PRIMARY RECONSTRUCTION OF ARTERIAL SUPPLY IN THE PALM AFTER AN INJURY: A CASE STUDY

INTRODUCTION

The human hand is one of the most sophisticated instruments, which enables its owner to grasp and also have contact with the environment. By means of its sensors it conveys information about the temperature, coolness, pain, deep sensation, and provides for an inexhaustible spectrum of nonverbal communication. It is hard to imagine life with a badly damaged hand, and even harder to imagine living without a hand. Advances in microsurgery techniques during the 1960s led to subsequent improvements, mainly in the area of fine neurovascular structures treatment, which would otherwise be impossible (1, 2, 14–19, 25). This technique among others allowed for the reconstruction of nerve or vascular defects by the use of suitable grafts from various donor areas. Extensive hand injuries should not be underestimated and should be primarily treated at specialized hand surgery workplaces, or perhaps replantation centers (7–9, 12). In case of amputations or ischemic hand injuries, the time between injury and revascularization of the amputated part plays a significant role (5, 11, 20). No hand injury is identical, and each requires absolutely individual treatment (4, 6, 23). We would like to share our experience with primary reconstruction of the hand arterial supply.

CASE STUDY

A 19-year-old patient, a manual worker, sustained subtotal ischemic amputation of his right hand on a circular saw. He injured his dominant hand. The patient was a non-smoker. Extensive tissue laceration was caused by the large diameter of the saw wheel with great saw teeth as well as the fact that the patient was not able to untangle his hand immediately from the place of injury, because he used heavy-duty work gloves (Fig. 1). From palmar side the area of the cut was through the fifth finger, through the center of palm towards the first metacarpal base. From the side view the area of the cut was from the dorsal side of the wrist obliquely towards the palm. The tangential cut caused severe devastation of soft tissues in the dorsum of the hand as well as in the palm. This resulted in complete absence of arcus palmaris superficialis, common digital arteries for 2^nd, 3^rd interdigital spaces (3, 13, 21, 22, 28). The common digital artery for 4^th interdigital space was destroyed, including branching of the digital arteries for the fifth and fourth fingers. The princeps pollicis artery in the area of first metacarpal base was also interrupted and defective. The ulnar and radial arteries were severed in the area of wrist. Next, the patient sustained open comminuted fracture of the base and middle digital phalanx of the fifth finger, rupture of the fourth and third metacarpal bones 1cm from the metacarpocarpal joint. The first metacarpal bone was ruptured immediately above its base with about 1cm of bone damage. The trapezium bone was ruptured in its distal third, and there was a deep cut in the trapezoid bone. All hand flexors and extensors were severed. The ulnar nerve was severed in the area of fifth metacarpal base, slightly defibered without significant defect. The median nerve in the palm was significantly bruised, and some fascicles were pulled out. The hand was connected with the central stump by a 2cm-wide skin bridge on the dorsum of the hand in the area of the fifth finger. The skin bridge did not contain any significant vascular structures. The hand was ischemic, livid, completely without blood supply. Warm ischemic time lasted 30 minutes; cold ischemia lasted 2 hours. Surgery was completed with an axillary block and lasted 9 hours. During the surgery the patient was started on wide-spectrum antibiotics (1.2 g of Augmentin). The surgery started with revision and careful cleaning of the wound of the foreign bodies and bone fragments. The skeleton of the fourth metacarpal bone was stabilized by axial Kirschner’s wire, while the trapezium bone, base of first and third metacarpals were fixed by screws (Fig. 2). Deep and superficial flexors were sutured according to Kleinert, extensors were sutured by mattress non-absorbable, single monofilament sutures (Prolen 3/0).

Under the medial malleolus we prepared the graft of vena saphena magna, including several venous branches in the direction of the sole. The number of venous branches was three branches higher than was required for the amount of reconstructed veins. The harvested graft was washed with saline solution with heparin. Instillation of the solution not only served to remove blood remains and hydrodilatation but also allowed venous valves to be found. The original presumption that the stem of vena saphena magna would substitute for the arcus palmaris superficialis and venous branches would substitute for the common digital arteries had to be revised due to the disposition of the valves. Anastomoses were completed between single branches to maintain correct blood flow (Prolen 10/0). The ulnar artery was chosen as a main source of arterial supply, single venous branches then substituted defective common digital arteries for the second and third interdigital spaces. For revascularization of the fifth finger we completed anastomosis between the ulnar digital artery and another venous branch from the venous graft. On the distal end of the venous graft end to end anastomosis with princeps pollicis artery was completed (Fig. 3, 4, 5). The venous graft was not connected to radial artery in order to maintain vascular supply of the skin graft on the dorsum of the hand. After a sharp resection of ends of median and ulnar nerve branches we completed perineural sutures of the remaining fascicles (Prolen 10/0). Venous drainage was restored by completion of three anastomoses of two venous stems with a diameter of 3–4 mm on the dorsum of the hand and one vein in the area above the first metacarpal bone with a diameter of 2 mm. After release of the venous clips the hand was immediately vascularized without the trend for venous spasms. Secondary to the arterial pressure in the middle of the palm above the skin niveau protruded the dilated venous graft with its branches. During the surgery we again considered the future function of severely lacerated fifth finger with its bone defect. This finger would heal in a severe flexion contracture. Therefore, despite good blood supply to the fifth finger we used tissues of the dorsal skin in the form of flap for the reconstruction of the palm skin defect and at the same time to cover the venous graft. Five days after the successful revascularization we removed the necrosis caused by the injury on the volar side of the thumb, and the defect was covered by a flap from the abdomen (10). After three weeks we disconnected the flap and reduced it. After four weeks the patient was discharged to outpatient care. After four months of intensive rehabilitation the patient returned to his original job (Fig. 6, 7).

DISCUSSION AND CONCLUSION

Treatment of extensive hand injuries in the area of palm are among the most complicated surgical procedures (27). This fact is due to the large amount of structures in a small area, which has to be perfectly treated. It is the perfect primary treatment of hand injuries that basically offers the operating surgeon the last opportunity to reconstruct all anatomical structures at the same time (24). In the further stages the reconstructive surgeries may be complicated by scars, adhesions that can significantly change the anatomical situation with lack of elasticity and tension. In conclusion, if the local and overall condition of the patient allows, the surgeon should try to primarily reconstruct all of the structures.

Following options were considered in the described case with extensive reconstruction of the arterial supply. A simple venous graft would create new arcus palmaris superficialis into which would be stitched single common arteries. That would mean the need to use more venous grafts to add on the length of unevenly long common digital arteries (26). The number of anastomoses would increase on the thin blood vessels, and therefore the risk of thromboses formation on the anastomosis would increase. The next possibility was to use two “Y” venous grafts stitched to the ulnar and radial arteries.

Before application of each venous graft it is appropriate to wash the graft with a saline solution with heparin (5000 units of Heparin to 100 ml of saline solution). That washes away the remaining blood; application of spray has an antirotation and antispastic effect. At the same time, the filling allows hydration of the venous graft; it is easier to judge the length of the graft for anastomosis and to determine the direction of the flow according to the valves.

We recommend that the venous graft is harvested from vena saphena magna, because it is a graft with more branches (2–3 more). It allows for more combination of the graft layout according to the present valves.

The use of multiple branches venous graft is one of other methods allowing for reconstruction of the arcus palmaris superficialis with the common digital arteries. The risk of thrombosis on the anastomoses of the small blood vessels is decreased by reducing the number of anastomoses and using end to end techniques.

Address for correspondence:

Andrej Sukop, M.D., Ph.D.

Dept. of Plastic and Reconstructive Surgery

3^rd Medical Faculty Charles Univ.

Univ. Hospital Královské Vinohrady

Šrobárova 50, 100 34, Prague 10

Czech Republic

E-mail: sukop@fnkv.cz