The integrity or deficiency of the soft tissue envelope predicates the 10 decisions for reconstruction of the mangled hand

Abstract

Combined upper extremity injuries involving both bone and soft tissue destruction are commonly referred to as “mangled hands”. These injuries often involve a twisting or crushing mechanism or are the result of a high energy trauma, and their reconstruction requires a knowledge of both advanced orthopedic and plastic surgery techniques – the epitome of an orthoplastic approach. In this review, we outline 10 decisions and technical steps to optimize the outcomes in these complex injuries. Specifically, we discuss why the integrity of the soft tissue envelope, or lack thereof, predicates our algorithm with regard to limb salvage and reconstruction. • Initial evaluation of the mangling hand injury should focus on cataloguing injuries and identifying ischemia. • Projecting the likely function of the hand in 2 years can assist with the decision for amputation or reconstruction. • A quality, systematic debridement under tourniquet sets the stage for successful future reconstruction. • In treatment, orthoplastic principles should be followed in a stepwise manner. • The integrity of the soft tissue envelope dictates the timing of reconstruction of nerve, tendon and bone injuries.