Soft tissue coverage of the mangled upper extremity

Abstract

Mangled upper extremity injuries usually involve high-impact trauma with crushing and tearing of the limb and its associated soft tissue structures. Such trauma is particularly mutilating because of the nature of the injury and the involvement of structures vital for proper function. Although advancements in flap technique and improvements in bone fixation methods have enabled good functional and clinical outcomes in limb salvage reconstruction, this remains a challenging area. Attempts at limb preservation should be fully exhausted before consideration is given for amputation, which results in significantly decreased function. Here the authors focus on the various modalities of soft tissue coverage available including allogenic substitutes, the adjunctive use of negative pressure wound therapy, and the design and utilization of flaps to address various defect configurations for the goals of wound healing, aesthetics, and functional restoration in the mangled upper extremity.

Keywords: hand; injury; soft tissue flap; upper extremity.

Fig. 1

A 52-year-old woman presented with a dorsal hand wound with exposed extensor tendons (A). The wound was covered with collagen wound matrix (Integra, Integra Life Sciences, Plainsboro, NJ) and skin grafted 1 month later, (B) Appearance of wound prior to skin grafting. (C) 3-month postoperative result.

Fig. 2

A 43-year-old man sustained a degloving injury of the volar aspect of his left hand and forearm from a cornpicker machine (A). (B) An anterolateral thigh flap was used for coverage. (C) 4-month postoperative result.

Fig. 3

A 25-year-old man sustained a saw injury to his right hand causing dorsal skin loss (A). (B) A superficial circumflex iliac artery perforator (SCIP) flap was designed and elevated. (C) Perforator seen entering the flap. (D) The flap has been harvested very thin to approximate the contour of the dorsal skin of the hand. (E) Immediate postoperative result.

Fig. 4

A 32-year-old woman sustained a right hand degloving injury following a motor vehicle accident with dorsal skin loss (A). (B) The wound was covered with a free lateral arm fascia only flap and later with a split thickness skin graft. (C) 5-month postoperative result.