Innovative Techniques in Bony Reconstruction to Facilitate Hand Salvage

Abstract

Mutilating injuries of the hand and congenital hand anomalies can present challenging reconstructive scenarios for salvage and restoration of function. During a 5-year period from 1993 to 1997, the plastic and reconstructive surgical unit of East Carolina University Medical Center was presented with a series of unique reconstructive challenges as a result of complex hand injuries that resulted in unexpected opportunities for the salvage of distal components. These traumatic injuries were unique in that, although devastating to the hand, they left the opportunity for salvage of distal vascularized and sensate components of the hand. Other unique challenges arose as a result of patients who did not want to pursue alternative reconstructive options such as toe-to-hand transfers or pollicization. These cases are presented to emphasize alternative algorithms to standard hand reconstruction in complex scenarios. Three patients presented with distal viable (vascularized and sensate) phalangeal components with proximal complex bony defects, 1 patient presented with a complex thumb defect and declined standard therapy, and 1 patient presented with a congenital thumb anomaly and declined standard therapy. All flaps survived and all hands were saved. These patients illustrate the clinical feasibility of osteocutaneous and free osseous grafting to provide strut stabilization in metacarpal defects and to preserve an opposable post after thumb amputation or thumb anomaly.

The Reconstruction of the Mutilated Hand

“…93,94 The defect in the upper extremity may necessitate the use of skin and muscle (myocutaneous flap), skin and bone (osseocutaneous flap), skin with vascularized tendon, or a chimerism of tissue. [95][96][97][98][99] Myocutaneous flaps were more popular before the advent of perforator flaps to ensure viability of the overlying skin. 100 Skin paddles can accompany any of the muscle flaps if added volume is required.…”

Heterotopic Procedures in Mutilating Hand Injuries

“…21 In general, unless a wound is considered to be heavily contaminated, primary nonvascularized bone grafting could be well indicated to bridge small osseous gaps. 21 Nonvascularized bone grafts have already been used successfully in digital reconstructions, 30,31 and autografts from amputated phalanges have been suggested as valuable reconstructive tools for a selected group of patients. 32 In review of the literature, as regards nonvascular tissue transfers from nonreplantable digits or digital parts, besides bone and skin, also nerve, artery, and vein grafts have been used successfully in the same framework.…”