CHAPTER 82 MANAGEMENT OF MUTILATING INJURIES OF THE UPPER EXTREMITY
JAIMIE T. SHORES AND W. P. ANDREW LEE
“Mangled” or “mutilating” injuries to the upper extremity are uncommon but devastating. A “mangled” extremity injury has injuries to at least three of the four following tissue groups: Integument/soft tissue, nerve, vasculature, and bone.1
Although this definition was created to define mangled lower extremity injuries, the same definition can be used for the upper extremity,2 though the incidence is less frequent than lower extremity injuries. Civilian studies have shown 23 mangled upper extremities versus 51 mangled lower extremities during a 10-year period at a tertiary care trauma center in the United States.3 In Japan, a study of 1,024 trauma center patients revealed 5 severe upper extremity injuries that demonstrated arterial involvement, with 3 patients qualifying as mangled.4 In recent U.S. military combat theaters, 23 patients with mangled upper extremity wounds over a 3-year period receiving complex reconstruction at a single institution represented the largest case series reported.5
The Mangled Extremity Severity Score (MESS) can be applied to the upper extremity, though it is done so infrequently. Originally described in 1990 as a lower extremity injury tool to predict amputation, it has not found widespread acceptance in application to the upper extremity.6 The MESS is a cumulative score with points given for skeletal/soft tissue injury, limb ischemia, shock, and age (Table 82.1). Commonly, a MESS ≥ 7 has been used as an indication for amputation in the lower extremity. However, it does not mandate or predict on an individual basis whether or not amputation should be performed. In addition, it is a score developed for the prediction of lower extremity salvage/amputation, which has functional implications that differ from those for the upper extremity. Lower extremity injuries carry a lower threshold for amputation due to the life-threatening consequences of large, nonviable muscles and because the loss can be adequately replaced with modern prosthetics. In a review from Walter Reed Army Medical Center in 2010, of the 750 lower extremity trauma-related amputations performed in the previous 10 years, 15% were due to unsatisfactory or “failed” limb salvage. In contrast, only two patients voluntarily requested late hand or upper extremity amputation following initial limb salvage,7 indicating the importance of the upper limb to patients, even when there is limited function. In another study of 52 patients with upper extremity vascular injuries, none of the 33 patients with a MESS < 7 underwent amputation. Interestingly, 63% of 19 patients with a MESS ≥ 7 also had limb salvage, with only 37% progressing to amputation.8 Thus, in its application to the upper extremity, the MESS seems to be a better predictor of limbs that will not require amputation than of those that will.
Mangled upper extremities may be life-threatening injuries themselves or may be associated with other life-threatening injuries. In combat populations, the etiologies include ballistic missiles, blast injuries (such as improvised explosive devices), and traditional mechanisms such as motor vehicle accidents (MVAs). Civilian populations may encounter devastating upper extremity injuries due to all mechanisms of trauma, with MVAs predominating. Industrial and agricultural injuries tend to be isolated upper extremity injuries. Civilian injuries also include firearm- and blast-related trauma.
Evaluation of the patient begins with standard ATLS protocols. Control of hemorrhage may require tourniquet placement. A secondary survey to determine the presence of more specific injuries should be performed efficiently. If possible, a full neurologic evaluation is performed prior to patient intubation. Standard pulse examination may be aided by the use of a hand-held Doppler. Function is ideally tested but may be hampered by pain and patient cooperation. Observations of gross deformity and digital cascade are documented. X-ray studies involving the affected portion of the extremity as well as the joints proximal and distal, and any region that is deemed clinically necessary, are obtained.
During primary and secondary survey, bleeding is controlled. In many instances this is as simple as gauze packing and a pressure dressing with extremity elevation; however, application of a tourniquet may be required. Clamping of vessels is discouraged because other structures, such as nerves, are easily injured. The affected extremity should be closely examined and radiographs of any traumatized region, in addition to the joints proximal and distal, are obtained.
Observations of the digital cascade and the position of the limb are noted, because this may help identify tendon injuries, joint dislocations, and fractures. Exposed tissues and the nature of contaminants are noted. Vascular and neurologic exams are performed, and pulses palpated and compared with the uninjured arm and correlated with the patient’s mean arterial pressure. The absence of palpable pulses should be confirmed with a hand-held Doppler probe. Color, warmth, and capillary refill are documented. If perfusion to an extremity is compromised in the setting of a joint dislocation or fracture, attempts to reduce the anatomic deformity are made to see if this restores perfusion. Any indication of compartment syndrome warrants an immediate compartment pressure evaluation. A neurological examination should be performed to evaluate sensory and motor function in all nerve distributions. If the patient has a head injury and is intubated or sedated, then neurological examination is difficult. Reflexes and protective responses to pain such as withdrawal may be obtained, but these may not be reliable in diagnosing compartment syndrome may not be reliable in diagnosing compartment syndrome or other conditions and injuries in this setting.
Any suspicion of injury to an extremity warrants X-ray evaluation. Three views of the hand and/or wrist, two views of the forearm, and two views of the elbow are standard examinations. Radiographic evaluation utilizing thin-slice computed tomography scanning may provide added information regarding complex injuries involving the wrist or elbow. Any patient with suspected major vascular injury due to mechanism of trauma or who has clinical evidence of vascular insufficiency should receive angiographic evaluation.
In all cases of severe upper extremity trauma, immunization for tetanus is administered immediately. Antibiotic prophylaxis is initiated as soon as possible in the patient’s treatment course. In a prospective study of 1,104 open fractures, Patzakis et al. demonstrated that the single most effective intervention in decreasing the wound infection rate in open fractures was beginning treatment with intravenous antibiotics within 3 hours of injury (not presentation to the emergency department).9
If the patient is not stable or suitable for definitive treatment of the upper extremity wound in the operating room (OR), a preliminary washout–debridement and wound packing should be performed in the emergency department. Antimicrobial agents can also be added to the solutions used for washout, but these agents have not been demonstrated to decrease infection rates.10,11 In fact, many of these agents have been shown to be toxic to host cells such as fibroblasts and may even impair host cell function.11 The use of saline and tap water was found to have similar outcomes for wound irrigation in the emergency department, including open fractures.12
Patients who have been physiologically stabilized and who do not have life-threatening injuries should have debridement, stabilization, and at least temporization of their wounds in the OR as soon as possible. Those patients with other life-threatening injuries or conditions that require direct admission to an intensive care unit (ICU) may be able to have some debridement and wound management even in the ICU setting. Patients taken to the OR emergently for other injuries may be able to have their extremity injuries managed simultaneously. Care for the multiply injured or critically ill requires excellent communication across all teams involved in the patient’s care.
Patients who are able to have their injuries managed operatively are to be addressed as soon as possible. However, the commonly held belief that management of open fractures requires operative debridement and stabilization within 6 hours has not been substantiated. Although most data for open fracture management have been derived from the more common lower extremity fractures, this dictum has been disproven more often than supported by evidence,9,13-16 even in children.17 Nonetheless, earlier wound debridement should be the goal for all mangled upper limb injuries.
Initial management in the OR is dictated by the extent of vascular compromise. Critical warm ischemia times vary from tissue to tissue (Table 82.2). Extremities with warm ischemia require expedient vascular reconstruction with concomitant fasciotomies. This may be in the form of an arterial repair, arterial reconstruction, or temporary shunt. Temporary shunts are synthetic conduits used for restoring flow in arteries, veins, or both and are used commonly for carotid bypass operations. Materials such as standard sterile IV tubing or pediatric feeding tubes may also be used.18 Shunts have been used in extremity revascularization and replantation since the 1970s with good results.19,20
If ischemia is not present or has not been prolonged, a complete and aggressive debridement should be performed, and written inventory of injured structures made. We frequently forego the use of pulsed-lavage irrigation due to concerns for soft tissue injury. Although sterile saline is our standard irrigant (using 3 L bags attached to cystoscopy tubing to provide constant and uninterrupted flow while scrubbing the affected tissue), castile soap has been shown in a recent prospective randomized trial of open lower extremity fractures to be superior to irrigation with a standard antibiotic (bacitracin). Patients treated with soap irrigation had fewer wound healing problems.21
Following debridement, if vascular reconstruction is still required, the surgeon may consider whether this should be performed before or after bony fixation (Table 82.3). Many surgeons believe that fracture fixation should precede definitive vascular reconstruction due to the risk of injury to reconstructed vessels.22 However, revascularization may be performed safely prior to fracture fixation and may help avoid fasciotomy for those injuries with shorter ischemia times.23 Vascular reconstruction of the arterial and/or venous systems will frequently require the use of vein grafts, such as reversed saphenous vein interposition and bypass grafts.24,25 If the patient has intact perfusion to the hand with a single radial or ulnar artery, some surgeons may choose to simply ligate the injured artery. However, the authors attempt to restore full anatomic arterial inflow when feasible, as long as the patient is stable during the operative procedure. Two-vessel in-flow to the forearm may result in improved muscle mass and cold intolerance.26
Bony fixation may consist of external fixation, internal fixation, or a combination of the two techniques. In the acute setting, shortening may be performed to prevent the need for bone grafting as well as to allow primary repair of debrided nerves and vessels and allow improved soft tissue defect management. Bone gaps in the humerus and forearm of up to 3 cm may tolerate shortening and preclude the need for bone grafting,27-29 but over-shortening should not be employed as a substitute for bone grafting defects greater than 3 cm. Care must also be taken to be sure the DRUJ (distal radio-ulnar joint) alignment is exact. Bony defects of 6 cm or more require vascularized bone grafting, which should only be performed in a clean wound with adequate soft tissue coverage. If initial rigid fixation is performed but concern remains for tissue viability, coverage, or contamination, then all forms of bone grafting should be delayed. Rigid internal fixation allows earlier rehabilitation and requires less postoperative wound care than external fixation, with a low risk of infection if a meticulous debridement has been performed.30
Initial soft tissue management may consist of debriding devitalized or heavily contaminated tissues with plans for subsequent debridement until the tissues appear clean and healthy enough for wound coverage or closure. We routinely perform quantitative wound cultures of contaminated acute wounds at each debridement to guide antibiotic management and timing of further reconstructive procedures such as bone grafting, nerve grafting, and wound coverage. This may require negative pressure wound therapy or open wound care such as moist dressings. Another scenario that requires temporary wound management with negative pressure wound therapy or dressings is the unstable patient who cannot undergo further reconstructive procedures at the time of initial injury debridement, or those who require transport to a higher level of care following initial debridement.31-33
Clean wounds require reconstruction based on their specific needs. Tendon loss may be treated by tendon grafts or tendon transfers. Although it may be tempting to obtain soft tissue coverage over a wound with segmental tendon loss and delay tendon reconstruction, it is preferable to achieve a clean wound and perform bone, tendon, and nerve reconstruction at the same time as flap coverage. (As demonstrated between figures 82.1 and 82.2 where initial debridement, vascular repair and bony stabilization were performed followed by return to OR in 24 hours for repeat debridement, primary bone grafting, and free flap coverage). In a small series of 14 patients, Sundine and Scheker demonstrated a return to final motion in one-third the time, substantially fewer operations, and a much higher chance of regaining employment with immediate reconstruction when compared with delayed reconstruction.34 For isolated tendon losses, tendon grafts may be taken from the palmaris longus (PL) or plantaris tendons if present, from a section of the flexor carpi radialis (FCR) tendon, or long toe extensor tendons. Tendon transfers may also be useful for isolated tendon loss, such as reconstructing the extensor pollicis longus with an extensor indicis proprius transfer. If isolated tendon loss and soft tissue coverage is missing, a tendocutaneous free flap incorporating the PL or FCR from the contralateral forearm may be used to reconstruct both problems. Tendocutaneous free flaps incorporating the dorsalis pedis and toe extensors have been described but have significant donor site morbidity. If the patient does not have available plantaris, palmaris, or other tendon donor sites but still has intact muscular motors, allograft tendons may be considered.35,36 In the event of the loss of an entire compartment, the patient may undergo innervated pedicled or free muscle transfer, usually after stable coverage and bone healing have been established. Tendon grafts should not be performed under skin grafts or have skin grafts placed upon them, due to poor graft and wound healing combined with poor expected tendon excursion.
FIGURE 82.1. Preoperative photos and X-rays of 9-year old-female shot through forearm with large caliber rifle with segmental radius fracture, large scale soft tissue loss, comminuted segmental radius fracture, and vessel injury.
FIGURE 82.2. Final postoperative results after scar revision and flap contouring. Range of motion (A–C) and 12 month X-ray (D).
The type of soft tissue coverage required depends upon the extent of the injury. If only muscle bellies are exposed, then split-thickness skin grafts are sufficient. Unmeshed “sheet” grafts provide a better cosmetic result and are used for dorsal hand wounds, but meshed split-thickness skin grafts provide more area of coverage and conform well to deeper, irregular wounds. Free and pedicled fasciocutaneous flaps, skin grafted fascia flaps, and skin grafted muscle free flaps, such as the serratus free flap, have been used successfully for dorsal hand coverage. Forearm and upper arm defects may be covered with regional flaps (such as the reverse lateral arm flap for elbow coverage or latissimus dorsi flap for upper arm coverage or restoration of function) or free flaps. Large wounds requiring broad areas of coverage may necessitate free flap coverage utilizing muscle flaps with skin grafting, such as the latissimus dorsi with or without the lower four to five slips of serratus anterior via the serratus branch. Fasciocutaneous flaps provide aesthetic reconstructions in thin patients, with the anterolateral thigh flap as our preferred choice. Scapular, parascapular, contralateral radial forearm, and lateral arm flaps may also be employed for various areas depending on the amount of tissue required and available donor sites.
Nerve reconstruction should begin when the wound is clean and coverage can be provided at the same time that reconstruction is performed. Sharply injured nerves may require minimal debridement and may undergo primary repair. Primarily repaired nerves are generally thought to have better sensory and motor recovery than grafted nerves.37 For crushed or avulsed nerves, debridement back to healthy nerves is required. All nerve repairs and reconstructions should be performed as soon as possible. Final motor recovery has been directly correlated with time to grafting of nerve injuries, with the best outcomes resulting from earlier reconstruction.38 A recent meta-analysis of upper extremity nerve repair/reconstruction demonstrated that younger age, distal injury, and earlier time of repair were associated with better motor recovery.39 Additionally, it is well known that ulnar nerve injuries tend to recover more poorly than median nerve injuries.39 Anterior transposition can convert a nerve gap requiring grafting to an end-to-end nerve repair for ulnar nerve injuries located in the proximal forearm or elbow. Although the reported gap capable of being overcome with transposition varies from 2 to 4 cm, a cadaver study reported that transposition resulted in only 9 mm of additional nerve length.40 Placing the wrist in 45° of flexion decreases the nerve gap by up to 11 mm.40
As stated earlier, intravenous antibiotics should be administered within 3 hours of injury and tetanus updated as appropriate.9 Although IV antibiotics are the recommended treatment protocol, a recent prospective randomized controlled trial demonstrated no benefit in the use of antibiotics in elective or traumatic hand surgery when meticulous wound care and debridement was performed.41 This study, however, has not been replicated. General recommendations for class III wounds42 (Table 82.4) are that either a first- or second-generation cephalosporin combined with an aminoglycoside or a third-generation cephalosporin should be given and continued for 5 days.43 “Barnyard” or “farmyard” injuries with a substantial amount of soil contamination should receive penicillin to protect against anaerobes such as clostridium, even though there is no direct level I evidence to support this practice. An attempt to form an evidence-based guideline for antimicrobial coverage of open fractures failed to identify convincing evidence to support the use of aminoglycosides or penicillins.44 The authors noted that even in soil contaminated fractures, gram-positive infections were the most common, and when gram-negative infections developed, it was usually a nosocomial infection resistant to the aminoglycoside treatment.44 In addition, the authors postulated that Clostridium perfringens prophylaxis may be unnecessary because of the rarity of these infections. They also noted that penicillin G, which is most commonly quoted for prophylaxis, is actually suboptimal therapy for this organism today.44
Any concern for compartment syndrome necessitates a fasciotomy of the injured limb. In a large retrospective study of trauma patients, the overall need for extremity fasciotomy was low (2.8% of all patients).49 Independent risk factors of fasciotomy of the upper limb included penetrating injuries (stab wound 4.4% and gunshot wounds 8.6%), vascular injuries (arterial injury 27.2%, venous injury 23.4%, and combined arterial and venous injuries 41.8%), elbow dislocation, open fracture, higher blood product transfusion requirements, and male gender.50 Interestingly, the study noted that despite injury severity scores remaining constant over time from 1998 to 2007, fasciotomy rates steadily declined after 2004. The exact causes are unknown but presumed to be improvements in resuscitation protocols and fluid management. Diagnosis of this entity is usually based upon clinical suspicion. If the patient is awake and cooperative, the five “P”’s of pain, pulselessness, pallor, paralysis, and paresthesias are commonly employed, though pain with passive extension is likely the most clinically important indicator.51,52,53 Individual physician’s threshold for needle/fluid column transduced compartment pressure measurements varies from 30 to 45 mm Hg for the diagnosis of compartment syndrome, whereas a difference between diastolic blood pressure and compartment pressure >30 mm Hg is also used for diagnosis.54
Mangled upper extremity injuries are complex and require reconstruction of skin and soft tissue, nerve, vascular, and bony structures simultaneously. This requires a multidisciplinary surgical team, involving vascular, orthopedic, and plastic surgeons, or a surgeon with adequate skills in vascular, bony, and soft tissue reconstruction of the upper extremity. The risk/benefit ratio of aggressive salvage operations is different for each individual patient based on the age, comorbidities, concomitant injuries, and reasonable expectations for outcome. The threshold for amputation of the upper extremity should be higher than a lower extremity, and salvage guidelines such as the MESS should be used with caution because it is a better determinant of salvage than need for amputation. As stated by Tintle et al., “…a ‘bad hand’ may be more functional than a ‘good amputation’…”7 In general, earlier definitive reconstructions yield better results in terms of functional recovery, earlier time to rehabilitation, earlier time to full functional recovery, and fewer operations. Familiarity with the myriad techniques available for bony fixation, vascular, nerve, and soft tissue reconstruction is paramount to success because no two mangled upper extremities are identical.
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