University of Medicine Iuliu Hatieganu Cluj Napoca, Romania; Clinical Rehabilitation Hospital, 46-50 Viilor Street, Cluj Napoca, 400347 Cluj, Romania.
U.O.C. Hand Surgery - Microsurgery, C.T.O. Hospital - Città della Salute e della Scienza, Via Zuretti 29, 10100 Torino, Italy.
Injury. 2021 Dec;52(12):3588-3604. doi: 10.1016/j.injury.2021.04.004. Epub 2021 Apr 7.
The management of mangled upper extremity is very challenging because the anatomical complexity of the region, the large number of possible involved anatomical elements, and the necessity of obtaining a good functionality. The impressive development of microsurgical techniques in the last decades contributed a lot to the salvage of several extreme injuries with mangled extremities considered untreatable in the past. Such injuries can nowadays be successfully managed by means of replantation/revascularization or complex reconstruction by using simple or complex microsurgical flaps. The more important steps in managing a mangled upper extremity are the decision making, the moment of reconstruction, the debridement, and the reconstruction by using customized methods. The decision regarding extremity salvage or amputation has to be individualized taking into account general and local factors. These factors influence the absolute or relative indication, but the final decision is up to the experience of every single surgical team. The timing of reconstruction is still a large debated subject, but it seems that the reconstruction as soon as possible is in the advantage of obtaining a much better functional recovery. The debridement should be very carefully performed in the attempt to preserve all the essential anatomical elements able to allow the obtaining of enough functionality. Most of these lesions are accompanied by simple or complex tissue defects. The coverage of these defects needs customized simple or composite flaps used both as free and local/regional microsurgical flaps. Based on the experience regarding the strategy and management of the mangled upper extremity in two European hand trauma centers, we conclude that the keystone in savaging this kind of lesions is represented by a very carefully assessment of the patient and lesion, an enough aggressive debridement, and an as soon as possible reconstruction.
严重创伤上肢的处理极具挑战性，因为该区域解剖结构复杂，涉及的解剖结构众多，并且需要获得良好的功能。过去被认为无法治疗的严重创伤上肢的肢端毁损伤，在过去几十年中，由于显微外科技术的显著发展，有很多都可以成功挽救。现在可以通过再植/血运重建或使用简单或复杂的显微外科皮瓣进行复杂重建来成功处理此类损伤。处理严重创伤上肢的更重要步骤是决策、重建时机、清创和使用定制方法进行重建。是否保留肢体或进行截肢的决策需要个体化考虑，要考虑到一般和局部因素。这些因素会影响绝对或相对适应证，但最终决策取决于每个手术团队的经验。重建时机仍然是一个备受争议的话题，但似乎尽快进行重建有利于获得更好的功能恢复。清创术应非常仔细地进行，以尽量保留所有能够获得足够功能的必要解剖结构。大多数此类损伤伴有简单或复杂的组织缺损。这些缺损的覆盖需要使用定制的简单或复合皮瓣，既可以作为游离的，也可以作为局部/区域显微外科皮瓣。基于在欧洲两家手部创伤中心处理严重创伤上肢的策略和管理经验，我们得出结论，挽救此类损伤的关键是仔细评估患者和损伤情况，进行足够积极的清创术，并尽快进行重建。
