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Starnoni M, Benanti E, Acciaro AL, De Santis G. Upper limb traumatic injuries: A concise overview of reconstructive options. Ann Med Surg (Lond) 2021; 66:102418. [PMID: 34141410 PMCID: PMC8188247 DOI: 10.1016/j.amsu.2021.102418] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/17/2021] [Indexed: 12/02/2022] Open
Abstract
Different options for upper limb reconstruction are described in literature: advancement or rotation flaps, regional flaps and free flaps are the most common. Local and regional flaps can represent the reconstructive options for small defects while large wounds require the use of free flaps or distant pedicled flaps. In case of large wound, the use of free flaps rather than distant pedicle flaps is usually preferred. To choose the best reconstructive option, it is essential for the surgeon to have a general overview about the different methods. In this review the Authors will refer to the most commonly used methods to cover soft tissues injuries affecting the dorsum and the palm of the hand and the forearm (excluding fingers). The aim is to show all flap reconstructive options so as to support the inexperienced surgeon during the management of traumatic injuries of the upper limb. Reconstruction of traumatic injuries of the upper limbs can be challenging. Small defects can be covered by local and regional flaps while large wounds need the use of free or distant pedicled flaps. The literature shows different opinions whether to use pedicled flaps (regional or distant) or free flaps. Dermal substitutes can be considered in patients who are not suitable for flaps reconstruction. Patient related factors and surgical background can significantly interfere with the surgical reconstructive solution.
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Affiliation(s)
- Marta Starnoni
- Department of Medical and Surgical Sciences, Division of Plastic Surgery, University of Modena and Reggio Emilia, Policlinico of Modena, Largo Pozzo 71, 41124, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Elisa Benanti
- Department of Medical and Surgical Sciences, Division of Plastic Surgery, University of Modena and Reggio Emilia, Policlinico of Modena, Largo Pozzo 71, 41124, Modena, Italy
| | - Andrea Leti Acciaro
- Department of Orthopaedics and Traumatology, Division of Hand Surgery and Microsurgery, University of Modena and Reggio Emilia, Policlinico of Modena, Largo Pozzo 71, 41124, Modena, Italy
| | - Giorgio De Santis
- Department of Medical and Surgical Sciences, Division of Plastic Surgery, University of Modena and Reggio Emilia, Policlinico of Modena, Largo Pozzo 71, 41124, Modena, Italy
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Chen J, Zhang AX, Chen QZ, Mu S, Tan J. Long-term functional, subjective and psychological results after single digit replantation. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:120-126. [PMID: 29454562 PMCID: PMC6136331 DOI: 10.1016/j.aott.2017.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 09/02/2017] [Accepted: 09/06/2017] [Indexed: 01/09/2023]
Abstract
Objective The aim of this study was to analyse the long-term functional, subjective, and psychological results after single-digit replantation. Methods Thirty cases of digital replantation (14 thumbs, 12 index fingers, 2 middle fingers, 1 ring finger, and 1 little finger) in 30 patients (7 females and 23 males) with a mean age of 44.2 years (20–65 years) were evaluated at the end of a mean follow-up time of 36 months (19–50 months). The active range of motion of joints, grip and pinch strength, cutaneous sensibility, upper-extremity functioning, and subjective satisfaction were determined using the Disability of Arm, Shoulder, and Hand (DASH) questionnaire and the Michigan Hand Outcomes questionnaire (MHQ). Psychological sequelae, including depression, anxiety, and posttraumatic stress disorder (PTSD), were assessed. A correlation analysis among variables was also performed. Results The mean score for the DASH questionnaire was 6.6 (range: 0–39.2). The symptom of cold intolerance occurred in 53% of the patients. Two patients were diagnosed with depression, and only one patient exhibited PTSD. The DASH score had a good statistical correlation with total grip strength, pinch grip strength, and static two-point discrimination (S-2PD) (P < 0.05). Several aspects of the MHQ were also statistically relevant to some or all of the three objective results. Furthermore, the grip strength showed significant correlation with DASH and most aspects of the MHQ in multivariate logistic regression analysis (P < 0.05). Conclusion Total grip strength is the most important factor positively related to subjective outcomes. The incidence rates of psychological symptoms after digit replantation are very low at long-term follow-up. Level of evidence Level IV, therapeutic study.
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Abstract
Restoration of structure, function, and sensation are critical after trauma or tumor resection of the hand. Thorough debridement, reconstruction of functional structures, and immediate soft tissue coverage are most effectively performed in a single stage within approximately 24 hours of the injury. Skin flaps provide robust, pliable, and cosmetically appropriate tissue that is not prone to contracture and that facilitates secondary reconstructive work. Muscle flaps retain indications for complex defects with substantial initial contamination or dead space, or for reanimation. In this article, the indications, options, and surgical techniques for free muscle flap reconstruction of upper limb defects are reviewed.
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Affiliation(s)
- Mark V Schaverien
- Department of Plastic and Reconstructive Surgery, Ninewells Hospital, Dundee DD1 9SY, UK.
| | - Andrew M Hart
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, The University of Glasgow, Jubilee Building, 84 Castle Street, Glasgow G4 0SF, UK
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Lawson RD, Tonkin MA. Technical considerations in microsurgical treatment of paediatric hand injuries. Injury 2013; 44:327-30. [PMID: 23352150 DOI: 10.1016/j.injury.2013.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Microsurgical techniques are vital for the treatment of many aspects of trauma in the child, both in initial management and later reconstructive surgery. The basic principles of microsurgery pertain to all patients, but there are nuances of technique and of the psycho-social and peri-operative aspects of treatment which are particularly important in the child. It is these distinctions that are examined in this paper.
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Affiliation(s)
- Richard D Lawson
- Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital, The Children's Hospital at Westmead, Sydney Medical School, University of Sydney, St Leonards NSW 2065, Australia.
| | - Michael A Tonkin
- Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital, The Children's Hospital at Westmead, Sydney Medical School, University of Sydney, St Leonards NSW 2065, Australia
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Bumbasirevic M, Stevanovic M, Lesic A, Atkinson HDE. Current management of the mangled upper extremity. INTERNATIONAL ORTHOPAEDICS 2012; 36:2189-95. [PMID: PMID: 22923227 PMCID: PMC3479293 DOI: 10.1007/s00264-012-1638-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Accepted: 07/25/2012] [Indexed: 12/16/2022]
Abstract
Mangled describes an injury caused by cutting, tearing, or crushing, which leads to the limb becoming unrecognizable; in essence, there are two treatment options for mangled upper extremities, amputation and salvage reconstruction. With advances in our understanding of human physiology and basic science, and with the development of new fixation devices, modern microsurgical techniques and the possibility of different types of bony and soft tissue reconstruction, the clinical and functional outcomes are often good, and certainly preferable to those of contemporary prosthetics. Early or even immediate (emergency) complete upper extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. Before any reconstruction is attempted, injuries to other organs must be excluded. Each step in the assessment and treatment of a mangled extremity is of utmost importance. These include radical tissue debridement, prophylactic antibiotics, copious irrigation with a lavage system, stable bone fixation, revascularization, nerve repair, and soft tissue coverage. Well-planned and early rehabilitation leads to a better functional outcome. Despite the use of scoring systems to help guide decisions and predict outcomes, the decision to reconstruct or to amputate still ultimately lies with the surgical judgment and experience of the treating surgeon.
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Affiliation(s)
- Marko Bumbasirevic
- School of Medicine, Clinic of Orthopaedic Surgery and Traumatology, Clinical Centre, University of Belgrade, Visegradska 26, 11000 Belgrade, Serbia.
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Nanda V, Jacob J, Alsafy T, Punnoose T, Iyasere G. Replantation of an amputated hand: a rare case report and acknowledgement of a multidisciplinary team input. Oman Med J 2011; 26:278-82. [PMID: 22043436 DOI: 10.5001/omj.2011.68] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Accepted: 05/14/2011] [Indexed: 11/03/2022] Open
Abstract
An amputation of the hand is a devastating injury. It adversely affects the victim's ability to earn a livelihood, support a family, and carry out daily activities. It has a great psychological impact. We report a middle aged male with an amputation at the level of the distal forearm who underwent replantation. The operative details of this case are described. Awareness of the possibility of salvage should be spread among healthcare personnel and the need for immediate attention by a multispeciality team is advocated. This report reviews the literature related to the operative technique, contraindications and long term results.
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Evriviades D, Jeffery S, Cubison T, Lawton G, Gill M, Mortiboy D. Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine. Philos Trans R Soc Lond B Biol Sci 2011; 366:219-30. [PMID: 21149357 DOI: 10.1098/rstb.2010.0237] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The conflict in Afghanistan has produced injuries similar to those produced from military conflicts for generations. What distinguishes the modern casualty of the conflict in Afghanistan from those of other conflicts is the effectiveness of modern field medical care that has led to individuals surviving with injuries, which would have been immediately fatal even a few years ago. These patients present several challenges to the reconstructive surgeon. These injured individuals present early challenges of massive soft-tissue trauma, unstable physiology, complex bony and soft-tissue defects, unusual infections, limited reconstructive donor sites, peripheral nerve injuries and traumatic amputations. Late challenges to rehabilitation include the development of heterotopic ossification in amputation stumps. This paper outlines the approach taken by the reconstructive team at the Royal Centre for Defence Medicine in managing these most difficult of reconstructive challenges.
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Nanda V, Alsafy T, Jacob J, Mohan L. Successful revascularization of near total amputation of the upper limb at the sultan qaboos hospital, salalah. Oman Med J 2009; 24:44-48. [PMID: 22303510 PMCID: PMC3269624 DOI: 10.5001/omj.2009.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Accepted: 11/29/2008] [Indexed: 05/31/2023] Open
Abstract
Severe crush injuries to the upper limb may require a formal amputation with devastating consequences to the patient. We report a patient with a near total amputation at the level of mid-forearm who underwent revascularization and salvage of his hand. The operative details of this case are described. It is the first time that such a patient has been treated successfully by plastic surgeons and orthopedic surgeons at the Sultan Qaboos Hospital, Salalah. Awareness of the possibility of salvage should be spread among health care personnel as well as the need for immediate attention by a multispeciality team. Literature related to the operative technique, contraindications and long term results is reviewed.
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Affiliation(s)
- Vipul Nanda
- Departments of Plastic Surgery, Sultan Qaboos Hospital, Salalah, Sultanate of Oman
| | - Taif Alsafy
- Departments of Plastic Surgery, Sultan Qaboos Hospital, Salalah, Sultanate of Oman
| | - Joe Jacob
- Departments of Plastic Surgery, Sultan Qaboos Hospital, Salalah, Sultanate of Oman
| | - Lalit Mohan
- Department of Orthopedics, Sultan Qaboos Hospital, Salalah, Sultanate of Oman
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Abstract
The aim of this retrospective study was to assess objective and subjective aspects of the long-term results of finger replantations and revascularisations. Forty patients with 59 successfully replanted or revascularised fingers, who had a mean age of 38 years, were followed-up over an average of 3.5 years. The assessment included: the profile of the blood flow in the digital arteries of replanted fingers with Doppler ultrasound, active range of motion, total grip strength, pinch grip, static two-point discrimination test and Semmes-Weinstein monofilament testing. The dexterity of the hand was evaluated subjectively with the Carlsson's questionnaire and cold intolerance with a modified McCabe's questionnaire. Statistical analysis was performed and a statistically significant correlation was found between the Carlsson's functional score, active range of motion and total grip strength. In 28 fingers (74%), blood flow in the digital arteries showed an undisturbed profile, while ten fingers showed mild stenosis or impaired microcirculation.
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Affiliation(s)
- I Walaszek
- Department of General and Hand Surgery, Pomeranian Medical University Szczecin, Szczecin, Poland
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Problems Associated with Forearm Reimplantation. POLISH JOURNAL OF SURGERY 2007. [DOI: 10.2478/v10035-007-0012-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Fifty-nine avulsed fingers were managed between May 1986-December 2004. Of 59 cases, 39 (66%) were treated with microsurgical techniques, and the remaining 20 cases (34%) were treated in the conventional manner. Follow-up time varied between 9-18 years. All cases were classified according to the Kay-Wolff classification. Replantation was done in 26 fingers, and revascularization in 13 fingers. The survival rate was 100% in the revascularization cases, and 80.7% in the replantation cases. The total active range of motion was more than 90 degrees in the interphalangeal joints in 48% of cases, and sensory recovery was good in 38% of cases (between 4-10 mm, static two-point discrimination test). Although the data show that avulsion injuries can be treated successfully by microsurgical techniques, functional results are not as successful. However, the decision for surgery at times is determined by nonmedical factors such as the patient's age, occupation, economic situation, and level of motivation.
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Affiliation(s)
- Ahmet Karaoğuz
- Department of Orthopedic Surgery, Kahramanmaraş Sütçü Imam University Medical School, Kahramanmaras, Turkey
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Affiliation(s)
- Cedomir S Vucetic
- Department of Microsurgery, Institute of Orthopaedic Surgery and Traumatology, Visegradska 26, 11000 Belgrade, Serbia and Montenegro.
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Hallock GG. The utility of both muscle and fascia flaps in severe upper extremity trauma. THE JOURNAL OF TRAUMA 2002; 53:61-5. [PMID: 12131391 DOI: 10.1097/00005373-200207000-00013] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe isolated upper extremity injuries are rarely lethal; however, they invariably are resource intensive, create significant disability, and promote resistance to a return to gainful employment. Appropriate soft tissue restoration is an essential component of any treatment protocol, and often requires a vascularized flap to protect the superficial neurovascular and musculotendinous structures. A basic schema to facilitate flap selection in the upper extremity is introduced. METHODS The role of local muscle and fascia flaps or free tissue transfers for severe upper extremity injuries was retrospectively reviewed from a two-decade experience. Excluding digital injuries, primary treatment of soft tissue traumatic wounds requiring some form of vascularized flap occurred in 33 limbs in 31 patients. The choice of flap donor site, type, specific complications and benefits as related to the severity of injury, and the effect of timing of wound closure were compared. RESULTS Initial coverage after significant upper extremity trauma in these 33 limbs required 16 local fascia flaps, 22 free flaps, 1 multistaged distant pedicled flap, and 1 local muscle flap. Flaps were selected in a nonrandom fashion on the basis of wound location, severity of injury, and flap availability. Complication rates were similar for local fascia and free flaps. The upper extremity could be divided into three regions that were differentiated according to the observed incidence of flap preference. Free flaps were more commonly used for hand and wrist wounds, or anywhere the defect was moderately large in size or extremely severe in overall injury. Local fascia flaps were a simpler option most applicable for the central upper limb. Local muscles as flaps were intentionally avoided to minimize any functional derangement. CONCLUSION A schema to guide flap selection for upper extremity coverage is introduced that is predicated on using the best available option. The shoulder girdle and axilla are reached by many local trunk muscle or fascia flaps. The central upper limb about the elbow often is conducive to coverage with specific local fascia flaps. The distal upper extremity may be best served by a free flap, as would any large wound in all upper limb regions.
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Affiliation(s)
- Geoffrey G Hallock
- Division of Plastic Surgery, The Lehigh Valley Hospital, Allentown, Pennsylvania, USA
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Abstract
Free tissue transfer is the autologous transplantation of composite tissue and its arterial and venous blood supply to a distant site. Free tissue transfers, also called free flaps, may include skin, fascia, muscle, or bone. Free flaps were once considered highly complex procedures; now they are frequently used as the reconstructive option of choice. While several variables must be considered when one plans a free tissue transfer, the most important consideration is the size and location of the defect created by the tumor resection. Free tissue transfer is a multistep procedure, including preparation of the recipient site, harvesting of the flap, and transfer and revascularization of the flap. For upper extremity reconstruction, the gracilis muscle flap has been particularly useful, as has the lateral arm fasciocutaneous flap. Semin. Surg. Oncol. 19:246-254, 2000.
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Affiliation(s)
- T M Willcox
- Department of Surgery, Mayo Clinic Scottsdale, Scottsdale, Arizona, USA
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Lykoudis EG, Panayotou PN, Stamatopoulos CN, Frangia KB, Papalois AE, Ioannovich JD. Microvascular repair following a modified crush-avulsion injury in a rat model: effect of recombinant human tissue-type plasminogen activator on the patency rate. Microsurgery 2000; 20:52-8. [PMID: 10702737 DOI: 10.1002/(sici)1098-2752(2000)20:2<52::aid-micr2>3.0.co;2-g] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The failure rate of replantations following a crush-avulsion type injury is high. This study has been designed to reproduce an effective standardized crush-avulsion injury model to the femoral artery of the rat and evaluate the antithrombotic efficacy of systemic intravenous administration of recombinant human tissue-type plasminogen activator (rt-PA). The crush-avulsion injury was reproduced by using a bulldog clamp and two hemostats and followed by microvascular repair. The animals were divided into three groups of 20 rats each and received either normal saline, heparin 100 U/kg body weight, or rt-PA 3.5 mg/kg body weight intravenously. Patency tests were performed 20 min and 48 h after blood flow reestablishment. Results showed that this experimental crush-avulsion injury model ensures low patency in the control group, whereas systemic rt-PA administration improves the patency rate statistically significantly compared to control and heparin groups at both 20 min and 48 h postrevascularization.
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Affiliation(s)
- E G Lykoudis
- Department of Plastic Surgery, Microsurgery and Burns Center, General State Hospital of Athens "G. Gennimatas", Athens, Greece
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