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Explosion injuries of the hand
EXPLOSION
INJURIES
OF THE HAND
Spatial relationship and injury pattern P. HAHN, J. BREDERLAU, H. KRIMMER and U. LANZ
From the Bad Neustadt Hand Centre and the Anaesthesiology Clinic, University of Wiirzburg, Germany Twenty-six hands in 25 male patients were treated for peace-time explosion injuries of the palmar aspect. All patients were examined after a mean interval of 7 (1-17) years. In order to establish a regional pattern for each injury the palmar surface of the hand was divided in 21 fields. For each field a score depending on the extent of injury was calculated. Comparing this regional score with the spatial relation between hand and exploding object resulted in six typical patterns depending on the grip during explosion. With knowledge of the three-dimensional relation between the hand and exploding object, the hand surgeon is prepared for potential problems during operation. Journal of Hand Surgery (British and European Volume, 1996) 21B: 6:785-787
Explosion injuries are fortunately rare during peacetime. Nicolai and Twisk (1988) recorded 125 injuries per year caused by fireworks in the Netherlands. The central registration of Berufsgenossenschaft in Germany registered 312 injuries in 1989, which occurred during industrial work. Treatment of explosion injuries is very challenging. They involve all the structures of the hand, combining laceration, avulsion, blast, crush and burns. Mistakes made in the first operation are difficult to rectify in later operations, so it is important to be prepared for potential problems before the operation begins. There are different mechanism causing the injury. First of all the tissues are damaged by the pressure of the explosion. In addition, small particles are driven into the wound, causing damage and inflammation as well as thermal and chemical reactions. Different tissues show different reactions to the injury. Arteries, veins and nerves are more elastic than bone, so they may show no macroscopic laceration although their function may be affected. Bones are normally crushed by the force of the explosion. The extent of the damage depends on three factors: the explosive effect of the exploding object; the medium of transmission; and the distance between the exploding and damaged objects. The last is defined by the spatial relationship between the exploding object and the hand. By retrospective investigation of 26 injuries to the palmar surface of the hand, we tried to find out if a defined spatial relationship between the hand and the exploding object resulted in a specific pattern of injury.
tomical regions (Fig 1). For each field a score depending on the extent of injury was calculated (Table 1). The score for each field was summarized for all patients for a specific spatial relationship between the exploding object and hand. By dividing the sum by the maximum possible score, we could establish a regional pattern. RESULTS
Five different spatial relations, resulting in six typical injury patterns were found. Prehension grip
Holding the exploding object in prehension grip (13 patients) caused two different injuries, ulnar-sided (8 patients; Fig la) or radial-sided (5 patients; Fig lb). The object is fixed between the fingers and thenar or hypothenar eminences, resulting in laceration of either of these two prominent arcs of the hand. Injuries varying from superficial damage up to total loss of the border of the hand are possible. The third ray, responsible for stability of the longitudinal arc, was not damaged in any of these cases. Precision grip
In two cases the object was fixed between thumb and long finger, resulting in fracture of the bone of the terminal phalanges accompanied by loss of soft tissue. Maintenance of length and sensitivity required cover of bone and tendons by distants flaps (Fig lc).
PATIENTS AND METHODS Recoil
We examined 26 hands involved by explosion injury in peace-time in 25 male patients. The mean age at the time of injury was 23 (8-59) years, 12 being younger than 20 years. All patients who were treated by us came back for re-examination after a mean interval of 7 (range: 1-11) years after injury. In evaluating the regional injury pattern we divided the palmar surface of the hand into 21 fields, corresponding to distinct ana-
Only a small part of the exploding object recoils with the full exploding energy. The linear spread of the whole energy to a small area of the hand resulted in severe lacerations of arteries, nerves, tendons and bone in the palm in three patients. In addition, amputations of the index or long finger occurred, the latter destabilizing the central arc of the hand (Fig ld). 785
786
THE JOURNAL OF HAND SURGERY VOL. 21B No. 6 DECEMBER 1996
)nl)DIi[ilDiiiMii)i)iiiiiii mm <10 <20 <30 <40 <50
Fig 1
<60 <70 <80 <90 <=100
Pattern of injury. Scale represents relative extent of damage. 100% is score 4 (deep structures and bone damaged) for all patients of the group. (a) Prehension grip, ulnar type. (b) Prehension grip, radial type. (c) Precision grip. (d) Recoil. (e) Flat lying. (f) Distance. (g) Total pattern.
Table 1 - - S e v e r i t y score
Damage Superficial lesion Bone Deep palmar structures Bone and deep palmar structures
Distance injury Points 1 2 2 4
Flat lying When the exploding object lay on the fiat open palm there was only superficial damage of the palmar skin in four cases, because the energy of the exploding object tended to take the way of lowest resistance (Fig le).
These four injuries presented a homogeneous pattern, spreading over the whole palm (Fig lf). Three of them had slight lacerations of the dorsum of the hand. DISCUSSION According to Kleinert and Williams (1962) the first operation after blast injuries should conserve as much vital tissue as possible to get maximum function with a minimum of secondary operative procedures. Entin (1968) established the concept of the basic hand: "The basic hand is defined as a hand with a stable wrist, a radial digit with good sensation and mobility and at least one or two fingers on the ulnar aspect of the hand . . . " . The tissue
EXPLOSION INJURIES
must be strong enough to be capable of touching and holding. Achieving this aim in the first operation is of outstanding importance. Therefore it is important to get as much information about the damage as possible before beginning the operation. Except for the study of Arcari et al (1959) of 42 exploding injuries, there is little information on this topic. Kleinert and Williams (1962), Koehnlein and Seitz (1978), Melzer and Arlt (1990) and Nicolai and Twisk (1988) demonstrated the widespread pattern of exploding injuries presenting in individual cases. These studies showed that it is mainly young male subjects who suffer blast injuries. The cumulative pattern (Fig lg) supports the theory of Brown (1993) that the extent of trauma is not predictable. But if the spatial relation between hand and exploding object is taken into consideration we can distinguish five different patterns. Three of them are of special interest in predicting the reconstruction needed. In 13 of our cases the exploding object was held in a prehension grip (Fig ta and b). This leads to injuries of thenar or hypothenar rays without damage to the central ray. In contrast to McGregor and Jackson (1969), who reported six of eight cases with a radial injury, we found an ulnar injury in eight of 13 cases and a radial injury in five cases. Two of these radial injuries resulted in a laceration of the thenar muscle associated with dislocation of the CMC joint of the thumb, as described by both McGregor and Jackson (1969) and Geishauser et al (1990). One of our cases required primary pollicization of the amputated index finger because there was no thumb to replant. The more frequent ulnar injuries extended from superficial skin lesions to ulnar hemiamputations resulting in "a thumb without a hand". Salvaging of as much tissue as possible on the ulnar side is necessary to provide a powerful grip. In three of
787
our cases, pedicled or free flaps for wound coverage were necessary. The injury in prehension grip (Fig la and b) does not affect the central stabilizing part of the third ray. In contrast to this the recoil explosion resulted in deep lacerations of the second and third rays, destabilizing the central arc of the hand. Explosion during precision grip (Fig lc) required reconstructiori' of the sensory grip areas at the tips of the thumb and long finger. In all cases this could be achieved by local or distance pedicled flaps. Reconstruction of hands mutilated by explosions is challenging. The surgeon performing the first operation must be able to deal with bone and tendons as well as with nerves, arteries and veins. Either pedicled or free flap cover may be necessary. By assessing the spatial relationship between the hand and exploding object the surgeon may be prepared for potential problems. References A R C A R I F A, LARSEN R D and POSCH J L (1959). Injuries to the hand from homemade rockets. American Journal of Surgery, 97: 471-476. B R O W N P. Open injuries of the hand. In: D P Green (Ed.), Operative hand surgery, 3rd Edn. Churchill Livingstone, New York, 1993: 1533-1562. ENTIN M (1968). Salvaging the basic hand. Surgical Clinics of North America, 48: 1063-1081. G E I S H A U S E R M, SCHWARZ M and L O W K A K (1990). Das Verletzungsmuster bei Explosionsverletzungen der Hand. Hefte zur Unfallheilkunde, 212:327 328. K L E I N E R T H E and WILLIAMS D J (1962). Blast injuries of the hand. Journal of Trauma, 2 : 1 0 35. K O E H N L E I N H E and SEITZ H D (1978). Rekonstruktive Moeglichkeiten bei subtotaler Amputation beider Haende. Unfallheilkunde, 81:690 693. M c G R E G O R I A and J A C K S O N I T (1969). Sodium chlorate bomb injuries of the hand. British Journal of Plastic Surgery, 22: 16-29. MELZER B and ARLT N (1990). Schuss- und Explosionsverletzungen der Hand. Zentralblatt fuer Chirurgie, 115: 223-229. NICOLAI J and TWISK R V (1988). H a n d injuries by fireworks. Netherlands Journal of Surgery, 40: 160-162.
Received: 11 March 1996 Accepted after revision: 22 April 1996 Dr P. Hahn, Klinick fur Handctfirurgie, Salzburger Leite 1, 97616 Bad Neustadt, Germany.
INJURIES
OF THE HAND
Spatial relationship and injury pattern P. HAHN, J. BREDERLAU, H. KRIMMER and U. LANZ
From the Bad Neustadt Hand Centre and the Anaesthesiology Clinic, University of Wiirzburg, Germany Twenty-six hands in 25 male patients were treated for peace-time explosion injuries of the palmar aspect. All patients were examined after a mean interval of 7 (1-17) years. In order to establish a regional pattern for each injury the palmar surface of the hand was divided in 21 fields. For each field a score depending on the extent of injury was calculated. Comparing this regional score with the spatial relation between hand and exploding object resulted in six typical patterns depending on the grip during explosion. With knowledge of the three-dimensional relation between the hand and exploding object, the hand surgeon is prepared for potential problems during operation. Journal of Hand Surgery (British and European Volume, 1996) 21B: 6:785-787
Explosion injuries are fortunately rare during peacetime. Nicolai and Twisk (1988) recorded 125 injuries per year caused by fireworks in the Netherlands. The central registration of Berufsgenossenschaft in Germany registered 312 injuries in 1989, which occurred during industrial work. Treatment of explosion injuries is very challenging. They involve all the structures of the hand, combining laceration, avulsion, blast, crush and burns. Mistakes made in the first operation are difficult to rectify in later operations, so it is important to be prepared for potential problems before the operation begins. There are different mechanism causing the injury. First of all the tissues are damaged by the pressure of the explosion. In addition, small particles are driven into the wound, causing damage and inflammation as well as thermal and chemical reactions. Different tissues show different reactions to the injury. Arteries, veins and nerves are more elastic than bone, so they may show no macroscopic laceration although their function may be affected. Bones are normally crushed by the force of the explosion. The extent of the damage depends on three factors: the explosive effect of the exploding object; the medium of transmission; and the distance between the exploding and damaged objects. The last is defined by the spatial relationship between the exploding object and the hand. By retrospective investigation of 26 injuries to the palmar surface of the hand, we tried to find out if a defined spatial relationship between the hand and the exploding object resulted in a specific pattern of injury.
tomical regions (Fig 1). For each field a score depending on the extent of injury was calculated (Table 1). The score for each field was summarized for all patients for a specific spatial relationship between the exploding object and hand. By dividing the sum by the maximum possible score, we could establish a regional pattern. RESULTS
Five different spatial relations, resulting in six typical injury patterns were found. Prehension grip
Holding the exploding object in prehension grip (13 patients) caused two different injuries, ulnar-sided (8 patients; Fig la) or radial-sided (5 patients; Fig lb). The object is fixed between the fingers and thenar or hypothenar eminences, resulting in laceration of either of these two prominent arcs of the hand. Injuries varying from superficial damage up to total loss of the border of the hand are possible. The third ray, responsible for stability of the longitudinal arc, was not damaged in any of these cases. Precision grip
In two cases the object was fixed between thumb and long finger, resulting in fracture of the bone of the terminal phalanges accompanied by loss of soft tissue. Maintenance of length and sensitivity required cover of bone and tendons by distants flaps (Fig lc).
PATIENTS AND METHODS Recoil
We examined 26 hands involved by explosion injury in peace-time in 25 male patients. The mean age at the time of injury was 23 (8-59) years, 12 being younger than 20 years. All patients who were treated by us came back for re-examination after a mean interval of 7 (range: 1-11) years after injury. In evaluating the regional injury pattern we divided the palmar surface of the hand into 21 fields, corresponding to distinct ana-
Only a small part of the exploding object recoils with the full exploding energy. The linear spread of the whole energy to a small area of the hand resulted in severe lacerations of arteries, nerves, tendons and bone in the palm in three patients. In addition, amputations of the index or long finger occurred, the latter destabilizing the central arc of the hand (Fig ld). 785
786
THE JOURNAL OF HAND SURGERY VOL. 21B No. 6 DECEMBER 1996
)nl)DIi[ilDiiiMii)i)iiiiiii mm <10 <20 <30 <40 <50
Fig 1
<60 <70 <80 <90 <=100
Pattern of injury. Scale represents relative extent of damage. 100% is score 4 (deep structures and bone damaged) for all patients of the group. (a) Prehension grip, ulnar type. (b) Prehension grip, radial type. (c) Precision grip. (d) Recoil. (e) Flat lying. (f) Distance. (g) Total pattern.
Table 1 - - S e v e r i t y score
Damage Superficial lesion Bone Deep palmar structures Bone and deep palmar structures
Distance injury Points 1 2 2 4
Flat lying When the exploding object lay on the fiat open palm there was only superficial damage of the palmar skin in four cases, because the energy of the exploding object tended to take the way of lowest resistance (Fig le).
These four injuries presented a homogeneous pattern, spreading over the whole palm (Fig lf). Three of them had slight lacerations of the dorsum of the hand. DISCUSSION According to Kleinert and Williams (1962) the first operation after blast injuries should conserve as much vital tissue as possible to get maximum function with a minimum of secondary operative procedures. Entin (1968) established the concept of the basic hand: "The basic hand is defined as a hand with a stable wrist, a radial digit with good sensation and mobility and at least one or two fingers on the ulnar aspect of the hand . . . " . The tissue
EXPLOSION INJURIES
must be strong enough to be capable of touching and holding. Achieving this aim in the first operation is of outstanding importance. Therefore it is important to get as much information about the damage as possible before beginning the operation. Except for the study of Arcari et al (1959) of 42 exploding injuries, there is little information on this topic. Kleinert and Williams (1962), Koehnlein and Seitz (1978), Melzer and Arlt (1990) and Nicolai and Twisk (1988) demonstrated the widespread pattern of exploding injuries presenting in individual cases. These studies showed that it is mainly young male subjects who suffer blast injuries. The cumulative pattern (Fig lg) supports the theory of Brown (1993) that the extent of trauma is not predictable. But if the spatial relation between hand and exploding object is taken into consideration we can distinguish five different patterns. Three of them are of special interest in predicting the reconstruction needed. In 13 of our cases the exploding object was held in a prehension grip (Fig ta and b). This leads to injuries of thenar or hypothenar rays without damage to the central ray. In contrast to McGregor and Jackson (1969), who reported six of eight cases with a radial injury, we found an ulnar injury in eight of 13 cases and a radial injury in five cases. Two of these radial injuries resulted in a laceration of the thenar muscle associated with dislocation of the CMC joint of the thumb, as described by both McGregor and Jackson (1969) and Geishauser et al (1990). One of our cases required primary pollicization of the amputated index finger because there was no thumb to replant. The more frequent ulnar injuries extended from superficial skin lesions to ulnar hemiamputations resulting in "a thumb without a hand". Salvaging of as much tissue as possible on the ulnar side is necessary to provide a powerful grip. In three of
787
our cases, pedicled or free flaps for wound coverage were necessary. The injury in prehension grip (Fig la and b) does not affect the central stabilizing part of the third ray. In contrast to this the recoil explosion resulted in deep lacerations of the second and third rays, destabilizing the central arc of the hand. Explosion during precision grip (Fig lc) required reconstructiori' of the sensory grip areas at the tips of the thumb and long finger. In all cases this could be achieved by local or distance pedicled flaps. Reconstruction of hands mutilated by explosions is challenging. The surgeon performing the first operation must be able to deal with bone and tendons as well as with nerves, arteries and veins. Either pedicled or free flap cover may be necessary. By assessing the spatial relationship between the hand and exploding object the surgeon may be prepared for potential problems. References A R C A R I F A, LARSEN R D and POSCH J L (1959). Injuries to the hand from homemade rockets. American Journal of Surgery, 97: 471-476. B R O W N P. Open injuries of the hand. In: D P Green (Ed.), Operative hand surgery, 3rd Edn. Churchill Livingstone, New York, 1993: 1533-1562. ENTIN M (1968). Salvaging the basic hand. Surgical Clinics of North America, 48: 1063-1081. G E I S H A U S E R M, SCHWARZ M and L O W K A K (1990). Das Verletzungsmuster bei Explosionsverletzungen der Hand. Hefte zur Unfallheilkunde, 212:327 328. K L E I N E R T H E and WILLIAMS D J (1962). Blast injuries of the hand. Journal of Trauma, 2 : 1 0 35. K O E H N L E I N H E and SEITZ H D (1978). Rekonstruktive Moeglichkeiten bei subtotaler Amputation beider Haende. Unfallheilkunde, 81:690 693. M c G R E G O R I A and J A C K S O N I T (1969). Sodium chlorate bomb injuries of the hand. British Journal of Plastic Surgery, 22: 16-29. MELZER B and ARLT N (1990). Schuss- und Explosionsverletzungen der Hand. Zentralblatt fuer Chirurgie, 115: 223-229. NICOLAI J and TWISK R V (1988). H a n d injuries by fireworks. Netherlands Journal of Surgery, 40: 160-162.
Received: 11 March 1996 Accepted after revision: 22 April 1996 Dr P. Hahn, Klinick fur Handctfirurgie, Salzburger Leite 1, 97616 Bad Neustadt, Germany.