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Case Study: Hand Revascularization and Reconstructive Microsurgery for Trauma Patient
A 17-year old female high school senior fell asleep at the wheel on her way home from the library. She was involved in a serious roll over accident that essentially amputated her left arm through the lower part of her forearm, and required emergent transfer to St. Louis Children's Hospital.
Upon arrival at St. Louis Children's Hospital, she required an aggressive trauma resuscitation followed by emergent aggressive cleaning of the wound in the operating room, fixation of both her radius and ulna, and revascularization of her hand by Ryan Calfee, MD, MSc, and Brinkley Sandvall, MD, as both major arteries in her hand were crushed by the accident and had no blood flow. There was also a major injury to her wrist that was fixed at that time.
There was discussion about whether or not an amputation would have been more reasonable given the degree of injury, but the decision was made at that time to try to preserve her hand. On examination in the operating room, it was apparent that major nerves in her forearm were cut at the time of the accident, and would require reconstruction. It was also obvious that an operation to give her stable and durable skin and soft tissue coverage would be necessary to prevent infection. Finally, the muscles that move her fingers were obliterated by the accident and would need to somehow be reconstructed as well.
First things first: skin coverage. A "flap" was designed based on arterial supply from perforator vessels around her umbilicus, and elevated off of her abdominal wall. It was sewn into the skin and soft tissue defect of her forearm, and allowed to heal for three weeks following which another surgical procedure was done to sever the flap from its origin on her belly. This procedure was performed by Martin Boyer, MD, FRCS(C), and David Brogan, MD, MSc.
Once this was complete, it was time to think about regaining function by repairing her median nerve, (which provides feeling to the palm), ulnar nerve (which provides feeling to the small finger and allows for fine motor control of the hand), and flexion of her fingers (which allows for making a fist, grip, or grasp). A "free functioning muscle transplant" was done by taking the gracilis muscle from her leg and moving it to her forearm. Arteries, veins and nerves were then sewn together to power the transplanted muscle to allow the patient to bend her fingers and thumb. At the same time, nerve grafts were taken from both legs to repair the nerves of her forearm that were destroyed during the accident. This reconstruction was completed in an eight hour procedure performed by Christopher Dy, MD, MPH, David Brogan, MD, MSc, and Martin Boyer, MD, FRCS(C)
The patient continues to recover, and was recently playing sports. She recently had another surgery to free up scar tissue in her MCP joints (knuckles) so as to make it easier for the muscle to power her finger flexion. Now, it's a waiting game for the nerves to regrow, the muscle to begin to work, and sensation to reappear.
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