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Our Strategy in Severe Crush Trauma of the Upper Extremity
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ABSTRACT
The increasing incidence of upper limb crush trauma has stimulated research for new surgical strategies and suitable techniques. Microsurgical techniques with free flaps are used when reconstruction through local or regional methods is not suitable. The “per primam intentionem” repair is outlined for all anatomical lesions.
Between January 1996 and December 2002, 431 patients with destructive upper limb trauma were treated at our institution. The etiology of trauma was crush injury in 125 patients, with complete or incomplete amputation in 25 patients. Our strategy involved emergency reconstruction with extensive debridement of all damaged tissues and appropriate tissue coverage.
Local resources or affected tissue replacement with equivalent functional and anatomical tissues using microsurgical methods included 16 revasularizations, 9 replantations, 4 flow-through flaps, and 44 free flaps. In two cases, two simultaneous flaps were used. The free flaps were used for surface coverage and functional rehabilitation. Wound closure was delayed for 48-72 hours only when the viability of local tissues was uncertain.
Local morphological reconstruction was considered acceptable by the patient and surgeon. Functional recovery varied from 30% (42 cases) to 90% (7 cases). In 109 cases, 2 reinterventions were necessary for tenolysis, tenoplasties, arthrodeses, or other palliative operations.
Early repair, especially per primam intentionem, of all elements is the key to good functional results because it prevents local fibrosis, joint stiffness, muscle denervation, and nerve degeneration. For tissue loss, local regional resources are considered first, but when they are unsuitable, free flaps adapt to the local anatomy and function.