Soft Tissue Coverage of the Digits and Hand

There are multiple options available for reconstruction of soft tissue defects of the digits. The main goal of reconstruction is to achieve normal or near-normal mobility. Soft tissue defects can be considered in the following groups: fingertip, nonfingertip, and multiple digits. The choice of reconstruction for fingertip defects depends primarily on the amount of volar skin available. The patient's functional demands and expectations, and the expertise of the surgeon, also determine the reconstructive strategy.

Use of the First Dorsal Metacarpal Artery-Based Fascial Flap for Reconstruction of Small Defects on the Dorsum of the Hands

PURPOSE

To describe the reconstruction of small defects on the dorsum of the hands using a first dorsal metacarpal artery-based fascial flap harvested through the borders of the defect.

METHODS

From January, 2015 to May, 2017, 29 patients (29 hands) with soft tissue defects on the dorsum of the hand were treated using a first dorsal metacarpal artery-based fascial flap. At final follow-up, we measured range of motion of the metacarpophalangeal joints and the first web span.

RESULTS

Average size of the defects was 2.7 × 2.5 cm. Average size of the flaps was 2.9 × 2.7 cm. Average length of the pedicle was 2.9 cm. All flaps survived. Range of motion of the second to fourth metacarpophalangeal joints reached 93% to 98% of the opposite hand. The span of the first web reached 98% of the opposite hand.

CONCLUSIONS

A first dorsal metacarpal artery-based fascial flap can be an alternative for reconstruction of small defects on the dorsum of the hands. Flap harvesting through the border of the defect avoided an additional scar at the donor site.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The use of dermal regeneration template for treatment of complex wound with bone/tendon exposed at the forearm and hand, a prospective cohort study

The purpose of this study was to assess the efficacy and safety of Pelnac and split-thickness skin graft for management of complex wound with underlying bone/tendon exposure at forearm and hand.This is a prospective study, beginning from March 2013 up to May 2017. There were 13 patients, with age of 31.2 years. All of them underwent the staged Pelnac and split-thickness skin graft to manage the complex wound with bone/tendon. Postoperatively, scheduled follow-up was conducted.The average follow-up was 15 months. There were no infections, wound necrosis, hematoma, or seroma during the phase when Pelnac was applied. There was 100% "take" of the Pelnac in 12/13 patients. In 11 patients, there was complete skin graft "take". Patients' satisfaction for the esthetic appearance of the grafted area was 75.0 ± 8.5/100. The VSS value was 2.9 ± 2.5. Regarding the sensory recovery, the response of "normal or near normal" could be obtained in 7/13 patients, "slight loss" in 5 patients and "significant loss" in 1 case. The average DASH score was 27.2 ± 18.5, and most patients (12/13) could obtain an acceptable ability to perform the daily activities.Pelnac dermal template is a favorable alternative to flap reconstruction in the treatment of complex wound with underlying tissues exposure.

Treating Hand Trauma in Low-Resource Setting: A Challenge for Low- and Middle-Income Countries

Hand trauma surgical treatment and perioperative therapy are often lacking in low- and middle-income countries resulting in high rates of patient morbidity following injury. Providing education through a multifaceted approach including in-person teaching, written resources, videos, and Internet and social media platforms and facilitating skill acquisition through simulation permits local providers to gain expertise in hand trauma care and thus benefits patients. This article outlines challenges faced by low- and middle-income countries in caring for hand trauma patients and possible implementable solutions.

Reconstruction of dorsal and palmar defects of hand with anterolateral thigh flaps from one donor site

The anterolateral thigh (ALT) flap is becoming the flap of choice for reconstruction of soft tissue defects with primary donor site closure. The purpose of this report was to review the reconstruction of dorsal and palmar defects of the hand with ALT flaps from one donor site. From 2016 to 2018, seven patients with dorsal and palm defects of the hand were reconstructed with the ALT flaps from one donor site. The cutaneous perforators of the two paddles were from a common vascular supply in five cases. The Michigan Hand Questionnaire (MHQ) score of the function was 37.8 ± 10.0 points, and pain score was 32.9 ± 23.4 points. All of the donor sites healed well in one stage. The use of ALT flaps from one donor site is a good strategy for the reconstruction of dorsal and palm defects of the hand with minimal donor site morbidity and a favorable outcome.

The Use of Preoperative Antibiotics in Elective Soft-Tissue Procedures in the Hand: A Critical Analysis Review

» The use of preoperative antibiotic prophylaxis is not supported for elective cases of patients undergoing soft-tissue hand procedures that are ≤2 hours in length.

» The use of preoperative antibiotic prophylaxis is not supported for patients with diabetes undergoing elective, soft-tissue hand surgical procedures.

» There is a paucity of literature evaluating the use of preoperative antibiotic prophylaxis in patients with rheumatoid arthritis, those with cardiac valves, and those taking corticosteroids; because of this, there is no evidence to vary from our general recommendations.

Upper Extremity Care for Children: Unique Medical and Psychosocial Aspects

Hand surgeons encountering pediatric patients should be attuned to both technical and practical facets of caring for congenital and traumatic pathologies. Psychosocial aspects include engaging children in conversation and factoring in both self and external perception of deformity. Medical considerations are also unique, from including child abuse in the differential to having techniques to assess active motion and sensation in the nonverbal child. Certain universal principles, such as minimizing radiation exposure and limiting needle sticks, have higher emphasis in pediatric patients than in adults. With these aspects in mind, treating children and their families can be a mutually rewarding experience.

Suture Anchor Repair of Avulsed Adductor Pollicis Injury, Secondary to Motor Vehicle Collision: Case Report and Technique

The thenar eminence of the thumb is made up of 4 intrinsic muscles: abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, and the adductor pollicis (ADD). While both heads of the ADD insert on the medial base of the thumb proximal phalanx, the oblique head originates on the capitate and second and third metacarpals, and the transverse head originates on the distal half of the third metacarpal. We present the case of a 36-year-old man who was involved in a motor vehicle collision and sustained a laceration in the first webspace with 1 cm extrusion of the ADD and no neurovascular deficiencies on examination. X-ray imaging noted no bony abnormalities. The only identifiable injury was to the ADD muscle which was avulsed from its origin and was extruded through the open wound in the first webspace. A double-row running locking 3-0 fiberwire suture technique was used to have a solid anchor point with which to secure the muscle to its origin. It was secured to the second metacarpal with Mitek mini suture anchors that was sutured on the opposing side of the double-row fiberwire suture and anchored to the second metacarpal proximally and distally in the metacarpal. We report good clinical outcomes postoperative, with intact range of motion and no surgical complication at the 6-month follow-up visit. The patient has ongoing physical therapy to reduce any residual strength deficits.

Indications for Replantation and Revascularization in the Hand

The indications for upper extremity replantation are fluid, and it has long been appreciated that they change with time. Traditional strong indications for replantation include hand, thumb, or multiple digit amputation in adults, and almost any amputation in a child. Patients often desire replantation of single nonthumb digits based on aesthetic preference and personal/cultural values. Replantation in these situations is acceptable and rewarding, but individual consideration of patient, injury, and circumstantial factors is critical to avoid patient morbidity and unsatisfactory outcomes.

A Decade of Progress Toward Establishing Regional Hand Trauma Centers in the United States

Although upper extremity amputations have become less common in the workplace because of improvements in safety and equipment, the American health system's ability to provide emergent microvascular care for these injuries remains highly fragmented, inconsistent, overburdened, and at times unavailable. Over the past decade, hand surgeons have worked to improve this disparity within health systems. This article discusses the need for emergent microsurgical treatment, barriers encountered in improving access to care, and a description of current and future efforts of developing a sustainable network of highly specialized regional hand trauma centers.

Revascularization and Replantation in the Hand: Presurgical Preparation and Patient Transfer

Replantation of a digit or hand is most successful when performed at a specialized, high-volume center. However, most patients with amputations initially present to local hospitals. Therefore, patients amenable to replantation frequently require expedited transfer to a tertiary center. To maximize success of digit replants, health care providers from both the referring and the referral hospital must be facile and expeditious at transferring the injured patient. The critical aspects of triage include assessment of the injury, patient communication, interfacility communication, preparation of the amputated part and patient, and a timely transfer.

End-to-side innervated sensate radial forearm flap in the hand: A 5-year follow-up

Optimal functional reconstruction of the palmar surface of the hand requires good sensibility especially for the thumb and the radial side of the fingers. We report the long-term results of a distally based radial forearm flap (RFF) used for soft tissue coverage in the palm, index and middle finger and an end-to-side neurorrhaphy between the lateral antebrachial cutaneous nerve (LACN) and the proper palmar digital nerve of the middle finger to restore sensation. At 5 years' follow-up, the patient's sensory recovery was assessed through static and moving two-point discrimination, light touch sensation, pain perception, hot and cold temperature perception, an electrophysiological study and sweat test. An S3+ sensory recovery on the British Medical Research Council scale, as modified by Mackinnon and Dellon, was noted together with a good perception in the palm compared to decreased perception in the volar surface of the proximal phalanx. These findings prove that the RFF can provide good functional coverage of the palm together with good sensitivity by end-to-side reinnervation.

International multiphase mixed methods study protocol to develop a cross-cultural patient-reported outcome and experience measure for hand conditions (HAND-Q)

INTRODUCTION

patient-reported outcome measures (PROMs) are instruments used to measure outcomes and experiences of healthcare from the patient perspective. The specific methodology used to develop a PROM should be communicated to establish the quality of the instrument. This mixed methods protocol describes the development of a cross-cultural, internationally applicable PROM for hand conditions, the HAND-Q.

METHODS AND ANALYSIS

The multiphase approach used for this study has been previously used with the development of other PROMs by our team (eg, BODY-Q, BREAST-Q, CLEFT-Q, FACE-Q). In Phase I, we establish what important concepts matter to patients with hand conditions. A conceptual framework is developed from a systematic review of existing PROMs in the field and an extensive international qualitative study. Interpretive description is the qualitative approach used. Item generation is based on the qualitative data. The preliminary scales will be created for each theme identified in the conceptual framework. These scales will be refined by cognitive debriefing interviews with participants and expert input. Phase II involves a large international sample of patients with varied hand conditions completing the field-test version of the HAND-Q. The scales will be refined using the modern psychometric approach of Rasch Measurement Theory. Analysis will result in a shortened set of clinically meaningful and scientifically robust HAND-Q scales.

ETHICS AND DISSEMINATION

This study is coordinated at Flinders University (Adelaide, Australia) where it has ethics board approval for phase I and phase II. Findings will be published in peer-reviewed journals and presented at local, national and international conferences.

The Stener Lesion and Complete Ulnar Collateral Ligament Injuries of the Thumb A Review

A Stener lesion is a complete tear of the ulnar collateral ligament (UCL) from the thumb proximal phalanx at the level of the metacarpophalangeal (MCP) joint that is displaced superficial to the adductor pollicis aponeurosis, leading to interposition of the aponeurosis between the UCL and the MCP joint. The interposition of the adductor aponeurosis distinguishes the Stener lesion from other UCL injuries and impedes healing, thereby necessitating surgery. A thorough clinical examination, including valgus stress testing of the MCP joint, is crucial to the diagnosis. In cases where the clinical evaluation is equivocal, imaging studies including ultrasound or magnetic resonance can be performed. Acute Stener lesions can be treated with repair of the UCL primarily through direct suture, suture anchor, or pull-out suture techniques. Chronic injuries are treated with dynamic (via tendon transfer) or static (via grafting) reconstruction methods, while MCP arthrodesis or arthroplasty can be reserved for cases where MCP joint osteoarthritis is present. Overall, patient outcomes are generally good with operative treatment of Stener lesions. This article reviews the relevant anatomy and pathogenesis, clinical evaluation, diagnostic studies, management, outcomes, complications, and an illustrative case of Stener lesions and complete UCL injuries of the thumb.

High-pressure injection injury of the hand: peculiar MRI features and treatment implications

High-pressure injection injuries of the hand are rare, but potentially devastating injuries. The amount of tissue damage is dependent on the magnitude of the pressure generated by the device and the composition of the injected material. The standard of care is emergent surgical debridement of the injected material and devitalized tissue. Although, preoperative advanced imaging is not routinely pursued, MRI may be helpful in determining the anatomic distribution of the foreign material, and associated soft tissue or osseous injury. We present a case of a 28-year-old male with complications related to a high-pressure grease injection injury to his non-dominant hand. The MRI demonstrated peculiar imaging features of retained grease deposits and played an important role in surgical planning.

Antegrade intramedullary Kirschner-wire fixation of displaced metacarpal shaft fractures

PURPOSE

The objective of this study was to analyze complications and patient-related functional outcome after antegrade intramedullary Kirschner-wire fixation of metacarpal shaft fractures.

METHODS

All consecutive patients treated from January 2010 until December 2015 were retrospectively analyzed using patient logs and radiographic images. Indications for operative fixation were angulation > 40°, shortening > 2 mm, or rotational deficit. Complications were registered from the patient logs. Functional outcome was assessed with the Patient-rated wrist/hand evaluation (PRWHE) and Disabilities of the Arm, Shoulder, and Hand score (DASH) questionnaire both ranging from 1 to 100 after a minimum follow-up of 6 months.

RESULTS

During the study period, 34 fractures of 27 patients could be included. Mean outpatient follow-up was 11 weeks (range 4-24 weeks). The mean interval for functional assessment was 30 months (range 8-62 months) and 19 patients (70%) responded to the questionnaires. During outpatient follow-up, all fractures proceeded to union with no signs of secondary fracture dislocation or implant migration. One re-fracture after a new adequate trauma was seen and one patient underwent tenolysis due to persistent pain and impaired function. In 26 cases (81%), the K-wires were removed of which 23 (68%) were planned removals. Functional outcome was excellent with mean PRWHE and DASH scores of 7 and 5 points, respectively.

CONCLUSIONS

If surgical treatment for metacarpal shaft fractures is considered, we recommend antegrade intramedullary K-wire fixation. This technique results in low complication rates and excellent functional outcome.

[Electrical Burn with an Extensive Deep Defect of the Fronto-Orbital Region]

A 34-year-old worker suffered electrical burns on his head and right hand caused by the contact with a 380 V power source. He was unconscious, intubated, hospitalised at the ICU, and later he woke up. The entry wound was on the right hand and the exit wound on the head. These factors resulted in an extensive deep mutilating defect of the right fronto-orbital region. This article describes the management and surgical treatment of this interesting case of burn injury. Key words:electrical injury, surgical treatment.

Descriptive Epidemiology and Return to Sport After Hand Fractures in NCAA Athletes

BACKGROUND

Metacarpal and phalanx fractures are common among professional athletes. There is a paucity of data to guide team physicians on expected return to play after hand fractures. The purpose of this study was to examine the epidemiology and return to play times after hand fractures in NCAA athletes. We hypothesized that surgical management of fractures may expedite return to play times.

METHODS

The NCAA Injury Surveillance Program database was queried for metacarpal and phalanx fractures during the 2009-2014 seasons in all sports. Injury rates per 100,000 athleteexposures (AEs) were calculated. Student's t-test, Wilcoxon Rank sum tests, Chi-Squared tests, and Fisher Exact Test were used. Statistical significance was set to p<0.05.

RESULTS

Sports with the highest rates of phalanx and metacarpal fractures included Men's Football, Men's Ice Hockey, Men's Wrestling, and Women's Field Hockey. Multiple sports had participants with no hand fractures over the study period. Male student-athletes with metacarpal fractures treated operatively returned to play at a mean of 31.8±29.4 days versus 13.8±23.6 days for those treated non-operatively. 92% of male student-athletes were able to return to sport in the same season without operative management versus 67% with operative management. Female student-athletes had a cohort too small for statistical analysis. Return to play times for male student-athletes with phalanx fractures were not significantly different between operative and non-operative groups (16.1±21.5 days versus 7.1±13.3 days).

CONCLUSIONS

Hand fractures are relatively common among NCAA student-athletes participating in contact sports. Student-athletes with metacarpal fractures returned to play at an average of 2-4 weeks after injury; those with phalanx fractures returned at an average of 1-2 weeks. The return to play times illustrated within this study can be used to counsel athletes, athletic trainers, and coaches.Level of evidence: IV.

Factors associated with limited hand motion after hand trauma

Hand injuries are common and have a significant impact on daily life. However, the factors associated with functional outcome after hand injuries are not well established. The purpose of this study was to identify factors that are independently associated with hand total active motion (TAM).A total of 50 patients with unilateral complex hand injury were included in this study. The associations between various demographic, injury-related, and clinical assessment factors and TAM were determined by univariate and multivariate linear regression analyses. Nerve injuries recognized during surgery and diagnosed with electrodiagnostic (EDX) studies were compared using Pearson chi-squared test.Among multiple injury-related and initial clinical assessment factors, nerve injury diagnosed with EDX studies, hospital stay length, elevated C-reactive protein, and skeletal injury were independently associated with TAM in the affected hand after adjusting for covariates. Nerve injuries diagnosed with EDX studies were not consistent with those recognized during surgery.Our results suggest that high-energy trauma leading to skeletal and nerve injury with inflammation is associated with limited hand motion after surgery and postoperative immobilization. A comprehensive EDX study may enable identifying occult or recovered nerve injuries, which would be helpful in understanding limitations in finger movements.

Bone infarction of the hip after hand allotransplantation: A case report

Vascularized composite allotransplantation represents as an emerging field in reconstructive surgery. However, some complications can be associated with the procedure. The authors describe a case of bone infarctions of the bilateral hip joints following the first hand allotransplantation in Taiwan. A 45-year-old man who experienced a traumatic amputation of the distal third of his forearm received a hand transplantation from a brain-dead donor. Immunosuppression included antithymocyte globulins, and bolus methylprednisolone (Solu-Medrol) was used for the induction. The maintenance therapy protocol included systemic tacrolimus, mycophenolate mofetil, and prednisone. The patient discontinued the systemic steroid 15 months after surgery. Two episodes of acute rejections were observed at 105 and 810 days after surgery. These signs disappeared after pulse therapy with Solu-Medrol, titration with tacrolimus, and topical immunosuppressive creams (tacrolimus and clobetasol). However, the patient felt pain in both hips after long periods of standing 30 months after the transplantation. A pelvic radiograph and magnetic resonance imaging revealed avascular necrosis (AVN) in both hip joints. Because of the progressive worsening of the pain, the patient underwent a decompression surgery on the left hip involving a fibula bone graft. The patient underwent a right hip hemi-arthroplasty with a bipolar prosthesis 3 months later. The patient remained in good health without major complications. These findings indicate that systemic steroids and tacrolimus might be the major predisposing factors for the induction of AVN after hand allotransplantation.

Four-Dimensional Imaging of Soft Tissue and Implanted Biomaterial Mechanics: A Barbed Suture Case Study for Tendon Repair

Timely, recent developments in X-ray microcomputed tomography (XμCT) imaging such as increased resolution and improved sample preparation enable nondestructive time-lapse imaging of polymeric biomaterials when implanted in soft tissue, which we demonstrate herein. Imaging the full three-dimensional (3D) structure of an implanted biomaterial provides new opportunities to assess the micromechanics of the interface between the implant and tissues and how this changes over time as force is applied in load-bearing musculoskeletal applications. In this paper, we present a case study demonstrating in situ XμCT and finite element analysis, using a dynamically loaded barbed suture repair for its novel use in tendon tissue. The aim of this study was to identify the distribution of stress in the suture and tendon as load is applied. The data gained demonstrate a clear 3D visualization of microscale features in both the tissue and implant in wet conditions. XμCT imaging has revealed, for the first time, pores around the suture, preventing full engagement of all the barbs with the tendon tissue. Subsequent finite element analysis reveals the localized stress and strain, which are not evenly distributed along the suture, or throughout the tissue. This case study demonstrates for the first time a powerful in situ mechanical imaging tool, which could be readily adapted by other laboratories to interrogate and optimize the interface between the implanted biomaterials and the soft tissue.

Functional, motor, and sensory assessment instruments upon nerve repair in adult hands: systematic review of psychometric properties

BACKGROUND

Outcome after nerve repair of the hand needs standardized psychometrically robust measures. We aimed to systematically review the psychometric properties of available functional, motor, and sensory assessment instruments after nerve repair.

METHODS

This systematic review of health measurement instruments searched databases from 1966 to 2017. Pairs of raters conducted data extraction and quality assessment using a structured tool for clinical measurement studies. Kappa correlation was used to define the agreement prior to consensus for individual items, and intraclass correlation coefficient (ICC) was used to assess reliability between raters. A narrative synthesis described quality and content of the evidence.

RESULTS

Sixteen studies were included for final critical appraisal scores. Kappa ranged from 0.31 to 0.82 and ICC was 0.81. Motor domain had manual muscle testing with Kappa from 0.72 to 0.93 and a dynamometer ICC reliability between 0.92 and 0.98. Sensory domain had touch threshold Semmes-Weinstein monofilaments (SWM) as the most responsive measure while two-point discrimination (2PD) was the least responsive (effect size 1.2 and 0.1). A stereognosis test, Shape and Texture Identification (STI), had Kappa test-retest reliability of 0.79 and inter-rater reliability of 0.61, with excellent sensibility and specificity. Manual tactile test had moderate to mild correlation with 2PD and SWM. Function domain presented Rosén-Lundborg score with Spearman correlations of 0.83 for total score. Patient-reported outcomes measurements had ICC of 0.85 and internal consistency from 0.88 to 0.96 with Patient-Rated Wrist and Hand Evaluation with higher score for reliability and Spearman correlation between 0.38 and 0.89 for validity.

CONCLUSIONS

Few studies included nerve repair in their sample for the psychometric analysis of outcome measures, so moderate evidence could be confirmed. Manual muscle test and Rotterdam Intrinsic Hand Myometer dynamometer had excellent reliability but insufficient data on validity or responsiveness. Touch threshold testing was more responsive than 2PD test. The locognosia test and STI had limited but positive supporting data related to validity. Rosén-Lundborg score had emerging evidence of reliability and validity as a comprehensive outcome following nerve repair. Few questionnaires were considered reliable and valid to assess cold intolerance. There is no patient-reported outcome measurement following nerve repair that provides comprehensive assessment of symptoms and function by patient perspective.

Reverse Thenar Perforator Flap for Large Palmar and Digital Defects

Reconstruction of large, full-thickness palmar and digital defects is challenging. The glabrous skin of the palm provides excellent color and texture match for palmar hand and digital defects. The reverse thenar perforator flap, which was previously infrequently used, provides a method for primary closure of large glabrous palmar skin defects. Because of the origin of the source vessels, the reverse thenar perforator flap is a good choice for larger radial-sided palmar and finger defects. This flap provides good aesthetic results for both the donor and the recipient.

Chronic Carpometacarpal Dislocation of the Thumb: A Case Report and Review of the Literature

CASE

We report a case of a chronic, irreducible carpometacarpal (CMC) dislocation of the thumb, which was managed with a trapeziometacarpal arthrodesis.

CONCLUSION

This case demonstrates that arthrodesis is a suitable salvage procedure for chronic, irreducible CMC dislocations of the thumb.

My 40-year perspective on hand surgery

The author presents his transition of his preferred methods for managing acute trauma and degenerative and congenital conditions of the hand. Based on his career-long experience, he discusses conceptual evolution and current status of treatment of Dupuytren's disease and several congenital anomalies of the hand.

Coronal Fracture of the Lunate in Advanced Kienböck Disease: Reestablishing Midcarpal Congruency to Enable Osteochondral Reconstruction: A Case Report

CASE

We describe a patient with Bain grade-2b Kienböck disease with a coronal fracture of the distal lunate articular surface with proximal structure collapse. To reestablish midcarpal congruity, we used a bone-anchored suture to repair the coronal split in the lunate in preparation for lunate preservation with osteochondral medial femoral trochlea (MFT) reconstruction.

CONCLUSION

In Bain grade-2b Kienböck disease, lunate reconstruction of both the proximal and distal joint surfaces can be performed. Successful reconstruction of the distal articular surface can be achieved using a bone-anchored FiberWire (Arthrex) suture technique. This can be employed in conjunction with an osteochondral MFT reconstruction of the proximal aspect of the lunate. Patients with this commonly encountered coronal fracture of the distal articular surface may be considered candidates for lunate reconstruction via this technique rather than conventional ablative procedures.

Laparoscopy-assisted Chimeric Peritoneal-deep Inferior Epigastric Perforator Flap for Reconstruction of Hand and Foot

Management of hand and foot defects with exposed tendons is a big challenge for plastic surgeons. Thin vascularized tissue offers an ideal surface for tendon excursion.

OBJECTIVE

This study examines the reconstructive benefits of a laparoscopy-assisted chimeric peritoneal-deep inferior epigastric artery perforator (DIEP) flap in the treatment of hand and foot injury defects.

MATERIALS AND METHODS

A retrospective review was performed on 8 patients (6 men, 2 women) that received hand or foot reconstruction with laparoscopy-assisted chimeric peritoneal-DIEP flap. Soft tissue defects of the hand or foot ranged from 16 cm x 10 cm to 22 cm x 14 cm. The peritoneum supplied by the peritoneal branches of the deep inferior epigastric artery was retrieved by laparoscopy to cover exposed extensor tendons, while the DIEP flap consisted of the cutaneous component part of this chimeric flap.

RESULTS

The flaps survived in 7 of 8 patients. Partial necrosis of the chimeric flap was observed in 1 patient due to venous thrombosis. A split-thickness skin graft then was performed to achieve wound closure on that patient. Motor and sensory functions of these 8 patients improved gradually within the first-year follow-up.

CONCLUSIONS

The laparoscopy-assisted chimeric peritoneal-DIEP flap is useful for reconstructing defects of the hand and foot with exposed tendons.

"Damage Control" Hand Surgery: Evaluation and Emergency Management of the Mangled Hand

Mangled hand injuries are defined as those with significant damage to multiple structures, which may be limb threatening. Historically these injuries resulted in amputation or death, but modern surgical and perioperative advances allow for complex reconstruction and the possibility of a sensate and functional limb. Evaluation begins with surveying for life-threatening injuries followed by a systematic approach to identify injured structures; management begins with preserving all parts, minimizing warm ischemia time, performing débridement, and planning an operative approach to optimize the chance of a functional limb. With careful surgical planning and a well-executed reconstruction, most limbs can be salvaged.

Acute hand injury splinting - the good, the bad and the ugly

Injuries to the hand comprise 20% of all emergency department attendances, with an estimated annual treatment cost of over £100 million in the UK. The initial assessment and management of hand injuries is usually undertaken by junior staff, many of whom have little or no training or experience in splinting hand fractures. In the Department of Orthopaedic Hand Surgery, Morriston Hospital, we regularly observe patients presenting to the specialist hand fracture clinics having had initial management that shows no appreciation for the treatment objectives or the safe positions for splinting. This article aims to provide guidance for frontline staff on the management of hand fractures, with particular emphasis on the appropriate nonoperative care to avoid any unnecessary morbidity.

Two-stage extensor tendon graft using the Paneva-Holevitch procedure: A new technique

Reconstruction of the extensor tendons remains a therapeutic challenge. Tendon transfers and grafts are a potential source of morbidity at the donor site, and the graft stock is limited. In the index finger, the tendon of the extensor indicis proprius can be anastomosed to the tendon of the extensor digitorum, and then the extensor digitorum tendon turned over after being cut at the forearm. We assessed the feasibility of this reconstruction on 12 upper limbs from 6 cadavers and we report the case of a 24-year-old patient who suffered destruction of the extensor apparatus in the index and middle fingers. For the cadaver study, in each case, the tendon could be moved onto the proximal interphalangeal joint, after having done an anastomosis downstream of the extensor retinaculum. The mean graft length was 13cm (9.7-15.2). This method was used in one clinical case with an excellent outcome. This is a simple technique that is without consequences since the tendons used are already cut, therefore saving a tendon graft. This technique should be part of our therapeutic arsenal.

[Treatment Options for Inveterate Injuries of Deep Finger Flexors - Primary Transplantation with Tendon Graft]

Injuries of the flexor finger apparatus are very common. Primarily, it is routinely treated by suture of the tendon. Isolated deep flexor injuries, when the flexion restriction only reaches the DIP joint, are sometimes overlooked by the surgeon or by the patients themselves, especially if the deep flexor is injured, after a closed rupture or cutaneous injury with a small skin wound. The patient is then sent to a department specializing in hand surgery after a few weeks. Subsequent shortening of the tendon apparatus makes flexor suture more difficult or sometimes even impossible. Many ways of suturing the tendons and subsequent treatment are described. The treatment results vary immensely. It depends on the mechanism of injury, injury zone, the suture suture technique used, time that has elapsed since primary treatment, surgeon experience and subsequent postoperative and rehabilitative care. One of them is reconstruction of the flexor apparatus by primary transplantation of an autologous tendon graft. Most commonly, the tendon graft is taken from the palmaris longusfrom the same hand. The tendon graft can subsitute the entire area of zones I and II. The tendon suture is made in the palm proximal to the A1 pulley outside the tendon sheath in the area where the muscular belly of thelumbricalis is located on the tendon of the deep flexor. The distal end is reinserted to the base of the distal phalanx. The primary use of the autologous tendon graft can be used in the reconstruction of obsolete deep-flexor injuries in Zone II, but also in primary treatments. This type of treatment has a number of advantages. Performing the reinforcement of the tendon at the base of the distal phalanxand the suture in the palm of the hand completely eliminates the complications caused by the tendon suture in zone II. There is no injury to the tendon sheath, or the need for intersection of the tendons. The transplanted tendon is smaller in diameter than the deep flexor, so it can also be used for older injuries when the tendon sheath is in partially missing. It removes painful palmar resistance by restoring the right position and a tension of tendon of lumbricalis and the tendon of the deep flexor. This type of reconstruction allows immediate active or semi-rehabilitation of the hand and fingers. Key words:tendon, injury, hand, transplantation, surgery, flexor, reconstruction, rupture, treatment.

Patients Transferred for Upper Extremity Amputation: Participation of Regional Trauma Centers

PURPOSE

Level-I trauma centers are required to provide hand and microsurgery capability at all times. We examined transfers to our center to better understand distant patient referrals and, indirectly, study referrals in our region.

METHODS

Records were reviewed from 2010 to 2015 to evaluate patients transferred to our level-I institution for upper extremity amputation. Patients were referred from 6 states to our institution over this period. We measured the straight-line distance from each patient's transferring facility to our facility and compared this distance with the straight-line distances from the zip code of the transferring facility to the zip code of each level-I trauma center.

RESULTS

We had data for 250 transferred patients (91% male, 9% female). For 110 patients (44%), our hospital was the nearest level-I trauma center; however, for the remaining 140 patients (56%), other level-I trauma facilities were located closer to the referring hospital. Among these 140 patients, the mean distance of the referring facility to the nearest level-I trauma center (30 miles; SD, 27) was significantly different from the mean distance of the referring facility to our facility (71 miles; SD, 60). A median of 4 (range, 1-10) level-I trauma centers were bypassed before patients arrived at our center. Medicaid and "self-pay" patients were more likely to be transferred to our facility.

CONCLUSIONS

Fifty-six percent of patients transferred to our hospital for upper extremity amputation had a level-I trauma center closer to their injury. Patients with upper extremity amputation are referred to our regional center despite the proximity of closer level-I trauma centers. This suggests that regional microsurgery expertise does not correlate with level-I trauma designation, and establishment of designated microsurgery centers and formal referral guidelines may be beneficial for management of these difficult injuries.

CLINICAL RELEVANCE

We believe that this study further supports the need for formal designation of regional centers of expertise for microsurgical hand trauma.

[Applied methods instead of autologous nerve transplantation in the reconstruction of nerve injuries on the hand]

For a long time in the clinical practice the autologous nerve transplants are used in reconstruction of the segmental defects of injured hand nerves. The published outcomes, especially in case of the motor and mixed (sensory and motor) nerves, however, were not satisfactory. Hence, it remained a problem and in the focus of research. The author aimed to study this topic and drawing conclusions in his literary review publication. According to the recent results, the replacement of the autologous nerve transplants with other materials (e.g. nerve conduits, various allografts, etc.) has shown good outcomes in mixed nerves too, if the distance of the resected nerve ends do not exceed 6 mm and the diameter of the nerves were not more than 3-7 mm. The applications of these methods have shown poor results, if the defect and/or the nerve diameter were larger. So, in these cases the autologous nerve transplantation remains the optimal management in the future. Orv Hetil. 2017; 158(30): 1163-1167.

Molecular Biology of Flexor Tendon Healing in Relation to Reduction of Tendon Adhesions

Tendon injuries are encountered after major and minor hand trauma. Despite meticulous repair technique, adhesion formation can occur, limiting recovery. Although a great deal of progress has been made toward understanding the mechanism of tendon healing and adhesions, clinically applicable solutions to prevent adhesions remain elusive. The goal of this paper is to review the most recent literature relating to the tendon healing and adhesion prevention.

Common Hand Problems with Different Treatments in Countries in Asia and Europe

Common hand problems are treated differently in different countries. This article attempts to bring together the views of surgeons from different countries on some of the most common hand problems that hand surgeons encounter in daily practice. In practice, the correct treatment of these problems may be the most important and influential to patients.

Three-dimensional virtual planning in precise chimeric fibula free flap for metacarpal defects: A case report

RATIONALE

Metacarpal and phalanx defects with soft tissue loss were suggested to be reconstructed by vascularized bone flap. The fibular osteocutaneous flap is a preferred method. Three-dimensional virtual planning has successfully applied in mandibular reconstruction with fibular free flap. We applied three-dimensional virtual planning in precise fibula flap harvest to maintain the continuity of the fibula and to achieve accurate metacarpal and phalanx reconstruction.

PATIENT CONCERNS

A 35-year-old male presented with extensive soft tissue defects and first metacarpal defect involving the first metacarpophalangeal joint.

DIAGNOSES

There were 4 cm of first metacarpal defect involving the first metacarpophalangeal joint and soft tissue defects of 5cm × 3cm + 3cm × 2cm.

INTERVENTIONS

By combining three-dimensional virtual planning, we harvested a chimeric fibular flap. The precise fibula partial osteotomies were performed with cutting guides designed in virtual planning.

OUTCOMES

All the chimeric flaps survived and no significant donor-site morbidity was noted. Michigan Hand Outcome Questionnaire scores indicated acceptable functional results.

LESSONS

Our preliminary experience with the approach of three-dimensional virtual planning in precise chimeric fibula free flap is practical and efficient. Although more cases and follow-up are needed to evaluate it, this approach is expected to benefit patients.

A mini-invasive tenolysis of the flexor tendons following hand fractures: case series

INTRODUCTION

The treatment of the flexor tendon adhesions following phalanx and metacarpal fractures, in closed or open injuries, is a great challenge for the hand surgeon. The outcomes are often poor, because of the severity of the lesion and the aggressiveness of the surgical procedure of the secondary tenolysis.

MATERIALS AND METHODS

The authors describe the technical findings and the results of a new mini-invasive tenolysis in order to treat the adhesions in zone 1 and 2 of the fingers, following phalangeal and metacarpal fractures. With an atraumatic Allis or Duval surgical forceps, the flexor tendons are separately and gently tracted making a twisting movement on themselves until the adhesions were torn and the tendons appeared released.

RESULTS

The relevant outcomes achieved show this technique is very useful to treat tendon adhesions, without adding trauma and scare to the tendinous canal and surrounding soft tissues.

Assisted Salvage of Ischemic Fasciocutaneous Flap Using Adipose-Derived Mesenchymal Stem Cells: In-Situ Revascularization

Adipose-derived mesenchymal stem cells (ASCs) have been shown to produce vascular endothelial growth factor (VEGF) and can increase perfusion in patients with critical limb ischemia. We will show that this concept can be applied to augment blood flow in zones of flap ischemia. We presented a case study of a 26-year-old man with a complex hand injury covered by a reverse radial perforator fasciocutaneous flap, which developed ischemic necrosis and was treated by debridement, transplantation of ASCs to enhance vascular support, and saline dressings. ASCs are found in the stromal vascular fraction (SVF), a heterogeneous collection of cells, including pericytes and endothelial cells, that is prepared from lipoaspirate using collagenase digestion followed by centrifugation. These were injected into the flap, the palmar tissues both subjacent and peripheral to the flap, and the skin-grafted donor site. The case was documented with photography, measurements at hand therapy, and follow-up angiography MRI. At 72 hours, new vessels appeared diffusely; at 1 week, the remaining tissues of flap were bleeding. The wound, 11 cm × 4 cm, contracted spontaneously and was healed at 21 days. The skin graft over the donor site demonstrated unusual suppleness and elasticity. 3D CT angiography disclosed a new layer of vascularity in the superficial tissues of the palm when compared with the normal side. The patient regained full composite flexion, pinch, opposition, and wrist extension. Application of ASCs into the supporting tissues surrounding the ischemic flap, and into the flap itself, constituted a form of in-situ revascularization (ISR) that was subjectively and objectively effective for this patient.

LEVEL OF EVIDENCE

5.

Neuromarkers of Post-Traumatic Stress Disorder (PTSD) in a patient after bilateral hand amputation - ERP case study

Introduction. There is a lack in the worldwide literature of reports on the Neuromarkers of Post-Traumatic Stress Disorder (PTSD) in patients after bilateral hand amputation The aim of this study was to test a hypothesis regarding developing Post-Traumatic Stress Disorder (PTSD) in a patient after bilateral hand amputation with the use of Event Related Potentials (ERPs). On the basis of previous research, the amplitudes of P3 ERP components elicited in the cued GO/NOGO tasks have been chosen as candidates for neuromarkers of PTSD. Case study. A 24-year-old patient had undergone bilateral hand amputation 12 months previously. The patient was repeatedly operated on (he had undergone successful bilateral hand replantation) and despite the severity of the injuries, he recovered. However, the patient complained of flashbacks, anxiety and sleep difficulties. Specialist tests showed the presence of PTSD. The patient participated in the cued GO/NOGO task (Kropotov, 2009) with recording 19-channel EEG. P3 GO and NOGO waves in this task were found to be significantly smaller, in comparison to a group of healthy control subjects of the same age (N=23) taken from the HBI normative database (https://www.hbimed.com/). This observed pattern of ERP waves in the patient corresponds to the pattern found in PTSD patients. Conclusions. ERPs in a GO/NOGO task can be used in the assessment of the functional brain changes induced by chronic PTSD.

Finger reconstruction using induced membrane technique and ulnar pedicled forearm flap: a case report

INTRODUCTION

Injuries referred to as "rollover hands" are associated with multiple and complex lesions of the dorsal aspect of the hand. We present a case of a multitissular reconstruction following a severe injury of the dorsum of the fingers in a 45-year-old woman.

MATERIALS AND METHODS

The bone loss reconstruction was performed in two stages using the Masquelet induced membrane technique. In the first stage, a cement spacer was inserted into the phalanx bone defects. For the second stage, the membrane induced by the foreign-body reaction was opened, the spacer was removed, and an autologous cancellous bone graft was inserted into the defects. The skin coverage was obtained using a reverse ulnar artery forearm pedicled flap. The digits were covered jointly. Three surgical procedures over the course of a 2-month period were required to desyndactylize the fingers and to defat the flap.

RESULTS

At the 2-year follow-up examination, the patient exhibited good integration of their hand use in daily living. The esthetic result was deemed to be satisfactory. Definitive bone consolidation occurred 4 months after the second stage.

CONCLUSIONS

Rollover hands are typically a challenge for both the patient and the hand surgeon. The risk of septic complications, as well as the need for several stages of surgical reconstruction, makes the Masquelet technique particularly attractive for the treatment of phalanx bone defects consecutive to rollover injuries.

Severe Hand Injuries From Fireworks: Injury Patterns, Outcomes, and Fireworks Types

PURPOSE

The purpose of this study was to characterize injury patterns and outcomes of fireworks-related hand injuries and determine if there was an association with certain fireworks types.

METHODS

A retrospective cohort study was conducted on patients treated at a trauma center between 2005 and 2015. A total of 105 patients sustaining operative hand injuries due to fireworks were identified. Medical records were reviewed to identify injury patterns, treatment outcomes, and fireworks types.

RESULTS

Eighty-eight patients (84%) sustained 92 thumb and/or first web space injuries. There were 12 thumb soft tissue-only injuries (13%) and 80 thumb fractures/dislocations (87%). Of these, there were 52 thumb carpometacarpal (CMC) joint dislocations (57%) and 36 thumb fractures outside the thumb CMC joint (39%). Fifteen hands (16%) sustained both thumb CMC joint dislocations and additional thumb fractures. Twenty-three hands (25%) required thumb revision amputation. The number of surgeries for acute reconstruction ranged from 1 to 7, with 17 patients (19%) requiring 3 or more. Sixty-three hands had deep first web space injuries, and 11 (17%) required flaps acutely for first web space reconstruction. Six hands required secondary reconstruction of a first web space contracture. An external fixator was applied to 6 hands to maintain the first web space; none of these required secondary web reconstruction. Excluding isolated pin removals and dressing changes under anesthesia, 19 patients (22%) required later-stage surgeries. Shells/mortars (59%) were the most common fireworks type causing injury.

CONCLUSIONS

Among operative hand injuries, fireworks most commonly fracture the thumb, destabilize the thumb CMC joint, and deeply damage the first web space. The first web space requires particular consideration because deep injury may result in adduction contracture and require secondary reconstruction if not prevented.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Turkey model for flexor tendon research: in vitro comparison of human, canine, turkey, and chicken tendons

BACKGROUND

Flexor tendon injuries are one of the most common hand injuries and remain clinically challenging for functional restoration. Canine and chicken have been the most commonly used animal models for flexor tendon-related research but possess several disadvantages. The purpose of this study was to explore a potential turkey model for flexor tendon research.

METHODS

The third digit from human cadaveric hands, canine forepaws, turkey foot, and chicken foot were used for this study. Six digits in each of four species were studied in detail, comparing anatomy of the flexor apparatus, joint range of motioņ tendon excursion, tendon cross-sectional area, work of flexion, gliding resistance at the level of the A2 pulley, modulus of elasticity, suture retention strength, and histology across species.

RESULTS

Anatomically, the third digit in the four species displayed structural similarities; however, the tendon cross-sectional area of the turkey and human were similar and larger than canine and chicken. Furthermore, the turkey digit resembles the human's finger with the lack of webbing between digits, similar vascularization, tendon excursion, work of flexion, gliding resistance, mechanical properties, and suture holding strength. More importantly, human and turkey tendons were most similar in histological appearance.

CONCLUSIONS

Turkey flexor tendons have many properties that are comparable to human flexor tendons which would provide a clinically relevant, economical, nonhuman companion large animal model for flexor tendon research.

[Minimal invasive osteosynthesis with cannulated screws in metacarpal fractures]

Metacarpal fractures comprise 18 to 44% of hand fractures. Fractures from the second to the fifth metacarpals are 88% of the metacarpal fractures and fractures of the fifth metacarpals are the most common. Fractures of the neck of the fifth metacarpal are about 20% of all the hand fractures. Most of these fractures can be treated conservatively with good functional results. However, for those neck and shaft unstable fractures that need surgical treatment, there is no gold standard for osteosynthesis. Recently, there have been reports of minimally invasive osteosynthesis using headless retrograde intramedullary cannulated screws with good functional results.

MATERIAL AND METHODS

We report our short term experience treating nine fifth metacarpal neck fractures, one fourth metacarpal neck fracture and a transverse fifth metacarpal shaft fracture that did not fulfill criteria for conservative treatment. We treated them with minimally invasive osteosynthesis using retrograde intramedullary headless cannulated screws.

RESULTS

All patients showed radiographic healing and had full range of motion of the metacarpophalangeal joint at one month follow up except for one patient who suffered a dorsal mutilating hand injury along with a fifth metacarpal neck fracture. One patient had osteoporotic bone and we could not control height loss with screws, so we had to use k-wires.

CONCLUSION

Minimally invasive osteosynthesis with cannulated headless retrograde screws is a good option to treat neck and transverse diaphyseal fractures of the metacarpals. It confers a stable construct that allows early range of motion and return to activities.

Reverse Radial Forearm Flap to Provide Arterial Inflow to a Toe Transfer

Background: Toe-to-thumb transfer has become the gold standard for thumb reconstruction, but in badly mutilated hands, additional soft tissue coverage may be required or a suitable recipient artery may not be available. There are only 3 case reports describing the successful use of a reverse radial forearm flap for coverage of a soft tissue defect around the thumb as well as providing arterial inflow for a toe transfer, performed either simultaneously or secondarily. Methods: A single surgeon's experience of all toe-to-hand transfers performed in conjunction with a reverse radial forearm flap between 1995 and 2014 was reviewed, including patient demographics, type of toe transfer and vascular pedicle, whether immediate or secondary, follow-up, and complications. Results: Eight toe-to-hand transfers were performed in 7 patients-3 children (age range, 3-15 years) and 4 adults (age range, 19-39 years). Three patients underwent primary toe-to-thumb transfer simultaneously with a reverse radial forearm flap, and 5 patients underwent secondary toe-to-hand transfer between 4 months and 2½ years after an initial reverse radial forearm flap. All toe transfers survived completely. Average follow-up was 5.1 years. All patients were satisfied with the function and appearance of their reconstructed thumb. Conclusion: The reverse radial forearm flap is a very reliable procedure as a "Sister" or "Siamese" flap to provide immediate arterial inflow to a simultaneous toe-to-thumb transfer, or to provide primary soft tissue coverage on the radial aspect of the hand and subsequently provide a recipient arterial inflow for a secondary toe transfer.

Extended Posterior Interosseous Artery Flap: Anatomical and Clinical Study

PURPOSE

A reverse-flow pedicled flap from the posterior interosseous artery (PIA) has been used to cover defects on the dorsal and volar aspects of the hand. However, the original description of this flap does not reach further than the metacarpophalangeal joints of the 4 ulnar digits. In the present study, we describe a distal variant (type 2) of the PIA flap, which changes the pivot point of the classic variant (type 1) and which can provide full coverage of single or multiple digits in the entire dorsum and palmar surface of the fingers.

METHODS

An anatomical study was performed on 26 cadaveric specimens to assess the presence of the anastomosis between the PIA and the dorsal intercarpal arch (DIA). In addition, the gain in pedicle length using the DIA anastomosis as a pivot point was compared with the classic pivot point at the anterior interosseous artery. A clinical study in 19 patients with soft tissue defects distal to the proximal interphalangeal joint of the fingers was also performed to assess the viability and clinical outcomes of the new variant of the PIA flap.

RESULTS

The PIA was identified reaching the dorsal carpal arch in all anatomical specimens. The mean pedicle length of the fifth extensor compartment artery was 4.8 cm (range, 4.1-5.3 cm). The mean arterial diameter was 0.8 mm (range, 0.6-1.2 mm). In the clinical study, 17 flap reconstructions were done for posttraumatic lesions and 2 postburn contractures. All extended PIA flap procedures were performed successfully without loss of the flap or significant partial necrosis. We had only 1 superficial infection. There was no need for revision of the flap in any case.

CONCLUSIONS

By extending the pivot point of the PIA flap through the DIA, instead of the anastomosis with the anterior interosseous artery, the flap distance can be increased by about 8.5 cm, allowing complete coverage of the fingers.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Management of Hand Fractures: Simple to Complex

Hand fractures are among the most common skeletal injuries. Approximately 150,000 hand fractures occur in the United States each year. The management of hand fractures consists of reduction, immobilization, and rehabilitation to return patients to their preinjury status. Hand fractures are managed by restoring articular congruity, reducing malrotation and angulation of the fracture, and maintaining the reduction, all of which should be accomplished with minimal surgical intervention. Surgeons must assess concomitant soft-tissue injuries and respect the soft tissues during the surgical management of hand fractures. Fractures through the metaphyseal bone at the base and neck will heal more quickly than fractures through the diaphyseal bone of the shaft, which makes provisional fixation of metaphyseal fractures more practical compared with provisional fixation of diaphyseal fractures. The fracture pattern determines the most practical type of fixation. Patterns of angulation should be anticipated and corrected during reduction. More rigid fixation is required if substantial comminution and bone loss are present. Bone loss also indicates a high-energy injury, which likely indicates more substantial soft-tissue injury. As the number of injured structures increases, the likelihood of full function after rehabilitation decreases.

The Posterior Interosseous Artery Free Flap

A case is reported in which retrograde flow in the posterior interosseous artery did not perfuse the posterior interosseous artery flap, which was subsequently transferred as a free tissue transfer based on the proximal posterior interosseous vessels.