Mutilating Hand Injuries, Hand Clinics, Volume 19, Issue 1, Pages 1-210 (February 2003)

Volume 19, Issue 1, Pages 1-209 (February 2003) Mutilating Hand Injuries

articles 1 - 17

1 Mutilating hand injuries Page xi Richard E. Brown and Michael W. Neumeister

2 Mutilating hand injuries: principles and management Pages 1-15 Michael W. Neumeister and Richard E. Brown

3 Biomechanics and hand trauma: what you need Pages 17-31 Steven L. Moran and Richard A. Berger

4 Antimicrobial management of mutilating hand injuries Pages 33-39 R. Dow Hoffman and Brian D. Adams

5 Psychological aspects of mutilating hand injuries Pages 41-49 Therese M. Meyer

6 Fracture fixation in the mutilated hand Pages 51-61 Alan E. Freeland, William C. Lineaweaver and Sheila G. Lindley

7 Soft tissue coverage in devastating hand injuries Pages 63-71 Goetz A. Giessler, Detlev Erdmann and Guenter Germann

8 Use of “spare parts” in mutilated upper extremity injuries Pages 73-87 Richard E. Brown and Tzu-Ying Tammy Wu

9 Replantation in the mutilated hand Pages 89-120 Bradon J. Wilhelmi, W. P. Andrew Lee, Geert I. Pagensteert and James W. May

10 Pediatric mutilating hand injuries Pages 121-131 Gregory M. Buncke, Rudolf F. Buntic and Oreste Romeo

11 Hand therapy management following mutilating hand injuries Pages 133-148 Shirley W. Chan and Paul LaStayo

12 Secondary procedures following mutilating hand injuries Pages 149-163 Robert C. Russell, Reuben A. Bueno and Tzu-Ying Tammy Wu

13 Toe-to-hand transplantation Pages 165-175 Fu-Chan Wei, Vivek Jain and Samuel Huan-Tang Chen

14 Passive hand prostheses Pages 177-183 Hooman Soltanian, Genevieve de Bese and Robert W. Beasley

15 Active functional prostheses Pages 185-191 Terry J. Supan

16 Outcomes after mutilating hand injuries: review of the literature and recommendations for assessment Pages 193-204 Reuben A. Bueno and Michael W. Neumeister

17 Index Pages 205-209

Preface

Mutilating hand injuries

Guest Editors

Perhaps the most challenging injury managed

by hand surgeons is the mangled or mutilated

hand. Mutilating injuries can occur from various

causes such as motor vehicle accidents, farm or

blast injuries, or industrial accidents. Such injuries

involve the many structures of the hand and, thus,

pose a difficult challenge to the surgeon to pre-

serve or reconstruct as much function as possible.

Previous issues of the Hand Clinics have dealt

with trauma to the various structures of the upper

extremity; however, none has been solely devoted

to the evaluation and management of the muti-

lated hand. In this issue, we have pulled together

the expertise of numerous authorities throughout

the world to discuss the diverse aspects of mutilat-

ing hand injuries from the acute management to

the secondary reconstruction as well as the psy-

chological and rehabilitation aspects.

We would like to thank the many authors who

have contributed to this issue. In addition, we

wish to thank the editorial staff at WB Saunders

for their assistance and patience. Lastly, we would

like to thank Cheryl Matthews for her secretarial

assistance and Maria Ansley for her photographic

contributions.

Richard E. Brown, MD, FACS

Division of Plastic Surgery

Southern Illinois University School of Medicine

Springfield Surgical Associates

Springfield Clinic

PO Box 19248, 501 N. 1st Street

Springfield, IL 62794-9248, USA

Michael W. Neumeister, MD, FRCSC, FACS

Southern Illinois University School of Medicine

The Plastic Surgery Institute

PO Box 19653, 747 N. Rutledge Street

Springfield, IL 62794-9653, USA

Michael W. Neumeister, MD, FRCSC, FACSRichard E. Brown, MD, FACS

0749-0712/03/$ - see front matter � 2003, Elsevier Science (USA). All rights reserved.

doi:10.1016/S0749-0712(02)00145-2

Hand Clin 19 (2003) xi

Mutilating hand injuries: principles and managementMichael W. Neumeister, MD, FRCSC, FACSa,*,

Richard E. Brown, MD, FACSbaSouthern Illinois University Plastic Surgery, P.O. Box 19653, Springfield, IL 62794, USA

bSpringfield Surgical Association, A Division of Springfield Clinic, P.O. Box 19248, Springfield, IL 62794, USA

Our hands are subject to many commonoccupational and domestic injuries, including

fingertip trauma, tendon lacerations, neurovascu-lar compromise, fractures, and soft tissue loss. Weare all aware that even minor trauma to a joint or

tendon can result in significant stiffness and lossof function of the finger. The greater the injury,the more likely the risk for compromise to thefunction of the hand. This is no more evident

than in mutilating upper extremity injuries inwhich the fine balance and interplay of the in-trinsic and extrinsic structures of the hand are

damaged or destroyed. Each finger has its in-herent role in the normal function of the hand.The American Medical Association, in the Guide-

lines to the Evaluation of Permanent Impairment,fifth edition, has described the functional contri-bution that each digit offers to the hand, the upper

extremity, and to the body as a whole (Table 1).Loss of the thumb is equivalent to a 40% loss offunction of the hand and a 25% loss of the wholebody function. Although the little and ring fin-

gersare not given as high a functional loss, thesedigits are important in grip strength, which hasenormous implications for laborers and tool

workers. The thumb is important for prehensiletasks, whereas the ulnar digits are important forpower grasps.

Hand surgeons are often challenged to salvageor restore function of mutilated upper extremitiesfor the ultimate goal of permitting patients eitherto return to work or at least to perform their

activities of daily living. The functional loss aftersuch devastating trauma is, therefore, measured

not only by objective analysis such as functionalcapacity evaluations but also by subjective data,in which pain, dexterity, and daily use become

important issues. Active and passive range ofmotion, sensation, and grip strength are easilyrecorded and may help define a successful re-construction of the hand, but ultimately the pa-

tient must incorporate their hand back into theirdaily activities; this is the true test of success.

The immediate management of these injuries

is similar no matter how severe or unique thetrauma. The template for success is defined bypatient survival, limb survival, limb function, and

incorporation back into a meaningful lifestyle.Ensuring patient survival is the initial conquest(Fig. 1). The patient must be hemodynami-

cally stable before embarking on any salvageprocedure.

A primary and secondary survey should beperformed with the emphasis of obtaining and

maintaining a patent airway, observing normalbreathing patterns, and providing circulatorysupport. The amount of force that is required

to mangle a hand may very well have causedsignificant injury to the internal viscera also.Intravenous access and fluid resuscitation are

required to optimize central and peripheral cir-culation. Life threatening injuries should obvious-ly be treated before limb threatening injuries.

During the treatment to stabilize the patient,

a thorough history should be obtained. A detailedhistory helps elicit the mechanisms of injury andlends further insight into the extent and severity

of the mutilation. Crush and avulsion injuriesresult in greater tissue damage and consequently

* Corresponding author.

E-mail address: [email protected]

(M.W. Neumeister).


doi:10.1016/S0749-0712(02)00141-5

Hand Clin 19 (2003) 1–15

portend a worse functional prognosis than guillo-tine type amputations. Greater contamination canbe expected from farming and industrial injuries

in which considerable debris is often buriedwithin the depths of the wounds [1,2]. It isprudent, therefore, to initiate intravenous anti-biotics while the patient is in the emergency depart-

ment. Broad-spectrum coverage is mandatory untildefinitive cultures return. The patient’s tetanusstatus should be recorded and updated if required.

Other significant elements of the history includeobtaining information on previous injuries, pre-morbid function of the hand, duration of ischemia

Fig. 1. (A,B) A 12-year-old boy had an M-80 explode in his hand. A subsequent fire ensued. The hand injury was

devastating. (C ) The systemic effects may be more life threatening than the limb injury. This patient sustained 40% total

body surface area burns that needed to be addressed before the mutilating hand injury.

Table 1

Guides to the evaluation of permanent impairment

% Impairment

Amputation

hand

Upper

extremity

Whole

body

Index or longer

finger

20 18 11

Ring or little finger 10 9 5

Thumb 40–50 36–45 22–27

Hand — 90 54

Upper extremity — — 60

(Data from AMA Guidelines of Permanent Impair-

ment, 5th ed. 2001.)

2 M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 1–15

of amputated parts, management of the wounds inthe field and at the local hospital, loss of con-sciousness, dizziness, chest pains, or shortness of

breath. Uncontrolled diabetes, acute chest pain,heart palpations, and shortness of breath can putpatients working on heavy machinery in danger-

ous situations in which a loss of concentrationcan result in devastating injuries. Such a historywould alert the emergency department physician orthe surgeon to perform further diagnostic studies

before attempting a potentially long and compli-cated surgery for limb salvage. Again the patientneeds to be stable with a controlled cardiovascular

and respiratory system to help avoid intraoperativeand postoperative systemic complications, includ-ing hypovolemia, renal failure, and cardiovascular

embarrassment [3–5].The hand surgeon’s initial physical exami-

nation of the mutilated upper extremity may belimited because of significant pain, contamination,

deformity, or patient apprehension. It is impor-

tant, however, to assess all structures, especiallythe vascularity of the traumatized digit and hand.Ischemic fingers mandate emergent care if one

hopes to salvage as much of the hand as possible.Many aspects of the physical examination do

not require the surgeon to actually lay their hands

on a patient hand to fully understand the sever-ity of the injury. Simple inspection of mutilatinghand injuries often can identify several injuredstructures. The color and turgor of the digits can

be assessed to identify vascular compromise. Thenormal cascade of the hand may be disruptedbecause of tendon lacerations or phalangeal frac-

tures. A gross visualization of skin loss andexposed structures also can be evaluated in theemergency department. Gross sensation can be

evaluated with light touch or with a sterile25-gauge needle. The emergency departmentevaluation permits the surgeon to alert the op-erating room staff of the specific instruments

that are required to best treat the injury. Bone

Fig. 2. (A) A 26-year-old male with a considerable soft tissue filet to the back of the hand. Multiple function and tendon

injuries are present. (B) Debridement and irrigation was performed before reconstruction of the involved structures. (C)

Definitive closure is performed only when the wound bed is clean. A scapular flap was used for closure.

3M.W. Neumeister, R.E. Brown / Hand Clin 19 (2003) 1–15

fixation devices, lavage solutions, microscopes

and microscopic instrumentation, and fluoros-copy may be needed to treat the various tissues.

The surgeon needs to decide the appropriate-

ness of attempting replantation or revasculariza-tion of the digits or hand, depending on the leveland site of amputation, contamination, ischemiatime, other associated injuries or medical illnesses,

and the concerns of the patient [6,7]. Manyfarmers are concerned only with getting back towork their land and request the most expedi-

ent yet functional surgery. Other patients arrivein a state of hysteria and unrealistically expectcomplete restoration of their hand. It is the

surgeon’s duty to fully evaluate the various av-enues of limb salvage and provide an educatedtreatment option for the patient and their family.

Many patients have difficulty with decisions madeto amputate fingers, despite knowing that re-

plantation attempts may be fraught with compli-

cations and further surgeries or may result ina nonfunctional, stiff, and insensate hand orfinger. Psychotherapists and psychiatrists may be

needed to help some patients deal with thepersonal, social, and professional sequelae ofmutilating hand injuries.

The cornerstone of the early intraoperative

management of mutilating hand injuries is de-bridement and irrigation. All grossly devitalizedtissue needs to be excised (Fig. 2). Copious pulse

lavage irrigation helps to eliminate debris andbacteria from the contaminated wounds [8]. Caremust be taken not to further damage those tissues

that might otherwise survive. This is especiallytrue for vital structures such as the nerves,arteries, tendons, and bone. The debridement com-

mences in an orderly fashion, starting with theskin and moving to the tissues in the deeper

Fig. 3. (A) A mutilating hand injury in a 50-year-old man. All fingers were devascularized with multiple levels of injury

to the entire hand. (B) After debridement and irrigation, the remaining tissue is evaluated for spare part reconstruction.

(C ) The long finger is transplanted to the only remaining metacarpal (fifth). A xenograft is used to cover remaining

exposed wound bed until all tissues have declared themselves as viable and the use of temporary dressings such as

xenograft is safe and buys time in case more tissue needs debridement or flap closure is required.


aspects of the wound. The repair of the tissuesusually follows the opposite direction, building

from the bottom of the wound outward.In general, the order of repair should follow

from the larger stabilizing structures to the finger

nutrient supplying structures. The authors there-fore prefer to obtain skeletal fixation first toprovide stability, maintain length, and offer pro-

tection to other tissues. The tendon repair followsso that the microscopic anastomosis can proceedwithout fear of endangering the more delicatestructures. Following nerve and artery repair,

attention is focused on soft tissue coverage. Thereare, however, exceptions to the order of repair.

Tissue that has been rendered ischemic forprolonged periods may require revascularization

much sooner than could be afforded by thecomplicated or prolonged osteosynthesis or ten-don repairs [6,9]. Occasionally the arterial repairs

therefore can be performed following the bonyfixation or even before the bony fixation by meansof a temporary vascular conduit. Such vascular

conduits provide arterial inflow into the devascu-larized distal tissue so that ischemia time can bedecreased. It is usually not necessary to providea venous outflow conduit. Instead the venous

blood is allowed to drain around the limb. Thisdecreases the flush of blood that contains

Fig. 4. (A) A 15-year-old girl caught her hand in a grinder. Multiple digits are involved with fractures and soft tissue

devascularization. (B) Osteosynthesis can be performed with K-wires, lag screws, plates, interosseous wires, external

fixators, or a combination of any of the above.

Fig. 5. (A) A nerve gap noted following injury to the index finger. (B) A nerve conduit can be used instead of nerve

grafts. Polyglycolic acid (Neurotube�) is easily fit to size and provides excellent regeneration of the nerve.


proinflammatory cytokines and breakdown prod-ucts from the revascularized limb into the systemiccirculation where a systemic inflammatory re-action (SIRS) phenomenon may result in multi-

organ failure and possibly death [5].Soft tissue coverage is often difficult to obtain

with mutilating hand traumas. Exposed tendon,

bone, joints, hardware, or neurovascular bundlesobviously require regional, distant, or free flapclosure. The contaminated nature of the injuries,

however, prevents the use of flaps until the tissuesare clean and optimized for infection control. Inthis light, it is prudent for the surgeon to return

to the operating theater for a second look,debridement, and irrigation approximately 24–48 hours following the initial surgery. Thissecond look surgery helps decrease the bacterial

load and identify those tissues that originallyseemed viable but subsequently declare them-selves otherwise. The need for further debride-

ment of devitalized tissue is not uncommon. Attimes, a third look may be required also. It is forthis reason that an emergency free tissue transfer

is not advocated. Once the surgeon is contentwith the cleanliness of the wound, soft tissueclosure can ensue [10–18].

Fig. 6. (A) A 23-year-old woman with a mutilating injury to the left arm from an explosion. Multiple metacarpal

phalanx fractures and radius fractures are present. The ulnar digits are compromised. (B) Salvage of as many digits as

possible may optimize function. A free rectus abdominal flap was used for closure of the forearm and hand. Good

function was returned to the thumb, index, and long fingers.

Fig. 7. As per case report 1.


Before the definitive closure, saline dressings,

xenografts, or allografts are sufficient to providetemporary coverage (Fig. 3). Occasionally, anti-biotic beads and opsite are used over wounds in

which bone gaps or defects are evident. The exactmeans of obtaining bony fixation is probably lessimportant than the adherence to the principles offracture management [19–26]. The fracture loca-

tion, geometry, deforming forces, and presence ofsoft tissue loss dictate the optimum treatment.

Plates, screws, K-wires, interosseous wires, or

external fixators all have a role in fracture fixationof various structures (Fig. 4). Severe comminu-tions of bone or frank loss of bone stock in

mutilating hand injuries offer a further challenge.External fixators are often used if segmentaldefects in the bone are present. The externalfixator maintains length and position until the

definitive bone graft from the iliac crest can beused to bridge the defects. Ultimately, the key to

Fig. 7 (continued )


success is a good functional outcome with skeletalunion, anatomic alignment, and joint mobility.Older patients, fractures with severe comminution

or bone loss, intra-articular fragments, associatedtendon injury, over-zealous periosteal stripping,and prolonged splinting are all factors that

increase the risk for nonunion, malunion, orstiffness. The severity of the injury, the bloodsupply to the tissues, the surgical dissection, and

the rehabilitation all play a significant role in theamount of scarring and functional outcome.

Soft tissue repair should follow skeletal stabi-lization. Significant loss of specialized tissue suchas nerves or vessels offers yet another challenge

for the hand surgeon. For instance, the greater theseverity of the injury, the greater the chance thatvein grafts will be needed for vascular repair. The

authors prefer to map out the volar forearm veinswith a sterile marking pen before tourniquets areapplied so that the exact location of these veins

can be easily identified. One leg is often preppedout also, in case larger veins are required from the

Fig. 7 (continued )


lesser or greater saphenous systems or from thedorsal venous arch on the foot. Vein grafts are

used commonly to bridge arterial and venousgaps. Vessels with obvious intimal damage need tobe cut back to normal appearing anatomy. Manysurgeons prefer to foreshorten the bone during

replantation to avoid using vein grafts. At times,however, there is little option other than to usesuch grafts. Emergency vein grafting is used to

salvage the digits or limbs and return normalvascularity to ischemic tissues. Emergency use ofgrafts for other specialized tissue, such as nerves

or tendons, is less justified because of the riskfor subsequent loss of the grafted tissue if thereis infection or subsequent soft tissue coverageloss. Nerve grafts, tendon grafts, and bone grafts

should be delayed until the stable soft tissuecoverage is obtained. The loss of a flap that is usedto cover a wound that had immediate nerve,

tendon, or bone grafting would likely result in lossof these specialized grafts. Not only does this putthe patient through another prolonged procedure,

but further donor sites will be needed, increasingthe morbidity of the overall management. At 4–6weeks following the soft tissue coverage the flap

can be elevated and the definitive grafting of thespecialized tissue performed. At times, the sameflaps used to provide soft tissue coverage can beused to carry with a nerve, bone, or tendon graft,

thus providing a vascularized graft. For example,the palmaris longus tendon or the antebrachial

nerve can be incorporated easily with the radialforearm flap. Vascularized bone grafts can beharvested with the groin, scapular, radial forearm,and osteoseptocutaneous fibular flaps. The donor

site morbidity and amount of graft required needsto be well assessed before contemplating these in-novative procedures.

Nerve grafts for use in the palm or digits areusually harvested from the distal posterior inter-osseous nerve at the dorsal wrist within the fourth

dorsal compartment or from the medial antebra-chial nerve. These donor nerves are usually a goodsize match for the palmar or digital nerves.Polyglycolic acid (PGA) conduits (Neurotube�,

Bel Air, Maryland) have been used to bridge smallgaps of less than 3 cm in the fingers [27] (Fig. 5).Some evidence exists that conduit repairs may

provide as good a recovery as the standard nervegrafts. Donor site morbidity is obviously avoidedwith the use of the PGA conzduits.

Tendon grafts can be harvested from the pal-maris longus, plantaris, or toe extensor tendons.Extensor indicis proprius or extensor digiti qunti

transfers can be used if only one tendon re-construction is required in the hand.

Complete amputations within the upper ex-tremities are often salvageable if ischemia time is

Fig. 7 (continued )


Fig. 8. As per case report 2.

Fig. 8 (continued )


Fig. 8 (continued )

limited, multiple levels of injury are not apparent,

the limb is not severely crushed or avulsed, ormedical conditions do not jeopardize the patient’slife [7]. The more proximal the amputation on the

extremity, the easier the technical demand for thesurgeons. Distal amputations offer greater tech-nical challenges. Functionally, however, the distal

amputations offer better results than do proximallimb amputations [6,28]. In general, less than6 hours of warm ischemia or 12 hours of coldischemia are often the quoted time limits to

attempt replantation. Reports of warm ischemiaup to 42 hours and cold ischemia up to 96 hourshave been published [29,30].

Despite the many advances in microsurgeryand replantation surgery, it is not always possibleto replant amputated parts. The tissue, digits, or

limbs that have been amputated, however, couldpossibly be used for other reconstructive purpo-ses. Some functions or skin coverage may besalvaged using principles of ‘‘spare parts’’ surgery

[31,32]. Fingers, joints, bone, and skin can betransferred, either on a vascular pedicle or as a freetissue transfer to other parts of the mutilated hand

to offer some element of function back to thelimb. Tissue should not be discarded either at thescene of the accident or in the hospital until all

options for possible use have been dismissed.Salvaging one or two digits that regain sensationand mobility is usually much more functional

than a prosthesis (Fig. 6).Severely mangled limbs are fraught with

multiple tissue injuries including bone, tendon,intrinsic muscles, neurovascular bundles, and

skin. The subsequent healing, swelling, and theneed for early immobilization in many cases mayrender the hand stiff and dysfunctional. Second-

ary procedures are extremely common to restoreeven basic functional tasks. Tenolysis, joint

contracture releases, web space deepening, or

finger lengthening may be required to improvemotion and function at the interphalangeal,metacarpal phalangeal, and wrist joints. Hands

left without a full complement of digits may haveimproved function with toe to hand transfers. Toeto hand transfers can usually restore prehen-

sion and improve the functional outcome of themutilating hand injury. Partial toe or toe wrap-around procedures may optimize functional andaesthetic appearances of the reconstructed hand

[33]. Second and third toe transfers are best suitedfor reconstruction of the more ulnar digits so thatmore adequate opposition can occur [32,34–36].

Sensate digits with restoration of some motionhave significant functional advantages over pros-theses [37]. Prostheses are usually designed for

a given set of limited tasks, and therefore do notappropriately aid in all of the activities of dailyliving. The cumbersome nature of some prosthesescompromises compliance and satisfaction in many

patients. Bearing this in mind, however, there isdistinct indication for the use of various prosthet-ics [38]. The prosthesis can be used in either an

active or passive fashion. Active prostheses havesome element of mobility so that procedures suchas holding, grasping, and pinching can be per-

formed. Passive prostheses on the other hand donot have the intrinsic ability to move, but mayact as an assist hand in some cases. Passive

prostheses also have an important role in return-ing the normal appearance to the finger or hand.Complete amputations of the hand, forearm,or upper arm are usually indications for active

prostheses. The prostheses may be biomechanical,using shoulder muscles or the intrinsic muscleswithin the forearm or arm. Alternatively, myo-

electric and computerized prostheses are nowtechnically available.

Fig. 8 (continued )


The following cases illustrate the complexitiesand many facets of managing mutilating handinjuries.

Case 1

A 52-year-old man sustained a mutilatinghand and wrist injury while mounting a tire onto

a wheel. The tire exploded and the rim struckhis right dominant hand. Initial inspection onpresentation to the hospital revealed a severe

degloving injury with marked intercarpal dislo-cations (Fig. 7A, B). Vascularity of the hand wasintact. The hand was irrigated and debrided in

the operating room. The carpus was reduced andpinned (Fig. 7C) and the skin loosely approxi-mated.

Within 2 days, compromise of the vascularity

became obvious with discoloration of severalfingertips (Fig. 7D). Arteriography revealed oc-clusion of his superficial and deep arches with

minimal flow to the fingers (Fig. 7E). He wastaken back to the operating room where thesmall finger was amputated. A palmar arch was

reconstructed using a venous arch from thedorsum of the foot (Fig. 7F). With further ob-servation, it became evident that the palmar anddorsal soft tissue coverage of the hand was

inadequate (Fig. 7G, H). Consequently, 3 weekspost injury, the hand was re-debrided and coveredwith a parascapular free flap (Fig. 7I, J).

Late secondary procedures included debulkingof the flap. He returned to his prior employmentwith a functional hand (Fig. 7K, L).

Case 2

A 21-year-old man sustained an injury to hisnondominant left hand in a motorcycle accidentwhile racing. During the accident, one of the tires

caused a severe friction burn to the hand anda dislocation of the thumb (Fig. 8A). The woundwas debrided and the dislocation was pinned

(Fig. 8B, C). Definitive closure was attemptedwith a parascapular fascial free flap and skingrafting 4 days later (Fig. 8D, E). Loss of the

distal end of the flap resulted in exposure ofthe index MP joint and loss of the extensor tothe index (Fig. 8F). A pedicled groin flap thenprovided secondary coverage (Fig. 8G, H). At

the time of division of the groin flap, a first webspace contracture was released and closed using

the opposite end of the groin flap (Fig. 8I–K).Five months post injury, coverage and range ofmotion was good except for lack of index

extension (Fig. 8L–N). Subsequent debulking ofthe second and third web spaces along withtendon grafting resulted in improved function(Fig. 8O–T).

These cases illustrate some of the principlesthat are used in treating mutilating hand injuries.Adherence to sound, safe principles helps prevent

further morbidity while fostering the restorationof hand function to return the patient to gainfulactivities of daily living.

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Biomechanics and hand trauma: what you needSteven L. Moran, MDa,*, Richard A. Berger, MD, PhDa,b

aDivision of Plastic Surgery, Division of Hand and Microsurgery, Mayo Clinic,

200 First Street SW, Rochester, MN 55905, USAbDepartment of Orthopaedic Surgery, Mayo Medical School, Rochester, MN 55905, USA

Mutilating hand injuries pose many challenges

to the hand surgeon. The variety and severity of

these injuries has led to the development of several

grading scales, flow charts, and algorithms to help

the surgeon organize his or her treatment plan [1–

4,112]. These tools help the surgeon in preparation

for surgery, but fail to predict hand function fol-

lowing reconstruction accurately. It can be agoniz-

ing for the hand surgeon, especially the young

hand surgeon, intraoperatively to contemplate

accurately the functional loss imposed by imme-

diate joint fusion or digital amputation. Heroic

attempts are often made to salvage joints and dig-

its, whose loss results in little functional deficit. In

addition, these severely injured fingers and joints

often become stiff and insensate, requiring delayed

amputations. This not only prolongs patient re-

covery but also prolongs the surgeon’s anxiety.

Many articles dealing with the mutilated hand

contain experience-based protocols and reference

previous anecdotal reports [5–8]. Are there any

biomechanical principles of hand dynamics that

could help in deciding what must be preserved

and what can be discarded? Unfortunately, biome-

chanical studies involving mutilating hand injuries

are scarce. This article establishes a biomechanical

foundation for determining what anatomic com-

ponents are needed for hand function.

The essentials

In its most elemental form, the hand is com-

posed of a stable wrist and at least two digits that

can oppose with some power. One digit should be

capable of motion so it can grasp objects. The

other digit need only act as a stable post against

which the movable digit can pinch. To allow for

prehensile movements the digits require some form

of cleft to divide them, which allows for the accom-

modation of objects. The digits need to be sensate

and pain free or they provide little benefit over

prosthesis [6,7,9]. Requirements for functional

sensation have been defined as two-point discrim-

ination of less than 10 to 12 mm [10].

The hand allows for prehension, which is the

ability to grasp and manipulate objects. As defined

by Tubiana et al [11], prehension ‘‘may be defined

as all the functions that are put into play when an

object is grasped by the hands—intent, permanent

sensory control, and a mechanism of grip.’’ Pre-

hension requires that the hand be able to ap-

proach, grasp, and release an object [11,12]. If

only two sensate digits remain to oppose each

other, some prehension is possible.

In terms of biomechanical motion the hand

performs approximately seven basic maneuvers,

which make up most hand function:

1. Precision pinch (terminal pinch). This in-

volves flexion at the distal interphalangeal

(DIP) joint of the index and at the interpha-

langeal joint (IP) joint of the thumb. The ends

of the fingernails are brought together as in

lifting a paper clip from a tabletop (Fig. 1).

2. Oppositional pinch (subterminal pinch). The

pulp of the index and thumb are brought

together with the DIP joints extended. This

allows for force tobe generated through thumb

opposition, first dorsal interosseous contrac-

tion, and index profundus flexion. This is often

measured with a dynamometer (Fig. 2).



(S.L. Moran).


doi:10.1016/S0749-0712(02)00130-0

Hand Clin 19 (2003) 17–31

3. Key pinch. The thumb is adducted to the ra-

dial side of the middle phalanx of the index

finger. Key pinch requires a stable post (usu-

ally the index finger), which has adequate

length and a metacarpal phalangeal (MP)

joint, which can resist the thumb adduction

force (Fig. 3).

4. Directional grip (chuck grip). The thumb, in-

dex, and long finger come together to sur-

round a cylindrical object. When using this

grip, a rotational and axial force is usually

applied to the held object (ie, using a screw-

driver) (Fig. 4).

5. Hook grip. This requires finger flexion at the

IP joints and extension at the MP joints. It is

the only type of functional grasp that does

not require thumb function. This grip is used

when one lifts a suitcase (Fig. 5).

6. Power grasp. The fingers are fully flexed while

the thumb is flexed and opposed over the

other digits, as in holding a baseball bat.

Force if applied through the fingers into the

palm (Fig. 6).

7. Span grasp. The DIP and proximal interpha-

langeal (PIP) joints flex to approximately 30

degrees and the thumb is abducted. Force is

generated between the thumb and fingers, dis-

tinct to power grasp where force is generated

between the fingers and the palm. Stability is

required at the thumb MP and IP. This grip

is used to lift cylindrical objects (Fig. 7)

[11,13,14].

Postoperatively, the hand’s ability to adopt

these positions and exert force through them

impacts how well the patient rehabilitates. These

maneuvers are predicated on good sensation in

the fingers and thumb. Through the preoperative

history, the hand surgeon can determine which

hand functions benefit the patient most in

Fig. 1. Precision pinch (terminal pinch).

Fig. 2. Oppositional pinch (subterminal pinch).

Fig. 3. Key pinch.

Fig. 4. Directional grip (chuck grip).

18 S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 17–31

returning to their previous employment or activ-

ities, and direct the reconstruction appropriately.

Many classification schemes divide hand

trauma into dorsal, volar, radial, and ulnar inju-

ries [1,3]. When assessing the effects of mutilating

trauma on hand mechanics, however, it may be

easier to think of the hand as containing four func-

tional units: (1) the opposable thumb; (2) the index

and long finger, whose stable basal joints serve as

fixed posts for pinch and power functions; (3) the

ring and small finger, which represent the mobile

unit of the hand; and (4) the wrist. It may also help

to think of only two major forms of hand motion,

as opposed to seven: thumb-finger pinch and digi-

topalmar grip. Pinch requires preservation of the

thumb unit and a stable post. If the patient is able

to add a third digit to pinch, they can achieve more

precision. Pinch function tends to be preserved

when the median nerve is intact and the thumb

and index-long units of the hand are salvageable.

Without median nerve function, thumb sensation

and thenar function are lost, making fine motor

movements negligible. In comparison, ulnar nerve

function and the ring-small finger unit are more

important for digitopalmar grip, where flexion and

sensation in the ulnar digits are essential. Thumb

preservation is also important in power grasp to

provide stability and control of directional forces.

With these principles in mind this article now

examines how digital loss affects hand function.

The biomechanical impact of amputation

Partial or complete amputations are present in

most mutilating hand injuries. It has been recom-

mended that immediate amputation be performed

when four of the six basic digital parts (bone, joint,

skin, tendon, nerve, and vessel) are injured [8,15–

20]. It is important to consider amputation in these

situations because long-term stiffness and pain in a

salvaged digit can severely hamper the rehabilita-

tion of the remaining hand. When performing an

amputation, however, one should understand how

digital loss impacts overall hand function.

The thumb

The functional importance of each digit has

been debated. If one were to prioritize the digits

to be saved following mutilating injury, the thumb,

with its importance in prehension and in all forms

of grasp, takes top priority [109]. It provides 40%

of overall hand function in the uninjured setting

[21–23]. Following mutilating trauma, when digits

are missing or stiff, the thumb can account for

greater than 50% of hand function [24]. Its unique-

ness and versatility in humans is caused by the

Fig. 5. Hook grip.

Fig. 6. Power grasp.

Fig. 7. Span grasp.

19S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 17–31

position of the thumb axis. The thumb axis is

based at the trapeziometacarpal (TMC) joint and

is pronated and flexed approximately 80 degrees

with respect to the other metacarpals in the hand

[25]. This positioning allows for circumduction,

which permits opposition [26–29].

Opposition of the thumb is necessary for all

useful prehension and its preservation provides

the basis for successful salvage procedures. Oppo-

sition of the thumb is the result of angulatory

motion, which is produced through abduction at

the TMC joint, and flexion and rotation of the

TMC and MP joints [30]. Multiple muscles are

required for functional opposition. These include

the abductor pollicis brevis, the opponens pollicis,

and the superficial head of the flexor pollicis bre-

vis. These muscles act simultaneously on the

TMC joint and theMP joint. The abductor pollicis

brevis provides the major component of opposi-

tion, with the opponens pollicis and flexor pollicis

brevis providing secondary motors for opposition.

All measures should be directed toward preserving

or reconstructing the abductor pollicis brevis if

possible [25,28–32]. The extensor pollicis longus

(EPL) and adductor pollicis (ADD) are antago-

nists to thumb opposition providing a supinating

extension and adduction force.

The priorities of thumb reconstruction vary

with the level of amputation, but at all levels recon-

struction should attempt to restore opposition and

pinch (Fig. 8). Injuries distal to the IP joint (zone 1

injuries) may produce little functional deficit,

because oppositional length tends to bemaintained

[33,34]. Residual insensibility and dysesthesia from

trauma produce more functional problems at this

level than the mechanical loss of length [35,36].

Subterminal pinch and precision pinch are com-

promised if an unstable or painful scar is present

at the thumb remnant. Loss of the distal phalanx

and IP joint (zone 2 injuries) may also not require

reconstruction. Functionmay be preserved if TMC

and MP motion is maintained [37].

Level three injuries, through the level of the

MP, are the most common and do represent a sig-

nificant loss of function. Unreconstructed injuries

result in a decrease in pinch dexterity and grip

strength [38]. The MP joint of the thumb has no

other mechanical equivalent in the hand. It has

three degrees of freedom; it represents a ball and

socket joint in extension, but when the joint is

flexed, the tightening of the collateral ligaments

causes the MP joint to function more like a hinge.

The intrinsic muscles provide motion but also pro-

vide dynamic stability to the joint.

Fig. 8. Diagram depicting levels of thumb injury, as originally described by Hentz [31]. Zone 1 injuries result in tissue

loss distal to the IP joint. Zone 2 injuries result in thumb loss distal to MP joint. Zone 3 injuries result in loss of the MP

joint but preservation of thenar musculature. Zone 4 injuries occur distal to TMC joint with loss of thenar musculature.

Zone 5 injuries result in loss of the TMC joint. The zone of injury determines reconstructive priorities.


In injuries proximal to the MP joint one may

proceed with a free toe transfer, which is the gold

standard. The great toe metatarsal phalangeal

joint can reproduce the flexion and extension arc

of the MP joint, but fails to reproduce the MP

joints 15 to 20 degrees of supination [35]. Func-

tional opposition is also possible with a toe wrap-

around flap. This reconstruction only allows for

TMCmotion. Excellent results have been obtained

when the fusion angles with bone graft were 30

degrees of flexion and 45 degrees of internal

rotation. These fusion angles allowed for pinch

between all fingers and produced pinch and grip

strengths of 60% and 97%, respectively [39]. Non-

microsurgical methods for reconstruction of level

three defects can include deepening of the first

web space, but any injury to the adductor or the-

nar musculature should be significantly discour-

aged in an already traumatized thumb.

Level four injuries result in damage to the thenar

muscles,with resultant instability to theTMC joint.

This produces a major stumbling block in thumb

reconstruction, because TMC stability is required

for any successful thumb reconstruction. Injuries

at this level often require some form of soft tissue

reconstruction for restoration of opposition and

pinch [38,40]. In its most primitive form pinch can

be recreated, as in the tetraplegic patient, with

fusion of the IP and MP and reconstruction of the

adductormusculature. For reconstruction of oppo-

sitional pinch, however, tendon transfers may be

necessary. In a study by Cooney et al [27], muscle

cross-sectional area andmoment arm analysis were

used to determine the best donor muscle for oppo-

sitional transfer. The flexor digitorum superficialis

(FDS) of the long finger and the extensor carpi

ulnaris (ECU) muscles closely approximated

thenar muscle strength and potential excursion.

Abduction from the palm was greatest after trans-

fer of the FDS from the long and ring fingers

and after ECU and extensor carpi radialis longus

(ECRL) transfers. Pulley location was found to

influence the motion and strength of transfers in

both the flexion and abduction planes. Both

Bunnell [41] and Cooney et al [27] stress the im-

portance of directing the force of the transfer

toward the pisiform. Transfers that are distal to

the pisiform, such as those using the extensor digiti

minimi (EDQ) or abductor digiti minimi (ADQ),

produce more flexion than abduction. Transfers

proximal to the pisiform, such as the FDS using

the flexor carpi ulnaris (FCU) loop as a pulley, pro-

duce more abduction and less metacarpal flexion

(Fig. 9).

Level five injuries represent a loss of the TMC

joint. In these cases restoration of TMC mobility

is probably best achieved by index ray polliciza-

tion, if available. The TMC joint is mechanically

equivalent to a universal joint [28,30,42]. The

TMC joint allows for thumb circumduction and

thumb extension with associated supination, and

pronation with thumb flexion. The TMC joint is

very complex because of its inherent instability at

the radial aspect of the wrist with no bony stabil-

izers proximal (mobile scaphoid). This inherent

instability accounts for the large number of liga-

mentous supports that surround the joint (Fig.

10.). There are five major internal ligamentous

stabilizers of the TMC joint: (1) dorsal radial

ligament, (2) posterior oblique ligament, (3) first

intermetacarpal ligament, (4) ulnar collateral liga-

ment, and (5) the anterior oblique ligament. The

dorsal radial ligament prevents lateral subluxa-

tion. The posterior oblique ligament provides

stability in flexion, opposition, and pronation.

The first intermetacarpal ligament is taut in abduc-

tion, opposition, and supination; it holds the first

metacarpal tightly against the second metacarpal.

The intermetacarpal ligament is joined by the

ulnar collateral ligament, which prevents lateral

subluxation of the first metacarpal on the tra-

pezium and controls for rotational stress. The base

of the index metacarpal should be spared during

any type of ray resection to preserve the intermeta-

carpal ligament [43,44]. The fifth and most impor-

tant ligament is the volar anterior oblique ligament

Fig. 9. Diagram depicting the use of the superficialis

tendon from the long finger for restoration of thumb

opposition. Tendon transfers directed proximal to the

pisiform tend to produce greater metacarpal abduction

and less metacarpal flexion as compared with transfers

directed distal to the pisiform. The superficialis tendons

from the long and ring fingers closely approximate the

excursion and strength of the original thenar mus-

culature, and provide for an ideal tendon for transfer.

FDS ¼ flexor digitorum superficialis; FCU ¼ flexor

carpi ulnaris; P ¼ pisiform.


with its deep and superficial components. The lig-

ament arises from the volar tubercle of the tra-

pezium and inserts on the volar aspect of the

thumb. The anterior oblique ligament is taut in

extension, abduction, and pronation; it controls

pronation stress and prevents radial translation.

The deep anterior oblique ligament serves as a

pivot point for the TMC joint and guides the meta-

carpal into pronation while the thenar muscles

work in concert to produce abduction and flexion.

These fibers limit ulnar translocation of the meta-

carpal during palmer abduction while working

with the superficial anterior oblique ligament to

constrain volar subluxation of the metacarpal.

The anterior oblique, intermetacarpal, and dorsor-

adial ligaments are the most critical for preserva-

tion and reconstruction [42–44].

The index finger

The index finger may be of next highest impor-

tance because of its flexion and extension inde-

pendence, its ability to abduct, and its closeness

to the thumb. It has a major role in precision pinch

and directional grip [11,13,45,46]. A good range of

motion for the index finger is more important than

length. Amputation through the PIP leaves all

remaining stump flexion to the control of the

intrinsics. This allows for flexion to approximately

45 degrees. It may be shortened to the end of the

proximal phalanx and still participate in direc-

tional grip, span grasp, and lateral pinch [13].

The body, however, is quick to bypass the digit

for the long finger if it becomes insensate or stiff.

The long finger replaces the index for terminal

and subterminal pinch if amputation exists below

the DIP level.

Elective loss of the index ray has been well

studied. Murray et al [47] studied patients who

underwent elective ray amputation. The study

found that power grip, key pinch, and supination

strength were diminished by approximately 20%

following surgery. Patients with persistent dyses-

thesia following ray amputation experienced larger

losses in grip strength. In addition, pronation

strength was diminished by 50% following ray

resection. Pronation strength is used for direc-

tional grip. This large decrease in pronation

strength is caused by a shortening of the palm’s

lever arm. In the intact hand, the width of the grip

extends from the hypothenar region to the index

finger. The ulnar aspect of the palm represents

the internal fulcrum and the radial aspect of the

palm represents the external fulcrum of move-

ment. With the loss of the index finger ray the ful-

crum is decreased by approximately 25% (Fig. 11).

This results in a loss of stability and a decrease

in mechanical advantage. Despite the loss of

strength, all patients in this study, without postop-

erative dysesthesia, believed that their overall hand

function had been improved, especially in regard

to prehension with the thumb [47]. This suggests

that the ability to perform precise activities is more

important for postoperative patient satisfaction

than the preservation of grip strength. In compar-

ison, a recent study of patients with traumatic

proximal phalanx amputations of the index finger

and patients with elective index ray resections

found that patients with amputation through the

proximal phalanx demonstrated a better func-

tional outcome when assessed with the DASH

questionnaire. A 30% decrease in pinch and grip

strength was seen in both groups. Cosmesis was

believed to be better with ray amputation [48].

Overall, it seems that a remaining proximal pha-

lanx stump does provide a benefit in terms of grip

Fig. 10. Diagram of the trapezio-metacarpal joint

showing the outlay of the dorsal and volar ligaments.

Special attention must be given to preservation of this

joint for adequate thumb stability. The most important

ligaments for reconstruction and preservation are the

dorsal radial ligament (DRL), posterior oblique ligament

(POL), ulnar collateral ligament (not depicted), first

intermetacarpal ligament (IML), and the anterior oblique

ligament, deep and superficial heads (DAOL and SAOL).

APL ¼ abductor pollicis longus; DIML ¼ dorsal inter-

metacarpal ligament; DT-II MC ¼ dorsal trapezio-II

metacarpal; DTT ¼ dorsal trapeziotrapezoid.


strength and overall hand function. In light of the

high rate of postoperative dysesthesia associated

with ray resection, it seems that immediate index

ray resection should be reserved for very proximal

injuries where there is little chance of postopera-

tive MP motion.

The long and ring fingers

The long finger does provide the most finger

flexion force when tested individually [49,50]. Its

central position allows it to participate in power

grip and precision grip. Patients are easily able to

substitute this digit for terminal and subterminal

pinch following the loss of the index finger. The

middle ray does lack the specialization of the first

dorsal interosseous muscle when performing pinch

functions. Transfer of the first dorsal interosseous

to the insertion of the second dorsal interosseous

has been suggested following first ray resection;

however, studies have shown that this does not sig-

nificantly increase pinch strength [47,51]. In addi-

tion, this transfer can lead to the development of

an intrinsic plus deformity in the long finger

[47,52]. The ring finger has less strength than either

the index or long. It is also rarely used for precision

pinch or grip. As an individual digit, Tubiana et al

[11] believe the ring finger’s loss leaves the least

functional deficit in the hand. When this finger is

combined with the small as a functional unit, how-

ever, it can provide for adequate power grip and

replace the index and long for pinch maneuvers

should both digits be lost.

Central ray deletion, or loss of both ring and

long fingers, may produce scissoring of the remain-

ing digits because of instability of the transverse

metacarpal ligament and compromised inteross-

eous function. Three-point chuck pinch is com-

promised, as is hand competence, because small

objects may fall through the central defect [53–

55]. Acute central ray resection with repair of the

transverse metacarpal ligament may still result in

scissoring of the neighboring digits, inadequate

closure of the gap, and loss of abduction of the

small ray [54,56,57]. In cases of central digital loss,

a ray transposition may alleviate hand incompe-

tence and reduce scissoring of the digits. Results

of strength testing following ray transposition for

central digital loss have found an average decrease

in grip and pinch strength of 20%, with larger

decreases in function being seen for index to long

transfer when compared with small to ring trans-

fers. Loss of motion was only 9% following

transfer [56]. Although ray amputation may be

indicated in cases of central digital loss, it seems

most prudent to perform this procedure in a

delayed fashion, after a discussion has been carried

out with the patient regarding his or her needs with

regard to hand strength and motion.

The small finger

The small finger has the least strength in flex-

ion; however, its loss can have broader implica-

tions on hand function. In digitopalmar grip the

fifth ray presses objects and tools into the palm.

This is caused by the additional motion provided

by its carpal-metacarpal (CMC) joint, which can

move forward 25 degrees. Stabilization is also

added by the hypothenar muscles, which augment

the flexion of the first phalanx of the small finger.

In addition, the small finger’s abduction capabil-

ities significantly enhance span grasp. Tubiana

et al [11] believe the fifth finger, with its metacarpal,

has the greatest functional value after the thumb.

Digital loss

For the most part single digit amputation, with

the exception of the thumb, does not result in the

loss of essential hand function. Brown [18] studied

183 surgeons who suffered partial or total digital

amputations. Only four surgeons were unable to

continue operating following their injuries. Most

Fig. 11. Diagram showing the resultant effects of ray

excision on pronation and supination strength. Resec-

tion of the metacarpal narrows the palms. This shortens

the palm’s lever arm and decreases the hand’s mechan-

ical advantage during pronation and supination.


surprising was the finding that 15 surgeons who

had experienced thumb amputations through the

metacarpal or MP joint level were able to continue

operating with only minimal adaptation in their

surgical practice. Brown [18] concluded that the

motivation of the patient is more important than

the actual number of retained digits when attempt-

ing to predict functional outcome for digital

amputation. Of note, none of these surgeons had

to perform repetitive strenuous activity with the

hand and grip strength presumably was not a

major issue.

Unlike single-digit amputation, the amputation

of several digits still remains a challenging prob-

lem. Unfortunately, in the mutilated hand, multi-

ple digital losses are the norm, because severely

crushed and avulsed digits preclude replantation.

Preservation of the thumb and a single digit allows

for some prehensile grasp, but for optimal func-

tion the reconstruction of an additional digit is

recommended [24,58–60]. The preservation or

reconstruction of the thumb and two digits allows

for the possibility of chuck pinch, which is stronger

than subterminal pinch. The use of a third digit

confers lateral stability in power pinch. A third

digit also allows the patient to perform hook grip

and power grasp. Span grasp is now possible

because functional palmar space is increased

allowing for grasp of larger objects [24,58–60].

Wei and Colony [24] have found it preferable to

place toes next to remaining mobile fingers or in

the interval between them. They believe the adja-

cent digits contribute to cosmesis, help coordinate

movement, and smooth oppositional contact.

In injuries where there is loss of all fingers but

sparing of the thumb, reconstructive goals should

attempt to maintain useful thumb web space and

an opposable ulnar post of adequate length. Addi-

tional digits may be created with microvascular toe

transfer [24,59–62]. Other options include the

transfer of remaining functional digits to more

useful positions. Transferring salvageable digits

to the ulnar side of the hand maintains the width

of the palm, and allows for power grasp and

the incorporation of pinch [21,22,24]. The radial

placement of reconstructed digits is more cosmeti-

cally pleasing but fails to take advantage of the

added power provided by intact hypothenar mus-

culature and the motion provided by the fifth

CMC joint. In cases where there has been loss of

all digits including the thumb, microvascular

reconstruction of the thumb is required with the

additional creation of a stable ulnar post. The pre-

vious practice of constructing a cleft hand has been

shown to provide little benefit for hand function. It

often has no effective prehension or grasp and does

not adequately compare with the results obtain-

able with microsurgical reconstruction [24,59–62].

The biomechanical impact of fusion

There are several instances where the severity of

the trauma precludes any anatomic restoration of

the joint surface. These situations may require

fusion. Unfortunately, change in a single joint has

implications on the balance of the entire digit, and

the biomechanics of the hand. How do fusions

impact overall hand function?

Finger fusion

Of all fusions, DIP fusions are well tolerated

and probably impart the least detriment to hand

function. Fifteen percent of intrinsic digital flexion

occurs at the DIP joint but the DIP joint contrib-

utes only 3% to the overall flexion arc of the finger

[63]. Recent mechanical testing has shown that

after simulated DIP fusion of the index and middle

finger, there is a 20% to 25% reduction in grip

strength when compared with prefusion values.

The decrease in grip strength may be secondary

to the limited excursion of the profundus tendon

following fusion; this can create a quadriga effect.

It has been suggested that fusion in a more flexed

position creates additional slack in the profundus

tendon, decreasing the loss of grip strength; how-

ever, this has not been shown clinically [64]. For

most individuals, with the exception of musicians,

arthrodesis is preferred over arthroplasty at the

DIP level.

The PIP joint produces 85% of intrinsic digital

flexion and contributes 20% to the overall arc of

finger motion. Littler and Thompson [65] de-

scribed this joint as the ‘‘functional locus of fin-

ger function.’’ PIP joint impairment can adversely

affect the entire hand; however, a full range of PIP

joint motion is not essential for hand function. An

arc extending from 45 to 90 degrees can provide

relatively normal function [66,108]. In addition,

mild flexor contractures at the PIP level can be

compensated for through hyperextension of the

MP joint. This allows the finger to move out of

the plane of the palm when attempting to lay the

hand flat or when placing objects into the palm.

A PIP fusion is often well tolerated in the index

finger because the index’s relatively independent

profundus function does not impose a significant

quadriga effect on the other fingers during power


grasp. PIP fusion of the long finger, however, has

been shown to decrease the excursion of all pro-

fundus tendons, reducing grip strength. PIP fusion

restricts profundus excursion to a greater extent

than DIP or MP fusion [47,67,68]. In a study by

Lista et al [67], a significant decrease in grip

strength occurred when the PIP joints of the index

and small finger were fixed at less than 45 degrees

and when the long and the ring were fused in a

position of less than 60 degrees of flexion. If both

MP and PIP joints are injured, salvage of the

MP joint through arthroplasty or other measures

is preferred over PIP joint arthroplasty. Grip

strength is decreased because of a quadriga effect,

but prehension can be maintained as long as the

thumb or border digit is capable of opposition. It

is important to remember that two consecutive

fusions increase stress at the next proximal joint,

because of an increase in the lever arm working

across the joint. This accelerates the degeneration

of adjacent joints if they are also injured.

Delayed arthroplasty of the PIP joints in cases

of trauma maintains motion and improves grip

strength [69]. Classic teaching has suggested that

index PIP joint arthrodesis be performed instead

of silicone arthroplasty, to provide stability for

key pinch. Surface replacement arthroplasty, how-

ever, may provide adequate stability for index

finger PIP arthroplasty. PIP stability has been pre-

served following surface replacement arthroplasty

with loads up to 22 N in experimental cases where

there was preservation of 50% of the index collat-

eral ligaments [70].

The MP joints probably represent the most

important joint for hand function. They contrib-

ute 77% of the total arc of finger flexion [63,

65,66,71,72]. Unlike the giglymoid IP joint, which

functions like a sloppy hinge joint, the condyloid

MCP joint is diarthrodial, allowing for flexion-

extension, abduction-adduction, and some rota-

tion [71,73–75]. Most prehension grips require

that the digits extend and abduct at the MP joint

[74,76]. Precision pinch requires flexion, rotation,

and ulnar deviation at theMP joint [73,74]. During

pinch the radial intrinsics and the collateral liga-

ment to the index must resist the stress applied

by the thumb. According to the American Medical

Association’s Guide to the Evaluation of Perma-

nent Impairment, fusion of the MP joint results

in a 45% impairment of the involved finger [77].

Some have suggested that a single stiff MP joint

can impair the entire hand’s function [78]. A full

range of motion, however, is not required for hand

function. Most activities of daily living require

only 50% of normal joint motion [73,79,80]. Stud-

ies have shown that obtaining 35 degrees of

motion at the MP is satisfactory if the arc of

motion is within the functional range and the

joint is stable [73]. Many rheumatoid patients

who have had PIP and DIP fusions maintain a

useful hand through the preservation of MP

motion. Previously, MCP arthrodesis was recom-

mended for border digits in heavy laborers; how-

ever, these indications may be reconsidered with

the availability of new surface replacement arthro-

plasty [70,80].

Wrist fusion

Although less common than finger fusion,

immediate limited wrist fusion or total wrist fusion

may be necessary following penetrating ballistic

trauma, punch press–type injuries, or in cases of

gross carpal instability. A stable wrist is necessary

for power grasp. In addition, a stable wrist pre-

vents the dissipation of finger flexion and exten-

sion forces as tendons pass over the carpus.

What are the requirements for a functional wrist

and what effect does fusion have on wrist and hand

function?

The requirements for functional wrist motion

have been debated. Palmer et al [81] found that

the normal wrist had an average flexion-extension

arc of 133 degrees, but only 5 degrees of flexion

and 30 degrees of extension were needed for most

activity. Brumfield and Champoux [82] found that

10 degrees of flexion and 35 degrees of extension

allowed one to complete the activities of daily liv-

ing. Ryu et al [83], however, found in 40 normal

patients that most activities of daily living could

be accomplished with 40 degrees of flexion, 40

degrees of extension, 10 degrees of radial devia-

tion, and 30 degrees of ulnar deviation.

Limited carpal fusions consist of intercarpal

fusions and radiocarpal fusions (Fig. 12). Mechan-

ical studies by Meyerdierks et al [84] show that

fusions that cross the radiocarpal joint produce

the greatest loss of motion. On average radiolu-

nate, radioscapholunate, and radioscaphoid fu-

sions decrease the flexion extension arc by 55%.

Recent studies have suggested that removal of

the distal pole of the scaphoid in radiocarpal

fusions unlocks the capitate, allowing unhindered

midcarpal motion. In the laboratory setting this

has produced flexion extension arcs that are equiv-

alent to normal wrist motion [85]. Fusions that

cross the midcarpal joint result in the next largest

loss of wrist motion. Scaphocapitolunate and


capitolunate fusion can produce a 35% loss of the

flexion and extension arc and up to a 31% loss

of radial and ulnar deviation. Scaphotrapezial-

trapezoid fusion produces a 23% decrease in the

flexion extension arc and 31% decrease in radial

and ulnar deviation, whereas scaphocapitate

fusion results in a 19% loss in the flexion extension

arc and a 19% loss in radial and ulnar deviation.

Inclusion of the lunate within partial wrist fusions

was found to nearly double the resultant loss of

wrist motion when compared with fusions that

did not include the lunate [84]. Fusion within the

same carpal row tends to have a minimal effect

on overall wrist motion, with average loss of only

12% of the flexion and extension arc.

The choice for total wrist fusion must be care-

fully contemplated. Removal of all wrist motion

results in the loss of the beneficial effect of tenode-

sis for any subsequent tendon transfer. In addi-

tion, wrist dorsiflexion is important for pushing

off, rising from a chair, and power grasp. In those

cases where there is substantial carpal loss, how-

ever, fusion may be the only option.

Wrist fusion can have a negative impact on MP

motion and thumb motion presumably because of

extensor adhesion [86]. A 25% decrease in grip

strength may be seen [86,87]. Strength with key

pinch, subterminal pinch, and directional grip are

better maintained at approximately 85% of the

normal side. Maximum preservation of power grip

is found to occur in 15 degrees of extension and

15% of ulnar deviation [88]. Weiss et al [89] found

that patients believed they were able to accomplish

85% of the activities of daily living following total

wrist fusion. Patients were least able to use a

screwdriver and perform perineal care. Overall,

skills that presented the most difficulty were those

that required significant wrist flexion in a small

space, where compensatory movements by the

shoulder and elbow are eliminated.

In severely mutilating trauma, the preservation

of wrist mobility imparts some function to a fore-

arm stump with the addition of prosthesis. Mod-

ern prosthetic techniques allow the incorporation

of the prosthesis to the wrist so that proximal

straps and attachment to the elbow are unneces-

sary. Preservation of wrist motion also eliminates

the need to incorporate a wrist articulation into

the prosthetic unit [6,17,90]. In addition, preserva-

tion of the distal radio-ulnar joint (DRUJ) further

improves function, because 50% of forearm rota-

tion can be transferred into the prosthesis [91].

Tendon requirements

Tendon injuries are present, in some aspect, in

all cases of mutilating hand trauma. Tendons

may be divided, avulsed, or have large segmental

gaps that prohibit immediate repair. It is impor-

tant to understand how tendon loss affects hand

function.

Extensor tendons

Multiple authors have pointed to the difficulties

in obtaining excellent results with extensor tendon

Fig. 12. Diagram depicts the multiple sites for limited wrist fusions. (1) Four corner fusion or midcarpal fusion.

(2) Scaphotrapezialtrapezoid (STT) fusion. (3) Radioscapholunate fusion (radiocarpal fusion). (4) Scaphocapitate (SC)

fusion. (5) Lunotriquetral (LT) fusion. Fusions involving the radiocarpal joint result in the greatest loss of motion.

Fusions involving the same carpal row result in a 12% to 15% loss of motion.


injuries [92–94]. The superficial position of the

extensor tendons, their complex architecture, and

paucity of surrounding subcutaneous tissue often

result in postoperative adhesions, which limit flex-

ion and produce extensor lags [94,111]. It has been

shown that injuries in the distal zones (1 through 5)

result in poorer outcomes and greater postopera-

tive extension deficits. Extensor tendon injuries

also carry a significantly worse prognosis when

associated with underlying fractures [19,94].

The extensor mechanism has less excursion

than the flexor system [95]. In addition, it has less

ability to compensate for significant shortening

because of the interconnections between the intrin-

sic and extrinsic mechanisms. Extensor tendon

excursion in the region of the PIP joint is only

between 2 and 5 mm. There is little margin for

adherence or shortening if a reasonable result is

expected [95,96]. If significant shortening takes

place following repair and the lateral bands and

oblique retinacular ligament are intact, one can

opt to leave the central extensor mechanism unre-

paired. This may avoid flexion loss, without pro-

ducing a PIP or DIP extension lag. Loss of long

extensor function can destabilize the MP joint,

however, resulting in a loss of active finger ab-

duction-adduction [97]. Further biomechanical

studies are required to determine the absolute

requirements for functional finger extension.

Maximizing intrinsic function helps in the pres-

ervation of full finger extension. Intrinsic function

can be compromised after metacarpal fractures.

Metacarpal shortening or fracture angulation

beyond 30 degrees can result in a shortening of

intrinsic muscle fiber length [98]. Muscle fiber

length determines the potential excursion of the

intrinsic tendon [31]. With metacarpal malre-

duction or shortening, potential excursion force

is wasted as slack in the muscle. Starting muscle

tension is also decreased. Both of these factors

decrease intrinsic tendon excursion and joint

motion [98,99]. This loss of intrinsic function

emphases the need for preservation of metacarpal

length and the anatomic reductions of fractures in

cases of significant hand trauma.

Extensor tendon injuries proximal to the junc-

tura produce less postoperative deficits. Quaba

et al [100] examined long-term function in patients

who had lost finger extensors in zones 6 and 7.

In the nine patients studied, no attempt was made

to reconstruct the extensor tendons. Soft tissue

coverage alone was provided to the dorsum of

the hand. In long-term follow-up, there was a

26% decrease in total active finger motion, most

evident at the MP joint. DIP and PIP extension

were preserved because of intact intrinsic function.

Active motion at the MP joint was only 60% of

normal. Surprisingly, patients reported a 90% sat-

isfaction rate with hand function. Difficulty was

noted with tying knots and unscrewing lids. All

patients did maintain the extension of their thumb

and wrist extensors. This emphasizes the impor-

tance of thumb abduction and extension for pre-

hensile function when MP motion is limited. The

ability to move the thumb out of the palm allows

for the accommodation and prehension of objects

even with a moderate digital flexion stance. The

loss of the central extensors decreases power grip

by approximately 30%, whereas severance of wrist

extensors results in a 50% reduction in grip

strength [97,100].

Flexor tendons

Loss of profundus function prevents subtermi-

nal and terminal pinch, unless the DIP joint is

fused. If the profundus tendon becomes adherent

to the remaining sublimis tendon or fracture callus

it may tether the profundus tendons of adjacent

uninjured fingers, preventing full digitopalmar

grip [14,101]. Classically this quadriga effect

applies only to the long through small fingers,

because of their common muscle belly. The quad-

riga effect can also extend to the index finger, how-

ever, because heavy synovium at the level of the

carpal tunnel, termed the fibromembranous retinac-

ulum, can link the index profundus tendon to the

other three [102].

Power grip and forceful pinch are still possible

with superficialis loss. Loss of the superficialis with

preservation of the profundus tendon may result

in hyperextension of the PIP joint in supple indi-

viduals. This phenomenon is called recurvatum. In

exaggerated cases, this may produce delayed finger

flexion. Patients may have to help the involved fin-

ger initiate PIP flexion with the adjacent digits

before active flexion can ensue. Recurvatum can

be avoided by leaving the portion of the superficia-

lis distal to the chiasm [14]. With loss of both pro-

fundus and superficialis tendons, flexion of theMP

joint to 45 degrees may be possible if intrinsic func-

tion is intact.

Retraction of the profundus tendon, following

more proximal amputations, may result in short-

ening and contracture of the corresponding lumbr-

ical. During flexion, contraction of the profundus

muscle belly places stretch on the shortened lum-

brical, which results in paradoxical extension of


the PIP joint. This is termed the lumbrical plus

deformity. This deformity can be offset by divid-

ing the lumbrical or suturing the profundus ten-

don to the flexor sheath in a relaxed position

[14,110].

With multiple digital amputations, retraction

of the flexor mechanism can lead to lumbrical

migration into the carpal tunnel. Proximal lumbr-

ical migration may then lead to compression of the

median nerve and development of carpal tunnel

syndrome [6,103]. These patients may not present

with classic digital paresthesias if there has been

significant digital soft tissue loss. Patients may

instead complain of generalized pain within the

wrist and palm, which may be exacerbated by the

standard provocative maneuvers. Carpal tunnel

release should be pursued in such instances.

During any flexor tendon surgery it is impor-

tant to preserve the A2 and A4 pulleys [104–107].

If either is divided the flexor tendon moves away

from the phalanx, leading to bowstringing. The

A2 and A4 pulleys are located over the bony shafts

of the proximal and middle phalanx. This ana-

tomic configuration prevents the bowstringing

that occurs with joint flexion and the bowstringing

that can occur over the phalanx shaft. Palmer plate

pulleys (A1, A3, and A5) have a variable relation-

ship to the joint axis depending on joint position,

and restrain only the joint-type of bow stringing.

They also shorten up to 50% with finger flexion,

which reduces their efficiency. Cruciate pulleys

vary the most in their anatomic position and have

little effect on restraining bowstringing [105,107].

Bowstringing increases the flexion moment arm

at the PIP and MP joints. A longer moment arm

allows the flexor mechanism to overcome the

extension forces, resulting in a flexion deformity.

A longer moment arm also means the tendon must

move through a longer distance to obtain the

same motion at the joint, decreasing mechanical

efficiency. As in the quadriga effect, grip strength

is decreased because full excursion is now

limited [107].

Summary

Mutilating hand trauma presents the surgeon

with many reconstructive challenges. This article

establishes some biomechanical guidelines to help

the surgeon evaluate the hand trauma patient.

Through a basic understanding of hand biome-

chanics, the surgeon may access more accurately

what motion and function can best be salvaged.

By understanding how amputation, fusion, and

tendon loss impact on postoperative hand motion,

the surgeon can better focus his or her reconstruc-

tive efforts to achieve the highest functional out-

come for the patient.

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Antimicrobial management of mutilatinghand injuries

R. Dow Hoffman, MDa, Brian D. Adams, MDb,*aDepartment of Orthopaedic Surgery, US Naval Hospital, 2080 Child Street, Jacksonville, FL 32214, USA

bDepartment of Orthopaedic Surgery, University of Iowa College of Medicine, Lower Level, Pappajohn Pavilion,

200 Hawkins Drive, Iowa City, IA 52242, USA

Amutilating injury, according to MiriamWeb-

ster’s dictionary, is one so severe that it ‘‘cuts off or

permanently destroys a limb or an essential part of

it’’ [1]. These complex injuries posemany challenges

to the treating hand surgeon because they occur in a

wide variety of environments and by a wide variety

of mechanisms. They often require multiple visits

to the operating room and complex reconstructive

procedures. By definition, the final outcome in the

absence of complications is less than perfect, and

infection during the course of treatment can signifi-

cantly compromise this final result. Hand surgeons

attempt to minimize the incidence of infection with

careful assessment of patient risk factors and atten-

tion to preoperative planning, meticulous surgical

technique, and close postoperative follow-up. In

the United States, antibiotics are routinely used as

oneweapon in the hand surgeon’s infection preven-

tion arsenal. However, the efficacy of this practice

has not been well quantified, and limited informa-

tion is available to guide the hand surgeon in choos-

ing the correct antibiotic regimen. In this review,

the literature pertaining to the use of antimicrobials

in the setting of the mutilated hand is examined in

an attempt to guide hand surgeons in their use

and identify questions that remain.

Background

Antibiotic prophylaxis in surgery has remained

a controversial topic since its inception earlier in

this century [2,3]. Early studies in the 1950s

reported in the general surgery literature noted

the failure of prophylactic antibiotic administra-

tion to decrease the rate of postoperative infection

[4,5]. Similar studies in the orthopedic literature

demonstrated no beneficial effects and potentially

harmful effects in the use of perioperative antibiot-

ics [6–8]. However, experimental work in the 1960s

significantly changed our views on the use of anti-

biotics to prevent surgical infections. A classic

study by Burke demonstrated in a guinea pig

model the important relationship between timing

of administration and efficacy of antibiotic pro-

phylaxis. He quantitatively and histologically dem-

onstrated a greater efficacy of penicillin when

administered before bacterial inoculation [9]. Sub-

sequent clinical studies leave little doubt that pro-

phylactic antibiotics decrease infection rates and

shorten hospital stays in certain contaminated

and clean contaminated surgical procedures, such

as vaginal hysterectomy and colon surgery [10].

Bacteriology of the mutilated hand

Although information from other surgical dis-

ciplines is helpful, one must be aware of the unique

characteristics of mutilating injuries of the hand

when considering antimicrobial use in this setting.

The patient with a mutilated hand often presents

with complex injuries to bone, joint, tendon, and

neurovascular structures. These injuries most

often involve the use of mechanical equipment in

the home, on the farm, or in industry. A large

number of potentially infective organisms can be

found in these wounds. Two studies published

from the same institution over a 5-year period

have helped define the complexity of determining



(B.D. Adams).


PII: 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 0 5 5 - 0

Hand Clin 19 (2003) 33–39

the role of antibiotic therapy in this situation. In

the first article [11], the authors reviewed the

bacteriology of 86 patients with mutilating hand

injuries, 48 prospectively and 38 retrospectively,

to determine the most common colonizing organ-

isms and their susceptibility to antimicrobials.

They identified 26 different pieces of equipment

involved in the injuries and divided the injuries

into those caused by farm implements and those

caused by home or industry machinery. Several

hundred bacterial isolates and 10 fungal isolates

were examined, and 22 different bacterial species

were cultured. The bacteriology of farm-related

injuries differs significantly from that of home-

and industry-related injuries. In farm-implement

injuries, roughly 40% of isolates were gram posi-

tive, and 60% were gram negative. Of the gram-

positive isolates, most were penicillin sensitive,

and those that were not were sensitive to methi-

cillin, cephalothin, and erythromycin. Of the 130

gram-negative isolates, only 10 were noted to be

gentamicin resistant, although a small number of

isolates obtained before 1969 were not tested with

gentamicin. In injuries occurring at home or in

industry, roughly 70% of isolates were gram posi-

tive, and 30% were gram negative. Most of the

injuries with gram-negative isolates involved a

lawnmower or gardening equipment. Antibiotic

susceptibilities were similar except that all gram-

negative isolates were gentamicin sensitive. The

authors noted that organisms isolated before the

initiation of treatment were significantly different

from those isolated after treatment was initiated.

In some cases, the emergence of resistant organ-

isms was noted. Only one ‘‘serious’’ wound infec-

tion developed among 86 patients in which

bacterial isolates were recovered, and the authors

state that the surgical wound management in that

patient was ‘‘inappropriate.’’ Seventy of the 86

patients received ‘‘prophylactic’’ antibiotics by a

variety of regimens.

The second study, published 5 years later by

four of the same authors, reported on the prospec-

tive analysis of 64 traumatic wounds of the hand

and forearm from which a tissue sample from

the time of presentation was taken for immediate

quantitative smear and quantitative culture. The

injury was described as mutilating in 12 cases. A

variety of gram-positive and gram-negative organ-

isms were isolated. Antibiotics were given on pre-

sentation to 36 of the 64 patients. The authors

found that quantitative smears and cultures of

the wound on presentation were helpful in predict-

ing the development of wound sepsis. The authors

noted the development of wound ‘‘sepsis’’ in 23 of

64 patients, including 48% of the crush and muti-

lating injuries, which contrasts significantly with

the 1% infection rate reported from the same insti-

tution mentioned above [12]. Defining the inci-

dence of infection after these injuries is difficult,

as is the prediction of infecting organism. Not all

authors have found initial cultures to be helpful

in predicting infection or predicting the infecting

organism [13,14].

Antimicrobials in extremity trauma

Bacterial contamination of the mutilating hand

wound occurs before antibiotic administration,

and the delay between injury and antibiotic ad-

ministration can be quite long. Consequently,

antibiotics in this setting are technically not

prophylactic. Prospective, randomized, placebo-

controlled studies are lacking in this clinical sce-

nario for a variety of reasons, including small

numbers of patients and the heterogeneous nature

of these injuries. Given this problem, rigid guide-

lines are difficult to generate, but certain principles

can be extracted from the orthopedic and hand

surgery literature. The efficacy of antibiotics in

the treatment of open long bone fractures is well

established. Patzakis et al [15] performed a pro-

spective randomized trial in 310 patients with open

extremity fractures that included 89 open forearm

and hand fractures. Patients receiving a 10-day

course of intravenous cephalothin had an infection

rate of 2.3% compared with 13.9% in the placebo

group. In this study, 12 of 115 tibia fractures devel-

oped infection, whereas only 10 of 218 open frac-

tures elsewhere became infected. If tibia fractures

are excluded, it is unknown whether antibiotics

decreased the rate of infection significantly. Patza-

kis and Wilkins later demonstrated in a larger

study of open extremity fractures that patients

receiving antibiotics within 3 hours of injury had

a lower rate of infection than those who did not.

They noted that a 3- to 5-day course of intrave-

nous cefamandole and tobramycin was the most

effective regimen, but they used it only in patients

with open tibia fractures [16]. Other investigators

have confirmed the efficacy of antibiotics in the

treatment of open fractures [17–19].

The efficacy of antimicrobials in open fractures

of the hand and mutilating hand injuries is not as

clear (Fig. 1). Numerous articles have been pub-

lished on the care of complex wounds of the hand,

with most reporting low rates of infection. The

majority of these studies are retrospective, and

34 R. Dow Hoffman, B.D. Adams / Hand Clin 19 (2003) 33–39

antimicrobials were often used routinely or not

mentioned in the reports [51]. In a frequently refer-

enced article, Burkhalter et al [20] reported on

their experience treating 135 high-velocity missile

injuries to the hand during the Vietnam War.

Intravenous penicillin, debridement, and delayed

primary closure were the cornerstones of treat-

ment, and only three patients developed infection.

A similar rate of infection has been reported in the

treatment of civilian gunshot wounds to the hand,

during which intravenous antibiotics were rou-

tinely used [21]. Other authors have reported infec-

tion rates in open fractures of the hand from all

causes to be in the range of 5% to 11% in centers

where perioperative antibiotics were routinely

used [13,22,23]. Numerous authors have reported

on the use of complex reconstructive procedures

performed acutely, such as early bone grafting or

emergency free tissue transfer, with extremely

low infection rates in the hand ranging from 0%

[24–27] to 6.9% [28]. Control groups are not avail-

able; therefore, the impact of antimicrobial use on

the rate of infection cannot be determined.

A small number of studies is available to help

tease out the effect of antibiotics on the incidence

of infection in open hand fractures. Peacock et al

[14] conducted a prospective, randomized, dou-

ble-blind, placebo-controlled study of a wide vari-

ety of hand injuries distal to the distal radioulnar

joint. All wounds were less than 24 hours old,

and most were treated on an outpatient basis.

Many injuries were complex, involving joints,

bones, tendons, and neurovascular structures. Pa-

tients were randomized to receive intravenous

cefamandole or placebo every 4 hours during the

procedure followed by a 3-day course of oral ceph-

alexin or placebo. A total of 87 patients were

included in the study. Only one patient in the pla-

cebo group developed an infection, and no infec-

tions occurred in the study group. Sloan et al [29]

conducted a prospective, randomized study that

was not blinded or placebo controlled to observe

the effects of antibiotics on the treatment of open

fractures of the distal phalanx seen within 6 hours

of injury. All amputations in this series were closed

primarily, with a skin graft, or with a V-Y ad-

vancement flap under local anesthesia. Three of

the 10 patients who did not receive an antibiotic

developed an infection, causing the authors to

abandon this aspect of their study. Only 2 of the

75 patients who received antibiotics developed an

infection. Of the three antibiotic regimens tested,

Fig. 1. A severe hand injury from an industrial accident. (A) Dorsal view of hand. (B) Palmar view of hand.

35R. Dow Hoffman, B.D. Adams / Hand Clin 19 (2003) 33–39

1 g intravenous cephradine preoperatively and

1 g orally postoperatively was found to be the sim-

plest regimen and equally efficacious compared

with the two antibiotic regimens with a longer

duration of postoperative administration. Suprock

et al [30] also conducted a prospective, randomized

study that was not blinded or placebo controlled

to assess the role of prophylactic antibiotics in

the management of 91 open finger fractures distal

to the MCP joint, 68 of which involved the distal

phalanx. Patients were treated with a 3-day course

of oral dicloxacillin, erythromycin, or first-genera-

tion cephalosporin. Four patients from each group

underwent fixation with K-wires. No patient was

excluded because of an underlying systemic disease

process or degree of wound contamination. Four

patients developed an infection in each group, with

no cases of osteomyelitis. No secondary surgical

procedures were required.

In perhaps the most convincing study, Madsen

et al conducted a prospective, randomized,

double-blind, placebo-controlled study of 599 pa-

tients with ‘‘a traumatic wound located distal to the

wrist or ankle joint with an underlying fracture, loss

of bone substance, injury of tendon or joint, or

any combination of these lesions.’’ Patients with

hand injuries made up 570 of 599 patients, and

42 required osteosynthesis. Patients requiring re-

vascularization were excluded. Strict definitions

of wound infection were noted, and doctors not

participating in the study assessed the wounds.

Patients were randomized to receive a single injec-

tion of 2 million units of intravenous penicillin G

followed by placebo tablet twice a day for 6 days;

placebo injection followed by penicillin V tablet 1

million units twice a day for 6 days; or placebo

injection followed by placebo tablet twice a day

for 6 days. The infection rates for the three groups

were 4.9%, 6.6%, and 10.2%, respectively. The dif-

ference in infection rate between patients receiving

penicillin injection and those receiving placebo was

statistically significant, whereas the differences

between the other groups were not. More than

80% of organisms isolated from infected wounds

were gram positive [31].

Topical antimicrobial irrigation

Throughout history, open wounds have been

treated with numerous topical agents in an

attempt to stimulate healing and reduce the risk

of infection. In more recent times, numerous

antiseptics, antibiotic solutions, and surfactants

have been studied to assess their effect on

wound healing and infection [32]. The majority

of reports in this area focus on cell culture

and animal models, and the majority of human

studies have been reported in the general sur-

gical literature. Their efficacy in orthopedic

surgery is unclear because of the paucity of con-

trolled human clinical studies in this area [33].

Maguire [34] reported a statistically significant

decrease in the infection rate in clean orthope-

dic cases with the use of bacitracin/neomycin

powder sprayed into the wound at the time of

closure. Nachamie et al, however, found no ben-

efit from a 0.1% neomycin solution instilled into

the wound before closure [35]. Controlled stud-

ies involving human subjects with open fractures

are rare. As a result, the use of topical anti-

microbials in human open fracture wounds,

and more specifically mutilating hand injuries,

cannot be recommended because of the lack of

clinical evidence documenting their efficacy and

the fact that use of certain agents does entail

some risk. Bacitracin use should probably be

avoided in patients with a history of exposure to

the drug because rare cases of anaphylaxis have

been reported [36–38]. Systemic toxicity from

neomycin solutions has also been reported, but

most cases occurred after long periods of conti-

nuous wound irrigation or after the use of large

doses of antibiotics [39].

Antibiotic choice

The list of pathogens known to cause a post-

operative wound infection is long. A prophylac-

tic systemic antibiotic should cover the most

probable infecting organisms, which may not

be the most common contaminating organisms.

The chosen antibiotic need not cover all poten-

tial pathogens [40]. This is a particularly impor-

tant point in the setting of open hand fractures

and mutilating injuries. In this setting, Staphylo-

coccus aureus has been found to be the most

common infecting organism after an open hand

fracture [14,23,29,30]. However, this organism is

only occasionally isolated from pre-debridement

cultures [11–13]. Infections with gram-negative

organisms are less common and tend to occur

in hands injured in an agricultural environment.

Given this information, it is reasonable to rec-

ommend the use of a first-generation cephalo-

sporin at presentation for the patient with a

mutilating hand injury occurring in the home

or industrial environment, excluding lawn and

garden injuries. Given the bacteriology of these


wounds, semi-synthetic penicillin would be

equally efficacious. Cephalosporins are more

popular because of their shorter dosing intervals

and because of the frequency of penicillin al-

lergy [40]. Vancomycin is commonly used in the

patient with a cephalosporin allergy or serious

penicillin allergy [37]. For patients sustaining

injuries in an agricultural or lawn and garden

setting, the addition of an aminoglycoside such

as gentamycin is reasonable. The duration of

antibiotic treatment is arbitrary. It is reason-

able to administer antibiotics as soon as possible

after injury, continue them through the initial

debridement, and administer before any later

reconstructive procedures. Unfortunately, there

are limited data available to guide the clinician

on the optimal duration of antimicrobial treat-

ment after debridement in the setting of the

mutilated hand. Data from long bone fractures

indicate that there is little benefit to extending

antibiotic treatment beyond 5 days [41].

Complications

The incidence of side effects from antibiotic use

in surgical patients is low. The most frequently

reported complication of antibiotic prophylaxis

is pseudomembranous colitis. Rates as high as

6% have been reported after the use of cefoxitin

[40,42]. Although this complication is typically

associated with prophylactic antibiotic courses

greater than 72 hours, it has been reported with

antibiotic regimens lasting fewer than 24 hours

[43]. Allergic reactions are also a complication of

prophylactic antibiotics. Penicillin allergies have

been reported in 5% to 10% of the adult popula-

tion [40,44]. A cephalosporin allergy is much less

common, and life-threatening reactions are rare

[45]. Reactivity to cephalosporins in patients with

a positive skin test to penicillin is uncommon and

is estimated at 3% to 7% [46]. Despite this low inci-

dence of cross-reactivity, some authors discourage

the use of antibiotic prophylaxis with a cephalo-

sporin in patients with a history of an immediate

or accelerated reaction to penicillin, such as hypo-

tension, bronchospasm, or urticaria [37,40,47]. If a

penicillin or cephalosporin agent is essential for

treatment and the patient’s allergy status is unclear

or uncertain, consultation with and skin testing

by an allergist or dermatologist is recommended.

Nephrotoxicity and ototoxicity are complica-

tions associated with the use of aminoglycosides.

Once-daily dosing of aminoglycosides may

decrease the risk of these complications without

compromising efficacy [48].

There is concern that the widespread use of anti-

biotics will result in the emergence of resistant

pathogens. Evidence exists that perioperative anti-

biotic administration alters the resident skin

flora [49]. Postoperative antibiotic prophylaxis of

greater than 4 days has been associated with altered

antimicrobial sensitivities of infecting organisms

[50]. No deleterious effects have been shown after

a 24-hour course of perioperative antibiotics [40].

Summary

Antimicrobial drugs are commonly used in the

treatment of mutilating hand injuries. Valid argu-

ments for the use of systemic antibiotics can be

made despite the lack of data clearly documenting

their efficacy in this clinical scenario. There is no

information to support the use of topical agents

in open hand injuries. When choosing an appro-

priate systemic antibiotic, the physician should

consider unique characteristics of these injuries,

the various environments in which they occur,

and the potential infecting organisms. The dura-

tion of antibiotic use is arbitrary but should be

minimized to avoid complications and the devel-

opment of bacterial resistance.

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Psychological aspects of mutilating hand injuriesTherese M. Meyer, PhD

Department of Psychology, Center for Neuromuscular Sciences, Memorial Medical Center,

701 N. First Street, Springfield, IL 62781, USA

A mutilating hand injury and subsequent dis-

ability do not occur in physiological isolation.

Health care professionals providing treatment to

individuals sustaining such injuries must be aware

of the variety of psychological and social problems

that arise in the face of such a potentially disabling

injury. As such, the long-term, functional outcome

of a mutilating injury can be greatly improved if

the hand surgeon adopts a biopsychosocial per-

spective [1].

The hand plays an immense and integral role in

an individual’s vocational, avocational, and social

functioning. The hands, more than any other

appendage, provide us with independence, compe-

tence, and a sense of autonomy. The upper extrem-

ities are used as a means of productivity;

employability; and expression of sexuality, affec-

tion, aggression, and communication, leading Kla-

pheke et al to comment that ‘‘amputation or

mutilation of the hand is a tremendous physical

and psychological trauma that can precipitate

powerful conflicts regarding loss of autonomy,

guilt/punishment, and potency’’ [2]. A hand injury

is particularly threatening to an individual who

relies upon fine motor skills to perform work-

related tasks. Consider the impact of a disabling

hand injury for the carpenter, chef, dentist, or sur-

geon. There is potential for a hand injury to

destroy a career and threaten quality of life [3].

In addition to the immense functional role of

the hands, the hands are vital aspects of the subjec-

tive body image. Given the readily visible nature of

the hand, a disfigured hand is easily observed and

evaluated by others, resulting in the individual

becoming acutely aware of any associated social

stigma. A perception of stigmatization may inter-

fere with an individual’s willingness to pursue

social relationships or interactions [4]. Injuries

resulting in a mutilation or amputation of hand

or arm ‘‘deal a blow to the person’s inner image

that reverberates through their entire psyche’’ [5].

Thus, in addition to the functional loss, the indi-

vidual must come to terms with a change in their

self-image. If the individual’s identity is heavily

determined by body image and bodily integrity, a

mutilating hand injury may lead to significant

adjustment problems beyond the acute adjustment

to functional loss [6]. Furthermore, heightened

sensitivity to a disfigured hand may complicate

functional recovery. For example, if an individual

cannot tolerate the sight of their disfigured hand or

tolerate allowing others to view it, they may be at

risk for failure to comply with or attend therapy

sessions, or they may avoid returning to work.

The purpose of this article is to identify the psy-

chological impact on the individual and family

after a mutilating hand injury. We describe fre-

quent psychological reactions, the occurrence of

psychological disorders, factors that affect adjust-

ment, strategies to promote positive adaptation,

and options for treatment of psychological disor-

ders when they occur. The chapter concludes with

a discussion of special issues in mutilating hand

injuries, including pain management, the pediatric

patient, and replantation issues.

Injury-related issues

It is frequently the assumption among health

care professionals that severity and extent of injury

plays a predominant role in the individual’s psy-

chological, social, and occupational adjustment

to that injury. There is, however, limited correla-

tion between tissue damage and functional lossE-mail address: [email protected].


PII: S 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 0 5 6 - 2

Hand Clin 19 (2003) 41–49

and the psychological adjustment to traumatic

injury [7–11]; there is limited correlation between

mutilating hand injuries and psychological adjust-

ment as well. Lee et al examined the relationship

between severity of hand injury and subsequent

psychological, social, and occupational adjust-

ment and found no correlation [12]. They con-

cluded that even though health care professionals

tend to place significant importance on the severity

of a physical injury in attempting to predict psy-

chological and social adjustment to injury, it is

not the sole or necessarily the most significant

determinant of long-term recovery and reintegra-

tion into society.

It is more beneficial to focus on the individual’s

perception and attribution of how the injury was

sustained when attempting to predict or under-

stand psychological adjustment. Although much

of what is known on this topic is derived from

research on other traumatic injuries [13,14], there

is indication that attribution of responsibility for

an injury plays a significant role in adjustment to

injury and disability. As stated by Johnson, ‘‘if a

worker is injured on the job, the nature and

severity of that worker’s anger at the injury is

going to be related to whether he or she views

the injury as a random, unpreventable event or

as the result of neglect or negligence on the part

of the employer’’ [15]. Negative emotional reac-

tions (anger, depression, anxiety) may be height-

ened if the traumatic injury was the perceived

result of someone’s uncaring negligence or mali-

cious act and thus could have been avoided [16].

Litigation issues have been viewed by health

care professionals as potentially complicating the

process of psychological adaptation to a mutilat-

ing hand injury, particularly in work-related, trau-

matic injuries [17]. Such issues may further cloud

the patient’s perception of injury and disability

and the health care providers’ perception of the

patient’s motivations and the interpretation of

their behavior. Hand surgeons can be placed in a

difficult position when litigation issues enter into

the diagnosis, treatment, and prognosis of work-

related injuries. Although there is often consider-

able concern among practitioners that litigation

may play a substantial role in the adjustment to

and functional presentation of a traumatic hand

injury, Grunert et al reviewed the relevant research

and concluded that compensation and litigation

issues do not play a significant role in regard to

psychological outcome [18]. Grunert et al con-

cluded that problems in psychological adjustment

are not maintained by the presence of litigation

and that such problems do not contribute to a

failure to return to work before the resolution of

litigation issues [18]. In addition, there was no

relationship between return to work and potential

size of settlement. All participants in this investi-

gation were diagnosed with post-traumatic stress

disorder (PTSD) and, as a result, received psycho-

logical intervention within several months of their

injury. The investigators concluded that this early

intervention likely played a key role in the absence

of relationship between litigation, psychological

symptom maintenance, and return to work.

Such research argues against a biasing focus

on litigation issues when interpreting patient be-

havior. Modlin maintains that, whereas abuse

of the system is likely to occur in a small frac-

tion of work-related injuries, the concept of ‘‘com-

pensation neurosis’’ (psychological symptoms

being subconsciously or volitionally maintained

by litigation issues) ‘‘is based on inadequate

and conflicting data, clinical anecdotes, and biased

observation’’ [19].

Psychological responses to a mutilating

hand injury

Individuals experiencing a mutilating hand

injury likely experience intense emotional reactions

as a result of their injury, subsequent treatment,

and immediate or long-term disability. Reactions

may be experienced as a wide range of emotions

including anxiety, depression, guilt, fear, frustra-

tion, sadness, and anger, among others [15]. Such

a range of emotions is normal, and strong emo-

tional reactions should not necessarily be viewed

as abnormal. Whether the affective response war-

rants a clinical diagnosis depends on the severity,

duration, and the incapacitating nature of the

response. Mutilating hand injuries can be associ-

ated with psychological disturbances such as acute

stress disorder (ASD), PTSD, other anxiety disor-

ders (panic and obsessive-compulsive disorders),

major depression, pain disorders, and adjustment

disorders [20]. Assessing the individual’s psychiat-

ric history can help determine the likelihood that

a diagnosable disorder will occur. Pre-injury per-

sonality dysfunction andpresence of psychopathol-

ogy have been correlated with poorer postinjury

adaptation [15,21] and should be assessed as a pos-

sible risk factor to optimal adjustment.

There is little research available regarding the

prevalence of psychological/psychiatric distur-

bances among individuals with mutilating hand

injuries. There is, however, extensive research

42 T. M. Meyer / Hand Clin 19 (2003) 41–49

regarding the prevalence of psychiatric distur-

bances in individuals with a new amputation. The

rate of clinically diagnosable depression occur-

ring among individuals with recent amputation

is approximately 30% [20,22–24]. Shukla et al

assessed individuals with a recent amputation

and found that a large number of these individuals

experienced depressed mood, tearfulness, sleep

problems, and anxiety [25]. Individuals with muti-

lating hand injuries may be prone to similar emo-

tional difficulties. A consistent finding has been

that depression after physical injury or illness is

associated with decreased functional ability [26–

28] and that once functional ability improves

through surgical intervention and rehabilitation,

symptoms of depression also improve [29].

In an investigation into the psychiatric aspects

of replantation surgery after a variety of digital,

upper limb, and lower limb amputations [21],

investigators found that symptoms of psychiatric

disorder are often mixed, including symptoms of

anxiety and depression. Anxiety was found to be

the most frequent and persistent symptom postop-

eratively. Sources of acute anxiety were the acci-

dent being perceived as a life-threatening event,

disrupted bodily integrity, and threat of loss of

the body part. Feelings of depressed mood and

sadness were also common but were mild and

short lived. In only a minority of cases did the

symptoms of depression persist beyond 1 week

and necessitate psychiatric treatment. Feelings of

depression were associated with perception of loss,

usually regarding the threatened body part or

threat of loss of lifestyle or relationships.

Symptoms of PTSD and ASD (a disorder

symptomatically identical to PTSD but diagnosed

when the individual is less than 1 month post-trau-

matic event) commonly occur as a result of severe

traumatic hand injuries. There is indication that

up to 94% of individuals experiencing a severe

hand injury experience symptoms associated with

one of these disorders [30]. These disorders are

probably the most frequent psychiatric diagnoses

for individuals who have experienced a traumatic

hand injury. Symptoms of ASD or PTSD include

recurrent flashback memories; nightmares and

other sleep disturbances; being easily startled; cog-

nitive, emotional, and behavioral avoidance of

stimuli representative of the traumatic event; feel-

ings of anxiety, detachment, depression, or guilt;

and cognitive difficulties affecting memory and

concentration [31].

In one of the few investigations examining fac-

tors contributing to emotional distress in the early

stages of traumatic hand injury, the occurrence of

the traumatic event itself was found to be one of

the core factors contributing to distress. Symp-

toms of ASD, such as flashback memories and

re-experiencing the event, were detected in 25%

of the injured individuals. Adding to the degree

of emotional distress were practical problems in

daily functioning, dependence on others, involun-

tary decrease in activity level, unknown functional

prognosis, the uncertainty of persistent pain, and

the disfigured appearance of the hand [32].

In another study [30], the acute (2 months or

less postinjury) psychological impact of a trau-

matic hand injury was examined. Ninety-four per-

cent of the individuals screened experienced one or

more symptoms associated with ASD or PTSD,

with the most common symptoms being night-

mares and flashback memories. Other acute psy-

chological symptoms included mood swings,

cognitive difficulties (impaired concentration and

attention), concerns regarding disfigurement,

phantom limb sensations, and fear of dying. These

symptoms generally resolved or were significantly

alleviated by 1 month postinjury. Although flash-

back memories and nightmares continued, they

were greatly diminished by the second month post-

injury.

Promoting healthy adjustment to injury

The assumption cannot be made that all indi-

vidual’s who have undergone a mutilating hand

injury will experience an episode of adjustment-

related difficulties. These individuals are not

doomed to experience depression, ASD, or PTSD.

Although variation in mood and affect undoubt-

edly occur as the individual comes to terms with

the injury, assumptions about the expected course

of adjustment should be avoided. The course of

adjustment will vary greatly among individuals,

as will the factors that influence their adjustment.

For some individuals, impaired functioning is the

primary concern; for others, disfigurement of the

hand is primary; for yet others, financial concerns

take precedence.

Regardless of the primary concerns for the indi-

vidual, there are strategies in which a health care

provider can promote positive adjustment for per-

sons with a mutilating hand injury. Promotion of a

healthy adjustment should begin as soon after the

injury as possible [30]. The hand surgeon is likely

one of the first health care providers to have con-

tact with the injured individual. For that reason,

it is important that the attending surgeon begin

43T. M. Meyer / Hand Clin 19 (2003) 41–49

to create ‘‘a realistic picture of acute and long-term

goals for the patient and family’’ [20]. Immediate

and long-term physical and psychological adjust-

ment is influenced by the surgeon’s interactions

with the patient before and after surgery. Positive

pre- and postsurgical interactions foster faith in

the physician, set the stage for patient compliance

with medical recommendations, and increase satis-

faction with care [20]. Patients should be provided

with a very realistic but hopeful perspective on

what life will be like after a mutilating hand injury

or amputation. As aptly stated by Pulvertaft [33],

the surgeon should not ‘‘be unduly optimistic

and give promises that cannot be honoured. There

are ways in which we can combine sympathy with

truth.’’ The attending surgeon can further promote

optimal adjustment by referring the individual to a

mental health professional who specializes in trau-

matic physical injuries and disability. There is

considerable evidence that early psychological

intervention after traumatic injury can substan-

tially reduce psychological morbidity and malad-

aptive coping [18,30] and facilitate more rapid

return to work [15,18,34]. Such a referral can facil-

itate the process of forming an adaptive perspec-

tive on injury, recovery, and eventual return to a

satisfying lifestyle. It is beneficial for the patient

to understand that many of their emotional reac-

tions to the traumatic event and subsequent injury

are not abnormal. Discussing these reactions with

a trained professional can reduce the associated

distress and potentially prevent further long-term

psychological difficulties. The rationale for such

a referral should be provided to the patient so that

they do not feel identified as being maladjusted or

‘‘crazy.’’ It can be suggested to them that a referral

to a mental health professional is being arranged

so that they may be better able to cope with and

adapt to the residual physical difficulties and asso-

ciated emotional consequences of their injury [15].

Psychological intervention should focus on

promoting the patient’s strengths and discourag-

ing dependence, feelings of victimization, or loss

of personal control. Early on, discussions may

focus on practical issues (dealing with pain, lost

wages, stress on family, the effect of the injury on

their lives, and stress of hospitalization). Eventu-

ally, discussions can turn to providing assistance

to the patient in formulating realistic plans for the

future, including employment, education, relation-

ships, and continuing to be a productivemember of

society. Such discussions are important in re-estab-

lishing feelings of self-worth that may have been

challenged as a result of a disabling injury [20].

In the world of coping research, it has been

repeatedly indicated that not all coping strategies

are created equal when dealing with illness, injury,

and traumatic life events. Coping strategies typi-

cally regarded as ‘‘engaging’’ in their approach

have been consistently found to be associated with

more positive psychological adjustment, whereas

coping strategies regarded as ‘‘disengaging’’ in

nature have been consistently associated with less

positive adjustment. Engaging strategies include

determining positive meaning in the event, active

problem-solving, and perceiving control over the

situation. Disengaging coping strategies include a

perception of helplessness, lack of control, cata-

strophizing, and emotional and behavioral avoid-

ance [35]. For example, in a study of adaptation

to lower extremity amputation, Gallagher and

MacLachlan determined that finding ‘‘something

good’’ as a result of amputation was associated

with more positive ratings of adjustment to limita-

tions and physical capabilities [36]. They further

concluded that identifying a positive outcome,

regardless of what form that may be, is an impor-

tant factor in positive adjustment. In many cases,

the acutely injured patient may not be able to per-

ceive anything positive resulting from their injury.

Over time and with subtle suggestion, however,

patients may be able to identify consequences of

their injury that may be viewed as a positive out-

come.

Specific psychological intervention strategies

Fortunately, for the individual who is experi-

encing significant difficulties in their adjustment

to a mutilating hand injury—either immediately

or long-term—there are psychological interven-

tions available that have proven efficacy. The

sooner the problem is identified and appropriate

treatment is initiated, the more likely the individ-

ual is to recover and return to normal psychosocial

functioning. In the case where a referral for mental

health services is indicated, it is important to con-

vey to the individual that mental health services

are an aspect of the overall treatment program

and not a ‘‘last resort’’ [16].

When an individual is identified by health care

personnel as experiencing mood or affective diffi-

culties as a result of injury, the advised initial step

is to obtain a psychological or psychiatric evalua-

tion. According to Johnson, ‘‘among the benefits

of conducting psychological assessments of injured

hand patients are the following: 1) To communi-

cate a sense of care and interest in the patient; 2)


To obtain accurate diagnostic information regard-

ing issues of malingering, pre-existing psychologic

conditions, and identification of factors amenable

to treatment; 3) To aid in decisions regarding

possible surgery; 4) To individualize medical

treatment so that health care does not become

impersonal and interpersonally distant; 5) To facil-

itate psychologic intervention, particularly in cases

of pain and post-traumatic stress disorders; 6) To

expedite an early return to work and decrease the

overall period of disability that could result from

untreated psychologic problems following the

injury; 7) To identify sources of non-compliance;

and 8) To allow patients the opportunity to thor-

oughly tell their stories’’ [15].

Once the evaluation is completed, the mental

health professional can plan and implement the

appropriate interventions. Such interventions

should include psychotherapy or psychotropic

medications [6,15]. It has been suggested [15] that

psychotropic medications be used sparingly and

only in cases in which the individual is strug-

gling to such an extent that overall functioning

is hindered or impeded. Medications may in-

clude an antidepressant or anxiolytic agent, but,

in extreme cases, neuroleptic medication may be

indicated [15].

Psychotherapy may involve training the patient

in self-management strategies (relaxation, anger

control, cognitive restructuring) to address pain,

anxiety, and depressed mood. Psychotherapy

may need to address issues of loss, the potential

for chronic disability, and existential issues that

arise as a result of a traumatic injury, such as fair-

ness in the world, perceived control over life

events, and the meaning of life [16]. The appropri-

ate intervention should be individualized accord-

ing to the patient’s pre-injury personality, type of

trauma experienced, previous trauma-related

experiences, and the reactions of others to the

injury [16].

The treatment of ASD and PTSD after an

upper-extremity injury is probably the most well

researched and discussed. Schwartz and Prout

highlight that in PTSD, treatment should occur

early and should be short term, with a particular

focus on returning the individual to a pre-injury

level of functioning; the ‘‘normalization’’ of the

emotional reactions; adaptive coping; and decreas-

ing emotional, cognitive, and behavioral avoid-

ance [26]. Various cognitive-behavioral treatment

strategies (systematic desensitization, graded

exposure, in vivo exposures) have demonstrated

tremendous success in the treatment of PTSD

[37]. Such strategies are focused and short term,

thus facilitating rapid return to a previous level

of psychological functioning.

Work-related injuries and the occurrence of

PTSD may present a particular challenge. One

of the cardinal symptoms of PTSD is avoidance

of stimuli that remind the individual of the

injury. In work-related injuries, this avoidance

may include the work environment. Although

surgical and rehabilitative efforts may have been

deemed a success, many employees traumatically

injured on the job fail to return to work because of

psychological factors [34]. Grunert et al described

a cognitive-behavioral treatment protocol in which

they were able to achieve a 61% return to work

for patients diagnosed with PTSD after a work-

related severe hand injury [34]. This rate dramati-

cally improved when graded work exposure and

on-site job evaluations (88.9% and 83.3%, re-

spectively) were incorporated into the treatment

protocol.

Based on research and clinical experience,

Grunert et al propose that coping skills, confron-

tation of the trauma, and reprocessing be used to

manage most of the injured worker’s emotional

reactions [34]. To promote return to work, they

suggest that a ‘‘hierarchy of exposure techniques

be attempted. Early return to work site is an eco-

nomical approach that can be used as a means of

screening for those patients with severe avoidance

reactions. Then for those patients unable to

return to work, graded work return should be

attempted. If this too is unsuccessful, we suggest

the use of an on-site job evaluation to accomplish

desensitization.’’

Special issues in mutilating hand injuries

Pain in mutilating hand injuries

Pain has been identified as one of the most

acutely stressful aspects of traumatic injuries and

their treatment—particularly if the pain is per-

ceived as poorly controlled or unavoidable [16].

The problem presented by pain should be ad-

dressed in a timely manner in the treatment of a

mutilating hand injury, lest it negatively influence

the immediate and long-term functional outcome.

Poorly managed pain can lead to maladaptive

psychological and emotional reactions such as

anger, anxiety, phobic reactions, and somatiza-

tion, which can lead to less adaptive physical and

functional recovery [38,39]. In addition, the con-

nection between pain and depression has been


clearly established [15,39]. Apprehension about

the uncontrollable or possible long-term nature

of pain is not uncommon [39]. There is indication

of a connection between pain and the experience of

symptoms associated with PTSD. In a case report

[40], the occurrence of PTSD was a result of the

pain associated with a traumatic eye injury rather

than the injury itself. In this case, the intense and

poorly managed pain was not an additional stres-

sor but was the traumatic element that led to

PTSD.

In a study examining work-related upper-

extremity disorders, disability, and pain [38],

investigators concluded that when an individual

has difficulty coping with pain and loss of func-

tioning, prolonged disability may result. Poor pain

tolerance along with persistent pain and height-

ened reactivity may account for more frequent

requests for surgical interventions. Unfortunately,

with such individuals, additional surgery may fail

to satisfactorily resolve pain complaints and asso-

ciated disability.

In the case of amputation after a hand injury,

phantom limb sensations and phantom limb pain

are very real events for the individual. There is

indication that at least 90% of individuals with

amputation experience phantom limb sensations

[41]. Although such sensations may not be painful,

they can be emotionally distressing for the individ-

ual. Over time, these sensations typically remit in

frequency and intensity [42]. Encouraging patients

to view these sensations as a normal experience in

the face of amputation can be reassuring to the

individual. Phantom limb pain, which occurs in

greater than 60% of amputations [42,43], has been

identified as a potential risk factor for poor adap-

tation postamputation [44]. Phantom limb pain

can be distressing for the individual. Unremitting

and severe phantom limb pain may have adverse

consequences for the individual’s psychological

functioning, possibly leading to drug abuse, clini-

cal depression, and severe anxiety. Fortunately,

because of improved surgical techniques and

advanced pharmacologic pain management,

severe and uncontrollable phantom limb pain is

nearly an issue of the past [45].

The pediatric patient

There is limited research regarding the psycho-

logical aspects of a mutilating hand injury in

pediatric patients. There is, however, extensive

information regarding the psychological impact

of amputations and other traumatic injuries in a

pediatric population. Much of this information

can be applied to the care of the pediatric patient

with a mutilating hand injury.

Although it would seem to be an accurate

assumption that an amputation or mutilating

hand injury would be a substantial emotional

insult to a child or adolescent, many pediatric

patients adapt psychologically fairly well after

traumatic injury and are able to obtain favor-

able functional outcomes [46]. Some children and

adolescents experience significant coping and

adjustment difficulties following these trau-

matic injuries, however [47].

There have been a number of risk and protec-

tive factors identified as contributing to a pediatric

patient’s overall adjustment to traumatic injury.

These factors include the child’s developmental

level and emotional age, pre-injury personality

functioning and ability to cope with stressors,

intellectual abilities, perceived responsibility for

the injury, past experience with medical and surgi-

cal interventions, parental reaction and adjust-

ment to the injury, level of attachment to the

primary caregiver, and extent of expected func-

tional impairment and physical disfigurement [46].

Misattributions of responsibility are more

likely in the younger the child. Children are prone

to interpreting the cause of the injury as punish-

ment for bad behavior [46,53]. Such attributions

should be discussed at a developmentally appro-

priate level with the young patient. It is also fairly

common for young children to display develop-

mentally regressed behavior—becoming more

dependent and wanting of attention—after a trau-

matic injury and during subsequent hospitaliza-

tion [47,48]. Such behaviors should be briefly

tolerated, normalized with parents and treatment

team members, and then age-appropriate behav-

iors should be encouraged and reinforced while

regressed behavior is discouraged or ignored.

The role of the parents and family in the child’s

adjustment to injury, subsequent hospitalization,

and treatment deserves emphasis. The reaction of

this primary source of support greatly influences

the child’s reaction and adjustment [48,49]. In an

investigation examining the factors influencing

the psychological adjustment of children with limb

deficiencies [49], demographic variables and extent

of limb loss were not predictive of symptoms of

depression, anxiety, or self-esteem. Rather, these

indicators of psychological adaptation were influ-

enced by family dynamics and other sources of

social influence (friends, teachers, and classmates).

The researchers concluded that ‘‘parental distress


and marital discord were found to be significant

risk factor predictors; conversely, family sup-

port and perceived social support from parents,

classmates, teachers, and friends were found to

be significant protective factor predictors of adap-

tation.’’ Involving these sources of social influence

in the pediatric patient’s process of recovery can

reap substantial rewards with regard to psycholog-

ical adaptation. Providing the parents and the

patient with support and frequent communication

plays a large role in reducing the child’s anxiety in

the short term and facilitating compliance to med-

ical recommendations in the long term [47–49]. In

addition, designating a treatment team member to

have contact with school personnel and potentially

visit the child’s classroom can facilitate successful

return and reintegration to school.

Replantation issues

Replantation procedures after a mutilating

hand injury present unique issues beyond those

presented by a mutilating hand injury alone. In

addition to experiencing the hand injury as a life-

threatening event, these individuals are typically

admitted to the hospital as emergencies, with deci-

sions regarding surgical interventions rapidly

occurring. As a result, there is minimal opportu-

nity for psychological or emotional preparation.

As with other mutilating hand injuries, replant

patients experience significant disruption in body

image and bodily integrity. The replanted hand

or digit may be perceived as foreign or altered

because of its appearance or changes in sensation.

Because of the visibility and functional importance

of the hand, the individual must confront potential

social stigma and the potential for functional

impairment with subsequent loss in vocational,

avocational, and interpersonal pursuits [27].

The hand surgeon is advised to consider the

psychological characteristics of the individual

before determining that replantation is the most

appropriate option [27,50,51]. Situations in which

replantation may be contraindicated because of

psychological issues include self-inflicted amputa-

tions or if the individual is insufficiently motivated

or is unable to comply with rehabilitative efforts

and recommendations [27]. McCabe encourages

the involvement of the patient, when feasible, in

the replantation decision [52]. He suggests that

patients are more likely to be satisfied with their

care when given the opportunity to participate in

decision-making, which would then lead to more

favorable treatment outcomes. Obtaining a

psychiatric or psychological evaluation may be

particularly helpful in instances in which the psy-

chological factors present as particularly complex

or convoluted. Such an evaluation may provide

guidance to the hand surgeon regarding potential

psychological factors that would negatively influ-

ence the functional outcome of a replantation pro-

cedure [27].

Summary

The immediate and long-term outcome of a

mutilating hand injury can be positively influenced

by health care professionals adopting a biopsycho-

social perspective toward treatment and manage-

ment. Such an injury produces a psychological

and social impact that should be openly and can-

didly addressed with the injured individual and

with the family. The earlier and the more skillfully

these issues are addressed, the more likely it is that

psychological factors will not impede functional

outcome.

Acknowledgments

The author thanks Dr. Charles Callahan of

Memorial Medical Center for his helpful com-

ments and suggestions.

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Fracture fixation in the mutilated handAlan E. Freeland, MDa,*, William C. Lineaweaver, MDb,

Sheila G. Lindley, MDa,b

aDepartment of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center,

2500 North State Street, Jackson, MS 39216, USAbDepartment of Surgery, University of Mississippi Medical Center, 2500 North State Street,

Jackson, MS 39216, USA

The hand is composed of five tissues: integu-

ment, skeletal tissue (bones, joints, and ligaments),

vessels, nerves, and tendons. Mutilating (complex)

injuries are devastating, soiled, high-energy multi-

structural wounds that cause substantial loss or

damage to one or more of these tissues. Other sim-

ple injuries, such as skin, vessel, tendon, or nerve

lacerations and simple fractures, may coexist.

The injury may primarily involve the radial, ulnar,

dorsal, or palmar side or the middle of the hand

[1]. One or more digits may be involved.

Industrial and farm machinery, snow blowers,

boat propellers, lawn mowers, blasts, fireworks,

vehicular collisions, power saws, wood chippers,

meat grinders and slicers, high-velocity (velocity

greater than 2000 ft/s) gunshots, and close-range

shotgun wounds are common causes of these inju-

ries [2–7]. Although low-velocity (velocity less than

1000 ft/s) gunshot wounds may involve only a sin-

gle digit or ray, the fractures that occur may be as

severe as in high-velocity gunshot wounds even if

the soft tissue wounds are not as severe [4,5,8].

Mutilating injuries occur in the workplace, on

farms, at homes, during civil disobedience, and

at war. Although these injuries are open, there

may be accompanying fractures that have no over-

lying wound. Wound contamination is the rule

rather than the exception; multiple organisms

may be involved. Confounding social, economic,

and psychological factors are commonly associ-

ated. Infection, functional loss, amputation, and

chronic pain are grave consequences of these

injuries.

Outcomes

Functional outcomes correlate highly with ini-

tial injury severity [9–16]. Contamination, the time

from wounding to treatment, joint involvement,

fractures adjacent to and tendon injuries within

the flexor sheathes, and full thickness skin loss

are also important outcome determinants. The

surgeon has the opportunity to influence outcome

favorably by early definitive wound excision, frac-

ture stabilization, and soft tissue repair or re-

construction and, when indicated, by early

arthrodesis or amputation.

Management in the emergency room

or equivalent setting (Battalion Aid Station)

The issue of tetanus prophylaxis should be

dealt with emergently. A gram stain and aerobic

and anaerobic cultures should be performed on

the wound exudates. When possible, this evalua-

tion should be done before initiating antibiotics.

Two examinations are performed: one in the pre-

operative emergency entry setting and the other

in the operating room [17]. The wound is inspected

for injuries. Examination of tendon and nerve

motor and sensory function is as thorough as pain

and patient cooperation allows. Injuries are cata-

logued as to site, the tissue involved, and severity

(simple or complex). Multiple-view radiographs

should be taken. Fractures may be simple (trans-

verse or oblique) or complex (comminuted or

involving loss).



(A.E. Freeland).

S0749-0712/03/$ - see front matter � 2003, Elsevier Science (USA). All rights reserved.

PII: S 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 0 5 7 - 4

Hand Clin 19 (2003) 51–61

Fracture management

Fractures are treated within the context of

overall wound management. Skeletal stabilization

is the foundation for wound management and

enhances the healing of all bone and soft tissue

repairs and reconstruction, including replantation

[4,5,10,11,18–34]. Anatomic (or near anatomic)

fracture reduction and stabilization also help to

control pain, minimize the risk of ‘‘dead space’’

in the wound, inhibit infection, and allow earlier

and more intensive hand rehabilitation. Stability

in this context connotes that the fracture would

not be at risk of spontaneous collapse or collapse

with active unresisted exercises. As little additional

soft tissue dissection should be done initially as

is necessary to achieve reliable stability. Early

delayed primary autogenous or synthetic bone

grafting is performed to fill skeletal defects and

sometimes to achieve arthrodesis for irreparable

joint defects [4,5,23,35]. Results are optimal when

all phases of repair and reconstruction are com-

pleted within the first few days after injury. 17C-

arm fluoroscopy is a definite advantage in treating

fractures when it is available.

Initial surgery

Ideally, when overall priorities, sufficient per-

sonnel, adequate operating room facilities, and

transportation permit, the patient is moved ex-

peditiously to the operating room. The wound is

irrigated to dilute or remove hematoma and con-

taminants, and clearly necrotic tissue is de-

brided [19,36]. A second set of gram stains

and cultures may be taken. Culture specimens ob-

tained from debrided tissue are more reliable

than those from wound swab or other superfi-

cial samples [37]. Injuries are again catalogued

by direct anatomic inspection. Antibiotics may

be started based on broad coverage or organism

expectations.

Concurrent fracture treatment

and revascularization

Revascularization is infrequently necessary in

mutilated hands because of the severity of the crush

and blast components, but re-establishment of tis-

sue perfusion is a priority when indicated. It is gen-

erally performed after skeletal fixation and tendon

and nerve repair unless there are urgent time con-

straints [16,24–26,38]. Modern methods of fracture

fixation usually permit stable anatomic definitive

fracture fixation to be accomplished quickly. The

microvascular surgeon may then proceed on a sta-

ble platform. The time lost during fracture fixation

may be regained by providing the microvascular

surgeon a stable environment. Whenever possible,

initial definitive stable fracture fixation obviates

the risk of later vascular occlusion caused by frac-

ture instability or injury while exchanging pro-

visional for more stable definitive fixation.

Although a single axial Kirschner wire or crossed

Kirschner wires may be used to splint fractures

and may provide sufficient fixation (especially in

children and when under urgent time constraints),

tension band and interosseous wiring techniques

[39] or 90-90 cerclage wires [40] are more reliable

wiring techniques. The woundmay allow the appli-

cation of a mini plate with little or no additional

dissection. The mini-H plate was especially

designed for such use in fractures that are trans-

verse or only slightly oblique [41]. Fractures may

be quickly shortened by transverse mini saw cuts

to achieve this configuration and, together with

excision of damaged adjacent tissue, may allow pri-

mary repair of undamaged ends of tendons, nerves,

skin, and vessels by cutting out the zone of injury.

Stable anatomic fracture reduction is a fundamen-

tal step in the surgeon’s effort to avoid a viable but

deformed or functionless digit that becomes an

impediment to overall hand function.

Simple fractures

We believe that most if not all simple frac-

tures may be stabilized at the time of initial sur-

gery with Kirschner wires or with mini external

fixation. Intramedullary Kirschner or equivalent

wires are used for transverse or short oblique

(less than 45� angle) fractures and are applied

transversely or obliquely to stabilize long obli-

que (greater than 45� angle) fractures. Kirschner

wires splint but do not compress fractures. Intra-

medullary Kirschner wires do not control frac-

ture rotation, and slight angulation may occur

because they do not fill the intramedullary canal.

Nonunion may also occur.

Kirschner wires are not as stable for long obli-

que diaphyseal or oblique intra-articular fractures

as are mini lag screws, which add stability by com-

pressing the fracture. They may be preferred, how-

ever, because of ease of application or small

fragment size.

Mini screws are Kirschner wires that have

threads on their core to purchase the distal frac-

ture fragment and a head to buttress the proximal

52 A.E. Freeland et al / Hand Clin 19 (2003) 51–61

fragment. They are not used for transverse or

short oblique fractures. These screws may be in-

serted initially or at the time of a second look at

the discretion of the surgeon.

One or more transfixation wires may be

applied proximally and distally to a simple dia-

physeal fracture of any configuration for either

provisional or definitive fixation. Mini external

fixatorsmay be similarly applied [21,30–32].When-

ever possible in extra-articular fractures, the

mini fixator should avoid spanning an unfrac-

tured joint so as to avoid interference with mobi-

lization and rehabilitation.

Complex fractures

Complex fractures should at least be provi-

sionally stabilized at the time of initial surgery

[19]. We prefer not to leave the operating room

without restoring fracture length and alignment.

Despite our best intentions to return to the oper-

ating room for definitive stabilization and often

delayed primary bone grafting of these fractures

within 48 to 72 hours after initial surgery, there

are times when unforeseen circumstances inter-

vene. Provisional fixation minimizes the risk of

later stiffness in the face of such circumstances.

Spacer wires, axial intramedullary wires, transfix-

ation wires, mini external fixators, or combina-

tions of these are used for provisional fixation

[21,30–32]. In instances of simple fractures, espe-

cially in children, they may provide definitive fix-

ation as well.

Repair and reconstruction

Ideally, the patient is returned to the operating

room for delayed primary fracture repair and bone

grafting 48–72 hours after initial surgery [23]. The

timing of the application of internal fixation, bone

grafting, soft tissue repair and reconstruction, and

wound closure or coverage is dependent upon

wound cleanliness (fewer than 105 bacteria/mL)

rather than a specified amount of time elapsed

[19,36,37,42]. If a wound is clean enough to close

or cover, it is clean enough to repair or recon-

struct. An experienced surgeon’s assessment by

inspection has accuracy parallel to that of bacter-

ial counts and is infinitely more practical. With

modern methods of wound excision and fracture

fixation, there is a growing trend to perform

comprehensive definitive treatment initially, at

least in cases selected for adequacy of debride-

ment. When successful, this may allow earlier

and more intensive rehabilitation and may have

a positive influence on functional outcome.

Additional consideration should be given to the

need for stable internal fracture fixation (mini

screws or plates) in the polyfractured hand. Such

fixation may be a necessity for optimal outcome

in comminuted fractures and in fractures with

bone loss. Kirschner wires or mini external fix-

ator pins may partially or completely impale ten-

dons, causing rupture by attrition or transfixing

the extensor mechanism and impeding motion.

Kirschner wires merely splint fractures. They lose

their effectiveness or must be removed 4–6 weeks

after application and may thus lead to fracture

nonunion or malunion [43]. Kirschner wires may

also migrate. They may irritate the skin or be dif-

ficult to remove if cut under the skin. These wires

may present associated drainage and infection

problems if allowed to protrude above the skin,

although this seldom leads to permanent damage.

The surgeon must consider these many and varied

factors in making a final decision for fracture

fixation.

Mini screws may easily be exchanged for

Kirschner wires in long oblique and intra-articular

fractures. Concentric Kirschner wire and mini

screw diameters facilitate this exchange. A 0.045-

inch (1.1-mm) diameter Kirschner wire is the same

diameter as the screw core of the 1.5-mm thread

diameter mini screw. A 0.062-inch (1.5-mm) diam-

eter Kirschner wire is the same diameter as the

screw core of the 2.0-mm thread diameter mini

screw. Removal of the Kirschner wire, drilling of

the proximal cortex to the mini screw thread diam-

eter, and insertion of the appropriate size self-tap-

ping mini screw achieves a stable compression mini

lag screw fixation. Four- or five-hole mini com-

pression plates may be substituted for intramedul-

lary wires to stabilize transverse or short oblique

fractures, often with minimal additional dissection

owing to the exposure provided by the wound

itself. The damage from further dissection may

be obviated by the additional stability achieved.

The disadvantage of the ‘‘foreign body’’ of the

mini plate is offset by the fact that stainless steel

and titanium do not support infection and also

that fracture stability inhibits infection and en-

hances the healing of all tissues. A clean wound

and fracture stability are the common denomina-

tors in successful internal fixation.

Mini plates are often the best choice to span

defects. Although hand fractures treated with mini

plate fixation are often said to have poorer out-

comes than those treated with other implants,

53A.E. Freeland et al / Hand Clin 19 (2003) 51–61

these results have not always been carefully corre-

lated with injury severity. When such correlations

are made, outcomes correlate more with wound

and fracture severity and with the amount of oper-

ative dissection necessary to apply the mini plate

than with the use of the mini plate itself [10,11].

When further operative dissection is necessary,

the risks of additional stiffness resulting from the

dissection are somewhat compensated by the sta-

bility, pain control, and earlier and more intensive

rehabilitation allowed by stable mini plate fixation.

In fractures with comminution or loss, straight

mini plates may be applied on the mid diaphysis,

and mini condylar plates may be applied near the

metaphyses. Delayed primary bone grafting is per-

formed concurrently when needed. Compressed

autogenous distal radial or iliac cancellous bone

graft or synthetic bone graft may be used for

incomplete defects or for complete defects of up

to approximately 1.5 cm. Cancellous bone is

loaded into the barrel of a syringe and compressed

with the syringe plunger. The bone can be removed

from the barrel by inserting a long spinal needle

retrograde into the syringe and pushing it out.

Autogenous corticocancellous bone grafts from

the same donor sites may be inserted into larger

diaphyseal defects. Either type of bone graft may

be inserted into destroyed joints to achieve delayed

primary arthrodesis. Bone carpentry may be used

to fashion adaptive dowel and socket or mortise

configurations to secure the fracture–bone graft

junctures [35]. This procedure enhances stability,

allows mini plate compression at either or both

junctures, and increases the surface area at the

junctures to help to ensure healing. Permanent sta-

ble internal fixation reduces the risks of fracture

collapse by premature implant removal, thus

decreasing the associated potential for nonunion,

malunion, and digital stiffness.

Amputation

Amputation is an extreme measure that is

reserved for nonviable digits that cannot be sal-

vaged by revascularization. This procedure is pref-

erable to an interminable effort to salvage a digit

that will be stiff, painful, and nonfunctional and

that will interfere with or obstruct remaining hand

function [9,38]. Parts of amputated digits may be

used to reconstruct adjacent salvageable digits

[44,45].

Although there are a number of methods of

scoring digital function to decide whether an

injury is severe enough to warrant amputation,

we have found none more practical and useful

than that of McCormack [46]. McCormack’s cri-

terion for digital amputation is the existence of

segmental damage to three or more of the tissues

that comprise a digit. The thumb is an exception

to the rule. Every effort should be made to pre-

serve the thumb, its length, and its function.

One useful alternative to amputation that may

be useful, especially in the thumb, is the shorten-

ing by a segmental excision of the damaged tis-

sues in the zone of injury, thus allowing their

primary repair.

Illustrative cases

Case 1

A young adult male truck driver rolled his

truck over. His left nondominant hand was

crushed between the top of the cab and the road

(Fig. 1A–C ). There was a mutilating injury of

the dorsum of the hand with some extension over

the volar surface of the thumb. His index, mid-

dle, and ring fingers were irreparably damaged.

He had no other serious injuries. On the day

of injury, the wounds were debrided, and the

thumb and small finger were stabilized with axial

Kirschner wires. Two days later, the wound

was redebrided; the 2nd and 3rd metacarpals

were osteotomized at their bases, and the distal

portions were resected; the bones of the index,

middle, and ring fingers were filleted; and the

remaining digital soft tissue was used as flap cov-

erage to partially cover the wounds. A subcapital

5th metacarpal fracture was stabilized with a

mini T-plate. Split-thickness skin grafts were

applied to the remaining open portion of the

wound (Fig. 1D–F). Two months later, the distal

interphalangeal joint of the small finger was

fused, and a rotational osteotomy of the base

of the 5th metacarpal was performed to align

the flexor pad of the small finger with that of

the thumb (Fig. 1G–J). The patient recovered a

functional 2-digit hand and was able to return

to his previous occupation as a truck driver.

Case 2

A young man’s hand was crushed in a punch

press, creating a bursting injury in the middle of

the hand centered over the 3rd metacarpal phalan-

geal joint where there were irreparable commi-

nuted fractures of the metacarpal head and base

of the proximal phalanx. There was segmental


Fig. 1. (A–C) Initial injury. (D–F) Delayed primary treatment. (G) Rotational osteotomy of the base of the 5th

metacarpal and arthrodesis of the distal interphalangeal joint of the small finger. (H–J) Final result.

damage to the extensor hood of the metacarpal

phalangeal joint of the middle finger. The middle

finger was insensate because of segmental crush

injuries of the digital nerves. There were also un-

stable oblique fractures of the 2nd and 3rd meta-

carpal shafts. There was dorsal skin loss over the

3rd metacarpal phalangeal joint (Fig. 2A–D). At

second-look surgery, the wounds were cleansed,

debrided, and directly inspected. We considered

the middle finger functionally unsalvageable. The

3rd metacarpal was osteotomized at its base, and

the distal portion was resected. The bones were fil-

leted from the middle finger. After reduction and

fixation of the 2nd metacarpal fracture, the filleted

middle finger flap was used to close the dorsal skin

defect, and the remaining wounds were sutured

(Fig. 2E–D). The patient recovered sufficient hand

function to return to his job.

Case 3

A young man sustained a high-velocity gunshot

wound to his right dominant thumb as a result of a

hunting accident. The distal thumb metacarpal

was totally destroyed. There was a comminuted

fracture of the base of the proximal phalanx. The

overlying extensor mechanism and adjoining seg-

ments of the extensors pollicus longus and brevis

were destroyed. There was substantial dorsal skin

loss. The flexor tendons were damaged but intact.

The thumb was viable and sensate. Initially, the

wound was debrided, and the thumb was provi-

sionally stabilized with an external fixator (Fig.

3A, B). A few days after initial surgery, the wound

was cleaned, and delayed primary arthrodesis of

the metacarpal phalangeal joint was performed

using a cortical cancellous iliac bone graft, dowel

and socket technique, and mini reconstruction

Fig. 2. (A, B) The hand at the time of the second look. (C, D) Initial radiographs. (E–H) After definitive surgery.


T-plates. A lateral arm free-flap was used for co-

verage (Fig. 3C–F) The patient recovered sufficient

thumb function to return to farm and general

labor work (Fig. 3G–I).

Case 4

A 62-year-old retired veteran sustained a power

saw injury to his right dominant thumb at his

home. There was an open intra-articular fracture

of the base of the proximal phalanx and segmental

loss of the overlying extensor tendons and the

radial neurovascular bundle (Fig. 4A, B). The zone

of injury was excised using parallel saw cuts for the

bone so that all of the injured structures could be

repaired primarily (Fig. 4C). Three years later,

the injured thumb was healed, pain-free, and was

shortened and slightly stiff but quite functional.

The patient was entirely satisfied with his result

(Fig. 4D–F).

Rehabilitation

Although the stages of rehabilitation are artifi-

cial and overlapping, they provide a plan and

sequencing of recovery that the physician, the

therapist, and, most importantly, the patient can

understand and implement. These stages include

wound healing; recovery of motion; strengthening

and conditioning; and return to the activities of

daily and independent living, work, family, and

household responsibilities, child and elder care,

and recreation.

Fig. 2 (continued )


Recovery of motion is the key component. All

else may be achieved provided motion is recov-

ered. Early motion instituted while collagen

remains tractable and before scar contraction

favors functional recovery.

As soon after surgery as wound conditions per-

mit, gentle progressive active and passive digital

motion exercises may be initiated, starting from

the midrange and working toward the extremes

of full flexion and extension. As pain and swelling

subside, intensity may be increased, and excursion

may advance proportionately. Fracture callus usu-

ally starts to calcify at 10–21 days after injury.

When calcified fracture callus is seen on radio-

graph, the fracture–bone graft-implant construct

has sufficient strength to allow an all-out effort to

achieve the extremes of motion. Early primary cal-

lus may be presumed at 21–28 days after injury in

fractures secured by rigid internal fixation (ie, the

fracture does not have micro motion with the

stresses of digital motion). Strengthening and con-

ditioning exercises may be initiated and progres-

sively implemented by increasing resistive forces

within the patient’s pain tolerance. Pain is an

important protective signal against excessive

forces. Soft polyfoam theraballs have proved an

outstanding method of combining digital motion

and early strengthening exercises. Endurance is

achieved by increasing repetitions. Warm water

soaks are soothing, and the buoyancy they afford

implements the recovery of motion. The risk of

increasing edema is compensated by elevation.

Retrograde massage and compression garments

such as Isotoner gloves worn at night counteract

edema. Compression pumps may also be used to

combat edema. Massage softens, desensitizes,

Fig. 3. (A) The thumb at the time of injury. (B) Radiograph after initial surgery. (C) At the time of delayed primary

reconstruction. The arrows in the background material point to the sockets that were fashioned in the remaining

metacarpal and proximal phalanx. (D) Corticocancellous iliac bone graft with dowels at each end. (E, F) Intraoperative

photograph and an radiograph demonstration of insertion and fixation of the bone graft with good alignment and

stabilization with mini reconstruction T-plates. (G–I) Good postoperative thumb function is shown (note the healed

lateral arm free-flap).


and mobilizes scar tissue. Vibration and soft silas-

tic application may also help to diminish scar indu-

ration. Static and dynamic splinting may help the

recovery of motion and may be started 4–6 weeks

after surgery, especially when active motion is not

progressing. Electrical muscle stimulation may

also be used in stubborn cases. These therapeutic

measures are continued until the patient reaches

a point of maximum medical improvement. Man-

ual tasks of routine daily living, work, and recrea-

tion may be simulated, and a specific programmay

be tailored for each individual to meet his or her

needs to re-establish lifestyle, regain employment,

and return to recreational activities.

Summary

Early anatomic (or near anatomic; fingers do

not impinge or overlap during flexion or exten-

sion) stable fracture fixation provides the founda-

tion for successful wound management and for

the repair, reconstruction, and healing of all

damaged tissues in a mutilating hand injury. It

also plays an instrumental role in pain control

and affords an optimal opportunity for timely and

favorable rehabilitation of and recovery from

mutilating injuries of the hand. Kirschner or other

wiring systems or mini external fixators may be

used for simple fractures, in children, when rapid

fracture fixation is necessary, and for provisional

Fig. 3 (continued )


fracture fixation. Mini plates should be considered

for fractures with comminution or loss and in

instances of multiple fractures. Fingers with seg-

mental injury of three or more tissues should be

considered for early amputation to avoid pro-

longed and impaired recovery of the hand. Every

effort should be made to preserve the thumb and

its function by repair or reconstruction.

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Soft tissue coverage in devastating hand injuriesGoetz A. Giessler, MD*, Detlev Erdmann, MD,

Guenter Germann, MD, PhDDepartment for Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen,

Plastic & Hand Surgery, University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany

Mutilating hand injuries can be defined as severe

multistructural injuries regularly including destruc-

tion of bones, tendons, soft tissues, and the integu-

ment to a various degree. The etiology includes

burns, crush and degloving injuries, amputations,

penetrating injuries, and high-pressure injections.

Plastic surgical therapy is focused on early rehabil-

itation by restoration of functional anatomy and

cosmesis. It represents a multifaceted task to the

hand surgeon, where considerations about indica-

tion, timing, and structure of the soft tissue cover-

age play a major role in the reconstructive concept

[1–3]. A sophisticated structural reconstruction of

the osseotendinous framework is useless if not pro-

tected with adequate soft tissue cover. It is the soft

tissue envelope of the hands that transfers touch,

sensibility, temperature feeling, pinch, and grip. A

stabile but flexible integument is also required for

the extremely important individualized intensive

physiotherapy after mutilating hand injuries. Fur-

thermore, the hands are important instruments of

interpersonal communication being some of the

few constantly visible contact zones.

The complexity of soft tissue reconstruction

after a devastating trauma [2] with the wide variety

of possible tissue transfers from local, regional, or

distant areas, sensate or not sensate, isolated or

combined in shape and structure needs a system-

atic approach to adjust it to the individual case

profile as follows:

Patient-specific factors (age, general health,mobility, comorbidity, profession, and socio-economic status)

Defect genesis (crush, penetration, degloving,thermal, amputating, and so forth)

LocalizationSize and depthExposed structuresStructures to be reconstructedContaminationSurrounding tissue (color, hair, and texture)

Algorithms based on the reconstructive ladder

help in decision making about soft tissue coverage

(Fig. 1) [2]. Based on the case profile, the quickest,

easiest, safest, and best suited methods have to be

used for the best possible outcome. This implies

that even a sophisticated free flap procedure is

no longer considered as an ‘‘ultima ratio option,’’

but is chosen rather early, if it provides the best

possible result. This is supported by a more aggres-

sive approach with respect to procedure timing,

which evolved in recent years. Encouraging data

were provided by Godina [4], who showed that

with early microsurgical reconstruction (up to 72

hours) following radical debridement, the postop-

erative morbidity, infection rate, and the number

of subsequent procedures was significantly lower

than with delayed or late operations. These results

were supported by the data of Lister and Scheker

[5] and Ninkovic et al [6] using emergency flap

coverage within 24 hours after injury. All authors

equally demonstrate successful long-term results

both clinically and socioeconomically.

Reconstructive algorithms

Even if the concept of early integrative recon-

struction promotes early vascularized flap cov-

erage, a thorough wound preparation is still

mandatory to prevent placement of a healthy flap* Corresponding author.

E-mailaddress:[email protected](G.A.Giessler).


doi:10.1016/S0749-0712(02)00128-2

Hand Clin 19 (2003) 63–71

Fig.1.Reconstructivealgorithm

forsofttissuecoverageofdevastatinghandinjuries.

64 G.A. Giessler et al / Hand Clin 19 (2003) 63–71

in a contaminated wound bed with remaining devi-

talized tissue [1]. All reconstructive procedures

must be preceded by a thorough surgical debride-

ment. This is initiated by tissue cleaning using soft

detergents, such as chlorhexidine. Pulsed irrigation

(jet lavage) is rarely indicated in the delicate struc-

tures in the hand, but may help in wounds with

large amounts of particulate foreign material.

Necrotic and questionably viable material is care-

fully excised [7]; vital functional structures should

be preserved whenever possible. The resulting

defect after debridement is often much larger than

previously estimated. In wounds with areas of

indeterminate tissue viability, heavy contamina-

tion, or in a vitally threatened patient it is wise

to close the wound temporarily. Vacuum sealing

and drainage or skin substitutes provide adequate

coverage until a scheduled second look is per-

formed 24 to 48 hours later [8].

In devastating hand injuries, the surgeon rarely

is confronted with superficial skin losses, which

can be closed with various techniques of split-

and full-thickness skin grafting [9]. The high

contracture potential, limited scar flexibility, and

disappointing sensibility limit their successful use

in hands, except in donor site coverage of some

locoregional flaps. Although both grafting tech-

niques still play a central role in burn surgery,

meshed skin grafts should be definitively avoided

in the hand.

Local flaps

Complex, full-thickness losses of the integu-

ment are more frequently encountered in complex

trauma to the hand. In the hand, it can be difficult

to replace ‘‘like with like’’ by local flaps, because

the availability of surrounding tissue can be scarce,

especially in the digits. Local flaps often play only

a minor role in mutilating injuries, but can still be

of importance in special reconstructions (ie, by

providing sensibility to the fingertips).

Nevertheless, the reconstructive surgeon has

always to take into account the additional opera-

tive trauma to the extremity, which results in scar

formation, and may acutely or chronically impair

lymphatic and venous drainage. There is an abun-

dance of local flaps in the hand, but the hand sur-

geon dealing with mutilating hand injuries should

be familiar with some reliable examples. Fingertip

amputations can often be treated with various

transposition flaps [10,11] to provide a stable fin-

gertip with acceptable two-point discrimination.

Smaller defects on the lateral aspect and the dorsum

of the fingers are preferably closed with pedicled

flaps, especially when the extensor tendon mecha-

nism is exposed. Cross-finger flaps [12], flaps based

on the dorsal metacarpal arteries [13], and various

sensate kite flaps [14,15] bring their own blood sup-

ply and provide stable coverage, rapid healing, and

good pliability. Their donor sites are homodigital

or heterodigital or from the dorsum of the hand,

and are closed primarily or with small skin grafts.

In severe hand injuries with involvement of sev-

eral regions of the hand, availability of local flaps

is frequently limited because of the potential dam-

age of the donor area. Especially in crush injuries

and high-pressure injection trauma, tissue viability

often cannot be estimated properly in the first

hours after the trauma, significantly increasing

the risk of using local solutions. In these cases,

regional or distant flaps provide more safety.

Regional flaps

The development of axial-pattern regional flaps

was a major breakthrough several decades ago

[16], but their importance has somewhat decreased

since the introduction of microsurgery. They can

still be extremely helpful, however, where the latter

is not available, and the use of a free flap is contra-

indicated or for other reasons is not possible.

The best known axial pattern flap in the upper

extremity is the radial forearm flap, based on the

radial artery. It can only be used if the patency

of both major vessels is preserved, and an Allen’s

test has been performed before the operation.

Although studies have shown that the perfusion

of the hand is not decreased when the radial artery

is missing, its use has decreased because the donor

site leaves a significant aesthetic impairment. In

young patients, preservation of limb vessels in case

of possible future injuries seems wise. In general,

pedicled flaps from the forearm should not be

based on major vascular axis whenever this is

permitted by the local conditions. The reverse

pedicled posterior interosseous artery flap [17],

the reverse ulnar perforator flap [18], or the reverse

radial artery perforator flap can provide excellent

results for mid-size soft tissue defects without sac-

rificing a major artery.

Distant flaps

One of the most important distant flaps is the

groin flap [16]. It is used mostly as an ipsilateral

pedicled flap, which is divided after 3 weeks, but

can also be used as a free flap. The latter is used less

65G.A. Giessler et al / Hand Clin 19 (2003) 63–71

frequently because of frequent vascular anomalies

of the arterial pedicle [19]. The definite advantage

of this flap is its donor site, where primary closure

is often possible up to a width of 10 to 12 cm, and

the scar easily can be hidden. The groin flap pro-

vides good coverage of defects for the hand and dis-

tal forearm. Because a relatively large skin area can

be dissected with the pedicle, the flap has certain

importance in wound closure of amputations

(thumb), where the additional tissue can provide

sufficient bulk for a later toe transfer [1]. It must

not be forgotten that despite its easy dissection,

the groin flap usually requires four to five proce-

dures to obtain a definite result, which is in part

caused by the variable volume of the flap depending

on the patient’s habitus. Finally, the patient treated

with a groin flap needs to be very compliant

throughout the whole pedicled phase, especially

when physiotherapy is performed in this stage.

Free flaps

Microvascular free flaps demonstrate the high-

est versatility of all soft tissue coverage procedures

and are among the first choices in treating muti-

lated hands. The main advantages are that they

can be harvested in almost any size required; are

raised from a distant donor site; bring their own

blood supply and angiogenic and lymphogenic

potential; and not only cover defects, but actively

improve venous and lymphatic drainage of the

traumatized area [20]. Although they are frequently

inferior to local flaps regarding texture and color

match, this is considered less important in mutilat-

ing injuries. In severely injured hands, often consid-

erable areas of skin and subcutaneous structures

are missing, and tendons, joints, vessels, or nerves

are exposed. Free flaps have adequate dimensions,

and allow harvesting of additional vascularized tis-

sue components, whichmake complete single-stage

reconstructive procedures possible (ie, chimeric

flaps [see Fig. 1]) [21–23]. Free transfer of equiva-

lent tissue from the contralateral hand should be

performed exclusively in bilateral mutilating inju-

ries carefully balancing the soft tissue situation in

both extremities. The following free flaps are part

of the standard armamentarium in soft tissue

reconstruction of mutilated hands, and provide a

wide variety of procedures for certain indications.

Parascapular, scapular, and latissimus dorsi flaps

These flaps belong to the subscapular artery

system, and are established work horses in plastic

surgery [24,25]. They can cover large defect areas,

have reliable and long vascular pedicles, and can

be combined with each other and other flaps of this

vascular system (eg, M. serratus flap) [25,26]. The

cutaneous parascapular flap yields good results

especially in slim patients, and usually provides

hairless skin. Equally important for upper extrem-

ity and hand defects is the possibility of gaining

gliding tissue by simultaneous elevation of fascia.

The latissimus dorsi muscle is one of the largest

flaps of the body and extremely pliable, but may

be bulky in the upper extremity. A skin island

can obviate the need for a split-thickness skin graft

(Case 1, Fig. 2). Both flaps can be harvested with a

vascularized bone segment from the lateral border

of the scapula (R. angularis), which can be used for

structural reconstructions of skeletal injuries [27].

The donor site can always be closed primarily,

and becomes inconspicuous under normal clothes.

Lateral arm flap

Clinically introduced by Katsaros et al [28] the

cutaneous lateral arm flap is a versatile flap for

medium-sized defects. It is mostly harvested ipsi-

lateral, and structural elements, such as a humeral

bone segment of several centimeters length or a

tendon slip from the triceps muscle, can be har-

vested with it [22]. The posterior cutaneous nerve

innervates the flap, which can make it useful for

reconstruction of the first web space or the palm.

Donor sites of up to 6 to 8 cm width usually can

be closed primarily, but may still result in a con-

spicuous scar. The flap may have a distinct subcu-

taneous fat layer, which later requires debulking.

Radial forearm flap

Since its clinical introduction during the early

eighties [29], the pedicled or free radial forearm

flap represents one of the most popular flaps in

reconstructive surgery [23,30]. The skin is thin,

very pliable, and of good texture and color match

in hand defects. The pedicle is long, large, and of

constant anatomy, but includes one of the main

arteries of the hand, which sometimes can impair

perfusion to the hand. A preoperative Allen’s test

is mandatory. The main drawback of the radial

forearm flap is the donor site, which usually has

to be closed with a skin graft, frequently leaving

unacceptable scars especially in young women.

Dissection of the flap either includes the contrala-

teral extremity into the surgical intervention where

one side is already involved, or imposes additional

donor site morbidity, such as tendon adherence


and lymphedema on the traumatized side. In the

authors’ experience, the forearm flap is no longer

one of the prime choices in defect coverage in muti-

lating hand injuries.

Temporoparietal and serratus fascia flap

As a superior extension of the facial superficial

musculoaponeurotic system (SMAS), this flap

combines very thin and pliable tissue with a hidden

donor site in patients with hair. Based on the

superficial temporal vessels, it is one of the best

flaps for the dorsum of the distal forearm, the

hand, and the fingers (Case 2, Fig. 3) [31]. The

authors have successfully used fascial flaps also

in the palm (Case 3, Fig. 4). The skin grafts usually

take easily on this well-vascularized gliding tissue,

and provide sufficient mechanical stability. The

temporoparietal fascia flap is of limited size, with

an average of 12 · 8 cm in adults, whereas the ser-

ratus fascia flap measures approximately up to 15

· 20 cm. Care has to be taken about the auriculo-

temporal nerve when elevating the temporoparie-

tal fascia with the usual Y- or T-shaped incision

(Fig. 3B) [32]. The long thoracic nerve has to be

spared when the serratus fascia flap is raised.

Discussion

Soft tissue coverage of mutilated hands is not

seen distinct from the other reconstructive steps,

such as osteosynthesis and tendon reconstruction,

but rather is integrated into the strategic surgical

concept. This is especially demonstrated by the

growing field of multicomponent chimeric flaps

[21–23]. The concept of early primary reconstruc-

tion (including emergency procedures) and fast

rehabilitation should be pursued. It can result in

excellent outcomes in the hands of an experienced

Fig. 2. (A–D) The patient was injured by a power saw cutting chain, which destroyed the complete anterior

compartment of his right arm. Initial thorough debridement and plate osteosynthesis were followed by a segmental

reconstruction of the radial and ulnar artery using an interposition saphenous vein graft. Both median and ulnar nerves

demonstrated 8- and 10-cm long defects and were reconstructed with sural nerve grafts in the same operation. Torn

muscles were adapted, tendons repaired, and the wound closed temporarily with a skin substitute. The remaining skin

defect was closed 48 hours later with a myocutaneous latissimus dorsi free flap.


Fig. 3. (A–F ) A 40-year-old taxi driver sustained a severe tangential tissue loss on three long fingers as his arm was

forced out of his car during a motor vehicle accident. After initial thorough debridement the fractured distal phalanx of

the fifth finger was stabilized with a K-wire, missing extensor tendon structures were reconstructed by palmaris longus

tendon, and the three injured fingers were syndactylized by running nylon sutures. A free microvascular temporoparietal

fascia flap covered with a split-thickness skin graft was used for closure and connected to the radial artery and a

neighboring vein. The hand was splinted during healing. Seventeen days later the fingers were divided again and

individual physiotherapy for each finger achieved excellent results.


Fig. 4. (A–F ) A bicycle accident from this 28-year-old female soccer team keeper resulted in a degloving-avulsion injury

to her right palm. No tendons or nerves were injured, but the skin defect after debridement was quite large. A serratus

fascia free flap was dissected and transplanted to the injured area, covered with a split-thickness skin graft. The extremity

was splinted for healing. Subsequent physiotherapy was limited by flexor tendon adherence, so surgical tenolysis was

performed directly through the well-healed flap, which resulted in a good functional outcome.


hand-plastic-micro surgeon including either single-

stage (Case 3) or multistage procedures (Cases 1

and 2). Mastering of a wide spectrum of surgical

techniques is mandatory for success.

Caution is recommended in evaluation of the

burn, crush, and injection injuries, because the

assessment of tissue viability can be extremely

difficult in these cases [33]. A proper temporary

wound closure followed by a second look may

improve the chances for a successful definitive clo-

sure. Forced one-stage reconstructions carry an

inherent risk of failure if the complexity of the case

is not matched by the correct assessment of the

problem, the infrastructure available, the individ-

ual surgical experience, and the available surgical

solutions. A realistic assessment of the case profile

and of one’s own surgical abilities is of direct ben-

efit for a patient with a mutilating hand injury, and

markedly increases the chances for good long-term

results.

Case 1

A 35-year-old patient was injured by a jammed

power saw, and the cutting chain destroyed the

complete anterior compartment of his right arm.

After initial thorough debridement and osteosyn-

thesis, a segmental reconstruction of the radial

and ulnar artery was performed using an inter-

position saphenous vein graft to salvage the avas-

cular hand. The median nerve demonstrated an

8-cm defect and the ulnar nerve showed a 10-cm

gap. Both were reconstructed with sural nerve

grafts in the same operation. Torn muscles were

coapted, tendons repaired, and the wound closed

temporarily with a skin substitute. Intravenous

antibiotics started preoperatively were continued.

The remaining skin defect was closed 48 hours

later with a myocutaneous latissimus dorsi free

flap (see Fig. 2).

Case 2

A 40-year-old taxi driver sustained a severe tan-

gential tissue loss on his left middle, ring, and small

finger as his arm was forced out of his car during

a motor vehicle accident. After initial thorough

debridement the fractured distal phalanx of the

fifth finger was stabilized with a K-wire, missing

extensor tendon structures were reconstructed by

palmaris longus tendon, and the three injured fin-

gers were syndactylized by running nylon sutures.

A free temporoparietal fascia flap was harvested

from the right side and anastomosed to the radial

artery and a neighboring vein on the injured hand.

It was covered with a split-thickness skin graft and

the hand was splinted during healing. Seventeen

days later the fingers were divided and individual

physiotherapy for each finger achieved excellent

results. No further surgery was needed (see Fig. 3).

Case 3

A 28-year-old keeper of a German female soc-

cer league team suffered a bicycle accident with a

degloving-avulsion injury to her right palm. Fortu-

nately, no tendons or nerves were injured, but the

skin defect after debridement was quite large. A

serratus fascia flap was dissected and transplanted

to the injured area, covered with a split-thickness

skin graft, and the extremity splinted for healing.

Subsequent physiotherapy was limited by flexor

tendon adherence, so surgical tenolysis was per-

formed directly through the well-healed flap result-

ing in a good functional outcome (see Fig. 4).

References

[1] Rockwell WB, Lister GD. Coverage of hand

injuries. Orthop Clin North Am 1993;24:411–23.

[2] Germann G, Sherman R, Levin LS. Decision-

making in reconstructive surgery. Heidelberg:

Springer; 2000.

[3] Levin LS, Erdmann D. Primary and secondary

microvascular reconstruction of the upper extrem-

ity. Hand Clin 2001;17:447–55.



Surg 1986;78:285.

[5] Lister G, Scheker L. Emergency free flaps to the

upper extremity. J Hand Surg 1988;13:22–8.

[6] Nincovic M, Deetjen H, Oehler K, Anderl H.

Emergency free tissue transfer for severe upper

extremity injuries. J Hand Surg [Br] 1995;20:53–8.

[7] Haury B, Rodeheaver G, Vensko J. Debridement:

an essential component of traumatic wound care.

Am J Surg 1978;135:238–42.

[8] Bauer P, Schmidt G, Partecke BD. Possibilities of

preliminary treatment of infected soft tissue defects

by vacuum sealing and PVA foam. Handchir

Mikrochir Plast Chir 1998;30:20–3.

[9] Brown JB, McDowell F. Skin grafting, 3rd edition.

Philadelphia: JB Lippincott; 1958.

[10] Kutler W. A new method for fingertip amputation.

JAMA 1947;133:29–30.

[11] Atasoy E, Iokamidis E, Kasdan ML, Kutz JE,

Kleinert HE. Reconstruction of the amputated

fingertip with a triangular volar flap: a new surgical

procedure. J Bone Joint Surg Am 1970;52:921–6.

[12] Cronin TD. The cross finger flap: a new method of

repair. Am Surg 1951;17:419–25.


[13] Earley MJ. The second dorsal metacarpal artery

neurovascular island flap. J Hand Surg [Br]

1989;14:434–40.

[14] Yang JY. The first dorsal metacarpal flap in first

webspace and thumb reconstruction. Ann Plast

Surg 1991;27:258–64.

[15] Germann G, Rutschle S, Kania N, Raff T. The

reverse pedicle heterodigital cross-finger island flap.

Br J Hand Surg 1997;22:25–9.

[16] Chuang DC, Colony LH, Chen HC, Wei FC. Groin

flap design and versatility. Plast Reconstr Surg

1989;84:100–7.

[17] Wang Y, Li X, Yuan Z, Seiler H. Anatomy and

clinical use of the posterior interosseous island

forearm flap. Unfallchirurg 1994;97:541–4.

[18] Becker C, Gilbert A. Le lambeau cubital. Ann Chir

Main Memb Super 1988;7:136–42.

[19] Penteado CV. Venous drainage of the groin flap.

Plast Reconstr Surg 1983;71:678–82.

[20] Slavin SA, Upton J, Kaplan WD, Van den Abbeele

AD. An investigation of lymphatic function follow-

ing free-tissue transfer. Plast Reconstr Surg

1997;99:730–43.

[21] Caroli A, Adani R, Castagnetti C, Pancaldi G,

Squarzina PB. Dorsalis pedis flap with vascularized

extensor tendons for dorsal hand reconstruction.


[22] Gosain AK, Matloub HS, Yousif NJ, Sanger JR.

The composite lateral arm free flap: vascular

relationship to triceps tendon and muscle. Ann

Plast Surg 1992;29:496–507.

[23] Yajima H, Inada Y, Shono M, Tamai S. Radial

forearm flap with vascularized tendons for hand

reconstruction. Plast Reconstr Surg 1996;98:328–33.

[24] Nassif T, Vidal L, Bovet J, Baudet J. The para-

scapular flap: a new cutaneous microsurgical free

flap. Plast Reconstr Surg 1982;69:772–8.

[25] Germann G, Bickert B, Steinau HU. Versatility and

reliability of combined flaps of the subscapular

system. Plast Reconstr Surg 1999;103:1386.

[26] Fissette J, Lahaye T, Colot G. The use of the free

parascapular flap in midpalmar soft tissue defect.

Ann Plast Surg 1983;10:235–8.

[27] Masaki F, Takehiro D, Ryuuichi M, Kumi M. Late

reconstruction of two total metacarpal bone defects

using lengthening devices and a double-barrel

osteocutaneous free parascapular flap. Plast


[28] Katsaros J, Schusterman M, Beppu M, Banis JC,

Acland RC. The lateral upper arm flap: anatomy

and clinical applications. Ann Plast Surg 1984;

12:489–500.

[29] Muhlbauer W, Herndl E, Stock W. The forearm

flap. Plast Reconstr Surg 1982;70:336–42.

[30] Mahaffey PJ, Tanner NSB, Evans HB, McGrouther

DA. The degloved hand: immediate complete

restoration of skin cover with a contralateral

forearm free flap. Br J Plast Surg 1985;38:101–6.

[31] Upton J, Rogers C, Durham-Smith G, Swartz WM.

Clinical application of emporoparietal flaps in hand

reconstruction. J Hand Surg [Am] 1986;11:475.

[32] Yano H, Nishimura G, Kagi S, Murakami R, Fujii

T. A clinical and histological comparison between

free temporoparietal and scapular fascial flaps. Plast


[33] Stark HH, Ashworth CR, Boyes JH. Paintgun

injuries of the hand. J Bone Joint Surg Am

1967;49:637.


Use of ‘‘spare parts’’ in mutilatedupper extremity injuries

Richard E. Brown, MDa,*, Tzu-Ying Tammy Wu, MDb

aSpringfield Clinic, Division of Plastic Surgery, Southern Illinois

School of Medicine, Springfield, IL 62794, USAbDivision of Plastic Surgery, Southern Illinois University, Springfield, IL 62701, USA

The management and treatment of complexmutilated upper extremity injuries often can bechallenging and at times seemingly formidable. A

reconstructive surgeon’s ability to mobilize, trans-pose, and transfer tissues has allowed not onlyclosure of complex wounds but also restoration of

function and form. The use of ‘‘spare parts’’ froman otherwise unsalvageable limb represents theultimate form of reconstruction that probes thecreative mind and challenges the reconstructive

knowledge of the surgeon. ‘‘Spare parts’’ representthose components that may be overlooked in a pileof presumed unusable and mutilated tissues.

These undamaged and potentially usable elementsinclude skin, bone, nerves, tendons, vessels, nailbed, or portions of composite functional units

such as a hand or finger. Because every traumaticinjury of the upper extremity is different, thesurgeon must scrutinize the remains of a mutilatedupper extremity to carefully distinguish the viable

from the nonviable. Of what is available, one mustthen determine the prospective use and contribu-tion of the remaining constituents to the overall

function and form of the limb. In this article, theauthors review the use of spare parts in a varietyof mutilated upper extremity wounds.

Background

In 1947, Cave and Rowe described using skin

from deformed and useless fingers to cover defects

in the hand [1]. They reported five cases ofgunshot wounds to the hypothenar region of thehand resulting in a nonfunctional small finger.

The stiff and nonfunctional finger was thenstripped of its tendons and bones and a digitalturnover skin flap was created to cover the

hypothenar defect. The importance of ‘‘preservingall possible skin of the hand at the time of initialdebridement’’ of the wound for potential later usewas emphasized. A similar principle was outlined

by Bunnell in which a fillet flap of a finger wasused to cover hand defects [2]. The use of palmarskin of amputated fingers to cover appropriately

sized hand defects was reiterated by Slocum [3].Peacock pointed out the unique features of thehand that would favor using local tissue for

restoration and reconstruction of hand defects [4].He described the island pedicle flap of a non-functional digit or hand in restoring skin, nerve,and composite tissue loss of the digits and hand.

Subsequently, there have been several reportsdescribing spare part usage of various compo-nents of the hand for reconstruction [5–20].

Evaluation

The magnitude of force that has resulted ina devastating hand injury can be immense. Thisforce may have pulled the patient into machines,

against equipment, or off heights. Therefore,patients with mutilating hand injuries may havesustained injuries of other organ systems that may

be life threatening. These victims should thus betreated as trauma patients. ATLS protocols mustbe followed in securing the patient’s airway,

breathing, and circulation. Once the patient is



(R.E. Brown).


doi:10.1016/S0749-0712(02)00143-9

Hand Clin 19 (2003) 73–87

stabilized, one may delve into the details of thehistory as to when, where, and how the injury

occurred. The socioeconomic circumstances of theinjury also must be taken into consideration.Although a young virtuoso violinist may wish topreserve as much length and function of a finger

as possible, a self-employed farmer may seek thesimplest method of reconstruction that wouldallow the most expeditious return to work.

The patient then should be brought to theoperating suite where a thorough examination can

be performed. Assessment of circulation, skincover, skeletal and joint stability, and nerve and

tendon integrity is completed. Careful debride-ment of obviously nonviable tissue is performedwhile preserving any tissue of uncertain viabilityfor reassessment at a second look. The objective is

to remove all tissue that is detrimental to woundhealing yet preserve as much as possible tomaximize limb function.

After completion of debridement, the wound isreassessed and the potential return of function is

Fig. 1. The patient sustained multiple finger amputations. The small fingertip amputation was replaced as a composite

graft. (A,B) Preoperative. (C) Postoperative.

74 R.E. Brown, T-Y.T. Wu / Hand Clin 19 (2003) 73–87

evaluated. At this juncture, decisions are made

regarding the restoration of function and formwith the available tissues.

Spare parts

The finger

As eloquently stated by Peacock, ‘‘A finger

contains all of the basic tissues which are foundelsewhere in the hand, and when the finger ceasesto be an integral part of the hand, it should beviewed as a valuable source of spare tissue’’ [4].

The following provides a systematic approach to

evaluating the potential assets of an otherwise

useless finger.

The ‘‘cap’’ composite tip graft

Following amputation, digital tip replacementas a composite graft is practiced in adults and

children [21–23]. Its success is more likely inchildren, and some have recommended thispractice only in those less than 5 years of agewith clean, sharp amputations [24]. Noting that

microsurgical replantation at this level presentsa challenge and that venous congestion is oftena sequelae and cause of flap failure, Moiemen et al

Fig. 2. (A–D) A 26-year-old man sustained a severe injury to the middle finger and loss of the ulnar side of the nail bed

and paronychium of the index finger. The middle finger was not salvageable but provided the missing ulnar nail bed and

paronychium to reconstruct the injured index finger. A functional and aesthetic fingertip was obtained. (From Van Beek

AL, Kassan MA, Adson MH, Dale V. Management of acute fingernail injuries. Hand Clinics 1990;6(1):23–35; with

permission.)

75R.E. Brown, T-Y.T. Wu / Hand Clin 19 (2003) 73–87

Fig. 3. (A–C) This diagram illustrates a method of lengthening the finger fillet flap as described by Al-Qattan. The flap is

divided longitudinally along the midvolar line from the PIP to the MP volar creases. The divided flap is then based on

either the radial or the ulnar digital neurovascular bundle and skin proximally, with the volar pulp connecting the two

halves of the flap (From Al-Qattan MM. Lengthening of the finger fillet flap to cover dorsal wrist defects. Journal of

Hand Surgery 1997;22A(2):550–1; with permission.)

Fig. 4. (A,B) A 55-year-old farmer who caught his hand in a combine. Note multiple amputated digits and a bone

forearm fracture. (C) Amputated thumb, index, long, and ring fingers. (D,E) Initial appearance following replantation of

the thumb and fillet flap of the index. Note fillet flap was revascularized and used to cover exposed metacarpal heads. (F–

H) Function 1 year following injury with no additional surgery.


performed a retrospective study in the UnitedKingdom of 50 consecutive children (ages 1–14

years, mean age 5.7 years) with 50 completelyamputated digital tips replaced as compositegrafts. The study revealed that the time delay

between amputation and replacement directlycorrelated with the success of the graft take [21].Eleven of the eighteen fingertips replaced within 5hours survived completely, whereas four partially

survived and three failed completely. None of thecap grafts survived completely when replacedafter a minimum delay of 5 hours, however [21].

By the same token, cap grafts may be used asspare parts and replaced onto another finger when

situations call for such heterotopic transfers. Thetechnique remains the same as for orthotopicreplacement. The amputated tip is cleansed and

debrided. In children less than 3 to 5 years of age,there is a higher chance of the amputated tiptaking as a composite graft without much defat-ting of the volar pulp. In adults, however,

defatting of the volar pulp of the amputated tip isperformed. Any residual bony tuft is removed also.The graft is now a composite of full-thickness

Fig. 4 (continued )


skin and nail bed and is ready to be replaced.Skin reapproximation is secured with 5-0 non-

absorbable sutures while nail bed repair and reap-proximation is done using 7-0 chromic sutures(Fig. 1).

The perionychium

The perionychium consists of the hypo-nychium, paronychium (which consists of thelateral nail folds and its adjacent cutaneous

portion), eponychium, and the nail bed. Eachcomponent of the perionychium contributes to the

health and function of the fingertip. Therefore,preservation and replacement of the perionychiumor its components on appropriate supporting

bony structures in mutilating finger or handinjuries contributes to the success of the re-construction.

The most frequently described reconstructionof the perionychium is the nail bed. The nail bedconsists of sterile and germinal matrices that

Fig. 4 (continued )


Fig. 5. Crush amputation of left index and near amputation of long finger with nonsalvageable middle phalanx.

Avulsion over thumb metacarpal removed a 4–5-cm segment of EPL tendon (A,B). The index finger was replanted to the

long finger proximal phalanx and an index ray resection was completed. The EPL was repaired with an intercalated

tendon graft harvested from the EDC to the index finger (C,D). Long-term followup shows good EPL function (E,F) and

good long finger function (G,H).


contribute to the formation of the nail. The nailbed can be harvested as full- or split-thicknessmatrix grafts [25]. Both types of grafts have been

used successfully [25–28]. A nail bed graft of 1 cmor less usually takes by inosculation even on thebare cortex of the distal phalanx [25]. Althoughscar contracture of the nail bed grafts is less than

that of the skin, a split-thickness nail bed graftshould be harvested 1–2 mm larger than the defect[28]. Although the orientation of a split-thickness

nail bed graft placement does not affect nailgrowth, according to Shepard, a full-thicknessnail bed graft needs to be placed in the correct

longitudinal orientation to achieve normal growthof the nail [28]. The nail bed can be harvestedfrom mutilated and unsalvageable fingers as split-or full-thickness grafts and used as a spare part

for other less severely injured fingertips with a nailbed avulsion. Similarly, full-thickness periony-chial grafts from fingertip amputations combined

with local fingertip flaps (volar or lateral V-Yadvancement, cross-finger flaps) have been de-

scribed to reconstruct mutilated fingertips [29,30].Although all the cases involved orthotopic re-placement of the perionychial grafts, one can

extrapolate this concept and replace the periony-chial grafts heterotopically in mutilating handinjuries involving multiple digits.

The use of portions of the perionychium as

‘‘spare parts’’ for reconstruction of fingertipinjuries has been illustrated by Van Beek [20](Fig. 2). A 26-year-old man sustained a severe

injury to the middle finger and loss of the ulnarside of the nail bed and paronychium of the indexfinger. The middle finger was not salvageable but

provided the missing ulnar nail bed and paro-nychium to reconstruct the injured index finger. Afunctional and aesthetic fingertip was obtained[20].

The skin

Harvesting areas of uninjured skin of mangledhands or upper extremities has been the most

Fig. 6. (A,B) A 34-year-old woman following a crush avulsion amputation at the right forearm level. (C) Initial

appearance after debridement and partial closure of amputation stump. (D) Radial forearm fillet flap from amputated

part. (E) Initial appearance of stump after closure with the fillet flap. (F) Appearance 2 months following injury and just

before prosthetic fitting.


commonly used spare part [1,3–6,10–12,15,16].The glabrous skin from a nonreplantable digit is

an invaluable source of tissue for palmar defects,and the thin dorsal skin offers thin, durablecoverage to regional areas devoid of integument.

The skin can be harvested as a split- or full-thickness graft or used as vascularized flap. Themost commonly described flap from the skin of

the finger is the fillet flap. This versatile flap hasundergone various modifications since its initialdescription [5,6,9–12,16]. As its name implies, thefillet flap consists of the skin and its remaining

soft tissue after the finger is stripped of its boneand tendons [14]. In its initial description by

Cave, the soft tissue from a stiff and function-less small finger was used to cover a hypothenarwound [1]. Slocum described its use in coverage

of a dorsal hand defect [3] as a turnover flap. Asa pedicled flap with intact neurovascular bundles,it can be used as a wraparound flap to cover an

adjacent mutilated digit to provide glabrous softtissue coverage with immediate restoration ofnormal sensibility to the adjacent mutilatedfinger [10].

Fig. 6 (continued )


Lengthening of the finger fillet also has beenreported to cover dorsal wrist defects [6]. This isaccomplished by dividing the fillet flap longitudi-

nally along the midvolar line, extending froma point between the proximal interphalangeal andmetacarpophalangeal joint creases, depending onthe desired length of the flap. A transverse incis-

ion is made, dividing either the radial or ulnarneurovascular bundle and skin proximally (Fig.3). The fillet flap thus has been split into two

halves that are connected by way of the fingerpulp. The reliability of this modified flap can be

enhanced by anastomosing the divided ulnar orradial digital artery and vein to the dorsal wristvessels.

Another modification of the finger fillet is thepulp neurovascular island flap [15] that is used tocover the proximal stump of an amputated finger.The flap is based on one or both of the neuro-

vascular bundles. Lanzetta et al describe its use asan alternative to the conventional finger amputa-tion. In their series of eight patients, no one

developed a neuroma and all retained fine tactilesensation and stereognosis at the stump level [15].

Fig. 7. (A) A 30-year-old man who had his right arm avulsed in a machine. Note exposed remaining humerus. (B)

Amputated arm. (C) Closure of wound with fillet flap of the forearm based on the radial artery. (D) Early postoperative

appearance before deepening of the axilla. (E,F) Range of motion of amputation stump following revision of axilla. (G)

Followup after prosthesis fitting.


With advancement of microsurgical technolo-

gy, free finger fillet flaps have been well described[5,11,12,16] (Fig. 4). In 1978, Alpert and Bunckedescribed using a free vascularized island flap

from a nonreplantable amputated digit to re-construct a severely injured but salvageable digit[5]. Idler and Mih reported a case of a free digitalfillet flap from an otherwise unsalvageable digit to

cover a palmar hand wound [12]. Additionalreports followed applying the same principle ofsalvaging nonreplantable finger parts for coverage

of hand and finger wounds, and in some casesusing the spare skin with intact digital artery asa flow-through flap for simultaneous coverage of

a soft-tissue defect and revascularization of aninjured finger [16].

Bones, tendons, nerves, vessels, and joints

In addition to the skin, other componentswithin the finger, such as bone, joint, tendon,nerves, and vessels also can be used as spare parts.

The bone can be used to maintain length of an

amputated thumb or other digits. It can beharvested and used as a nonvascularized graft orreplaced as a vascularized unit with the skin [9].Free joint transfers have been described in delayed

reconstructions and acute traumatic settings [31–33]. The indications for free joint transfers inspare-part surgery would include multilevel in-

juries in which segments of a finger including thejoints are spared, whereas those in between cannotbe used. Vascularized joint transfers are more

successful in young patients with severe com-pound tissue loss without other concomitantinjuries that would preclude them from early

range of motion.Tendon remnants can be used for tendon

grafts and for reconstruction of pulleys andligaments (Fig. 5). The nerves and vessels can be

used as grafts, although at the digital level theyare often taken with overlying skin to providesensate coverage.

Gainor described in 1985 an osteocutaneousfillet flap for reconstruction of the thumb ina gunshot wound to the hand [9]. The flap was

derived from the injured index finger in which thedistal second metacarpal, including the metacar-pophalangeal joint together with the radial digital

neurovascular bundle, was destroyed by thegunshot. The proximal phalanx of the thumb,together with the extensor hood, was alsodestroyed except for a proximal articular frag-

ment. The index fillet flap with its intact osseouscomponent was transferred to the thumb. Theextensor indicis proprius and extensor digitorum

communis to the index finger were used toreconstruct the extensor hood of the thumb. Thepatient returned to his premorbid gainful employ-

ment and activities of daily living in a timelymanner. This example illustrates the successful useof the various usable components of a severelydamaged digit to restore function and form of the

hand.

The finger as composite tissue transfer

With advancement of microsurgery, replanta-

tion of fingers has evolved into a standard pro-cedure for traumatic hand injuries when indicated.Most replantations are performed orthotopically.Heterotopic replantations or transplantations,

however, can be performed also. Chiu reporteda case of heterotopic transplantation of a reat-tached but useless index finger to a functionally

deficient ring digit to improve overall function ofthe hand [34]. Although the patient did gain more

Fig. 7 (continued )


Fig. 8. (A,B) A 45-year-old man who was struck by a train, sustaining an avulsion amputation of the left arm through

the shoulder and a crush amputation of the right hand. (C) Amputated parts. Note severe crush of right hand and left

upper arm precluding replantation. Also note fairly undamaged left hand. (D) Initial appearance following replantation

of the left hand onto the right forearm at the wrist level. (E–H) Two-year followup.


functional use of the reconstructed hand, Chiucautioned on performing these procedures rou-

tinely because the patient with the twice-reat-tached finger experienced less sensibility recovery,more pronounced cold intolerance, decreasedbasal skin temperature, and a slower digital

rewarming time than the once-reattached ipsilat-eral digit and other normal fingers [34] (Fig. 5).

The hand and forearm

Along the same principles of the finger fillet flap,the mutilated hand and forearm are also excellent

sources of reusable parts for salvaging upperextremity injuries. The amputated hand and fore-arm provide a potentially greater surface area ofskin and longer segments of tendon, nerves, vessels,

and bone than the finger [17,19]. An interesting useof spare parts in a multileveled injury and ampu-tation of both upper extremities was reported by

Hammond et al [11]. In their case report, a frostbiteinjury resulted in amputation of a dominant rightwrist and nondominant index, long, ring, and small

fingers at the level of themidproximal phalanx withskin loss several centimeters proximal to the level ofthe exposed bone. Shortening the bone of the

nondominant fingers would have compromisedmetacarpophalangeal joint motion. The authorsproceededwith a functional amputationof the rightmid-forearm while simultaneously harvesting a ra-

dial forearm flap from the distal aspect of theamputated forearm for free flap coverage of theamputation stumps of the contralateral fingers.

Delayed inset and tailoring of the flap to contourthe finger stumps was performed 4 weeks later withstable soft-tissue coverage and preservation of the

metacarpophalangeal jointmotion.A below-elbowprosthesis was fitted for the dominant limb. Thisexample illustrates the need for careful planning

and execution to maximize the potential use of anotherwise discarded body part.

Fig. 6 illustrates a case of a 34-year-old womanwho sustained an avulsion amputation of her right

forearm. A radial forearm free flap was harvestedfrom the amputated limb and used to covera portion of her forearm stump and provided

stable coverage for later fitting of a below-elbowprosthesis. Similarly, Fig. 7 illustrates the use ofa radial forearm fillet flap from a nonreplantable

arm. The flap was used to cover and preservelength of the remaining humerus for laterprosthesis fitting. Deepening of the axilla wasperformed at a secondary stage. Similar case

reports have been reported in the literature [19].A unique example of using major amputated

limbs in a spare part fashion involves a cross-hand

transfer as illustrated in Fig. 8. Such a transferrequires careful planning and execution. Asillustrated here, however, such spare part surgery

can provide function unobtainable by any othermanner.

In cases in which the arteries are not viable,

venous flaps from the forearm or hand may beharvested for use as arterialized or flow-throughflaps for coverage of another damaged digit [35–37], skin defects of the hand [38,39], or coverage

of the amputation stump.

Fig. 8 (continued )


Although we have an extensive armamentari-um with which to reconstruct and restore formand function in mutilating injuries of the upper

extremity, use of spare parts is an important toolthat we must bear in mind as we approach themangled limb during the acute phase of manage-ment. We must preserve and carefully evaluate the

amputated parts and their potential contributionto the injured limb with regard to form andfunction orthotopically or heterotopically. The

use of spare parts minimizes further donor sitemorbidity and makes use of local tissue, thusallowing reconstruction with like components.

Restoration of a functional limb that is sensate,painless, useful, and aesthetic is the ultimate goaltoward which we must strive.

References

[1] Cave EF, Rowe CR. Utilization of skin from

deformed and useless fingers to cover defects in

the hand. Ann Surg 1947;125:126.

[2] Bunnell S. Injuries of the hand. In: Bunnell S,

editor. Surgery of the hand. 4th edition. Philadel-

phia: JB Lippincott; 1964.

[3] Slocum DB. Palmar skin flaps salvaged from

amputated fingers. NW Med 1960;59:1397–8.

[4] Peacock Jr EE. Reconstruction of the hand by the

local transfer of composite tissue island flaps. Plast

Reconst Surg 1960;25: 298–311.

[5] Alpert BS, Buncke HJ. Mutilating multidigital

injuries: use of a free microvascular flap from

a non-replantable part. J Hand Surg 1978;3:196.

[6] Al-Qattan MM. Lengthening of the finger fillet flap

to cover dorsal wrist defects. J Hand Surg 1996;

22A:550–1.

[7] Chase RA. The damaged index digit. A source of


Joint Surg 1968;50A:1152.

[8] Chase RA. Atlas of hand surgery. Philadelphia: WB

Saunders Company; 1973. p. 162–77.

[9] Gainor BJ. Osteocutaneous digital fillet flap: a

technical modification. J Hand Surg 1985;10B:

79–82.

[10] Hallock GG. Salvage of ring degloving injury with

wraparound flap from adjacent mutilated digit.

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Replantation in the mutilated handBradon J. Wilhelmi, MDa,*, W.P. Andrew Lee, MDb,Geert I. Pagensteert, MDc, James W. May Jr, MDd

aHand /Microsurgery, The Plastic Surgery Institute at Southern Illinois University School of Medicine,

747 North Rutledge, 3rd Floor, Springfield, Illinois 62794, USAbDivision of Plastic Surgery, Hand Surgery, University of Pittsburgh School of Medicine, PA, USA

cSurgery Resident, Freiberg, GermanydDivision of Plastic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA

The treatment of the mutilated hand is perhaps

the most challenging acute hand injury that hand

surgeons treat. Many of these injuries involve the

repair of devascularized and amputated parts of

the upper extremity. The decision to attempt re-

plantation and the techniques involved in replan-

tation of amputated parts are often extremely

difficult.

Thousands of severed body parts have been

reattached since the first replant 40 years ago, pre-

serving a quality of life not provided by the void

remaining after amputation. Ronald Malt per-

formed the first replantation on May 23, 1962 at

the Massachusetts General Hospital for a 12-

year-old boy who amputated his right arm in

a train accident [1]. The level of amputation

occurred at the neck of the humerus (Fig. 1). The

osteosynthesis for this replantation was done with

a steel rod through the humerus. The brachial

artery, both communicating brachial veins, and

the median, ulnar, and radial nerves were repaired

with this replantation (Fig. 2). He performed

another replant and in 1964 published a report

on both replantations in the Journal of the Ameri-

can Medical Association (JAMA) [1] (Fig. 3).

Later, Malt reported that the patient had some

recovery of function of the replanted right arm

after wrist arthrodesis and tendon transfers [2]

(Fig. 4). Technologic advances and the use of the

microscope have made possible the replantation

of other parts including the thumb, fingers, ear,

scalp, facial parts, and genitalia (6,12,13,16,20,29,

31,34,44,45,47,55,67–80).

Indications

Not all amputees benefit from or are candi-

dates for replantation. The decision to attempt

replantation of a severed part is influenced by

many factors, including the importance of the

part, level of injury, expected return of function,

and mechanism of injury. Thumb and multiple

finger replants should be attempted, as function

is severely compromised without opposition [3–

6]. Moreover, functional outcomes following

replantation vary significantly with the level of

injury. Good functional results can be achieved

with replantation of injuries at the level of the

fingers distal to the flexor superficialis insertion,

the hand at the wrist, and the upper extremity

at the distal forearm [7–11] (Fig. 5). Replantation

of the above elbow amputation should be at-

tempted for elbow preservation, even though

the chance for nerve recovery is low. If subse-

quent nerve regeneration is inadequate after

upper arm replantation, revision amputation at

the mid forearm level can then allow for a below

elbow prosthesis [7]. A below elbow prosthesis

with a gravity activated grip is more functional

than an above elbow prostheses. Less functional

recovery is expected for replants at certain levels

including amputations proximal to flexor superfi-

cialis insertion within zone II of the fingers and

at the muscle belly and elbow level.



(B.J. Wilhelmi).


doi:10.1016/S0749-0712(02)00137-3

Hand Clin 19 (2003) 89–120

As zone II replants can be expected to result in

stiffness and rehabilitation that significantly delays

return to work with minimal or no functional ben-

efit, a relative contraindication to replantation

exists for single digits amputated within the zone

II level [12]. Replantation of zone II finger ampu-

tations have been justified in Japan, so patients can

avoid being confused with Japanese gangsters (or

Yakuza) who amputate their finger as a symbol

of devotion to their mob boss.

Perhaps the most predictive indicator for suc-

cess with replantation is the mechanism of injury.

O’Brien has demonstrated significantly higher

success rates with replantations of guillotine ver-

sus avulsion amputations [5]. It may be an unre-

alistic expectation to successfully replant severely

crushed and mangled body parts. Avulsion inju-

ries with traction along the neurovascular bun-

dles create intimal tears and disruption of small

branches to the skin. Small hematomas seen in

the skin along the course of the neurovascular

bundle result in the ‘‘red line sign.’’ This sign sig-

nifies such detrimental injury to the neurovascu-

lar bundle that replantation is often fraught with

poor success.

Replantation attempts in digits with the red

line sign require vein grafting across this zone

of injury. Another indication of injury to the ves-

sels of an amputated digit is the ‘‘ribbon sign.’’

The ribbon sign is an indication of torsion and

stretch on a vessel. The vessel resembles a ribbon

that has been stretched and curled for decoration

on a birthday present. Vessels that have the rib-

bon sign often are not amenable to sustaining

blood flow, precluding replantation attempts

[13] (Fig. 6). Two other relative contraindications

to replantation include multiple level injuries and

mentally unstable patients. The only absolute

contraindication to replantation exists when as-

sociated injuries or preexisting illness preclude

a prolonged and complex operation. In this cir-

cumstance temporary ectopic replantation has

been described for preservation of the amputated

Fig. 1. Ronald Malt with his patient, the first to

undergo a replant procedure. Used with permission from

Williams Wilkins.

Fig. 2. The first replant was performed at the level of the

humerus and involved repair of ulnar, median, and

radial nerves and the brachial artery and venae com-

mitante. Used with permission from Williams Wilkins.

90 B.J. Wilhelmi et al / Hand Clin 19 (2003) 89–120

extremity before eventual elective replantation

later [14–16] (Fig. 7).

Preoperative considerations

Replantation of arms, hands, digits, or even fin-

gertips has become common in various institu-

tions. Remote physicians, paramedics, and even

the patients themselves are more educated on the

possibility of replantation. Because of this, it is

common to have the amputated part arrive with

the patient at the emergency department. Even if

not replantable, this amputated part can provide

a valuable tissue source for reconstruction. The

amputated part should be wrapped in a saline

moistened gauze sponge and placed in a plastic

bag. The plastic bag should be sealed and placed

on ice (Fig. 8). The amputated part should not

be placed directly on ice because this can result

in a frostbite injury to the tissue [17]. The part

should not be immersed in water because this has

been demonstrated by Urbaniak to make digital

vessel repair more difficult and less reliable

[18,19]. Bleeding vessels in the stump should not

be clamped. Hemostatic control of the stump can

be achieved with a compressive dressing and

elevation.

The recommended ischemia times for reliable

success with replantation are 12 hours of warm

and 24 hours of cold ischemia for digits, and 6

hours of warm and 12 hours of cold ischemia for

major replants (ie, parts containing muscle).

Reports of successful replantation after longer

ischemia times exist [20–24] (Table 1). May

reported a successful digit replantation after 39

hours of cold ischemia, the seventh of a seven-

finger replant case [21] (Fig. 9). Subsequently,

Wei reported successful digital replantations after

84, 86, and 94 hours of cold ischemia [24]. The

minimization of ischemia time is more critical in

replantation of limbs proximal to the digits. In

such cases, a temporary shunt to the amputated

limb may be beneficial [14–16].

Before surgery, radiographs of the amputated

parts and the stump should be performed to de-

termine the levels of injury and suitability for

Fig. 3. Title page of the report for the first replantation ever performed. (FromMalt RA, McKhann CF. Replantation of

severed arms. JAMA 1964;189(10):716–22; with permission.)

91B.J. Wilhelmi et al / Hand Clin 19 (2003) 89–120

replantation. Both parts should be photographed

for documentation. An informed consent should

be obtained, discussing the pros and cons with

the patient and family regarding the failure rates,

length of rehabilitation, realistic expectation of

sensation, mobility, and function. The preopera-

tive preparation also should include prophylactic

antibiotics, updating the patient’s tetanus status,

fluid resuscitation to prevent hypotension, warm-

ing the patient to prevent hypothermia and vaso-

constriction/spasm, Foley insertion for volume

monitoring, and protection of pressure points dur-

ing an expected long operation.

Operative considerations

The preparation of the amputated part can

be initiated before the patient is brought to

the operating room. This preparation is per-

formed on a back table under sterile conditions

in the operating room. The use of a microscope

assists with the assessment of the digital vessels

for replantation. Signs of arterial damage should

be noted, including the telescope, cobweb, and

ribbon signs or terminal thrombosis, which

would require freshening of the vessel [25]

(Fig. 10). Resection of the vessel distal to the

zone of injury may result in a defect requiring

a vein graft that should be harvested before

osteosynthesis to minimize warm ischemia time.

If the amputated part is grossly contaminated,

it should be cleansed gently with Normal Saline

(N/S) irrigation. Care must be taken not to

further injure the digital vessels or soft tissue.

The neurovascular structures of the fingers are

exposed with either bilateral longitudinal inci-

sions in the midaxial line or with volar zigzag

and dorsal longitudinal incisions [25,26] (Fig.

11). The neurovascular structures are then iden-

tified and tagged with 5-0 nylon sutures or

hemaclips to facilitate and expedite identification

at the time of coaptation.

Fig. 4. The first replantation several years after tendon

transfers and wrist arthrodesis. Used with permission

from Williams Wilkins.Fig. 5. Levels of replantation. (From Callico CG.

Replantation and revascularization of the upper extrem-

ity. In May JW, Littler JW, editors: McCarthy Plastic

Surgery, Volume 7. The Hand. Philadelphia: WB

Saunders Company; 1990; with permission.)


Fig. 6. (A) The red line and ribbon signs are poor prognostic signs for replantation. (From Boulas HJ. Amputations of

the fingers and hand: indications for replantation. Journal of the American Academy of Orthopaedic Surgeons

1998;6(2):101; with permission.) (B) This patient degloved a hand in a log crusher-splitter, resulting in multilevel

neurovascular and bone injuries.

Fig. 7. (A,B) This patient underwent ectopic implantation of an amputated hand before eventual replantation when he

was stable from other injuries. (From Chernofsky MA, Sauer PF. Temporary ectopic implantation. The Journal of the

Hand Surgery 1990;15A(6):913; with permission).


Many surgeons prefer to shorten the bone to

avoid the potential need for arterial, venous, and

nerve grafts later. The tagged neurovascular struc-

tures are gently relocated during the bone shorten-

ing (Fig. 12A). Approximately 5–10 mm of bone

shortening may be necessary for tension-free vessel

repairs. Through the bony shortening, nerve or vein

grafts may be avoided [27]. The bone shortening

should be performed on the amputated part if

possible, to retain length should the replant fail.

Fig. 8. The amputated part is wrapped in gauze and placed in a plastic bag. The plastic bag is set on ice. (From Callico

CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic

Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

Table 1

Longest reported ischemia times for successful

replantation

Author Part Ischemia time

May (1981) Fourth digit 28 hours/cold

May (1984) Seventh digit 39 hours/cold

Wei (1986) Digits 84, 86, 94 hours/

warm

VanderWilde

(1991)

Hand 54 hours/cold

Chui (1983) Hand 33 hours/warm


Bone can be resected on the stump side for the fin-

gers, but not for the thumb where length preserva-

tion is more critical, if the amputation level is near

the joint on the amputated part. Hand function is

compromised with thumb loss proximal to the

interphalangeal joint. If the amputation level is

through the joint, fusion in the functional position

is required. Primary implant arthroplasty has been

described in replantation but with increased risk

for infection [28]. Then, retrograde K-wires or

intraosseous wires can be placed through the bone

on the amputated part (Fig. 12B).

Usually there is enough time before the pa-

tient is transported to the operating room for

Fig. 9. (A–D) This patient amputated all eight fingers in a metal press. He underwent successful replantation of seven of

the digits, the last after 39 hours of cold ischemia. (From May JW Jr, Hergrueter CA, Hanson RH. Seven-digit

replantation: digit survival after 39 hours cold ischemia. Plast Reconstr Surg 1986:522–3; with permission.)


preparation of the amputated part. Alternatively a

second team can be recruited to begin the prepara-

tion of the stump. The neurovascular structures

are isolated, identified, and tagged on the stump

side under tourniquet control. Before the arterial

anastomosis, the tourniquet is deflated to assess

inflow pressure by the proximal vessel spurt [25]

(Fig. 13). If the spurt is inadequate, additional pro-

ximal vessel shortening is required. Furthermore,

in preparing the stump, exposure of the proxi-

mal flexor tendon for placement of a core suture

is better at this point than after bone fixation.

The order for repairing the various structures is

individualized. The sequence of repairing the bone,

extensor, veins, dorsal skin, artery, nerve, and

flexor is preferred by the authors, as it efficiently

allows for repairing all the dorsal structures before

the volar structures [5] (Table 2). If the warm ische-

mia time is unusually long, the artery can be

repaired earlier.

Techniques of osteosynthesis vary: many sur-

geons prefer cross K-wires, because they are quick

and safe (Fig. 14). Union rates have been reported

to be better with intraosseous wires, however,

either in combination with a K-wire as 90-90 wires

[29,30]. Ninety-ninety wires are two intraosseous

Fig. 10. Signs of arterial damage should be appreciated,

including the telescope, cobweb, and ribbon signs or

terminal thrombosis, which would require freshening of

the vessel. (From Callico CG. Replantation and revas-

cularization of the upper extremity. In May JW, Littler

JW, editors: McCarthy Plastic Surgery, Volume 7. The

Hand. Philadelphia: WB Saunders Company; 1990; with

permission.)

Fig. 11. (A,B) Exposure of the neurovascular structures to be labeled on the amputated part. (From Callico CG.

Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery,

Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)


Fig. 12. Once the neurovascular structures of the amputated part have been identified and tagged, they can be carefully

retracted for bone shortening. (A) Approximately 5–10 mm of bone shortening is necessary for tension-free vessel repairs

and the avoidance of neurovascular defects requiring grafts. (From Callico CG. Replantation and revascularization of

the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia:

WB Saunders Company; 1990; with permission.). (B) Then, retrograde K-wires or intraosseous wires can be placed

through the bone on the amputated part.


wires placed perpendicular to each other. Whitney

et al found this technique to have lower nonunion

rates with replantation procedures because 90-90

wires actually compress the fracture site [30]

(Table 3). Another advantage of 90-90 wires is that

they are low profile and easy to work around.

K-wires can occasionally be awkward and obscure

other structures that require repair.

After the osteosynthesis, the hand is pronated

and the extensor tendon is repaired first (Fig. 15).

If the amputation is at the proximal phalanx level

it is important to repair the lateral slips, to prevent

loss of extension at interphalangeal joints. The

dorsal veins are repaired. Next, at least two veins

should be repaired in finger replants, especially

for replants proximal to the proximal interphalan-

geal joint. Dorsal veins are preferred because they

are larger and don’t interfere with subsequent

repair of volar structures (Figs. 16 and 17).

Because the veins become smaller and more diffi-

cult to identify and repair the more distal the

injury, arterial repair may be required first to

locate the veins by back bleeding. Once the dorsal

structures have been repaired, the dorsal skin is

loosely approximated with small-caliber, simple,

interrupted sutures.

The hand is then supinated to repair the injured

volar structures. At least one digital artery is

repaired. Several anastomotic techniques have

been described (Fig. 18). One described technique

of microvascular repair involves placing the first

two sutures at 10 o’clock and 2 o’clock, then 12

o’clock; the vessel is then turned 180 degrees and

additional simple interrupted sutures are placed

in sequence. After the completion of the digital

artery repairs, the tourniquet is deflated and

clamps are removed. The patency of the arterial

anastomosis can be assessed with the milk test,

capillary refill, and bleeding on pinprick. If arterial

flow seems inadequate, one should confirm that

the patient has adequate blood pressure and vol-

Fig. 13. The tourniquet is deflated to assess inflow

pressure by the proximal vessel spurt. If the spurt is

inadequate, additional vessel shortening is required.

(From Callico CG. Replantation and revascularization

of the upper extremity. In May JW, Littler JW, editors:

McCarthy Plastic Surgery, Volume 7. The Hand.

Philadelphia: WB Saunders Company; 1990; with

permission.)

Table 2

Sequence of repairs in digital replantation

Skeletal fixation

Extensor tendon

Dorsal veins (arteries · 2)

Dorsal skin

Digital artery

Volar nerves

Flexor profundus

Volar skin

Table 3

Nonunion rates for various techniques of osteosynthesis

with replantation

Group Method (digits) Nonunion

Required

osteotomy

I Crossed K-wire (38) 8 (21%) 5

II Single K-wire (7) 1 (14%) 1

III Perpendicular

interosseous (8)

0 0

IV K+intraosseous (12) 1 (8%) 1

V K+Cassel (3) 1 (33%) 1

VI Cassel (7) 1 (14%) 0

Fig. 14. In performing the bone fixation, many prefer

K-wires, which are quick and safe and can be placed in

cross or axial configuration. Union rates have been

reported to be better with intraosseous wires, however,

either in combination with a K-wire as described by

Lister or as 90-90 wires. Ninety-ninety wires are two

intraosseous wires placed perpendicular to each other,

which was found to have lower nonunion rates. (From

Goldner RD, Urbaniak JR. Replantation. In Green DP,

editor: Green’s operative hand surgery. 4th edition. New

York: Churchill Livingstone; 1999. p. 1139–55; with

permission.)


ume, and that the tourniquet actually has been

deflated. Bathing the vessel with papaverine, lido-

caine, magnesium sulfate, and warm irrigation has

been described to counteract the vasospasm [31].

The hand can even be placed in the dependent

position to increase inflow pressure with gravity

[32]. One should allow at least 10 minutes observa-

tion time for resolution of vasospasm before

manipulating the anastomosis. If the milk test is

abnormal or if petechiae of the measles sign or

ballooning of the sausage sign is encountered, sus-

pect thrombosis and redo the anastomosis [25,33]

(Fig. 19). Frequently, in reperforming the anasto-

mosis, further vessel resection is necessary. If the

additional vessel resection places the vessel re-

pair under tension, an interposition vein graft is

Fig. 15. The hand is pronated, and of the dorsal structures, the extensor is repaired first. If the amputation is at the

proximal phalanx level it is important to repair the lateral slips to prevent loss of extension at interphalangeal joints.

(From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors:

McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

Fig. 16. At least two veins should be repaired in finger replants, especially for replants proximal to the PIP joint. Dorsal

veins are preferred because they are larger and don’t interfere with repair of volar structures later. (From Callico CG.

Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery,

Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)


required. A second artery should be repaired as a

safeguard measure.

Located superficial and volar to the digital

arteries, the digital nerves are coapted next. This

can be performed before or after the tourniquet

has been deflated. The epineurial nerve repair tech-

nique is preferred and can be performed with as

few as three sutures (Fig. 20). A nerve conduit or

graft is required if one is unable to repair the nerve

primarily. Some prefer nerve conduits instead of

direct coaptation. Weber et al reported a statisti-

cally improved return of sensation using the poly-

glycolic acid nerve conduits when compared with

end-to-end coaptation [34]. Upper extremity nerve

graft donors include the medial antebrachial and

posterior interosseous nerves. Alternatively, a vein

graft can be used for small defects of 2 cm or less

(Fig. 21).

At this point, the flexor tendon is repaired,

tying the previously placed proximal and distal

core sutures (Fig. 22). Performing the tendon

repair later permits finger extension, giving better

exposure for the microsurgical repair of the digital

arteries and digital nerves (Fig. 23).

Common indications for arterial interposition

vein grafts include thumb replants, ring avulsions,

and segmental artery loss or trauma [35–38].

Potential vein graft harvest sites for distal digital

replants include the palmar forearm and wrist.

The wrist is preferred by many because the volar

wrist veins match the digital vessels [13,39–41].

The leg or contralateral arm may be used to

harvest vein grafts for major replants of the

hand, forearm, or multiple fingers, as they can

be harvested by a second team simultaneously

(Fig. 24). Vein grafts must be reversed for arterial

interposition because of the valves.

Special considerations and specific cases

Thumb replants

In the thumb, the ulnar digital artery is usually

of larger caliber than the radial digital artery

[42,43]. Arterial revascularization in thumb

replantation therefore is more reliable when

based on the ulnar digital artery. This vessel is

difficult to expose for the microsurgery, however,

and requires extreme arm pronation or supination.

An arterial interposition vein graft from the radial

artery in the anatomic snuffbox to the distal end of

the ulnar digital artery in the amputated thumb

helps avoid the cumbersome position of extreme

rotation. Alternatively, the digital artery repair

could be performed before the osteosynthesis.

Care certainly must be taken to prevent disrupting

the anastomosis during the bony fixation if

this method is chosen [32,42,43] (Figs. 25 and 26).

When the thumb has been amputated at or

near the MCP joint and the proximal ulnar dig-

ital artery has retracted and is difficult to

expose, a vein graft can be used from the ulnar

digital artery distally to the radial artery in the

snuffbox, end to side. In using this vein graft

to radial artery technique for replantation of

the thumb, retrograde K-wires are placed first

into the bone on the amputated part. Then core

sutures are placed in the proximal and distal

ends of the flexor pollicis longus (FPL) tendon.

The digital nerves are labeled with long sutures

for easier identification later. A subcutaneous

tunnel is created from the ulnar aspect of the

thumb base to the snuffbox. The radial artery

is exposed in the snuffbox and double pott’s ties

are placed on the radial artery proximally and

Fig. 17. This is an example of a dorsal vein repair with

10-0 nylon sutures in simple, interrupted fashion over

the previously repaired extensor tendon.


distally in preparation for end-to-side anastomo-

sis of the vein graft to the radial artery. The

vein graft is first anastomosed end-to-end to

the ulnar digital artery with the microscope.

Again this provides much better exposure for

the microanastomosis of the ulnar aspect digital

artery to the thumb. The vein graft is then

pulled through the subcutaneous tunnel to the

radial artery in the snuffbox. The digital nerves

also can be repaired at this point with better

exposure. The osteosynthesis is carefully per-

formed by passing the previously placed K-wires

retrograde through the proximal bone. At this

point the extensor tendon and dorsal veins are

repaired. The vein graft is then repaired end

to side to the radial artery in the snuffbox

(Fig. 26).

If the amputation level is distal to the MCP

joint and the proximal end of the ulnar aspect

digital artery is well exposed, a primary arterial

anastomosis can sometimes be performed without

Fig. 18. This is a well accepted technique that involves placing the first two sutures at 10 o’clock and 2 o’clock, then 12

o’clock, then the vessel is turned 180 degrees and additional simple, interrupted sutures are placed in sequence. (From

Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy

Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

Fig. 19. If petechiae of the measles sign or if ballooning

of the sausage sign is encountered, suspect thrombosis

and redo anastomosis. (From Callico CG. Replantation

and revascularization of the upper extremity. In May

JW, Littler JW, editors: McCarthy Plastic Surgery,

Volume 7. The Hand. Philadelphia: WB Saunders

Company; 1990; with permission.)


the need for a graft. A technique that has been

described to optimize exposure of the ulnar digital

artery during the microanastomosis involves

performing the microanastomosis before the

osteosynthesis [44,45] (Figs. 27 and 28). The K-

wires are placed retrograde through the distal

amputated part first. The ulnar digital artery and

nerve are then repaired with the hand in supina-

tion that provides a better angle for the micro-

scope and exposure for the anastomosis. The

bone ends are then aligned and the osteosynthesis

is completed carefully. The digital artery clamps

are left in place until the extensor tendon and

dorsal veins are repaired. Finally, the flexor core

sutures are carefully tied and the skin loosely

approximated.

Fig. 20. Then, the digital nerves are coapted. This can be performed after the tourniquet has been deflated. Of the

different digital nerve repairs, the epineurial technique is preferred and can be performed with as few as three sutures.

(From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors:

McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

Fig. 21. This is an example of a digital artery repair on

the left and digital nerve repair superimposed over

digital artery repair on the right. Notice the flexor

digitorum profundus tendon core sutures have not yet

been tied, which allows for finger extension and better

exposure of neurovascular structures.

b


Multiple finger replantation

In multiple finger replantation, the finger with

the best chance for successful replantation, best

expected recovery, and contribution to function

should be repaired first. If all the fingers are

injured at the same level and with the same chance

for success, the authors prefer to repair the middle,

then index, then ring, and finally the small finger.

If the index finger is stiff or insensate, the patient

will bypass this to use the middle finger. When

all the fingers are stiff, the index finger can actually

impede the function and opposition of the other

fingers to the thumb (Fig. 29). Because it is essen-

tial to minimize ischemia time with multiple digit

replantations, each finger is replanted separately.

The amputated fingers should be brought to the

operating room as soon as possible, where the dig-

ital vessels, nerves, and tendons can be identified

and tagged with sutures or clips, to save time and

minimize ischemia. The order for repairs can be

improvised with multiple replantations. Initially,

the osteosynthesis, extensor tendon, one dorsal

vein, and one digital artery can be repaired for

each finger to minimize overall ischemia time.

Fig. 22. At this point, the flexor tendon is repaired, tying the previously placed proximal and distal core sutures. (From

Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy

Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

Fig. 23. This is the same finger after tying of the flexor

tendon core sutures, bleeding on pinprick.


Another dorsal vein, the digital nerves, and

the flexor tendon core sutures can be repaired

later, once the blood flow to the fingers has been

reestablished.

Major replants

Upper extremity replants

The order of the replant procedure is modified

for major replantations of the hand and upper

extremity. Early use of shunting has been

described to minimize muscle ischemia time

[15,16,32]. It is critical to minimize warm ischemia

time to less than 4 hours to avoid muscle necrosis.

Intravenous tubing or carotid shunts can be used

to infuse and return blood to and from the ampu-

tated part (Fig. 30). Fasciotomies are required

with major limb replantation and can be per-

formed during the shunting reperfusion to save

Fig. 24. (A,B) This is a vein graft interposing this arterial defect between the two forceps. Notice the size match with this

vein graft harvested from the palmar forearm.

Fig. 25. First, the vein graft is repaired to the distal

ulnar artery. Then the vein graft is pulled through a

subcutaneous tunnel to the snuffbox and repaired end-

to-side to radial artery. (From Goldner RD, Urbaniak

JR. Replantation. In Green DP, editor: Green’s

operative hand surgery. 4th edition. New York: Church-

ill Livingstone; 1999. p. 1139–55; with permission.)


Fig. 26. (A–D) This patient nearly amputated his thumb in a saw. The distal thumb hangs by a dorsal skin bridge. The

neurovascular structures were tagged; the flexor pollicis longus tendon core sutures were placed proximally and distally.

K-wires were placed in the retrograde fashion distally. The distal ulnar digital artery was repaired to the vein graft with

excellent exposure. Then the osteosynthesis was performed, reducing the fracture line and carefully passing the K-wires

in retrograde fashion into the proximal bone. Finally the vein graft is tunneled subcutaneously to the snuffbox, where it is

repaired end-to-side to the radial artery.


time. Bone shortening may avoid the need for

nerve and vein grafting and allow for soft tissue

closure over the repairs. With humeral level

replants, the brachial artery and brachial venae

commitante are repaired. The ulnar, median, and

radial nerves are repaired. The skin is lightly reap-

proximated. Skin grafts are usually required for

definitive closure. These upper extremity replants

may require several operating room debridements

at 48-hour intervals to remove devascularized,

nonviable muscle. Amputations at this level often

denervate the biceps muscles and later require lat-

issimus or pectoralis muscle transfers to provide

for active elbow flexion.

Hand replants

Again, vessels, nerves, and tendons are iden-

tified and tagged and K-wires are placed in the

Fig. 27. A technique that has been described to optimize

exposure of the ulnar aspect digital artery during the

microanastomosis involves performing the microanasto-

mosis before the osteosynthesis. (From Caffee HH.

Improved exposure for arterial repair in thumb replan-

tation. The Journal of Hand Surgery 1985;10A(s):416;

with permission.)

Fig. 28. (A–D) This patient amputated his thumb with a rope in a boating accident. This replantation actually involved

repairs at two levels. First, K-wires were placed in the amputated part. Repairs on the amputated part were performed

first. Two dorsal veins and the ulnar aspect digital artery and nerve were repaired in the amputated part with the

microscope on the back table. Then, the ulnar aspect digital artery of the amputated part was repaired to the proximal

end of the ulnar aspect digital artery on the stump side with the microscope, before osteosynthesis to avoid the struggle

for exposure often requiring extreme hand pronation. Then the digital nerve was repaired. Then the osteosynthesis was

performed carefully passing the K-wires distal-to-proximal. The amputated part, extensor pollicis longus tendon, and

two dorsal veins were repaired to the stump, before removal of the digital artery clamps proximal and distal to the

microanastomosis. Leaving the clamps maintains hemostatic control and better exposure for the vein repairs. Finally,

the flexor pollicis longus (FPL) tendon core sutures are carefully tied and the skin is loosely approximated.


retrograde fashion into the amputated part in

the operating room before the patient is trans-

ported from the emergency room (Fig. 31). Sim-

ilarly, the ischemia time can be minimized by

shunting, during which fasciotomies can be per-

formed if necessary. The most time-consuming

part of a hand replantation is the tendon re-

pairs. The exposure of the proximal flexor tendon

ends can be optimized by placing a longitudinal

incision up the mid portion of the forearm. Also,

tagging of the proximal and distal flexor tendon

ends before the osteosynthesis can facilitate the

repair of the flexor tendons later. It is important

to understand the stacked array of the flexor ten-

dons with the middle and ring flexor digitorum

sublimis tendon (FDP) volar to the index and

small finger superficialis flexors (Fig. 32). Replan-

tation of hand amputations at the wrist level may

necessitate bone shortening (eg, proximal row car-

pectomy) to avoid nerve and vein grafts. Overall,

the ulnar and radial arteries, four veins, median,

ulnar, and superficial radial nerves are repaired

and many tendons as possible. At least the four

flexor digitorum profundus tendons, flexor carpi

radialis, flexor carpi ulnaris, four extensor digiti

communis tendons, extensor carpi ulnaris, exten-

sor carpi radialis, extensor pollicis longus, and

flexor pollicis longus should be performed. In

general, replantations at this level can achieve

very good results.

Cross hand transfer

A special circumstance may call for considering

a cross hand transfer (ie, bilateral hand upper

extremity crush avulsion amputations with signif-

icant soft tissue or bone destruction precluding

bilateral ipsilateral replantation) [46–48]. The

patient in Fig. 33 had a brachial plexus injury ren-

dering his right hand functionless [48] (Fig. 34).

Accordingly, this right hand was electively trans-

ferred to the contralateral side, which had a thumb

but was devoid of all four fingers. This elective

cross partial hand transfer was performed at the

level of the carpometacarpal joint with intraoss-

eous wires (excluding the thumb). This was the first

elective partial cross hand transfer (excluding the

thumb) reported in the literature. He went on to

attain good functional use of this hand following

transfer.

Postoperative care

Postoperative care has traditionally included

warming the patient’s room to avoid vasospasm

Fig. 28 (continued )


and positioning the extremity at the heart level

to minimize edema but not compromise arterial

or venous flow. Anticoagulation is generally rec-

ommended. Several investigators recommend the

routine use of aspirin and dextran with replanta-

tion, [5,49,50] and therapeutic heparin for crush

avulsion injuries [32,49]. Depending on the

mechanism of injury, antibiotics are considered.

Patients are encouraged to abstain from smok-

ing and caffeine use for 1 month [51,52]. The

replanted part is monitored by checking color,

capillary refill, tissue turgor, and temperature.

Sympathetic blocks have been described for

high-risk replantations after crush avulsion inju-

ries [25]. Arterial insufficiency is the most com-

mon cause for replantation failure, accounting

for approximately 60% of failures in two studies

[5,49]. Arterial insufficiency is suggested by

decreased capillary refill, tissue turgor, and

temperature. Treatment of arterial insufficiency

includes removal of potentially constricting

dressings and tight sutures, decreasing extremity

elevation to promote inflow with gravity, and

sympathetic blockade. Finally, early operative

intervention can be considered if there is no

improvement with the above measures. Reexplo-

ration to correct arterial insufficiency has been

reported to be successful in 50% of return visits

[5,49]. Venous congestion is a less common

cause for replantation failure [5,49]. Venous con-

gestion should be suspected with rapid capillary

refill, increased tissue turgor, or bleeding of

wound edges [49]. Treatment of venous conges-

tion includes removal of tight dressings and

Fig. 29. (A–G ) This 50-year-old man amputated all four of his fingers in a printing press. Each finger is replanted

separately to minimize warm ischemia time. Two dorsal veins and one digital artery were repaired for each finger in the

dorsal and volar sequence described by O’Brien. The fingers were replanted in order of functional importance. The

authors repaired this patient’s index finger last, because the amputation level was to the proximal interphalangeal level

and would be less functional. All four replants survived: He quickly regained the ability to write. With tenolysis

procedure and correctional osteotomy of the index finger, he went on to regain >50% total active motion (TAM). He

even created this glove that he uses to help lift weights.



sutures and increasing elevation to promote

venous drainage with gravity. Leeches are also

effective at treating venous congestion in replan-

tation. Nail plate removal and application of a

heparin soaked sponge to the nail bed has been

described for distal replantations when a vein

cannot be repaired and the patient refuses

leeches [53]. Finally, operative revision can be

considered, but is less successful than reexplora-

tion for arterial insufficiency.

Outcomes

Overall success rates for replantation

approach 80%. In reviewing large volume

retrospective reports, these success rates range

from 54% in China’s Sixth People’s Hospital

to 82% in North Carolina [54–57] (Table 4).

Overall, success rates are significantly higher

for replantation of guillotine (77%) versus crush

(49%) amputations [5,49]. In general, approxi-

mately 50% achieve two-point discrimination (2

PD) less than 10 mm [58–62]. Seventy percent

of Tamai’s 228 replants achieved 2 PD <15 mm,


Table 4

Survival rates for replantations

Author Number Survival rate

Tamai (1982) 157 80%

Kleinert (1980) 347 70%

Urbaniak (1979) 107 82%

Sixth People’s Hospital (1975) 320 54%

Fig. 30. (A–G) This 40-year-old man amputated his left arm in a rollover car accident. His amputated arm was found in

a ditch, 30 feet in front of him and his upside-down car. The arm was brought to the operating room before the patient

arrived; it was extensively irrigated and structures to be repaired were identified and labeled. The humerus was shortened

enough to allow for skin approximation over the repairs. Then osteosynthesis was performed with a 4.0 compression

plate. Next, the use of carotid shunts to and from the amputated part minimized the total ischemia time to 3 hours.

During this shunting reperfusion, forearm and hand fasciotomies were performed. Then the brachial artery was repaired

with a reversed saphenous vein graft. The brachial venae commitante were repaired. Then the median, ulnar, and radial

nerves were coapted. At 48 hours and several times after that he returned to the operating room for debridement of

portion of the triceps, distal deltoid, and biceps muscles and skin edges. Finally, at 2 months postoperatively, he did not

have any open areas or evidence of nerve regeneration.



Fig. 31. (A–D) This 63-year-old woman accidentally amputated her left hand while helping cut wood with a radial saw for

her family fence-makingbusiness.Theamputationwas at the distal carpal row.K-wireswere used forosteosynthesis. Before

the osteosynthesis, the neurovascular structures were identified and labeled, together with the tendons. Overall, the ulnar

and radial arteries, four veins, median, ulnar and superficial radial nerves, and 18 tendons were repaired. Postoperatively,

despite her advanced age and less than optimal participation with therapy she had some return of function.

whereas 65% of Larsen’s 142 replants attained

2 PD <10 mm [57,58]. In general, younger

patients with distal guillotine amputations ex-

perienced better return of sensation. Several stud-

ies have determined the average replant to

achieve 50% of normal function (ie, 50% total

active motion and 50% grip strength) [60,63–

65]. Return of function was worse for zone II

injuries and for patients of advanced age. Rus-

sell published the largest review of major limb

replantations and found 11/24 achieved >50%

total active motion and 19/24 achieved protec-

tive sensation, and 22/24 patients were satisfied

with the function and appearance of their

replanted part [10].

Jupiter showed the function of replanted digits

could be significantly improved with tenolysis pro-

cedures [66]. In his review, the total active motion

of 37 replanted digits was significantly improved

(P < 0.001) with tenolysis and no digits were lost

[66]. The patient in Fig. 34 underwent replantation

of the middle and ring fingers after amputation in a

log splitter (Fig. 34). He went on to experience loss

of active and passive flexion. To improve the

socially unacceptable posture of his permanently

extended middle finger, he required flexor tenoly-

sis, extensor tenolysis, and capsulotomy proce-

dures. A median nerve catheter was used to

provide the patient with better pain control post-

operatively, for immediate active range of motion

exercises. Postoperatively, he had full active range

of motion at 6 weeks.

Summary

With the evolution of surgical techniques and

scientific technology, replantation has become

more refined, establishing specific indications for

replantation, rituals for preparation, efficient tech-

niques to ultimately minimize ischemia times,



Fig.32.A

simple

methodofdem

onstratingthearrangem

entofsublimis

tendonsatwrist

withthemiddle

andringfingersvolarto

theindex

andsm

allfingers.

(�Frank

Netter.ClinicalSymposia,Volume21(3).Summit,NJ:

CibaPharm

aceuticals;1969.p.88).


improved survival rates, guidelines for postoper-

ative care, strategies for treating complications,

and goals for outcomes. Patient satisfaction

hinges on their level of expectation as defined

and explained in the preoperative discussion

and informed consent. Studies have demon-

strated patients can be expected to achieve 50%

function and 50% sensation of the replanted

part. Initially all that was amputated was re-

planted, as surgeons adopted the philosophy of

George C. Ross (1843–1892): ‘‘Any fool can

cut off an arm or leg but it takes a surgeon to

save one.’’ Forty years after the first replant

(1962–2002), however, we recognize the ultimate

Fig. 33. (A) This patient had a brachial plexus injury rendering his right hand functionless. Accordingly, the right hand

was electively transferred to the contralateral side, which had a thumb but was devoid of all your fingers and

metacarpals. (B,C ) This elective cross hand transfer was performed at the level of the carpal metacarpal joint with

intraosseous wires. (D–F ) This patient went on to attain good functional use of this hand following transfer.


goal: not merely to preserve all living tissue

through nonselective replantation, but rather to

preserve one’s quality of life by improving their

function and appearance. This objective to care

for the patient with the intent to optimize func-

tion and appearance is important not only to

the replantation of amputations but to all muti-

lated hand injuries.


Fig. 34. (A–K ) This patient underwent replantation of

the middle and ring fingers after amputation in a log

splitter. He went on to experience loss of active and

passive flexion. To improve the socially unacceptable

posture of his middle finger, he required flexor tenolysis,

extensor tenolysis, and capsulotomy procedures. A

median nerve catheter was used to provide the patient

with better pain control postoperatively, for immediate

active range of motion exercises. Postoperatively, he had

full active range of motion at 6 weeks.




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Pediatric mutilating hand injuriesGregory M. Buncke, MDa,b,c,*, Rudolf F. Buntic, MDb,c,

Oreste Romeo, MDc

aDepartment of Plastic Surgery, University of California, 350 Parnassus Avenue, San Francisco, CA 94117, USAbDepartment of Plastic Surgery, Stanford University Medical Center, CA 94305, USA

cBuncke Clinic, 45 Castro Street, Suite 140N, San Francisco, CA 94010, USA

The treatment of mutilating hand injuries con-

tinues to be one of the most difficult challenges

faced by reconstructive hand surgeons. With the

advent of microsurgical techniques, parts that

had been discarded are now replanted or revascu-

larized. In addition, reconstruction for soft tissue

coverage and finger lengthening with toe trans-

plantation has become an essential part of the

reconstructive surgeon’s armamentarium.

Managing children is particularly rewarding

to the hand and microsurgeon because the out-

come tends to be better than with adults in terms

of mobility, sensory return, and appearance and

because children who sustain mutilating hand inju-

ries tend to rebound more quickly than adults

from both a functional and psychologic perspec-

tive. The parents of the injured child, however,

can add another level of complexity to surgical

management. The trauma that causes the mutilat-

ing injury in children is often related to parental

neglect or caused by situations and circumstances

that a diligent parent could have avoided: unfortu-

nately children are often left unsupervised in

dangerous settings. Parents who own and operate

restaurants, garages, farms, ranches, or factories

often have small children in the work environment

during the parents’ work hours. A child may acci-

dentally catch his or her hand in machinery while

trying to help an adult at work. In addition, the

parents may not have the financial means to obtain

quality child care.

Parental guilt related to the accident is often a

difficult problem for both surgeons and nurses.

Parents often transfer their guilt to health care pro-

viders by becoming overly involved and critical of

the child’s care in the hospital and in the outpatient

setting. Professional counseling for the family after

admission can be of enormous help in caring for the

child. Although an outpatient, hand therapy often

serves two purposes: assisting the child inmaximiz-

ing his or her function, and allowing an outlet for

parents to become more involved in their child’s

care. Parents meet other parents of injured children

or other adults who have injuries andmay set up an

informal type of group therapy, which often helps

allay the depressed parents’ feeling of guilt [1].

Types of injures

The diversity of mechanisms of injury leads to a

multiplicity of types of injuries in the pediatric

mutilated hand. The mechanisms of mutilation

include meat grinders, saws, stationary bicycles,

doors, hinges, explosives, guns, firecrackers, dog

and other animal bites, burn injury from both

hot water and exposed heating elements or elec-

tricity, and lawn mowers [2–5]. Unfortunately,

children’s mutilating injuries tend to be less ame-

nable to replantation than the typical hand saw

injury seen so commonly in adults. As a result,

children frequently need secondary operations to

maximize function and appearance.

Initial management and preoperative evaluation

Frequently, when a child has had a devastating

injury to an extremity, most of the attention is


Buncke Clinic, 45 Castro Street, Suite 140N, San

Francisco, CA 94010.

E-mail address: [email protected](G.M.Buncke).


doi:10.1016/S0749-0712(02)00076-8

Hand Clin 19 (2003) 121–131

Fig. 1. (A) A 6-year-old child with his hand caught in a meat grinder. (B) The grinder was removed using a carbon

cutting circular saw. The patient has a severe mutilating injury. (C ) The small finger was salvaged; all carpal bones on the

radial aspect of the hand had to be removed. (D) Great toe to thumb transplant (proximal phalanx of the toe to the distal

radius) to create prehension. (E,F ) The child can now swing a baseball bat, write, and use eating utensils with his

reconstructed right dominant hand.

122 G.M. Buncke et al / Hand Clin 19 (2003) 121–131

focused on the injured part. Frantic parents and

friends often make it difficult to assess the entire

patient in the emergency room. As is true with

any emergency patient, the ABCs (airway, breath-

ing and circulation) are addressed first.

Unlike an adult, a young child often is unable

to give a reliable history and may be unable to

describe pain successfully in other locations. Un-

fortunately, if the child is too young, the history

must then be obtained from a witness, either a

parent or possibly the ambulance crew that arrived

on the scene. Key elements in the history include

the nature of the injury, mechanism of injury,

and the possibility of contamination. Sometimes

the mechanism is quite obvious (Fig. 1). If there

has been a crushing or avulsion element to the

injury, the surgeon must be concerned about a

more proximal injury, such as muscle tearing in

the forearm and possible delayed compartment

syndromes. Severe contamination from farm inju-

ries needs more aggressive debridement and perio-

perative antibiotics that cover gram-negative

bacteria. Obviously, any chronic medical condi-

tion that precludes a long general anesthesia also

needs to be determined.

A thorough general physical examination is very

important. The evaluating physician should have a

low threshold for obtaining radiographs of any

potentially injured part or tender site on the body.

With regard to the injured limb, key elements of

the examination in the emergency room before

taking the patient to the operating room can often

be performed with the dressing intact. If there has

been an injury to the proximal fingers, mid-palm,

wrist, or forearm the examining surgeon may be

able gently to examine the tips of the fingers for

vascularity, sensation if the patient is old enough

to cooperate, and any voluntary motion. Sensory

examination may be the most helpful preopera-

tively, because the surgeon may not need to dissect

as extensively for nerve injury intraoperatively if

sensation is intact. Particularly in young children,

however, the trauma of examining an obviously

mangled extremity must be weighed against the

unlikely possibility of obtaining any clinical infor-

mation that helps with the emergency operation.

In cases of amputation, a quick evaluation of

the amputated part can be performed in the emer-

gency room under loupe magnification to alert the

patient’s parents of nonreplantable limbs or digits.

Every effort should be made, however, to attempt

replantation in children.

Religious and cultural issues are often apparent

in the emergency room when discussing treatment

with the parents. For example, certain religious

groups do not believe in blood transfusions. If

replantation or revascularization is contemplated

in such a child, the parents should be alerted that

the child will probably need blood transfusion

sometime during the hospitalization. The parents

may elect to have the child not undergo replanta-

tion in such a circumstance.

Because of cultural issues in the Asian popula-

tion, the authors have frequently replanted muti-

lated parts that they were sure would have a poor

functional outcome. According to some Asian cul-

tural philosophies, however, if an individual dies

without all of his or her body parts they have some-

how disgraced their ancestors. The authors have

many happy Asian patients with stiff fingers.

The initial assessment of the injured extrem-

ity and amputated part is then completed in the

operating room when the child is under general

anesthesia. Once a complete evaluation of the

mutilated extremity is performed in the operating

room, the surgeon may take a short break from

the procedure and discuss the examination with

the anxious parents. Certainly replantation and

revascularization should take precedence over

allaying parental anxiousness. Decisions should

be made with the parents’ assistance, however, if

at all possible.

Many patients are transferred to a replantation

center from several hours away. During the prepa-

ration for transport of the child, several steps

should be performed before the patient’s transfer.

Specifically, the patient should be hemodynami-

cally stable before transfer. The injured extremity

should be wrapped with a bulky dressing wrap-

ped tight enough to prevent continuous oozing

from the hand but not so tight as to cause pain or

vascular compromise. A tourniquet should not be

placed on the extremity. The amputated part

should be wrapped in slightly moistened saline

gauze. It can then be placed in a plastic bag or a

water-tight container and placed on ice. Care

should be taken not to place the part directly on

ice without a protective layer of gauze or directly

in ice to avoid freezing the part. Placing the part

in soaked saline sponges or allowing the part to

float in saline leads to maceration of the part.

The operative procedure: general concepts

If available, the authors often try to have two

operative teams working simultaneously in major

amputations. The amputated part is taken to the

operating room while another team is evaluating

123G.M. Buncke et al / Hand Clin 19 (2003) 121–131

and preparing the patient for surgery. The so-

called tagging team examines the amputated or

mutilated parts under an operating room micro-

scope and puts tagging sutures, specifically No.

6-0 silk, around structures to be repaired, such as

digital arteries, nerves, and veins. Debridement

of obviously contaminated tissue should be per-

formed at the same time.

Once the patient is stable hemodynamically, he

or she is brought into the operating room and gen-

eral anesthesia begins. Usually the tagging team is

working in the same room identifying structures

on the amputated parts. A tourniquet is placed

on the arm and the arm is elevated if severe blood

loss is anticipated during dressing removal. The

tourniquet may, however, need to be released to

determine viability of damaged parts and the pos-

sible need for revascularization.

Debridement is then performed. If replantation

or revascularization is necessary, debridement

should be performed expeditiously to minimize

ischemia time. Clearly infected, contaminated tis-

sue needs to be removed. Marginally vascularized

tissue of significant importance, such as nerves,

tendons, joints, and bones, should be left intact.

Muscle, devascularized fat, and skin should all

be debrided aggressively. Debridement should be

performed under tourniquet control. After release

of tourniquet there should be good bleeding from

the debrided edges; if not, more debridement

should be performed. Skin bridges, which may

provide critical venous drainage, should be pre-

served whenever possible. Superficial veins in sub-

cutaneous tissue may be required in future

reconstructive efforts, such as microvascular soft

tissue coverage operations. The veins can be de-

brided definitively and immediately at the time of

anastomosis.

Tendon debridement should be performed

sparingly and paratenon should be preserved if

at all possible for future skin grafting. Undebrided

tendon ends are convenient grasping points while

manipulating a tendon for tenorrhaphy. Bony ends

must be debrided of foreign contaminated tissue

before any osteosynthesis.

In patients who have suffered burn injuries or

crushing injuries with avulsion, care must be taken

not to remove marginally vascularized tissue. The

authors believe in serial debridements over the

next several days to maximize the amount of viable

tissue available for reconstruction.

After debridement is completed, irrigation

should be performed with bulb syringes or pulse

lavage. Once irrigation is completed and hemosta-

sis is obtained, the surgeon next needs to consider

coverage of the wound. If primary closure cannot

be obtained at the time of the emergency opera-

tion, then skin grafting is considered. Large skin

grafts or emergency microvascular transplants,

however, should not be performed unless the sur-

geon is sure of having adequately debrided the

wound. This is often difficult in the mutilated

extremity, because there frequently is a burn,

crush, or avulsion component to the injury. What

seems viable at the emergency operation may be

necrotic 3 or 4 days later at a subsequent debride-

ment operation.

To avoid desiccation of the wound with tradi-

tional wet-to-dry dressing changes the authors

use a subatmospheric (VAC sponge) pressure

dressing for wound management [6]. This system

is well tolerated by patients. The system seems to

keep the wounds moist and is especially well liked

by the nursing staff who no longer need to do three

to four times a day wet-to-dry dressing changes.

The sponge is generally changed in the operating

room.

Replantation and revascularization

The concepts and techniques for replantation

and revascularization in mutilating injuries in chil-

dren are similar to those in adults [7,8]. Once

tagged, amputated parts are placed in a small

operative basin that is then placed on ice to mini-

mize warm ischemia. The second operative team

performs debridement and at the same time identi-

fies the corresponding structures that were previ-

ously identified in the amputated part by the

tagging team, specifically arteries, nerves, veins,

and flexor and extensor tendons.

Thereplantation-revascularizationeffort should

begin with the most ulnar-amputated digit. The

sequence of replantation begins with osteosyn-

thesis [9]. Occasionally, in the situation where a

large part has been amputated, like an entire hand,

forearm, or upper arm, revascularization may be

performed before osteosynthesis to prevent muscle

ischemia. In this situation a T-shaped shunt is

placed in the proximal and distal artery. The other

end of the T is attached to a syringe containing

heparinized saline. Once arterial inflow is estab-

lished in the amputated part, osteosynthesis can

be performed. The authors generally perfuse the

part for about 20 minutes and then clamp off the

shunt. Bleeding can be profuse during this time

and the anesthesiologist should usually hang


blood during such a reperfusion effort. To perform

an end-to-end anastomosis of arteries, veins, and

nerves, bone shortening is usually performed. Up

to 3 to 4 cm can be removed from the radius and

ulna or humerus without any significant functional

loss in amputation injuries. Rigid plate fixation

should be performed in long-bone repairs, being

careful not to injure growth centers. In contradis-

tinction, osteosynthesis of finger replants is gener-

ally preformed with K-wire fixation over plate

fixation to speed along the replantation effort.

Plates may also become exposed if there is mar-

ginal necrosis of the skin at the repair site.

Once osteosynthesis is performed in the large

part replant, an arterial anastomosis is performed

either with or without a vein graft, depending on

the defect. Throughout this time the replanted part

is allowed to bleed from the venous side. At first

the blood that comes from the veins is quite dark

in color, rich in muscle breakdown products. The

authors usually allow this venous blood to drain

for several minutes before venous repair. The

patient may lose up to one to two units of blood

during this time. The venous repair is not per-

formed until the color and consistency of the

venous outflow appear normal. Venous blood

sampling for potassium has been reported: if the

potassium is less than 6.5, then the risk of systemic

injury is unlikely [10].

During any crushing or replantation-revascu-

larization operation, the surgeon needs to be

aware of possible compartment syndromes. This is

missed easily in patients who have had avulsion

injuries of the fingers and have had tearing at the

musculotendinous junction in the forearm. The

patient can develop compartment syndrome some-

times several hours after the injury. Revascu-

larized or replanted arms or hands should be

watched closely for elevated compartment pres-

sures in the hand. Dorsal incisions should be made

to release the intrinsic musculature by releasing the

fascia in the intermetacarpal space. Compartment

pressures can be measured accurately with the

Stryker system (Stryker Surgical Division, Kala-

mazoo, MI) [11]. Compartment pressures above

25 mm Hg signal the need for compartment

release. The surgeon, however, should have a low

threshold for compartment release because edema

and elevated pressures may develop several hours

after surgery.

When replanting fingers vascular repairs often

can be tedious and technically very difficult in chil-

dren. Vein grafts [12] are used liberally in crushed

and avulsed injuries. Resection of damaged vessels

is very important to maintain the patency of a vas-

cular repair.

In a very distal replant, for example distal to the

distal interphalangeal (DIP) joint, arterial repair

may be possible, but a venous repair may not.

The surgeon should look for a volar vein or repair

the distal artery to a proximal vein thereby using

the second artery in the digit as outflow for the

replanted part [13].

The use of a venous flow-through flap [14] can

serve as a vein conduit and also act as soft tissue

cover for an area of questionably viable skin on

the volar or dorsal surface of a mutilated finger,

as in ring avulsion injuries. The venous flap can

be harvested easily from the volar surface of the

wrist. Vein grafts can also be harvested from this

area. The vein vessel diameter is approximately

the same size as the arteries of the finger.

Next in the sequence of replantation and revas-

cularization is the digital nerve repair. Usually after

microvascular arterial repair, the nerve is in the

operating field and nerve repair can be performed

expeditiously. Digital nerve repair should be per-

formed end-to-end if possible. A nerve graft can

be placed in the primary emergency setting. If there

is marginal necrosis and exposure of the nerve

graft, however, one may lose the nerve graft and

have lost a precious donor site. A nerve graft can

be harvested from the superficial peroneal region

on the dorsum of the foot [15] or the sural nerve

region. Care should be taken to harvest the nerve

high enough up the calf so that the patient does

not develop a neuroma at the upper boot level. A

nerve graft can also be harvested from the ulnar

aspect of the forearm. Patients often complain,

however, of numbness over the volar forearm. Vein

conduits also can be used for nerve gaps. The

patient can obtain similar results with a vein con-

duit as nerve graft if the defect is 3 cm or less [16].

Flexor tendon repair is next performed using a

double-opposing locking loop stitch technique

[17,18] with or without epitendinous stitch depend-

ing on the contour and irregularity of the repair. If

there is a tendon gap, a tendon graft can be used.

One should avoid tendon grafts, however, if mar-

ginal necrosis of the skin is anticipated. The sur-

geon may be more inclined to use a tendon graft

in a potentially problematic wound if tendon graft

is harvested from a nonreplantable part. Grafts

can also be harvested from the palmaris longus,

plantaris tendon, or extensor digitorum longus to

the middle three toes [12].

The next step in the sequence of replantation

involves repairing extensor tendons and dorsal


Fig. 2. (A) A 10-year-old boy suffered a nonreplantable left middle finger amputation. (B) Markings for a second toe

transplant for finger reconstruction. (C) Intraoperative image of second toe transplantation. (D,E) Postoperative

demonstration of length and function.

veins. After the volar skin incision is closed loosely,

the hand is turned over. The extensor tendon is

repaired using as strong a repair as possible. If

there is adequate tendon, a double-opposing lock-

ing stitch should be performed. Alternatively, a

mattress repair is usually adequate. Venous repair

is performed under the operating microscope with

vein grafts if necessary. In general, veins can usu-

ally be repaired in end-to-end fashion.

Once the replantation-revascularization opera-

tion has been performed, the patient is empirically

started on low-molecular-weight dextran [19,20]

Fig. 3. (A,B) Late result of a mutilating injury of the right hand in a 4-year-old boy. (C,D) Intraoperative image of

simultaneous great toe and rectus muscle transplant. (E,F) Immediate postoperative results with STSG over the rectus

muscle. Venous Doppler probe is in place. (G,H) Nine months’ postoperative view of function.


(total dose not greater than 20 mL/kg in 24 hours).

Dextran is usually continued for 5 days. Heparin

may be added as a second anticoagulant if a vein

graft has been used of if there have been intraoper-

ative thrombosis problems [21,22]. The authors

generally run heparin at 5 to 25 units/kg/h and

titrate the dose to the clinical response. A loose,

bulky dressing with a dorsal protective splint is

then fashioned. Xeroform or any other nonadher-

ent petroleum-based gauze should not be placed

circumferentially around the finger, to avoid a

tourniquet effect with swelling.

Monitoring is performed using quantitative flu-

orometry. A venous Doppler probe [23] is helpful

for real-time monitoring of the circulation in large

replanted parts or microvascular transplant.

Medicinal leeches are used when there is any

sign of venous insufficiency or in severely bruised

or traumatized soft tissue in the mutilated hand

[24,25].

Soft tissue coverage

Adequate soft tissue coverage is essential to re-

establish any reasonable functional result in a

mutilated hand, especially in children. For small

defects, such as fingertip avulsions with exposed

distal phalanx, cross finger flaps or pedicle flaps

may be of value. In a larger wound, however,

especially if there is any crush or avulsion asso-

ciated with the injured upper extremity, keeping

the patient’s hand in a dependent position for

a groin flap may cause undue swelling. Young

children may not tolerate pedicle flap or being

in this uncomfortable position for the 2-week

requirement.

Microvascular transplants of muscle with split-

thickness skin graft coverage, cutaneous flaps,

or fascial flaps with skin graft can serve as ex-

cellent coverage for immediate or delayed ten-

don, bone, nerve, or joint reconstruction [26].

Tendon repairs or tendon grafts may have less

adhesion if tunneled through subcutaneous fat

of a skin flap or through muscle rather than lay-

ing the tendon directly onto healing bone frac-

tures [12].

The timing of soft tissue coverage is a contro-

versial issue. Several others have recommended a

strict time frame for definitive soft tissue coverage

in mutilating extremity injuries [27,28]. It has been

Fig. 3 (continued )


the authors’ experience that soft tissue coverage

should take place when the responsible surgeon

believes that the wound has been debrided

adequately in a serial fashion. The authors have

had a few cases of infection from inadequate

debridement and early coverage of a wound that

had been presumably deemed ready for coverage

within 48 hours of the injury. With the use of the

VAC sponge system, the problems with desicca-

tion and loss of potentially viable tissue are no lon-

ger a significant problem.

Emergency microvascular coverage is probably

indicated in the case where a portion of a nonrep-

lantable part can be used as a microvascular trans-

plant, either as an arterial-to-venous repair or a

venous flow-through for soft tissue coverage. In

those circumstances, a normal donor site is not

wasted should a postoperative complication occur.

Emergency toe transplants have been performed

on the authors’ service in specific, unique circum-

stances. For example, a child suffered a below-knee

avulsion amputation with no injury to the foot and

Fig. 4. (A) Severe burn crush injury to 7-year-old girl. (B) Radiographs showing loss of all fingers. (C,D) Postoperative

image of hand appearance and function after simultaneous right second toe and serratus muscle transplant and

subsequent left second and third toe transplant.


also had a nonreplantable thumb injury [29,30]. In

that situation the toe was harvested from the non-

replantable below-knee amputation and trans-

planted to the thumb position.

Delayed treatment of the mutilating hand injury

Unfortunately, in many children who have

undergone mutilating hand injuries, the surgeon

may not be able to salvage any of the amputated

parts. The patient is frequently deficient in soft tis-

sue and has either lost all of their fingers or has one

finger remaining. This is especially true in the meat

grinder-type injury (Fig. 2). Restoring prehensile

function or pinch is the goal [31–36]. When the

reconstructive surgeon is presented with a patient

who has had this sort of injury, one needs to deter-

mine whether soft tissue coverage is adequate and

whether there is adequate blood supply to trans-

plant soft tissue and toes for finger and thumb

reconstruction [37,38]. When evaluating for possi-

ble toe transplantation, the surgeon needs to define

whether digital nerves, flexor, or extensor tendons

are available for repair to the toe. If all of this is

present soft tissue and toe transplant can be per-

formed simultaneously in the appropriate setting.

Otherwise, a staged sequence of operations needs

to be performed [39,40]. In general, soft tissue

reconstruction is preformed first followed by toe

transplantation (Figs. 3 and 4).

Summary

Mutilating hand injuries in children are a

devastating problem. With aggressive efforts at

replantation and revascularization, methodic de-

bridement, timely soft tissue coverage, and early

mobilization, however, the results in these un-

fortunate children can be quite rewarding. The

child often does well with the functional aspect

of recovery and rehabilitation but will probably

hide his or her deformed hand from friends and

family. These children generally become more

shy and reserved.

The parents are the key to rehabilitation. A

good relationship between the parent, the physi-

cian, and the hand therapist is essential for the best

result. Interestingly, the parents who are the most

demanding on the staff during the initial emer-

gency period are often the most appreciative

parents and their children often achieve the best

result. Conscientious parents are the best advo-

cates for their children.

Obviously, the prevention of these devastating

injuries is much preferable to extraordinary heroic

reconstruction. Unfortunately, some injuries are

inevitable. It is nearly impossible to create an

absolutely hazard-free environment for children.

Potential injuries can be avoided, however, simply

by keeping hazardous machines and equipment

out of the reach of the child and by keeping chil-

dren out of the potentially dangerous workplace.

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[3] Benson LS, Waters PM, Meier SW, et al. Pediatric

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[4] Brandner M, Bunkis J, Trengove-Jones G. Meat

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Hand therapy management following mutilatinghand injuries

Shirley W. Chan, OTR, CHTa,*, Paul LaStayo, PhD, PT, CHTb

aDepartment of Physical Medicine and Rehabilitation, California Pacific Medical Center, Davies Campus,

P.O. Box 7999, San Francisco, CA 94120, USAbDepartment of Physical Therapy, Northern Arizona University, Box 15105, Flagstaff, AZ 86011, USA

Overview of the rehabilitation process

for mutilating hand injuries

Mutilating injuries are among the most com-plex and devastating injuries to the upper

extremity [1]. Common types of mutilatinginjuries include crush, avulsion, and amputation.The outcome prognosis largely depends on the

severity, type, and location of the injury [2].Generally partial and clean amputations havebetter outcomes than crushing or avulsion injuries

[3]. The manner in which these patients aremanaged operatively and postoperatively alsogreatly influences the outcome. This article fo-

cuses on the postoperative management of mu-tilating hand injuries.

Mutilating injuries differ from other types ofhand injuries in that multiple systems and struc-

tures are involved [1]. These include skin, vascu-lar, nerve, tendon, muscle, bone, and the softtissue envelope around joints. Despite the shared

wound healing characteristics, each structure hasa unique healing time frame, precautions, andoptimal treatment approach. Some of the primary

factors that can affect the healing process andultimate outcome include the patient’s age,occupation, psychologic status, the surgical pro-cedure, and past medical history [4]. The therapist

must take all these factors into consideration toformulate the optimal treatment approach foreach case.

Because of the severe nature of these injuries,one must keep in mind several principles whentreating this population:

� The therapist should maintain close commu-nication with the treating surgeon about his

or her patient management approach, patientprogress, and postoperative treatment plan.

� The therapist also must have thorough

knowledge of anatomy, wound healing, bio-mechanics, and treatment guidelines of vari-ous traumatic injuries.

� The therapist should have a thorough under-standing of the injuries and types of repairsperformed. That understanding should in-clude location and quality of repair, types of

sutures used, associated injuries, and anystructures that were injured but not repaired.

The general rehabilitation process can bedivided into the early, intermediate, and late

phases.

Early phase (protective)

This refers to the first 5–10 days after the injury

and is usually a part of the patient’s inpatient stay.The therapist takes an active role in the multi-disciplinary team. This includes communicatingwith the physician to obtain details of the injury

and surgery and working with nursing and socialservice staff to prepare for the patient’s dischargefrom the hospital. Attending inpatient rounds is

an excellent way to obtain pertinent information,to observe the wounds, to meet the patient and thefamily, and to discuss the treatment plan with the

team. Reviewing the chart, imaging studies, and* Corresponding author.

E-mail address: [email protected] (S.W. Chan).


doi:10.1016/S0749-0712(02)00140-3

Hand Clin 19 (2003) 133–148

operative report also yields additional informa-tion that should be factored into the design of thetreatment program [1,3,5]. This may include but

not be limited to the following:

1. Type and stability of skeletal fixation

2. Joint status: free, pinned, or fused3. Tendon repairs; note flexor system and addi-

tional repairs (eg, finger pulleys)

4. Vessel repairs5. Nerve repairs6. Uninjured versus unrepaired structures

7. Location of repairs8. Condition of repairs9. Skin coverage

This information is vital not only for treatmentplanning but also for providing insight into future

surgical needs and helping formulate a realisticexpectation for recovery [1,3,5].

Although most of the traditional hand assess-

ments are not appropriate because of variousprecautions, the therapist should interview thepatient to obtain information pertaining to the

medical and social history and begin patient edu-cation regarding positioning, precautions, the re-habilitation process, and the expected outcome.

If the patient cannot return to the same facility foroutpatient care, the treating therapist also ar-ranges for referral to a therapist at the patient’shometown and coordinates the plan of care. A

protective splint to protect repaired structures isfrequently fabricated at this time and daily woundcare is initiated. Depending on precautions and

other medical factors, the patient may begingentle range of motion (ROM) exercises to theuninvolved joints. Generally active and active

assistive exercises are preferred if they do notcause excessive stress to the repair site. Earlymobilization to the involved structures also maybe introduced, depending on precautions and

contraindications.

Intermediate phase (mobilization)

This phase begins 5–7 days after the injury andlasts until 6–8 weeks after surgery. At this stage,

gentle controlled stress is introduced to decreaseadhesions, promote intrinsic healing, improvenutrition, promote collagen remodeling, increase

tensile strength of soft tissues, and prevent jointcontractures [6]. The program is progressed as therepaired structures undergo wound healing andgain tensile strength. The protective splint needs

to be remolded as edema subsides and the need for

wound dressings decrease. Once the wound ishealed and the chance for dehiscence is low, scarmanagement begins. In this phase the patient

takes an active role in therapy and in their homeexercise program. Activity of daily living (ADL)needs and training are addressed, especially if thedominant hand is involved [42]. The patient also

may need psychologic intervention to assist withadjustment to the physical and psychologictrauma.

Late phase (strengthening)

This stage begins 6–8 weeks after surgery and

lasts until the patient is discharged from therapy.This is the time when hand function retrainingand strengthening become the focus of therapy.

Progressive physical demands are placed on therepair to promote strength, hand function, coor-dination, and endurance through resistive exer-

cises and functional activities. ADL training mayfocus on specific problems as they emerge, such asopening the car door or buttoning. The protective

splint is usually discontinued and splints used atthis time are usually for overcoming joint stiffness,increasing tendon glide, or as an assist to function.Depending on the rehabilitation goals and out-

come, the therapist also may be involved in workretraining or communicating closely with thephysician to plan further reconstructive surgeries.

Healing process of the systems

Skin

The skin is a highly vascularized organ andheals quickly. A robust inflammatory responseusually lasts approximately 3 days and is charac-

terized by the presence of warmth and swelling. Afibrin mesh then provides a trellis, which guidesproliferating fibroblasts and capillary buds intothe wound [7]. The fibroblastic response begins at

3–5 days and is marked by the production of newcollagen that provides strength to the woundtissue [7,8]. The tensile strength of a wound

increases rapidly at 1 week and peaks at 42 days.Wounds that are closed by primary intention areoften healed in 10–14 days, at which time the

sutures can be removed. Scar management alsocan begin at this time. As the wound matures, thescar contracts in all dimensions and often seemsred and raised because of the profound biologic

activity that can last for months. Eventually thewound takes on a denser construct and the

134 S.W. Chan, P. LaStayo / Hand Clin 19 (2003) 133–148

biologic activity diminishes (ie, a balance betweenthe production of collagen by fibroblasts anddegradation of collagen by collagenase is reachedby 1 year) [7,8].

Blood vessels

Microsurgical repairs of blood vessels are

generally protected for 4 weeks to prevent clottingat the anastomosis site and arterial spasms. This isachieved by avoiding tension and pressure at the

anastomosis site and by keeping the revascular-ized body part warm. The patient is usually onanticoagulants during this time. The revascular-ized part should be positioned at the level of the

heart [3,9]. Excessive elevation may cause arterialinsufficiency and dependent position may causevenous congestion. Smoking is also prohibited, as

nicotine is a vasoconstrictor and can cause thereplantation to fail [10,11]. Once the vascularity iswell established and stable, compression dressing

and dependent position tolerance training can begradually introduced.

Nerve

Although the healing of the nerve repair issimilar to other soft tissues, functional recovery isa much longer process. A completely transacted

and repaired nerve should be protected for 3–4weeks to avoid tension and compression at thecoaptation site. In a complex injury in which

multiple structures are involved, however, earlymobilization is vitally important to promote earlynerve gliding while protecting the repair, thusminimizing scar adhesion [7]. After a nerve repair

there is a latency period of 3–4 weeks beforeaxonal regeneration of approximately 1 mm perday occurs [12,13]. Factors inversely correlated

with nerve regeneration include: amount of scar,age, type of injury, and the length of nerve injuredin a crush or stretch injury. In sensory nerves, the

return of pain and sympathetic function does notnecessarily imply the return of cutaneous sensi-bility; however, the lack of sympathetic function

usually suggests the absence of cutaneous sen-sibility. Sensibility recovers in the following se-quence: pain, deep pressure, pinprick, movingtouch, static light touch, and finally discriminative

touch. In motor nerves, the muscle reinnervationoccurs in the order in which the muscles wereoriginally innervated. The Tinel sign, return of

muscle activity, and sensory testing should beused to monitor the status of the regeneratingnerve [13,14]. As the nerve regenerates, the Tinel

sign should migrate distally along the nerve path.This should coincide with the return of motorfunction or sensory reinnervation.

Tendon

Following a tendon repair, the goal is toprotect the repair and insure that it glides freely.

Three approaches to the postoperative manage-ment of tendons exist: (1) immobilization, (2)early passive mobilization, and (3) early active

mobilization [15], but some form of early motionis optimal. Although tendons likely heal by way ofa combination of extrinsic healing (a fibroblasticresponse extrinsic to the tendon, which optimizes

healing but results in restricting adhesions) andintrinsic healing (a cellular response intrinsic tothe tendon, which minimizes adhesions), early

postoperative motion (active or passive) facilitatesthe latter, enhances strength of the repair, andreduces the chances for restricting adhesions

[16–18]. The early phase of rehabilitation is char-acterized by an inflammatory reaction thatdiminishes the tensile strength of the repaired

tendon but also primes the repair site forfibroblastic activity during the intermediate phase.This fibroplasia provides the constituents neces-sary for improving tendon strength. The inter-

mediate phase also includes a remodeling of thedeposited fibroblastic scar so as to allow free andunrestricted tendon gliding. This remodeling of

tissue continues into the late phase of rehabil-itation, during which stressors to the tendon canbe increased and tendon strength and function

continue to improve [15]. Unfortunately, becauseof the multiple injuries in a mutilated hand,tendons often heal in a fashion not conducive togliding and return of hand function. Therefore,

often a tenolysis (the surgical release of nonglid-ing adhesions) is required 6–12 months followingthe repair in an attempt to salvage tendon func-

tion [19].

Bone and dense connective tissues

When a fracture is rigidly fixed, primaryhealing occurs and mechanical integrity is re-established immediately. The lack of motion at afracture site held together with plates or screw

fixation (ie, rigid fixation) does not induce afibrous callus, the characteristic response ofsecondary healing, however, early motion can

and should be initiated. The clinical irony ofprimary healing is that rigid/stable union isestablished immediately by way of externally

135S.W. Chan, P. LaStayo / Hand Clin 19 (2003) 133–148

applied compression across the fracture site, yetthe biologic healing is prolonged.

When secondary healing of a fracture occurs,

an interfragmentary gap remains (ie, rigid fixationis not applied). In this case the gap is stabilizedthrough semi-rigid fixation devices or immobiliza-tion techniques. Because the fracture gap is not

rigidly fixed some obligatory motion occurs at thegap site in secondary healing—called secondarybecause an intermediate connective tissue (callus)

is formed early and then is secondarily replaced bybone. This process is characterized by threediscrete yet overlapping stages of inflammation,

repair, and remodeling that are commensuratewith the early, intermediate, and late phases ofrehabilitation, respectively [20].

The therapist, by way of the application or

avoidance of stressors across a healing fracturesite, can influence how bone consolidates; how-ever, their greatest influence is on the soft tissues

surrounding the fracture site. One of the mostinfluential factors affecting the clinical outcomeafter a fracture resulting from a mutilating hand

injury is whether the soft tissues are glidingnormally. Although closed and open reductionsof fractures have their respective advantages and

disadvantages, both fracture management ap-proaches adversely affect the soft tissue glidinglayers and the function of the extremity. Thereality of fracture management is that it is

clinically irrelevant whether bones unite by pri-mary healing or secondary callus. What isessential, however, is (1) whether or not the bone

heals in a stable, well aligned fashion, (2) how well

the soft tissues glide, and (3) how the extremityfunctions after it is healed.

Treatment techniques relating to the systems

Skin

Wound careThe primary goal after a mutilating injury is

wound closure, and wound care is often in the

domain of the hand therapist. Wound assessmentshould be carried out with each dressing change tomonitor for signs of infection such as excessive

redness, pain, swelling, and also to monitor thepatient’s progress in wound healing. In revascu-larization cases, vascularity also should be closely

monitored by checking color, turgor, and capil-lary refill. A white revascularized part indicates anarterial compromise as opposed to a blue–purplecolor that suggests venous congestion [3]. Skin

grafts should be pink and adherent to the woundbed. The patient is taught what to look for inhome dressing changes and any abnormal obser-

vations should be reported to the physicianimmediately.

Wound care is performed gently to remove

drainage, dry blood, and loose eschar (Fig. 1).Clear serum or bloody drainage is normal duringthe healing process. Thick purulent drainage isa sign of infection and should be reported to the

physician immediately. Special caution should betaken when removing adherent dressings near orover healing skin grafts and anastomosis sites.

Whirlpool is generally not used postrevasculariza-

Fig. 1. The wound is gently cleaned using a sterile applicator to remove drainage, dry blood, and loose eschar.


tion because of the need to place the body part ina gravity-dependent position [3,21]. Nonadherentprotective dressings are used and care must betaken that they are applied in a nonconstrictive

fashion. Each digit should be separated in thedressing to facilitate the ability to perform inde-pendent finger exercises (Fig. 2).

Scar managementScar mobilization can be introduced once the

wound is healed. Compression therapy is added

once the vascularity is stable at approximately4 weeks. Pressure wraps, compression garments,elastomer inserts, and silicone gel sheets are some

of the common methods to provide compressionto aid in scar remodeling [22]. Pressure promotesapproximation of collagen cross-linking, thus

aiding in the control of hypertrophic scaring[7,22,23]. Areas with skin grafts and excessivescar have compromised function of the oil glands;hence, lubricating lotions have to be applied

periodically to rehydrate the skin.

Vascular system

Edema controlMethods for edema control and their time

frames are similar to those of scar management[14]. Because compression, by way of coban orspecialized garments, is not introduced until ap-

proximately the fourth week postoperatively,elevation is the primary means of controllingedema in the early phase. Retrograde massage and

lymphatic drainage techniques also can be used toaid in edema control. Custom-made pressuregarments may be necessary for scar and edema

control if the contour of the hand has been sig-nificantly altered by the injury or soft tissuecoverage and prefabricated garments do not fitproperly.

Gravity-dependent position tolerance trainingGravity-dependent position tolerance training

can be introduced once the wound is completely

healed and vascularization and edema are stable.This occurs spontaneously in most cases when thepatient begins to use the extremity and places the

hand in a gravity-dependent position for briefperiods during functional use. If the patient hasdifficulty with increasing the tolerance, structured

training can be used. After applying the compres-sion wrap, the revascularized part is allowed tobe put in a dependent position for a brief period,

typically starting with 3 minutes several timesa day. The pressure wrap is removed afterward toinspect the circulation and edema of the revascu-larized part. The duration and frequency of the

dependent positioning is gradually increased if noadverse color or appearance occurs. This programis especially important if the hand therapist is

involved after free flap coverage in lower extrem-ity mutilating injury cases so that the patient canbegin crutch training.

Nerve

Protection educationAfter a mutilating injury, sensibility is often

impaired or absent, depending on the severity of

the nerve injury. Sensibility should be tested oncethe wound is completely healed and then moni-tored on a monthly basis. If the involved part does

Fig. 2. Each finger is wrapped separately to allow for individual finger exercise.


not have protective sensation, the patient shouldbe taught precautions and protection techniquesto prevent thermal and sharp injuries [3,14]. In

cases in which there is also vascular involvement,the lymphatic system cannot dissipate heat read-ily. The involved part can be burned easily eventhough the temperature may be tolerated by an

uninjured part [3,9]. Therefore, thermal modalitiesmust be used at lower temperatures and withextreme care [24].

Sensory re-educationOnce the involved part has regained protective

sensation, sensory re-education can begin. This is

accomplished by texture discrimination, size andshape discrimination, and stimuli localizationactivities [12,14]. The activity is usually repeated

with and without visual input so the patient cancognitively retrain sensory perception [25]. As thepatient’s hand function improves, sensory re-

education also can be incorporated with func-tional activities.

DesensitizationThe patient may develop hypersensitivity,

a frequent complication, in the stump or scar.Desensitization can be started once the wound is

healed. This is achieved by introducing gradedtextures, starting with the least irritable to thepatient and building up tolerance to a coarsertexture [9] (Fig. 3). Pressure tolerance also can be

increased with graded pinch exercise and thepatient is frequently placed on a desensitizationhome program. If the patient does not respond to

desensitization and the pain is in a localized area,a neuroma might be the source of pain [1].

Bone, tendon, and joint capsule

Once a fracture is stable, either by way ofa closed or open reduction, the following clinicalinterventions should be temporally incorporatedin the therapy protocol to maximize the gliding of

tendons and dense connective tissue structures(eg, the joint capsule): (1) protection or an ex-ternal support, (2) edema control, (3) protected

and controlled mobilization of the joints arounda stable fracture site, (4) tendon gliding, (5) pas-sive range of motion (PROM) and the splinting

regimes to enhance PROM, and (6) strengthening(Fig. 4).

During the early phase of rehabilitation an

external immobilizing or protective splint shouldbe used following a closed or open reductionrespectively. As the fracture and surrounding softtissues are healing and the rehabilitation segues

from the early to intermediate phases, some pro-tected or controlled physiologic motion is impor-tant to institute. Protected mobilization (during

the external immobilization phase followingclosed reduction) to the nonimmobilized jointsis needed to avoid joint contractures proximal

or distal to the fracture site and to actively glidesoft tissue structures such as tendons. Eitheractive or passive motion is appropriate forprotected mobilization, whereas active motion

should be emphasized for controlled mobilization(Fig. 5).

Fig. 3. Graded textures are used for treatment of scar hypersensitivity.


Once the external immobilizer is removed,typically toward the mid to latter half of theintermediate phase (4–6 weeks), controlled mobi-

lization (ie, active motion of the previouslyimmobilized joints) is started. In addition, how-ever, further protection of the fracture site is

typically needed and accomplished by a remov-able splint. Following an open reduction and

stable fixation, a protective splint coupled withedema control measures is necessary during theearly phase, but controlled mobilization is usually

started no later than and often before thebeginning of the intermediate phase.

Passive motion is often not initiated until the

latter part of the intermediate phase, approx-imately 4–8 weeks after the fracture (and usually

Fig. 4. Fracture algorithm. Once the fracture is stabilized by way of a closed or open reduction, an external support or

protective splint (or brace) is needed, respectively. The external supports after a closed reduction may include casts,

braces, splints, or external fixators. Coupled with the external support or protective splint during the early phase is the

need to control (ie, reduce or prevent the formation of) edema. Protected mobilization in the form of gentle active or

passive motion (during the external immobilization phase following closed reduction) to the nonimmobilized joints is

needed to avoid joint contractures proximal or distal to the fracture site and to glide soft tissue structures. Active motion,

however, should be emphasized for controlled mobilization and for tendon gliding. Although protective splinting is still

needed during the intermediate phase, treatments that address passive range of motion (PROM) deficits can be initiated

following open reduction, whereas PROM interventions following a closed reduction are delayed until the remodeling

stage. The reference noted in this article (Flowers, 2002) addresses the hierarchic approach to splinting for overcoming

joint stiffness. Strengthening is typically initiated following closed and open reductions in the late phase. The hierarchic

splinting regimen and strengthening often is not continued past the first 6 months, but these interventions may be

required (hence the stippled arrows) for up to 1 year.


approximately 2 weeks after controlled mobiliza-

tion of the joint). Splinting, especially usinga hierarchic approach [26] to overcome a passivejoint limitation, is an excellent way to enhance

PROM; the reader is referred to the many reportson the use of low-load prolonged stress (LLPS)and how monitoring the total end-range time(TERT) can overcome many of these passive joint

limitations [26–30] (Fig. 6).Following a closed and an open reduction,

strengthening (by way of resistance exercises)

typically is not started until the healing boneand soft tissues are structurally capable oftolerating high muscle forces across them; there-

fore, caution should be used when using resistanceexercises before 8 weeks following a mutilatinghand injury with resultant fractures and soft tissuedisruptions. Resistance exercises should not be

used until the fracture site is stable.When tendon gliding is impaired and a func-

tional arc of finger motion has not been attained,

the therapist should determine if a ‘‘lag’’ is pre-

sent. A lag is defined as demonstrably greater

passive ROM versus active ROM [31]. In thehand, this can be attributed to a neurologic deficitor weakness and pain. Most often, however,

restricting scar adhesions have formed and thetendon cannot be actively pulled by its respectivemuscle; however, the joint can be passivelymoved. An algorithmic approach toward deal-

ing with these adhesions is presented in Fig. 6.This approach uses a clinical assessment of thepresence of a lag and a dosage of stress, by way of

an exercise, that attempts to reduce this lag(Fig. 7).

A cadre of modalities can be used in the

treatment of mutilating hand injuries. During theintermediate and late phases of rehabilitation,thermal agents such as superficial heat, deep heat,and paraffin can be used to decrease pain and

enhance the return of joint motion and soft tissuegliding [32]. With any thermal agent, extreme caremust be used when a patient has impaired sen-

sation or cognition so as to not cause a burn.

Fig. 5. (A) Traction splints can be used for phalangeal fractures to provide stability by way of the principle of

ligamentotaxis while allowing for protective motion to minimize adhesion. This treatment approach is especially useful

with intra-articulate and comminuted fractures [40,41]. (B) In this case there is a large bony defect at the MCP joint from

a crush injury. The traction splint is used to hold the digit out to length during wound healing. ROM exercises are done

in the splint and an MCP arthroplasty has been planned as a secondary procedure.


Likewise if swelling is a problem, heat should be

coupled with an elevated hand position orretrograde massage to prevent further swelling.The presence of open wounds also should be

considered a precaution for thermal agents suchas a hot pack or ultrasound (unless used speci-fically for wound healing) and a contraindicationfor paraffin baths. Continuous wave ultrasound

can serve as a deep heat source that may beespecially potent when trying to overcome capsu-

lar tightness. Electrotherapeutic agents, by way of

transcutaneous electrical nerve stimulation, alsocan be used for pain relief and restoring neuro-muscular control and strength [14].

General rehabilitation guidelines following

surgical procedures unique to mutilating injuries

In the following section, general postoperativetreatment guidelines are presented. The reader

Fig. 6. Joint stiffness. Stiffness algorithm: an algorithm to guide the use of treatments for joint stiffness secondary to

structural changes to periarticular soft tissues. HLBS ¼ high load brief stress; LLPS ¼ low load prolonged stress;

TERT ¼ total end range time (duration � frequency of treatment per treatment session); load ¼ the amount of force

applied during treatment session; adverse tissue reaction ¼ swelling, heat, pain.


must keep in mind that these are only generalguidelines. Each patient is unique, each injury is

different, and the treatment program must bemodified depending on the patient’s injury, pro-gress, and complications.

Soft tissue coverage

Pedicle flapsPedicle flaps are two-stage procedures. The

flap covering the defect in the injured hand is leftattached to the donor site for 2–4 weeks [33,34].During the first stage, the recipient extremity

should be supported to prevent tension on theflap. In the case of a chest or groin flap tothe hand, heat and gentle joint mobilization to

the shoulder can minimize stiffness in the prox-imal joint. If the digits are free, pressure wrapsand retrograde massage can be used to minimize

dependent edema. Active and passive ROM of theuninvolved joints should be emphasized as long as

it does not stress the flap. Pillows, foam position-ing devices, and splints may be used to support the

extremity, to minimize tension of the repair, andto prevent contracture on the uninvolved joints aslong as they do not interfere with the flap.

After the flap is detached, therapy is focusedon wound healing, edema control, scar manage-ment, regaining ROM, and strength. Pressure

garments often are used to help contour the flapafter the wounds are completely healed.

Free flapsFree flaps are vascularized tissue transfers

(Fig. 8) and several precautions must be observed

[33,34]. The therapist should communicate with thesurgeon to find out the location of the anastomosissite. Tension and pressure to these areas must be

avoided and the flapmust be keptwarm to optimizevascularity. The extremity is positioned at the levelof the heart. The bulky postoperative cast is usuallyreplaced by a protective splint before the patient is

Fig. 7. Lag algorithm. The assessment for the presence or absence of a lag (greater passive ROM than active ROM

because of restricting scar adhesions) following a soft tissue repair (eg, tendon repair) initiates this algorithm. If no lag is

present and joint stiffness is the impairment, then see Fig. 6. If a lag is present, a hierarchic approach to exercise is

implemented. Active exercises should be used first in an attempt to overcome the lag, followed by light and then heavier

resistance exercises. A continual reassessment as to the presence of a lag is required following each exercise trial. Finally,

if the lag persists, a surgical release is necessary. Conversely if no lag exists and there is full passive ROM during the first

3 months following repair, further protection of the repair is required. (Adapted from McClure PW, Blackburn LG,

Dusold C. The use of splints in the treatment of joint therapy biological rationale and an algorithm for making clinical

decisions. Physical Therapy 1994;74:1101–7; with permission.)


discharged from the hospital. The splint is designed

to avoid pressure on the flap while protecting thetransfer and positioning the involved joints infunctional positions [9]. Once the flap is stable,

gentle passive ROM can begin as early as 5–7 daysafter surgery. If there are associated tendon repairs,care should be taken to not apply excessive tension

to the repairs, following treatment guidelines forthe specific repairs. If the anastomosis is at a joint,ROMmay be delayed or performed in a protectiverange, depending on vascular stability. Active

ROM can begin once passive ROM is tolerated.To improve tendon glide, electrical stimulation canbe used if needed 1 week after active ROM has

begun.Once the flap is well healed, scar massage can

begin at 3 weeks. At 4 weeks, vascularity is stable

and light pressure wrapping and dynamic splint-ing can be introduced. If the splint applies directpressure on the flap, this may be delayed another

week and splint-wearing time is gradually in-creased. At 6 weeks, protective splints can be dis-continued. In addition, pressure garments can bemeasured and ordered at 6 weeks to be worn at

8 weeks [3]. As each new treatment is introduced,the flap’s vascular status should be carefullymonitored.

For functional muscle transfers, passive ROMshould be maintained at the distal joints. Evidenceof muscle regeneration may be noted in 2–4

months. At that time, muscle re-education shouldbegin. Some investigators advocate the use ofdirect current electrical stimulation to maintain

viability of the denervated muscles until there are

signs of motor return, although this is still a topic

of controversy [17,35,36,43].

Replantation

Replantation is unique in that the flexor and

extensor tendons are involved in addition to allother systems previously mentioned. The initialprotective stage starts in the operating room whenthe surgeon places a plaster splint to protect the

repairs. For a finger repair, the protective positionis wrist neutral, metacarpophalangeal (MCP) jointflexion at 608–908, and interphalangeal (IP) joint

extension [6,37]. In this position both tendonsystems are protected, the collateral ligamentlength is preserved, and flexion contracture of

the proximal interphalangeal (PIP) joints isavoided [3,6].

A thermoplastic protective splint is fabricated

as soon as the patient is off anticoagulants, usuallyon the fourth to seventh postoperative day toallow for ease of wound care and exercises in themobilization phase [3,21,37]. In selected cases,

depending on surgeon preference, gentle con-trolled stress is applied as early as the secondpostoperative day if the repairs are strong and

there is no complication. Because the flexor andextensor systems are involved, special consider-ations must be given to the exercise program. An

early protective mobilization program is designedto prevent joint stiffness and minimize adhesionswhile protecting the repairs. This program is sub-divided into two stages. Early protective Motion I

(EPM I) consists of gentle wrist flexion and

Fig. 8. Free flaps are vascularized tissue transfers that can provide excellent coverage for large soft tissue defects in

the hand.


simultaneous finger extension by virtue of the teno-desis effect [3,6] (Fig. 9A) The motion occurs in a

ratio, that is, if wrist flexion is limited, only a pro-portional amount of MCP extension is allowed.Following this the wrist is brought to neutral ex-

tension with gentle passive and gravity-assistedflexion of the MCP (Fig. 9B). This is designedto move the MCP and the wrist to prevent jointcontractures while maintaining balanced tension

between the flexors and extensors, at the sametime still protecting the repairs [3,6]. The wristextension-MCP flexion position preserves MCP

collateral ligament length while the wrist flexion-MCP extension position provides relief from theintrinsic plus position and prevention of PIP volar

plate shortening. Edema control, wound care, pa-tient education, and psychologic adjustment arealso important aspects of the treatment.

EPM II, the second phase, begins at 10–14days and consists of the intrinsic minus and theintrinsic plus position, also known as the ‘‘hook’’

and ‘‘table’’ positions respectively [3,6]. With thehook position, the wrist is supported in neutral

while the MCP joint is gently brought intoextension and IP joints into flexion (Fig. 10A).Using the radian concept, Brand has calculated

that for every 57.298 or 1 radian of PIP flexion,there is 7.5 mm of excursion to the central slip[6,27]. In other words, to achieve 3–5 mm oftendon excursion, the PIP joint needs to flex

22.98–38.28 [16,17]. Clinically, 258–358 of PIPflexion is allowed initially and is increasedgradually in subsequent weeks. If there is extensor

tendon tissue loss, the amount of PIP flexion isfurther reduced. To prevent attenuation of thecentral slip, PIP flexion is limited to 608 until 4–6

weeks [3,6]. This ‘‘hook’’ position is followed bythe ‘‘table,’’ or intrinsic plus position of MCPjoint flexion and IP joint extension (Fig. 10B).

Again, the wrist is supported at neutral. Studieshave shown that the ‘‘hook’’ position provides themost differential gliding between the flexor

Fig. 9. Early protective motion (EPM) I. (A) Gentle active wrist flexion and simultaneous assisted finger extension by

tenodesis effect. (B) Gentle assisted wrist extension to neutral with passive MCP flexion.

Fig. 10. Early protective motion (EPM) II. (A) Passive intrinsic minus or the ‘‘hook’’ position. With the wrist in neutral,

the MCP joint is brought into extension while the PIP joint is gently flexed. (B) Passive intrinsic plus or the ‘‘table’’

position. With the wrist in neutral, the MCP joint is gently flexed and the IP joints are extended.


digitorum superficialis and flexor digitorum pro-fundus tendons, whereas the ‘‘table’’ positionmaintains intrinsic muscle function [6,38]. Thesepositions also produce less excursion to the

extrinsics as compared with composite motion,therefore protecting the newly repaired tendons[3,6]. Obviously, the exercise program and posi-

tions need to be augmented when there arelimiting factors such as unstable fractures, Kwires crossing joints, or tendons and nerves

repaired under tension.Between 14–21 days, active intrinsic plus and

intrinsic minus exercises are introduced, starting

with ‘‘place and hold,’’ and progress to activeexercises. The goals during this time includeprotection of repairs, maintaining intrinsic func-tion, minimizing adhesions, improving tendon

tensile strength and differential tendon gliding,and promoting longitudinal reorientation of col-lagen fibers.

For thumb replantation, a dorsal protectivesplint is fabricated with the wrist in neutral andthe thumb positioned midway between abduction

and extension to maintain the web space [3,9].Thumb C bars are generally avoided to minimize

pressure at the anastomosis site. The timeframefor introducing exercises is similar to that of theother digits. The EPM I for the thumb consistsof gentle passive CMC motion and active and

passive wrist flexion to tension and extension toneutral. After several sessions of passive CMCjoint exercises, active CMC joint motion can

begin. Passive EPM II begins 10–14 days afterreplantation with the wrist in neutral. It consistsof gentle MP and IP joint flexion with the CMC

joint extended and gentle MP and IP jointextension with the CMC joint flexed. Progressionto active EPM II and composite motions of the

wrist and thumb are the same as in fingerreplantations.

For finger or thumb repairs, wrist extensionbeyond neutral, blocking exercises, and tendon

gliding exercises are introduced at 4–5 weeks. At5–6 weeks, composite motion and functionalactivities are introduced. Blocking splints and

dynamic splints also can be added, whereas theprotective splint is discontinued at 6 weeks.Strengthening begins at 6–8 weeks. Cold intoler-

ance is a common problem in this population andcan last for months [3].

Fig. 11. (A–C) Functional retraining after a double toe to finger transfer.


Toe to digit transfers

In cases in which replantation is not possible,toe to thumb or finger transfers are oftenperformed [21,39] (Fig. 11). These are elective

operations and the surgery often can be scheduledat the time when the patient is prepared and ableto participate in the postoperative rehabilitationprocess. After the initial amputation, the patient is

seen in therapy for wound care, scar management,desensitization, and strengthening. This is alsoa good time to discuss and anticipate postopera-

tive needs and rehabilitation outcome. The homeenvironment and social needs are discussedbecause the patient will be wheelchair bound for

approximately 3 weeks [39]. A temporary pros-thesis also can be fabricated with thermoplasticmaterial to improve hand function and maintainprehension memory while waiting for the proce-

dure (Fig. 12). Frequently patients find it benefi-cial to talk to other patients who have gonethrough the operation.

The postoperative splint and early motionprogram are similar to the finger and thumbreplantation protocol discussed previously. Lower

extremity-dependent position tolerance training isintroduced at 2.5–3 weeks after the donor woundis completely healed and progressed to heel touchambulation. In the late phase of a toe to thumb

transplantation, a thumb web spacer is oftennecessary and is fabricated once the vascularstatus has stabilized, the wounds are completely

healed, and the joints are stable to tolerate stress[3,6].

Mutilating hand injuries are challenging cases

for the hand therapists and outcomes depend onseveral factors. With team effort between thephysician, therapist, and patient, functional out-

come can be maximized [2,3,5,21,33].

Acknowledgement

The authors would like to thank Nancy Chee,

OTR, CHT for providing the photographs.

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Fig. 12. (A–D) A temporary prosthesis made with thermoplastic material is used to improve hand function and to

maintain prehension memory while the patient is getting ready for a digit transfer or a permanent prosthesis.


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Secondary procedures followingmutilating hand injuries

Robert C. Russell, MD, FACS, FRACSa,*,Reuben A. Bueno, Jr., MDb, Tzu-Ying Tammy Wu, MDc

aHeartland Plastic Surgery, 5260 South Sixth Street, Springfield, IL 62703, USAbSouthern Illinois University School of Medicine, Institute for Plastic Surgery,

P.O. Box 19653, Springfield, IL 62794, USAcSouthern Illinois University School of Medicine, Institute for Plastic Surgery,

P.O Box 19653, Springfield, IL 62794, USA

The human hand is a complex organ that has

greatly facilitated the cultural advance of Homosapiens 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, andmake scientific discoveries that have revolution-ized our world in only the last 12,000 years.

Humans are a product of their intellect and theirhand function and are severely handicapped whenhand function is lost.

Severe hand trauma can result in varyingdegrees of injury to any of the hand’s anatomiccomponents, including bone, tendon, nerves,

blood vessels, muscle, or skin. The surgeon’s ul-timate goal is to restore as much hand functionas possible after an injury by repairing or recon-structing the injured structures either primarily or

secondarily at a later date. The initial sequence ofsurgical debridement of devitalized tissue, irriga-tion, bone reduction and fixation, tendon repair,

arterial and venous repair, nerve coaptation, andsoft tissue repair or coverage are familiar to allsurgeons caring for patients with traumatic hand

injuries. The replantation and trauma literatureis clear, however, the more structures that areinjured, the more likely the patient is to have

a complication or require a secondary procedure

[1]. Some judgment is, therefore, required by the

initial surgeon who must decide whether to com-plete an amputation or to proceed with repair orreconstruction of a severely injured hand or digit.The patient or the family members want the

injured hand to be restored to normal and for themost part have little if any knowledge of what toexpect from surgery or of the therapy necessary to

obtain the best functional result. It is often thesurgeon, armed with the knowledge of possiblereconstructive options and using the experience

gained from previous cases, who must then decidewhether and how to proceed with the initial re-pair. In summary, complex hand trauma may

require a series of decisions and operative pro-cedures that may or may not be planned by thesurgeon but are infrequently anticipated by thepatient.

All wounds heal by the formation of scartissue, which, with the possible exception of bone,is persistent and can be seen years after an injury.

British seamen whose diet lacked vitamin Cfrequently developed scurvy, resulting in the dis-ruption of old wounds. Without the knowledge

that vitamin C is a cofactor required for collagensynthesis, the British Navy mandated that a barrelof limes be added to the ships inventory of all

Royal Navy line ships, which eliminated scurvyand eventually lead to the nickname for Britishseamen as ‘‘Limeys.’’ The problem for hand sur-geons and their patients, however, is that although

we need collagen synthesis to heal our tendon



(R.C. Russell).


doi:10.1016/S0749-0712(02)00146-4

Hand Clin 19 (2003) 149–163

repairs and skin lacerations, excessive scar tissuein the hand can result in stiffness and decreasedhand function. The concept of ‘‘one wound, one

scar’’ [2], described by Earl L. Peacock, is alwaysa problem for hand surgeons who must immobi-lize the hand to allow fracture or tendon healingand then are required to deal with stiff joints and

scarred, adherent soft tissues and tendons thatinhibit function.

The technique or adequacy of the initial

surgical care influences the need for secondaryprocedures. Stable plate and screw fixation ofa phalangeal or metacarpal fracture, for example,

may permit early active or passive joint mobiliza-tion resulting in less digital stiffness or adhesionformation [3]. Patients with flexor tendon repairswho are managed with active extension/passive

flexion [4], or place-and-hold passive motion handtherapy protocols [5] that allow healing tendonssome degree of gliding motion, usually have

improved function, decreasing the likelihood thatsecondary tenolysis procedures will be required.Early flap coverage of hand injuries with extensive

soft tissue loss provides healthy uninjured softtissue coverage of exposed bone, tendons, andneurovascular structures. This early closure pre-

vents desiccation of vital structures and providesa healthy environment for healing. Thus, the out-come of the initial debridement, repair, soft tissuecoverage, and hand therapy greatly influences the

need for secondary procedures.The basic requirements for optimal hand func-

tion include pliable soft tissue coverage, stable

fracture fixation and healing, supple joints, glidingflexor and extensor tendons, intrinsic and extrinsicmuscle function, and sensibility. Most secondary

procedures are done to address one or more ofthese issues, which because of the degree of injuryor the adequacy of the initial repair and healingare less than desirable and have resulted in

decreased hand function.Complex hand injuries can have many second-

ary problems after healing, but stable wound

coverage and bone healing must be achievedbefore any other secondary procedures such astenolysis are attempted. In general, secondary

procedures that require hand immobilization aftersurgery, such as bone grafting, secondary tendonreconstruction, or nerve repair should be com-

pleted before those procedures that require motionafter surgery, such as capsulotomy or tenolysis.Complex hand trauma may, therefore, necessitatea multistage plan for reconstruction, requiring

several months to complete. This should be ex-

plained to the patient and their families at theinitial stage of surgery.

Secondary bone procedures

Malunion/nonunion

The first principal for the repair and recon-struction of a severely traumatized hand is to

obtain stable fracture reduction and fixation. Ex-tensive comminution, disruption of surroundingsoft tissue, or residual contamination followinginadequate irrigation or debridement can result in

avascular necrosis, nonunion, or the developmentof osteomyelitis necessitating a secondary pro-cedure.

Metacarpal and phalangeal fracture nonunionsare uncommon but can be successfully treated,after debridement of fibrous tissue, using a cancel-

lous bone graft from the radius or iliac crest andmaintained in place with a compression plate [6].Most severely traumatized hands require at least3 months for the soft tissue envelope to soften.

Stable, pliable tissue is preferable to a thick, firmcicatrix before secondary bone grafting should beattempted. Soft tissue coverage must be adequate

before embarking on such procedures becausemanipulation of poor quality tissue may result inproblematic compromise and exposure of the

graft or plate. It is best to leave a plane of softtissue beneath the overlying extensor tendons andthe underlying bone graft during the dissection to

reduce the chance of subsequent extensor tendonadhesions. Phalangeal fractures that require a sec-ondary bone graft are less likely to result in a fullyfunctional digit because of intrinsic joint stiffness

and extrinsic flexor and extensor tendon adhe-sions that are commonly observed after graftingand immobilization [7,8]. New mini plates and

screws designed for phalangeal fractures mayallow earlier motion over standard pin fixation andmay decrease digital stiffness [3]. Alternatively,

external fixators can be used to maintain lengthand fracture reduction until the grafted bone heals(Fig. 1).

Osteomyelitis

The development of a bone infection afteropen reduction and internal fixation of handfractures is fortunately rarely a problem, ranging

from 2%–11% [8,9]. Most surgeons treatingsevere hand trauma with open fractures use meti-culous debridement, irrigation, and prophylactic

antibiotic coverage to prevent the development of

150 R.C. Russell et al / Hand Clin 19 (2003) 149–163

osteomyelitis. Occasionally bone infection canoccur following massive contamination or inade-

quate debridement. Delayed infection can occurfrom bacteria seeded along exposed K-wires, orwhen overlying soft tissue is lost, exposing bone.The authors have treated three cases of phalangeal

osteomyelitis by surgical debridement to bleedingbone and placement of antibiotic impregnatedmethyl methacrylate beads in combination with

systemic antibiotic therapy. Two to three monthslater, the methyl methacrylate beads were re-moved and a secondary cancellous bone graft was

then packed in the defect. This resulted in bonyunion in all three cases [10]. Bone grafts must beplaced under stable, well vascularized soft tissue.

Patients with thin, scarred, stiff, or missing softtissue first require soft tissue replacement withlocal or distant flap coverage before secondarybone 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 witha thin, fine-line scar. More severe injuries in-

volving multiple structures with crushed softtissue result in increased extravasation of edema-tous fluid into the soft tissues, seen clinically asswelling. This fluid shift pushes the digits into

a claw deformity with metacarpal (MP) jointextension and interphalangeal (IP) joint flexion,a posture that can result in permanent digital

stiffness. The safe position for an injured handafter surgery is wrist extension, MP joint flexion,IP joint extension with some thumb abduction

and opposition. Massive swelling impedes post-operative digital motion and results in soft tissuefibrosis and ligament contracture leading to joint

stiffness. Skin loss resulting in exposed soft tissuestructures or bone must be closed with a splitthickness skin graft or some type of flap coverage.The thinner the skin graft, the more contraction

occurs with scar maturation and the more likelya secondary surgical release will be required.Thus, most larger hand injuries that require skin

grafting should be closed with a thick splitthickness or even a full thickness skin graft from

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.

151R.C. Russell et al / Hand Clin 19 (2003) 149–163

the groin to decrease the chance of late contrac-tures. Small fingertip injuries with exposed pulpare best treated with a thin split thickness skin

graft that contracts and pulls surrounding gla-brous skin centrally.

Web scar contracture

A common sequelae of a crush injury to thehand is a first web space adduction contracture.This creates a thumb that cannot be placed intoopposition with the other digits, interfering with

pinch and grasp function. The adductor pollicisbrevis muscle may be tight and scarred, togetherwith the fascia over the first dorsal interosseous

muscle. The skin in the first web space itself can becontracted and of poor quality, also restrictingmotion. A secondary release of the first web space

involves either replacement of the scarred skinwith a flap, or a thick split or full thickness skingraft, or when good quality skin is present, by

local tissue rearrangement such as four-flap Z-plasties or jumping man flaps [11]. The fascia overthe first dorsal interosseous muscle must beincised and released and the adductor pollicis

brevis muscle must be stretched or released fromits origin on the third metacarpal. The thumb isthen abducted from the palm and rotated into

some opposition. It can be held in the desiredposition using a threaded 62-gauge K-wire placedbetween the first and second metacarpals.

A four-flap Z-plasty is designed using dorsaland volar skin flaps whose limbs are ideally ofequal length. The flaps should include the firstdorsal interosseous muscle fascia dorsally and the

palmar fascia volarly to protect the blood supplyinto these flaps. The fascia can be carefullyreleased beyond the base of the flap if it restricts

flap rotation after elevation. Injuries that result inscarred, poor quality first web space skin can beclosed following release with a skin graft. Web

space skin grafts can be reliably compressedagainst the underlying soft tissue with a foamstent dressing using the sponge from a surgical

scrub brush or a piece of gas sterilized egg-cratefoam commonly used to pad the operating tableduring long cases. Sponge dressings tied over theskin graft provide an elastic compressive force and

help absorb any serum that extrudes throughsmall holes placed in the skin graft. This preventsblood or serum from accumulating under the skin

graft and facilitates blood vessel ingrowth andgraft survival. Occasionally a massive crush injuryresults in a severe adduction deformity that, after

release, requires flap coverage. The ideal flapshould be thin and pliable to allow unhinderedthumb motion. The authors have used the ex-

tended end of a groin flap elevated at the level ofScarpa’s fascia, a reverse radial forearm, flap orthin fasciocutaneous free flaps such as the deltoidor 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 ina long arm cast. Hand elevation and immobiliza-tion after surgery decreases swelling and in skin-

grafted patients facilitates revascularization andgraft survival. Free tissue transfers are monitoredhourly for 3–5 days using a Doppler flow probeand by assessing flap color and capillary refill. If

pins were used to maintain the thumb positionafter surgery, they are removed 3–4 weeks aftersurgery and active range of motion exercises are

begun. The thumb is splinted at night and betweenexercise sessions using an Orthoplast splint for thenext 3 weeks, at which time only night-splinting is

continued for 2 weeks.

Secondary procedures to release scar

Scarred contracted dorsal or volar hand skincan restrict digital flexion or extension. In addi-tion, skin injured by a deep second-degree burn or

severe crush injury may survive, but can becomestiff and inelastic and is prone to break down withuse. Good quality, elastic skin is required over the

MP and proximal interphalangeal (PIP) joints foroptimal function. Thin or retracted skin canrestrict flexion or break down with use, exposing

underlying tendons or joints. These areas are besttreated by resection of the scarred, poor qualityskin 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 anarterialized side finger flap from the lateral volar

aspect of the digit when no adjacent dorsal handskin is available. The digital nerve is left intact topreserve tip sensation and the donor site is closed

with a skin graft. Less commonly, an upside-downcross finger flap de-epithelialized and elevatedfrom the uninjured dorsal surface of an adjacent

digit can be used secondarily to resurface the PIPjoint. This flap is not available, however, when thedorsal surfaces of multiple digits are injured.Larger areas of unstable skin may have to be

resurfaced with a large full thickness skin graft


that should be applied with the MP joints flexed to

at least 80� and the PIP joints flexed 45� despitethe possibility of developing a PIP joint flexioncontracture. Surgical release of the MP joint

collateral ligaments may be necessary to obtainadequate flexion before placing a skin graft or flapcoverage. The MP joint collateral ligaments are

released through an incision in the central ex-tensor tendon over the MCP joint. The splittendon edges are retracted laterally and the joint

capsule is opened transversely. A small ellipse ofdorsal joint capsule can be excised. The MP jointis entered along the cartilaginous surface of thehead of the metacarpal. A #15 blade is then placed

into the MP joint and swept dorsally along thelateral surface of the metacarpal head to releasethe 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 theproximal phalanx into the head of the metacarpal.The dorsal skin surface is then reconstructed using

a full thickness graft or by flap coverage. Pins areremoved in 2–3 weeks and active range of motionexercises are begun.

Palmar scar contracture

Scar contracture on the volar surface of thedigit can prevent full digital extension of any andall joints along the ray. Volar glabrous skin isthicker and more resistant to injury than the

thinner dorsal hand skin and volar contracturesoften can be treated by local tissue rearrangementusing Z-plasties, Y-V-plasties, or local rotation or

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.


cross finger flaps from the same or an adjacentdigit.

A central longitudinal scar along the volar sur-

face of the digit can be excised and Z-plastiesdesigned using 45� angles with the lateral incisionsending 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 byWatson along the ‘‘assembly line’’ [12] is oftenrequired in long-standing cases of PIP joint con-

tracture to restore PIP joint extension, which caninitially be held with aK-wire. The retracted check-rein ligaments are divided proximally to allow the

volar plate to slide distally, facilitating PIP jointextension. The pin is removed at 3–4 weeks andactive range of motion exercises begun with in-

termittent and night splinting maintained for 3–4weeks. Secondary release of a PIP joint flexion con-tracture with severely damaged skin may requireflap coverage from the dorsal surface of an un-

injured adjacent finger when the release results inexposed flexor tendons or neurovascular structures

that cannot be skin grafted. All cross finger flapsused to cover either dorsal or volar soft tissue de-fects are divided at 2–3 weeks, following elevation

depending on the individual patient, the quality ofthesurroundingsoft tissue,andtheareaofflapinset.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 mobi-lization procedures can be done. Templates can be

made using sterile gloves and opening one side tonote the size of the tentative flap. Tissue expan-sion of the donor site may be useful to harvest

a larger flap and still allow primary donor siteclosure(Fig.4).Theflapsmayrequireseveraldebulk-ing procedures for the overall contoured result.

Secondary nerve procedures

Delayed nerve repair

Mutilating hand injuries can result in completeor partial transaction of peripheral nerves in the

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).


arm, hand, or digits. Careful dissection followedby primary repair of the cut nerve ends undermagnification gives the best chance for quality

nerve regeneration. Primary repair of the nerveends, however, is not always possible in somemutilating hand injuries in which nerve substancemay be crushed or lost. Nerve grafts, or vein

conduits, or manufactured conduits can be usedto bridge gaps. If nerve conduits are used, theproximal and distal nerve ends are sutured

without tension inside an appropriately sizedneural tube and seem to allow axons to regeneratealong the polyglycolic acid (PGA) mesh into the

distal nerve, giving functional results comparableto standard autogenous nerve grafts [13]. Second-ary nerve grafting or placement of a syntheticconduit, as described by Mackinnon and Dellon

[14], remains the reconstructive option of choicewhen primary nerve repair is not possible.Peripheral sensory nerves including the sural,

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.


medial, or lateral antebrachial cutaneous, or theterminal branch of the posterior interosseousnerve, are most often used as free nerve cable

grafts, depending on the length of the defect andthe diameter of the nerve to be reconstructed [15].Cable nerve grafts should be placed under well

vascularized soft tissue for best results. Syntheticnerve conduits can be used to reconstruct smallhand or digital nerve defects up to 3 cm [13,14].

Nerve grafting at the time of the acute injury isnot recommended because there is a potential tolose the graft if the overlying tissue or flap is

compromised through ischemia or infection. If theSurgeon anticipates rising nerve grafts, the nerveends should be sutured out to length and taggedfor future grafting.

Neuroma management

Amputation stump neuroma formation canoccur when the endoneurium is disrupted, allow-

ing the regenerating axons to escape and advancein a disorganized fashion into the surroundingsoft tissues [16]. Histologically, neuromas consist

of whorls of disorganized nerve fibers encased incollagen scar [16,17]. Patients often present withlocalized pain and hypersensitivity and a positiveTinel sign in the vicinity of the neuromatous bulb.

The pain may become so debilitating that, withoutproper treatment, the function of the entire handor extremity may be lost. Nonoperative treatment

by repeated nerve stimulation including local

percussion, massage, ultrasound, and electricalstimulation can be used to desensitize someneuromas [16]. Local steroid injections into the

area of neuroma formation also have beendescribed [16,18] with short-term success [18]. Inaddition, medications such as amitriptyline, car-bamazepine, and neurontin have been used re-

cently 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 byneuroma resection, allowing the nerve ends toretract proximally into more healthy soft tissue

[20]. Various chemical methods to inhibit axonalregrowth after neuroma resection have been used[16,21–24]. The freshly cut nerve end is treatedwith alcohol, tannic acid, formaldehyde, chromic

acid, iodine, uranium nitrate, gentian violet,phenol, mercuric chloride, hydrochloride, picricacid, 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 bestused in the hand or forearm where the nerve endcan be sutured deeply into the soft tissue or into

a drilled hole in the bone. Chiu and Strauch haveused vein grafts or PGA tubes to direct regenerat-ing axons away from the amputation stump afterneuroma resection [28].

Secondary joint and tendon procedures

Procedures to improve digital motion are themost common secondary operations required

after a mutilating hand injury [1] and should beanticipated by the hand surgeon. A stiff finger canoccur for a variety of reasons, including edema,

ligament tightness, skin contracture or scarring,and tendon adhesions. The surgeon and handtherapist must determine the etiology of theproblem before surgical correction is attempted.

The status of the joint surfaces after healing ina stiff finger should be determined by radiograph,especially in patients who have sustained peri-

articular fractures. A bony callus or an irregularlyhealed intra-articular fracture may block finaljoint flexion or extension. A digit with a normal

passive range of motion (280�) that cannot beactively flexed completely by the patient, forexample, is likely to have flexor tendon adhesionsand may be improved by flexor tenolysis alone.

A digit that lacks active and passive motion after

Fig. 4 (continued )


adequate hand therapy may require simultaneousflexor and extensor tenolysis and joint ligament orcapsule release to improve motion. The surgeonmust properly assess and identify the reason for

digital stiffness and be prepared to address anyand all causes in a sequential fashion duringsurgery.

Secondary tendon procedures

Tenolysis

Scar tissue that forms around healing tendons,

fractures, or the overlying soft tissue can restricttendon motion after surgery. The degree ofperitendinous scar formation is influenced by the

severity of injury, the initial operative technique,the patient’s own systemic response to injury andcollagen synthesis, and the availability of andpatient dedication to hand therapy. Severe hand

trauma with crushed soft tissue, comminutedfractures, or frayed tendon ends all produce anenhanced systemic inflammatory response, result-

ing in increased collagen synthesis and scarformation. A patient who sustains a sharp, clean,zone II flexor tendon laceration that is repaired

primarily with atraumatic surgical technique andmanaged with dynamic splinting by a trainedhand therapist usually obtains a good to excellentfunctional result [29]. Conversely, the same pa-

tient who sustains a more severe complex injury tothe hand involving multiple structures, requiringmore extensive dissection and repair, followed by

prolonged immobilization or lacking adequatehand therapy is likely to develop a stiff, scarred,and immobile hand that will require secondary

tenolysis or capsulotomy procedures to regaindigital motion (Fig. 5). The most common se-condary procedure following digital replantation

surgery, for example, is flexor or extensor tendontenolysis [1,30].

All flexor and extensor tendon repairs shouldbe done using atraumatic technique followed by

protective splinting to permit primary healing.The treatment protocol after surgery must beindividualized for each patient, balancing the

need for digital and wrist immobilization toallow bone and tendon healing against thefunctional requirement of tendon excursion and

joint motion. The use of active and passiveprotocols by a dedicated hand therapist is thebest way to prevent tendon adhesions and stiffjoints. Early passive range of motion exercises

after tendon repair have been shown experimen-

tally to strengthen the repair and improvemotion [31].

The return of digital motion after the initialprocedure is followed closely by the hand thera-

pist, who records the degrees of active and passivedigital motion at each finger joint before and aftereach therapy session. A good hand therapist not

only provides instruction to the patient for exer-cises to be performed at home between handtherapy visits, but also sets goals and helps

provide the motivation to achieve them. Scarmassage [32], silicone gel [33], topical vitamin E[34], and silicone sheeting [35] have all been used

to soften scar and improve digital motion. Threeto six months is usually required for scar tissue tosoften, at which time the need for a secondary pro-cedure to improve digital motion can be con-

sidered.Strickland describes flexor tenolysis as ‘‘per-

haps the most demanding of all flexor tendon

operations with respect to attention to detail andpatient–doctor cooperation’’ and must be ‘‘ap-proached as a major surgical effort, with great

consideration for patient selection, operativetechnique, and postoperative management’’ [29].Tenolysis procedures usually are performed 3–6

months after the initial procedure, when therapygains in active or passive range of motion haveceased. Flexor or extensor tendons are usually‘‘stuck’’ at the site of a previous tendon repair,

where tendons pass over a healed fracture, orwhere tendons pass through a tight space such asthe fibro-osseous digital pulley system in zone II

in the hand. A surgeon performing a tenolysismust consider the locations of previous skinlacerations or incisions in approaching the area

of tendon adhesion to preserve the skin’s bloodsupply. Often the prior incisions must be reopeneddespite a less than desirable location or directionto insure skin vascularity and survival after

a tenolysis. Small #15 or Beaver scalpel bladesand Kuntz or Freer elevators or Mitchell Trimmesare used to sharply dissect tendon adhesions with

atraumatic technique preserving the critical A2and A4 pulleys in zone II to prevent bow-stringingduring active motion after surgery. A separate

proximal wrist incision is usually required duringflexor tenolysis to determine the adequacy of thedistal tendon scar release. Each distal tenolysed

flexor tendon is identified at the wrist and tractionis applied to be certain that active digital motioncan be achieved. Release of tight joint capsules oradherent extensor tendons when present must be

done first to obtain near-normal passive range of


digital motion before proceeding with flexortenolysis. A general or Bier block anesthetic canbe converted to a regional block using local

anesthetic at the wrist, to test the patient’s abilityto move the digits independently after the scarrelease. It is sometimes desirable for the patient to

visualize the amount of active motion, which isactually possible before the limitations of painand swelling occur after surgery. The hand andforearm usually are immobilized in a bulky

compressive dressing for 1–3 days after surgery

and held in an elevated position to decreaseedema. The dressings are then removed andaggressive active and passive range of motion

exercises are begun by hand therapy. Occasional-ly, intermittent splinting is used to maintain jointposition between motion exercises. The use of

indwelling catheters to instill local anesthetic hasbeen described to decrease pain in the immediatepostoperative period, allowing the patient pain-free motion [36]. Continuous passive motion

machines also have been used in cases involving

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.


multiple digits to preserve full passive motionbetween active exercise sessions [37].

Secondary tendon reconstruction

Secondary tendon reconstruction may be re-quired in some patients after a mutilating handinjury for a variety of reasons. The initial trauma

may not have allowed primary tendon nerverepair if tendon substance was lost. The proximaltendon ends should be sutured out to length insuch cases to the carpal ligament or A1 pulley to

hold the extrinsic musculotendinous units out tolength. A staged tendon reconstruction may beplanned, especially in zone II injuries. A silastic

Hunter rod can be placed from the insertion of theflexor digitorum profundus through the fibro-osseous pulley system into the palm or wrist [38].

This can be done at the time of the initial woundclosure or as a secondary procedure. If A2 and A4pulley reconstruction is required, it should bedone when the Silastic rod is placed. This allows

the reconstructive pulleys to be strong and func-tional when the rod is removed and replaced bythe tendon graft. Some guarded motion is then

possible without tendon bow-stringing aftersurgery.

When a staged single flexor tendon reconstruc-

tion is planned, the author prefers to use theproximal flexor digitorum sublimis (FDS) muscu-lotendinous unit as the motor for the tendon graft,

which passes across all joints and is inserted intothe base of the distal phalanx. The FDS hasindependent motion and avoids the potentialproblem of quadriga associated with using the

flexor digitorum profundus (FDP), which is dif-ficult to adjust to the correct tension. Thelumbrical muscle must be released from the FDP

tendon when using the FDS as a motor, toprevent the development of a lumbrical plus de-formity when the FDP retracts proximally.

Tendon grafts are first inserted into the base ofthe distal phalanx using a wire suture tied overa dorsal button or a Mitek anchor drilled into the

base of the distal phalanx. The tendon graftattached to the Silastic rod is then pulled fromdistal to proximal into the palm or wrist andsutured to the proximal FDS tendon using a

Pulvertaft weave. The correct tension is adjustedby flexing and extending the wrist and noting theposition of the reconstructed finger in relation to

the cascade of the other digits.It is sometimes difficult, in patients who de-

velop a stiff finger after the repair of a severe

injury, to determine if a severed and repairedflexor tendon is stuck in scar or has actuallyruptured. A planned tenolysis procedure some-times ends in a staged tendon reconstruction when

the surgeon finds a ‘‘ruptured’’ and not a ‘‘stuck’’flexor tendon. This potential problem, whichnecessitates another surgical procedure, should

be explained and discussed with the patient beforesurgery.

Secondary thumb reconstruction

Surgical efforts to restore thumb fingertipprehension are among the most important ofsecondary procedures required to achieve the bestfunctional result following a mutilating hand

injury. Prehensile grip requires the thumb toabduct and oppose the fingers [39]. It is estimatedthat 40% of hand function is derived from the

thumb [40], and thumb loss results in significantdisability. Every attempt, therefore, should bemade in the acute setting to replant or otherwise

salvage an amputated or devascularized thumbfor this reason. When the amputated thumb isunable 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, adequatestrength and stability to resist the opposing forces

of the fingers during pinch and grasp functions,correct positioning of the thumb with a wide webspace, and mobility of the carpometacarpal

(CMC) joint with intrinsic muscles to stabilizeand position the thumb.

Selecting the most appropriate method forthumb reconstruction depends on several factors,

including the level of injury, the status of the re-maining hand, the age, occupation, overall health,and functional demands of the patient. An older

patient with vascular disease and low functionaldemand or injury of a nondominant thumbwould not be a candidate for microsurgical

thumb reconstruction and might benefit froma lengthening procedure. Conversely, a younger,well motivated patient who wants the best

aesthetic and functional result would be a goodcandidate for a Morrison type toe-to-hand trans-fer [42] (Fig. 6).

Before the development of microsurgery and

free tissue transfers, thumb reconstruction wasdone by phalangization of the thumb metacarpal


[43], pollicization of the index finger [44], or

osteoplastic thumb reconstruction [45]. The trans-fer of a toe to the thumb became possible with theadvent of microsurgery [46,47]. Refinements intechnique developed by Morrison [42] and Wei

[48] have further improved the appearance andfunction of a toe to hand transfer.

Distal thumb amputations or those with loss of

sensate volar soft tissue requiring only restorationof the skin and subcutaneous tissue can bereconstructed 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 middlethird of the thumb, phalangealization thumbfunction can be improved by deepening the webspace with a Z-plasty [52] and lengthening the

amputation stump by release of the first dorsalinterosseous muscle and proximal transfer of theadductor pollicis insertion [53,54]. Additional

thumb length can then be obtained by makingan osteotomy through the first metacarpal andplacement of an external distraction device [55].

The thumb is then pulled to length gradually with

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.


the external fixation device and the resulting bonedefect grafted when the thumb has been stretchedto the desired length.

If amputation occurs in the area of the MCP

joint, toe to hand transfer is now the procedure ofchoice in most patients. This transfer providesstable, sensate composite tissue with an excellent

functional and cosmetic result [56]. Amputationsproximal to the CMC joint limit the recon-structive options to pollicization when another

digit is available for transfer. Length, sensation,and motion have been successfully restored by

index finger pollicization to recreate a thumb[57,58].

The restoration of function also may involvetoe to hand transfer digits other than the thumb.

The second and third toes are appropriate donorsfor digit transfers to the hand. It is important,however, to optimize the soft tissue coverage to

the hand before the transfer of toes. This mayrequire further flap coverage over the metacarpalheads to ensue that enough pliable tissue is

present so that vital structures are not exposedafter the toe to hand transfer (Fig. 7).

Fig. 7. (A) A 34-year-oldman sustainedmultiple 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.


Summary

Mutilating hand injuries result in injury tomultiple anatomic structures, which increases the

possibility that secondary procedures or stagedreconstruction will be necessary. Secondary pro-cedures often are required to provide stablewound coverage, restore sensation, provide bony

stability, increase range of motion, or allowprehension, all of which are performed to improvehand function. The patient, the surgeon, and the

therapist must all work together to achieve thebest functional result following a severe mutilat-ing hand injury.

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[46] Buncke Jr HJ, Buncke CM, Schulz WP. Immediate

Nicoladoni procedure in the rhesus monkey or

hallux-to-hand transplantation, utilizing micromin-

iature vascular anastomoses. Br J Plast Surg

1966;19:332.

[47] Cobbett JR. Free digital transfer: report of a case of

transfer of a great toe to replace an amputated

thumb. J Bone Joint Surg 1969;51B:677–9.

[48] Wei FC, Chen HC, Chuang CC, Chen SH. Micro-

surgical thumb reconstruction with toe transfer:

selection of various techniques. Plast Reconstr Surg

1994;93:345.

[49] Moberg E. Aspects of sensation in reconstructive

surgery of the extremity. J Bone Joint Surg 1964;

46A:817.

[50] Littler JW. Neurovascular pedicle transfer of tissue

in reconstructive surgery of the hand. J Bone Joint

Surg 1956;38A:917.

[51] Foucher G, Khouri RK. Digital reconstruction with

island flaps. Clin Plast Surg 1997;24:1.

[52] Winspur I. Single-stage reconstruction of the sub-

totally amputated thumb: a synchronous neurovas-

cular flap and Z-plasty. J Hand Surg 1981;6A:70.

[53] Goldner RD, Howson MP, Nunley JA, et al. One

hundred eleven thumb amputations: replantation vs

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[54] Emerson ET, Krizek TJ, Greenwald DP. Anatomy,

physiology, and functional restoration of the

thumb. Ann Plast Surg 1996;36:180.

[55] Matev IB. Thumb reconstruction through meta-

carpal bone lengthening. J Hand Surg 1980;5A:482.

[56] Chung KC, Wei FC. An outcome study of thumb

reconstruction using microvascular toe transfer.

J Hand Surg 2000;25A:651.

[57] Brunelli GA, Brunelli GR. Reconstruction of

traumatic absence of the thumb in the adult by

pollicization. Hand Clin 1992;8:41.

[58] Stern PJ, Lister GD. Pollicization after traumatic

amputation of the thumb. Clin Orthop 1981;155:85.


Toe-to-hand transplantationFu-Chan Wei, MD, FACS*, Vivek Jain, MCh ORTHO,

Samuel Huan-Tang Chen, MDDepartment of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Medical College,

199 Tun Hwa North Road, Taipei, Taiwan

Toe-to-hand transplantation constitutes one of

the most significant advances in the history of

reconstructive microsurgery [1,2]. The 1970s and

1980s witnessed a furious pace of technical and

conceptual advancements in various toe trans-

plantations. Today, the thumb and finger can be

reconstructed with various toe transplantations

[3–6].

Toe transplantation permits a one-stage total

reconstruction of mobile digits providing sensibil-

ity, stable joints, and near normal appearance of

the hand. With meticulous preoperative plan-

ning, the donor site morbidity remains low and

acceptable.

The functional and cosmetic requirements of

both the hand and the donor site must be consid-

ered. The patient’s preference must also be consid-

ered in the planning of the transfer. The level of

amputation, structures preserved, location and

extent of any defects in the injured hand, and hand

dominance and growth potential should all be

evaluated and appropriately weighted before

undertaking toe-to-hand transfer [6,7]. The ulti-

mate patient satisfaction and functional outcomes

depend on these factors and the quality and simi-

larities between the normal thumb and the toe des-

ignated for the transplant.

Timing of reconstruction

Toe transplantation can be performed as a pri-

maryprocedurewithanopenwoundoras a second-

ary procedure after the wounds have healed. Early

and single-stage reconstruction are preferred if the

patient’s and the wound’s conditions are suitable.

This includes simultaneous reconstruction of the

thumb and fingers if needed. The results in terms

of survival, immediate and late complications,

and the need for secondary procedures have been

shown to be similar between primary and secon-

dary reconstruction [8]. The advantage of primary

toe transplantation is a reduction in overall recov-

ery and rehabilitation period, permitting an earlier

return to work.

Pre–toe transplant preparations

Planning of definitive toe-to-hand transplanta-

tion reconstruction should begin from emergency

management. All grossly viable tissues, including

mobile joints and neurovascular bundles, should

be preserved as much as possible [9]. Adequate

or even some redundant skin cover over the stump

of the hand is required and can be obtained with a

pedicled groin flap before definitive reconstruc-

tion. This additional skin is of use during later

reconstruction, because it can cover the lateral as-

pect of transplanted toes, protect the pedicle, or

form a web space in the hand. It also allows less

skin to be harvested from the foot, allowing direct

closure of the donor site. Local flaps should be

avoided because resultant scarring may increase

difficulty of later reconstructive procedures. If

the metacarpal length is deficient, distraction

osteogenesis or a nonvascular bone graft from

the iliac crest can also augment it at the same time

as soft tissue reconstruction. This preserves meta-

tarsal length and reduces donor site morbidity,

especially in the great toe.



(F-C. Wei).


doi:10.1016/S0749-0712(02)00127-0

Hand Clin 19 (2003) 165–175

Surgical anatomy of the foot related to toe

transplantation

Although the foot has many anatomic features

similar to the hand, there are also some anatomic

differences, because they have different functions.

The great toe transverse diameter is about one

third bigger than the thumb. All great toe pha-

langes are slightly longer than those of the thumb;

its toenail is also bigger and there is more subcuta-

neous tissue in the pulp. All modified great toe har-

vesting techniques involve reduction in size of its

various components. The lesser toes are shorter

than the digits and have a square shape at the dis-

tal ends. The joints have limited flexion and also

have a tendency to claw. The anterior and poste-

rior tibial arteries supply the foot. The anterior

tibial artery continues as the dorsalis pedis artery

on the dorsum of the foot and runs laterally to

the extensor hallucis longus tendon toward the

first web space. Proximal to the base of the first

and second metatarsals, it gives off the arcuate

artery, which provides the second, third, and

fourth dorsal metatarsal arteries. Distally, the dor-

salis pedis artery bifurcates just past the base of the

first and second metatarsal, into the deep plantar

artery and the first dorsal metatarsal artery. The

deep plantar artery (also known as the perforating

or communicating branch) courses downward

between the first two metatarsals to contribute to

the plantar arch. The anatomic variations in the

arterial pattern should be kept in mind when har-

vesting a toe transplantation [10,11]. The first dor-

sal metatarsal artery always passes dorsal to the

deep transversal metatarsal ligament. At this point

it divides into medial and lateral branches, named

as digital arteries to the second and great toes,

respectively, and a communicating branch to the

first plantar metatarsal artery (FPMA). This is a

constant anatomic landmark helpful in arterial

identification during toe harvesting. There is dor-

sal-dominant system with the first dorsal metatar-

sal artery bigger than FPMA in about 70% of

cases, plantar dominant in 20%, and in the rest

both arteries can be of similar size [12].

The dorsal digital veins run along the dorsal

margins of each toe and unite in their webs to form

common dorsal digital veins, which join to form a

dorsal venous arch on the dorsum of the foot.

Veins leave the dorsal venous arch and converge

medially to form the great saphenous vein and lat-

erally to form the small saphenous vein. The plan-

tar foot surface has a superficial and a deep venous

system. The deep veins originate from the plantar

digital veins and communicate with the dorsal dig-

ital veins by perforating veins.

The dorsum of the foot is innervated from the

sural, superficial, and deep peroneal nerves. The

plantar surface is innervated by the tibial nerve,

which divides into the medial and lateral plantar

nerves supplying the medial three and a half toes

and lateral one and a half toes, respectively.

Toe harvesting: general principles

The dissection begins in the dorsum of the first

web space, where the junction of the lateral digital

artery of the great toe and the medial digital artery

of the second toe is identified. In the dorsal-domi-

nant arterial system, retrograde dissection contin-

ues until a suitable length and diameter of artery

are achieved. In a planar-dominant system, plan-

tar dissection is continued up to the middle meta-

tarsal shaft, where the union between the FPMA

and toe dorsalis pedis artery through the proximal

communicating artery is located. The FPMA is

divided at this point, because further dissection

of the communicating branch might be tedious

and destructive for the foot. If required, an inter-

position vein graft can be used for the vascular

anastomosis [12].

Complete skeletonization of even small vessels

and nerves during toe dissection facilitates passing

the vessels and nerves under the skin bridge, to

reach recipient vessels at a proximal level without

being compressed. This technique is particularly

useful in distal digital reconstruction. All other

structures are dissected and divided at the proper

level.

The donor site management is crucial for over-

all patient satisfaction. During great toe harvest, it

is advisable to preserve at least 1 cm of the proxi-

mal phalanx to maintain the foot span, the appear-

ance, and push off function of the donor foot to

prevent windlass effect. Skin grafting of the donor

site should be avoided in toe transplantation

because the graft seldom takes adequately, delays

foot function recovery, and remains as an unstable

and painful scar.

Recipient site preparation

The amputation stump is exposed through

cross-incisions to create four mobile skin flaps.

The scar is excised to obtain thin skin flaps for

smooth skin closure.

The bone end is prepared with minimal perios-

teal elevation. If composite joint repair with the

166 F-C. Wei et al / Hand Clin 19 (2003) 165–175

corresponding joint in the transplanted toe is

planned, the joint capsule and ligaments must

be dissected carefully while exposing the cartilage

surface.

Usually the extensor tendon can be identified

close to the bony stump and should be left intact

because integrity of the extensor mechanism is es-

sential for finger function. The flexor tendons have

different locations in distal and proximal finger

amputations. It is important to preserve the pulley

system while exposing and preparing the flexor

tendon to obtain a good tendon excursion. Tenol-

ysis is performed if necessary.

The digital or common digital nerve stumps are

identified and dissected proximally to the point

where they appear normal or near normal. The

recipient artery can be either the radial artery in

the snuffbox or the princeps pollicis artery for

the thumb, and digital or common digital artery

for fingers. It can be prepared with a separate inci-

sion, creating a subcutaneous tunnel for passage of

the pedicle. Usually one vein on the dorsal aspect

of the hand is prepared as the recipient vein.

Insetting of the transplants

Initially osteosynthesis is performed using

interosseous wires [13]. This technique provides

stability for early mobilization of the joints, pre-

venting tendon adhesions and improving the over-

all range of motion. Next, the extensor tendon is

repaired with the interphalangeal and metacarpo-

phalangeal joints in full extension. This helps min-

imize extension lag and flexion deformity. The

long flexor tendon is repaired with the flexor polli-

cis longus in the thumb and the flexor digitorum

profundus in the finger. The nerves are approxi-

mated in an end-to-end fashion with 10-0 nylon.

The vascular pedicle is tunneled to the recipient

site. The four skin flaps built in the recipient stump

are tailored and interposed with the triangular

flaps of the transferred toe, creating an even clo-

sure. The arterial anastomosis is performed first

followed by the vein, and the remaining wounds

are closed. If there is some tension in closing the

skin, partial closure and skin grafting the partially

opened surface is advisable, although it should be

uncommon with adequate preoperative planning.

Thumb reconstruction

The thumb plays 40% to 50% of the role in total

hand function. Whenever possible, replantation of

an amputated thumb should always be attempted.

When replantation fails or is not feasible, trans-

plantation becomes the first reconstructive option,

especially when amputation occurs proximal to the

interphalangeal joint.

There are several toe transplantations com-

monly used for thumb reconstruction, depend-

ing on the functional and esthetical needs of the

patient [4,7]. Irrespective of the technique of recon-

struction, the position of the thumb achieved

should be that of opposition to the digits for key

pinch and grasp. Although movement at the meta-

carpophalangeal or interphalangeal joints is not an

absolute prerequisite, the function of the recon-

structed thumb improves if joint movements are

present.

Total great toe transplantation

Functionally, the great toe provides the best

results by providing a stronger pinch and better

grasp. It should be considered for thumb amputa-

tions between the interphalangeal joint and base of

metacarpal shaft. It should be used for patients

who request better hand function and appearance

and who are willing to accept mild to moderate

functional disturbance of the foot. It is also indi-

cated in severe injury involving other parts of the

hand, when strong grip and pinch are desirable.

It is best suited when the size difference between

the thumb and great toe is acceptable. Usually

the left great toe is preferred for transplantation,

irrespective of which thumb is to be reconstructed,

because the left foot bears less functional stress.

The results for great toe transplantation including

sensibility, stability, grip strength, pinch power,

and interphalangeal joint motion are usually the

best among the various toes used for thumb recon-

struction. The appearance of the reconstructed

thumb, however, is too big and the donor foot

morbidity is greater compared with all other toe

transplantation techniques (Fig. 1).

Trimmed great toe transplantation

This technique reduces the bony and soft tissue

girth of the great toe to make it more equivalent to

the thumb, at the same time preserving the inter-

phalangeal joint articulation [6]. Trimming is done

on the tibial aspect, because the pedicle is located

on the fibular side. This technique is most suitable

for patients who are concerned about both appear-

ance and function. It is indicated for thumb ampu-

tations at or distal to the metacarpophalangeal

joint when there is an obvious size discrepancy

167F-C. Wei et al / Hand Clin 19 (2003) 165–175

between the thumb and great toe and when the

movement at the interphalangeal joint is desirable.

Initially, this technique was used in adults only,

but the long-term results of careful trimming of

an immature growth plate have been shown to

preserve its blood supply and integrity, thereby

maintaining the growth potential (Jain et al,

unpublished data) (Fig. 2).

Great toe wraparound flap

This technique was devised as an alternative to

a total great toe transplantation [5]. In its original

description, it consists of only the nail and soft tis-

sue envelope of the great toe without the skeleton

and tendons, retaining the great toe. It addresses

the donor site concerns and the size discrepancy

between great toe and thumb. The thumb skeleton,

if not already preserved, needs to be reconstructed

with a nonvascularized iliac crest graft. Subse-

quent modification of this technique included the

distal phalanx for nail support, which also pre-

vented swiveling of the wraparound flap and

grafted bone fracture or absorption [14,15]. The

appearance of the reconstructed thumb is usually

excellent, and the great toe need not be sacrificed

entirely. This flap is ideal for thumb amputations

distal to the interphalangeal joint and for soft tis-

sue avulsion distal to the metacarpophalangeal

joint with intact joint, skeleton, and tendons

(Fig. 3) [7].

Second toe transplantation

The second toe is not the first choice for thumb

reconstruction, because it has a smaller and bul-

bous contact surface, a tendency for clawing, a

smaller toenail, inferior cosmesis, and less ideal

functions as compared with either a trimmed or

total great toe transplantation. The second toe is

also not advisable in cases where the patient’s

occupation requires a broad area for opposition,

when the thenar muscle function is suboptimal,

for reconstruction of dominant hands, and in man-

ual laborers. It is indicated, however, in cases

where preservation of the great toe is necessary

and when its size mates the thumb. In reconstruc-

tion of nondominant hands or for patients who are

satisfied with second toe looks and function, a sec-

ond toe is a good selection. In proximal thumb

Fig. 1. Thumb amputation at metacarpophalangeal joint reconstructed with a total great toe. (A) Before reconstruction.

(B,C ) After reconstruction.


amputations involving the metacarpal shaft, the

great toe transplantation is not advisable because

of donor site morbidity considerations; however

a transmetatarsal second toe transplantation can

be used (Fig. 4).

Finger reconstruction

Single finger amputation

Because the functional deficit following the loss

of a single finger is minimal, toe transplantation

for digit reconstruction proximal to the interpha-

langeal joint level has not been generally accepted.

Reconstruction with like-tissue transfer from the

feet usually offers satisfactory results, however,

particularly for finger amputations distal to the

proximal interphalangeal joint (Figs. 5 and 6)

[16,17].

Multiple fingers amputation

With proximal amputation of multiple fin-

gers, the functional deficit becomes greater and

Fig. 2. Thumb amputation at proximal phalanx reconstructed with a trimmed great toe. (A) Longitudinal reduction of

one third of phalanges and interphalangeal joint of the great toe. (B) Postoperative appearance. (C ) Interphalangeal

joint motion.


reconstruction becomes necessary for better pre-

hension. Reconstruction of two fingers instead of

only one has several advantages [18,19], including

a useful tripod pinch, stronger hook grip, en-

hanced lateral stability, and increased handling

precision (Fig. 7). The options for adjacent ampu-

tated fingers include two separate lesser toe trans-

plantations or a combined second and third (or

third and fourth) toe transplantation on a single

vascular pedicle. In amputations distal to the

web space, two separate lesser toes are preferable

because transplantation of combined second and

third toe creates an objectionable sydactylous

appearance [18,19]. In contrast, for finger amputa-

tions proximal to the web space, combined second

and third toe transplantation is a better choice for

reconstruction. When the amputation is through

the metacarpophalangeal joint with intact meta-

carpal articular surface, the metacarpophalangeal

joint can be reconstructed using the articular sur-

face of the proximal phalanx and joint capsule

in the toe (composite joint reconstruction). This

Fig. 3. Thumb skin-nail avulsion reconstructed with a great toe wraparound flap. (A) Before reconstruction. (B)

Harvested great toe wraparound flap. (C ) After reconstruction.


allows a functional range of motion of the recon-

structed metacarpophalangeal joint [20,21]. If the

metacarpal articular surface has been damaged

or is absent, transmetatarsal toe transplantation

is performed to augment length.

Metacarpal hand reconstruction

The metacarpal hand has always been a great

challenge to hand surgeons. Before toe transplan-

tation became a clinical reality, a reasonable

reconstructive result was almost impossible to

achieve. A type I metacarpal hand can now be

reconstructed using a combined second and third

toe unit with a good tripod pinch functional result

(Fig. 8). In a type II metacarpal hand, both thumb

and fingers can be reconstructed with multiple toe

transplantations (Fig. 9). With careful planning,

the donor morbidity can be minimal even after a

total of five toe harvests.

Postoperative management

The patients are ideally cared for by specialized

nurses for the first several days. The proximal palm

and wrist are gently wrapped with the fingers

uncovered for continuous observation. The hand

and forearm are kept slightly elevated resting over

a smooth support to reduce edema. Bulky dress-

ings are not advised because blood clots can be

retained around the wounds, and to remove them

could induce vasospasm. It is not possible to start

early postoperative rehabilitation.

An initial bolus of 100 mL of dextran 40 (low

molecular weight) is rapidly administered intrave-

nously 10 minutes before completing the arterial

anastomosis, followed by a continuous infusion

(25 mL per hour) during the next 4 to 5 days.

Aspirin (325 mg daily) is administered for 2 weeks

to reduce platelet aggregation risk. Prophylactic

antibiotics are seldom needed but in prolonged

surgical cases or dirty wounds antibiotics covering

gram-positive and gram-negative bacteria should

be administered.

The vascular conditions in the transplanted toe

are subjectively monitored by direct observation of

the skin color, capillary refill, and turgor, and

objectively by measuring the surface temperature

in the toe in comparison with the adjacent normal

finger and opposite hand. Assessing the artery

patency with ultrasound Doppler is helpful when

these subjective and objective evaluations are in

doubt.

The donor foot is gently covered with nitrofur-

azone gauze over the wound and a light fluff dress-

ing. No splints are used in the donor foot or the

recipient hand. The foot can be uncovered in 2

days without further dressings. The patient is

allowed to walk a few steps on the heel of the

donor foot after the second week. It must be

emphasized that any contact with the anterior

plantar weight-bearing surface should be avoided

during this time. After approximately 6 weeks,

the patient is allowed to walk in shoes with a nor-

mal gait if the wound is healed.

Rehabilitation

Well-planned and supervised hand therapies,

including motor and sensory rehabilitation, should

be instituted following transplantations. The cur-

rent program consists of a protective stage (first

3 postoperative days); early mobilization stage

Fig. 4. Thumb amputation at proximal phalanx reconstructed with a second toe. (A) Before reconstruction. (B) After

reconstruction.


(3rd day to 3rd week); active motion stage (4th

through 5th week); activities of daily living train-

ing stage (5th through 7th week); and prevoca-

tional training stage (after 7th week). This early

mobilization regimen results in less stiffness, fewer

tendon adhesions, and an early return to activities

[22].

Intraoperative and postoperative complications

and management

Vasospasm is one of the most frequent compli-

cations that can occur intraoperatively or in the

immediate postoperative period. Arterial vaso-

spasm during the procedure can be relieved by top-

ical instillation of lidocaine (Xylocaine 1% to 2%)

Fig. 6. Single distal index finger amputation reconstructed with a second toe wraparound flap. (A) Before

reconstruction. (B) After reconstruction.

Fig. 5. Finger pulp defect reconstructed with glabrous skin flap from the foot. (A) Harvested glabrous skin flap from the

first web space. (B) After reconstruction.


or papaverine. Stripping of the adventitia helps in

relieving the spasm and should be carried out

under magnification. The vascular anastomosis

should be without any tension and vein grafts

should be used if required. Vessels should be kept

moist during the procedure and the skin closure

should not be tight so as to compress vessels.

A number of factors can precipitate postopera-

tive vasospasm, including low room temperature,

low blood pressure, anxiety in the patient, or

excessive manipulation of the hand. Prevention

consists of keeping an optimal blood pressure,

supplying adequate fluids, and avoiding overseda-

tion. If vasospasm occurs, some skin sutures

should be removed and vasodilators intermittently

instilled to the partially opened wounds. Sublin-

gual nitroglycerin or nifedipine [3] and regional

blocks [23] may help relieve vasospasm. The

threshold for re-exploration should be low and if

no improvement of circulation is noted after

observation for an hour, prompt re-exploration

in the operation room is mandatory. In some cases

Fig. 7. Simultaneous two second toe transplantations to index and middle fingers. (A) Before reconstruction. (B,C )

After reconstruction.


incomplete stripping of the adventitia or small

hematomas may be responsible for local vaso-

spasm. Once the adventitial layer has been

adequately excised or the hematomas drained,

the vasospasm may be relieved. When there is a

refractory vasospasm or the artery is thrombosed,

redoing the anastomosis is indicated, with or with-

out an interposed vein graft.

Vascular thrombosis is comparatively less com-

mon than arterial vasospasm, and is often related

to incorrect positioning, such as twisting or kink-

ing or compression by the tunnel, hematomas, or

tight skin closure. Most instances of vascular com-

promise in toe transplantation can be salvaged if

re-exploration is done early enough.

Other complications observed in the first 2

weeks usually involve skin coverage and wound

healing problems. In most cases these are second-

ary to partial necrosis of the skin flaps in the

transplanted toe or in the scarred recipient site.

With exposure of important structures, such as

tendons, nerves, and vessels, immediate coverage

reconstruction should be performed to prevent

desiccation of these structures and subsequent

sequelae.

Late complications and their management

Late complications include stiffness caused by

tendon and joint adhesions, extension lag, and

nonunion at the osteosynthesis site. Some of these

can be prevented or minimized by using early,

supervised, and aggressive postoperative rehabili-

tation [22].

For tendon adhesions, tenolysis can be done.

The incidence of tendon-related secondary proce-

dures, however, such as tenolysis, tenorrhaphy,

and tendon transfer, have been shown to be fewer

than 10% [24].

Extensor lag usually results from tendon repair

under inadequate tightness or loosening of the

Fig. 9. Metacarpal hand type II reconstructed with a total great toe and a combined second and third toe unit. (A)

Before reconstruction. (B) After reconstruction.

Fig. 8. Metacarpal hand type I reconstructed with a combined second and third toe unit. (A) Before reconstruction. (B)

After reconstruction.


repair. It can be corrected with tightening of the

repair or prolonged splinting in extension. The re-

sults of secondary tendon repair are usually poor.

Alternatively, the terminal joint can be arthro-

desed in an extended position.

Joint stiffness can be avoided by early intensive

supervised postoperative therapy. If required, ar-

throlysis or arthrodesis can be carried out second-

arily. The incidence of joint-related secondary

procedures in the authors’ series was 2.3% [24].

Nonunion is uncommon with interosseous wir-

ing, with an incidence of only 1.5% [24]. If sympto-

matic, secondary osteosynthesis or bone grafting

can be undertaken.

Summary

In the mutilated hand microsurgical toe-to-

hand transplantation provides thumb and finger

reconstruction that is superior to conventional

techniques in appearance and function [14,25].

Hand reconstruction using toe transplantation

should be individually planned and carefully exe-

cuted to obtain optimal results and minimal dis-

ability in the donor foot [3,23].

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[20] Strauch RJ, Wei FC, Chen SHT. Composite finger

metacarpophalangeal joint reconstruction in com-

bined second and third free toe-to-hand transfers.

J Hand Surg [Am] 1993;18:972–7.

[21] Wilson CS, Buncke HJ, Alpert BS, Gordon L.

Composite metacarpophalangeal joint reconstruc-

tion in great to-to-hand free tissue transfers. J Hand

Surg [Am] 1984;9:645–8.

[22] Ma HS, El Gammal TA, Wei FC. Current concepts

of toe to hand transfer: surgery and rehabilitation.

J Hand Ther 1996;9:41–6.

[23] Neimkin RJ, May JW, Roberts J, Sunder N.

Continuous axillary block trough in an indwelling

Teflon catheter. J Hand Surg [Am] 1984;9:830–3.

[24] Yim KK, Wei FC. Secondary procedures to

improve function after to-to-hand transfers. Br J

Plast Surg 1995;48:487–91.

[25] Wei FC, Chen HC, Chuang DC, Jeng SF, Lin CH.

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gery. Plast Reconstr Surg 1996;98:485–90.


Passive hand prosthesesHooman Soltanian, MDa, Genevieve de Bese, BA, MBAb,

Robert W. Beasley, BA, MD, FACSa,*aHand Surgery Services, New York University Medical Center, New York, NY 10016, USA

bAmerican Hand Prostheses, Inc., New York, NY, USA

Despite major advancements in surgical tech-

niques, including microsurgical revascularization

and free composite tissue transfer, there are a large

number of patients with hand mutilations who are

best served with high quality prosthetics targeted

to carefully determine the prime needs of each

individual. Once defined, a master plan to optimize

the meeting of these needs often includes pre-

liminary surgical procedures. Logical conclusions

require consideration of all alternatives, surgical

and prosthetic. Hand surgeons should, therefore,

be knowledgeable about the basic principles, po-

tentials, and limitations of the various prostheses.

The pattern of hand injuries has been progres-

sively changing, with total hand loss becoming

increasingly infrequent and bilateral total hand

loss extremely rare. Partial hand losses are more

frequent and one may see several hundred hand

mutilations with some remaining parts for each

total hand amputation. Candidates for passive

hand prostheses are those patients who have some

remaining digits but could use a static complement

to enhance the value of remaining natural parts

(Fig. 1). One of the basic axioms of all limb ampu-

tations is as true today as it was in the past: the

more distal the loss, the greater the sensory feed-

back essential for automatic or subconscious con-

trol and the greater the resulting improvement in

physical capability.

Another prudent point is that the deformity

constitutes a real socioeconomic handicap because

of the rapid shifting of the work force frommanual

labor to service industries in which one’s living is

made by dealing directly with others. A passive

prosthesis should not be considered a cosmetic

device. Cosmesis is a term that should be dis-

carded, as it can unjustly deprive patients of bene-

fits to which they are entitled. Cosmesis means

changing something normal to have a better

appearance, in one’s opinion. We are treating spe-

cific amputation deformities and passive prosthe-

ses can eliminate the stigma of disfigurement in

partial or complete hand mutilations. Disfigure-

ment can be a real socioeconomic handicap. In

fact, the United States Supreme Court in the case

of the School Board of Nassau County v Arleen,

490 US 273, 1987 has confirmed the extreme social

and economic impact of deformity.

Goals and realistic expectations

First we must expand the concept of function

beyond prehensile capacity to a global concept

of acceptance of the individual in society. There

should be clear understanding by everyone that

no prosthesis is truly replacing missing parts. The

purpose of passive prostheses is to minimize the

physical, emotional, social, and economic conse-

quences of deformities. Also, it is fundamentally

necessary to appreciate the high level of specificity

of all hand prostheses. The same patient may need

a different type of prosthesis for different occa-

sions. One prosthesis may be required for a factory

job, whereas a different prosthesis may be needed

for business or social affairs (Fig. 2).

All photographs were graciously provided by Amer-

ican Hand Prosthetics, Inc., 332 East 30th Street, New

York, NY 10016.


E-mail address: [email protected] (R.W. Beasley).


doi:10.1016/S0749-0712(02)00132-4

Hand Clin 19 (2003) 177–183

Because it is not possible for the prosthetic

device to restore all of which a normal hand is

capable, time should be spent in determining the

paramount goals for each patient. If this is done

and an appropriate, top quality prosthesis is pro-

vided, a high success rate can be anticipated.

Unrealistic expectations are fraught with non-

compliance and failure.

Another basic axiom is that there is no relation-

ship between the extent of physical loss and the

emotional response to it. It cannot be assumed that

a patient with partial loss of a single digit will make

a rapid recovery and assign appropriate signif-

icance to the loss. It is crucial for every patient to

understand the goals of the proposed prosthetics

and their limitations. Again, the purpose of pros-

theses is tominimize the physical, emotional, social,

and economic consequences of the deficiencies.

Aesthetic considerations

With the importance of social presentation in

our society having been established, a word about

our system of visual perception is in order. Basi-

cally our concern about the aesthetics of prosthetics

is a practical one. What the patient considers to

be a stigma is generally correct, because those peo-

ple involved with the patient will, for themost part,

also share the same attitudes and cultural values.

In this context there are two aspects of aes-

thetics to be considered. The obvious one is the

artistic characteristic of size, shape, color, and

texture that the artist can duplicate with great accu-

racy. A perfect color match is difficult because

autogenous tissue changes color constantly with

temperature, emotional state, and other factors

modifying blood flow. The second aspect of aes-

thetics, however, comes into play and basically

neutralizes the constant color changes. This factor

is the extent to which ordinary tasks can be accom-

plished in the expectedmanner. Basically our visual

perception is to see only that which we expect to see

unless there is some unexpected event provoking a

critical analysis of the situation. For example, if a

person has an index finger ray amputation and

takes a sip of wine and replaces the glass on the

table, most observers will not recognize that a fin-

ger is missing. Thus, there is an important aesthetic

contribution from motion and improving physical

capability should be an important design criterion

Fig. 1. (A) Mutilated hand closed with distant flap. The thumb is normal but virtually useless. (B,C ) Fine custom partial

hand prosthesis. (D) Prosthetic fingers fabricated with new micro-hinged passively adjustable armature greatly enhance

capability.

178 H. Soltanian et al / Hand Clin 19 (2003) 177–183

for every prosthesis. It is a rare exception that an

appropriately designed passive hand prosthesis

fails to make a positive contribution to better phys-

ical capability. They enhance the usefulness of

remaining parts, which in turn provide various

degrees of sensory feedback for subconscious con-

trol of movements.

Master plan

In the treatment of a mangled hand, a master

plan should be developed in the early stages of

the patient’s care. It can be modified, based on

the patient’s progress. Such a plan requires a thor-

ough knowledge of surgical and reconstructive

potentials as well as prosthetic fundamentals and

possibilities. It is not wise to embark on long and

complicated surgical procedures without having

an eye on the long-term result with respect to global

function. The hand surgeons should leave the parts

in the best possible condition for complimenting

their efforts prosthetically when appropriate. Even

the closure of a finger amputation should be consid-

ered a reconstructive procedure, leaving the stump

in the best form for prosthetic fitting. A finger

amputation stump should be slightly smaller than

normal so a prosthesis of normal finger size can fit

over it. The end should be smooth and tapered.

There has been a progressive shift from the clas-

sic teaching of ‘‘ideal levels of amputation’’ that

often led to elective shortening. It is safe to say that

in almost every instant as much length as possible

should be preserved, provided good and direct soft

tissue closure is possible. Local or even occasional

distant flaps may be indicated to save length. Con-

trary to previous recommendations, the flare of the

radial styloid should be preserved with a wrist

disarticulation. This permits fitting of a short

suction-held socket hand prosthesis. Otherwise a

long socket extending above the elbow is required

because the forearm changes shape with prona-

tion/supination. There are innumerable individual

considerations, but the principle of initial length

preservation is a fundamentally important concept

with rare exception.

Types of prostheses

There are two categories of hand prostheses.

1. Active prostheses (also known as ‘‘carrier

tool prostheses’’)

2. Passive prostheses

Fig. 2. (A) Severely mutilated right hand. (B) Strong and rugged, but not grotesque, fiberglass prosthetic device restores

function of the normal thumb for work in a factory. (C ) Fine custom silicone life-like prosthesis for business and social

occasions.

179H. Soltanian et al / Hand Clin 19 (2003) 177–183

One should not refer to active prostheses as

‘‘functional,’’ as that implies incorrectly that pas-

sive prostheses are ‘‘nonfunctional.’’ Most patients

with passive prostheses enjoy a substantial degree

of improvement in physical capabilities because

these prostheses use the critical sensory feedback

through the remaining natural structures.

The passive prostheses are designed intention-

ally without mechanical clamping units in them.

Passive and active prosthesis target different goals

and needs. Passive prostheses enhance the function

of the remaining digits of the hand and also restore

good social presentation.

New material and technology

Silicone has proven to be the best material for

handprostheses.Tworecent and significant techno-

logic innovations have enormously improved the

possibilities for digital and partial hand prostheses.

The first is the Bio-Chromatic� coloring tech-

nique for silicones. This technique mimics nature

by depositing color pigments on the interior sur-

face of the clear silicone prosthetic glove. The clear

exterior layer is similar to the colorless epidermis

of normal skin. This gives the prosthesis a similar

translucency. The superiority of color matching

with this technique obviates the need for the tradi-

tional ring or small bandage applied to the junction

of the prosthesis with the normal skin. It also per-

mitted the creation of digital prostheses for the

thumb and fingers without the need to extend prox-

imally over intact interphalangeal joints. The same

technology led to the development of a ‘‘sub-mini’’

prosthesis for a mutilated distal phalanx or even

for a lost or damaged fingernail.

The second major innovation relates to digital

armatures. Armatures are structures built into

prosthetic fingers to allow passive adjustment of

their contour by the normal hand for various

tasks. This allows more efficient function of the

remaining natural parts. Copper and stainless steel

armatures were flawed by oxide formation causing

discoloration and metal fatigue with breakage.

Also, wire armatures require secure anchorage of

their proximal end to modify their contour. The

development of stainless steel micro-hinged arma-

tures has resolved all three of these problems.

These prostheses do not require proximal anchor-

age to adjust for their configuration. The flexion/

extension occurs along the entire length of the

micro-hinged armature rather than at one point.

This eliminates the problems of metal fatigue and

need for anchoring the proximal ends of the arma-

tures that often is difficult to achieve. The new

armatures can be used to create prostheses for fin-

gers amputated at the level of the proximal phalanx.

The finger can be placed in basic extension for

thumb opposition. Alternatively, the digit may be

curved for typing or other activities (Fig. 3).

Specific prostheses

Passive hand prostheses can be conveniently

divided into three groups: (1) thumb, (2) fingers,

and (3) partial hands, the latter term reserved for

mutilating injuries with loss of a major portion

of the hand.

Partial hand

The goal of a partial hand prosthesis is to

enhance the usefulness of the remaining natural

parts while also providing a socially acceptable

appearance. The design and development of the

partial hand prostheses is the most challenging of

all, and often the most rewarding; however, natu-

Fig. 3. (A) The common transmetacarpal amputation with a normal but almost useless thumb preserved. (B) Custom

life-like prosthesis enhances use of the thumb.


ral parts with intact sensibility provide an advant-

age over any other device. A severe mutilating

injury that illustrates the dramatic value of a top-

quality partial hand prosthesis is loss of all four

fingers through their distal metacarpals, with a

normal thumb and palm preserved (Fig. 4). Before

micro-hinged armatures, one would have to

shorten the metacarpals to their neck levels in the

case of MP disarticulations to have space for prox-

imal anchorage of wire armatures.

Thumb

Fortunately, proximal thumb amputations are

rare. There is really no satisfactory means of

Fig. 5. (A) Thumb amputation through proximal phalanx. (B) Securely fitting digital prosthesis places the thumb pad

where the brain expects it to be and sensory feedback is so good that capability is near normal. Social presentation was

also simultaneously restored to normal.

Fig. 4. (A) Mutilated right hand. (B,C ) Fine custom, silicone, passive, partial hand prosthesis for which remaining parts

provide active motion. (D) Intact sensory feedback for subconscious control improves capability to a degree no active

prosthesis can approach.


securing the prosthetic attachment at this level of

amputation. There were hopes that osseointegra-

ted implants, so successful in the dental field,

would resolve this situation, but this has not been

realized.

Many thumb injuries are at the level of the

proximal phalanx. In these cases, it is important

to preserve maximum length, which may require

wound closure with a flap. A minimal length of

15 mm of proximal phalanx is needed for securing

a prosthetic suction attachment (Fig. 5).

For thumb amputations at the metacarpal-pha-

langeal (MP) joint level, slight deepening of the

first web with tapering of the condyles and

Fig. 7. (A) Middle finger amputation at neck of middle phalanx. (B) The remarkable Bio-Chromatic� coloring technique

permitted development of ‘‘mini’’ or short digital prostheses that leave the PIP joint uncovered and totally free. (C ) The

passive prosthetic fit provides sensory feedback, which with the finger’s pad where the brain expects it to be, can give

remarkable results. This has been a major technological breakthrough for prosthetics.

Fig. 6. (A) Mutilated hand with digital amputations and fused PIP joints. (B) Precisely fitting custom digital full-length

prostheses provide excellent sensory feedback, and, fabricated with the passively adjustable micro-hinged armatures, a

remarkable degree of fine functional rehabilitation.


removal of sesamoid bones makes secure fitting of

the prosthesis possible. The deepening should not

be more than 15 mm because further deepening

would result in a cleft rather than a web. This will

be aesthetically disturbing and will contribute to

progressive damage to the thumb’s adductor

muscles.

Other cases of thumb amputation near the MP

joint may be best treated by distraction osteotomy

lengthening of the first metacarpal with bone graft-

ing. The authors have gained additional lengths up

to 34 mm with this technique.

Finger

Contrary to common belief, finger prostheses

are not for appearance only. By placing fingertips

where the brain expects them to be and because of

the excellent sensory feedback to the brain neces-

sary for subconscious or automatic control from

their precision fit, finger prostheses can be among

the most helpful.

When possible, finger amputations are much

better treated with individual prostheses than a

partial hand prosthesis that requires covering the

hand with a glove (Fig. 6).

Proximal phalanx

Loss of both interphalangeal joints results in

enormous reduction of finger dexterity. As pros-

theses are now available with multiple micro-

hinged armatures that can be passively contoured

without the need for proximal fixation, long finger

prostheses can be useful for typing and similar

activities. A length of 12–15 mm of finger distal

to the interdigital web is required for secure suc-

tion attachment of finger prostheses. Occasionally,

judicious deepening of the web can provide a crit-

ical additional 3–5 mm of length.

Middle phalanx

The traditional full-length prostheses for all lev-

els of finger amputation covered the important

proximal interphalangeal joint (PIP) compromis-

ing its mobility. The PIP joint provides the critical

segment of the finger’s flexion–extension arc of

motion for most activities. With the advent of the

short or ‘‘mini’’ digital prosthesis made possible

by the Bio-Chromatic� coloring technique, no

restriction is imposed on PIP jointmobility (Fig. 7).

Distal phalanx

The loss of a fingertip or even a deformed fin-

gernail can be stressful to some patients. Using

the new technology developed for middle phalan-

geal amputations, a ‘‘sub-mini’’ digital prosthesis

has become available for the distal phalanx. There

is no restriction of motion. The fingernail prosthe-

sis is thin to permit transmission of sensibility from

the finger. A perfect fit results in secure suction

attachment and the acrylic fingernail, duplicated

from the other hand, is always correctly positioned

with no problems with skin irritation or cellulitis

(Fig. 8).

Summary

For many mangled hands, appropriately

designed passive prostheses now available, alone

or in conjunction with surgical reconstruction,

can offer the best available improvement, provided

they are of high quality and backed by prompt and

reliable after-delivery services. Invariably, there is

improvement in physical capability along with

restoration of good social presentation.

Fig. 8. (A) Partial amputation of only distal phalanx or even loss or damage of a fingernail can cause some patients great

distress, and for this there is no satisfactory surgical treatment. (B) The same technology resulting in the ‘‘mini’’ digital

prosthesis has been applied for a ‘‘sub-mini’’ prosthesis over the distal phalanx only, so both interphalangeal joints are

free. As illustrated, it can be used for a fingernail alone.


Active functional prosthesesTerry J. Supan, CPO, FAAOP

Orthotics and Prosthetics Associates of Central Illinois, 355 W. Carpenter Street, Suite B, Springfield, IL 62702, USA

This article discusses the use of prostheses ingeneral and more specifically what can be done forthe patient with injuries through the hand and

carpal region. Although the article is titled Func-tional prostheses, the author focuses on activelycontrolled devices. Rationale is made for ‘‘opti-mum’’ amputation levels and prescription recom-

mendations. Finally, examples of prostheticdesigns and fitting strategies are presented.

The two primary functions of upper limb

prostheses are to grasps objects and restore bodyimage. Secondary functions are to hold objectsdown or carry them. The prosthesis also must be

designed to allow the amputee to position theterminal device in space.

Presently, complex grasp patterns with multi-ple degrees of freedom are not possible. Research

has been done on more dexterous prosthetichands but none are commercially available. Cablecontrolled hooks usually provide a voluntary

controlled lateral prehension in one directiononly. Electric hands try to simulate oppositionbut only in one plane. They provide more function

because they do allow the amputee to controlopening and closing of the hand.

The silicone prostheses for carpal and meta-

carpal injuries cannot provide an active grasp ontheir own. They are used primarily to restore bodyimage and secondarily to hold objects against theother hand, the body, or other surfaces. If there is

enough residual phalanx to provide motion andsuspension of the silicone prosthetic fingers, theremay be enough muscle control and resistance for

some opposition.From the prosthetist perspective, the leading

cause for amputations of the upper limb is

trauma, either crushing injuries or electricalburns. This is followed by congenital anomalies,infections, and tumors. Only 10% of amputations

treated by prosthetists are of the hand or arm. Ofthose, most of the amputation sites are at thetransradial (below elbow) level, followed by thetranshumeral (above elbow) level, and a combi-

nation of the shoulder disarticulation and scap-ularthoracic levels. Historically, partial hand andfinger amputations rarely were provided with

prostheses because of the lack of componentsthat were either cosmetically or functionally ac-ceptable to the amputee. Recent advances in

silicone prostheses and the availability of electricalhands for carpel level amputations should changethat.

In the case of an elective amputation, length

does make a difference in the functional use of aprosthesis. A transhumeral amputation distal tothe midshaft level has more leverage to provide

the lifting force to flex the prosthetic elbow. Adistal transradial amputation allows more of theforearm’s supination and pronation to preposi-

tion the terminal device.But a limb that is ‘‘too long’’ can create just as

much difficulty for the prosthetist as one that is

too short. Disarticulations at the wrist and elboware no longer recommended, because their extralength restricts the types of prosthetic componentsthat can be used within the prosthesis. As a quick

reference, use the ‘‘three finger widths’’ rule todetermine the amputation level proximal to thewrist and elbow joint lines. Amputations more

distal to those points cause the prosthetic elbow tobe too low or do not allow enough space for aprosthetic wrist that permits easy changing of the

prosthetic hand or other terminal device.Unlike the individual with an amputation of a

leg, the arm amputee can adapt easily and rapidlyE-mail address: [email protected]


doi:10.1016/S0749-0712(02)00139-7

Hand Clin 19 (2003) 185–191

to one handedness. How soon a person is fittedwith a prosthesis after an amputation determines

how much they maintain their ‘‘bimanualness’’and how much they incorporate the prosthesisinto their lifestyle. The same is true for the child

born with some type of congenital anomaly.When the child would normally start bimanualactivities is when they could and should start touse a prosthesis. In both cases early is better.

Malone et al provided some interesting datawhen they reviewed the use of immediate andearly postoperative prosthetic fittings in adult

patients in the 1980s [1]. There was a significantdifference in the functional outcomes of individ-uals who began to use their prosthesis within 30

days after their surgery and those fitted later.There was also a decrease in the phantom pain

commonly associated with amputation.In the case of children, there is a long

established practice of fitting the child with some

type of passive prosthesis at 6 months or whenthey begin sitting independently. As the childdevelops cognitively and physiologically, theprosthesis can be modified to provide spring-

loaded followed by active grip (Fig. 1). Thequestion is always raised, ‘‘Will the amputee bea �user� of a prosthesis?’’ The response is that the

individual, be it an adult or a child, usesthe prosthesis as long as the benefit of wearingthe prosthesis outweighs the ‘‘nuisance factor’’ of

Fig. 1. Spring-loaded TRS Adept� holds objects placed in the prosthesis.

Fig. 2. This patient has chosen not to use a prosthesis for her metacarpal level congenital anomaly. Painting the

fingernails on the limb buds illustrates how comfortable she is with her self-image.

186 T.J. Supan / Hand Clin 19 (2003) 185–191

having the prosthesis interfere with their life. Ifthe prosthesis is a functional tool for them or if itimproves their self-image, they will wear it. If not,

they will quickly discard it and adapt to a one-handed lifestyle. Unfortunately there is no way ofpredetermining who will use their prosthesis and

who will not (Fig. 2).Individuals with high-level unilateral ampu-

tations at the shoulder region rarely use a pros-thesis. Those with an interscapular-thoracic

amputation wear some type of ‘‘shoulder cap’’to balance out their clothing. The longer lever armof a more distal transhumeral amputation results

in more function and therefore an increasedlikelihood of prosthesis use. The same is true ofthe transradial level. Although most individuals

function well with their prosthesis, those whohave a proximal amputation tend not to use aprosthesis because of the leverage and prosthetic

weight. As noted earlier, individuals with finger

and partial hand amputations who use a prosthe-sis are the exception.

Finally, individuals with bilateral amputations

or contralateral limb involvement usually wearand function remarkably well with at least oneprosthesis. They have more function with the

longer limb if there is a difference between the twoextremities. But as with the unilateral amputees,the partial hand and high level make it less likelyfor these individuals to use a prosthesis.

The bottom line is that all amputees should befitted with the type of prosthesis that fits theirgoals and lifestyle as soon as possible after their

amputation. They will determine if the use of aprosthesis is best for them.

When the patient is first evaluated by the

prosthetist, functional goals and lifestyles are usedto try to determine what is the best type ofprosthesis for the amputee. If cosmetic image is

the most important goal of the patient then the

Fig. 3. (A) Alginate impression of residual limb and contralateral hand of patient and completed silicone prosthesis. (B)

Transparent evaluation prosthesis is used to determine fit and shape before the final prosthesis is fabricated.

187T.J. Supan / Hand Clin 19 (2003) 185–191

use of a nonactive silicone prosthesis or a siliconecustom glove over an electric hand would be thefirst choice. If the amputee indicates a desire formore rugged activities, then a mechanical design

like a cable powered hook would be moreappropriate.

The passive silicone prostheses are more

cosmetic and potentially can improve the self-image of the patient. They add considerableexpense to the overall cost of the prosthetic care.

Newer designs for transcarpal and distal amputa-tions are self-suspending and more durable. Thereis less problem with stains and inks with the

silicone prostheses than with the PVC gloves thatwere used in the past.

Although they are now more readily available,the prosthetist does need special training to

provide this type of prosthesis. Alginate or RTVrubber is used to take an impression of theresidual limb and the contralateral hand to matchthe shape and size as closely as possible. Photo-

graphs or digital images and color swatches areused to make sure that the skin pigmentationmatches. A transparent evaluation socket or glove

is used to insure proper shape, fit, and suspension.Color samples are matched again before theprosthesis is completed (Fig. 3).

The advantage of the cable controlled hookprostheses is that they are more durable than thesilicone prostheses and less complex than the

electric prostheses. The mechanical terminal devi-ces (TD) are either voluntary closing (VC) like theTRS Grip� (TRS, Inc., Boulder, Colorado) orAdept� (TRS, Inc., Boulder, Colorado), or

Fig. 4. Grieffer� (Otto Bock Health Care, Minneapolis, Minnesota) electric hook applied to a wrist disarticulation level

prosthesis.

Fig. 5. (A) Disassembled transcarpal level prosthesis with internal flexible suspension and hinge to allow residual wrist

flexion motion. Patient has congenital anomaly with shortening of the forearm bones. Overall length of limb is equal to

contralateral forearm. (B) Partially assembled prosthesis. Center section connects electric hand to distal section of

prosthesis.


voluntary opening (VO) like the usual Hosmersplit hook (HosmerDorrance Corporation, Camp-bell, California). Both types of TDs can be adapted

for heavy-duty use with metacarpal level amputa-tions. At any level, a body powered prosthesisis controlled by motions of the shoulder joint.

Forward flexion of the arm causes the cable toopen the hook while rubber bands close it. For theVC terminal device, a spring holds it open and theshoulder joint motion causes it to grip the object

tighter. The amputee only has active control in onedirection. In most cases the prosthesis is used in thebaseball ‘‘strike zone.’’ Outside that range, cable

excursion is lost and the hook is more difficult toopen or close.

Electric hands are controlled in opening and

closing. Earlier versions used simple on–offelectronics. These evolved into proportional elec-tronics and are now controlled by microproces-

sors for more exact manipulation of the middleand index fingers and thumb. Myoelectric handsare controlled by the forearm muscles and not by

any shoulder/elbow motion. Therefore, the ampu-tee can open and close the TD throughout the fullrange of motion of their arm. They can just as

easily open and close the hand at the floor, overtheir head, or behind their back. Because of theirshape and the cosmetic covering, they tend toenhance self-image. In children, the ‘‘Six Million

Dollar Man’’ has a higher approval rating than‘‘Captain Hook.’’

Electric hooks are available for amputations at

the wrist disarticulation level and more prox-imally. Because they lack the cosmetic glove, theyare more durable and can be interchanged with an

electric hand. At the present time there are nodesigns that work with carpal/metacarpal levelamputations (Fig. 4).

Prostheses are usually suspended on the pa-tient limb in one of three ways: part of the con-trol harness holds the prosthesis in place, theprosthesis is designed to encapsulate the bony

structure of the limb, or a positive air seal causesatmospheric pressure to maintain the prosthesis inplace. The level of amputation and the type of

prosthesis prescribed determine which manner ofattachment is used.

Mechanically controlled prostheses usually use

part of the harness for suspension. For ampu-tations below the elbow, the straps in front ofthe involved shoulder transfer the weight of theprosthesis and anything it is carrying to the

opposite axilla, usually in a figure eight pattern.Amputations between the shoulder and elbow aresuspended either from the opposite axilla or

around the chest.In the case of bony suspensions, the increased

width of the condyles and styloids compared with

Fig. 6. (A) Semi-flexible inner socket on wrist disarticulation prosthesis allows the styloid to pass the smaller mid-shaft

area. (B) Prosthetic wrist can be passively rotated but does not allow flexion or extension.

Fig. 7. Flexible inner silicone insert is rolled onto limb

then both are inserted into the socket of the prosthesis.

The distal pin engages a locking mechanism within the

prosthesis.


the area just proximal to them allows the

prostheses to be self-suspending. The fit of thisarea of the prosthesis is more critical to gainenough pressure to suspend but not too much

pressure to cause discomfort. Depending on thelevel of amputation and the terminal device used,this bony suspension can be made of either rigid

or flexible material. Either the flexible materialexpands to allow the larger distal bony structureto pass by or the rigid socket shape is designed toallow the condyles to pass when the joint is held at

a certain angle (Figs. 5 and 6).Atmospheric pressure techniques also vary

depending on the level and the components used

in the prosthesis. The proximal socket’s circum-ference is made smaller and a distal valve is usedto allow the limb to be ‘‘pulled’’ into the

prosthesis. With the valve sealed, the limb then

acts like a cork in a wine bottle. This is usually for

amputation at the transhumeral level. The inter-nal socket is usually made of a semi-flexibleplastic.

The second technique is to use a flexiblesuspension liner that is rolled on and seals to theskin of the limb. This liner is then connected to the

prosthesis by special locking mechanisms (Fig. 7).An external sleeve also can be used as either

primary or secondary suspension of the prosthe-sis. Like the roll-on insert, this also acts as an air

seal but allows more supination and pronation ofthe forearm without affecting the function of theterminal device. The sleeves are usually made

from silicone or other similar material (Fig. 8).

Fig. 8. Flexible silicone sleeve seals the prosthesis and maintains the suspension.

Fig. 9. Medial and lateral pressure is applied to the

distal end of the limb during the impression-taking to

better control residual rotation of the bones. This then

transfers any motion of the radius to the prosthesis.

Fig. 10. A partially completed prosthesis for an ampu-

tation of the fingers (thru the second metacarpal-

phalangeal [MP] joint to the distal shaft of the fifth

metacarpal). The ‘‘finger’’ can hook around objects and

provide either lateral or tip prehension from the thumb.


With this type of suspension up to 50% of theresidual forearm rotation can be transferred

through the prosthesis. To do this, the distalend of the limb is flattened during the impres-sion-taking to create a ‘‘screwdriver’’ technique

to harness this motion. The closer the amputa-tion is to the wrist level, the more pre-positioningof the terminal device the amputee will have,

thus increasing the function of the prosthesis(Fig. 9).

When only a portion of the hand has been

amputated the design criteria can be more difficultto assess. If either the thumb or fingers are re-moved, then the prosthesis is usually constructedto provide opposition for the remaining digits.

Most of these are designed for specific tasks andare for more rugged manual activities. Simplisticthumb posts or finger posts are used to provide the

counter force to hold an object or tool. Fingerreplacements are usually curved to allow a choiceof either lateral pinch or tip pinch (Fig. 10).

For a larger grasp pattern, a conventionalhook or other terminal device can be modified tothis level of amputation. The prosthesis is usuallylonger than the other arm. Wrist motion can still

be available to improve pre-positioning of the TD.Usually the TD is mounted on the palmar surface,but if the thumb is still present, it is attached to

the back of the hand (Fig. 11).Recent developments in electric hands now

allow the prosthetist to design a myoelectric

prosthesis when either the proximal or distal rowof carpal bones is present. In the case of carpal/

metacarpal amputations, the Otto Bock 8E44Transcarpal Hand� (Otto Bock Health Care,Minneapolis, Minnesota) can now be used. The

Short Hand version of the Motion Control Pro-Hand� (Motion Control, Inc., Salt Lake City,Utah) can be used for either wrist disarticulations

or proximal carpal level amputations. Althoughthe Otto Bock hand has a fixed connection atthe wrist, the Motion Control short version still

allows a quick disconnect and rotation at thewrist.

Finally, the recent development in osseointe-gration has resulted in direct attachment of

myoelectric prostheses (at the transradial level)and silicone prostheses for the thumb [2]. As thecomplications of the bone/internal prosthesis/

external prosthesis are resolved, this may becomethe suspension technique of choice for futureamputees with mutilated hands.

Reference

[1] Malone JM, et al. Immediate, early, late postsurgical

management of upperlimb amputation. J Rehala Res

& Devel May 1984;21(1):33–41.

[2] Lundborg G, Branemark PI, Rosen B. Osseointe-

grated thumb prostheses: a concept for fixation of

digit prosthetic devices. J Hand Surg 1996;2:

216–221.

Fig. 11. A voluntary closing TRS Grip II� terminal device is mounted to the dorsum of the prosthesis to allow the

amputee to hold larger objects. The patient’s thumb is present but has a reduced range of motion. The cable provides

power to close the hook when the shoulder is flexed.


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

for assessmentReuben 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 beingthe most commonly injured part of our body.Acting as mechanical extensions of our bodies,

our hands and upper extremities are instrumentalin our ability to eat, to dress, to perform personalhygiene, and for most people, to pursue a pro-

ductive role in society and at home. Hands havebeen used to display power, passion, friendship,gratitude, and anger. The blind use their hands toread and the deaf to communicate. These highly

specific functions of the upper extremity necessi-tate a fine balance between the sensory organs inthe hand and its biomechanic movements.

Mutilating hand trauma can render the limbcompletely dysfunctional, thereby detrimentallyimpacting lives of patients and their families.

Reparative and reconstructive surgeries are nobleattempts to regain some of the lost functions ofa mangled hand. The limitations of surgery and the

prognosis of the final, functional outcome ofmutilating hand injuries depend not only on theseverity and extent of the initial injury, but also onthe patient’s age, underlying health condition,

overall expectations, compliance, and psychosocialdisposition. Each of these factors can be a signifi-

cant variable in the final functional outcome ofmutilated hand injuries. Any evaluation of out-

comes following such devastating injuries mustkeep 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, immobi-

lization, and scarring can lead to contractures andstiffness, whereas insensate digits are subject torepeated trauma and further dysfunction. Throughaggressive physical therapy and secondary recon-

structive procedures, however, lost function, atleast in part, can be returned to the remainingelements of the mutilated hand. Digit lengthening,

web space deepening, tendon transfers, nerve graft-ing, and toe transfers all have been used to improvea patient’s ability to perform their activities of daily

living and, perhaps more importantly, to returnthem to a productive profile in society.

Our ability to salvage some function in the

mutilated upper extremity makes hands signifi-cantly different from their lower extremity counterparts (Fig. 1). Most patients with a severelymangled foot would be more functional with

a lower leg prosthesis than an attempt at limbsalvage. Patients with severe hand injuries, on theother hand, can achieve significantly more func-

tion and benefit from initial salvage surgery andsecondary reconstructive procedures if prehensionand sensation are restored. Better neural regener-

ation and an ability to bring new digits up to thehand offer the promise of favorable, functionaloutcomes in managing these severe hand injuries.



(M.W. Neumeister).


doi:10.1016/S0749-0712(02)00142-7

Hand Clin 19 (2003) 193–204

Successful reconstructive efforts are aimed atsensibility restoration and the ability to perform

prehensile tasks with the final outcome beingmeasured by gainful use of the hand and patientsatisfaction. Burkhalter stated ‘‘The goal remains

achieving maximal hand function’’ [1] whendealing with mangled hands. Chen Chun-Weiechoed 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 tomaximize the patient’s functional outcome after

mutilating hand injuries. When does the surgeonsacrifice severely traumatized yet viable digits?How confident are we as hand surgeons that if we

salvage a limb, that this remaining hand, with orwithout secondary reconstruction, will give thepatient better use than a prosthesis might? What

variables in a mangled and severely compromisedhand or upper extremity allow us to know what to

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.

194 R.A. Bueno, M.W. Neumeister / Hand Clin 19 (2003) 193–204

replant or transplant? What degree of multiplelevel trauma or nerve injury precludes upper limbor hand salvage? How does the patient’s age affectthe surgeon’s decision to perform limb salvage in

secondary procedures? When do we recommendamputation and prosthesis fitting in severely in-jured upper extremities? Each of these questions

meanders through the minds of most handsurgeons when they are confronted with decisionsregarding mutilating hand injuries. Each injury is

given an individualized ‘‘game plan’’ in an attemptto offer the patient the optimum result. Unfor-tunately, there is no definitive decision tree that

can be used to guide surgeons as to which re-maining elements of the mangled hand shouldbe salvaged or amputated. There are no scoringsystems that offer the foresight to be able to

grade an injury, add in the possible secondary re-constructive procedures, and then predict whatthe functional outcome will be. There are not any

scoring systems like those in the lower extremityor in multiple organ trauma that help define whenan amputation of the hand or extremity is con-

sidered most appropriate. The rationale for thisis easily understood because we have a greaterability to restore ‘‘some’’ function in the hand or

upper extremity with secondary reconstructionthan we do with lower extremities. One canambulate easily with a prosthesis. It is extremelydifficult, however, to button a shirt or brush one’s

teeth with an upper extremity prosthesis. Theunique function and utility of the hand and upperextremity, therefore, mandate a greater consider-

ation and forethought by the surgeon in the initialevaluation and surgical management of patientswith mutilating hand injuries.

The principles of treatment and options forreconstruction in mutilating hand injuries havebeen addressed in previous articles. This articlereviews the outcome measures of mutilating hand

injuries, examines the use of scoring systems of theextremities, and describes current methods ofobjective and subjective evaluation.

Clinical outcomes

Reports in the literature on mutilating handinjuries have evolved from a focus on achievingadequate skin coverage in the earliest case reports

to reconstructing more functional hands in laterreviews. Advances in microsurgery have fosteredthe restoration of function with improved tech-

niques in replantation of amputated parts, free

tissue transfer for adequate coverage of wounds,improved nerve coaptation, and toe-to-handtransfers.

Underlying the treatment of mutilating hand

injury is the basic principle advocated by Brownin one of the earliest articles on mutilating handinjury: ‘‘Any salvage of workable or sensory parts

in a hand is worthwhile and infinitely better thana prosthesis’’ [3]. This view is supported by laterreports from Peacock and Tsai [4] and Graham

et al [5], who compared the functional results ofreplantation versus amputation and prosthesis inthe upper extremity. Peacock and Tsai [4] pre-

sented a single case of a child with bilateralamputations treated by replantation of one limband amputation and prosthesis on the other.Graham et al [5] presented a series of 22 patients

who suffered traumatic arm amputations andunderwent replantation. He compared this groupwith 22 other patients who had revision amputa-

tion of their arms and subsequent prostheticapplication. Superior functional results were ob-tained with the replantation of the arms com-

pared 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 quantitativemeasures, such as strength, range of motion,pinch, key pinch, and grasp, to assess functional

outcome of the reconstructed hand followingmutilating injury. Clinical series increasingly em-phasized objective measurements to evaluate

recovery and thereby guide initial treatment. Inaddition, the patient’s return to work status wasmore commonly included in the assessment of

outcome, supporting the belief that restoration ofmeaningful function is at the forefront in guidingtreatment and in evaluating outcome.

The literature is replete with functional out-

come data pertaining to mutilating hand injuries.Replantation or revascularization procedures areoften only a component of mutilating hand in-

juries, and as such the information on ultimatefunction in the mangled hand cannot always beextrapolated from the outcome data that arises

from these salvage procedures. The outcomes mayvary depending on whether the injury involvescompromise to different tissues including bone,

nerve, and soft tissue, with or without devascular-ization or amputations. Limb survival is mostcertainly not synonymous with limb function. Thesurvival of limbs subsequent to the initial struc-

tural repair, revascularization, or replantation

195R.A. Bueno, M.W. Neumeister / Hand Clin 19 (2003) 193–204

depends on the adequacy of the initial surgicaldebridement, the development of infection, themethod of injury, the level of injury, and the

duration of ischemia. Nonviable tissues witha heavy bacterial contamination are specific in-gredients for infection and are often associatedwith loss of the salvaged limb [7]. Although the

most common infection leading to the loss ofmangled limbs is unknown, Fitzgerald et al [8]reported the most common bacterial isolates in 86

mutilating hand injuries. Farming injuries hada greater number of mixed gram-negative andgram-positive infections compared with home and

industry. The most common gram-positive organ-ism was Staphylococcus epidermidis followed byStaphylococcus aureus and Streptococcus group D,respectively, in the prospective and retrospec-

tive arm of the study. Enterobacter agglomerans,Clostridium, and Klebsiella pneumonia were themost common gram-negative organisms, respec-

tively [8].The mechanism of injury also plays a specific

role in limb survival and function. Crush,

avulsion, and electrical burn injuries can portenda worse prognosis for survival [4,9–13]. Crushinjuries have a greater area of tissue damage with

multiple levels of vascular compromise (Fig. 2).This leads to an increased risk for thrombosis andinfection. The vascular compromise is often at thesmall vessel or capillary bed level. Muscle, skin,

and soft tissue stripped of their blood supply arerendered nonviable, forming a nidus for infectionif not debrided. Avulsion injuries have longer

segments of nerve and vascular compromise oflarger vessels resulting from the stretch andtorsion (Fig. 3).

Electrical injuries can result in fractures, burns,compartment syndrome, and progressive tissuedeath, ultimately leading to amputation (Fig. 4)[14–16]. The mechanisms of these devastating

injuries include electro-confirmation changes ofcells, joule heat, electroporation, and thermalburns. High voltage electrical injuries may neces-

sitate early amputation to insure the survival ofthe patient, who is in jeopardy from the musclebreakdown 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.


The functional outcome of major amputations

and devascularizations is often governed bythe same variables that govern the survival ofthe tissue alone. The level and mechanism of the

injury therefore have a significant impact on the

ultimate functional outcome of these injuries [5].In general, the more proximal the amputationthe worse the functional recovery. Proximalamputations have a worse prognosis for several

reasons. There is more muscle mass in themore proximal limb, which is more susceptibleto increased ischemia times. This is a greater

abundance of metabolic breakdown products.Another factor that hinders recovery from themore proximal amputations is nerve regenera-

tion. The toxicity of the metabolic breakdownproducts in muscle results in a reperfusionsyndrome [17] that clinically presents as hyper-

thermia, decreased level of consciousness, jaun-dice, cardiac irregularities leading to multi-organfailure secondary to hyperkalemia, metabolicacidosis, and myoglobinuria. Woods [18] re-

ported 4 deaths out of 36 above elbow replantsin patients who developed reperfusion syndrome.Patients are usually not subjected to reperfusion

syndrome when amputations are at the level ofthe mid-forearm or distally, because of the ratherminor contribution of muscle to this area. Nerve

regeneration in the proximal amputation is lesspredictable than in more distal amputations. Thegreater the distance the nerve has to regenerate,

the less likely the motor endplates will survive[9,19].

Clean guillotine-type amputations are general-ly considered to have a better functional outcome

(Fig. 5). The different types of tissue damaged incrush and avulsion injuries make the evaluation ofthe overall function somewhat unpredictable.

Many investigators have reported a worse prog-nosis with such injuries [5,9].

Fig. 3. Avulsed index finger with stretched neuro-

vascular structures making salvage difficult because of

extended level of injury.

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.


The ischemia time for the amputated limb alsohas a role in the overall functional outcome.

Although many investigators consider warmischemia time of less than 6 hours and coldischemia time of less than 12 hours a generalguideline for more reliable and safer replantation

or revascularization, the exact amount of ischemiatime that is considered inappropriate to replanta limb is somewhat ill defined. Reports in the

literature have varied from 1 to 6 hours to asmuch as 42 hours of warm ischemia with success-ful replantation [20]. These time frames have been

doubled if cold ischemia has been used. Weireported a successful replant with 96 hours of coldischemia.

Another variable in defining the functionaloutcome following mutilating hand injuries is thepatient’s age. Children and young adults havea better functional outcome than older patients

[5,9,21]. Younger patients may have a superiornerve regeneration capability, resulting in greaterextrinsic 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 thepatient, the more likely they will acclimatize or

adjust to their injury, thereby fostering improvedfunction. Older patients may not be as compliantor able to withstand the duration of surgery or thesignificant rehabilitation and subsequent second-

ary procedures often required with these injuries.An absolute age limit for revascularization andreplantation of limbs and digits has not been

identified, although most hand surgeons wouldconsider advanced age a relative contraindicationbecause of the risk for rather poor functional

outcome.Ultimately the functional outcome of revascu-

larization and replantation procedures depends on

the equation that incorporates age, mechanism andlevel of injury, associated trauma to structures atdifferent levels, ischemia time, associated traumato structures at different levels, contamination,

tissue loss and destruction, patient compliance andmotivation, rehabilitation, secondary procedures,dynamic stability, and premorbid medical pathol-

ogy. Clearly the functional outcome has a limitedchance of an accurate evaluation at the time of

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.


injury because of these variables. The relativecontributions of each variable, however, shapes thehand surgeon’s decision to attempt salvage andproduce a functional limb.

The Subcommittee on Replantation for theInternational Federation of Societies for Surgeryof the Hand [23] has adopted Chen’s criteria

[24,25] for all arm and forearm replantations, andNakamura and Tamai criteria [26] for hand anddigit replantations. Each system, however, is

an evaluation of the functional outcome of theinitial replantation alone and not for addedbenefits of subsequent secondary procedures that

could improve the use of the hand. Numerousinvestigators have attempted to assess the func-tional outcome following major limb replanta-tion. The range of good to excellent outcomes

assessed by different criteria range from 36% to100%, depending on the level, etiology, and ageof the patient.

Much of the earlier data on outcomes followingsevere hand injury came from several replantationand revascularization series. Although they did

not look exclusively at ‘‘mutilating’’ hand injuries,these series did assess outcomes in a systematicmanner that could be extrapolated to most severe

injuries of the hand. Chen’s assessment of func-tional outcome following replantation looked atthe patient’s ability to work, range of motion,sensation, and muscular power [27]. Kleinert’s

review of 347 replants in 245 patients includedtwo-point discrimination sensibility ratings, gripstrength, range of motion, absence of cold in-

tolerance, and return to employment for outcomeassessment criteria [28]. Tsai’s series on recon-struction using second and third toe-to-hand

transfers following severe transmetacarpal muti-lating hand injuries included objective measures,such as grip strength, key pinch, two-point dis-crimination, and active range of motion, and the

more subjective yet equally as important meas-ure, return to work status to assess outcome [29].Each series reported good results following treat-

ment 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 orrevascularized digits looking at the followingparameters: range of motion, activities of daily

living, sensation, subjective symptoms, cosmesis,and patient satisfaction [26]. This scoring sys-tem represented one of the earliest attempts tocombine objective measures with subjective meas-

ures to evaluate overall hand function. This

concept would become increasingly important inthe development of outcome measures in thefuture.

Any discussion of restoration of hand function

following mutilating hand injury must begin withthe ability to perform prehensile activities. Objec-tive measures, such as grip strength and key pinch,

are based on the presence of a moveable thumbthat circumnavigates by way of opposition toreach another stable digit. Alternatively, the

thumb may be the stable stationary post whileother mobile digits oppose to it. In Tubiana’sdescription of prehension, prehensile grip is

determined by the thumb’s ability to abduct andoppose [30]. Historically, options to restore anopposing post on the ulnar side of the hand haveincluded prosthesis, phalangization of the fifth

metacarpal, and bone grafting and flap recon-struction. Before the era of microsurgery and freetissue transfer, thumb reconstruction was accom-

plished with bone grafts under a sensate flap,distraction osteogenesis, pollicization of otherfingers, or phalangization. As a result of advances

in microsurgery and the pioneering work byBunke [31], Cobbett [32], Morrison [33], andWei [34–36], the transfer of a toe to a hand has

restored function in the face of nonreplantable orirreparable digits.

More thorough assessments of function, in-cluding objective and subjective measures, have

appeared in the literature over the last twodecades. Gorsche’s review [37] of corn pickerinjuries sought to assess reconstruction and

functional results by including the patient’s sub-jective evaluation of the usefulness of the injuredextremity. A good result was defined by a useful

grasp and pinch and independence from theopposite noninjured extremity. The analysis ofthe outcomes of the 15 patients in his seriesemphasized the importance of prehension in

restoration of hand function. Prehension wasaccomplished through toe to hand transfers forthumb reconstruction and the creation of an ulnar

post, allowing patients to grasp objects and usethe hand at least as an ‘‘assist’’ extremity in dailyactivities.

Wei’s series of 152 reconstructions of mutilateddistal digits with foot tissue included 56 toe-to-thumb transfers [38]. He reported a 98% success

rate with the following results: sensory recoveryranging from 5 mm to 15 mm, average post-operative active range of motion of the PIP jointfor fingers and IP joint for the thumb at 60% of

preoperative value, no significant cold intolerance,


and minimal donor site morbidity. Successfulfunctional use of the reconstructed digits in thepatients’ activity of daily living was also reported,

although the types and levels of activities were notspecified.

Scoring systems

As noted earlier, advances in trauma manage-ment, microsurgery, skeletal fixation, soft tissue

coverage, and antibiotics have salvaged severelyinjured extremities that would have been ampu-tated in the past. Occasionally, however, one mustjustify the extensive reconstruction efforts to

reflect on the best functional interest of thepatient. The impact of the injury on the patientcan be devastating. The outcome of the initial

salvage surgery and the complex reconstructionthereafter may be compromised by morbidity ofmultiple surgeries, long hospitalizations, and

family and work issues. All of the factors mayalso affect patient compliance.

As techniques in reconstruction after a mutilat-

ing extremity injury were developing, a variety ofscoring systems for injured extremities emerged inthe trauma literature [39–42]. The goals for eachof these systems were to establish guidelines for

the treatment of mangled extremities and, depend-ing on injury severity, to provide surgeon andpatient 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 aresalvageable. These scoring systems include theMangled Extremity Syndrome Index (MESI) [39],the Predictive Salvage Index (PSI) [40], the Limb

Salvage Index (LSI) [42], and the MangledExtremity Severity Score (MESS) [41]. The MESSis a lower extremity scoring system that was

developed to discriminate between salvageableand unsalvageable limbs. The MESS scoring sys-tem is based on skeletal/soft-tissue injury, limb

ischemia, shock, and patient age [41]. Unfortu-nately, this system, as is true of many others ofits kind, does not address the potential functional

outcome of the upper extremity following theinitial injury and the subsequent secondary re-construction. Reconstructive efforts can restoresome or most of the function of the hand to a much

greater degree than lower extremity reconstructioncan restore the function of the foot, ankle, and leg.Whereas a prosthesis is extremely functional in the

lower extremity, native functional sensate tissue isirreplaceable in the hand.

The mere existence of a multitude of scoring

systems provides support for one of their commoncriticisms: there are not universally acceptedcriteria for what should be measured. Althoughthe quality of skin, muscle, bone, and ischemia are

variables in all of these scoring systems, vesselinjury is addressed in the MESI, PSI, and LSI,whereas nerve injury is included in the MESI and

LSI. Other factors such as shock, age, andmechanism of injury are components of the MESIand MESS. An overall injury score, the ISS, and

comorbid conditions are also included in theMESI score.

In the application of these measures, somelimitations have become apparent. All measures

were developed for trauma of the lower extremity,not the upper extremity. The practical use of thesescoring 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 pre-

dictive usefulness in any of these indices fordifferentiating patients who would benefit withamputation from patients whose limb should be

salvaged [43]. A similar finding was reported byDurham in his retrospective scoring of upper andlower extremity injuries with the MESI, MESS,PSI, and LSI [44]. Because no differences in

scoring were seen between patients with good andpoor functional outcomes, they concluded thatnone of the scoring systems were reliable pre-

dictors of functional outcome. Slaughterback,however, did find the MESS to be an accuratepredictor of amputation of the severely injured

upper extremity in his retrospective application to43 severely injured limbs, but conceded that thesurgeon’s clinical judgment should be the mainfactor 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]. Fourgrades of increasing severity of hand injury aredescribed, based on separate anatomic compo-

nents: integument, skeletal, motor, and neural.Each ray is examined separately and is assigneda weighted factor, based on functional impor-

tance, for calculation of the final score. Openfractures and contaminated wounds increase thefinal score. Although the HISS is only a descriptivesystem that has no bearing on prognosis, it does

provide a score at the time of injury that can be


used in conjunction with functional assessmentsand long-term outcome studies to guide therapy inthe acute stage and in rehabilitation.

Shortly after the appearance of the HISS

emerged, another scoring system specific to thehand, the Hand Function Score (HFS), wasdeveloped by Watts, Greenstock, and Cole [47].

Unlike previous scoring systems, the HFS isa subjective assessment based on activities ofdaily living that is used to plan and monitor

progress in rehabilitation after hand trauma. TheHFS consists of 25 commonly performed activi-ties focusing on clothing, cleansing, and feeding

oneself. Each activity is assigned a score from1 (easy) to 4 (impossible) by the patient, anda total score is obtained by adding the score foreach of the 25 activities. The assessment is done at

the time of presentation and again at the end ofa rehabilitation program to provide a score forcomparison of subjective functional outcome

following therapy. The creators of the HFS pro-pose using the score in conjunction with moreobjective measures to assess a patient’s progress

through rehabilitation.

Outcomes research

The field of outcomes research has developedas providers of care have come to recognize theimportance of studying effectiveness of treatment

in ways that are most meaningful and relevantto the patient. It is no longer good enough toimplement a treatment plan without considering

the long-term clinical outcome. With the ongoingdebate on how best to allocate financial resourcesin this environment of cost-consciousness, the

outcome of a procedure must be shown to be ofsignificant benefit to the patient, in restoration offunction, patient satisfaction, and return to a pro-

ductive lifestyle. Recent literature has emphasizedthe need for assessing outcome using validatedand reliable patient questionnaires so that mean-ingful conclusions can be drawn regarding treat-

ment and outcome [48,49]. Evidence that supportsa treatment method versus no treatment oranother method is of interest to patient, surgeon,

hospital, and third-party payers. Acknowledg-ment of the need for evidence-based studies toevaluate outcomes following treatment is being

seen in all areas of surgery. In the near future,surgeons may have to bear more of the re-sponsibility in demonstrating that their proce-dures are beneficial to the patient with regard to

functional outcome and costs.

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, restora-

tion 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 cost-

efficient care of the highest quality.Even if there is acknowledgment that sub-

jective data is important in measuring outcome,

developing an appropriate measurement instru-

ment 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 out-

comes 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


subjectively patient satisfaction and functionafter upper extremity trauma and treatment. TheUEFT provides a score based on 33 separate

everyday activities, including pinch, grasp, stabil-ity, strength, and coarse and fine movement, andrepresents one of the first attempts at a standard-ized subjective evaluation of extremity function.

Russell et al [9] and Graham et al [5] have usedCarroll’s UEFT to assess outcome followingupper extremity replantation and revasculariza-

tion. Each of these studies recognized the impor-tance of including patients’ subjective assessmentof their condition and did not rely solely on limb

viability or a measured value to determine thefunctional outcome.

In response to criticism that subjective ques-tionnaires are unreliable, inconsistent, and un-

scientific, the field of outcomes research, orevidence-based medicine, has recently establishedcriteria that should be upheld by subjective

questionnaires so that the data acquired can beused to draw meaningful conclusions on out-comes. As outlined by Amadio, these criteria

include: validity, responsiveness, reliability, in-ternal consistency, and sensitivity [48]. Validityrefers to how reasonable it is to expect that

a questionnaire is measuring what it is supposedto be measuring and how accurate it is in thismeasurement. Responsiveness defines whethera questionnaire is able to detect a significant

difference before and after a treatment. Reliabilitymeans a questionnaire results in the same answerfrom one administration of the questionnaire to

another. Internal consistency refers to questionsthat ‘‘hang together,’’ moving in the same di-rection and reinforcing each other. Sensitivity of

a questionnaire is determined by how finelygraded are the differences that can be measured.Increasing the range of possible answers withmore questions increases the questionnaire’s sen-

sitivity [48]. If a questionnaire meets these rig-orous criteria, more meaningful conclusions canbe made regarding outcome and comparison of

treatments from this data than from resultsfrom a nonvalidated questionnaire.

Questionnaires have evolved from ones as-

sessing overall general health, such as the ShortForm 36 (SF-36) [55], which addresses the entirespectrum of physical, mental, and social well-

being for the whole person, to more specificinstruments focusing on the upper extremity,such as the DASH [56], or on the hand, such asthe Michigan Hand Questionnaire [57]. The

DASH (Disabilities of the Arm, Shoulder, and

Hand) represents a multidisciplinary effort todevelop a clinically useful outcome measure forthe upper extremity based on previously tested

questionnaires. The DASH consists of 30 ques-tions, narrowed down from 800, and askspatients to rate their ability to perform everydaytasks and the severity of their symptoms. The

DASH also has additional modules for sports,music, and heavier work activities. It has beenshown to be a reliable and valid instrument to

assess functional outcome and has been used toevaluate a variety of shoulder, elbow, wrist, andhand problems [56].

The Michigan Hand Questionnaire (MHQ) isanother recently developed measurement tool thatis composed of questions in six separate catego-ries: overall hand function, hand-related activities

of daily living, pain, work performance, aes-thetics, and patient satisfaction with hand func-tion. The MHQ has been shown to be reliable,

consistent, valid, and responsive to change overtime [57]. Validated disease-specific measures alsoexist for carpal tunnel syndrome [58] and wrist

problems [59]. These more specific instrumentsmay better assess functional outcome for thatspecific disease than a generic health questionnaire

such as the SF-36, or a region-specific instrumentsuch as the DASH or MHQ. A subjective ques-tionnaire specific to mutilating hand injuries, how-ever, does not exist at the present time.

Each of these scoring systems, however, doesnot address the ability to predict the amount offunction that would return after the initial injury.

Ideally, one would require a scoring system thatpermits the surgeon to evaluate the mangled handfor each of its lost or impaired structures, dictate

the subsequent line of treatment, be it replanta-tion, reconstruction, transplantation, or amputa-tion, and predict the ultimate function followingthese series of procedures and rehabilitation. At

what point is a toe transfer better than salvaginga finger or thumb? Does the final outcome changeif severely traumatized digits are salvaged, only to

be amputated at a later date? Is the outcomeaffected by early amputation and digit transplantsrather than delayed procedures? Unfortunately,

there are too many variables that come into playthat affect the final functional outcome in anyscenario. Intrinsic factors, such as swelling, scar-

ring, pain, and poor healing, obstruct progressat each step of therapy. Extrinsic factors, such asthe patient’s age, motivation, expectations, com-orbid health condition, expenses, and copingmech-

anisms may alter the final outcome also.


Summary

The functional outcome of a mutilating handinjury cannot be fully assessed at the time ofinjury alone. The measure of functional outcome

must incorporate the evaluation and severity ofthe initial injury and the subsequent reconstruc-tive surgeries. The complexity of the hand

deserves no less. Restoration of prehensile func-tion is the top priority in reconstruction followingmutilating hand injuries, and assessment of out-

come should address this goal. Flaps and special-ized tissue grafts can restore architecture andbalance in the hand. One can reconstruct a thumb

and fingers with the big toe and smaller toes togive a functional sensate grip. The assessment offunctional outcome should include not onlyobjective measures but also subjective question-

naires that focus on issues most relevant to thepatient. The use of questionnaires that have beenshown to be valid, reliable, consistent, responsive,

and sensitive allows the most meaningful con-clusions about and comparisons between treat-ments. Perhaps because of the unique challenges

presented by mutilating hand injuries, a newinstrument, specific to mutilating hand injury,may provide the most beneficial information to

guide treatment and assess outcome.

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Index

Note: Page numbers of article titles are in boldface type.

A

Amputation(s), adaptation following, 185–186

biomechanical impact of, 19–24

cause for, 185

elective, length and, 185

guillotine-type, functional outcome following,

197, 198

in fractures of mutilated hand, 54

Antibiotics, choice of, for mutilating hand

injuries, 36–37

for prophylaxis in surgery, 33

in extremity trauma, 2–3, 34–36

side effects of, 37

Antimicrobials, in management of mutilating

injuries, 33–39

topical, irrigation with, 36

B

Blood vessels, repair of, following mutilating

injuries of hand, 5–6, 8–9, 135

used as ‘‘spare parts’’ in mutilating injuries,

79, 83–85

Bone(s), healing of, following mutilating injuries

of hand, 135–136

secondary procedures on, in mutilating

injuries, 150, 151


79, 83–85

C

Child(ren), hand injuries in, types of, 121

mutilating injuries in, 1, 2, 46–47, 121–132

passive hand prostheses for, 186

Cross hand transfer, for replantation in

mutilating injuries, 103

D

Desensitization, to treat scar hypersensitivity, 138

Digit(s). See also Finger(s); Thumb.

fusion of, biomechanical of, 24–26

loss of, 23–24

motion of, improvement following mutilating

injuries, 156–157

salvaging of, in mutilating injuries, 6, 13

E

Edema, control of, after mutilating injuries of

hand, 137

Electric hand, for myoelectric prosthesis, 188,

189–190, 191

Electric hook, on wrist level disarticulation

prosthesis, 187, 189, 190

Emergency room, management of mutilated

hand in, 51

Exercise(s), protective motion, following

replantation in mutilating injuries, 143–145

F

Finger(s), as composite tissue transfer in

mutilating injuries, 79, 85

for use in mutilating injuries, 75

fusion of, 24–25

index, importance of, 22

ray, elective loss of, 22–23

individual, functional contribution of, 1

long and ring, central ray deletion in, 23

multiple, amputation of, toe transplantation

for, 169–171, 173

multiple replantation of, in mutilated hand,

102, 109–111

passive prosthesis for, 180–181

permanent impairment of, evaluation of, 2

reconstruction of, toe-to-hand transplantation

for, 169–171, 172

single, amputation of, toe transplantation for,

169, 172

small, flexion by, 23

Finger fillet flap, lengthening of, 76

Fingertip, ‘‘cap’’ composite graft, in mutilating

injuries, 74, 75–78


doi:10.1016/S0749-0712(03)00020-9

Hand Clin 19 (2003) 205–209

Foot (Foot), surgical anatomy of, toe-to-hand

transplantation and, 167

Forearm, hand and, as source of reusable parts

in mutilating injuries, 80–81, 85–86

Fracture(s), complex, in mutilated hand, 53

in mutilated hand, amputation in, 54

cases illustrating, 54–57, 58, 59

management of, 5, 7–8, 52

rehabilitation following, 57–59

repair and reconstruction in, 53–54

treatment of, and revascularization in, 52

in mutilating injuries of hand, rehabilitation

following, 138–140

simple, in mutilated hand, 52–53

Free flaps, in mutilating hand injuries,

142–143

G

Grasp, power, 18, 19

span, 18, 19

Grip, directional, 18

hook, 18, 19

H

Hand, and forearm, as source of reusable parts

in mutilating injuries, 80–81, 85–86

cross transfer of, for replantation in


electric, for myoelectric prosthesis, 188,

189–190, 191

essentials for, 17

injuries of, in children, types of, 121

metacarpal, reconstruction of, toe

transplantation in, 171, 174

mutilating injuries of. See Mutilating injuries.

partial, passive prosthesis for, 180–181

prehension of, 17

prostheses for. See Prosthesis(es).

replants from, for replantation in mutilating

injuries, 103, 113, 114

seven basic maneuvers of, 17–18

trauma to, biomechanics and, 17–31

classification of, 19

Hook, electric, on wrist level disarticulation

prosthesis, 187, 189, 190

I

Infection, as cause of loss of salvaged limb, 196

Injuries, mutilating. See Mutilating injuries.

Ischemia, in mutilating injuries, functional

outcome and, 198

J

Joints, secondary procedures on, in mutilating

injuries, 156–159

stiffness of, treatment following mutilating

injuries, 140, 141


79, 83–85

L

Limb, survival of, and limb function, 195–196

M

Malunion/nonunion, in mutilating injuries,

secondary procedures in, 150, 151

Mutilating injuries, antimicrobial management of,

33–39

bacteriology of, 33–34

bones, tendons, nerves, vessels, and joints

used in, 79, 83–85

‘‘cap’’ composite tip graft in, 74, 75–78

complex, management of, 6–9, 10–13, 14

crush, outcomes after, 196

debridement and irrigation in, 4–5

electrical, outcomes after, 196, 197

emergency room management of, 51

etiology of, 51, 63

finger as composite tissue transfer in, 79, 85

finger for use in, 75

fracture fixation in. See Fracture(s), in

mutilated hand.

hand and forearm as source of reusable parts

in, 80–81, 85–86

healthy adjustment of, promotion of, 43–44

history taking in, 1–3

in children, 1, 2, 46–47, 121–132

delayed treatment of, 128–130, 131

initial management and preoperative

evaluation in, 121–124

operative procedure in, 124–125

replantation and revascularization in,

125–126

soft tissue coverage in, 126–131

initial surgery of, 52

injury-related issues in, 41–42

limb of hand salvage in, factors influencing,

194–195

management of, and principles of, 1–15

factors influencing, 63

immediate, 1, 2, 3, 4–5

206 Index / Hand Clin 19 (2003) 205–209

reconstructive algorithms in, 63–65

outcomes after, 193–204

age as influence on, 198

assessment of, 199

clinical outcomes, 195–200

factors influencing, 193, 196–197

goals of, 195

objective assessment of, 201–202

outcomes research on, 201

salvage of function and, 193, 194

scoring systems for, 200–201

treatment views and, 195

outcomes in, 51

pain in, 45–46

patient evaluation in, 73–75

perionychium for reconstruction in, 75, 78–80

physical examination in, 3–4

principles of, and management of, 1–15

psychological aspects of, 41–49

psychological intervention strategies in, 44–45

psychological responses to, 42–43

rehabilitation process for, 133

replantation in. See Replantation,

in mutilated hand.

secondary procedures following, 149–163

early care influencing, 150

involving nerves, 155–156

on bone, 150, 151

on joints and tendons, 156–159

on soft tissue, 151–152

on thumb, 159–161

requirements for hand function

and, 13, 150

to release scar, 152–155

skin harvesting in, 76–78, 80–83

soft tissue coverage in. See Soft tissue

coverage, in mutilating injuries.

special issues in, 45–47

stabilization of patient in, 1

therapy following, 133–148

early phase(protective), 133–134

healing process and, 134–136

intermediate phase(mobilization), 134

late phase(strengthening), 134

use of ‘‘spare parts’’ in, 73–87

N

Nerve(s), delayed repair of, following mutilating

injuries, 5, 9, 155–156

healing of, following mutilating injuries of

hand, 135

protection of, following mutilating injuries of

hand, 137–138


injuries, 155–156


79, 83–85

Neuroma, management of, following mutilating

injuries, 156

O

Osteomyelitis, following mutilating injuries,

150–151

Osteosynthesis, in replantation in mutilated hand,

96, 98

P

Pain, in mutilating injuries, 45–46

Pedicle flaps, in mutilating hand injuries, 142

Perionychium, reconstruction of, in mutilating

injuries, 75, 78–80

Phalanx, proximal, passive prosthesis for, 183

Pinch, key, 18

oppositional, 17–18

precision, 17

Position tolerance, gravity-dependent, after

mutilating injuries of hand, 137

Prosthesis(es), active, 13, 185–191

patient acceptance of, 186–188

fabrication of, 187, 189, 190

flexible silicone sleeve of, 189, 191

passive, 177–183

candidates for, 177, 178

distal phalanx, 183

finger, 183

for child, 186

goals and expectations for, 13, 177–178, 179

master plan for treatment using, 179

middle phalanx, 183

new material and technology for, 180

partial hand, 180–181

proximal phalanx, 183

thumb for, 181–183

types of, 179–183

suspension on limb, 189, 190–191

transcarpal level, with electric hand, 188,

189–190, 191

voluntary closing grasping device on, 190, 191

wrist level disarticulation, electric hook on,

187, 189, 190

with semi-flexible inner socket, 188, 191

207Index / Hand Clin 19 (2003) 205–209

R

Rehabilitation, following fractures in mutilated

hand, 57–59

following mutilating injuries, 133, 138–141,

142

following toe-to-hand transplantation,

171–172

Replantation, in mutilated hand, 89–119

care of amputed part for, 91, 94

debridement and labeling for, 92–94, 96

hand replants in, 103, 113, 114

history of, 89, 90, 91, 92

indications for, 89–91, 92, 93

issues in, 47

multiple finger replantation for, 102,

109–111

operative considerations for, 92–100, 101,

102, 103, 104

osteosynthesis techniques for, 96, 98

outcomes following, 107, 199

postoperative care following, 103–105

preoperative considerations for, 91–92,

94, 95

protective motion exercises following,

143–145

repair of volar structures for, 98–100, 101,

104, 105

special considerations for, 100–107

tendon repair for, 98, 99, 100

thumb replants for, 100–102, 105–109

upper extremity replants for, 102–103,

111–112

S

Scar, management of, after mutilating injuries

of hand, 137

palmar contracture, following crush injury,

management of, 153–156

release of, in mutilating injuries, 152–155

web contracture, following crush injury,

management of, 152, 153, 154

Skin, harvesting of, in mutilating injuries, 76–78,

80–83

therapy of, following mutilating injuries of

hand, 134–135

Skin flaps, for reconstruction of mutilated hand,

65–67

Soft tissue, damage to, in mutilating injuries,

197


injuries, 151–152

Soft tissue coverage, in mutilating injuries, 63–71

assessments for, 4, 6–7

cases illustrating, 67–69, 70

distant flaps for, 65–66

free flaps for, 66–67

in children, 126–131

local flaps for, 65

regional flaps for, 65

of mutilating injuries, 142–143

Splints, traction, in fractures in mutilating

injuries, 138, 140

Superficialis tendon, for reconstruction

of thumb, 21

T

Tendon(s), extensor, injuries of, 27

flexor, loss of function of, 28

healing of, following mutilating injuries of

hand, 135

loss of, and hand function, 26–28

repair of, for replantation in mutilated hand,

98, 99, 100


injuries, 156–159

secondary reconstruction of, following


used as ‘‘spare parts’’ in mutilating injuries, 9,

79, 83–85

Tenolysis, following mutilating injuries, 157–159

Thumb, for passive prosthesis, 181–183

functional importance of, 1, 19–20

level five injuries of, 21–22

level four injuries of, 21

level three injuries of, 20–21

reconstruction of, priorities of, 20

toe-to-hand transplantation for, 167

replants for, in mutilated hand, 100–102,

105–109

secondary reconstruction of, in mutilating

injuries, 159–161

Toe-to-hand transplantation, 165–175, 194

for finger reconstruction, 169–171, 172

for thumb reconstruction, 167

great toe wraparound flap, 168

harvesting of toe for, 166

in mutilating injuries, motion program

following, 145–146

insetting of transplants in, 167

intraoperative and postoperative

complications of, 172–174

late complications of, 174–175

208 Index / Hand Clin 19 (2003) 205–209

postoperative management for, 171

preparation for, 165

recipient site preparation for, 166–167

rehabilitation following, 171–172

second toe transplantation for, 168–169, 171

surgical anatomy of foot and, 166

timing of, 165

total great toe transplantation in, 167

trimmed great toe transplantation in, 167–168

U

Upper extremity(ies), mutilated, replantation in,

replants for, 102–103, 111–112

mutilating injuries of, use of ‘‘spare parts’’ in,

73–87

trauma to, antibiotics in,

34–36

side effects of, 37

W

Wound care, after mutilating injuries of hand,

136–137

Wrist, functional motion of, requirements for, 25

fusion of, 25–26

limited fusions of, 25–26

209Index / Hand Clin 19 (2003) 205–209

Documents

Mutilating Hand Injuries, Hand Clinics, Volume 19, Issue 1, Pages 1-210 (February 2003)