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Surgical treatment of hand injuries
SURGICAL TREATMENT OF H A N D INJURIES
By E. AHRER From the Surgical Clinic of the University of Innsbruck, Austria IT is hardly necessary to mention that hand injuries constitute a large portion of all occurring injuries. It is therefore not surprising to find that of zo,445 recent injuries received at the surgical ward of the Innsbruck University Clinic, Austria, in I958, 2,378 were hand injuries. This means that 22-76 per cent. or approximately one-fourth of all injuries were hand injuries (Table I). TABLE I Year I 9 5 8 Total n u m b e r of injuries Total n u m b e r of hand injuries Open hand injuries
IO,445 2,378 I,I63 ( I I ' I 3 per cent. of all injuries) (48 "5 per cent. of all hand injuries)
It is perhaps interesting to note that Innsbruck--a city of lO%OOOinhabitants-and its surroundings have no especially large industrial areas. In fact, the majority of hand injuries occur among a predominantly agricultural population. On the other hand, Innsbruck has a high incidence of winter sport accidents, primarily injuries resulting from ski-ing. That in spite of this hand injuries account for almost one-fourth of all accidents, is a further proof of their importance. Approximately one-half, 48"5 per cent. (z,I63 cases), of these hand injuries were open wounds, which, of course, required immediate surgical treatment (Table I). In 72-2 per cent. of these cases only the skin was injured, whereas in 27-8 per cent. injuries of tendons, joints, and bones occurred. The latter are listed under combined injuries in Table II. TABLE I I Open hand injuries Skin lesions only Combined injuries Requiring primary plastic repair .
z,z63 840 323 88
cases cases cases cases
(Ioo per cent.) (72.z per cent.) (27"8 per cent.) (7 per cent.)
With reference to the relatively high number of recent open injuries of the hand, it is understandable that in approximately 7 per cent. of the cases a primary skin plastic was performed. A primary skin plastic is necessary when skin defects resulting from the injury cannot be successfully closed with a simple skin suture. Further, favourable ,conditions should be created for possible future operations, that is, well vascularised .and easily movable skin. Before we proceed with the indications for and the techniques of primary :skin plastics, it is perhaps expedient to mention some general objectives : I. Our primary objective is the attainment of optimal function of the hand .as an organ for grasping and touching. With respect to the latter function, for .example, it is necessary to preserve the sensory innervation of the fingers. A 317
318
BRITISH JOURNAL OF PLASTIC SURGERY
finger which has lost the sense of touch is worthless, even dangerous, for the hand. Therefore, in indicated cases, we attempt to suture a digital nerve. The action of grasping can be performed only when both thumb and part of the hand against which it can be opposed are preserved. We must therefore attempt everything in our power to retain the thumb. 2. We endeavour to do as much as possible to restore hand function at the primary wound treatment. When possible, we suture tendons and treat broken bones to achieve osteosynthesis. In the latter case, crossed wires have preserved their value as a technique. This point of view is gaining in acceptance and only occasionally, for example when suturing the flexor tendons in " N o Man's L a n d " (Bunnell), is an operation deferred to the second treatment. Another group o f hand injuries exists by which primary treatment must be more limited in scope : here are included patients who have suffered other serious injuries simultaneously and are in a critical condition. 3. It should be mentioned here that, of course, all primary restoratory operations are to be performed only after scrupulous excision (Friedrich). This still provides the best security for primary healing, which is decisive for future function of an injured hand. 4. Finally, it is necessary to consider at the primary treatment whether the respective operation can be correlated with the occupation, social position, and the intelligence of the patient. For example, an attempt to save the distal finger joint may be inadvisable in a heavy labourer, whereas it can be occupationally indicated in a musician. TECHNIQUE
Before we perform the actual skin plastic it is necessary to fulfil certain preliminary conditions. As mentioned above, the wound must be prepared by excision. Eventual osteosynthesis, tendon, or nerve sutures must first be completed. When the decision to perform a skin plastic has been made, it must be remembered that after such a procedure the wound edges tend to shrink. It is well known that especially in the hand unfavourable scars cause contracture and lead to the formation of keloids, which can result in an extensive restriction of function. For example, scars which run lengthwise along the flexor surface of the fingers or in the between-the-finger creases should be avoided. In such cases it is even better to sacrifice healthy skin in order to avoid wound angles by the excision. Further' bleeding should be prevented, because a hmmatoma which might later occur could ruin the skin plastic, rendering the success questionable, The following possibilities are open :-i. Free skin transfer. 2. Pedicle in the immediate area. 3. Pedicle at a distance. These different possibilities are used according to the individual indications. I. Free Skin Transfer.--This technique requires a good bed, that is, no. bones, joints, or tendons should be opened. This technique is used for direct covering of the wound area or for covering a defect resulting from a pedicle.
SURGICAL
TREATMENT
OF
HAND
INJURIES
319
With the different kinds of free skin transfer, we are in possession of techniques which can be chosen according to the stress and strain. (a) Reverdin Grafts.--This method is the simplest technique and can be performed in the ordinary consuhaticn hour. In addition, it is the least exacting plastic as it heals over joints, tendons, and bones. Another advantage is that
FIG. I Serious injury to the h a n d in a rotary saw with loss of ring a n d little fingers, as well as partial loss o f t h e m i d d l e finger. Extensive injury to s u r r o u n d i n g tissue. Covering with a d e r m a t o m e graft. G o o d functional results. R e m a i n i n g fingers freely movable.
FIG. 2 I n j u r y of the h a n d in a dredger. I n addition to extensive c r u s h i n g a n d t r a u m a t i c tearing off of t h e ring a n d little finger, t h e i n d e x finger was vascularised only t h r o u g h t h e radial nerve a n d vessel b u n d l e a n d a I cm. wide bridge of skin. T h i s finger was t r a n s p l a n t e d on t h e f o u r t h metacarpal a n d t u r n e d s o m e w h a t against t h e t h u m b . T h e vessels of t h e middle finger were completely tied off. After two m o n t h s , good grasping ability o f the hand. D e r m a t o m e graft covering t h e ball of the t h u m b a n d t h e d o r s u m of t h e hand.
when occasionally a skin flap fails to grow properly the functional results are not so endangered. Cosmetic results are less satisfying because of scars which often occur at the donor site. We use Reverdin grafts, therefore, only in cases where the injury is small. It appears, however, that the Reverdin graft has been,_with injustice, almost completely forgotten. (b) Dermatome Grafts (Figs. I to 4).--The Padgett-Hood dermatome or the electric dermatome enables as to remove skin grafts of the correct size and identical thickness throughout. The thinner the graft, the better it will heal. A thicker graft, however, offers better functional results. As donor site for smaller defects
320
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
we use the inner side of the upper arm, for larger defects the thigh or the abdomen. After removal of the graft, which must be the same size as the area to be covered, it is sutured with Perlon. I f larger grafts are used, we make small incisions into the graft in order to secure proper drainage and to prevent the graft from rising from the wounded area. (c) The Full-thickness Graft (Wolfe-Krause).--This method utilises the full thickness of the skin, which has first been cleared o f subcutaneous fat. It
FIG. 3
FIG. 4
Fig. 3 . - - L o s s of t h e u l n a r side of the h a n d after the patient was r u n over by a train. Serious a c c o m p a n y i n g injuries ; therefore, p r i m a r y t r e a t m e n t only, free skin transfer. L a t e r contracture o n m i d d l e finger a n d sensitive scar t i s s u e ; therefore, pedicle at a distance, f r o m t h e a b d o m e n . Fig. 4 . - - T r a n s p l a n t a t i o n o f a d e r m a t o m e graft. A l t h o u g h this illustration refers to t h e covering of a crural ulcer rather t h a n a n injury of the h a n d , it is included because of its excellent portrayal o f t h e technique. N o t e the stitch incision.
results in the most resistant skin but is the most difficult of all free skin transfers. It is especially well suited for the flexor surface of the fingers and the palm. T h e same donor sites are used here as for dermatome grafts. It must be remembered, however, that hairs which may be present on the donor flap can continue to grow. In other respects, the transplanted full-thickness graft is sutured in exactly the same manner as the dermatome graft, also with small stitch incisions. The donor site is often closed with sutures after undermining of the wound edges. In some cases of degloving, the severed skin is used in the same manner as a full-thickness graft, after it has first been cleared of subcutaneous fat. 2. Pediele in the I m m e d i a t e Area.--(a) The Z-plasty is used as a primary treatment only when a wound runs across the flexor crease of the proximal finger joints. Apart from this, it is utilised primarily in reconstructive surgery and lies outside the scope of this paper. (b) The rotation flap is used to close a wound with healthy skin. The resulting defect is then repaired with a free skin transfer (see above). It must be stressed that this skin replacement from the area surrounding the injury can be used only
SURGICAL
TREATMENT
OF
HAND
INJURIES
321
on the lower arm, the dorsum of the hand, and possibly on the extensor surface o f the fingers. It should not be used for the flexor surface of the fingers or the palm. When possible, the entire surface of the graft should not be undermined, in order not to endanger the vascularisation.
FIG. 5 C r u s h i n g of the e n d of t h e t h u m b in a collapsing easy chair. f r o m the skin of t h e a b d o m e n ,
Pedicle flap
FIG. 6 Pedicle on t h e tip of t h e t h u m b , in w h i c h the middle finger was u s e d as donor. T h e resulting defect was covered with a full-thickness graft.
3. Pedicle at a D i s t a n e e . - - T h e purpose of this method is to transplant subcutaneous fat as well as skin and to allow the graft to remain in contact with its donor site until it has sufficiently adhered to the site of transplantation. The flap itself must be just as large as the area to be covered. It must be so laid as to prevent its being creased, twisted, or stretched. The donor site is closed either by undermining the wound edges or with a dermatome graft in order that a completely closed surface results. All possible infections should be avoided. In cases where the pedicle flap runs free between the donor and the receiving site, 4c
322
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
it should be separated from the receiving site by a dermatome graft or an opposing flap. Good donor sites are the upper arm, the breast, the inguinal region, or, for the tip of the fingers, the ball of the thumb or of the little finger. In defects of the ball of the thumb, we use the middle finger as donor. In more serious injuries it is often possible to cover a finger with skin from a finger which must be sacrificed anyway on account of the seriousness of the injury (Figs. 5 and 6). After three weeks at the earliest the stem of the flap is cut or, in case the stem is very wide, it is first notched and only after an additional week completely cut.
Post-operatlve Treatment and Immobilisation.--The free skin graft is first covered with a wire screen and then compressed with foam rubber. F o r the palm, steel wool patches wrapped in gauze are used. The steel wool patches are sized and formed to allow the fingers to be fixed in the mid-position of the joints with elastic bandages. In the pedicle at a distance, a plaster cast is applied in order to assure complete immobilisation of the flap. Otherwise, the usual rules for immobilisation in the functional position of the hand are valid. SUMMARY The large number and the accompanying importance of recent hand injuries is stressed. Here are included a considerable number of injuries which require primary skin grafts. The importance of extensive primary treatment to restore the function of the hand is emphasised. The various possibilities, indications, and techniques for skin grafting are discussed.
By E. AHRER From the Surgical Clinic of the University of Innsbruck, Austria IT is hardly necessary to mention that hand injuries constitute a large portion of all occurring injuries. It is therefore not surprising to find that of zo,445 recent injuries received at the surgical ward of the Innsbruck University Clinic, Austria, in I958, 2,378 were hand injuries. This means that 22-76 per cent. or approximately one-fourth of all injuries were hand injuries (Table I). TABLE I Year I 9 5 8 Total n u m b e r of injuries Total n u m b e r of hand injuries Open hand injuries
IO,445 2,378 I,I63 ( I I ' I 3 per cent. of all injuries) (48 "5 per cent. of all hand injuries)
It is perhaps interesting to note that Innsbruck--a city of lO%OOOinhabitants-and its surroundings have no especially large industrial areas. In fact, the majority of hand injuries occur among a predominantly agricultural population. On the other hand, Innsbruck has a high incidence of winter sport accidents, primarily injuries resulting from ski-ing. That in spite of this hand injuries account for almost one-fourth of all accidents, is a further proof of their importance. Approximately one-half, 48"5 per cent. (z,I63 cases), of these hand injuries were open wounds, which, of course, required immediate surgical treatment (Table I). In 72-2 per cent. of these cases only the skin was injured, whereas in 27-8 per cent. injuries of tendons, joints, and bones occurred. The latter are listed under combined injuries in Table II. TABLE I I Open hand injuries Skin lesions only Combined injuries Requiring primary plastic repair .
z,z63 840 323 88
cases cases cases cases
(Ioo per cent.) (72.z per cent.) (27"8 per cent.) (7 per cent.)
With reference to the relatively high number of recent open injuries of the hand, it is understandable that in approximately 7 per cent. of the cases a primary skin plastic was performed. A primary skin plastic is necessary when skin defects resulting from the injury cannot be successfully closed with a simple skin suture. Further, favourable ,conditions should be created for possible future operations, that is, well vascularised .and easily movable skin. Before we proceed with the indications for and the techniques of primary :skin plastics, it is perhaps expedient to mention some general objectives : I. Our primary objective is the attainment of optimal function of the hand .as an organ for grasping and touching. With respect to the latter function, for .example, it is necessary to preserve the sensory innervation of the fingers. A 317
318
BRITISH JOURNAL OF PLASTIC SURGERY
finger which has lost the sense of touch is worthless, even dangerous, for the hand. Therefore, in indicated cases, we attempt to suture a digital nerve. The action of grasping can be performed only when both thumb and part of the hand against which it can be opposed are preserved. We must therefore attempt everything in our power to retain the thumb. 2. We endeavour to do as much as possible to restore hand function at the primary wound treatment. When possible, we suture tendons and treat broken bones to achieve osteosynthesis. In the latter case, crossed wires have preserved their value as a technique. This point of view is gaining in acceptance and only occasionally, for example when suturing the flexor tendons in " N o Man's L a n d " (Bunnell), is an operation deferred to the second treatment. Another group o f hand injuries exists by which primary treatment must be more limited in scope : here are included patients who have suffered other serious injuries simultaneously and are in a critical condition. 3. It should be mentioned here that, of course, all primary restoratory operations are to be performed only after scrupulous excision (Friedrich). This still provides the best security for primary healing, which is decisive for future function of an injured hand. 4. Finally, it is necessary to consider at the primary treatment whether the respective operation can be correlated with the occupation, social position, and the intelligence of the patient. For example, an attempt to save the distal finger joint may be inadvisable in a heavy labourer, whereas it can be occupationally indicated in a musician. TECHNIQUE
Before we perform the actual skin plastic it is necessary to fulfil certain preliminary conditions. As mentioned above, the wound must be prepared by excision. Eventual osteosynthesis, tendon, or nerve sutures must first be completed. When the decision to perform a skin plastic has been made, it must be remembered that after such a procedure the wound edges tend to shrink. It is well known that especially in the hand unfavourable scars cause contracture and lead to the formation of keloids, which can result in an extensive restriction of function. For example, scars which run lengthwise along the flexor surface of the fingers or in the between-the-finger creases should be avoided. In such cases it is even better to sacrifice healthy skin in order to avoid wound angles by the excision. Further' bleeding should be prevented, because a hmmatoma which might later occur could ruin the skin plastic, rendering the success questionable, The following possibilities are open :-i. Free skin transfer. 2. Pedicle in the immediate area. 3. Pedicle at a distance. These different possibilities are used according to the individual indications. I. Free Skin Transfer.--This technique requires a good bed, that is, no. bones, joints, or tendons should be opened. This technique is used for direct covering of the wound area or for covering a defect resulting from a pedicle.
SURGICAL
TREATMENT
OF
HAND
INJURIES
319
With the different kinds of free skin transfer, we are in possession of techniques which can be chosen according to the stress and strain. (a) Reverdin Grafts.--This method is the simplest technique and can be performed in the ordinary consuhaticn hour. In addition, it is the least exacting plastic as it heals over joints, tendons, and bones. Another advantage is that
FIG. I Serious injury to the h a n d in a rotary saw with loss of ring a n d little fingers, as well as partial loss o f t h e m i d d l e finger. Extensive injury to s u r r o u n d i n g tissue. Covering with a d e r m a t o m e graft. G o o d functional results. R e m a i n i n g fingers freely movable.
FIG. 2 I n j u r y of the h a n d in a dredger. I n addition to extensive c r u s h i n g a n d t r a u m a t i c tearing off of t h e ring a n d little finger, t h e i n d e x finger was vascularised only t h r o u g h t h e radial nerve a n d vessel b u n d l e a n d a I cm. wide bridge of skin. T h i s finger was t r a n s p l a n t e d on t h e f o u r t h metacarpal a n d t u r n e d s o m e w h a t against t h e t h u m b . T h e vessels of t h e middle finger were completely tied off. After two m o n t h s , good grasping ability o f the hand. D e r m a t o m e graft covering t h e ball of the t h u m b a n d t h e d o r s u m of t h e hand.
when occasionally a skin flap fails to grow properly the functional results are not so endangered. Cosmetic results are less satisfying because of scars which often occur at the donor site. We use Reverdin grafts, therefore, only in cases where the injury is small. It appears, however, that the Reverdin graft has been,_with injustice, almost completely forgotten. (b) Dermatome Grafts (Figs. I to 4).--The Padgett-Hood dermatome or the electric dermatome enables as to remove skin grafts of the correct size and identical thickness throughout. The thinner the graft, the better it will heal. A thicker graft, however, offers better functional results. As donor site for smaller defects
320
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
we use the inner side of the upper arm, for larger defects the thigh or the abdomen. After removal of the graft, which must be the same size as the area to be covered, it is sutured with Perlon. I f larger grafts are used, we make small incisions into the graft in order to secure proper drainage and to prevent the graft from rising from the wounded area. (c) The Full-thickness Graft (Wolfe-Krause).--This method utilises the full thickness of the skin, which has first been cleared o f subcutaneous fat. It
FIG. 3
FIG. 4
Fig. 3 . - - L o s s of t h e u l n a r side of the h a n d after the patient was r u n over by a train. Serious a c c o m p a n y i n g injuries ; therefore, p r i m a r y t r e a t m e n t only, free skin transfer. L a t e r contracture o n m i d d l e finger a n d sensitive scar t i s s u e ; therefore, pedicle at a distance, f r o m t h e a b d o m e n . Fig. 4 . - - T r a n s p l a n t a t i o n o f a d e r m a t o m e graft. A l t h o u g h this illustration refers to t h e covering of a crural ulcer rather t h a n a n injury of the h a n d , it is included because of its excellent portrayal o f t h e technique. N o t e the stitch incision.
results in the most resistant skin but is the most difficult of all free skin transfers. It is especially well suited for the flexor surface of the fingers and the palm. T h e same donor sites are used here as for dermatome grafts. It must be remembered, however, that hairs which may be present on the donor flap can continue to grow. In other respects, the transplanted full-thickness graft is sutured in exactly the same manner as the dermatome graft, also with small stitch incisions. The donor site is often closed with sutures after undermining of the wound edges. In some cases of degloving, the severed skin is used in the same manner as a full-thickness graft, after it has first been cleared of subcutaneous fat. 2. Pediele in the I m m e d i a t e Area.--(a) The Z-plasty is used as a primary treatment only when a wound runs across the flexor crease of the proximal finger joints. Apart from this, it is utilised primarily in reconstructive surgery and lies outside the scope of this paper. (b) The rotation flap is used to close a wound with healthy skin. The resulting defect is then repaired with a free skin transfer (see above). It must be stressed that this skin replacement from the area surrounding the injury can be used only
SURGICAL
TREATMENT
OF
HAND
INJURIES
321
on the lower arm, the dorsum of the hand, and possibly on the extensor surface o f the fingers. It should not be used for the flexor surface of the fingers or the palm. When possible, the entire surface of the graft should not be undermined, in order not to endanger the vascularisation.
FIG. 5 C r u s h i n g of the e n d of t h e t h u m b in a collapsing easy chair. f r o m the skin of t h e a b d o m e n ,
Pedicle flap
FIG. 6 Pedicle on t h e tip of t h e t h u m b , in w h i c h the middle finger was u s e d as donor. T h e resulting defect was covered with a full-thickness graft.
3. Pedicle at a D i s t a n e e . - - T h e purpose of this method is to transplant subcutaneous fat as well as skin and to allow the graft to remain in contact with its donor site until it has sufficiently adhered to the site of transplantation. The flap itself must be just as large as the area to be covered. It must be so laid as to prevent its being creased, twisted, or stretched. The donor site is closed either by undermining the wound edges or with a dermatome graft in order that a completely closed surface results. All possible infections should be avoided. In cases where the pedicle flap runs free between the donor and the receiving site, 4c
322
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
it should be separated from the receiving site by a dermatome graft or an opposing flap. Good donor sites are the upper arm, the breast, the inguinal region, or, for the tip of the fingers, the ball of the thumb or of the little finger. In defects of the ball of the thumb, we use the middle finger as donor. In more serious injuries it is often possible to cover a finger with skin from a finger which must be sacrificed anyway on account of the seriousness of the injury (Figs. 5 and 6). After three weeks at the earliest the stem of the flap is cut or, in case the stem is very wide, it is first notched and only after an additional week completely cut.
Post-operatlve Treatment and Immobilisation.--The free skin graft is first covered with a wire screen and then compressed with foam rubber. F o r the palm, steel wool patches wrapped in gauze are used. The steel wool patches are sized and formed to allow the fingers to be fixed in the mid-position of the joints with elastic bandages. In the pedicle at a distance, a plaster cast is applied in order to assure complete immobilisation of the flap. Otherwise, the usual rules for immobilisation in the functional position of the hand are valid. SUMMARY The large number and the accompanying importance of recent hand injuries is stressed. Here are included a considerable number of injuries which require primary skin grafts. The importance of extensive primary treatment to restore the function of the hand is emphasised. The various possibilities, indications, and techniques for skin grafting are discussed.