Cases (IV)
12.12 Skill level III: Case 1
Authors Timo Schmid, Esther Vögelin
Case history
16-year-old white male patient
Student
Right-hand dominant
Landau-Kleffner syndrome (infantile acquired condition of unknown origin consisting of aphasia and epilepsy) treated with Valproate® (valproic acid) medication
Single
Nonsmoker
While constructing an explosive device of unknown composition with his friend, the blasting charge exploded in the patient′s hands. The patient was treated by emergency personnel in the field with a clean bandage and splinting, intravenous fluids and analgesics, as well as intubation for airway management. He was transported to the hospital by helicopter.
Upon admission to the emergency department, the patient was examined by a multidisciplinary team consisting of trauma surgeons, hand surgeons, and ophthalmologists. The following clinical findings were reported:
both eyes presented with perforations to the ocular globes
superficial soft-tissue injury of the left knee
severe hand injuries
arm injuries
no life-threatening chest or abdominal injuries.
Wound conditioning: none.
Present status
In the operating room on the night of admission, the patient was found to have the following injuries of the right upper extremity ( Fig 12.12-1a–b, 12.12-2 ):
several superficial wounds on the upper and lower arm with multiple foreign bodies
traumatic subtotal amputation of the little finger at the level of the proximal interphalangeal joint
full-thickness skin defect including the dorsal aspect of the mid hand as well as at the index, middle and ring fingers with concomitant fractures of the proximal interphalangeal joint of the middle and ring fingers
intact palmar skin
normal neurovascular structures of the index, middle, and ring fingers
uninjured thumb.
The left hand also showed severe injuries, the management of which, however, will not be discussed as part of this case.
Decision making
Open questions
Is secondary healing an option?
Does the defect have to be covered?
What type of tissue shall be used for defect coverage (vascularized or nonvascularized tissue)?
Is it possible to jeopardize perfusion of the fingers by sacrificing one of the main arteries of the forearm?
Is decreased tendon gliding to be expected?
Options and plan
The hand includes many important and susceptible structures within a very small area. Preserving viable bone as well as tendinous and neurovascular structures is important for the restoration of function. However, destroyed, nonviable tissue has to be removed aggressively in order to prevent nonunion, excessive scar tissue or late infection, regardless of its later potential function. It is a delicate balancing act between the preservation of important structures (such as intact but devascularized digital nerves or tendons) and the debridement of contaminated or dead tissues (such as bone fragments or cortical fractions, joints, soft tissues). The borders of healthy, vascularized tissue are sometimes very difficult to define, particularly very early after the trauma, ie, before demarcation of necrotic tissue. Therefore, it may be necessary to postpone final soft-tissue coverage until after a second or third look.
With the possible functional outcome in mind, debridement and a plan for reconstructive surgery have to be addressed for the subtotal amputation of the little finger and the injuries to the hand and arm. The aim is to maximize function of the hand in the long term.
In some situations involving, for example, the critical general state of the patient or gross contamination of the hand, reconstruction (tendon, bone, nerves) and final soft-tissue coverage must be postponed until after repeated debridement, thus becoming a two- or multi-step procedure. Technical and infrastructural difficulties should only cause a delay of reconstruction in exceptional cases. However, in this case, provisional closure by means of a synthetic skin (eg, Epigard®) or negative-pressure wound therapy over a paraffin gauze has proven effective in keeping the wound environment clean or even conditioning the wound if tendons, nerves and/or vessels are exposed. In some situations, the use of skin grafts or skin substitutes can offer provisional wound closure.
In some rare cases of complex hand injuries, skin grafts may be a definitive option for covering exposed muscles, dermis, or tendons with maintained paratenon in an area where only very little mobility is required and/or minimum mechanical stress is applied.
The right hand presents with an intact thumb. The intraarticular fractures of the index finger and of the ring finger include a bone defect and the destruction of the proximal interphalangeal joint, though the fractures may heal after bone grafting and arthrodesis. Stable fixation of the intraarticular fracture of the proximal interphalangeal joint of the middle finger by means of conventional open reduction and internal fixation is important, because the ring and little fingers have been severely injured, respectively amputated. The goal must therefore be to reconstruct a functional 4-fingered hand of good quality in order to restore opposition of the thumb to the remaining fingers ( Fig 12.12-3 ).
The full-thickness soft-tissue defect of the right hand measures ~ 8 × 3 cm and exposes the extensor tendons and the metacarpal bone over the middle and ring finger, including the implant material for fracture fixation. Secondary healing, therefore, is not an option. Skin grafts would not adhere or revascularize on exposed tendons devoid of paratenon. Furthermore, a well-functioning hand needs tendons surrounded by a gliding layer.
In addition, complex injuries as described here often require secondary interventions or salvage procedures, such as bone grafting to treat delayed or nonunion of the bone, tenolysis or hardware removal due to limited range of motion. Hence, well-vascularized tissue such as a flap is needed in order to cover the tendons, the reconstructed bones and their hardware as well as the dorsum of the mid hand and fingers. Taking the right forearm into consideration, only a pedicled flap from the same extremity would be able to replace like with like. Nevertheless, the donor-site defect and the need for bilateral reconstruction must be taken into consideration. A free-style perforator flap may be an option, if the skin of the forearm has remained uninjured (chapter 10.4). Otherwise, free flaps are always an option, as long as the arterial supply to the hand is not reduced to one artery or considerably diminished. This could induce a so-called steal phenomenon, ie, perfusion of the flap at the expense of the hand or some fingers, particularly if a muscle flap with a high perfusion demand (high-flow flap) is applied (chapter 10.6).
Thin flaps such as fasciocutaneous flaps and low perfusion demand flaps (low-flow flaps) (chapter 10.6) (eg, lateral forearm flap, anterolateral thigh flap, thoracodorsal perforator flap), fascial flaps (eg, temporal fascia) plus split-thickness skin grafts, or muscle flaps (eg, serratus anterior flap, gracilis flap) are preferable options. They not only resurface well the affected limb, but also may provide a better tendon sheath with high gliding capacities.
Procedure
The patient was taken to the operating room for initial debridement and irrigation. Both hands underwent debridement and reconstructive surgery to address the amputations and bone injuries ( Fig 12.12-3 ).
The large dorsal soft-tissue defect (size 8 × 3 cm) of the middle and ring finger of the right hand was covered with a pedicled fasciocutaneous radial forearm flap with retrograde perfusion (chapter 10.5). This was carried out once sufficient inflow to the hand via the ulnar artery had been confirmed by an Allen test (chapter 10.5.2).
The flap was elevated including the cephalic vein (superficial venous system), passed dorsally above the tendons of the first extensor compartment and, subcutaneously, pulled to the dorsum of the hand. The flap was trimmed to fit the dorsal defect, ie, the middle and ring finger, resulting in a cutaneous syndactyly. The donor site was covered with a meshed split-thickness skin graft ( Fig 12.12-4a–b ) (chaper 10.2).
All possible effort has been put into reconstruction and restoration of function of the left hand, in order to provide two “functional instruments” for daily professional life.
Follow-up
On the right hand, active and passive mobilization was initiated rather early after surgery by hand therapy, taking into consideration primarily the rate of soft-tissue healing and solidity of bone fixation. Complete healing of the flap was uneventful, allowing for the division of the cutaneous syndactyly 3 weeks after initial surgery. Another 3 weeks later at the follow-up ( Fig 12.12-5 ), it was decided to reduce the bulky flap volume by fat removal procedures and scar revisions. This was repeated at the 9-month follow-up ( Fig 12.12-6 ).
At the 1-year follow-up, the remaining joints of the right-hand fingers presented with nearly full range of motion except for the arthrodesed proximal interphalangeal joint of the index and ring finger. Perfusion and sensation were normal. There was good grip strength of 40 kp using the Jamar dynanometer on his right dominant hand. The patient was last seen at a 6-year follow-up and showed good function of both hands that allowed full activity ( Fig 12.12-7 ).
Points to remember
Early, thorough debridement in concert with reconstructive procedures may lead to good functional results.
The radial forearm flap is a useful flap for coverage of extensive soft-tissue defects of the distal forearm and of the hand with exposed tendons, vessels, and/or nerves. One of its major disadvantages is the sacrifice of the radial artery. In other words, perfusion of the hand depends entirely on an intact distal ulnar-radial arterial communication as well as the anterior and posterior interosseous arteries.
The radial perforator flap is a good alternative to the classic radial forearm flap, although its perfusion depends on one or more perforators that render the flap less predictable. Furthermore, the flap has a limited arc of rotation, at most reaching the metacarpophalangeal joints but not the fingers in comparison to the posterior interosseous flap.
Maximum effort to reconstruct mutilating hand injuries as best as possible is of utmost importance, particularly in patients who suffer from diseases (such as in this case epilepsy) or lose vision/go blind from the trauma. Yet, such information is often not known by the surgeon during damage-control or initial reconstruction. Reconstruction must focus on the long term. A mobile and sensitive 3- or 4-fingered hand may be better than to save all severed, injured parts of a mutilated hand.
12.13 Skill level III: Case 2
David A Volgas
Case history
24-year-old white female patient
Computer graphics designer
Married, two small children
Nonsmoker
No other medical problems
The patient was attempting to strap a child into the child seat in the back of the car, when the car started to roll backwards, knocking the patient to the ground. The medial side of the lower leg was dragged along the ground. Prehospital treatment included clean bandage, short leg air splint, and intravenous fluids, given by paramedics.
The patient was examined by trauma surgeons on presentation to the trauma bay. Chest, abdomen, pelvis, and spine were normal.
Findings at the right lower extremity:
superficial abrasion along the medial side of the lower leg with punctate bleeding ( Fig 12.13-1 )
full-thickness skin defect measuring 8 × 6 cm
deep abrasion of the medial ankle with loss of the medial malleolus and exposure of the mid-tarsal joints ( Fig 12.13-1 )
wound contamination with gravel and dirt
ruptured tibialis posterior tendon ( Fig 12.13-2 )
intact tibial nerve and posterior tibial artery
loss of the medial malleolus confirmed by an AP x-ray ( Fig 12.13-3 ).
The patient was taken for emergency debridement and irrigation on the day of admission. The assessment after adequate debridement revealed:
skin defect with exposed bone and joint measuring 8 × 10 cm
exposed peritenon of the extensor tendons
repairable rupture of the tibialis posterior tendon
intact medial neurovascular structures.
Wound conditioning: An antibiotic bead pouch ( Fig 12.13-4 ) was placed on the wound in order to keep the exposed bone and tendon moist as well as the wound sterile.
Present status
On the third day postinjury, the patient returned to the operating room for a second debridement. In the operating room, the wound was found to be stable with the defect essentially the same as after the last debridement.
Decision making
Open questions
What is the functional goal for this patient and her injury?
Is the malleolus salvageable?
Do the muscles work?
What are definitive treatment options?
Does this defect have to be covered?
Is secondary healing an option?
How shall this defect be covered?
What to use: nonvascularized or vascularized tissue?
If vascularized tissue, pedicled versus free flap and fasciocutaneous versus muscle flap?
What type of bone stabilization should be chosen?
Options and plan
The functional goal should be to restore near-normal ankle function with a closed soft-tissue envelope that allows wearing a shoe.
In this case, the soft-tissue injury may be managed with a tissue transfer of some type and should result in a durable, flexible skin cover. Shoe wear may be affected until the flap matures, but the end result should be excellent. The rupture of the tibialis posterior tendon is repairable and will not result in substantial functional impairment. The bone defect may probably be managed with a bone graft or by immobilization.
The soft-tissue defect is large, and healing by secondary intention would be a very time-consuming option. Furthermore, there would be an increased risk of infection if granulation was allowed. In order to cover the bone, joint, and hardware, vascularized tissue is required. Skin grafts will not take in a nonvascularized recipient bed such as metal or exposed joint. Due to adherences, a skin graft will lose mobility when placed on tendons without peritenon. Last but not least, as the graft will show a significant tendency to contract, this may further reduce the range of motion if placed across a joint.
In this case, all traumata are localized on the medial side of the leg. Therefore, the pedicle for a sural flap is not compromised as the donor site of the flap is located posteriorly. There are abrasions along the entire medial side of the leg, which would likely interfere with the pedicle of the posterior tibial artery in case of a free tissue transfer. Perhaps this might even compromise the healing of the incision needed to expose the recipient vessel for a free flap or requiring the dissection of the anterior tibial artery. The defect size is certainly within the limits of a regional fasciocutaneous flap. Since the fasciocutaneous sural flap was felt to have a low risk of morbidity and a reasonably good probability of healing, this option was chosen (chapter 10.5.2). As always, the option with the greatest chance of success was chosen, preferably replacing like with like, ie, skin and subcutaneous tissue together.
Bone stabilization is also an issue in this case. Certainly, if no suitable allograft had been available, this might have precluded the reconstruction of the medial malleolus. However, an allograft was available and selected in order to achieve a good long-term result. Otherwise, with the lateral ligaments being intact as in this case, the ankle might have been quite stable without medial bone support. As this young woman is quite active, stability might have become questionable in the long run. Of course, if the ankle would have developed arthritis, an ankle arthrodesis would have been an option.
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