12 - Reconstructive surgery of the mutilated hand

Abstract

Mutilated injuries to the hand are severe injuries with loss of substance resulting in loss of function. Unless treated appropriately they result in severe morbidity and disability to the individual. With the available techniques and skill levels it is possible to obtain an acceptable hand with adequate function even in severe injuries. A stable wrist, with at least two opposable sensate digits and a wide first web space is the minimum requirement for a functional hand. Since the compliance rate of usage of even the best available upper limb prosthesis is still low, it is imperative to salvage the mutilated hand at all times Infection is the important negative outcome determinant. Rate of infection is related to the quality of debridement, and early soft tissue cover. Presence of senior decision-making personnel at the time of arrival of the patient to the hospital and their participation in the initial decision-making process and debridement is a positive outcome determinant. There are no effective scores to guide a surgeon to decide on salvage or amputation of mutilated injuries of the upper limb. Much depends upon the skill levels and attitude of the surgeon who first sees the patient and the infrastructure within which the individual surgeon works. With effective debridement, primary reconstruction of all injured structures is possible. It reduces the rehabilitation time, length of hospital stay, and cost of care. While primary reconstruction is desirable, at least debridement and skeletal stabilization must be done on day 1 in all patients. Soft-tissue cover must be completed before infection sets in and definitely before 5 days. Secondary procedures to reconstruct injured structures must be done within 6 months and procedures to enhance function are done when the wound conditions have settled and the induration has subsided. Secondary procedures like free functioning muscle transfers and toe transfers have extended the indications of salvage in the primary situation.