gms | German Medical Science

Objectives/Interrogation: Mangling injuries of the upper extremity usually provoke significant disability of hand function and have a lasting psychological impact on the patient. In the absence of a structured approach to the treatment of these injuries, the surgeon can easily get lost in the chaos of mangled tissues. In this presentation an algorithm for the diagnosis and treatment of the mangled hand and forearm will be presented.

Methods: Eighteen patients with 19 mangled hands and forearms were operated and followed for an average period of 8 years. Demographic information including; age, sex, etiology and mechanism of injury, diagnostic and surgical procedures was recorded. The hand cases were classified and evaluated using Del Pinal's classification. The diagnostic algorithm contains two main points; assessment of the vitality and functional capacity of the available tissues and the judgment of which structures should be saved and which should be sacrificed in order to maximize final hand function. The therapeutic strategy contains two stages: Acute and Reconstruction. The main therapeutic principles are: 1) saving the life, and 2) saving the most important functions of the hand. The treatment is characterized by multiple operations until an acceptable level of hand function is achieved.

Results and Conclusions: Eight out of 11 operated hands were restored to an acceptable function. Acceptable function, according to Del Pinal's definition is a hand with an opposition-capable thumb and two or 3 movable digits. Five cases were originally classified as "crippled hand" and after reconstruction were evaluated as "acceptable". Three of the injured hands were originally classified as "mutilated hand". After treatment they were defined as "acceptable". In 3 cases there was no change in the functional level. Sixteen patients did not achieve full range of motion in the hand. Eight of hands did not recover full sensation, and 3 of them had incomplete motor recovery. Two out of 6 replanted fingers necrotized and were removed.

Management of the mangled hand and forearm requires a completely different treatment approach than that of simple hand injuries. In order to achieve the best possible results, the lead surgeon must be capable to evaluating and prioritizing treatment options. The proposed algorithm gives a systematic approach on how to create a realistic plan for restoring integrity and function after these devastating injuries.