AOTrauma Masters CourseCurrent Concepts Module 2 Case 4

AOTrauma Masters Course—Current Concepts Module 2, Case 4: Multiple fractures and dislocations of the hand wrist, massive dorsal skin defect segmental tendons lost Davos Courses December 2018

Case description • • 47 -year-old food industry worker Sustained severe injury to his dominant hand Injury while operating a flour mill Series of surgical debridement were performed in a regional hospital • Patient was seen (follow-up) 1 week after injury

Initial clinical evaluation Discuss 1. Describe the injury and patient requirements 2. Plan of reconstruction 3. The question of complex reconstruction versus early amputation and prosthesis

Initial clinical evaluation • Massive dorsal skin defect • Segmental tendons lost • Granulation tissue • Exposed bone and joint? • No distal vascular deficit

Evaluation after radical debridement • Massive dorsal skin defect • Segmental all tendons loss • Exposed bone and joint • 3 rd and 4 th metacarpal fractures • Carpometacarpal dislocations • Radiocarpal dislocation

X-ray evaluation

Reconstructive ladder of soft-tissue injury

Repair and reconstruction • Bone and joints, ligaments - Soft tissues - Skin - Nerves - Tendons • If possible, no staged repair or reconstruction • All in a single surgical procedure

Bone repair and reconstruction

Bone repair and reconstruction • Total wrist fusion • Carpometacarpal fusion • Metacarpal fixation

Tendon grafts • Palmaris longus • Plantaris • Toe extensors

Anterolateral thigh and tensor fascia lata flaps

Tendon grafts through the flap

Bone joint, hardware and tendon grafts covered by the flap

11 years postoperative

Early microsurgical reconstruction of complex trauma of the extremities • Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986 Sep; 78: 285‒ 292 • Godina's work showed that with a radical debridement and early microsurgical soft-tissue reconstruction within 72 hours, infection risk, morbidity, and time to healing were all dramatically improved

Emergency free flap (publications) • The concept of emergency complete reconstruction proposed by Godina (soft-tissue reconstruction with free tissue transfer) was reinforced by other published series • Lister G, Scheker L. Emergency free flaps to the upper extremity. J Hand Surg Am. 1988 Jan; 13: 22– 28 • Chen SHT, Wei FC, Chen HC, et al. Emergency free flap transfer for reconstructions of acute complex extremity wounds. Plast Reconst Surg. 1992 May; 89(5): 882– 888

Learning objectives • Evaluate injury and identify the loss and exposed anatomical structures • Emphasize importance of the functional requirements of the patient • Recognize importance of early and extensive debridement • Explain usefulness and benefits of early microsurgical reconstruction (emergency free flaps) in this type of injury based on the published evidence • Select in the reconstructive ladder of soft-tissue coverage the adequate procedure considering the injury presented