Minor injuries of the hand can often have the full extent of the trauma evaluated at first presentation within the emergency department. Some of these injuries, such as fingertip trauma and extensor tendon lacerations can be safely and accurately treated in the emergency room. Mutilating injuries, however, are often too severe to fully appreciate the extent and pathology within the emergency room setting ( Fig. 1 A, B ). Patients are often unable to allow an adequate examination because of the extent of trauma, pain, and apprehension. Their injuries require intraoperative exploration for irrigation, debridement, and repair.

( A , B ) Example of a mutilating hand injury too severe to fully evaluate in the emergency room. Such injuries often require intra-operative exploration for adequate assessment, irrigation, debridement, and repair.

Hand surgeons should work with the patient to define the goals of the management of the mutilated hand/upper extremity. The goals should include restoration of range of motion of digits, return of sensation, pain control, and digit alignment. The surgeon prioritizes the trauma of the patient to first preserve life followed by preservation of the limb, preservation of limb function, and restoration of function through secondary procedures ( Fig. 2 A–C ).

( A , C ) Prioritization in the management of mutilating hand/upper extremity injuries. ( A ) Preservation of life, ( B ) Preservation of limb, ( C ) Restoration of limb function and planning for secondary reconstructive procedures.

There are various scoring systems for mangled extremities, focused largely on predicting the salvage potential of the affected limb. The Mangled Extremity Severity Score (MESS) is one of the most widespread scoring systems and incorporates bone and soft tissue damage and patient characteristics. The Narakawa Index Score constitutes an alteration of the original MESS that includes a nerve injury element. The Musculoskeletal Score for Severity of Injury (MESI) estimates the risk of amputation by including the same as the MESS as well as the period from the occurrence of trauma. Meta-analysis of outcomes from different scoring systems suggests that managing complex upper extremity injuries requires a comprehensive approach that should take into account the diverse factors influencing management and overall outcomes. Serlis and colleagues highlight that clinical benefits of scores are limited and highlighted the importance of patient involvement in decision-making and the importance of psychological factors and social support. Overall, higher scores of all scoring systems appear to be associated with amputation, although the cutoffs depend on the scoring. ^, There are no clear score thresholds for amputation versus salvage, although there is evidence that the mechanism of injury also has an impact, with worse outcomes in crush and blast injuries. The most used and studied scoring system, the MESS, typically uses a cutoff of 7 to determine the likelihood of salvage. Limb salvage can be achieved regardless of MESS; although some evidence suggests that success rates of salvage procedures are higher for MESS less than 7, high scores are not necessarily predictive of salvage failure. Importantly, despite being the most widespread scoring system used, MESS is more reliable for evaluating lower extremity than upper extremity injuries. ^, MESS and disability of arm, shoulder and hand scores do not correlate well with some studies citing that half of patients indicated for amputation based on MESS achieved good functional outcomes at long-term follow-up. The MESI in contrast has been shown to be more reliable for upper extremity evaluation with sensitivity of 86% to 100% and specificity of 83% to 100% depending on the study. ^, This area of management of complex upper extremity injuries continues to have potential for development. The recently created Mangled Upper Extremity Score (MUES) seeks to further expand its evaluation by also including injury variables. The MUES has shown some potential as it correlates with complications and length of stay unlike MESS; however at this time, predicting outcomes for upper extremities based on a scoring system remains difficult.

All patients with mutilating upper extremity injuries should be considered trauma patient s. Severe injury may be associated with other potentially life-threatening trauma. Airway, breathing, and circulation (ABC’s) are of primary importance ( Fig. 3 A, B ). Primary and secondary surveys are preformed to help rule out other injuries. The patient’s tetanus status is reviewed and appropriate administration of the toxoid or immunoglobulin may be administered depending on their immunization record. Intravenous antibiotics are initiated (usually Ancef 1–2gm IV depending on the patient’s weight) but wound cultures should be obtained immediately upon initiating the debridement in the operating theater to identify organisms that may colonize the wound or cause infection and further tissue compromise.

( A , B ) Initial trauma evaluation of the patient with a mutilating upper extremity injury. ( A ) Primary survey emphasizing ABCs, ( B ) Secondary survey to assess for additional injuries.

An emergency room evaluation of the mangled extremity allows the surgeon to obtain a rough guide as to the extent of the pathology. The vascular evaluation is of primary importance, as devascularized or amputated parts will require immediate operative repair to salvage the part. Capillary refill, turgor, temperature, and color of the fingers and hand are all recorded to help ascertain the integrity of the vascular arches and digital vessels proper. The ischemia time should be noted for all avascular parts such as amputations. The more proximal the amputation of the extremity, the less tolerant the tissue, especially muscle, is to prolonged ischemia. Usually less than 4 to 6 hours of warm ischemia and 8 to 12 hours of cold ischemia are tolerated. Revascularization beyond the critical ischemia time may result is an ischemia-reperfusion injury not only to the amputated part but also systemically due to central circulation of muscle breakdown products. Tissue amputated or devascularized that are on the cusp of critical ischemia time can be perfused with a temporary conduit, such as IV tubing, between the proximal vessels and the vessels of the devascularized part ( Fig. 4 ). A thorough examination of the skeletal support as well as preoperative X-rays are mandatory. Soft tissue evaluation including the integrity of the flexor and extensor tendons is performed. Sensibility should be tested. It is only through the thorough examination of the muscular skeletal system, soft tissue, and neurovascular system that the hand surgeon can fully understand preoperatively what the surgery will entail. The surgical staff can then be fully alerted as to the extent of the procedure so that efficiency is maintained. Microscopes, microinstruments, bone fixator devices, and other appropriate tissue instruments should be made available before the surgery begins.

Temporary perfusion of amputated or devascularized tissue using an intravenous tubing conduit between proximal and distal vessels to extend ischemia time and improve chances of successful revascularization.

The challenging surgical management of the mangled upper extremity has led many hand surgeons to develop systematic approaches to the care of these patients to provide efficient, safe, and functional outcomes. ^,,,,,,,,,,,, The mutilated extremity should be explored under tourniquet control. Excess bleeding only impairs the surgeon’s ability to evaluate tissue. Before inflating the tourniquet at the start of the procedure, the volar forearm veins should be identified and mapped with a sterile marker. Similarly, it is often wise to prep out a leg since vein grafts from the foot, leg, or forearm may be required to bridge gaps of vascular incongruity. The length of disruption of the vessels to the hand may be too extensive to accommodate primary repair necessitating interposition vein grafts to restore continuity. The wounds require irrigation and debridement. The importance of copious irrigation of all wounds cannot be overstated. ^,,,,,,,,,,,, The obviously devitalized tissue should be debrided by treating the wound as if they were a pseudotumor ( Fig. 5 A–D ). Together, the irrigation and debridement act not only decrease the bacterial load, but also remove debris and contaminants that serve as a potential breeding ground for facultative pathogens. Following debridement and irrigation, the tourniquet can be released to offer further controlled debridement if tissue perfusion appears definitively compromised. Secondary infection is a leading cause of further tissue loss, limb loss, and patient compromise making this initial debridement a very important step in the reconstructive efforts.

( A – D ) Intraoperative debridement of mutilated hand wounds: treating devitalized tissue as a pseudotumor, with copious irrigation and meticulous removal of debris to reduce bacterial load and prepare for reconstruction.

A comprehensive understanding of the intricate anatomy of the hand is mandatory. This basic knowledge will expedite identification and isolation of injured tissues so that (a) operative time is well spent, (b) viable and noninjured tissues are not further damaged, and (c) injured yet viable tissue is not inadvertently compromised. Hematomas, tissue swelling, and debris may obscure visualization. It is prudent therefore, to identify areas of normal anatomy out of the immediate zone of injury and follow the involved structures through the zone of trauma to protect vital structures still in continuity; known to unknown .

It is not uncommon with mutilating injuries of the upper extremity to have various digits or parts amputated as well. The amputated parts should also be subjected to a meticulous evaluation and debridement. Restoring function including grip strength and key pinch are of tremendous importance to returning the patient to activities of daily living. The hand surgeon should advise the transferring physician on appropriate care of the amputated part during the transportation to the receiving hospital. This entails wrapping the amputated part in a saline gaze, placing the wrapped part in a bag, and placing the packaged part in an ice bath secured container. The amputated part should not be placed directly on ice for fear of cold thermal damage. Once the patient and amputated part arrive to the hospital, the patient is stabilized and the part evaluated for possible replantation. The amputated parts can often precede the patient to the operating theater where the part is inspected, debrided, and dissected of vital structures for repair once the patient arrives to the operating theater. The amputated part can be placed in a betadine solution for sterilization before evaluation and dissection. The nail plate may be removed early in the dissection in case the surgeon wishes to allow bleeding from the nailbed postoperatively. The nerves, arteries, veins, and tendons are then dissected and made ready for replantation. The distal bone osteosynthesis fixation can be applied for time efficiency before the patient’s arrival in the operating theater.

The integrity and stability of the radius, ulna, wrist, metacarpals, and phalanges are assessed radiographically (preoperative) and during the exploration of the wounds. Small nonvascular bone chips are often better discarded. Larger bony fragments should be preserved to aid in the anatomic realignment and bone stability. Many modalities of bone fixation are used by hand surgeons. Bone fixation is discussed later in this review.

Extrinsic and intrinsic tendons should be handled with delicate forceps (Bishop-Harmans or Iris) preferably at their transected ends. Traumatic manipulation of these tendons, particularly flexors, induces further injury and promotes adhesions, ultimately impairing postoperative range of motion. ^,

The quality of the transected ends of the neurovascular bundles requires scrutinization before the repair is undertaken. The nerve and vascular ends are cut back to identifiably normal anatomy. Failure to remove an area of traumatized artery will result in postanastomotic intraluminal thrombosis and vascular insufficiency to the distal structures. Traumatized nerve ends may lead to painful neuroma formation or poor motor or sensibility recovery. Do not hesitate to use vein grafts to bridge gaps between the proximal and distal artery ends following debridement. It is better to use vein grafts than to attempt anastomosis under tension, as tension may result in turbulent blood flow and subsequent thrombosis. Similarly, the nerve ends should be freshened to see relatively uninjured fascicles pouting from the ends. This helps to optimize nerve regeneration and prevent painful neuroma formation at the coaptation site.

There are several case reports and small case series of ectopic banking of an amputated part when direct primary replantation was deemed unwise at the initial operative intervention in managing the mutilated upper extremity. ^,,,,, Although replantation has become common at tertiary institutions, occasionally the degree of contamination or tissue loss may raise concern about potential loss of the amputated part from infection or possibly the lack of an appropriate skeletal foundation for the amputated part, and therefore ectopic transplantation of a desired amputated part is performed. The amputated part needs to be of high value and appropriate quality to warrant ectopic transplantation. The ectopic banking is not commonly performed and rarely needed but does permit serial debridements of the injured limb and/or staged reconstruction of the limb before translocating the ectopic part back to its native limb. The site of ectopic banking varies from the groin to the axilla, to the leg/foot, or to the opposite upper extremity. The time to the second stage orthotopic translocation also varies depending on the patient stability, recipient readiness, and the other reconstructive needs of the involved extremity. It is obviously ideal to be able to replant the part immediately so that inflammation is minimized and function optimized but occasionally, this is not possible. Prolonged inflammation of the recipient site and the ectopically banked part may lead to significant stiffness and loss of function. Many reports of ectopic banking demonstrate excellent viability but limited function of the part in long-term follow-up. ^,,,

There is some controversy on the use of specialized tissue grafting in an acute mutilating hand injury. The benefits of obtaining the definitive repair at the first operative setting must be weighed against the risks and morbidity of the grafting. Infection is devastating to bone, nerve, and tendon grafts. The graft may be lost leaving the patient with morbidity of the graft donor site and still a need for a second graft from another donor site at a future date. Loss of adequate soft tissue coverage may expose the graft and render them desecrated. Further grafts will then be required adding to more donor morbidity. Finally, the increase in the operative time at the initial surgery for the donor harvest and reconstruction may not be warranted depending on other comorbid injuries. Second look surgeries and severe wound contamination are absolute contraindications to acute grafting procedures. Once the wound has been irrigated and debrided, the full extent of the injury can be appreciated. The repair and reconstruction can now ensue ( Fig. 6 A–F ). Tendon and nerve ends can be tagged and sutured out to length if later grafting is required. Alternatively, tendon grafting or transfers may be performed following the last debridement so that early mobilization can be started to limit secondary stiffness. Acute nerve grafting is controversial if a donor autologous nerve is being used as the nerve harvest may leave a noticeable donor sensory deficit depending on the nerve selected as a donor. Autologous grafting may provide better recovery of sensation but may not always be feasible. Autologous nerve substitutes include autologous tubes (veins), nerve allograft, and nerve conduits. Nerve allograft or conduit reconstruction for segmental defects of the nerve may be warranted if autologous donor nerves are not desired. Soft tissue coverage is obtained to set the stage for the secondary grafting once the wounds have healed. External fixators or bone spacers can keep the bony skeleton out to length and in anatomic alignment for future bone grafting.

( A – F ) Reconstruction sequence following thorough irrigation and debridement: tagging of tendon and nerve ends, staged tendon or nerve grafting as needed, and use of bone spacers or external fixators to maintain skeletal alignment.

The tissues involved should be repaired in an orderly fashion. Skeletal stabilization should precede other soft tissue reconstruction. This provides support and protection to the soft tissue structures. The type of skeletal fixation is less important than obtaining anatomic alignment. K-wire fixation, interosseous wires, plates, lag screws, or external fixators have been employed successfully. The choice of fixation is often left to the discretion, experience, and comfort level of the surgeon.

K-wire and interosseous wire fixation is less invasive, faster, often easier, provides less hardware. This type of fixation, though, does not provide rigid stability, and the hand is often immobilized for 6 weeks to allow for appropriate healing. K-wires left external to the skin may provide a portal for bacterial invasion into the wounds and pin track infection is not uncommon. Interosseous wires configured in a 90° fashion to each other are a strong means of fixation and are completely embedded under the tissues. Modular hand plates have a low profile and are usually made of titanium or stainless steel. This system can provide rigid fixation to initiate early range of motion and therapy. Lag screw fixation is extremely strong and is one of the best means of coapting bony fragments and fostering primary healing. Early mobilization can often be achieved with lag screw fixation. External fixators are an appropriate means of securing skeletal stabilization, particularly if the surgeon wishes to keep foreign material out of the wound or if there is a bony gap that needs to be bridged temporarily. For comminuted fractures, circulage wiring may bundle the bony fragments into relative coaptation where other types of fixation are impossible or unable to coapt the fragments. Phalangeal distraction can be achieved with transverse k-wires distal to the fragment site. Outrigger splints or a digital distraction devise are particularly useful when the metacarpophalangeal (MP) or proximal interphalangeal (PIP) joints are involved to such an extent that early mobilization with remodeling is imperative for any reasonable functional outcome. The inflammation and swelling from the injury will result in joint stiffness and fibrosis necessitating early mobilization of joints. The fixation technique of choice should be dictated by the desire to optimize range of motion.