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Cardoz Lobo I, Manek S, Bhosale K, Verma C, Devale M, Parekh A, Kerketta P. Evaluation of Outcome Measures of Zone V Flexor Tendon Injury: A Systematic Review. Indian J Plast Surg 2023; 56:480-487. [PMID: 38105874 PMCID: PMC10721374 DOI: 10.1055/s-0043-1775864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
Background Flexor tendon injury zone V is a multicomponent soft tissue injury involving tendons, nerves, and vessels. Outcome assessment of repair thus requires evaluation of the hand as a whole rather than solely evaluating tendon function. The purpose of this Preferred Reporting Items for Systematic Reviews and Meta-Analyses -compliant systematic review was to identify and assess the components of outcome measures used in flexor zone V. Methods A total of 3,761 studies were retrieved from four databases (PubMed, ProQuest, Cochrane Central, and Google Scholar). These studies were then screened for inclusion using a validated screening form. Fifteen articles fulfilling the eligibility criteria were included in the review. Subsequently, the included studies were assessed for methodological quality using the Joanna Brigg Institute tool. Results Out of the 15 studies, 11 were case series, 3 were cross-sectional studies, and 1 was a randomized controlled trial. Out of 15 included studies, 13 were of low risk, whereas 2 studies suggested moderate risk when assessed for methodological quality using the Joanna Brigg Institute tool. Eight outcome measures were identified, out of which the most frequently used were Total Active Motion by the American Society for Surgery of Hand (TAM-ASSH) and Noaman's criteria. Our study found that Noaman's criteria assessed sensory-motor function and finger deformity in addition to the range of motion (ROM), which was found to be assessed by all the other outcome measures. Conclusion We concluded that although Buck-Gramcko criteria is well suited for the ROM evaluation, Noaman's criteria, a recently developed outcome measure used exclusively for combined injuries in zone V, took into consideration the implications of nerve injury along with tendon function. Although being specifically designed for combined injuries of tendons, nerves, and vessels in zone V, there is a lack of usage of Noaman's in the literature. There still exists a lack of a consistent and appropriate choice of outcome measure.
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Affiliation(s)
- Iris Cardoz Lobo
- Department of Plastic Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
| | - Sonali Manek
- Physiotherapy School and Centre, Topiwala National Medical College and B Y L Nair Charitable Hospital, Mumbai Central, Mumbai, Maharashtra, India
| | - Krutika Bhosale
- Physiotherapy School and Centre, Topiwala National Medical College and B Y L Nair Charitable Hospital, Mumbai Central, Mumbai, Maharashtra, India
| | - Chhaya Verma
- Physiotherapy School and Centre, Topiwala National Medical College and B Y L Nair Charitable Hospital, Mumbai Central, Mumbai, Maharashtra, India
| | - Maksud Devale
- Department of Plastic Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
| | - Aditi Parekh
- Physiotherapy School and Centre, Topiwala National Medical College and B Y L Nair Charitable Hospital, Mumbai Central, Mumbai, Maharashtra, India
| | - Priyanka Kerketta
- Department of Plastic Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
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Ghimire S, Shah SK, Mandal S. Primary repair of the severe "spaghetti wrist" with good functional outcome measured using quick dash scoring system: Management from LMIC perspective. Int J Surg Case Rep 2023; 112:108908. [PMID: 37837665 PMCID: PMC10667760 DOI: 10.1016/j.ijscr.2023.108908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/29/2023] [Accepted: 09/30/2023] [Indexed: 10/16/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Spaghetti wrist as a part of occupational injury is common among the young adults. Involvement of the multiple neurovascular structures and tendons at wrist may severely impact the quality of life. But if timely intervention can be undertaken the prognosis can be modified with good functional outcome. Moreover the need for common consensus for the appropriate management protocols of such severe traumatic injuries is utmost. CASE PRESENTATION A 29 years old working male sustained severe cut injury at volar aspect of wrist from glass involving multiple tendons and neurovascular structure as a part of occupational injury. Patient was rushed within 1 h to the nearest tertiary care center and further within 2 h emergency reconstructive surgery was carried out with primary repair of ten tendons, one nerve and one artery. At 9 months follow up patient had satisfactory sensory and motor functional outcome and further at 10 month follow up Qucik Dash scoring system for measuring functional outcome showed significant score suggestive of good functional outcome. CLINICAL DISCUSSION Spaghetti wrist being one of the grievous hand injuries requiring immediate surgical intervention. The involvement of multiple neurovascular structures and tendons might result in poor functional outcome if there is delay in proper management. Despite absence of adequate guidelines in treatment of such occupational injuries immediate primary repair can be also a significant modality of management. CONCLUSION Spaghetti wrist being severe traumatic injury without any common consensus for proper management, despite this timely intervention with only primary repair have shown good functional outcome with enhanced quality of life.
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Affiliation(s)
- Sagun Ghimire
- KIST Medical College and Teaching Hospital, Lalitpur, Nepal.
| | | | - Sunny Mandal
- KIST Medical College and Teaching Hospital, Lalitpur, Nepal
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Lad PB, Venkateshwaran N, Thatte MR, Tanpure S. A Rare Case of Bilateral Spaghetti Injuries in Children due to Assault by Mother and Analysis of Functional Outcome at Three Years. J Hand Microsurg 2023; 15:230-235. [PMID: 37388567 PMCID: PMC10306995 DOI: 10.1055/s-0041-1735346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Management of child abuse with flexor tendons, neurovascular injuries, and life-threatening conditions is challenging. It needs a multisectoral coordinated and synchronized team effort for successful outcomes. We present a case series of children abused by a parent with a sharp object. The children sustained multiple flexor tendon injuries, neurovascular injuries in upper limbs, and tracheal injury compromising respiration. We performed a tracheostomy to save a child and subsequently repaired numerous flexor tendons, nerves, and arteries. During follow-up, these children required secondary reconstruction (tenolysis, tendon lengthening, nerve reconstruction) for flexor contractures, stiffness, and sensory loss in distal forearms. We measured the range of movements and assessed the children's functional outcome using the Strickland score at 3-year follow-up. The range of movement and functional outcome was excellent in both children in our series. A timely performance of surgery, aided with efficient intensive care, therapy, and consistent posttraumatic psychosocial rehabilitation, produced excellent results in our series.
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Affiliation(s)
- Parag B. Lad
- Department of Orthopaedics, Jupiter Hospital, Thane, Maharashtra, India
| | - N. Venkateshwaran
- Department of Plastic Surgery, Jupiter Hospital, Thane, Maharashtra, India
| | - M. R. Thatte
- Department of Plastic Surgery, Bombay Hospital, Mumbai, Maharashtra, India
| | - Sanket Tanpure
- Department of Orthopaedics, Jupiter Hospital, Thane, Maharashtra, India
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Matzkeit N, Kisch T, Waldmann A, Schweiger U, Mailänder P, Westermair AL. Deep wrist injuries from suicide attempts vs. accidents do not differ regarding sensorimotor outcome, but regarding patient-reported outcome measures. J Plast Surg Hand Surg 2023; 57:95-102. [PMID: 34730072 DOI: 10.1080/2000656x.2021.1993868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Despite the clinical importance of deep wrist injuries (DWIs), data comparing the outcome of suicide attempt survivors vs. accident survivors are lacking. Patients admitted to our Clinic for acute treatment of a DWI from 2008 to 2016 were contacted for a follow-up assessment of sensory, motor and functional outcomes. Patients also completed the Disability of the Arm, Shoulder and Hand Questionnaire, the Modified Mayo Wrist Score, the Boston Carpal Tunnel Questionnaire, and the WHOQOL-BREF questionnaires. 51 patients could be followed up, on average 4.3 ± 2.9 years after their injury. Suicide attempt survivors did not differ from accidents survivors concerning two-point discrimination, grip and pinch strength, but showed poorer outcomes in self-reported disability, symptom severity, and quality of life. Patients with DWIs from suicide attempts vs. accidents do not differ in sensorimotor outcomes but patient-reported outcome measures. Level of Evidence: II.
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Affiliation(s)
- Nico Matzkeit
- Clinic of Plastic Surgery, University of Lübeck, Lübeck, Germany
| | - Tobias Kisch
- Clinic of Plastic Surgery, University of Lübeck, Lübeck, Germany
| | - Annika Waldmann
- Institute for Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany.,Hamburg Cancer Registry, Ministry for Health and Consumer Protection, Hamburg, Germany
| | - Ulrich Schweiger
- Hamburg Cancer Registry, Ministry for Health and Consumer Protection, Hamburg, Germany
| | - Peter Mailänder
- Clinic of Plastic Surgery, University of Lübeck, Lübeck, Germany
| | - Anna Lisa Westermair
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
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Hassan NA, Elsawy NA, Kotb HH, El-Hamid MMA, El Emairy WS, Kholosy HM. Evaluation of outcome after primary median and/or ulnar nerve(s) repair at wrist: clinical, functional, electrophysiologic, and ultrasound study. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2021. [DOI: 10.1186/s43166-021-00095-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
A major problem in surgery of peripheral nerve injuries of the upper extremities is the unpredictable final outcome. More insight and understanding of the proper methods of outcome assessment and the prognostic factors is necessary to improve functional outcome after repair of peripheral nerves. The objective of this study is to assess the outcome and identify possible prognostic factors for functional recovery of median and/or ulnar nerves repairs at wrist. Forty patients with median, ulnar or combined median-ulnar nerve injuries were included. Smoking, age, sex, repaired nerve, associated artery and/ or tendon repairs, joint stiffness and scar tissue were analyzed as prognostic factors for functional outcome after repair. Outcome parameters were medical research counsel (MRC) scoring for sensory and motor recovery, grip and pinch strength, disability of arm, shoulder and hand (DASH) questionnaire, electrophysiology and ultrasonographic evaluation.
Results
The mean age of the studied patients was 29.1 ± 8.3 and it was statistically correlated with grip strength (p = 0.045), DASH score (p = 0.046) and hyperesthesia score (p = 0.040). EMG results showed signs of regeneration in all patients in the form of small nascent MUAPs and polyphasic MUAPs. CMAP amplitudes of median and ulnar nerves positively correlated with the MRC scale for muscle strength (p = 0.001)
There were statistically significant negative correlations between DASH score and MRC score for sensory evaluation (p = 0.016), grip (p = 0.001), and pinch strength (p = 0.001). There were statistically significant positive correlations between patient's opinion of recovery and MRC score for sensory evaluation (p = 0.029), grip (p = 0.001), and pinch strength (p = 0.001). The MRC score for muscle strength has statistical significant positive correlations with the MRC score for sensory evaluation, grip (p = 0.003), and pinch strength (p = 0.040)
Conclusions
It was concluded that; MRC scale for muscle power, MRC scale for sensory evaluation, functional scores, grip and pinch strength are valuable tools for evaluation of functional outcome. Age, smoking, associated tendon repair, damaged nerve, compliance to rehabilitation protocol, return to work, clinically visible wound adhesions, residual hand joint stiffness, and scar tissue detected by ultrasound were found to be prognostic factors for outcome after nerve repair.
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Stefanou N, Kontogeorgakos V, Varitimidis S, Malizos KN, Dailiana Z. Spaghetti wrist: Transverse injury, axial incision, layered microsurgical reconstruction. Injury 2021; 52:3616-3623. [PMID: 33888333 DOI: 10.1016/j.injury.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/24/2021] [Accepted: 04/04/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Among various patterns of complex injuries of the wrist and forearm, "spaghetti wrist" refers to an extensive volar forearm laceration, in which several of the 12 tendons, 2 major nerves and 2 major arteries are transected, leading to lifelong disability and psychological, social and economic consequences. The aim of the study is to emphasize the keynote principles for the management of these injuries through retrospective review of a large group of patients treated by a team of experienced hand surgeons. MATERIAL-METHODS Data were retrospectively obtained for 61 patients (49 males and 12 females with average age of 34.7 years) treated for spaghetti wrist lacerations and followed for a minimum period of two years, in two accredited Orthopaedic / Hand-Upper Extremity Surgery and Microsurgery Departments in Greece. All patients were treated within 16 hours of injury and underwent primary, layered reconstruction of all injured structures through an axial forearm exposure. RESULTS The most frequent mechanism of injury was glass-related lacerations. Overall, 541 structures were reconstructed, of which 417 were tendons, 76 nerves, and 48 arteries. An average of 8.86 structures were injured per patient, including 6.83 tendons, 1.24 nerves, and 0.79 arteries. The majority of the patients (28/61) had ≥10 structures injured (45.9%), while 32.7% (20/61) and 21.3% (13/61) of patients had 6-9 and 3-5 injured structures respectively. Almost 80% (49/61) of patients had excellent/good grading in all six tests used for the functional assessment post-operatively. DISCUSSION Spaghetti wrist injuries usually occur in a transverse wound pattern and necessitate timely and definitive operative reconstruction of all injured structures in layers, through an axial approach, by experienced hand surgeons to maximize outcome and to avoid complications. The most important prognostic factor of functional recovery is not the number of transected tendons, but the involvement of ulnar and/or median nerve injury.
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Affiliation(s)
- Nikolaos Stefanou
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Thessaly, 3 Panepistimiou St, Biopolis41500Larissa, Greece
| | - Vasileios Kontogeorgakos
- Department of Orthopaedic Surgery, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Sokratis Varitimidis
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Thessaly, 3 Panepistimiou St, Biopolis41500Larissa, Greece
| | - Konstantinos N Malizos
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Thessaly, 3 Panepistimiou St, Biopolis41500Larissa, Greece
| | - Zoe Dailiana
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Thessaly, 3 Panepistimiou St, Biopolis41500Larissa, Greece; Hand, Upper Extremity and Microsurgery Department, IASO Thessalias, Nikaia41500Larissa, Greece.
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Combined nerve, vessel, and tendon injuries of the volar wrist: Multidisciplinary treatment and functional outcomes. HAND SURGERY & REHABILITATION 2021; 40:729-736. [PMID: 34403786 DOI: 10.1016/j.hansur.2021.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 06/28/2021] [Accepted: 07/11/2021] [Indexed: 11/23/2022]
Abstract
The superficial location of critical structures, including tendons, nerves and vessels, in the volar surface of the wrist makes them vulnerable to penetrating trauma. Extensive injuries to these structures are described as "spaghetti wrist". The main objective of this study was to report functional outcome in spaghetti-wrist injuries. The records of patients presenting to our clinic with extensive volar wrist injuries between January 2016 and January 2019 were reviewed retrospectively. Age, gender, comorbidities, date of injury, injury mechanism, affected hand and transected structures were noted. Tendon function, opposition, intrinsic hand function, deformity and sensitivity were evaluated following the Noaman report. The Michigan Hand Outcomes Questionnaire (MHOQ) was used to evaluate hand-specific outcomes. Twenty patients were included. Mean age was 32.7 years (range, 18-47 years). Mean follow-up was 21.9 months (range, 12-50 months). Mean number of injured structures was 11.9 (range, 10-16 structures) per patient. Physiotherapy duration had an effect on postoperative outcome in all six MHOQ domains (r = 0.821, p = 0.00001). However, no significant difference in overall hand function was found according to the number of injured structures (r = -0.105, p = 0.661). Precise initial evaluation, meticulous surgical treatment within 24 h and early physical therapy are essential after spaghetti-wrist injury. Good functional results are associated with prolonged physical therapy, but not with the number of structures injured.
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Management of spaghetti wrist under WALANT technique. HAND SURGERY & REHABILITATION 2021; 40:655-659. [PMID: 34166849 DOI: 10.1016/j.hansur.2021.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/02/2021] [Accepted: 06/13/2021] [Indexed: 11/21/2022]
Abstract
This study aimed to evaluate the effectiveness of the WALANT technique in managing spaghetti wrist lacerations. Thirteen consecutive patients with spaghetti wrist laceration were operated on under WALANT technique and followed prospectively. All patients were operated on by the same hand surgeon in a university hospital setting. At the final follow-up, arterial patency, tendon repair, nerve regeneration, handgrip strength and overall patient satisfaction were assessed. All patients were male, with a mean age of 23.8 ± 7.7 years (range, 18-42). The mean waiting time from admission to operation was 33.6 ± 5.1 min (range, 26-42). The operation lasted a mean 119.6 ± 33.8 min (range, 75-185). Mean time from admission to discharge was 269.3 ± 35.0 min (range, 225-341). Mean VAS for intraoperative pain was 1.0 ± 0.9 points (range, 0-3). Patients were followed up for at least 6 months: mean 9.8 ± 1.6 months (range, 7-12). Ten of the 12 repaired arteries were patent and 2 were occluded at the final follow-up. Six of the 17 repaired nerves were evaluated as excellent, 9 as good and 2 as fair on 2-point discrimination test. Total active range of motion was perfect in 6 patients, good in 6, and fair in 1. Grip strength was averaged 86.8% (range, 76.9-93.5%) of the contralateral value. All patients were either very satisfied (n: 9) or satisfied (n: 4). The WALANT technique can be used for spaghetti wrist lacerations involving the tendons, arteries and nerves, with favorable outcome. Major arterial anastomosis can be performed without any surgical limitation.
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Usmani RH, Rainville A, Botkin D, Merrell GA. Evaluation of Tension at Median and Ulnar Nerve Repairs at the Wrist in a Cadaveric Model. Hand (N Y) 2021; 16:188-192. [PMID: 31155954 PMCID: PMC8041421 DOI: 10.1177/1558944719851223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Median and ulnar nerve lacerations at the wrist are often combined with zone 5 tendon injury. The inability to provide early range of motion leads to increased adhesions. Current therapy protocols recommend the wrist be held in 30° of flexion post operatively to protect the nerve repair. However, if tension and elongation across the nerve repair stay under a critical level in less wrist flexion, postoperative splinting in more extension could allow for better tendon excursion and less adhesions. Methods: Six cadaveric specimens were used. After appropriate dissection, the median and ulnar nerves were transected and repaired with a single 10-0 nylon suture. The wrist was ranged from 30° flexion to 45° extension to see if the repair would fail. Next, an epineural repair was accomplished with 9-0 nylon suture. The percent elongation along the nerve repair was measured at set increments from 30° flexion to 45° extension. Results: In all 6 specimens, median and ulnar nerve repairs with a single 10-0 nylon suture did not fail with wrist range of motion from 30° flexion to 45° extension. Mean percent elongation stayed under critical levels in up to 30° of extension. Conclusions: Both median and ulnar nerve repairs stayed under critical levels of tension and elongation in up to 30° of wrist extension. We believe it is possible to be more aggressive with wrist positioning in wrist level median and ulnar nerve repairs.
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Affiliation(s)
- Rashad H. Usmani
- University of Louisville, KY, USA,Rashad H. Usmani, Department of Orthopaedic Surgery, University of Louisville, 550 South Jackson Street, 1st Floor ACB, Louisville, KY 40202, USA.
| | | | - Deana Botkin
- Indiana Hand to Shoulder Center, Indianapolis, USA
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Kisch T, Matzkeit N, Waldmann A, Schweiger U, Stang F, Mailänder P, Westermair AL. Time heals all wounds - Outcomes of deep palmar wrist injuries may improve long after reinnervation. HAND SURGERY & REHABILITATION 2021; 40:331-337. [PMID: 33640517 DOI: 10.1016/j.hansur.2020.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/25/2020] [Accepted: 12/27/2020] [Indexed: 11/18/2022]
Abstract
Despite the clinical importance of deep wrist injuries (DWIs), data on the timeframe of possible improvements in hand function are scarce. We tested the hypotheses that a) the length of follow-up is positively correlated with the outcome, and b) this correlation is tempered by nerve involvement. All patients admitted to the Clinic of Plastic Surgery with an acute DWI between 2008 and 2016 were contacted for a follow-up examination including two-point discrimination, range of motion, grip, and pinch strength, as well as DASH and MMWS questionnaires and employment status. Possible confounders such as age, handedness, and intentionality of the injury (accidental or suicidal) were assessed and controlled for statistically. Fifty-three patients were reviewed (74% male and 26% female, 86% right-handed, 70% accidental injuries, mean age at injury 42.0 ± 17.1 years), an average of 4.3 ± 2.9 years after their injury. In patients with a nerve injury, length of follow-up had significant effects on two-point discrimination, grip and pinch strength, self-reported symptom severity and impairment. Contrary to conventional knowledge, the clinical outcome of DWIs may improve beyond 3 years when there is nerve involvement. This important prognostic finding has far-reaching implications for both clinicians (e.g., asked to give their medical opinion) and patients (e.g., considering re-training after a DWI).
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Affiliation(s)
- T Kisch
- Clinic of Plastic Surgery, University Hospital Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
| | - N Matzkeit
- Clinic of Plastic Surgery, University Hospital Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - A Waldmann
- Institute for Social Medicine and Epidemiology, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany; Hamburg Cancer Registry, Ministry for Health and Consumer Protection, Billstraße 80, 20539 Hamburg, Germany
| | - U Schweiger
- Department of Psychiatry and Psychotherapy, University Hospital Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - F Stang
- Clinic of Plastic Surgery, University Hospital Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - P Mailänder
- Clinic of Plastic Surgery, University Hospital Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - A L Westermair
- Department of Psychiatry and Psychotherapy, University Hospital Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
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Hinchcliff KM, Ho CN, Meamar P, Irwin CS. Maintained Hand Perfusion in the Setting of Radial and Ulnar Artery Transections: A Report of 2 Cases. JBJS Case Connect 2020; 10:e1900365. [PMID: 32910601 DOI: 10.2106/jbjs.cc.19.00365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Two otherwise healthy male patients presented with lacerations to the volar distal forearm. Both patients had capillary refill at the fingertips and intact Doppler signals of the palmar arch. Computed tomography angiography revealed cessation of flow in the major forearm arteries at the level of the lacerations, with distal reconstitution from the anterior interosseous artery in both cases and from a branch off the ulnar artery in 1 case. The patients underwent operative exploration, where complete transections of the radial and ulnar arteries were found and repaired. CONCLUSIONS In patients without arterial disease, contributions from minor forearm arteries can be sufficient for hand perfusion in the setting of radial and ulnar artery transection.
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12
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Jeong SH, Gu JH, Kim WK. Analysis of Self-Inflicted Lacerations to the Wrist: A Multi-Disciplinary Approach to Treating. J Hand Surg Asian Pac Vol 2020; 25:47-53. [PMID: 32000597 DOI: 10.1142/s242483552050006x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Self-inflicted wrist lacerations have the potential to lead to crippling sequelae and repeated suicidal attempt. To obtain good results, we have treated self-inflicted wrist lacerations using a multidisciplinary team - emergency, hand surgery, psychiatry, and rehabilitation. This study aims to review features of this type of injuries and suggest multidisciplinary team approach as an optimal treatment. Methods: Our multidisciplinary approach can be summarized as follows: initial evaluation, psychological interview, surgery, and rehabilitation. The medical records including wound features, injured structures and psychological data were reviewed retrospectively. Assessment of functional outcomes, and comparative analysis of various psychological parameters were conducted. Results: Most patients resulted in excellent or good functional outcomes. Five patients reattempted wrist cutting with suicidal intent during follow-up. Only 21.3% patients had a suicidal intent and it was not associated with injury severity and functional recovery. Alcohol ingestion and presence of associated injuries was significant different between severity groups. Presence of suicidal intent was irrelevant to injury severity and functional recovery, but relevant to alcohol ingestion, presence of associated injuries and presence of psychiatric diagnosis. Conclusions: In order to minimize catastrophic disability and repeated suicide attempts, a balanced multidisciplinary approach is one of the best methods to obtain excellent functional outcomes and prevent repeated injuries in patients with self-inflicted wrist lacerations.
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Affiliation(s)
- Seong-Ho Jeong
- Department of Plastic Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Ja Hea Gu
- Department of Plastic Surgery, Dankook University Hospital, Cheonan, Korea
| | - Woo-Kyung Kim
- Department of Plastic Surgery, Korea University Guro Hospital, Seoul, Korea
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Raherinantenaina F, Randriantsoa MP, Rabemanantsoa R, Andrianandraina MCG, Avotsihoarana TH, Mampiadana ML, Randrianirina A, Solofomalala GD, Rakoto Ratsimba HN, Rajaonanahary TMA. Combined injuries to the radial and ulnar arteries of the forearm. JOURNAL DE MÉDECINE VASCULAIRE 2020; 45:228-231. [PMID: 32571565 DOI: 10.1016/j.jdmv.2020.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
Affiliation(s)
- F Raherinantenaina
- Vascular Surgery department, CHU of Morafeno, Toamasina, Madagascar; Medicine faculty, Toamasina University, Madagascar.
| | - M P Randriantsoa
- Orthopedic and Trauma Surgery department, CHU of Morafeno, Toamasina, Madagascar; Medicine faculty, Antananarivo University, Antananarivo, Madagascar
| | - R Rabemanantsoa
- Vascular Surgery department, CHU of Morafeno, Toamasina, Madagascar; Medicine faculty, Antananarivo University, Antananarivo, Madagascar
| | - M C G Andrianandraina
- Vascular Surgery department, CHU of Morafeno, Toamasina, Madagascar; Medicine faculty, Antananarivo University, Antananarivo, Madagascar
| | - T H Avotsihoarana
- Vascular Surgery department, CHU of Morafeno, Toamasina, Madagascar; Medicine faculty, Antananarivo University, Antananarivo, Madagascar
| | - M L Mampiadana
- Vascular Surgery department, CHU of Morafeno, Toamasina, Madagascar; Medicine faculty, Antananarivo University, Antananarivo, Madagascar
| | - A Randrianirina
- Orthopedic and Trauma Surgery department, CHU of Morafeno, Toamasina, Madagascar; Medicine faculty, Toamasina University, Madagascar
| | - G D Solofomalala
- Orthopedic and Trauma Surgery department, CHU Anosiala, Antananarivo, Madagascar; Medicine faculty, Antananarivo University, Antananarivo, Madagascar
| | - H N Rakoto Ratsimba
- General and Vascular Surgery department, CHUJRA Antananarivo, Antananarivo, Madagascar; Medicine faculty, Antananarivo University, Antananarivo, Madagascar
| | - T M A Rajaonanahary
- Vascular Surgery department, CHU of Morafeno, Toamasina, Madagascar; Medicine faculty, Toamasina University, Madagascar
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Bucknam RB, Dunn JC, Fernandez I, Nesti LJ, Gonzalez GA. Outcomes and Return to Work Following Complex Nerve Lacerations in the Volar Forearm in an Underserved Spanish-Speaking Population. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2020; 2:67-73. [PMID: 35415480 PMCID: PMC8991548 DOI: 10.1016/j.jhsg.2019.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/19/2019] [Indexed: 11/26/2022] Open
Abstract
Purpose Lacerations to the ulnar and median nerve in the volar forearm have demonstrated considerable long-term clinical and socioeconomic impacts on patients. The purpose of this study was to evaluate the outcomes of complex volar forearm lacerations involving one or more major peripheral nerves in an economically disadvantaged patient population. Methods In this study, a retrospective analysis of 61 patients who sustained lacerations to the median nerve, ulnar nerve, or both with volar wrist lacerations was performed. Each patient’s preinjury and postinjury occupation, dominant extremity, and demographic variables were evaluated. Sensation recovery, motor recovery, Disabilities of the Arm, Shoulder, and Hand scores, visual analog scale scores, cold intolerance, and return to work were evaluated at 3, 6, and 12 months after the injury. Results Patients with isolated median nerve injuries demonstrated improved motor recovery compared with patients with isolated ulnar nerve injuries. Patients with combined nerve injuries had worse sensation recovery and motor recovery, and lower rates of return to work than either group of patients with isolated nerve injuries. Manual laborers had worse motor recovery and lower rates of return to work than did patients who were office workers. Conclusions Patients with combined median and ulnar nerve injuries have worse functional recovery and lower rates of return to work than do patients with isolated median or isolated ulnar nerve injuries at 1 year. Manual laborers demonstrated worse functional recovery and lower rates of return to work compared with office workers at 1 year. Type of study/level of evidence Therapeutic III.
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Long-Term Follow-up of Full-Awake Hand Surgery in Major Flexor Tendon Injury of the Hand and Forearm. Ann Plast Surg 2019; 83:163-168. [DOI: 10.1097/sap.0000000000001969] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The Reason Matters: Deep Wrist Injury Patterns Differ with Intentionality (Accident versus Suicide Attempt). PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2139. [PMID: 31333923 PMCID: PMC6571333 DOI: 10.1097/gox.0000000000002139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/18/2018] [Indexed: 11/30/2022]
Abstract
Background: Despite the clinical importance of suicidal deep wrist injuries (DWIs), we currently do not know whether their injury patterns differ from accidental injuries. Methods: This retrospective study included all patients admitted to the Clinic of Plastic Surgery for acute treatment of a DWI from 2008 to 2016, except for isolated injuries to the palmaris longus (PL) and amputations. Intentionality of the injury was determined using documentation of psychiatric evaluations; cases that could not be categorized regarding intentionality were excluded. Results: About 20% of DWIs stemmed from suicide attempts, which involved the nondominant hand in 94.5%. Suicidal DWIs were more likely to involve the median nerve, radial artery, PL, and flexor carpi radialis (FCR), especially on the nondominant hand, but were less likely to involve the ulnar artery and nerve on the dominant hand. The effect of the protective structures PL/flexor carpi ulnaris on the median nerve/ulnar artery could be confirmed for suicidal DWIs, but intactness of the FCR was associated with increased radial artery injuries. Longitudinal cut orientation in suicidal DWIs was associated with more radial artery injuries, but fewer injuries to tendons and nerves. Frequencies of various other injury constellations are tabulated to aid in clinical assessment. Conclusions: Suicidal and accidental DWIs differed in various aspects of injury pattern. Suicidal injuries were mostly localized to the nondominant radial side, and accidental injuries to the ulnar side. Also, the so-called protective structure FCR had the opposite effect in suicidal injuries. Thus, findings regarding injury patterns in accidental DWIs cannot be generalized to suicidal injuries.
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Meals CG, Chang J. Ten Tips to Simplify the Spaghetti Wrist. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 6:e1971. [PMID: 30656097 PMCID: PMC6326610 DOI: 10.1097/gox.0000000000001971] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 08/14/2018] [Indexed: 11/26/2022]
Abstract
Hand surgeons refer to deep lacerations of the volar distal forearm as “spaghetti wrists.” Given that multiple tendons, vessels, and nerves often require repair, this injury may be intimidating. We review management of spaghetti wrists and summarize with 10 simplifying tips.
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Affiliation(s)
| | - James Chang
- Stanford University Division of Plastic & Reconstructive Surgery, Palo Alto, Calif
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Abstract
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.
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Koshy K, Prakash R, Luckiewicz A, Alamouti R, Nikkhah D. An Extensive Volar Forearm Laceration - The Spaghetti Wrist: A Systematic Review. JPRAS Open 2018; 18:1-17. [PMID: 32158832 PMCID: PMC7061608 DOI: 10.1016/j.jpra.2018.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/28/2018] [Indexed: 10/28/2022] Open
Abstract
Purpose 'Spaghetti wrist' is an extensive laceration that involves multiple structures in the volar wrist, including tendons, nerves and arteries. This injury is frequently encountered in trauma units, but despite its complex nature, management is often handled by junior surgeons.Furthermore, the guidance on how to approach these injuries is limited, with a relatively poor evidence base on management and outcomes. Methods In this article, we perform a systematic review of the literature on the management and outcomes of the spaghetti wrist injury. Patient demographics, definitions of spaghetti wrist, mechanism of injury, operative and rehabilitative techniques and surgical outcomes are discussed. Results Results from this study show significant physical, functional, psychological and financial impacts of spaghetti wrist injuries. Operative technique appears relatively consistent; even though reporting of injuries and outcomes was heterogeneous, no current classification system is in common usage. Conclusions An increased focus on the standardisation of assessment, management and rehabilitation and on overcoming the obstacles to care will serve as a guidance to the operative and post-operative management of the spaghetti wrist injury. The use of a single definition and classification system has been proposed to standardise outcome measures and improve inter-observer reliability. Type of study/level of evidence Systematic Review: Level IIa evidence.
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Affiliation(s)
- Kiron Koshy
- Brighton and Sussex University Hospitals, Brighton, UK
| | | | - Andrzej Luckiewicz
- University College London, Medical Sciences, University College London, Gower Street, London
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Demirdover C, Ozturk F, Yazgan H, Yogurtcu N, Sevindik M, Vayvada H. Surgical treatment and functional outcomes of multicomponent soft tissue injuries of the wrist. HAND SURGERY & REHABILITATION 2018; 37:160-166. [DOI: 10.1016/j.hansur.2018.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 12/07/2017] [Accepted: 02/09/2018] [Indexed: 11/30/2022]
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Yazdanshenas H, Naeeni AF, Ashouri A, Washington ER, Shamie AN, Azari K. Treatment and Postsurgery Functional Outcome of Spaghetti Wrist. J Hand Microsurg 2016; 8:127-133. [PMID: 28018057 DOI: 10.1055/s-0036-1586487] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 06/30/2016] [Indexed: 10/21/2022] Open
Abstract
Background The outcomes of treating severe wrist injuries are not well understood and despite their complexity and prevalence, particularly among young adults, spaghetti wrist is rarely investigated. The aim of this study is to evaluate the postsurgery, functional outcome of spaghetti wrist injuries. Material and Methods In this prospective cross-sectional study, 153 patients with spaghetti wrist injuries were followed up for approximately 20 months and were assessed regarding returning to work and postsurgical functional outcomes that included tendon functionality, opposition, intrinsic function, deformity, sensation, and grip strength. Results The mean age was 28.3 ± 5 years. The most common cause of injury was glass window panes and bottles. Moreover, the most commonly involved structures were the tendons of flexor digitorum superficialis 3, 4, and 5. During the follow-up, the tendon functionality in 120 (78%), opposition in 115 (75.1%), and intrinsic function in 62 (40.5%) were "excellent." Hand sensation was "fair" in 75 patients (49.1%), "good" in 46 patients (30%), and "excellent" in 28 patients (18.3%). The average return time to activities of daily living was 10 months. Conclusion In this study, worse outcomes were seen in older patients and those with higher number of damaged structures (especially nerves).
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Affiliation(s)
- Hamed Yazdanshenas
- Departments of Orthopedic Surgery and Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, California, United States; Department of Orthopedic Surgery, University of California, Los Angeles (UCLA), California, United States
| | - Alireza Fadaee Naeeni
- Department of Plastic and Reconstructive Surgery, Guilan University of Medical Sciences, Gilan, Iran
| | - Anousheh Ashouri
- Department of Internal Medicine-Pediatrics, Loma Linda University, Loma Linda, California, United States
| | - Eleby R Washington
- Departments of Orthopedic Surgery and Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, California, United States
| | - Arya Nick Shamie
- Department of Orthopedic Surgery, University of California, Los Angeles (UCLA), California, United States
| | - Kodi Azari
- Department of Orthopedic Surgery, University of California, Los Angeles (UCLA), California, United States
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Obstacles to the Care of Patients With Multicomponent Volar Wrist Lacerations at a County Hospital. Ann Plast Surg 2016; 76 Suppl 3:S238-40. [DOI: 10.1097/sap.0000000000000801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zheng DW, Li ZC, Shi RJ, Sun F, Xu L, Shou KS. Use of giant-sized flow-through venous flap for simultaneous reconstruction of dual or multiple major arteries in salvage therapy for complex upper limb traumatic injury. Injury 2016; 47:364-71. [PMID: 26772451 DOI: 10.1016/j.injury.2015.11.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 11/17/2015] [Accepted: 11/22/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND/OBJECTIVES Salvage repair after complex upper limb traumatic injury is surgically challenging due to underlying major arterial impairment with complicating a large-sized soft tissue defect. The purpose of this study was to evaluate the effectiveness and safety of using a giant-sized (≥100 cm(2)) flow-through venous flap for reconstruction of dual or multiple forearm, metacarpal, or digital arteries after complex upper limb traumatic injury. METHODS Seven patients were consecutively hospitalized for emergency salvage repair after complex upper limb traumatic injury between March 2012 and May 2014. The forearm and palmar artery defects were repaired using the calf great saphenous vein flap and the volar forearm venous flap, respectively. RESULTS The flow-through venous flap ranged from 9.5 cm × 12.0 cm to 12.0 cm × 20.0 cm (mean, 158.4 cm(2)) in size. The flaps and affected limbs survived uneventfully in five patients, with one patient experiencing distal flap marginal necrosis and a second patient requiring amputation of the affected limb. Computed tomography angiography showed patent vessels in all patients. The mean total active motion of the repaired fingers was 199.5° versus 258.8° for the contralateral counterpart (77.1%). The sensory return was determined to be S2 in 2 patients, S3 in 3 patients and S3+ in 1 patient. The disability scores for the arm, shoulder, and hand ranged from 4.6-18.2 (mean, 11.3), and the mean Michigan hand outcomes questionnaire score was 7.8 ± 0.9. CONCLUSIONS The flow-through venous flap is an effective and safe treatment alternative for salvage therapy of a ≥100-cm(2) complex upper limb traumatic injury with dual or multiple major arterial impairment. This technique allows simultaneous reconstruction of dual or multiple artery injuries and an extensive soft tissue defect. Serious surgical site infection remains a major safety concern and necessitates radical debridement in complicating cases.
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Affiliation(s)
- Da-Wei Zheng
- Department of Hand Surgery, Xuzhou Renci Hospital, Xuzhou 221004, Jiangsu Province, P. R. China.
| | - Zhang-Can Li
- Department of Hand Surgery, Xuzhou Renci Hospital, Xuzhou 221004, Jiangsu Province, P. R. China
| | - Rong-Jian Shi
- Department of Hand Surgery, Xuzhou Renci Hospital, Xuzhou 221004, Jiangsu Province, P. R. China
| | - Feng Sun
- Department of Hand Surgery, Xuzhou Renci Hospital, Xuzhou 221004, Jiangsu Province, P. R. China
| | - Li Xu
- Department of Hand Surgery, Xuzhou Renci Hospital, Xuzhou 221004, Jiangsu Province, P. R. China
| | - Kui-Shui Shou
- Department of Hand Surgery, Wuxi Hand Surgery Hospital, Wuxi 214062, Jiangsu Province, P. R. China
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Punching Glass: A 10-Year Consecutive Series. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e436. [PMID: 26180737 PMCID: PMC4494506 DOI: 10.1097/gox.0000000000000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 05/07/2015] [Indexed: 11/26/2022]
Abstract
Introduction: Punching glass can cause severe and debilitating injuries. The literature is scant in regards to the injury patterns, optimal management, and preventative strategies. We have reviewed our experience of these injuries at a regional Australian hospital. Methods: A retrospective chart review of all patients who had punched glass and presented to Cairns Base Hospital between January 2003 and December 2012. Data collected included age, gender, marital status, employment status, alcohol consumption, side of injury, intent, time of presentation, damaged structures, treatment required, operative time, total hospital stay, and required follow-up. Results: 137 eligible patients were identified during the 10-year study period. Mean age was 26.3 years. Most were men (n = 113), single (n = 122), unemployed (n = 95), and intoxicated (n = 91). Most of these injuries presented outside of normal working hours (P < 0.001). Ninety-one patients had superficial skin lacerations only and did not require operative intervention. The remaining 46 patients had a total of 46 tendon, 18 muscle, 12 nerve, 8 vessel and 5 bone injuries, and all required operative intervention. Tendon, nerve and vessel injuries were strongly associated with each other (P < 0.05). Conclusions: This represents the largest case series of glass punching injuries in the English literature. Punching glass can cause significant morbidity in a young age group and is therefore a major public health concern. Thorough physical examination, appropriate imaging and operative repair can improve outcomes. Preventative measures such as stricter legislation and safety glass will reduce the burden of these injures on the individual and healthcare system in Australia.
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Bauer S, Savundra J. Temporary arterial stenting in a full-house spaghetti wrist injury in a remote rural setting: benefit for hand perfusion or risk of increased morbidity? BMJ Case Rep 2013; 2013:bcr-2013-008575. [PMID: 23505277 DOI: 10.1136/bcr-2013-008575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of temporary arterial plastic tube stenting of the ulnar and radial artery in a complete spaghetti wrist injury in a remote rural setting. Exploration in a specialist centre 18 h postinjury revealed that the tubes were clotted off with adjacent thrombi but hand perfusion was maintained. Intimal damage required vein grafting of both arteries 24 h postinjury. Hand perfusion was not compromised at follow-up. This case highlights that arterial hand perfusion can be maintained without the ulnar and radial artery. Arterial manipulation and tube insertion outside a specialist centre bears the risk of increased morbidity and potential microembolism and must therefore not be attempted.
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Affiliation(s)
- Stefan Bauer
- Department of Orthopaedics, Royal Perth Hospital, Perth, Western Australia, Australia.
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Galanakos SP, Zoubos AB, Mourouzis I, Ignatiadis I, Bot AG, Soucacos PN. Prognostic scoring system for peripheral nerve repair in the upper extremity. Microsurgery 2012; 33:105-11. [DOI: 10.1002/micr.22000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 04/13/2012] [Indexed: 02/02/2023]
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Noaman HH. Salvage of complete degloved digits with reversed vascularized pedicled forearm flap: a new technique. J Hand Surg Am 2012; 37:832-6. [PMID: 22397844 DOI: 10.1016/j.jhsa.2012.01.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Revised: 05/26/2011] [Accepted: 01/23/2012] [Indexed: 02/02/2023]
Abstract
Complete ring avulsion injury necessitates a difficult choice between microvascular repair and revision amputation. Microvascular repair is technically difficult and amputation may leave an unsatisfactory result. We describe an alternative method whereby a reverse radial forearm flap is wrapped around the complete degloved digit. This provides good quality cover to the whole volar, dorsum, and both sides of the finger. We performed 26 pedicle radial forearm flaps for 26 patients in the Hand and Reconstructive Microsurgery Unit, Sohag University Hospital, from 2001 to 2009. Indications included soft tissue coverage of the thumb (n = 8), ring finger (n = 11), index finger (n = 4), middle finger (n = 2), and little finger (n = 1). Finger salvage was successful in 96% of patients. There was complete loss of 1 flap and partial flap loss of a second. Finger range of motion was excellent in 18 fingers, good in 7, and fair in 1. Two donor sites were closed primarily; the rest were closed with split-thickness skin grafts. There were no reports of cold intolerance of the hand or dysesthesias in the superficial radial nerve or lateral antebrachial nerve distribution.
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Affiliation(s)
- Hassan Hamdy Noaman
- Department of Orthopaedics and Traumatology, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt.
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Galanakos SP, Zoubos AB, Johnson EO, Kanellopoulos AD, Soucacos PN. Outcome models in peripheral nerve repair: Time for a reappraisal or for a novel? Microsurgery 2012; 32:326-33. [DOI: 10.1002/micr.20972] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 09/28/2011] [Indexed: 01/28/2023]
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Dehghani M, Shemshaki H, Eshaghi MA, Teimouri M. Diagnostic accuracy of preoperative clinical examination in upper limb injuries. J Emerg Trauma Shock 2011; 4:461-4. [PMID: 22090738 PMCID: PMC3214501 DOI: 10.4103/0974-2700.86629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 03/09/2011] [Indexed: 11/20/2022] Open
Abstract
Background: Injuries in hands and forearms may cause significant discomfort and disability. Aim: To evaluate the accuracy of preoperative clinical examination in depicting lesions caused by penetrating wounds of hands or forearms. Setting and Design: This prospective study was conducted from August 2006 to September 2009 at Kashani University Hospital, Isfahan University of Medical Sciences, Iran. Materials and Methods: Two hundred and fifty patients with clean penetrating injury to the hand/forearm were enrolled in this study. After patient's data registration, a careful clinical examination and routine exploration without expansion of wound were done by an orthopedic resident. Each tendon was tested at each joint level. Nerves were evaluated with a two-point discrimination test, and arteries were tested with palpable pulses. Surgical exploration was done by a single hand surgeon in operation room. Accuracy of clinical examination was compared to surgical examination. Results: During the study period, 180 (72%) males and 70 (28%) females with mean age of 28±4 years participated. The preoperative examination showed a predominance of the volar zone IV injuries followed by volar zone II, III, thumb zone II, volar zone V and thumb zone III. Despite the enough accuracy of preoperative examinations in dorsal side injuries of hands and forearms (error rate = 8.3%), the preoperative examinations significantly underestimated the amount of damage to soft tissues on the volar side of hands and forearms (error rate = 14%). Conclusions: The precise surgical evaluations should be considered in patients with penetrating injury to the hand or forearm, especially in those with volar side injuries.
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Affiliation(s)
- Mohammad Dehghani
- Department of Orthopedic Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
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Galanakos SP, Zoubos AB, Ignatiadis I, Papakostas I, Gerostathopoulos NE, Soucacos PN. Repair of complete nerve lacerations at the forearm: An outcome study using Rosén-Lundborg protocol. Microsurgery 2010; 31:253-62. [DOI: 10.1002/micr.20845] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Revised: 09/08/2010] [Accepted: 09/09/2010] [Indexed: 11/05/2022]
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Werdin F, Schaller HE. [Combined flexor tendon and nerve injury of the hand]. DER ORTHOPADE 2009; 37:1202-9. [PMID: 19037629 DOI: 10.1007/s00132-008-1327-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Any restoration of hand function following tendon and nerve injury has to include the repair or replacement of the hand's ability to perform a great many tasks. It is hard at first to appreciate fully the loss that occurs with flexor tendon injury. Also sensibility can be compromised from tendon injury without direct injury to the nerve, as object recognition in the absence of vision requires finger movement. When peripheral nerve injury is combined with flexor tendon injury, sensibility is directly impaired. There is a loss in the sense of finger or thumb position, pain temperature and touch or pressure recognition, in addition to the tendon injury. However, the outcome after operative treatment of these"minor" injuries of the hand is horrible. Therefore, we try to summarize practical consequences for the repair of combined flexor tendon and nerve injuries which will improve operative outcome. These guidelines are based on current scientific knowledge and our own experience.
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Affiliation(s)
- F Werdin
- Klinik für Hand-, Plastische-, Rekonstruktive und Verbrennungschirurgie, Berufsgenossenschaftliche Unfallklinik, Universitätsklinik Tübingen, Schnarrenbergstrasse 95, 72076, Tübingen, Deutschland.
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