A LONG-TERM RESULT OF SURGICAL TREATMENT OF A SERVICEMAN WITH A HEAVY INJURY TO THE UPPER LIMB (CLINICAL OBSERVATION) Khominets V.V., Tkachenko M.V., Ivanov V.S., Gubochkin N.G., Mikhaylov S.V. , Averkiev D.V.
Kirov Military Medical Academy,
St. Petersburg, Russian Federation
According to various authors, about 70 % of locomotor system injuries are injuries to the upper extremity. It is directly related to faster lifestyle of the population, scientific and technical progress, significant increase in industry and increasing amount of road traffic accidents [1. 2]. More than 13 million injuries, including 33.7 % of upper extremity injuries, were recorded in Russia in 2016 [3].
Hand injuries take the leading place (28-30 % of all injuries). 75 % of such injuries are opened, 4.8 % of cases are accompanied by extensive soft tissue defects which require for plastic surgery [4-7]. The consequences of severe injuries to the extremities often cause disability. The important fact is disability (45.9 %) in associated injuries to nerves, tendons, vessels and bones of the upper extremity [8]. In the end of the previous century, the rapid development of microsurgical techniques changed the opinions on possibilities of replacement of extensive tissue defects and reconstruction of injured limbs [9-13].
We present a clinical case of the complex surgical treatment of a military man with a severe injury to the upper extremity.
Objective – to present the possibilities of modern reconstructive surgery in the treatment of a patient with heavy polystructural trauma of the extremities.
The study corresponded to World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013, and to the Rules for Clinical Practice in the Russian federation (the Order by Russian Health Ministry, June 19, 2003, No.266). The patient gave his informed consent for publishing the clinical case.
Clinical case
The military man T., age of 20, was admitted to the clinic of Kirov Military Medical Academy. He suffered in a road traffic accident. He received an associated injury to the head, the chest and the extremities (August 5, 2016), closed traumatic brain injury, brain concussion, opened fragmented fracture of the greater tubercle of the right humerus with displaced fragments, stumps of the first and second fingers of the right hand at the level of metacarpophalangeal joints, opened fracture of proximal phalanx of the third finger of the right hand with soft tissue defect, traumatic brachial right-sided plexopathy with predominant lesion of the upper primary brachial plexus, a contused extensive wound in the right knee with skin detachment (140 cm2), lung contusion and posttraumatic anemia of middle severity (Fig. 1a, b, c).
Figure 1
The serviceman T., age of 20, appearance of the right hand and X-ray images on admission:
a) appearance of the right hand; b) frontal X-ray images of the right shoulder: a fracture of a large tubercle of humerus; c) frontal and lateral X-ray images of the right hand: the absence of thumb and the index finger at the level of the heads of metacarpal bones.
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Figure 1a appearance of the right hand |
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Figure 1b frontal X-ray images of the right shoulder: a fracture of a large tubercle of humerus |
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Figure 1c frontal and lateral X-ray images of the right hand: the absence of thumb and the index finger at the level of the heads of metacarpal bones. |
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After stabilization of general condition, recurrent preparations of the wounds of the right upper extremity and the right lower extremity were conducted, as well as closing the skin defects in the anteroexternal surface of the right knee joint and the right leg (140 cm2) with the autograft. Complete recovery was achieved in 3 weeks after surgery (Fig. 2a, b).
Figure 2
The serviceman T., age of 20, appearance of the right knee joint: à) defect of the skin on the anterior and external surface; b) 3 weeks after surgery.
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Figure 2a defect of the skin on the anterior and external surface |
Figure 2b 3 weeks after surgery |
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The surgery was carried out for restoration of movements in the right shoulder joint: redressement, transosseous suturing of the greater tubercle, opened reposition, fixation with a screw. The extremity was immobilized in Smirnov-Weinstein plaster for 6 weeks after surgery. After completion of immobilization, the patient received the rehabilitation course. The shoulder joint function was satisfactory (Fig. 3 a, b).
Figure 3
The serviceman T., age of 20. Anatomically-functional result in the early postoperative period (3 months after surgery): a) frontal X-ray images of the right shoulder; b, c) appearance of the patient and the function of the right shoulder joint.
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Figure 3a frontal X-ray images of the right shoulder |
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Figure 3b, Figure 3c appearance of the patient and the function of the right shoulder joint |
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However 3 months after surgery, the patient demonstrated the evident atrophy of deltoid and biceps of the right arm, the significant decrease in active flexion of the right forearm and right shoulder abduction, persistent scarry flexion contracture of the third finger, adduction contracture of the first intermetacarpal space of the right hand, absence of hand grip function.
For recovery of lost functions of the upper right extremity, we planned some staged surgical interventions. Primarily, after cicatrectomy, the soft tissue defect of the first intermetacarpal space of the right hand was replaced with use of right forearm non-free dorsal fasciocutaneous flap on the distal vascular pedicle. Non-free cross skin plasty was conducted for the defect on the palmar surface of the main phalanx of the third finger with use of skin from the dorsal surface of the fourth finger and resection. The second metacarpal bone was resected (Fig. 4a, b).
Figure 4
The serviceman T., age of 20, appearance of the right hand: a) before surgery: desmogenic flexion contracture of the 3rd finger joint, adduction contracture of the 1st metacarpal bone, the stump of the thumb and the 2nd finger at the level of the metacarpophalangeal joints; b) after surgery: replacement of the defect of the first intermetacarpal interval of the right hand with a unfree posterior interosseous fascial-cutaneous flap of the right forearm, removal of the flexion contracture of the 3rd finger.
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Figure 4a The serviceman T., age of 20, appearance of the right hand before surgery: desmogenic flexion contracture of the 3rd finger joint, adduction contracture of the 1st metacarpal bone, the stump of the thumb and the 2nd finger at the level of the metacarpophalangeal joints |
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Figure 4b The serviceman T., age of 20, appearance of the right hand after surgery: replacement of the defect of the first intermetacarpal interval of the right hand with a unfree posterior interosseous fascial-cutaneous flap of the right forearm, removal of the flexion contracture of the 3rd finger. |
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Six months after trauma, the restoration of flexion function of the forearm was performed with neurotization of motor branches of the musculocutaneous nerve of the right shoulder with use of the motor branches of the ulnar nerve (Oberlin surgery, 1994) [14]. Intrasurgical electric stimulation in the upper one-third of the shoulder separated the motion bundle innervating the ulnar flexor of the wrist, and the muscular branch of the musculocutaneous nerve innervating the biceps of the arm. After mobilization, the separated branches were matched and anastomosed with the epineural suture in end-to-end manner (Fig. 5a, b).
Figure 5
The serviceman T., age of 20. Stages of Oberlin surgery: à) the dissection of the branch of the musculocutaneous nerve, innervating the biceps muscle; b) epineural suture of the branch of the musculocutaneous nerve with a bundle of the ulnar nerve.
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Figure 5a The serviceman T., age of 20. Stages of Oberlin surgery: the dissection of the branch of the musculocutaneous nerve, innervating the biceps muscle |
Figure 5b The serviceman T., age of 20. Stages of Oberlin surgery: epineural suture of the branch of the musculocutaneous nerve with a bundle of the ulnar nerve |
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After reconstruction of the right thumb, the third stage included the planned surgery: microsurgical free transfer of the second finger of the left foot to the position of the right thumb, fixation with pins, the mesh graft for the defect of the internal surface of the transferred finger. After the surgery, the patient received the angiography of the donor and recipient extremities for determination of location of arteries in the operated segments and for exclusion of inborn absence of the first dorsal metatarsal artery and the dorsal artery of the foot (Belousov A.E., 1998) [15].
The surgical intervention was conducted under general anesthesia with optical magnification. The patient was in supine position, with his upper extremity abducted to the side table. The left lower extremity was placed horizontally with his foot fixed (Fig. 6a, b). The surgical intervention for the donor and recipient regions was conducted by two surgical teams. A longitudinal incision was made in the plane of the dorsal artery of the foot (25 cm). The branches leading to the graft were preserved during separation of the first dorsal metatarsal artery. The tendon of the short extensor of the first finger was transected. After separation of the tendons and the nerves on the plantar surface of the foot, osteotomy of the second instep bone was conducted. The autograft was drawn aside. The vessels of the formed autograft were dissected after final preparation of the host bed. The formed flap was transferred to the partially resected first metacarpal bone of the right hand. K-wire was used (Fig. 6c, d).
Figure 6
The serviceman T., age of 20: à) appearance of the right hand; b) preoperative marking of left foot;
ñ) stage the dissection of the graft (the second finger of the left foot) with the vascular pedicle;
d) reconstruction of the thumb of the hand with the second toe.
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Figure 6a The serviceman T., age of 20: appearance of the right hand |
Figure 6b The serviceman T., age of 20: preoperative marking of left foot |
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Figure 6c The serviceman T., age of 20: stage the dissection of the graft (the second finger of the left foot) with the vascular pedicle |
Figure 6d The serviceman T., age of 20: reconstruction of the thumb of the hand with the second toe. |
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The right thumb was sutured with the tendons of the second toe of the left foot. Also the vein and the artery of the flap were sutured with the radial artery and the cephalic vein in the lower one-third of the forearm with end-to-end type. The total time of heat anoxia of the flap was 2 hours and 35 minutes (Fig. 7a, b).
Figure 7
The serviceman T., age of 20. Appearance of the right hand: à) after a free microsurgical transplantation of the second finger of the left foot into the position of the first finger of the right hand; b) X-ray images after surgery.
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Figure 7a The serviceman T., age of 20. Appearance of the right hand: à) after a free microsurgical transplantation of the second finger of the left foot into the position of the first finger of the right hand |
Figure 7b The serviceman T., age of 20. Appearance of the right hand: X-ray images after surgery. |
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In the postsurgical period, the patient received the general tonic, vasoactive and antibacterial therapy, and the course hyperbaric oxygenation. The right hand was immobilized in the plaster splint for 4 weeks. The wounds healed with primary tension. The patient received the rehabilitation course (massage, remedial gymnastics with improvement in movements in the joints of the upper extremities, electric stimulation, health resort treatment). Periosteal union of the graft and the first metacarpal bone was achieved after a month. The full union was achieved in 6 months after the surgery (Fig. 8a, b).
Figure 8
The serviceman T., age of 20. X-ray images of the right forearm:
a) 1 month after surgery;
b) 6 months after surgery.
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Figure 8a The serviceman T., age of 20. X-ray images of the right forearm: 1 month after surgery |
Figure 8b The serviceman T., age of 20. X-ray images of the right forearm 6 months after surgery. |
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The treatment resulted in restoration of the full range of movements in the right shoulder, ulnar and hand joints. The external rotation of the shoulder was 10°, in the joints of the formed thumb – within 20°. The rough and pincer grip of the hand appeared. The arm circumference in the middle one-third: 30 cm to the left, 28 cm to the right. The muscle strength in the right upper extremity: shoulder abduction above the horizontal line (the deltoid muscle) – 4.5 points, flexion in the ulnar joint (biceps) – 4.5 points; in other muscles – sufficient (Fig. 9a, b, c, d).
Figure 9
The serviceman T., age of 20. Functional result after 18 months: a) abduction of the shoulder (90º);
b) flexion of the forearm (135º); c) rough grasp in the hand; d) restore the power parameters of the hand by 50 % compared to the opposite.
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Figure 9a The serviceman T., age of 20. Functional result after 18 months: abduction of the shoulder (90º) |
Figure 9b The serviceman T., age of 20. Functional result after 18 months:flexion of the forearm (135º) |
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Figure 9c The serviceman T., age of 20. Functional result after 18 months: rough grasp in the hand |
Figure 9d The serviceman T., age of 20. Functional result after 18 months: restore the power parameters of the hand by 50 % compared to the opposite |
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The general period of treatment was 18 months. The expertise showed the fitness for military service.
CONCLUSION
The presented clinical case demonstrates the possibilities of successful surgical treatment of severe injury to the upper extremity in the military man with polytrauma. Undoubtedly, the features of the treatment were technical difficulty of the performed surgical interventions, availability of operational microscope and tools, trained medical personnel, and individual anatomical characteristics of the limb. Such result is possible only with treatment in the multi-profile facility with availability of specialists in hand surgery and microsurgery, with possibilities for modern rehabilitation for restoration of movements in joints, strength and coordination parameters of anatomical structures of the upper extremity.
Information on financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of clear or potential conflicts of interests relating to publishing this article.