a priority. For others, deletion of the index finger allows the middle finger to assume much of the function of the index finger and prevents gaps between the digits, which can be problematic for the patient as well as aesthetically undesirable. For these
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reasons, the index finger has a low priority for repair or replacement, especially if the parts can be put to better use elsewhere. This is similar to the situation in single-digit replantation. In the case of multiple-digit amputations that include the proximal interphalangeal joints, all digits, including the index finger, should be replanted with the goal of a “mitten hand,” which has good length but only metacarpophalangeal joint function. Those emphasizing power grasp will make the ulnar side of the hand a priority. Depending on the ultimate number of digits, different ideal arrangements exist (Fig. 15-5).
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FIGURE 15-4. A, Industrial injury to the hand with multiple-digit and soft tissue injury. B, After completion amputation of the middle and index fingers, replantation of the little finger at the proximal interphalangeal joint level is performed. A groin flap is performed to set the stage for later thumb reconstruction. C, After second-toe-to-thumb transfer. D, Final result with opposable digits for grasp and manipulations. Overall, adequate function was achieved.
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Three Digits
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* grasp/strength
FIGURE 15-5. Optimal positioning of replanted digits. (Stars denote positionings that offer more favorable relationships between the digits.)
It is better to have fewer digits with better length, joint preservation, and sensibility than to salvage more digits that will be shorter, stiffer, and insensate. Depending on the scenario the surgeon chooses for the patient, less-functional digits can be sacrificed and used for spare parts in the reconstruction of other injured digits, either at the time of initial replantation or later as a revision to improve hand function.20,39 Similar improvements can be made later using toe-to-digit transfers, if warranted.
CONCLUSION Microsurgical replantation is a vital part of management of the patient with a mutilating hand injury. Many decisions that are made at the time of initial treatment will affect the patient and the ultimate function of the hand for the duration of the patient’s life. As Ch’en Chun-Wei stated, “Survival without restoration of function is not a success.”6 We have many tools in our reconstructive armamentarium to replace lost hand function. Because
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each case is unique, each must be evaluated to preserve hand function and make use of all possible tissues before deciding on the expedient. Creativity will be rewarded in time with happier, more functional patients.
References 1. Baek SM, Kim SS: Ten-digit and nine-digit replantation (4 cases). Br J Plast Surg 45:407–412, 1992. 2. Baker GL, Kleinert JM: Digit replantation in infants and young children: Determinants of survival. Plast Reconst Surg 94:139–145, 1994. 3. Brown PW: Less than ten: Surgeons with amputated fingers. J Hand Surg 7:31–37, 1982. 4. Camacho FJ, Wood MB: Polydigit replantation. Hand Clin 8:409–412, 1992. 5. Chen CT, Wei FC, Chen HC, et al: Distal phalanx replantation. Microsurg 15:77–82, 1994. 6. Chen C-W: American replantation mission to China: Replantation surgery in China. Plast Reconstr Surg 52:476–489, 1973. 7. Chiu DT, Ascherman JA: Heterotopic transplantation of a reattached digit. Plast Reconstr Surg 95:152–155, 1995. 8. Chui HY, Chen MT, Lin TW, et al: A technique for simultaneous replantation of multiple amputated digits at Tamai’s zone V. J Trauma 36:216–221, 1994. 9. Chui HY, Lu SY, Lin TW, Chen MT: Transpositional digital replantation. J Trauma 25:440–443, 1985. 10. Chui HY, Shieh SJ, Hsu HY: Multivariate analysis of factors influencing the functional recovery after finger replantation or revascularization. Microsurgery 16:713–717, 1995. 11. Fukui A, Inada Y, Maeda M, et al: Pedicled and “flow– through” venous flaps: Clinical applications. J Reconstr Microsurg 5:235–243, 1989. 12. Fukui A, Maeda M, Inada Y, et al: Arteriovenous shunt in digit replantation. J Hand Surg 15A:160–165, 1990. 13. Gaul III JS, Nunley JA: Microvascular replantation in a seven-month-old girl: A case report. Microsurg 9:204–207, 1988. 14. Gelberman RH, Urbaniak JR, Bright DS, Levin LS: Digital sensibility following replantation. J Hand Surg 3:313–319, 1978. 15. Goldner RD, Stevanovic MV, Nunley JA, Urbaniak JR: Digital replantation at the level of the distal interphalangeal joint and the distal phalanx. J Hand Surg 14:214–220, 1989. 16. Hallock GG: Transient single-digit ectopic implantation. J Recostr Microsurg 8:309–311, 1992. 17. Jones JM, Schenck RR, Chesney RB: Digital replantation and amputation: Comparison of function. J Hand Surg 7:183–189, 1982. 18. Kim WK, Lee JM, Lim JH: Eight cases of nine-digit and ten-digit replantations. Plast Reconstr Surg 98:477–484, 1996. 19. Kramer BA, Korber KE, Aquino TI, Engleman A: Use of leeches in plastic and reconstructive surgery: A review. J Reconstr Microsurg 4:381–386, 1988.
20. Levin LS, Aponte RL: The use of spare parts in surgery of the hand. Atlas Hand Clin 1998, pp 235–252. 21. Lu YU, Ge J, Huang YT, et al: Successful replantation in tendigit complete amputations. J Reconstr Microsurg 4:123–129, 1988. 22. Matsuda M, Chikamatsu E, Shimizu Y: Correlation between number of anastomosed vessels and survival rate in finger replantation. J Reconstr Microsurg 9:1–4, 1993. 23. May JW, Hergrueter CA, Hansen RH: Seven-digit replantation: Survival after 39 hours of cold ischemia. Plast Reconstr Surg 78:522–525, 1986. 24. Nissenbaum M: A surgical approach for replantation of complete digital amputations. J Hand Surg 5:58–62, 1980. 25. Nunley JA, Ugino MR, Goldner RD, et al: Use of the anterior branch of the medial antebrachial cutaneous nerve as a graft for the repair of defects of the digital nerve. J Bone Joint Surg 71A:563–567, 1989. 26. Pomerance J, Truppa K, Bilos ZJ, et al: Replantation and revascularization of the digits in a community practice. J Reconstr Microsurg 13:163–170, 1997. 27. Qing-tai L, Chang-qing JZ, Ke-fei Y, et al: Successful replantation in 10-digit complete amputations. Plast Reconstr Surg 98:348–353, 1996. 28. Rose EH, Buncke HJ: Selective finger transpostion and primary metacarpal ray resection in multidigit amputations of the hand. J Hand Surg 8:78–182, 1983. 29. Saies AD, Urbaniak JR, Nunley JA, et al: Results after replantation and revascularization in the upper extremity in children. J Bone Joint Surg 76:1766–1776, 1994. 30. Soucacos PN, Beris AE, Touliatos AS, et al: Current indications for single digit replantation. Acta Orthop Scand 66:12–15, 1995. 31. Tamai S: Analysis of 163 replantations in an 11-year period. Clin Plast Surg 5:195–210, 1978. 32. Taras JS, Nunley JA, Urbaniak JR, et al: Replantation in children. Microsurgery 12:216–220, 1991. 33. Tsai TM: A complex reimplantation of digits: A case report. J Hand Surg 4:145–149, 1979. 34. Tsai TM, Matiko JD, Breidenbach W: Venous flaps in digital revascularization and replantation. J Reconstr Microsurg 3:113–119, 1987. 35. Urbaniak JR: Digit and hand replantation: Current status. Neurosurgery 4:551–559, 1979. 36. Waikakul S, Sakkarnkosol S, Vanadurongwan V, Unnanuntana A: Results of 1018 digital replantations in 552 patients. Injury 31:33–40, 2000. 37. Weber RA, Breidenbach WC, Brown RE, et al: A randomized prospective study of polyglycolic acid conduits for digital nerve reconstruction in humans. Plast Reconst Surg 106:1036–1045, 2000. 38. Wei FC, Chang YL, Chen HC, Chuang CC: Three successful digital replantations in a patient after 84, 86, and 94 hours of cold ischemia time. Plast Reconstr Surg 82:346–350, 1988. 39. Weiland AJ, Villarreal-Rios A, Kleinert HE, et al: Replantation of digits and hands: Analysis of surgical techniques and functional results in 71 patients with 86 replantations. J Hand Surg 2:1–12, 1977.
16 Joint Transfer Tsu-Min Tsai, MD Jui-Tien Shih, MD
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I-Chen Chen, MD
HISTORY The history of joint replacement in the finger with a nonvascularized toe joint can be traced back to the early twentieth century. In 1907, Bachman reported the first whole joint transfer to the upper limb. In 1925, an autogenous metatarsophalangeal (MTP) joint was transferred to replace an elbow joint.22 In 1945, Cuthbert reported the transfer of an autogenous MTP joint to replace the metacarpophalangeal (MCP) joint of the thumb.7 In 1954, Graham reported the transfer of a nonvascularized MTP joint of the fourth toe to replace the MCP joint of thumb. The result was reported to be “fair.”14 Replacing diseased finger joints with various nonvascularized hemijoints or whole joints from the foot was continued by Peacock,23 Entin and colleagues,9 and Erdelyi.10 Entin et al. demonstrated various factors contributing to the failure of nonvascularized autogenous joint transfer in a dog model.9 They found that the architecture of the transferred joint remained relatively normal up to about 15 weeks after surgery. Subsequently, morphologic changes appeared, including narrowing of the joint space, widening of the bone ends, cartilaginous degeneration, fragmentation of adjacent bone, and invasion of the joint space by fibrous tissue. Because of these morphologic changes, nonvascularized whole joint transfer was gradually abandoned. It was at this time that the first experimental studies of vascularized joint transfer began. Judet and Padovani reported the first experimental study of vascularized joint transfer in a dog knee model.19,20 Vascularized joint transfer experiments were later repeated in the small joints of a dog and in a primate model.16,29 In 1982, Tsai et al. demonstrated, in a primate model, the technical feasibility of vascularized joint transfer to the human hand.29 Their experiment demonstrated the histological differences between nonvascularized and vascularized joint transfers 7–10 months after surgery. In the nonvascularized joints, the joint spaces were lost and filled with scar tissue and a few remnants of synovium, the hyaline cartilage was essentially destroyed, and the subchondral bone demonstrated focal necrosis and evidence of creeping substitution. In the vascularized joints, the joint spaces were preserved, and the subchondral bone was viable. Synovial fluid production in the vascularized joint is the key factor contributing to this difference. The first vascularized small joint transfer in a human was reported by Buncke and colleagues in 1967.3 An MCP joint from a severely traumatized index finger was transferred to the adjacent middle finger to replace the proximal interphalangeal joint. Foucher et al. demonstrated the first vascularized toe joint transfer in 1980.13 Tsai et al. reported the first clinical series of vascularized toe joint transfers for finger joint reconstruction in 1982.27 225
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NONVASCULARIZED OSTEOCHONDRAL GRAFT Autogenous osteochondral grafts have been found useful in replacing articular defects of small joints in the hand.2 An articular defect that is limited to one side of the joint surface with minimal deficiency of subchondral bone substance can be satisfactorily replaced by an osteochondral autograft from a corresponding toe joint. The donor site might possibly be the proximal interphalangeal (PIP) joint or the MTP joint of the lesser toes.1,17 The smaller the size of the graft, the greater is the chance of a good result. A functioning tendon system and pliable soft tissue around the joint are also of paramount importance to the final outcome.
Indications and Contraindications Defects of the articular surface limited to one side of a finger joint can be replaced by an osteochondral graft harvested from the lesser toes or unsalvageable fingers. Hemi- or partial defects of MCP joints of the index or middle fingers are the most common indications for an osteochondral graft. An autogenous osteochondral graft is not beneficial in a severely traumatized joint with significant soft tissue deficiency and tendon destruction; in this case, arthrodesis can possibly provide a painless stable joint.
Surgical Technique There are four points to consider in planning of the surgical technique (Fig. 16-1). 1. Preparation of the recipient site. An adequately defined and stable bony stump is needed; the associated soft tissue damage must be precisely repaired. 2. Harvesting of the graft. The donor joint is approached by a longitudinal dorsal incision. The osteochondral graft is harvested from either side of the toe joint according to the contour of the defect, keeping in mind that a larger graft is preferable for later contouring. 3. Fixation of the graft. A lag screw or K-wire can be used for fixation of the graft. In a very thin and small graft, an absorbable K-wire or suture might be useful. 4. Closure of the donor site. The joint capsule can be interposed in the joint space; thus, the donor toe joint can be treated as a resection arthroplasty.
Postoperative Management Postoperative rehabilitation is crucial to the functional outcome. Protective passive range of motion can be
started as early as tolerated by the patient. The progress of the rehabilitation program is adjusted according to the stability of graft fixation and soft tissue healing.
Results Satisfactory results using the osteochondral graft are limited. The most promising results are reported by Boulas.1 In five cases, osteochondral grafts from the toes replaced the MCP defects. The average range of motion of the MCP joints was 0/74° (0/60–85°). Ishida also reported good results in ten cases.17 Osteochondral grafts were harvested from the distal or proximal side of the index or middle finger carpometacarpal joints of the ipsilateral hand. The graft was subsequently transferred to the site of the defect in the PIP or distal interphalangeal (DIP) joint. The mean angular deformity decreased from 33° to 4°, and the mean active range of motion increased from 22° to 38°.
VASCULARIZED JOINT TRANSFER Currently, reported techniques of vascularized joint transfer include the following: ❚ Vascularized finger joint transfer from a nonsalvageable finger ❚ Pedicle transfer of a finger DIP joint to a PIP joint ❚ Free transfer of a PIP joint of the second toe ❚ Free transfer of a MTP joint of the second toe
Vascularized Joint Transfer from a Nonsalvageable Finger Nonsalvageable fingers can serve as a suitable donor when a vascularized joint is needed. Ideally, replacement of a destroyed finger joint with an intact vascularized joint from a damaged finger that cannot be replanted offers the best chance of anatomic reconstruction and functional restoration. The reserved finger joint can be transferred to the defect by pedicle transfer or free transfer. The indication relies greatly on the integrity of donor tissue and the requirements of the recipient.
Finger Distal Interphalangeal Joint to Proximal Interphalangeal Joint Transfer The functional range of motion of the joints of the hand varies in each joint. In the fingers, the average functional range of motion of the DIP joint is 39°, that of the PIP joint is 60°, and that of the MCP joint is 61°.15 Transfer of the DIP joint with a vascular pedicle to the position of the PIP joint in the same finger converts the
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FIGURE 16-1. Nonvascularized osteochondral graft harvest and transfer. A, Radiograph showing traumatic arthritis of the middle finger metacarpophalangeal joint. B, Resection of the middle finger metacarpal head. C, Replacement of the metacarpal head with a metatarsal osteochondral graft harvested from the foot. D, Fixation of the osteochondral graft with absorbable Kirschner wires. E, Radiograph showing the smooth surface of the middle finger metacarpal head 1 year after surgery. E
finger from a three-joint system to a two-joint system (from DIP-PIP-MCP to fusion-DIP-MCP). The concept of DIP joint to PIP joint transfer is derived from the fact that the DIP joint is responsible for only 15% of the arc of finger joint mobility, compared with 80% for the PIP joint.11 Hand function is improved by transferring a mobile DIP joint, which is less respon-
sible for finger mobility, to the position of the damaged, immobile PIP joint, which contributes more to the range of motion of a finger.
Indications and Contraindications DIP-to-PIP joint transfer is indicated when there is PIP joint stiffness. A poor result after surgical treatment for
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acute trauma is the most common indication. This technique demands a pair of patent digital neurovascular bundles and functioning extensor and flexor tendons. A prerequisite to this transfer is an intact DIP joint. The surgical procedure involves four osteotomies in the same finger. Therefore, growing children with open epiphyseal plates are not good candidates for this transfer. Other contraindications include doubtful vascular status of fingers, severely traumatized soft tissue, and less demanding patients when fusion or other less complicated alternatives are indicated.
Surgical Technique Surgical technique for DIP-joint-to-PIP-joint transfer is as follows (Fig. 16-2): 1. Exploration of finger joints. The finger joint is approached distally from a dorsal incision at the base of the proximal phalanx. The skin incision is converted to a Y shape on the distal phalanx. Tenolysis of the extensor tendon is performed from the PIP joint to the DIP joint. The extensor tendon is divided transversely just proximal to the DIP joint. Dissection of the digital neurovascular bundles is performed from the dorsal approach. As recommended by Foucher, the dominant digital artery of a particular finger is usually selected for the joint flap; for example, the ulnar digital artery of the index or the radial digital artery of the ring and little finger. Either digital artery of the middle finger can be used as the donor vessel.12 2. Dissection of DIP joint and neurovascular pedicle. The digital neurovascular bundle that is preserved for the finger is dissected free from the bone and the DIP joint. The selected digital neurovascular bundle is carefully mobilized from the finger, and care is taken to preserve the articular branches to the DIP joint. The digital nerve is dissected free from the radial digital artery under the microscope. The adipose soft tissue surrounding the digital neurovascular bundle provides important venous drainage and should be preserved if at all possible. 3. Debridement of PIP joint and mobilization of DIP joint. The malfunctioning PIP joint is excised from the finger by making transverse osteotomies on either side of the joint. The excised segment is preserved for distal bone grafting. After osteotomy through the middle and distal phalanges, the DIP joint and its selected accompanying digital vessels are elevated under the microscope. The dissection permits a free arc of rotation of the pedicled DIP joint flap. The pneumatic tourniquet is then deflated so that the tissue can reperfuse. 4. Fixation of the recipient and donor site. Usually, interosseous wires, K-wires, or plate and screws
are used for fixation of the DIP joint at the level of the PIP joint. The bone graft, previously excised from the PIP joint, is fixed to the level of the DIP joint using K-wires or interosseous wires or both. The extensor mechanism is then reattached to the dorsal bony fragment, and the flexor digitorum profundus, previously divided from the distal phalanx, is reattached to the end of the bony fragment. Intraoperative xi-scan (Xi Tec, Inc., East Windsor, CT) is used for checking the alignment of the joint and bony fixation. The hand and forearm are immobilized in a dorsal extension block splint.
Postoperative Management Gentle passive movement of the PIP joint under the protection of an extension block splint can be started on the second day after surgery. The passive range of motion increases gradually according to the stability of bony fixation. Active range-of-motion exercises, under protection, can be started 3 weeks after surgery. K-wires are removed after 6–8 weeks. Full range-of-motion and strengthening exercises begin after clinical evidence of solid bony union. Results Very limited data have been reported regarding the pedicled DIP-to-PIP transfer. In a series of seven homodigital DIP-to-PIP transfers, using a more sophisticated technique, Foucher reported an average of 52° of active range of motion.12
Second-Toe Proximal Interphalangeal Joint Transfer Composite tissue from the foot provides various donor materials for reconstructive procedures in the hand. The PIP joint of the second toe is a preferred donor for vascularized joint transfer to the hand. The donor site morbidity is relatively lower when compared to that of the MTP joint of the toe. When small amounts of soft tissue and bony stock are needed, the donor toe can be preserved. The PIP joints of the toes tend to hyperflex. This tendency to hyperflex results in the appearance of an extension lag even though flexion movement may be excellent. In an effort to overcome the hyperflexion tendency of the toe PIP joint, refinement of procedures continues. Tsai et al.27 advocated a step-cut osteotomy in the middle phalanx to preserve the extensor mechanism of the recipient finger. Foucher demonstrated that suturing the extensor digitorum brevis of the donor toe to the intrinsic mechanism and suturing the extensor digitorum longus of the toe to the extrinsic extensor tendon decrease hyperflexion tendencies.11
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FIGURE 16-2. Finger distal interphalangeal joint to proximal interphalangeal joint transfer. A, Radiograph showing arthrodesis of the proximal interphalangeal (PIP) joints of the right ring and little fingers. B, Exploration of the interphalangeal joints from a dorsal longitudinal incision. C, The distal interphalangeal (DIP) is set back to the position of the PIP joint. D, The joint is fixed with interosseous wires. The donor defect is filled with bone graft and fixed with K-wire. The extensor tendon is sutured after fixation of the joint and bony structures. E, Skin closure. Continued E
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FIGURE 16-2 cont’d. F, Postoperative radiograph showing solid bony union at the DIP fusion and joint transfer. G, The right ring finger in full extension, showing 15° of extension lag, 18 months after surgery. The ring finger is shorter than normal because of the procedure. H, Active PIP flexion of 40°. H
Indications and Contraindications The PIP joint of the second toe has been recommended as a suitable alternative for replacement of the PIP joint and the MCP joint of the finger because of minimal growth requirement, greater flexion range, lateral stability, size matching, and a less significant secondary defect. However, the toe PIP joint contains only one open epiphyseal plate; therefore transfer of a vascularized toe PIP joint in children has resulted in less than favorable growth potential.8,32 Vascularized PIP joint transfer can be a good solution in replacing a stiff PIP or MCP joint of a finger in an individual who is highly motivated to maintain motion and in whom the extrinsic tendon system of the diseased finger is functioning relatively well. Definite indications for transferring a vascularized PIP joint from toe to hand remain controversial. Anticipating a 10–40° extension lag with an average of 30–45° of total active motion is a reasonable approach to formulate the surgical plan.
Surgical Technique The following list details technique for a toe PIP joint transfer to the PIP joint of a finger (Fig. 16-3). 1. Preoperative evaluation. Physical examination and Doppler ultrasound usually provide an adequate evaluation of the lower extremity. The same is true for the upper extremity, with the addition of an Allen’s test. A palpable dorsalis pedis pulse is essential. Radiographs are required to ensure that a nonarthritic donor joint is present and to determine the relative lengths of the metatarsal, metacarpal, and phalanges to plan osteotomy sites in both the hand and foot. 2. Preparation of the recipient site. Dissection of the recipient site is carried out under tourniquet control. Through a dorsal lazy-S incision, the extensor tendon is dissected free from the skin and the bone, and an osteotomy is performed through the midportion of the proximal phalanx. The central
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FIGURE 16-3. Second-toe proximal interphalangeal joint transfer. A, Radiograph showing traumatic arthritis at the proximal interphalangeal (PIP) joint of the left index finger. The PIP joint is painful and stiff. B, A dorsal skin incision is used to explore the joint and prepare the recipient site. C, Ideally, a step-cut osteotomy is made at the middle phalanx to preserve the central slip insertion. D, The PIP joint of the second toe is approached from a dorsal incision that crosses proximally to access the vascular pedicle. A skin island on the fibular side of the big toe is included in the joint flap. E, The joint flap is harvested for transfer. Continued
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FIGURE 16-3 cont’d. F, A photoplethysmograph probe is sutured on the flap for continuous monitoring of flap circulation. G, Range-of-motion exercise is started as early as the second postoperative day. H, The joint flap is fixed with plate, screws, and interosseous wires. The radiograph shows excellent preservation of the joint space 1 year after surgery. I, Full extension of the finger, with 30° extension lag. J, The patient obtained 55° PIP flexion 6 months after surgery. J
slip insertion is identified, and a step-cut osteotomy through the middle phalanx is carried out partially on the volar side. About 50–75% of the volar segment of the middle phalanx is incised with an oscillating saw. The volar segment, about 1 cm in length distal to the articular surface of the PIP joint, is excised. The resected bone gap is measured and prepared to accompany the toe joint. Flexor tenolysis is then performed through the bony defect, and if necessary, the flexor tendon is further exposed through the palm to finish the tenolysis. The common digital artery at the palm level is prepared for an end-to-side anastomosis, and the dorsal vein is prepared for an end-to-end venous anastomosis. 3. Dissection of the second toe PIP joint. Donor site dissection is performed under tourniquet control. A skin island, about 1 ⫻ 3 cm based on the fibular digital neurovascular bundle of the big toe, is marked along with the joint flap. Preoperative radiographs of the foot are taken to determine the most appropriate toe for transfer. The PIP joint is then harvested by a dorsal longitudinal incision between the first and second rays to explore the dorsalis pedis and first dorsal metatarsal arteries and the venous arch. The arterial dissection continues to the common digital artery. The subcutaneous vein, along with the greater saphenous vein, is carefully dissected. The medial half of the dorsal vein plexus of the second toe is preserved for the joint transfer, and the lateral half of the dorsal vein plexus is preserved for the remaining portion of the second toe. The dorsal vein of the skin flap from the big toe is also preserved to the joint flap. Depending on the recipient site, the extensor digitorum longus and brevis are transected 2–3 cm proximal to the level of the MCP joint. The neurovascular bundle supplying the great toe and second toe is explored carefully in the first webspace, and it is dissected free from the surrounding branches. The fibular neurovascular bundle, without the digital nerve, is dissected from the big toe for the skin flap monitor and coverage. The tibial site neurovascular bundle is separated from the MCP joint of the second toe and connected to the graft. The tibial vascular bundle is further explored proximally pending the planned anastomosis. The fibular neurovascular bundle is dissected away from the graft to supply the remaining toe. If the common digital artery in the palm is the donor, then the first dorsal metatarsal artery at the proximal metatarsus should be long enough to use for grafting.
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Before division, measurement of the first dorsal metatarsal artery is necessary to confirm adequate length. After disarticulation through the DIP joint and osteotomy through the proximal phalanx, the toe joint is dissected with the extensor tendon. The joint flap contains a combination of the skin flap from the big toe and the PIP joint from the second toe including vascular bundle, dorsal vein, and extensor tendon. The pneumatic tourniquet can be deflated for 30 minutes before the division of artery and veins. 4. Inset of the joint flap. Bone fixation is carried out with K-wires supplemented with either interosseous wires or plate fixation. The extensor tendon is sutured beneath the extensor of the recipient site, and the DIP joint is immobilized in a straight position using K-wires. The flexor sheath is reconstructed with the toe joint flexor sheath to the recipient flexor sheath. Intraoperative X-rays are used to confirm proper position. The range of motion and the gross alignment of the flap are rechecked before vascular anastomoses are done. 5. Microvascular anastomosis. The digital artery is repaired end-to-side to the common digital artery in the palm. At least two dorsal veins of the joint flap need to be anastomosed to the recipient veins. The skin and the flap are inset, and a splitthickness skin graft is often needed to complete the closure. An optional photoplethysmography probe is sutured to the skin flap for postoperative monitoring. The hand is immobilized in a dorsal extension block splint.
Postoperative Management Postoperative monitoring of vascular patency is essential. Parameters of observing the circulation to the island skin flap of the joint include capillary refill, color, and temperature. Photoplethysmography is frequently used for continuous monitoring of the microvascular circulation. Under the protection of a dorsal extension block splint, limited range-of-motion exercise can be started the second day after surgery. The rehabilitation program can be advanced aggressively, provided that a stable and secure bony fixation is accomplished. The K-wire fixing the DIP joint is removed 1 month after surgery, and then full range-of-motion exercise can begin. Results A review of a combined series of 89 vascularized joint transfers in 79 patients was reported by Tsai and Wang in 1992.32 All of the clinical series reported that free vascularized joint transfer resulted in good long-term cartilage preservation, restored a permanently functioning new joint, and only rarely entailed subsequent degenerative
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changes. When the toe PIP joint was transferred to the finger PIP joint, an average range of motion of 26.7° was reported. Transfer of the toe PIP joint to the MCP joint of the finger resulted in an average of 35° total active range of motion. Chen and Wei reported a series of 44 vascularized joint transfers.4 Toe PIP joint transfer to hand PIP joint resulted in an average of 23.5° total active range of motion. Toe PIP joint transfer to the hand MCP joint resulted in an average of 34° active ROM.
Second-Toe Metatarsophalangeal Joint Transfer The MTP joint of the second toe can be transferred to the hand for replacement of a joint with similar size and motion. Transfer of a vascularized MTP joint in children carries two open epiphyseal plates, which support greater growth potential than that of the PIP toe joint.18 Singer et al. concluded that MTP-to-MCP vascularized joint transfer can provide painless, functional, stable motion with near normal growth potential.25 The MTP joint naturally tends to hyperextend. The hyperextension deformity can be corrected either by rotating the long axis of the joint 180° to make the plantar surface of the joint become the extensor side or by making an oblique osteotomy of the metatarsal head to tilt the joint approximately 45°.
Indications and Contraindications Harvesting the MTP joint instead of the PIP joint from the second toe results in more significant morbidity to the donor site; therefore transfer of the MTP joint should be done more conservatively. The most reasonable indications for a vascularized second toe MTP joint transfer are (1) to replace an MCP joint or (2) to replace the interphalangeal joint of the thumb in a growing child. In an adult patient, the MTP joint of the toe is fairly suitable for replacement of an MCP joint. However, the PIP joint of the hand is a less ideal recipient site because of the hyperextensive nature of the MTP joint and discrepancy in size. To predict a successful outcome, the soft tissue condition of the recipient area must be supple, and the extensor and flexor tendons should be functioning well. Surgical Procedure Consider the following when undertaking a second toe MTP to MCP transfer (Fig. 16-4): 1. Preoperative evaluation. The preoperative evaluation is identical to that for PIP joint transfer. Physical examination and Doppler ultrasound usually provide an adequate evaluation of the lower extremity. The same is true for the upper extrem-
ity, with the addition of an Allen’s test. A palpable dorsalis pedis pulse is essential. Radiographs are required to ensure that a nonarthritic donor joint is present and necessary to determine the relative lengths of the metatarsal, metacarpal, and phalanges to plan osteotomy sites in both the hand and foot. 2. Preparation of the recipient site. Anesthesia and limb preparation are also the same as those for PIP joint transfer. Dissection of the recipient finger is performed under tourniquet control. A dorsal zigzag incision can be used to explore the recipient site. Tenolysis of the extensor and flexor tendons is carried out to release the tendons from the underlying bone. The MCP joint is resected using transverse osteotomies. Dorsal veins at the metacarpal level and common digital artery in the palm are dissected, under operating microscope, for anastomoses. The actual size of the bony defect is measured before deflation of the pneumatic tourniquet. 3. Dissection of the metatarsophalangeal joint. The donor foot dissection is also performed under tourniquet control. The left foot is usually preferred because the right foot is needed for operating an automobile. A zigzag incision is made on the dorsal aspect of the foot. A skin island is always included in the incision design. The saphenous vein, first dorsal metatarsal artery, and pedis dorsalis artery are approached as follows: ❚ The saphenous vein is dissected and preserved to attach to the skin flap of the MTP joint. ❚ The extensor tendons are divided according to the recipient site. ❚ The articular branches from the first dorsal metatarsal artery to the MTP joint are carefully preserved. ❚ The tibial digital artery of the second toe is divided at the middle of the proximal phalanx where the transverse osteotomy is performed. ❚ The flexor tendon sheath is opened longitudinally, and the proximal osteotomy is performed at the metatarsus according to the requirement of the defect. ❚ The tourniquet is deflated before the division of vessels to allow temporary reperfusion of the joint flap. 4. Inset of the joint flap. After approximately 30 minutes of flap perfusion, the pedicle is divided, and the MTP joint is moved to the hand. Fixation of the bony structure is achieved by using K-wires and interosseous wires. Some authors advocate the inset of a joint flap in 180°
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E F FIGURE 16-4. Second-toe metatarsophalangeal joint transfer. A, Radiograph showing a destroyed, stiff metacarpophalangeal (MCP) joint of the right index finger because of septic arthritis caused by a human bite. B, The recipient site is approached from a dorsal incision. C, Preparation of the recipient site includes debridement and excision of the destroyed joint, tenolysis of extensor and flexor tendon, and dissection of recipient vessels. Transverse osteotomies are used for joint resection. D, An island skin flap on the fibular side of the big toe is included in the dorsal zigzag incision for metatarsophalangeal (MTP) joint dissection. E, The MTP joint is dissected free from the donor site. The pedicle of the MTP joint is still connected to the foot. F, The MTP joint is transferred to the right hand. The skin island serves as a monitor of flap circulation. Continued
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FIGURE 16-4 cont’d. G, Closure of the donor site. H, The patient obtained 50° of active range of motion of the MCP joint 6 months after surgery.
rotation along its own axis to take advantage of the hyperextensive nature of the MTP joint.26 Others prefer to adjust the angle of bone fixation and tension of tendon repair to minimize hyperextension of the toe. An oblique osteotomy at the head of the metacarpal or metatarsal or both can facilitate a volar tilt of the joint to overcome the hyperextensive nature of the joint. The extensors are sutured under the extensor of the hand. 5. Microvascular anastomosis. The first dorsal metatarsal artery is anastomosed to the common digital artery in the palm in an end-to-side fashion. At least two dorsal veins of the joint flap are anastomosed to the dorsal veins of the hand. Tension-free skin closure is critical, and a skin graft may be used whenever needed.
Postoperative Management After surgery, the hand is immobilized in a dorsal block splint. Flap circulation is monitored by periodically observing the color, temperature, and capillary refill of the skin flap. Photoplethysmography provides objective information of flap circulation. Gentle passive motion can be started after the second postoperative day, and the rehabilitation program proceeds at a pace similar to that of the vascularized PIP toe joint transfer. Results Kuo et al. reported six cases of vascularized second toe MTP joint transfer.21 The range of motion of the transferred joint varied from 0/5° to 20/90⬚ with an average of 30° total active range of motion. A combined series review revealed an average of 29.9° total active range
of motion in vascularized MTP joint transfers to MCP joints of the hand.8 Chen et al. also reported an average of 27° total range of motion in vascularized MTP joint transfers to the MCP joints of the hand.4
CONCLUSION Vascularized joint transfer provides reasonable alternatives to the functional reconstruction of the hand. Refinement of techniques and indications continues to evolve over time. Transfer of DIP and PIP joints of the second toe as a unit to replace a finger PIP joint greatly improves the range of motion when compared to other procedures.30 Different techniques of harvesting both the MTP and PIP joint of the second toe to replace two joints of the hand have been reported by various authors, although the indications for this type of transfer are very rare. 5,11,28 The MTP joint of the second toe can be transferred to the basal joint of a Blauth type IIIb hypoplastic thumb.24 Although not common, transfer of a vascularized toe joint has been performed in an emergency situation with satisfactory results (good ROM, grip strength).6,31 Free joint transfer provides composite tissue stock including skin, tendon, bone, as well as neurovascular tissue for one-stage immediate reconstruction of a complex traumatic defect. Vascularized joint transfer is a well-developed technique in joint reconstruction. At present, the procedures are still very technically demanding, and the results are never certain. The formulation of a surgical plan must be well guarded by a thorough knowledge of the balance between the benefit of functional result and the sacrifice of donor site and surgical morbidity.
References 1. Boulas HJ: Autograft replacement of small joint defects in the hand. Clin Orthop 327:63–71, 1996. 2. Boulas HJ, Herren A, Buchler U: Osteochondral metatarsophalangeal autografts for traumatic articular metacarpophalangeal defects: A preliminary report. J Hand Surg 18A:1086–1092, 1993. 3. Buncke HJ, Daniller AL, Schulz WP, et al: The fate of autogenous whole joints transferred by micro-vascular anastomoses. Plast Reconstr Surg 39:333–341, 1967. 4. Chen HT, Wei FC, Chen HC: Vascularized toe joint transfer. Hand Clinic 15(4):613–627, 1999. 5. Chen IC, Tsai TM, Firrell JC: Single pedicle vascularized double joint transfer: Anatomic study of two models. Microsurgery 18(5):312–319, 1998. 6. Chen SH, Wei FC, Noordhoff SM: Free vascularized joint transfers in acute complex hand injuries: case reports. J Trauma 33(6):924–930, 1992. 7. Cuthbert JB: The late treatment of dorsal injury of the hand associated with loss of the skin. Br J Surg 33:66, 1945. 8. Ellis PR, Hanna D, Tsai TM: Vascularized single toe joint transfer to the hand. J Hand Surg 16A:160–168, 1991. 9. Entin MA, Alger JR, Biard RM: Experimental and clinical transfer of autogenous whole joints. J Bone Joint Surg 44A: 1518–1536, 1962. 10. Erdelyi R: Reconstruction of ankylosed finger joint by means of transfer of joints from the foot. Plast Reconstr Surg 31:140–150, 1963. 11. Foucher G: Vascularized joint transfers. In Green DP, Hotchkiss RN, Pederson WC, Lampert R (eds): Green’s Operative Hand Surgery. Philadelphia, Churchill Livingstone, 1999, pp 1251–1270. 12. Foucher G, Lenoble E, Smith D: Free and island vascularized joint transfer for proximal interphalangeal reconstruction: A series of 27 cases. J Hand Surg 19A:8–16, 1994. 13. Foucher G, Merle M, Maneaud M, Michon J: Microsurgical free partial toe transfer in hand reconstruction: A report of 12 cases. Plast Reconstr Surg 65:616–627, 1980. 14. Graham WC: Transfer of joints to replace diseased or damaged articulation in the hand. Am J Surg 88:136–141, 1954. 15. Hume MC, Gellman H, McKellop H, Brumfield RH: Functional range of motion of the joints of the hand. J Hand Surg 15A:240–243, 1990. 16. Hurwitz PJ: Experimental transfer of small joints by microvascular anastomoses. Plast Reconstr Surg 64:221–231, 1979. 17. Ishida O, Ikuta Y, Kuroki H: Ipsilateral osteochondral grafting for finger joint repair. J Hand Surg 19A:372–377, 1994.
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18. Ishida O, Tsai TM: Free vascularized whole joint transfer in children. Microsurgery 12(3):196–206, 1991. 19. Judet H, Padovani JP: Transfer of a complete joint with immediate reestablishment of circulation by arterial and venous anastomoses. Mem Acad Chir 94:520–526, 1968. 20. Judet H, Padovani JP: Transfer of a whole joint with immediate circulation restoration by arterial and venous anastomosis in dog. Rev Chir Orthop 59:125–138, 1973. 21. Kuo ET, Ji ZL, Zhao YC, et al: Reconstruction of metacarpophalangeal joint by free vascularized autogenous metatarsophalangeal joint transfer. J Reconstr Microsurg 1:65–74, 1984. 22. Lexer E: Joint transfers and arthroplasty. Surg Gynecol Obstet 40:782–809, 1925. 23. Peacock EE: Reconstructive surgery of hands with injured central metacarpophalangeal joints. J Bone Joint Surg 38A: 291–302, 1956. 24. Shibata M, Yoshizu T, Seki T, Goto M, Saito H, Tajima T: Reconstruction of a congenital hypoplastic thumb with use of a free vascularized metatarsophalangeal joint. J Bone Joint Surg 80A:1469–1476, 1998. 25. Singer DI, O’Brien BM, McLeod AM, et al: Long-term follow-up of free vascularized joint transfers to the hand in children. J Hand Surg 13A:776–783, 1988. 26. Smith PJ, Jones BM: Free vascularized transfer of the metatarsophalangeal joint to the hand: A technical modification. J Hand Surg 10B:109–112, 1985. 27. Tsai TM, Jupiter JB, Kutz JE, Kleinert HE: Vascularized autogenous whole joint transfer in the hand: A clinical study. J Hand Surg 7A:335–342, 1982. 28. Tsai TM, Lim BH: Free vascularized transfer of the metatarsophalangeal and proximal interphalangeal joints of the second toe for reconstruction of the metacarpophalangeal joints of the thumb and index finger using a single vascular pedicle. Plast Reconstr Surg 98(6):1080–1086, 1996. 29. Tsai TM, Ogden L, Jaeger SH, Okubo K: Experimental vascularized total joint autograft: A primate study. J Hand Surg 7A:140–146, 1982. 30. Tsai TM, Singer R: Elective free vascularized double transfer of toe joint from second toe to proximal interphalangeal joint of index finger: A case report. J Hand Surg 9A:816–820, 1984. 31. Tsai TM, Singer R, Elliott E, Klein H: Immediate free vascularized joint transfer from second toe to index finger proximal interphalangeal joint: A case report. J Hand Surg 10B:85–89, 1985. 32. Tsai TM, Wang WZ: Vascularized joint transfers-indications and results. Hand Clinic 8(3):525–536, 1992.
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17 Transmetacarpal Replantation and Revascularization Norman Weinzweig, MD, FACS
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Transmetacarpal amputations and devascularizing injuries are devastating to the patient and present a formidable challenge to the hand surgeon. These anatomically complex injuries involve the metacarpals, flexor and extensor tendons, nerves, and blood vessels, including the superficial and deep palmar arches. They are differentiated from more proximal or distal injuries in that the lumbrical and interosseous muscles lie within the zone of injury. This unique subset of upper extremity injuries is characterized by (1) irreparable direct damage to the tiny intrinsic muscles, (2) interruption of the blood supply from the palmar arches and digital arteries, producing an ischemic middle ground in the palm, even with successful distal revascularization, and (3) creation of a common wound involving bone, tendon, muscle, nerve, and vessel. This chapter highlights the pertinent literature on this particular subset of injuries; discusses the personal experience of the author, including long-term functional outcome; and postulates possible explanations for these findings based on anatomic considerations. The rehabilitation of these patients is also described.
LITERATURE REVIEW Few reports in the literature specifically address transmetacarpal injuries, and even fewer document long-term functional outcome. These series contain small, heterogeneous groups of patients, often do not distinguish between replantations and revascularizations, describe various mechanisms of injury ranging from severe crush injuries to guillotine-type amputations, and state different objective parameters of function. This makes direct comparisons of long-term functional outcome difficult if not impossible. Nonetheless, these are substantial injuries with severe consequences. In 1976, Meyer et al.4 reported a successful transmetacarpal replantation of a guillotinetype amputation of all five metacarpals. They astutely hypothesized that “in the contracture of the intrinsic muscles (in our case), tissue damage from ischemia was possibly of importance.” In a follow-up article published 5 years later, Meyer3 chronicled the need for further release of the intrinsic muscles in this patient. In the five subsequent cases, he shortened the metacarpals by 12 mm (rather than by 7 mm) and no longer encountered this problem. Scott et al.8 reported total active motion of 192 degrees after revascularization of 13 fingers and one thumb (four hands) at the transmetacarpal level, correlating with a fair result. Russell et al.6 documented the late functional results following seven complete and one incomplete transmetacarpal amputations. At an average of 34 months, the average total active motion of 239
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26 replanted or revascularized fingers in the seven available patients was 94 degrees. Pinch and grasp strengths and intrinsic muscle function were absent or weak in all patients. Digital abduction or adduction was not observed in a single patient. Recovery of sensibility was very poor (15–30 mm or worse). According to the grading system of functional recovery devised by Chen et al.2 there were four (57%) grade III and three (43%) grade IV results. Five of the seven patients underwent secondary surgery (range: one to three procedures). Four of the seven patients returned to work, two did not return, and one was retired at the time of his injury. Tark et al.12 evaluated functional outcome in 18 complete and 11 incomplete midhand amputations. Despite excellent salvage rates, functional outcome was poor. Recovery of digital total active motion was fair to poor in most patients. Intrinsic function was very weak or absent in all patients. Recovery of sensibility was fair. In contrast to these earlier reports, Scheker et al.9,10 cited favorable results after four transmetacarpal replantations with total active motion of the fingers averaging 189 degrees; grip strength, 37 lb; and pinch strength, 5.6 lb. Two-point discrimination ranged from 5 to 10 mm in three patients. According to the grading system of Chen et al.,2 three (75%) were grades I and II, and one (25%) was grade III. Scheker et al.9 attributed these results to resection of the devascularized and denervated distal intrinsic muscles to allow the intrinsic tendons to tenodese in an intrinsic-plus position and a new postoperative protocol initiated 3 days after replantation consisting of early protective active mobilization with anticlaw splinting. Weinzweig et al.14 retrospectively reviewed 13 consecutive transmetacarpal replantations and revascularizations in 12 patients. Ten patients (11 hands) sustained crush injuries; one withstood an explosive blast; and one suffered a guillotine-type amputation. Nine revascularizations (one thumb and 31 fingers) and four replantations (one thumb and 16 fingers), including bilateral procedures in one patient, were performed. The overall salvage rate was 90% (44 of 49 replantable digits). Ten patients (11 hands) required secondary surgery (mean: 4.5 procedures/hand), 60% for tendon and joint scarring and 14% for bony nonunions or malunions. The digital range of motion averaged 109 degrees. Pinch and grip strengths and intrinsic muscle function were weak or absent. Recovery of sensibility was poor. According to Chen’s grading system,2 31% were grade II, 31% were grade III, and 38% were grade IV. Follow-up ranged from 2.5 to 11 years. Only one patient resumed his prior occupation as supervisor; two were permanently disabled, three pursued new and unrelated occupations; two were still in therapy; and four were lost to late follow-up. None of the manual laborers (11 patients) was able to return to his preinjury
livelihood. Nonetheless, all patients were satisfied with the surgery (Figs. 17-1 and 17-2). In these series, there was a high incidence of digital survival following transmetacarpal replantations and revascularizations. This may be attributed to the normal vascular anatomy of the hand. Nakamura et al.5 reported a successful four-finger transmetacarpal replantation after anastomosis of the third common digital artery alone. Postoperative angiography demonstrated cross-connections between the digital arteries proximal to the interphalangeal joints, with retrograde flow reaching the common digital vessels of the second and fourth webspaces, revascularizing the index and little fingers. Tonkin et al.13 reported three transmetacarpal replantations in which the patency of one common digital vessel alone provided blood flow to all fingers (in two cases, to the thumb) through transverse commissural vessels connecting the digital vessels proximal to the interphalangeal joints. Retrograde flow to the adjacent common digital vessels revascularized the other digits. Thus digital survival is ensured by the peculiar vascular anatomy in the palm; however, this same anatomy results in ischemia of the intrinsic muscles. Today, successful replantation is no longer measured by survival of the amputated or devascularized part, but rather by function of that part. The discouragingly poor long-term functional results following transmetacarpal injuries are not the result of failure of the replantation or revascularization technique, but rather a result of intrinsic muscle ischemia due to either direct muscle injury or interruption of their delicate blood supply and creation of a “common wound.” In crush injuries with an extensive zone of injury, the intrinsic muscles suffer irreparable damage; the resultant fibrosis and scarring result in a high incidence of intrinsic-related complications. However, even in guillotine-type injuries at the transmetacarpal level, intrinsic tightness plays a major role in the poor functional results.
ANATOMIC CONSIDERATIONS The lumbrical and interosseous muscles play a key functional role in fine motor manipulation of the normal hand. Ischemia of the intrinsic muscles plays an important role in the poor functional results that are seen after transmetacarpal replantations and revascularizations. In his original case report, Meyer et al.4 hypothesized that intrinsic muscle ischemia played a key role in his findings. This can be better appreciated by understanding the vascular anatomy of the lumbrical and interosseous muscles. Perhaps the earliest description of the blood supply to the intrinsic muscles is found in the classic treatise by Salmon and Dor, Les Arteres des Muscles des Membres et du Tronc, published in 1933.7 These visionary anatomists
17
B
241
C
17
A
TRANSMETACARPAL REPLANTATION AND REVASCULARIZATION
D
E
F
FIGURE 17-1. A, B, A 56-year-old machinist sustained a guillotine-type amputation of his nondominant hand. C–F, The amputated hand was prepared, and replantation was performed. Subsequent procedures included flexion contracture releases of the PIP joints of the middle and little fingers. G and H, At 2-year follow-up, total active motion ranged from 124° to 147° with recovery of protective sensation. (Images A, C, D, G, and H from Weinzweig N, Sharzer LA, Starker I: Replantation and revascularization at the transmetacarpal level: Longterm functional results. J Hand Surg 21A:877–883, 1996; with permission.) G
H
A
B
C
D
E
F
FIGURE 17-2. A–C, A 19-year-old machinist sustained bilateral complete transmetacarpal amputations after a punch-press injury. D, Replantation was performed. E and F, The patient at 2-year follow-up. Primary tenorrhaphy and nerve repair could not be performed owing to the extensive zone of injury. Two fingers could not be salvaged. Secondary procedures included tendon and nerve grafting, metacarpophalangeal joint capsulectomies and resection arthroplasties with silastic joints, and tenolyses.
242
TRANSMETACARPAL REPLANTATION AND REVASCULARIZATION
focused on “the explanation of various pathologic processes based on an understanding of the underlying blood supply, and ‘the dangerous zones’ in which ligation of major vessels in the extremities could spell disaster for the circulation of the distal part.” In Kaplan’s classic text, Functional and Surgical Anatomy of the Hand,11 Salmon and Dor’s original description of the vascular anatomy of the intrinsic muscles is reiterated.7 According to these anatomists, each of the lumbrical muscles is supplied on its deep surface by the lumbrical artery, a long (20- to 30-mm) branch from the volar aspect of the deep palmar arch. The lumbrical artery courses distally in an oblique volar direction to the deep surface of the muscle, where it divides into ascending and descending branches, piercing the first two lumbrical muscles close to their midportions and the last two lumbricals slightly more distally. The lumbricals receive less significant contributions from the anterior interosseous artery, which enters the lumbrical on its deep surface, and from small branches of the digital arteries of the superficial palmar arch on its superficial surface. The palmar and dorsal interossei are supplied primarily by abundant small vessels emanating from the common digital (palmar metacarpal) arteries of the superficial palmar arch and by direct branches from the deep palmar arch. The dorsal arch does not appear to contribute to the dorsal interossei, which have an independent, highly irregular pattern of blood supply. Zbrodowski et al.17 looked specifically at the contributions of the superficial palmar arch to the blood supply of the hand, without investigating the role of the deep palmar arch. Most of the arteries to the lumbricals were found to arise from the common palmar digital arteries and from some direct branches of the superficial palmar arch. The latter arise from a common trunk that divides into a branch penetrating the muscle and a branch supplying the surrounding connective tissue of the palm of the hand. Wilgis16 first described the use of a lumbrical as a muscle flap to cover local neuromas-in-continuity. The lumbrical muscle flap was approximately 5 cm in length and 1.5 cm in width. The vascular supply to the lumbricals arose from the common digital arteries of the respective digits. Based on one or two twigs from the common digital artery, usually one arising proximally and one entering the muscle in the midportion, the lumbrical muscle was isolated on a 1.5 to 2 cm pedicle. Bilbo and Stern1 found a constant dorsal and palmar arterial blood supply to the first dorsal interosseous muscle (FDIM) emanating from four major branches of the radial artery and deep palmar arch, with the palmar blood supply dominant: (1) a dorsal metacarpal artery arising just before the radial artery pierces the FDIM, (2) branches directly from the radial artery as it passes between the muscle heads that terminally ramify at the
243
base of both heads, and (3 and 4) the first and second palmar metacarpal arteries arising from the deep arch that travel along the palmar surfaces of their respective metacarpals to supply multiple branches as they pass adjacent to each head. Weinzweig et al.15 found that the muscle bellies of the lumbrical muscles are supplied from both their volar and dorsal surfaces by both the superficial and deep palmar arches in both axial and segmental fashions. The superficial arch or common digital artery gives origin to a direct axial vessel on the volar surface of the lumbrical. This finding is most pronounced on the radial side of the hand. In addition to this constant volar axial blood supply, there is a volar segmental blood supply. Segmental vessels derived from adjacent common digital arteries pierce the volar surface of each lumbrical muscle along its entire length (Figs. 17-3 to 17-5). This rich volar blood supply is augmented by dorsal vessels.
17
17
FIGURE 17-3. Anatomy of the hand. The lumbricals receive a dual blood supply to both their deep and superficial surfaces from both the deep and superficial arches in both axial and segmental distributions. A significant axial vessel (a) originates from either the superficial palmar arch or the common digital artery (DIG 1) to enter the proximal volar aspect of the lumbrical (L). Several segmental vessels (s) arising from the adjacent common digital artery (DIG 2) and the deep palmar arch can be appreciated entering the midposterior aspect of the lumbrical.
244
THE MUTILATED HAND
FIGURE 17-4. Anatomy of the hand. A single common digital artery (DIG) arising from the superficial palmar arch (SUP) supplies both axial (a) and segmental (s) vessels to adjacent lumbricals (L).
Each lumbrical muscle is also supplied by a lumbrical artery, a branch of the metacarpal artery, arising from the deep palmar arch. The lumbrical artery enters the first and second lumbricals at approximately the middle of the muscle and more distally on the third and fourth
muscles (Figure 17-6). The dorsal and volar interossei receive their major blood supply from the deep arch and metacarpal arteries. No distinct pattern of axial or segmental vessels could be identified (Figure 17-7). Of clinical significance, these minute vessels cannot be repaired
FIGURE 17-5. The superficial palmar arch (retracted by vessel loops) directly supplies an isolated lumbrical muscle with a volar axial vessel (a).
FIGURE 17-6. The lumbricals also receive a significant dorsal contribution of axial and segmental blood vessels from the deep palmar arch, seen here following reflection of the superficial arch and profundus tendons. Each lumbrical muscle is supplied by a lumbrical artery (a), a branch of the metacarpal artery, arising from the deep palmar arch and penetrating the dorsal surface of the lumbricals.
17
TRANSMETACARPAL REPLANTATION AND REVASCULARIZATION
245
and are not reconstituted even with arch reconstruction. Moreover, with injuries distal to the arch, dissection of the digital arteries further disrupts this blood supply.
CONCLUSION In these anatomic investigations, the blood supply to the intrinsic muscles of the hand was found to be rich and extensive with numerous anastomotic networks between the deep and superficial palmar arches. Both arches and their primary branches, the metacarpal and common digital arteries, contributed to the blood supply of the lumbrical and interosseus muscles. However, little if any of this vascular architecture is reestablished when we perform replantations or revascularizations at the transmetacarpal level. In fact, in the process of mobilizing the cut ends of vessels to perform either primary or vein graft anastomoses, this delicate system is disrupted even further. Moreover, in an effort to bypass the zone of injury, we bring vein grafts from the radial or ulnar arteries directly to the digital arteries, which successfully revascularizes the digits but leaves an ischemic “middle ground” in the palm of the hand directly at the level of injury. Although the distal blood supply is clearly reestablished, the intrinsic muscles are left ischemic with resultant contracture. Can this zone be revascularized? The small caliber of the vessels precludes it. Should the intrinsic muscles be resected or their tendons released? Should the bone be shortened? If so, by how much to minimize intrinsic tightness? Meyer et al.4 propose resection of the involved intrinsic musculature and adequate metacarpal shortening (at least 12 mm). This deserves further investigation. An alternative approach might be to resect the tendons of the intrinsics at the time of replantation.
What measures can be taken in postoperative rehabilitation to optimize the functional outcome? According to Scheker et al.,9,10 favorable results after transmetacarpal injuries may be attributed to resection of the denervated and devascularized intrinsic muscles and early active mobilization with anticlaw splinting. After deep palmar injuries, the intrinsic tendons become stuck in a lengthened position, resulting in an intrinsic-minus posture. Metacarpophalangeal joint extension block-splinting prevented this deformity by allowing the intrinsic tendons to scar down in a shortened position. Thus, early mobilization with dynamic traction splinting preserved tendon gliding, muscle strength, and muscle excursion and prevented the development of an intrinsic-minus posture. The intrinsic-plus posture produced a far more functional grasping hand. This merits further investigation by way of prospective clinical trials in a large group of patients. Despite excellent salvage rates after transmetacarpal amputations and devascularizing injuries, long-term functional outcome is discouragingly poor. Does this mean that we should not be performing these procedures? This question can be best answered by the patients themselves. Regardless of the ultimate result, these patients were satisfied with use of their replanted hand and would have undergone the same procedure rather than primary amputation.
References 1. Bilbo JT, Stern PJ: The first dorsal interosseous muscle: An anatomical study. J Hand Surg 11A:748, 1986. 2. Chen C-W, Quian Y-O, Vu Z-J: Extremity replantation. World J Surg 2:513–524, 1978. 3. Meyer VE: Zum problem der kontraktur der kleinen handmuskeln nach mittelhand-replantation. Handchirurgie 13:103–107, 1981.
17
FIGURE 17-7. The interossei (I) receive their major blood supply via tiny vessels emanating from the deep arch (DEEP).
246
THE MUTILATED HAND
4. Meyer VE, Mailard G, Maass D, Azzoni Z: Successful replantation of a hand amputated through the metacarpus. J Bone Joint Surg 588:474–477, 1976. 5. Nakamura J, Kinoshita Y, Hama H, Ishimori Y. Successful replantation of four fingers with a single common digital artery anastomosis. J Microsurgery 2:53–57, 1980. 6. Russell RC, O’Brien BMcC, Morrison WA, et al: The late functional results of upper limb revascularization and replantation. J Hand Surg 9A:623–633, 1984. 7. Salmon M, Dor J: Les Arteres des Muscles des Membres et du Tronc. Paris, Masson, 1933. 8. Scott FA, Howar JW, Boswick JA: Recovery of function following replantation and revascularization of amputated hand parts. J Trauma 21:204–214, 1981. 9. Scheker LR, Chesher SP, Netscher DT, Julliard KN, O’Neill WL: Functional results of dynamic splinting after transmetacarpal, wrist, and distal forearm replantation. J Hand Surg [Br] 20(5):584–590, 1995. 10. Scheker LR, Hodges A: Brace and rehabilitation after replantation and revascularization. Hand Clin 17(3):473–480, 2001.
11. Spinner M: Kaplan’s Functional and Surgical Anatomy of the Hand. Philadelphia, JB Lippincott, 1984, pp 102–112. 12. Tark KC, Kim YW, Lee YH, Lew JD: Replantation and revascularization of hands: Clinical analysis and functional results of 261 cases. J Hand Surg 14A:17–27, 1989. 13. Tonkin MA, Ames El, Wolff TW, Larsen RD: Transmetacarpal amputations and replantation: The importance of the normal vascular anatomy. J Hand Surg 138:204–209, 1988. 14. Weinzweig N, Sharzer L, Starker I: Replantation and revascularization at the transmetacarpal level: Long-term functional results. J Hand Surg 21A:877–883, 1996. 15. Weinzweig N, Starker I, Sharzer LA, Fleegler EJ: Revisitation of the vascular anatomy of the lumbrical and interosseous muscles. Plast Reconstr 99:785–790, 1997. 16. Wilgis EFS: Local muscle flaps in the hand: Anatomy as related to reconstructive surgery. Bull Hosp Joint Disease 44:552, 1984. 17. Zbrodowski AS, Gajisin J, Grodecki H: The anatomy of the digitopalmar arches. J Bone Joint Surg 638:108, 1981.
18 Secondary Surgery Following Replantation Huan Wang, MD, PhD Tanya Oswald, MD
18
William Lineaweaver, MD, FACS
Since the first successful replantation of an amputated thumb by Komatsu and Tamai in 1965,18 finger replantation has flourished throughout the world. With rapid progress in microsurgical instrumentation and techniques, the rate of successful replantation has steadily improved from less than 50% in early reports46 to greater than 90% in more recent reviews.26,45 Today, however, success is not measured simply by survival of the replanted part. By the 1980s, clinicians realized that a digit that survived following replantation was not necessarily functional. Function is the real measure of success of this procedure. Therefore, emphasis has shifted to postreplantation functional outcome rather than viability, and secondary operations to improve function of the replanted digits and hands have become an important part of patient management. The incidence of reported secondary surgery varies from 2.6% to 91.7% following finger and hand replantations (Table 18-1). Secondary operations are almost always necessary in major limb replantations and can include major flap procedures for coverage; corrective osteotomies; bone grafting; release of joint, muscle, and skin contractures; nerve grafting; tendon or muscle transfer or tenolysis; sequestrectomy; free neurotized muscle transfer; and below-elbow amputation.7,51 In contrast, fingers that are replanted distal to the superficialis flexor tendon insertion rarely require further reconstruction. Patradul26 reported distal digital replantation and revascularization of 237 digits in 192 patients, and only five replanted digits underwent secondary bone grafting for nonunion of the arthrodesis of the distal interphalangeal joint. Secondary operations after digital replantation include skin, tendon, bone, joint, and nerve procedures (Table 18-2). As Table 18-2 shows, the incidence of tendon surgery is the highest. Operations for joint mobility and skeletal reconstruction, such as capsulotomies, arthroplasties, joint fusions, silastic joint replacement, corrective osteotomies, and bone grafting, make up the second largest group of operations. Soft tissue reconstruction and nerve grafting are other common secondary procedures. It is encouraging that reports of secondary amputation are rare. Infection,42,52 disabling paresthesia,25 severe hypersensitivity,33 and persistent cold intolerance44 are factors that contribute to the necessity for secondary amputation. 247
248
THE MUTILATED HAND
TABLE 18-1
Incidence of Secondary Surgery Following Successful Finger and Hand Replantation Number of Patients
Number of Patient with Secondary Procedures
Number of Secondary Procedures
Weiland et al.46 (1977)
32
20
20
1
Morrison et al.24 (1977)
100
14
22
1.57
14%
Tamai39 (1978)
97
29
34
1.17
29.9%
Schlenker et al.33 (1980)
46
12
20
1.67
26.1%
Scott et al.36 (1981)
38
30
53
1.77
78.9%
Pitzler et al.27 (1982)
106
49
104
2.12
46.2%
18
1
1
Author
May et al.22 (1982) 32
Russell et al.
(1984)
Meyer23 (1985) Urbaniak et al.44 (1985)
Number of Secondary Procedures per Patient
Overall Frequency 62.5%
1
5.6%
30
16
43
2.69
53.3%
105
24
57
2.38
22.9%
51
15
26
1.73
29.4%
157
94
221
2.35
59.9%
69
29
Caroli et al. (1991)
18
11
15
1.36
61.1%
Weinzweig et al.47 (1996)
12
11
49
4.5
91.7%
Yildiz et al.52 (1998)
22
4
4
1
18.2%
1
Buncke et al.5 (1988) Goldner et al.10 (1990) 6
26
Patradul et al.
(1998)
Waikakul et al.45 (2000)
TABLE 18-2
1 (33%), 2⫹ (9%)
192
5
5
508
180
460
42%
2.6%
2.56
35.4%
Incidence of Various Types of Postreplantation Surgery
Author
Number of Procedures
Skin
Skeleton
Joint
Tendon
Nerve
Amputation 0
Weiland et al.46 (1977)
20
0
0
0
9
11
Morrison et al.25 (1978)
47
0
0
3
25
16
3
Tamai39 (1978)
34
0
9
4
14
7
0
Schlenker et al.33 (1980)
20
3
2
2
9
3
1
36
Scott et al.
(1981)
Tamai40 (1982) Pitzler et al.27 (1982) May et al.22 (1982) 23
Meyer
51
7
1
13
25
5
0
98
24
18
20
23
13
0
104
27
9
18
30
20
0
1
1
0
0
0
0
0 0
(1985)
57
13
7
6
20
11
Urbaniak et al.44 (1985)
26
0
4
9
9
2
2
Steichen37 (1987)
55
0
0
19
36
0
0
Tark et al.42 (1989)
46
31
2
1
6
0
6
6
Caroli et al. (1991) Lineaweaver19 (1995) Weinzweig et al.47 (1996) Yildiz et al.52 (1998) 45
Waikakul et al. Total
(2000)
15
7
3
1
3
1
0
140
25
7
42
48
15
3
49
2
6
11
28
2
0
4
0
1
0
2
0
1
460
n/a
69
76
275
n/a
0
1227
140
138
225
562
106
16
(11.4%)
(11.2%)
(18.3%)
(45.8%)
(8.6%)
(1.3%)
18
In planning secondary procedures following replantation, the surgeon should bear in mind the importance of applying realistic goals to patients’ needs. Both the patient and the surgeon need to have a clear understanding of the anticipated outcome of secondary surgery. Communication between the surgeon, hand therapist, and patient will provide the patient with details of possible future surgery, postoperative rehabilitation requirements, consequent recovery time and expected results. When a patient requires secondary surgery, he or she should be well informed, realistic, and motivated. Although there is only a remote chance of loss of the replanted finger following secondary operations, this possibility should be discussed frankly with the patient. Successful surgery in a replanted digit requires careful protection of the original neurovascular repairs, which are encased in scar tissue and may be in abnormal positions. Clear, detailed records of the original replantation procedure are necessary for knowledge of the location of arterial, venous, and nerve repairs; defects of the digital nerves; involvement of the tendons; presence of unusual components such as a vein graft that traverses a flexor tendon; and other information that can influence surgical planning. As is evident in Table 18-1, most patients have more than one secondary procedure. Therefore, one important element in surgical planning is to establish the order in which the procedures should be performed. Stable and supple skin coverage is necessary before any further reconstruction can take place. Skeletal stabilization and alignment are the next priorities, and skin and skeletal procedures can sometimes be performed at the same time. Secondary nerve repair or nerve grafting can also be done at the same time as skin and skeletal reconstruction, as long as the dissection for exposure is not too extensive and coverage is secure. Joint reconstruction follows these procedures, since supple skin coverage, skeletal stability, and protective and proprioceptive sensation are required
TABLE 18-3
249
to maximize the chance for a functional success. Finally, tendon reconstruction is performed, based on secure skin coverage, solid skeletal components, sensation, and supple joints. All the planned operations should be discussed with the hand therapist to formulate a dedicated postoperative regimen and to exclude any mutually incompatible postoperative rehabilitation requirements in a multicomponent operation. The timing of secondary surgery is determined primarily by the course of the replant in therapy. Therefore, continuous monitoring by experienced hand therapists and constant communication between the hand therapist, surgeon, and patient are needed to evaluate the recovery process. For the initial secondary procedure, it is best to wait until improvement of joint, nerve, and tendon function levels off. This plateau usually occurs 4 to 6 months after the replantation.39,40 However, bone nonunion, skin defects, or malunion hindering therapy and function should be corrected once these conditions are recognized.48
SURGICAL PROCEDURES The surgical techniques for secondary procedures do not vary greatly from descriptions of standard procedures that are available in current hand surgery texts.11,15 Most of the aspects that are unique to secondary surgery after replantations concern the timing and order of the surgery, as discussed above. Table 18-3 lists the necessary preconditions and postoperative requirements of different categories of secondary surgery. All the variables must be considered to establish reconstructive priorities, and only compatible procedures should be performed simultaneously. In general, the postoperative immobilization that is required for significant skin coverage, bone reconstruction procedures, and nerve repair makes it unwise to perform tenolysis at the same time. Conversely, tenolyses, arthrolyses, and arthroplasties may be performed simultaneously.
Preconditions and Postoperative Requirements for Postreplantation Surgery
Secondary Procedure
Necessary Preconditions
Postoperative Requirements
Skin
Replant viability
Immobilization, edema control
Skeleton
Stable skin coverage
Immobilization, edema control
Nerve
Stable skin and bone structures
Immobilization
Joint
Skin coverage, skeletal stability, protective and proprioceptive sensation
Passive and active mobilization
Tendon
Skin and skeletal stability, protective and proprioceptive sensation, supple joint
Active or/and passive mobilization
18
PATIENT SELECTION, TIMING, AND PREOPERATIVE PLANNING
SECONDARY SURGERY FOLLOWING REPLANTATION
250
THE MUTILATED HAND
Procedures that are frequently performed after finger replantation are outlined below.
Secondary Soft Tissue Reconstruction Skin Grafting for Small Defects Areas of marginal necrosis frequently develop at the incisions of a replanted finger. Most of these areas heal with local wound care. If allowing the wound to heal secondarily might cause joint or webspace contracture, consider skin grafting. Full-thickness skin grafts are preferred because they undergo less contraction than split-thickness grafts. Recommended donor sites are in the groin areas, avoiding any donor wounds in the upper extremities. The skin graft is defatted to the dermal layer and fixed to the contour of the defect by 5-0 or 6-0 chromic sutures. FIGURE 18-1. A Y-V advancement flap. A, A Y incision is made at the narrow webspace. The V flap is placed on the supple aspect. B, After the small triangles are trimmed, the flap is advanced. C, Primary closure reveals the conversion from a Y to a V.
Webspace Contracture Release Replantation of adjacent fingers at the level just distal to the webspace often causes webspace scarring and contracture. Soft tissue contracture of the first webspace is also common after thumb replantation because of contracture of the thumb adductors or tissue loss and scarring. If the contracture is small and both dorsal and volar skin are supple, a Z-plasty is performed to release the contracture by transposing the flaps. Large contractures or contractures with only one plane of supple skin are released with a Y-V advancement flap, using the supple skin for the flap (Fig. 18-1). Small triangles excised at the base of the flap allow primary closure. First webspace contracture can also be treated by Z-plasty or some other soft tissue rearrangement, with the occasional need for a full-thickness skin graft. In severe webspace contracture, however, release of the scar and intrinsic adductors of the thumb usually leaves a larger defect that needs to be
18
SECONDARY SURGERY FOLLOWING REPLANTATION
251
covered by a transposition flap from the index finger (Figs. 18-2 and 18-3), or a microvascular free flap from remote donor sites.
the contracture can be covered by pliable, thin first webspace flap from the foot.43
Flexion Contracture Release Flexion contracture occurs most frequently at the proximal interphalangeal joint. When skin contracture coexists, the replantation scar should be incorporated into a Bruner-type incision. The incision defines the flaps, which are raised, allowing underlying capsulotomy. Y-shaped extensions are then made at the tip of each V incision to straighten the finger and open up limbs to receive the advanced skin flaps. This advancement usually leaves an open area proximal to the flaps that cover the proximal interphalangeal joint. This space can be covered by a fullthickness skin graft (Figs. 18-4 and 18-5). In case of progressive volar scarring, the defect resulting from release of
Secondary Skeletal Reconstruction
18
Revision of Nonunion The incidence of nonunion of a replanted digit depends on the zone and mechanism of injury. Crush injury to Zone II results in a 15% nonunion rate.4 Fixation methods also contribute to the incidence of postreplantation nonunion and malunion, with K-wires serving as a simple, reliable fixation technique.48 Nonunion is recognized immediately after removal of the K-wire at 4 to 8 weeks after replantation. Achieving bony union by surgery can reduce splinting time and thus facilitate therapy, resulting in a better functional outcome.
FIGURE 18-2. A transposition flap from the index finger. A, The dorsal index finger flap is harvested after release of the first webspace. B, The flap is transposed to the open first webspace. C, The defect on the dorsum of the index finger is covered with a skin graft.
252
THE MUTILATED HAND
FIGURE 18-3. A dorsal transposition flap. A, The adducted-flexed thumb is released from both palmar and dorsal approaches. B, A dorsal flap on the index and middle metacarpal is outlined and elevated. C, The flap is rotated to the open first webspace for coverage. D, The dorsal defect is covered with a skin graft.
A dorsal approach, incorporating the replantation scar into an S-shaped incision, is used to expose the nonunion site. The extensor tendon is split longitudinally to expose the bone. All fibrous tissue, bony irregularities, nonviable bone, and tendon intrusions are removed. Healthy, wellmatched bone ends then can be secured with K-wires, miniplates, or interosseous wires (Fig. 18-6). If resection of a nonunion results in unacceptable shortening of the digit, a bone graft is indicated. Dorsal vein repairs might not be spared by this approach. Circulatory embarrassment, however, should not occur if the incision is not extended to the volar aspect. Postoperative edema control is an important requirement.
Corrective Osteotomy Crossing-over or scissoring of replanted digits results from poor primary bony alignment, postoperative
instability and shift, bony absorption, and reinjury (Fig. 18-7). Either angular, rotational, or combination angular-rotational deformities can develop.1 The deformity can be connected when first noticed, or later when functional improvement makes scissoring obvious. Exposure of the deformity is similar to that of nonunion, as described above. Corrective osteotomy is done to correct the angulation or reduce the rotation. After realignment, bony fixation is achieved with K-wires or miniplates. Small plates seem to have a more precise realignment. Bone grafting is rarely indicated. If the original fracture site is too complex to tolerate revision or the soft tissue coverage at that site is unfavorable, a corrective osteotomy at a more proximal level to eliminate the scissoring should be considered. The metacarpal shaft is a good alternative in this circumstance.
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18
FIGURE 18-4. Release of a flexion contracture. A, The replantation scar is incorporated into a Bruner-type incision. Y extensions are made at the tips of each V incision dorsally. B, After the contracture is released and the finger is straightened, the V flaps are advanced into the open arms of the Y incisions. C, The proximal defect is covered with a skin graft.
Secondary Nerve Reconstruction
FIGURE 18-5. The long-term result of a full-thickness skin graft to the ulnar side of the middle finger.
Secondary nerve reconstruction procedures include neurolyses, neurorraphies, or interpositional nerve grafts. These procedures should be considered only after soft tissue healing and skeletal stability have been achieved. The neurovascular bundles of the replanted digits may be in unexpected positions. Dissection of the neurovascular bundles should begin proximal to the level of replantation to identify the digital nerve and artery in a relatively normal soft tissue area. Dissection of the identified structures into the area of scarring can then be done more safely. Poor function of a digital nerve repair should lead to re-exploration if the functional deficit is significant for the patient. If waxy, scarred nerves with gross loss of fascicular configuration or neuroma-in-continuity
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FIGURE 18-6. Revision of a nonunion. A, The replantation scar is incorporated into an S incision to achieve maximal exposure. B, The extensor mechanism is longitudinally incised and split to expose the bony structure. C, The fibrous element and fragmentation are debrided, leaving a defect that is filled with bone graft. D, The phalanx and bone graft are fixed with a miniplate.
(Fig. 18-8) is found intraoperatively, the grossly abnormal nerve segment should be resected and repaired by direct neurorraphy, if applicable, or by nerve grafting. Nerve grafts should be used when a nerve defect exists from the primary injury or is created after secondary resection of the abnormal segments (Fig. 18-9). Grafts can be used to bridge the area of repair from normal proximal nerve to normal distal nerve. Although there are reports of using various conduits to bridge digital nerve defects and of attempts to use vascularized nerve grafts in postreplantation surgery,31 properly executed conventional sural nerve grafting is still the most widely used procedure.
Secondary Joint Operations Capsulotomy Capsulotomies are almost exclusively done for proximal interphalangeal joint contractures. Distal interphalangeal joints generally respond poorly to capsulotomy, and metacarpophalangeal joints rarely have contracture. To avoid circulatory disruption, only one side of a replanted finger is explored at a single setting. Careful analysis of the contracture is therefore necessary to isolate dorsal and volar components of the problem.
18
B
255
C
18
A
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FIGURE 18-7. A, Comminuted fracture site of a replanted middle finger. B, Malunion. C, Shortening of the middle finger. D, Corrective osteotomy with K-wire fixation. E, Stable result. D
E
Dorsal capsulotomy requires wide exposure and mobilization of the extensor mechanism and the dorsal hemisphere of the joint capsule, including the radial and ulnar collateral ligaments. The dorsum of the joint capsule is sharply incised. The extensor hood is completely mobilized, and the extensor tenolysis may be extended proximally to release possible adhesion of the extensor mechanism to the joint, fracture site, intrinsic slip, and skin. Intrinsic release can also be considered if scar excision does not relieve the intrinsic tightness (Figs. 18-10 and 18-11).
Volar capsulotomy is approached via a zigzag volar incision. If the situation is complicated by flexion contracture of the skin, the incision can be modified using Y-V flaps. The likelihood of abnormal neurovascular bundle position must be considered to avoid inadvertent injury. The flexor tendon sheath is opened over the joint. Tenolysis of the profundus tendon is performed if indicated, and the tendon is retracted to expose the superficialis insertion and volar aspect of the joint. If the remnant of the superficialis is the constraint, it should be excised. The volar plate is freed by being incised at
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FIGURE 18-8. Neuroma-in-continuity of a digital nerve.
FIGURE 18-9. Gap in a digital nerve.
FIGURE 18-10. Dorsal capsulotomy. A, The replantation scar is incorporated into a longitudinal S incision. B, The extensor mechanism is exposed, and the whole structure, including the extensor hood, is released C, The extensor mechanism is retracted. The dorsum of the joint capsule is sharply incised.
18
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B
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A
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FIGURE 18-11. A, Index finger without flexion. B, Metacarpophalangeal joint motion after a dorsal capsulotomy. C, Full composite flexion. C
the level of the proximal phalangeal condyle and as lateral as necessary to allow full extension of the joint (Fig. 18-12). A dorsal splint should be applied postoperatively to prevent hyperextension.
Capsuloplasty Early motion after replantation can cause unfavorable deformities of the finger such as mallet, swan necks, and intrinsic minus deformities39 because of elongation of the injured tendon. Capsulorrhaphy is indicated to correct significant deformity. One common deformity is hyperextension of the proximal interphalangeal joint in patients who have replantation at the level of proximal phalanx and have gained active extension and good passive range of motion of the proximal interphalangeal joint. This deformity may be caused by flexor tendon adhesion, unopposed extensor tendon and intrinsic muscle action, therapy, and original injury. Volar plate capsuloplasty can be done at the time of flexor tenolysis. The volar plate is found to be stretched, allowing hyperextension of the joint. A Y incision is made on the volar plate and converted to a V by advancement of the flap.
The volar plate is thus shortened, and the hyperextension is corrected in conjunction with the functioning flexor tendon and postoperative splinting (Fig. 18-13).
Arthroplasty Fingers with trauma to the joints at the time of amputation generally undergo arthrodesis during replantation (Fig. 18-14). Replacement of these arthrodeses by silicone joint prostheses at the metacarpophalangeal or proximal interphalangeal joints in these digits can produce functional results.3,37 The standard Swanson implant technique can be used in these cases.38 The surgeon must take special care to obtain good seating of the implant into the bone and secure centralization of the extensor mechanism, since there is no dorsal capsule to close over the implant. Stability might be a problem in such cases, since many replants lack stabilizing structures of the joint following trauma. A two-piece unconstrained surface replacement prosthesis that is inserted with minimal bony excision and optimal preservation of the collateral ligaments might offer a more stable joint.20
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FIGURE 18-12. Volar capsulotomy. A, The replantation scar is incorporated into a zigzag incision. B, The triangular flaps are elevated to expose the flexor tendon. C, The flexor digitorum profundus tendon is released, if indicated, and retracted to expose the volar joint capsule, which is incised with a sharp scalpel.
FIGURE 18-13. Capsuloplasty. A, The flexor tendon is retracted to expose the stretched volar plate. A Y incision is made on the volar plate. B, The Y flap is advanced to a V, thus tightening the volar plate.
18
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B
Secondary Tendon Operations Stiffness of the replanted digits is common because of the multiple injured structures that are involved at the same level, postreplantation immobilization, and tissue and joint swelling. While hand therapy may overcome the obstacles in Zone I replants, many replants proximal to the sublimis insertion might need secondary tenolysis with or without joint capsule release. Tendon procedures can be performed only when skin, skeletal, nerve, and joint functions are restored.
Tenolysis Extensor tenolysis (Fig. 18-15) is scheduled when the digit is limited in its active as well as passive range of motion. The tendon is approached dorsally by incorporating the replantation scar into the S incision. If range of motion is still incomplete after extensor release, dorsal capsulotomy is also performed. Approximately 6 weeks later, when rehabilitation has reached a plateau and active range of motion is significantly less than passive range of motion, flexor tenolysis is performed with incorporation of the traumatic scar into Bruner incision. The flexor tendon is released, preserving whenever possible the annular pulleys or their scarred remnant. Tendon Grafting If the tendon is ruptured, bridged with scar tissue, or thinned out after tenolysis, staged flexor tendon reconstruction should be performed. After tendon debridement, pulleys are reconstructed as indicated, and a silicone tendon rod is inserted to induce a pseudosheath for later tendon grafting. The procedures for the twostage flexor tendon reconstruction are generally the same
as those for nonreplanted digits, as is described elsewhere.12,17,34 As long as tension-free skin closure can be achieved, a tendon rod of the largest size should be chosen, generally 2 to 4 mm in diameter. The rod is placed beneath the distal end of the tendon distal to the proximal interphalangeal joint and carefully secured with nonabsorbable mattress sutures with the suture knots placed beneath the rod (Fig. 18-16). The proximal end of the rod is tunneled and left free in the palm. Secondstage tendon grafting is carried out at 10 to 12 weeks.
Pulley Reconstruction Successful reconstruction of the flexor tendon system not only depends on the tendon itself, but also involves the important pulley structures. The A2 pulley is essential to avoid bowstringing of the tendon and loss of flexor function. When the A2 pulley is absent, it should be reconstructed. Pulley reconstruction techniques vary.49,50 Figure 18-17 illustrates a technique using the insertion of one slip of the superficialis tendon. One slip of the superficialis insertions is mobilized and brought across the profundus tendon or the tendon rod. It is then sewn to the other border of the superficialis tendon, creating a proximal phalangeal pulley. If the superficialis tendon has been resected during replantation, yet there is a long enough insertion left, it can be used to make a pulley. The tail is left attached at the insertion, and the free end is swung over the profundus tendon or the tendon rod to be sutured to either periosteum or the rim of the pulley remnant of the opposite side, creating a pulley at the A3 area (Fig. 18-18). This procedure can be done within the incision for flexor tenolysis, tendon rod insertion, or volar capsulotomy and thus reduces the chance of compromising blood circulation.
18
FIGURE 18-14. A, Middle finger with secondary silastic arthroplasty after replantation at the proximal interphalangeal joint. B, Flexion with arthroplasty.
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A
B
FIGURE 18-15. A, Devascularization of four fingers. B, Completion of the emergency procedure. C, Range of motion after extensor tenolysis. C
Surgical Procedures for Cold Intolerance Cold intolerance, which is a frequent cause of patient dissatisfaction, is a problem in almost all patients after replantation.10,24,39,40,44,46 Although most believe that the cold symptoms slowly improve with time (after approximately 2 years),1,24,46 some studies28,29 have shown that cold intolerance persists for many years. Disturbance of autonomic control of vasoregulation8 or reduced arterial perfusion might account for cold hypersensitivity. Schlenker et al.33 found a relationship between cold intolerance and sensibility and pulse pressure. Microsurgical attempts have been made to relieve both diminished circulation and autonomic dysfunction. Hussl et al.13 reported vascular pedicle anastomosis to four replanted fingers with cold intolerance and atrophic changes. Twelve centimeters of the thoraco-
dorsal vascular pedicle anastomosed was harvested and implanted to the affected fingers. The thoracodorsal artery was anastomosed proximally to the radial artery in the radial fossa in end-to-side fashion, whereas the accompanying veins were anastomosed in end-to-end fashion. The vascular pedicle was tunneled to the fingertip, and its end was covered with a split-thickness skin graft. Patency of the transferred vascular bundle was confirmed by Doppler ultrasonography after 18 months of follow-up. None of the patients had further complaints of cold intolerance, and the trophic disturbances improved. Schwabegger et al.35 reported transfer of a free serratus fascia flap, pedicled on the thoracodorsal vessels or the serratus branch, which resulted in diminishing of cold intolerance and of the trophic disorders of four replanted fingers.
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Amputation Although rarely reported, reamputation can sometimes be a logical choice in cases of persistent infection, recalcitrant scar tissue contractures, joint destruction, and poor sensation. Late amputations are performed just proximal to the most proximal stiff joint. The stump can be adapted to digital prostheses, which can be of great psychological and social benefit to the patient. If the index finger is to be amputated at its proximal interphalangeal joint or at a more proximal level, the
remaining stump can be awkward and can hinder pinch between the thumb and middle finger. If the middle or ring finger is amputated at the very proximal level, a gap in the transverse palmar arch is created through which small objects can drop. In some patients, the remaining fingers deviate toward the midline on flexion because of the absence of the middle or ring finger. If these problems are significant enough to the patient, a ray resection can be considered. This decision requires careful consideration, however, because despite the
FIGURE 18-17. A2 pulley reconstruction. A, The flexor digitorum profundus tendon is retracted to expose the flexor digitorum superficialis tendon. B, One slip of the flexor digitorum superficialis insertion is mobilized and swung across the flexor digitorum profundus tendon and is sewn to the opposite border to create a pulley structure at the proximal phalanx.
18
FIGURE 18-16. Tendon rod interposition for two-stage flexor tendon reconstruction. A, The distal end of the tendon rod is attached to the flexor tendon distal to the proximal interphalangeal joint, while the proximal end of the rod is left free in the palm. B, The rod is tucked beneath the tendon, and the suture knots are beneath the rod.
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FIGURE 18-18. A3 pulley reconstruction. The tail of the flexor digitorum superficialis tendon is mobilized, leaving its insertion still attached. The free end is sutured to either the opposite periosteum or the rim of the remnant A2 pulley to form a pulley structure over the A3 level.
improved appearance, a narrowed palm reduces twist grip strength.21
POSTOPERATIVE CARE AND REHABILITATION Principles in hand surgery apply to the postoperative care in each category of the secondary procedures. All skeletal and soft tissue reconstructions are splinted before the patient is discharged, and appropriate mobilization for joint and tendon procedures is started. Hand therapists play a critical role in the care of patients following revisionary surgery. The patient’s postoperative demands should be coordinated with occupational and vocational rehabilitation requirements. A comprehensive postoperative plan is developed immediately after surgery. The patient is closely followed in hand therapy for monitoring of wound healing, supervising of therapy programs, and evaluation of functional progress. The recovery process is documented and updated. This provides the basis for identifying the need and timing of future operations.
RESULTS There are only a few reports of studies describing the results of postreplantation surgery in the literature. Regeneration of the primarily repaired digital nerves in replantation is generally satisfactory, attaining at least protective sensation or two-point discrimination of about 10 mm in several reports,9,14,41,42,44 and is believed to be nearly as good as for isolated digital nerve repair. The results that have been achieved with secondary nerve repair have been disappointing in Weiland’s series (11 patients who did not have primary neurorrhaphy, among whom two had nerve grafts).46 Berger et al.2 evaluated 27 cases of postreplantation nerve grafting using the Highet and Millesi schemes: 11.1% were graded as S4, 14.8% as
S3⫹, 40.7% as S3, 18.5% as S2, 3.7% as S1, and 11.1% as S0 (3.7% had two-point discrimination ⬍6 mm, 7.4% had two-point discrimination 6 to 11 mm, 14.8% had two-point discrimination ⬎12 mm; protective sensibility: 59.3%, perception of pain and touch: 3.7%, insensibility: 11.1%). Jupiter et al.16 evaluated the results of flexor tendon tenolysis in 41 finger and thumb replants and demonstrated the total active motion for the 37 fingers increased from a mean of 72⬚ before the procedure to 130⬚ after tenolysis. The potential active motion increased from a mean of 43% to 70% after tenolysis. However, consistent improvement in the four thumbs was not documented. Steichen37 reported improvement of total active motion from 102⬚ (38% of the normal) before tenolysis to 128⬚ (52% of the normal) after tenolysis in 13 replanted digits. Urbaniak et al.,44 however, mentioned in his report of 15 patients who had secondary procedures following finger replantation that despite the additional procedures (release of the proximal interphalangeal joint, tendon grafting, and tenolysis), improvement in active range of motion was disappointing. Buncke5 reported silastic arthroplasty in 75 patients for proximal interphalangeal joint replacement during a secondary operation. An average of 44⬚ of active motion was achieved, while primary implantation of the silastic prosthesis in two patients yielded only 10⬚ of proximal interphalangeal joint active motion. Silastic replacement arthroplasty of the proximal interphalangeal joint in five replanted digits of Steichen’s37 series resulted in 43⬚ of proximal interphalangeal and distal interphalangeal joint final total active motion, which was 25% of the normal proximal interphalangeal and distal interphalangeal joint total active motion. Whitney et al.48 reported successful secondary skeletal stabilization following nonunion of replanted fingers. Postreplantation reconstruction has a growing patient population. Careful functional evaluation of these secondary procedures is scarcely reported. The detailed work of clearly defining the results of such surgery remains to be done.
CONCLUSION
30
According to Zhong-Wei Chen, “Survival without restoration of function is not success.” Secondary procedures should be considered a straightforward extension of the replantation procedure to obtain a maximally functional result.
Acknowledgment Illustrations for this chapter were drawn by Dr. Tanya Oswald.
References 1. Backman C, Nystrom A, Bjerle P: Arterial spasticity and cold intolerance in relation to time after digital replantation. J Hand Surg 18B:551–555, 1993. 2. Berger A, Brenner P, Flory P, et al: Progress in limb and digital replantation: Part B. World J Surg 14:807–818, 1990. 3. Buncke GM, Buncke HJ, Kind GM, Buntic R: Replantation. In Russell RC (ed): Plastic Surgery: Indications, Operations, and Outcomes, vol 4: Hand Surgery. St. Louis, Mosby, 2000, p 2131. 4. Buncke HJ, Buncke GM, Kind GM, Buntic RF: Replantation, revascularization and toe-to-hand transplantation. In Goldwyn RM, Cohen MN (eds): The Unfavorable Result in Plastic Surgery: Avoidance and Treatment, 3rd ed. Philadelphia, Lippincott Williams & Wilkins, 2001, p 785. 5. Buncke HJ, Whitney TM: Secondary reconstruction after replantation. In Buncke HJ (ed): Microsurgery: Transplantation-Replantation: An Atlas-Text. Philadelphia, Lea and Febiger, 1991, p 651. 6. Caroli A, Adani R, Castagnetti C, et al: Replantation and revascularization of large segments of the hand and forearm. Ital J Orthop Trauma 17(4):433–447, 1991. 7. Daoutis N, Gerostathopoulos N, Bouchlis G, Efstaphopoulos D, Misitzis D, Anagnostou S, Gianakopoulos P: Clinical analysis and evaluation of the function of replanted and revascularized parts of the upper limb. Microsurgery 13:178–181, 1992. 8. Freelander E: The relationship between cold intolerance and cutaneous blood flow in digital replantation patients. J Hand Surg 11B:15–19, 1986. 9. Glickman LT, Mackinnon SE: Sensory recovery following digital replantation. Microsurgery 11:236–242, 1990. 10. Goldner RD, Howson MP, Nunley JA, et al: One hundred eleven thumb amputations: Replantation vs revision. Microsurgery 11:243–250, 1990. 11. Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, pp 147–191, 1851–2021. 12. Hunter JH, Aulicino PL: Salvage of scarred tendon systems using passive and active Hunter tendon implants. In Jupiter JB (ed): Flynn’s Hand Surgery, 4th ed. Baltimore, Williams & Wilkins, 1991, p 300. 13. Hussl H, Jungwirth W, Hasenohrl K: Microsurgery for cold intolerance after finger replantation (letter). Lancet Sep 16:690, 1989.
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14. Ikeda K, Yamauchi S, Hashimoto F, et al: Digital replantation in children: A long-term follow-up study. Microsurgery 1:261–264, 1990. 15. Jupiter JB: Flynn’s Hand Surgery, 4th ed. Baltimore, Williams & Wilkins, 1991, pp 211–450. 16. Jupiter JB, Gray MP, Bour CJ: Results of flexor tendon tenolysis after replantation in the hand. J Hand Surg 14A:35–44, 1989. 17. Kleinert HE, Smith Jr DJ, Pulvertaft RG: Flexor tendon graft in the hand. In Jupiter JB (ed): Flynn’s Hand Surgery, 4th ed. Baltimore, Williams & Wilkins, 1991, p 283. 18. Komatsu S, Tamai S: Successful replantation of a completely cut-off thumb: Case report. Plast Reconstr Surg 42:374–377, 1968. 19. Lineaweaver WC: Secondary surgery following digit replantation. In Grotting JC (ed): Reoperative, Aesthetic and Reconstructive Plastic Surgery. St. Louis, Quality Medical Publishing, 1995, p 1479. 20. Linscheid RL, Murray PM, Vidal MA, Beckenbaugh RD: Development of a surface replacement arthroplasty for proximal interphalangeal joints. J Hand Surg 22A:286–298, 1997. 21. Louis DS, Jebson PJ, Graham TJ: Amputations. In Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, pp 58–68. 22. May JW, Toth BA, Gardner M: Digital replantation distal to the proximal interphalangeal joint. J Hand Surg 7:161–166, 1982. 23. Meyer V: Upper Extremity Replantation: Basic Principals, Surgical Technique and Strategy. New York, Churchill Livingstone, 1985, p 96. 24. Morrison WA, O’Brien BM, Macleod AM: Evaluation of digital replantation: A review of 100 cases. Orthop Clin North Am 8:295–308, 1977. 25. Morrison WA, O’Brien BM, MacLeod AM: Digital replantation and revascularization: A long term review of one hundred cases. Hand 10(2):125–134, 1978. 26. Patradul A, Ngarmukos C, Parkpian V: Distal digital replantations and revascularizations: 237 digits in 192 patients. J Hand Surg 23B(5):578–582, 1998. 27. Pitzler D, Buck-Gramcko D: Secondary operations after replantation. Ann Chir Gynaecol 71:19–27, 1982. 28. Povlsen B, Nylander G, Nylanda E: Cold-induced vasospasm after digital replantation does not improve with time: A 12-year prospective study. J Hand Surg 20B:237–239, 1995. 29. Povlsen B, Nylander G, Nylanda E: Natural history of digital replantation: A 12-year prospective study. Microsurgery 16:138–140, 1995. 30. Replantation surgery in China: Report of the American replantation mission to China. Plast Reconstr Surg 52: 476–489, 1973. 31. Rose EH, Kowalski TA, Norris MS: The reversal venous arterialized nerve graft in digital nerve reconstruction across scarred beds. Plast Reconstr Surg 83:593–604, 1989. 32. Russell RC, O’Brien BM, Morrison WA, et al: The late functional results of upper limb revascularization and replantation. J Hand Surg 9A:623–633, 1984.
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33. Schlenker JD, Kleinert HE, Tsai TM: Methods and results of replantation following traumatic amputation of the thumb in 64 patients. J Hand Surg 5:63–70, 1980. 34. Schneider LH: Flexor tendons: Late reconstruction. In Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, p 1898. 35. Schwabegger AH, Hussl H, Rainer C, Anderl H, Ninkovic M: Clinical experience and indications of the free serratus fascia flap: A report of 21 cases. Plast Reconstr Surg 102(6):1939–1946, 1998. 36. Scott FA, Howar JW, Boswick JA: Recovery of function following replantation and revascularization of amputated hand parts. J Trauma 21:204–214, 1981. 37. Steichen JB: Management of flexor tendon injury associated with digital replantation or revascularization. In Hunter JM, Schneider LH, Mackin E (eds): Tendon Surgery of the Hand. St. Louis, Mosby, 1987, p 156. 38. Swanson AB, Swanson GG: Flexible implant resection arthroplasty in the upper extremity. In Jupiter JB (ed): Flynn’s Hand Surgery, 4th ed. Baltimore, Williams & Wilkins, 1991, p 342. 39. Tamai S: Digital replantation: Analysis of 163 replantations in an 11-year period. Clin Plast Surg 5:195–209, 1978. 40. Tamai S: Twenty years’ experience of limb replantation: Review of 293 upper extremity replants. J Hand Surg 7:549–556, 1982. 41. Taras JS, Nunley JA, Urbaniak JR, et al: Replantation in children. Microsurg 12:216–220, 1991. 42. Tark KC, Kim YW, Lee YH, Lew JD: Replantation and revascularization of hands: Clinical analysis and functional results of 261 cases. J Hand Surg 14A:17–27, 1989.
43. Tseng O, Tsai YC, Wei FC, Staffenberg DA: Replantation of ring avulsion of index, long, and ring fingers. Ann Plast Surg 36:625–628, 1996. 44. Urbaniak JR, Roth JH, Nunley JA, et al: The results of replantation after amputation of a single finger. J Bone Joint Surg 67A:611–619, 1985. 45. Waikakul S, Sakkarnkosol S, Vanadurongwan V, Un-nanuntana A: Results of 1018 digital replantations in 552 patients. Injury 31(1):33–40, 2000. 46. Weiland AJ, Villarreal-Rios A, Kleinert HE, Kutz J, Atasoy E, Lister G: Replantation of digits and hands: Analysis of surgical techniques and functional results in 71 patients with 86 replantations. J Hand Surg 2(1):1–12, 1977. 47. Weinzweig N, Sharzer LA, Starker I, Park F: Replantation and revascularization at the transmetacarpal level: Long–term functional results. J Hand Surg 21A:877–883, 1996. 48. Whitney TM, Lineaweaver WC, Buncke HJ, Nugent K: Clinical results of bony fixation methods in digital replantation. J Hand Surg 15A:328–334, 1990. 49. Widstrom CJ, Johnson G, Doyle JR, et al: A mechanical study of six digital pulley reconstruction techniques. Part I: Mechanical effectiveness. J Hand Surg 14A:821–825, 1989. 50. Widstrom CJ, Johnson G, Doyle JR, et al: A mechanical study of six digital pulley reconstruction techniques. Part II: Strength of individual reconstruction. J Hand Surg 14A:826–829, 1989. 51. Wood MB, Cooney WP III: Above-elbow limb replantation: Functional results. J Hand Surg 11A(5):682–687, 1986. 52. Yildiz M, Sener M, Baki C: Replantation in children. Microsurgery 18:410–413, 1998.
19 The Phalangeal Hand Fu-Chan Wei, MD, FACS Vivek Jain, MCh Ortho Chih-Hung Lin, MD
19
Hand injuries may involve amputation of multiple digits at various levels. In the “phalangeal hand,” multiple fingers are amputated at, or distal to, the middle of the proximal phalanx, with or without involvement of the thumb at, or distal to, the interphalangeal joint. Since the injury is distal to the critical level46 of the middle of the proximal phalanx of the finger or the thumb interphalangeal joint, some basic functional capacity of the hand is still preserved. However, there are functional, aesthetic, and psychological deficits that must be addressed. The lost parts of the digit may include specialized tissues with specialized functional attributes such as the nail and sensate glabrous pulp, the proximal and distal interphalangeal joints and attachments of the flexors and extensors in the fingers, and the interphalangeal joint and flexor and extensor attachments in the thumb. The glabrous skin consists of stratified squamous epithelium that is resistant to wear and tear and has grooves and ridges attached to the distal phalanx by numerous septae, which provide a nonslip surface for grasping. The arrangement of the fatty tissue between these septae allows the pulp to conform to the shape of objects in pinch and grasp.15 The nail is an exoskeleton that stabilizes the pulp and facilitates tactile sensibility of the pulp. It is valuable in tip pinch55,56 and also has significant aesthetic value, especially for women and in some cultures.47 The pulp is also richly supplied with sensory nerve endings, making it a principal organ for touch and prehension. The goal of phalangeal hand reconstruction is to replace all specialized tissues that have been lost. Thus, transfer of various “like” tissues from the foot using microsurgical techniques has become the preferred reconstructive option. Toe-to-thumb transfer has achieved widespread acceptance, but there is still controversy about toe-to-finger transfer probably because of less important finger function compared to the thumb. However, it must be empasized that the fingers should also have adequate length, mobility, sensibility, and power to achieve optimal hand function. The traditional reconstructive techniques for reconstruction of phalangeal hands involved rearrangement and transfer of bone, joint, and soft tissues. These techniques1,4,6,14,22–25,32,35,38,39 even now may be indicated in some selected cases, but overall functional and cosmetic results are disappointing. Digital prostheses5,37 never became popular because of lack of movement and sensibility. With the advent of single-stage toe-to-hand transfer,2,8 reconstruction of the thumb and fingers has attained new heights. The last decades of the 20th century witnessed an accelerated pace of development of various digital reconstruction techniques, including multiple toe,30,44 combined second and third toe,49 total great toe,31,41 and its variants such as trimmed great toe,43 great-toe wraparound,29 and modified great-toe wraparound flaps.10,19 Distal digital reconstruction also became possible with 267
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the development of vascularized nail graft,28 toe pulp,53 lesser-toe wraparound,42 and partial-distal-toe transfer10 techniques. Modern jobs and hobbies, such as working on a computer keyboard, playing a musical instrument, and bowling, often demand the presence of all digits with proper length, movements, and sensation.
GENERAL CONSIDERATIONS OF PHALANGEAL HAND RECONSTRUCTION When digits are amputated and replantation is not possible or fails, microsurgical transfer of the foot tissues should be considered. The level of amputation, number of digits involved, patient’s occupational demands, and hand dominance should be weighed against donor site considerations.45 The patient’s general health, associated injuries, and level of activities also must be evaluated. Age usually is not a contraindication, though functional and sensory recovery might be slightly inferior in elderly patients.9 When multiple digits are amputated, it is advisable to reconstruct at least two adjacent digits and the thumb for tripod pinch. In patients with a job requiring fine dexterity, radial digit reconstruction is preferred; however, in manual workers, ulnar digit reconstruction is a better choice. Traditionally, toe transfer is preferred as a secondary procedure after definitive coverage of the wounds. However, it can also be performed as a primary procedure in motivated patients with a clean wound. It has been shown that survival and complication rates are similar in primary and secondary toe transfers.54 The advantages of primary reconstruction are reduced hospital stay, shorter recovery time, and earlier return to work.
INITIAL CARE OF DIGITAL INJURIES AND PREPARATION FOR TOE TRANSFER Replantation remains the best option for traumatic amputations. If replantation is not successful or not possible owing to severe crush, avulsion, and multiple-level injuries, further reconstruction should be planned at the time of initial management. All viable tissues, including bone, joint, tendon, nerves, and vessels in the stump, should be properly preserved.40 Shortening of the skeleton to assist in primary closure should be avoided, since as little as 5 mm of bone length is enough for skeletal fixation using interosseous wiring during microsurgical toe transfer.51 The extensor
tendon and its insertion should be maintained, and the flexor tendons should be conservatively debrided. Preservation of nerve length allows faster sensory recovery in toe transfer. Lengths of the artery and vein should be preserved, if possible, to obviate the need for proximal foot dissection or vein grafting during toe transfers. Soft tissue coverage deserves special consideration. Local flaps should not be employed. Even a redundant distant pedicle flap may be useful for tailoring the soft tissue at the junction of the stump and toe transfer.
RELEVANT SURGICAL ANATOMY The foot and hand share many anatomic features. Therefore, counterparts of the hand in the foot automatically become donor sites of “like tissue” for digital reconstructions. However, some differences should be appreciated to achieve the optimal reconstructive result. The lesser toes are shorter than the digits and have a square shape at the distal ends. The joints have limited flexion and a tendency to claw. The great toe is approximately one-third larger than the thumb when involving all of the components, including bones, joint, nail, pulp, and the subcutaneous tissue. The skin on the dorsum of the foot is thin and mobile. The plantar skin is thick and contains many sweat glands and more fat in the subcutaneous tissue. The sural nerve and the superficial and deep peroneal nerves innervate the dorsum of the foot. Sensation on the plantar surface of the foot is supplied by branches of the tibial, medial, and plantar nerves. The anterior tibial artery continues as the dorsalis pedis artery onto the dorsum of the foot and runs lateral to the extensor hallucis longus tendon toward the first webspace. Proximal to the base of the first and second metatarsals, it gives off the arcuate artery, which provides the second, third, and fourth dorsal metatarsal arteries. Distally, the dorsalis pedis artery bifurcates just beyond the bases of the first and second metatarsal into the deep plantar artery and the first dorsal metatarsal artery (FDMA). The deep plantar artery (also known as the descending, perforating, or communicating branch) courses downward between the first two metatarsals to contribute to the plantar arch. The anatomic variations in the arterial pattern should be kept in mind in harvesting the toe.11,12,20,21,25 The FDMA always passes dorsal to the deep transverse metatarsal ligament. At this point, it divides into medial and lateral branches, named as digital arteries to the second and great toes, respectively, and a communicating branch to the first plantar metatarsal artery (FPMA). In approximately 70% of patients, the FDMA is larger than the FPMA (the dorsal dominant system); in 20%, the FPMA is larger than the FDMA (the plantar dominant system); and in the
19
TECHNIQUES FOR VARIOUS TISSUE TRANSFERS IN PHALANGEAL HAND RECONSTRUCTION Neurosensory free glabrous skin flaps from the pulp or the first webspace can be used for digital pulp reconstruction. The nail can be transferred together with the distal phalanx as a vascularized nail graft. The distal phalanx and nail, with variable amounts of proximal skin or even the whole skin from the great or lesser toes, can be transferred to wrap a denuded digital skeleton. The distal part of any lesser toe, with the proximal and distal interphalangeal joints and the flexor and extensor tendons, can be used for more proximal amputations between the middle of the middle phalanx and the base of the distal phalanx.30 For finger amputations at the middle of proximal phalanx, all of the lesser toes can be transferred.
Glabrous Skin Flap (Pulp and First Webspace) Pulp or first webspace neurosensory free flaps from the great toe or second toe are indicated for large pulp defects that cannot be covered by available local flaps. They are also useful for smaller defects of the fingers and the thumb in patients who require sensate glabrous skin in the digital pulp for certain occupations or hobbies, as well as for replacement of skin grafts or local flaps previously used for pulp reconstruction that resulted in an unstable or painful scar.12,47,53 The first webspace flap has greater dimensions and can be used to reconstruct palm, webspace, or multiple contiguous digital pulp defects.26,27,36,52
Flap Design and Elevation The great toe is selected more often as a donor site for pulp and hemipulp flaps because it has greater dimensions and better sensation than the second toe (Fig. 19-1).3 There is also less donor site morbidity, as direct closure of the wound is more likely. The flap is usually designed on the lateral side of the pulp in the great toe and is extended proximally depending on dimensions of the defect in the recipient digit. The skin incisions are outlined for flap elevation and pedicle dissection. All superficial veins in the lateral and dorsal surface of the great toe in continuity with one sizable vein are included and dissected. The dominant
269
artery to the great toe is identified in the first webspace and dissected in retrograde fashion. All small arterial branches are meticulously ligated or cauterized. Both the deep peroneal nerve to the lateral aspect of the great toe and the proper digital nerve are included. The neurovascular structures are skeletonized to facilitate passage through the subcutaneous tunnel during flap insetting. The first webspace flap design and elevation are performed in similar fashion.
Vascularized Nail Transfer Microvascular nail transfer ensures adequate vascularity to the nail bed,17,28,34 adequate function, and superior aesthetic appearance33,55 compared to nonvascularized nail grafts. Its indications are fingertip injuries involving the nail bed and nail reconstruction after tumor excision. It can also be used for replacement of painful or unaesthetic nails in posttraumatic hook nail deformity. In most of these cases, the eponychial fold, pulp, and skeleton may also be injured or lost by trauma. Technically, it is easier to transfer the entire distal second (Fig. 19-2) or third toe, distal to the distal interphalangeal joint, instead of using nail segments with small flaps, as the venous outflow might be compromised.18 When a larger amount of soft tissue is included with the transferred toenail, variable amounts of normal tissue might need to be removed from the recipient finger for proper insetting.10
Flap Design and Elevation Although the great toenail has a better match for thumbnail reconstruction, consideration of the secondary donor foot deformity precludes its frequent use. The second toenail is smaller than the fingernails and thumbnails but has been the donor site of choice because of less donor site morbidity (Fig. 19-2). The dorsal skin flap with the toenail should include small veins on the dorsal surface of the toe. Usually, the dorsal skin flap extends from the eponychial fold up to at least the interphalangeal joint level. The entire width of the nail is harvested, including both lateral eponychial folds. The size of the pulp tissue to be harvested is determined according to the recipient defect. However, to incorporate the proper digital artery, the pulp on the medial side of the second toe should be included in the flap. A second-toe wraparound flap is a better option when the nail defect is associated with a greater than two-thirds circumference defect of the digit. The dorsal digital nerve is included to restore nail sensation. The dissection of the artery and veins is similar to that of the pulp or first webspace flap harvest. The remnant of the second toe after toenail harvest is preferably removed through metatarsophalangeal disarticulation.
19
remaining 10%, both arteries can be of similar size.48 The dorsal digital veins unite in each toe web to form common dorsal digital veins, which join to form a dorsal venous arch on the dorsum of the foot.
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THE MUTILATED HAND
B
A
D
C
FIGURE 19-1. A traumatic left index pulp defect was reconstructed with a glabrous skin flap from the left great toe. A, The soft tissue defect involves the middle and distal phalanges of the left index finger. B, A glabrous skin flap is harvested from the lateral aspect of the great toe. C, Follow-up at 6 months demonstrates good functional and aesthetic results. D, The donor site appearance after a split-thickness skin graft from the instep of the left foot.
Second-Toe Wraparound Flap The second-toe wraparound flap can be used to reconstruct both the thumb and the fingers. Though the toenail is smaller than the thumbnail, it can also be used for thumb reconstruction in patients who do not want to use the great toe. A wraparound flap can be elevated
from other lesser toes as well.42 The second-toe wraparound flap is indicated for reconstruction of a circumferential or dorsal hemicircumferential loss of skin and nail distal to the proximal part of middle phalanx, with intact skeleton, tendons, and proximal interphalangeal joint.42,47,48 It can be harvested with or without tendons,
19
271
B
19
A
THE PHALANGEAL HAND
FIGURE 19-2. The lost index nailbed was reconstructed by using a vascularized nail from the left second toe. A, Preoperative appearance. B, Immediate postoperative result. C, Appearance after 2 years. C
depending on recipient site requirements. The distal phalanx is always included to prevent swiveling, instability, and bone resorption of the reconstructed finger (Fig. 19-3).
Second-Toe Transfer Total or partial second-toe transfer is indicated for reconstruction of digits amputated at various levels.
Flap Design and Elevation The length of the second toe is decided according to the finger amputation level and is confirmed with an X-ray film. Two microsurgical teams working simultaneously reduce the surgical time and help to assess the lengths of various structures to be harvested. The dorsal and plantar skin flaps are designed in a V shape to ensure primary wound closure without tension. The vertex of the V-shaped skin incision is marked 5 to 10 mm proximal to
272
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B
A
FIGURE 19-3. Right index, middle, ring, and little finger amputations. The index and middle fingers were reconstructed using two second-toe wraparound flaps. A, Right hand appearance before second-toe wraparound flap reconstructions. B, Harvested two second-toe wraparound flaps. C, D, Reconstructed index and middle fingers at 2-year follow-up. C
D
the osteotomy site in the dorsal and plantar aspects of the toe, while the two divergent points in the V-flap are at the midpoint of the first and second webspaces. The dissection of arteries, veins, and nerves is similar to that for pulp, first webspace, vascularized nail flap, and second-toe wraparound flap. The fibrofatty tissue between the plantar skin and neurovascular bundles can be discarded to decrease the anteroposterior bulk of the reconstructed digit. On the plantar surface, the incision should avoid the weight-bearing surface. The plantar
dissection is carried proximally to the desired lengths of nerves and flexor tendon. Once all anatomic components have been isolated and the required length has been determined, the nerves are divided and tagged with 6-0 nylon. The flexor tendons are pulled out and cut. The proximal phalanx is osteotomized, or the metatarsophalangeal joint is disarticulated. Before being transferred, the artery and vein in the pedicle are divided after reperfusion for at least 30 minutes.
19
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Third-Toe Transfer Third-toe transfers are indicated when the second toe is not available or when the great toe from the same foot has already been harvested for thumb reconstruction. In the latter circumstance, the second toe is spared for gait. The third toe is also used when multiple toe transfers are needed for reconstruction or
19
The donor site in the foot should be closed primarily without tension. It is not necessary to repair the intermetatarsal ligament, and no drains are necessary. To facilitate primary closure, metatarsophalangeal joint disarticulation or proximal metatarsal amputation can be performed. Skin graft at the donor site should be avoided to prevent foot morbidity and deformity (Fig. 19-4).
THE PHALANGEAL HAND
A
B
C
E
D
FIGURE 19-4. Right index and ring fingers were amputated at the proximal phalangeal joint level and reconstructed with two second toes. A, B, Preoperative appearance; note the selected recipient arteries (red) and veins (blue). C, Harvested two second toes. D, E, Appearance and function at 1-year follow-up.
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A
B
C
D
FIGURE 19-5. Right index, middle, and ring fingers were amputated at the level of the middle phalanges. Two second toes were simultaneously used to reconstruct the index and middle fingers. Subsequent ring finger reconstruction was achieved with left third-toe transfer. A, Reconstruction of the index and middle fingers was performed by using two secondtoe transfers. Note the failed middle-finger transfer. B, The left third-toe harvest is designed. C, Immediate postoperative appearance of the ring finger reconstruction using the left third toe. D, E, Appearance and function of the reconstructed index and ring fingers. E
when the third toe has a better size match for finger reconstruction.50
Flap Design and Elevation Guidelines similar to those for the second toe are also applied to the third toe. The third toe receives its blood supply from the second and third dorsal metatarsal arteries and the second and third plantar metatarsal arteries. As the majority of patients undergoing third-toe transfer already have undergone transfer of the great or second toe, the second metatarsal pedicle might not be preserved; therefore the third toe is usually transferred on the basis of the third common plantar digital artery.50 Although the third common plantar artery might be smaller, it still can be anastomosed by most microsurgeons. It is therefore recommended that the plantar vascular pedicle be dissected directly. The donor site is closed in the same way as described for the second toe (Fig. 19-5). For an in-depth discussion of the modified great-toe wraparound flap and of the surgical procedure, postoperative care and rehabilitation, complications, and complication management related to any of these procedures, please refer to Chapter 13, “Modified Great-Toe Wraparound Flap,” and Chapter 20, “Microsurgical Reconstruction of the Metacarpal Hand.”
CONCLUSION The functional deficits and the body image concerns in a patient with a phalangeal hand have often been overlooked because of the lack of reasonable reconstructive options in the past. With technical refinement of microsurgical toe transfer, the fingers can be reconstructed to a level comparable to that of toe-to-thumb reconstruction. Various tissues from the foot can provide an ideal source of spare parts for phalangeal hand reconstruction.
References 1. Brunelli GA, Brunelli GR: Reconstruction of the traumatic absence of thumb in the adult by pollicization. Hand Clin 8:41–45, 1992. 2. Buncke HJ: Digital reconstruction by second toe transfer. In Buncke HJ (ed): Microsurgery: Transfer, Replantation: An Atlas Text. Philadelphia, Lea and Feibiger, 1991, pp 61–101. 3. Buncke HJ, Buncke GM: Free pulp transfer. In Foucher G (ed): Fingertip and Nailbed Injuries. New York, Churchill Livingstone, 1991, pp 92–97. 4. Bunnel S: Physiologic reconstruction of the thumb after total loss. Surg Obstet Gynaecol 52:245, 1931. 5. Bunnel S: The management of the nonfunctional hand: Reconstruction v/s prosthesis. Artificial Limbs 4:76–102, 1957.
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6. Chase RA: An alternative to pollicization in subtotal thumb reconstruction. Plast Reconstr Surg 44:421, 1969. 7. Chen HC, Tang YB, Wei FC, Noordhoff SM: Finger reconstruction with triple toe transfer from the same foot for a patient with a special job and previous foot trauma. Ann Plast Surg 27:272–277, 1991. 8. Cobett JR: Free digital transfer: Report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg 51B:677–679, 1969. 9. Dellon AL: Sensory recovery in replanted digits and transplanted toes: A review. J Reconstr Microsurg 2:123–129, 1986. 10. El Gammal TA, Wei FC: Micro vascular reconstruction of the distal digit by partial toe transfer. Clin Plast Surg 24(1):49–55, 1997. 11. Foucher G, Merle M, Maneaud M, Michon J: Microsurgical free partial toe transfer in hand reconstruction: A report of 12 cases. Plastic Reconstr Surg 65:616–627, 1980. 12. Foucher G, Moss AL: Microvascular second toe to finger transfer: A statistical analysis of 55 transfers. Br J Plast Surg 44: 87–90, 1991. 13. Foucher G, Norris RW: The dorsal approach in harvesting the second toe. J Reconstr Microsurgery 4:185–187, 1988. 14. Fultz FW, Lester DK, Hunter JM: Single-stage lengthening by intercalary bone graft in patients with congenital hand deformities. J Hand Surg 11B:40–46, 1986. 15. Glicenstein J, Dardour JC: The pulp: Anatomy and physiology. In Tubiana R (ed): The Hand. Philadelphia, WB Saunders, 1981, pp 116–120. 16. Gordon L: Toe-to-thumb transfer. In Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery. Edinburgh, Churchill Livingstone, 1993, pp 1253–1282. 17. Koshima I, Morguchi T, Soeda S, et al: Free thinosteo-onychocutaneous flaps from the big toe for reconstruction of the distal phalanx of the fingers. Br J Plast Surg 45:1–5, 1992. 18. Koshima I, Soeda S, Dakase T, Yamasaki M: Free vascularized nail grafts. J Hand Surg 13A:29–32, 1988. 19. Lee KS, Park JW, Chung WK: Thumb reconstruction with a wrap-around free flap according to the level of amputation. Microsurg 20:25–31, 2000. 20. Leung PC: Use of an intramedullary bone peg in digital replantation, revascularization and toe-transfers. J Hand Surg 6:281–284, 1981. 21. Leung PC: The Chinese culture and hand reconstruction. In Landi A (ed): Reconstruction of the Thumb. London, Chapman and Hall, 1989, pp 11–16. 22. Littler JW: Reconstruction of the thumb in traumatic loss. In Converse JM (ed): Reconstructive Plastic Surgery, 2nd ed. Philadelphia, WB Saunders, 1977, pp 3350–3367. 23. Matev IB: Thumb reconstruction in children through metacarpal lengthening. Plast Reconstr Surg 64:665–669, 1979. 24. Matev IB: Reconstructive surgery of the thumb. Brentwood, Essex, England, Pilgrims Press, 1983. 25. Matev IB: The bone lengthening method in hand reconstruction: 20 years experience. J Hand Surg Am 14(2): 376–378, 1989.
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26. May JJ, Chait LA, Cohen BE, O’Brien BM: Free neurovascular flap from the first web of the foot in hand reconstruction. J Hand Surg 2A:387–396, 1977. 27. Minami A, Usui M, Katoh H, Ishii S: Thumb reconstruction by free sensory flaps from the foot using microsurgical techniques. J Hand Surg 9:239–244, 1984. 28. Morrison WA: Micro vascular nail transfer. Hand Clin 6:69–76, 1990. 29. Morrison WA, McLeod AM: Thumb reconstruction with a free neurovascular wrap around flap from the big toe. J Hand Surg 5:575–583, 1980. 30. O’Brien BM, Brennen MB, MacLeod AM: Simultaneous double toe transfer for the severely disabled hand. Hand 10:232–240, 1978. 31. O’Brien GM, MacLeod AM, Sykes PJ, et al: Hallux-to-hand transfer. Hand 7:128, 1975. 32. Seitz Jr WH, Dobyns JH: Digital lengthening with emphasis on distraction osteogenesis in the upper limb. Hand Clin 9(4):699–706, 1993. 33. Shepard GH: Treatment of nail bed avulsion with split thickness nail bed grafts. J Hand Surg 8:49–54, 1983. 34. Shibata M, et al: Microsurgical toenail transfer to the hand. Plast Reconstr Surg 88:102–110, 1991. 35. Smith RJ, Gumley GJ: Metacarpal distraction lengthening. Hand Clin 1:417–429, 1985. 36. Strauch B, Tsur H: Restoration of sensation to the hand by a free neurovascular flap from the first web space of the foot. Plastic Reconstr Surg 62:361–367, 1978. 37. Swanson AB: Restoration of hand function by the use of partial or total prosthetic replacement. J Bone Joint Surg 45A:276–283, 1963. 38. Tubiana R, Roux JP: Phalangisation of the first and fifth metacarpal: Indications, operative techniques and results. J Bone Joint Surg Am 56:447–457, 1974. 39. Verdan C: The reconstruction of the thumb. Surg Clin North Am 48:1033, 1968. 40. Wei FC: Tissue preservation in hand injury: The first step to toe-to-hand transfer. Plast Reconstr Surg 102:2497–2501, 1998. 41. Wei FC, Chen HC, Chuang CC, Chen SHT: Microsurgical thumb reconstruction with toe transfer: Selection of various techniques. Plast Reconstr Surg 93:345, 1994.
42. Wei FC, Chen HC, Chuang DCC, et al: Second toe wraparound flap. Plast Reconstr Surg 88:837–843, 1991. 43. Wei FC, Chen HC, Chuang CC, Noordhoff MS: Reconstruction of thumb with a trimmed great toe transfer technique. Plast Reconstr Surg 82:506, 1988. 44. Wei FC, Chuang DC , Chen HC, et al: Simultaneous multiple toe transfer in hand reconstruction. Plast Reconstr Surg 81:366–277, 1988. 45. Wei FC, Colony LH: Microsurgical reconstruction of opposable digits in mutilating hand injuries. Clin Plast Surg 16:491–504, 1989. 46. Wei FC, El-Gammal TA: Toe-to-hand transfer: Current concepts, techniques and research. Clin Plast Surg 23(1):103–116, 1996. 47. Wei FC, Epstein MD, Chen HC, et al: Microsurgical reconstruction of distal digits following mutilating hand injuries: Results in 121 patients. Br J Plast Surg 46:181–186, 1993. 48. Wei FC, Santamaria E: Toe to finger reconstruction. In Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery. Philadelphia, Churchill Livingstone, 1993. 49. Wei FC, Strauch RJ, Chen H , et al: Reconstruction of four damaged or destroyed ipsilateral fingers with free toe to hand transfer. Plast Reconstr Surg 93:608–614, 1994. 50. Wei FC, Yim KK: Single third-toe transfer in hand reconstruction. J Hand Surg 20A:388–394, 1995. 51. Yim KK, Wei FC: Interosseous wiring in toe-to-hand transfer. Ann Plast Surg 35:66–69, 1995. 52. Yim KK, Wei FC: Secondary procedures to improve function after toe-to-hand transfers. Br J Plastic Surg 48:487–491, 1995. 53. Yim KK, Wei FC: Pulp reconstruction and neurosensory free flaps. In Peimer CH (ed): Surgery of the Upper Extremity. New York, McGraw Hill, 1996, pp 1919–1939. 54. Yim KK, Wei FC: A comparison between primary and secondary toe to hand transfer. Plast Reconstr Surg. In press. 55. Zook EG, Russell RC: Reconstruction of a functional and esthetic nail. Hand Clin 6:59–68, 1990. 56. Zook EG, Van Beek AL, Russell RC, Beatty ME: Anatomy and physiology of the paronychium: A review of the literature and anatomic study. J Hand Surg 5:528–536, 1980.
20 The Metacarpal Hand Vivek Jain, MCh Ortho Fu-Chan Wei, MD, FACS
20
Mutilating hand injuries often involve amputation of multiple digits at various levels. The term metacarpal hand refers to the situation in which all fingers are amputated at, or proximal to, the middle of the proximal phalanx, with or without involvement of the thumb.20 This hampers the prehensile function of the hand and thus severely incapacitates these patients. Prehension requires opposition between the thumb and fingers to perform the coordinated pinch that is necessary for control and manipulation of objects; a minimum of two opposable elements is required. These elements must have adequate skeletal length, mobile and stable joints, pain-free contact surfaces, and, ideally, at least protective sensibility. Traditionally, these hands have been salvaged by “phalangization”13,14,18 with index ray amputation to create a webspace.2,6,26 Deepening of the first webspace by phalangization creates an illusion of increased length and may also augment the breadth of the hand, allowing firmer grasp of larger objects. It converts the thumb metacarpal into a phalanx that protrudes relatively farther from the hand, thereby increasing the area that is available for grasp. In the absence of soft tissue contracture, the first webspace can be easily widened with a large Z-plasty. In the presence of severe contracture, additional skin in the form of local or pedicled flaps, might be required. Resection of a useless index ray may further widen the webspace. In extreme cases, trapeziometacarpal capsulotomy or even trapeziectomy might be necessary to allow sufficient thumb metacarpal abduction. Excessive release of the first dorsal interosseous and adductor pollicis is not advised as it can result in significant flexion-adduction weakness. Preservation of adductor function17 and proximal migration of the origins of the first dorsal interosseous and adductor pollicis muscles preserve their function.33 The function and aesthetics of the reconstructed hand following phalangization are always suboptimal. An opposition post can be reconstructed by using either local tissue or distant flaps elongated by iliac bone grafts.1,19,21 Osteoplastic reconstruction adds length to the thumb amputated at or proximal to the interphalangeal joint level. In a procedure that was first described as the Gilles “cocked-hat flap” procedure, the bone graft is placed under a volar-based flap to provide additional length of 1.0 to 1.5 cm. However, sensation is poor; the bone graft might be resorbed; and tissue rearrangement might decrease web depth. In its modification, this procedure is performed in stages. Initially, an iliac crest bone graft is inserted and covered by a tubed pedicle; this is followed by tube division and neurovascular pedicle transfer for restoration of sensibility. Reconstruction is still less than ideal, as there is no interphalangeal joint, and sensation is perceived at the donor digit. Additionally, appearance is inferior, as there is no nailplate, and the flap can be bulky. Furthermore, there can be long-term complications, such as resorption and fracture of the bone graft.3,23,29 277
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CLASSIFICATION OF THE METACARPAL HAND Toe-to-hand transfer has been intimately related to development of microsurgical technique, which constitutes one of the most significant advances in the history of reconstructive surgery. Hand reconstruction by toe transfer for the thumb as well as for the fingers has now gained widespread acceptance. Reconstruction of these complex cases has achieved new heights in function and appearance. The thumb and fingers can be reconstructed by using the great toe, great-toe variants, lesser toe,25,27,41 combined second and third toe,31,36 or different toe combinations.4,54 Toe-to-hand transfer can also be combined with other free tissue transfers, including soft tissue or bone or both.52 Although various combinations of toe-to-hand transfer have been used for reconstruction, the indications have not been clearly defined.15 The classification of the metacarpal hand proposed by Wei et al.48 is based on whether the amputation involves only the fingers or the fingers and the thumb. Wei and associates designate two basic types of metacarpal hand: one requiring reconstruction of the fingers only and one requiring reconstruction of the fingers and the thumb. The injury is further subclassified depending on the level of amputation and the extent of injury. This classification provides useful guidelines for selection of proper reconstruction technique and predicts functional outcome following reconstruction (Tables 20-1 and 20-2).
Type I Metacarpal Hand In Type I metacarpal hand, all fingers have been amputated proximal to the middle of the proximal phalanx with either an intact thumb or a thumb amputated distal to the interphalangeal joint. Depending on the level of amputation of the fingers, the Type I metacarpal hand is further classified into three subtypes: ❚ Type IA: finger amputation distal to the metacarpophalangeal joint
TABLE 20-1 Subtype IA
❚ Type IB: finger amputation through the metacarpophalangeal joint with an intact metacarpal articular surface ❚ Type IC: finger amputation through the metacarpophalangeal joint with a damaged metacarpal articular surface (i.e., transmetacarpal amputation).
Type II Metacarpal Hand In Type II metacarpal hand, there is amputation of the fingers proximal to the middle of the middle phalanx with thumb amputation proximal to the interphalangeal joint. Depending on the level of thumb amputation and the integrity of the remaining thenar muscles and the first carpometacarpal joint, Type II metacarpal hands are further classified into the following subtypes: ❚ Type IIA: Thumb amputation distal to the metacarpal neck ❚ Type IIB: Thumb amputation proximal to the metacarpal neck with adequate thenar function ❚ Type IIC: Thumb amputation at any level proximal to the interphalangeal joint with inadequate thenar musculature ❚ Type IID: Thumb amputation at any level proximal to the interphalangeal joint with a damaged first carpometacarpal joint.
INITIAL MANAGEMENT OF THE METACARPAL HAND For ultimate recovery of hand function, it is essential that the planning for reconstruction begin with initial emergency management. All grossly viable tissues should be preserved.35 A realistic plan should be made that takes into consideration the patient’s age, occupation, functional demands, aesthetic concerns, psychology, motivation, and commitment to postoperative rehabilitation. Adequate or even redundant skin cover over the stump of the hand is required and can be achieved with a pedicled groin flap. This additional skin will be of use
Type I Metacarpal Hand
Level of Finger Amputation Distal to metacarpophalangeal joint
Recommendations for Reconstruction Bilateral second toes for amputations distal to the webspace Or Combined second and third toes for amputations proximal to the webspace
IB
Through metacarpophalangeal joint with intact articular surface
Combined second and third toes (composite joint transfer)
IC
Transmetacarpal
Combined second and third toes (transmetatarsal transfer)
20
Subtype
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Type II Metacarpal Hand Level of Thumb Amputation
Recommendations for Reconstruction in Unilateral Metacarpal Hand
IIA
Distal to metacarpal neck
Whole or trimmed great-toe transfer for thumb and simultaneous finger reconstruction
IIB
Proximal to neck with adequate thenar muscles
Preliminary distraction-lengthening or bone graft, then whole/trimmed great-toe transfer or transmetatarsal toe transfer for thumb reconstruction and simultaneous finger reconstruction
IIC
Any level with inadequate thenar muscles
Staged reconstruction, fingers, then thumb reconstruction, opponensplasty
IID
Any level with damaged basal joint
Same as IIA or IIB, but aim at reconstructing an immobile thumb post
during later reconstruction, as it can cover the lateral aspect of the transferred toes, protect the pedicle, or form a webspace. It will also allow less skin to be harvested from the foot and permit primary closure of the donor site. Use of local flaps should be avoided, since these induce scarring of already injured tissues and might hamper later reconstructive procedures. Definitive toe transfer begins 2 to 3 months following pedicled soft tissue reconstruction. Deficient metacarpal length can also be augmented by distraction osteogenesis of nonvascularized bone grafts from the iliac crest prior to the toe transfer procedure concurrent with soft tissue reconstruction. This will preserve metatarsal length, especially in the great toe, reducing donor site morbidity. Reconstruction of the metacarpal hand by toe transfer can also be performed primarily when the wound is still open if the wound is clean and the patient is well informed.
RECONSTRUCTION The Unilateral Metacarpal Hand In the Type I metacarpal hand, it is recommended that the hand surgeon reconstruct at least two adjacent fingers to provide for tripod pinch, strong hook grip, and grasping larger objects with a wider hand span.32 The principal considerations of reconstruction include selection of the digits to be reconstructed and selection of toes to be harvested. Reconstruction of the ulnar two fingers is preferred for patients in professions requiring strong grasp and grip for lifting weights, while the two radial digits should be reconstructed if fine manipulation is more important.45 If a first webspace contracture is present, index ray amputation can be performed, and the middle and ring fingers can be reconstructed. Depending on the level of amputation in relation to the webspace, either bilateral lesser toes or combined second/third toes (or third/fourth toes) can be transferred (see Table 20-1). In Type IA injuries, transfer of two
lesser toes is preferred when the amputation is distal to the webspace to avoid a syndactylous appearance.40 Combined second and third toes are suitable for reconstruction of two adjacent fingers amputated proximal to the digital web.40 In Type IB injuries with preserved metacarpal articular surface, the new joint can be reconstructed by repairing the joint capsules between the articular surfaces of the proximal phalanx of the toe and the joint capsule of the metacarpophalangeal joint. This technique of composite joint reconstruction can provide active range of motion averaging 35°.28 Transmetatarsal combined second- and third-toe transfer performed in Type IC metacarpal hands can provide an average of 15° and 30° range of motion in the reconstructed proximal and distal interphalangeal joints, respectively.28 Reconstruction of the Type II metacarpal hand is more complex. It usually requires three toe transfers for reconstruction of tripod pinch. A systematic strategy needs to be ensured for selection of donor toes and stages of reconstruction (see Table 20-2). Reconstruction of the thumb improves hand function even if the thumb is amputated as far distal as the interphalangeal joint because its length can compensate for the reduced length and mobility of the transferred toes (new fingers). Thumb opposition function is mainly dependent on the carpometacarpal joint and thenar muscles (Fig. 20-1). In Type IID metacarpal hand, the basal joint is destroyed. Toe transfer will serve only as an immobile post. In this case, the transferred toe should be placed in such a position that the reconstructed fingers can touch. The decision to reconstruct the thumb and fingers simultaneously or in two stages depends on the status of the thenar musculature,46 which might be disrupted in transmetacarpal thumb amputations or might be crushed directly with thumb amputation at any other level. Since there is no quantitative method to measure thenar muscle function, assessment of thenar function is largely subjective and can be difficult particularly in the presence of a first webspace contracture. When thenar function is adequately preserved (Types IIA and IIB), a one-stage reconstruction of the thumb and fingers is preferable. If the
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TABLE 20-2
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A
B
C
D
FIGURE 20-1. Unilateral Type 1 metacarpal hand reconstructed using a right great-toe and left second- and third-toe transfers in one stage. A, Coverage with a pedicle groin flap. B, Adequate thenar muscle function. C, Design of skin incision and recipient vessels at the amputation stumps. D, Design of the right great toe and left combined second and third toes. E, Tripod pinch at 3 year follow-up. E
thenar muscles are inadequate or absent (Types IIC and IID), a staged reconstruction is planned, with the fingers reconstructed first and the thumb reconstructed at a second stage.46 The length and position of the recon-
structed thumb are decided by using a temporary prosthetic thumb post after the first-stage finger reconstruction. Tendon transfer (opponensplasty) can be carried out with thumb reconstruction in Type IIC metacarpal hand,
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F
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G
to shorten the rehabilitation period. The decision as to what type of toe transfer is used for thumb reconstruction depends on the functional and aesthetic requirement of the reconstructed hand and donor foot. Both total great-toe and trimmed great-toe procedures37,40,43,48 are suitable for reconstruction of a thumb that is amputated at or distal to the middle of the first metacarpal shaft. Since the great toe is about 1.5 cm longer than the thumb, it can compensate for thumb amputation up to the level of the metacarpal neck, even with preservation of the proximal 1 cm of the proximal phalanx to maintain push-off function of the foot. Trimmed great-toe transfer provides a better size match and preserves interphalangeal joint motion. In cases of amputations at more proximal levels (Type IIB), rather than harvesting the great toe through the metatarsophalangeal joint, either an interpositional bone graft for bone length augmentation of a great toe or a transmetatarsal lesser toe should be used to reduce donor morbidity.40
The Bilateral Metacarpal Hand If not managed properly, bilateral metacarpal hands leave the patient without prehensile ability in both hands. In addition to the various principles that are applicable to unilateral metacarpal hand reconstruction described earlier, other considerations must be addressed in bilateral metacarpal hand reconstruction. With thorough plan-
ning, multiple toe-to-hand transfers can provide adequate prehensile function in reconstructed bilateral metacarpal hands with acceptable donor site morbidity50 (Fig. 20-2). In bilateral Type II metacarpal hands, at least five toes are required for total reconstruction: two for both thumbs, two toes for opposable fingers in the dominant hand, and one toe for one finger in the nondominant hand. Although three toes to each hand could provide tripod pinch for both hands, potential donor site morbidity would be increased. For bilateral thumb reconstruction, left great-toe transfer to dominant thumb and transfer of one of the lesser toes for the nondominant thumb is preferred, as the right great toe has higher functional demands and harvesting both great toes will increase donor foot morbidity significantly. Donor foot morbidity remains acceptable for properly executed procedures.38,39,45
OPERATIVE TECHNIQUES Various toe transfer techniques for thumb and finger reconstruction have been described elsewhere28,30,32–41, 44–50,54 and are beyond the scope of this chapter. For details, the reader is advised to refer to these articles. However, because combined second- and third-toe transfer is one of the most useful tools in reconstruction of the metacarpal hand, it is appropriate to shed some light on specific techniques concerning harvest and inset.
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FIGURE 20-1 cont’d. F, Buttoning at 3 year follow-up. G, Donor sites appearance of the feet.
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A
B
D
C
FIGURE 20-2. Bilateral Type 1 metacarpal hands reconstructed using two combined second- and third-toe transfers. A, B, C, Appearance and functions at 8-year follow-up. D, Appearance of the donor feet.
Combined Second- and Third-Toe Transfer Combined second- and third-toe transfer is indicated for reconstruction of two adjacent fingers that are amputated proximal to the digital webs31,40 when the remaining fingers are not longer than the little finger. Advantages of
combined second- and third-toe transfer over bilateral second-toe transfer include (1) improved tripod pinch, hook grip, and lateral stability;32,40,44,45 (2) the requirement for only a single set of recipient vessels (multiple recipient vessels might otherwise be difficult to locate in
severely injured hands when two different toes are used); (3) reduced operative time; and (4) limiting of potential donor site morbidity to one foot only. Nevertheless, because of its length limitation, it cannot be expected that the transferred combined second and third toes will satisfactorily emulate the fingers’ functional capabilities, particularly in pinch point and grasp arch. Optimal function and appearance are attained when the reconstructed fingers, together with the remaining fingers, are of relatively uniform length with the distal tip of the normal little finger used as a guide.40 When the remaining finger extends beyond this point, the tandem second and third toe transfer will be shorter and contribute less to smooth prehension. The level of the fingers’ amputation dictates the level of osteotomy of the second and third toes. If 5 to 6 mm of length is present in the proximal finger’s phalanx, the toes are harvested through a metatarsophalangeal joint disarticulation, and the bases of the proximal phalanges are shortened during the toes’ insetting by raising the periosteum to the osteotomy level. During the subperiosteal dissection and osteotomy of the phalanx, all anatomic structures in the toe must be protected from injury, and excessive manipulation of the neurovascular pedicle should be avoided. In cases of disarticulation through the metacarpophalangeal joint with an intact joint surface, capsule, and ligaments in the amputated stump, the tandem toes are transferred with the respective metatarsophalangeal joint for composite joint repair in the hand. In more proximal transmetacarpal amputations, both toes can be harvested by using a transmetatarsal osteotomy. In the past, it was suggested that the missing bony arch in the donor foot be replaced after transmetatarsal amputation of both toes by using a nonvascularized bone graft.40 However, this is no longer recommended, as no functional difference was revealed in biomechanical gait analysis.9 Formerly, radial amputations were reconstructed by using combined second- and third-toe transfer from the contralateral foot, whereas ipsilateral toes were used for ulnar amputations with the purpose of placing the longer second toe in a more acceptable central position.32,40 Currently, when only one combined second and third toe is needed, we always harvest the tandem toes from the left foot because of higher demand applied on the right foot for daily activities. The right foot is selected only when the left foot is not suitable or the left great toe has already been removed (in multiple-toe transfer cases). The skeletal length of the reconstructed fingers can be adjusted by the level of osteotomy in the toes. Skin flaps with a V shape are outlined in the dorsal and plantar aspect of the second and third toes. The outlined skin incisions should not extend beyond the midpoint of the first and third webspaces in the foot. By
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including narrow skin flaps with the toes, it is always possible to close the donor site directly, without tension. Dissection of the flap starts in the dorsal aspect of the foot, isolating one suitable donor vein of the saphenous venous system in connection with all draining small veins from the second and third toes. The first webspace is then dissected to identify the dominant (dorsal or plantar) vascular pedicle to the second toe. The vessels, the deep and superficial peroneal nerves, and the extensor tendons to the second and third toes are dissected next. To preserve the communicating vessels between these two toes, it is advisable to avoid excessive manipulation of the soft tissue connections in the second webspace, especially when the bone is dissected distal to the metatarsophalangeal joint. Next, the plantar skin flap is raised to the base of the proximal phalanx in both toes. All fibrofatty tissue under the skin and over the plantar neurovascular bundles is carefully removed (Fig. 20-3). This reduction of the anteriorposterior dimensions of the toe, especially in the metatarsophalangeal joint area, is essential for better appearance and metatarsophalangeal joint flexion. The following three nerves are identified on this surface and included in the unit: the proper digital nerve to the fibular side of second toe, the second common digital nerve, and the proper digital nerve to the tibial side of the third toe. In our recent study of reliability of the arterial blood supply in combined second- and third-toe transfers, blood supply to the third toe was found to be inadequate in 20% of cases after revascularization with the dominant artery only.6 Currently, the second and third common plantar digital arteries are also preserved to be used for a second arterial anastomosis when blood perfusion of the third toe is in doubt. Once the osteotomy level is decided, all anatomic structures are divided at the proper levels, except the main vascular pedicle. The two toes are allowed to reperfuse for at least 15 minutes before being transferred. The wound incisions are closed without tension. Skin grafts to close the donor site are unacceptable and can lead to severe complications in the foot.
Combined Third- and Fourth-Toe Transfer Combined third- and fourth-toe transfer is indicated only when the second toe is not available or has to be spared for gait when the great toe has been harvested from the same foot or when the second toe has to be spared for thumb reconstruction. Combined third- and fourth-toe transfer30 is particularly useful in bilateral metacarpal hand reconstruction. Although foot deformity can be marked, there is no significant functional limitation when these combined toes are properly removed. The anatomy and harvesting techniques essentially remain similar to those of second- and third-toe transfer.
20
20
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A
B
FIGURE 20-3. Harvest of combined second and third toes. A, Removal of a thick fibrofatty tissue between the plantar skin and neurovascular bundles and flexor tendons. B, Disarticulation at metatarsophalangeal joints. C, Harvested combined second and third toes. C
RECIPIENT SITE PREPARATION AND TOE TRANSPLANT INSET The amputated stump is prepared through a cruciate incision, creating four flaps. The bone, extensor and flexor tendons, recipient artery, vein, and nerves are prepared at the recipient site in the usual manner.
Skeletal Fixation After verification of proper length, bone fixation is performed using interosseous wiring56 (Fig. 20-4). This technique, while not providing rigid fixation, does achieve adequate skeletal stability. It permits postoperative correction of position if the transferred toe is not well aligned. For composite joint repair, the plantar plate and collateral ligaments of the toe are repaired with the
FIGURE 20-4. Interosseous wires at amputation stumps. A1 pulley is preserved and neurovascular bundles are prepared.
20
Tendon Repair After the bone is fixed, the extensor tendon is repaired. The toe extensor longus tendon is inserted through two separate longitudinal slits made in the extensor tendon in the finger and sutured with nonabsorbable suture to maintain the interphalangeal and metacarpophalangeal joints in full extension. Next, the long flexor tendon is repaired with the flexor tendon of the finger. If possible, the A1 pulley should be preserved to prevent a bowstring deformity after tendon repair. The tension between both tendons should be adjusted to place the finger in neutral position and to provide the natural cascade position of the fingers.
Nerve Repair All proper or common digital nerves are coapted in endto-end fashion with 10-0 nylon suture. Both the deep and superficial peroneal nerves are also repaired when recipient nerves are available (Fig. 20-4).
Vascular Anastomoses The arterial anastomosis is performed first. Once it has been completed, the color, capillary refill in the skin, and venous return should be observed. If blood outflow is poor, the arterial anastomosis and the entire course of the vessel must be evaluated. If inadequate perfusion of the third toe is suspected, a second arterial anastomosis should be attempted in combined second- and third-toe transfer.5
Skin Closure The artery and vein are tunneled to the corresponding recipient site. The four skin flaps created in the recipient stump are tailored and interposed with the triangular flaps of the transferred toe, creating a regular surface. All wounds are closed after the venous anastomosis is completed. If there is some tension in closing the skin, partial closure and skin grafting the exposed defect is advisable; however, this is uncommon with adequate preoperative planning. A small silastic drain is used to prevent hematoma formation. Caution should be taken to avoid contact between the drain and the vascular anastomoses. In toe transfer, extreme care should be taken to prevent a secondary donor site defect and potential morbidity. Skeleton length preservation and good skin coverage are desirable in closing the wound defect. However, as a
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general principle, adequate skin coverage is more important in the foot, except for the great toe, in which it is advisable to preserve 1 cm of the proximal phalanx to improve the appearance and for push-off function of the donor foot. All bony irregularities should be shortened by either osteotomy or proximal joint disarticulation. If closure at the metatarsophalangeal joint is still difficult due to limited remaining soft tissue, removal of the dorsal metatarsal head can facilitate wound closure. With adequate planning and surgical techniques, it is possible to preserve a functional foot in the great majority of cases. Skin grafting the donor site should be avoided in all cases of toe transfer. With adequate planning, there should rarely be any problem in tension-free closure of the wound in the foot. No drains are required in the donor site, and the skin sutures are left for 2 to 4 weeks.
POSTOPERATIVE MANAGEMENT Ideally, patients should be cared for in a special microsurgery intensive care unit for several days, where specialized nurses are available for close monitoring of the transferred toes and the patient’s general condition. The proximal palm and wrist are gently wrapped, with the reconstructed digits left uncovered for continuous observation. The hand and forearm are kept slightly elevated to reduce edema. Bulky dressings are not recommended, as blood clots can be retained around the wounds, and attempts to remove them may induce vasospasm. Bulky dressings also prevent the reconstructed metacarpal hand from being treated with early postoperative rehabilitation. An initial bolus of 100 cc of Dextran 40 (low molecular weight) is rapidly administered intravenously 10 minutes prior to completion of the arterial anastomosis, followed by continuous infusion (25 mL per hour) during the next 4 to 5 days. Aspirin (325 mg daily) is administered for 2 postoperative weeks to reduce the risk of platelet aggregation. Prophylactic antibiotics are used in elective cases and in primary toe transfer. In prolonged surgical cases or dirty wounds, antibiotics against both Gram-positive and Gram-negative bacteria are given. Vascular conditions in the toes are subjectively monitored by direct observation of the skin color, capillary refilling, and turgor and objectively monitored by measuring the surface temperature in the toe and comparing with the adjacent normal finger and the opposite hand. Ultrasound or laser Doppler helps to assess vascular anastomotic patency. The donor foot is gently covered with antibioticsoaked gauze over the wound and a light fluff dressing. No splints are used in the donor foot or the recipient hand. The foot is uncovered 2 days later without need
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corresponding structures of the hand, using nonabsorbable sutures.28 The plantar plate has to be sutured with proper tension to prevent joint subluxation.
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for further dressings. The patient is allowed to walk a few steps on the heel of the donor foot after the second week. It must be emphasized that any contact with the anterior plantar weight-bearing surface should be avoided during this time. After 6 weeks, the patient is allowed to walk with a normal gait in shoes.
Intraoperative and Postoperative Complications and Pitfalls Vasospasm is the most frequent vascular complication. It can occur intraoperatively or postoperatively. It is observed more often in distal digital reconstruction with partial-toe transfer. Arterial vasospasm during the procedure can be relieved by topical instillation of local anesthetic agents such as lidocaine (Xylocaine 1% to 2%) or papaverin. Removal of the adventitia helps in relieving the spasm and should be carried out under the operating microscope. Avoid tension on the vascular anastomosis. If necessary, employ vein grafts. Note, however, that with adequate preoperative planning, vein grafts should not be necessary. Keep the vessels moist during the procedure, and ensure that the skin closure is not tight. Postoperative vasospasm can be precipitated by low room temperature, low blood pressure, anxiety in the patient, or excessive manipulation of the hand. Prevention consists of maintaining optimal blood pressure, supplying adequate fluids, and avoiding oversedation. If vasospasm occurs, some skin sutures should be removed, and vasodilators such as lidocaine (Xylocaine) should be intermittently instilled via the partially opened wounds. Sublingual nitroglycerin or nifedipine24 and regional blocks22 may help in combating unrelieved vasospasm. However, if no improvement of circulation is noted after observation for a reasonable period (1 hour), prompt re-exploration in the operation room is mandatory. In some cases, incomplete removal of the adventitia or a small hematoma is responsible for local vasospasm. Once the adventitial layer has been adequately excised or after draining the hematoma, the vasospasm may be relieved. When there is refractory vasospasm or the artery is thrombosed, redoing the anastomosis is indicated, with or without an interposed vein graft. If the second and third plantar metatarsal arteries are preserved in combined second- and third-toe transfer, one of these vessels can be used for a second arterial anastomosis in the event that arterial insufficiency is secondary to inadequate blood supply.5 In contrast to arterial thrombosis, venous thrombosis is less common and is often related to incorrect positioning due to twisting, kinking, compression by tunneling, hematoma, or tight skin closure. In most instances of vascular compromise, it is possible to salvage the transferred toe after re-exploration.5 From our experience with 103
transfers for thumb reconstruction, 13 (12.6%) required exploration for circulatory compromise, with a successful result in 98% of cases.37 In 149 toe transfers for distal finger reconstruction, re-exploration was required in 12 (7.9%) with a 98% success rate,49 and in 57 combined second- and third-toe transfers, the re-exploration rate was 19.2%, with a success rate of 94.8%.5 Therefore, the attitude toward re-exploration and vein grafting (if necessary) should be aggressive. Other complications that are observed in the first 2 weeks usually involve skin coverage and wound-healing problems. In most cases, these are secondary to partial necrosis of thin skin flaps in the transferred toe or in the scarred recipient site. With exposure of important structures such as tendons, nerves, and vessels, immediate coverage reconstruction should be performed to prevent desiccation of these structures and subsequent sequelae.
Secondary Procedures In our study of 133 cases of toe-to-hand transfer, secondary procedures for functional improvement were necessary in 19 (14.3%) transfers, after an average time of 8.8 months.57 The incidence of secondary procedures on tendon, bone, joint, and soft tissue was 9.0%, 1.5%, 2.3%, and 3.8%, respectively. Tenolysis was the most commonly performed secondary procedure (6.8%), followed by arthrodesis (3.0%) and webspace deepening (3.0%). Other series reported secondary procedures in up to 20% of cases, including tendon and nerve grafts, tendon transfers, osteotomies, or capsulotomies.10–12,16,34,57 Secondary procedures usually yielded satisfactory results, particularly flexor tendon tenolysis. Secondary procedures are also used for aesthetic improvement after toe-to-finger reconstruction. Pulpplasties are necessary to correct bulbous-appearing reconstructed fingers.42,55 Scar revisions and Z-plasties in the junction between the transferred toe and the recipient finger are used for correction of soft tissue irregularities that resulted from inadequate tailoring and adjustment of the skin during the toe insetting.42
DONOR SITE MORBIDITY AND GAIT ANALYSIS Removal of combined second and third toes, either by metatarsophalangeal joint disarticulation or by transmetatarsal osteotomy, creates acceptable donor site morbidity if the aforementioned principles of toe harvest are observed. Skin flap necrosis is usually related to the elevation of very thin flaps in dissecting the proximal pedicle in the dorsal foot and excessive tension during wound closure, due to inadequate surgical planning.
Donor foot function has been studied with biomechanical measures after various toe transfers.8,9 Following second-toe transfer, there is minimally increased loading on the first toe and first metatarsal during stance and walking. Foot kinetics analysis reveals no significant change in gait parameters such as walking velocity, cadence, step length and width, duration of stance phase, and percentage of single- and double-limb support phases.9 However, it has been found that harvesting the combined second and third toes unloads the metatarsal region and increases the load on the big toe and, to a lesser extent, the heel, which reflects adequate compensation for the simultaneous loss of these toes. Clinically, there were also no significant complaints from these patients. Thus combined second- and third-toe transfer can be safely used for finger reconstruction in properly selected patients, provided that cautionary measures related to toe harvesting and postoperative care of the donor site are carefully observed.
REHABILITATION Rehabilitation after toe-to-finger transfer is aimed at improving motor capability and sensory function of the transferred toe.
Motor Rehabilitation Early controlled motor rehabilitation not only prevents joint stiffness and tendon adhesion, but also enhances coordination and dexterity of the reconstructed hand. The rehabilitation program that we have developed in our unit consists of five stages starting from the first postoperative day.9 1. Protective stage (days 1 to 3): During this stage, psychological support is provided to the patient. Interaction between the patient and the hand therapist is established at this stage. 2. Early mobilization stage (day 4 to week 4): In this stage, the rehabilitation is directed to prevent excessive swelling and joint stiffness. The hand is kept higher than the level of the heart to prevent edema. Gentle passive range of motion exercises of the joints are commenced by day 4, by individually moving each joint about 15°. Special care should be taken not to compromise the viability of the transferred toe while the exercises are being performed. In the second week, the joint distal to the bony union site is moved through full range while the wrist is kept in neutral position. In the third and fourth weeks, the proximal joints are moved as well, avoiding full range of motion so as not to interfere with bone healing. A light-pressure
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tubular bandage or “coban” is also applied at this time, leaving the fingertips exposed. The patient is taught gentle massage. A protective splint is provided between exercises. As a general principle, the splint should be placed in a position that prevents stressing the repaired tendons or neurovascular structures. 3. Active motion stage (weeks 5 to 6): During this stage, gentle active exercise is added to the passive exercise, and the splint is changed to a dynamic one. During the sixth week, once the tendons are healed, blocking flexion and extension exercises are initiated. Compression bandages are always used to help reduce edema and minimize scar formation, which are additional aims of this rehabilitation stage. Ultrasound and scar massage are used to produce a softer scar and increase range of motion. 4. Activities of daily living training stage (weeks 7 to 8): Rehabilitation aims at providing tasks that require training to strengthen the muscle power and improve joint ROM. According to the patient’s capabilities, different manual jobs that simulate daily manual activities are assigned. 5. Prevocational training stage (week 8 ⫹): During this stage, vocational activities are designed to further improve muscle strength, hand dexterity, and coordination. To prevent claw deformity, the patient is encouraged to use extension splints during the night for at least 1 year. He or she is encouraged to resume normal activities using the reconstructed hand and sometimes to attend interactive group sessions with other patients who have also received toe-to-hand transfer.
Sensory Rehabilitation It is difficult to achieve functional sensory recovery after toe-to-hand transfer without sensory rehabilitation.9 Sensory reeducation helps the patient to interpret the altered sensory impulses reaching the brain from the peripheral nerves.7,53 It does not make axons grow faster or cause receptors to form, but it employs higher cortical functions such as concentration, learning, and memory to maximize sensory function provided by the regenerated nerves. The program of sensory reeducation is divided into early and delayed sensory reeducation. In the early stage, reeducation focuses on facilitating perception of touch submodalities with correct localization. Training is initiated when the patient can perceive with the reconstructed fingertip 30-cps vibrations from a tuning fork. Training is continued on the basis of a sequence of sensory recovery.7 Late-phase sensory reeducation focuses on size and shape discrimination and object identification. This
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program is begun following the recovery of touch sensation. The patient attempts to appreciate several objects with different textures, sizes, and shapes with the tip of the transferred toe instead of the adjacent normal finger surface. This stage can be implemented as a home rehabilitation program, and significant improvement is possible in the final result.51
CONCLUSION The metacarpal hand presents one of the most difficult and complex traumatic hand conditions, especially if the affliction is bilateral. The salient points to be considered in planning the reconstruction of metacarpal hands are optimal tissue preservation at initial surgery, adequate soft tissue coverage before toe transfer, meticulous preoperative planning, skillful microsurgical techniques, and well-planned early mobilization during postoperative rehabilitation. Microsurgical toe transfer techniques have enriched the repertoire of the hand surgeon. By using various types of toe transfers, the lost prehensile function of the metacarpal hand can be successfully reconstructed with acceptable donor site morbidity.
References 1. Albee FH: Synthetic transfer of tissues to form new fingers with restored function of the hand. Ann Surg 69:379–383, 1919. 2. Arana GB: Phalangization of the first metacarpal. Surg Gynaecol Obstet 40:859, 1925. 3. Bunnel S: The management of the non functional hand: Reconstruction v/s prosthesis. Artif Limbs 4:76–102, 1957. 4. Chen HC, Tang YB, Wei FC, et al: Finger reconstruction with triple toe transfer from the same foot for a patient with a special job and previous foot trauma. Ann Plast Surg 27:272–277, 1991. 5. Chen MH, Wei FC, Santama E, Chen HC: Single versus double arterial anastomosis in combined second and third toe transfer. Plast and Reconstr Surg 102(7):2408–2412, 1998. 6. Clayton M: Index ray amputation. Surg Clin North Am 43:367, 1967. 7. Dellon AL: Sensory re-education after fingertip injury and reconstruction. In Foucher G (ed): Fingertip and Nailbed Injuries. New York, Churchill Livingstone, 1991, pp 27–39. 8. El-Gammal TA, Wei FC, Ma HS, et al: Biomechanical analysis of foot function following transfer of the second toe. J Hand Surg (submitted). 9. El-Gammal TA, Wei FC, Wu JJ, Chen CM: Biomechanical analysis of foot function following transfer of combined second and third toes from the same foot. J Hand Surg (submitted). 10. Foucher G, Moss AL: Microvascular second toe to finger transfer: A statistical analysis of 55 transfers. Br J Plast Surg 44:87–90, 1991.
11. Frykman GK, O’Brien BM, Morrison WA, MacLeod AM: Functional evaluation of the hand and foot after one-stage toe-to-hand transfer. J Hand Surg 11A:9–17, 1986. 12. Gordon L, Leitner DW, Buncke HJ, Alpert BS: Hand reconstruction for multiple amputation by double microsurgical toe transfer. J Hand Surg 10A:218–225, 1985. 13. Gottlieb O: Metacarpal amputation: The problem of four fingered hand. Acta Chir Scand (suppl). 343:132, 1965. 14. Huguier PC: Replacement of du ponce par son metacarpien, par l’agrandissement du premier espace interroseux. Arch Gen Med 1:78, 1874. 15. Le Quang C: Digital reconstruction by microvascular transfer. In Campbell DA, Tubiana R (eds): Mutilating Injuries of the Hand. Edinburgh, Churchill Livingstone, 1984, pp 107–119. 16. Lister GD, Kalismann M, Tsai TM: Reconstruction of the hand with free microneurovascular toe-to-hand transfer: Experience with 54 toe transfers. Plast Reconstr Surg 71:372–384, 1983. 17. Matev IB: The bone lengthening method in hand reconstruction: Twenty years’ experience. J Hand Surg (Am) 14(2):376–378, 1989. 18. Michon J: The metacarpal hand. In Campbell DA, Tubiana R (eds): Mutilating Injuries of the Hand. Edinburgh, Churchill Livingstone, 1984, pp 88–92. 19. Michon J, Jandeux M: Le main metacarpienne. Ann Plast 19:97–104, 1974. 20. Michon J, Dolich BH: The metacarpal hand. Hand 6:285, 1974. 21. Muller GM: Construction of a palmar post. Br J Plast Surg 3:47–49, 1950. 22. Neimkin RJ, May JW, Roberts J, Sunder N: Continuous axillary block trough an indwelling Teflon catheter. J Hand Surg 9A:830–833, 1984. 23. Nicolle FV, Woodhouse FM: Restoration of sensory function in severe degloving injuries of the hand. J Bone Joint Surg 48(A):1511–1518, 1966. 24. Nilsson H, Jonasson T, Ringquist I: Treatment of digital vasopastic disease with the calciumentry blocker, nifedipine. Acta Med Scand 215:135–139, 1984. 25. O’Brian BM, Brennen MB, Macleod AM: Simultaneous double toe transfer for severely disabled hands. Hand 10(3):232–240, 1978. 26. Peze W, Iselin F: Cosmetic amputation of the long finger with carpal osteotomy. Ann Chir Main 3:232–236, 1984. 27. Rose EH, Buncke HJ: Simultaneous transfer of right and left second toes for reconstruction of amputated index and middle fingers in the same hand: Case report. J Hand Surg 5:590–593, 1980. 28. Strauch RJ, Wei FC, Chen SHT: Composite finger metacarpophalangeal joint reconstruction in combined second and third free toe to hand transfers. J Hand Surg 18A:972, 1993. 29. Swanson AB: Restoration of hand function by the use of partial or total prosthetic replacement. J Bone Joint Surg 45(A):276–283, 1963. 30. Tan BK, Wei FC, Chang KT, et al: Combined third and fourth toe transfer. Hand Clin 15(4):589–596, 1999. 31. Tsai TM: Second and third toe transfer to a transmetacarpal amputated hand. Ann Acad Med Singapore 8:413–418, 1979.
32. Tsai TM, Jupiter JB, Wolff TW, Atasoy E: Reconstruction of severe transmetacarpal mutilating hand injuries by combined second and third toe transfer. J Hand Surg 6A:319, 1981. 33. Tubiana R, Roux JP: Phalangization of the first and fifth metacarpal: Indications, operative techniques and results. J Bone Joint Surg Am 56:447–457, 1974. 34. Valauri FA, Buncke HJ: Thumb and finger reconstruction by toe-to-hand transfer. Hand Clin 8:551–574, 1992. 35. Wei FC: Tissue preservation in hand injury: The first step to toe-to-hand transfer (editorial). Plast Reconstr Surg 102:2497–2501, 1998. 36. Wei FC, Chen HC, Chuang CC: Reconstruction of a hand, amputated at the metacarpophalangeal level, by means of combined second and third toes from each foot: A case report. J Hand Surg 11(3):340–344, 1986. 37. Wei FC, Chen HC, Chuang CC, Chen SHT: Microsurgical thumb reconstruction with toe transfer: Selection of various techniques. Plast Reconstr Surg 93:345, 1994. 38. Wei FC, Chen HC, Chuang CC, Noordhoff MS: Reconstruction of a hand amputated at the metacarpophalangeal joint level by means of combined second and third toes from each foot. J Hand Surg 11A:340, 1986. 39. Wei FC, Chen HC, Chuang CC, Noordhoff MS: Simultaneous multiple toe transfers in hand reconstruction. Plast Reconstr Surg 81:366, 1988. 40. Wei FC, Chen HC, Chuang CC, Noordhoff MS: Combined second and third toe transfer. Plast Reconstr Surg 84:651, 1989. 41. Wei FC, Chen HC, Chuang CC, et al: Simultaneous multiple toe transfers in hand reconstruction. Plast Reconstr Surg 81:366–374, 1988. 42. Wei FC, Chen HC, Chuang DC, et al: Aesthetic refinements in toe-to-hand transfer surgery. Plast Reconstr Surg 98:485–490, 1996. 43. Wei FC, Chen HC, Chuang CC, et al: Reconstruction of the thumb with a trimmed-toe transfer technique. Plast Reconstr Surg 82(3):506, 1988.
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44. Wei FC, Coessens B, Ganos D: Multiple microsurgical toeto-hand transfer in the reconstruction of the severely mutilated hand: A series of fifty-nine cases. Ann Chir Main Memb Superior 16:177–187, 1992. 45. Wei FC, Colony MH: Microsurgical reconstruction of the distal digital function. Clin Plast Surg 16:443, 1989. 46. Wei FC, Cossens B, Ganos D: Multiple microsurgical toe to hand transfer in the reconstruction of mutilated hand: A series of 59 cases. Ann Chir Main Memb Super 11:177, 1992. 47. Wei FC, El Gammal TA: Toe-to-hand transfer: Current concepts, techniques and research. Clin Plast Surg 23:103, 1996. 48. Wei FC, El Gammal TA, Lin CH, et al: Metacarpal hand: Classification and guidelines for microsurgical reconstruction with toe transfers. Plast Reconstr Surg 99:122, 1997. 49. Wei FC, Epstein MD, Chen HC, et al: Microsurgical reconstruction of distal digits following mutilating hand injuries: Results in 121 patients. Br J Plast Surg 46:181–186, 1993. 50. Wei FC, Lutz BS, Cheng SL, et al: Reconstruction of bilateral metacarpal hands with multiple toe transplants. Plast Reconstr Surg 104:1698–1704, 1999. 51. Wei FC, Ma HS: Delayed sensory reeducation after toe-tohand transfer. Microsurgery 16:583–585, 1995. 52. Wei FC, Seah CS, Chen HC, et al: Functional and esthetic reconstruction of a mutilated hand using multiple toe transfers and iliac osteocutaneous flap: A case report. Microsurgery 14:388–393, 1993. 53. Wei FC, Silverman TS, Hsu WM: Retrograde dissection of the vascular pedicle in toe harvest. Plast Reconstr Surg 96:1211–1214, 1995. 54. Wei FC, Strauch RJ, Chen HC: Reconstruction of four damaged or destroyed ipsilateral fingers with free toe to hand transfer. Plast Reconstr Surg 93:608–614, 1994. 55. Wei FC, Yim KK: Pulp plasty after toe-to-hand transfer. Plast Reconstr Surg 96:661–666, 1995. 56. Yim KK, Wei FC: Interosseous wiring in toe-to-hand transfer. Ann Plast Surg 35:66–69, 1995. 57. Yim KK, Wei FC: Secondary procedures to improve function after toe-to-hand transfers. Br J Plastic Surg 48:487–491, 1995.
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21 The Mutilated Wrist Moheb S. Moneim, MD, FRCS Steven D. Young, MD Elizabeth A. Mikola, MD
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Reconstruction of severe, combined injuries of the upper extremity has become commonplace for the hand surgeon. Because of the superficial location of the structures traversing the wrist, this is an area that is particularly susceptible to mutilating injuries. The hand surgeon must be cognizant of a wide spectrum of injuries that run the gamut from an innocuousappearing sharp laceration at the wrist to a severely mangled wrist. The surgeon must realize the severe loss of function—and possibly the hand itself—that may occur from the less impressive but much more common injury: the spaghetti wrist. Therefore in this chapter, we will also discuss the spaghetti wrist, which is often the equivalent of a physiologic amputation.
MECHANISM OF INJURY Mutilating injuries of the wrist are caused by a variety of motor vehicle, industrial, agricultural, ballistic, and household accidents. Many mutilating injuries are caused by farm machinery such as corn pickers and grain augers.4 We have seen a number of rope avulsions of the wrist and injuries from rollover motor vehicle accidents while the arm was outside the window of the car. Regardless of the etiology, injury is produced by sharp laceration, tearing, crushing, avulsion or crush-avulsion, in increasing order of severity. It is important to understand the mechanism of injury, as this will affect surgical decision making and patient prognosis.
ASSESSMENT The emergency room evaluation of the wrist is frequently inaccurate. This occurs for a variety of reasons, including pain, anxiety, or intoxication. Gibson reviewed the accuracy of the preoperative examination in zone 5 lacerations, finding an average of three errors per patient.3 However, this should be done to give the surgeon an estimate of the required intervention. Radiographs with three views are necessary to detect a possible fracture or ligamentous injury. Assessing capillary refill, skin color and two-point discrimination, as well as observing the resting position of the fingers and the location of the injury, is required. One should try to test for individual flexor digitorum superficialis, flexor digitorum profundus, and extensor tendon function; however, this is the most difficult part of the examination as the patient might be quite apprehensive about moving the digits secondary to pain and discomfort. 291
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Patient comfort should be assured by administering appropriate intravenous narcotic medication after operative consent has been obtained. Tetanus prophylaxis and prophylactic intravenous antibiotics should be administered. A first-generation cephalosporin such as cefazolin should be given for Gram-positive coverage. This should be combined with an aminoglycoside for Gram-negative coverage if the wound is severely contaminated. Antibiotics should be given before surgery and for 48 to 72 hours following the initial surgery. Assessment of the circulatory status of the hand is of paramount importance and should receive priority. This will determine the urgency of the operative intervention. Although more frequently applied to the lower extremity, a mangled extremity severity score (MESS) has been devised and can be applied to the upper extremity.15 The MESS is a scoring system that was proposed in an effort to more clearly define which limbs should be reconstructed and which should be immediately amputated. The system uses the magnitude of energy that caused the trauma, ischemia, shock, and patient age as factors in determining the score. A review of 43 severely injured upper extremities at our institution showed that all nine injuries with a MESS greater than or equal to seven were amputated. The 34 extremities with a MESS of less than seven were salvaged. There were 13 extremities with Grade III fractures. Five of them with a MESS of seven and above had amputation. Those were all Grade III C fractures, occurring proximal to the hand, including 18 distal radius and ulna fractures. Although amputations and prosthetic fittings should not be viewed as treatment failures, one must realize that this approach is more applicable to the lower extremity. A partially functional hand is usually better accepted by the patient than a prosthesis is. Therefore the surgeon should make certain that all reconstruction options are exhausted before proceeding with amputation.
without tourniquet control. This allows for use of the tourniquet in performing vessel and nerve repair. It is important that the tourniquet be inflated for no longer than 2 hours continuously. If additional time is needed, a 15- to 20-minute reperfusion interval is necessary before reinflation.19 Additionally, one must make certain that a good pressure head is established from an injured artery prior to repair or failure of the anastamosis is likely; obviously, this cannot be evaluated under tourniquet control. Finally, one should avoid reinflation of the tourniquet after a vessel repair, as this might lead to stasis at the suture line and subsequent thrombosis. Initially, the wound should be aggressively irrigated and debrided. All obviously devitalized tissue should be excised. Skin should be debrided to healthy, bleeding edges. Bone without soft tissue attachments should be removed. No devitalized muscle should be left behind, as this could lead to wound infection. The muscle should be evaluated for color, consistency, capacity to bleed, and contractility; nonviable muscle will be gray, lack bleeding when debrided, and demonstrate no contractions when touched with the electrocautery. If there is any doubt about the adequacy of debridement, serial evaluations performed over several days are necessary. One should remember that an aggressive mechanical debridement is more important than irrigation or antibiotics in preventing infection. Figure 21-1 illustrates adequate debridement in a patient who had extensive soft tissue loss after a fall. At this point, coverage is undertaken with a groin flap and split-thickness skin grafting (Fig. 21-2). Irrigation is performed with several liters of sterile saline solution utilizing the hydrojet pulse lavage system. We believe there is no advantage to utilizing antibiotics in the irrigation fluid. In addition, it is not worthwhile to obtain cultures at the time of surgery. These should be
MANAGEMENT The patient is taken to the operating room on an emergent basis. Administration of general anesthesia is preferable, but a long-lasting axillary block with bupivacaine can also be used, providing 6–8 hours of adequate anesthesia. Tourniquet pressure is usually set at 250 mm Hg for adults and between 150 and 200 mm Hg for children. These values may vary according to the patient’s blood pressure. If the wound is grossly contaminated, exsanguination should be avoided. The timing of tourniquet inflation is based on surgeon preference. We prefer to do the initial irrigation, debridement, bony fixation, and tendon repairs
FIGURE 21-1. Dorsal wrist and forearm avulsion injury with exposed extensor tendons that will necessitate flap coverage.
FIGURE 21-2. Intraoperative photograph illustrating the groin flap in place and split-thickness skin grafting.
obtained after debridement if infection develops despite adequate empiric antibiotic treatment. Bony fixation is the first reconstructive priority. With severe comminution or bony loss, standard fixation methods may give way to creativity. When possible, fractures should be treated as they would be in the isolated situation. For example, volar plate fixation is appropriate for volar shear fractures of the distal radius and open reduction and internal fixation with ligament reconstruction for perilunate injuries. An attempt should be made to approach the fracture through the wound. If skin incisions are made, acute flap angles less than 60° and thin skin bridges should be avoided.9 Internal fixation is preferred for wound care purposes; when
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gross contamination or severe fracture instability exists, it might be necessary to place an external fixator, at least temporarily. Early bone grafting might also be necessary to prevent bony collapse. Although some concern might exist about resorption of the bone graft if placed early, waiting will lead to fracture healing in a collapsed position. In cases in which extensive bone loss has occurred, a proximal row carpectomy can be performed at the time of initial debridement.17 Alternatively, a wrist arthrodesis with iliac crest bone graft can be planned at the time of wound coverage or later. We prefer to perform the definitive bony procedure before or at the time of wound coverage (Figs. 21-3 and 21-4). A primary wrist arthrodesis, tendon transfers, median nerve repair, and groin flap were done to manage a wrist mutilated by a close-range rifle blast. At one-year follow-up, the groin flap had decreased in size (Fig. 21-5). Stiffness is a common complication in these injuries. Tenolysis was later performed because of limited digital flexion (Fig. 21-6). Tendon repairs should follow bony fixation. Extensor tendon repairs are performed before repair of the flexor tendons. At the wrist level, the extensor tendons allow for placement of a core suture. This is usually performed with 3-0 Ethibond utilizing a fourstrand cruciate repair. This has been found to be approximately twice as strong as a Kessler suture and takes about the same amount of time for suture placement. At 6 weeks, the suture strength for the four-strand is approximately 52 Newtons compared to 28 Newtons for the two-strand repair.10 A running circumferential
FIGURE 21-3. Anteroposterior and oblique views of the right wrist with significant bony injury in the carpal and metacarpal regions after a close-range rifle blast.
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FIGURE 21-4. Anteroposterior and lateral X-rays after primary wrist fusion using a 3.5-mm LC-DCP plate and screws with iliac crest bone grafting. Distal ulna excision and K-wire fixation of the metacarpal fractures were also performed primarily.
epitendinous stitch of 5-0 Ethibond is added to the repair to decrease gap formation.7 The same suture technique is used for the flexor tendons. On the dorsum of the wrist, it is important to repair or reconstruct the extensor retinaculum to prevent tendon bowstringing. On the volar side of the wrist, the flexor retinaculum overlying the carpal tunnel might need to be divided for added exposure. This structure does not need to be repaired or reconstructed. If tendon substance has been lost, multiple treatment options are available. These include acute
intercalary tendon grafting, transposition of tendon substance from the proximal or distal stump to span a defect, acute tendon transfers, placement of silicone rods with plans for later reconstruction, passive tenodesis, and debridement with appropriate joint arthrodeses. With extensor tendon loss, which does not involve all of the digits, suturing the injured extensor digitorum communis tendons into intact extensor digitorum communis tendons is preferred. Extensor indicis proprius or extensor digiti minimi tendons may also be transferred. If none of these are feasible, the flexor digitorum
FIGURE 21-5. Well-healed groin flap appearance on the dorsum of the hand at 1 year following surgery.
FIGURE 21-6. A limited amount of flexion is seen prior to release of extrinsic extensor contractures.
superficialis of the ring or middle fingers may be used. If a proposed donor tendon has been injured and repaired, it should not be chosen for transfer. Other transfer options for finger extension include the wrist flexors, the flexor carpi ulnaris, flexor carpi radialis, or pronator teres. Additionally, transfer through the interosseous membrane in the face of an associated wrist injury might subject the transfer to an unacceptable, scarred bed. If the bed is severely damaged, it might be necessary to place silicone rods deep to a flap and plan for later reconstruction. A less desirable treatment would be tendon debridement without reconstruction; this might be acceptable in the low demand patient. The retained intrinsic tendons allow for extension of the interphalangeal joints and maintain reasonable function in the presence of intact extrinsic flexors. Finally, all flexor tendon lacerations should be repaired when possible. Alternatives include a superficialis finger with a distal interphalangeal joint arthrodesis or a profundus finger. Wound coverage is achieved after a clean bed is obtained, usually several days after injury. We prefer to do that at 5 to 7 days. Flap coverage is required whenever bone or tendon is exposed. In cases of massive loss involving the dorsum of the distal forearm and wrist and hand area, we use a combination of split-thickness skin graft for the forearm and a flap for the hand. We prefer to use a pedicled groin flap for several reasons. This flap can cover the entire dorsum of the hand and wrist, does not require microsurgical expertise, and is very reliable.8 Figure 21-7 shows the appearance of a groin flap divided at 3 weeks. Patients can tolerate this position for up to 3 weeks. The flap is then detached, and tendon reconstruction can be done several months later if needed. An alternative can be a free flap or a pedicled radial forearm
FIGURE 21-7. A groin flap demonstrates excellent perfusion from the surrounding bed after division and inset. At this stage, the bulk of the flap is evident.
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flap; however, we prefer a groin flap for the above reasons. When the wound is being explored initially, the radial and ulnar arteries should be identified, and vessel clamps should be placed on the injured vessel(s). The ends should be trimmed back to healthy intima, and pulsatile blood flow should be confirmed from the proximal segment before the anastomosis is performed. If only one vessel is injured, the presence of retrograde flow should be confirmed. If the arterial ends can be approximated without tension, they should be repaired with 80 nylon in simple interrupted fashion. The anterior wall is sutured first using a triangulation technique. Two stitches are placed at 120° to each other, and the intervening space is closed with two sutures; the posterior wall is then repaired by placing a central stitch and two sutures on each side. Although the repairs may be done with loupe magnification, better visualization is obtained by using the operating microscope. Similarly, we advocate using the microscope for the nerve repair(s). With a crush or avulsion injury, one might need to place a vein graft to span an arterial defect. The donor may be the saphenous vein from the lower leg or the cephalic vein. The vein should be marked with a suture or vessel clamp when harvested for proper orientation. In addition, saline can be used to irrigate the lumen; the presence of valves will allow flow in only one direction, and perforations of the vein can be identified and repaired. Irrigation of the anastomotic site with heparinized saline during the repair is advantageous. Once the anastomoses have been performed, the patient is given a single bolus of dextran. Postoperative thromboprophylaxis consists of enteric-coated aspirin, 325 mg per day. The nerves are next repaired with 8-0 nylon suture in simple epineural fashion. Proper orientation is critical to avoid suturing sensory fascicles to motor fascicles. The longitudinal vasa nervorum is helpful in this regard. Unlike the situation with the arteries, one does not need to plan for nerve grafting acutely. This can be done several weeks after the injury, utilizing the sural nerve. Two or three cable grafts might be needed for each nerve, and each should be approximately 15% longer than the measured defect. The overall prognosis is inversely proportional to the length of the nerve grafted, particularly if it is greater than 5 centimeters.16 At the completion of the procedure, the extremity is placed in a dorsal splint with the wrist volar-flexed 30°, the metacarpophalangeal joints flexed to 70°, and the interphalangeal joints in full extension. Postoperative intravenous antibiotics are continued while in the hospital, and the patient is sent home with 2 to 3 days of additional oral antibiotics; the standard protocol consists of intravenous cefazolin followed by oral cephalexin.
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Sutures are removed at 7 to 10 days. Early finger motion is instituted, but the wrist should be immobilized for 3 to 4 weeks to allow for healing of the nerve and arterial repairs. Occupational therapy may be continued for several months and consists of range of motion exercises, strengthening exercises, sensory reeducation, and splinting to control clawing and first webspace contracture. Improvement in function may continue for several years, with the final result ultimately depending on nerve recovery.1,12
THE “SPAGHETTI WRIST” An extensive laceration on the volar aspect of the wrist is frequently referred to as a “spaghetti wrist”; other common eponyms include “flexor full-house,” “suicide wrist,” and “glass-punch injury.” Even innocuousappearing lacerations can produce a great deal of damage because of the close proximity of all the structures in the volar wrist. As many as 16 major structures may be damaged, including 12 tendons, 2 nerves, and 2 arteries.13,18 Despite the frequency of this injury, there is a paucity of literature addressing the topic. Likewise, there is no standard definition of what constitutes a “spaghetti wrist.” The number of injured structures that are required to classify a spaghetti wrist has ranged from three to as many as ten. Lack of bony injury is implied; however, in the case of a severely mutilated wrist, it is not uncommon to see this injury combined with fractures, dislocations, degloving, or dorsal wrist injuries, all of which worsen the overall prognosis. This injury is predominantly seen in young males with a male-to-female ratio of 7 to 3.18 The average age has ranged from 22 to 29 years. Rarely is this injury seen in individuals older than 40 years old.13 In developed countries, most often these injuries are secondary to a glass cut.5 In Puckett and Meyer’s series, 31 of 38 injuries occurred from a glass cut; 27 of these 31 were due to an intentional thrusting of the hand through a plate glass window.13 Yii presented 44 of 52 cases of “spaghetti wrist” caused by broken glass.20 The average number of structures injured is usually between seven and nine.13 The hand is pronated, and the ulnar border is the leading contact surface in the “glass-punch” injury. Thus there is a predilection for injury to the ulnar aspect of the wrist. In the study by Weinzweig and coworkers, the most common pattern of injury (41.7%) involved the ulnar triad consisting of the flexor carpi ulnaris, ulnar artery, and ulnar nerve.18 Overall, the flexor carpi ulnaris was the most commonly injured structure, seen in 66.7% of individuals. This was followed in frequency by the median nerve (60%), ulnar nerve (58.3%), and ulnar artery (56.7%). Despite its superficial location, the palmaris longus was
lacerated in only 48.3% of patients. Sixty percent of patients had at least one arterial injury, most being the ulnar artery; the radial artery was injured in only 16.7% of individuals. One-third of patients had no arterial injury; thus both arteries were injured rarely (6.7%). Injury to both nerves occurred 23.3% of the time. A physiologic amputation occurs when both nerves are lacerated (almost one-fourth of the time). Puckett and Meyer also found that nerves were cut more frequently than arteries (94.7% versus 68.4%).13 Rogers found a mean of 9.3 flexor tendons divided per case in his series of 11 patients.14 Weinzweig and coworkers managed these patients surgically with extensile exposure and identifying, and tagging of lacerated structures.18 The structures were repaired from deep to superficial. Neurovascular structures were repaired with the operating microscope. Rehabilitation included dynamic splinting with active extension and passive finger flexion at zero to four weeks. At four to six weeks, the patients began protective early motion. The splint was removed at six to eight weeks and activity was progressed. There was return to full activity at 12 weeks. Range of motion was excellent in 12 of 19 patients and good in the other 7 in Weinzweig’s series.18 Intrinsic recovery was good in 7 of 12 patients and fair to poor in 5 patients. Sensory return was somewhat disappointing. Seven of 12 recovered protective sensation only and 5 of 12 regained two-point discrimination ranging from 7–12 mm in 3 patients and 2–6 mm in 2 patients.
CONCLUSION Establishing blood flow to the extremity is the highest priority for obvious reasons. When both arteries are injured, repair of both might prove wise. Although repair of a single vessel is usually successful in this situation, the consequence of postoperative thrombosis is significant. Additionally, cold intolerance might be more severe. Preoperative assessment of capillary refill in the presence of double arterial injury might be misleading; one should not assume that the interosseous vessels are supplying adequate blood flow to the hand, as this is rarely the case. Kleinert demonstrated continuous blood flow to the digits in only one of 200 patients when both the radial and ulnar arteries were compressed.6 In Gelberman’s series, none of the 34 patients with a single arterial injury had inadequate circulation to the hand.2 This does not imply, however, that the artery should be ligated; this could potentially lead to postoperative symptoms of cold intolerance if an associated nerve injury exists. Cold intolerance infrequently occurs in the absence of combined nerve and artery injury. Despite repair attempts, there is a significant postoperative
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SUMMARY Because each structure responsible for hand function passes through the narrow confines of the wrist, it is easy to see how a simple laceration can produce
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devastating functional consequences. These injuries virtually always call for emergent surgical intervention. The surgeon’s knowledge of anatomy is tested, as are his or her microvascular skills. The patient population involved is rarely compliant, which may further compromise surgical outcome. However, despite a noncompliant patient, one must understand that a good result is possible, though complete return of motor and sensory function is very unlikely.
References 1. Gaul JS: Intrinsic motor recovery: A long-term study of ulnar nerve repair. J Hand Surg 7:502–508, 1982. 2. Gelberman RH, Nunley JA, Koman LA, et al: The results of radial and ulnar arterial repair in the forearm: Experience in three medical centers. J Bone Joint Surg Am 64:383–387, 1982. 3. Gibson TW, Schnall SB, Ashley EM, Stevanovic M: Accuracy of the preoperative examination in zone 5 wrist lacerations. Clin Orthop 365:104–110, 1999. 4. Gupta A, Wolff TW: Management of the mangled hand and forearm. J Am Acad Orthop Surg 3(4):226–236, 1995. 5. Hudson DA, deJager LT: The spaghetti wrist: Simultaneous laceration of the median and ulnar nerves with flexor tendons at the wrist. J Hand Surg 18B:171–173, 1993. 6. Kleinert HE, Schepel S, Gill T: Flexor tendon injuries. Surg Clin of N Am 61(2):267–286, 1981. 7. Kleinert JM, Fleming SG, Abel CS, Firrell J: Radial and ulnar artery dominance in normal digits. J Hand Surg 14A:504–508, 1989. 8. Li Y, Wang J, Lu Y, Huang J: Resurfacing deep wound of upper extremities with pedicled groin flaps. Burns 26:283–288, 2000. 9. Lister GD, Pederson WC: Skin flaps. In Green DP (ed): Green’s Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, pp 1783–1850. 10. McLarney E, Hoffman H, Wolfe SW: Biomechanical analysis of the cruciate four-strand flexor tendon repair. J Hand Surg 24A:295–301, 1999. 11. Moneim MSA, Omer Jr GE: Clinical outcome following acute nerve repair. In Omer GE Jr (ed): Management of Peripheral Nerve Problems, 2nd ed. Philadelphia, WB Saunders, 1998, pp 414–419. 12. Omer Jr GE, Eversmann WW Jr: Peripheral nerve problems. In Burkhalter SE (ed): Orthopedic Surgery in Vietnam. Washington, DC, Office of the Surgeon General and the Center of Military History, US Army, 1994, pp 155–188. 13. Puckett CL, Meyer VH: Results of treatment of extensive volar wrist lacerations: The spaghetti wrist. Plast Reconstr Surg 75(5):714–719, 1985. 14. Rogers GD, Henshall AL, Sach RP, Wallis KA: Simultaneous laceration of the median and ulnar nerves with flexor tendons at the wrist. J Hand Surg 15A: 990–995, 1990.
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thrombosis rate. In the case of a single arterial laceration, patency rates at follow-up have been shown to be slightly less than 50%. This is consistent with early opinion that a repaired vessel will usually thrombose in the presence of an intact arterial supply to the extremity. In the case of double arterial injury with both repaired, at least one artery will remain patent more than 90% of the time. Fifty percent exhibited thrombosis of a single artery, and 41% had both arteries patent. It is uncommon for both arteries to thrombose when the mechanism of injury is a sharp laceration; this is more likely when a crush-avulsion, gunshot wound, or saw injury is responsible. The overall success rate for all repairs in Gelberman’s study was 54%: 47% for single-artery lacerations and 57% for two-artery lacerations. If both arteries were lacerated, repair of a single vessel was successful in six of six patients.2 The major determinant of postoperative outcome is the status of nerve recovery. Positive prognostic factors as determined by Sunderland include children, early repairs, single-function nerve, distal repairs, and short nerve grafts.16 Repair of a distal “spaghetti wrist” without the need for nerve grafting is a favorable prognostic factor. However, both the median (90% sensory, 10% motor) and ulnar (55% sensory, 45% motor) nerves are mixed nerves, and, most important, these injuries usually occur in the adult population, thus severely decreasing the chance of full recovery. In fact, Moneim and Omer have stated that “return of normal function following nerve injury and repair in adults is not possible.”11 They also thought that sensory recovery was slower and less satisfactory than motor recovery. Gaul as well as Omer and Eversmann have noted continued recovery of intrinsic motor recovery for up to 6 to 8 years postoperatively in adults; the time frame in children is in the range of 2 years postoperatively.1,12 Utilizing the Medical Research Council Grading System for Nerve Recovery, Moneim and Omer demonstrated M4 or better recovery and S3 or better recovery in 62% and 84%, respectively, of all end-to-end repairs of the median and ulnar nerves.11 In the distal forearm, these respective values for the median nerve were 69% and 92%; for the ulnar nerve, they were 67% and 87%. Interestingly, ulnar nerve repairs performed by grouped fascicular method demonstrated 84% M4 or better function versus 45% for the median nerve repairs. Nevertheless, results are usually felt to be similar for grouped fascicular and epineural repairs. We perform epineural repairs utilizing the operating microscope.
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15. Slauterbeck JR, Britton C, Moneim MS, Clevenger FW: Mangled extremity severity score: an accurate guide to treatment of the severely injured upper extremity. J Orthop Trauma 8(4):282–285, 1994. 16. Sunderland S: Nerve injuries and their repair: A critical appraisal. New York, Churchill Livingstone, 1991. 17. Torres JE, Freeland AE, Barbieri RA: Primary proximal row carpectomy. Orthopedics 21(3):377–379, 1998.
18. Weinzweig N, Chin G, Mead M, Gonzalez M: “Spaghetti wrist”: Management and results. Plast Reconstr Surg 102(1):96–102, 1988. 19. Wilgis EFS: Observations on the effects of tourniquet ischemia. J Bone Joint Surg 53A:1343–1346, 1971. 20. Yii NW, Urban M, Elliot D: A prospective study of flexor tendon repair in zone 5. J Hand Surg 23B:642–648, 1998.
22 Krukenberg’s Operation Raoul Tubiana, MD, Hon FRCS (Ed)
The objective of Krukenberg’s operation, also called “digitalization of the forearm,” is to fashion the forearm into an active pincer with two opposable limbs covered with sensate skin. This procedure was devised by Krukenberg3 in 1917 with the purpose of providing the individual whose hand had been amputated with a stump possessing useful autonomous function. The technique has also been described by Kallio,2 who has considerable experience with the operation. Additional refinements have been described by Swanson,5 Maurer,4 and Tubiana.6–8
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TECHNIQUE Skin Incisions Two forearm skin flaps are used to cover each limb of the pincer. It is essential that the terminal portions of each limb and their opposing surfaces, used for gripping objects, have good sensibility. The anterior flap is based on an ulnar pedicle (Fig. 22-1). The incision begins 5 to 6 cm distal to the elbow, just medial to the longitudinal axis of the forearm, and extends radially and distally 1 cm from the radial border of the forearm to the edge of the stump. This flap is innervated predominantly by the medial cutaneous nerve of the forearm. The posterior flap is based on a radial pedicle. The incision is the reverse. It is innervated predominantly by the lateral cutaneous nerve of the forearm. Swanson5 employs an approach similar to that advocated by Bunnell1 for the treatment of syndactyly. One of two V-shaped, proximally based flaps is used to establish the webspace. The skin flaps are raised, together with the underlying superficial aponeurosis, to ensure adequate vascularity.
Muscle Dissection The muscles of the forearm are divided into two groups. One group is required for opening the pincer; these include the adductors of the radius: the biceps, brachioradialis, and extensor carpi radialis. The other group is required for closure of the pincer; these include the radial adductors, the pronator teres, and the supinator. For power grip, it is important that the ulna be stabilized by contraction of the triceps, the brachialis, and the anconeus. The other forearm muscles are purely accessory; one should not hesitate to remove them if their bulk makes skin closure difficult. There is considerable variation from patient to patient. The preserved muscles are divided into two groups: the muscles arising from the medial epicondyle and those arising from the lateral epicondyle. 299
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Biceps
Pronator teres Supinator
Anterior incision
Posterior incision
FIGURE 22-1. The two cutaneous flaps and the muscles activating the radius. The important muscles activating the radius are almost all proximal: (1) the biceps, (2) the pronator teres, and (3) the supinator. The stabilizers of the ulna are also proximal: (1) the triceps, (2) the brachialis, and (3) the anconeus muscles. (From Tubiana R: Krukenberg’s operation. Orthop Clin North Am 12(4):821, Fig 1, 1981.)
Anteriorly, the first step is to expose the pronator teres (Fig. 22-2), which marks the upper limit of separation of the two arms of the pincer. Dissection proceeds between the brachioradialis and the flexor carpi radialis (Fig. 22-3) and then between the pronator teres and the flexor digitorum superficialis (Fig. 22-4). An alternative when the muscles are narrow is to split the flexor digitorum superficialis between the bellies going to the middle and ring fingers. The muscle arcade is divided. On a deeper plane, one should dissect between the flexor digitorum profundus on the ulnar side and the flexor pollicis longus radially. Posteriorly (Fig. 22-5), one passes between the extensor digitorum communis radially and the extensor digiti minimi ulnarly (Fig. 22-6), then in a deeper plane between the abductor pollicis longus radially and the extensor indicis proprius ulnarly. The pronator quadratus, the flexor digitorum profundus and the flexor pollicis
FIGURE 22-2. The anterior flap has an ulnar pedicle. The pronator teres, which marks the upper limit of separation of the two arms, is exposed.
longus are resected in the anterior compartment and, if necessary, also the flexor carpi radialis and palmaris longus. In the extensor compartment, the abductor pollicis longus, extensor pollicis brevis, and extensor pollicis longus are resected. The extensor carpi radialis and the extensor digitorum communis may also be excised. Both surfaces of the interosseous membrane are now exposed.
FIGURE 22-3. Anterior dissection of the muscles.
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FIGURE 22-4. Transverse section at the middle third of the forearm showing the anterior and posterior approaches toward the interosseous membrane. (From Tubiana R, Krukenberg procedure. In Tubiana R, Gilbert A, Masquelet A (eds): An Atlas of Surgical Techniques of the Hand and Wrist. London, Martin Dunitz, p 46, Fig 4, 1999.)
FIGURE 22-5. The posterior skin flap has a radial pedicle.
FIGURE 22-6. The posterior muscles of the forearm are exposed.
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22
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Resection of Nerves The median nerve is divided as it emerges from the pronator teres, and its distal segment is resected (Fig. 22-7). The ulnar nerve will be directed to the ulnar limb of the pincer; its distal edge is resected away from the skin suture line. The posterior interosseous nerve to the extensor muscles is preserved. The interosseous vascular bundles are identified at the proximal end of the interosseous membrane and resected. As a rule, the motor nerves to muscles that are to be discarded are divided proximally, whereas the radial and ulnar vessels are ligated as distally as possible.
Resection of the Interosseous Membrane Both surfaces of the interosseous membrane are exposed. The membrane is divided throughout its length, first along its ulnar periosteal attachment, then along its radial attachment.
Separation of the Bones The ulnar and radial rays are separated after complete division of the interosseous membrane. The bones may be separated widely (by 10 to 12 cm) at the ends in the adult (Fig. 22-8); they are cut 1 to 2 cm proximal to the upper edge of the pronator quadratus. One must avoid separating the limbs of the pincer too forcefully because the proximal radioulnar joint can be damaged. The resection must not be proximal to the insertion of the pronator teres.
FIGURE 22-8. The two skin flaps are wrapped around the two arms of the pincer.
The optimal length of the arms of the pincer in the adult is 12 to 14 cm (this length does not include the distance between the elbow crease and the commissure of the pincer). However, sometimes one may have to accept much shorter arms. Short arms measuring only 7 to 8 cm are nevertheless agile and useful because the muscles activating the pincer are mostly proximal5 (Fig. 22-9). In juvenile cases, the distal ulnar and radial epiphyseal plates are carefully preserved. In congenital agenesis, if a digit is present at the end of the stump, it should be retained with muscles and tendons moving its joints, as the presence of this single digit may improve the patient’s prehensile patterns.5
CLOSURE OF THE SOFT TISSUES
FIGURE 22-7. The median nerve is divided; the interosseous vessels are ligated.
The tendons that have been retained are divided into two groups. The distal ends of the tendons are sutured to the periosteum at the ends of the bones. Excess muscle, fat, and fibrous tissue should be resected to allow wound closure without tension. The tourniquet is released, and hemostasis is achieved. The two skin flaps are wrapped around the two arms of the pincer. The anterior flap is introduced between the two bones over the pronator teres, and its outer upper angle is sutured to the corresponding angle of the posterior defect (Fig. 22-8). The inner upper angle of the posterior flap
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A
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B
is likewise sutured to the corresponding angle of the anterior defect. The edges of the flaps are rotated across the ends of the rays (Fig. 22-10) so that the distal tips of the pincer will not have scars on their opposing surfaces.
It is imperative that the skin covering opposing surfaces of the pincer have good sensation. The dermis should be sutured to the periosteum to provide grip stability. Any residual skin deficiencies are covered by skin grafts. A conforming dressing is applied, separating the rays at their tips by 6 to 10 cm, and the limb is elevated.
Reeducation
FIGURE 22-10. The distal skin of the flaps is rotated over the end of each ray so that the distal tips of the pincer will not have scar tissue.
Reeducation can be started as soon as healing permits, usually in the second week. The key exercise consists of mobilizing the radius while stabilizing the ulnar limb by the antagonistic contractions of the triceps and brachialis. It is important that the patient be taught to avoid supination on opening the pincer and pronation on closing it as these movements interfere with grip precision. The therapist should first immobilize the ulna with the elbow in slight flexion and instruct the patient to mobilize the radius in the sagittal plane in neutral pronation-supination. The simple principle of chopsticks is employed by the patient with amazing facility. Sensory reeducation is initiated immediately after the skin has healed. Sensation at the tip of the pincer improves gradually. Two-point discrimination can become as fine as 4 or 5 mm, although it might be more than 1 cm in normal forearm skin. Swanson has observed tactile discrimination comparable with that of a normal hand in juveniles who have undergone the Krukenberg procedure.5
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FIGURE 22-9. Short arms measuring only 6 to 7 cm are nevertheless mobile, strong, and very useful. (From Tubiana R: Krukenberg’s operation. Orthop Clin North Am 12, 1981, Fig. 2.)
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Results Functional results on the whole are highly satisfactory, and patients do utilize their pincer for most everyday activities. They can take small objects from their pockets and identify them by touch and are also able to grip larger objects, up to 10 cm in diameter. The power at the tip of the pincer rarely exceeds 2 to 3 kg, but at its proximal part with the elbow flexed, it can reach up to 8 or 10 kg. The appearance of the pincer remains a problem, not usually for the patient, who is often delighted by the functional result, but for his or her family. This can be improved for social purposes by a prosthetic hand that can be activated by the limbs of the Krukenberg claw.
INDICATIONS The Krukenberg procedure may be indicated in cases of congenital or traumatic amputations of the hand. It can even be performed for midforearm amputations, since most of the muscles required for activating the pincer have proximal origins. In congenital amputations, Swanson advises early operation, from the age of 2 years, and has obtained excellent results.5 In traumatic amputations, the indications for Krukenberg’s operation are difficult to postulate. On the one hand, functional results can be spectacular when they reestablish a powerful, sensitive grip and hence meet the physical needs of the individual who has lost a hand. Therefore, one might be tempted to expand the surgical indications and support the operation against unjust criticism. On the other hand, construction of an “unnatural claw” may arouse within the patient’s family, friends, and associates a rejection reaction that can affect the patient. Hence, one must consider not only the eventual functional result, but also the cosmetic, psychological, and social factors. It is essential that patients be fully informed preoperatively about the nature of the planned procedure. They may be encouraged by seeing the results obtained in other patients. Showing a film of previous cases is valuable. In unilateral amputations, in which the remaining hand ensures the patient’s independence, a prosthesis is usually preferred to an operation that is designed only to provide additional help. However, when the patient is young and has an occupation that requires sensation in both upper extremities, the Krukenberg pincer offers the maximum potential for function. If one hand has
been amputated and the remaining hand is seriously handicapped, Krukenberg’s operation on the amputated limb might be indicated to achieve a wide grasp and strong grip, particularly in countries where facilities for prosthetic fitting are limited. Krukenberg’s operation should be performed only on the amputated side, to preserve one long limb that can reach the scapular, lumbar, and gluteal regions.8 In bilateral amputations, the Krukenberg procedure can be performed either bilaterally or unilaterally. This must be discussed with the patient. Bilateral amputees treated by this technique regain total independence. They can wash, dress, and feed themselves; drive a car; write; and even sew or type with the help of a small pusher adapted to one tip. A pincer that has skin sensibility is particularly essential for blind patients. The strongest indication for the operation is probably in those patients who have lost both hands and both eyes in an explosion.
CONCLUSION Despite the ingenuity of this surgical technique, this operation is hardly ever performed in Western countries, as the resultant appearance of the limb is considered cosmetically unattractive. This disadvantage has resulted in the unjust categorical rejection of the procedure, although it has proved to be very beneficial in carefully selected patients.
References 1. Bunnell S: Surgery of the Hand. Philadelphia, J.B. Lippincott, 1944, pp 634–639. 2. Kallio KE: Recent advance in Krukenberg’s operation. Acta Chir Scand 97:165–188, 1948. 3. Krukenberg H: Uber Plastiche Umwerting von Amputation Stumpfen. Stuttgart, Ferdinand Enke, 1917. 4. Maurer P: Krukenberg’s operation. In Tubiana R (ed): The Hand, vol. 3. Philadelphia, WB Saunders, 1988, pp 1232–1235. 5. Swanson AB: The Krunkenberg procedure in the juvenile amputee. J. Bone Joint Surg 46A:1540–1549, 1964. 6. Tubiana R: Krukenberg’s operation. Orthop Clin North Am 12:819–826, 1981. 7. Tubiana R: Bilateral hand mutilations. In Tubiana R (ed): The Hand, vol. 3. Philadelphia, WB Saunders, 1988, pp 1216–1231. 8. Tubiana R: Krukenberg procedure. In Tubiana R, Gilbert A, Masquelet A (eds): An Atlas of Surgical Techniques of the Hand and Wrist. London, Martin Dunitz, 1999, pp 45–51.
23 Management of the Degloved Hand Lee E. Edstrom, MD
THE PROBLEM DEFINED
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The degloved hand has not had a recent comprehensive review in the hand surgery literature. Since the traditional treatment methods were laid out a generation ago, the subject has been dealt with under the headings of replantation, flap reconstruction, classification of injury, and type of mutilation injury.51 It is, however, a significant subject by itself to warrant a focused look. Avulsion and degloving injuries have generally been viewed as among the most difficult of injuries to manage because of the extensive nature of their associated damage. Tendons and nerves are often injured far from the immediate site of injury, but blood vessels (in particular, arteries), because of their great elasticity, are stretched and separated with irreversible injury along the entire length of involvement. Associated injury can occur 25 inches or more from the actual separation site, particularly in the case of tendons. In traditional hand surgery, the answer to these injuries was often simply to complete amputation and reconstruct with the methods available. In the last two decades, many technical advances have been made to expand the options available for treating these injuries, and the literature is now replete with successful efforts to restore avulsed and degloved parts. In this chapter, we will describe the injuries, outline the methods of treating these injuries, and then address each individual area of the hand, since in each the issues are different.
Mechanism of Injury Avulsion and degloving injuries are caused by a wide array of mechanisms, machines, and situations in which the hand is fixed and a pulling force is applied. The obvious machines are rollers, presses, and wringers, which draw the hand in between spinning rollers or drums, but many machines have the capacity to apply avulsion forces to the hand. These include the farm machinery injuries caused by feed augers, corn pickers, and power takeoffs. The familiar namesake injury, the literal “ring avulsion,” is itself all too common, as the left hand is used to steady the body in a leap from a height, and the ring is caught as the hand is letting go; ring modifications have been devised to prevent the injury.13 Many other mechanisms provide the same fixation followed by an avulsive force, such as a water-ski tow rope wrapping around the hand or forearm and pulling (Fig. 23-1).
Incidence, Prevalence, and Significance Because of the nature of the injury and the lack of widespread agreement in reporting criteria, no data exist on the prevalence of degloving or degloving components in hand injuries. Needless to say, they represent a significant loss of time from work and loss to the economy each year. 307
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A
B
FIGURE 23-1. A, A water-ski tow rope wrapped around the forearm of this young woman, avulsing the skin and subcutaneous tissue from her forearm. B, C, Because the soft tissue could not be recovered, the forearm was reconstructed with a latissimus dorsi myocutaneous free flap, seen here after revisions for contouring. C
This brings up an important point that is common to many aspects of hand surgery: There is often a conflict between expeditious treatment (completion of amputation) leading to an early return to work and more aggressive and restorative treatment in the form of replantation or other more difficult and time-consuming methods, which often result in much more prolonged rehabilitation. At times the latter results in a hand that is even less capable of returning to work than is one with an expeditious amputation. The hand surgeons in our institution spend considerable time debating whether to conserve or amputate, and the answer is usually not clear. The issues are complex, including the background and desires of the patient and the skills and motivation of the surgeon. Experience and good judgment seldom have more importance and value than they do in the making of these decisions. Below are some of the issues for consideration. We discuss the types of injury, methods of treatment, and the issues applied to the specific areas on the hand in an orderly method that we hope will make this difficult subject more accessible to all surgeons.
Classification of Injuries The most widely used method for classifying degloving injuries was devised for ring avulsion injuries by Urbaniak.44 Class I injuries (Table 23-1) retained adequate circulation, and conventional28 treatment was sufficient. Class II injuries retained some tissue attachment but had inadequate circulation and required vessel repair (Fig. 23-2). Class III injuries were those with “complete degloving or complete amputation,” for which survival might be possible with revascularization but injury was so severe that projected functional return might be too poor to justify the effort (Fig. 23-3).
. Original Urbaniak TABLE 23-1 Classification System Class I
Circulation adequate
Class II
Circulation inadequate
Class III
Complete amputation or complete degloving
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B
Many authors have since used the basic concepts of this classification system to discuss degloving injuries, often beyond the pure ring avulsion injury.4,23,24,28,32,44,45,51,53 We will be using this system as well, differentiating among injuries with adequate vascularity (treatment of which is easy and noncontroversial), those with inadequate perfusion, those needing revascularization but having some tissue continuity, and those that are completely separated, requiring a maximum of effort for vessels, nerves, and all other tissues involved. Nissenbaum32 introduced the IIA classification, which separates out those Class II injuries in which only digital arter-
ies are damaged. Later, Beris4 defined the Class IIIa (skin avulsion at the level of the proximal phalanx and amputation at the distal interphalangeal joint with intact flexor digitorum superficialis) and Class IIIb (skin avulsion and complete amputation at the level of the proximal phalanx, with severance of both flexor tendons) injuries. A more complete classification system might include these more detailed definitions (Table 23-2). There are many techniques of reconstruction, and each has its place in the palette of the reconstructive surgeon dealing with a continuum of injury patterns in several different locations on the hand.
A
B
FIGURE 23-3. A, B, Examples of Urbaniak Class III avulsion injuries, demonstrating complete avulsion-amputations. It can be very difficult to find recipient arteries to replant these parts.
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FIGURE 23-2. A, A typical Urbaniak Class II avulsion injury, with skin avulsed from the base of the finger to the distal interphalangeal joint. B, Gray, avascular appearance of the skin when replaced in Urbaniak Class II avulsion.
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TABLE 23-2
Extended Urbaniak Classification System
Class I
Circulation adequate
Class IIa
Circulation inadequate
Class IIb
Circulation inadequate
Other structures damaged as well
Class IIIa
Complete amputation or complete degloving
Skin avulsion at the level of the proximal phalanx and amputation at the distal interphalangeal joint with intact flexor digitorum superficialis
Class IIIb
Complete amputation or complete degloving
Skin avulsion and complete amputation at the level of the proximal phalanx with severance of both flexor tendons
GENERAL METHODS OF RECONSTRUCTION “Traditional” Methods and Results Simple Replacement of Avulsed Tissue In Class I injuries, by definition, vascularity is intact, and simple replacement is indicated, whether involving a finger, dorsal skin, or palmar skin. In Class III injuries, replacement of avulsed tissue will result in necrosis, and more imaginative solutions must be found. In Class II injuries, in which it is not clear whether or not tissue is viable, revascularization is generally the safest, most prudent treatment option, since waiting for tissue to “declare itself” sacrifices that which was not adequately perfused. When there is no revascularization option, degloved or avulsed tissue may be laid back whence it came, but gently and with no tension. This usually means not completely to the original site but with a gap, giving the avulsed tissue every chance to survive tensionfree, perhaps with adhesive strips maintaining position. Later, with viability assured, tissue may be advanced back to its original site, or nearly so, with the maximum amount saved. Amputation Naturally, amputation is always an option, and often the best one. With Class IIIb injuries4,20 in which there is amputation through the proximal phalanx, functional results after replantation might not be good enough to justify the effort, especially in single digits other than the thumb. The more damage there is distally, the poorer the expected result and the stronger the amputation option. The patient’s age and occupation, physical and psychological condition, and basic feelings about amputation must all be considered. In general, the lessons of replantation surgeons over the last 30 years must be emphasized: Single-digit replantations are usually not a good idea, but multiple digits and any amputation of the thumb should be considered for replantation.
Only digital arteries damaged
Split-Thickness Skin Graft Split-thickness skin grafts are used for defects that have well-vascularized beds to accept grafts. This may be the base of a finger but is more often a superficial avulsion on the dorsum or sometimes the palmar surface of the hand. Split-thickness grafts will not suffice for deeper avulsions, which have left tendons, nerves or vessels, or bony repairs with hardware exposed. Often, in an extensive degloving of the dorsum or palm of the hand, a portion of the defect must be replaced with a flap or revascularized, while the proximal portion will be suitable for a split-thickness skin graft (Fig. 23-4). Full-Thickness Skin Graft Full-thickness grafts generally have no place in degloving injuries. These grafts have poor take characteristics except under the most ideal conditions, and their advantages over split-thickness grafts (better contour, color, and texture and less contraction) are of secondary importance when the primary consideration is obtaining rapid wound closure. The exception to this is in the use of the avulsed or degloved tissue itself as a full-thickness graft.12 Pedicled Flaps Traditional pedicled flaps are the workhorse reconstruction options when a portion or all of a degloving injury is irretrievable. These are many in number, from local flaps such as cross-finger flaps to contralateral upper arm, inframammary, and groin flaps, among others. These serve the purpose of supplying coverage over wounds of any depth and complexity, unlike split-thickness skin grafts. In addition, they can be used to reconstruct damaged veins as a vascularized vein graft carrier.26 These flaps, in addition, allow subsequent surgery to be performed beneath them, either by raising them from the side or by operating directly through them. They require, except for the local transposition or regional island flaps (radial forearm or posterior interosseous58), a second and sometimes a third procedure to separate the flap from its original blood supply (the pedicle) and inset the edges of the flap.
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MANAGEMENT OF THE DEGLOVED HAND
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B
One very useful flap whose pedicle does not have to be divided is the sensate neurovascular island flap, attributed to Littler (Fig. 23-5) and a great help in completing the reconstruction of denervated digits reconstructed with insensate flap tissue.
Free Flaps “Traditional” free flaps might be considered those that are supplied by an arterial input and venous outflow. These free flaps consist of fasciocutaneous flaps, muscle
FIGURE 23-5. A large neurovascular island flap was used to provide sensibility to the entire ulnar side of the reconstructed thumb; a split-thickness skin graft was used to cover the donor site on the ulnar side of the ring finger.
flaps with split-thickness skin grafts, fascial flaps, and composite tissue flaps, such as toe-to-thumb and wraparound flaps. These flaps, as with the previous category, are used when the degloved or avulsed tissue is not usable and replacement with flap tissue is necessary (see Fig. 23-1). They have the advantage over the distant pedicled flaps of involving a single-stage procedure, allowing easier and more expeditious inset of the flap into the recipient site. In addition, the hand and arm are not attached to the donor site for a prolonged time, so rehabilitation is easier, both in the injured hand and in the ipsilateral elbow and shoulder. The fasciocutaneous flaps consist mainly of the contralateral radial forearm flap but include the lateral arm flap, the posterior calf flap,47 and others from the extremities. When flaps are taken from the trunk, there is generally too much subcutaneous tissue. They provide relatively thin skin but more difficult donor sites. The muscle flaps with split-thickness skin graft cover are frequently used and effective, ranging from the large latissimus dorsi to the much smaller gracilis and others. These flaps are very thin when they eventually atrophy and provide cover very much like that of native skin. A more imaginative approach is with the fascial flaps: temporoparietal,5,16,17,39 lateral arm,7,56 posterior calf,48 and others. This tissue is extremely thin and can wrap around tendons and nerves or entire degloved fingers, and the donor sites are ideal. Unless buried, they require split-thickness skin grafts for cover.
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FIGURE 23-4. A, Dorsal skin avulsion that did not survive replacement. B, A splitthickness skin graft was applied after debridement.
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Composite tissue flaps are also used when avulsed tissue is not reusable. Toe-to-thumb transfer is usually performed as a secondary procedure but has been described at the time of the acute injury.38
Microvascular Replantation of the Avulsed Tissue Replantation of degloved or avulsed tissue is a challenging technical feat, but reports of successful replantations of degloved soft tissue have appeared since the early days of replantation surgery. Many complete amputations and incomplete amputations have a component of avulsion, often with tendons and nerves dangling from the amputated part, proximal to the amputation site (and separated from it by many centimeters). There may be a significant amount of degloving of soft tissue with these injuries as well, and arterial injury is usually the major challenge to replantation. Nerve injuries are significant problems with long-term sequelae but do not affect the immediate challenge of replantation survival. Veins do not suffer the same stretching injury that is so harmful to the arterial walls but rather simply tear, with much less injury proximally or distally. Solutions to these difficult problems have been ingenious. Most obviously, vein grafts have been used to bridge the long gaps that are often left when injured arteries are debrided and alone have allowed replantation of total finger deglovings.49 Another technique that is used in finger deglovings is the transfer of vascular bundles from adjacent fingers, particularly in the thumb.1,2,6,8,25,35 But deglovings often have no artery for recipient anastomosis, and here the imagination of the surgeon has been most challenged. The use of arterialized venous revascularization has allowed flaps to survive where no arterial enhancement was possible.9,43,54 The use of unconventional vascularized flaps is discussed elsewhere in this chapter.
More Contemporary Flaps: “Traditional” Island Flaps As microvascular techniques have been pushed to the limit, there have been advances in the design and utilization of pedicled flaps, and in the hand, several island flaps have been particularly useful. The workhorse radial forearm40,50 has been joined by the posterior interosseous island flap11,27,34,57 on the dorsum of the distal forearm. These two flaps, along with the ulnar forearm flap, have allowed rapid and easy coverage of avulsion and degloving injuries of the palmar and dorsal skin of the palm and web spaces.
Many local island flaps, such as that based on the first dorsal metacarpal artery,14 have been explored for use in distal coverage problems.
Unconventional Flaps: Venous-Venous, ArterialVenous, and Arterial-Arterial Flaps Starting in the early 1980s with pioneering work done by Nakayama,29 many authors have explored the concept of arterializing the venous system to enhance survival of flaps. These “venous free flaps” have been particularly helpful in avulsion injuries, since these injuries jeopardize the vascular system, leaving an unpredictable pattern of mixed damage and loss, taxing the ingenuity of the reconstructive surgeon. Since the early work with these flaps, it has been shown that survival can be achieved with all three possibilities of flap construction: (1) venous-venous, in which the venous system of the flap is connected to a proximal vein for outflow and a distal vein for inflow; (2) arterial-venous, in which arterial blood is sent into the venous system at the distal end of the flap and drained into a proximal vein; and (3) arterial-arterial, in which the venous system receives arterial input proximally, draining into a distal artery. This latter configuration is known as a “flow-through” flap and can be used to reconstruct a recipient site arterial system and achieve coverage at the same time. These flaps have the great advantages of easy dissection and low donor site morbidity, large vessels, thin tissue, and ease of repair of arterial injuries. Their disadvantages are all related to the less efficient delivery of blood to flap tissues and high venous pressures in the arterialized flaps. Swelling is a problem, and survival is not as reliable as with traditional flaps. There have now been many reports in the literature of these flaps being used successfully in clinical situations,* and, since Nakayama’s early work, several laboratory studies exploring the physiology of these flaps.30,31,54,57 As was mentioned in an earlier section of this chapter, the same concept has been used to enhance survival of avulsed tissue, when no possibility of arterial enhancement exists. In devascularized tissue where no artery can be found, the venous system is enhanced with arterial input, often with success.9,43
SPECIFIC SITES Now that we have outlined the techniques available to reconstruct avulsion and degloving injuries, we will consider specific injuries and sites and discuss the
*See references 10, 15, 18, 19, 21, 22, 33, 36, 52, 55.
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Factors Generally Influencing Outcome It should first be stated that there are many factors that can make an avulsion and degloving injury more difficult to deal with. In the least severe injuries, avulsion is incomplete, and tissue can be replaced with complete survival, as in the Urbaniak I ring avulsion injury. Sometimes the replaced tissue must be only partially returned to its original position at first to allow marginal arterial or venous circulation to maintain viability without tension until the final repositioning in the original position. The more complete avulsions create distally based flaps that are not viable if replaced and require vascular reconstruction, as in the Urbaniak Class II ring avulsion injury. Some of these injuries can be reconstructed with arterial repair (Class IIA), at times including venous repair, often with grafting for the artery, and some might need arterial augmentation (arterialization) of the flap venous system. Complete amputation, as in the Urbaniak Class III ring avulsion injuries, does not always represent the most difficult or severe injuries, since these at times occur with less avulsion injury and therefore less vascular injury. If separation is very distal, however, arterial injury might leave nothing to use for a distal arterial recipient, necessitating venous arterialization to achieve survival. Of course, even though vascular injury might be less, and therefore simple survival might be easier to
A
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obtain, complete amputation involves more structures, with bony, tendinous, and nerve injury complicating the final results. In general, the more extensive the arterial injury, the more distally it extends, the more structures involved, the more concomitant injury (heat, foreign body), and the more unfavorable the nerve injury, the more compromised will be the result.
Thumb General Principles The overriding principle in avulsion injuries to the thumb is to preserve length whenever possible. Therefore it might be justified to go to extraordinary lengths to accomplish a difficult replantation of a distal or severely injured degloving that would not be justified elsewhere on the hand. Likewise, a thumb loss, even partial, that cannot be reconstituted represents an indication for reconstruction by classic techniques, such as pollicization, skin flap with bone graft post, or toe-to-thumb transfer. Urbaniak Class II The Urbaniak Class II injury, which is rather common in the thumb, often represents the most difficult of avulsion and degloving injuries, with extensive injury to nerves and arteries (Fig. 23-6). Generally, vascular grafts— venous or arterial from amputated parts—are needed to replace the injured arterial inflow, or transfer of vascular pedicle from an adjacent finger might be appropriate. If the nerve is not transferred with the vascular pedicle, it
B
FIGURE 23-6. A, B, A Class II avulsion injury of the thumb, appearing relatively mild until the avulsed skin and other structures are uncovered.
23
unique problems inherent in each and how they all affect the decision-making process.
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is generally reconstructed by grafting at a later time, when the extent of its injury can be ascertained and a reliable recipient bed is available. The veins are much less elastic and more fragile than arteries and nerves and usually tear without extensive injury, allowing repair with little or no debridement.
Urbaniak Class III In the thumb, the difficulties described by Urbaniak in his Class III injuries are less important than the other fingers. Again, preserving length is the overriding principle, and poor interphalangeal joint motion because of adhesions or joint destruction is less important. As was stated elsewhere, these injuries may be the most severe of all, with total soft tissue degloving, or may perhaps be less severe than a severe Urbaniak Class II injury if separation of bone and tendons has allowed a less extensive vascular injury. Replantable These injuries are treated as amputations to be replanted. At times, vascular grafts may be adequate to allow survival, but distally based soft tissue flaps might require extra attention. Nerve repairs might have to be done far proximal to the site of amputation, such as in the carpal tunnel.46 Techniques such as transferring soft tissue with bridging vessels3 might be useful and may be done with fasciocutaneous flaps or purely fascial flaps, establishing vascular continuity as well as providing soft tissue coverage.3,22 Arterialization of an avulsed soft tissue envelope might be the only way to provide input of arterial blood if the arterial injury extends beyond the distal phalanx. Not Replantable: Skeletotendinous Unit Remaining If the avulsed tissue cannot be replanted and the remaining digit is stripped of all soft tissue but the tendinous skeletal unit, a soft tissue flap can be formed to cover the remaining unit, and critical sensibility can be restored with a neurovascular island flap (see Fig. 23-5). Critical points include making the flap thin enough to avoid extensive flap revisions and constructing the neurovascular island flap soon, preferably at the division and inset of the primary flap, so as to provide blood supply to maintain the new thumb tip in as healthy a state as possible. The groin flap is generally used for this purpose, since it easily lends itself to the formation of a tubed flap shaped like a thumb (Fig. 23-7). It is important to remember to excise the remaining nail bed to avoid the formation of a nail remnant under the flap. It is tempting to simply cover the stripped distal phalanx with a flap, but as much as several years later the patient may reappear in your office with a massive “nailoma” (Fig. 23-8).
It might be the preference of the surgeon and patient, however, to elect a toe-to-thumb transfer, with its inherent advantages.
Not Replantable: Completely Amputated When the completely amputated avulsed thumb cannot be replanted, traditional methods are available. A toe-tothumb transfer might be selected, offering a cosmetically excellent reconstruction with superb function as well (Fig. 23-9). Or it might be that a traditional bone post covered by a tubed flap is chosen (Fig. 23-10). In this case, it is even more critical that a neurovascular island flap be transferred as early as possible, since the extra blood supply is critical in preventing reabsorption of the bone graft (see Fig. 23-5). This is a particularly good method if the avulsion has preserved the metacarpophalangeal joint of the thumb, since the loss of interphalangeal flexion with a single-piece bone graft is of no consequence.
Ring Fingers and Other Single Digits General Principles The ring finger—the finger referred to in the “ring avulsion” injury—follows far after the thumb in suitability for single-finger replantation. In accordance with the accepted practice for single-digit replantations, the ring finger is not reconstructed following a devastating injury for functional purposes, but only for cosmetic ones, unless the wearing of a wedding ring can be considered a functional use. It therefore sometimes occurs that a patient will prevail in his or her wishes to have a ring finger replanted or revascularized after an injury that will leave the finger useless or in the way but still present for wearing a ring. Urbaniak Class II The same considerations apply that were set out for the thumb (see above). However, while going to extreme measures is usually indicated for a thumb, it is less often so for a ring finger. The severely limited ring finger, set among normal adjacent fingers, is in the way and detracts from the function of the hand. However, if reasonably good function can be expected and the patient’s wishes concur, it might be worthwhile performing a very difficult revascularization, particularly since the tendinoskeletal unit is intact in Class II injuries. Class IIa injuries usually require an attempt to revascularize. The surgeon must not let an intact set of bone, tendons, and joints lead him or her to believe that function will be easy to recover if the soft tissue cover (in Class IIb injuries) might be expected to heal with difficulty and remain swollen for some time (see Table 23-2). Also, never underestimate the importance of nerve injury and the difficulties lack of sensibility adds to rehabilitation of the finger.
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B
23
A
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C D
FIGURE 23-7. A severe, multiple-digit injury (A) demonstrating the use of a tubed groin flap to resurface a completely degloved thumb (B), with excellent maintenance of range of motion (C–E). This case also demonstrates the use of an adjacent flap skin from the thigh to provide coverage for other degloved regions. E
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A
B
FIGURE 23-8. A, B, A completely degloved thumb, reconstructed with a groin flap, presenting 5 years later with a massive buried nail grown from the nail bed remnant.
Urbaniak Class III These injuries, whether Class IIIa (skin avulsions at the level of the proximal phalanx and amputation at the distal interphalangeal joint with intact flexor digitorum superficialis) or Class IIIb (skin avulsion and complete amputation at the level of the proximal phalanx, with severance of both flexor tendons), are seldom
candidates for reconstruction (see Fig. 23-7), since the results in the ring finger are usually not good enough to justify the effort, either functionally or cosmetically, and an ugly stiff finger is not adequate for wearing a ring.
Multiple Digits General Principles In some of the devastating injuries that render multiple digits in need of reconstruction, individual consideration must be brought to bear. The surgeon’s judgment and relationship with the patient must be carefully brought to bear to achieve the most reasonable, intelligent management options in keeping with the patient’s needs. Some patients need the index, middle, and ring finger stumps closed to get back to premorbid activities as soon as possible; the next patient might need every attempt possible to preserve length and function (see Fig. 23-10). A poorly functioning finger next to other poorly functioning fingers might be much more useful than no fingers at all (see Fig. 23-8). Of course, young patients generally are better candidates for elaborate reconstructive efforts than are older ones.
FIGURE 23-9. A toe-to-thumb transfer, demonstrating excellent appearance and superb function.
Urbaniak Class II and Class III The principles stated above apply for these classes as well.
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B
Palmar Skin General Principles Palmar skin, being uniquely furnished with glabrous skin and firm attachments to the underlying palmar fascia, is also very dependent on perforating blood supply through the fascia and is accordingly susceptible to devascularizing avulsion injury. A frequent injury is the roller avulsion, in which the hand is pulled into the rollers (seen in press operators) and gets caught at the base of the palm, with the palmar skin avulsed distally as the roller continues to turn (see Fig. 23-9). These injuries gain severity when the rollers are hot and when ink or other foreign material becomes embedded in the avulsion site. Also, the skin might not be the only structure injured, neurovascular structures being the next most frequently injured, thus jeopardizing the fingers as well. Ultimately, the entire soft tissue envelope may be avulsed (literally “degloving”), with or without tendinoskeletal elements. Generally, these injuries require the ingenuity of the surgeon to reconstruct the soft tissues as well as possible. Partial Skin Avulsion Principles in skin avulsion injuries are similar to those promoted in other sites, such as the lower extremity. The problem is that the palmar skin has poor axial blood supply, and the avulsion is distal, creating a distally based flap, with even more problems of arterial input and venous drainage. Here also, arterialization of the venous system is seldom a possibility.9 If it appears that a significant portion of the skin might survive, the surgeon should lay the avulsed skin back down whence it came but resist the temptation to suture it back in place,
rather letting it lie with no tension whatsoever. After a day or two, the surviving skin will be evident, and the rest can be debrided away and replaced with skin graft. An alternative method is to recognize that most of the avulsed flap will not survive and to remove it, trim it, and replace it then or later as a full-thickness graft. In that way, the precious glabrous skin is preserved.12 If at least some of the underlying fascia is preserved, the palmar skin should be replaced with skin graft, not a flap, to maintain the close approximation of the palmar skin to the underlying fascia. It might be desirable, either at the time or later, to replace lost palmar skin with glabrous skin from the instep area of the foot.37
Skin and Fascia When the injury is deeper, involving the fascia and even the deeper structures, it might be necessary to delay reconstruction to fully identify nonviable tissue for debridement, but then flap tissue is necessary for replacement coverage. In this instance, the radial forearm flap has become a workhorse although the groin flap and other forearm flaps are useful as well. They must be thinned sufficiently to provide mechanically stable skin for adequate grip.
Dorsal Skin General Principles This is a frequent injury, like the palmar skin avulsion that is often seen with roller injuries, and often occurs at the same time. The dorsal skin survives more easily from a distal avulsion than does the palmar skin but must be
23
FIGURE 23-10. Reconstruction of the thumb with carved bone graft from iliac crest A, wrapped in a tubed groin flap B.
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treated similarly as described for the palmar skin (see Table 23-2).
Skin Avulsion Alone When the skin is still attached distally, but is clearly nonviable, arterialization is a good possibility; the anatomy of the flap and recipient site are favorable for this solution. Survival has been reported using a branch of the dorsal radial artery in the hand to arterialize a vein; a proximal vein is usually needed to ensure venous drainage, and survival has been reported.42 Otherwise, as with the palmar skin, an avulsion that involves only the skin is generally best replaced with a skin graft obtained from a convenient site. As was described with palmar skin, defatting and replacement as a full thickness graft are possible if injury to the skin and to the underlying recipient bed is not too severe. Skin Involving Tendons Generally, with an injury of this severity, a flap will be necessary for reconstruction. The choice of a flap for this location, involving the underlying extensor tendons, has the requirement of a thin flap, beneath which tendon reconstructions, either primary or delay, must be performed.41 This can be accomplished with various free flaps,10,39 island flaps from the forearm,27,57 or the old workhorse, the groin flap.
Whole Hand When the skin is completely degloved, with or without bony and tendinous elements, the severity of the injury mandates extraordinary effort, often in multiple stages.
A
FIGURE 23-11. The ring can still be seen distally, at the amputation site, of this Class IIIb injury, with near total amputation at the distal interphalangeal joint; the flexor digitorum superficialis was intact.
The general principles expressed throughout this book are fully brought into play, and the totality of the surgeon’s judgment and technical expertise is challenged (Fig. 23-11). If the avulsed tissue cannot be salvaged, the reconstructive techniques are no different from those described elsewhere in this book (Figs. 23-12 through 23-15).
B
FIGURE 23-12. A, Complete degloving of thumb and index finger and partial degloving of middle and ring fingers. B, A groin flap was tubed for the thumb, and the index and middle fingers were buried beside it, in the thigh.
23
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C
FIGURE 23-12 cont’d. C–E, Partial separations were done to prepare for full division and inset, and the final result preserved significant function of all involved fingers. E
FIGURE 23-13. Four of eight amputated fingers were replanted to preserve significant function with uninjured thumbs.
FIGURE 23-14. Severe palmar skin avulsion.
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D
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A
B
FIGURE 23-15. A, Patient with avulsion of nearly the entire hand soft tissue and bones of the middle and little fingers. The thumb has already been resurfaced with a tubed groin flap, and the first webspace is being reconstructed with a reverse radial forearm flap. B, C, The patient regained some grasp function, with good position in opposition and abduction of his reconstructive thumb. C
It is worth mentioning, however, that arterialization of the avulsed soft tissue might make salvage of all or any portion of the avulsed tissue a possibility,42 whereas with traditional techniques, it is generally impossible to find a recipient artery for a successful revascularization. In general, salvage of the original avulsed tissue is preferable to replacement with flap tissue from elsewhere and should be the first thought in the reconstructive algorithm.
References 1. Adani R, Castagnetti C, et al: Transfer of vessels in the management of thumb and ring avulsion injuries. Ann Acad Med Singapore 24(4 Suppl):51–57, 1995. 2. Adani R, Castagnetti C, et al: Ring avulsion injuries: Microsurgical management. J Reconstr Microsurg 12(3): 189–194, 1996. 3. Behan C, Cavallo AV, et al: Ring avulsion injuries managed with homodigital and heterodigital Venous Island Conduit (VIC) flaps. J Hand Surg Br 23(4):465–471, 1998. 4. Beris AE, Soucacos PN, et al: Microsurgical treatment of ring avulsion injuries. Microsurgery 15(7):459–463, 1994. 5. Brent B, Upton J, et al: Experience with the temporoparietal fascial free flap. Plast Reconstr Surg 76(2):177–88, 1985.
6. Castagnetti C, Adani R, et al: Transfer of vessels in the management of ring avulsion injury: Case report. Scand J Plast Reconstr Surg Hand Surg 26(3):331–333, 1992. 7. Chen HC, el-Gammal TA: The lateral arm fascial free flap for resurfacing of the hand and fingers. Plast Reconstr Surg 99(2): 454–459, 1997. 8. Cheng SL, Chuang DC, et al: Successful replantation of an avulsed middle finger. Ann Plast Surg 41(6):662–666, 1998. 9. Cheng SL, Wong SS: Salvage of superficial palmar avulsion. J Trauma 40(1):22–26, 1996. 10. Cho BC, Byun JS, et al: Dorsalis pedis tendocutaneous delayed arterialized venous flap in hand reconstruction. Plast Reconstr Surg 104(7):2138–2144, 1999. 11. Costa H, Soutar DS: The distally based island posterior interosseous flap. Br J Plast Surg 41(3):221–227, 1988. 12. DeFranzo AJ, Marks MW, et al: Vacuum-assisted closure for the treatment of degloving injuries. Plast Reconstr Surg 104(7):2145–2148, 1999. 13. Dubert T, Diop A, et al: An experimental study of ring avulsion injuries and two preventive devices. J Hand Surg Br 25(5):418–421, 2000. 14. El–Khatib HA: Clinical experiences with the extended first dorsal metacarpal artery island flap for thumb reconstruction. J Hand Surg Am 23(4):647–652, 1998.
15. Galumbeck MA, Freeman BG: Arterialized venous flaps for reconstructing soft-tissue defects of the extremities. Plast Reconstr Surg 94(7):997–1002, 1994. 16. Hing DN, Buncke HJ, et al: Use of the temporoparietal free fascial flap in the upper extremity. Plast Reconstr Surg 81(4):534–544, 1988. 17. Hirase Y, Kojima T, et al: Secondary reconstruction by temporoparietal free fascial flap for ring avulsion injury. Ann Plast Surg 25(4):312–316, 1990. 18. Inoue G, Maeda N: Complications in wrap-around-flap donor sites after reconstruction using an arterialized venous flap. J Reconstr Microsurg 14(6):377–380, discussion: 380–381, 1988. 19. Inoue G, Suzuki K: Arterialized venous flap for treating multiple skin defects of the hand. Plast Reconstr Surg 91(2):299–302, discussion: 303–306, 1993. 20. Kay S, Werntz J, et al: Ring avulsion injuries: Classification and prognosis. J Hand Surg Am 14(2 Pt 1):204–213, 1989. 21. Kayikcioglu A, Akyurek M, et al: Arterialized venous dorsal digital island flap for fingertip reconstruction. Plast Reconstr Surg 102(7):2368–2372, discussion: 2373, 1998. 22. Koch H, Moshammer H, et al: Wrap-around arterialized venous flap for salvage of an avulsed finger. J Reconstr Microsurg 15(5):347–350, 1999. 23. Kupfer DM, Eaton C, et al: Ring avulsion injuries: A biomechanical study. J Hand Surg Am 24(6):1249–1253, 1999. 24. Levy HJ: Ring finger ray amputation: A 25-year follow-up. Am J Orthop 28(6):359–360, 1999. 25. Lobay GW, Moysa GL: Primary neurovascular bundle transfer in the management of avulsed thumbs. J Hand Surg Am 6(1):31–34, 1981. 26. Martin DL, Kaplan IB, et al: Use of a reverse cross-finger flap as a vascularized vein graft carrier in ring avulsion injuries. J Hand Surg Am 15(1):155–159, 1990. 27. Masquelet AC, Penteado CV: The posterior interosseous flap. Ann Chir Main 6(2):131–139, 1987. 28. Myers W: Thrombosis of the digital arteries as the cause of a class IIA ring avulsion. South Med J 87(2):264–265, 1994. 29. Nakayama Y, Soeda S, et al: Flaps nourished by arterial inflow through the venous system: An experimental investigation. Plast Reconstr Surg 67(3):328–334, 1981. 30. Nichter LS, Haines PC: Arterialized venous perfusion of composite tissue. Am J Surg 150(2):191–196, 1985. 31. Nichter LS, Jazayeri MA: The physiologic basis for nonconventional vascular perfusion. Plast Reconstr Surg 95(2):406–12, 1995. 32. Nissenbaum M: Class IIA ring avulsion injuries: An absolute indication for microvascular repair. J Hand Surg Am 9(6):810–815, 1984. 33. Ohtsuka H, Ohtani K: A free arterialized venous loop flap. Plast Reconstr Surg 89(5):965–967, 1992. 34. Penteado CV, Masquelet AC, et al: The anatomic basis of the fascio-cutaneous flap of the posterior interosseous artery. Surg Radiol Anat 8(4):209–215, 1986. 35. Pho RW, Chacha PB, et al: Rerouting vessels and nerves from other digits in replanting an avulsed and degloved thumb. Plast Reconstr Surg 64(3):330–335, 1979. 36. Reynoso R, Haddad JL, et al: A few considerations regarding enhancement of arterialized skin flap survival. Microsurgery 20(4):176–180, 2000.
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37. Robotti EB, Edstrom LE: Split-thickness plantar skin grafts for coverage in the hand and digits. J Hand Surg Am 16(1):143–146, 1991. 38. Rose EH, Hendel P: Primary toe-to-thumb transfer in the acutely avulsed thumb. Plast Reconstr Surg 67(2):214–218, 1981. 39. Rose EH, Norris MS: The versatile temporoparietal fascial flap: Adaptability to a variety of composite defects. Plast Reconstr Surg 85(2):224–232, 1990. 40. Stern PJ, Amin AK, et al: Early joint and tendon reconstruction for a degloving injury to the dorsum of the hand. Plast Reconstr Surg 72(3):391–396, 1983. 41. Soutar DS, Tanner NSB: The radial forearm flap in the management of soft tissue injuries of the hand. Br J Plast Surg 37:18, 1984. 42. Takeuchi M, Sasaki K, et al: Treatment of a degloved hand injury by arteriovenous anastomosis: A case report. Ann Plast Surg 39(2):174–177, 1997. 43. Theile DR, Berger AC, et al: Afferent arteriovenous anastomosis for thumb replantation: A case report. Microsurgery 15(11):808–810, 1994. 44. Urbaniak JR, Evans JP, et al: Microvascular management of ring avulsion injuries. J Hand Surg Am 6(1):25–30, 1981. 45. van der Horst CM, Hovius SE, et al: Results of treatment of 48 ring avulsion injuries. Ann Plast Surg 22(1):9–13, 1989. 46. Vlastou C, Earle AS: Avulsion injuries of the thumb. J Hand Surg Am 11(1):51–56, 1986. 47. Walton RL, Bunkis J: The posterior calf fasciocutaneous free flap. Plast Reconstr Surg 74(1):76–85, 1984. 48. Walton RL, Matory Jr WE, et al: The posterior calf fascial free flap. Plast Reconstr Surg 76(6):914–926, 1985. 49. Weeks PM, Young VL: Revascularization of the skin envelope of a denuded finger. Plast Reconstr Surg 69(3):527–531, 1982. 50. Weinzweig N, Chen L, Chen Z-W: The distally-based radial foream fasciosubcutaneous flap with preservation of the radial artery: An anatomical and clinical approach. Plast Reconstr Surg 94(5):675, 1994. 51. Weinzweig J, Weinzweig N: The “tic-tac-toe” classification system for mutilating injuries of the hand. Plast Reconstr Surg 100(5):1200–1211, 1997. 52. Woo SH, Jeong JH, et al: Resurfacing relatively large skin defects of the hand using arterialized venous flaps. J Hand Surg Br 21(2):222–229, 1996. 53. Yano H, Nishimura G, et al: A clinical and histologic comparison between free temporoparietal and scapular fascial flaps. Plast Reconstr Surg 95(3):452–462, 1995. 54. Yilmaz M, Menderes A: Investigation of metabolism and perfusion in arterialized venous replantation: Experimental study in rabbits. Ann Plast Surg 43(1):67–73, 1999. 55. Yilmaz M, Menderes A, et al: Free arterialized venous forearm flap. Ann Plast Surg 34(1):88–91, 1995. 56. Yousif NJ, Warren R, et al: The lateral arm fascial free flap: Its anatomy and use in reconstruction. Plast Reconstr Surg 86(6):1138–1145, discussion: 1146–1147, 1990. 57. Yuen QM, Leung PC: Some factors affecting the survival of venous flaps: An experimental study. Microsurgery 12(1): 60–64, 1991. 58. Zancolli EA, Angrigiani C: Posterior interosseous island forearm flap. J Hand Surg Br 13(2):130–135, 1988.
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24 The Severely Burned Hand Jeffrey Weinzweig, MD, FACS Norman Weinzweig, MD, FACS
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The severely burned hand represents a complex and evolving problem. Optimal management requires careful consideration of a number of crucial variables, such as the need for escharotomy or fasciotomy in the acute setting, the method of wound debridement, internal and external splinting, choice of dressings, timing of burn wound excision and grafting, additional soft tissue reconstruction, and subsequent rehabilitation. Each of these factors plays a critical role in contributing to the ultimate function of the hand that is achieved following severe burn injury. Inasmuch as a transmetacarpal amputation, degloving injury, or ulnar column destruction is considered a mutilating injury of the hand, the severe hand burn should be similarly viewed, as the reconstructive efforts are often as complex to ensure a satisfactory functional outcome. Loss of prehension, joint contractures, soft tissue, and, occasionally, bony destruction, are problems that must be addressed for each hand that has sustained a severe burn in a manner often parallel to that utilized in cases of dorsal, palmar, or radial mutilation injuries. Severe “burns” of the hand, which include electrical injuries, frostbite, and chemical injuries, are often classified as “combination injuries” (see Chapter 3, “Classification Systems for Mutilating Injuries”) owing to the complex nature of these injuries as dictated by the anatomy and pathophysiology in each specific case. Since the hand is involved in myriad occupational, recreational, and daily activities, it is not surprising that the upper extremity is the most frequently injured anatomic structure.29 In a study conducted by the U.S. Consumer Product Safety Commission, it was estimated that 39% of burn wounds associated with product-related injuries involved some portion of the hand or upper extremity.10 Therefore, a thorough understanding of the appropriate management of these relatively common injuries is a mandatory component of the hand surgeon’s armamentarium. Proper initial management of burns of the hand with subsequent diligent therapy and rehabilitation can result in normal hand function in 97% of patients with superficial injuries and 81% of patients with deep dermal injuries.31
SURGICAL ANATOMY AND BIOMECHANICS Contracture is the enemy of function. It is nowhere better demonstrated than in the patient with severe hand burns. Prevention of joint contracture and deformity is perhaps the most important component in the restoration of hand function. Adequate wound closure, including skin grafting and soft tissue reconstruction, is also an integral part of the equation. More than half a century ago, Sterling Bunnell astutely emphasized the propensity of the hand to stiffen with resultant functional loss.7 “An ever-present menace in hand 323
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surgery is the decided tendency for the hand to stiffen and to stiffen in the position of nonfunction.”4 Injury, infection, excessive immobilization, and inadequate splinting of the hand all predispose a patient to the development of joint stiffness and the ensuing adverse sequelae. The initial response to any insult to the hand is localized edema. Fluid resuscitation in the management of severe burns produces systemic edema due to increased capillary permeability. This edema is prominent in the pulmonary system and extremities. The accumulation of fluid or hematoma within the capsular structures of the joint or within the synovial space acutely impairs joint function and subsequently promotes joint stiffness and contracture.36 An increase in the fluid content of the articular capsule and collateral ligaments will effectively shorten these structures, while excess fluid within the synovial space will distend the capsule. The intrinsic-minus hand, consisting of interphalangeal joint flexion, metacarpophalangeal joint extension, thumb adduction, and wrist flexion, is the resultant deformity. The metacarpophalangeal (MP) joint is key to the development of the intrinsic-minus hand. When nearly fully extended, the MP joint has maximal capsule and collateral ligament laxity as well as intracapsular fluid capacity. Potential abduction, adduction, and rotation are maximal; the joint contact surface area is minimized; and the joint is relatively unstable. When fully flexed, the intracapsular fluid capacity of the MP joint is minimal, and the joint is stable, allowing minimal abduction, adduction, or rotation. In this position, the collateral ligaments are taut with a broad, full-width joint contact surface area. Following injury, edema fluid hydraulically drives the MP joints into extension. This position increases flexor tension and decreases extensor tension. As a result, the fingers flex at the proximal interphalangeal and distal interphalangeal joints. There is only minimal change in the anatomy and fluid capacity of the flexed versus extended interphalangeal joints and no hydraulic drive, compared to the MP joints. The positional changes in the interphalangeal joints are therefore secondary to changes in the MP joints. The total power capacity of the flexor tendons significantly exceeds that of the extensor tendons; therefore, slight wrist flexion is usually present in a neglected, edematous hand.6
PATHOPHYSIOLOGY Burn wounds involving more than 20% of the total body surface area typically produce a systemic inflammatory response with resultant capillary leak.12 An outpouring of protein-rich fluid occurs that initiates an
inflammatory response leading to increased fibrous protein synthesis.24 Extracapillary efflux of this protein-rich fluid is accompanied by the extracellular fluid shifts that necessitate replacement to maintain fluid balance and homeostasis. The pathophysiology of burn injuries predisposes the burned hand to the development of severe contracture and functional limitation unless appropriate prophylactic measures are taken in the acute setting to avert disability and deformity. Fluid shifts within the capsular and ligamentous structures of the hand result in positional changes that predispose to contracture and functional loss. Such fluid shifts within a nondistensible structure, as occur following severe burns of the hand and upper extremity, predispose to compartment syndrome, vascular compromise, Volkmann’s contracture, and intrinsic muscle necrosis. Additional factors apart from the initial injury contribute to postburn deformity and functional loss, including persistent edema, wound infection, improper or prolonged immobilization, and delayed or inadequate skin coverage.28 Each of these factors can result in a prolonged period of inflammation with resultant increases in fibrosis of normal, initially uninjured structures. The most comfortable position for the burned hand in the acute setting is typically the position of deformity with adduction of the thumb, flexion of the proximal interphalangeal joints, hyperflexion of the MP joints, and flexion of the wrist. This position permits laxity of the collateral ligaments of the MP joints with resultant shortening and fibrosis. Shortening of the transverse metacarpal ligaments results in loss of the transverse metacarpal arch. MP joint hyperextension impairs flexor tendon function at the MP joint level, while adhesion and scarring of the sagittal bands further limits the excursion of the central slip of the extensor tendon. Unopposed flexor tendon activity at the proximal interphalangeal joint level soon results in these joints becoming fixed in flexion. Persistent flexion of the proximal interphalangeal joint or direct burn injury to the extensor mechanism at this level can result in volar migration of the lateral bands below the axis of the joint with resultant hyperextension of the distal interphalangeal joint and the development of a boutonnière deformity. Every attempt must be made in the acute postburn setting to prevent the evolution of such devastating deformities.
EVALUATION The burn patient is a trauma patient and must be treated as such. Innumerable injury mechanisms can produce burns of the hand and upper extremity. The particular mechanism that is involved must be quickly identified, as that information will often direct treatment. Ng et al.
reported a large series of occupational causes of hand burns that included electrical (29.5% percent), flame (24.4%), flash (9.8%), tar and asphalt (9.3% percent), scale (7.8%), chemical (5.1%), steam (4.7%), and grease (1%).20 Nonoccupational causes include house fires, cooking mishaps, and motor vehicle accidents. Almost 90% of patients with major burns have burns involving the hands.1 With this in mind, evaluation of the patient with burns of the hand begins with a comprehensive assessment for associated and, in particular, more serious injuries that must be addressed first. As with all trauma patients, burn patients require a thorough ABC (airway, breathing, circulation) assessment. Potential lifethreatening injuries, such as those involving the cervical spine or those with an inhalation component, must be ruled out before beginning with a focused evaluation of the hand and upper extremity. Evaluation of the burned hand commences with an assessment of the depth and extent of the injury. In general, partial-thickness burns are red and hypersensitive and associated with blistering that occurs at the dermalepidermal junction. In contrast, full-thickness burns are often white, waxy, and leather-like in appearance and usually insensitive. A number of variables affect the ultimate depth of a particular burn, such as location, etiology, and age. A burn on the dorsum of the hand, where the skin is much thinner, is likely to be deeper than one on the volar surface of the hand, certainly in a child. Similarly, a short-exposure scald burn is more likely to produce a partial-thickness injury than is a flame burn, which more often produces a full-thickness burn.28 However, there is no uniform means of assessing burn depth, and it is often difficult to determine whether a burn is partial- or fullthickness at the time of injury. Serial observation and proper management permit determination of the depth of most burns. Desiccation, infection, and improper early treatment can cause conversion of a partial-thickness burn, which might have been managed nonoperatively, to a full-thickness one requiring excision and grafting. The skin of the hand is exceptionally important because of its physical qualities, sensory properties, and microcirculation. The surface area to volume relationship of the hand is comparable only to that of the brain, whose surface is proportionately much greater than its total volume. A volume of 1 cm3 in the digit corresponds to a skin surface area of 2.5 cm2, whereas in the forearm, the value drops to 0.5 cm2.19 The skin of the hand can be divided into two types: the thin, mobile dorsal skin, which permits free articular motion in flexion, and the specialized, thick palmar (glabrous) skin, which is resistant to pressure, stabilizes the grip, and has important sensory functions. The palmar skin does not possess a pilosebaceous system and is therefore referred to as glabrous skin but does have an
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abundance of exocrine sweat glands (400 per square centimeter). This glabrous skin possesses papillary ridges, which are responsible for the cutaneous striations that form fingerprints. The papillary ridges, designed for prehensile grip and moistened by eccrine sweat glands, overlie the fat pads of the fingertips, thenar and hypothenar eminences, and metacarpal heads. These pads and ridges are endowed with the highest density of sensory end organs in the body and supply texture and grip surface to the hand. Free nerve endings and Merckel cell complexes are found in the epidermis and function as mechanoreceptors with slow adaptation. Meissner’s, Krause’s, Ruffini’s, and Pacini’s corpuscles are found in the dermis. Meissner’s, Pacini’s, and Krause’s corpuscles function as mechanoreceptors with rapid adaptation, while Ruffini’s corpuscles function as mechanoreceptors with slow adaptation. With such a complex network of sensory end organs in the hand, it is easy to understand why disruption of this system by burn injuries can produce severe impairment in sensibility. However, pain is an unreliable indicator that a burn is not full-thickness, as the injury may exhibit components of both superficial and deep partial-thickness (second-degree) burns as well as full-thickness (third-degree) burns. Therefore, the presence of pain does not rule out full-thickness injury. In the immediate setting, it is crucial to detect vascular compromise in the patient with circumferential burns. Pain due to vascular ischemia must be differentiated from that due to the cutaneous burn itself. In addition, the absence of a pulse does not necessarily indicate vascular compromise due to the burn. Inadequate fluid resuscitation and relative hypovolemia can result in markedly diminished peripheral pulses in an attempt to perfuse vital organs while maintaining cardiac output and venous return to the heart. Therefore, systemic perfusion should be assessed by means of central venous pressure catheters and urine output. Swan-Ganz catheter assessment of pulmonary artery wedge pressures may be indicated in the elderly or severely burned patient in whom significant fluid shifts are anticipated and must be closely monitored. The absence of pulses in a patient with circumferential burns who is adequately resuscitated might very well be due to vascular compromise secondary to edema in a nondistensible extremity and presents an indication for escharotomy.
NONOPERATIVE TREATMENT The first 24 hours following a severe burn injury are crucial. In this relatively brief period, accurate serial assessment of the adequacy of fluid resuscitation and the perfusion of an involved limb must be made. Appropriate fluid resuscitation ensures adequate circulating volume
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and limb perfusion. However, significant edema results secondary to increased capillary permeability and the massive fluid loads required to maintain intravascular volume. The effect of edema on vasculature compression is substantially compounded by the tourniquet effect of an unyielding circumferential burn eschar.1 The result is tissue ischemia, which must be expediently addressed by escharotomy (see below).
Local Wound Care In the stable patient without vascular compromise, attention should be directed toward wound closure and prevention of deformity and loss of function. To accomplish this, proper assessment of the wound is mandatory. By definition, the presence of blistering represents separation of the skin at the dermal-epidermal junction and therefore indicates a partial-thickness injury. However, the exact depth of the partial-thickness, or second-degree, burn and the propensity for the injury to progress to a full-thickness, or third-degree, burn are often not readily determined at the time of initial evaluation. Factors that serve to minimize the likelihood of conversion of a burn from partial- to full-thickness include bacteriologic control of the wound and prevention of desiccation. This is accomplished by the application of a number of topical antibacterial agents. Following debridement of blisters and other nonviable tissue, either mechanically or enzymatically,13,15 1% silver sulfadiazine cream (Silvadene) is commonly used and applied twice daily. A custom fit can be achieved by using gauze strips and elastic netting while permitting maximal movement of the extremity.1 The application of topical antibacterial agents can be facilitated by using a glove created from products such as Biobrane, Gore-Tex, or Op-Site.3,32,35 These gloves permit easy movement of the hand and optimize healing conditions by providing a moist environment and maximizing contact with antibacterial topical agents. The Biobrane glove fits and adheres well and can be left in place during the healing process for partial-thickness burns of the hand that do not require debridement.1 However, prolonged application of Biobrane and other synthetic dressings must be administered with careful monitoring, as infection beneath these products can culminate in toxic shock syndrome.37
FIGURE 24-1. Kirschner wire fixation of the MP joints in flexion and interphalangeal joints in extension minimizes the incidence of collateral ligament shortening and joint contracture.
ately institute active and passive range-of-motion exercises.5 Because of the knowledge of how the collateral ligaments shorten when improperly managed, all patients should be placed in splints that maintain the MP joints at 70° to 80° of flexion and the interphalangeal joints fully extended. Owing to the significant swelling that occurs shortly following a major burn, it is often necessary to initially flex the MP joints as much as is possible or tolerable by the patient and subsequently to modify the splint daily as additional flexion becomes feasible. Continual elevation of the hand helps to reduce edema. Customized splints fashioned from thermoplastic materials are generally the most effective and easiest to modify on a daily basis. With severe burns of the hand, it is often necessary place Kirschner wires across the proximal interphalangeal and MP joints to ensure proper joint positioning in order to minimize the incidence of joint contracture (Fig. 24-1). This is usually done within the first several days of the injury with the ultimate goal of maintaining the Kirschner wires for no more than 2 to 3 weeks, during which time the edema resolves and the skin coverage is usually completed.
Splinting Preservation of function is the most important aspect of burn management of the hand. A functionless hand is a worthless hand. In fact, it is a hindrance. The burn claw deformity consists of MP joint extension, proximal interphalangeal joint flexion, thumb adduction, and wrist flexion. This deformity can be prevented if attention is paid to properly splinting the hand on the day of injury as well as securing the involvement of a hand therapist to immedi-
SURGICAL MANAGEMENT Escharotomy The combination of edema and circumferential injury with resultant unyielding circumferential eschar should lead one to consider performing an escharotomy.
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Circulatory compromise to the upper extremity at any level is an absolute indication for escharotomy. Although this might not be necessary within the first 24 hours following injury, edema continues to progress over the next 12 to 24 hours, and close observation is mandatory during this period should the need for release become evident. Delay can lead to severe muscular necrosis with resultant Volkmann’s contracture and functional loss. Assessment of the burned extremity to determine the need for escharotomy must focus on quantitative monitoring of subcutaneous pressures, as circulatory compromise can occur even in the presence of palpable pulses. This is best done by using a Stryker pressure gauge or, more simply, a manometer connected to an arterial line setup. Filling pressures of 30 mm Hg or greater on two separate readings indicate the need for escharotomy. If the hand, wrist, or forearm is tight on clinical examination, one should always err on the side of performing an escharotomy.1 In the presence of vascular compromise, escharotomy of the upper extremity should include release of the burned arm, wrist, intrinsic compartments, and each involved finger. Escharotomy can be performed at the bedside by using an electrocautery, which also facilitates hemostasis and minimizes blood loss. The escharotomy incision is typically made in the midlateral plane extending from the most proximal portion of the circumferential injury, across the entirety of the constricting burn, and distally down to the wrist, then across the midlateral plane of the hand and onto the
thenar and hypothenar eminences28 (Fig. 24-2). A radially or ulnarly based flap should be incorporated into the incision design at the level of the wrist to ensure adequate coverage of the median nerve. Similarly, incision design at the level of the medial epicondyle should be made anterior to the epicondyle to avoid injury to the ulnar nerve. Dorsal incisions between the metacarpals permit exposure of the dorsal interossei (Fig. 24-3). A hemostat can be used to spread the edematous tissue, permitting division of the investing fascia with a scalpel. Complete release of the intrinsic compartments is crucial, as intrinsic muscle ischemia and necrosis can result in significant postburn disability of the hand.29 Longitudinal division of the investing fascia allows for decompression of the intrinsic musculature. Digital release is usually accomplished with a single incision along the midaxial plane of each finger. It is usually not necessary to make an incision along both sides of each finger unless the burns are severe and a single-sided incision does not provide adequate release. When possible, it is preferable to make incisions along the nondominant side of each finger. Thus, midlateral incisions should be performed along the ulnar aspect of the index, middle, and ring fingers to minimize the possibility of a painful scar where the thumb opposes the fingers.1 Although the incisions should not be deep enough to expose the neurovascular bundles, which might subject the digital nerves to desiccation, it is still our preference not to use electrocautery for these incisions, thereby minimizing the likelihood of iatrogenic nerve injury. Following escharotomy, the hand and arm are elevated.
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FIGURE 24-2. A, Escharotomy of the hand usually includes release of the thenar and hypothenar compartments, the intrinsic compartments (via a dorsal approach), and the individual digits. B, Release of the volar surface of the hand or forearm should include radially—or ulnarly—based flaps to ensure coverage of the median and ulnar nerves. Decompression of the carpal tunnel and Guyon’s canal is also recommended to prevent damage to the median and ulnar nerves at the level of the wrist. Use of a Jacob’s ladder, in which a vessel loop is secured in zigzag fashion using staples to the edges of the wound, facilitates wound closure following release as the edema subsides.
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FIGURE 24-3. A, Release of the intrinsic compartments is performed by using dorsal longitudinal incisions over the metacarpals. Proximal extension of these incisions can be performed to release a circumferential burn of the wrist, as in this case. B, Digital escharotomy should initially utilize incisions along the nondominant side of each finger. If these prove inadequate, incisions are then made along both sides of each finger. Whenever possible, the surgeon should avoid longitudinal incisions along the radial aspect of the index finger, the ulnar aspect of the thumb, and the ulnar aspect of the little finger. However, one should never compromise the vascularity to the digit if additional incisions are necessary.
The wounds can be treated open with a topical chemotherapeutic agent similar to treatment of the rest of the burn wounds. When escharotomy is appropriately performed and subsequently managed, excellent hand function can be preserved long term (Fig. 24-4).
Excision and Skin Grafting
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The decision to excise and graft a burn is based on the determination that it will not heal satisfactorily within 2 to 3 weeks. Early excision and grafting minimize the incidence of hypertrophic scarring and contracture
FIGURE 24-4. Three months following escharotomies, there is excellent functional recovery of both hands. Aggressive hand therapy is paramount in achieving these results.
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hand function without development of secondary deformities.34 The common “safe” position of the hand, with the MP joints flexed to 80° to 90°, the interphalangeal joints extended, and the wrist extended to 20° to 30°, has been commonly used for immobilizing the hand following grafting. However, this position specifically protects hand function; it does not ensure adequate skin grafting of the dorsum of the hand. Split-thickness skin grafts contract up to 30 to 50% of the original size owing to secondary contraction. Insufficient skin graft increases the propensity for contracture deformity of the dorsal hand.8 Burm and Oh advocate the fist position, in which all MP and interphalangeal joints of the fingers and the wrist are flexed, thereby maximally stretching the dorsal surface of the hand before skin grafting.9 Compared with the safe position, the fist position produces an increase in length of the dorsal surface of the hand of 11% to 20% and of the dorsal surface of the finger of 12% to 17%. This position was maintained for 7 to 9 days after skin grafting with excellent function and cosmetic results obtained in the authors’ report.
ELECTRICAL INJURIES High-voltage electrical injuries produce an arc of current that passes from an entrance wound through a pathway of least resistance to an exit wound. As a result, these injuries are more prone to producing devastating soft tissue injury and loss.17,18 The hand and upper extremity are the most frequent sites of entry in electrical injuries, which are usually job-related and the result of inadvertent contact with a high-voltage source. These injuries are often associated with other serious injuries that may be the result of falling from heights while working on power poles or roofs. Therefore, all victims of highvoltage electrical trauma must be treated aggressively until more severe injuries, such as cervical fractures, have been ruled out. All victims of high-voltage electrical trauma should be admitted to a trauma or burn intensive care unit. Muscular destruction secondary to electrical injury will often produce myoglobinuria, an indicator of rhabdomyolysis and myonecrosis. If left untreated, myoglobinuria is associated with intratubular deposition of pigments, which leads to acute renal failure. Urine flow in the range of 75 to 100 cc/hour must be maintained either by administering a sufficient volume of lactated Ringer’s solution or by inducing diuresis with mannitol or furosemide and alkalinizing the urine by sodium bicarbonate infusion to maintain pigment solubility. Electrical injury can also produce refractory cardiac arrhythmias and serum electrolyte derangements, which can prove fatal if they are not adequately assessed and managed.
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formation while facilitating early mobilization and rehabilitation. Early excision of a full-thickness burn wound can be performed any time after injury, as it will not heal by conservative means and will surely result in hypertrophic scarring and deformity. In addition, excision of a full-thickness eschar within 4 to 5 days following injury will minimize the incidence of significant bacterial invasion and infection.5 Full-thickness eschar excision is usually performed to the level of the paratenon or to the fascia. This is followed by autografting when possible or the application of allograft or other biological dressings in severe burns where sufficient donor sites are unavailable. Tangential excision of a burn wound, using a Weck or Goulian knife or dermatome, removes necrotic tissue in layers until healthy bleeding tissue is reached. In cases in which tangential excision is performed down to the level of the dermis, adequate epithelial elements should be present to permit spontaneous healing without grafting. Such wounds may be covered with a biological or synthetic dressing that can be replaced every 4 to 5 days until healing is completed. However, reepithelialization occurs more rapidly beneath a biological dressing (e.g., allograft) than it does beneath a synthetic dressing (e.g., Biobrane), with less risk of bacterial invasion.5 When a burn wound is tangentially excised down to the level of subcutaneous tissue—the equivalent of a fullthickness excision—autografting must be done. Skin graft donor sites should be selected on the basis of color and texture match, availability, and ease of concealment. Typical donor sites include the upper thighs and buttocks. With severe burns involving a significant percent of the total body surface area, in which multiple regions require grafting, donor sites from which thin grafts have been obtained (0.010 to 0.012 inch) can generally be reharvested in 2 to 3 weeks. Of course, thicker grafts contract less than thinner grafts do, a feature supporting the use of thicker grafts for the hand. In such cases, it is occasionally necessary to harvest skin from the scalp, a source of thick skin that can be reharvested without difficulty. Skin grafts to the hand are usually not meshed, as an unattractive permanent fishnet pattern often results following healing of the interstices of the graft. In addition, meshed grafts contract to a greater extent than unmeshed grafts do. For grafting relatively small defects of the volar surface of the hand and fingers, as well as for release of burn contractures and syndactyly, Park et al. recommend the use of full-thickness skin grafts harvested from the ulnar aspect of the wrist with direct closure of the donor site.23 In a series of 20 patients, they reported restoration of normal function in each case and a resultant scar that was inconspicuous. The goal of skin grafting of the dorsum of the hand is to adequately resurface the area and restore normal
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A small skin defect may be associated with massive damage to underlying muscles, nerves, or vessels.1 Indeed, variable skeletal muscle, neural, and vascular tissue injury is typically distributed along the path of the current.11 Several decades ago, limb amputation rates were reported to be as high as 71%.27 Today, the ability to reconstruct anatomic defects and restore function has dramatically increased the rate of limb salvage following such devastating injuries. Limb swelling usually accompanies significant deep soft tissue injury. Suspicion of compartment syndrome based on clinical manifestations of muscle or nerve ischemia or tenseness on palpation should be confirmed with serial measurement of compartment pressures every 6 to 8 hours for the first 24 hours postinjury. When compartment pressures exceed 30 mm Hg, fasciotomy should be performed utilizing incisions placed similarly to those described for escharotomy. A low threshold for fasciotomy should be maintained in these patients, as the consequences resulting following inadequately treated compartment syndrome are devastating. Serial debridements are usually necessary to determine the extent of devitalized tissue, which is often not apparent during the initial debridement procedure. The need for subsequent debridements can often be guided by performing quantitative wound cultures. After each debridement, the application of allografts or topical antimicrobial agents to the wounds is generally performed. Reconstructive requirements following electrical injury are often more extensive and more complex than those following thermal burns. Once a limb has been satisfactorily debrided without evidence of residual necrotic tissue or infection, skin grafts, local skin flaps, fasciocutaneous flaps, or microvascular free flaps can be used to cover the wound and salvage the injured extremity.
CHEMICAL INJURIES Chemical injuries can be categorized into four groups: acid burns, alkali burns, phosphorus burns, and chemical injection injuries. Although alkalis, as a group, are the most common chemicals involved in cutaneous burns, the most frequent single chemical agent involved is sulfuric acid.33 Chemical injection injuries can result from industrial accidents; with subcutaneous injection of oil, paint, and other substances; or from intravenous extravasation injuries, with passage of chemotherapeutic and other medicinal agents into the soft tissue compartments of the hand. In fact, more than 60% of chemical injuries are the result of work-related mishaps.26 Acid burns cause coagulation necrosis; alkalines cause saponification followed by liquefaction necrosis and, in general, penetrate more deeply and carry a greater risk of severe systemic toxicity. Mechanisms of injury and methods of treatment differ among the four groups, although some similarities exist.
Because most injuries occur during handling of chemical substances, the hand and upper extremity are affected most often. Moreover, these injures, which typically result in a much smaller percentage of total body surface area being involved than in thermal injuries, often result in greater morbidity as a greater percentage of these injuries produce full-thickness burns. Chemical injuries produce tissue destruction not as the result of a “burning” process but rather owing to tissue protein coagulation with resultant necrosis. The major difference between thermal and chemical injuries is the length of time of tissue destruction. Thermal burn injuries are the result of momentary exposure, whereas chemical injuries continue to cause damage until the offending agent is entirely removed or neutralized. Therefore, the most important steps in the initial management of a chemically injured patient are (1) removal of any clothing articles contaminated with the offending agent and (2) immediate, copious, and continuous irrigation with water. This will serve to dilute the chemical agent, minimizing contact and tissue penetration, decrease the rate of chemical reaction, decrease tissue metabolism, and restore normal skin pH.26 Only injuries due to elemental sodium, potassium, and lithium should not be irrigated with water, which would cause ignition and additional thermal injury. Injuries resulting from exposure to hydrofluoric acid are among the most painful of the chemical injuries. This may be attributable to its bimodal mechanism of action. The H⫹ ion that is released, as with all acid burns, must be rapidly neutralized to minimize tissue necrosis. Subsequently, the powerful Fl⫺ ion is released and binds with tissue cations, in particular calcium and magnesium.26 Tissue damage and bony decalcification progress until the ion is neutralized. Treatment is therefore directed at absorption of the negative ions. This is initially done with irrigation of the wound with water followed by application of a 2.5% calcium gluconate gel. Cessation of pain is indicative of adequate treatment. Persistent symptoms indicate the need for injection of the wound with 10% calcium gluconate or magnesium sulfate solutions, administered as 0.5 mL/cm2. Intra-arterial infusion of calcium gluconate is advocated if the exposure area is greater than 2% of the total body surface area or symptoms remain after other forms of treatment of smaller wounds. Using a radial arterial line, a solution of 2 grams of calcium gluconate in 250 cc D5W is infused over 4 hours and usually repeated in 6 to 8 hours. Cardiac monitoring for signs of hypocalcemia and serum calcium level monitoring are crucial.1 Debridement of blisters, bullae, and all necrotic tissue is performed following adequate irrigation and management of the involved extremity. At this point, wound care consists of the application of topical antimicrobial agents, such as 1% silver sulfadiazine dressings BID, until healing has occurred for partial-thickness
injuries or excision and skin grafting or flap reconstruction for full-thickness injuries.
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The most common problem following burn injuries of the hand is the development of skin and soft tissue contractures, which may be the result of skin grafts of inadequate size or thickness, hypertrophic scar or keloid formation, inadequate postinjury splinting, or an inadequate physical therapy rehabilitation program.29 Contractures of the palm following burns to the volar surface of the hand occur commonly when the hand has
not been properly splinted following injury. The propensity for flexion contractures of the wrist and fingers and adduction contractures of the thumb necessitates splinting the hand with the wrist in hyperextension, the thumb fully abducted, and all fingers flexed at the MP joints and extended at the interphalangeal joints for at least a portion of the day. The immediate use of a fitted Jobst garment can significantly decrease the extent of hypertrophic scarring and contracture formation. Prevention of contracture is essential. Once contracture has developed, surgical release and split-thickness or full-thickness skin grafting of the palm are necessary.23 Incisions parallel to the distal palmar and thenar creases often provide sufficient release. The groin crease or lower abdominal wall usually provides adequate full-thickness skin graft donor sites. In addition, a contracted PIP joint volar plate might require incision and release to permit finger extension. Adequate splinting and an aggressive therapy program following contracture release will play a crucial role in preventing contracture recurrence. A regimen including night splinting for 1 year with the wrist and fingers fully extended and the early use of pressure garments is necessary to maintain mobility and function. The use of continuous passive motion devices has also been advocated for this purpose4 (Fig. 24-5). Contractures of the dorsum of the hand can be just as debilitating as those of the volar surface. Tightness, MP joint hyperextension or even dislocation, and limitation of flexion of the fingers can result and necessitate excision and grafting of the dorsum of the hand. In cases of severe contracture, the extensor tendons might be markedly shortened, severely scarred, and unamenable to tenolysis or step cut lengthening.29 Such cases may require tendon transection or excision to allow MP joint flexion. Once good passive range of motion of the MP joints has been reestablished, adequate soft tissue coverage must be
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RECONSTRUCTION OF THE BURNED HAND Proper initial management of the burned hand is crucial to ensure a favorable long-term outcome. However, the complex nature of burn injuries and the resultant tissue destruction invite a whole host of potential complications or sequelae of the initial injury. In the best of cases, in which adequate soft tissue coverage is achieved shortly after the burn injury and healing progresses without infection or other acute adverse consequence, most patients following significant burns must contend with skin and soft tissue contractures, including webspace contractures and adduction contractures of the thumb webspace. In addition, syndactylism, claw deformities, and hypertrophic scarring can also occur following burn injuries and must be addressed if adequate function is to be preserved or restored. The reconstructive burn surgeon must possess an armamentarium of procedures with which to address these complex problems.
Skin and Soft Tissue Contractures
FIGURE 24-5. A variety of continuous passive motion devices are currently used to prevent contractures and maximize hand function following burns.
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provided that will enable subsequent tendon gliding and prevent recurrence of contracture (Fig. 24-6). A variety of approaches, including the use of groin flaps (Fig. 24-7), abdominal wall flaps, radial forearm fasciocutaneous flaps, and free flaps, can be used in these cases with excellent results.14,21,25,30
Hypertrophic Scars and Keloids The development of hypertrophic scars and the formation of keloids remain poorly understood from a physiologic perspective. Indeed, while these two entities behave quite different clinically, they are virtually identical histologically. The best means of addressing these complex problems is prevention, as once they have developed, they are almost impossible to correct without extensive surgery. The Jobst glove pressure garment
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remains the best method of prevention and should be used for any patient who has undergone skin grafting of the hand or patients in whom burn wounds have taken longer than 14 days to heal spontaneously. Scar massage and application of various oil preparations, such as Lubriderm, minimize the occurrence of ulceration and new scar formation. Injection of thickened scars along graft suture lines with Kenalog (triamcinolone acetonide) often yields some degree of improvement.
Webspace Contracture Contracture of the webspace is the most common deformity of the webspace following burns.1 Thickened scar or graft contracture along the dorsal edge of the web can produce dorsal hooding, or “distal creep.” Without the use of splints to maintain the fingers in an abducted
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FIGURE 24-6. A-C, Release of dorsal hand and webspace contractures requires complete excision of all restrictive scar tissue and resurfacing with soft, pliable tissue. Thick splitthickness or full-thickness sheet skin grafts are often used; flap coverage is performed when skin grafting cannot provide adequate coverage of vital structures. C
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FIGURE 24-6 cont’d. D, E, The dorsal burn scar is excised. F, A volar flap is transposed into the first webspace. G, The dorsum is grafted with a thick split-thickness sheet graft with darting along the midlateral aspects of the digits. G
position, which are infrequently used, they usually assume an adducted position at rest. As a result, the burned web often heals in a state of contracture.29 Z-plasty release is often adequate to release the simpler webspace contracture. However, more extensive contractures in which the “creeping” webspace has extended from one-half to three-fourths of the distance from the MP joint to the proximal interphalangeal joint benefit from a V-M-plasty in which five flaps are created in the webspace to reconstitute the proximal position of the web.2 Advanced webspace contractures that require significant release and
flap advancement may also require a skin graft on the lateral aspects of the involved fingers.1
Burn Syndactyly Syndactyly occurring following a severe burn that resembles congenital syndactyly, with skin loss along the entire length of the lateral digits, is uncommon. When it does occur, it is treated by release and skin grafting. Flap design can be a bit more complicated than that performed to release a congenital syndactyly case,
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C
D
FIGURE 24-7. A, B, Serial debridement following fullthickness burns (third- and fourth-degree) yields exposed phalanges and tendons requiring soft tissue coverage. Distal digital amputations are often necessary. C, A groin/epigastric flap is designed on the basis of the superficial inferior epigastric artery or superficial circumflex iliac artery. D, E, The fasciocutaneous flap is elevated and inset to cover all exposed structures of the hand. The groin flap is usually divided 2 to 3 weeks later. E
as this condition is the result of extensive scarring rather than failure of digital separation.
Adduction Contracture of the Thumb An adduction contracture of the thumb involves the first webspace. It is a complex deformity, as it involves not only scarring of the skin of the first webspace but also
fibrosis of the adductor muscle and the first dorsal interosseous muscle.16 Therefore, it is unlikely, except in rare circumstances, that a Z-plasty alone will provide adequate release of an adductor contracture. MP joint hyperextension is often associated with adductor contracture secondary to dorsal scarring. Therefore, the releasing incision should extend from dorsally over the MP joint through the webspace and volarly along the thenar crease
24
335
B
FIGURE 24-8. A, B, A four-flap Z-plasty is designed to release a contracture of the first webspace. C, Six months following release, a well-defined webspace is evident. C
to adequately release the MP joint as well.29 Care must be taken during release of the adductor contracture to avoid the sensory branch of the radial nerve as well as the neurovascular bundles to the thumb and radial side of the index finger. Fascia and muscle are released until an
adequate webspace has been created. Four-flap Z-plasties (Fig. 24-8) and five-flap Z-plasties (Fig. 24-9) are often designed to release contractures of the first webspace. When deeper structures have not been exposed, resurfacing of the webspace with a skin graft is often sufficient;
A
B
FIGURE 24-9. A, B, A five-flap Z-plasty is designed to release an adduction contracture involving not only skin but also underlying muscle. Continued
24
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THE SEVERELY BURNED HAND
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C
D
FIGURE 24-9 cont’d. C, Flap elevation reveals the underlying neurovascular bundles, which require coverage. D, The flaps are then transposed and sutured in place.
coverage of deeper structures is often accomplished with a groin flap or distally based radial forearm flap when available (Fig. 24-10).38 Before grafting or flap coverage is performed, the thumb and index metacarpals are abducted and pinned apart to maintain the breadth of the webspace, and the MP joint is pinned in maximum flexion to optimize subsequent joint mobility.
A
B
CONCLUSION Proper management of severe burns of the hand and upper extremity requires an aggressive approach incorporating the efforts of the hand surgeon, physical and occupational therapists, and patient to preserve complex anatomic structures and maximize long-term functional
C
FIGURE 24-10. A, One year following severe bilateral burns, reconstruction is undertaken to release a severe adduction contracture of the left hand. Prior to this, the patient underwent groin flap coverage of the dorsum of the hand and digits followed by digitalization. B, A distally based radial forearm fascial flap is designed. C, The contracture is released and the flap is elevated.
24
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THE SEVERELY BURNED HAND
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E
recovery. The importance of appropriate splinting, determining the need for escharotomy, and timing of burn wound excision and skin grafting cannot be overemphasized. Reconstruction of webspace and adduction contractures and other sequelae following burn injuries often necessitates various types of Z-plasty procedures as well as the use of local, regional, and free flaps. Familiarity with these techniques is essential in the reconstruction of such secondary problems.
8.
9.
10.
References 1. Achauer BM: The burned hand. In Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1998, pp 2045–2060. 2. Alexander JW, MacMillan BG, Martel L: Correction of postburn syndactyly: An analysis of children with introduction of the V-M-plasty and postoperative pressure inserts. Plast Reconstr Surg 70:345–352, 1982. 3. Bache J: Clinical evaluation of the use of Op-Site gloves for the treatment of partial thickness burns of the hand. Burns 14:413–416, 1988. 4. Bentham JS, Brereton WD, Cochrane IW, Lyttle D: Continuous passive motion device for hand rehabilitation. Arch Phys Med Rehabil 68:248–250, 1987. 5. Boswick Jr JA: Early management of burns of the hand. In The Art and Science of Burn Care, 1987, pp 347–352. 6. Brand PW: Clinical Mechanics of the Hand. St. Louis, CV Mosby, 1985, pp 61–87. 7. Bunnell S: Splinting the hand. American Academy Orthopaedic Surgeons, Edwards. Ann Arbor, MI.
11. 12.
13.
14.
15.
16.
Instructional Course Lectures, 9:233–243, 1952; Surgery of the Hand, 3rd ed. Philadelphia, JB Lippincott, 1956. Burm JS, Chung CH, Oh SJ: Fist position for skin grafting on the dorsal hand. I: Analysis of length of the dorsal hand surface in hand positions. Plast Reconstr Surg 104:1350–1355, 1999. Burm JS, Oh SJ: Fist position for skin grafting on the dorsal hand. II: Clinical use in deep burns and scar contractures. Plast Reconstr Surg 105:581–588, 2000. Consumer Product Safety Commision: Consumer Productrelated injuries treated in hospital emergency rooms. Jan. 1–Dec. 31, 1976. Washington, DC, U.S. Consumer Product Safety Commision, April 1978. Danielson JR, Capelli-Schellpfeffer M, Lee RC: Upper extremity electrical injury. Hand Clin 16:225–234, 2000. Flowers KR, Pheasant SD: The use of torque angle curves in the assessment of digital joint stiffness. J Hand Ther 1:69–74, 1988. Gant TD: The early enzymatic debridement and grafting of deep dermal burns to the hand. Plast Reconstr Surg 66:185, 1980. Gao JH, Hyakusoku H, Inoue S, Aoki R, Kanno K, Akimoto M, Hirai T, Fumirri M, Luo JH: Usefulness of narrow pedicled intercostal cutaneous perforator flaps for coverage of the burned hand. Burns 20:65–70, 1994. Hansbrough JF, Achauer BM, Dawson J, Himel H, Luterman A, Slater H, Levenson S, Salzberg CA, Hansbrough WB, Dore C: Wound healing in partial-thickness burn wounds treated with collagenase ointment versus silver sulfadiazine cream. J Burn Care Rehabil 16:241–247, 1995. Kurtzman LC, Stern PJ, Yakuboff KP: Reconstruction of the burned thumb. Hand Clin 8:107–119, 1992.
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FIGURE 24-10 cont’d. D, The flap is then elevated on the basis of the distal perforators of the radial artery. E, It is transposed into the first webspace following K-wire fixation of the thumb and index metacarpals in abduction.
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17. Lee RC: Injury by electrical forces: Pathophysiology, manifestations, and therapy. Curr Probl Surg 34:677–765, 1997. 18. Lee RC, Astumian RD: The physiochemical basis for thermal and nonthermal “burn” injuries. Burns 22:509–519, 1996. 19. Morel Fatio D: Surgery of the skin. In Tubiana R (ed): The Hand. Philadelphia, WB Saunders, 1961, pp 224–225. 20. Ng D, Anastakis D, Douglas LG, Peters WJ: Work-related burns: A 6-year retrospective study. Burns 17:151, 1991. 21. Park C, Shin KS: Total palmar resurfacing with scapular free flap in a 26-year contracted hand. Ann Plast Surg 26:183–187, 1991. 22. Park S, Hata Y, Ito O, Tokioka K, Kagawa K: Full-thickness skin graft from the ulnar aspect of the wrist to cover defects on the hand and digits. Ann Plast Surg 42:129–131, 1999. 23. Pensler JM, Steward R, Lewis SR, Herndon DN: Reconstruction of the burned palm: Full-thickness versus split-thickness skin grafts long-term follow-up. Plast Reconstr Surg 81:46–49, 1988. 24. Pruitt BA, Goodwin CW, Pruitt SK: Burns, In Sabiston, DC, Lyerly HK (eds): Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 15th ed. Philadelphia, WB Saunders, 1997, pp 881–898. 25. Quaba AA, Davision PM: The distally-based dorsal hand flap. Brit J Plast Surg 43:28–39, 1990. 26. Reilly DA, Garner WL: Management of chemical injuries to the upper extremity. Hand Clin 16:215–224, 2000. 27. Rouge RG, Dimick AR: The treatment of electrical injury compared to burn injury: A review of pathophysiology and comparison of patient management protocols. J Trauma 18:43, 1978.
28. Salisbury RE: Acute care of the burned hand. In McCarthy JG (ed): Plastic Surgery. Philadelphia, WB Saunders, 1990, pp 5399–5417. 29. Salisbury RE, Dingeldein GP: The burned hand and upper extremity. In Green DP (ed): Operative Hand Surgery, 3rd ed. New York, Churchill Livingstone, 1993, pp 2007–2031. 30. Shen TY, Sun YH, Cao DX, Wang NZ: The use of free flaps in burn patients: Experiences with 70 flaps in 65 patients. Plast Reconstr Surg 81:352–357, 1988. 31. Sheridan RL, Hurley J, Smith MA: The acutely burned hand: Management and outcome based on a ten-year experience with 1047 acute hand burns. J Trauma 38:406–411, 1995. 32. Smith DJ, McHugh TP, Phillips LG, Robson, MC, Heggers JP: Biosynthetic compound dressings: Management of hand burns. Burns 14:405–408, 1988. 33. Sykes RA, Mani MM, Hiebert JM: Chemical burns: Retrospective review. J Burn Care Rehabil 7:343–347, 1986. 34. Tattini C, Weinzweig J, Versaci A: Functional aesthetics of burn scar contracture: Approach to the dorsum of the hand. Riv Ital Chir Plastica-Clin Exp Plast Surg 34:39–46, 2002. 35. Terrill PJ, Edwards SM, Lawrence JC: The use of Gore-Tex bags for hand burns. Burns 17:161–165, 1991. 36. Watson HK, Weinzweig J: Stiff joints. In Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1998, pp 552–562. 37. Weinzweig J, Gottlieb LJ, Krizek TJ: Toxic shock syndrome associated with use of biobrane in a scald burn victim, Burns 20:180–181, 1994. 38. Weinzweig N, Chen L, Chen ZW: The distally-based forearm fasciosubcutaneous flap with preservation of the radial artery: An anatomical and clinical approach. Plast Reconstr Surg 94(5):675, 1994.
25 Emergency Free Flaps Luis R. Scheker, MD
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Advances in anesthesia, pharmacology, imaging, and instrumentation; broader knowledge of the anatomy and physiology of flaps; and the formation of emergency microsurgical teams have led to more comprehensive and immediate treatment of patients with severe soft tissue loss in the upper extremity. In particular, the use of emergency free flaps has increased. Emergency free flaps are defined as free flap transfer for the coverage of soft tissue defects after immediate and extensive débridement during only one surgical reconstruction (called primary) within 24 hours after the injury. The concept of delayed closure of contaminated wounds (multiple-stage reconstruction) was established much earlier than free flaps and still has a place in reconstructive hand surgery, depending on the type of wound. However, several reports have shown the benefits of emergency free flap coverage of extremity injuries, including earlier recovery, faster return to maximum range of motion, and shorter time to return to work than in multiple-stage, delayed reconstruction. These reports demonstrate that the traditionally accepted technique of delayed closure of contaminated wounds has been effectively challenged.1,3,7,16,17,20,24,26 This chapter provides a brief history of emergency free flaps, indications for free tissue coverage, evaluation of the injury, the necessity for immediate and extensive débridement, choosing the types of free flaps, complications and morbidity associated with emergency free flaps, case studies, and the advantages and disadvantages of immediate free tissue coverage.
DEFINITIONS The timing of the reconstruction is defined as “primary” when it is performed within 24 hours after the injury; “delayed primary” when it occurs within 48 to 72 hours after the injury; and “secondary” when it is done more than 72 hours after the injury. In the past, most surgeons advocated secondary reconstruction.
HISTORY
The first textbook of surgery, written by Guy de Chauliac in 1363,13 stated that certain wounds should be treated by delayed closure, such as ulcerated, abscessed, and contused wounds and bone surgery. In 1545, Ambrose Pare introduced the concept of débridement, but it was Pierre-Joseph Desault in the late 18th century who coined the term “débridement.” By the 19th century, Louis Pasteur and Robert Koch had established the concept of infection by germs. This germ theory led Joseph Lister to develop the use of carbolic acid, an antiseptic that is used to control infection. Soon thereafter, aggressive 339
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treatment of severe acute wounds became popular in Europe. During World War I, the use of quantitative bacteriology to indicate the risk of infection became common. Cultures of wounds that showed the absence of streptococcus and fewer than 105 colonies of other organisms per plate were treated with delayed primary closure.1 The remaining wounds were left open to heal on their own. The concept of serial débridement followed by wound closure between the fourth and sixth days became a common practice by the end of World War II. Until recently, early closure of wounds was thought to increase the risk of infection.10,12 The perception of increased infection associated with immediate reconstruction was effectively challenged by the success of early replantations. Because amputation by any means other than a clean guillotine mechanism represented a dirty wound, the remaining proximal part and the detached part required thorough débridement before replantation, as advocated by Chen et al.3 Free flaps had not yet become popular, and only staged and pedicled flaps were used. Therefore, the only immediate closure method available was primary closure. The disadvantage of primary closure was thought to be a risk of infection.10 Successful replantation techniques taught surgeons to perform thorough and immediate débridement because of the limited time they had in which to successfully replant the part. By 1978, free flaps became readily available, and with the practice of immediate and extensive débridement, early closure actually decreased infection rates.11
FREE TISSUE TRANSFER TODAY It is generally accepted that each traumatized extremity must be evaluated individually, the mechanism of the injury being taken into account before the appropriate treatment is determined. In the past, most severe injuries to the extremities occurred during wars. However, since the beginning of the industrial age, accidents in the workplace caused by industrial machinery such as the punch press and by farm machinery such as the corn picker have become the major causes of these injuries. In addition, motor vehicle collisions, especially those involving motorcycles and cars, also contribute to the incidence of extremity injuries. An uncomplicated skin incision might simply require irrigation and closure. However, a severely contaminated and mutilated limb might require amputation. The repair of an injured extremity should always follow the reconstructive ladder: simple closure (also called “primary” or “direct” closure), skin grafts, local flaps, regional flaps, distant pedicled flaps, and free flaps.25
Many surgeons now believe that early wound closure after severe trauma to the extremities has an overall beneficial outcome. This belief is based on the success of reconstruction, from the initial steps taken in 1963 by Harold Kleinert,14 when he performed the first revascularization of the thumb, to the first successful thumb replantation performed in 1967 by Tamai15 using microvascular technique. This thought process inspired McGregor and Jackson18 to develop the groin flap as a single-pedicled flap and Daniel and Taylor5 to transfer this flap by microvascular anastomoses. Over the last 30 years, we have learned that replantation should only be done if the wound can be immediately and extensively debrided and the structures can be repaired. Through replantation, we have relearned the art of wound débridement as the first stage of treatment. Emergency free tissue transfer has been the obvious next step in the reconstruction of extremities with severe injuries that, if properly treated, might have a better chance of an excellent result than will replantations.17 A combination of this knowledge and experience is what enables us to use and develop emergency free flaps. The expansion of free flaps and the description of new donor sites have offered new options to cover wounds immediately. Hand surgeons propose immediate coverage for injuries where tissue is available, using cross-finger flaps, rotational flaps, and skin grafts; however, they have not been enthusiastic about immediately covering large wounds that required the use of a free flap for fear that the flap would fail. However, Marco Godina has demonstrated the superiority of early over late free flap coverage in both lower and upper extremities.8 In his posthumously published article, Godina divided his reconstructive cases into three categories: ❚ Immediate (within 72 hours of the injury) ❚ Intermediate (between 72 hours and 3 months of the injury) ❚ Delayed (between 3 months and 12.6 years of the injury) Godina found that free flaps performed earlier had better results than those done later. The earlier reconstructions, those performed within 72 hours, were found to have a significantly improved flap survival rate, decreased incidence of postoperative infection, accelerated bone healing time, shorter length of hospitalization, decreased rehabilitation time, and fewer operative procedures. In our hand care center in Louisville, Kentucky, we studied the different flap surgeries done from October 1980 to June 1984. An emergency free flap was defined as one that was performed at the end of primary débridement or within 24 hours of the time of injury.1,17,20,21 Our original study17 included patients
25
INDICATIONS Indications for primary free tissue coverage (emergency free flaps) of a traumatic upper extremity injury wound include the following: ❚ A major artery or nerve exposed ❚ Bone devoid of periosteum or exposed hardware after bony fixation ❚ Tendon denuded of paratenon ❚ Joints exposed ❚ Circumferential injuries with poor vascularity Before emergency free tissue transfer can be performed, however, the patient must be in stable condition, and the surgeon should be experienced in microvascular surgery. In addition, the wound must meet the following requirements: ❚ Adequate débridement of the wound until it is considered a surgically clean wound ❚ Stable bone fixation ❚ Good recipient vessels ❚ Viable tissues with a good blood supply adjacent to the recipient site Emergency free flap surgery may be performed in patients of any age. It is easier to define the small number of patients who are not candidates for this procedure than to list the many patients who would benefit from early reconstruction of a traumatic extremity injury. Patients who are not candidates include the following: ❚ Unstable patients who cannot tolerate lengthy operative procedures ❚ A patient whose injuries are sufficiently severe that immediate and extensive débridement would destroy the possibility of later function. An extreme
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example of this situation is the ectopic implantation of an undamaged amputated hand by Godina et al. in 1984 in Yugoslavia.8 The hand was temporarily attached on the thoracic wall under the axillary fossa (for 65 days) and revascularized via the thoracodorsal vessels. The hand was later replanted after delayed healing of the wound stump ❚ A patient in whom it is determined that immediate and extensive débridement and early reconstruction would result in poorer function than would a prosthesis ❚ Critically ill burn patients whose condition and skin make the harvesting of free flaps impossible. On some burn victims, however, free flaps can be done Microvascular free tissue transfer might also be indicated in certain instances in which local flaps can be performed, but a distant flap is preferred. For instance, to avoid prolonged immobilization of an already injured extremity and to obtain a successful skin graft to the donor site, microvascular transfer of distant tissue may better serve a patient who has a dorsal hand defect than would a distally pedicled radial forearm flap. Each defect will have different requirements, and the flap used should be specifically tailored to the wound. When a flap is needed to cover structures that cannot be properly covered by a skin graft, because either the graft will not take or the structure will not work properly under a skin graft (for example, flexor tendons without paratenon), nothing is gained by delaying the repair to wait for so-called “healthy granulation tissue.” After trauma, leaking capillaries allow proteinrich fluid to escape into interstitial spaces, creating edema and reducing the pliability of the tissues. Delayed repair makes reconstruction more difficult because the defect cannot contract in size owing to the lack of elasticity in the surrounding tissue. Therefore, the pedicle must be lengthened as the edema migrates proximally through the tissue planes. Furthermore, the vessels that were divided and could have been used as an anastomosis site for the flap will now thrombose up to the last intact branch, and the flow will be reduced to the size of the last patent branch. This chain of events takes place fairly quickly as the edema peaks on the third day. Immediate reconstruction takes place before these changes occur, and when they do occur, they are a part of the healing process. Early reconstruction of the injured extremity will allow for rapid mobilization and improved function in contrast to the stiff joints and adherent tendons that generally accompany delayed repair and the use of a dependent pedicled flap (Fig. 25-1).
25
undergoing free flaps after injury, and we looked for a common factor in those with the best results. We analyzed the success rate, the complication rate, and the length of stay, concluding that the surgeries performed within 24 hours of the injury and immediately after débridement had the fewest complications and the best functional results. These patients had a better postoperative course with less morbidity, an increased flap survival rate, and a faster functional recovery. In a later study,16 139 emergency free flaps to the extremities were performed (136 patients); 115 of the cases involved the upper extremity. The overall flap survival rate was 96.5%. Since 1988, many authors have concurred with the use of emergency free flaps, which have found a secure place in the armamentarium of the reconstructive surgeon.
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FIGURE 25-1. The stiffness and edema that are apparent in this immobilized hand attached to a pedicled groin flap can be avoided by the use of emergency free flaps.
EVALUATION OF THE INJURED HAND After obtaining a thorough history, examination of the injured hand is first done in the emergency room, where vascularity, sensation, active motion, soft tissue loss, and bone injury are assessed. Radiographs and laboratory studies, including wound cultures, are then obtained. Intravenous fluids and antibiotics are given. After the surgeon has a thorough discussion with the patient and informs him or her of the surgical options, the realistic outcome, and the need for postoperative rehabilitation, the patient is taken to the operating room. The injured hand is completely evaluated under appropriate anesthesia, usually an axillary block for isolated upper extremity trauma. In addition to minimizing the length of general anesthesia, the use of regional anesthesia provides postoperative vasodilation of the extremity, thus increasing blood flow to the injured areas and to the free flap. The injured hand is examined for vascularity of the digits and for injuries to the skin, tendons, bones, joints, nerves, and vessels to determine whether primary reconstruction is possible.
DÉBRIDEMENT Adequate débridement is essential and is probably the most important factor in a successful surgery. The goal of débridement is to remove all compromised or contaminated tissue. Tourniquet control is initially used during débridement to minimize bleeding and to increase
visualization of anatomic structures and nonviable tissues. Later, débridement is done with the tourniquet down (or deflated) to see exactly what does and does not bleed. Débridement is begun at the periphery of the wound, where the surgeon establishes a plane of dissection between the normal and injured tissues. Fractured bone is debrided clean of small fragments that provide no structural support. Bone fragments with viable soft tissue or articular cartilage attached to them are left in place. Bone devoid of any soft tissue attachment is removed. Muscles that are severely contused and will not recover function, as well as those that are divided and the distal portion of which does not have a vascular supply, should also be removed. Tendons of such muscles may be woven end-to-side to the remaining musculotendinous units. Nonviable and even questionably viable tissue is excised back to bleeding margins. Débridement continues until only normal-appearing tissue remains. According to Godina, débridement should be a wound excision similar to that performed in cancer surgery in which the tumor is not seen by the knife; in fact, the wound should look like the site of a surgically extirpated tumor.7 Certain anatomic structures, however, should be preserved. These structures include large vessels with normal flow and tendons and nerves that appear to be functional. Once the wound is considered to be clean, the tourniquet is slowly released to assess blood supply to the area; any tissue that does not bleed and cannot be revascularized is excised. Copious irrigation of the wound by means of a bulb syringe, usually with Ringer’s lactate solution, follows complete débridement. Cultures are taken at this point. The tourniquet is then reapplied, and further débridement is done as needed. Once débridement is complete, the tourniquet is slowly released; the wound is surveyed for significant bleeding points that are controlled. If the wound appears completely healthy at this point, preparations for reconstruction are made. If the surgeon is in doubt about the appearance of the wound, a Gram stain can be used to determine the presence of bacteria in the wound after débridement; reconstruction is then postponed, and antibiotic beads are placed in the wound. Free flap transfer is performed within the first 48 hours. The role of quantitative cultures is not useful in these cases because the results are received after a potential flap is performed. Regular cultures and sensitivity are used to adjust antibiotic therapy to treat the appropriate bacteria after surgery. In most cases, the culture is negative after extensive débridement and profuse irrigation.
FREE TISSUE TRANSFER Defects not amenable to closure by skin grafting or by a local flap will require flaps from distant donor sites, as either pedicled or free flaps. Free flaps have many advantages over distant pedicled flaps. Free flaps often require only one operation and allow the other reconstructive procedures to be done in a single stage.24 Free flaps also bring a new blood supply to the reconstructed area, whereas pedicled flaps must rely on the recipient site for vascularization. Immediate motion and elevation of the hand are possible after free flap surgery. Because occupational therapy can be started as soon as the patient recovers from anesthesia, the use of free flaps decreases postoperative edema and stiffness. Complex injuries can be reconstructed with the use of a single, composite flap that provides all the necessary components for reconstruction.27 For example, the use of a single metatarsal together with the skin and one or two tendons from the foot will allow for perfect reconstruction with minimum donor site morbidity. When more than one metatarsal is required, the foot might be significantly compromised such that walking might be impossible. In such cases, composite reconstruction may be accomplished by separately harvesting the nonvascularized corticocancellous bone graft, the tendon graft, and the vascularized tissue from different sites, thus minimizing donor site morbidity.6,24
CHOOSING THE TYPES OF FREE FLAPS Many types of free flaps are available for reconstruction of the upper extremity. Although no formal algorithm has been established for choosing free flaps, it is important to consider both the functional needs of the recipient site and the loss of function at the donor site. It is best to choose a flap that results in minimum donor site morbidity. These factors will require greater consideration as the complexity of the wound and the reconstructive requirements increase. The first step in choosing a donor site is measuring the dimensions of the wound, which is done by taking into account not only the surface area but also the volume requirements of the wound. The length of pedicle required must also be determined at this time. A template of the wound can be made by using a surgical towel or glove paper, keeping in mind the threedimensional aspect of the defect as well as the length and positioning of the pedicle. Other factors that might need to be assessed include the amount of miss-
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ing bone, the length of the tendon defects, the need for vein grafting, and the length of the nerve gap. For a flat wound, fascial and fasciocutaneous flaps can provide excellent surface cover with minimal donor site morbidity and minimal restriction in range of motion. For wounds that require large volume, muscle and musculocutaneous flaps will fill in the defects, the gaps, and the irregularities. This will prevent the development of dead spaces, which is one of the most important goals in treating these complex, large-volume wounds. Both the latissimus dorsi and serratus anterior muscles can provide well-vascularized tissue to fill defects in volume injuries. Preferably, injured tissue should be exchanged with tissue that has similar qualities. For example, the palmar aspect of the hand should be replaced with the plantar aspect of the foot. Unfortunately, availability is limited to the non-weight-bearing area of the foot. Fingertips and thumb tips should be replaced by flaps with similar quality skin, such as the fibular aspect of the big toe and the first webspace. Although Taylor and Corlett have proposed the use of skin, tendon, and bone from the dorsum of the foot, in some cases multiple metacarpal injuries require multiple bone grafts.27 If such large amounts of tissue are harvested for reconstruction, taking a flap that contains more than one metatarsal might cause a defect at the donor site that is unacceptable, such as one that causes the patient to limp. The most commonly used flaps for large surface defects are the latissimus dorsi flap, based on the thoracodorsal artery, or the scapular flap, based on the circumflex scapular artery. For medium-sized defects, the lateral arm flap and groin flap are used. For a small surface injury, a flap from the first webspace of the foot or from the dorsum of the foot would be appropriate; for example, for the thumb tip or finger, the first webspace of the foot and skin of the great and second toes are used. Other free flaps for the hand and thumb have been recently suggested, including lateral arm fasciocutaneous flap, toe flaps, the latissimus dorsi flap, a radial forearm flap combined with autologous bone grant implantation, and the posterior interosseous free flap with an extended pedicle.2,4,19 The rectus abdominis flap can be used to fill irregular spaces. Pedicled flaps from the forearm are avoided because in many cases the injury includes damage to the palmar arch and the viability of a distally based flap that survives by retrograde circulation might be in jeopardy. We also choose the donor site on the basis of the patient’s gender. For medium-sized defects, we often choose the groin flap in women because the area there is flat and tissue harvest leaves a discrete donor scar.
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The lateral arm flap in a woman usually provides too much adipose tissue. Furthermore, a lateral arm flap in a woman might leave a donor scar that might affect a woman’s self-image. We prefer to use the lateral arm flap for male patients whose arms often have less adipose tissue and who might be more tolerant of the donor site scar. The aesthetic appearance of the donor site should always be discussed with the patient before surgery. Another consideration before choosing a flap is whether the surgeon will establish circulation in the flap through an end-flow or a through-flow system in the central artery. This decision can affect the success or failure of the flap.22
6 cm. This flap width creates an obvious cosmetic defect. The most significant complaint against the lateral arm flap at the recipient site was the excessive bulk. However, additional surgery can be performed to thin (debulk) the flap.9 Tenderness of the scar tissue at the donor site is always possible, but the tenderness usually abates over time. Even though flap reconstruction might be successful, donor site complications might occur if good hemostasis is not achieved in the donor bed. Infection can occur at the donor site, usually caused by the excessively tight closure of the site or by a hematoma. Our flap failure rate is 3%. Almost all flap failures are the result of underlying infection. One can minimize flap failure by extensive and immediate débridement, by using healthy vessels, and by the appropriate timing of the surgery.
COMPLICATIONS AND MORBIDITY The complications and morbidity that are experienced with free tissue transfer are related to the donor and recipient sites. Scheker et al. found that with the lateral arm flap, the complications were lateral epicondylar pain and forearm numbness, which were caused by the division of the posterior cutaneous nerve of the forearm during the raising of the flap.23 These complications appear to be minor and are not contraindications for the use of this flap. Most donor site problems were associated with split-thickness grafting, which was required when the width of the flap was greater than
CASE STUDIES Because of the diverse nature of the injuries, the different mechanisms of injury, and the personal circumstances of the patients, an attempt to classify the resulting trauma to the extremity is difficult. However, the following case studies will help to illustrate how we have been able to help these patients regain function in the affected extremity and reduce the resulting morbidity at the donor sites.
CASE 1 A 28-year-old farmer caught his right forearm in the power takeoff of farm machinery, incurring a severe crush injury. The patient had an obvious deformity of the forearm caused by a segmental fracture of the ulna and a severely volarly angulated and open radius fracture (Fig. 25-2A). Distal to the wrist, sensation was not appreciated, and pulses were not palpated. The patient was taken to the operating room, where the surgeon performed fasciotomies and thorough débridement of the right forearm, arm, and hand. Cultures were taken before and after copious irrigation. The segmental fractures of the ulna were fixed with two 3.5-mm compression plates, and the radius was fixed with a volar 3.5-mm dynamic compression plate (Fig. 25-2B). Complete disruption of the flexor digitorum superficialis, the flexor pollicis longus, and the flexor carpi radialis and partial laceration of the flexor digitorum profundus tendons were found. After débridement, end-to-end tendon repairs were performed. Owing to extensive swelling, the volar incision could not be closed primarily; a wide flap was
used to cover the exposed tendons, vessels, and nerves. A large skin graft could have provided coverage, but the tendons would have adhered to it, thus decreasing the range of motion. A free scapular flap was selected to cover the defect. Some areas of exposed muscles proximally were covered with split-thickness skin grafts from the thigh (Fig. 25-2C ). A month after the initial surgery, physical therapy began on the right hand and arm, including both range-of-motion and grip-strengthening exercises. Six months after the initial surgery, the skin graft was excised, primary closure was performed on the right forearm, and the upper part of the scapular flap was trimmed. A year after the initial surgery, the plates and screws were removed from the right arm. Complete healing of the fractures (Fig. 25-2D) and full flexion (Fig. 25-2E ) and extension (Fig. 25–2F ) of the fingers and complete pronation and supination of the forearm were achieved. The patient returned to unrestricted work activities 2 years after the accident with an excellent result.
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FIGURE 25-2. A, Segmental fracture of the ulna associated with a distal third displaced fracture of the radius. B, The segmental fractures of the ulna were fixed with two 3.5-mm dynamic compression plates, and the radius was fixed with a volar 3.5-mm dynamic compression plate. C, Free scapular flap and split-thickness skin grafts cover the volar aspect of the forearm. A plethysmography probe is placed on top of the flap to monitor its vascular flow. D, Complete healing of the fractures. E, Full flexion of all fingers. F, Full extension of the fingers after debulking of the flap 1 year after surgery.
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CASE 2 A 20-year-old man sustained a crushing and degloving injury to the dorsum of the left hand in a motor vehicle collision. The index, middle, and ring finger metacarpals were exposed, and the dorsal skin of the hand was severely damaged (Fig. 25-3A). The patient was unable to extend his fingers. In the operating room, cultures were taken. After initial débridement, the skin defect measured 9.5 cm by 11 cm (Fig. 25-3B). The extensor tendons were absent from the index, middle, and ring fingers. Even though a thorough débridement was performed, the wound was not considered to be surgically clean for immediate reconstruction. Antibiotic beads were placed on the dorsum of the hand and maintained in position with an adhesive plastic cover. A secondlook operation was undertaken 48 hours later, and further débridement was performed. At this point, the wound was
A
considered ready for coverage. A template was made of the wound, and a lateral arm free flap was harvested from the same injured extremity (Fig. 25-3C ). Reconstruction of the extensor mechanism of the index, middle, and ring fingers was performed with tendon grafts taken from the extensor tendons of the foot. The tendons were then passed through the subcutaneous fat of the lateral arm flap, in tunnels created for each tendon, and the repair was performed using the Pulvertaft technique (Figs. 25-3D and 25-3E ). The flap vessels were anastomosed to the radial artery and venae comitantes in the snuffbox. An extensor outrigger splint was placed 2 days after the reconstructive surgery, and therapy was initiated 48 hours later. Five months after the operation, the patient had full range of motion of the fingers and normal strength of the hand and arm (Figs. 25-3F and 25-3G ).
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FIGURE 25-3. A, Crush and degloving injury with extensive soft tissue damage of the dorsum of the left hand. The index, middle, and ring finger metacarpals are exposed. B, After extensive débridement, the skin defect measured 9.5 cm by 11 cm. C, Lateral arm flap landmarks and design. C
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FIGURE 25-3 cont’d. D, Tunnels are created for each tendon. through the subcutaneous fat of the lateral arm flap. E, Tendon grafts are passed through the tunnel, and repairs are performed using the Pulvertaft technique. F, G, Good extension and flexion are obtained 1 year after surgery.
CASE 3 A 19-year-old woman sustained a severe soft tissue injury to the dorsum of her right hand in a motor vehicle collision. The wound was highly contaminated with road dust, sand, and gravel (Fig. 25-4A). Initially, the wound was thoroughly debrided, all of the abraded skin was excised, and the extensor tendons to the ring and little fingers were lost. Loss of the dorsal cortex of the ring and little finger metacarpals was observed. The metacarpal head was fractured and had missing bone; in its place, we found gravel. Débridement and irrigation of the wound were performed. A 15 cm by 6 cm soft tissue defect was present (Fig. 25-4B). A tobramycin bead pouch was placed in the wound and covered with a sterile adhesive plastic (Fig. 25-4C ). Twenty-four hours later, the patient was taken to the operating room; a volar plate arthroplasty was
performed to replace the little finger metacarpophalangeal joint, which sustained extensive loss of the articular surface. A right groin free flap was harvested (Fig. 25-4D). The procedure of tendon repair was similar to that of Case 2; the plantaris tendon was used in this case. The superficial circumflex iliac artery was anastomosed in end-to-side fashion to the ulnar artery. No infection developed, and the flap survived without complication (Fig. 25-4E ). Physical therapy was started within 48 hours by placing the hand in an outrigger splint. Subluxation of the extensor tendon of the ring finger was evident 10 months later. Reconstruction of the juncturae tendinea was performed. Grip strength improved to 83% of the contralateral side, and good range of motion of the wrist and fingers was obtained (Figs. 25-4F and 25-4G ).
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FIGURE 25-4. A, This patient sustained an injury to the dorsoulnar aspect following a motor vehicle collision. The wound was highly contaminated with road dust, sand, and gravel. B, Thorough débridement is performed. C, Antibiotic beads are placed for 24 hours. D, Landmarks of the groin flap are illustrated. E, Early postoperative result following coverage of the defect with a free groin flap. F, Good flexion of all fingers. G, Good extension of all fingers.
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CASE 4 severely comminuted fractured of the distal ulna were necessary to obtain a healthy bone. A 3.5-mm dynamic compression plate was used for osteosynthesis (Fig. 25-5C ). Both radial and ulnar arteries were repaired by using vein grafts. The extensor tendons were shortened to accommodate the length of the forearm bones after fracture fixation. A latissimus dorsi muscle free flap was harvested to cover the extensive soft tissue defect (Fig. 25-5D). This flap was anastomosed to the radial artery at a proximal site. A skin graft from the leg was used to cover the muscle flap. No infection developed. Adequate extension of the metacarpophalangeal joints was achieved; however, there was diminished flexion (Figs. 25-5E and 25-5F ). Sensation was impaired in the ulnar distribution because of the contusion but recovered to a twopoint discrimination of 10 mm.
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A 41-year-old obese woman sustained a severe crush injury to her left forearm in a motor vehicle collision. Her forearm was caught between the car and the ground as the car rolled over. The radius was fractured at the level of the midshaft, and the distal ulna was fractured just proximal to the ulnar head. Soft tissue injuries included skin and subcutaneous tissue loss on the dorsum of the forearm, measuring approximately 20 cm by 15 cm. Loss of muscle mass on the extensor aspect of the forearm was also observed (Fig. 25-5A). The ulnar artery was completely transected, the radial artery had a long segment of thrombosis, and the cephalic vein was injured. The ulnar and median nerves were in continuity but contused over approximately 2 cm. Extensive débridement and irrigation of the wound were done (Fig. 25-5B). Shortening of 2.5 cm of the radius and excision of the
FIGURE 25-5. A, Motor vehicle collision injury. Open radius and ulna fractures (Grade IIIC) with extensive soft tissue injury to the dorsum of the forearm. B, Tissue obtained after extensive débridement of the wound. C, Shortening of 2.5 cm of the radius and excision of the severely comminuted fracture of the distal ulna were necessary. A 3.5-mm dynamic compression plate was used for osteosynthesis. D, Latissimus dorsi muscle flap was anastomosed to the radial artery proximally. Plethysmography probe was observed to monitor vascular flow of the flap. Continued
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E
F
FIGURE 25-5 cont’d. E, Good extension of the fingers was observed 1 year after surgery. F, Diminished metacarpophalangeal joint flexion but with good range of motion of the proximal interphalangeal joints.
CASE 5 A 37-year-old man injured his thumb while working with a motorized wood planer, resulting in an 8 cm by 3 cm soft tissue and bone defect. The dorsal aspect of the thumb metacarpal head was lost. The middle and distal phalanges sustained significant dorsal bone loss (Figs. 25-6A and 25-6B). Metacarpophalangeal and interphalangeal joints were severely
damaged, and 85% of the interphalangeal joint was destroyed. After débridement, the wound was clean, and immediate cover was indicated. A lateral arm osteocutaneous free flap was chosen for the reconstruction of the dorsal skin and bone. Bone was included to maintain the length of the thumb while arthrodesis of the interphalangeal joint was performed.
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FIGURE 25-6. Wood planer injury involving the dorsum of the thumb. A, Soft tissue defect of the dorsum of the thumb. B, Radiograph revealed an intra-articular fracture of the interphalangeal joint with bone loss.
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The lateral arm osteocutaneous free flap was anastomosed to the dorsal branch of the radial artery, and K-wire fixation through the metacarpophalangeal and interphalangeal joints was done (Fig. 25-6C ). It was necessary to cover the dorsoradial aspect of the thumb with a split-thickness skin graft taken
from the forearm. The patient did well. The only secondary procedure was debulking of the flap after the bone healed. Functional pinch and good flexion and extension were achieved (Figs. 25-6D and 25-6E ). Grip strength was the same as in the contralateral hand.
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FIGURE 25-6 cont’d. C, Lateral arm osteocutaneous free flap was performed. The interphalangeal joint was fused using two intramedullary K-wires. D, Good flexion is achieved after complete healing of bone fusion and soft tissue. E, Good extension is achieved. E
DISADVANTAGES OF EMERGENCY FREE FLAPS
ADVANTAGES OF EMERGENCY FREE FLAPS
The only disadvantage of emergency free flaps is the uncertainty of adequate débridement. If the surgeon is not certain that he or she has thoroughly debrided the wound, the opportunity to perform an immediate free flap is gone; staged débridement and multiple-stage reconstruction are then necessary. The only disadvantage of early closure, compared to delayed reconstruction, is the inconvenience to the surgeon. Emergency free flap coverage of traumatic wounds requires that the surgeon be available at all hours, or at least within 24 hours. This availability might interfere with planned elective surgeries or office appointments.
Immediate microvascular free tissue transfer to cover acute upper-extremity wounds has several advantages: ❚ Better healing of exposed vital structures ❚ A decrease in the infection rate compared to that of delayed closure. The low infection rate that is seen with the early closure of wounds in comparison to that of delayed closure suggests that most wounds can be extensively and completely debrided immediately after an injury. Bacteria do not have time to colonize a wound that is covered early. A higher infection rate associated with
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delayed wound closure is most likely related to retained foreign bodies, infected granulation tissue, necrotic tissue, and a compromised blood supply to the injured area ❚ Preservation of bone structures. Bone that is devoid of periosteum and exposed in an open wound will desiccate and become necrotic. With early closure, most bone fragments may be left in place to heal. When wound closure is delayed, more radical débridement will be required to remove necrotic bone ❚ Shorter hospitalization time ❚ Lower cost of immediate coverage compared to delayed coverage because fewer operative procedures are necessary, since complete débridement, repair, and reconstruction are performed at the initial operation By using emergency free flaps, we avoid the following problems that are encountered in delayed wound closure: ❚ Tissue that is left exposed in an open wound will desiccate and become necrotic despite wet dressing changes. ❚ Structures become edematous and indurated. ❚ Granulation tissue develops that is filled with infected organisms and is poorly penetrated by antibiotics. ❚ Granulation tissue is subsequently replaced by scar tissue. ❚ When serial débridement is contemplated, immediate débridement is often incomplete. Tissue of questionable viability is left behind and might not be removed at the next débridement because this tissue might be hidden among granulation tissue and fibrin. The increased rate of infection that is seen after delayed closure of traumatic wounds suggests that the surgeon is too conservative in the excision of tissue of marginal viability during the first of many débridements. Nonviable and contaminated tissue can be left behind and is difficult to detect in the subsequent débridements. Because of the edema and fibrosis that develop in the days after an injury, it might be more difficult to assess normal tissue during delayed débridement than it is during immediate débridement. ❚ Vessels that can be utilized as a recipient for a free flap will thrombose if distal runoff is not provided. Vessels also become edematous, friable, and eventually fibrotic. These constricted vessels result in decreased blood flow to the injured area. ❚ Delayed free flaps require longer pedicles because of the poor condition of the vessels at the injury site. ❚ Free flap failure rate was higher in delayed versus earlier flaps, as demonstrated by Godina.8
Posttraumatic fibrosis affecting the veins in the vicinity of the injury is thought to contribute to this increased failure rate.
CONCLUSION In mutilating hand injuries, the use of emergency free flaps has low morbidity and high success rates. Most hand injuries with exposed vital structures and large soft tissue defects that are not amenable to skin grafts or local flaps are candidates for emergency free flaps. Surgical reconstruction of the mutilated hand in the immediate setting by emergency free flaps is indicated if emergency microsurgical teams are available, the patient is stable enough for a long procedure, the wound can be adequately debrided, tension-free closure of healthy skin can be achieved, and the surgeon has the required skill and experience. The best treatment, however, is always injury prevention. Although the number of mutilating hand injuries is decreasing because more safety devices are being installed in power tools and farm machinery, workers often bypass the safety devices for efficiency. For example, farmers have been known to disconnect kill switches and thus keep tractors and machinery going while the operator steps down from the tractor to clean out dangerous moving parts. We have also encountered paper shredders, lawn mowers, and power tools in which safety devices have been bypassed. Part of our mission as hand surgeons is to remind our patients about the importance of operating tools according to the safety instructions rather than incurring a mutilating hand injury as a more painful reminder.
Acknowledgment My sincere thanks to Elaine Bammerlin, MA, CMI, for her help in preparing the photographs and to Danna Pearsall and Stan Goldman, PhD, for their review of the manuscript.
References 1. Breidenbach WC: Emergency free tissue transfers for reconstruction of acute upper extremity wounds. Clin Plast Surg 16(3):505–514, 1989. 2. Cavadas PC: Posterior interosseous free flap with extended pedicle for hand reconstruction. Plast Reconstr Surg 108(4):897–901, 2001. 3. Chen SHT, Wei FC, Chen HC, et al: Emergency free-flap transfer for reconstruction of acute complex extremity wounds. Plast Reconstr Surg 89(5): 882–888, 1992. 4. Chen HC, Buchman MT, Wei FC: Free flaps for soft tissue coverage in the hand and fingers. Hand Clin 15(4):541–554, 1999.
5. Daniel RK, Taylor GI: Distant transfer of an island flap by microvascular anastomosis: A clinical technique. Plast Reconstr Surg 52(2):111–117, 1973. 6. Dzwierzynski WW, Sanger JR, Yousif JN, Matloub HS: Case report: Sequential vascular connection of free flaps in the upper extremity. Ann Plast Surg 39(3):303–307, 1997. 7. Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 78(3):285–292, 1986. 8. Godina M, Bajec J, Baraga A: Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part. Plast Reconstr Surg 78:295–299, 1986. 9. Graham B, Adkins P, Scheker LR: Complications and morbidity of the donor and recipient sites in 123 lateral arm flaps. J Hand Surg 17B:189–192, 1992. 10. Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg 58A(4):453–458, 1976. 11. Gustilo RB, Gruninger RP, Davis T: Classification of type III (severe) open fractures relative to treatment and results. Orthopedics 10(12):1781–1788, 1987. 12. Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 24(8):742–746, 1984. 13. Haller J: Guy de Chauliac and his chirugia magna. Surgery 55:337, 1964. 14. Kleinert HE, Kasdan ML: Anastomosis of digital vessels. J Ky Med Assoc 63:106, 1965. 15. Komatsu S, Tamai S: Successful replantation of a completely cut-off thumb. Plast Reconstr Surg 42(4):374–377, 1968.
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16. Lim B-H, Gupta A, Scheker LR: Emergency free flap in major trauma of the upper extremity. Paper presented at International FSH, Helsinki, Finland, July 1995. 17. Lister G, Scheker L: Emergency free flaps to the upper extremity. J Hand Surg 13A:22–28, 1988. 18. McGregor IA, Jackson IT: The groin flap. Br J Plast Surg 25:3–16, 1972. 19. Nejedly A, Tvrdek M, Kletensky J: Thumb reconstruction using free flap transfer. Acta Chir Plast 32(4):225–238, 1990. 20. Ninkovic M, Deetjen H, Ohler K, Abderl H: Emergency free tissue transfer for severe upper extremity injuries. J Hand Surg 20B(l):53–58, 1995. 21. Ninkovic M, Schwabegger AH, Wechselberger G, et al: Reconstruction of large palmar defects of the hand using free flaps. J Hand Surg Br 22:623, 1997. 22. Nystrom A, Handle DP, Scheker L, Schwartz KS, Lister G: Free flap circulation and modes of arterial insertion: An experimental study. Microsurgery 11:265–267, 1990. 23. Scheker LR, Kleinert HE, Hanel DP: Lateral arm composite tissue transfer to ipsilateral hand defects. J Hand Surg 12A[2 Pt 1]:665–672, 1987. 24. Scheker LR, Langley SJ, Martin DL, Julliard KN: Primary extensor tendon reconstruction in dorsal hand defects requiring free flaps. J Hand Surg 18B:568–575, 1993. 25. Scheker LR: Soft-tissue defects of the upper limb. In Soutar DS (ed): Microvascular Surgery and Free Tissue Transfer. London, Edward Arnold, 1993, pp 63–77. 26. Sundine M, Scheker LR: A comparison of immediate and staged reconstruction of the dorsum of the hand. J Hand Surg 21B:216–221, 1996. 27. Taylor GI, Corlett R: Microvascular free transfer of a dorsalis pedis skin flap with extensor tendons. In: Strauch B, Vasconez LO, Hall-Findley EJ (eds): Grabb’s encyclopedia of flaps. Boston, Little, Brown, pp 1109–1111, 1990.
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26 Secondary Soft-Tissue Reconstruction James Chang, MD Neil F. Jones, MD, FRCS
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The mutilated hand represents a formidable challenge to the reconstructive hand surgeon. In addition to managing the critical care of the trauma patient, the surgeon must have a detailed knowledge of all pertinent anatomy. This anatomy might be markedly distorted by the trauma. Most important, the surgeon must have an understanding of secondary reconstructive options so that planning can begin from the time of the initial emergency operation. In short, the surgeon who debrides initially should ideally be the same surgeon who eventually reconstructs the upper extremity. Sterling Bunnell realized this concept in 1944: “The hand is so intricate in structure that if dissected in turn by three different specialists it is likely to be wrecked beyond repair. The bones, joints, muscles, tendons, nerves, and skin are all parts of a composite mechanism in the function of the hand and they can best be repaired by the surgeon who assumes responsibility for the whole. Hand surgery is an area specialty, not a tissue specialty.”3 Our algorithm for management of the mutilated hand begins with exploration and debridement. Aggressive debridement is necessary to remove all devitalized tissue. Thereafter, the sequence of reconstruction takes into account immediate issues such as revascularization, bone stabilization, and initial wound coverage. The purpose of this chapter is to outline and discuss options for secondary soft tissue reconstruction. Rather than listing all the possible techniques that have been described, we will present the workhorse grafts and flaps, those that have proven to be reliable and that will achieve stable and durable coverage in the majority of injuries. Knowledge of the techniques described in this chapter will allow soft tissue reconstruction of almost any defect in the upper extremity.
INDICATIONS Indications for secondary reconstruction of the mutilated hand include definitive secondary coverage of open wounds, coverage of critical hardware, contracture release and scar resurfacing, and establishment of a vascularized bed to support nerve, tendon, joint, or skeletal reconstruction. In some instances, the mutilated hand will need to undergo several debridement procedures prior to definitive wound coverage. An open wound may be temporarily dressed with a variety of dressings including saline wet-to-wet gauze or xeroform. It is critical that the wound does not desiccate. Alternatively, dressing changes can help debride contaminated wounds with excessive drainage. Definitive wound coverage must be deferred until control of the wound is achieved. One situation in which early wound coverage is indicated is when hardware used to achieve bony stability is exposed. Although we prefer external fixation out of the zone of 355
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injury, in some cases internal fixation may be preferable. This mandates early wound coverage with flaps. Even exposed hardware may be salvaged with thorough irrigation, debridement, and timely vascularized flap coverage. Another indication for secondary reconstruction with the use of flaps is resurfacing after scar contracture release. The elbow is a classic area in which scar contracture may limit extremity function by preventing normal joint motion, in this case, full elbow extension. Similarly, hand function is significantly compromised by an adduction contracture of the thumb–index finger webspace or by flexion contracture of the fingers. The dorsum of the hand is another region where skin grafts may tether extensor tendon and/or metacarpophalangeal joint movement. Skin grafts previously placed onto a scarred bed of extensor tendons might need to be excised and replaced with thicker skin flaps. A distally based radial forearm flap is especially useful in this situation. Secondary reconstruction of extensor tendons might require a staged approach. First, silastic rods are placed and are left for 3 months to produce a pseudosheath that will allow tendon gliding. In the second stage, tendon grafts are tunneled through these sheaths to reestablish extensor tendon continuity. Finally, in areas where nerve repairs or tendon repairs are performed primarily or secondarily, flaps might need to be performed simultaneously to cover these critical repairs or might need to be performed prior to secondary tendon or nerve reconstruction. The options for secondary soft tissue coverage of the hand include the following: 1. 2. 3. 4. 5. 6.
Split-thickness and full-thickness skin grafting Local flaps from the hand Regional flaps from the forearm Distant flaps from the chest or abdomen Free flaps Specialized neurosensory flaps
Skin Grafting The first option for reconstruction of open wounds or after secondary release of contractures of the upper extremity is skin grafting. In areas without exposed vital structures, skin grafting is the simplest technique. In small wounds, thinned full-thickness grafts harvested from the groin or flexion creases of the upper extremity can provide durable skin that is less likely to contract. However, when larger areas need coverage, split-thickness skin grafts are used. We have routinely used “fenestrated” but unmeshed skin if enough skin is readily available. This prevents the “fishnet stocking” appearance of meshed skin in contrast to a sheet graft.
The primary requirement for effective skin graft “take” is a well-vascularized bed with adequate granulation tissue. This can be provided by frequent wet-to-dry saline gauze dressings. Recently, the use of the vacuumassisted closure technique in which negative atmospheric pressure is applied has been successful in treatment of open wounds of the upper extremity.12 This type of dressing needs to be changed only once every few days and is effective in promoting granulation tissue. Meara et al. reported their experience using a vacuum-assisted closure device to treat nine degloving injuries in five patients.30 De Franzo et al. also discussed successful reapplication of full-thickness degloved skin after degloving injuries of the foot or hand using vacuum-assisted closure therapy.8 Wound coverage with skin grafts might not be ultimately successful because of the possible problems of breakdown or scarring. If the skin graft periodically ulcerates, it is deemed unstable and might need to be replaced with more durable cover. In addition, if the healed skin graft causes joint contracture or limitation in tendon excursion, then this initial attempt at wound coverage might need to be excised and replaced with full-thickness flap tissue.
Local Flaps from the Hand For small wounds, random flaps may be the optimal choice because the local tissue about the hand is an excellent match in color and texture. However, this tissue is limited in quantity, and may have restricted mobility. The palmar skin, because of its thick underlying fascia, is especially immobile. Dorsal skin in the finger and hand is also notoriously limited in its arc of rotation or transposition. The three general categories of flaps used are rotation, advancement and transposition. Rotation flaps are random flaps that are designed with a large gentle arc of curved rotation from the defect itself.29 Differential suturing of the incision allows “rotation” of the flap into the defect itself. The use of either a back-cut, or a Burow’s triangle, in which a triangular excision of normal skin on the end of the flap opposite from the defect is made, may facilitate wound closure. An advancement flap can either be random or axial, based on a vessel within the flap.32 The tissue is raised and simply advanced into the defect. As with rotation flaps, advancement flaps are limited by the dimensions within the hand and the relative inelasticity of the tissue. Transposition flaps are more complex and may also be either random or axial.19 The Limberg (rhomboid) flap is an example of a random transposition flap.21 Alternatively, the flag flap from the metacarpophalangeal region is an example of an axial transposition flap. The
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Four-Flap Z-plasty The four-flap Z-plasty is best reserved for the thumbindex finger webspace. This flap was popularized by Limberg, who converted the standard two-flap Z-plasty into the four-flap design, providing maximum gain in length and easier transposition.18 This flap is especially useful in the first webspace because ample dorsal and volar skin exists for transposition. In addition, significant lengthening is required to effectively release the adduction contracture. Indications include a scarred first
webspace and following partial thumb amputation where shortness of the thumb stump can be compensated by deepening the first webspace. In this technique, the dorsal and volar skin of the first webspace is first examined for evidence of scarring that would preclude use of this skin as Z-plasty flaps. The skin is first marked along the edge of the web. Lines are drawn perpendicular (90°) to this first line. Thereafter, these 90° lines are bisected to make a total of four 45° flaps. Each line that is drawn is of equal length. The four flaps are marked sequentially A, B, C, and D (Fig. 26-1A) and, once the flaps are mobilized and transposed, will fall into the configuration C, A, D, B (Fig. 26-1B). Care should be taken to avoid injury to the ulnar digital nerve of the thumb and the radial digital nerve of the index finger. This simple procedure is very effective in releasing and lengthening the first webspace (Fig. 26-1C). In cases in which there is extensive scarring in the first web, a dorsal transposition flap can be used to bring in suitable skin. Friedman and Wood recently reviewed their experience with the dorsal transposition flap for congenital contractures of the first webspace.10
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transposition flap is defined as a flap that is elevated and transposed over normal tissue before being inset into the wound defect. Lister divided these flaps into type I, in which the secondary defect is skin-grafted, and type II, in which the secondary defect is directly closed.22 Full description of these various types of flaps is beyond the scope of this chapter, particularly because in the mutilated hand, the extensive nature of the injuries and the limited tissue available do not allow consistent use. Several local flaps from the hand deserve mention because they have specific indications and uses in mutilating injuries of the hand and upper extremity.
FIGURE 26-1. A, Scarred thumb-index webspace after near amputation of the thumb. Four-flap Z-plasty is designed with flaps marked A, B, C, and D. B, Four flap Z-plasty after transposition of flaps. Note the new arrangement of the flaps— C, A, D, and B—and the lengthening of the thumb-index webspace. C, Postoperative result of four-flap Z-plasty of the right thumb-index webspace compared to the normal left hand. C
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Cross-Finger Flap A second useful flap in mutilating injuries within a single finger is the cross-finger flap.16 Multiple variations of this technique exist. The principle is to transfer a delayed skin flap from the dorsum of an adjacent finger to the dorsal or volar side of the mutilated finger to cover exposed tendon, bone, or nerve. Cronin is usually credited with popularizing this flap in 1951.7 Indications for flap use include early coverage of exposed flexor tendon and digital nerves; resurfacing of scarred volar skin causing a flexion contracture; and coverage of exposed bone, interphalangeal joints, and extensor tendons on the dorsal surface. In the standard technique in which dorsal skin is used to provide skin cover for a volar wound on an adjacent finger, the first step after debridement of the recipient bed is careful design of the flap. A template is made, and the location on an adjacent finger that allows easy and comfortable postoperative positioning is chosen. Most flaps are based laterally and elevated off the extensor tendon of the middle phalanx. The remaining paratenon is preserved to allow a full-thickness skin graft to take on the donor bed. Cleland’s ligaments might need to be incised to completely mobilize the flap. Insetting is performed with fine removable sutures. Two to three weeks of flap attachment is sufficient time for neovascularization before the flap pedicle can be divided and inset. Improved sensation may be achieved in the crossfinger flap by suturing the dorsal sensory nerve branch within the transferred flap to the proximal end of the proper digital nerve in the injured digit.6 Similarly, a branch of the radial sensory nerve on the dorsum of the index finger may be coapted to the proper digital nerve in the thumb to augment sensory function.11,31
Fillet Flaps In mutilating injuries to the hand, the bone, nerves, and/or tendons may be so severely damaged that reconstruction of that digit is not possible. In this situation, the soft tissue might remain well vascularized and might be salvaged to provide coverage of open wounds in other fingers or in the more proximal hand. This concept had been introduced by several surgeons, and Chase wrote extensively about the idea of salvaging “spare parts.”4,5 Filleting a finger involves removing all bone and tendon, leaving the skin and soft tissue perfused by one or both of the digital vascular bundles. Careful planning must be taken in the design of fillet flaps to ensure that the flap reaches the proposed destination. In addition, longitudinal incisions are made so that bone and tendon are easily removed while preserving blood supply to the flap. Finally, the distal pulp and nail bed are usually discarded because this tissue is bulky and unsightly.
Dorsal Metacarpal Artery Flaps The dorsal arterial circulation of the hand is the source of multiple intrinsic hand flaps. The radial artery and the dorsal carpal arch give off the first and second metacarpal arteries, which run in the intermetacarpal spaces between the thumb and index finger and between the index finger and middle finger, respectively. The third metacarpal artery is much smaller and is less reliable for flap transfer. Although multiple uses and variations have been described, the simplest method to catalogue these flaps is by artery and by direction of flow. Therefore both the first and second dorsal metacarpal arteries may be used in an anterograde or retrograde fashion. The first dorsal metacarpal artery (FDMA) has been found to originate from the dorsal radial artery, just distal to the extensor pollicis longus tendon. In a series of 30 hand dissections, 90% of the hands had superficial or fascial FDMAs, 40% had a deep intramuscular branch, and 30% had both vessels present.9 The external diameter averaged 1.0 to 1.5 mm at the largest part. This vessel can be used to harvest a pedicled island flap of skin from the dorsum of the index proximal phalanx innervated by a branch of the radial sensory nerve.39 In the anterograde fashion, this flap may reach about the dorsum of the radial two-thirds of the hand and even to a portion of the volar hand. The reach of the FDMA flap can be extended distally if it is designed in a retrograde fashion.25 The second dorsal metacarpal artery (SDMA) was found in 29 of 30 (97%) hands dissected.9 The origin of this vessel varied, including the dorsal carpal arch, radial artery, FDMA, and posterior interosseous artery. Once the SDMA reached the index finger extensor tendons, the vessel passed deep to the tendons and within the fascia of the second dorsal interosseous muscle. The SDMA branched and became superficial at the level of the metacarpophalangeal joints. The pedicle, being more central than the FDMA, can reach nearly the entire dorsum of the hand and can also be extended in a retrograde fashion to reach the level of the proximal interphalangeal joints of the index and middle fingers.13 These dorsal metacarpal artery flaps are limited in size and depend on delicate vessels. Therefore they may be used in mutilating injuries of the hand only if the defect is small and the pedicle is beyond the zone of injury. Careful dissection is necessary to include the artery, veins, and possibly branches of the radial sensory nerve. Neurovascular Island Flaps The neurovascular island flap principle was presented by Littler in 1960.24 This technique allows the transfer of protective sensation from the ulnar aspect of either the middle or ring finger to the thumb. There has been much debate among hand surgeons regarding the quality of the transferred sensation.27,44 Some authors have advised performing nerve suture of the proximal digital
nerve of the thumb to the transferred digital nerve.46 Other authors such as Lister have reported adequate two-point discrimination (from 3 mm to 10 mm with an average of 6.4 mm in ten cases) and have therefore advised against nerve suture.20 The needs for padding, sensation, and/or skin cover on the thumb are the main indications for this flap. The island flap is generally harvested from the ulnar aspect of the middle or ring finger. We favor harvesting from the middle finger because of easier reach to the thumb and because both the middle finger and the thumb are innervated by the median nerve. Alternatively, if there has been more proximal injury to the entire median nerve, then the ring finger offers ulnar-innervated sensation. Once the recipient site on the thumb is prepared, the flap is marked on the donor finger. The Doppler ultrasound probe is used to ensure that there is adequate flow not only to the flap vessel—the ulnar digital artery—but also to the remaining radial digital artery of the donor finger and the ulnar digital artery of the adjacent finger. Depending on the size of the flap needed, the dimensions can span from the web to the distal tip, from the volar midline to the midlateral line. Through a zigzag incision in the palm, the common digital artery and nerve are inspected. The flap is then raised, including all the subcutaneous tissue down to the level of the tendon sheath. Laterally, the skin is adherent because of Cleland’s ligaments, which are released. At all times, it is critical to ensure that the neurovascular bundle remains in the skin flap. The fibrofatty tissue around the neurovascular bundle is preserved to allow venous drainage. At the level of the web space, the proper radial digital artery to the adjacent finger is ligated, and the common digital nerve is gently split. With the flap elevated and the neurovascular bundle isolated, a generous tunnel is made in the palmar skin to allow flap transfer or alternatively zigzag incisions are extended to the base of the thumb. The pedicle must be inspected for kinking through the entire range of motion of the thumb. The flap is sutured into position, and the donor site is covered with a full-thickness skin graft. Once the tourniquet is deflated, it is more likely that the flap will have venous congestion owing to the lack of major venous drainage. However, this congestion usually resolves, and the flap will “pink up” over time.
Regional Flaps from the Forearm Radial Forearm Flap The most reliable flap for use in reconstruction of the mutilated hand is the radial forearm flap.41,42,43 Virtually the entire volar skin of the forearm may be perfused by the radial artery via septocutaneous perforators in the septum between the brachioradialis muscle and the flexor carpi radialis muscle. The anatomy is constant and
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reliable. The skin and subcutaneous tissue that are harvested are thin and pliable. When based in either anterograde or retrograde fashion, this flap can reach from the proximal forearm to the fingers. Before harvesting this flap, it is critical to assess flow through the ulnar artery. This is especially true in the mutilated hand, when the zone of injury may involve collateral damage to both radial and ulnar arteries. After adequate ulnar refill is appreciated by performing an Allen’s test and after careful mapping of the course of the radial artery from the antecubital fossa to the wrist, the flap that is needed is marked out, but usually the radial border of the flap should not extend beyond the radial border of the forearm. A vessel loop can be used to mimic the radial artery during simulated transposition of the flap to the recipient site. If the flap is used in a reversed or retrograde fashion to cover the dorsum of the hand; then it should be harvested from the midforearm to allow for an adequate arc of rotation (Fig. 26-2). Conversely, if the flap is to be used in an antegrade flow fashion to cover the elbow, then the flap should be designed over the distal forearm (Fig. 26-3). The skin is incised circumferentially including the underlying fascia. The proximal and distal radial artery and venae comitantes are isolated. The radial sensory nerve along the radial aspect of the flap dissection is carefully preserved to avoid bothersome neuroma formation. The cephalic vein is also isolated for possible inclusion in antegrade flaps for dual venous drainage. The superficial veins drain into the cephalic vein, and the deeper radial venae comitantes also communicate with the cephalic vein in the proximal forearm, so both systems can be preserved in antegrade flaps. However, in the reversed radial forearm flap, adequate venous drainage is possible only by retrograde “stepladder” flow via the venae comitantes. Protective sensation can also be transferred in antegrade or free radial forearm flaps by including the lateral antebrachial cutaneous nerve of the forearm, which can be sutured to a recipient sensory nerve in the hand. Once these important structures have been isolated, the flap is raised beneath the fascia until the flexor carpi radialis is encountered from the ulnar dissection and the brachioradialis is encountered from the radial side. The delicate perforators to the skin paddle may be injured if care is not taken to preserve the intermuscular septum and include the radial artery and venae comitantes on the deep surface of the flap. Either the proximal or distal radial artery and veins are ligated at this point, and the flap is transposed into the recipient site. In many instances, this flap can be tunneled under normal skin to reach the defect. However, special care must be taken not to allow kinking or compression of the pedicle. The paratenon of the exposed volar forearm tendons should be preserved during flap harvest. The distal portion of the flexor carpi radialis is most likely to be
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FIGURE 26-2. A, Degloving injury of the left hand with missing finger extensor tendons and exposed bones. B, A reverse radial forearm flap is tunneled beneath the radial skin to cover the dorsal defect, allowing durable skin cover for eventual extensor tendon reconstruction. C, The donor site of the reverse radial forearm flap is covered with a split-thickness skin graft. D, Postoperative result at 3 months. The hand is ready for staged extensor tendon reconstruction.
exposed, but it is possible to “wrap” muscle from the underlying flexor digitorum sublimis muscles around this exposed tendon to produce a smooth, shallow muscle bed that requires skin grafting. This allows better skin graft take without appreciable functional problems. The forearm donor defect is covered with unmeshed split-thickness skin graft. A splint is placed to immobilize the graft for 7 days. One very useful modification is the radial forearm fascial flap with preservation of the radial artery. In this technique, a plane is dissected in the subcutaneous tissue, separating the skin from the fascia. Thereafter, the fascia is raised in the usual fashion.45 After inset, the fascial flap is covered with a skin graft. The benefits of this technique are that the forearm donor site is covered by primary closure of the skin and the radial artery is preserved, with the fasciosubcutaneous tissue nourished by the perforating vessels of the distal radial artery.
Posterior Interosseous Artery Island Flap In specific instances, when it is inadvisable to sacrifice one of the two major arteries to the hand or when either the radial artery or ulnar artery is already injured, an alternative procedure would be the posterior interosseous artery flap. This flap was originally described by Zancolli and Angrigiani in 1987.47 A retrograde island flap of dorsal forearm skin may be harvested on the basis of the distal anastomosis between the anterior and posterior interosseous arteries. Therefore the flap is perfused by blood flow originally from the anterior interosseous artery volar to the interosseous membrane, then through the interosseous membrane by anastomosis to the posterior interosseous membrane located just proximal to the distal radioulnar joint. Flap harvest to a width of up to 3 to 4 cm may allow primary closure of the donor site. When this island flap
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FIGURE 26-3. A, Intraoperative view of left arm degloving from a rollover motor vehicle accident. Note the exposed ulnar nerve, medial epicondyle, brachial artery, and median nerve at the level of the elbow joint. B, An antegrade radial forearm flap is designed over distal remaining forearm skin. C, Left forearm wounds are reconstructed with a combination of antegrade radial forearm flap and split-thickness skin grafts. D, Three-month postoperative view of the left forearm with durable skin cover at the elbow provided by an antegrade radial forearm flap. E, Three-month postoperative view of the left forearm showing normal elbow flexion. E
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is transposed, it may reliably reach the metacarpophalangeal joints of the hand. The flap is especially useful for resurfacing a contracted first webspace and allows coverage with thin, pliable skin. However, many surgeons have found this to be less reliable than the reverse radial forearm flap owing to the small caliber of the posterior interosseous artery and the difficulty of the flap dissection (Fig. 26-4).
Dorsal Ulnar Artery Flap A flap that has limited indications for the mutilated hand is the dorsal ulnar artery flap. This flap does not sacrifice the ulnar artery itself. Instead, the pedicle is a consistent branch of the main ulnar artery that runs along the dorsoulnar aspect of the distal forearm. Becker and Gilbert first described the vascular anatomy of this flap in 1988.1 From their anatomic dissections, the dorsal ulnar artery was 1.0 to 1.3 mm in diameter and passed
dorsally from the ulnar artery deep to the flexor carpi ulnaris muscle. This vessel supplied skin and fascia in the distal two-thirds of the ulnar aspect of the forearm (length 9 to 20 cm, width 1.5 to 10 cm). This flap is useful in covering small defects around the wrist and proximal portion of the hand (Fig. 26-5). This flap can also be based distally to increase the arc of rotation.17 The dissection of the dorsoulnar flap is continued distally to follow the descending branch of the dorsal ulnar artery onto the dorsum of the wrist, thereby allowing retrograde flow via this descending branch.
Distant Pedicled Flaps Distant flaps are derived from other parts of the body and can be used to reconstruct the mutilated upper extremity. Even with the development of microsurgical free flaps, distant flaps can still play an important role in reconstruction.
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FIGURE 26-4. A, Left wrist with exposed distal radius and extensor tendons. B, The reversed posterior interosseous artery flap is designed. C, The reverse posterior interosseous artery flap is elevated. D, Exposed bone and extensor tendon are covered with reversed posterior interosseous artery flap, and the remainder of the wound is covered with a split-thickness skin graft.
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FIGURE 26-5. A, A volar wrist wound with exposed flexor tendons and median nerve. B, The reverse dorsal ulnar artery flap is raised. C, The dorsal ulnar artery flap is transposed to cover the volar defect. The majority of the donor site may be closed primarily; the remainder is covered by a split-thickness skin graft.
In many instances, when local or regional flaps are not available or when the patient does not wish for or cannot tolerate microsurgical free tissue transfer, a distant pedicled flap can be an effective alternative. The drawback of these flaps is the period of immobilization, which might cause discomfort and joint stiffness. Although multiple possibilities for pedicled flaps exist, the two most useful regions from which to harvest flap tissue are the contralateral chest and the ipsilateral groin. A third alternative is the random abdominal flap. Random chest or abdominal flaps can be raised to cover small defects in the hand if the dimensions are carefully planned. The chest flap is chosen in males because it allows the extremity to be positioned in an elevated, nondependent position. Conversely, for women, the groin flap is favored because the donor incision can be easily hidden in the inguinal crease. Flap division is usually scheduled between 2 and 3 weeks postoperatively.
Chest Flap This flap is best designed on the contralateral chest to allow the elbow to be positioned in a relatively comfortably flexed position. This flap is usually a random pattern
flap designed with a 1:1 length-to-width ratio. The most important aspect of this procedure is proper flap design. After the recipient defect is debrided, the hand is brought up on to the chest and placed into the optimal comfortable position. The skin flap is then designed on the chest based either superiorly or laterally. A template of sterile foam padding is useful in estimating the amount of tissue that is required. The flap is raised in the subcutaneous plane and may be thinned with preservation of the subdermal plexus. Once the flap is raised and inset, it might be possible to close the donor site after undermining.
Groin Flap Unlike the chest flap, the groin flap is an axial flap based on the superficial circumflex iliac artery.23,28 This vessel arises from the femoral artery and passes laterally across the sartorius muscle approximately 2 cm below the inguinal ligament. As this vessel crosses the medial border of the sartorius muscle, it pierces the deep fascia and becomes superficial and subcutaneous. Elevation of this flap begins with careful marking of the vascular pedicle and often may be found with a Doppler probe. The flap is centered along this vascular
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axis, which usually runs 2 cm below the inguinal ligament. A width of up to 10 cm may be closed primarily; however, this depends on the laxity of each patient, and “pinching” will allow estimation of the width that can be easily closed. The medial limit of this flap is the femoral artery, and laterally, the flap can be safely elevated as far posterior to the anterior superior iliac spine (ASIS), as the flap is random lateral to the ASIS. It is also possible to include a portion of iliac crest for osteoplastic reconstruction (Fig. 26-6).
One must carefully design this flap to prevent excessive length on the flap that would cause kinking and thereby compromise blood flow. The flap is incised along the markings to the level of the deep fascia and raised in a lateral to medial direction. Once the sartorius muscle is encountered, it is important to incise the deep fascia over the sartorius to release the superficial circumflex iliac artery pedicle. If this fascia is not released, then the pedicle might be tethered as it crosses the deep fascia into the subcutaneous tissue. The random portion of the
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FIGURE 26-6. A, An avulsion injury of the left thumb that was not replantable. B, Radiograph at the time of injury showing the level of thumb injury at the midproximal phalanx. C, Immediate coverage was obtained by using a pedicled left groin flap. The microforceps to the left points to the superficial circumflex iliac artery vascular pedicle. D, The thumb is covered with the groin flap.
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FIGURE 26-6 cont’d. E, The patient did not want thumb reconstruction with toe-to-thumb transfer. She underwent osteoplastic reconstruction with secondary bone grafting from the iliac crest and a neurovascular island flap. The iliac crest bone graft is secured by using 90–90 intraosseous wires and a temporary K-wire. The neurovascular island flap is marked along the ulnar border of the middle finger. F, The skin and neurovascular pedicle of the ulnar aspect of the middle finger are raised. G, The neurovascular flap is transferred to the volar aspect of the osteoplastic thumb reconstruction to provide protective sensation. H, The final result following groin flap, iliac crest bone graft, and neurovascular island flap for osteoplastic reconstruction of the thumb.
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flap lateral to the ASIS should be radically thinned almost to the subdermal level to produce a thin flap for insetting on the hand. The donor incision is closed first, and then the proximal portion of the groin flap is tubed. These two portions should be performed first because once the flap is inset, it is difficult to gain access to the groin incision and the underside of the tube. The flap is then inset into the recipient defect. If the groin flap is properly designed, the arm should be in a comfortable position with allowance of some elbow flexion and extension and even some pronation and supination. The surgeon must ensure that the tube will not become kinked. Finally, the hand is taped to the hip to maintain optimal position of the flap pedicle. As the patient is awakened from anesthesia, it is critical for the surgeon to hold onto the hand and flap to prevent the patient from “disconnecting” the flap while in a disoriented state. Both the chest flap and groin flap are surprisingly well tolerated. These patients are usually kept in the hospital for a period of 1 to 2 days so that they become comfortable walking around with their hand attached. These pedicled flaps can be safely divided at 2 to 3 weeks. Some authors have advocated preliminary ligation of the superficial circumflex iliac artery at 2 weeks followed by division of the pedicle at 3 weeks; others divide the entire pedicle at 3 weeks. Thereafter, aggressive range of motion at the shoulder, elbow, and hand will prevent excessive stiffness from the period of immobilization. Though not “state-of-the-art,” these distant pedicled flaps can still provide reliable soft tissue coverage when other options are not available.
Free Flaps Microsurgical reconstruction can be used for complex mutilated hand defects when other options such as skin grafting, local flap transfer, and distant flap transfer are not sufficient. Microsurgery is not always the best solution for all reconstructive dilemmas and certainly is not the first choice in the reconstructive ladder. However, it can offer the reconstructive hand surgeon a wide range of possibilities for complex reconstruction. Microsurgical free tissue transfers can be long and technically difficult operations. In addition, there exists the possible need for emergency reoperation either to evacuate hematomas or to revise thrombosed microsurgical anastomoses. Therefore contraindications for this type of procedure include severe medical illnesses that would preclude the ability to tolerate prolonged anesthesia. Medical problems such as cardiovascular disease, renal disease, and diabetes mellitus are not true contraindications if these conditions are well controlled. Liver failure and coagulopathy are more likely to be contraindications owing to the risk of general anesthesia and uncontrolled hemorrhage. Furthermore, ongoing
sepsis is a contraindication. Advanced age is not necessarily a contraindication to microsurgery if the patient is healthy and the surgical indications are sound. Decision making is critical to the success of microsurgical reconstruction of the hand. Once the decision to proceed with microsurgery has been made, the optimal flap must be chosen. This is based on a combination of the size of the defect, the type of tissue needed (bone, muscle, fascia, tendon, nerve, skin), the zone of recipient vessel injury, the length of the vascular pedicle, and the reliability of the flap. In addition, one must always consider the morbidity of the donor site. Careful planning of the procedure should take into account the size and nature of the defect and the candidate flaps available. Rather than listing all flaps available to the hand microsurgeon, only the workhorse flaps—those that have reliable anatomy and are straightforward to harvest—are presented. If the hand surgeon is totally familiar with these flaps, then the vast majority of microsurgical soft tissue reconstruction of the hand can be performed.
Latissimus Dorsi Flap The dominant vascular pedicle is the thoracodorsal artery and vein. The average external diameter of the artery is 3 mm. The length of the pedicle is long, and it can be further lengthened by dissecting it proximally to include the subscapular artery up to the level of the axillary artery. Motor innervation may be preserved if necessary by including the thoracodorsal nerve. This flap is a very reliable and extremely versatile free flap because of its long vascular pedicle and large dimensions. According to Serafin, the average surface area of this triangular muscle is 105 cm2 in the female and 192 cm2 in the male.36 The flap can be harvested either as a pure muscle flap or as a musculocutaneous flap. The skin paddle is reliable over the muscle itself, and skin paddles up to 9 cm in width and 22 cm in length will allow primary closure. The size of the latissimus muscle may be customized to produce hemilatissimus or “tailored” latissimus dorsi flaps if the surgeon understands the branching of the thoracodorsal artery pedicle into transverse and medial intramuscular branches. In addition, it is sometimes necessary to trim the distal watershed region of the muscle owing to poor perfusion from the main pedicle. The latissimus dorsi muscle may also be raised with the serratus anterior muscle and/or scapular flap on one single pedicle for additional tissue (discussed below). One drawback of the latissimus dorsi flap is the need for positioning the patient in a lateral decubitus position during harvest. The latissimus dorsi muscle or musculocutaneous flap is ideally suited for reconstruction of extensive palmar or dorsal defects involving either the forearm, wrist, or hand.
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Scapular Flap The scapular flap can be raised as a cutaneous flap or with a portion of scapula bone as an osteocutaneous flap. The dominant pedicle is the circumflex scapular artery (transverse cutaneous branch) and vein and is long and reliable. This pedicle can also be lengthened by including the subscapular artery and vein. Sensory innervation is potentially available from the lateral and posterior cutaneous nerves of the third to fifth intercostal nerves. Flap dimensions up to 10 cm in width and 22 cm in transverse length can still be closed primarily.38 This territory can be extended by including the parascapular flap based on the descending cutaneous branch off the circumflex scapular artery. In massive defects, this flap may be combined with the latissimus dorsi and serratus anterior muscles on a single subscapular artery pedicle. There are several drawbacks to this flap. The patient must be positioned in either the lateral decubitus position or the prone position for harvest. Flap dissection is technically difficult, as the dissection proceeds proximally into the triangular space. The sensory innervation is not reliable, and the skin may be too bulky, depending on the body habitus of the patient. Lateral Arm Flap The lateral arm flap is raised as either a fascial or fasciocutaneous flap. The dominant pedicle is the posterior
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radial collateral artery and venae comitantes, a branch of the profunda brachii artery. This artery has a diameter between 1 and 2 mm and a length of 7 to 8 cm. Sensory innervation is provided by the posterior cutaneous nerve of the arm and may be used to provide protective sensation. In specific cases, a portion of the humerus may be harvested to make this an osteocutaneous flap.35 The advantage of this flap is that it does not require sacrifice of a major vessel in the arm and may be harvested from the same upper extremity that requires reconstruction. However, the fasciocutaneous flap can be bulky, and the pedicle is often short. The donor site may be either closed primarily, if there is laxity in the upper arm, or skin grafted. In either case, the donor scar can be conspicuous. Finally, it is important to understand the anatomic course of the radial nerve to prevent injury during dissection.
Radial Forearm Flap The radial forearm flap is usually used in reconstruction of the mutilated hand as a reverse pedicled flap, but occasionally, a free radial forearm flap can be harvested from the contralateral forearm. The dominant pedicle is the radial artery, with venous outflow through the dual system of the venae comitantes and cephalic vein. Sensory innervation may be derived from the medial and lateral antebrachial cutaneous nerves. This flap can also be harvested as a fascial or osteocutaneous flap. This is a very useful and versatile flap with a long vascular pedicle and thin, pliable skin.42 However, it does sacrifice a major artery to the contralateral hand. One specific indication of a contralateral radial forearm free flap is to provide simultaneous coverage and revascularization of either or both the radial and ulnar arteries in a mutilated extremity injury.2 The osteocutaneous flap risks fracture of the distal radius if careful harvesting is not performed. In addition, exposure of the flexor tendons must be avoided by careful preservation of the paratenon and coverage of tendons with surrounding muscle bellies prior to skin grafting. Rectus Abdominis Flap The rectus abdominis flap can be raised as either a muscle or a musculocutaneous flap. The dominant pedicles are both the deep inferior and superior epigastric arteries and veins. Microsurgical flap transfer is usually carried out using the deep inferior epigastric pedicle. The deep inferior epigastric artery originates from the external iliac artery just above the inguinal ligament. The artery is approximately 3 mm in diameter at its origin and extends 7.6 cm until it enters the posterior rectus sheath.37 Motor innervation is possible from the seventh to twelfth intercostal nerves, in segmental fashion, and sensory innervation is provided by the lateral cutaneous nerves of the seventh to twelfth intercostal nerves.
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Serratus Anterior Muscle Flap For smaller defects in which less muscle mass is needed, the serratus anterior flap offers a reliable alternative with the same advantages of a very long vascular pedicle. The arterial supply is the branch to the serratus muscle off the thoracodorsal artery. Venous outflow follows the arterial pattern. Therefore a pedicle length even longer than that of the latissimus flap can be harvested by including the subscapular artery. Motor innervation can also be reliably transferred by using the long thoracic nerve, thus allowing the possibility of functional innervated muscle transfer. The inferior three slips of the serratus muscle can be harvested without causing winging of the scapula. These three slips originate from the sixth, seventh, and eighth ribs and provide an approximate surface area of 10 cm by 12 cm. The serratus muscle is much thinner than the latissimus dorsi muscle and may be tailored to achieve a better contour result. In addition, the serratus muscle flap can be harvested with rib to reconstruct segmental bone defects.34 A cutaneous paddle has been described but is less reliable. In the mutilated extremity that requires extensive flap coverage, the latissimus and serratus muscles may be combined on a single pedicle to achieve maximal composite tissue transfer14 (Fig. 26-7).
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FIGURE 26-7. A, A severely mutilated left forearm after a rollover motor vehicle accident. B, A radiograph showing comminuted left radius and ulna fractures. C, The left forearm after debridement, bony stabilization with external fixation, and tendon and nerve repairs. D, Coverage of this extensive wound is achieved with a combined latissimus dorsi muscle (to the forearm) and serratus anterior muscle (to the elbow) free flap. The muscle flaps are then covered with a split-thickness skin graft. E, Postoperative result at 6 months. E
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Gracilis Flap The gracilis flap may be harvested as either a muscle or a musculocutaneous flap. The vascular pedicle is the ascending branch of the medial circumflex femoral artery and vein. The length of the pedicle is approximately 6 to 7 cm with an external diameter of 1 to 1.5 cm. Motor innervation is from the anterior branch of the obturator nerve. The skin paddle may derive sensation from the anterior femoral cutaneous nerve; however, the skin paddle might be unreliable owing to a paucity of musculocutaneous perforators from the gracilis muscle. The gracilis muscle flap is the optimal flap for restoring extremity muscle function, specifically as a functional innervated muscle transfer for flexor or extensor tendons.26 It is rarely used for secondary soft tissue coverage alone. The main advantage of this flap is that the donor site morbidity is minimal. However, the vascular pedicle is short, and the vessels are small in comparison to those in the other free flaps described. Groin Flap The groin flap was one of the earliest described free flaps.28 While very useful in a pedicled fashion, as described previously in this chapter, the groin flap is less commonly used today in free tissue transfer because more reliable alternatives exist. The vascular pedicle, the superficial circumflex iliac artery, is comparably long; however, its diameter is smaller than that of the other free flaps described. In addition, the venous anatomy can be quite variable.33 Usually, the groin flap is not innervated, although the lateral cutaneous branch of the subcostal (twelfth thoracic) nerve crosses the iliac crest 5 cm posterior to the anterior superior iliac spine and therefore may be coapted to a cutaneous nerve in the hand when an extended groin flap is used.15
Specialized Neurosensory Flaps Transfer of sensation is possible using many of the flaps described in this chapter. To date, outcome analysis of
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the results of these neurosensory flaps has proven to be difficult. Different authors have reported conflicting results because these patients and their injuries vary greatly. Nevertheless, it is important for the reconstructive hand surgeon to attempt restoration of protective sensation to critical areas such as the thumb, fingertips, and resting surfaces of the hand. Local flaps that are most useful in restoring sensation include the neurovascular island flap, the anterograde dorsal metacarpal artery flaps, and the innervated cross-finger flap. Free neurovascular skin flaps are also possible. Reliable free neurosensory flaps include the radial forearm flap with sensation transferred by the lateral antebrachial cutaneous nerve, the dorsalis pedis flap with sensation from the deep peroneal nerve, and the toe or toe pulp flap with digital nerve sensation.
CONCLUSION The mutilated hand represents the ultimate challenge to the reconstructive hand surgeon. The approach presented here is a reliable algorithm for secondary soft tissue reconstruction. Knowledge of these specific flaps will allow reliable coverage of nearly every deformity resulting from severe trauma to the hand and upper extremity.
References 1. Becker C, Gilbert A: The ulnar flap. Handchir Mikrochir Plast Chir 20:180–183, 1988. 2. Brandt K, Khouri RK, Upton J: Free flaps as flow through vascular conduits for simultaneous coverage and revascularization of the hand or digit. Plast Reconstr Surg 98:321, 1996. 3. Bunnell, S: Conclusions on the care of injured hands in World War II derived from the experiences of the civilian consultant for hand surgery to the Secretary of War. In Bunnell, S. (ed): Surgery in World War II: Hand Surgery. Washington, DC: Office of the Surgeon General, Department of the Army, 1955, pp 20–21. 4. Chase RA: The damaged index digit: A source of components to restore the crippled hand. J Bone Joint Surg 50A: 1152–1160, 1968. 5. Chase RA: Belaboring a principle. Ann Plast Surg 11: 255–260, 1983. 6. Cohen BE, Cronin ED: An innervated cross-finger flap for fingertip reconstruction. Plast Reconstr Surg 72:688–697, 1983. 7. Cronin TD: The cross finger flap: A new method of repair. Am Surg 17:419–425, 1951. 8. De Franzo AJ, Marks MW, Argenta LC, Genecov DG: Vacuum-assisted closure for the treatment of degloving injuries. Plast Reconstr Surg 104:2145–2148, 1999. 9. Earley MJ, Milner RH: Dorsal metacarpal flaps. Br J Plast Surg 40:333–341, 1987.
26
While these innervation patterns are described, sensory and motor reinnervation are unreliable. This is a relatively rarely used but versatile flap with a large muscle mass and skin paddle. The rectus abdominis muscle can be harvested from the pubis to the sternocostal attachment, for a muscle size approximately 6 cm in width and 20 cm in length. The skin paddle may be oriented directly over the muscle in either a vertical fashion or a transverse fashion and may be harvested with the patient in a supine position. One drawback to this flap is the possibility of abdominal hernia after sacrifice of one of the rectus abdominis muscles. Careful closure of the layers of the abdominal wall is critical to prevent this occurrence.
SECONDARY SOFT-TISSUE RECONSTRUCTION
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10. Friedman R, Wood VE: The dorsal transposition flap for congenital contractures of the first web space: A 20-year experience. J Hand Surg Am 22:664–670, 1997. 11. Gaul JS: Radial-innervated cross finger flap from the index to provide sensory pulp to injured thumb. J Bone Joint Surg 51A:1257–1263, 1969. 12. Greer SE, Longaker MT, Margiotta M, Mathews AJ, Kasabian A: The use of subatmospheric pressure dressing for the coverage of radial forearm free flap donor-site exposed tendon complications. Ann Plast Surg 43:551–554, 1999. 13. Hao J, Liu X, Ge B, et al: The second dorsal metacarpal flap with vascular pedicle composed of the second dorsal metacarpal artery and the dorsal carpal branch of radial artery. Plast Reconstr Surg 92:501–506, 1993. 14. Harii K, Yamada A, Ishihara K, et al: A free transfer of both latissimus dorsi and serratus anterior flaps with thoracodorsal vessel anastomosis. Plast Reconstr Surg 70:620, 1982. 15. Joshi BB: Neural repair for sensory restoration in a groin flap. Hand 9:221–225, 1977. 16. Kappel DA, Burech JG: The cross-finger flap: An established reconstructive procedure. Hand Clinics 1:677–684, 1985. 17. Karacalar A, Ozcan M: Preliminary report: the distally pedicled dorsoulnar forearm flap for hand reconstruction. Br J Plast Surg 52:453–457, 1999. 18. Limberg AA: Design of local flaps. In Gibson T (ed): Modern Trends in Plastic Surgery. London, Butterworth, 1966, p 38. 19. Lister G: The theory of the transposition flap and its practical application in the hand. Clin Plast Surg 1981; 8:115–128. 20. Lister G: Skin flaps. In Green DP (ed): Green’s Operative Hand Surgery. New York, Churchill Livingstone, 1993, p 1775. 21. Lister G, Gibson T: Closure of rhomboid skin defects: The flaps of Limberg and Dufourmentel. Br J Plast Surg 25: 300–314, 1972. 22. Lister GD, Pederson WC: Skin flaps. In Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, pp 1783–1796. 23. Lister GD, Pederson WC: Skin flaps. In: Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, pp 1831–1838. 24. Littler JW: Neurovascular skin island transfer in reconstructive hand surgery. In: Transactions of the Second International Congress of the Society of Plastic Surgeons, 1960, pp 175–179. 25. Maruyama Y: The reverse dorsal metacarpal flap. Br J Plast Surg 43:24–27, 1990. 26. Manktelow RT, McKee NH: Free muscle transplantation to provide active finger flexion. J Hand Surg 3:416, 1978. 27. McGregor IA: Less satisfactory experiences with neurovascular island flaps. Hand 1:21–22, 1969. 28. McGregor IA, Jackson IT: The groin flap. Br J Plast Surg 25:3, 1972.
29. McGregor IA, Morgan G: Axial and random pattern flaps. Br J Plast Surg 26:202–213, 1973. 30. Meara JG, Guo L, Smith JD, Pribaz JJ, Breunig KH, Orgill DP: Vacuum-assisted closure in the treatment of degloving injuries. Ann Plast Surg 42:589–594, 1999. 31. Miura T: Thumb reconstruction using radial-innervated cross-finger pedicle graft. J Bone Joint Surg 55A:563–569, 1973. 32. Moberg E: Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg 46A:817–825, 1964. 33. Penteado CV: Venous drainage of the groin flap. Plast Reconstr Surg 71:678–684, 1983. 34. Richards MA, Poole MD, Godfrey A: The serratus anterior/rib composite flap in mandibular reconstruction. Br J Plast Surg 38:466, 1985. 35. Scheker LR, Kleinert HE, Hanel DP: Lateral arm composite tissue transfer to ipsilateral hand defects. J Hand Surg 12:665, 1987. 36. Serafin S: The latissimus dorsi muscle-musculocutaneous flap. In Serafin S: Atlas of Microsurgical Composite Tissue Transplantation, Philadelphia, WB Saunders, 1996, pp 205–219. 37. Serafin S: The rectus abdominis flap. In Serafin S: Atlas of Microsurgical Composite Tissue Transplantation, Philadelphia, WB Saunders, 1996, pp 221–247. 38. Serafin S: The scapular flap. In Serafin S: Atlas of Microsurgical Composite Tissue Transplantation, Philadelphia, WB Saunders, 1996, pp 339–345. 39. Small JO, Brennan MD: The first dorsal metacarpal artery neurovascular island flap. J Hand Surg 13B:136–145, 1987. 40. Smith PJ, Foley B, McGregor IA, Jackson IT: The anatomical basis of the groin flap. Plast Reconstr Surg 49:41–47, 1972. 41. Song R, Gao Y, Song Y, et al: The forearm flap. Clin Plast Surg 9:21, 1982. 42. Soutar DS, Tanner NSB: The radial forearm flap in the management of soft tissue injuries of the hand. Br J Plast Surg 37:18–26, 1984. 43. Swanson E, Boyd JB, Manktelow RT: The radial forearm flap: Reconstructive applications and donor-site defects in 35 consecutive patients. Plast Reconstr Surg 85:258–266, 1990. 44. Tubiana R, Duparc J: Restoration of sensibility in the hand by neurovascular skin island transfer. J Bone Joint Surg 43B:474–480, 1961. 45. Weinzweig N, Chen L, Chen Z–W: The distally–based radial foream fasciosubcutaneous flap with preservation of the radial artery: An anatomical and clinical approach. Plast Reconstr Surg 94(5):675, 1994. 46. Wintsch K: Transport von fingerteilen mittels: Bauchhautlappen zur finger- und danmenanfbauplastik. Handchirurgie 13:56–61, 1981. 47. Zancolli EA, Angrigiani C: Posterior interosseous island forearm flap. J Hand Surg 13B:130–135, 1987.
27 Principles of Bony Reconstruction Steffen Baumeister, MD Günter K. Germann, MD, PhD
Trauma, tumor, or infection can lead to severe destruction of the hand, including the skeleton. Bony reconstruction of the hand is indicated in many clinical situations, including simple, displaced, or comminuted fractures, as well as bony defects following trauma, infection, or tumor resections. The reconstructive principles for the management of fractures and osseous defects are discussed in this chapter. The final goal of reconstruction is reestablishing form and function of the hand with bony consolidation and a pain-free, normal range of motion with complete stability.
HISTORICAL ASPECTS
1. 2. 3. 4.
27
The history of hand surgery dates back to Hippocrates (born in 460 BC), whose original writings are compiled and edited in the Hippocratic Collection. The ten-volume translation contains details about reduction of dislocated finger joints, patterns of carpal dislocations, similar to “anterior dislocation of the lunate” and “perilunate dislocation,” and principles of splinting and wound care, which are in many cases still valid today.46 However, other literature concerning hand surgery throughout the centuries is rare. At the beginning of the 20th century, fracture treatment of the hand consisted of two alternatives: splinting or amputation.78 Until the 1960s, almost all fractures were treated conservatively.10 Even today, the majority of fractures in the hand are treated without surgery;10 however, the percentage of operative interventions has markedly increased. According to a study by Dobyns, the percentage of surgically treated wrist or hand fractures rose from 5% to 25% in the 20 years before 1983.39 This historical development towards more aggressive operative bone management throughout the last century was largely influenced by four factors: Technical refinement of osteosynthesis Improvement of diagnostic techniques Development of microsurgery Progress toward earlier mobilization regimens
Osteosynthesis The first description of the operative internal fixation of a phalangeal fracture was recorded in 1904 by Lambotte of Antwerp, who used a carpenter’s nail.78,92 Later, surgeons searched for suitable small fixation equipment using steel phonograph needles or piano strings with 373
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diameters as small as 0.7 mm.74,92 During the first half of the 20th century, there were scattered reports of the use of K-wires, cerclage wiring, external fixation, screws, and plates (none of which gained widespread acceptance).92 The breakthrough in bone reconstruction was the foundation of the AO/ASIF (Arbeitsgemeinschaft Osteosynthese/Association of the Study of Internal Fixation) in 1958.87 The development of new devices, the systematic scientific approach to bone healing, and the introduction of training in 1960 have revolutionized bony reconstruction in the hand.59,60 Since then, various fixation techniques and equipment have become standard tools, such as the small fragment set of the AO with small, calibered screws and plates. Further devices include lag screws, prebent plates, and dynamic compression plates (DC-plate) as well as limited contact dynamic compression plates (LCDC-plate). For the treatment of scaphoid fractures, various specified screws have been developed, such as the Herbert screw,61 newer cannulated screws (AO™, Herbert™, Accutrac™, Bold™),15 or the miniHerbert screw. These devices are explained in detail in Chapter 28.
that “movement recovers more rapidly if the torn structures are immobilized and protected until the traumatic exudation has subsided.”140 Libscomb recommended splinting in the position of function rather than in the intrinsic-plus position.81 Luther recommended additional immobilization of metacarpal fractures after K-wire fixation for 5 weeks and immobilization of Bennett’s fractures for at least 8 weeks. However, these reports are more the exception than the rule. Overall, shorter immobilization regimens became the accepted standard. This was possible because improved fixation techniques provided stability, thereby allowing motion. Furthermore, soft tissue treatment improved. Nerve injuries are not generally immobilized any more, wounds are covered early after trauma, and early mobilization regimens after a tendon injury have been developed by Chow, Duran and Hauser, Kleinert, and others.29,41,75,82,138 In summary, advances in hand surgery during the past several decades involve more aggressive surgical approaches, earlier mobilization regimens and technical advances that lead to an improved preoperative and intraoperative assessment.
Improvements in Diagnostic Tools Diagnostic imaging, including intraoperative assessment of fracture alignment, has made considerable progress in fracture management.122 The development of plain X-ray films, polytomography, computed tomography (CT), and magnetic resonance imaging (MRI) has facilitated precise preoperative diagnosis and has broadened our knowledge of injury patterns. In particular, carpal injuries are now routinely diagnosed; these injuries were not routinely recognized 30 years ago, including trapezoid and pisiform fractures, scapholunate ligament ruptures, and dislocations.39 The use of diagnostic arthroscopy has further improved the diagnosis of carpal injuries. Moreover, minifluoroscopy units allow intraoperative assessment of fracture reduction and fixation as well as dynamic studies for the assessment of stability.
Early Mobilization Regimens Early mobilization is key to a successful functional outcome after fracture; this was already known to early hand surgeons. Lambotte, in 1928, was aware of the importance of early postoperative motion in his patients who were started on active and passive mobilization exercises on the first postoperative day.78 Bosworth did not use any postoperative immobilization after fixation of metacarpal fractures in 1937.21 Later in the century, some authors favored immobilization regimens that today seem antiquated. Sir Watson-Jones stated, as a principle of fracture treatment,
TREATMENT OF FRACTURES Classification of Fractures Evaluation of fracture treatment and comparison of treatment strategies and functional outcome require a common classification. The extent of concomitant soft tissue injury is usually not considered in these classifications but plays a decisive role in fracture outcome.
Bone Trauma There are four useful classifications for hand and wrist fractures: 1. Long bones: The AO/ASIF classified the fractures of the long bones in the hand (phalanges/ metacarpals) (Fig. 27-1). 2. Scaphoid: The classification of scaphoid fractures by Herbert provides the most useful therapeutic guidelines as far as stability of the fracture (Type A ⫽ stable), risk of avascular necrosis (Type B3), and indication for operation is concerned (Fig. 27-2). 3. Carpal bones: The AO/ASIF classification of carpal bones,2 including the scaphoid, contains useful additional information about comminuted fractures that is missing in Herbert’s classification (Fig. 27-3). 4. Pediatric fractures: Pediatric fractures are classified according to Salter-Harris (Fig. 27-4). Text continued on page 378
AO/ASIF Fracture Classification Phalanges and Metacarpals
A2
A3
Diaphyseal butterfly fracture
Comminuted diaphyseal fracture
27
A1 Simple oblique diaphyseal fracture
B1
B2
B3
Simple oblique metaphyseal fracture
Metaphyseal butterfly fragment fracture
Metaphyseal comminuted fracture
C1
C2
C3
Unicondylar intra-articular fracture
Bicondylar intra-articular fracture
Comminuted intra-articular fracture
FIGURE 27-1. AO classification of fractures of the long bones in the hand.
375
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THE MUTILATED HAND
Herbert's Classification – Scaphoid Fractures
A1
A2
Fracture of tubercle
Incomplete fracture through waist
B1
B2
B3
B4
Distal oblique fracture
Complete fracture through waist
Proximal pole fracture
Trans-scaphoid perilunate fracture – dislocation of carpus
C Delayed union
D1
D2
D3
D4
Fibrous union
Pseudarthrosis Early deformity
Sclerotic pseudarthrosis Advanced deformity
Avascular necrosis Fragmented proximal pole
FIGURE 27-2. Herbert classification of scaphoid fractures.
AO/ASIF Classification of Scaphoid and Carpal Fractures
A1
A2
A3
27
Tubercle fracture
B1
B2
B3 Longitudinal body fracture
Waist fracture
C2
C1
C3
Comminuted body fracture
FIGURE 27-3. AO classification of scaphoid and carpal fractures.
377
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THE MUTILATED HAND
Salter-Harris Classification of Pediatric Growth Plate Fractures
I
II
IV
III
V
FIGURE 27-4. Salter-Harris classification of pediatric fractures.
Soft Tissue Injuries Various studies have shown that the outcome of a fracture is negatively correlated with the extent of associated soft tissue damage.24,64 Not only should closed fractures be differentiated from open fractures, but the fracture mechanism is important as well. Crush injuries can cause significant soft tissue damage without an open wound and carry a poorer prognosis. Soft tissue injury classifications for the upper extremity are rare and have often been derived from classifications for the lower extremity. Gustilo and Anderson recognized the impact of soft tissue damage on functional outcome and classified open fractures after experience with 1025 fractures.56 They further subdivided Type III open fractures into A, B, and C after
analyzing an additional 87 Type III open fractures.57 Freeland and Jabaley applied this classification to hand injuries44 (Table 27-1). The Hand Injury Severity Score (HISS) (Table 27-2) and the Mangled Extremity Severity Score (MESS) are other classifications of soft tissue or combined extremity injuries (Table 27-3). However, the goal of a practical classification for routine every day use has not yet been achieved.
Factors Influencing Functional Outcome Functional recovery is the overall aim of fracture treatment. Figure 27-5 gives an overview of the factors that influence the functional outcome.123
27
TABLE 27-1
PRINCIPLES OF BONY RECONSTRUCTION
379
Classification of Open Fractures (by Gustilo56,57, Modified and Applied to Hand Injuries by Freeland and Jabaley44)
Type 1
Small and clean wound under 1 cm length
Type 2
Wound larger than 1 cm without massive soft tissue injury
Type 3
Open fracture with massive soft tissue, muscle, vessel, or nerve injury. All soiled injuries and open fractures more than 8–12 hours old should be classified as type 3 injuries.44 A. Adequate soft tissue coverage of a fractured bone despite extensive soft tissue lacerations or flaps or high-energy trauma regardless of the size of the wound. B. Extensive soft tissue injury with periosteal stripping and bony exposure, usually associated with massive contamination. C. Significant arterial injury with only residual blood flow requiring vascular repair.
1. Patient factors include age, comorbidity, socioeconomic factors, and compliance. 2. Injury factors include the mechanism of injury, such as a crush injury or a sharp cut. It further includes any concomitant soft tissue, nerve, or tendon injury. The fracture factors describe the site and the type of the fracture (Types A, B, and C in the AO classification), any dislocation and joint involvement. These aspects have a high impact on functional outcome but cannot be influenced by the treating surgeon. 3. Management factors comprise the four R’s of treatment: recognition, reduction, retention, and rehabilitation. These factors are directly linked to the surgeon and are of highest importance, since the surgeon can hereby influence the outcome. These factors influence functional outcome and will be discussed in detail in the next paragraphs.
Patient Factors: Age In a study of 415 phalangeal fractures, Strickland demonstrated an age-related decrease in the total active motion (TAM). The TAM was 88% of the norm in the first two decades, was 70% for the third, fourth, and fifth decades, and showed a substantial drop in the sixth and seventh decades.123 Patient Factors: Comorbidity Decreased perfusion, an increased risk of infection, or impaired wound healing in corticosteroid-dependent patients, diabetes, and peripheral arterial occlusive disease in heavy smokers are likely to worsen outcome. However, to our knowledge, no study exists that demonstrates a correlation of outcome and comorbidity. Patient Factors: Compliance The functional outcome depends largely on the patient’s understanding and motivation to participate in physical and occupational therapy and to appear for regular
follow-up examinations. Hall analyzed profiles of noncompliant patients. He found them to be mostly men under the age of 28 with a drinking history at the time of the injury who sought medical advice often days after the injury. They removed their splints, did not follow instructions for physical therapy, and demonstrated a high incidence of malunions. He recommended unremovable heavy splints to achieve the necessary immobilization.58 Surgery with stable fixation seems to be an alternative treatment option in noncompliant patients.
Injury and Fracture Factors: Open Fractures, Soft Tissue Injuries, and Associated Injuries Associated soft tissue injuries, such as tendon or ligament lacerations and crushed or severely damaged soft tissue, largely influence the functional outcome of hand fractures. Several studies demonstrate a poorer outcome with damaged soft tissues, which appears to be the most important single factor determining outcome.30,40,64,103 Concomitant flexor tendon injuries led to a poorer outcome than extensor tendon injuries in a study by Chow,30 which was confirmed by Huffaker et al.’s results.64 Huffaker et al. could show a decrease in the active range of motion (AROM) with concomitant crush injuries, skin loss, and joint involvement. Strickland et al., on the other hand, found poorer results after associated extensor tendon injuries compared to flexor tendon lesions in an analysis of 180 open phalangeal fractures with tendon involvement.123 Büchler and Hastings describe a complication rate of 8% in isolated fractures in comparison to 17% in combined soft tissue and bone injuries in the hand. The number of procedures increased from 1.32 in isolated bony lesions to 2.7 in combined lesions; the time off work was 4.7 times longer in combined injuries.24 Fractures with an associated crush injury have a poor outcome. Impaired blood supply leads to an increase of delayed unions or nonunions; increased edema formation leads to scarring and adhesions by increased fibroblast proliferation. Early mobilization and
27
Three categories can be differentiated:
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THE MUTILATED HAND
TABLE 27-2
Hand Injury Severity Score (HISS)
Injury
Score
Integument Skin loss
Absolute values (hand)
Dorsum
⬍1 cm
5
⬎1 cm
10
⬎5 cm
20
⬍1 cm
2
⬎1 cm
3
⬍25%
3
⬎25%
5
Palm Dorsum ⫻ 2 Weighed values (digit)
Dorsum Pulp
Skin laceration
⬍1 cm
1
If extends across more than one
⬎1 cm
2
ray, include in both ray scores Nail damage Skeletal Fractures
Simple shaft
1
Comminuted shaft
2
Intraarticular DIPJ
3
Intraarticular PIP/IPJ of thumb
5
Intraarticular MCPJ
4
Dislocation
Open
4
Closed
2
Ligament injury
Sprain
2
Rupture
3
Extensor tendon
Proximal to PIPJ
1
Distal to PIPJ
3
Flexor profundus
Zone 1
6
Zone 2
6
Zone 3
5
Motor
Flexor superficials
5
Intrinsics
2
Neural Absolute values
Recurrent branch of the
30
median nerve Deep branch of the ulnar nerve Weighed values
3
Digital nerve ⫻ 2 (multiple)
4
The absolute point values are translated into grades developed by expert opinions. Grade
30
Digital nerve ⫻ 1 (simple)
HISS points
I. Minor
⬍20
II. Moderate
21–50
III. Severe
51–100
IV. Major
⬎100
27
TABLE 27-3
Mangled Extremity Severity Score (MESS)
Injury
Score
PRINCIPLES OF BONY RECONSTRUCTION
381
Patient factors age, comorbidity, socioeconomic factors, understanding, motivation, compliance
A. Skeletal/Soft Tissue Injury Low energy (stab, simple fracture, civilian GSW)
1
Medium energy (open or multiple fractures, dislocation)
2
High energy (close range shotgun, military GSW, crush injury)
3
Very high energy (above plus gross contamination, soft tissue avulsion)
4
B. Limb Ischemia Pulse reduced or absent but perfusion normal
1
Pulseless, paraesthesia, diminished capillary refill
2
Cool, paralyzed, insensate, numb
3
Fracture / Injury factors Associated soft tissue injury: crush injury, tendon injury, multiple ray injury, nerve injury Open-Closed Location Articular – Non-Articular Displaced – Non-displaced Stable – Unstable Comminuted
Score is doubled for ischemia lasting ⬎6 h C. Shock Systolic pressure always ⬎90 mm Hg
0
Transient hypotension
1
Persistent hypotension
2
Management factors
D. Age (years) ⬍30
0
30–50
1
⬎50
2
Cutoff point ⫽ 7
Recognition
Reposition
Critical score ⬎7; suggest amputation
guided physical therapy, whenever possible, elevation of the hand, and lymphatic drainage are important measures to prevent tendon adhesion and joint stiffness.69 The importance of the soft tissue damage has led to a more aggressive surgical approach, with early soft tissue reconstruction leading to favorable results.48
Injury and Fracture Factors: Location The outcome of a fracture also depends on the location within the hand skeleton. Digital fractures demonstrate a less favorable outcome than metacarpal fractures do.40 An analysis of the active range of motion after digital fractures showed less favorable results in fractures of the proximal phalanx.30,40 Injury and Fracture Factors: Intra-articular Fractures The treatment and long-term outcome of articular fractures have been a long-standing subject of debate. Several authors have shown an impaired functional outcome of articular fractures of the fingers.64 Strickland’s analysis of 415 phalangeal fractures confirmed a negative influence of joint involvement. He found on average a 5% (12.3°) decrease of the range of motion after intra-articular fractures.123
Conservative – Operative Operative: appropriate fixation technique
Rehabilitation
Treatment of complication
FIGURE 27-5. Factors influencing functional outcome after fractures in the hand.
Furthermore, the location of the involved joint plays an important role. Duncan analyzed intra-articular phalangeal fractures and found 42% good or excellent functional results in the metacarpophalangeal and distal interphalangeal joints versus only 10% when the proximal interphalangeal joint was involved. This confirmed two aspects of joint involvement: first, a generally poorer outcome because more than half of the patients could not achieve good results; second, that involvement of the
27
Retention
382
THE MUTILATED HAND
proximal interphalangeal (PIP) joint is associated with an even worse outcome. On the other hand, it has been shown that Gedda’s47 statement that “it is evident that displacement in the joint will give rise to arthritis” is not true in all cases. O’Rourke reported a low incidence of arthritic changes after phalangeal intra-articular fractures. The average follow-up time was 132 months. Only 14 of 59 joints showed arthritic changes; pain was reported in only seven cases. The incidence of arthritic changes was largely influenced by the degree of displacement. O’Rourke et al. found arthritic changes in 7 of 15 cases with subluxation or joint depression. Without subluxation or depression of the articular surface, the incidence of arthritis was one out of 34 cases (3%).96
Injury and Fracture Factors: Displacement Versus No Displacement and Stability Versus Instability Displacement and stability are two relative terms used in fracture descriptions that are often not clearly defined in the literature. This reduces the comparability of study results. Displaced fractures carry a poorer prognosis. Pun interchanges the term nondisplacement with acceptable alignment for finger fractures.102 His definition includes angulation of the fracture with a maximum of 10° in the sagittal and coronal plane. In the metaphyseal region, even 20° angulation in the sagittal plane is accepted. The overlap of the fracture fragments must be at least 50%. No rotational deformity is accepted. Pun found poorer functional results in fractures not matching these criteria.102 Strickland also found a decrease in TAM of 88% in nondisplaced versus 62% in displaced fractures of the proximal phalanx.123 Injury and Fracture Factors: Comminuted Fractures Comminution is another important factor influencing functional outcome. Chow et al. analyzed 245 open phalangeal fractures. Unstable fractures or fractures with associated soft tissue injury were treated operatively (two-thirds of the cases). Their results showed a poorer functional result in comminuted fractures.30 Strickland confirmed these results. He found only 62% of the contralateral TAM in comminuted fractures compared to 76% of TAM in transverse, noncomminuted fractures.123 In summary, a poorer functional outcome has been shown with soft tissue destruction (particularly flexor tendon and crush injuries), digital fractures (particularly in the proximal phalanx), intra-articular fractures (particularly with proximal interphalangeal involvement), displaced fractures, and comminuted fractures. Consequences are early definitive soft tissue reconstruction48 and immediate mobilization whenever possible.
Management Factors This is the most interesting facet of outcome analysis, since these factors can be influenced by the surgeon. Steel pointed out the two mainstays of fracture therapy: “to avoid over-treatment of simple injuries and failure to recognize serious fractures.”121 Fracture treatment is characterized by the four R’s. 1. 2. 3. 4.
Recognition Reduction Retention Rehabilitation
In recognition of injury, pain, tenderness, swelling, discoloration and hematoma, deformity, and loss of mobility and function are clinical signs often encountered. The clinical examination involves the diagnosis of shortening, angulation, or rotation of the injured finger. X-ray films are mandatory even if clinical examination makes a fracture unlikely. X-rays serve three functions: 1. To diagnose a fracture 2. To diagnose ligamentous ruptures indirectly by identification of tiny fragments or bony malalignment 3. To diagnose foreign bodies It should be routine to check all aspects even if one bony pathology has already been found. This helps to identify injuries that are frequently overlooked, such as perilunate fracture-dislocations, metacarpal dislocations, or fractures of the base of the proximal phalanx. Other fractures that are easily overlooked are transverse fractures through the neck of the proximal phalanx, which are mostly found in children. A true lateral view is mandatory but difficult to obtain in small children, as dorsal displacement or volar angulation almost always occurs and can easily be overlooked.54 Periarticular injuries, close to a joint, might require an oblique view in addition to the standard anteroposterior and true lateral views. Oblique views are standard in metacarpal injuries; true lateral views are required only if joint dislocation is suspected. Scaphoid fractures are commonly overlooked, and a precise radiologic examination is necessary. Specialized X-ray views, such as a scaphoid series and a Stecher projection (fist in ulnar abduction) are most useful,33 although these projections are frequently replaced by CT scan43 or MRI scan.23 In comparisons of CT and MRI scans, the MRI is more sensitive, and “bone bruises” might be misinterpreted as fractures. An advantage of the CT scan is the picturing of trabecular structures and its suitability to facilitate operative planning.76 Reduction is the repositioning of the fragments in an anatomically precise or functionally acceptable position. The necessity of reduction varies with the location and type of the fracture. Significant clinical shortening,
rotation, or angulation of the involved finger requires reduction. It is obvious that periarticular or intra-articular fractures require exact alignment.93 Phalangeal fractures do not leave much room for error, whereas metaphyseal metacarpal fractures are more “forgiving.” Three questions have to be answered regarding reduction and repositioning of the fractured fragments. Each answer requires sufficient personal experience of the surgeon. 1. Is it necessary to perform a reduction? 2. Is it possible to achieve better fragment alignment by reduction? 3. Is closed reduction adequate, or is surgical reduction preferable? After acceptable fragment alignment has been achieved, either with or without reduction, the next step is maintaining the anatomically correct or best position of the fracture fragments for the period of healing. This step is retention. Retention can be accomplished either by conservative treatment (immobilization in a cast) or by operative treatment with fixation by internal or external devices. Deciding between a conservative or surgical approach is one of the surgeon’s most important management decisions. We focus on this decision process in the next paragraphs. The choice of the appropriate fixation techniques is addressed in the following chapters. Advantages of a surgical approach include better anatomic reduction in many cases in which conservative reduction yields unsatisfactory results. Alignment can be maintained by stable fixation. Physical therapy can be initiated early,27 avoids stiffness caused by immobilization, and can lead to faster functional recovery with early return to work. Disadvantages are the risks of operation and the additional trauma caused by exploration and fixation of the fracture. The advantage of a conservative approach is the avoidance of the risks of an operation. On the other hand, dystrophic changes or even reflex sympathetic dystrophy are more likely with prolonged immobilization.145 In addition, after immobilization treatment, patients require a longer period of time after trauma to restore a normal range of motion compared to early active motion.70 The decision for either a conservative or a surgical treatment is not always clear-cut. Barton summarizes that the place for surgical treatment is where the complications of operations are low, and the long-term results are at least as good as those of conservative treatment.10 The development of better technical devices that facilitate surgery encourages the tendency to believe that any “bad” hand fracture must be operated on. This applies particularly to younger hand surgeons who are
PRINCIPLES OF BONY RECONSTRUCTION
383
gaining experience with the availability of improved devices. To justify the routine use of surgery in a particular fracture, improvements in outcome compared to previous conservative approaches have to be demonstrated. However, comparison of treatment regimens is difficult because comparative studies that provide treatment results for both a conservative and a surgical approach for the same fracture type are rare.77 Particularly, studies with long-term follow-up results of operative therapies are often unavailable, and fixation techniques and devices change rapidly. Studies reporting results of conservative treatment should be kept in mind even if they are older. We will therefore not answer the question of conservative or surgical management for each individual fracture but will present general pros and cons for the two alternatives and a treatment algorithm for the decision-making process (Fig. 27-6). Three questions have to be asked when surgical treatment is considered: Is the position of the fracture acceptable to achieve optimal function? If not, can this position be achieved conservatively, or does it require an operation? (Reduction) Once the fracture fragments are in an acceptable position, these questions need to be asked: Is the fracture stable? Will immobilization be sufficient to maintain optimal positioning, or does it require an operation? (Retention) If conservative and operative treatments are both options, these questions must be asked: Would internal fixation allow for early motion, and would the patient benefit from early physical therapy? (Rehabilitation) Again, each question requires the personal experience of the surgeon. If only one of the answers favors an operative approach, surgery should be performed. Only if all three questions are in favor of a conservative approach should a splint be applied. To further facilitate the decision-making process, we provide algorithms for the treatment of fractures in the distal phalanx (Fig. 27-7), or the metacarpal, proximal, or middle phalanx (Fig. 27-8), and of the carpal bones (Fig. 27-9). Apart from general considerations, there are specific indications for operative treatment of fractures with which most surgeons agree:11 ❚ Fractures of the shafts of the phalanges – If closed reduction fails to achieve perfect alignment – If the fracture is considered unstable after closed reduction ❚ Intra-articular fractures – With a large portion of the articular surface involved – With subluxation
27
27
Conservative or Operative treatment? Recognition
Diagnosis of fracture/lesion Classify fracture
Reduction Are the fragments in an acceptable position?
YES
NO
Is there significant clinical or radiological deviation, rotation, shortening?
NO
Is an improvement of the fragment positioning possible?
YES
NO
YES Is reduction only possible/ preferable surgically?
NO
YES Operation
Retention Can the fragments be held by conservative treatment?
NO
YES Operation
Rehabilitation Is rehabilitation faster with surgery and does the patient wish to use this advantage?
NO
YES Operation
Conservative FIGURE 27-6. Treatment algorithm for the decision-making process of surgical versus conservative treatment of fractures.
384
27
PRINCIPLES OF BONY RECONSTRUCTION
385
Distal Phalanx Shaft, tuft
Base
C1 (Mallet deformity)
C2,3
Open
Closed
Open
Reduction
Reduction
Percutaneous pin Functional splinting after short immobilizatioin
Closed reduction
Articular congruity o.k.
No
Stabilization (pin/screw)
Articular congruity o.k.
Yes
No
Yes
No
Stabilization K–wire
Primary fusion
Percutaneous pins
Primary fusion* or Fixation using K–wire (wait for ankylosis)
Tension band wiring
Consevative treatment
Internal fixation
Closure, – soft tissue coverage
27
Articular congruity o.k.
Yes
Closed
Closure, – soft tissue coverage * Primary fusion if joint reconstruction does not seem to allow pain-free motion or patient desires definitive solution
A
FIGURE 27-7. Treatment algorithm for fractures in the distal phalanx. A, Base.
– Distal condylar fractures of the head of a phalanx (for instance, in the proximal phalanx143) ❚ Multiple fractures ❚ Revascularized digits11 ❚ Scaphoid fractures – Herbert type B – Proximal pole fracture – Dorsal dislocation (dorsal intercalated segment instability [DISI-position]) – Dislocation of ⬎1 mm12
Continued
In contrast to these clear indications for surgical treatment, there are fracture types such as unstable fractures, intra-articular fractures, and metacarpal fractures in which the mode of therapy is controversial. 1. Unstable fractures require surgical stabilization. However, to simply classify fractures as stable or unstable is imprecise; stability is a continuous process, and “stable” and “unstable” are only endpoints. Many authors do not define stability,38 a
386
THE MUTILATED HAND
Distal Phalanx Shaft
Open
Possible pinning in conjunction with nailbed repair
Tuft
Closed
Splint (Aluminum Foam Stack-Splint)
Open
Excise very small bone fragments Leave other fragments in place. Remove only when patient complains after healing
Closed
Splint (Aluminum Foam Stack-Splint)
Closure, – soft tissue coverage Closure, – soft tissue coverage B
FIGURE 27-7 cont’d. B, Shaft, tuft.
fact that limits the comparability of results. A stable fracture implies that immobilization in a splint will hold the fragments sufficiently, which is the most reasonable definition, or it might imply that active motion can be applied without dislocation of the fragments. Chow defined functional stability if “acceptable alignment” could be held with more than 30% active motion of the normal range of motion of the adjacent joints.30 2. Intra-articular fractures of the phalanges are not obligatory indications for an operation. Various studies showed a satisfactory outcome after conservative management.9,80 Bennett’s fractures were treated conservatively by Cannon et al.,26 with favorable functional results and only two of 22 patients had significant symptoms after 9.6 years. In a study by Griffiths, only six of 44 patients had significant symptoms; only four patients had radiologic arthritic changes after 6.8 years.55 Lee showed in intra-articular and periarticular fractures of the phalanges with a followup of up to 10 years that neither arthritic radiologic changes nor pain nor functional impairment is inevitable.80 O’Rourke et al.’s results, after an 11-year follow-up of articular phalangeal fractures, support these findings.96 We agree with Lee and O’Rourke’s indications for operative treatment of displaced fractures of the head of the proximal phalanx and subluxations that cannot be held conservatively. Avulsion fractures of collateral ligaments or the palmar plate and mallet fractures
should be treated conservatively when they are not grossly displaced. For Bennett’s and Rolando’s fractures, however, we favor operative treatment in most cases. We operated on 25 intra-articular fractures of the first carpometacarpal joint. Our follow-up results 3 years after trauma showed subjective results almost identical to those of Cannon’s study after conservative treatment. Only two of 25 patients complained of significant symptoms (unpublished data). This underlines that both treatment options—conservative or operative—can be considered in these fractures without clear indications for one or the other. 3. Fractures of the metacarpal neck of the little finger (boxer’s fracture) have been the subject of debate.91 Indications for an operation range from any angulation145 or angulation of more than 20°20 to an angulation of more than 70°.63 We see a relative indication for surgery with an angulation of more than 30° on a true lateral X-ray. In borderline cases, the patient’s occupational and personal situation plays a major role for the decision of surgical fixation. After a decision regarding an operative or conservative approach has been made, further therapeutic considerations are important: ❚ When an operative treatment has been chosen, the appropriate fixation technique has to be selected. ❚ When conservative treatment has been chosen, various basic principles must be applied regarding immobilization and splinting. Prolonged immobilization is often blamed as the cause of joint stiffness. Awareness of this potential complication has increased. Three questions are of particular interest when immobilization is considered in fracture treatment: 1. How many and which joints should be immobilized? Böhler’s paradigm of immobilization of the adjacent joints is still valid.22 In the hand, small custom-made splints can be applied individually with minimal immobilization of adjacent fingers and joints. With conservative treatment and immobilization, a follow-up radiograph should be taken at 7 to 10 days. Loss of reduction can still be corrected at this time. Immobilization after a scaphoid fracture has long been the subject of debate. State of the art is a forearm cast, including the thumb metacarpophalangeal joint.12 2. In which position should the joints be immobilized? Prevention of stiffness is best achieved by immobilizing the hand in the intrinsic-plus position. In this position, the metacarpophalangeal joints are flexed (70° to 90°) to stretch the collateral ligaments. The interphalangeal joints are “safe” in
Metacarpals, Proximal and Middle Phalanges
Metacarpals, Proximal and Middle Phalanges A/B (Shaft and metaphysis)
Non-comminuted simple fractures A, B, C 1
C Intra-articular (MP. PIP) Stable
Comminuted A, B 2-3
Simple A, B, C 1 see pp. 74, 75
Open
Comminuted C 2-3 see p. 76
Open
Closed
Closed
Bone defect
Stable fixation
Unstable
Internal fixation Conservative Percutaneous treatment K-wires When soft tissue is compromised
No Bone defect
External fixation
Internal fixation or
Primary Primary bone graft bone graft
Percutaneous K-wires
Closure – Soft tissue coverage
External/internal fixation (combined)
i.e., splinting dorsal extension block splints, buddy taping
Internal fixation (under special circumstances)* Closure, – soft tissue coverage
Soft tissue healing
Soft tissue coverage
Closure, – soft tissue coverage
Secondary Secondary bone bone graft and grafting and stable fixation stable fixation
*Patients who perform manual work and/or desire early return to work C
Metacarpals, Proximal and Middle Phalanges
Non - comminuted simple fractures A, B, C 1
Closed comminuted fractures A, B 2-3
Unstable
Soft tissue intact
Open
Soft tissue compromised
Internal fixation* Percutaneous K-wire External fixation
Conservative treatment
Percutaneous K-wires
Closed
Internal fixation
Internal fixation
Percutaneous K-wires
Plate, Screws
External fixation Functional brace (Splint)
Intra-medullary K-wires (Boxer’s fracture)
Functional Immobilization External brace (children) fixation (Splint) Closure – Soft tissue coverage
*Patients who perform manual work and/or desire early return to work B
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Metacarpals, Proximal and Middle Phalanges
A
Percutaneous K-wire (when soft tissue is compromised)
D
FIGURE 27-8. Treatment algorithms of fractures of the metacarpal, proximal, or middle phalanges. A, Shaft and metaphysis (A, B): comminuted (2, 3) open. B, Shaft and metaphysis: comminuted closed. C, Non-comminuted simple (A, B, C 1): stable. D, Non-comminuted simple (A, B, C 1): unstable. Continued
387
388
THE MUTILATED HAND
Metacarpals, Proximal and Middle Phalanges Non-articular comminuted fractures C 2, 3 Closed Impaction Major articular displacement
Joint destruction
Minor articular displacement
Attempt of close Distraction by reduction and external fixation/ distraction percutaneous manipulation Reduction o.k. Yes
No impaction
Closed reduction
Early motion
Reduction o.k.
No
Yes
No
Percutaneous stabilization even if reduction is not perfect soft tissue healing
Percutaneous fixation External fixation
Open reduction
Percutaneous stabilization
Supporting bone graft Fixation (screw/pin)
Early motion
Active motion as long as possible
Percutaneous of length (External fixation/ percutaneous pins)
Primary fusion Arthroplasty Amputation
Open reduction Stabilization
Early motion
Definitive solution: Arthroplasty (MP) Fusion (PIP, DIP) Vascularized joint transfer (MP, PIP) Amputation
Active motion as long as possible Definitive solution: Arthroplasty (MP) Fusion (PIP, DIP) Vascularized joint transfer (MP, PIP) Amputation
E
FIGURE 27-8 cont’d. E, Intra-articular (C) comminuted (2, 3): closed.
extension (0°) because the palmar plate and fibers between the collateral ligaments and palmar plate are maximally stretched in this position. This position facilitates motion after the immobilization period. The intrinsic-plus position must be differentiated from the position of function. It is a common misconception to consider the so-called position of function81 as the best position of immobilization. The position of function provides the best function of the hand in the case of already existing stiffness or arthrodesis; however, in no way does the “position of immobilization” prevent
stiffness. The ideal position for the immobilized thumb is full extension and palmar abduction.93 3. How long should the fracture be immobilized? The shorter the time of immobilization, the better is the functional result. The optimal period of immobilization varies in the literature for phalangeal fractures between 3 weeks68,146 and 4 weeks.123 To allow bone healing, we generally immobilize for 3 weeks in children and 4 weeks in adults. Green recommends 3 weeks for closed fractures in adults54 and found a significant increase of stiff joints when immobilization was longer than this.
27
PRINCIPLES OF BONY RECONSTRUCTION
389
Metacarpals, Proximal and Middle Phalanges Intra-articular comminuted fractures C 2, 3
Open
Major articular displacement
Minor articular displacement
Attempt of reduction
distraction by external fixation/ percutaneous manipulation
Reduction o.k.
Early motion active motion as long as possible
Yes
Joint destruction
Reduction o.k.
No
Internal fixation screw/pin (supplementary bone graft if necessary)
Yes
Percutaneous of length (External fixation/ percutaneous pins)
Primary fusion Arthroplasty Amputation
Soft tissue reconstruction
Soft tissue reconstruction Early motion
Early motion
Active motion as long as possible
No
Percutaneous stabilization even if reduction is not perfect
Eternal fixation
Soft tissue reconstruction
No impaction
Definitive solution: Arthroplasty (MP) Fusion (PIP, DIP) Joint transfer (MP, PIP) Amputation
Active motion as long as possible
Definitive solution: Arthroplasty (MP) Fusion (PIP, DIP) Joint transfer (MP, PIP) Amputation
F
FIGURE 27-8 cont’d. F, Intra-articular (C) comminuted (2, 3): open.
For scaphoid fractures, there is general agreement to allow 12 weeks for full consolidation before unrestricted use of the hand is permitted. With a stable osteosynthesis, active physical therapy can be started as early as the first postoperative day without any postoperative splinting. Stable fractures (Herbert Type A) are treated conservatively with 6 weeks of immobilization followed by active occupational therapy.
Rehabilitation Rehabilitation is a key factor in restoration of function. It is of utmost importance that the patient knows his or
her role in the rehabilitation program. It should be made clear to the patient that physical and occupational therapy is done not only by physical or occupational therapists, but first of all by the patient himself or herself. The stages of rehabilitation are wound healing, recovery of motion (active physical therapy), recovery of strength and power (passive physical therapy, occupational therapy, stress loading), and recovery of endurance.44 The initiation of physical therapy and the degree of stress loading are the two main considerations in
27
Impaction
Principles of soft tissue management see pp. 43, 45
390
THE MUTILATED HAND
Carpus
Open
Closed
Same treatment as closed
Scaphoid, lunate, trapezium, trapezoidem, capitate, hamate, pisiform, triquetrum
CT-scan/spiral CT special views/scaphoid series
Proceed with soft tissue algorithms for corresponding areas
Displaced
Non-displaced
Consider ORIF for lunate, capitate, hook of hamate if gap is > 1 mm
Casting – see below for scaphoid (short arm cast for 6 weeks)
Scaphoid Proximal B3 B3 (unstable)
Waist B1/2 B2/3, C1–3 (unstable)
Distal A1/2 A1–3, B1 (Stable)
Displaced
Non-displaced
Displaced
Non-displaced
ORIF (dorsal approach, mini-Herbert screw)
ORIF dorsal approach, mini-Herbert screw
ORIF Herbert screw Cannulated AO screw Accutrac screw
ORIF
Displaced
Herbert AO/ASIF
Non-displaced
ORIF
Cast 6 weeks
*Cast 1 day – 2 weeks
Cast 4 – 6 weeks
(Long arm or short arm – no definitive data in literature. Confirm union with CT-scan!/ tomography)
(Long arm or short arm – no definitive data in literature. Confirm union with CT-scan!/ tomography)
(Long arm or short arm – no definitive data in literature. Confirm union with CT-scan!/ tomography)
A... = AO/ASIF classification A... = Herbert classification
* Length of casting depends on quality of fixation
FIGURE 27-9. Treatment algorithm for carpal fractures.
Beware: Trans-scaphoid fracture-dislocations TFCC lesions S-L dissociation L-T lesions Perilunate dislocation Arthroscopy
27
❚ The earlier motion is initiated, the better. Early mobilization helps to reduce edema, as does elevation of the hand and adequate use of compression gloves. ❚ Mobilization protocols start with active physical therapy, followed by passive physical therapy. Passive physical therapy and occupational therapy require sufficient stability of the fracture to allow stress loading. Both forms of therapy can therefore be initiated at about the same time. ❚ Squeezing of an elastic ball is commonly recommended but is of limited use, as it prevents full closure of the fingers to a fist. ❚ Physical therapy does not harm the patient with respect to the development of a chronic regional pain syndrome (CRPS) as long as it is within the patient’s individual pain tolerance. Use of pain medication may facilitate the first period of exercise and reduces the risk of a dystrophic syndrome. ❚ The diagnosis of a healed fracture is both radiologic and clinical. After the usual time for healing has passed, radiographs might still show nonhealing when a consolidated fracture site is not yet calcified. In these cases, the diagnosis of consolidation is aided by clinical examination and careful palpation. When there is no sign of instability or pain, active physical therapy is usually started despite insufficient radiologic consolidation. ❚ If a fracture of the phalanx has not healed after 6 weeks, it has to be considered a “nonunion.” After mobilization is started, either there are no further symptoms, and the fracture will finally consolidate radiologically as well, or instability will cause significant symptoms. In this case, further operative procedures are indicated.
TREATMENT OF BONY DEFECTS Bony defects can result from a destructive injury, as the sequelae of tumor resection, or from osteomyelitis, pseudoarthrosis, or avascular necrosis. The goal of bony reconstruction is the restitution of form, stability, and function. Three aspects of the treatment of bony defects will be discussed: 1. Classification of the type of bone substitution, substances, and materials such as autologous or allogeneic bone grafts, osteogenic proteins, and tissue engineering
391
2. Bone reconstruction with respect to the location of the defect, for example, metacarpal or phalangeal bone defects and joint destruction 3. Timing of the reconstruction with respect to the etiology of the defect (e.g., infection, trauma, tumor)
Classification of Bone Substitution Several strategies exist for bone replacement and reconstruction of bony defects. Bone grafts (auto-allo-xenograft) are the oldest and still most frequently used technique. In recent years, various alternatives have appeared on the horizon such as the use of osteogenic proteins, tissueengineered bone, or alloplastic material (metal/Silastic). In selected cases, distraction-lengthening is an alternative to bridge bony defects.
Bone Grafts Tissue grafts can be obtained from the same individual (autologous), a different individual of the same species (allogen), or a different species (xenogen). In hand surgery, only autologous bone grafts are routinely used. An autologous bone graft can be taken as a nonvascularized or vascularized (free or pedicled) bone graft. The primary vascularization of a bone graft is decisive for incorporation of the graft and its survival at the recipient site. A nonvascularized free bone graft is equivalent to the term conventional bone graft, as it was the only form of osseus transplantation before the era of microsurgery. Disadvantages of this technique are due to the lack of initial perfusion. Barth described the process of bone resorption, neovascularization, and new bone formation in 1895 and named it “creeping substitution.”8 The transferred donor bone dies and is replaced by recipientderived bone. During this remodeling period, there will be a mechanical weakness of the bone for 6 to 12 months after transfer. The need of neovascularization limits the indications to a well-perfused recipient area, adequate soft tissue coverage, absence of infection, and small defect size. Bishop recommends nonvascularized grafts in the face of otherwise ideal conditions only for defects up to 6 cm.17 Advantages of nonvascularized grafts are easy harvest and availability with a low complication rate at the donor site. Nonvascularized bone grafts can be taken from the iliac crest, radius, ulna, metacarpal bone, or tibia. The decision process for a particular donor site depends on the needs and availability, and the following aspects have to be considered. 1. Should cortical or cancellous graft be used? Cortical bone has the advantage of higher stability by structural support. It serves as a scaffold for ingrowth of
27
mobilization protocols. This varies for each individual fracture and has to be determined by the surgeon. General principles are as follows:
PRINCIPLES OF BONY RECONSTRUCTION
392
THE MUTILATED HAND
new bone (osteoconductive). A cortical component is necessary to maintain stability in segmental defects. This is especially valid in corrective osteotomies or segmental defects when no bridging osteosynthesis is performed. A disadvantage is the slower process of revascularization and remodeling. Cancellous bone has a higher capability for osteogenesis on the basis of two properties: 1. Induction of bone formation of graft origin by transferred viable osteoblasts or preosteoblasts. 2. Bone formation of host origin by the osteoinductive effect. Osteoinduction describes the recruitment and differentiation of host mesenchymal cells into osteoblasts by proteins such as the bone morphogenic protein (BMP).51 Cancellous bone can easily be tailored or molded to fit the defect, for example, in enchondroma treatment, small bone defects, or arthrodesis with a joint defect. A disadvantage is the initially low mechanical stability until remodeling is complete.50 2. What is the size of the graft required? The donor site depends on the defect size. The distal radius provides smaller bone grafts than the iliac crest. McGrath and Watson used cortical grafts from the distal radius with a size of 3 ⫻ 1 cm and several cubic centimeters of cancellous bone. For larger cortical grafts, they used the proximal ulna with up to 4.5 ⫻ 1 cm grafts.90 The iliac crest provides sufficient bone for any procedure in the hand; the limitation for its use is vascularization of the graft. Grafts larger than 6 cm should be taken as a vascularized graft. 3. What is the age of the patient? In children, cortical grafts are incorporated faster than in adults and can be used when cancellous bone is needed in adults. To protect a still-growing epiphysis, cancellous bone is not taken from the distal radius. In small children under the age of 2 years, cortical grafts can be taken from the little finger metacarpal.90 4. What is the donor site morbidity? McGrath and Watson reviewed 124 bone graft donor sites from the hand and forearm (distal radius, proximal ulna, fifth metacarpal). They found no donor site complication and only two failures to incorporate.90 Bone grafts from the distal radius can theoretically lead to weakness of the radius. In a study of 131 radius donor sites, Mirly et al. report only one case of significant morbidity with a fracture of the distal radius.94 Disadvantages of the tibia as a donor site are the potential of weakening a weight-bearing limb with the risk of fracture induction. Delayed ambulation is required, and for this reason the tibia is not widely used anymore.
Disadvantages of the iliac crest are reported to be perioperative bleeding and a high incidence of postoperative pain. Younger and Chapman found a complication rate after iliac crest grafts of 8.6%, including infection, chronic pain, prolonged drainage, and meralgia pareasthica.147 Additionally, taking a graft from a distant site in hand surgery (iliac crest/tibia) increases the magnitude and time of the operation and requires general anesthesia. 5. What is the rate of incorporation? In a study by Hull et al.,66 the iliac crest and radius bone grafts were compared for outcome in scaphoid nonunion. The rate of union was higher for iliac crest bone (73%) than for radial bone (47%). Russe also favored the iliac crest as a donor site in the belief that it has a high osteogenic potential.109 Seitz et al. report complete incorporation of iliac crest grafts in 96% of the cases after 6 months.113 Gonzalez et al. report 100% primary union rates of iliac crest bone grafts in gunshot wounds to the phalanges and metacarpals.13,52,53 There are other surgeons, however, who favor bone grafts from the radius.141 Mirly et al. used the distal radius in 131 procedures of bone grafting and reported a healing rate of 82%, which is comparable to healing rates with bone grafts from the iliac crest.94 Andrews et al. also favored radial bone grafts for scaphoid nonunions to avoid an additional incision at the iliac crest.3 McGrath and Watson also found excellent incorporation rates with radial grafts, with only one failure out of 78 grafts.90 Biddulph published a detailed critical discussion of the distal radius and the iliac crest as donor sites for bone grafts.16 He showed histologic and biological superiority of bone from the iliac crest with a higher density and increased cellularity. Particularly with increased age, chronic illness, or a paralyzed arm, he does not recommend the distal radius as a donor site. However, clinically, the radial bone grafts are equally successful. Biddulph attributes this clinical success to the greater porosity of radial bone, which allows better compaction, more accurate filling of defects, and easier nourishment of the graft by surrounding body fluids.16,111 Vascularized bone grafts1 can be free or pedicled. They have the advantage of remaining viable after vascular anastomosis and bring their own blood supply. There is no remodeling, bone resorption, or weakening, and the transferred bone will incorporate more rapidly. The bone retains its original structure and mechanical characteristics. Strength, elasticity, and stiffness are increased 2 to 4 times compared to nonvascularized grafts.37,95,117 In cases of mechanical stress, vascularized grafts can respond by hypertrophy, which is more important in lower-extremity reconstruction with weight bearing. Vascularized bone is also more resistant to infection.
27
393
used in a demineralized form that still contains an osteoinductive capability. Upton et al. reported the use of demineralized xenogeneic bovine bone implants (powder and corticocancellous blocks) for reconstruction of phalangeal defects after enchondroma excision in a case report.135 He further used demineralized human allogeneic bone transfers in 12 patients with enchondroma or congenital hand defects.136 Whiteman et al. also report good results with demineralized bone powder with healed bone defects in the hand in 20 cases.144 Advantages of the allogeneic or xenogeneic transplants are unlimited supply of cortical and cancellous grafts, no donor site morbidity, and easy shaping of the graft. On the other hand, the grafts are mostly nonvascularized and should be used only in a well-vascularized recipient bed. Allografts have less osteogeneic potential than autografts. Another disadvantage is the high cost, which Smith and Brushart in 1985 reported to be $1747.61 on average in metacarpal reconstruction.119 Furthermore, the long-term durability and stability and the immunogenic rejection or resorption, with possible long-term stress fractures, still need to be studied in more detail. Fresh autogenous bone grafts remain the graft of choice if available.
Osteogenic Proteins In recent years, several bone morphogenic proteins (BMP) have been identified, and their biological potential has been evaluated. After successful biotechnical production of, for instance, OP-1, BMP-2, and BMP-4 or the human bone morphogenetic protein (hBMP),34,139 sufficient quantities have been available for experimental and clinical testing. Urist et al. used BMP successfully in a clinical case to fill an enchondroma-induced bone defect in the hand.137 However, the clinical value has yet to be determined. Tissue-Engineered Bone Tissue engineering describes the in vitro production of human tissues. Significant advances with production and first clinical usage have been achieved for almost every human tissue type (cartilage, bone, muscle, skin, nerve, etc.). Tissue-engineered bone consists of two components: autologeous osteoblasts and chondroblasts, which are cultured in vitro, and a structural lattice to serve as a scaffold (osteoconductive). Together, the two components form osteochondral constructs in an individually designed shape for in vivo transplantation. There have been a few preliminary reports, but the clinical value has yet to be determined. Distraction-Lengthening The concept of distraction lengthening involves slow distraction of bone and/or soft tissue by using an external
27
The indications for vascularized bone grafts have been summarized by Bishop:17 segmental defects larger than 6 to 8 cm, a poorly vascularized or infected recipient bed/adjacent bone, complex reconstruction with composite tissue loss, second-line treatment when conventional bone grafts have failed, avascular necrosis of the lunate or scaphoid in selected cases, and reconstructive cases in which longitudinal growth is needed, which can be achieved by the inclusion of vascularized epiphysis (i.e., proximal fibular graft).112 A disadvantage of a free vascularized bone graft22,129,130,133,142 is the time-consuming, challenging, and technically demanding surgery. Availability is restricted. The most common donor sites for free vascularized bone grafts are the fibula,126 the iliac crest, the rib, and the scapula rim. Table 27-4 gives an overview of the free vascularized bone grafts with respect to size, anatomy, advantages, disadvantages, and literature. Bone can also be harvested, together with the lateral arm flap, radial flap, or the dorsalis pedis flap. Bone segments can also be harvested on their vascular pedicle and will include their intrinsic blood supply.67 For reconstruction of bony defects in the wrist and hand, pedicled grafts have been used from the radius, the pisiform bone, the hamate bone, and the second metacarpal. Pedicled grafts combine the advantages of intrinsic blood supply with the disadvantage of a limited availability and pliability due to a restricted arc of rotation as well as being a demanding surgical procedure. They may also be used as free vascularized bone transfers. Defects that can be reconstructed are small. In the traumatic situation, skeletal segments of largely destroyed fingers or metacarpals can be transposed as pedicled grafts. Allogeneic or xenogeneic bone grafts have been used on various occasions either as corticocancellous grafts or as demineralized bone or powder.14,132 Reports in the literature range from uncomplicated incorporation to a considerable complication rate.85 Allogeneic and xenogeneic bone grafts lead to immune responses in the host. Successful attempts to reduce immunogenicity include freezing, freeze-drying, irradiation, and demineralization. Incorporation by osteoinduction and osteoconduction is reduced and delayed in comparison to autologous bone graft.51 Various reports about the clinical use of allogeneic or xenogeneic bone exist. Smith used cortical allogeneic bone for metacarpal reconstruction in 12 cases. In 23 out of 24 cases, the recipient-allograft juncture site healed within 8 months. After freezing and irradiation, no immunosuppression was used, and no obvious clinical rejection was seen. Other allogeneic grafts have been used after freezedrying.119 Tropet et al. used an iliac crest allograft in addition to serratus anterior flap for a complex hand injury.131 Allogenic or xenogeneic bone grafts can be
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TABLE 27-4
Vascularized Bone Grafts: Blood Supply, Size, Advantages, Disadvantages, and Literature
Graft
Fibula
Vessel
Peroneal artery (length 6–8 cm/arterial diameter 1.5–3 mm)
Size
Maximum size of 26–30 cm, leaving at least 6 cm of proximal and distal fibula in situ
Advantages
1. Circular cortical bone with high degree of stability 2. Minimal donor leg functional morbidity with good patient tolerance and usually no impact on daily life, despite symptoms in up to 30% of the patients4,6,62 3. Combination with fasciocutaneous skin paddle (10 ⫻ 20 cm) or muscular component (flexor hallucis longus, soleus, peroneal muscles) possible97 4. Inclusion of the proximal growth plate is possible to maintain physeal function133 5. Multiple vascularized segments can be harvested71,97 6. 68% primary healing rate, 82% healing rate after regrafting with a supplemental graft17 7. Hypertrophy is more common than with other vascularized bone grafts17
Disadvantages
Literature
1. Unsightly scar 2. Tedious dissection with danger of damage to the peroneal or tibial nerve or to the nerve of the flexor hallucis longus 3. About 30% of the patients have some symptoms with hypoesthesia, pain, wound dehiscence, hammer toe, tendon exposure, ankle or knee weakness, mild edema4,6,62 4. The septocutaneous perforators to the skin paddle can be unreliable110 5. Coghlan found a higher complication rate in contrast to other studies with reoperations in more than 50% of the cases32 References 4,6,32,62,71,79,97,109,133,141
Graft
Iliac crest
Vessel
Dual blood supply: 1. The deep circumflex iliac artery (DCIA) (main artery)18,19 arises: from the external iliac Ⲑartery in the region of the inguinal canal (pedicle length: 5–7 cm/arterial diameter: 2.78 mm mean) 2. Superficial circumflex iliac artery (SCIA)
Size
The deep circumflex iliac artery supplies the whole iliac crest. The curvature of the ilium limits the bone graft to a smaller size: 10 cm in length, 4 cm in height, and the entire thickness of the iliac crest (1–1.5 cm)115
Advantages
1. Pedicled use possible 2. Osteocutaneous flap possible31,104
Disadvantages
1. Excessive soft tissue bulk for hand reconstruction may require debulking procedures 2. Lower overall succes rates compared to fibular grafts with an average period of 7 months until union, 38% requiring secondary bone grafting and eventual healing in only 67%17 3. Sensory loss in the lateral thigh due to a sacrifice of the lateral cutaneous femoral nerve 4. Abdominal herniation has been described
Literature
References 17–19,31,67,104,115
Graft
Rib
Vessel
Vascularized rib bone grafts can be harvested on several pedicles, depending on the location of the rib (posterior, posterolateral, lateral, anterior rib segment) 1. Thoracodorsal artery : A composite flap of a rib segment (possible sixth to ninth rib) with the serratus anterior flap can be taken on this pedicle.65,105 A segment of up to 12–16 cm can be included. 2. Internal mammary artery : An anterior osseus rib flap can be taken on this pedicle. The pedicle can measure up to 8–10 cm in length. The arterial external diameter is 2–3 mm on average. The internal mammary artery gives rise to the anterior intercostal artery supplying the rib graft. The midclavicular line represents the watershed between the anterior intercostal artery and the posterior intercostal artery. Usually the anterior fourth or fifth rib is taken in segments of up to 8–9 cm.
Advantages
1. Limited soft tissue bulk when limited to rib segment and intercostal musculature 2. Musculocutaneous flap possible including the pectoralis major muscle 3. Usually a primary donor site closure is possible
Disadvantages
1. Rib curvature limits use in long straight defects 2. Risk of thoracotomy during flap harvest
27
TABLE 27-4
PRINCIPLES OF BONY RECONSTRUCTION
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Vascularized Bone Grafts: Blood Supply, Size, Advantages, Disadvantages, and Literature—cont’d
Graft
Rib
Vessel
3. Posterior intercostal artery (PIA): Two osseous flaps can be taken on this pedicle: the posterior rib osseous flap (usually the tenth rib) and the posterolateral-lateral rib osseous flap. The arterial diameter measures 2.5 mm on average. The artery supplies both the endosteal (nutrient) and periosteal circulation of the rib.
Posterior rib osseus flap Advantages 1. Long bony segments of up to 23–26 cm can be harvested and a cutaneous flap can be included based on the lateral cutaneous branches of the PIA (18 ⫻12.5 cm) Disadvantages
1. Tedious and dangerous dissection with the risk of paraplegia and thoracotomy 2. Short pedicle when leaving the dorsal branch of the PIA intact 3. Rib curvature limits use or requires osteotomies
Disadvantage
1. Risk of thoracotomy 2. Rib curvature limits use or requires osteotomies
Literature
References 5,7,65,73,105,114,116,130
Graft
Scapula
Vessel
Osseus segments can be taken from the lateral and medial borders of the scapula: The circumflex scapular artery (length: 3–4 cm arterial diameter: 2.5–3.5 mm) arising from the subscapular artery (arterial diameter: 4–4.5 mm) supplies this flap. The lateral segment is supplied by direct musculoperiosteal branches of the circumflex artery. In addition, branches of the thoracodorsal artery supply the inferior third of the lateral rim separately. The medial segment is supplied by fasciocutaneous connections from the scapula flap to the underlying bone. Therefore the scapular flap must be included.
Size
Lateral border of the scapula: 3–4 cm width, 11–14 cm length, 1.5–3 cm thickness: The bone segment is located between insertion of the long head of the triceps and the inferior angle of the scapula. The muscle insertions at the inferior angle of the scapula (teres major and serratus anterior muscle) should be left intact. Medial border of the scapula: 3–4 cm width, 10–12 cm length, 0.75–1.5 cm thickness: The bone segment is located inferior of the spine of the scapula to the inferior angle leaving muscle insertions intact.
Advantages
1. Two separate segments of bone can be taken from the lateral border, supplied by the circumflex scapular artery or by the thoracodorsal artery 2. Long vascular pedicle 3. 3–4 cm distance between skin paddle and medial scapula provide more versatility 4. Easier dissection medially than laterally 5. Minimal donor site deformity and shoulder dysfunction
Disadvantages
1. Meticulous dissection in the triangular space 2. Thick soft tissue for hand reconstruction might require debulking procedures 3. With a medial segment the scapular flap must always be included
Literature
References 36,49,86,125,128
27
Posterolateral rib/lateral rib osseus flap Advantages 1. The pedicle can measure 6–9 cm in length 2. Bony segment can measure 2–15 cm 3. Limited bulk including the intercostal musculature 4. A cutaneous flap can be included based on the lateral cutaneous branches of the PIA 5. Easier and less dangerous dissection in comparison to the posterior rib segment
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device. It may be used for cases of skeletal deficiency caused by trauma or—most commonly—congenital absence. After insertion of an external device (lengthening apparatus) about 0.25 mm increments can be applied about four times a day. After lengthening, a period of consolidation takes 2–3 times the duration of the lengthening. Although this method still has its indications and has been used for digital lengthening after traumatic amputation,108,127 it is very time consuming, requires perfect patient compliance and carries the risk of various complications (pin track infections, necrosis of bone, non-union, and scarring). We see the main indications to be confined to congenital malformations (see chapter 30).
Defect Coverage by Location The decision for a particular reconstructive procedure also depends on the site of destruction, of which there are two types: 1. Destruction of the most distal part of the ray (amputation injuries) 2. Destruction of a central part of the ray, for example, the metacarpal or a phalangeal bone, or a joint destruction with an otherwise intact distal digit
Metacarpal Bony Defect Metacarpal reconstruction is vital to maintain function of the digits. As mobility of the metacarpals is marginal even in the healthy hand, emphasis is placed on stability. In the case of destruction of the associated digit, ray amputation is an option that has good functional results.72 Several options are available for reconstruction of metacarpal defects. Autologeous bone grafts are the method of choice. In segmental defects and wellvascularized wound beds, nonvascularized bone grafts can be used. In larger defects, in poor wound beds, or in case of infection, vascularized bone grafts are preferred. There are numerous reports in the literature of metacarpal reconstruction with grafts from different donor sites (fibula, iliac crest, radius, scapula, rib, tibia, humerus, metatarsus). ■ Fibula After excision of a giant cell tumor, the defect of the third metacarpal was replaced by a free fibula graft.110 Ugwonali et al. also report in a similar case the use of a nonvascularized fibular graft.134 Fibula can be taken in multiple segments,71 which Lee et al. used to reconstruct multiple metacarpal defects.79 ■ Iliac crest Richards and Nunley used a free autogenous iliac crest graft for reconstruction of the index
metacarpal. The involved metacarpophalangeal joint surface was reconstructed by using a 1-mm-thick free cartilage graft obtained from the sixth costal cartilage. The patient gained 50° of motion in the metacarpophalangeal joint.106 McGeoch and Varian also used an iliac crest transplant (6 ⫻ 1.5 cm) for reconstruction of the thumb metacarpal after excision of an osteoclastoma.89 Reinisch et al. also used the osteocutaneous groin flap in traumatic thumb metacarpal defect. He emphasizes the pedicled use of this flap to avoid microsurgery.104 Osaka et al. treated a leiomyosarcoma of the hand by radical excision including partial index, middle and ring metacarpals, the trapezoid, capitate and hamate. Reconstruction included a large iliac crest bone graft with a dorsalis pedis free flap including extensor tendons.98 ■ Radius Pennington et al. reconstructed a defect of the middle finger metacarpal by a pedicled radial flap with a vascularized segment of the radius after excision of a fibrosarcoma.101 ■ Scapula Combined flaps are also provided by the subscapular area.49 Datiashvili et al. used two distinct bone segments from the scapula in addition to a scapula fascial flap for hand reconstruction. The bony segments were derived from the lateral border of the scapula on two distinct vessels (circumflex scapula and thoracodorsal artery).36 Masaki et al. also used a parascapular osteocutaneous flap to replace two metacarpal bones.86 The bone segment was also derived from the lateral border of the scapula (2 ⫻ 13 cm) but was based on only one vascular pedicle (circumflex scapula vessels). ■ Rib Hui et al. used the combined serratus-rib flap for metacarpal reconstruction of post-traumatic defects.65 ■ Tibia Littler used bone grafts from the upper end of the tibia for metacarpal reconstruction and reported favorable results in 53 cases, although the donor site morbidity is not addressed.83 The tibia has lost its importance for bone grafts with the development of microsurgical techniques. ■ Humerus Teoh et al. describe the use of the combined lateral arm flap in 14 cases. Humeral bone grafts up to 1.5 ⫻ 10 cm can be harvested.128 ■ Metatarsus The foot is a useful donor site if metacarpal defects in combination with joint are needed.
27
Phalangeal Bony Defect The reconstruction of phalangeal defects depends largely on the digit involved and on the site within the digit. Thumb reconstruction is of the utmost importance. Bony defects in the digit can be classified into three categories depending on the site: 1. Amputation injuries involve the most distal part of the digit. If replantation is not possible, treatment options are limited to an amputation or a free vascularized transfer of a toe or another digit. The indication for a toe or digit transfer depends largely on patient profile, gender, occupation, expectations, and the socioeconomic and cultural surrounding. 2. Defects involving a joint are common if anatomical reconstruction of the joint is not possible, arthrodesis is often the only option either with or without an additional bone graft. An alternative is a vascularized joint transfer, e.g., from a toe. A joint prosthesis is another theoretical alternative for the PIP or metacarpophalangeal joint, but it requires ligamentous stability which is often missing after a traumatic incident. 3. Segmental defects in the digit without joint involvement require bone grafting. The distal radius, iliac crest, or spare bony parts of another destructed digit are the donor sites of choice.
Etiology of the Defect and Timing of Bony Reconstruction The timing of bony reconstruction depends on the etiology of the defect.
Infection/Osteomyelitis In the case of osteomyelitis or septic arthritis, radical debridement of all infected tissue and bone is indicated, following the same principles as in radical tumor resection. Antibiotic coverage, both locally and systemically, is recommended. Reconstruction can be performed primarily when the infection is considered cured after radical surgical debridement. In this setting, vascularized bone transfers are the method of choice as they provide good blood supply with antibiotic delivery.28,88 If there is any doubt that infection has been eliminated, reconstruction is postponed.
397
Trauma Closed fractures should be stabilized either primarily, within hours following the injury before the development of significant swelling, or after the swelling has subsided within the first 3 to 4 days after fracture. Open fractures present an “emergency indication” and should be operated on as soon as possible. Soft tissue reconstruction is desirable in the initial procedure or within 24 to 72 hours, rarely at 5 to 7 days. Bone reconstruction can be performed at three different points in times: 1. Immediate (primary): Bony defects can be treated primarily in the first operation. Radical debridement, transfer of bone grafts, and (wellpreserved) soft tissue coverage are performed during the same operation.120 2. Delayed (primarily): If the soft tissue situation is considered inadequate with high risk of infection, bony reconstruction should be postponed. Metacarpal length is maintained by provisional stabilization, local antibiotics, and spacers consisting of antibiotic-releasing beads can be inserted. Sequential re-exploration and additional débridement of the wound at 48-hour intervals is preferred until soft tissue coverage is completed within a week after injury. Bone reconstruction is performed at this time as a delayed procedure. Time periods reported in the literature vary. Freeland et al. advocate the first 10 days;45 Gonzalez et al., the first week;53 Cziffer et al., the first 2 weeks;35 and Calkins et al., the first 2 1/2 weeks25 after injury for bone transfer and stabilization. Calkins et al. noted higher infection rates if bone grafting was performed after this period. Gonzalez et al. report excellent healing rates (100%) of iliac crest bone grafts in phalangeal and metacarpal defects performed 1 to 7 days after the injury. No infection was encountered.52,53 3. Secondary: According to this school of thought, bone reconstruction is performed when wounds have matured and joint motion has been regained. In a report by Peimer et al., the whole process of bone and soft tissue reconstruction took an average of about 2 years.100 In our view, immediate or delayed primary bone grafting is definitely the method of choice. The advantages are earlier bone healing42 and rehabilitation, operation in a nonscarred area, fewer operations, and reduced treatment costs due to shorter hospital stays.
Antibiotics The role of antibiotics in open phalangeal fractures is controversial. Although Sloan et al. advocate a single
27
Rose took the 2nd and 3rd metatarsals and 2nd metatarsophalangeal joint for replacement of a metacarpal defect in a 12-year-old boy. He noted some residual bone growth and good functional result in the hand. However, he does not report the donor site morbidity.107 Macionis used the osteoarthrocutaneous dorsalis pedis flap for a thumb carpometacarpal defect.84
PRINCIPLES OF BONY RECONSTRUCTION
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preoperative and postoperative dose of antibiotics in any open fracture of the distal phalanx,118 most authors agree that antibiotics should not be used routinely in open fractures of the fingers99,124 but only in severely contaminated fractures or in marginally perfused wounds.
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57. Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 24(8):742–746, 1984. 58. Hall Jr RF.: Treatment of metacarpal and phalangeal fractures in noncompliant patients. Clin Orthop 2(14):31–36, 1987. 59. Heim U, Pfeiffer KM: Small fragment set manual. Berlin, Springer Verlag, 1991. 60. Heim U, Pfeiffer KM, Meuli HC: Results of 332 AOosteosyntheses of the hand skeleton. Handchirurgie 5(2):71–77, 1973. 61. Herbert TJ, Fisher WE, Leicester AW: The Herbert bone screw: A ten year perspective. J Hand Surg [Br] 17(4):415–419, 1992. 62. Hidalgo DA, Rekow A: A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 96(3):585–596, 1995. 63. Holst-Nielsen F: Subcapital fractures of the four ulnar metacarpal bones. Hand 8(3):290–293, 1976. 64. Huffaker WH, Wray Jr RC, Weeks PM: Factors influencing final range of motion in the fingers after fractures of the hand. Plast Reconstr Surg 63(1):82–87, 1979. 65. Hui KC, Zhang F, Lineaweaver WC, et al: Serratus anteriorrib composite flap: Anatomic studies and clinical application to hand reconstruction. Ann Plast Surg 42(2):132–136, 1999. 66. Hull WJ, House JH, Gustillo RB, et al: The surgical approach and source of bone graft for symptomatic nonunion of the scaphoid. Clin Orthop 115:241–247, 1976. 67. Ikeda K, Yokoyama M, Okada K, et al: Long-term followup of the vascularized iliac bone graft. Microsurgery 18(7):419–423, 1998. 68. James JI: Fractures of the proximal and middle phalanges of the fingers. Acta Orthop Scand 32(401–410), 1962. 69. James JI: Common, simple errors in the management of hand injuries. Proc R Soc Med 63(1):69–71, 1970. 70. Jones AR: Reduction of angulated metacarpal fractures with a custom fracture-brace. J South Orthop Assoc 4(4):269–276, 1995. 71. Jones NF, Swartz WM, Mears DC, et al: The “double barrel” free vascularized fibular bone graft. Plast Reconstr Surg 81(3):378–385, 1988. 72. Karle B, Wittemann M, Germann G: Funktion und Patientenzufriedenheit nach Strahlamputation und Grundgliedamputation des Zeigefingers. Unpublished work, 2001. 73. Kerrigan CL, Daniel RK: The intercostal flap: An anatomical and hemodynamic approach. Ann Plast Surg 2(5):411–421, 1979. 74. Kirschner M: Verbesserungen der drahtextension. Arch Klin Chir 148:651–658, 1927. 75. Kleinert HE, Kutz JE, Atasoy E, et al: Primary repair of flexor tendons. Orthop Clin North Am 4(4):865–876, 1973. 76. Krimmer H, Schmitt R, Herbert T: Scaphoid fractures: Diagnosis, classification and therapy. Unfallchirurg 103(10):812–819, 2000. 77. Küntscher, M: Multicenter study on metacarpal fractures sponsored by A.O. International. Personal communication, 2001.
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78. Lambotte A: The classic contribution to conservative surgery of the injured hand by Dr. A. Lambotte. 1928. Clin Orthop 2(14):4–6, 1987. 79. Lee HB, Tark KC, Kang SY, et al: Reconstruction of composite metacarpal defects using a fibula free flap. Plast Reconstr Surg 105(4):1448–1452, 2000. 80. Lee MLH: Intra-articular and peri-articular fractures of the phalanges. J Bone Joint Surg Br 45(1):103–109, 1963. 81. Libscomb PR: Management of fractures of the hand. Am Surg 29(4):277–282, 1963. 82. Lister GD, Kleinert HE, Kutz JE, et al: Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg [Am] 2(6):441–451, 1977. 83. Littler JW: Metacarpal reconstruction. J Bone Joint Surg Am 29(3):723–737, 1947. 84. Macionis V: Reversed free osteoarthrocutaneous dorsalis pedis flap for simultaneous reconstruction of the trapeziometacarpal joint and the first metacarpal bone. Plast Reconstr Surg 99(7):2066–2070, 1997. 85. Mankin HJ, Doppelt S, Tomford W: Clinical experience with allograft implantation. The first ten years. Clin Orthop 1(74):69–86, 1983. 86. Masaki F, Takehiro D, Ryuuichi M, et al: Late reconstruction of two total metacarpal bone defects using lengthening devices and a double-barrel osteocutaneous free parascapular flap. Plast Reconstr Surg 106(1):102–106, 2000. 87. Matter P: History of the AO and its global effect on operative fracture treatment. Clin Orthop 3(47):11–18, 1998. 88. McFadden JA: Vascularized partial first metatarsal transfer for the treatment of phalangeal osteomyelitis. J Reconstr Microsurg 14(5):309–312, 1998. 89. McGeoch CM, Varian JP: Osteoclastoma of the first metacarpal. J Hand Surg [Br] 10(1):129–130, 1985. 90. McGrath MH, Watson HK: Late results with local bone graft donor sites in hand surgery. J Hand Surg [Am] 6(3):234–237, 1981. 91. McKerrell J, Bowen V, Johnston G, et al: Boxer’s fractures: Conservative or operative management? J Trauma 27(5):486–490, 1987. 92. Meals RA, Meuli HC: Carpenter’s nails, phonograph needles, piano wires, and safety pins: The history of operative fixation of metacarpal and phalangeal fractures. J Hand Surg [Am] 10(1):144–150, 1985. 93. Meyer VE, Chiu DT, Beasley RW: The place of internal skeletal fixation in surgery of the hand. Clin Plast Surg 8(1):51–64, 1981. 94. Mirly HL, Manske PR, Szerzinski JM: Distal anterior radius bone graft in surgery of the hand and wrist. J Hand Surg [Am] 20(4):623–627, 1995. 95. Moore JB, Mazur JM, Zehr D, et al: A biomechanical comparison of vascularized and conventional autogenous bone grafts. Plast Reconstr Surg 73(3):382–386, 1984. 96. O’Rourke SK, Gaur S, Barton NJ: Long-term outcome of articular fractures of the phalanges: An eleven year follow up. J Hand Surg [Br] 14(2):183–193, 1989. 97. Orgill DP, Pribaz JJ: Reverse peroneal flaps: Two surgical approaches. Ann Plast Surg 33(1):17–22, 1994. 98. Osaka S, Hoshi M, Sano S, et al: Description of new composite tissue transfer for salvage of a complex hand defect. Clin Orthop 3(28):91–93, 1996.
99. Peacock KC, Hanna DP, Kirkpatrick K, et al: Efficacy of perioperative cefamandole with postoperative cephalexin in the primary outpatient treatment of open wounds of the hand. J Hand Surg [Am] 13(6):960–964, 1988. 100. Peimer CA, Smith RJ, Leffert RD: Distraction-fixation in the primary treatment of metacarpal bone loss. J Hand Surg [Am] 6(2):111–124, 1981. 101. Pennington DG, Marsden W, Stephens FO: Fibrosarcoma of metacarpal treated by combined therapy and immediate reconstruction with vascularized bone graft. J Hand Surg [Am] 16(5):877–881, 1991. 102. Pun WK, Chow SP, So YC, et al: A prospective study on 284 digital fractures of the hand. J Hand Surg [Am] 14(3):474–481, 1989. 103. Pun WK, Chow SP, So YC, et al: Unstable phalangeal fractures: Treatment by A.O. screw and plate fixation. J Hand Surg [Am] 16(1):113–117, 1991. 104. Reinisch JF, Winters R, Puckett CL: The use of the osteocutaneous groin flap in gunshot wounds of the hand. J Hand Surg [Am] 9A(1):12–17, 1984. 105. Richards MA, Poole MD, Godfrey AM: The serratus anterior/rib composite flap in mandibular reconstruction. Br J Plast Surg 38(4):466–477, 1985. 106. Richards RR, Nunley JA: Metacarpal reconstruction with free autogenous cartilage and bone following tumor resection: A case report. Clin Orthop 1(90):223–226, 1984. 107. Rose EH: Reconstruction of central metacarpal ray defects of the hand with a free vascularized double metatarsal and metatarsophalangeal joint transfer. J Hand Surg [Am] 9A(1):28–31, 1984. 108. Rudolf KD, Preisser P, Partecke BD: Callus distraction in the hand skeleton. Injury Suppl. 1:113–120, 2000. 109. Russe O: Fracture of the carpal navicular. Diagnosis, nonoperative treatment and operative treatment. J Bone Joint Surg 42A:759–768, 1960. 110. Sanjay BK, Raj GA, Vishwakarma GK: En bloc excision and reconstruction with a fibular autograft of giant-cell tumour of the metacarpal: A case report. J Hand Surg [Br] 14(2):226–228, 1989. 111. Schnitzler CM, Biddulph SL, Mesquita JM, et al: Bone structure and turnover in the distal radius and iliac crest: A histomorphometric study. J Bone Miner Res 11(11):1761–1768, 1996. 112. Schusterman MA, Reece GP, Miller MJ, et al: The osteocutaneous free fibula flap: Is the skin paddle reliable? Plast Reconstr Surg 90(5):787–793, 1992. 113. Seitz Jr WH, Froimson AI, Leb RB: Autogenous bone marrow and allograft replacement of bone defects in the hand and upper extremities. J Orthop Trauma 6(1):36–42, 1992. 114. Serafin D: Atlas of Microsurgical Composite Tissue Transplantation, 1st ed. Philadelphia, WB Saunders Company, 1996. 115. Serafin D: The groin-iliac crest: Deep circumflex iliac artery flap. In: Atlas of Microsurgical Composite Tissue Transplantation, 1st ed. Philadelphia, WB Saunders Company, 1996, pp 525–536. 116. Serafin D, Villarreal-Rios A, Georgiade NG: A rib-containing free flap to reconstruct mandibular defects. Br J Plast Surg 30(4):263–266, 1977.
117. Shaffer JW, Field GA, Goldberg VM, et al: Fate of vascularized and nonvascularized autografts. Clin Orthop 1(97):32–43, 1985. 118. Sloan JP, Dove AF, Maheson M, et al: Antibiotics in open fractures of the distal phalanx? J Hand Surg [Br] 12(1):123–124, 1987. 119. Smith RJ, Brushart TM: Allograft bone for metacarpal reconstruction. J Hand Surg [Am] 10(3):325–334, 1985. 120. Stahl S, Lerner A, Kaufman T: Immediate autografting of bone in open fractures with bone loss of the hand: A preliminary report. Case reports. Scand J Plast Reconstr Surg Hand Surg 33(1):117–122, 1999. 121. Steel WM: The management of fractures in the hand. J Hand Surg [Br] 15(3):279–280, 1990 122. Stern PJ: Management of fractures of the hand over the last 25 years. J Hand Surg [Am] 25(5):817–823, 2000. 123. Strickland JW, Steichen JB, Kleinman WB, et al: Factors influencing digital performance after phalangeal fracture. In Strickland JW, Steichen JB (eds): Difficult problems in hand surgery. St. Louis, CV Mosby, 1982, pp 126–139. 124. Suprock MD, Hood JM, Lubahn JD: Role of antibiotics in open fractures of the finger. J Hand Surg [Am] 15(5): 761–764, 1990. 125. Swartz WM, Banis JC, Newton ED, et al: The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 77(4):530–545, 1986. 126. Taylor GI, Miller GD, Ham FJ: The free vascularized bone graft: A clinical extension of microvascular techniques. Plast Reconstr Surg 55(5):533–544, 1975. 127. Teh S, Narita S, Arai K, et al: Distraction lengthening by callotasis in the hand. J Bone Joint Surg Br 84(2):205–210, 2002. 128. Teoh LC, Khoo DB, Lim BH, et al: Osteocutaneous lateral arm flap in hand reconstruction. Ann Acad Med Singapore 24(4 Suppl):15–20, 1995. 129. Teot L, Bosse JP, Tassin X: Scapular crest. Anatomical and harvesting technique. Ann Chir Plast Esthet 38(1):100–106, 1993. 130. Thoma A, Heddle S, Archibald S, et al: The free vascularized anterior rib graft. Plast Reconstr Surg 82(2):291–298, 1988. 131. Tropet Y, Garbuio P, Gerard F, et al: Complex injuries of the dorsum of the hand. Therapeutic reflections apropos of 2 cases. Chirurgie 122(4):285–290, 1997. 132. Trumble TE, Friedlaender GE: Allogeneic bone in the treatment of tumors, trauma, and congenital anomalies
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of the hand. Orthop Clin North Am 18(2):301–310, 1987. Tsai TM, Ludwig L, Tonkin M: Vascularized fibular epiphyseal transfer: A clinical study. Clin Orthop 2(10):228–234, 1986. Ugwonali O, Eisen RN, Wolfe SW: Repair of a multiply recurrent giant cell reparative granuloma of the hand with wide resection and fibular grafting. J Hand Surg [Am] 24(6):1331–1336, 1999. Upton J, Boyajian M, Mulliken JB, et al: The use of demineralized xenogeneic bone implants to correct phalangeal defects: A case report. J Hand Surg [Am] 9(3):388–391, 1984. Upton J, Glowacki J: Hand reconstruction with allograft demineralized bone: Twenty-six implants in twelve patients. J Hand Surg [Am] 17(4):704–713, 1992. Urist MR, Kovacs S, Yates KA: Regeneration of an enchondroma defect under the influence of an implant of human bone morphogenetic protein. J Hand Surg [Am] 11(3):417–419, 1986. Verdan CE: Primary repair of flexor tendons. J Bone Joint Surg Am 42A:647–657, 1960. Wang EA, Rosen V, D’Alessandro JS, et al: Recombinant human bone morphogenetic protein induces bone formation. Proc Natl Acad Sci USA 87(6):2220–2224, 1990. Watson-Jones D: Fractures and joint injuries. Edinburgh, E & S Livingstone, 1943, p 578. Watson HK, Hempton RF: Limited wrist arthrodeses. I: The triscaphoid joint. J Hand Surg [Am] 5(4):320–327, 1980. Wei FC, Chen HC, Chuang CC, et al: Fibular osteoseptocutaneous flap: Anatomic study and clinical application. Plast Reconstr Surg 78(2):191–200, 1986. Weiss AP, Hastings H: Distal unicondylar fractures of the proximal phalanx. J Hand Surg [Am] 18(4):594–599, 1993. Whiteman D, Gropper PT, Wirtz P, et al: Demineralized bone powder: Clinical applications for bone defects of the hand. J Hand Surg [Br] 18(4):487–490, 1993. Wilhelm K, Hauer G: Indikationen zur AO-Behandlung von Handskelettfrakturen. Munch Med Wochenschr 115(9):371–377, 1973. Wright TA: Early mobilization in fractures of the metacarpals and phalanges. Can J Surg 11(491–499), 1968. Younger EM, Chapman MW: Morbidity at bone graft donor sites. J Orthop Trauma 3(3):192–195, 1989.
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28 Principles of Internal Fixation Steffen Baumeister, MD Günter K. Germann, MD, PhD “Life is movement—Movement is Life.”
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This axiom should be the guiding principle in modern fracture care. Full active pain-free early posttraumatic mobilization not only gives the best result in operative fracture treatment, but also results in rapid normalization of physiology. The management of fractures in the hand has undergone dramatic changes in the last 40 years.23 It has shifted from a predominantly conservative approach with occasional crude attempts at internal fixation to a more aggressive surgical approach based on the development of a vast variety of sophisticated instruments and implants (Fig. 28-1). Many factors have contributed to the development of modern treatment concepts. Anesthesia regimens have changed considerably from the use of general anesthesia to various forms of regional or local anesthesia combined with sedation and monitored anesthesia care. Impressive technical improvements have been achieved in radiographic imaging. Precise radiographic images are essential for proper diagnosis, intraoperative fracture alignment, and intraoperative assessment of fracture reduction and implant positions. Image intensifiers have become progressively smaller, and intraoperative fluoroscopy is now a standard procedure in operative fracture treatment. There has also been significant progress in recent years in the handling of soft tissue injuries. Since the decisive role of the soft tissue envelope for the healing and function of underlying structures has been recognized,4,12 treatment strategies have moved toward early stable soft tissue coverage.6 Immediate soft tissue reconstruction after bone repair is believed to optimize functional outcome. However, application of internal fixation techniques for open injuries might require additional soft tissue dissection, though this “operative trauma” is considered less harmful than blunt trauma. Many stabilization techniques and accompanying implants have been developed in the last four decades.8,9,17,20,22 The spectrum ranges from Kirschner wires to absorbable screws and plates,5,15 from simple neutralizing plates to sophisticated plates providing angular stability, from rather large cancellous bone screws to highly refined cannulated screws for scaphoid fracture treatment (Fig. 28-2).
SCIENTIFIC BASIS Physical Properties of Bone Bone as a material has approximately one-tenth of the strength of steel. One has to differentiate between compression strength, which is due to the apatite structure of bone, and tensile 403
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strength, which is attributed to collagen fibers. Distribution of strength patterns varies greatly; for instance, the tensile strength of the tibia is 20% less than its compression strength, while that of the radius is 20% higher. Fractures occur under sudden impacts of energy as a result of mechanical overload. The type of mechanical overload is responsible for the fracture pattern; that is, torque results in spiral fractures, bending results in short oblique fractures, and axial compression results in comminuted impaction fractures. Release of stored energy or the impact of intruding energy leads to concomitant soft tissue injuries.
Biological Reaction
FIGURE 28-1. AO instruments (compact hand set) for internal fixation.
FIGURE 28-2. Various implants for internal fixation.
The process of bone healing depends on the integrity of the cellular functions, which is directly correlated to the vascularity at the fracture site and the mechanical strain on the repaired tissues. Relative instability induces strain and leads to callus formation and simultaneous bone resorption at the fracture site (indirect healing).2 During the process of healing, the initially more “cloudy” callus becomes mineralized and transforms into solid bone. This process leads to sufficient stability but at the cost of palpable callus that can lead to tendon adhesions and functional impairment. If a perfect anatomic reduction with no visible gap between the fragments is achieved and maintained by stable internal fixation that does not impair bone perfusion, direct bone formation is possible, and callus formation as well as bone resorption at the fracture site is avoided or minimal. This process is called primary healing (Fig. 28-3). On the other hand, bone resorption is induced by instability, which in turn induces increasing instability of the repair. However, if no gross instability is present immediately after bone repair, certain systems of internal fixation such as the LISS system or intramedullary nails allow micromotion at the fracture site resulting from limited axial instability that do not result in a higher rate of nonunion. The hypothesis supporting this phenomenon is based on the individual strain tolerance of the repaired tissues. If the strain on a cellular level remains below the tolerance that leads to disruption, even complex fractures with gross instability can heal. The vascularity of the bone at the fracture site can be compromised by several factors, including the longitudinal disruption by the fracture itself due to disturbance of blood flow resulting from the major soft tissue injury and periosteal stripping during the osteosynthesis or the decrease of blood supply caused by implant contact. However, if stabilization can be achieved, medullary blood flow can be reestablished within 2 weeks. The surgeon must always weigh the risk of additional trauma of the osteosynthesis against the faster reinstitution of normal blood flow to the fracture site.
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FIGURE 28-3. A, Intra-articular fracture (AO classification: C). Intraoperative imaging with an image intensifier demonstrated the true extent of the fracture. B, Postoperative result after internal screw fixation. Primary bone healing without any callus formation.
B
Bone Healing Bone healing, as the macroscopically visible restoration of structural integrity, is the goal of osteosynthetic surgery. Even though bone, as a supporting structure, might be radiologically consolidated and fully functional, it can take years before internal remodeling at the cellular level is completed. Spontaneous indirect bone healing consists of three typical stages: 1. Granulation tissue forms in the gap between the fragments. 2. Surface resorption causes widening of the gap. 3. Bone formation progresses through several stages from callus to cortical bone. In direct healing, callus formation is minimal and almost imperceptible. Fragment resorption hardly occurs and does not influence bone formation. Owing to intense remodeling close to the fracture site, the gap appears to widen sometimes during the consolidation process. Callus formation in this context is usually interpreted as a sign of instability.
Nonunions Nonunions may occur owing to two conditions: mechanical strain and impaired biological capacity. Nonunions under mechanical strain result in hypertrophic pseudarthrosis. Treatment consists of correction of the
mechanical instability. Hypotrophic pseudarthroses are the result of impaired cellular repair. Improvement of the blood supply, correction of instability, and application of bone graft usually lead to consolidation. Direct healing does not occur in cases of resorption or bony fragment shortening. Therefore, compression plates or lag screw fixation does not tolerate minimal instability except in segments of cancellous bone. Intramedullary nails, on the other hand, do not require absolute stability, resulting in indirect healing with callus formation.
Osteosynthesis Pioneering work in the field of osteosynthesis has been contributed to by the founding fathers of AO/ASIF.8,19 Four criteria have been established that yield the best results in bone repair: 1. Anatomic reduction, whenever possible, is crucial, especially in intra-articular fractures; the development of posttraumatic arthritis depends on the precise restoration of the joint surface and may be prevented or delayed by perfect restoration of the articular surface. One technical example is the lag screw technique in spiral fracture (Fig. 28-4) or scaphoid reconstruction, where anatomic reduction is essential with respect to rotational malalignment and intracarpal articular surfaces. However,
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FIGURE 28-4. A, Spiral fracture of the proximal phalanx. B, Anatomic reduction and lag screw fixation.
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in recent years, this principle has undergone some modifications in long bone shaft fractures. It becomes more and more accepted that minor irregularities can be accepted to avoid excessive dissection and denudation of the bone, as long as there is no obvious axial or rotational malalignment. The concept of bridging plates, providing angular stability, is also intriguing for complex fractures. The fracture site is not deprived of the remaining blood supply by “perfect” anatomic reduction, and plate failure due to excessive deformation can be avoided. This concept is called “biological osteosynthesis” and includes the “less invasive placement of implants” (LISS) principle. The LISS principle has not been applied to fractures in the hand. The reason might lie in the close contact of the tendons with the bone. The most precarious region is the proximal phalanx with its extensor hood. Here, the relation of moving and counteracting tendon fibers to bone is so close that insertion of percutaneous pins or screws might injure tendon structures. 2. Stable fixation has also undergone significant changes in its philosophy. All methods of operative stabilization must provide adequate stability to maintain length, axes, and rotation. The aim of earlier concepts to achieve callus-free bone healing has been altered with the advent of bridging plates, or intramedullary nailing, in which the
development of visible callus, caused by micromotion at the fracture site, is accepted and desired. Callus-free healing has only clinical relevance in interfragmentary compression by means of lag screws with or without combination of neutralizing plates. 3. Atraumatic surgical technique is crucial in producing an optimal result and has been widely recognized and accepted. It is obvious that the success of internal fixation largely depends on the integrity of the soft tissue envelope providing good vascularity for the repaired tissues. 4. Early pain-free mobilization has stood the test of time as a critical element to ensure a successful outcome. It has been accepted that early motion not only prevents stiffness, but also reduces the incidence of reflex sympathetic dystrophy. It promotes healing and the social and professional reintegration of the patient (Fig. 28-5).
INDICATIONS FOR INTERNAL FIXATION The main indications for internal fixation include the following: ❚ Avoidance of long-term immobilization with loss of function, muscle atrophy, and joint stiffness
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Load Different types of loads are exerted at fracture sites after stable fixation: ❚ The static force generated by the implant ❚ The dynamic force resulting from limb function ❚ The contact force related to the extent of surface on which the forces act No load component is evenly distributed over the fracture area. This is why various forms of bone healing are observed within the same fracture area, including: ❚ Internal remodeling in overloaded areas ❚ Internal remodeling or “contact healing” of intact contact areas ❚ Indirect healing after fracture resorption ❚ Indirect healing with delayed union
❚ Restoration of joint surfaces to prevent posttraumatic arthrosis ❚ Early recovery of limb function
Stability Stable fixation means minimal displacement of fragments under load. It does not mean absolute stability along the fracture with the absence of any relative displacement between the fragments. Relative motion between fragments is compatible with bone healing as long as the strain resulting from micromotion does not exceed the critical level for the formation of repair tissue. This explains why comminuted fractures tolerate micromotion better than fractures with a single narrow gap. In comminuted fractures, the strain is distributed among many fracture gaps, and therefore the relative displacement is reduced for any single gap. Micromotion also does not obstruct differentiation of repair tissues, provided that the inherent strain does not exceed a critical limit. However, if initial small degrees of instability exist in a situation in which intermittent loading of the repair site under a plate occurs, this can lead to gross instability with consecutive bone resorption. The worst-case scenario in these cases may result in nonunion of the fracture.
Splinting Splinting describes the connection of a relatively rigid device to the bone. Reduction of the mobility of the fracture is proportional to the stiffness of the implant. These implants do not eliminate mobility at the fracture site. Splinting can be performed with intramedullary nails, percutaneous pins, or plates. Buttressing is a special form of splinting in which comminuted areas are bridged until the restored fracture site can take up loading again. This is frequently found in comminuted distal radius fractures. There are two basic principles of splinting. One allows micromotion (gliding) of the fragments, as in intramedullary nails, in which the gliding of the fragments does not hinder bone healing, since the nail provides sufficient stability. The other does not allow motion, such as a neutralizing plate. However, a simple plate without lag screws would not suffice to stabilize a weight-bearing bone such as the tibia. The plate serves in these cases as an unloading device for the additional interfragmentary compression, usually achieved by lag screws.
Compression Compression can achieve fracture stabilization with a minimal amount of implanted material. Two different types of compression have been described: Static compression,
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FIGURE 28-5. Short splint for metacarpal fractures. This type of splint provides sufficient support for the fracture and allows full active range of motion of all adjacent joints.
Local overload combined with excessive dissection and periosteal stripping can lead to failure of internal healing despite a radiologically perfect reduction. Another risk is implant failure due to bone resorption, leading to a wider gap formation and significant implant deformity. The implant usually breaks if bone healing fails. Two basically different mechanisms are applied in internal fixation: splinting and compression.
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in which the force remains unchanged over the course of time, and dynamic compression, in which delivered forces, that is, limb function, lead to periodic loading and unloading of the contact surfaces. Compression is effective in two ways: 1. Production of preloading, which means that the surface contact is maintained as long as the compression force is higher than the counteracting forces 2. Production of friction, which prevents sliding of the fragments as long as the friction forces are higher than the shear forces, for instance, weight-bearing in oblique fractures
Compression Principles Lag Screw Principles The lag screw principle provides interfragmentary compression by application of a screw across the fracture.13 When the tip of the screw is anchored in the fragment opposite the head of the screw, a pulling force is created when the screw is tightened to press this fragment against the fragment with the screw head. The insertion hole is slightly overdrilled. For proper function of the gliding
A
B
hole, the screw has to be positioned exactly in the axis of the drill hole. Measurements have shown that sliding of the fragments already occurs when the axis of the screws is inclined 20° to the perpendicular of the fracture line.16 Force across the fracture can reach 2000 to 4000 N.3 However, it must be emphasized that the force has to be applied perpendicular to the fracture line (Fig. 28-6). In spiral fractures, lag screws usually suffice to provide stability for immediate active motion. In these cases, inclination is usually chosen corresponding to a bisecting angle in relation to the visible fracture line. The force generated across the fractures decreases with distance to the screw axis. A single screw therefore does not provide sufficient stability to resist the torque acting within the fracture plane. Two or more screws, however, provide motionless fixation (absolute stability) in short, oblique fractures. The lag screw compression is frequently protected by a neutralization plate. Neutral screws are frequently used for fixation of small fragments as in Busch or monocondylar fractures (Figs. 28-7 and 28-8).
Plate Compression Compression by a plate itself is achieved by application of a prebent plate or a so-called DC (dynamic compression) plate. The DC principle is based on horizontal
C
D
FIGURE 28-6. Lag screw principle. A, Bicortical drilling after fracture reduction. B, Measurement of screw length with a depth gauge. C, After bicortical drilling, the proximal hole is overdrilled. Self-tapping screws are used in the hand (with the exception of metacarpal fractures in young males with thick cortices). D, To avoid splitting of the bone, screw placement should not be too close to the tip of bone spike. (From Haddad FS, Goddard NJ: Acute percutaneous scaphoid fixation using a cannulated screw. Chir Main 17(2):119–126, 1998.)
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B
compression along the axis of the bone. When a prebent plate is fixed to the bone, it has the tendency to recoil into its original state of deformation. Elevation of a short section of the plate over the fracture then results in compression of the cortex far from the plate, thus compressing the fracture gap. This is especially important in transverse osteotomies in which the displacement under torque or load occurs near the plate and the lever arm of the far cortex is significantly higher than the one of the near cortex. Single overloading, which can occur in lag screws, can be avoided by the DC plate (Figs. 28-9 to 28-13). A neutralization plate can be transformed into a DC plate by eccentric drilling of the holes closest to the fracture line. It has been shown that compression is created only within the drill holes closest to the fracture. When the screws are inserted eccentrically into the outer segments of the oval-shaped drill hole, they slide into the hole in the plate and move the fragments toward the fracture line by exertion of axial compression. The remaining holes are drilled neutrally, meaning in the center of the hole, and provide only neutralizing stability.
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B
FIGURE 28-8. A, Monocondylar fracture of the proximal phalanx. B, Radiograph after neutral screw fixation.
Tension Band Principle The concept of tension band fixation is similar to the dynamic compression principle. Tightening of a wire applied to the outer surface of a fractured bone by twisting the loose ends produces compression by a dynamic component of the functional load. The tension band creates pressure immediately below the band and prevents deviation of the contralateral cortices. The tension band fixation does not achieve absolute stability but permits some movement. It is therefore frequently used in the metaphyseal segments where the cancellous bone is less affected by micromovement than the cortical bone in the diaphysis and for joint fusions in which large contact
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FIGURE 28-7. A, Busch fracture with a large fragment of the distal phalanx. B, Internal fixation after best possible reduction with a 1.1-mm neutral screw.
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areas of cancellous bone are present. The K-wire provides rotational stability in these cases13. Intraosseus wiring is a modification of the tension band principle. It is also reserved for the indication of arthrodesis and on rare occasions for osteosynthesis in tendon transfers. The technique usually utilizes an obliquely inserted K-wire for alignment of the bones.18 Two drill holes are made parallel to the bony surfaces, and a cerclage wire (0.6 mm) is inserted through the holes. Insertion is facilitated by the insertion of an injection needle as a guiding tube for the flexible cerclage wire. The cerclage wire is then twisted until sufficient compression is achieved. Both techniques are especially suited for patients with diminished bone quality, such as in rheumatoid arthritis or osteoporosis, in which the insertion of compression screws for arthrodesis may pose unnecessary risks (Fig. 28-14).
Biological Plating The data regarding healing and its interaction with blood supply, mechanical strain, and cellular function led to the development of the biological plate, or LC-DCP (limited contact–dynamic compression plate). These types of plates have recently become available for hand surgery and could enhance our options, especially in metacarpal fractures. This concept incorporates essential principles such as the following:
FIGURE 28-9. Plate principle. Schematic illustration of internal plate stabilization of a horizontal fracture. Neutralization plates are usually used in phalangeal fractures; compression plates are usually used in metacarpal fractures. In these cases, the holes closest to the fracture are drilled eccentrically; compression is then exerted when the screws glide into the hole.
A
❚ Minimal damage to the bone during dissection ❚ Improved healing in the critical zone covering by the plate ❚ Minimal contact of the plate with the bone to avoid damage of the blood supply ❚ Optimal tissue tolerance of the implant The groove on the undersurface of the plate serve three purposes: Blood circulation is improved by minimal implant contact, small bone ridges can be formed to
B
FIGURE 28-10. A, Neutral drilling of holes distant to the fracture site in an AO practice hand. B, Eccentric drilling of the holes closest to the fracture.
28
A
PRINCIPLES OF INTERNAL FIXATION
411
B
FIGURE 28-11. A, Periarticular fracture of the proximal phalanx. B, Internal fixation with a neutralization mini-plate.
absorb stress, and the stiffness of the plate is more evenly distributed. The healing pattern demonstrates abundant bone formation at the fracture site with a shell of mature callus. Bone resorption is not found in biological plating.
FIGURE 28-12. A fracture of the proximal phalanx (AO classification: A2) treated with a neutralization plate.
28
Nails Intramedullary nailing is a rather new principle in hand fracture fixation. It is usually reserved for fractures of the metacarpal neck as are seen in “boxer” fractures. Insertion of the slightly prebent K-wires can be performed proximally, and immediate active motion of all adjacent joints is possible. The wires can be inserted manually or with a power drill. Usually, two wires are required to provide sufficient axial and rotational stability; in rare cases with narrow intramedullary canals, one wire might prove sufficient. This technique is a valuable addition to the armamentarium of the hand surgeon, since it has to be considered a truly minimal invasive procedure that can be performed even in swollen soft tissues through a minimal incision. No bone is dissected, and the risk of damage of perfusion or infection is minimal. Indication is limited to metaphyseal fractures (B-type fractures in AO classification) (Fig. 28-15).
FIGURE 28-13. The “Synthes Compact Set.”
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THE MUTILATED HAND
FIGURE 28-14. Arthrodesis with an orthograde K-wire and intraosseous wiring.
K-Wires K-wire osteosynthesis has frequently been considered a combined internal-external principle. K-wires are inserted percutaneously to provide internal stabilization without exposure of the subcutaneous structures. It is indicated in comminuted fractures of the metacarpals or the phalanges when the soft tissue conditions do not allow internal reduction and fixation, or when the fracture type is not suited for open reduction and stable internal osteosynthesis (Figs. 28-16 to 28-18).
A
K-wires frequently allow reconstruction of destroyed articular surfaces by retaining small fragments that cannot be held with screws. K-wire osteosynthesis is usually not considered stable and frequently requires immobilization to achieve bone healing. However, in many cases, careful active or passive motion is possible within the limitations of custom-made splints. Periarticular or intra-articular fractures involving the proximal interphalangeal joint are treated with a protocol used for ligamentous or combined proximal interphalangeal joint injuries. Complete stiffness of the joints can be prevented by controlled physical therapy. In fractures of the distal interphalangeal joint with rupture of the extensor tendon, K-wires can be applied to reduce and retain the bony fragment with the attached tendon using the “door stop” technique in which the wire blocks the dorsal dislocation of the fragment and still allows active proximal interphalangeal joint motion (Figs. 28-19 and 28-20).
The Lag Screw Principle in Scaphoid Fractures Scaphoid fractures have been treated conservatively for many decades (Fig. 28-21). Consolidation of the fracture was considered a success; however, little attention was paid to the anatomically correct alignment of the fragment. Many fractures consolidated as humpback deformities, thus creating predilection sites for posttraumatic arthrosis. Since accumulating data have shown that the risk of radiocarpal arthrosis is increased with
B
FIGURE 28-15. A, Subcapital fracture of the second metacarpal (boxer’s fracture). B, Stabilization with orthograde prebent K-wires serving as intramedullary nails.
28
PRINCIPLES OF INTERNAL FIXATION
413
A
incorrect scaphoid alignment, internal osteosynthesis has gained more widespread acceptance. First attempts were made with regular cortical or cancellous compression screws. A significant improvement came with the first version of the Herbert screw. This screw was designed with different pitches in the head and the tip areas. This permitted intrascaphoidal compression similar to the lag screw principle, where the slightly lower pitch of the head served as the “gliding hole.” Other screws followed. The Accutrac screw has a steadily increasing pitch and provides the greatest compression. The AO screw uses a separately inserted “washer” to serve as a gliding hole.1 The role of compression for the healing rate of scaphoid fractures is still controversial. Since most screws achieve similar union rates, it becomes increasingly apparent that the fracture type and preserved vascularization are probably more important for the healing rate than is the compression exerted by the screw. The insertion of the original Herbert screw was complicated by the instrumentation. Positioning the “jig” proved to be a significant obstacle for many sur-
28
FIGURE 28-16. Schematic illustration of K-wire insertion perpendicular to the fracture line.
B
FIGURE 28-17. A, K-wire osteosynthesis in comminuted fractures with severe soft tissue injury. B, Replacement of K-wires with a mini-plate after delayed union and stabilization of the soft tissue envelope of the ring finger.
geons,11,21 so the screw did not gain widespread popularity beyond hand surgery centers. The new types of recently developed screws are cannulated. A K-wire serves to maintain the fracture reduction and as a guide wire for the screw.1 Several
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FIGURE 28-18. Functional result in a severe case of bone and soft tissue injury.
systems are on the market that differ in technical details but, on the basis of the data available so far, do not show any marked differences in union rates. In experienced hands and with appropriately selected fracture types without major dislocation, the insertion can be performed percutaneously so that the operative trauma and the risk of infection are diminished. Cannulated screws have the advantage of not requiring the jig that frequently caused cartilage damage of the radius surface.7,25 If a single K-wire does not provide sufficient rotational stability, a second wire can be inserted parallel to the first to maintain stability temporarily. In selected cases of secondary scaphoid reconstruction, an additional wire might be necessary. Acute fractures of the scaphoid can be mobilized shortly after the operation with excellent union rates.
FIGURE 28-19. Screw fixation of a bony avulsion of the collateral ligament in the interphalangeal joint of the thumb.
Secondary reconstructions should be immobilized until bony consolidation is achieved. Thereby, union rates of approximately 90% can be achieved; these far exceed the results of Herbert, who reported 50% in proximal scaphoid nonunion reconstructions.10 Fractures of the proximal pole are frequently dislocated and, by definition, unstable. Internal osteosynthesis with the “mini-Herbert” screw has resulted in significant progress. The screw is inserted through a small dorsal incision, and the screw head is completely buried below the cartilage surface. Union rates of 90% are achievable even in nonunion reconstructions.
PRINCIPAL DIFFERENCES BETWEEN OSTEOSYNTHESIS IN THE HAND AND IN THE LONG BONES The hand is not weight-bearing, so all stable osteosynthetic procedures allow early active motion. Metacarpal fractures can be protected with special splints that are comfortable for the patient, allow inspection of the wound, and permit the exertion of force during exercises. Finger fractures are mostly restricted to active motion without force, since the strength of the implant is limited. K-wire osteosyntheses are frequently restricted to limited active or guided passive motion. The ultimate goal of postoperative protocols is to initiate early motion to prevent adhesions and loss of function.14 The radiologic appearance is delayed behind the functional result. If the surgeon is not certain that a better functional result will be achieved with the operative fracture treatment than with conservative measures, there is no indication for operative treatment. Sequelae of incorrect alignments have to go into this equation.
28
A
PRINCIPLES OF INTERNAL FIXATION
415
B
28
FIGURE 28-20. A, Fractures of the metacarpal neck of the index finger. B, Orthograde stabilization with K-wires serving as intramedullary nails.
A
B
FIGURE 28-21. A, Severe de Quervain’s fracture dislocation. B, Internal fixation with K-wires for the radius and a BOLD® screw for the scaphoid.
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THE MUTILATED HAND
Many fractures are actually bony avulsions of tendon or ligament insertions. These fractures have to be addressed with special attention. When the decision for operative treatment is made, the result should be stable to allow similar follow-up protocols as for tendon or ligament injuries. Open fractures frequently require immediate or early soft tissue coverage. This is more important than in femur fractures, in which temporary wound dressings may be applied until stable coverage is achieved. In the hand, early postinjury motion is essential for the functional result, so stable soft tissue coverage with local or microvascular flaps plays an important role in the treatment of comminuted fractures.
MINIMALLY INVASIVE TECHNIQUES Minimally invasive internal techniques have become increasingly popular. Percutaneous insertion of screws in scaphoid fractures and monocondylar fractures of the phalanges are the main indications. Antegrade insertion of intramedullary K-wires for the treatment of metacarpal fractures are another minimally invasive technique. Profound knowledge of the anatomy is mandatory for these procedures because surgical access has to consider the structures running through the access corridor to avoid secondary damage.
COMPLICATIONS There is no operative procedure without complications. Complications of osteosynthesis in the lower extremity, such as skin breakdown or infections, are rare in the hand. The main complications are unsatisfactory function due to adhesions and nonunions following arthrodesis.24 Adhesions are frequently the result of insufficient followup treatment, when operated fractures are immobilized or the patient is noncompliant. Secondary iatrogenic complications are rare but occur. Concomitant injuries frequently determine the outcome of fractures, especially in case of nerve or tendon lacerations. In these cases, the application of internal fixation techniques has to be weighed against the increased risk of posttraumatic infection.
References 1. Bickert B, Baumeister S, Sauerbier M, et al: Use of a cannulated 3.0 mm AO screw with an intraosseous support washer in osteosynthesis of the scaphoid: Results and analysis of problems in 28 cases. Handchir Mikrochir Plast Chir 32(4):277–282, 2000. 2. Brennwald J: Bone healing in the hand. Clin Orthop 214:7–10, 1987.
3. Brennwald J, Matter P, Arx C, et al: Measurement of torque in bone screws during surgery. Z Unfallmed Berufskr 68(3):123–126, 1975. 4. Buchler U, Hastings H: Combined injuries. In Green DP, Hotchkiss RN, Pederson WC, Lampert R (eds): Green’s Operative Hand Surgery, 4th ed. Philadelphia, Churchill Livingstone, 1999, pp 1631–1650. 5. Fernandez RJ, Lucas GL: Biodegradable implants in hand and wrist fracture management. Kans Med 97(3–4):6–8, 1997. 6. Germann G: Principles of flap design for surgery of the hand. Atlas Hand Clin 3(33–57), 1998. 7. Haddad FS, Goddard NJ: Acute percutaneous scaphoid fixation using a cannulated screw. Chir Main 17(2): 119–126, 1998. 8. Heim U, Pfeiffer KM: Small Fragment Set Manual. New York, Springer Verlag, 1991. 9. Heim U, Pfeiffer KM, Meuli HC: Results of 332 AOosteosyntheses of the hand skeleton. Handchirurgie 5(2): 71–77, 1973. 10. Herbert TJ, Filan SL: Proximal scaphoid nonunion-osteosynthesis. Handchir Mikrochir Plast Chir 31(3):169–173, 1999. 11. Herbert TJ, Fisher WE, Leicester AW: The Herbert bone screw: A ten year perspective. J Hand Surg [Br] 17(4): 415–419, 1992. 12. Huffaker WH, Wray Jr RC, Weeks PM: Factors influencing final range of motion in the fingers after fractures of the hand. Plast Reconstr Surg 63(1):82–87, 1979. 13. Jabaley ME, Freeland AE: Rigid internal fixation in the hand: 104 cases. Plast Reconstr Surg 77(2):288–298, 1986. 14. James JI: Common, simple errors in the management of hand injuries. Proc R Soc Med 63(1):69–71, 1970. 15. Jensen CH, Jensen CM: Biodegradable pins versus Kirschner wires in hand surgery. J Hand Surg [Br] 21(4):507–510, 1996. 16. Johner R, Joerger K, Cordey J, et al: Rigidity of pure lagscrew fixation as a function of screw inclination in an in vitro spiral osteotomy. Clin Orthop 178:74–79, 1983. 17. Jones WW: Biomechanics of small bone fixation. Clin Orthop 214:11–18, 1987. 18. Lister G: Intraosseous wiring of the digital skeleton. J Hand Surg [Am] 3(5):427–435, 1978. 19. Matter P: History of the AO and its global effect on operative fracture treatment. Clin Orthop 347:11–18, 1998. 20. Meyer VE, Chiu DT, Beasley RW: The place of internal skeletal fixation in surgery of the hand. Clin Plast Surg 8(1):51–64, 1981. 21. Radford PJ, Matthewson MH, Meggitt BF: The Herbert screw for delayed and non-union of scaphoid fractures: A review of fifty cases. J Hand Surg [Br] 15(4):455–459, 1990. 22. Steel WM: The AO small fragment set in hand fractures. Hand 10(3):246–253, 1978. 23. Stern PJ: Management of fractures of the hand over the last 25 years. J Hand Surg [Am] 25(5):817–823, 2000. 24. Weinzweig N, Weinzweig J: Bone and joint injuries. In Goldwyn RM, Cohen M (eds): The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. Philadelphia, Lippincott-Raven, 2001. 25. Wozasek GE, Moser KD: Percutaneous screw fixation for fractures of the scaphoid. J Bone Joint Surg Br 73(1): 138–142, 1991.
29 Principles of External Fixation Michael P. Brunelli, MD David Ring, MD Jesse B. Jupiter, MD
Mutilating hand injuries are characterized by tissue devitalization, tissue loss, and contamination—good indications for external fixation at many skeletal sites. Nonetheless, internal fixation is favored for most patients with mutilating hand injuries because deep infections are uncommon if devitalized tissue and contaminated tissue are thoroughly debrided and secure internal fixation allows immediate mobilization of the hand. External fixation can be useful in the treatment of severely contaminated wounds and wounds with extensive loss of tissue and bone, for immobilization of joints in a functional position in the face of massive soft tissue swelling, for neutralization of a comminuted articular fracture that has been fixed internally, and for distraction lengthening.
HISTORY
29
Albin Lambotte was a pioneer of both internal and external fixation and is often referred to as the “father of osteosynthesis.”20 During the early 1900s, Lambotte connected wires drilled into bone to a unilateral metal frame. Although this frame was used most commonly for the treatment of lower extremity injuries, it was also used to treat open fractures of the clavicle, “floating” elbows, and metacarpal and phalangeal fractures.26,27 In the 1930s, several surgeons began using external frames more regularly, and their experience forms the basis for modern external fixation devices.3,22,23,35 When surgeons began using these techniques in the hand, they built external fixation frames from Kirschner wires embedded in a methylmethacrylate frame7,16,18 (Fig. 29-1). These small frames proved useful leading to the design of external fixation frames specifically for the hand.6,25
IMPLANTS, MECHANICS, AND TECHNIQUES External fixation systems for the hand incorporate wires with threaded tips ranging in diameter from 1.1 to 2.5 mm attached to a metal or carbon fiber frame. The basic principles of external fixator mechanics for large bones are used to design the external fixator configuration.24 Ideally, at least two pins are used to fix each major fracture fragment. The pins are spaced as widely as possible in the fracture fragment (i.e., one as close to the fracture site as feasible and the other as far away as possible). The fixator bar connecting the wires is placed as close to the skin as possible without interfering with wound care or causing pressure sores. 417
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THE MUTILATED HAND
FIGURE 29-1. The first fixation devices in the hand consisted of Kirschner wires attached to methylmethacrylate frames. The indication in this patient was metacarpal bone loss. This patient also had the metacarpophalangeal joints pinned in flexion because the soft tissue injury and massive swelling made effective splinting difficult.
A second fixator bar greatly increases stability. Other measures for added stability include the use of transfixion pins and the application of a second frame in an orthogonal plane.4,5,10,12–14 In practice, a unilateral frame is usually sufficient. The weakest link of the external fixator is typically the pins, which have been shown to be the most important parameter determining external fixator stiffness.15 Stuchin and Kummer have studied the mechanics of external fixators in the hand and have confirmed that the principles established for the use of larger external fixation systems are valid for the small systems used in the hand.36 In treating comminuted fractures or those associated with bone loss, it is sometimes impossible to place more than one pin in one or both of the major fracture fragments.9 In this situation, the surgeon can either span the adjacent joint, placing a pin in the more proximal or distal bone, or add an ancillary intramedullary Kirschner wire, depending on the pattern of the fracture.9,17 Some external fixation devices have been designed to allow motion at the proximal interphalangeal joint while maintaining reduction of the joint and associated fractures. The dynamic force couple splint designed by Agee uses three Kirschner wires and a rubber band to create a hinged external fixator that maintains reduction and applies a dynamic extension force.1 The small Compass Hinge external fixator (Richards, Inc.; Memphis, Tennessee) is a unilateral hinged external fixator.28 It can provide sustained traction across the joint, hold the joint reduced, and allow active motion. In addition, a worm gear incorporated into the fixator can apply
a static progressive stretch as part of the rehabilitation program. Pennig and colleagues suggested techniques for limiting transfixation of the extensor hood when applying an external fixator to a phalanx.31 In the index and little fingers, the pins for the external fixator can be applied on the radial and ulnar sides of the digit, respectively. In the middle and ring fingers, the pins can be inserted obliquely (approximately 45° from direct dorsal) from the radial or ulnar side according to the fracture pattern. If possible, there should be two pins per fragment, but one pin may be employed distally if it will help to avoid transarticular fixation. Halliwell studied the location of phalangeal pin placement and reached different conclusions regarding attempts to limit extensor hood entrapment.29 Using cadaver specimens, he placed 1.8-mm Kirschner wires into the phalanges either in the direct dorsal aspect or into what he termed the “10 o’clock position,” just dorsal to the midlateral line. The pins were placed in extension, and the digits were then flexed passively. The 10 o’clock position caused the oblique fibers of the extensor hood to become tethered on the Kirschner wire in flexion. In contrast, the dorsally placed wires made smooth linear tears in the extensor hood in line with fibers as the finger was flexed. Once present, these tears limited the tethering effect of the pins. Consequently, Halliwell recommends placement of the fixator wires dorsally in all phalanges, the pin being just radial or ulnar to the extensor thickening over the proximal phalanx and in the direct midline over the middle and distal phalanges. After pin placement in extension, the digit should be passively flexed to deliberately create longitudinal tears in the extensor hood that may facilitate rehabilitation.
INDICATIONS AND ALTERNATIVES External fixation can be used as the primary means of stabilizing a realigned fracture, as a means of providing sustained distraction or portable traction, to neutralize a relatively tenuous internal fixation, or to immobilize a limb segment. The advantages of external fixation include avoidance of additional operative dissection, potential facilitation of wound care, and no need for a second operation to remove implants. External fixation is used sparingly as the primary mode of stabilizing fractures in the hand. Kirschner wires remain the mainstay of fracture treatment in the hand; they are simple to use, do not require specialized equipment, and they provide adequate stability in most cases. A plate and screws can usually be used safely, even in the case of mutilating injuries and contamination. Plates and screws are often desirable in mutilating
29
419
joint is a hinged external fixator that can allow immediate active movement. External fixation is very useful for neutralizing forces across complex articular reconstructions. The use of traction wires and external fixation devices has been described for the realignment of complex articular fractures.21,34 External fixation provides a useful method for intraoperative distraction of the fractures. It can then be left in place once the articular fragments have been realigned and secured with Kirschner wires or small screws.11 The external fixation shields the fracture from compressive, bending, and rotational forces while early healing is established. The frame is removed within 3 to 6 weeks, depending on the complexity of the fracture, and mobilization of the injured joint is initiated. The external fixator can also be useful for temporary immobilization of a limb segment. Mutilating hand injuries are often associated with massive soft tissue swelling, particularly when there has been a crushing component to the injury. In this setting, custom-molded splints might not be able to adequately control the hand. For instance, we often used Kirschner wires to hold the metacarpophalangeal joints in flexion because splints have often proved inadequate resulting in extension contractures (see Fig. 29-1). External fixation can be used for similar purposes to preserve a webspace in the face of extensive soft tissue swelling and complex wounds (Fig. 29-5).
29
hand injuries because they can provide stability sufficient to allow immediate mobilization of the hand. An external fixator might be able to provide comparable stability to the limb segment, but the wires can transfix tendons, might interfere with the movement of adjacent fingers, and are cumbersome to wear. External fixation might be preferred in the rare circumstance when there is extensive contamination of the wounds, such as with some farm injuries, but the fracture pattern is not well addressed with Kirschner wires alone. External fixation is also an option for the stabilization of skeletal segments when there is extensive loss of bone. For metacarpal bone loss, Kirschner wire transfixation to adjacent, intact metacarpals—or a Kirschner wire bent and used as a spacer—are often adequate because of the stability provided by the adjacent metacarpals. Maintenance of bone length in the first metacarpal or the phalanges is more difficult and is an excellent indication for external fixation (Fig. 29-2). External fixation can provide sustained traction. Many cumbersome splints have been described and used for sustained portable traction, some allowing active and passive joint motion, and external fixation provides a useful alternative33,34 (Figs. 29-3 and 29-4). An external fixator crossing a joint can often be removed within 3 or 4 weeks, and exercises can be initiated. An alternative at the proximal interphalangeal
PRINCIPLES OF EXTERNAL FIXATION
A
B
FIGURE 29-2. This patient sustained a low-velocity gunshot fracture to the middle phalanx. A, A lateral radiograph demonstrates extensive fragmentation. B, There is severe soft tissue injury. Continued
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THE MUTILATED HAND
C
D
E
FIGURE 29-2 cont’d. C, Debridement and external fixation create a bony defect. D, After the wound was stabilized, a corticocancellous bone graft was applied that bridged the defect. E, F, Functional motion was obtained. (Case courtesy of Clayton Peimer, MD.) F
A
B
29
FIGURE 29-3. This patient with a crushing injury to the hand had a complex phalangeal fracture. A, A quadrilateral frame incorporating transfixation wires through the distal phalanx was used to provide sustained traction. B, A radiograph shows alignment of a complex articular and extra-articular fracture.
A
B
FIGURE 29-4. A, This complex articular fracture of the base of the thumb metacarpal was treated with an external fixator used as sustained traction. B, A quadrilateral frame between the distal radius and thumb metacarpal has provided an improved alignment of the fracture.
421
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THE MUTILATED HAND
FIGURE 29-6. An unreliable patient had external fixation of the arm to the iliac crest to protect a groin flap. FIGURE 29-5. A small external fixation frame was used to maintain the first webspace in this complex injury.
A novel use for an external fixator in a mutilating hand injury is to protect a groin flap in an unreliable patient (Fig. 29-6).
THE RESULTS OF EXTERNAL FIXATION OF THE METACARPALS Pennig and colleagues described their experience with the low-profile minifixator.31 They describe safe zones for the orientation of pin insertion that are tailored to the specific metacarpal and level of insertion to limit interference with tendon motion. They also suggest using two converging pins in a vertical plane when one of the major fragments is too small to accept two pins along the axis of the metacarpal. They reported the early results of their first 30 patients with metacarpal fractures treated with external fixation, the majority of which were fractures of the little finger metacarpal. The indications were not stated. None of the fractures displaced, all healed within 8 weeks, and none of the patients lost more than 10% metacarpophalangeal motion as compared to the opposite side. Drenth and Klasen noted in their series of 29 phalangeal and seven metacarpal fractures that metacarpal fractures had a better outcome from treatment with external fixation than phalangeal fractures did.19 There
were five poor results among phalangeal fractures and two among metacarpal fractures. Nearly all patients with poor results had complex injuries with tendon laceration. Complications included pin loosening in six patients, soft tissue interference in two patients, and fracture displacement due to impingement of the fixator on the adjacent finger in one patient.
Portable Traction or Neutralization for Complex Articular Fractures Proubasta used external fixation to treat five patients with comminuted Rolando’s fractures that were thought to be too complex for internal fixation.32 A small external fixation from the trapezium was applied to the metacarpal shaft as a means of portable traction. Within 3 months, all five patients had achieved full painless range of motion. There were no complications related to the external fixation device. Buchler and colleagues reported on the use of external fixation as a neutralization device to protect internal fixation of a complex articular fracture of the thumb metacarpal base.11 Ten patients were treated with open reduction, internal fixation, and support of the articular reconstruction with an autogenous cancellous bone graft. A quadrilateral external fixation frame was applied between the thumb and index metacarpals to provide sustained traction. A volar radial operative exposure was then used to directly realign and secure
29
Metacarpal Bone Loss Peimer et al. reported on nine patients with severe open wounds to the hand with metacarpal bone loss.30 They used external fixation to maintain length and alignment in two patients, but transfixation to adjacent metacarpals with Kirschner wires proved adequate in most cases. The authors made several useful observations. When bone loss is present in several adjacent metacarpals or in the thumb metacarpal, transfixion with Kirschner wires alone was insufficient. When there is bone loss in all four metacarpals, it might prove useful to link the pins in the distal fragments to a single fixed carpal wire. The frames stabilizing each set of distal wires can then be rotated with respect to the proximal carpal wire to prevent flattening of the transverse palmar arch.
THE RESULTS OF EXTERNAL FIXATION OF THE PHALANGES Bilos and Eskestrand reported results of external fixation in proximal phalangeal gunshot wounds in 15 patients.9 This is a good indication for external fixation, as the fractures can be extensively fragmented, there is associated soft tissue injury, and there is often bone loss. In most cases, Kirschner wires alone will not provide sufficient stability to maintain length and alignment. On the other hand, external fixation can be very difficult in these circumstances, as one of the major fracture fragments might be so small that it will accept only one external fixation pin. Alternatives include crossing the adjacent joint or adding an ancillary intramedullary Kirschner wire. At a very short follow-up of 15 weeks, the fracture healed in 13 patients, and metacarpophalangeal motion was preserved. On the other hand, severe contractures of the proximal interphalangeal
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joint were common, and Bilos and Eskestrand recommend the use of external fixation in the digits only when loss of bone substance and extensive comminution make other fixation forms impossible. They cite the complications of infection, fracture distraction, and extensor scarring as further reasons to avoid this technique if possible. Agee recommends his dynamic force couple device for the treatment of unstable proximal interphalangeal joint fracture-dislocations in which the fracture involves more than 30% of the proximal aspect of the middle phalanx.2 The nine patients in his series who were treated for acute injuries regained an average active range of motion of 95°, but few patients regained full extension. Krakauer and Stern reported on the use of the Compass Hinge for proximal interphalangeal joint injuries in 20 patients, 12 of whom had an acute injury.28 The patients with acute injuries regained average proximal interphalangeal joint motion from 9° short of full extension to 82° of flexion at 10 months follow-up. Final radiographs showed recurrent subluxations in three patients. Bain et al. reported similar results with the Compass PIP Hinge but recommend a delay in mobilization after fixator placement.8 They believe that this delay allows the initial inflammatory stages to pass and will therefore decrease the most common complication of infection.
References 1. Agee J: Unstable fracture dislocations of the proximal interphalangeal joint of the fingers: A preliminary report of a new technique. J Hand Surg 3A(4):386–389, 1978. 2. Agee J: Unstable fracture dislocations of the proximal interphalangeal joint: Treatment with the force couple splint. Clin Orthop 214:101–112, 1987. 3. Anderson R, O’Neil G: Comminuted fractures of the distal end of the radius. Surg Gynecol Obstet 78:434–440, 1944. 4. Aro H, Chao E: Biomechanics of external fixation: A dynamic approach to fracture union problems. Part 1. Surgical for Orthopaedics 17–21, 1990. 5. Aro H, Chao E: Biomechanics of external fixation: A dynamic approach to fracture union problems. Part 2. Surgical for Orthopaedics 45–50, 1990. 6. Asche G, Haas H, Klemm K: First experiences with the external mini fixator of Jaquet. Aktuel Traumatol 9:261–268, 1979. 7. Avon J: Using methylmethacrylate to make external fixation splints. J Bone Joint Surg 58A:151, 1976. 8. Bain G, Mehta J, Heptinstall R: Dynamic external fixation for injuries of the proximal interphalangeal joint. J Bone Joint Surg (Br) 80(6):1014–1019, 1998. 9. Bilos Z, Eskestrand T: External fixator use in comminuted gunshot fractures of the proximal phalanx. J Hand Surg 4A:357–359, 1979.
29
articular fragments. Internal fixation was used in nine of the ten patients, with Kirschner wires used in six patients, small screws in one patient, and both screws and wires in two patients. The external fixator was removed an average of 6.5 weeks after the operation (range 5 to 12 weeks). At an average follow-up of 35 months, four patients had focal articular irregularities on radiographs, but none had advanced arthrosis. Only one patient had an unsatisfactory functional rating. Compared to the noninjured side, axial rotation averaged 79%, radial abduction 89%, key pinch 88%, and grip strength 81%. The authors recommend this technique of open reduction and combined internal and external fixation because they believe that closed reduction monitored with fluoroscopy is not sufficient to ensure appropriate articular reduction.
PRINCIPLES OF EXTERNAL FIXATION
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10. Briggs B, Chao E: The mechanical performance of the standard Hoffman-Vidal external fixation apparatus. J Bone Joint Surg 64A:566, 1982. 11. Buchler U, McCollam S, Oppikofer C: Comminuted fractures of the basilar joint of the thumb: Combined treatment by external fixation, limited internal fixation, and bone grafting. J Hand Surg 16A:556–560, 1991. 12. Burny F: Biomechanics of external fixation: A general review. Med Hygiene 41:1589, 1983. 13. Chao E: Biomechanics of external fixation. In Lane J (ed): Fracture Healing. New York, Churchill Livingstone, 1987, pp 105–122. 14. Chao E, Briggs B, McCoy M: Theoretical and experimental analyses of Hoffman-Vidal external fixation system. In Brooker A, Edwards C (eds ): External Fixation: The Current State of the Art. Baltimore, Williams & Wilkins, 1979, pp 345–370. 15. Chao E, Kasman R, An K: Rigidity and stress analysis of external fixation devices: A theoretical approach. J Biomech 15:971–983, 1982. 16. Crockett D: Rigid fixation of bones of the hand using K-wires bonded with acrylic resin. Hand 6:106, 1974. 17. Dhalla R, Streker W, Manske P: A comparison of two techniques for digital distraction lengthening in skeletally immature patients. J Hand Surg 26A:603–610, 2001. 18. Dickson R: Rigid fixation of unstable metacarpal fractures using transverse K-wires bonded with acrylic resin. Hand 7:284, 1975. 19. Drenth D, Klasen H: External fixation for phalangeal and metacarpal fractures. J Bone Joint Surg (Br) 80B:227–330, 1998. 20. Elst VE: Les Dubuts de l’Osteosyntheseen Belique. Brussels, Imp des Sciences, 1971. 21. Gelberman R, Vance R, Zakaib G: Fractures at the base of the thumb: Treatment with oblique traction. J Bone Joint Surg 61A:260–262, 1979. 22. Haynes H: Treating fractures by skeletal fixation of the individual bone. South Med J 32:720–724, 1939.
23. Hoffman R: Rotules a pour la Reduction Dirigee Non Sanglante des Fractures. Paris, Congres Francais de Chirurgie, 1938. 24. Huiskes R, Chao E: Guidelines for external fixation frame rigidity and stresses. J Orthop Res 4:68–75, 1986. 25. Jakob R: Die Distaktion instabiler distaler Radiustrummerfrakturen mit einem Fixateur externe-ein neuer Behandlungsweg. Z Unfallmed Berufskr 73:115–120, 1980. 26. Lambotte A: L’intervention Operatoire dans les Fractures Recenteset Anciennes Envisages Particulierement au Pointde-vue de l’Osteosynthese avec la Description de Plusiers Techniques Nouvelles. Bruxelles, Lambertin, 1907. 27. Lambotte A: Chirurgie Operatoire des Fractures. Paris, Masson, 1913. 28. Krakauer J, Stern P: Hinged device for fractures involving the proximal interphalangeal joint. Clin Orthop 327:29–37, 1996. 29. Halliwell P: The use of external fixators for finger injuries. J Bone Joint Surg 80B:1020–1023, 1998. 30. Peimer C, Smith R, Leffert R: Distraction-fixation in the primary treatment of metacarpal bone loss. J Hand Surg (Am) 6(2):111–124, 1981. 31. Pennig D, Gausepohl T, Mader K, Wulke A: The use of minimally invasive fixation in fractures of the hand: The minifixator concept. Injury 31:102–112, 2000. 32. Proubasta I: Rolando’s fracture of the first metacarpal: Treatment by external fixation. J Bone Joint Surg 74B: 416–417, 1992. 33. Schenck R: Dynamic traction and early passive movement for fractures of proximal interphalangeal joint. J Hand Surg 11A:851, 1986. 34. Spanberg O, Thoren L: Bennett’s fracture: A method of treatment with oblique traction. J Bone Joint Surg (Br) 45:732–739, 1963. 35. Stader O: A preliminary announcement of new method of treating fractures. North Am Vet 18:37, 1937. 36. Stuchin S, Kummer F: Stiffness of small-bone external fixation methods: An experimental study. J Hand Surg 9A:718, 1984.
30 Distraction Lengthening for Reconstruction of the Hand William H. Seitz, Jr., MD
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Mutilating injuries of the hand clearly present a challenge to the hand surgeon who is managing them in the acute situation. However, even in the best of hands, some of these injuries result in persistent deformity and functional deficits that are not reconstructable acutely. Late reconstruction of these injuries can be quite difficult and require significant planning while an understanding of the needs and expectations of the patient is developed. When multiple digits or the thumb has sustained a severe loss of bone and soft tissue, one option for reconstruction is the use of distraction lengthening.20 Matev popularized the use of distraction lengthening with interposition bone grafting for thumb reconstruction; others have used the technique of distraction lengthening for reconstruction of congenital hand anomalies.3,4,7,12,13,16,17–22,28 Recently, the effectiveness of callus distraction in the lower extremity has been successfully applied to the upper extremity and small bones of the hand.2,6,8,9–11,14–16,21,23,24,29 Staged lengthening by relatively rapid stretching of the soft tissues and interposition bone grafting has often required at least one additional operation for insertion of the bone graft and fixation. This has been associated with nonunion of the inserted bone graft and excessive pain.20 Callus distraction has been successful in utilizing vascularized periosteal tissue and healing fracture callus to provide a mechanical signal to slowly stretch the healing bone and create a tube of completely new structurally sound bone within the distraction gap by means of slow, rhythmic distraction.2 This technique allows stretching of sensate soft tissue, use of the hand throughout the lengthening process, early rehabilitation, and, ultimately, good functional use of the hand.16,17,18,20 Nonetheless, it requires adequate sensate soft tissue coverage, a compliant patient (and/or family in the case of children) and meticulous surgical technique. Indications for distraction lengthening have been the loss of multiple digits and/or of the thumb when adjacent digits have been injured and pollicization is not possible and toe transfer is not acceptable to the patient. Contraindications include a noncompliant patient and/or family (hence the importance of not rushing into any decisions about this technique and getting to know the patient quite well before embarking on such a reconstructive course).
SURGICAL TECHNIQUE The ray to be lengthened must have sensate soft tissue coverage over its distal end and must be free of painful scar tissue and neuromata. If this is not the case, adjacent neurovascularized pedicle flaps should be considered to provide such terminal coverage, or some skeletal length should be sacrificed early to provide adequate coverage (Fig. 30-1). 425
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B
A
C D
FIGURE 30-1. A, B, Severe thermal injury to the dominant hand of a 2-year-old child has resulted in significant soft tissue and skeletal loss. C, Initial management includes ray resection to rotate flaps for stump coverage with well-padded viable sensate skin. D, After healing and maturation of the flaps, the lengthening process commences. E, After lengthening, revision of the syndactylized digits has been performed as a separate procedure. E
30
DISTRACTION LENGTHENING FOR RECONSTRUCTION OF THE HAND
427
G
F
30
I
H
K
FIGURE 30-1 cont’d. At 6-months (F), 2-year (G, H) and 5-year follow-ups, the lengthened digits continue to grow and function normally (I, J, K). J
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THE MUTILATED HAND
Dorsal incisions should be made both for insertion of fixator pins and for osteotomy of the bone that is to be lengthened. Predrilling using a drill guide should be performed using a power drill. The drill bit should be the same size as the core diameter of the fixator pin to be utilized. Drill bits should be sequentially replaced with self-tapping threaded half pins of appropriate size. Once the pins are in place, the periosteum at the site of osteotomy should be incised longitudinally and gently elevated and preserved (Fig. 30-2). The periosteum is then locally elevated and protected. A sharp osteotome should be used to divide the bone (power should not be used, to avoid burning of the bone and injury of the periosteum). Once the bone has been circumferentially divided, the periosteum is sutured closed with a fine absorbable suture, the skin is closed, and the half-frame lengthening device is applied to the pins with the divided bone ends in apposition. The position is confirmed with the image intensifier, and a soft tissue compressive dressing is applied for the first few days. The osteotomy is allowed to begin to heal for 5 days in children and 7 days in adults to allow adequate callus to form.2,27 On the fifth day in children and the seventh day in adults, the lengthening process is begun. The first lengthening is done in the surgeon’s office, and therapists instruct patients and/or parents in pin site care (twice-daily swabbing of the pin sites with peroxide for the first week followed by twice-daily swabbing with alcohol thereafter). Lengthenings are done four times per day (breakfast, lunch, dinner, and bedtime). Each lengthening consists of 0.25 mm, the four lengthenings therefore totaling 1.0 mm per day. The device should be calibrated so as to specify the relationship between the amount turned on the lengthening knob and resultant degree of distraction created by the device. (We have used a miniature lengthener by Stryker Howmedica/Osteonics, Rutherford, New Jersey, in which one-half turn equals 0.25 mm.) The lengthening process continues with daily record keeping of each lengthening and recording of the corresponding degree of lengthening on the device. Functional rehabilitation, including use of the hand with the lengthening apparatus in place, begins with the first postoperative hand therapy visit (Fig. 30-3) and continues throughout the lengthening and consolidation period (Fig. 30-4). Lengthening of the digits is continued until an optimally functional length has been achieved (usually about the level of the distal interphalangeal joint of the fingers and as close to normal length as possible of the thumb). A period of consolidations follows the process of lengthening. It usually takes approximately twice the duration of the lengthening process in children and three times the
lengthening duration in adults for adequate bone consolidation to occur. Consolidation can be considered adequate for device removal when cortical bone can be seen to bridge the distraction gap on at least three surfaces when viewed in multiplanar X-rays (Fig. 30-5). In most cases, the device can be removed in the office. With young children, however, sedation might be required, and removal might need to be performed in the operating room. Following removal of the device, continued functional use and progressive strengthening take place through additional hand rehabilitation. When complete consolidation cannot be achieved, bone grafting is utilized. In the case of the thumb, stable fixation with miniplate and screws can afford continued early function (Fig. 30-6).
COMPLICATIONS Complications of distraction lengthening have been well described and include pin tract infection, deep infection, premature consolidation, failure of consolidation, regenerate fracture, adjacent joint luxation, angulation, and distal tip skin breakdown.1,5,20,25,26 Many of these problems and complications can be minimized or even avoided by careful vigilance, patient and family education, and meticulous surgical technique.18,20 Careful handling of the tissues and avoidance of damage to the periosteum and thermal injury to the bone can minimize the risk of pin tract infection and failure of regenerate formation. Close postoperative follow-up can discover superficial pin tract infections when they are nascent, and prompt management with local wound care and oral antibiotics avoiding progression to deeper infection. Patient and family education in terms of pin site care, device care, process of the lengthening, and the importance of regular follow-up can prevent problems with the device and premature consolidation. Stabilization of potentially unstable adjacent joints can avoid adjacent luxation; progressive rehabilitation and protection following device removal can help to avoid fracture of the regenerated bone.20
CONCLUSION The technique of distraction lengthening following severe hand trauma can restore significant function, but it requires careful attention to detail, meticulous surgical technique, and close postoperative follow-up by the surgeon and rehabilitation team. In doing so, problems and complications can be minimized, and the functional outcome can be most rewarding.
30
DISTRACTION LENGTHENING FOR RECONSTRUCTION OF THE HAND
B
C
D
30
A
429
FIGURE 30-2. The surgical technique. A, B, Predrilling is performed with power and half-pin insertion is performed under direct vision. C, Osteotomy is performed after careful periosteal elevation. D, E, Complete osteotomy is demonstrated by free rotation of the two segments. Periosteal closure around the osteotomy site is performed. The skin is closed, and the device is assembled. Lengthening is carried out in four daily increments of 0.25 mm through one-half turn of the lengthening apparatus. E
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THE MUTILATED HAND
A
B
C
D
E
F
FIGURE 30-3. A, Pin site care is demonstrated by this patient undergoing multiple digital lengthenings following a punch press injury with loss of multiple fingers. Activities of daily living (B, C) and fine manipulation and prehensible activities are learned as part of the standard rehabilitation protocol (D, E, F).
30
DISTRACTION LENGTHENING FOR RECONSTRUCTION OF THE HAND
B
C
D
30
A
431
FIGURE 30-4. Functional rehabilitation (A), activities of daily living (B), and pin site care (C ) are proceeding during the lengthening process (D, E, F, G, H ) of this patient who lost his thumb and index finger in an industrial accident, preparing him for return to his job as a machinist. E
Continued
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THE MUTILATED HAND
F
G
FIGURE 30-4 cont’d H
30
DISTRACTION LENGTHENING FOR RECONSTRUCTION OF THE HAND
433
B
A
30
D
C
E
FIGURE 30-5. A, B, This adult who lost multiple fingers in a lawn mower accident has been managed with advancement flap coverage. C, D, E, After healing and maturation of the soft tissue flaps, the lengthening process has been initiated, and the rehabilitation process has commenced. Continued
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G
F
H
I
J
K
FIGURE 30-5 cont’d. F, G, H, I, J, K, Complete bony consolidation has been achieved with a successful functional outcome. Six months after the injury, the patient returned to work.
30
B
435
C
30
A
DISTRACTION LENGTHENING FOR RECONSTRUCTION OF THE HAND
D
E
FIGURE 30-6. A, B, In this 64-year-old patient with a severe burn injury and loss of a thumb, the bony remnant was somewhat atrophic. C, Flap coverage was needed to ensure well-padded sensate skin over the end of the thumb to be lengthened. D, E, Because of scar tightness, a central K-wire was used during lengthening to prevent angular deformity. Because of poor bone vascularity, regenerative bone did not form. Continued
F
G
H
J
I
K
FIGURE 30-6 cont’d. F, Bone grafting and internal fixation were performed. G, H, I, The bone graft was harvested from his contralateral hand, where an index ray amputation was performed to create a “mitten” because of loss of all fingers. The patient has resumed normal activities of daily living (J ) and returned to his prior occupation as a tailor (K ).
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References 1. Aquerreta JD, Forriol F, Canadell J: Complications of bone lengthening. Int Orthop 18:299–303, 1994. 2. Aronson J: The biology of distraction osteogenesis. In Bianchi-Maiocchi A, Aronson J (eds): Operative Principles of Ilizarov: Fracture Treatment, Nonunion, Osteomyelitis, Lengthening, Deformity Correction. Baltimore, Williams & Wilkins, 1991, pp 42–52. 3. Carroll RE, Green DP: Reconstruction of the hypoplastic digits using toe phalanges. J Bone Joint Surg 57A:727, 1975. 4. Cowan NJ, Loftus Jr JM: Distraction augmentation manoplasty: Technique for lengthening digits or entire hands. Orthop Rev 7:45–53, 1978. 5. Dahl MT, Gulli B, Berg T: Complications of limb lengthening: A learning curve. Clin Orthop 301:10–18, 1994. 6. DeBastiani G, Aldegheri R, Renzi-Brivio L, Trivella G: Limb lengthening by callus distraction (callotasis). J Pediatr Orthop 7:129–134, 1987. 7. Havlik RJ, Upton III J: Skeletal distraction-lengthening in the upper extremity: A follow-up study of 72 cases. Orthop Trans 17:363, 1993. 8. Ilizarov GA: The tension-stress effect on the genesis and growth of tissues. I: The influence of stability of fixation and soft-tissue preservation. Clin Orthop 238:249–281, 1989. 9. Ilizarov GA: The tension-stress effect on the genesis and growth of tissues. II: The influence of the rate and frequency of distraction. Clin Orthop 239:263–285, 1989. 10. Ilizarov GA: Clinical application of the tension-stress effect for limb lengthening. Clin Orthop 250:8–26, 1990. 11. Karaharju EO, Aalto K, Kahri A, Lindberg LA, Kallio T, Karaharju-Suvanto T, Vauhkonen M, Peltonen J: Distraction bone healing. Clin Orthop 297:38–43, 1993. 12. Kessler I, Baruch A, Hecht O: Experience with distraction lengthening of digital rays in congenital anomalies. J Hand Surg 2:394–401, 1977. 13. Matev IB: Thumb reconstruction through metacarpal bone lengthening. J Hand Surg 5:482–487, 1980. 14. Price CT, Cole JD: Limb lengthening by callotasis for children and adolescents. Clin Orthop 250:105–111, 1990.
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15. Seitz Jr WH: Distraction osteogenesis of a congenital amputation at the elbow. J Hand Surg 14A:945–948, 1989. 16. Seitz Jr WH, Dobyns JH: Digital lengthening with emphasis on distraction osteogenesis in the upper limb. Hand Clin 9:699–706, 1993. 17. Seitz Jr WH: Distraction treatment of the hand. In BuckGramcko, D (ed): Congenital Malformations of the Hand and Forearm. New York: Churchill Livingstone, 1998, pp 119–128. 18. Seitz Jr WH: Distraction lengthening in the hand and upper extremity. In Green DP, Hotchkiss RN, Pederson WC, Richard Lampert R (eds): Green’s Operative Hand Surgery, 4th ed. New York: Churchill Livingstone, 1999, pp 619–635. 19. Seitz Jr WH, Froimson AI: Multifaceted pediatric congenital hand reconstruction. Orthop Rev 18:769–773, 1989. 20. Seitz Jr WH, Froimson AI: Callotasis lengthening in the upper extremity. Indications, techniques, and pitfalls. J Hand Surg 16A:932–939, 1991. 21. Seitz Jr WH, Froimson AI: Digital lengthening using the callotasis technique. Orthopedics 18:129–138, 1995. 22. Smith RJ, Gumley GJ: Metacarpal distraction lengthening. Hand Clin 1:417–429, 1985. 23. Stricker SJ: Ilizarov lengthening of a postraumatic below elbow amputation stump: A case report. Clin Orthop 306:124–127, 1994. 24. Tetsworth K, Krome J, Paley D: Lengthening and deformity correction of the upper extremity by the Ilizarov technique. Orthop Clin North Am 22:689–713, 1991. 25. Velazquez RJ, Bell DF, Armstrong PF, Babyn P, Tibshirani R: Complications of use of the Ilizarov technique in the correction of limb deformities in children. J Bone Joint Surg 75A:1148–1156, 1993. 26. Wenner SM: Angulation occurring during the distraction lengthening of digits. Orthop Rev 15:177–179, 1986. 27. White SH, Kenwright J: The timing of distraction of an osteotomy. J Bone Joint Surg 72B:356–361, 1990. 28. Yankov E, Paneva-Holevich E: Lengthening of the fingers after traumatic amputation. Handchir Mikrochir Plast Chir 14:213–219, 1982. 29. Yasui N, Kojimoto H, Sasaki K, Kitada A, Shimizu H, Shimomura Y: Factors affecting callus distraction in limb lengthening. Clin Orthop 293:55–60, 1993.
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31 Spare Parts in Upper Extremity Reconstruction Parham A. Ganchi, MD, PhD Julian J. Pribaz, MD
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Trauma presents reconstructive hand surgeons with some of their most challenging work. Restoring both form and function to the pretraumatic state is ideal. Unfortunately, this is not feasible in the majority of cases. Even under ideal circumstances, the sharply severed hand or digit may be replanted to restore near-perfect form, but full function is rarely achieved. Furthermore, hand injuries rarely happen under ideal circumstances. The typical mechanism of injury is a crush or avulsion with diffuse and frequently unpredictable damage to the entire extremity. Often, there is concomitant injury to other organ systems. In these cases, the astute hand surgeon will remain focused on optimizing form and function, not necessarily recreating the preinjury state. Moreover, while restoration of form is always a priority, function comes first. In discussing their philosophy of reconstruction of the mutilated hand, Chase and Hentz stress “a tissue-oriented approach to evaluate the injured hand . . . to avoid error of omission and aiding the organization of a treatment plan.” They emphasize their priorities of restoring circulation, repairing divided structures, and achieving stable and adequate coverage.12 A well-conceived plan will not compromise future secondary procedures and will preserve viable components for both primary and late reconstruction.37
BASIC HAND FUNCTION The hand is a fantastic and complex instrument. It is such an integral part of everything we do that it is quite difficult to imagine life without functional hands. They help us to express ourselves. The angry fist and the loving caress are as much a part of our “language” as are the words on this page. For the deaf and mute, hands replace the voices and ears; for the blind, the hands become their eyes. Functions from basic prehension to the most intricate and subtle movements of a pianist’s hands all result from a well-orchestrated interplay between the central nervous system and the peripheral muscles with their tendons wrapped around joints, stabilized by ligaments, all encased in a unique cutaneous cover. The skin of the hand is one of the many specialized components of the hand. The tough, glabrous, sensitive, and relatively immobile palmar skin is clearly distinct from the thin, mobile, temperature-sensitive skin of the dorsum. The delicate nail complex shaping each fingertip serves to stabilize while enhancing sensitivity and finesse. In addition, each finger has developed a unique function and meaning. The extended thumb of the hitchhiker asks for a ride; the pointed index finger focuses our attention; the indignant raised middle finger arouses our anger; the ring finger wears the 441
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symbol of our love; and the little finger is indispensable to the refined tea drinker or the avid nosepicker. When assessing the severely injured or mutilated hand, the surgeon must have clear functional goals in mind. One of the keys to high-quality hand function is sensory feedback. Therefore restoration of sensation should have a high priority in any hand reconstruction. An insensate, painful digit in the context of an otherwise functional hand limits function, and the patient might be better served by amputation of the digit. However, the same digit might be quite beneficial in a mutilated hand missing multiple digits. Clearly, the reconstructive plan must be tailored to the patient and the injury and, above all, should be realistic in scope. Perhaps all that can be salvaged is the simplest pinch and grasp, forsaking higher function and form. There are several types of pinch, including pulp-to-pulp pinch, key pinch, three-point or chuck pinch, and nailto-nail pinch. Each serves a specialized function and requires specific intact anatomy or restored functioning parts.43 For simple pinch, the minimum requirement is a thumb and an opposable digit or stump. The fingers alone are sufficient for simple grasp, with the ulnar digits providing the power. Even stiff, scarred, seemingly useless fingers that cannot flex enough to form a full fist can be effective for hook grip. Generally, restoration of sensate coverage, gliding tendons, mobile joints, and functional muscles will enhance both pinch and grasp. The initial step in the management of the patient with a mutilated hand is evaluation by an experienced hand surgeon. The surgeon will outline a customized blueprint to guide the reconstructive process, keeping in mind the goals of optimizing both form and function. This strategy will be guided not only by the hand and the injured parts, but also by the age, occupation, hobbies, handedness, cultural background, and desires of the patient. If a staged approach is deemed to be in the best interest of the patient, the primary reconstruction should enhance and in no way compromise the secondary procedures. To fine-tune the reconstructive plan and to optimize the functional outcome, many options must be considered. Amputated parts can be used in many ways. They can be a source of simple graft tissues. They can be replanted with meticulous microvascular technique. Damaged yet viable tissues can be rearranged in elaborate ways to optimize the final reconstruction. Occasionally, function is maximized with innovative and unusual flaps salvaged from tissues that would otherwise be discarded. The key to an optimal reconstruction is to keep an open mind and to be aware of all the alternatives. Select the best options, individualize them for each patient, and make a detailed plan to achieve the optimal results.
GRAFT MATERIAL FROM AMPUTATED PARTS Any amputated part, whether suitable for replantation or not, should be viewed as a potential source of graft material.1,9,27,41 Specialized tissues that might not be available from other sites, such as glabrous pulp skin or pliable dorsal skin, can be used to replace like tissue on an injured but more functionally viable digit. The nail bed is another specialized graftable tissue that can be used as a split nail bed graft or as a full-thickness graft.48 Tendons, both flexors and extensors, can be used as interpolated grafts in pulley reconstruction and as soft tissue spacers in arthroplasty.24 Bone grafts can be harvested to bridge bony deficits, add length to amputated digits, and stabilize fractures as small dowels (see Cases 3 and 7). Nerve tissue is also a valuable source of graft material, obviating the need to violate a distant donor site.3,9,20 On the other hand, vascular grafts, both venous and arterial, are generally not used from injured parts. The scope of damage is usually unclear and greater than what is evident. As a result, using vascular grafts from injured parts is risky and might compromise vascular repairs and revascularized tissues. Major limb amputations are an exception. Distal, clearly uninjured segments of major amputations can be an excellent source of vascular grafts (see Case 8). In general, all tissues should be considered as a source of graft material before being discarded. Spare parts obtained from these “like” tissues are apt to result in a significantly better reconstructive outcome than using tissues recruited from a distance.
REARRANGEMENT OF INJURED PARTS Multidigit mutilating hand injuries are common and quite devastating. After extensive debridement and salvage of viable parts, the patient is often left with short remnants for fingers that have little if any function. This scenario not uncommonly involves the thumb, index finger, and middle finger. Pollicization is a classic and frequently used option in these patients (see Case 3). While an index finger or middle finger that has been amputated through the proximal phalanx is of little functional value in its native position, its length is similar to that of the thumb and makes it an excellent donor for pollicization.5,13,23,26 When the index finger is used to reconstruct the thumb, a functionally advantageous consequence is a widened webspace. This is especially beneficial for patients with burn contractures (see Case 3). The injured index finger is generally thought to be an excellent source of spare parts.10,46 Once injured, the
31
index finger quickly loses its function and can even become a functional limitation for the rest of the hand. With distal loss, it retains little but key pinch while the middle finger assumes its remaining functions. The function of the middle finger can be enhanced in such cases by transfer of the index finger extensor to provide the middle finger with independent extension. If a ray amputation of the index finger is performed, the first dorsal interosseous tendon can also be transferred to the middle finger to provide it with powerful abduction (see Case 1). Furthermore, the injured index finger can also be used as a neurovascular flap, an osteocutaneous flap, a cutaneoungual flap, or any requisite composite flap to reconstruct adjacent structures (see Case 2).6,8,10,14,21,29,35,40 It is not uncommon for injured tissues to be functionally more effective when replaced heterotopically, and this strategy should always be considered, especially in the severely injured hand.11,16,34
EVALUATION OF AMPUTATED PARTS As the tools and techniques of microsurgery were refined, replantation of limbs and digits became not only a reality, but also expected. Without significant knowledge of long-term functional outcomes, an attempt was made to replant all amputated limbs and digits, most often orthotopically and sometimes not in the patient’s best interest. However, as experience with these replant patients accumulated, it became quite clear that not all replants are created equal.25,32,33,42,44
SPARE PARTS IN UPPER EXTREMITY RECONSTRUCTION
443
Not all patients benefited from having an amputated part reattached. For example, in the context of an otherwise normal hand, single-digit replants other than the thumb often limit function and are a burden to the patient. However, a single digit can be replanted for cosmetic reasons in women and in patients whose cultures associate missing digits with the criminal element. Furthermore, all digits are replanted in children, as children are clearly more resilient and likely to regain useful function than are adults. In contrast, multiple-digit amputations are usually replanted. Each amputated digit and the hand are carefully evaluated, explored in the operating room, and debrided as necessary. Both ends of all severed structures are identified and tagged. A clear plan is made, each amputated part being replanted where it is most beneficial functionally, not necessarily restoring “normal” anatomy. An amputated index or middle finger might be more useful replacing an injured thumb than in its native position (see Case 4). Transfer of an amputated digit to a heterotopic position with a functional PIP joint is clearly preferable to restoring a finger with a stiff proximal interphalangeal joint. Each amputated part should be viewed as an invaluable source of spare parts, available to be used wherever necessary to maximize useful hand function. When the surgeon is unable to restore all the digits that are injured, thumb reconstruction takes first priority. This is followed by the middle or ring finger to form a post for the thumb, restoring pinch function and also contributing some grasp or hook grip.
CASE 1
72-year-old female presented to the surgical oncology service with a 3 cm by 4 cm malignant mixed tumor of the Adorsum of her hand. She underwent radical excision. The specimen included the extensors to the index finger, the first dorsal interosseous muscle, and the index metacarpal. The neurovascular bundles were preserved. The reconstructive team was asked to cover the resultant defect in the first webspace and over the dorsum of the hand (Fig. 31-1A). A sensate fillet flap was dissected from the now defunctionalized index finger based on the intact digital neurovascular bundles (Fig. 31-1B). The phalanges, the remaining flexor and extensor mechanisms, and the nail complex were removed, creating a malleable, thin, and well-perfused cutaneous flap to cover the adjacent soft tissue defect. Before the flap was inset, the detached lumbrical and interosseous muscles of the index finger were transferred to the radial aspect of the middle finger to augment abduction in this digit. The flap was then inset, providing excellent
coverage and a wide, functional webspace (Fig. 31-1C ). The patient went on to do well with stable coverage of her hand (Fig. 31-1D).
Discussion Attempts to reconstruct an isolated index finger injury such as this are usually futile, resulting in a stiff, dysfunctional digit that not only fails to provide any useful function, but also hinders the normal function of the remaining hand. However, as was discussed above, the injured index finger is an excellent source of spare parts that can be used to reconstruct the rest of the hand. In this case, the sensate skin of the lost digit provided ideal coverage for the defect in the webspace, obviating the need to create a distant donor site. Furthermore, the detached intrinsic muscles were recycled to provide added function to the neighboring middle finger that would take on the functions of the lost index finger.
31
A Neurovascular Fillet Flap from a Defunctionalized Index Finger to a First Webspace Defect
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A
B
C
D
FIGURE 31-1. A, A large defect over the dorsum of the hand and first webspace after resection of a sarcoma. B, Dissecting a sensate filet flap from the defunctionalized index finger. C, Flap inset into the defect. D, Healed, stable coverage.
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CASE 2 Neurovascular Composite Transfer of an Index Proximal Interphalangeal Joint and Flexor Tendon to Reconstruct the Middle Finger cabinetmaker suffered a saw injury to his dominant index and middle fingers at work. His index finAger26-year-old was amputated at the level of the middle phalanx, and
the distal reconstruction (Fig. 31-2C ). The ischemic distal segment of the middle finger was revascularized, with the digital artery of the flap serving as a flow-through vessel while the nerve defects were bridged by the donor digital nerve segments. The index stump was closed. To provide this working man with the benefit of the full width of his hand, a ray amputation was not performed. The patient did well. A tenolysis of the middle finger flexor tendon was performed 6 months later. At the 2-year follow-up, the patient’s range of motion in the reconstructed middle finger was 0° to 110° at the metacarpophalangeal joint, 10° to 90° at the proximal interphalangeal joint, and 20° to 35° degrees at the distal interphalangeal joint (Figs. 31-2D and 31-2E ). Two-point discrimination was 4 mm on the radial side and 3 mm on the ulnar side of the finger. The patient retired from cabinetmaking and undertook a less strenuous vocation.
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the distal fragment was lost. The middle finger sustained segmental loss of skin, flexor tendon, both neurovascular bundles, and the proximal segment of the middle phalanx with disruption of the proximal interphalangeal joint (Fig. 31-2A). Given the multiple-digit nature of the injury, a plan was made to reconstruct the middle finger with specialized components recycled from the injured index finger. Accordingly, a neurovascular osteocutaneous flap was harvested from the index finger stump, taking skin, flexor tendon, bilateral neurovascular bundles, and the underlying proximal interphalangeal joint (Fig. 31-2B). After the middle finger was debrided appropriately, the proximal osteosynthesis was performed with a plate, and Kirschner wires were used for
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FIGURE 31-2. A, A saw injury resulting in complete amputation of the index finger through the middle phalanx. The middle finger has segmental loss of volar skin, flexor tendon, both neurovascular bundles, and disruption of the proximal interphalangeal joint with loss of the base of the middle phalanx. B, A neurovascular osteocutaneous flap being transferred from the index stump through the palmar tunnel to reconstruct the missing segment of middle finger. Continued
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FIGURE 31-2 cont’d. C, Osteosynthesis was obtained with Kirschner wires distally and with a plate and screws proximally. D, E, Two years postoperative; note the range of motion of the reconstructed middle finger, especially at the PIP joint. E
CASE 3 Pollicization of an Amputated Index Finger Stump to a Thumb Stump with a Great-Toe Wraparound Flap right-hand-dominant artist was referred for hand reconstruction 11 months after she sustained severe burns to Aher56-year-old upper torso, upper extremities, and right hand. She had loss of all of the digits of her right hand (Fig. 31-3A). All digits, including her thumb, were amputated at the level of the proximal phalanx. She had very little function of this hand and could grasp only small objects in what remained of her first webspace. To restore some basic function to her hand, she would require reconstruction of her thumb as well as a post for opposition. The patient underwent pollicization of her index finger stump to provide the much-needed length to her thumb and
a widened first webspace (Fig. 31-3B). To provide the newly reconstructed thumb with soft tissue coverage and a nail complex, a great-toe wraparound flap was harvested from the foot and transferred as a free flap to her hand (Fig. 31-3C). Finally, the remaining index finger metacarpal fragment was used to lengthen the middle finger metacarpal, providing a more functional post for basic pinch function (Fig. 31-3D). The combination of a functional thumb, a deep webspace, and an opposition post allowed the patient to regain the use of her hand and continue painting (Figs. 31-3E and 31-3F).
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C
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FIGURE 31-3. A, An old burn injury resulting in the loss of all fingers, including the thumb, through the proximal phalanx. Incisions are marked for planned pollicization of the index finger stump. B, The widened webspace after transfer of the index finger stump to the thumb. The proximal fragment of the index metacarpal was used to lengthen the middle finger. C, A great-toe wraparound flap being harvested to provide soft tissue coverage and a nail complex to the newly reconstructed thumb. D, Plate and screw fixation of the middle finger extension. Kirschner wires were used to secure the pollicization. E, The wellhealed neo-thumb, a wide webspace, and a stable opposition post allow for basic hand function. F, Reconstructed hand and donor site are shown. F
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CASE 4 An Amputated Index Finger and Wraparound Great-Toe Free Flap to a Thumb 33-year-old man suffered a severe mutilating injury to his left hand in the gears of a lumber saw. The thumb was Aavulsed just distal to the metacarpophalangeal joint and was lost in the machinery (Fig. 31-4A). The index finger sustained a multilevel crush injury and was amputated at the level of the proximal phalanx (Fig. 31-4B). The part was preserved on ice and brought to the emergency room with the patient. It was severed in a very ragged, crushing fashion with dirt and grease ground into the wound. There was an additional crush injury distally, flaying the distal pulp to the distal interphalangeal joint. Despite the severity of the crush injury, the patient was taken to the operating room to attempt thumb reconstruction utilizing the damaged remnant of the index finger. In this situation, reconstruction of the thumb clearly takes priority over restoring the index finger. A replanted, stiff, potentially insensate index finger is not only minimally beneficial, but also likely to be a hindrance to the normal function of the rest of the hand. However, adding length to the thumb can make the difference between a useless,
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neglected hand and a functional, effective hand. Therefore after thoroughly debridement and irrigation of the hand and the amputated part, the index finger remnant was fixed to the thumb stump with crossed Kirschner wires. The digital arteries had been completely avulsed from the thumb stump. As a result, a vein graft was used to anastomose the newly attached index finger vessels to the radial artery in the snuffbox. The flexor and extensor tendons were repaired, and the skin defect in the webspace was skin grafted (Fig. 31-4C ). Unfortunately, there was necrosis of the distal part of the new thumb with volar skin loss extending into the webspace (Fig. 31-4D). However, the proximal part of the replanted digit survived, providing structural length to the thumb, thus reducing the subsequent reconstructive needs from the foot. Rather than an entire great toe being harvested, a less deforming great-toe wraparound free flap was harvested and used to cover the areas of tissue loss while providing a functional nail complex (Fig. 31-4E ). The patient went on to do quite well with his new thumb (Fig. 31-4F ).
C
FIGURE 31-4. A, A lumbar saw injury with avulsion of the thumb and index finger. The amputated thumb was lost in the machinery. B, The index finger remnant had sustained a multilevel crush injury. C, The avulsed index finger was used to reconstruct the missing thumb. Vein grafts were used to place the vascular anastomoses outside the wide zone of injury.
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F
SALVAGE OF WHOLE OR PARTS OF MAJOR LIMB AMPUTATIONS Major limb amputations present the surgeon with a formidable challenge. These injuries are rarely clean, sharp amputations. Rather, there is often a significant element of crush or avulsion associated with a poorly defined zone of injury. These patients require emergent resuscitation, a full trauma evaluation, and expeditious transfer to the operating room. Unlike digital amputations, ischemia time is a crucial factor in limb amputations. Early reperfusion is critical. Perfusion of the limb with heparinized lactated Ringer’s solution and University of Wisconsin solution can be beneficial. Alternatively, an axillary artery cannula can be used to perfuse the limb with the patient’s own blood for a period of 15 to 20 minutes. The venous drainage is discarded, and the patient is transfused appropriately to maintain blood volume. As the byproducts of ischemia are washed out, the ischemia timer is reset, allowing for thorough debridement of devitalized tissues within the zone of injury, evaluation of the true extent of trauma, and the formulation of a detailed plan
tailored to optimize the potential future function of that extremity. Fasciotomies are a requirement. Occasionally, when orthotopic replantation is not feasible, innovative solutions can be limb saving. Godina and colleagues describe salvage of an amputated hand by initial ectopic implantation into the axilla to restore circulation.15,22 The hand was subsequently transferred to its native position once local factors were optimized. Amputated limbs that are deemed unlikely to regain useful function as a result of extensive crush or avulsion injury are still excellent donors for spare parts. Tissues outside the zone of injury can be salvaged and used to cover and preserve the length of the amputation stump, facilitating the fitting of a prosthesis and enhancing function (see Case 8). May and Gordon and Hallock describe the salvage of a free flap from the palm in an upper-extremity amputation to resurface and preserve the length of the forearm stump.7,18,19,28,30,38,39,45,47 Similarly, the following case shows how the uninjured distal components of a major amputation can be recycled to not only cover but actually lengthen the amputation stump. The elbow joint is used to make a neo-shoulder joint.
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FIGURE 31-4 cont’d. D, The distal part of the neo-thumb necrosed. There was volar skin loss extending into the webspace. E, A great-toe wraparound flap was harvested to reconstruct the necrotic tip, cover the cutaneous defect, and provide a nail complex. F, The result is a very functional and aesthetic thumb.
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CASE 5 Stump Length Preservation and Elbow-to-Shoulder-Joint Transfer man with severe progressive arteriovenous malformations of the left shoulder girdle and arm was referred Ato 25-year-old the surgical service for amputation. The vascular malformation had been embolized multiple times without success and had led to severe, painful ulcerations (Figs. 31-5A and 31-5B). Given the extent of the anomaly, the patient underwent forequarter amputation. The axillary artery and vein were preserved and continued to perfuse the amputated arm (Fig. 31-5C). The remaining malformation was then excised from the proximal arm to the level of the distal humerus while maintaining the perfusion of the distal arm (Fig. 31-5D). The hand was amputated, and the ulna and radius were shortened, as much
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soft tissue being preserved as possible. What remained of the arm was essentially normal. Rather than leaving the patient with a very proximal amputation defect at the root of the neck, the elbow joint and remaining components of the arm were used to reconstruct the deformity in the shoulder area and to create a stump that would enable the patient to wear normal clothes. The specimen was filleted open (Fig. 31-5E). The humerus was then impaled onto the stump of the clavicle and secured with screws (Fig. 31-5F). The elbow joint was now the new shoulder joint (Fig. 31-5G). The neo-shoulder healed nicely. The patient was able to wear normal shirts and carry a backpack without difficulty.
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FIGURE 31-5. A, B, A large malformation of the shoulder girdle and arm with severe, painful ulceration. C, Forequarter amputation with the intact axillary artery and vein keeping the specimen perfused. C
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FIGURE 31-5 cont’d. D, The remaining malformation was excised from the arm. The hand was amputated. A perfused, essentially normal elbow joint remained. The specimen was filleted open. (E) and the stump of the humerus was impaled onto the clavicle and fixed with screws (F). G, The neo-shoulder allowed the patient to wear normal shirts and to carry a backpack without difficulty.
SMALL FREE FLAPS FROM AMPUTATED PARTS While the major amputation is commonly used as a rich source of spare parts, the small, more distal, nonreplantable amputation is often overlooked as a source of much needed tissues. There are many unique opportun-
ities to harvest small free flaps from these distal amputations.21 These situations often arise in multiple-digit crush and avulsion injuries with segmental damage resulting in the differential loss of specialized tissues in the digits. Examples of these specialized tissues include joints, flexor and extensor tendons, and the nail complex. The following case demonstrates this concept.
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CASE 6 Composite Free Flap from an Amputated Middle Finger to Replace Segmental Loss of All Layers in a Viable Ring Finger man presented at the emergency room after sustaining a band saw injury to his nondominant left hand. AHis46-year-old injuries were ragged and multilevel (Figs. 31-6A and 31-6B). He had complete amputation of his middle finger through the distal proximal phalanx with disruption of the proximal interphalangeal joint (Figs. 31-6C and 31-6D). The ring finger remained perfused through an intact ulnar neurovascular bundle and skin bridge. The distal phalanx, pulp, and nail complex were intact and sensate. However, the patient was missing the central segment of this finger. There
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was complete loss of the middle phalanx, including the proximal interphalangeal and distal interphalangeal joints. Both flexor tendons, the extensor mechanism, and the radial neurovascular bundle were absent (Figs. 31-6A and 31-6B). On the basis of these findings, it was decided that the amputated middle finger would best be used as a donor of spare parts to reconstruct the injured ring finger. Replanting the amputated middle finger with an injured proximal interphalangeal joint would most likely result in a stiff, relatively insensate finger without significant functional benefit to the
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FIGURE 31-6. A, B, C, D, A ragged, multilevel band saw injury with complete amputation of the middle finger, near-amputation of the ring finger, and jagged lacerations of the little finger. The ring finger remained perfused and sensate through the intact ulnar neurovascular bundle. There was loss of the middle phalanx, including both the distal interphalangeal and proximal interphalangeal joints, both flexor tendons, the extensor mechanism, and the radial neurovascular bundle. D
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E
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H
F
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I
FIGURE 31-6 cont’d. E, F, A small free flap was harvested from the amputated middle finger. The middle phalanx would replace the missing ring finger middle phalanx, and the distal interphalangeal joint would become the new proximal interphalangeal joint. The neurovascular bundle, flexor tendons, and extensor tendon replaced their respective missing components. G, Crossed Kirschner wires were used to secure the free flap. H, I, The defect was covered with a full-thickness skin graft harvested from the amputated remnants, obviating the need to violate a distant donor site. G
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patient. In either case, the intact index finger would take over the functions of the dysfunctional middle finger. Therefore a small free flap containing all the requisite structures was designed and harvested from the amputated middle finger (Figs. 31-6E and 31-6F). The distal interphalangeal joint would become the new proximal interphalangeal joint; the flexor and extensor tendons would replace their respective missing segments; and the middle phalanx would restore bony con-
tinuity (Fig. 31-6G). The radial neurovascular bundle was anastomosed to perfuse and innervate the flap. After the incisions were closed, a skin deficiency remained over the neurovascular bundle. Skin was harvested from the remnants of the amputated part, thinned, and used as a full-thickness skin graft to cover the defect, obviating the need to create a distant donor site (Fig. 31-6H). The flap healed without complications, and the patient was able to return to work (Fig. 31-6I).
transfer of an index finger stump to augment thumb function.2,4
CROSS-HAND MICROVASCULAR TRANSFER Unfortunately, severe mutilating injuries are not always limited to one hand. Some accident-prone patients, after multiple injuries, are left with two dysfunctional hands; others lose bilateral hand function in a single devastating accident. In these cases, the goal is the optimal functional restoration of the whole patient and not necessarily each hand. With the luxury of time and elective decision making, the surgeon can develop a close relationship with the patient, carefully assess the patient’s functional strengths and weaknesses, and develop a detailed, custom-designed plan to optimize the patient’s function. Poorly functioning or dysfunctional components of one hand might serve as spare parts to augment the function of the other hand. This can obviate the need to harvest tissues from the more common donor site: the feet. Generally, the transfer of a functional digit to the contralateral hand is not recommended, although this has been reported by Morrison.31 However, transferring an index finger stump to augment the contralateral thumb can be highly beneficial. Bartlett et al. and Brownstein have reported on the cross-hand
SPARE PARTS FROM THE INJURED LOWER EXTREMITY Traditionally, the intact, uninjured lower extremity has been a valuable source of spare parts for the reconstruction of the injured hand.17,36 The versatile dorsalis pedis pedicle and its many branches are a rich source of a variety of tissues, including whole toes, parts of toes, bone, joints, tendons, nail complex components, and skin. All of these specialized components are excellent substitutes for their counterparts in the hand. In the rare situation in which the lower extremity and hand are both injured, the hand surgeon is faced with the unique opportunity of having the damaged lower extremity as a vital source of specialized components to reconstruct and skin to resurface the injured hand. The toe transfer is one of the most commonly performed spare parts operations involving the lower extremity as a donor (see Cases 3 and 4).
CASE 7 Thumb Reconstruction with a Cross-Hand Transfer of the Index Metacarpal 37-year-old man sustained severe burns to his torso and both hands in a house fire. His digits on both hands suffered Afourth-degree burns and all mummified (Figs. 31-7A and 31-7B). He underwent amputation of all digits, including his thumbs. A right groin flap and a left midabdominal flap were used to provide soft tissue coverage (Fig. 31-7C). The amputations were more proximal in the right hand. The thumb amputation on the right side was at the level of the metacarpophalangeal joint, while the left thumb was amputated through the interphalangeal joint. Similarly, all the fingers on the right hand were amputated through the metacarpophalangeal joint, and the fingers on the left hand were amputated about 2 cm distal to the metacarpophalangeal joint. Once stable soft tissue coverage had
been obtained and the patient had recovered from his acute burn injury, he was left with a short thumb and fingers on the left hand, no thumb or fingers on the right hand, and a restricted first webspace bilaterally (Figs. 31-7D and 31-7E). To enhance the first webspace, plans were made to do bilateral index ray amputations. At the same time, the amputated index rays could be used as spare parts not only to reconstruct the absent thumb on the left, but also to create opposition posts bilaterally for the thumbs. First, the distal left index ray was harvested and transferred as a free flap to the right thumb stump, adding significant length (Figs. 31-7F and 31-7G ). Crossed Kirschner wires were used to obtain osteosynthesis. Next, the remaining fragments of
31
the two metacarpals were used to lengthen the finger stumps by about 3.5 cm on each side with good results (Fig. 31-7H ). Eventually, the patient returned for further release of his webspace. Coverage was obtained with a
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reverse-flow posterior interosseous fasciocutaneous flap (Figs. 31-7I and 31-7J ). The end result was a pair of functional hands that were capable of basic pinch and grasp (Fig. 31-7K ).
B
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D
E
FIGURE 31-7. A, B, A house fire resulted in fourth-degree burns to both hands involving all digits. C, All the mummified digits, including the thumbs, were amputated, and a right groin flap and a left midabdominal flap were used to obtain coverage. D, After recovering from his burn injuries, the patient was left with a short thumb and fingers on the left hand. The webspace was constricted. E, The right hand had no fingers or thumb. Continued
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G
H
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K
FIGURE 31-7 cont’d. F, G, The distal left second ray was harvested as a free flap and transferred to the right thumb to provide length. H, The remaining segments of both second rays were used to create opposition stumps on both hands while the webspaces were opened bilaterally. I, J, Later, the patient had further release of his webspace. Coverage was obtained with a reverse-flow posterior interosseous fasciocutaneous flap. K, Two functional hands capable of both pinch and grasp were the long-term result.
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CASE 8 Double Fillet of Foot Free Flaps for Maintenance of Leg Stump Length and for Hand Coverage with Eventual Toe-to-Thumb Transfer 36-year-old woman was run over by a train, sustaining severe injury to her right leg and left hand. The leg was Acompletely amputated, with approximately 14 cm of bone
31
loss below the knee. However, the skin loss extended to above the knee. The amputated foot was not otherwise traumatized. The left hand also sustained severe degloving injury over the entire dorsum, the distal palm, and all the digits except the index finger. The thumb sustained severe crush and avulsion injury and was devitalized, though it remained attached. Multiple metacarpals were fractured (Figs. 31-8A and 31-8B). Realizing the significant advantage of a below-knee amputation over an above-knee amputation, a free flap was raised from the sole of the intact but amputated foot and used to cover the exposed bone, achieving stable coverage of the below-knee stump. Next, arterial and venous grafts were obtained from the amputated leg and used to revascularize the tenuous thumb. Although perfusion was obtained, the long-term viability of the thumb was in question. As a result, it was thought that banking the great toe from the amputated foot would be wise. Furthermore, debridement of the hand left an area over the dorsum without adequate soft tissue coverage. Therefore a free flap containing skin and the great toe was harvested from the dorsum of the amputated foot and used to cover the denuded area on the injured hand while the great toe was banked for later use if necessary.
This flap was raised on the anterior tibial vessels and anastomosed end-to-side to the ulnar vessels at the level of the wrist (Fig. 31-8C ). Over the next several weeks, the patient required multiple debridements of devitalized tissues in the hand. Eventually, a subtotal amputation of the thumb through the interphalangeal joint had to be performed. The only functional finger that remained was the index finger, which had normal sensation. To obtain any meaningful function, a thumb reconstruction was necessary. Six months later, the patient was taken back to the operating room for thumb reconstruction. The banked great toe was transferred across the palm as a neurovascular island without the need for further microsurgery (Figs. 31-8D and 31-8E ). The transfer was successful, and the patient went on to regain some basic hand function, including pinch and weak grasp. This allowed her to use her left hand effectively as an assist hand (Fig. 31-8F ). The below-knee amputation stump was also revised and did quite well. The astute hand surgeon is fully aware of the value of spare parts. Not only are they a precious resource during acute hand reconstruction, but they should also be kept in mind for secondary procedures. As such, any specialized tissues that might be needed in later procedures or that might replace struggling components, should they fail, should be preserved.
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FIGURE 31-8. A, A severe, mutilating, degloving injury involving all the digits and metacarpal bones of the left hand. B, The amputated foot, which was uninjured below the level of the ankle, was a source of spare parts. C, A free flap based on the dorsalis pedis artery was harvested from the amputated foot and used for soft tissue coverage of the hand. Given the tenuous nature of the thumb, the toes were included in the flap, where they were banked for later use if needed. Continued
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D
E
F
FIGURE 31-8 cont’d. D, The hand before the great-toe transfer. Note the thumb length with amputation through the proximal phalanx. E, The great-toe pedicle flap ready for transposition to the thumb position. F, Performing active pinch with the left hand. The right leg healed following a free flap from the sole of the amputated foot. (Source: Pribaz, JJ, Morris, DJ, Barral, D: Double fillet of foot free flaps for emergency leg and hand coverage with ultimate great toe to thumb transfer. Plast Reconstr Surg 91:1151–1153, 1993, with permission.)
CONCLUSION Normal hand function relies on the delicate interplay of a number of unique and highly specialized components. Function is superior when like is reconstructed with like. Over the past 30 years, spare parts surgery has evolved to optimally recycle these specialized tissues to maximize functional outcomes in hand and upper-extremity reconstruction. The algorithms for
reconstruction are well established, and with growing experience in microsurgery and transfer of composite flaps, the surgical options seem as infinite as the injuries themselves. The cognizant, creative hand surgeon views injured tissues in the context of the overall functional needs of the patient and as potential spare parts to optimize form and function in the injured hand.
References 1. Alpert B, Buncke H: Mutilating multidigital injuries: Use of a free microvascular flap from a nonreplantable part. J Hand Surg 3:196, 1978. 2. Bartlett S, Moses M, May J: Thumb reconstruction by free microvascular transfer of an injured index finger. Plast Reconstr Surg 77:660, 1986. 3. Boyes J: Bunnell’s Surgery of the Hand, 4th ed. Philadelphia, JB Lippincott, 1964. 4. Brownstein M: Thumb reconstruction by free transplantation of a damaged index ray from the other hand. Plast Reconstr Surg 60:280, 1977. 5. Bunnell S: Physiological reconstruction of a thumb after total loss. Surg Gynecol Obstet 52:245, 1931. 6. Bunnell S: Injuries of the hand. In Bunnell S (ed): Surgery of the Hand. Philadelphia, JB Lippincott, 1948, p 605. 7. Cavadas P: The free forearm fillet flap in traumatic arm amputation. Plast Reconstr Surg 98:1119, 1996. 8. Cave E, Rowe C: Utilization of skin from deformed and useless fingers to cover defects in the hand. Ann Surg 125:126, 1947. 9. Chase R: Conservation of usable structures in injured hands. In Converse J (ed): Reconstructive Plastic Surgery: Principles and Procedures in Correction, Reconstruction and Transplantation. Philadelphia, WB Saunders, 1964, p 1579. 10. Chase R: The damaged index digit: A source of components to restore the crippled hand. J Bone Joint Surg Am 50:1152, 1968. 11. Chase R: Atlas of Hand Surgery. Philadelphia, WB Saunders, 1973. 12. Chase R, Hentz V: The philosophy of hand salvage and repair. In Wolfort F (ed): Acute Hand Injuries: A Multispecialty Approach. Boston, Little, Brown and Company, 1980, p 1. 13. Dunlop J: The use of the index finger for the thumb: Some interesting points in hand surgery. J Bone Joint Surg 5:99, 1923. 14. Gainor B: Osteocutaneous digital fillet flap a technical modification. J Hand Surg 10B:79, 1985. 15. Godina M, Bajec J, Baraga A: Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part. Plast Reconstr Surg 78:295, 1986. 16. Graham W: Transplantation of joints to replace diseased or damaged articulation in the hand. Am J Surg 88:136, 1954. 17. Gumley G, MacLeod A, Thistlethwaite S: Case report: Total cutaneous harvesting from an amputated foot: Two free flaps used for acute reconstruction. Br J Plast Surg 40:313, 1987. 18. Hallock G: Isle of palm and sole fillet flaps. Ann Plast Surg 26:514, 1991. 19. Hammond D, Matloub H, Kadz B, Yousif N, Sanger J, Larson D: The free-fillet flap for reconstruction of the upper extremity. Plast Reconstr Surg 94:507, 1994. 20. Holevich J: A new method of restoring sensibility to the thumb. J Bone Joint Surg Br 45:496, 1963. 21. Idler R, Mih A: Soft tissue coverage of the hand with a free digital fillet flap. Microsurgery 11:215, 1990. 22. Jennings J, Murphy R, Chernofsky M, Chowdary R: Amputation stump salvage using a “banked” free-tissue transfer. Ann Plast Surg 27:361, 1991.
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23. Kessler I: Cross transposition of short amputation stumps for reconstruction of the thumb. J Hand Surg 10B:76, 1985. 24. Kleinert H, Bennett J: Digital pulley reconstruction employing the always present fibrous rim of the previous pulley. Paper presented at the annual meeting of the American Society for Surgery of the Hand, Las Vegas, Nevada, 1977. 25. Kleinert H, Jablon M, Tsai T: An overview of replantation and results. J Trauma 20:390, 1980. 26. Littler J: The neurovascular pedicle method of digital transposition for reconstruction of the thumb. Plast Reconstr Surg 12:303, 1953. 27. London P: Simplicity of approach to treatment of the injured hand. J Bone Joint Surg Br 43:454, 1961. 28. May J, Gordon L: Palm of hand free flap for forearm length preservation in nonreplantable forearm amputation: A case report. J Hand Surg 5:377, 1980. 29. Milford L: Resurfacing hand defects by using deboned useless fingers. Am Surg 32:196, 1966. 30. Mixter R, Rao V, DeAngelis A, Donald C: Salvage of proximal humeral amputations with a remnant forearm flap. Plast Reconstr Surg 87:965, 1991. 31. Morrison W, MacLeod A, O’Brien B: Digital reconstruction in the mutilated hand. Ann Plast Surg 9:392, 1982. 32. Morrison W, O’Brien B, MacLeod A: Long term nerve function in replantation surgery of the hand and digits. Ann Chir 29:1041, 1975. 33. Morrison W, O’Brien B, MacLeod A: Evaluation of digital replantation: A review of 100 cases. Orthop Clin North Am 8:295, 1977. 34. Peacock E: Reconstructive surgery of hands with injured central metacarpophalangeal joints. J Bone Joint Surg 38:291, 1956. 35. Peacock E: Reconstruction of the hand by local transfer of composite tissue island flaps. Plast Reconstr Surg 25:298, 1960. 36. Pribaz J, Morris D, Barrall D: Double fillet of foot free flaps for emergency leg and hand coverage with ultimate great toe to thumb transfer. Plast Reconstr Surg 91:1151, 1993. 37. Pribaz J, Pelham F: Upper extremity reconstruction using spare parts. Probl Plast Reconstr Surg 3:373, 1993. 38. Rees M, deGeus J: Immediate amputation stump coverage with forearm free flaps from the same limb. J Hand Surg 13A:287, 1988. 39. Richard A, Klaasen M, Parkhouse N: The free-fillet flap for reconstruction of the upper extremity. Plast Reconstr Surg 96:488, 1995. 40. Rosenberg L, Yanai A, Mahle D: A nail island flap for treatment of macrodactyly. Hand 15:167, 1983. 41. Slocum D: Palmar skin flaps salvaged from amputated fingers. Northwest Med 59:1397, 1960. 42. Tamai S: Twenty years experience of limb replantation: A review of 293 upper extremity replants. J Hand Surg 7:549, 1982. 43. Wei F-C, Colony L: Microsurgical reconstruction of opposable digits in mutilating hand injuries. Clin Plast Surg 16:491, 1989. 44. Weiland A, Vallarreal-Rios A, Kleinert H: Replantation of digits, and hands: Analysis of surgical techniques and
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functional results in 71 patients with 86 replants. J Hand Surg 2:1, 1977. 45. Weinberg M, Al-Qattan M, Mahoney J: “Spare part” forearm free flaps harvested from the amputated limb for coverage of amputation stumps. J Hand Surg [Br] 22B:615, 1997. 46. White W: Why I hate the index finger. Orthop Rev 9:23, 1980.
47. Zachary L, Gottlieb L, Simon M, Ferguson M, Calkins E: Forequarter amputation wound coverage with an ipsilateral, lymphedematous, circumferential forearm fasciocutaneous free flap in patients undergoing palliative shoulder-girdle tumor resection. J Reconstr Microsurg 9:103, 1993. 48. Zook E: The perionychium. In Green D (ed): Operative Hand Surgery. New York, Churchill-Livingstone, 1988, p 1340.
32 Microsurgical Cross-Hand Digital Transfer Stephen Pap, MD Joseph Upton, MD
32
Restoration of function to amputated or severely injured digits can be very technically difficult and often demands a creative approach. Plastic surgeons instinctively observe Gillies’ tenet: “Never throw anything away until you are sure you don’t want it.”7 The use of an amputated, devascularized, discarded, or nonfunctional body part to restore function presents a unique challenge to surgeons. The literature on the use of nonfunctional body parts is scant. Early reports describe the reconstruction of the most important part of the hand: the thumb. In 1971, Orticochea presented the concept of an immediate reconstruction of the thumb after amputation and loss of the thumb at the metacarpal level.16 Two local flaps with intact sensation from dorsal and palmar skin surfaces were delayed and, within 2 weeks of injury, were rotated to form a tube over the thumb stump. The stump was then lengthened with an autogenous corticocancellous bone graft. Long-term follow up of this immediate osteoplastic reconstruction showed a stable post with intact sensibility, with the patient able to write and perform fine hand work. Prior to the widespread use of microsurgical techniques, Edgerton reported a successful cross-hand transfer of a ring ray at the metacarpal level, using the principles of pedicle flap transfer.6 During the first stage, the skeleton was joined, and the skin was left attached as a pedicle from the other hand. Tendons and nerves were joined at the second stage. Months later, two-point discrimination and strength were reported to be within normal limits. This concept was not new. In 1900, Nicoladoni, working in Austria, described a toe-to-thumb reconstruction in which the hand was attached to the foot for 3 weeks.14 This technique gained some popularity for thumb reconstruction over the next 30 years.4,10,12,15 Microsurgery has changed our thinking and approach to trauma. Today, a reattached and revascularized undamaged or partially traumatized part is the optimal reconstruction following most severe injuries to the hand or upper arm. With some injuries, this is not always possible. The osteoplastic concepts were refined by Doi and colleagues, who reported a series of four thumb reconstructions in which a free sensory dorsalis pedis flap was employed to cover an iliac bone graft.5 As early as 1977, an undamaged index finger was transferred to the opposite hand for thumb reconstruction following trauma.2 Within a very short time, the hand literature contained a number of reports in which amputated parts were stored heterotopically before being reattached in their proper region,8,9 severed digits were reattached on the opposite hand or amputation stumps,3,17,22 and hands and forearms were reattached on the opposite side.1,11,19 In most of these unique case reports, sensory function and motion were restored to varying degrees, and a functional hand (or terminal portion of a limb) was achieved. All arguably functioned better than prostheses. During this time, resourceful surgeons also used the soft tissue from the amputated parts to cover the exposed amputation stumps. 461
462
THE MUTILATED HAND
The elective use of cross-hand spare parts was next reported by a team at Massachusetts General Hospital.13 Four intact digits were transferred from a limb that had been rendered useless by a brachial plexus avulsion to the opposite hand, which contained only a thumb. At 5-year follow-up, protective sensation and a grip strength of 20 pounds were documented. We will describe the elective transfer of a ring finger from one hand to the other, performed in 1983.
CASE REPORT A 28-year-old street person was hit by a bus early one morning. On arrival at the local trauma center, he was unconscious from a closed head injury and had sustained a grade IIIC injury to one leg. During emergency surgery to decompress a subdural hematoma and cerebral contusion and to revascularize his left leg, the right middle finger was noted to be missing. Attempts to retrieve the digit were unsuccessful. When he regained consciousness 2 weeks later, a full hemiparesis was present, and he was referred FIGURE 32-1. A, Preoperative appearance of a patient with an amputation of the middle finger at the proximal interphalangeal joint level in the right hand level and an intact but nonfunctional left hand due to severe spastic hemiparesis. B, Radiograph demonstrates that all bones and joints are intact in the hemiparetic left hand. Note the adducted thumb with metacarpophalangeal joint hyperextension.
A
B
to our microvascular center for coverage and grafting of his left tibia. Vascularized ipsilateral fibula and nonvascularized corticocancellous iliac bone grafts covered with a free latissimus dorsi muscle flap and split-thickness skin graft resulted in a solid skeletal union with stable soft tissue coverage within 4 months. He was ambulatory in a brace (partial weight-bearing) with one major problem: a profound spastic hemiparesis. Over the next 2 years, pharmacologic treatment and alcohol injections effectively improved his ambulation, but his right upper limb was useless. Tight wrist flexion and ulnar deviation, coupled with an adducted and flexed thumb on the left hand, rendered this hand useless for any fine prehension tasks, as he could manage only a marginal voluntary grasp. During his prolonged rehabilitation, he learned to read, write, and type; within 1 year, he had earned a high school equivalency diploma. During a routine clinic evaluation, it became clear that the patient could improve not only his typing/computer skills but also his power grip if he had an intact, sensate right middle finger, which had been previously amputated at the proximal interphalangeal joint level (Fig. 32-1).
32
463
Authority. He has become an accomplished one-handed typist and demonstrated a grip strength of 85 lb/in.2
TWIN DONORS A potential source of expendable organs is the identical twin donor. This has been explored in a wide area of transplants, including kidneys, spleen,18 and testes.21 We have transferred portions of expanded scalp in monozygotic twins. Despite the recent highly publicized clinical hand allograft transfers, the prime indication for composite thumb, digital, or hand transfers must include a patient or a monozygotic twin with expendable spare parts. Unfavorable outcomes following allograft transfers will remain predictable until the graft-versus-host reaction can be eliminated or manipulated without significant host morbidity.20 We have no experience with composite nerve allograft transplantation, as reported by others, but have had the opportunity to perform one allograft transfer under very unusual circumstances. A baby who was born with bilateral residua of bilateral in utero Volkmann’s ischemic injuries is the only such patient in the literature. The father of this infant offered on many occasions to donate his own tissue to reconstruct his daughter’s deficient limbs. He got his chance after he had died from a ruptured intracranial aneurysm. His radius and radial nerve were harvested and used to reconstruct his daughter’s ulna and ulnar nerve.
CONCLUSION The emergent and elective use of limb parts is rare, but the concept has greatly expanded our reconstructive possibilities. In an era when one’s first instinct, FIGURE 32-2. A, During an elective procedure, the intact left ring finger was amputated at the proximal interphalangeal joint level. All tendons and neurovascular structures were left long. B, The recipient right hand had been prepared for the elective transfer. Tension-free nerve coaptations and vascular anastomoses were performed. Both extrinsic and intrinsic muscle tendon units, including the lumbrical of the flexor digitorum profundus tendon, were repaired.
32
The right hand was otherwise normal. The obvious spare part was the intact and nonfunctional ring finger on his left hand. With two surgical teams, the cross-hand free transfer of the anatomically normal left ring finger to the right middle stump was performed much like a replant. All structures in both recipient and donor regions were dissected proximally to the level of the metacarpophalangeal joint (Fig. 32-2). Skeletal fixation was achieved with an interosseous wire, a technique that was popular at that time. The A1 pulley was preserved, as only the flexor digitorum profundus was joined at the lumbrical insertion level within the palm. The recipient intrinsic tendons were joined to the transferred extensor, which was not sutured directly over the skeletal union. Periosteal flaps covered the interosseous wire used for skeletal fixation. Both radial and ulnar digital arteries, palmar and dorsal sensory nerves, and three dorsal veins were repaired under the operating microscope. Early motion with rubber band traction on the middle finger was initiated on the third postoperative day. Six weeks later, a 30° flexion contracture at the proximal interphalangeal joint was corrected with dynamic splinting. Within 6 months, the patient had protective sensation on both sides of the digital pulp, and at 5 years, he maintained a moving two-point discrimination of 6.0 mm. He could flex the tip of the middle finger to within 0.5 cm of the distal palmar flexion crease with total active motion of 230°. When the patient was last examined, 17 years post transfer, motion at the metacarpophalangeal and proximal interphalangeal joints was normal, and he lacked the final 25° of motion at the terminal joint (Fig. 32-3). Moving two-point discrimination measured 6.0 mm on both radial and ulnar sides of the pulp tissue. There was no rotation or angulation. For the past 6 years, he has worked as a supervisor for the Metropolitan Boston Transit
MICROSURGICAL CROSS-HAND DIGITAL TRANSFER
464
THE MUTILATED HAND
FIGURE 32-3. A, Sixteen years later, the clinical appearance of the patient’s hand has not changed significantly. The left hand is still useless. B, C, Excellent digital flexion and extension are demonstrated. The appearance and function of the hand are good, although the patient still lacks the last 5⬚ of flexion from the terminal joint. Two-point discrimination in the middle finger is 5.0 mm on both radial and ulnar sides. Side-to-side movement, via the intrinsic muscles, is present.
following a severe mutilating injury, is to find the amputated part with the intent of functional reattachment, the same thinking should be applied to elective reconstruction, especially in children who will biologically achieve better functional outcomes.
References 1. Adkins P, Graham B, Kutz JE: Functional evaluation of an emergency cross hand replantation: A 9 year follow-up. J Hand Surg [Am] 17:214, 1992. 2. Brownstein ML: Thumb reconstruction by free transplantation of a damaged index ray from the other hand: Case report. Plast Reconstr Surg 60(2):280–283, 1977. 3. Cheng GL, Pan DD, et al: Transplantation of severed digits to forearm stump for restoration of partial hand function. Ann Plast Surg 15(4):356–366, 1985. 4. Clarkson P: Reconstruction of hand digits by toe transfer. J Bone Joint Surg 37A:270–276, 1955. 5. Doi K, Hattori S, et al: New procedure on making a thumb: One-stage reconstruction with free neurovascular flap and iliac bone graft. J Hand Surg [Am] 6(4):346–350, 1981.
6. Edgerton MT: The cross-hand finger transfer. Plast Reconstr Surg 57(3):281–493, 1976. 7. Gillies H, Millard D: The Principles and Art of Plastic Surgery. Boston, Little, Brown, 1957, p 52. 8. Godina M, Bajac A, Baraga A: Salvage of the mutilated upper extremity with temporary implantation of the undamaged part. Plast Reconstr Surg 78:295, 1986. 9. Graf P, Groner R, Horl W, et al: Temporary ectopic implantation for salvage of amputated digits. Br J Plast Surg 49(3): 174–177, 1996. 10. Joyce JL: A new operation of the substitution of a thumb. Br J Plast Surg 5:499–504, 1918. 11. Kutz JE, Sinclair SW, Rao V, Carlier A: Cross hand replantations: Preliminary case report. J Microsurg 3:251, 1982. 12. Lambert O: Resultat eloigne d’une transplantation de gros orteil remplacement du pouce. Bull Mem Soc Chir, Paris, 5 May 1920, p 689. 13. May J, Rothkopf D, et al: Elective cross-hand transfer: A case report with a five-year follow-up. J Hand Surg [Am] 14(A):28–34, 1989. 14. Nicoladoni C: Daumenplastik und organischer Ersatz der Fingerspitze (Anticheiroplastik und Daktyloplastik). Arch Klin Chir 61:606–614, 1900.
32
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19. Reagan DS, Reagan JM: Emergency cross arm transfer. Plast Reconstr Surg 106:648, 2000. 20. Siemionow M, Ozar K: Advances in composite tissue allograft transplantation as related to the hand and upper extremity. J Hand Surg 27A:565–580, 2002. 21. Silber SJ: Transplantation of a human testis for anorchia. Fertil Steril 30:181–187, 1978. 22. Tegtmeier RE: Thumb-to-thumb transfer following severe electrical burns to both hands. J Hand Surg [Am] 6(3): 269–271, 1981.
32
15. Oehlecker F: Endergebnis der Uberpflanzung der grossen Zehe als Daumenersatz. Langenbecks Arch Klin Chir 189:674–680, 1937. 16. Orticochea M: Reconstruction of the thumb using two flaps from the same hand. Br J Plast Surg 24(4):345–350, 1971. 17. Quaba AA, Sommerlad BC: Salvage replantation: Free composite transfer from a non-replantable arm. Br J Plast Surg 40(3):310–312. 18. Raccuglia G, Lansing A: Spleen transplantation in a leukemic individual from his healthy identical twin. Clin Exp Immunol 14:1–18, 1973.
MICROSURGICAL CROSS-HAND DIGITAL TRANSFER
33 Microsurgical Cross-Hand Transfer Linda K. Cendales, MD Joseph E. Kutz, MD, FACS
CASE REPORT
33
A 38-year-old man sustained bilateral upper extremity crush injuries after being caught between a passing truck and a rock wall. When the patient arrived at our facility 3 hours after the accident, the left hand was found to be amputated at the level of the carpus with avulsion of several tendons and the median and ulnar nerves at the proximal forearm level (Fig. 33-1). The right upper extremity presented with unrecoverable damage to the distal arm, elbow, and proximal forearm, resulting in a devascularized hand (Fig. 33-2). The only option available to restore some function to the patient was a cross-hand replantation. The right hand was amputated at the level of the distal radius and ulna. The flexor and extensor tendons, the radial and ulnar arteries, and the median and ulnar nerves were amputated at the proximal forearm level. The muscle bellies in the tendons were completely debrided. The right upper extremity amputation was completed at the level of the midhumerus. The left forearm structures were exposed through midpalmar and mid-dorsal incisions. The muscle bellies of the flexor pollicis longus, flexor digitorum profundus, extensor digitorum communis, extensor carpi radialis longus and brevis, and extensor indicis propius were severely impaired. The remaining forearm muscles were in better condition. The median nerve was avulsed at the level of the elbow, but the motor branches of the forearm flexors were found to be in continuity. The ulnar nerve and radial and ulnar arteries were in continuity to the midforearm. The repair was accomplished as shown in Table 33-1. The forearm bones were plated following the AO compression technique. Four dorsal veins were anastomosed. The ulnar nerve was shortened to length, and 8 cm of the remaining nerve was utilized as a graft to the median nerve at the level of the elbow. Epineural sutures were placed to repair the nerves. A split-thickness skin graft was required to close the palmar aspect of the forearm. The graft was harvested from the amputated right upper extremity. Postoperative care followed our protocol for replantation. A small area of the skin graft was lost, but secondary healing was achieved successfully. The patient was followed on regular basis. At four months, a delayed union of the distal ulna was corrected (Fig. 33-3). No other procedures have been performed to improve functional outcome. In our 9-year follow-up report,1 the patient reported that the replantation played the dominant role in all of his daily activities. Although he had a body-powered prosthesis for the right upper extremity, he stated that he never used it. Cold intolerance was evident. The patient denied the presence of pain. He described a deep, protective sensation. Some of the activities of daily living that he could do independently with the replanted hand included being able to get dressed with pullover shirts, elastic waist trousers, and slip-on shoes; mow 467
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THE MUTILATED HAND
FIGURE 33-1. A severely crushed and avulsed left hand. (Published with permission from Microsurgery, vol. 3, 251–254, 1982.)
FIGURE 33-2. A right upper limb showing crush injuries of the arm and forearm. (Published with permission from Microsurgery, vol. 3, 251–254, 1982.)
the lawn; drive a car; and write (Fig. 33-4). He had difficulty with lace-up shoes and shaving. Functional recovery at 9 years revealed an active range of motion as shown in Figures 33-5 and 33-6. Static and moving two-point discrimination measured
greater than 15 mm. Grip strength, evaluated with the Jamar dynamometer on setting II, was 5 pounds, and key pinch was 7 pounds. Patency of both the radial and ulnar arteries was present. The Carroll test was 56 out of 99 points.2
TABLE 33-1
Scheme for cross-hand replantation Attachments
Anatomic structures Bones
Vessels
Nerves
Muscles
Proximal Radius
Ulna
Ulna
Radius
Radial artery
Ulnar artery
Ulnar artery
Radial artery
Median
Median
Ulnar
Ulnar
Flexor carpi ulnaris
Flexor carpi radialis
Palmaris longus
Flexor pollicis longus
Flexor carpi radialis
Flexor digitorum profundis (X4)
Flexor digitorum superficialis
Flexor digitorum superficialis (X4)
Brachioradialis
Flexor carpi ulnaris
Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Extensor fascia Extensor carpi ulnaris
Not repaired
Distal
}
Extensor carpi ulnaris Extensor digitorum communis
{
Extensor pollicis longus
{
Extensor pollicis brevis
Extensor carpi radialis brevis Extensor carpi radialis longus
Abductor pollicis longus
33
MICROSURGICAL CROSS-HAND TRANSFER
469
A
FIGURE 33-3. Correction of the delayed union of the distal ulna.
In February 2000, the patient presented with a history of having been admitted to the hospital for treatment of dehydration, nausea, and vomiting. During the hospitalization, intravenous access was required. The brachial artery was accessed in another facility, result-
B
FIGURE 33-5. A, Active flexion at 9-year follow-up. B, Active extension at 9-year follow-up.
CONCLUSION
FIGURE 33-4. Patient demonstrating the ability to write with the formerly nondominant hand. (Published with permission from The Journal of Hand Surgery, vol. 17A(2), March 1992.)
The transfer of tissues from one part of the body to another has been accomplished since the beginning of the 20th century when Nicoladoni transferred a toe to a thumb in a 5-year-old.15 Since then, advancements in microsurgical techniques have made possible toe-to-hand transfers to reconstruct injured or congenital hands in one-stage procedures, as well as the replantation of tissues that otherwise would have left patients with amputations. Many techniques in tissue transfers for hand reconstruction have been utilized. Pollicization for correction of congenital deformities and emergency pollicization in cases of severe loss of the thumb are only some examples. However, replantation is not always possible at the original site. The state of the injured tissues
33
ing in infiltration. Since that procedure, the function of the replanted hand has suffered significantly. When last seen in August 2001, the patient had complete loss of all function of the hand. This condition has had an impact on his overall psychological condition and his quality of life.
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THE MUTILATED HAND
and the functional outcome that is expected from a replantation are factors to be considered when faced with an amputation. Preservation of a hand by anastomosis in the axilla and later replantation at its original site have been also performed.7 In cases of bilateral severe injuries, cross-hand finger transfer has been reported,5 and a cross-hand transfer from a right brachial plexus injury to an amputated left hand was performed by May, Rothkopf, Savage, and Atkinson in 1989.14 With the advancement of immunosuppressive medication, the transplantation of organs and composite tissues have also become possible. Clinical allogenic free fibula graft with immunosuppression was performed by Doi in 1994.4 Good results with vascularized knee joints have been reported by Hofmann and coworkers, who performed the first clinical transplantation of a vascularized knee joint in 1996 and reported on three additional patients in 1998.9 Hand transplantation has also been performed.10 Hand and finger injuries are among the most common occupational injuries and disabilities.11 However, these injuries not only cause physical impairment, which can be related to the severity of the injury and the success of the possible reconstruction, but also can cause a psychological impact on the body image and identity. The image and the hands, in particular, play an important role in the mental representation of ourselves throughout life. As Freud pointed out, “A man’s state of mind is manifested, almost without exception, in the tensions and relaxations of his facial muscles . . . in the movement of his limbs and in particular of his hands.”6 The loss of a limb or a hand can evoke feelings and conflicts regarding loss, dependency, and potency.12 Kolb has talked about the disturbances in the body image after severe trauma of the limbs: “The distortion of the customary body-image is experienced as a distortion of the self”;13 and the adaptation to a new image is influenced by personality and environmental factors. Kolb mentions that a sign of adaptation is the patient’s ability to talk about his or her own disfigurement and accept alternatives for reconstruction. So when considering the possible functional outcome after reconstruction of a severely traumatized upper extremity, one may take into consideration that the personality and previous experiences of the patient will not only play a role in the recovery, but also influence the outcome when the patient is faced with a complication. Prostheses have been acceptable alternatives when reconstruction is not an option. Although a prosthesis offers the possibility of regaining some function, the reason for use of a prosthesis is not always function. Burger and Marincek showed that 78% of a total of 414 patients used their prostheses for cosmetic reasons
only.3 Among the reasons for not wearing the prosthesis were heat and the associated sweating of the stump. More than one-third of the patients reported dissatisfaction with the prosthesis. Graham et al. showed a statistically significant advantage for replantation compared to use of a prosthesis.8
References 1. Adkins P, Graham B, Kutz J: Functional evaluation of an emergency cross-hand replantation: A 9-year follow-up. J Hand Surg 17A(2):213–216, 1992. 2. Carroll D: A quantitative test of upper extremity function. J Chron Dis Vol 18:479–491, 1965. 3. Burger H, Marincek C: Upper limb prosthetic in Slovenia. Prosthet Orthot Int 18(1):25–33, 1994. 4. Doi K, Akino T, Shigetomi M, et al: Vascularized bone allografts: A review of current concepts. Microsurgery 15(12): 831–841, 1994. 5. Edgerton M: The cross-hand finger transfer. Plast Reconstr Surg 57(3):281–293, 1976. 6. Freud S. The ego and the id. In: Strachey J (ed, transl): The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol 19. London, Hogarth Press, 1961, pp 1–66 (original work published in 1923). 7. Godina M, Bajec J, Baraga A: Salvage of the mutilated upper extremity with temporary ectopic replantation of the undamaged part. Plast Reconstr Surg 78:295–299, 1986. 8. Graham B, Adkins P, Tsai TM, et al: Major replantation versus revision amputation and prosthetic fitting in the upper extremity: A late functional outcomes study. J Hand Surg Am 23(5):783–791, 1998. 9. Hofmann GO, Kirshchner MH, Wagner FD, et al: Allogeneic vascularized transplantation of human femoral diaphyses and total knee joints: First clinical experiences. Transplant Proc 30:2754–2761, 1998. 10. Jones JW, Gruber SA, Barker JH, Breidenbach WC: Successful hand transplantation: One year follow-up. N Eng J Med 343(7):468–474, 2000. 11. Kelsey JL, Pastides H, Kreiger N, et al: Upper Extremity Disorders: A Survey of Their Occurrence and Cost to the Nation. A Study by the Department of Epidemiology and Public Health. New Haven, CT, Yale University, 1979. 12. Klapeke M, Marcell C, Taliaferno G, Creamer B: Psychiatric assessment of candidates for hand transplantation. Microsurgery 20(8):453–457, 2000. 13. Kolb L: Disturbance of the body-image. In Arieti S (ed): American Handbook of Psychiatry, vol 1. New York, Basic Books, 1959, pp 749–769. 14. May J, Rothkopf D, Savage R, Atkinson R: Elective crosshand transfer: A case report with a five-year follow-up. J Hand Surg 14A(1):28–34, 1989. 15. Nicoladoni A: Daumenplastik und organischer ersatz der fingerspitze (anticheiroplastik und dactyloplastik). Arch Klin Chir 61:606, 1900.
34 Replantation and Revascularization in Children Christian E. Sampson, MD Julian J. Pribaz, MD
34
Replantation and revascularization surgery is rooted in 19th-century medicine, with Murphy16 in 1896 performing the first end-to-end anastomosis, but has become a reality only in the past 30 to 40 years. Hopfner performed the first experimental replantation of a dog’s limb in 1903. In 1906, Carrel and Guthrie reported their work in homograft transplantation of canine limbs, setting the stage for composite tissue replantations and transplantation surgery.4 In 1962, Malt and McKhann performed the first clinical replantation in history with the reattachment of an above-elbow amputation in a 12-year-old boy.12 Three years later, Komatsu and Tamai in Japan reported the replantation of a severed thumb.10 Kleinert et al. described the first finger revascularization in 1963.9 With these early clinical reports and the experimental work in microvascular surgery by Buncke and Schulz,2 the scope of revascularization and replantation surgery expanded rapidly. The Sixth People’s Hospital in Shanghai reported its experience with traumatic amputations of the upper limb in 1967, including 20 successfully replanted digits.20 In 1973, Lendvay reported a 46% survival rate of 63 replanted digits and partial and complete hand amputations.11 The development of specialized instruments, needles, sutures, and operating microscopes soon followed, allowing for the development of many centers specializing in microvascular replantation surgery. Currently, most centers will have an 80% to 90% survival rate for adult replantations. Ikeda et al. reported an overall success rate of 88% in 14 cases of digital replantation in children under the age of 12.8 However, the survival rate of digital amputations in children under the age of 4 is less than 70%.14 Between 1994 and 1999, there were 39 thumb and finger amputations in Massachusetts in children between 1 and 4 years of age. During the same period, there were 63 thumb and finger amputations in children between 5 and 11 years of age. Fortunately, these are not common injuries. Large-segment upper extremity amputations are even less common.13 In contrast to industrial accidents in adults, in whom the amputation or devascularization injury is often guillotine-like, injuries in children are often avulsion or crush injuries from a moving wheel, chain sprocket, or ring avulsion. Such injuries are more difficult to manage and may be one of the reasons for the lower replantation survival rates that are seen in children. Other factors are that (1) surgeons will attempt replantation of a more severely damaged part in a child; (2) there is a higher degree of vasospasm in children both preoperatively and postoperatively; and (3) the technical challenge of repairing vessels as small as 0.2 mm in diameter.17 There are many similarities in the treatment of pediatric and adult hand injuries. It is important to remember, however, that a child’s hand is not simply a small adult hand. Similar mechanisms of injury can produce very different patterns of injury in a child’s hand compared to an adult’s hand. Children also react differently to trauma than adults do. For example, being in the 473
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THE MUTILATED HAND
emergency room can cause more fear and anxiety, which contribute to the greater degree of peripheral vasoconstriction seen in children.23 This can make it difficult in the emergency room setting to determine whether or not an injury has caused a devascularization. In those cases in which it is not readily apparent that an operation is necessary, conservative management would dictate that the patient be taken to the operating room for exploration. In dealing with these types of injuries, understanding the terminology to distinguish revascularization from replantation is important. Replantation is the reattachment of an amputated part. Revascularization is the restoration of perfusion to an injured part. A part that requires revascularization has sustained an injury to its arterial inflow but remains attached to the hand, held in place by a bridge of soft tissue that might or might not contain vessels, nerves, and/or tendons. Injuries requiring revascularization are not necessarily associated with a fracture.
INDICATIONS
“spare parts” surgery and the conversion to a belowelbow amputation should be attempted. A below-elbow prosthesis offers superior function compared to an above-elbow prosthesis. Successful replantation of amputations through the distal forearm or wrist can result in good function. Amputations at any level in the hand should be replanted. With multiple-digit amputations, only the least damaged digits should be considered for replantation. The amputated parts that are least damaged can be moved to the least damaged amputation stumps. Every amputated digit should be considered to be a “spare part” and should be reattached at the most functional position. The first priority is to replant the thumb. If the thumb is not replantable, then one of the fingers is replanted in the thumb position (Fig. 34-1). The next order of priority is replanting a digit on the ulnar side of the hand, in the ring or middle ray position, to serve in pinch function with the replanted thumb. Distal fingertip injuries may be classified separately, as follows:6
As was stated earlier, children can be poor candidates for replantation owing to the small size of their vessels compounded by peripheral vasoconstriction. However, the only contraindications to attempting replantation surgery in children is when the child has other, more life-threatening injuries or the amputated part has a multiple-level injury or is otherwise severely mangled. For upper extremity amputations proximal to the radiocarpal joint, every effort should be made to reattach an avulsion or crush amputation at the elbow or at a more proximal level. With proximal amputations, if the entire limb cannot be salvaged, the concept of
■ Zone 1: The amputated part does not include bone.
A
B
■ Zone 2: The amputation is through the nail bed, preserving at least one-half of the nail bed and sterile matrix. ■ Zone 3: The amputation is at the eponychial fold. ■ Zone 4: The amputation is just distal to the distal interphalangeal joint.
FIGURE 34-1. A 12-year-old boy with replantation of an avulsed right thumb.
34
A
REPLANTATION AND REVASCULARIZATION IN CHILDREN
475
B
FIGURE 34-2. A 13-year-old boy with replantation of a sharply amputated index finger at the distal interphalangeal joint level.
epithelization when the eschar separates. In managing revascularization or replantation injuries in children, it is important to keep in mind that children’s growth plates are vulnerable to the effects of ischemia.3,4,14,21 In addition, growth in macroreplantations can be affected by
34
Replantation should be attempted for all but the most severely mutilated thumb amputations. This includes very distal thumb amputations at the level of the eponychial fold. Single-digit replantation is generally attempted in children (Fig. 34-2). Replantation of amputations distal to the flexor digitorum superficialis tendon insertion can offer excellent range of motion. Amputations through the proximal interphalangeal joint and those involving the physis should be considered replantable. Growth retardation should be expected if the physis has been damaged (Fig. 34-3). Even if the physis is intact, there will be some growth retardation. In one study by Urbaniak,25 of 25 replanted digits in children, the overall growth was 81% of the contralateral digit (range: 21% to 118%). The possibility of growth disturbances should be discussed, when possible, with the child’s parents preoperatively (Fig. 34-4). The difficulty arises when the amputation is of a very small part or is very distal. High-power operating objectives (20⫻ to 30⫻) and 11-0 and 12-0 nylon are necessary for success. Vessels as small as 0.2 mm can be repaired. When replantation of a digit cannot be performed owing to technical considerations such as vessel size or in those cases in which a revascularized or replanted digit fails owing to thrombosis and cannot be salvaged, there are two options. A completion amputation can be performed, or if the level is at or distal to the distal interphalangeal joint, consideration should be given to reattaching the part as a nonvascularized composite graft. This is more successful in children than in adults, and even if the part does not “take,” there might be adequate
FIGURE 34-3. A 6-year-old girl, 12 months after distal amputation of the left index finger through the physis at the distal interphalangeal joint level, showing a well-vascularized but shorter finger.
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THE MUTILATED HAND
A
B
FIGURE 34-4. A 5-year-old boy, 9 months after replantation of the left index and middle fingers through the physis at the distal interphalangeal joint level, showing some radial deviation.
the associated high denervation injury. Very proximal nerve injuries or root avulsions can exacerbate growth retardation.18
INITIAL ASSESSMENT Children who present to the emergency room with severe injuries to the hand should be approached as one would any trauma patient. An initial assessment must be made to look for other, potentially more serious, injuries. When other, potentially life-threatening injuries exist, the extremity injury should be cleansed, dressed, and splinted to await definitive treatment when the child’s condition has stabilized. With devascularization or amputation injuries, surgical treatment can in many cases take place concomitantly with surgery for other trauma. When there is only an extremity injury, the approach can be more focused. The child will often be scared and anxious, and all efforts should be made to allay the child’s fears and to keep the child comfortable and warm. The mechanism of injury and the time and place at which the injury occurred are important pieces of information to obtain. The wound should be assessed in the emergency room, while the child is kept as comfortable as possible. A frightened, cold child who is in pain will have a significant degree of peripheral vasoconstriction, which can confound assessment of the injury, especially with regard to devascularization injuries. When a clear deter-
mination cannot be made as to whether there has been a devascularization, the child should be taken to the operating room for exploration. For microreplantations, it is useful to categorize the level of injury. A simple classification scheme has been proposed by Sailes et al., as follows:19 ■ Level I: Injuries are distal to the insertion of the flexor digitorum superficialis and flexor pollicis longus tendons. ■ Level II: Injuries are proximal to the insertion of the flexor digitorum superficialis and flexor pollicis longus tendons and distal to the wrist. ■ Level III: Injuries are proximal to or at the wrist. Sensory examination in children is unreliable, even in nontrauma settings, and should not be used as a guide to management. The need to go to the operating room with amputation injuries is self-evident. It is generally agreed that the indications for replantation in children can be broader than in adults, and an attempt should be made to replant all amputated parts. Major replantations at the forearm or upper arm level, rarely considered in the adult, can be performed in children. The smaller muscle mass probably allows for a longer ischemia time, and children usually do not have comorbidities that would be considered contraindications (e.g. smoking, diabetes, atherosclerosis).
Whenever possible, the amputated part should be brought to the operating room by one operating team, ahead of the patient, to begin the process of debridement and identification of the neurovascular structures with the aid of the operating microscope. This can greatly reduce operating time and ischemia time. The other team continues to prepare the patient for surgery. X-rays should be taken of both the amputated part and the injured extremity. A chest X-ray should be obtained if warranted by the mechanism of injury. Routine blood chemistry, complete blood count, prothrombin time, partial thromboplastin time, and type and cross-match are obtained. The blood loss for these types of injuries can be substantial, especially with amputations of the forearm or upper arm. A blood transfusion is often needed in these situations. The patient’s tetanus status must be determined and updated if necessary. In general, a first-generation cephalosporin is adequate antibiotic coverage, but this should be broadened as needed depending on the nature and degree of wound contamination. These are typically lengthy procedures, a single-digit replant requiring 3 to 4 hours work by an experienced team. The parents should be made aware of this fact preoperatively. Also, the parents should know of the possibility of failure; the possible need for reoperative surgery, either in the early postoperative time period or later; and the need for extensive physical and occupational therapy.
OPERATIVE MANAGEMENT Amputation Injuries For purposes of discussion, we define “microreplantation” as injuries at or distal to the radiocarpal joint. More proximal injuries are macroreplantation injuries.
Microreplantation in the Hand and Digits General anesthesia is uniformly required in the pediatric population. In older children, this can be supplemented with an axillary block or indwelling axillary catheter to assist with postoperative pain control and prevention of vasospasm. A Foley catheter is placed after induction of anesthesia. Small hemoclips and a bipolar cautery should be requested for hemostasis. The patient’s extremity should be prepped and draped free after application of a well-padded pediatric tourniquet. In children, the ipsilateral upper extremity is an adequate source for vein grafts, if needed, and therefore the lower extremity does not need to be prepped and draped as in adults. The caveat for this is in macroreplantations when a leg vein graft might be needed or in cases in which a nerve and/or skin graft might be needed.
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The injury should be explored under tourniquet control at 200 mm Hg or 50 mm Hg above the systolic blood pressure. The initial approach is debridement and identification and tagging of the vessels and nerves. The most difficult structures to find are the veins. This is particularly true in dealing with amputations distal to the distal interphalangeal joint. In some cases, the veins will not be readily identifiable. In these cases, once the arterial anastomosis has been performed and there is venous back bleeding, the veins may be more easily dissected. The sequence of repair is the same as for adult amputation injuries and is as follows: 1. Stabilize the bone, shortening it only if absolutely necessary, reconstruct the joints, and preserve the epiphyses. 2. Repair the extensor tendons. 3. Repair the flexor tendons. 4. Anastomose the arteries. 5. Repair the nerves. 6. Anastomose the veins. 7. Obtain skin coverage. The surgical approach is more conservative with children than with adults in that in children, bone length should be maintained whenever possible, and joint injuries should be reconstructed. Obviously, the epiphysis must be protected. In general, one should not shorten the bone any more than 3 to 5 mm. Osteosynthesis can be achieved with a variety of standard fixation techniques, but the most preferred is Kirschner wires. These can be placed axially, as described by Urbaniak,25 or two crossed Kirschner wires may be used. When using power tools for the placement of Kirschner wires, one must pay particular attention to avoid contact with, and potential damage to, surrounding soft tissues by the rapidly turning wire. For middiaphyseal injuries, consideration can be given to miniplates or interosseous wires, since crossed Kirschner wires can be difficult to place at this location. In the case of very distal amputations, osteosynthesis can be obtained with small-gauge injection needles placed axially.6,15 Next, the arterial anastomosis is performed. The vessel ends should be inspected for damage, and the zone of injury should be completely resected. Damaged vessels will have petechial hemorrhages evident within the adventitia from trauma to the vaso vasorum. The vessel ends, proximal and distal, must be resected back to healthy artery. Small branches are either divided between small hemoclips or cauterized with the bipolar cautery on a low setting. Double-opposing or individual vascular clamps may be used. There must be no visible separation of the endothelium, muscularis, or adventitial layer. The vessel ends are then dilated with jewelers
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THE MUTILATED HAND
forceps and heparinized saline (100 units/cc) injected proximally and distally, beyond the noncrushing vascular clamps. Whenever possible, the ipsilateral arteries should be repaired under no tension. If there is a gap, a vein graft is indicated, or some surgeons elect to use a crossover technique (radial digital artery to ulnar digital artery or vice versa) with an oblique injury.1 However, it is important to note that if a crossover technique is utilized, revision surgery such as tenolysis can be more difficult. Adequate arterial inflow must be determined before the anastomosis is performed, and this requires deflation of the tourniquet. The inflow should be pulsatile. Vascular clamps are again applied, and heparinized saline is injected proximally and distally. Three considerations must be kept in mind if a vein graft is needed. First, choose a vein graft with an appropriate size match; second, avoid too much redundancy in the graft so that there is no kinking; and third, be sure to avoid putting a twist in the vein graft when performing the anastomoses. Hydrodistension of the vein graft helps to unravel the graft and prevent twisting. The microvascular anastomosis is then performed using the operating microscope. A “lead hand” will aid in stabilizing the hand during the anastomoses. The backwall technique7 is preferred. This allows for direct inspection of the lumen of the vessel during the anastomosis to ensure a patent repair. Special care must be taken in using a vein graft with a size mismatch. The back wall is repaired first, with subsequent sutures bisecting the remaining circumference until the anastomosis is complete. The vascular clamps are removed, and the anastomosis is inspected for patency. There are often immediate signs of distal perfusion, but one should not be concerned if the amputated part remains pale. Any leak at the anastomosis should be repaired. The operating room should be warmed, and the replanted part may be covered with sponges soaked in warm saline. The vessel can be dilated with topical papaverine and 1% or 2% lidocaine. If the anastomosis is patent yet there remains no distal perfusion, the artery should be dissected distally to clip or cauterize any side branches, as they might be contributing to segmental spasm. If this does not correct the problem, use of tissue plasminogen activator may be considered to restore perfusion. If there is no flow across the anastomosis, it must be opened and inspected for technical problems and/or thrombosis or platelet plugging. There should be a low threshold for completely revising the anastomosis, using a vein graft if necessary. If distal perfusion has been difficult to achieve and is established only after the above maneuvers, heparin therapy should be initiated. If distal perfusion cannot be established, then a completion amputation should be performed unless it is
a very distal amputation in which the part may be left as a composite graft. Next, the neurorrhaphies are performed. A tensionfree neurorrhaphy is essential, and nerve grafts are used if necessary. Healthy fascicles must be seen at the proximal and distal nerve stumps. An interrupted, 10-0 nylon epineural suture technique is used. Primary nerve grafting should not be performed in badly contaminated wounds, if the wound cannot be closed primarily, or if there is concern the replanted part might not survive. Delayed nerve grafting can be more appropriately performed 1 or 2 months later in a healthy, viable replanted part. The flexor tendons are repaired next, using a modified Kessler repair with a 3-0 or 4-0 nonabsorbable suture material and 6-0 nylon epitenon stitch. A primary tendon transfer from a nonreplantable digit stump may be used if the proximal tendon is not available or is badly damaged in the replanted digit.1 Next, the volar incision is closed loosely, and attention is directed to repair of the extensor tendons. This is performed by using a nonabsorbable 4-0 suture material with horizontal mattress or figure-of-eight stitches. The veins are repaired next, again by using the operating microscope. An attempt should be made to repair two veins per artery repaired, but in some cases, one vein is adequate. An exception is for zone 2 and 3 tip amputations owing to the absence of dorsal veins.15 Vein length can be increased by careful dissection in the subdermal layer and division of branches. If no veins can be repaired, then removal of the nail plate, scoring of the sterile matrix, and use of heparinsoaked pledgetts placed on the sterile matrix can be considered. Leech therapy is another option. The dorsal skin wound is closed. Skin grafts are used as needed to prevent an overly tight closure. When replantation is not possible, consideration may be given to nonvascularized composite grafting of the amputated part. A nonadhering gauze dressing is applied to the suture lines and any skin-grafted areas. A bulky gauze dressing is then applied, care being taken to avoid a circumferential dressing on replanted digits. A wellpadded long arm splint is then fabricated. The fingers should be exposed to allow for postoperative monitoring. The arm and hand should be elevated above the level of the chest.
Macroreplantation Macroreplantation is less common in children than in adults (Fig. 34-5). Amputations of the upper extremity between the shoulder and radiocarpal joint are managed similarly to microreplantation injuries. There are, however, several differences. Because of the greater muscle
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A
479
B
FIGURE 34-5. A 16-year-old boy with replantation of a severely crushed left hand at the radiocarpal joint.
transfers are needed immediately or within the first week after surgery.
Devascularization Injuries The operative management of devascularization injuries is similar to that of amputation injuries. These injuries cover a wide spectrum of severity. Appropriate exposure of the zone of injury is critical. When one is operating only through the wound, mistakes are more common and the full extent of the injury might not be realized. The wound should be extended proximally and distally as needed. The wound is then irrigated and debrided, and an inventory is made of all damaged structures. In general, sharp injuries are more easily managed, as the zone of injury is quite narrow. More difficult are crushing and avulsion injuries or those caused by a cutting tool with a wide kerf. In these cases, it is essential to fully resect the traumatized segment of the vessel(s) back to healthy-appearing adventitia and intima. In many such cases, reversed vein grafts will be needed for vascular reconstruction. The anastomoses must not be under any tension whatsoever with the hand and fingers in extension. One must avoid the temptation of artificially gaining length of the artery by flexing the involved part. When vein grafts are needed, the inner forearm usually provides veins of reasonable size match (Fig. 34-6).
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mass involved in these type of injuries, the tolerable ischemia time is less. Three hours of warm ischemia and 8 to 10 hours of cold ischemia are the generally accepted limits.18 For macroreplantations, the amputated part can be gently flushed with a cold, heparinized solution to flush the toxic by-products of muscle ischemia from the amputated part. If the patient arrives in the operating room more than 3 or 4 hours after the injury, it is best to reperfuse the amputated part by the use of a temporary shunt. Fasciotomies should be performed in virtually all cases to reduce the risk of a reperfusion compartment syndrome. In children, osteosynthesis can more likely result in epiphyseal injury. Consideration should be given to fracture stabilization with external fixators when use of plate and screws or Kirschner wires might damage a nearby growth plate(s). Once osteosynthesis has been obtained, the next step is to repair all deep structures, which would otherwise be too difficult to perform after the vessel repair. When vein grafts are needed, the greater and lesser saphenous veins are good donor sites. With macroreplantations, if there are problems with the arterial anastomosis, a small Fogarty catheter can be used very cautiously on larger vessels to retrieve any clots and produce some vasodilatation. Soft tissue coverage can be more difficult with large-segment replantations. In some cases, microvascular free tissue
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A
B
C D
FIGURE 34-6. A, A 15-year-old boy with a diffuse crushing and devascularizing injury of the right hand, wrist, and forearm. B, After debridement. C, Two long vein grafts from the radial and ulnar arteries to the common digital arteries. D, The revascularized hand placed in a groin flap. E, After groin flap division. E
POSTOPERATIVE CARE After surgery, the child must be kept warm and as pain-free as possible. Young children can be uncooperative in the postoperative period. Pain, restlessness, and struggling and a cool ambient temperature will contribute to arterial spasm. Analgesics, sedation, and parental involvement will help in keeping the child comfortable and calm, which can alleviate spasms. In most cases, the child is monitored in an intensive care
unit for the first 24 hours, as this allows for easier room warming, hourly assessment of the revascularized or replanted part, and accurate assessment of the patient’s hemodynamic status. Adequate hydration is important for replant survival. Several methods are available for monitoring the replanted or revascularized part. The commonest are Doppler ultrasound, temperature probes, and pulse oximetry. Pulse oximeter probes offer the advantage of ease of use and reliability. In addition, Doppler monitoring of the part is performed hourly.
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nonunion. For macroreplantations, several procedures have been used to optimize function. These include skeletal distraction lengthening, tendon lengthening, and tendon transfers, depending on the requirements in each individual case.18
All patients are started on daily low-dose aspirin for an antiplatelet effect (3 to 5 mg/kg/day). Use of lowmolecular-weight dextran, typically started intraoperatively, for several days after the surgery is controversial; however, depending on the surgeon’s preferences and difficulty with the operative repair, its use is reasonable. Heparin is rarely needed as an adjunct to the initial surgical procedure unless there has been a very distal amputation with very small vessels, especially in a crush and avulsion type of injury. Splint immobilization is important for both postoperative pain control and to protect the operative site. In most cases, it must be a long-arm splint that is sufficiently bulky to completely immobilize the entire extremity yet allow for vascular monitoring. The patient’s hemodynamic status must be monitored carefully. The hematocrit should be maintained in the high 20s. The potential need for transfusion continues to exist in the postoperative period. This is especially true in cases in which there is “planned” venous bleeding, such as when an artery-only repair is performed, or if chemical leeching or actual leeches are used to salvage a replanted part.
As with any surgery, the possible complications of infection, bleeding, and scarring exist. The main issues of concern, however, relate to function of the injured part. Whenever there is tendon, bone, or joint involvement, there exists the possibility of loss of motion due to scarring, and secondary surgery is often needed. As a rule, children fare better in regard to tendon scarring than adults do. Of particular concern is the effect on open growth plates. Rarely is there complete growth plate arrest, but it is generally agreed that growth rate will be impaired when the revascularized or replanted part is compared to the contralateral part.24 There have, however, been reports of bony overgrowth.
REVISION SURGERY
RESULTS
Early Any detectable change in the perfusion of the revascularized or replanted part must be investigated. In some cases, it can be due to vasoconstriction from pain and/or cooling. Also, care should be taken to ensure that the dressing and/or skin closure is not too tight. Any change that is not reversible after attending to these possible causes warrants a return to the operating room. A cool, white appearance will indicate an arterial anastomosis problem, whereas a congested, blue appearance will indicate a venous anastomosis problem. In either case, the anastomosis (or anastomoses) will need to be revised. In some cases, when there is an identifiable technical problem with the anastomosis, a straightforward revision of the anastomosis is all that is required. If tension on the anastomosis is thought to be a problem, then a reversed vein graft(s) will be necessary. It is in revision surgery that heparinization is usually instituted. If the initial skin closure was too tight, then tension-free soft tissue coverage should be obtained.
Late Late revision surgery is often necessary to correct functional problems. The most common procedure is lysis of tendon adhesions. Other procedures might be necessary owing to late infection or osteomyelitis, malunion, or
COMPLICATIONS
Survival rates are higher after revascularization than after replantation. In one series published by Yildiz et al.,24 the overall survival rate was 94.6% after revascularization and 84.6% after replantation. Another series, by Sailes et al.,19 reported overall survival rates of 88% after revascularization and 63% after replantation. One possible explanation for the discrepancy in survival rates in these two series is that all operations in Yildiz et al.’s series were performed between 1990 and 1995, whereas in Sailes et al.’s series, the procedures were performed earlier, between 1974 and 1988. Sensibility results are better than functional results, with two-point discrimination less than 10 mm in more than 80% of patients who sustained amputations in Sailes et al.’s series.19 The mechanism of injury is the most important factor affecting survival rates, and the level of injury is the main factor affecting functional outcome.19 The best functional result can be expected with Level I injuries. In general, with small children, the more distal the injury, the lower the success rate, because of technical considerations. Revascularization and replantation have higher success rates when there has been a sharp injury. This is because the zone of injury is much narrower, resulting in less tissue damage and less intimal damage to the vessels.19 The growth rate of the revascularized or replanted part can be expected to be approximately 85% that of the contralateral part.24 There are few series of macroreplantations in the literature. Raimondi et al. reported a 100% survival in nine macroreplantations.18
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Their functional results varied depending on the mechanism of injury, the results in proximal and/or avulsion injuries being worse. There is no universally accepted scoring system for outcome assessment in children with amputation injuries. Chen and Yu established criteria for functional outcome in adults.5 They evaluated four variables: (1) return to work status, (2) range of motion of the joint, (3) recovery of sensation, and (4) recovery of strength. In their series of 243 upper-extremity replantations, at 3 years, 38% had grade I recovery (resumption of previous work, 60% range of motion, complete or nearcomplete sensory recovery, grade 4 to 5 strength), 37% had grade II recovery (resumption of some work, 40% range of motion, near-complete sensory recovery, grade 3 to 4 strength), 28% had grade III recovery (activities of daily living, 30% range of motion, partial recovery of sensation, grade 3 strength), and 3% had grade IV (almost no function). The functional outcome in children will generally be better than that in adults.23 Ikeda et al.8 reported long-term follow-up results in 14 children with a total of 17 digit replantations using Tamai’s functional criteria.22 Tamai’s method is a 100point system as follows: range of motion (40 points), activities of daily living (10 points), sensation (20 points), subjective symptoms (10 points), and patient satisfaction (10 points). The point range in Ikeda et al.’s series was 73 to 100 (average: 87), with excellent results (above 80) in 12 cases and good results (above 60) in one case. They concluded that their very good results were due in large part to the ability of children to recover sensation after nerve repair. Indeed, recovery of sensation in their patients was excellent, with two-point discrimination of 3 mm or less in 13 digits and 5 mm in one digit. The expected results in children can be summarized as follows:25 1. Two-point discrimination in replanted digits will be 5 mm or better in more than 50% of patients. 2. Nerve recovery for motor and sensory recovery should be comparable to that for repair of an isolated peripheral nerve. 3. For joints involved in, or in close proximity to, the zone of injury, active range of motion will be 50% of normal. 4. Cold intolerance can be expected but subsides within 2 years and never persists in children. 5. The growth potential depends on several factors, including injury and vascularity of the physis. Direct injury to the physis will almost always result in some growth disturbance. Near-normal growth may be expected with middiaphyseal injuries.
6. The cosmetic result after replantation is usually better than any type of completion amputation, reconstructive procedure, or prosthesis.
CONCLUSION Revascularization and replantation should be attempted in all children who present with such injuries. Such surgery is technically more demanding than similar surgery in adults, but improvements in optics, instruments, and suture material have made it feasible. The only contraindications are when there are associated life-threatening injuries or when the amputated part itself is not salvageable owing to a multilevel or mangling injury. Functional and cosmetic results are superior in comparison to those of completion amputation, but secondary surgery is sometimes needed to obtain the optimal result.
References 1. Buncke GM, Buncke HJ, Kind GM, Buntic R: Replantation. In Coleman JJ (ed): Hand Surgery, vol. 4: Plastic Surgery: Indications, Operations, and Outcomes. St. Louis, Mosby, 2000, pp 2131–2147. 2. Buncke HJ, Schulz WP: Experimental digital amputation and replantation. Plast Reconstr Surg 36:62, 1965. 3. Carey LA, Weiss AP, Weiland AJ: Quantifying the effect of ischemia on epiphyseal growth in an extremity replant model. J Hand Surg 15(4):625–630, 1990. 4. Carrel A, Guthrie CC: Results of replantation of a thigh. Science 23:393, 1906. 5. Chen ZW, Yu HL: Current procedures in China on replantation of severed limbs and digits. Clin Orthop 215:15, 1987. 6. Dautel G: Fingertip replantation in children. Hand Clin 16(4):541–546, 2000. 7. Harris G, Finseth F, Buncke HJ: Posterior wall first technique in microsurgery. Br J Plast Surg 34:47, 1981. 8. Ikeda K, Yamauchi S, Hashimoto F, Tomita K, Yoshimura M: Digital replantation in children: A long-term follow-up study. Microsurgery 11:261–264, 1990. 9. Kleinert HE, Kasdan ML, Romero JL: Small blood vessel anastomosis for salvage of severely injured upper extremity. J Bone Joint Surg 45A:788, 1963. 10. Komatsu S, Tamai S: Successful replantation of a completely cut off thumb: Case report. Plast Reconstr Surg 42: 374, 1968. 11. Lendvay PG: Replacement of the amputation digit. Br J Plast. Surg 26:398, 1973. 12. Malt RA, McKhann C: Replantation of severed arms. JAMA 189:716, 1964. 13. Massachusetts Hospital Discharge Database. Boston, Division of Health Care Finance and Policy, 2001. 14. Matsuno T, Ishida O, Arihiro K, Sunagawa T, Mori N, Ikuta U: Cell proliferation and death of growth plate
15. 16.
17.
18. 19.
chondrocyte caused by ischemia and reperfusion. Microsurgery 21(1):30–36, 2001. Merle M, Dautel G: Advances in digital replantation. Clin Plast Surg 24(1):87–105, 1997. Murphy JB: Resection of arteries and veins injured in continuity: End-to-end suture—Experimental and clinical research. Med Rec 51:73, 1987. McC O’Brien B, Franklin JD, Morrison WA, Macleod AM: Replantation and revascularization surgery in children. The Hand 12(1):12–24, 1980. Raimondi PL, Petrolati M, Delaria G: Replantation of large segments in children. Hand Clin 16(4):547–561, 2000. Sailes AD, Urbaniak JR, Nunley JA, Taras JS, Goldner RD, Fitch RD: Results after replantation and revascularization in the upper extremity in children. J Bone Joint Surg 76A(12):1766–1776, 1994.
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20. Sixth People’s Hospital, Shanghai. Reattachment of traumatic amputations: A summing up of experience. Chin Med J 1:392–401, 1967. 21. Stark RH, Matloub HS, Sanger JR, Cohen EB, Lynch K: Warm ischemic damage to the epiphyseal growth plate: A rabbit model. J Hand Surg Am 12(1):54–61, 1987. 22. Tamai S: Twenty years’ experience of limb replantation: Review of 293 upper extremity replants. J Hand Surg 7:549–556, 1982. 23. Taras JS, Nunley JA, Urbaniak JR, Goldner RD, Fitch RD: Replantation in children. Microsurgery 12:216–220, 1991. 24. Yildiz M, Sener M, Baki C: Replantation in children. Microsurgery 18:410–413, 1998. 25. Urbaniak JR: Replantation in children. In Serafom D, Georgiade NG (eds): Pediatric Plastic Surgery, vol 2. St. Louis, Mosby, 1984.
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35 Reconstruction of the Pediatric Mutilated Hand Robert Hagan, MD Joseph Upton, MD
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Mutilating hand injuries in children present challenging problems with potentially devastating implications, proving to be emotionally taxing and labor intensive for both the family and the entire medical team. The long-term outcomes of these extreme injuries are often altered by growth and, with few exceptions, require secondary procedures and major life adjustments on the part of the patient and his or her family. Surgeons often use the terms mutilated or mangled to vividly describe severe injuries to the extremities. Webster’s dictionary defines mutilate as “to cut off or permanently destroy a limb or essential part” and mangle as “to be injured with deep disorganizing wounds by cutting, tearing, or crushing.” Even with these definitions, it is difficult to determine precise guidelines for diagnosis and treatment owing to the tremendous variability in the mechanism of the injury, zone of the injury, and age of the child. Fortunately, these injuries are rare; but when they do occur, the potential consequences can be much more complex than might be the case for an adult patient. Often, the expectations of a given child and, more directly, the family vary in relation to the child’s age, talents, interests, values, and aspirations. Regardless, in all severe pediatric mutilating injuries, a well-planned strategy should be formulated as soon as possible. Preoperative preparation includes clearly defining goals, careful consideration of alternatives for treatment, and thorough discussion with the patient (if older than 5 years of age) and the patient’s family. This will help to alleviate further emotional trauma to the child and discourage fantasies about the doctor returning the hand or limb to its original, uninjured appearance and function. Our objective in this chapter is not to restate well-documented principles for the treatment of individual tissue injuries, which are outlined elsewhere in this book, but to discuss the management differences and various caveats involved in these complex pediatric injuries. The basic principles of management of the individual injuries are much the same as those for adults, but pediatric extremity surgeons can often rely heavily on the superior healing potential and tremendous functional reserves of young patients.
DIFFERENCES IN CHILDREN Perhaps the single most important step in the treatment of children is to realize that they are not miniature adults (see Table 35-1). In many ways, this works to the surgeon’s advantage: Children are not smokers or alcohol abusers, they do not have arteriosclerosis or a list of at 485
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TABLE 35-1
Differences in Treating the Pediatric Patient
270 260
Children are not adults in miniature and have: Few, if any, associated diseases
250
Superior wound healing Superior skeletal healing, few nonunions More predictable neural regeneration Faster total recovery and rehabilitation Unexpected favorable recoveries Continued improvement with growth
Mean score
Normal anatomy and healthy vessels 240 230 220 210 0 Native
Nerve Injuries Children with peripheral nerve injuries generally have better motor and sensory recovery than adults. Often, amazing recoveries defy clear-cut scientific explanations (Figs. 35-1 and 35-2). The most important determinant of good long-term functional capacity in a salvaged portion of a limb is intact protective sensation. In a child, an insensate hand, digit, or thumb is not likely to be used. Worse yet, children often accidentally or absentmindedly injure these insensate parts.1,22 Therefore, the realistic potential of a sensory recovery is the prime consideration before any attempted salvage of an amputated or mangled part or limb. Although numerous clinical studies document the fact that children achieve better outcomes after peripheral nerve repairs, there are no definitive studies determining why this happens.11,16,23 These improved results seem to be based on both central and peripheral mechanisms. As early as 1962, Onne reported that recovery of sensation was inversely proportional to a patient’s age.16 It has since been shown in animal models that after peripheral nerve injury, there is a reorganization of cortical representation of the involved area of denervated skin.8,14,15 More recently, the notion of critical
8 –10 11–15 17– 22 Age of arrival (years)
23 – 28 31– 39
FIGURE 35-1. Curve indicating how the scores of immigrants on a grammar test decline with the age at which they started to learn to speak the English language. (Reproduced with permission. Barinaga M: Neuroscience: A critical issue for the brain. Science 288:2116–2119, 2000.)
periods has come to the fore. In a very interesting study, Lundborg et al. showed that the recovery of functional sensibility and the ability to acquire a second language follow a similar pattern (Fig. 35-3).13 This
= one patient Normal 1
0.8 Mean score tactile gnosis
least 20 other comorbidities, and they do not have occupations or interests that make them vulnerable to serious injuries. Their overall anatomy is usually undisturbed by previous surgeries, and their soft tissues, bones, and joints are generally all healthy. Children are known to have a superior capacity for wound healing, fracture healing, and nerve regeneration. Furthermore, they possess an amazing ability to adapt to the long-term effects of severe injuries. Therefore, it is not that we treat the individual tissue injuries so differently but that we are able to achieve better outcomes, given these various advantages.
3 –7
0.6
0.4
0.2
0 <10
11–15 16–20 21–25 26–30 31–35 36–40 >40 Age at surgery (years)
FIGURE 35-2. Mean recovery of tactile gnosis in 54 patients at least 2 years after injury and repair of major nerves of the forearm. There is a remarkable similarity to the slope of the curve in Figure 35-1. (Reproduced with permission from Lundborg G: Sensory relearning after nerve repair. Lancet 358: Issue 9284, Sept 2001, pp 809–810.)
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487
FIGURE 35-3. Multilevel propeller injury. A, This 7-year-old presented with a multilevel powerboat propeller injury with no arterial flow to the hand and no sensation in the ulnar nerve distribution. The propeller had lacerated the forearm and hand at eight levels. B, The lateral radiograph shows an oblique and comminuted fracture of the distal humerus and fractures of the middle and proximal thirds of the ulna and radius. Not obvious is a complete dislocation of the elbow. C, Initial debridement included fasciotomies of all muscle compartments, excision of all nonviable tissue, and revascularization of the brachial artery directly over the site of elbow dislocation and ulnar nerve severance. Five days later, the ulnar nerve was transposed anteriorly, and the medial collateral ligament of the elbow was reconstructed with an autogenous tendon. D, The postoperative radiograph shows anatomic reduction and relocation of the elbow joint. E, The ulnar nerve was repaired 5 days later when the open wounds were skin grafted. F, Within 1 year, the patient had regained sensation in the ulnar nerve and intrinsic muscle function of the hand. Extrinsic flexors to the thumb and all digits were functional but weak. There was a remarkable amount of wound contracture. Continued
35
35
488
THE MUTILATED HAND
FIGURE 35-3 cont’d. G, At this time, the flaps were reelevated, advanced, and closed, allowing excision of all but a small area of grafted skin. The elbow range of motion was normal. H, The appearance at the time of closure. The boy is now 18 months postoperation with normal ulnar sensation and wrist and hand extension. His father reports that “he can do handstands.”
concept—that children learn faster and more effectively than adults—is supported by much of the current literature on complex cortical reorganization after these injuries.6,7,15,17 One of the more common effects of a peripheral nerve repair in a child involves the misdirected regeneration of axons. If the ends of the severed nerve are not perfectly oriented at the fascicular level during the repair, then motor and sensory components can become misaligned, causing reinnervation to incorrect portions of the hand. This results in a functional remodeling of projectional areas of the hand within the somatosensory brain cortex.13 Since children have a greater capacity for cerebral compliance (or “plasticity”), they rapidly adjust to these mixed signals from the periphery and may integrate these signals into normal patterns. This will not occur in adults, whose central computer (brain) seems to be permanently programmed. Peripherally, there are several factors to consider in children. First, the microanatomy of the maturing nerve differs from that of the adult. In a cross-sectional view, axonal tissue represents 80% of the area in the child’s nerve, compared to 60% in the adult’s. This improves the odds of axonal alignment during and following surgical repair, offering a potential reduction in scar tissue and a potential increase in axonal penetration. Second, following nerve severance in a child, there is an immediate bulging of axonal tissue from
within individual fascicles. This is due to increased axonal pressure and better axoplasmic flow, both of which aid regeneration. Finally, in addition to these biological factors, a functional recovery is faster owing to the simple fact that in a smaller limb, there is less distance for the nerve to travel from the site of injury to the fingertip.2 The immature nervous system also benefits from a reduced amount of overall pain and fewer pain syndromes when compared to that of an adult. Often, cases of complete division are unaccompanied by pain, and, logically, partial nerve injuries are more likely to be painful. It is difficult to say how this truth applies to the mutilated injury in the acute phase, but it certainly has benefits in the long term. Cases of reflex sympathetic dystrophy or central mediated pain disorders do occur in children but are very infrequent. Because these young patients do not usually complain, any persistent pain should be taken seriously and signals the need for a complete workup to identify the cause. Severely mutilated upper extremities often contain open wounds at many levels. These are difficult to examine in the emergency room and are best assessed in the operating room with the patient asleep. However, one can determine the presence or absence of sensation on initial examination if the child is awake and cooperative. Appropriate radiographs and photographs are invaluable for later planning and reconstruction. The
initial debridement of soft tissue should be aggressive and accompanied by immediate skeletal fixation and soft tissue coverage. Severed nerves should be repaired without tension, and all nerves in continuity should be left untouched and covered with well-vascularized tissue. If there is no recovery, then a secondary procedure will be necessary at another stage. Later signs of nerve injury include thinning of the skin, atrophy of the digits, wasting in the hand, ulcerations, nonhealing wounds, stiffness, joint contractures, and growth disturbances. All of these signs can be helpful in identifying missed injuries or failed repairs. As with fractures, growth disturbances are seen in denervated parts and can cause up to a 30% difference in skeletal length. Unlike the case in the lower extremity, this inconsistency is very well tolerated.
Skeletal Injuries and Growth One should never overlook the importance of secure skeletal fixation in these devastating injuries. The popular surgical myth that “children always do better” should not be mistaken for permission to become more lax with regard to pediatric fractures. Current standards adhere to strict principles of rigid fixation, and residual deformities are unacceptable in children with isolated fractures. Mutilating injuries with crushing and avulsion at multiple levels usually contain open, comminuted fracture fragments that require anatomic reduction (Fig. 35-3). The periosteum in children is very thick and should be viewed as the surgeon’s friend in the form of a vascularized bone graft. Large or small bone fragments firmly attached to vascularized periosteum should be retained and minimally manipulated or stripped. Damage to the growth centers will inevitably have long-term functional and aesthetic sequelae that might not be appreciated until long after the fracture has healed. Follow-up examination and radiographs in the early postoperative period are absolutely necessary to determine any changes. Repeat radiographs should be obtained at periodic intervals until the child has reached skeletal maturity. Intra-articular fractures should be reduced in a manner that does not injure the physis. Any “step-off” of alignment of the joint surface will ultimately result in some degree of arthritis. Anatomic reduction should be the rule. Children have been noted to heal from fractures twice as quickly as adults do; however, malunions are the most common complication of the hands in children. Nonunions and joint stiffness are more common in adults.
RECONSTRUCTION OF THE PEDIATRIC MUTILATED HAND
489
In children, some deformities will improve with growth. Angulation of a digit, forearm, or arm in the flexion-extension (anterior-posterior) plane can be expected to improve or “remodel” more than that in the radioulnar (medial-lateral) plane. In addition, angulation and rotational deformities that are acquired earlier in life can be expected to correct more than those that occur at time closer to skeletal maturity because there is more expected growth.
MANAGEMENT If the extremity injury does not have a high priority compared to other, more life-threatening injuries, then adequate temporary dressing and immobilization must be done, and further care should be coordinated with the primary trauma team (see Table 35-2). The perfusion of the injured part must be determined and maintained if there is a waiting period between injury and repair. There is no bleeding in the upper limb that cannot be temporarily controlled with elevation and a direct pressure dressing. Excessive blind probing for bleeders within a bloody wound should be discouraged because of potential injury to neurovascular structures. However, brisk bleeding proximal to the brachial artery requires immediate attention and temporary clamping to prevent exsanguination. As always, the history and physical examination are very important to the initial evaluation, as these injuries may be caused by many different mechanisms. In children, crush and/or avulsion injuries (e.g., from animal bites, lawnmowers, or blasts from fireworks), crush injuries (e.g., from door slams, folding chairs, or falling objects), and sharp (glass) injuries are more common than the contaminated farm and industrial, high-energy explosion, and motor vehicle injuries that are seen in adults. Fortunately, children do not normally play with skill saws, the most common source of severe
TABLE 35-2
Principles of Management
Initial resuscitation of patient and control of bleeding Radiographs (anteroposterior and lateral) of injured limb Assess degree of contamination and tissue injury/loss Preoperative planning: debridement, coverage, and reconstruction Debridement Coverage Secondary reconstruction
35
35
490
THE MUTILATED HAND
upper-limb injury in adults living in both suburban and rural communities. The initial quick assessment must also rule out a compartment syndrome, which will require an immediate release. Once the child is stabilized physiologically, the initial priority for the reconstructive surgeon is to establish a clear understanding of the composite nature of the injuries. This starts with a thorough physical examination, which can be difficult if not impossible in an awake pediatric patient. If possible, information regarding sensation should be obtained immediately. In more mature patients with complex open wounds, light touch and two-point discrimination should be tested to identify specific nerve lacerations. However, in younger patients, a great deal of information about the residual function of the hand can be obtained by simple observation. In many cases, this may be all the examination you are able to complete before anesthesia is induced. Once the child has been anesthetized, a systematic evaluation of each tissue (skin, muscle, nerve, tendon, vessel, bone and joint) within the injured portion of the extremity should be completed. The overall sequence for treating extremity trauma is debridement, fixation, revascularization, soft tissue coverage, and functional reconstruction. If a child has sustained an amputation and the structure remains viable, it should be reattached.18 A thorough debridement of all nonviable tissue, using caution with regard to the nerves, may require more than one trip to the operating room. This process should be accompanied by accurate fixation of all fractures, revascularization of injured vessels and parts, and repair of musculotendinous injuries. The nerves should be repaired at this time only if they will not be disturbed by sequential debridements. When the entire flexor or extensor muscle compartments of the forearm have been lost, it is important to identify proximal motor nerves and either mark them with clips or wrap them with a colored sheet. They might be useful later as recipient nerves for free muscle transfers. After the acute reconstruction has been completed, one should proceed immediately to soft tissue coverage. The importance of this stage, especially of soft supple tissue coverage, is often overlooked. Many wounds in children can be covered with a simple skin graft and, given the elastic capabilities of their integument, can later be serially excised at the time of secondary reconstructive procedures. If the wound demands tissue transfer, then local flaps, pedicle flaps, or free tissue transfers can be utilized; these are discussed in following sections. After attaining good, soft, supple tissue coverage, one can move on to definitive functional reconstruction such as tendon transfers or grafts.
REPLANTATION AND REVASCULARIZATION The most commonly cited textbooks of hand surgery and reports in refereed journals insist that all pediatric amputations should be reattached. This is not true! Careful attention must be given to each individual case, understanding the factors previously discussed, especially those of nerve regeneration (Figs. 35-4 and 35-5). We have seen many failed digital and limb reattachments that were doomed from the outset, primarily from gross contamination, extensive crushing or avulsion injuries, or multilevel injury (Fig. 35-6). Keeping that caveat in mind, there is no question that the indications for reattachment can be extended in this age group. Again, the likelihood of good neural regeneration has been the single most important point to assess in these difficult cases (Figs. 35-7 to 35-10). Of course, judicious consideration of all other contributing factors must be given to each child, and a good surgeon must not be forced to acquiesce to parental pressures when the outcome of a successful revascularization is hopeless. Yet whenever we have been in doubt in regard to a successful outcome, we have always taken the amputated part and patient to the operating room for a careful inspection of both amputated and recipient parts before making a determination. The initial consultation with the parents and family of a child with a mangled limb can be very challenging for anyone, especially younger surgeons with limited experience. The help and advice of older microsurgeons who are more experienced with these delicate discussions should be sought whenever possible.
PEDICLE FLAPS Pedicle flaps, though not always considered in children, have stood the test of time and should not be overlooked (see Table 35-3). They are excellent sources of abundant, supple soft tissue. If properly designed, pedicle flaps result in very little donor site morbidity and are generally tolerated well by these young patients. In most cases, they will provide a better result than free tissue transfer (Figs. 35-11 to 35-13). Once the surgeon has identified the flap of choice, it is important to determine whether tissue expansion of the donor site is required (Fig. 35-14). Always be sure to measure the flap with the child in both the standing and supine positions. The most common cause of failure of these flaps is poor design related to insufficient fixation that was determined with the patient in the supine position only (under a general anesthetic). If there is any doubt about whether enough tissue is available, then expansion—usually in
35
RECONSTRUCTION OF THE PEDIATRIC MUTILATED HAND
491
FIGURE 35-4. Four-digit amputation. A, This old Ektachrome slide shows the initial appearance of a 12-year-old boy whose four fingers had been cleanly amputated. His central two fingers had been amputated at the level of the middle phalanx of the central two fingers; the index and little fingers had been lost distal to the distal interphalangeal joints. The central two fingers were reattached, and thenar and hypothenar flaps were used to resurface the pulp loss of the border fingers. B, Flexion of the four fingers is seen 24 years later. C, The palmar aspect of all four fingers can be appreciated with close-up views. The new whorl patterns on the index and little finger pulp surfaces are of course reflective of the palmar donor sites. Two-point discrimination in this “like tissue” was 3.0 mm.
Index
the thorax, flank, or groin region—is worthwhile. Overcorrection is advised, as it is much easier to eliminate excess tissue than to add more. Prior to flap transfer and inset, all nonviable and infected soft tissue should be excised. Large bone fragments, especially those with firm periosteal attachment, should be replaced. All scar tissue in acute or chronic wounds is preferably excised at the time of definitive coverage with either skin grafts or flaps. The ideal replacement is, of course, similar full-thickness, supple tissue with the same characteristics as the recipient site. Often, it is best to cover a wound temporarily with a skin graft or other biological dressing and to provide full-thickness coverage when infection and secondary contracture have been minimized. After a closed system inset with a pedicle flap has been completed, half the battle has been won. Now immobilization of repair is the key to the postoperative course. At this point, parental commitment to managing the child is paramount. If the child becomes too active
or too frustrated, the surgeon’s hard work can be undone in moments. To secure and dress the wound, we use several layers of a gauze roll, followed by absorbent padding, foam tape, and, finally, an ace wrap that immobilizes the arm in a comfortable position against the chest wall. At 2 and 3 weeks post-transfer, appropriate delays are completed, and the flap is detached and inset 4 weeks after the original transfer. At this time, the parents usually express a great sigh of relief.
PEDIATRIC MICROSURGERY Microvascular surgery in the pediatric patient can be both the most rewarding and the most challenging aspect of reconstructive surgery (see Figs. 35-10 to 35-12). With more refined equipment, a better understanding of anatomy and tissue physiology, and improved anesthesia methods and medications, microvascular surgery has
35
Little
492
THE MUTILATED HAND
FIGURE 35-5. Hand amputation. A, The dominant hand of this child with Down syndrome was amputated when he was trying to split wood with a hydraulic log splitter. Fractures were present at the level of the proximal carpal row. B, Removal of all the carpal bones within the proximal row permitted sufficient shortening, tension-free vascular anastomoses, and neural coaptations. Dorsal and palmar capsules were repaired, and pins were removed at 4 weeks. C, D, Twenty years later, the patient maintained excellent wrist and digital motion. Two-point discrimination in median and ulnar nerve distributions was 4 mm. Grip strength was equal to the opposite hand. This case represents the ideal situation for a major hand reattachment in a young child or adolescent.
D.
become a more dependable treatment option for children.3–5,9,10,12,18–21,24–27 Nevertheless, many excellent surgeons who are proficient in hand surgery are uncomfortable with the level of difficulty and the size of pediatric patient’s vessels and flaps. However, “vessels are only as small as you think,” and outstanding surgeons will discover that careful technique can yield more rewarding results in children, given their great capacity to heal and recover. Microsurgery in the pediatric patient has several benefits. First, it expands the palette from which donor tissues can be selected, increasing the ability to replace like with like tissue and minimizing donor site scars. This is especially valuable in complex mutilation injuries, which often require more than one type of tissue to complete the reconstruction. Second, these vas-
cularized units bring with them the potential of growth that most traditional grafts lack. This is especially important for reconstructions involving joints or large segmental bone loss. Third, one free tissue transfer can help to reduce the number of staged procedures required. When attempting free tissue transfer in the pediatric patient, the following general principles should be considered. The surgical design should, as always, replace like with like tissue and use expendable donor sites that minimize the loss of function elsewhere. Donor scars should be hidden when possible and are best tolerated on the back and abdomen with closures completed in flexion creases if possible. The amount of tissue required should not be underestimated in children, who need plenty of tissue to accommodate for growth. In
35
A.
RECONSTRUCTION OF THE PEDIATRIC MUTILATED HAND
B.
493
C.
FIGURE 35-6. Unsuccessful thumb reattachment. A, B, The nondominant left thumb of this child became caught and entangled within an industrial press, which her father was operating. The crush avulsion injury included soft tissue injuries at multiple levels and many comminuted fractures of the phalanges. The thumb remained attached only by the flexor tendon and a portion of the extensor tendons. The reattachment effort in this child lasted 14 hours and included multiple autogenous vein grafts followed by poor venous outflow. C, A nonviable thumb is seen 14 days later, at which time the thumb was debrided and the defect was covered with a groin flap. In retrospect, this should have been the primary procedure.
B.
35
A.
FIGURE 35-7. Crushed digit revascularization. A, Not all severe fingertip injuries are hopeless, even in this 14-month-old baby. This distal fingertip appeared nonviable following a door slam crushing injury. Both digital arteries were lacerated and repaired after dilatation to a 0.4-mm diameter. Two dorsal veins were repaired. The distal interphalangeal joint was reduced and held with a K-wire. The open pulp was covered with a hypothenar skin graft. B, Eight years later, a small scar is present, and the graft not distinctly recognizable. The nail plate is smaller and has a slightly slower growth rate than that of the contralateral little finger.
494
THE MUTILATED HAND
A.
B.
E.
F.
C.
G.
D.
H.
FIGURE 35-8. Distal thumb revascularization. A, This teenager sustained bilateral thumb avulsion injuries in a junior high school shop class. His dominant right thumb is seen here dislocated at the interphalangeal joint and attached only by both digital nerves. The opposite thumb was amputated at the level of the eponychial fold and resurfaced with a crossfinger flap. The revascularization was accomplished with two vein grafts extending from the midportion of the proximal phalanx to the level of the tuft of the distal phalanx. The lumen of the distal artery was 0.3 mm in diameter. B, Brisk bleeding is seen at the end of the procedure. Two dorsal veins were anastomosed. C, Macerated but viable, edematous skin is seen at the first dressing change 12 days later. D, One week later, that midlateral incision is beginning to close. E, Four months later, the thumb is thin and stiff. The patient had been wearing Coban religiously. F, Six months later, with return of sensation, the tissue turgor is improved. G, A two-staged flexor tendon reconstruction was completed 14 months postinjury; it was not initiated until full passive range of motion had been obtained. H, The patient has maintained 180° of extension and 50° of interphalangeal joint flexion 2 years later.
addition, the configuration of the flap inset should not cross perpendicular to a flexion crease of the elbow, wrist, or digit where scar can result in flexion contractures on the volar surfaces. Tight circular insets and scars will also cause unnecessary flap redundancies or “biscuiting.”
A proper setup, the key to a smooth surgery, starts with precise positioning of the patient and wide exposure and draping, which allow for intraoperative alterations. All tissues from the donor and recipient sites must be meticulously dissected under tourniquet control whenever possible, and all-important anatomic
35
B.
D.
495
C.
E.
FIGURE 35-9. Incomplete hand amputation and a missing part. A, This teenaged boy’s left hand was dislocated at the carpal level and devascularized following a water skiing towrope accident during which the rope of the accelerating boat became wrapped around his wrist. The thumb was amputated at the interphalangeal joint level. B, The hand had no sensation and absent capillary refill. Bleeding from the lacerated radial and ulnar arteries had been controlled with direct pressure and elevation of the extremity. The flexor tendons were intact. C, The radial and ulnar vessels were reconstructed with vein grafts, and the ragged nerves were reapproximated directly. The lumbrical and interosseous muscles were excised owing to the prolonged warm ischemia time. Despite the vigorous attempts of skin divers to locate the missing thumb, the amputated part could not be found. D, E, The soft tissue deficit of the palmar wrist and distal forearm was covered 13 days later with a free scapular flap. The patient did not desire any thumb lengthening or reconstruction and went on to become an outstanding hockey and lacrosse player in high school and college, where he competed at the varsity level. He is now 32 years old and reports normal sensation and no disability in his left hand.
35
A.
RECONSTRUCTION OF THE PEDIATRIC MUTILATED HAND
FIGURE 35-10. Multiple areas covered with one flap. A, A live grenade exploded in the midpalm of this 10-year-old boy. The entire pulp of the thumb, index, and middle fingers was lost. B, The thumb was completely dislocated at the carpometacarpal joint level, and the adductor and flexor pollicis muscles were lost. C, The composite tissue losses are seen following three debridements performed at 48-hour intervals. The index and middle fingers have been temporarily syndactylized. D, The bilobed scapular fasciocutaneous free flap was designed to resurface the first webspace, thumb pulp, and palmar surface of the index and middle digits. The dorsal inset is seen. E, The flap has been revascularized and inset. F, Following detachment, the new coverage is bulky and floppy. All three areas were debulked during the next 18 months. G, The same hand is seen 21 years later with no revisions. The patient attended West Point and had a very successful military career with no partial disability. Moving two-point discrimination in all flap areas was 7 to 8 mm. H, The patient maintained full metacarpophalangeal and proximal interphalangeal motion of the digits. The thumb has been stable at all levels.
496
35
Technical Caveats: Pedicle Flaps
Excellent option(s) for coverage, often not even considered Design flap with child in standing and supine position Mini-flap(s) ⫽ mini-result Skin expansion in thorax, flank, or groin region valuable Excision of all scar tissue Overcorrection necessary to accommodate for growth Immobilization is key to success Parental commitment vital Pedicle flaps will not “burn any bridges”
neurovascular structures must be identified. This is particularly important given that the patients might be quite small. Keep in mind that very few children have comorbidities that affect their vessels, and spasm is more likely
A.
497
secondary to imprecise dissection or dissection within a bloody field. Meticulous control of potential bleeders with both bipolar and hand-held battery cauteries is very helpful. When outlining the periphery and pedicle of the flap, always measure twice, add more, and then cut (see Figs. 35-13 to 35-15). During the elevation of free-tissue transfers, a bloodless dissection of the pedicle should progress as proximally as possible for the exposure and use of larger vessels. This simple maneuver converts the procedure from a micro (less than 1.0 mm) level to a more predictable macro (greater than 1.0 mm) level. Under the operating microscope, both surgeons should be in a comfortable position before attempting vascular anastomoses or nerve coaptations. At this point, the surgeon must work slowly but meticulously, with minimal manipulation of the vessels and adjacent soft tissue. All loose adventitia on either side of the anastomosis must be trimmed, all intraluminal
B.
FIGURE 35-11. Flap coverage, secondary reconstruction. A, A pipe bomb constructed during high school chemistry class exploded in this teenager’s left hand, resulting in a complete dislocation of the thumb, amputation of the index finger at the metacarpophalangeal joint level, and soft tissue loss of the entire first webspace. B, The thumb dislocation at the carpometacarpal joint level was reduced and pinned. C, An ipsilateral groin flap was transferred for appropriate coverage. The thumb pulp is anesthetic. D, Eight months later, when full passive range of motion was achieved, a staged flexor tendon reconstruction was initiated. Continued
35
TABLE 35-3
RECONSTRUCTION OF THE PEDIATRIC MUTILATED HAND
498
THE MUTILATED HAND
FIGURE 35-11 cont’d. E, Sural nerve cable grafts were used on both sides of the thumb. F, The contour of the first webspace was maintained and is excellent 24 years later. G, H, Flexion and extension of the thumb and fingers are normal.
clots and debris must be removed, and vessel calibers must be matched. End-to-end anastomoses are preferred, but a wide end-to-side anastomosis is just as reliable if carefully performed. During this portion of the procedure, the assistant, scrub nurse, and circulating nurse or assistant should specifically focus on the microscope, not other distractions within the operating room. Following transfer, the inset of the flap must be partially completed first. Range of motion of the extremity should be tested in all directions to ensure adequate pedicle length and the absence of kinking or compression. After this phase of the procedure has been completed, passive range of motion of the extremity should be retested. Finally, all wounds must be carefully closed, preferably with subcuticular techniques, which eliminate the need for postoperative suture removal. When in doubt, drains should be used.
SECONDARY PROCEDURES With growth and weight gain, the need for secondary revision surgery in these patients is common. If this point is reinforced to the parents during the initial hospitalization, future surgeries can be anticipated without unnecessary and often frustrating redundant parental inquiries. The child can be reassured that the deformity can be improved, and the parents can be advised as to what to anticipate. It is unusual for a major injury not to require revision surgery, and the surgeon should take the time to determine a comprehensive program at the outset and then stick to it as closely as possible.
OUTCOMES The immediate technical complications of both pedicle flaps and free tissue transfer are the same as those in adults and need not be repeated. Healthy children are
A. B.
C.
D.
35
E.
FIGURE 35-12. Ulnar-sided defect. A, This 11-year-old boy sustained a pipe bomb blast to the ulnar side of the hand. The thumb and index finger were not injured; the distal portions of the ulnar three digits were blown off and were unusable as spare parts. Multiplelevel fractures and arterial and tendon injuries of the ring and little fingers were present. B, All nonviable tissue was debrided, and the hand was placed in an ipsilateral groin flap. Following two delays at 2 and 3 weeks, the flap was detached and inset. C, The same hand is seen 12 years later. One debulking had been performed at the time a flexor tendon was grafted to the middle finger. D, The digital extension and contour are quite satisfactory. E, Flexion of the index and middle fingers is good. The grip strength has been reduced by 60% owing to the loss of the ulnar two digits.
499
500
THE MUTILATED HAND
FIGURE 35-13. Central and ulnar defect. A, An extensive Fourth of July fireworks injury in a young high school student literally blasted the entire middle and ulnar palm away. The injured fingers could not be reattached using the available parts. B, A free groin flap based on both deep and superficial circumflex arteries was outlined and performed during the late 1970s. C, Sural nerve cable grafts were used to reconstruct both sides of the thumb. D, The groin flap was used to resurface and contour the remaining ulnar border of the hand. Twentyfive years later, the patient’s two-point discrimination measured 7 mm. His hand is functional as a helper. No revision surgery had been performed.
35
A.
RECONSTRUCTION OF THE PEDIATRIC MUTILATED HAND
501
FIGURE 35-14. Temporary skin graft coverage first. A, This 5-year-old youngster sustained a severe loss of soft tissue over the entire dorsum of the forearm and wrist when she fell off a riding lawn mower. The initial wound was debrided and covered with a split-thickness skin graft. A template for coverage is seen over the expanded abdominal skin. B, The recipient area on the dorsal surface of the forearm and wrist is prepared. C, The large area to be resurfaced is seen following debridement, tenolysis, and dorsal capsulotomy of the wrist. The flap has been prepared, and the donor defect has been closed at the same time with an advancement flap. D, The flap has been inset, and the donor site beneath has been closed with an advancement flap. E, After one delay at 3 weeks, the flap was detached at 4 weeks. F, Eight months later, there is remarkable mobility of the wrist and thumb. Continued
C.
D.
E.
35
B.
502
THE MUTILATED HAND
FIGURE 35-14 cont’d. G, Local flap advancement and Z-plasties have improved the mobility and grasp of the thumb. H, With good, supple soft tissue coverage, tenolyses, tendon transfers, and joint releases are possible. The radiograph shows the loss of the entire thumb metacarpal, which can be lengthened at the next stage of reconstruction. I, The abducted thumb can now be integrated into functional use.
A.
B.
35
C.
FIGURE 35-15. Loss of all fingers. A, The amputated fingers and radiograph of a 13-yearold boy whose left hand was mangled in a school printing press are shown. Multiple longitudinal phalangeal fractures are characteristic of this type of crushing injury. The ring finger was the most intact and least traumatized finger. B, Using vein grafts on both the arterial and venous reconstruction, the ring finger was placed on top of the index metacarpophalangeal joint. Two days later, the dorsal hand defect was covered with a groin flap. C, The same hand is seen 26 years later. Secondary procedures included rotational osteotomy to match the index and thumb pulp pinch and several flap debulkings. Two-point discrimination of the index is 5 mm on both the radial and ulnar pulp surfaces.
503
504
THE MUTILATED HAND
TABLE 35-4
Pediatric Microsurgery
TABLE 35-5
Outcomes
All the advantages of free tissue transfers
Few complications
Marked increase in degree of difficulty, particularly with smaller babies
Superior results, often unexpected recoveries
Surgical design/incision planning:
Mutilated hand/limb becomes the helper limb
Use expendable (not affected by growth) donor sites
Sensation: single most important factor Secondary revisions/reconstructions very helpful
Carefully position incisions Use flexion creases whenever possible Transfer more tissue than needed Surgical techniques: Micro-to-macro Setup of donor and recipient sites is key to success Spasm due to imprecise dissection, poor hemostasis Vessels not as small as perceived Always inset flap and test in all directions
much better equipped to tolerate serious complications, prolonged intensive care unit stays, and extensive injuries than adults are (see Table 35-5). Following a successful revascularization of a completely or partially amputated part, the prospect for protective sensation is, of course, the single most important factor in a functional recovery. The child will neglect any por-
A.
B.
tion of the limb or hand that does not regain protective sensation with a moving two-point discrimination of 8.0 to 9.0 mm. Babies might even bite or chew an insensate hand or digit. However, always bear in mind that a young child might achieve a surprising return of sensation in areas where is it not expected or might regain both motor and sensory recovery of a mixed nerve in the median, ulnar, or radial distributions. Despite the child’s remarkable regenerative potential, digits, hands, or upper limbs will never be restored to their uninjured state and commonly become “helper” extremities following extensive injuries (Fig. 35-16). As these children grow, it is important to evaluate them at 1- to 2-year intervals, as secondary revisions can be instrumental in the improvement of both function and appearance.
C.
FIGURE 35-16. Loss of all fingers and thumb. A, This 9-year-old child lost all fingers and the thumb at the proximal phalangeal level when her toddler brother gave her a live grenade, which he had picked up outside their front door. Amputated parts were not salvageable, and the open wounds were covered with a groin flap. B, One year later, the planned reconstruction was a triple toe transfer from the ipsilateral foot. Incisions are outlined. C, The three toes are seen during transfer. Both dorsal and plantar arterial systems were anastomosed to the princeps pollicis and second common digital artery in the hand.
35
D.
E.
RECONSTRUCTION OF THE PEDIATRIC MUTILATED HAND
505
F.
CONCLUSIONS Although the technical demands can be very high, treating the pediatric patient is one of the most rewarding experiences in a surgeon’s long career. However, the belief that “children always do better” is a myth. Pediatric patients can have many of the usual potential short-term and long-term problems, but they do have the resilience and regeneration capacity to achieve far superior outcomes with fewer complications than are seen in adults. Surgical planning and execution are much more difficult in children than in adults, but problems can be minimized by prompt treatments, thorough debridement, careful reconstructions, attention to detail, and good communication with the family. Of course, sensation is the key to successful final outcomes in the reconstructed hand. Furthermore, it is always important to make sure the parents understand that even with the best results, most of these limbs will be reestablished as no more than helpers and that these reconstructions are generally lengthy processes that require multiple surgeries.
References 1. Al-Quattan M: Self-mutilation in children with obstetric plexus palsy. J Hand Surg 24:547–549, 1999. 2. Bora Jr FW (ed): The Pediatric Upper Extremity: Diagnosis and Management. Philadelphia, WB Saunders, 1986. 3. Chicarilli ZN: Pediatric microsurgery: Revascularization and replantation. J Pediatr Surg 21(8):706–710, 1986.
4. Clarke HM, et al: Pediatric free tissue transfer: An evaluation of 99 cases. Can J Surg 36(6):525–538, 1993. 5. Devaraj VS, et al: Microvascular surgery in children. Br J Plast Surg 44(4):276–280, 1991. 6. Florence SL, et al: Sensory afferent projections and area 3b somatotopy following median nerve cut and repair in macaque monkeys. Cereb Cortex 4(4):391–407, 1994. 7. Jain N, Florence SL, Kaas JH: Reorganization of somatosensory cortex after nerve and spinal cord injury. News Physiol Sci 13:143–149, 1998. 8. Kaas JH, Merzenich MM, Killackey HP: The reorganization of somatosensory cortex following peripheral nerve damage in adult and developing mammals. Ann Rev Neurosci 6:325–356, 1983. 9. Kay S, McGuiness C: Microsurgical reconstruction in abnormalities of children’s hands. Hand Clin 15(4):563–583, 1999. 10. Kay S, Lees VC: Free-tissue transfer in children. In Gupta A, Kay SPJ, Scheker LR (eds): The Growing Hand: Diagnosis and Management of the Upper Extremity in Children, St. Louis, Mosby, 2000. 11. Lindsay WK, Farmer AW: Traumatic peripheral nerve injuries in children: Results of repair. Plast Reconstr Surg 30:462–468, 1962. 12. Lister G, Scheker L: The role of microsurgery in the reconstruction of congenital deformities of the hand. Hand Clin 1(3):431–442, 1985. 13. Lundborg G, Rosen B: Sensory relearning after nerve repair. Lancet 358(9284):809–810, 2001. 14. Merzenich MM, et al: Progression of change following median nerve section in the cortical representation of the hand in areas 3b and 1 in adult owl and squirrel monkeys. Neuroscience 10(3):639–665, 1983.
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FIGURE 35-16 cont’d. D, E, F, Thirteen years later, the patient returned to have her child treated. A “basic hand” had been created with a mobile thumb, two fingers on the ulnar side of the hand, and an intervening deep webspace. Moving two-point discrimination was 5 mm in the thumb and 6 mm in the ulnar two fingers.
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15. Merzenich MM, et al: Somatosensory cortical map changes following digit amputation in adult monkeys. J Comp Neurol 224(4):591–605, 1984. 16. Onne L: Recovery of sensibility and sudomotor in the hand after nerve suture. Acta Chir Scand Suppl 300:1–70, 1962. 17. Rosen B, Lundborg G: The long term recovery curve in adults after median or ulnar nerve repair: A reference interval. J Hand Surg [Br] 26(3):196–200, 2001. 18. Russel A, Shatford LS: Mutilating hand injuries: Assessment and general principles. In Gupta A, Kay SPJ, Scheker LR (eds): The Growing Hand: Diagnosis and Management of the Upper Extremity in Children. St. Louis, Mosby, 2000. 19. Shapiro J, Akbarnia BA, Hanel DP: Free tissue transfer in children. J Pediatr Orthop 9(5):590–595, 1989. 20. Shenaq SM, Dinh TA: Pediatric microsurgery: Replantation, revascularization, and obstetric brachial plexus palsy. Clin Plast Surg 17(1):77–83, 1990.
21. Shenaq SM, Dinh TA: Pediatric microsurgery: Reconstruction by free tissue transfer. Clin Plast Surg 17(1):85–94, 1990. 22. Swoboda KJ, et al: Mutilating hand syndrome in an infant with familial carpal tunnel syndrome. Muscle Nerve 21(1):104–111, 1998. 23. Tajima T, Imai H: Results of median nerve repair in children. Microsurgery 10(2):145–146, 1989. 24. Upton J, Havlik RJ, Coombs CJ: Use of forearm flaps for the severely contracted first web space in children with congenital malformations. J Hand Surg [Am] 21(3):470–477, 1996. 25. Upton J, Havlik RJ, Khouri RK: Refinements in hand coverage with microvascular free flaps. Clin Plast Surg 19(4): 841–857, 1992. 26. Van Beek AL, Wavak PW, Zook EG: Microvascular surgery in young children. Plast Reconstr Surg 63(4):457–462, 1979. 27. Zuker RM, Posnick JC: The role of microsurgery in pediatric craniofacial reconstruction. Clin Plast Surg 19(4):833–839, 1992.
36 Psychological Aspects of Mutilating Hand Injuries Brad K. Grunert, PhD Jo M. Weis, PhD Kimberly J. Anderson, PsyD
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The hand is our primary mechanism of physical contact with the world. A handshake, a wave, a delicate touch, and a pat on the back are all ways in which human beings connect physically and emotionally. The hand plays a significant role in nonverbal social interaction. Arguably, it is the most physically active part of the human body and clearly is the most readily and frequently visualized by an individual. Mutilating hand injuries produce both physiological and psychological devastation for the individuals sustaining them. The mutilation itself significantly alters interactions both physically and socially with the world around us. Several factors contribute to the psychological impact of the hand injury. Hands both symbolize and mediate the individual’s capacity to manipulate the environment and accomplish work, play, and social activities. Following a hand injury, the individual might experience feelings of vulnerability and loss of control. Tasks that had been performed in a skilled and habitual manner are suddenly forced into the realm of conscious attending. Psychologically as well as physically, hands are a primary component in sexual and intimate interactions. Hand injuries often result in feelings of sexual inadequacy, awkwardness, and social inferiority. The disfigured hand is obvious to all with whom the injured person interacts, but of greater emotional significance is the incessant direct visualization by the injured individual. Without conscious recognition, we look at our hands during countless activities and tasks throughout the day. To the injured individual, the view of the hand is a constant reminder of the physical and emotional pain and trauma that have been suffered. Cosmetic concerns include the injured individual’s perception of the mutilated hand, others’ perceptions of the injury, and the injured individual’s assumptions of others’ perceptions. Hands are a highly public part of one’s body. Following a mutilating hand injury, concerns of cosmesis often drive the individual to hide the maimed finger or portion of the hand from public view. Keeping the hand in a pocket or continuing to bandage it long after healing is complete is common. The individual might sever association with the mutilated hand, viewing it as not real or not a part of the self. The injured person might feel, and believe, that the hand is visually unattractive, disgusting, and distressing to others as well as to himself or herself. A mutilating hand injury results in significant feelings of social inadequacy. It is important to normalize these uncomfortable responses and to encourage 509
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ownership of the injured hand. The normalization process can be impeded by social ignorance regarding hand injuries. For example, some people might believe that the hand injury is contagious or that they might cause further injury through simple touch. In extreme cases, onlookers might respond with horror, both verbally and nonverbally, to the disfigurement.
Surgical Expectations and Outcomes Patients’ surgical expectations following a traumatic hand injury are generally naively optimistic. Injured patients often expect that with surgical procedures or replantation, they will regain complete functioning and sensation of the hand. Despite surgeons’ recommendations, patients often opt for multiple reconstructive procedures to improve cosmetic appearance at the possible expense of functionality. Replantation of an appendage is not a guarantee for return of total function and sensation. Permanent cosmetic disfigurement and scarring occur. Color changes with exposure to hot and cold are common. For patients who presume that replantation and reconstruction guarantee return to preinjury status, it is emotionally difficult to cope with anything less. When expectations are not met, patients tend to become more symptomatic. It is not uncommon for patients to misjudge the severity of their injuries as evidenced by misappraisals while in the emergency room. Impending emotional sequelae are often signaled by the expression of a premature desire to return to work.
Issues of Rehabilitation Patients are frequently unable to correctly anticipate the time required for physical, occupational, and emotional rehabilitation. Financial strain as a result of loss of work and demands of medical expenses are realistic concerns that compound the emotional consequences of the injury. Psychologically, the necessity for almost total preoccupation with a body part that had been taken for granted can be exhausting. The ordinary tasks of daily living coupled with treatment activities are constant sources of confrontation with one’s limitations due to the injury and frustration. The hand becomes a cue for reexperiencing the trauma. Hand injuries most commonly occur at work and in all likelihood in a situation in which the individual watched the injury occur. Superficially, the extent of the injury is clearly apparent to the individual immediately after the event. Throughout the rehabilitation process, the individual is constantly reminded of the injury. This serves to precipitate and maintain the symptomatology of posttraumatic stress disorder. Cues of the memories associated with the trauma are abundant. The individual is essentially unable to get away from triggers of the trauma.
Traumatic Aspects of Hand Injuries Prior to experiencing a mutilating hand injury, many people view the world as a safe place. The accident dramatically alters this perception, leaving the individual feeling unsafe in a world that is now unpredictable. The individual’s sense of control over the environment is lost, leading to avoidance of stimuli associated with the traumatic event.25 Not only does avoidance promote the illusion of safety, it also prolongs the symptomatology of trauma. The more out of control the individuals perceived themselves to be during the injury, the more at risk they are at for developing posttraumatic stress symptoms.21 Psychological symptoms such as flashbacks, nightmares, and intrusive thoughts are common after a traumatic hand injury and serve to make that which the individual is trying to avoid a daily encounter.
PSYCHOLOGICAL SYMPTOMATOLOGY OF MUTILATING HAND INJURIES Early and Late Aspects of Symptom Development Traumatic injuries result in a wide range of psychological symptomatology. The most frequent DSM-IV diagnosis given is posttraumatic stress disorder (PTSD).1 The most common symptoms experienced with PTSD include intrusive thoughts, flashbacks, nightmares, heightened startle response, disturbed sleep, avoidance, guilt, memory impairment, and decreased concentration. With a mutilating hand injury, lifestyle is significantly altered, which can result in additional affective experiences associated with depression, irritability, anger, and feelings of loss, grief, and low self-esteem. Flashbacks and nightmares are unequivocally the most prevalent symptoms immediately following mutilating hand injuries.28 Flashbacks are recollections of trauma that result in emotional, physical, and psychological re-experiencing. The content of the flashbacks and nightmares differ. Flashbacks tend to be vivid recollections of the actual injury, while nightmares tend to entail images of more severe injures or anticipated future losses. Nightmares tend to subside within approximately 1 month of the injury. Flashbacks are more persistent, last longer, and occur with greater frequency.28 Cosmetic concerns increase dramatically for the first 12 months after the injury and are most prevalent in individuals who sustained significant scarring rather than amputations.28 The person with an amputation might experience resolution in that there is clearly no hope for a return to the preinjured state. The person without an
amputation can continue to hope for return to the preinjured state. When injured individuals were asked to appraise the appearance of the injured hand, they rated it almost exactly the same as others rated the appearance of the hand.44 When the individual rated the hand on the basis of beliefs about other’s perception, however, the rating was significantly worse.44 Individuals who are reluctant to show others the injury are encouraged to begin this process in a therapeutic milieu that is supportive and accepting. An inquisitive and empathic reaction encourages the person to begin exposing the hand to friends and family if he or she has not yet begun to do so. Following amputation, phantom limb sensation also increases over the first 2 months. This is consistent with the biological course of neural activity, whereby the brain and neural networks are programmed to send signals to the location where the member was present. The result is conflict for the patient about what is experienced visually versus sensorally. The individual’s awareness that the limb is gone conflicts with the kinesthetic feedback of the limb’s presence. This conflict leads to heightened emotional arousal, increasing susceptibility to intrusive thoughts and the delayed integration of a new body image. Flashbacks, nightmares, cosmesis concerns, and phantom limb sensation all persist over the first few months. Data indicate that affective lability, attention and concentration, fear of death, and denial and avoidance all resolve gradually over approximately 18 months.21 Individuals who experience nightmares and flashbacks benefit from psychotherapeutic interventions that encourage the flashbacks and nightmares to occur naturally.20 Individuals are encouraged to utilize flashbacks and nightmares to improve their understanding of what occurred during the accident. Psychological intervention can also benefit individuals who have cosmetic concerns and phantom limb to preclude the natural increase of these symptoms that occurs over time.28 Late aspects of PTSD include avoidant responses to work and social interaction. Difficulty with concentration becomes problematic when the individual is exposed to environmental stimuli that trigger memories of the trauma. If PTSD remains untreated, anxiety disorders or major depressive disorder might occur.
Development of PTSD and Acute Stress Disorder: Patterns and Predictors PTSD is the primary sequelae to traumatic events experienced across the life span. Information-processing and cognitive theories of emotion are quintessential to trauma theory. Horowitz’s information-processing model depicting the theoretical underpinnings of trauma was the gold standard by which trauma theories evolved.32 His theory is also instrumental in the formation of the DSM-III
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diagnostic criteria for PTSD.32–34 Horowitz’s theory postulates that traumatic events are filled with substantial amounts of sensorial information, including sight, sound, smell, touch, and taste. As information is taken in from the environment, the natural tendency of human beings is to match the current information with already established information. Information absorbed during the trauma is highly inconsistent with established schemata. Intense information overload occurs when feelings, images, and affective experiences fail to be integrated with already existing self-schema. Traumatic memories, consequently, are pushed out of awareness and left unprocessed in their rawest form. Unprocessed thoughts, images, and affects tend to resurface in the form of nightmares and flashbacks attempting to integrate. Denial and avoidance are attempts to keep this disturbing information out of consciousness. Until the information is fully integrated and processed, a vicious cycle of intrusion, denial, and avoidance persists. Present theory surrounding trauma is in agreement that symptoms result from incomplete emotional processing of the traumatic event.9,10 Foa and Kozak integrate cognitive and affective components into their information-processing model.10 They postulated that fear following a traumatic event is represented in memory structures. Within memory structures are fear networks identified by physiological changes in response to an associated stimulus and to the meaning given to that stimulus. Bessel van der Kolk, of the Harvard Trauma Study Group, offers a psychobiological theory of information processing of the traumatic event. Traumatic events are encoded iconically and kinesthetically rather than linguistically. Until traumatic events are processed and converted from their iconic and kinesthetic forms to language, the individual remains in states of hyperarousal. In this state, avoidant behaviors and intrusive flashbacks and nightmares persist.31,40,59,60,62 Van der Kolk stated, “this failure to process information on a symbolic level following trauma is at the very core of pathology of PTSD.62 For the trauma survivor, even innocuous stimuli can generalize to fear responses, and the person remains in a constant state of increased fear and anxiety.2,7,60,62 Autonomic hyperarousal and hypervigilance are appropriate survival reactions to threats. The natural release of endogenous opioids contributes to physical pain management and emotional blunting after serious injury to aid in the survival process. However, these normal responses are subject to long-term negative consequences of traumatic stress and can lead to alterations in a number of neurobiological systems.* The traumatic nature of mutilating hand injuries has been arduously examined and detailed in the literature by Grunert and colleagues over the last * See references 6, 7, 18, 30, 38, 48, 57, 58, 61, 63, 64.
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two decades.22–26,66 Within an adult hand-injured population, flashbacks are quintessential to psychological prognosis.20 The high incidence of flashbacks in the hand-injured population is not surprising. The majority of hand injuries occur in direct view of the individual. The results of the injury (i.e., amputation, crush, and burn) are immediately recognizable, and fear of future injury and/or death is imminent. The hand serves as a consistent and remarkable stimulus for the onset and recurrence of flashbacks. Injured individuals often manage to control flashbacks, however, by avoidance and suppression mechanisms. Three types of flashbacks are identified in hand trauma literature.20 Replay flashbacks are a replaying of the events immediately preceding the injury and continuing to the point of actual injury. Appraisal flashbacks are an image of the injured hand immediately following the trauma. Finally, projected flashbacks are images of the injury beyond what actually occurred. Most patients have a combination of the replay, appraisal, and projected flashbacks.20 Replay flashbacks serve a substantially positive purpose. Patients can determine how the outcome could have been more positive through replay of the event. This serves to establish a sense of control and mastery over the situation and in developing methods of avoiding future injury.20 Combinations of appraisal and projected flashbacks and replay and projected flashbacks have a negative impact on processing of the event. During appraisal/projected flashbacks, the individual perceives very little control over injury and is afraid of further injury. Any stimuli associated with the initial injury are avoided. Replay/projection flashbacks elicit two distinct responses. The first is feeling fortunate that the injury was not worse and is preventable in the future. In contrast, others believe that the injury or accident was totally beyond their control and likewise that things beyond their control kept them from being more severely injured. Consequently, anxiety levels intensify, and stimuli associated with the trauma are avoided.20 The most common psychological sequelae to a mutilating hand injury in children is PTSD and the symptoms associated with it. Children are generally reluctant to discuss affective consequences with parents and/or health care providers. Symptoms often go unnoticed and unattended to.43 Several theories attempt to account for this, including a child’s astute recognition of parental distress following the injury. Children attempt to avoid causing a parent additional concern and therefore fail to report emotional fears or experiences. Second, parental distress in and of itself results in a lack of parental recognition of injury-related psychological symptoms in children. While a child
might socially withdraw, have difficulty in school, or experience affective lability, parents often do not recognize symptoms at all or do not recognize symptoms as trauma related.50 Rusch et al. examined psychological effects of mutilating injuries to children.50 Within 4 days of the injury, all but one child (N ⫽ 57) displayed psychological symptoms that included avoidance, startle, irritability, fear of reinjury, impaired concentration and sleep, cosmetic concern, and flashbacks. At a 1-year follow up, slightly fewer than half of the children reported two or more psychological symptoms associated with the trauma. Symptoms dissipated over time. At 1 year, however, most children still displayed one or two of the symptoms associated with PTSD. If symptoms persisted after 1 month, children were generally less behaviorally physical, more fearful and anxious about family members’ safety, and more fearful of activities associated with the trauma. Children who still carried a PTSD diagnosis at 12 months after the trauma also tended to be more fearful of reinjury and to experience more difficulty in social settings. Children were able to view their injuries earlier than were adults. Data indicate that children adjust to the sight of the injury within 1 month,50 whereas adults adjust within 3 months. The type of injury does not seem to be a precursor to development of psychological symptoms in children. For example, children with arm amputations do not develop PTSD at a higher rate than do children with fingertip amputations.50 Developmental level is also an important consideration. Autonomy and initiative are important developmental tasks of childhood. Psychosocially, children need to maintain as much use of the hand as possible to regain or establish a positive sense of control over the environment. Although older children may initially express intense concern regarding peer response, they generally are better equipped with coping mechanisms to help modulate social responses. Adolescents respond to traumatic injuries in ways similar to adults. Flashbacks occur at the same rate as they do for adults and are dependent on attributions. However, following an injury, adolescents are more reactive to issues of cosmesis and body image. This correlates with the developmental stage of identity formation in adolescence. Adolescents strive to develop a self and social identity within and separate from their peer group. A traumatic hand injury leaves the adolescent physically mutilated and different from his or her peers. The new identity is discordant from the already established sense of self, resulting in significant confusion. The effect of traumatic hand injury on adolescents is not detailed in the literature and is an area of ongoing research.
Panic Disorder A number of people with traumatic hand injuries develop panic disorder rather than PTSD. As the posttraumatic stress symptoms dissipate, panic symptoms surface. If panic disorder existed premorbidly, it inevitably resurfaces following trauma. Treatment is much different for panic disorder than for PTSD. In contrast to in vivo exposure and on-site work visits, hierarchical imaginal desensitization programs are developed. In these programs, the individual establishes a hierarchy of fears associated with the trauma. Through imaginal exposure, these fear networks are accessed and confronted. Desensitization to these fear structures gradually enables the individual to return to work and to tasks of daily living.
Sexuality and Hand Injuries Sexual dysfunction occurs in almost 50% of individuals who suffer traumatic hand injuries. Sexual dysfunction can take many forms. It is of interest to note that 12% of the male patients reach the point of impotence, which continues for at least 6 months after the injury.21 This troubling situation, with multiple causes and consequences, is often overlooked. The hand, as one of its capacities, has the ability to induce sensation, desire, and emotion. In sexual contact and intimacy, it is often the hand that precipitates, promotes, and maintains the stimulation. However, with the mutilated hand patient, this sensation of intimacy is compromised by feelings of clumsiness perhaps coupled with feelings of inadequacy. Often, the patient will then become even more fearful of rejection by his or her partner, engendering even more sexual dysfunction. Sexual intimacy and sexual desire are both highly affected by self-concept, which encompasses body image. Patients begin to believe that they are undesirable and sexually incompetent. This leads to feelings of undesirability and unworthiness and fears of abandonment. Approximately 65% of hand-injured patients experience an initial decrease in sexual desire.21 This is interpreted as an avoidance response protecting the individual from perceived rejection. Among men, erectile dysfunction evolves in many cases. This tends to occur secondary to pain experienced during foreplay or as a result of distressing flashbacks that occur during sexual encounters. Fear of flashbacks becomes a self-perpetuating cycle of avoidance in the classical conditioning model. The injured individual is not the only one who is affected sexually by the mutilated hand. Fears of causing further harm to the injury site or even of severing a replanted digit are common concerns. Although the injured party might only be projecting revulsion and fear of rejection onto the partner, it might indeed be difficult for the partner to accommodate the new sights
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and sensations. Addressing and normalizing the sexual changes within the partnership can reduce distortions and forestall significant dysfunction.
INTERVENTIONS FOR ACUTE STRESS DISORDER AND PTSD Individuals who have experienced the horrifying trauma of mutilating hand injuries are often confused by their emotional reactions. Heightened arousal in response to once-familiar cues, frightening re-experiencing of the traumatic event, and unsuccessful attempts to avoid these intrusive symptoms render one overwhelmed and out of control. Lost in oscillation between overcontrol and undercontrol of the traumatic re-experiencing, the patient struggles to integrate that which is in conflict with existing schemas. Natural attempts to avoid intrusions serve only to perpetuate the diagnostic symptom clusters that are hallmarks of acute stress and PTSD.
Attributional Style Evaluation of individual attributional styles allows for appropriate understanding of traumatized individuals’ views of the world before and after the accident. Cognitive schemas are beliefs about oneself and about the world. Janoff-Bulman’s research focus indicates that people generally believe that the world is a just place where events are controllable and predictable.35,36 She stated that most individuals hold three fundamental assumptions about life: (1) The world is benevolent and good, (2) the world is meaningful and comprehensible, and (3) they themselves are worthy and effective. The experience of trauma shatters these assumptions and forces the individual to create new meanings about themselves and the world around them. Edna Foa theorizes that recovery from traumatic events involves not only reducing or alleviating the fear and anxiety surrounding trauma, but also changing cognitive schemas and correcting misattributions about the events.16 Cognitive schemas that interfere with processing traumatic events include viewing oneself as a competent person in a world that is just and safe and priming the view that one is incompetent and the world is a dangerous place. When a person maintains rigid views of the self and the world, processing ambiguous events becomes extremely problematic. Present attributional theories delineate factors such as internal versus external control, stable versus unstable variables, and global versus specific conditions.65 Different combinations of these characteristics define one’s causal attributions and can influence the prevalence of PTSD in traumatized
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populations. In studies of industrial accidents, PTSD was more frequent among individuals with external stable attributions.23,66 The employee who identifies strongly with his or her employer, is never late for work, and never misses a day of work views himself or herself as a competent and productive worker. In addition, this person views the employer as benevolent and always looking out for his or her safety and welfare. Suddenly, a machine malfunctions and the worker’s right hand is amputated. Where in this person’s rigid cognitive schema does this traumatic event fit? The injured person is forced to attribute the event to external forces outside of his or her control, and the stability with which the person viewed the world is now shattered. The world has become an unsafe place. These individuals are at extreme risk for developing the intrusive, avoidant, and hyperarousal symptoms that characterize PTSD. Their attributions of the event become generalized, and they view themselves as externally controlled and powerless. This attributional style then becomes stable across events, interfering with symptoms stabilization and integration of the trauma. The same individual might instead be involved in an accident while at home working on a table saw in which he or she amputates several fingers. In this circumstance, the person recognized that he or she lost control of the saw and attributed the accident to an isolated and preventable event. The person maintained an internal locus of control and attributed the trauma to unstable factors: He or she lost concentration momentarily. The development of PTSD symptoms is unlikely, and treatment would focus on the normalization and integration of the individual’s responses. The individual who has an external locus of control and views the world as a dangerous place represents an additional attributional style that might interfere with the processing of traumatic events. Trauma serves to prime this already maladaptive attributional style, and clinicians see this population presenting with increased PTSD prevalence. The goal of treatment is to help the client decrease intrusive, avoidant, and hyperarousal symptoms and to change cognitive schemas and correct misattributions. Reframing the traumatic event so that it becomes part of an unfortunate past event facilitates the client in the development of less rigid schematic representations and fosters feelings of empowerment and mastery. This will aid in the reduction of victimization schema and PTSD symptomatology. It is imperative that interventions to facilitate normalization of the trauma experience begin as rapidly as possible after the injury to minimize the risk of acute stress and PTSD. These interventions must include psychoeducation addressing normal responses to traumatic
events and the anticipation of the normal progression of responses to trauma. It is often helpful to discuss iconic and linguistic encoding of memories and the impact of these encoding styles on the symptoms experienced. Being informed and understanding what he or she is experiencing and what to anticipate facilitates the injured individual’s sense of regaining control. The assessment of attributional style helps the therapist to shape individualized interventions. The interview process itself can serve as the initial exposure and desensitization session. Early intervention should also explore and increase the individual’s tolerance for and connection to the environment within which the accident occurred. Additional attention should examine whether the stress symptoms associated with the accident environment are being generalized to other life situations. Behavioral desensitization will be further discussed later.
Imaginal Exposure Present theory surrounding trauma suggests that symptoms are resultant of incomplete emotional processing of the traumatic event.8,31,39,59,60 To complete emotional processing, the original fear of the traumatic event must be accessed.8 Sherman conducted a meta-analysis of various treatments for PTSD and noted that all effective treatments included exposure of some sort in the presence of activating the original fear response and then completing appropriate emotional processing.52 Indicators of corrective emotional processing include a decrease in physiological reporting of fear activation during imaginal exposure, a decrease in physiological reactions (habituation) within imaginal exposure sessions, and a decrease in reaction to feared stimulus across imaginal exposure sessions.10 Many studies demonstrate that prolonged, repeated imaginal exposure to traumatic events, including combat, rape, and sexual assaults, ameliorates PTSD symptomology.3–5,11–15,17,19,37,42,43,47 Brief relaxation training is taught prior to the use of imaginal exposure, during which patients are asked to imagine in great kinesthetic detail the complete sequence of their traumatic memories. The use of the first person and present tense is central to the re-experiencing process. Throughout the imaginal exposure sessions, patients rate their discomfort using a rating scale consisting of 0 to 100 Subjective Units of Distress (SUDs).67 Exposure sessions are audiotaped and used for practice at home between sessions. The length of each exposure session varies between 60 and 90 minutes. Exposure must be long enough to allow for reduction in physiological arousal and habituation both within and across sessions.10,41,51 Repeatedly reliving the traumatic event imaginally facilitates the organizing of memories so that they can fit into existing schemas.45,46,49 In addition to assisting with
the integration of the traumatic event, exposure serves to desensitize and habituate the victim to the traumatic material, reduces anxiety, and increases the injured individual’s sense of self-control. The time of suffering, time lost from life responsibilities, and fiscal implications are substantial and can be positively affected by early intervention. In a study by Weis and Grunert, the effects of early versus delayed imaginal exposure were explored with a population of 60 individuals with accidental upper-extremity injuries.66 There was a significant difference in the number of treatment sessions required for reduction of PTSD symptomatology. The early-treatment group required fewer treatment sessions than did the delayed-treatment group. If early intervention is to occur, professionals across health disciplines must be trained in the early recognition of trauma prognostic indicators. Emergency room staff and other early interveners can profoundly affect the outcome for individuals by taking an appropriate psychological as well as medical approach. It is possible that early trauma assessment and effective intervention would substantially reduce the onset of PTSD for the population with work-related injuries.
Imagery Rescripting Victims of traumatic injury struggle with images of helplessness and uncontrollability. Treatments that focus on transforming these cognitive appraisals can help move forward those people who do not adequately benefit from imaginal exposure alone. Imaginal exposure has been expanded to include the experience of reframing, reprocessing, and integrating cognitive distortions that have been a part of the PTSD experience to increase personal perceptions of mastery and control over traumatic memories. Imagery rescripting and reprocessing therapy (IRRT) was originally developed for treating adult survivors of childhood trauma.53–56 The goal of imagery rescripting is to alter maladaptive trauma-related schemas (e.g., vulnerability, powerlessness, victimization) and assist in the development of competency-based self-perceptions and self-nurturing skills. Critical components of IRRT include imaginal exposure, imagery rescripting, and emotionallinguistic processing of the trauma. Imaginal exposure involves assessing and re-experiencing the fear network. Imagery rescripting supports the client in the creation of self-generated images of mastery and control, which replace images of victimization and helplessness. The creation of these mastery images is centrally supported by the transformation of traumatic images into narratives that can be reprocessed and linguistically explored and challenged. Socratic dialogue applied in the context of imagery promotes a sense of intrinsic mastery and control. It encourages victims to empower themselves as
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they process and rework their traumatic experiences. Patients develop their own mastery and self-calming imagery, which confronts and transforms their previously held trauma-related beliefs and schemas. Patients are asked during IRRT to develop mastery imagery by visualizing the survivor they are today entering the trauma image to support, confront, challenge, and take charge of themselves and others within that image. The therapist can facilitate this process through questions such as “Can you visualize yourself today, the survivor, entering the scene?” “Is there anything you, the survivor, would like to do or say?” “Can you see yourself doing or saying that?” “How does the traumatized you respond?” “How are others around you responding?” “What is happening in the imagery between the traumatized you and the survivor you?” “How does the traumatized you feel about the survivor you being there?” SUDS levels are taken frequently to give the therapist feedback on the patient’s distress level and how the affective process is unfolding. A sudden drop in these levels can alert the therapist to any dissociation or numbing that the client might be experiencing. Practice between sessions provides patients with the opportunity not only to review and integrate the mastery and nurturance illustrated in the taped IRRT sessions, but also to expand on these newly acquired skills and apply them to other situations. This further supports the transformation of the negative attributions and beliefs about the self and the traumatic experience into positive introjects of mastery and competence across life experiences. In work with victims of traumatic industrial accidents since the mid-1980s, Grunert and colleagues have consistently found that although some patients who are suffering from PTSD respond positively to imaginal exposure often coupled with some type of in vivo exposure, a significant percentage of these patients do not respond.22,24,26,29,66 Current research indicates that supplementing exposure therapy with a cognitive restructuring component improved outcomes with the previous treatment failure population.29
Behavioral Desensitization and Gradual Return to Work Behavioral desensitization can be helpful in assisting patients in overcoming their avoidance of work or other setting within which the injury occurred. Clients often use avoidance in the naive belief that it will remain a sufficient control for the uncomfortable and often debilitating PTSD symptoms of hypervigilance and intrusions. Graded work exposure can be a highly successful technique for returning patients to their previous employment. Graded return to work might require many approaches, including but not limited to telephone
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contact with the employer and coworkers, driving past or entering the work environment, slowly increasing the time in the work environment, and on-site visits with the therapist. Gradual return to work requires a considerable amount of psychological support. Although exposure, reprocessing, and coping skills training help to reduce PTSD symptomatology, they often incompletely address the avoidance accompanying return to the injury or work site. When in vivo exposure is impossible, whether it is secondary to extreme anxiety or physical incapacity or unavailability of the accident site, the use of a graduated hierarchical imaginal exposure process can be beneficial. It is not uncommon for patients to experience an exacerbation of symptoms, particularly flashbacks, following the implementation of a gradual return-to-work program.22
CONCLUSION Mutilating hand injuries have a multitude of deleterious psychological effects on the individuals who sustain them. Intrapsychic aspects range from flashbacks to hypervigilance to altered personal cosmesis. Each of the symptoms discussed in this chapter can affect the personal, interpersonal, and vocational adjustment of the individual who experiences them. A variety of techniques are available to facilitate the adjustment of individuals who sustain mutilating hand injuries; however, much remains to be done in this area. Complete rehabilitation requires both physiological and psychological interventions to promote optimal functioning.
References 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, Author, 1994. 2. Armony JL, LeDoux JE: How the brain processes emotional information. In Yehuda R, McFarlane AC (eds): Psychobiology of Posttraumatic Stress Disorder: Annals of the New York Academy of Sciences, vol 821. New York, New York Academy of Sciences, 1997, pp 259–270. 3. Brett EA, Ostroff R: Imagery and posttraumatic stress disorder: An overview. Am J Psychiatry 142(4):417–424, 1985. 4. Bryant RA, Harvey AG: Visual imagery in posttraumatic stress disorder. J Trauma Stress 9(3):613–619, 1996. 5. Bryant RA, Harvey AG, Dang SY, et al: Treatment of acute stress disorder: A comparison of cognitive-behavioral therapy and supportive counseling. J Consult Clin Psychol 66(5):862–866, 1998. 6. Canive JM, Lewine JD, Orrison Jr WW, et al: MRI reveals gross structural abnormalities in PTSD. In Yehuda R, McFarlane AC (eds): Psychobiology of Posttraumatic Stress Disorder: Annals of the New York Academy of Sciences, vol 821. New York, New York Academy of Sciences, 1997, pp 512–515.
7. Charney DS, Deutch AY, Krystal JH, et al: Psychobiologic mechanisms of posttraumatic stress disorder. Arch Gen Psychiatry 50:294–305, 1993. 8. Foa EB: Psychological processes related to recovery from a trauma and an effective treatent for PTSD. In Yehuda R and McFarlane AC (eds): Psychobiology of Posttraumatic Stress Disorder—Annals of the New York Academy of Sciences. New York, New York Academy of Sciences, 821:410–424, 1997. 9. Foa EB, Hearst-Ikeda D: Emotional dissociation in response to trauma: An information-processing approach. In Michelson LK, Ray WJ (eds): Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives. New York, Plenum Press, 1996, pp 207–224. 10. Foa EB, Kozak MJ: Emotional processing of fear: Exposure to corrective information. Psychol Bull 99(1):20–35, 1986. 11. Foa EB, Molnar C, Cashman L: Change in rape narratives during exposure therapy for posttraumatic stress disorder. J Trauma Stress 8(4):675–699, 1995. 12. Foa EB, Riggs DS, Gershuny BS: Arousal, numbing, and intrusion: Symptom structure of PTSD following assault. Am J Psychiatry 152(1):116–120, 1995. 13. Foa EB, Rigg, DS, Massie ED, Yarczowier M: The impact of fear activation and anger on the efficacy of exposure treatment for posttraumatic stress disorder. Behav Ther 26:487–499, 1995. 14. Foa EB, Rothbaum BO: Rape: Can victims be helped by cognitive behavior therapy? In Hawton K, Cowen P (eds): Dilemmas and Difficulties in the Management of Psychiatric Patients. Oxford, England, Oxford University Press, 1990, pp 197–204. 15. Foa EB, Rothbaum BO, Steketee GS: Treatment of rape victims. J Interpersonal Violence 8(2):256–276, 1993. 16. Foa EB, Steketee GS, Rothbaum BO: Behavioral-cognitive conceptualizations of post-traumatic stress disorder. Behav 20:155–176, 1989. 17. Friedman MJ: Posttraumatic stress disorder. J Clin Psychiatry 58(9):33–36, 1997. 18. Griffin MG, Nishith P, Resick PA, Yehuda R: Integrating objective indicators of treatment outcome in posttraumatic stress disorder. In Yehuda R, McFarlane RC (eds): Psychobiology of Posttraumatic Stress Disorder: Annals of the New York Academy of Sciences, vol 821. New York, New York Academy of Sciences, 1997, pp 388–409. 19. Grigsby JP: Single case study: The use of imagery in the treatment of posttraumatic stress disorder. J Nerv Ment Dis 175(1):55–59, 1987. 20. Grunert BK, Devine CA, Matloub HS, et al: Flashbacks after traumatic hand injuries: Prognostic indicators. J Hand Surg 13A(1):125–127, 1988. 21. Grunert BK, Devine CA, Matloub HS, et al: Psychological adjustment following work-related hand injury: 18 month follow-up. Ann Plast Surg 29(6):537–542, 1992. 22. Grunert BK, Devine CA, McCallum-Burke S, et al: On-site work evaluations: Desensitization for avoidance reactions following severe hand injuries. J Hand Surg 14B(2): 239–241. 23. Gruert BK, Dzwierzynski WW: Prognostic factors for return to work following severe injuries. Techniques in Hand and Upper Extremity Surgery 1(3):213–218, 1997.
24. Grunert BK, Devine CA, Smith CJ, et al: Graded work exposure to promote work return after severe hand trauma: A replicated study. Ann Plast Surg 29(6):532–536, 1992. 25. Grunert BK, Hargarten SH, Matloub HS, et al: Predictive value of psychological screening in acute hand injuries. J Hand Surg 17A(2):196–199, 1992. 26. Grunert BK, Matloub HS, Sanger JR, Yousif NJ: Treatment of posttraumatic stress disorder after work-related hand trauma. J Hand Surg 15A(3):511–515, 1990. 27. Grunert BK, Matloub HS, Sanger JR, et al: Effects of litigation on maintenance of psychological symptoms after severe hand injury. J Hand Surg 16A(6):1031–1034, 1991. 28. Grunert BK, Smith CJ, Devine CA, et al: Early psychological aspects of severe hand injuries. J Hand Surg 13B(2):177–180, 1988. 29. Grunert BK, Smucker MR, Weis JM, Rusch MD: When prolonged exposure fails: Adding an imagery-based cognitive restructuring component in the treatment of industrial accident victims suffering from PTSD. Cognitive and Behavioral Practice 10(4), 2003. 30. Heim C, Owens MJ, Plotsky PM, Nemeroff CB: The role of early adverse life events in the etiology of depression and posttraumatic stress disorder: Focus on corticotropinreleasing factor. In Yehuda R, McFarlane AC (eds): Psychobiology of Posttraumatic Stress Disorder: Annals of the New York Academy of Sciences, vol 821. New York, New York Academy of Sciences, 1997, pp 194–207. 31. Herman JL: Trauma and recovery. New York, Basic Books, 1992. 32. Horowitz MJ, Kaltreider NB: Brief therapy of the stress response syndrome. Psychiatr Clin North Am 2(2): 365–377, 1979. 33. Horowitz MJ, Stinson C, Field N: Natural disasters and stress response syndromes. Psychiatr Ann 21(9):556–562, 1991. 34. Horowitz MJ, Nilner N, Alvarez N: Impact of event scale: A measure of subjective stress. Psychosomatic Medicine, 41(3):209–218, 1979. 35. Janoff-Bulman R: The aftermath of victimization: Rebuilding shattered assumptions. In Figley CR (ed): Trauma and Its Wake: The Study and Treatment of Post-traumatic Stress Disorder. New York, Brunner/Mazel, 1985, pp 15–35. 36. Janoff-Bulman R: Shattered assumptions: Towards a new psychology of trauma. New York: The Free Press, 1992. 37. Jaycox LH, Foa EB, Morral AR: Influence of emotional engagement and habituation of exposure therapy for PTSD. J Consult Clin Psychol 66(1):185–192, 1998. 38. McEwen BS, Magarinos AM: Stress effects on morphology and function of the hippocampus. In Yehuda R, McFarlane AC (eds): Psychobiology of Posttraumatic Stress Disorder: Annals of the New York Academy of Sciences, vol 821. New York: New York Academy of Sciences, 1997, pp 271–284. 39. Meichenbaum D: A Clinical Handbook/Practical Therapist Manual: For Assessing and Treating Adults with Posttraumatic Stress Disorder (PTSD). Waterloo, Ontario, Institute Press, 1994. 40. Murburg MM: The psychobiology of posttraumatic stress disorder: An overview. In Yehuda R, McFarlane AC (eds):
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37 Rehabilitation of the Mutilated Hand Barbara E. Puddicombe, OTR/L, CHT Deryl J. C. Robson, MS, OTR/L
Treatment of the mutilated hand creates a unique challenge for the hand therapist. The injury can consist of a fairly straightforward single-digit amputation or one that involves multiple systems, including soft tissue, skeletal, and neurovascular structures. It demands from the therapist a thorough knowledge of all rehabilitation techniques as well as knowledge of the intricate anatomy of the hand. The most successful outcomes are best achieved through the coordinated team approach of the surgeon, therapist, and patient. The therapist and surgeon together prioritize the medical and rehabilitative aspects, and the patient assists in prioritizing functional and aesthetic goals. The surgeon should inform the therapist of the surgical procedures that are performed and the expected outcome of each procedure. The outcome of rehabilitation depends on the skill of both the surgeon and the therapist and relies heavily on the patient’s ability and willingness to comply with the home program. This chapter is intended primarily for the surgeon who will treat and oversee the rehabilitation of acute mutilating hand injuries. It is a systematic overview of the hand therapist’s process of treating mutilating injuries. A strong knowledge of upper extremity anatomy, physiology, biomechanics, and pathology is assumed. The chapter first reviews amputations, multisystem injuries, and crush injuries and concludes with a discussion of evaluation and treatment methods.
AMPUTATIONS
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The approach to rehabilitating patients with amputations is determined by the involved parts of the hand, including the type and level of amputation, the quality of soft tissue coverage, sensibility, and the patient’s degree of pain. The restoration of function will relate directly to these issues.
Single-Digit Amputation Amputation of a single digit can result in a functional and a cosmetic loss. Distal loss can lead to proximal joint stiffness. If the amputation is proximal to the insertion of the sublimis, there will be no active flexion to the remaining portion of the middle phalanx. Amputation proximal to the proximal interphalangeal joint can result in limited metacarpophalangeal flexion. If the amputation involves the metacarpophalangeal joint of the middle or ring finger, a gap exists in the palm, and the patient will be prone to having small objects such as coins fall out of the hand.62 The therapist must also be aware that single-digit amputations with limited motion can cause limited motion of uninvolved digits. This is called the “quadriga effect” and 519
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more commonly occurs when the mutilated finger is the middle or ring finger. In its more subtle form, it can result in loss of digital strength at the extremes of tendon excursion.11,60 Loss of a digit on the ulnar side of the hand will result in the loss of power grasp. Hypersensitivity and neuroma pain can also be complicating factors in the single-digit amputation.
Multiple-Digit Amputation All factors associated with single-digit amputation apply to multiple-digit amputation as well. In addition, the patient’s ability to oppose the remaining digits or portion of digits must be addressed. Opposition of the thumb to the pads of the index and middle fingers provides prehension. As long as one digit is in a satisfactory position with good sensibility and the thumb has sufficient length, precision manipulation can be preserved7 (Fig. 37-1). If the thumb is present but a transmetacarpal amputation has occurred to the digits, the therapist can fabricate a thermoplastic attachment to the hand so that early prehension will be possible. If the patient has diffuse pain following multiple-digit amputations, carpal tunnel syndrome should be considered. This can occur through proximal migration of the flexor tendon system and/or the lumbricals, causing compression on the median nerve.10
Thumb Amputation Functional requirements of the thumb include adequate sensation, enough length and mobility to oppose the other digits, and joint stability to allow strong function and freedom from pain.56 Total amputation of the thumb results in the loss of prehension and is equivalent to a 40% loss of hand function.2 Preservation of the
FIGURE 37-1. A mutilating hand injury involving multiple systems. The thumb has sufficient length to allow opposition to the ring finger.
thumb length is a critical component in determining the patient’s functional ability. The majority of all functional activities can be accomplished with approximately half of the proximal phalanx remaining.7 During the rehabilitation period, the surgeon might suggest the possibility of future reconstructive surgery. To assist in the decision-making process, the therapist can offer the patient insight into and education about the type of surgery being discussed. If not enough functional length remains after adequate healing has occurred, the therapist can fabricate a temporary thermoplastic post that will allow for early functional opposition (Fig. 37-2). This not only enhances early prehensile tasks, but also allows the patient to start contemplating reconstructive surgery such as a toe-to-thumb transfer or pollicization.
Treatment of Amputations Early treatment consists of wound care, edema management, and range-of-motion exercises. It is important for the therapist to know the types of dressings that the surgeon prefers and the frequency of dressing changes desired. The dressing change might be the first time that the patient and his or her family have seen the hand since the day of the injury. The therapist should be sensitive and supportive at all times. Range-of-motion exercises for the remaining portion of the hand and the involved extremity should also be started early. Upper extremity guarding that could lead to proximal limitations such as a frozen shoulder should be prevented (Fig. 37-3). Edema management using elevation and Coban (Medical Products/3M, St. Paul, Minnesota) should also be initiated early. Once wound closure has been achieved, desensitization and scar management should begin. Protection of hypersensitive areas with Silipos Sleeves (Silipos, Niagara Falls, New York) is recommended. Heat modalities can also be added at this time to decrease pain and increase tissue extensibility. Range-of-motion exercises for both the involved and uninvolved joints should continue, and splinting can be added to promote prolonged stretch techniques. Also important at this time are fine motor manipulation and functional activities. Strengthening and work simulation should be initiated as soon as the patient can tolerate them comfortably. As therapy progresses, recommendations should be made to the surgeon if the therapist observes that a neuroma resection or tip revision might be necessary. By communicating with the surgeon, the therapist will also assist in determining whether the patient is a candidate for reconstructive surgery such as an opponensplasty, toe-to-thumb transfer, or ray resection. During the rehabilitation process, the therapist should observe that the patient is making appropriate psychological adjustments and notify the surgeon if there is a concern. With the
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A
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B
FIGURE 37-2. A, A total thumb amputation. B, A thermoplastic post was fabricated to provide functional opposition. This patient ultimately chose to have a toe-to-thumb transfer.
MULTISYSTEM INJURIES Multisystem injuries to the hand involve variable disruptions to the skin, bones, joints, vascular supply, nerves, and tendons (Fig. 37-4). The rehabilitative approach is determined by the structures involved as well as by how the surgeon treated and repaired them. There must be a balance between restoration of function and protection of the repairs. In determining the treatment plan for
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surgeon’s approval, the use of a finger prosthesis for function or aesthetics can also be explored at this time. Actual referral would not be appropriate until complete healing, including complete edema reduction, has been achieved.
FIGURE 37-3. Range of motion to the shoulder is initiated early to avoid proximal limitations such as adhesive capsulitis.
FIGURE 37-4. In multisystem injuries, it is imperative that the surgeon communicate to the therapist all structures involved and how they were treated. Each system should be analyzed separately to guide the total treatment plan.
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these patients, it is simplest and safest to analyze each system separately to prioritize and cautiously begin gentle mobilization of the hand as allowed by the healing of the structures involved.
Skin In a clean, surgically closed wound, there is minimal need for therapist intervention. The wound should be kept clean with a light dressing. Tensile strength is provided by the sutures, which safely allow therapy to be initiated if there are no other precautions. Open wounds that are allowed to heal by secondary intention or are to be closed by a skin graft, flap, or delayed primary technique need to be kept meticulously clean to promote healing. Whether the open wound is clean or necrotic will influence the type and frequency of the dressing.51 In many clinics, the therapist will be responsible for these dressing changes. The therapist should always receive precise orders from the surgeon, as this early phase is critical and preferences in wound cleansing, disinfecting, and type of dressing vary. Whirlpool treatments might be recommended with open wounds and should be administered at skin temperature to promote wound cleansing and enhance circulation via the mechanical effect of water agitation.43 If therapy is begun at this time, it should not be overly aggressive; this can prolong the inflammatory phase. When flaps or grafts are to be used for soft tissue coverage, care must be taken to avoid any tension to these sites as they are intolerant of any mobilization immediately after division. The method of coverage that is used will dictate the time needed for this protection.6 Percutaneous pin sites and external fixator pin sites must also be attended to. Care of these sites differs from surgeon to surgeon; therefore the therapist should be aware of the surgeon’s preference. The therapist should alert the surgeon if there is any sign of pin tract redness, drainage, or pin loosening.
Bone Fractures are common in the mutilating injury; stabilization and anatomic reduction must be achieved so that early motion can begin. Bone repair occurs through three overlapping phases: the inflammatory phase, the reparative phase, and the remodeling phase.6 In the inflammatory phase, a hematoma develops at the fracture site. Edema and pain are present. Osteoclasts reabsorb necrotic bone, and granulation tissue begins to replace the fracture hematoma. In the reparative phase, the hematoma begins to organize with the formation of callus. This is divided into two stages: the soft callus stage and the hard callus stage. Soft callus is primarily cartilage and forms adjacent to the fracture gap and sta-
bilizes the fracture clinically. The patient’s pain should decrease at this time. Hard callus occurs with endochondral ossification of the cartilaginous callus to form woven bone. This ends with clinical and radiographic healing of the fracture. Bone remodeling begins within months of the initial injury and can continue for years. During this phase, woven bone is converted to lamellar bone, callus is resorbed, and there is reconstitution of the medullary canal.50 The type of treatment will be influenced by the type of fracture, the type of fixation, and the other injuries that are sustained. Initially, edema should be addressed through elevation and range of motion to the uninjured portion of the extremity. Priority must also be given to wound healing. Splinting is utilized to maintain maximum length of the ligaments with the metacarpophalangeal joints flexed, the interphalangeal joints extended, and the thumb in palmar abduction. Splinting might be necessary to protect other associated injuries or repairs from undesirable motion, such as a dorsal block splint if a flexor tendon was lacerated. Generally, by 7 to 10 days after injury, the swelling and pain associated with the hematoma and organization phase begin to subside as vascular fibrous ingrowth into the hematoma begins.36 The therapist and surgeon should be in close communication at this time, as rehabilitation should be as aggressive as healing allows. Treatment plans must carefully balance the goal of healing with the goal of restoration of functional use. Fracture healing must be assessed, and rapid remobilization must begin as quickly as possible. The soft tissue damage associated with the mutilating injury enhances the necessity of early motion. Immobilization might be necessary for fracture healing, but the longer the immobilization the more likely the occurrence of the devastating effects of adhesion formation, ligamentous contracture, and bone demineralization.50 Active and active-assisted range of motion as well as light activity can usually be increased at 4 to 6 weeks, regardless of the type of fixation. When the percutaneous pins or the external fixators are removed, the therapist must ensure that the soft tissue between the skin and the bone is gliding. Advancement of the therapy program at this stage will be guided by both radiographic and clinical findings.
Tendon The exact mechanism of tendon healing is still unknown. Researchers have reported that tendon healing can occur through extrinsic healing, intrinsic healing, or a combination of both. Extrinsic healing occurs from outside the tendon and relies on the ingrowth of fibroblasts, inflammatory cells, and extratendinous vascular invasion. Extrinsic healing depends on the formation of adhesions, which increases the vascularity and the healing process
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of soft tissue trauma, which correlates with more extrinsic healing and therefore more adhesion formation. Control of swelling and early controlled mobilization are imperative for these injuries.61 However, if other repaired structures need to be protected, early mobilization of tendons might be contraindicated. If the tendon is not mobilized until 2 to 3 weeks after the repair, the exercise must be very gentle because the immobilized tendon repair is not as strong as a mobilized tendon is.32 In the remodeling phase of tendon healing, collagen fibers reorganize into parallel bundles as stress is applied, greatly increasing their strength.61 This phase is very active from 3 weeks to 6 months and then continues for many months at a reduced rate. Therapy during this scar maturation phase is aimed at mobilization and at restoration of strength and function. At 3 to 4 weeks, gentle active motion and gentle scar massage are initiated. Between 4 and 6 weeks, the splint may be removed for gentle active exercise and sedentary, nonresistive activities. The splint should continue to be worn at night and for risky activities up to 8 weeks. At 6 weeks, light resistance, gentle functional activities, and ultrasound, if needed to enhance tendon gliding, are begun. Some studies suggest that earlier use of ultrasound can promote the healing process; however, further research is needed in this area.61 By 8 weeks, the tensile strength is greatly increased.42 Now resistive forces can be increased, and splinting for mobilization and elongation of soft tissue can be initiated. By 12 to 14 weeks, unrestricted activities are allowed. These are general guidelines and, of course, must be tailored to the patient’s specific needs.
Nerves Recovery of function in the mutilating injury can be profoundly affected by the integrity of the peripheral nerves. Severe injuries can cause multilevel nerve lesions, resulting in even greater challenges. Denervation presents as a loss of sensation, as a paralysis of the involved muscles, or both. It is important that the therapist be aware of the nature and the mechanism of the injury. A peripheral nerve can be transected, crushed, compressed, or stretched. Peripheral nerve tissue has the ability to regenerate; however, the prognosis for recovery is greatly affected by the type of injury as well as by which components of the nerve were damaged. The classification systems of Seddon and Sunderland continue to be the two primary systems in use today to describe the degree of disruption.52 Any injury to a peripheral nerve results in a predictable sequence of events; however, there are many factors that can influence regeneration. A sharp, guillotine-type injury results in less damage than a crush does. Avulsion lesions are potentially the most damaging. A simple, clean laceration generally has a better result
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but might also limit tendon gliding. Intrinsic healing occurs within the tendon without the formation of adhesions. Intrinsic healing occurs through synovial fluid diffusion and the activity of tenocytes and the intratendinous blood supply.40,46,61 There are three overlapping phases in tendon healing. The inflammatory phase begins immediately after the injury occurs. Fibroblasts migrate into the defect, phagocytosis of debris occurs, and collagen synthesis begins. The strength of the repair is minimal at this time and relies on the suturing technique. It is very helpful for the therapist to be informed of the type of suture repair that has been performed. Therapy during this period is aimed at controlling pain and edema as well as promoting wound healing. Range of motion to the unaffected parts of the extremity is begun. At the first dressing change, a protective splint may be made that will become an essential component of the therapy treatment protocol. The type of splint will depend on the tendons that were repaired and the postoperative protocol that will be followed. Splints are used to provide protection to the healing tendon and to specify motion parameters for controlled early mobilization programs.23 Other injuries that have been sustained must also be taken into consideration in fabricating the orthotic device. Some authors have advocated that controlled mobilization begin immediately;38 others recommend delaying this until 3 days after the repair. Motion started prior to 3 days after the repair might cause bleeding and an increased inflammatory reaction, which then increases the force and resistance necessary to mobilize the traumatized digits.29 The fibroplasia phase begins at 3 to 4 days and continues for 3 weeks. Fibroblasts predominate and rapidly lay down collagen fibers in a random pattern. Tensile strength is fragile at this time. Controlled mobilization is begun if other repaired structures are stable enough. There are numerous approaches to controlled mobilization, including passive motion techniques, “place and hold” regimens, and protective active motion protocols.53 The rationale for these early controlled motion protocols is that a mobilized tendon with controlled stress results in fewer adhesions, greater tensile strength, and better gliding compared with immobilized tendons.26,27,55 In most clinics, early mobilization following flexor tendon repairs is the standard of care; however, their use in the treatment of extensor tendons is not as widely accepted. Extensor tendon adhesions might not be as critical because there is no fibro-osseous sheath, but early mobilization after surgery is beneficial. Complications associated with immobilization include adherent tendon to bone, loss of digital flexion, extensor lag, and joint contracture. Early mobilization programs have been designed to avoid these complications.19 In the mutilating injury, there can be a significant amount
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than a dirty laceration does. Delayed repairs can diminish the results. A distal injury has a better outcome than a proximal injury does, and children have a better functional recovery than adults do. Sensory or pure motor nerve repairs respond better than mixed nerve repairs do. Regeneration is also affected by the amount of scar and internal disorganization that occurs following nerve injury.13 As an injury increases in its severity, more scarring is produced, and functional recovery is diminished. Prior to the initiation of therapy, the therapist must also ascertain whether the nerve was repaired under tension, whether a nerve graft was used, and whether joints were flexed to achieve the repair. Excessive tension at the repair site has been shown to cause necrosis and fibrosis of the nerve repair.39 If joints were flexed to achieve repair, mobilization will cause traction to the nerve, ultimately affecting the functional outcome. Initially, splints are fabricated to immobilize the repair. Care should be taken that there is no tension or direct compression to the nerve. The nerve should also not be placed on excessive slack because of the risk of adherence to the adjacent tissues that will later restrict nerve gliding. If a nerve is incompletely transected and was repaired without tension or if the nerve was simply contused, then only minimal immobilization might be necessary.54 The exact length of time to immobilize a nerve repair and the exact tensile strength of the nerve during wound healing are not known. Three to four weeks of immobilization was reported by World War II surgeons and supported by subsequent wound-healing research; however, with multisystem injuries, 3 weeks of immobilization might be undesirable. The surgeon can place the involved joints through a controlled range of motion at surgery to assess the tension, which can then guide the postoperative therapy program.17 After appropriate immobilization, mobilization is begun. The goal of mobilization is to maintain or restore motion, to prevent contractures and permanent deformities, and to keep denervated areas supple and ready to accept the growing axons. Functional imbalance can result after a motor nerve injury, for example, clawing after an ulnar nerve injury. Splinting is imperative to avoid these types of permanent hand deformities. Once reinnervation begins, strengthening of the appropriate muscle groups should be initiated. Muscle reinnervation occurs in the order of the original innervation. Sensory deficits are also addressed. Appropriate protection of anesthetic areas and compensation techniques should be taught. As protective sensation returns, sensory reeducation is initiated and advanced to increase discriminative sensation. Desensitization and scar management techniques are also begun as necessary. The therapist must also help the patient to adapt to any permanent deficits in motor, sensibility, or sympathetic function.
The rate of axonal regeneration after a 3- to 4-week latent period is 1 millimeter per day.49 It might take 2 years to achieve “functional recovery,” and improvements have been observed up to 3 to 5 years after injury.17 The treatment plan must be updated as sensory and motor regeneration occurs. Patient education is a crucial part of the therapist’s role, particularly in regard to the time required for maximum recovery, which can be very frustrating for the patient.
Blood Vessels Injuries to blood vessels rarely occur in isolation in the upper extremity, and long-term disability is more often related to other associated injury than to vascular problems.30 The therapist must know the tension and patency of the anastomoses as well as all other systems involved. Mobilization can begin in 1 to 2 weeks after endothelial healing has occurred. However, the timing of mobilization, the type of mobilization, the type of protective splinting, and the long-term treatment protocols often depend on the healing process of other repaired structures. During the postsurgical period, dressing changes must be done gently to avoid vasospasm and trauma to soft tissue. The extremity should be elevated at all times; however, excessive elevation should be avoided if there is arterial congestion. During elevation, care should be taken that the elbow does not assume a prolonged flexed position, leading to cubital tunnel syndrome. Extremes in temperature should be avoided to maintain vascular stability. The therapist must take care that the splints and dressings do not apply excessive external compression or pressure. Signs of vascular compromise include a change in color, a decrease in temperature, an increase in edema, decreased capillary refill, or an increase in pain. When mobilization is begun, vigorous exercise that causes pain can precipitate vasospasm and should therefore be avoided.9,57
CRUSH INJURIES Crush injuries present a special set of circumstances. There might be very little, if any, disruption of the skin. The injury might result in immediate or delayed circulatory impairment with or without physical disruption of the artery; there might be subsequent thrombosis, arterial spasm, and impaired flow from the progressing edema. Volkmann’s ischemia is a well-known example of ischemia due to compression. Edema or blood accumulates within an enclosed fascial compartment, increasing the pressure above the level at which the arterial perfusion pressure of the compartment can maintain a positive blood flow through the compartment. Viability of any tissue within the compartment might be lost, and
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EVALUATION A comprehensive evaluation establishes a complete baseline and should be completed as early in the course of treatment as possible. Gathering of all information can be done over several sessions if the patient is overwhelmed or too fatigued to tolerate an entire evaluation. The assessment must also be tailored to take into consideration healing of specific tissues. It is the first opportunity the therapist will have in the important role of patient education. During the evaluation, the therapist should explain what is being done and why. The therapist should also establish meaningful short-term and long-term goals with the patient, giving the patient the opportunity to be part of the rehabilitation process from the beginning. Establishing the treatment plan with the patient allows the patient to learn about the rehabilitation process early on, helping to alleviate anxiety about the future course of treatment. Reevaluations done on a regular basis provide feedback for the patient, the therapist, and the surgeon on the efficacy of the specific treatments being provided. Changes or modifications to treatment are based on this feedback. Reevaluations are also a time to establish new goals with the patient, assuring them that their goals are considered. The initial evaluation should begin by identifying all pertinent patient information, including referring surgeon, age, sex, hand dominance, past medical history medications, and occupation. A detailed history, including the date of injury, the exact mechanism of injury, the precise injuries sustained, and date(s) and description(s) of surgeries and prior treatments, should be documented. Radiographs, computed tomography scans, and all other diagnostic tests should be reviewed. Avocational activ-
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ities, a psychosocial history, and a functional assessment should also be included. A detailed inspection of the injury should include the appearance of the wound, any signs of infection, skin coverage, incisions, sutures, and type of immobilization and/or fracture fixation. An interpretation of the patient’s pain should be included in the evaluation. The location, nature, and behavior of the pain are assessed.20 Many rating scales such as the visual analog scale give the therapist a quick and simple tool to assess the intensity of the pain.45 Composite hand and forearm edema can be quickly and accurately measured with a water displacement volumeter (Volumeters Unlimited, Idyllwild, Ca) if wound healing will permit immersion. The volumeter is accurate within 10 milliliters when the manufacturer’s procedural guidelines are adhered to.63 The volumeter is utilized in subsequent evaluations to assess the effectiveness of edema reduction techniques and to check for edema changes before and after exercises or modalities. When volumetric measurements are contraindicated, circumferential measurements utilizing a soft tape measure are used. This is also a desirable option if only one or two digits are involved because the edema might not be significant enough to be detected by the volumeter.33 Consistency in the placement and degree of tension on the tape is necessary.21 Goniometric measurements of the entire extremity, including active and passive measurements, should be recorded as precautions allow. Discrepancies between active and passive motion should be noted with an explanation for the difference, such as capsular tightness versus limited intrinsic or extrinsic tendon excursion. Consistency in the design and size of the goniometer, the amount of force applied, and placement of the goniometer improves the reliability of each reevaluation3 (Fig. 37-5).
37
necrosis might occur. The rate of progression varies and can develop over a period of a week or more. It is important to know the mechanism of injury, as this is key to the severity of the situation. The forearm compartments and the intermetacarpal spaces in the hand should both be examined. Immediate recognition is crucial. Signs and symptoms include pain out of proportion to the injury, pain that increases with passive stretch, a decline in temperature and sensibility of the hand, and pulselessness.6,30,35 Decompression must be completed promptly to ensure good return of function. If the compression goes unrecognized and surgery is delayed, necrosis and subsequent contracture can result. The therapist should communicate with the surgeon to determine what tissues were found to be necrotic and the status of the peripheral nerves. After decompression, it is important to start motion early. The muscle-pumping action aids in edema reduction, maintains motion to unaffected joints, and promotes tendon gliding.
REHABILITATION OF THE MUTILATED HAND
FIGURE 37-5. An initial baseline evaluation as well as re-evaluations are important components in establishing goals and assessing progress. A finger goniometer is utilized to accurately assess digital range of motion.
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THE MUTILATED HAND
The nature and degree of injury will determine sensibility testing. Testing might be delayed secondary to pain, dressings, open wounds, complete nerve transection, or edema. Sensibility testing assists in determining the degree of nerve injury as well as the extent and type of sensory recovery. Many assessments are commonly used in clinics today; these include provocation tests (i.e., Tinel’s sign), stress tests, Semmes-Weinstein pressure aesthesiometer, static or moving two-point discrimination, and the Moberg Pickup test. A battery of tests is the most useful in providing a complete assessment. All tests should be completed in a standardized manner in a distraction-free room.14 Grip and pinch strength should also be assessed as precautions allow. When both grip and pinch strength are being evaluated, the patient should be seated with the shoulder adducted, the elbow flexed to 90⬚, and the forearm and wrist in a neutral position. The use of a standard adjustable-handle dynamometer is recommended. It is important that calibration of the dynamometer be maintained for accurate readings. It is recommended that the second handle position of the dynamometer be used, if only one handle span is used, and that the mean of three successive trials be recorded.4,21 Pinch strength can be measured by a commercially available pinchmeter (Fig. 37-6). The mean value of three successive trials is recorded for key pinch, tip-totip pinch, and three-jaw chuck pinch. The time of day when the measurement is taken should be recorded, as it might influence the measurement, and when possible, subsequent measurements should be taken at the same time of day.47 Manual muscle testing is useful to assess the strength of specific muscles. This information is of particular value when there has been nerve involvement. Manual muscle testing aids in determining the prognosis of muscle return
and helps to determine the need for and type of tendon transfers.4 Isolation of specific muscles also allows the therapist to assess the degree of excursion of the muscletendon unit and differential tendon gliding.16 The examiner must ensure proper and consistent positioning, stabilization, and pressure. It is essential that the therapist have a thorough knowledge of anatomy and kinesiology. A variety of standardized tests are available to assess functional outcomes and dexterity. They may be utilized when sufficient healing has occurred. Tests that are commonly used in clinics are the Jebsen Hand Function Test,34 the Minnesota Rate of Manipulation Test (American Guidance Service, Inc., Publisher’s Building, Circle Pines, Minnesota, 1969), the Purdue Pegboard Test (Science Research Associates, Chicago, Illinois, 1948),58 and the O’Connor test.31 The Valpar Work Samples (Valpar Corporation, Tucson, Arizona) and the Baltimore Therapeutic Equipment (Baltimore Therapeutic Equipment Company, Baltimore, Maryland) work simulator are instrumental in evaluating work readiness and are utilized in the end stages of treatment.
TREATMENT A wide range of therapeutic techniques are used in the hand clinic, but patient education and a home program are the essential components throughout the healing process to ensure optimal results. The patient should understand his or her role from the start, and this should be reinforced and updated throughout the rehabilitation process. A home program should be given in writing with specific instructions such as frequency and repetitions noted. These should be available in all of the languages necessary in each particular population. The hand clinic itself is an important aspect of the patient’s rehabilitation. It is very often the environment where patients or their families first see the injury. Consideration should be given to whether the patient should initially be treated in a private area or in an open clinic. If a patient is concerned about the appearance of the hand or how it is affecting his or her life, the clinic can serve as a “safe” place for the patient to make adjustments with other patients who can truly understand what is being felt. The therapist can help to foster this positive emotionally healing experience. If there is concern that the patient is not making the appropriate psychological adjustment, a referral for psychological intervention should be discussed with the surgeon.
Edema Management FIGURE 37-6. A commercially available pinchmeter is used to evaluate pinch strength.
Edema is the normal response to inflammation in the traumatized hand; however, edema must be controlled quickly. Persistent edema can result in tissue fibrosis and
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Retrograde massage mobilizes tissue fluid and increases the lymphatic flow.59 A firm massage from distal to proximal, with the hand in elevation, is recommended.12 Massage should not be performed if infection is present. Artzberger recommends the use of modified manual edema mobilization for subacute and chronic hand edema. Modified manual edema mobilization consists of (1) light skin-tractioning massage performed in proximal-to-distal segments following the direction of lymphatic flow, (2) exercises to “clear” lymph nodes and stimulate venous and lymphatic flow through muscle contraction, and (3) adaptations of traditional edema control techniques according to light pressure and lymph flow patterns. Modified manual edema mobilization uses a one-handed technique so that patients can do it themselves. This technique is never started in the acute phase of wound healing, and the patient must not have an infection, an open wound, cancer, or a cardiac or pulmonary condition.5 External compression supports are effective in edema reduction by reinforcing the tissue hydrostatic pressure and facilitating venous and lymphatic drainage.28 They must be applied with care, distal to proximal, or they might cause damage to the underlying tissue. They should be worn full time except for bathing. Many types of supports and techniques are available. Initially, compression is achieved by the bulky surgical dressing. When this ceases, Coban (Medical Products/3M, St. Paul, Minnesota) is a good choice, as it is comes in different widths, is inexpensive, and allows unrestricted motion of the digits. Coban also offers good compression for residual limb shaping for the patient who has sustained an amputation (Fig. 37-8). Commercial products such as the Silopad Digital Cap (Silipos, Niagara Falls, New York) and tapered elastic finger sleeves (Smith & Nephew Roylan, Inc., Germantown, Wisconsin) are also available and are helpful, especially when several fingers are involved. Flowers
FIGURE 37-7. Edema can be reduced or prevented by early elevation.
FIGURE 37-8. Coban is often used to reduce digital edema by circumferential compression.
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adhesions and, ultimately, restrictions of range of motion and impaired hand function. Edema tends to occur on the dorsum of the hand, resulting in a “false intrinsic minus” attitude. The metacarpophalangeal joints extend, and the interphalangeal joints and wrist flex while the thumb adducts, decreasing the thenar webspace. Soft, pitting edema associated with the inflammatory phase is far easier to treat than the “brawny,” thick, gel-like edema associated with chronic inflammation. Elevation of the extremity is simple and is the most effective procedure for prevention and reduction of edema59 (Fig. 37-7). Elevation reduces hydrostatic pressure within the blood vessels of the elevated area. This decreases the capillary filtration pressure at the arterial ends and facilitates venous and lymphatic outflow from the limb.1 The hand must be positioned above the proximal arm and the most proximal part must be positioned above the heart. This can be achieved through properly positioned pillows or commercially available elevation supports. Elevation levels might need to be altered following microsurgical procedures so that arterial occlusion resulting in ischemia does not occur. Temperature and color changes should be monitored, and adjustments in the elevation levels should be made accordingly.33 Slings are still often recommended to provide elevation. However, they seldom provide the elevation necessary to reduce edema and might cause secondary shoulder and elbow restrictions; therefore their effectiveness is limited. If a splint is being used, the straps should not restrict the dorsal venous system. Active motion should begin as soon as the healing process permits, since exercise causes an increase in both the venous and lymphatic outflow from the limb.59 However, the patient should not be overly zealous in the early stage of healing, as this could cause an inflammatory reaction and result in an increase in edema rather than a decrease. Performing the exercises in an elevated position will enhance their effectiveness.
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has shown that the combination of string wrapping and massage is effective in reducing digital edema.24 When edema is present throughout the hand, custom-fitted compression garments are recommended. They provide the proper grade of support and ease of application. External compression devices such as the Jobst Intermittent Compression Pump (Jobst Company, Toledo, Ohio) also produce a reduction in chronic posttraumatic hand edema.12 They accelerate the lymphatic and venous flow by intermittent mechanical compression that is applied by a pneumatic sleeve inflated under pressure and then deflated.59 The amount of pressure is adjusted according to the patient’s diagnosis but must be set at a pressure greater than 25 mm Hg (capillary pressure) and kept lower than diastolic pressure at all times.24
Therapeutic Exercise The goal of therapeutic exercises is to promote safe mobilization of the hand while at the same time protecting the repaired structures (Fig. 37-9). Controlled motion should be started as early as possible to maximize joint mobility and gliding between all bone and soft-tissue structures. During approximately the first 4 weeks, tendon and nerve repairs will need to be protected. Motion may be active or passive, depending on the nature of the repair. Often, protective splinting is utilized in conjunction with exercise. Active motion should also be initiated to all uninvolved structures to prevent loss of motion secondary to disuse or protective positioning. Most repaired structures can be further mobilized by the fourth week; however, the therapist should always coordinate this with the surgeon. Blocking exercises, as well as differential tendon-gliding exercises, are begun at this time. Passive range of motion is utilized for a contracted
FIGURE 37-9. The patient sustained an amputation to his thumb, index, middle, and ring fingers. His middle finger was replanted. Range of motion is being performed to his little finger to maximize joint mobility.
joint or to maintain full joint mobility when tendon gliding is not fully achieved. Continuous passive range of motion devices and neuromuscular electrical stimulation and biofeedback may be used as an adjunct to the treatment program. Continuous passive range of motion devices prevent adhesions and joint stiffness and stimulate the healing of articular tissues.48 Neuromuscular electrical stimulation provides muscle activation and tendon gliding but should not be used until it is safe to introduce resisted exercises.43 Biofeedback is useful in providing the patient with a visual or auditory signal to enhance muscle contraction, relaxation, or a combination of the two, such as when muscular cocontraction occurs. It also provides motivation.8 Strengthening exercises can usually be safely initiated by the eighth week (Fig. 37-10). Graded putty, resistive hand grippers, and Theraband (HCM-Hygienic Corporation, distributed by Smith & Nephew Roylan, Inc., Germantown, Wisconsin) are relatively inexpensive and can be issued for use in a home program. The Baltimore Therapeutic Equipment work simulator (Work Simulator, Baltimore Therapeutic Equipment Company, Baltimore, Maryland) provides both dynamic and static resistance to a variety of tools and handles. It is important that the patient not overdo the resistive exercises and develop further difficulties such as tendonitis.
Splinting Splinting may be utilized throughout the rehabilitative course. Initially, splints may be used to protect the repaired structures and/or to allow motion in defined parameters (Fig. 37-11). They may be used to maintain the hand in a position of function to prevent soft tissue and joint contracture. This position would place the
FIGURE 37-10. Strengthening exercises with graded putty were initiated at 8 weeks after thumb replantation. This patient sustained amputation of his index finger and multisystem injuries to his remaining digits.
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529
edema and bleeding. It is also contraindicated in the presence of decreased sensation and decreased circulation.15 Cold is the preferred agent during the acute stages of inflammation, as it decreases edema and controls inflammation and pain. Ice massage or cold packs can be utilized. Disadvantages include decreased tissue extensibility and increased joint stiffness. Cold should not be used after revascularization or replants and is also contraindicated for patients with impaired sensation, peripheral vascular disease, circulatory compromise, cold hypersensitivity or intolerance, Raynaud’s disease, or over regenerating peripheral nerves.15 FIGURE 37-11. A protective splint was fabricated following replantation and full-thickness skin grafting.
Scar Management
Thermal modalities are additional tools that are available to assist in the rehabilitative process. They are seldom used in isolation but are used in conjunction with other therapeutic techniques. Heat modalities are used to increase the extensibility of collagen tissue, decrease joint stiffness, increase blood flow, decrease muscle spasm, and provide pain relief. The effectiveness of heat depends on the type of tissue being heated, the depth of the tissue, and the degree of heat that is achieved. Superficial thermal agents such as hot packs, paraffin, and fluidotherapy may be used before exercise, soft tissue mobilization, or serial splinting to increase tissue extensibility.41 Residual tissue elongation is best achieved when both heat and stress are applied.37 Deep heating of selective tissues can be provided by the use of ultrasound. Heat is contraindicated in acute inflammation and can produce further
FIGURE 37-12. The patient is performing a scar massage to mobilize the skin from underlying tissue.
wrist in approximately 10° of extension with the metacarpophalangeal joints flexed to 70°, the interphalangeal joints extended to neutral, and the thumb in palmar abduction. Care must be taken that the strapping of the splint does not increase edema. When healing allows, splints are beneficial in restoring passive motion in a contracted joint. A low-load prolonged stretch technique is needed to promote collagen realignment. The length of time that a joint is held at its end range is directly proportional to the increase in passive range of motion achieved.25 The force that is applied must be gentle. Forces that are too great can cause pain, increase inflammatory response, and cause additional scar formation.22 A prolonged stretch can be achieved through static splints, dynamic splints, serial casting, and static progressive splints. Patient education and compliance are crucial to the success of these techniques.
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Thermal Modalities
Scar formation is a dynamic process of collagen synthesis that remains active at least 6 months to a year after injury. Secondary problems frequently occur, including restriction of gliding structures, joint tightness, skin shortening, and the formation of an unaesthetic scar. Scar massage mobilizes the skin from underlying tissue. Massage should be gentle on newly healed tissue, but pressure can be increased as the skin matures (Fig. 37-12). Non-water-based creams such as lanolin or cocoa butter are recommended. Theraband can also be used to help hold the tissue as it is mobilized. Controlled pressure can also help to control scars. This can be achieved initially through bulky dressings. When healing allows, continuous pressure can be achieved through products such as Coban, commercially available noncustom gloves, or custom-made pressure gloves. Localized pressure can also be supplied by molded splints, Silicone Elastomer (Smith & Nephew Roylan, Inc., Germantown, Wisconsin), dermal pads, and Otoform-K (Dreve Otoplastik GmbH, Unna, Germany). Iontophoresis has also been recommended in controlling scar formation.44
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A
B
FIGURE 37-13. A, The patient is utilizing contact particles from the Three Phase Hand Sensitivity Test. B, The patient is utilizing a textured dowel from the Three Phase Hand Sensitivity Test.
Desensitization
Functional Activities
Hypersensitivity is common following hand trauma. The patient experiences a painful or irritable response to a normally nonnoxious stimulus. This can lead to significant functional deficits and must be addressed early. Desensitization techniques utilize a graded program to gradually increase the patient’s tolerance to tactile stimuli. This may include pressure, vibration, and/or textures. The Three Phase Hand Sensitivity Test and Treatment (LMB Hand Rehab Products, Inc., San Luis Obispo, California) is a commercially available product that is designed to establish a hierarchy of sensitivity and then to provide treatment in an organized and objective manner (Fig. 37-13). Massage, transcutaneous electrical nerve stimulation, fluidotherapy, and functional activities are other techniques that are useful in treatment. Desensitization programs should be incorporated into the home program and should be done several times a day.
Functional activities, including activities of daily living and fine motor/dexterity drills, should be incorporated into the patient’s program as early as possible (Fig. 37-14). These activities not only enhance the goals of treatment, such as increased range of motion, improved strength, or decreased hypersensitivity, but also improve the patient’s functional independence and self-esteem. Work-related issues should also be addressed as early as is deemed appropriate (Fig. 37-15). A job description is helpful in devising this aspect of the treatment plan and can be obtained directly from the employer or the case manager, if one is involved. A functional capacity evaluation, a work-hardening or work-conditioning program, and/or a job site visit might be indicated to achieve a successful
Sensory Reeducation Functional sensation is often poor after a peripheral nerve injury. A sensory reeducation program consists of specific sensory exercises that are designed to have the patient learn to correctly interpret altered profiles of impulses in the central nervous system when the regenerating nerve is stimulated. These exercises are usually divided into two phases. The protective sensory reeducation phase is used to teach the patient to compensate for lack of protective sensation. Once protective sensation is present, discriminative sensory reeducation is initiated.18 This program will help in enabling patients to reach their full sensory potential by maximizing sensory discrimination.
FIGURE 37-14. Cylinder foam is added to a fork, allowing the patient to eat independently.
FIGURE 37-15. Work-related activities were initiated early in this patient’s rehabilitation. Despite bilateral injuries, including multiple amputations, he was able to return to work as a commercial artist.
return to work. Referral for vocational intervention might also be necessary.
CONCLUSION Achievement of the best functional result in this challenging situation depends not only on the surgeon’s technical expertise, but also on the therapist’s knowledge and clinical skills and on the lines of communication among the surgeon, the therapist, and the patient. The therapist must keep the surgeon abreast of the patient’s progress and should clearly review each new phase of rehabilitation with the patient. Both the therapist and the surgeon must be sensitive to the patient’s concerns about present and future cosmesis and functional use. The therapist should be a skilled hand specialist who is capable of planning the treatment of multiple systems simultaneously and interpreting results during each stage of healing. It is also important that the therapist be able to express empathy and share a genuine rapport with the patient while maintaining a professional manner.
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(eds): Rehabilitation of the Hand: Surgery and Therapy. St. Louis, CV Mosby, 1995, pp 1495–1519. Newton RA: Contemporary views on pain and the role played by thermal agents in managing pain symptoms. In Michlovitz SL (ed): Thermal Agents in Hand Rehabilitation. Philadelphia, FA Davis, 1986. Potenza A: Critical evaluation of flexor tendon healing and adhesion formation within artificial digital sheaths: An experimental study. J Bone Joint Surg Am 45A:1217, 1963. Reynolds C: The stiff hand. In Malick M, Kasch M (eds): Manual on Specific Hand Problems. Pittsburgh, AREN Publications, 1984, pp 88–110. Salter RB, Hamilton HW, Saringer JH: Clinical application of basic research on CPM for disorders and injuries of synovial joints: A preliminary report of a feasibility study. J Orthop Res 1:325–342, 1984. Seddon HJ: Surgical Disorders of the Peripheral Nerves, 2nd ed. Edinburgh, Churchill Livingstone, 1975. Slade J, Chou K: Bony tissue repair. J Hand Ther 11:118–124, 1998. Smith K. Wound care for the patient. In Hunter JM, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand: Surgery and Therapy. St. Louis, CV Mosby, 1995, pp 237–250. Smith K: Nerve response to injury and repair. In Hunter JM, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand: Surgery and Therapy. St. Louis, CV Mosby, 1995, pp 609–626. Stewart K, van Strein G: Postoperative management of flexor tendon injuries. In Hunter JM, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand: Surgery and Therapy. St. Louis, CV Mosby, 1995, pp 433–462. Stewart K: Therapist’s management of the complex injury. In Hunter JM, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand: Surgery and Therapy. St. Louis, CV Mosby, 1995, pp 1057–1073. Strickland JW: Biologic rationale, clinical application, and results of early motion following flexor tendon repair. J Hand Ther 2:71–83, 1989. Strickland J: Restoration of thumb function after partial or total amputation. In Hunter JM, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand: Surgery and Therapy. St. Louis, CV Mosby, 1995, pp 1101–1128. Theisen L: Upper extremity vessel repair. In Clark G, Wilgis EF, Aiello B, Eckhaus D, Eddington LV (eds): Hand Rehabilitation: A Practical Guide. New York, Churchill Livingstone, 1993, pp 43–46. Tiffin J, Asher E: The Purdue Pegboard: Norms and studies of reliability and validity. J Appl Psychol 32:234, 1948. Vasudevan S, Melven J: Upper extremity edema control: Rationale of the techniques. Am J Occup Ther 133:520–523, 1979. Verdan C: Syndrome of the quadrigia. Surg Clin North Am 40:425–426, 1960. Wang E: Tendon repair. J Hand Ther 11:105–109, 1998. Ware LC: Partial digit amputation. In Clark G, Wilgis EF, Aiello B, Eckhaus D, Eddington LV (eds): Hand Rehabilitation: A Practical Guide. New York, Churchill Livingstone, 1993, pp 225–228. Waylett–Rendall J, Seibly D: A study of the accuracy of a commercially available volumeter. J Hand Ther 4:10–13, 1991.
38 Painful Digits and Amputation Stumps of the Hand Irvin M. Wiesman, MD Susan E. Mackinnon, MD, FRCS(C)
The mutilated hand presents a therapeutic challenge to the reconstructive hand surgeon during all stages of the patient’s care. The most meticulous of surgical reconstructions coupled with aggressive hand therapy and psychological support and guidance might still be futile if the patient develops a painful digit or amputation stump. This chapter will deal with the difficult-to-manage neurogenic pain problems involving the painful digit and amputation stump.
NEUROMAS
38
Following injury to a peripheral nerve, a patient may experience complete or partial loss of motor and/or sensory function. The extent of recovery depends on the initial degree of injury and the outcome of surgical intervention. Preventing functional loss due to failure of nerve regeneration is a significant concern to the hand surgeon. However, it is equally important to prevent painful sequelae or neuroma formation. Patients may develop significant pain problems after a severe hand and nerve injury. Management of these pain problems is often so difficult that the recovery of function becomes secondary to the patient’s concern about alleviating pain. Some degree of pain is to be expected after nerve injuries. However, it is the pathologic pain, often related to abnormal or incomplete nerve regeneration, that is difficult to manage. After a nerve transection, Wallerian degeneration occurs in the distal segment of the nerve. Proximally, traumatic degeneration occurs for a variable distance, depending on the severity of the injury and the proximity of the injury to the cell body. The neuronal cell body will attempt to regenerate the injured nerve axonal unit. However, a neuroma will form if nerve regeneration is blocked by scar tissue, if regenerating axons escape the endoneurial confines of the nerve at the nerve repair site, or if these axons enter the surrounding soft tissue in cases of amputation. There are two main patterns of neuroma formation: neuromas-in-continuity and neuromas in completely severed nerves. A neuroma-in-continuity is an injury that results in axonal disruption but epineural continuity (Sunderland IV degree or Mackinnon VI degree). In a Mackinnon VI degree injury, the loss of axonal continuity is of varying degrees across different fascicles. This injury poses a surgical challenge to the reconstructive surgeon, who must repair the injured segment of the nerve while maintaining the integrity of the nerve fascicles that are functioning or will recover spontaneously. When a nerve is completely severed 533
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(Sunderland V degree), the classically described neuroma occurs. Amputation stump neuromas are an example of this; some defining features are that the proximal segment is in close proximity to the skin and therefore susceptible to more direct trauma, the neuroma is often entrapped in significant scar tissue, and phantom pain may also be present. These features cause the amputation stump neuroma to be very disabling to the patient and quite challenging to the surgeon.
Anatomy and Histology of Neuromas The classic neuroma demonstrates regenerating nerve fibers that are randomly oriented within scar tissue (Fig. 38-1). The size of the neuroma is proportional to the amount of scar tissue and the number of axonal ingrowths, fibroblasts, Schwann cells, and blood vessels. The closer the injury is to the nerve cell body, the larger the neuroma tends to be; this might be due to an increase in axoplasmic volume. However, it is important to keep in mind that the size of a neuroma does not correlate with the amount of pain experienced.
Neurophysiology of Neuromas Nociceptors are innervated by the small-diameter C and A-delta fibers. The nociceptors mediate the intensity, frequency, and duration of painful stimuli. After a nerve is severed, there is a brief period of spontaneous electrical activity. If the nerve is not repaired, axonal regeneration from the proximal stump will develop into a neuroma, which might or might not become painful. Factors that elucidate the formation of painful neuromas have not been determined. Studies using single-unit nerve-fiber recordings have shown that nerve fibers in neuromas fire
FIGURE 38-1. Neuroma histology demonstrating the random orientation of the nerve fibers and the large amount of inflammatory tissue. In comparison, note the histology of a normal nerve at the bottom right of the picture.
spontaneously and send impulses toward the central nervous system.30 Ephaptic conduction occurs within the neuroma itself;10 that is, adjacent nerve fibers can induce impulses within each other in the absence of a true synaptic connection. After a peripheral nerve transection, changes occur in the dorsal root ganglion, the dorsal horn of the spinal cord, and the sympathetic nervous system. An ephapse may exist between the sympathetic and pain fibers, which might in part explain the association between the neuroma patient and the patient with chronic regional pain syndrome and sympatheticmaintained pain syndrome.14 The large A-beta fibers play an important role in the development of hyperalgesia, which is associated with painful nerve injuries. These fibers normally mediate light touch; following nerve injury, they may be responsible for hyperalgesia.10,31 The importance of this fact is twofold. First, it challenges the gate control theory of Melzack and Wall20 (especially in the situation of sympathetically maintained pain syndrome), which states that the large diameter A-beta fibers block the pain messages from the smaller-diameter pain fibers, C and A-delta. Second, it explains the ability during physical examination to selectively block and differentiate between either neuromatous pain (using local anesthetic infiltration) or hyperalgesia (by tourniquet ischemia alone).3 Much of the information about the pathophysiology of neuroma is provided by animal studies. The primate neuroma models are similar to the human. Meyer et al.21 have shown that neuromas in the adult baboon hand have mechanoreceptor properties and produce painful signals through the C and A-delta fibers. These neuromas not only were spontaneously active with respect to C and A-delta activity, but also were exquisitely mechanosensitive. These findings support the importance of neuroma transposition away from areas of mechanical stimulation. Another important property that has been noted in the primate model is the ability of the nerve’s microenvironment to affect its regenerative capabilities. It has been shown that transposing the severed proximal end of a sensory nerve directly into muscle significantly inhibits neuroma formation.15 In the primate studies, the proximal sensory nerve endings that were implanted into muscle demonstrated significantly less connective tissue than did the nerves that were left under the surgical scar in a subcutaneous location (40% versus 80%). In the muscle-implanted nerves, there was no evidence of invasion or regeneration into the surrounding innervated muscle. The nerve fibers were arranged in the same direction rather than in the random and disorganized fashion described for the classic neuroma.21 Clinically, physicians have been transposing sensory nerves into muscle since Moszkowicz first did so in 1918.23 The success of this technique was confirmed in a clinical study published by Mackinnon and colleagues in 1985.15
PATIENT SELECTION FOR SURGICAL TREATMENT In treating a patient with a traumatized hand, the initial management includes close postoperative follow-up, intensive physical therapy (including desensitization techniques), and appropriate pain medication or other pharmacologic agents (e.g., Neurontin or tricyclic antidepressants) to allow the patient to achieve the maximum benefit from the reconstructive procedure. If, despite the above interventions, the patient still complains of severe pain that prevents the achievement of full functional ability, patients should be evaluated for a surgically correctable neurogenic cause for the pain (Fig. 38-2). Before any surgical procedure is attempted, a very structured workup is necessary to confirm the diagnosis and to select the appropriate surgical candidate. Mackinnon and Novak15,18 have modified a rating scale to assess patients with extremity pain (see Appendix 1). This pain evaluation form consists of a body diagram pain drawing, 10-cm visual analog scales for quantifying the pain, a list of pain descriptors, and questions about work, home, medications, and other stressors. The above categories are considered positive when more than three adjectives are chosen to describe the pain, the body diagram does not follow a known anatomic pattern, and the patient scores higher than 20 points when answering the questionnaire. This rating scale allows the practitioner to select the most appropriate surgical candidate (none or only one positive category) as well as to identify the patients whose pain complexes are associated with a functional overlay, which would predict a poorer result with surgery. Patients who score high enough to suggest that the cause of the pain is more than organic (two positive categories) should consider a psychiatric consultation, multiple follow-up visits, and possibly a second opinion before surgery is attempted. Patients who score positively on all three categories (pain descriptor, pain drawing, and numerical scale) are not surgical candidates. Grip strength testing is useful for evaluating the patients and can also be performed in a way (i.e., rapid simultaneous grip strength tests) that identifies the malingering or noncompliant patient.7 After baseline grip measurements are made, patients are given two Jamar grip meters and are asked to squeeze them simultaneously and rapidly. Patients with true weakness will not significantly increase their baseline measurement in the weak hand compared to the patient who is malingering, whose grip strength will approach the normal hands strength. Patients who feign weakness will tend to equalize the grip measurement in both hands (i.e., the strong normal hand will show a decrease in grip measurement, and the hand with the feigned weakness
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will show an increase in grip measurement recordings). Patients who malinger will usually be noncompliant and usually will not do the test at all or will refuse to do the test rapidly so that they can continue to control their faked weakness. In dealing with neuromatous pain in the hand, diagnostic nerve blocks assist in identifying the involved nerve or nerves and help to identify a sensory nerve overlap pattern that leads to the patient’s pain. Neuromatous pain is diagnosed by eliciting pain in the distribution of a peripheral nerve by percussion of that nerve at the site of injury. This sensation is called a Tinel’s sign. For the patient with established severe pain that is neuromatous, a very thorough examination is necessary to identify the nerve or nerves that are causing the symptoms. The patient is asked to identify the most painful area. The surgeon then evaluates potential contributors to the pain syndrome (e.g., radial sensory, lateral antebrachial cutaneous nerve, ulnar or median nerve and their branches). Mackinnon13 has described a very useful clinical test to evaluate whether or not a particular nerve is innervating the neuroma. The potentially involved nerve is tapped along its course well proximal to the actual neuroma. If the nerve is involved, a “Tinel’s” like response is noted about 2 to 4 inches proximal to the neuroma that radiates into the distribution of the involved nerve. The patient might also describe tenderness with direct palpation of the involved nerve 2 to 4 inches proximal to the neuroma. Therefore this evaluation does not require direct contact with the neuroma, which is usually so painful as to preclude determination of the specific nerves that are involved. Once the involved nerves have been established with the “Mackinnon tap test,” the examiner then taps the opposite normal hand in the area corresponding to the painful area of the involved hand and asks the patient how he or she would respond to similar percussion in the affected hand. This gives the examiner an idea of how painful the patient perceives the area of discomfort to be. The patient is then asked to touch the area of maximum pain as the surgeon observes the patient’s response. Only then will the examiner attempt to percuss or touch the area of maximum discomfort or neuroma formation and only then with the patients permission. This technique lets the patient know that the surgeon has at least some idea of the amount of pain the patient is experiencing and gives the patient confidence in the surgeon. Frequently, we do not need to palpate the area of maximum pain to determine that patients are potential surgical candidates and indeed have severe neuromatous pain. At other times, direct palpation of the “painful” area will not elicit much pain response from the patient, suggesting that surgery would not be indicated, as the
38
38
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THE MUTILATED HAND
MANAGEMENT OF THE PAINFUL HAND Neurogenic No
Yes R/O neuroma
R/O degenerative joint disease, inclusion cyst, remnant stump, pain No
Yes
R/O SMP No
Pain management
Sympathetic component to the pain
Yes
Respond to medical sympathectomy *No
Pain management
Yes
• Surgical sympathectomy • Spinal cord stimulator • Pain management
No
Nerve reconstructable No
Proximal transposition
Yes
• Primary repair • Interposition graft • Nerve conduit or nerve transfer
Yes
R/O SMP No
Treat the neuroma* and pain management
Yes
Respond to medical sympathectomy
No
Treat neuroma∗ and pain management
Yes
• Surgical sympathectomy • Spinal cord stimulator followed by the treatment of the neuroma* and pain management
FIGURE 38-2. An algorithm demonstrating the workup and treatment of the patient presenting with a painful posttraumatic hand. (SMP ⫽ sympathetic-maintained pain)
patient does not have enough discomfort to likely benefit from surgical exploration. Selective anesthetic nerve blocking can be done to determine the nerves that are involved in the neuroma
and also show the patient the type of “numbness” that can be anticipated from the neurotomy. Occasionally, patients will describe the “numbness” associated with the nerve block as more annoying than the actual pain
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PAINFUL DIGITS AND AMPUTATION STUMPS OF THE HAND
2. If the function of the injured nerve is not critical or the treatment outline above fails, if the distal nerve stump is not available (as with amputation neuromas), or if the tissue bed and local environment are not suitable for a nerve graft (such as the radial sensory near the wrist), the neuroma is resected, and the proximal nerve is transposed into an area that is subjected to the least amount of mechanical stimulation. 3. Rarely, a distal nerve is not available, and restoration of function in the injured nerve distribution is critical. An innervated free tissue transfer (such as innervated great toe, wraparound flaps or innervated skin flaps, or neurovascular island flaps) can be considered to accept the regenerating nerves from the injured sensory nerve. 4. If conventional surgical procedures fail to relieve symptoms, then a peripheral nerve stimulator placed in the upper arm on the involved main nerve should be considered.
from the neuroma. These individuals are also not surgical candidates. If the radial sensory nerve is considered a candidate for the patient’s pain, then it is blocked just dorsal to the junction of the brachioradialis tendon and the brachioradialis muscle. If this block alleviates the patient’s pain, then proximal transposition of the radial sensory into brachioradialis muscle might be all that is necessary. The lateral antebrachial cutaneous nerve is similarly evaluated by blocking the nerve adjacent to the cephalic vein in the proximal forearm. If a digital nerve is involved, the block is done well proximal to the neuroma.
PRINCIPLES IN THE MANAGEMENT OF NEUROMAS The ultimate goal in treating the patient with a painful neuroma is to alleviate pain and preserve or restore function. In general, physicians should follow four basic principles when dealing with the surgical management of the painful neuroma:14
The intact cell body and proximal axon maintain the capability of regeneration for an indefinite period of time after injury. When axons escape the confines of the epineurium, a neuroma develops. Therefore the optimum approach to treating and preventing neuroma formation when repairing a peripheral nerve is the meticulous alignment of the proximal and distal nerve segments so that the proximal regenerating units are channeled into the distal nerve. This approach maximizes the chances for functional recovery as well
38
1. If appropriate distal nerve and sensory receptors are available, a tension-free primary repair (Fig. 38-3) or a nerve graft can be used to direct the regenerating nerve fibers from the proximal stump into the distal nerve and sensory receptors. This will reverse the changes that occur along the peripheral and central nervous systems subsequent to division of a sensory nerve. At the same time, it will restore sensory function.
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A
B
FIGURE 38-3. A, This patient had a laceration of the radial digital nerve to the left index finger. B, At the time of surgery, the distal neuroma and proximal glioma were resected, and a direct end-to-end repair was possible without the need for a nerve graft.
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as minimizing the risk of neuroma formation. This is the standard of care whether the nerve is repaired primarily, with a nerve graft or with a nerve conduit.
TECHNIQUE OF NERVE GRAFTING The goal in restoring nerve continuity is to direct the regenerating nerve fibers into the environment of the distal nerve with little or no loss of regenerating axonal units at the repair site. Mackinnon and Dellon14 described eight basic axioms that form the basis for management of the nerve-injured patients: 1. Quantitative preoperative and postoperative clinical assessment is required for both the motor and sensory system. 2. Microsurgical technique, including magnification, microsurgical instruments, and sutures, is used. 3. A nerve repair must be tension free. 4. When a tension-free repair is not possible, a nerve graft is used. 5. Postural positioning of the extremity to facilitate an end-to-end repair is avoided. The nerve repair or nerve graft is performed with the extremity in a neutral position with no tension at the repair site. 6. A primary nerve repair is performed whenever the clinical and surgical conditions permit. 7. When the internal neural topography of the peripheral nerve permits, a group fascicular repair is performed. When the fascicles do not have a well-defined or specific sensorimotor function, then an epineural repair is performed. 8. A course of postoperative motor and sensory reeducation4 will maximize the potential surgical result. We would also emphasize a ninth axiom: early protected movement. This will decrease scarring around the repair site and facilitate nerve gliding. There is no obvious functional benefit between epineural and fascicular repair. With a fascicular repair, potential problems include mismatching of fascicles as well as increased technical trauma and difficulty of repair. While some surgeons believe that the epineural repair provides less specificity of fascicular alignment, proponents of the epineural repair believe that epineural alignment might allow neurotropic effects to influence the specificity of nerve regeneration. With monofascicular nerves, we perform epineural repairs using anatomic landmarks, such as vascular markings on the epineurium, to help align corresponding fascicles. In the situation of multifascicular nerves with
groups of fascicles with specific functions, we perform group fascicular repairs.
MANAGEMENT OF NEUROMAS OCCURRING IN THE HAND AND AMPUTATION STUMP Digital neuromas in the nonamputated hand are best managed with resection of the neuroma and scar back to healthy nerve fascicles and then reconstitution of the nerve gap with a nerve graft (Fig. 38-4). A nerve graft is necessary if there is tension on the nerve after a repair. If the nerve ends cannot be approximated with the use of one or two 8-0 sutures, then the tension on the nerve is too great for a direct repair. In general, if you think you need a graft, use it. The same size nerve defect might or might not tolerate a primary repair, depending on its location in the upper extremity. The ability to adequately mobilize the proximal and distal nerve segments depends on where the nerve lies. Even a short defect in the digits might not tolerate a primary repair. Undue tension at a nerve repair site will result in scar formation that will block nerve regeneration. The surgical technique for nerve grafting is very similar to that for a primary nerve repair. Important principles that we follow when using a nerve graft are as follows: 1. When cutting back the proximal and distal nerve segments to normal tissue, débride the end of the fascicles to equal lengths so that the repairs will all be carried out at the same level. This technique will allow the regenerating fibers to be “captured” by adjacent nerve grafts if they “wander” outside of their designated graft. 2. Try to achieve accurate alignment of motor and sensory fascicles at the proximal and distal repair sites. 3. If the proximal nerve has a mixed or unknown fascicular pattern but the distal nerve has divided into dedicated sensory or motor fascicles, proximal fascicles can be selectively directed to reinnervate only critical (e.g., motor) function; that is, if you are unsure of what the topography is proximally, at least don’t waste fibers in functionally unimportant fascicles distally. 4. Consider awake stimulation to identify motor versus sensory fascicles proximally. 5. In using a relatively long nerve graft, the graft is reversed (place the distal end proximally and vice versa). This ensures that the regenerating axons will be convergent rather than divergent as they regenerate through the graft and are not lost through side branches.
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PAINFUL DIGITS AND AMPUTATION STUMPS OF THE HAND
A
B
C
D
539
FIGURE 38-4. A, This woman previously had an endoscopic carpal tunnel release and had significant pain in the palmar cutaneous distribution and also in the distribution of the third webspace. B, The divided median nerve that would innervate the third webspace is seen. C, The proximal and distal ends of the nerves to the third webspace are identified and will be resected back to healthy fascicles. D, A nerve graft using the anterior branch of the medial antebrachial cutaneous nerve will be used to reconstruct this defect. The palmar cutaneous nerve will be neurolyzed and transferred proximal into the forearm muscles.
sits under the sublimis muscle and the distal repair site can be covered with a transferred abductor digiti minimi muscle. The nerve grafts that are most commonly used are the lateral antebrachial cutaneous nerve, the anterior branch of the medial antebrachial cutaneous nerve, and the sural nerve. The terminal portion of the anterior interosseous nerve at the level of the pronator quadratus muscle can be used to avoid any sensory deficit. The authors have had excellent experience using the anterior branch of the medial antebrachial cutaneous nerve. It has little donor deficit, and the scar is well hidden above the elbow.
38
6. Often, a donor nerve graft is slightly smaller at one end or the other. When nerve grafting to control pain, err on the side of having the nerve graft at the proximal repair slightly larger than the proximal nerve and at the distal end slightly smaller. This will ensure that all of the regenerating sensory pain fibers are “captured” at the repair site and not “lost” into surrounding tissue to cause painful suture line neuromas (Fig. 38-5). 7. When treating a painful median nerve injury at the wrist with a nerve graft, consider making the nerve graft slightly longer than necessary (Fig. 38-6) so that the proximal nerve repair site
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THE MUTILATED HAND
Proximal coaptation site
Distal coaptation site
FIGURE 38-5. Demonstration of the principle of having the larger end of the nerve graft at the proximal coaptation site and the smaller end at the distal coaptation site. This technique helps to ensure that all the regenerating axons are captured and directed into the distal nerve end.
The use of conduits to bridge a nerve gap is gaining popularity with good results for the treatment of digital nerve defects less than 3 cm.32 The use of an absorbable conduit has theoretical and practical advantages over a nerve graft. These include obviating the need for a donor nerve and the morbidity associated with harvesting the donor nerve. This technique can be used in an acute injury, especially if the extent of nerve damage is not clear and thus sacrifice of a donor nerve is of concern. If a short segment (1 to 2 mm) of healthy nerve is moved into the midportion of the conduit, then the gap distance is decreased, an in situ source of trophic factors is supplied, and regeneration is enhanced.5
FIGURE 38-6. Management of a median nerve neuroma at the wrist. Lengthen the nerve gap so that the proximal nerve graft coaptation site lies under the sublimis muscle and the distal nerve graft coaptation site lies under a transposed abductor digiti minimi muscle flap.
Multiple procedures have been developed to try to prevent neuroma formation. Surgeons have capped the transected nerve end with substances ranging from silicon21 to metal foil and epineurium.28 Ligation,1,24 electrical coagulation, and chemical agents including alcohol, phenol, and formaldehyde have all been tried to temper nerve regeneration. While the use of ricin is clinically not applicable owing to systemic toxicity, it is theoretically intriguing. This agent causes neural cell death via retrograde transport into the cell body, a “suicide transport.” The above techniques have been attempted with the proximal nerve stump left in situ as well as combined with proximal transposition of the nerve stump. Depending on the location of the neuroma, the transposed nerve can be placed into bone, muscle, or fat. The key to any transposition is to place the proximal nerve into an area that will protect it from direct trauma and mechanical stimulation, avoiding excessive movement and allowing it to rest without any tension. Our specific treatment for neuromas depends on their location in the hand. If a single digital nerve neuroma is the cause of pain, the painful neuroma is resected back to healthy fascicles. We then “cap” the proximal end with bipolar electrocautery and transfer the nerve end proximally without tension and implant it into the medullary canal after drilling a hole into the appropriate phalanx. If both digital nerves are involved, we do not leave the patient with an anesthetic digital pulp. Therefore the nerve is dissected to the point at which healthy branches are noted innervating the skin, and the integrity of these branches are maintained so as not to leave deinnervated skin flaps, which will be a “lure” to aberrant regeneration and collateral sprouting that might be interpreted as painful hyperalgesia. If necessary, we will revise or perform a primary amputation to allow innervated skin to cover the digit. The proximal end of the nerve is directed into the phalanx and secured with an epineural-periosteal suture, always without tension on the nerve. Occasionally, the neuroma will only involve a dorsal digital branch. In this situation, the dorsal digital branch is transferred into the phalanx, and the main digital nerve is protected. If the neuroma involves the common digital nerves or digital nerves in the palm and repair with a nerve graft or other conduit is not possible, and the patient does not have a significant or firmly established pain syndrome, we will transpose the nerve from the palmar aspect of the hand dorsally into the soft tissue of the hand in the interosseous muscles. This places the nerve in an environment away from mechanical stimulation. The lumbrical muscles are not a suitable environment to transpose the proximal nerve segment. This relates to their small size and significant excursion. Therefore this area provides little protection to the nerve and poses a
PAINFUL DIGITS AND AMPUTATION STUMPS OF THE HAND
541
higher chance for mechanical stimulation of the transposed nerve. If the digital nerves are the cause of the neuromatous pain, the neuroma is excised and the involved nerve is transposed proximally (Fig. 38-7). If the digital neuroma is relatively proximal in the hand and there is insufficient length to transpose the nerve, extra length can be recruited by neurolyzing the involved fascicles from the main nerve. The length of involved nerve can then be transposed proximally to have the nerve end lie in the muscle interface between the deep and superficial flexors. Transmetacarpal amputations, especially index ray amputations, are particularly problematic. They tend to have a high incidence of neuroma formation, up to 85% in some series.9 In performing the initial ray amputation, the sensory nerves are identified and dissected “long” to allow for a controlled proximal transposition (Fig. 38-8). Branches innervating the skin that will remain are maintained so that this skin flap remains innervated. A deinnervated skin flap will be a “lure” to adjacent sensory nerves and might result in aberrant painful reinnervation and hyperalgesia. Notably, in treating the patient with neuromatous pain and a painful scar, simply excising the involved skin and performing a resurfacing procedure without treating the underlying nerve injury itself will not address the etiology of the patient’s symptoms; it will inevitably lead to a failed procedure.2 For those complicated patients who continue to complain of neuromatous-type digital and hand pain despite previous operations, Mackinnon12 has described using a wandering nerve graft technique. She presented a case in
which a patient with an index ray amputation developed neuromas and, despite local transposition, continued to complain of severe pain. In this patient, the digital nerves to the index metacarpal were neurolyzed from the median nerve proper and transposed dorsally. A sural nerve graft (22 cm) was coapted to the involved digital nerves, and the free end (proximal) was placed under the brachioradialis muscle. This patient had almost complete relief of his hyperalgesia. This procedure should be considered as a salvage operation for the patient for whom other interventions fail. These problems might be more easily controlled in the future when the use of nerve allografts becomes more readily available.16 In patients with pain following index ray amputation, if the radial sensory and lateral antebrachial cutaneous nerves are involved, they are transferred proximally into the brachioradialis muscle (Fig. 38-9). If the median nerve is also involved, the distal portion of the radial sensory nerve can be used as a source of “wandering nerve graft” material, if needed. A peripheral nerve stimulator on the median nerve in the proximal arm can also be used to salvage these very challenging pain problems.25 If pain control has not been achieved despite previous surgical interventions of a nerve-related problem, implantation of a peripheral nerve stimulator might provide pain relief. The patient who is suitable for implantation of a peripheral nerve stimulator has (1) pain localized to a specific nerve, (2) pain relief after a local nerve block, and (3) satisfactory results after a psychological evaluation. Studies have shown that in a recalcitrant patient population who have failed to achieve pain relief and all other surgical interventions have failed, more than
A
B
FIGURE 38-7. A, This patient had had several previous procedures involving the left ring finger and continued to have severe causalgia, neuromatous pain, stiffness, and tenderness in the left ring finger. The digital nerves innervating the left ring finger are neurolyzed. B, The involved nerves are then neurolyzed from the median nerve and ulnar nerves, and these nerves are then transferred proximally. They will be positioned between the superficial and deep flexors.
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B
C
D
FIGURE 38-8. A, This patient has had numerous previous procedures involving the digital nerves to the left index finger and had a stiff and painful index finger. A ray amputation of this painful nonfunctioning digit was elected. B, The main dorsal branches of the ulnar and radial digital nerves are noted. A branch of the radial sensory nerve is noted. These nerves are “skeletonized.” The distal end of the nerves will be cauterized and then turned back dorsally to lie in the bone or away from the mechanically stimulated area of the hand. C, The involved nerves are placed in the index metacarpal. D, Postoperatively, the patient has good pain relief and a full range of movement.
60% of these patients have good to excellent pain relief with nerve stimulator implantation devices.25
REFLEX SYMPATHETIC DYSTROPHY, SYMPATHETIC-MAINTAINED PAIN SYNDROME, AND COMPLEX REGIONAL PAIN SYNDROME Reflex sympathetic dystrophy (RSD), initially described in 1864 by Mitchell et al.,22 continues to be a diagnostic and therapeutic dilemma. Diffuse hand pain, impaired
hand function, and autonomic dysfunction characterize this disorder. The sympathetic nervous system might or might not be involved. Even those patients who appear to have “sympathetic” changes might have pain independent of the sympathetic nervous system. The patient’s response, with reported pain relief, after a sympathetic block will identify the degree of sympatheticmaintained pain (SMPS) versus sympathetic-independent pain (SIPS) involved in the pain syndrome. Owing to the confusion and ambiguity surrounding the term “reflex sympathetic dystrophy,” this disorder has been given a new classification based on its clinical findings and has been termed “complex regional pain syndrome (CRPS).”27 CRPS is considered to comprise two main
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PAINFUL DIGITS AND AMPUTATION STUMPS OF THE HAND
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C
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FIGURE 38-9. A, This patient suffered a crush injury to his left wrist (star). Tinel’s sign was elicited proximal to the point of maximum tenderness (Mackinnon’s sign) along the course of the lateral antebrachial cutaneous nerve and the dorsal radial sensory nerve. B, The lateral antebrachial cutaneous nerve and dorsal radial sensory nerve are dissected long. C, The proximal nerve ends are “capped” with bipolar cautery. D, The nerves are then transposed proximally into the brachioradialis muscle.
1. Patient complaint of pain that does not follow the distribution of a peripheral nerve 2. Diminished hand function 3. Joint stiffness 4. Skin and soft tissue changes with or without vasomotor instability
CRPS I (RSD) can be described as having three stages: 1. The early phase exhibits very dramatic vasomotor overactivity, which is demonstrated by redness, warmth, and cyanosis and sweating of the involved digit or hand with or without edema. 2. The intermediate phase is less dramatic, with less edema and vasomotor instability but with increasing stiffness and atrophy of the joint and soft tissues. The hand might appear cool and pale. 3. The late phase presents with joint stiffness, which is usually due to a form of disuse atrophy. The patient might now be incorporating symptoms in other joints of the involved extremity.
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subtypes. Type I demonstrates all the features of reflex sympathetic dystrophy without any definable nerve lesion. Type 2 occurs when there is a specific nerve injury as a trigger for the patient’s symptoms. CRPS I or II might or might not be maintained in whole or in part by abnormalities in the sympathetic nervous system. Mackinnon and Holder have established a set of diagnostic criteria for CRPS I (RSD):17
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THE NEUROPATHOPHYSIOLOGY OF SMPS Normally, the pain fibers (nociceptors) in the skin carry afferent information via C and A-delta fibers to the spinal cord and synapse with the dorsal horn neurons. These neurons in turn convey central information via ascending tracts for information processing and also synapse with motor and sympathetic neurons in the spinal cord. SMPS can influence several components of the nociceptive loop. Substances that excite (bradykinin) or sensitize (prostaglandins) skin nociceptors are released in the skin. The same substances have an effect on the sympathetic nervous system and on skin capillaries, producing vasodilation and
FIGURE 38-10. A, Model of the pain pathway demonstrating how in the normal situation the touch receptors (or low-threshold mechanoreceptors) are not involved in the central perception of pain. B, Model of sympatheticmaintained pain syndrome (SMP). Nociceptor afferents creates sensitization within the central nervous system such that the afferents form the touch receptors (low-threshold mechanoreceptors) will now lead to the perception of painful hyperalgesia. The efferent activity in the sympathetic nervous system will also upregulate the nociceptors. (Modified from Campbell et al, 1994.)
increased capillary permeability. The sympathetic nerves may excite the nociceptors and influence the release of various algesic substances in the skin, which in turn will produce capillary changes typical of SMPS.14 In the situation of SMPS, the nociceptors upregulate the expression of the alpha-adrenergic receptors. This makes them more sensitive to the catecholamines released by the sympathetic nervous system. Within the central nervous system, central pain signaling neurons are sensitized such that input from low-threshold mechanoreceptors (which normally do not carry pain information) also will evoke a pain response. It is this abnormal physiology between the afferent sensory system and the efferent sympathetic system that is associated with SMPS (Fig. 38-10).
PAIN PATHWAY PNS
CNS
Injury
PAIN Central Pain Signaling Neuron (CPSN)
Pain receptors
Touch receptors Sympathetic neurons A
SMP PNS
Cutaneous stimuli
CNS
Injury
PAIN
Pain receptors
Central Pain Signaling Neuron (CPSN)
NE receptor Touch receptors NE Sympathetic block B
+ Modulation Sympathetic neurons
A response to sympathetic blockade supports the diagnosis of SMPS. Diagnostic tests that help to support the presence of SMPS include the following: 1. Cold-induced hyperalgesia. 2. A response to a sympatholytic medication (e.g., intravenous phentolamine) 3. A response to an alpha-2 agonist such as clonidine 4. A response to sympathetic ganglion blocks If there is evidence of a sympathetic component to the patient’s pain syndrome, then aggressive blockade of the sympathetics should alleviate pain. A neuroma, a neuroma-in-continuity, or a compression neuropathy can cause CRPS II, and cautious surgical correction of an underlying nerve injury should be considered. An abnormal triple-phase bone scan correlates with a diagnosis of CRPS.17 The triple-phase bone scan consists of three phases: the radionuclide angiogram, the blood pool or tissue phase, and the delayed (metabolic) images. To be considered a positive scan, phase 1 has to be increased in all portions on the wrist and hand. Phases 2 and 3 have to show increased activity in the areas of the carpal, intercarpal, carpometacarpal, metacarpophalangeal, and juxta-articular joints. Increased diffuse activity in phase 3 of the bone scan correlates with the diagnosis of CRPS. Mackinnon and Holder found that the diffuse increased tracer uptake in phase 3 of the bone scan is diagnostic for CRPS with a specificity of 98% and a sensitivity of 96%. Without a focus of nociceptive irritation, the best form of treatment is early diagnosis and aggressive treatment. Therapy is most effective if provided during the early phase of CRPS.14 Therapy includes range-of-motion exercises, desensitization treatments, and physiotherapy. Some physicians (although it is not our experience) have found a transcutaneous electrical nerve stimulation unit beneficial in improving symptoms by inhibiting smaller nociceptor pain fibers.11,19,26 A series of sympathetic blocks might be successful in breaking the pain cycle. If the patient has achieved temporary, but not permanent, relief of symptoms with sympathetic blocks and has achieved maximum benefit from physical therapy but is still experiencing pain, a surgical sympathectomy should be considered. Once patients are in the late stages of the syndrome, no form of treatment is very successful. Some physicians have found success in treating the joint stiffness during the late stages of CRPS by using an intravenous anesthetic bier block mixed with 80 mg of methylprednisolone sodium succinate. In this procedure, while the patient is blocked, the surgeon gently manipulates the stiff joints. This can be followed by a series of such blocks over successive days as well as aggressive use of passive and active motion and an oral steroid taper.14 Recently, spinal cord stimulation has been shown to help improve the pain associated with CRPS in patients who
PAINFUL DIGITS AND AMPUTATION STUMPS OF THE HAND
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have failed less conservative treatment,8 and intrathecal baclofen, a GABA-receptor agonist, has been shown to improve the dystonia found in some of these patients.29
CONCLUSION Management of the painful hand after severe trauma is one of the most challenging problems encountered by the reconstructive hand surgeon. Musculoskeletal problems such as traumatic arthritis, a foreign body, or synovitis due to an amputation remnant6 can be easily diagnosed with plain X-rays. Soft tissue contractures and adhesions should be obvious on clinical examination. Treatment of neuromas in the hand includes reestablishment of the continuity of the nervous system with reapproximation or use of autologous nerve grafts. If there is not an adequate distal nerve segment to attempt a nerve repair, then the proximally transected nerve is transposed into a favorable environment of bone or muscle. A “wandering nerve graft” or a nerve stimulator can be useful in salvage procedures. Neuromas-incontinuity should be treated similarly to neuromas. Great care should be taken to avoid downgrading the nerve injury in resecting the injured fascicles. Associated CRPS should be considered as a possible cause of the painful hand. Early recognition, surgical intervention of correctable dystrophic foci, and aggressive physical therapy provide for the best outcome. If these methods fail, sympathectomies (surgical or medical) and spinal cord or peripheral nerve stimulation all have a role in the management of these devastating problems.
References 1. Battista AF, Cravioto HM, Budzilovich GN: Painful neuroma: Changes produced in peripheral nerve after fascicle ligation. Neurosurgery 9:589–600, 1981. 2. Brown H, Flynn JE: Abdominal pedicle flap for hand neuromas and entrapped nerves. J Bone Joint Surg 55A: 875–879, 1973. 3. Campbell LN, Raja SN, Meyer RA, Mackinnon SE: Myelinated fibres in peripheral nerve signals hyperalgesia that follows nerve injury. Pain 32:89–94, 1988. 4. Dellon AL: Evaluation of Sensibility in Re-education of Sensation of the Hand. Baltimore, Williams & Wilkins, 1981. 5. Francel PC, Francel TJ, Mackinnon SE, Hertl C: Enhancing nerve regeneration across a silicone tube conduit by using interposition nerve segment: J Neurosurg 87(6):887–892, 1997. 6. Gross SC, Watson HK: Revision of the painful distal tip amputation. Orthopaedics 12(12)1561–1564, 1989. 7. Joughlin K, Gulati P, Mackinnon SE, et al: An evaluation of the rapid exchange and simultaneous grip test. J Hand Surg Am 18A:245–252, 1993.
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8. Kemler MA, Barendse GAM, VanKleef M, et al: Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. N Engl J Med 343:618–624, 2000. 9. Laborde KJ, Kalisman M, Tsai T: Results of surgical treatment of painful neuromas of the hand. J Hand Surg 2:190–193, 1982. 10. Lindbloom U, Verillo RT: Sensory functions in chronic neuralgia. J Neurol Neurosurg Psychiatry 42:422–435, 1979. 11. Long DM: Electrical stimulation for relief of pain from chronic nerve injury. J Neurosurg 39:718–722, 1973. 12. Mackinnon SE: Wandering nerve graft technique for management of the recalcitrant painful neuroma in the hand: A case report. Microsurgery 9:95–101, 1988. 13. Mackinnon SE: Neuromas. Foot Ankle Clin 3(3):385–403, 1998. 14. Mackinnon SE, Dellon AL: Surgery of the Peripheral Nerve. New York, Thieme Medical Publishing 1988. 15. Mackinnon SE, Dellon AL, Hudson AR, et al: Alteration of neuroma formation produced by manipulation of neural environment in primates. Plast Reconstr Surg 76:345–352, 1985. 16. Mackinnon SE, Doolabh VB, Trulock EB, Novak CB: Outcome following clinical nerve allograft transplantation. Plast Reconstr Surg 107:1419–1429, 2001. 17. Mackinnon SE, Holder LE: The use of three phase radionuclide bone scanning in the diagnosis of reflex sympathetic dystrophy. J Hand Surg 9:556–563, 1984. 18. Mackinnon SE, Novak CB: Evaluation of the patient with thoracic outlet syndrome. Semin Thorac Cardiovasc Surg 8:190–200, 1996. 19. Melzack R: Prolonged relief of pain by brief, intense transcutaneous somatic stimulation. Pain 1:357–373, 1975. 20. Melzack R, Wall PD: Pain mechanism: A new theory. Science 150:971–979, 1965. 21. Meyer RA, Raja SN, Campbell JN, et al: Neural activity originating from a neuroma in the baboon. Brain Res 325:255–260, 1985.
22. Mitchell SW, Morehouse G, Keen WW: Gunshot wounds and other injuries of the nerve. Philadelphia: JB Lippincott, 1864. 23. Moszkowicz LP: Behandlung der schmerzhaften neuroma. Zentrafbl Chir 15:547, 1918. 24. Munro D, Mallory GK: Elimination of the so-called amputation neuromas of the divided peripheral nerves. N Engl J Med 260:358, 1959. 25. Novak CB, Mackinnon SE: Outcome following implantation of a peripheral nerve stimulator in patients with chronic nerve pain. Plast Reconstr Surg 105(6):1067–1072, 2000. 26. Richlin DM, Carron H, Rowlingson JC, et al: Reflex sympathetic dystrophy. Successful treatment by transcutaneous nerve stimulation. J Pediatr 93:84–86, 1978. 27. Stanton-Hicks M, Janig W, Hassenbusch S, et al: Reflex sympathetic dystrophy: Changing concepts and taxonomy. Pain 63:127–133, 1995. 28. Tupper JW, Booth DM: Treatment of painful neuromas of sensory nerves in the hand: A comparison of traditional and newer methods. J Hand Surg 1:144–151, 1976. 29. VanHilten BJ, van de Beek W-JT, Hoff JI, et al: Intrathecal baclofen for the treatment of dystonia in patients with reflex sympathetic dystrophy. N Engl J Med 343:625, 2000. 30. Wall PD, Gutnick M: Properties of afferent nerve impulses originating from a neuroma. Nature 248:740–748, 1974. 31. Wallin G, Torebjork E, Hallin R: The preliminary observations on the pathophysiology of hyperalgesia in the causalgic pain syndrome. In Zotterman Y (ed): Sensory Function of the Skin in Primates. Elmsford, NY, Pergamon Press, 1976, pp 489–499. 32. Weber RA, Breidenbach WC, Brown RE, et al: A randomized prospective study of polyglycolic acid conduits for digital nerve reconstruction in humans. Plast Reconstr Surg 106(5):1036–1045, 2000.
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Continued
APPENDIX 1. Pain evaluation score sheet and questionnaire. (From Novak CB, Mackinnon SE: Evaluation of the patient with thoracic outlet syndrome. Chest Surg Clin North Am 9(4):725–746, 1999; with permission.)
A
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39 Revision Amputations of the Hand and Digits Dimitris G. Vardakas, MD Dean G. Sotereanos, MD
DIGITAL AMPUTATIONS A properly performed digital amputation will generally lead to a happy patient and a happy surgeon. Significant shortening of the thumb is not recommended, since a long, painless stump is needed for good function. When a painful or short thumb is present, other reconstructive procedures must be applied. Revision amputation of a digit can be performed after failed attempts to save the digit, when a stiff and painful stump exists, when the remaining stump obstructs the function of the hand, or for cosmetic reasons. There are three different levels at which a revision amputation can be considered: the distal phalanx, the middle phalanx, and the proximal phalanx.
DISTAL AND MIDDLE PHALANX
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When the remaining stump is just distal or proximal to the distal interphalangeal joint, the goal of the amputation is to preserve length, motion, and sensibility.1 When the index finger becomes stiff and painful, the middle finger usually will substitute for the index finger in opposing the thumb (Fig. 39-1). In this case, shortening of the distal or middle phalanx enough to allow for primary skin closure is recommended.14 Preservation of the base of the distal phalanx, if possible, will maintain flexion and extension of the distal interphalangeal joint, as long as the insertions of the flexor digitorum profundus and the conjoined lateral bands remain intact. Usually, in revision amputations of the distal phalanx, the fingernail has to be completely removed. Amputation distal to the flexor digitorum superficialis insertion will preserve proximal interphalangeal joint motion, which should be attempted when possible.11,24 When it is not possible, a disarticulation at the proximal interphalangeal joint is recommended to assist in soft tissue closure without affecting hand function.
Techniques of Digital Amputations The distal segment of the digit is removed, care being taken to preserve the skin flaps for primary closure. Skin flaps are fashioned to preserve volar skin for covering the bony stump. If a disarticulation is performed, the condyles of the phalanx are tapered in line with the shaft. The distal articular cartilage is preserved, if possible, to minimize the risks of hematoma formation and infection.10,25 Midlateral incisions are made on both the ulnar and 549
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THE MUTILATED HAND
Complications of Digital Amputations
FIGURE 39-1. In this patient, the middle finger has replaced the stiff and painful index finger for precision pinch.
radial sides of the digit and are extended proximally for 1.5 cm (Fig. 39-2A). In the case of a middle phalanx amputation, the flexor digitorum profundus is identified, pulled distally, and cut under tension. The flexor tendons must never be sutured to the extensor tendons, to avoid decreasing the excursion of both and thus limiting the function of the noninjured digits, producing a quadriga effect.17 The digital vessels are identified and ligated. The digital nerves are dissected free from the surrounding soft tissues, pulled distally under tension, and cauterized (Fig 39-2B). The use of midlateral incisions ensures that the nerve ends are dissected from the distal stump, hence avoiding neuroma formation. The edges of the skin flaps are trimmed to enable a cosmetic closure (Fig. 39-3). The wound is dressed in sterile fashion, and immediate active range of motion is encouraged to minimize complications and reduce the rehabilitation time.
FIGURE 39-2. Middle phalanx amputation of the index finger. A, Midlateral incisions are made along the ulnar and radial sides. B, The digital nerve is cauterized under traction and allowed to retract proximally.
Possible complications are symptomatic neuroma, lumbrical-plus finger, and profundus tendon blockage.14,12,17,18 A symptomatic neuroma can be avoided by cutting the digital nerve under tension with a bipolar cautery and letting it retract from the traumatized tissue.1 Hemostasis can also decrease the incidence of symptomatic neuromas by limiting the formation of hematomas. Hematomas contain growth factors, and these proteins can promote scar formation by stimulating the proliferation of fibroblasts.21 If a symptomatic neuroma has developed, neuroma relocation to a more proximal site where it is not likely to be compressed is recommended.12 A lumbrical-plus finger can develop after release of the flexor digitorum profundus insertion. This occurs most often in the index finger owing to the relative independence of the flexor digitorum profundus. After the tendon is cut distally, it is free to move proximally, thus increasing the tension in the lumbrical tendon and its contribution to the extensor mechanism of the proximal interphalangeal joint. During active flexion of the digit, further proximal migration of the lumbrical can impair proximal interphalangeal joint flexion, leading to paradoxical extension. Prophylactic division of the lumbrical tendon is not warranted at the time of amputation unless the deformity can be identified perioperatively.14 If a lumbrical-plus finger occurs after an amputation, simple division of the lumbrical tendon under local anesthesia is performed.18 Profundus tendon blockage occurs when the profundus tendon of the amputated finger adheres to an adjacent structure and thereby limits the excursion of the profundus tendons to the intact fingers (the quadriga effect).17 This is more likely to occur in the middle, ring, and little fingers, since their flexor profundus muscle acts as a unit. Clinical symptoms include cramping pain in the wrist and forearm with active flexion and decreased strength in the intact fingers when gripping and holding small objects.17 If both flexion and strength are decreased in an uninjured
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FIGURE 39-3. Completion of a middle phalanx amputation of the index finger.
finger, release of the scarred profundus tendon of the amputated finger is recommended.17
REVISION AMPUTATIONS OF THE HAND AND DIGITS
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based on motor control of the intrinsic muscles and the extensor digitorum communis (Fig. 39-4).14 An index ray deletion reduces grip strength by 20% and reduces stability for handling tools by 50%.16 Furthermore, ray resection narrows the palm and decreases grip function.1 Therefore the proximal phalanx should be preserved for patients who must grasp and stabilize objects such as a hammer, wrench, golf club, or tennis racket.16 However, for a person who is concerned about cosmesis or for an amputated stump that has become fixed in extension and painful, a ray deletion with or without ray transposition is indicated. A ray deletion is also indicated when the remaining stump is very small or the amputation is at the metacarpophalangeal joint. In this case, especially for the central ray, small objects can fall from the palm through the space between the adjacent fingers (Fig. 39-5).2–9,13,15,16,19,20,22,23 However, ray deletions are rarely recommended as the initial treatment;14,16 they are generally held for a revision operation. When the stump is going to remain in place, the same principles for the amputation as described for the middle phalanx are valid.
PROXIMAL PHALANX INDEX FINGER RAY AMPUTATION Index ray deletion eliminates an obstructing amputated stump between the thumb and the middle finger.5 This procedure also creates a smooth cosmetic webspace.
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Any remaining segment of the proximal phalanx will participate in maintaining grip strength and, for the middle or ring finger, will prevent small objects from falling from the patient’s grasp.6,16 The remaining stump usually maintains at least 45⬚ of metacarpophalangeal flexion
A
B
FIGURE 39-4. The amputation stump of the proximal phalanx of the middle finger preserves adequate range of motion in extension (A) and flexion (B).
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THE MUTILATED HAND
proximal portion of the flexor tendon sheath are transected sharply, and the amputation specimen is removed. The periosteal tube is closed, and the skin is trimmed and closed after tourniquet release and meticulous hemostasis (Figs. 39-6E and 39-6F). A soft dressing is applied, and early motion is begun on the first postoperative day. Transfer of the profundus or superficialis to the base of the proximal phalanx of the middle finger7 or suturing of the first dorsal interosseous muscle to the extensor hood or second dorsal interosseous muscle15 has been recommended. In theory, these transfers are designed to increase pinch strength. However, Murray et al.16 found no difference between patients with these transfers and patients without them. Furthermore, excessive intrinsic function in the middle finger developed in three of the nine patients with interosseous transfers; in another patient with a flexor tendon transfer, a rotatory deformity developed.16
FIGURE 39-5. Small objects such as coins can fall from a patient’s hand through the created space after an amputation at the metacarpophalangeal joint of the middle finger.
Therefore, both the function and the aesthetics of the hand improve. 5,16,22
Technique of Index Finger Ray Amputation Under regional anesthesia, the arm is exsanguinated, and a tourniquet is applied. A racquet incision is made around the base of the index finger and extended proximally over the dorsum of the hand. The incision is curved toward the base of the second metacarpal (Figs. 39-6A and 39-6B). The dorsal veins are ligated, and the branches of the superficial radial nerve are cut sharply under tension. The extensor indicis proprius and extensor digitorum communis are sectioned under traction at the level of the index metacarpal. The periosteum is incised longitudinally, and the metacarpal is subperiosteally dissected free of soft tissue. The dorsal and volar interosseous muscles are released at their insertions (Fig. 39-6C). The neurovascular bundles are identified volarly, and the arteries are ligated. The nerves are mobilized 1 to 2 cm proximal to the incision, cut 1 to 2 cm distal to the incision, and buried within the interosseous muscles at the end of the procedure (Fig. 39-6D). The metacarpal is then transected obliquely at its base, the shorter side being the radial side. The extensor carpi radialis longus insertion is preserved. The flexor tendons are transected under tension. The volar plate, the deep transverse metacarpal ligament, and the
Complications of Index Finger Ray Amputation Possible complications after index ray deletion include a prominent index metacarpal stump, symptomatic neuroma formation, and hyperesthesia in the thumb– middle finger webspace. Slocum and Pratt noted that when the metacarpal was transected distal to its midshaft, it could become prominent and create a tender first webspace.22 This complication can be averted by resecting the metacarpal at its base as described. Fisher and Goldner noted that an index ray deletion that is not properly performed can lead to causalgia and neuromas.8 Murray et al. found that hyperesthesia in the thumb–middle finger webspace interfered with function in 37% of the patients who underwent this procedure and severely disabled 10%.16 The authors attributed the disability to excessive mobilization of the radial digital nerve to the index finger.16 Therefore limited dissection of the nerve and placement of the nerve end in the soft tissue envelope of the interosseous muscle are recommended.
LITTLE FINGER RAY AMPUTATION Although ray deletions of the little finger improve the aesthetics of the injured hand, they also decrease the breadth of the palm. This decrease in width reduces grip strength and the ability to stabilize tools.1,16 Therefore, a little finger ray deletion is recommended only when the goal is to improve the appearance of the hand.
Technique of Little Finger Ray Amputation A volar-dorsal V-shaped incision is made over the little finger ray (Fig. 39-7A). Care is taken to preserve the dorsal
A
B
C
D
E
F
REVISION AMPUTATIONS OF THE HAND AND DIGITS
FIGURE 39-6. Skin incisions for an index finger ray deletion at the dorsal (A) and volar (B) aspect of the index ray. A stiff and painful index finger obstructs the function of this patient’s hand. C, Through the dorsal incision, the index metacarpal is stripped of soft tissues and osteotomized at its base. D, Through the volar incision, the digital nerves are dissected far enough to be buried at the interosseous muscles at the end of the procedure. Dorsal (E) and volar (F ) aspects of the hand after the completion of the procedure.
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39
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THE MUTILATED HAND
cutaneous branch of the ulnar nerve. The extensor digitorum communis and extensor digiti minimi are transected. The metacarpal is subperiosteally dissected from surrounding tissues, and it is divided obliquely at its base, preserving the insertions of the flexor and extensor carpi ulnaris (Fig. 39-7B). The flexor tendons, the third volar interosseous, the lumbrical, and the hypothenar tendons are identified and divided. The digital vessels are ligated, and the nerves are transected sharply and buried into the metacarpal tube to protect them from direct trauma. The volar plate, the deep transverse metacarpal ligament, and the proximal portion of the flexor tendon sheath are transected sharply, and the amputation specimen is removed (Fig. 39-7C). The hypothenar muscles are trimmed to create a smooth ulnar border of the hand. Attachment of these muscles to the tendon of the fourth dorsal interosseous is not recommended.14 After tourniquet release, hemostasis is obtained, and the skin is closed (Fig. 39-7D). A bulky dressing is applied, and range-of-motion exercises are encouraged on the first postoperative day.
MIDDLE FINGER RAY AMPUTATION A painful proximal phalanx amputation stump of the middle or ring finger that is fixed in extension, an amputation of the metacarpophalangeal joint, which allows small objects to fall from the palm, or an aesthetically displeasing stump must be revised by using a ray deletion.6,9,13 The “symmetrical three-fingered hand” that is created with this procedure is more functional and cosmetically improved.3,6,19 The operation can involve either resection of the middle ray followed by closure of the defect by imbrication of the deep transverse metacarpal ligament or resection of the middle ray and transposition of the osteotomized border metacarpal to the resected middle ray.3,6,13,19,20,23 Colen et al., in a retrospective study of 19 patients with an index-to-middle or little-to-ring finger transposition, noticed that total average grip strength recovered 80% and range of motion decreased 9% compared to the contralateral hand.6 In another retrospective study of 13 patients who had a middle ray resection and ligament imbrication without transposition, Steichen and Idler reported that when the dominant hand was involved, the average postoperative grip strength was 74% of that in the noninvolved hand.23 Patients were satisfied with the function and the appearance of their hands in both studies. The main advantage of a digit transposition over a webspace closure after a ray deletion is that the osteotomy site can be adjusted to prevent discrepancies in length and rotation. The disadvantages of a digital transposition are greater soft tissue dissection, which can lead to a functionally significant decrease in motion, prolonged immobilization, and the possibility of a nonunion at the site of fixation of the transposed metacarpal.
Technique of Middle Finger Ray Amputation with Ray Transposition
FIGURE 39-7. Little finger ray amputation. A, Volar and dorsal skin incisions over the little finger ray. B, The little finger metacarpal is stripped of soft tissues, and the osteotomy site is marked. C, After removal of the amputation specimen, the digital nerves are relocated in the created soft tissue tube. D, The appearance of the hand after completion of the procedure.
The technique for resecting the middle ray and transposing the index to the remaining base of the middle metacarpal has been described by Carroll.3 The same steps can be followed to resect the ring ray and transpose the little ray to the remaining base of the ring metacarpal. Under regional anesthesia, the arm is exsanguinated, and a tourniquet is applied. When the middle ray has to be resected, a dorsal longitudinal incision is made between the index and middle metacarpal, starting at the metacarpal base. The incision is extended distally around the amputation stump, and a small, volar, V-shaped incision is created (Fig. 39-8A). The extensor digitorum communis is transected and allowed to retract. The periosteum of the middle metacarpal is incised longitudinally, and a subperiosteal dissection of the metacarpal is carried out (Fig. 39-8B). Care is taken to preserve the
39
REVISION AMPUTATIONS OF THE HAND AND DIGITS
555
This osteotomy can be adjusted to avoid creating a short ray. In a little-to-ring transposition, the osteotomy in the little metacarpal should be performed at a more proximal level than that in the ring metacarpal. In this way, 1.0 to 1.5 cm in length can be gained in the ring metacarpal.20 Next, the periosteal tube of the middle metacarpal is closed. The transverse metacarpal ligament is reefed to firmly approximate the index to the ring metacarpal. The index metacarpal shaft is then placed on the base of the middle metacarpal. Stable fixation, using either crossed Kirschner wires or plate and screws, is then achieved, while the fingers are held aligned in flexion. The wound is closed after meticulous hemostasis is obtained, and a cast is applied up to the metacarpal heads (Fig. 39-8D). The patient is encouraged to start range of motion exercises in the first postoperative week. The cast remains in place until radiographic evidence of healing can be seen.
Complications of Middle Finger Ray Amputation with Ray Transposition
origin of the adductor pollicis muscle and motor nerve. A transverse or step-cut osteotomy is performed at the metaphyseal flare of the middle metacarpal, and the metacarpal is then freed from surrounding soft tissue in a proximal-to-distal direction.3,20 The deep transverse metacarpal ligament is preserved. The flexor tendons are transected under tension and allowed to retract proximally. The hand is turned palmarly, and the digital neurovascular bundles are identified. The vessels are ligated, and the nerves are cut sharply under traction. The amputated specimen is then removed from the field. Through the same skin incision, the proximal shaft and the base of the index metacarpal is exposed. The origin of the first dorsal interosseous is elevated from its shaft without entering the index metacarpophalangeal joint. When more motion is needed during the transposition, the second dorsal interosseous origin is elevated from the index metacarpal. An osteotomy is then performed at the index metacarpal base to divide the shaft and free the index finger for transposition (Fig. 39-8C).
Technique of Middle Finger Ray Amputation with Webspace Closure The same technique is applied for either the middle or ring ray deletion. Under regional anesthesia, the arm is exsanguinated, and a tourniquet is inflated. A V-shaped incision is made from the metacarpal head to its base. A second, smaller palmar incision is created and connected to the dorsal incision by incising the skin around the amputation stump (Fig. 39-9A).23 At this time, as much skin as possible is maintained; it will be trimmed at the end of the procedure to ensure a cosmetic web and proper rotation of the fingers. The ray that is being resected is subperiosteally dissected away from the surrounding soft tissues after the extensor
39
FIGURE 39-8. Middle finger ray amputation with index finger ray transposition. A, Volar and dorsal skin incisions. B, The middle metacarpal is stripped of soft tissues, and the osteotomy site is marked in both the index and middle metacarpal. C, The index metacarpal is transposed to the base of the middle metacarpal. D, The hand after completion of the procedure.
Delayed union and nonunion at the osteotomy site have been reported.6,19,20 They are attributed to the fact that the osteotomy was performed distally on the shaft and not at its base. Performing the osteotomy as proximally as possible at the metaphyseal flare can reduce the incidence of this complication.6,19,20,23 Tendon adhesions and joint stiffness are possible complications due to greater soft tissue dissection and prolonged immobilization. These complications can be avoided by stable internal fixation and early motion.6,19,23 We prefer not to include the metacarpophalangeal joints in the cast, so that they can move freely. Symptomatic neuroma formation is another reported complication, as with every type of amputation. It can be prevented by burying the neural stumps deep into the muscular interosseous space to protect the inevitable neuromas from external trauma.1,6
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digitorum communis is transected under tension. An osteotomy is then performed at the metacarpal base (Fig. 39-9B). Dissection of the soft tissues is then completed in a proximal-to-distal direction, while great care is taken to preserve the origin of the adductor pollicis muscle and motor nerve (in the case of the middle metacarpal). Through the palmar incision, the digital arteries are ligated, and the digital nerves are divided under tension and allowed to retract proximally. If a neuroma preexists, the nerve is mobilized and buried into the soft tissue pocket created by the resection. The flexor tendons are transected under tension. The deep transverse metacarpal ligament is identified as it passes between the lumbrical and interosseous muscles. Care is taken to preserve its attachment to the volar plate when completing the metacarpal resection. After the metacarpal is resected, the created space is reduced by manual compression, and one or two intermetacarpal Kirschner wires are placed to maintain
the correct reduction. The deep transverse metacarpal ligament is imbricated in a vest-over-pants method, using nonabsorbable suture (Fig. 39-9C). The palmar incision is then closed. The dorsal skin can help in adjustment of finger rotation, by dermatodesis. With the wrist in extension, the skin flaps are trimmed and sutured to align the fingers (Fig. 39-9D). A circumferential dressing is applied, and range-of-motion exercises are started in 2 weeks. Kirschner wire fixation is removed after 6 to 8 weeks.
Complications of Middle Finger Ray Amputation with Webspace Closure Intrinsic adhesions have been reported, and in a series of 13 patients, one surgical release was needed.23 Early active range of motion can avert this complication. Symptomatic neuroma formation is another reported complication, as with every type of amputation. It can be prevented by burying the neural stumps deep into the muscular interosseous space to protect the inevitable neuromas from external trauma.1,6
SUMMARY We believe that a properly executed digital amputation can lead to very long-term satisfaction for patients.
References
FIGURE 39-9. Ring finger ray amputation with webspace closure. A, Volar and palmar skin incisions. B, After the metacarpal is stripped of soft tissues, an osteotomy at its base is performed. C, The deep transverse metacarpal ligament is imbricated in a vest-over-pants method. D, The appearance of the hand after completion of the procedure.
1. Beasley RW: Surgery of hand and finger amputations. Orthop Clin North Am 12:763–803, 1981. 2. Bevin AG, Chase RA: Management of ring avulsion injuries and associated conditions of the hand. Plast Reconstr Surg 32:391–400, 1963. 3. Carroll RE: Transposition of the index finger to replace the middle finger. Clin Orthop 15:27–34, 1960. 4. Carroll RE: Ring injuries in the hand. Clin Orthop 104:175–182, 1974. 5. Chase RA: The damaged index digit: A source of components to restore the crippled hand. J Bone Joint Surg 50A:1152–1160, 1968. 6. Colen L, Bunkis J, Gordon L, Walton R: Functional assessment of ray transfer for central digit loss. J Hand Surg 10A:232–237, 1985. 7. Eversmann WW, Burkhalter WE, Dunn C: Transfer of the long flexor tendon of the index finger to the proximal phalanx of the long finger during index-ray amputation. J Bone Joint Surg 53A:769–773, 1971. 8. Fisher EG, Goldner JL: Index ray deletion: Complication and sequel. J Bone Joint Surg 54A:898, 1972. 9. Graham WC, Brown GB, Cannon B, Riordan DG: Transposition of fingers in severe injuries of the hand. J Bone Joint Surg 29:998–1004, 1947. 10. Graham WP, Kilgore ES, Whitaker LA: Transarticular digital joint amputations: Preservation of the articular cartilage. Hand 5:58–62, 1973.
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18. Parkes A: The “lumbrical plus” finger. J Bone Joint Surg 53B:236–239, 1971. 19. Peacock EE: Metacarpal transfer following amputation of a central digit. Plast Reconstr Surg 29:345–355, 1962. 20. Posner MA: Ray transposition for central digital loss. J Hand Surg 4A:242–257, 1979. 21. Schmidt CC, Georgescu HI, Kwoh CK, Blomstrom GL, Engle CP, Larkin LA, Evans CH, Woo SL: Effect of growth factors on the proliferation of fibroblasts from the medial collateral and anterior cruciate ligaments. J Orthop Res 13:184–190, 1995. 22. Slocum DB, Pratt DR: The principles of amputations of the fingers and hand. J Bone Joint Surg 26:535–546, 1944. 23. Steichen JB, Idler RS: Results of central ray resection without bony transposition. J Hand Surg 11A:466–474, 1986. 24. Urbaniak JR, Roth JH, Nunley JA, Goldner RD, Koman LA: The results of replantation after amputation of a single finger. J Bone Joint Surg 67A:611–619, 1985. 25. Whitaker LA, Graham WP, Riser WH, Kilgore E: Retaining the articular cartilage in finger joint amputations. Plast Reconstr Surg 49:542–547, 1972.
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11. Herndon JH: Amputations of the hand. In Evans CM (ed): Surgery of the Musculoskeletal System, 2nd ed. New York, Churchill Livingstone, 1990, pp 727–744. 12. Herndon JH, Eaton RG, Littler GW: Management of painful neuromas in the hand. J Bone Joint Surg 58A:369–373, 1976. 13. Hyroop GL: Transfer of a metacarpal with or without its digit for improving the function of the crippled hand. Plast Reconstr Surg 4:45–58, 1949. 14. Louis DS, Jebson PJL, Graham TJ: Amputations. In Green DP, Hotchkiss RN, Pederson WC (ed): Green’s Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, pp 48–94. 15. Mahoney JH, Phalen GS, Frackelton WH: Amputation of the index ray. Surgery 21:911–918, 1947. 16. Murray JF, Carman W, MacKenzie JK: Transmetacarpal amputation of the index finger: A clinical assessment of hand strength and complications. J Hand Surg 2A:471–481, 1977. 17. Neu BR, Murray JF, MacKenzie JK: Profundus tendon blockage: Quadriga in finger amputations. J Hand Surg 10A:878–883, 1985.
REVISION AMPUTATIONS OF THE HAND AND DIGITS
40 Prostheses for Mutilated Hands Robert W. Beasley, MD, FACS
The dictionary defines mutilated as “cut off or permanent destruction of an essential part,”1 in this case of a hand or its parts. Despite the enormous advances in surgical care and tissue replantation and revascularization, there are many situations for which appropriately prescribed prostheses of high quality, alone or in conjunction with surgical repairs, offer the best help available.2 These include traumatic losses and many congenital mishaps with which the same physical deficiencies have very different impact and needs. Patients with developmental failures have no sense of physical impairment, in contrast to those with acquired deformities who have established patterns of performance instantaneously disrupted. Techniques used by congenitally deficient patients might be different, but they get the job done and in a manner that is normal to them. The two groups share the burden of disfigurement, a real and ever-increasing socioeconomic handicap, often without surgical solutions (Fig. 40-1). Logical recommendations and decisions can be made only by comparing all alternatives.3 For the care of mutilated hands, these include a thorough knowledge of the surgical and reconstructive potentials but also at least an awareness of the prosthetic possibilities. An early master plan, which of course can be modified according to developments, is needed. It is no longer acceptable for the surgeon “to go as far as he can” and then refer the patient for prosthetic development. Invariably, this outdated approach results in a compromise to that which might be achieved. It is most important that the hand surgeon have a basic knowledge of prosthetic potentials that can be developed to complement their efforts, leaving anatomic structures in the best condition possible for this (Fig. 40-2). The best situation is working with a prosthetic group with open communication for the common interest of delivering the best possible outcome for each patient. Simply writing a prescription for “prosthesis, please” with referral to a prosthetist to do the best he or she can is far from ideal.
BEING REALISTIC
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It is most important to have realistic expectations in order to avoid disappointment. The goals of hand prostheses must be understood and accepted. There is no pretense that prostheses truly replace lost parts. They are gone and gone forever. The purpose of prostheses is to minimize the physical, emotional, social, and economic consequences of the deficiencies.4 With recognition of this concept, high-quality prostheses can be of great help to many patients. Hand mutilations that fall short of total hand amputation range from fingernail injuries to transcarpal amputations with or without loss of the thumb. 559
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THE MUTILATED HAND
A
B
FIGURE 40-1. There is no surgical solution for this congenital anomaly. Congenital patients have no sense of physical impairment; nonetheless, like patients with acquired amputations, they suffer the socioeconomic consequences of disfigurement. High-quality prostheses minimize the physical, emotional, social, and economic consequences of the deficiencies for which there are no surgical solutions.
TYPES OF PROSTHESES All prostheses can be classified into one of two categories. Active prostheses, also known as “carrier tool prostheses,” have built into them mechanical clamping mechanisms that may be either body or externally powered. They are a consideration for total hand loss, for amputations of the arm or forearm, and rarely for a proximal carpal row level of amputation.5
FIGURE 40-2. Technical showmanship prevailing over good judgment can result in tragic conditions. The great-toe transfer is not only useless but also precludes prosthetic development.
It is incorrect to refer to active prostheses as “functional,” as this implies incorrectly that other prostheses are “nonfunctional.” Even in terms of prehension, this is incorrect. Most patients for whom passive prostheses are developed enjoy a greater degree of improvement in physical capability because the prosthesis restores utilization of the critical sensory feedback present in remaining natural parts. Active prostheses have almost no potential application for mutilated hands (those that fall short of full amputation) with the possible rare exception of a proximal transcarpal amputation, which technically is short of total. Body-powered active prostheses have the advantage of low cost, ruggedness, low maintenance requirements, universal availability, silent operation, and some sensory feedback of force and position, as their movement is directly linked to movements of the opposite shoulder. Simpson termed this benefit “extended extrasensory proprioception.”7 Because of the ease of visual guidance of positioning, most body–powered active prostheses use a split hook terminal unit. The main disadvantage is a poorly acceptable social presentation. This is also substantially true of the terminal units that are more in the shape of a hand. Of all the external power sources, only electricity has proven practical, even though electric motors deliver energy at a very low rate compared to hydraulic or pneumatic devices. Theoretically, a hybrid system would be best, with a miniature electric motor maintaining pressure in a small and portable fluid or gas reservoir to be drawn on as needed. However, problems of leakage, complexity, and lack of an adequately
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FIGURE 40-3. While limited by the poor shape of the myoelectric hand prosthesis, a glove of socially acceptable appearance has greatly increased patient acceptance of these devices when indicated. On the right is a currently available silicone custom cover, compared to the linoleumlike standard cover.
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The term mutilated hand implies severe damage but something less than total hand amputation or agenesis. For mutilated hands, only passive prostheses can be of benefit. Basically, they enhance the capability of the remaining intact parts. The variety of situations encountered is endless, but this is the basic principle for all. In addition, only high-quality passive hand prostheses can provide near-normal social presentation, which is an increasingly important consideration with the rapid shift of people from labor to the service industries (Fig. 40-4).
ACHIEVING ACCEPTABLE SOCIAL PRESENTATION That disfigurement is a real socioeconomic handicap is no longer an issue. The U.S. Supreme Court has confirmed this (School Board of Nassau County v. Arleen, 490 U.S. 273, 1987) in its interpretation of the Americans With Disabilities Act, a fact that physicians should know and insurance companies in general do not want to hear about. Treatment of disfigurement should not be confused with cosmesis. The latter, on which Americans spend more than 50 billion dollars each year, means the changing of something normal to be more attractive in their opinion. To use the word cosmetic in relation to prostheses not only is incorrect but often results in denial of just benefits to patients from insurance companies. The term artificial hand should also be discarded, as it implies a restoration that cannot possibly be provided. Minimizing the consequences of disfigurement from a mutilated hand requires consideration in two fundamental areas: artistic and performance. They are not mutually exclusive but should be carefully combined in treatment plans. The artistic aspects of the prosthesis are the shape, duplication of the individual’s details, and color matching. The best prosthetic manufacturers can now produce these artistic characteristics with an amazingly high degree of accuracy, although this still requires working directly with each patient. The second basic area of consideration in minimizing the consequences of disfigurement revolves around our system of visual perception. A camera records with equal accuracy all light stimuli passing through its lens, but the human eye does not. Under direction from the cerebral cortex, our eye filters out and passes on for processing and interpretation only light stimuli from something in which the individual has a particular interest at that instant. That which the brain filters out can be instantaneously changed if something unexpectedly occurs to provoke an interest and critical analysis. Thus, the manner in which one is able to perform ordinary tasks is as
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refined sensory feedback system to provide subconscious or automatic control have made the theoretical impractical. The latter is true even for electric active prostheses. Sadly, enormous efforts, including those of the IBM Corporation, have failed to develop a satisfactory control system even for electric prostheses. Myoelectric control of active prostheses is the current standard for motorized units, but they are velocity-based systems that provide no direct sensory feedback, so the control is neither automatic nor subconscious.7 What is needed is a force position–based control system, but no practical one yet exists. It has to be recognized that all active prostheses are nothing more than a simple clamp that can open and close. They have none of the manipulating capabilities that characterize our hands, as has deceptively been presented from time to time. Efforts to put miniature motor devices into prosthetic fingers for partial hand prosthesis have not proven to be helpful. As with total hand prostheses, the fundamental unsolved problem relates directly to the absence of a satisfactory control system. While myoelectric controlled prostheses are very rarely appropriate for mutilated hands, their acceptance has been greatly advanced by availability of covers of socially acceptable appearance (Fig. 40-3). The other basic type of prostheses are passive prostheses, which purposely have no mechanical clamping units in them. It is not a matter of an active or passive type of prosthesis being better than the other. They simply are targeted at different objectives and prime needs.
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B
A
FIGURE 40-4. The mutilated left hand has intact sensibility and control of the remnants of the thumb and little finger. These parts are utilized in the fine custom-designed partial hand prosthesis seen holding the book. The little finger is placed in the prosthetic ring finger to be more central; it will fit there in a prosthetic glove of the same size as the normal hand.
important to socially acceptable presentation as the artistic details of the prosthesis. Enhancing physical capability is therefore a most important design criteria for every prosthesis, and with understanding and thoughtful design, it is rare that a high-quality passive prosthesis fails to improve the physical capability of a mutilated hand. Individualization is most important. When possible, finger amputations are much better treated with individual finger prostheses than are partial hand prostheses, which require covering the hand with a glove that invariably reduces its capability. The manner in which things are accomplished has an important aesthetic
A
impact; we basically see what we expect to see unless something unexpected provokes a critical analysis. Openness to new ideas should be applied to all prosthetic development, avoiding rigidly fixed preconceptions (Fig. 40-5).
SPECIFICITY OF PROSTHESES It is again emphasized that no prosthesis can begin to compete with a normal hand. Each prosthesis is designed and targets relatively specific prime needs of
B
FIGURE 40-5. This patient with index ray and partial middle finger amputations requested a partial hand prosthesis. A digital prosthesis was developed for the middle finger, making the normal ring finger appear to be the middle finger, which restored visual balance while improving capability.
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B
FIGURE 40-6. Because of the specificity of prostheses, a patient often needs different ones for different activities. The patient might need a rugged, but not grotesque, orthotictype device for the factory (A) but a prosthesis of near-normal appearance for business, social, and other occasions (B).
THE RELATIONSHIP BETWEEN PHYSICAL LOSS AND EMOTIONAL RESPONSES AND EXPANSION OF THE CONCEPT OF FUNCTION The treatment goal for every patient with a mutilated hand is to return him or her to an adjusted, self-supporting, and productive life. Therefore, we must change the concept of function from mere prehensile capacity to the global concept of function of the individual in society. Grotesque disfigurement of a hand, constantly exposed to scrutiny, may today be a greater handicap than major physical losses were only a few years ago. Whether persistent handicap is physical or emotional, the economic consequences are exactly the same. Third-party insurers should recognize this reality. There is no predictable relationship between the extent of physical loss and the emotional response to it for each individual (Fig. 40-7). It cannot be assumed
that a person with partial loss of a single finger will make a rapid and appropriate accommodation to it. Even loss or damage of a fingernail, for which there is no surgical solution, can be devastating to some patients.
SURGERY IN RELATION TO PROSTHETIC DEVELOPMENT It is again emphasized that an early master plan for patients, combining surgical repairs with considerations for eventual prosthetic fitting, is optimal. Some patients require major surgical reconstructions; however, even closure of a finger amputation should be viewed as a reconstructive procedure, leaving the part in the best possible condition for prosthetic development. If possible, the finger should be slightly smaller in diameter than normal so that a prosthesis of normal size can fit over it. This is usually possible owing to contraction of the flexor tendons. Additionally, the finger’s end should be tapered and smooth, not bulbous. For major mutilations, the combination of carefully considered surgical repairs and appropriate prosthetic fitting can be most rewarding. In considering amputations at any level of the upper limb, there has been a major departure from the timehonored concept of “ideal levels of amputation.” In almost every instance, it is desirable to preserve as much length as is feasible if there is the possibility of primary soft tissue closure. In many cases, a distant flap is indicated to preserve length.8 For example, this might be a proximal forearm amputation, for which even 10 cm of forearm distal to the elbow can be extremely useful. It
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each patient. As an analogy, consider a hammer, which is superb for driving nails but worthless for tightening bolts. Similarly an individual might need more than one type of basic prosthesis: a rugged device to meet the physical needs of work in a factory or on a farm and a prosthesis of near-normal appearance for business and other occasions (Fig. 40-6). It is the fundamental principle of treatment to sort out accurately the prime needs of each patient and then to target them specifically. This is the route to a high degree of successful prosthetic help.
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THE MUTILATED HAND
A
B
FIGURE 40-7. This patient, who was out of work for 2 years, kept the hand with the shortened little finger in his pocket. This is a good example of the varying relationship between the degree of physical loss and the patient’s response. His full rehabilitation was a matter of developing a fine digital prosthesis.
has been taught that with wrist disarticulation or very distal forearm amputations that removal of the styloid process of the radius should be done. To do this creates a major problem for prosthetic fitting, requiring a forearm socket extending above the elbow to be molded around the condyles of the humerus as the forearm shape changes with pronation and supination. This precludes fitting of a short suction-held socket, but maintaining the flare of the radial styloid obviates this. Of course, the number of individual considerations is almost endless, but the principle of initially preserving length is a fundamentally important concept with rare exceptions.
TECHNOLOGY THAT HAS CHANGED PROSTHETIC POTENTIALS FOR MUTILATED HANDS Two recent and fundamental technological innovations, both from the same laboratory, have enormously improved the possibilities for digital and partial hand prostheses for the mutilated hand. The first was the Bio-Chromatic® (American Hand Prosthetics, New York, NY) coloring technique for silicones (Fig. 40-7B). It mimics nature by depositing color pigments on the interior surface of the clear silicone prosthetic glove with variations according to the characteristics of each patient. The clear exterior layer is like the colorless epidermis of normal skin, so the technique gives the prostheses a similar translucency. The color matching from this technique can be so good that there is no longer a need for the traditional ring or small bandage applied to
mask the juncture between the prosthesis and the patient’s normal skin. This development led to the availability of a short or “mini” digital prosthesis that does not extend proximal to the important proximal interphalangeal joint if present, leaving it totally unrestricted. It has also been important in providing prostheses for thumb amputations distal to the metacarpophalangeal joint to restore normal thumb length and the fingernail. This same technology eventually led to the development of a “submini” digital prosthesis for the distal phalanx of the finger or even for a lost or damaged fingernail, a problem for which there is no satisfactory surgical solution. The second major technological innovation that has greatly improved the potential for digital and hand prosthesis was developed in the same laboratory and relates to digital armatures. Armatures are devices that are built into prosthetic fingers or thumbs that allow their contour to be passively changed by the normal hand to allow the prosthesis to work more efficiently with remaining natural parts for various tasks. Traditionally, digital armatures have been made of heavy wire, usually No. 8 copper. However, this oxidizes to a green color that bleeds into the prosthesis to change its color, but bending at the same point changes its shape. This results in metal fatigue and eventual breakage. The use of braided stainless steel wire armatures reduced these problems considerably but did not address an even greater problem: Heavy wire armatures have to be anchored securely at their proximal end, or pressure applied to change their contour or configuration fails. Without anchorage of the proximal end, the armatures will simply “hobby horse” when pressure is applied and the contour will not be changed. This has
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usually will not be placed in the corresponding prosthetic finger. They will be placed into a prosthetic finger that is larger so that the positioning of the actively moving finger will usually be more central. This also prevents having to make the prosthetic glove larger than normal to fit over the remaining finger or fingers.
PARTIAL HAND PROSTHESES Hand prostheses are divided into three groups: thumb, fingers, and partial hands. The latter term has, by common usage, come to be applied to severe mutilations with loss of multiple parts. In all cases, the goals are to enhance the usefulness of the remaining natural parts (see Figs. 40-1 and 40-4) while also providing a socially acceptable appearance. The design and development of partial hand prostheses are the most challenging but also often the most rewarding aspects, as natural parts with intact sensibility provide an advantage that no artificial device has.
THUMB PROSTHESES The special importance of the thumb to hand function is always emphasized. Fortunately, the proximal position of the thumb often results in its escaping loss even with amputations of the fingers through the metacarpals. If the thumb is injured, very often it will be through the proximal phalanx. In such cases preservation of length is of greatest importance, and a digital prosthesis can be remarkably satisfactory (Fig. 40-8).
B
FIGURE 40-8. The metacarpophalangeal joint is the critical level for thumb losses. At this level, only lengthening with sensate skin will contribute to improved function. Otherwise, prosthetic development can be rewarding.
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been a commonly encountered problem in the case of loss of all fingers at the metacarpophalangeal joints but with preservation of a normal thumb. Obviously, prosthetic fingers against which the thumb can work will greatly enhance its function, but this can be better if the degree of flexion or extension of the fingers can also be readily adjusted. If the interdigital webs of the prosthetic glove are more distal than normal, the thumb will no longer have the correct relationship to the prosthetic fingers, so the potential for improved function will be lost. Resecting the metacarpal heads to provide room for traditional armature anchorage is obviously undesirable. A remarkable solution to these problems has come from the development of stainless steel micro-hinged armatures, which can be flexed or extended every 3 or 4 mm along their entire length. These armatures require no proximal anchorage for easy adjustment of their configuration, and since flexion-extension occurs along the whole length of the device rather than at one point, the problems of metal fatigue and breakage have been eliminated. These new armatures can even be placed in a prosthesis for fingers amputated through the proximal phalanx with which both interphalangeal joints have been lost. This has proven to be very useful as a finger may be placed in extension for opposition to the thumb pad, or it may be appropriately curved for such activities such as typing or playing a musical instrument. The new micro-hinged armature makes it possible for a hand with a single functioning finger to be remarkably useful. The prosthetic glove provides fixation of the prosthetic thumb into which an armature can be placed for passive positioning in relation to the finger. When the partial hand prosthesis is for a mutilation in which only one or two fingers remain, those fingers
PROSTHESES FOR MUTILATED HANDS
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If a thumb amputation has occurred at the metacarpophalangeal joint level, this is one situation for which slight deepening of the thumb web generally will permit prosthesis fitting. Deepening should not be more than 15 mm, as the result thereafter will be a cleft rather than a web, with progressive damage to the muscles of thumb adduction power. For metacarpophalangeal level amputations, the condyles of the head of the first metacarpal should be tapered, and the sesamoid bones should be removed. An alternative to this slight deepening of the thumb web is a distraction osteotomy at the distal shaft of the metacarpal followed by bone grafting to maintain bone lengthening developed by Ilizarov. I have gained as much as 34 mm of thumb length by this technique. With this technique, sesamoid bones also will need to be removed, along with tapering of the condyles. Twelve to fifteen mm of length distal to the thumb web is needed for secure prosthetic suction attachment. The major problem for the thumb, and for which there is no really satisfactory solution, is amputations proximal to the middle of the first metacarpal shaft (Fig. 40-9). Even if the basal joints are in good condition, there is not enough muscle to give good control of a thumb prosthesis. Also at this level, there is no satisfactory manner of attaching the prosthesis securely to the hand. This can be done only with a glove over the hand, which obviously is undesirable. It was hoped that the metal implants which are so successful in the dental field, would resolve the problem of proximal thumb and finger prosthetic fixation.
However, metal implants penetrating skin cause problems that are not encountered with penetration of oral mucosa. Even with the most meticulous hygiene for the constantly developing serum coagulation at the implantskin interface, cellulitis remains an unresolved problem.
FINGER PROSTHESES Contrary to the traditional wisdom that finger prostheses are only for improved appearance, finger prostheses of the quality available today can be the most helpful of all devices. Their precision fit provides sensory feedback to the brain, essential for subconscious or automatic control (Fig. 40-10).
Finger Amputations Through the Proximal Phalanx Loss of both interphalangeal joints always results in a substantial reduction in finger dexterity. However, development of the unique multiple micro-hinged armatures, which require no proximal fixation for easy passive alteration of their contour, has proven to reduce this problem significantly for typing and similar activities. Combined with the Bio-Chromatic coloring system, this has proven to be a real technological advance for both thumb and finger prostheses (Fig. 40-11). A finger length of at least 12 to 15 mm distal to the interdigital web is needed for secure prosthetic suction attachment, and occasionally, judicious deepening of the web is needed to provide this. It must be done as for creating an interdigital web when correcting a syndactyly, as a Z-plasty is inadequate.
Finger Amputations Through the Middle Phalanx I was always distressed to see the important proximal interphalangeal joint with a useful portion of the middle phalanx covered with a full-length finger prosthesis, the time-honored standard practice. The proximal interphalangeal joint provides a critical segment of a finger’s flexion-extension arc of motion, and its restriction imposes a significant limitation of finger function. The solution to this came with perfection of the BioChromatic coloring technique, which has eliminated the need to disguise the prosthetic-skin juncture. Its proximal end is distal to the proximal interphalangeal joint, so it imposes no restriction of motion (Fig. 40-12). FIGURE 40-9. There is no satisfactory prosthetic solution for thumb amputations at or proximal to the middle of the metacarpal shaft. Prosthetic attachment would require a glove on the hand, which is acceptable only in the most unusual circumstances. The solution for this usually is pollicization by digital transposition based on intact neurovascular pedicles.
The Unique “Sub-Mini” Digital Prosthesis It has been emphasized that there is no constant relationship between the actual physical loss and its impact on each individual patient. This is dramatically illustrated
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PROSTHESES FOR MUTILATED HANDS
567
A
B
FIGURE 40-10. Properly fabricated digital prostheses transmit both position and motion sensory feedback, resulting in subconscious control. This, in conjunction with restoration of finger length so that the tip is where the brain expects it to be, is greatly beneficial for typing and similar activities.
A
B
FIGURE 40-11. A major change in attitude about finger prosthesis has followed two major technological achievements from the same laboratory. One is the Bio-Chromatic coloring technique, which eliminates efforts to artificially disguise prosthetic-skin junctures; the other is multiple micro-hinged armatures replacing traditional heavy wire. The latter permits placement of armatures in prostheses for fingers that have lost both interphalangeal joints.
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C
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THE MUTILATED HAND
B
FIGURE 40-12. Perfection of the Bio-Chromatic coloring technique led to the development of the short, or “mini,” digital prosthesis, which ends distal to the proximal interphalangeal joint, leaving it totally unrestricted in movements. Full function of the proximal interphalangeal joint of the police officer’s ring finger and its prosthetic lengthening permitted him to qualify with his service revolver to resume full duty.
by the distress some patients experience from loss of a fingertip or mutilation of a fingernail. Good surgical solutions are established for loss of distal finger pads but not for loss or damage of a fingernail. Previously described technological advances have been applied to the development of a “sub-mini” digital prosthesis. As it is for the distal phalanx only, there is no restriction of motion, and its thinness allows transmission of sensibility to the finger pad much like that of a surgeon’s glove. Perfect fit results in secure suction attachment, and the prosthetic fingernail carefully duplicated from the other hand is always perfectly positioned with no skin irritation or cellulitis problems (Fig. 40-13).
A
TOE PROSTHESES Fingers and toes have both similarities and differences. It is worth mentioning that there is a surprising demand for prosthetic toes among beach people, and those who entertain around their pools or take winter cruises. These prostheses require nothing unique for development and can provide remarkable satisfaction. The most frequently encountered problem is attachment due to the shortness of remaining parts. However, when required by shortness, a glove on the distal foot for secure prosthetic fixation does not present the objectionable features it does on a hand.
B
FIGURE 40-13. The unique “sub-mini” digital prosthesis for the distal phalanx is shown. It can restore the pad of a fingertip but also offers the first satisfactory solution for a lost or damaged fingernail. Fixation is secure, and there is no restriction of finger mobility.
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The cost of developing custom prostheses for mutilated hands is reasonable if one considers that a myoelectric hand prosthesis with a silicone glove, elbow unit, and arm socket as well as the required training currently costs in excess of $40,000. While repairs will be required from time to time and in proportion to the care or abuse given the passive prosthesis, maintenance costs and replacements are very low compared to those for myoelectric active devices. It has been emphasized that optimal prosthetic development has to be done on an individual basis. This is the only means of getting top quality, and anything short of this is a waste of money, with the traditional “black glove” being better. Also, it is important to have rapid and reliable services available for any needed adjustment or repair after delivery. Therefore, careful selection of the provider is an important consideration. What is the service life of a prosthesis for a mutilated hand? There is no simple answer to this question. The prosthesis has to be looked on as fine custom clothing that remains in good shape in relation to the care or the lack of care it is given. Some people will go through a pair of high-quality leather shoes in 2 to 3 months, whereas identical shoes will serve others for several years. With good care and prompt repair of damage while it is minor, the service life of a prosthesis is in the range of about 4 to 5 years. Some have been used 7 to 8 years, but this is the exception.
PROSTHETIC FITTING OF CHILDREN Sadly, children do get hurt and congenital defects occur. The time to consider prosthetic fitting for a child is when the child, not the family, is consistently demanding it. If fitted before this time, use of the prosthesis will be worn only in portion to the police action
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of the family. With an occasional exception, the earliest age of fitting should be about 6 or 8 years, by which time social awareness and competition are realities. Of course, this has to be individualized. Another practical consideration for the timing of fitting is that before 6 to 8 years of age, care of their prosthesis is generally irresponsible. With the rapid growth of children, satisfactory fit and thus the service life of a prosthesis will be short-lived.
Acknowledgments All photographic material presented in the chapter was generously provided by American Hand Prosthetics, Inc., of New York. I appreciate the help given by their general manager, Ms. Genevieve de Bese, BA, MBA, whose work has set new standards for hand prostheses. I serve as an unpaid medical advisor to this company and hold no financial investment in it.
References 1. Baumgartner R: Active and carrier-tool prostheses for upper limb prostheses. Orthop Clin North Am 12:955, 1981. 2. Beasley R, ed. Hand Injuries. Philadelphia, WB Saunders, 1981, p 345. 3. Beasley R: Upper limb prostheses. In Beasley’s Surgery of the Hand. New York and Stuggart, Thieme, 2003. 4. Beasley R, DeBese G: Upper limb amputations and prostheses. In Grabb and Smith’s Plastic Surgery, 5th ed Philadelphia, Lippincott-Raven, 1997, p 1014. 5. Beasley R, DeBese G: Upper limb amputations and prostheses. In Grabb and Smith’s Plastic Surgery, 5th ed Philadelphia, Lippincott-Raven, 1997, p 1017. 6. Brown P: The rational selection of treatment for upper extremity amputations. Orthop Clin North Am 4:1009–1020, 1981. 7. Simpson D: Extended physiologic proprioception. In Robert W. Beasley (ed), International Symptom of the Control of Upper Extremity Prostheses, Goteborg, Sweden, 1971. 8. Webster’s Ninth New Collegiate Dictionary. Springfield, Merriam-Webster, 1987.
40
COST AND UTILIZATION OF PROSTHESES FOR MUTILATED HANDS
PROSTHESES FOR MUTILATED HANDS
41 Experimental Limb Allotransplantation Thomas H. Tung, MD Susan E. Mackinnon, MD, FRCS(C)
41
A composite tissue transplant consists of tissues such as skin, connective tissue, fat, muscle, bone, nerve, or a whole or partial limb. The potential role of composite tissue transplantation is the functional and/or aesthetic reconstruction of tissue deficits due to trauma, congenital deficiency, or cancer resection. Because of its nonvital nature, the clinical application of composite tissue transplantation for reconstruction of the hand is limited by the potential side effects and toxicity that are associated with host immunosuppression. Recent hand transplants have met with considerable controversy. Unilateral and bilateral hand transplants have been performed to date.30,53 The results in these cases have been promising, but follow-up remains limited, and one patient has undergone rejection and amputation of the hand allograft. The unsuccessful outcome in this patient appears likely due to poor patient selection and noncompliance. Many questions still remain about the final functional outcome that can be expected and the longterm risks of the current immunosuppressive regimens. At the core of the controversy is whether the potential improvements in the quality of life gained by such a procedure are worth the indefinite exposure to potentially life-threatening risks of systemic immunosuppression.69,73,97 Application of transplantation techniques to other tissue grafts could potentially allow a more aesthetic and functional reconstruction of highly visible areas with specialized tissues that are otherwise difficult if not impossible to replace, such as the ear, scalp, or nose in the craniofacial region. Such reconstructions have the potential to be superior to current reconstructive options that allow wound healing but still incite the stigmata that ultimately contribute to social isolation and emotional distress. Nevertheless, for such nonvital transplants, the controversy will continue until the risks associated with immunosuppression are considerably lessened or altogether eliminated. Reduction in the adverse effects of immune-modulating therapy can be achieved only by either more efficacious modes of immunosuppression or, ultimately, the induction of donor-specific immune tolerance. The induction of donor-specific unresponsiveness in transplantation is a realistic goal. Newer and more specific approaches have emerged that suggest the direction of future research. Costimulation theory and blockade have achieved unprecedented success in animal models, including nonhuman primates, and the resumption of clinical trials in organ transplantation is forthcoming.55 Stem cell and gene therapy also hold the promise of increasingly specific targets with little or no interference with normal immune function and might also have broader clinical applications, such as in the management of infectious and autoimmune diseases. Only strategies that can produce donor-specific unresponsiveness while maintaining generalized immune competence will achieve universal acceptance of composite tissue transplantation as a safe and viable therapeutic option. 573
574
THE MUTILATED HAND
ANIMAL MODELS Many animal models exist for limb and composite tissue transplantation. The most commonly used model has been the rat. The advantages of rodent models include low initial and maintenance costs, ease of handling, larger numbers for statistical analysis, and lack of ethical concerns. The larger-animal models include the rabbit, dog, and, more commonly, the pig and nonhuman primates. Although much more expensive and difficult to handle, the swine and primate models especially provide data that are more applicable immunologically to humans, and their use is necessary before clinical application can be considered.
Rodent Models The earliest report of successful limb transplantation was in 1936 by Schwind, who used the technique of parabiotic union in the rat model to vascularize a limb allograft.96 In the late 1970s, better characterization of the rat immune system29,82 and the emergence of microvascular techniques to anastomose vessels less than 1 mm in diameter98 established the rat orthotopic hindlimb model as the prototype model for composite tissue allotransplantation research. The most commonly used strains include Lewis, ACI, Buffalo, Fischer, and
FIGURE 41-1. Rat model of an orthotopic hindlimb transplantation.
Brown-Norway rats. The standard model consists of orthotopic transplantation of the hindlimb at the midfemur level with intramedullary bone fixation, microvascular anastomoses of the femoral vessels, and microsurgical repair of the femoral and sciatic nerves (Fig. 41-1).98 Variations of this model have included transplantation of the musculoskeletal component of the hindlimb and coverage with recipient skin to minimize the problems of automutilation of insensate allografts and skin rejection (Fig. 41-2).4,63 A model of heterotopic hindlimb transplantation without nerve repair has also been described (Fig. 41-3).36 Other models of composite tissue transplantation in the rat include allografts of vascularized skin, muscle,71 bone (knee joint),118 and nerve.7 The vascularized knee joint model is similar to the canine whole knee model described in 1966.101 All of these models are based on the femoral vessels as both the donor vascular pedicle and recipient vessels. Most recently, a xenograft model has been described using the mouse hindlimb as the donor and the rat as the recipient animal.112 Although very interesting from the immunological standpoint, xenograft models of limb transplantation are very few and have no clinical applicability. The mouse model is much better characterized immunogenetically and remains the most commonly used model for basic science, immunologic research,
41
EXPERIMENTAL LIMB ALLOTRANSPLANTATION
575
FIGURE 41-2. Variation of an orthotopic hindlimb model with removal of all donor skin except that of the foot.
first murine model of heterotopic lower-hindlimb transplantation. Postoperative mortality is significantly decreased by avoiding amputation of the ipsilateral hindlimb and thereby reducing the physiological stress, operating time, and blood loss of the recipient surgery. This model uniquely allows the use of genetically engineered animals and the most recently available reagents and antibodies. The use of transgenic and knockout mice is particularly essential for determining the mechanism of strategies of immune suppression or tolerance. To study functional outcomes and nerve regeneration in the setting of a limb transplant, however, either the murine orthotopic hindlimb model will need to be improved to increase survival rates or a larger-animal model will need to be used to increase reproducibility.
FIGURE 41-3. Rat model of a heterotopic hindlimb transplantation.
41
and transplantation research. Most of these models of organ transplantation (heart, kidney) use the abdominal aorta and inferior vena cava, or nonvascularized islet cell or skin allografts.20,108,123,124 The extremely small size of the vessels of the extremities has made the mouse a very difficult and technically challenging model for limb transplantation research. Furthermore, the mouse’s small size and weight (approximately 1/10 that of the rat) and minute blood volume (approximately 1 to 2 cc for a 20- to 30-g mouse) also make the mouse a physiologically fragile model. In 1999, Zhang et al. described the first murine model of orthotopic hindlimb transplantation that is very similar technically to the rat hindlimb transplantation model.122 Limb allograft survival was achieved, but early postoperative mortality was high. Our laboratory has developed the
576
THE MUTILATED HAND
Larger-Animal Models Larger-animal models that have been used for composite tissue transplantation research have included the rabbit, dog, pig, and monkey. Models using the rabbit were reported in the 1980s and consisted of orthotopic forelimb transplantation (Fig. 41-4)60 and the heterotopic vascularized knee allograft,99,119 which is based on the canine vascularized knee allograft model. Application to detailed immunologic studies is limited, however, because of a lack of genetic definition at the major histocompatibility complex-equivalent locus. Much of the earlier larger-animal work used the outbred canine model. In 1966, Goldwyn et al. described the orthotopic limb transplantation model, which consisted of transplantation of the hindlimb at the midthigh level with vascular anastomoses of the femoral vessels.41 A canine vascularized knee joint allograft was also reported for orthopedic and immunologic research.27,101 As used by several investigators, the canine model was plagued by a relatively high technical failure rate (~50%) and, like the rabbit model, is not well characterized immunogenetically.
FIGURE 41-5. Swine model of a partial forelimb composite tissue transplantation consisting of skin, muscle, bone, nerve, and vascular pedicle.
FIGURE 41-4. Rabbit model of an orthotopic hindlimb transplantation.
In 1998, Üstüner described an interesting porcine model for composite tissue transplantation.113 Using young outbred swine, the vascularized allograft was harvested from the forelimb and consisted of a segment of radius, the flexor carpi radialis muscle, and overlying skin. The median nerve was included, and the vascular pedicle consisted of the brachial artery and cephalic veins (Fig. 41-5). The allograft was inset in the orthotopic position, but because it did not include a joint, such a model allowed for assessment of allograft survival but was unable to evaluate motor nerve regeneration and functional recovery. That same year, Lee et al. described a model of heterotopic partial limb transplantation in the inbred swine.70 The allograft was harvested from the hindlimb and included the distal femur, knee joint, tibia, fibula, and associated musculature based on the femoral artery and vein. End-to-side anastomoses are performed to the recipient vessels, and because no skin is included, the partial limb is inset in a subcutaneous position in the recipient’s abdomen. This model focuses on allograft survival and not functional recovery but does not permit assessment of donor skin survival. However, because it is completely buried, it minimizes the risk of trauma and automutilation of the graft and
41
FIGURE 41-6. Baboon model of a partial digital composite tissue transplantation consisting of skin, subcutaneous tissue, nerve, and vascular pedicle.
577
These models were able to demonstrate return of function in mechanoreceptors of both the palmar and dorsal skin but with elevated thresholds, as well as motor reinnervation of the donor intrinsic hand musculature. In 1990, Stevens et al. described a model of partial hand transplantation in the rhesus monkey.52,106 The vascularized allograft consisted of a radial forearm flap in conjunction with the thumb ray and included all tissue components (Fig. 41-7). Each of these models proved to be technically successful, but as will be described in more detail below, prolonged allograft survival could not be achieved without unacceptable adverse effects, including sepsis and malignancy.
IMMUNOSUPPRESSION The focus of composite tissue transplantation research to date has been on the use of general immunosuppressive agents to optimize allograft survival and function. Therapy has usually included combinations of several agents, or pharmacologic therapy has been combined with other modalities in an attempt to induce chimerism and possibly tolerance. The earlier regimens included azathioprine, 6-mercaptopurine, prednisolone, and antilymphocyte serum in various combinations and dosages.26,40,42,65,101 Although more successful in organ transplantation, for the most part these agents allowed only modest and inconsistent limb allograft survival, with significant morbidity and mortality from the effects of systemic immunosuppression (Table 41-1). Researchers of composite tissue transplantation have applied drugs and regimens that have been most successful in organ transplantation. Cyclosporin A (CsA) first appeared in the transplantation literature in 1976.11 The efficacy of CsA and its antiproliferative effect on lymphocytes was proved in many animal models of organ transplantation.13,14,19,91 Its application to limb transplantation represented a turning point, as it produced the first consistent series of prolonged allograft survival.8 CsA became the focus of intensive investigation, but it ultimately became clear that CsA alone could not achieve long-term survival of limb allografts without significant host morbidity and mortality due to general immunosuppression (Tables 41-2 and 41-3).10,51,52,64 Tacrolimus (FK506) was discovered in 198743 and was found to be a more effective immunosuppressant for composite tissue and limb allografts63 with neuroenhancing properties.40 In general, therapy with FK506 alone was able to extend allograft survival even further,75 and in sporadic cases, it was even able to achieve longterm survival after only a limited postoperative course of treatment.4 However, eventually, most successful recipients succumbed to opportunistic infections because of generalized immunosuppression.3,12 Thus as with CsA,
41
does not interfere with ambulation. As the immunologic understanding and the ability for genetic engineering of the swine model increases, the swine could become the large-animal preclinical model of choice. The primate model has the anatomic and functional, as well as immunologic, characteristics to best simulate a human hand transplant. In 1984, Egerszegi et al. reported two models for use in composite tissue transplantation research.33 A primary aim was the assessment of functional recovery, and this is the main advantage of the nonhuman primate model over all other animal models. The baboon was selected because of anatomic similarity to the human hand in regard to sensory neural pathways and end organs. The first model consisted of a whole hand transplant at the level of the distal forearm and included rigid bony fixation of the distal radius and ulna, repair of all tendons except those of the flexor digitorum superficialis, and microsurgical repair of the ulnar, median, and radial nerves and the radial artery and cephalic vein. The second model consisted of transplantation of digital soft tissue from the index finger, including skin and soft tissue coverage based on a digital neurovascular pedicle but did not include tendons and ligaments (Fig. 41-6).21
EXPERIMENTAL LIMB ALLOTRANSPLANTATION
578
THE MUTILATED HAND
FIGURE 41-7. Rhesus monkey model of a partial hand composite tissue transplantation consisting of skin, muscle, tendon, bone, nerve, and vascular pedicle.
TABLE 41-1 Pre–Cyclosporin A Studies in Limb Allotransplantation Year
Author
Animal Model
n
Immunomodulation
Graft Survival
Complications
1966
Goldwyn et al.42
Dog hindlimb
11
Azathioprine, 6-MP
1 to 28 days
Microvascular thrombosis, pneumonitis
1968
Reeves88–90
Dog knee joint
5
Azathioprine, antilymphocyte serum
10 days to ⬎8 months
Vascular thrombosis, canine hepatitis
1973/1980
Goldberg et al.40,41
Dog knee joint
24
Azathioprine, prednisolone, antilymphocyte serum
Elective sacrifice at 1 year
Vascular thrombosis, sepsis
1978
Doi et al.26
Rat hindlimb
41
Azathioprine, 6-MP, prednisolone
9 to 24 days
Anesthetic death, vascular thrombosis, autotomy, probable sepsis in all treated animals
All animals were male or gender unspecified unless otherwise noted; all immunosuppressant drugs were administered beginning day of surgery (POD 0) unless otherwise noted. All dosages not otherwise specified represent continuous therapy. Abbreviation: 6-MP, 6-mercaptopurine
579
Rat hindlimb
Rat hindlimb
Rat hindlimb
Rabbit (adult) knee (juvenile) Rat hindlimb
Rat hindlimb
Rabbit forelimb
Black et al.9,38,49,50
Kim et al.105
Siliski et al.99
Black, et al.48
Press et al.86
Dörrler et al.25
83
Press et al.85
Paskert et al.
Black et al.10
1983, 1985
1983
1984
1984
1985
1986
1986
1987
1988
41
Rat hindlimb
Black et al.8
1982
Rat hindlimb
Heterotopic rat knee
Animal Model
Author
ACI→LEW
LEW→F344
LEW→BN
4 7
24 10d 24d 15d
d
10
9 4 5 5
F344→LEW
[outbred]
4 6 6 5
LBN→LEW
9 6 5 5
BUF→LEW
8 7
8 12 6
F344→LEW
[outbred] [outbred]
1 5 4
4
n
LBN→LEW
LBN→LEW
MHC Barrier
Cyclosporin A and Graft Survival
Year
TABLE 41-2
4 mg/kg/d SC ⫻ 20 d 8 mg/kg/d SC ⫻ 20 d
10 mg/kg/d SC 10 mg/kg/d SC ⫻ 14 d 10 mg/kg/d SC 10 mg/kg/d SC ⫻ 14 d
20 mg/kg/d SC
1.25 mg/kg/d IP [⫹4 mg/kg/d IP prednisone] 2.5 mg/kg/d IP [⫹2 mg/kg/d IP prednisone] 1.25 mg/kg/d IP [⫹ IP prednisone taper] 1.25 mg/kg/d IP [⫹6 mg/kg/d IP prednisone]
2 mg/kg/d SC ⫻ 20 d 4 mg/kg/d SC ⫻ 20 d 8 mg/kg/d SC ⫻ 20 d 25 mg/kg/d SC ⫻ 20 d
15 mg/kg/d IM 15 mg/kg/d IM
10 mg/kg/d IM ⫻ 14 d 10 mg/kg/d IM ⫻ 60 d [Azathioprine 10 mg/kg/d IP] [Prednisolone 10 mg/kg/d IP]
5 mg/kg/d IP [⫹6 mg/kg/d IP prednisone] 5 mg/kg/d IP [⫹4 mg/kg/d IP prednisone] 5 mg/kg/d IP
25 mg/kg/d SC ⫻ 20 d 8 mg/kg/d SC ⫻ 20 d then 8 mg/kg twice weekly SC 8 mg/kg/d SC ⫻ 20 d then 8 mg/kg twice weekly PO
25 mg/kg/d SC
CsA Regimen
26.8 ⫾ 6.5 d 37.6 ⫾ 3.0 d
70 db n/s 70 db 70 db
Continued
13 to 127 d [mean 62.7]
18 to 210 d 20 to 70 d 14 to 30 d 4 to 90 d
~20 to ~22 dc ~28 to ~60 dc ~35 to ~108 dc ~55 to ~110 dc
100 d in 3/8 animalsb 90 d in 2/7 animalsb
32.9 ⫾ 3.0 d 67.7 ⫾ 1.9 d 7.2 ⫾ 0.4 d 7.8 ⫾ 1.9 d
mean 11 d mean 10.5 d mean 16.3 d
504 da 404 to 441 db ~174 to ~648 dc
median 101 d
Graft Survival
580 Rat hindlimb
Dog knee Rabbit forelimb Dog whole knee Pig partial limb
Hotokebuchi et al.51
Doi et al.27
Kniha et al.60
Rosso et al.93
Lee et al.70
1989
1989
1989
1997
1998 [inbred/major] [inbred/minor]
[outbred]
[outbred]
[outbred]
BN → F344
LEW → F344
MHC Barrier
4 4
4
24
5
10 10 10 10
n
10 mg/kg/d IV ⫻ 12 d 10 mg/kg/d IV ⫻ 12 d
15 mg/kg/d SC ⫻ 7 d then 10 mg/kg/d SC ⫻ 21 d then 8 mg/kg/d SC n/s; treatment initiated 1 wk pre-op, dosage adjusted to maintain levels
20 mg/kg/d PO [⫹azathioprine 1 mg/kg/d PO]
25 mg/kg/d SC ⫻ 16 d 25 mg/kg/d SC ⫻ 16 d then 25 mg/kg/d SC twice weekly 25 mg/kg/d SC ⫻ 16 d 25 mg/kg/d SC ⫻ 16 d 25 mg/kg/d SC twice weekly
CsA Regimen
All ⬍42 d 178 to 280b
13 to 150 d [mean 64.47 d] 6 mob
~4 months
52 weeksb 52 weeksb 44.9 ⫾ 11.1 d 56.4 ⫾ 18.6 d
Graft Survival
All animals were male or gender unspecified unless otherwise noted; all immunosuppressant drugs were administered beginning day of surgery (POD 0) unless otherwise noted. All dosages not otherwise specified represent continuous therapy. Abbreviations: n/s, not specified; SC, subcutaneous; PO, per os/gavage; BN, Brown Norway rat strain; ACI, ACI rat strain; IM, intramuscular; IP, intraperitoneal; LBN, Lewis X Brown Norway; F1, offspring rat strain; LEW, Lewis rat strain; F344, Fischer rat strain; BUF, buffalo rat strain; 6-MP, 6-mercaptopurine. a One or more animals alive at time of publication. b Elective sacrifice. c Range represents estimates from graphs corresponding to approximate onset of skin changes and intragraft temperature decline of 5°C; numerical data not supplied. d Female animals used.
Animal Model
Author
Cyclosporin A and Graft Survival—cont'd
Year
TABLE 41-2
41
TABLE 41-3
EXPERIMENTAL LIMB ALLOTRANSPLANTATION
581
Primate Studies in Composite Tissue Allotransplantation
Year
Author
Animal Model
1986
Daniel et al.21,33,95,100
Baboon hand
Immunomodulation
Graft Survival
4b
CsA 20 mg/kg IM BID, d⫺4 to sac; dosage adjusted to maintain levels 800 to 1000; steroid taper began DOS
26, 71, 187,a 311 days
Baboon neurovascular free flap
8b
CsA 20 mg/kg IM BID, d⫺4 to sac; dosage adjusted to maintain levels 800 to 1000; steroid taper began DOS
20, 123,b 141,a 147,a 161, 193, 196, 211a
8
CsA 20 mg/kg SC divided BID, d⫺4 to sac; dosage adjusted to maintain levels ⬎800; steroid taper began DOS
2, 5, 7, 13, 13, 15, 296a
CsA 25 mg/kg SC, d⫺1 to sac; steroid taper began DOS
21, 22, 29, 30, 33, 33, 79, 85, 97, 121, 144, 179
1987
Stark et al.102
Baboon hand
1990
Stevens et al.105,106
Rhesus monkey partial hand
n
12
All animals were male or gender unspecified unless otherwise noted; all immunosuppressant drugs were administered beginning day of surgery (POD 0) unless otherwise noted. Abbreviations: CsA, cyclosporine A; IM, intramuscular; SC, subcutaneous; BID, twice daily; DOS, day of surgery; SCA, sacrifice date. a Elective sacrifice. b Female animals used.
tested in the swine model and consist of MMF combined with either CsA or FK506.32 Such data form the basis of the immunosuppressive regimen being used on the current human hand transplant recipients and consists of FK506, MMF, and prednisone.30,53
TOLERANCE INDUCTION Tolerance is a state of donor-specific immune unresponsiveness in an otherwise immunocompetent recipient and is the ultimate goal of transplantation research. Although current immunosuppressive regimens prevent acute rejection, they are not effective against chronic rejection, which has become a prevalent cause of allograft failure in organ transplantation.15,45,76,79 A state of donor-specific unresponsiveness would eliminate the risks of acute and chronic rejection as well as the need for chronic immunosuppression. Immune tolerance or unresponsiveness is an active process, and active regulatory mechanisms are essential to the induction and maintenance of the tolerant state. Such a state is specific, as antigen recognition must necessarily occur at some time after transplantation for specific tolerance to develop.58 Donor-specific tolerance has been much more readily produced in rodent models while translation of effective strategies to larger animal and primate models has proven to be difficult.28
41
effective and successful immunosuppression to allow limb allograft survival could not be obtained with FK506 alone without significant host toxicity (Table 41-4).69 Several newer agents have been studied more recently, including 15-deoxyspergualin (DOS),24,116 mycophenolate mofetil (MMF, RS-61443, Cellcept),6,84 rapamycin (Sirolimus),115,35 FTY720,37,78 and 61,121 Leflunomide. These have all shown initial promise in models of organ transplantation. Their application to composite tissue transplantation has been limited, but for the most part, long-term allograft survival or the induction of tolerance has not been forthcoming when used as single-agent therapy (see Table 41-4). In clinical transplantation, nonspecific immunosuppressive drug regimens remain the cornerstone of successful allotransplantation with impressive short-term results. The goal of combination therapy is to minimize the adverse effects of any single agent while maintaining sufficient overall immunosuppression by blocking the immune response at multiple levels. In many cases, synergy is noted when agents with different mechanisms of action are combined, and this forms the basis of current combination therapy. Various combinations of immunosuppressants have been studied for use in composite tissue transplantation and usually include a calcineurin inhibitor (CsA or FK506) and corticosteroids and/or one of the newer agents mentioned previously (Table 41-5). The most promising regimens have been
582 Rat hindlimb Rat hindlimb
Rat hindlimb
Rat hindlimb
Rat hindlimb
Rat hindlimb
Walter et al.116
Kuroki et al.63
Arai et al.3,4
Arai et al.3
Kuroki et al.62
Benhaim et al.6
van den Helder, et al.114
1989
1989
1989
1989
1993
1993
1994
Rat hindlimb
Animal Model
Author
MMF, 30 mg/kg/d PO, POD 7 to sac
MMF, 30 mg/kg/d PO, POD 9 to sac
11
9
BN → F344
MMF, 30 mg/kg/d PO continuously CsA, 10 mg/kg/d SC ⫻ 20 d, then 10 mg/kg/ d SC twice weekly
FK506, 1 mg/kg/d IM d ⫺7 to ⫹6 FK506, 1 mg/kg/d IM d ⫺7 to ⫹6, donor-specific blood transfusion, day ⫺7
FK506, 10 mg/kg IM ⫻ 1 on POD 7 FK506, 10 mg/kg IM ⫻ 1 on POD 10 FK506, 10 mg/kg IM ⫻ 1 on POD 0, then 3 mg/kg IM weekly
FK506, 0.2 mg/kg/d IM ⫻ 14 d FK506, 1 mg/kg/d IM ⫻ 14 d FK506, 5 mg/kg/d IM ⫻ 14 d FK506, 2 mg/kg IM ⫻ 1 FK506, 10 mg/kg IM ⫻ 1 FK506, 50 mg/kg IM ⫻ 1
FK506, 0.32 mg/kg/d IM ⫻ 14 d FK506, 0.64 mg/kg/d IM ⫻ 14 d CsA, 15 mg/kg/d IM ⫻ 14 d
DOS, 2.5 mg/kg/d IP ⫻ 10 d DOS, 2.5 mg/kg/d IP ⫻ 20 d
Immunosuppression
6
6 6
6 6 8
6e 6e 6e 6e 6e 5e
12 14 12
5 5
n
BN → F344
LEW → PVG
BN → F344
BN → F344
LEW → PVG
DA → LEW
MHC Barrier
FK506, Other Immunosuppressants and Graft Survival
Year
TABLE 41-4
n/s [reported successful reversal of acute rejection in 7/11 animals] n/s [reported successful reversal of acute rejection in 4/9 animals]
231 to 251b 223 to 244b
36.3 ⫾ 8.9d 36.0 ⫾ 6.9d
56.7 ⫾ 20.4 46.0 ⫾ 4.2 in 3/6 animals 214 to ⬎290a
14.7 ⫾ 2.5 149.5 ⫾ 63.9 101.7 ⫾ 8.5 16.0 ⫾ 2.8 51.3 ⫾ 6.2 104.4 ⫾ 17.2
33.9 ⫾ 4.5 49.8 ⫾ 5.0 31.0 ⫾ 3.2
18.2 ⫾ 1.4 23.6 ⫾ 2.0
Graft Survival (days)
583
Rat hindlimb
Rat hindlimb
Rat hindlimb
Min et al.75
Llull et al.72
Muramatsu et al.78
1995
1997
1998
DA → LEW
LEW → BN
ACI → LEW
BN → LEW
6
n/s n/s
10d
10d 11 9 10d 10d 9d 8d 9d
4 3 3 3 3 5 3
FTY720, 1.5 mg/kg/d IV/IP ⫻ 10 d FTY720, 3 mg/kg/d IV/IP ⫻ 10 d
FK506, 1 mg/kg/d IM ⫻ 28 d FK506, 1 mg/kg/d IM ⫻ 14 d, then 1 mg/kg/week
FK506, 1 mg/kg/d IM ⫻ 14 d FK506, 1 mg/kg/d IM ⫻ 14 d FK506, 1 mg/kg/d IM POD 1 to 14 FK506, 1 mg/kg/d IM POD 3 to 16 FK506, 2 mg/kg/d IM ⫻ 14 d FK506, 20 mg/kg/d IM ⫻ 1 on POD 3 CsA, 25 mg/kg/d IM ⫻ 14 d FK506, 1 mg/kg/d IM POD 3 to 16, then 1 mg/kg twice weekly FK506, 2 mg/kg/d IM POD 1 to 14, then 2 mg/kg twice weekly
RPM, 3 mg/kg/d IP ⫻ 14 d RPM, 4.5 mg/kg/d IP ⫻ 14 d RPM, 6 mg/kg/d IP ⫻ 14 d FK506, 6 mg/kg/d PO ⫻ 14 d FK506, 6 mg/kg/d PO ⫻ 14 d ⫹ salvage FK506, 6 mg/kg/d PO ⫻ 90 d CsA, 3 mg/kg/d IP ⫻ 14 d
6.0 ⫾ 0.9 7.9 ⫾ 1.5
38.5 176
296 ⫾ 29.78
40 ⫾ 7.65 45 ⫾ 9.57 58 ⫾ 24.27 45 ⫾ 10.54 122 ⫾ 159.35 64 ⫾ 33.19 30 ⫾ 2.20 149 ⫾ 83.71
9.5 ⫾ 2.1 10.6 ⫾ 2.1 8.7 ⫾ 4.1 28 ⫾ 0.8 41 to 85db ⬎90a 17.3 ⫾ 4.5
41
All animals were male or gender unspecified unless otherwise noted; all immunosuppressant drugs were administered beginning day of surgery (POD 0) unless otherwise noted. Abbreviations: PO, per os/gavage; IM, intramuscular; IP, intraperitoneal; SC, subcutaneous; IV, intravenous; MMF, mycophenolate mofetil (Cellcept); RPM, rapamycin (Sirolimus); POD, post-op day; BN, Brown Norway rat strain; F344, Fischer rat strain; ACI, ACI rat strain; CsA, cyclosporine A; DA, Dark Agouti rat strain; LEW, Lewis rat strain; PVG, PVG rat strain; DOS, 15-deoxyspergualin; FK506, tacrolimus; n/s, not specified. a One or more animals alive at time of publication. b Elective sacrifice. c Onset of rejection according to authors. d Female animals used.
Rat hindlimb
Fealy et al.35
1994
584 Rat hindlimb
Rat hindlimb
Rat neurovascular myocutaneous graft
Hindlimb xenotransplant
Rat hindlimb
Rat hindlimb
Inceoglu et al.54
Benhaim et al.5
Yeh et al.120
Hebebrand et al.47
Muramatsu et al.77
Yeh et al.121
Üstüner et al.
1994
1996
1996
1997
1997
1997
1998
[outbred]
BN → LEW
DA → LEW
HAM → LEW
BN → LEW
BN → F344
LBN → LEW
BUF → WF
MHC Barrier
10
6
8 9 12 9 3 9 10
10
13 14 14 12 11
6 6 7
11 17 18
12 12 12
n/s n/s
n
CsA 40 mg/kg/d PO (adjusted per trough levels) ⫹ MMF 500 mg/d PO ⫹ prednisone taper 2 to 0.1 mg/kg/d PO
LEF 10 mg/kg/d PO ⫹ CsA 5 mg/kg/d PO d ⫺2 to 60
CsA 15 mg/kg/d IM ⫻ 30 d DOS 2.5 mg/kg/d IM ⫻ 30 d FK506 1 mg/kg/d IM ⫻ 30 d CsA 15 mg/kg/d IM ⫻ 30 d ⫹ DOS 2.5 mg/kg/d IM ⫻ 15 d CsA 15 mg/kg/d IM ⫻ 30 d ⫹ DOS 2.5 mg/kg/d IM ⫻ 30 d FK506 1 mg/kg/d IM ⫻ 30 d ⫹ DOS 2.5 mg/kg/d IM ⫻ 15 d FK506 1 mg/kg/d IM ⫻ 30 d ⫹ DOS 2.5 mg/kg/d IM ⫻ 30 d
FK506 2 mg/kg/d IM ⫻ 14 d MMF 30 mg/kg/d PO ⫻ 14 d FK506 2 mg/kg/d IM ⫹ MMF 30 mg/kg/d PO ⫻ 14 d FK506 1 mg/kg/d IM ⫹ MMF 20 mg/kg/d PO ⫻ 14 d FK506 2 mg/kg/d IM from POD 1 ⫹ MMF 30 mg/kg/d PO from POD 4 ⫻ 14 d FK506 2 mg/kg/d IM from POD 4 ⫹ MMF 30 mg/kg/d PO from POD 1 ⫻ 14 d
LEF 10 mg/kg/d PO, d ⫺2 to 60/rejection CsA 5 mg/kg/d PO, d ⫺2 to 60/rejection CsA 5 mg/kg/d PO ⫹ LEF 10 mg/kg/d PO day ⫺2 to 60/rejection
CsA 1.5 mg/kg/d SC MMF 15 mg/kg/d PO CsA 1.5 mg/kg/d SC ⫹ MMF 15 mg/kg/d PO
FA 6 mg/cm2/d TOP CsA 4 mg/kg/d SC CsA 4 mg/kg/d SC ⫹ FA 6 mg/cm2/d TOP cont.
CsA 4 mg/kg/d IV ⫻ 14 d CsA 2 mg/kg/d IV ⫻ 14 d RPM 0.8 mg/kg/d IV ⫻ 14 d RPM 0.08 mg/kg/d IV ⫻ 14 d RPM 0.08 mg/kg/d IV ⫻ 14 d ⫹ CsA 2 mg/kg/d IV ⫻ 14 d
Immunosuppression ⫾ ⫾ ⫾ ⫾ ⫾ 1.8 4.5 0.9 4.6 3.0
90 in 6/10
60a
37 ⫾ 3.4 44 ⫾ 6.2 61 ⫾ 13.3 36 ⫾ 1.5 All dead 76 ⫾ 6.3 76 ⫾ 2.6
8.0 ⫾ 1.5
10.2 ⫾ 7.0 10.0 ⫾ 2.5 All ⬍13 8.25 ⫾ 1.3 9.2 ⫾ 2.8
24.33 ⫾ 10.48 28.5 ⫾ 6.12 60b in 6/7
~20 to ~100b ~25 to ⬎300b 231 to 254 in 16/18
~17f ~19f ~33f
58.8 21.2 59.6 20.6 57.8
Graft Survival (days)
All animals were male or gender unspecified unless otherwise noted; all immunosuppressant drugs were administered beginning day of surgery (POD 0) unless otherwise noted. All dosages not otherwise specified represent continuous therapy. Abbreviations: CsA, cyclosporine A; DOS, 15-Deoxyspergualin; FA, fluocinolone acetonide; FK506, tacrolimus; LEF, leflunomide; RPM, rapamycin (Sirolimus); NNF, mycophenolate mofeticl (Cellcept); n/s, not specified; BN, Brown Norway rat strain; BUF, Buffalo rat strain; DA, Dark Agouti rat strain; F344, Fischer rat strain; HAM, Golden syrian hamster; LEW, Lewis rat strain; LBN, Lewis X Brown Norway; F1, offspring rat strain; WF, Wistar Furth rat strain; IM, intramuscular; PO, per os/gavage; POD, post-op day; SC, subcutaneous; TOP, topically. a Elective sacrifice. b Estimate based on graphic data; no numeric data provided.
Pig limb
Rat hindlimb
Aboujaqude et al.2
1991
113
Animal Model
Author
Combination Immunosuppression and Graft Survival
Year
TABLE 41-5
41
Stem Cell Transplantation and Chimerism Chimerism is the persistence of donor strain cells in the recipient animal following transplantation. The presence of chimerism might be important for the induction of stable donor-specific immune unresponsiveness80,103,109,117 but the mechanism remains under investigation. Following solid organ transplantation, “passenger” leukocytes from the donor organ are detectable in the peripheral circulation of the recipient animal in the early postoperative period and can persist for years.80,104 Hematopoietic stem cell engraftment by
585
bone marrow transfusion has the potential to induce durable donor-specific unresponsiveness because of the multilineage potential of these cells and their ability for self-renewal. This strategy has usually required some type of recipient conditioning with irradiation (whole body, sublethal, and/or thymic) and/or cytoablative agents such as monoclonal antibody to CD3, CD4, or CD8 to facilitate engraftment.29,107 In this setting, transplanted hematopoietic cells migrate to the host thymus to induce clonal deletion of responsive developing thymocytes. Other possible mechanisms of tolerance include donor T cells that “veto” or inactivate alloreactive host T cells, or host T cell suppressor activity.28 A state of mixed chimerism is induced if both recipient and donor cells contribute to hematopoiesis, and the resulting T cell pool in the host thymus is tolerized to antigens of both the donor and recipient animal.80 Such mixed chimeras have improved immunocompetence,111 and their production does not require host myeloablation.110 Bone marrow transplantation continues to be an essential component of strategies for the induction of tolerance, and engraftment usually requires a large number of cells (ⱖ2 ⫻ 107–8 cells). Similar strategies using donor-specific splenocytes or blood transfusion have not been as successful.74 A limb allograft is unique because it is also a vascularized bone marrow transplant and may be able to induce hematopoietic stem cell engraftment. As such, it has a greater potential for the production of chimerism and durable donor-specific immune unresponsiveness.109 However, the amount of bone marrow that accompanies a hand/distal forearm transplant is limited, and for the induction of tolerance, exogenous administration of donor bone marrow might still be necessary.
Costimulation Theory and Blockade Antigen recognition and activation of T lymphocytes is essential to the immune response. This process is initiated by antigen binding to the T cell receptor (TCR) that is composed of membrane proteins expressed only on T cells. The TCR specifically binds to antigen peptide– major histocompatibility complexes on the surface of antigen-presenting cells or target cells. Both the cell surface expression of TCR molecules and their function in activating T cells are further dependent on other transmembrane proteins, such as the CD3 molecules. These molecules transduce signals to the T cell cytoplasm, leading to the activation of a number of enzymes, including calcineurin, a critical enzyme in TCR signaling, and ultimately to functional T cell activation.1 To achieve full activation responses, two distinct extracellular signals are required. Peptide-major histocompatibility complex binding to the TCR provides the first signal, and costimulatory molecules, which are surface
41
The tolerant state can be classified broadly as central or peripheral and involves several mechanisms that are not mutually exclusive.28 Central tolerance occurs in the thymus gland and is induced by the mechanism of clonal deletion. The essential mechanisms are analogous to the development of self-tolerance in the fetal/neonatal period. Basically, T cell clones that are reactive to selfantigens are negatively selected and deleted by apoptosis, or programmed cell death, before release into the peripheral circulation. Peripheral tolerance occurs outside of the thymus and in the lymphoid organs and involves the mechanisms of (1) anergy or functional inactivation and (2) suppression. In the anergic state, alloreactive T cells recognize allogeneic antigens but do not respond. Anergic unresponsiveness can be reversed by the administration of IL-2. The regulation of tolerance by the suppression of T cell activity has been shown in both in vitro and in vivo experiments.81,87 The precise mechanism of suppression is not well understood but might be related to the cytokine environment and the controversial TH1/TH2 paradigm.18,28,44 Helper (CD4⫹) T cells can be further subdivided into T helper 1 (TH1) and T helper 2 (TH2) cells, which are distinguished by their respective cytokine profiles. TH1 cells secrete IL-2, IL-12, and IFN-␥; are mainly involved in cell-mediated responses; and have been shown to predominate in the setting of allograft rejection. TH2 cells secrete IL-4, IL-5, IL-10, and IL-13; mediate humoral immune responses; and have been shown to be associated with the tolerant state. Suppressor activity may also be the mechanism of “infectious tolerance,” whereby a naive animal can be made tolerant by the administration of T cells from a tolerant animal.16,87 Regimens for the induction of tolerance need to meet several requirements: (1) the control or elimination of existing donor-reactive recipient cells, (2) protection of the allograft early after transplantation during the induction phase, (3) the control or elimination of future donor-reactive recipient cells that may develop, and (4) a low toxicity profile. The components of the more successful regimens in experimental organ and limb transplantation are discussed below.
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THE MUTILATED HAND
molecules of antigen-presenting cells that bind to specific receptors on the T cell and transduce activational signals, provide the second signal.46 Two significant costimulatory signals are the CD40/40 ligand and the B7/CD28 pathways. Both are known to play an important role in the rejection of allografted tissues.68 Treatment with a monoclonal antibody (mAb) that is specific for CD40L has resulted in the prolonged survival of allografted tissues or organs in a donor-specific manner, with less global immune suppression in several animal models. Initial studies in a rodent model demonstrated markedly prolonged rejection-free survival when anti-CD40L mAb was administered at the time of cardiac transplantation.66 However, neither blockade of the CD40 nor B7/CD28 pathway alone has been found to prolong survival of skin allografts in the murine model.67 Subsequent studies in the rodent model have therefore focused on the synergy between anti-CD40L mAb and CTLA4-Ig, a fusion protein that blocks the interaction between B7 and CD28. This combination has produced long-term acceptance of skin as well as cardiac allografts in the mouse67 and xenogenic cardiac (rat-to-mouse) and skin (pig-tomouse) transplants.34 Use of these strategies in the nonhuman primate model has also achieved very promising but somewhat different results. CTLA4-Ig alone, while effective in the rodent model, has been disappointing in primates and has been less effective than anti-CD40L mAb alone.58 The combination of anti-CD40L mAb and CTLA4-Ig has achieved prolonged allograft survival in the rhesus monkey allograft model and is superior to a brief course of either therapy alone. However, an extended course (2 to 4 weeks) of anti-CD40L mAb alone in the same model has prolonged survival even further.59 CD40L-blocking antibody has also recently been shown to be effective for the long-term survival of pancreatic islet cell transplants as induction and a finite period of maintenance therapy as well as the reversal of rejection.56 Monoclonal antibody to CD40 has also been used, with results comparable to those achieved with anti-CD40L antibody. In both the rodent and nonhuman primate models, CD40L-blocking antibody has also been combined with other modalities, such as donor-specific transfusion, with variable success.23,59 A promising regimen for the long-term acceptance of skin allografts was recently described that combines CD40 pathway blockade in the place of cytoreductive conditioning with donor-specific bone marrow transfusion.31 Both are given simultaneously in multiple repeated doses for up to 2 to 3 months after transplantation. Strategies involving costimulation blockade have yet to be applied to a model of vascularized composite tissue transplantation but should be forthcoming.
Gene Therapy Gene therapy is directed at the level of cellular gene transcription and therefore has the potential to be very specific in its action. The implications for the clinical application of gene therapy are tremendous and might allow the treatment and possibly the cure of a wide range of diseases. There are several possible mechanisms of gene therapy for the induction of transplantation tolerance.22 The first is the modulation of cytokine-mediated regulation of the alloimmune response. Such an approach might target the TH2 subset that is associated with the tolerant state and could involve TH2 transcription factors or TH2 cytokines such as IL-4 and IL-10. A second mechanism is the induction of functional immune unresponsiveness and might be effected again by the blockade of costimulatory pathways. Another approach might involve the process of activation-induced cell death, or apoptosis, which might also play a significant role in transplantation tolerance. Such therapy could be directed at fas-fas ligand interactions and fas-mediated cell death, or the transcription of “protective” genes. The advantage of gene therapy is the ability to direct therapy to effect a specific cell, enzyme, or growth factor and thus to further minimize or eliminate untoward effects. Nevertheless, the application of gene therapy still requires a complete understanding of the mechanisms of transplant rejection and acceptance.
CONCLUSION The current short-term success of organ transplantation is excellent, with 1-year allograft survival rates of up to 80 to 90% or more.17,92 The current series of human hand transplants would suggest that a similar early success rate is possible with optimal patient selection and compliance. However, chronic rejection remains a problem and is the primary cause of long-term allograft failure. Chronic rejection manifests in lung transplantation as bronchiolitis obliterans and in heart transplantation as post-transplant vasculopathy. The signs of chronic rejection following a hand transplant might include scarring and loss of mobility or possibly small-vessel disease and ischemia. Until such processes can be eliminated, however, the role of nonvital transplantation is likely to remain limited and controversial. As in organ transplantation, the goal of composite tissue allotransplantation research is the achievement of donor-specific immune tolerance. The attainment of this goal would have broad implications for the field of reconstructive surgery, as well as other surgical and related specialties, in which nonvital transplantation has the potential to dramatically improve the quality of life.
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41
41
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73. 74.
75. 76.
77.
78.
79. 80. 81.
82.
83.
84.
85.
86.
87. 88. 89. 90. 91.
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92. Remuzzi G: Transplant tolerance: Facts and future. Transplant Proc 31:2955–2957, 1999. 93. Rosso R, Schaefer D, Fricker R, et al: Functional and morphological outcome of knee joint transplantation in dogs depends on control of rejection. Transplantation 63:1723, 1997. 94. Samulack DD, Dykes RW, Munker BL: Neurophysiologic aspects of allogeneic skin and upper extremity composite tissue transplantation in primates. Transplant Proc 20(suppl 2):279, 1988. 95. Samulack DD, Munger BL, Dykes RW, Daniel RK: Neuroanatomical evidence of reinnervation in primate allografted (transplanted) skin during cyclosporine immunosuppression. Neurosci Lett 72:1, 1986. 96. Schwind JV: Successful transplantation of a leg in albino rats with reestablishment of muscular control. Science 84:355, 1936. 97. Siegler M: Ethical issues in innovative surgery: Should we attempt a cadaveric hand transplantation in a human subject? Transplant Proc 30(6):2779–2782, 1998. 98. Shapiro RI, Cerra FB: A model for reimplantation and transplantation of a complex organ: The rat hindlimb. J Surg Res 24:501, 1978. 99. Siliski JM, Simpkin S, Green CJ: Vascularized whole knee joint allografts in rabbits immunosuppressed with cyclosporine A. Arch Orthop & Trauma Surg 103:26, 1984. 100. Skanes SE, Samulack DD, Daniel RK: Tissue transplantation for reconstructive surgery. Transplant Proc XVIII:898, 1986. 101. Slome D, Reeves B: Experimental homotransplantation of the knee-joint. Lancet 2(7456):205, 1966. 102. Stark GB, Swartz WM, Narayanan R, Moller A: Hand transplantation in baboons. Transplant Proc 19:3968, 1987. 103. Starzl TE, Demetris AJ, Murase N, Trucco M, Thomson AW, Rao AS: The lost chord: Microchimerism and allograft survival. Immunol Today 17(12):577–584, 1996. 104. Starzl TE, Demetris AJ, Murase N, Valdivia L, Thomson AW, Fung J, Rao AS: The future of transplantation: with particular references to chimerism and xenotransplantation. Transplant Proc 29:19–27, 1997. 105. Stevens HP, Hovius SER, Heeney JL, et al: Immunologic aspects of complications of composite tissue allografting for upper extremity reconstruction: A study in the rhesus monkey. Transplant Proc 23:623, 1991. 106. Stevens HP, Hovius SER, Vuzevski VD, et al: Immunological aspects of allogeneic partial hand transplantation in the rhesus monkey. Transplant Proc 22:2006, 1990. 107. Stewart FM, Crittendon RB, Lowry PA, Pearson-White S, Quesenberry PJ: Long-term engraftment of normal and post-5-fluorouracil murine marrow into normal nonmyeloablated mice. Blood 81:2566, 1993. 108. Superina RA, Peugh WN, Wood KJ, Morris PJ: Assessment of primarily vascularized cardiac allografts in mice. Transplantation 42:226–227, 1986. 109. Suzuki H, Hewitt CW, Tran HS, Puc MM, Patel NG, Matthews M, Dalsey RM, Doolin EJ, DelRossi AJ: Composite tissue/vascularized bone marrow transplantation: A hierarchy of tissue tolerogenicity. Graft 2(3): 111–115, 1999. 110. Sykes M: Chimerism and central tolerance. Curr Opin Immunol 8:694–703, 1996.
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111. Sykes M: Hematopoietic cell transplantation for the induction of allo- and xeno-tolerance. Clin Transplant 10:357–363, 1996. 112. Tanabe YN, Randolph MA, Shimizu A, Lee WP: Xenotransplantation model for vascularized musculoskeletal tissues in rodents. Microsurgery 20(2):59–64, 2000. 113. Üstüner ET, Zdichavsky M, Ren X, et al: Long-term composite tissue allograft survival in porcine model with cyclosporine/mycophenolate mofetil therapy. Transplantation 66:1581, 1998. 114. van den Helder TBM, Benhaim P, Anthony JP, et al: Efficacy of RS-61443 in reversing acute rejection in a rat model of hindlimb allotransplantation. Transplantation 57:427, 1994. 115. Vezina C, Kudelski A, Sehgal SN: Rapamycin (AY-22,989), a new antifungal antibiotic. I: Taxonomy of the producing streptomycete and isolation of the active principle. J Antibiot (Tokyo) 28:721, 1975. 116. Walter P, Menger MD, Thies J, et al: Prolongation of graft survival in allogeneic limb transplantation by 15-deoxyspergualin. Transplant Proc 21:3186, 1989. 117. Wood K, Sachs DH: Chimerism and transplantation tolerance: Cause and effect. Immunol Today 17(12):584–588, 1996.
118. Yaremchuk MJ, Nettelblad H, Randolph MA, Weiland AJ: Vascularized bone allograft transplantation in a genetically defined rat model. Plast Reconstr Surg 75:355, 1985. 119. Yaremchuk MJ, Sedacca T, Schiller AL, May JW: Vascular knee allograft transplantation in a rabbit model. Plast Reconstr Surg 71:461, 1983. 120. Yeh L-S, Gregory CR, Griffey SM, et al: Effects of leflunomide and cyclosporine on myocutaneous allograft survival in the rat. Transplantation 62:861, 1996. 121. Yeh L-S, Gregory CR, Griffey SM, et al: Combination leflunomide and cyclosporine prevents rejection of functional whole limb allografts in the rat. Transplantation 64:919, 1997. 122. Zhang F, Shi DY, Kryger Z, et al: Development of a mouse limb transplantation model. Microsurgery 19:209, 1999. 123. Zheng Z, Schlachta C, Duff J, Stiller C, Grant D, Zhong R: Improved techniques for kidney transplantation in mice. Microsurgery 16:103–109, 1995. 124. Zhong R, Zhang Z, Quan D, Duff J, Stiller C, Grant D: Development of a mouse intestinal transplantation model. Microsurgery 14:141–145, 1993.
42 Hand and Composite Tissue Allotransplantation: Past, Present, and Future Vijay S. Gorantla, MD, PhD Ruben N. Gonzalez, MD Warren C. Breidenbach III, MD, MSc, FRCS(C)
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Limb transplants are defined as composite tissue allografts because they are modules of distinct tissues, including skin, muscle, ligament, tendon, nerve, blood vessel, bone, joint and cartilage, bone marrow, and lymph nodes.93 Composite tissue allotransplantation is among the newest of transplant areas and combines the time-tested techniques of reconstructive microsurgery with the immunologic principles of transplantation. The overall goal of composite tissue allotransplantation is to improve the quality of life of patients who have significant tissue defects. Each year, millions of individuals sustain injuries, have tumors surgically excised, or are born with congenital defects that require complex reconstructive surgeries to repair the resulting large tissue defects. In the United States alone, the numbers of extremity amputations are estimated to be around 1,285,000 per year.108 Conventional treatments for such tissue deficiencies, such as prosthetic rehabilitation or multiple reconstructions (with autologous tissues), do not achieve optimal aesthetic and functional outcomes54 or are associated with considerable morbidity. In this aspect, composite tissue allotransplantation offers a better alternative because deficiencies can be corrected by utilizing identical tissue, subsequent reconstructions might not be necessary, and prolonged morbidity can be prevented. Despite the obvious advantages offered by composite tissue alloreconstruction, one factor has hampered its widespread application. This is the need for long-term immunosuppressive therapy to maintain the allograft. The risks posed by antirejection drugs are considered by many to be justified in life-saving procedures such as solid organ transplants in patients with terminal organ failure. However, such risks are considered to be too high a price to pay for life-enhancing (non-life-saving) transplants such as composite tissue allografts. This has been a subject of ongoing debate in the hand surgery community and is beyond the scope of this chapter. Notably, routine immunosuppression (as used in solid organ transplantation) has resulted in successful hand transplantation with no mortality and minimal morbidity. Therefore the outlook for hand transplantation seems promising, but long-term predictions on outcomes are not yet possible. This chapter is organized into three sections: past, present, and future. The first section will outline a brief history of composite tissue allotransplantation, the immunology of composite tissue allografts, and the scientific basis for composite tissue allotransplantation. The second section will discuss the modern chronology of clinical composite tissue and hand 591
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THE MUTILATED HAND
transplantation, procedural aspects of hand transplantation, functional outcomes after hand transplantation, hand transplantation versus replantation, cortical reorganization after hand replantation/transplantation, and hand and composite tissue allograft registry. The concluding section will focus on promising tolerance strategies aimed at reduction or elimination of immunosuppressive drugs in transplantation.
A BRIEF HISTORY OF CLINICAL COMPOSITE TISSUE ALLOTRANSPLANTATION Historically, composite tissue transplantation predates organ transplantation. The earliest accounts of pedicled autografts from the forehead, neck, and cheek to restore mutilating injuries of the nose and ear are found in the Suˇsruta Samhita.8,68,69 This treatise, written by the Indian surgeon Suˇsruta, who lived around 480 BC, describes in detail the techniques of rhinoplasty. About 870 years later, Cosmos and Damian, the patron saints of surgeons, are credited with performing the first limb allotransplantation.27,29,81 Legend has it that around the year AD 348, they successfully transplanted the right leg of a dead Moor onto a patient after amputating his gangrenous leg. A 15th century fresco in the St. Julius Basilica in Milan shows St. Julius replanting the amputated thumb of a man.24 In the 16th century, Gaspare Tagliacozzi, an Italian surgeon from Bologna, described a method of nasal and aural “alloreconstruction” in his book De curtorum chiruriga per insitionem (“On the Surgery of Mutilation by Grafting”).139–141 He supposedly used skin from the inner aspect of the arm of a slave to reconstruct the nose of a wealthy patient who had injured it during a sword fight.48 This unsubstantiated account reports that the reconstructed nose allegedly survived for 3 years, after which the donor flap was rejected. In his book, Tagliacozzi concludes that allografts are possible but present practical difficulties in binding two persons (referring to tissues) to one another for a sufficient length of time. It took another 300 years before these “practical difficulties” in transplantation began to be elucidated. During this time, advances in antisepsis, anesthesia, hemostasis, organ preservation, and, most important, microvascular surgery led to rapid progress in reconstructive microsurgery. In 1902, Alexis Carrell described the surgical technique of vascular anastomosis, thus laying the foundation for conventional vascular surgery.20 Carrell successfully accomplished the revascularization of experimental organ allografts21,22 but failed to achieve permanent graft acceptance. Carrell attributed this “organ failure” to vascular complications because he had no
knowledge of the process of rejection.20 In 1932 and 1937, the first attempts at skin grafting were performed between identical twins.14,110 Again, no mention was made of rejection. In 1944, Hall published the first detailed theoretical account of cadaveric donor upperextremity transplantation (at the midhumeral level).57 In this protocol, he describes the need for an experienced surgical team in a well-equipped hospital to perform the procedure and includes descriptions of organ preservation, osteosynthesis, and vascular anastomoses. Potential complications related to thrombosis and infections are discussed, but again no reference is made to the occurrence of rejection. Strikingly, Hall was not aware that Sir Peter Brian Medawar, a young zoologist in Britain, had made the historic discovery of the immunologic phenomenon of allograft rejection in the same year (1944).100
The Evolution of Immunosuppressive Drugs in Transplantation Our understanding of the immunologic behavior of allografts lagged behind technical developments in surgery. It is only the knowledge gained from landmark discoveries in the past century2,30–32,46,87,109,126,142 that has facilitated the manipulation or suppression of the immune response, allowing successful prolongation of graft survival. After Medawar’s demonstration that rejection was an immunologic event, the next logical question was “Why not prevent this phenomenon by suppressing the immune system?” In the 1950s, corticosteroids and irradiation were used for immunosuppression.60,61 In the 1960s, the antimetabolite 6-mercaptopurine and its derivative azathioprine were introduced, along with agents such as antilymphocyte globulin. These drugs were used either alone105,106 or in combination with corticosteroids.86,129,133 Graft survival improved but was still dismal because these drugs acted indiscriminately and were associated with severe organ-specific and systemic adverse effects. In 1964, the first hand transplantation was performed using pharmacologic immunosuppression.63,66,107 Dr. Roberto Gilbert in Guayaquil, Ecuador, transplanted the right forearm of a 28-year-old sailor who had lost his limb at the wrist level from a hand-grenade explosion the previous day (Fig. 42-1). The donor was a laborer who had died of hematemesis (with gastric bleeding) a few hours earlier. The recipient was given heparin, dextran, and a broad-spectrum antibiotic after the surgery and was maintained on a combination regimen of prednisone and 6-mercaptopurine. The 6-mercaptopurine was replaced 24 hours later by azathioprine. These drugs can be considered primitive according to present-day standards, and signs of acute allograft rejection occurred after two and a half weeks. The patient was then moved to Peter Bent Brigham Hospital in Boston,
42
HAND AND COMPOSITE TISSUE ALLOTRANSPLANTATION: PAST, PRESENT, AND FUTURE
593
the small bowel to be transplanted.130,146,147 The success of the calcineurin inhibitors cyclosporine A and tacrolimus made them the cornerstone drugs of the modern era of transplantation.50 The 1990s saw the introduction of novel drugs such as the antimetabolite mycophenolate mofetil1 (MMF, approved by FDA in 1995) and rapamycin150 (sirolimus, discovered in 1976 but approved by the FDA only in 1999). Combining these drugs with a calcineurin inhibitor59,80,99,123 significantly reduced acute rejection and improved solid organ graft survival with a reduction in adverse effects.
The Evolution of the Field of Composite Tissue Allotransplantation
where at 3 weeks, aggressive rejection set in, and the forearm had to be reamputated 4 centimeters above the wrist level.62 Unfortunately, the advanced state of necrosis prevented any histopathologic evaluation of the graft. This bold and pioneering attempt at hand transplantation laid the foundation for the successful attempts yet to come. In 1976, another major breakthrough in transplantation came with the discovery of the immunosuppressive properties of the calcineurin inhibitor cyclosporine A.12,37 In 1978, cyclosporine was first used clinically in organ18 as well as bone marrow transplantation with remarkable results. Cyclosporine A was approved by the FDA for use in the United States in 1983. Cyclosporine A, along with agents such as anti-CD3 antibody (OKT3, introduced in 1981),26 effectively reduced reliance on high-dose steroids for the prevention of rejection. The calcineurin inhibitor tacrolimus (FK-506) was discovered in 1987,52 clinical trials were conducted in 1989,135 and FDA approval came in 1994. Tacrolimus led to dramatic improvements in solid organ transplantation,3,45,131,145 allowing highly immunogenic grafts such as
TABLE 42-1
Milestones in Composite Tissue Allotransplantation
Tissue/Transplant
Author
Reference
Skin
Wendt et al.
151
Muscle
Jones et al.
77
Vessel (vein)
Carpenter et al.
19
Nerve
Mackinnon et al.
94–96
Tendon
Guimberteau et al.
55,56
Bone, joint, and cartilage
Hofmann et al.
70–72
Larynx
Strome et al.
138
42
FIGURE 42-1. The first human hand allotransplantation by Dr. Roberto Gilbert, in Ecuador in February 1964. (Source: Picture with permission from Ms. Delia de Gilbert.)
The initial results of graft and patient survival after organ transplantation in the 1960s were poor. Editorials in major clinical journals, including the New England Journal of Medicine,15,42,111,112 questioned the feasibility and ethical basis of these procedures. There was great concern about the adverse effects of chronic immunosuppression, especially the risk of opportunistic infections and malignancies. During the next four decades, because of the improvements in immunosuppression and in the management of post-transplant complications, this ingrained pessimism abated. Extensive experience with organ transplantation has provided valuable information about the immunologic consequences of organ allografting and the efficacy and toxicity of immunosuppressive drugs. The field of transplantation evolved from transplanted kidneys101 and hearts6,35 to livers,132 lungs,33 pancreas,92 small bowel,53 multiple abdominal viscera,134 bone marrow,143 and, most recently, composite tissue allografts (Table 42-1). Remarkably, however, attempts at hand transplantation,38,39 after three decades of quiescence since the first attempt in Ecuador,66 met with vigorous opposition. Paradoxically, most of the criticism came from hand surgeons.25,43,64,65,90,118,137 They argued that the risks of
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immunosuppressive therapy were justifiable in potentially life-saving organ transplants but not in qualityof-life-enhancing transplants such as hand transplants. Furthermore, many hand surgeons thought that the immunologic, ethical,124,125 and psychological85 issues associated with hand transplantation still needed to be addressed.76
THE IMMUNOLOGY OF COMPOSITE TISSUE TRANSPLANTS Much knowledge about the immunologic aspects of composite tissue allografts has been gained from studies in small- and large-animal models. Animal research has confirmed that each tissue in a composite tissue allograft has its own distinct degree of antigenicity and is rejected by different mechanisms. This is because each of the component tissues is characterized by different antigen expression and presentation mechanisms.91 The components of a composite tissue allograft express different amounts of major histocompatibility complex antigens and tissue-specific antigens, which are primarily responsible for the elicitation of the recipient’s cellular-mediated response.153 Antigen recognition and targeting by the recipient immune system also differ among the allograft tissue elements, owing to their different vascular and lymphatic supply. Altogether, these facts explain a pattern of differential rejection observed in whole limb transplanted allografts. For example, transplanted muscle elicits mainly a cell-mediated immune response, whereas skin elicits both cellular and humoral responses.40 In general, skin and bone marrow appear to reject earlier and more aggressively than does muscle, bone, cartilage or tendon. Therefore it is logical to presume that to prevent rejection, the most effective immunosuppressive strategy would be a combination of agents that affect different pathways of the immune response through different mechanisms.50 Ideally, this combination of drugs must be selective, specific, and synergistic; free of toxic reactions; easy to administer; and inexpensive. Most of the information about potential immunosuppressive regimens has been derived from small-animal (rat) and large-animal (porcine, canine, and primate) composite tissue allograft models.
SCIENTIFIC BASIS OF COMPOSITE TISSUE ALLOTRANSPLANTATION In early rodent limb transplant studies (in the pre–cyclosporine A era), recipients who were treated with various combinations of immunosuppressive doses of 6-mercaptopurine or its derivative azathioprine and
prednisone all died from drug-induced side effects before the onset of macroscopic signs of rejection.34 Even with the introduction of cyclosporine A, studies reported very poor limb or animal survival despite using high doses as monotherapy.11,44,83,103,120 The incidence of side effects and morbidity and mortality owing to the high drug doses was significant. The use of cyclosporine A monotherapy has been uniformly unsuccessful in prolonging composite tissue allograft survival not only in small animal models, but also in nonhuman primate models. Because of the close phylogenetic relationship to humans, nonhuman primate models have been considered to be representative of the human immune system and the best predictors of success in clinical trials.75 Remarkably, however, composite tissue allograft studies in nonhuman primates have shown that rejection cannot be prevented unless trough levels of cyclosporine A are three to four times the level achieved in human solid organ transplantation. Nonhuman primates did not tolerate such high doses of cyclosporine A and succumbed to peritransplant infections and malignancies.28,41,74,128 None of the above-mentioned studies attempted to combine a calcineurin inhibitor and an antimetabolite drug (such as mycophenolate mofetil) with or without steroids. None of these studies could consistently demonstrate long-term limb allograft survival. In 1996, Benhaim and colleagues demonstrated that a combination of cyclosporine A with mycophenolate mofetil could successfully prolong rat hind limb allograft survival.7 For the first time, predictable long-term, functional limb allograft survival was achieved. Using a similar regimen, the only large-animal model that demonstrated longterm survival of fully mismatched composite tissue allografts was the swine model.79,148 It should be noted that like the nonhuman primates, swine and humans share immunologic similarities. These include the structure of major histocompatibility complex and the expression of major histocompatibility complex class II antigens (on endothelial cells, epithelial cells, and dendritic cells).58 Therefore there was sufficient sound evidence in both small-animal (rodent)88,113 and large-animal composite tissue allograft models,79,148 implying that the experimental basis of human extremity composite tissue allotransplantation was feasible.13 The success in rodent and swine models did not translate to primate studies. This was because modern combination immunosuppression (tacrolimus or cyclosporine A with mycophenolate mofetil ⫾ steroids) has never been tested in a nonhuman primate composite tissue allograft model.75 However, given the marked success of the early hand transplant experience (92% graft survival with 100% 1- and 2-year patient survival) using standard combination therapy, the lack of a preclinical primate model might now be only semirelevant.
HAND AND COMPOSITE TISSUE ALLOTRANSPLANTATION: PAST, PRESENT, AND FUTURE
The rationale for proceeding with clinical trials of hand transplantation using modern immunosuppression has been based on scientific progress on several fronts: (1) the availability of novel immunosuppressive drugs that have improved efficacy and lower risk profiles, (2) improved prophylaxis and treatment of opportunistic fungal or viral infections (such as Pneumocystis carinii and cytomegalovirus), (3) improved therapies for posttransplant malignancies (such as Rituximab for posttransplant lymphoproliferative disorder), (4) better expertise with drug dosing and fine-tuning of immunosuppressive drug combinations based on years of experience with solid organ transplantation, and, most important, (5) the fact that all individual component tissues of the hand, including skin, muscle, tendons, vessels, nerve, bone, joint, and cartilage were successfully transplanted in humans before the modern era of hand transplantation.51
CHRONOLOGY OF CLINICAL COMPOSITE TISSUE AND HAND TRANSPLANTATION The first unilateral hand transplant was performed in Guayaquil, Ecuador, in February 1964.66 In September 1991, the first conference on composite tissue allotransplantation was held in Washington, D.C., in conjunction with the Rehabilitation Research & Development Service of the Department of Veterans Affairs.10 The purpose of the meeting was to “determine the clinical feasibility of transplanting limbs in patients with limb loss” and the “direction in which clinically oriented limb transplantation research should head.” The participants concluded that composite tissue allotransplantation would be possible in the near future and that “historic” trials would commence in the next 2 to 5 years. When such trials had not materialized even 6 years later, the 1st International Symposium on Composite Tissue Allotransplantation was convened in Louisville, Kentucky, in November 1997. The goal of this meeting was to discuss the “scientific, clinical and ethical barriers standing in the way of performing the first human hand transplant.” International experts at the meeting predicted that limb allotransplantation was not far from “becoming a clinical reality.”5 Within the next 22 months, 34 years after the first hand transplant,66 surgeons in Lyon, France, performed the world’s second unilateral hand transplant in September 1998.39,115 In January 1999, the first unilateral hand transplant in the United States was performed in Louisville, Kentucky.78 Two unilateral hand transplants were performed in Guangzhou, China, in September 1999.114 In January 2000, the world’s first bilateral hand transplant was performed in Lyon, France,149 and two
595
unilateral hand transplants were performed in Guangxi, China. A second bilateral transplant was performed in Innsbruck, Austria (March 2000).97,117 One unilateral transplant was reported from Malaysia (May 2000), between homozygous twins. In May 2000, the 2nd International Symposium on Composite Tissue Allotransplantation was organized in Louisville, Kentucky, to evaluate the status not only of the hand, but also of other composite tissue allograft procedures performed thus far (Table 42-1).4,136 The recipients of the first U.S. hand transplant and the first larynx transplant9,138 were present at the conference and were evaluated by clinicians and researchers. The meeting provided the opportunity for international teams to discuss their results in an open scientific forum in the presence of physicians, scientists, patients, and members of the community. The meeting highlighted the unique collaboration and cooperative endeavor of two distinct medical specialties: plastic and reconstructive/hand surgery and transplant surgery. The overall consensus of the meeting was cautiously optimistic but confirmed without doubt that these composite tissue allotransplantation procedures warranted further clinical trials.127,136 Since the symposium, more hand transplants have been performed. These include one bilateral transplant in Guangzhou, China (September 2000); one unilateral transplant in Milan, Italy (October 2000); one bilateral transplant in Harbin, China (January 2001); one unilateral transplant in Louisville, Kentucky, (February 2001); and one unilateral transplant in Milan, Italy (October 2001) (data from www.handregistry.com). The 3rd International Symposium on Composite Tissue Allotransplantation was held in Lyon, France, in November 2001 to discuss the world experience in hand transplantation. After the meeting, one unilateral transplant was performed in Brussels, Belgium ( June 2002), and another unilateral transplant in Milan, Italy (November 2002). At the time of this publication, the total number of reported hand transplant procedures is 24, including 12 unilateral and 6 bilateral hand transplantations in 18 recipients. The data were derived from www.handregistry.com and includes all patients receiving human leucocyte antigen-mismatched transplants and maintained on modern combination immunosuppressive regimens. The early attempt in Ecuador (performed before the era of modern immunosuppression) and the Malaysian patient (a human leucocyte antigen-matched transplant) are excluded from the count. The 4th International Symposium on Hand Transplantation and Composite Tissue Allograft was held in Varenna, Italy, in September 2002. The symposium is held yearly in rotating international cities. The 5th International Symposium on Hand Transplantation and Composite Tissue Allograft was held in Brussels, Belgium, in December 2003.
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THE MUTILATED HAND
PROCEDURAL ASPECTS OF HAND TRANSPLANTATION Recipient Selection Inclusion criteria for the Louisville hand transplantation as approved by the Institutional Review Board are listed in Table 42-2.78 Ideally, the recipient must be a nonsmoker, must have maintained awareness of the missing limb (nonpainful phantom limb sensation), and must be evaluated for previous prosthetic use. Assessment of muscle power and range of motion testing of shoulder and elbow must be performed.
Age Our age range for inclusion in the selection process is 18 to 65 years. Patients below the age of 18 are not considered to be adults; therefore there are issues of informed consent in an experimental procedure. Furthermore, pediatric patients are more likely to develop immunosuppressive-related complications such as posttransplant lymphoproliferative disorder than adults are.152 Patients over the age of 65 are excluded because of increased immunosuppression-related complications, limited years of potential gain from the transplant, vascular problems, and decreased nerve regeneration. Anatomic Defect Unilateral (dominant/nondominant) and/or bilateral amputations between midforearm and wrist are considered for transplantation (Fig. 42-2). The level of amputation should be distal enough to allow forearm muscle innervation with sufficient bulk to confer motor function to the donor hand. A level of amputation distal to the wrist as an inclusion criterion is more problematic. A midpalm amputation in a unilateral amputee is problematic in terms of risk/reward evaluation for radioulnar joint motion being preserved in the recipient or supplied
TABLE 42-2
FIGURE 42-2. Recipient stump with the level of amputation at the middle third of the forearm.
by the donor. This becomes particularly complex if there is a remnant of thenar eminence function in the recipient. Obviously, these anatomic inclusion criteria are not absolute at the present time. They are in a state of flux as we continue to evaluate the risk/reward relationship of hand transplantation. Another anatomic defect that has been considered an indication for hand transplantation is blindness.116 The argument is that a bilateral amputee who is blind would benefit from the sensory input of his or her new hands. We would not, however, transplant such a patient now. We have evaluated such patients who wished transplantation, and since we cannot yet guarantee the extent or rapidity of sensory return in the hand, blind patients will be poor candidates.73,89 Their postoperative management would be extremely difficult because they could not fend for themselves as they awaited sensory return. Furthermore, protective sensation might be insufficient sensory function for a blind
Recipient Selection in Hand Transplantation
Parameter
Selection Criteria
Age range
18–65 years
Type of deformity or limb loss
Traumatic amputation
Involvement
Unilateral or bilateral loss below elbow
Prosthetic use
Proven nonacceptance of prosthetic alternatives to transplantation
Medical history
No systemic illness or preexisting medical condition
Social history
Excellent family support
Psychological history
No history of psychiatric illness, able to give informed consent
Other factors
Financial security (insurance cover to pay for long-term/life-long drug costs), availability for regular follow-up and monitoring, resident of country where transplanted
HAND AND COMPOSITE TISSUE ALLOTRANSPLANTATION: PAST, PRESENT, AND FUTURE
597
patient. In other words, the patient might be blind both in his or her eyes and in his or her hands. Some have argued that the anatomic defect (hand loss) occurring in a solid organ transplant recipient is an indication for allotransplantation. We would approach these patients with caution. The misunderstanding here is the failure to appreciate the extensive systemic damage that was done before hand transplantation by the solid organ failure. Hand transplantation, unlike organ transplantation, should be limited to healthy patients. A patient who is in renal, cardiac, pulmonary, or hepatic failure is excluded whether previously transplanted with solid organs or not.
the rigorous pretransplant and post-transplant rehabilitation program or drug regimens for the rest of their lives.
Psychological and Social Criteria Simplistically, one can classify individuals as neurotic, borderline, or psychotic. Ideally, we seek neurotic patients for hand transplants and exclude borderline and psychotic patients. Psychiatric evaluation of solid organ transplant patients has developed a methodology of evaluating the appropriate neurotic patient. The “brittle neurotic” (also known as the “obsessive compulsive”), “histrionic,” and “passive aggressive” personality types might prove to be inadequate recipients. Here is where the skill of the psychosocial team is paramount. A thorough assessment of body-image adaptation, including the psychological meaning of a hand to the candidate, the psychological impact of the amputation on identity and relationships, coping/adjustment to limb loss, motivation for hand transplantation, anticipated comfort with the cadaver hand, prosthetic use, and phantom limb sensation, is performed in all candidates.85 Evaluation of the total family support system is also important. The apparently ideal candidate who lacks family support is not an ideal candidate. These patients will be dependent on a positive family structure, certainly within the first 3 months if not for the life of the transplant. A family support system that does not encourage strict adherence to the rigorous postoperative regimen will fail. This rigorous regimen includes physical therapy, timely compliance with multiple daily medications, repeated medical assessments, and avoiding certain activities and substances that can increase the risk of immunosuppressive-related complications. The degree of expectations concerning the transplant outcome and the recognition of the experimental nature of the procedure are also estimated. Finally, the level of personality strength, including coping skills and regression, is assessed. An additional objective perspective regarding the pros and cons of hand transplantation is provided (independent of the transplant team) to the recipient through a patient advocate, who is a respected peer from the recipient’s home community. It is beyond the scope of this chapter to elucidate how this delicate decision is made. Psychological criteria are used to evaluate the competency of recipients to comply with
Financial Security/Insurance Our patients received surgery and the immediate postoperative care up to 3 months without charge. After that point, the patient must have sufficient insurance and/or personal financial security to cover the costs of immunosuppressive medications and possible postoperative complications. Patients without insurance and/or financial security are excluded from the selection process. Accepting a patient and paying for all postoperative medications and management of complications raises the issue of moral hazard, with the specter of monetary enticement for hand transplantation.
Prosthetic Use We require that our patients be 6 months to 1 year from the time of amputation and to have made a good-faith effort at using prosthesis. Sufficient time needs to pass for the patient to conceivably accept his or her loss. Furthermore, a patient with hand transplant complications might be faced with a decision about stopping medications to save his or her life. This risk evaluation requires that the patient understand the value of the prosthetic state.
Medical Screening of the Recipient Medical screening includes a complete medical history and physical examination; routine laboratory studies; blood typing and cross-matching; human leucocyte antigen typing; testing for panel-reactive antibodies; and serology for Epstein-Barr virus, cytomegalovirus, HIV, and viral hepatitis. Other tests include radiography (to plan for osteosynthesis), angiography (to exclude abnormal vascular patterns), electromyography, and nerve conduction velocity.
Informed Consent To verify that the recipient has complete comprehension of the procedure, a clear and extensive informed consent is obtained (and may be filmed for records). Factors to be addressed include the risks of surgery and immunosuppressive therapy, including death; rejection of the graft; serious infections; cancer; adverse drug effects; and graft amputation.
Donor Selection and Evaluation Most of the criteria that are used for donor selection are similar to those used in organ transplantation. These include histocompatibility testing for tissue matching, and blood cross-matching (cross-match negative). The
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THE MUTILATED HAND
ideal patient is a donor who is a nonsmoker, in good health, with no history of drug abuse or hand injuries and whose age matches that of the recipient as closely as possible. Specifically, the hand transplant donor is selected after matching for sex, color and tone of skin, age, and comparable forearm diameter/bone size. Absolute contraindications are history of previous malignancy, viral hepatitis (B or C), or viral infections such as HIV. The presence of seropositivity for cytomegalovirus or Epstein-Barr viruses is not a contraindication for donor selection; however, antiviral prophylaxis is indicated in cytomegalovirus-seronegative recipients who receive transplants from such donors.
Donor Limb Procurement and Preparation Consent for tissue donation should be obtained from the local organ procurement organization and from the family of the donor. All steps of the dissection are performed in a sterile manner, and the donor limb is procured according to recipient requirements. The limit of the donor limb resection is planned preoperatively (Fig. 42-3). The harvested limb is cooled by topical application of sterile saline and arterial perfusion of the brachial artery with the University of Wisconsin solution at 4°C. The limb is wrapped in moist sponges and placed in a sterile bag surrounded by ice and transported to the hospital.
Perioperative Immunosuppression (Induction) The most common induction regimens used by hand transplant teams were Basiliximab (Simulect) or antithymocyte globulin.
Operative Procedure To minimize the cold ischemia time, two surgical teams are necessary. The first team works on preparation of the distal part of the forearm in the recipient while a second team prepares the donor limb for transplant. On the donor surgical table, the limb is trimmed of excess skin and bone as determined by the extent of tissue loss in the recipient.
It should be emphasized that strict adherence to cold ischemia of the donor part can be crucial to the success of hand transplantation. It is possible that allohand transplantation is more sensitive to warm ischemia (and reperfusion injury) than is auto-hand replantation. Experimentally, studies have shown that the potentiation of the inflammatory response by warm ischemia is associated with allograft rejection.121 Therefore we advocate continuous cooling of the donor arm until the vascular anastomosis is performed.
Sequence of Transplantation Unlike replantation, transplantation requires early revascularization for the reasons described previously. In replantation, the order is bone-tendon-artery-nerve-vein (BTANV). However, in transplantation, we have followed the order of bone-artery-few veins-tendon-nerve-remaining veins (BAVTNV). The exact sequence of the procedure can vary according to the preference of the surgical team. Priority should be given to bone fixation and vascular anastomosis. Anatomic structures such as muscles, tendons, vascular bundles, nerves, and bones are identified and tagged by two surgical teams (one team for the donor and one team for the recipient) working simultaneously. Next, the decision for the need for tendon transfers or grafts is made. Commonly, bone fixation (osteosynthesis) is performed first to anatomically align and stabilize the donor limb onto the recipient stump. The plate that is recommended for osteosynthesis is a 3.5-mm compression plate, although different options are available. The second step is anastomosis of at least two main arteries and at least one or two veins (remaining veins completed later). The suturing of tendons and coaptation of nerves are the next steps. If sufficient tendon length is available on the recipient and donor, a Pulvertaft weave is superior to an end-to-end repair. Whichever tendon repair is used should be strong enough to allow early, active postoperative range of motion. Skin grafts or flaps can be considered as necessary. Skin closure will be better if the recipient and donor incisions are offset by 90°. Generous dressings should be applied, and the limb should be immobilized in a long-arm splint.
Postoperative Care
FIGURE 42-3. Donor allograft.
The recipient is cared for according to established guidelines for the management of major replants that are in place in the hand transplant unit. In the immediate post-transplant phase, digital temperature monitoring and anticoagulation are mandatory. It is crucial to understand that within the first week the patient needs to be in a splint, which places the hand in an intrinsicplus position, protects flexors and extensors, and allows for controlled motion. A forearm-based dynamic craneextension outrigger with an adjustable metacarpophalangeal block is applied within 3 to 6 days, and the hand
HAND AND COMPOSITE TISSUE ALLOTRANSPLANTATION: PAST, PRESENT, AND FUTURE
599
FIGURE 42-4. Dynamic crane extension outrigger and brace. M.S. (the first U.S. hand transplant recipient) demonstrates protected active range of motion in the transplanted hand.
FIGURE 42-6. Clinical signs of acute rejection at 6 weeks post-transplant. Note the circumferential maculopapular rash and edema in the donor allograft (left half of the picture).
is actively mobilized (Fig. 42-4).67 The dynamics of this outrigger splint are not well appreciated. The purpose of this splint is to achieve constant tension throughout the range of motion of the digits. The intrinsic-plus position must be maintained to avoid a claw deformity. The patient is then weaned off daily outrigger use to nighttime use only within 2 to 3 weeks. The patient is maintained in an anticlaw splint for 6 months to a year (Fig. 42-5). The active rehabilitation program after hand transplantation may vary between individual centers but is similar to that used after major replantation.
In summary, the key factors that differed during surgical planning and execution of hand transplantation procedures performed thus far were the anatomic level at which the donor limb was harvested, method of preparation of donor limb, duration of ischemia time, and the type of perioperative induction medications used. All transplant surgeries were performed under broad antibiotic coverage and anticoagulation therapy. The maintenance immunosuppression protocol was the same in all the centers and consisted of tacrolimus, mycophenolate mofetil, and prednisone, although the doses and trough levels of each drug differed between some centers. Successful reversal of acute rejection episodes (Figs. 42-6 and 42-7) has been achieved by using topical
FIGURE 42-5. An anticlaw splint.
FIGURE 42-7. Histologic confirmation of moderate acute cellular rejection. A punch biopsy of the skin reveals moderate perivascular and dermal lymphocytic infiltration and mild epidermal degeneration. (Hematoxylin and eosin, ⫻40.)
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42
600
THE MUTILATED HAND
FIGURE 42-8. A skin biopsy after treatment with topical tacrolimus and topical clobetasol. Complete resolution of infiltrates is noted. (Hematoxylin and eosin, ⫻10.)
clobetasol or tacrolimus ointment with or without a shortterm bolus increase in steroid doses (Fig. 42-8).78,82
FUNCTIONAL OUTCOMES AFTER HAND TRANSPLANTATION Ideally, a hand transplant would restore extrinsic and intrinsic motor function and normal sensation. Along with this, the patient would gain the aesthetic value of a normal-appearing hand. These goals, at this time, have not been perfectly obtained, and it is important for both surgeons and patients to understand the limitations of hand transplantation. Motor function in a transplanted hand (without intrinsic muscle function) can be achieved with no motor reinnervation from the recipient. This takes place, since the extrinsic motor function of the transplanted hand is supplied by the recipient, as long as the level of transplantation is sufficiently distal. Furthermore, only minimal return of sensation in the hand is required for good hand function. “Minimal” sensation refers to the return of “protective” sensation, which includes the modalities of hot and cold, pinprick or pain sensation, and some degree of digital localization. Good motor function is defined by the Carroll score and classification.23 In other words, even with the absence of both moving and static two-point and intrinsic motor function, the transplanted hand can still obtain a good score as measured by the Carroll test. The outcomes that have been reported to date by the various transplant teams indicate that all recipients have shown a high quality of functional return, except the first French recipient.39 This patient was amputated
electively at 28 months post-transplant owing to his noncompliance with the immunosuppressive drug regimen. Hand transplants have restored abilities that are not afforded by prostheses. These include abilities such as grasping small objects, pouring water from pitchers, tying shoelaces, playing chess, throwing a ball, and using hands in activities of daily living and professional tasks. Recipients have demonstrated rapid progression of their Tinel’s sign and early return (at 1 year) of temperature, pressure sensation, touch localization, and pain sensation in the hand and fingers. The return of motor power and grip strength has also been observed. Electrophysiologic testing has confirmed clinical evidence of motor return in the transplanted intrinsic muscles of the hand, and in a few cases, true recovery of partial intrinsic function has been observed. Studies comparing replantations with prosthetic fittings have demonstrated that, in general, replants are superior to prostheses.54,122 Further, results of early objective testing using the Carroll test after hand transplantation also show that functional return with hand transplants mirrors that after replantation and is consequently superior to that of prostheses.13 The functional return in the two Louisville recipients is shown in Figures 42-9 and 42-10.
HAND TRANSPLANTATION VERSUS REPLANTATION There are advantages and disadvantages when replants are compared to transplants (Table 42-3). Hand transplantation allows for the planned procurement of the donor hand that is modified to match the site-specific needs of the recipient. Since the harvesting of the donor hand is a planned procedure, warm ischemia times can be reduced to minutes. The cold ischemia time is variable in both transplantation and replantation. Hand replantation has the advantage of dealing with unscarred, acutely injured tissue. Hand transplantation has the disadvantage of a recipient with marked muscle contracture, motor atrophy, and long-standing absence of distal motor and sensory axonal reinnervation. Replants might lack potential structures such as tendons or nerves, thereby necessitating immediate or later grafting. Transplants have the advantage that structures that are missing in the recipient can be bridged by similar donor tissues obtained from the allograft. Replantation normally allows end-to-end tendon repair. Transplantation has the advantage of stronger tendon repair with Pulvertaft weave using extra donor tendon length.
42
HAND AND COMPOSITE TISSUE ALLOTRANSPLANTATION: PAST, PRESENT, AND FUTURE
A
B
C
D
E
F
601
Hand replantation sometimes requires immediate soft tissue coverage such as emergency free-tissue transfer. Hand transplantation is able to avoid the problems of soft tissue coverage by the extra donor tissue derived from the allograft. In summary, except for scarring of the graft bed, technically transplantation has many advantages.
In both replantation and transplantation, reintegration of the hand into the neural circuitry of the premotor cortex occurs with time. Common factors that can affect functional outcome after replantation or transplantation include a higher level of amputation, ischemia times, the age of the patient, coexisting medical conditions, and psychosocial issues.
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FIGURE 42-9. J.F. (the second U.S. hand transplant recipient) at 1 year after surgery. A, Flexion at the metacarpophalangeal, proximal, and distal interphalangeal joints of the fingers without wrist stabilization. B, Extension at the metacarpophalangeal, proximal, and distal interphalangeal joints of the fingers without wrist stabilization. C, Abduction of the thumb. D, Adduction of the thumb. E, Forearm pronation. F, Forearm supination.
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THE MUTILATED HAND
B
A
FIGURE 42-10. M.S. (the first U.S. hand transplant recipient) demonstrating active digital flexion and range of motion without wrist stabilization at 3 years after surgery. A, Key pinch with the thumb and index finger. B, Demonstration of grip.
TABLE 42-3
Hand Transplantation versus Hand Replantation Hand Transplantation
Hand Replantation
Surgery
Planned and performed electively
Emergency surgery
Donor tissues
Intact
Missing, avulsed, crushed or contaminated
Modification of donor graft
Tailored to match specific recipient requirements
Limited by type of injury
Recipient site
May be scarred with muscle contracture and reduced tendon excursion
Missing, avulsed, crushed or contaminated
Warm ischemia time
Minutes
Minutes to hours
Immunosuppression
Long-term antirejection drugs needed
Not necessary
CORTICAL REORGANIZATION AFTER HAND REPLANTATION/ TRANSPLANTATION A unique phenomenon that is observed after hand transplantation is the reassignment of portions of the recipient’s brain to control the new hand. This is called “reorganization” or “plasticity” of the brain. Previous studies have demonstrated that changes in cortical organization occur after amputation. However, the impact of limb transplantation on spatial reorganization of the motor cortex is just now being revealed.47 After a hand is amputated, the area of the brain that was receiving signals from the hand is gradually lost and is taken over by other functions. However, after a hand transplant, that area of the brain can
reestablish its original function, and the signals from the new hand go back to the area of brain that was used to control the original hand. Such neural integration of the transplant into the premotor cortex has been demonstrated by using functional magnetic resonance imaging studies. This phenomenon has not been reported after organ transplantation. In addition, hand transplants differ from organ transplants in several aspects (Table 42-4).
Unique Aspects of Hand Transplantation The use of immunosuppressive drugs such as tacrolimus has been shown in animal models not only to prolong the survival of limb allografts7,88,113 but also to augment
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Hand Transplantation versus Organ Transplantation Hand Transplantation
Organ Transplantation
Visual monitoring of rejection
Possible
Not possible
Biopsy from site of ongoing rejection
Possible
Not always possible
Topical drug therapy
Possible
Not possible
Rejection episodes affect rate of functional return
No
Yes
Functional return after transplantation
Delayed (motor and sensory return)
Immediate (physiologic function)
Premotor cortical reorganization after transplantation
Yes
Not applicable
Nonimmunosuppressive role of tacrolimus
Nerve regeneration may be improved
None
Post-transplant donor microchimerism
Not been reported
Reported
Graft-versus-host disease
Not been reported in any cases to date (despite bone marrow in limb)
Reported to occur (small bowel and liver transplants)
Human leucocyte antigen-matching
Difficult owing to small donor pool, effects of human leucocyte antigen mismatch on long-term graft survival unknown
Facilitated by larger donor pool, inverse correlation between human leucocyte antigen mismatch and graft survival
Exit strategy in event of complications
Stop immunosuppression and amputation (less morbidity and mortality)
Retransplantation (greater morbidity and mortality)
nerve regeneration.36,49 The early return of function after clinical hand transplantation might reflect the positive neuroregenerative effects of this drug, but this remains to be scientifically confirmed. The role of human leucocyte antigen mismatch on graft survival is proven in solid organ transplants. In renal transplants, for example, the best function, survival, and histologic appearance of allograft, as well as the least dependence on immunosuppression, is seen with zero-human leucocyte antigen mismatches.102 Zero-human leucocyte antigen mismatched donors are hard to find in hand transplants, as the donor pool is small and living-related donor transplantation is not a possibility. The effect of greater human leucocyte antigen mismatches on long-term outcomes of hand transplants performed thus far remains to be seen. Finally, previous experience with kidney transplants points to a relationship between the number of acute rejection episodes and eventual graft outcome. The risk of chronic rejection with concomitant late graft loss increases in proportion with the number and severity of early acute rejection.98 On the contrary, at the 4-year time point, there is no evidence that acute rejection episodes hamper progress of functional return after hand transplantation (data presented at the American Transplant Congress, May 2002, Washington, D.C.). The long-term risk of chronic rejection in hand transplants is yet undetermined.
HAND AND COMPOSITE TISSUE TRANSPLANTATION REGISTRY Hand and other composite tissue allotransplantation procedures continue to increase in numbers around the world. This has resulted in the establishment of an international society for hand and composite tissue allotransplantation, information Web sites such as www.handtransplant.com, and a registry for hand and composite tissue allotransplantation (www.handregistry.com). The overall goal of this registry is to serve as an up-to-date collection of scientific data contributed by individual centers. Preliminary details of this registry were discussed at the 4th International Symposium on Hand Transplantation and Composite Tissue Allograft held in Varenna, Italy, in September 2002. With the advent of newer drugs, information drawn from data sharing and comparison of innovative therapies between centers can help transplant teams to modify recipient drug regimens and improve allograft outcomes. The registry and the hand transplant Web site will help in improving public awareness of innovative composite tissue allotransplantation procedures and educate potential recipients about the risks and benefits involved. The comparison of composite tissue allotransplantation registry data with data from existing solid organ transplant registries can also help to statistically analyze differences in graft outcomes, efficacy/adverse
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TABLE 42-4
HAND AND COMPOSITE TISSUE ALLOTRANSPLANTATION: PAST, PRESENT, AND FUTURE
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THE MUTILATED HAND
effects of immunosuppressive therapy, and the role of human leucocyte antigen matching on graft survival/ chronic rejection.
THE FUTURE OF COMPOSITE TISSUE AND HAND TRANSPLANTATION Despite the excellent results thus far, the risks of immunosuppression in composite tissue allotransplantation need to be reduced or eliminated. One potential strategy to achieve this goal is through tolerance induction. A strict mechanistic definition of tolerance is lacking. An operational definition would be “the long-term functional survival of an allograft in a patient without the need for maintenance immunosuppression.”16 Such a tolerant state is characterized by hyporesponsiveness to donor tissue with the preservation of the recipient’s immune responses to microorganisms (bacteria, viruses) and tumor antigens. The strategies for allograft tolerance can be broadly divided into approaches utilizing donor bone marrow transplantation and approaches inducing peritransplant depletion of recipient T cells.
Strategies Utilizing Donor Bone Marrow Cells These include the antithymocyte globulin model and the mixed chimerism model, which appear to be operative through different mechanisms of action. Fundamentally, when donor bone marrow containing stem cells is transplanted in a treated recipient, the newly developing recipient T cells begin to see donor cells as “self.” Therefore the recipient perceives an organ from the same marrow donor as “self” and accepts it without immunosuppression. The antithymocyte globulin model consists of depleting the T cells in the host with antithymocyte globulin, followed by infusion of donor bone marrow cells.104 The mixed chimerism model involves induction of allograft tolerance by establishing long-term mixed chimerism, a state in which donor and recipient hematopoietic cells coexist.119 In contrast to the antithymocyte globulin model, it requires engraftment of donor stem cells.
the donor tissue, thus preventing rejection. Kirk and colleagues reported long-term survival but not tolerance in rhesus monkeys receiving mismatched renal allografts and treated with the costimulatory blocking antibody CTLA4-Ig.84 The STEALTH protocol used by Thomas and colleagues utilizes neither chimerism nor costimulatory blockade to achieve stable tolerance. This model capitalizes on a unique synergy between anti-CD3 immunotoxin and Deoxyspergualin. STEALTH is an acronym for “Specific Tolerance by early Evasion of APC-Lymphocyte interactions and Th2 deviation.” The anti-CD3 immunotoxin depletes T cells. Deoxyspergualin prevents T cells from encountering antigen. This protocol has achieved prolonged (1.4 to 4.5 years) survival of fully mismatched kidney transplants with normal function in nonhuman primates.144 Human renal transplant trials were initiated by using Campath-1H, which is an antibody that binds to the CD52 receptor, which is critical for T cell function in humans. Campath-1H leads to depletion of T cells, B cells, and monocytes but spares bone marrow stem cells. These trials with Campath-1H demonstrated that allograft survival could be prolonged but with low doses of maintenance immunosuppression.17 Such a state of tolerance is called “prope-tolerance” or “tolerance-lite.”16 Over the past five decades, more than 50 different methods of tolerance induction have succeeded in smallor large-animal models, yet tolerance protocols have not widely replaced immunosuppression in clinical transplantation. The reason for this is straightforward. Many of the tolerance protocols are too risky for clinical application. In other protocols, the risks remain unknown. Therefore the transition of experimental tolerance protocols to the clinical transplant arena is fraught with questions. Can experimental tolerance protocols meet the stringent fail-safe clinical standards of reliability and efficacy? How durable or persistent is the tolerant state? How immunocompetent will the recipient be? What is the universally accepted test or “assay” for tolerance? What are the long-term adverse effects of tolerance induction? The few tolerance strategies that hold future promise are at very early stages of research and application. Until these questions can be answered and true tolerance becomes a reality, routine immunosuppression as used in organ transplantation will remain the gold standard in composite tissue allotransplantation.
Strategies Utilizing Peritransplant Depletion of Recipient T Cells Fundamentally, allograft rejection is caused by activated T cells and cannot occur in their absence. To function, the T cells must be activated by two signals: antigen, or signal 1, and costimulatory, or signal 2. Interference of the second signal using certain antibodies results in death of recipient T cells attacking
CONCLUSION The hand is a remarkable organ. Hands are needed for almost every activity of daily living and are critical for communication and ego development. To this day, it has not been possible to optimally restore the myriad
HAND AND COMPOSITE TISSUE ALLOTRANSPLANTATION: PAST, PRESENT, AND FUTURE
functions of a hand by means of prosthetic alternatives. Ideally, all amputations should be replanted, but this is not always possible. Hand transplantation offers the prospect of returning disabled patients to the mainstream of society as functional individuals. Preliminary results of hand transplants around the world have demonstrated functional return similar to that of replants. Graft survival after hand transplantation has far exceeded survival in all initial attempts at solid organ transplantation. Hand transplantation is the most successful new procedure in the history of transplantation. This procedure holds tremendous promise in the reconstruction of limb defects. However, results with this experimental procedure are still emerging. It is possible, on the basis of solid organ transplant experience, that the majority of hand transplants will eventually be lost to rejection. To date, 24 hands have been transplanted in 18 recipients with a 92% allograft survival rate. Published or presented reports indicate that two hands have been lost to rejection. The first French recipient was amputated electively at 28 months post-transplant owing to noncompliance with the drug regimen. The first Chinese recipient was amputated at 39 months post-transplant due to a purported “allergic” skin reaction that was treated with steroids (data presented at the 2nd Congress of the World Society of Reconstructive Microsurgery, Heidelberg, Germany, June 2003). Therefore it is important to note that hand transplantation should be neither routinely encouraged nor hastily embargoed. Hand transplantation should be limited to specialized centers that have surgeons experienced in the techniques of reconstructive microsurgery and the practice of organ transplantation. It should be recommended in a select group of patients and must be performed according to universally standardized ethical guidelines. All procedures should be open to professional scrutiny through periodic reporting at scientific forums and to the public through news media. If all these guiding principles are strictly adhered to, hand transplantation might herald a new era in reconstructive and transplant surgery.
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Index Note: Page numbers followed by f indicate figures; those followed by t indicate tables. Abdominal flap, 17, 20f Acute renal failure, following replantation, 209 Acute stress disorder development of, 511–512 interventions for, 513–516 attributional style and, 513–514 behavioral desensitization and, 515–516 imagery rescripting and, 515 imaginal exposure and, 514–515 return to work and, 515–516 Adduction contracture, of thumb, burn injuries and, 334–336, 335f–337f Adipofascial turnover flaps, 17, 19f for dorsal mutilation, 53 Adolescents, psychological reactions of, 512 Allotransplantation. See Limb allotransplantation. Amputated parts. See Spare parts. Amputation, surgical for degloving injuries, 310 Krukenberg’s operation for. See Krukenberg’s operation. neuromas in stump and. See Neuroma(s). revision, 549–556 digital, 549–551, 550f, 551f distal and middle phalanx, 549–551, 550f index finger ray amputation, 551–552, 553f little finger ray amputation, 552, 554, 554f middle finger ray amputation, 554–556, 555f, 556f proximal phalanx, 551, 551f, 552f secondary, 261–262 Amputation(s), traumatic, 18–22 classification of, 195 concept of, 3 historical background of legislation and, 10–11 of techniques, 9f, 9–10, 10f in children, replantation/revascularization for, 477–479, 479f legal and punitive, historical background of, 6–7 mechanism of, 193–194 of ulnar column, 94 phantom limb sensation following, 510–511 ray, 18–21, 21f
Amputation(s), traumatic (Continued ) rehabilitation following, 519–521 multiple-digit, 520, 520f of thumb, 520, 521f single-digit, 519–520 treatment of amputations and, 520–521, 521f replantation following. See Replantation. second-toe transfer for, 21–22, 21f–23f self-inflicted, historical background of, 7–8 stump revision for, 18 total, of hand, prehension and, 127 Anastomotic techniques, for reestablishing circulation, 205, 205f, 206f Antibiotics, for bony defect reconstruction, 397–398 Anticoagulant therapy, postreplantation, 212 Aristotle, 3 Arm. See also Forearm. proximal region of, resection of, followed by replantation, 215 segmental resection of, replantation and, 215–216 total resection of, followed by replantation, 215 Arm flaps forearm, for ulnar injuries, 89, 90f, 91–92 lateral, 17 for palmar injuries, 76f, 76–78, 77f medial, for palmar injuries, 78 Arterial anastomosis, 206 Arterial obstruction, postreplantation, 210, 211t Arterial-arterial flaps, for degloving injuries, 312 Arterial-venous flaps, for degloving injuries, 312 Arteries, initial reconstruction of, 16 Arthroplasty, secondary, 257, 259f Artificial hands, electronic, 199, 199f Attributional style, psychological response to injury and, 513–514 Avulsion severances, 194 Axial-pattern flaps, for palmar injuries, 75f, 75–76 Behavioral desensitization, 515 Bilateral hand mutilation, prehension and, 127–128, 128f, 129f
Biological plating, for internal fixation of fractures, 410–411 Biomechanics, palmar, 87, 88f Blood vessels. See also Arterial entries; Vascular entries; Venous entries. debridement of, 202 rehabilitation following multisystem injuries and, 524 Blood volume deficit, following replantation, 209 Body, philosophical concept of, 3–4 Bone(s). See also Osteo- entries; Skeletal entries. debridement of, 200 fractures of. See Fracture(s). healing of, 405 initial reconstruction of, 16 physical properties of, 403–404 reconstitution of skeletal framework and, for replantation, 202–203, 203f rehabilitation following multisystem injuries and, 522 Bone grafts for bony defect reconstruction, 391–393, 394t–395t, 396–397 for distraction-lengthening of thumb, 135, 137f Bone loss, metacarpal, 423 Bone marrow cells, donor, for hand allotransplantation, 604 Bone morphogenetic proteins, for bony defect reconstruction, 393 Bone transfer, free, vascularized, 26–29, 27f, 28f Bony defects, 391–398 bony reconstruction for, 391–398 classification of bone substitution and, 391–396, 394t–395t defect coverage by location and, 396–397 etiology of defect and timing of reconstruction and, 397–398 Bony fixation, for wrist injuries, 293, 293f, 294f Bony reconstruction, 373–398 for bony defects, 391–398 classification of bone substitution and, 391–396, 394t–395t defect coverage by location and, 396–397 etiology of defect and timing of reconstruction and, 397–398
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Bony reconstruction (Continued ) for fractures, 374–391 classification of fractures and, 374–378, 375f–378f, 379t–381t factors influencing functional outcome of, 378–379, 381f, 381–391 for ulnar injuries, 91, 92f historical background of, 373–374 diagnostic tools and, 374 early mobilization regimens and, 374 osteosynthesis and, 373–374 Brehon Laws, 10–11 Buck-Gramcko, Dieter, 106–107, 107f Buncke, Harry, 108, 108f Bunnell, Sterling, 103f, 103–104, 105 Burn injuries, 323–337 chemical, 330–331 electrical, 329–330 escharotomy for, 326–328, 327f, 328f evaluation of, 324–325 excision and skin grafting for, 328–329 nonoperative treatment of, 325–326 local wound care, 326 splinting, 326, 326f pathophysiology of, 324 reconstruction of hands following, 331–336 adduction contracture of thumb and, 334–336, 335f–337f burn syndactyly and, 333–334 hypertrophic scars and keloids and, 332 skin and soft tissue contractures and, 331–332, 331f–334f webspace contractures and, 332–333 surgical anatomy and biomechanics and, 323–324 surgical management of, 326–329 Byzantine period, treatment during, 11, 12f Cambodian culture, 3 Capsuloplasty, secondary, 257, 258f Capsulotomy, secondary, 254–255, 256f–258f, 257 Carpectomy, for wrist injuries, 293, 293f, 294f Carpometacarpal joints dislocation of, treatment of, 91 response to distraction forces, 137–138, 138f Cave paintings, 4, 4f Central America, punitive amputation in, 7 Chemical injuries, 330–331 Chest flaps, for secondary reconstruction, 363 Children distraction-lengthening of thumb in, 138, 141f prostheses for, 569 psychological reactions of, 512 reconstruction of mutilated hand in, 485–505 differences in children and, 485–489, 486t management for, 489t, 489–490 microsurgery for, 491–492, 494, 497–498, 504t nerve injuries and, 486, 486f–488f, 488–489 outcomes with, 498, 504, 504f–505f, 504t pedicle flaps for, 490–491, 497f–502f, 497t replantation and revascularization and, 490, 491f–496f secondary procedures and, 498 skeletal injuries and growth and, 489
Children (Continued ) replantation/revascularization in, 473–483, 490, 491f–496f complications of, 481 for amputation injuries, 477–479, 479f for devascularization injuries, 479, 480f indications for, 474–476, 474f–476f initial assessment for, 476–477 postoperative care for, 480–481 results with, 481–482 revision surgery for, 481 Chimerism, stem cell transplantation and, 585 China, punitive amputation in, 7 Chinese culture, 3, 4 Chronic regional pain syndrome, 542–543 Circulation assessment of, 210, 211t local, impairment of, following replantation, 210–212, 211t reestablishment of, 203–208, 204f arterial anastomosis for, 206 general principles for, 203–204, 204f repair of vascular defects and, 206–207, 207f vascular suturing techniques for, 134, 205f, 206f venous anastomosis for, 205–206 Classification of mutilating injuries, 31–46 authors’ system for, 31–32, 32f, 32t, 47, 47t Clawing, with ulnar injuries, 93 Cold intolerance, following replantation, surgical procedures for, 260 Combination injury, classification of, 41, 42f–46f, 42–46 Compartment syndromes, with ulnar injuries, 88 Composite grip, 115–116 Compression, internal fixation and, 407–414 biological plating and, 410–411 K-wires and, 412, 413f–415f lag screw principles and, 408, 408f, 409f, 412–414, 415f nails and, 411, 412f plate compression and, 408–409, 410f, 411f tension band principle and, 409–410, 412f Compression severances, 194 Confucian philosophy, 3, 4 Contractures adduction, of thumb, burn injuries and, 334–336, 335f–337f flexion, release of, 251, 253f of adjacent joint, with distractionlengthening of thumb, 139 webspace burn injuries and, 332–333 release of, 250–251, 250f–252f with burn injuries, 331–333, 331f–334f Cosmetic concerns of patients, 510–511 with prostheses, 561–562, 562f Cost(s) of limb allotransplantation, 597 of prostheses, 569 Costimulation, limb allotransplantation and, 585 Cretien de Troyers, 5 Cross-finger flaps, for secondary reconstruction, 358 Cross-hand transfer microsurgical, 467–469, 468f, 468t, 469f digital, 461–464, 462f–464f twin donors for, 463 microvascular, 454–455, 455f–456f
Crush injuries, rehabilitation following, 524–525 Crushing severances, 194 Cyclosporin A, for limb allotransplantation, 577, 579t–580t Dead hand, in Irish legend, 5 Débridement, 15 for emergency free flap reconstruction, 342 Degloving injuries, 307–320 classification of, 41, 41f, 308t, 308–309, 309f, 310t flaps for, 17, 19f, 20f incidence, prevalence, and significance of, 307–308 management of, 51 mechanism of injury, 307, 308f reconstruction of hand and, 310–312 dorsal skin and, 317–318 factors generally influencing outcome of, 313 microvascular replantation of avulsed tissue for, 312 multiple digits and, 316 palmar skin and, 317 ring finger and other single digits and, 314, 316 thumb and, 313–314, 313f–317f “traditional” island flaps for, 312 “traditional” method for, 310–312, 311f whole hand and, 318, 318f–320f, 320 Deoxyribonucleic acid, degradation of, 198 Desensitization, 530, 530f Devascularization injuries, in children, replantation/revascularization for, 479, 480f Digit(s). See also Finger(s); Toe(s). multiple. See Multiple-digit entries. muscle and tendon repair in, for replantation, 207–208 revision amputations of, 549 complications of, 550–551 techniques of, 549–550, 550f, 551f Digital artery, anatomy of, 69 Digital nerve repair, for palmar injuries, 72, 72f Digital replantation, 196, 197f Digital transfer, cross-hand, microsurgical, 461–464, 462f–464f Digital transposition for thumb reconstruction, 147–148, 149f, 150, 151f in multiple-digit replantations, 221 “Digitalization of the forearm.” See Krukenberg’s operation. Digito-palmar grip, 116, 117f Distal phalanx, revision amputation of, 549–551, 550f Distant flaps, 17, 19f, 20f for dorsal mutilation, 53–54, 55f for palmar injuries, 76 Distraction osteogenesis, 24–25 Distraction-lengthening, 425–436 complications of, 428 for bony defect reconstruction, 393, 396 for thumb reconstruction. See Thumb reconstruction. surgical technique for, 425, 426f–427f, 428, 429f–436f DNA, degradation of, 198 Dorsal interosseous compartment, anatomy of, 88
INDEX
Dorsal metacarpal artery flaps, for secondary reconstruction, 358 Dorsal mutilation classification of, 33, 33f management of, 51–65 flap selection for, 52f, 52–62 general wound management principles and, 51 skin grafting in, 52 Dorsal skin, avulsion injuries and, 317–318 Dorsal ulnar artery flaps, for secondary reconstruction, 362, 363f Dorsalis pedis flaps, 17 for dorsal mutilation, 58f, 58–59, 60f, 61f Early mobilization, for bony reconstruction, 374 Eastern cultures, 3–4 Edema, management of, 526–528, 527f Elbow, resection of, followed by replantation, 215 Elbow-to-shoulder-joint transfer, 450, 450f–451f Electrical burn injuries, 329–330 Electronic artificial hands, 199, 199f Electrostimulation, of osteogenesis, for distraction-lengthening of thumb, 135, 136f Endoneurium, suturing of, 208, 208f End-to-end anastomosis, for reestablishing circulation, 205, 205f End-to-side anastomosis, for reestablishing circulation, 205, 205f Epineurium, suturing of, 208, 208f Escharotomy, for burned hands, 326–328, 327f, 328f Exercise, therapeutic, 528, 528f Expectations, of patients for prostheses, 559 for surgery, 510 Extensor digitorum communis injuries, reconstruction of, 93 External fixation. See Fracture(s), external fixation of. Fascial flaps, 17 for dorsal mutilation, 54, 56, 56f temporoparietal, 17 Fasciocutaneous flaps, 17 for degloving injuries, 311 Fat embolism, following replantation, 209–210 Fibula, vascular free bone transfer using, 26–29, 27f, 27–28, 28f Fillet flaps foot, for maintenance of leg stump length and hand coverage with eventual toe-to-thumb transfer, 457, 457f–458f for secondary reconstruction, 358 from defunctionalized index finger, to first webspace defect, 443, 444f Finger(s). See also Digit(s). distal interphalangeal joints of, transfer to proximal interphalangeal joint, 226–228, 229f–230f nonsalvageable, vascularized joint transfer from, 226 Finger prostheses, 566–568, 567f for amputations through middle phalanx, 566, 568f for amputations through proximal phalanx, 566, 567f “sub-mini,” 566, 568, 568f
Finger transposition, 105 of index finger into thumb position, 102, 102f of long finger into thumb position, 104–105, 105f First webspace, deepening of, in distractionlengthening of thumb, 138, 139f First webspace flaps, for palmar injuries, 78, 78f, 79f Fixation, 15. See also Fracture(s), external fixation of; Fracture(s), internal fixation of. FK506, for limb allotransplantation, 577, 581, 582t–583t Flaps. See also Distant flaps; Free flaps; Local flaps; specific flaps. choice of, 16–17 for dorsal mutilation, 52f, 52–62 Flashbacks, 510, 511, 512 Flexion contractures, release of, 251, 253f Flexor tendon middle finger reconstruction using, 445, 445f, 446f repair of, for palmar injuries, 71f, 71–72 Folklore, 5–6 Forearm digitalization of. See Krukenberg’s operation. distal third of, muscle and tendon repair in, for replantation, 207–208 segmental resection of, replantation and, 215–216 total resection of, replantation and, 215–216 Forearm flaps, for ulnar injuries, 89, 90f, 91–92 Four-flap Z-plasty, for secondary reconstruction, 357, 357f Fracture(s), 374–391 classification of, 374–378 bone trauma and, 374, 375f–378f soft tissue injuries and, 378, 379t–381t external fixation of, 417–423 historical background of, 417, 418f implants, mechanics, and techniques for, 417–418 indications for, 418–419, 419f–422f, 422 of metacarpals, 422–423 of phalanges, 423 functional outcome of treatment for, 378–379, 381f, 381–391 injury and fracture factors affecting, 379, 381–382 management factors affecting, 382–383, 384f–390f, 385–386, 388–389 patient factors affecting, 379 rehabilitation and, 389, 391 internal fixation of, 403–416, 404f, 405f biological reaction and, 404, 405f bone healing and, 405 complications of, 416 compression and, 407–414 indications for, 406–407 load and, 407 minimally invasive techniques for, 416 nonunions and, 405 osteosynthesis and, 404–405, 405f, 407f, 414, 416 physical properties of bone and, 403–404 splinting and, 407 stability and, 407 nonunion of, 405 revision of, following reconstruction, 251–252, 254f open, with ulnar injuries, 91
613
Free bone transfer, vascularized, 26–29, 27f, 28f Free flaps emergency, 339–352 advantages of, 351–352 case studies of, 344–351, 345f–351f complications and morbidity with, 344 current status of, 340–341 débridement and, 342 disadvantages of, 351 evaluation of injured hand for, 342 free tissue transfer and, 343 historical background of, 339–340 indications for, 341, 342f selecting flaps for, 343–344 timing of reconstruction and, 339 fascial for dorsal mutilation, 54, 56, 56f for palmar injuries, 80 for degloving injuries, 311–312 for secondary reconstruction gracilis flaps, 369 groin flaps, 369 lateral arm flaps, 367 latissimus dorsi flaps, 366 radial forearm flaps, 367 rectus abdominis flaps, 367, 369 scapular flaps, 367 serratus anterior muscle flaps, 367, 368f for ulnar injuries, 89, 90f from amputated parts, 451–454 osteocutaneous, for dorsal mutilation, 62, 64f sensory skin, for dorsal mutilation, 56–57 tendocutaneous, for dorsal mutilation, 57–59, 58f, 60f–63f, 61–62 Free tissue transfers, for palmar injuries, 76–80 Function evaluation and restoration of, following replantation, 213t, 213–214 of hand, 441–442 rehabilitation and, 530f, 530–531, 531f Gene therapy, limb allotransplantation and, 586 Glabrous skin flaps, for phalangeal hand reconstruction, 269, 270f Gosset, J., 104, 104f Gracilis muscle flaps for secondary reconstruction, 369 for ulnar injuries, 89 Gracilis muscle transfer, for gripping, 25–26, 26f Graft material, from amputated parts. See Spare parts. Great toe wraparound flaps, for thumb reconstruction, 183–188, 448, 448f, 449f anatomy relevant to, 184 modified, 184–188 complications of, 188 flap design and donor management for, 185–186 indications for, 185, 185f, 186f postoperative management for, 187–188 preoperative planning for, 186 procedure for, 187 recipient site preparation for, 187 toe transfer inset for, 187 original procedure for, 184 pollicization of amputated index finger stump to thumb stump with, 446, 447f
614
INDEX
Great toe-to-thumb transfer, 163–172 case studies of, 165–172 of distal phalangeal amputation, 165, 165f–167f of toe transfer to proximal phalanx, 167, 167f–169f of toe transfer to thumb metacarpal, 169, 170f–172f drawbacks of, 183 patient selection and preoperative evaluation for, 163–164 postoperative care, complications, and rehabilitation following, 165 procedure for, 164 trimmed, 183–184 Grip composite, 115–116 digito-palmar, 116, 117f dynamic, 114 functional muscle transfer for, 25–26, 26f hook, 116, 117f interdigital, 116, 117f mechanics of, 113–114 selection of, 116, 118, 118f supporting, 114 thumb-finger pinch and, 114f, 114–115, 115f tripod fixation and, 115, 116f Groin flaps, 17, 19f axial pattern, for thumb reconstruction, 108 for dorsal mutilation, 53–54, 55f for secondary reconstruction, 363–364, 364f–365f, 366, 369 Growth, skeletal injuries and, 489 Guidotti, Galgano, 5–6, 6f Guillotine severances, 194 Hand shrines, in Irish legend, 5 Hand therapy, following great toe-to-thumb transfer, 165 Hemorrhagic shock, reestablishment of circulation with, 203–208, 204f Hilgenfeldt, Otto, 104–105, 105f Hook grip, 116, 117f Horse, role in hand amputations, 12–13, 13f Hyperbaric oxygen therapy, postreplantation, 212–213 Hypertrophic scars, on burned hands, 332 Hypothenar compartment, anatomy of, 88 Hypovolemia, following replantation, 209 Imagery rescripting, 515 Imaginal exposure, psychological response to injury and, 514–515 Immunosuppression, for allotransplantation, 577, 578t–584t evolution of, 592–593, 593f Index finger pollicization of, 104, 104f pollicization of amputated index finger stump to thumb stump with great toe wraparound flap and, 446, 447f thumb reconstruction with cross-hand transfer of index metacarpal and, 454–455, 455f–456f transfer into thumb position, 102, 102f Index finger ray amputation, revision, 551–552, 553f Infection(s) bony defects due to, reconstruction for, 397 postreplantation, 212 Informed consent, for limb allotransplantation, 597
Injured parts, rearrangement of, 442–443 Interdigital grip, 116, 117f Internal fixation. See Fracture(s), internal fixation of. Interosseous arterial flaps, posterior, for palmar injuries, 76 Interosseous island flaps, posterior, 17, 18f Interphalangeal joints proximal, middle finger reconstruction using, 445, 445f, 446f stabilization of, for palmar injuries, 70, 71 Intramedullary nailing, 411, 412f Intraosseous wiring, 410, 412f Invagination anastomosis, for reestablishing circulation, 205, 206f Irish legends, 5 Ischemia, hyperbaric oxygen therapy for, postreplantation, 212–213 Ischemia time, replantation and, 196–198 Ischemia-reperfusion injury, replantation and, 214 Islamic thought, 3 Island flaps for degloving injuries, 312 for palmar injuries, 76 interosseous, posterior, 17, 18f neurovascular for secondary reconstruction, 358–359 for thumb reconstruction, 105–106 step-advancement, 16, 17f Italian legends, 5f, 5–6, 6f Japanese culture, 3 Joint transfer, 225–236 historical background of, 225 neovascularized osteochondral grafts for, 226, 227f vascularized, 226–236 finger distal interphalangeal joint to proximal interphalangeal joint, 226–228, 229f–230f from nonsalvageable finger, 226 second-toe metatarsophalangeal joint, 234–236, 235f–236f second-toe proximal interphalangeal joint, 228, 230–234, 231f–232f Keloids, on burned hands, 332 Khmer culture, 3 Koran, punitive amputation in, 6–7 Korea, political protest in, 8–9 Krukenberg’s operation, 299–304 closure of soft tissues for, 303f, 303–304 indications for, 304 interosseous membrane resection for, 302 muscle dissection for, 299–300, 300f, 301f nerve resection for, 302, 302f reeducation and, 303 results with, 304 separation of bones for, 302, 302f, 303f skin incisions for, 299, 300f K-wires and, for internal fixation of fractures, 412, 413f–415f Lag screws, for internal fixation of fractures, 408, 408f, 409f, 412–414, 415f Lateral arm flaps fascial, for dorsal mutilation, 56, 56f for secondary reconstruction, 367 Lateral pinch, 114–115, 115f
Latissimus dorsi flaps for secondary reconstruction, 366 for ulnar injuries, 89 Leech therapy, for multiple-digit replantations, 220 Legends, 5–6 Legum Regis Canuti Magni, 11 Limb allotransplantation, 591–605 chronology of, 595 donor bone marrow cells for, 604 experimental, 573–586 animal models and, 574–577, 574f–578f immunosuppression for, 577, 578t–584t tolerance induction for, 581, 585–586 future of, 604 hand and composite tissue transplantation registry and, 603–604 historical background of, 592–594 evolution of field, 593t, 593–594 immunosuppressive drugs and, 592–593, 593f immunology of, 594 of hand, 596–600 cortical reorganization after, 602–603, 603t donor limb procurement and preparation for, 598, 598f donor selection and evaluation for, 597–598 functional outcomes after, 600, 601f, 602f future of, 604 informed consent for, 597 medical screening of recipient for, 597 operative procedure for, 598 perioperative immunosuppression for, 598 postoperative care for, 598–600, 599f, 600f recipient selection for, 596t, 596–597 replantation versus, 600–601, 602t peritransplant depletion of recipient T cells for, 604 scientific basis of, 594–595 Limb amputations, salvage of whole or parts of, 449–451 Little finger ray amputation, revision, 552, 554, 554f Littler, J. William, 99, 100f, 105, 105f Load, internal fixation and, 407 Local circulation, impairment of, following replantation, 210–212, 211t Local flaps, 16–17, 18f, 19f for dorsal mutilation, 53, 54f for secondary reconstruction cross-finger flaps, 358 dorsal metacarpal artery flaps, 358 fillet flaps, 358 four-flap Z-plasty and, 357, 357f neurovascular island flaps, 358–359 random, for palmar injuries, 75 Lumbrical arteries, 244, 244f Lumbrical muscles, anatomy of, 243, 243f, 244f Macroreplantation, in children, 478–479, 479f Major limb amputations, salvage of whole or parts of, 449–451 Matev, Ivan, 107, 107f Median nerve anatomy of, 69 repair of, for palmar injuries, 72 Metacarpal(s) external fixation of, 422–423 fractures of, treatment of, 91, 92f lengthening of, 107 muscle and tendon repair in, for replantation, 207–208
INDEX
Metacarpal amputations. See also Transmetacarpal replantation/ revascularization. prehension and, 126–127 Metacarpal arteries, 244, 245f Metacarpal bone loss, 423 Metacarpal bony defects, reconstruction for, 396–397 Metacarpal hand, 121–123, 122f, 277–288 classification of, 278, 278t, 279t complications and pitfalls with, 286 donor site morbidity and, 286 gait analysis and, 287 initial management of, 278–279 nerve repair for, 285 postoperative management for, 285–286 prehension and, 124, 126–127, 127f reconstruction of, 279–281 combined second- and third-toe transfer for, 282–283, 284f combined third- and fourth-toe transfer for, 283 for bilateral metacarpal hand, 281, 282f for unilateral metacarpal hand, 279–281, 280f–281f rehabilitation for, 287–288 motor, 287 sensory, 287–288 secondary procedures for, 286 skeletal fixation for, 284f, 284–285 skin closure for, 285 tendon repair for, 285 vascular anastomoses for, 285 Metacarpophalangeal joints, stabilization of, for palmar injuries, 70–71 Microreplantation, in children, 477–478 Microsurgery, for thumb reconstruction, 178 Microvascular techniques, for thumb reconstruction, 107–109 Middle finger, composite free flap from, to replace segmental loss of all layers of viable ring finger, 452, 452f–453f, 454 Middle finger ray amputation, revision, 554–556, 555f, 556f Middle phalanx, revision amputation of, 549–551, 550f Moberg, Eric, 105, 106f Monoclonal antibodies, limb allotransplantation and, 586 Multiple-digit amputations, rehabilitation following, 520, 520f Multiple-digit avulsion injuries, 316 Multiple-digit replantations, 217–224 bone fixation for, 219 decision to carry out, 217 digital transposition for, 221 distal, 220–221 nerve repair for, 220 operative protocol for, 217–219, 218f, 218t, 219f priorities for, 221–223, 221f–223f tendon repair for, 219–220 vascular repair for, 220 Multisystem injuries, rehabilitation following, 521f, 521–524 blood vessels and, 524 bone and, 522 nerves and, 523–524 skin and, 522 tendons and, 522–523 Muscle(s). See also specific muscles. debridement of, 200
Muscle repair, for replantation, 207–208 Muscle transfer, for gripping, 25–26, 26f Mutilation, ancient evidence of, 4, 4f Nail(s), lack of, with distraction-lengthening of thumb, 139 Nail transfer, vascularized, for phalangeal hand reconstruction, 269, 271f Nails (hardware), for internal fixation of fractures, 411, 412f Nerve(s), rehabilitation following multisystem injuries and, 523–524 Nerve injuries, in children, 486, 486f–488f, 488–489 Nerve reconstruction for ulnar injuries, 91–93 initial, 16 secondary, 253–254, 256f Nerve repair for multiple-digit replantations, 220 for replantation, 208, 208f for wrist injuries, 295 Neural coaptation, 208 Neuroma(s), 533–542 anatomy and history of, 534, 534f in hand and amputation stump, 538–542, 539f–543f nerve grafting technique for, 538 neurophysiology of, 534 of ulnar column, 93 patient selection for surgical treatment of, 535–537, 536f principles of management of, 537f, 537–538 Neurosensory flaps, specialized, for secondary reconstruction, 369 Neurovascular island flaps, for secondary reconstruction, 358–359 Neurovascular island transfers, for thumb reconstruction, 150 Nicoladoni, Carl, 100–102, 101f Nightmares, 510, 511 Nonunions, 405 revision of, following reconstruction, 251–252, 254f O’Brien, Bernard McC., 140, 140f Open fractures, with ulnar injuries, 91 Ossification, electrostimulation of, for distraction-lengthening of thumb, 135, 136f Osteochondral grafts, nonvascularized, for joint transfer, 226, 227f Osteocutaneous flaps, for dorsal mutilation, 62, 64f Osteogenesis distraction, 24–25 stimulation of, for distraction-lengthening of thumb, 134–135, 135f, 136f Osteomyelitis, bony defects due to, reconstruction for, 397 Osteoplastic reconstruction, of thumb, 144, 144f–147f Osteosynthesis, 404–405, 405f, 407f historical background of, 373–374 in hand versus long bones, 414, 416 K-wire, 412, 413f–415f Osteotomy corrective, following reconstruction, 252, 255f for distraction-lengthening of thumb, 132
615
Pain, 533–545 chronic regional pain syndrome and, 542–543 neuromas and. See Neuroma(s). reflex sympathetic dystrophy and, 542–543 score sheet and questionnaire for evaluating, 547–548 sympathetic-maintained pain syndrome and, 542 neuropathophysiology of, 544f, 544–545 Palmar arch, superficial, 69 anatomy of, 88 Palmar fascia, 67, 68f, 69 Palmar mutilating injuries, 67–82, 81f, 82f anatomy relevant to, 67–68, 69f, 70 blood vessel repair for, 72, 72f–74f, 74 classification of, 34, 34f flexor tendon repairs for, 71f, 71–72 general considerations with, 70 nerve repair for, 72, 72f operative assessment of, 70 preoperative assessment and management of, 70 skeletal stabilization for, 70–71, 71f soft tissue coverage for, 74f, 74–80, 75f axial-pattern flaps for, 75f, 75–76 distant flaps for, 76 first webspace flap for, 78, 78f, 79f lateral arm flap for, 76f, 76–78, 77f local random flaps for, 75 medial arm flap for, 78 medial plantar flap for, 78 Palmar skin, avulsion injuries and, 317 Panic disorder, 513 Partial hand prostheses, 565 Pediatric patients. See Children. Pedicle flaps for degloving injuries, 310–311, 311f for secondary reconstruction chest flaps, 363 groin flaps, 363–364, 364f–365f, 366 in children, 490–491, 497t, 497–502f Perfusion, of vascular bed, 201–202 Phalangeal bony defects, reconstruction for, 397 Phalangeal hand reconstruction, 267–275 glabrous skin flap for, 269, 270f initial care of digital injuries and, 268 preparation for toe transfer and, 268 second-toe transfer for, 271–273, 273f second-toe wraparound flap for, 270–271, 272f surgical anatomy relevant to, 268–269 third-toe transfer for, 273, 275, 275f vascularized nail transfer for, 269, 271f Phalangization, 100, 143–144 Phalanx(ges) distal, revision amputation of, 549–551, 550f external fixation of, 423 middle, revision amputation of, 549–551, 550f proximal of thumb, distraction-lengthening of, 138, 139f, 140f revision amputation of, 551, 551f, 552f Phantom limb sensation, 510–511 Plantar flaps, medial, for palmar injuries, 78 Plate compression, for internal fixation of fractures, 408–409, 410f, 411f
616
INDEX
Pollicization, 143–160 amputation level and, 152, 152t, 153f–158f historical background of, 143–150 digital transposition and, 147–148, 149f, 150, 151f neurovascular island transfers and, 150 osteoplastic reconstruction and, 144, 144f–147f phalangization and, 143–144 toe transfer and, 144, 147, 148f indications for, 152–153, 160f of amputated index finger stump to thumb stump, with great toe wraparound flap, 446, 447f of index finger, 104, 104f Posterior interosseous artery island flaps, for secondary reconstruction, 360, 362, 362f Posterior interosseous flaps, reverse-flow, for dorsal mutilation, 53, 54f Posttraumatic stress disorder development of, 511–512 interventions for, 513–516 attributional style and, 513–514 behavioral desensitization and, 515–516 imagery rescripting and, 515 imaginal exposure and, 514–515 return to work and, 515–516 Prehension, 113–129 of mutilated hand, 118–129 prosthetic appliances for, 128–129 with bilateral hand mutilations, 127–128, 128f, 129f with complete amputation of thumb, 123, 124f–126f with metacarpal hand, 124, 126–127, 127f with normal thumb, 119, 120f–122f with partial amputation of thumb, 120–121, 122f–124f with total amputation of hand, 127 with transmetacarpal amputation, 126–127 of normal hand, 113–118 composite grip and, 115–116 digito-palmar grip and, 116, 117f grip mechanics and, 113–114 grip selection and, 116, 118, 118f hook grip and, 116, 117f interdigital grip and, 116, 117f thumb-finger pinch and, 114f, 114–115, 115f tripod fixation and, 115, 116f Prostheses, 559–569, 560f acceptable social presentation for, 561–562, 562f attempt to use, before limb allotransplantation, 597 cost of, 569 finger, 566–568, 567f for amputations through middle phalanx, 566, 568f for amputations through proximal phalanx, 566, 567f “sub-mini,” 566, 568, 568f for children, 569 partial hand, 565 prehension and, 128–129 realistic expectations for, 559 relationship between physical loss and emotional responses and, 563, 564f specificity of, 562–563, 563f surgical planning in relation to, 563–564 technological innovations and, 564–565 thumb, 565f, 565–566, 566f
Prostheses (Continued ) toe, 568 types of, 560–561, 561f, 562f utilization of, 569 Proximal interphalangeal joint, middle finger reconstruction using, 445, 445f, 446f Psychological factors, 509–516 limb allotransplantation and, 597 physical loss related to, 563, 564f posttraumatic and acute stress disorders and development of, 511–512 interventions for, 513–516 symptom development and early and late aspects of, 510–511 panic disorder and, 513 posttraumatic stress disorder and acute stress disorder and, 511–512 sexuality and, 513 Pulley reconstruction, secondary, 259, 261f, 262f Pulvertaft classification, 31 Radial artery, anatomy of, 69 Radial forearm flaps for palmar injuries, 75f, 75–76 for secondary reconstruction, 359–360, 360f, 361f, 367 reverse-flow, for dorsal mutilation, 53 Radial mutilation, classification of, 35f–37f, 36–37 Ray amputation, 18–21, 21f Reamputation, 261–262 Reconstructive procedures. See also specific sites. in children. See Children. of bone. See Bony reconstruction. secondary. See Secondary reconstruction. 20th-century development of, 13 Rectus abdominis flaps for secondary reconstruction, 367, 369 for ulnar injuries, 89 Red hand, in Irish legend, 5 Red Hand of Ulster, 8 Reflex sympathetic dystrophy, 542–543 Regional flaps, from forearm, for secondary reconstruction dorsal ulnar artery flaps, 362, 363f posterior interosseous artery island flaps, 360, 362, 362f radial forearm flaps, 359–360, 360f, 361f Rehabilitation, 519–531 evaluation for, 525f, 525–526, 526f following amputations, 519–521 multiple-digit, 520, 520f of thumb, 520, 521f single-digit, 519–520 treatment of amputations and, 520–521, 521f following crush injuries, 524–525 following great toe-to-thumb transfer, 165 following multisystem injuries, 521f, 521–524 blood vessels and, 524 bone and, 522 nerves and, 523–524 skin and, 522 tendons and, 522–523 following postreplantation secondary surgeries, 262 for metacarpal hand, 287–288 motor, 287 sensory, 287–288
Rehabilitation (Continued ) functional outcome of treatment for fractures and, 389, 391 patients’ psychological response to, 510 treatment and, 526–531 desensitization and, 530, 530f edema management and, 526–528, 527f functional activities and, 530f, 530–531, 531f scar management and, 529, 529f sensory reeducation and, 530 splinting for, 528–529, 529f therapeutic exercise and, 528, 528f thermal modalities for, 529 Reid, D. A. C., 106, 106f classification system of, 31 Renaissance, treatment during, 11–12, 13f Renal failure, acute, following replantation, 209 Replantation, 193–216, 194f cortical reorganization after, 602–603, 603t debridement and, 199–202, 200f of blood vessels, 202 of skin, muscles, tendons, and bone, 200 vascular bed assessment and, 200–202, 201f hand transplantation versus, 600–601, 602t indications for, 195–199, 197f–199f microvascular, of avulsed tissue, 312 multiple-digit. See Multiple-digit replantations. of distal portion of limb, following resection of tumor-bearing segment, 214t, 214–216 postoperative management for, 209–214 anticoagulant therapy and, 212 function restoration and evaluation and, 213t, 213–214 hyperbaric oxygen in, 212–213 infection and, 212 ischemia-reperfusion injury and, 214 local circulatory impairment and, 210–212, 211t swelling of replanted limb or digit and, 212 systemic reaction and, 209–210 secondary surgeries following. See Secondary surgeries, following replantation. segmental, indication for, 214 technique for, 202–209 muscle and tendon repair and, 207–208 nerve repair and, 208, 208f reestablishment of circulation and, 203–208, 204f skeletal framework reconstitution and, 202–203, 203f skin covering and, 208–209 Replantation/revascularization in children. See Children, replantation/ revascularization in. transmetacarpal, 239–245 anatomic considerations for, 240, 243–245, 243f–245f literature review for, 239–240, 241f, 242f Resection, segmental indication for, 214 types of, 215–216 Retinacular system, 69 Return to work, 515 Revascularization. See Children, replantation/ revascularization in; Replantation/ revascularization.
INDEX
Revision surgery. See also Secondary entries. following replantation/revascularization in children, 481 Ribs, vascular free bone transfer using, 29 Ring finger avulsion injuries of, 314, 316 composite free flap from middle finger to replace segmental loss of all layers of, 452, 452f–453f, 454 Rolando’s fractures, external fixation for, 422–423 Rolling severances, 194 Salvage, of whole or parts of major limb amputations, 449–451 Scaphoid fractures, lag screw principle in, 412–414, 415f Scapula, vascular free bone transfer using, 29 Scapular flaps, for secondary reconstruction, 367 Scapular region resection of, followed by replantation, 215 total resection of, followed by replantation, 215 Scars hypertrophic, on burned hands, 332 management of, 529, 529f Secondary reconstruction, 355–369 distant pedicled flaps for, 362–366, 364f–365f chest flaps, 363 groin flaps, 363–364, 364f–365f, 366 free flaps for, 366–369, 368f gracilis flaps, 369 groin flaps, 369 lateral arm flaps, 367 latissimus dorsi flaps, 366 radial forearm flaps, 367 rectus abdominis flaps, 367, 369 scapular flaps, 367 serratus anterior muscle flaps, 367, 368f indications for, 355–356 local flaps for, 356–359, 357f cross-finger flaps, 358 dorsal metacarpal artery flaps, 358 fillet flaps, 358 four-flap Z-plasty and, 357, 357f neurovascular island flaps, 358–359 regional flaps from forearm for, 359–362, 360f–363f dorsal ulnar artery flaps, 362, 363f posterior interosseous artery island flaps, 360, 362, 362f radial forearm flaps, 359–360, 360f, 361f skin grafting for, 356 specialized neurosensory flaps for, 369 Secondary surgeries, following replantation, 247–263, 248t patient selection, timing, and preoperative planning for, 249 postoperative care and rehabilitation following, 262 results with, 262 surgical procedures for, 249t, 249–262 amputation, 261–262 for cold intolerance, 260 joint operations, 254–257, 256f–259f nerve reconstruction, 253–254, 256f skeletal reconstruction, 251–252, 254f, 255f soft tissue reconstruction, 250–251, 251f–253f tendon operations, 259, 260f–262f
Second-toe transfer, 21–22, 21f–23f for phalangeal hand reconstruction, 271–273, 273f for thumb reconstruction, 175–180 technique for, 175–177 Second-toe wraparound flap, for phalangeal hand reconstruction, 270–271, 272f Segmental resection indication for, 214 types of, 215–216 Self-amputations, historical background of, 7–8 Sensory reeducation, 530 Sensory skin flaps, for dorsal mutilation, 56–57 Serratus anterior muscle flaps fascial, for dorsal mutilation, 56 for secondary reconstruction, 367, 368f Sexuality, hand injuries and, 513 Shoulder, elbow-to-shoulder-joint transfer and, 450, 450f–451f Skeletal fixation, 15, 51 for multiple-digit replantations, 219 for palmar injuries, 70–71, 71f Skeletal injuries, growth and, 489 Skeletal reconstruction, secondary, 251–252, 254f, 255f Skin contractures of, with burn injuries, 331–332, 331f–334f debridement of, 200 dorsal, avulsion injuries and, 317–318 palmar, avulsion injuries and, 317 rehabilitation following multisystem injuries and, 522 Skin grafts for burned hands, 328–329 for degloving injuries, 310, 311f for dorsal mutilation, 52 for palmar injuries, 74f, 74–75, 75f for replantation, 208–209, 250 Soft tissue, contractures of, with burn injuries, 331–332, 331f–334f Soft tissue coverage, for palmar mutilating injuries, 74f, 74–80, 75f Soft tissue defects, initial reconstruction of, 16–17, 17f–20f Soft tissue injuries, with fractures, 378, 379t–381t Soft tissue reconstruction, secondary, 250–251, 250f–253f South America, punitive amputation in, 7 “Spaghetti wrist,” 296 Spare parts amputated parts as evaluation of, 443 graft material from, 442 salvage of whole or parts of major limb amputations and, 449–451 small free flaps from, 451–454, 452f–453f cross-hand microvascular transfer and, 454–455, 455f–456f from injured lower extremity, 454, 457, 457f–458f twin donors for, 463 Splinting, 528–529, 529f internal fixation and, 407 of burned hands, 326, 326f Stability, internal fixation and, 407 Stem cell transplantation, chimerism and, 585 Step-advancement island flaps, 16, 17f Stress. See Acute stress disorder; Posttraumatic stress disorder.
617
Stump(s), neuromas in. See Neuroma(s). Stump revision, 18 Subterminal pulpar pinch, 114, 114f Surgery, planning of, prostheses and, 563–564 Surgical expectations, of patients, 510 Swelling, of replanted limb or digit, 212 Sword, in Italian legend, 5f, 5–6, 6f Sympathetic-maintained pain syndrome, 542 neuropathophysiology of, 544f, 544–545 Syndactyly, burn injuries and, 333–334 Synovial sheaths, digital, 68–69 T cells, peritransplant depletion of, for hand allotransplantation, 604 Tacrolimus, for limb allotransplantation, 577, 581, 582t–583t Taoism, 4 Temporoparietal fascial flaps, for dorsal mutilation, 54, 56 Tendocutaneous flaps, for dorsal mutilation, 57–59, 58f, 60f–63f, 61–62 Tendon(s) debridement of, 200 grafting of, secondary, 259, 261f initial reconstruction of, 16 rehabilitation following multisystem injuries and, 522–523 Tendon grafts, for clawing, 93 Tendon injuries, of ulnar column, reconstruction of, 93 Tendon operations, secondary, 259, 260f–262f Tendon repair for multiple-digit replantations, 219–220 for replantation, 207–208 for wrist injuries, 293–295 Tendon transfers, for clawing, 93 Tenolysis, secondary, 259, 260f Tension bands, for internal fixation of fractures, 409–410, 412f Termino-terminal pinch, 114, 114f Therapeutic exercise, 528, 528f Thermal modalities, 529 Third-toe transfer, for phalangeal hand reconstruction, 273, 275, 275f Thrombosis vasospasm differentiated from, 210, 211t venous, with great toe wraparound flap, 188 Thumb(s) amputation of, rehabilitation following, 520, 521f avulsion injuries of, 313–314, 313f–317f complete amputation of, prehension and, 121, 123, 124f with complete amputation of all fingers, 124, 126–127, 127f with complete amputation of one or more fingers, 123, 125f with partial mutilation of fingers, 123, 124f congenitally absent, reconstruction of, 106–107, 107f great toe wraparound flap to, 448, 448f, 449f grip selection and, 116, 118, 118f in multiple-digit replantations, 221f, 221–222 normal with complete amputation of one or more fingers, prehension and, 119, 120f–122f with multidigital amputations, prehension and, 119 with partial amputation of middle finger, prehension and, 119
618
INDEX
Thumb(s) (Continued ) opposition of, numbered method for evaluating, 115, 115f partial amputation of, prehension and, 120–121, 122f–123f with amputation of all fingers, 121, 123f with amputations of metacarpals, 121 pollicization of amputated index finger stump to thumb stump with great toe wraparound flap and, 446, 447f traumatic loss of, pollicization for. See Pollicization. Thumb prostheses, 565f, 565–566, 566f Thumb reconstruction. See also Pollicization. development of, 99–109, 100f during 1847–1948, 100–104, 101f–103f during 1949–1969, 104–107, 104f–107f from 1968 to present, 107–109, 108f distraction-lengthening for, 131–140 bone grafting of interfragment gap in, 135, 137f bone-lengthening device for, 135–136, 138f carpometacarpal joint response to distraction forces, 137–138, 138f complications of, 139 deepening of first webspace for, 138, 139f distraction phase of, 132–133, 133f, 134f drawbacks and advantages of, 140 historical background of, 131, 132f in children, 138, 141f lack of nail and, 139 length of bone stump and, 132, 132f of proximal phalanx, 138, 139f, 140f osteotomy for, 132 postoperative period and, 132 rest phase of, 133 skin of thumb stump and, 131 stimulation of osteogenesis for, 134–135, 135f, 136f great toe wraparound flap for. See Great toe wraparound flaps, for thumb reconstruction. microsurgical, 178 microvascular techniques for, 107–109 of congenitally absent thumb, 106–107, 107f second-toe transfer for, 175–180 drawbacks of, 179 indications for, 178f, 179f, 179–180 postoperative course with, 177 results with, 177 technique for, 175–177 toe transfer for. See Great toe-to-thumb transfer; Toe transfer, for thumb reconstruction. using amputated index finger, 448, 448f, 449f with cross-hand transfer of index metacarpal, 454–455, 455f–456f Thumb-finger pinch, 114f, 114–115, 115f Tic-tac-toe classification system, 31–32, 32f, 32t, 47, 47t Tissue-engineered bone, for bony defect reconstruction, 393 Toe(s). See also Digit(s). great. See Great toe wraparound flaps; Great toe-to-thumb transfer.
Toe(s) (Continued ) second metatarsophalangeal joint transfer from, 234–236, 235f–236f proximal interphalangeal joint transfer from, 228, 230–234, 231f–232f Toe prostheses, 568 Toe transfer, 25, 25f for metacarpal hand reconstruction. See Metacarpal hand. for phalangeal hand reconstruction. See Phalangeal hand reconstruction. for thumb reconstruction, 102, 102f, 140, 144, 147, 148f foot fillet flaps for maintenance of leg stump length and hand coverage preceding, 457, 457f–458f second-toe. See Second-toe transfer, for thumb reconstruction. using great toe. See Great toe-to-thumb transfer. great toe, for thumb reconstruction. See Great toe-to-thumb transfer. second-toe, 21–22, 21f–23f for thumb reconstruction. See Secondtoe transfer, for thumb reconstruction. Tolerance induction, for allotransplantation, 581, 585–586 Transmetacarpal amputation, prehension and, 126–127 Transmetacarpal replantation/ revascularization, 239–245 anatomic considerations for, 240, 243–245, 243f–245f literature review for, 239–240, 241f, 242f Transplantation limb. See Limb allotransplantation. stem cell, chimerism and, 585 Transverse amputation, classification of, 37–40, 38f–40f Traumatic injuries, bony defects due to, reconstruction for, 397 Treatment, historical development of, 11–13 Trimmed great-toe transfer, 183–184 Tripod fixation, 115, 116f Tubiana, Raoul, 105–106, 106f Ulnar artery, anatomy of, 88 Ulnar artery flaps, reversed, for palmar injuries, 76 Ulnar column amputation of, 94 arterial system of, 88 compartments of, 88 neuromas of, 93 reconstruction of, 88–94 clawing and, 93 for tendon injuries, 93 neuromas and, 93 of bone, 91, 92f of nerves, 91–93 of soft tissue, 89, 90f, 91 staging of, 88–89 tendon injuries of, reconstruction of, 93 Ulnar mutilating injuries, 87–94 anatomy relevant to, 88 biomechanics and, 87, 88f classification of, 34, 34f, 35 ulnar column amputation for, 94 ulnar column reconstruction for, 88–94
Ulnar nerve anatomy of, 69, 88 repair of, for palmar injuries, 72 Urbaniak Class II injuries of multiple digits, 316 of ring finger and other single digits, 314 of thumb, 313f, 313–314 Urbaniak Class III injuries of multiple digits, 316 of ring finger and other single digits, 316 of thumb, 314 Vascular bed, assessment of, 200–202 locating blood vessels and, 200–201, 201f perfusion of vascular bed and, 201–202 Vascular defects, repair of, 206–207, 207f Vascular repair. See also Arterial entries; Children, replantation/ revascularization in; Replantation/revascularization; Venous entries. for multiple-digit replantations, 220 for palmar injuries, 72, 72f–74f, 74 for wrist injuries, 295 Vascular suturing techniques, 134, 205f, 206f Vascularized free bone transfer, 26–29, 27f, 28f Vasospasm postreplantation, 210–211 thrombosis differentiated from, 210, 211t with great toe wraparound flap, 188 Veins, initial reconstruction of, 16 Venous anastomosis, 205–206 Venous flaps, for dorsal mutilation, 59, 61–62, 62f, 63f Venous obstruction, postreplantation, 210, 211t Venous thrombosis, with great toe wraparound flap, 188 Venous-venous flaps, for degloving injuries, 312 Vibration, for stimulation of osteogenesis, for distraction-lengthening of thumb, 134–135 Volar compartment, anatomy of, 88 V-Y flaps, 16 Wartenberg’s sign, 93 Webspace, first, deepening of, in distractionlengthening of thumb, 138, 139f Webspace contractures of burned hands, 332–333 release of, 250–251, 250f–252f Weinzweig classification, 31–32 Wei’s classification, 31 Work, return to, 515 Wound management, 15–16 debridement and fixation for, 15 general principles of, 51 presurgical considerations for, 16 Wrist muscle and tendon repair in, for replantation, 207–208 mutilated, 291–297 assessment of, 291–292 management of, 292f–295f, 292–296 mechanism of injury and, 291 “spaghetti wrist,” 296
