Vascular Disease and Trauma of Hand and Amputations Flashcards
A 36-year-old man presents to the clinic 1 year after repair of an isolated brachial artery laceration. Prior to arterial repair, the hand and forearm were dysvascular. Fasciotomies were not performed at the time of repair. The patient is unable to extend his fingers actively or passively with the wrist held in neutral position, but he is able to actively make a full fist. Sensation is intact. Which of the following interventions is most appropriate to improve finger extension and preserve grip strength in this patient?
A) Flexor pronator slide
B) Free functional gracilis transfer
C) Joint release and tenolysis
D) Splinting
The correct response is Option A.
Volkmann ischemic contracture is a devastating condition with serious motor and sensory functional implications for the upper extremity, most typically the forearm. It is the result of an acute compartment syndrome, following severe soft-tissue trauma and accompanying vascular insult. The patient in the scenario demonstrates a moderate contracture that is best treated with a flexor pronator slide.
When treatment of acute compartment syndrome is delayed or neglected, the muscles of the forearm undergo necrosis and contracture due to secondary fibrosis, causing the typical flexed deformity. This results in impairment of hand and finger function.
Surgical treatment is based on severity of contracture and function of the residual motor units. Mild contractures allow for full passive extension of the fingers with the wrist in volar flexion and can be treated with tendon lengthening and skin release, or selective flexor pronator slide, depending on the source of constrainment. Patients with moderate contractures demonstrate an inability to passively extend the fingers with the wrist in flexion but retain flexor muscle function. These contractures require consideration for a flexor pronator slide alone or in conjunction with tendon lengthening. Complete loss of muscle function necessitates consideration of free functional muscle transfer. Superficialis to profundus transfers are a consideration in the setting of significant contracture and functional limitation. It is typically used to facilitate improved hygiene and confers limited function. This would not be as good of an option for the patient in this question as it would compromise his strength and function. Neurolysis should be considered in conjunction with any reconstructive procedures. Splinting is an important adjunct to any reconstructive procedure and potentially can be employed as an initial treatment prior to surgical intervention to prevent worsening contracture.
References
Farber A, Tan TW, Hamburg NM, et al. Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: a review of the National Trauma Data Bank. Injury. 2012;43(9):1486-1491.
Pettitt DA, McArthur P. Clinical review: Volkmann’s ischaemic contracture. Eur J Trauma Emerg Surg. 2012;38(2):129-137.
Stevanovic M, Sharpe F. Management of established Volkmann’s contracture of the forearm in children. Hand Clin. 2006;22(1):99-111.
Tsuge K. Treatment of established Volkmann’s contracture. J Bone Joint Surg Am. 1975;57(7):925-929.
Braun RM, Vise GT, Roper B.J. Preliminary experience with superficialis-to-profundus tendon transfer in the hemiplegic upper extremity. Bone Joint Surg Am. 1974 Apr;56(3):466-72.
Stevanovic, Milan V.; Sharpe, Frances. “Compartment Syndrome and Volkmann Ischemic Contracture” Green’s Operative Hand Surgery. Pages 1763-1787.Published January 1, 2017.
A 10-year-old girl is brought to the office by her mother because of difficulty using her hand. Medical history includes supracondylar fracture 6 months ago treated with a closed reduction and casting. The fingers of the affected hand are held in the intrinsic minus position. Volkmann ischemic contracture following the fracture is suspected. Which of the following muscles is LEAST likely to be affected by Volkmann contracture?
A) Brachioradialis
B) Flexor digitorum profundus
C) Flexor digitorum superficialis
D) Flexor pollicis longus
E) Pronator teres
The correct response is Option A.
Volkmann ischemic contracture results from forearm muscle shortening and fibrosis as a result of ischemia of forearm muscles during increased compartment pressures. Common reasons for increased compartment pressures include gunshot wounds and fractures, particularly supracondylar pediatric fractures. The radial artery is superficially located, whereas the ulnar artery is deeply positioned, traversing deep to the pronator teres muscles. The ulnar artery becomes the common interosseous artery, which divides immediately into anterior and posterior interosseous branches. The muscles dependent on this deep circulatory pattern are more likely to be affected by ischemia during increased compartment pressures. Flexor muscles commonly involved in this process are the flexor digitorum superficialis, flexor digitorum profundus, flexor pollicis longus, and pronator teres. The brachioradialis is not typically affected due to its more superficial radial artery circulation. Patients with significant functional loss may require surgical procedures such as a free gracilis functioning muscle transfer.
References
Fischer JP, Elliott RM, Kozin SH, Levin LS. Free function muscle transfers for upper extremity reconstruction: a review of indications, techniques, and outcomes. J Hand Surg Am. 2013;38(12):2485-2490.
Harris IE. Supracondylar fractures of the humerus in children. Orthopedics. 1992;15(7):811-817.
Stevanovic M, Sharpe F. Management of established Volkmann’s contracture of the forearm in children. Hand Clin. 2006;22(1):99-111.
Zuker RM, Bezuhly M, Manktelow RT. Selective fascicular coaptation of free functioning gracilis transfer for restoration of independent thumb and finger flexion following Volkmann ischemic contracture.J Reconstr Microsurg. 2011 Sep. 27(7):439-44.
Brahmamdam P1, Plummer M, Modrall JG, Megison SM, Clagett GP, Valentine RJ. Hand ischemia associated with elbow trauma in children. J Vasc Surg. 2011 Sep;54(3):773-8.
A 45-year-old carpenter presents with a six-month history of an ulceration of the ring fingertip and pain at rest. Digital brachial index is 0.45, and angiography demonstrates occlusion of the ulnar artery. The patient has tried three months of calcium channel blockers and aspirin without relief. Which of the following is the most appropriate treatment for this patient?
A) Amputation of the fingertip
B) Chemical sympathectomy
C) Reconstruction of the ulnar artery
D) Stellate ganglion block
E) Surgical sympathectomy
The correct response is Option C.
Conservative treatment includes smoking cessation, calcium channel blockers, anticoagulation therapy, stellate ganglion block, and behavior modification. Nonoperative management is generally considered first-line treatment, because most patients will have at least partial resolution of their symptoms. With that said, 70% of those treated nonoperatively had partial resolution of their symptoms, and only 12% had complete resolution. Of patients treated operatively, 42% had complete resolution of their symptoms and 42% had partial resolution.
For patients with evidence of more advanced disease such as digital ulceration, chronic resting pain, or conservative management failure, operative intervention may be considered. Preoperative noninvasive vascular studies can be used to determine which patients may require reconstruction versus simple excision and ligation. Studies have suggested that a digital brachial index less than 0.7 indicates reconstruction may be warranted. An index of less than 0.5 suggests critical ischemia, which may result in tissue loss.
Surgical options fall into two basic groups: resection of the involved arterial segment with ligation, and vascular reconstruction with or without interposed graft. Graft occlusion is reported in as high as 78% of patients. Despite a high percentage of occlusion, patients remained satisfied. Patients with occluded reconstructions did not experience worsening of symptoms in comparison with the patent reconstructions. Preoperative digital brachial index values, although informative as to the patient’s digital perfusion, do not mandate a particular operative intervention. The general treatment algorithm is to perform surgery on patients who have failed on medical management and local treatment to heal any digital soft tissues. A decision on ligation versus reconstruction can be made with the assistance of information gathered by preoperative angiography and noninvasive vascular studies, as well as intraoperative assessment of ulnar digital perfusion with temporary occlusion of the ulnar artery. Poor perfusion following temporary occlusion mandates reconstruction of the artery, whereas adequate perfusion, despite occlusion, can be treated with simple excision or ligation of the diseased ulnar artery segment.
References
Endress RD, Johnson CH, Bishop AT, Shin AY. Hypothenar hammer syndrome: long-term results of vascular reconstruction. J Hand Surg Am. 2015;40(4):660-665.e2.
Lifchez SD, Higgins JP. Long-term results of surgical treatment for hypothenar hammer syndrome. Plast Reconstr Surg. 2009;124(1):210-216.
Vartija L, Cheung K, Kaur M, Coroneos CJ, Thoma A. Ulnar hammer syndrome: a systematic review of the literature. Plast Reconstr Surg. 2013;132(5):1181-1191
A 5-year-old boy presents to the emergency department 4 hours after he sustained an amputation of his left index finger when it was slammed in a door. The parents brought the amputated digit in a plastic bag on ice. The amputation is at the level of the mid proximal phalanx. Which of the following is the most important reason to attempt replantation?
A) The amputation is proximal to the flexor digitorum superficialis insertion
B) The cold ischemia time is less than 6 hours
C) It is the index finger
D) It is a single-digit amputation
E) The patient is a child
The correct response is Option E.
Digital replantation should almost always be attempted in a child, except when the amputated part is severely crushed or there are other life-threatening injuries that preclude surgery. Replantation in children is technically more challenging due to the smaller size of the vessels. However, functional outcomes are more superior than in adults. The replanted parts have better sensory return and can have normal growth. Amputations through joints also exhibit remarkable joint remodeling.
A single digit amputation, especially proximal to the flexor digitorum superficialis (FDS) insertion is considered a contraindication to replantation. Digit replantations proximal to the FDS insertion have a poor range of motion as compared to amputations distal to the FDS insertion. This is, thus, an important landmark when making decisions about amputation versus replantation. Multiple digit amputations are an indication for replantation as the functioning deficit with loss of multiple digits is great. The thumb is responsible for 40% of the function of the hand and should always be replanted, if possible. Even if it is stiff and insensate, a replanted thumb will act as a post for opposition.
Index finger amputations at or proximal to the proximal interphalangeal joint are considered by many to be an indication for amputation. A stiff and painful index finger is likely to be excluded by the patient; amputation will result in better global hand function.
Digits tolerate longer ischemia times than more proximal level amputations, due to absence of muscle. Amputated digits tolerate warm ischemia times of 6 to 12 hours and cold ischemia times of 12 to 24 hours. Digital replantation has been reported with warm ischemia time of 33 hours and cold ischemia time of 94 hours. Cold ischemia time is thus not a major consideration in the decision-making process for amputation versus replantation.
References
Barbary S, Dap F, Dautel G. Finger replantation: surgical technique and indications. Chir Main. 2013;32(6):363-372.
Pederson WC. Replantation. Plast Reconstr Surg. 2001;107(3):823-841.
Prucz RB, Friedrich JB. Upper extremity replantation: current concepts. Plast Reconstr Surg. 2014;133(2):333-342.
A 15-year-old boy sustained a traumatic amputation of the left index finger at the proximal interphalangeal joint level from a sharp injury. Replantation of the digit is performed, with vein grafting of the radial digital artery and vein. The distal tip of the digit appears congested, so medicinal leeching is instituted. Which of the following antibiotics is the most appropriate prophylaxis for this patient?
A) Amoxicillin and clavulanic acid
B) Ampicillin
C) Cephalexin
D) Ciprofloxacin
E) Vancomycin
The correct response is Option D.
The antibiotic choice that constitutes the best prophylaxis for this patient undergoing leech therapy is ciprofloxacin. Hirudo medicinalis is the most common leech species used in medicine, and its gut flora includes Morganella, Rikenella, and Aeromonas isolates. These bacteria are all sensitive to ciprofloxacin. Doxycycline or ceftriaxone are alternative treatments for Aeromonas prophylaxis.
Animal toxicology data available with the first quinolone compounds revealed an association with inflammation and subsequent destruction of weight-bearing joints in canine puppies. This observation limited further development or large-scale evaluation of this class of antibiotic agents in children at that time. However, there continued to be increased use of fluoroquinolones for pediatric patients over the past 30 years with data on the lack of toxicity when used in children. In 2004, ciprofloxacin became the first fluoroquinolone agent approved for use in children 1 through 17 years of age.
Cephalexin (Keflex) is a first-generation cephalosporin that is used to treat respiratory tract, middle ear, skin, bone, and urinary tract infections. Most Aeromonas strains are resistant to penicillin, ampicillin, carbenicillin, and ticarcillin. And most Aeromonas and Morganella strains have complete or intermediate resistance to amoxicillin and clavulanic acid (Augmentin). Vancomycin is a macrolide antibiotic, and has limited effectiveness for Aeromonas strains with high levels of antibiotic resistance.
References
Jackson MA and Schutze GE. The Use of Systemic and Topical Fluoroquinolones. Pediatrics. 2016 Nov; 138(5):e1-e13.
Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.
Whitaker IS, Elmiyeh B, Wright DJ. Hirudo medicinalis: the need for prophylactic antibiotics. Plast Reconstr Surg. 2003 Sep 15;112(4):1185-1186.
Whitaker IS, Maltz M, Siddall ME, et al. Characterization of the digestive tract microbiota of Hirudo orientalis (medicinal leech) and antibiotic resistance profile. Plast Reconstr Surg. 2014 Mar;133(3):408e-418e.
Which of the following comorbidities is associated with the highest risk of digital replant failure?
A) Alcohol abuse
B) Chronic obstructive pulmonary disease
C) Diabetes mellitus
D) Psychotic disorders
E) Tobacco use
The correct response is Option D.
In a study looking at all amputation injuries and digital replantations captured by the National Inpatient Sample from 2001 to 2012, the comorbid conditions associated with the highest risk of replant failure were psychotic disorders, peripheral vascular disease, and electrolyte imbalances. The risk of replant failure increased 79% in a patient with a psychotic disorder. Alcohol abuse increased the risk of replant failure by 16%, tobacco use by 7%, diabetes by 3%, and chronic obstructive pulmonary disease by 1%. Interestingly, age in and of itself was not associated with a higher chance of replant failure in this and other studies.
References
Dec W. A meta-analysis of success rates for digit replantation. Tech Hand Up Extrem Surg. 2006 Sep;10(3):124-129.
Hustedt JW, Chung A, Bohl DD, et al. Evaluating the effect of comorbidities on the success, risk, and cost of digital replantation. J Hand Surg Am. 2016 Dec;41(12):1145-1152.
Nazerani S, Motamedi MH, Ebadi MR, Nazerani T, Bidarmaghz B. Experience with distal finger replantation: a 20-year retrospective study from a major trauma center. Tech Hand Up Extrem Surg. 2011 Sep;15(3):144-50.
A 37-year-old man who works as a laborer sustains a saw injury to the non-dominant left hand. X-ray studies are shown. Which of the following is the most appropriate functional option for reconstruction of this thumb defect?
A) Metacarpal lengthening
B) Osteoplastic reconstruction
C) Pollicization
D) Prosthesis
E) Toe transfer
The correct answer is Option C.
The x-ray study shows a carpometacarpal-level amputation of the thumb. Toe transfer, osteoplastic reconstruction, and metacarpal lengthening require part or most of the thumb metacarpal to be present. A thumb prosthesis would have limited functionality and be insensate.
Pollicization would potentially allow a sensate, functional index finger to accomplish some of the functions of the thumb. It is, however, not without its drawbacks because it is technically demanding and has a high likelihood of requiring secondary procedures. For a carpometacarpal-level amputation, pollicization provides the best option for function.
References
Graham D, Bhardwaj P, Sabapathy SR. Secondary thumb reconstruction in a mutilated hand. Hand Clin. 2016 Nov;32(4):533-547.
Muzaffar AR, Chao JJ, Friedrich JB. Posttraumatic thumb reconstruction. Plast Reconstr Surg. 2005 Oct;116(5):103e-122e.
Pet MA, Ko JH, Vedder NB. Reconstruction of the traumatized thumb. Plast Reconstr Surg. 2014 Dec;134(6):1235-1245.
Graham DJ, Venkatramani H, Sabapathy SR. Current reconstruction options for traumatic thumb loss. J Hand Surg Am. 2016 Dec;41(12):1159-1169.
A 40-year-old woman presents with small, non-healing ulcers of the right index and middle fingertips. Medical history includes limited scleroderma diagnosed 5 years ago, chronic pain, and color changes of the fingers in cold temperatures. The patient’s symptoms have not improved with administration of nifedipine. Angiography shows diffuse vascular narrowing without any focal lesions. Which of the following is the most appropriate intervention for pain relief and ulcer healing in this patient?
A) Cervical sympathectomy
B) Continuous brachial plexus blockade
C) Digital bypass
D) Onabotulinum toxin A
E) Stellate ganglion block
The correct response is Option D.
This patient has Raynaud’s phenomenon associated with scleroderma. The pathophysiology of Raynaud’s is thought to be related to sympathetic hyperactivity, elevated plasma endothelin, increased peripheral alpha-2 receptors, and possibly abnormal platelet and red cell function. Botulinum toxin type A has been shown to improve digital perfusion on laser Doppler, decrease pain, and result in ulcer healing. In a series of 33 patients injected with 50 to 100 U of onabotulinum toxin A, all patients had ulcer healing by 60 days postinjection. Pain relief typically occurred within 5 to 10 minutes of injection and complication rates were low and limited to injection site reactions. A prospective, randomized, placebo-controlled trial showed patients with limited scleroderma and shorter duration of disease had the best response to onabotulinum toxin A.
Stellate ganglion blocks have been shown to have only variable success for Raynaud’s with only short-term symptom relief and no effect on ulcer healing. Stellate blocks may not disrupt all sympathetic input to the extremity. Brachial plexus blocks may help with perfusion temporarily but are advocated mainly in patients undergoing microvascular surgery. Their use is not recommended in this setting. Surgical bypass to the superficial palmar arch has been shown to increase blood flow to the hand and improve ulcer healing. However, bypass to the digital vessels would not be indicated as the distal target vessels are often diminutive without adequate flow.
References
Bello RJ, Cooney CM, Melamed E, et al. The Therapeutic Efficacy of Botulinum Toxin in Treating Scleroderma-Associated Raynaud’s Phenomenon: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Arthritis Rheumatol. 2017 Aug;69(8):1661-1669.
Neumeister MW, Chambers CB, Herron MS, et al. Botox Therapy for Ischemic Digits. Plast Reconstr Surg. 2009 Jul;124(1):191-201.
Porter SB, Murray PM. Raynaud Phenomenon. J Hand Surg Am. 2013 Feb;38(2):375-377.
Neumeister MW. Botulinum Toxin Type A in the Treatment of Raynaud’s Phenomenon. J Hand Surg Am. 2010 Dec;35(12): 2085-2092.
A 22-year-old man who is a college student sustains a volar oblique fingertip amputation while chopping vegetables. Examination shows involvement of the hyponychium, but the nail is undamaged. The wound measures 1 × 1.5 cm, and no exposed bone is noted. Which of the following is the most appropriate treatment to encourage healing by secondary intention?
A) Apply negative pressure wound therapy
B) Apply povidone iodine to the wound daily and cover with dry gauze
C) Cover wound with semiocclusive dressing and change weekly
D) Leave wound open to air
E) Soak wound in hydrogen peroxide daily and cover with moist gauze
The correct response is Option C.
Fingertip or thumb tip amputations that result in small wounds (less than 1.5 cm2) and minimal exposed bone are best managed with healing by secondary intention. The only exception to this might be a laborer anxious to get back to work with a healed wound sooner than 3 to 4 weeks. Mennen reported a series of 200 such injuries treated with a semi-occlusive dressing, and average healing time was 20 days.
A semiocclusive dressing is semi-permeable and transparent, allowing air to pass through the dressing, but providing a barrier to moisture. Commonly available semipermeable dressings are marketed under brand names like Tegaderm (3M) and OPSITE (Smith & Nephew). These dressings maintain a moist wound environment, which speeds healing. If dressings are changed every 5 to 7 days, manipulation of the wound is minimized and, therefore, healing is less disrupted.
Leaving a wound open to air would allow tissues to dry out, which would delay healing. Likewise, the use of povidone-iodine and/or hydrogen peroxide would slow down healing due to drying of the wound. Although these topical agents are effective at eliminating bacteria from dirty or infected wounds, prolonged use will interfere with normal wound healing. Finally, a wound of this small size would not warrant negative pressure wound therapy. Even the small, intrinsically-powered negative pressure wound therapy devices would not offer any advantages over a semiocclusive dressing and would increase cost substantially.
References
Germann G, Rudolf KD, Levin SL, Hrabowski M. Fingertip and thumb tip wounds: changing algorithms for sensation, aesthetics, and function. J Hand Surg Am. 2017 Apr;42(4):274-284.
Germann G, Sauerbier M, Rudolf KD, Hrabowski M. Management of thumb tip injuries. J Hand Surg Am. 2015 Mar;40(3):614-622.
Mennen U, Wiese A. Fingertip injuries management with semi-occlusive dressing. J Hand Surg Br. 1993 Aug;18(4):416-422.
Panattoni JB, De Ona IR, Ahmed MM. Reconstruction of fingertip injuries: surgical tips and avoiding complications. J Hand Surg Am. 2015 May;40(5):1016-1024.
A 40-year-old man sustained traumatic amputation of all fingers of the dominant hand 3 months ago. Tripod pinch reconstruction is planned with a double second toe transfer. Which of the following arteries is most likely to be the dominant blood supply to the second toe transfer in this patient?
A) First dorsal metatarsal artery
B) First plantar metatarsal artery
C) Lateral plantar artery
D) Medial plantar artery
E) Third plantar metatarsal artery
The correct response is Option A.
The first dorsal metatarsal artery (FDMA) is the dominant blood supply (to the great toe and second toe) in approximately 70% of cases. The first plantar metatarsal artery (FPMA) is the dominant blood supply in 20% of cases. The FDMA and the FPMA have a similar vessel caliber in the remaining 10% of cases.
The dominant vascular pattern can be evaluated by careful retrograde dissection that begins at the dorsal aspect of the first web space. The junction of the lateral digital artery of the great toe and the medial digital artery of the second toe can be identified just above the intermetatarsal ligament. Proximal dissection continues dorsally and plantarly to evaluate the FDMA and FPMA.
If the FDMA is the larger caliber vessel or of similar caliber to the FPMA, then the toe transfer can be based on the FDMA. Proximal dissection of the FDMA to obtain length is relatively straightforward. In the setting of a plantar dominance, dissection of the FPMA is carried out proximally, which can be more challenging. Plantar proximal dissection is typically limited to the mid metatarsal level to avoid additional morbidity. If additional length is required on the FPMA pedicle, a vein graft can be used. It is important to note that in bilateral second toe transfers, the dominant vascular pattern can be asymmetric in 20% of patients.
References
Coskunfirat OK, Wei FC, Lin CH, Chen HC, Lin YT. Simultaneous double second toe transfer for reconstruction of adjacent fingers. Plast Reconstr Surg. 2005 Apr;115(4):1064-1069.
Henry SL, Wei FC. Thumb reconstruction with toe transfer. J Hand Microsurg. 2010 Dec;2(2):72-78.
Spanio S, Wei FC, Coskunfirat OK, Lin CH, Lin YT. Symmetry of vascular pedicle anatomy in the first web space of the foot related to toe harvest: clinical observations in 85 simultaneous bilateral second-toe transfer patients. Plast Reconstr Surg. 2005 Apr 15;115(5):1325-1327.
Wei FC, Henry SL. Toe-hand-transplantation. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. Philadelphia, PA: Elsevier Churchill Livingstone; 2011:1807-1837.
An otherwise healthy 26-year-old woman undergoes zone 2 wide-awake flexor tendon repair of the right index finger. A solution of 1% lidocaine with 1:100,000 epinephrine is injected into the hand and digit. After surgical repair of the flexor digitorum profundus (FDP) tendon, the patient’s finger is still pale without capillary refill. Administration of which of the following classes of drug is most likely to reverse the effects of epinephrine in this patient?
A) Alpha-adrenergic receptor activator
B) Alpha-adrenergic receptor blocker
C) Beta-adrenergic receptor blocker
D) Potassium channel activator
E) Sodium channel blocker
The correct response is Option B.
The medication that is used to reverse the effects of epinephrine is phentolamine, which is an alpha-adrenergic receptor blocker. The wide-awake Hand Surgery is well described by Donald Lalonde and utilizes the effects of local anesthesia to perform a wide variety of hand-surgical procedures without general anesthesia.
An alpha-adrenergic receptor activator, such as epinephrine, could increase vasoconstriction and worsen the scenario, as could a beta-adrenergic receptor blocker. Sodium channel blockers and potassium channel activators are not indicated for reversal of epinephrine effect.
References
Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rupture with intraoperative total active movement examination. Plast Reconstr Surg. 2010 Sep;126(3):941-945.
Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie project clinical phase. J Hand Surg Am. 2005 Sep;30(5):1061-1067.
Lalonde DH. Wide-awake flexor tendon repair. Plast Reconstr Surg. 2009 Feb;123(2):623-625.
Nodwell T, Lalonde D. How long does it take phentolamine to reverse adrenaline-induced vasoconstriction in the finger and hand? A prospective, randomized, blinded study: the Dalhousie project experimental phase. Can J Plast Surg. 2003 Winter;11(4):187-190.
An otherwise healthy 35-year-old man sustains an amputation of the right thumb while using a cutting saw. Assuming appropriate cooling of the amputated part is performed immediately, successful replantation of the digit could be realistically achieved if performed within which of the following maximum time frames?
A) 2 hours
B) 4 hours
C) 6 hours
D) 12 hours
E) 24 hours
The correct response is Option E.
The reasonable maximum time frame for replantation of an appropriately cooled and stored digit (referred to as cold ischemia time) is 24 hours. However, the warm ischemia time for digital replantation is 12 hours. These times are further reduced when replanting more proximally amputated limbs, such as an arm or leg, because of the presence of ischemia-sensitive muscle. The recommended maximum cold ischemia time to replantation in these major replants is 12 hours; the warm ischemia time is 6 hours. Despite these recommended time frames, successful replantations performed many hours after the amputations have been reported. In 1986, May et al. reported a successful digit replantation after 39 hours of cold ischemia, the seventh of a seven-finger replant. Then, in 1988, Wei et al. reported successful digital replantations after 84, 86, and 94 hours of cold ischemia. Whenever there is more muscle mass in the replanted limb, ischemia time becomes more critical. In these clinical scenarios, immediate shunting should be considered especially when the ischemia time is nearing the time frames described above.
The other options are incorrect because they are within the ideal maximum time frame.
References
Prucz RB, Friedrich JB. Upper extremity replantation: current concepts. Plast Reconstr Surg. 2014 Feb;133(2):333-42.
May JW. Digit replantation with full survival after 28 hours of cold ischemia. Plast Reconstr Surg. 1981 Apr. 67(4):566.
Chiu HY, Chen MT. Revascularization of digits after thirty-three hours of warm ischemia time: a case report. J Hand Surg Am. 1984 Jan. 9A(1):63-7.
May JW Jr, Hergrueter CA, Hansen RH. Seven-digit replantation: digit survival after 39 hours of cold ischemia. Plast Reconstr Surg. 1986 Oct. 78(4):522-5.
Wei FC, Chang YL, Chen HC, et al. Three successful digital replantations in a patient after 84, 86, and 94 hours of cold ischemia time. Plast Reconstr Surg. 1988 Aug. 82(2):346-50.
A 48-year-old man presents with pain 4 days after he underwent elective surgery of the right hand. The procedure included injection of 1% lidocaine with 1:100,000 epinephrine into the palm. Physical examination shows cold, pale digits, with prolonged capillary refill. Which of the following is the most appropriate management?
A) Inpatient admission and hourly wound checks for signs of necrosis
B) Local phentolamine infiltration
C) Topical nitroglycerin with warm water immersion
D) Topical terbutaline infiltration
E) No further management is necessary
The correct response is Option B.
Case reports have been documented of ischemia and subsequent tissue necrosis following elective hand surgery using lidocaine with epinephrine. The vasoconstrictive effect of epinephrine is a result of its stimulation of alpha-adrenergic receptors. Phentolamine, an alpha-adrenergic antagonist, has been used effectively to reverse the vasoconstrictive effect of epinephrine. When used in the hand, phentolamine rescue is carried out by injecting 1 to 2 mg of phentolamine in 1 to 5 mL of saline into the area where epinephrine was used. The reversal of vasoconstriction should result within 1 hour. Digital ischemia following accidental EpiPen injection into the hand has also been reported. The use of topical terbutaline infiltration has been attempted in such cases. In one case series, terbutaline infiltration was found to be effective in reversing vasoconstriction in some, but not all cases. The conclusion reached in the study was that terbutaline should be considered as an alternative when phentolamine is not available. The use of topical nitroglycerin and warm water immersion has not been proven to be an effective method to reverse the alpha-adrenergic effect of epinephrine. If prolonged ischemia is a concern following the use of lidocaine with epinephrine, further management, such as phentolamine rescue, should be considered given that complications such as distal digital amputation have occurred.
References
Zhang JX, Gray J, Lalonde DH, et al. Digital Necrosis After Lidocaine and Epinephrine Injection in the Flexor Tendon Sheath Without Phentolamine Rescue. J Hand Surg Am. 2017 Feb;42(2):e119-e123.
Velissariou I, Cottrell S, Berry K, et al. Management of adrenaline (epinephrine) induced digital ischaemia in children after accidental injection from an EpiPen. Emerg Med J. 2004 May;21(3):387-8.
A 52-year-old man sustains an amputation of the index finger of his dominant right hand from a table saw. Physical examination shows a sharp amputation immediately distal to the flexor digitorum superficialis insertion. He does not smoke cigarettes. Which of the following factors is the most appropriate indication to perform a replantation?
A) Dominant hand
B) Index finger amputation
C) Level of amputation
D) Nonsmoking status
E) Patient age
The correct response is Option C.
The most appropriate indication to perform a replantation is the level of the amputation. Replantation of an amputation distal to the flexor digitorum superficialis is attempted because the function of the digit is improved with additional length to a normal proximal interphalangeal joint. An amputation in a child is an indication for replantation (adult age is not). Hand dominance is not a major variable in the determination of whether or not to perform a replantation. Replantation of single digits (including the index finger) at the proximal phalanx or proximal interphalangeal joint in adults often is not performed because the limited motion of the digit can inhibit overall hand function. An exception is any level amputation of the thumb, which is a major indication for replantation because the thumb provides 40 to 50% of hand function. Smoking status is not a major variable for the consideration of replantation.
References
Prucz RB, Friedrich JB. Upper extremity replantation: current concepts. Plast Reconstr Surg. 2014 Feb;133(2):333-42.
Jazayeri L, Klausner JQ, Chang J. Distal digital replantation. Plast Reconstr Surg. 2013 Nov;132(5):1207-17.
A 35-year-old woman presents with a fixed adduction contracture of the first web space that has not improved with splinting and hand therapy for 4 months. Medical history includes a crush injury with complex laceration to the first web and dorsal hand and index finger five months ago. A photograph is shown. Which of the following is the most appropriate plan for reconstruction of the first web space contracture in this patient?
A) First dorsal metacarpal artery flap
B) Flexor carpi ulnaris flap
C) Posterior interosseous artery flap
D) Thenar flap
E) Split-thickness skin grafting
The correct response is Option C.
Contracture of the first web space may be secondary to cutaneous scarring, skin deficiency, fibrosis of the fascia and thenar muscles, or joint contractures. Mild contractures may be isolated to the skin; however, deeper structures are most likely involved as the contracture becomes more severe. It is important to understand the mechanism of injury, length of time the contracture has been present, and any prior treatments.
Reconstruction of the first web space involves complete contracture release and resurfacing with adequate vascularized tissue. The dissection should be carried out palmarly and dorsally with release of the palmar fascia and adductor aponeurosis as needed. Intrinsic muscle and joint contractures should be addressed at this time, and a trapeziectomy may be needed to restore carpometacarpal (CMC) motion.
This patient has a severe contracture that likely involves multiple structures given her history of deep lacerations and bony injury. This requires resurfacing with thin, pliable vascularized tissue. In this setting, the posterior interosseous artery (PIA) flap is the best choice. This flap is outside the zone of injury and provides an adequate amount of vascularized tissue for resurfacing of the web space. The PIA runs between the extensor carpi ulnaris and extensor digit quinti and forms an anastomosis with the anterior interosseous artery 2cm proximal to the distal radioulnar joint.
Skin grafting alone, either split-thickness or full-thickness, should be avoided because of the inherent tendency for secondary contracture. Skin grafts may be combined with local flaps such as a 4-flap or 5-flap z-plasty in mild to moderate contractures.
Tissue flaps from the dorsum of the hand such as the first dorsal metacarpal artery fasciocutaneous flap or dorsal hand transposition flap may be good options in some patients with small- to moderate-sized skin deficits. However, this patient sustained trauma to the dorsal hand with dorsal skin lacerations. This makes a random-pattern transposition flap unreliable. The defect in question is also too large to be completely resurfaced with a first dorsal metacarpal artery (FDMA) flap. The flexor carpi ulnaris flap is useful for elbow coverage as a turn-over flap but will not reach the hand.
References
Moody L, Galvez M, Chang J. Reconstruction of First Web Space Contractures. J Hand Surg Am. 2015 Sept;40:1892-95.
Cavadas P et al. The Simplified Posterior Interosseous Flap. J Hand Surg Am. 2016 Sep;41(9):e303-7.
Which of the following is the arterial supply of the flap for digital tip reconstruction shown?
A) Distally based from the contralateral digital artery
B) Dorsal perforating vessels
C) Perineural perforating vessels
D) Proximally based from the ipsilateral digital artery
The correct response is Option A.
A reverse homodigital island flap is shown. It is a distally based flap that is useful in the repair of fingertip injuries. Arterial inflow is based upon the contralateral digital artery in the crossing ladder vessels of the palmar digital arch that lie just dorsal to the volar plate at each joint. The flap requires sacrifice of the ipsilateral digital artery and care must be taken to preserve the digital nerve during elevation of the skin paddle. Typically, the donor site is grafted.
References
Regmi S, Gu JX, Zhang NC, Liu HJ. A Systematic Review of Outcomes and Complications of Primary Fingertip Reconstruction Using Reverse-Flow Homodigital Island Flaps. Aesthetic Plast Surg. 2016 Apr;40(2):277-83.
Foucher G and Khouri RK: Digital reconstruction with island flaps. Clin Plast Surg. 1997 Jan;24(1):1-32.
An 86-year-old farmer is brought to the emergency department because of a large dorsal wound of his nondominant left hand sustained when his hand was caught in a flail mower. After debridement is performed, examination shows normal volar structures, including nerve and tendon function, and loss of dorsal skin and tendons. Medical history includes myocardial infarction 1 month ago. An x-ray study and photograph are shown. Which of the following is the most appropriate method of reconstruction for this patient?
A) Bilaminate neodermis (Integra) and skin grafting with delayed bone grafting
B) External fixator and posterior interosseous artery flap
C) Finger fillet flaps of index and middle finger
D) Free anterior lateral thigh flap with secondary bone grafting
E) Pedicle radial forearm flap with secondary bone grafting
When caring for patients with mangling hand injuries, it is imperative to consider all aspects of the patient’s history and future goals. This patient would be at risk for cardiac complications if a longer procedure such as a free flap were chosen. The amount of bone loss in the index and middle metacarpals is also problematic and would most likely require multiple procedures. Just placing an external fixation and covering the wound with a local flap is also possible but will require several procedures. Bone grafting while receiving bilaminate neodermis (Integra) and skin grafts is not recommended because of the lack of subcutaneous tissue and poor blood supply. The most expeditious method of covering this patient’s wounds in one procedure is finger fillet flaps of the injured digits. Finger fillet flaps can cover a large area for reconstruction as shown.
References
Leunam S, Prugsawan K, Kosiyatrakul A ,et al. Neural anatomy of the anterolateral thigh flap. J Hand Microsurg. 2015;7:49-54.
Lachia RD. Evidence-Based medicine: management of acute lower extremity trauma. Plast Reconstr Surg. 2017;139:287-301e.
A 51-year-old woman is scheduled to undergo needle aponeurotomy for Dupuytren disease of the small finger. A photograph is shown. The addition of lipografting after needle aponeurotomy is most likely to decrease the rate and severity of recurrence in this patient by which of the following mechanisms?
A) Decreasing the proximity of residual cord tissue to the skin
B) Increasing the density of myofibroblast cell-to-cell contact
C) Increasing the density of the residual cord tissue
D) Inhibiting myofibroblast proliferation
E) Providing stem cells to promote collagen production
The correct response is Option D.
Fat grafting (also called lipofilling) has shown promise as a means to improve outcomes after percutaneous needle aponeurotomy for Dupuytren disease. It is believed to work by several mechanisms:
Reducing the density of cell-to-cell myofibroblast contact
Inhibiting myofibroblast proliferation via adipose-derived stem cells
Acting as an interposed tissue graft
Providing passing over the cords to replace native subdermal fat displaced by the nodules and cords
A randomized prospective trial by Kan and colleagues showed that aponeurotomy with lipofilling showed equivalent results at one year out from treatment with a much faster recovery compared with limited fasciectomy.
References
Hovius SER, Kan HJ, Smit X, et al. Extensive percutaneous aponeurotomy and lipografting: a new treatment for Dupuytren’s disease. Plast Reconstr Surg. 2011.128:221-8.
Kan HJ, Selles RW, van Nieuwenhoven CA, et al. Percutaneous aponeurotomy and lipofilling (PALF) versus limited fasciectomy in patients with primary Dupuytren’s contracture: a prospective, randomized, controlled trial. Plast Reconstr Surg. 2016. 137:1800-12.
Murphy A, Lalonde DH, Eaton C, et al. Minimally invasive options in Dupuytren’s contracture: aponeurotomy, enzymes, stretching, and fat grafting. Plast Reconstr Surg. 2014. 134:822e-829e.
Verhoekz JSN, Mudera V, Walbeehm ET, Hovius SER. Adipose-derived stem cells inhibit the contractile myofibroblast in Dupuytren’s disease. Plast Reconstr Surg. 2013.132:1139-48.
A 27-year-old man is brought to emergency department because of a thumb avulsion injury measuring 3 × 3 cm. A photograph is shown. Which of the following is the best option for sensate, soft-tissue coverage?
A) Cross-finger flap
B) First dorsal metacarpal artery flap
C) Moberg flap
D) Pedicled groin flap
E) Skin grafting
The correct response is Option B.
There are several sensate options for thumb pulp deformities. These include neurovascular island flaps, Moberg flaps, free toe pulp flaps, and the first dorsal metacarpal artery flap (FDMA). Cross finger flaps, skin grafts, and pedicle groin flaps do not have innate innervation. The defect in the question involves the entire pulp of the thumb overlying the distal phalanx and is too large for a Moberg advancement flap.
The FDMA flap is supplied by its eponymous artery, which travels in the fascia overlying the index metacarpal and supplies the skin overlying the dorsum of the proximal phalanx. The vessel is accompanied superficially by a branch of the radial nerve that provides neural activation to the skin overlying the proximal phalanx of the index finger. The flap can be transposed to provide sensate coverage of the tip of the thumb, and can provide sufficient size to resurface relatively large defects.
Cortical reorientation is the fact that the brain recognizes a stimulus from the flap area as a stimulus from the thumb, and not from the index finger. This process takes some time, but is usually complete after 2 years. Average static two-point discrimination in these flaps utilized for thumb resurfacing is 10 to 11 mm.
Use of the FDMA flap for resurfacing of the thumb pulp has been compared to heterodigital island flaps in several studies. Both remain options to be considered, but the ease of elevation, limited dissection, and acceptable donor site morbidity make the FDMA flap a common primary option for thumb tip resurfacing.
References
Tränkle M, Sauerbier M, Heitmann C, Germann G. Restoration of thumb sensibility with the innervated first dorsal metacarpal artery island flap. J Hand Surg Am. 2003; 28(5):758–766.
Muyldermans T, Hierner R. First dorsal metacarpal artery flap for thumb reconstruction: a retrospective clinical study. Strat Traum Limb Recon. 2009; 4:27.
Delikonstantinou IP, Gravvanis AI, Dimitriou V, Zogogiannis I, Douma A, Tsoutsos DA. Foucher first dorsal metacarpal artery flap versus Littler heterodigital neurovascular flap in resurfacing thumb pulp loss defects. Ann Plast Surg. 2011 Aug;67(2):119-22.
A 45-year-old woman with systemic sclerosis (scleroderma) has severe Raynaud phenomenon. A photograph is shown. Periarterial injection of botulinum toxin type A is being considered for treatment in this patient. This treatment is believed to relieve vasospasm in Raynaud phenomenon by which of the following mechanisms?
A) Blocking fast sodium channels in axonal gap junctions
B) Increasing the activity of chronically down-regulated group C nerve fiber nociceptors
C) Inhibiting Rho/Rho kinase activity
D) Obstructing myofibroblast contractile activity in vascular smooth muscle
E) Promoting substance P secretion/receptor sensitivity
The correct response is Option C.
Several mechanisms have been proposed to explain the effect of botulinum toxin type A (Botox) to inhibit Raynaud phenomenon in patients with scleroderma. Studies have demonstrated inhibition of Rho/Rho kinase activity, inhibition of substance P secretion and receptor sensitivity, and decreasing the activity of chronically up-regulated C-fiber nociceptors all to occur in models of Raynaud phenomenon that responded to Botox treatment. Fast sodium channels conduct axonal signals AT in gap junctions, but have not been shown to be affected by Botox. Myofibroblasts may be involved in late fibrosis of scleroderma patients but do not exist within the vascular smooth muscle.
References
Fonseca C, Abraham D, Ponticos M. Neuronal regulators and vascular dysfunction in Raynaud’s phenomenon and systemic sclerosis. Curr Vasc Pharmacol. 2009;7(1) :34–39.
Iorio ML, Masden DL, Higgins JP. Botulinum toxin A treatment of Raynaud’s phenomenon: a review. Semin Arthritis Rheum. 2012 Feb;41(4):599-603.
Neumeister MW. The role of botulinum toxin in vasospastic disorders of the hand. Hand Clin. 2015 Feb;31(1):23-37.
Uppal L, Dhaliwal K, Butler PE. A prospective study of the use of botulinum toxin injections in the treatment of Raynaud’s syndrome associated with scleroderma. J Hand Surg Eur Vol. 2014 Oct;39(8):876-80.
A 30-year-old man is scheduled to undergo transhumeral amputation after unsalvageable brachial artery occlusion. A photograph is shown. Use of targeted muscle reinnervation may allow improved functional recovery by which of the following means?
A) Better bulk and durability by preventing denervation atrophy of muscles at the amputation stump
B) Better prosthesis control by input from median and ulnar nerve signals
C) Better sensory detection in the prosthesis by positioning amputated nerve stumps closer to the skin closure
D) More precise control of an osseointegrated body-powered prosthesis
E) Preservation of greater bony length in the amputation stump
The correct response is Option B.
A body-powered prosthesis uses motion of remaining joints, such as the gleno-humeral and scapulo-thoracic joints, to control an upper extremity prosthesis.
Targeted muscle reinnervation (TMR) would not affect function of a body-powered prosthesis. TMR positions amputated nerve stumps well within the remaining muscle and far from the cutaneous closure. Current prosthetics are not yet able to detect sensation and transmit this to the patient. Having nerve stumps near the amputation closure site increases the risk for neuroma pain.
TMR has not been shown to decrease denervation atrophy of residual upper extremity muscles. TMR has gained increasing acceptance in the treatment of patients who have undergone or will undergo upper extremity amputation. Resected nerves, such as the median and ulnar nerves, can be coapted to nerve branches to remaining muscles, such as the pectoralis and deltoid. Transcutaneous EMG detectors are positioned over these reinnervation sites to detect nerve signal, which a myoelectric prosthesis can then use to better control distal joints.
TMR does not affect the amount of bony length that can be preserved in an amputation.
References
Dumanian GA, Ko JH, O’Shaughnessy KD, et al. Targeted reinnervation for transhumeral amputees: current surgical technique and update on results. Plast Reconstr Surg. 2009 Sep;124(3):863-9.
Souza JM, Cheesborough JE, Ko JH, et al. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop Relat Res. 2014 Oct;472(10):2984-90.
Hijjawi JB, Kuiken TA, Lipschutz RD, et al. Improved myoelectric prosthesis control accomplished using multiple nerve transfers. Plast Reconstr Surg. 2006 Dec;118(7):1573-8.
Solarz MK ,Thoder JJ, Rehman S. Management of Major Traumatic Upper Extremity Amputations. Orthop Clin of North Am. 2016; 47(1):127–36
