Severely mangled limbs are fraught with multiple tissue injuries including bone tendon, intrinsic muscles, neurovascular bundles, and skin. Secondary procedures are extremely common to restore basic function. In this course, we aimed to focus on the basic principles of management and strategies to optimize the hand function.

Topics covered:

A. Description, classification, and evaluation of the mutilated hand. The variety and severity of mangled hand injuries has led to the development of several grading scales, classifications, and algorithms to help the surgeon organize the treatment plan. We discuss some of these classification schemes in determining and predicting the functional outcome after reconstruction.

B. What functions do we need to restore? Various functions of the hand including grip (hook, power, span, chuck), pinch (key, precision, chuck) can be simplified to think of the hand as containing 4 functional units: (1) an opposing thumb, (2) Fixed units of index and long, (3) More mobile ring and small fingers, (4) the wrist.

C. Fracture fixation in the mutilated hand. Skeletal stabilization is the foundation for wound management and enhances the healing of tissue repairs and reconstruction, including replantation. In this lecture, we specifically discuss various fracture types and implant designs in addition to timing and the choice of bone grafts.

D. Soft tissue coverage options: Local, regional, and distant flaps. The concept of early rehabilitation depends on early coverage. We discuss various coverage options and how to balance them with the experience of the treating hand surgeon.

E. Replantation/revascularization in the mutilated hand. Not all amputees benefit from or are candidates for replantation. The decision to attempt replantation of a severed part is influenced by many factors, including the part, level of injury, expected return of function, mechanism of injury and psychosocial status of the patient. We discuss basic replantation techniques and those factors affecting the outcome.

F. Case examples on specific injury types and reconstruction. Case examples of radial-sided, ulnar-sided, dorsal-sided, volar sided and mid-palmar mutilating injuries will be discussed with the audience.