بسم الله الرحمن الرحیم

Management of the mangled hand چگونگی برخورد با دست له شده H.Saremi MDH.Saremi MD Orthopaedic hand&shoulder surgeonOrthopaedic hand&shoulder surgeon Hamedan University of medical sciencesHamedan University of medical sciences Hamedan,IRAN

Do you Really know the importance of Hands???Do you Really know the importance of Hands??? Look at the following pictures and Think againLook at the following pictures and Think again

الیه یصعد الکلم الطیب والعمل الصالح یرفعه

Management of the mangled hand Needs a multi-speciality team approachNeeds a multi-speciality team approach No two cases are alikeNo two cases are alike - No preferred approach - No preferred approach - A set of principles - A set of principles

History -When? - delay>6-12h precluding primary closure or coverage - delay>6-12h precluding primary closure or coverage-Where?-How?

History Health and co morbiditiesHealth and co morbidities Smoking or other vaso active drugsSmoking or other vaso active drugs Functional needs and goalsFunctional needs and goals

Examination Difficult in emergency departmentDifficult in emergency department Vascular statusVascular status SensibilitySensibility Muscle tendon unit functionMuscle tendon unit function RadiographyRadiography -standard -standard -additional views -additional views -amputated part -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 outcomeThe initial debridement is perhaps the single most important step that determines the functional outcome Performing it properly requires experience and judgmentPerforming it properly requires experience and judgment

Debridement Pasteur : It is the environment not the bacteria that determines whether a wound becomes infectedPasteur : It is the environment not the bacteria that determines whether a wound becomes infected

Debridement Conservativedebridement

Debridement Marginally viable tissuesMarginally viable tissues -further toxic insult of adjacent tissues -systemic complications -systemic complications

debridement Aggressive debridement of minimally vascularized tissue specially muscleAggressive debridement of minimally vascularized tissue specially muscle Two exceptionsTwo exceptions - revascularization - pure skin flaps critical for coverage of vital structures

Debridement TourniquetTourniquet Loupe magnificationLoupe magnification Bone fragmentsBone fragments - attached and potentially viable - non viable structural non structural

Debridement IrrigationIrrigation - pulse-lavage -bulb-syringe -mechanical debridement Release tourniquetRelease tourniquet Culture?Culture? Repeat debridement in 24-36hRepeat 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 TIME Initial operation At the very least within the first week

Fixation The only chance 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 Important decision Restore anatomic length or shorten the bones (bone,nerve,arteries,graft)

fixation 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 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 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 Carpal,metacarpal,phalangeal fx -focus to provide sufficientely stable fixation to allow early motion

fixation Metacarpal and phalanges Metacarpal and phalanges -Mini plate and screw fixation

Carpus Cannulated compression screw fixation - ligaments reattached with bone anchores

K wire Still has role Still has role -in reconstructing articular fragments and fx around a joint -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/ mm core diameter mm -0/ mm core diameter mm

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