Mains de « blast » : stratégie thérapeutique

INTRODUCTION

Blast injuries of the hand result from the manipulation of handmade explosives, the blast causes most damage in the first web. Our purpose is to propose a classification of these injuries so as to lead to a therapeutic strategy.

METHOD

We report a series of nine blast injuries of the hand in eight patients of average age 24 years. The aetiologie was handmade explosive manufacture (five cases) and the manipulation of munitions (four cases). Five hands presented an amputation of the thumb together with the index and in three of them, the long finger was involved as well. Only one thumb was revascularised successfully. Four thumbs were reconstructed, two by toe transfer, and two by "index bank".

DISCUSSION

We observed four different stages: Stage 1: Isolated musculo-cutaneous injury. An intermetacarpal pin avoids first web contracture. Skin coverage is achieved by a pedicled local flap or a skin graft. Stage 2: Osteo-articular injuries of the thumb and second ray but sparing the trapezo-metacarpal joint. The thumb reconstruction is often based upon rinciple. Stage 3: Characterised by a destructive injury of the trapezo-metacarpal joint. Stage 4: Amputation or devascularization of the thumb. Extensive vascular injuries neccessitate a bypass from a healthy zone. The amputations, which are mostly proximal, require a preliminary osteocutaneous reconstruction of the first metacarpal before any toe transfer. Finger translocations are made difficult because of the high rate of serious injuries of the index and palm.

A Comparison between Primary and Secondary Toe-to-Hand Transplantation

Although primary toe-to-hand transplantation is performed with increasing frequency, its use is still controversial because of the lack of any comparative studies documenting its safety and efficacy. Between August of 1990 and December of 1993, 175 consecutive toe-to-hand transplantations for crush and avulsion injuries were performed in 122 patients. The average interval between injury and primary reconstruction was 7 days, and the average interval between injury and secondary reconstruction was 10.7 months. Follow-up ranged from 18 to 91 months, with an average follow-up of 58 months. There were 31 primary transplantations and 144 secondary transplantations. The survival rate was 96.8 percent (30 of 31) for primary reconstruction and 96.5 percent (139 of 144) for secondary reconstruction. Intraoperative anastomotic revision was necessary in 3.2 percent (one of 31) of primary transplantations and 7.6 percent (11 of 144) of secondary transplantations. Three primary toe-to-hand transplantations (9.7 percent) and 17 secondary toe-to-hand transplantations (11.8 percent) were re-explored in the postoperative period. Each group had one superficial infection. The infection rate was 6.5 percent and 0.7 percent in the primary and secondary groups, respectively. Other complications included partial skin loss, which occurred in one patient (3.2 percent) in the primary group and six patients (4.2 percent of 144 transplantations) in the secondary group. Secondary procedures to improve function were necessary in six secondary transplantations (4.2 percent) and in none of the primary transplantations. There was no statistical difference between the two groups in terms of survival, intraoperative anastomotic revision, re-exploration, future secondary procedure, infection, and complications. This series demonstrates that primary toe-to-hand transplantation can be performed in the suitable candidate safely with as much success as secondary reconstruction. Primary toe transplantation can potentially reduce the overall period of recovery and rehabilitation, allowing the patient to return to work sooner. Further study to evaluate and compare the final functional outcome and return to work time between primary and secondary toe-to-hand transplantation is needed.

The multiple monoblock toe-to-hand transfer in digital reconstruction. a report of ten cases

Ten hands with multiple traumatic finger amputations or congenital agenesis underwent reconstruction by monoblock transfer of multiple toes. Eight patients underwent monoblock transfer of the great and second toes, one patient received the great toe and the metatarsophalangeal joint from the second toe with the same vascular pedicle, and another patient the great, second and third toes as a block. Only part of the great toe was ever taken, while the second toe was totally or partially taken. The surgical technique and the outcome are detailed in this work, with a mean postoperative follow-up of 6 years.

Immediate toe transfer following index finger amputation for extensive giant cell tumor of the tendon sheath with intraosseous invasion

Giant cell tumor of the tendon sheath (GCTTS) is the second most common benign tumor of the hand. Although bony indentation from external compression by the GCTTS is frequently seen on x-ray film, the intraosseous invasion is relatively rare and is a sign for high recurrence. We present a woman with extensive GCTTS located in the left index finger at the level of distal interphalangeal joint. X-ray films revealed multiple osteolytic cystic cavities in the shaft of the middle phalanx. Amputation of the index finger at the base of the middle phalanx was performed because of extensive bony involvement and concern about possible recurrence from inadequate excision. Her left second toe was transferred to replace the amputated index finger in the same session. Follow-up examination at 15 months postoperative revealed good function and appearance of the reconstructed index.

Intercalary non-vascularised toe phalanx transplantation for short finger-type symbrachydactyly

A two-year-old boy with short finger-type symbrachydactyly involving the index, middle, and ring fingers was treated with intercalary nonvascularised toe phalanx transplantation into the middle finger to obtain stability of the middle finger before syndactyly release. He underwent syndactyly release one year after the transplantation. Two years after the transplantation, the clinical result was satisfactory, although X-ray showed fibrous union between the transplanted phalanx and the host phalanx. Intercalary nonvascularised toe phalanx transplantation is one of the way of stabilising a finger after syndactyly release.

Immediate Toe-to-Hand Transfer in Acute Hand Injuries: Overall Results, Compared with Results for Elective Cases

In the past 5 years, 25 mutilated digits were reconstructed with immediate toe-to-hand transfers after acute hand injuries, for 21 patients. The overall results of the immediate toe-to-hand transfers were evaluated and compared with the results of 65 elective procedures performed during the same period by the same surgeon. There were 15 cases of great toe-to-hand transfer for thumb reconstruction, two cases of second toe transfer for index finger reconstruction, and four cases of simultaneous two-toe transfer for reconstruction of multiple-digit amputations. Two cases (two of 25 cases, 8 percent) were successfully salvaged with emergency reexploration. The incidences of emergency reexploration and postoperative infection were not significantly different from those for elective toe-to-hand transfer cases. The duration of industrial insurance coverage was much shorter than for elective cases, averaging 225 days (p < 0.001). Approximately 44 percent of the patients maintained their original jobs after immediate toe-to-hand transfer. The subjective satisfaction self-assessment scores of aesthetic appearance and function for the newly reconstructed thumb averaged 80 and 88 (of a total score of 100), respectively. Although satisfaction was lower than for elective reconstruction (p < 0.001), it was higher than for reconstruction of other digits. The donor-site appearance after great toe harvesting was mostly unsatisfactory. Immediate toe-to-hand transfer provides many advantages over the elective procedure in acute hand injuries, including single-stage reconstruction, shortened convalescence, early return to work, and socioeconomic efficiency. Because there were no significant differences in the success rates, frequencies of complications, or ultimate functional results, immediate toe-to-hand transfer is a safe and reliable procedure that is indicated for specific cases of acute digital amputation.

Microsurgical Second Toe-Metatarsal Bone Transfer for Reconstructing Congenital Radial Deficiency with Hypoplastic Thumb

This study describes a consecutive series of 11 children who received a microsurgical second toe-metatarsal bone transfer for reconstructing a hypoplastic thumb associated with radial club hand, between 1996 and 2000. The parents refused pollicization in all cases for aesthetic and cultural reasons. Surgery was intended to improve hand function and cosmetic appearance. The average patient age was 3 years, and the average follow-up period was 4 years. Average surgery time for the second toe-metatarsal bone transplantation was 8 hr. The primary success rate was 90.9 percent, with one patient requiring repeat surgery owing to venous occlusion. The surgical outcomes reveal a normal growth of the transferred toe, an acceptable range of motion, and satisfactory recovery of sensation. All children achieved both small and large grasp functions. The parents were satisfied with the reconstruction procedures. Based on the preliminary results, second toe-metatarsal bone transfer appears an acceptable alternative for reconstructing radial deficiency with hypoplastic thumb.

Primary Reconstruction of a Degloved Hand Using Multiple Toe Transfers on a Single Pedicle and a Reversed Radial Artery Flap

This case study reports one-stage reconstructive surgery on an 18-year-old man who was injured by an industrial roller machine and who presented with a degloved hand. Non-replantable delgloving occurred in all fingers, with the loss of the palmar and part of the dorsal skin. Multiple free contiguous toes were transferred based on a single dorsalis pedis artery pedicle. The artery was anastomosed to a reversed radial artery flap, which was used to cover the palm for primary reconstruction of the degloved hand. Multiple toes were harvested from the same foot, based on a single pedicle, to contain the potential morbidity to one foot, to enable primary reconstruction, and to decrease the length of the operation. The flaps healed well, and the patient demonstrated adequate tripod pinch and key pinch with the transferred toes, with a two-point discrimination of 12 mm at 1-year follow-up. The patient was satisfied with both the appearance and function of the hand and foot.

Combined free-tissue transfer for primary reconstruction of radial part of the hand

This paper presents 14 cases of primary reconstruction of radial-part hand defect by combined free-tissue transfer. The thumb was reconstructed by wraparound flap or second-toe transfer, while a lateral upper-arm flap or anterolateral thigh flap was transferred to cover the soft-tissue defect of the radial part of the hand. The arteries of the toe and flap were anastomosed and cascaded with the radial artery in an anatomical "snuffbox." Fourteen toes and 13 flaps survived in 14 cases. Only one flap was lost. Two-point discrimination of thumb tips was between 4-8 mm. The results suggest that combined free-tissue transfer appears to be a promising way of reconstructing a defect of the radial part of the hand.

[Results of Kirschner wire osteosynthesis and intramedullary bone peg in toe-transfers]

During 1995-2002 in General and Hand Surgery Department 21 digits were reconstructed by toe to hand transplantation performed in 16 patients. There were 10 cases thumb was reconstruction with 4 great toe and 6 second toe transfers. Rest 11 fingers there were index, middle and ring were restored by II and III toe. Twelve osteosynthesis were performed by Kirschner wire and nine by bone peg. All fixations were sufficient stable to start early rehabilitation. In one case after Kirschner fixation occurred ostitis and malunion. This patient was cured by autovaccine. After bone peg we do not recorded any complication.

Functional evaluation of a great toe transfer and the osteoplastic technique for thumb reconstruction in the same individual

Since the popularization of microvascular toe transfer, there has been a tendency to relegate osteoplastic reconstruction techniques for the thumb to history. A case is presented which shows that a successful and well-planned osteoplastic thumb reconstruction can match microsurgical reconstruction in all functional activities. Cosmetically, the toe transfer is the better reconstructive option but it may cause significant donor site morbidity.

Combined pollicization and toe transfer for thumb reconstruction

A 45-year-old orthopaedic surgeon sustained a complete thumb amputation and severe injuries to his index finger in a lawn mower accident. He was treated with a combined second toe transfer and an index finger pollicization.

Minimizing impairment in laborers with finger losses distal to the proximal interphalangeal joint by second toe transfer

Traditionally, toe-to-hand transfers have been reserved for thumb amputations or for use after severe mutilating injuries. The authors report their experience with the use of second toe-for-finger amputations with preserved or reconstructible proximal interphalangeal joints in manual workers. The aim of the procedure was to reduce impairment and to upgrade the hand from a functional and cosmetic standpoint. Fifteen second-toe wrap-around or variations were carried out on 11 adults (18 to 41 years old). Four patients with two or more finger amputations received two sequential second toes; four patients with two finger amputations received one toe; and each of three patients with single-digit amputation received a single toe. All but one amputation were performed less than 3 weeks after the accident. All toes survived. Range of motion at the native proximal interphalangeal joint was more than 90 percent in all patients but one; however, it was minimal at the transplanted joints. Patient satisfaction was high from a cosmetic and functional standpoint. Ten of 11 laborers resumed their previous activity. On the basis of this experience, a classification with aesthetic and functional implications is proposed to help in the decision-making process when dealing with multidigital injuries. It is concluded that second-toe transfer is an excellent choice for finger amputation distal to the proximal interphalangeal joint in laborers. Its prime indication is for amputations of two fingers where at least one toe should be transferred, as required, to achieve an "acceptable hand" (three-fingered hand). Early transfer allows salvage of critical structures from the damaged finger, such as joints, tendons, and bone, that otherwise would be lost. Early transplantation is highly recommended.

Thumb amputations from team roping

BACKGROUND

Thumb injuries during team roping have elements of both avulsion and crush, resulting in a poor prognosis for replantation success.

PURPOSE

To review 19 cases of thumb amputation from team roping at our institution since 1983.

STUDY DESIGN

Retrospective cohort study.

METHODS

Cases were included in the study only if a microvascular repair of artery and vein was needed for the thumb to survive. Vein grafts were used to span the damaged vessel segment. Of the 19 thumb amputation cases, 15 attempts were made to replant the thumb. In the remaining four cases, patients had bone shortening and primary closure. The force of injury was calculated based on mechanism.

RESULTS

Of the 15 attempts at replantation, only 5 (33%) were successful, despite meticulous technique. One patient subsequently had an emergency toe-to-thumb transfer after an unsuccessful replant, and the remaining nine underwent amputation. Nine of the 10 patients with failed replants had poor flow intraoperatively. In the group of patients younger than 15, the success was 3 of 5 (60%) and in the group 15 years or older the success was 2 of 10 attempts (20%.) Follow-up was available in 13 of the 15 cases of replanted thumbs.

CONCLUSIONS

All patients were subjectively satisfied with their results, and all patients with successful replants and seven patients with no thumb returned to rodeo. Biomechanical analysis showed a huge amount of force and pressure, several times larger than that of ring avulsion injury, results when a steer pulls on the thumb.

Two-stage reconstruction of four-digit amputation: distal ulnar artery flap and combined second- and third-toe transfer

We report a case of combined two toe transfer after distal ulnar artery fasciocutaneous flap in a 10-year-old boy who has four-digit amputation. Four years after the operation, satisfactory results were obtained both functionally and cosmetically.

Thumb reconstruction for aesthetic reasons using an exteriorised microvascular pedicle

Thumb reconstruction following amputation is usually performed in order to restore function. Nevertheless, the reconstruction should be cosmetically acceptable in order to be fully functional, and, in some cases, reconstructive surgery may be justified for purely aesthetic reasons. The most satisfying aesthetic results in adults are obtained with microsurgical partial great-toe transfer. The technique that we use for thumb reconstruction is illustrated by two case reports: that of a 26-year-old female patient and that of a 35-year-old male patient. Both patients had a distal thumb amputation with destroyed nail apparatus, and both sought thumb reconstruction for cosmetic reasons. Aesthetic reconstruction was performed in both cases with a partial ipsilateral great-toe transfer, composed of nail apparatus, underlying bone and custom-made pulp tissue. The vascular anastomosis was done at the snuff-box, through a small incision, with an exteriorised pedicle. The result was satisfactory in both cases, with minimal donor-site sequelae. Partial toe transfer has proven to be a reliable technique for thumb reconstruction. It is an evolving technique. Many modifications have been introduced to optimise the aesthetic result and to reduce donor-site morbidity. Our technique allows us to restore thumb length, replace the missing nail and reconstruct the pulp, with acceptable sequelae at the donor toe. The exteriorised-pedicle technique prevents pedicle compression and twisting and reduces scarring and stiffness. It does, however, require delicate postoperative care and a second procedure for pedicle division.

[Contemporary possibilities of thumb reconstruction. II. microsurgical methods]

Microsurgery has revolutionised thumb reconstruction procedures, not only allowing addition of new structures, but also performing whole reconstruction during a single, one stage procedure. This paper presents only the fundamental techniques: toe transfers (great and second toe), the wrap--around technique, trimmed-toe transfer, twisted-two-toes, free vascular joint transfer. Indications, surgical techniques, results and complications are discussed.

Thumb reconstruction by pedicled transfer of the second toe

Microsurgery and free tissue transfer play a vital role in the modern practice of reconstructive surgery. Prior to the advent of microsurgical free tissue transfer pedicle flaps were the workhorse of a reconstructive surgeon. We report a case of thumb reconstruction by pedicled transfer of the second toe with functional and aesthetic outcome. This case was performed in Pakistan where microsurgical facilities were not available.

Toe-to-hand transplantation

In the mutilated hand microsurgical toe-to-hand transplantation provides thumb and finger reconstruction that is superior to conventional techniques in appearance and function. Hand reconstruction using toe transplantation should be individually planned and carefully executed to obtain optimal results and minimal disability in the donor foot.

[Finger reconstruction by microvascular second toe-to-finger transplantation in patients with traumatic loss of all fingers]

PURPOSE

To assess the utility of second toe-to-finger transplantation with neurovascular reconstruction in patients with loss of all four digits.

METHOD

Analysis of 24 toe-to-finger transplantations in 18 patients regarding over-all survival, complications and secondary procedures, sensibility, function, foot symptoms, and patient satisfaction. The original metacarpophalangeal joint was preserved in 50 % of the transplantations. In six patients, a second transplantation was performed.

RESULTS

A mean follow-up of 5.8 years was available in 94 % of the patients. 92 % of the transplanted toes survived, in 38 % of the cases complications occurred followed by a secondary procedure. Two-point-sensibility was present in 62 % of the transplantations, the largest range of motion of ca. 50 degrees was obtained in the metacarpophalangeal joint. An increase in the range of motion could be achieved by preservation of the original finger joint. The mean extension lag was 37 degrees independent of the preservation of the metacarpophalangeal joint. Foot symptoms were mild in four patients, in two cases severe donor-site-problems were observed. Cold intolerance was present in 47 % of the transferred toes. Overall patient satisfaction was high with 83 % of the patients confirming their decision to undergo operative treatment.

CONCLUSION

Second toe-to-finger transplantation is indicated in patients with traumatic loss of all digits. By this method, a great functional gain could be achieved as well as a high level of satisfaction. The rate of complications and possible foot symptoms should be considered. The preservation of the original metacarpophalangeal joint seems to be of importance for the function of the transplanted toe.