Introduction
Mutilation of a hand implies a serious injury has occurred, leading to damage of multiple tissues and rendering the hand significantly dysfunctional. Although many definitions exist for a mutilated hand, the one propounded by Campbell Reid explains the damage to the hand and the goal that should be set in its management: “ The mutilated hand has suffered a severe injury with loss of substance and has been left lacking in prehension. ”
Mutilated hands demonstrate varying amounts of loss of substance of skin, soft tissue, musculotendinous units, nerves, blood vessels, and skeleton, and they may include partial hand or upper limb amputations. Extensive skin and subcutaneous tissue loss and skeletal injury are almost always present. The goals of clinical management are to preserve the limb and restore basic function of the hand, especially prehension, whereby the thumb should meet the fingers. This chapter summarizes the current trends of management and details the best practices based on the experience of the authors.
Classifications
Scores and classifications used to decide between salvage and amputation
Various scores and classifications have been introduced to help surgeons evaluate the efficacy of different salvage techniques and compare outcomes. Several classifications exist for mutilated hands. Some are based on the extent of amputation, and some on the tissues lost. Campbell and Kay evolved the Hand Injury Severity Score for injuries distal to the carpus; in this method, the injuries to each ray are assessed and, using specific weighting factors for each ray, a final number is determined. A score greater than 50 indicates a mutilated hand. Based on our combined experience, we feel it is difficult to fit every mutilated hand injury into any of these classifications, and none are helpful in making the “amputation versus salvage” decision. We believe the skill level and attitude of the surgeon greatly influences this decision and the outcome. It is difficult to incorporate this “surgeon factor” into any of the scoring systems, and this makes it impossible to develop a score to dictate amputation or salvage.
In injuries proximal to the wrist, if the hand is structurally intact or can be made functional, every attempt is made to salvage. Despite advances of the last decade in the development of upper limb prostheses, the incidence of patients discarding upper limb prostheses is 50% or more. As most upper limb injuries are unilateral, the patients are not candidates for transplantation. As a consequence, at the forearm and arm levels, salvage is favored wherever possible. In units that deal with these injuries regularly, technical impossibility is the only absolute indication for amputation, as at least a basic hand can be obtained using secondary procedures, even after severe injury.
We are unanimous in the opinion that senior-level input at the time of initial patient assessment and debridement influences the decision to salvage. We are also agreed that it is inadvisable to make the “amputation or salvage” decision based on transmitted digital images. In borderline situations, the decision to amputate is made at the end of debridement, as what at first may look to be unsalvageable may, in fact, be reconstructible. A basic hand may then be salvaged using available structures and incorporating heterotopic replants and fillet flaps.
The first steps
Management of a mutilated hand starts at the time of the patient’s arrival at the hospital. The system of “ on arrival block, and in theater resuscitation,” introduced at Ganga Hospital, India, is the preferred model of care. All patients with major injuries, as judged by the input of the referring doctor—those with severe injuries involving blood-soaked dressings and patients in poor general condition—are received directly into the anteroom of the operating theater. Nothing is done in a separate emergency room or department. In the anteroom of the operation theater, the patient is received by a senior anesthesiologist, plastic surgeon, and orthopedic surgeon. After a quick survey based on the advanced trauma life support (ATLS) protocol, a brachial plexus block is administered. Once a pain-free state has been achieved, the dressings are removed. Radiologic examination is completed once the block is working and the dressings are removed to achieving good radiographs without overlap of fractured bones. The same anesthesia is then used for the index procedure. The advantages of this system are (1) the patient becomes pain-free immediately after arrival, boosting their confidence in the system; (2) immediate senior input is given; (3) good radiographs are achieved; (4) significant bleeding is identified and stopped by application of direct pressure and/or a tourniquet; and (5) a short “arrival to operating table” time is achieved. Most of these goals are hindered by a preparatory visit to an emergency department.
Mutilating injuries create psychological and social impacts that should be openly and candidly addressed with the patient and their family. Meyer found that the earlier and the more skillfully these issues are addressed, the more likely it is that psychological factors will not impede functional outcome. The “on arrival block” system that makes the patient pain free allows us to do this, as the patient and family can see the extent of the injury during open preoperative discussion with senior medical personnel. Use of this system demands the availability of senior personnel and dedicated operating rooms at all times. Because many of these patients will have loss of function of the upper extremity to a variable degree and some of them may require partial or total amputation (as the repaired or reconstructed tissues may not survive or the repaired limb may not be sufficiently functional), this preoperative discussion requires frank senior surgical input as to the various possible endpoints of surgery with a clear understanding that there will be further explanation later of what has been achieved and what could not be restored. We believe that obtaining good outcomes in mutilating injuries depends as much on these organizational logistics as the skill levels of the surgical team members.
Setting the goals and treatment
The goal, while attempting to achieve the best repair possible and restore the limb to as close to preinjury functional status as possible, should be realistic, while also considering the cost of care. While reaching the preinjury status may not be possible, we should attempt to restore an acceptable hand. This is one with a thumb and at least three fingers of the correct length, with motion preserved at the proximal interphalangeal joints and sensation. Baltzer and Moran stated that the minimal requirements for a hand to function are a stable wrist and two opposing, sensate, and painless digits. Regarding motion, one digit can be static, and the other should be sufficiently mobile to meet the other. Both digits should be sufficiently stable to provide good pinch strength. The gap between the digits determines the size of the objects that can be grasped, so creation of web space is important. The goal is the same in extensive proximal injuries, with preservation or reconstruction of painless, stable major joints that allow positioning of the hand for function.
Sometimes, the thumb or several fingers are not salvageable. However, the patient may be willing to undergo secondary toe-to-hand transfers to restore basic function of the hand. For such patients, the initial surgery should preserve the remaining salvageable joints to facilitate secondary toe-to-hand transfer later. As the hands are exposed to view at most times, over and above the function, the reconstruction should also consider the appearance of the hand, especially for young female patients.
Debridement
Adequate radical debridement is a fundamental requisite for success; this has not changed with time, but the ideal time of debridement continues to be debated. The validity of the 6-hour rule for debridement has been questioned. An extensive metaanalysis of observational studies was conducted using raw and adjusted estimates to determine whether there is an association between the timing of initial debridement and infection. All of the studies measured infection as the outcome. The analysis revealed an increased risk of infection with progressive delay in debridement. , We feel that it is not just prevention of infection that matters in the overall care of the patient. With a shorter time getting to the operating room, the patient’s duration of pain, amount of blood loss, and feelings of uncertainty are reduced. Thus, it is important to keep the time to debridement, a surgeon-controlled variable, to a minimum. This time can be longer when there is no operating room or skilled personnel available, making the risk of surgery higher relative to the benefit provided. However, the lack of robust evidence for the 6-hour rule should not be used to make debridement an elective procedure.
We feel that, barring electrical burn injuries, a single, primary debridement is the only such procedure necessary for most injuries. Although we are not against the “second look” concept, we believe that a single debridement suffices in 90% of cases.
Consensus supports the use of a tourniquet, and we use a tourniquet for debridement followed by wound assessment after release of the tourniquet to verify the adequacy of debridement. If this process reveals any doubtful areas, the tourniquet is inflated again, and the doubtful areas are debrided; this sequence is repeated until adequate debridement is achieved. In situations of distal ischemia, adequacy of debridement must be reassessed after revascularization. That a “clean” appearance does not equate to a low infection rate is an important point. Some injuries, such as those contaminated by black industrial oil, present a “dirty” appearance but have a relatively low infection rate. Industrial contamination contains few bacteria and, arguably, the “dirty” appearance forces surgeons to spend more time debriding. Consequently, the infection rate is much lower than that after agricultural injuries.
We all recommend administration of antibiotics, and most units give antibiotics on arrival. , If the wound is highly contaminated, a gentle wash is given to remove large particulate matter. We believe the best way to remove small ingrained dirt particles is with a scalpel, performing “wound excision” as advocated by Godina.
Use of irrigating solutions is a subject of debate. Normal saline is the most popular solution used, with the volume and timing of irrigation varying among surgeons. Irrigation is performed after primary sharp debridement, as earlier irrigation carries the risk of driving contaminants into the joints and intermuscular planes. A soft bulb can be used to provide low-pressure irrigation. Pressure irrigation and pulsatile lavage have not been shown to affect outcome. In Ganga Hospital in India, where the surgical unit deals with a large number of these injuries, autoclaved water has been used for wound irrigation for 3 decades with no difference in outcome but with a lower cost. In Shandong Provincial Hospital in China, hydrogen peroxide and saline are routinely used for washing before sharp debridement, hydrogen peroxide being beneficial to cleaning the wound.
How far to go on day 1?
Increasing familiarity with the practice of radical debridement and with the use of microsurgical free flaps has moved experienced surgeons to prefer primary reconstruction. However, primary reconstruction should only be performed when one is confident of the adequacy of debridement and the ability to provide soft tissue cover.
On day 1, at least two steps must be completed, namely debridement and skeletal fixation. Even in instances of polytrauma, after management of life-threatening injuries, upper limb debridement and skeletal fixation is performed. Failure to do so results in increased morbidity, including infections. If there is distal ischemia, revascularization must also be included in the primary procedure. Skeletal stabilization is done prior to revascularization. Even when the limb appears viable, if the major vessel is injured and pulsatile blood flow is not present, revascularization is advised. Good pulsatile distal blood flow ensures viability, facilitates survival of any flaps, and preserves more options for future reconstruction. Flow-through flaps are a useful means of revascularization and also provide immediate soft tissue cover. They are particularly useful for defects in the hand. However, for major injuries, the length of the vessel missing and the extent of the soft tissue defect make flow-through flaps less practical. Often, the vessel defect is vein grafted, and a separate flap is used as cover.
In viable upper limbs, it is necessary to achieve stable fracture fixation. The methods of skeletal fixation in mutilated upper limb injuries have not changed over the last 3 decades. We advise internal fixation with plates and screws for the long bones and Kirschner wires for the hand skeleton. Internal fixation is safe, and the risk of infection in hand fractures is low. In demanding situations, acute primary shortening and creation of a one-bone forearm are good options for management. , Shortening of up to 10 cm is well tolerated in the upper limb, and this offers the advantage of radical debridement, direct repair of vessels and nerves, and primary wound closure ( Fig. 26.1 ). Secondary bone lengthening via the Illizarov technique can be used for restoration of the length of the upper extremity, if necessary. External fixation is favored less, as it may interfere with flap cover. However, in some situations such as inadequate skin cover over a fracture site or seriously contaminated injuries with high likelihood of infection, etc., we use Kirschner wires combined with external fixators for skeletal fixation.
Timing of soft tissue cover
Analysis of our practices and study of the literature do not provide an ideal time by which soft tissue cover must be completed. However, we all agree it is best achieved as early as possible. “Early” is influenced more by local logistics than by science. This usually means between 24 and 72 hours, certainly within 5 days. With good debridement and antibiotic cover, practice has shifted away from emergency flap cover except in situations in which vascular repairs or vein grafts are exposed. In instances of exposures of critical neurovascular structures, some of us may use a cellular dermal matrix as temporary cover, although we feel flap cover is safer. Negative pressure wound therapy (NPWT) as a temporary cover is used less often in the management of mutilated hands than it is in the management of mutilated lower limbs. NPWT is an ideal solution when the general condition of a polytraumatized patient requires delay of definitive soft tissue cover.
Early reconstruction of soft tissue defects achieves earlier and perhaps better restoration of function and decreases the patient’s time off work; thus, excepting when the wound is seriously contaminated, we always try to reconstruct the tissue defect primarily, though not necessarily on the first day. Delaying the flap coverage for a few days leads to outcomes similar to those of immediate primary reconstruction. If the wound is seriously contaminated, the flap coverage can be delayed until the risk of infection is lower or infection is controlled.
Types of soft tissue cover
Most mutilated injuries require flap coverage to protect exposed critical structures. There is a wide array of flaps from which to choose. Free flaps can be tailored to provide a good functional and esthetic outcome for almost any defect. Muscle flaps have the advantage of filling up cavities brought about by debridement, while skin flaps are preferred when there is a possible need for access for secondary procedures. In major circumferential injuries, the critical areas and the pathway of future reconstructions are covered with flaps, and the rest of the denuded area with grafts. There have been no differences in infection rates between pedicled and free flaps or between muscle and skin flaps, which, arguably, identifies the role of good debridement before flap coverage. Ultimately, the choice depends upon a complex interplay of patient-, defect-, and surgeon-specific factors, with the surgeon’s training and familiarity being the most important determinant. With refinements of techniques, even total primary reconstruction is possible using pedicled flap coverage. Regional or pedicle flaps do not require microsurgical vessel anastomosis, and regional flaps mostly have a better texture and skin color match with the recipient area. However, regional or pedicle flaps may be limited by the size of the flap and length of the pedicle and may need secondary pedicle division (e.g., after use of the groin flap). A decision will always be made based upon a combination of all of the factors mentioned above. Needless to say, use of novel or technically demanding flaps that are either unnecessary or no better than traditional flaps, should be avoided.
Flow-through flaps are frequently used for simultaneously resurfacing a defect and revascularizing the more distal part of the extremity ( Figs. 26.2 and 26.3 ). Different flow-through flaps are used in different situations. The most frequently used flaps in upper-extremity and hand reconstructions include the anterolateral thigh (ALT) flap ( Figs. 26.2 and 26.3 ), the posterior tibial artery flap, the medial plantar flap, and venous flaps. If both arteries and veins need to be reconstructed, such as in replantation of an amputated limb associated with skin, artery, and venous segmental deficits, our first choice would be a free posterior tibial artery flap because the posterior tibial artery can be used as a flow-through flap to reconstruct a major artery defect of the brachial, radial, or ulnar artery, and the great saphenous vein and the two venae comitantes can be used to reconstruct three veins, if necessary. However, the posterior tibial artery is absent, or tiny, in about 9% of legs; so, before surgery, this artery should be checked with Doppler to decide which leg is chosen as the donor site. Free ALT flow-through flaps are more often used for hand reconstruction ( Fig. 26.3 ). Medial plantar and venous flaps are used for digital reconstruction.
