Mutilating Hand Injuries Research Articles

Predicting Functional Recovery and Return to Work After Mutilating Hand Injuries: Usefulness of Campbell's Hand Injury Severity Score

We investigated the effect of severity and form of mutilating hand injuries on functional recovery and return to work, and the usefulness of an injury-severity score in predicting these outcomes. We reexamined patients in whom finger amputation or near amputation had been treated with replantation or revascularization at our institution at least 3 years earlier. We evaluated radiographs, sensory recovery, finger range of motion, skin temperature, and current overall hand function to calculate Tamai and Quick Disabilities of the Arm, Shoulder, and Hand scores, and recorded return-to-work status, duration of treatment, and time away from work. We determined injury level, number of involved fingers, type of injury, and Campbell's Hand Injury Severity score (HISS) from the medical record. The average age of the 50 enrolled patients was 43 years (range, 18-69 years); average follow-up was 7.8 years (range, 3.1-15.3 years). More proximal injuries, more involved fingers, and more complicated injury predicted poorer functional recovery. HISS was highly correlated with Tamai's score (r = -0.77; p<.001) and moderately correlated with the Quick Disabilities of the Arm, Shoulder, and Hand score (r = 0.39; p = .009). HISS was only moderately correlated with length of treatment (r = 0.32; p<.05) and with time away from work (r = 0.34; p<.05). Mean HISS among the 3 return-to-work groups differed remarkably. When HISS was <50, 11 of 12 patients returned to their original jobs; when it was between 50 and 150, 17 of 23 patients were able to return; and when it was >150, only 4 of 15 were able to return to work. Given the current surgical care of patients with mutilated hand injuries, HISS determined at the time of injury can adequately predict functional outcome and return to work status. Larger studies will be necessary to validate these findings.

Use of the Reversed Posterior Interosseous Flap in Staged Reconstruction of Mutilating Hand Injuries before Toe Transfers

Cavadas, Pedro C. M.D., Ph.D.; Ibañez, Javier M.D.; Landin, Luis M.D.; Roger, Ignacio M.D. Author Information

Emergency reconstruction of mutilating injuries of the wrist and palm

Objective To report the experience and methods of emergency hand reconstruction in mutilated wrist and hand injuries by replantafion of salvageable fingers to the distal forearm stump. Methods Four patients of mutilating injury of the wrist and palm were treated with this approach. Immediately following debridement the salvageable fingers were replanted to the distal stumps of the ulna and radius. Systematic rehabilitation was carried out to restore partial function of the hand. Results All 4 reconstructed hands survived. Follow up period ranged from 1 to 20 years. The hands had some extent of flexion and extension, grasping and opposition function. Two point discrimination is 5-7 mm Conclusion For patients with mutilating injury of the wrist and palm, replanting fingers to the distal stump of ulna and radius is an ideal method to restore part of hand function. Key words: Arm injuries; Microsurgery; Hand reconstruction

Vascularized iliac osteocutaneous flap for management of mutilated hand

Objective To investigate the treatment effect of one stage reconstruction of mutilated hand with multiple metacarpal composite tissue defect using vascularized iliac osteocutaneous flap, palm tissue defect accompanied with multiple metacarpal bones defect by iliac flap through anastomosing deep iliac circumflex artery. Methods Since 1996, 8 patients with serious mutilating injury of the palm that resulted in multiple metacarpal bone and soft tissue defect underwent transfer of iliac osteocutaneous flap through anastomosing the deep iliac circumflex artery. Tendons and nerves were also repaired in the same stage. In 3 cases 2 metacarpal bones were missing, 3 cases had 3 metacarpal bones gone, while the other 2 cases with 4 metacarpal bone defect. The tendon and nerve defect in 6 cases were shorter than 2-3 cm and direct repair was achieved by shortening the bone graft. One stage Y osteotomy was done in 1 case of 2-5 metacarpal bone defect to increase bony contact surface and decrease the size of harvested iliac bone graft. One case underwent conventional lilac bone graft to the first metacarpal to restore independent thumb movement. Arthreplasty of the metacarpophalangeal joint was done in 2 cases with metacarpal head defect. Results All osteocutancous flaps survived. Wound healed in one-stage in 7 cases, and healed in second stage in 1 case because of swelling. During 1-3 years follow-up post-operatively, the clinical bony union lime was 3 to 5 weeks. There was no complication of the donor site. Hand function was graded excellent in 1 case, good in 5 cases, fair in 1 case, and bad in 1 case one year post-operatively. Conclusion Reconstruction of mutilated palm by transfer iliac osteccutaneous flap through anastomosing deep iliac circumflex artery and repairing tendons and nerves in one-stage can restore acceptable hand appearance and function. It is an effective treatment for mutilating hand injuries. Key words: Tissue transplantation; Hand injuries; Microsurgery; Iliac flaps; Reconstruction

Extra-Anatomic Microvascular Second Toe Transfer for Creation of a Helper Hand – a Long-Term Follow-Up

Mutilating hand injuries can significantly alter a patient's life. Return to work and daily activities remain the ultimate goal. A case report and long-term follow-up of a patient who caught his hand in a generator fan at work is presented. He sustained an injury that left him with a wrist and metacarpal stump. When prostheses failed, an extra-anatomic second toe transfer was used to produce a functional distal extremity. This transfer allowed the patient to return to his job and was surprisingly durable, resulting in a useful helper hand for 15 years.

Osteoplastic Thumb Ray Restoration with or without Secondary Toe Transfer for Reconstruction of Opposable Basic Hand Function

Mutilating hand injuries result in bone and soft-tissue defects. Osteocutaneous flaps can be used for osteoplastic thumb ray reconstruction as a definitive procedure or followed by toe transfer. Twenty-four hands with thumbs amputated proximal to the metacarpophalangeal joint underwent osteoplastic surgery for first ray bone and soft-tissue reconstruction. The Kapandji classification was used for the evaluation of basic hand function (opposable ulnar and radial components) after osteoplastic surgery and after toe transfer. Thirteen of 24 osteoplastic neothumbs (54 percent) achieved opposition; the other 11 patients underwent corrective osteotomies or toe transfer on the osteoplastic thumb rays. Five in this group achieved opposition, for an overall result of basic hand function in this series of 83.3 percent (20 of 24). Thirteen of 15 patients (86.7 percent) who had thumb amputations regained basic hand function only after osteoplastic thumb ray reconstruction, and 14 of 15 (93.3 percent) did so after revision. Six of nine patients (66.7 percent) with multiple-digit amputations regained opposition after osteoplastic thumb ray reconstruction and secondary revision. Ten patients received 12 toe flaps, two received sensate flaps, and one received an opponensplasty. Ten patients undergoing toe transfers had an average improvement of 4.1 on the Kapandji scale. Osteoplastic thumb ray reconstruction followed by osteotomies or sensate flap transfers can yield satisfactory results for some patients. Optimal functional outcomes are achieved when osteoplastic thumb ray reconstruction is followed by toe transfer.

Toe-to-Hand Transfer from a Cross-Foot Replantation in a Traumatic Four-Extremity Amputation

Treatment of mutilating hand injuries often requires multiple innovative procedures. This report describes a case of multi-limbed amputations from a train injury and the extraordinary microsurgical approaches for a two-hand reconstruction. The first stage of the procedure was a cross replantation of the left foot to the right leg. The second stage was a combined second and third toe transfer from the cross replantation of the left foot to the right hand, and a sensate fibular osteocutaneous flap transfer for left hand reconstruction. Satisfactory function was restored, including good protective sensation. These kinds of extraordinary microsurgical approaches are useful salvage procedures for hand reconstruction, when presented with a case of multi-limb amputation.

‘Jumping’ cross finger flaps: a useful technique for salvaging parts in mutilating hand injuries

In multi-digital injuries, soft tissue from non-adjacent injured fingers, which would have otherwise been discarded, can be used to cover small defects in salvageable digits. This was found useful in the salvage of four digits and one thumb. Anticipation of the need for a flap cover, and the possible availability of tissue in non-adjacent digits, is of paramount importance during the planning process in these injuries. This technique of using 'jumping' cross finger flaps is a useful method, when dealing with multiple finger mutilations that need soft tissue cover.

Fitting a hand-glove prosthesis to enhance the reconstructed mutilated hand

Microsurgical reconstruction of the severely mutilated hand aimed at improving prehensile functions often does not address the esthetic aspects of the hand. The poor appearance of the reconstructed hand affects its active display and use. A hand-glove prosthesis may be prescribed in this instance to enhance the overall form and function of the mutilated hand. We reviewed 16 cases of mutilating hand injuries in which surgical reconstructions were performed and the patients were subsequently fitted with a hand-glove prosthesis to augment the outcome. An improved appearance was achieved in all patients fitted with the prosthesis. The patients' sense of confidence was also enhanced, which in turn promoted the active and open use of the reconstructed hands. While prescribed primarily to improve the appearance of the reconstructed hands, these prostheses were documented to enhance the physical hand functions in 11 cases by increasing the span of the hand and providing an opposable post and a palmar base for holding and for anchorage. The prosthesis enhanced assistive functions of the reconstructed hands and freed the contralateral normal hand for use in bimanual activities, such as holding a wallet and taking out money, supporting a note pad for writing, and holding a plate at buffet receptions. At the 18-month follow-up visit, 13 (87%) of the patients continued to use their prosthesis. Wear and tear were problems associated with the frequent use of the prosthesis. The expected life span of the prosthesis with daily use ranged from 2 to 3 years. All the patients acknowledged that the prosthesis played a role in their rehabilitation and that it helped them to overcome the initial psychological trauma and to come to terms with their physical loss.

The "Tic-Tac-Toe" classification system for mutilating injuries of the hand.

Several classifications of mutilating hand injuries exist in the literature. Unfortunately, each of these provides a categorization that is arbitrarily grouped according to the part of the hand predominantly involved. It is imperative that a comprehensive classification system incorporate the degree and precise location of soft-tissue and/or bony destruction and the vascular integrity in addition to the predominantly involved part of the hand. We therefore devised a new classification system for mutilating injuries of the hand which categorizes them into seven types: (I) dorsal mutilation, (II) palmer mutilation, (III) ulnar mutilation, (IV) radial mutilation, (V) transverse amputations, (VI) degloving injuries, and (VII) combination injuries. These types are subcategorized into three subtypes: (A) soft-tissue loss, (B) bony loss, and (C) combined tissue loss. Vascular integrity is recorded with subscript notation: (0) vascularization intact or (1) devascularization. The hand is then systematically divided into nine numerical zones in "tic-tac-toe" fashion with radial, central, and ulnar columns and proximal, central, and distal rows. The "Tic-Tac-Toe" classification system allows the examining surgeon to describe precisely any mutilating injury of the hand. This system permits accurate assessment of each hand injury by assignment of the appropriate classification type, subtype, vascular status, and zone involvement. Clinical examples illustrate the user-friendliness and practicality of this new classification system.

Microsurgical reconstruction of distal digits following mutilating hand injuries: results in 121 patients

From 1982–1989, 152 mutilated distal digits were reconstructed with microsurgical foot tissue transfers in 121 patients. These various foot tissues included wrap-around flaps or pulp from the great toe, second toe, or third toe, as well as partial toe, nail, web space skin, and other portions of the foot. The reconstructions were carried out primarily and secondarily in 78 and 74 patients respectively. The immediate success rate was 98%. Most of the patients were satisfied with both the cosmetic appearance and the functional result. This relatively minor microsurgical foot tissue transfer proved to be an ideal reconstructive option for distal digital defects.

Eleven Consecutive Combined Latissimus Dorsi and Serratus Anterior Free Muscle Transplantations

We reviewed our experience with 11 consecutive combined latissimus dorsi and serratus anterior free-muscle transplantations from 1980 to 1990. All 11 flaps were successful and there was minimal morbidity. This combined muscle flap is ideal for soft-tissue coverage in extensive lower extremity wounds, in mutilating hand injuries with dorsal and palmar defects, and in situations when a long vascular pedicle is needed to get out of the "zone of injury."

Restoration of sensibility in mutilating hand injuries

Restoration of sensibility in mutilating hand injuries

Microsurgical Reconstruction of Opposable Digits in Mutilating Hand Injuries

Multilating hand injuries with multiple digital amputations require a cooperative patient, a highly skilled hand/microsurgical team, and a continuum of hand rehabilitation therapy for optimal functional salvage. A systematic approach for assessing a patient's functional deficit and reconstructive requirements contributes to a coordinated reconstruction and rehabilitation plan designed to optimize functional gains. Today's sophisticated microsurgical reconstruction coupled with comprehensive hand therapy generally represents the best option for patients with mutilating hand injuries. Throughout reconstruction and rehabilitation the ultimate goal of multilating hand injury care, that of restoring a functional extremity that is useful in a patient's daily life must be remembered.

Restoration of Sensibility in Mutilating Hand Injuries

The restoration of hand sensibility should be a high priority in providing soft tissue coverage for extensive hand injuries. Initial wound management may be effectively provided by conventional techniques, including skin grafts and groin flaps as a first stage. Once the magnitude of the injury is determined and the reconstructive goals are established, many of these procedures can be performed at a second operation. More circumscribed tissue losses, in which restoration of sensibility is the primary reconstructive goal, may be addressed in the acute or semiacute setting with primary sensory flap reconstructions. The advantage of this approach is that dissection of vessels and nerves is generally easier without the problems of scarring and fibrosis, thereby significantly hastening functional recovery.

Microsurgical Restoration of Distal Digital Function

Advances in microsurgery have produced multiple options for microsurgical restoration of distal digital function. However, because of the complexity of most mutilating hand injuries, these possibilities can be readily overlooked. A surgical awareness of these options for "like" tissue transplantation is now necessary for complete mutilating hand injury care. These "minor" aesthetic and functional microsurgical procedures can be major factors in overall patient acceptance and utilization of the reconstructed hands.

Mutilating corn-picker injuries of the hand

Our experience with 15 patients who had acute mutilating hand injuries from corn-picker machines is reviewed. Three injury patterns were defined. Type I involved severe injury to all digits of the hand, including the thumb; type II injuries involved amputation of all fingers, in whole or in part, but with sparing of the thumb; and type III injuries involved amputation of multiple fingers with sparing of the thumb and at least one other digit. Attempts at revascularization or at complex reconstruction of the injured digits in the period immediately after injury failed in all 15 patients. The most satisfactory results in patients with type I injuries were obtained by complex reconstructive procedures such as toe-to-hand transfer. Patients with type II injuries were best treated with construction of a mitten-type hand by various methods. Patients with type III injuries were best treated by amputation of the devascularized digits.

Double toe transfers

Ten double toe transfers for mutilating hand injuries have been studied. In two patients with total loss of all digits, pincer pinch was restored by the transfer of two separate toes, one to each side of the stump. Seven patients had survival of the thumb and a three-point chuck pinch was provided by transfer of a second toe plus a wrap-around flap over a bone graft to create a third, but stiff digit. One patient required three fingers and was treated by one single toe transfer and one double toe transfer.

Double toe transfers.

Ten double toe transfers for mutilating hand injuries have been studied. In two patients with total loss of all digits, pincer pinch was restored by the transfer of two separate toes, one to each side of the stump. Seven patients had survival of the thumb and a three-point chuck pinch was provided by transfer of a second toe plus a wrap-around flap over a bone graft to create a third, but stiff digit. One patient required three fingers and was treated by one single toe transfer and one double toe transfer.

Therapist's Management of the Mutilated Hand

A staged approach to therapeutic management of mutilating hand injuries is presented. Edema control, wound management, structural mobility, and pain are among the topics discussed.