‫بسم هللا الرحمن الرحیم‬
Management of the mangled
hand
‫چگونگی برخورد با دست له شده‬
• H.Saremi MD
• Orthopaedic hand&shoulder surgeon
• Hamedan University of medical sciences
Hamedan,IRAN
• Do you Really know the
importance of Hands???
• Look at the following
pictures and Think again
‫الیه یصعد الکلم الطیب‬
‫والعمل الصالح یرفعه‬
Management of the mangled hand
• Needs a multi-speciality team approach
• No two cases are alike
- No preferred approach
- A set of principles
History
-When?
- delay>6-12h precluding primary closure or
coverage
-Where?
-How?
History
• Health and co morbidities
• Smoking or other vaso active drugs
• Functional needs and goals
Examination
•
•
•
•
•
Difficult in emergency department
Vascular status
Sensibility
Muscle tendon unit function
Radiography
-standard
-additional views
-amputated part
Evolution in the treatment
• Primary method : Amputation
• 1950s : Minimal debridement and preserving
length (antibiotics-anesthesia)
• 1970s Delayed closure to reduce infection
• 1980s Thorough debridement,early ORIF,early
vascularized soft tissue coverage
Recomended approach to treatment
• Emergent treatment
• Operative treatment
-Debridement/wound excision
-Skeletal/joint reconstruction
-Soft tissue reconstruction
Emergent treatment
-evaluate and treat other life threatening injuries
-control hemorrhage by direct pressure.dont
blindly clamp
-reduce
gross skeletal deformity
-administer tetanus prophylaxis and antibiotics
-if a major limb is ischemic,place temporary
vascular shunt
-cool devascularized tissue,,leave skin bridges
intact
Debridement
• The initial debridement is perhaps the single
most important step that determines the
functional outcome
• Performing it properly requires experience and
judgment
Debridement
• Pasteur : It is the environment not the bacteria
that determines whether a wound becomes
infected
Debridement
Conservative
debridement
Debridement
• Marginally viable tissues
-further toxic insult of adjacent tissues
-systemic complications
debridement
• Aggressive debridement of minimally
vascularized tissue specially muscle
• Two exceptions
- revascularization
- pure skin flaps critical for coverage of
vital structures
Debridement
• Tourniquet
• Loupe magnification
• Bone fragments
- attached and potentially viable
- non viable
structural
non structural
Debridement
• Irrigation
- pulse-lavage
-bulb-syringe
-mechanical debridement
• Release tourniquet
• Culture?
• Repeat debridement in 24-36h
- heavily contaminated
- critical areas viability not certain
Debridemrnt
Decisions must be made
(replantation , amputation , partial amputation ,
reconstrucition)
- Save “spare parts” for later use in primary
reconstruction
Skeletal/Joint Reconstruction
GOAL
Restore
- length
- alignment
- stability
- anatomically smooth and stable
articulation
Skeletal/Joint Reconstruction
TIME
Initial operation
At the very least within the
first week
Fixation
The only chance
Adequate stable fixation to allow early motion is
the only chance to overcome the inevitable scar
formation
Fixation
When?
With the exception of severe contamination
,fixation is best performed at the initial
operation (excellent vascularity in compare to
lower extremity)
Fixation
Approach for fixation
-open injury----------------wound often dictate the
approach
-intra operative x ray control even with good
exposure
Fixation
Important decision
Restore anatomic length --------or---------shorten the bones
(bone,nerve,arteries,graft)
fixation
-1---1.5 cm shortening in phalanges and
metacarpals
-up to 4 cm in the forearm
Without significant loss of function
Fixation
Intra articular fractures
-reconstructable----------or---------primary or secondary fusion?
Intra articular fractures
Reconstruction
-50% to75% of the articular surface
remains
-depressed articular fragments should be elevated
- if fragments are large SCREWS provide
excellent skeletal fixation
-minicondilar plates are very useful
Intra articular fractures
Test the stability of the joint
-ligament repair or reconstruction ,preferably with
adjacent tissues
-some times “spare parts “ tendon or Palmaris
langus graft
-trans articular k wire
fixation
Shaft of radius and/or ulna fx
Best treated with 3.5 dcp plates
fixation
Distal ulna or ulnar styloid fx
-K wire and tension band wire
reconstruction
Distal radius fx
-anatomic reconstruction of the articular
surface
-dorsal or volar buttress plate
-When metaphysical comminution or
multiple carpal fx/dx,risk of shortening
over time is great-------- external or internal
spanning fixation
Distal radius fx
Internal spanning fixation
-2.4 mm mandibular reconstruction plate
-tunnel between 2th and4thdorsal compartment
-locking screws
-left for 3-4 months
-rigid splint is required
-provides stability and maintains length, better
than an external fixator
fixation
Carpal,metacarpal,phalangeal fx
-focus to provide sufficientely stable fixation to
allow early motion
fixation
Metacarpal and phalanges
-Mini plate and screw fixation
Carpus
Cannulated compression screw fixation
-ligaments reattached with bone anchores
K wire
Still has role
-in reconstructing articular
fx around a joint
fragments and
-if remains beyond 4w cut them below the skin
K wire
Even crossed is unable to rotational or
horizontal stability unless numerous
-is internal splint rather than rigid fixation
K wire
As provisional fixation drill for screw
exchange
-0/045-----------1.1mm-----------core
diameter--------1.5mm
-0/062-----------1.5mm----------core diameter---------2mm
External fixation
-if not possible to achieve rigid internal
fixation(comminution or internal fx anatomy)
-maintaining the first web space to prevent
adduction contraction
Bone defect
Because of good vascularity, primary bone
graft unless:
-significant contamination
-poor soft tissue coverage
-compromised adjacent tissue vascularity
Bone defect
If wound or coverage unsuitable for primary bone
graft,
-antibiotic impregnated PMM beads or spacers
-after wound stabilization and maturation,the
spacers are replaced with bone graft