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Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Treatment of the Severely Injured Upper Extremity*

AMIT GUPTA, M.D., F.R.C.S., RUSSELL A. SHATFORD, M.D., THOMAS W. WOLFF, M.D., TSU-MIN TSAI, M.D., LUIS R. SCHEKER, M.D., LOUISVILLE, KENTUCKY and L. SCOTT LEVIN, M.D., DURHAM, NORTH CAROLINA

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

	Introduction

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The human hand is a supremely adaptable organ of prehension, sensation, expression, and communication. With its complex, integrated structures of skin, muscles, tendons, nerves, vessels, bones, and joints, the hand allows people to explore their environment, care for themselves, and earn a living. To watch a virtuoso pianist at work is to appreciate fully how the hand is capable of performing highly coordinated actions. The hand is so important as a tool and as a sensory organ that it could be claimed that the primary function of the upper extremity is to position the hand in space. Injuries of the upper extremity thus have a direct bearing on the function, sensation, and movement of the hand.

The upper extremity, our interface with the external world, is subjected to the forces of the world and is easily injured. Such injuries—industrial, agricultural, domestic, or vehicular—disrupt the fine, intricately balanced anatomy of the structurally complex and functionally adaptable hand and can devastate the life and livelihood of the injured person. For many patients, such as laborers, musicians, carpenters, surgeons, and dentists, loss of hand function means loss of a career. However, advances in the pathophysiology of tissue trauma, microsurgery, antibiotics, and bone and tendon fixation techniques have enabled reconstructive surgeons to achieve better outcomes that maximize function and minimize disability for patients who have a severe injury of the upper extremity⁴¹.

In this article, we present our concept of immediate comprehensive treatment of such injuries. Our discussion includes assessment of the patient, classification of injuries, provisional preoperative planning, wound excision, definitive decision-making, structural repair techniques, soft-tissue coverage, operative innovation and imagination in reconstruction, rehabilitation, and determinants of outcome.

	Assessment

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The first step in the treatment of an injury of the upper extremity is the assessment of the patient's condition—that is, the extent, severity, and nature of the injury—and the hospital resources available for the patient's care. Before all else, an assessment of the patient's life-threatening injuries is imperative. There is always the danger of being sidetracked by a visually striking, bloody, and mangled upper extremity and thus overlooking potentially life-threatening conditions in the abdomen, chest, or head¹⁷. Other areas to keep in mind are the pelvis, spinal cord, and lower extremities, especially in the presence of open fractures. A trauma team and an appropriately equipped trauma room are needed to assess multiply injured patients adequately and safely according to the principles of the advanced trauma life-support procedure published by the American College of Surgeons⁹.

Once life-threatening injuries have been expeditiously and conclusively ruled out, attention should be turned to the assessment of the patient's overall condition. This assessment should include a medical history, with medications, habits, allergies, and previous operations and other types of treatment recorded. The patient's gender, age, hand dominance, profession, hobbies, wishes, and aspirations should be noted as well. The history should also include when the patient last received the tetanus toxoid vaccination, the preinjury functional capability, and previous injuries of the upper extremity. The examiner should particularly look for diseases or habits that might (1) affect the peripheral capillary circulation (atherosclerosis, diabetes mellitus, smoking, and abuse of cocaine or another drug), (2) increase the risk of infection (immunosuppression such as with steroids, a history of transplantation, acquired immunodeficiency syndrome, and skin diseases), (3) influence the choice and dose of medication such as antibiotic prophylaxis (drug allergies and renal or liver diseases), (4) determine the feasibility and outcome of postoperative rehabilitation (psychiatric disorders, mental retardation, and drug abuse), and (5) increase the risk of postoperative bleeding, hematoma formation, or thrombosis (intake of aspirin or another anticoagulant medication and hypercoagulable states).

Present Injury
Once the medical history has been recorded, attention is turned to obtaining information about the present injury. This information includes the time, place, mechanism, and nature of the injury.

The time elapsed from the injury or from the onset of ischemia affects the functional outcome of any reconstruction. There is a direct association between the duration of ischemia and the potential for compartment syndrome, the risk and severity of infection, and the feasibility of macroreplantation.

The environment where the injury was sustained affects the risk of infection. Mutilating hand injuries that occur as a result of farming accidents, for example, are associated with a high risk of bacterial contamination. Extensive contamination is also seen in injuries resulting from motor-vehicle collisions, snowblowers, woodworking tools, and industrial machinery such as a punch press¹⁸.

The mechanism of injury can be associated with a specific constellation or pattern of injuries. The type of tissue damage can be somewhat anticipated if the cause of the injury is known. The type of machine or equipment, with specific details regarding the machine blades, the distance between the blades, and the number of blades or rollers, is essential information. The possibility of pressure injection, including the pressure rating and the chemicals that were injected, needs to be determined.

The nature of the injury defines the amount of tissue that was injured around the wound. A sharp, clean incision damages tissue only locally and around the area of ischemia, whereas an avulsion wound injures a much greater length of vessels or nerves. A crush injury produces varying degrees of damaged tissue according to the distance from the center of the wound. A thermal injury produces three concentric zones of dead or injured tissue: a central zone of coagulation, which is surrounded by a stasis zone, which in turn is surrounded by a zone of hyperemia²². A chemical injury, especially a pressure injection injury, produces extensive damage along spaces and compartments. A degloving injury tends to produce distally based flaps that are ischemic for a longer distance than usually is anticipated.

Calm and warm surroundings, compassionate and confident behavior on the part of the examiner, and concern for the stability and comfort of the patient allow for an extensive evaluation of an injured extremity. Liberal use of pain medications is indicated. Keeping pain to a minimum may sometimes mean deferring the complete evaluation until the patient is under anesthesia. Nevertheless, there is some benefit in gathering as much information as humanely possible in the emergency room if this can be done quickly and with relatively little discomfort. The examiner has to assess the circulation and sensibility of the extremity as well as basic functions that indicate whether major nerves are intact. This information along with a preliminary radiographic survey allows for proper preparation of the operating-room staff and for proper planning of the procedure.

The next step in the evaluation of an injured upper extremity is a clinical assessment of different factors determining outcome. The examiner should note active bleeding, which of course needs to be controlled but also indicates adequate perfusion and vascularity; the extent of devascularization, which in turn defines the extent of the débridement and the revascularization that is needed; the status of the skin, as any reconstruction will be threatened without a stable envelope and accompanying soft-issue coverage; the posture of the fingers, which may indicate tendon injuries needing repair and which directly affects the outcome and treatment plan; any deformities signifying fractures or dislocations, which necessitate appropriate preparation and operative planning; and the location and extent of the wound, which, together with the posture of the extremity during the injury, indicates the structures that were most probably injured.

Diagnostic Modalities
After the clinical assessment, there are several diagnostic modalities that can be helpful in the treatment of an injury of the upper extremity. These include radiographs of the extremity and the amputated parts, which provide information about osseous injuries of the extremity and the content and condition of bone in the amputated part; stress radiographs or fluoroscopy, which assist in the diagnosis of a ligamentous injury or even a rupture; and perfusion monitors (such as Doppler flow monitors) and compartment-pressure monitors, which can give valuable information about the patency of a vessel or the adequacy of perfusion of a certain anatomical area or compartment.

Classification of Injuries
The classification of injuries allows the surgeon to assess the potential for complications such as wound infection and to plan the necessary operative procedure. Rank et al.³⁸ classified wounds as tidy and untidy. The tidy wounds included a simple cut in the skin, a slicing injury with loss of soft tissue, a guillotine amputation, and an incised wound involving tendon or nerve injury.

Gustilo²⁰ proposed the widely accepted fracture classification bearing his name. In this system, type I indicates an open fracture with a clean wound that is less than one centimeter long; type II, an open fracture with a wound that is more than one centimeter long without extensive soft-tissue damage; and type III, an open fracture with extensive soft-tissue damage. Type-III injuries are subdivided into type IIIA (adequate soft-tissue coverage), type IIIB (periosteal stripping and exposure of bone, usually with massive contamination), and type IIIC (arterial injury necessitating repair). In this classification system, the importance of an adequate soft-tissue envelope and tissue perfusion is evident.

Büchler and Hastings⁷ developed a different classification system that takes into consideration the so-called relevant structural systems of the upper extremity; these include bones, joints, extrinsic extensors, extrinsic flexors, intrinsic system, nerves, arterial blood supply, venous drainage, skin, and nails. They classified injuries as isolated (involving only one relevant structural system at a specific location) or combined (involving two or more relevant structural systems at a specific location). Combined injuries include crush injuries, volar combined injuries, extensive volar defects, dorsal combined injuries, and dorsal and volar combined injuries.

At our clinic, we modified this classification to include more details about the injury and to allow better communication between clinicians. Our classification system includes information on the location of the wound, with a letter indicating the location on the upper extremity (A indicates the arm; E, the elbow; F, the forearm; W, the wrist; H, the hand; and D, a digit) and a number (1 through 5) indicating the digit. The system also classifies the adequacy of the circulation (i indicates adequate and ii indicates inadequate). The injuries are also defined as isolated (I), combined (II), or complete amputations (III). Isolated injuries can be closed (a) or open (b), and combined injuries can be dorsal (A), palmar (B), or dorsal and palmar (C). Thus, according to this classification system, a devascularized ring finger with flexor tendon and osseous injury would be classified as D4IIBii, a palmar laceration of the wrist with good circulation and cut flexor tendons and nerves would be classified as WIIBi, and an amputation of the forearm would be classified as FIII.

	Provisional Preoperative Planning

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It is important to have a thorough understanding of the soft-tissue injury when treating a mangled upper extremity. An evaluation that includes radiographs should be performed to assess the skeleton for injury patterns. When interpreting radiographs, the examiner should note the soft-tissue shadows to assess osseous devascularization. It is also necessary to assess bone loss, comminution of fracture fragments, dislocation, and whether there are injuries at multiple levels. The examiner must determine what implants should be selected and what functional loss might result from the destroyed joints and the amount of bone loss. All of these factors play a part in decisions about treatment.

Decisions with regard to anesthesia include whether to use regional block or general anesthesia. Regional anesthesia (axillary block) offers the specific advantages of vasodilation and postoperative pain control, but general anesthesia may be needed if the operative procedure is long, if the patient is uncooperative under regional anesthesia, if the regional block provides inadequate analgesia, or if an anesthesiologist who is experienced with axillary blocks is not available. Appropriate monitoring, such as with a Swan-Ganz catheter and an arterial line, should be used, particularly in elderly patients and for major limb injuries where revascularization and blood shifts may cause hypotension, high lactate-acid loads, and cardiovascular stress.

When the operating-room staff has been notified that a patient will be treated, the staff must be sure to have available the necessary equipment, such as an operating microscope, microsurgical instruments, fixation sets, and antibiotic bone-spacers. Once the patient arrives in the operating room, appropriate communication with the operating-room staff should include instructions regarding positioning of the table relative to the requirements for making radiographs, using operating microscopes, and performing fluoroscopy. Furthermore, the appropriate tourniquet should be applied to both the upper and the lower extremities, and the correct positioning should be determined by the type of free tissue transfer that is needed. The patient is prepared and draped for the removal of vein grafts, nerve grafts, and skin grafts; for free tissue transfer; and for débridement of the extremity.

When amputation is a possibility, the operating team should be prepared for salvage of any structures from the amputated part, such as bone, skin, vessels, or nerves, that can be used not only to preserve the length of the injured upper extremity but also to provide material for grafts at other body sites in a patient who has sustained multiple injuries.

	Wound Excision

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Although every reconstructive surgeon has a clear concept of what is meant by thorough débridement, these concepts vary radically. There are, however, two basic strategies for débridement: serial débridement and wound excision (immediate débridement). Serial débridement removes only the tissue that is clearly dead. Wound excision, or immediate débridement, leaves only tissue that is clearly alive. A traditional serial débridement preserves questionably viable tissue in the hope that it is viable and will remain viable. However, serial débridement is the cause of many infections. A surgeon who uses this traditional and tentative approach endeavors to save a few strands of viable but probably functionless tissue at the risk of a devastating infection. Serial débridement also leaves open wounds that allow for desiccation of skin edges and bone ends. In addition, edema and granulation tissue can obscure the tissue planes and deeper structures, making a decision about their viability difficult. Furthermore, the wound resulting from a serial débridement may be even larger than that after a débridement performed on the day of the injury.

In contrast, immediate extensive débridement involves the removal of all doubtfully viable tissue and extension of the excision to live bleeding tissue. Immediate débridement is better than serial (delayed) débridement because tissue planes are visible when the wound is fresh. We therefore prefer the term wound excision, which has the connotation of tumor excision. When completed, the wound should look like the site of an operative tumor extirpation.

Wound excision is the most important step in the treatment of a severely injured upper extremity. Without a thorough débridement, none of the complex reconstructions that we will describe are possible or advisable. Therefore, it is imperative that wound excision be supervised by a senior surgeon and not be left to the most junior member of the team. The process should be carried out under loupe magnification and with tourniquet control.

Traditionally, one of the techniques used to determine the adequacy of débridement margins has been bleeding. Traditionalists, therefore, decry the use of a tourniquet for débridement. However, without a tourniquet, bleeding may obscure the field, placing vital structures at risk. Furthermore, bleeding from adjacent live tissue may make it appear that devitalized tissue is bleeding and therefore alive. Also, bleeding is not the only indicator of injured tissue. With careful examination under loupe magnification, healthy tissue is usually easily distinguished from injured tissue. The only exception is healthy tissue with a destroyed arterial supply. Here, assessment of bleeding is a useful adjunct. After thorough débridement, the tourniquet can be released or it can be briefly released and then reinflated. This staged release of the tourniquet allows the viability of all structures to be examined and wound excision to proceed without torrential bleeding obscuring the surgeon's view.

Wound excision after a mutilating injury of the upper extremity involves several decisions. The surgeon must decide how much to debride, how to debride, and when débridement should be carried out again. Wound excision should be performed centripetally, starting at the periphery of the wound and working toward its center. Two millimeters of skin edge should be excised to obtain arterial dermal bleeding. We sharply excise crushed and contaminated skin to yield clear, vertical skin edges. Skin bridges, which may carry precious venous drainage, are preserved if possible, particularly during débridement of digits. However, if the skin bridge gets in the way or in any way hampers the débridement, it should be excised. All nonviable tissue, except blood vessels and nerves, is cut back to bleeding viable tissue. Subcutaneous tissue that is soiled should be debrided back to healthy fat. Fascia should be excised when it has been avulsed from overlying muscle and shows no sign of vascularity. Muscle is debrided to the level of healthy-appearing muscle. Devascularized and avulsed muscles are excised to bleeding tissue. Epineurium that is soiled can be removed, leaving fascicles behind. Nerves with ground-in contamination are debrided under higher magnification. Structurally relevant bone fragments are preserved. If a bone segment is crushed and contaminated, however, it should be excised, thus shortening the bone in preparation for internal fixation. All bone devoid of soft-tissue attachments should be removed.

The tourniquet is elevated again, the wound is excised further, and then the tourniquet is released. This process is repeated two or three times. Every hidden pocket is explored. Any thrombosed veins should be excised, and blood vessels should be preserved for reconstruction of vascular inflow.

Irrigation is used for the most part to keep tissues moist, but extensive pulsatile lavage should not be a substitute for appropriate débridement. Often, extensive pulsatile lavage insufflates tissue planes and can be destructive rather than therapeutic. Therefore, once the wound is completely excised, it is irrigated with Ringer's lactate solution, with use of a bulb syringe. Pressure irrigation is not necessary.

Some surgeons, however, place almost complete reliance on wound lavage, particularly pulsatile lavage, to perform the débridement and minimally excise only the most obviously dead tissue visualized without magnification. Lavage can be efficacious. In one study, lavage removed 70 percent of the silicone sand rubbed into experimental wounds³⁵. Although impressive, this finding means that 30 percent of the particles were not removed. Such a wound débridement, which leaves heavy contamination and devitalized tissue or bone, or both, followed by an excessively tight closure of injured skin is associated with a high rate of complications. The results of operations performed in this manner should not be considered perspicuous evidence against immediate reconstruction; they simply demonstrate that immediate reconstruction will not be successful if débridement is inadequate.

If débridement is definitive—that is, if normal tissue planes are encountered at all levels—then reconstruction of bone, tendons, nerves, vessels, and skin coverage can proceed unimpaired. When, despite the surgeon's best efforts, the adequacy of the débridement is uncertain, such as in the treatment of crush injuries, infections, fasciitis, and contusion, then a return to the operating room within twenty-four to forty-eight hours should be considered. After wound excision, forearm and hand compartments are released as necessary. Carpal tunnel release is done if there are signs of nerve compression. Then the surgeon can proceed with further reconstruction.

	Definitive Decision-Making

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After wound excision, the treatment of impaired arterial, venous, or arterial and venous circulation in a mutilated upper extremity must be considered. Most important, it is necessary to determine whether there is arterial damage or arterial insufficiency. Second, venous outflow of the wound may be impaired or insufficient, such as in patients with a large skin avulsion injury that has a distally based flap. Often, dermal perfusion and inflow are adequate but outflow will restrict ultimate inflow, resulting in necrosis of the flap. There are times when both the arterial and the venous systems need to be reestablished. In major limb revascularization, it is often desirable to reestablish arterial inflow before venous outflow because of the increased accumulation of metabolites, lactate, and cell-breakdown products that can be hazardous to the patient if immediate venous flow is reestablished without purging of the revascularized part.

At times, temporary shunting is desirable to reestablish blood flow in the setting of major limb devascularization or replantation. In some patients, restoration of blood flow, even temporarily, should be done before excision of tissue if large amounts of muscle are devascularized and the duration of warm ischemia is long. (A devascularized part placed in plastic and then on ice will have less metabolic damage than a warm ischemic part that is not placed on ice.) Temporary shunting can be achieved with heparinized feeding tubes, Sundt shunts, or heparinized intravenous tubes. Arterial shunts should be established as quickly as possible to avoid prolonged muscle ischemia. Once arterial inflow has been reestablished, outflow is observed through cutaneous and deep veins. The anesthesiologist and the operating team need to be prepared for rapid blood loss and must monitor the patient carefully.

After the shunt has been established, débridement and provisional or definitive osseous stabilization can be performed. While the débridement and the stabilization are being performed, a separate team should be removing an autogenous reverse saphenous vein graft, which is usually used in revascularization procedures. Shunting should be considered if the duration of ischemia is greater than four hours or if débridement and stabilization will take longer than several hours. For optimum use of an interpositional vein graft, the graft should not be made too loose or too tight and, whenever possible, it should be routed so that it is under a major muscle group rather than through a wound. If revascularization is completed and the vein graft can be hidden, there is no need for emergency coverage with a free tissue transfer. However, if the vein graft that is used to revascularize a threatened limb is exposed, then emergency free tissue transfer is strongly preferred to cover that graft and thus to prevent it from becoming desiccated or from rupturing. Occasionally, venous-venous interpositional grafts are used as well. Superficial veins may have to be reconstructed in major replantations because venae comitantes alone may not be sufficient to decrease postoperative edema.

Decisions about wound closure follow the reconstructive ladder: simple closure, skin grafts, local flaps, regional flaps, pedicled flaps, and, finally, free flaps. The decision between temporary closure with antibiotic beads, Epigard, pigskin, or Xeroform and definitive closure with full-thickness or split-thickness grafts can be made at the time of the final wound closure.

	Structural Repair Techniques

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Planning of the Reconstruction
The surgeon should consider all of the reconstructive options, including amputation. Amputation should not be considered a failure but the first step in the reconstruction. The decision to amputate requires a judgment on the part of the surgeon. If adequate wound excision will remove so much tissue that functional reconstruction would be impossible, then an amputation should be performed.

Several injury-severity scores have been designed to try to make the decision to reconstruct or amputate more objective. The mangled extremity severity score (MESS), which was designed for the lower extremity, has been used for the upper extremity as well²³. However, because the upper extremity has much different functional requirements, the score is inadequate for rating of the upper extremity.

Skeletal Reconstruction
Skeletal stability is the basis for all other reconstructions. The importance of definitive stable bone fixation must be emphasized because the vascular and functioning neuromuscular units that join with the skeleton to form a reconstructed extremity rely on a stable skeleton. Skeletal stabilization allows the surgeon to fix and forget the bone and concentrate on the rehabilitation of the patient.

Open reduction and internal fixation has been established as the so-called gold standard in the treatment of closed displaced unstable fractures of the upper extremity, with the possible exception of some humeral diaphyseal fractures, for which bracing still has a role. However, the treatment of open fractures is controversial.

The goals of treatment of open fractures include prevention of infection, stable fixation to allow early mobilization of joints and gliding of tendons, and achievement of union without deformity. The main impediment to treating open fractures in a manner similar to treating closed fractures stems from a fear of infection. Traditionally, the fear that devascularized, crushed, and contaminated bone fragments will lead to devastating infection and osteomyelitis has prompted the adoption of delayed primary closure, application of an external fixator, and delayed fracture treatment.

Fear of infection and nonunion after treatment of an open fracture is based on the experience with the lower extremity. In a series of eighty-seven type-III open fractures, Gustilo et al.^19,20 reported that 52 percent of the type-IIIB fractures, 42 percent of the type-IIIC fractures, and 4 percent of the type-IIIA fractures were complicated by infection. Although the data of Gustilo et al. included fractures of the upper extremity, there were only a few (only five radial and three ulnar type-III fractures). Moed et al.³³ reported that two (3 percent) of seventy-nine open fractures of the forearm were complicated by deep wound infection. One of these fractures was type II and one was type III, as classified according to the system of Gustilo and Anderson¹⁹. Unpublished data from our center showed that, of twenty-four type-III fractures (nine type-IIIB and fifteen type-IIIC), none were complicated by deep infection or osteomyelitis (95 percent confidence interval, 0 to 11.7 percent) after treatment with open reduction, internal fixation, and immediate wound coverage (Figs. 1-A, 1-B, 1-C, 1-D and 1-E).

View larger version (155K): [in this window] [in a new window]   Figs. 1-A through 1-E: A forty-three-year-old patient who sustained a fracture of the ulna with a large soft-tissue defect, muscle loss, injury of the radial artery, and exposure of the median nerve. Fig. 1-A: Photograph showing the injured forearm.

View larger version (77K): [in this window] [in a new window]   Fig. 1-B Radiographs showing plate fixation of the ulnar fracture.

View larger version (75K): [in this window] [in a new window]   Fig. 1-C Photograph made after immediate coverage with a lateral arm flap.

View larger version (55K): [in this window] [in a new window]   Fig. 1-D Photograph showing flexion.

View larger version (48K): [in this window] [in a new window]   Fig. 1-E Photograph showing extension.

Even if external fixation is superior to internal fixation in the lower extremity, this does not mean that it is better in the upper extremity. The upper extremity differs from the lower extremity with regard to vascularity, functional requirements, and a greater ability to tolerate shortening. There are a number of disadvantages to using an external fixator in the upper extremity: the devices are bulky, they transfix muscles, they interfere with flap design and vascular access, and they cause joint stiffness. Moreover, it is difficult to use orthoses with external fixators. Also, in the forearm, it is extremely difficult to achieve and to maintain anatomical reduction of the radius and ulna, especially in the presence of comminuted or segmental fractures.

The other technique that we use extensively in the treatment of open fractures of the upper extremity is bone-shortening. Bone-shortening, which the upper extremity is able to tolerate quite well, allows us to bypass a comminuted segment, thus avoiding complex internal fixation in crushed and devascularized segments. Moreover, by shortening bones, we can avoid vein grafts and nerve grafts in favor of end-to-end anastomoses of these structures. Meyer³¹ pointed out that bone-shortening was at least partially responsible for the overall good results of replantation in a combined series of patients from Shanghai, Louisville, and Zurich. This conclusion was reinforced by Axelrod and Büchler². In our unpublished series of twenty-four type-III fractures of the forearm, bone-shortening was carried out in 96 percent (twenty-three). The amount of bone-shortening ranged from 0.5 to 2.5 centimeters, with an average of one centimeter.

Having outlined the rationale for our approach to open fractures of the upper extremity, we will discuss the bones individually because each bone possesses certain anatomical characteristics that require consideration before an operation. If an operation for fixation is well reasoned and planned, the surgeon will encounter few setbacks; however, poorly planned fracture treatment with ad hoc intraoperative improvisations can prove frustrating and ineffective. All of our recommendations with regard to techniques are made with the assumption that adequate wound excision will be achieved first.

Humerus
Treatment of the humerus involves several anatomical considerations. First, there is an intimate and integral association between the rotator cuff tendons and the proximal end of the humerus. Second, the distal fourth of the humerus is flattened anteroposteriorly, which greatly reduces the intramedullary diameter. Third, there are four major nerves (axillary, radial, ulnar, and musculocutaneous) associated with the humerus; the first two are vulnerable to injury during placement of locking screws. Fourth, there is a substantial soft-tissue envelope around the bone that increases the risk of pin-related problems if external fixation is used.

The first, second, and third considerations make the humerus anatomically unsuitable for locking intramedullary nailing. The third and fourth considerations increase the risk of complications associated with external fixation. The use of external fixators as a temporary measure is less than satisfactory because definitive fixation will require another procedure through a zone of injury with recently reconstructed nerves and vessels. Furthermore, if there is drainage about the pin tracks, a delay between removal of the fixator and definitive internal fixation is usually necessary.

In view of the problems and limitations associated with the use of intramedullary devices and external fixators, our recommendation for the treatment of most diaphyseal humeral fractures in severely injured upper extremities is internal fixation with a 4.5-millimeter dynamic compression plate and screws. An extensile approach to the entire humerus is readily available and often facilitated by the soft-tissue injury. Open reduction and internal fixation of diaphyseal humeral fractures with a plate and screws allows débridement of crushed and devascularized bone segments and shortening in case of segmental bone loss. This protocol creates a simpler fracture profile, sound rotational control, and stable interfragmentary fixation. The reconstruction of distal intra-articular fractures with interfragmentary compression and neutralizing reconstruction plates is unrivaled in terms of stability and restoration of anatomy, thereby facilitating early return of function.

Forearm
Several anatomical considerations must be taken into account when treating the forearm. First, the radius and the ulna are two intimately linked bones, articulating with each other both proximally and distally and through the intervening interosseous membrane. The radius and the ulna are functionally interdependent. A structural or anatomical deficit of one is reflected by malfunction of the other. Accurate reduction of fractures of the forearm and subsequent maintenance with stable fixation are, therefore, vital in restoring rotation of the forearm.

Second, although the ulna is a relatively straight bone, the radius is not. Thus, stable internal fixation of the radius can be difficult if not impossible to achieve with intramedullary devices.

Third, there is an intimate relationship between the musculotendinous units and the underlying bones on the palmar and, especially, the dorsal surface of the distal part of the forearm. The tendons rub against or are trapped by pins used for external fixation. There are few problem-free areas in the soft tissue over the metaphysis of the distal part of the radius in which external pins can be placed safely.

The first and second considerations preclude the use of intramedullary devices in the forearm if the goal of treatment is early restoration of function without external splints. Furthermore, soft-tissue care in a severely injured limb is facilitated by the absence of external splints. The third consideration highlights the problems generated by external fixation. We think that external fixation has little place in the immediate treatment of fractures of the forearm except as a temporizing measure in patients with a single-bone segmental defect for whom a delayed bone reconstruction is planned. The use of a 3.5-millimeter low-contact dynamic compression plate and screws gives predictable, accurate, stable, definitive fixation in patients with severe injuries and should be the fixation of choice for these difficult fractures. Sometimes, more than one plate may have to be used to stabilize segmental fractures.

Metacarpals
The anatomical and biomechanical considerations in the treatment of metacarpals include the following. First, intact metacarpals lend stability to an adjacent broken one. The palmar surface does not lend itself to adequate exposure or the placement of a fixation device. Second, the dorsal surface is easily accessible but superficial. Bulky metal plates can be prominent and cause irritation of tendons. Third, some metacarpals have muscle and wrist tendon attachments that need careful protection to prevent entrapment. Fourth, accurate anatomical restoration of the mobile fourth and fifth metacarpal bases at the carpometacarpal joints is necessary to avoid a reduction of grip power. Fifth, during finger flexion, strong tensile forces act across the dorsal cortices of the metacarpals, generating, in turn, strong compressive forces on the palmar cortices of the metacarpals.

Stable fixation of diaphyseal fractures of the metacarpals is best achieved with plates and screws. In men and in women with large hands, 2.7 or 2.4-millimeter dynamic compression plates (dorsally placed because of the first, second, and fifth considerations) provide good, stable fixation. In small hands or in the treatment of uncomminuted fractures, 2.0-millimeter plates may suffice. Fractures of the bases of metacarpals can be treated effectively with interfragmentary screws supplemented with plates and screws. Occasionally, judiciously placed Kirschner wires will suffice.

In replantation, it is preferable not to undertake the extensive dissection necessary to place a plate and screws. Lister's method of wiring²⁷ or 90–90 wiring (placement of wires at 90 degrees to each other) provides sufficient stability for early motion (Figs. 2-A and 2-B).

View larger version (82K): [in this window] [in a new window]   Figs. 2-A and 2-B: A thirty-year-old patient who had complete transmetacarpal amputation of all digits. Fig. 2-A: Preoperative radiographs.

View larger version (91K): [in this window] [in a new window]   Fig. 2-B Radiographs made after replantation, showing stable fixation of all metacarpals with 90–90 wiring.

Phalanges
Treatment of the phalanges should be based on the following anatomical and biomechanical considerations. First, the extensor expansion is intimately related to the dorsum of the phalanx, thus allowing little room for metal plates or pins without interfering with tendon function. Second, metacarpophalangeal joints can be kept flexed for a few weeks without fear of joint stiffness because the eccentrically placed collateral ligaments are lengthened during flexion of the joint. Flexion of the metacarpophalangeal joint forms the basis for treatment of an unstable fracture of the proximal phalanx with the technique described by Belsky et al.⁴. Third, the collateral ligament attachment to the head of the proximal phalanx does not allow a great deal of error in the placement of a condylar plate or undue bulk of the plate. Fourth, there is no room for conventional dorsal plates in the middle phalanx because of the intimate relationship of the extensor mechanism. Fifth, the insertion of the extensor tendon to the base of the distal phalanx is close to the germinal matrix of the nail bed.

Displaced basal fractures of the proximal phalanx can be stabilized with the technique described by Belsky et al.⁴; with interfragmentary screws; or, in some situations, with a laterally placed condylar blade-plate or a dorsal T-plate. Extensively comminuted segments should be excised and replaced with corticocancellous bone graft and a condylar blade-plate. Bone graft and a plate give immediate stability to the phalanx and allow for débridement of the crushed bone.

Displaced transverse fractures of the proximal phalanx without comminution can be firmly stabilized with sagittal interosseous wires (or 90–90 wires), supplemented, if necessary, with an oblique Kirschner wire cut flush with the bone⁴⁶. Spiral fractures of the proximal phalanx are best fixed with 1.5-millimeter interfragmentary screws. Fractures involving one condyle can be suitably stabilized with interfragmentary screws and an additional Kirschner wire to control rotation. Bicondylar fractures are best treated with interfragmentary screws and a 1.5-millimeter condylar plate.

The treatment of fractures of the middle phalanx follows the same principles. If plate fixation is necessary, the plate should be placed laterally with minimum soft-tissue dissection. Early protected motion is essential. In replantations, extensive soft-tissue dissection is avoided, but stable bone fixation is carried out with the help of Lister's technique of wiring²⁷ or 90–90 wire. Terminal phalangeal fractures are stabilized with appropriately placed Kirschner wires.

Joint Injuries
Major joint injuries are almost always more complex to reconstruct than are extra-articular fractures. Whereas bone from the iliac crest can be used to reconstruct the relatively small diaphyseal segments of the hand bones, joints are specialized tissue for which there are limited options, depending on the circumstances. Whichever option for joint reconstruction is chosen, it must be consistent with the overall treatment of the extremity. The surgeon cannot plan to treat a severe intra-articular fracture of a metacarpophalangeal joint with early motion while at the same time planning to treat surrounding fractures of the same ray with immobilization. This is why the so-called balkanized treatment of injuries of the upper extremity, in which different services care for different structures, can lead to poor results. Optimum results are possible only if there is consideration of the rehabilitation needs of all structures by the entire team or if one person decides on the integrated management of the reconstruction.

Options for treatment of a joint injury include immobilization, open reduction and internal fixation, arthrodesis, soft-tissue arthroplasty, joint transfer, and prosthetic arthroplasty. Joint injuries with minimum displacement of the articular surface—especially those with minimum critical motion, such as the second carpometacarpal joint—are good candidates for consideration of immobilization. Unfortunately, immobilization of a severely injured upper extremity often leads to severe stiffness.

Open reduction and internal fixation is the best choice for a severely injured joint, as long as sufficient fragments are present (or replaceable) for reconstruction of the joint. Since immobilization of a joint, such as the metacarpophalangeal or proximal interphalangeal joint, is associated with increased morbidity, and since other injuries, such as those involving tendons, necessitate early motion, then joint fixation should be sufficiently stable to support early motion. In addition to the standard AO/ASIF armamentarium, absorbable Kirschner wires placed through small cartilage or subchondral bone fragments, or both, allow for the anatomical reduction of articular surfaces without immobilization of the joint. Areas of pure cartilage loss cannot be reconstructed without obtaining cartilage-covered bone from another source. However, if the subchondral bone remains bare, multiple small drill-holes may lead to fibrocartilage filling in the gaps between the normal cartilage. Care must be taken to avoid burning the bone.

Sources of cartilage-covered bone for reconstruction include spare material such as a nonsalvageable digit. (This solution is less applicable to larger, more proximal joints such as the elbow.) If there is no appropriate spare material, sometimes a less critical joint, such as a toe joint, may be partially or completely removed to reconstruct a more critical joint. Khouri et al.²⁵ described the replacement of a proximal interphalangeal joint with a distal interphalangeal joint. Hastings et al.²¹ used the dorsal lip of the hamate to reconstruct the volar lip of the proximal interphalangeal joint. Rib cartilage or subchondral bone has also been used to resurface joints⁴³. As with any bone reconstruction, the field must be adequate for reconstruction. Once again, an impeccable débridement is the critical feature. Historically, bone fixation in the presence of inadequate débridement, particularly when coupled with a closure under tension of devitalized skin over devitalized contaminated tissue, has led to severe infections.

Arthrodesis is a useful technique, especially for joints that can lose motion without causing severe functional loss. The second and third carpometacarpal joints and, to a lesser extent, the distal interphalangeal joints are examples of joints that provide motion that is less critical to overall hand function, except in hands on which the highest demands are placed, such as those of a musician.

Soft-tissue arthroplasty is an option when the joint is not reconstructible, although better results can be expected in joints with lateral motion that is constrained by adjoining structures. An example is the metacarpophalangeal joints for which the other digits provide lateral stabilization. In joints without secondary stabilization, soft-tissue arthroplasty is more stable if a substantial portion of the joint remains intact, as is the case with an Eaton¹⁰ proximal interphalangeal joint arthroplasty.

Joint transfer, such as the pedicled transfer of the distal interphalangeal joint to the proximal interphalangeal joint that was previously noted, can also be used to replace joints. Compatible joints from the foot are often transferred to the hand. Unfortunately, a good result of a transfer of a toe joint produces only 50 percent of normal motion. Such poor results differ little from those of an arthrodesis. Removal of the toe joint also creates an injury in a previously uninjured part of the body.

Complete joint transfers usually must be vascularized. Without vascularization, bone is eventually replaced by creeping substitution, but, until it is, the subchondral bone is unable to maintain the cartilage. Partial joint transfers, in contrast, allow some metabolic support of cartilage through joint fluid produced by the vascularized portion of the joint. Thus, we perform nonvascularized partial joint transfers but use vascularized complete joint transfers.

Prosthetic arthroplasty should be the solution for any joint injury that is not reconstructible. Unfortunately, prosthetic joints in the upper extremity are usually very poor options after injury. Although elbow prostheses continue to be improved and have some role in late reconstruction—particularly in an elbow on which low demands will be placed—they are far from ideal. Wrist prostheses have equivalent problems. Silicone metacarpophalangeal joint prostheses are an excellent short-term solution to the treatment of a hand on which an elderly rheumatoid patient will place low demands, but they are seldom satisfactory after an injury in a younger patient who will place high demands on the hand. Prostheses continue to be improved. An exciting development would be the availability of reliable off-the-shelf replacement parts.

Reconstruction of Blood Vessels
Whenever possible, we prefer to perform end-to-end vascular repair. However, when end-to-end arterial anastomosis is not possible, the next option is a vein graft. The radial and ulnar arteries can be reconstructed with use of a portion of the cephalic vein as a reversed vein graft, but only after it has been ensured that the vein has not been injured. Some surgeons have observed aneurysmal dilatations when arm veins have been used for reconstruction of major vessels. Aneurysmal dilatation occurs because these veins have thin walls. If aneurysmal dilatation is a real concern, then a reversed saphenous vein graft should be used. It is imperative that there is a good size match between the vessels. Sometimes, a flow-through free flap may be used to provide soft-tissue coverage and, at the same time, vascular inflow to the distal portion.

The superficial palmar arch is a challenge for reconstruction. There are a few options, including (1) the subscapular-thoracodorsal complex, which provides, through its many branches, an ingenious method of reconstructing the arch; (2) a reversed vein graft from the dorsal venous arch of the foot, although this should be avoided if a toe transfer may be used later; and (3) a reversed saphenous vein graft connected to either the radial or the ulnar artery, with the common digital arteries anastomosed, end to side, to the vein graft. If a flow-through vessel along with a long segment of bone is needed for reconstruction, the peroneal artery is an ideal graft (Figs. 3-A, 3-B, 3-C and 3-D).

View larger version (146K): [in this window] [in a new window]   Figs. 3-A through 3-D: A twenty-two-year-old patient who was referred from another facility after a gunshot wound to the forearm. Fig. 3-A: Photograph showing the injured forearm. There was extensive loss of skin and other soft tissues, including the radial artery and the median nerve.

View larger version (37K): [in this window] [in a new window]   Fig. 3-B Radiograph showing a large segmental defect in the radius.

View larger version (81K): [in this window] [in a new window]   Fig. 3-C Radiographs made after a flow-through free fibular graft was used to reconstruct the radius. The peroneal artery was used to reconstruct the segmental defect in the radial artery.

View larger version (77K): [in this window] [in a new window]   Fig. 3-D Photograph showing a skin paddle with a fibular flap covering the soft-tissue defect.

Tendon Reconstruction
The treatment of tendon injuries depends on multiple factors, some of which are interdependent. These factors include the location of the injury; whether the injury is to the flexor system, the extensor system, or both the flexors and the extensors; the nature and severity of the associated injuries; and the effect of these other injuries on the rehabilitation plan.

There are considerable anatomical differences between the flexor system and the extensor system. The extensor system is anatomically much more complex than the flexor system. Distal to the metacarpophalangeal joint, the extensor mechanism is an extremely complex system that allows multiple muscles to delicately balance three joints (the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints), providing stability, strength, and motion. This complexity makes the extensor mechanism virtually impossible to reconstruct with current operative techniques. Nevertheless, dogma has it that almost all extensor repairs do well and that these repairs can be relegated to the most junior surgeon available. The actual results are not as uniformly excellent as this view holds³⁴; however, the limited excursion of the extensor system and the power of the flexor system can yield imperfect results that satisfy some patients.

Conceptually, the flexor system is a simple cable between muscle and bone. However, the large amount of excursion that is required makes any dense scar tissue potentially disabling. Smooth tendon-gliding is especially critical where the tolerances are very fine, as in zone II, thus making flexor tendon injuries difficult to treat. (The extensor tendons can have similar problems in zone VII, the extensor retinaculum.) In general, the more severe the injury of the tendon, the greater the importance of early motion. If there is a severe abrasion of the flexor tendon within zone II, early motion is critical to prevent dense scar tissue from forming throughout the sheath and virtually immobilizing the hand. This is even more critical when there are osseous injuries to the floor of the sheath as well.

Of all of the variables affecting the outcome of operative treatment of tendons, the level of the injury, the extent of the injury, and the associated injuries probably have the greatest influence. Although the specific repair for each tendon at each level is outside of the focus of this discussion, some generalizations can be made. The overall starting goal for tendon reconstruction is sturdy anatomical reconstruction with early motion. Tendon injuries necessitate early protected motion with dynamic splints. The more severe the injury, the greater the importance of early protected motion. Early motion is even more important after the treatment of flexor tendon injuries than it is after the treatment of extensor injuries.

Anatomical reconstruction of tendons is best accomplished with primary repair. If tendon substance has been lost, then a tendon graft can be used. Tendons from nonusable parts are the first choice if it is not more useful to preserve them for tendon transfers. If the tendon is going to be discarded anyway and a graft is needed, the tendon should be used. A tendon graft can also be obtained from standard sites for obtaining such grafts. The ipsilateral palmaris longus is the most commonly used donor tendon, although greater length is often needed and the ipsilateral palmaris longus may serve a more important use later as a tendon transfer. Other sources of grafts include the contralateral palmaris longus and the plantaris and long extensors of the toes. Usually, we leave the great-toe extensor because of its importance and only take the extensor digitorum longus from the toes that will extend through the extensor brevis—that is, the second, third, and fourth toes.

Tendon transfers, either primary or secondary, are another alternative. Despite our advocacy of primary reconstruction, tendon transfers should be done with caution in the period immediately after the injury. In general, we wait to reevaluate the patient until it becomes clearer what deficits will be present. Secondary tendon transfers can then be done.

In those rare cases in which early motion cannot be achieved because of other injuries, staged reconstruction with silicone tendon rods should be considered. This procedure is particularly beneficial in a patient who has a severe multiple-level injury involving the flexor tendons in zone II as well as other structures. In flexor tendon injuries in zone II, immobilized flexor tendons and sheaths fuse into one large scar mat. A late tenolysis would be of unlikely benefit and might harm other critical structures, such as nerves and arteries encased in the same scar.

Assuming that motion is possible, postoperative rehabilitation should include protection of the tendon repair with dynamic splinting to allow for motion but to minimize traction on the repair site. Splinting is more complex with combined extensor and flexor surface injuries. In patients with such injuries, the tendon repair that is the weakest and the one that would be most difficult to repair secondarily should receive the most protection. Usually, light extensor traction can be used, depending on the level of the injury.

Regardless of how the injury is treated, and even when the hand cannot be mobilized early, it is necessary to avoid the intrinsic minus position (extension of the metacarpophalangeal joints and flexion of the proximal and distal interphalangeal joints). This is particularly true if stiffness is inevitable, as it is following most severe injuries. The proximal interphalangeal joint has a propensity for flexion contracture, which, once fully developed, may be highly resistant to therapy. It is also preferable to maintain flexion of the metacarpophalangeal joints as extension contracture of these joints is often resistant to therapy.

Nerve Reconstruction
Of all of the facets of upper extremity reconstruction, nerve reconstruction is the most difficult. Although techniques for reconstruction of joints and tendons may be imperfect, excellent results are frequently achieved. In contrast, despite elegant research by many investigators, nerve reconstruction in adults virtually never restores preinjury function, even when the patient had a clean, sharp laceration, the most favorable of injuries. Severe traction injuries, with diffuse injury and a large nerve gap, have a much worse prognosis.

Wherever possible, nerve reconstruction is performed by simple neurorrhaphy (the nerve ends held together by 9-0 epineural sutures) if this can be done without excessive tension. In the special case of ulnar nerve injuries about the elbow, extra length can be gained by transposing the nerve. Short distances between nerves can be bridged by conduits, so-called artificial nerves such as inverted vein, silicone, and absorbable tubes.

The current standard option for the reconstruction of longer nerve gaps is with nerve grafts. Although vascularized nerve grafts can be used, there is no clear proof that they are superior. Nonvascularized grafts must be of relatively small diameter to allow for nutrition from the surrounding bed. Clearly, the surrounding bed must be capable of supplying that nutrition. Furthermore, removal of the nerve for the graft should leave a minimum deficit. Local sensory nerves such as the medial antebrachial cutaneous and lateral antebrachial cutaneous nerves can be used, especially if they have been lacerated proximally. The posterior interosseus nerve at the wrist can be removed with relative impunity, although the resulting graft is marginally sufficient to reconstruct a short segment of digital nerve. Sometimes, if use of a free flap such as the lateral arm flap is planned, sensory nerves that traverse the flap can be used as grafts. The sural nerve remains an excellent source for long fibers, and removal results in minimum disability.

Once again, the quality of débridement and the advantages of immediate reconstruction must be considered when deciding whether to perform an immediate reconstruction of nerves. If the wound is impeccable with a well vascularized bed, there is no deterrent to immediate nerve-grafting. If there is a slight concern about the bed, the decision of whether to graft may depend on the source of the nerve graft. For instance, the surgeon may not wish to consume a virtually irreplaceable resource, such as the sural nerve, and may choose to delay the reconstruction. However, unless the wound bed is bleak, it is not reasonable to throw away badly needed nerve graft from a nonsalvageable finger.

Soft-Tissue Coverage
The goals of soft-tissue management are to protect vulnerable structures such as vessels (particularly grafts), vessel anastomoses, nerves, and tendons that may desiccate. Furthermore, that protection or coverage should not add to the disability by limiting hand function. Thus, soft-tissue coverage should provide maximum comfort and not restrict the range or power of motion as some burn scars do. Ideally, soft-tissue coverage should be sensate (this is less important proximally than distally) and cosmetically acceptable to the patient.

Although it is difficult to achieve all of these goals, a pragmatic approach is to choose the procedure that will result in the lowest morbidity and provide reasonable coverage with viable skin under reasonable tension. The reconstructive ladder helps to organize the treatment options into simple closure, skin grafts, local flaps, regional flaps, pedicled flaps, and free flaps⁴⁰.

Simple closure is the obvious choice whenever it can reasonably be done. However, when there is a severe injury of the upper extremity without bone-shortening, primary closure is often impossible.

Skin grafts are the next-simplest type of coverage. Traditionally, skin grafts are either split-thickness or full-thickness, with thinner grafts having more contraction. Contraction can often be desirable, as it shrinks the wound and pulls normal sensate skin in around the graft. However, grafts that are much thinner than 0.008 inch (0.02 centimeter) are difficult to handle. Full-thickness grafts produce better-quality skin, but they have more difficulty surviving initially. They also produce a donor defect that requires closure. Thicker grafts are usually reserved for large defects of glabrous skin with an excellent bed.

Most grafts are meshed to prevent loss of the graft owing to the development of seromas. However, the graft can also be placed as a sheet graft with small holes, or so-called pie-crusting, for drainage of seromas, although pie-crusting is rarely as effective as meshing for drainage. Sheet grafts are considered more cosmetically pleasing, although some argue that the minor differences between an unstretched mesh graft and a sheet graft are unimportant in the upper extremity. It is universally agreed that a stretched mesh graft is cosmetically inferior to a sheet graft with equal take. This is particularly true as the mesh ratio increases beyond 1.5:1.

Since skin grafts require nutrition from the surrounding tissue, the underlying bed must be reasonably healthy. Skin grafts will not take over large areas of denuded bone or tendon. Skin grafts may bridge small (less than one-centimeter-wide) areas of denuded bone or tendon, but they do not always do so. In some cases, although the skin graft takes, coverage is suboptimum. Skin grafts provide limited protection. They can be used to cover vascular anastomoses, long vein grafts, and neurorrhaphy sites; however, they do not provide optimum coverage, especially if the plan is to excise the graft later. Even if a graft takes by bridging prominent hardware, this will not provide a permanent solution. A skin graft is a particularly poor choice for coverage if secondary reconstruction such as tendon reconstruction, tendon transfer, or tenolysis will be performed.

Use of a local flap is the logical next step if a skin graft cannot be employed. Local flaps include, among others, the V-Y¹, rotation, transposition, and cross-finger flaps; the flaps described by Moberg³², Foucher et al.^13-15, Büchler and Frey⁶, Venkataswami and Subramanian⁴⁴ (and Evans and Martin¹¹), and Quaba and Davison³⁷; and their variations. Although these flaps are very useful in the treatment of injuries of the fingers, most are too small to be used in the treatment of more extensive injuries of the upper extremity.

Regional flaps have a greater role in the treatment of severe injuries of the upper extremity. The reversed radial forearm flap is the most commonly used regional flap and has the advantages of being thin and pliable. The disadvantage is loss of one of the two major arteries to the hand. Clearly, the reversed radial forearm flap would be a poor choice in a patient who had destruction of the ulnar artery, injury of the palmar arch, or an incomplete arch as shown by the Allen test. We rarely use the radial artery flap because we want to avoid damaging the circulation in an already damaged extremity. However, the radial forearm flap is the first choice of some hand surgeons.

The ulnar artery flap is the mirror flap of the reversed radial artery flap. Because the ulnar artery is considered the dominant vessel, the ulnar artery flap is much less commonly used. All of the prohibitions against using the reversed radial forearm flap apply to the ulnar artery flap.

The posterior interosseous flap³⁰ is pedicled on a reversed posterior interosseous vascular bundle with perfusion from a distal anastomosis between the posterior and anterior interosseous arteries. The flap described by Becker and Gilbert³ is based on a distal ulnar artery perforator that is used to pivot distal forearm skin onto the hand. Both of these flaps have the advantage of sparing the radial and ulnar arteries. The radial artery and posterior interosseous flaps can also be used as free flaps.

Distant flaps, either pedicled or free, are used if none of the already described solutions is acceptable. The most frequently used pedicle flap is the groin flap, which is an axial pattern flap. However, random flaps from the abdomen or thorax can also be used. Because these flaps require two to three weeks for a new blood supply to develop from the skin into which they are inset, they have tended to be eclipsed by the use of free flaps. Certainly, there is a real potential for shoulder stiffness when pedicle flaps immobilize the extremity, particularly in an older patient who sustained even mild trauma to the shoulder at the time of the injury of the upper extremity. Other disadvantages of pedicled flaps include the obvious annoyance to the patient of having the hand attached to the body, the dependent position that the hand assumes, and the difficulty with performing therapy and allowing for early motion.

Nevertheless, pedicled flaps, either ipsilateral or contralateral to the injury, remain a very useful technique depending on the geography of the wound. The pedicled groin flap may be the initial choice for patients who have suboptimum vascular access in the extremity. The pedicled groin flap is an excellent fallback when free flaps have failed. Thus, the option of using the pedicled groin flap should be preserved, even when use of a free flap is planned. One condition under which the pedicled groin flap may be the preferred choice is when a toe-to-thumb transfer is planned at a later date. The pedicled groin flap does not consume vascular access, produces a good soft-tissue tube, and allows incisions to be made without having to compromise the incision to preserve the pedicle.

The list of possible free flaps for reconstruction of the upper extremity is long. However, from a practical standpoint, a few so-called standard flaps are used most of the time. These standard flaps vary from institution to institution and depend on local preference. In Louisville, the lateral arm, latissimus, and scapular flaps are mainly used, with the rectus, groin, and serratus flaps used less frequently³³. Each flap has specific advantages and disadvantages in terms of position of removal, size, thickness, pedicle length, and donor defect. We most commonly use the lateral arm flap (Figs. 4-A, 4-B, 4-C, 4-D, 4-E and 4-F). The site of removal can usually be closed if the width is less than six centimeters, and flaps of more than twenty centimeters in length can be obtained by extending the flap as much as ten centimeters distal to the lateral epicondyle.

View larger version (137K): [in this window] [in a new window]   Figs. 4-A through 4-F: A sixty-five-year-old patient who sustained a crush injury to the hand with soft-tissue injury and loss of the radial artery. Fig. 4-A: Photograph showing the injured hand.

View larger version (75K): [in this window] [in a new window]   Fig. 4-B Radiograph showing multiple metacarpal fractures.

View larger version (139K): [in this window] [in a new window]   Fig. 4-C Photograph showing the hand after débridement.

View larger version (95K): [in this window] [in a new window]   Fig. 4-D Radiograph made after internal fixation.

View larger version (69K): [in this window] [in a new window]   Fig. 4-E Photograph showing extension with a lateral arm flap covering the defect.

View larger version (77K): [in this window] [in a new window]   Fig. 4-F Photograph showing flexion with a lateral arm flap covering the defect.

	Immediate Reconstruction

Top Introduction Assessment Provisional Preoperative... Wound Excision Definitive Decision-Making Structural Repair Techniques Immediate Reconstruction Operative Imagination and... Rehabilitation Determinants of Outcome Pitfalls and Complications of... Overview References

 
Reconstruction can be performed in either a delayed or an immediate fashion. Traditional treatment consists of serial débridement and delayed reconstruction. Although this is a useful approach and is the fallback technique, immediate reconstruction combines débridement, reconstruction, and coverage into a single operation. One-stage treatment, particularly in its most extreme form (the emergency free flap), is strongly rejected by traditionalists, who think that there is no advantage but considerable additional morbidity to such an approach.

It is true that, from a logical standpoint, serial débridement should result in the greatest conservation of tissue. If only the absolutely dead tissue is removed, marginal tissue has the chance to recover and be saved. Serial débridement also allows time for quantitative results of cultures, although there is no proved advantage to these cultures⁵. Serial débridement leaves vital structures exposed, leading to desiccation of vulnerable tendons, nerves, and vessels. Surrounding these vulnerable structures with viable healthy tissue as soon as possible may contribute to the survival of marginal critical structures²⁹.

The perception of increased morbidity associated with immediate reconstruction is historically based on experience almost solely with the lower extremity. However, beliefs regarding treatment of the lower extremity, whether accurate or not, cannot be blindly transferred to the upper extremity. The upper extremity has entirely different functional requirements, in terms of power, motion, stability, and sensibility, than the lower extremity.

Traditional treatment also is steeped in wartime traditions. On the battlefield, where an unlimited number of casualties can be expected, it is not possible to commit all available resources to one patient. Le Maitre, who is responsible for the modern conception of excisional débridement, noted that thorough débridement could be done only between battles¹². The circumstances surrounding the injury also play a role. For example, in World War I, debilitated soldiers, lying wounded for many hours in the manure-impregnated battlefields of Flanders and then managed with inadequate débridement and tight closure of nonviable skin, invariably had severe wound infections. This experience from The Great War developed into a prohibition against immediate reconstruction and coverage.

Flying in the face of this prohibition is replantation. A replant is a devascularized open fracture with tendon, nerve, and arterial injury, yet the treatment is thorough débridement, osteosynthesis, tendon repair, revascularization, nerve repair, and closure. In reality, a replant is nothing more than a badly obtained contaminated composite free flap with a long duration of ischemia.

The perception of increased morbidity from immediate reconstruction is refuted by data from multiple reports showing that emergency free flaps can be done with a high success rate and low morbidity. Furthermore, immediate reconstruction reduces the number of operations, rehabilitation time, and overall cost⁴².

In the mid-1980s, Godina¹⁶ reported the results of free-flap procedures that had been done within seventy-two hours (usually within twenty-four hours) and compared them with the results of delayed reconstruction. He reported a failure after 0.7 percent (one) of 134 free-flap procedures done within seventy-two hours, 12.0 percent (twenty) of 167 done between seventy-two hours and three months, and 9.5 percent (twenty-two) of 231 done after more than three months. An infection developed after 1.5 percent (two) of the flap procedures done within seventy-two hours, 17.4 percent (twenty-nine) of those done between seventy-two hours and three months, and 6.1 percent (fourteen) of those done after more than three months. The number of operations and the duration of the hospital stay were dramatically reduced for the group that had the immediate flap procedure.

The initial results of emergency free-flap procedures performed in Louisville were reported in 1988²⁸. Thirty-one emergency free-flap procedures were done within twenty-four hours after the injury, and the only complications were two infections (6 percent) and one loss of a flap due to infection. Similar results have been obtained in China⁸ and Austria³⁶.

Since the published 1988 study, we have tracked the results of emergency free-flap procedures at our clinic. In a sample of ninety-five emergency free flaps, used in a group that included forty severe open fractures, eight flaps were reexplored for thrombosis and two were lost (a 98 percent rate of survival). The average duration of hospitalization was eleven days (range, four to fifty days), and an average of 1.7 procedures were performed. There were fourteen infections, although the definition of infection was not uniform. Seven of the infections followed the treatment of open fractures. There was no osteomyelitis and no limb loss from infection.

Despite these good results reported from multiple centers, immediate reconstruction in general and immediate free flaps in particular remain underused. Anecdotes of disastrous consequences of coverage of contaminated wounds are recounted as the reason to avoid emergency free flaps. However, many of the procedures described in these anecdotes were not performed with the precepts defined here; that is, they were done without thorough débridement and tension-free closure of healthy skin.

Our conviction is that most severe injuries benefit greatly from immediate reconstruction (Figs. 5-A, 5-B, 5-C, 5-D, 5-E and 5-F). Immediate reconstruction offers the best chance for the least residual functional deficit by allowing for early motion. Even for those who remain unconvinced by the evidence in favor of early motion, the low morbidity, decreased duration of hospitalization, and lower costs should be important considerations.

View larger version (136K): [in this window] [in a new window]   Figs. 5-A through 5-F: A twenty-one-year-old patient who fell asleep with the hand on a train track. Fig. 5-A: Photograph showing the injured hand.

View larger version (96K): [in this window] [in a new window]   Fig. 5-B Photograph made after débridement.

View larger version (90K): [in this window] [in a new window]   Fig. 5-C Photograph made after immediate coverage with a lateral arm flap.

View larger version (99K): [in this window] [in a new window]   Fig. 5-D Photograph showing the result of the procedure.

View larger version (52K): [in this window] [in a new window]   Fig. 5-E Photograph showing extension.

View larger version (63K): [in this window] [in a new window]   Fig. 5-F Photograph showing flexion.

In addition, the patient must be a good candidate for the procedure. Severe multiple injuries often preclude a single, long reconstruction of less vital structures because the risks associated with anticoagulation are high. Although free-flap procedures can be performed without anticoagulation, it is certainly helpful to have the option of anticoagulation in case problems with the free flap develop.

Immediate reconstruction is also a poor choice for certain types of wounds. Although almost all wounds can be debrided until they are clean, certain types of wounds, such as severe electrical burns and a large number of contaminated puncture wounds, sometimes cannot be adequately debrided. Immediate reconstruction also is not appropriate for infected wounds or for wounds for which amputation is the strongly preferred treatment.

	Operative Imagination and Innovation in Reconstruction

Top Introduction Assessment Provisional Preoperative... Wound Excision Definitive Decision-Making Structural Repair Techniques Immediate Reconstruction Operative Imagination and... Rehabilitation Determinants of Outcome Pitfalls and Complications of... Overview References

 
Much of the decision-making with regard to reconstruction can be organized into a systematic approach. The first step is to determine whether a single-stage or multistage débridement will be performed. Second, if an adequate single-stage débridement has been performed, the surgeon should evaluate what structures are present, what structures were lost, and what structures are needed. Third, the reconstructive approach must be chosen, a decision that is greatly aided by operative experience (either direct experience or that gathered from indirect sources such as mentors, texts, or the medical literature) and by knowledge of what kind of results can be expected from specific reconstructive procedures.

Although such a formal, organized approach is the key to obtaining the best possible results, the surgeon's imagination and innovation also are integral parts of decision-making with regard to reconstruction. The need for imagination and innovation is especially great when multiple structures are being reconstructed simultaneously or so that the use of material that would otherwise be discarded (from nonsalvageable digits, for example) can be maximized (Figs. 6-A, 6-B, 6-C, 6-D, 6-E, 6-F, 6-G and 6-H).

View larger version (130K): [in this window] [in a new window]   Figs. 6-A through 6-H: A thirty-year-old patient who was injured by a saw. Fig. 6-A: Photograph showing the injured hand. The index finger was amputated at the proximal interphalangeal joint; the amputated part was not replantable. The long finger was partially amputated with preservation of the ulnar digital artery and nerve.

View larger version (102K): [in this window] [in a new window]   Fig. 6-B Radiograph showing the injured hand.

View larger version (64K): [in this window] [in a new window]   Fig. 6-C Radiograph providing a close-up view of the proximal interphalangeal joint of the long finger, showing loss of the radial segment of the joint.

View larger version (201K): [in this window] [in a new window]   Fig. 6-D Photograph made after the distal interphalangeal joint from the amputated index finger was used as a nonvascularized osteochondral graft to reconstruct the proximal interphalangeal joint of the long finger.

View larger version (57K): [in this window] [in a new window]   Fig. 6-E Lateral and anteroposterior radiographs showing the completed reconstruction.

View larger version (45K): [in this window] [in a new window]   Fig. 6-F Lateral and anteroposterior radiographs showing the completed reconstruction.

View larger version (124K): [in this window] [in a new window]   Fig. 6-G Photographs showing excellent function after the reconstruction.

View larger version (117K): [in this window] [in a new window]   Fig. 6-H Photographs showing excellent function after the reconstruction.

View larger version (155K): [in this window] [in a new window]   Figs. 7-A through 7-E: A forty-one-year-old patient who sustained a punch-press injury to the hand. Fig. 7-A: Photograph showing the injured hand.

View larger version (88K): [in this window] [in a new window]   Fig. 7-B Radiograph showing the injured hand.

View larger version (122K): [in this window] [in a new window]   Fig. 7-C Photograph made after the operation. The intact distal part of the index ray was pollicized, and the soft-tissue defect was covered with a lateral arm flap.

View larger version (72K): [in this window] [in a new window]   Fg. 7-D Photograph showing extension.

View larger version (68K): [in this window] [in a new window]   Fig. 7-E Photograph showing flexion.

Although innovative thinking is currently of great value for reconstruction after mutilating injuries of the upper extremity, future clinical breakthroughs may greatly simplify reconstruction if transplantation can be done with an acceptable rate of morbidity.

	Rehabilitation

Top Introduction Assessment Provisional Preoperative... Wound Excision Definitive Decision-Making Structural Repair Techniques Immediate Reconstruction Operative Imagination and... Rehabilitation Determinants of Outcome Pitfalls and Complications of... Overview References

 
Decisions about rehabilitation are based on the extent of the injury, the stability of the osseous platform, and the structures that were repaired. Rehabilitation starts immediately in the operating room by the surgeon elevating the limb, placing the hand in the position of function, and optimizing the safe position of the hand. The principle is to do as much as possible as early as possible, but the motor-tendon units, joints, and fractures need to be monitored so that the fixation of these structures is not affected. Late reconstructive decisions, made months or even as long as a year after a mutilating injury, are based on the need for additional bone grafts, tendon transfers, tenolysis, provision of more stable coverage, neural grafts, and improving function. There is also a role for aesthetic aftercare with the use of tissue expanders and scar revisions that may be important to patients, particularly adolescent girls whose body image has been changed by a traumatic injury.

The extensive reconstruction that we described will surely fail unless it is matched by an efficient and structured rehabilitation program consisting of bracing, physical therapy, and occupational therapy. Each rehabilitation program must be individualized to the patient, the injury, and the reconstruction. The goal is early motion to ensure tendon-gliding and joint movement, which, in turn, reduces edema and subsequent stiffness.

For rehabilitation after combined palmar injuries, we use a modified version of the dynamic brace that was originally proposed by Kleinert et al.²⁶ and modified by Werntz et al.⁴⁵. If there is a distal ulnar-nerve lesion, however, this brace is contraindicated. In that situation, we consider a brace with a light extension assist and an active and assisted passive flexor protocol. For rehabilitation after combined dorsal lesions, we attempt to protect and to assist the extensor mechanism with an extension outrigger splint allowing for full active flexion. The extension outrigger can provide passive extension at the metacarpophalangeal or interphalangeal joint. When a patient has combined dorsal and palmar injuries, the extension outrigger is modified to provide both passive extension and early active flexion.

Early use of transcutaneous electrical nerve stimulation helps to prevent the onset of reflex sympathetic dystrophy in susceptible individuals. We also use external muscle stimulation before reinnervation of muscles and early strengthening programs to optimize the patient's return to work.

It is essential to note that patients do not block out severe trauma but remember the incident in great detail, returning to the moment of injury again and again in their minds. Patients grieve for missing parts and often suffer depression²⁴. Many patients even remember the anniversary of the injury, reliving the event and often amplifying it in their minds. These patients need psychological assistance to help them let go of the constant preoccupation with the injury experience.

	Determinants of Outcome

Top Introduction Assessment Provisional Preoperative... Wound Excision Definitive Decision-Making Structural Repair Techniques Immediate Reconstruction Operative Imagination and... Rehabilitation Determinants of Outcome Pitfalls and Complications of... Overview References

 
In our experience, the most important determinants of outcome have included the nature and severity of the injury, the reconstruction technique (with immediate reconstruction providing better results than multistage reconstruction⁴²), the rehabilitation technique, and the patient's compliance.

	Pitfalls and Complications of Treatment

Top Introduction Assessment Provisional Preoperative... Wound Excision Definitive Decision-Making Structural Repair Techniques Immediate Reconstruction Operative Imagination and... Rehabilitation Determinants of Outcome Pitfalls and Complications of... Overview References

 
The most important pitfall is improper assessment of the patient's general condition. Another important pitfall is poor judgment. A good treatment decision, such as a timely amputation, can quickly put a patient on the path to rehabilitation. However, it is easy to commit a patient to years of fruitless, frustrating, and expensive reconstruction. Inadequate wound excision is the major cause of complications such as deep infection leading to loss of a flap or to osteomyelitis.

Logistical support in terms of equipment and personnel, sophisticated training, and meticulous technique are important prerequisites for undertaking the reconstruction that we described. If these conditions cannot be met, such complex reconstruction should not be attempted. After stabilization, the patient should be transferred to a facility where the reconstruction can be carried out properly. Alternatively, the route of staged reconstruction could be chosen, albeit with the cost of lost function.

Adequate postoperative pain relief ensures the patient's cooperation with early mobilization programs. Moreover, pain relief reduces the likelihood of reflex sympathetic dystrophy developing. It is important to realize that poor rehabilitation affects the result of even the most brilliant reconstruction. The patient's compliance can be ensured with information, education, and compassion.

	Overview

Top Introduction Assessment Provisional Preoperative... Wound Excision Definitive Decision-Making Structural Repair Techniques Immediate Reconstruction Operative Imagination and... Rehabilitation Determinants of Outcome Pitfalls and Complications of... Overview References

 
It is crucial to stress that the treatment protocol that we described is inherently a team approach with the surgeon as the team leader. It is the responsibility of the reconstructive surgeon to use so-called orthoplastic techniques—that is, state-of-the-art techniques of orthopaedic and plastic surgery—for structural restoration. Similarly, it is the surgeon's responsibility to make sure that the whole process, from the initial assessment of the patient to the final rehabilitation, is handled smoothly and professionally. All of the treatment decisions that were discussed in this article must be included in the surgeon's analysis, not weeks after, but at the time of, the mutilating injury.

NOTE: The authors thank Stan Goldman, Ph.D., for editing the article.

	Footnotes

 
*Printed with permission of the American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 49, American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March 2000.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Christine M. Kleinert Institute, 225 Abraham Flexner Way, Suite 850, Louisville, Kentucky 40202.

Duke University Medical Center, P.O. Box 3945, Durham, North Carolina 27710.

	References

Top Introduction Assessment Provisional Preoperative... Wound Excision Definitive Decision-Making Structural Repair Techniques Immediate Reconstruction Operative Imagination and... Rehabilitation Determinants of Outcome Pitfalls and Complications of... Overview References

 

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