25. September 2015 · Comments Off on Secondary Reconstruction of the Severely Injured Hand · Categories: 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.

 

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