The primary treatment of hand trauma frequently requires access to microsurgical facilities for small vessel and nerve repair. Such facilities need to be available on a 24 hour-a-day basis.
At present, this service is best provided in medium-sized or larger plastic surgery units with appropriate operating facilities and follow-up hand clinics, with experienced physiotherapists and occupational therapists on site. This may, therefore, involve transferring patients from other acute hospitals if such facilities and expertise are not available.
What surgery is available, and what techniques are used?
Hand trauma surgery varies according to the nature of the injury sustained. Burns and skin loss, for instance, will require surgical flaps and grafts, while the traumatic loss of digits may be treated by what is known as toe to hand surgery.
Toe to hand surgery involves the microsurgical transfer of digits from the foot to the hand. The absence of a finger does not usually have much effect on either the function or the appearance of the hand, but when the missing digit is a thumb, or when many digits are missing, surgery may be needed.
Generally, the guideline in considering reconstruction is whether or not the overall function of the hand may be improved, although it is also natural and necessary to take into consideration the appearance of the hand.
Whichever toe is transferred, its blood vessels (artery and nerve) must be successfully joined to similar vessels in the hand for it to survive. Tendons (to allow movement where required), nerves (to allow feeling), and the bone must also be rejoined to suitable counterparts in the hand.
What can I expect as a patient?
Following the microsurgical transplantation of a toe to the hand, the whole arm is immobilised in a dressing which includes a plaster splint. This will usually be left undisturbed for two or three weeks before the first change of dressing.
The first change of dressing will be performed either under a brief anaesthetic in theatre, or on the ward if only a simple removal of the dressing is required. Usually stitches will be absorbable and do not require removal, whilst the pins used to fix the bones may be removed without an anaesthetic.
Regular follow-up appointments are essential, and occasionally minor repositioning procedures are required, while secondary surgery may be necessary for the adjustment of scars or bones.
BSSH- The British Association for Surgery of the Hand