Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

References
Lee, DH, Dickson, KF, Bradley, EL. The incidence of wrist interosseous ligament and triangular fibrocartilage articular disc disruptions: a
cadaveric study. J Hand Surg Am. 2004;29(4):676-684.
Berger, RA. The ligaments of the wrist: a current overview of anatomy with considerations of their potential functions. Hand Clin.
1997;13(1):63-82.In this article, the author carefully describes the extrinsic and intrinsic ligaments of the wrist and details the functional implications
of injury. This is one of the first comprehensive descriptions of the wrist soft-tissue anatomy and continues to be used as a guide for future publications.
Bourne, MH, Linscheid, RL, Dobyns, JH. Concomitant scapholunate dissociation and Kienbock’s disease. J Hand Surg Am. 1991;16(3):460-464.
Chang, IY, Mutnal, A, Evans, PJ, Sundaram, M. Kienbock’s disease and scapholunate advanced collapse. Orthopedics. 2014;37(9):578, 637-579.
Muramatsu, K, Ihara, K, Tanaka, H, Kawai, S. Carpal instability in rheumatoid wrists. Rheumatol Int. 2004;24(1):34-36.
Mayfield, JK. Wrist ligamentous anatomy and pathogenesis of carpal instability. Orthop Clin North Am. 1984;15(2):209-216.This is the original
publication in which Mayfield describes the progression of bony and ligamentous injury around the lunate. He describes the predictable pattern of
instability that usually begins on the radial side of the wrist and progresses to complete lunate dislocation. This seminal work should be appreciated as it
remains essential in understanding the spectrum of perilunate pathology.
Geissler, WB. Arthroscopic management of scapholunate instability. J Wrist Surg. 2013;2(2):129-135.
Lee, SK, Desai, H, Silver, B, et al. Comparison of radiographic stress views for scapholunate dynamic instability in a cadaver model. J Hand
Surg Am. 2011;36(7):1149-1157.
Whipple, TL. The role of arthroscopy in the treatment of wrist injuries in the athlete. Clin Sports Med. 1998;17(3):623-634.
Whipple, TL. The role of arthroscopy in the treatment of scapholunate instability. Hand Clin. 1995;11(1):37-40.
Linscheid, RL, Dobyns, JH. Treatment of scapholunate dissociation: rotatory subluxation of the scaphoid. Hand Clin. 1992;8(4):645-652.
Walsh, JJ, Berger, RA, Cooney, WP. Current status of scapholunate interosseous ligament injuries. J Am Acad Orthop Surg. 2002;10(1):32-42.
Harvey, EJ, Berger, RA, Osterman, AL, et al. Bone-tissue-bone repairs for scapholunate dissociation. J Hand Surg Am. 2007;32(2):256-264.
Harvey, EJ, Sen, M, Martineau, P. A vascularized technique for bone-tissue-bone repair in scapholunate dissociation. Tech Hand Up Extrem
Surg. 2006;10(3):166-172.
Shin, SS, Moore, DC, McGovern, RD, Weiss, AP. Scapholunate ligament reconstruction using a bone-retinaculum-bone autograft: a
biomechanic and histologic study. J Hand Surg Am. 1998;23(2):216-221.
Brunelli, GA, Brunelli, GR. A new technique to correct carpal instability with scaphoid rotary subluxation: a preliminary report. J Hand Surg
Am. 1995;20(3 Pt 2):
 S82-S85.This article covers what has become the reference standard in the reconstruction of SL with associated static deformity.
The authors elegantly describe their technique of using the FCR tendon to correct the flexed posture of the scaphoid while simultaneously reconstructing
the dorsal SL ligament. This procedure and its associated outcomes has become the benchmark by which all SL reconstructive procedures are compared.
Garcia-Elias, M, Lluch, AL, Stanley, JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical
technique. J Hand Surg Am. 2006;31(1):125-134.
Chabas, JF, Gay, A, Valenti, D, et al. Results of the modified Brunelli tenodesis for treatment of scapholunate instability: a retrospective study
of 19 patients. J Hand Surg Am. 2008;33(9):1469-1477.
Nienstedt, F. Treatment of static scapholunate instability with modified Brunelli tenodesis: results over 10 years. J Hand Surg Am.
2013;38A:887-892.
Rahgozar, P, Zhong, L, Chung, KC. A comparative analysis of resource utilization between proximal row carpectomy and partial wrist
fusion: a population study. 
 J Hand Surg Am. 2017;42(10):773-780.
Linscheid, RL, Dobyns, JH. Athletic injuries of the wrist. Clin Orthop Relat Res. 1985;(198):141-151.
Reagan, DS, Linscheid, RL, Dobyns, JH. Lunotriquetral sprains. J Hand Surg Am. 1984;9(4):502-514.
Kleinman, WB. Physical examination of the wrist: useful provocative maneuvers. J Hand Surg Am. 2015;40(7):1486-1500.
Beckenbaugh, RD. Accurate evaluation and management of the painful wrist following injury. An approach to carpal instability. Orthop Clin
North Am. 1984;15(2):289-306.
Mikic, ZD. Arthrography of the wrist joint: an experimental study. J Bone Joint Surg Am. 1984;66(3):371-378.
Trentham, DE, Hamm, RL, Masi, AT. Wrist arthrography: review and comparison of normals, rheumatoid arthritis and gout patients. Semin
Arthritis Rheum. 1975;5(2):105-120.
Viegas, SF, Patterson, RM, Hokanson, JA, Davis, J. Wrist anatomy: incidence, distribution, and correlation of anatomic variations, tears, and
arthrosis. J Hand Surg Am. 1993;18(3):463-475.
Cantor, RM, Stern, PJ, Wyrick, JD, Michaels, SE. The relevance of ligament tears or perforations in the diagnosis of wrist pain: an
arthrographic study. J Hand Surg Am. 1994;19A(6):945-953.
Weiss, LE, Taras, JS, Sweet, S, Osterman, AL. Lunotriquetral injuries in the athlete. Hand Clin. 2000;16(3):433-438.
Osterman, AL, Seidman, GD. The role of arthroscopy in the treatment of lunatotriquetral ligament injuries. Hand Clin. 1995;11(1):41-50.
Gilula, LA, Weeks, PM. Post-traumatic ligamentous instability of the wrist joint. Vestn Rentgenol Radiol. 1993;(2):16-26.
Michelotti, BF, Chung, KC. Diagnostic wrist arthroscopy. Hand Clin. 2017;33(4):571-583.
Weiss, AP, Sachar, K, Glowacki, KA. Arthroscopic debridement alone for intercarpal ligament tears. J Hand Surg Am. 1997;22(2):344-349.
Shin, AY, Weinstein, LP, Berger, RA, Bishop, AT. Treatment of isolated injuries of the lunotriquetral ligament: a comparison of arthrodesis,
ligament reconstruction and ligament repair. J Bone Joint Surg Br. 2001;83(7):1023-1028.
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Shahane, SA, Trail, IA, Takwale, VJ, et al. Tenodesis of the extensor carpi ulnaris for chronic, post-traumatic lunotriquetral instability. J Bone
Joint Surg Br. 2005;87B:1512-1515.
Sennwald, GR, Fischer, M, Mondi, P. Lunotriquetral arthrodesis: a controversial procedure. J Hand Surg Br. 1995;20(6):755-760.
Wagner, ER, Elhassan, BT, Rizzo, M. Diagnosis and treatment of chronic lunotriquetral ligament injuries. Hand Clin. 2015;31(3):477-486.
Herzberg, G, Comtet, JJ, Linscheid, RL, et al. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am.
1993;18(5):768-779.
Trumble, T, Verheyden, J. Treatment of isolated perilunate and lunate dislocations with combined dorsal and volar approach and
intraosseous cerclage wire. J Hand Surg Am. 2004;29(3):412-417.
Gilula, LA. Carpal injuries: analytic approach and case exercises. Am J Roentgenol. 1979;133(3):503-517.
Gilula, LA, Destouet, JM, Weeks, PM, et al. Roentgenographic diagnosis of the painful wrist. Clin Orthop Relat Res. 1984;(187):52-64.
Jasmine, MS, Packer, JW, Edwards, GS Jr. Irreducible trans-scaphoid perilunate dislocation. J Hand Surg Am. 1988;13(2):212-215.
Linscheid, RL, Dobyns, JH, Beabout, JW, Bryan, RS. Traumatic instability of the wrist: diagnosis, classification, and pathomechanics. J Bone
Joint Surg Am. 1972;54(8):1612-1632.
Melone, CP, Murphy, MS, Raskin, KB. Perilunate injuries: repair by dual dorsal and volar approaches. Hand Clin. 2000;16(3):439.
Blazar, PE, Murray, P. Treatment of perilunate dislocations by combined dorsal and palmar approaches. Tech Hand Up Extrem Surg.
2001;5(1):2-7.
Sotereanos, DG, Mitsionis, GJ, Giannakopoulos, PN, et al. Perilunate dislocation and fracture dislocation: a critical analysis of the volar-
dorsal approach. J Hand Surg Am. 1997;22(1):49-56.
Hildebrand, KA, Ross, DC, Patterson, SD, et al. Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and
radiographic evaluation. J Hand Surg Am. 2000;25:1069-1079.
Knoll, VD, Allan, C, Trumble, TE. Trans-scaphoid perilunate fracture dislocations: results of screw fixation of the scaphoid and lunotriquetral
repair with a dorsal approach. J Hand Surg Am. 2005;30(6):1145-1152.
Geissler, WB, Fernandez, DL, Lamey, DM. Distal radioulnar joint injuries associated with fractures of the distal radius. Clin Orthop Relat Res.
1996;(327):135-146.
Lindau, T, Adlercreutz, C, Aspenberg, P. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after
distal radial fractures. J Hand Surg Am. 2000;25(3):464-468.
Palmer, AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am. 1989;14(4):594-606.
Corso, SJ, Savoie, FH, Geissler, WB, et al. Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: a
multicenter study. Arthroscopy. 1997;13(1):78-84.
Anderson, ML, Larson, AN, Moran, SL, et al. Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex
tears. J Hand Surg Am. 2008;33(5):675-682.
Seo, JB, Kim, JP, Yi, HS, Park, KH. The outcomes of arthroscopic repair versus debridement for chronic unstable triangular fibrocartilage
complex tears in patients undergoing ulnar-shortening osteotomy. J Hand Surg Am. 2016;41(5):615-623.
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C H A P T E R 8 2
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Management of Mutilating Upper Extremity
Injuries
Jessica I. Billig and Kevin C. Chung
Key Points
Owing to the severe nature of these injuries, management begins with Advanced Trauma Life
Support.
Important decision-making regarding limb salvage versus amputation is essential.
Systematic evaluation of the injury and damaged part facilitates treatment.
Principles of operative treatment include debridement, possible vascular shunting, skeletal fixation,
revascularization, tendon/muscle repair, nerve repair, soft-tissue reconstruction.
The use of spare parts can deliver a satisfactory functional outcome.
Mutilating trauma to the upper extremity are devastating injuries with complex fracture patterns,
substantial soft-tissue deficits, questionable neurovascular viability of the extremity, and possible
additional injuries to other parts of the body. Treatment of these injuries is challenging and requires a
thorough debridement and often needs creative reconstructive techniques. However, the treating surgeon
and physician must adhere to Advanced Trauma Life Support (ATLS) before treatment of these injuries.
All patients with mangled upper extremities should be evaluated as trauma patients because they may
have additional devastating injuries. Furthermore, major upper extremity injuries may be life-
threatening, and one must often choose life over limb.
Once the patient has been cleared from a trauma standpoint, a thorough evaluation of the upper
extremity is essential to catalog all of the injured structures (Figure 82.1). Operative principles include the
following:
Complete debridement
Restoration of blood flood with possible shunting
Skeletal fixation
Muscle and tendon repair
Arterial and venous repair
Nerve repair
Soft-tissue coverage
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FIGURE 82.1 Initial evaluation in the emergency department of a 63-year-old woman with extensive left forearm crush injury of
her forearm and hand after an auger injury.
The surgeons should strive to complete the reconstruction in a one-staged approach if possible, unless the
wound is so contaminated that it requires multiple debridements. However, with experience in radical
debridement, the surgeon can transform a dirty wound into a relatively clean wound. After the initial
debridement, we recommend another debridement within 48 to 72 hours to prepare the wound for
coverage at the second operation.
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Evaluation
The principles of ATLS must be strictly followed. Management begins with the primary survey and the
ABCs (airway, breathing, circulation). The surgeon must not become distracted by the devastating upper
extremity injury and miss other life-threatening injuries. Tourniquets can be used to help control massive
hemorrhage and have been shown to improve survival. 1 However, one should also be aware of possible
nerve injury with prolonged tourniquet usage, and tourniquets should be released every 2 hours for
blood flow to the distal extremity. Blind clamping of vessels is inappropriate, as other surrounding
structures may get injured in the process. A secondary survey according to ATLS should be performed
quickly and efficiently to uncover any additional injuries. Resuscitation and stabilization of the patient
must be performed before treating the mangled upper extremity.
The decision for limb salvage versus amputation is complex. Although difficult to predict, surgeons must
determine the functional outcomes of amputation compared with limb salvage. Unlike in the lower
extremity where amputation is more tolerable, amputation proximal to the fingers is disabling. The
surgeon should always strive for salvage rather than amputation for the upper limb. Patient factors such
as age and health status play a critical role in this decision-making process. If the patient is lucid, a
thorough history of the incident should be obtained. Important medical information including comorbid
medical diseases, occupation, smoking status, hand dominance, and a recount of the injury are beneficial
in devising a reconstructive surgical plan. The ultimate decision to attempt limb salvage requires a full
evaluation of the patient and the circumstances surrounding the injury. Criteria for considering
amputation include the following 2 :
Open fractures with large soft-tissue defect
Warm ischemia time longer than 6 hours with muscle involvement
Proximal major nerve injury (e.g., brachial plexus involvement)
Unstable patient
Older patient
Associated major organ trauma
Comorbid medical problems with increased risk with prolonged anesthesia (e.g., myocardial
infarction, stroke)
When considering limb amputation, current upper extremity prosthetics lack the ability to replicate the
functionality and sensibility of the human hand. Even with recent advances in the field, many patients
continue to abandon their prosthetics because of limited dexterity 3 ; therefore, future prosthetic use must
be weighed in the decision for amputation. Furthermore, primary amputation is more beneficial from a
functionality standpoint compared with a failed reconstruction attempt. Finally, a surgeon’s experience
plays a role in the decision to pursue limb salvage or amputation. 4
Currently, there are no validated scoring systems to predict upper extremity amputations after mutilating
injuries. Some surgeons have extrapolated the Mangled Extremity Severity Score, which is used for lower
extremity injuries, to guide management of these mutilating upper extremity injuries. However, in the
lower extremity, a Mangled Extremity Severity Score of seven or higher has been used as a cutoff to
perform amputation, but this has not been validated in the upper extremity. 5 Given the lack of robust
data surrounding when to amputate, the surgeon must treat patients and each injury individually.
If amputation in the field has occurred, the appropriate transfer of the amputated part includes wrapping
in a protective dressing, such as saline-soaked gauze, and placing the part on ice (Figure 82.2). One
should not place the amputated part directly on ice to avoid freezing of the tissues and frostbite injury.
Traditionally accepted ischemia time is 6 hours for a warm extremity, 12 hours for a cold extremity,
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12 hours for a warm digit, and 24 hours for a cold digit. However, the traditionally accepted digit
ischemia times have been challenged by multiple surgeons with successful replantations at longer
ischemic intervals. 6,7 As compared with digits, upper extremities have shorter ischemia times because of
degradation of deoxygenized muscle. In patients with amputations of the upper extremity, functional
outcomes are substantially worse than digit replantation. However, transhumeral replantation should be
attempted to preserve the elbow, which greatly impacts function and prosthetic use. 8 Additionally, in a
study by Atzei et al., the objective long-term results from proximal forearm amputations were poor, but
patients found the replanted extremity useful for activities of daily living and were satisfied with their
surgical outcome. 9 This highlights the importance of an individualized approach to mutilating upper
extremity injuries and amputations.
FIGURE 82.2 This 19-year-old suffered a saw amputation at the level of distal third of the forearm. The part was placed in
gauze and on ice for transport.
Prior to going to the operating room, it is preferable to perform a thorough evaluation of the injured
extremity. However, this may be impossible in the trauma bay due to pain or other distracting injuries.
Nonetheless, the vascularity of the extremity must be assessed immediately, and radiographic
examination can easily be performed without wasting time. 10 Splinting of the extremity can be carried
out quickly and efficiently. Tetanus prophylaxis should be updated in all patients according to previous
immunization status. If the patient presents with an open fracture, early antibiotic administration
targeted against gram-negative and gram-positive organisms has been shown to reduce infection rate. 11
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Operative Treatment
Debridement
Adequate wound debridement is the foundation of treatment of mutilating upper extremity injuries.
Debridement may be performed in the immediate or delayed setting depending on the stability of the
patient and availability of a reconstructive surgeon. 12 If the patient is stable, early aggressive
debridement should be performed in the operating room (Figure 82.3). Meticulous debridement using
fresh sharp knife blades removes bacteria, foreign bodies, and nonviable tissue. It also facilitates a
thorough inspection of the wound and cataloging of all injured entities. We prefer a staged approach to
debridement. Early debridement is performed at the time of presentation and then another debridement
is performed within a few days in conjunction with definitive reconstruction. The first debridement
removes necrotic tissue and infectious burden, permitting adequate time for demarcation of nonviable
tissues. 10
FIGURE 82.3 Operative debridement was performed to remove all nonviable tissue and decrease the infectious burden. The
yellow arrow is pointing at the ulna, and the blue arrow indicates the radius.
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Temporary Shunting
With mutilating upper extremity injuries, the vascular status of the extremity is exceedingly important.
Presence of a peripheral pulse may not exclude impending arterial compromise. Signs and symptoms of
vascular compromise include the following 13 :
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Definitive Signs of Vascular Injury
Pulselessness
Pallor
Massive hemorrhage
Rapidly expanding hematoma
Palpable thrill/audible bruit
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Suggestions of Vascular Injury
History of bleeding in transit
Proximity-related injury
Neurologic injury of known nerve adjacent to a large artery
Hematoma over a known large artery
Pain
Paresthesia
Paralysis
Doppler ultrasound can be used as an adjunct tool in the trauma bay and has an accuracy of
approximately 98% in diagnosing vascular compromise. 13 If the patient is stable, preoperative
angiography may provide vital data regarding their vascular status. Criteria for angiography in upper
extremity injury include the following 15 :
Exclusion of vascular injury in absence of clinical signs of definitive vascular injury
When not evident on physical examination:
Determination of level of injury
Determination of extent of injury
Determination of nature of injury
If there is any concern for vascular compromise, however, delaying surgical intervention with upper
extremity angiography is inappropriate because the vascular injury will be apparent upon exploration.
When muscles are injured, ischemia time of greater than 6 hours may lead to irreversible myocyte
damage and subsequent ischemia reperfusion injury. Ischemia reperfusion injury is associated with
decreased viability of the extremity, multiple organ failure syndrome, and acute respiratory distress
syndrome. 14
After debridement, controversy exists regarding the most important next step in surgical management.
Most surgeons will perform vascular repair to restore circulation prior to any skeletal fixation. However,
some argue that skeletal fixation should be performed prior to vascular repair as it may stabilize the limb
and protect the vascular repair. 15 In such cases, temporary shunting is commonly used to minimize the
overall ischemia time and reduce postoperative complications. Shunting has been associated with
maintenance of tissue viability, thus enhancing the functional outcome of the patient. 16,17 Temporary
shunting is commonly performed prior to skeletal fixation and can reestablish arterial flow, mitigating
the long-term sequelae of ischemia reperfusion injury.
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Skeletal Fixation
Fractures associated with mutilated upper extremity injuries are often comminuted, unstable, and may
have bony loss. These fractures are usually open and highly contaminated. Surgeons must decide
appropriate fracture fixation with functional recovery in mind. Identification of salvageable components
marks the initial step in fracture fixation. 18 This will help determine which type of fixation to use.
Treatment of mutilating upper extremity skeletal injuries is technically challenging. The presentation of
the injury including degree of displacement and ability to maintain fracture reduction plays a substantial
role in surgical management. Duncan et al. investigated complications after open hand fractures and
found that final postoperative range of motion was influenced by severity of soft-tissue injury; more
extensive soft-tissue injuries were associated with higher infection and amputation rates, thus
highlighting the difficulties with providing a good functional outcome in mutilating upper extremity
injuries. 19
Typical fixation used for skeletal stability includes Kirschner wires (K-wires), screw and plate fixation,
and external fixators. The most common fixation method in mutilated hand injuries are wires or pins
because of the relative ease in placement and universal availability. 20 However, K-wires and pins do not
provide strong fracture stability, and patients should not perform early postoperative aggressive range of
motion. Many surgeons advocate the use of crossed K-wires to improve rigidity especially in hand
injuries. 18 Plate and screw fixation is another method commonly used, specifically in mutilated injuries
involving the forearm (Figure 82.4). Plating systems require wide undermining of the periosteum for
appropriate exposure and placement, which may compromise the vascular supply to the bone. However,
plates and screw provide rigid fixation for earlier mobilization. Finally, in severely comminuted,
contaminated, and open fractures, external fixators can be used for immediate fracture stabilization.
External fixators are generally applied in severely contaminated wounds, until such time when more
definitive fixation can be performed after wound debridement. They can be placed easily with minimal
devitalization of bony fragments. No matter what fixation method is chosen, the ultimate goals are
initiation of range of motion to provide improved function and minimization of soft tissue stripping to
achieve bony healing and union of the fracture.
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FIGURE 82.4 Same patient as in Figure 82.2. A, B. Thenar, hypothenar, carpal tunnel, and dorsal fasciotomies of the hand
were performed. C. The radius and ulna were fixated using plates and screws.
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Tendon and Muscle Repair
Appropriate identification of both proximal and distal musculotendinous units facilitates repair. Given
the extensive damage associated with these injuries, it is often impossible to repair all musculotendinous
units. In situations with loss of proximal musculotendinous units, Faibisoff et al. advocate repairing the
distal tendons to other available tendons/muscles proximally. 21 However, surgeons must consider
synergy when performing tendon repairs between divergent proximal and distal musculotendinous
units. Primary repair of the musculotendinous unit is ideal; however, utilization of tendon grafts or
delayed repair with secondary tendon reconstruction may be necessary. Commonly used donors for
tendon grafts include palmaris longus, plantaris, toe extensors, or spare parts from other tendons in the
injured extremity.
Flexor tendon repairs are often challenging and require precise surgical technique. When performing a
flexor tendon repair, the strength of the repair will determine early range of motion and the ultimate
functional outcome. For optimal flexor tendon repair, multistrand core suture repair techniques should be
prioritized to reduce gapping and tendon rupture. 22 In addition to a multistrand core suture repair, the
use of an epitendinous suture provides a more robust repair and use of early range of motion protocols. 23
Surgeons should strive to use this technique in all flexor tendon repairs in the mutilated upper extremity
to prevent tendon rupture and promote better functional outcomes. However, when there are multiple
tendons lacerated in zone 5, the tedious epitendinous sutures are often not performed to expedite the
surgical sequence because of the relative lack of restrictive adhesion formation in this zone.
Pulley reconstruction in mutilating upper extremity injuries should be performed if multiple digits are
involved. 24 Preservation of A2 and A4 pulleys avoids bowstringing and promotes appropriate tendon
gliding. Primary pulley repair should be attempted, but if primary repair cannot be done, reconstruction
with tendon grafts wrapped around the phalanx or attached to available remnant pulleys can be
performed. Appropriate repair of tendons in these complex injuries will promote optimal function and
increased range of motion.
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Vascular Repair
Vascular reconstruction involves both the arterial and venous system. When assessing the degree of
vascular injury, it is important to debride the artery and vein to outside of the zone of injury. The ribbon
sign has been used to identify areas of arterial vessel wall avulsion and intimal injury and confers a poor
prognosis for replantation. 25 Areas with the ribbon sign should be debrided both proximally and distally,
and the gap created should be bridged by a vein graft. Without appropriate debridement, vascular
anastomosis will fail. For microsurgical success, Buncke et al. recommended anastomosis of the vessel
walls without tension, atraumatic surgical treatment of the vasculature, precise suture placement without
trapping the adventitia, and prevention of suture crowding. 26
If possible, primary anastomosis should be attempted, and in upper extremity injuries, both the radial
and ulnar artery should be repaired. If primary anastomosis cannot be accomplished, however, vein
grafting should be used to optimize successful repair. Commonly used vein grafts include veins or
branches of veins from the dorsal or volar forearm such as the basilic or cephalic vein or the saphenous
vein from the lower extremity (used as a reverse saphenous vein graft). Veins from the upper extremity
can only be utilized when small segments of graft are required. For more extensive vascular
reconstruction, such as the palmar arch, surgeons must use creative and complex reconstructive
techniques. To reconstruct the palmar arch, a Y-vein graft from the volar forearm is used to perform end-
to-end anastomoses to reconstruct multiple common digital arteries concurrently (Figure 82.5).
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FIGURE 82.5 A. A Y-vein graft was used to reconstruct the palmar arch of a 36-year-old man who sustained a crush injury to
his right upper extremity. B. The arrow indicates the Y-vein graft in situ.
With severe crush injuries, revascularization is substantially more difficult. Severely crushed or mangled
extremities portend a poorer prognosis with associated vascular compromise. 27 In these injuries, vessels
may be damaged beyond the zone of injury and require an extensive debridement. Surgeons must be
aware of the degree of vessel injury to optimize successful revascularization.
Venous reconstruction is challenging in the digits, and surgeons should strive for at least one venous
repair or more if possible to avoid venous complications. Thrombosis of the repair leads to venous
congestion and ultimately replantation and revascularization failure. When faced with venous
congestion, surgeons utilize adjunct treatments such as medical leeches and anticoagulation. Every upper
extremity surgeon must be equipped with microsurgical skills to optimize vascular repairs and ultimate
survival in mutilating upper extremity injuries.
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Nerve Repair
In mutilating upper extremity injuries, nerves can be damaged extensively and often have traction or
crush injuries. For restoration of sensibility and function, direct end-to-end nerve repair without tension
is the primary goal. However, with complex upper extremity trauma, direct repair may not be feasible.
Again, surgeons must ensure that an adequate debridement has been performed, and this includes
debridement of crushed and avulsed nerves until healthy fascicles are present. This will provide the ideal
environment for return of function and sensibility. Additionally, it is preferable to perform the nerve
repair outside the zone of injury to ensure success. Once a thorough debridement has been performed,
the nerves are aligned according to their fascicular pattern and coapted using an epineural repair using
microsurgical techniques.
If primary repair has undue tension, surgeons can use interposition autogenous nerve grafts, nerve
conduits, or processed nerve allografts to bridge the gap. Primary nerve grafting with interposition
autografts from the upper and lower extremity provides viable nerve cells including Schwann cells,
which may aid in nerve regeneration. 28,29 Commonly used donor nerves include the medial or lateral
antebrachial cutaneous, sural, and posterior interosseous nerve. Cutaneous nerves of the forearm can be
easily harvested for grafting. With more extensive injuries, the sural nerve from the lower extremity
offers additional grafting material.
Use of autologous nerve grafts is the standard for nerve repairs; however, there are specific instances
when nerve conduits or processed nerve allografts are valuable. Given the finite amount of autologous
nerve grafts available, in cases with extensive nerve injuries, some surgeons may choose to use conduits
or nerve allografts. These nerve substitutes do not require additional donor sites and are available off the
shelf. Indications for the use of conduits include nerve gaps of less than 3 cm, nerves that are of small
diameter, and noncritical, typically sensory nerves. 30,31 Nerve conduits have been shown to provide
sensory recovery but are inferior to autologous nerve grafting for motor regeneration. 32
Processed nerve allografts have shown promise in digital nerve repair and are now commercially
available. Rinker et al. showed equivalent sensory outcomes for processed nerve allografts when
compared with nerve autografts, and they had superior sensory outcomes when compared with nerve
conduits. 33 For motor recovery, there are better motor functional outcomes when 5 to 50 mm processed
nerve allografts are used. 34 In specific instances, nerve substitutes such as conduits and processed nerve
allografts can aid in nerve recovery.
In proximal injuries, autologous nerve grafting, nerve conduits, and processed nerve allografts may not
provide the desired motor and sensory recovery. Certain nerve injuries, specifically those proximal to the
elbow, such as the ulnar nerve, will not have a functional recovery because of the long path needed for
nerve generation to reach the target muscle. In these instances, surgeons may opt to perform primary
nerve transfers or babysitting nerve transfers. This promotes continued muscle innervation while the
nerve is regenerating, such as the anterior interosseous nerve transferred in an end-to-side fashion to the
ulnar nerve. Surgeons must be well versed in autologous nerve grafting, nerve conduits, processed nerve
allografts, and nerve transfers.
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Soft-Tissue Coverage
In the mangled upper extremity, there is often extensive soft-tissue and skin loss, requiring complex soft-
tissue coverage. When choosing the appropriate soft-tissue coverage, surgeons must provide durable
coverage of vital structures. The soft-tissue deficit can be managed with various reconstructive
techniques. The reconstructive ladder, starting with the simplest surgical technique and moving to more
complicated surgical techniques, has been touted as the optimal framework for reconstruction. However,
in these complex injuries, the reconstructive ladder may get replaced by the reconstructive elevator, as
simpler reconstructive techniques are not viable with extensive injuries, and surgeons may need to jump
to free tissue transfer. In mutilating injuries, skin grafts often cannot be used when there are exposed
nerves, vessels, and tendons. However, in skin-only defects, both full thickness and split thickness skin
grafts are ideal. Injudicious use of skin grafting delays definitive reconstruction using flaps, which may
require more difficult secondary procedures in the future.
Flap-based coverage is often used in mutilating upper extremity injuries and provides ideal durable
coverage from both a functional and cosmetic perspective (Figure 82.6). Surgeons must be equipped to
use both local flaps and free tissue transfer when treating these complex upper extremity injuries.
Because of the extent of the injury, local flap options may not be available; therefore, microsurgical
techniques for soft-tissue reconstruction may be needed. 35 However, free tissue transfer may not always
be a possibility as the recipient vessels can be damaged, thus rendering microsurgery impossible.
Furthermore, there are situations where a trained microsurgeon is unavailable. Therefore, when
managing mutilating upper extremity injuries, it is imperative that the surgeon be well versed in all
reconstructive techniques to tailor treatment to the individual patient and injury.
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FIGURE 82.6 A 3-year-old boy suffered a left proximal arm avulsion injury from a motor vehicle collision. He underwent
debridement, ulnar nerve repair, fasciotomies, and a latissimus dorsi pedicled flap.
For a successful reconstruction, soft-tissue coverage should be taken from outside the zone of injury for
adequate healing. Coverage must provide tendon gliding to optimize functional recovery. Timing for
flaps reconstruction continues to be controversial. Flaps can be performed as primary free flap closure (12–
24 hours after injury), delayed free flap closure (2–7 days after injury), and secondary wound closure (beyond
7 days after injury). 36 We prefer to perform a complete initial debridement at the time of injury and
delayed free flap closure within 2 to 7 days after the injury. At the second surgery, nonviable tissues will be
demarcated and definitive reconstruction can be performed after the second debridement.
Fasciocutaneous flaps are usually the work horse flaps for mutilating upper extremity injuries. For optimal
color match, local flaps including pedicled radial forearm flap can provide durable coverage with an ideal
environment to promote tendon gliding. When the dorsal hand is involved, surgeons may use groin flaps
in a two-stage approach. These flaps require an additional operation for flap division. Additionally, there
are numerous free flaps that can be used to provide adequate coverage such as the anterior lateral thigh
flap. However, in extremely large soft-tissue defects, free muscle flaps, such as the latissimus dorsi, may
be used for coverage. Lastly, free functional muscle transfer is often employed to recreate function in
addition to coverage. The individual characteristics of the patient and injury should guide the surgeon’s
choice in flap reconstruction.
Adjunct treatments may aid in successful reconstruction. Negative pressure wound therapy promotes
granulation tissue between debridements and definitive reconstruction and is often used as a temporary
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dressing. Additionally, there has been an increased use of acellular dermal matrix (ADM) in complex
upper extremity wounds and burns. 37 ADM replaces the missing dermis prior to placing a skin graft. It
promotes granulation tissue over areas lacking paratenon or periosteum that would otherwise desiccate,
and ADM can be used to aid in the coverage of exposed vital structures, such as nerves, arteries, and
tendons. For soft-tissue coverage of mutilating upper extremity injuries, surgeons must use an
individualized approach and be able to master all reconstructive techniques from skin grafts to free tissue
transfer.
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Use of Spare Parts
Spare parts use creative reconstructive techniques to employ presumably unusable tissues that are
nonreplantable or unsalvageable. This technique avoids additional donor site morbidity by using parts
that would have otherwise been discarded. The spare parts technique affords surgeons the opportunity to
match tissue for definitive reconstruction and can be a source of soft tissue, nerves, vessels, tendon, or
bones (Figure 82.7). For example, the glabrous skin from a nonreplantable digit is an excellent source of
skin for palmar defects. Additionally, bony remnants can be used as a nonvascularized bone graft to
provide additional length for an amputated digit. When approaching the mangled upper extremity, the
amputated parts should be thoroughly evaluated and not discarded. Preservation of the amputated or
mangled entities may provide spare parts that can substantially contribute to the reconstructive treatment
plan. The use of spare parts provides additional tools to reconstruct mutilating upper extremity injuries.
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FIGURE 82.7 A. This patient suffered a dye-punch injury while at work. B–D. The spare parts technique was used to transfer
his left ring finger proximal interphalangeal joint as a composite pedicled graft to reconstruct the left middle finger
metacarpophalangeal joint. The arrow in B indicates the transferred left ring finger proximal interphalangeal joint placed in its
new location at the middle finger metacarpophalangeal joint.
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(Reproduced with permission from Osterman, AL. Arthroscopic and open triangular fibrocartilage complex repair. In: Wiesel, S, ed. Operative Techniques in
Orthopaedic Surgery. Vol 3. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams and Wilkins;2011:2520.Figure 49-2A.)
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Fasciotomy
In upper extremity trauma, patients are at increased risk of compartment syndrome, which if
unrecognized can lead to devastating consequences including limb loss and mortality. The clinical
diagnosis of compartment syndrome includes pain especially on passive stretch of the muscle, pallor,
pulselessness, paresthesias, poikilothermia, and paralysis. However, adjunct measurement of
compartment pressures may aid in the diagnosis. In a study by Branco et al., approximately 1% of all
upper extremity trauma patients will need a fasciotomy, especially in those patients who suffered an
arterial and venous injury. 38 Therefore, surgeons must recognize compartment syndrome and have a low
threshold to perform fasciotomies. Furthermore, in instances with vascular compromise in the mangled
upper extremity, preemptive compartment releases should be performed because of the reperfusion
injury and muscle ischemia after the return of blood flow.
All compartments within the hand and forearm must be fully released for adequate decompression. We
prefer a two-incision release of the forearm compartments, using two longitudinal incisions—one
overlying the flexor muscles on the volar radial aspect of the forearm and another overlying the extensor
muscles on the dorsal ulnar aspect of the forearm. 39 This approach can fully release the volar, dorsal, and
mobile wad compartments without risking exposure of the median nerve or flexor and extensor tendons.
In the hand, a five-incision approach is used. The carpal tunnel, thenar eminence, and hypothenar
eminence must be released in the palmar hand. On the dorsum of the hand, we recommend two
longitudinal incisions overlying the radial index and ring finger metacarpals. Unrecognized compartment
syndrome in the upper extremity can lead to substantial disability and even limb loss and death; thus
surgeons must promptly intervene to avoid devastating consequences.
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Special Considerations
Pediatric Injuries
Pediatric mutilating upper extremity injuries are a unique entity because children tend to have better
outcomes when compared with adults. Children recover quicker and have increased function with
enhanced mobility and sensory return. 40 The mechanisms surrounding these injuries in children
substantially differ from adult injuries and can be divided into three categories: accidental, nonaccidental,
and self-mutilation. 41 In an epidemiologic study from a regional trauma center, approximately 53% of
pediatric amputation injuries occurred without any adult supervision. 42 Common mechanisms of injury
include lawn mowers, animal bites, burns, explosives, and injuries from other dangerous household
equipment. 40,41,43
Evaluation of mutilating upper extremity injuries in children poses a unique challenge, as both the
parents and child may be anxious and scared. However, similar with adults, ATLS should be followed to
assess for other life-threatening injuries. Once the child is cleared from a trauma standpoint and
hemodynamically stable, an evaluation of the extremity should be attempted. Children may need
anesthetic blocks in the emergency department for examination of the injury. However, a sensory
examination should be documented prior to placement of an anesthetic block. As in adults, the operative
principles are complete debridement, restoration of blood flood with possible shunting, skeletal fixation,
muscle and tendon repair, venous and arterial repair, nerve repair, and soft-tissue coverage. However, in
children, epiphyseal plates may still be intact, and bones may continue to grow after the injury or
replantation, thus requiring special handling and consideration. 44,45 With any reconstruction, it is
important to involve the parents and help them understand the expected outcomes.
In children, postoperative management can be quite difficult. We recommend splinting or casting the
patient in an above-elbow fashion for complete immobilization. The operated extremity should remain as
inactive as possible to optimize healing. Despite being immobilized for longer periods of time, children
recover mobility of the operated extremity much easier than adults. Treatment of a child with a
mutilating upper extremity injury requires participation of the family and can often lead to a functional
reconstruction.
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Combat Injuries
Mutilating upper extremity injuries during combat are common. War time involves complicating
circumstances including limited resources and delayed treatment, 46 which can hinder reconstructive
efforts. Management begins with saving the life, then saving the limb, and lastly maintaining function of
the upper extremity. In a study by Dougherty et al., there was a 2.3% mortality rate for upper extremity
injuries in Operation Iraqi Freedom. 47 Common mechanisms of injury include gunshot wounds and blast
injuries from improvised explosive devices or land mines, 48 which can create large segmental mutilating
injuries with permanent disability. Additionally, there are substantial late sequelae that combat-wounded
service members suffer, subsequently requiring late upper extremity amputation. Krueger et al.
determined that loss of wrist and finger motion, neurogenic pain, and heterotopic ossification contribute
to delayed upper extremity amputation. 49 Furthermore, revision surgery of upper extremity amputations
sustained while in combat are common because of phantom limb pain requiring neuropathic
medications. 50 These complications provide barriers to prosthetic use and should be promptly recognized
to permit an optimal functional recovery. Combat injuries to the upper extremity create substantial
morbidity and mortality and pose unique challenges for the reconstructive surgeon.
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Conclusion
Treatment of mutilating upper extremity injuries requires creativity and an armamentarium of
reconstructive surgical techniques. A thorough primary and secondary survey, in accordance with ATLS,
assures that other life-threatening injuries are not missed. Operative treatment should begin with an
aggressive debridement and then follow a systematic operative approach. Even with the most meticulous
technique, mutilating upper extremity injuries often result in poor motor and sensory recovery. Future
research in prosthetics, vascularized composite allotransplantation, and tissue engineering will improve
the functional outcomes and make these injuries less devastating.
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Questions
1. A 52-year-old right-hand-dominant farmer is found unconscious in a field next to a haulm topper.
He is brought into a community hospital by emergency medical services without access to a hand
surgeon. A trauma code is called. Primary survey is performed without any other injuries found
except his partially amputated left upper extremity, which has substantial bleeding. What is the next
step in management of this patient?
a. Place tourniquet on left upper extremity
b. Intubate the patient
c. Perform a secondary survey
d. Go straight to the operating room
e. Transfer to a more experienced center
2. A 5-year-old girl was found in her front lawn after suffering a lawn mower injury to her left upper
extremity at the level of the forearm. The parents accompany her in the ambulance to a level II
trauma center. On examination, her left upper extremity is cool with minimal capillary refill. She has
no additional injuries noted on examination. A surgeon is called to the emergency department. What
is the next step in management?
a. Serial hand examinations
b. Emergent operative intervention
c. Transfer to level I trauma center
d. Place tourniquet on left upper extremity
3. A 70-year-old left-hand-dominant man was using a table saw and amputated his right upper
extremity at the midforearm level. A tourniquet is placed in the field, the amputated part is
appropriately wrapped and placed on ice, and he is immediately taken to the nearest hospital. There
is no hand surgeon on call, so he is transferred to a level I trauma center. By the time he arrives, his
upper extremity has been amputated for 6 hours. After evaluation in the emergency department, he
is immediately taken to the operating room. Which technique will prevent further systemic injury?
a. Skeletal fixation
b. Microvascular anastomosis with vein grafts
c. Microsurgical flap reconstruction
d. Aggressive debridement
e. Vascularized shunt
4. A 60-year-old left-hand-dominant man presents to the emergency department after suffering a
wood splitter injury to the right hand. There is extensive soft-tissue injury, but the fingers appear to
be well perfused with capillary refill less than 2 seconds. He has diminished two-point
discrimination in the median nerve distribution. He is taken to the operating room for emergent
exploration and debridement. In the operating room, his median nerve is noted to be cut and crushed
at the level of the carpal tunnel. What is your next step in the operation?
a. Anastomose the cut ends of the median nerve
b. Use a nerve graft taken from the medial antebrachial cutaneous nerve to bridge the gap
c. Debride the median nerve back to healthy fascicles
d. Use a nerve conduit to bridge the gap
5. A 40-year-old man is found 20 ft from a motor vehicle collision. He is unconscious, and his right
upper extremity has a large soft-tissue defect on the dorsum of the hand with gross contamination
and debris. He is intubated in the field and taken to the nearest level I trauma center, where a
primary and secondary survey is performed. No other injuries are found on examination. X-rays
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reveal segmental loss of index, middle, and ring metacarpals. He is cleared by anesthesia for
operative intervention if necessary. What is the next step in management?
a. Serial hand examinations
b. Wait until he is extubated to perform a more thorough history and physical examination
c. Obtain consent from his wife and take him to the operating room for debridement and
exploration
d. Obtain consent from his wife and take him to the operating room for debridement and
definitive reconstruction with repair of bony loss with bone grafts, nerve repairs, and tendon
repairs
1. Answer: c. Before transfer to a more experienced trauma center, the patient must be stabilized.
According to ATLS, once the primary survey is completed, then the secondary survey commences.
Even though the patient is bleeding from the partially amputated left upper extremity, the secondary
survey should take less than a few minutes. It is important to not be distracted by the mutilated
upper extremity injury. These injuries are often accompanied by injuries to other parts of the body
that may be more life-threatening.
2. Answer: b. In this scenario, there is concern for vascular compromise. The patient needs to be
taken to the operating room for exploration, debridement, and likely vascular repair. There should be
a surgeon on call who is capable of treating this injury. Any delay in operative intervention will place
the patient at risk for amputation.
3. Answer: e. The upper extremity has been amputated for longer than 6 hours, which places the
patient at risk for ischemia of the muscle and subsequent ischemia reperfusion injury. This can affect
other organ systems such as the kidneys. To avoid this consequence, blood flow should be
reestablished to the amputated part as soon as possible; therefore, a vascularized shunt should be
used.
4. Answer: c. Even though a debridement will create a larger nerve gap, it is necessary to promote
healthy nerve regeneration. The first step should be a debridement of the median nerve back to
healthy fascicles. Once this has been performed, the nerve gap can be bridged using nerve grafts and
an interfascicular repair.
5. Answer: c. The injury is grossly contaminated, and the patient needs a debridement to remove
nonviable soft tissue and debris. Given the contamination, definitive reconstruction should not be
performed in this setting as it will likely lead to infection. Reconstruction should be performed in a
delayed fashion with an additional debridement at the time of the secondary surgery. This will allow
for demarcation of nonviable tissues and time to develop a reconstructive plan.
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Acknowledgments
The work was supported by a Midcareer Investigator Award in Patient-Oriented Research (2 K24-
AR053120-06) to Kevin C. Chung. The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes of Health.
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References
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Wei, FC, Chang, YL, Chen, HC, Chuang, CC. Three successful digital replantations in a patient after 84, 86, and 94 hours of cold ischemia
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Patzakis, MJ, Wilkins, J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res. 1989;(243):36-40.
Ng, ZY, Salgado, CJ, Moran, SL, Chim, H. Soft tissue coverage of the mangled upper extremity. Semin Plast Surg. 2015;29(1):48-54.
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Gillani, S, Cao, J, Suzuki, T, Hak, DJ. The effect of ischemia reperfusion injury on skeletal muscle. Injury. 2012;43(6):670-675.
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Weinstein, MH, Golding, AL. Temporary external shunt bypass in the traumatically amputated upper extremity. J Trauma. 1975;15(10):912-
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Nunley, JA, Koman, LA, Urbaniak, JR. Arterial shunting as an adjunct to major limb revascularization. Ann Surg. 1981;193(3):271-273.
Bhardwaj, P, Sankaran, A, Sabapathy, SR. Skeletal fixation in a mutilated hand. Hand Clin. 2016;32(4):505-517.
Duncan, RW, Freeland, AE, Jabaley, ME, Meydrech, EF. Open hand fractures: an analysis of the recovery of active motion and of
complications. J Hand Surg Am. 1993;18(3):387-394.In this study, the authors investigate the long-term functional outcomes after operative fixation
of open hand fractures. With more extensive soft-tissue injuries, patients had significantly decreased range of motion. Furthermore, open reduction
internal fixation of metacarpal fractures had better range of motion when compared with phalangeal fractures.
Henry, MH. Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization. J Am Acad Orthop Surg.
2008;16(10):586-595.
Faibisoff, B, Daniel, RK. Management of severe forearm injuries. Surg Clin North Am. 1981;61(2):287-301.
Osei, DA, Stepan, JG, Calfee, RP, et al. The effect of suture caliber and number of core suture strands on zone II flexor tendon repair: a study
in human cadavers. J Hand Surg Am. 2014;39(2):262-268.This is the seminal article that proved the benefit of multistrand core suture repair for
flexor tendon injuries in an animal model. An eight-strand repair was approximately 43% stronger than a four-strand repair, highlighting the
importance of additional core sutures to strengthen flexor tendon repairs.
Fufa, DT, Osei, DA, Calfee, RP, et al. The effect of core and epitendinous suture modifications on repair of intrasynovial flexor tendons in an
in vivo canine model. J Hand Surg Am. 2012;37(12):2526-2531.
Dy, CJ, Daluiski, A. Flexor pulley reconstruction. Hand Clin. 2013;29(2):235-242.
Van Beek, AL, Kutz, JE, Zook, EG. Importance of the ribbon sign, indicating unsuitability of the vessel, in replanting a finger. Plast Reconstr
Surg. 1978;61(1):32-35.This is the first article to describe the ribbon sign, which indicates avulsion and crush of an artery. When attempting
revascularization, the authors suggest that if the ribbon sign is present, then a thorough debridement of the artery should be performed and a vein graft
used to bridge the gap.
Buncke, HJ, Alpert, B, Shah, KG. Microvascular grafting. Clin Plast Surg. 1978;5(2):185-194.
Cooney, WP III. Revascularization and replantation after upper extremity trauma: experience with interposition artery and vein grafts. Clin
Orthop Relat Res. 1978(137):227-234.
Millesi, H. Bridging defects: autologous nerve grafts. Acta Neurochir Suppl. 2007;100:37-38.
Moore, AM, Wagner, IJ, Fox, IK. Principles of nerve repair in complex wounds of the upper extremity. Semin Plast Surg. 2015;29(1):40-47.
Moore, AM, Kasukurthi, R, Magill, CK, et al. Limitations of conduits in peripheral nerve repairs. Hand (NY). 2009;4(2):180-186.
Mackinnon, SE, Dellon, AL. Clinical nerve reconstruction with a bioabsorbable polyglycolic acid tube. Plast Reconstr Surg. 1990;85(3):419-
424.This is a retrospective study of 15 patients who underwent nerve repair using a bioabsorbable polyglycolic acid nerve conduit. The authors report
excellent sensory return with these nerve conduits when used for gaps up to three centimeters. These sensory results were similar to traditional nerve
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grafts.
Safa, B, Buncke, G. Autograft substitutes: conduits and processed nerve allografts. Hand Clin. 2016;32(2):127-140.
Rinker, BD, Ingari, JV, Greenberg, JA, et al. Outcomes of short-gap sensory nerve injuries reconstructed with processed nerve allografts from
a multicenter registry study. J Reconstr Microsurg. 2015;31(5):384-390.
Cho, MS, Rinker, BD, Weber, RV, et al. Functional outcome following nerve repair in the upper extremity using processed nerve allograft. J
Hand Surg Am. 2012;37(11):2340-2349.
Lee, K, Roh, S, Lee, D, Kim, J. Skin coverage considerations in a mutilating hand injury. Hand Clin. 2016;32(4):491-503.
Ninkovic, M, Mooney, EK, Ninkovic, M, et al. A new classification for the standardization of nomenclature in free flap wound closure. Plast
Reconstr Surg. 1999;103(3):903-914.This is a retrospective review of 68 patients who underwent emergency free tissue transfer. This article classifies
free flap reconstruction for traumtic wound closure as three separate entities: primary free flap closure (12–24 hours after the injury), delayed primary
free flap closure (2–7 days after the injury), and secondary free flap closure (7 days after the injury). The authors explain that this new nomenclature
follows traditional wound-healing biology and chronologic considerations and should be used for uniform communication among surgeons.
Ellis, CV, Kulber, DA. Acellular dermal matrices in hand reconstruction. Plast Reconstr Surg. 2012;130(5 suppl 2):256S-269S.
Branco, BC, Inaba, K, Barmparas, G, et al. Incidence and predictors for the need for fasciotomy after extremity trauma: a 10-year review in a
mature level I trauma centre. Injury. 2011;42(10):1157-1163.
Giladi, AM, Chung, KC. Fasciotomy for compartment syndrome of the hand. In: Chung, KC , ed. Operative Techniques: Hand and Wrist
Surgery. New York, NY: Elsevier; 2018. vol. 3:13-22.
Buncke, GM, Buntic, RF, Romeo, O. Pediatric mutilating hand injuries. Hand Clin. 2003;19(1):121-131.
Thirkannad, SM. Mutilating hand injuries in children. Hand Clin. 2016;32(4):477-489.
Trautwein, LC, Smith, DG, Rivara, FP. Pediatric amputation injuries: etiology, cost, and outcome. J Trauma. 1996;41(5):831-838.
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Demiri, E, Bakhach, J, Tsakoniatis, N, et al. Bone growth after replantation in children. J Reconstr Microsurg. 1995;11(2):113-122.
Kim, JY, Brown, RJ, Jones, NF. Pediatric upper extremity replantation. Clin Plast Surg. 2005;32(1):1-10, vii.
Mathieu, L, Bertani, A, Gaillard, C, et al. Surgical management of combat-related upper extremity injuries. Chir Main. 2014;33(3):174-182.
Dougherty, AL, Mohrle, CR, Galarneau, MR, et al. Battlefield extremity injuries in operation Iraqi freedom. Injury. 2009;40(7):772-777.
Mathieu, L, Bertani, A, Gaillard, C, et al. Wartime upper extremity injuries: experience from the Kabul International Airport combat support
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Krueger, CA, Wenke, JC, Cho, MS, Hsu, JR. Common factors and outcome in late upper extremity amputations after military injury. J Orthop
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2012;94(16):e1191-e1196.
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C H A P T E R 8 3
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Replantation Strategies of the Hand and Upper
Extremity
Sang Hyun Woo
Key Points
Sequences of the operative technique of replantation are variable up to the type of injury and
amputation level.
Postoperative anticoagulation and rehabilitation are important for achieving satisfactory functional
restoration.
Depending on the amputation level and type of amputation, unique characteristics of replantation
should be understood.
Management and prevention of complications of replantation relate to the amputation level.
In traumatic amputation of digits, the hand or upper extremities, the decision of whether to perform
microsurgical replantation or revision amputation depends on the condition of the amputation stump, the
condition of the amputated parts, the level of injury, and the patients’ medical condition. By definition,
replantation is the reattachment of all structural tissues following complete amputation. The term
revascularization is used to refer to the repair of an incomplete amputation where there is some tissue
still intact, but without arterial circulation. Malt and McKhann performed the first replantation of an
amputated arm at the midhumeral level in 1962. Kleinert reported the first vascular repair in fingers the
next year, followed by Tamai reporting replantation of a totally amputated thumb. 1-3
Since these early developments, microsurgery has become an integral part of the training of plastic
surgeons and hand surgeons in most major hospitals. Frequent emergency replantation surgery
spontaneously evolves to elective microsurgical free tissue transfer. Even though an emergency
replantation surgery as a resident or plastic surgeon can be a laborious job, it should be performed with a
sense of responsibility and pride to resurrect amputated dead tissues. Experience of microanastomosis
techniques for the replantation of very distal amputation can be developed for supermicrosurgery-

related perforator free flaps or lymphatic surgery. Also, emergency replantation of a major limb is
sufficient to replace the clinical practice of allotransplantation of the extremities.
With the refinement of microsurgical techniques and development of microscope capabilities, the success
rate of replantation has increased dramatically. Most plastic and hand surgeons have tried to perform
replantation at all levels and with all types of injury patterns in accordance with the needs of the patients
based on cultural background or specific conditions.
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Indications and Contraindications
Any patient with any level of amputation from the fingertip to the upper arm is a candidate for
replantation. The decision to replant and the outcome of that decision have significant consequences for
the patient, the hospital, and the public purse. Before the final decision to proceed with replantation, the
following three factors should be considered. The variables in amputation factors are type of injury
(guillotine, crush, and avulsion), level of amputation, warm ischemia time, and multiple or bilateral and
segmental injuries (Figure 83.1). Patient factors include age, general condition for prolonged anesthesia,
preexisting diseases or other combined major injuries, occupation and intelligence for cooperation of
postoperative care and rehabilitation, the last factor being a socioeconomic factor which includes relative
medical cost per quality-adjusted life-year gained, duration of hospitalization, sick leave, and so on.
However, patients’ strong demands often override textbook indications for replantation.
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FIGURE 83.1 Different types of amputations. A. Guillotine amputation. B. Local crushing amputation. C. Avulsion amputation.
D. Combined amputation caused by a combination of crush, avulsion, and segmental injury.
The indications for replantation have seen little significant change over the years 4 :
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Absolute Indications
Thumb
Multiple-digit
Transmetacarpal
Wrist
Forearm
Single digit in children
Individual digit distal to the flexor digitorum superficialis (FDS) tendon insertion
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Relative Indications
Distal to distal interphalangeal joint (DIPJ)
Single digit proximal to the FDS tendon insertion
Local crushing or clear avulsion
Elbow and above elbow, sharply amputated or moderately avulsed
Patients of advanced age
These indications are not based solely on potential viability but are predicated on the potential for long-
term function. In the case of thumb amputation, replantation probably offers the best functional return
among any other option for thumb reconstruction. Even with poor motion and sensation, the thumb is
useful to the patient as a post for opposition.
Although single-finger replantation is generally not performed, replantation beyond the level of the FDS
tendon insertion, and zone 1 in a flexor tendon injury, usually results in satisfactory function. The
replantation of a single digit amputated proximal to the insertion of the FDS is more indicative of revision
amputation. 5,6 The flexor and extensor tendons can adhere to the healing bone and require secondary
tenolysis to improve motion, and the results after tenolysis are often not good. The replanted digit may
even interfere with overall hand function. Recent reports, however, demonstrate the justification of
replantation of this zone by the benefits of functional and aesthetic improvement in spite of higher cost,
longer hospital stay, and sick leave. 7,8 The posttraumatic stress and psychological sequelae of amputation
of the single digit should not be underestimated. 9 The severity of consequence of a distal single-digit
injury in one patient may be greater than that of a major limb amputation in another individual.
In Asian countries, Confucian moral values and the greater emphasis on maintaining body integrity and
appearance give further reason to perform these procedures. 10 Moreover, in situations when amputation
of the digit is considered a stigma, when the motivated patient may need all fingers for his or her
occupation, when cosmetic considerations are important, or in children, a single-digit amputation may be
indicated for replantation.
Replantation of distal digital amputation is becoming more popular in special replantation centers. In the
West, the loss of function in the fingertip is perceived to be negligible despite the lack of scientific
evidence supporting this.
Amputation of digits in children is a clear indication for replantation, no matter whether it is single or
multiple-digit or proximal or distal digits involved. Digital replantation in children is no longer a
challenging procedure, and survival rates are increasing. With refinement of replantation techniques, the
success rate is as high as in adults, and the ultimate functional result is shown to be successful in long-
term follow-up studies. Replantation of a single digit is generally indicated in children. Successful
replantation provides improved wound healing and nerve regeneration allowing not only improved
overall function of the hand but also the child’s future potential.
Contraindications to replantation exist when injuries or serious preexisting diseases preclude a prolonged
anesthesia:
Life-threatening-associated injuries
Psychologically unstable patients
Systemic illness (e.g., severely arteriosclerotic vessels)
Severe crushing or avulsion
Multiple segmental injuries of the amputated part
Extreme contamination
Prolonged warm ischemia time in major limb amputation
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Suspended or delayed replantation 11 or ectopic transplantation 12 of the digits is another option for
patients with acute combined injury or disease and seriously contaminated amputation. Of the factors
relating to the injury, amputation level and injury type are not considered as contraindications.
Prolonged warm ischemia time is strongly correlated with contraindication to the replantation of
amputation at the proximal forearm or upper arm. Because muscle is the tissue most susceptible to
ischemia, in normal ambient temperatures, irreversible changes can develop in muscle within only
2 hours of ischemia. 13 In contrast, digits do not contain muscle and can tolerate much longer ischemic
conditions. The recommended ischemic 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
limb replants. Delayed or suspended replantation of the digits even after 48 hours of cold ischemia time
can be considered for patients with immediate life-threatening injuries that can be stabilized during the
first 24 hours.
In cases of severe crushing or avulsed amputation of the digits, if the patient wants replantation, the
decision to go ahead relies on the results of the microscopic exploration of the vessel condition of the
amputated part. Severe crushing or avulsion injury shows the red line sign, which is a bruised line of the
skin along the course of neurovascular bundles (Figure 83.2A). Because of intimal tears and disruption of
small branches to the skin, there is no blood flow to the skin even after successful arterial anastomosis.
Under loupe magnification, avulsed vessels reveal the ribbon sign (Figure 83.2B), demonstrating intimal
injury by torsion and stretch on a vessel. The vessel resembles a ribbon like those curled for decoration on
a wrapped gift. In these cases, replantation requires vein grafting proximal and distal to this zone of
injury.
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FIGURE 83.2 Clinical signs suggesting injury to the digital arteries. A. Red line sign indicating disruption of branches of digital
artery. B. Ribbon sign indicating avulsion of digital artery.
Even with digit amputation in the elderly, there is no difference in perioperative complications or
mortality when comparing replantation patients under 65 years of age and those aged 65 years and
above. 14 Advanced age in itself is not a factor for contraindication of replantation. However, extreme
contamination or multilevel or segmental amputation of the digit is regarded as a contraindication.
When the patient requests replantation despite one existing contraindication, hand and plastic
microsurgeons should try to perform replantation or revascularization surgery at any level of amputation
and any type of injury of the digits of patients of any age. Textbook contraindications should not be used
as justification for passive surgeons to decline the patients’ request for replantation of their amputated
tissues under the pretext of failure to achieve functional recovery.
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Preparation
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Transport of Amputated Part to the Replantation Center
The amputated part should be wrapped in saline moistened gauze sponge and placed in a sealed plastic
bag, then placed in a container of water and ice at a temperature of 4°C (Figure 83.3). The amputated part
should not directly contact the ice and should not be immersed in water. Cold injury directly damages the
tissue cells and causes damage to the endothelial lining of small blood vessels with a consequent increase
in capillary permeability. Compressive dressing and elevation is sufficient to control bleeding of the
amputation stump without clamping. When transferring amputation patients, if necessary, fluid
resuscitation, tetanus prophylaxis, and broad-spectrum intravenous antibiotics should be commenced.
Upon arrival at the emergency room, it is important that the referring physician inform the patient that
they are being transferred for amputation evaluation, not miraculous replantation surgery. An
experienced microsurgeon will then determine whether replantation is possible.
FIGURE 83.3 Preservation of the amputated part for transport. A. Wash amputated part with water to remove gross
contaminants. B. Wrap amputated part in moist gauze. C. Place wrapped amputated part in water-tight plastic bag. D. Place
bag with amputated part in another plastic bag with ice and water mixture.
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Preoperative Evaluation
A physical examination is performed to exclude associated injuries or medical problems. Routine
investigations include radiographs, electrocardiogram, complete blood count, and electrolytes. Blood
typing and crossmatching are necessary for replantation of a major limb or amputation of two of three
digits or more. In this case, a central line should be maintained and Foley insertion implemented for
volume monitoring. Protection for pressure point is mandatory to prevent complications.
In the emergency department, discussion surrounding replantation should include the potential need for
5 to 7 days hospitalization, the need for blood transfusion, the potential for emergency re-
 exploration
when the finger becomes ischemic, and the need for revision amputation or local flap coverage when the
replantation fails. Intensive care monitoring is necessary for complications caused by massive transfusion
as well as for maintaining the patient’s general condition. Patients should also be informed that most will
require additional surgery in the future to improve the function as well as appearance of the digits.
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Anesthesia
Axillary brachial plexus block with long-acting local anesthetics provide satisfactory anesthesia for digital
or hand replantation in adults and cooperative adolescents. An axillary nerve block with an infusion
mixture of 20 mL 2% lidocaine, 20 mL 0.75% ropivacaine, 10 mL normal saline, and 0.1 mL epinephrine
keeps the patient pain free for 6 to 8 hours. If the operation time is prolonged, one more injection is
feasible if conditions allow. This offers the additional benefit of decreased postoperative pain and
possible vasodilatation. There is another advantage of the regional nerve block in case of amputation with
multiple traumas. Intraoperative talk with patients or monitoring of patient’s cooperation during the
operation is invaluable to assess mental changes, abdominal discomforts, and respiratory difficulty.
However, in cases of prolonged anesthesia, patients are frequently uncomfortable after lying supine on
the operating table for several hours. Postoperative use of indwelling pain catheters is not recommended
because of concerns about hematoma formation secondary to anticoagulation protocols used following
replantation.
For proximal amputations above the elbow, younger children, very nervous patients, patients on
anticoagulants, and in prolonged surgery such as in multiple-digit or bilateral amputations, general
anesthesia is usually preferable.
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Preparation of the Amputated Part
The preparation of the amputated part should be started on a back table with sterile drapes before the
patient is brought through to the operating room. As for early microsurgical reconstruction, copious
irrigation and radical debridement of devitalized and contaminated tissue and foreign materials are the
most important steps in promoting neovascularization between the amputated part and stump. Even in
very distal replantation, it is as crucial a step as vessel anastomosis as delayed wound healing and
inflammation may deteriorate newly established circulation by vessel anastomosis. At the same time, the
decision is made whether to proceed with replantation or not depending on the results of the microscopic
examination of the vessels. If there are signs of arterial damage, including the telescope, cobweb, and
ribbons signs or terminal thrombosis, long segment resection of the injured artery and harvesting of a
vein graft is mandatory for successful replantation.
Each finger has a dominant digital artery. The dominant artery of each finger is usually located close to
the midline of the hand. In the index finger, the ulnar digital artery is dominant, and in the little finger,
the radial digital artery is dominant. In the middle and ring fingers, ulnar and radial digital arteries are
dominant, respectively, but dominance is less obvious.
The position of the digital nerve can be easily determined by first fully flexing the finger; when the finger
is flexed, the most dorsal aspect of both proximal interphalangeal joint (PIPJ) and DIPJ flexion creases
should be marked with a dot. Connecting a line between these dots shows the course of the digital nerve
(Figure 83.4A). In the thumb, neurovascular bundles are located to both lateral sides of the mid-volar line
(Figure 83.4B). The digital artery is always located on the dorsolateral aspect of the digital nerve (Figure
83.5).
FIGURE 83.4 A. Surface anatomy of the neurovascular bundle of the digit. When the finger is flexed, the most dorsal aspect
of both proximal interphalangeal and distal interphalangeal joint flexion creases is marked with a black dot. Connecting a yellow
line between these dots shows the course of the digital nerve. B. In the thumb, the nerves (two yellow lines) are located just
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lateral to the mid-volar dotted line.
FIGURE 83.5 Cross-section of digit shows the digital artery is always located on the dorsolateral aspect of the digital nerve.
A longitudinal mid-lateral incision placed slightly volar to the mid-axial line is made on both sides of the
severed digit and extended to the next joint. During elevation of the two dorsal and volar flaps, venous
channel should be dissected as a whole and not as separate vein. Skin flap should be preserved at
constant thickness to avoid later necrosis. The longitudinal incisions over the vascular pedicles are
sometimes difficult to close without compressing the pedicles. Because of this problem, volar zigzag
incisions are preferable. It can be left partially open without exposure of vessels to accommodate swelling
and can be extended proximally as far as necessary to identify undamaged artery and nerve.
After identification of arteries and nerves, these are then tagged with 6-0 black silk for easy and quick
location after later bone fixation and tendon repair. At least 0.5 to 1 cm of intact digital artery and nerve
should be dissected free for easy coaptation and placement of vascular or nerve clamp. The ruptured
ends of the flexor are easily found at the same level of amputation. The ends of tendons are cut sharply
with a scalpel and any ragged or contaminated parts debrided. A core suture with braided nylon is
placed into the flexor digitorum profundus (FDP) tendon. This type of incision requires another incision
on the dorsum of the digit for dissection of the veins. Tagging of the extensor tendon is not usually
necessary.
For rigid fixation, it is advantageous to spend time on the bone shortening procedure as it facilitates
primary bone union, direct nerve repair, end-to-end vessel repair, and tension-free closure of the soft
tissue without grafts. This reduces the total operation time required for revascularization. Bone
shortening of the amputated part is preferred to maintain the maximum stump length if the replantation
fails. Acceptable length of the bone shortening is 0.5 to 1 cm of the digits. During the bone shortening, the
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periosteum on the amputated bone is elevated and preserved for repair after bone fixation. Bone
shortening can usually be performed safely with a rongeur and a power saw; the tagged neurovascular
structures are gently retracted to avoid injury. If the amputation passes through a joint, primary
arthrodesis accomplishes both bony shortening and bony fixation. This is especially indicated in
amputations of the DIP joint of the digits, the IP joint or metacarpophalangeal (MCP) joint of the thumb.
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Preparation of the Amputation Stump
As described with the amputated part, the same procedures of debridement, identification, and tagging
of all structures are performed. Identification of the retracted flexor tendon is time consuming because
retrieval of the flexor tendons is not possible at the level of amputation. Additional proximal incision to
find and transfix flexor tendon with a 23-gauge needle may be required. A similar core suture of 4-0
braided nylon can be placed into the proximal stump. Spurting of the proximal artery should be checked
under deflation of the tourniquet. If the spurt is inadequate, additional shortening of the more proximal
vessel is required.
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Surgical Technique of Replantation
The sequence for repairing the various structures in a finger replant is dependent on the surgeon’s
preference and the injury. It is probably more logical to perform the bony fixation, extensor tendon repair,
and flexor tendon repairs under inflation of the tourniquet, and then after deflation, arterial anastomosis,
nerve repairs, venous repair, and skin closure can be carried out. If veins are repaired immediately after
extensor tendon repair, it minimizes repositioning of the hand to facilitate venous anastomosis in a
bloodless field and may minimize venous congestion. It is also easier to repair the nerve just before
repairing the artery.
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