Slide 2 Management of the mangled hand H.Saremi MDH.Saremi MD
Orthopaedic hand&shoulder surgeonOrthopaedic hand&shoulder
surgeon Hamedan University of medical sciencesHamedan University of
medical sciences Hamedan,IRAN Slide 3 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 Slide 4 Slide 5 Slide 6 Slide 7 Slide 8
Slide 9 Slide 10 Slide 11 Slide 12 Slide 13 Slide 14 Slide 15 Slide
16 Slide 17 Slide 18 Slide 19 Slide 20 Slide 21 Slide 22 Slide 23
Slide 24 Slide 25 Slide 26 Slide 27 Slide 28 Slide 29 Slide 30
Slide 31 Slide 32 Slide 33 Slide 34 Slide 35 Slide 36 Slide 37
Slide 38 Slide 39 Slide 40 Slide 41 Slide 42 Slide 43 Slide 44
Slide 45 Slide 46 Slide 47 Slide 48 Slide 49 Slide 50 Slide 51
Slide 52 Slide 53 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 Slide 54 History -When? - delay>6-12h
precluding primary closure or coverage - delay>6-12h precluding
primary closure or coverage-Where?-How? Slide 55 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 Slide 56 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 Slide 57 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 Slide 58 Recomended approach to treatment
Emergent treatment Operative treatment -Debridement/wound excision
-Skeletal/joint reconstruction -Soft tissue reconstruction Slide 59
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 Slide 60 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 Slide 61 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 Slide 62
Debridement Conservativedebridement Slide 63 Debridement Marginally
viable tissuesMarginally viable tissues -further toxic insult of
adjacent tissues -systemic complications -systemic complications
Slide 64 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 Slide 65 Debridement
TourniquetTourniquet Loupe magnificationLoupe magnification Bone
fragmentsBone fragments - attached and potentially viable - non
viable structural non structural Slide 66 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 Slide 67
Debridemrnt Decisions must be made (replantation, amputation,
partial amputation, reconstrucition) - Save spare parts for later
use in primary reconstruction Slide 68 Skeletal/Joint
Reconstruction GOAL Restore - length - alignment - stability -
anatomically smooth and stable articulation Slide 69 Skeletal/Joint
Reconstruction TIME TIME Initial operation At the very least within
the first week Slide 70 Fixation The only chance The only chance
Adequate stable fixation to allow early motion is the only chance
to overcome the inevitable scar formation Slide 71 Fixation When?
With the exception of severe contamination,fixation is best
performed at the initial operation (excellent vascularity in
compare to lower extremity) Slide 72 Fixation Approach for fixation
-open injury----------------wound often dictate the approach -intra
operative x ray control even with good exposure Slide 73 Fixation
Important decision Important decision Restore anatomic length
--------or--------- -shorten the bones (bone,nerve,arteries,graft)
Slide 74 fixation -1---1.5 cm shortening in phalanges and
metacarpals -up to 4 cm in the forearm Without significant loss of
function Slide 75 Fixation Intra articular fractures
-reconstructable----------or---------- primary or secondary fusion?
Slide 76 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
Slide 77 Slide 78 Slide 79 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 Slide 80 fixation Shaft of radius and/or ulna fx Best
treated with 3.5 dcp plates Slide 81 fixation Distal ulna or ulnar
styloid fx -K wire and tension band wire reconstruction Slide 82
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 Slide 83 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 Slide 84 Slide 85
fixation Carpal,metacarpal,phalangeal fx
Carpal,metacarpal,phalangeal fx -focus to provide sufficientely
stable fixation to allow early motion Slide 86 fixation Metacarpal
and phalanges Metacarpal and phalanges -Mini plate and screw
fixation Slide 87 Slide 88 Slide 89 Carpus Cannulated compression
screw fixation - ligaments reattached with bone anchores Slide 90 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 Slide 91 K wire Even crossed is unable to rotational
or horizontal stability unless numerous -is internal splint rather
than rigid fixation Slide 92 K wire As provisional fixation drill
for screw exchange -0/045-----------1.1mm-----------core
diameter--------1.5mm -0/062-----------1.5mm----------core
diameter- ---------2mm Slide 93 External fixation -if not possible
to achieve rigid internal fixation(comminution or internal fx
anatomy) -maintaining the first web space to prevent adduction
contraction Slide 94 Bone defect Because of good vascularity,
primary bone graft unless: -significant contamination -poor soft
tissue coverage -compromised adjacent tissue vascularity Slide 95
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 Slide 96
