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A few severe hand injuries represent a gray zone for the reconstructive surgeon, for which autologous tissue transfer and allotransplantation can yield satisfactory results, but not without downsides or morbidity.This article is written to address the dilemma of application of both techniques in those selected cases., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The metacarpal-like and metacarpal hand injuries are devastating conditions that render the hand nonfunctional. Although the metacarpal hand is well-studied, the metacarpal-like hand is never addressed. The authors, using the same principles as in the classification and treatment of metacarpal hand, propose an easy to follow treatment algorithm for metacarpal-like hand injury to guide the reconstructive surgeon. For both injuries, microsurgical toe-to-hand transplantation can restore an acceptable level of function if done properly. Meticulous planning is essential for the toe-to-hand surgery to achieve its prime goal of stable tripod pinch with insignificant morbidity at the donor sites., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Degloving and mutilation of the hand is a rare but formidable challenge. When replantation is not possible, we rely on distant pedicled flaps. We present a technique using pedicled anterolateral thigh (ALT) and groin flaps to sandwich and resurface the degloved hand. The purpose of this study is to describe the rationale, indications, methods and outcomes of combined pedicled ALT and groin flap reconstruction of the degloved hand., Methods: Five injuries were treated at this center between 2011 and 2014. Charts were retrospectively reviewed and outcomes evaluated. Four ALT-groin flaps were performed in a single stage for degloving, crush and combined injuries. In one case, partial necrosis of a tight groin flap necessitated secondary ALT coverage at a second stage., Results: Flaps survived after division at 4 weeks, and venous congestion was not observed at any point. Debulking, syndactyly release and toe transfer followed reconstruction to enhance outcomes., Conclusions: The combined ALT-groin flap is safe and feasible for the reconstruction of the degloved or mutilated hand when replantation is not an option. It is attractive for familiar donor anatomy, donor-site morbidity and the quantity and composition of the tissue it provides., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Return to work is an important outcome following traumatic work-related hand injuries. It is unclear how psychosocial factors affect the time to return to work following traumatic work-related hand injury., Aims: To investigate the relationships between hand injury severity, self-perceived health, demographics and time off work (TOW) following traumatic work-related hand injuries and the influence of psychosocial factors on the readiness of return to work., Methods: Data from 120 traumatic work-related hand injured patients were gathered. The Modified Hand Injury Severity Score (MHISS) and Short Form Health Survey (SF-36) were used to assess the severity of hand trauma and self-perceived health, respectively. The relationships between MHISS, SF-36, demographics and TOW were analysed by multiple regression analysis., Results: Mean duration of TOW was 127 days for patients with a mild MHISS, 108 days for a moderate score, 160 days for a severe score and 236 days for those with a major score. A positive correlation between MHISS and duration of TOW was identified. Self-perceived physical functioning was found to have a negative correlation with TOW, whereas self-perceived mental health was positively correlated with TOW., Conclusions: This study highlights the importance of self-perceived health in considering return to work following traumatic work-related hand injury.

Background: The challenge of modern hand reconstruction goes beyond simple coverage. Thanks to the advances of microsurgery, there are ever-improving standards of functional and esthetic outcomes in hand reconstruction. The versatile donor site of the medial sural artery perforator flap can fulfill this purpose., Materials: Between June 2006 and October 2008, we used free medial sural artery perforator flaps for hand reconstruction in 14 cases. The sites of reconstruction included digits (n=7), dorsal hand (n=3), palmar hand (n=2), and wrist (n=2). Associated tendon and nerve defects were found in five patients. The plantaris tendon (n=4), split Achilles tendon (n=1), saphenous nerve (n=1), and sural nerve (n=1) were harvested for reconstructive purpose from the same donor site in this series., Results: The proximal perforator of the medial sural artery emerged 8 cm to 13 cm from the midpoint of the popliteal crease, correlating with the axis of the medial sural artery. Twelve flaps were raised with a single perforator. One flap failed because of perioperative vasospasm. The donor defect could be closed without skin grafts when the flap width was <6 cm., Conclusion: The free medial sural artery perforator flap transfer is appropriate for small- to medium-sized hand defect reconstruction. The donor site not only supplies a thin fasciocutaneous flap but also provides the option to harvest a segment of tendon or nerve graft through the same incision for composite tissue reconstruction in a single stage., (Copyright © 2011 by Lippincott Williams & Wilkins)

Background: Arterialized venous flaps can be useful for hand/digit reconstruction, providing very thin skin coverage. However, their popularity has been limited by concerns over poor peripheral perfusion and severe congestion, which may be to be due to unrestricted arteriovenous shunting and pressurization of the efferent vein. To mitigate these problems, we design our flaps to restrict shunting. This report describes our clinical experience with these techniques., Methods: A consecutive series of 15 flaps was reviewed. All flaps were transferred with antegrade flow. Shunt restriction was achieved in one of the following ways, according to the flap's venous pattern: (1) two parallel veins (II-pattern): use of separate veins for inflow and outflow; (2) two parallel veins with connecting branch (H-pattern): as for II-pattern, with ligation of connecting branch; (3) branching vein (Y/lambda-pattern): ligation of one branch near bifurcation, with use of that branch for outflow and other segment for inflow (or vice versa); and (4) one continuous vein (I-pattern): ligation at midpoint. Laser Doppler flowmetry was used to compare flap perfusion with and without shunt restriction in two patients., Results: All flaps survived entirely. Color, turgor, temperature, and capillary refill mimicked conventional arterial flaps, facilitating postoperative monitoring. Six flaps demonstrated mild-to-moderate venous congestion at the afferent end, with some developing epidermolysis but no full-thickness loss. Intraoperative flowmetry showed enhanced perfusion in the flap's periphery when shunting was restricted., Conclusions: Restriction of arteriovenous shunting enhances peripheral perfusion and decreases congestion of venous flaps, thereby improving reliability and utility for hand/digit reconstruction.

Background: Toe-to-hand transfer is an accepted procedure for reconstruction of thumbs and fingers. Although the vascular anatomy of the toe has been well studied, its symmetry on both feet has not previously been reported., Methods: A retrospective review of 85 cases of simultaneous bilateral toe-to-hand transfers, performed between 1984 and 2002, was carried out. All of the pedicles were dissected in a retrograde fashion., Results: A symmetric vascular pedicle anatomy was found in 78.8 percent of the patients, whereas 21.2 percent of the patients had an asymmetric vascular pattern., Conclusions: This result cautions surgeons about the possibility of vascular pedicle asymmetry between two feet in bilateral toe harvest. It proves once more the advantage of a retrograde pedicle dissection technique, which allows for a safe and straightforward toe harvest regardless of the vascular pedicle course variations.

The medialis pedis flap (MPF) has been used for the reconstruction of soft-tissue defects in the hand since 1990. From January 1997 through January 2000, 19 patients (15 male, 4 female) with hand injuries underwent microsurgical MDF reconstruction at Chang Gung Memorial Hospital. There were finger injuries in 16 patients and palm defects in 3 patients. The mean patient age was 32.6 years (age range, 16-58 years). Flap size ranged from 4.5 x 2 cm to 7 x 6 cm (mean, 6 x 2.8 cm). Only one flap had partial loss. The donor site was closed primarily in 9 patients, and was closed using a split-thickness skin graft in 9 patients and a full-thickness skin graft in 1 patient. At a mean follow-up of 13 months, the protective sensation was 16 mm using the static two-point discrimination test and was 10 mm using the moving two-point discrimination test. Based on this retrospective study the authors conclude that (1) the MPF has the advantages of thin and glabrous skin, (2) the size of pedicle is compatible with the recipient vessel in the hand, (3) there is low donor site morbidity, and (4) achieving protective sensation is possible.

Thenar function impairment or destruction is not uncommon in hand crush injury or thumb avulsion injury. Although complete evaluation of thenar muscle function is difficult during an emergency setting because of skeletal instability and pain, if left untreated the injured hand may result in deficiency of opposition and may require secondary reconstruction. When the palmaris longus tendon is available from the open wound, a Camitz opponensplasty can be performed in the emergency operation setting even as an augmentation procedure for opposition if there is any suspicion of thenar muscle impairment. Seven patients with such injuries who underwent immediate Camitz opponensplasty were assessed to have an 80% angle of separation, a 90% angle of circumduction, and an 88% Kapandji test of the normal opposite hand. An emergency Camitz procedure provided a reliable, immediate one-stage reconstruction of thenar function.

Background: Early division of the pedicled groin flap can be achieved by using ischemic preconditioning. The goal of this study was to investigate the devices available for ischemic preconditioning and determine which device is the most effective and results in lowest patient discomfort., Methods: Rubber bands, custom-made Orthoplast sheets, long-nose locking pliers, intestinal clamps, and a pneumatic tourniquet device were used for ischemic preconditioning on 13 patients who sustained severe hand injuries with reconstruction of pedicled groin flaps. The devices were compared by using laser Doppler flowmetry and the patient's local pain levels., Results: Twelve of 13 flaps were successfully divided at a mean period of 8.3 days by using a custom-made Orthoplast sheet or a pneumatic tourniquet device. All devices except the rubber bands could result in a biologic zero flow level., Conclusion: The pneumatic tourniquet device is the most desirable ischemic preconditioning device, having the advantages of excellent ischemic effect, easy application, and minimal discomfort.

With mastery of conventional methods, free flaps are indicated in selected cases for coverage of the hand and fingers. Careful preoperative planning, delicate intraoperative management, and postoperative physiotherapy are the mainstays for success in functional recovery and aesthetic result. Thin flaps of good vascularity are favored for coverage of the hand and finger. For hand surgeons, the lateral arm fasciocutaneous or fascia flap, toe flaps, and the latissimus dorsi flap seem to be the easiest and most useful free flaps applicable to most situations.

Background: Skin and soft-tissue defects of the hand and digit present a challenge for the hand surgeon especially in meeting the reconstructive needs of thickness, texture, color matching, and sensation. It becomes an even bigger challenge to reconstruct the defect in a devascularized finger with segmental loss of the neurovascular bundle. We use the relatively new flap, the medialis pedis flap, to solve the above conditions and compare it with traditional flaps., Methods: From May of 1994 to March of 1997, the free medialis pedis flap was used to reconstruct 19 digit and hand defects; the flap sizes ranging from 1.5 x 3.0 cm to 3.0 x 9.0 cm. Sixteen flaps were used for simple coverage of digit defects, including 12 for single-digit and 4 for multiple-digit reconstruction. The remaining three flaps were used as coverage and a flow-through flap for devascularized fingers., Results: All 19 flaps survived and achieved a good protective sensation. The appearance was very satisfactory, and the donor-site scars were without sensory problems., Conclusion: Compared with traditional flaps, the free medialis pedis has the following advantages: it provides good thickness, texture, and color matching for hand and digit resurfacing; it can be used as a flow-through flap and as coverage for a devascularized finger in a one-stage procedure; the size of the feeding vessels of the flap matches those of the digital vessels well; and it consists of glabrous skin rich in nerve endings, so it has good potential for sensory recovery. Because of all of these characteristics, the free medialis flap may become a better consideration for hand surgeons.

Objectives: The main disadvantage of the pedicled groin flap for hand reconstruction is the long period of immobilization required. Early division of the pedicled groin flap is desirable for both patients and surgeons. The aims of this study were to investigate whether ischemic preconditioning can effectively accelerate the neovascularization of the junction between the donor and recipient sites in the pedicled flap, and the most objective method of judging the timing of early division of the pedicled groin flap. This report is the first prospective study to use ischemic preconditioning for early division of pedicled cutaneous flap combined with laser Doppler measurement., Methods: The severe hand injuries of 12 patients were reconstructed by using the pedicled groin flap method. The ischemic preconditioning program was prospectively performed as scheduled for 5 to 7 days postoperatively. The pedicled groin flap was monitored with laser Doppler when the flap was elevated, inset, with clamping and nonclamping postoperatively., Results: Eleven of the 12 pedicled groin flaps were divided safely and survived completely. Only one pedicled groin flap with a simultaneous harvest of iliac bone graft had partial flap loss, giving a success rate of 90.1%., Conclusion: With ischemic preconditioning, the pedicled groin flap can be safely divided postoperatively at a mean period of 8.4 days according to the laser Doppler measurement, especially when the perfusion unit ratio of clamping over nonclamping reaches more than 36.6%.

Background: Conventional posterior interosseous flap has the disadvantage of partial or even complete necrosis of the flap when there is anatomical variation or contusion around its distal pedicle. To make it a more reliable flap, three types of auxiliary procedures were designed., Methods: (1) When there is congestion after inset of the distally based flap, an additional venous anastomosis was carried out. (2) When there is anatomical variation so that a distally based flap could not be raised without compromising the nerve branches, or when contusion was found around the distal pedicle, the flap was changed into a free flap. This design is also indicated for coverage of the distal fingers. (3) When the patient is elderly with possible peripheral arterial disease, the flap was raised with a wide base, incorporating the branches of both the anterior and posterior interosseous arteries. There were eight, 36, and five patients in each group, respectively., Results: There was only one failure in the free flap group. No partial necrosis of the flap was found. Other complications were analyzed., Conclusion: With these backup procedures, the posterior interosseous flap can be more widely used with safety. By combining various reconstructive armaments, the result of a conventional procedure can be improved.

The distally based forearm island flap is vascularized by the perforators of the distal radial artery. The skin flap is along the axis of the radial artery, and the pivot point of its subcutaneous pedicle is about 2 to 4 cm above the radial styloid process. We have treated 12 patients with 12 flaps for soft-tissue defects of the hand. Of these recipient sites, seven were in dorsal hands, two were in thumbs, two were in forearms, and one was in the palmar area. The donor-tissue variants included eight skin flaps, two adipofascial flaps, and two sensate flaps. The sizes of the flaps ranged from 6 x 4 cm to 14 x 6 cm. The donor site wound could be closed primarily in five patients. Two sensate flaps, innervated by the lateral antebrachial cutaneous nerve, could provide sensation for thumb reconstruction. The advantage of this flap is its constant and reliable blood supply without sacrifice of the main radial artery. The elevation of the flap is simple and rapid. There is the potential that this flap can be used as an innervated flap, and there is no need of microsurgical technique.

Twelve patients with circumferentially degloved hands were treated with full-thickness skin grafts harvested from defatted avulsed flaps. All injuries were industrial accidents caused by various roller machines, not crush injuries. Of these 12 patients, 9 patients were degloved from the wrist level and 3 patients were degloved from the forearm. There were 11 distally based skin flaps and one flap was completely detached. Four patients were avulsed distally to the mid palm, with volar neurovascular bundles damaged at the "fenestrae" of the palm, which resulted in devascularization of the involved fingers. Among them, distal fingers were successfully revascularized by microsurgical techniques in 3 patients. The full-thickness skin grafts were prepared from the attached, avulsed skin flap to avoid junctional hypertrophic scarring. The graft was then secured to its anatomic position with multiple skin staples to improve skin graft take. Initial take of the graft averaged 93% (range, 85%-100%). Compared with conventional methods, this approach provides a higher rate of skin take and better cosmetic and functional results.

Repairing complex soft-tissue defects of the hand and fingers remains a daunting task. Maintenance of functional mobility and sensibility are paramount in determining donor-site tissue. Critical sensibility is important for defects of the fingers and can be replaced only with tissue from the palmar surface of the hand itself or by free-tissue transfer from the toes. In this regard, glabrous skin and pulp from the great toe demonstrates the most critical level of sensibility, followed by tissue from the second toe. Complex soft-tissue defects of the palm, dorsum of the hand, or first web space can be replaced effectively by flaps that provide protective sensibility. The standard flaps employed are the lateral arm or radial forearm. The ultimate consideration in dealing with these difficult problems must be determined by the judgment and technical sophistication of the surgeon.

Nine cases of hand degloving injuries were treated successfully with arteriovenous shunting technique. Of these nine cases, four were degloved from the wrist level and one from the forearm, three were degloved at the palm and one at the dorsum of the hand. All injuries resulted in distally based skin flaps, which were either superficial to the palmar fascia or within the subcutaneous layer. Lack of active bleeding from the periphery of the avulsed flaps substantiated circulatory compromise before revascularization. Survival of the avulsed flaps was achieved by directing the proximal arterial flow into the venous channel within the avulsed skin flaps. The post-operative care and rehabilitation were straightforward, and functional results were satisfactory.

Seven patients with extensive loss of soft tissue, extensor tendon, and exposure of bone and joint of dorsum of hand and foot were treated with free composite flaps from the groin area. To retard the adhesion by scarring, membrane interposition between tendon and bone was recommended. The groin flap, based on superficial circumflex iliac vessels, was combined with a well-vascularized external oblique aponeurosis. The groin skin flap provided skin coverage, and the aponeurosis was used simultaneously to create a gliding surface for reconstructed tendons in a single one-stage procedure. All composite free-tissue transfers were successful. The advantages of this technique are: (1) a single, one-stage procedure; (2) fewer adhesions of reconstructed tendons, and no need of secondary tenolysis; and (3) good cosmesis and minimal morbidity at donor site.

A 66-year-old patient sustained a severe right hand injury resulting in a thumb pulp defect and unreplantable amputation of the index, long, and ring fingers at the metacarpophalangeal joint with joint exposure. There was also an 8 cm defect of the radial digital nerve of the little finger. Immediate one-stage total reconstruction of all of the defects was accomplished by a free groin flap and a free glabrous skin flap from the foot. Opposable function of the hand was thus preserved.

There are situations in which amputated hands or fingers cannot be replanted directly back to their original positions. When there is severe segmental injury across the hand and wrist but one or several fingers are still healthy, the fingers can be selected to be replanted at the forearm bones to restore pinch function. This is different from the toe to antebrachial stump transplantation presented by Dr. Vilkki. From the results in four patients, the following conclusions are drawn: (1) When the fingers are replanted at the forearm bone(s), only pinch function can be obtained. There is no opposition. (2) Grip function is weak because the intrinsics are lost and only a few fingers are replanted. The forearm bones are often shortened, as are the flexors. (3) Of particular importance is the creation of a large web space between the radial digit and ulnar digit(s), because fingers are longer than toes. (4) The sensory recovery is not so good as in ordinary finger replantation. However, this is a salvage procedure. Regardless of these facts, the patients are still satisfied with the results out of such severe injuries. With good pinch function, not only are they independent in daily life, but they also can do a lot of work. It is a worthwhile procedure. A functional prosthesis can be added distally after this replantation.

Skin defects in some areas of the digits are difficult to reconstruct, such as the ulnar aspect of the little or ring finger, radial aspect of the index, dorsal or volar aspect of fingers with proximal interphalangeal or metacarpophalangeal joint involvement, and proximal phalanx of the thumb. Moderate or severe contracture of the web space and multiple finger injuries without an available cross-finger flap are also a challenge to reconstructive surgeons. The reverse dorsometacarpal flap presents an option for reconstruction because of these difficulties. It is reliable and versatile in design. The donor site can be closed primarily provided the flap is less than 2 cm wide.

Thirty-six patients with 72 metacarpal and phalangeal fractures with associated injuries to the neurovascular bundle, tendon, soft tissue, or bone following acute complex hand injury were treated with miniature plates and screws and reconstruction of the disrupted and missing structures. The results were judged according to the criteria of the American Society for Surgery of the Hand. The overall results were good in 46.3%, fair in 32.2%, and poor in 21.5%. Although traditional wiring techniques are certainly useful in complex hand injuries, internal osteosynthesis with miniature plates and screws has definite indications in cases requiring stable and rigid internal fixation.

To achieve better functional results following mutilating multidigital trauma, every effort should be made to maximize the ultimate function of the hand, and the plan of replantation should be guided accordingly. All usable parts should be salvaged from the amputated nonreplantable areas. A patient is reported in whom two fingers taken from the nonreplantable midpalm were used to reconstruct the thumb and ring fingers, ultimately improving the overall quality of the patient's life.

The loss of function of the metacarpophalangeal joint is a significant disability. Simultaneous reconstruction of the soft tissue, extensor mechanism, joint, and flexor tendon in a complex hand injury is difficult and challenging. Free vascularized autogenous toe joint transplantation is a useful technique that provides not only joint replacement but also the soft tissue, extensor mechanism, and flexor tendon in more severe complex hand injuries. Two patients underwent immediate, free vascularized metatarsophalangeal joint transfer of the second toe to replace the long and ring finger metacarpophalangeal joint in acute complex hand injuries. The follow-up results at 16 months and 8 months postoperatively are presented.

Nine patients with complex extremity injuries were treated with emergency free-flap transfers over a 3 1/2-year period. The transferred emergency free flaps were performed to cover exposed vital structures. All flaps survived without infection. Complete and careful assessment of the systemic condition of the patient and the nature of the injured extremity is mandatory. Emergency free-flap transfers may salvage the limb or finger and may improve the functional and aesthetic results with the shortest possible hospital stay.

The severely mutilated hand is defined as the hand which has lost opposable digit function either through: a) The amputation of all four fingers proximal to the PIP joint or b) The loss of the thumb proximal to the IP joint combined with the loss of at least three fingers proximal to the PIP joint. We have outlined guidelines for the restoration of useful function and appearance to such hands utilising a variety of microsurgical toe-to-hand transfers. Specific points regarding postoperative management have been made.

Twenty-seven patients with osseous trauma and soft-tissue loss were subjected to a treatment protocol aimed at obtaining definitive wound coverage within 10 days of injury. Reconstructive procedures included 19 successful microvascular tissue transfers as well as 8 pedicle flaps. The rate of serious complications was 8%, and patient morbidity was significantly reduced compared with a previous regimen of late reconstruction. An outline of the protocol is presented and technical points, which might enhance results, are discussed.

The groin flap is a reliable and well-established reconstructive option for pedicled or free-tissue transfer. Concern regarding its variable vascular origin and caliber has limited its use. To overcome this, a simplified guideline based on the transverse diameter of the patient's index and long fingers at the distal interphalangeal level has been developed. Thus "rule of two finger widths" positions the origin of the vascular pedicle from the femoral vessels two finger widths below the inguinal ligament, the upper flap border two finger widths above the inguinal ligament, the lower flap border two finger widths below the vascular origin, and both parallel to the flap axis, which lies along a line from the vascular origin to the anterosuperior iliac spine. This new groin flap design provides the necessary guidelines for vascular identification, accommodates pediatric and adult stature, and ensures primary donor-site closure if flap dimensions are within the prescribed boundaries. In addition, a new sartorius-cutaneous groin flap is presented. This combines the cutaneous groin flap with the proximal sartorius muscle (up to 15 cm), which is supplied by the deep vessels of the superficial circumflex iliac system. The sartorius-cutaneous groin flap further emphasizes the concept of single-pedicle compound or combined flaps and additionally enhances the extensive reconstructive versatility of previously described groin flaps. Over 200 pedicled and free groin flaps have been performed according to the "rule of two finger widths" over the past 5 years. There have been no complications related to flap design, such as difficulty with flap elevation, marginal necrosis, or donor-site closure.(ABSTRACT TRUNCATED AT 250 WORDS)

Severe hand trauma caused by an industrial accident resulted in composite tissue loss in the basal joint area of the right hand. The crushed metacarpal bone was replaced, and ligamentous and capsular reconstruction was performed with flexor carpi radialis tendon and additional tendon graft. We present our experience, with a follow-up of one year and eight months.

Multilating hand injuries with multiple digital amputations require a cooperative patient, a highly skilled hand/microsurgical team, and a continuum of hand rehabilitation therapy for optimal functional salvage. A systematic approach for assessing a patient's functional deficit and reconstructive requirements contributes to a coordinated reconstruction and rehabilitation plan designed to optimize functional gains. Today's sophisticated microsurgical reconstruction coupled with comprehensive hand therapy generally represents the best option for patients with mutilating hand injuries. Throughout reconstruction and rehabilitation the ultimate goal of multilating hand injury care, that of restoring a functional extremity that is useful in a patient's daily life must be remembered.