Severe Hand Injuries

Hand injuries are commonly seen in the Emergency Department. These injuries range from simple lacerations to complex wounds involving multiple structures such as skin, tendons, nerves, and bone. In severely injured hand cases, digits or even the entire hand may be incompletely or completely amputated or badly crushed to the point where replantation or revascularization isn’t even feasible.

When these patients initially present, their care may be relegated to a physician inexperienced in the care of the severely injured hand, especially the more complex ones. Even when the initial care is provided by an experienced hand surgeon, there are often sequela and complications that can only be appropriately addressed by the most experienced of hand surgeons.

Often, secondary reconstruction is mandatory in order to achieve a functional hand. The hand surgeon may need to perform tenolyses or breaking up of the dense scar adhesions between the tendon. This can involve the flexor or extensor tendons or both. Occasionally, the scarring is so severe that the tendons cannot adequately be lysed to provide useful motion and a staged flexor tendon reconstruction needs to be performed. Dr. Norman Weinzweig frequently performs the two-stage procedure for these cases. In the first stage, all densely scarred tendon is completely excised and a silastic Hunter rod is placed. Pulleys can be reconstructed at this time around the silastic rod. During this time, the patient undergoes occupation therapy to maintain excellent passive range of motion. At 3 months, the rod is removed and a tendon graft is threaded through the newly formed tendon sheath. The new tendon sheath forms as a reaction to the rod, which acts as a foreign body. The donor tendon can be the palmaris longus or other tendon. Patient then undergoes a specific protocol to facilitate passive, and later, active range of motion.

If there is sufficient stiffness prior to the tendon grafting, this must first be addressed to maximize passive range of motion. This may entail joint capsulotomies or capsulectomies for arthrofibrosis of the respective joints. Occasionally, tendon transfers are performed where tendons have been injured or even destroyed.

In many cases, there has been severe injury to the nerves. This can result in permanent loss of sensation or motor function. Usually, there is little sensory recovery in adults following nerve injuries and limited recovery of motor function. For example, following laceration of a digital nerve in an adult, there is rarely, if ever, recovery of sensation beyond protective sensation. In some case, simple neurolysis of the nerve will dramatically improve motor or sensory function. This happens when the nerve is intact but scar tissue envelopes the nerve. In more sever cases of injury to major peripheral nerves, such as the median, or ulnar nerves, tendon transfers must be performed to restore useful function.

A severely injured  or mutilated hand may require a number of surgical procedures to restore useful function. This may entail procedures such as thumb reconstruction or even great toe or second toe-to-thumb transfers. In cases of extensive soft tissue loss or scarring, various soft tissue procedure smay need to be performed. These procedures include contracture releases, such as by four-flap Z-plasty, full-thickness skin grafting or even local and distant flap reconstruction, tenolyses or tendon reconstruction, neurolyses, tendon transfers, and bony reconstruction.

At The Chicago Institute for Hand Surgery & Rehabilitation, Dr. Weinzweig and his staff regularly evaluate and treat the entire gamut of hand surgery patients. Furthermore, Dr. Weinzweig’s specialty within the field of hand surgery is the care of complex hand injuries entailing knowledge and use of all these procedure to obtain the optimal functional outcome. Dr. Norman Weinzweig co-edited the textbook entitled THE MUTILATED HAND which specifically addresses these complex issues.

Fireworks injuries of the hand commonly occur not only on July 4^th but throughout the year. These injuries range from soft tissue injuries often with loss of skin and subcutaneous tissue to disruption of the flexor and extensor tendons to fractures with or without bone loss to mutilating injuries of the hand with need for possible revascularization or replantation. In the more severe cases, replantation and revascularization are not even feasible due to tremendous destruction to the soft tissues and bone with amputation being the only option.

As with other injuries, prevention is key. Safety in the use of fireworks is of the upmost importance. Even among fireworks professionals, these injuries occur.

In dealing with fireworks injuries, it is important to assess the extent of damage to the body in addition to the hand. While the hands are most frequently involved by the very nature of the injury mechanism, other parts of the body such as the face, torso and legs may be involved. Some of these injuries resemble burns and may be treated as such.

After the accident, the hand surgeon carefully evaluates the injured hand and proceeds to salvage as much viable tissue as possible. It is important to consider not only the injury but the different steps in future reconstruction and the rehabilitative process. In the more severe and extensive injuries, patients often require multiple staged procedures in hope of regaining as much useful function as possible. Often, the patient is stabilized in the Emergency Department and surgery is performed to salvage as much soft tissue and bone as possible. At this time, it is critical that the patient seek out a hand surgeon experienced in dealing with these complex injuries. Few hand surgeons have this type of experience.

An occupational therapist has several modalities to work with the patient having a painful fingertip. The hand surgeon also has various options to restore useful function to the injured finger. While seemingly minor, compared to more extensive injuries involving multiple structures, they still require appropriate care from an experienced hand surgeon.

At The Chicago Institute for Hand Surgery & Rehabilitation, Dr. Norman Weinzweig has treated hundreds of similar injuries with excellent clinical and aesthetic results, allowing patients to get back to the workplace or to their recreational activities as soon as possible.

Interestingly, classification of mutilating injuries of the hand can be as simple as Tic-Tac-Toe. In fact, more than a decade ago, Drs. Norman and Jeffrey Weinzweig designed a classification scheme to simplify the description of these complex injuries, allowing a more direct approach to communicating the nature of these injuries from one surgeon to another. This classification is based upon the pattern of involvement of the bones, involvement of soft tissue, bones or both, and vascular integrity.

However, while this classification scheme facilitates the description of the injury, management is far more complex, both in acute and chronic settings. Initially, the goal is to maximize the survivability of the digits. These can be tedious and lengthy operative procedures requiring microsurgical expertise. Often, 6 or 8 sutures are placed around the circumference of a vessel no larger than the tip of a pencil or less than 1mm in diameter. Surgical precision and flawless technique is mandatory to maximize the probability of survival of the digit. Frequently, intraoperative decisions have to be made to optimally utilize the viable tissues. Fractures are reduced and fixed, tendons and nerves are repaired and hopefully, blood perfusion is restored. This is the “opening game”, as in chess. Dr. Norman Weinzweig has extensive experience in the management of these injuries throughout his career.

Following successful replantation or revascularization, the “middle game” begins. This consists of careful monitoring of the digit, various procedures to restore early function and satisfactory appearance and occupational therapy to optimize function of the surviving digit. A normal appearing digit without useful function fails to achieve the maximal benefit of the surgery. Often, there are setbacks in the “middle game” and while there may be a normal appearing digit, it may be stiff, painful and unable to function appropriately.

This brings us to the “end game”, where the hand surgeon’s experience is often limited. At The Chicago Institute for Hand Surgery, Dr. Weinzweig has patients referred to him from all over the country, These patients have limited function and require surgery, intense occupational therapy, the Continuous Passive Motion Machine and gentle intraoperative manipulations of the joints under anesthesia to optimize the long-term functional outcome. The occupational therapists at The Chicago Institute for Hand Surgery are uniquely trained to care for these patients. Furthermore, close supervision under Dr. Norman Weinzweig optimizes the eventual functional outcome.