DECLARATION

I have no conflict of interest or disclosure in relation to this

presentation

Christian Dumontier, MD, PhD

 COMPLEX UPPER LIMB
TRAUMA RECONSTRUCTION
INCLUDING CHIMERIC FLAPS

Christian Dumontier, MD, PhD

Professor or Plastic and Hand Surgery
Guadeloupe, French West Indies

Presentations and references can be downloaded at www.diuchirurgiemain.org

 COMPLEX HAND TRAUMA ?

• Multiple tissues injuries, necessitating a

specialized environment (including
microsurgical skills), severe enough to
induce sequelae (including amputation)

• Mangled hand [from the anglo-northmen

« Mangonner »  (To traumatize, to
mutilate) which comes from the old French
« Mahaigner" (to cut in pieces)].
COMPLEX HAND TRAUMA: EPIDEMIOLOGY

• Only 5% of hand fractures are open, most of them are not complex

• Over 1024 patients of a trauma center, 5 had arterial lesions with ischemia

• Over 6000 patients of a tertiary referral center in India, 51 had

replantations and 91 revascularisations.

• Over 20 years, an Austrian team collected 606 open fractures of the

upper limb of which 54 (9%) were Gustilo type III

• In polytraumatised patients, upper limb amputation represents 0,2 to 3%

of cases
 COMPLEX HAND TRAUMA

• Rare injuries (agricultural,

industrial, MVA)
 AS A CONSEQUENCE
• The surgeon on call will feel
very lonesome, with no
guidelines to help him what
to decide

I’m a poor lonesome cowboy

I’m a long long way from home
And this poor lonesome cowboy
Has got a long long way to roam
Over mountains over prairies
From dawn till day is done
My horse and me keep riding
Into the setting sun
 SOME PRINCIPLES FOR
COMPLEX HAND TRAUMA
COMPLEX HAND TRAUMA: SUCCESS STARTS WITH:

• Patient’s survival (life

before limb)

• Limb survival

• A residual hand function

• Finally with a useful hand

PREOPERATIVE EVALUATION OF THE PATIENT

• Age, hand dominance, medical past history

(diabetes or any immuno-deficiency), employment,
hobbies, tobacco use, vaccine status, allergies,
preferences

• Associated lesions ? 9% of death in a series

Fochtmann A, et al. Third degree open fractures and traumatic sub-/total amputations of the upper extremity: Outcome and
relevance of the Mangled Extremity Severity Score. Orthop Traumatol Surg Res. 2016;102(6):785-90.
 PREOPERATIVE EVALUATION OF THE
ACCIDENT

• Time

• Mechanism (crushing
injury, avulsion, blast…)

• Importance of
contamination
PREOPERATIVE EVALUATION OF THE LIMB

• Active bleeding ?

• Compression ➡ Tourniquet
➡ Arterial control
PREOPERATIVE EVALUATION OF THE LIMB
• Ischemia ?

• Conservation of
amputated fragments ?

• Type of injury

• Nerve injuries ?

• Osteo-articular lesions ?

• Skin and soft-tissues

involvement ?
 Direct correlation between delay before
Delay
revascularisation and limb survival
Crushing injuries and high-velocity injuries have a
Mechanism
poorer prognosis
Lower limb vessels injuries have a poorer
Anatomy
prognosis

Associated lesions

Age and physiology

Shock or limb ischemia have a more unfavorable

Clinical presentation
evolution

Environnement Combat zone, under-medicalized area,…

Pronostic factors in complex injuries of limbs. American college of Surgeons 2006

 Variables MESS Score
Low energy (stab, simple fracture, single gunshot wound) 1
Skeletal soft-tissue Medium energy (open or multiple fractures, dislocations), 2
injury High energy (High speed MVA or rifle gunshot wound) 3
Very High energy (high speed trauma + gross contamination) 4
Limb ischemia Pulse reduced or absent but perfusion normal 1
(score doubled if Pulseless; paresthesias; diminished capillary refill 2
ischemia > 6 hours) Cool, paralyzed, insensate, numb 3
Systolic BP always > 90 mmHg 0
Shock Hypotensive transiently 1
Persistent hypotension 2
< 30 0
Age (years) 30-50 1
> 50 2

Johansen K, Daines M, Howey T, Helfet D, Hansen ST, Jr. Objective criteria accurately predict amputation following lower
extremity trauma. J Trauma. 1990;30(5):568-72; discussion 72-3.
A MESS SCORE > 7
IS PREDICTIVE OF
AMPUTATION
SURGICAL GOALS ?
 GIVE THE PATIENT A FUNCTION,
REGARDLESS OF THE ANATOMY +++
• Thumb = 40% of hand function
➡ priority

• 1st web muscles = 80% of pinch

strength
Heterotopic
• Radial-sided fingers are for replantation and bank-
precision pinch, ulnar-sided finger are to be
fingers for strength. considered in every
patient
 SURGICAL PRIORITIES
• A thumb of enough length

• With one (or preferably two) long

fingers, long and mobile enough to
allow for a pinch with the thumb
(prefer middle and long finger
reconstruction)

• A sensible hand (an insensate hand is

no more functional than a prosthesis)

• With an adequate skin coverage to

allow for secondary reconstruction
 GIVE THE PATIENT A FUNCTION,
REGARDLESS OF THE ANATOMY +++

• A single long finger amputation has

limited consequences (out of 183
surgeons, 179 were able to
continue surgery)
REPLANTATION VS AMPUTATION
• All studies agree than a replanted
segment is more functional than
a prosthesis

• A functional limb can be

expected in:

• 25% of arm replantation,

• 30% of forearm/elbow

• 58% for wrist replantation.

REPLANTATION VS AMPUTATION

• A mutilated hand can only

be accepted if it is
cosmetically acceptable (ex:
Krukenberg)
 EARLY
REVASCULARISATION
• If a vascular shunt is necessary, it is done
before débridement.

• One can use perfusion tube and I/V

catheter

• Do not forget first to clean up the

vessels (Fogarty® ’s balloon catheter)
SURGERY STARS WITH
DEBRIDEMENT
 DEBRIDEMENT
• A major issue: dead tissues cannot heal !

• Infection is responsible for most of early failures in

mangled hand reconstruction +++

• As already stated by Pasteur, it is the environment, not

the bacteria which determines if a wound get
infected or not

• Debridement will limit chemical and enzymatic reaction of

ischemic or dead tissues (free radicals) that are responsible
for secondary thromboses and infection.

• In complex injuries, try to be in a primary

healing situation
 DEBRIDEMENT
• Scrub around the wound

• Clean up the wound with a wet gauze to remove debris

• Debride plane by plane, from superficial layers to deep

ones

• Bacterias present in 62% of cases before debridement

were absent in 87% of cases after (no need to do
bacterial sampling during surgery)
 DEBRIDEMENT
• Skin: all contused parts are excised.
Keep small skin bridges if they are of
quality (they contain veins).
Ecchymoses get necrotic. Detached
skin means a rupture of the vasculaire
network.

• Fat: ischemic fat get easily infected

• Fascia: poorly vascularised, do not

hesitate to excise.
 DEBRIDEMENT
• Muscles: excise any muscle that does not look normal.

• The 4 C rule (color, consistency, contractility and

capacity to bleed) can help.

• Interosseous muscles should be excised.

• Ischemic muscles cannot recover after 7 hours.

• Bones: small, non pedicled fragments are excised.

 DEBRIDEMENT
• Small vessels are coagulated. Larger vessels are
clamped with vascular clips ( to be re-used if
necessary)

• Beware of signs of arterial injury: a tortuous artery,

wind up on itself (ribbon sign); a thrombosis of the
lumen; petechia on the arterial wall; a telescope
sign; (intima is longer than adventicia);; a spider
web appearance are signs of intimal lesions

• Th red-line sign is the witness of avulsion of

collateral branches with no possibility of skin
revascularisation.

• After clamp removal, bleeding should be

maintained over 30 seconds (otherwise check for
a spasm or a intra-adventitial injury)
 NERVE DEBRIDEMENT

• Always difficult to handle

• Endoneural bleeding is a
good evaluation sign

• Smaller defects can be

treated with conduits

• nerve repair can be

postponed
 LAVAGE
• After debridement (vitality
is less easy to appreciate
in wet tissues)

• With little pressure (no

Karcher)

• With Saline (no

Dilution is the solution to pollution
antiseptics)
 RECONSTRUCTION OF
COMPLEX HAND TRAUMA
EMERGENCY

• Vessels

• Bone

• All you can do in

one stage
 EARLY

• Skin coverage

• Tendons, nerves
if possible
 SECONDARY

• Tendons
(function)

• Nerves
SKIN RECONSTRUCTION
SKIN COVERAGE: THE LADDER
• Free flaps

• Distant flaps

• Local flaps

• Skin grafts

• Direct suture

• Spontaneous healing
(including VAC)
 SPONTANEOUS HEALING
• Only small surfaces

• Without exposed
structures underneath

• Gives poor functional and

cosmetic results
 DIRECT SUTURES

• Ideally

• Only on well-vascularized
tissues

• Always loose sutures

 TAKE THE ELEVATOR !

• Free flaps

• Distant flaps

• Local flaps

• Skin grafts

Try to be ambitious
DISTANT FLAP

• Limited indication in complex

injuries as the pedicle is often
contused, it prevents early
mobilisation, it is often of
limited size,

• Except for groin flap (not

watertight, decline position,
limit early rehabilitation,…)
 FREE FLAPS ARE FAVORED

• More versatile

• Donor site is in a non-traumatized area

• Preservation of local vessels (for secondary use-

toe transfer as a example)
 MANY TYPES OF
FLAPS ARE
AVAILABLE

• Historically we started from

random flaps, then
musculo-cutaneous flaps
then fascio-cutaneous

• Perforators and more

sophisticated flaps are the
most advanced flaps
available
 Nakajima’s
classification
Tolhurst DE. A comprehensive classification of flaps: the atomic system. Plast Reconstr Surg 1987; 80: 608–609.
 FLAPS ARE CHOSEN
• According to the lesions +++

• And Surgeons’s preferences

• Cutaneous flaps are more cosmetic

and easier to thin secondarily

• It is easier to raise a fascio-cutaneous

flap than a muscular flap on a second
stage

• Muscular flaps are able to fill

important defect

• Some muscular flaps can be

revascularises
 COMPLEX FLAPS
• Some cutaneous flaps can also include bone, tendon,…
 COMBINED FLAPS
• Two different flaps with their own vascularisation are raised during the
same procedure to increase the surface to cover

Zelken JA et al. The combined ALT–groin flap for the mutilated and degloved hand. Injury 2015; 46(8):1591-1596.
 CHIMERIC FLAP
• A chimeric flap is composed of more than one flap
each on its own pedicle but with both on a common
source pedicle (only one pair of microsurgical inflow
and outflow recipient vessels is needed).

• The chimeric flap was originally conceived as a

combination of local flaps from the same
anterolateral thigh angiosome
Hallock GG. Simultaneous transposition of anterior thigh muscle and fascia flaps: an introduction to the chimera flap principle.
Ann Plast Surg 1991; 27: 126–131.
 Chimera is a fire-breathing creature of Lycia in Asia Minor, composed of the parts of
more than one animal. It is usually depicted as a lion, with the head of a goat arising from
its back, and a tail that might end with a snake's head.
It is one of the offspring of Typhon and Echidna and a sibling of other monsters
It was killed by Bellophoron with the help of Pegasus (Mosaic from Rhodes museum)
 EXAMPLES OF CHIMERIC FLAP
• Fascial (e.g., scapular or parascapular), muscular (e.g., serratus anterior
or latissimus dorsi), and osseous (e.g., rib or scapula) flaps can be
harvested based on the thoracodorsal or circumflex scapular branches.

• Anterolateral thigh and rectus femoris muscle

• Anterolateral thigh flap split into two skin and fat paddles on two
different perforators both connected to the lateral 


femoral circumflex system

• 

Hsu CC, Tseng J, Lin Y-T. Chimeric Medial Femoral Condyle Osteocutaneous Flap for Reconstruction
of Multiple Metacarpal Defects. J Hand Surg Am. 2018;43(8):781.e1-e9
Hsu CC, Tseng J, Lin Y-T. Chimeric Medial Femoral Condyle Osteocutaneous Flap for Reconstruction
of Multiple Metacarpal Defects. J Hand Surg Am. 2018;43(8):781.e1-e9
Tang L et al. Combined multi-lobed flaps: A series of 39 extensive hand and multi-digit injuries one-staged reconstructions using
modified designs of ALT, DPA and chimeric linking flaps. Injury, Int. J. Care Injured 48 (2017) 1527–1535
Tang L et al. Combined multi-lobed flaps: A series of 39 extensive hand and multi-digit injuries one-staged reconstructions using
modified designs of ALT, DPA and chimeric linking flaps. Injury, Int. J. Care Injured 48 (2017) 1527–1535
Zheng H et al. Free conjoined or chimeric medial sural artery perforator flap for the reconstruction of multiple defects in
hand. JPRAS 2015 68, 565-570
Ye S-M et al. One-stage reconstruction of complex soft tissue defects in the hands using multidigit, chimeric, lateral arm,
perforator flaps. JPRAS 2019 (in press)
Ju J et al. Microsurgery in 46 cases with total hand degloving injury. Asian Journal of Surgery (2015) 38, 205-209
CHOUKRAN