What is Post-traumatic Reconstruction of the Upper Extremity?
Post-traumatic reconstruction of the upper extremity is a surgical procedure to repair or replace damaged soft tissue or bony structures of the upper extremity due to an upper extremity trauma. Upper limb trauma is an injury caused by cutting, tearing, or crushing which leads to the limb becoming unrecognizable.
Based on the gravity of the upper extremity defects, treatment may involve reconstruction of the affected structures with flaps and grafts of bone, skin, muscle, or other tissue from a healthy donor (allograft) or the patient’s own body (autograft). The objective of post-traumatic upper extremity reconstruction is to restore lost function and to obtain a good cosmetic result.
Anatomy of the Upper Extremity
The arm or upper extremity is a functional unit of the upper body. It comprises of 3 parts, the upper arm, forearm, and hand. It extends from the shoulder joint to the fingers and contains 30 bones. It also comprises of many nerves, blood vessels (arteries and veins), and muscles.
Indications for Post-traumatic Reconstruction of the Upper Extremity
Post-traumatic upper extremity reconstruction is usually indicated for upper extremity traumatic injuries due to high-energy impacts such as motor vehicle accidents or football collisions. Traumatic injuries may include fractures, tendon injuries, digit amputation, or lacerations with nerve or blood vessel damage.
Preparation for Post-traumatic Reconstruction of the Upper Extremity
In general, preparation for post-traumatic upper extremity reconstruction will involve the following steps:
- A review of your medical history and a physical examination is performed to check for any medical issues that need to be addressed prior to surgery.
- Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could compromise the safety of the procedure.
- You will be asked if you have allergies to medications, anesthesia, or latex.
- You should inform your doctor of any medications or supplements you are taking or any conditions you have such as heart or lung disease.
- You may be asked to stop taking certain medications, such as blood thinners or anti-inflammatories, or other supplements for a week or two.
- You should refrain from alcohol and tobacco at least a few days prior to surgery and several weeks after, as it can hinder the healing process.
- You should not consume any solids or liquids at least 8 hours prior to surgery.
- You should arrange for someone to drive you home after surgery.
- A signed informed consent form will be obtained from you after the pros and cons of the surgery have been explained.
Procedure for Post-traumatic Reconstruction of the Upper Extremity
Surgical techniques for post-traumatic reconstruction of the upper extremity may include:
Skin grafts
A skin graft is a healthy patch of skin taken from another part of your body (donor site) to cover the damaged or missing area. Your doctor will choose a skin graft depending on the damaged area.
- Split-thickness skin graft: Your surgeon will use skin layers that are close to its surface for treating burns or other injuries.
- Full-thickness skin graft: Your surgeon will use all skin layers from the donor site for treating small defects on the upper limb.
- Composite graft: Your surgeon will use all layers of the skin, fat, and also underlying cartilage to treat wounds that have a complex shape.
Flap surgery
Flap surgery is the transfer of a piece of tissue from one part to another part of your body, along with the blood vessels. Flaps can repair more complex defects due to the presence of their own blood vessels. The types of flaps used for reconstruction include:
- Local flap: Your surgeon will create a flap from the skin lying close to the wound, along with its underlying tissue and blood supply, and will pull it over the wound.
- Regional flap: Your surgeon will use a tissue flap by keeping a specific blood vessel attached to it. In case of an open fracture, your surgeon will move a muscle flap over the open fractured site while keeping a narrow attachment common with the original site.
- Free flap or microsurgery: Your surgeon will transfer a section of tissue from one part of your body to another along with its blood vessels. This modified procedure may take the free flap from your inner thigh and reconnect the blood vessels through microsurgery (using a microscope).
- Bone graft: Your surgeon will transfer bone tissue along with blood supply.
Post-traumatic reconstructive surgery of the upper extremity can be performed through either an open or arthroscopic approach under regional or general anesthesia. The surgery to be performed depends on several factors such as the age of the individual and the severity and type of injury.
In arthroscopic surgery, small keyhole incisions (portals), about a half-inch in length, are made around the treatment area of the upper extremity. Through one of the incisions, an arthroscope - a small flexible tube with a light and video camera at the end - is passed into the treatment area. The camera displays images of the inside of the treatment area on a monitor, allowing your surgeon to view the damage and carry out the required repair.
In open surgery, a long incision of several centimeters is made over the upper extremity. The underlying soft tissues are carefully moved aside to expose the treatment area. Special surgical tools are used to carry out the required repair. Once the repair is complete, the instruments are removed, and the incisions are closed with stitches or small sterile bandage strips.
In general, post-traumatic upper extremity reconstruction surgery will involve the following:
- You will lie on the operating table under regional or local anesthesia with your upper extremity held in a specific position.
- Your surgeon cleans the treatment area with an antiseptic solution and an arthroscopic or open surgical approach is involved in accessing the treatment area.
- Your surgeon performs debridement of the treatment area using special surgical instruments. Debridement is the medical term for the removal of infected, damaged, or dead tissue to improve the healing potential of the remaining healthy tissue.
- Reduction (realignment of broken bones) and external fixation of broken bones (using pins, plates, staples, screws, or casts) are carried out for traumatic fractures of the upper limb.
- For severe soft tissue injuries, your surgeon will use magnification technology and special microsurgical instruments to repair the delicate blood vessels and nerves.
- A specific type of skin grafts, harvested flaps, and bone grafts are then placed on the treatment area to cover the soft tissue and bony defect.
- Your surgeon may also carry out other repairs as necessary.
- The overlying soft tissue and skin are closed with sutures, and sterile bandages are applied.
Postoperative Care and Instructions
In general, postoperative care instructions and recovery after posttraumatic reconstruction of the upper extremity will involve the following:
- You will be transferred to the recovery area where your nurse will closely monitor your vital signs as you recover from the effects of anesthesia.
- You may notice pain, swelling, and discomfort in the upper extremity area. Pain and anti-inflammatory medications are provided as needed to address these.
- Antibiotics are also prescribed to address the risk of surgery-related infection.
- You are advised to keep your upper extremity elevated as much as possible during the first month to reduce swelling and pain.
- Instructions on surgical site care and bathing will be provided to keep the wound clean and dry.
- You may start rehabilitation or a physical therapy regimen as recommended by your surgeon after a specified period of time to strengthen upper extremity muscles and optimize arm function.
- Refrain from strenuous activities for the first few months and lifting heavy weights for at least 6 months from the operated hand. A gradual increase in activities is recommended.
- You should be able to use the treated hand a couple of months after surgery. However, it may take at least 6 to 12 months for your upper extremity to regain its full strength.
- You may return to your work in a month or two if your job is not too physically demanding. Those with physically demanding jobs will require a longer recovery period.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Risks and Complications
Posttraumatic upper extremity reconstruction surgery is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as the following:
- Infection
- Bleeding
- Pain and weakness in the arm
- Damage to adjacent soft tissue structures
- Loss of sensation
- Arm stiffness
- Delayed healing or failure to heal
- Failure of the fixation devices