Objective To evaluate the effectiveness of free flaps in repairing hot-crush injury in the dorsum of hand. Methods Between February 2003 and February 2012, 32 cases of hot-crush injuries in the dorsum of hand were repaired. There were 25 males and 7 females with an average age of 24 years (range, 16-45 years). The injury causes included machine crush injury in 9 cases, machine-press injury in 13 cases, and iron panel injury in 10 cases. The time from injury to admission ranged from 90 minutes to 8 hours (mean, 3 hours). The wound size ranged from 6 cm × 5 cm to 17 cm × 11 cm. Associated injuries included the extensor tendon necrosis in 12 cases, and the second metacarpal bone necrosis in 1 case. One-stage emergency debridement was performed in all cases; two-stage flap repair was given at 7-21 days when the necrotic area became determined. The dorsalis pedis flaps were used in 9 cases, the anterolateral thigh flaps in 9 cases, the latissimus dorsi flaps in 3 cases, the thoraco-umbilical flaps in 3 cases, and the lower abdominal flaps in 8 cases. The flap size ranged from 7 cm × 5 cm to 18 cm × 16 cm. The donor site was repaired by skin graft or sutured directly. Results All the flaps survived. Primary healing of wound was obtained in 25 cases and delayed healing in 7 cases. Skin graft at donor site survived, with healing of incision by first intention. Twenty-three cases were followed up 6-25 months (mean, 13 months). Thinning was carried out in 8 bulky flaps; the other flaps had good appearance and texture. At last follow-up, the range of motion (ROM) of the metacarpophalangeal joint ranged from 40 to 80° (mean, 58°); ROM of the proximal interphalangeal joint ranged from 35 to 70° (mean, 52°); and ROM of the distal interphalangeal joint ranged from 5 to 25° (mean, 12°). The sensation recovery of the flaps were more than S2. No scar formed at donor site. Conclusion Suitable free flap should be selected to repair hot-crush injury in the dorsum of hand according to size of wound, which will achieve satisfactory results.
Objective To review the research progress of lymphaticovenous anastomosis (LVA) in the treatment of severe extremity trauma and prospect its clinical application prospects. Methods Based on the existing literature, this study elaborated on the pathological mechanism and adverse effects of post-traumatic lymphatic drainage disorder, systematically sorted out the clinical research cases and therapeutic effects of LVA in the treatment of severe extremity trauma, and analyzed the limitations of the current clinical application of LVA. Results Severe extremity trauma can cause extensive disruption of superficial and deep lymphatic vessels, which exacerbates post-traumatic limb swelling in the early stage and easily progresses to chronic lymphedema in the long term, thus hindering the process of wound repair and reducing patients’ quality of life. Existing small-sample clinical studies and cases have confirmed that LVA can effectively reconstruct the lymphatic drainage pathway and exert a definite therapeutic effect on post-traumatic lymphedema. However, this technique is still in the early stage of clinical application, with unsolved problems including no consensus on the optimal application timing, incompletely elucidated underlying mechanism of action, and relatively high technical threshold. Conclusion LVA exhibits important clinical application potential in the treatment of severe extremity trauma, and can serve as an effective method for clinically controlling limb swelling caused by post-traumatic lymphatic stasis. In the future, research should focus on the early therapeutic application of LVA for extremity trauma, clarify its optimal intervention timing and indications, optimize the treatment regimen by combining with traditional detumescence measures, so as to further enhance its clinical value in the treatment of severe extremity trauma.
Objective?To investigate the surgical method and clinical efficacy of repairing whole-hand destructive injury or hand degloving injury with the transplant of pedis compound free flap.?Methods?From February 2003 to June 2008, 21 patients with whole-hand destructive injury or hand degloving injury were treated, including 15 males and 6 females aged 18-45 years old (average 25 years old). The injury was caused by punching machine crush in 10 cases, roller crush in 7 cases, and imprinter crush in 4 cases. The time between injury and operation was 1-9 hours. Eleven cases had the skin-degloving injury of the whole hand, while the other 10 cases had the proximal palm injury combined with dorsal or palmar skin and soft tissue defect. After debridement, the size of wound was 9 cm × 7 cm - 15 cm × 10 cm in the dorsal aspect and 10 cm × 7 cm -16 cm × 10 cm in the palmar aspect. The defect was repaired by the thumbnail flap of dorsalis pedis flap and the second toenail flap of dorsalis pedis flap in 5 cases, the thumbnail flap of dorsalis pedis flap and the second toe with dorsalis pedis flap in 4 cases, and bilateral second toe with dorsalis pedis flap in 12 cases. The flap area harvested during operation ranged from 6 cm × 5 cm to 16 cm × 11 cm. Three fingers were constructed in 2 cases and two fingers in 19 cases. Distal interphalangeal joint toe amputation was conducted in the thumbnail flap donor site, metatarsophalangeal joint toe amputation was performed in the second toenail flap donor site, and full-thickness skin grafting was conducted in the abdomen.?Results?At 7 days after operation, the index finger in 1 case repaired by the second toenail flap suffered from necrosis and received amputation, 1 case suffered from partial necrosis of distal dorsalis pedis flap and recovered after dressing change, and the rest 42 tissue flaps survived. Forty-three out of 44 reconstructed fingers survived. All the wounds healed by first intention. At 2 weeks after operation, 2 cases had partial necrosis of the donor site flap and underwent secondary skin grafting after dressing change, the rest skin grafts survived, and all the wounds healed by first intention. Nineteen cases were followed up for 6-36 months (average 11 months). The flaps of palm and dorsum of hand showed no swelling, the reconstructed fingers had a satisfactory appearance and performed such functions as grabbing, grasping, and nipping. The sensory of the flaps and the reconstructed fingers recovered to S2-S4 grade. The donor site on the dorsum of the foot had no obvious scar contracture, without obvious influence on walking.?Conclusion?For the whole-hand destructive injury or hand degloving injury, the method of transplanting pedis compound free flap can repair the defect in the hand and reconstruct the function of the injured hand partially. It is an effective treatment method.