Complex Hand Injuries Research Articles

Free serratus anterior muscle transplantation for hand reconstruction

Free transplantation of the serratus anterior muscle has allowed salvage or reconstruction of difficult hand injuries with advantages compared to traditional methods. Free muscle tissue adds vascularity to poorly vascularised and potentially infected wounds and allows hand elevation and early mobilisation. Dynamic reinnervation is possible with segmental preservation of the long thoracic nerve. The serratus anterior muscle is easily harvested and has a long, reliable vascular pedicle. It is thin, easily contoured to the defect and can be separated into its component slips. The muscle provides stable coverage when covered with a meshed split thickness skin graft. Scapular winging does not occur since only the lower two or three slips of muscle are used. The muscle has been used in 15 complex hand wounds, three within a week of revascularisation or digital replantation for hand salvage. Three dynamic muscle transfers were performed to restore thumb opposition with one simultaneous toe-to-thumb transplantation.

Internal fixation for complex hand injuries

Internal fixation with special implants and techniques aids in the care of the severely injured hand. Plates, microbolts, and intramedullary devices small enough to avoid damage to gliding tissues, but still providing enough stability for early functional rehabilitation, have been devised. These include a 2.2- mm cancellous screw and a 1.5-mm cortex screw. A 0.8-mm thin 24-hole microplate is cut and placed either dorsally or laterally on the metacarpals or proximal phalanges. Oblique and transverse microbolts are used for larger juxta-articular fractures. Intramedullary fixation is obtained with either multiple pins or a triangular nail that can be fixed with a K-wire or cement. Transverse fractures near joints are held with cemented screws. These methods are demanding but rewarding.

The use of the osteocutaneous groin flap in gunshot wounds of the hand

Since 1972, the groin flap has been used as an excellent source of skin coverage for the hand. This flap can incorporate the underlying iliac crest to provide both soft tissue and vascularized bone for the reconstruction of complex hand injuries. Three patients who sustained gunshot wounds of the hand with loss of the thumb metacarpal and extensive soft tissue were treated with a groin flap that included the iliac crest. Bony union was rapid and thumb stability was excellent in all patients 3 months after initial reconstruction. The advantages of the osteocutaneous flap include the ability to: (1) supply vascularized bone to what is frequently a poor recipient bed for a bone graft, (2) reconstruct both soft tissue and bony defects simultaneously, and (3) be used in facilities without capability for microvascular surgery.

Basic Technical Considerations in Reattachment Surgery

Replantation surgery offers a rewarding challenge for one to apply basic biologic and functional concepts to deal with an infinite variety of amputation problems. Although there is an obvious requirement for technical skill, there is no place for stereotype procedures. Often the exact plan of treatment cannot be determined until debridement is completed, so by taking on the responsibility to manage these problems one must have not only fine technical skills but also a thorough knowledge and comprehensive experience in hand surgery, Upper limb amputations are complex and difficult compound hand injuries involving not only the vascular system but the bone, tendon, nerve, muscle, and skin as well. To entertain the concept that upper limb amputations are simply microvascular problems is indicative of a complete lack of comprehension of the realities of the situation. Every hand surgeon must add the ability to perform microsurgical techniques to his or her technical armamentarium, but to endorse the concept of a microsurgeon is bad for medicine and counter to both reality and concerned patient care.