I'm very excited to announce our fourth and final panel today on soft tissue coverage and nerve. I've asked someone who's a pro in both of these arenas to moderate the session today and that's Dr. David Brogan from WashU. Great. Thanks so much, Paige. I really appreciate the opportunity to participate and thank you to all the organizers for this fantastic webinar today. I'm very honored to be here with our panelists, Dr. Christopher Dee, an associate professor at Washington University in orthopedic surgery and expert in peripheral nerve reconstruction. Dr. Ellen Satteson, a professor at the University of Florida in the plastic surgery division and also an expert in peripheral nerve and soft tissue reconstruction. And Stacey Baker, one of our very talented hand therapists here at Washington University. So the format today will be that we will present a number of cases that involve challenging soft tissue and complex nerve injuries. We'll ask our panel to discuss their thought process and the options for reconstruction and preservation of function, as well as how to maximize outcomes utilizing hand therapy. So without further ado, we'll begin with Dr. Dee, please. Thank you, David, for the introduction. Am I coming across okay in terms of audio and everything? Wonderful. Okay, so let's have some fun. Good morning or good afternoon to wherever you're tuning in from. I will do my best to keep this entertaining because I know we're at the tail end of the meeting. I do not have any financial relationships to disclose, so I'm assuming there are no conflicts of interest here that pertain. So here's a few, a couple of nerve reconstruction cases. I will say I'm very fortunate to be part of a group. David is a fantastic partner. You can see our other partners, Lindley Wall, Ryan Calfee, Chuck Goldfarb, Marty Boyer, and our former partner and leader, Richard Gelberman. And we're excited to welcome Maria Morris to the group starting in August of next year. So here's a case for radial nerve reconstruction that has a lot of pertinent details, and it's nice because we have some early follow-up, too, which will be good to see. So this is a patient who is 51. She is right-hand dominant. She fell in Florida while she's on a job site. She's a marketing executive, so this is a workers' compensation case. She fell into her left arm and had a left humeral shaft fracture in Florida. She was placed in a coaptation splint, and she returned to St. Louis for definitive management by one of our partners on the shoulder and elbow service. Like I said, she works in marketing. She's mainly behind the desk. Pertinent to this, she actually is a little bit anxious, very type A, and is very eager. Of note for her fracture, you can see on the far image that she has a bit of a split running up into her humeral head as well. So her radial nerve was intact before surgery. Her deltoid was not firing robustly, but likely related to pain and her fracture pattern. So this patient was treated by one of our partners on the shoulder and elbow service, and you can see here the complexity of her fracture. There was an open approach performed, and this was through an anterolateral approach. The surgeon did not visualize the radial nerve. So you can see the construct here, a proximal humerus locking plate that extends down to the shaft. You can see there's an interfragmentary screw here as well to help stabilize that oblique component of the fracture. So David and I have worked very hard to make our residents and our colleagues aware that we are available to them pretty much 24-7 for any peripheral nerve issues. And we have a low threshold to have people call us for things because we would rather be on the early end of things and assist people with non-operative treatment rather than be on the late end. So post-op day one, she has zero out of five wrist extension. She's got intact wrist flexion, pronation, her extrinsic median, and ulnar function is working. But she's unable to extend her fingers at the MP joints, and she has intact elbow range of motion. So she did have a block after surgery, so we monitored this. You can see that she's got some diseases in her ulnar distribution likely related to the block, but she did have absent superficial radial nerve distribution sensation. So she comes in for follow-up, and we obtained a nerve study at the six-week or nine-week mark after her surgery. You can see that she has an absence of sensory conduction for her radial nerve, but her median and ulnar nerves are intact. And on her motor studies, you can see that she has decreased CMAP amplitudes for her EIP. So there is something there, but it is quite faint. And you can see perhaps she has some baseline ulnar nerve issues as well, but certainly nothing that is clinically relevant at this point. So, David, as you see, actually, let me see. We have one more step. So here's a nerve study here. And you can see on her nerve study she has some abnormality in her triceps, but she's got no motor units whatsoever in her EDC, no motor units in her ECR, either L or B, whichever one they tested, no motor units in her brachioradialis, and nothing in her supinator. Ulnar nerve is clean, deltoid biceps clean here. So, David, as you think about this case nine weeks out, what's your thought process? I've been able to see this patient at least two or three times now, and we obtained the nerve study. Sure. So, obviously, sometimes you'll find clinical evidence of regaining function before you have some of the neurologic kind of clear changes on the EMG. Sometimes you'll see a little bit of strength while the nerve study can still look pretty disappointing. So I want to do a good physical examination. But the big thing is that I'm concerned that, especially if she had a functional nerve before surgery and now has a nonfunctional nerve after surgery, that probably changes my thought process a little bit. I'm a little bit more apt to undergo early exploration. I think that adjunctive imaging could be helpful. We've utilized ultrasound with some success here. So I'm curious, Ellen, anything that you would do at this point? No, I agree with you. I think physical exam is key. And if you've got access to an ultrasound to try to take a look at the nerve, I think that's very worthwhile. Excellent points. And I think that when I accidentally advanced the slide, you saw the ultrasound. But first, before we get to that, Stacy, what are your thoughts here? How are you talking to this patient? At Washington University, we're very fortunate to have hand therapists cohabitate our clinics with us and lend their expertise. So what are your thoughts as you're seeing this patient with us in clinic? Probably one of my big thoughts is for function. How is her everyday life? I know she's going to be at a computer, like you mentioned, with her occupation. So she's going to need wrist extension, finger extension to be adequate at her job. I know it's a work comp case, so that could potentially have her not back to work and still at home. But I would really look at her function and her quality of life. Yeah, I agree with that entirely. And certainly the keyboarding aspect of it drives my decision making here. So I think that as I'm thinking about how this case may unfold over the following months, I would love to get independent finger extension for her to be typing. That is very challenging. If we end up doing attendant transfer, I would say impossible to get independent finger extension. Now, if she spontaneously recovers on her own, which she very well might, that would be great. Then the other option, I'm thinking in the back of my mind, which is more popular here in St. Louis and perhaps in other places, is a nerve transfer. But I think to David's point, we got to see the nerve. Ellen brought it up also. And we obtained an ultrasound. So let's see if we can advance this here. So I love getting the ultrasound at the same time. The ultrasound demonstrated here that the radial nerve in the spinal groove was seen immediately adjacent to a hyperechoic structure protruding from the humerus with focal enlargement of the nerve and hypoechoic signal within the radial nerve, and it's enlarged. So you can see kind of the tip of something here. And you can see perhaps they look like threads. Let's see here. What do you make of the hypoechoic signal within the nerve? What does that tell you? Probably swelling within the nerve. Obviously, I don't know for sure whether it's something going on internally within the ultrastructure of the nerve. Say, for example, fibrosis or scarring like an axonomatic type injury. It's reassuring that the nerve structurally is in one piece. And that's the biggest thing I take away from it. You've done a lot of work with ultrasound. What do you make of something like that? No, I agree with you. I think it suggests an internal derangement of the nerve and increased water content potentially and swelling or something like that. Let's see if we could get that ultrasound to play. Hold on. It may not work here. If either Zach or Megan can hit the play button, it's not showing up for me. If not, it's no big deal. ASSH, man, they're good. So you saw something a little bit. So the radial nerve, you can see back along here. And if we play it again, if you don't mind. Right along the humerus here. And that right there, that thing that we just saw pushing on the radial nerve. And just, Zach, one more time just so everybody can watch it again. The orthopedic surgeons in the audience are just like what you feel in your stomach when you see something like that. Anyway, it's fixed the humerus. And I'm sure any of the plastic surgeons also are feeling bad for that radial nerve. So let's see. Let's go to our next slide here. So I am keen to explore, especially with ultrasound findings like that. I think that maybe you could watch this. But one image that's burned in my mind that Dr. Gelberman shared with me when I was writing a textbook chapter earlier in my career, earlier in my career, I should say, is a picture of him trimming a screw tip from a radial nerve, or from a humerus shaft or a shaft that was tickling the radial nerve. So that's always, that's been embellished in my brain. So we opened it up and we explored. And you can see that we found an enlarged, thickened portion of the radial nerve right in the middle third of the brachium. And we found intact branches to the triceps, which was nice. And you saw that clinically as well. And look at this little guy right in here. And look at this little guy right in here. Tickling our nerve, making all of us unhappy. So the nerve itself is structurally, at least on the outside, okay. But it feels really firm in there. And as David alluded to, we really don't know what's going on on the inside of that nerve. We don't know how severely damaged this nerve was, either from persistent pressure from the screw, mechanical irritation, or when the screw was put in, as the drill is passing through, as the depth gauge is passing through. Maybe there were multiple hits to this nerve. So I don't feel great about only trimming this and then letting the nerve kind of do its thing on its own. But I absolutely could see how that would be a very reasonable thing to do. I think that, as Stacy mentioned, the stakes are, I think, a little bit higher for somebody like this in terms of radial nerve function, just because of the type of work that she does and the fact that workers' compensation is involved. I don't let the workers' comp thing dictate the majority of my care, but I think it does influence. It's one part of the decision-making calculus. So partial disruption of the nerve. I saw some disruption of the nerve itself, partially, but I couldn't find a proximal stump. And I wasn't going to disrupt it a whole lot more. But what we ended up doing was trimming that screw tip, rasping down the edges so it wasn't prominent, getting it flush down the bone. And because I just want to make sure nothing irritates it, I mobilized a bit of the triceps and attached it over the screw so that it wouldn't irritate the nerve anymore. David, would you call it a day here? Well, no, I'm concerned because I think that that nerve, if it feels hard and firm, that that's clearly not a normal nerve. I think the difficulty is trying to decide how badly that nerve is injured. It's going to recover or not. That's the kind of inherent problem that we have in terms of intraoperative evaluation of nerves. And so I think that what you do next depends on what your ultimate move is going to be. I think if it's tendon transfers, you have time to watch and you don't lose anything by doing that. I think if you're going to consider nerve transfers, then you're probably going to be more motivated to act more quickly. So, Ellen, what would you do? I agree with you. Visibly, there are significant changes to the nerve. Like you mentioned, it's going to be a little more quick to act if I'm thinking nerve transfers, which I think is reasonable in this case. And I would just do it while I'm there if that's my plan. Great. Chris, I just want to say I'm very proud of you. You did a flap. That's great. That's about as flappy as you're going to get from me, okay? You billed for that? I dictated it. I don't know if it got billed for. I'm not good about billing, so I'm not one of the savvy ones, Paige. Maybe you can teach me something. So we actually have a chat Q&A or question from A. Schrader. So how long into the impaired nerve issue did surgical exploration intervention take place? Wondering typical timeline wait. I believe this was 11 weeks after the injury. You know, I admit I think I'm a bit more aggressive because I don't believe that nerves always get out of the way, as we're taught dogmatically. So if somebody didn't visualize the nerve after that screw was put in or visualize the nerve on the way in, I'm going to explore. And I know that's commonplace in other settings, particularly, for example, in the UK. So I think in the U.S., we probably are a little more reticent to explore, but I like exploring because I feel like I can give the patient useful information. And again, some people would just close up here, and I think that's totally reasonable. Show us what you did. Okay, so let's keep it moving here. So because I had talked to her about this exact scenario and discussed what we would do, we then decided to proceed with nerve transfers. So some of you may be very familiar with this concept pioneered by Susan McKinnon in terms of this particular set of nerve transfers, and then fine-tuned by Jean-May Bertelli, but median to radial nerve transfers. And at the same time, typically coupled with a pronator-teres-to-ECRV tendon transfer to act as an internal splint. I think if you're purely academic, you want to say, well, do you know whether the tendon transfer or the nerve transfer is causing the wrist extension? I don't know. I mean, early on, it's pretty clear it's the tendon transfer. But as many of our therapy colleagues who are listening know, patients love getting out of the brace. So I think that helps them quite a bit. And even if the brace is focusing just on the MPs, that helps them as opposed to having their wrist drop down and needing to wear a brace. So we proceeded with two sets of nerve transfers. So those of you that have read Dr. McKinnon's papers have seen the nice results that she's demonstrated. It's difficult to gauge how well those results will be reproduced elsewhere. Bertelli has done a nice job trying to present his results as well. And one thing that he noticed when he was looking at his results, both for nerve transfers and for tendon transfers, was that thumb extension was lacking. And one tweak that he used was to, instead of doing the standard suite that Dr. McKinnon talks about of FCR to PIN and an FDS branch to the ECRV, instead of just doing that, he actually added the AIN-PQ branch, which we know from the supercharging work for the ulnar nerve, can be used pretty without any consequence, using that to target the deep aspect of the PIN, which specifically will go for the thumb. So again, she and I had talked about this, and I wanted to give her the full monty if we were going to do nerve transfers. So here are pictures of the intraoperative exploration. This PIN looks unhappy. You can see it just, it looks a little bit paler than it typically would look and it is inflamed. And you can see we dissected out an ECRB branch on top of it. And then we did find this deeper branch of the PIN after exposing it more distally and tracing it back. Another image of that there. So now we went dorsal. So the first one was through the Vuller approach. Now we went dorsal, which was the other incision that you saw. We went and found the AIN branch from the dorsum, which you can do it either way. I did it from the dorsum this time. I have done it in the past from the Vuller approach and ended up transferring that in. And this is just a schematic. You can see that Dr. Bertelli's got his, in his paper here, the AIN here. I have my AIN here, deep branch of PIN there. And I've got my deep branch over here. So it's getting close to Valentine's day. So I made a nice little heart and transferred those guys in. Will you be mine, David? And after that, we went ahead and went back to the Vuller approach and did FCR to PIN and FDS to ECRB. And we also did the PT to ECRB tendon transfer. And we also released her superficial radial nerve out of completeness sake. So she has, she went to hand therapy. I know we're running a little bit short on time for this case, but she has made great progress. I think that the important part is that, you know, the assessment, she is a fantastic patient in terms of coming to therapy. Her digit and thumb extension showing initial activation. She had been working on the nerve transfer protocol and I'll ask Stacey for her thoughts on that in a second. Subjectively, she's able to straighten her fingers better. Still difficult to do things at six months. Thumb still is really weak. Show this before we ask for Stacey's thoughts, but you can see here, her surgery was in June. And as we get towards December, as you go down for her manual muscle test and you can see her wrist extension, that's the tendon transfer, that's the tendon transfer. Maybe this is the nerve transfer kicking in, okay? And then you can see digit extension is starting to kick in at six months post-op or just under six months post-op. And now she's starting to get trace thumb, which I'm thrilled about. So Stacey, from a therapy perspective, you've had the opportunity to treat probably many of Dr. McKinnon's patients and probably some of mine too, so. Yeah, I think from a therapy standpoint, understanding the nerve transfer, understanding the anatomy, understanding and having a good open communication with your physician is extremely important. And luckily here we do have that and a lot of times we're able to be in their clinics, which is great. I think initially what you wanna do is you wanna have that, they're not gonna have the muscle power right away, as you can see in these diagrams that you're demonstrating, but what you wanna do is you wanna flood the donor because as that is getting sent to the donor, it's gonna then slide over to the recipient. So that's how you're gonna start to train that. And you're not gonna see that movement. And essentially you don't even go into adding resistance of any kind until you even see a twitch. And so a lot of times you are tracking and watching and a lot of times you also have to be a cheerleader for your patient because they're impatient and they want that back. But I do love that you added in the tendon transfer because you do get that wrist extension from the tendon transfer earlier and the patient can see that and it becomes more motivating for them. Fantastic, thank you. Ellen, do you have any comments? I just was gonna ask a question. Certainly in this case with the tendon transfer, the patient sees a little bit of immediate results, but any tips for counseling patients when you do a nerve transfer, the lack of instant changes? Yeah, I mean, I'm very honest and perhaps too honest. I've learned how to be honest without being pessimistic. I've learned to be a realist without being excessively optimistic. I think the rub of what we do both as therapists and surgeons is trying to give patients appropriate expectations without having them lose hope. But it's a long recovery. I tell them it's gonna be nine months to a year in some cases and so we start to see a flicker. She's early and of course everybody shows their best cases at a meeting. I showed her because it's visually a very cool case and she happened to do well. So we have patients who either never get activation of their nerve transfers, which of course you're not going to see in the literature or they end up with just a very modest result. I have yet to have somebody, I'm trying to find some wood to knock on, but go from a nerve transfer to ended up getting a tendon transfer very early. I'm sure it's going to happen to me pretty soon. David, how do you talk to people about these? No, I think that all your points are very salient. I've tended to do more tendon transfers, but just because I don't think I've had a patient yet that has been particularly interested in the nerve transfers, but it might be also in the way that I'm selling it or counseling and such too. So, but I think your points are great and important considerations and certainly another tool in the armamentarium to help these patients with difficult problems. Again, I'd like to remind everybody in the chat, please feel free to put questions in there and we can ask our panelists as we go along. And we mean for this to be as interactive as possible. So we welcome any thoughts and comments from the group also. So Chris, any final thoughts in your case before we move on to Ellen's? Yeah, I mean, I think that, you know, for radial nerve injuries, tendon transfers still are the mainstay. And I think the surgical trainees out there, you need to learn how to do tendon transfers. We're in an era where everybody's super excited about nerves, self-included, but as you go further into practice, you will find patients that either come to you too late or they're not good candidates. They're not gonna either insurance issues, personality issues, they're just not going to come to therapy consistently. It's probably outdated, but about five years ago, I was presenting alongside Dr. McKinnon and asked her about what ratio of patients she sees with radial nerve palsies get tendon transfers and nerve transfers. And at that time, it was five to one tendon to nerve. And I would say for me, it's probably three to one, I think tendon to nerve. Again, I don't see the same volume that she does, but I feel like we see a fair number of people with these injuries. And, you know, I'm confident I can suss out with the help of our therapists, you know, who work with us in clinic, figure out who is better suited for it. I see a question in the chat here for the radial nerve. I may have missed it, but was there any nerve stimulation or nerve action potential? So nothing in surgery. So we didn't do like a nerve to nerve action potentials. We did not do any intraoperative stimulation of the nerve. I know that's a very sexy topic nowadays. If you were at the ASPN meeting, that was talked a lot. We are starting to dip our toes in and I think it's gonna be super interesting. So yes, good points. And David, let me go ahead and advance. I think I'm done with, yes, it's Ellen's turn. So if anybody else has questions, please put them in the chat. I'll try to chat along while Ellen's presenting to answer anything else on the radial nerve stuff. Thank you. Excellent. All right, well, thank you very much, Chris. That's a great case. And now Ellen, if you can take us through your thoughts on soft tissue coverage, please. Yeah, of course. So the case I'm gonna present here is a 62-year-old right-hand dominant gentleman. He presented to our ER four days after sustaining a burn to his left dorsal hand. His story is a little inconsistent, but supposedly he spilled some boiling water on it and tried to treat it at home. Hand and fingers started turning black, so he called EMS. His past medical history was significant for marked malnourishment. He's G-tube dependent for esophageal strictures. So certainly that comes into play in terms of wound healing. And then also had some concomitant psychiatric issues that were of concern as well. Of note, he had no social support, no friends or family to help him out, which certainly comes into play when thinking about wound care and some of the logistics with something like this. He was initially evaluated by and admitted to our burn surgery service. And at the time of presentation, he was noted to have full thickness burns to the dorsal hand with some demarcating necrosis of the index and thumb. Pretty impressive for a scald burn, so maybe not consistent with his story, but regardless, they let him do some wound care for a couple of days, a little bit further progression of the demarcation of his necrosis. And then ultimately the burn surgery team took him to the operating room. They performed a tangential excision of his burns. At that point, they felt his index finger was not viable and performed a disarticulation of the MCP joint. Their debridement included some debridement of the intrinsics of the hand, as well as the extensor tendons to the thumb, index and middle fingers. At this point there was exposed bone and joint, so they decided to kind of defer reconstruction, get a hand surgeon involved. So they temporized him with allograft and called me. So this is what he was dealing with when I met him. So at this point, still some necrotic tissue. I took him to the operating room and did some additional debridement. When I was done with his debridement at that point, extensor tendons were completely gone in the wound, basically from the wrist to the fingertips. I had to debride or burr down some of the necrotic bone that had been exposed from the dorsal cortex was non-viable. And then he had exposed and very unstable joints at the thumb, MCP and IP, as well as the IPs at the middle and ring finger. So at this point, certainly a challenging reconstructive case in terms of both function and soft tissue coverage. So there are a few options to talk about here. Needing to address soft tissue coverage, stabilization of the joints, and then kind of timing and how to go about extensor tendon reconstruction. In terms of the soft tissue coverage, something I want to mention, not great for this particular patient, but I have had a lot of success with doing a staged dermal matrix with skin grafting for dorsal hand wounds, even with exposed tendon. Certainly not for him, but it's a great tool, especially for older patients who are maybe lower demand and just a simple skin, the gloving that can expose some tendons. Before I tell you what I did, maybe the other panelists, what are your go-tos for a big dorsal hand wound extending onto multiple digits? I just want to ask kind of to that point about, and we hear a lot about Integra, and I feel like Integra gets thrown about a lot on the dorsal hand and is often talked about and used and appropriately sometimes, maybe inappropriately sometimes. What's your decision points with, when is it ideal? And when would you say absolutely not, not the person for this? So for me, I think not ideal if someone's had an extensor tendon repair where the repair site's going to be underneath the tendon, or excuse me, underneath the dermal matrix. The patients I tend to use this in, I mentioned are kind of older patients who've had a fall and the gloving of their dorsal hand, they're going to be relatively low demand. Somebody who's not a great candidate for a big reconstructive surgery and a small area of exposed tendon. Stacey, from the therapy standpoint, what are the considerations? What do you want to be able to maximize? This patient's going to need, obviously, a number of staged procedures and probably a lot of intensive therapy. What are the things that you're worried about or really hoping for from a reconstruction here? I think a lot of concerns come to, for me, are maybe social support for this patient as well as with wound healing regarding having the G-tube and how is he, if he doesn't have the social supports, how is he nourishing his body to then heal everything that we're going to potentially ask and demand of his wound with healing. So those would be some of my concerns as well as his understanding and comprehension of rehab protocols after because sometimes this can be really tricky and complex and it's hard to discuss between us, let alone discuss it with a patient and get them to understand. Ellen, I just wanted to chime in that you asked our go-tos for this. My go-to is our moderator. As Paige mentioned, David is an expert in nerve as well as soft tissue coverage and I'm very fortunate enough to have him around for something like this. David, I had a question for you and Ellen. What type of tissue do you need? What thickness, what type of tissue do you need over dorsal aspect of the hand? You're going to go back eventually for extensor tendon reconstruction. You've got exposed necrotic dorsal bone that you've debrided back. Do you need bustle? Do you need fascia? Obviously you need skin and subcutaneous tissue, but what do you need? So for me, the dorsal tissue on the hand is very thin. So you want something that's going to be thin and pliable. And if I'm going back to put extensor tendons in, ideally something fascia cutaneous. Muscle flap is just a little bit harder to dissect under to go back in and put tendons in. And so for me, in terms of local options, PIA or reverse radiiform, little large wound in this case, but those can be good matches in terms of tissue thickness. For free tissue transfer, ALT can be nice, but it's often, especially in patients we see here in Florida, often very thick. And so I think it can be a very challenging issue, especially in patients who you're also having to deal with multiple digits on the backside of the hand. Totally agree. So, all right, show us what you did. Okay. So I did a super thin interpolated abdominal flap. So this is just using abdominally based tissue, basically to make a glove. Described kind of as a glove flap places. So for him, particularly a very thin patient, I'm worried he's not gonna be a great candidate in terms of some of his other medical issues for free flap. I basically just placed the hand in the most comfortable position with the patient awake and mark out the glove design of my flap. The nice thing about this is you can make it a really thin flap. You're just in the subcutaneous plane as you elevate a pocket for the hand in each individual digit. So even someone who has a pretty thick abdominal tissue layer there, you can leave most of the fat down and almost kind of just be in subdermal tissue to get a really nice thickness match for the dorsum of the hand. We'll show you once we inset it here. So you just suture the end of the fingertips and make this nice little pocket. I will say a technical pearl that I've learned from doing a couple of these is I recommend doing a pinrose drain in between each digit. Just a lot of fluid can build up in there and can be kind of hard to do addressing changes to keep it from getting macerated. And so for him, came back at three weeks and divided this. The other nice thing about this is you're able to individually interdigitate the fingers, recreate the rubbed spaces acutely on this and ideally be able to get them moving back toward therapy more quickly. Something we hadn't really talked about was in terms of the joint stabilization for this patient. I went ahead and just pinned the joints. I try to get people as close to intrinsic plus as possible when I'm doing a soft tissue reconstruction like this, knowing that it's gonna be a little while before they're able to move. And did immediately put him in an orthoplast intrinsic plus splint with the thumb kind of abducted to try to prevent a first one space contracture here. This is a beautiful technique and a very elegant technique and beautiful results. So well done. Can you expand upon the, it's an important point about the dividing the finger tissue acutely versus in say like a groin flap or an ALT where you make a mitten, you're probably not going to do that. Can you kind of discuss why that matters? Yeah, so in terms of this, it's a really thin viable flap that you basically with your each tunnel made an individual flap to each finger. So the tissues vascularized from the wound bed of the fingers. And so when you come back, you just need to make sure when you actually put it in that you're leaving enough space to cover the fingers depending on what kind of defect you have. And versus if I'm doing a groin flap or some other fascia cutaneous flap, I'm coming back using a staged fashion to divide that just in terms of concern for vascularity that you're still required. This is perfused by the wound bed itself rather than some sort of axial blood flow that you have to wait to come back and divide. Elna, that actually comes to something I wanted to ask you. Has this technique supplanted the use of a growing flap in your practice? Because that's how many generations of hand surgeons would have covered this. Yeah, so certainly anything where I'm looking at multiple digits like this, yeah, I think this is great. Great. All right, Stacey, anything from a therapy perspective? Or Elna, do you have anything else to show on this? Nothing else. Unfortunately, this patient passed away a couple of weeks after surgery, so I have no follow-up on him. But Stacey and I kind of talked about things to consider for what you do for post-op rehab for these patients. Yeah, so we, yeah, we had like a nice conversation about getting him into that Intrinsic Plus to get that MP joints out of that kind of open-packed position. With the pin still in the fingers, you're not gonna have any IP joint motion, but you really wanna maintain that first web space so you don't have any joint contracture and that you can have that functional position as well. We talked about starting some MP motion, so active flexion, and you're gonna have to have passive extension with the lack of the extensor tendons. But I think getting it moving and going, and still protecting it with a brace is gonna be super important. Absolutely, that's great. All right, well, thank you very much. Any other thoughts or comments? Before we do our last case? Okay, let's move on if we can. So I'll take control. If, Ellen, if you can advance this and then, yep. Perfect. So kind of one final case to bring together some of the principles that we've been talking about. And let's see if I can get it, there we go. So this is a patient, he's a six-year-old farmer who had a left forearm crush injury from a corn auger. It took him a while to get out at the scene because he was trapped for quite a bit. He had numbness and tingling throughout his hands and ear pain. He's otherwise healthy, but some heart disease. And he's a farmer and doesn't have any other advices, really, so. David, David, for those that are, I see some people from my old institution in New York, hi, Alex, who may not know what a corn auger is. I did not know what a corn auger was when I arrived in St. Louis. So what is a corn auger? That's a corn auger. That's for you, big guy. So the, also known as the hand-messer-upper, basically. So we have had multiple, I had a corn auger injury in December. So it is not an uncommon problem for us, particularly for folks taking care of rural patients. So this patient, he had absent radial pulse, big forearm wounds, no sensation, median nerve distribution. And I don't have his initial injury, but I'll show you after the debridement. We took him immediately for debridements, for compartment releases, and carpal tunnel release, and found that he had a number of things injured. His radial artery was transected. He had a crush and avulsion of his median nerve, transection of the FTS and FTP tendons to the index and long fingers, and then a partial transection of his FCR. So we repaired the tendons, FCR wasn't really repairable. We tagged his median nerve, and this is what he's at a couple of days after his initial kind of debridement. You can see the wounds from the compartment release, carpal tunnel release, and then also some kind of questionable skin on the dorsal aspect of the hand and forearm, which looks echemotic and probably not viable as well. So Ellen, when you're looking at this, what are your thoughts in terms of what you're going to do, and is this a case for Integra or a skin graft? So certainly a skin graft, an Integra skin graft, a lot of volar forearm wounds. Something this contaminated with this much exposure of tendons, I'm certainly not going to consider that. The other thing I worry about is the median nerve. If it's anywhere near the surface of the wound without good muscle coverage, I want durable soft tissue coverage. And again, as I mentioned before, the tendon repairs underneath have had even a small, very small wound with a little bit of exposed tendon that was somebody that, for what had other polytrauma stuff going on, we Integra skin grafted, and the repair site kind of starts to eventually run through the sutures, poke through the skin eventually. So, and this, in my hands, a hundred percent of the time is getting some kind of soft tissue coverage. What's your go-to for a volar forearm wound of this size? Usually either a LAT or ALT. I like the LAT. It's easier for me in terms of dissection and getting the flap harvested more quickly. So that's usually what I lean toward. Any, ever use groin or pup flap or anything pedicle for this? I have. Not, probably not for something this big. The donor site would be a little bit harder to close, but certainly something you can consider. I've had a couple of patients that have had both radial and ulnar arteries injured and reconstructed with Bain graft, where I was a little concerned in terms of doing a free tissue transfer acutely in that setting that I've done a groin flap in that circumstance. Great. Chris, median nerve, what are we going to do with it? Now in the future, what's your timing? What do you want to do? I probably will let it cool off a little longer, to be honest with you. I think you probably, it's dogmatic, but we like to wait probably three weeks or so for that zone of injury on the nerve to declare itself. Obviously you have priorities here with soft tissue coverage, and it's good that you are aware that that needs to be part of your flap decision-making. So I agree with the debridement back to healthy ends. I think sometimes it's helpful to tack the ends to whatever surrounding tissue you can so it doesn't retract and just make it easier to find in the future, but that can wait. I think that one other thing you may consider if you're feeling fancy is potentially doing an ADM to recurrent motor branch nerve transfer just to get out of that zone of injury and assume that, you know, because whatever you have to graft, you're probably not going to get the nerve function back. So that's something that it's lower on your priority list, but you should probably consider doing. Great. So these are all the things that we talked about. And this was his median nerve. So it's not just a clean transection, it's a crush as well. So that's obviously concerning. May influence your treatment algorithms. But what we did, and I think it's a very reasonable kind of discussion point is with regards to timing. So I was concerned about having to go back. From a practical standpoint, didn't think that I was going to convince this guy to have another surgery in another three or four weeks with all the trauma that he'd been through. And so decided to go ahead and try and graft him acutely. But recognizing that that's actually, and perhaps that's a mistake because defining the zone of injury is difficult. And I think being confident that you're out of the zone of injury and repairing healthy nerve to healthy nerve is something that is hard to be reliant upon. So I don't know the answer to that. I think that the textbook certainly says wait. The practicality of going back in, lifting up your ALT, your LAT, or whatever else for three weeks is not a whole lot of fun. So you have to kind of decide what you're comfortable with and what you'll take as a result. But we did cut it back to where we saw a kind of normal fascicular architecture, both proximally and distally. And then did a cable graft from the sterile nerve. I like sterile nerve for this. Eleanor, Chris, is this a case for an allograft? I have started using allograft a little bit more, but certainly a little hesitation to switch even though I know that there is some good evidence for it. I think in this kind of circumstance, this large of a gap in the forearm, I'm using an allograft, I mean an autograft. This is autograft to me, it's too high stakes. I mean, I understand there's some evidence. I'll push back on you a little bit, Ellen. I don't think there's good evidence. There are some publications that our industry supported that would support the use of allograft for a mixed nerve, but if this was mine, it'd be autograft. So we did a latissimus flap. For me, given the fact that he had both solar and dorsal problems with skin, it's a little bit easier to wrap a lat than an ALT. I think an ALT is nice for a contained defect. He's also a little bit of a, kind of the slightly pudgy Midwestern farmer, so his ALT was gonna be a bit thick. So I thought a lat would contour nicely for him. So we're running out of time, I won't belabor the point, but this is what it looks like here. And I always tell folks, it's gonna look like a terrible, big, meaty steak on your hand or your leg, and you're gonna think it's awful. We went into his rate already approximately because he's already been transected. And this is him at six weeks. And then Stacy, tell us what you know. So the fun thing about this patient was this was actually one that I didn't take part in rehabbing in the care. So he initially got most of his therapy inpatient, and he was actually seen outpatient about two and a half weeks post-op. Our initial focus was, how do we get these digits that are so stiff, so swollen, moving? We did have him in a dorsal block orthosis because of the repaired flexor tendons, starting some gentle half fists, really a lot of wound care. We had to do a lot of teaching with his wife and family. And so that was a big component. He did stay in the dorsal block orthosis until about the six week point. Important considerations that really helped this patient was he had good family support and he had health insurance. So that was a good benefit. He had no transportation issues. His wife brought him to every single appointment. He had no impairments in understanding what we were asking. He had no history of mental health issues, and he had a good, real positive, he was so motivated, I just love this guy. But we did still have areas of concern because we were wanting to make sure that the flap healed and all of his soft tissues. He was a little leery about looking at the arm and touching the arm. And we kind of really worked through that with him. He still had a lot of anxiety related to the issue because as a farmer, you can't stop farming. So there was a lot of anxieties related to taking care of things around the house and the weight of how that feels. We felt like he was internalizing a lot of things that he didn't want to necessarily vocalize to us. So we kind of worked through that with him. He still was holding on to so much swelling because he didn't have a lot of active motion to pump the swelling out, and still was getting a lot of joint stiffness. And also he was starting position in a wrist flex position, and we were starting to worry about his scar tissue. So this was initially in that first three months. After three months, we started focusing on, is there any adhesions under the tissue? Is the gliding of the tendons being impaired? Does he have still considered, considerably amount of joint stiffness? And we went on to like static progressive splinting at this point to help get some of that mobility back. We also really focused on making sure that we weren't forgetting the rest of his arm, his elbow, his shoulder, what was going on with those things, and really focused on functional use. I remember the first time he picked up a cone in therapy, and he told me, I can't do that. You're asking me to do too much. And when he did, the look on his face was just priceless. We also worked on, how can we strengthen the upper body at this point, even though we can't necessarily, he didn't have a lot of strength in the hand. I think that was really motivating for him too, because he could still see that his body could do things. At three months post-op, he still had that good family support, which sometimes I feel in these big traumatic injuries, families they're really initially, but as this becomes long-term, they start to lose a lot of that support. He started driving himself to therapy. So that was a big accomplishment. And it wasn't a quick drive. He lived probably almost an hour away. So for him to come and see us two or three times a week was huge. He still had great insurance that was covering therapy. And he was doing things on the farm. So he'd come in every time and tell us what he's doing, what he had to take care of the day before and things like that. Areas of concern still were his limited motion, his weakness and his reduced sensation because of working outside. And in cold Missouri weather, he was dealing a lot of pain related to how the winter was and getting a glove on the hand and just that working outside. So quick, hopefully, can someone, there we go. So when we kind of look back at his therapy measurements, some of the things that popped out to me and some of the therapy team that I work with here was if you look at that first month, I don't think the slides are advancing. There we go. That first month, we had a concern because his wrist was really not wanting to extend. He was starting to really pull into a lot of that soft tissue adhesions in the front of his wrist. So we're looking at how do we get these flexor tendons to glide under there? How do we get them to pull through when you are at a mechanical disadvantage in a wrist flex position? So we're really starting to work on getting his wrist back. And then if you can see there, his flexion to DPC was really not that great. As opposed to five months, we got about an 80 degree arc of motion, which really helps pulling those tendons down and giving him a little bit better of a mechanical advantage. And then you can start to see a lot of his digits kind of started coming down. We almost cut that motion in half. Also at that five month mark, I remember him coming into therapy and telling me that he was trying to clip his nails, missed the nail and clip the skin and felt pain for the first time in his hand. And he was pretty excited about that. So I do know that he was starting to get some feelings back into the hand. Sometimes he wasn't happy about that because it did mean pain, but we've discussed a lot about how that was a good sign, especially to keep him from re-injuring. Unfortunately with this, it put us right when the pandemic started. So he opted to continue therapy on his own at that time, but Dr. Brogan was able to see him at that one year follow-up time in clinic. And that's where I kind of pulled these measurements from. So I'll let you kind of finish off the case, Dr. Brogan. Yeah, so this is, thanks Stacey. That's perfect. I think all of those considerations are super important for patients. And he had a lot going for him, aside from the fact that he had a pretty devastating injury. And this is him at one year. And so his lat has shrunk quite a bit. It's contoured nicely. You can still see the ridges from the skin graft and the difference in the contour of the skin. But overall, the shape of the arm is fairly similar to the contralateral side. And you can see here his range of motion is digital. Our promotion is actually quite good. He can make essentially a composite fist and fully extend. His two-point discrimination is still not normal. Probably will never be given his age and then the length of the gap, but overall it's a functional hand. He's pleased with his outcome, although certainly not perfect. And obviously a lot of areas for us to improve on in the future. And then I think with that, we are probably out of time. Any other thoughts, questions from the audience or closing comments from our panelists? Did you get back thinners on him at all, Brogan? He had not much. You can see he's not fully wasted. You can see a little bit of a contour of his APB. He didn't have the thumb and the palm, he's probably maybe three out of five, if anything. So maybe a little. Functionally, he didn't complain of it. He didn't feel like he needed anything, but not a normal, you know, for sure. Well, I wanna thank Dr. Brogan and all the panelists. This was a really, you know, nice look at three cases, really in depth from, you know, nerves, soft tissue coverage therapy. It was really great. So thank you all so much for your participation. Thank you to all our attendees. We hope you enjoyed Electives 2022. And importantly, you will get a chance to give some feedback on the course. Please fill out those surveys. They help us make the course better each year and help make the faculty better each year. So please fill those out when you get them and sign up for your CME starting Tuesday, or if you're with Hand Therapy, please email the address in the syllabus. Thank you, everybody. Thanks a lot. Take care. Thank you, David. Thank you, Paige, Stacey, Helen. Thank you, guys.

hand injuries

soft tissue coverage

nerve reconstruction

radial nerve injury

severe burn injury

dermal matrix

crush injury

median nerve injury