Phẫu Thuật Tạo Hình (Tập 6): Bàn Tay Và Chi Trên – Neligan (Ấn bản 4)

261
Treatment/surgical technique
to allow venous outflow. A solution of 1000 units of heparin
in 0.1 mL saline is injected subcutaneously into the tip of the
congested replanted finger. Heparin subcutaneous injections
are reported to be more cost-effective than medical leeches
and simpler to administer, and heparin action can last for over
6 hours.36
Another technique which should be considered is subcuta­
neously pocketing of the distal replantation. This technique
was initially described using a subdermal pocket on the chest
wall36 to prevent the awkward immobilization of a chest flap;
the subdermal pocket has been described on the palm.60 An
arterial repair is performed if possible. If there are no veins to
repair or the finger appears congested, the pulp of the ampu­
tated finger is de-epithelialized and a subdermal pocket is
made in the palm or thenar crease. The finger is secured in a
flexed position attached to the palm for 7 days. After 7 days
the patient is brought to the operating room and the finger is
detached. Retrospective reviews have found this method to
be reliably successful in saving the nailbed, and preserving
length even in adult patients without an artery or vein
repair.61,62 With distal phalanx amputation, replantation can
achieve a success rate of over 90% when venous anastomosis
is performed. Even without venous anastomosis, success rates
over 75% can be achieved.38,41,43,44 Given these success rates,
distal fingertip replantation is justifiable and these fingers
should be aggressively treated.63 The aesthetic and psycho­
logical benefit of distal fingertip replantation should not be
ignored.
Ring avulsion injuries
Ring avulsions are some of the most difficult injuries to treat.
The classification scheme popularized by Urbaniak et al.64 and
modified by Kay et al.65 is commonly used (Table 11.4). Injuries
of class 2 and above require microvascular repair; class 3 ring
avulsions are the most challenging, due to their degloving,
avulsion, and amputation (Fig. 11.18). Under the operating
microscope a midlateral incision is made on the ulnar aspect
of the amputated digit. Nonviable tissue should be debrided.
Damaged arteries should be bypassed. Inadequate debride­
ment leads to poor outcome. Vein grafts are almost universally
required due to the significant extent of the vascular damage.
Because of difficulty in arterial size matching, a second step-
down vein graft can be harvested; alternatively, an arterial
pedicle from the adjacent digit may be used.66
A minimum of two veins should be repaired. Vein grafts
should be utilized if needed. If the amputation occurs at
the DIP joint, primary arthrodesis of the joint should be
Fig. 11.16  (A) Single-digit amputation of the index finger at the level of the distal interphalangeal joint. The patient desired replantation. The surgery was performed as an
outpatient, with the patient discharged home on oral aspirin. (B) Postoperative view of the hand. (C) Volar view of replanted finger.
A
B
C
Fig. 11.17  Ishikawa and Tamai classification for distal replantation.
feed usually for 10–40 minutes, after which they detach or
should be removed. Absorbent dressing is utilized to avoid
further constriction from the continued oozing, which may
last for up to 6 hours. A new leech is applied if the finger
appears congested again, usually no sooner than 4 hours.
Leech therapy is slowly weaned at approximately 5 days.
At this point venous circulation should be re-established.
Aeromonas species bacteria in the leech gut are essential for
digestion of blood.34 Aeromonas hydrophila is not normally a
pathogen, but precautions should be utilized. Prophylactic
antibiotics to cover Aeromonas should be considered. These are
mainly third-generation cephalosporins or aminoglycosides.
Leeches may not always be available and other methods of
venous outflow can be utilized. Removing the distal nail plate
and mechanical rubbing of the sterile matrix followed by
application of a dressing with a 1000 unit/mL heparin solu­
tion may achieve active oozing in the congested finger. This
technique is repeated hourly until congestion is improved.35,59
Another option is the injection of heparin subcutaneously. In
this technique, a fish mouth incision is made in the distal digit

262
SECTION II
CHAPTER 11 • Replantation and revascularization
Fig. 11.18  (A) Child with a type IV ring avulsion injury. (B) Immediately postoperative after replantation. (C) Crossed K-wire fixation. (D) Fourteen months after injury,
extension of finger. (E) Flexion of fingers. (F) Radiographs demonstrate bone union but premature closure of growth plate. (Courtesy of James R. Sanger, MD.)
A
B
C
D
E
F
Table 11.4  Ring avulsion injuries classification
I
Circulation adequate
II
Circulation inadequate, no skeletal injury
a
Arterial circulation inadequate only
v
Venous circulation inadequate only
av
Arterial and venous circulation inadequate
III
Circulation inadequate, skeletal injury
a
Arterial circulation inadequate only
v
Venous circulation inadequate only
av
Arterial and venous circulation inadequate
IV
Complete amputation
considered. Following replantation at this level, motion at the
DIP joint is poor and fusion may permit bony shortening,
which may aid in nerve repair and skin closure. The skin
should not be pulled taut in order to close the skin defect or
to attempt to get a primary skin closure. Skin grafts should be
utilized to avoid a tight closure. A venous flap should be
considered for coverage of the skin defect. A retrospective
review of venous flaps used for ring avulsion injuries showed
100% survival of all flaps and fingers. The venous flaps pro­
duced a supple skin envelope and made subsequent surgeries
such as tenolysis or capsulotomy easier to perform. Venous
flaps should be vascularized only by the arterial inflow, as

263
Treatment/surgical technique
Ectopic transplantation secondary at replantation
Godina et al. performed the first ectopic replantation in 1983
when they transferred an amputated hand to the axilla after
a contaminated multilevel farm injury.70 Sixty-five days later
the hand was successfully replanted to the forearm. This
technique has subsequently been utilized for a variety of
amputated parts, including fingers, thumbs, ears, penises,
and scalps.71–74 The recipient sites best used are the thora­
codorsal, the deep inferior epigastric, the superficial inferior
epigastric, the radial and the dorsalis pedal vessels. These
vascular pedicles are familiar to most microsurgeons. The
choice of recipient vessel for ectopic replant depends on the
flaps vascularized with venous outflow have had poor sur­
vival rates.47 (Fig. 11.19).
Survival rates for ring avulsion injuries requiring revascu­
larization range from 60% to 81%. Adani et al. achieved an
88% success rate in 33 patients, with an average total arc of
motion (TAM) of 185°. They concluded the most important
factor for success was resection of the avulsed digital artery
and vein.67 The factor most significantly associated with
revascularization failure is repair of fewer than two veins.
Cigarette smoking and level of bone injury have not been
found to affect survival. The most commonly occurring
complications are flexion contracture, cold intolerance, and
malunion. A majority of patients can expect two-point dis­
crimination greater than 8 mm. In patients with ring avulsion
injuries, finger reconstruction generally gives a better result
than amputation, although in patients with ring avulsion
amputation proximal to the insertion of the flexor superficialis
tendon, amputation or ray amputation should be considered,
since these patients are likely to have poor hand function.68
Sears and Chung performed a systematic review of avulsion
injuries and found the results are much better than historically
cited and challenged the practice of performing amputations
for these injuries.69
Fig. 11.19  (A) Venous flap designed on the volar forearm. (B) Harvested flap in situ
with venous network diagram. (C) Vein matches size of digital vessels.
A
B
C
Clinical tips
In type III and IV ring avulsion injuries, fusion of the distal
interphalangeal (DIP) joint can allow easier bony fixation and
sufficient shortening to allow primary approximation of the
dorsal veins, skin, and nerves. Range of motion of the DIP
joint is generally poor even after attempts to preserve the joint.

264
SECTION II
CHAPTER 11 • Replantation and revascularization
children. The operative procedure in children is similar to that
in adults, and the sequence of the procedure is identical.
Surgery may be more challenging because of the size of the
vessels and a greater tendency for spasm in the pediatric age
group.57 Replantation of multiple digits should begin with the
thumb, then with the most ulnar amputated digits. An oppos­
able thumb and two ulnar digits provide essential power grip.
In finger replantation, K-wire fixation is preferred over plate
fixation to avoid growth disturbances.76 The replanted part
can be expected to grow to 90% compared to normal unless
there is significant damage directly to the growth plate.77
Recovery of nerve and muscle function is generally better
in pediatric patients. After a mutilating hand injury, children
tend to rebound more quickly from both functional and
psychological aspects. Parents add a level of complexity to the
care of the child, often because of guilt issues. Family psycho­
logical counseling may be beneficial. A long-term follow-up
of 14 children with digital replantation shows an 88% success
rate. Satisfactory sensory recovery was obtained in all fingers.
The growth rate of the digit was 86% compared to the contra­
lateral, non-injured extremity. Twelve of the 14 cases were
judged to have excellent results.78
Postoperative care
Anticoagulation
Pharmacological management of replantation and revascular­
ization remains a controversial topic. Platelet aggregation is
the most prevalent underlying cause of arterial thrombosis.
Venous thrombosis is generally caused by fibrin clotting. The
length of the expected pedicle as well as donor site morbidity
(Fig. 11.20). Adequate surgical debridement is essential prior
to replantation of the digit. Often a staged local or free flap is
needed for soft-tissue coverage prior to second-stage trans­
plantation. The ectopic site must be outside the zone of injury.
Complications were significant in all series of ectopic
replantations.72 These occurred mostly after the second stage
of transplantation. Nazerani and Motamedi74 reported a series
of 24 staged distal finger ectopic replantations, initially trans­
planting the digit to the ipsilateral groin, anastomosing an
artery and a vein. After 8–12 weeks, the finger was transferred
to the hand as a pedicle groin flap. A success rate of 75% was
achieved by this method with few complications. This tech­
nique may be of clinical use in thumb amputation where there
is need for flap coverage along with salvage of bony length
and the cosmetic appearance of the thumb.
Pediatric replantation
In children, less stringent criteria for replantation and revas­
cularization are generally employed. Replantation should be
considered for all amputated parts, including amputations of
the lower extremity. Success rate in replantation is lower in
children than in adults, but this may be due to the fact that
surgeons are more aggressive in salvaging and attempting to
replant parts in children. Disparities have been found to exist
in the management of children with amputations in the US.
Whites and children with private health insurance are more
likely to receive replantation than Blacks, Hispanics and
children without insurance.75 Clean guillotine amputations
generally have the greatest success; however, crush and avul­
sion injuries from bicycle and mechanical sports equipment
with spokes or chains are the most common form of injury in
Fig. 11.20  (A) Avulsion injury of the radial aspect of the forearm and wrist. (B) Thumb ectopically transplanted to the wrist via the radial artery. (C) Thumb replantation
after staged reconstruction with second toe second metatarsophalangeal joint and dorsalis pedis free flap. (D) Opposition of the thumb and toe transfer. (Courtesy of N.
John Yousif, MD.)
A
B
C
D

265
Postoperative care
surgeon who routinely used low-molecular-weight dextran.
There was no significant difference between the two groups
in regard to microvascular thrombosis, flap loss, hematoma,
or bleeding.85 Disa et al.86 prospectively analyzed 100 con­
secutive patients undergoing microvascular free flap surgery.
All patients were randomized into one of three anticoagula­
tion groups, which included low-molecular-weight dextran
(20 cc/h for 48 hours), low-molecular-weight dextran
(20 cc/h for 120 hours), or aspirin (325 mg for 120 hours).
There were no total flap losses, three flaps were re-explored,
and systemic complications were greatest at 51% in patients
with 120 hours of dextran, 29% in patients who had 48 hours
of dextran, and only 7% in patients receiving aspirin. Based on
this prospective study, the surgeons at this institution elimi­
nated the use of dextran for microvascular surgery at their
institution.86
Aspirin (acetylsalicylic acid) inhibits platelet enzyme cyclo­
oxygenase and impedes arachidonic acid breakdown through
thromboxane and prostacyclin. Preoperative aspirin has
been shown to decrease microvascular thrombosis formation;
however, the administration is very time-dependent. Rat
studies suggest aspirin needs to be given 10 hours before
surgery.80
Many animal studies have suggested that anticoagulation
may be useful, especially in the crush or avascular injury, yet
prospective studies in humans are limited. Khouri and the
International Microvascular Research Group prospectively
studied the use of anticoagulation in microvascular surgery.
This was a 6-month study of 23 free flap surgeons analyzing
data for 493 free flaps. While the study was prospective in
nature, it was not randomized, and all of the surgeons per­
formed their standard anticoagulation therapy, including the
use of heparin, aspirin, and Dextran 40. This study was on
elective free flap surgeries and not replantation. They found
the overall rate of thrombosis was 9.9% with a 60% salvage
rate after re-exploration of thrombosed vessels. There was no
increased risk of thrombosis in young or old patients, smokers,
or diabetics. The use of intraoperative anticoagulation therapy
did not reduce the risk of thrombosis. They concluded that
only subcutaneous heparin given postoperatively may have
decreased the rate for thrombosis, but the use of heparin
irrigation intraluminally had no beneficial effect on prevent­
ing thrombosis.87
Conrad and Adams reviewed the use of anticoagulation in
microsurgery. They conceded that most of the better studies
have been performed in animals and very few studies with a
high level of evidence have been performed in humans.
Irrespective of these limitations, they recommended in replan­
tation surgery using a loading dose of aspirin, 1.4 mg/kg
(100 mg aspirin in a 70-kg adult) followed by aspirin 1.4 mg/
kg/day for 2 days. They advocate the use of heparin irrigation
at a dilution of 100 units/mL during surgery and a heparin
bolus of 50–100 units/kg before release of a microvascular
clamp.88
Continuous brachial plexus blockade may be beneficial in
preventing microvascular thrombosis and for early continuous
pain relief. Sixteen patients were evaluated after replantation
or revascularization surgery. One group received continuous
brachial plexus blockade; the second received conventional
management. The group undergoing conventional treatment
had two microvascular thromboses, which were explored and
salvaged. Pain control was adequate in both groups, although
risk of thrombosis is highest in the first two postoperative
days, with 80% of thromboses being seen in this time period.
Various schemes of pharmacological management have been
utilized. No consensus exists on the use of anticoagulation
therapy after microsurgery. The most commonly utilized
agents are heparin, low-molecular-weight dextran, and
aspirin, but little evidence is available on the efficacy of any
of these regimens. A survey of microsurgeons showed that
90% used anticoagulation in free flap and microvascular
surgery.79
Heparin has been used for over 50 years. Heparin binds to
antithrombin III, enhancing its antiprotease activity. Various
factors, including thrombin and factor Xa, are rendered
inactive.80 Heparin also has a vasodilatory effect. Heparin
can be administered systemically by intravenous methods,
by subcutaneous injection, or by direct irrigation. When
given intravenously or subcutaneously, heparin needs to
be monitored by measuring activated partial thromboplas­
tin time levels. Side-effects of heparin include hematoma
formation and heparin-induced thrombocytopenia. Low-
molecular-weight heparin (LMWH) is a derivative of stan­
dard unfractionated heparin with the same activity against
factor X but weaker antithrombotic factor II activity. LMWH
is as effective as heparin in its antithrombogenic effects but
has fewer adverse reactions. The advantage of LMWH is
that there is no need for monitoring and it can be used on
an outpatient basis. Chen et al. examined topical effects of
LMWH compared to unfractionated heparin in a crush injury
model and found the thrombosis rates were significantly
reduced with both treatments.81 A Cochrane review of LMWH
found no difference in microvascular success rate compared
to unfractionated heparin but few postoperative bleeds and
hypocoagulability.82 Dextran 40 is a group of polysaccharides
synthesized by Leuconostoc mesenteroides streptococcus. The
exact mechanism by which Dextran 40 works is unclear.
The antithrombotic effect of dextran is thought to be due to
binding to erythrocytes, platelets, and the vascular endothe­
lium. It is mostly thought to interfere with the formation of
fibrin clot and to prevent the aggregation of red thrombi. This
effect is thought to be significantly greater than any effect on
platelets. Dextran has a low risk of postoperative bleeding
and hematoma formation. It has some rare, but serious, con­
sequences, including that of pulmonary edema due to fluid
overload.83
The use of Dextran 40 has been shown to be beneficial in
animal studies. There has been no trial to date that demon­
strates any significant beneficial effect in humans with the
use of dextran. There is no generally accepted regimen for the
administration of dextran. Jallali in his review on the use of
dextran advocates initiation of Dextran 40 at a rate of 0.4 cc/
kg per hour for 2 days, then reducing the rate to 0.2 cc/kg per
hour on day 3 and 4, and weaning on day 5.83 Ridha et al.84
surveyed the practice of 161 microsurgeons and found 45%
routinely used dextran postoperatively with 17% combining
it with aspirin or heparin. Forty percent of surgeons using
dextran used it for less than 72 hours; 52% used it for 5 days.
Eight percent used it for greater than 5 days. There was no
difference of survival in the patients who used dextran versus
those who did not use dextran. A single institutional study
from Memorial Sloan Kettering compiled data from 505 free
flap surgeries. One group treated by surgeons who routinely
used only aspirin was compared to a group treated by a

266
SECTION II
CHAPTER 11 • Replantation and revascularization
Postoperative therapy
Therapy is essential to regaining function. During the first few
days after surgery the therapist fabricates splints, and initiates
gentle range of motion to the non-affected joints. At postop­
erative days 5–7, a formal therapy program is initiated; this
includes dressing changes, passive splinting, and instruction
regarding activities of daily living. Blood vessel and nerve
repairs are protected for 3–4 weeks. Tendon therapy initially
involves immobilization to prevent injury, but early active
and passive mobilization can be initiated if there is rigid bone
fixation and a solid multistrand tendon repair. After 6–8
weeks, the therapy program is increased to include strength­
ening and full range-of-motion programs. Sensory re-education
is initiated after any nerve injuries. Desensitization programs
start using fabric textures and progress to vibratory sensory
re-education.93 Patients who started therapy before day 14
postoperatively have better recovery of motion than those
who start therapy later.24
Psychosocial aspects of replantation
The surgeon treating a patient with an amputation must
not only treat the amputation, but the whole patient, and
the family. The psychological implications of amputation
and replantation must not be overlooked when caring for
these patients. The hand has a significant role in a patient’s
identity and psyche. The hands are an individual’s second
most visually prominent structure, second only to the face.
Most individuals view their hands far more than they view
their own faces. The hands are not only a source of contact
with the world, but a means of communication and an
instrument of sexuality. Injury or disfigurement to the hands
can be a source of tremendous psychological difficulty. The
psychological consequences of amputation may not correlate
with the degree of injury.94 The consequences of a distal
single-digit injury in one patient may be more severe than that
of a major limb amputation in another individual. Despite
those in the conventional anesthesia group required more
intravenous pain medication.89
For revascularizations and sharp guillotine-type injuries,
the author uses heparin irrigation intraoperatively (100 units/
mL) and aspirin. Aspirin 325 mg is given in the recovery room
and daily for 1 month. In patients with crush or avulsion
injuries, LMWH at a deep-vein thrombosis prophylaxis dose
is utilized. The first dose is given in the operating room, and
it is continued for 2 weeks postoperatively. The patient and
family are instructed on home injection prior to discharge.
The LMWH regimen is based on animal studies on the efficacy
of heparins in crush injuries.90 The advantage of the LMWH
regime is that patients can be discharged home while still on
therapy.
Postoperative monitoring
Careful postoperative monitoring is essential in replantation
surgery. Eighty percent of vascular occlusions occur within
the first 48 hours after surgery. The salvage rate in a failing
replantation explored early ranges from 66% to 80%.91 A dedi­
cated replantation team is essential for monitoring the patient.
The best monitor is a conscientious nursing staff. When the
patient arrives on the floor, the physician should examine the
replant with the nurse, judging its color, capillary refill, and
turgor. The finger is examined every hour by the nursing staff.
If there is any change from the baseline level, the physician
should be notified (Table 11.5). Proper handoff between
nursing shifts is essential: at the bedside the clinical parameters
are assessed with both nursing teams at each shift change.
Venous occlusion is more insidious and harder to assess than
acute arterial thrombosis. Venous occlusion will eventually
lead to arterial thrombosis. If there is any doubt regarding the
clinical assessment of the digit, the pulp of the finger can be
pricked with a 25-gauge needle. If the blood is blue, has brisk
bleeding, delayed bleeding or serous fluid exudate; explora­
tion of the digit should be performed.
Technology cannot replace a dedicated, experienced nurse,
but can aid in the postoperative assessment of viability. The
most commonly used devices are pulse oximetry, ultrasonic
Doppler, digital thermometry, and the laser Doppler.91 Each
of these devices can help identify an early vascular occlusion,
but each has its shortcomings. While temperature measure­
ments are inexpensive, variations such as room temperature
can affect the accuracy. Laser Dopplers have a high sensitivity
and specificity. When compared to thermometry, the sensitiv­
ity of the Doppler is 93% while that of thermometry is 84%.
Specificity is 94% with the laser Doppler and 86% with
thermometry.92
Table 11.5  Circulation
Normal circulation
Venous occlusion
Arterial occlusion
Color
Pink
Blue/purple hue, cyanotic
Pale, mottled
Capillary refill time
1–2 seconds
Increased, <1 second
Decreased, >2 seconds
Temperature
Warm
Warm–cool
Cold
Turgor
Full
Distended, swollen
Hollow
Dermal bleeding
Bright red blood
Dark red or bluish
Bleeds briskly
Minimal bleeding only serum
Clinical tips
The best monitor of the replanted digit is a well-trained nursing
staff. The surgeon should examine the replantation with the
nursing staff and ask to be called at any change in
appearance. Shift change handoffs should be made at the
bedside, so that all care members know the physical
appearance of the replantation.

267
Outcome, prognosis, and complications
Outcome, prognosis, and complications
Outcome after replantation and revascularization surgery can
be measured in many ways. The simplest of these is survival
of the replanted part. Overall survival can be expected in over
90% of digits. The largest single-institution study found a
success rate of 92.9%.25 Several factors are associated with
worse prognosis. The most significant of these is mechanism
of injury. Crush and avulsion injuries have a poorer anasto­
motic success rate than clean amputations. The anastomotic
success after a clean amputation approaches 100%.25,97
Other factors associated with poorer success rates include
the total number of anastomosed vessels. The more vessels
anastomosed (whether arteries or veins) improved survival.
Even in very distal replantation where anastomosis of a vein
is not possible, a high success rate of over 60% can still be
obtained.28 A positive correlation exists between the number
of vessels anastomosed and the mechanism of injury; crush
injuries generally reduce the number of anastomosed vessels
and veins.33 The use of vein grafts is not associated with a
poorer outcome. Cigarette smoking leads to a poorer outcome,
but alcohol consumption does not affect survival.
A better indicator of outcome is objective measurement
of hand function. Standard measurements include range of
motion, grip strength, and sensation. These measurements
can be compared to non-injured hands or to hands with
amputations. Long-term follow-up of 59 successfully replanted
digits showed that average active range of motion was 44–56%
of the normal contralateral hand. Grip strength was 67% of
the contralateral hand. Only three digits had normal two-
point discrimination. Over one-half achieve 10 mm or less
two-point discrimination.98
The best measurement of outcome is the use and function
of the hand. A variety of tests are available to judge outcome,
including the short-form 36 (SF36), upper extremity functional
test (UEFT), and the Disability of the Arm, Shoulders
and Hand (DASH). Outcome assessment after major upper
extremity replantation is difficult.99,100 Outcome of replanta­
tion can be compared to amputation, the normal hand, or
other surgical reconstructions.58 Various scales have been
devised to try to assess and predict functional recovery after
mutilating hand injuries and replantations; these include the
Tamai scale, the Chen scale (Table 11.6), and the Campbell
hand injury severity scale (HISS).56,101–103 The HISS performed
at the time of injury can be predictive in assessing return to
work and functional recovery of the patient. The more proxi­
mal level of injury and the more injured fingers predicted
poorer functional outcome.104 A comparison of four commonly
common misconceptions, the presence or absence of worker’s
compensation or litigation does not seem to correlate with the
patient’s psychological reaction after injury.95
The psychological response to amputation may take
various forms, including anxiety, depression, anger, guilt, fear,
frustration, and sadness. All of these emotions are normal
after an injury, but their prolonged manifestation may be
pathological and lead to full acute stress disorder and post-
traumatic stress disorder (PTSD). PTSD symptoms may
include flashbacks, nightmares, sleep disturbances, avoid­
ance, and detachment.
The physician should convey hope but also give the patient
realistic expectations prior to surgery. Patients need to be
reassured that everything possible will be done to make them
whole again.
Nightmares and flashbacks are commonly seen after
traumatic injuries. Flashbacks are an almost universal com­
ponent of the traumatic hand injury. These can be “replay
flashbacks” where an individual replays the entire traumatic
event, or an “appraisal flashback” where the patient sees a
snapshot of the injured hand. Patients may also have “pro­
jection flashbacks” where the injury is seen as more severe
than it actually is. The type and persistence of flashbacks are
strong prognostic factors in predicting PTSD and the eventual
return to work and function. Psychological care of the patient
with a traumatic hand amputation begins immediately in
the emergency room. The patient is asked two questions:
how did this accident occur, and what do you perceive was
responsible for the injury? Whether patients take responsibil­
ity for the injury or attribute it to something out of their
control is an important prognostic sign. Patients who see the
accident as under their control, e.g., I knew I should not have
removed the blade guard, do significantly better than those
who believe they lack control, e.g., the machine intermittently
malfunctions.
Patients are also asked how the injury appears to them
and their emotional reaction. Finally they are asked about
flashbacks. After discharge from the hospital, patients should
be followed up with psychological treatment. Patients who
are experiencing signs of PTSD are begun on a course of
desensitization and systematic exposure training. Grunert
et al.95 were able to achieve over 90% return to work with
a graded return-to-work exposure program in patients
with PTSD.
Children with traumatic injuries are a special challenge to
the surgeon. Rusch et al. found that 98% of children with
traumatic injuries had symptoms of PTSD, depression, or
anxiety 1 month after injury. Twelve months after injury, 21%
still met the criteria for PTSD.96
Table 11.6  Chen classification of functional results after replantation/revascularization
Grade
Return to work
AROM (%)
Sensation
Cold intolerance
Grip strength (five-grade scale)
I
Same profession
>60
Normal
−
4–5
II
Other profession
40–60
Satisfactory
−
3–4
III
Not returned to work
30–40
Protective
Yes
Slight
IV
The limb survived, but is functionally severely disabled
AROM, Active range of motion.

268
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CHAPTER 11 • Replantation and revascularization
correct arterial insufficiency can be successful in over 50% of
patients with a failing replantation.103,109 Close observation of
the patient postoperatively for signs of thrombosis and urgent
re-exploration of the vessel is the essential first step in suc­
cessful re-exploration. In the patient’s room, the dressing
should be removed and if skin sutures appear to be constrict­
ing venous outflow, they should also be removed. The patient
is given a bolus of intravenous heparin and the operating
room is readied. The anastomosis is opened and clots are
atraumatically evacuated. The use of a Fogarty catheter may
be considered; however, a catheter can cause significant
intimal damage. If white thrombus or intimal injury is present,
a vein graft should be utilized. Intravascular tissue plasmino­
gen activator is considered; however, there is very limited
clinical data and outcome of its effectiveness. After establish­
ing flow, prophylactic therapy with aspirin or heparin should
be strongly considered.85,110
Cold intolerance is common in varying degrees in almost all
replanted digits; it usually resolve in 1–2 years but may be
permanent.98 Eighty-one adults from Norway were evaluated
for cold sensitivity after successful replantation or revascular­
ization. Twenty percent were severely or extremely cold-
hypersensitive. Cold-hypersensitivity is significantly higher in
replantations as compared to revascularizations.111 Only 40%
of children with replanted digits reported cold intolerance.50
Secondary procedures
The incidence of secondary procedures after digital replanta­
tion ranges from 15% to 80%.108,109 Most series report an
approximate 50% rate of reoperative surgery. Procedures
include those performed immediately, mostly related to
vascular anastomosis and skin closure, and late secondary
procedures relating mainly to bony nonunion, or tendon
adhesions.112 Yu et al. reviewed a series of 102 secondary
procedures in 55 patients with injuries in 79 digits. Ninety-
two percent of the early procedures were for soft-tissue cover­
age and 67% of later procedures were for tendon function.
Significant factors related to the need for secondary surgeries
are avulsion or degloving injuries, and proximal replantations
in zones 3–5.113 In digital replantations proximal to the super­
ficialis insertion, a high rate of secondary procedures can be
expected. Many of these secondary surgeries have a poor
outcome.114 Tenolysis after finger replantation and revascular­
ization is technically demanding, but the results can be
rewarding (Fig. 11.21). Tenolysis in these digits may produce
a modest total improvement in motion, but this functional
improvement can be substantial. The risk of tendon rupture
in these patients is significant.115
Revascularization and replantation remains one of the most
challenging procedures in hand surgery. The surgeon must
have a meticulous plan and exacting surgical technique. The
postoperative management may be as complicated as the sur­
gical procedure itself. Yet the rewards of a successful replanta­
tion for the patient and the surgeon are immeasurable.
Future directions
Replantation remains one of the most challenging surger­
ies performed. Microsurgery and “supermicrosurgery” is
used scales, the Tamai, Ipsen, Chen, and DASH, found a high
correlation between the Ipsen, Tamai and DASH. The Chen
had a moderate correlation with the others.105 Despite results
of functional outcome, patient satisfaction after replantation
is high; long-term follow-up in successfully replanted digits
shows good satisfaction by a majority of the patients.
Replantation distal to the FDS insertion offers excellent
functional results. Hattori et al. compared the functional results
of single fingertip amputations versus replantation in regard to
symptoms of pain, paresthesias, cold intolerance, and DASH
scores. Grip strength did not differ between the amputation
group and the replantation group. Range of motion of the
proximal interphalangeal joint was better in the replantation
group. Replantation patients had significantly improved
DASH scores. Ninety-six percent of patients obtained protec­
tive sensation. Less than 10% of replantation patients com­
plained of pain, 60% of patients with amputation complained
of pain, half of these patients rarely or never use their affected
fingers for activities of daily living. All patients with successful
replantations were highly or very satisfied. Only 60% of
patients in the amputation group were highly or very satis­
fied.97 Patients with primary amputation revisions have a
higher incidence of painful and uncomfortable sensation in
their amputation stumps. Patients with replanted index and
middle fingers have improved use and function of these fingers
compared with patients with amputation revision. When cost
was compared, a successful replantation cost 20% more than
unsuccessful replantation and 300 times more than primary
amputation revision.106 The level of injury had a significant
influence on the final function, with the worse function in
amputations in flexor tendon zone II. In this area, repairing the
profundus stump to the superficialis had improved outcome.25
The surgical success rate for major limb replantation ranges
from 36% to 100% depending on the level of amputation,
etiology of amputation, and age of the patient.98 Using the
Carroll Quantitative Test of Upper Extremity Function, the
Louisville group compared the outcomes of replantation to
prosthesis in adults with amputations proximal to the wrist.
In injuries between the wrist and elbow, good to excellent
outcomes were achieved in 50% of replantation patients. No
patients in the prosthetic group had good or excellent func­
tion.106 Better outcomes were seen in younger patients and
those with more distal injuries. Outcomes for injuries proxi­
mal to the elbow were significantly worse in both groups.
Replantation, even after significant mangling injuries, is
still worthwhile. Avulsion amputations in the forearm were
evaluated based on the patient’s overall satisfaction, recovery
of motion, and ability to perform daily activities: 100% success
rate of replantation was achieved. Postoperative function was
rated as excellent to good in 40%, but poor in 30% of patients.107
Amputation at the transmetacarpal level is an intermediary
between the digital amputation and major limb replantation.
A review of 10 patients with transmetacarpal-level replanta­
tions showed 90% salvage of the replanted hands. Intrinsic
muscle function was weak or absent in all patients. Only one
patient was able to resume his prior occupation. Despite this
fact, all patients were satisfied with their replantation.108
Complications
The most devastating complication after replantation and
revascularization is anastomotic failure. Re-exploration to

269
Future directions
Fig. 11.21  (A,B) A 24-year-old status post five-finger amputation and replantation with stiff fingers. (C) Exploration at time of tenolysis shows severe scarring and
attenuation of the digital pulleys. (D) Hunter rod inserted, and A2 and A4 pulley reconstruction.
A
B
C
D
and psychological results of replantation with that of ampu­
tation revision.116 In this changing healthcare environment,
economic and cost effectiveness studies of replantation are
still lacking and are needed to establish the benefit of these
procedures.117
allowing reattachment of more distal amputations. Newer
procedures such as palmar pocketing allow successful reat­
tachment of very distal amputations even without a venous
anastomosis. Outcomes analyses generally show good to
excellent satisfaction with replantation and revascularization
surgery, yet there are few studies which compare functional
3. Buncke HJ Jr. Microvascular hand surgery transplants and replants
over the past 25 years. J Hand Surg Am. 2000;25:415–428. The pioneer
of US microsurgery discusses the history of microsurgery and
replantation. Tips and techniques from a lifetime of experience are
included.
11. Chung KC, Kowalski CP, Walters MR. Finger replantation in the
United States: rates and resource use from the 1996 Healthcare Cost
and Utilization Project. J Hand Surg Am. 2000;25A:1038–1042. The
database from the Agency for Healthcare Policy and Research was
reviewed to obtain data on the frequency and cost of digital replantation.
Only 60% of the 906 hospitals performed any replantation. Only 2% of
hospitals performed 10 or more cases of replantation.
25. Waikakul S, Sakkarnkosol S, Vanadurongwan V, et al. Results of
1018 digital replantations in 552 patients. Injury. 2000;31:33–40. The
largest series of digital replantation published from Bangkok, Thailand
with at least 2-year follow-up. A 92.9% success rate in digits. Risk factors
and outcome are discussed.
33. Chaivanichsiri P, Rattanasrithong P. Type of injury and number of
anastomosed vessels: impact on digital replantation. Microsurgery.
2006;26:151–154. A retrospective review of 130 digital replantations was
performed. The type of injury and the number of vessel anastomoses were
the most significant predictors of successful outcome. Crush injuries had
significantly worse outcome than sharp injuries. In distal replantations,
an arterial repair even without repair of a vein can achieve a high success
rate.
37. Zhang X, Wen S, Wang B, et al. Reconstruction of circulation in the
fingertip without vein repair in zone 1 replantation. J Hand Surg
Am. 2008;33A:1597–1601.
49. Rosson GD, Buncke GM, Buncke HJ. Great toe transplant versus
thumb replant for isolated thumb amputation: critical analysis of
functional outcome. Microsurgery. 2008;598–600.
59. Li J, Guo Z, Zhu Q, et al. Finger replantation: determinants of
survival. Plast Reconstr Surg. 2008;122:833–839. A retrospective review
of 211 finger amputations was performed over a 16-year period. An 81.5%
Access the complete reference list online at

270
SECTION II
CHAPTER 11 • Replantation and revascularization
success rate was achieved. Injury mechanism, platelet count, smoking, and
the use of vein grafting were found to be the main predictors for the
survival of the replanted fingertip.
68. Sanmartin M, Fernandes F, Lajoie AS, et al. Analysis of prognostic
factors in ring avulsion injuries. J Hand Surg Am.
2004;29a:1028–1037.
76. Buncke GM, Buntic RF, Romeo O. Pediatric mutilating hand
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91. Bakri K, Moran SL. Monitoring for upper extremity free flaps and
replantations. J Hand Surg Am. 2008;33A:1905–1908.

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109. Yu JC, Shieh SJ, Lee JW, et al. Secondary procedures following
digital replantation and revascularization. Br J Plast Surg.
2003;56:125–128.
110. Hanasono MM, Butler CE. Prevention and treatment of thrombosis
in microvascular surgery. J Reconstr Microsurg. 2008;24:305–314.
111. Vaksvik T, Hetland K, Rokkum M, et al. Cold hypersensitivity 6 to
10 years after replantation or revascularization of fingers:
consequences for work and leisure activities. J Hand Surg Eur Vol.
2009;34E:12–17.
112. Matsuzaki H, Kouda H, Maniwa K. Secondary surgeries after
digital replantations: a case series. Hand Surg. 2012;17:351–357.
113. Yu JC, Shieh SJ, Lee JW, et al. Secondary procedures following
digital replantation and revascularization. Br J Plast Surg.
2003;56:125–128.
114. Pitzler D, Buck-Gramcko D. Secondary operations after
replantation. Ann Chir Gynaecol. 1982;71:19–27.
115. Jupiter JB, Pess GM, Bour CJ. Results of flexor tendon tenolysis
after replantation in the hand. J Hand Surg Am. 1989;14:35–44.
116. Sebastin SJ, Chung KC. A systematic review of the outcomes of
replantation of distal digital amputation. Plast Reconstr Surg.
2011;128:723–737.
117. Sears ED, Shin R, Prosser LA, Chung KC. Economic analysis of
revision amputation and replantation treatment of finger
amputation injuries. Plast Reconstr Surg. 2014;133:827–840.

SECTION II • Acquired Traumatic Disorders
12 
Reconstructive surgery of the
mutilated hand
William C. Pederson and Randolph Sherman
SYNOPSIS
■ Thorough debridement is essential in the management of these
patients to decrease risk of infection and scarring.
■ In cases of arterial insufficiency, provisional revascularization via a
shunt or temporary vein graft should be considered.
■ Adequate skeletal stabilization should be performed early and
preferentially is done with internal fixation to allow definitive repairs of
neurovascular structures and soft-tissue coverage.
■ Definitive vascular reconstruction is usually delayed until after skeletal
stabilization is achieved.
■ Musculotendinous reconstruction should be done early if possible, to
the point of performing early tendon transfers.
■ Nerve repair is also best performed early, to allow proper alignment of
nerves and to avoid having to dissect the nerve out of scar at a
secondary procedure.
■ Proper management of the soft-tissue envelope is essential to allow all
of the other structures to be repaired as noted above. Proper flap
selection allows early rehabilitation and facilitates secondary surgery
when necessary.
■ Postoperative management revolves around proper planning at the first
stage of reconstruction. Every surgery should be performed with an
eye to what will need to be done in the future.
Introduction
General
Management of the mangled upper extremity is complex,
demands special skills and expertise, and is facilitated by a
team approach with participation of all those dedicated to
upper extremity surgery. When adequate facilities, equip­
ment, and surgical expertise are not available to manage the
patient’s degree of injury, the patient should be transferred
with the extremity splinted. If the limb is ischemic, or if part
of the limb is amputated, the extremity should be cooled. The
ischemic limb should be carefully covered in ice, with a pro­
tective barrier to prevent frostbite injury. The amputated part
should be wrapped in a saline-soaked gauze, placed on ice,
and sent with the patient. The ideal temperature is +4°C. Dry
ice or alcohol should not be used to aid in cooling during
transport of the part as this can cause actual freezing of the
tissues.
Resuscitation of the patient is a priority over addressing
the extremity injury. However, in the event of a coexisting
life-threatening injury, the extremity injury must not be
neglected. Assessment of vascularity, realignment, and splint­
ing are not time-consuming and should be done as soon as
possible. Provisional revascularization through shunting may
be an option to quickly restore circulation to the extremity
while the trauma team simultaneously addresses the coexist­
ing injuries. Consent of the patient should initially be obtained
for wide debridement of the wound; internal versus external
fixation; repair or reconstruction as indicated of nerves,
vessels, tendons, and muscles; use of vein grafts for arterial
and venous reconstruction; possible donor sites for flap cover­
age; and primary amputation. The selected treatment is based
on the intraoperative findings.
The initial treatment includes meticulous debridement,
wound irrigation, wound culture, antibiotic administration,
and tetanus prophylaxis. Copious irrigation of the wound
coupled with debridement is important because it removes
foreign bodies and decreases the bacterial load. High-pressure
and/or pulsed lavage of the soft tissues is to be avoided in
these types of injuries, as it may force debris and bacteria into
the tissues and has a tendency to force fluid into the tissues,
potentially creating more edema in the postoperative period.
The cultures most predictive of later infecting organisms are
the post-irrigation cultures. Antibiotics will help reduce infec­
tion and should be administered in the emergency department
and continued intravenously for at least 72 hours. Antibiotic
coverage should be effective against both gram-positive and
gram-negative organisms. The authors currently prefer to use
a first-generation cephalosporin and an aminoglycoside in
combination. In cases of soil contamination, as in farm injuries,
  Access video content for this chapter online at expertconsult.com

272
SECTION II
CHAPTER 12 • Reconstructive surgery of the mutilated hand
are to be reconstructed is done with the tourniquet released.
At the completion of debridement, assess and record what
structures remain intact and what the functional losses are.
Some of the remaining intact muscles may be suitable for
immediate tendon transfer to replace important functional
losses.
Provisional revascularization
When the extremity is amputated or ischemic and the delay
to surgery or anticipated length of time for debridement and
definitive skeletal stabilization exceeds 6 hours, provisional
revascularization can be done with use of a shunt, such as a
Javid, Ishihara, or comparable segment of plastic tubing (Fig.
12.2). Another option is to rapidly perform reversed vein
grafting between the arterial ends to re-establish arterial
inflow. After definitive skeletal stabilization, the length of the
vein graft can be adjusted and the anastomosis revised.
Skeletal stabilization
Definitive stable internal fixation should be done immediately
when possible to allow therapeutic access to the extremity for
wound care and early joint range of motion when applicable.
In general, the use of external fixation is to be avoided. These
Fig. 12.1  43-year-old patient who suffered a crush injury to his hand when an
airplane fell on it while under repair. This hand will require extensive debridement to
delineate which tissues are viable and which are not.
A
Fig. 12.2  (A) 24-year-old patient after mid-forearm amputation. Shunt placed from
radial artery to radial artery to perfuse limb while debridement and bony fixation is
performed. (B) View of shunt perfusing limb while debridement is performed.
B
coverage against anaerobic organisms should always be
added. High-dose penicillin provides excellent anaerobic
coverage. The possibility of gas gangrene should also be
considered in these cases. The antibiotic regimen should
subsequently be modified depending on the culture results.
Tetanus prophylaxis should be administered in accordance
with the status of previous immunization.
Debridement (Video 12.1 )
Radical debridement with elimination of all nonviable tissue
is the crucial step in the management of these injuries. This is
performed under tourniquet control to provide the best visu­
alization of the extent of injury and to prevent iatrogenic
injury to intact structures. Once nerves and vessels are identi­
fied, the tourniquet may be released to better assess the viabil­
ity of the remaining tissue (Fig. 12.1).
Skin and subcutaneous tissues are sharply debrided to
bleeding edges. Muscle is debrided until bright red blood is
seen. Color and twitch are used to assess muscle tissue;
however, these characteristics are not totally reliable in deter­
mining viability. If the muscle does not bleed, it is dead and
should be debrided. Small bone fragments devoid of soft-
tissue attachments are avascular and should be discarded
unless they constitute part of an articular surface. Contused
or contaminated nerves are left in continuity. Superficial dis­
section above the epineurium can be carefully done to remove
foreign material if it is present. Cut nerves are debrided to
healthy-appearing fascicles. At the time of reconstruction, this
is done under microscopic visualization because a primary
repair or nerve graft will fail if the entirety of the injured
segment is not resected.
The wound is copiously irrigated. Tissue margins are
re-evaluated, and further debridement is performed as neces­
sary. Hemostasis should be done cautiously. Do not cauterize
vessels that may be needed for arterial or venous reconstruc­
tion. Side branches may be controlled with small sutures or
vascular clips. Arterial debridement is performed for cut or
thrombosed vessels. Definitive debridement of arteries that

273
Introduction
devices carry the risk of neurovascular injury during pin
placement, restrict circumferential access to the extremity, and
may limit rehabilitation. They may be useful as a temporary
solution for severely contaminated wounds with extensive
soft-tissue injury, however. External fixation should not be
used for the reason to avoid exposed hardware. Potentially
exposed hardware should be addressed with appropriate
soft-tissue coverage.
Diaphyseal fractures of the arm and forearm are usually
amenable to plate fixation. If the fracture is segmental or com­
minuted over a large segment, a flexible interlocking intra­
medullary nail can be used. Fractures should be reduced
anatomically with respect to rotational alignment. One must
carefully check pronation and supination prior to final fixa­
tion to avoid placing the hand in a poor position. Comminuted
bone fragments without soft tissue attachments should be
removed. Shortening of the humerus up to 5 cm and of the
radius and ulna up to 4 cm is acceptable. Indications for
shortening include significant comminution over a segment
with bone and soft-tissue loss and bony shortening has the
advantage of allowing primary repair of vessels and, more
important, of nerves.
Complex diaphyseal fractures include Galeazzi fractures
(radial diaphyseal fracture with disruption of the distal radio­
ulnar joint), Monteggia fractures (proximal ulna fractures
with radial head dislocation or radial head or neck fracture),
and Essex-Lopresti injuries (radial head fracture with associ­
ated rupture of the interosseous membrane to the level of the
wrist). These fractures must be restored to anatomic length to
restore joint congruity and alignment.
Diaphyseal fractures of the hand are fixed with Kirschner
wires, with attention to maintaining rotational alignment.
Shortening of the metacarpals or phalanges between 5 and
6 mm may be necessary in replantation. For other injuries,
length can be restored or maintained with internal or external
fixation and primary or delayed bone grafting. In general,
initial use of plate fixation is not recommended in the hand,
particularly in the phalanges. This requires more stripping of
the periosteum and later has an adverse effect on functional
outcome because of potential tendon adhesions around the
plate.
In contrast to lower extremity injuries, primary bone graft­
ing is acceptable and recommended in the upper extremity.
Primary iliac crest bone graft or bone allograft may be used
for defects up to 4 cm. For larger defects, vascularized bone
grafts, in particular a vascularized segment of free fibula,
should be considered (see below). With massive bone loss,
creation of a one-bone forearm can be considered as a salvage
procedure when other options are not available. The results
of this procedure in trauma are not as good as in limb salvage
surgeries for tumor reconstruction.
Intra-articular fractures should be anatomically reduced.
Stable fixation is imperative to allow early range of motion.
Fixation can be done with plates, screws, K-wires, or tension
band wiring as dictated by the fracture pattern and location.
Articular fragments free of soft-tissue attachments should be
preserved to reconstruct the joint surface. Primary bone graft­
ing should be done to address bone defects, to enhance the
stability of the fixation, and to promote bone healing. If there
is complex injury to the distal radius and/or wrist, spanning
plates across the wrist may be used to provide excellent fixa­
tion and allow healing of complex bony and ligamentous
injuries.1 These have been shown to be an excellent option in
the face of severe injury and soft-tissue dissection can be
minimal, without the disadvantages of external fixation2
(Fig. 12.3). When the joint surface cannot be reconstructed
owing to severe comminution or bone loss, other reconstruc­
tive options are available. At the shoulder and elbow, a
primary allograft or a prosthesis can be used. At the wrist
joint, primary fusion should be the first treatment option. If
wrist motion is critical to the patient, vascularized free fibula,
retaining the proximal articular cartilage, can be used to
reconstruct the joint surface. Prosthetic devices for total wrist
arthroplasty are poor at present, and historically do not do
well in post-traumatic wrists regardless.
In summary, the goal of skeletal stabilization is to achieve
stable anatomic fixation to allow early range of motion and
rehabilitation. Soft-tissue stripping of bone is limited to only
that which is necessary for fixation. Comminuted fragments
with attached soft tissue are retained. Bone defects are treated
primarily whenever possible. The potential of exposed hard­
ware should not limit the choice of fixation. Exposed bone,
hardware, or joints are addressed with appropriate soft-tissue
coverage, whether it be pedicled or free.
Vascular reconstruction
Definitive revascularization is done once skeletal stabilization
is completed. Lacerated vessels are resected to healthy-
appearing vessel wall both proximally and distally. Contusion
along the adventitia suggests injury within the intimal layer
as well. A “ribbon sign” (convoluted or tortuous course of the
digital vessels) indicates injury to the media layer of the vessel
and requires resection of the length of the involved area and
reversed vein grafting (Fig. 12.4). Inflow is assessed, and if it
is not adequate, the vessel should be resected more proximally
until excellent pulsatile flow is achieved.
When possible, primary repair is preferred. However, it is
better to resect appropriately and to use a reversed vein graft
than to perform a primary repair under tension. Reversed
vein grafts are available from several sites. The most com­
monly used for long segments in the upper extremity is the
saphenous vein. For reconstruction in the hand, local grafts
from the dorsal or volar forearm can be used.
Reconstruction of the superficial palmar arch and its mul­
tiple common digital arteries may be difficult. Branched vein
grafts from the dorsum of the foot and use of the subscapular
artery and its branches have been described for this. The
descending branch of the lateral femoral circumflex artery
may also be utilized as a smaller arterial graft to make use of
its branches to reconstruct the arch. The conventional method
is to harvest two Y vein segments from the volar forearm and
to perform end-to-end or end-to-side anastomoses as neces­
sary. Vein grafts should be routinely used to reconstruct
venous outflow if primary repair cannot be achieved. There
is almost no role for artificial grafts for vascular reconstruction
in the upper extremity distal to the axillary artery, particularly
in contaminated wounds.
When the need for coverage and vascular repair present
themselves simultaneously, one can consider “flow-through”
free flaps to both bridge the arterial defect and obtain
coverage at the same time. The radial forearm free flap
is very useful in this regard, as the radial artery offers an
excellent choice for a long bypass.3 Due to trauma to the

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CHAPTER 12 • Reconstructive surgery of the mutilated hand
with tendon grafts or Silastic tendon rods. Immediate recon­
struction is favored with use of available donor tendons
(palmaris, plantaris, local tendons that cannot be recon­
structed, and toe extensors).
In flexor tendon injuries in the hand, priority is usually
given to reconstruction of the profundus tendons. If there is
trauma to the distal interphalangeal joint requiring fusion,
priority is rather given to the superficialis tendon. The lesser
priority tendon can be used for reconstruction of the other
when necessary. It can be used as a donor tendon for other
sites or for pulley reconstruction as necessary. One should pay
close attention to the status of the pulleys in the fingers, and
the A2 and A4 should be reconstructed with portions of
tendon grafts when necessary.
forearm, however, this may not be an appropriate choice of
flap. In this case, the anterolateral thigh flap with its long
segment of the descending branch of the lateral femoral
circumflex can be utilized.4,5 Small venous free flaps with
arterialized segments of vein can be utilized to great utility
for revascularization of fingers in the face of a soft-tissue
loss volarly.6
Musculotendinous reconstruction
Primary tendon repair is preferred when permitted by the
injury. There is often a crush or avulsive component to the
injury, which may preclude primary repair. In these cases,
treatment options include primary or delayed reconstruction
Fig. 12.3  (A,B) Preoperative X-rays of patient
suffering crushing injury to the wrist. Note midcarpal
capitate fracture/dislocation and radial styloid
fracture. (C,D) After reduction and fixation with
spanning plate. (Courtesy of Dr. Ramesh Srinivasan,
the Hand Center of San Antonio.)
A
B
C
D

275
Introduction
clearer at the time of injury rather than later and dissecting a
nerve out of a scarred bed is technically challenging (Fig.
12.5). Common donor nerves include the sural or saphenous
nerves, sensory branch of the radial nerve (if lacerated from
the injury), medial or lateral antebrachial cutaneous nerves,
and the posterior interosseous nerve. In multiple nerve inju­
ries, primary nerve transfers can be performed.8 These include
transfer of the anterior interosseous nerve (distal to the branch
to the flexor pollicis longus) to the motor branch of the ulnar
nerve and transfer of the sensory branch of the radial nerve
to the digital nerves of the thumb and index finger.9 When a
nerve defect is greater than 15 cm, an end-to-side neurorrha­
phy of the distal stump of the injured nerve to a neighboring
intact major nerve can be done, although functional outcomes
of this procedure are generally poor.
Skin and soft-tissue reconstruction
Appropriate soft-tissue coverage is of paramount importance
for coverage of bone, joint, tendons, neurovascular structures,
and hardware. The selection of coverage should provide a
gliding surface for mobile structures and enhance vascularity
in the injured area.
Extensive skin and soft-tissue loss is one of the major
problems in the mangled upper extremity. Isolated skin loss
may be managed by split-thickness skin grafting (if not over
a bony prominence, hardware, or exposed tendons). Local
random skin flaps have limited utility even in superficial soft
tissue defects owing to their restricted mobility, precarious
blood supply, and frequent involvement in the injury.
Soft-tissue loss can be managed in a variety of ways. A
simple approach is to leave the wound open and let it heal
by secondary intention with granulation tissue. However,
exposed tissues sensitive to desiccation, such as nerves and
tendons, will become necrotic, scarring will be promoted, and
function will be compromised. Local muscle flaps are usually
not suitable because of their proximity to the zone of injury,
the limited amount of coverage that they provide, and the
resulting functional deficit. Two-stage distant pedicled flap
procedures are avoided when possible; immobilization of the
reconstructed area will lead to stiffness and swelling. If this
means of coverage is required, the most common sources are
the pedicled groin flap, cross-arm flap, thoracoacromial flap,
and abdominal flap. In mangling injuries, the need for exten­
sive coverage, reliable vascularity of the flap, and early
mobilization usually necessitates use of axial flaps (local or
regional), one-stage distant pedicled flaps, or free flaps. The
type of coverage depends on site and extent of the defect. This
is particularly important for bone, tendon, nerve, and hard­
ware coverage, as well as for facilitation of future reconstruc­
tive procedures in planning a staged reconstruction. As
discussed above, one should think one or two steps ahead in
terms of what reconstructive procedures are potentially going
to be performed later under or though the chosen flap.
Fasciocutaneous flaps or cutaneous flaps with subcutane­
ous tissue are recommended when tendons are exposed as
this tissue facilitates tendon gliding. However, many fascio­
cutaneous flaps over time do not have a good cosmetic
appearance (color match can be poor and they can be too
bulky). The primary fasciocutaneous flaps used with accept­
able cosmetic appearance include the radial forearm flap, as
either a free or rotational flap; the lateral arm flap; and the
Fig. 12.4  “Ribbon” sign in an avulsed finger. Note corkscrewing of vessel which
indicates severe avulsion damage to the adventitial layer.
Functional reconstruction of muscle deficits and tendon
injuries should be done immediately whenever possible.7
Unrecoverable muscle function can be treated with tendon
transfer, and it is preferable to perform this as a primary
procedure. However, this can also be performed at a later
stage of reconstruction. Delayed transfers are generally more
difficult because they have to be performed through a scarred
tissue bed, and this requires additional surgical procedures
and further delays the patient’s rehabilitation and recovery.
When no donor tendons are available for transfer muscle
function can be restored with functional free muscle transfer.
The gracilis is the most commonly used muscle for functional
reconstruction and can actually provide both coverage and
restoration of muscle function to the fingers. Again, this can
be done either primarily or at a later stage of reconstruction,
however primary reconstruction is favored as available nerves
and vessels are easier to locate and one is not operating
through a scarred bed of tissue. This procedure will be dis­
cussed in more length below and in Chapter 35.
Nerves
Nerves may have internal derangement without loss of ana­
tomic continuity and they can be partially or completely
disrupted. Severe contusion to the nerve with internal hemor­
rhage without actual division may mitigate against functional
return, however contused or attenuated nerves are usually
left intact. If lacerated, the nerve ends should be debrided
serially under magnification until healthy-appearing fascicles
appear. Do not compromise the resection to preserve length,
as nerve regeneration will not occur through scarred nerve
tissue, and nerves repaired under tension also do not recover
well.
Mobilizing the proximal and distal stumps to achieve
primary repair is not recommended because this results in
devascularization of large segments of the nerve. Mobiliza­
tion can be done over a 1- to 2-cm distance to allow repair,
but to avoid repair under tension, nerve grafting is preferable.
If a staged repair is planned, nerve ends are tagged with 6-0
polypropylene suture for later identification. Primary nerve
grafting is recommended, however, as the orientation is much

276
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CHAPTER 12 • Reconstructive surgery of the mutilated hand
gracilis is most commonly used for this transfer in the forearm
as noted above.
Postoperative management
In the immediate postoperative period, the extremity is
splinted in an appropriate position to prevent capsuloliga­
mentous shortening and tension on repaired structures. Eleva­
tion is necessary to reduce edema and help control pain. The
patient’s pain and anxiety should be adequately controlled.
The ambient temperature should be at least 25°C and adjusted
to the patient’s body temperature. Hydration should be suf­
ficient to maintain urine output between 80 and 100 mL/hr.
Anticoagulant therapy is used by many surgeons. However,
the authors are selective in using heparin; aspirin is used daily
for 4 to 6 days after surgery. Appropriate antibiotic therapy is
continued in the postoperative period and later modified as
necessary according to culture results.
Extremity and flap monitoring is critical. Early recognition
of arterial hypoperfusion or venous congestion will occur
only in a well-monitored environment with trained nursing
groin flap. These can all be utilized as free flaps, but the groin
flap is generally utilized today as a pedicled flap due to the
small size and short available vascular pedicle. An alternative
to the fasciocutaneous flap is a fascial flap. Donors for this
include the temporoparietal fascia, the parascapular fascia,
and the radial forearm fascia. The free fascial flap is placed on
the defect and then covered with an unmeshed split-thickness
skin graft. It has been our experience, though, that it can be
difficult to lift a fascial flap later for tenolysis or other
procedures.
Muscle flaps are used when a moderate to large soft-tissue
defect is present. Although muscle flaps may be harvested
with a skin component, harvesting of muscle alone is pre­
ferred. This is then covered with a split-thickness skin graft.
In the arm and elbow, the latissimus dorsi can be used as a
one-stage distal pedicled rotational flap. Most other recon­
structions are done with a free muscle transfer using the
gracilis, rectus abdominis, latissimus dorsi, or serratus ante­
rior. When a functional deficit is present, consideration should
be given to use of a functional free muscle transfer to provide
both functional restoration and soft-tissue coverage. The
Fig. 12.5  (A) View of upper arm in patient suffering avulsive injury and global nerve
palsy in the hand. (B) Close-up view of nerves. Median and ulnar over background
in front and radial behind. (C) Nerves after debridement to healthy fascicles and
sural nerve grafting.
A
B
C

277
Basic science/disease process
Mangling injuries are produced by high-energy forces.
High-power equipment – agricultural (corn picker, grain
auger), industrial (punch press, power saw), or household
(lawn mower, snow blower) – may cause such an injury (Fig.
12.6). In addition, gunshot wounds, explosives, and motor
vehicle accidents (especially with the arm of the patient being
outside the car window11) account for many cases. The injury
may have a combination of sharp, crushing, avulsive, and
thermal components. The wound may be severely contami­
nated, depending on the location and mechanism of injury.
Types of injury
Amputation involves complete severing of a part from the
body. This is common in the upper extremities, and ranges
from fingertip amputation (an extremely common injury and
one of the most common ones seen in emergency depart­
ments) to amputation of the entire upper extremity at the
shoulder. While fingertip amputations may be managed in
any number of ways (most by benign neglect) with excellent
outcomes, management of major limb amputations can lead
to significant functional and cosmetic deformity and present
significant local and systemic problems in management.
Replantation of amputated parts requires microsurgical skills
and may necessitate other procedures to lead to final restora­
tion of function.
Crush injuries may and may not lead to amputation, but
involve significantly more damage to the involved structures
than straightforward and sharp amputations. These injuries
often lead to major loss of bony and soft-tissue structures and
have much poorer results both in terms of survival (if replan­
tation is required) and function. Familiarity with various
options for bony and soft-tissue reconstruction, as well as
nerve and musculotendinous reconstruction, is often required.
Avulsion injuries primarily involve the soft tissues of the
upper extremity. The etiology of these injuries is often due to
industrial accidents in roller press machines which cause both
bone dislocations in the hand and can lead to loss of the entire
soft-tissue envelope to the hand (Fig. 12.7). These injuries
predictably lead to severe scarring and often poor function
despite the type of reconstruction performed. Early motion is
essential for reasonable outcomes in these injuries.
staff. If there is a question about tissue viability, the dressings
are released and the entirety of the revascularized tissue is
exposed for further assessment of perfusion, congestion,
temperature, turgor, and color with Doppler examination.
Release of the dressings alone may be sufficient to alter the
vascular issue. If viability is still in question after 30 minutes,
immediate re-exploration and further assessment may prevent
failure of the revascularized tissue, whether it be the extremity
or a free flap.
Early and motivated rehabilitation of the extremity is an
important factor in achieving a successful outcome. Early
motion reduces edema, adhesions, and scarring. It prevents
muscle atrophy and facilitates healing of the soft tissues by
remodeling of collagen fibers. The details of the rehabilitation
program are determined by the existing injuries and the
reconstruction procedure.
Basic science/disease process
Upper extremity function and facial appearance and expres­
sion are the two centrally defining features of our humanity.
Movement of the hand through space along with precise
grasp, pinch, and positioning allows us to perform the most
rudimentary to the most highly complex tasks to actualize the
entire range of our wishes, dreams, and ambitions. Man
without hands is akin to a plane without wings. Nearly all
tasks combine positioning of the hand with shoulder, elbow,
and wrist motion followed by intricate manipulation of finger
joint position with both intrinsic and extrinsic muscle force
modulation.
Injuries to any part of the upper extremity, no matter how
minor, may immediately compromise and chronically debili­
tate the user’s ability to perform. Witness the enormously
negative impact of work-related injuries on our economy.
Productivity is reduced, medical costs are escalated, and the
work environment is disrupted, not to mention the enormous
personal and family suffering caused by pain and loss of
function. Some have estimated the cost to our economy
from upper extremity trauma to run in the hundreds of
billions of dollars. In light of the significantly problematic
consequences that result from extensive upper extremity
injuries, it is paramount that early diagnosis and, more
important, strategically sound treatment be instituted from
the outset.
Extensive skin and soft-tissue trauma along with composite
injuries involving multiple structures must be managed
actively, there being few circumstances in the hand in which
open wound management and healing by secondary inten­
tion play a role. Maximum preservation of motion and sensi­
bility should be ever present in the mind of the reconstructive
surgeon from the moment of first evaluation, with prompt
wound closure given high priority.
The term mangled is commonly used to describe the hand
and upper extremity after major trauma. Gregory et al. used
the term mangled to describe a severe injury to at least three
of the four organ and tissue systems of skin, bone, vessel, and
nerve.10 According to the Oxford English Dictionary, to mangle
is “to reduce by cutting, tearing or crushing to a more or less
unrecognizable condition”. Each of these definitions implies
a severe, high-energy injury that involves multiple anatomic
structures, usually over an extended topography.
Fig. 12.6  View of hand after it was caught in a 9-ton press. This is the definition
of mangled, however it was also unfortunately unsalvageable.

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CHAPTER 12 • Reconstructive surgery of the mutilated hand
by an experienced team, and early, motivated rehabilitation
reduce the morbidity associated with these injuries.
Diagnosis/patient presentation
Evaluation of the patient in
the emergency room
Evaluation of the patient with a high-energy injury includes
a thorough trauma work-up, beginning with the basics of
airway, breathing, and circulation. Whereas the mangled
extremity is often the most apparent injury, careful evaluation
of the entire patient for potential life-threatening or other
associated injuries is critical to formulation of a treatment
plan.
The patient’s history focuses on the time and mechanism
of injury and any associated chemical, electrical, or thermal
components of the injury. The mechanism of and the time
from injury, which is especially crucial when ischemia is
present, are the most important factors in determining the
zone of injury and predicting the ability to salvage the extrem­
ity. A medical history is taken to determine the patient’s ability
to tolerate a prolonged anesthetic with the potential for sig­
nificant blood loss, fluid shifts, and release of metabolic
byproducts after revascularization of ischemic tissue. Medical
conditions such as diabetes, hypertension, vasculitis or other
inflammatory diseases, and smoking history can adversely
affect outcome and should be considered in developing a
treatment plan. Similarly, the occupational history and social
Fig. 12.7  Hand of 25-year-old male with avulsion injury of entire skin of hand and
distal portions of phalanges. This is a devastating injury and will require a number
of procedures for adequate reconstruction.
Fig. 12.8  (A) 27-year-old male who got his hand caught in a roller press. Note avulsion of muscles and position of hand. (B) AP X-ray of hand and wrist. Patient has a
longitudinal dislocation between the 3rd and 4th rays (a “peri-hamate peri-pisiform” injury) which is typical of crushing injuries to the hand. (C) Lateral X-ray of the hand and
wrist. Note the carpometacarpal dislocation of the thumb in this view, also fairly typical of crushing injuries to the hand.
A
B
C
Roller injuries occur when the hand is caught between two
rollers whose function is usually to compress sheets of metal.
This can result in an array of injuries including degloving of
the skin of the hand, fractures, and potentially crushing of all
the tissues of the hand and forearm. These are devastating
injuries and call on the entire armamentarium of the surgeon
to manage the bony fractures, dislocations, and coverage and
functional issues from soft-tissue damage (Fig. 12.8).
Careful evaluation of both the patient and the injury, for­
mulation of a treatment plan, meticulous operative treatment

279
Diagnosis/patient presentation
Emergency room to operating room –
making a plan
Planning in patient management starts when the patient is
first seen in the emergency room. As a general rule, however,
multiple examinations of the extremity by multiple physicians
(emergency physician, intern, resident, fellow, etc.) is to be
avoided. In the unanesthetized patient this is painful and
leads to further anxiety which can lead to vasospasm and
further problems. The quality of circulation in the extremity
must be assessed, and a rough idea of the soft-tissue deficit
should be obtained in a single examination. X-ray studies of
the extremity (and of the distal portion in cases of amputa­
tion) done in the emergency room can also give an idea of
what might be necessary in terms of bony fixation. Consent
must be obtained for whatever might be necessary to include
bony fixation, revascularization (including potential vascular
graft donor sites), and coverage. While an emergency free flap
is rarely indicated, the patient should be informed of potential
soft-tissue flap donor sites as well. The patient and family
should also be informed of the need for further surgery,
including second looks/wash-outs which should be per­
formed in the first several days.
Planning for reconstruction
In deciding how best to treat the mangled extremity, a variety
of factors are considered. They can be broadly classified as
patient and extremity factors. Pertinent patient factors include
the general condition, age, handedness, occupation, functional
requirements, and socioeconomic background of the patient.
Associated injuries resulting in cardiopulmonary or hemody­
namic compromise as well as pre-existing medical problems
will mitigate against a lengthy salvage procedure, especially
in a patient of advanced age. Conditions adversely affecting
the blood vessels, such as diabetes mellitus, vasculitis, or
smoking, will increase the risk of anastomotic failure and
should be taken into consideration. Psychiatric disorders may
be a contraindication to reconstruction because of possible
repeated suicide attempts or anticipated noncompliance with
the rehabilitation program. A morose patient may be tempo­
rarily incompetent to participate in determining treatment.
Because time is a critical factor in treatment, it may be better
to err in attempting to salvage an extremity than to perform
a primary amputation.
Important extremity factors include the time since the injury,
the severity of the injury, and the previous functional status
of the extremity. Warm ischemia time longer than 6 hours
results in progressively irreversible changes in cellular struc­
ture of muscle. Even if vascularity is re-established, tissue
necrosis will not be avoided. Systemic risks of revascularizing
a limb with prolonged ischemia must also be considered and
addressed. These include acidosis, hyperkalemia, and rhab­
domyolysis. In amputations of digits, where no muscle is
present, the delay until reperfusion with use of cold ischemia
may be extended to 20 hours. Finally, the previous condition
of the extremity is considered. A history of major trauma,
neurologic disease, or congenital deformity resulting in
impaired function may not justify a salvage attempt.
The multitude of factors and the complex interrelations
among them make reaching a decision a difficult task, even
for experienced surgeons. Specialized scoring systems have
history are important in determining postoperative compli­
ance and in addressing the reconstructive goals. The presence
of one or several adverse factors is not an absolute contrain­
dication to salvage of an extremity or to microvascular repair
and/or reconstruction. However, these factors should be
considered in selecting the type of reconstruction to be used
and in better predicting outcome.
Examination of the mangled extremity should be systematic
and address vascular status, skeletal stability, motor and
sensory function, and soft-tissue loss. The vascular status is
evaluated by assessment of peripheral pulses, color, tempera­
ture, and capillary refill time in the distal extremity. Pulse
oximetry is generally readily available in the emergency
department and is helpful in assessing ischemia in the fingers.
Doppler examination and angiography can also be used. Arte­
riographic exam in the mangled extremity may simply delay
revascularization, however, and should be utilized very selec­
tively. Skeletal injury is assessed clinically by the presence of
deformity, crepitance, or bone tenderness. Radiographs should
be taken of the entire extremity – particularly to evaluate the
joints above and below the level of injury. A motor and sensory
examination should be documented. The examiner should be
aware that motor or sensory loss can result from muscle,
tendon, or nerve injury as well as from ischemia. The ultimate
assessment of the mangled extremity occurs in the operating
room, however, after the debridement of nonviable tissue.
In the case of limb-threatening ischemia in a mangling
injury, evaluation of the status of the vessels is generally
performed in the operating room without the delay necessary
for an arteriogram. An intraoperative angiogram may aid in
determining the level and extent of arterial injuries, however.
Radiographs taken in the operating room are usually of better
quality than those taken in the emergency department because
the extremity can be positioned without causing the patient
discomfort. Traction radiographs allow better delineation of
the fracture pattern and number of fragments, especially in
evaluating intra-articular fractures about the wrist and elbow.
Photographic documentation of the injury should be done
throughout the course of treatment from initial evaluation to
conclusion of treatment.12
Clinical tips
Initial management
• Debridement of all nonvital tissue is essential
• Save intact vessels, nerves, and tendons
• May need to return in 24–48 hours to reassess
• Fixation is important in management
• Internal fixation is superior
• Consider “spanning” plates across joints
• As you clean up, consider timing and type of coverage
• May need a flap early to cover neurovascular structures
• Can re-debride under flap
• Consider single-stage reconstruction when appropriate
• Reconstruct tendons with grafts
• Reconstruct nerves with grafts
• Consider delayed bony reconstruction or vascularized
bone transfer

280
SECTION II
CHAPTER 12 • Reconstructive surgery of the mutilated hand
tendons (or wounds with gaps in tendons) with some type of
fascial or fasciocutaneous flap.
Timing of reconstruction
Definitive reconstruction of the mangled extremity may be
undertaken either early or late. In both reconstructive plans,
the initial treatment includes aggressive debridement, skeletal
stabilization, revascularization, and soft-tissue coverage.
Early soft-tissue coverage is of paramount importance to limb
salvage.15 This improves the vascularity to the traumatized
area, limits exposure to hospital pathogens, and reduces the
risk of infection. Coverage is technically easier to perform
early; with delay, edema obscures tissue planes, vessels
become friable, and vascular grafts may be needed to perform
microanastomoses out of the zone of injury.16
Reconstruction of bone, tendons, and nerves can be per­
formed either early or late. Early reconstruction implies repair
or reconstruction of all injured structures during the initial
phase of treatment, up to 10 days from the initial injury.
Delayed reconstruction implies staged repair of bone, tendon,
nerve, and soft tissue at different periods in the course of
treatment. The choice of the reconstructive approach depends
on the characteristics of the injury and the preference and
expertise of the treating surgeon.
Early reconstruction (single-stage)
This approach requires debridement of the wound followed
by reconstruction of all structures: bone, tendon, and nerve.
This is done ideally within 24 to 72 hours. Primary corticocan­
cellous bone graft or vascularized bone grafts, nerve grafts,
tendon transfers, tendon grafting, and free functional muscle
transfer are performed at the time of soft-tissue coverage.
Reconstruction can be delayed up to 10 days in the event of
a severely contaminated wound, which requires several
debridements to reduce the contaminant load.
Primary reconstruction of all structures is technically easier
to perform when the tissue bed is fresh rather than later
through a scarred soft-tissue bed. It decreases the number
of subsequent procedures, total hospitalization time, and
cost. Also, rehabilitation can begin earlier. The development
of adhesions is decreased, and the functional outcome is
improved.17,18 This type of reconstruction by its nature,
however, usually mandates experience and skill with micro­
surgical repair (nerves) and tissue transfer (for complex and
composite tissue loss).7 If one lacks experience in this type of
reconstruction, it is usually best to get primary soft-tissue
coverage by whatever means is best and delay the reconstruc­
tion of the other structures until a stable soft-tissue bed is
obtained.
Delayed reconstruction (multiple stage)
In the past, delayed, staged reconstruction was the primary
method of treatment of severe injuries with multiple structural
defects. In this treatment plan, vascularity is established, and
the soft-tissue injuries are treated with serial debridements
performed at 24- to 72-hour intervals. Appropriate wound
coverage is performed when the wound is clean and all
necrotic tissue has been debrided. This should be within the
first 10 days from injury, regardless of the technique chosen.
Bone, tendon, and nerve reconstruction is delayed until “soft
been developed on the basis of lower extremity injuries. These
may offer valuable guidelines for evaluating the lower
extremity but cannot be applied well to the upper extremity.13
Each case is unique, however, and the final decision should
be an individualized one based on assessment of the patient
and extremity parameters as well as sound judgment. The
patient’s knowledge of the potential risks and benefits of
surgery and the possibility of early or later amputation is
important.
A third factor which is rarely discussed is the surgeon
factor. The skill and experience of the surgeon managing the
patient is extremely important in determining the outcome.14
While obviously the experienced surgeon is more likely to
have a more favorable outcome, reasonable results can be
obtained by others if they follow basic principles and stick to
what they are comfortable doing. The surgeon who only
occasionally performs microsurgical tissue transfer may better
serve his patient by performing a pedicled flap for initial
coverage than attempting an esoteric and complex microsur­
gical procedure that he read about once. It is always better to
perform an initial reconstruction using a technique that you
are familiar with rather than attempting to perform a proce­
dure that has a high potential for failure. In any case, it is
preferable to refer a patient with a complex extremity injury
to a center which routinely deals with these problems rather
than attempt reconstruction if one is not familiar with these
types of problems.
The single most important factor in planning reconstruc­
tion of a mangled extremity is to in fact have a plan and to
know what you are going to need to do next. While the merits
of early reconstruction and primary vs. delayed reconstruc­
tion will be discussed below, the surgeon must have a plan
and be ready to alter this depending on the findings at surgery
and potential problems as they arise. The reconstructive
surgeon must always think at least one or two steps ahead of
where he is today in order to maximize his reconstructive
efforts. Anticipation of what will need to be done in the future is
the primary determinant of what needs to be accomplished today. If
one decides to delay bone grafting but proceed with soft-
tissue coverage (which is often applicable) the soft-tissue
reconstruction should be done in such a manner to make the
secondary bony reconstruction both feasible and easy. If there
is a large bony defect which may potentially require vascular­
ized bone grafting, the soft-tissue flap should be performed
in such a manner as to facilitate performance of the vascular­
ized fibula transfer later. This may mean that a pedicled
soft-tissue flap is a superior choice to a free flap (to save
recipient vessels for the later bone transfer), but if this type of
coverage is not feasible, then the anastomosis for the soft-
tissue transfer should be performed in a location and to a
vessel which will not make a second microsurgical bone
transfer technically more challenging that it already is. The
same philosophy applies when one anticipates later toe
transfer(s) for thumb or digital reconstruction. Another
example is the potential need for later tenolysis or tendon
grafting under a soft-tissue flap which is placed at the initial
surgery. There is no question that it is much easier to re-operate
through a soft-tissue flap than it is under a muscle flap. Muscle
flaps scar rather severely underneath when placed on a
wound, while soft-tissue flaps do not. Tendons also glide
much easier under a fascia or fatty tissue flap than they do
under a muscle flap, thus it is preferable to cover exposed

281
Treatment/surgical technique
for a replantation or revascularization attempt. In this setting,
amputation is not a failure but rather a step toward stabiliza­
tion of the patient and rehabilitation of the extremity.
Spare-parts utilization
In some instances in severe injury to the upper extremity,
there may be uninjured tissues, which while not salvageable
in their native position, may be utilized for coverage and/or
reconstruction of the defect. This is certainly the case in mul­
tiple digital amputations when the thumb is severely damaged
and another finger can be placed in the thumb position to
reconstruct this important function (Fig. 12.9). Likewise, the
tissue from an amputated finger or forearm can be utilized for
coverage of another defect, or even an amputation stump, to
salvage length and preclude the necessity for another flap.
One should remember to salvage whatever may be useable
for reconstruction from parts not deemed suitable for replan­
tation, and this can include skin (grafts or flaps), bone graft,
joints (vascularized or not), nerves and tendons.
Treatment/surgical technique
Options for bony reconstruction
Mangling injuries to the hand and upper extremity usually
involve the bone structure as well as the soft tissue. This can
tissue equilibrium” is achieved. This is when the tissues have
healed and are free of infection, edema has resolved, scar
tissue has matured, and the joints are supple and have
achieved their maximum passive range of motion. Delayed
reconstruction is a good option when the patient’s comorbidi­
ties or a severely contaminated or infected wound prevents
early definitive treatment.
Salvage versus amputation
The surgeon may be confronted with the decision to attempt
salvage or to amputate a mangled, nonviable upper extremity.
The appropriate decision is difficult because recovery of func­
tion in a salvaged extremity may be limited or absent.19 Thus,
multiple reconstructive procedures with associated morbidity,
prolonged hospitalization, disability time, psychological dis­
tress, and financial demands may be too expensive a price to
pay for the end result of a useless and painful limb. In contrast
to prostheses for the leg, prostheses for the hand and forearm
offer limited restoration of function. Even with the most
advanced prosthetic devices available today, there is no
sensory feedback from the prosthesis, and for most purposes,
this makes a prosthesis less functional than a sensate yet
injured hand. Thus, most mangled upper extremities should
be considered for salvage. Nevertheless, serious associated
injuries or diseases, ischemia time longer than 6 hours, and
parts that are severely crushed, avulsed, contaminated, or
injured at multiple levels constitute unfavorable conditions
Fig. 12.9  (A) Hand of 38-year-old male after saw injury with amputation of index
and middle fingers with mangling injury to thumb. Thumb is not replantable.
(B) View of index finger after debridement and identification of structures for
replantation. (C) Hand after replantation of index finger in thumb position.
A
B
C

282
SECTION II
CHAPTER 12 • Reconstructive surgery of the mutilated hand
severe contamination, a second wash-out at 48–72 hours
should be planned with elevation of the soft tissues, further
debridement, and irrigation.
Bone loss may or may not present a problem. Small seg­
ments may not preclude healing, but large segments may
need reconstruction. Bones should still usually be placed in
proper relationship with internal fixation whenever possible,
and as noted above, with the ends in anatomic alignment
around the gap. In heavily contaminated wounds, primary
bone grafting (with non-vascularized grafts) is not indicated,
as the bone graft could be lost to infection. Soft-tissue cover­
age should be obtained first and the gap dealt with by either
standard bone graft (if the defect is less than 6 cm) or vascu­
larized bone grafting (usually a free fibula transfer in the
upper extremity). In cases where a significant amount of bone
has been lost in both bones of the forearm, an external fixator
may be required until adequate soft-tissue reconstruction can
be performed and internal bony stabilization applied.
Options for vascular reconstruction
Ideally, primary repair of vascular injury will be possible, but
if there is any doubt about potential injury to the ends of the
vessels, one should rapidly perform a bypass graft. For most
purposes in the upper extremity, this is going to involve the
use of vein grafts. Artificial conduits smaller than 6 mm
(primarily expanded PTFE or Gore-Tex) have extremely poor
patency rates, and are not indicated for bypass grafting. That
leaves primarily venous grafts and in some instances arterial
grafts. For long segments in the upper arm or forearm, the
preferred vein graft is the saphenous from the medial thigh
or lower leg (Fig. 12.11). The lesser saphenous, located on
the posterior-lateral portion of the ankle and running up the
midline of the calf, presents another option if the saphenous
is absent or severely varicose. Arm veins (the basilica or
cephalic) can be utilized for bypass in the arm, but in the face
of severe injury, these may not be available and in fact may
be needed for venous outflow (particularly in the face of
replantation).
For reconstruction of injuries distal to the wrist, small vein
grafts from the volar forearm or dorsal foot may be used. The
use of arterial grafts in reconstruction of the ulnar artery and
arch has some advocates, and donor sites for this include
the subscapular–thoracodorsal axis from the axilla and the
descending branch of the lateral femoral circumflex artery in
the lateral thigh.4 Both of these give a reasonable size match
for the vessels of the arch, and may offer multiple side
branches to anastomose to the common digital vessels as they
come off of the reconstructed arch. In cases of traumatic injury
with ischemic distal tissue, however, the time it takes to
dissect these arterial grafts out (as compared to subcutaneous
veins) is probably not worth it. To date, we are not aware that
there is any proven benefit to utilizing arterial grafts over
venous grafts.
Another option in the face of a moderately large wound
with the need for arterial bypass grafting is the use of “flow-
through” flaps. As noted above, several flaps are available for
this, and the radial forearm free flap, anterolateral thigh,
temporoparietal fascia,20 and omentum have all be utilized as
arterial flow-through free flaps. One can also utilize arterial­
ized venous flaps, which have a great deal of utility in digital
revascularization to cover small volar defects and provide
range from dislocations to significant bone loss. Each of these
must be managed primarily to allow stabilization for vascular
and soft-tissue repairs. Dislocations are generally managed
with relocation and pinning with Kirschner wires, which
usually require 6–8 weeks in place to allow for healing of liga­
mentous structures. Crushing and roller press injuries com­
monly lead to longitudinal dislocations in the metacarpal and
carpal bones, most frequently between the 3rd and 4th rays
(axial loading dislocations or “meat cleaver” injuries). One
may also see the thumb ray dislocated with the trapezium on
the radial side of the hand. Ligament repair is rarely possible
in these injuries, and the bony injury can be missed due to the
fact that the soft-tissue issues are often quite dramatic (see
Fig. 12.8B,C). Management of these injuries is appropriate
reduction of the dislocations and/or fractures and pinning
(Fig. 12.10). Immobilization is needed for 6–8 weeks. Other
wrist dislocations are usually managed in a similar manner.
Fractures of the hand are often best managed with simple
K-wire fixation, as this is a rapid and reliable technique.
Taking a great deal of time to perform plate fixation in the
case of severe injuries in the hand is often counter-productive,
especially if the distal extremity is ischemic. This type of fixa­
tion usually will not allow early motion, but this is frequently
difficult to do in any case in mangling injuries. On the other
hand, fractures of the radius and ulna are best managed by
internal plate fixation. This can be performed relatively
rapidly, and gives very stable fixation. We prefer to utilize
stainless steel locking plate fixation, and ideally there should
be three screws placed on either side of the fracture. The state
of the soft tissues should not be a deterrent to plate fixation,
as providing good soft-tissue coverage (with an appropriate
flap) should be part of the initial plan. The bone must be
thoroughly debrided and contaminated fragments with no
blood supply should be discarded, however. In the case of
Fig. 12.10  X-ray of patient shown in Fig. 12.7 after reduction and pinning of
dislocations using Kirschner wires.

283
Treatment/surgical technique
and/or grafts should be surrounded with well-vascularized
tissue. This may require the use of vascularized flap transfer
to maximize nerve recovery, however a flap may be needed
regardless. Nerve repairs and nerve grafts should not be done
if there is inadequate soft tissue surrounding the repair and
should certainly not be placed under skin grafts.
Primary repair of damaged nerves is the ideal, but if this
cannot be achieved, the nerve should be grafted. Small gaps
of smaller, sensory nerves may be treated with any of the
number of “tubes” available,22 however their utility in larger
nerves and in longer gaps remains unproven.23,24 The recently
approved nerve allograft has shown some possible applica­
tion in nerve gaps, but the results in larger nerves have not
proven to be the equal of autologous nerve grafts.25 Autolo­
gous nerve grafts remain the gold standard, and a number of
donor sites are available. The most commonly utilized is the
sural nerve running from the posterior knee to the lateral
ankle, but other peripheral sensory nerves can be utilized as
arterial inflow at the same time, while larger flaps based on
the saphenous vein with large skin paddles have been suc­
cessfully utilized.21 Another option in the case of large seg­
ments of amputated tissue is to provide both coverage and
salvage of length utilizing all or a portion of the amputated
tissue as a flow-through flap. The use of all of these flaps for
both coverage and bypass is unusual, but the surgeon dealing
with severe extremity injuries should be familiar with the
options.
Nerve reconstruction
The ideal time for nerve reconstruction is usually at the time
of injury, because it is easiest to determine level of damage
(by observing bruising of the nerve), and dissection and ori­
entation of the nerve are obvious prior to the onset of scarring.
Nonetheless, the goal should be repair of nerve damage at the
time of initial treatment with the caveat that nerve repairs
Fig. 12.11  (A) Arm of patient after vehicle roll-over with crush-avulsion injury.
There were no palpable pulses in the wrist and the hand was cool. Surgeons at an
outlying hospital planned to amputate the limb. (B) View of brachial artery after
excision. Note severe intimal avulsion injury in mid-portion. (C) Portion of
saphenous vein harvested for revascularization. Note branch taken with graft, which is
to be utilized for anastomosis to free muscle transfer for coverage. (D) Vein graft
distended with blood after removal of vascular clamps.
A
B
C
D

284
SECTION II
CHAPTER 12 • Reconstructive surgery of the mutilated hand
many smaller wounds in the upper extremity are amenable
to small local or regional flaps, this discussion centers on the
use of major axial-based pedicle or free flaps for the manage­
ment of larger wounds.
Wounds should be definitively closed as soon as the wound
bed is clean. This applies equally to flap coverage as well as
simple primary closure. As discussed above, wound debride­
ment is essential to provide control of tissue necrosis and
infection. If the status of the tissue is in doubt, serial debride­
ments should be performed to avoid removal of viable tissue
and yet assure a well-vascularized wound with minimal
bacterial contamination. In patients with vital structures
exposed, it is often best to place a muscle flap (usually a free
muscle flap), with the plan to return to the operating room
every 48 hours. The flap is not definitively sutured down, and
is lifted at each subsequent procedure and debridement and
irrigation is carried out. Once the muscle flap starts becoming
adherent to the underlying tissue and there is a decrease in
cloudy fluid under the flap, it is ready for definite insetting
and coverage with a skin graft (Fig. 12.12). Vacuum-assisted
wound closure provides an excellent temporizing measure
between debridements,31,32 and may be utilized in the upper
part of the arm to optimize a wound bed prior to skin grafting.
This wound management technique has the advantage of
removing edema and exudates from the wound and tends to
keep swelling down in our experience. It should be utilized
with caution in the hand, however, as extended use can lead
to increased scar (in the form of granulations) and a great deal
of stiffness. When utilized for a relatively short period of time,
however, it can be advantageous.
Types of flaps – cutaneous vs. muscle
Wounds of the hand and upper extremity can be covered by
either cutaneous flaps or muscle flaps. Myocutaneous flaps
are not utilized as much today as in the past, because surpris­
ingly they are not generally as cosmetic as a simple muscle
flap covered with a split-thickness skin graft. Muscle flaps
have always been thought of as superior for coverage of
untidy and/or infected wounds,29 however fasciocutaneous
flaps (at least with inclusion of the well-vascularized fascia)
are actually equally applicable to these wounds in terms of
the ability to manage infection.30 For hand coverage, we prefer
cutaneous flaps whenever possible, as it is usually easier to
re-operate through skin and subcutaneous fat than muscle.
While the muscle has the advantage that it atrophies over
time, there tends to be a fairly severe amount of scarring
under a muscle flap, which makes it more difficult to raise for
secondary procedures and mitigates against tendon gliding.
Thus, in general, we prefer to utilize any of the number of
fasciocutaneous flaps when covering the hand. In severe
injuries and in the face of a large dead-space needing to be
filled, however, muscle is probably superior. There has been
a great deal of interest in the so-called “perforator flap” based
on septal perforators supplying the skin.33 In the case of a
severe injury to the hand most perforator flaps available in
the upper extremity are probably too small to provide adequate
coverage. The severity of injury would also likely render
many of these flaps unavailable. While the hand and upper
extremity affords a large number of local and regional flaps,
this chapter will deal primarily with larger flaps and empha­
size free tissue transfer for coverage of the hand.
well. These include the saphenous nerve, the medial and
lateral antebrachial cutaneous nerve, the radial sensory
branch, and the medial brachial cutaneous nerve. These sec­
ondary sources of nerve graft are all limited by their diameter
and available length compared to the sural. When nerves are
grafted, an attempt must be made to line up similar areas of
fascicular bundles on the nerves to maximize functional
recovery.
As noted above, nerve transfers may be the best option
when multiple nerves have been injured.8,9 The reader is
referred to Chapters 32 and 33 in this text for more informa­
tion on these subjects.
Muscle and tendon repair and reconstruction
As with other structures, primary repair of muscles and
tendons is desirable. Tendons and tendon repair will also
require good, vascular soft-tissue coverage in order to both
survive and have maximal function. Flexor tendons in the
hand and fingers should be repaired with a double core suture
whenever possible, with the addition of an epitenon stitch of
fine monofilament suture to aid in gliding.26 In the case of
injury to both the flexor digitorum superficialis and profundus
tendons in the finger, one may opt to simply repair only the
profundus, particularly if the cut ends are untidy. If the ends
cannot be brought together, one must consider either primary
tendon grafting or the possibility of tendon transfer to provide
the missing function if it is essential. Primary tendon grafting
should not be performed in a bad wound bed, as the odds of
success are small. In these cases, one might also consider
placing silastic tendon rods along the course of the tendon
requiring reconstruction. Grafts can then be placed in the
tracts of the rods. This scenario would most commonly
accompany flap coverage, however, and in general cutaneous
flaps are a much better bed than muscle for placing tendon
grafts. Direct injury to muscles can often be sutured, but with
severe injury the damaged muscle will often require debride­
ment. Loss of function from removing muscle can be recon­
structed with tendon transfers on occasion but may require
free innervated muscle transfer to repair the loss.
Soft-tissue reconstruction
The approach to wounds of the upper extremity should follow
the usual parameters of soft-tissue reconstruction, the so-called
reconstructive ladder. In complex wounds, however, this
concept is being replaced by that of the “reconstructive eleva­
tor”, which proposes bypassing simple reconstructions and
providing the best functional coverage available (despite the
fact that a wound might “get by” with a skin graft.) Many
wounds nonetheless can be covered with a split-thickness
skin graft or with regional flaps, particularly in the hand. The
ultimate morbidity of any local or regional flap must be
considered, however, especially in relation to later hand func­
tion. Because the hand is highly visible, the cosmetic aspect
of certain local and regional flaps must be considered as well.
Although certain wounds may be adequately covered with a
flap from the same extremity, one should consider what offers
the best coverage in terms of the overall reconstruction.27 This
will often lead to use of a free flap for many hand and upper
limb wounds. The selection of flap coverage for a clean wound
allows use of composite tissue in many cases.28–30 Whereas

A
B
C
D
E
F
G
Fig. 12.12  (A) Forearm of young patient 48 hours after replantation at proximal
forearm level. Note necrotic-appearing muscle in forearm. (B) View of forearm after
debridement. Note exposed vein bypass grafts. (Patient and family refused
amputation at this point.) (C) Patient at same surgery after placement of rectus
abdominis muscle free flap to cover vessels and bone. (D) View of forearm at time
of re-exploration 48 hours after last debridement and flap cover. (E) Nonviable
muscle debrided at this surgery. Note rectus muscle flap flipped back to allow
debridement and wash-out and nonviable muscle in basin. (F) Forearm at third
wash-out, 6 days after injury. There was no further muscle necrosis noted on this
exploration, and the muscle flap was becoming adherent to the underlying tissues.
(G) Forearm at fourth wash-out, 9 days after injury. The wounds were very clean and
the muscle flap was sutured down and a split-thickness skin graft was placed. This
patient never developed evidence of sepsis and no infection developed in either the
soft tissues or bone, despite severe contamination at the time of injury.

286
SECTION II
CHAPTER 12 • Reconstructive surgery of the mutilated hand
Pedicled flaps – the groin flap
The pedicled groin flap remains one of the workhorses for
hand coverage. It provides a very large portion of soft tissue
which can cover many large defects in the hand and forearm.
This flap was the first axial-pattern flap described, and was
the first flap transferred microsurgically. Its use as a free flap
has been supplanted by many flaps with better vasculature,
but it should be a part of the armamentarium of every hand
surgeon. The blood supply is based on the superficial circum­
flex iliac vessels, which exit the femoral vessels in the groin
and run approximately two centimeters below and parallel to
the inguinal ligament (Fig. 12.13). This artery can be located
with a pencil Doppler and can be mapped out roughly to the
level of the anterior superior iliac spine (ASIS). This flap can
(and should be) taken out beyond the ASIS to allow the
proximal portion to be tubed to allow some shoulder and
elbow motion. It can be radically defatted, especially the more
distal portion (which will be placed on the hand), and con­
tours very well on the hand. It can be utilized for coverage of
the dorsal hand, forearm, first webspace, and has great utility
as a first step prior to toe transfer for thumb or digital
reconstruction.
The flap is first marked out with the vessel in the center
axis of the flap (which we prefer to locate with a Doppler)
(Fig. 12.14). Dissection proceeds from lateral to medial. Care
should be taken to avoid leaving a great deal of the fat from
Fig. 12.13  Anatomy of groin flap and superficial inferior epigastric artery (SIEA)
flap. Note that superficial circumflex iliac artery runs approximately 2 cm (or two
fingerbreadths) below the inguinal ligament. These two flaps can provide coverage
of very large wounds of the hand.
Superficial circumflex
iliac artery
Superficial inferior epigastric artery
Groin flap
SIEA pedicled flap
Femoral artery
Right leg
Umbilicus
Fig. 12.14  Locating the groin flap pedicle (superficial circumflex iliac artery) with
a pencil Doppler.
the iliac area on the deep surface of the flap, as this will have
to be removed regardless. The landmark to look for as dissec­
tion proceeds medially is the sartorius, as the artery pierces
the fascia of the sartorius at its medial edge. We prefer to
incise the fascia at the lateral edge of the muscle and stop the
dissection short of the space medial to the muscle, which
obviates damage to the vascular pedicle. Once the flap has
been dissected up, the donor site is closed. The edges of the
donor site should not be undermined, as this simply makes the
wound larger. Closure is facilitated by bending the hip and
placing a pillow under the knee. Once the donor site is closed,
the proximal portion of the flap is usually sewn into a tube.
The distal flap to be placed on the hand is defatted centripe­
tally, avoiding defatting the central portion too much to avoid
damage to the pedicle. Once this is done, the flap is sewn in
place in the defect on the hand (Fig. 12.15).
We have not seen a patient pull the flap off the hand once
they are fully awake, but it is prudent to either strap the arm
down to the torso or put a very large suture between the wrist
and the body until the patient is fully awake and on the ward.
If the arm is strapped, this should be removed once the patient
is cogent as it can lead to swelling and congestion in the hand.
In the postoperative period, the patient is instructed how to
move the shoulder and elbow through their available range
based on the tubed portion of the pedicle. The flap can usually
safely be divided at around three weeks, but this is dependent
on how well the flap is healed on the hand. If healing has been
delayed or there has been a partial dehiscence, division may
need to be delayed. The flap can also be “delayed” prior
to division, which is accomplished by either making a
small incision in the tubed portion and dividing all the deep
tissues (i.e., the pedicle) or conversely by incising the tube

287
Treatment/surgical technique
circumferentially to interrupt the subdermal plexus. Once this
has been done, the flap can usually be safely divided in 5–7
days.
At the time of division, the donor site is closed and the flap
is gently inset on the hand. Some advocate leaving the tubed
portion dangling on the hand to allow for potential demarca­
tion of the flap into viable and nonviable portions. Our experi­
ence has been that if the flap is well healed on the hand, the
flap can usually be safely trimmed and inset. The patient is
begun on a rigorous physical therapy program to regain
shoulder and elbow motion, as well as motion in the hand.
The pedicled groin flap can usually be contoured (defatted)
adequately when first placed on the hand, but on occasion
will require secondary procedures to inset and decrease the
bulk later. The primary advantage of the pedicled groin flap
is that it does not require microsurgical expertise, while the
primary disadvantage of this flap is that the hand is placed in
a dependent position and may lead to stiffness in the shoulder.
One caveat concerning the donor site is that if this area gets
infected, is it unwise to remove all the sutures. This will lead
to a gigantic wound which can be quite difficult to manage
(Fig. 12.16). It is much better to treat this by removing a few
Fig. 12.15  (A) Markings on groin of patient for pedicled groin flap. Patient had failed replantation of thumb and flap is to prepare for later toe transfer for thumb
reconstruction. (B) Flap elevated. Note size of donor defect after elevation. Be aware that undermining these edges simply makes this defect more difficult to close.
(C) Donor site has been closed primarily and flap has been tubed. (D) Flap after placement on hand. (E) Final view after three and a half weeks at time of division and
insetting of flap.
A
B
C
D
E
Fig. 12.16  Patient who suffered infection and dehiscence of groin flap donor site
after 3 weeks of wound care, prior to placement of split-thickness skin graft. This
can be avoided by treating the wound carefully in the postoperative period and
avoiding leaving it open.

288
SECTION II
CHAPTER 12 • Reconstructive surgery of the mutilated hand
The radial artery provides a large-caliber vessel for anastomo­
sis and may be used for revascularization of the distal limb if
necessary as a “flow-through” free flap. The venous drainage
is through the dual concomitant veins of the radial artery;
larger flaps can be drained by cutaneous veins. There has been
some controversy as to the primary venous drainage of these
flaps, but the venae comitantes offer reliable drainage even in
the absence of superficial veins. This flap may be innervated
by anastomosis of the lateral antebrachial cutaneous nerve,
part of which is invariably in the flap. The quality of sensation
in such reinnervated flaps is not great, but it may be useful.
If the patient has a palmaris longus tendon, it may be taken
in the flap as well and offers an excellent option for tendon
reconstruction, especially on the dorsal hand. Because the
tendon is taken with its surrounding tissue, it has excellent
gliding when transferred as part of the flap. A portion of the
volar radius may be harvested with the flap as well and is
particularly useful in reconstruction of missing segments of
metacarpal35,36 (Fig. 12.18). The radial artery can be taken with
the fascia only, which offers a thin flap that is particularly
useful in reconstruction of the palm.
The advantages of this flap as a free flap are its thinness,
its reliability (based on the radial artery), and the multitude
of other tissues that may be harvested with it. The main dis­
advantage of this flap is the resulting donor site, which must
usually be covered with a skin graft. The donor site is usually
aesthetically unpleasing but causes few functional problems.
Another relative contraindication to this flap is the loss of the
radial artery, but studies have shown that significant problems
are unusual. Cold sensitivity is seen but may be related to
other factors. Whereas the radial forearm flap is an excellent
free flap, it can usually be used as a distally pedicled island
flap for hand reconstruction (Fig. 12.19). If this flap is not
available for some reason as a pedicled flap, a skin flap is
usually selected from another area, and a radial forearm flap
is not taken from the contralateral uninjured arm.
Lateral arm free flap
This fasciocutaneous flap from the lateral distal upper arm is
based on the posterior radial collateral artery, a branch of the
profundus brachii.37 This vessel runs with the radial nerve in
the spiral groove and comes to lie in the posterior intermus­
cular septum between the brachialis and lateral head of the
triceps (Fig. 12.20). It gives arterial supply to the skin overly­
ing the septum as well as the underlying humerus (Fig. 12.21).
Distal to the intermuscular septum, the posterior radial col­
lateral artery has a rich system of anastomoses with vessels
in the proximal lateral forearm, which will allow extension of
the flap onto the proximal forearm. This flap can also be based
distally for coverage of small to moderate defects of the elbow
(Fig. 12.22). The pedicle for this flap is relatively short (5 to
7 cm), and the proximal artery has a small diameter (1.5 to
2 mm) compared with the flaps previously discussed. The
length of the pedicle is limited by the fact that it exits the spiral
groove with the radial nerve, and damage to this nerve must
be avoided in the dissection. Acland and Shatford, in unpub­
lished video demonstrations, have demonstrated a safe and
effective method to significantly lengthen the pedicle through
an alternative proximal dissection. The skin paddle can be
based directly over the intermuscular septum for a smaller
flap or extended distally for a larger one. Donor sites up to
Fig. 12.17  Anatomy of radial forearm flap. This flap can be taken anywhere over
the radial artery in the forearm, and can include skin, fascia, tendon, and bone.
Intermuscular septum
Radial artery
Brachioradialis
Flexor carpi radialis
Ulnar artery
Cephalic vein
Basilic vein
sutures and irrigating the area under the sutures daily which
will rid the area of infection without the morbidity of a
massive wound on the hip.
Free flaps – fasciocutaneous flaps
The radial forearm flap
This flap offers almost ideal characteristics for hand recon­
struction.3 Its primary application is as a pedicled flap, based
on reversed flow through the distal radial artery and venae
comitantes.34 It may be elevated on a proximal vascular
pedicle to cover wounds in the forearm or about the elbow.
Nonetheless, it may be used as a free flap in certain instances
and affords excellent hand coverage. This flap can be raised
anywhere along the course of the radial artery, and a skin
island from very small to quite large may be taken (Fig. 12.17).

289
Treatment/surgical technique
two primary branches, giving rise to the “transverse” scapular
flap, which is sited transversely across the back, and the
“parascapular” flap, which is sited obliquely down the back
(Fig. 12.25). Based on this vascular supply, a large skin flap
can be designed that will cover most defects of the forearm
and arm.44 Although a number of cutaneous nerves enter the
skin, there is not a dominant nerve to this area, and thus this
flap has poor potential for innervations. Branches from the
primary pedicle feed the lateral surface of the scapula, and a
portion of this bone can be taken to repair bone defects. This
bone is flat, however, and its primary indication is reconstruc­
tion of smaller defects in the hand. Donor sites in the 8 cm
range can usually be closed primarily, but this is usually
limited to the parascapular design of the flap.
The primary advantages of this flap are the length and
diameter of its pedicle along with its potential large size. The
primary disadvantage of this flap is the need for turning the
patient to harvest it. The scapular flap is an excellent choice
for coverage of large wounds of the forearm and can be used
in place of a pedicled groin flap for hand coverage (Fig. 12.26).
It can be combined with the latissimus dorsi and serratus
anterior muscle flaps on a single pedicle to provide a huge
amount of tissue and for coverage of different surfaces of the
hand and arm.44 Fascia alone can be harvested if back skin
and subcutaneous tissue is deemed too bulky for an effective
transfer.
Temporoparietal fascia flap
The temporoparietal fascia offers a flap of specialized tissue
that has great utility in reconstruction of the hand.20 This flap
is supplied by the superficial temporal artery and vein and
has a pedicle in the 2- to 3-cm range, which is about 1.5 to
2.5 mm in diameter45 (Fig. 12.27). The temporal fascia lies on
the temporal region of the skull, beginning on the zygoma and
running superiorly. There is a larger superficial layer as well
as a deep temporal fascial layer, and both may be taken with
this flap. The use of both layers of fascia has been promoted
for wrapping adherent tendons on the dorsum of the hand
7 cm in width can be closed primarily, but larger ones require
a skin graft.38 When closed primarily, the donor site can be
cosmetic, but the scar will widen significantly in some patients.
The posterior cutaneous nerve to the arm may be taken to
innervate the flap; the posterior cutaneous nerve to the
forearm may be used as a flow-through vascularized nerve
graft.39 A portion of the lateral humerus can be taken with the
flap for bone reconstruction, based on its vascular supply
from the overlying pedicle.40 The lateral arm flap is purported
to be a “thin” flap, but because of the tissue in the intermus­
cular septum, it is a bit bulky when placed on a flat recipient
site (i.e., the back of the hand). This problem can be avoided
by using the fascia only, which also decreases donor site
problems.38,41 The primary advantages of this flap are that it
can be taken from the ipsilateral arm (of injury) (Fig. 12.23),
it avoids the sacrifice of a major vessel, it has the potential to
serve as a multicomponent composite transplant, and the
donor site can often be closed primarily. The primary disad­
vantages of the lateral arm free flap are its somewhat limited
size, the short and small-diameter pedicle, the resultant
contour deformity in the arm, and forearm dysesthesias. It is
useful in coverage of small defects of the hand and works well
in the first webspace (Fig. 12.24). In thin patients, it can be
used to cover a degloving injury of the thumb with the added
benefit of reinnervation through the cutaneous nerve. It has
served nicely as a composite osteocutaneous flap to recon­
struct multicomponent defects about the antecubital fossa
and elbow.
Scapular flap
The scapular and parascapular flaps offer a versatile large
skin flap for coverage of defects in the upper extremity.42 The
vascular supply is based on the circumflex scapular vessels
that branch from the subscapular system.43 The pedicle for
this flap is long (4 to 6 cm) because the subscapular vessels
can be taken if necessary, and this provides vessels of large
diameter at the takeoff from the axillary artery. The vessels lie
in the fascia with branches to the overlying skin. There are
Fig. 12.18  Cross-section anatomy of the forearm. The
radial forearm flap is based on the radial artery as it runs
between the flexor carpi radialis muscle and the
brachioradialis muscle. Muscle and/or bone may be
harvested with this flap.
Flexor digitorum superficialis
Flexor carpi ulnaris
Palmaris longus
Ulnar artery and nerve
Anterior interosseous artery and nerve
Ulna
Basilic vein
Cephalic vein
Radial artery and
superficial branch of
radial nerve
Median nerve
Lateral antebrachial
cutaneous nerve
Flexor digitorum
profundus
Brachioradialis
Flexor carpi radialis
Extensor carpi
radialis longus
Radius
Extensor carpi
radialis brevis
Lateral intermuscular septum
Flexor pollicis longus

290
SECTION II
CHAPTER 12 • Reconstructive surgery of the mutilated hand
Fig. 12.19  (A) Degloving injury in 13-year-old boy after automobile roll-over injury. Patient and family refused pedicled groin flap coverage. (B) Outline of distally-based
pedicled radial forearm flap for coverage of wound. (C) Flap elevated. Note that the palmaris longus tendon has been harvested in the flap for extensor tendon
reconstruction. (D) Flap placed on hand. Note that flap and pedicle will be placed through a subcutaneous tunnel to reach the dorsal hand. (E) Healed flap on dorsal hand.
Note color and texture match of flap with hand. (F) Donor site on volar forearm after healing of split-thickness skin graft.
A
B
C
D
E
F

291
Treatment/surgical technique
after tenolysis in a scarred bed. The deep fascia can provide
tissue for reconstruction of small tendons on the dorsal hand
as well. A flap of moderate dimensions may be taken, in the
8- to 10-cm range. The potential for harvesting vascularized
bone with this flap exists, but the thin, outer table bone avail­
able has little indication in the hand. Although the donor scar
is one of the best in terms of cosmesis, the problem of alopecia
exists because the superficial fascia must be dissected from
just beneath the hair follicles of the scalp.
The primary advantages of this flap include the potential
to provide a gliding surface and a donor site that is one of the
best in terms of cosmesis. The primary disadvantage of this
flap is that it is thin and must be covered with a skin graft.
The frontal branch of the facial nerve can be injured in its
dissection. Temporoparietal fascia offers nice coverage for
defects of the fingers and hand, but the size of the flap is
limited.46 This tissue does seem to improve the gliding ability
of tendons, particularly on the dorsum. When covered with a
split-thickness skin graft, the temporoparietal fascia flap
offers the thinnest coverage available (excluding other fascial
flaps) (Fig. 12.28).
Anterolateral thigh flap
The anterolateral thigh flap is a more recently popularized
flap which has application in reconstruction of wounds in the
hand. It is based on the descending branch of the lateral
femoral circumflex artery in the thigh, and can be taken with
a large skin paddle, fascia, and potentially muscle (Fig. 12.29).
This flap was originally thought to be a septal perforator type
of flap, but it is well-recognized now that most of these flaps
are supplied by intramuscular perforators through the vastus
lateralis muscle.47 Donor sites in the 6–7 cm width range can
be closed primarily, but larger flaps will require a skin graft
for the donor site. This flap can supply a large amount of
tissue for coverage, and the fascia may be useful in reconstruc­
tion of tendons (i.e., the distal triceps tendon). It can also be
utilized to revascularize the distal extremity as a flow-through
flap via the descending branch which also supplies the flap.48
When placed on the hand, the flap can be thinned rather radi­
cally to obviate a too-bulky piece of tissue.5
The flap is designed by marking a line from the anterior
superior iliac spine to the lateral border of the patella. This
should roughly follow the septum between the rectus femoris
and the vastus lateralis. The primary perforators are located
roughly half the way down this line. While some design
the flap without identifying the perforators,49 we prefer to
utilize a pencil Doppler to locate the primary perforators
along the medial border of the vastus lateralis. Once the
central axis of the flap is laid out, the dissection begins by
raising the medial aspect of the flap. This is raised over to
the intermuscular septum between the rectus femoris and
vastus lateralis, which is inspected to see if there are any
perforators present. The dissection then proceeds from medial
to laterally over the vastus, and great care must be taken to
lift the flap very carefully and identify and preserve any and
all perforators coming through the muscle and fascia lata
into the skin paddle. Once these perforators are identified,
the lateral edge of the flap can be incised and the remainder
of the flap lifted. The perforators are then carefully dis­
sected out of the muscle down to the level of the descending
branch of the lateral femoral circumflex vessels. Once these
Fig. 12.20  Anatomical depiction of anatomy of lateral arm free flap.
Long head of biceps brachii
Radial collateral artery
Long head
of triceps
Lateral head
of triceps
Radial nerve
Deltoideus
Brachial artery
Lateral intermuscular septum
Lateral brachial cutaneous nerve
Fasciocutaneous perforators
Fig. 12.21  Dissection of lateral arm free flap.
Radial collateral artery
Intermuscular septum
Medial head of triceps
Lateral head of triceps

292
SECTION II
CHAPTER 12 • Reconstructive surgery of the mutilated hand
Fig. 12.22  (A) Recurrent wound of elbow in paraplegic patient. (B) Markings for distally pedicled lateral arm flap for coverage. Note that distal extent of recurrent radial
artery has been located with a pencil Doppler and marked. (C) Flap after elevation. Note distal pedicle at elbow. Vascular clamp is on proximal vessel, note excellent
perfusion of flap without evidence of venous congestion. (D) Flap sutured in place. (E) Donor site closed primarily. (F) Flap healed at three months with good coverage.
A
B
C
D
E
F

293
Treatment/surgical technique
thoracodorsal nerve,54 but the latissimus is generally used in
the upper limb for coverage of large, degloving-type wounds
(Fig. 12.31).
The advantages of this muscle are that it has a totally reli­
able vascular supply and is very large. Its primary disadvan­
tage is that the patient must be turned in the lateral decubitus
position for harvest of the muscle. If the contralateral muscle
is taken, the patient can be turned on the side and the injured
arm can be prepared simultaneously with muscle harvest
(assuming that appropriate surgical assistance is available). It
can be taken as a musculocutaneous flap or harvested with
the entire subscapular axis to include up to two muscles (latis­
simus and a portion of the serratus anterior), a fasciocutane­
ous paddle, and vascularized bone; but for most indications
in the upper extremity, the muscle only is taken and covered
with a split-thickness skin graft. The donor site is easily
closed, but seroma formation is a common sequela of this
donor site. The functional morbidity from the loss of muscle
is minimal in most patients, but its use should be avoided in
patients who must adduct the arm strongly (crutch-walkers
and paraplegics).
are dissected out, the flap pedicle can be ligated and the
flap moved.
The primary indication for the anterolateral thigh flap is in
large defects of the forearm and/or hand (Fig. 12.30). As noted
above, it can be utilized for distal revascularization as well.
The donor site is generally well-tolerated, even if it has to be
grafted.50 The primary downside of this flap is that it tends to
be bulky, particularly in obese patients.
Free flaps – muscle flaps
Latissimus dorsi
The latissimus dorsi muscle is a large muscle of the back and
shoulder, and its vascular supply for free transfer is based on
the subscapular–thoracodorsal system51,52 (see Fig. 12.25). The
pedicle is lengthy (8–11 cm) and has a relatively large diam­
eter proximally (up to 6 mm). This is the largest single muscle
available for transfer, and its area of coverage can be expanded
by including a portion of the serratus anterior muscle by its
nourishing branch that arises from the thoracodorsal artery.53
It can be used as an innervated muscle because of the single
Fig. 12.23  (A) Avulsion injury on dorsum of 24-year-old patient’s hand. (B) Lateral
arm flap raised. Note position of pedicle between triceps and brachialis and pedicle
on deep surface of fascia of flap. (C) Free flap after being inset on hand.
Anastomosis was to radial artery in anatomic snuffbox.
A
B
C

Fig. 12.24  (A) Patient with severe first webspace contracture after crush injury. (B) Flap being raised from posteriorly. Underside of flap showing pedicle at base of
septum, note triceps muscle posterior to flap. (C) Flap raised on its pedicle. Arrow points to radial nerve in septum. (D) Flap after suturing in place.
A
B
C
D
Fig. 12.25  Anatomy of the thoracodorsal/subscapular vascular tree with the flaps (scapular/parascapular/latissimus/serratus anterior) that can be raised on this pedicle.
Subscapular artery
Parascapular skin flap
Thoracodorsal nerve
Thoracodorsal
artery
Long thoracic
nerve
Thoracodorsal
artery and nerve
Teres major
Circumflex scapular
artery
Circumflex scapular
artery
Subscapular
artery
Latissimus dorsi
(flipped back)
Humerus
Long head
of triceps
Serratus anterior
(flipped out)
Axillary artery
Pectoralis minor
Axillary artery

295
Treatment/surgical technique
Fig. 12.26  (A) Patient with amputation and degloving of dorsal hand from rope injury. (B,C) Parascapular free flap utilized for coverage.
A
B
C
Fig. 12.27  Anatomy of the temporoparietal fascia.
Parotid gland
Auriculotemporal nerve
Auricularis posterior
Temporalis
Temporal branch of facial nerve
Superficial temporal
artery and vein
Superficial temporal fascia
Deep temporal fascia
Rectus abdominis
The rectus abdominis is a muscle widely used in microsurgery,
primarily today as the transverse rectus abdominis muscle
flap and perforator variants for breast reconstruction. This
muscle is on the anterior abdominal wall and runs from the
medial lower ribs to the pubis. It lies in a sheath composed
anteriorly of continuations of the external and internal oblique
muscle layers. The posterior sheath is a continuation of the
transversus abdominis but is quite thin in the lower abdomen
(below the linea semicircularis). It is a fairly large muscle and
has a reliable vascular pedicle based on the deep inferior
epigastric system. The pedicle is fairly long (5 to 7 cm) and
the diameter fairly large (2.5 to 3 mm).
The rectus abdominis muscle will cover most defects of the
hand and/or forearm,55,56 and it will cover large defects of the
forearm if most of the muscle is harvested and placed “barber
pole” fashion around the arm.57 The advantages of this muscle
are that it has a reliable vascular pedicle and may be taken
with the patient supine. The disadvantage of this muscle is
that a hernia can result from its harvest if fascia is taken (for
a myocutaneous flap) or if the anterior sheath is weak. For
coverage of the upper extremity, this muscle is usually har­
vested without a skin paddle and covered with a split-
thickness skin graft. The muscle can actually be harvested as
a pedicled flap and placed on the forearm in rare situations
where microsurgery might be difficult or pose other problems
(Fig. 12.32).

296
SECTION II
CHAPTER 12 • Reconstructive surgery of the mutilated hand
Fig. 12.28  (A) Degloving injury of dorsal hand. (B) View of temporal vessels
within temporal fascia on side of head. Temporal artery is tortuous, vein is anterior
and straighter. (C) Healed dorsal hand after flap covered with meshed split-thickness
skin graft.
A
B
C
Serratus anterior
This muscle is useful for coverage of smaller hand defects.53,58
It consists of nine slips of muscle that connect from ribs at the
anterior axillary line to the tip of the scapula. The lower slips
are vascularized by a branch coming off the thoracodorsal
artery; the upper slips are vascularized by a branch of the
lateral thoracic artery. The lower three slips may be taken
individually or together as a free muscle flap based on the
thoracodorsal pedicle. This dissection is tedious because
branches of the long thoracic nerve may be intertwined with
the vessels, and damage to the nerve supplying the remaining
slips of muscle can lead to winging of the scapula.59 The
branch to the serratus is usually taken with the proximal
thoracodorsal vessels, both for lengthening the pedicle and
because of the larger diameter of the proximal vessel. This can
give a lengthy pedicle (15 to 17 cm) with a large diameter (3
to 6 mm) (see Fig. 12.25).
The primary advantage of this muscle is its small size and
lengthy vascular pedicle. The disadvantages of this muscle
are the potential for long thoracic nerve injury and the decu­
bitus position necessary for harvest. This flap can be used for
coverage of the dorsal or palmar hand and first web space. It
has the potential for innervation through a branch of the long
thoracic nerve, but this application would be limited in the
upper extremity.
Clinical tips
Flap selection
• Wound factors
• Is the wound clean or relatively dirty?
• Will you need to perform further surgery through or
under flap?
• Patient factors
• What donor site morbidity is acceptable to the patient?
• Soft-tissue reconstruction only vs. composite tissue
transfer
• Surgeon factors
• Which flap(s) are you comfortable with and can you
transfer reliably?
Postoperative care
In the immediate postoperative period, the extremity is
splinted in an appropriate position to prevent capsuloliga­
mentous shortening and tension on repaired structures.

297
Secondary procedures
Early and motivated rehabilitation of the extremity is an
important factor in achieving a successful outcome. Early
motion reduces edema, adhesions, and scarring. It prevents
muscle atrophy and facilitates healing of the soft tissues by
remodeling of collagen fibers. The details of the rehabilitation
program are determined by the existing injuries and the
reconstruction procedure.
Outcomes, prognosis, and
complications
Reconstruction of complex hand injuries remains a challenge.
The ultimate desired outcome is “normal” function of the
hand and upper limb, but this can rarely be obtained. Actual
outcome studies in terms of the management of these injuries
are very limited, however. Based on the few studies available,
the primary determinants of the quality of eventual function
are the severity of nerve injury and the need for emergency
fasciotomy (which may lead to functional muscle loss).61
Likewise, it is not surprising that outcomes have been shown
to be better in younger patients, both from their ability to
recover function and to adapt.62 del Pinal has suggested that
the initial goal in reconstruction of mutilating hand injuries
should be the “acceptable hand”, which he defines as a hand
with three fingers, near normal length, near normal sensation,
and a functional thumb.14 This would seem to be a reasonable
approach in these severe injuries, however it is not always
obtainable.
There are many complications that can arise in the manage­
ment of these injuries, with the early problems centering
around infection. As noted above, this can be largely mitigated
by early and thorough debridement, with return to the operat­
ing room frequently in the early period to re-assess the wound
and to perform more debridement of nonviable tissues as
necessary.63,64 Appropriate antibiotic coverage is helpful, but
is not a substitute for debridement. While the principle of
“early” coverage in the first days after injury was proposed
by Godina and has been the gold standard for nearly 25
years,17 recent experience with the management of war
wounds in the conflicts in the Middle East has proven that
wounds can be safely and properly managed in a delayed
fashion. These studies have shown that early debridement,
followed by wound management with negative pressure
therapy can temporize and decrease the infection rate in
heavily contaminated wounds. The results of management of
patients in this fashion is equivalent to that with early cover­
age in most instances.65–67 These patients also suffer from the
complications (or more properly labeled “sequelae”) found in
any injury to the hand or upper extremity, including tendon
adhesions, poor nerve recovery, bony problems (malunion
and/or nonunion), etc. These are managed by the surgeon in
standard fashion, but particular problems will be addressed
below.
Secondary procedures
Free fibula transfer
Most bone defects in the upper extremity can be managed
with standard bone grafts; however, long defects (>6 cm) and
Elevation is necessary to reduce edema and help control pain.
The patient’s pain and anxiety should be adequately con­
trolled. The ambient temperature should be at least 25°C and
adjusted to the patient’s body temperature. Hydration should
be sufficient to maintain urine output between 80 and 100 mL/
hr. Anticoagulant therapy is used by many surgeons. However,
the authors are selective in using either heparin or dextran;60
aspirin is used daily for 4 to 6 days after surgery. Appropriate
antibiotic therapy is continued and later modified according
to the culture results.
Flap monitoring is critical. Early recognition of arterial
hypoperfusion or venous congestion will occur only in a well-
monitored environment, with trained nursing staff. If there is
a question about tissue viability, the dressings are released
and the entirety of the revascularized tissue is exposed for
further assessment of perfusion, congestion, temperature,
turgor, and color and Doppler examination. Release of the
dressings alone may be sufficient. If viability is still in ques­
tion after 30 minutes, immediate re-exploration and further
assessment may prevent failure of the revascularized tissue.
Fig. 12.29  Anatomy of descending branch of lateral femoral circumflex artery and
anterolateral thigh flap. This flap offers one of the largest cutaneous free flaps
available, and can be taken with vascularized muscle and/or fascia.
Lateral femoral
circumflex artery
Vastus lateralis
Vastus medialis
Skin paddle anterolateral
thigh flap
Descending branch of lateral
femoral circumflex artery
Rectus femoris
Femoral artery

298
SECTION II
CHAPTER 12 • Reconstructive surgery of the mutilated hand
Fig. 12.30  (A) Forearm of patient who suffered severe electrical burn with loss of all volar musculature.
Plan is for coverage with free anterolateral thigh flap and placement of tendon rods followed by innervated
muscle transfer and tendon grafting. (B) Markings on leg for flap. Hip is to the right and knee to the left in
this view. (C) Forearm and hand after placement of tendon rods and pulley reconstruction. (D) View after
vascular anastomosis and insetting of flap. (E) Hand and forearm after three months prior to innervated
gracilis transfer.
A
B
C
D
E

299
Secondary procedures
taken with the vascularized epiphysis in children to promote
later growth,73 and this application will be discussed further
in Chapter 30.
A portion of the skin overlying the fibula can be taken
with the bone, and thus compound defects can be managed
with this flap. The perforators to the skin run around the
posterior aspect of the bone, and thus it is best to include
a cuff of muscle along the posterior surface of the bone if
a skin paddle is to be included. If a skin paddle is taken,
most donor sites will require a skin graft on the overlying
muscles. The primary advantage of this donor site is the
large amount of bone that can be taken. In adults, a total
of up to 24 to 26 cm of bone may be harvested. The fibular
head should be left in place at the knee level, and 6 cm of
the distal fibula should remain to avoid problems with the
ankle. In children, a screw should be placed across the distal
fibular–tibial joint to avoid proximal migration of the fibula.
The disadvantages of this donor site are few; the pedicle
is relatively short (2 to 4 cm) and there is some morbidity
from harvesting, but this usually does not present functional
problems.
those associated with recurrent nonunions may be candidates
for microvascular bone transfer.68 Whereas several flaps are
available that can include a portion of vascularized bone (iliac
crest, scapula, lateral arm, radial forearm, dorsalis pedis), the
fibula osseocutaneous flap offers the best piece of bone for
reconstruction of significant defects of the long bones of the
upper extremity.69,70 Smaller defects, such as those in the hand,
can be managed by one of the previously discussed flaps with
inclusion of a segment of bone. Larger defects of the radius,
ulna, or humerus will usually require a piece of bone such as
the fibula71,72 (Fig. 12.33). The vascular supply of the free fibula
is based on the peroneal vessels of the leg. These vessels run
along the deep surface of the fibula from just below the tibio­
peroneal trunk to the level of the ankle. Whereas the peroneal
vessels provide an endosteal nutrient artery to the medullary
canal of the fibula, they also provide rich periosteal blood
supply to the cortical surface. The proximal portion of the
fibula can be taken for reconstruction of the radiocarpal joint,
but this segment of bone gets its primary blood supply from
a branch of the anterior tibial artery,71 which must be taken to
ensure viability of this segment. The proximal portion can be
Fig. 12.31  (A) View of patient’s elbow with wound breakdown after total elbow
replacement for traumatic fracture/dislocation. (B) Patient after wound debridement,
and pedicled latissimus dorsi for coverage. (C) Close-up of muscle in wound. Note
that there is plenty of length to reach beyond the elbow proper.
A
B
C

300
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CHAPTER 12 • Reconstructive surgery of the mutilated hand
Fig. 12.32  (A) 33-year-old patient after forearm amputation and coverage with latissimus dorsi muscle flap. Hand is supplied by vein grafts as is latissimus flap. (B) View
of rectus abdominis muscle being raised proximally as a pedicled flap. (C) Flap after insetting on arm. (D) Flap healed at four weeks. (E) View of flap at three months after
division.
B
C
A
D
E

301
Secondary procedures
Fig. 12.33  (A) X-ray of forearm of 15-year-old male after automobile accident with loss of majority of radius through open fracture. (B) X-ray view of arm after external
fixation to align bones. (C) X-ray after vascularized free fibula transfer to reconstruct defect of radius. (D) View of X-ray at six months. Note interface between fibula and
distal radial remnant. (Patient developed osteomyelitis of distal ulna and required long-term intravenous antibiotics, but functionally had no problems from this.)
A
B
C
D
Fig. 12.34  (A) Hand of fireman, who lost fingers due to burn injury, after two second toe transfers for digital reconstruction. (B) Flexion of toes. Note good motion at
native metacarpophalangeal joints but rather poor motion of interphalangeal joints of toes.
A
B
Digital reconstruction with toe transfer
Microvascular toe transfer represents one of the pinnacles of
reconstructive surgery. The ability to replace in kind a missing
digit with a mobile, sensate toe offers the best type of recon­
struction available. Although this is a complex microsurgical
procedure that should not be undertaken without experi­
ence,74 it remains the benchmark for thumb and most digital
reconstructions (Fig. 12.34). There are a number of variations
of toe transfer, and almost any tissue needed for digital recon­
struction can be transferred. These range from pulp-only
transfers to double second- and third-toe transfers to
reconstruct the metacarpal hand.75,76 All great- and second-toe
transfers ideally have their vascular basis on the dorsalis
pedis–first dorsal metatarsal system. This anatomy is highly
variable, however, and a thorough knowledge of this is the
basis for safe harvesting of these flaps. The venous drainage
is based on dorsal superficial veins of the foot; the deep
system that accompanies the arterial supply is usually very
small.77 The flaps can be innervated by the proper plantar
digital nerves to the toe as well as by the deep peroneal nerve
that accompanies the dorsalis pedis–dorsal metatarsal vessels.
The actual details of all the complexities of digital reconstruc­
tion with toe transfer is beyond the scope of this chapter, but

302
SECTION II
CHAPTER 12 • Reconstructive surgery of the mutilated hand
injuries is undoubtedly the best approach, but this goal
remains elusive. This is especially true when one considers
that despite all of our technology, many industries (drilling
for oil and heavy manufacturing come to mind) still rely on
the versatility of the human hand to guide the machines.
These hands are put in harm’s way on a daily basis, and until
such activities can be truly completely automated, mangling
hand injuries will unfortunately be with us.
Probably the most promising development in the last
several years has been the successful transplantation of hands
and arms in patients. Most of these individuals have had
bilateral amputations or injuries, and some have suffered the
loss of their lower limbs as well. Despite early enthusiasm,
this area has not grown particularly, and while many centers
have set up “hand transplant” programs, few have proceeded.
This is undoubtedly due to the relative lack of appropriate
donor hands and ongoing concerns about immunosuppres­
sion. Despite the protestations of those who have performed
hand transplants, the issues involving rejection, infections,
and other systemic metabolic conditions related to the immu­
nosuppression remain problematic. Barring a major break­
through in immunosuppressive regimens to make these drugs
less likely to cause side effects, the authors do not see hand
transplantation as currently offering the best solution in most
cases of mangling hand injuries.
Fortunately prosthetic options in the hand are improving,
and with approaches including targeted muscle reinnervation
and the work being done on allowing prosthetics to have
sensory feedback, these may offer better solutions for missing
digits and hands in the future. The primary issue with these
advanced prosthetics is their cost, and the fact that the more
sophisticated the prosthetic, the less able it is to withstand the
wear and tear of daily use.
Tissue engineering may hold hope for the future, but
engineering all or a portion of a hand (bones, tendons, nerves,
soft tissue) from a scaffold of collagen or a 3D printer remains,
the authors believe, a far distant hope.
the reader is referred to several excellent review articles on
this subject.75–77 Toe transfer for thumb reconstruction is dis­
cussed in detail in Chapter 14.
Innervated muscle transfer
In the case of loss of functional muscle in the forearm,
the options for reconstruction of this function are either
tendon transfer or innervated microvascular muscle transfer.
Although many losses can be adequately reconstructed with
standard tendon transfers, patients with significant loss of
muscle substance (such as those with Volkmann ischemic
contracture) may benefit from reconstruction of function with
a microvascular muscle transfer.78 The muscles available for
this include the gracilis, latissimus dorsi, and rectus femoris.
The latissimus dorsi can be used in the forearm as a free
functional transfer,79 but it is not ideal. It is better suited as a
replacement for elbow flexion when biceps function is lost. In
this case, a pedicle transfer is perfectly adequate. The rectus
femoris has been used for this in the past, but again, it is not
the optimal muscle due to its short excursion. The gracilis
muscle, on the other hand, is nearly ideal for reconstruction
of the muscles of the forearm. It has adequate excursion to
provide finger flexion or extension, it is of appropriate size
(both length and width), and it has an excellent neurovascular
pedicle. The reader is referred to Chapter 35 for the details of
this procedure.
Future directions
Reconstruction of severe mangling hand injuries can be very
frustrating, particularly if complications are encountered.
Loss of replanted or transplanted tissues can lead to increased
infection rates, fibrosis, and stiffness. These are all the enemies
of the hand surgeon, but there are times when they cannot be
avoided and/or adequately treated. Prevention of these
17. Godina M. Early microsurgical reconstruction of complex trauma of
the extremities. Plast Reconstr Surg. 1986;78:285–292. This is the
classic paper by Godina on early coverage of severe trauma with free flaps.
In this paper he proves the rationale for early coverage.
18. Gupta A, Shatford RA, Wolff TW, et al. Treatment of the severely
injured upper extremity. J Bone Joint Surg Am. 2000;81:1628–1651.
This paper from an AAOS instructional course lecture gives a very
organized and well-structured overview of the subject from the orthopedic
standpoint.
61. Topel I, Pfister K, Moser A, et al. Clinical outcome and quality of
life after upper extremity arterial trauma. Ann Vasc Surg.
2009;23:317–323. This paper from Germany looked at 33 patients with
arterial trauma with DASH scores at the time of final follow-up. Not
surprisingly, they found that nerve and orthopedic trauma had more
long-term impact than vascular injury (short of those patients with
muscle damage from ischemia).
65. Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from the
modern battlefield: successful upper extremity injury reconstruction
in the subacute period. J Trauma. 2009;67:752–757. This recent paper
dealing with injuries in US soldiers from the Middle East wars notes that
successful flap reconstruction can be performed in a delayed fashion
(contradicting the long-held notions of Godina). Their average time to flap
reconstruction was 31 days, with a 4% flap loss rate and 8% infection
rate, which are both very acceptable.
Access the complete reference list online at

302.e1
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SECTION II • Acquired Traumatic Disorders
13 
Thumb reconstruction:
Non-microsurgical techniques
Nicholas B. Vedder and Jeffrey B. Friedrich
SYNOPSIS
■ Thumb reconstruction should aim to restore the cardinal thumb
actions: mobility, stability, sensibility, length, and appearance.
■ Level of thumb loss is divided into thirds: distal (tip to interphalangeal
joint), middle (interphalangeal joint to metacarpal neck), and proximal
(metacarpal neck to carpometacarpal joint).
■ Distal third reconstruction typically requires only soft-tissue
restoration.
■ Numerous options exist for middle-third reconstruction, including
increasing thumb ray length (metacarpal lengthening, osteoplastic
reconstruction) and increasing relative length (phalangization).
■ Proximal third reconstruction may be accomplished with pollicization
or on-top plasty (pollicization of a damaged index finger). However,
microsurgical reconstruction (discussed in Chapter 14) is preferred at
this level.
Introduction
■ When thumb loss occurs due to trauma, replantation is
the best method of reconstruction for many patients.
When replantation is not possible, thumb reconstruction
is warranted.
■ The level of thumb amputation guides the type of
reconstruction. Determination of level of loss is based on
physical examination and radiographs.
■ Any thumb reconstruction method requires input and
acceptance by the patient. The reconstruction should be
tailored to the patient’s personal and professional needs.
Because significant rehabilitation may be required, the
patient must be a willing participant in both the
reconstruction and rehabilitation.
■ Functional compensation following distal-third thumb
loss is easily achieved; therefore, reconstruction at this
level is chiefly soft tissue alone. Techniques such as the
neurovascular advancement (Moberg) flap and the
cross-finger flap remain reliable methods for
reconstruction at this level.
■ For losses in the middle third of the thumb, restoration of
length is a priority. This can be done via absolute length
restoration with metacarpal lengthening or osteoplastic
reconstruction, or via relative length restoration using
phalangization of the thumb.
■ Proximal third thumb losses are best treated with
microsurgical reconstruction. However, in some cases this
may not be possible. In these situations, transfer of
another finger can provide an excellent thumb
replacement. A normal finger (typically the index) can be
pollicized to become a thumb. A damaged index finger
can also be transferred (on-top plasty) to become a stable
post for opposition, pinch, and grip.
■ Hand rehabilitation after reconstruction is absolutely
necessary, especially following middle- and proximal-
third reconstructions. Rehabilitation can last months, but
allows the patient to regain motion and strength. For
some procedures, such as neurovascular island flaps and
digit transfer, sensory re-education is an important part
of the rehabilitation.
■ This chapter will provide a comprehensive description of
non-microsurgical thumb reconstruction, including
reconstruction decision-making, technical approaches,
and post-reconstruction management.
Access the Historical perspective section online at

Basic science/disease process
By far, the most common “disease process” necessitating
thumb reconstruction is traumatic injury. The majority of
these patients are working-age males. Within the larger
trauma classification, thumb injury can be the result of a
  Access video and video lecture content for this chapter online at expertconsult.com

303.e1
Historical perspective
Historical perspective
Littler extensively reviewed the history of thumb reconstruc­
tion, a field in which he has been a major contributor.1
Nicoladoni introduced two techniques, namely, osteoplastic
reconstruction and toe transfer through the pedicle method.2
Guermonprez was among the first to pollicize a finger, a
technique subsequently refined by the island principle, attrib­
uted to Littler and Gosset.3–7 A mobile and sensate thumb was
obtained, but at the price of sacrificing a finger. Matev origi­
nated the technique of progressive lengthening through dis­
traction, maintaining good sensibility and improving length.8,9
A major advance was the introduction of microvascular
techniques, which led to microvascular free toe-to-hand
transfer. First- and second-toe transfers were initially
described, followed by refined techniques allowing the
surgeon to improve the appearance of the reconstructed
thumb while at the same time minimizing donor site
morbidity.