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Experience of a hand surgery service
EXPERIENCE
OF A H A N D
SURGERY SERVICE
By DOUGLAS A. CAMPBELL REID, M.B., F.R.C.S.
Royal Infirmary, Derby THE object of this article is an attempt to define the scope o f hand surgery as practised at a specialised centre. It is based on experience gained during the fifteen-month period, August 1954 to October 1955, in the Derby H a n d Surgery Service. We feel that such a service is o f a unique character in this country, since it embraces the treatment o f all hand cases from an area totalling nearly half a million inhabitants. It will be generally agreed that the hand provides a sphere of surgery where the plastic and orthopmdic specialties overlap and there has been a tendency in the past for the plastic surgeon to deal with the skin problems and the orthopmdic surgeon with the bones and joints, the tendons being shared. In many hand problems, however, all these components may be involved and therefore become inseparable. It stands to reason that for anyone to tackle a complex hand problem efficiently he must be able to deal with the hand as a whole, not just one aspect. We hope that what follows may prove o f some interest and also o f some value. ORGANISATION
Regarding acute trauma, there can be no doubt as to the need for an organised Hand Service. This applies particularly to the industrial areas like Derby. In and around Derby there is highly concentrated industry--heavy and light engineering, coal mining and textiles, as well as agriculture in the surrounding rural district. All the trauma for the area is dealt with at one centre and comes under the Accident Service. This means that all hand injuries are automatically directed to the one hospital where the H a n d Service forms part o f the accident unit. All major hand injuries are admitted to this unit and dealt with by the same team. T h e less severe cases, those not requiring admission, are either dealt with by the casualty officers, who work in conjunction with the hand team in the management o f these injuries, or referred direct to the H a n d Clinic (Table I). Here there is an independent theatre unit available for the treatment o f these cases. T h i s means that delay in the treatment o f such cases is avoided. TABLE I Fifteen-month Period, August I954 to October I955 Minor hand cases requiring surgery Cases presenting with skin loss Septic hands requiring surgery Major hand injuries requiring admission Cases presenting with skin loss
595 I32 959 68 35
It is interesting to note that almost one-quarter of the minor cases presented with skin loss, whilst more than half of the major ones did so. II
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BRITISH JOURNAL OF PLASTIC SURGERY
It will be seen that there is a close liaison between the H a n d Service and the Casualty Department, a link which is absolutely essential if these cases are to receive the best and most efficient treatment. T h e casualty officers are instructed in the basic elements of atraumatic technique and in the straightforward methods
FIG. I Photographic record of standard position of hands.
of skin replacement by means of free grafts. T h e y are not encouraged, however, to undertake the more exacting repairs using flaps. A series of lectures with slides and films is given from time to time to the residents, all of whom undertake their turn in casualty at nights and week-ends. This covers the various aspects of hand surgery. Twenty beds are available in the service for the treatment of cold cases. Most of these are at Harlow Wood Hospital. New cases are seen at the H a n d Clinics
EXPERIENCE
OF
A HAND
SURGERY
SERVICE
13
and the acute traumatic ones followed up (Table II). The Hand Clinic is part of the Accident and Orthopaedic Out-Patient Department, which is a selfcontained unit. It contains consulting rooms, cubicles, dressing facilities, plaster room, X-ray department, and theatre unit already referred to. To facilitate photographic records we use the method suggested by Joseph Boyes. This simply involves having a duplicated set of numbered photographs of the hand in standard positions (Fig. I). One set is kept in the Hand Clinic and the other in the Photographic Department. We have then only to order the required positions according to the appropriate numbers. TABLE II Fifteen-month Period, August 1954 to October 1955 N u m b e r of " cold " hand operations
335
Ten-month Period, January to October 1955 Attendances at weekly hand clinic .
2,218
Attendances include only those at the main weekly H a n d Clinic. Subsidiary clinics are not included in these figures.
Finally, in the organisation septic hands are treated primarily by the casualty officers in their own department, but again under the supervision of the Hand Service. THE
SCOPE OF A H A N D SERVICE
i. Acute T r a u m a . - - ( a ) Management of Skin Loss.--Efficient immediate skin cover must be the aim in all hand injuries presenting with loss of skin. This applies equally to the cases of major degloving and to the avulsed finger tip. It is obvious that the major hand injuries must inevitably be attended by a prolonged period of incapacity, but it is not generally recognised that digital injuries associated with skin loss, unless treated early and adequately, can be the cause of prolonged disability and loss to industry. Major degloving accidents of the upper limb do present a tremendous challenge to us. The necessity for immediate total skin cover in these cases cannot be stressed too much. This may have to be a combined flap and free graft replacement in the total circumferential type. A patient (Fig. 2) caught his left arm in the belt of a machine and sustained total degloving from the base of the hand to the middle third of the arm. This was treated by an immediate abdominal flap to cover the forearm tendons, all of which were exposed, and by split-skin grafts to the rest. The patient has since returned to work with very reasonable function in the hand and arm as shown. It is useless stitching back large flaps of skin based distally. We do not favour using the avulsed skin as a free graft but prefer to apply fresh split-skin provided the case lends itself to free graft replacement. If there is associated damage to tendons, bones, or joints, these injuries may be repaired at the same time as appropriate skin cover is provided. In a typical
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recent case a patient caught his right ring finger in a machine and sustained a compound dislocation of the terminal interphalangeal joint, division of the extensor tendon, and skin loss over the dorsum of the middle and terminal interphalangeal ioints of the finger. The dislocation was reduced and held temporarily by means of a Kirschner wire driven across the joint surfaces, the
A
B
FIG. 2 A, Post-operative condition showing flap replacement of forearm and free grafts covering rest of area. Note degree of extension at elbow joint. B, T h i s demonstrates the satisfactory range of flexion achieved. C, Shows function in the hand. T h e patient has a very reasonable grip and is able to work with the hand.
extensor tendon was repaired, and immediate skin cover provided by means of an infraclavicular flap. The flap was divided three weeks later, the Kirschner wire removed, and the patient regained good function in the finger. Finger-tip Avulsions.--In our opinion the thenar flap is the method of choice for the repair of the avulsed finger tip involving moderate loss of pulp and bone. It is reasonable that where there has been loss of skin and subcutaneous tissue (pulp) both these elements should be replaced, that is, by a flap. The alternative is to use a full-thickness graft. We recently reviewed the results in fifty cases of
EXPERIENCE
OF
A HAND
SURGERY
SERVICE
15
free grafts for this injury. The average disability time was between seven and eight weeks. These repairs were largely undertaken by the casualty officers, but the results agree closely with other recently reported series (Robins, I954 ; Barclay, I955). Sensation returned in varying degrees. The majority in this series regained only crude sensation. Thenar flap repair provides skin of the right texture containing numerous
FIG. 3 A, Flaps in position. First dressing at t e n days. Note Wolfe graft r e p l a c e m e n t of defect on ring finger. T h e edge o f the graft on t h e t h e n a r defect is just visible. B a n d C, C o n d i t i o n three m o n t h s later. N o t e satisfactory appearance of donor area on ring finger. T h e nail b e d of t h e m i d d l e finger would be better r e m o v e d b u t the patient preferred to keep t h e nail r e m n a n t .
A
B
C
tactile end organs, so ensuring a satisfactory sensory reinnervation. This is particularly valuable to the skilled craftsman. We divide the flap at two weeks. The average disability period in the last fifteen consecutive cases was just under five weeks. Cross-finger flaps are also useful in finger-tip or thumb-tip avulsions. Their particular value is in covering defects on the volar aspect of the fingers when the flexor tendons are exposed. It is important that the donor area should not encroach beyond the mid-lateral line and we cover the donor site with a full-thickness
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graft. Sometimes cross-finger and thenar flaps may be combined in the same case for the repair of multiple injuries. One patient, a keen amateur pianist, sustained traumatic amputation of the middle and ring fingers through the terminal phalanges, the middle through the proximal third, and the ring through the distal third. It was most important to preserve length in his case, and the fingers were repaired as shown (Fig. 3)- We feel that the cross-arm or cross-forearm flaps have a definite place in the repair of acute injuries, for example in more extensive or multiple injuries of the digits. Recently we have had two cases of degloving of the terminal phalanx, the bone being intact with normal flexor and extensor action. These have been repaired immediately by tubing a small flap on the opposite forearm (Fig. 4). By taking the flap from the volar aspect, the hand lies comfortably, and one is able to place the seam at the back of the finger. This is not easy to achieve with a chest flap. When still more extensive flaps or multiple ones are required, then the chest must be used, or failing that the abdomen. There is a place for immediate digital reconstruction following traumatic loss, particularly in the case of the thumb and index finger. If the amputated digit has been preserved it is a feasible proposition to regraft it, using the Gillies method (Gillies, 194o; Gillies and Reid, I955), provided the conditions are suitable--that is, clean-cut amputation without disorganisation of the amputated portion. In loss of the thumb where the avulsed portion has not been preserved, immediate reconstruction may be undertaken by tubing a flap on the chest wall and attaching one end to the thumb stump as a primary procedure. A bone graft may also be inserted at this stage or subsequently. This procedure has been described elsewhere (Reid, 1956). (b) Tendon Injuries.--Extensor tendons are repaired primarily. No attempt is made to perform primary repair of severed flexor tendons in "no-man's-land " as recently advocated (Wakefield, 1955 i Bogdanov, 1955). At this level we still prefer to do a careful wound toilet ~lnd skin suture only and to undertake secondary repair of the tendon by a free tendon graft as soon as the wound is sound and the hand settled. Severed flexor tendons in the fingers distal to sublimis insertion, in the hand proximal to the distal crease, and at the wrist are repaired primarily provided the wound conditions are suitable. (c) Nerve Injuries.--We follow Seddon's teaching and repair nerves as a secondary measure with the possible exception of the digital nerves in a clean incised wound. (d) Injuries to Bones.--We cannot stress too strongly the value of internal fixation for phalangeal and certain metacarpal fractures. This may be by means of a Kirschner wire or intramedullary peg bone graft. The case shown (Fig. 5) demonstrates particularly well the value of this principle. This was a severe crush injury of the hand with gross disorganisation of the skeletal structure. The first essential in reconstructing such a hand is to obtain a stable bony framework on which the hand may be built up. This was achieved by Kirschner wires as shown, the soft tissues being repaired by means of an abdominal flap. (e) Burns.--On the whole we have tended to treat these cases by exposure, with very satisfactory results. We do not consider that the period of limited function necessary while the coagulum is forming and while it separates or is excised prejudices the subsequent result. The hands naturally assume the position
EXPERIENCE
J
OF
A HAND
B
C
FIG. 4 Initial condition. Cross-forearm flap repair, Post-operative appearance. Demonstrates full flexion at terminal interphalangeal joint. E, Radiological appearance three months later.
IB
SERVICE
A
A
A, B, C, D,
SURGERY
D
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FIG. 5 A, Initial condition. The ring finger was non-viable and had to be amputated. The extensor tendons to the remaining fingers were avulsed. B, Initial radiological appearance demonstrating complete disorganisation. C, Fixation of fractures with Kirschner wires. D and E, Subsequent condition demonstrating reasonable grip. The extensor tendons have been replaced by grafts. Subsequently capsulectomies were undertaken on the metacarpophalangeal joints and increased their range of flexion. A
B
D
E
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o f function. Exposure treatment is, of course, contraindicated in the circumferentiaI type of burn because of the danger of tourniquet effect by the eschar. There is a place for the primary excision if there is undoubted full-thickness loss. This may well involve the immediate application of a flap, but the chances of regaining reasonable function subsequently are more promising. Granulating surfaces are treated pre-operatively with a 5 per cent. solution of chloramphenicol in propylene glycol, which is also applied immediately prior to grafting. This solution controls wound infections effectively (Flint et al., 1952) and enhances the successful take of a graft. 2. Cold S u r g e r y . - - S o m e twenty beds are available in the Hand Service for cold cases---corrective operations for contractures, tendon grafts and transplants, reconstructive procedures for congenital abnormalities, excision of tumours, etc. Dupuytren's Contracture.--We use the standard radical fasciectomy and, when the fingers are involved, deal with them by the M c l n d o e method. We have occasionally found it necessary to replace skin shortage as a primary procedure. The local dorsal flap described by Bruner (I949), whilst extremely useful, is not always adequate. We have found, then, that the cross-forearm flap is the method of choice. Some dislike this method because of the nursing difficulties but, in our opinion, it has an invaluable place in certain instances, as demonstrated by the following cases : - CASE REPORTS
Case L--This was a medical student aged 24 with a five years' history of bilateral Dupuytren's contracmre. The hands had previously been operated on, and when first seen by us he had severe contracmres of both the little fingers. In the left hand there was an associated congenital contracture of this finger and we advised amputation. The little finger of the right hand was flexed into the palm and there was a fixed flexion contracture at the metacarpo-phalangeal and the proximal interphalangeal joints of almost 9o degrees. The skin here was also badly involved and scarred from the previous operation. Radical fasciectomy was undertaken in the usual way and the little finger released. Some of the badly involved skin at the base of the finger had to be removed with the fascia. This enabled the finger to be brought out into full extension but left a considerable skin defect overlying bare tendon and digital nerves. This was covered with a cross-forearm flap (Fig. 6, A) which was divided three weeks later. Within six weeks he had regained virtually full function (Fig. 6, B and c). Case 2.--A middle-aged docker was treated by us for a severe bilateral Dupuytren's contracture involving ring and little fingers of both hands. He underwent the standard fasciectomy which included opening the affected fingers of both hands by the Z-plasty method. The right hand proved entirely satisfactory, but he developed a recurrent contraction in the ring finger of his left hand within three months. The proximal interphalangeal joint was flexed to 90 degrees. We decided to reopen this finger and proceeded to a capsulectomy of the proximal interphalangeal joint. Full extension was then possible, but a skin defect was left over the proximal segment of the finger. This was covered with a cross-forearm bridge flap (Fig. 7). This type of flap we find particularly valuable for comparatively narrow volar defects on the digits. Its double blood supply increases its safety and one can divide either end at staged intervals.
Tendon Grafts.--The tendon work at this centre is familiar to you all, and so I intend to make only a few points. During a visit to the Sahlgrenska Hospital
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in GSteborg last August I had the good fortune to spend the time there with my host Erik Moberg in the company of Littler, Wakefield, and Tubiana. What struck me more than anything was that a comparison of results at the various Hand Centres represented tended to show that minor variations in technique were
A
B
C FXG. 6 A, Replacement of the skin defect by means of a cross-forearm flap. B and C, Post-operative condition demonstrating function six weeks later.
unimportant. It seemed to matter little whether one used silk or stainless-steel wire, whether one approached the theca behind or in front of the digital nerve, or whether one made the proximal or distal junction first. Provided basic principles are the same, it is the meticulous performance, the atraumatic technique, and the careful h~emostasis that really count. Tenolysis.--There is a definite place for this procedure in selected cases. It
EXPERIENCE
OF
A
HAND
SURGERY
SERVICE
2I
must be radical and meticulous, the tendon or graft being exposed throughout its length. We have now combined tenolysis with post-operative cortisone in six cases. This would appear to be the ideal indication for using cortisone in this sphere. We know it delays healing, but after tenolysis there is no risk of tendon rupture. We feel that the results in these six cases have been appreciably better than in cases in which tenolysis alone has been employed. Obviously one can gain only impressions from such a limited experience, but it would appear to merit further trial. We have started cortisone systemically on the fourth or fifth postoperative day, but it would probably be better to start even earlier. One hundred milligrams in divided doses are given in the first twenty-four hours and gradually reduced to 5o mg. by the fifth day. This is then continued up to ten days and then gradually tailed off. Thumb Reconstruction.-Pollicisation by the neurovascular pedicle method as perfected by Fro. 7 Littler of New York (Littler, 1953) Repair by cross-forearm bridge flap. appears to us to be the most attractive method of thumb reconstruction, although we have had little personal experience of the method. It is particularly indicated, of course, when there is associated partial loss of the index finger and a thumb metacarpal remnant is present together with the thenar muscle group. It is justifiable, in experienced hands, to pollicise a normal index finger when the thumb and first metacarpal are missing entirely. In this case the second metacarpal should be shortened, otherwise the pollicised finger is too long. The Gillies cocked hat or thumbstall lengthening of the thumb is an excellent operation in suitable cases. We have used it with success to lengthen an existing thumb metacarpal left as a result of traumatic loss of the thumb or where there is absence due to congenital abnormality. Good sensation is ensured as the median supply to the palmar aspect is left intact. The increased webbing which results from this procedure may subsequently be corrected by means of a Z-plasty. The tubed pedicle and bone graft is also a useful method of thumb reconstruction. The main disadvantage is the lack of sensation in the transplanted skin. We prefer to use the chest as the donor area, since this offers skin of a better texture than the abdomen. The upper subcutaneous surface of the ulna provides a ready site for the bone graft. One advantage of this repair is that it may be used for the immediate reconstruction of the thumb as has been already described. Finally, pedo-carpal transfer may have a limited place in thumb reconstruction. Bones andJoints.--There is a place for the internal fixation of certain fractures of the phalanges and metacarpals, for example in unstable transverse fractures.
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FIG. 8
A~ Typical transverse fracture of metacarpal. B, Fashioning the cortical graft using file and anvil. C, D, and E, Insertion of the graft. It is important to insert it as far proximally as possible first. The distal metacarpal fragment is then levered over the graft into position and the two fragments are approximated.
A
B
D
C
E
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An intramedullary peg bone graft provides the most certain method of secure fixation and rapid union. A typical case is shown in which this method was used (Fig. 8). The alternative is Kirschner wire fixation. This method we usually use for holding the bone ends when arthrodesing one of the finger joints. Here again a peg bone graft may also be used, and it will lead to a more rapid consolidation of the arthrodesed joint. Capsulectomy.--This is a useful procedure for the metacarpo-phalangeal joints which have become stiff in extension, provided X-ray shows a satisfactory joint. The collateral ligaments, which may be exposed through a dorso-lateral incision on either side or alternatively through an incision splitting the extensor expansion longitudinally, must be resected completely. The metacarpo-phalangeal joints are then immobilised in flexion for four weeks followed by six weeks' elastic traction. We have had very reasonable results in selected cases. Tumours.--In a hand service one encounters a wide variety of tumours of soft tissues and FIG. 8 F bones alike. Two typical illustrative examples Two weeks later. Note callus are shown. Fig. 9 shows an extensive papilloma already forming. of the skin of the fifth finger which was treated by radical excision and replacement with a full-thickness graft. This is the type of condition that might readily undergo malignant change. Fig. ic
FIG. 9 A Initial appearance.
FIG. 9 B After excision and Wolfe graft replacement.
FIG. IO Typical epithelioma.
depicts an epithelioma of the left thumb in an elderly man which had bee.~ present for eight years.
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Septic Hands.raThe management of the septic hand is a most important surgical problem, yet it is frequently left to the junior casualty officers. We feel that these cases should be supervised by the Hand Service. After all, the same principles of exposure apply in septic hand surgery as in the other aspects of hand surgery. The casualty officers treat most of these cases, but they are instructed in the principles of surgical exposure. Stress is laid upon early and adequate drainage with a bloodless field. The value of these points is demonstrated
A
B FIG. I I Demonstrates range of movement regained in middle finger following early treatment for suppurative tenosynovitis.
by the following case. This was a case of suppurative tenosynovitis treated by early and adequate exposure of the tendon sheath via a mid-lateral incision throughout the length of the finger. The sheath was opened in its entire length and purulent fluid evacuated. The incision was immediately sutured and full systemic antibiotics given. The patient subsequently regained very reasonable function (Fig. I I). I am most grateful to Mr R. Guy Pulvertaft for his helpful criticism and advice, and also for taking a number of the photographs. I wish also to thank Dr K. P. Veliskakis for the drawings and Mr J. S. Fayers for much of the photographic work. REFERENCES BARCLAY, T. L. (1955). Brit..7. plast. Surg., 8, 38. BOGDANOV, R. F. (1955). Brit. med.,7., I, 1315. BRUNER, J. M. (1949). Plast. reconstr. Surg., 4, 559FLINT, M. H., GILLIES, H. D., and REID, D. A. C. (1952). Lancet, I, 541. GILLIES, H. D. (194o). Lancet, I, lOO2. GILLIES, H. D., and REID, D. A. C. (1955). Brit..7. plast. Surg., 7, 338. LITTLER, J. W. (1953). Plast. reconstr. Surg., x2, 3o3. REID, D. A. C. (1956). Transactions of the lmernational Society of Plastic Surgeons. (In press.) ROBINS, R. H. C. (1954)- Brit. `7. Surg., 41, 515 • .~, WAKEFIELD, A. R. (1955). Personal communication.
OF A H A N D
SURGERY SERVICE
By DOUGLAS A. CAMPBELL REID, M.B., F.R.C.S.
Royal Infirmary, Derby THE object of this article is an attempt to define the scope o f hand surgery as practised at a specialised centre. It is based on experience gained during the fifteen-month period, August 1954 to October 1955, in the Derby H a n d Surgery Service. We feel that such a service is o f a unique character in this country, since it embraces the treatment o f all hand cases from an area totalling nearly half a million inhabitants. It will be generally agreed that the hand provides a sphere of surgery where the plastic and orthopmdic specialties overlap and there has been a tendency in the past for the plastic surgeon to deal with the skin problems and the orthopmdic surgeon with the bones and joints, the tendons being shared. In many hand problems, however, all these components may be involved and therefore become inseparable. It stands to reason that for anyone to tackle a complex hand problem efficiently he must be able to deal with the hand as a whole, not just one aspect. We hope that what follows may prove o f some interest and also o f some value. ORGANISATION
Regarding acute trauma, there can be no doubt as to the need for an organised Hand Service. This applies particularly to the industrial areas like Derby. In and around Derby there is highly concentrated industry--heavy and light engineering, coal mining and textiles, as well as agriculture in the surrounding rural district. All the trauma for the area is dealt with at one centre and comes under the Accident Service. This means that all hand injuries are automatically directed to the one hospital where the H a n d Service forms part o f the accident unit. All major hand injuries are admitted to this unit and dealt with by the same team. T h e less severe cases, those not requiring admission, are either dealt with by the casualty officers, who work in conjunction with the hand team in the management o f these injuries, or referred direct to the H a n d Clinic (Table I). Here there is an independent theatre unit available for the treatment o f these cases. T h i s means that delay in the treatment o f such cases is avoided. TABLE I Fifteen-month Period, August I954 to October I955 Minor hand cases requiring surgery Cases presenting with skin loss Septic hands requiring surgery Major hand injuries requiring admission Cases presenting with skin loss
595 I32 959 68 35
It is interesting to note that almost one-quarter of the minor cases presented with skin loss, whilst more than half of the major ones did so. II
3[2
BRITISH JOURNAL OF PLASTIC SURGERY
It will be seen that there is a close liaison between the H a n d Service and the Casualty Department, a link which is absolutely essential if these cases are to receive the best and most efficient treatment. T h e casualty officers are instructed in the basic elements of atraumatic technique and in the straightforward methods
FIG. I Photographic record of standard position of hands.
of skin replacement by means of free grafts. T h e y are not encouraged, however, to undertake the more exacting repairs using flaps. A series of lectures with slides and films is given from time to time to the residents, all of whom undertake their turn in casualty at nights and week-ends. This covers the various aspects of hand surgery. Twenty beds are available in the service for the treatment of cold cases. Most of these are at Harlow Wood Hospital. New cases are seen at the H a n d Clinics
EXPERIENCE
OF
A HAND
SURGERY
SERVICE
13
and the acute traumatic ones followed up (Table II). The Hand Clinic is part of the Accident and Orthopaedic Out-Patient Department, which is a selfcontained unit. It contains consulting rooms, cubicles, dressing facilities, plaster room, X-ray department, and theatre unit already referred to. To facilitate photographic records we use the method suggested by Joseph Boyes. This simply involves having a duplicated set of numbered photographs of the hand in standard positions (Fig. I). One set is kept in the Hand Clinic and the other in the Photographic Department. We have then only to order the required positions according to the appropriate numbers. TABLE II Fifteen-month Period, August 1954 to October 1955 N u m b e r of " cold " hand operations
335
Ten-month Period, January to October 1955 Attendances at weekly hand clinic .
2,218
Attendances include only those at the main weekly H a n d Clinic. Subsidiary clinics are not included in these figures.
Finally, in the organisation septic hands are treated primarily by the casualty officers in their own department, but again under the supervision of the Hand Service. THE
SCOPE OF A H A N D SERVICE
i. Acute T r a u m a . - - ( a ) Management of Skin Loss.--Efficient immediate skin cover must be the aim in all hand injuries presenting with loss of skin. This applies equally to the cases of major degloving and to the avulsed finger tip. It is obvious that the major hand injuries must inevitably be attended by a prolonged period of incapacity, but it is not generally recognised that digital injuries associated with skin loss, unless treated early and adequately, can be the cause of prolonged disability and loss to industry. Major degloving accidents of the upper limb do present a tremendous challenge to us. The necessity for immediate total skin cover in these cases cannot be stressed too much. This may have to be a combined flap and free graft replacement in the total circumferential type. A patient (Fig. 2) caught his left arm in the belt of a machine and sustained total degloving from the base of the hand to the middle third of the arm. This was treated by an immediate abdominal flap to cover the forearm tendons, all of which were exposed, and by split-skin grafts to the rest. The patient has since returned to work with very reasonable function in the hand and arm as shown. It is useless stitching back large flaps of skin based distally. We do not favour using the avulsed skin as a free graft but prefer to apply fresh split-skin provided the case lends itself to free graft replacement. If there is associated damage to tendons, bones, or joints, these injuries may be repaired at the same time as appropriate skin cover is provided. In a typical
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SURGERY
recent case a patient caught his right ring finger in a machine and sustained a compound dislocation of the terminal interphalangeal joint, division of the extensor tendon, and skin loss over the dorsum of the middle and terminal interphalangeal ioints of the finger. The dislocation was reduced and held temporarily by means of a Kirschner wire driven across the joint surfaces, the
A
B
FIG. 2 A, Post-operative condition showing flap replacement of forearm and free grafts covering rest of area. Note degree of extension at elbow joint. B, T h i s demonstrates the satisfactory range of flexion achieved. C, Shows function in the hand. T h e patient has a very reasonable grip and is able to work with the hand.
extensor tendon was repaired, and immediate skin cover provided by means of an infraclavicular flap. The flap was divided three weeks later, the Kirschner wire removed, and the patient regained good function in the finger. Finger-tip Avulsions.--In our opinion the thenar flap is the method of choice for the repair of the avulsed finger tip involving moderate loss of pulp and bone. It is reasonable that where there has been loss of skin and subcutaneous tissue (pulp) both these elements should be replaced, that is, by a flap. The alternative is to use a full-thickness graft. We recently reviewed the results in fifty cases of
EXPERIENCE
OF
A HAND
SURGERY
SERVICE
15
free grafts for this injury. The average disability time was between seven and eight weeks. These repairs were largely undertaken by the casualty officers, but the results agree closely with other recently reported series (Robins, I954 ; Barclay, I955). Sensation returned in varying degrees. The majority in this series regained only crude sensation. Thenar flap repair provides skin of the right texture containing numerous
FIG. 3 A, Flaps in position. First dressing at t e n days. Note Wolfe graft r e p l a c e m e n t of defect on ring finger. T h e edge o f the graft on t h e t h e n a r defect is just visible. B a n d C, C o n d i t i o n three m o n t h s later. N o t e satisfactory appearance of donor area on ring finger. T h e nail b e d of t h e m i d d l e finger would be better r e m o v e d b u t the patient preferred to keep t h e nail r e m n a n t .
A
B
C
tactile end organs, so ensuring a satisfactory sensory reinnervation. This is particularly valuable to the skilled craftsman. We divide the flap at two weeks. The average disability period in the last fifteen consecutive cases was just under five weeks. Cross-finger flaps are also useful in finger-tip or thumb-tip avulsions. Their particular value is in covering defects on the volar aspect of the fingers when the flexor tendons are exposed. It is important that the donor area should not encroach beyond the mid-lateral line and we cover the donor site with a full-thickness
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graft. Sometimes cross-finger and thenar flaps may be combined in the same case for the repair of multiple injuries. One patient, a keen amateur pianist, sustained traumatic amputation of the middle and ring fingers through the terminal phalanges, the middle through the proximal third, and the ring through the distal third. It was most important to preserve length in his case, and the fingers were repaired as shown (Fig. 3)- We feel that the cross-arm or cross-forearm flaps have a definite place in the repair of acute injuries, for example in more extensive or multiple injuries of the digits. Recently we have had two cases of degloving of the terminal phalanx, the bone being intact with normal flexor and extensor action. These have been repaired immediately by tubing a small flap on the opposite forearm (Fig. 4). By taking the flap from the volar aspect, the hand lies comfortably, and one is able to place the seam at the back of the finger. This is not easy to achieve with a chest flap. When still more extensive flaps or multiple ones are required, then the chest must be used, or failing that the abdomen. There is a place for immediate digital reconstruction following traumatic loss, particularly in the case of the thumb and index finger. If the amputated digit has been preserved it is a feasible proposition to regraft it, using the Gillies method (Gillies, 194o; Gillies and Reid, I955), provided the conditions are suitable--that is, clean-cut amputation without disorganisation of the amputated portion. In loss of the thumb where the avulsed portion has not been preserved, immediate reconstruction may be undertaken by tubing a flap on the chest wall and attaching one end to the thumb stump as a primary procedure. A bone graft may also be inserted at this stage or subsequently. This procedure has been described elsewhere (Reid, 1956). (b) Tendon Injuries.--Extensor tendons are repaired primarily. No attempt is made to perform primary repair of severed flexor tendons in "no-man's-land " as recently advocated (Wakefield, 1955 i Bogdanov, 1955). At this level we still prefer to do a careful wound toilet ~lnd skin suture only and to undertake secondary repair of the tendon by a free tendon graft as soon as the wound is sound and the hand settled. Severed flexor tendons in the fingers distal to sublimis insertion, in the hand proximal to the distal crease, and at the wrist are repaired primarily provided the wound conditions are suitable. (c) Nerve Injuries.--We follow Seddon's teaching and repair nerves as a secondary measure with the possible exception of the digital nerves in a clean incised wound. (d) Injuries to Bones.--We cannot stress too strongly the value of internal fixation for phalangeal and certain metacarpal fractures. This may be by means of a Kirschner wire or intramedullary peg bone graft. The case shown (Fig. 5) demonstrates particularly well the value of this principle. This was a severe crush injury of the hand with gross disorganisation of the skeletal structure. The first essential in reconstructing such a hand is to obtain a stable bony framework on which the hand may be built up. This was achieved by Kirschner wires as shown, the soft tissues being repaired by means of an abdominal flap. (e) Burns.--On the whole we have tended to treat these cases by exposure, with very satisfactory results. We do not consider that the period of limited function necessary while the coagulum is forming and while it separates or is excised prejudices the subsequent result. The hands naturally assume the position
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FIG. 4 Initial condition. Cross-forearm flap repair, Post-operative appearance. Demonstrates full flexion at terminal interphalangeal joint. E, Radiological appearance three months later.
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FIG. 5 A, Initial condition. The ring finger was non-viable and had to be amputated. The extensor tendons to the remaining fingers were avulsed. B, Initial radiological appearance demonstrating complete disorganisation. C, Fixation of fractures with Kirschner wires. D and E, Subsequent condition demonstrating reasonable grip. The extensor tendons have been replaced by grafts. Subsequently capsulectomies were undertaken on the metacarpophalangeal joints and increased their range of flexion. A
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o f function. Exposure treatment is, of course, contraindicated in the circumferentiaI type of burn because of the danger of tourniquet effect by the eschar. There is a place for the primary excision if there is undoubted full-thickness loss. This may well involve the immediate application of a flap, but the chances of regaining reasonable function subsequently are more promising. Granulating surfaces are treated pre-operatively with a 5 per cent. solution of chloramphenicol in propylene glycol, which is also applied immediately prior to grafting. This solution controls wound infections effectively (Flint et al., 1952) and enhances the successful take of a graft. 2. Cold S u r g e r y . - - S o m e twenty beds are available in the Hand Service for cold cases---corrective operations for contractures, tendon grafts and transplants, reconstructive procedures for congenital abnormalities, excision of tumours, etc. Dupuytren's Contracture.--We use the standard radical fasciectomy and, when the fingers are involved, deal with them by the M c l n d o e method. We have occasionally found it necessary to replace skin shortage as a primary procedure. The local dorsal flap described by Bruner (I949), whilst extremely useful, is not always adequate. We have found, then, that the cross-forearm flap is the method of choice. Some dislike this method because of the nursing difficulties but, in our opinion, it has an invaluable place in certain instances, as demonstrated by the following cases : - CASE REPORTS
Case L--This was a medical student aged 24 with a five years' history of bilateral Dupuytren's contracmre. The hands had previously been operated on, and when first seen by us he had severe contracmres of both the little fingers. In the left hand there was an associated congenital contracture of this finger and we advised amputation. The little finger of the right hand was flexed into the palm and there was a fixed flexion contracture at the metacarpo-phalangeal and the proximal interphalangeal joints of almost 9o degrees. The skin here was also badly involved and scarred from the previous operation. Radical fasciectomy was undertaken in the usual way and the little finger released. Some of the badly involved skin at the base of the finger had to be removed with the fascia. This enabled the finger to be brought out into full extension but left a considerable skin defect overlying bare tendon and digital nerves. This was covered with a cross-forearm flap (Fig. 6, A) which was divided three weeks later. Within six weeks he had regained virtually full function (Fig. 6, B and c). Case 2.--A middle-aged docker was treated by us for a severe bilateral Dupuytren's contracture involving ring and little fingers of both hands. He underwent the standard fasciectomy which included opening the affected fingers of both hands by the Z-plasty method. The right hand proved entirely satisfactory, but he developed a recurrent contraction in the ring finger of his left hand within three months. The proximal interphalangeal joint was flexed to 90 degrees. We decided to reopen this finger and proceeded to a capsulectomy of the proximal interphalangeal joint. Full extension was then possible, but a skin defect was left over the proximal segment of the finger. This was covered with a cross-forearm bridge flap (Fig. 7). This type of flap we find particularly valuable for comparatively narrow volar defects on the digits. Its double blood supply increases its safety and one can divide either end at staged intervals.
Tendon Grafts.--The tendon work at this centre is familiar to you all, and so I intend to make only a few points. During a visit to the Sahlgrenska Hospital
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in GSteborg last August I had the good fortune to spend the time there with my host Erik Moberg in the company of Littler, Wakefield, and Tubiana. What struck me more than anything was that a comparison of results at the various Hand Centres represented tended to show that minor variations in technique were
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unimportant. It seemed to matter little whether one used silk or stainless-steel wire, whether one approached the theca behind or in front of the digital nerve, or whether one made the proximal or distal junction first. Provided basic principles are the same, it is the meticulous performance, the atraumatic technique, and the careful h~emostasis that really count. Tenolysis.--There is a definite place for this procedure in selected cases. It
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must be radical and meticulous, the tendon or graft being exposed throughout its length. We have now combined tenolysis with post-operative cortisone in six cases. This would appear to be the ideal indication for using cortisone in this sphere. We know it delays healing, but after tenolysis there is no risk of tendon rupture. We feel that the results in these six cases have been appreciably better than in cases in which tenolysis alone has been employed. Obviously one can gain only impressions from such a limited experience, but it would appear to merit further trial. We have started cortisone systemically on the fourth or fifth postoperative day, but it would probably be better to start even earlier. One hundred milligrams in divided doses are given in the first twenty-four hours and gradually reduced to 5o mg. by the fifth day. This is then continued up to ten days and then gradually tailed off. Thumb Reconstruction.-Pollicisation by the neurovascular pedicle method as perfected by Fro. 7 Littler of New York (Littler, 1953) Repair by cross-forearm bridge flap. appears to us to be the most attractive method of thumb reconstruction, although we have had little personal experience of the method. It is particularly indicated, of course, when there is associated partial loss of the index finger and a thumb metacarpal remnant is present together with the thenar muscle group. It is justifiable, in experienced hands, to pollicise a normal index finger when the thumb and first metacarpal are missing entirely. In this case the second metacarpal should be shortened, otherwise the pollicised finger is too long. The Gillies cocked hat or thumbstall lengthening of the thumb is an excellent operation in suitable cases. We have used it with success to lengthen an existing thumb metacarpal left as a result of traumatic loss of the thumb or where there is absence due to congenital abnormality. Good sensation is ensured as the median supply to the palmar aspect is left intact. The increased webbing which results from this procedure may subsequently be corrected by means of a Z-plasty. The tubed pedicle and bone graft is also a useful method of thumb reconstruction. The main disadvantage is the lack of sensation in the transplanted skin. We prefer to use the chest as the donor area, since this offers skin of a better texture than the abdomen. The upper subcutaneous surface of the ulna provides a ready site for the bone graft. One advantage of this repair is that it may be used for the immediate reconstruction of the thumb as has been already described. Finally, pedo-carpal transfer may have a limited place in thumb reconstruction. Bones andJoints.--There is a place for the internal fixation of certain fractures of the phalanges and metacarpals, for example in unstable transverse fractures.
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FIG. 8
A~ Typical transverse fracture of metacarpal. B, Fashioning the cortical graft using file and anvil. C, D, and E, Insertion of the graft. It is important to insert it as far proximally as possible first. The distal metacarpal fragment is then levered over the graft into position and the two fragments are approximated.
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An intramedullary peg bone graft provides the most certain method of secure fixation and rapid union. A typical case is shown in which this method was used (Fig. 8). The alternative is Kirschner wire fixation. This method we usually use for holding the bone ends when arthrodesing one of the finger joints. Here again a peg bone graft may also be used, and it will lead to a more rapid consolidation of the arthrodesed joint. Capsulectomy.--This is a useful procedure for the metacarpo-phalangeal joints which have become stiff in extension, provided X-ray shows a satisfactory joint. The collateral ligaments, which may be exposed through a dorso-lateral incision on either side or alternatively through an incision splitting the extensor expansion longitudinally, must be resected completely. The metacarpo-phalangeal joints are then immobilised in flexion for four weeks followed by six weeks' elastic traction. We have had very reasonable results in selected cases. Tumours.--In a hand service one encounters a wide variety of tumours of soft tissues and FIG. 8 F bones alike. Two typical illustrative examples Two weeks later. Note callus are shown. Fig. 9 shows an extensive papilloma already forming. of the skin of the fifth finger which was treated by radical excision and replacement with a full-thickness graft. This is the type of condition that might readily undergo malignant change. Fig. ic
FIG. 9 A Initial appearance.
FIG. 9 B After excision and Wolfe graft replacement.
FIG. IO Typical epithelioma.
depicts an epithelioma of the left thumb in an elderly man which had bee.~ present for eight years.
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Septic Hands.raThe management of the septic hand is a most important surgical problem, yet it is frequently left to the junior casualty officers. We feel that these cases should be supervised by the Hand Service. After all, the same principles of exposure apply in septic hand surgery as in the other aspects of hand surgery. The casualty officers treat most of these cases, but they are instructed in the principles of surgical exposure. Stress is laid upon early and adequate drainage with a bloodless field. The value of these points is demonstrated
A
B FIG. I I Demonstrates range of movement regained in middle finger following early treatment for suppurative tenosynovitis.
by the following case. This was a case of suppurative tenosynovitis treated by early and adequate exposure of the tendon sheath via a mid-lateral incision throughout the length of the finger. The sheath was opened in its entire length and purulent fluid evacuated. The incision was immediately sutured and full systemic antibiotics given. The patient subsequently regained very reasonable function (Fig. I I). I am most grateful to Mr R. Guy Pulvertaft for his helpful criticism and advice, and also for taking a number of the photographs. I wish also to thank Dr K. P. Veliskakis for the drawings and Mr J. S. Fayers for much of the photographic work. REFERENCES BARCLAY, T. L. (1955). Brit..7. plast. Surg., 8, 38. BOGDANOV, R. F. (1955). Brit. med.,7., I, 1315. BRUNER, J. M. (1949). Plast. reconstr. Surg., 4, 559FLINT, M. H., GILLIES, H. D., and REID, D. A. C. (1952). Lancet, I, 541. GILLIES, H. D. (194o). Lancet, I, lOO2. GILLIES, H. D., and REID, D. A. C. (1955). Brit..7. plast. Surg., 7, 338. LITTLER, J. W. (1953). Plast. reconstr. Surg., x2, 3o3. REID, D. A. C. (1956). Transactions of the lmernational Society of Plastic Surgeons. (In press.) ROBINS, R. H. C. (1954)- Brit. `7. Surg., 41, 515 • .~, WAKEFIELD, A. R. (1955). Personal communication.