Secondary procedures following mutilating hand injuries

Hand Clin 19 (2003) 149–163

Secondary procedures following mutilating hand injuries Robert C. Russell, MD, FACS, FRACSa,*, Reuben A. Bueno, Jr., MDb, Tzu-Ying Tammy Wu, MDc a

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

b

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

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

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

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

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Fig. 1. (A) A 27-year-old farmer sustained an auger injury to his left hand. The injury resulted in soft tissue, tendon, and bone loss. (B) A free deltoid flap was used for soft tissue coverage. An external fixator maintained length and position of the thumb. (C) Definitive bone grafting is performed after 4–6 weeks. The external fixator maintains the position while the graft heals. (D) A stable skeleton and soft tissue coverage was obtained.

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

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

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

release, requires flap coverage. The ideal flap should be thin and pliable to allow unhindered thumb motion. The authors have used the extended end of a groin flap elevated at the level of Scarpa’s fascia, a reverse radial forearm, flap or thin fasciocutaneous free flaps such as the deltoid or lateral arm flap to resurface the first web space (Figs. 2, 3). The entire hand should be immobilized after surgery in a bulky hand dressing with a dorsal splint and in children or noncompliant adults in a long arm cast. Hand elevation and immobilization after surgery decreases swelling and in skingrafted patients facilitates revascularization and graft survival. Free tissue transfers are monitored hourly for 3–5 days using a Doppler flow probe and by assessing flap color and capillary refill. If pins were used to maintain the thumb position after surgery, they are removed 3–4 weeks after surgery and active range of motion exercises are begun. The thumb is splinted at night and between exercise sessions using an Orthoplast splint for the next 3 weeks, at which time only night-splinting is continued for 2 weeks. Secondary procedures to release scar Scarred contracted dorsal or volar hand skin can restrict digital flexion or extension. In addition, skin injured by a deep second-degree burn or severe crush injury may survive, but can become stiff and inelastic and is prone to break down with use. Good quality, elastic skin is required over the MP and proximal interphalangeal (PIP) joints for optimal function. Thin or retracted skin can restrict flexion or break down with use, exposing underlying tendons or joints. These areas are best treated by resection of the scarred, poor quality skin with secondary coverage using a full thickness graft from the groin or by flap coverage. Small areas of skin loss or breakdown over the PIP joint, for example, can be closed using an arterialized side finger flap from the lateral volar aspect of the digit when no adjacent dorsal hand skin is available. The digital nerve is left intact to preserve tip sensation and the donor site is closed with a skin graft. Less commonly, an upside-down cross finger flap de-epithelialized and elevated from the uninjured dorsal surface of an adjacent digit can be used secondarily to resurface the PIP joint. This flap is not available, however, when the dorsal surfaces of multiple digits are injured. Larger areas of unstable skin may have to be resurfaced with a large full thickness skin graft

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

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

joint is placed in 80 –90 of flexion and held with a single K-wire placed through the base of the proximal phalanx into the head of the metacarpal. The dorsal skin surface is then reconstructed using a full thickness graft or by flap coverage. Pins are removed in 2–3 weeks and active range of motion exercises are begun. Palmar scar contracture Scar contracture on the volar surface of the digit can prevent full digital extension of any and all joints along the ray. Volar glabrous skin is thicker and more resistant to injury than the thinner dorsal hand skin and volar contractures often can be treated by local tissue rearrangement using Z-plasties, Y-V-plasties, or local rotation or

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

cross finger flaps from the same or an adjacent digit. A central longitudinal scar along the volar surface of the digit can be excised and Z-plasties designed using 45 angles with the lateral incisions ending at the PIP or MP joint flexion crease and extending as far dorsally as the midlateral line. Proximal release of the volar plate as described by Watson along the ‘‘assembly line’’ [12] is often required in long-standing cases of PIP joint contracture to restore PIP joint extension, which can initially be held with a K-wire. The retracted checkrein ligaments are divided proximally to allow the volar plate to slide distally, facilitating PIP joint extension. The pin is removed at 3–4 weeks and active range of motion exercises begun with intermittent and night splinting maintained for 3–4 weeks. Secondary release of a PIP joint flexion contracture with severely damaged skin may require flap coverage from the dorsal surface of an uninjured adjacent finger when the release results in exposed flexor tendons or neurovascular structures

that cannot be skin grafted. All cross finger flaps used to cover either dorsal or volar soft tissue defects are divided at 2–3 weeks, following elevation depending on the individual patient, the quality of the surrounding soft tissue, and the area of flap inset. Resurfacing of the entire volar or palmar skin may be necessary to reduce the risk of tendon adhesion. Stable, pliable soft tissue coverage is required before tendon transfers, tenolysis, or joint mobilization procedures can be done. Templates can be made using sterile gloves and opening one side to note the size of the tentative flap. Tissue expansion of the donor site may be useful to harvest a larger flap and still allow primary donor site closure (Fig. 4). The flaps may require several debulking procedures for the overall contoured result. Secondary nerve procedures Delayed nerve repair Mutilating hand injuries can result in complete or partial transaction of peripheral nerves in the

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Fig. 4. (A) A 36-year-old man sustained an avulsion, crush injury to his left hand. The hand was covered with split thickness skin grafts. Limited mobility and contractures prevented reasonable function. (B) The skin graft is removed and the first web space released. (C) A template out of a sterile glove is used to fashion the exact design of the flap. (D) The unfolded sterile glove gives the size of the defect. (E) An expanded scapular flap permits an abundance of soft tissue and allows primary donor site closure. (F) The flap is inset and in 2–3 months is ready for debulking and tenolysis procedures.

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

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

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Fig. 4 (continued )

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

percussion, massage, ultrasound, and electrical stimulation can be used to desensitize some neuromas [16]. Local steroid injections into the area of neuroma formation also have been described [16,18] with short-term success [18]. In addition, medications such as amitriptyline, carbamazepine, and neurontin have been used recently and seem to help some patients [17,19]. Some neuromas, such as those on the end of a digital amputation stump or of common digital nerves in the palm, can be best treated by neuroma resection, allowing the nerve ends to retract proximally into more healthy soft tissue [20]. Various chemical methods to inhibit axonal regrowth after neuroma resection have been used [16,21–24]. The freshly cut nerve end is treated with alcohol, tannic acid, formaldehyde, chromic acid, iodine, uranium nitrate, gentian violet, phenol, mercuric chloride, hydrochloride, picric acid, and nitrogen mustard, none of which are 100% successful [16,21–24]. Relocation of the nerve stump after neuroma resection into bone or muscle also has been used to prevent recurrence [25–27]. This method is best used in the hand or forearm where the nerve end can be sutured deeply into the soft tissue or into a drilled hole in the bone. Chiu and Strauch have used vein grafts or PGA tubes to direct regenerating axons away from the amputation stump after neuroma resection [28].

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

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

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

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tally to strengthen the repair and improve motion [31]. The return of digital motion after the initial procedure is followed closely by the hand therapist, who records the degrees of active and passive digital motion at each finger joint before and after each therapy session. A good hand therapist not only provides instruction to the patient for exercises to be performed at home between hand therapy visits, but also sets goals and helps provide the motivation to achieve them. Scar massage [32], silicone gel [33], topical vitamin E [34], and silicone sheeting [35] have all been used to soften scar and improve digital motion. Three to six months is usually required for scar tissue to soften, at which time the need for a secondary procedure to improve digital motion can be considered. Strickland describes flexor tenolysis as ‘‘perhaps the most demanding of all flexor tendon operations with respect to attention to detail and patient–doctor cooperation’’ and must be ‘‘approached as a major surgical effort, with great consideration for patient selection, operative technique, and postoperative management’’ [29]. Tenolysis procedures usually are performed 3–6 months after the initial procedure, when therapy gains in active or passive range of motion have ceased. Flexor or extensor tendons are usually ‘‘stuck’’ at the site of a previous tendon repair, where tendons pass over a healed fracture, or where tendons pass through a tight space such as the fibro-osseous digital pulley system in zone II in the hand. A surgeon performing a tenolysis must consider the locations of previous skin lacerations or incisions in approaching the area of tendon adhesion to preserve the skin’s blood supply. Often the prior incisions must be reopened despite a less than desirable location or direction to insure skin vascularity and survival after a tenolysis. Small #15 or Beaver scalpel blades and Kuntz or Freer elevators or Mitchell Trimmes are used to sharply dissect tendon adhesions with atraumatic technique preserving the critical A2 and A4 pulleys in zone II to prevent bow-stringing during active motion after surgery. A separate proximal wrist incision is usually required during flexor tenolysis to determine the adequacy of the distal tendon scar release. Each distal tenolysed flexor tendon is identified at the wrist and traction is applied to be certain that active digital motion can be achieved. Release of tight joint capsules or adherent extensor tendons when present must be done first to obtain near-normal passive range of

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

digital motion before proceeding with flexor tenolysis. A general or Bier block anesthetic can be converted to a regional block using local anesthetic at the wrist, to test the patient’s ability to move the digits independently after the scar release. It is sometimes desirable for the patient to visualize the amount of active motion, which is actually possible before the limitations of pain and swelling occur after surgery. The hand and forearm usually are immobilized in a bulky compressive dressing for 1–3 days after surgery

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

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

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

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

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

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

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

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

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

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Summary Mutilating hand injuries result in injury to multiple anatomic structures, which increases the possibility that secondary procedures or staged reconstruction will be necessary. Secondary procedures often are required to provide stable wound coverage, restore sensation, provide bony stability, increase range of motion, or allow prehension, all of which are performed to improve hand function. The patient, the surgeon, and the therapist must all work together to achieve the best functional result following a severe mutilating hand injury.

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