Volume 19, Issue 1, Pages 1-209 (February 2003) Mutilating Hand Injuries articles 1 - 17 1 Mutilating hand injuries Page

xi Richard E. Brown and Michael W. Neumeister Mutilating hand injuries: principles and management Pages 1-15 Michael W. Neumeister and Richard E. Brown Biomechanics and hand trauma: what you need Pages 17-31 Steven L. Moran and Richard A. Berger Antimicrobial management of mutilating hand injuries Pages 33-39 R. Dow Hoffman and Brian D. Adams Psychological aspects of mutilating hand injuries Pages 41-49 Therese M. Meyer Fracture fixation in the mutilated hand Pages 51-61 Alan E. Freeland, William C. Lineaweaver and Sheila G. Lindley Soft tissue coverage in devastating hand injuries Pages 63-71 Goetz A. Giessler, Detlev Erdmann and Guenter Germann Use of spare parts in mutilated upper extremity injuries Pages 73-87 Richard E. Brown and Tzu-Ying Tammy Wu Replantation in the mutilated hand Pages 89-120 Bradon J. Wilhelmi, W. P. Andrew Lee, Geert I. Pagensteert and James W. May Pediatric mutilating hand injuries Pages 121-131 Gregory M. Buncke, Rudolf F. Buntic and Oreste Romeo Hand therapy management following mutilating hand injuries Pages 133-148 Shirley W. Chan and Paul LaStayo

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Secondary procedures following mutilating hand injuries Pages 149-163 Robert C. Russell, Reuben A. Bueno and Tzu-Ying Tammy Wu Toe-to-hand transplantation Pages 165-175 Fu-Chan Wei, Vivek Jain and Samuel Huan-Tang Chen Passive hand prostheses Pages 177-183 Hooman Soltanian, Genevieve de Bese and Robert W. Beasley Active functional prostheses Pages 185-191 Terry J. Supan Outcomes after mutilating hand injuries: review of the literature and recommendations for assessment Pages 193-204 Reuben A. Bueno and Michael W. Neumeister Index Pages 205-209

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Hand Clin 19 (2003) xi

Preface

Mutilating hand injuries

Richard E. Brown, MD, FACS

Michael W. Neumeister, MD, FRCSC, FACS Guest Editors

Perhaps the most challenging injury managed by hand surgeons is the mangled or mutilated hand. Mutilating injuries can occur from various causes such as motor vehicle accidents, farm or blast injuries, or industrial accidents. Such injuries involve the many structures of the hand and, thus, pose a dicult challenge to the surgeon to preserve or reconstruct as much function as possible. Previous issues of the Hand Clinics have dealt with trauma to the various structures of the upper extremity; however, none has been solely devoted to the evaluation and management of the mutilated hand. In this issue, we have pulled together the expertise of numerous authorities throughout the world to discuss the diverse aspects of mutilating hand injuries from the acute management to the secondary reconstruction as well as the psychological and rehabilitation aspects. We would like to thank the many authors who have contributed to this issue. In addition, we

wish to thank the editorial sta at WB Saunders for their assistance and patience. Lastly, we would like to thank Cheryl Matthews for her secretarial assistance and Maria Ansley for her photographic contributions. Richard E. Brown, MD, FACS Division of Plastic Surgery Southern Illinois University School of Medicine Springeld Surgical Associates Springeld Clinic PO Box 19248, 501 N. 1st Street Springeld, IL 62794-9248, USA Michael W. Neumeister, MD, FRCSC, FACS Southern Illinois University School of Medicine The Plastic Surgery Institute PO Box 19653, 747 N. Rutledge Street Springeld, IL 62794-9653, USA

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. doi:10.1016/S0749-0712(02)00145-2

Hand Clin 19 (2003) 115

Mutilating hand injuries: principles and management

Michael W. Neumeister, MD, FRCSC, FACSa,*, Richard E. Brown, MD, FACSb
b a Southern Illinois University Plastic Surgery, P.O. Box 19653, Springeld, IL 62794, USA Springeld Surgical Association, A Division of Springeld Clinic, P.O. Box 19248, Springeld, IL 62794, USA

Our hands are subject to many common occupational and domestic injuries, including ngertip trauma, tendon lacerations, neurovascular compromise, fractures, and soft tissue loss. We are all aware that even minor trauma to a joint or tendon can result in signicant stiness and loss of function of the nger. The greater the injury, the more likely the risk for compromise to the function of the hand. This is no more evident than in mutilating upper extremity injuries in which the ne balance and interplay of the intrinsic and extrinsic structures of the hand are damaged or destroyed. Each nger has its inherent role in the normal function of the hand. The American Medical Association, in the Guidelines to the Evaluation of Permanent Impairment, fth edition, has described the functional contribution that each digit oers to the hand, the upper extremity, and to the body as a whole (Table 1). Loss of the thumb is equivalent to a 40% loss of function of the hand and a 25% loss of the whole body function. Although the little and ring ngersare not given as high a functional loss, these digits are important in grip strength, which has enormous implications for laborers and tool workers. The thumb is important for prehensile tasks, whereas the ulnar digits are important for power grasps. Hand surgeons are often challenged to salvage or restore function of mutilated upper extremities for the ultimate goal of permitting patients either to return to work or at least to perform their

* Corresponding author. E-mail address: mneumeister@siumed.edu (M.W. Neumeister).

activities of daily living. The functional loss after such devastating trauma is, therefore, measured not only by objective analysis such as functional capacity evaluations but also by subjective data, in which pain, dexterity, and daily use become important issues. Active and passive range of motion, sensation, and grip strength are easily recorded and may help dene a successful reconstruction of the hand, but ultimately the patient must incorporate their hand back into their daily activities; this is the true test of success. The immediate management of these injuries is similar no matter how severe or unique the trauma. The template for success is dened by patient survival, limb survival, limb function, and incorporation back into a meaningful lifestyle. Ensuring patient survival is the initial conquest (Fig. 1). The patient must be hemodynamically stable before embarking on any salvage procedure. A primary and secondary survey should be performed with the emphasis of obtaining and maintaining a patent airway, observing normal breathing patterns, and providing circulatory support. The amount of force that is required to mangle a hand may very well have caused signicant injury to the internal viscera also. Intravenous access and uid resuscitation are required to optimize central and peripheral circulation. Life threatening injuries should obviously be treated before limb threatening injuries. During the treatment to stabilize the patient, a thorough history should be obtained. A detailed history helps elicit the mechanisms of injury and lends further insight into the extent and severity of the mutilation. Crush and avulsion injuries result in greater tissue damage and consequently

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. doi:10.1016/S0749-0712(02)00141-5

M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 115

Table 1 Guides to the evaluation of permanent impairment % Impairment Amputation hand Index or longer nger Ring or little nger Thumb Hand Upper extremity 20 10 4050 Upper extremity 18 9 3645 90 Whole body 11 5 2227 54 60

(Data from AMA Guidelines of Permanent Impairment, 5th ed. 2001.)

portend a worse functional prognosis than guillotine type amputations. Greater contamination can be expected from farming and industrial injuries in which considerable debris is often buried within the depths of the wounds [1,2]. It is prudent, therefore, to initiate intravenous antibiotics while the patient is in the emergency department. Broad-spectrum coverage is mandatory until denitive cultures return. The patients tetanus status should be recorded and updated if required. Other signicant elements of the history include obtaining information on previous injuries, premorbid function of the hand, duration of ischemia

Fig. 1. (A,B) A 12-year-old boy had an M-80 explode in his hand. A subsequent re ensued. The hand injury was devastating. (C ) The systemic effects may be more life threatening than the limb injury. This patient sustained 40% total body surface area burns that needed to be addressed before the mutilating hand injury.

M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 115

Fig. 2. (A) A 26-year-old male with a considerable soft tissue let to the back of the hand. Multiple function and tendon injuries are present. (B) Debridement and irrigation was performed before reconstruction of the involved structures. (C) Denitive closure is performed only when the wound bed is clean. A scapular ap was used for closure.

of amputated parts, management of the wounds in the eld and at the local hospital, loss of consciousness, dizziness, chest pains, or shortness of breath. Uncontrolled diabetes, acute chest pain, heart palpations, and shortness of breath can put patients working on heavy machinery in dangerous situations in which a loss of concentration can result in devastating injuries. Such a history would alert the emergency department physician or the surgeon to perform further diagnostic studies before attempting a potentially long and complicated surgery for limb salvage. Again the patient needs to be stable with a controlled cardiovascular and respiratory system to help avoid intraoperative and postoperative systemic complications, including hypovolemia, renal failure, and cardiovascular embarrassment [35]. The hand surgeons initial physical examination of the mutilated upper extremity may be limited because of signicant pain, contamination, deformity, or patient apprehension. It is impor-

tant, however, to assess all structures, especially the vascularity of the traumatized digit and hand. Ischemic ngers mandate emergent care if one hopes to salvage as much of the hand as possible. Many aspects of the physical examination do not require the surgeon to actually lay their hands on a patient hand to fully understand the severity of the injury. Simple inspection of mutilating hand injuries often can identify several injured structures. The color and turgor of the digits can be assessed to identify vascular compromise. The normal cascade of the hand may be disrupted because of tendon lacerations or phalangeal fractures. A gross visualization of skin loss and exposed structures also can be evaluated in the emergency department. Gross sensation can be evaluated with light touch or with a sterile 25-gauge needle. The emergency department evaluation permits the surgeon to alert the operating room sta of the specic instruments that are required to best treat the injury. Bone

M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 115

Fig. 3. (A) A mutilating hand injury in a 50-year-old man. All ngers were devascularized with multiple levels of injury to the entire hand. (B) After debridement and irrigation, the remaining tissue is evaluated for spare part reconstruction. (C ) The long nger is transplanted to the only remaining metacarpal (fth). A xenograft is used to cover remaining exposed wound bed until all tissues have declared themselves as viable and the use of temporary dressings such as xenograft is safe and buys time in case more tissue needs debridement or ap closure is required.

xation devices, lavage solutions, microscopes and microscopic instrumentation, and uoroscopy may be needed to treat the various tissues. The surgeon needs to decide the appropriateness of attempting replantation or revascularization of the digits or hand, depending on the level and site of amputation, contamination, ischemia time, other associated injuries or medical illnesses, and the concerns of the patient [6,7]. Many farmers are concerned only with getting back to work their land and request the most expedient yet functional surgery. Other patients arrive in a state of hysteria and unrealistically expect complete restoration of their hand. It is the surgeons duty to fully evaluate the various avenues of limb salvage and provide an educated treatment option for the patient and their family. Many patients have diculty with decisions made to amputate ngers, despite knowing that re-

plantation attempts may be fraught with complications and further surgeries or may result in a nonfunctional, sti, and insensate hand or nger. Psychotherapists and psychiatrists may be needed to help some patients deal with the personal, social, and professional sequelae of mutilating hand injuries. The cornerstone of the early intraoperative management of mutilating hand injuries is debridement and irrigation. All grossly devitalized tissue needs to be excised (Fig. 2). Copious pulse lavage irrigation helps to eliminate debris and bacteria from the contaminated wounds [8]. Care must be taken not to further damage those tissues that might otherwise survive. This is especially true for vital structures such as the nerves, arteries, tendons, and bone. The debridement commences in an orderly fashion, starting with the skin and moving to the tissues in the deeper

M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 115

Fig. 4. (A) A 15-year-old girl caught her hand in a grinder. Multiple digits are involved with fractures and soft tissue devascularization. (B) Osteosynthesis can be performed with K-wires, lag screws, plates, interosseous wires, external xators, or a combination of any of the above.

aspects of the wound. The repair of the tissues usually follows the opposite direction, building from the bottom of the wound outward. In general, the order of repair should follow from the larger stabilizing structures to the nger nutrient supplying structures. The authors therefore prefer to obtain skeletal xation rst to provide stability, maintain length, and oer protection to other tissues. The tendon repair follows so that the microscopic anastomosis can proceed without fear of endangering the more delicate structures. Following nerve and artery repair, attention is focused on soft tissue coverage. There are, however, exceptions to the order of repair.

Tissue that has been rendered ischemic for prolonged periods may require revascularization much sooner than could be aorded by the complicated or prolonged osteosynthesis or tendon repairs [6,9]. Occasionally the arterial repairs therefore can be performed following the bony xation or even before the bony xation by means of a temporary vascular conduit. Such vascular conduits provide arterial inow into the devascularized distal tissue so that ischemia time can be decreased. It is usually not necessary to provide a venous outow conduit. Instead the venous blood is allowed to drain around the limb. This decreases the ush of blood that contains

Fig. 5. (A) A nerve gap noted following injury to the index nger. (B) A nerve conduit can be used instead of nerve grafts. Polyglycolic acid (Neurotube) is easily t to size and provides excellent regeneration of the nerve.

M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 115

Fig. 6. (A) A 23-year-old woman with a mutilating injury to the left arm from an explosion. Multiple metacarpal phalanx fractures and radius fractures are present. The ulnar digits are compromised. (B) Salvage of as many digits as possible may optimize function. A free rectus abdominal ap was used for closure of the forearm and hand. Good function was returned to the thumb, index, and long ngers.

proinammatory cytokines and breakdown products from the revascularized limb into the systemic circulation where a systemic inammatory reaction (SIRS) phenomenon may result in multiorgan failure and possibly death [5]. Soft tissue coverage is often dicult to obtain with mutilating hand traumas. Exposed tendon, bone, joints, hardware, or neurovascular bundles obviously require regional, distant, or free ap closure. The contaminated nature of the injuries, however, prevents the use of aps until the tissues are clean and optimized for infection control. In this light, it is prudent for the surgeon to return

to the operating theater for a second look, debridement, and irrigation approximately 24 48 hours following the initial surgery. This second look surgery helps decrease the bacterial load and identify those tissues that originally seemed viable but subsequently declare themselves otherwise. The need for further debridement of devitalized tissue is not uncommon. At times, a third look may be required also. It is for this reason that an emergency free tissue transfer is not advocated. Once the surgeon is content with the cleanliness of the wound, soft tissue closure can ensue [1018].

Fig. 7. As per case report 1.

M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 115

Fig. 7 (continued )

Before the denitive closure, saline dressings, xenografts, or allografts are sucient to provide temporary coverage (Fig. 3). Occasionally, antibiotic beads and opsite are used over wounds in which bone gaps or defects are evident. The exact means of obtaining bony xation is probably less important than the adherence to the principles of fracture management [1926]. The fracture location, geometry, deforming forces, and presence of soft tissue loss dictate the optimum treatment.

Plates, screws, K-wires, interosseous wires, or external xators all have a role in fracture xation of various structures (Fig. 4). Severe comminutions of bone or frank loss of bone stock in mutilating hand injuries oer a further challenge. External xators are often used if segmental defects in the bone are present. The external xator maintains length and position until the denitive bone graft from the iliac crest can be used to bridge the defects. Ultimately, the key to

M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 115

Fig. 7 (continued )

success is a good functional outcome with skeletal union, anatomic alignment, and joint mobility. Older patients, fractures with severe comminution or bone loss, intra-articular fragments, associated tendon injury, over-zealous periosteal stripping, and prolonged splinting are all factors that increase the risk for nonunion, malunion, or stiness. The severity of the injury, the blood supply to the tissues, the surgical dissection, and the rehabilitation all play a signicant role in the amount of scarring and functional outcome.

Soft tissue repair should follow skeletal stabilization. Signicant loss of specialized tissue such as nerves or vessels oers yet another challenge for the hand surgeon. For instance, the greater the severity of the injury, the greater the chance that vein grafts will be needed for vascular repair. The authors prefer to map out the volar forearm veins with a sterile marking pen before tourniquets are applied so that the exact location of these veins can be easily identied. One leg is often prepped out also, in case larger veins are required from the

M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 115

Fig. 7 (continued )

lesser or greater saphenous systems or from the dorsal venous arch on the foot. Vein grafts are used commonly to bridge arterial and venous gaps. Vessels with obvious intimal damage need to be cut back to normal appearing anatomy. Many surgeons prefer to foreshorten the bone during replantation to avoid using vein grafts. At times, however, there is little option other than to use such grafts. Emergency vein grafting is used to salvage the digits or limbs and return normal vascularity to ischemic tissues. Emergency use of grafts for other specialized tissue, such as nerves or tendons, is less justied because of the risk for subsequent loss of the grafted tissue if there is infection or subsequent soft tissue coverage loss. Nerve grafts, tendon grafts, and bone grafts should be delayed until the stable soft tissue coverage is obtained. The loss of a ap that is used to cover a wound that had immediate nerve, tendon, or bone grafting would likely result in loss of these specialized grafts. Not only does this put the patient through another prolonged procedure, but further donor sites will be needed, increasing the morbidity of the overall management. At 46 weeks following the soft tissue coverage the ap can be elevated and the denitive grafting of the specialized tissue performed. At times, the same aps used to provide soft tissue coverage can be used to carry with a nerve, bone, or tendon graft,

thus providing a vascularized graft. For example, the palmaris longus tendon or the antebrachial nerve can be incorporated easily with the radial forearm ap. Vascularized bone grafts can be harvested with the groin, scapular, radial forearm, and osteoseptocutaneous bular aps. The donor site morbidity and amount of graft required needs to be well assessed before contemplating these innovative procedures. Nerve grafts for use in the palm or digits are usually harvested from the distal posterior interosseous nerve at the dorsal wrist within the fourth dorsal compartment or from the medial antebrachial nerve. These donor nerves are usually a good size match for the palmar or digital nerves. Polyglycolic acid (PGA) conduits (Neurotube, Bel Air, Maryland) have been used to bridge small gaps of less than 3 cm in the ngers [27] (Fig. 5). Some evidence exists that conduit repairs may provide as good a recovery as the standard nerve grafts. Donor site morbidity is obviously avoided with the use of the PGA conzduits. Tendon grafts can be harvested from the palmaris longus, plantaris, or toe extensor tendons. Extensor indicis proprius or extensor digiti qunti transfers can be used if only one tendon reconstruction is required in the hand. Complete amputations within the upper extremities are often salvageable if ischemia time is

Fig. 8. As per case report 2.

M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 115

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Fig. 8 (continued )

Fig. 8 (continued )

M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 115

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Fig. 8 (continued )

limited, multiple levels of injury are not apparent, the limb is not severely crushed or avulsed, or medical conditions do not jeopardize the patients life [7]. The more proximal the amputation on the extremity, the easier the technical demand for the surgeons. Distal amputations oer greater technical challenges. Functionally, however, the distal amputations oer better results than do proximal limb amputations [6,28]. In general, less than 6 hours of warm ischemia or 12 hours of cold ischemia are often the quoted time limits to attempt replantation. Reports of warm ischemia up to 42 hours and cold ischemia up to 96 hours have been published [29,30]. Despite the many advances in microsurgery and replantation surgery, it is not always possible to replant amputated parts. The tissue, digits, or limbs that have been amputated, however, could possibly be used for other reconstructive purposes. Some functions or skin coverage may be salvaged using principles of spare parts surgery [31,32]. Fingers, joints, bone, and skin can be transferred, either on a vascular pedicle or as a free tissue transfer to other parts of the mutilated hand to oer some element of function back to the limb. Tissue should not be discarded either at the scene of the accident or in the hospital until all options for possible use have been dismissed. Salvaging one or two digits that regain sensation and mobility is usually much more functional than a prosthesis (Fig. 6). Severely mangled limbs are fraught with multiple tissue injuries including bone, tendon, intrinsic muscles, neurovascular bundles, and skin. The subsequent healing, swelling, and the need for early immobilization in many cases may render the hand sti and dysfunctional. Secondary procedures are extremely common to restore even basic functional tasks. Tenolysis, joint

contracture releases, web space deepening, or nger lengthening may be required to improve motion and function at the interphalangeal, metacarpal phalangeal, and wrist joints. Hands left without a full complement of digits may have improved function with toe to hand transfers. Toe to hand transfers can usually restore prehension and improve the functional outcome of the mutilating hand injury. Partial toe or toe wraparound procedures may optimize functional and aesthetic appearances of the reconstructed hand [33]. Second and third toe transfers are best suited for reconstruction of the more ulnar digits so that more adequate opposition can occur [32,3436]. Sensate digits with restoration of some motion have signicant functional advantages over prostheses [37]. Prostheses are usually designed for a given set of limited tasks, and therefore do not appropriately aid in all of the activities of daily living. The cumbersome nature of some prostheses compromises compliance and satisfaction in many patients. Bearing this in mind, however, there is distinct indication for the use of various prosthetics [38]. The prosthesis can be used in either an active or passive fashion. Active prostheses have some element of mobility so that procedures such as holding, grasping, and pinching can be performed. Passive prostheses on the other hand do not have the intrinsic ability to move, but may act as an assist hand in some cases. Passive prostheses also have an important role in returning the normal appearance to the nger or hand. Complete amputations of the hand, forearm, or upper arm are usually indications for active prostheses. The prostheses may be biomechanical, using shoulder muscles or the intrinsic muscles within the forearm or arm. Alternatively, myoelectric and computerized prostheses are now technically available.

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M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 115

The following cases illustrate the complexities and many facets of managing mutilating hand injuries.

Case 1 A 52-year-old man sustained a mutilating hand and wrist injury while mounting a tire onto a wheel. The tire exploded and the rim struck his right dominant hand. Initial inspection on presentation to the hospital revealed a severe degloving injury with marked intercarpal dislocations (Fig. 7A, B). Vascularity of the hand was intact. The hand was irrigated and debrided in the operating room. The carpus was reduced and pinned (Fig. 7C) and the skin loosely approximated. Within 2 days, compromise of the vascularity became obvious with discoloration of several ngertips (Fig. 7D). Arteriography revealed occlusion of his supercial and deep arches with minimal ow to the ngers (Fig. 7E). He was taken back to the operating room where the small nger was amputated. A palmar arch was reconstructed using a venous arch from the dorsum of the foot (Fig. 7F). With further observation, it became evident that the palmar and dorsal soft tissue coverage of the hand was inadequate (Fig. 7G, H). Consequently, 3 weeks post injury, the hand was re-debrided and covered with a parascapular free ap (Fig. 7I, J). Late secondary procedures included debulking of the ap. He returned to his prior employment with a functional hand (Fig. 7K, L).

the opposite end of the groin ap (Fig. 8IK). Five months post injury, coverage and range of motion was good except for lack of index extension (Fig. 8LN). Subsequent debulking of the second and third web spaces along with tendon grafting resulted in improved function (Fig. 8OT). These cases illustrate some of the principles that are used in treating mutilating hand injuries. Adherence to sound, safe principles helps prevent further morbidity while fostering the restoration of hand function to return the patient to gainful activities of daily living.

References
[1] Gorsche TS, Wood MB. Mutilating corn picker injuries of the hand. J Hand Surg 1988;13:4237. [2] Burkhalter WE. Mutilating injuries of the hand. Hand Clin 1986;2:4568. [3] Brown HC, Williams HB, Woodhouse FM. Principles of salvage in mutilating hand injuries. J Trauma 1968;8:31821. [4] Russell WL, Sailors DM, Whittle TB, et al. Limb salvage versus traumatic amputations. Ann Surg 1991;213:47380. [5] Baek SM, Kim SS. Successful digital replantation after 42 hours of warm ischemia. J Reconstr Microsurg 1992;9:455. [6] Axelrod TS, Buchler U. Severe complex injuries to the upper extremity: revascularization and replantation. J Hand Surg 1991;16(4):57484. [7] Ipsen T, Lundkvist L, Barfred T, Pless J. Principles of evaluation and results in microsurgical treatment of major limb amputations. A follow-up study of 26 consecutive cases 19781987. Scand J Plast Reconstr Surg Hand Surg 1990;24(1):7580. [8] Moore RS, Tan V, Dormans JP, Bozentka DJ. Major pediatric hand trauma associated with reworks. J Orthop Trauma 2000;14(6):4268. [9] Pei GX, Zhao DS, Xie CP, Wang ST. Replantation of multi-level hand severances. Injury 1998; 29(5):35761. [10] Lille S, Mowlavi A, Russell RC. Management of ngertip injuries. Plastic surgery indications, operations and outcomes. In: Russell RC, editor. Hand surgery, Vol IV. St. Louis: Mosby; 2000:177192. [11] Walton RL, Neumeister MW. Pedicled aps and grafts. Plastic surgery indications, operations and outcomes. In: Russell RC, editor. Hand surgery, Vol IV St. Louis: Mosby; 2000. p. 17931817. [12] Chen HC, Buchman MT, Wei FC. Free aps for soft tissue coverage in the hand and ngers. Hand Clin 1999;15(4):54153. [13] Salgado CJ, Orlando GS, Serletti JM. Clinical application of the posterior rectus sheath-peritoneal free ap. Plast Reconstr Surg 1999;106(2):3216.

Case 2 A 21-year-old man sustained an injury to his nondominant left hand in a motorcycle accident while racing. During the accident, one of the tires caused a severe friction burn to the hand and a dislocation of the thumb (Fig. 8A). The wound was debrided and the dislocation was pinned (Fig. 8B, C). Denitive closure was attempted with a parascapular fascial free ap and skin grafting 4 days later (Fig. 8D, E). Loss of the distal end of the ap resulted in exposure of the index MP joint and loss of the extensor to the index (Fig. 8F). A pedicled groin ap then provided secondary coverage (Fig. 8G, H). At the time of division of the groin ap, a rst web space contracture was released and closed using

M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 115 [14] Russell RC, Guy RJ, Zook EG, Merrell JC. Extremity reconstruction using the free deltoid ap. Plast Reconstr Surg 1985;76(4):58695. [15] Reigstad A, Hetland KR, Bye K, Rokkum M. Free aps in the reconstruction of hand and distal forearm injuries. J Hand Surg 1992;17B:1858. [16] Watanabe T, Iwasawa M, Kushima H, Kikuchi N. Free temporal fascial ap for coverage and extensor tendon reconstruction. Ann Plast Surg 1996;37(5): 469472. [17] Fassio E, Laulan J, Aboumoussa J, Senyuva C, Goga D, Ballon G. Serratus anterior free fascial ap for dorsal hand coverage. Ann Plast Surg 1999; 43(1):7782. [18] Pribaz J, Orgill D, Epstein MD, Sampson CE, Hergrueter CA. Anterolateral thigh free ap. Ann Plast Surg 1995;34(6):5961. [19] Lins RE, Myers BS, Spinner RJ, Levin LS. A comparative mechanical analysis of plate xation in a proximal phalangeal fracture model. J Hand Surg 1996;21A(6):105964. [20] Prevel CD, Eppley BL, Jackson R, Moore K, McCarty M, Wood R. Mini and micro plating of phalangeal and metacarpal fractures: a biomechanical study. J Hand Surg 1995;20A(1):449. [21] Matloub HS, Jensen PL, Sanger JR, Grunert BK, Yousif NJ. Spiral fracture xation techniques. Br J Hand Surg 1993;18B(4):5159. [22] Hastings H. Unstable metacarpal and phalangeal fracture treatment with screws and plates. Clin Orthop 1987;214:3752. [23] Halliwell PJ. The use of external xators for ngerinjuries. Br J Bone Joint Surg 1998;80B: 10203. 1993. [24] Krenth DJ, Klasen HJ. External xation for phalangeal and metacarpal fractures. Br J Bone Joint Surg 1998;80B:22730. [25] Cziffer E. Static xation of nger fractures. Hand Clin 1993;9(4):63950. [26] Bischoff R, Buechler U, DeRoche R, Jupiter J. Clinical results of tension band xation of avulsion fractures of the hand. J Hand Surg 1994;19A(6): 101926.

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[27] 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 2000;106(5):10468. [28] Kleinert HE, Jablon M, Tsai TM. An overview of replantation and results of 347 replants in 245 patients. J Trauma 1980;20:3908. [29] Baek SM, Kim SS. Successful digital replantation after 42 hours of warm ischemia. J Reconstr Microsurg 1992;8(6):4558. [30] Wei FC, Chang YL, Chen HC, et al. Three successful digital replantations in a patient after 84, 86 and 94 hours of cold ischemia time. Plast Reconstr Surg 1988;82:436. [31] Epstein W, Chen HC, Chuang CC, Chen HT. Microsurgical reconstruction of distal digits following mutilating hand injuries: results in 121 patients. Br J Plast Surg 1993;46:1816. [32] Morrison WA, MacLeod AM, OBrien B. Digital reconstruction in the mutilated hand. Ann Plast Surg 1982;9(5):392. [33] Wei FC, Colony LH, Chen HC, et al. Combined second and third toe transfer. Plast Reconstr Surg 1989;85:651. [34] Wei FC, Chen HC, Chuang CC, et al. Simultaneous multiple toe transfers in hand reconstruction. Plast Reconstr Surg 1988;81:366. [35] Wei FC, Epstein D, Chen HC, et al. Microsurgical reconstruction of distal digits following mutilating hand injuries: results in 121 patients. J Plast Surg 1992;46:1816. [36] Peacock K, Tsai TM. Comparison of functional results of replantation versus prosthesis in a patient with bilateral arm amputation. Clin Orthop Rel Res 1987;214:1539. [37] Graham B, Adkins P, Tsai TM, et al. Major replantation versus revision amputation and prosthetic tting in the upper extremity. A late functional outcomes study. J Hand Surg 1998;l23: 78391. [38] Soling M, Bajec J, Gang RK. Salvage of a mutilated hand using various microsurgical procedures. J Hand Surg 1991;16B(2):1624.

Hand Clin 19 (2003) 1731

Biomechanics and hand trauma: what you need

Steven L. Moran, MDa,*, Richard A. Berger, MD, PhDa,b
Division of Plastic Surgery, Division of Hand and Microsurgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA b Department of Orthopaedic Surgery, Mayo Medical School, Rochester, MN 55905, USA
a

Mutilating hand injuries pose many challenges to the hand surgeon. The variety and severity of these injuries has led to the development of several grading scales, ow charts, and algorithms to help the surgeon organize his or her treatment plan [1 4,112]. These tools help the surgeon in preparation for surgery, but fail to predict hand function following reconstruction accurately. It can be agonizing for the hand surgeon, especially the young hand surgeon, intraoperatively to contemplate accurately the functional loss imposed by immediate joint fusion or digital amputation. Heroic attempts are often made to salvage joints and digits, whose loss results in little functional decit. In addition, these severely injured ngers and joints often become sti and insensate, requiring delayed amputations. This not only prolongs patient recovery but also prolongs the surgeons anxiety. Many articles dealing with the mutilated hand contain experience-based protocols and reference previous anecdotal reports [58]. Are there any biomechanical principles of hand dynamics that could help in deciding what must be preserved and what can be discarded? Unfortunately, biomechanical studies involving mutilating hand injuries are scarce. This article establishes a biomechanical foundation for determining what anatomic components are needed for hand function. The essentials In its most elemental form, the hand is composed of a stable wrist and at least two digits that

can oppose with some power. One digit should be capable of motion so it can grasp objects. The other digit need only act as a stable post against which the movable digit can pinch. To allow for prehensile movements the digits require some form of cleft to divide them, which allows for the accommodation of objects. The digits need to be sensate and pain free or they provide little benet over prosthesis [6,7,9]. Requirements for functional sensation have been dened as two-point discrimination of less than 10 to 12 mm [10]. The hand allows for prehension, which is the ability to grasp and manipulate objects. As dened by Tubiana et al [11], prehension may be dened as all the functions that are put into play when an object is grasped by the handsintent, permanent sensory control, and a mechanism of grip. Prehension requires that the hand be able to approach, grasp, and release an object [11,12]. If only two sensate digits remain to oppose each other, some prehension is possible. In terms of biomechanical motion the hand performs approximately seven basic maneuvers, which make up most hand function: 1. Precision pinch (terminal pinch). This involves exion at the distal interphalangeal (DIP) joint of the index and at the interphalangeal joint (IP) joint of the thumb. The ends of the ngernails are brought together as in lifting a paper clip from a tabletop (Fig. 1). 2. Oppositional pinch (subterminal pinch). The pulp of the index and thumb are brought together with the DIP joints extended. This allows for force to be generated through thumb opposition, rst dorsal interosseous contraction, and index profundus exion. This is often measured with a dynamometer (Fig. 2).

* Corresponding author. E-mail address: moran.steven@mayo.edu (S.L. Moran).

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. doi:10.1016/S0749-0712(02)00130-0

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Fig. 1. Precision pinch (terminal pinch).

3. Key pinch. The thumb is adducted to the radial side of the middle phalanx of the index nger. Key pinch requires a stable post (usually the index nger), which has adequate length and a metacarpal phalangeal (MP) joint, which can resist the thumb adduction force (Fig. 3). 4. Directional grip (chuck grip). The thumb, index, and long nger come together to surround a cylindrical object. When using this grip, a rotational and axial force is usually applied to the held object (ie, using a screwdriver) (Fig. 4). 5. Hook grip. This requires nger exion at the IP joints and extension at the MP joints. It is the only type of functional grasp that does not require thumb function. This grip is used when one lifts a suitcase (Fig. 5). 6. Power grasp. The ngers are fully exed while the thumb is exed and opposed over the other digits, as in holding a baseball bat. Force if applied through the ngers into the palm (Fig. 6).

Fig. 3. Key pinch.

7. Span grasp. The DIP and proximal interphalangeal (PIP) joints ex to approximately 30 degrees and the thumb is abducted. Force is generated between the thumb and ngers, distinct to power grasp where force is generated between the ngers and the palm. Stability is required at the thumb MP and IP. This grip is used to lift cylindrical objects (Fig. 7) [11,13,14]. Postoperatively, the hands ability to adopt these positions and exert force through them impacts how well the patient rehabilitates. These maneuvers are predicated on good sensation in the ngers and thumb. Through the preoperative history, the hand surgeon can determine which hand functions benet the patient most in

Fig. 2. Oppositional pinch (subterminal pinch).

Fig. 4. Directional grip (chuck grip).

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Fig. 5. Hook grip.

Fig. 7. Span grasp.

returning to their previous employment or activities, and direct the reconstruction appropriately. Many classication schemes divide hand trauma into dorsal, volar, radial, and ulnar injuries [1,3]. When assessing the eects of mutilating trauma on hand mechanics, however, it may be easier to think of the hand as containing four functional units: (1) the opposable thumb; (2) the index and long nger, whose stable basal joints serve as xed posts for pinch and power functions; (3) the ring and small nger, which represent the mobile unit of the hand; and (4) the wrist. It may also help to think of only two major forms of hand motion, as opposed to seven: thumb-nger pinch and digitopalmar grip. Pinch requires preservation of the thumb unit and a stable post. If the patient is able to add a third digit to pinch, they can achieve more precision. Pinch function tends to be preserved when the median nerve is intact and the thumb

and index-long units of the hand are salvageable. Without median nerve function, thumb sensation and thenar function are lost, making ne motor movements negligible. In comparison, ulnar nerve function and the ring-small nger unit are more important for digitopalmar grip, where exion and sensation in the ulnar digits are essential. Thumb preservation is also important in power grasp to provide stability and control of directional forces. With these principles in mind this article now examines how digital loss aects hand function. The biomechanical impact of amputation Partial or complete amputations are present in most mutilating hand injuries. It has been recommended that immediate amputation be performed when four of the six basic digital parts (bone, joint, skin, tendon, nerve, and vessel) are injured [8,15 20]. It is important to consider amputation in these situations because long-term stiness and pain in a salvaged digit can severely hamper the rehabilitation of the remaining hand. When performing an amputation, however, one should understand how digital loss impacts overall hand function. The thumb The functional importance of each digit has been debated. If one were to prioritize the digits to be saved following mutilating injury, the thumb, with its importance in prehension and in all forms of grasp, takes top priority [109]. It provides 40% of overall hand function in the uninjured setting [2123]. Following mutilating trauma, when digits are missing or sti, the thumb can account for greater than 50% of hand function [24]. Its uniqueness and versatility in humans is caused by the

Fig. 6. Power grasp.

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position of the thumb axis. The thumb axis is based at the trapeziometacarpal (TMC) joint and is pronated and exed approximately 80 degrees with respect to the other metacarpals in the hand [25]. This positioning allows for circumduction, which permits opposition [2629]. Opposition of the thumb is necessary for all useful prehension and its preservation provides the basis for successful salvage procedures. Opposition of the thumb is the result of angulatory motion, which is produced through abduction at the TMC joint, and exion and rotation of the TMC and MP joints [30]. Multiple muscles are required for functional opposition. These include the abductor pollicis brevis, the opponens pollicis, and the supercial head of the exor pollicis brevis. These muscles act simultaneously on the TMC joint and the MP joint. The abductor pollicis brevis provides the major component of opposition, with the opponens pollicis and exor pollicis brevis providing secondary motors for opposition. All measures should be directed toward preserving or reconstructing the abductor pollicis brevis if possible [25,2832]. The extensor pollicis longus (EPL) and adductor pollicis (ADD) are antagonists to thumb opposition providing a supinating extension and adduction force.

The priorities of thumb reconstruction vary with the level of amputation, but at all levels reconstruction should attempt to restore opposition and pinch (Fig. 8). Injuries distal to the IP joint (zone 1 injuries) may produce little functional decit, because oppositional length tends to be maintained [33,34]. Residual insensibility and dysesthesia from trauma produce more functional problems at this level than the mechanical loss of length [35,36]. Subterminal pinch and precision pinch are compromised if an unstable or painful scar is present at the thumb remnant. Loss of the distal phalanx and IP joint (zone 2 injuries) may also not require reconstruction. Function may be preserved if TMC and MP motion is maintained [37]. Level three injuries, through the level of the MP, are the most common and do represent a signicant loss of function. Unreconstructed injuries result in a decrease in pinch dexterity and grip strength [38]. The MP joint of the thumb has no other mechanical equivalent in the hand. It has three degrees of freedom; it represents a ball and socket joint in extension, but when the joint is exed, the tightening of the collateral ligaments causes the MP joint to function more like a hinge. The intrinsic muscles provide motion but also provide dynamic stability to the joint.

Fig. 8. Diagram depicting levels of thumb injury, as originally described by Hentz [31]. Zone 1 injuries result in tissue loss distal to the IP joint. Zone 2 injuries result in thumb loss distal to MP joint. Zone 3 injuries result in loss of the MP joint but preservation of thenar musculature. Zone 4 injuries occur distal to TMC joint with loss of thenar musculature. Zone 5 injuries result in loss of the TMC joint. The zone of injury determines reconstructive priorities.

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In injuries proximal to the MP joint one may proceed with a free toe transfer, which is the gold standard. The great toe metatarsal phalangeal joint can reproduce the exion and extension arc of the MP joint, but fails to reproduce the MP joints 15 to 20 degrees of supination [35]. Functional opposition is also possible with a toe wraparound ap. This reconstruction only allows for TMC motion. Excellent results have been obtained when the fusion angles with bone graft were 30 degrees of exion and 45 degrees of internal rotation. These fusion angles allowed for pinch between all ngers and produced pinch and grip strengths of 60% and 97%, respectively [39]. Nonmicrosurgical methods for reconstruction of level three defects can include deepening of the rst web space, but any injury to the adductor or thenar musculature should be signicantly discouraged in an already traumatized thumb. Level four injuries result in damage to the thenar muscles, with resultant instability to the TMC joint. This produces a major stumbling block in thumb reconstruction, because TMC stability is required for any successful thumb reconstruction. Injuries at this level often require some form of soft tissue reconstruction for restoration of opposition and pinch [38,40]. In its most primitive form pinch can be recreated, as in the tetraplegic patient, with fusion of the IP and MP and reconstruction of the adductor musculature. For reconstruction of oppositional pinch, however, tendon transfers may be necessary. In a study by Cooney et al [27], muscle cross-sectional area and moment arm analysis were used to determine the best donor muscle for oppositional transfer. The exor digitorum supercialis (FDS) of the long nger and the extensor carpi ulnaris (ECU) muscles closely approximated thenar muscle strength and potential excursion. Abduction from the palm was greatest after transfer of the FDS from the long and ring ngers and after ECU and extensor carpi radialis longus (ECRL) transfers. Pulley location was found to inuence the motion and strength of transfers in both the exion and abduction planes. Both Bunnell [41] and Cooney et al [27] stress the importance of directing the force of the transfer toward the pisiform. Transfers that are distal to the pisiform, such as those using the extensor digiti minimi (EDQ) or abductor digiti minimi (ADQ), produce more exion than abduction. Transfers proximal to the pisiform, such as the FDS using the exor carpi ulnaris (FCU) loop as a pulley, produce more abduction and less metacarpal exion (Fig. 9).

Level ve injuries represent a loss of the TMC joint. In these cases restoration of TMC mobility is probably best achieved by index ray pollicization, if available. The TMC joint is mechanically equivalent to a universal joint [28,30,42]. The TMC joint allows for thumb circumduction and thumb extension with associated supination, and pronation with thumb exion. The TMC joint is very complex because of its inherent instability at the radial aspect of the wrist with no bony stabilizers proximal (mobile scaphoid). This inherent instability accounts for the large number of ligamentous supports that surround the joint (Fig. 10.). There are ve major internal ligamentous stabilizers of the TMC joint: (1) dorsal radial ligament, (2) posterior oblique ligament, (3) rst intermetacarpal ligament, (4) ulnar collateral ligament, and (5) the anterior oblique ligament. The dorsal radial ligament prevents lateral subluxation. The posterior oblique ligament provides stability in exion, opposition, and pronation. The rst intermetacarpal ligament is taut in abduction, opposition, and supination; it holds the rst metacarpal tightly against the second metacarpal. The intermetacarpal ligament is joined by the ulnar collateral ligament, which prevents lateral subluxation of the rst metacarpal on the trapezium and controls for rotational stress. The base of the index metacarpal should be spared during any type of ray resection to preserve the intermetacarpal ligament [43,44]. The fth and most important ligament is the volar anterior oblique ligament

Fig. 9. Diagram depicting the use of the supercialis tendon from the long nger for restoration of thumb opposition. Tendon transfers directed proximal to the pisiform tend to produce greater metacarpal abduction and less metacarpal exion as compared with transfers directed distal to the pisiform. The supercialis tendons from the long and ring ngers closely approximate the excursion and strength of the original thenar musculature, and provide for an ideal tendon for transfer. FDS exor digitorum supercialis; FCU exor carpi ulnaris; P pisiform.

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Fig. 10. Diagram of the trapezio-metacarpal joint showing the outlay of the dorsal and volar ligaments. Special attention must be given to preservation of this joint for adequate thumb stability. The most important ligaments for reconstruction and preservation are the dorsal radial ligament (DRL), posterior oblique ligament (POL), ulnar collateral ligament (not depicted), rst intermetacarpal ligament (IML), and the anterior oblique ligament, deep and supercial heads (DAOL and SAOL). APL abductor pollicis longus; DIML dorsal intermetacarpal ligament; DT-II MC dorsal trapezio-II metacarpal; DTT dorsal trapeziotrapezoid.

with its deep and supercial components. The ligament arises from the volar tubercle of the trapezium and inserts on the volar aspect of the thumb. The anterior oblique ligament is taut in extension, abduction, and pronation; it controls pronation stress and prevents radial translation. The deep anterior oblique ligament serves as a pivot point for the TMC joint and guides the metacarpal into pronation while the thenar muscles work in concert to produce abduction and exion. These bers limit ulnar translocation of the metacarpal during palmer abduction while working with the supercial anterior oblique ligament to constrain volar subluxation of the metacarpal. The anterior oblique, intermetacarpal, and dorsoradial ligaments are the most critical for preservation and reconstruction [4244]. The index nger The index nger may be of next highest importance because of its exion and extension inde-

pendence, its ability to abduct, and its closeness to the thumb. It has a major role in precision pinch and directional grip [11,13,45,46]. A good range of motion for the index nger is more important than length. Amputation through the PIP leaves all remaining stump exion to the control of the intrinsics. This allows for exion to approximately 45 degrees. It may be shortened to the end of the proximal phalanx and still participate in directional grip, span grasp, and lateral pinch [13]. The body, however, is quick to bypass the digit for the long nger if it becomes insensate or sti. The long nger replaces the index for terminal and subterminal pinch if amputation exists below the DIP level. Elective loss of the index ray has been well studied. Murray et al [47] studied patients who underwent elective ray amputation. The study found that power grip, key pinch, and supination strength were diminished by approximately 20% following surgery. Patients with persistent dysesthesia following ray amputation experienced larger losses in grip strength. In addition, pronation strength was diminished by 50% following ray resection. Pronation strength is used for directional grip. This large decrease in pronation strength is caused by a shortening of the palms lever arm. In the intact hand, the width of the grip extends from the hypothenar region to the index nger. The ulnar aspect of the palm represents the internal fulcrum and the radial aspect of the palm represents the external fulcrum of movement. With the loss of the index nger ray the fulcrum is decreased by approximately 25% (Fig. 11). This results in a loss of stability and a decrease in mechanical advantage. Despite the loss of strength, all patients in this study, without postoperative dysesthesia, believed that their overall hand function had been improved, especially in regard to prehension with the thumb [47]. This suggests that the ability to perform precise activities is more important for postoperative patient satisfaction than the preservation of grip strength. In comparison, a recent study of patients with traumatic proximal phalanx amputations of the index nger and patients with elective index ray resections found that patients with amputation through the proximal phalanx demonstrated a better functional outcome when assessed with the DASH questionnaire. A 30% decrease in pinch and grip strength was seen in both groups. Cosmesis was believed to be better with ray amputation [48]. Overall, it seems that a remaining proximal phalanx stump does provide a benet in terms of grip

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Fig. 11. Diagram showing the resultant eects of ray excision on pronation and supination strength. Resection of the metacarpal narrows the palms. This shortens the palms lever arm and decreases the hands mechanical advantage during pronation and supination.

strength and overall hand function. In light of the high rate of postoperative dysesthesia associated with ray resection, it seems that immediate index ray resection should be reserved for very proximal injuries where there is little chance of postoperative MP motion. The long and ring ngers The long nger does provide the most nger exion force when tested individually [49,50]. Its central position allows it to participate in power grip and precision grip. Patients are easily able to substitute this digit for terminal and subterminal pinch following the loss of the index nger. The middle ray does lack the specialization of the rst dorsal interosseous muscle when performing pinch functions. Transfer of the rst dorsal interosseous to the insertion of the second dorsal interosseous has been suggested following rst ray resection; however, studies have shown that this does not signicantly increase pinch strength [47,51]. In addition, this transfer can lead to the development of an intrinsic plus deformity in the long nger [47,52]. The ring nger has less strength than either the index or long. It is also rarely used for precision pinch or grip. As an individual digit, Tubiana et al [11] believe the ring ngers loss leaves the least functional decit in the hand. When this nger is

combined with the small as a functional unit, however, it can provide for adequate power grip and replace the index and long for pinch maneuvers should both digits be lost. Central ray deletion, or loss of both ring and long ngers, may produce scissoring of the remaining digits because of instability of the transverse metacarpal ligament and compromised interosseous function. Three-point chuck pinch is compromised, as is hand competence, because small objects may fall through the central defect [53 55]. Acute central ray resection with repair of the transverse metacarpal ligament may still result in scissoring of the neighboring digits, inadequate closure of the gap, and loss of abduction of the small ray [54,56,57]. In cases of central digital loss, a ray transposition may alleviate hand incompetence and reduce scissoring of the digits. Results of strength testing following ray transposition for central digital loss have found an average decrease in grip and pinch strength of 20%, with larger decreases in function being seen for index to long transfer when compared with small to ring transfers. Loss of motion was only 9% following transfer [56]. Although ray amputation may be indicated in cases of central digital loss, it seems most prudent to perform this procedure in a delayed fashion, after a discussion has been carried out with the patient regarding his or her needs with regard to hand strength and motion. The small nger The small nger has the least strength in exion; however, its loss can have broader implications on hand function. In digitopalmar grip the fth ray presses objects and tools into the palm. This is caused by the additional motion provided by its carpal-metacarpal (CMC) joint, which can move forward 25 degrees. Stabilization is also added by the hypothenar muscles, which augment the exion of the rst phalanx of the small nger. In addition, the small ngers abduction capabilities signicantly enhance span grasp. Tubiana et al [11] believe the fth nger, with its metacarpal, has the greatest functional value after the thumb. Digital loss For the most part single digit amputation, with the exception of the thumb, does not result in the loss of essential hand function. Brown [18] studied 183 surgeons who suered partial or total digital amputations. Only four surgeons were unable to continue operating following their injuries. Most

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surprising was the nding that 15 surgeons who had experienced thumb amputations through the metacarpal or MP joint level were able to continue operating with only minimal adaptation in their surgical practice. Brown [18] concluded that the motivation of the patient is more important than the actual number of retained digits when attempting to predict functional outcome for digital amputation. Of note, none of these surgeons had to perform repetitive strenuous activity with the hand and grip strength presumably was not a major issue. Unlike single-digit amputation, the amputation of several digits still remains a challenging problem. Unfortunately, in the mutilated hand, multiple digital losses are the norm, because severely crushed and avulsed digits preclude replantation. Preservation of the thumb and a single digit allows for some prehensile grasp, but for optimal function the reconstruction of an additional digit is recommended [24,5860]. The preservation or reconstruction of the thumb and two digits allows for the possibility of chuck pinch, which is stronger than subterminal pinch. The use of a third digit confers lateral stability in power pinch. A third digit also allows the patient to perform hook grip and power grasp. Span grasp is now possible because functional palmar space is increased allowing for grasp of larger objects [24,5860]. Wei and Colony [24] have found it preferable to place toes next to remaining mobile ngers or in the interval between them. They believe the adjacent digits contribute to cosmesis, help coordinate movement, and smooth oppositional contact. In injuries where there is loss of all ngers but sparing of the thumb, reconstructive goals should attempt to maintain useful thumb web space and an opposable ulnar post of adequate length. Additional digits may be created with microvascular toe transfer [24,5962]. Other options include the transfer of remaining functional digits to more useful positions. Transferring salvageable digits to the ulnar side of the hand maintains the width of the palm, and allows for power grasp and the incorporation of pinch [21,22,24]. The radial placement of reconstructed digits is more cosmetically pleasing but fails to take advantage of the added power provided by intact hypothenar musculature and the motion provided by the fth CMC joint. In cases where there has been loss of all digits including the thumb, microvascular reconstruction of the thumb is required with the additional creation of a stable ulnar post. The previous practice of constructing a cleft hand has been

shown to provide little benet for hand function. It often has no eective prehension or grasp and does not adequately compare with the results obtainable with microsurgical reconstruction [24,5962].

The biomechanical impact of fusion There are several instances where the severity of the trauma precludes any anatomic restoration of the joint surface. These situations may require fusion. Unfortunately, change in a single joint has implications on the balance of the entire digit, and the biomechanics of the hand. How do fusions impact overall hand function? Finger fusion Of all fusions, DIP fusions are well tolerated and probably impart the least detriment to hand function. Fifteen percent of intrinsic digital exion occurs at the DIP joint but the DIP joint contributes only 3% to the overall exion arc of the nger [63]. Recent mechanical testing has shown that after simulated DIP fusion of the index and middle nger, there is a 20% to 25% reduction in grip strength when compared with prefusion values. The decrease in grip strength may be secondary to the limited excursion of the profundus tendon following fusion; this can create a quadriga eect. It has been suggested that fusion in a more exed position creates additional slack in the profundus tendon, decreasing the loss of grip strength; however, this has not been shown clinically [64]. For most individuals, with the exception of musicians, arthrodesis is preferred over arthroplasty at the DIP level. The PIP joint produces 85% of intrinsic digital exion and contributes 20% to the overall arc of nger motion. Littler and Thompson [65] described this joint as the functional locus of nger function. PIP joint impairment can adversely aect the entire hand; however, a full range of PIP joint motion is not essential for hand function. An arc extending from 45 to 90 degrees can provide relatively normal function [66,108]. In addition, mild exor contractures at the PIP level can be compensated for through hyperextension of the MP joint. This allows the nger to move out of the plane of the palm when attempting to lay the hand at or when placing objects into the palm. A PIP fusion is often well tolerated in the index nger because the indexs relatively independent profundus function does not impose a signicant quadriga eect on the other ngers during power

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grasp. PIP fusion of the long nger, however, has been shown to decrease the excursion of all profundus tendons, reducing grip strength. PIP fusion restricts profundus excursion to a greater extent than DIP or MP fusion [47,67,68]. In a study by Lista et al [67], a signicant decrease in grip strength occurred when the PIP joints of the index and small nger were xed at less than 45 degrees and when the long and the ring were fused in a position of less than 60 degrees of exion. If both MP and PIP joints are injured, salvage of the MP joint through arthroplasty or other measures is preferred over PIP joint arthroplasty. Grip strength is decreased because of a quadriga eect, but prehension can be maintained as long as the thumb or border digit is capable of opposition. It is important to remember that two consecutive fusions increase stress at the next proximal joint, because of an increase in the lever arm working across the joint. This accelerates the degeneration of adjacent joints if they are also injured. Delayed arthroplasty of the PIP joints in cases of trauma maintains motion and improves grip strength [69]. Classic teaching has suggested that index PIP joint arthrodesis be performed instead of silicone arthroplasty, to provide stability for key pinch. Surface replacement arthroplasty, however, may provide adequate stability for index nger PIP arthroplasty. PIP stability has been preserved following surface replacement arthroplasty with loads up to 22 N in experimental cases where there was preservation of 50% of the index collateral ligaments [70]. The MP joints probably represent the most important joint for hand function. They contribute 77% of the total arc of nger exion [63, 65,66,71,72]. Unlike the giglymoid IP joint, which functions like a sloppy hinge joint, the condyloid MCP joint is diarthrodial, allowing for exionextension, abduction-adduction, and some rotation [71,7375]. Most prehension grips require that the digits extend and abduct at the MP joint [74,76]. Precision pinch requires exion, rotation, and ulnar deviation at the MP joint [73,74]. During pinch the radial intrinsics and the collateral ligament to the index must resist the stress applied by the thumb. According to the American Medical Associations Guide to the Evaluation of Permanent Impairment, fusion of the MP joint results in a 45% impairment of the involved nger [77]. Some have suggested that a single sti MP joint can impair the entire hands function [78]. A full range of motion, however, is not required for hand function. Most activities of daily living require

only 50% of normal joint motion [73,79,80]. Studies have shown that obtaining 35 degrees of motion at the MP is satisfactory if the arc of motion is within the functional range and the joint is stable [73]. Many rheumatoid patients who have had PIP and DIP fusions maintain a useful hand through the preservation of MP motion. Previously, MCP arthrodesis was recommended for border digits in heavy laborers; however, these indications may be reconsidered with the availability of new surface replacement arthroplasty [70,80]. Wrist fusion Although less common than nger fusion, immediate limited wrist fusion or total wrist fusion may be necessary following penetrating ballistic trauma, punch presstype injuries, or in cases of gross carpal instability. A stable wrist is necessary for power grasp. In addition, a stable wrist prevents the dissipation of nger exion and extension forces as tendons pass over the carpus. What are the requirements for a functional wrist and what eect does fusion have on wrist and hand function? The requirements for functional wrist motion have been debated. Palmer et al [81] found that the normal wrist had an average exion-extension arc of 133 degrees, but only 5 degrees of exion and 30 degrees of extension were needed for most activity. Brumeld and Champoux [82] found that 10 degrees of exion and 35 degrees of extension allowed one to complete the activities of daily living. Ryu et al [83], however, found in 40 normal patients that most activities of daily living could be accomplished with 40 degrees of exion, 40 degrees of extension, 10 degrees of radial deviation, and 30 degrees of ulnar deviation. Limited carpal fusions consist of intercarpal fusions and radiocarpal fusions (Fig. 12). Mechanical studies by Meyerdierks et al [84] show that fusions that cross the radiocarpal joint produce the greatest loss of motion. On average radiolunate, radioscapholunate, and radioscaphoid fusions decrease the exion extension arc by 55%. Recent studies have suggested that removal of the distal pole of the scaphoid in radiocarpal fusions unlocks the capitate, allowing unhindered midcarpal motion. In the laboratory setting this has produced exion extension arcs that are equivalent to normal wrist motion [85]. Fusions that cross the midcarpal joint result in the next largest loss of wrist motion. Scaphocapitolunate and

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Fig. 12. Diagram depicts the multiple sites for limited wrist fusions. (1) Four corner fusion or midcarpal fusion. (2) Scaphotrapezialtrapezoid (STT) fusion. (3) Radioscapholunate fusion (radiocarpal fusion). (4) Scaphocapitate (SC) fusion. (5) Lunotriquetral (LT) fusion. Fusions involving the radiocarpal joint result in the greatest loss of motion. Fusions involving the same carpal row result in a 12% to 15% loss of motion.

capitolunate fusion can produce a 35% loss of the exion and extension arc and up to a 31% loss of radial and ulnar deviation. Scaphotrapezialtrapezoid fusion produces a 23% decrease in the exion extension arc and 31% decrease in radial and ulnar deviation, whereas scaphocapitate fusion results in a 19% loss in the exion extension arc and a 19% loss in radial and ulnar deviation. Inclusion of the lunate within partial wrist fusions was found to nearly double the resultant loss of wrist motion when compared with fusions that did not include the lunate [84]. Fusion within the same carpal row tends to have a minimal eect on overall wrist motion, with average loss of only 12% of the exion and extension arc. The choice for total wrist fusion must be carefully contemplated. Removal of all wrist motion results in the loss of the benecial eect of tenodesis for any subsequent tendon transfer. In addition, wrist dorsiexion is important for pushing o, rising from a chair, and power grasp. In those cases where there is substantial carpal loss, however, fusion may be the only option. Wrist fusion can have a negative impact on MP motion and thumb motion presumably because of extensor adhesion [86]. A 25% decrease in grip strength may be seen [86,87]. Strength with key pinch, subterminal pinch, and directional grip are better maintained at approximately 85% of the normal side. Maximum preservation of power grip is found to occur in 15 degrees of extension and 15% of ulnar deviation [88]. Weiss et al [89] found that patients believed they were able to accomplish

85% of the activities of daily living following total wrist fusion. Patients were least able to use a screwdriver and perform perineal care. Overall, skills that presented the most diculty were those that required signicant wrist exion in a small space, where compensatory movements by the shoulder and elbow are eliminated. In severely mutilating trauma, the preservation of wrist mobility imparts some function to a forearm stump with the addition of prosthesis. Modern prosthetic techniques allow the incorporation of the prosthesis to the wrist so that proximal straps and attachment to the elbow are unnecessary. Preservation of wrist motion also eliminates the need to incorporate a wrist articulation into the prosthetic unit [6,17,90]. In addition, preservation of the distal radio-ulnar joint (DRUJ) further improves function, because 50% of forearm rotation can be transferred into the prosthesis [91].

Tendon requirements Tendon injuries are present, in some aspect, in all cases of mutilating hand trauma. Tendons may be divided, avulsed, or have large segmental gaps that prohibit immediate repair. It is important to understand how tendon loss aects hand function. Extensor tendons Multiple authors have pointed to the diculties in obtaining excellent results with extensor tendon

S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

27

injuries [9294]. The supercial position of the extensor tendons, their complex architecture, and paucity of surrounding subcutaneous tissue often result in postoperative adhesions, which limit exion and produce extensor lags [94,111]. It has been shown that injuries in the distal zones (1 through 5) result in poorer outcomes and greater postoperative extension decits. Extensor tendon injuries also carry a signicantly worse prognosis when associated with underlying fractures [19,94]. The extensor mechanism has less excursion than the exor system [95]. In addition, it has less ability to compensate for signicant shortening because of the interconnections between the intrinsic and extrinsic mechanisms. Extensor tendon excursion in the region of the PIP joint is only between 2 and 5 mm. There is little margin for adherence or shortening if a reasonable result is expected [95,96]. If signicant shortening takes place following repair and the lateral bands and oblique retinacular ligament are intact, one can opt to leave the central extensor mechanism unrepaired. This may avoid exion loss, without producing a PIP or DIP extension lag. Loss of long extensor function can destabilize the MP joint, however, resulting in a loss of active nger abduction-adduction [97]. Further biomechanical studies are required to determine the absolute requirements for functional nger extension. Maximizing intrinsic function helps in the preservation of full nger extension. Intrinsic function can be compromised after metacarpal fractures. Metacarpal shortening or fracture angulation beyond 30 degrees can result in a shortening of intrinsic muscle ber length [98]. Muscle ber length determines the potential excursion of the intrinsic tendon [31]. With metacarpal malreduction or shortening, potential excursion force is wasted as slack in the muscle. Starting muscle tension is also decreased. Both of these factors decrease intrinsic tendon excursion and joint motion [98,99]. This loss of intrinsic function emphases the need for preservation of metacarpal length and the anatomic reductions of fractures in cases of signicant hand trauma. Extensor tendon injuries proximal to the junctura produce less postoperative decits. Quaba et al [100] examined long-term function in patients who had lost nger extensors in zones 6 and 7. In the nine patients studied, no attempt was made to reconstruct the extensor tendons. Soft tissue coverage alone was provided to the dorsum of the hand. In long-term follow-up, there was a 26% decrease in total active nger motion, most

evident at the MP joint. DIP and PIP extension were preserved because of intact intrinsic function. Active motion at the MP joint was only 60% of normal. Surprisingly, patients reported a 90% satisfaction rate with hand function. Diculty was noted with tying knots and unscrewing lids. All patients did maintain the extension of their thumb and wrist extensors. This emphasizes the importance of thumb abduction and extension for prehensile function when MP motion is limited. The ability to move the thumb out of the palm allows for the accommodation and prehension of objects even with a moderate digital exion stance. The loss of the central extensors decreases power grip by approximately 30%, whereas severance of wrist extensors results in a 50% reduction in grip strength [97,100]. Flexor tendons Loss of profundus function prevents subterminal and terminal pinch, unless the DIP joint is fused. If the profundus tendon becomes adherent to the remaining sublimis tendon or fracture callus it may tether the profundus tendons of adjacent uninjured ngers, preventing full digitopalmar grip [14,101]. Classically this quadriga eect applies only to the long through small ngers, because of their common muscle belly. The quadriga eect can also extend to the index nger, however, because heavy synovium at the level of the carpal tunnel, termed the bromembranous retinaculum, can link the index profundus tendon to the other three [102]. Power grip and forceful pinch are still possible with supercialis loss. Loss of the supercialis with preservation of the profundus tendon may result in hyperextension of the PIP joint in supple individuals. This phenomenon is called recurvatum. In exaggerated cases, this may produce delayed nger exion. Patients may have to help the involved nger initiate PIP exion with the adjacent digits before active exion can ensue. Recurvatum can be avoided by leaving the portion of the supercialis distal to the chiasm [14]. With loss of both profundus and supercialis tendons, exion of the MP joint to 45 degrees may be possible if intrinsic function is intact. Retraction of the profundus tendon, following more proximal amputations, may result in shortening and contracture of the corresponding lumbrical. During exion, contraction of the profundus muscle belly places stretch on the shortened lumbrical, which results in paradoxical extension of

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S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

the PIP joint. This is termed the lumbrical plus deformity. This deformity can be oset by dividing the lumbrical or suturing the profundus tendon to the exor sheath in a relaxed position [14,110]. With multiple digital amputations, retraction of the exor mechanism can lead to lumbrical migration into the carpal tunnel. Proximal lumbrical migration may then lead to compression of the median nerve and development of carpal tunnel syndrome [6,103]. These patients may not present with classic digital paresthesias if there has been signicant digital soft tissue loss. Patients may instead complain of generalized pain within the wrist and palm, which may be exacerbated by the standard provocative maneuvers. Carpal tunnel release should be pursued in such instances. During any exor tendon surgery it is important to preserve the A2 and A4 pulleys [104107]. If either is divided the exor tendon moves away from the phalanx, leading to bowstringing. The A2 and A4 pulleys are located over the bony shafts of the proximal and middle phalanx. This anatomic conguration prevents the bowstringing that occurs with joint exion and the bowstringing that can occur over the phalanx shaft. Palmer plate pulleys (A1, A3, and A5) have a variable relationship to the joint axis depending on joint position, and restrain only the joint-type of bow stringing. They also shorten up to 50% with nger exion, which reduces their eciency. Cruciate pulleys vary the most in their anatomic position and have little eect on restraining bowstringing [105,107]. Bowstringing increases the exion moment arm at the PIP and MP joints. A longer moment arm allows the exor mechanism to overcome the extension forces, resulting in a exion deformity. A longer moment arm also means the tendon must move through a longer distance to obtain the same motion at the joint, decreasing mechanical eciency. As in the quadriga eect, grip strength is decreased because full excursion is now limited [107]. Summary Mutilating hand trauma presents the surgeon with many reconstructive challenges. This article establishes some biomechanical guidelines to help the surgeon evaluate the hand trauma patient. Through a basic understanding of hand biomechanics, the surgeon may access more accurately what motion and function can best be salvaged. By understanding how amputation, fusion, and

tendon loss impact on postoperative hand motion, the surgeon can better focus his or her reconstructive eorts to achieve the highest functional outcome for the patient. References
[1] Campbell DA, Kay SP. The hand injury severity scoring system. J Hand Surg [Br] 1996;21:2958. [2] German G, Sherman R, Levin LS. Decisionmaking in reconstructive surgery (upper extremity). Berlin: Springer; 2000. [3] Tomaino MM. Treatment of composite tissue loss following hand and forearm trauma. Hand Clin 1999;15:31933. [4] Weinzweig J, Weinzweig N. The tic-tac-toe classication system for mutilating injuries of the hand. Plast Reconstr Surg 1997;100:120011. [5] Brown HC, Williams HB, Woolhouse FM. Principles of salvage in mutilating hand injuries. J Trauma 1968;8:31932. [6] Burkhalter W. Mutilating injuries of the hand. Hand Clin 1986;2:4568. [7] Hentz VR, Chase RA. The philosophy of salvage and repair for acute hand injuries. In: Wolfort FG, editor. Acute hand injuries: a multispecialty approach. St. Louis: Mosby; 1979. [8] Michon J. Complex hand injuries: surgical planning. In: Tubiana R, editor. The hand, vol. 2. Philadelphia: WB Saunders; 1985. p. 196213. [9] Entin MA. Salvaging the basic hand. Surg Clin North Am 1968;48:106281. [10] Moberg E. Reconstructive hand surgery in tetraplegia, stroke, and cerebral palsy: basic concepts in physiology and neurology. J Hand Surg [Am] 1976;1:2934. [11] Tubiana R, Thomine J, Mackin E. Movements of the hand and wrist. In: Tubiana R, Thomine J, Mackin E. Examination of the hand and wrist. St Louis: Mosby; 1996. p. 40125. [12] Radischong P. Les problemes fondamentaux du retablissement de la prehension. Ann Chir 1971; 25:927. [13] Duparc J, Alnot J-Y, May P. Single digit amputations. In: Campbell DA, Gosset J, editors. Mutilating injuries of the hand. Edinburgh: Churchill Livingstone; 1979. p. 3744. [14] Smith P. Listers the hand. London: Churchill Livingstone; 2002. [15] Arellano AO, Wegener EE, Freeland AE. Mutilating injuries to the hand: early amputation or repair and reconstruction. Orthopedics 1999;22:6834. [16] Beasley RW, DeBeze G. Upper limb amputations and prostheses. In: Aston SJ, Beasley RW, Thorne CHM, editors. Grabb and Smith: plastic surgery. 5th edition. Philadelphia: Lippincott-Raven; 1997. p. 100920. [17] Brown P. Sacrice of the unsatisfactory hand. J Hand Surg 1979;4:41723.

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S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731 carpalphalangeal implants. J Bone Joint Surg Am 1976;58:4837. Flatt AE. Care of the rheumatoid hand. 4th edition. St. Louis: Mosby; 1983. Krishnan J, Chipchase L. Passive and axial rotation of the metacarpophalangeal joint. J Hand Surg [Br] 1997;22:2703. Zancolli E. Structural and dynamic bases of hand surgery. 2nd edition. Philadelphia: JB Lippincott; 1983. American Medical Association. Guides to the evaluation of permanent impairment. 2nd edition. Chicago: American Medical Association; 1984. Hagert CG, Branemark PI, Albrektsson T, et al. Metacarpalphalangeal joint replacement with osseointegrated endoprostheses. Scand J Plast Reconstr Surg 1986;20:20718. Doi K, Kuwata N, Kawai S. Alumina ceramic nger implants: a preliminary biomaterial and clinical evaluation. J Hand Surg [Am] 1984;9:7409. Linscheid RL, Beckenbaugh RD. Arthroplasty of the metacarpal phalangeal joint. In: Morrey BF, An K-N, editors. Reconstructive surgery of the joints. 2nd edition. New York: Churchill Livingstone; 1996. p. 287. Palmer AK, Werner FW, Murphy D, Glisson R. Functional wrist motion-a biomechanical study. J Hand Surg [Am] 1985;10:3946. Brumeld RH, Champoux JA. A biomechanical study of normal functional wrist motion. Clin Orthop 1984;187:235. Ryu J, Cooney III WP, Askew LJ, et al. Functional ranges of motion of the wrist joint. J Hand Surg [Am] 1991;16:40919. Meyerdierks EM, Mosher JF, Werner FW. Limited wrist arthrodesis; a laboratory study. J Hand Surg [Am] 1987;12:5269. McCombe D, Ireland DCR, Mcnab I. Distal scaphoid excision after radioscaphoid arthrodesis. J Hand Surg [Am] 2001;26:87782. Field J, Herbert TJ, Prosser R. Total wrist fusion. J Hand Surg [Br] 1996;21:42933. Labosky DA, Waggy CA. Apparent weakness of the median and ulnar motors in radial nerve palsy. J Hand Surg 1986;11:52833. Pryce JC. The wrist position between neutral and ulnar deviation that facilitates the maximum power grip strength. J Biomech 1980;13:50511. Weiss AP, Wiedeman G, Quenzer D, et al. Upper extremity function after wrist arthrodesis. J Hand Surg [Am] 1995;20:8137. Childress DS, Hampton FL, Lambert CN, Thompson RG, Schrodt MJ. Myoelectric immediate postsurgical procedure: a concept for the tting the upper extremity amputee. Artif Limbs 1969; 13:5560. Wright TW, Hagen AD, Wood MB. Prosthetic usage in major upper extremity amputations. J Hand Surg [Am] 1995;20:61922.

[57] Steichen JB, Idler RS. Results of central ray resection without bony transposition. J Hand Surg. [Am] 1986;11:46674. [58] Tsai TM, Jupiter JB, Wol TW, Atasoy E. Reconstruction of severe transmetacarpal mutilating hand injuries by combined second and third toe transfer. J Hand Surg 1981;6:31928. [59] Wei FC, Chen HC, Chuang CC, et al. 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 [Am] 1986;11:340. [60] Wei FC, Chen HC, Chuang CC, Noordho MS. Simultaneous multiple toe transfers in hand reconstruction. Plast Reconstr Surg 1988;81: 36677. [61] Gorsche TS, Wood MB. Mutilating corn-picker injuries of the hand. J Hand Surg [Am] 1988; 13:4237. [62] Wei FC, Colony LH, Chen HC, Chuang CC, Noordho MS. Combined second and third toe transfer. Plast Reconstr Surg 1989;84:65161. [63] Littler JW, Herndon JH, Thompson JS. Examination of the hand. In: Converse JM, Littler JW, editors. Reconstructive plastic surgery, vol 6. Philadelphia: WB Saunders; 1977. p. 2973. [64] Morgan WJ, Schulz LA, Chang JL. The impact of simulated distal interphalangeal joint fusion on grip strength. Orthopedics 2000;23:23941. [65] Littler JW, Thompson JS. Surgical and functional anatomy. In: Bowers WH, editor. The interphalangeal joints. New York: Churchill Livingstone; 1987. p. 142. [66] Foucher G, Hoang P, Citron N, et al. Joint reconstruction following trauma: comparison of microsurgical transfer and conventional methods: a report of 61 cases. J Hand Surg [Br] 1986;11: 38893. [67] Lista FR, Neu BR, Murray JF, et al. Profundus tendon blockage (the quadrigia syndrome) in the hand with a sti nger. Presented at the 43rd annual meeting of the American Society for Surgery of the Hand. Baltimore, September, 1988. [68] Neu BR, Murray JF, MacKenzie JK. Profundus tendon blockage: quadriga in nger amputations. J Hand Surg [Am] 1985;10:87883. [69] Kleinert JM, Lister GD. Silicone implants. Hand Clin 1986;2:27190. [70] Linscheid RL, Murray PM, Vidal MA, Beckenbaugh RD. Development of a surface replacement arthroplasty for proximal interphalangeal joints. J Hand Surg [Am] 1997;22:28698. [71] Ellis PR, Tsai T. Management of the traumatized joint of the nger. Clin Plast Surg 1989;16:45773. [72] Swanson AB. Flexible implant arthroplasty for arthritic nger joints. J Bone Joint Surg Am 1972; 54:43555. [73] Beckenbaugh RD, Dobyns JH, Linscheid RL, et al. Review and analysis of silicone-rubber meta-

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Hand Clin 19 (2003) 3339

Antimicrobial management of mutilating hand injuries

R. Dow Homan, MDa, Brian D. Adams, MDb,*
b a Department of Orthopaedic Surgery, US Naval Hospital, 2080 Child Street, Jacksonville, FL 32214, USA Department of Orthopaedic Surgery, University of Iowa College of Medicine, Lower Level, Pappajohn Pavilion, 200 Hawkins Drive, Iowa City, IA 52242, USA

A mutilating injury, according to Miriam Websters dictionary, is one so severe that it cuts o or permanently destroys a limb or an essential part of it [1]. These complex injuries pose many challenges to the treating hand surgeon because they occur in a wide variety of environments and by a wide variety of mechanisms. They often require multiple visits to the operating room and complex reconstructive procedures. By denition, the nal outcome in the absence of complications is less than perfect, and infection during the course of treatment can signicantly compromise this nal result. Hand surgeons attempt to minimize the incidence of infection with careful assessment of patient risk factors and attention to preoperative planning, meticulous surgical technique, and close postoperative follow-up. In the United States, antibiotics are routinely used as one weapon in the hand surgeons infection prevention arsenal. However, the ecacy of this practice has not been well quantied, and limited information is available to guide the hand surgeon in choosing the correct antibiotic regimen. In this review, the literature pertaining to the use of antimicrobials in the setting of the mutilated hand is examined in an attempt to guide hand surgeons in their use and identify questions that remain. Background Antibiotic prophylaxis in surgery has remained a controversial topic since its inception earlier in this century [2,3]. Early studies in the 1950s
* Corresponding author. E-mail address: Brian-D-Adams@uiowa.edu (B.D. Adams).

reported in the general surgery literature noted the failure of prophylactic antibiotic administration to decrease the rate of postoperative infection [4,5]. Similar studies in the orthopedic literature demonstrated no benecial eects and potentially harmful eects in the use of perioperative antibiotics [68]. However, experimental work in the 1960s signicantly changed our views on the use of antibiotics to prevent surgical infections. A classic study by Burke demonstrated in a guinea pig model the important relationship between timing of administration and ecacy of antibiotic prophylaxis. He quantitatively and histologically demonstrated a greater ecacy of penicillin when administered before bacterial inoculation [9]. Subsequent clinical studies leave little doubt that prophylactic antibiotics decrease infection rates and shorten hospital stays in certain contaminated and clean contaminated surgical procedures, such as vaginal hysterectomy and colon surgery [10]. Bacteriology of the mutilated hand Although information from other surgical disciplines is helpful, one must be aware of the unique characteristics of mutilating injuries of the hand when considering antimicrobial use in this setting. The patient with a mutilated hand often presents with complex injuries to bone, joint, tendon, and neurovascular structures. These injuries most often involve the use of mechanical equipment in the home, on the farm, or in industry. A large number of potentially infective organisms can be found in these wounds. Two studies published from the same institution over a 5-year period have helped dene the complexity of determining

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. PII: 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 0 5 5 - 0

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the role of antibiotic therapy in this situation. In the rst article [11], the authors reviewed the bacteriology of 86 patients with mutilating hand injuries, 48 prospectively and 38 retrospectively, to determine the most common colonizing organisms and their susceptibility to antimicrobials. They identied 26 dierent pieces of equipment involved in the injuries and divided the injuries into those caused by farm implements and those caused by home or industry machinery. Several hundred bacterial isolates and 10 fungal isolates were examined, and 22 dierent bacterial species were cultured. The bacteriology of farm-related injuries diers signicantly from that of homeand industry-related injuries. In farm-implement injuries, roughly 40% of isolates were gram positive, and 60% were gram negative. Of the grampositive isolates, most were penicillin sensitive, and those that were not were sensitive to methicillin, cephalothin, and erythromycin. Of the 130 gram-negative isolates, only 10 were noted to be gentamicin resistant, although a small number of isolates obtained before 1969 were not tested with gentamicin. In injuries occurring at home or in industry, roughly 70% of isolates were gram positive, and 30% were gram negative. Most of the injuries with gram-negative isolates involved a lawnmower or gardening equipment. Antibiotic susceptibilities were similar except that all gramnegative isolates were gentamicin sensitive. The authors noted that organisms isolated before the initiation of treatment were signicantly dierent from those isolated after treatment was initiated. In some cases, the emergence of resistant organisms was noted. Only one serious wound infection developed among 86 patients in which bacterial isolates were recovered, and the authors state that the surgical wound management in that patient was inappropriate. Seventy of the 86 patients received prophylactic antibiotics by a variety of regimens. The second study, published 5 years later by four of the same authors, reported on the prospective analysis of 64 traumatic wounds of the hand and forearm from which a tissue sample from the time of presentation was taken for immediate quantitative smear and quantitative culture. The injury was described as mutilating in 12 cases. A variety of gram-positive and gram-negative organisms were isolated. Antibiotics were given on presentation to 36 of the 64 patients. The authors found that quantitative smears and cultures of the wound on presentation were helpful in predicting the development of wound sepsis. The authors

noted the development of wound sepsis in 23 of 64 patients, including 48% of the crush and mutilating injuries, which contrasts signicantly with the 1% infection rate reported from the same institution mentioned above [12]. Dening the incidence of infection after these injuries is dicult, as is the prediction of infecting organism. Not all authors have found initial cultures to be helpful in predicting infection or predicting the infecting organism [13,14]. Antimicrobials in extremity trauma Bacterial contamination of the mutilating hand wound occurs before antibiotic administration, and the delay between injury and antibiotic administration can be quite long. Consequently, antibiotics in this setting are technically not prophylactic. Prospective, randomized, placebocontrolled studies are lacking in this clinical scenario for a variety of reasons, including small numbers of patients and the heterogeneous nature of these injuries. Given this problem, rigid guidelines are dicult to generate, but certain principles can be extracted from the orthopedic and hand surgery literature. The ecacy of antibiotics in the treatment of open long bone fractures is well established. Patzakis et al [15] performed a prospective randomized trial in 310 patients with open extremity fractures that included 89 open forearm and hand fractures. Patients receiving a 10-day course of intravenous cephalothin had an infection rate of 2.3% compared with 13.9% in the placebo group. In this study, 12 of 115 tibia fractures developed infection, whereas only 10 of 218 open fractures elsewhere became infected. If tibia fractures are excluded, it is unknown whether antibiotics decreased the rate of infection signicantly. Patzakis and Wilkins later demonstrated in a larger study of open extremity fractures that patients receiving antibiotics within 3 hours of injury had a lower rate of infection than those who did not. They noted that a 3- to 5-day course of intravenous cefamandole and tobramycin was the most eective regimen, but they used it only in patients with open tibia fractures [16]. Other investigators have conrmed the ecacy of antibiotics in the treatment of open fractures [1719]. The ecacy of antimicrobials in open fractures of the hand and mutilating hand injuries is not as clear (Fig. 1). Numerous articles have been published on the care of complex wounds of the hand, with most reporting low rates of infection. The majority of these studies are retrospective, and

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35

Fig. 1. A severe hand injury from an industrial accident. (A) Dorsal view of hand. (B) Palmar view of hand.

antimicrobials were often used routinely or not mentioned in the reports [51]. In a frequently referenced article, Burkhalter et al [20] reported on their experience treating 135 high-velocity missile injuries to the hand during the Vietnam War. Intravenous penicillin, debridement, and delayed primary closure were the cornerstones of treatment, and only three patients developed infection. A similar rate of infection has been reported in the treatment of civilian gunshot wounds to the hand, during which intravenous antibiotics were routinely used [21]. Other authors have reported infection rates in open fractures of the hand from all causes to be in the range of 5% to 11% in centers where perioperative antibiotics were routinely used [13,22,23]. Numerous authors have reported on the use of complex reconstructive procedures performed acutely, such as early bone grafting or emergency free tissue transfer, with extremely low infection rates in the hand ranging from 0% [2427] to 6.9% [28]. Control groups are not available; therefore, the impact of antimicrobial use on the rate of infection cannot be determined. A small number of studies is available to help tease out the eect of antibiotics on the incidence of infection in open hand fractures. Peacock et al

[14] conducted a prospective, randomized, double-blind, placebo-controlled study of a wide variety of hand injuries distal to the distal radioulnar joint. All wounds were less than 24 hours old, and most were treated on an outpatient basis. Many injuries were complex, involving joints, bones, tendons, and neurovascular structures. Patients were randomized to receive intravenous cefamandole or placebo every 4 hours during the procedure followed by a 3-day course of oral cephalexin or placebo. A total of 87 patients were included in the study. Only one patient in the placebo group developed an infection, and no infections occurred in the study group. Sloan et al [29] conducted a prospective, randomized study that was not blinded or placebo controlled to observe the eects of antibiotics on the treatment of open fractures of the distal phalanx seen within 6 hours of injury. All amputations in this series were closed primarily, with a skin graft, or with a V-Y advancement ap under local anesthesia. Three of the 10 patients who did not receive an antibiotic developed an infection, causing the authors to abandon this aspect of their study. Only 2 of the 75 patients who received antibiotics developed an infection. Of the three antibiotic regimens tested,

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1 g intravenous cephradine preoperatively and 1 g orally postoperatively was found to be the simplest regimen and equally ecacious compared with the two antibiotic regimens with a longer duration of postoperative administration. Suprock et al [30] also conducted a prospective, randomized study that was not blinded or placebo controlled to assess the role of prophylactic antibiotics in the management of 91 open nger fractures distal to the MCP joint, 68 of which involved the distal phalanx. Patients were treated with a 3-day course of oral dicloxacillin, erythromycin, or rst-generation cephalosporin. Four patients from each group underwent xation with K-wires. No patient was excluded because of an underlying systemic disease process or degree of wound contamination. Four patients developed an infection in each group, with no cases of osteomyelitis. No secondary surgical procedures were required. In perhaps the most convincing study, Madsen et al conducted a prospective, randomized, double-blind, placebo-controlled study of 599 patients with a traumatic wound located distal to the wrist or ankle joint with an underlying fracture, loss of bone substance, injury of tendon or joint, or any combination of these lesions. Patients with hand injuries made up 570 of 599 patients, and 42 required osteosynthesis. Patients requiring revascularization were excluded. Strict denitions of wound infection were noted, and doctors not participating in the study assessed the wounds. Patients were randomized to receive a single injection of 2 million units of intravenous penicillin G followed by placebo tablet twice a day for 6 days; placebo injection followed by penicillin V tablet 1 million units twice a day for 6 days; or placebo injection followed by placebo tablet twice a day for 6 days. The infection rates for the three groups were 4.9%, 6.6%, and 10.2%, respectively. The difference in infection rate between patients receiving penicillin injection and those receiving placebo was statistically signicant, whereas the dierences between the other groups were not. More than 80% of organisms isolated from infected wounds were gram positive [31]. Topical antimicrobial irrigation Throughout history, open wounds have been treated with numerous topical agents in an attempt to stimulate healing and reduce the risk of infection. In more recent times, numerous antiseptics, antibiotic solutions, and surfactants have been studied to assess their eect on

wound healing and infection [32]. The majority of reports in this area focus on cell culture and animal models, and the majority of human studies have been reported in the general surgical literature. Their ecacy in orthopedic surgery is unclear because of the paucity of controlled human clinical studies in this area [33]. Maguire [34] reported a statistically signicant decrease in the infection rate in clean orthopedic cases with the use of bacitracin/neomycin powder sprayed into the wound at the time of closure. Nachamie et al, however, found no benet from a 0.1% neomycin solution instilled into the wound before closure [35]. Controlled studies involving human subjects with open fractures are rare. As a result, the use of topical antimicrobials in human open fracture wounds, and more specically mutilating hand injuries, cannot be recommended because of the lack of clinical evidence documenting their ecacy and the fact that use of certain agents does entail some risk. Bacitracin use should probably be avoided in patients with a history of exposure to the drug because rare cases of anaphylaxis have been reported [3638]. Systemic toxicity from neomycin solutions has also been reported, but most cases occurred after long periods of continuous wound irrigation or after the use of large doses of antibiotics [39]. Antibiotic choice The list of pathogens known to cause a postoperative wound infection is long. A prophylactic systemic antibiotic should cover the most probable infecting organisms, which may not be the most common contaminating organisms. The chosen antibiotic need not cover all potential pathogens [40]. This is a particularly important point in the setting of open hand fractures and mutilating injuries. In this setting, Staphylococcus aureus has been found to be the most common infecting organism after an open hand fracture [14,23,29,30]. However, this organism is only occasionally isolated from pre-debridement cultures [1113]. Infections with gram-negative organisms are less common and tend to occur in hands injured in an agricultural environment. Given this information, it is reasonable to recommend the use of a rst-generation cephalosporin at presentation for the patient with a mutilating hand injury occurring in the home or industrial environment, excluding lawn and garden injuries. Given the bacteriology of these

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37

wounds, semi-synthetic penicillin would be equally ecacious. Cephalosporins are more popular because of their shorter dosing intervals and because of the frequency of penicillin allergy [40]. Vancomycin is commonly used in the patient with a cephalosporin allergy or serious penicillin allergy [37]. For patients sustaining injuries in an agricultural or lawn and garden setting, the addition of an aminoglycoside such as gentamycin is reasonable. The duration of antibiotic treatment is arbitrary. It is reasonable to administer antibiotics as soon as possible after injury, continue them through the initial debridement, and administer before any later reconstructive procedures. Unfortunately, there are limited data available to guide the clinician on the optimal duration of antimicrobial treatment after debridement in the setting of the mutilated hand. Data from long bone fractures indicate that there is little benet to extending antibiotic treatment beyond 5 days [41].

decrease the risk of these complications without compromising ecacy [48]. There is concern that the widespread use of antibiotics will result in the emergence of resistant pathogens. Evidence exists that perioperative antibiotic administration alters the resident skin ora [49]. Postoperative antibiotic prophylaxis of greater than 4 days has been associated with altered antimicrobial sensitivities of infecting organisms [50]. No deleterious eects have been shown after a 24-hour course of perioperative antibiotics [40]. Summary Antimicrobial drugs are commonly used in the treatment of mutilating hand injuries. Valid arguments for the use of systemic antibiotics can be made despite the lack of data clearly documenting their ecacy in this clinical scenario. There is no information to support the use of topical agents in open hand injuries. When choosing an appropriate systemic antibiotic, the physician should consider unique characteristics of these injuries, the various environments in which they occur, and the potential infecting organisms. The duration of antibiotic use is arbitrary but should be minimized to avoid complications and the development of bacterial resistance. References
[1] Merriam-Webster On Line: Collegiate Dictionary. Available at: http://www.merriam-webster.com/ dictionary.htm. Accessed January 7, 2002. [2] Dipiro JT, Bivins BA, Record KE, et al. The prophylactic use of antimicrobials in surgery: current problems in surgery. Chicago: Year Book Medical Publishers; 1983. p. 70132. [3] Oishi CS, Carrion WV, Hoaglund FT. Use of parenteral prophylactic antibiotics in clean orthopaedic surgery. Clin Orthop Rel Res 1993;296:24955. [4] McKittrick LS, Wheelock FC Jr. The routine use of antibiotics in elective abdominal surgery. Surg Gynecol Obstet 1954;99:3767. [5] Sanchez-Ubeda R, Fernand E, Rousselot LM. Complication rate in general surgical cases: the value of penicillin and streptomycin as postoperative prophylaxis: a study of 511 cases. New Engl J Med 1958;259:104550. [6] Olix ML, Klug TJ, Coleman CR, et al. Prophylactic penicillin and streptomycin in elective operations on bones, joints, and tendons. Surg Forum 1956; 10:8189. [7] Schonholtz GJ, Borgia CA, Blair JD. Wound sepsis in orthopaedic surgery. J Bone Joint Surg 1962;44A: 154852.

Complications The incidence of side eects from antibiotic use in surgical patients is low. The most frequently reported complication of antibiotic prophylaxis is pseudomembranous colitis. Rates as high as 6% have been reported after the use of cefoxitin [40,42]. Although this complication is typically associated with prophylactic antibiotic courses greater than 72 hours, it has been reported with antibiotic regimens lasting fewer than 24 hours [43]. Allergic reactions are also a complication of prophylactic antibiotics. Penicillin allergies have been reported in 5% to 10% of the adult population [40,44]. A cephalosporin allergy is much less common, and life-threatening reactions are rare [45]. Reactivity to cephalosporins in patients with a positive skin test to penicillin is uncommon and is estimated at 3% to 7% [46]. Despite this low incidence of cross-reactivity, some authors discourage the use of antibiotic prophylaxis with a cephalosporin in patients with a history of an immediate or accelerated reaction to penicillin, such as hypotension, bronchospasm, or urticaria [37,40,47]. If a penicillin or cephalosporin agent is essential for treatment and the patients allergy status is unclear or uncertain, consultation with and skin testing by an allergist or dermatologist is recommended. Nephrotoxicity and ototoxicity are complications associated with the use of aminoglycosides. Once-daily dosing of aminoglycosides may

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R. Dow Homan, B.D. Adams / Hand Clin 19 (2003) 3339 [25] Chen SHT, Wei FC, Chen HC, et al. Emergency free-ap transfer for reconstruction of acute complex extremity wounds. Plast Reconstr Surg 1992; 89:8828. [26] Ninkovic M, Deetjen H, Ohler K, et al. Emergency free tissue transfer for severe upper extremity injuries. J Hand Surg 1995;20B:538. [27] Stahl S, Lerner A, Kaufman T. Immediate autografting of bone in open fractures with bone loss of the hand: a preliminary report. Scand J Plast Reconstr Hand Surg 1999;33:11722. [28] Brenner P, Lassner F, Becker M, et al. Timing of free microsurgical tissue transfer for the acute phase of hand injuries. Scand J Plast Reconstr Hand Surg 1997;31:16570. [29] Sloan JP, Dove AF, Maheson M, et al. Antibiotics in open fractures of the distal phalanx? J Hand Surg 1987;12B:1234. [30] Suprock MD, Hood JM, Lubahn JD. Role of antibiotics in open fractures of the nger. J Hand Surg 1990;15A:7614. [31] Madsen MS, Neumann L, Andersen JA. Penicillin prophylaxis in complicated wounds of hands and feet: a randomized, double-blind trial. Injury 1996; 27:2758. [32] Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg 2001;9:21926. [33] Dirschl DR, Wilson FC. Topical antibiotic irrigation in the prophylaxis of operative wound infections in orthopaedic surgery. Orthop Clin N Am 1991;22:41926. [34] Maguire WB. The use of antibiotics, locally and systemically, in orthopaedic surgery. Med J Aust 1964;2:4124. [35] Nachamie BA, Siert RS, Bryer MS. A study of neomycin instillation into orthopedic surgical wounds. JAMA 1968;204:6879. [36] Netland PA, Baumgartner JE, Andrews BT. Intraoperative anaphylaxis after irrigation with bacitracin. Case Report. Neurosurgy 1987;21:9278. [37] Shapiro DB. Postoperative infection in hand surgery: cause, prevention and treatment. Hand Clin 1994;10:112. [38] Sprung J, Schedewie HK, Kampine JP. Intraoperative anaphylactic shock after bacitracin irrigation. Anesth Analg 1990;71:4303. [39] Benjamin JB, Volz RG. Ecacy of a topical antibiotic irrigant in decreasing or eliminating bacterial contamination in surgical wounds. Clin Orthop Rel Res 1984;184:1147. [40] Kaiser AB. Antimicrobial prophylaxis in surgery. New Engl J Med 1986;315:112938. [41] Wilkins J, Patzakis M. Choice and duration of antibiotics in open fractures. Orthop Clin North Am 1991;22:433. [42] Block BS, Mercer LJ, Ismail MA, et al. Clostridium dicile associated diarrhea follows perioperative prophylaxis with cefoxitin. Am J Obstet Gynecol 1985;153:8358.

[8] Tachdjian MO, Compere EL. Postoperative wound infections in orthopaedic surgery: evaluation of prophylactic antibiotics. J Int Coll Surg 1957;28: 797805. [9] Burke JF. The eective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery 1961;50:1618. [10] Burnakis TG. Surgical antimicrobial prophylaxis: principles and guidelines. Pharmacotherapy 1984;4: 24871. [11] Fitzgerald RH Jr, Cooney WP, Washington JA, et al. Bacterial colonization of mutilating hand injuries and its treatment. J Hand Surg 1977;2:859. [12] Cooney WP III, Fitzgerald RH Jr, Dobyns JH, et al. Quantitative wound cultures in upper extremity trauma. J Trauma 1982;22:1127. [13] McLain RF, Steyers C, Stoddard M. Infections in open fractures of the hand. J Hand Surg 1991; 16A:10812. [14] Peacock KC, Hanna DP, Kirkpatrick K, et al. Ecacy of perioperative cefamandole with postoperative cephalexin in the primary outpatient treatment of open wounds of the hand. J Hand Surg 1988;13A:9604. [15] Patzakis MJ, Harvey P Jr, Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg 1974;56A:53241. [16] Patzakis MJ, Wilkins J. Factors inuencing infection rate in open fracture wounds. Clin Orthop 1989;243:36. [17] Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty ve open fractures of long bones. retrospective and prospective analyses. J Bone Joint Surg 1976; 58A:4538. [18] Gustilo RB, Merkow RL, Templeman D. Current concepts review. the management of open fractures. J Bone Joint Surg 1990;72A:299304. [19] Worlock P, Slack R, Harvey L, et al. The prevention of infection in open fractures: an experimental study of the eect of antibiotic therapy. J Bone Joint Surg 1988;70A:13417. [20] Burkhalter WE, Butler B, Metz W, et al. Experiences with delayed primary closure of war wounds of the hand in Vietnam. J Bone Joint Surg 1968;50A:94554. [21] Chappell JE, Mitra A, Weinberger J, et al. Gunshot wounds to the hand: management and economic impact. Ann Plast Surg 1999;42:41823. [22] Duncan RW, Freeland AE, Jabaley ME, et al. Open hand fractures: an analysis of the recovery of active motion and of complications. J Hand Surg 1993;18A:38794. [23] Swanson TV, Szabo RM, Anderson DD. Open hand fractures: prognosis and classication. J Hand Surg 1991;16A:1017. [24] Calkins MS, Burkhalter W, Reyes F. Traumatic segmental bone defects in the upper extremity. J Bone Joint Surg 1987;69A:1927.

R. Dow Homan, B.D. Adams / Hand Clin 19 (2003) 3339 [43] Clarke HJ, Jinnah RH, Byank RP, et al. Clostridium dicile infection in orthopaedic patients. J Bone Joint Surg 1990;72A:10569. [44] Shapiro S, Slone D, Siskind V, et al. Drug rash with ampicillin and other penicillins. Lancet 1969;2: 96972. [45] Spruill FG, Minette LJ, Sturner WQ. Two surgical deaths associated with cephalothin. JAMA 1974; 229:4403. [46] Saxon A. Immediate hypersensitivity reactions to beta-lactam antibiotics. Rev Infect Dis 1983;5: S36876. [47] Betts RF. Skin testing. In: Mandell GL, Douglas RG Jr, Bennett JE, editors. Principles and practice of infectious diseases. New York: John Wiley; 1985. p. 150.

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[48] Nicolau DP, Freeman CD, Belliveau PP, et al. Experience with a once-daily aminoglycoside program administered to 2,184 adult patients. Antimicrob Agents Chemother 1995;39:6505. [49] Archer GL. Alteration of cutaneous Staphylococcal ora as a consequence of antimicrobial prophylaxis. Rev Infect Dis 1991;13:S8059. [50] Conte JE Jr, Cohen SN, Roe BB, et al. Antibiotic prophylaxis and cardiac surgery: a prospective double-blind comparison of single-dose versus multiple-dose regimens. Ann Intern Med 1972; 76:9439. [51] Freeland AE, Jabaley ME, Burkhalter WE, et al. Delayed primary bone grafting in the hand and wrist after traumatic bone loss. J Hand Surg 1984;9A:228.

Hand Clin 19 (2003) 4149

Psychological aspects of mutilating hand injuries

Therese M. Meyer, PhD
Department of Psychology, Center for Neuromuscular Sciences, Memorial Medical Center, 701 N. First Street, Springeld, IL 62781, USA

A mutilating hand injury and subsequent disability do not occur in physiological isolation. Health care professionals providing treatment to individuals sustaining such injuries must be aware of the variety of psychological and social problems that arise in the face of such a potentially disabling injury. As such, the long-term, functional outcome of a mutilating injury can be greatly improved if the hand surgeon adopts a biopsychosocial perspective [1]. The hand plays an immense and integral role in an individuals vocational, avocational, and social functioning. The hands, more than any other appendage, provide us with independence, competence, and a sense of autonomy. The upper extremities are used as a means of productivity; employability; and expression of sexuality, aection, aggression, and communication, leading Klapheke et al to comment that amputation or mutilation of the hand is a tremendous physical and psychological trauma that can precipitate powerful conicts regarding loss of autonomy, guilt/punishment, and potency [2]. A hand injury is particularly threatening to an individual who relies upon ne motor skills to perform workrelated tasks. Consider the impact of a disabling hand injury for the carpenter, chef, dentist, or surgeon. There is potential for a hand injury to destroy a career and threaten quality of life [3]. In addition to the immense functional role of the hands, the hands are vital aspects of the subjective body image. Given the readily visible nature of the hand, a disgured hand is easily observed and evaluated by others, resulting in the individual becoming acutely aware of any associated social stigma. A perception of stigmatization may inter-

fere with an individuals willingness to pursue social relationships or interactions [4]. Injuries resulting in a mutilation or amputation of hand or arm deal a blow to the persons inner image that reverberates through their entire psyche [5]. Thus, in addition to the functional loss, the individual must come to terms with a change in their self-image. If the individuals identity is heavily determined by body image and bodily integrity, a mutilating hand injury may lead to signicant adjustment problems beyond the acute adjustment to functional loss [6]. Furthermore, heightened sensitivity to a disgured hand may complicate functional recovery. For example, if an individual cannot tolerate the sight of their disgured hand or tolerate allowing others to view it, they may be at risk for failure to comply with or attend therapy sessions, or they may avoid returning to work. The purpose of this article is to identify the psychological impact on the individual and family after a mutilating hand injury. We describe frequent psychological reactions, the occurrence of psychological disorders, factors that aect adjustment, strategies to promote positive adaptation, and options for treatment of psychological disorders when they occur. The chapter concludes with a discussion of special issues in mutilating hand injuries, including pain management, the pediatric patient, and replantation issues.

Injury-related issues It is frequently the assumption among health care professionals that severity and extent of injury plays a predominant role in the individuals psychological, social, and occupational adjustment to that injury. There is, however, limited correlation between tissue damage and functional loss

E-mail address: meyer.therese@mhsil.com.

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. PII: S 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 0 5 6 - 2

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and the psychological adjustment to traumatic injury [711]; there is limited correlation between mutilating hand injuries and psychological adjustment as well. Lee et al examined the relationship between severity of hand injury and subsequent psychological, social, and occupational adjustment and found no correlation [12]. They concluded that even though health care professionals tend to place signicant importance on the severity of a physical injury in attempting to predict psychological and social adjustment to injury, it is not the sole or necessarily the most signicant determinant of long-term recovery and reintegration into society. It is more benecial to focus on the individuals perception and attribution of how the injury was sustained when attempting to predict or understand psychological adjustment. Although much of what is known on this topic is derived from research on other traumatic injuries [13,14], there is indication that attribution of responsibility for an injury plays a signicant role in adjustment to injury and disability. As stated by Johnson, if a worker is injured on the job, the nature and severity of that workers anger at the injury is going to be related to whether he or she views the injury as a random, unpreventable event or as the result of neglect or negligence on the part of the employer [15]. Negative emotional reactions (anger, depression, anxiety) may be heightened if the traumatic injury was the perceived result of someones uncaring negligence or malicious act and thus could have been avoided [16]. Litigation issues have been viewed by health care professionals as potentially complicating the process of psychological adaptation to a mutilating hand injury, particularly in work-related, traumatic injuries [17]. Such issues may further cloud the patients perception of injury and disability and the health care providers perception of the patients motivations and the interpretation of their behavior. Hand surgeons can be placed in a dicult position when litigation issues enter into the diagnosis, treatment, and prognosis of workrelated injuries. Although there is often considerable concern among practitioners that litigation may play a substantial role in the adjustment to and functional presentation of a traumatic hand injury, Grunert et al reviewed the relevant research and concluded that compensation and litigation issues do not play a signicant role in regard to psychological outcome [18]. Grunert et al concluded that problems in psychological adjustment are not maintained by the presence of litigation

and that such problems do not contribute to a failure to return to work before the resolution of litigation issues [18]. In addition, there was no relationship between return to work and potential size of settlement. All participants in this investigation were diagnosed with post-traumatic stress disorder (PTSD) and, as a result, received psychological intervention within several months of their injury. The investigators concluded that this early intervention likely played a key role in the absence of relationship between litigation, psychological symptom maintenance, and return to work. Such research argues against a biasing focus on litigation issues when interpreting patient behavior. Modlin maintains that, whereas abuse of the system is likely to occur in a small fraction of work-related injuries, the concept of compensation neurosis (psychological symptoms being subconsciously or volitionally maintained by litigation issues) is based on inadequate and conicting data, clinical anecdotes, and biased observation [19]. Psychological responses to a mutilating hand injury Individuals experiencing a mutilating hand injury likely experience intense emotional reactions as a result of their injury, subsequent treatment, and immediate or long-term disability. Reactions may be experienced as a wide range of emotions including anxiety, depression, guilt, fear, frustration, sadness, and anger, among others [15]. Such a range of emotions is normal, and strong emotional reactions should not necessarily be viewed as abnormal. Whether the aective response warrants a clinical diagnosis depends on the severity, duration, and the incapacitating nature of the response. Mutilating hand injuries can be associated with psychological disturbances such as acute stress disorder (ASD), PTSD, other anxiety disorders (panic and obsessive-compulsive disorders), major depression, pain disorders, and adjustment disorders [20]. Assessing the individuals psychiatric history can help determine the likelihood that a diagnosable disorder will occur. Pre-injury personality dysfunction and presence of psychopathology have been correlated with poorer postinjury adaptation [15,21] and should be assessed as a possible risk factor to optimal adjustment. There is little research available regarding the prevalence of psychological/psychiatric disturbances among individuals with mutilating hand injuries. There is, however, extensive research

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regarding the prevalence of psychiatric disturbances in individuals with a new amputation. The rate of clinically diagnosable depression occurring among individuals with recent amputation is approximately 30% [20,2224]. Shukla et al assessed individuals with a recent amputation and found that a large number of these individuals experienced depressed mood, tearfulness, sleep problems, and anxiety [25]. Individuals with mutilating hand injuries may be prone to similar emotional diculties. A consistent nding has been that depression after physical injury or illness is associated with decreased functional ability [26 28] and that once functional ability improves through surgical intervention and rehabilitation, symptoms of depression also improve [29]. In an investigation into the psychiatric aspects of replantation surgery after a variety of digital, upper limb, and lower limb amputations [21], investigators found that symptoms of psychiatric disorder are often mixed, including symptoms of anxiety and depression. Anxiety was found to be the most frequent and persistent symptom postoperatively. Sources of acute anxiety were the accident being perceived as a life-threatening event, disrupted bodily integrity, and threat of loss of the body part. Feelings of depressed mood and sadness were also common but were mild and short lived. In only a minority of cases did the symptoms of depression persist beyond 1 week and necessitate psychiatric treatment. Feelings of depression were associated with perception of loss, usually regarding the threatened body part or threat of loss of lifestyle or relationships. Symptoms of PTSD and ASD (a disorder symptomatically identical to PTSD but diagnosed when the individual is less than 1 month post-traumatic event) commonly occur as a result of severe traumatic hand injuries. There is indication that up to 94% of individuals experiencing a severe hand injury experience symptoms associated with one of these disorders [30]. These disorders are probably the most frequent psychiatric diagnoses for individuals who have experienced a traumatic hand injury. Symptoms of ASD or PTSD include recurrent ashback memories; nightmares and other sleep disturbances; being easily startled; cognitive, emotional, and behavioral avoidance of stimuli representative of the traumatic event; feelings of anxiety, detachment, depression, or guilt; and cognitive diculties aecting memory and concentration [31]. In one of the few investigations examining factors contributing to emotional distress in the early

stages of traumatic hand injury, the occurrence of the traumatic event itself was found to be one of the core factors contributing to distress. Symptoms of ASD, such as ashback memories and re-experiencing the event, were detected in 25% of the injured individuals. Adding to the degree of emotional distress were practical problems in daily functioning, dependence on others, involuntary decrease in activity level, unknown functional prognosis, the uncertainty of persistent pain, and the disgured appearance of the hand [32]. In another study [30], the acute (2 months or less postinjury) psychological impact of a traumatic hand injury was examined. Ninety-four percent of the individuals screened experienced one or more symptoms associated with ASD or PTSD, with the most common symptoms being nightmares and ashback memories. Other acute psychological symptoms included mood swings, cognitive diculties (impaired concentration and attention), concerns regarding disgurement, phantom limb sensations, and fear of dying. These symptoms generally resolved or were signicantly alleviated by 1 month postinjury. Although ashback memories and nightmares continued, they were greatly diminished by the second month postinjury. Promoting healthy adjustment to injury The assumption cannot be made that all individuals who have undergone a mutilating hand injury will experience an episode of adjustmentrelated diculties. These individuals are not doomed to experience depression, ASD, or PTSD. Although variation in mood and aect undoubtedly occur as the individual comes to terms with the injury, assumptions about the expected course of adjustment should be avoided. The course of adjustment will vary greatly among individuals, as will the factors that inuence their adjustment. For some individuals, impaired functioning is the primary concern; for others, disgurement of the hand is primary; for yet others, nancial concerns take precedence. Regardless of the primary concerns for the individual, there are strategies in which a health care provider can promote positive adjustment for persons with a mutilating hand injury. Promotion of a healthy adjustment should begin as soon after the injury as possible [30]. The hand surgeon is likely one of the rst health care providers to have contact with the injured individual. For that reason, it is important that the attending surgeon begin

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to create a realistic picture of acute and long-term goals for the patient and family [20]. Immediate and long-term physical and psychological adjustment is inuenced by the surgeons interactions with the patient before and after surgery. Positive pre- and postsurgical interactions foster faith in the physician, set the stage for patient compliance with medical recommendations, and increase satisfaction with care [20]. Patients should be provided with a very realistic but hopeful perspective on what life will be like after a mutilating hand injury or amputation. As aptly stated by Pulvertaft [33], the surgeon should not be unduly optimistic and give promises that cannot be honoured. There are ways in which we can combine sympathy with truth. The attending surgeon can further promote optimal adjustment by referring the individual to a mental health professional who specializes in traumatic physical injuries and disability. There is considerable evidence that early psychological intervention after traumatic injury can substantially reduce psychological morbidity and maladaptive coping [18,30] and facilitate more rapid return to work [15,18,34]. Such a referral can facilitate the process of forming an adaptive perspective on injury, recovery, and eventual return to a satisfying lifestyle. It is benecial for the patient to understand that many of their emotional reactions to the traumatic event and subsequent injury are not abnormal. Discussing these reactions with a trained professional can reduce the associated distress and potentially prevent further long-term psychological diculties. The rationale for such a referral should be provided to the patient so that they do not feel identied as being maladjusted or crazy. It can be suggested to them that a referral to a mental health professional is being arranged so that they may be better able to cope with and adapt to the residual physical diculties and associated emotional consequences of their injury [15]. Psychological intervention should focus on promoting the patients strengths and discouraging dependence, feelings of victimization, or loss of personal control. Early on, discussions may focus on practical issues (dealing with pain, lost wages, stress on family, the eect of the injury on their lives, and stress of hospitalization). Eventually, discussions can turn to providing assistance to the patient in formulating realistic plans for the future, including employment, education, relationships, and continuing to be a productive member of society. Such discussions are important in re-establishing feelings of self-worth that may have been challenged as a result of a disabling injury [20].

In the world of coping research, it has been repeatedly indicated that not all coping strategies are created equal when dealing with illness, injury, and traumatic life events. Coping strategies typically regarded as engaging in their approach have been consistently found to be associated with more positive psychological adjustment, whereas coping strategies regarded as disengaging in nature have been consistently associated with less positive adjustment. Engaging strategies include determining positive meaning in the event, active problem-solving, and perceiving control over the situation. Disengaging coping strategies include a perception of helplessness, lack of control, catastrophizing, and emotional and behavioral avoidance [35]. For example, in a study of adaptation to lower extremity amputation, Gallagher and MacLachlan determined that nding something good as a result of amputation was associated with more positive ratings of adjustment to limitations and physical capabilities [36]. They further concluded that identifying a positive outcome, regardless of what form that may be, is an important factor in positive adjustment. In many cases, the acutely injured patient may not be able to perceive anything positive resulting from their injury. Over time and with subtle suggestion, however, patients may be able to identify consequences of their injury that may be viewed as a positive outcome. Specic psychological intervention strategies Fortunately, for the individual who is experiencing signicant diculties in their adjustment to a mutilating hand injuryeither immediately or long-termthere are psychological interventions available that have proven ecacy. The sooner the problem is identied and appropriate treatment is initiated, the more likely the individual is to recover and return to normal psychosocial functioning. In the case where a referral for mental health services is indicated, it is important to convey to the individual that mental health services are an aspect of the overall treatment program and not a last resort [16]. When an individual is identied by health care personnel as experiencing mood or aective diculties as a result of injury, the advised initial step is to obtain a psychological or psychiatric evaluation. According to Johnson, among the benets of conducting psychological assessments of injured hand patients are the following: 1) To communicate a sense of care and interest in the patient; 2)

T. M. Meyer / Hand Clin 19 (2003) 4149

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To obtain accurate diagnostic information regarding issues of malingering, pre-existing psychologic conditions, and identication of factors amenable to treatment; 3) To aid in decisions regarding possible surgery; 4) To individualize medical treatment so that health care does not become impersonal and interpersonally distant; 5) To facilitate psychologic intervention, particularly in cases of pain and post-traumatic stress disorders; 6) To expedite an early return to work and decrease the overall period of disability that could result from untreated psychologic problems following the injury; 7) To identify sources of non-compliance; and 8) To allow patients the opportunity to thoroughly tell their stories [15]. Once the evaluation is completed, the mental health professional can plan and implement the appropriate interventions. Such interventions should include psychotherapy or psychotropic medications [6,15]. It has been suggested [15] that psychotropic medications be used sparingly and only in cases in which the individual is struggling to such an extent that overall functioning is hindered or impeded. Medications may include an antidepressant or anxiolytic agent, but, in extreme cases, neuroleptic medication may be indicated [15]. Psychotherapy may involve training the patient in self-management strategies (relaxation, anger control, cognitive restructuring) to address pain, anxiety, and depressed mood. Psychotherapy may need to address issues of loss, the potential for chronic disability, and existential issues that arise as a result of a traumatic injury, such as fairness in the world, perceived control over life events, and the meaning of life [16]. The appropriate intervention should be individualized according to the patients pre-injury personality, type of trauma experienced, previous trauma-related experiences, and the reactions of others to the injury [16]. The treatment of ASD and PTSD after an upper-extremity injury is probably the most well researched and discussed. Schwartz and Prout highlight that in PTSD, treatment should occur early and should be short term, with a particular focus on returning the individual to a pre-injury level of functioning; the normalization of the emotional reactions; adaptive coping; and decreasing emotional, cognitive, and behavioral avoidance [26]. Various cognitive-behavioral treatment strategies (systematic desensitization, graded exposure, in vivo exposures) have demonstrated tremendous success in the treatment of PTSD

[37]. Such strategies are focused and short term, thus facilitating rapid return to a previous level of psychological functioning. Work-related injuries and the occurrence of PTSD may present a particular challenge. One of the cardinal symptoms of PTSD is avoidance of stimuli that remind the individual of the injury. In work-related injuries, this avoidance may include the work environment. Although surgical and rehabilitative eorts may have been deemed a success, many employees traumatically injured on the job fail to return to work because of psychological factors [34]. Grunert et al described a cognitive-behavioral treatment protocol in which they were able to achieve a 61% return to work for patients diagnosed with PTSD after a workrelated severe hand injury [34]. This rate dramatically improved when graded work exposure and on-site job evaluations (88.9% and 83.3%, respectively) were incorporated into the treatment protocol. Based on research and clinical experience, Grunert et al propose that coping skills, confrontation of the trauma, and reprocessing be used to manage most of the injured workers emotional reactions [34]. To promote return to work, they suggest that a hierarchy of exposure techniques be attempted. Early return to work site is an economical approach that can be used as a means of screening for those patients with severe avoidance reactions. Then for those patients unable to return to work, graded work return should be attempted. If this too is unsuccessful, we suggest the use of an on-site job evaluation to accomplish desensitization.

Special issues in mutilating hand injuries Pain in mutilating hand injuries Pain has been identied as one of the most acutely stressful aspects of traumatic injuries and their treatmentparticularly if the pain is perceived as poorly controlled or unavoidable [16]. The problem presented by pain should be addressed in a timely manner in the treatment of a mutilating hand injury, lest it negatively inuence the immediate and long-term functional outcome. Poorly managed pain can lead to maladaptive psychological and emotional reactions such as anger, anxiety, phobic reactions, and somatization, which can lead to less adaptive physical and functional recovery [38,39]. In addition, the connection between pain and depression has been

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clearly established [15,39]. Apprehension about the uncontrollable or possible long-term nature of pain is not uncommon [39]. There is indication of a connection between pain and the experience of symptoms associated with PTSD. In a case report [40], the occurrence of PTSD was a result of the pain associated with a traumatic eye injury rather than the injury itself. In this case, the intense and poorly managed pain was not an additional stressor but was the traumatic element that led to PTSD. In a study examining work-related upperextremity disorders, disability, and pain [38], investigators concluded that when an individual has diculty coping with pain and loss of functioning, prolonged disability may result. Poor pain tolerance along with persistent pain and heightened reactivity may account for more frequent requests for surgical interventions. Unfortunately, with such individuals, additional surgery may fail to satisfactorily resolve pain complaints and associated disability. In the case of amputation after a hand injury, phantom limb sensations and phantom limb pain are very real events for the individual. There is indication that at least 90% of individuals with amputation experience phantom limb sensations [41]. Although such sensations may not be painful, they can be emotionally distressing for the individual. Over time, these sensations typically remit in frequency and intensity [42]. Encouraging patients to view these sensations as a normal experience in the face of amputation can be reassuring to the individual. Phantom limb pain, which occurs in greater than 60% of amputations [42,43], has been identied as a potential risk factor for poor adaptation postamputation [44]. Phantom limb pain can be distressing for the individual. Unremitting and severe phantom limb pain may have adverse consequences for the individuals psychological functioning, possibly leading to drug abuse, clinical depression, and severe anxiety. Fortunately, because of improved surgical techniques and advanced pharmacologic pain management, severe and uncontrollable phantom limb pain is nearly an issue of the past [45]. The pediatric patient There is limited research regarding the psychological aspects of a mutilating hand injury in pediatric patients. There is, however, extensive information regarding the psychological impact of amputations and other traumatic injuries in a

pediatric population. Much of this information can be applied to the care of the pediatric patient with a mutilating hand injury. Although it would seem to be an accurate assumption that an amputation or mutilating hand injury would be a substantial emotional insult to a child or adolescent, many pediatric patients adapt psychologically fairly well after traumatic injury and are able to obtain favorable functional outcomes [46]. Some children and adolescents experience signicant coping and adjustment diculties following these traumatic injuries, however [47]. There have been a number of risk and protective factors identied as contributing to a pediatric patients overall adjustment to traumatic injury. These factors include the childs developmental level and emotional age, pre-injury personality functioning and ability to cope with stressors, intellectual abilities, perceived responsibility for the injury, past experience with medical and surgical interventions, parental reaction and adjustment to the injury, level of attachment to the primary caregiver, and extent of expected functional impairment and physical disgurement [46]. Misattributions of responsibility are more likely in the younger the child. Children are prone to interpreting the cause of the injury as punishment for bad behavior [46,53]. Such attributions should be discussed at a developmentally appropriate level with the young patient. It is also fairly common for young children to display developmentally regressed behaviorbecoming more dependent and wanting of attentionafter a traumatic injury and during subsequent hospitalization [47,48]. Such behaviors should be briey tolerated, normalized with parents and treatment team members, and then age-appropriate behaviors should be encouraged and reinforced while regressed behavior is discouraged or ignored. The role of the parents and family in the childs adjustment to injury, subsequent hospitalization, and treatment deserves emphasis. The reaction of this primary source of support greatly inuences the childs reaction and adjustment [48,49]. In an investigation examining the factors inuencing the psychological adjustment of children with limb deciencies [49], demographic variables and extent of limb loss were not predictive of symptoms of depression, anxiety, or self-esteem. Rather, these indicators of psychological adaptation were inuenced by family dynamics and other sources of social inuence (friends, teachers, and classmates). The researchers concluded that parental distress

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and marital discord were found to be signicant risk factor predictors; conversely, family support and perceived social support from parents, classmates, teachers, and friends were found to be signicant protective factor predictors of adaptation. Involving these sources of social inuence in the pediatric patients process of recovery can reap substantial rewards with regard to psychological adaptation. Providing the parents and the patient with support and frequent communication plays a large role in reducing the childs anxiety in the short term and facilitating compliance to medical recommendations in the long term [4749]. In addition, designating a treatment team member to have contact with school personnel and potentially visit the childs classroom can facilitate successful return and reintegration to school. Replantation issues Replantation procedures after a mutilating hand injury present unique issues beyond those presented by a mutilating hand injury alone. In addition to experiencing the hand injury as a lifethreatening event, these individuals are typically admitted to the hospital as emergencies, with decisions regarding surgical interventions rapidly occurring. As a result, there is minimal opportunity for psychological or emotional preparation. As with other mutilating hand injuries, replant patients experience signicant disruption in body image and bodily integrity. The replanted hand or digit may be perceived as foreign or altered because of its appearance or changes in sensation. Because of the visibility and functional importance of the hand, the individual must confront potential social stigma and the potential for functional impairment with subsequent loss in vocational, avocational, and interpersonal pursuits [27]. The hand surgeon is advised to consider the psychological characteristics of the individual before determining that replantation is the most appropriate option [27,50,51]. Situations in which replantation may be contraindicated because of psychological issues include self-inicted amputations or if the individual is insuciently motivated or is unable to comply with rehabilitative eorts and recommendations [27]. McCabe encourages the involvement of the patient, when feasible, in the replantation decision [52]. He suggests that patients are more likely to be satised with their care when given the opportunity to participate in decision-making, which would then lead to more favorable treatment outcomes. Obtaining a

psychiatric or psychological evaluation may be particularly helpful in instances in which the psychological factors present as particularly complex or convoluted. Such an evaluation may provide guidance to the hand surgeon regarding potential psychological factors that would negatively inuence the functional outcome of a replantation procedure [27].

Summary The immediate and long-term outcome of a mutilating hand injury can be positively inuenced by health care professionals adopting a biopsychosocial perspective toward treatment and management. Such an injury produces a psychological and social impact that should be openly and candidly addressed with the injured individual and with the family. The earlier and the more skillfully these issues are addressed, the more likely it is that psychological factors will not impede functional outcome.

Acknowledgments The author thanks Dr. Charles Callahan of Memorial Medical Center for his helpful comments and suggestions.

References
[1] Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196: 78108. [2] Klapheke MM, Marcell C, Taliaferro G, et al. Psychiatric assessment of candidates for hand transplantation. Microsurgery 2000;20:4537. [3] Chin KR, Lonner JH, Jupiter BS, et al. The surgeon as a hand patient: the clinical and psychological impact of hand and wrist fractures. J Hand Surg 1999;24A:5963. [4] Williamson GM, Schulz R, Bridges MW, et al. Social and psychological factors in adjustment to limb amputation. J Soc Behav Pers 1994;9:24968. [5] Grant GH. The hand and the psyche. J Hand Surg 1980;5:4179. [6] Klapheke MM. Transplantation of the human hand: psychiatric considerations. Bull Menninger Clin 1999;63:15973. [7] Bowden ML, Feller I, Tholen D, et al. Self-esteem of severely burned patients. Arch Phys Med Rehabil 1980;61:44952. [8] Craig AR, Hancock KM, Dickson HG. A longitudinal investigation into anxiety and depression in

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T. M. Meyer / Hand Clin 19 (2003) 4149 the rst 2 years following a spinal cord injury. Paraplegia 1994;32:6759. Krause JS, Crewe NM. Chronologic age, time since injury, and time of measurement: eect on adjustment after spinal cord injury. Arch Phys Med Rehabil 1991;72:91100. Sheeld CG, Irons GB, Mucha P, et al. Physical and psychological outcome after burns. J Burn Care Rehabil 1988;9:1727. Williams EE, Griths TA. Psychological consequences of burn injury. Burns 1991;17:47880. Lee PW, Ho ES, Tsang AK, et al. Psychosocial adjustment of victims of occupational hand injuries. Soc Sci Med 1985;20:4937. Davis CG, Lehman DR, Silver RC, et al. Self-blame following a traumatic event: the role of perceived avoidability. Pers Soc Psychol Bull 1996;22:55767. Van den Bout J, Son-Schoones N, Schipper J, et al. Attributional cognitions, coping behavior, and selfesteem in inpatients with severe spinal cord injuries. J Clin Psychol 1988;44:1722. Johnson RK. Psychologic assessment of patients with industrial hand injuries. Hand Clin 1993; 9:2219. Miller L. Civilian post-traumatic stress disorder: clinical syndromes and psychotherapeutic strategies. Psychotherapy 1994;31:65564. Louis DS. Evolving concerns relating to occupational disorders of the upper extremity. Clin Orthop 1990;254:1403. Grunert BK, Matloub HS, Sanger JR, et al. Eects of litigation on maintenance of psychological symptoms after severe hand surgery. J Hand Surg 1991;16A:10314. Modlin HC. Compensation neurosis. Bull Am Acad Psychiatry Law 1986;14:26371. Mendelson RL, Burech JG, Polack EP, et al. The psychological impact of traumatic amputations. Hand Clin 1986;2:57783. Schubert DS, Burns R, Paras W, et al. Decrease of depression during stroke and amputation rehabilitation. Gen Hosp Psychiatry 1992;14:13541. Kashini JH, Frank RG, Kashini SR, et al. Depression among amputees. J Clin Psychiatry 1983;44:26778. Rybarczyk B, Nyenhuis DL, Nicholas JJ, et al. Body image, perceived social stigma, and the prediction of psychosocial adjustment to leg amputation. Rehabil Psychol 1995;40:95110. Rybarczyk B, Nyenhuis DL, Nicholas JJ, et al. Social discomfort and depression in a sample of adults with leg amputations. Arch Phys Med Rehabil 1992;73:116973. Shukla GD, Sahu SC, Tripathi RP, et al. A psychiatric study of amputees. Br J Psychiatry 1982;141:503. Schwartz R, Prout M. Integrative approaches in the treatment of post traumatic-stress disorder. Psychotherapy 1991;28:364. [27] Schweitzer I, Rosenbaum MB. Psychiatric aspects of replantation surgery. Gen Hosp Psychiatry 1982;4:2719. [28] Williamson GM. The central role of restricted normal activities in adjustment to illness and disability: a model of depressed aect. Rehabil Psych 1998;43:32747. [29] Schubert DP, Taylor C, Lee S, et al. Physical consequences of depression in the stroke patient. Gen Hosp Psychiatry 1992;14:6976. [30] Grunert BK, Smith CJ, Devine CA, et al. Early psychological aspects of severe hand injury. J Hand Surg 1988;13B:17780. [31] Diagnostic and statistical manual of mental disorders. 4th edition. Washington (DC): American Psychiatric Association; 1994. [32] Gustafsson M, Persson LO, Amilon A. A qualitative study of stress factors in the early stage of acute hand trauma. J Adv Nurs 2000;32:133340. [33] Pulvertaft RG. Psychological aspects of hand injury. In: Hunter JM, Schneider LH, editors. Rehabilitation of the hand: surgery and therapy, 3rd edition. St. Louis: Mosby; 1990. [34] Grunert BK, Matloub HS, Sanger JR, et al. Treatment of posttraumatic stress disorder after work-related hand trauma. J Hand Surg 1990; 15A:5115. [35] Livneh H, Antonak RF, Gerhardt J. Multidimensional investigation of the structure of coping among people with amputations. Psychosomatics 2000;41:23544. [36] Gallagher P, MacLachlan M. Positive meaning in amputation and thoughts about the amputated limb. Prosthet Orthot Int 2000;24:196204. [37] Thompson J. Stress theory and therapeutic practice. Stress Med 1992;8:14750. [38] Himmelstein JS, Feuerstein M, Stanek EJ, et al. Work-related upper-extremity disorders and work disability: clinical and psychosocial presentation. J Occup Environ Med 1995;37:127885. [39] Miller L. Psychotherapeutic approaches to chronic pain. Psychotherapy 1993;30:11524. [40] Schreiber S, Galai-Gat T. Uncontrolled pain following physical injury as the core-trauma in post-traumatic stress disorder. Pain 1993;54: 10710. [41] Krane EJ, Heller LB. The prevalence of phantom limb sensation and pain in pediatric amputees. J Pain Symptom Manage 1995;10:219. [42] Wichell E. Coping with limb loss. Garden City Park (NY): Avery; 1995. [43] Sherman R, Sherman C. Prevalence and characteristics of chronic phantom limb pain among American veterans: results of a trial survey. Am J Phys Med 1983;62:22738. [44] Pell JP, Donnan PT, Fowkes FR, et al. Quality of life following lower limb amputation for peripheral arterial vascular disease. Eur J Vasc Surg 1993;7: 44851.

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[49] Varni JW, Setoguchi Y. Eects of parental adjustment on the adaptation of children with congenital or acquired limb deciencies. J Dev Behav Pediatr 1993;14:139. [50] Kleinart HE, Tsu-Min T. Microvascular repair in replantation. Clin Orthop 1978;133:20511. [51] Phelps DB, Lilla JA, Boswick JA. Common problems in clinical replantation and revascularization in the upper extremity. Clin Orthop 1978;133: 1125. [52] McCabe SJ. Patient participation in the decision for replantation. Hand Clin 2001;17:3515. [53] Turgay A, Birsen S. Emotional aspects of arm or leg amputation in children. Can J Psychiatry 1983; 28:2947.

Hand Clin 19 (2003) 5161

Fracture xation in the mutilated hand

Alan E. Freeland, MDa,*, William C. Lineaweaver, MDb, Sheila G. Lindley, MDa,b
a

Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA b Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA

The hand is composed of ve tissues: integument, skeletal tissue (bones, joints, and ligaments), vessels, nerves, and tendons. Mutilating (complex) injuries are devastating, soiled, high-energy multistructural wounds that cause substantial loss or damage to one or more of these tissues. Other simple injuries, such as skin, vessel, tendon, or nerve lacerations and simple fractures, may coexist. The injury may primarily involve the radial, ulnar, dorsal, or palmar side or the middle of the hand [1]. One or more digits may be involved. Industrial and farm machinery, snow blowers, boat propellers, lawn mowers, blasts, reworks, vehicular collisions, power saws, wood chippers, meat grinders and slicers, high-velocity (velocity greater than 2000 ft/s) gunshots, and close-range shotgun wounds are common causes of these injuries [27]. Although low-velocity (velocity less than 1000 ft/s) gunshot wounds may involve only a single digit or ray, the fractures that occur may be as severe as in high-velocity gunshot wounds even if the soft tissue wounds are not as severe [4,5,8]. Mutilating injuries occur in the workplace, on farms, at homes, during civil disobedience, and at war. Although these injuries are open, there may be accompanying fractures that have no overlying wound. Wound contamination is the rule rather than the exception; multiple organisms may be involved. Confounding social, economic, and psychological factors are commonly associated. Infection, functional loss, amputation, and

chronic pain are grave consequences of these injuries. Outcomes Functional outcomes correlate highly with initial injury severity [916]. Contamination, the time from wounding to treatment, joint involvement, fractures adjacent to and tendon injuries within the exor sheathes, and full thickness skin loss are also important outcome determinants. The surgeon has the opportunity to inuence outcome favorably by early denitive wound excision, fracture stabilization, and soft tissue repair or reconstruction and, when indicated, by early arthrodesis or amputation. Management in the emergency room or equivalent setting (Battalion Aid Station) The issue of tetanus prophylaxis should be dealt with emergently. A gram stain and aerobic and anaerobic cultures should be performed on the wound exudates. When possible, this evaluation should be done before initiating antibiotics. Two examinations are performed: one in the preoperative emergency entry setting and the other in the operating room [17]. The wound is inspected for injuries. Examination of tendon and nerve motor and sensory function is as thorough as pain and patient cooperation allows. Injuries are catalogued as to site, the tissue involved, and severity (simple or complex). Multiple-view radiographs should be taken. Fractures may be simple (transverse or oblique) or complex (comminuted or involving loss).

* Corresponding author. E-mail address: afreeland@orthopedics.umsmed.edu (A.E. Freeland).

S0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. PII: S 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 0 5 7 - 4

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Fracture management Fractures are treated within the context of overall wound management. Skeletal stabilization is the foundation for wound management and enhances the healing of all bone and soft tissue repairs and reconstruction, including replantation [4,5,10,11,1834]. Anatomic (or near anatomic) fracture reduction and stabilization also help to control pain, minimize the risk of dead space in the wound, inhibit infection, and allow earlier and more intensive hand rehabilitation. Stability in this context connotes that the fracture would not be at risk of spontaneous collapse or collapse with active unresisted exercises. As little additional soft tissue dissection should be done initially as is necessary to achieve reliable stability. Early delayed primary autogenous or synthetic bone grafting is performed to ll skeletal defects and sometimes to achieve arthrodesis for irreparable joint defects [4,5,23,35]. Results are optimal when all phases of repair and reconstruction are completed within the rst few days after injury. 17Carm uoroscopy is a denite advantage in treating fractures when it is available. Initial surgery Ideally, when overall priorities, sucient personnel, adequate operating room facilities, and transportation permit, the patient is moved expeditiously to the operating room. The wound is irrigated to dilute or remove hematoma and contaminants, and clearly necrotic tissue is debrided [19,36]. A second set of gram stains and cultures may be taken. Culture specimens obtained from debrided tissue are more reliable than those from wound swab or other supercial samples [37]. Injuries are again catalogued by direct anatomic inspection. Antibiotics may be started based on broad coverage or organism expectations. Concurrent fracture treatment and revascularization Revascularization is infrequently necessary in mutilated hands because of the severity of the crush and blast components, but re-establishment of tissue perfusion is a priority when indicated. It is generally performed after skeletal xation and tendon and nerve repair unless there are urgent time constraints [16,2426,38]. Modern methods of fracture xation usually permit stable anatomic denitive

fracture xation to be accomplished quickly. The microvascular surgeon may then proceed on a stable platform. The time lost during fracture xation may be regained by providing the microvascular surgeon a stable environment. Whenever possible, initial denitive stable fracture xation obviates the risk of later vascular occlusion caused by fracture instability or injury while exchanging provisional for more stable denitive xation. Although a single axial Kirschner wire or crossed Kirschner wires may be used to splint fractures and may provide sucient xation (especially in children and when under urgent time constraints), tension band and interosseous wiring techniques [39] or 90-90 cerclage wires [40] are more reliable wiring techniques. The wound may allow the application of a mini plate with little or no additional dissection. The mini-H plate was especially designed for such use in fractures that are transverse or only slightly oblique [41]. Fractures may be quickly shortened by transverse mini saw cuts to achieve this conguration and, together with excision of damaged adjacent tissue, may allow primary repair of undamaged ends of tendons, nerves, skin, and vessels by cutting out the zone of injury. Stable anatomic fracture reduction is a fundamental step in the surgeons eort to avoid a viable but deformed or functionless digit that becomes an impediment to overall hand function. Simple fractures We believe that most if not all simple fractures may be stabilized at the time of initial surgery with Kirschner wires or with mini external xation. Intramedullary Kirschner or equivalent wires are used for transverse or short oblique (less than 45 angle) fractures and are applied transversely or obliquely to stabilize long oblique (greater than 45 angle) fractures. Kirschner wires splint but do not compress fractures. Intramedullary Kirschner wires do not control fracture rotation, and slight angulation may occur because they do not ll the intramedullary canal. Nonunion may also occur. Kirschner wires are not as stable for long oblique diaphyseal or oblique intra-articular fractures as are mini lag screws, which add stability by compressing the fracture. They may be preferred, however, because of ease of application or small fragment size. Mini screws are Kirschner wires that have threads on their core to purchase the distal fracture fragment and a head to buttress the proximal

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fragment. They are not used for transverse or short oblique fractures. These screws may be inserted initially or at the time of a second look at the discretion of the surgeon. One or more transxation wires may be applied proximally and distally to a simple diaphyseal fracture of any conguration for either provisional or denitive xation. Mini external xators may be similarly applied [21,3032]. Whenever possible in extra-articular fractures, the mini xator should avoid spanning an unfractured joint so as to avoid interference with mobilization and rehabilitation. Complex fractures Complex fractures should at least be provisionally stabilized at the time of initial surgery [19]. We prefer not to leave the operating room without restoring fracture length and alignment. Despite our best intentions to return to the operating room for denitive stabilization and often delayed primary bone grafting of these fractures within 48 to 72 hours after initial surgery, there are times when unforeseen circumstances intervene. Provisional xation minimizes the risk of later stiness in the face of such circumstances. Spacer wires, axial intramedullary wires, transxation wires, mini external xators, or combinations of these are used for provisional xation [21,3032]. In instances of simple fractures, especially in children, they may provide denitive xation as well. Repair and reconstruction Ideally, the patient is returned to the operating room for delayed primary fracture repair and bone grafting 4872 hours after initial surgery [23]. The timing of the application of internal xation, bone grafting, soft tissue repair and reconstruction, and wound closure or coverage is dependent upon wound cleanliness (fewer than 105 bacteria/mL) rather than a specied amount of time elapsed [19,36,37,42]. If a wound is clean enough to close or cover, it is clean enough to repair or reconstruct. An experienced surgeons assessment by inspection has accuracy parallel to that of bacterial counts and is innitely more practical. With modern methods of wound excision and fracture xation, there is a growing trend to perform comprehensive denitive treatment initially, at least in cases selected for adequacy of debridement. When successful, this may allow earlier

and more intensive rehabilitation and may have a positive inuence on functional outcome. Additional consideration should be given to the need for stable internal fracture xation (mini screws or plates) in the polyfractured hand. Such xation may be a necessity for optimal outcome in comminuted fractures and in fractures with bone loss. Kirschner wires or mini external xator pins may partially or completely impale tendons, causing rupture by attrition or transxing the extensor mechanism and impeding motion. Kirschner wires merely splint fractures. They lose their eectiveness or must be removed 46 weeks after application and may thus lead to fracture nonunion or malunion [43]. Kirschner wires may also migrate. They may irritate the skin or be difcult to remove if cut under the skin. These wires may present associated drainage and infection problems if allowed to protrude above the skin, although this seldom leads to permanent damage. The surgeon must consider these many and varied factors in making a nal decision for fracture xation. Mini screws may easily be exchanged for Kirschner wires in long oblique and intra-articular fractures. Concentric Kirschner wire and mini screw diameters facilitate this exchange. A 0.045inch (1.1-mm) diameter Kirschner wire is the same diameter as the screw core of the 1.5-mm thread diameter mini screw. A 0.062-inch (1.5-mm) diameter Kirschner wire is the same diameter as the screw core of the 2.0-mm thread diameter mini screw. Removal of the Kirschner wire, drilling of the proximal cortex to the mini screw thread diameter, and insertion of the appropriate size self-tapping mini screw achieves a stable compression mini lag screw xation. Four- or ve-hole mini compression plates may be substituted for intramedullary wires to stabilize transverse or short oblique fractures, often with minimal additional dissection owing to the exposure provided by the wound itself. The damage from further dissection may be obviated by the additional stability achieved. The disadvantage of the foreign body of the mini plate is oset by the fact that stainless steel and titanium do not support infection and also that fracture stability inhibits infection and enhances the healing of all tissues. A clean wound and fracture stability are the common denominators in successful internal xation. Mini plates are often the best choice to span defects. Although hand fractures treated with mini plate xation are often said to have poorer outcomes than those treated with other implants,

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these results have not always been carefully correlated with injury severity. When such correlations are made, outcomes correlate more with wound and fracture severity and with the amount of operative dissection necessary to apply the mini plate than with the use of the mini plate itself [10,11]. When further operative dissection is necessary, the risks of additional stiness resulting from the dissection are somewhat compensated by the stability, pain control, and earlier and more intensive rehabilitation allowed by stable mini plate xation. In fractures with comminution or loss, straight mini plates may be applied on the mid diaphysis, and mini condylar plates may be applied near the metaphyses. Delayed primary bone grafting is performed concurrently when needed. Compressed autogenous distal radial or iliac cancellous bone graft or synthetic bone graft may be used for incomplete defects or for complete defects of up to approximately 1.5 cm. Cancellous bone is loaded into the barrel of a syringe and compressed with the syringe plunger. The bone can be removed from the barrel by inserting a long spinal needle retrograde into the syringe and pushing it out. Autogenous corticocancellous bone grafts from the same donor sites may be inserted into larger diaphyseal defects. Either type of bone graft may be inserted into destroyed joints to achieve delayed primary arthrodesis. Bone carpentry may be used to fashion adaptive dowel and socket or mortise congurations to secure the fracturebone graft junctures [35]. This procedure enhances stability, allows mini plate compression at either or both junctures, and increases the surface area at the junctures to help to ensure healing. Permanent stable internal xation reduces the risks of fracture collapse by premature implant removal, thus decreasing the associated potential for nonunion, malunion, and digital stiness. Amputation Amputation is an extreme measure that is reserved for nonviable digits that cannot be salvaged by revascularization. This procedure is preferable to an interminable eort to salvage a digit that will be sti, painful, and nonfunctional and that will interfere with or obstruct remaining hand function [9,38]. Parts of amputated digits may be used to reconstruct adjacent salvageable digits [44,45]. Although there are a number of methods of scoring digital function to decide whether an injury is severe enough to warrant amputation,

we have found none more practical and useful than that of McCormack [46]. McCormacks criterion for digital amputation is the existence of segmental damage to three or more of the tissues that comprise a digit. The thumb is an exception to the rule. Every eort should be made to preserve the thumb, its length, and its function. One useful alternative to amputation that may be useful, especially in the thumb, is the shortening by a segmental excision of the damaged tissues in the zone of injury, thus allowing their primary repair.

Illustrative cases Case 1 A young adult male truck driver rolled his truck over. His left nondominant hand was crushed between the top of the cab and the road (Fig. 1AC ). There was a mutilating injury of the dorsum of the hand with some extension over the volar surface of the thumb. His index, middle, and ring ngers were irreparably damaged. He had no other serious injuries. On the day of injury, the wounds were debrided, and the thumb and small nger were stabilized with axial Kirschner wires. Two days later, the wound was redebrided; the 2nd and 3rd metacarpals were osteotomized at their bases, and the distal portions were resected; the bones of the index, middle, and ring ngers were lleted; and the remaining digital soft tissue was used as ap coverage to partially cover the wounds. A subcapital 5th metacarpal fracture was stabilized with a mini T-plate. Split-thickness skin grafts were applied to the remaining open portion of the wound (Fig. 1DF). Two months later, the distal interphalangeal joint of the small nger was fused, and a rotational osteotomy of the base of the 5th metacarpal was performed to align the exor pad of the small nger with that of the thumb (Fig. 1GJ). The patient recovered a functional 2-digit hand and was able to return to his previous occupation as a truck driver. Case 2 A young mans hand was crushed in a punch press, creating a bursting injury in the middle of the hand centered over the 3rd metacarpal phalangeal joint where there were irreparable comminuted fractures of the metacarpal head and base of the proximal phalanx. There was segmental

Fig. 1. (AC) Initial injury. (DF) Delayed primary treatment. (G) Rotational osteotomy of the base of the 5th metacarpal and arthrodesis of the distal interphalangeal joint of the small nger. (HJ) Final result.

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Fig. 2. (A, B) The hand at the time of the second look. (C, D) Initial radiographs. (EH) After denitive surgery.

damage to the extensor hood of the metacarpal phalangeal joint of the middle nger. The middle nger was insensate because of segmental crush injuries of the digital nerves. There were also unstable oblique fractures of the 2nd and 3rd metacarpal shafts. There was dorsal skin loss over the 3rd metacarpal phalangeal joint (Fig. 2AD). At second-look surgery, the wounds were cleansed, debrided, and directly inspected. We considered the middle nger functionally unsalvageable. The 3rd metacarpal was osteotomized at its base, and the distal portion was resected. The bones were lleted from the middle nger. After reduction and xation of the 2nd metacarpal fracture, the lleted middle nger ap was used to close the dorsal skin defect, and the remaining wounds were sutured (Fig. 2ED). The patient recovered sucient hand function to return to his job.

Case 3 A young man sustained a high-velocity gunshot wound to his right dominant thumb as a result of a hunting accident. The distal thumb metacarpal was totally destroyed. There was a comminuted fracture of the base of the proximal phalanx. The overlying extensor mechanism and adjoining segments of the extensors pollicus longus and brevis were destroyed. There was substantial dorsal skin loss. The exor tendons were damaged but intact. The thumb was viable and sensate. Initially, the wound was debrided, and the thumb was provisionally stabilized with an external xator (Fig. 3A, B). A few days after initial surgery, the wound was cleaned, and delayed primary arthrodesis of the metacarpal phalangeal joint was performed using a cortical cancellous iliac bone graft, dowel and socket technique, and mini reconstruction

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Fig. 2 (continued )

T-plates. A lateral arm free-ap was used for coverage (Fig. 3CF) The patient recovered sucient thumb function to return to farm and general labor work (Fig. 3GI). Case 4 A 62-year-old retired veteran sustained a power saw injury to his right dominant thumb at his home. There was an open intra-articular fracture of the base of the proximal phalanx and segmental loss of the overlying extensor tendons and the radial neurovascular bundle (Fig. 4A, B). The zone of injury was excised using parallel saw cuts for the bone so that all of the injured structures could be repaired primarily (Fig. 4C). Three years later, the injured thumb was healed, pain-free, and was

shortened and slightly sti but quite functional. The patient was entirely satised with his result (Fig. 4DF).

Rehabilitation Although the stages of rehabilitation are articial and overlapping, they provide a plan and sequencing of recovery that the physician, the therapist, and, most importantly, the patient can understand and implement. These stages include wound healing; recovery of motion; strengthening and conditioning; and return to the activities of daily and independent living, work, family, and household responsibilities, child and elder care, and recreation.

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Fig. 3. (A) The thumb at the time of injury. (B) Radiograph after initial surgery. (C) At the time of delayed primary reconstruction. The arrows in the background material point to the sockets that were fashioned in the remaining metacarpal and proximal phalanx. (D) Corticocancellous iliac bone graft with dowels at each end. (E, F) Intraoperative photograph and an radiograph demonstration of insertion and xation of the bone graft with good alignment and stabilization with mini reconstruction T-plates. (GI) Good postoperative thumb function is shown (note the healed lateral arm free-ap).

Recovery of motion is the key component. All else may be achieved provided motion is recovered. Early motion instituted while collagen remains tractable and before scar contraction favors functional recovery. As soon after surgery as wound conditions permit, gentle progressive active and passive digital motion exercises may be initiated, starting from the midrange and working toward the extremes of full exion and extension. As pain and swelling subside, intensity may be increased, and excursion may advance proportionately. Fracture callus usually starts to calcify at 1021 days after injury. When calcied fracture callus is seen on radiograph, the fracturebone graft-implant construct has sucient strength to allow an all-out eort to achieve the extremes of motion. Early primary callus may be presumed at 2128 days after injury in

fractures secured by rigid internal xation (ie, the fracture does not have micro motion with the stresses of digital motion). Strengthening and conditioning exercises may be initiated and progressively implemented by increasing resistive forces within the patients pain tolerance. Pain is an important protective signal against excessive forces. Soft polyfoam theraballs have proved an outstanding method of combining digital motion and early strengthening exercises. Endurance is achieved by increasing repetitions. Warm water soaks are soothing, and the buoyancy they aord implements the recovery of motion. The risk of increasing edema is compensated by elevation. Retrograde massage and compression garments such as Isotoner gloves worn at night counteract edema. Compression pumps may also be used to combat edema. Massage softens, desensitizes,

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59

Fig. 3 (continued )

and mobilizes scar tissue. Vibration and soft silastic application may also help to diminish scar induration. Static and dynamic splinting may help the recovery of motion and may be started 46 weeks after surgery, especially when active motion is not progressing. Electrical muscle stimulation may also be used in stubborn cases. These therapeutic measures are continued until the patient reaches a point of maximum medical improvement. Manual tasks of routine daily living, work, and recreation may be simulated, and a specic program may be tailored for each individual to meet his or her needs to re-establish lifestyle, regain employment, and return to recreational activities.

Summary Early anatomic (or near anatomic; ngers do not impinge or overlap during exion or extension) stable fracture xation provides the foundation for successful wound management and for the repair, reconstruction, and healing of all damaged tissues in a mutilating hand injury. It also plays an instrumental role in pain control and aords an optimal opportunity for timely and favorable rehabilitation of and recovery from mutilating injuries of the hand. Kirschner or other wiring systems or mini external xators may be used for simple fractures, in children, when rapid fracture xation is necessary, and for provisional

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Fig. 4. (A, B) Photograph and radiograph at the time of injury. (C) Postoperative radiograph demonstrating the fracture xation. (D) Fracture healing 3 years after injury. (From Freeland AE. Hand fractures: repair, reconstruction, and rehabilitation. Philadelphia: Churchill Livingstone; 2000, p. 282; with permission.)

fracture xation. Mini plates should be considered for fractures with comminution or loss and in instances of multiple fractures. Fingers with segmental injury of three or more tissues should be considered for early amputation to avoid prolonged and impaired recovery of the hand. Every eort should be made to preserve the thumb and its function by repair or reconstruction.

[5]

[6] [7] [8]

References
[1] Reid DAC. The severely mutilated hand. In: Reid DAC, Gosset J, editors. Mutilating injuries of the hand. New York: Churchill Livingstone; 1979. p. 314. [2] Brandner M, Bunkis J, Trengove-Jones G. Meat grinder injuries to the upper extremity. Ann Plast Surg 1985;14:4547. [3] Burkhalter W. Mutilating injuries of the hand. Hand Clin 1986;2:4568. [4] Gonzalez MH, Hall M, Hall RF. Low velocity gunshot wounds of the proximal phalanx: treatment [9]

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by early stable xation and bone grafting. J Hand Surg 1998;23A:1505. Gonzalez MH, McKay W, Hall RF. Low velocity gunshot wounds of the metacarpal: treatment by early stable xation. J Hand Surg 1993;18A: 26770. Gorsche TS, Wood MB. Mutilating corn-picker injuries of the hand. J Hand Surg 1988;13A:4237. Kon M. Fireworks injuries to the hand. Ann Chir Main 1991;10:44377. Elton RC, Bouzard WC. Gunshot and fragment wounds of the metacarpals. South Med J 1975; 68:83343. Arnoud JP, Mallet T, Pecout C, et al. Role of amputation in isolated complex injuries of the index nger. J Chir 1986;123:3215. Chow SP, Pun WK, So YC, et al. A prospective study of 245 open digital fractures of the hand. J Hand Surg 1991;16B:13740. Duncan RW, Freeland AE, Jabaley ME, et al. Open hand fractures: an analysis of the recovery of active motion and of complications. J Hand Surg 1993; 18A:38794.

A.E. Freeland et al / Hand Clin 19 (2003) 5161 [12] Huaker WH, Wray RC Jr., Weeks PM. Factors inuencing nal range of motion in the ngers after fractures of the hand. Plast Reconstr Surg 1979; 63:827. [13] McLain RF, Steyers C, Stoddard MD. Infections in open fractures of the hand. J Hand Surg 1991; 16A:10812. [14] Strickland JW, Steichen JB, Kleinman WB, et al. Phalangeal fractures: factors inuencing performance. Orthop Rev 1982;1:3950. [15] Swanson TV, Szabo RM, Anderson DD. Open hand fractures: prognosis and classication. J Hand Surg 1991;16A:1017. [16] Utvag SE, Grundes O, Reikeraos O. Eects of periosteal stripping on healing of segmental fractures in rats. J Orthop Trauma 1996;10:27984. [17] Weeks PM. Hand injuries. Curr Probl Surg 1993;30:721807. [18] Chen SHT, Wei FC, Chen HC, et al. Miniture plates and screws in complex hand injuries. J Trauma 1994;37:23742. [19] Churchill ED. The surgical management of the wounded in the Mediterranean theater at the time of the fall of Rome. Ann Surg 1944;120:26883. [20] Czier E, Farkas J, Turchanyi B. Management of potentially infected complex hand injuries. J Hand Surg 1991;16A:8324. [21] Freeland AE. External xation for skeletal xation of severe open fractures of the hand. Clin Orthop 1987;214:93100. [22] Freeland AE, Jabaley ME. Stabilization of fractures of the hand and wrist with traumatic soft tissue and bone loss. Hand Clin 1988;4:42536. [23] Freeland AE, Jabaley ME, Burkhalter WE, et al. Delayed primary bone grafting in the hand and wrist after traumatic bone loss. J Hand Surg 1984;9A:228. [24] Friedel R, Schmidt I. The treatment concept in severe hand injuries. Zentralbl Chir 1997;122:101623. [25] Germann G, Karle B, Bruner S, et al. Treatment strategy in complex hand injuries. Unfallchirurg 2000;103:3427. [26] Levin LS, Condit DP. Combined injuries: soft tissue management. Clin Orthop 1996;327:17281. [27] Merritt K, Dowd JD. Role of internal xation in infection of open fractures with Staphylococcus aureus and Proteus mirabilis. J Orthop Res 1987; 5:238. [28] Pechlaner S, Hussl H. Complex trauma of the hand. Orthopade 1998;27:116. [29] Puckett CL, Welsh CF, Croll GH, et al. Application of maxillofacial miniplating and microplating

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systems to the hand. Plast Reconstr Surg 1993; 92:699709. Schmidt I, Markgraf E, Friedel R, et al. Indications for a new joint-bridging miniature external xator in primary and secondary management of complex hand injuries. Zentralba Chir 1995;120:94551. Seitz WH Jr., Gomez W, Putnam MD, et al. Management of severe hand trauma with a mini external xateur. Orthopedics 1987;10:60110. Siebert HR, Senst S. Combined internal-external osteosynthesis in severe hand injuries: indications and techniques. Tech Orthop 1991;6:3440. Smith RS, Alonso J, Horowitz M. External xation of open comminuted fractures of the proximal phalanx. Orthop Rev 1987;16:93741. Wannske M. Complex hand injuries. Handchir Mikrochir Plast Chir 1995;27:210. Littler JW. Metacarpal reconstruction. J Bone Joint Surg 1947;29A:72337. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:28592. Heller W, Gottlieb L, Zachary L, et al. The use of quantitative bacteriologic assessment of bone. Plast Reconstr Surg 1997;100:397401. Osuna-Arellano A, Wegener EE, Freeland AE. Mutilating injuries to the hand: early amputation or repair and reconstruction. Orthopedics 1999; 22:6834. Lister G. Intraosseous wiring of the digital skeleton. J Hand Surg 1978;3A:42735. Zimmerman NB, Weiland AJ. Ninety-ninety interosseous wiring for internal xation of the digital phalanx. Orthopedics 1989;12:99104. Nunley JA, Goldner RD, Urbaniak JR. Skeletal xation in digital replantation. Clin Orthop 1987; 214:6671. Jabaley ME, Peterson HD. Early treatment of war wounds of the hand and forearm in Vietnam. Ann Surg 1973;177:16773. Whitney TM, Lineaweaver WC, Buncke HJ, et al. Clinical results of bony xation methods in digital replantation. J Hand Surg 1990;15A:32834. Chase RA. The damaged index nger: a source of components to restore the crippled hand. J Bone Joint Surg 1968;50A:115260. Chase RA. The severely injured upper limb: to amputate or reconstruct: that is the question. Arch Surg 1970;100:38292. McCormack RM. Reconstructive surgery and the immediate care of the severely injured hand. Clin Orthop 1959;13:7582.

Hand Clin 19 (2003) 6371

Soft tissue coverage in devastating hand injuries

Goetz A. Giessler, MD*, Detlev Erdmann, MD, Guenter Germann, MD, PhD
Department for Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic & Hand Surgery, University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany

Mutilating hand injuries can be dened as severe multistructural injuries regularly including destruction of bones, tendons, soft tissues, and the integument to a various degree. The etiology includes burns, crush and degloving injuries, amputations, penetrating injuries, and high-pressure injections. Plastic surgical therapy is focused on early rehabilitation by restoration of functional anatomy and cosmesis. It represents a multifaceted task to the hand surgeon, where considerations about indication, timing, and structure of the soft tissue coverage play a major role in the reconstructive concept [13]. A sophisticated structural reconstruction of the osseotendinous framework is useless if not protected with adequate soft tissue cover. It is the soft tissue envelope of the hands that transfers touch, sensibility, temperature feeling, pinch, and grip. A stabile but exible integument is also required for the extremely important individualized intensive physiotherapy after mutilating hand injuries. Furthermore, the hands are important instruments of interpersonal communication being some of the few constantly visible contact zones. The complexity of soft tissue reconstruction after a devastating trauma [2] with the wide variety of possible tissue transfers from local, regional, or distant areas, sensate or not sensate, isolated or combined in shape and structure needs a systematic approach to adjust it to the individual case prole as follows: Patient-specic factors (age, general health, mobility, comorbidity, profession, and socioeconomic status)

Defect genesis (crush, penetration, degloving, thermal, amputating, and so forth) Localization Size and depth Exposed structures Structures to be reconstructed Contamination Surrounding tissue (color, hair, and texture) Algorithms based on the reconstructive ladder help in decision making about soft tissue coverage (Fig. 1) [2]. Based on the case prole, the quickest, easiest, safest, and best suited methods have to be used for the best possible outcome. This implies that even a sophisticated free ap procedure is no longer considered as an ultima ratio option, but is chosen rather early, if it provides the best possible result. This is supported by a more aggressive approach with respect to procedure timing, which evolved in recent years. Encouraging data were provided by Godina [4], who showed that with early microsurgical reconstruction (up to 72 hours) following radical debridement, the postoperative morbidity, infection rate, and the number of subsequent procedures was signicantly lower than with delayed or late operations. These results were supported by the data of Lister and Scheker [5] and Ninkovic et al [6] using emergency ap coverage within 24 hours after injury. All authors equally demonstrate successful long-term results both clinically and socioeconomically.

Reconstructive algorithms Even if the concept of early integrative reconstruction promotes early vascularized ap coverage, a thorough wound preparation is still mandatory to prevent placement of a healthy ap

* Corresponding author. E-mail address: giessler@hotmail.com (G.A. Giessler).

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. doi:10.1016/S0749-0712(02)00128-2

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Fig. 1. Reconstructive algorithm for soft tissue coverage of devastating hand injuries.

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in a contaminated wound bed with remaining devitalized tissue [1]. All reconstructive procedures must be preceded by a thorough surgical debridement. This is initiated by tissue cleaning using soft detergents, such as chlorhexidine. Pulsed irrigation (jet lavage) is rarely indicated in the delicate structures in the hand, but may help in wounds with large amounts of particulate foreign material. Necrotic and questionably viable material is carefully excised [7]; vital functional structures should be preserved whenever possible. The resulting defect after debridement is often much larger than previously estimated. In wounds with areas of indeterminate tissue viability, heavy contamination, or in a vitally threatened patient it is wise to close the wound temporarily. Vacuum sealing and drainage or skin substitutes provide adequate coverage until a scheduled second look is performed 24 to 48 hours later [8]. In devastating hand injuries, the surgeon rarely is confronted with supercial skin losses, which can be closed with various techniques of splitand full-thickness skin grafting [9]. The high contracture potential, limited scar exibility, and disappointing sensibility limit their successful use in hands, except in donor site coverage of some locoregional aps. Although both grafting techniques still play a central role in burn surgery, meshed skin grafts should be denitively avoided in the hand. Local aps Complex, full-thickness losses of the integument are more frequently encountered in complex trauma to the hand. In the hand, it can be dicult to replace like with like by local aps, because the availability of surrounding tissue can be scarce, especially in the digits. Local aps often play only a minor role in mutilating injuries, but can still be of importance in special reconstructions (ie, by providing sensibility to the ngertips). Nevertheless, the reconstructive surgeon has always to take into account the additional operative trauma to the extremity, which results in scar formation, and may acutely or chronically impair lymphatic and venous drainage. There is an abundance of local aps in the hand, but the hand surgeon dealing with mutilating hand injuries should be familiar with some reliable examples. Fingertip amputations can often be treated with various transposition aps [10,11] to provide a stable ngertip with acceptable two-point discrimination. Smaller defects on the lateral aspect and the dorsum

of the ngers are preferably closed with pedicled aps, especially when the extensor tendon mechanism is exposed. Cross-nger aps [12], aps based on the dorsal metacarpal arteries [13], and various sensate kite aps [14,15] bring their own blood supply and provide stable coverage, rapid healing, and good pliability. Their donor sites are homodigital or heterodigital or from the dorsum of the hand, and are closed primarily or with small skin grafts. In severe hand injuries with involvement of several regions of the hand, availability of local aps is frequently limited because of the potential damage of the donor area. Especially in crush injuries and high-pressure injection trauma, tissue viability often cannot be estimated properly in the rst hours after the trauma, signicantly increasing the risk of using local solutions. In these cases, regional or distant aps provide more safety. Regional aps The development of axial-pattern regional aps was a major breakthrough several decades ago [16], but their importance has somewhat decreased since the introduction of microsurgery. They can still be extremely helpful, however, where the latter is not available, and the use of a free ap is contraindicated or for other reasons is not possible. The best known axial pattern ap in the upper extremity is the radial forearm ap, based on the radial artery. It can only be used if the patency of both major vessels is preserved, and an Allens test has been performed before the operation. Although studies have shown that the perfusion of the hand is not decreased when the radial artery is missing, its use has decreased because the donor site leaves a signicant aesthetic impairment. In young patients, preservation of limb vessels in case of possible future injuries seems wise. In general, pedicled aps from the forearm should not be based on major vascular axis whenever this is permitted by the local conditions. The reverse pedicled posterior interosseous artery ap [17], the reverse ulnar perforator ap [18], or the reverse radial artery perforator ap can provide excellent results for mid-size soft tissue defects without sacricing a major artery. Distant aps One of the most important distant aps is the groin ap [16]. It is used mostly as an ipsilateral pedicled ap, which is divided after 3 weeks, but can also be used as a free ap. The latter is used less

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frequently because of frequent vascular anomalies of the arterial pedicle [19]. The denite advantage of this ap is its donor site, where primary closure is often possible up to a width of 10 to 12 cm, and the scar easily can be hidden. The groin ap provides good coverage of defects for the hand and distal forearm. Because a relatively large skin area can be dissected with the pedicle, the ap has certain importance in wound closure of amputations (thumb), where the additional tissue can provide sucient bulk for a later toe transfer [1]. It must not be forgotten that despite its easy dissection, the groin ap usually requires four to ve procedures to obtain a denite result, which is in part caused by the variable volume of the ap depending on the patients habitus. Finally, the patient treated with a groin ap needs to be very compliant throughout the whole pedicled phase, especially when physiotherapy is performed in this stage.

surgery [24,25]. They can cover large defect areas, have reliable and long vascular pedicles, and can be combined with each other and other aps of this vascular system (eg, M. serratus ap) [25,26]. The cutaneous parascapular ap yields good results especially in slim patients, and usually provides hairless skin. Equally important for upper extremity and hand defects is the possibility of gaining gliding tissue by simultaneous elevation of fascia. The latissimus dorsi muscle is one of the largest aps of the body and extremely pliable, but may be bulky in the upper extremity. A skin island can obviate the need for a split-thickness skin graft (Case 1, Fig. 2). Both aps can be harvested with a vascularized bone segment from the lateral border of the scapula (R. angularis), which can be used for structural reconstructions of skeletal injuries [27]. The donor site can always be closed primarily, and becomes inconspicuous under normal clothes. Lateral arm ap

Free aps Microvascular free aps demonstrate the highest versatility of all soft tissue coverage procedures and are among the rst choices in treating mutilated hands. The main advantages are that they can be harvested in almost any size required; are raised from a distant donor site; bring their own blood supply and angiogenic and lymphogenic potential; and not only cover defects, but actively improve venous and lymphatic drainage of the traumatized area [20]. Although they are frequently inferior to local aps regarding texture and color match, this is considered less important in mutilating injuries. In severely injured hands, often considerable areas of skin and subcutaneous structures are missing, and tendons, joints, vessels, or nerves are exposed. Free aps have adequate dimensions, and allow harvesting of additional vascularized tissue components, which make complete single-stage reconstructive procedures possible (ie, chimeric aps [see Fig. 1]) [2123]. Free transfer of equivalent tissue from the contralateral hand should be performed exclusively in bilateral mutilating injuries carefully balancing the soft tissue situation in both extremities. The following free aps are part of the standard armamentarium in soft tissue reconstruction of mutilated hands, and provide a wide variety of procedures for certain indications. Parascapular, scapular, and latissimus dorsi aps These aps belong to the subscapular artery system, and are established work horses in plastic

Clinically introduced by Katsaros et al [28] the cutaneous lateral arm ap is a versatile ap for medium-sized defects. It is mostly harvested ipsilateral, and structural elements, such as a humeral bone segment of several centimeters length or a tendon slip from the triceps muscle, can be harvested with it [22]. The posterior cutaneous nerve innervates the ap, which can make it useful for reconstruction of the rst web space or the palm. Donor sites of up to 6 to 8 cm width usually can be closed primarily, but may still result in a conspicuous scar. The ap may have a distinct subcutaneous fat layer, which later requires debulking. Radial forearm ap Since its clinical introduction during the early eighties [29], the pedicled or free radial forearm ap represents one of the most popular aps in reconstructive surgery [23,30]. The skin is thin, very pliable, and of good texture and color match in hand defects. The pedicle is long, large, and of constant anatomy, but includes one of the main arteries of the hand, which sometimes can impair perfusion to the hand. A preoperative Allens test is mandatory. The main drawback of the radial forearm ap is the donor site, which usually has to be closed with a skin graft, frequently leaving unacceptable scars especially in young women. Dissection of the ap either includes the contralateral extremity into the surgical intervention where one side is already involved, or imposes additional donor site morbidity, such as tendon adherence

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Fig. 2. (AD) The patient was injured by a power saw cutting chain, which destroyed the complete anterior compartment of his right arm. Initial thorough debridement and plate osteosynthesis were followed by a segmental reconstruction of the radial and ulnar artery using an interposition saphenous vein graft. Both median and ulnar nerves demonstrated 8- and 10-cm long defects and were reconstructed with sural nerve grafts in the same operation. Torn muscles were adapted, tendons repaired, and the wound closed temporarily with a skin substitute. The remaining skin defect was closed 48 hours later with a myocutaneous latissimus dorsi free ap.

and lymphedema on the traumatized side. In the authors experience, the forearm ap is no longer one of the prime choices in defect coverage in mutilating hand injuries. Temporoparietal and serratus fascia ap As a superior extension of the facial supercial musculoaponeurotic system (SMAS), this ap combines very thin and pliable tissue with a hidden donor site in patients with hair. Based on the supercial temporal vessels, it is one of the best aps for the dorsum of the distal forearm, the hand, and the ngers (Case 2, Fig. 3) [31]. The authors have successfully used fascial aps also in the palm (Case 3, Fig. 4). The skin grafts usually take easily on this well-vascularized gliding tissue, and provide sucient mechanical stability. The temporoparietal fascia ap is of limited size, with an average of 12 8 cm in adults, whereas the ser-

ratus fascia ap measures approximately up to 15 20 cm. Care has to be taken about the auriculotemporal nerve when elevating the temporoparietal fascia with the usual Y- or T-shaped incision (Fig. 3B) [32]. The long thoracic nerve has to be spared when the serratus fascia ap is raised. Discussion Soft tissue coverage of mutilated hands is not seen distinct from the other reconstructive steps, such as osteosynthesis and tendon reconstruction, but rather is integrated into the strategic surgical concept. This is especially demonstrated by the growing eld of multicomponent chimeric aps [2123]. The concept of early primary reconstruction (including emergency procedures) and fast rehabilitation should be pursued. It can result in excellent outcomes in the hands of an experienced

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Fig. 3. (AF ) A 40-year-old taxi driver sustained a severe tangential tissue loss on three long ngers as his arm was forced out of his car during a motor vehicle accident. After initial thorough debridement the fractured distal phalanx of the fth nger was stabilized with a K-wire, missing extensor tendon structures were reconstructed by palmaris longus tendon, and the three injured ngers were syndactylized by running nylon sutures. A free microvascular temporoparietal fascia ap covered with a split-thickness skin graft was used for closure and connected to the radial artery and a neighboring vein. The hand was splinted during healing. Seventeen days later the ngers were divided again and individual physiotherapy for each nger achieved excellent results.

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Fig. 4. (AF ) A bicycle accident from this 28-year-old female soccer team keeper resulted in a degloving-avulsion injury to her right palm. No tendons or nerves were injured, but the skin defect after debridement was quite large. A serratus fascia free ap was dissected and transplanted to the injured area, covered with a split-thickness skin graft. The extremity was splinted for healing. Subsequent physiotherapy was limited by exor tendon adherence, so surgical tenolysis was performed directly through the well-healed ap, which resulted in a good functional outcome.

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hand-plastic-micro surgeon including either singlestage (Case 3) or multistage procedures (Cases 1 and 2). Mastering of a wide spectrum of surgical techniques is mandatory for success. Caution is recommended in evaluation of the burn, crush, and injection injuries, because the assessment of tissue viability can be extremely dicult in these cases [33]. A proper temporary wound closure followed by a second look may improve the chances for a successful denitive closure. Forced one-stage reconstructions carry an inherent risk of failure if the complexity of the case is not matched by the correct assessment of the problem, the infrastructure available, the individual surgical experience, and the available surgical solutions. A realistic assessment of the case prole and of ones own surgical abilities is of direct benet for a patient with a mutilating hand injury, and markedly increases the chances for good long-term results. Case 1 A 35-year-old patient was injured by a jammed power saw, and the cutting chain destroyed the complete anterior compartment of his right arm. After initial thorough debridement and osteosynthesis, a segmental reconstruction of the radial and ulnar artery was performed using an interposition saphenous vein graft to salvage the avascular hand. The median nerve demonstrated an 8-cm defect and the ulnar nerve showed a 10-cm gap. Both were reconstructed with sural nerve grafts in the same operation. Torn muscles were coapted, tendons repaired, and the wound closed temporarily with a skin substitute. Intravenous antibiotics started preoperatively were continued. The remaining skin defect was closed 48 hours later with a myocutaneous latissimus dorsi free ap (see Fig. 2). Case 2 A 40-year-old taxi driver sustained a severe tangential tissue loss on his left middle, ring, and small nger as his arm was forced out of his car during a motor vehicle accident. After initial thorough debridement the fractured distal phalanx of the fth nger was stabilized with a K-wire, missing extensor tendon structures were reconstructed by palmaris longus tendon, and the three injured ngers were syndactylized by running nylon sutures. A free temporoparietal fascia ap was harvested from the right side and anastomosed to the radial

artery and a neighboring vein on the injured hand. It was covered with a split-thickness skin graft and the hand was splinted during healing. Seventeen days later the ngers were divided and individual physiotherapy for each nger achieved excellent results. No further surgery was needed (see Fig. 3). Case 3 A 28-year-old keeper of a German female soccer league team suered a bicycle accident with a degloving-avulsion injury to her right palm. Fortunately, no tendons or nerves were injured, but the skin defect after debridement was quite large. A serratus fascia ap was dissected and transplanted to the injured area, covered with a split-thickness skin graft, and the extremity splinted for healing. Subsequent physiotherapy was limited by exor tendon adherence, so surgical tenolysis was performed directly through the well-healed ap resulting in a good functional outcome (see Fig. 4). References
[1] Rockwell WB, Lister GD. Coverage of hand injuries. Orthop Clin North Am 1993;24:41123. [2] Germann G, Sherman R, Levin LS. Decisionmaking in reconstructive surgery. Heidelberg: Springer; 2000. [3] Levin LS, Erdmann D. Primary and secondary microvascular reconstruction of the upper extremity. Hand Clin 2001;17:44755. [4] Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285. [5] Lister G, Scheker L. Emergency free aps to the upper extremity. J Hand Surg 1988;13:228. [6] Nincovic M, Deetjen H, Oehler K, Anderl H. Emergency free tissue transfer for severe upper extremity injuries. J Hand Surg [Br] 1995;20:538. [7] Haury B, Rodeheaver G, Vensko J. Debridement: an essential component of traumatic wound care. Am J Surg 1978;135:23842. [8] Bauer P, Schmidt G, Partecke BD. Possibilities of preliminary treatment of infected soft tissue defects by vacuum sealing and PVA foam. Handchir Mikrochir Plast Chir 1998;30:203. [9] Brown JB, McDowell F. Skin grafting, 3rd edition. Philadelphia: JB Lippincott; 1958. [10] Kutler W. A new method for ngertip amputation. JAMA 1947;133:2930. [11] Atasoy E, Iokamidis E, Kasdan ML, Kutz JE, Kleinert HE. Reconstruction of the amputated ngertip with a triangular volar ap: a new surgical procedure. J Bone Joint Surg Am 1970;52:9216. [12] Cronin TD. The cross nger ap: a new method of repair. Am Surg 1951;17:41925.

G.A. Giessler et al / Hand Clin 19 (2003) 6371 [13] Earley MJ. The second dorsal metacarpal artery neurovascular island ap. J Hand Surg [Br] 1989;14:43440. [14] Yang JY. The rst dorsal metacarpal ap in rst webspace and thumb reconstruction. Ann Plast Surg 1991;27:25864. [15] Germann G, Rutschle S, Kania N, Ra T. The reverse pedicle heterodigital cross-nger island ap. Br J Hand Surg 1997;22:259. [16] Chuang DC, Colony LH, Chen HC, Wei FC. Groin ap design and versatility. Plast Reconstr Surg 1989;84:1007. [17] Wang Y, Li X, Yuan Z, Seiler H. Anatomy and clinical use of the posterior interosseous island forearm ap. Unfallchirurg 1994;97:5414. [18] Becker C, Gilbert A. Le lambeau cubital. Ann Chir Main Memb Super 1988;7:13642. [19] Penteado CV. Venous drainage of the groin ap. Plast Reconstr Surg 1983;71:67882. [20] Slavin SA, Upton J, Kaplan WD, Van den Abbeele AD. An investigation of lymphatic function following free-tissue transfer. Plast Reconstr Surg 1997;99:73043. [21] Caroli A, Adani R, Castagnetti C, Pancaldi G, Squarzina PB. Dorsalis pedis ap with vascularized extensor tendons for dorsal hand reconstruction. Plast Reconstr Surg 1993;92:132630. [22] Gosain AK, Matloub HS, Yousif NJ, Sanger JR. The composite lateral arm free ap: vascular relationship to triceps tendon and muscle. Ann Plast Surg 1992;29:496507. [23] Yajima H, Inada Y, Shono M, Tamai S. Radial forearm ap with vascularized tendons for hand reconstruction. Plast Reconstr Surg 1996;98:32833.

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[24] Nassif T, Vidal L, Bovet J, Baudet J. The parascapular ap: a new cutaneous microsurgical free ap. Plast Reconstr Surg 1982;69:7728. [25] Germann G, Bickert B, Steinau HU. Versatility and reliability of combined aps of the subscapular system. Plast Reconstr Surg 1999;103:1386. [26] Fissette J, Lahaye T, Colot G. The use of the free parascapular ap in midpalmar soft tissue defect. Ann Plast Surg 1983;10:2358. [27] 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 ap. Plast Reconstr Surg 2000;106:1026. [28] Katsaros J, Schusterman M, Beppu M, Banis JC, Acland RC. The lateral upper arm ap: anatomy and clinical applications. Ann Plast Surg 1984; 12:489500. [29] Muhlbauer W, Herndl E, Stock W. The forearm ap. Plast Reconstr Surg 1982;70:33642. [30] Mahaey PJ, Tanner NSB, Evans HB, McGrouther DA. The degloved hand: immediate complete restoration of skin cover with a contralateral forearm free ap. Br J Plast Surg 1985;38:1016. [31] Upton J, Rogers C, Durham-Smith G, Swartz WM. Clinical application of emporoparietal aps in hand reconstruction. J Hand Surg [Am] 1986;11:475. [32] Yano H, Nishimura G, Kagi S, Murakami R, Fujii T. A clinical and histological comparison between free temporoparietal and scapular fascial aps. Plast Reconstr Surg 1995;95:45262. [33] Stark HH, Ashworth CR, Boyes JH. Paintgun injuries of the hand. J Bone Joint Surg Am 1967;49:637.

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Use of spare parts in mutilated upper extremity injuries

Richard E. Brown, MDa,*, Tzu-Ying Tammy Wu, MDb
Springeld Clinic, Division of Plastic Surgery, Southern Illinois School of Medicine, Springeld, IL 62794, USA b Division of Plastic Surgery, Southern Illinois University, Springeld, IL 62701, USA
a

The management and treatment of complex mutilated upper extremity injuries often can be challenging and at times seemingly formidable. A reconstructive surgeons ability to mobilize, transpose, and transfer tissues has allowed not only closure of complex wounds but also restoration of function and form. The use of spare parts from an otherwise unsalvageable limb represents the ultimate form of reconstruction that probes the creative mind and challenges the reconstructive knowledge of the surgeon. Spare parts represent those components that may be overlooked in a pile of presumed unusable and mutilated tissues. These undamaged and potentially usable elements include skin, bone, nerves, tendons, vessels, nail bed, or portions of composite functional units such as a hand or nger. Because every traumatic injury of the upper extremity is dierent, the surgeon must scrutinize the remains of a mutilated upper extremity to carefully distinguish the viable from the nonviable. Of what is available, one must then determine the prospective use and contribution of the remaining constituents to the overall function and form of the limb. In this article, the authors review the use of spare parts in a variety of mutilated upper extremity wounds. Background In 1947, Cave and Rowe described using skin from deformed and useless ngers to cover defects

in the hand [1]. They reported ve cases of gunshot wounds to the hypothenar region of the hand resulting in a nonfunctional small nger. The sti and nonfunctional nger was then stripped of its tendons and bones and a digital turnover skin ap was created to cover the hypothenar defect. The importance of preserving all possible skin of the hand at the time of initial debridement of the wound for potential later use was emphasized. A similar principle was outlined by Bunnell in which a llet ap of a nger was used to cover hand defects [2]. The use of palmar skin of amputated ngers to cover appropriately sized hand defects was reiterated by Slocum [3]. Peacock pointed out the unique features of the hand that would favor using local tissue for restoration and reconstruction of hand defects [4]. He described the island pedicle ap of a nonfunctional digit or hand in restoring skin, nerve, and composite tissue loss of the digits and hand. Subsequently, there have been several reports describing spare part usage of various components of the hand for reconstruction [520]. Evaluation The magnitude of force that has resulted in a devastating hand injury can be immense. This force may have pulled the patient into machines, against equipment, or o heights. Therefore, patients with mutilating hand injuries may have sustained injuries of other organ systems that may be life threatening. These victims should thus be treated as trauma patients. ATLS protocols must be followed in securing the patients airway, breathing, and circulation. Once the patient is

* Corresponding author. E-mail address: drrbrown@springeldclinic.com (R.E. Brown).

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. doi:10.1016/S0749-0712(02)00143-9

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Fig. 1. The patient sustained multiple nger amputations. The small ngertip amputation was replaced as a composite graft. (A,B) Preoperative. (C) Postoperative.

stabilized, one may delve into the details of the history as to when, where, and how the injury occurred. The socioeconomic circumstances of the injury also must be taken into consideration. Although a young virtuoso violinist may wish to preserve as much length and function of a nger as possible, a self-employed farmer may seek the simplest method of reconstruction that would allow the most expeditious return to work. The patient then should be brought to the operating suite where a thorough examination can

be performed. Assessment of circulation, skin cover, skeletal and joint stability, and nerve and tendon integrity is completed. Careful debridement of obviously nonviable tissue is performed while preserving any tissue of uncertain viability for reassessment at a second look. The objective is to remove all tissue that is detrimental to wound healing yet preserve as much as possible to maximize limb function. After completion of debridement, the wound is reassessed and the potential return of function is

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Fig. 2. (AD) A 26-year-old man sustained a severe injury to the middle nger and loss of the ulnar side of the nail bed and paronychium of the index nger. The middle nger was not salvageable but provided the missing ulnar nail bed and paronychium to reconstruct the injured index nger. A functional and aesthetic ngertip was obtained. (From Van Beek AL, Kassan MA, Adson MH, Dale V. Management of acute ngernail injuries. Hand Clinics 1990;6(1):2335; with permission.)

evaluated. At this juncture, decisions are made regarding the restoration of function and form with the available tissues. Spare parts The nger As eloquently stated by Peacock, A nger contains all of the basic tissues which are found elsewhere in the hand, and when the nger ceases to be an integral part of the hand, it should be viewed as a valuable source of spare tissue [4]. The following provides a systematic approach to

evaluating the potential assets of an otherwise useless nger. The cap composite tip graft Following amputation, digital tip replacement as a composite graft is practiced in adults and children [2123]. Its success is more likely in children, and some have recommended this practice only in those less than 5 years of age with clean, sharp amputations [24]. Noting that microsurgical replantation at this level presents a challenge and that venous congestion is often a sequelae and cause of ap failure, Moiemen et al

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Fig. 3. (AC) This diagram illustrates a method of lengthening the nger llet ap as described by Al-Qattan. The ap is divided longitudinally along the midvolar line from the PIP to the MP volar creases. The divided ap is then based on either the radial or the ulnar digital neurovascular bundle and skin proximally, with the volar pulp connecting the two halves of the ap (From Al-Qattan MM. Lengthening of the nger llet ap to cover dorsal wrist defects. Journal of Hand Surgery 1997;22A(2):5501; with permission.)

Fig. 4. (A,B) A 55-year-old farmer who caught his hand in a combine. Note multiple amputated digits and a bone forearm fracture. (C) Amputated thumb, index, long, and ring ngers. (D,E) Initial appearance following replantation of the thumb and llet ap of the index. Note llet ap was revascularized and used to cover exposed metacarpal heads. (F H) Function 1 year following injury with no additional surgery.

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Fig. 4 (continued )

performed a retrospective study in the United Kingdom of 50 consecutive children (ages 114 years, mean age 5.7 years) with 50 completely amputated digital tips replaced as composite grafts. The study revealed that the time delay between amputation and replacement directly correlated with the success of the graft take [21]. Eleven of the eighteen ngertips replaced within 5 hours survived completely, whereas four partially survived and three failed completely. None of the cap grafts survived completely when replaced after a minimum delay of 5 hours, however [21].

By the same token, cap grafts may be used as spare parts and replaced onto another nger when situations call for such heterotopic transfers. The technique remains the same as for orthotopic replacement. The amputated tip is cleansed and debrided. In children less than 3 to 5 years of age, there is a higher chance of the amputated tip taking as a composite graft without much defatting of the volar pulp. In adults, however, defatting of the volar pulp of the amputated tip is performed. Any residual bony tuft is removed also. The graft is now a composite of full-thickness

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Fig. 4 (continued )

skin and nail bed and is ready to be replaced. Skin reapproximation is secured with 5-0 nonabsorbable sutures while nail bed repair and reapproximation is done using 7-0 chromic sutures (Fig. 1). The perionychium The perionychium consists of the hyponychium, paronychium (which consists of the lateral nail folds and its adjacent cutaneous

portion), eponychium, and the nail bed. Each component of the perionychium contributes to the health and function of the ngertip. Therefore, preservation and replacement of the perionychium or its components on appropriate supporting bony structures in mutilating nger or hand injuries contributes to the success of the reconstruction. The most frequently described reconstruction of the perionychium is the nail bed. The nail bed consists of sterile and germinal matrices that

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Fig. 5. Crush amputation of left index and near amputation of long nger with nonsalvageable middle phalanx. Avulsion over thumb metacarpal removed a 45-cm segment of EPL tendon (A,B). The index nger was replanted to the long nger proximal phalanx and an index ray resection was completed. The EPL was repaired with an intercalated tendon graft harvested from the EDC to the index nger (C,D). Long-term followup shows good EPL function (E,F) and good long nger function (G,H).

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contribute to the formation of the nail. The nail bed can be harvested as full- or split-thickness matrix grafts [25]. Both types of grafts have been used successfully [2528]. A nail bed graft of 1 cm or less usually takes by inosculation even on the bare cortex of the distal phalanx [25]. Although scar contracture of the nail bed grafts is less than that of the skin, a split-thickness nail bed graft should be harvested 12 mm larger than the defect [28]. Although the orientation of a split-thickness nail bed graft placement does not aect nail growth, according to Shepard, a full-thickness nail bed graft needs to be placed in the correct longitudinal orientation to achieve normal growth of the nail [28]. The nail bed can be harvested from mutilated and unsalvageable ngers as splitor full-thickness grafts and used as a spare part for other less severely injured ngertips with a nail bed avulsion. Similarly, full-thickness perionychial grafts from ngertip amputations combined with local ngertip aps (volar or lateral V-Y advancement, cross-nger aps) have been de-

scribed to reconstruct mutilated ngertips [29,30]. Although all the cases involved orthotopic replacement of the perionychial grafts, one can extrapolate this concept and replace the perionychial grafts heterotopically in mutilating hand injuries involving multiple digits. The use of portions of the perionychium as spare parts for reconstruction of ngertip injuries has been illustrated by Van Beek [20] (Fig. 2). A 26-year-old man sustained a severe injury to the middle nger and loss of the ulnar side of the nail bed and paronychium of the index nger. The middle nger was not salvageable but provided the missing ulnar nail bed and paronychium to reconstruct the injured index nger. A functional and aesthetic ngertip was obtained [20]. The skin Harvesting areas of uninjured skin of mangled hands or upper extremities has been the most

Fig. 6. (A,B) A 34-year-old woman following a crush avulsion amputation at the right forearm level. (C) Initial appearance after debridement and partial closure of amputation stump. (D) Radial forearm llet ap from amputated part. (E) Initial appearance of stump after closure with the llet ap. (F) Appearance 2 months following injury and just before prosthetic tting.

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Fig. 6 (continued )

commonly used spare part [1,36,1012,15,16]. The glabrous skin from a nonreplantable digit is an invaluable source of tissue for palmar defects, and the thin dorsal skin oers thin, durable coverage to regional areas devoid of integument. The skin can be harvested as a split- or fullthickness graft or used as vascularized ap. The most commonly described ap from the skin of the nger is the llet ap. This versatile ap has undergone various modications since its initial description [5,6,912,16]. As its name implies, the llet ap consists of the skin and its remaining

soft tissue after the nger is stripped of its bone and tendons [14]. In its initial description by Cave, the soft tissue from a sti and functionless small nger was used to cover a hypothenar wound [1]. Slocum described its use in coverage of a dorsal hand defect [3] as a turnover ap. As a pedicled ap with intact neurovascular bundles, it can be used as a wraparound ap to cover an adjacent mutilated digit to provide glabrous soft tissue coverage with immediate restoration of normal sensibility to the adjacent mutilated nger [10].

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Lengthening of the nger llet also has been reported to cover dorsal wrist defects [6]. This is accomplished by dividing the llet ap longitudinally along the midvolar line, extending from a point between the proximal interphalangeal and metacarpophalangeal joint creases, depending on the desired length of the ap. A transverse incision is made, dividing either the radial or ulnar neurovascular bundle and skin proximally (Fig. 3). The llet ap thus has been split into two halves that are connected by way of the nger pulp. The reliability of this modied ap can be

enhanced by anastomosing the divided ulnar or radial digital artery and vein to the dorsal wrist vessels. Another modication of the nger llet is the pulp neurovascular island ap [15] that is used to cover the proximal stump of an amputated nger. The ap is based on one or both of the neurovascular bundles. Lanzetta et al describe its use as an alternative to the conventional nger amputation. In their series of eight patients, no one developed a neuroma and all retained ne tactile sensation and stereognosis at the stump level [15].

Fig. 7. (A) A 30-year-old man who had his right arm avulsed in a machine. Note exposed remaining humerus. (B) Amputated arm. (C) Closure of wound with llet ap of the forearm based on the radial artery. (D) Early postoperative appearance before deepening of the axilla. (E,F) Range of motion of amputation stump following revision of axilla. (G) Followup after prosthesis tting.

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Fig. 7 (continued )

With advancement of microsurgical technology, free nger llet aps have been well described [5,11,12,16] (Fig. 4). In 1978, Alpert and Buncke described using a free vascularized island ap from a nonreplantable amputated digit to reconstruct a severely injured but salvageable digit [5]. Idler and Mih reported a case of a free digital llet ap from an otherwise unsalvageable digit to cover a palmar hand wound [12]. Additional reports followed applying the same principle of salvaging nonreplantable nger parts for coverage of hand and nger wounds, and in some cases using the spare skin with intact digital artery as a ow-through ap for simultaneous coverage of a soft-tissue defect and revascularization of an injured nger [16]. Bones, tendons, nerves, vessels, and joints In addition to the skin, other components within the nger, such as bone, joint, tendon, nerves, and vessels also can be used as spare parts. The bone can be used to maintain length of an

amputated thumb or other digits. It can be harvested and used as a nonvascularized graft or replaced as a vascularized unit with the skin [9]. Free joint transfers have been described in delayed reconstructions and acute traumatic settings [31 33]. The indications for free joint transfers in spare-part surgery would include multilevel injuries in which segments of a nger including the joints are spared, whereas those in between cannot be used. Vascularized joint transfers are more successful in young patients with severe compound tissue loss without other concomitant injuries that would preclude them from early range of motion. Tendon remnants can be used for tendon grafts and for reconstruction of pulleys and ligaments (Fig. 5). The nerves and vessels can be used as grafts, although at the digital level they are often taken with overlying skin to provide sensate coverage. Gainor described in 1985 an osteocutaneous llet ap for reconstruction of the thumb in a gunshot wound to the hand [9]. The ap was derived from the injured index nger in which the distal second metacarpal, including the metacarpophalangeal joint together with the radial digital neurovascular bundle, was destroyed by the gunshot. The proximal phalanx of the thumb, together with the extensor hood, was also destroyed except for a proximal articular fragment. The index llet ap with its intact osseous component was transferred to the thumb. The extensor indicis proprius and extensor digitorum communis to the index nger were used to reconstruct the extensor hood of the thumb. The patient returned to his premorbid gainful employment and activities of daily living in a timely manner. This example illustrates the successful use of the various usable components of a severely damaged digit to restore function and form of the hand. The nger as composite tissue transfer With advancement of microsurgery, replantation of ngers has evolved into a standard procedure for traumatic hand injuries when indicated. Most replantations are performed orthotopically. Heterotopic replantations or transplantations, however, can be performed also. Chiu reported a case of heterotopic transplantation of a reattached but useless index nger to a functionally decient ring digit to improve overall function of the hand [34]. Although the patient did gain more

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Fig. 8. (A,B) A 45-year-old man who was struck by a train, sustaining an avulsion amputation of the left arm through the shoulder and a crush amputation of the right hand. (C) Amputated parts. Note severe crush of right hand and left upper arm precluding replantation. Also note fairly undamaged left hand. (D) Initial appearance following replantation of the left hand onto the right forearm at the wrist level. (EH) Two-year followup.

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Fig. 8 (continued )

functional use of the reconstructed hand, Chiu cautioned on performing these procedures routinely because the patient with the twice-reattached nger experienced less sensibility recovery, more pronounced cold intolerance, decreased basal skin temperature, and a slower digital rewarming time than the once-reattached ipsilateral digit and other normal ngers [34] (Fig. 5). The hand and forearm Along the same principles of the nger llet ap, the mutilated hand and forearm are also excellent

sources of reusable parts for salvaging upper extremity injuries. The amputated hand and forearm provide a potentially greater surface area of skin and longer segments of tendon, nerves, vessels, and bone than the nger [17,19]. An interesting use of spare parts in a multileveled injury and amputation of both upper extremities was reported by Hammond et al [11]. In their case report, a frostbite injury resulted in amputation of a dominant right wrist and nondominant index, long, ring, and small ngers at the level of the midproximal phalanx with skin loss several centimeters proximal to the level of the exposed bone. Shortening the bone of the nondominant ngers would have compromised metacarpophalangeal joint motion. The authors proceeded with a functional amputation of the right mid-forearm while simultaneously harvesting a radial forearm ap from the distal aspect of the amputated forearm for free ap coverage of the amputation stumps of the contralateral ngers. Delayed inset and tailoring of the ap to contour the nger stumps was performed 4 weeks later with stable soft-tissue coverage and preservation of the metacarpophalangeal joint motion. A below-elbow prosthesis was tted for the dominant limb. This example illustrates the need for careful planning and execution to maximize the potential use of an otherwise discarded body part. Fig. 6 illustrates a case of a 34-year-old woman who sustained an avulsion amputation of her right forearm. A radial forearm free ap was harvested from the amputated limb and used to cover a portion of her forearm stump and provided stable coverage for later tting of a below-elbow prosthesis. Similarly, Fig. 7 illustrates the use of a radial forearm llet ap from a nonreplantable arm. The ap was used to cover and preserve length of the remaining humerus for later prosthesis tting. Deepening of the axilla was performed at a secondary stage. Similar case reports have been reported in the literature [19]. A unique example of using major amputated limbs in a spare part fashion involves a cross-hand transfer as illustrated in Fig. 8. Such a transfer requires careful planning and execution. As illustrated here, however, such spare part surgery can provide function unobtainable by any other manner. In cases in which the arteries are not viable, venous aps from the forearm or hand may be harvested for use as arterialized or ow-through aps for coverage of another damaged digit [35 37], skin defects of the hand [38,39], or coverage of the amputation stump.

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R.E. Brown, T-Y.T. Wu / Hand Clin 19 (2003) 7387 [15] Lanzetta M. St-Laurent J-Y. Pulp neurovascular island ap for nger amputation. J Hand Surg 1996;21A:91821. [16] Libermanis O, Gundars K, Kapickis M, et al. Use of the microvascular nger llet ap. J Reconstr Microsurg 1999;15:57780. [17] May Jr JW, Gordon L. Palm of hand free ap for forearm length preservation in nonreplantable forearm amputation: a case report. J Hand Surg 1980; 5:377. [18] Milford L. Resurfacing hand defects by using deboned useless ngers. Am Surg 1966;32:196. [19] Rees MJW, Geus JJ. Immediate amputation stump coverage with forearm free aps from the same limb. J Hand Surg 1988;13A:287. [20] Van Beek AL, Kassan MA, Adson MH, et al. Management of acute ngernail injuries. Hand Clin 1990;6(1):2335. [21] Moiemen NS, Elliot D. Composite graft replacement of digital tips: part II. A study in children. J Hand Surg 1997;22B(3):34652. [22] Douglas B. Successful replacement of completely avulsed portions of ngers as composite grafts. Plast Reconstr Surg 1959;23:21325. [23] Rose E, Norris M, Kowalski T. The cap technique: non-microsurgical reattachment of ngertip amputations. J Hand Surg 1989;14A:5138. [24] Zachary SV, Peimer CA. Salvaging the unsalvageable digit. Hand Clin 1997;13(2):23949. [25] Zook EG, Brown RE. The perionychium. In: Green DP, Hotchkiss RN, Pederson WC, editors. Greens operative hand surgery. 4th edition. New York: Churchill Livingstone; 1999. p. 135380. [26] Saito H, Suzuki Y, Fujino K, et al. Free nail bed graft for treatment of nail bed injuries of the hand. J Hand Surg 1983;8(2)A:1718. [27] Shepard GH. Treatment of nail bed avulsions with split thickness nail bed grafts. J Hand Surg 1983;8: 4954. [28] Shepard GH. Management of acute nail bed avulsions. Hand Clin 1990;6:3956. [29] Brown RE, Zook EG, Russell RC. Reconstruction of ngertips with a combination of local aps and nail bed grafts. J Hand Surg 1999;24A(2):34551. [30] Netscher DT, Meade RA. Reconstruction of ngertip amputations with full-thickness perionychial grafts from the retained part and local aps. Plast Reconstr Surg 1999;104:170512. [31] Chen SHT, Wei FC, Noordhoff SM. Free vascularized joint transfers in acute complex hand injuries: case reports. J Trauma 1992;33(6):92430. [32] Foucher G. Vascularized joint transfers. In: Green DP, Hotchkiss RN, Pederson WC, editors. Greens operative hand surgery. 4th edition. New York: Churchill Livingstone; 1999. p. 125170. [33] Graham W. Transplantation of joints to replace diseased or damaged articulations in the hands. Am J Surg 1954;88:13641.

Although we have an extensive armamentarium with which to reconstruct and restore form and function in mutilating injuries of the upper extremity, use of spare parts is an important tool that we must bear in mind as we approach the mangled limb during the acute phase of management. We must preserve and carefully evaluate the amputated parts and their potential contribution to the injured limb with regard to form and function orthotopically or heterotopically. The use of spare parts minimizes further donor site morbidity and makes use of local tissue, thus allowing reconstruction with like components. Restoration of a functional limb that is sensate, painless, useful, and aesthetic is the ultimate goal toward which we must strive. References
[1] Cave EF, Rowe CR. Utilization of skin from deformed and useless ngers to cover defects in the hand. Ann Surg 1947;125:126. [2] Bunnell S. Injuries of the hand. In: Bunnell S, editor. Surgery of the hand. 4th edition. Philadelphia: JB Lippincott; 1964. [3] Slocum DB. Palmar skin aps salvaged from amputated ngers. NW Med 1960;59:13978. [4] Peacock Jr EE. Reconstruction of the hand by the local transfer of composite tissue island aps. Plast Reconst Surg 1960;25: 298311. [5] Alpert BS, Buncke HJ. Mutilating multidigital injuries: use of a free microvascular ap from a non-replantable part. J Hand Surg 1978;3:196. [6] Al-Qattan MM. Lengthening of the nger llet ap to cover dorsal wrist defects. J Hand Surg 1996; 22A:5501. [7] Chase RA. The damaged index digit. A source of components to restore the crippled hand. J Bone Joint Surg 1968;50A:1152. [8] Chase RA. Atlas of hand surgery. Philadelphia: WB Saunders Company; 1973. p. 16277. [9] Gainor BJ. Osteocutaneous digital llet ap: a technical modication. J Hand Surg 1985;10B: 7982. [10] Hallock GG. Salvage of ring degloving injury with wraparound ap from adjacent mutilated digit. J Hand Surg 1995;20(3)A:4035. [11] Hammond DC, Matloub HS, Kadz BB, et al. The free-llet ap for reconstruction of the upper extremity. Plast Reconstr Surg 1994;94:50712. [12] Idler RS, Mih AD. Soft-tissue coverage of the hand with a free digital llet ap. Microsurg 1990;11:215. [13] Keiter JE. Immediate pollicization of an amputated index nger. J Hand Surg 1980;5:5845. [14] Lanier V. The llet ap principle. Orthop Rev 1981;10:63.

R.E. Brown, T-Y.T. Wu / Hand Clin 19 (2003) 7387 [34] Chiu DTW, Ascherman JA. Heterotopic transplantation of a reattached digit. Plast Reconstr Surg 1995;95(1):1525. [35] Cheng TJ, Chen HC, Tang YB. Salvage of a devascularized digit with free arterialized venous ap: a case report. Injury, infections, and critical care. J Trauma 1996;40(2):30810. [36] De Lorenzi F, van der Hulst RRWJ, den Dunnen WFA, et al. Arterialized venous free aps for softtissue reconstruction of digits: a 40-case series. J Reconstr Microsurg 2002;18:56977.

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[37] Koch H, Moshammer H, Spendel S, et al. Wraparound arterialized venous ap for salvage of an avulsed nger. J Reconstr Microsurg 1999;15(5): 34750. [38] Iwasawa M, Ohtsuka Y, Kushima H, et al. Arterialized venous aps from the thenar and hypothenar regions for repairing nger pulp tissue losses. Plast Reconstr Surg 1997;99(6):176570. [39] Kantarci U, Cepel S, Gurbuz C. Venous free aps for reconstruction of skin defects of the hand. Microsurg 1998;18:1669.

Hand Clin 19 (2003) 89120

Replantation in the mutilated hand

Bradon J. Wilhelmi, MDa,*, W.P. Andrew Lee, MDb, Geert I. Pagensteert, MDc, James W. May Jr, MDd
Hand /Microsurgery, The Plastic Surgery Institute at Southern Illinois University School of Medicine, 747 North Rutledge, 3rd Floor, Springeld, Illinois 62794, USA b Division of Plastic Surgery, Hand Surgery, University of Pittsburgh School of Medicine, PA, USA c Surgery Resident, Freiberg, Germany d Division of Plastic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
a

The treatment of the mutilated hand is perhaps the most challenging acute hand injury that hand surgeons treat. Many of these injuries involve the repair of devascularized and amputated parts of the upper extremity. The decision to attempt replantation and the techniques involved in replantation of amputated parts are often extremely dicult. Thousands of severed body parts have been reattached since the rst replant 40 years ago, preserving a quality of life not provided by the void remaining after amputation. Ronald Malt performed the rst replantation on May 23, 1962 at the Massachusetts General Hospital for a 12year-old boy who amputated his right arm in a train accident [1]. The level of amputation occurred at the neck of the humerus (Fig. 1). The osteosynthesis for this replantation was done with a steel rod through the humerus. The brachial artery, both communicating brachial veins, and the median, ulnar, and radial nerves were repaired with this replantation (Fig. 2). He performed another replant and in 1964 published a report on both replantations in the Journal of the American Medical Association (JAMA) [1] (Fig. 3). Later, Malt reported that the patient had some recovery of function of the replanted right arm after wrist arthrodesis and tendon transfers [2] (Fig. 4). Technologic advances and the use of the microscope have made possible the replantation

of other parts including the thumb, ngers, ear, scalp, facial parts, and genitalia (6,12,13,16,20,29, 31,34,44,45,47,55,6780).

Indications Not all amputees benet from or are candidates for replantation. The decision to attempt replantation of a severed part is inuenced by many factors, including the importance of the part, level of injury, expected return of function, and mechanism of injury. Thumb and multiple nger replants should be attempted, as function is severely compromised without opposition [3 6]. Moreover, functional outcomes following replantation vary signicantly with the level of injury. Good functional results can be achieved with replantation of injuries at the level of the ngers distal to the exor supercialis insertion, the hand at the wrist, and the upper extremity at the distal forearm [711] (Fig. 5). Replantation of the above elbow amputation should be attempted for elbow preservation, even though the chance for nerve recovery is low. If subsequent nerve regeneration is inadequate after upper arm replantation, revision amputation at the mid forearm level can then allow for a below elbow prosthesis [7]. A below elbow prosthesis with a gravity activated grip is more functional than an above elbow prostheses. Less functional recovery is expected for replants at certain levels including amputations proximal to exor supercialis insertion within zone II of the ngers and at the muscle belly and elbow level.

* Corresponding author. E-mail address: bwilhelmi@Siumed.edu (B.J. Wilhelmi).

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. doi:10.1016/S0749-0712(02)00137-3

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Fig. 1. Ronald Malt with his patient, the rst to undergo a replant procedure. Used with permission from Williams Wilkins.

Fig. 2. The rst replant was performed at the level of the humerus and involved repair of ulnar, median, and radial nerves and the brachial artery and venae commitante. Used with permission from Williams Wilkins.

As zone II replants can be expected to result in stiness and rehabilitation that signicantly delays return to work with minimal or no functional benet, a relative contraindication to replantation exists for single digits amputated within the zone II level [12]. Replantation of zone II nger amputations have been justied in Japan, so patients can avoid being confused with Japanese gangsters (or Yakuza) who amputate their nger as a symbol of devotion to their mob boss. Perhaps the most predictive indicator for success with replantation is the mechanism of injury. OBrien has demonstrated signicantly higher success rates with replantations of guillotine versus avulsion amputations [5]. It may be an unrealistic expectation to successfully replant severely crushed and mangled body parts. Avulsion injuries with traction along the neurovascular bundles create intimal tears and disruption of small branches to the skin. Small hematomas seen in the skin along the course of the neurovascular bundle result in the red line sign. This sign sig-

nies such detrimental injury to the neurovascular bundle that replantation is often fraught with poor success. Replantation attempts in digits with the red line sign require vein grafting across this zone of injury. Another indication of injury to the vessels of an amputated digit is the ribbon sign. The ribbon sign is an indication of torsion and stretch on a vessel. The vessel resembles a ribbon that has been stretched and curled for decoration on a birthday present. Vessels that have the ribbon sign often are not amenable to sustaining blood ow, precluding replantation attempts [13] (Fig. 6). Two other relative contraindications to replantation include multiple level injuries and mentally unstable patients. The only absolute contraindication to replantation exists when associated injuries or preexisting illness preclude a prolonged and complex operation. In this circumstance temporary ectopic replantation has been described for preservation of the amputated

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Fig. 3. Title page of the report for the rst replantation ever performed. (From Malt RA, McKhann CF. Replantation of severed arms. JAMA 1964;189(10):71622; with permission.)

extremity before eventual elective replantation later [1416] (Fig. 7). Preoperative considerations Replantation of arms, hands, digits, or even ngertips has become common in various institutions. Remote physicians, paramedics, and even the patients themselves are more educated on the possibility of replantation. Because of this, it is common to have the amputated part arrive with the patient at the emergency department. Even if not replantable, this amputated part can provide a valuable tissue source for reconstruction. The amputated part should be wrapped in a saline moistened gauze sponge and placed in a plastic bag. The plastic bag should be sealed and placed on ice (Fig. 8). The amputated part should not be placed directly on ice because this can result in a frostbite injury to the tissue [17]. The part should not be immersed in water because this has been demonstrated by Urbaniak to make digital vessel repair more dicult and less reliable

[18,19]. Bleeding vessels in the stump should not be clamped. Hemostatic control of the stump can be achieved with a compressive dressing and elevation. The recommended ischemia times for reliable success with replantation are 12 hours of warm and 24 hours of cold ischemia for digits, and 6 hours of warm and 12 hours of cold ischemia for major replants (ie, parts containing muscle). Reports of successful replantation after longer ischemia times exist [2024] (Table 1). May reported a successful digit replantation after 39 hours of cold ischemia, the seventh of a sevennger replant case [21] (Fig. 9). Subsequently, Wei reported successful digital replantations after 84, 86, and 94 hours of cold ischemia [24]. The minimization of ischemia time is more critical in replantation of limbs proximal to the digits. In such cases, a temporary shunt to the amputated limb may be benecial [1416]. Before surgery, radiographs of the amputated parts and the stump should be performed to determine the levels of injury and suitability for

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Fig. 4. The rst replantation several years after tendon transfers and wrist arthrodesis. Used with permission from Williams Wilkins.

replantation. Both parts should be photographed for documentation. An informed consent should be obtained, discussing the pros and cons with the patient and family regarding the failure rates, length of rehabilitation, realistic expectation of sensation, mobility, and function. The preoperative preparation also should include prophylactic antibiotics, updating the patients tetanus status, uid resuscitation to prevent hypotension, warming the patient to prevent hypothermia and vasoconstriction/spasm, Foley insertion for volume monitoring, and protection of pressure points during an expected long operation.

Fig. 5. Levels of replantation. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

Operative considerations The preparation of the amputated part can be initiated before the patient is brought to the operating room. This preparation is performed on a back table under sterile conditions in the operating room. The use of a microscope assists with the assessment of the digital vessels

for replantation. Signs of arterial damage should be noted, including the telescope, cobweb, and ribbon signs or terminal thrombosis, which would require freshening of the vessel [25] (Fig. 10). Resection of the vessel distal to the zone of injury may result in a defect requiring a vein graft that should be harvested before osteosynthesis to minimize warm ischemia time. If the amputated part is grossly contaminated, it should be cleansed gently with Normal Saline (N/S) irrigation. Care must be taken not to further injure the digital vessels or soft tissue. The neurovascular structures of the ngers are exposed with either bilateral longitudinal incisions in the midaxial line or with volar zigzag and dorsal longitudinal incisions [25,26] (Fig. 11). The neurovascular structures are then identied and tagged with 5-0 nylon sutures or hemaclips to facilitate and expedite identication at the time of coaptation.

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Fig. 6. (A) The red line and ribbon signs are poor prognostic signs for replantation. (From Boulas HJ. Amputations of the ngers and hand: indications for replantation. Journal of the American Academy of Orthopaedic Surgeons 1998;6(2):101; with permission.) (B) This patient degloved a hand in a log crusher-splitter, resulting in multilevel neurovascular and bone injuries.

Fig. 7. (A,B) This patient underwent ectopic implantation of an amputated hand before eventual replantation when he was stable from other injuries. (From Chernofsky MA, Sauer PF. Temporary ectopic implantation. The Journal of the Hand Surgery 1990;15A(6):913; with permission).

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Fig. 8. The amputated part is wrapped in gauze and placed in a plastic bag. The plastic bag is set on ice. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.) Table 1 Longest reported replantation Author May (1981) May (1984) Wei (1986) VanderWilde (1991) Chui (1983)

Many surgeons prefer to shorten the bone to avoid the potential need for arterial, venous, and nerve grafts later. The tagged neurovascular structures are gently relocated during the bone shortening (Fig. 12A). Approximately 510 mm of bone shortening may be necessary for tension-free vessel repairs. Through the bony shortening, nerve or vein grafts may be avoided [27]. The bone shortening should be performed on the amputated part if possible, to retain length should the replant fail.

ischemia Part Fourth digit Seventh digit Digits Hand Hand

times

for

successful

Ischemia time 28 hours/cold 39 hours/cold 84, 86, 94 hours/ warm 54 hours/cold 33 hours/warm

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Fig. 9. (AD) This patient amputated all eight ngers in a metal press. He underwent successful replantation of seven of the digits, the last after 39 hours of cold ischemia. (From May JW Jr, Hergrueter CA, Hanson RH. Seven-digit replantation: digit survival after 39 hours cold ischemia. Plast Reconstr Surg 1986:5223; with permission.)

Bone can be resected on the stump side for the ngers, but not for the thumb where length preservation is more critical, if the amputation level is near the joint on the amputated part. Hand function is compromised with thumb loss proximal to the interphalangeal joint. If the amputation level is through the joint, fusion in the functional position

is required. Primary implant arthroplasty has been described in replantation but with increased risk for infection [28]. Then, retrograde K-wires or intraosseous wires can be placed through the bone on the amputated part (Fig. 12B). Usually there is enough time before the patient is transported to the operating room for

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Fig. 10. Signs of arterial damage should be appreciated, including the telescope, cobweb, and ribbon signs or terminal thrombosis, which would require freshening of the vessel. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

preparation of the amputated part. Alternatively a second team can be recruited to begin the preparation of the stump. The neurovascular structures are isolated, identied, and tagged on the stump side under tourniquet control. Before the arterial anastomosis, the tourniquet is deated to assess inow pressure by the proximal vessel spurt [25] (Fig. 13). If the spurt is inadequate, additional proximal vessel shortening is required. Furthermore, in preparing the stump, exposure of the proximal exor tendon for placement of a core suture is better at this point than after bone xation. The order for repairing the various structures is individualized. The sequence of repairing the bone, extensor, veins, dorsal skin, artery, nerve, and exor is preferred by the authors, as it eciently allows for repairing all the dorsal structures before the volar structures [5] (Table 2). If the warm ischemia time is unusually long, the artery can be repaired earlier. Techniques of osteosynthesis vary: many surgeons prefer cross K-wires, because they are quick and safe (Fig. 14). Union rates have been reported to be better with intraosseous wires, however, either in combination with a K-wire as 90-90 wires [29,30]. Ninety-ninety wires are two intraosseous

Fig. 11. (A,B) Exposure of the neurovascular structures to be labeled on the amputated part. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

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Fig. 12. Once the neurovascular structures of the amputated part have been identied and tagged, they can be carefully retracted for bone shortening. (A) Approximately 510 mm of bone shortening is necessary for tension-free vessel repairs and the avoidance of neurovascular defects requiring grafts. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.). (B) Then, retrograde K-wires or intraosseous wires can be placed through the bone on the amputated part.

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Fig. 13. The tourniquet is deated to assess inow pressure by the proximal vessel spurt. If the spurt is inadequate, additional vessel shortening is required. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

wires placed perpendicular to each other. Whitney et al found this technique to have lower nonunion rates with replantation procedures because 90-90 wires actually compress the fracture site [30] (Table 3). Another advantage of 90-90 wires is that they are low prole and easy to work around. K-wires can occasionally be awkward and obscure other structures that require repair. After the osteosynthesis, the hand is pronated and the extensor tendon is repaired rst (Fig. 15). If the amputation is at the proximal phalanx level it is important to repair the lateral slips, to prevent loss of extension at interphalangeal joints. The dorsal veins are repaired. Next, at least two veins should be repaired in nger replants, especially for replants proximal to the proximal interphalangeal joint. Dorsal veins are preferred because they are larger and dont interfere with subsequent repair of volar structures (Figs. 16 and 17). Because the veins become smaller and more dicult to identify and repair the more distal the injury, arterial repair may be required rst to locate the veins by back bleeding. Once the dorsal structures have been repaired, the dorsal skin is loosely approximated with small-caliber, simple, interrupted sutures.

Fig. 14. In performing the bone xation, many prefer K-wires, which are quick and safe and can be placed in cross or axial conguration. Union rates have been reported to be better with intraosseous wires, however, either in combination with a K-wire as described by Lister or as 90-90 wires. Ninety-ninety wires are two intraosseous wires placed perpendicular to each other, which was found to have lower nonunion rates. (From Goldner RD, Urbaniak JR. Replantation. In Green DP, editor: Greens operative hand surgery. 4th edition. New York: Churchill Livingstone; 1999. p. 113955; with permission.)

The hand is then supinated to repair the injured volar structures. At least one digital artery is repaired. Several anastomotic techniques have been described (Fig. 18). One described technique of microvascular repair involves placing the rst two sutures at 10 oclock and 2 oclock, then 12 oclock; the vessel is then turned 180 degrees and additional simple interrupted sutures are placed in sequence. After the completion of the digital artery repairs, the tourniquet is deated and clamps are removed. The patency of the arterial anastomosis can be assessed with the milk test, capillary rell, and bleeding on pinprick. If arterial ow seems inadequate, one should conrm that the patient has adequate blood pressure and vol-

Table 2 Sequence of repairs in digital replantation Skeletal xation Extensor tendon Dorsal veins (arteries 2) Dorsal skin Digital artery Volar nerves Flexor profundus Volar skin

Table 3 Nonunion rates for various techniques of osteosynthesis with replantation Group I II III IV V VI Method (digits) Crossed K-wire (38) Single K-wire (7) Perpendicular interosseous (8) K+intraosseous (12) K+Cassel (3) Cassel (7) Nonunion 8 (21%) 1 (14%) 0 1 (8%) 1 (33%) 1 (14%) Required osteotomy 5 1 0 1 1 0

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Fig. 15. The hand is pronated, and of the dorsal structures, the extensor is repaired rst. If the amputation is at the proximal phalanx level it is important to repair the lateral slips to prevent loss of extension at interphalangeal joints. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

ume, and that the tourniquet actually has been deated. Bathing the vessel with papaverine, lidocaine, magnesium sulfate, and warm irrigation has been described to counteract the vasospasm [31]. The hand can even be placed in the dependent position to increase inow pressure with gravity [32]. One should allow at least 10 minutes observation time for resolution of vasospasm before

manipulating the anastomosis. If the milk test is abnormal or if petechiae of the measles sign or ballooning of the sausage sign is encountered, suspect thrombosis and redo the anastomosis [25,33] (Fig. 19). Frequently, in reperforming the anastomosis, further vessel resection is necessary. If the additional vessel resection places the vessel repair under tension, an interposition vein graft is

Fig. 16. At least two veins should be repaired in nger replants, especially for replants proximal to the PIP joint. Dorsal veins are preferred because they are larger and dont interfere with repair of volar structures later. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

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exposure for the microsurgical repair of the digital arteries and digital nerves (Fig. 23). Common indications for arterial interposition vein grafts include thumb replants, ring avulsions, and segmental artery loss or trauma [3538]. Potential vein graft harvest sites for distal digital replants include the palmar forearm and wrist. The wrist is preferred by many because the volar wrist veins match the digital vessels [13,3941]. The leg or contralateral arm may be used to harvest vein grafts for major replants of the hand, forearm, or multiple ngers, as they can be harvested by a second team simultaneously (Fig. 24). Vein grafts must be reversed for arterial interposition because of the valves.

Special considerations and specic cases Thumb replants In the thumb, the ulnar digital artery is usually of larger caliber than the radial digital artery [42,43]. Arterial revascularization in thumb replantation therefore is more reliable when based on the ulnar digital artery. This vessel is dicult to expose for the microsurgery, however, and requires extreme arm pronation or supination. An arterial interposition vein graft from the radial artery in the anatomic snubox to the distal end of the ulnar digital artery in the amputated thumb helps avoid the cumbersome position of extreme rotation. Alternatively, the digital artery repair could be performed before the osteosynthesis. Care certainly must be taken to prevent disrupting the anastomosis during the bony xation if this method is chosen [32,42,43] (Figs. 25 and 26). When the thumb has been amputated at or near the MCP joint and the proximal ulnar digital artery has retracted and is dicult to expose, a vein graft can be used from the ulnar digital artery distally to the radial artery in the snubox, end to side. In using this vein graft to radial artery technique for replantation of the thumb, retrograde K-wires are placed rst into the bone on the amputated part. Then core sutures are placed in the proximal and distal ends of the exor pollicis longus (FPL) tendon. The digital nerves are labeled with long sutures for easier identication later. A subcutaneous tunnel is created from the ulnar aspect of the thumb base to the snubox. The radial artery is exposed in the snubox and double potts ties are placed on the radial artery proximally and

Fig. 17. This is an example of a dorsal vein repair with 10-0 nylon sutures in simple, interrupted fashion over the previously repaired extensor tendon.

required. A second artery should be repaired as a safeguard measure. Located supercial and volar to the digital arteries, the digital nerves are coapted next. This can be performed before or after the tourniquet has been deated. The epineurial nerve repair technique is preferred and can be performed with as few as three sutures (Fig. 20). A nerve conduit or graft is required if one is unable to repair the nerve primarily. Some prefer nerve conduits instead of direct coaptation. Weber et al reported a statistically improved return of sensation using the polyglycolic acid nerve conduits when compared with end-to-end coaptation [34]. Upper extremity nerve graft donors include the medial antebrachial and posterior interosseous nerves. Alternatively, a vein graft can be used for small defects of 2 cm or less (Fig. 21). At this point, the exor tendon is repaired, tying the previously placed proximal and distal core sutures (Fig. 22). Performing the tendon repair later permits nger extension, giving better

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Fig. 18. This is a well accepted technique that involves placing the rst two sutures at 10 oclock and 2 oclock, then 12 oclock, then the vessel is turned 180 degrees and additional simple, interrupted sutures are placed in sequence. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

Fig. 19. If petechiae of the measles sign or if ballooning of the sausage sign is encountered, suspect thrombosis and redo anastomosis. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

distally in preparation for end-to-side anastomosis of the vein graft to the radial artery. The vein graft is rst anastomosed end-to-end to the ulnar digital artery with the microscope. Again this provides much better exposure for the microanastomosis of the ulnar aspect digital artery to the thumb. The vein graft is then pulled through the subcutaneous tunnel to the radial artery in the snubox. The digital nerves also can be repaired at this point with better exposure. The osteosynthesis is carefully performed by passing the previously placed K-wires retrograde through the proximal bone. At this point the extensor tendon and dorsal veins are repaired. The vein graft is then repaired end to side to the radial artery in the snubox (Fig. 26). If the amputation level is distal to the MCP joint and the proximal end of the ulnar aspect digital artery is well exposed, a primary arterial anastomosis can sometimes be performed without

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Fig. 20. Then, the digital nerves are coapted. This can be performed after the tourniquet has been deated. Of the dierent digital nerve repairs, the epineurial technique is preferred and can be performed with as few as three sutures. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

the need for a graft. A technique that has been described to optimize exposure of the ulnar digital artery during the microanastomosis involves performing the microanastomosis before the osteosynthesis [44,45] (Figs. 27 and 28). The Kwires are placed retrograde through the distal amputated part rst. The ulnar digital artery and nerve are then repaired with the hand in supination that provides a better angle for the microscope and exposure for the anastomosis. The bone ends are then aligned and the osteosynthesis is completed carefully. The digital artery clamps are left in place until the extensor tendon and dorsal veins are repaired. Finally, the exor core sutures are carefully tied and the skin loosely approximated.

b Fig. 21. This is an example of a digital artery repair on the left and digital nerve repair superimposed over digital artery repair on the right. Notice the exor digitorum profundus tendon core sutures have not yet been tied, which allows for nger extension and better exposure of neurovascular structures.

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Fig. 22. At this point, the exor tendon is repaired, tying the previously placed proximal and distal core sutures. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

Multiple nger replantation In multiple nger replantation, the nger with the best chance for successful replantation, best expected recovery, and contribution to function should be repaired rst. If all the ngers are injured at the same level and with the same chance for success, the authors prefer to repair the middle, then index, then ring, and nally the small nger. If the index nger is sti or insensate, the patient will bypass this to use the middle nger. When all the ngers are sti, the index nger can actually impede the function and opposition of the other ngers to the thumb (Fig. 29). Because it is essential to minimize ischemia time with multiple digit replantations, each nger is replanted separately. The amputated ngers should be brought to the operating room as soon as possible, where the digital vessels, nerves, and tendons can be identied and tagged with sutures or clips, to save time and minimize ischemia. The order for repairs can be improvised with multiple replantations. Initially, the osteosynthesis, extensor tendon, one dorsal vein, and one digital artery can be repaired for each nger to minimize overall ischemia time.

Fig. 23. This is the same nger after tying of the exor tendon core sutures, bleeding on pinprick.

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Fig. 24. (A,B) This is a vein graft interposing this arterial defect between the two forceps. Notice the size match with this vein graft harvested from the palmar forearm.

Another dorsal vein, the digital nerves, and the exor tendon core sutures can be repaired later, once the blood ow to the ngers has been reestablished.

Major replants Upper extremity replants The order of the replant procedure is modied for major replantations of the hand and upper extremity. Early use of shunting has been described to minimize muscle ischemia time [15,16,32]. It is critical to minimize warm ischemia time to less than 4 hours to avoid muscle necrosis. Intravenous tubing or carotid shunts can be used to infuse and return blood to and from the amputated part (Fig. 30). Fasciotomies are required with major limb replantation and can be performed during the shunting reperfusion to save

Fig. 25. First, the vein graft is repaired to the distal ulnar artery. Then the vein graft is pulled through a subcutaneous tunnel to the snubox and repaired endto-side to radial artery. (From Goldner RD, Urbaniak JR. Replantation. In Green DP, editor: Greens operative hand surgery. 4th edition. New York: Churchill Livingstone; 1999. p. 113955; with permission.)

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Fig. 26. (AD) This patient nearly amputated his thumb in a saw. The distal thumb hangs by a dorsal skin bridge. The neurovascular structures were tagged; the exor pollicis longus tendon core sutures were placed proximally and distally. K-wires were placed in the retrograde fashion distally. The distal ulnar digital artery was repaired to the vein graft with excellent exposure. Then the osteosynthesis was performed, reducing the fracture line and carefully passing the K-wires in retrograde fashion into the proximal bone. Finally the vein graft is tunneled subcutaneously to the snubox, where it is repaired end-to-side to the radial artery.

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time. Bone shortening may avoid the need for nerve and vein grafting and allow for soft tissue closure over the repairs. With humeral level replants, the brachial artery and brachial venae commitante are repaired. The ulnar, median, and radial nerves are repaired. The skin is lightly reapproximated. Skin grafts are usually required for denitive closure. These upper extremity replants may require several operating room debridements at 48-hour intervals to remove devascularized, nonviable muscle. Amputations at this level often denervate the biceps muscles and later require latissimus or pectoralis muscle transfers to provide for active elbow exion.
Fig. 27. A technique that has been described to optimize exposure of the ulnar aspect digital artery during the microanastomosis involves performing the microanastomosis before the osteosynthesis. (From Caee HH. Improved exposure for arterial repair in thumb replantation. The Journal of Hand Surgery 1985;10A(s):416; with permission.)

Hand replants Again, vessels, nerves, and tendons are identied and tagged and K-wires are placed in the

Fig. 28. (AD) This patient amputated his thumb with a rope in a boating accident. This replantation actually involved repairs at two levels. First, K-wires were placed in the amputated part. Repairs on the amputated part were performed rst. Two dorsal veins and the ulnar aspect digital artery and nerve were repaired in the amputated part with the microscope on the back table. Then, the ulnar aspect digital artery of the amputated part was repaired to the proximal end of the ulnar aspect digital artery on the stump side with the microscope, before osteosynthesis to avoid the struggle for exposure often requiring extreme hand pronation. Then the digital nerve was repaired. Then the osteosynthesis was performed carefully passing the K-wires distal-to-proximal. The amputated part, extensor pollicis longus tendon, and two dorsal veins were repaired to the stump, before removal of the digital artery clamps proximal and distal to the microanastomosis. Leaving the clamps maintains hemostatic control and better exposure for the vein repairs. Finally, the exor pollicis longus (FPL) tendon core sutures are carefully tied and the skin is loosely approximated.

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Fig. 28 (continued )

retrograde fashion into the amputated part in the operating room before the patient is transported from the emergency room (Fig. 31). Similarly, the ischemia time can be minimized by shunting, during which fasciotomies can be performed if necessary. The most time-consuming part of a hand replantation is the tendon repairs. The exposure of the proximal exor tendon ends can be optimized by placing a longitudinal incision up the mid portion of the forearm. Also, tagging of the proximal and distal exor tendon ends before the osteosynthesis can facilitate the repair of the exor tendons later. It is important to understand the stacked array of the exor tendons with the middle and ring exor digitorum sublimis tendon (FDP) volar to the index and small nger supercialis exors (Fig. 32). Replantation of hand amputations at the wrist level may necessitate bone shortening (eg, proximal row carpectomy) to avoid nerve and vein grafts. Overall, the ulnar and radial arteries, four veins, median, ulnar, and supercial radial nerves are repaired and many tendons as possible. At least the four exor digitorum profundus tendons, exor carpi radialis, exor carpi ulnaris, four extensor digiti communis tendons, extensor carpi ulnaris, extensor carpi radialis, extensor pollicis longus, and exor pollicis longus should be performed. In

general, replantations at this level can achieve very good results.

Cross hand transfer A special circumstance may call for considering a cross hand transfer (ie, bilateral hand upper extremity crush avulsion amputations with significant soft tissue or bone destruction precluding bilateral ipsilateral replantation) [4648]. The patient in Fig. 33 had a brachial plexus injury rendering his right hand functionless [48] (Fig. 34). Accordingly, this right hand was electively transferred to the contralateral side, which had a thumb but was devoid of all four ngers. This elective cross partial hand transfer was performed at the level of the carpometacarpal joint with intraosseous wires (excluding the thumb). This was the rst elective partial cross hand transfer (excluding the thumb) reported in the literature. He went on to attain good functional use of this hand following transfer.

Postoperative care Postoperative care has traditionally included warming the patients room to avoid vasospasm

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and positioning the extremity at the heart level to minimize edema but not compromise arterial or venous ow. Anticoagulation is generally recommended. Several investigators recommend the routine use of aspirin and dextran with replantation, [5,49,50] and therapeutic heparin for crush avulsion injuries [32,49]. Depending on the mechanism of injury, antibiotics are considered. Patients are encouraged to abstain from smoking and caeine use for 1 month [51,52]. The replanted part is monitored by checking color, capillary rell, tissue turgor, and temperature. Sympathetic blocks have been described for high-risk replantations after crush avulsion injuries [25]. Arterial insuciency is the most common cause for replantation failure, accounting for approximately 60% of failures in two studies

[5,49]. Arterial insuciency is suggested by decreased capillary rell, tissue turgor, and temperature. Treatment of arterial insuciency includes removal of potentially constricting dressings and tight sutures, decreasing extremity elevation to promote inow with gravity, and sympathetic blockade. Finally, early operative intervention can be considered if there is no improvement with the above measures. Reexploration to correct arterial insuciency has been reported to be successful in 50% of return visits [5,49]. Venous congestion is a less common cause for replantation failure [5,49]. Venous congestion should be suspected with rapid capillary rell, increased tissue turgor, or bleeding of wound edges [49]. Treatment of venous congestion includes removal of tight dressings and

Fig. 29. (AG ) This 50-year-old man amputated all four of his ngers in a printing press. Each nger is replanted separately to minimize warm ischemia time. Two dorsal veins and one digital artery were repaired for each nger in the dorsal and volar sequence described by OBrien. The ngers were replanted in order of functional importance. The authors repaired this patients index nger last, because the amputation level was to the proximal interphalangeal level and would be less functional. All four replants survived: He quickly regained the ability to write. With tenolysis procedure and correctional osteotomy of the index nger, he went on to regain >50% total active motion (TAM). He even created this glove that he uses to help lift weights.

Fig. 29 (continued )

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B.J. Wilhelmi et al / Hand Clin 19 (2003) 89120 Table 4 Survival rates for replantations Author Tamai (1982) Kleinert (1980) Urbaniak (1979) Sixth Peoples Hospital (1975) Number Survival rate 157 347 107 320 80% 70% 82% 54%

cannot be repaired and the patient refuses leeches [53]. Finally, operative revision can be considered, but is less successful than reexploration for arterial insuciency.

Outcomes Overall success rates for replantation approach 80%. In reviewing large volume retrospective reports, these success rates range from 54% in Chinas Sixth Peoples Hospital to 82% in North Carolina [5457] (Table 4). Overall, success rates are signicantly higher for replantation of guillotine (77%) versus crush (49%) amputations [5,49]. In general, approximately 50% achieve two-point discrimination (2 PD) less than 10 mm [5862]. Seventy percent of Tamais 228 replants achieved 2 PD <15 mm,

Fig. 29 (continued )

sutures and increasing elevation to promote venous drainage with gravity. Leeches are also eective at treating venous congestion in replantation. Nail plate removal and application of a heparin soaked sponge to the nail bed has been described for distal replantations when a vein

Fig. 30. (AG) This 40-year-old man amputated his left arm in a rollover car accident. His amputated arm was found in a ditch, 30 feet in front of him and his upside-down car. The arm was brought to the operating room before the patient arrived; it was extensively irrigated and structures to be repaired were identied and labeled. The humerus was shortened enough to allow for skin approximation over the repairs. Then osteosynthesis was performed with a 4.0 compression plate. Next, the use of carotid shunts to and from the amputated part minimized the total ischemia time to 3 hours. During this shunting reperfusion, forearm and hand fasciotomies were performed. Then the brachial artery was repaired with a reversed saphenous vein graft. The brachial venae commitante were repaired. Then the median, ulnar, and radial nerves were coapted. At 48 hours and several times after that he returned to the operating room for debridement of portion of the triceps, distal deltoid, and biceps muscles and skin edges. Finally, at 2 months postoperatively, he did not have any open areas or evidence of nerve regeneration.

Fig. 30 (continued )

Fig. 31. (AD) This 63-year-old woman accidentally amputated her left hand while helping cut wood with a radial saw for her family fence-making business. The amputation was at the distal carpal row. K-wires were used for osteosynthesis. Before the osteosynthesis, the neurovascular structures were identied and labeled, together with the tendons. Overall, the ulnar and radial arteries, four veins, median, ulnar and supercial radial nerves, and 18 tendons were repaired. Postoperatively, despite her advanced age and less than optimal participation with therapy she had some return of function.

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Fig. 31 (continued )

whereas 65% of Larsens 142 replants attained 2 PD <10 mm [57,58]. In general, younger patients with distal guillotine amputations experienced better return of sensation. Several studies have determined the average replant to achieve 50% of normal function (ie, 50% total active motion and 50% grip strength) [60,63 65]. Return of function was worse for zone II injuries and for patients of advanced age. Russell published the largest review of major limb replantations and found 11/24 achieved >50% total active motion and 19/24 achieved protective sensation, and 22/24 patients were satised with the function and appearance of their replanted part [10]. Jupiter showed the function of replanted digits could be signicantly improved with tenolysis procedures [66]. In his review, the total active motion of 37 replanted digits was signicantly improved (P < 0.001) with tenolysis and no digits were lost [66]. The patient in Fig. 34 underwent replantation

of the middle and ring ngers after amputation in a log splitter (Fig. 34). He went on to experience loss of active and passive exion. To improve the socially unacceptable posture of his permanently extended middle nger, he required exor tenolysis, extensor tenolysis, and capsulotomy procedures. A median nerve catheter was used to provide the patient with better pain control postoperatively, for immediate active range of motion exercises. Postoperatively, he had full active range of motion at 6 weeks.

Summary With the evolution of surgical techniques and scientic technology, replantation has become more rened, establishing specic indications for replantation, rituals for preparation, ecient techniques to ultimately minimize ischemia times,

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Fig. 32. A simple method of demonstrating the arrangement of sublimis tendons at wrist with the middle and ring ngers volar to the index and small ngers. ( Frank Netter. Clinical Symposia, Volume 21(3). Summit, NJ: Ciba Pharmaceuticals; 1969. p. 88).

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Fig. 33. (A) This patient had a brachial plexus injury rendering his right hand functionless. Accordingly, the right hand was electively transferred to the contralateral side, which had a thumb but was devoid of all your ngers and metacarpals. (B,C ) This elective cross hand transfer was performed at the level of the carpal metacarpal joint with intraosseous wires. (DF ) This patient went on to attain good functional use of this hand following transfer.

improved survival rates, guidelines for postoperative care, strategies for treating complications, and goals for outcomes. Patient satisfaction hinges on their level of expectation as dened and explained in the preoperative discussion and informed consent. Studies have demonstrated patients can be expected to achieve 50%

function and 50% sensation of the replanted part. Initially all that was amputated was replanted, as surgeons adopted the philosophy of George C. Ross (18431892): Any fool can cut o an arm or leg but it takes a surgeon to save one. Forty years after the rst replant (19622002), however, we recognize the ultimate

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Fig. 33 (continued )

Fig. 34. (AK ) This patient underwent replantation of the middle and ring ngers after amputation in a log splitter. He went on to experience loss of active and passive exion. To improve the socially unacceptable posture of his middle nger, he required exor tenolysis, extensor tenolysis, and capsulotomy procedures. A median nerve catheter was used to provide the patient with better pain control postoperatively, for immediate active range of motion exercises. Postoperatively, he had full active range of motion at 6 weeks.

goal: not merely to preserve all living tissue through nonselective replantation, but rather to preserve ones quality of life by improving their function and appearance. This objective to care

for the patient with the intent to optimize function and appearance is important not only to the replantation of amputations but to all mutilated hand injuries.

Fig. 34 (continued )

Fig. 34 (continued )

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B.J. Wilhelmi et al / Hand Clin 19 (2003) 89120 [10] Russell RC, Obrien B, Morrison WA. The late functional results of upper limb revascularization and replantation. J Hand Surg 1984;9A(5): 62333. [11] Vanstralen P, Panini RPG, Sykes PJ, et al. The functional results of hand replantation. J Hand Surg 1993;18B(3):55664. [12] Urbaniak JR, Roth JH, Nunley JA. The results of replantation after amputation of a single nger. J Bone Joint 1985;67A(4):6119. [13] Van Beek AL, Kutz JE, Zook EG. Importance of the ribbon sign indicating unsuitability for the vessel in replanting a nger. Plast Reconstr Surg 1973; 61(1):328. [14] Bajec J, Grossman JA, Gilbert D. Upper extremity preservation before replantation. J Hand Surg 1987;12(2):3212. [15] Chernofsky NA, Sauer PF. Temporary ectopic implantation. J Hand Surg 1990;15A(6):9104. [16] Godina M, Bazec J, Baraga A. Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part. Plast Reconstr Surg 1986;78(3):2959. [17] Hayhurst JW, McC, OBrien B, Ishida H. Experimental digital replantation after prolonged cooling. J Hand Surg 1974;6(2):13441. [18] Usui M, Ishii S, Muramatsu I, Takahata N. An experimental study on replantation toxemia. The eect of hypothermia on an amputated limb. J Hand Surg 1978;3(6):58995. [19] Van Geisen PJ, Seaber AV, Urbaniak JR. Storage of amputated parts prior to replantation: an experimental study with rabbit ears. J Hand Surg 1983;8(1):605. [20] Chiu HY, Chen MT. Revascularization of digits after thirty-three hours of warm ischemia time: case report. J Hand Surg 1984;9A(1):637. [21] May JW Jr, Hergrueter CA, Hanson RH. Sevendigit replantation: digit survival after 39 hours cold ischemia. Plast Reconstr Surg 1986;78(4):5223. [22] May JW Jr. Digit replantation with full survival after 28 hours cold ischemia. Plast Reconstr Surg 1981;67(4):566. [23] VanderWilde RS, Wood MB, Zeng-gui S. Hand replantation after 54 hours of cold ischemia:a case report. J Hand Surg 1992;17A(2):21720. [24] Wei FC, Chen HC, Chuang CC. Three successful digital replantations in a patient after 84, 86, and 94 hours cold ischemia time. Plast Reconstr Surg 1988;82(2):34650. [25] Gallico GG. Replantation and revascularization of upper extremity. In: McCarthy JW, editor. Plastic surgery. Philadelphia: W.B. Saunders; 1990. p. 435583. [26] Nissenbaum M. A surgical approach for replantation of complete digital amputations. J Hand Surg 1980;5(1):5862. [27] Urbaniak JR, Hayes MG, Bright DS. Management of bone in digital replantation free vascularized and

Fig. 34 (continued )

References
[1] Malt RA, McKhann CF. Replantation of severed arms. JAMA 1964;189(10):71622. [2] Malt RA, Remensnyder JP, Harris WH. Long-term utility of replanted arms. Ann Surg 1972;176(3): 33442. [3] Buncke HJ, Alpert BS, Johnson-Giebink R. Digital replantation. Surg Clin N Am 1981;61(2): 38392. [4] Kleinert HE, Juhala CA, Tsai TM, et al. Digital replantation selection technique and results. Symposium on replantation and reconstructive microsurgery. Ortho Clin N Am 1977;8(2):30918. [5] OBrien B. Replantation surgery. Clin Plast Surg 1974;1(3):40526. [6] Tsai TM. Experimental and clinical application of microvascular surgery. Ann Surg 1973;181(2):16977. [7] Brown RW. The rational selection of treatment for upper extremity amputations. Ortho Clin N Am 1981;12(4):8438. [8] May JW Jr, Toth BA, Gardner M. Digital replantation distal to the proximal interphalangeal joint. J Hand Surg 1982;7(2):1615. [9] Meyer VE. Hand amputations proximal but close to the wrist joint: prime candidates for reattachment. J Hand Surg 1985;10A(6):98991.

B.J. Wilhelmi et al / Hand Clin 19 (2003) 89120 composite bone grafts. Clin Ortho Res 1978; 133:18494. Wray RC, Young VL, Weeks PM. Flexible implant arthroplasty and nger replantation. Plast Reconstr Surg 1984;74:97. Lister G. Intraosseous wiring of the digital skeleton. J Hand Surg 1978;3(5):42735. Whitney TM, Lineaweaver WC, Buncke HJ, Nugent D. Clinical results of bony xation methods in digital replantation. J Hand Surg 1990; 15A(2):32834. Swartz WA, Brink RR, Buncke HJ. Prevention of thrombosis in arterial and venous microanastomosis by using topical agents 1976;58(4):47881. Goldner RD, Urbaniak JR. Replantation. In: Green DP, editor. Greens operative hand surgery. 4th edition. New York: Churchill Livingstone; 1999; 1:113955. Acland R. Signs of patency in small vessel anastomosis. Surgery 1972;72(5):7448. Weber RA, Breidenbach WC, Brown RE, Jabaley ME, Mass DP. A randomized prospective study of polyglycolic acid conduits for digital nerve reconstruction in humans. Plast Reconstr Surg 2000; 106(5):103645. Comtet JJ, Willems P, Mouret P. Ring injury with bilateral rupture of the digital arteries without skin damage. J Hand Surg 1979;4A(5):4156. Earley MJ, Watson JS. Twenty-four thumb replantations. J Hand Surg 1984;9B(1):98102. Schlenker JD, Kleinert HE, Tsai TM. Methods and results of replantation following traumatic amputation of the thumb in sixty-four patients. J Hand Surg 1980;5(1):6370. Tsai TM, Manstein C, DuBou R, et al. Primary microsurgical repair of ring avulsion amputation injuries. J Hand Surg 1984;9A:6872. Beimer E. Vein grafts in microvascular surgery. Br J Plast Surg 1977;30:1979. Buncke HJ, Alpert B, Shah KG. Microvascular grafting. Clin Plast Surg 1978;5(2):18594. Urbaniak JR, Evans JP, Bright DS. Microvascular management of ring avulsion injuries. J Hand Surg 1981;6(1):2530. Hamilton RB, OBrien B, Morrison A, MacLeod AM. Survival factors in replantation and revascularization for the amputated thumb: 10 years experience. Scand J Plast Reconstr Surg 1984;18: 16373. Parks BJ, Arbelaez J, Horner RL. Medical and surgical importance of the arterial blood supply of the thumb. 1978;3(4):3835. Caee HH. Improved exposure for arterial repair in thumb replantation. J Hand Surg 1984;10A(3):416. Sharo BB, Palmer AK. Simplied technique for replantation for the thumb. J Hand Surg 1981;6A(6):6234. Adkins P, Graham B, Kutz JE. Functional evaluation of an emergency cross-hand replantation: a

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9-year follow-up. J Hand Surg 1992;17A(2): 2146. Kutz JE, Sinclair SW, Rao V, Carler A. Cross hand replantation: preliminary case report. J Microsurg 1982;3:2514. May JW Jr, Rothkopf DM, Savage RC, Atkinson R. Elective cross-hand transfer: a case report with a ve-year follow-up. J Hand Surg 1989;14A(1): 2834. OBrien B, Miller GDH. Digital reattachment and revascularization. J Bone Joint 1973; 55A(4): 71423. Tamai S. Twenty years experience of limb replantation: review of 293 upper extremity replants. J Hand Surg 1982;7(6):54956. Adrichem LNA, Hovius SER, Strik R, van der Meulen JC. The acute eect of cigarette smoking on microcirculation of a replanted digit. J Hand Surg 1992;17A(2):2304. American Society for Surgery of Hand. The hand: primary care of common problems, 2nd edition. New York: Churchill Livingstone; 1990. p. 61. Gordon L, Leitner DW, Buncke HJ, Alpert BS. Partial nail plate removal after digital replantation as an alternative method of venous drainage. J Hand Surg 1985;0A(3):3604. Kleinert KE, Jablon M, Tsai TM. An overview of replantation and results of 347 replants in 245 patients. J Trauma 1980;20(5):3908. Sixth Peoples Hospital. Replantation surgery in China, report of the American replantation mission to China. Plast Reconstr Surg 1973;52(5):47689. Sixth Peoples Hospital. Replantation of severed ngers: clinical experiences in 217 cases involving 373 severed ngers. Chines Med J 1975;1(3):18496. Tamai S. Digit replantation. Clin Plast Surg 1978;5(2):195209. Gelberman RH, Urbaniak JR, Bright DS, Levin LS. Digital sensibility following replantation. J Hand Surg 1978;3(4):3139. Poppen NK, McCarroll HR, Doyle JR, Niebauer JJ. Recovery of sensibility after suture of digital nerves. J Hand Surg 1979;4A(3):2126. Tark KC, Kin YW, Lee YH, Lew JD. Replantation and revascularization of hands: clinical analysis and functional results of 261 cases. J Hand Surg 1989; 14A(1):1726. Zumiotti A, Ferriera MC. Replantation of digits: factors inuencing survival and functional results. Microsurg 1994;15:1821. Yamauchi S, Nomura S, Yoshimura M, et al. A clinical study of the order and speed of sensory recovery after digital replantation. J Hand Surg 1983;8(5):5459. Matsuda M, Shibahara H, Kato N. Long-term results of replantation of 10 upper extremities. World J Surg 1978;2:60312. Scott FA, Howar JW, Boswick JA. Recovery of function following replantation and revascularization

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B.J. Wilhelmi et al / Hand Clin 19 (2003) 89120 of amputated hand parts. J Trauma 1981; 21(3): 20414. Wei CC, Qing QY, Jia YZ. Extremity replantation. World J Surg 1978;2:51324. Jupiter JB, Pess GM, Bour CJ. Results of exor tendon tenolysis after replantation in the hand. J Hand Surg 1989;14A(1):3544. Baudet J. Successful replantation of severed ear parts. Plast Reconstr Surg 1973;51:82. Chen CW, Chien YC, Pao YS. Salvage of forearm following complete traumatic amputation: report of case. Chin Med J 1963;82:632. Chen ZW, Zen BF. Replantation of the lower extremity. Symp Clin Microvasc Surg 1983; 10(1):10313. Cohen BE, May JW Jr.. Successful clinical replantation of an amputated penis by microneurovascular repair: case report. Plast Reconstr Surg 1974; 59:2769. Gayle LB, Lineaweaver WC, Buncke GM, et al. Lower extremity replantation. Clin Plast Surg 1991; 18(3):43747. Kleinert HE, Kasdan ML. Anastomosis of digital vessels. J Kentucky Med Assoc 1965;63:1068. [73] Komatsu S, Tamai S. Successful replantation of a completely cut-o thumb. Plast Reconstr Surg 1968;42:3756. [74] Lu M. Successful replacement of avulsed scalp. Plast Reconstr Surg 1967;43:231. [75] Lu SY, Cjui HY, Lin TW, Chen MT. Evaluation of survival in digital replantation with thermometric monitoring. J Hand Surg 1984;9A(6):8059. [76] Nahai F, Hayhurst JN, Silibian AH. Microvascular surgery in avulsive trauma to the external vascular surgery in avulsive trauma to the external ear. Clin Plast Surg 1978;5:423. [77] Nahai F, Herteau J, Vasconez LO. Replantation of entire scalp and ear by microvascular anastomosis of only one artery and vein. Br J Plast Surg 1978;31:339. [78] Norman JJ. Survival of large replanted segment of upper lip and nose. Plast Reconstr Surg 1976; 58:623. [79] Seran D, Kutz JE, Kleinert HE. Replantation of completely amputated distal thumb without venous anastomosis. Plast Reconstr Surg 1973;52(5): 57982. [80] Walton RL, Beahm EK, Brown RE, et al. Microsurgical replantation of lip: a multi-institutional experience. Plast Reconstr Surg 1998;102(2):35868.

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Hand Clin 19 (2003) 121131

Pediatric mutilating hand injuries

Gregory M. Buncke, MDa,b,c,*, Rudolf F. Buntic, MDb,c, Oreste Romeo, MDc
a

Department of Plastic Surgery, University of California, 350 Parnassus Avenue, San Francisco, CA 94117, USA b Department of Plastic Surgery, Stanford University Medical Center, CA 94305, USA c Buncke Clinic, 45 Castro Street, Suite 140N, San Francisco, CA 94010, USA

The treatment of mutilating hand injuries continues to be one of the most dicult challenges faced by reconstructive hand surgeons. With the advent of microsurgical techniques, parts that had been discarded are now replanted or revascularized. In addition, reconstruction for soft tissue coverage and nger lengthening with toe transplantation has become an essential part of the reconstructive surgeons armamentarium. Managing children is particularly rewarding to the hand and microsurgeon because the outcome tends to be better than with adults in terms of mobility, sensory return, and appearance and because children who sustain mutilating hand injuries tend to rebound more quickly than adults from both a functional and psychologic perspective. The parents of the injured child, however, can add another level of complexity to surgical management. The trauma that causes the mutilating injury in children is often related to parental neglect or caused by situations and circumstances that a diligent parent could have avoided: unfortunately children are often left unsupervised in dangerous settings. Parents who own and operate restaurants, garages, farms, ranches, or factories often have small children in the work environment during the parents work hours. A child may accidentally catch his or her hand in machinery while trying to help an adult at work. In addition, the parents may not have the nancial means to obtain quality child care.

Parental guilt related to the accident is often a dicult problem for both surgeons and nurses. Parents often transfer their guilt to health care providers by becoming overly involved and critical of the childs care in the hospital and in the outpatient setting. Professional counseling for the family after admission can be of enormous help in caring for the child. Although an outpatient, hand therapy often serves two purposes: assisting the child in maximizing his or her function, and allowing an outlet for parents to become more involved in their childs care. Parents meet other parents of injured children or other adults who have injuries and may set up an informal type of group therapy, which often helps allay the depressed parents feeling of guilt [1]. Types of injures The diversity of mechanisms of injury leads to a multiplicity of types of injuries in the pediatric mutilated hand. The mechanisms of mutilation include meat grinders, saws, stationary bicycles, doors, hinges, explosives, guns, recrackers, dog and other animal bites, burn injury from both hot water and exposed heating elements or electricity, and lawn mowers [25]. Unfortunately, childrens mutilating injuries tend to be less amenable to replantation than the typical hand saw injury seen so commonly in adults. As a result, children frequently need secondary operations to maximize function and appearance.

* Corresponding author. Buncke Clinic, 45 Castro Street, Suite 140N, San Francisco, CA 94010. E-mail address: gbuncke@buncke.org(G.M.Buncke).

Initial management and preoperative evaluation Frequently, when a child has had a devastating injury to an extremity, most of the attention is

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. doi:10.1016/S0749-0712(02)00076-8

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Fig. 1. (A) A 6-year-old child with his hand caught in a meat grinder. (B) The grinder was removed using a carbon cutting circular saw. The patient has a severe mutilating injury. (C ) The small nger was salvaged; all carpal bones on the radial aspect of the hand had to be removed. (D) Great toe to thumb transplant (proximal phalanx of the toe to the distal radius) to create prehension. (E,F ) The child can now swing a baseball bat, write, and use eating utensils with his reconstructed right dominant hand.

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focused on the injured part. Frantic parents and friends often make it dicult to assess the entire patient in the emergency room. As is true with any emergency patient, the ABCs (airway, breathing and circulation) are addressed rst. Unlike an adult, a young child often is unable to give a reliable history and may be unable to describe pain successfully in other locations. Unfortunately, if the child is too young, the history must then be obtained from a witness, either a parent or possibly the ambulance crew that arrived on the scene. Key elements in the history include the nature of the injury, mechanism of injury, and the possibility of contamination. Sometimes the mechanism is quite obvious (Fig. 1). If there has been a crushing or avulsion element to the injury, the surgeon must be concerned about a more proximal injury, such as muscle tearing in the forearm and possible delayed compartment syndromes. Severe contamination from farm injuries needs more aggressive debridement and perioperative antibiotics that cover gram-negative bacteria. Obviously, any chronic medical condition that precludes a long general anesthesia also needs to be determined. A thorough general physical examination is very important. The evaluating physician should have a low threshold for obtaining radiographs of any potentially injured part or tender site on the body. With regard to the injured limb, key elements of the examination in the emergency room before taking the patient to the operating room can often be performed with the dressing intact. If there has been an injury to the proximal ngers, mid-palm, wrist, or forearm the examining surgeon may be able gently to examine the tips of the ngers for vascularity, sensation if the patient is old enough to cooperate, and any voluntary motion. Sensory examination may be the most helpful preoperatively, because the surgeon may not need to dissect as extensively for nerve injury intraoperatively if sensation is intact. Particularly in young children, however, the trauma of examining an obviously mangled extremity must be weighed against the unlikely possibility of obtaining any clinical information that helps with the emergency operation. In cases of amputation, a quick evaluation of the amputated part can be performed in the emergency room under loupe magnication to alert the patients parents of nonreplantable limbs or digits. Every eort should be made, however, to attempt replantation in children. Religious and cultural issues are often apparent in the emergency room when discussing treatment

with the parents. For example, certain religious groups do not believe in blood transfusions. If replantation or revascularization is contemplated in such a child, the parents should be alerted that the child will probably need blood transfusion sometime during the hospitalization. The parents may elect to have the child not undergo replantation in such a circumstance. Because of cultural issues in the Asian population, the authors have frequently replanted mutilated parts that they were sure would have a poor functional outcome. According to some Asian cultural philosophies, however, if an individual dies without all of his or her body parts they have somehow disgraced their ancestors. The authors have many happy Asian patients with sti ngers. The initial assessment of the injured extremity and amputated part is then completed in the operating room when the child is under general anesthesia. Once a complete evaluation of the mutilated extremity is performed in the operating room, the surgeon may take a short break from the procedure and discuss the examination with the anxious parents. Certainly replantation and revascularization should take precedence over allaying parental anxiousness. Decisions should be made with the parents assistance, however, if at all possible. Many patients are transferred to a replantation center from several hours away. During the preparation for transport of the child, several steps should be performed before the patients transfer. Specically, the patient should be hemodynamically stable before transfer. The injured extremity should be wrapped with a bulky dressing wrapped tight enough to prevent continuous oozing from the hand but not so tight as to cause pain or vascular compromise. A tourniquet should not be placed on the extremity. The amputated part should be wrapped in slightly moistened saline gauze. It can then be placed in a plastic bag or a water-tight container and placed on ice. Care should be taken not to place the part directly on ice without a protective layer of gauze or directly in ice to avoid freezing the part. Placing the part in soaked saline sponges or allowing the part to oat in saline leads to maceration of the part. The operative procedure: general concepts If available, the authors often try to have two operative teams working simultaneously in major amputations. The amputated part is taken to the operating room while another team is evaluating

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and preparing the patient for surgery. The socalled tagging team examines the amputated or mutilated parts under an operating room microscope and puts tagging sutures, specically No. 6-0 silk, around structures to be repaired, such as digital arteries, nerves, and veins. Debridement of obviously contaminated tissue should be performed at the same time. Once the patient is stable hemodynamically, he or she is brought into the operating room and general anesthesia begins. Usually the tagging team is working in the same room identifying structures on the amputated parts. A tourniquet is placed on the arm and the arm is elevated if severe blood loss is anticipated during dressing removal. The tourniquet may, however, need to be released to determine viability of damaged parts and the possible need for revascularization. Debridement is then performed. If replantation or revascularization is necessary, debridement should be performed expeditiously to minimize ischemia time. Clearly infected, contaminated tissue needs to be removed. Marginally vascularized tissue of signicant importance, such as nerves, tendons, joints, and bones, should be left intact. Muscle, devascularized fat, and skin should all be debrided aggressively. Debridement should be performed under tourniquet control. After release of tourniquet there should be good bleeding from the debrided edges; if not, more debridement should be performed. Skin bridges, which may provide critical venous drainage, should be preserved whenever possible. Supercial veins in subcutaneous tissue may be required in future reconstructive eorts, such as microvascular soft tissue coverage operations. The veins can be debrided denitively and immediately at the time of anastomosis. Tendon debridement should be performed sparingly and paratenon should be preserved if at all possible for future skin grafting. Undebrided tendon ends are convenient grasping points while manipulating a tendon for tenorrhaphy. Bony ends must be debrided of foreign contaminated tissue before any osteosynthesis. In patients who have suered burn injuries or crushing injuries with avulsion, care must be taken not to remove marginally vascularized tissue. The authors believe in serial debridements over the next several days to maximize the amount of viable tissue available for reconstruction. After debridement is completed, irrigation should be performed with bulb syringes or pulse lavage. Once irrigation is completed and hemosta-

sis is obtained, the surgeon next needs to consider coverage of the wound. If primary closure cannot be obtained at the time of the emergency operation, then skin grafting is considered. Large skin grafts or emergency microvascular transplants, however, should not be performed unless the surgeon is sure of having adequately debrided the wound. This is often dicult in the mutilated extremity, because there frequently is a burn, crush, or avulsion component to the injury. What seems viable at the emergency operation may be necrotic 3 or 4 days later at a subsequent debridement operation. To avoid desiccation of the wound with traditional wet-to-dry dressing changes the authors use a subatmospheric (VAC sponge) pressure dressing for wound management [6]. This system is well tolerated by patients. The system seems to keep the wounds moist and is especially well liked by the nursing sta who no longer need to do three to four times a day wet-to-dry dressing changes. The sponge is generally changed in the operating room.

Replantation and revascularization The concepts and techniques for replantation and revascularization in mutilating injuries in children are similar to those in adults [7,8]. Once tagged, amputated parts are placed in a small operative basin that is then placed on ice to minimize warm ischemia. The second operative team performs debridement and at the same time identies the corresponding structures that were previously identied in the amputated part by the tagging team, specically arteries, nerves, veins, and exor and extensor tendons. The replantation-revascularization eort should begin with the most ulnar-amputated digit. The sequence of replantation begins with osteosynthesis [9]. Occasionally, in the situation where a large part has been amputated, like an entire hand, forearm, or upper arm, revascularization may be performed before osteosynthesis to prevent muscle ischemia. In this situation a T-shaped shunt is placed in the proximal and distal artery. The other end of the T is attached to a syringe containing heparinized saline. Once arterial inow is established in the amputated part, osteosynthesis can be performed. The authors generally perfuse the part for about 20 minutes and then clamp o the shunt. Bleeding can be profuse during this time and the anesthesiologist should usually hang

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blood during such a reperfusion eort. To perform an end-to-end anastomosis of arteries, veins, and nerves, bone shortening is usually performed. Up to 3 to 4 cm can be removed from the radius and ulna or humerus without any signicant functional loss in amputation injuries. Rigid plate xation should be performed in long-bone repairs, being careful not to injure growth centers. In contradistinction, osteosynthesis of nger replants is generally preformed with K-wire xation over plate xation to speed along the replantation eort. Plates may also become exposed if there is marginal necrosis of the skin at the repair site. Once osteosynthesis is performed in the large part replant, an arterial anastomosis is performed either with or without a vein graft, depending on the defect. Throughout this time the replanted part is allowed to bleed from the venous side. At rst the blood that comes from the veins is quite dark in color, rich in muscle breakdown products. The authors usually allow this venous blood to drain for several minutes before venous repair. The patient may lose up to one to two units of blood during this time. The venous repair is not performed until the color and consistency of the venous outow appear normal. Venous blood sampling for potassium has been reported: if the potassium is less than 6.5, then the risk of systemic injury is unlikely [10]. During any crushing or replantation-revascularization operation, the surgeon needs to be aware of possible compartment syndromes. This is missed easily in patients who have had avulsion injuries of the ngers and have had tearing at the musculotendinous junction in the forearm. The patient can develop compartment syndrome sometimes several hours after the injury. Revascularized or replanted arms or hands should be watched closely for elevated compartment pressures in the hand. Dorsal incisions should be made to release the intrinsic musculature by releasing the fascia in the intermetacarpal space. Compartment pressures can be measured accurately with the Stryker system (Stryker Surgical Division, Kalamazoo, MI) [11]. Compartment pressures above 25 mm Hg signal the need for compartment release. The surgeon, however, should have a low threshold for compartment release because edema and elevated pressures may develop several hours after surgery. When replanting ngers vascular repairs often can be tedious and technically very dicult in children. Vein grafts [12] are used liberally in crushed and avulsed injuries. Resection of damaged vessels

is very important to maintain the patency of a vascular repair. In a very distal replant, for example distal to the distal interphalangeal (DIP) joint, arterial repair may be possible, but a venous repair may not. The surgeon should look for a volar vein or repair the distal artery to a proximal vein thereby using the second artery in the digit as outow for the replanted part [13]. The use of a venous ow-through ap [14] can serve as a vein conduit and also act as soft tissue cover for an area of questionably viable skin on the volar or dorsal surface of a mutilated nger, as in ring avulsion injuries. The venous ap can be harvested easily from the volar surface of the wrist. Vein grafts can also be harvested from this area. The vein vessel diameter is approximately the same size as the arteries of the nger. Next in the sequence of replantation and revascularization is the digital nerve repair. Usually after microvascular arterial repair, the nerve is in the operating eld and nerve repair can be performed expeditiously. Digital nerve repair should be performed end-to-end if possible. A nerve graft can be placed in the primary emergency setting. If there is marginal necrosis and exposure of the nerve graft, however, one may lose the nerve graft and have lost a precious donor site. A nerve graft can be harvested from the supercial peroneal region on the dorsum of the foot [15] or the sural nerve region. Care should be taken to harvest the nerve high enough up the calf so that the patient does not develop a neuroma at the upper boot level. A nerve graft can also be harvested from the ulnar aspect of the forearm. Patients often complain, however, of numbness over the volar forearm. Vein conduits also can be used for nerve gaps. The patient can obtain similar results with a vein conduit as nerve graft if the defect is 3 cm or less [16]. Flexor tendon repair is next performed using a double-opposing locking loop stitch technique [17,18] with or without epitendinous stitch depending on the contour and irregularity of the repair. If there is a tendon gap, a tendon graft can be used. One should avoid tendon grafts, however, if marginal necrosis of the skin is anticipated. The surgeon may be more inclined to use a tendon graft in a potentially problematic wound if tendon graft is harvested from a nonreplantable part. Grafts can also be harvested from the palmaris longus, plantaris tendon, or extensor digitorum longus to the middle three toes [12]. The next step in the sequence of replantation involves repairing extensor tendons and dorsal

Fig. 2. (A) A 10-year-old boy suered a nonreplantable left middle nger amputation. (B) Markings for a second toe transplant for nger reconstruction. (C) Intraoperative image of second toe transplantation. (D,E) Postoperative demonstration of length and function.

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Fig. 3. (A,B) Late result of a mutilating injury of the right hand in a 4-year-old boy. (C,D) Intraoperative image of simultaneous great toe and rectus muscle transplant. (E,F) Immediate postoperative results with STSG over the rectus muscle. Venous Doppler probe is in place. (G,H) Nine months postoperative view of function.

veins. After the volar skin incision is closed loosely, the hand is turned over. The extensor tendon is repaired using as strong a repair as possible. If there is adequate tendon, a double-opposing locking stitch should be performed. Alternatively, a mattress repair is usually adequate. Venous repair

is performed under the operating microscope with vein grafts if necessary. In general, veins can usually be repaired in end-to-end fashion. Once the replantation-revascularization operation has been performed, the patient is empirically started on low-molecular-weight dextran [19,20]

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Fig. 3 (continued )

(total dose not greater than 20 mL/kg in 24 hours). Dextran is usually continued for 5 days. Heparin may be added as a second anticoagulant if a vein graft has been used of if there have been intraoperative thrombosis problems [21,22]. The authors generally run heparin at 5 to 25 units/kg/h and titrate the dose to the clinical response. A loose, bulky dressing with a dorsal protective splint is then fashioned. Xeroform or any other nonadherent petroleum-based gauze should not be placed circumferentially around the nger, to avoid a tourniquet eect with swelling. Monitoring is performed using quantitative uorometry. A venous Doppler probe [23] is helpful for real-time monitoring of the circulation in large replanted parts or microvascular transplant. Medicinal leeches are used when there is any sign of venous insuciency or in severely bruised or traumatized soft tissue in the mutilated hand [24,25]. Soft tissue coverage Adequate soft tissue coverage is essential to reestablish any reasonable functional result in a

mutilated hand, especially in children. For small defects, such as ngertip avulsions with exposed distal phalanx, cross nger aps or pedicle aps may be of value. In a larger wound, however, especially if there is any crush or avulsion associated with the injured upper extremity, keeping the patients hand in a dependent position for a groin ap may cause undue swelling. Young children may not tolerate pedicle ap or being in this uncomfortable position for the 2-week requirement. Microvascular transplants of muscle with splitthickness skin graft coverage, cutaneous aps, or fascial aps with skin graft can serve as excellent coverage for immediate or delayed tendon, bone, nerve, or joint reconstruction [26]. Tendon repairs or tendon grafts may have less adhesion if tunneled through subcutaneous fat of a skin ap or through muscle rather than laying the tendon directly onto healing bone fractures [12]. The timing of soft tissue coverage is a controversial issue. Several others have recommended a strict time frame for denitive soft tissue coverage in mutilating extremity injuries [27,28]. It has been

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Fig. 4. (A) Severe burn crush injury to 7-year-old girl. (B) Radiographs showing loss of all ngers. (C,D) Postoperative image of hand appearance and function after simultaneous right second toe and serratus muscle transplant and subsequent left second and third toe transplant.

the authors experience that soft tissue coverage should take place when the responsible surgeon believes that the wound has been debrided adequately in a serial fashion. The authors have had a few cases of infection from inadequate debridement and early coverage of a wound that had been presumably deemed ready for coverage within 48 hours of the injury. With the use of the VAC sponge system, the problems with desiccation and loss of potentially viable tissue are no longer a signicant problem.

Emergency microvascular coverage is probably indicated in the case where a portion of a nonreplantable part can be used as a microvascular transplant, either as an arterial-to-venous repair or a venous ow-through for soft tissue coverage. In those circumstances, a normal donor site is not wasted should a postoperative complication occur. Emergency toe transplants have been performed on the authors service in specic, unique circumstances. For example, a child suered a below-knee avulsion amputation with no injury to the foot and

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also had a nonreplantable thumb injury [29,30]. In that situation the toe was harvested from the nonreplantable below-knee amputation and transplanted to the thumb position.

Delayed treatment of the mutilating hand injury Unfortunately, in many children who have undergone mutilating hand injuries, the surgeon may not be able to salvage any of the amputated parts. The patient is frequently decient in soft tissue and has either lost all of their ngers or has one nger remaining. This is especially true in the meat grinder-type injury (Fig. 2). Restoring prehensile function or pinch is the goal [3136]. When the reconstructive surgeon is presented with a patient who has had this sort of injury, one needs to determine whether soft tissue coverage is adequate and whether there is adequate blood supply to transplant soft tissue and toes for nger and thumb reconstruction [37,38]. When evaluating for possible toe transplantation, the surgeon needs to dene whether digital nerves, exor, or extensor tendons are available for repair to the toe. If all of this is present soft tissue and toe transplant can be performed simultaneously in the appropriate setting. Otherwise, a staged sequence of operations needs to be performed [39,40]. In general, soft tissue reconstruction is preformed rst followed by toe transplantation (Figs. 3 and 4).

Obviously, the prevention of these devastating injuries is much preferable to extraordinary heroic reconstruction. Unfortunately, some injuries are inevitable. It is nearly impossible to create an absolutely hazard-free environment for children. Potential injuries can be avoided, however, simply by keeping hazardous machines and equipment out of the reach of the child and by keeping children out of the potentially dangerous workplace. References
[1] Petrilli J, Milne E, Nugent K. Hand therapy. In: Buncke HJ, editor. Microsurgery: transplantation and replantation. Philadelphia: Lea and Febiger; 1991. p. 74859. [2] Al-Arabi KM, Sabet NA. Severe mincer injuries of the hand in children in Saudi Arabia. J Hand Surg [Br] 1984;9:24950. [3] Benson LS, Waters PM, Meier SW, et al. Pediatric hand injuries due to home exercycles. J Pediatr Orthop 2000;20:349. [4] Brandner M, Bunkis J, Trengove-Jones G. Meat grinder injuries to the upper extremity. Ann Plast Surg 1985;14:4547. [5] Moore Jr. RS, Tan V, Dormans JP, et al. Major pediatric hand trauma associated with reworks. J Orthop Trauma 2000;14:4268. [6] Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38:56376; discussion 577. [7] Buncke GM. Replantation. In: Achauer BM, editor. Plastic surgery: indication, operations and outcomes, Vol. 4. Saint Louis: Mosby; 2000. p. 213148. [8] Dautel G. Fingertip replantation in children. Hand Clin 2000;16:5416. [9] Buncke HJ, Clapson JB, Whitney TM. Bony xation and replantation. In: Buncke HJ, editor. Microsurgery: transplantation and replantation. Philadelphia: Lea and Febiger; 1991. p. 63450. [10] Waikakul S, Vanadurongwan V, Unnanuntana A. Prognostic factors for major limb re-implantation at both immediate and long-term follow-up. J Bone Joint Surg Br 1998;80:102430. [11] Botte MJ, Gelberman RH. Acute compartment syndrome of the forearm. Hand Clin 1998;14: 391403. [12] Shatford RA, Scheker LA. Mutilating hand injuries assessment and general management principles. In: Gupta A, Kay S, Scheker L, editors. The growing hand: diagnosis and management of the upper extremity in children. New York: Mosby; 2000. p. 1079114. [13] Suzuki Y, Ishikawa K, Isshiki N, et al. Fingertip replantation with an eerent A-V anastomosis for venous drainage: clinical reports. Br J Plast Surg 1993;46:18791.

Summary Mutilating hand injuries in children are a devastating problem. With aggressive eorts at replantation and revascularization, methodic debridement, timely soft tissue coverage, and early mobilization, however, the results in these unfortunate children can be quite rewarding. The child often does well with the functional aspect of recovery and rehabilitation but will probably hide his or her deformed hand from friends and family. These children generally become more shy and reserved. The parents are the key to rehabilitation. A good relationship between the parent, the physician, and the hand therapist is essential for the best result. Interestingly, the parents who are the most demanding on the sta during the initial emergency period are often the most appreciative parents and their children often achieve the best result. Conscientious parents are the best advocates for their children.

G.M. Buncke et al / Hand Clin 19 (2003) 121131 [14] Tsai TM, Matiko JD, Breidenbach W, et al. Venous aps in digital revascularization and replantation. J Reconstr Microsurg 1987;3:1139. [15] Buntic RF, Buncke HJ, Kind GM, et al. The harvest and clinical application of the supercial peroneal sensory nerve for grafting motor and sensory nerve defects. Plast Reconstr Surg 2002; 109:14551. [16] Chiu DT, Janecka I, Krizek TJ, et al. Autogenous vein graft as a conduit for nerve regeneration. Surgery 1982;91:22633. [17] Lee H. Double loop locking suture: a technique of tendon repair for early active mobilization. Part I: Evolution of technique and experimental study. J Hand Surg [Am] 1990;15:94552. [18] Lee H. Double loop locking suture: a technique of tendon repair for early active mobilization. Part II: Clinical experience. J Hand Surg [Am] 1990;15: 9538. [19] Bygdeman S, Tangen O. The eect of dextran on collagen-induced platelet aggregation in vitro. Thromb Res 1975;6:10920. [20] Wolfort SF, Angel MF, Knight KR, et al. The benecial eect of dextran on anastomotic patency and ap survival in a strongly thrombogenic model. J Reconstr Microsurg 1992;8:3758. [21] Khouri RK, Cooley BC, Kenna DM, et al. Thrombosis of microvascular anastomoses in traumatized vessels: brin versus platelets. Plast Reconstr Surg 1990;86:1107. [22] May Jr. JW, Rothkopf DM. Salvage of a failing microvascular free muscle ap by direct continuous intravascular infusion of heparin: a case report. Plast Reconstr Surg 1989;83:10458. [23] Kind GM, Buntic RF, Buncke GM, et al. The eect of an implantable Doppler probe on the salvage of microvascular tissue transplants. Plast Reconstr Surg 1998;101:126873; discussion 1274. [24] Anthony JP, Lineaweaver WC, Davis Jr. JW, et al. Quantitative uorimetric eects of leeching on a replanted ear. Microsurgery 1989;10:1679. [25] Batchelor AG, Davison P, Sully L. The salvage of congested skin aps by the application of leeches. Br J Plast Surg 1984;37:35860.

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[26] Canales F, Lineaweaver WC, Furnas H, et al. Microvascular tissue transfer in paediatric patients: analysis of 106 cases. Br J Plast Surg 1991;44:4237. [27] Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:28592. [28] Lister G, Scheker L. Emergency free aps to the upper extremity. J Hand Surg [Am] 1988;13:228. [29] Buncke HJ, Buncke GM, Lineaweaver WC, et al. The contributions of microvascular surgery to emergency hand surgery. World J Surg 1991;15: 41828. [30] Hing DN, Buncke H, Alpert B. To replant or to transplant? Adv Plast Reconstr Surg 1988;4:177. [31] Brown HC, Williams HB, Woolhouse FM. Principles of salvage in mutilating hand injuries. J Trauma 1968;8:31932. [32] Burkhalter W. Mutilating injuries of the hand. Hand Clin 1986;2:4568. [33] Harris GD, Nagel DJ, Bell JL. Mutilating injuries. In: Jupiter JB, editor. Flynns hand surgery. Baltimore: Williams and Wilkins; 1991. p. 10314. [34] Trautwein LC, Smith DG, Rivara FP. Pediatric amputation injuries: etiology, cost, and outcome. J Trauma 1996;41:8318. [35] Tubiana R. Repair of bilateral hand mutilations. Plast Reconstr Surg 1969;44:32330. [36] Weinzweig J, Weinzweig N. The tic-tac-toe classication system for mutilating injuries of the hand. Plast Reconstr Surg 1997;100:120011. [37] Buncke GM. Lengthening by toe transfer. In: Foucher G, editor. Reconstructive surgery in hand mutilation. United Kingdom: Martin Dunitz; 1997. p. 1016. [38] Buncke HJ, Clapson JB, Whitney TM. Great toe transplantation. In: Buncke HJ, editor. Microsurgery: transplantation and replantation. Philadelphia: Lea and Febiger; 1991. p. 643. [39] Buncke HJ, Whitney TM. Multiple microvascular transplants. In: Buncke HJ, editor. Microsurgery: transplantation and replantation. Philadelphia: Lea and Febiger; 1991. p. 57088. [40] Jackson RL, Buncke HJ, Buncke GM. Immediate reconstruction of mutilating hand injuries. Plastic Surgery Forum, 1994;868.

Hand Clin 19 (2003) 133148

Hand therapy management following mutilating hand injuries

Shirley W. Chan, OTR, CHTa,*, Paul LaStayo, PhD, PT, CHTb
a

Department of Physical Medicine and Rehabilitation, California Pacic Medical Center, Davies Campus, P.O. Box 7999, San Francisco, CA 94120, USA b Department of Physical Therapy, Northern Arizona University, Box 15105, Flagstaff, AZ 86011, USA

Overview of the rehabilitation process for mutilating hand injuries Mutilating injuries are among the most complex and devastating injuries to the upper extremity [1]. Common types of mutilating injuries include crush, avulsion, and amputation. The outcome prognosis largely depends on the severity, type, and location of the injury [2]. Generally partial and clean amputations have better outcomes than crushing or avulsion injuries [3]. The manner in which these patients are managed operatively and postoperatively also greatly inuences the outcome. This article focuses on the postoperative management of mutilating hand injuries. Mutilating injuries dier from other types of hand injuries in that multiple systems and structures are involved [1]. These include skin, vascular, nerve, tendon, muscle, bone, and the soft tissue envelope around joints. Despite the shared wound healing characteristics, each structure has a unique healing time frame, precautions, and optimal treatment approach. Some of the primary factors that can aect the healing process and ultimate outcome include the patients age, occupation, psychologic status, the surgical procedure, and past medical history [4]. The therapist must take all these factors into consideration to formulate the optimal treatment approach for each case.

Because of the severe nature of these injuries, one must keep in mind several principles when treating this population:  The therapist should maintain close communication with the treating surgeon about his or her patient management approach, patient progress, and postoperative treatment plan.  The therapist also must have thorough knowledge of anatomy, wound healing, biomechanics, and treatment guidelines of various traumatic injuries.  The therapist should have a thorough understanding of the injuries and types of repairs performed. That understanding should include location and quality of repair, types of sutures used, associated injuries, and any structures that were injured but not repaired. The general rehabilitation process can be divided into the early, intermediate, and late phases. Early phase (protective) This refers to the rst 510 days after the injury and is usually a part of the patients inpatient stay. The therapist takes an active role in the multidisciplinary team. This includes communicating with the physician to obtain details of the injury and surgery and working with nursing and social service sta to prepare for the patients discharge from the hospital. Attending inpatient rounds is an excellent way to obtain pertinent information, to observe the wounds, to meet the patient and the family, and to discuss the treatment plan with the team. Reviewing the chart, imaging studies, and

* Corresponding author. E-mail address: chans@sutterhealth.org (S.W. Chan).

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. doi:10.1016/S0749-0712(02)00140-3

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operative report also yields additional information that should be factored into the design of the treatment program [1,3,5]. This may include but not be limited to the following: 1. Type and stability of skeletal xation 2. Joint status: free, pinned, or fused 3. Tendon repairs; note exor system and additional repairs (eg, nger pulleys) 4. Vessel repairs 5. Nerve repairs 6. Uninjured versus unrepaired structures 7. Location of repairs 8. Condition of repairs 9. Skin coverage This information is vital not only for treatment planning but also for providing insight into future surgical needs and helping formulate a realistic expectation for recovery [1,3,5]. Although most of the traditional hand assessments are not appropriate because of various precautions, the therapist should interview the patient to obtain information pertaining to the medical and social history and begin patient education regarding positioning, precautions, the rehabilitation process, and the expected outcome. If the patient cannot return to the same facility for outpatient care, the treating therapist also arranges for referral to a therapist at the patients hometown and coordinates the plan of care. A protective splint to protect repaired structures is frequently fabricated at this time and daily wound care is initiated. Depending on precautions and other medical factors, the patient may begin gentle range of motion (ROM) exercises to the uninvolved joints. Generally active and active assistive exercises are preferred if they do not cause excessive stress to the repair site. Early mobilization to the involved structures also may be introduced, depending on precautions and contraindications. Intermediate phase (mobilization) This phase begins 57 days after the injury and lasts until 68 weeks after surgery. At this stage, gentle controlled stress is introduced to decrease adhesions, promote intrinsic healing, improve nutrition, promote collagen remodeling, increase tensile strength of soft tissues, and prevent joint contractures [6]. The program is progressed as the repaired structures undergo wound healing and gain tensile strength. The protective splint needs to be remolded as edema subsides and the need for

wound dressings decrease. Once the wound is healed and the chance for dehiscence is low, scar management begins. In this phase the patient takes an active role in therapy and in their home exercise program. Activity of daily living (ADL) needs and training are addressed, especially if the dominant hand is involved [42]. The patient also may need psychologic intervention to assist with adjustment to the physical and psychologic trauma. Late phase (strengthening) This stage begins 68 weeks after surgery and lasts until the patient is discharged from therapy. This is the time when hand function retraining and strengthening become the focus of therapy. Progressive physical demands are placed on the repair to promote strength, hand function, coordination, and endurance through resistive exercises and functional activities. ADL training may focus on specic problems as they emerge, such as opening the car door or buttoning. The protective splint is usually discontinued and splints used at this time are usually for overcoming joint stiness, increasing tendon glide, or as an assist to function. Depending on the rehabilitation goals and outcome, the therapist also may be involved in work retraining or communicating closely with the physician to plan further reconstructive surgeries. Healing process of the systems Skin The skin is a highly vascularized organ and heals quickly. A robust inammatory response usually lasts approximately 3 days and is characterized by the presence of warmth and swelling. A brin mesh then provides a trellis, which guides proliferating broblasts and capillary buds into the wound [7]. The broblastic response begins at 35 days and is marked by the production of new collagen that provides strength to the wound tissue [7,8]. The tensile strength of a wound increases rapidly at 1 week and peaks at 42 days. Wounds that are closed by primary intention are often healed in 1014 days, at which time the sutures can be removed. Scar management also can begin at this time. As the wound matures, the scar contracts in all dimensions and often seems red and raised because of the profound biologic activity that can last for months. Eventually the wound takes on a denser construct and the

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biologic activity diminishes (ie, a balance between the production of collagen by broblasts and degradation of collagen by collagenase is reached by 1 year) [7,8]. Blood vessels Microsurgical repairs of blood vessels are generally protected for 4 weeks to prevent clotting at the anastomosis site and arterial spasms. This is achieved by avoiding tension and pressure at the anastomosis site and by keeping the revascularized body part warm. The patient is usually on anticoagulants during this time. The revascularized part should be positioned at the level of the heart [3,9]. Excessive elevation may cause arterial insuciency and dependent position may cause venous congestion. Smoking is also prohibited, as nicotine is a vasoconstrictor and can cause the replantation to fail [10,11]. Once the vascularity is well established and stable, compression dressing and dependent position tolerance training can be gradually introduced. Nerve Although the healing of the nerve repair is similar to other soft tissues, functional recovery is a much longer process. A completely transacted and repaired nerve should be protected for 34 weeks to avoid tension and compression at the coaptation site. In a complex injury in which multiple structures are involved, however, early mobilization is vitally important to promote early nerve gliding while protecting the repair, thus minimizing scar adhesion [7]. After a nerve repair there is a latency period of 34 weeks before axonal regeneration of approximately 1 mm per day occurs [12,13]. Factors inversely correlated with nerve regeneration include: amount of scar, age, type of injury, and the length of nerve injured in a crush or stretch injury. In sensory nerves, the return of pain and sympathetic function does not necessarily imply the return of cutaneous sensibility; however, the lack of sympathetic function usually suggests the absence of cutaneous sensibility. Sensibility recovers in the following sequence: pain, deep pressure, pinprick, moving touch, static light touch, and nally discriminative touch. In motor nerves, the muscle reinnervation occurs in the order in which the muscles were originally innervated. The Tinel sign, return of muscle activity, and sensory testing should be used to monitor the status of the regenerating nerve [13,14]. As the nerve regenerates, the Tinel

sign should migrate distally along the nerve path. This should coincide with the return of motor function or sensory reinnervation. Tendon Following a tendon repair, the goal is to protect the repair and insure that it glides freely. Three approaches to the postoperative management of tendons exist: (1) immobilization, (2) early passive mobilization, and (3) early active mobilization [15], but some form of early motion is optimal. Although tendons likely heal by way of a combination of extrinsic healing (a broblastic response extrinsic to the tendon, which optimizes healing but results in restricting adhesions) and intrinsic healing (a cellular response intrinsic to the tendon, which minimizes adhesions), early postoperative motion (active or passive) facilitates the latter, enhances strength of the repair, and reduces the chances for restricting adhesions [1618]. The early phase of rehabilitation is characterized by an inammatory reaction that diminishes the tensile strength of the repaired tendon but also primes the repair site for broblastic activity during the intermediate phase. This broplasia provides the constituents necessary for improving tendon strength. The intermediate phase also includes a remodeling of the deposited broblastic scar so as to allow free and unrestricted tendon gliding. This remodeling of tissue continues into the late phase of rehabilitation, during which stressors to the tendon can be increased and tendon strength and function continue to improve [15]. Unfortunately, because of the multiple injuries in a mutilated hand, tendons often heal in a fashion not conducive to gliding and return of hand function. Therefore, often a tenolysis (the surgical release of nongliding adhesions) is required 612 months following the repair in an attempt to salvage tendon function [19]. Bone and dense connective tissues When a fracture is rigidly xed, primary healing occurs and mechanical integrity is reestablished immediately. The lack of motion at a fracture site held together with plates or screw xation (ie, rigid xation) does not induce a brous callus, the characteristic response of secondary healing, however, early motion can and should be initiated. The clinical irony of primary healing is that rigid/stable union is established immediately by way of externally

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applied compression across the fracture site, yet the biologic healing is prolonged. When secondary healing of a fracture occurs, an interfragmentary gap remains (ie, rigid xation is not applied). In this case the gap is stabilized through semi-rigid xation devices or immobilization techniques. Because the fracture gap is not rigidly xed some obligatory motion occurs at the gap site in secondary healingcalled secondary because an intermediate connective tissue (callus) is formed early and then is secondarily replaced by bone. This process is characterized by three discrete yet overlapping stages of inammation, repair, and remodeling that are commensurate with the early, intermediate, and late phases of rehabilitation, respectively [20]. The therapist, by way of the application or avoidance of stressors across a healing fracture site, can inuence how bone consolidates; however, their greatest inuence is on the soft tissues surrounding the fracture site. One of the most inuential factors aecting the clinical outcome after a fracture resulting from a mutilating hand injury is whether the soft tissues are gliding normally. Although closed and open reductions of fractures have their respective advantages and disadvantages, both fracture management approaches adversely aect the soft tissue gliding layers and the function of the extremity. The reality of fracture management is that it is clinically irrelevant whether bones unite by primary healing or secondary callus. What is essential, however, is (1) whether or not the bone heals in a stable, well aligned fashion, (2) how well

the soft tissues glide, and (3) how the extremity functions after it is healed.

Treatment techniques relating to the systems Skin Wound care The primary goal after a mutilating injury is wound closure, and wound care is often in the domain of the hand therapist. Wound assessment should be carried out with each dressing change to monitor for signs of infection such as excessive redness, pain, swelling, and also to monitor the patients progress in wound healing. In revascularization cases, vascularity also should be closely monitored by checking color, turgor, and capillary rell. A white revascularized part indicates an arterial compromise as opposed to a bluepurple color that suggests venous congestion [3]. Skin grafts should be pink and adherent to the wound bed. The patient is taught what to look for in home dressing changes and any abnormal observations should be reported to the physician immediately. Wound care is performed gently to remove drainage, dry blood, and loose eschar (Fig. 1). Clear serum or bloody drainage is normal during the healing process. Thick purulent drainage is a sign of infection and should be reported to the physician immediately. Special caution should be taken when removing adherent dressings near or over healing skin grafts and anastomosis sites. Whirlpool is generally not used postrevasculariza-

Fig. 1. The wound is gently cleaned using a sterile applicator to remove drainage, dry blood, and loose eschar.

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tion because of the need to place the body part in a gravity-dependent position [3,21]. Nonadherent protective dressings are used and care must be taken that they are applied in a nonconstrictive fashion. Each digit should be separated in the dressing to facilitate the ability to perform independent nger exercises (Fig. 2). Scar management Scar mobilization can be introduced once the wound is healed. Compression therapy is added once the vascularity is stable at approximately 4 weeks. Pressure wraps, compression garments, elastomer inserts, and silicone gel sheets are some of the common methods to provide compression to aid in scar remodeling [22]. Pressure promotes approximation of collagen cross-linking, thus aiding in the control of hypertrophic scaring [7,22,23]. Areas with skin grafts and excessive scar have compromised function of the oil glands; hence, lubricating lotions have to be applied periodically to rehydrate the skin. Vascular system Edema control Methods for edema control and their time frames are similar to those of scar management [14]. Because compression, by way of coban or specialized garments, is not introduced until approximately the fourth week postoperatively, elevation is the primary means of controlling edema in the early phase. Retrograde massage and lymphatic drainage techniques also can be used to aid in edema control. Custom-made pressure garments may be necessary for scar and edema

control if the contour of the hand has been signicantly altered by the injury or soft tissue coverage and prefabricated garments do not t properly. Gravity-dependent position tolerance training Gravity-dependent position tolerance training can be introduced once the wound is completely healed and vascularization and edema are stable. This occurs spontaneously in most cases when the patient begins to use the extremity and places the hand in a gravity-dependent position for brief periods during functional use. If the patient has diculty with increasing the tolerance, structured training can be used. After applying the compression wrap, the revascularized part is allowed to be put in a dependent position for a brief period, typically starting with 3 minutes several times a day. The pressure wrap is removed afterward to inspect the circulation and edema of the revascularized part. The duration and frequency of the dependent positioning is gradually increased if no adverse color or appearance occurs. This program is especially important if the hand therapist is involved after free ap coverage in lower extremity mutilating injury cases so that the patient can begin crutch training. Nerve Protection education After a mutilating injury, sensibility is often impaired or absent, depending on the severity of the nerve injury. Sensibility should be tested once the wound is completely healed and then monitored on a monthly basis. If the involved part does

Fig. 2. Each nger is wrapped separately to allow for individual nger exercise.

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not have protective sensation, the patient should be taught precautions and protection techniques to prevent thermal and sharp injuries [3,14]. In cases in which there is also vascular involvement, the lymphatic system cannot dissipate heat readily. The involved part can be burned easily even though the temperature may be tolerated by an uninjured part [3,9]. Therefore, thermal modalities must be used at lower temperatures and with extreme care [24]. Sensory re-education Once the involved part has regained protective sensation, sensory re-education can begin. This is accomplished by texture discrimination, size and shape discrimination, and stimuli localization activities [12,14]. The activity is usually repeated with and without visual input so the patient can cognitively retrain sensory perception [25]. As the patients hand function improves, sensory reeducation also can be incorporated with functional activities. Desensitization The patient may develop hypersensitivity, a frequent complication, in the stump or scar. Desensitization can be started once the wound is healed. This is achieved by introducing graded textures, starting with the least irritable to the patient and building up tolerance to a coarser texture [9] (Fig. 3). Pressure tolerance also can be increased with graded pinch exercise and the patient is frequently placed on a desensitization home program. If the patient does not respond to

desensitization and the pain is in a localized area, a neuroma might be the source of pain [1]. Bone, tendon, and joint capsule Once a fracture is stable, either by way of a closed or open reduction, the following clinical interventions should be temporally incorporated in the therapy protocol to maximize the gliding of tendons and dense connective tissue structures (eg, the joint capsule): (1) protection or an external support, (2) edema control, (3) protected and controlled mobilization of the joints around a stable fracture site, (4) tendon gliding, (5) passive range of motion (PROM) and the splinting regimes to enhance PROM, and (6) strengthening (Fig. 4). During the early phase of rehabilitation an external immobilizing or protective splint should be used following a closed or open reduction respectively. As the fracture and surrounding soft tissues are healing and the rehabilitation segues from the early to intermediate phases, some protected or controlled physiologic motion is important to institute. Protected mobilization (during the external immobilization phase following closed reduction) to the nonimmobilized joints is needed to avoid joint contractures proximal or distal to the fracture site and to actively glide soft tissue structures such as tendons. Either active or passive motion is appropriate for protected mobilization, whereas active motion should be emphasized for controlled mobilization (Fig. 5).

Fig. 3. Graded textures are used for treatment of scar hypersensitivity.

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Fig. 4. Fracture algorithm. Once the fracture is stabilized by way of a closed or open reduction, an external support or protective splint (or brace) is needed, respectively. The external supports after a closed reduction may include casts, braces, splints, or external xators. Coupled with the external support or protective splint during the early phase is the need to control (ie, reduce or prevent the formation of) edema. Protected mobilization in the form of gentle active or passive motion (during the external immobilization phase following closed reduction) to the nonimmobilized joints is needed to avoid joint contractures proximal or distal to the fracture site and to glide soft tissue structures. Active motion, however, should be emphasized for controlled mobilization and for tendon gliding. Although protective splinting is still needed during the intermediate phase, treatments that address passive range of motion (PROM) decits can be initiated following open reduction, whereas PROM interventions following a closed reduction are delayed until the remodeling stage. The reference noted in this article (Flowers, 2002) addresses the hierarchic approach to splinting for overcoming joint stiness. Strengthening is typically initiated following closed and open reductions in the late phase. The hierarchic splinting regimen and strengthening often is not continued past the rst 6 months, but these interventions may be required (hence the stippled arrows) for up to 1 year.

Once the external immobilizer is removed, typically toward the mid to latter half of the intermediate phase (46 weeks), controlled mobilization (ie, active motion of the previously immobilized joints) is started. In addition, however, further protection of the fracture site is typically needed and accomplished by a removable splint. Following an open reduction and

stable xation, a protective splint coupled with edema control measures is necessary during the early phase, but controlled mobilization is usually started no later than and often before the beginning of the intermediate phase. Passive motion is often not initiated until the latter part of the intermediate phase, approximately 48 weeks after the fracture (and usually

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Fig. 5. (A) Traction splints can be used for phalangeal fractures to provide stability by way of the principle of ligamentotaxis while allowing for protective motion to minimize adhesion. This treatment approach is especially useful with intra-articulate and comminuted fractures [40,41]. (B) In this case there is a large bony defect at the MCP joint from a crush injury. The traction splint is used to hold the digit out to length during wound healing. ROM exercises are done in the splint and an MCP arthroplasty has been planned as a secondary procedure.

approximately 2 weeks after controlled mobilization of the joint). Splinting, especially using a hierarchic approach [26] to overcome a passive joint limitation, is an excellent way to enhance PROM; the reader is referred to the many reports on the use of low-load prolonged stress (LLPS) and how monitoring the total end-range time (TERT) can overcome many of these passive joint limitations [2630] (Fig. 6). Following a closed and an open reduction, strengthening (by way of resistance exercises) typically is not started until the healing bone and soft tissues are structurally capable of tolerating high muscle forces across them; therefore, caution should be used when using resistance exercises before 8 weeks following a mutilating hand injury with resultant fractures and soft tissue disruptions. Resistance exercises should not be used until the fracture site is stable. When tendon gliding is impaired and a functional arc of nger motion has not been attained, the therapist should determine if a lag is pre-

sent. A lag is dened as demonstrably greater passive ROM versus active ROM [31]. In the hand, this can be attributed to a neurologic decit or weakness and pain. Most often, however, restricting scar adhesions have formed and the tendon cannot be actively pulled by its respective muscle; however, the joint can be passively moved. An algorithmic approach toward dealing with these adhesions is presented in Fig. 6. This approach uses a clinical assessment of the presence of a lag and a dosage of stress, by way of an exercise, that attempts to reduce this lag (Fig. 7). A cadre of modalities can be used in the treatment of mutilating hand injuries. During the intermediate and late phases of rehabilitation, thermal agents such as supercial heat, deep heat, and paran can be used to decrease pain and enhance the return of joint motion and soft tissue gliding [32]. With any thermal agent, extreme care must be used when a patient has impaired sensation or cognition so as to not cause a burn.

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Fig. 6. Joint stiness. Stiness algorithm: an algorithm to guide the use of treatments for joint stiness secondary to structural changes to periarticular soft tissues. HLBS high load brief stress; LLPS low load prolonged stress; TERT total end range time (duration frequency of treatment per treatment session); load the amount of force applied during treatment session; adverse tissue reaction swelling, heat, pain.

Likewise if swelling is a problem, heat should be coupled with an elevated hand position or retrograde massage to prevent further swelling. The presence of open wounds also should be considered a precaution for thermal agents such as a hot pack or ultrasound (unless used specically for wound healing) and a contraindication for paran baths. Continuous wave ultrasound can serve as a deep heat source that may be especially potent when trying to overcome capsu-

lar tightness. Electrotherapeutic agents, by way of transcutaneous electrical nerve stimulation, also can be used for pain relief and restoring neuromuscular control and strength [14]. General rehabilitation guidelines following surgical procedures unique to mutilating injuries In the following section, general postoperative treatment guidelines are presented. The reader

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Fig. 7. Lag algorithm. The assessment for the presence or absence of a lag (greater passive ROM than active ROM because of restricting scar adhesions) following a soft tissue repair (eg, tendon repair) initiates this algorithm. If no lag is present and joint stiness is the impairment, then see Fig. 6. If a lag is present, a hierarchic approach to exercise is implemented. Active exercises should be used rst in an attempt to overcome the lag, followed by light and then heavier resistance exercises. A continual reassessment as to the presence of a lag is required following each exercise trial. Finally, if the lag persists, a surgical release is necessary. Conversely if no lag exists and there is full passive ROM during the rst 3 months following repair, further protection of the repair is required. (Adapted from McClure PW, Blackburn LG, Dusold C. The use of splints in the treatment of joint therapy biological rationale and an algorithm for making clinical decisions. Physical Therapy 1994;74:11017; with permission.)

must keep in mind that these are only general guidelines. Each patient is unique, each injury is dierent, and the treatment program must be modied depending on the patients injury, progress, and complications. Soft tissue coverage Pedicle aps Pedicle aps are two-stage procedures. The ap covering the defect in the injured hand is left attached to the donor site for 24 weeks [33,34]. During the rst stage, the recipient extremity should be supported to prevent tension on the ap. In the case of a chest or groin ap to the hand, heat and gentle joint mobilization to the shoulder can minimize stiness in the proximal joint. If the digits are free, pressure wraps and retrograde massage can be used to minimize dependent edema. Active and passive ROM of the uninvolved joints should be emphasized as long as

it does not stress the ap. Pillows, foam positioning devices, and splints may be used to support the extremity, to minimize tension of the repair, and to prevent contracture on the uninvolved joints as long as they do not interfere with the ap. After the ap is detached, therapy is focused on wound healing, edema control, scar management, regaining ROM, and strength. Pressure garments often are used to help contour the ap after the wounds are completely healed. Free aps Free aps are vascularized tissue transfers (Fig. 8) and several precautions must be observed [33,34]. The therapist should communicate with the surgeon to nd out the location of the anastomosis site. Tension and pressure to these areas must be avoided and the ap must be kept warm to optimize vascularity. The extremity is positioned at the level of the heart. The bulky postoperative cast is usually replaced by a protective splint before the patient is

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Fig. 8. Free aps are vascularized tissue transfers that can provide excellent coverage for large soft tissue defects in the hand.

discharged from the hospital. The splint is designed to avoid pressure on the ap while protecting the transfer and positioning the involved joints in functional positions [9]. Once the ap is stable, gentle passive ROM can begin as early as 57 days after surgery. If there are associated tendon repairs, care should be taken to not apply excessive tension to the repairs, following treatment guidelines for the specic repairs. If the anastomosis is at a joint, ROM may be delayed or performed in a protective range, depending on vascular stability. Active ROM can begin once passive ROM is tolerated. To improve tendon glide, electrical stimulation can be used if needed 1 week after active ROM has begun. Once the ap is well healed, scar massage can begin at 3 weeks. At 4 weeks, vascularity is stable and light pressure wrapping and dynamic splinting can be introduced. If the splint applies direct pressure on the ap, this may be delayed another week and splint-wearing time is gradually increased. At 6 weeks, protective splints can be discontinued. In addition, pressure garments can be measured and ordered at 6 weeks to be worn at 8 weeks [3]. As each new treatment is introduced, the aps vascular status should be carefully monitored. For functional muscle transfers, passive ROM should be maintained at the distal joints. Evidence of muscle regeneration may be noted in 24 months. At that time, muscle re-education should begin. Some investigators advocate the use of direct current electrical stimulation to maintain viability of the denervated muscles until there are

signs of motor return, although this is still a topic of controversy [17,35,36,43]. Replantation Replantation is unique in that the exor and extensor tendons are involved in addition to all other systems previously mentioned. The initial protective stage starts in the operating room when the surgeon places a plaster splint to protect the repairs. For a nger repair, the protective position is wrist neutral, metacarpophalangeal (MCP) joint exion at 608908, and interphalangeal (IP) joint extension [6,37]. In this position both tendon systems are protected, the collateral ligament length is preserved, and exion contracture of the proximal interphalangeal (PIP) joints is avoided [3,6]. A thermoplastic protective splint is fabricated as soon as the patient is o anticoagulants, usually on the fourth to seventh postoperative day to allow for ease of wound care and exercises in the mobilization phase [3,21,37]. In selected cases, depending on surgeon preference, gentle controlled stress is applied as early as the second postoperative day if the repairs are strong and there is no complication. Because the exor and extensor systems are involved, special considerations must be given to the exercise program. An early protective mobilization program is designed to prevent joint stiness and minimize adhesions while protecting the repairs. This program is subdivided into two stages. Early protective Motion I (EPM I) consists of gentle wrist exion and

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Fig. 9. Early protective motion (EPM) I. (A) Gentle active wrist exion and simultaneous assisted nger extension by tenodesis effect. (B) Gentle assisted wrist extension to neutral with passive MCP exion.

simultaneous nger extension by virtue of the tenodesis eect [3,6] (Fig. 9A) The motion occurs in a ratio, that is, if wrist exion is limited, only a proportional amount of MCP extension is allowed. Following this the wrist is brought to neutral extension with gentle passive and gravity-assisted exion of the MCP (Fig. 9B). This is designed to move the MCP and the wrist to prevent joint contractures while maintaining balanced tension between the exors and extensors, at the same time still protecting the repairs [3,6]. The wrist extension-MCP exion position preserves MCP collateral ligament length while the wrist exionMCP extension position provides relief from the intrinsic plus position and prevention of PIP volar plate shortening. Edema control, wound care, patient education, and psychologic adjustment are also important aspects of the treatment. EPM II, the second phase, begins at 1014 days and consists of the intrinsic minus and the intrinsic plus position, also known as the hook

and table positions respectively [3,6]. With the hook position, the wrist is supported in neutral while the MCP joint is gently brought into extension and IP joints into exion (Fig. 10A). Using the radian concept, Brand has calculated that for every 57.298 or 1 radian of PIP exion, there is 7.5 mm of excursion to the central slip [6,27]. In other words, to achieve 35 mm of tendon excursion, the PIP joint needs to ex 22.9838.28 [16,17]. Clinically, 258358 of PIP exion is allowed initially and is increased gradually in subsequent weeks. If there is extensor tendon tissue loss, the amount of PIP exion is further reduced. To prevent attenuation of the central slip, PIP exion is limited to 608 until 46 weeks [3,6]. This hook position is followed by the table, or intrinsic plus position of MCP joint exion and IP joint extension (Fig. 10B). Again, the wrist is supported at neutral. Studies have shown that the hook position provides the most dierential gliding between the exor

Fig. 10. Early protective motion (EPM) II. (A) Passive intrinsic minus or the hook position. With the wrist in neutral, the MCP joint is brought into extension while the PIP joint is gently exed. (B) Passive intrinsic plus or the table position. With the wrist in neutral, the MCP joint is gently exed and the IP joints are extended.

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digitorum supercialis and exor digitorum profundus tendons, whereas the table position maintains intrinsic muscle function [6,38]. These positions also produce less excursion to the extrinsics as compared with composite motion, therefore protecting the newly repaired tendons [3,6]. Obviously, the exercise program and positions need to be augmented when there are limiting factors such as unstable fractures, K wires crossing joints, or tendons and nerves repaired under tension. Between 1421 days, active intrinsic plus and intrinsic minus exercises are introduced, starting with place and hold, and progress to active exercises. The goals during this time include protection of repairs, maintaining intrinsic function, minimizing adhesions, improving tendon tensile strength and dierential tendon gliding, and promoting longitudinal reorientation of collagen bers. For thumb replantation, a dorsal protective splint is fabricated with the wrist in neutral and the thumb positioned midway between abduction and extension to maintain the web space [3,9]. Thumb C bars are generally avoided to minimize

pressure at the anastomosis site. The timeframe for introducing exercises is similar to that of the other digits. The EPM I for the thumb consists of gentle passive CMC motion and active and passive wrist exion to tension and extension to neutral. After several sessions of passive CMC joint exercises, active CMC joint motion can begin. Passive EPM II begins 1014 days after replantation with the wrist in neutral. It consists of gentle MP and IP joint exion with the CMC joint extended and gentle MP and IP joint extension with the CMC joint exed. Progression to active EPM II and composite motions of the wrist and thumb are the same as in nger replantations. For nger or thumb repairs, wrist extension beyond neutral, blocking exercises, and tendon gliding exercises are introduced at 45 weeks. At 56 weeks, composite motion and functional activities are introduced. Blocking splints and dynamic splints also can be added, whereas the protective splint is discontinued at 6 weeks. Strengthening begins at 68 weeks. Cold intolerance is a common problem in this population and can last for months [3].

Fig. 11. (AC) Functional retraining after a double toe to nger transfer.

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Fig. 12. (AD) A temporary prosthesis made with thermoplastic material is used to improve hand function and to maintain prehension memory while the patient is getting ready for a digit transfer or a permanent prosthesis.

Toe to digit transfers In cases in which replantation is not possible, toe to thumb or nger transfers are often performed [21,39] (Fig. 11). These are elective operations and the surgery often can be scheduled at the time when the patient is prepared and able to participate in the postoperative rehabilitation process. After the initial amputation, the patient is seen in therapy for wound care, scar management, desensitization, and strengthening. This is also a good time to discuss and anticipate postoperative needs and rehabilitation outcome. The home environment and social needs are discussed because the patient will be wheelchair bound for approximately 3 weeks [39]. A temporary prosthesis also can be fabricated with thermoplastic material to improve hand function and maintain prehension memory while waiting for the procedure (Fig. 12). Frequently patients nd it benecial to talk to other patients who have gone through the operation. The postoperative splint and early motion program are similar to the nger and thumb replantation protocol discussed previously. Lower

extremity-dependent position tolerance training is introduced at 2.53 weeks after the donor wound is completely healed and progressed to heel touch ambulation. In the late phase of a toe to thumb transplantation, a thumb web spacer is often necessary and is fabricated once the vascular status has stabilized, the wounds are completely healed, and the joints are stable to tolerate stress [3,6]. Mutilating hand injuries are challenging cases for the hand therapists and outcomes depend on several factors. With team eort between the physician, therapist, and patient, functional outcome can be maximized [2,3,5,21,33].

Acknowledgement
The authors would like to thank Nancy Chee, OTR, CHT for providing the photographs. References
[1] Stewart Pettengill K. Theraspists management of the complex injury. In Mackin EJ, et al, editors: Rehabilitation of the hand. St. Louis: Mosby; 2002.

S.W. Chan, P. LaStayo / Hand Clin 19 (2003) 133148 [2] Waikakul S, et al. Result of 1018 digital replantations in 552 patients. Inj Int J Care Injured 2000;31:3340. [3] Buncke H, Jackson R, Buncke G, Chan S. The surgical and rehabilitation aspects of replantation and revascularization of the hand. In Hunter JM, et al, editors: Rehabilitation of the hand. St. Louis: Mosby; 1995. [4] Mulder G. Factors complicating wound repairs. In: Kloth L, McCulloch JM, Feedar JA, editors. Wound healing: alternatives in management, contemporary concepts in rehabilitation. Philadelphia: FA Davis; 1990. [5] Jones N, Chang J, Kashani P. The surgical and rehabilitative aspects of replantation and revascularization of the hand. In Mackin EJ, et al, editors: Rehabilitation of the hand. St. Louis: Mosby; 2002. [6] Silverman PM, et al. Early protective motion in digital revascularization and replantation. J Hand Ther 1989;2:2. [7] Kloth L, McCulloch JM, Feedar JA. Wound healing: alternatives in management, contemporary concepts in rehabilitation. Philadelphia: FA Davis; 1990. [8] Peacock Jr EE. Wound repair. 3rd edition. Philadelphia: WB Saunders; 1984. [9] Chan SW, Jaglowski JM, Kaplan R. Rehabilitation of hand injuries. In: Cohen M, editor. Mastery of surgery: plastic and reconstructive surgery. Boston: Little, Brown and Company; 1994. [10] Van Adrchem LNA, et al. The effect of cigarette smoking on the microcirculation of a replanted digit. J Hand Surg 1992;17A(2):2303. [11] Yaffee B, Cushing B, Strauch B. Effects of cigarette smoking on experimental anastomosis. Mircrosurg 1984;5:702. [12] Dellon AL. Sensory recovery in replanted digits and transplanted toes: a review. J Microsurg 1986; 2:1239. [13] Dellon AL. Evaluation of sensibility and reeducation of sensation in the hand. Baltimore: Williams & Wilkins; 1981. [14] Malick M, Kasch M. Manual on management of specic hand problems. Philadelphia: AREN Publications; 1984. [15] Stewart Pettengill K, van Strien G. Postoperative management of exor tendon injuries. In: Mackin EJ, et al. Rehabilitation of the hand and upper extremity. 5th edition. Philadelphia: Mosby; 2002. p. 43156. [16] Gelberman RH, et al. Effects of early intermittent passive mobilization on healing canine exor tendons. J Hand Surg 1983;7:170. [17] Gelberman RH, et al. The inuence of protective passive mobilization on healing exor tendons. A biochemical and microangiographic study. Hand 1981;13:120.

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[18] Gelberman RH, Woo SL-Y. The physiological basis for application of controlled stress in the rehabilitation of exor tendon injuries. J Hand Ther 1989;2:66. [19] Schneider LH, Feldscher SB. Tenolysis: dynamic approach to surgery and therapy. In: Mackin EJ, et al. Rehabilitation of the hand and upper extremity. 5th edition. Philadelphia: Mosby; 2002. p. 45768. [20] McKibbin B. The biology of fracture healing in long bones. J Bone Joint Surg 1978;60B:15062. [21] Buncke HJ, editor. Microsurgery: transplantationreplantation, an atlas-text. Philadelphia: Lea & Febiger; 1991. [22] Walsh M, Muntzer E. Wound management. In: Stanley BG, Tribuzi SM, editors. Concepts in hand rehabilitation. Philadelphia: FA Davis; 1992. [23] Jensen L, Parshley P. Postburn contractures: histology and effects of pressure treatment. J Burn Care Rehab 1984;5(2):119. [24] Michlovitz SL. Thermal agents in rehabilitation. In: Contemporary perspectives in rehabilitation. 2nd edition. Vol 6. Philadelphia: FA Davis; 1992. [25] Roroicht S, et al. Reorganization of human motor cortex after hand replantation. Ann Neurol 2001; 50:2. [26] Flowers K. A proposed decision hierarchy for splinting the stiff joint, with an emphasis on force application parameters. J Hand Ther 2002;15(2): 15862. [27] Brand P, Hollister A. Clinical mechanics of the hand. 2nd edition. St Louis: Mosby Year Book; 1992. [28] Fess EE, Philips CA. Hand splinting: principles and methods. 2nd edition. St. Louis: CV Mosby; 1987. [29] Flowers KR, LaStayo PC. Effect of total end range time on improving passive range of motion. J Hand Ther 1994;7(3):1507. [30] LaStayo PC, Jaffe R. Assessment and management of shoulder stiffness. A biomechanical approach. J Hand Ther 1994;7(2):12230. [31] Cifaldi-Collins D, Schwarze L. Early progressive resistance following immobilization of exor tendon repairs. J Hand Ther 1991;4:1116. [32] Fedorczyk J. Heat and cold in hand rehabilitation. In: Michlovitz SL, editor. Thermal agents in rehabilitation, contemporary perspectives in rehabilitation. 2nd edition. Vol 6. Philadelphia: FA Davis; 1992. p. 35580. [33] Burkhalter W. Mutilating injuries of the hand. In Hunter JM, et al, editors: Rehabilitation of the hand. St. Louis: Mosby; 1995. [34] Huish S, Hartigan B, Stern P. Combined injuries of the hand. In Mackin EJ, et al, editors: Rehabilitation of the hand. St. Louis: Mosby; 2002. [35] Eberstein A, Eberstein S. Electrical stimulation of denervated muscle: is it worthwhile? Med Sci Sports Exercise 1966;28(12):14631469. [36] Williams HB. A clinical pilot study to assess functional return following continuous muscle stimulation after nerve injury and repair in the

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S.W. Chan, P. LaStayo / Hand Clin 19 (2003) 133148 [40] Kearney L, Brown K. The therapists management of intra-articular fractures. Hand Clin 1994;10:2. [41] Schenck R. The dynamic traction method. Hand Clin 1994;10:2. [42] Horovitz ER, Casler PT. Replantation: current clinical treatment. In: Moran CA. editor. Hand rehabilitation, clinics in physical therapy. New York: Churchill Livingstone; 1986. [43] Nicolaidis S, Williams HB. Muscle preservation using an implantable electrical system after nerve injury and repair. Microsurg 2001;21: 241247.

upper extremity using a completely implantable electrical system. Microsurg 1996;17:597605. [37] Scheker L, Hodges A. Brace and rehabilitation after replantation and revascularization. Hand Clin 2001; 17:3. [38] Wehbe MA, Hunter JM. Flexor tendon gliding in the hand. Part 1: differential gliding. J Hand Surg 1985;10A:575. [39] Urbaniak J. Reconstruction of the amputated thumb by great toe-to-hand microvascular transfer. Microsurgery for upper limb reconstruction. St. Louis: Mosby; 1987.

Hand Clin 19 (2003) 149163

Secondary procedures following mutilating hand injuries

Robert C. Russell, MD, FACS, FRACSa,*, Reuben A. Bueno, Jr., MDb, Tzu-Ying Tammy Wu, MDc
a b

Heartland Plastic Surgery, 5260 South Sixth Street, Springeld, IL 62703, USA Southern Illinois University School of Medicine, Institute for Plastic Surgery, P.O. Box 19653, Springeld, IL 62794, USA c Southern Illinois University School of Medicine, Institute for Plastic Surgery, P.O Box 19653, Springeld, IL 62794, USA

The human hand is a complex organ that has greatly facilitated the cultural advance of Homo sapiens from a huntergatherer to a civilized man. Humans have used their hands to plant crops, domesticate animals, build cities, wage war, sign peace treaties, create governments, write laws, and make scientic discoveries that have revolutionized our world in only the last 12,000 years. Humans are a product of their intellect and their hand function and are severely handicapped when hand function is lost. Severe hand trauma can result in varying degrees of injury to any of the hands anatomic components, including bone, tendon, nerves, blood vessels, muscle, or skin. The surgeons ultimate goal is to restore as much hand function as possible after an injury by repairing or reconstructing the injured structures either primarily or secondarily at a later date. The initial sequence of surgical debridement of devitalized tissue, irrigation, bone reduction and xation, tendon repair, arterial and venous repair, nerve coaptation, and soft tissue repair or coverage are familiar to all surgeons caring for patients with traumatic hand injuries. The replantation and trauma literature is clear, however, the more structures that are injured, the more likely the patient is to have a complication or require a secondary procedure
* Corresponding author. E-mail address: rweistart@dochos.com (R.C. Russell).

[1]. Some judgment is, therefore, required by the initial surgeon who must decide whether to complete an amputation or to proceed with repair or reconstruction of a severely injured hand or digit. The patient or the family members want the injured hand to be restored to normal and for the most part have little if any knowledge of what to expect from surgery or of the therapy necessary to obtain the best functional result. It is often the surgeon, armed with the knowledge of possible reconstructive options and using the experience gained from previous cases, who must then decide whether and how to proceed with the initial repair. In summary, complex hand trauma may require a series of decisions and operative procedures that may or may not be planned by the surgeon but are infrequently anticipated by the patient. All wounds heal by the formation of scar tissue, which, with the possible exception of bone, is persistent and can be seen years after an injury. British seamen whose diet lacked vitamin C frequently developed scurvy, resulting in the disruption of old wounds. Without the knowledge that vitamin C is a cofactor required for collagen synthesis, the British Navy mandated that a barrel of limes be added to the ships inventory of all Royal Navy line ships, which eliminated scurvy and eventually lead to the nickname for British seamen as Limeys. The problem for hand surgeons and their patients, however, is that although we need collagen synthesis to heal our tendon

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. doi:10.1016/S0749-0712(02)00146-4

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repairs and skin lacerations, excessive scar tissue in the hand can result in stiness and decreased hand function. The concept of one wound, one scar [2], described by Earl L. Peacock, is always a problem for hand surgeons who must immobilize the hand to allow fracture or tendon healing and then are required to deal with sti joints and scarred, adherent soft tissues and tendons that inhibit function. The technique or adequacy of the initial surgical care inuences the need for secondary procedures. Stable plate and screw xation of a phalangeal or metacarpal fracture, for example, may permit early active or passive joint mobilization resulting in less digital stiness or adhesion formation [3]. Patients with exor tendon repairs who are managed with active extension/passive exion [4], or place-and-hold passive motion hand therapy protocols [5] that allow healing tendons some degree of gliding motion, usually have improved function, decreasing the likelihood that secondary tenolysis procedures will be required. Early ap coverage of hand injuries with extensive soft tissue loss provides healthy uninjured soft tissue coverage of exposed bone, tendons, and neurovascular structures. This early closure prevents desiccation of vital structures and provides a healthy environment for healing. Thus, the outcome of the initial debridement, repair, soft tissue coverage, and hand therapy greatly inuences the need for secondary procedures. The basic requirements for optimal hand function include pliable soft tissue coverage, stable fracture xation and healing, supple joints, gliding exor and extensor tendons, intrinsic and extrinsic muscle function, and sensibility. Most secondary procedures are done to address one or more of these issues, which because of the degree of injury or the adequacy of the initial repair and healing are less than desirable and have resulted in decreased hand function. Complex hand injuries can have many secondary problems after healing, but stable wound coverage and bone healing must be achieved before any other secondary procedures such as tenolysis are attempted. In general, secondary procedures that require hand immobilization after surgery, such as bone grafting, secondary tendon reconstruction, or nerve repair should be completed before those procedures that require motion after surgery, such as capsulotomy or tenolysis. Complex hand trauma may, therefore, necessitate a multistage plan for reconstruction, requiring several months to complete. This should be ex-

plained to the patient and their families at the initial stage of surgery. Secondary bone procedures Malunion/nonunion The rst principal for the repair and reconstruction of a severely traumatized hand is to obtain stable fracture reduction and xation. Extensive comminution, disruption of surrounding soft tissue, or residual contamination following inadequate irrigation or debridement can result in avascular necrosis, nonunion, or the development of osteomyelitis necessitating a secondary procedure. Metacarpal and phalangeal fracture nonunions are uncommon but can be successfully treated, after debridement of brous tissue, using a cancellous bone graft from the radius or iliac crest and maintained in place with a compression plate [6]. Most severely traumatized hands require at least 3 months for the soft tissue envelope to soften. Stable, pliable tissue is preferable to a thick, rm cicatrix before secondary bone grafting should be attempted. Soft tissue coverage must be adequate before embarking on such procedures because manipulation of poor quality tissue may result in problematic compromise and exposure of the graft or plate. It is best to leave a plane of soft tissue beneath the overlying extensor tendons and the underlying bone graft during the dissection to reduce the chance of subsequent extensor tendon adhesions. Phalangeal fractures that require a secondary bone graft are less likely to result in a fully functional digit because of intrinsic joint stiness and extrinsic exor and extensor tendon adhesions that are commonly observed after grafting and immobilization [7,8]. New mini plates and screws designed for phalangeal fractures may allow earlier motion over standard pin xation and may decrease digital stiness [3]. Alternatively, external xators can be used to maintain length and fracture reduction until the grafted bone heals (Fig. 1). Osteomyelitis The development of a bone infection after open reduction and internal xation of hand fractures is fortunately rarely a problem, ranging from 2%11% [8,9]. Most surgeons treating severe hand trauma with open fractures use meticulous debridement, irrigation, and prophylactic antibiotic coverage to prevent the development of

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Fig. 1. (A) A 27-year-old farmer sustained an auger injury to his left hand. The injury resulted in soft tissue, tendon, and bone loss. (B) A free deltoid ap was used for soft tissue coverage. An external xator maintained length and position of the thumb. (C) Denitive bone grafting is performed after 46 weeks. The external xator maintains the position while the graft heals. (D) A stable skeleton and soft tissue coverage was obtained.

osteomyelitis. Occasionally bone infection can occur following massive contamination or inadequate debridement. Delayed infection can occur from bacteria seeded along exposed K-wires, or when overlying soft tissue is lost, exposing bone. The authors have treated three cases of phalangeal osteomyelitis by surgical debridement to bleeding bone and placement of antibiotic impregnated methyl methacrylate beads in combination with systemic antibiotic therapy. Two to three months later, the methyl methacrylate beads were removed and a secondary cancellous bone graft was then packed in the defect. This resulted in bony union in all three cases [10]. Bone grafts must be placed under stable, well vascularized soft tissue. Patients with thin, scarred, sti, or missing soft tissue rst require soft tissue replacement with local or distant ap coverage before secondary bone reconstruction. Secondary soft tissue procedures Clean, sharp hand cuts have a small narrow zone of tissue injury and when good surgical

technique is used, can be expected to heal with a thin, ne-line scar. More severe injuries involving multiple structures with crushed soft tissue result in increased extravasation of edematous uid into the soft tissues, seen clinically as swelling. This uid shift pushes the digits into a claw deformity with metacarpal (MP) joint extension and interphalangeal (IP) joint exion, a posture that can result in permanent digital stiness. The safe position for an injured hand after surgery is wrist extension, MP joint exion, IP joint extension with some thumb abduction and opposition. Massive swelling impedes postoperative digital motion and results in soft tissue brosis and ligament contracture leading to joint stiness. Skin loss resulting in exposed soft tissue structures or bone must be closed with a split thickness skin graft or some type of ap coverage. The thinner the skin graft, the more contraction occurs with scar maturation and the more likely a secondary surgical release will be required. Thus, most larger hand injuries that require skin grafting should be closed with a thick split thickness or even a full thickness skin graft from

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the groin to decrease the chance of late contractures. Small ngertip injuries with exposed pulp are best treated with a thin split thickness skin graft that contracts and pulls surrounding glabrous skin centrally. Web scar contracture A common sequelae of a crush injury to the hand is a rst web space adduction contracture. This creates a thumb that cannot be placed into opposition with the other digits, interfering with pinch and grasp function. The adductor pollicis brevis muscle may be tight and scarred, together with the fascia over the rst dorsal interosseous muscle. The skin in the rst web space itself can be contracted and of poor quality, also restricting motion. A secondary release of the rst web space involves either replacement of the scarred skin with a ap, or a thick split or full thickness skin graft, or when good quality skin is present, by local tissue rearrangement such as four-ap Zplasties or jumping man aps [11]. The fascia over the rst dorsal interosseous muscle must be incised and released and the adductor pollicis brevis muscle must be stretched or released from its origin on the third metacarpal. The thumb is then abducted from the palm and rotated into some opposition. It can be held in the desired position using a threaded 62-gauge K-wire placed between the rst and second metacarpals. A four-ap Z-plasty is designed using dorsal and volar skin aps whose limbs are ideally of equal length. The aps should include the rst dorsal interosseous muscle fascia dorsally and the palmar fascia volarly to protect the blood supply into these aps. The fascia can be carefully released beyond the base of the ap if it restricts ap rotation after elevation. Injuries that result in scarred, poor quality rst web space skin can be closed following release with a skin graft. Web space skin grafts can be reliably compressed against the underlying soft tissue with a foam stent dressing using the sponge from a surgical scrub brush or a piece of gas sterilized egg-crate foam commonly used to pad the operating table during long cases. Sponge dressings tied over the skin graft provide an elastic compressive force and help absorb any serum that extrudes through small holes placed in the skin graft. This prevents blood or serum from accumulating under the skin graft and facilitates blood vessel ingrowth and graft survival. Occasionally a massive crush injury results in a severe adduction deformity that, after

release, requires ap coverage. The ideal ap should be thin and pliable to allow unhindered thumb motion. The authors have used the extended end of a groin ap elevated at the level of Scarpas fascia, a reverse radial forearm, ap or thin fasciocutaneous free aps such as the deltoid or lateral arm ap to resurface the rst web space (Figs. 2, 3). The entire hand should be immobilized after surgery in a bulky hand dressing with a dorsal splint and in children or noncompliant adults in a long arm cast. Hand elevation and immobilization after surgery decreases swelling and in skingrafted patients facilitates revascularization and graft survival. Free tissue transfers are monitored hourly for 35 days using a Doppler ow probe and by assessing ap color and capillary rell. If pins were used to maintain the thumb position after surgery, they are removed 34 weeks after surgery and active range of motion exercises are begun. The thumb is splinted at night and between exercise sessions using an Orthoplast splint for the next 3 weeks, at which time only night-splinting is continued for 2 weeks. Secondary procedures to release scar Scarred contracted dorsal or volar hand skin can restrict digital exion or extension. In addition, skin injured by a deep second-degree burn or severe crush injury may survive, but can become sti and inelastic and is prone to break down with use. Good quality, elastic skin is required over the MP and proximal interphalangeal (PIP) joints for optimal function. Thin or retracted skin can restrict exion or break down with use, exposing underlying tendons or joints. These areas are best treated by resection of the scarred, poor quality skin with secondary coverage using a full thickness graft from the groin or by ap coverage. Small areas of skin loss or breakdown over the PIP joint, for example, can be closed using an arterialized side nger ap from the lateral volar aspect of the digit when no adjacent dorsal hand skin is available. The digital nerve is left intact to preserve tip sensation and the donor site is closed with a skin graft. Less commonly, an upside-down cross nger ap de-epithelialized and elevated from the uninjured dorsal surface of an adjacent digit can be used secondarily to resurface the PIP joint. This ap is not available, however, when the dorsal surfaces of multiple digits are injured. Larger areas of unstable skin may have to be resurfaced with a large full thickness skin graft

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Fig. 2. (A) A 22-year-old woman sustained massive trauma to her left hand in a hot press. There was soft tissue and extensor tendon loss and bony destruction with a destroyed index metacarpal phalangeal joint. (B) A let ap of the index nger was used to cover the dorsal defect. Secondary rst web space contracture required an extensive release. (C) A free lateral arm ap provided stable coverage and restored prehensile function.

that should be applied with the MP joints exed to at least 80 and the PIP joints exed 45 despite the possibility of developing a PIP joint exion contracture. Surgical release of the MP joint collateral ligaments may be necessary to obtain adequate exion before placing a skin graft or ap coverage. The MP joint collateral ligaments are released through an incision in the central extensor tendon over the MCP joint. The split tendon edges are retracted laterally and the joint capsule is opened transversely. A small ellipse of dorsal joint capsule can be excised. The MP joint is entered along the cartilaginous surface of the head of the metacarpal. A #15 blade is then placed into the MP joint and swept dorsally along the lateral surface of the metacarpal head to release the origin of the collateral ligaments. The MP

joint is placed in 80 90 of exion and held with a single K-wire placed through the base of the proximal phalanx into the head of the metacarpal. The dorsal skin surface is then reconstructed using a full thickness graft or by ap coverage. Pins are removed in 23 weeks and active range of motion exercises are begun. Palmar scar contracture Scar contracture on the volar surface of the digit can prevent full digital extension of any and all joints along the ray. Volar glabrous skin is thicker and more resistant to injury than the thinner dorsal hand skin and volar contractures often can be treated by local tissue rearrangement using Z-plasties, Y-V-plasties, or local rotation or

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Fig. 3. (A) A 29-year-old man had a devastating automobile injury to his left hand. The wounds were closed temporarily with porcine skin grafts. The extensors to the index nger were avulsed at the primary injury. (B) A reverse radial forearm ap was used to provide stable coverage of the back of the hand and rst web space. The palmaris longus tendon also was harvested to provide a vascularized tendon interposition graft for the extensor indices. (C,D) The nal functional results with full extension and exion of the index nger and stable soft tissue coverage. (From Neumeister MW. Pedicled aps and grafts: plastic surgery. In: Russel RC, editor. Secondary procedures following mutilating hand injuries. Philadelphia: Mosby; 2000; with permission).

cross nger aps from the same or an adjacent digit. A central longitudinal scar along the volar surface of the digit can be excised and Z-plasties designed using 45 angles with the lateral incisions ending at the PIP or MP joint exion crease and extending as far dorsally as the midlateral line. Proximal release of the volar plate as described by Watson along the assembly line [12] is often required in long-standing cases of PIP joint contracture to restore PIP joint extension, which can initially be held with a K-wire. The retracted checkrein ligaments are divided proximally to allow the volar plate to slide distally, facilitating PIP joint extension. The pin is removed at 34 weeks and active range of motion exercises begun with intermittent and night splinting maintained for 34 weeks. Secondary release of a PIP joint exion contracture with severely damaged skin may require ap coverage from the dorsal surface of an uninjured adjacent nger when the release results in exposed exor tendons or neurovascular structures

that cannot be skin grafted. All cross nger aps used to cover either dorsal or volar soft tissue defects are divided at 23 weeks, following elevation depending on the individual patient, the quality of the surrounding soft tissue, and the area of ap inset. Resurfacing of the entire volar or palmar skin may be necessary to reduce the risk of tendon adhesion. Stable, pliable soft tissue coverage is required before tendon transfers, tenolysis, or joint mobilization procedures can be done. Templates can be made using sterile gloves and opening one side to note the size of the tentative ap. Tissue expansion of the donor site may be useful to harvest a larger ap and still allow primary donor site closure (Fig. 4). The aps may require several debulking procedures for the overall contoured result. Secondary nerve procedures Delayed nerve repair Mutilating hand injuries can result in complete or partial transaction of peripheral nerves in the

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Fig. 4. (A) A 36-year-old man sustained an avulsion, crush injury to his left hand. The hand was covered with split thickness skin grafts. Limited mobility and contractures prevented reasonable function. (B) The skin graft is removed and the rst web space released. (C) A template out of a sterile glove is used to fashion the exact design of the ap. (D) The unfolded sterile glove gives the size of the defect. (E) An expanded scapular ap permits an abundance of soft tissue and allows primary donor site closure. (F) The ap is inset and in 23 months is ready for debulking and tenolysis procedures.

arm, hand, or digits. Careful dissection followed by primary repair of the cut nerve ends under magnication gives the best chance for quality nerve regeneration. Primary repair of the nerve ends, however, is not always possible in some mutilating hand injuries in which nerve substance may be crushed or lost. Nerve grafts, or vein conduits, or manufactured conduits can be used to bridge gaps. If nerve conduits are used, the proximal and distal nerve ends are sutured

without tension inside an appropriately sized neural tube and seem to allow axons to regenerate along the polyglycolic acid (PGA) mesh into the distal nerve, giving functional results comparable to standard autogenous nerve grafts [13]. Secondary nerve grafting or placement of a synthetic conduit, as described by Mackinnon and Dellon [14], remains the reconstructive option of choice when primary nerve repair is not possible. Peripheral sensory nerves including the sural,

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Fig. 4 (continued )

medial, or lateral antebrachial cutaneous, or the terminal branch of the posterior interosseous nerve, are most often used as free nerve cable grafts, depending on the length of the defect and the diameter of the nerve to be reconstructed [15]. Cable nerve grafts should be placed under well vascularized soft tissue for best results. Synthetic nerve conduits can be used to reconstruct small hand or digital nerve defects up to 3 cm [13,14]. Nerve grafting at the time of the acute injury is not recommended because there is a potential to lose the graft if the overlying tissue or ap is compromised through ischemia or infection. If the Surgeon anticipates rising nerve grafts, the nerve ends should be sutured out to length and tagged for future grafting. Neuroma management Amputation stump neuroma formation can occur when the endoneurium is disrupted, allowing the regenerating axons to escape and advance in a disorganized fashion into the surrounding soft tissues [16]. Histologically, neuromas consist of whorls of disorganized nerve bers encased in collagen scar [16,17]. Patients often present with localized pain and hypersensitivity and a positive Tinel sign in the vicinity of the neuromatous bulb. The pain may become so debilitating that, without proper treatment, the function of the entire hand or extremity may be lost. Nonoperative treatment by repeated nerve stimulation including local

percussion, massage, ultrasound, and electrical stimulation can be used to desensitize some neuromas [16]. Local steroid injections into the area of neuroma formation also have been described [16,18] with short-term success [18]. In addition, medications such as amitriptyline, carbamazepine, and neurontin have been used recently and seem to help some patients [17,19]. Some neuromas, such as those on the end of a digital amputation stump or of common digital nerves in the palm, can be best treated by neuroma resection, allowing the nerve ends to retract proximally into more healthy soft tissue [20]. Various chemical methods to inhibit axonal regrowth after neuroma resection have been used [16,2124]. The freshly cut nerve end is treated with alcohol, tannic acid, formaldehyde, chromic acid, iodine, uranium nitrate, gentian violet, phenol, mercuric chloride, hydrochloride, picric acid, and nitrogen mustard, none of which are 100% successful [16,2124]. Relocation of the nerve stump after neuroma resection into bone or muscle also has been used to prevent recurrence [2527]. This method is best used in the hand or forearm where the nerve end can be sutured deeply into the soft tissue or into a drilled hole in the bone. Chiu and Strauch have used vein grafts or PGA tubes to direct regenerating axons away from the amputation stump after neuroma resection [28].

Secondary joint and tendon procedures Procedures to improve digital motion are the most common secondary operations required after a mutilating hand injury [1] and should be anticipated by the hand surgeon. A sti nger can occur for a variety of reasons, including edema, ligament tightness, skin contracture or scarring, and tendon adhesions. The surgeon and hand therapist must determine the etiology of the problem before surgical correction is attempted. The status of the joint surfaces after healing in a sti nger should be determined by radiograph, especially in patients who have sustained periarticular fractures. A bony callus or an irregularly healed intra-articular fracture may block nal joint exion or extension. A digit with a normal passive range of motion (280 ) that cannot be actively exed completely by the patient, for example, is likely to have exor tendon adhesions and may be improved by exor tenolysis alone. A digit that lacks active and passive motion after

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adequate hand therapy may require simultaneous exor and extensor tenolysis and joint ligament or capsule release to improve motion. The surgeon must properly assess and identify the reason for digital stiness and be prepared to address any and all causes in a sequential fashion during surgery.

Secondary tendon procedures Tenolysis Scar tissue that forms around healing tendons, fractures, or the overlying soft tissue can restrict tendon motion after surgery. The degree of peritendinous scar formation is inuenced by the severity of injury, the initial operative technique, the patients own systemic response to injury and collagen synthesis, and the availability of and patient dedication to hand therapy. Severe hand trauma with crushed soft tissue, comminuted fractures, or frayed tendon ends all produce an enhanced systemic inammatory response, resulting in increased collagen synthesis and scar formation. A patient who sustains a sharp, clean, zone II exor tendon laceration that is repaired primarily with atraumatic surgical technique and managed with dynamic splinting by a trained hand therapist usually obtains a good to excellent functional result [29]. Conversely, the same patient who sustains a more severe complex injury to the hand involving multiple structures, requiring more extensive dissection and repair, followed by prolonged immobilization or lacking adequate hand therapy is likely to develop a sti, scarred, and immobile hand that will require secondary tenolysis or capsulotomy procedures to regain digital motion (Fig. 5). The most common secondary procedure following digital replantation surgery, for example, is exor or extensor tendon tenolysis [1,30]. All exor and extensor tendon repairs should be done using atraumatic technique followed by protective splinting to permit primary healing. The treatment protocol after surgery must be individualized for each patient, balancing the need for digital and wrist immobilization to allow bone and tendon healing against the functional requirement of tendon excursion and joint motion. The use of active and passive protocols by a dedicated hand therapist is the best way to prevent tendon adhesions and sti joints. Early passive range of motion exercises after tendon repair have been shown experimen-

tally to strengthen the repair and improve motion [31]. The return of digital motion after the initial procedure is followed closely by the hand therapist, who records the degrees of active and passive digital motion at each nger joint before and after each therapy session. A good hand therapist not only provides instruction to the patient for exercises to be performed at home between hand therapy visits, but also sets goals and helps provide the motivation to achieve them. Scar massage [32], silicone gel [33], topical vitamin E [34], and silicone sheeting [35] have all been used to soften scar and improve digital motion. Three to six months is usually required for scar tissue to soften, at which time the need for a secondary procedure to improve digital motion can be considered. Strickland describes exor tenolysis as perhaps the most demanding of all exor tendon operations with respect to attention to detail and patientdoctor cooperation and must be approached as a major surgical eort, with great consideration for patient selection, operative technique, and postoperative management [29]. Tenolysis procedures usually are performed 36 months after the initial procedure, when therapy gains in active or passive range of motion have ceased. Flexor or extensor tendons are usually stuck at the site of a previous tendon repair, where tendons pass over a healed fracture, or where tendons pass through a tight space such as the bro-osseous digital pulley system in zone II in the hand. A surgeon performing a tenolysis must consider the locations of previous skin lacerations or incisions in approaching the area of tendon adhesion to preserve the skins blood supply. Often the prior incisions must be reopened despite a less than desirable location or direction to insure skin vascularity and survival after a tenolysis. Small #15 or Beaver scalpel blades and Kuntz or Freer elevators or Mitchell Trimmes are used to sharply dissect tendon adhesions with atraumatic technique preserving the critical A2 and A4 pulleys in zone II to prevent bow-stringing during active motion after surgery. A separate proximal wrist incision is usually required during exor tenolysis to determine the adequacy of the distal tendon scar release. Each distal tenolysed exor tendon is identied at the wrist and traction is applied to be certain that active digital motion can be achieved. Release of tight joint capsules or adherent extensor tendons when present must be done rst to obtain near-normal passive range of

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Fig. 5. (A) A 39-year-old man sustained a signicant electrical injury to his right hand. The skin of the back of the hand was skin grafted, whereas the wrist required a free anterolateral thigh ap for closure because extensors were exposed. (B) Capsular contractures at the MP joints and tendon adhesions prevented motion. (C) Extensor tendon adhesions at the MP joint. (D) Tenolysis of all cicatricial adhesions at the MP joint. A capsulotomy was required also. (E) Full passive range of motion was obtained.

digital motion before proceeding with exor tenolysis. A general or Bier block anesthetic can be converted to a regional block using local anesthetic at the wrist, to test the patients ability to move the digits independently after the scar release. It is sometimes desirable for the patient to visualize the amount of active motion, which is actually possible before the limitations of pain and swelling occur after surgery. The hand and forearm usually are immobilized in a bulky compressive dressing for 13 days after surgery

and held in an elevated position to decrease edema. The dressings are then removed and aggressive active and passive range of motion exercises are begun by hand therapy. Occasionally, intermittent splinting is used to maintain joint position between motion exercises. The use of indwelling catheters to instill local anesthetic has been described to decrease pain in the immediate postoperative period, allowing the patient painfree motion [36]. Continuous passive motion machines also have been used in cases involving

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multiple digits to preserve full passive motion between active exercise sessions [37]. Secondary tendon reconstruction Secondary tendon reconstruction may be required in some patients after a mutilating hand injury for a variety of reasons. The initial trauma may not have allowed primary tendon nerve repair if tendon substance was lost. The proximal tendon ends should be sutured out to length in such cases to the carpal ligament or A1 pulley to hold the extrinsic musculotendinous units out to length. A staged tendon reconstruction may be planned, especially in zone II injuries. A silastic Hunter rod can be placed from the insertion of the exor digitorum profundus through the broosseous pulley system into the palm or wrist [38]. This can be done at the time of the initial wound closure or as a secondary procedure. If A2 and A4 pulley reconstruction is required, it should be done when the Silastic rod is placed. This allows the reconstructive pulleys to be strong and functional when the rod is removed and replaced by the tendon graft. Some guarded motion is then possible without tendon bow-stringing after surgery. When a staged single exor tendon reconstruction is planned, the author prefers to use the proximal exor digitorum sublimis (FDS) musculotendinous unit as the motor for the tendon graft, which passes across all joints and is inserted into the base of the distal phalanx. The FDS has independent motion and avoids the potential problem of quadriga associated with using the exor digitorum profundus (FDP), which is difcult to adjust to the correct tension. The lumbrical muscle must be released from the FDP tendon when using the FDS as a motor, to prevent the development of a lumbrical plus deformity when the FDP retracts proximally. Tendon grafts are rst inserted into the base of the distal phalanx using a wire suture tied over a dorsal button or a Mitek anchor drilled into the base of the distal phalanx. The tendon graft attached to the Silastic rod is then pulled from distal to proximal into the palm or wrist and sutured to the proximal FDS tendon using a Pulvertaft weave. The correct tension is adjusted by exing and extending the wrist and noting the position of the reconstructed nger in relation to the cascade of the other digits. It is sometimes dicult, in patients who develop a sti nger after the repair of a severe

injury, to determine if a severed and repaired exor tendon is stuck in scar or has actually ruptured. A planned tenolysis procedure sometimes ends in a staged tendon reconstruction when the surgeon nds a ruptured and not a stuck exor tendon. This potential problem, which necessitates another surgical procedure, should be explained and discussed with the patient before surgery. Secondary thumb reconstruction Surgical eorts to restore thumb ngertip prehension are among the most important of secondary procedures required to achieve the best functional result following a mutilating hand injury. Prehensile grip requires the thumb to abduct and oppose the ngers [39]. It is estimated that 40% of hand function is derived from the thumb [40], and thumb loss results in signicant disability. Every attempt, therefore, should be made in the acute setting to replant or otherwise salvage an amputated or devascularized thumb for this reason. When the amputated thumb is unable to be salvaged or replantation eorts fail, other methods must be used to restore thumb function. The requirements for thumb reconstruction have been outlined by Heitmann and Levin [41] and include a sensate and nontender thumb tip, stability of the IP and MCP joints, adequate strength and stability to resist the opposing forces of the ngers during pinch and grasp functions, correct positioning of the thumb with a wide web space, and mobility of the carpometacarpal (CMC) joint with intrinsic muscles to stabilize and position the thumb. Selecting the most appropriate method for thumb reconstruction depends on several factors, including the level of injury, the status of the remaining hand, the age, occupation, overall health, and functional demands of the patient. An older patient with vascular disease and low functional demand or injury of a nondominant thumb would not be a candidate for microsurgical thumb reconstruction and might benet from a lengthening procedure. Conversely, a younger, well motivated patient who wants the best aesthetic and functional result would be a good candidate for a Morrison type toe-to-hand transfer [42] (Fig. 6). Before the development of microsurgery and free tissue transfers, thumb reconstruction was done by phalangization of the thumb metacarpal

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Fig. 6. (A) A 38-year-old farmer sustained an auger injury to his left hand. (B) Two digits are salvaged and a groin ap used to provide stable coverage. One digit is covered with the ap. (C) A rst web space is created while part of the ap is debulked. (D) A Morrison wrap-around ap is planned to provide sensate coverage for the thumb. (E) A sensate pinch grip has been provided through the series of procedures.

[43], pollicization of the index nger [44], or osteoplastic thumb reconstruction [45]. The transfer of a toe to the thumb became possible with the advent of microsurgery [46,47]. Renements in technique developed by Morrison [42] and Wei [48] have further improved the appearance and function of a toe to hand transfer. Distal thumb amputations or those with loss of sensate volar soft tissue requiring only restoration of the skin and subcutaneous tissue can be reconstructed with a palmar advancement ap [49], a neurovascular island ap from another

nger [50], or a rst dorsal metacarpal artery ap [51]. If the level of amputation is at the middle third of the thumb, phalangealization thumb function can be improved by deepening the web space with a Z-plasty [52] and lengthening the amputation stump by release of the rst dorsal interosseous muscle and proximal transfer of the adductor pollicis insertion [53,54]. Additional thumb length can then be obtained by making an osteotomy through the rst metacarpal and placement of an external distraction device [55]. The thumb is then pulled to length gradually with

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the external xation device and the resulting bone defect grafted when the thumb has been stretched to the desired length. If amputation occurs in the area of the MCP joint, toe to hand transfer is now the procedure of choice in most patients. This transfer provides stable, sensate composite tissue with an excellent functional and cosmetic result [56]. Amputations proximal to the CMC joint limit the reconstructive options to pollicization when another digit is available for transfer. Length, sensation, and motion have been successfully restored by

index nger pollicization to recreate a thumb [57,58]. The restoration of function also may involve toe to hand transfer digits other than the thumb. The second and third toes are appropriate donors for digit transfers to the hand. It is important, however, to optimize the soft tissue coverage to the hand before the transfer of toes. This may require further ap coverage over the metacarpal heads to ensue that enough pliable tissue is present so that vital structures are not exposed after the toe to hand transfer (Fig. 7).

Fig. 7. (A) A 34-year-old man sustained multiple amputations of the ngers of the right hand. The amputations were at the level of the proximal phalanx. (B) Early soft tissue coverage was obtained with multiple slips of a groin ap. (C) The groin ap provided adequate coverage for the secondary second toe to hand transfers to provide improved hand function.

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R.C. Russell et al / Hand Clin 19 (2003) 149163 construction in humans. Plast Reconstr Surg 2000;106(5):103645. Mackinnon SE, Dellon AL. A study of nerve regeneration across synthetic (Maxon) and biologic (collagen) nerve conduits for nerve gaps up to 5 cm in the primate. J Reconstr Microsurg 1990;6: 117121. Brushart TM. Nerve repair and grafting. In: Green DP, Hotchkiss RN, Pederson WC, editors. Greens operative hand surgery. 4th edition. New York: Churchill Livingstone; 1999. p. 1381403. Whipple RR, Unsell RS. Treatment of painful neuromas. Orthop Clin N Am 1988;19:17585. Nath RK, Mackinnon SE. Management of neuromas in the hand. Hand Clin 1996;12(4):74556. Smith JR, Gomez HH. Local injection therapy of neuromata of the hand with triamcinolone acetonide: a preliminary study of twenty-two patients. J Bone Joint Surg 1970;52A:71. Gilman AG, Rall TW, Nies AS, et al. Goodman and Gilmans the pharmacological basis of therapeutics. 8th edition. New York: Maxwell House, Pergamon Press; 1991. Herndon JH, Eaton RG, Littler WJ. Management of painful neuromas in the hand. J Bone Joint Surg 1976;58A:369. Goldman R. Clinical experience with nitrogen mustard therapy. Arch Int Med 1948;82:125. Guttman L, Medawar PB. The chemical inhibition of bre regeneration and neuroma formation in peripheral nerves. J Neurol Psychiatr 1942;5:130. Huber GC, Lewis D. Amputation neuromas: their development and prevention. Arch Surg 1920;1:85. Petropoulos PC, Stefanko S. Experimental observations on the prevention of neuroma formation. J Surg Res 1961;1:241. Goldstein SA, Sturim HS. Intraosseous nerve transposition for treatment of painful neuromas. J Hand Surg 1985;10:270. Laborde KJ, Kalisman M, Tsai TM. Results of surgical treatment of painful neuromas of the hand. J Hand Surg 1982;7:1903. Dellon AL, Mackinnon SE. Treatment of the painful neuroma by neuroma resection and muscle implantation. Plast Reconstr Surg 1986;77:427433. Chiu DTW, Strauch B. A prospective clinical evaluation of autogenous vein grafts used as a nerve conduit for distal sensory nerve defects of 3 cm or less. Plast Reconstr Surg 1990;86:92834. Strickland JW. Flexor tenolysis. Hand Clin 1985;1:12132. Yim KK, Wei FC. Secondary procedures to improve function after toe-to-hand transfers. Br J Plast Surg 1995;48:48791. Gelberman RH, Manske PR. Factors inuencing exor tendon adhesions. Hand Clin 1985;1:3542. Patino O, Novick C, Benaim F, et al. Massage in hypertrophic scars. J Burn Care Rehab 1999;20: 26871.

Summary Mutilating hand injuries result in injury to multiple anatomic structures, which increases the possibility that secondary procedures or staged reconstruction will be necessary. Secondary procedures often are required to provide stable wound coverage, restore sensation, provide bony stability, increase range of motion, or allow prehension, all of which are performed to improve hand function. The patient, the surgeon, and the therapist must all work together to achieve the best functional result following a severe mutilating hand injury. References
[1] Buncke HJ, Whitney TM. Secondary procedures after replantations. In: Buncke HJ, editor. Microsurgery: transplantation, replantations. An atlas text. Philadelphia/London: Lea & Febiger; 1991. p. 65183. [2] Peacock EE. Some technical aspects and results of exor tendon repair. Surgery 1965;58:33045. [3] Hastings II H. Unstable metacarpal and phalangeal fracture treatment with screws and plates. Clin Orthop 1987;214:3752. [4] Kleinert HE, Schepels S, Gill T. Flexor tendon injuries. Surg Clin N Am 1981;61:26786. [5] Duran RJ, Hansen RG, Stover MG. Management of exor laceration in zone II using controlled passive motion postoperatively. In: Hunter JM, Schneider LH, Mackin EJ, Bell JA, editors. Rehabilitation of the hand. St. Louis: CV Mosby; 1978. [6] Wray Jr RC, Glunk R. Treatment of delayed union, nonunion, and malunion of phalanges of the hand. Ann Plast Surg 1989;22:148. [7] Huffaker WH, Wray Jr RC, Weeks PM. Factors inuencing nal range of motion in the ngers after fractures of the hand. Plast Reconstr Surg 1979;63:827. [8] Chow SP, Pun WK, So YC, et al. A prospective study of 245 open digital fractures of the hand. J Hand Surg 1991;16B:13740. [9] McLain RF, Steyers C, Stoddard MD. Infections in open fractures of the hand. J Hand Surg 1991; 16A:10812. [10] Russell RC. Personal communication [unpublished case report]. July 2002. [11] Limberg AA. Design of local aps. In: Gibson T, editor. Modern trends in plastic surgery. 2nd edition. London: Butterworths; 1966. [12] Watson HKI, Light TR, Johnson TR. Checkrein resection for exion contracture of the middle joint. J Hand Surg 1979;4:6771. [13] Weber RA, Breidnebach SC, Brown RE, Jabaley ME, Mass DP. A randomized prospective study of polyglycolic acid conduits for digital nerve re[19] [14]

[15]

[16] [17] [18]

[20]

[21] [22]

[23] [24]

[25]

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R.C. Russell et al / Hand Clin 19 (2003) 149163 [33] Escarmant P, Zimmerman S, Amar A, Ratoanina JL. The treatment of 783 keloid scars by iridium 192 interstitial irradiation after surgical excision. Int J Radiat Oncol Biol Phys 1993;26:245. [34] Palmieri B, Gozzi G, Palmieri G. Vitamin E added silicone gel sheets for treatment of hypertrophic scars and keloids. Int J Dermatol 1995;34(7): 5069. [35] Hirshowitz B, Ullmann Y, Har-shair Y, Vilenski A, Peled IJ. Silicone occlusive sheeting (SOS) in the management of hypertrophic scarring, including the possible mode of action of silicone, by static electricity. Eur J Plast Surg 1993;16:5. [36] Schneider LH, Mackin EJ. Tenolysis: dynamic approach to surgery and therapy. In: Hunter JM, Schneider LH, Mackin EJ, Callahan A, editors. Rehabilitation of the hand. 3rd edition. St. Louis: CV Mosby; 1990. p. 41726. [37] McCarthy JA, Lesker PA, Peterson WW, Manske PR. Continuous passive motion as an adjunct therapy for tenolysis. J Hand Surg 1986;11B:8890. [38] Hunter JM. Staged exor tendon reconstruction. J Hand Surg 1983;8A:78993. [39] Tubiana R, Stack HG, Hakstian RW. Restoration of prehension after severe mutilations of the hand. J Bone Joint Surg Br 1966;48:45573. [40] American Medical Association. Guides to the evaluation of permanent impairment. 4th edition. Chicago: American Medical Association; 1995. [41] Heitmann C, Levin SL. Alternatives to thumb replantation. Plast Reconstr Surg 2002;110: 1492503. [42] Morrison WA, OBrien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wraparound ap from the big toe. J Hand Surg 1980; 5A:575. [43] Huguier PC. Du remplacement du pouce par son metacarpien, par lagrandissement du premier espace interosseux. Arch Gen Med 1874;1:78. [44] Gossett J. La pollicisation de lindex (technique chirurgicale). J Chir (Paris) 1949;65:403.

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[45] Lister G. The choice of procedure following thumb amputation. Clin Orthop 1985;195:45. [46] Buncke Jr HJ, Buncke CM, Schulz WP. Immediate Nicoladoni procedure in the rhesus monkey or hallux-to-hand transplantation, utilizing microminiature vascular anastomoses. Br J Plast Surg 1966;19:332. [47] Cobbett JR. Free digital transfer: report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg 1969;51B:6779. [48] Wei FC, Chen HC, Chuang CC, Chen SH. Microsurgical thumb reconstruction with toe transfer: selection of various techniques. Plast Reconstr Surg 1994;93:345. [49] Moberg E. Aspects of sensation in reconstructive surgery of the extremity. J Bone Joint Surg 1964; 46A:817. [50] Littler JW. Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. J Bone Joint Surg 1956;38A:917. [51] Foucher G, Khouri RK. Digital reconstruction with island aps. Clin Plast Surg 1997;24:1. [52] Winspur I. Single-stage reconstruction of the subtotally amputated thumb: a synchronous neurovascular ap and Z-plasty. J Hand Surg 1981;6A:70. [53] Goldner RD, Howson MP, Nunley JA, et al. One hundred eleven thumb amputations: replantation vs revision. Microsurg 1990;11:243. [54] Emerson ET, Krizek TJ, Greenwald DP. Anatomy, physiology, and functional restoration of the thumb. Ann Plast Surg 1996;36:180. [55] Matev IB. Thumb reconstruction through metacarpal bone lengthening. J Hand Surg 1980;5A:482. [56] Chung KC, Wei FC. An outcome study of thumb reconstruction using microvascular toe transfer. J Hand Surg 2000;25A:651. [57] Brunelli GA, Brunelli GR. Reconstruction of traumatic absence of the thumb in the adult by pollicization. Hand Clin 1992;8:41. [58] Stern PJ, Lister GD. Pollicization after traumatic amputation of the thumb. Clin Orthop 1981;155:85.

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Toe-to-hand transplantation
Fu-Chan Wei, MD, FACS*, Vivek Jain, MCh ORTHO, Samuel Huan-Tang Chen, MD
Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Medical College, 199 Tun Hwa North Road, Taipei, Taiwan

Toe-to-hand transplantation constitutes one of the most signicant advances in the history of reconstructive microsurgery [1,2]. The 1970s and 1980s witnessed a furious pace of technical and conceptual advancements in various toe transplantations. Today, the thumb and nger can be reconstructed with various toe transplantations [36]. Toe transplantation permits a one-stage total reconstruction of mobile digits providing sensibility, stable joints, and near normal appearance of the hand. With meticulous preoperative planning, the donor site morbidity remains low and acceptable. The functional and cosmetic requirements of both the hand and the donor site must be considered. The patients preference must also be considered in the planning of the transfer. The level of amputation, structures preserved, location and extent of any defects in the injured hand, and hand dominance and growth potential should all be evaluated and appropriately weighted before undertaking toe-to-hand transfer [6,7]. The ultimate patient satisfaction and functional outcomes depend on these factors and the quality and similarities between the normal thumb and the toe designated for the transplant.

ary procedure after the wounds have healed. Early and single-stage reconstruction are preferred if the patients and the wounds conditions are suitable. This includes simultaneous reconstruction of the thumb and ngers if needed. The results in terms of survival, immediate and late complications, and the need for secondary procedures have been shown to be similar between primary and secondary reconstruction [8]. The advantage of primary toe transplantation is a reduction in overall recovery and rehabilitation period, permitting an earlier return to work.

Pretoe transplant preparations Planning of denitive toe-to-hand transplantation reconstruction should begin from emergency management. All grossly viable tissues, including mobile joints and neurovascular bundles, should be preserved as much as possible [9]. Adequate or even some redundant skin cover over the stump of the hand is required and can be obtained with a pedicled groin ap before denitive reconstruction. This additional skin is of use during later reconstruction, because it can cover the lateral aspect of transplanted toes, protect the pedicle, or form a web space in the hand. It also allows less skin to be harvested from the foot, allowing direct closure of the donor site. Local aps should be avoided because resultant scarring may increase diculty of later reconstructive procedures. If the metacarpal length is decient, distraction osteogenesis or a nonvascular bone graft from the iliac crest can also augment it at the same time as soft tissue reconstruction. This preserves metatarsal length and reduces donor site morbidity, especially in the great toe.

Timing of reconstruction Toe transplantation can be performed as a primary procedure with an open wound or as a second-

* Corresponding author. E-mail address: fcw2007@adm.cgmh.org.tw (F-C. Wei).

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. doi:10.1016/S0749-0712(02)00127-0

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Surgical anatomy of the foot related to toe transplantation Although the foot has many anatomic features similar to the hand, there are also some anatomic dierences, because they have dierent functions. The great toe transverse diameter is about one third bigger than the thumb. All great toe phalanges are slightly longer than those of the thumb; its toenail is also bigger and there is more subcutaneous tissue in the pulp. All modied great toe harvesting techniques involve reduction in size of its various components. The lesser toes are shorter than the digits and have a square shape at the distal ends. The joints have limited exion and also have a tendency to claw. The anterior and posterior tibial arteries supply the foot. The anterior tibial artery continues as the dorsalis pedis artery on the dorsum of the foot and runs laterally to the extensor hallucis longus tendon toward the rst web space. Proximal to the base of the rst and second metatarsals, it gives o the arcuate artery, which provides the second, third, and fourth dorsal metatarsal arteries. Distally, the dorsalis pedis artery bifurcates just past the base of the rst and second metatarsal, into the deep plantar artery and the rst dorsal metatarsal artery. The deep plantar artery (also known as the perforating or communicating branch) courses downward between the rst two metatarsals to contribute to the plantar arch. The anatomic variations in the arterial pattern should be kept in mind when harvesting a toe transplantation [10,11]. The rst dorsal metatarsal artery always passes dorsal to the deep transversal 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 rst plantar metatarsal artery (FPMA). This is a constant anatomic landmark helpful in arterial identication during toe harvesting. There is dorsal-dominant system with the rst dorsal metatarsal artery bigger than FPMA in about 70% of cases, plantar dominant in 20%, and in the rest both arteries can be of similar size [12]. The dorsal digital veins run along the dorsal margins of each toe and unite in their webs to form common dorsal digital veins, which join to form a dorsal venous arch on the dorsum of the foot. Veins leave the dorsal venous arch and converge medially to form the great saphenous vein and laterally to form the small saphenous vein. The plantar foot surface has a supercial and a deep venous system. The deep veins originate from the plantar

digital veins and communicate with the dorsal digital veins by perforating veins. The dorsum of the foot is innervated from the sural, supercial, and deep peroneal nerves. The plantar surface is innervated by the tibial nerve, which divides into the medial and lateral plantar nerves supplying the medial three and a half toes and lateral one and a half toes, respectively. Toe harvesting: general principles The dissection begins in the dorsum of the rst web space, where the junction of the lateral digital artery of the great toe and the medial digital artery of the second toe is identied. In the dorsal-dominant arterial system, retrograde dissection continues until a suitable length and diameter of artery are achieved. In a planar-dominant system, plantar dissection is continued up to the middle metatarsal shaft, where the union between the FPMA and toe dorsalis pedis artery through the proximal communicating artery is located. The FPMA is divided at this point, because further dissection of the communicating branch might be tedious and destructive for the foot. If required, an interposition vein graft can be used for the vascular anastomosis [12]. Complete skeletonization of even small vessels and nerves during toe dissection facilitates passing the vessels and nerves under the skin bridge, to reach recipient vessels at a proximal level without being compressed. This technique is particularly useful in distal digital reconstruction. All other structures are dissected and divided at the proper level. The donor site management is crucial for overall patient satisfaction. During great toe harvest, it is advisable to preserve at least 1 cm of the proximal phalanx to maintain the foot span, the appearance, and push o function of the donor foot to prevent windlass eect. Skin grafting of the donor site should be avoided in toe transplantation because the graft seldom takes adequately, delays foot function recovery, and remains as an unstable and painful scar. Recipient site preparation The amputation stump is exposed through cross-incisions to create four mobile skin aps. The scar is excised to obtain thin skin aps for smooth skin closure. The bone end is prepared with minimal periosteal elevation. If composite joint repair with the

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corresponding joint in the transplanted toe is planned, the joint capsule and ligaments must be dissected carefully while exposing the cartilage surface. Usually the extensor tendon can be identied close to the bony stump and should be left intact because integrity of the extensor mechanism is essential for nger function. The exor tendons have dierent locations in distal and proximal nger amputations. It is important to preserve the pulley system while exposing and preparing the exor tendon to obtain a good tendon excursion. Tenolysis is performed if necessary. The digital or common digital nerve stumps are identied and dissected proximally to the point where they appear normal or near normal. The recipient artery can be either the radial artery in the snubox or the princeps pollicis artery for the thumb, and digital or common digital artery for ngers. It can be prepared with a separate incision, creating a subcutaneous tunnel for passage of the pedicle. Usually one vein on the dorsal aspect of the hand is prepared as the recipient vein. Insetting of the transplants Initially osteosynthesis is performed using interosseous wires [13]. This technique provides stability for early mobilization of the joints, preventing tendon adhesions and improving the overall range of motion. Next, the extensor tendon is repaired with the interphalangeal and metacarpophalangeal joints in full extension. This helps minimize extension lag and exion deformity. The long exor tendon is repaired with the exor pollicis longus in the thumb and the exor digitorum profundus in the nger. The nerves are approximated in an end-to-end fashion with 10-0 nylon. The vascular pedicle is tunneled to the recipient site. The four skin aps built in the recipient stump are tailored and interposed with the triangular aps of the transferred toe, creating an even closure. The arterial anastomosis is performed rst followed by the vein, and the remaining wounds are closed. If there is some tension in closing the skin, partial closure and skin grafting the partially opened surface is advisable, although it should be uncommon with adequate preoperative planning. Thumb reconstruction The thumb plays 40% to 50% of the role in total hand function. Whenever possible, replantation of an amputated thumb should always be attempted.

When replantation fails or is not feasible, transplantation becomes the rst reconstructive option, especially when amputation occurs proximal to the interphalangeal joint. There are several toe transplantations commonly used for thumb reconstruction, depending on the functional and esthetical needs of the patient [4,7]. Irrespective of the technique of reconstruction, the position of the thumb achieved should be that of opposition to the digits for key pinch and grasp. Although movement at the metacarpophalangeal or interphalangeal joints is not an absolute prerequisite, the function of the reconstructed thumb improves if joint movements are present. Total great toe transplantation Functionally, the great toe provides the best results by providing a stronger pinch and better grasp. It should be considered for thumb amputations between the interphalangeal joint and base of metacarpal shaft. It should be used for patients who request better hand function and appearance and who are willing to accept mild to moderate functional disturbance of the foot. It is also indicated in severe injury involving other parts of the hand, when strong grip and pinch are desirable. It is best suited when the size dierence between the thumb and great toe is acceptable. Usually the left great toe is preferred for transplantation, irrespective of which thumb is to be reconstructed, because the left foot bears less functional stress. The results for great toe transplantation including sensibility, stability, grip strength, pinch power, and interphalangeal joint motion are usually the best among the various toes used for thumb reconstruction. The appearance of the reconstructed thumb, however, is too big and the donor foot morbidity is greater compared with all other toe transplantation techniques (Fig. 1). Trimmed great toe transplantation This technique reduces the bony and soft tissue girth of the great toe to make it more equivalent to the thumb, at the same time preserving the interphalangeal joint articulation [6]. Trimming is done on the tibial aspect, because the pedicle is located on the bular side. This technique is most suitable for patients who are concerned about both appearance and function. It is indicated for thumb amputations at or distal to the metacarpophalangeal joint when there is an obvious size discrepancy

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Fig. 1. Thumb amputation at metacarpophalangeal joint reconstructed with a total great toe. (A) Before reconstruction. (B,C ) After reconstruction.

between the thumb and great toe and when the movement at the interphalangeal joint is desirable. Initially, this technique was used in adults only, but the long-term results of careful trimming of an immature growth plate have been shown to preserve its blood supply and integrity, thereby maintaining the growth potential (Jain et al, unpublished data) (Fig. 2). Great toe wraparound ap This technique was devised as an alternative to a total great toe transplantation [5]. In its original description, it consists of only the nail and soft tissue envelope of the great toe without the skeleton and tendons, retaining the great toe. It addresses the donor site concerns and the size discrepancy between great toe and thumb. The thumb skeleton, if not already preserved, needs to be reconstructed with a nonvascularized iliac crest graft. Subsequent modication of this technique included the distal phalanx for nail support, which also prevented swiveling of the wraparound ap and grafted bone fracture or absorption [14,15]. The appearance of the reconstructed thumb is usually

excellent, and the great toe need not be sacriced entirely. This ap is ideal for thumb amputations distal to the interphalangeal joint and for soft tissue avulsion distal to the metacarpophalangeal joint with intact joint, skeleton, and tendons (Fig. 3) [7]. Second toe transplantation The second toe is not the rst choice for thumb reconstruction, because it has a smaller and bulbous contact surface, a tendency for clawing, a smaller toenail, inferior cosmesis, and less ideal functions as compared with either a trimmed or total great toe transplantation. The second toe is also not advisable in cases where the patients occupation requires a broad area for opposition, when the thenar muscle function is suboptimal, for reconstruction of dominant hands, and in manual laborers. It is indicated, however, in cases where preservation of the great toe is necessary and when its size mates the thumb. In reconstruction of nondominant hands or for patients who are satised with second toe looks and function, a second toe is a good selection. In proximal thumb

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Fig. 2. Thumb amputation at proximal phalanx reconstructed with a trimmed great toe. (A) Longitudinal reduction of one third of phalanges and interphalangeal joint of the great toe. (B) Postoperative appearance. (C ) Interphalangeal joint motion.

amputations involving the metacarpal shaft, the great toe transplantation is not advisable because of donor site morbidity considerations; however a transmetatarsal second toe transplantation can be used (Fig. 4). Finger reconstruction Single nger amputation Because the functional decit following the loss of a single nger is minimal, toe transplantation

for digit reconstruction proximal to the interphalangeal joint level has not been generally accepted. Reconstruction with like-tissue transfer from the feet usually oers satisfactory results, however, particularly for nger amputations distal to the proximal interphalangeal joint (Figs. 5 and 6) [16,17]. Multiple ngers amputation With proximal amputation of multiple ngers, the functional decit becomes greater and

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Fig. 3. Thumb skin-nail avulsion reconstructed with a great toe wraparound ap. (A) Before reconstruction. (B) Harvested great toe wraparound ap. (C ) After reconstruction.

reconstruction becomes necessary for better prehension. Reconstruction of two ngers instead of only one has several advantages [18,19], including a useful tripod pinch, stronger hook grip, enhanced lateral stability, and increased handling precision (Fig. 7). The options for adjacent amputated ngers include two separate lesser toe transplantations or a combined second and third (or third and fourth) toe transplantation on a single vascular pedicle. In amputations distal to the web space, two separate lesser toes are preferable

because transplantation of combined second and third toe creates an objectionable sydactylous appearance [18,19]. In contrast, for nger amputations proximal to the web space, combined second and third toe transplantation is a better choice for reconstruction. When the amputation is through the metacarpophalangeal joint with intact metacarpal articular surface, the metacarpophalangeal joint can be reconstructed using the articular surface of the proximal phalanx and joint capsule in the toe (composite joint reconstruction). This

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Fig. 4. Thumb amputation at proximal phalanx reconstructed with a second toe. (A) Before reconstruction. (B) After reconstruction.

allows a functional range of motion of the reconstructed metacarpophalangeal joint [20,21]. If the metacarpal articular surface has been damaged or is absent, transmetatarsal toe transplantation is performed to augment length. Metacarpal hand reconstruction The metacarpal hand has always been a great challenge to hand surgeons. Before toe transplantation became a clinical reality, a reasonable reconstructive result was almost impossible to achieve. A type I metacarpal hand can now be reconstructed using a combined second and third toe unit with a good tripod pinch functional result (Fig. 8). In a type II metacarpal hand, both thumb and ngers can be reconstructed with multiple toe transplantations (Fig. 9). With careful planning, the donor morbidity can be minimal even after a total of ve toe harvests. Postoperative management The patients are ideally cared for by specialized nurses for the rst several days. The proximal palm and wrist are gently wrapped with the ngers uncovered for continuous observation. The hand and forearm are kept slightly elevated resting over a smooth support to reduce edema. Bulky dressings are not advised because blood clots can be retained around the wounds, and to remove them could induce vasospasm. It is not possible to start early postoperative rehabilitation. An initial bolus of 100 mL of dextran 40 (low molecular weight) is rapidly administered intravenously 10 minutes before completing the arterial anastomosis, followed by a continuous infusion

(25 mL per hour) during the next 4 to 5 days. Aspirin (325 mg daily) is administered for 2 weeks to reduce platelet aggregation risk. Prophylactic antibiotics are seldom needed but in prolonged surgical cases or dirty wounds antibiotics covering gram-positive and gram-negative bacteria should be administered. The vascular conditions in the transplanted toe are subjectively monitored by direct observation of the skin color, capillary rell, and turgor, and objectively by measuring the surface temperature in the toe in comparison with the adjacent normal nger and opposite hand. Assessing the artery patency with ultrasound Doppler is helpful when these subjective and objective evaluations are in doubt. The donor foot is gently covered with nitrofurazone gauze over the wound and a light u dressing. No splints are used in the donor foot or the recipient hand. The foot can be uncovered in 2 days 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 anterior plantar weight-bearing surface should be avoided during this time. After approximately 6 weeks, the patient is allowed to walk in shoes with a normal gait if the wound is healed.

Rehabilitation Well-planned and supervised hand therapies, including motor and sensory rehabilitation, should be instituted following transplantations. The current program consists of a protective stage (rst 3 postoperative days); early mobilization stage

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Fig. 5. Finger pulp defect reconstructed with glabrous skin ap from the foot. (A) Harvested glabrous skin ap from the rst web space. (B) After reconstruction.

(3rd day to 3rd week); active motion stage (4th through 5th week); activities of daily living training stage (5th through 7th week); and prevocational training stage (after 7th week). This early mobilization regimen results in less stiness, fewer tendon adhesions, and an early return to activities [22].

Intraoperative and postoperative complications and management Vasospasm is one of the most frequent complications that can occur intraoperatively or in the immediate postoperative period. Arterial vasospasm during the procedure can be relieved by topical instillation of lidocaine (Xylocaine 1% to 2%)

Fig. 6. Single distal index nger amputation reconstructed with a second toe wraparound ap. (A) Before reconstruction. (B) After reconstruction.

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Fig. 7. Simultaneous two second toe transplantations to index and middle ngers. (A) Before reconstruction. (B,C ) After reconstruction.

or papaverine. Stripping of the adventitia helps in relieving the spasm and should be carried out under magnication. The vascular anastomosis should be without any tension and vein grafts should be used if required. Vessels should be kept moist during the procedure and the skin closure should not be tight so as to compress vessels. A number of factors can precipitate postoperative vasospasm, including low room temperature, low blood pressure, anxiety in the patient, or excessive manipulation of the hand. Prevention

consists of keeping an optimal blood pressure, supplying adequate uids, and avoiding oversedation. If vasospasm occurs, some skin sutures should be removed and vasodilators intermittently instilled to the partially opened wounds. Sublingual nitroglycerin or nifedipine [3] and regional blocks [23] may help relieve vasospasm. The threshold for re-exploration should be low and if no improvement of circulation is noted after observation for an hour, prompt re-exploration in the operation room is mandatory. In some cases

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Fig. 8. Metacarpal hand type I reconstructed with a combined second and third toe unit. (A) Before reconstruction. (B) After reconstruction.

incomplete stripping of the adventitia or small hematomas may be responsible for local vasospasm. Once the adventitial layer has been adequately excised or the hematomas drained, the vasospasm may be relieved. When there is a refractory vasospasm or the artery is thrombosed, redoing the anastomosis is indicated, with or without an interposed vein graft. Vascular thrombosis is comparatively less common than arterial vasospasm, and is often related to incorrect positioning, such as twisting or kinking or compression by the tunnel, hematomas, or tight skin closure. Most instances of vascular compromise in toe transplantation can be salvaged if re-exploration is done early enough. Other complications observed in the rst 2 weeks usually involve skin coverage and wound healing problems. In most cases these are secondary to partial necrosis of the skin aps in the transplanted 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.

Late complications and their management Late complications include stiness caused by tendon and joint adhesions, extension lag, and nonunion at the osteosynthesis site. Some of these can be prevented or minimized by using early, supervised, and aggressive postoperative rehabilitation [22]. For tendon adhesions, tenolysis can be done. The incidence of tendon-related secondary procedures, however, such as tenolysis, tenorrhaphy, and tendon transfer, have been shown to be fewer than 10% [24]. Extensor lag usually results from tendon repair under inadequate tightness or loosening of the

Fig. 9. Metacarpal hand type II reconstructed with a total great toe and a combined second and third toe unit. (A) Before reconstruction. (B) After reconstruction.

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repair. It can be corrected with tightening of the repair or prolonged splinting in extension. The results of secondary tendon repair are usually poor. Alternatively, the terminal joint can be arthrodesed in an extended position. Joint stiness can be avoided by early intensive supervised postoperative therapy. If required, arthrolysis or arthrodesis can be carried out secondarily. The incidence of joint-related secondary procedures in the authors series was 2.3% [24]. Nonunion is uncommon with interosseous wiring, with an incidence of only 1.5% [24]. If symptomatic, secondary osteosynthesis or bone grafting can be undertaken. Summary In the mutilated hand microsurgical toe-tohand transplantation provides thumb and nger reconstruction that is superior to conventional techniques in appearance and function [14,25]. Hand reconstruction using toe transplantation should be individually planned and carefully executed to obtain optimal results and minimal disability in the donor foot [3,23]. References
[1] Buncke HJ, Buncke CM, Schulz WP. Immediate Nicoladani procedure in rhesus monkey, for hallux to hand transplantation, utilizing microminiature vascular anastomosis. Br J Plast Surg 1996;19:332. [2] Cobett JR. Free digital transfer: report of a case of transfer of great toe to replace an amputated thumb. J Bone Joint Surg Br 1969;51:677. [3] Nilsson H, Jonasson T, Ringquist I. Treatment of digital vasospastic disease with the calcium-entry blocker, nifedipine. Acta Med Scand 1984;215: 1359. [4] Gilbert A. Composite tissue transfer from the foot: anatomic basis and surgical technique. In: Daniller AI, Strauch B, editors. Symposium on microsurgery. St Louis: CV Mosby; 1976. pp. 23042. [5] Morrison WA, MacLeod AM. Thumb reconstruction with a free neurovascular wrap around ap from the big toe. J Hand Surg 1980;5:57583. [6] Wei FC, Chen HC, Chuang CC, Noordho MS. Reconstruction of thumb with a trimmed great toe transfer technique. Plast Reconstr Surg 1988;82:506. [7] Wei FC, Chen HC, Chuang CC, Chen SH. Microsurgical thumb reconstruction: selection of various techniques. Plast Reconstr Surg 1994;93:34551. [8] Yim KK, Wei FC. A comparison between primary and secondary toe to hand transplantation.

[9]

[10]

[11]

[12]

[13] [14]

[15]

[16]

[17]

[18]

[19]

[20]

[21]

[22]

[23]

[24]

[25]

Presented at the 12th annual meeting of the American Society for Reconstructive Microsurgery. Florida, January 13, 1997. Wei FC. Tissue preservation in hand injury: the rst step to toe-to-hand transplantation [editorial]. Plast Reconstr Surg 1998;102:2497501. Foucher G, Norris RW. The dorsal approach in harvesting the second toe. J Reconstr Microsurg 1988;4:1857. Foucher G, Merle M, Maneaud M, Michon J. Microsurgical free partial toe transfer in hand reconstruction: a report of 12 cases. Plast Reconstr Surg 1980;65:61627. Wei FC, Silverman TS, Hsu WM. Retrograde dissection of the vascular pedicle in toe harvest. Plast Reconstr Surg 1995;96:12114. Yim KK, Wei FC. Intraosseous wiring in to-tohand transplantation. Ann Plast Surg 1995;35:669. El Gammal TA, Wei FC. Micro vascular reconstruction of the distal digit by partial toe transfer. Clin Plast Surg 1997;24:4955. Foucher G, Binhammer P. Plea to save the great toe in total thumb reconstruction. Microsurgery 1995; 16:3736. Deglise B, Botta Y. Microsurgical fee toe pulp transfer for digital reconstruction. Ann Plastic Surg 1991;26:3416. Wei FC, Colony LH. Microsurgical reconstruction of opposable digits in mutilating hand injuries. Clin Plast Surg 1989;16:491504. Tsai TM. Second and third toe transplantation to a transmetacarpal amputated hand. Ann Acad Med Singapore 1979;8:4138. Wei FC, Colony LH, Chen HC, Chuang CC, Noodho MS. Combined second and third toe transfer. Plast Reconstr Surg 1989;84:65161. Strauch RJ, Wei FC, Chen SHT. Composite nger metacarpophalangeal joint reconstruction in combined second and third free toe-to-hand transfers. J Hand Surg [Am] 1993;18:9727. Wilson CS, Buncke HJ, Alpert BS, Gordon L. Composite metacarpophalangeal joint reconstruction in great to-to-hand free tissue transfers. J Hand Surg [Am] 1984;9:6458. Ma HS, El Gammal TA, Wei FC. Current concepts of toe to hand transfer: surgery and rehabilitation. J Hand Ther 1996;9:416. Neimkin RJ, May JW, Roberts J, Sunder N. Continuous axillary block trough in an indwelling Teon catheter. J Hand Surg [Am] 1984;9:8303. Yim KK, Wei FC. Secondary procedures to improve function after to-to-hand transfers. Br J Plast Surg 1995;48:48791. Wei FC, Chen HC, Chuang DC, Jeng SF, Lin CH. Aesthetic renements in toe-to-hand transfer surgery. Plast Reconstr Surg 1996;98:48590.

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Passive hand prostheses

Hooman Soltanian, MDa, Genevieve de Bese, BA, MBAb, Robert W. Beasley, BA, MD, FACSa,*
a

Hand Surgery Services, New York University Medical Center, New York, NY 10016, USA b American Hand Prostheses, Inc., New York, NY, USA

Despite major advancements in surgical techniques, including microsurgical revascularization and free composite tissue transfer, there are a large number of patients with hand mutilations who are best served with high quality prosthetics targeted to carefully determine the prime needs of each individual. Once dened, a master plan to optimize the meeting of these needs often includes preliminary surgical procedures. Logical conclusions require consideration of all alternatives, surgical and prosthetic. Hand surgeons should, therefore, be knowledgeable about the basic principles, potentials, and limitations of the various prostheses. The pattern of hand injuries has been progressively changing, with total hand loss becoming increasingly infrequent and bilateral total hand loss extremely rare. Partial hand losses are more frequent and one may see several hundred hand mutilations with some remaining parts for each total hand amputation. Candidates for passive hand prostheses are those patients who have some remaining digits but could use a static complement to enhance the value of remaining natural parts (Fig. 1). One of the basic axioms of all limb amputations is as true today as it was in the past: the more distal the loss, the greater the sensory feedback essential for automatic or subconscious control and the greater the resulting improvement in physical capability.

Another prudent point is that the deformity constitutes a real socioeconomic handicap because of the rapid shifting of the work force from manual labor to service industries in which ones living is made by dealing directly with others. A passive prosthesis should not be considered a cosmetic device. Cosmesis is a term that should be discarded, as it can unjustly deprive patients of benets to which they are entitled. Cosmesis means changing something normal to have a better appearance, in ones opinion. We are treating specic amputation deformities and passive prostheses can eliminate the stigma of disgurement in partial or complete hand mutilations. Disgurement can be a real socioeconomic handicap. In fact, the United States Supreme Court in the case of the School Board of Nassau County v Arleen, 490 US 273, 1987 has conrmed the extreme social and economic impact of deformity. Goals and realistic expectations First we must expand the concept of function beyond prehensile capacity to a global concept of acceptance of the individual in society. There should be clear understanding by everyone that no prosthesis is truly replacing missing parts. The purpose of passive prostheses is to minimize the physical, emotional, social, and economic consequences of deformities. Also, it is fundamentally necessary to appreciate the high level of specicity of all hand prostheses. The same patient may need a dierent type of prosthesis for dierent occasions. One prosthesis may be required for a factory job, whereas a dierent prosthesis may be needed for business or social aairs (Fig. 2).

All photographs were graciously provided by American Hand Prosthetics, Inc., 332 East 30th Street, New York, NY 10016. * Corresponding author. E-mail address: rwbeasley@ren.com (R.W. Beasley).

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved. doi:10.1016/S0749-0712(02)00132-4

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Fig. 1. (A) Mutilated hand closed with distant ap. The thumb is normal but virtually useless. (B,C ) Fine custom partial hand prosthesis. (D) Prosthetic ngers fabricated with new micro-hinged passively adjustable armature greatly enhance capability.

Because it is not possible for the prosthetic device to restore all of which a normal hand is capable, time should be spent in determining the paramount goals for each patient. If this is done and an appropriate, top quality prosthesis is provided, a high success rate can be anticipated. Unrealistic expectations are fraught with noncompliance and failure. Another basic axiom is that there is no relationship between the extent of physical loss and the emotional response to it. It cannot be assumed that a patient with partial loss of a single digit will make a rapid recovery and assign appropriate significance to the loss. It is crucial for every patient to understand the goals of the proposed prosthetics and their limitations. Again, the purpose of prostheses is to minimize the physical, emotional, social, and economic consequences of the deciencies. Aesthetic considerations With the importance of social presentation in our society having been established, a word about our system of visual perception is in order. Basically our concern about the aesthetics of prosthetics

is a practical one. What the patient considers to be a stigma is generally correct, because those people involved with the patient will, for the most part, also share the same attitudes and cultural values. In this context there are two aspects of aesthetics to be considered. The obvious one is the artistic characteristic of size, shape, color, and texture that the artist can duplicate with great accuracy. A perfect color match is dicult because autogenous tissue changes color constantly with temperature, emotional state, and other factors modifying blood ow. The second aspect of aesthetics, however, comes into play and basically neutralizes the constant color changes. This factor is the extent to which ordinary tasks can be accomplished in the expected manner. Basically our visual perception is to see only that which we expect to see unless there is some unexpected event provoking a critical analysis of the situation. For example, if a person has an index nger ray amputation and takes a sip of wine and replaces the glass on the table, most observers will not recognize that a nger is missing. Thus, there is an important aesthetic contribution from motion and improving physical capability should be an important design criterion

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Fig. 2. (A) Severely mutilated right hand. (B) Strong and rugged, but not grotesque, berglass prosthetic device restores function of the normal thumb for work in a factory. (C ) Fine custom silicone life-like prosthesis for business and social occasions.

for every prosthesis. It is a rare exception that an appropriately designed passive hand prosthesis fails to make a positive contribution to better physical capability. They enhance the usefulness of remaining parts, which in turn provide various degrees of sensory feedback for subconscious control of movements. Master plan In the treatment of a mangled hand, a master plan should be developed in the early stages of the patients care. It can be modied, based on the patients progress. Such a plan requires a thorough knowledge of surgical and reconstructive potentials as well as prosthetic fundamentals and possibilities. It is not wise to embark on long and complicated surgical procedures without having an eye on the long-term result with respect to global function. The hand surgeons should leave the parts in the best possible condition for complimenting their eorts prosthetically when appropriate. Even the closure of a nger amputation should be considered a reconstructive procedure, leaving the stump in the best form for prosthetic tting. A nger amputation stump should be slightly smaller than

normal so a prosthesis of normal nger size can t over it. The end should be smooth and tapered. There has been a progressive shift from the classic teaching of ideal levels of amputation that often led to elective shortening. It is safe to say that in almost every instant as much length as possible should be preserved, provided good and direct soft tissue closure is possible. Local or even occasional distant aps may be indicated to save length. Contrary to previous recommendations, the are of the radial styloid should be preserved with a wrist disarticulation. This permits tting of a short suction-held socket hand prosthesis. Otherwise a long socket extending above the elbow is required because the forearm changes shape with pronation/supination. There are innumerable individual considerations, but the principle of initial length preservation is a fundamentally important concept with rare exception. Types of prostheses There are two categories of hand prostheses. 1. Active prostheses (also known as carrier tool prostheses) 2. Passive prostheses

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One should not refer to active prostheses as functional, as that implies incorrectly that passive prostheses are nonfunctional. Most patients with passive prostheses enjoy a substantial degree of improvement in physical capabilities because these prostheses use the critical sensory feedback through the remaining natural structures. The passive prostheses are designed intentionally without mechanical clamping units in them. Passive and active prosthesis target dierent goals and needs. Passive prostheses enhance the function of the remaining digits of the hand and also restore good social presentation. New material and technology Silicone has proven to be the best material for hand prostheses. Two recent and signicant technologic innovations have enormously improved the possibilities for digital and partial hand prostheses. The rst is the Bio-Chromatic coloring technique for silicones. This technique mimics nature by depositing color pigments on the interior surface of the clear silicone prosthetic glove. The clear exterior layer is similar to the colorless epidermis of normal skin. This gives the prosthesis a similar translucency. The superiority of color matching with this technique obviates the need for the traditional ring or small bandage applied to the junction of the prosthesis with the normal skin. It also permitted the creation of digital prostheses for the thumb and ngers without the need to extend proximally over intact interphalangeal joints. The same technology led to the development of a sub-mini prosthesis for a mutilated distal phalanx or even for a lost or damaged ngernail. The second major innovation relates to digital armatures. Armatures are structures built into

prosthetic ngers to allow passive adjustment of their contour by the normal hand for various tasks. This allows more ecient function of the remaining natural parts. Copper and stainless steel armatures were awed by oxide formation causing discoloration and metal fatigue with breakage. Also, wire armatures require secure anchorage of their proximal end to modify their contour. The development of stainless steel micro-hinged armatures has resolved all three of these problems. These prostheses do not require proximal anchorage to adjust for their conguration. The exion/ extension occurs along the entire length of the micro-hinged armature rather than at one point. This eliminates the problems of metal fatigue and need for anchoring the proximal ends of the armatures that often is dicult to achieve. The new armatures can be used to create prostheses for ngers amputated at the level of the proximal phalanx. The nger can be placed in basic extension for thumb opposition. Alternatively, the digit may be curved for typing or other activities (Fig. 3). Specic prostheses Passive hand prostheses can be conveniently divided into three groups: (1) thumb, (2) ngers, and (3) partial hands, the latter term reserved for mutilating injuries with loss of a major portion of the hand. Partial hand The goal of a partial hand prosthesis is to enhance the usefulness of the remaining natural parts while also providing a socially acceptable appearance. The design and development of the partial hand prostheses is the most challenging of all, and often the most rewarding; however, natu-

Fig. 3. (A) The common transmetacarpal amputation with a normal but almost useless thumb preserved. (B) Custom life-like prosthesis enhances use of the thumb.

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Fig. 4. (A) Mutilated right hand. (B,C ) Fine custom, silicone, passive, partial hand prosthesis for which remaining parts provide active motion. (D) Intact sensory feedback for subconscious control improves capability to a degree no active prosthesis can approach.

ral parts with intact sensibility provide an advantage over any other device. A severe mutilating injury that illustrates the dramatic value of a topquality partial hand prosthesis is loss of all four ngers through their distal metacarpals, with a normal thumb and palm preserved (Fig. 4). Before micro-hinged armatures, one would have to

shorten the metacarpals to their neck levels in the case of MP disarticulations to have space for proximal anchorage of wire armatures. Thumb Fortunately, proximal thumb amputations are rare. There is really no satisfactory means of

Fig. 5. (A) Thumb amputation through proximal phalanx. (B) Securely tting digital prosthesis places the thumb pad where the brain expects it to be and sensory feedback is so good that capability is near normal. Social presentation was also simultaneously restored to normal.

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Fig. 6. (A) Mutilated hand with digital amputations and fused PIP joints. (B) Precisely tting custom digital full-length prostheses provide excellent sensory feedback, and, fabricated with the passively adjustable micro-hinged armatures, a remarkable degree of ne functional rehabilitation.

securing the prosthetic attachment at this level of amputation. There were hopes that osseointegrated implants, so successful in the dental eld, would resolve this situation, but this has not been realized. Many thumb injuries are at the level of the proximal phalanx. In these cases, it is important

to preserve maximum length, which may require wound closure with a ap. A minimal length of 15 mm of proximal phalanx is needed for securing a prosthetic suction attachment (Fig. 5). For thumb amputations at the metacarpal-phalangeal (MP) joint level, slight deepening of the rst web with tapering of the condyles and

Fig. 7. (A) Middle nger amputation at neck of middle phalanx. (B) The remarkable Bio-Chromatic coloring technique permitted development of mini or short digital prostheses that leave the PIP joint uncovered and totally free. (C ) The passive prosthetic t provides sensory feedback, which with the ngers pad where the brain expects it to be, can give remarkable results. This has been a major technological breakthrough for prosthetics.

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Fig. 8. (A) Partial amputation of only distal phalanx or even loss or damage of a ngernail can cause some patients great distress, and for this there is no satisfactory surgical treatment. (B) The same technology resulting in the mini digital prosthesis has been applied for a sub-mini prosthesis over the distal phalanx only, so both interphalangeal joints are free. As illustrated, it can be used for a ngernail alone.

removal of sesamoid bones makes secure tting of the prosthesis possible. The deepening should not be more than 15 mm because further deepening would result in a cleft rather than a web. This will be aesthetically disturbing and will contribute to progressive damage to the thumbs adductor muscles. Other cases of thumb amputation near the MP joint may be best treated by distraction osteotomy lengthening of the rst metacarpal with bone grafting. The authors have gained additional lengths up to 34 mm with this technique. Finger Contrary to common belief, nger prostheses are not for appearance only. By placing ngertips where the brain expects them to be and because of the excellent sensory feedback to the brain necessary for subconscious or automatic control from their precision t, nger prostheses can be among the most helpful. When possible, nger amputations are much better treated with individual prostheses than a partial hand prosthesis that requires covering the hand with a glove (Fig. 6). Proximal phalanx Loss of both interphalangeal joints results in enormous reduction of nger dexterity. As prostheses are now available with multiple microhinged armatures that can be passively contoured without the need for proximal xation, long nger prostheses can be useful for typing and similar activities. A length of 1215 mm of nger distal to the interdigital web is required for secure suction attachment of nger prostheses. Occasionally,

judicious deepening of the web can provide a critical additional 35 mm of length. Middle phalanx The traditional full-length prostheses for all levels of nger amputation covered the important proximal interphalangeal joint (PIP) compromising its mobility. The PIP joint provides the critical segment of the ngers exionextension arc of motion for most activities. With the advent of the short or mini digital prosthesis made possible by the Bio-Chromatic coloring technique, no restriction is imposed on PIP joint mobility (Fig. 7). Distal phalanx The loss of a ngertip or even a deformed ngernail can be stressful to some patients. Using the new technology developed for middle phalangeal amputations, a sub-mini digital prosthesis has become available for the distal phalanx. There is no restriction of motion. The ngernail prosthesis is thin to permit transmission of sensibility from the nger. A perfect t results in secure suction attachment and the acrylic ngernail, duplicated from the other hand, is always correctly positioned with no problems with skin irritation or cellulitis (Fig. 8). Summary For many mangled hands, appropriately designed passive prostheses now available, alone or in conjunction with surgical reconstruction, can oer the best available improvement, provided they are of high quality and backed by prompt and reliable after-delivery services. Invariably, there is improvement in physical capability along with restoration of good social presentation.

Hand Clin 19 (2003) 185191

Active functional prostheses

Terry J. Supan, CPO, FAAOP
Orthotics and Prosthetics Associates of Central Illinois, 355 W. Carpenter Street, Suite B, Springeld, IL 62702, USA

This article discusses the use of prostheses in general and more specically what can be done for the patient with injuries through the hand and carpal region. Although the article is titled Functional prostheses, the author focuses on actively controlled devices. Rationale is made for optimum amputation levels and prescription recommendations. Finally, examples of prosthetic designs and tting strategies are presented. The two primary functions of upper limb prostheses are to grasps objects and restore body image. Secondary functions are to hold objects down or carry them. The prosthesis also must be designed to allow the amputee to position the terminal device in space. Presently, complex grasp patterns with multiple degrees of freedom are not possible. Research has been done on more dexterous prosthetic hands but none are commercially available. Cable controlled hooks usually provide a voluntary controlled lateral prehension in one direction only. Electric hands try to simulate opposition but only in one plane. They provide more function because they do allow the amputee to control opening and closing of the hand. The silicone prostheses for carpal and metacarpal injuries cannot provide an active grasp on their own. They are used primarily to restore body image and secondarily to hold objects against the other hand, the body, or other surfaces. If there is enough residual phalanx to provide motion and suspension of the silicone prosthetic ngers, there may be enough muscle control and resistance for some opposition. From the prosthetist perspective, the leading cause for amputations of the upper limb is

E-mail address: tsupan@siu.med.edu

trauma, either crushing injuries or electrical burns. This is followed by congenital anomalies, infections, and tumors. Only 10% of amputations treated by prosthetists are of the hand or arm. Of those, most of the amputation sites are at the transradial (below elbow) level, followed by the transhumeral (above elbow) level, and a combination of the shoulder disarticulation and scapularthoracic levels. Historically, partial hand and nger amputations rarely were provided with prostheses because of the lack of components that were either cosmetically or functionally acceptable to the amputee. Recent advances in silicone prostheses and the availability of electrical hands for carpel level amputations should change that. In the case of an elective amputation, length does make a dierence in the functional use of a prosthesis. A transhumeral amputation distal to the midshaft level has more leverage to provide the lifting force to ex the prosthetic elbow. A distal transradial amputation allows more of the forearms supination and pronation to preposition the terminal device. But a limb that is too long can create just as much diculty for the prosthetist as one that is too short. Disarticulations at the wrist and elbow are no longer recommended, because their extra length restricts the types of prosthetic components that can be used within the prosthesis. As a quick reference, use the three nger widths rule to determine the amputation level proximal to the wrist and elbow joint lines. Amputations more distal to those points cause the prosthetic elbow to be too low or do not allow enough space for a prosthetic wrist that permits easy changing of the prosthetic hand or other terminal device. Unlike the individual with an amputation of a leg, the arm amputee can adapt easily and rapidly

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Fig. 1. Spring-loaded TRS Adept holds objects placed in the prosthesis.

to one handedness. How soon a person is tted with a prosthesis after an amputation determines how much they maintain their bimanualness and how much they incorporate the prosthesis into their lifestyle. The same is true for the child born with some type of congenital anomaly. When the child would normally start bimanual activities is when they could and should start to use a prosthesis. In both cases early is better. Malone et al provided some interesting data when they reviewed the use of immediate and early postoperative prosthetic ttings in adult patients in the 1980s [1]. There was a signicant dierence in the functional outcomes of individuals who began to use their prosthesis within 30

days after their surgery and those tted later. There was also a decrease in the phantom pain commonly associated with amputation. In the case of children, there is a long established practice of tting the child with some type of passive prosthesis at 6 months or when they begin sitting independently. As the child develops cognitively and physiologically, the prosthesis can be modied to provide springloaded followed by active grip (Fig. 1). The question is always raised, Will the amputee be a user of a prosthesis? The response is that the individual, be it an adult or a child, uses the prosthesis as long as the benet of wearing the prosthesis outweighs the nuisance factor of

Fig. 2. This patient has chosen not to use a prosthesis for her metacarpal level congenital anomaly. Painting the ngernails on the limb buds illustrates how comfortable she is with her self-image.

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Fig. 3. (A) Alginate impression of residual limb and contralateral hand of patient and completed silicone prosthesis. (B) Transparent evaluation prosthesis is used to determine t and shape before the nal prosthesis is fabricated.

having the prosthesis interfere with their life. If the prosthesis is a functional tool for them or if it improves their self-image, they will wear it. If not, they will quickly discard it and adapt to a onehanded lifestyle. Unfortunately there is no way of predetermining who will use their prosthesis and who will not (Fig. 2). Individuals with high-level unilateral amputations at the shoulder region rarely use a prosthesis. Those with an interscapular-thoracic amputation wear some type of shoulder cap to balance out their clothing. The longer lever arm of a more distal transhumeral amputation results in more function and therefore an increased likelihood of prosthesis use. The same is true of the transradial level. Although most individuals function well with their prosthesis, those who have a proximal amputation tend not to use a prosthesis because of the leverage and prosthetic weight. As noted earlier, individuals with nger

and partial hand amputations who use a prosthesis are the exception. Finally, individuals with bilateral amputations or contralateral limb involvement usually wear and function remarkably well with at least one prosthesis. They have more function with the longer limb if there is a dierence between the two extremities. But as with the unilateral amputees, the partial hand and high level make it less likely for these individuals to use a prosthesis. The bottom line is that all amputees should be tted with the type of prosthesis that ts their goals and lifestyle as soon as possible after their amputation. They will determine if the use of a prosthesis is best for them. When the patient is rst evaluated by the prosthetist, functional goals and lifestyles are used to try to determine what is the best type of prosthesis for the amputee. If cosmetic image is the most important goal of the patient then the

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Fig. 4. Grieer (Otto Bock Health Care, Minneapolis, Minnesota) electric hook applied to a wrist disarticulation level prosthesis.

use of a nonactive silicone prosthesis or a silicone custom glove over an electric hand would be the rst choice. If the amputee indicates a desire for more rugged activities, then a mechanical design like a cable powered hook would be more appropriate. The passive silicone prostheses are more cosmetic and potentially can improve the selfimage of the patient. They add considerable expense to the overall cost of the prosthetic care. Newer designs for transcarpal and distal amputations are self-suspending and more durable. There is less problem with stains and inks with the silicone prostheses than with the PVC gloves that were used in the past. Although they are now more readily available, the prosthetist does need special training to

provide this type of prosthesis. Alginate or RTV rubber is used to take an impression of the residual limb and the contralateral hand to match the shape and size as closely as possible. Photographs or digital images and color swatches are used to make sure that the skin pigmentation matches. A transparent evaluation socket or glove is used to insure proper shape, t, and suspension. Color samples are matched again before the prosthesis is completed (Fig. 3). The advantage of the cable controlled hook prostheses is that they are more durable than the silicone prostheses and less complex than the electric prostheses. The mechanical terminal devices (TD) are either voluntary closing (VC) like the TRS Grip (TRS, Inc., Boulder, Colorado) or Adept (TRS, Inc., Boulder, Colorado), or

Fig. 5. (A) Disassembled transcarpal level prosthesis with internal exible suspension and hinge to allow residual wrist exion motion. Patient has congenital anomaly with shortening of the forearm bones. Overall length of limb is equal to contralateral forearm. (B) Partially assembled prosthesis. Center section connects electric hand to distal section of prosthesis.

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Fig. 6. (A) Semi-exible inner socket on wrist disarticulation prosthesis allows the styloid to pass the smaller mid-shaft area. (B) Prosthetic wrist can be passively rotated but does not allow exion or extension.

voluntary opening (VO) like the usual Hosmer split hook (Hosmer Dorrance Corporation, Campbell, California). Both types of TDs can be adapted for heavy-duty use with metacarpal level amputations. At any level, a body powered prosthesis is controlled by motions of the shoulder joint. Forward exion of the arm causes the cable to open the hook while rubber bands close it. For the VC terminal device, a spring holds it open and the shoulder joint motion causes it to grip the object tighter. The amputee only has active control in one direction. In most cases the prosthesis is used in the baseball strike zone. Outside that range, cable excursion is lost and the hook is more dicult to open or close. Electric hands are controlled in opening and closing. Earlier versions used simple ono electronics. These evolved into proportional electronics and are now controlled by microproces-

Fig. 7. Flexible inner silicone insert is rolled onto limb then both are inserted into the socket of the prosthesis. The distal pin engages a locking mechanism within the prosthesis.

sors for more exact manipulation of the middle and index ngers and thumb. Myoelectric hands are controlled by the forearm muscles and not by any shoulder/elbow motion. Therefore, the amputee can open and close the TD throughout the full range of motion of their arm. They can just as easily open and close the hand at the oor, over their head, or behind their back. Because of their shape and the cosmetic covering, they tend to enhance self-image. In children, the Six Million Dollar Man has a higher approval rating than Captain Hook. Electric hooks are available for amputations at the wrist disarticulation level and more proximally. Because they lack the cosmetic glove, they are more durable and can be interchanged with an electric hand. At the present time there are no designs that work with carpal/metacarpal level amputations (Fig. 4). Prostheses are usually suspended on the patient limb in one of three ways: part of the control harness holds the prosthesis in place, the prosthesis is designed to encapsulate the bony structure of the limb, or a positive air seal causes atmospheric pressure to maintain the prosthesis in place. The level of amputation and the type of prosthesis prescribed determine which manner of attachment is used. Mechanically controlled prostheses usually use part of the harness for suspension. For amputations below the elbow, the straps in front of the involved shoulder transfer the weight of the prosthesis and anything it is carrying to the opposite axilla, usually in a gure eight pattern. Amputations between the shoulder and elbow are suspended either from the opposite axilla or around the chest. In the case of bony suspensions, the increased width of the condyles and styloids compared with

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Fig. 8. Flexible silicone sleeve seals the prosthesis and maintains the suspension.

the area just proximal to them allows the prostheses to be self-suspending. The t of this area of the prosthesis is more critical to gain enough pressure to suspend but not too much pressure to cause discomfort. Depending on the level of amputation and the terminal device used, this bony suspension can be made of either rigid or exible material. Either the exible material expands to allow the larger distal bony structure to pass by or the rigid socket shape is designed to allow the condyles to pass when the joint is held at a certain angle (Figs. 5 and 6). Atmospheric pressure techniques also vary depending on the level and the components used in the prosthesis. The proximal sockets circumference is made smaller and a distal valve is used to allow the limb to be pulled into the prosthesis. With the valve sealed, the limb then

acts like a cork in a wine bottle. This is usually for amputation at the transhumeral level. The internal socket is usually made of a semi-exible plastic. The second technique is to use a exible suspension liner that is rolled on and seals to the skin of the limb. This liner is then connected to the prosthesis by special locking mechanisms (Fig. 7). An external sleeve also can be used as either primary or secondary suspension of the prosthesis. Like the roll-on insert, this also acts as an air seal but allows more supination and pronation of the forearm without aecting the function of the terminal device. The sleeves are usually made from silicone or other similar material (Fig. 8).

Fig. 9. Medial and lateral pressure is applied to the distal end of the limb during the impression-taking to better control residual rotation of the bones. This then transfers any motion of the radius to the prosthesis.

Fig. 10. A partially completed prosthesis for an amputation of the ngers (thru the second metacarpalphalangeal [MP] joint to the distal shaft of the fth metacarpal). The nger can hook around objects and provide either lateral or tip prehension from the thumb.

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Fig. 11. A voluntary closing TRS Grip II terminal device is mounted to the dorsum of the prosthesis to allow the amputee to hold larger objects. The patients thumb is present but has a reduced range of motion. The cable provides power to close the hook when the shoulder is exed.

With this type of suspension up to 50% of the residual forearm rotation can be transferred through the prosthesis. To do this, the distal end of the limb is attened during the impression-taking to create a screwdriver technique to harness this motion. The closer the amputation is to the wrist level, the more pre-positioning of the terminal device the amputee will have, thus increasing the function of the prosthesis (Fig. 9). When only a portion of the hand has been amputated the design criteria can be more dicult to assess. If either the thumb or ngers are removed, then the prosthesis is usually constructed to provide opposition for the remaining digits. Most of these are designed for specic tasks and are for more rugged manual activities. Simplistic thumb posts or nger posts are used to provide the counter force to hold an object or tool. Finger replacements are usually curved to allow a choice of either lateral pinch or tip pinch (Fig. 10). For a larger grasp pattern, a conventional hook or other terminal device can be modied to this level of amputation. The prosthesis is usually longer than the other arm. Wrist motion can still be available to improve pre-positioning of the TD. Usually the TD is mounted on the palmar surface, but if the thumb is still present, it is attached to the back of the hand (Fig. 11). Recent developments in electric hands now allow the prosthetist to design a myoelectric

prosthesis when either the proximal or distal row of carpal bones is present. In the case of carpal/ metacarpal amputations, the Otto Bock 8E44 Transcarpal Hand (Otto Bock Health Care, Minneapolis, Minnesota) can now be used. The Short Hand version of the Motion Control ProHand (Motion Control, Inc., Salt Lake City, Utah) can be used for either wrist disarticulations or proximal carpal level amputations. Although the Otto Bock hand has a xed connection at the wrist, the Motion Control short version still allows a quick disconnect and rotation at the wrist. Finally, the recent development in osseointegration has resulted in direct attachment of myoelectric prostheses (at the transradial level) and silicone prostheses for the thumb [2]. As the complications of the bone/internal prosthesis/ external prosthesis are resolved, this may become the suspension technique of choice for future amputees with mutilated hands.

Reference
[1] Malone JM, et al. Immediate, early, late postsurgical management of upperlimb amputation. J Rehala Res & Devel May 1984;21(1):3341. [2] Lundborg G, Branemark PI, Rosen B. Osseointegrated thumb prostheses: a concept for xation of digit prosthetic devices. J Hand Surg 1996;2: 216221.

Hand Clin 19 (2003) 193204

Outcomes after mutilating hand injuries: review of the literature and recommendations for assessment
Reuben A. Bueno, Jr., MD, Michael W. Neumeister, MD, FRCSC, FACS*
Southern Illinois University School of Medicine, 747 North Rutledge, 3rd Floor, P.O. Box 19653, Springeld, IL 62794, USA

When you have nothing, a little is a lot. Sterling Bunnell

We use our hands in almost every activity of daily living. The hand also has notoriety as being the most commonly injured part of our body. Acting as mechanical extensions of our bodies, our hands and upper extremities are instrumental in our ability to eat, to dress, to perform personal hygiene, and for most people, to pursue a productive role in society and at home. Hands have been used to display power, passion, friendship, gratitude, and anger. The blind use their hands to read and the deaf to communicate. These highly specic functions of the upper extremity necessitate a ne balance between the sensory organs in the hand and its biomechanic movements. Mutilating hand trauma can render the limb completely dysfunctional, thereby detrimentally impacting lives of patients and their families. Reparative and reconstructive surgeries are noble attempts to regain some of the lost functions of a mangled hand. The limitations of surgery and the prognosis of the nal, functional outcome of mutilating hand injuries depend not only on the severity and extent of the initial injury, but also on the patients age, underlying health condition, overall expectations, compliance, and psychosocial disposition. Each of these factors can be a signi-

* Corresponding author. E-mail address: mneumeister@siumed.edu (M.W. Neumeister).

cant variable in the nal functional outcome of mutilated hand injuries. Any evaluation of outcomes following such devastating injuries must keep most, if not all, of these variables in mind. Mutilating hand injuries are usually associated with varying degrees of fractures, tendon, nerve, and vessel injury, soft tissue loss or compromise, and amputations. Postoperative swelling, immobilization, and scarring can lead to contractures and stiness, whereas insensate digits are subject to repeated trauma and further dysfunction. Through aggressive physical therapy and secondary reconstructive procedures, however, lost function, at least in part, can be returned to the remaining elements of the mutilated hand. Digit lengthening, web space deepening, tendon transfers, nerve grafting, and toe transfers all have been used to improve a patients ability to perform their activities of daily living and, perhaps more importantly, to return them to a productive prole in society. Our ability to salvage some function in the mutilated upper extremity makes hands signicantly dierent from their lower extremity counter parts (Fig. 1). Most patients with a severely mangled foot would be more functional with a lower leg prosthesis than an attempt at limb salvage. Patients with severe hand injuries, on the other hand, can achieve signicantly more function and benet from initial salvage surgery and secondary reconstructive procedures if prehension and sensation are restored. Better neural regeneration and an ability to bring new digits up to the hand oer the promise of favorable, functional outcomes in managing these severe hand injuries.

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Fig. 1. (A) Severely mutilated hand secondary to a corn-picker injury with complete loss of all ngers. (B,C) Restoration of functional pinch with stable, sensate soft tissue from two toe-to-hand transfers.

Successful reconstructive eorts are aimed at sensibility restoration and the ability to perform prehensile tasks with the nal outcome being measured by gainful use of the hand and patient satisfaction. Burkhalter stated The goal remains achieving maximal hand function [1] when dealing with mangled hands. Chen Chun-Wei echoed this concern when he stated: Survival without restoration of function is not success [2]. With this in mind, hand surgeons are often

confronted with surgical dilemmas of how to maximize the patients functional outcome after mutilating hand injuries. When does the surgeon sacrice severely traumatized yet viable digits? How condent are we as hand surgeons that if we salvage a limb, that this remaining hand, with or without secondary reconstruction, will give the patient better use than a prosthesis might? What variables in a mangled and severely compromised hand or upper extremity allow us to know what to

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replant or transplant? What degree of multiple level trauma or nerve injury precludes upper limb or hand salvage? How does the patients age aect the surgeons decision to perform limb salvage in secondary procedures? When do we recommend amputation and prosthesis tting in severely injured upper extremities? Each of these questions meanders through the minds of most hand surgeons when they are confronted with decisions regarding mutilating hand injuries. Each injury is given an individualized game plan in an attempt to oer the patient the optimum result. Unfortunately, there is no denitive decision tree that can be used to guide surgeons as to which remaining elements of the mangled hand should be salvaged or amputated. There are no scoring systems that oer the foresight to be able to grade an injury, add in the possible secondary reconstructive procedures, and then predict what the functional outcome will be. There are not any scoring systems like those in the lower extremity or in multiple organ trauma that help dene when an amputation of the hand or extremity is considered most appropriate. The rationale for this is easily understood because we have a greater ability to restore some function in the hand or upper extremity with secondary reconstruction than we do with lower extremities. One can ambulate easily with a prosthesis. It is extremely dicult, however, to button a shirt or brush ones teeth with an upper extremity prosthesis. The unique function and utility of the hand and upper extremity, therefore, mandate a greater consideration and forethought by the surgeon in the initial evaluation and surgical management of patients with mutilating hand injuries. The principles of treatment and options for reconstruction in mutilating hand injuries have been addressed in previous articles. This article reviews the outcome measures of mutilating hand injuries, examines the use of scoring systems of the extremities, and describes current methods of objective and subjective evaluation.

Clinical outcomes Reports in the literature on mutilating hand injuries have evolved from a focus on achieving adequate skin coverage in the earliest case reports to reconstructing more functional hands in later reviews. Advances in microsurgery have fostered the restoration of function with improved techniques in replantation of amputated parts, free

tissue transfer for adequate coverage of wounds, improved nerve coaptation, and toe-to-hand transfers. Underlying the treatment of mutilating hand injury is the basic principle advocated by Brown in one of the earliest articles on mutilating hand injury: Any salvage of workable or sensory parts in a hand is worthwhile and innitely better than a prosthesis [3]. This view is supported by later reports from Peacock and Tsai [4] and Graham et al [5], who compared the functional results of replantation versus amputation and prosthesis in the upper extremity. Peacock and Tsai [4] presented a single case of a child with bilateral amputations treated by replantation of one limb and amputation and prosthesis on the other. Graham et al [5] presented a series of 22 patients who suered traumatic arm amputations and underwent replantation. He compared this group with 22 other patients who had revision amputation of their arms and subsequent prosthetic application. Superior functional results were obtained with the replantation of the arms compared with those with the prosthesis [4,5]. Although earlier reports focused on stable wound coverage and return to work status as the primary outcomes examined, Midgleys series [6] represented a shift toward using more quantitative measures, such as strength, range of motion, pinch, key pinch, and grasp, to assess functional outcome of the reconstructed hand following mutilating injury. Clinical series increasingly emphasized objective measurements to evaluate recovery and thereby guide initial treatment. In addition, the patients return to work status was more commonly included in the assessment of outcome, supporting the belief that restoration of meaningful function is at the forefront in guiding treatment and in evaluating outcome. The literature is replete with functional outcome data pertaining to mutilating hand injuries. Replantation or revascularization procedures are often only a component of mutilating hand injuries, and as such the information on ultimate function in the mangled hand cannot always be extrapolated from the outcome data that arises from these salvage procedures. The outcomes may vary depending on whether the injury involves compromise to dierent tissues including bone, nerve, and soft tissue, with or without devascularization or amputations. Limb survival is most certainly not synonymous with limb function. The survival of limbs subsequent to the initial structural repair, revascularization, or replantation

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depends on the adequacy of the initial surgical debridement, the development of infection, the method of injury, the level of injury, and the duration of ischemia. Nonviable tissues with a heavy bacterial contamination are specic ingredients for infection and are often associated with loss of the salvaged limb [7]. Although the most common infection leading to the loss of mangled limbs is unknown, Fitzgerald et al [8] reported the most common bacterial isolates in 86 mutilating hand injuries. Farming injuries had a greater number of mixed gram-negative and gram-positive infections compared with home and industry. The most common gram-positive organism was Staphylococcus epidermidis followed by Staphylococcus aureus and Streptococcus group D, respectively, in the prospective and retrospective arm of the study. Enterobacter agglomerans, Clostridium, and Klebsiella pneumonia were the most common gram-negative organisms, respectively [8]. The mechanism of injury also plays a specic role in limb survival and function. Crush,

avulsion, and electrical burn injuries can portend a worse prognosis for survival [4,913]. Crush injuries have a greater area of tissue damage with multiple levels of vascular compromise (Fig. 2). This leads to an increased risk for thrombosis and infection. The vascular compromise is often at the small vessel or capillary bed level. Muscle, skin, and soft tissue stripped of their blood supply are rendered nonviable, forming a nidus for infection if not debrided. Avulsion injuries have longer segments of nerve and vascular compromise of larger vessels resulting from the stretch and torsion (Fig. 3). Electrical injuries can result in fractures, burns, compartment syndrome, and progressive tissue death, ultimately leading to amputation (Fig. 4) [1416]. The mechanisms of these devastating injuries include electro-conrmation changes of cells, joule heat, electroporation, and thermal burns. High voltage electrical injuries may necessitate early amputation to insure the survival of the patient, who is in jeopardy from the muscle breakdown products and acidosis.

Fig. 2. (AD) Severely injured upper extremity with crush and avulsion injury to skin, tendon, vessel, nerve, and bone. Multiple level injuries with multiple structures involved carry the worst prognosis.

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Fig. 3. Avulsed index nger with stretched neurovascular structures making salvage dicult because of extended level of injury.

The functional outcome of major amputations and devascularizations is often governed by the same variables that govern the survival of the tissue alone. The level and mechanism of the injury therefore have a signicant impact on the

ultimate functional outcome of these injuries [5]. In general, the more proximal the amputation the worse the functional recovery. Proximal amputations have a worse prognosis for several reasons. There is more muscle mass in the more proximal limb, which is more susceptible to increased ischemia times. This is a greater abundance of metabolic breakdown products. Another factor that hinders recovery from the more proximal amputations is nerve regeneration. The toxicity of the metabolic breakdown products in muscle results in a reperfusion syndrome [17] that clinically presents as hyperthermia, decreased level of consciousness, jaundice, cardiac irregularities leading to multi-organ failure secondary to hyperkalemia, metabolic acidosis, and myoglobinuria. Woods [18] reported 4 deaths out of 36 above elbow replants in patients who developed reperfusion syndrome. Patients are usually not subjected to reperfusion syndrome when amputations are at the level of the mid-forearm or distally, because of the rather minor contribution of muscle to this area. Nerve regeneration in the proximal amputation is less predictable than in more distal amputations. The greater the distance the nerve has to regenerate, the less likely the motor endplates will survive [9,19]. Clean guillotine-type amputations are generally considered to have a better functional outcome (Fig. 5). The dierent types of tissue damaged in crush and avulsion injuries make the evaluation of the overall function somewhat unpredictable. Many investigators have reported a worse prognosis with such injuries [5,9].

Fig. 4. (A) Extensive soft tissue damage at entrance wound of electrical burn. The hand is in a contracted and xed position. Electrical injuries result in progressive necrosis that requires multiple debridements or amputations. (B) This extensive damage from an electrical burn led to below-the-elbow amputation for patient in Fig. 4A.

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Fig. 5. (A) Guillotine amputation at the wrist in a 37-year-old man from Miter saw injury. This type of injury has the best prognosis after revascularization. (BD) Excellent return of range of motion and sensation led to near normal function.

The ischemia time for the amputated limb also has a role in the overall functional outcome. Although many investigators consider warm ischemia time of less than 6 hours and cold ischemia time of less than 12 hours a general guideline for more reliable and safer replantation or revascularization, the exact amount of ischemia time that is considered inappropriate to replant a limb is somewhat ill dened. Reports in the literature have varied from 1 to 6 hours to as much as 42 hours of warm ischemia with successful replantation [20]. These time frames have been doubled if cold ischemia has been used. Wei reported a successful replant with 96 hours of cold ischemia. Another variable in dening the functional outcome following mutilating hand injuries is the patients age. Children and young adults have a better functional outcome than older patients [5,9,21]. Younger patients may have a superior nerve regeneration capability, resulting in greater extrinsic and intrinsic motor function. Bony union rates in children exceed those of adults [22]. Young patients are also less likely to have

subsequent sti joints. Finally, the younger the patient, the more likely they will acclimatize or adjust to their injury, thereby fostering improved function. Older patients may not be as compliant or able to withstand the duration of surgery or the signicant rehabilitation and subsequent secondary procedures often required with these injuries. An absolute age limit for revascularization and replantation of limbs and digits has not been identied, although most hand surgeons would consider advanced age a relative contraindication because of the risk for rather poor functional outcome. Ultimately the functional outcome of revascularization and replantation procedures depends on the equation that incorporates age, mechanism and level of injury, associated trauma to structures at dierent levels, ischemia time, associated trauma to structures at dierent levels, contamination, tissue loss and destruction, patient compliance and motivation, rehabilitation, secondary procedures, dynamic stability, and premorbid medical pathology. Clearly the functional outcome has a limited chance of an accurate evaluation at the time of

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injury because of these variables. The relative contributions of each variable, however, shapes the hand surgeons decision to attempt salvage and produce a functional limb. The Subcommittee on Replantation for the International Federation of Societies for Surgery of the Hand [23] has adopted Chens criteria [24,25] for all arm and forearm replantations, and Nakamura and Tamai criteria [26] for hand and digit replantations. Each system, however, is an evaluation of the functional outcome of the initial replantation alone and not for added benets of subsequent secondary procedures that could improve the use of the hand. Numerous investigators have attempted to assess the functional outcome following major limb replantation. The range of good to excellent outcomes assessed by dierent criteria range from 36% to 100%, depending on the level, etiology, and age of the patient. Much of the earlier data on outcomes following severe hand injury came from several replantation and revascularization series. Although they did not look exclusively at mutilating hand injuries, these series did assess outcomes in a systematic manner that could be extrapolated to most severe injuries of the hand. Chens assessment of functional outcome following replantation looked at the patients ability to work, range of motion, sensation, and muscular power [27]. Kleinerts review of 347 replants in 245 patients included two-point discrimination sensibility ratings, grip strength, range of motion, absence of cold intolerance, and return to employment for outcome assessment criteria [28]. Tsais series on reconstruction using second and third toe-to-hand transfers following severe transmetacarpal mutilating hand injuries included objective measures, such as grip strength, key pinch, two-point discrimination, and active range of motion, and the more subjective yet equally as important measure, return to work status to assess outcome [29]. Each series reported good results following treatment using similar criteria to assess outcome. Tamai continued this trend of incorporating objective data with subjective data when he developed a scoring system for replanted or revascularized digits looking at the following parameters: range of motion, activities of daily living, sensation, subjective symptoms, cosmesis, and patient satisfaction [26]. This scoring system represented one of the earliest attempts to combine objective measures with subjective measures to evaluate overall hand function. This

concept would become increasingly important in the development of outcome measures in the future. Any discussion of restoration of hand function following mutilating hand injury must begin with the ability to perform prehensile activities. Objective measures, such as grip strength and key pinch, are based on the presence of a moveable thumb that circumnavigates by way of opposition to reach another stable digit. Alternatively, the thumb may be the stable stationary post while other mobile digits oppose to it. In Tubianas description of prehension, prehensile grip is determined by the thumbs ability to abduct and oppose [30]. Historically, options to restore an opposing post on the ulnar side of the hand have included prosthesis, phalangization of the fth metacarpal, and bone grafting and ap reconstruction. Before the era of microsurgery and free tissue transfer, thumb reconstruction was accomplished with bone grafts under a sensate ap, distraction osteogenesis, pollicization of other ngers, or phalangization. As a result of advances in microsurgery and the pioneering work by Bunke [31], Cobbett [32], Morrison [33], and Wei [3436], the transfer of a toe to a hand has restored function in the face of nonreplantable or irreparable digits. More thorough assessments of function, including objective and subjective measures, have appeared in the literature over the last two decades. Gorsches review [37] of corn picker injuries sought to assess reconstruction and functional results by including the patients subjective evaluation of the usefulness of the injured extremity. A good result was dened by a useful grasp and pinch and independence from the opposite noninjured extremity. The analysis of the outcomes of the 15 patients in his series emphasized the importance of prehension in restoration of hand function. Prehension was accomplished through toe to hand transfers for thumb reconstruction and the creation of an ulnar post, allowing patients to grasp objects and use the hand at least as an assist extremity in daily activities. Weis series of 152 reconstructions of mutilated distal digits with foot tissue included 56 toe-tothumb transfers [38]. He reported a 98% success rate with the following results: sensory recovery ranging from 5 mm to 15 mm, average postoperative active range of motion of the PIP joint for ngers and IP joint for the thumb at 60% of preoperative value, no signicant cold intolerance,

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and minimal donor site morbidity. Successful functional use of the reconstructed digits in the patients activity of daily living was also reported, although the types and levels of activities were not specied.

Scoring systems As noted earlier, advances in trauma management, microsurgery, skeletal xation, soft tissue coverage, and antibiotics have salvaged severely injured extremities that would have been amputated in the past. Occasionally, however, one must justify the extensive reconstruction eorts to reect on the best functional interest of the patient. The impact of the injury on the patient can be devastating. The outcome of the initial salvage surgery and the complex reconstruction thereafter may be compromised by morbidity of multiple surgeries, long hospitalizations, and family and work issues. All of the factors may also aect patient compliance. As techniques in reconstruction after a mutilating extremity injury were developing, a variety of scoring systems for injured extremities emerged in the trauma literature [3942]. The goals for each of these systems were to establish guidelines for the treatment of mangled extremities and, depending on injury severity, to provide surgeon and patient with some idea of the prognosis of a functional outcome. In an attempt to use objective measures as predictive indices, several scoring systems have been developed to identify those limbs that are salvageable. These scoring systems include the Mangled Extremity Syndrome Index (MESI) [39], the Predictive Salvage Index (PSI) [40], the Limb Salvage Index (LSI) [42], and the Mangled Extremity Severity Score (MESS) [41]. The MESS is a lower extremity scoring system that was developed to discriminate between salvageable and unsalvageable limbs. The MESS scoring system is based on skeletal/soft-tissue injury, limb ischemia, shock, and patient age [41]. Unfortunately, this system, as is true of many others of its kind, does not address the potential functional outcome of the upper extremity following the initial injury and the subsequent secondary reconstruction. Reconstructive eorts can restore some or most of the function of the hand to a much greater degree than lower extremity reconstruction can restore the function of the foot, ankle, and leg. Whereas a prosthesis is extremely functional in the

lower extremity, native functional sensate tissue is irreplaceable in the hand. The mere existence of a multitude of scoring systems provides support for one of their common criticisms: there are not universally accepted criteria for what should be measured. Although the quality of skin, muscle, bone, and ischemia are variables in all of these scoring systems, vessel injury is addressed in the MESI, PSI, and LSI, whereas nerve injury is included in the MESI and LSI. Other factors such as shock, age, and mechanism of injury are components of the MESI and MESS. An overall injury score, the ISS, and comorbid conditions are also included in the MESI score. In the application of these measures, some limitations have become apparent. All measures were developed for trauma of the lower extremity, not the upper extremity. The practical use of these scoring systems and the retrospective data from which they were derived also has been questioned. In a retrospective application of the MESI, MESS, PSI, and LSI, Bonanni found no predictive usefulness in any of these indices for dierentiating patients who would benet with amputation from patients whose limb should be salvaged [43]. A similar nding was reported by Durham in his retrospective scoring of upper and lower extremity injuries with the MESI, MESS, PSI, and LSI [44]. Because no dierences in scoring were seen between patients with good and poor functional outcomes, they concluded that none of the scoring systems were reliable predictors of functional outcome. Slaughterback, however, did nd the MESS to be an accurate predictor of amputation of the severely injured upper extremity in his retrospective application to 43 severely injured limbs, but conceded that the surgeons clinical judgment should be the main factor in deciding on amputation or salvage of an injured extremity [45]. Campbell and Kay presented a scoring system exclusively for the hand with the introduction of the Hand Injury Severity Score (HISS) [46]. Four grades of increasing severity of hand injury are described, based on separate anatomic components: integument, skeletal, motor, and neural. Each ray is examined separately and is assigned a weighted factor, based on functional importance, for calculation of the nal score. Open fractures and contaminated wounds increase the nal score. Although the HISS is only a descriptive system that has no bearing on prognosis, it does provide a score at the time of injury that can be

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used in conjunction with functional assessments and long-term outcome studies to guide therapy in the acute stage and in rehabilitation. Shortly after the appearance of the HISS emerged, another scoring system specic to the hand, the Hand Function Score (HFS), was developed by Watts, Greenstock, and Cole [47]. Unlike previous scoring systems, the HFS is a subjective assessment based on activities of daily living that is used to plan and monitor progress in rehabilitation after hand trauma. The HFS consists of 25 commonly performed activities focusing on clothing, cleansing, and feeding oneself. Each activity is assigned a score from 1 (easy) to 4 (impossible) by the patient, and a total score is obtained by adding the score for each of the 25 activities. The assessment is done at the time of presentation and again at the end of a rehabilitation program to provide a score for comparison of subjective functional outcome following therapy. The creators of the HFS propose using the score in conjunction with more objective measures to assess a patients progress through rehabilitation. Outcomes research The eld of outcomes research has developed as providers of care have come to recognize the importance of studying eectiveness of treatment in ways that are most meaningful and relevant to the patient. It is no longer good enough to implement a treatment plan without considering the long-term clinical outcome. With the ongoing debate on how best to allocate nancial resources in this environment of cost-consciousness, the outcome of a procedure must be shown to be of signicant benet to the patient, in restoration of function, patient satisfaction, and return to a productive lifestyle. Recent literature has emphasized the need for assessing outcome using validated and reliable patient questionnaires so that meaningful conclusions can be drawn regarding treatment and outcome [48,49]. Evidence that supports a treatment method versus no treatment or another method is of interest to patient, surgeon, hospital, and third-party payers. Acknowledgment of the need for evidence-based studies to evaluate outcomes following treatment is being seen in all areas of surgery. In the near future, surgeons may have to bear more of the responsibility in demonstrating that their procedures are benecial to the patient with regard to functional outcome and costs.

Objective assessment Methods to assess hand function in an objective manner following injury and treatment are well established in the literature. Active and passive ranges of motion are measured using the goniometer. Grip strength is measured with the Jamar dynamometer [50] and sensation threshold is assessed with either Von Frey hairs [51] or Semmes-Weinstein monolaments [52], or with a two-point discriminator. Imaging studies, such as plain radiographs, CT scans, MRI, and bone scans, can oer a more complete assessment. The literature of mutilating hand injuries has used these measurement tools to study the outcomes with general agreement and acceptance on how data is obtained from each of these measures. Objective tests found to be within an accepted value, however, may not portray the patients ability to perform their activities of daily living or work. Although objective measurement represents a signicant factor in assessing outcome after hand injuries, it must be viewed within the context of the restoration of a functional hand and whether that goal has been achieved. There is no agreement, however, on standards, appropriate measures, or instrument tools to assess more subjective data, such as relief from pain, patient satisfaction, quality of life, restoration of daily activities, and return to meaningful work. Subjective measures have been criticized in the past because of variability in patient response and attitudes, lack of reliability, and diculty in validating these measures. It is precisely this data, however, that represents the outcomes that are often the most relevant to the patient. Despite the challenge of incorporating subjective data in measuring outcome, hand surgeons must address those issues that are most important to patients if they are to be able to provide the most costecient care of the highest quality. Even if there is acknowledgment that subjective data is important in measuring outcome, developing an appropriate measurement instrument is a complex and demanding task. In discussing the choice of the most appropriate subjective measurement tool, Keller noted, The instruments must reliably measure the clinical factors of interest, change over time, and outcomes that are important to patients [53]. Although never validated, the Upper Extremity Function Test (UEFT), originally developed by Carroll [54] for patients with neurologic disease or rheumatoid arthritis, has been used to evaluate

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subjectively patient satisfaction and function after upper extremity trauma and treatment. The UEFT provides a score based on 33 separate everyday activities, including pinch, grasp, stability, strength, and coarse and ne movement, and represents one of the rst attempts at a standardized subjective evaluation of extremity function. Russell et al [9] and Graham et al [5] have used Carrolls UEFT to assess outcome following upper extremity replantation and revascularization. Each of these studies recognized the importance of including patients subjective assessment of their condition and did not rely solely on limb viability or a measured value to determine the functional outcome. In response to criticism that subjective questionnaires are unreliable, inconsistent, and unscientic, the eld of outcomes research, or evidence-based medicine, has recently established criteria that should be upheld by subjective questionnaires so that the data acquired can be used to draw meaningful conclusions on outcomes. As outlined by Amadio, these criteria include: validity, responsiveness, reliability, internal consistency, and sensitivity [48]. Validity refers to how reasonable it is to expect that a questionnaire is measuring what it is supposed to be measuring and how accurate it is in this measurement. Responsiveness denes whether a questionnaire is able to detect a signicant dierence before and after a treatment. Reliability means a questionnaire results in the same answer from one administration of the questionnaire to another. Internal consistency refers to questions that hang together, moving in the same direction and reinforcing each other. Sensitivity of a questionnaire is determined by how nely graded are the dierences that can be measured. Increasing the range of possible answers with more questions increases the questionnaires sensitivity [48]. If a questionnaire meets these rigorous criteria, more meaningful conclusions can be made regarding outcome and comparison of treatments from this data than from results from a nonvalidated questionnaire. Questionnaires have evolved from ones assessing overall general health, such as the Short Form 36 (SF-36) [55], which addresses the entire spectrum of physical, mental, and social wellbeing for the whole person, to more specic instruments focusing on the upper extremity, such as the DASH [56], or on the hand, such as the Michigan Hand Questionnaire [57]. The DASH (Disabilities of the Arm, Shoulder, and

Hand) represents a multidisciplinary eort to develop a clinically useful outcome measure for the upper extremity based on previously tested questionnaires. The DASH consists of 30 questions, narrowed down from 800, and asks patients to rate their ability to perform everyday tasks and the severity of their symptoms. The DASH also has additional modules for sports, music, and heavier work activities. It has been shown to be a reliable and valid instrument to assess functional outcome and has been used to evaluate a variety of shoulder, elbow, wrist, and hand problems [56]. The Michigan Hand Questionnaire (MHQ) is another recently developed measurement tool that is composed of questions in six separate categories: overall hand function, hand-related activities of daily living, pain, work performance, aesthetics, and patient satisfaction with hand function. The MHQ has been shown to be reliable, consistent, valid, and responsive to change over time [57]. Validated disease-specic measures also exist for carpal tunnel syndrome [58] and wrist problems [59]. These more specic instruments may better assess functional outcome for that specic disease than a generic health questionnaire such as the SF-36, or a region-specic instrument such as the DASH or MHQ. A subjective questionnaire specic to mutilating hand injuries, however, does not exist at the present time. Each of these scoring systems, however, does not address the ability to predict the amount of function that would return after the initial injury. Ideally, one would require a scoring system that permits the surgeon to evaluate the mangled hand for each of its lost or impaired structures, dictate the subsequent line of treatment, be it replantation, reconstruction, transplantation, or amputation, and predict the ultimate function following these series of procedures and rehabilitation. At what point is a toe transfer better than salvaging a nger or thumb? Does the nal outcome change if severely traumatized digits are salvaged, only to be amputated at a later date? Is the outcome aected by early amputation and digit transplants rather than delayed procedures? Unfortunately, there are too many variables that come into play that aect the nal functional outcome in any scenario. Intrinsic factors, such as swelling, scarring, pain, and poor healing, obstruct progress at each step of therapy. Extrinsic factors, such as the patients age, motivation, expectations, comorbid health condition, expenses, and coping mechanisms may alter the nal outcome also.

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Summary The functional outcome of a mutilating hand injury cannot be fully assessed at the time of injury alone. The measure of functional outcome must incorporate the evaluation and severity of the initial injury and the subsequent reconstructive surgeries. The complexity of the hand deserves no less. Restoration of prehensile function is the top priority in reconstruction following mutilating hand injuries, and assessment of outcome should address this goal. Flaps and specialized tissue grafts can restore architecture and balance in the hand. One can reconstruct a thumb and ngers with the big toe and smaller toes to give a functional sensate grip. The assessment of functional outcome should include not only objective measures but also subjective questionnaires that focus on issues most relevant to the patient. The use of questionnaires that have been shown to be valid, reliable, consistent, responsive, and sensitive allows the most meaningful conclusions about and comparisons between treatments. Perhaps because of the unique challenges presented by mutilating hand injuries, a new instrument, specic to mutilating hand injury, may provide the most benecial information to guide treatment and assess outcome. References
[1] Burkhalter WE. Mutilating injuries of the hand. Hand Clin 1986;2:4568. [2] American Replantation Mission to China. Replantation surgery in China. Plast Reconstr Surg 1973;52:47689. [3] Brown HC, Williams HB, Woodhouse FM. Principles of salvage in mutilating hand injuries. J Trauma 1968;8:31832. [4] Peacock K, Tsai TM. Comparison of functional results of replantation versus prosthesis in a patient with bilateral arm amputation. Clin Orthop Rel Res 1987;214:15359. [5] Graham B, Adkins P, Tsai TM, et al. Major replantation versus revision amputation and prosthetic tting in the upper extremity: a late functional outcomes study. J Hand Surg Am 1998;23:78391. [6] Midgley RD, Entin MA. Management of mutilating injuries of the hand. Clin Plast Surg 1976;3:99109. [7] Wang SH, Young KF, Wei JN. Replantation of severed limbsclinical analysis of 91 cases. J Hand Surg 1981;6:311. [8] Fitzgerald RH, Cooney WP, Washington JA, et al. Bacterial colonization of mutilating hand injuries and its treatment. J Hand Surg 1977;2:85.

[9] Russell RC, OBrien BM, Morrison WA, et al. The late functional results of upper limb revascularization and replantation. J Hand Surg Am 1984;9: 62333. [10] Ipsen T, Lundkvisk L, Barfred T, et al. Principles of evaluation and results in microsurgical treatment of major limb amputations. Stand J Plast Reconstr Hand Surg 1990;24:75. [11] Kleinert HE, Jablon M, Tsai TM. An overview of replantation and results of 347 replants in 245 patients. J Trauma 1998;20:390. [12] Meyer VE. Hand amputations proximal but close to the wrist joint: prime candidates for reattachment (long-term functional results). J Hand Surg 1985; 10:989. [13] Patradul A, Ngarmukos C, Parkpain V. Major limb replantation: a Thai experience. Ann Acad Med Singapore 1995;24:82. [14] Tropea BI, Lee RC. Thermal injury kinetics in electrical trauma. J Biomech Engr May 1992;114: 24150. [15] Lee RC, et al. Role of cell membrane rupture in the pathogenesis of electrical trauma. J Jur Res 1988; 44:67082. [16] Chen W, Lee RC. Evidence for electric shockinduced conformational damage electrical injury: a multidisciplinary approach to therapy, prevention, and rehabilitation. Proc NY Acad Sci 1994. [17] Waikakul S, Vanadurongwan V, Unnanuntana A. Prognostic factors for major limb re-implantation at both immediate and long-term follow-up. J Bone Joint Surg Br 1998;80:1024. [18] Wood MB, Cooney WP. Above elbow limb replantation: functional results. J Hand Surg Am 1986;11:6827. [19] Van Beek AL, Omer Jr GE, Landis GL. Reconstruction of the replanted upper arm. In: Management of peripheral nerve problems. 2nd edition. Philadelphia: WB Saunders; 1998. p. 70616. [20] Baek SM, Kim SS. Successful digital replantation after 42 hours of warm ischemia. J Reconstr Microsurg 1992;9:455. [21] Daigle JP, Kleinert JM. Major limb replantation in children. Microsurg 1991;12:221. [22] Ireland ML, Taleisnik J. Nonunion of metacarpal extraarticular fractures in children: report of two cases and review of the literature. J Pediatr Orthop 1986;6(3):3525. [23] Tamai S, Michon J, Tupper J, et al. Report of subcommittee on replantation. J Hand Surg 1983; 8:730. [24] Chen CW. Extremity replantation. World J Surg 1978;2:513. [25] Chen ZW, Meyer VE, Kleinert HE, et al. Present indications and contraindications for replantation as reected by long-term functional results. Orthop Clin N Am 1981;12:849.

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R.A. Bueno, M.W. Neumeister / Hand Clin 19 (2003) 193204 [43] Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring of mangled lower extremities. J Trauma 1993;34:99103. [44] Durham RM, Mistry BM, Mazuski JE, et al. Outcome and utility of scoring systems in the management of the mangled extremity. Am J Surg 1996;172:56974. [45] Slaughterback JR, Britten C, Moneim MS, et al. Mangled extremity severity score: an accurate guide to treatment of the severely injured upper extremity. J Orthop Trauma 1994;8:28285. [46] Campbell DA, Kay PJ. The hand injury severity scoring system. J Hand Surg 1996;21:29598. [47] Watts AM, Greenstock M, Cole RP. Outcome following the rehabilitation of hand trauma patients. The importance of a subjective functional assessment. J Hand Surg Br 1998;23:48589. [48] Amadio PC. Outcome assessment in hand surgery and hand therapy: an update. J Hand Ther 2001; 14:637. [49] Szabo RM. Outcomes assessment in hand surgery: when are they meaningful? J Hand Surg Am 2001;26:9931002. [50] Bechtal CO. Grip test: the use of a dynamometer with adjustable handle spacings. J Bone Joint Surg Am 1954;36:82024. [51] Levin LS, Pearsall G, Runderman RJ. Von Freyss method of measuring pressure sensibility in the hand: an engineering analysis of the WeinsteinSemmes pressure aesthesiometer. J Hand Surg Am 1978;3:21116. [52] Semmes J, Weinstein S, Ghent L, Teuber HL. Somato-sensory changes after penetrating brain wounds in man. Cambridge: Harvard University Press; 1960. [53] Keller RB. Measuring outcomes. J Orthop Res 1996;14:1712. [54] Carroll D. A quantitative test of upper extremity function. J Chronic Dis 1965;18:47991. [55] Ware JE, Snow KK, Kosinski M, et al. SF-36 health survey: manual and interpretation guide. Boston: The Health Institute; 1993. [56] Hudak PL, Amadio PC, Bombardier C, et al. Development of an upper extremity health status instrument. Am J Ind Med 1996;29:6028. [57] Chung KC, Pillsbury MS, Walters MR, et al. Reliability and validity testing of the Michigan Hand Outcomes Questionnaire. J Hand Surg Am 1998;23:57587. [58] Levine DW, Simmons BP, Koris MJ, et al. A selfadministered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg Am 1993; 75:158592. [59] MacDermid JC, Turgeon T, Richards RS, et al. Patient rating of wrist pain and disability: a reliable and valid instrument tool. J Orthop Trauma 1998;12:57786.

[26] Tamai S. Twenty years experience of limb replantation. Review of 293 upper extremity replants. J Hand Surg Am 1982;7:54956. [27] Chen CW, Yun-Qing Q, Zhong-Jia Y, and the Research Laboratory for Replantation of Severed Limbs. Extremity replantation. World J Surg 1978;2:51324. [28] Kleinert HE, Jablon M, Tsai TM. An overview of replantation and results of 347 replants in 245 patients. J Trauma 1980;20:39098. [29] 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 Am 1981;6:31928. [30] Tubiana R, Stack HG, Hakstian RW. Restoration of prehension after severe mutilations of the hand. J Bone Joint Surg Br 1966;48:45573. [31] Buncke HJ, Buncke CM, Schultz WP. Immediate Nicoladani procedure in the rhesus monkey, or hallux-to-hand transplantation, utilizing microvascular anastamoses. Br J Plast Surg 1966;19:33237. [32] 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 1969;51:67780. [33] Morrison WA, OBrien BM, McLeod AM. Thumb reconstruction with a free neurovascular wraparound ap from the big toe. J Hand Surg Am 1980;5:575. [34] Wei FC, Chen HC, Chuang CC, et al. Microsurgical thumb reconstruction with toe transfer: selection of the various techniques. Plast Reconstr Surg 1992;93:345. [35] Wei FC, Chen HC, Chuang CC, et al. Simultaneous multiple toe transfers in hand reconstruction. Plast Reconstr Surg 1988;81:36677. [36] Wei FC, Epstein D, Chen HC, et al. Microsurgical reconstruction of distal digits following mutilating hand injuries: results in 121 patients. Br J Plast Surg 1993;46:1816. [37] Gorsche TS, Wood MB. Mutilating corn-picker injuries of the hand. J Hand Surg Am 1988;13: 42327. [38] Wei FC, Colony LH, Chen HC, et al. Combined second and third toe transfer. Plast Reconstr Surg 1989;84:65161. [39] Gregory RT, Gould RJ, Peclet M, et al. The mangled extremity syndrome (M.E.S.): a severity grading system for multisystem injury of the extremity. J Trauma 1985;25:114750. [40] Howe RH, Poole GV, Jansen KJ, et al. Salvage of lower extremities following combined orthopedic and vascular trauma. Am Surg 1987;53:2058. [41] Johansen KJ, Daines M, Howey T, et al. Objective criteria accurately predicts amputation following lower extremity trauma. J Trauma 1990;30:56872. [42] Russell WL, Sailors DM, Whittle TB, et al. Limb salvage versus traumatic amputation. Ann Surg 1991;213:47380.

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Index
Note: Page numbers of article titles are in boldface type.

A
Amputation(s), adaptation following, 185186 biomechanical impact of, 1924 cause for, 185 elective, length and, 185 guillotine-type, functional outcome following, 197, 198 in fractures of mutilated hand, 54 Antibiotics, choice of, for mutilating hand injuries, 3637 for prophylaxis in surgery, 33 in extremity trauma, 23, 3436 side eects of, 37 Antimicrobials, in management of mutilating injuries, 3339 topical, irrigation with, 36

loss of, 2324 motion of, improvement following mutilating injuries, 156157 salvaging of, in mutilating injuries, 6, 13

E
Edema, control of, after mutilating injuries of hand, 137 Electric hand, for myoelectric prosthesis, 188, 189190, 191 Electric hook, on wrist level disarticulation prosthesis, 187, 189, 190 Emergency room, management of mutilated hand in, 51 Exercise(s), protective motion, following replantation in mutilating injuries, 143145

B
Blood vessels, repair of, following mutilating injuries of hand, 56, 89, 135 used as spare parts in mutilating injuries, 79, 8385 Bone(s), healing of, following mutilating injuries of hand, 135136 secondary procedures on, in mutilating injuries, 150, 151 used as spare parts in mutilating injuries, 79, 8385

F
Finger(s), as composite tissue transfer in mutilating injuries, 79, 85 for use in mutilating injuries, 75 fusion of, 2425 index, importance of, 22 ray, elective loss of, 2223 individual, functional contribution of, 1 long and ring, central ray deletion in, 23 multiple, amputation of, toe transplantation for, 169171, 173 multiple replantation of, in mutilated hand, 102, 109111 passive prosthesis for, 180181 permanent impairment of, evaluation of, 2 reconstruction of, toe-to-hand transplantation for, 169171, 172 single, amputation of, toe transplantation for, 169, 172 small, exion by, 23 Finger llet ap, lengthening of, 76 Fingertip, cap composite graft, in mutilating injuries, 74, 7578

C
Child(ren), hand injuries in, types of, 121 mutilating injuries in, 1, 2, 4647, 121132 passive hand prostheses for, 186 Cross hand transfer, for replantation in mutilating injuries, 103

D
Desensitization, to treat scar hypersensitivity, 138 Digit(s). See also Finger(s); Thumb. fusion of, biomechanical of, 2426

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Foot (Foot), surgical anatomy of, toe-to-hand transplantation and, 167 Forearm, hand and, as source of reusable parts in mutilating injuries, 8081, 8586 Fracture(s), complex, in mutilated hand, 53 in mutilated hand, amputation in, 54 cases illustrating, 5457, 58, 59 management of, 5, 78, 52 rehabilitation following, 5759 repair and reconstruction in, 5354 treatment of, and revascularization in, 52 in mutilating injuries of hand, rehabilitation following, 138140 simple, in mutilated hand, 5253 Free aps, in mutilating hand injuries, 142143

Ischemia, in mutilating injuries, functional outcome and, 198

J
Joints, secondary procedures on, in mutilating injuries, 156159 stiness of, treatment following mutilating injuries, 140, 141 used as spare parts in mutilating injuries, 79, 8385

L
Limb, survival of, and limb function, 195196

M
Malunion/nonunion, in mutilating injuries, secondary procedures in, 150, 151 Mutilating injuries, antimicrobial management of, 3339 bacteriology of, 3334 bones, tendons, nerves, vessels, and joints used in, 79, 8385 cap composite tip graft in, 74, 7578 complex, management of, 69, 1013, 14 crush, outcomes after, 196 debridement and irrigation in, 45 electrical, outcomes after, 196, 197 emergency room management of, 51 etiology of, 51, 63 nger as composite tissue transfer in, 79, 85 nger for use in, 75 fracture xation in. See Fracture(s), in mutilated hand. hand and forearm as source of reusable parts in, 8081, 8586 healthy adjustment of, promotion of, 4344 history taking in, 13 in children, 1, 2, 4647, 121132 delayed treatment of, 128130, 131 initial management and preoperative evaluation in, 121124 operative procedure in, 124125 replantation and revascularization in, 125126 soft tissue coverage in, 126131 initial surgery of, 52 injury-related issues in, 4142 limb of hand salvage in, factors inuencing, 194195 management of, and principles of, 115 factors inuencing, 63 immediate, 1, 2, 3, 45

G
Grasp, power, 18, 19 span, 18, 19 Grip, directional, 18 hook, 18, 19

H
Hand, and forearm, as source of reusable parts in mutilating injuries, 8081, 8586 cross transfer of, for replantation in mutilating injuries, 103 electric, for myoelectric prosthesis, 188, 189190, 191 essentials for, 17 injuries of, in children, types of, 121 metacarpal, reconstruction of, toe transplantation in, 171, 174 mutilating injuries of. See Mutilating injuries. partial, passive prosthesis for, 180181 prehension of, 17 prostheses for. See Prosthesis(es). replants from, for replantation in mutilating injuries, 103, 113, 114 seven basic maneuvers of, 1718 trauma to, biomechanics and, 1731 classication of, 19 Hook, electric, on wrist level disarticulation prosthesis, 187, 189, 190

I
Infection, as cause of loss of salvaged limb, 196 Injuries, mutilating. See Mutilating injuries.

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reconstructive algorithms in, 6365 outcomes after, 193204 age as inuence on, 198 assessment of, 199 clinical outcomes, 195200 factors inuencing, 193, 196197 goals of, 195 objective assessment of, 201202 outcomes research on, 201 salvage of function and, 193, 194 scoring systems for, 200201 treatment views and, 195 outcomes in, 51 pain in, 4546 patient evaluation in, 7375 perionychium for reconstruction in, 75, 7880 physical examination in, 34 principles of, and management of, 115 psychological aspects of, 4149 psychological intervention strategies in, 4445 psychological responses to, 4243 rehabilitation process for, 133 replantation in. See Replantation, in mutilated hand. secondary procedures following, 149163 early care inuencing, 150 involving nerves, 155156 on bone, 150, 151 on joints and tendons, 156159 on soft tissue, 151152 on thumb, 159161 requirements for hand function and, 13, 150 to release scar, 152155 skin harvesting in, 7678, 8083 soft tissue coverage in. See Soft tissue coverage, in mutilating injuries. special issues in, 4547 stabilization of patient in, 1 therapy following, 133148 early phase(protective), 133134 healing process and, 134136 intermediate phase(mobilization), 134 late phase(strengthening), 134 use of spare parts in, 7387

secondary procedures on, in mutilating injuries, 155156 used as spare parts in mutilating injuries, 79, 8385 Neuroma, management of, following mutilating injuries, 156

O
Osteomyelitis, following mutilating injuries, 150151 Osteosynthesis, in replantation in mutilated hand, 96, 98

P
Pain, in mutilating injuries, 4546 Pedicle aps, in mutilating hand injuries, 142 Perionychium, reconstruction of, in mutilating injuries, 75, 7880 Phalanx, proximal, passive prosthesis for, 183 Pinch, key, 18 oppositional, 1718 precision, 17 Position tolerance, gravity-dependent, after mutilating injuries of hand, 137 Prosthesis(es), active, 13, 185191 patient acceptance of, 186188 fabrication of, 187, 189, 190 exible silicone sleeve of, 189, 191 passive, 177183 candidates for, 177, 178 distal phalanx, 183 nger, 183 for child, 186 goals and expectations for, 13, 177178, 179 master plan for treatment using, 179 middle phalanx, 183 new material and technology for, 180 partial hand, 180181 proximal phalanx, 183 thumb for, 181183 types of, 179183 suspension on limb, 189, 190191 transcarpal level, with electric hand, 188, 189190, 191 voluntary closing grasping device on, 190, 191 wrist level disarticulation, electric hook on, 187, 189, 190 with semi-exible inner socket, 188, 191

N
Nerve(s), delayed repair of, following mutilating injuries, 5, 9, 155156 healing of, following mutilating injuries of hand, 135 protection of, following mutilating injuries of hand, 137138

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R
Rehabilitation, following fractures in mutilated hand, 5759 following mutilating injuries, 133, 138141, 142 following toe-to-hand transplantation, 171172 Replantation, in mutilated hand, 89119 care of amputed part for, 91, 94 debridement and labeling for, 9294, 96 hand replants in, 103, 113, 114 history of, 89, 90, 91, 92 indications for, 8991, 92, 93 issues in, 47 multiple nger replantation for, 102, 109111 operative considerations for, 92100, 101, 102, 103, 104 osteosynthesis techniques for, 96, 98 outcomes following, 107, 199 postoperative care following, 103105 preoperative considerations for, 9192, 94, 95 protective motion exercises following, 143145 repair of volar structures for, 98100, 101, 104, 105 special considerations for, 100107 tendon repair for, 98, 99, 100 thumb replants for, 100102, 105109 upper extremity replants for, 102103, 111112

Soft tissue coverage, in mutilating injuries, 6371 assessments for, 4, 67 cases illustrating, 6769, 70 distant aps for, 6566 free aps for, 6667 in children, 126131 local aps for, 65 regional aps for, 65 of mutilating injuries, 142143 Splints, traction, in fractures in mutilating injuries, 138, 140 Supercialis tendon, for reconstruction of thumb, 21

T
Tendon(s), extensor, injuries of, 27 exor, loss of function of, 28 healing of, following mutilating injuries of hand, 135 loss of, and hand function, 2628 repair of, for replantation in mutilated hand, 98, 99, 100 secondary procedures on, in mutilating injuries, 156159 secondary reconstruction of, following mutilating injuries, 159 used as spare parts in mutilating injuries, 9, 79, 8385 Tenolysis, following mutilating injuries, 157159 Thumb, for passive prosthesis, 181183 functional importance of, 1, 1920 level ve injuries of, 2122 level four injuries of, 21 level three injuries of, 2021 reconstruction of, priorities of, 20 toe-to-hand transplantation for, 167 replants for, in mutilated hand, 100102, 105109 secondary reconstruction of, in mutilating injuries, 159161 Toe-to-hand transplantation, 165175, 194 for nger reconstruction, 169171, 172 for thumb reconstruction, 167 great toe wraparound ap, 168 harvesting of toe for, 166 in mutilating injuries, motion program following, 145146 insetting of transplants in, 167 intraoperative and postoperative complications of, 172174 late complications of, 174175

S
Scar, management of, after mutilating injuries of hand, 137 palmar contracture, following crush injury, management of, 153156 release of, in mutilating injuries, 152155 web contracture, following crush injury, management of, 152, 153, 154 Skin, harvesting of, in mutilating injuries, 7678, 8083 therapy of, following mutilating injuries of hand, 134135 Skin aps, for reconstruction of mutilated hand, 6567 Soft tissue, damage to, in mutilating injuries, 197 secondary procedures on, in mutilating injuries, 151152

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postoperative management for, 171 preparation for, 165 recipient site preparation for, 166167 rehabilitation following, 171172 second toe transplantation for, 168169, 171 surgical anatomy of foot and, 166 timing of, 165 total great toe transplantation in, 167 trimmed great toe transplantation in, 167168

mutilating injuries of, use of spare parts in, 7387 trauma to, antibiotics in, 3436 side eects of, 37

W
Wound care, after mutilating injuries of hand, 136137 Wrist, functional motion of, requirements for, 25 fusion of, 2526 limited fusions of, 2526

U
Upper extremity(ies), mutilated, replantation in, replants for, 102103, 111112