Upper limb traumatic injuries: A concise overview of reconstructive options

Presentations and management of hospitalized patients with upper extremity fractures at a level 1 trauma center: a 5-year observational study

BACKGROUND

Upper extremity injuries (UEIs) are common in the emergency departments, yet they are under-reported in developing countries. This study examined the frequency, injury characteristics, and treatment approaches of upper extremity fractures (UEFs) among hospitalized trauma patients in a nationally representative population.

METHODS

We conducted a retrospective, observational study including all the hospitalized patients with UEFs in the only level 1 trauma center in Qatar between July 2015 and August 2020. Comparative analyses were performed according to injury mechanisms, severity, and management approach.

RESULTS

A total of 2,023 patients sustained UEIs with an average age of 34.4 ± 12.9 years, and 92% were males. Motor vehicle crashes (MVCs; 42.3%) were the primary cause of shoulder girdle injuries in 48.3% of cases. Fractures of the radius, ulna, and hands occurred in 30.8, 16.5 and 14.5%, respectively. Young adults were more involved in MVCs and motorcycle crashes (MCCs), while pedestrians who were typically older had a higher rate of humerus fractures. Patients with MCCs had a higher rate of clavicle and ulna fractures. Pedestrians were at risk of serious injuries, with a higher mean injury severity score and lower Glasgow Coma Scale.

CONCLUSION

Most UEFs patients were young males and mainly affected by MVCs. Shoulder girdle, particularly clavicle and scapula/glenoid fractures, emerged as common injury sites. The study highlighted the potential risk of pedestrian injuries, as reflected in higher injury severity, concomitant injuries, and higher mortality. Future studies are needed to optimize preventive measures by incorporating insights into specific injury mechanisms and patterns of UEIs.

Reliability, validity and responsiveness of composite finger flexion in patients with traumatic hand injuries: A clinical measurement study

BACKGROUND

Composite finger flexion (CFF) is proposed to be a convenient alternative to total active motion (TAM) and total passive motion (TPM). Passive CFF (PCFF) may be useful for early monitoring in post-operative rehabilitation of traumatic hand injuries.

PURPOSE

To determine whether active and passive CFF are reliable, valid, and responsive measures of hand motion and of higher utility to the tester.

STUDY DESIGN

Cross-sectional observational clinical measurement study.

METHODS

Fifty hand injury patients were recruited from a hospital-based out-patient clinic. TAM, TPM, repeated measures of active CFF (ACFF) and PCFF, self-reported stiffness, patient reported wrist/hand evaluation (PRWHE) scores, and grip strength were recorded. Intraclass correlation coefficients (ICCs) and standard error of measurement were calculated for inter-rater and test-retest reliability. Criterion and construct validity were assessed using correlation coefficients. Responsiveness was explored by calculating correlation coefficients of change scores, effect sizes, and standardized response means. Time taken to measure CFF and TAM/TPM was recorded to consider utility.

RESULTS

The average age of participants was 47 years and 36% were female. Inter-rater and test-retest reliability estimates for ACFF and PCFF were excellent (ICCs = 0.95-98). Standard error of measurement values ranged from 0.21 to 0.33. The correlation coefficient for criterion validity between ACFF and TAM was -0.69; PCFF and TPM was -0.65; and ACFF and PCFF was 0.83. For construct validity, ACFF and TAM were similarly correlated with PRWHE. Correlations between changes in stiffness with ACFF and PCFF were 0.43 and 0.26, respectively. Effect sizes of ACFF and PCFF were small at 0.1 and 0.2. Time taken to measure CFF was much shorter than TAM/TPM.

CONCLUSIONS

The results of this study support the use of active and passive CFF as a reliable, valid, and efficient tool in the clinical setting. Further study is required to verify the responsiveness of CFF.

Clinical application of an expanded reverse-island flap with two dorsal metacarpal arteries and dorsal metacarpal nerves in index- and middle-finger-degloving injury repair and amputation reconstruction

The dorsal metacarpal artery flap (DMAF) is irrefutable as an effective way of repairing long finger defects, and hand surgeons might consider using it for long finger reconstruction or degloved injury repair. Unfortunately, the DMAF containing a single dorsal metacarpal artery (DMA) hinders the treatment effect. The sensory restoration of long fingers and the reconstruction of phalangeal joints and tendon grafts are unsolved challenges as well. We reported our experience in reconstructing the index and middle finger by a reverse-island flap with two DMAs and dorsal metacarpal nerves (DMNs) with blood supply. We reviewed ten patients with finger-crush injuries affecting eight index fingers and two middle fingers. Degloving injuries occurred in two patients, and finger amputations occurred in eight others. Two patients received simple flap reconstruction, and eight received finger reconstruction, including seven from abandoned phalangeal joints and tendon grafts of the severed finger and one from the iliac crest bone graft. All patients underwent finger reconstruction by an expanded reverse-island flap consisting of two DMAs and DMNs up to a maximal size of 9 × 8 cm². Postoperative follow-up evaluation showed a satisfactory appearance and functional recovery of the reconstructed fingers. We posit that the expanded reverse-island flap involving two DMAs and DMNs constitutes a feasible and safe option for restoring a severely damaged index or middle finger, particularly for patients who are unwilling to undergo toe-to-finger transplantation to reconstruct the injured long fingers.

Reconstruction of the Palmar Defect of the Hand with a Sensory Medial Plantar Artery Flap

Background

There are many approaches to repair the palmar defect of the hand, but due to the complex tissue structure, versatile functions, and high restoration demands, the repair of the palmar defect of the hand has always been a difficult task. Choosing suitable flaps to repair this kind of injury is always a tough challenge for the reconstructive surgeon because of the limitation of the number of arteries in the recipient hand and high restoration demands. The sensory medial plantar artery flap is considered as the ideal choice to repair the palmar defect of the hand. Based on this technique, in the current study, we used the free sensory medial plantar artery flap to reconstruct the palmar defect of the hand and obtained satisfactory results. The purpose of this study was to review the use of the sensory medial plantar artery flap for the reconstruction of the palmar defect of the hand.

Method

From January 2019 to December 2020, nine patients with the palmar defect of the hand underwent extremity reconstruction by a sensory medial plantar artery flap. The indications for this surgery were that the palmar defect of the hand need to be reconstructed and both anterior and posterior tibial arteries should be free-flowing. Patients who had systemic diseases such as diabetes millitus, vascular diseases, heavy smoking histories, and injuries of the donor site were ruled out for the surgery.

Results

Nine patients were successfully treated by using a sensory medial plantar artery flap, with a mean age of 39.44 (range 19–58) years. Five of the patients were male and the remaining four were female. Seven of them had a machine crush, and the other two suffered thermal injury. In all cases, reconstruction was performed during the second stage of treatment. All flaps survived completely, and all of the donor sites healed well in Stage 1, except for one case of ischaemic skin necrosis due to tight sutures, which healed after suture removal.

Conclusion

Our experience showed that the free sensory medial plantar artery flap was an alternative for one-stage reconstruction of the soft-tissue defect in the palm of the hand. This flexible approach not only repaired the soft-tissue defect, but also offered a satisfactory recovery of the sensory of the palm with minimal donor site morbidity.

Digital Replantations: Comparison Veins Anastomoses first versus Arteries Anastomoses first

PURPOSE

This retrospective study analyses the effect performing veins anastomoses before arteries anastomoses in digital replantation.

PATIENTS AND METHODS

38 adult patients with replantation of 12 thumbs and 39 fingers, in whom the veins anastomoses were performed prior to the arteries anastomoses, were compared with 29 patients with replantation of 9 thumbs and 30 fingers, in whom the arteries anastomoses were done first, with respect to the survival rate, total active motion, grip strength, and duration of the replantation.

RESULTS

There was no significant difference between the two groups with respect to the survival rates, total active motion, and grip strength, while the duration of the replantation was significantly shorter in patients, in whom the veins anastomoses were performed prior to the arteries anastomoses (2 hours and 50 minutes versus 3 hours and 42 minutes; p < 0.001).

CONCLUSION

Performing veins anastomoses before arteries anastomoses in digital replantations reduces the replantation time significantly without influencing the survival rate and the clinical outcome.