A 28-year-old woman presenting 10 days after sustaining a blast injury to her left hand . (a) Intraoperative photo following debridement, showing the composite defect on the dorsum of the hand (skin, extensor tendons, and metacarpal bones to small, middle, and ring fingers). (b, c) Pedicled reverse posterior interosseous flap for skin and soft tissue coverage 2 days after presentation. (d, e, f) Bone reconstruction with DCIA free bone flap for reconstruction of the metacarpal bones, day 14 following the posterior interosseous flap surgery
It is worthwhile mentioning the temporary ectopic implantation of amputated parts, especially fingers and hand , as an option in treating upper limb blast injuries . It is considered for injuries with composite defect at the site of amputation that renders direct replantation of the amputated part impossible (Fig. 16.2). This maintains a normal blood perfusion to the amputated part while allowing enough time to debride the proximal stump and reconstruct an anatomical platform able to receive the amputated part in a later stage .
A 35-year-old man who sustained a gunshot injury to his right hand . (a) Preoperative picture showing the composite defect of the hand and its extent. (b) Ectopic implantation of the amputated fingers on the opposite radial artery and basilic vein. (c, d, e) Harvesting and anastomosis of the DCIA free osteocutaneous flap for reconstruction of the metacarpal bones, skin, and soft tissue defects, 10 days after the injury. (f, g) Two months following ectopic implantation, retransfer of the fingers block based on the Radial artery and basilic vein to their anatomical site, fixed to the iliac crest bone. (h, i) Final result at 1 year follow-up, with the patient demonstrating a limited pinch
Free flaps offer the same advantages for blast injuries as for the diabetic foot. They provide additional vascularity that increases blood turnover and insures ideal conditions for faster and better wound healing. Also, fingers amputations can benefit from the reconstructive microsurgery tools, particularly, free toe to finger transfer should be considered when a finger is amputated distally to the insertion of the FDS tendon (Fig. 16.3).
A 15-year-old boy presenting 2 h after sustaining a blast injury to the right index. (a) Preoperative photo before debridement 1 day following his injury, showing loss of index pulp distal to the DIP joint and the extent of volar soft tissue injury. (b) The defect following debridement. (c, d, e) Harvesting of the right custom-made second toe for reconstruction of the index tip amputation. (f) Intraoperative result following the toe-to-hand transfer. (g) Postoperative result at 1 week
Finally, early amputation in the severely injured limb prevents the morbidity associated with failed attempts at reconstruction. Early amputation is preferable to protracted attempts at reconstruction .
In the hand, primary amputation should be considered mainly for injuries of a single digit associated with a comminuted articular fracture and a combination of tendon and nerve injuries. In these cases, there are little functional restoration expectations.