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Frequently burns of the hand occur as part of a major thermal injury, but appropriate treatment of the hands has high priority, because even small burns of the hand may result in severely limited function and compromised aesthetic appearance. The functional importance of the hand cannot be overemphasized, because the patient's ability to perform useful work after recovery or the ability to care for themselves is to a great degree determined by residual hand function. This article describes the management of burn injuries involving the hand, stressing the importance of appropriate initial treatment. A comprehensive review of hand reconstruction and rehabilitation, to optimize form and function, is provided., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Improvements in critical care and burn victim resuscitation have led to increased survival of burned patients. Initial resuscitation, early excision of burned tissues, prevention of burn wound sepsis, and wound coverage remain mainstays of care. Many burn wounds require complex reconstruction. This is particularly important in the hand. Coverage of tendons, ligaments, joints, vessels, nerves, and bones of the hand requires healthy vascularized tissue to maintain viability and function. Local flaps or regional flaps may be within the burn zone of injury. Refined microvascular free tissue transfer techniques offer free tissue transfer as a procedure that can be safely performed., (Published by Elsevier Inc.)

Devastating hand and forearm injuries almost exclusively need free flap transfer if reconstruction is attempted. Early active and passive motion is only possible with aggressive, early, and comprehensive reconstruction. Despite recent advances in compound flaps, in selected cases it might be wise to harvest several smaller flaps and microsurgically combine them to one "chain-linked" flap "system." Four microsurgically fabricated chimeric free flaps were used in four patients for complex hand and forearm injuries. The combinations were sensate anterolateral thigh (ALT) flap plus sensate extended lateral arm flap (2x), ALT plus free fibula, and ALT plus functional musculocutaneous gracilis muscle. All flaps survived completely. Functional rehabilitation was possible immediately after flap transfer. There were no donor-site complications except two widened scars. The microsurgical fabrication of chimeric free flaps, as well established in head and neck reconstruction, can be successfully adapted to massive hand injuries as well. Individual placement of selected tissue components, early comprehensive reconstruction, and reduction of the number of operations are beneficial in cases that need more than one free flap., (© Thieme Medical Publishers.)

Background: Dermal substitutes are used increasingly in deep partial and full-thickness burn wounds in order to enhance elasticity and pliability. In particular, the dorsum of the hand is an area requiring extraordinary mobility for full range of motion. The aim of this comparative study was to evaluate intra-individual outcomes among patients with full-thickness burns of the dorsum of both hands. One hand was treated with split-thickness skin grafts (STSG) alone, and the other with the dermal substitute Matriderm(®) and split-thickness skin grafts., Material and Methods: In this study 36 burn wounds of the complete dorsum of both hands in 18 patients with severe burns (age 45.1±17.4 years, 43.8±11.8% TBSA) were treated with the simultaneous application of Matriderm(®), a bovine based collagen I, III, V and elastin-hydrolysate based dermal substitute, and split-thickness skin grafting (STSG) in the form of sheets on one hand, and STSG in the form of sheets alone on the other hand. The study was designed as a prospective comparative study. Using both objective and subjective assessments, data were collected at one week and 6 months after surgery. The following parameters were included: After one week all wounds were assessed for autograft survival. Skin quality was measured 6 months postoperatively using the Vancouver Burn Skin Score (VBSS). Range of motion was measured by Finger-Tip-Palmar-Crease-Distance (FPD) and Finger-Nail-Table-Distance (FNTD)., Results: Autograft survival was not altered by simultaneous application of the dermal matrix (p>0.05). The VBSS demonstrated a significant increase in skin quality in the group with dermal substitutes (p=0.02) compared to the control group with non-substituted wounds. Range of motion was significantly improved in the group treated with the dermal substitute (p=0.04)., Conclusion: From our results it can be concluded that simultaneous use of Matriderm(®) and STSG is safe and feasible, leading to significantly better results in respect to skin quality of the dorsum of the hand and range of motion of the fingers. Skin elasticity was significantly improved by the collagen/elastin dermal substitute in combination with sheet-autografts., (Copyright © 2010 Elsevier Ltd and ISBI. All rights reserved.)

Background: The purpose of this retrospective study was to verify the advantages and disadvantages of the free lateral arm flap for defect reconstruction of the forearm and hand., Patients and Methods: The data of 21 patients who underwent defect coverage of the forearm and hand with the free lateral arm flap between 2002 and 2010 were analyzed. The mean patient age was 48 years (range 17-78 years). The results concerning defect origin, flap size, pedicle length, operative time, revision of the anastomosis or other complications, donor site morbidity and length of hospital stay were evaluated., Results: In 6 cases the defect was on the forearm and in 15 on the hand. The majority of defects were infections or chronic wounds. The overage flap width ranged from 3 to 8 cm and the length from 5 to 20 cm. Revision of the anastomosis was only necessary in one case and flap survival rate was 100%. In all patients primary closure of the donor site was possible without complications during the healing procedure., Conclusion: The results underline the good reliability of the free lateral arm flap with a satisfactory aesthetic appearance excellent tissue quality and frequent primary donor site closure.

This study evaluated the effectiveness of a patient-oriented, hand rehabilitation programme compared to a standard programme regarding functional outcomes, return to work, patient satisfaction and costs. Patients were recruited in two consecutive cohorts. One cohort received the standard treatment programme (n = 75) and the other a programme based on principles of patient orientation (n = 75). Data were collected at the beginning and end of rehabilitation and 6 months after discharge. Clinical variables included range of motion, grip and pinch strength. Self-reported measures included pain, upper extremity functioning, health status, satisfaction and job situation. Analysis of variance for repeated measurements was used to calculate the main effects. The patient-oriented group showed more favourable results with respect to DASH scores (P <.05), pain (P <.001) and patient satisfaction (P <.0001). More patients returned to their former jobs and time off sick was reduced. We concluded that the patient-oriented approach was more effective and cost-saving.

Soft tissue defects in the hand with exposed tendons, bones, or joints present difficult reconstructive challenges. A wide variety of highly sophisticated intrinsic flaps offer a wide range of therapeutic options of locoregional soft tissue coverage to achieve acceptable aesthetic and functional results. This article gives an overview of the various groups of flaps, indication, and their use in clinical situations based on the experience with more than 100 flaps over a 4-year period.

Background: An efficient medical documentation is mandatory for a trauma-oriented department in the DRG environment. Besides the continuously increasing clinical/administrative demands, the additional documentation for quality assurance, clinical studies, and research requires additional efforts. Standard solutions are only partially effective. Especially in hand surgery there is a high demand for sophisticated clinical documentation, represented by a wide variety of classifications in diagnosis and therapy. The standard documentation tools lack accuracy. The development of a software tool that defines administrative/business processes and simultaneously generates clinical and administrative information was the goal of this project., Methods and Results: With a standard medical terminology, an innovative semantic network, and a completely new graphical user interface, it was possible to develop and introduce a software program specifically adjusted for hand surgery. This program facilitated for the first time a single-stage acquisition of clinically relevant scientific data and the simultaneous generation of DRG, quality assurance, and administrative data relevant for the hospital's revenues., Conclusions: The newly developed software tool is a step forward into a new dimension of medical software, obviating the need for multi/documentation and significantly improving the quality of clinically relevant medical data.

Background: Blast injuries of the hand represent a demanding surgical emergency for the reconstructive hand surgeon. Commercially available fireworks are often regarded as less dangerous compared to combat ammunition, but the following examples demonstrate their real potential for devastating hand injuries. Some of the closed injuries can represent a pitfall for correct assessment of trauma severity., Patients and Methods: Fifty patients who were seen after fireworks explosions from December 1995 until April 2005 were analyzed in respect to their patterns of injury and their subsequent surgical treatment. The severity was graded using the Hand Injury Severity Score (HISS). The majority of patients were injured during the New Year's day celebrations and presented with complex blast injuries due to commercially available, CE-certified fireworks., Results: Depending on the size of the explosives comparable patterns of injury were seen. Larger shells led to traumatic subtotal amputations of the exposed fifth finger ray and thenar ray. Complex destructions with multiple fractures and avulsions of the midhand were also present. Smaller explosives caused multiple lacerations in the palm of the hand, subcutaneous flexor tendon ruptures, and closed fingertip fractures., Discussion: Acute neurapraxias and neural compartment syndromes were clinically present. All patients (50) had to be operated primarily, and subsequent operations were necessary in 19 cases (number of operations 1-4, med. 1). In the HISS grading, 18 "minor" (HISS <20), 16 "moderate" (HISS 21-50), 7 "severe" (HISS 51-100), and 9 "major" (HISS >100) explosion injuries were present (range: 2-155, med. 47)., Conclusion: Blast injuries of the hand need a fast, strategically planned surgical approach. This is also true for presumably harmless, CE-certified fireworks. In a multiple patient scenario, triage based on surgical urgency may be necessary. A detailed clinical examination and surgical exploration is mandatory to avoid possible pitfalls like in closed injuries. Profound skills in reconstructive and microvascular hand surgery are essential to achieve an optimal clinical outcome.

Distally based DMCA flaps are an established procedure for soft tissue reconstruction in the hand. Since the introduction of the DMCA flaps, several variants have been developed to match specific defect requirements. The aim of this retrospective study is to give an overview of the experience with the DMCA flaps based on a single center's experience. 41 distally based DMCA flaps have been performed from 2000 to 2004. Twenty-nine times a distally based DMCA flap has been performed, nine times the extended distally based DMCA flap and three times a distally based DMCA fascial flap. In summary, 34 flaps showed no complications, five had a partial necrosis, but were successfully treated with split-thickness skin graft, and two flaps were lost due to infections. The distally based DMCA flaps II to IV have proven to be reliable flaps, but nevertheless require sufficient surgical experience. They are suitable for any kind of defects, including burn reconstruction. Defects of the entire finger can be covered by the various variants of the DMCA flaps.

Background: The purpose of this study was to evaluate the results of conservative and operative treatment for burn injuries in the palmar region of the hand. METHODS AND CLINICAL MATERIAL: One hundred ten patients from the severe burn center in Ludwigshafen, Germany were evaluated a mean of 28 months postoperatively. Sixty-one had been treated with split-thickness skin grafts (43 sheet and 18 mesh grafts). In addition to subjective evaluation (including pain assessment and aesthetic outcome rating by visual analog scale), objective outcome analysis included clinical tests, measurement of active range of motion and grip strength, and sensibility testing with the two-point discrimination and Semmes-Weinstein monofilament tests., Results: Of the patients, 90% were satisfied with the results, showing excellent pain relief with an average score under 13 on the visual analog scale. Aesthetic outcome was rated good with sheet grafts; in appearance, mesh grafts tended to be rated average or insufficient. Functional outcome tests demonstrated a significant correlation between depth of injury and range of motion. Grip strength analysis revealed superior results with sheet grafts. Sensibility in the injured areas was lower than on the contralateral hands. The Semmes-Weinstein test average was 3.4 degrees at the burned area vs 3.0 degrees in healthy hands, underscoring lower sensibility after burns., Conclusion: Surgical treatment of burned palms leads to good subjective and objective results, if specialized burn units are involved. Overall sheet transplantation seems to be the better choice for surgical reconstruction of the palmar burned hand.

Purpose: Coverage of exposed functional structures such as tendons, bones, vessels or nerves at the dorsal and palmar surface of the hand requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result. Free fascial flaps are possible alternatives to cutaneous, fasciocutaneous and muscle flaps. The purpose of this retrospective study was to evaluate the functional and aesthetic results after coverage of the hand with free serratus fascial flaps in our department., Method and Clinical Material: From 1994 to 2002, ten patients underwent free fascial flap coverage of the hand with eleven serratus fascial flaps. Six patients could be re-examined and answered a questionnaire about their satisfaction with the functional and aesthetic results. The mean follow-up was after 34 months., Results: Average active range of motion of the hand, functional improvement and the aesthetic result were satisfying in all follow-up patients. No secondary debulking or other contouring procedures were required., Conclusion: We recommend the use of free serratus fascial flaps as a valuable alternative to fasciocutaneous or muscle flaps since the functional results are excellent; no additional procedures were necessary and the aesthetical results are appealing.

Fillet flaps offer an additional reconstruction opportunity for complex hand defects after trauma, burns, tumors or infections. This retrospective study elucidates the concept of fillet flaps and presents the results of an overall of 34 plastic surgical reconstructions of the hands in 31 patients. Pedicled axial pattern flaps were used predominantly, except 2 cross finger flaps. In 10 cases the defects were localized in the dorsal and in 9 cases in the palmar aspect of the hand. 14 finger defects and one of the ulnar hand were covered. Very few complications occured. In only 2 cases partial flap loss was observed. An additional wound infection required revision in one case. Another case was left to secondary healing. Prior to any amputation, possible use of spare parts for defect reconstruction should be considered as a matter of principle. Our data suggest that the concept of fillet flaps is suitable for the reconstruction of complex defects of the hands without additional donor site morbidity.

Hands are most frequently involved in severe burns. The treatment of the burned hand is one of the most challenging problems in plastic surgery. The success of therapy is determined by the severity of the initial injury, the first aid provided, and the correct balance between mobilization, splinting and plastic surgery. In this respect, it is vital to have a highly qualified interdisciplinary team approach consisting of plastic surgeons, well-trained physical therapists, psychologists and a highly motivated patient.

Coverage of exposed functional structures such as tendons, bones, vessels, or nerves at the dorsal and palmar surface of the hand requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result. The purpose of this retrospective study was to evaluate the functional and aesthetic results after coverage of the hand with free fascial flaps. From 1994-2002, 14 patients underwent free fascial flap coverage of the hand with 4 tempo-parietal fascia flaps and 11 serratus fascia flaps. Eight patients could be reexamined and answered a questionnaire about their satisfaction with the functional and aesthetic results. The mean follow-up was 41.7 months. Average active range of motion of the hand, functional improvement, and the aesthetic result were satisfying in all follow-up patients. No secondary debulking or other contouring procedures were required. We recommend the use of free fascial flaps as a valuable alternative to fasciocutaneous or muscle flaps, since the functional results are excellent, no additional procedures were necessary, and the aesthetic results are appealing.

This retrospective study evaluates a dynamic active motion protocol for extensor tendon repairs in zones V to VII. Fifty-eight patients with 87 extensor tendon injuries were examined. Using Geldmacher's and Kleinert and Verdan's evaluation systems, the results were graded as "excellent" and "good" in more than 94%, and as "satisfactory" in the remainder. The need for secondary tenolysis was low (6%), and no other surgical complication occurred.

Plastic surgical therapy of mutilating hand injuries represents a multifaceted task to the hand surgeon, where considerations about indication, timing, and structure of the soft tissue coverage play a major role in reconstruction. The concept of early primary reconstruction (including emergency procedures) and fast rehabilitation not only demands thoughtful tissue preparation but also mastering of a bandwidth of plastic surgical techniques. Systematic algorithms based on the reconstructive ladder help in decision making in the complexity of soft tissue coverage but have to be adjusted to the individual case profile. General considerations and strategic planning are explained and illustrated by three clinical cases.

Metacarpal fractures are frequently immobilized for several weeks in forearm plaster cast, even after operative stabilisation. The purpose of this study was to assess the results after early functional treatment using metacarpal braces. 87 patients with 105 metacarpal fractures were included in a prospective study from February 1997 until November 2000. The AO-classification of the fractures was assessed for all patients: n=33 A1,n=9 A2,n=3 A3, n=27 B1,n=6 B2,n=7 B3,n=10 C1,n=7 C2, n=3 C3.Exclusion criteria were tendon or nerve injuries,pathological fractures (tumor or metabolic),additional digital fractures of the same ray,and a patients age of less then 18 years. All fractures were treated operatively. 73 patients (84%) were recruited for follow up after an average period of nine months. Average grip strength reached 96% (Jamar II) for the power grip, 97% for the three finger and 98% for the pinch grip compared to the contra-lateral side in the group where the dominant hand was affected. It was 88% for the power grip, 91% for the three finger grip and 94% for the pinch grip after injury of the non-dominant hand. The mean postoperative pain score on the visual analog scale was 0.2 for resting conditions, 0.8 for motion and 2.2 under stress.A decreased total range of motion was observed in 15 of 73 patients (21%). The average DASH score reached 6.5 points. Physical therapy was required for an average of 6.7 weeks. Only 41% of the patients with early functional treatment required further physical therapy after removal of the brace. The metacarpal brace used in this series protects from direct trauma,and provides a high patients comfort.It has no disadvantages considering fracture retention compared to conventional plaster casts or splints. The need for physical therapy is reduced after functional fracture bracing.Thus, the metacarpal brace has proven to be a suitable tool for early functional treatment after operative stabilisation of metacarpal fractures.

The hypothenar hammer syndrome (HHS) is a rare form of secondary Raynaud's phenomenon in workers who frequently use the ulnar side of the palm as a hammer. Clinically the patient with HHS shows neurologic symptoms such as paresthesia, numbness and pain and signs of vascular insufficiency such as coldness, pallor, discoloration and blanching of the affected ulnar sided fingers. The diagnosis is verified by angiography, showing thrombosis or aneurysm of the distal ulnar artery. We report on the treatment and outcome of 5 patients with HHS. All patients were painfree after treatment. But with the ongoing working habit of using the hand as a hammer there is always the risk of a recurrence. Therefore the job environment has to be changed considerably and the most effort should go into prevention and prophylaxis. If the change of the working habit is not possible, the job is clearly at stake.

Background: Complex defects of the forearm and hand are associated with the loss of important structures. Single-stage reconstruction of these defects requires composite tissue transplantations. The subscapular region offers various components for the coverage of complex defects. The scapular and the parascapular flaps can be used each as cutaneous, fasciocutaneous and osteocutaneous or as a combined flap as well. The purpose of this study was to present our experience with the combined scapular-parascapular free flap for defect coverage of the forearm and hand in 13 patients., Patients and Method: Evaluation of 12 patients who underwent coverage of forearm and hand defects with the combined scapular-parascapular free flap during a five-year period. Other treatment options are discussed., Results: Average age of the patients was 39 years, there were ten male and two female patients. Average follow-up was 20 months. Eleven patients suffered from massive trauma, one patient from severe infection of the forearm and hand. The defect size varied from 12 x 8 cm to 45 x 20 cm. In nine cases, a cutaneous and/or fasciocutaneous scapular-parascapular flap was used, two patients underwent defect coverage with an osteocutaneous scapular-parascapular flap, and in one patient, a "four-flap-mega-flap" was transplanted. One flap developed a partial necrosis. Eight patients developed a good or very good functional outcome with their hand and forearm, two patients have a moderate degree of disability. Two patients can use their hand as a supporting hand., Conclusion: This study demonstrates that the combined scapular-parascapular free flap is a reliable treatment choice for early coverage of defects of the forearm and hand. The advantages are the long, large and consistent vascular pedicle, the possibility of combination with other flaps and "custom-tailoring", including whatever component is necessary to close the particular defect.

Hands are involved in over 70% of all serious burns. This study comprised 80 hands in 41 patients with burns of the dorsum of the hand. Eighty percent of the hands in our study had deep partial-thickness and full-thickness burns that had to be grafted. This study was performed to evaluate the patency of the dorsal metacarpal artery (DMCA) system in burn-injured hands. Sixteen hands healed spontaneously; 62 had to be excised and grafted. Doppler mapping of the dorsum of the hand was completed using an 8-MHz probe. Patent vessels were found in a pattern similar to that of a normal population in spontaneously healed and grafted partial-thickness burns. The incidence of dorsal arteries decreased from 100% for the first DMCA to 80% for the DMCA in the fourth web space. In full-thickness burns the correlation of burned hands to normal volunteers was only 80%. It can be concluded from the data that the DMCA system is not damaged by deep partial-thickness burns that are excised and grafted. The DMCA system is still intact in 80% of patients with full-thickness burns. The potential for elevating a DMCA flap is therefore preserved after burn excision and grafting. Preoperative Doppler examinations are recommended before planning the flaps.

There are no clear definitions of serious or complex hand injuries in the literature. Multistructural injuries involving a vital risk to the affected part of the body part are usually classified as complex. The quality of the reconstruction, based on sound management principles, determines the aesthetic and functional outcome for the patient. The strategies basically consist of: Careful radical dbridement, thorough analysis of the defect and evaluation of lost functions, injury classification, Patient oriented reconstructive procedures, careful and realistic explanation of perspectives and risks to the patient. Following these principles will most likely achieve the planned objectives of treatment, such as, best possible restoration of form and function, cost-effective therapy, and early professional and social reintegration. Algorithmic approaches are an important aid in the clinical approach to these kinds of problems, making it possible to reach clear reproducible decisions that are amenable to standardization. Despite all individual decisions necessary to achieve optimal care, this standard theoretical framework will be able to improve the quality of care.

Chronic exercise-induced compartment syndrome of the first dorsal interosseous muscle of the hand is a rare condition. The presented complaint is a dull muscle pain which can be increased by hyperextension of the index metacarpo-phalangeal joint and by repetitive key grip. Two patients complaining of these symptoms could successfully be treated by simple fasciotomy of the first dorsal interosseous compartment.

Two new indications for the use of the first dorsal metacarpal artery (1st DMA) in reconstruction following severe hand injury are reported. In the first case, a primary pollicization of the index finger was based solely on the dorsal arterial network. The second case involves a microvascular arterial revascularisation of a 1st dorsal metacarpal artery island flap. Neither procedure has previously been described.

A study was carried out involving 167 patients who had received primary treatment in alio loco for injuries diagnosed as 'minor cuts, twists and sprain', and who were then seen in the out-patient department at a later date. The patient group was analyzed with regard to the following: a more precise identification of the initial injury, the initiated treatment regimen and more particularly, the socio-economic consequences of the injury. Duration of treatment programmes, loss of working days and compensatory payments were cost-analyzed. The results showed that a delayed primary surgical intervention was possible in only 17% of cases, it was necessary to alter the treatment regimen in 29% and in 28% it was no longer realistic even to initiate treatment. Comparisons between this population and a group of a patients who had received adequate primary care showed that in the study group length of treatment and days lost at work was prolonged by the factor 1.3; furthermore the number of cases in which the reduction of working ability was 20% and more was increased by 2.7. Increased costs incurred by financial compensations were approx. DM 27,000/patient.