SOFT TISSUE MANAGEMENT IN HAND TRAUMA

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SOFT TISSUE MANAGEMENT IN HAND TRAUMA

• L C Bainbridge
• Consultant Hand Surgeon

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Introduction

• Always the last chapter or lecture
• On course of this sort difficult to see the
  relevance.
• 90 of all hand fractures can be treated
  conservatively with an excellent outcome
• But the soft tissue injury will usually define
  the outcome in terms of ROM and function

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You are not competent to fix the fracture
unless you are equally competent in managing
the soft tissues
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Classification

• Freeland adaptation of Gustilo
• Hand Injury Severity Score (HISS)
• Buchler
• The prognosis relates to the energy of injury and
  the soft tissue component.

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• I - Tidy laceration lt1cm length, no soiling,
  crush or loss
• II - Tidy laceration lt2cm in length, outside
  in, no soiling or tissue loss, partial
  muscle laceration
• IIIa - Laceration gt2cm, penetrating or
  puncturing projectile, frankly soiled
• IIIb - 3a plus periosteal elevation and
  stripping
• IIIc - 3b neurovascular injury

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Tissues affected

• Flexors
• Tight compartment
• Large surface area for adhesion
• Beware avulsion
• Extensors
• Large surface area
• No synovial layer to maintain gliding
• Poor nutrition
• Usually compromised by fracture approach

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Tissues affected

• Intrinsics
• Very small excursion per degree of ROM
• Easily forgotten
• Important cause of late restriction of flexion
• Compartment syndrome!
• Nerves
• Probably THE major determinant of fracture
  outcome
• Bruise - crush - division - neuroma
• Carpal tunnel Syndrome

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Tissues affected

• Arteries
• Finger will possibly survive without arteries but
  cold intolerance and claudication are real
  problems for many patients
• Most crush injuries will need a graft
• Digital arteries require a minimum maximum of 9/0
  nylon. 10/0 or 11/0 is not unusual. 8/0 is
  unacceptable as is failing to use a microscope

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Tissues affected

• Veins
• Less frequent but can be a problem in the early
  stages. Some parts of the wound are best left
  open
• Muscle
• Thenar, hypothenar, intrinsics, lumbricals
• Crush with fibrosis

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Tissues affected

• Psyche
• Large soft tissue wounds take longer to recover
• Ligaments
• Scapho-lunate ligament injuries in
  intra-articular fractures
• Collateral ligament of the PIP joints
• Volar Plate

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Tissues affected

• Skin
• Abraded
• Avulsed
• Contaminated
• Periosteum
• Vital for mobility
• Approaches to the bone

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Reconstructive ladder

• SSG
• FTG
• Local flap
• Random flap
• Pedicle flap
• Free flap
• Free composite flap (bone, tendon, nerve, etc)

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Reconstructive Lift

• Go directly to the most appropriate cover
• A IIIb or IIIc will almost always do better
  with the free flap

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Direct closure
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Split Skin Grafts

• Disadvantages
• Vascular bed
• Immobilisation
• Poor durability
• Contract
• Failure
• Donor site

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Full Thickness Graft

• Disadvantages
• Very vascular bed
• Infection
• Small quantity available
• Immobilisation
• Colour match
• Innervation

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Local flaps

• Disadvantages
• Technically demanding
• Scars on uninjured digits
• Restricted movement eg cross finger flaps
• Often require a skin graft to the donor site
• Small volume available

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858 vy advancement
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Pedicle flaps

• Disadvantages
• Parasitic, need to pick up a blood supply
• Immobilisation often dependent
• Difficult to take vascularised bone
• Scarring
• Separation

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Free flaps

• Vast volume
• Multiple tissue types
• Brings in blood supply
• Antibiotic delivery system
• Primary wound healing
• Early movement
• One stage procedures

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Sensory flaps
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Your choice!