Mangled Hand Research Articles

Vascularized Bone Graft in Mangled Hand Reconstruction

Extensive bone defects especially in conjunction with associated coverage involvement in mangled hands, pose significant challenges to hand and upper extremity surgeons. Vascularized bone grafts often play a vital role for effective treatment now-a-days. It not only bypasses the drawbacks of conventional grafts but also allows for simultaneous one stage reconstruction of its coverage as well as repairs other injured structures.Preoperative evaluation of mangled hand is crucial, the injury extent, including circulation, patient expectations and clinical reality should be all taken into consideration before finalizing the reconstruction plan. The fibula bone and other vascularized bone flaps such as iliac crest bone and medial femoral condyle and some others as well as corresponding spare part can provide effective solutions. Especially important considerations about surgeons’ experience and expertise , donor site morbidity , postoperative care and rehabilitation are essential for optimal outcomes. In this article , we would like to share our current practicing vascularized bone flaps in mangled hand reconstructions.

Salvage and Reconstruction of the Mangled Hand: A Case Study Utilizing a Multi-Composite Tissue Product Reconstructive Approach

Objective: To evaluate the efficacy of a novel reconstructive approach utilizing Multiple Composite Tissue Products (MCTPs) in severe hand injuries with risk of amputation. Methods: A comprehensive, single MCTP operation was performed at a single institution involving three tissue products to salvage the nerves, tendons, bone, and skin. This patient case study exemplifies the successful reconstruction of a mangled hand. Results: The application of three tissue products resulted in securing the integrity of the mangled hand’s structures and preservation of basic hand and wrist function, obviating the need for amputation. The patient regained significant restoration substantiating the safety and efficacy of this approach for structural, functional, and cosmetic outcomes. Discussion: Preoperative assessment and multi-disciplinary coordination of care was imperative in optimizing the successful outcomes. The patient’s medical history was complicated by diabetes mellitus, neuropathy, and osteonecrosis. Intensive postoperative rehabilitation, including Passive and Active Range of Motion (PROM, AROM), contributed to recovery and outcomes. Significance: The MCTP reconstructive approach is a promising avenue for optimizing tissue viability to recover from mangled hand injuries. The amelioration of adhesion formation directs proper tissue recovery which conserves tissue that might otherwise necessitate further excision, and possibly amputation. Per patient centered outcomes, this strategy mitigated extensive pain and minimized scarring, which enhanced the cosmetic appeal of reconstructing the mangled hand. These findings underscore the reconstructive potential of a MCTP approach in complex hand salvage, contributing to the recovery of function and cosmetic appeal. Future research should aim to validate similar findings of this case study strategy in a larger cohort.

Mangled right hand: A case report

The mangled hand is a complex and uncommon injury of the upper extremity. It involves injury to multiple structures i.e., bone, soft tissue, and neurovascular bundles of the hand leading to loss of function and viability. These injuries are usually caused due to trauma from high-energy equipment. A 32-year female presented with a crush injury to her right hand by a grass-cutting machine. The right hand was de-vascularised with injury to both radial and ulnar arteries. She had multiple lacerations, fractures of the distal radius and ulna, and multiple fractures of the metacarpals and phalanges. An initial revascularization procedure with a vein graft was done in the ulnar artery, joints were stabilized, and planned for reconstructive surgery at a later date. Initial evaluation includes a decision to salvage or amputate the limb. Early intervention to restore vascularity is key to salvaging a mangled hand. This should be followed by a multidisciplinary team approach. Preference is given to reconstruction procedures rather than amputation and prosthesis procedures. Early intervention, a multispecialty approach, and staged procedures are required for the successful management of a mangled hand. Eventually, physiotherapy has a key role in the restoration of function.

Management of mangled hand injuries with JESS fixator in a tertiary care hospital in North East India: A prospective study

IntroductionMangled hand injuries have proved to be a tough challenge for both the patients and surgeons alike. Severe bony and soft tissue injuries necessitate the requirement of a multidisciplinary approach. MaterialsIn our tertiary care facility, a prospective study was done on the use of the Joshi's external stabilization system (JESS) fixator in the treatment of 31 instances with mangled hand injuries from November 2019 to November 2020. The cases were evaluated for functional outcome at the end of 12 months of follow up. Results31 cases of mangled hand injuries with 43 fractures were treated with the said intervention. The mean age of the patients was 33.7 ± 4.2 years and almost 90% patients were males. Machinery injuries were the most frequent type of injury (55%). Cases were intervened at an emergency basis within 24 h of the injury. Functional evaluation was done by Modified Mayo Wrist Score with an average score of 84 ± 10. Good results were seen in about 60% of cases and there were no Poor results. ConclusionThe application of JESS fixator for the prompt treatment of mangling hand injuries yielded satisfactory results in the working population with an early return to function. The strict adherence to the principles of ligamentotaxis, appropriate wound care and post-operative physiotherapy are other variables in the final outcome of such injuries. Level of evidenceII.

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

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.

Deworming the Grinder for Successful Extrication of a Mangled Hand: A Case Report

Grinding machine injuries are known to cause severe mutilating injuries of the upper limb. In some cases, the machinery equipment may still be attached to the limb when the patient reaches the hospital. In treating these injuries, the patient’s hemodynamic status should be the first priority of resuscitation. Following this and whenever possible, a reversal of the grinding mechanism should be done to free the limb. This would allow assessment of the extent of zone-of-injury prior to starting the surgical procedure. We report a case of a 28-year-old male who sustained a mangled hand injury that was successfully extricated from an industrial grinding machine, thereby allowing preservation of precious length of the limb during surgery. This case highlights the importance of adhering to safety precautions at the workplace to reduce the risk of potential occupational hazards when dealing with machinery equipment.

Deworming the Grinder for Successful Extrication of a Mangled Hand: A Case Report and Review of Literature

Grinding machine injuries are known to cause severe mutilating injuries of the upper limb. In some cases, the machinery equipment may still be attached to the limb when the patient reaches the hospital. In treating these injuries, the patient’s hemodynamic status should be the first priority of resuscitation. Following this and whenever possible, a reversal of the grinding mechanism should be done to free the limb as this would allow assessment of the extent of zone-of-injury prior to starting the surgical procedure. We report a case of a 28-year-old male who sustained a mangled hand injury that was successfully extricated from an industrial grinding machine, thereby allowing preservation of precious length of the limb during surgery. This case highlights the importance of adhering to safety precautions at the workplace to reduce the risk of potential occupational hazards when dealing with machinery equipment.

Reconstruction of a Mangled Hand with a Thoracodorsal Artery Perforator Free Flap: A Report of Two Cases

Mangled hands are a severely injured condition that is a rare and challenging problem for reconstructive surgeons. Surgical flaps such as anterolateral thigh, radial forearm, or thoracodorsal artery flaps have been used for multiple-digit resurfacing. In this report, we describe two cases of complex defects that included multiple digits in patients who underwent reconstruction with thoracodorsal artery perforator (TDAP) free flaps. All massive soft tissue defects were completely covered with a TDAP free flap. The thinner perforator flap could be harvested, and the patients regained the ability to pinch and grasp. Therefore, the authors present two cases of mangled hands successfully treated with TDAP free flap.

Management of patients with forearm and hand injuries

Background: Injuries to the hand and the forearm, particularly crush injuries have always been a major challenge to even the best of surgeons, whether it is a major case of a mangled hand by a high pressure injury or even a small case as an injury to the tip of the finger by getting squashed in a closing door. Any injuries in the forearm and the hand requires a very meticulous and thoughtful approach towards coverage with the aim of maximal restoration of function as well aesthetic appearance.Methods: The study was conducted in the Department of Surgery, Himalayan Institute of Medical Sciences (HIMS), Swami Ram Nagar, Dehradun, over the period of 12 months. Subjects were recruited from patients presenting in emergency/surgery OPD, HIMS, Dehradun with a primary diagnosis of soft tissue injuries in the forearm and the hand. A total of 114 patients were included in the study.Results: 39.5% (45 patients) were treated with combined modalities, including debridement, grafting & flap coverage. 14.1% (16 patients) required some form of orthopaedics intervention. 21.1% (24 patients) needed neurovascular or tendon repair surgery. 37.7% (43 patients) faced some sort of early or late complications. Conclusions: Proper assessment and management of complex injuries of hand and forearm is mandatory for a good functional and aesthetic outcome.

Team Approach: Modern-Day Prostheses in the Mangled Hand.

» Early prosthesis fitting enhances prosthesis acceptance and utilization.» Establishing a relationship early with the team can improve surgical planning and expedite postoperative care.» Targeted muscle reinnervation performed in the acute phases of care can greatly improve neuroma pain control and prosthesis functionality.» There is a high rate of mental health issues at various times during treatment. A high suspicion for these problems is paramount in effective treatment.» Peer-driven support has been instrumental in successful recovery in these devastating injuries.

Screening for Posttraumatic Stress Disorder in Civilians With Mangled Hand Injury: A Practice Enhancement Approach.

Posttraumatic stress disorder (PTSD) is a symptom cluster of intrusion, avoidance, negative alteration in cognition, and alteration in arousal and reactivity following trauma. PTSD occurs frequently after a physical trauma such as a severe hand injury. It is often not recognized and consequently untreated. Previous research has shown that 10%-40% of civilian trauma survivors experience PTSD in the first 12 months after injury. There is great urgency to identify patients in the early stage of recovery from trauma, as PTSD becomes more difficult to treat in its chronic form. Mangling hand injuries are particularly disabling because they are an integral part of our social body image. We wanted to investigate the degree of PTSD screening and the follow-up-referral procedures in all mangled hand cases at the hand clinic of a large Northwestern Trauma Center. A retrospective medical record review was conducted from January to December 2012 using an existing PTSD screen with data from the electronic medical records. We found that 40% of the patients with mangled hand injury were classified as "at risk" according to our PTSD screening but only 22% of those cases were referred to rehabilitation psychiatry for further evaluation and treatment. The low rate of referral for PTSD after mangled hand injury was alarming. On the basis of this, we instituted a new screening protocol for all patients with mangled hand injury using the 4-item Primary Care-PTSD screening tool and provided an informational brochure on PTSD. The investigation led to a positive change in the practice environment and workflow of the clinic. We have not conducted any follow-up study as yet, but our goal is to screen all patients with mangled hand injury and refer all patients for psychiatric therapy who have positively answered 3 of the 4 screening questions.

Toe-to-finger combined with free flap transfer for primary one-stage post-traumatic reconstruction of the complex fingerless hand

Toe-to-finger transplantation is intimately related to the development of microsurgical free tissue transplantation, which is one of the most important advances in the history of reconstructive surgery. It is also generally acknowledged that a mangled hand with massive tissue loss and amputation of multiple digits presents a challenge for plastic and reconstructive surgeons. In this retrospective study we reviewed 11 cases of primary one-stage post-traumatic reconstruction of complex fingerless hands using a combination of toe-to-finger and free tissue transplantation performed in Shanghai Jiao Tong University affiliated Sixth People's Hospital and Shanghai Jiao Tong University School of Medicine affiliated Ninth People's Hospital from January 2001 to November 2014. Primary healing was achieved in 10 cases, while in the other case partial flap loss was documented and secondary healing was achieved by skin grafting. We concluded from this study that, by selecting suitable patients, use of a combination of toe-to-finger and free tissue transplantation may provide an alternative option for mangled hand salvage with satisfactory functional and esthetic results.

New workhorse flaps in hand reconstruction.

With the passage of time, certain hand surgery procedures are anecdotally dubbed "workhorse" techniques. These are procedures that are extremely reliable and have repeatedly demonstrated good results. However, with time, paradigms undergo shifts, and this is as true for hand surgery as any other field. In this article, we will describe the use of three new "workhorse" flaps that we have found to have reliable results in complex hand reconstruction: the pedicled radial forearm fascia flap for dorsal hand reconstruction, the free anterolateral thigh flap for mangled hand reconstruction, and the medial femoral condyle vascularized bone graft for scaphoid fracture nonunion reconstruction.

EFFICACY OF JOSHI’S EXTERNAL STABILIZING SYSTEM IN FRACTURES AND MANGLED HAND-A PROSPECTIVE STUDY

Background and Objective: Human hand has evolved into an organ of exceptional prehensile function capable of highly complex movements, manipulation and cosmesis is also equally important as far as the hand is concerned. In the present study we evaluated the efficacy of Joshi external stabilizing system in fractures and mangled hand. Materials and Methods: The present prospective study involved 25 Patients with hand injuries or fractures and mangled hand after the ethical guidelines of the institution. The cases are selected for study after evaluating the nature of injury and included the cases of fractures and mangled hand. Results: In the present prospective study, we described the results of 25 Patients with hand injuries/ fractures and mangled hand. We observed a 100% recovery from the injuries after the application of JESS as external fixators and distracters and were evaluated by taking the X-rays. Conclusion: The Joshi External Stabilisation System frame is ideally suited for the fractures and mangled hand.

Principles in the management of a mangled hand

Mangling hand injuries are high energy complex conditions that are challenging to manage. They require careful planning and meticulous execution of treatment. A clear set of anatomical and functional goals at the outset guides the planning. The first surgery is crucial to ensure good vascularity to the salvaged tissue, prevent infection and achieve bony stabilization. Re-look surgery and definitive reconstruction can then follow. Post-operative therapy is an important component of treatment. Despite best efforts, outcomes are variable in these devastating injuries. Secondary procedures and provision of prostheses will do much to improve the patient's body image and limb function. This article provides a set of principles that will guide the assessment and treatment of such injuries.

Management of the Mangled Hand and Forearm.

In this article the authors describe the methods and procedures that have been used to help patients regain hand and forearm function after mangling injuries. Assessment of the pathophysiologic condition, careful inventory of the injured structures, and early aggressive wound excision and reconstruction, followed by expert rehabilitation, are advocated. The importance of vascular restoration, stable skeletal fixation, and provision of adequate skin cover are stressed. In addition to describing their treatment approach, the authors emphasize the need for the surgeon to be well acquainted with each phase of the treatment process.

The mangled hand: Causes, prevention, and principles of management

A mangled hand is, literally, a hand which has been crushed between the rollers of a mangle, but common usage now includes similar injuries from other causes. It is by definition a severe injury, with an element of crushing and usually considerable distortion of the normal anatomy. Most such injuries are caused by machinery: indeed it has been said that ‘Unfortunately the artificial machine, which is an extension of the human hand, continuously destroys the hand’.’ Although the commonest site of injury is a factory, machines are also used in the home.? The old-fashioned mangle was used to wring out washed clothes, but in advanced countries these have been replaced by more modern machines such as tumble-driers, which may also cause hand injuries, but of a different type. This illustrates the changing pattern of injury: each new machine causes a new type of damage. One example is the recently reported case of a woman who cooked her hand in a microwave oven3 producing an injury which has never happened before in the history of the world. Farms are another source of machine injuries, uniquely dangerous because here children have access to heavy machinery which can produce very severe injuries.J Injuries of the same general type, which may also be described as mangled hands. can be caused by heavy objects falling on to the hand, in car accidents, and by explosions and gunshot wounds.

Revascularization and Replantation After Upper Extremity Trauma

Improved techniques and experience in microvascular surgery make it possible to repair vessels and replant digits and extremities with increasing success. Patients with sharp or localized crush injuries are excellent candidates, and the expected survival of the extremities is greater than 80%. A good functional result can be anticipated. Generalized crush and avulsion injuries, which were common in our clinical experience, are difficult problems requiring careful selection criteria, appreciation of diffuse vessel damage that may require bypass vein or artery grafts, and the appropriate use of anticoagulants to prevent vessel thrombosis. Severe crush or mangled hand injuries, brachial plexus nerve avulsions, multilevel crush or power takeoff injuries, and excessive bacterial wound contamination are unfavorable situations for revascularization efforts, and the expected results are poor. To warrant attempts at revascularization, it must be anticipated that nerve regeneration and muscle function will be achieved and that functional use will be better than that possible with a prosthesis.

Skin Coverage of the Mangled Hand

Skin Coverage of the Mangled Hand