Functional Implications after Emergency All-in-One Reconstruction in Severe Traumas of the Upper Limb

Generally, the best solution for solving complex trauma problems in the upper limb is to first manage the morphologic problem, followed by reconstructing the functional issues after a period of time. In the authors' experience which involves a great number of upper limb complex traumas, it was possible to solve in emergency both the morphologic and functional problems, resulting in a more rapid and better functional rehabilitation. The authors presented their experience in using the principles and techniques for emergency all-in-one reconstruction of this sort of trauma. At the same time, they presented a new classification for emergency free flaps.

They discussed cases of complex upper limb traumas with medium and large cutaneous defects, associated with muscular, tendinous, vascular, neural and/or bone defects. In all these cases, they used all-in-one reconstruction, in a period of time between the first hours and the first 7 days after trauma. The moment for reconstruction was chosen depending on the ethiology of the trauma, the defect aspect, the age and biologic bases of the patient, or other possibly associated traumas.

Concerning the surgical strategy, they used a unique protocol that consisted of surgical debridement, ostheosynthesis, repair of all damaged anatomic elements, and coverage of soft tissue loss. When immediate coverage was not possible, it was performed up to a 72-hr maximum interval. Meanwhile, the wound was actively surveyed and repeated surgical debridement was done, if necessary. In all cases, amicrobial contamination was assessed daily. To cover soft tissue defects, different types of flaps (fasciocutaneous, muscular, musculocutaneous, osteomusculocutaneous, osteomuscular, digital transfers) were utilized, depending on the requirements and as unique or concomitant double flaps. Also, for complete/incomplete amputations with soft tissue defects, flow-through flaps were utilized.

Based on a 10-year experience in emergency surgery and microsurgical practice, the authors proposed a small change in the Godina, Lister, or Ninkovic classifications.