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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 28  |  Issue : 4  |  Page : 244-247

Palmar vertical hemi-hand amputation: A rare form of amputation


Private Aesthetic, Plastic and Reconstructive Surgery Clinic, Bursa, Turkey

Date of Submission02-Aug-2019
Date of Acceptance10-Nov-2019
Date of Web Publication28-Sep-2020

Correspondence Address:
Dr. Ayhan Okumus
Private Aesthetic, Plastic and Reconstructive Surgery Clinic, Bursa
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_70_19

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  Abstract 


The patient presented in this study was admitted to our clinic with an uncommon injury as a result of the accidental insertion of his hand in a rope winding machine at a textile factory. A 26-year-old male patient was responsible for the control of a rope wrapping machine at a textile factory. While working, the employee's left hand was injured by making contact with the running machine. He had no problem with the dorsal aspect of his hands, but the volar examination revealed a soft-tissue defect on his wrist flexor line from the pulp level. The defect contained more than the palmar half of the hand's lateral width and all structures were amputated in the impaired manner. The patient was treated with a sensory inguinal flap and two-stage flexor tendoplasty. He is now able to perform routine daily tasks such as hand gripping, holding a pencil, buttoning buttonholes, and dressing.

Keywords: Groin flap, hand amputation, industrial accident, sensorial reconstruction, vertical amputation


How to cite this article:
Okumus A. Palmar vertical hemi-hand amputation: A rare form of amputation. Turk J Plast Surg 2020;28:244-7

How to cite this URL:
Okumus A. Palmar vertical hemi-hand amputation: A rare form of amputation. Turk J Plast Surg [serial online] 2020 [cited 2020 Oct 29];28:244-7. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/4/244/296472




  Introduction Top


Industrial developments, complicated work machines, and automated system production units produce products in quantities and at a quality that cannot be achieved through workforce. However, workplaces that engage in man-machine cooperation, there are serious occupational accidents that can occur among workers who cannot reach the machine's speed and discipline or who lack sufficient training.[1]

The patient presented in this study was admitted to our clinic with an uncommon injury as a result of the accidental insertion of his hand in a rope winding machine at a textile factory.


  Case Report Top


A 26-year-old male patient was responsible for the control of a rope wrapping machine at a textile factory. The machine that was controlled by an employee and that caused the injury works at high speed and has multiple sharp teeth. While working, the employee's left hand was injured by making contact with the running machine. On physical examination of the patient who was admitted to the emergency room of the hospital, he had no problem with the dorsal aspect of his hands, but volar examination revealed a soft-tissue defect on his wrist flexor line from the pulp level. The defect contained more than the palmar half of the hand's lateral width, and all structures were amputated in the impaired manner. From the flexor wrist level to the pulped median and ulnar nerves, all arteries and veins, all superficial and deep flexor tendons of the 2–5 fingers, the long flexor tendon of the thumb, 2–5 from the distal end, metacarpals, metacarpophalangeal joints, interphalangeal joints (IPJs) and distal interphalangeal joints (DIPJs), proximal and middle phalanx, and joint capsules had been approximately 50% amputated in the vertical plane [Figure 1], [Figure 2], [Figure 3], [Figure 4]. The broken parts were lost on the machine. When the patient turned his hand with the volar face-up, all the structures were deformed in a convex manner [Figure 3]. The deep dorsal branch of the radial artery and the ulnar artery was intact, and there was no circulation disorder in either the hand or the rest of the fingers. The hand volar region resembled a long-haired red carpet. The absence of capsules and ligaments in the volar half of the joints had caused the volar side of the hand to rotate upwardly without responding to gravity. When the dorsal part of the hand was removed, there was a healthy hand image as there had been no injury because the joint dorsal parts were intact.
Figure 1: View of the injured hand from the dorsal view

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Figure 2: View of the injured hand from the volar view

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Figure 3: View of the injured hand from the lateral view

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Figure 4: View of the injured hand from the dorsal view

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The patient was operated on urgently, and all damaged and noncirculated structures were debrided in all damaged tissues. There was a large and complicated defect that was approximately 9 cm × 18 cm, deeper in the thenar and hypothenar regions, and more superficial in the area of the fingers. By using ligament and pulley residues that had good circulation around the joint, repairs were made to provide a capsule for the volar and lateral sides of the joints and to provide stabilization. Two-stage flexor tendoplasty was planned for the flexor digitorum profundus (FDP) tendons and the flexor pollicis longus (FPL) tendon. Silicon tendon prostheses DIPJ and IPJ at the distal to FDP and FPL tendons were detected at the proximal residue at the wrist level [Figure 5].
Figure 5: Insertion of tendon prostheses

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In the left inguinal region, an axial flap was planned as a superficial circumflex iliac artery (SCIA) and superficial circumflex iliac vein (SCIV) as basal from the hairless area as possible. The flaps were 10 cm × 22 cm larger than the defect to prevent tension and to create bulky tissue in the deep defect in the proximal region. The lateral cutaneous nerve flap was included in the preparation of the flap, and the hand was brought to the inguinal area. However, the flap was not detected at the distal part of the wrist as applied in the routine. The proximal flap was thicker and wider, partially hairy, and had been adapted to the proximal deep defect at the wrist level because it was suitable for ulnar and median nerve repair. While the flap had been adapted to the defect in the fingers, the parts coming into the finger volar defects had been thinned, and attention was paid to the rest of the veins to maintain circulation and to keep the fingers apart. The lateral parts of the finger defect were fixed to the flap. During this process, care was paid so as not to disturb the flap circulation [Figure 6]. The lateral cutaneous nerve was divided in two; the portion corresponding to the ulnar side of the flap was sutured to the ulnar nerve and the part corresponding to the radial side was sutured to the median nerve.
Figure 6: Adaptation of the inguinal flap to the defect

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Postoperative 3 weeks later, the pedicle was clamped, and circulation was tested [Figure 7]. The flap was separated after the discovery of adequate blood circulation without pedicle support. After physical therapy for 2 weeks with the wrist, shoulder, and elbow, the patient underwent surgery at the 4th week, and his finger webs were separated according to the principles of syndactyly. In the same session, silicone prostheses were replaced with tendon grafts. Tendon grafts were harvested from the residue of the forearm flexor digitorum superficialis and plantar tendons. Passive exercises began in the 1st week following the second operation. Active physical therapy was started after 4 weeks.
Figure 7: Postoperation week 5

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The patient did not resume his treatment after 6 months of physical therapy. The patient was followed up for 13 years. At the final examination, there was hand protection sensation and the two-point discrimination test was 8 mm. Neither circulatory problems nor hair and skin contracture developed, but the patient had extension limitation due to volar face contracture. However, the patient did not accept a new operation. He is now able to perform routine daily tasks such as hand gripping, holding a pencil, buttoning buttonholes, and dressing [Figure 8], [Figure 9], [Figure 10].
Figure 8: Postoperative 13th year, view from above. Flexion of the fingers

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Figure 9: Postoperative 13th year, volar appearance. Extension of the fingers

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Figure 10: Postoperative 13th year, dorsal view

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  Discussion Top


An amputation pattern involving all volar structures in the vertical plane is rare. The simultaneous and vertical longitudinal amputation of many anatomical structures and loss of joint support considerably reduce the number of reconstruction options. The fact that all structures were not repaired longitudinally or replanted along the hand brings about a very high risk of complications at the end of the repair.

In horizontal amputations, it is possible to repair/replant structures that have been cut, and they can be repaired/replanted even if they have been crushed and heavily damaged with and very satisfactory results.[2] For amputations that cannot be replanted, the primary repair decision can be given easily, and prosthesis options can be offered.[3],[4] However, as in the case presented in this study, the decision to amputate is quite difficult when the dorsal half of the hand is quite healthy. In this type of injury, a free flap is the first possible alternative. There are several flap alternatives that can be prepared sensitively and at the required size.[5] However, having a defect in the fingers together with the hand makes the choice of free flaps difficult. In the same session, it may be difficult to thin the flap to close the fingers or a thin flap that can provide advantages in the fingers will be insufficient in the proximal deep defect. The forearm fasciocutaneous flaps appear to be a good alternative, but they are not enough to close the entire defect.[6] The inguinal flap has been a conservative alternative for hand injuries for many years. In this study, it was possible to obtain a good result since that part can be thinned, prepared to an appropriate size and sensory in the defect, adapted to the deep and superficial parts of the defect, and does not include risks related to microsurgery.[7],[8]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Neumeister MW, Brown RE. Mutilating hand injuries: Principles and management. Hand Clin 2003;19:1-15, v.  Back to cited text no. 1
    
2.
Vedder N, Hanel D. The mangled upper extremity. In: Green DP, Hotchkiss RN, Pederson WC,et al., editors. Green's Operative Hand Surgery. 7th ed. Philadelphia, PA: Elsevier; 2005. p. 1587-628.  Back to cited text no. 2
    
3.
Russell RC, Bueno RA Jr., Wu TY. Secondary procedures following mutilating hand injuries. Hand Clin 2003;19:149-63.  Back to cited text no. 3
    
4.
Graham B, Adkins P, Tsai TM, Firrell J, Breidenbach WC. Major replantation versus revision amputation and prosthetic fitting in the upper extremity: A late functional outcomes study. J Hand Surg Am 1998;23:783-91.  Back to cited text no. 4
    
5.
del Piñal F. Severe mutilating injuries to the hand: Guidelines for organizing the chaos. J Plast Reconstr Aesthet Surg 2007;60:816-27.  Back to cited text no. 5
    
6.
Mih AD. Pedicle flaps for coverage of the wrist and hand. Hand Clin 1997;13:217-29.  Back to cited text no. 6
    
7.
Sabapathy SR. Refinements of pedicle flaps for soft tissue cover in the upper limb. In: Venkataswami R, editor. Surgery of the Injured Hand. New Delhi, Delhi: Jaypee Publishers; 2009.p. 131–8.  Back to cited text no. 7
    
8.
Friedrich JB, Katolik LI, Vedder NB. Soft tissue reconstruction of the hand. J Hand Surg Am 2009;34:1148-55.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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