Outcomes after mutilating hand injuries: review of the literature and recommendations for assessment

Outcomes after mutilating hand injuries: review of the literature and recommendations for assessment

Hand Clin 19 (2003) 193–204 Outcomes after mutilating hand injuries: review of the literature and recommendations for assessment Reuben A. Bueno, Jr...

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Hand Clin 19 (2003) 193–204

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, Springfield, 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 specific functions of the upper extremity necessitate a fine 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 final, functional outcome of mutilating hand injuries depend not only on the severity and extent of the initial injury, but also on the patient’s age, underlying health condition, overall expectations, compliance, and psychosocial disposition. Each of these factors can be a signifi-

* Corresponding author. E-mail address: [email protected] (M.W. Neumeister).

cant variable in the final 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 stiffness, 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 patient’s ability to perform their activities of daily living and, perhaps more importantly, to return them to a productive profile in society. Our ability to salvage some function in the mutilated upper extremity makes hands significantly different 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 significantly more function and benefit 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 offer the promise of favorable, functional outcomes in managing these severe hand injuries.

0749-0712/03/$ - see front matter Ó 2003, Elsevier Science (USA). All rights reserved. doi:10.1016/S0749-0712(02)00142-7

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

Successful reconstructive efforts are aimed at sensibility restoration and the ability to perform prehensile tasks with the final 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 patient’s functional outcome after mutilating hand injuries. When does the surgeon sacrifice severely traumatized yet viable digits? How confident 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 patient’s age affect the surgeon’s decision to perform limb salvage in secondary procedures? When do we recommend amputation and prosthesis fitting 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 offer the patient the optimum result. Unfortunately, there is no definitive 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 offer 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 define 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 difficult, however, to button a shirt or brush one’s 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

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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 infinitely 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 suffered 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, Midgley’s 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 patient’s 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 different 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 specific 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 specific role in limb survival and function. Crush,

avulsion, and electrical burn injuries can portend a worse prognosis for survival [4,9–13]. 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) [14–16]. The mechanisms of these devastating injuries include electro-confirmation 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. (A–D) 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 finger with stretched neurovascular structures making salvage difficult 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 significant impact on the

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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 different 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 fixed 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. (B–D) 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 defined. 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 defining the functional outcome following mutilating hand injuries is the patient’s 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 stiff 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 significant 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 identified, 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 different levels, ischemia time, associated trauma to structures at different 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 surgeon’s 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 Chen’s 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 benefits 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 different 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. Chen’s assessment of functional outcome following replantation looked at the patient’s ability to work, range of motion, sensation, and muscular power [27]. Kleinert’s 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]. Tsai’s 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

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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 Tubiana’s description of prehension, prehensile grip is determined by the thumb’s 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 fifth metacarpal, and bone grafting and flap reconstruction. Before the era of microsurgery and free tissue transfer, thumb reconstruction was accomplished with bone grafts under a sensate flap, distraction osteogenesis, pollicization of other fingers, or phalangization. As a result of advances in microsurgery and the pioneering work by Bunke [31], Cobbett [32], Morrison [33], and Wei [34–36], 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. Gorsche’s review [37] of corn picker injuries sought to assess reconstruction and functional results by including the patient’s subjective evaluation of the usefulness of the injured extremity. A good result was defined 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. Wei’s 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 fingers and IP joint for the thumb at 60% of preoperative value, no significant 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 specified.

Scoring systems As noted earlier, advances in trauma management, microsurgery, skeletal fixation, 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 efforts to reflect 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 affect 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 [39–42]. 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 efforts 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 differentiating patients who would benefit with amputation from patients whose limb should be salvaged [43]. A similar finding was reported by Durham in his retrospective scoring of upper and lower extremity injuries with the MESI, MESS, PSI, and LSI [44]. Because no differences 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 find 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 surgeon’s 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 final score. Open fractures and contaminated wounds increase the final 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 specific 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 patient’s progress through rehabilitation. Outcomes research The field of outcomes research has developed as providers of care have come to recognize the importance of studying effectiveness 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 financial resources in this environment of cost-consciousness, the outcome of a procedure must be shown to be of significant benefit 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 beneficial to the patient with regard to functional outcome and costs.

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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 monofilaments [52], or with a two-point discriminator. Imaging studies, such as plain radiographs, CT scans, MRI, and bone scans, can offer 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 patient’s ability to perform their activities of daily living or work. Although objective measurement represents a significant 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 difficulty 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 costefficient 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 fine movement, and represents one of the first attempts at a standardized subjective evaluation of extremity function. Russell et al [9] and Graham et al [5] have used Carroll’s 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 unscientific, the field 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 defines whether a questionnaire is able to detect a significant difference 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 finely graded are the differences that can be measured. Increasing the range of possible answers with more questions increases the questionnaire’s 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 specific 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 effort 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-specific measures also exist for carpal tunnel syndrome [58] and wrist problems [59]. These more specific instruments may better assess functional outcome for that specific disease than a generic health questionnaire such as the SF-36, or a region-specific instrument such as the DASH or MHQ. A subjective questionnaire specific 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 finger or thumb? Does the final outcome change if severely traumatized digits are salvaged, only to be amputated at a later date? Is the outcome affected by early amputation and digit transplants rather than delayed procedures? Unfortunately, there are too many variables that come into play that affect the final 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 patient’s age, motivation, expectations, comorbid health condition, expenses, and coping mechanisms may alter the final 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 fingers 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, specific to mutilating hand injury, may provide the most beneficial information to guide treatment and assess outcome. References [1] Burkhalter WE. Mutilating injuries of the hand. Hand Clin 1986;2:45–68. [2] American Replantation Mission to China. Replantation surgery in China. Plast Reconstr Surg 1973;52:476–89. [3] Brown HC, Williams HB, Woodhouse FM. Principles of salvage in mutilating hand injuries. J Trauma 1968;8:318–32. [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;214:153–59. [5] Graham B, Adkins P, Tsai TM, et al. Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study. J Hand Surg Am 1998;23:783–91. [6] Midgley RD, Entin MA. Management of mutilating injuries of the hand. Clin Plast Surg 1976;3:99–109. [7] Wang SH, Young KF, Wei JN. Replantation of severed limbs—clinical 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.

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