An Extensive Volar Forearm Laceration - The Spaghetti Wrist: A Systematic Review

Evaluation of Outcome Measures of Zone V Flexor Tendon Injury: A Systematic Review

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.

Primary repair of the severe "spaghetti wrist" with good functional outcome measured using quick dash scoring system: Management from LMIC perspective

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.

Spaghetti wrist: Transverse injury, axial incision, layered microsurgical reconstruction

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.

Management of spaghetti wrist under WALANT technique

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.

The 'outside to inwards' approach in the spaghetti wrist

•

The ‘spaghetti wrist’ is a complex injury pattern.

•

Emptying the forearm and carpal tunnel permits repair accurate repair of volar structures working from deep to superficial.

•

This pragmatic approach permits better anatomical appreciation and sequence of repair.