The outline of the ICO is designed to progressively lead you through the treatment of the mangled hand, from getting started to getting the patient back to work. I'd like to thank all of the speakers for being involved. Each of the speakers offers a unique perspective, and we're all very excited to share with you a little bit about our experience taking care of these injuries. We'll progress through the five talks without pausing, and at the end, we'll do questions and interaction. I'm Marlo Van Stein. Several years ago, I had the opportunity to get back into the treatment of severe hand trauma after being away from it in the early years of my practice. So for those of you who are just starting out or still training, I'd like to share with you three of the things that helped me be successful when I was first starting out. The first of those is preparation. It's very difficult to be fully prepared when we first start. There's so much to learn through time and experience, but I believe that we can maximize our training and continue to prepare throughout our careers through reading and collaboration. When I got back into severe trauma, I'd been away from microvascular work for a few years, and while it was something I always enjoyed and was drawn to, I felt like I needed to get in some practice. So what I did is I took a week away from my clinical practice and did a week-long advanced microvascular course. The experience was invaluable to me, and I can't recommend it enough for those of you who may be in a similar situation. But maybe for you, it's not microvascular. Maybe it's complex bone reconstruction or soft tissue coverage. Do what you can ahead of time to prepare, and if you're still in training, seek out cases and opportunities to round out your experience and knowledge. I've also found that one of the strongest tools in my toolbox is the ability to collaborate with my peers, and on the next slide, I'll be sharing with you a case where I used collaboration to get my patient a better outcome. I've had the opportunity to be able to be a part of a group that regularly collaborate on complex cases. If you don't have such a group, I would challenge you to use some of this time while you're here at the Hand Society to form a group of colleagues. The ASSH Listserv is also a great opportunity to be able to get some interaction with your colleagues. One of the things I've appreciated most about my group is that we're all from a variety of background and training programs, and we've all learned so much from each other over the years. When we first start out, sometimes surgical decision-making feels complex or difficult, but all of the decisions that we make in these severely traumatized extremities can be boiled down to how can we provide the patient with the maximum functional outcome. You're going to hear many cases today of heroic salvage and complex reconstruction, but I wanted to make sure that we talked about at least one case where amputation was chosen over salvage. The picture on the screen is a patient who came in with an explosion injury to the hand and forearm. There was severe bone trauma with extrusion of the carpus. Both the radial and ulnar arteries had been evolved, and the carpal arch was thrombosed. There were no remaining musculotendinous units that had not been evolved and were damaged beyond immediate repair. But in my mind, what made this injury most devastating was the degree of nerve injury. The median and ulnar nerves had been evolved distally and were damaged over a more than 20-centimeter length beyond repair. To make matters worse in this case, the patient had a history of IV and narcotic pain medication abuse. And while he'd been clean for a few months, he was still early in his rehabilitation process. So I made the decision to proceed with a trans-radial amputation with targeted muscle reinnervation. This patient left the hospital on day number four and has been on no narcotics since leaving the hospital. He is using a prosthetic arm and back at work on a limited basis. This is a case of a patient who had a severe industrial crush injury to the hand. Initially I had to revascularize the thumb with a vein graft from the radial artery. And I also had to reconstruct the ulnar artery with a long segment vein graft to the forearm. When I reconstructed the ulnar artery, there was a segment of exposed vein graft just proximal to the level of the wrist. And I considered a lot of options to get that reconstructed vessel covered. But I found the best answer through collaboration. I sent this case to Dr. Agnew, who's on the panel with me today. And she recommended doing a dorsal adjacent tissue transfer, which gave me just enough soft tissue to get that reconstructed ulnar artery covered. And the patient went on to achieve a reasonable outcome and keep all of the digits. I also recommend trying to progress efficiently in the operation when possible. We certainly can never rush. These are cases that require attention to detail and all the time that they take. But I found it helpful to try to progress efficiently through portions of the operation that are not going to make a functional difference in the patient's outcome. And for me, this usually involves trying to get the bones stabilized as efficiently as possible so that I can save my focus, energy, and sometimes tourniquet time for what I consider to be the more complicated parts of the case. I also wanted to share with you guys two little tips and tricks that I've used over the years. The first is to consider doing the microvascular work from dorsal. I know a lot of us use this at times for the ulnar side of the thumb. I've also occasionally used this in select cases on the radial aspect of the digits. And this is particularly useful in cases where the trauma is dorsal and goes up to but not through the bolar skin and you wouldn't need to make a bolar incision. I've also found it helpful to keep the skin moisturized after microvascular repair. And I've observed this to greatly limit the degree of vasospasm after microvascular repair. What I do is as soon as the vessel is repaired, I apply a sterile ointment and I have the nurses apply lotion with the post-operative vascular checks. This is not evidence-based, but give it a try and I think you'll find it helpful. Also when you're first starting out, please don't forget the importance of leadership. I believe and I have observed that we can make a difference in our patient's outcome through strong leadership. These patients have had a life-changing trauma and it helps them to have someone guiding them through the recovery process. What I do is I set very defined goals with my patients and I tell them that we're going to break down the recovery into sizable chunks. Initially those goals are often just getting out of the hospital or getting off of narcotic pain medication. But those goals become increasingly complex as far as range of motion, strength, and finally back to work. I've also found that patients respond favorably to return-to-work discussions very early on. I start talking to the patient right away about return-to-work expectations. If you're like me, this is your least favorite part of being in the office. But like it or not, we're the best people to have these discussions with our patients. I've found that patients start thinking about their recovery, realistic return-to-work expectations, and they can often resume purposeful work on the other side of the trauma. So in summary, for those of you just getting started, be sure to maximize your training and continue to prepare throughout your careers through reading and collaboration. Use surgical decision-making focused on functional outcome and provide strong leadership to guide your patients to a better outcome. Thank you for your attention. Our next speaker is Dr. Hari Venkatramani from Coimbatore, India. Dr. Venkatramani is a very skilled reconstructive plastic surgeon. He wasn't able to be here today due to COVID restrictions, but I think you'll all really enjoy his talk. I thank Dr. Marlowe for giving me this wonderful opportunity. I have been asked to speak on initial evaluation of mangled hand. I bring experience from Ganga Hospital, Coimbatore, where I'm working as a consultant plastic and reconstructive surgeon. So let us see what do we see in our emergency department on very regular basis. So this is a small girl, 12-year-old girl who presents to us two hours after injury, and that is how she is. So the first step is to give good resuscitation, take care of the A, B, C, D, E as we do for any major trauma. Then we need to think calmly. However bad a situation looks, there is always a way out. The first person who sees a patient plays the most significant role. It is very important to call for help early, and also very important to make a complete plan. So you need to inspect the wound, think what needs to be done, plan the treatment, and then act. Many times, this is not in this order. So you start doing something without inspecting the wound thoroughly, and also you start acting before making a complete plan, and that can often lead to disaster. So now, having stabilized this child, given a block and given general anesthesia, we need to think what needs to be done. So here, there is loss of median now, loss of biceps, brachial artery, and there is an open fracture of humerus. So the child will need, after resuscitation, a radical debridement, fixation of the humerus, brachial artery repair, most likely a vein graft, and median nerve repair. And this will be followed by a pedicle lat-dorsi flap, both for cover and elbow flexion. And that's what has been done, and this is the result at two-year follow-up. So this is an ideal situation which we should always sort of aim at. But then, we often face situations like this where the sequence has gone wrong. Here, the patient has been poorly resuscitated, the wound has been poorly debrided, skeletal fixation is not stable enough, and there is significant necrotic tissue, as seen here. So now, when a patient presents like this, again, you go back to the same sequence, think what needs to be done, plan what can be done, and then go ahead and doing them in that sequence. So after a good debridement, the patient underwent a flap cover, and subsequently, he underwent a free fibula transfer. The outcome is not optimal, but then we were able to salvage the limb. In upper extremity, unlike the lower extremity, the threshold for salvage should be very low, and we should always go for salvage as compared to lower extremity, where the threshold for amputation is low. Now, when you see a mangled hand like this, here, only the little finger is intact, we need to think like a kintsugi master, and this is a very interesting concept. If you have Googled and seen, there is a, in Japan, they use this concept of repairing torn or broken pottery or pots. With gold and platinum, depending upon the economic status of the individual. So the fact is that they make it far more beautiful and then the original, and give them a new lease of life. So I consider that every hand surgeon is like a kintsugi master, and this is how it looks at the end of the reconstruction. So for inspecting the wound correctly and planning the treatment plan, giving an on-arrival block is extremely useful, and this was recently published by our department, whereby the patient is given a block on arrival in the ante room of the operation theater. This makes inspecting the wound, planning the treatment, and even discussing with the caregivers extremely easy and very useful. So coming back to the same hand which we saw, after we have blocked, we see how can we make this hand useful? Here, only the index finger is available. So what we need is a radial post. The ulnar post already exists. So we use the index finger as a heterotropically replantation onto the thumb. So what we need to do is, when we have a mangled hand, we need to mentally put all the tissues back in place, as seen here. It's just like a jigsaw puzzle. Everything is existing, but they are displaced and not lying in the anatomical position. So here again, the FPL has been shortened. The bone has been fixed. Vein graft and the nerve has been reconstructed, and that's a result at one year follow-up. The bone has gone on to unite well. He does have a small scar contracture in the first web space, which subsequently has undergone a Z plus T. So coming to where do we place if we have multi-digit amputation? Here again, we have one good digit. So where do we place the digit? So we have found that to be functionally useful and also aesthetically useful, placing it on the index finger is most optimal. Contrary to what has been in prior literature where people have tried to put it onto the little finger, it is cosmetically not good, as well as functionally also not so good. So for all our day-to-day functions like writing, even typing and texting, index finger is an optimal position. But then sometimes, as seen here, we have three-finger amputation, index, middle, and thumb. This is a small one-year-old child, but the index finger doesn't look nice. So here we can shift the ring onto the index and the middle onto the middle itself, and we can get a result like this. And this achieves a tripod pinch. So functionally and aesthetically looks better than having a loss of index finger. Now, after you debride, you need to make the plan. Many times, on arrival may look non-salvageable, but then after giving anesthesia and doing a thorough debridement, we can find that we can salvage the limb. And once you have salvaged the limb, it is followed by skeletal stabilization. And only after skeletal stabilization should we go or plan for a flap cover. And that's a result of the same patient. Of course, underwent subsequent arthrodesis of the IP joint of the thumb and the PIP joints of the index and middle finger. Now, coming to vascular injury, whenever you see a vascular limb, you should be prepared for a vein graft. And vein graft, as you put digitally, you will always find a size discrepancy. So you should be prepared to repair in difficult conditions. As seen here, the vein graft taken from the forearm itself is big for the common digital artery. So that's how it looks. But then if you are able to suture it in the manner which was shown in the previous slide, you can achieve a good result. And always remember, the vein graft needs cover. So here, the skin on the palmar skin went for necrosis. So immediately, the vein graft, before it gets exposed and dried off, you should go and cover it with, so here we have covered it with a perforator-based radial artery flap. The thumb was already necrotic, so that's why we prefer the radial artery perforator flap. Now, when you reconstruct the palmar arch, you should be prepared to take skin graft from the dorsum of foot, as seen here. And you should always look for the direction of flow. So the direction of flow should be distal to proximal, and the branching should be more proximal. So that way, you can reconstruct the palmar arch. And then, as seen here, the palmar arch is reconstructed. The two branches go to the two digital, common digital arteries. And again, cover them as early as possible. In this case, after 24 hours, it was covered with a ALT flap. When flaps are hanging loose, or when the skin is avalanched, it is always nice to augment blood supply. It not only improves the quality of wound healing, it also prevents the flaps from dying. So here is a degloved skin. As you see here, the whole skin is raised and attached only distally, and the ulnar artery is thrombosed. The radial artery is intact, but still, if you revascularize the ulnar artery, we will find that the vascularity is good. Is there any role of embolectomy at this stage? If you see a thrombus in continuity, we always excise it and put a vein graft, because at the level of injury, there will be intimal damage. So that's what has been done. A vein graft has been put. This vein graft not only improves the blood supply to the hand, also through the perforators along the wrist, the entire skin flap survives. So it is always nice to augment blood supply. Then comes debridement. Whenever we have injuries like this, extensive pockets are there where dirt and mud is there. You need to have an extent of debridement as seen here. You need to debride, respect the white structures, which is the bone, joint, tendon, nerves. So you take care of them, but at the same time, remove everything else. And once you have done that, you need to cover them early. So if it is done middle of the night, we prefer to do it as first case in the morning list so that we get a good cover. Here, we have used an ALT free flap. We have found that the type of flap cover does not decide on the wound healing or subsequent reconstruction. It is just that it should be done comfortably and should be able to cover the defect nicely. And then subsequently, underwent nerve reconstruction. If you cannot do it immediately, if the patient is sick or in the intensive care, then what we do is we cover with collagen sheets so that it keeps it moist for 48 hours and come back and do a groin flap. When multiple digits are involved, we just trim the tips of the fingers and try for primary flaps as well as separate flaps. The advantage of giving separate flaps, we can thin them nicely and we can make individual tubes, which is aesthetically and functionally better. Now coming to fracture fixation, stable fixation is very important because loose or poor fixation is the beginning of end. You should not have non-union and always think of function. So here, any defect around the wrist joint or through the carpal bone, when the carpal bone cannot be salvaged, we prefer primary wrist fusion. It gives a very stable fixation and here, a gracilis free flap on top. This also founds a foundation for the reconstruction. When it is very close to the joints, elbow joint, every effort is made to preserve the joint. It is always nice to fix it primarily when the wound is open and this has been done by our orthopedic department. They did this customized nails and then it went on to unite well. Only thing we did was early flap cover. Early means doing within 48 hours. So primary bone healing and that's a range of movement he could get. Now, when the flaps are thinned out and there is only viable distal fingers available, we avoid shortening them and closing the stump. Always think how you can preserve extra length. So here, you can put bone graft and a groin flap and that's a result you can get. Distal to the MP joint, even if they don't have PIP and DIP joint, functionally, they are very useful. Another example, here, the bolar skin is intact. There is loss of bone as well as dorsal skin. Debride them thoroughly. These are done primarily on the day of injury and an abdominal flap and that's a long-term outcome. Now, coming to tendons, tendons can be avulsed or injured in two manner. One is distally or at the muscle level. So if they are at the musculocutaneous level as seen here, if the tendons are avulsed at the musculocutaneous level, you need to debride to this extent where you just take away all the muscle and then retain the proximal muscle and weave it into the proximal muscle. So that's the amount of movement you can get. So this is at one year follow-up, you can see the shortening has been done and the same patient at 10 year follow-up, no subsequent reconstruction has been done. At 10 year follow-up, good power in the wrist is maintained, there is good finger movement and there is good sensation. Now if the proximal muscle is also avulsed or if there is double level injury, then we prefer as I said primary wrist fusion, flap cover followed by functioning muscle transfer and you can get a result like this. So this is what we need to keep in mind when we see avulsed tendons. If the tendons are avulsed in the palm, then first stage we just debride them, leave it. We avoid putting primary tendon rods because we are not sure of the viability and we are also not sure of the chances of infection. So you can always come back later and put tendon rod and do as a two-stage reconstruction. Second stage we use long facial autographs and that's the same individual at the end of two year follow-up. Now coming to nerves, primary repair is always preferable. Long distance nerve direct repair can also get good distal recovery. But if the nerves are avulsed as seen here in an arm replant, what we do is we can plate the humerus and tunnel the nerve and bring them away from the site of repair and then subsequently you just need to open it the site where they have been banked and then put nerve grafts and this is the other way around. Here the distally they are avulsed, so you tunnel them and bring it in the proximal forearm and then subsequently you go in and do nerve reconstruction. Most of the time because we have done bone shortening we can do direct nerve repair also and that's a result of the same patient. Finally when you see a wound always think the final plan. So here this patient needs a flap because as we can see after debridement there will be loss of skin as well as the muscles. So you may need some form of reconstruction. So it is very tempting that after a sitting of back you can get a wound like this and graft the whole area but you should not do that because you need subsequent reconstruction in the forefinger flexion. So always go for a flap cover. If it needs a flap on day one it always needs a flap. So that has been done. The volar side has been abdominal flap has been done and the extensor side has been skin grafted. Subsequently we do a functioning muscle transfer and can get a result like this. So the take-home message is whenever you have a major trauma or mangled extremity always remain calm but think hard. However bad it looks there is a way out. Make a plan and walk the path. Keep all reconstructive options available. Think of global function. Aim for dynamic aesthetics and stage reconstruction if safer is always a better option. Thank you very much. All right good afternoon. My name is David Brogan. I'm at Washington University in St. Louis. And I appreciate the opportunity to speak with you today. Thank you for that and it's an honor to be here with all these panelists. It's a bit daunting following Dr. Venkatramani because anything I show you is not going to look nearly as impressive but I'll do what I can. My charge was to show you talk about soft tissue coverage of the mangled hand. These are my disclosures. My other disclosure is I'm an orthopedic surgeon which seems weird that the ortho guy got asked to talk about soft tissue but we do all of our coverage for our department. So it's a passion of ours and my goal today or my learning objective is basically this. So that if you see this on the left instead of having this expression that hopefully you'll end up feeling something like this. And to do that we're going to talk about kind of the factors that will determine soft tissue coverage. I'm going to try and give you a road map of some of the common things that I will use based on the level of the defect that you're facing. But really the things that you should consider in global terms much as we just heard is to think about the tissue that's missing what's exposed that terms the timing of the coverage usually earlier is better and then also the complexity of the coverage. The location will tell you what options you have local muscle local skin versus something distant or regional. And then also I think surgeon comfort is a reasonable thing to discuss that we all have different skill sets and so some people will feel very comfortable doing complex microsurgical reconstructions and others are going to want to stick to something that's regional or something that's a pedicle flap and that's okay. I think you just need to know yourself know your limitations and if nothing else know when to ask for help. When I think about soft tissue coverage I really kind of think about it as what do I have and what do I need. So if you've got this kind of and the way I explain to patients is think of it as like we're trying to get grass to grow right. And they can they can understand the concept of getting a nice green lawn and because everybody says well why don't you just put some skin graft on it. And I say well skin graft is like grass seed right and you've got bone and plate and that's like throwing grass seed on exposed gravel. It's just not going to grow very healthy lawn there. So we need good soil which is muscle or we need turf which is like a fascia cutaneous flap and and that will hopefully get us a nice lawn depending on just what we need. But I think that you have to recognize that as the complexity of the problem increases so do the so does the complexity of the solution. So some of the things that we just saw need obviously very complex solutions and that's a function of the skill applied as well. So here's the roadmap. There is a lot of different ways to skin a cat and there's no perfect solution for any particular defect I think. And so how you get there is really up to you. But I hope to give you a couple different options based on the location of the defect that we have. So we'll start off with the fingers and then work our way back more proximate towards the elbow. And so if you have a relatively simple defect I think that something like a cross finger flap is an often overlooked much talked about probably rarely used flap. But I think in the right hands and for the right reasons and the right patient this is actually kind of a fun thing to do and can work quite well. So the way that we do the cross finger flap is fairly quite simple. You just go down and you take we're sorry do we have a pointer laser pointer just the mouse. All right. There we go. OK. So you take and you leave the protein on here and then raise a full thickness fascia cutaneous flap on the dorsal aspect of the adjacent digit bend this up and then just sew it in there. And then three weeks later two to three weeks later you divide it. So for me the ideal person is something like this. This is a guy who was working on an engine and stuck his hand into an alternator. He had this kind of nasty wound with exposed FTP tendon here. We cleaned it up and he's left with a defect like this. And so it's in a good spot. We don't have to bend his finger very much to get it to reach. You can use the adjacent healthy long finger fascia cutaneous flap full thickness leave the peritoneum on so it will take a skin graft take the skin graft from the forearm somewhere however you like defat it and then so this end over there and you do that. This is what it looks like at the end. It contours nicely. Here's our skin graft on top. And then we send him to therapy and got him a splint to protect it. And then here he was. He actually got covered in the interim so it delayed. I normally would divide him about three weeks but he was stayed out to about five weeks. It looks a little gross from just the eschar but this is healing OK and this is healing and fine. And then about two months postoperatively he's got actually a fairly reasonable result for him. So a cross finger flap in the right patient not a bad idea. If you want to get a little bit fancier and you don't if you're concerned about the stiffness that a cross finger flap might impart then another possibility is a reverse homodigital island flap. And again this is one of those ones that we all got tested on for OITE or in training exams but we probably have rarely had a chance to do. But it's actually not that hard. Just think of it as like the world's smallest reverse radial forearm flap. So you take the digital artery here design a flap more proximally and it's great for any sort of distal defect. You're the kind of go no go spot is that you don't want to go past the distal interphalangeal joint crease because it relies on these little ladder arteries going across. In reality if you design it proximally then you only have to go essentially half if you pivot in the midpoint of the finger that will get you to the end of the finger. Right. So you should never have to dissect your pedicle beyond halfway up your digit essentially. Okay. So find it cut it here tease the nerve out and then take this all with just a fat around it and put it on the finger there and then you can skin graft or oftentimes you can probably just close these primarily depending on the size of your flap. So this is an 11 year old kid. He plays for the AAA Blues the hockey team in St. Louis and he got an amputation when he was playing around with one of his teammates the kid his buddy stepped onto his finger and basically cut it in this kind of longitudinal fashion. And so this is what he looks like here. He's got this defect he has exposed bone underneath this kind of granulation tissue there. It looks kind of funny and he's got to use his hand for his stick. So we pinned him. He had an open fracture pinned it debrided it got it clean and then we made this cross finger flap design the pedicle here again tease the nerve out so you maintain the sensation to the finger and then open this up rotate it down as you can see here and don't try and skeletonize the vessel you can take a big cuff of fat with it that's totally fine and then place it onto here with our pin and then this is what it looks like interoperatively. I don't close over this I'm too chicken to close anywhere near my pedicle so I just leave it open it granulates in just like when you have kind of a little tough fracture that's not got much exposed and here he is a couple weeks out and he's three or four weeks out at this point and starting to contour starting to fill in this is a little unsightly he's young and had a robust kind of cichlid transformation you could make this more of a curvilinear scar if you're into that and then now here he is at like two months my esteemed Dr. Boyer saw him my esteemed partner saw him and asked him to pose for the camera so he's happy with it I think. So that's a those are the finger flaps you have some good finger flap options Integra is an option I would say resist the urge to put Integra onto everything I think there are some elegant options that you can use instead it's a good bailout if you need it but think about the other stuff. So questions or comments on fingers feel free to pipe up if you like I mean it to be interactive. So we'll talk about the hand and a relatively simple defect in the hand what we can do for those. So I think that the reversed posterior neurostasis artery flap is actually a decent flap for this this is an extended one but there's variations on the theme essentially but this is a nice flap for a dorsal hand defect where the wrist is not involved if the wrist is involved and you've got a defect coming back to here your pedicle is probably going to not be salvageable and so you need to reconsider and do something else but it's a good flap if you don't want to take the rate of artery if you have concerns about this the and the continuity of the arch so say a like a central fireworks blast injury where they take out the middle of their hand this is a good one to to utilize and the donor defect is pretty minimal it can be a little footsie try this on a cadaver before you do it because you have to find that interval between the EDC and the ECU and once you do that it's pretty straightforward to raise but the first time or two it's it's can be a little stressful in the OR to do that so for me a person to use this on is this guy who is a 50 year old who was he lives in a trailer and he was throwing fireworks onto his neighbor's property in his trailer because they were having some sort of fight and so he held on too long and karma is is a wicked thing and so it blew up his hand basically so he comes in with this he gets debrided I tried to close him primarily which in hindsight was kind of a stupid thing to do I thought he was clean and then comes back to clinic and it's pussed out we took him back to breed him again and now he's got this big central defect in the middle of his two remaining digits basically so he doesn't have an intact arch or at least I don't trust that he does so I need something local because I guy who's throwing fireworks at his neighbors probably he doesn't have running water either so I need something that's going to be simple and easy relatively for him so PI is a good option so we raise it here you be careful about how approximately you extend it you don't want to get too much closer than about six centimeters to the lateral epicondyle find these intervals raise up the fascia flap fascia cutaneous flap and then this is your vessel coming in through here and then proving to myself that it's actually bleeding I don't know if it shows up on this it's got a little bit of blood coming there so I felt relatively confident that the flap was going to be okay and then sewed it into this and then even at five days post-op the flap is healthy it's it's got 100% survivability his skin graft is taking nicely and so this is a reasonable option for this gentleman and does not require microsurgery if you have a more complex defect and that the PI isn't going to work you have a larger defect the PI is involved if you don't want to take the radial forearm for some reason then I think a nice option for especially the dorsal aspect of the hand is an ALT flap ALT for really so living in Missouri are my patients are not necessarily svelte and so if you have a very large patient you're going to have a very thick ALT and that's something to consider that it's like putting a German chocolate cake on the back of somebody's hand so a bigger patient I may consider like a muscle or a local pedicle flap but for a relatively slender patient or a medium size patient an ALT is a good option the anatomy has been well described in multiple articles but I like the kind of 18, 23, 28 rule that if you measure from ASIS 18, 23, and then 28 are going to be the locations of your A, B, and C perforators make a drawing of a line from the anterior superior leg spine to the superior lateral border of the patella and about 1.8 centimeters lateral to that at 18, 23, 28 is where you're going to find those dopplable perforators and it's a relatively straightforward flap to raise for the most part and this is our prototypical case 17 year old male was in an ATV degloved his hand he's down to bone over here he has no fractures he kind of skived off the tops of his metacarpals and he's missing all his extensor tendons right so he's going to need durable soft tissue coverage it's too big for a PIA flap you could do a radial form but it's pretty big for a radial forearm as well you could consider a muscle but the problem is that we're going to put a tendon we'll initially have to to do something to kind of stabilize this so we decided to put silicone rods in to hold the tendons out and then come back later and do tending grass so I knew I was going to come back for a secondary reconstruction and muscle is you can certainly lift it up for later reconstructions but if you can use skin instead it is a nicer easier thing to uh to work with so we designed an ALT flap it's not too thick you can see here he's not particularly slender but it's it's okay with his body type a nice long pedicle which makes it easier to work with and then we've put in our hunter rods here essentially to the extensor tendons got our pedicle hooked into the radial artery and it it does okay with that so another uh one that we just uh just did on Monday so 56 year old with a crush injury in a lime mining elevator um and uh the elevator turned on crushed it and they covered it in lime which is severely caustic because it's alkali so he shows up and he's got this so he's got burns basically as well as a crush injury and this is when you pull the skin back this is what the inside of the hand looks like these are ischemic and really not salvageable and such so this is a problem and as Dr. Venkatramani told us really debridement and an eye towards kind of what the next steps are is important in the initial care so my my partners took care of the initial debridement and took care of him on call cleaned it did the amputation of the rays of the fourth and the fifth saved the rest of it they did multiple more debridements and got a nice clean wound and what I try and tell our residents is that we can deal with a big clean wound a small dirty wound is an insurmountable problem so if you're in it if in doubt just to breathe and to breathe big so he's got this defect you can see as exposed uh I think that's capitate there um and so he's going to need some sort of coverage given the size of it we decided to use a latissimus flap I like the latissimus for irregular defects if you have to contour around say the ulnar or radial border of the hand a lat will contour very nicely and I'll show you some examples of long-term follow-up that they they heal down and actually atrophy quite nicely so for him uh an ALT would have been hard to make the ALT wrap especially if they're a little thicker and so a muscle is a little bit more pliable for these large irregular defects but I think there's a number of things you could have done for that so then moving forward so we talked about the hand especially dorsal aspect and we talked about the fingers and then now kind of talking about a forearm how do we take care of those when when they come in so one of the things that is a nice and maybe not often talked about uh option for uh non-microsurgical reconstruction of a forearm defect is a pup flap and this is a pretty simple flap to do it's it's basically a version of a groin flap but instead of doing the superficial circumflex iliac artery down here you go up to these parambilical perforators which are part of the system that supplies the rectus and the skin overlying that and you can dial for out around the belly button you can find these little constellation of vessels get a doppler signal on them and then draw a line to the inferior angle of the scapula and then you can create a flap based on kind of this leash of vessels there it's fairly straightforward to raise it's not hard to do it's nicer than a groin flap for a forearm injury and the reason is if you think about the logistics of a groin flap groins are fairly low and so if you have to get up to near your elbow with a groin flap then the patient has to be kind of pulled down to their groin to allow to reach if you have a pup flap their hand or arm can rest comfortably at the level of their mid abdomen and it's not so difficult on the patient so i would suggest for a forearm you might find that a pup flap is a little bit easier to reach than a groin flap so this was a 17 year old female was one of my favorite patients she was the prom queen got crowned in the hospital played on the boys football team as a lineman and and was captain of everything so she was exhausted she fell asleep at the wheel and then mangled her arm in an mva she was initially stabilized by my partners on call bony stability revascularized her arm fixed the nerves and such and got her clean so she's got this and now we have to cover it and so for her a pup flap is a decent option because i didn't want to go into her single vessel in her form so i want to do a non-microsurgical option because we had to go back later for free functioning muscle to restore her flexor tendons the one thing that you should tell patients especially young women and i neglected for to tell her this and she brought it up later is that you are tightening the skin here and so it can create asymmetry in their breast and so you know a guy probably may not care but a young woman should at least mention it to them they can be fixed later but it's it can be noticeable just depending on the size of the flap so we elevate it you can get a fairly long flap and then close up behind it and then this is it inset into her form you can see here different views and then this is her about a year later so it can actually have a relatively nice contour for this result for her similarly so this is a guy who fell asleep in chicago in the snow and had frostbite to both his hands we had to do amputations through his mcp joints and i wanted somebody to cover it and so an option for him is a pup flap which was you could use your groin there's a million different options but we did staged pup flaps for him and this is his result again non-microsurgical options uh to have a decent amount of tissue on the hand that's fairly simple to do and fairly quick and then finally i'll finish with kind of forearm complex defects i like the latissimus flap for a big form defect i think it's easy relatively straightforward to do you harvest it kind of a long incision somewhere along here along the course of the latissimus muscle thracodorsal vessel is relatively large so the micro is not super difficult this is a 54 year old farmer that caught his form in a grain auger and had flexor tendon disruptions media nerve injury and all sorts of problems with this needed coverage lost a lot of skin on the dorsal aspect we obviously his latissimus he's a farmer his latissimus is huge and ample soft or ample tissue there we then fixed his median nerve with cable grafts and then you want to create a well vascularized supportive environment for that nerve to grow and so a skin back or sorry wound backer and skin graft is not optimal after a big median nerve reconstruction so we did the latissimus flap i always tell patients it looks like a big hunk of steak and you're i'm going to come in and say like oh it looks great and you say what the heck are you looking at and the way i explain to them is i say it's like a mother with an ugly baby they see the potential all right and so um and usually that helps a little bit and you can see here the lighting's a little tough but at a year he's come you know it's it's actually quite a bit the contour looks pretty similar to a a normal forearm essentially so it looks much better so overall this is the road map at least you know this can be altered in so many ways but just a basic starter for when you start thinking about these wounds how to address them i think there's rarely one perfect solution it's what works best in your hands and debris debris debris get it clean and then you have lots of options after that thank you so much My name is Sonia Agnew. I'm very honored to be here today. Sounds a little bit odd to say that mangling injuries are some of my favorite injuries, but I think reconstruction of patients who have mangling injuries is one of the greatest challenges and is one of the most rewarding things that you can do as an upper extremity surgeon. And I think we have the potential to change people's lives based on the length of time that you end up having to deal with these patients and how you can help them through the psychological and emotional trauma that they experience. So I practice in Chicago. I'm at Loyola University. And I have no disclosures. I'm going to begin with my summary slide, which is to explain that the whole goal of mangling injuries is to achieve a stable and less painful hand. Patients in these injuries always have pain. And so what you want to do is over-promise and under-deliver your results, because it'll make you look like a hero, number one, and it's honest, number two. And you both over-deliver and under-promise motion and pain. And as Marla was pointing out, amputation may be better in some instances where patients end up with stiff and very painful fingers. You want to talk to your patients about depression, which all of them experience, and post-traumatic stress disorder, which is very, very common in these patients. And this is a photograph that is very, very similar to the slides that you've seen earlier today. And I think, as pointed out earlier, their first reaction is like, oh, great. Now what am I going to do? Can't see what's happening. You don't know what's injured. So you have to take a step back and inspect the wound, explore the wound, and think about options. And you have to avoid the concept of thinking that anything you do will be better than what they came in with, because that's simply not true. So you have to imagine what life will be like two years from now and think about those options the night or the day that the patient comes in. There really, unfortunately, are no recipes for these injuries. As was pointed out earlier, there's a lot of different options. And the order is generally staged reconstruction. But there are many ways to treat these patients. And I think what you have to think about right at the very beginning is which path you're going to take. Are you going to go down the long road of salvage? Or are you going to decide for yourself and the patient that amputation is the right choice? And you have to, as was mentioned earlier, understand what you can do. So there's what you may be able to do, and what you can do, and then what you should do. So first, in order to determine if there is anything you can do in terms of salvage, you have to understand the injury characteristics and the zone of injury. Is it a single zone of injury or a segmental zone of injury? Obviously, segmental injuries are far more complicated and have a poorer outcome. Is it a sharp laceration or is it a crush injury? Obviously, mangling injuries are typically the latter. Are you dealing with a subacute injury of a patient who already has fibrotic tissues, osteomyelitis, scarred nerves? And if you are, then you have to understand that delaying management of these patients, if you're inheriting these patients six months in, you may want to consider amputation versus a prolonged course of salvage in these patients. And then you have to make a laundry list of what you need. So in the hand, priority is to opposition and pinch, sensation and power grasp. In the forearm, you need a stable wrist and elbow. You need extrinsic tendons. You need a sensate hand, and you need intrinsic function. And so then you go on to decide, once you realize what you don't have, you need to understand what you do have. And so you could do a part-by-part laundry list of the injured structures that you have, and sort of the injured structures, and then what you have left. And I usually write this down. And I write down what was absent the night of the injury. And I paste it in the top of my note, my progress note, so that I remember how bad the injury was. Because in many of these cases, six months down the road, the skin envelope is closed. You can't really tell what the initial injury was. And it's really, really helpful to remind both you and the patient how far you've come. So pasting that in every note is actually really helpful. It sort of makes you feel that you've achieved some form of progress. So you're making a list, list of options for skin coverage, list of options for skeletal reconstruction. Unstable joints, fuse them. Missing cartilage, you can consider arthroplasty. And even though we tend not to think of arthroplasty and traumatic joint injuries, it's actually, if the skin envelope and the soft tissue envelope is fibrotic, it can actually be, you can work in your favor and you can have some motion. And then for missing bone, you can use a mascalade technique, iliac crest bone graft, or free bone graft. I'm sorry, microvascular bone graft. In general, I think of tendon grafts, not so much for motion and mangling injuries, but to reposition the joints. It's very, very hard to get a very mobile or normally mobile hand after these injuries. And then again, you have to decide if you can, and then should you? Because sometimes the path you walk down is something you end up regretting. So how I decide whether or not I should reconstruct is something that is not based on one particular thing. There's no magic number of injured structures that dictates what you can and cannot do. But in general, you want to overestimate the number of stages and the time frame for reconstruction so that both you and the patient are mentally prepared for the road ahead. And then again, your expected results. Patients often have no concept of how bad their injury is. So you want to talk about what you predict their function to be, that you want to aim for very broad strokes goals. So a less painful hand, you want to be able to pinch or grasp objects, position your hand in space. And think about whether or not the expected result is going to be in line with the patient's occupation. And of course, if they're dominant on that hand, you may be more willing to undergo reconstruction versus amputation. And then finally, to our patients, the aesthetic result is important. And so as was pointed out earlier, an index finger reconstruction in a patient who's amputated all of their digits with the exception of the thumb is aesthetically much more pleasing than the cleft hand or the claw hand. Patient motivation is something you can never assess on the night of the injury. But it is a huge factor in whether or not patients get better. And we've all had patients who you feel like you're dragging them along the entire time. They're depressed. They're patients that really can't cope. But you may decide to shorten the course or minimize the number of stages based on your getting to know the patient and understanding whether or not they can tolerate reconstructions. These are the kind of patients that I spend a lot of time with. So I don't rush them through clinic. I get to know what their families are like, where they were born, what their pet's names are. And I try to get them to buy into the fact that I'm their ally. Because in that way, they are already going to become dependent on you for this. And in that way, they can at least understand that the decisions you make are in their best interest. And then eventually, return to work and financial factors and patients not being able to afford yet another surgery, not having rides anymore to come to the hospital, those are real things. So you have to be cognizant and understand where your patients are coming from. And then considering the alternative to salvage, obviously, is would a prosthetic be better? Again, you can't really determine that in the acute setting. So salvage is always the first goal. Having a patient consult with the prosthetist is also a very good idea. So I have a prosthetist that I work very closely with and oftentimes try to bounce ideas off of for patients like this. First case is a 31-year-old gentleman whose forearm and hand was pinned in a plastic press. And he had lost all the soft tissue and the dorsal capsule on the dorsum of the forearm. And he had dorsal carpus exposed and no extensor tendons. So he's missing his finger and thumb wrist extensors and dorsal carpus. And he has an exposed radiocarpal joint and proximal ulna. So can I is the first question you ask. And you say, yeah, I can do it. They're a healthy patient. And it's acute injury. It's a clean wound. And these are surmountable injuries. Should I? Immediately, I don't know the patient. But he appears to be motivated. He understands that there's going to be multiple stages. At least I think he understands. And then the expected final function is acceptable to both me and the patient. So after initial debridements, we use antibiotic beads just to create an envelope into which later a bone graft can be placed. And for reality, and as was pointed out earlier, in Chicago, we have sort of a thicker population. So oftentimes, our anterolateral thighs are a little bit larger. And then we transition to a total wrist fusion because the entirety of his carpus and distal radius were too badly damaged with an iliac crest bone graft. For finger function or finger extensor tendon reconstruction, I used pronataries to extensor digitorum with a interposition of flexor carpi radialis because we didn't need his FCR anymore. And over a year and a half and 12 total operations, he's on no narcotics. He's back to work. And he has minimal excursion of his tendons. But he has a restored MP position, which was the goal of, again, doing the tendon grafts. Second case is the picture we saw earlier. It's a 35-year-old left-hand dominant woman whose hand was crushed in a printing press. And going through the algorithm here, KNI, she's left-hand dominant, is an acute injury. And the zone is the entire hand and wrist. So it's a pretty tall order for reconstruction. She's lost both her thumb CMC joints, the entirety of the thumb ray, and her index CMC. So that's a really big problem. We saw photographs earlier of using the index finger to policize for the thumb. And that's a lot easier when you have a CMC joint. In this patient, we didn't have that. But given that it was her dominant hand, I really wanted to give her something to oppose to. And as, of course, you go to literature, and there is a paper that sort of helps you understand this. But you need soft tissue coverage in order to do this. So the patient underwent initial debridements. I talked to a lot of my colleagues. I sort of provisionally pinned her thumb in a ridiculous position, like total recall. And then I temporarily plated her forearm and debrided her multiple times. Arthrodeserm and carpal joint. I ended up doing a revision osteotomy to get the thumb out of the plane of the hand. And she had a total of eight procedures over three years. And hopefully this plays a little video of her writing. So she uses a splint, but is able, with a little bit of assistance, to write and hold a pen. It's painstakingly slow, but for someone like her with the use of a splint, she actually has a functional thumb. And it looks like a thumb once the splint is on. So aesthetically, it's not the best result. Third case is a 22-year-old right-hand dominant worker who crushed his left hand. He came to me with this wound. He'd already undergone a debridement and integral placement. And in his case, he had a CMC joint. Subacute injury with a small zone injury, surmountable, and was missing his thumb as well as soft tissue envelope. So yay, we have a CMC joint. That's what he looked like. But we need a thumb and a soft tissue envelope. So the first step is to create that soft tissue envelope with a reverse radial forearm flap. And then the second is to create an opposable thumb. He was not interested in taking his great toe, so I took his second toe. And even with that radial forearm flap, I still had to place integra over the pedicle to keep it covered. It was a lot more of a challenge to position the thumb than I thought it would be. And then I had to debulk his flap. And as it turned out, I placed his second toe in an extended position. And so I ended up having to osteotomize him because he couldn't really pinch within the position I placed him. You can see he's almost there. So just recently, and this is after I did a teenolysis, just recently I did a corrective osteotomy to reposition his thumb. But what I learned from this is don't teenolize second toes. They never move, so don't bother. If you remember one thing from this, that's probably good. And I just did an angulation osteotomy to reposition the thumb. I don't have any videos because I just did that about a month ago. But two years and five procedures so far, he's doing well. And when amputation is better than salvage, you wanna not just perform the amputation and then leave the patient to fly on their own. You have to understand that there are a lot of resources out there for amputees. And so I would encourage you to share these with your patient. There's vehicle modification resources, there's employment and education resources, college funding. Not all amputees are eligible for disability, but it's something you need to empower your patients to find because a lot of patients may not understand that that's there. So just to review, preparing your patients, have them understand that they're gonna undergo many procedures over the next several years and that they're gonna get to know you for a long time. Don't over-promise motion in a mangled hand. And consider that amputation may be a better option in some patients and talk about depression with your patients. Thank you very much. Thank you. Thanks. My name's Matt Butler. I'm from northeast Wisconsin. And these have been some great talks. I'm going to wrap up by speaking on some postoperative considerations in taking care of patients who have been through mangling hand injuries. So I think broadly we could define some of the objectives of care as trying to minimize the direct and psychosocial effects of the injury. And that includes both maximizing objective limb function and also minimizing some of the damage to patient's psyche and body image. Considerations to keep in mind that make this variable include patient livelihood and other life activities that may be germane to their quality of life. When a lot of us think of postoperative care, the term therapy comes to mind. But unlike many of the routine or elective hand surgical cases that we do that are amenable to standardization and protocols, a little bit more thought and care has to go into the planning and therapy for these combined injuries. Obviously the variability of what tissues are lost, what's remaining, what's had to be repaired is important. We may be able to pull from some of our standardized protocols, but we'll need to be a little bit more thoughtful. If you happen to have in-house occupational therapy, that's great. If you don't, I think it's worthwhile identifying therapists and centers in your area and communities where you can send these more complex cases. And I'd encourage an early therapy referral. Frequent visits early on can facilitate simple things like dressing changes, adjustments to splints, and keeping open good communication with a therapist can allow you to intervene if challenges and complications come up, and they almost always will. So in all of hand surgery, stiffness is our enemy, but it's even more important in these combined injuries. We're familiar with this concept of one wound and one scar and that everything kind of wants to mat together. This is a picture of a concrete hand, which is what I feel like I'm trying to fight against most of the time. Some basic concepts of edema control and initiating some amount of motion when possible early on I think are important to maintain joint mobility, and some differential gliding of the different tissue layers. Later on as the patients heal, again, the therapist can be very helpful intervening with things like dynamic and functional splints and other modalities that can help with scarring. Work simulation can be very helpful for patients to get back to work. And the other thing I'd encourage you to do is to look in your area to see, particularly for the work injured patients, if there are interdisciplinary centers that you can send patients to. I have some resources in my area that incorporate occupational medicine and physical medicine with therapy and in psychologic counseling, and they can be very helpful in managing things like return to work, pharmacotherapy, and splint adjustments and really make your life easier and I think are also good for the patient. I'm going to talk a little bit now about the psychologic impact of hand trauma. We don't get to pick our patients, but I think most of us if we had the opportunity would pick the farmer versus this other guy for most of our cases. We've all seen patients with devastating injuries who have great coping skills and are able to reintegrate back into a fairly normal life in spite of a terrible injury, and we all have patients who have relatively minor injuries that struggle mightily. I'm going to focus more on the post-traumatic or post-morbid mental illness and PTSD. So what PTSD is is a mental health condition that has symptoms that basically fall into four categories. They include intrusive thoughts, avoidance behaviors, alterations in cognition and mood, and alterations in arousal or activity. In general, anything in biology is best looked in the context of evolution and survival mechanisms. So from that standpoint, these are the exact responses that would impart a survival advantage in life-threatening or traumatic situations. You can imagine that hypervigilance, avoidance of danger, swift reactions, light sleep, anger, and flashbacks or remembering traumatic situations, although very unpleasant, are better than the alternative of death. So it's only when these normal mechanisms become pathologic or drawn out that patients really have true PTSD. So if you're treating patients with significant hand trauma, you're seeing PTSD whether you're identifying it or not. Easily up to a third of our patients will, if screened, meet the criteria for PTSD. So what can we do as hand surgeons? None of us want to spend additional time necessarily doing psychotherapy formally in clinic. But it's very easy to screen patients for this. All you have to do is ask the question, are you willing to see someone to discuss the feelings you have about your trauma? If they say no, you can leave it open-ended, but at least you've laid that out for them. If they say yes, then you make a one-time referral to a mental health professional for what is essentially a screening process. They have one visit. They go through the screening process. If they screen negative, then they're done. If they screen positive, then you've done them a solid and gotten them some help. And since COVID, this all really happens via telehealth. The psychologist that I utilize is in Milwaukee. It's about an hour from our office. And he meets with people virtually. He has a one-time session with them. If they need help, then they're plugged in. If they don't, it's not a big waste of resources. You don't have to feel like you're wasting your patient's time, because this can all be done remotely. The other thing that is under our control is thoughtful management of patient return to work. It's been clearly shown that getting our patients back into the workplace early on, even if it's just for a few hours, or doing something one-handed or in a protected environment, will break some of the avoidance behaviors that they have from PTSD. And then lastly, I'll just touch on the role of prosthetics. I won't get too involved in this. Sonia also brought this up. But if you take care of severe injuries, you're likely going to have patients who are amputees. And making that early prosthetics referral is very important in terms of having them adopt the prosthetic into the recovery process and then using it later on. And likely, with new advancements in technology and prosthetics, this will be a better and better option for our patients in the future. I'll finish with just one case. This is a 32-year-old right-hand dominant female letter, right dominant hand crushed in a press at work. So a crushing injury with a large zone of injury. All of her fingers were either amputated or non-salvageable, non-viable, at least for me. Hari might have put them all back on and had it work perfectly, but not for me. But the thumb was in relatively good condition. So my feeling was that saving the thumb rather than doing a wrist level or distal forearm amputation would allow this person to have a partial hand prosthetic fit. So really not anything fancy. This is K-wire stabilization for the skeletal injury. All of the skin, I don't know if this mouse works. All of the skin did die, so I did do a lateral arm flap for me. I don't do a lot of free flaps, so that's a much more intuitive flap for me to harvest than the interlateral thigh flap. I don't do that flap. And then a thumb tenolysis. And this was her final result. Thumb up. Sorry, I skipped ahead. Open your hand. Take the ball. Grab it. Okay. Your ball. Give me back the ball. Okay. Now grab the ball. So by no means a normal hand, but this patient has this myoelectric prosthetic that works with her native thumb for tasks around the house, and then she has a clamp terminal device that she uses at work as a welder. So just some of the take-home points from this patient that I think helped her were an early referral to occupational therapy, early referral to a mental health specialist to talk about PTSD, and early prosthetics referral. And with that, we'll wrap it up. Thank you. Those were all fantastic talks. Thank you guys so much. Does anybody out there have any questions? Great question. So the question was how do you temporize wounds that have exposed hardware tendons and nerves? I'll start off. So you know there's there's dirty and there's real dirty and so dirty that's got low gravel you clean it up and stuff and you want to temporize it I think a wound vac is ideal for that as long as you don't have some contraindication with a huge vangraft or something. If it's real dirty then I think sometimes I've had people have wound vacs cause kind of more of like a Pseudomonas they let Pseudomonas brew and so you pull it off and it just smells awful the next time. Those patients I mean I think Dakin's like the wet to dry Dakin's changes on the floor is fine and I've had really good results even with kind of exposed hardware if people kind of catastrophic stuff Dakin's works great. I think that there's a temptation to put something like Integra or some expensive wound dressing on on wounds but as I pointed out earlier if it's gonna need soft tissue construction don't delay that. Try to get it done as soon as possible. If there's some reason like if they're polytrauma and you know you're not gonna be able to get to them for three weeks then I think it's not unreasonable to put to put Integra on but you also be just as good putting a wound vac with whatever choice of sponge you have on it. What do you do if there's an exposed vessel? Sometimes you can kind of tuck it in the forearm below some muscle nearby or just kind of move some muscle over it and then wound back. I definitely have seen bones take longer to heal and crush injuries. I think it's probably due to the disruption of the periosteal blood supply. Yeah, I think that open fractures like that, or even closed fractures with high energy, it's a soft tissue injury that happens to have a fracture underneath it, right? And so I think we all, especially as orthopods, focus on the x-ray and kind of look at that. But I think that obviously the surrounding soft tissue insult is sometimes much more important than the actual how many pieces the bone is in, basically. And you see it with tibias, right? Like a type 1 open tibia is a very different animal than a type 3 open tibia, and the amount of time it's going to take it to heal, even with good bone opposition, is dramatically different because of the periosteal stripping and the relative blood supply, I think. For like a metacarpal or something? My personal thing is that I can deal with loss of fixation or malunions and things like that, and they're generally well tolerated anyways, but stiff fingers are really hard to fix. So I tend to fix everybody in such a way, I hope, that I can move them within two or three days. And if I don't feel comfortable with that, then I usually tell myself I probably need to figure out a better way to fix them, basically. And if I can't fix them because, like with a plate or something because of the wound, then I need to figure out a better way to cover the wound so I can do a better job of fixing the bones, basically. Others? Yeah, I agree. I think pain in these patients is a big problem, and so if you give them license to not move, then you're never going to get them back. I think groin flaps are tough for patients where you are, I tried not to use them for unless, if I've got other options, because their fingers get stiff. They're dependent, they don't move them, they're scared to move them. And so for a fireworks where it's just a mangled hand, you're just trying to get something covering it, I think it works fine. But for somebody who's got like actually a decent hand, they're gonna get really stiff fingers. And that's a bigger problem down the road, I think. Yeah. I do. You know, the jury to me is still out on this. Our therapists are very, they like them, so we've had a number of patients that have gotten them. You know, whether they actually go home and use those versus, you know, a proximal phalanx or, you know, level amputation, I'm not sure. I think most people probably take it off and use a proximal phalanx level amputation that they can actually feel and is sensate rather. I think my general rule is you wait until the soft tissue envelope is supple. So usually I won't, I try to avoid going back and doing any sort of secondary procedures until generally three months unless I'm forced to for some other reason because I want it to be very supple and swelling to be down and such. And then for tenolysis, I usually wait until they've plateaued with therapy. And generally I won't go back, I try and make them wait at least six months but it's the plateau in therapy and the soft tissue envelope. Unfortunately, tenolysis in an angle injury is very different than tenolysis in a table saw, for example. And so I feel like you have to be pretty stiff to get a tenolysis in my hands because I've been so disappointed in tenolysis in these types of injuries. So if they really are like, you know, this, then sure. But otherwise I think a capselectomy and tenolysis you do once and you don't get What has helped me is to really give the patient this, talk to them early on. So we have you on narcotics, you need them right now, but we are going to get you off of those. And then I'm pretty strict about it. And I tell them, I want you off of these medicines. I think you're gonna have a better outcome if you are. I'm worried about you being on these medicines long-term. And most of my patients respond really well to that. And I am kind of a bad guy with it. Just if they need it, that's one thing. I mean, some of these injuries are very, very painful, but I believe strongly that pain can be managed with alternative means and often is. I think you can't forget the depression, anxiety worse than pain. So I think a lot of patients who are really refusing to stop asking you for refills or patients you might want to refer to psychology, or there's, we have a great group at our hospital that's addiction psychology. And they work with the pain management folks. And you're not really just pushing them away, you're helping them understand all the different means that are available to them to treat their pain, which I think is definitely physical, but especially mangle injuries becomes chronic and sort of a supertentorial issue as well. But I use Gabapentin freely. We I have not used it personally. I've used it. I've never been super impressed with it. Yeah we have hyperbaric. My general algorithm for that is kind of the more of the vasculopaths who have an ischemic ulcer because they just have poor tissue. In the trauma setting it's usually they're either missing tissue or they've got destruction of tissue from a secondary infection. If they're missing tissue the hyperbaric you can get there with kind of They're eroding tissue because of infection, which is very common in somebody who had an open tibia that was closed and comes back bussed out. Those people just need a good debridement and a wide debridement. And then they have a hole, and then the hole generally I would deal with health issues. Anyone else? All right I think that's it. Thank you guys so much for coming. Enjoy the rest of the conference.

hand injuries

surgical decision-making

collaboration

amputation

bone reconstruction

flaps

timing

wound cleaning

therapy

psychological impacts

functional recovery