Management Goals For The Child With Severe Bilateral Upper-Extremity Injuries
James M. Hunter, M.D. Mahaveer P. Prabhakar, M.D. John Fenlin, M.D.
In children, traumatic injury to the upper extremities frequently occurs bilaterally, representing both direct and indirect effects of the forces of injury. The child seems particularly vulnerable to injury from moving machinery on the farm and around the home, while some of the more devastating bilateral injuries follow thermal burns, shotgun blasts, and explosions from homemade rockets and bombs.
When injury results in the amputation of both upper extremities, one side will usually be more acceptable for prosthetic fitting and training as the dominant, or lead, extremity. Nevertheless, the serious disability of the bilateral upper-extremity amputee constantly challenges the surgeon, despite the tremendous strides made in prosthetic design and training during the past few years. Several considerations in amputation surgery that might improve function and modify disability on at least one side have been proposed:
Through experience, we have learned that there is no so-called elective level of amputation in the upper extremity and that all length possible should be saved. The skilled prosthetist has learned to utilize extra length to better seat and stabilize the socket and to reduce wasted motion by more efficient harnessing.
The short humeral neck amputation can be lengthened with a skin pedicle flap from the chest and a fibular bone graft, converting the extremity to a short above-elbow stump for more effective prosthetic fitting.
By reconstruction, a very short below-elbow stump with a useful elbow joint can be extended sufficiently to trigger function at the elbow or afford added support for the forearm socket.
Shoulder and elbow joint contractures can be released to provide an increased range of motion, or damaged shoulder and elbow joints can be arthrodesed in a functional position to provide added stability and improved transport of the prosthesis.
If forearm length has been preserved on one side in bilateral amputations of the upper extremity, the patient may be given prehension with a sense of touch by the Kruken-berg procedure. This operation divides the forearm stump between the radius and ulna, creating two functional posts that operate like chopsticks, motored by cross transfer of the forearm muscles (Fig. 1 and 2 ). The presence of skin with sensation gives the patient new advantages in daily activities such as dressing, bathing, eating, and toileting. (1) A long below-elbow socket and a functional hand can be worn as needed for public contacts if the appearance of the reconstructed forearm is considered to be objectionable.
At the Children's Hospital at Elizabethtown, where essentially the same personnel are involved in both the Hand and Prosthetic Clinic teams, a most stimulating challenge is the young patient whose bilateral upper-extremity injuries will necessitate a prosthesis on the one side and on the other side the preservation of sufficient uninjured parts to restore some degree of prehension and sensation by reconstructive hand surgery.
This discussion will deal with two general surgical problems: (1) the partially amputated hand where the return of basic prehension is paramount, and (2) the intact hand with peripheral nerve injury where return of sensation is essential if the patient is to have a useful leading extremity.
Returning Prehension To the Partially Amputated Hand
Partial and Complete Amputation of Thumb. Amputation of the thumb at the distal interphalangeal joint level usually does not preclude the achievement of good function. Amputation at the metacarpophalangeal joint level may give the patient acceptable pinch and support grip if the web space between the thumb metacarpal and the index metacarpal is deepened by Z-plasty or skin grafting. In this procedure the intrinsic muscles should be retained, to afford movement and power to the shortened stump.
Levels of amputation below the metacarpophalangeal joint will require some type of build-up to restore useful length. The addition of as little as 3/4-inch length at this level can provide a significant improvement in function. This can be accomplished by transferring a full-thickness skin pedicle from the abdomen and, at a later stage, the introduction of a bone graft, usually from the ilium. This procedure has a partial disadvantage of limited areas of sensation, since, at best, the skin pedicle will respond to deep pressure and be devoid of refined sensation. It is possible to overcome this deficit by turning a skin flap with normal sensation from a portion of the palm, or transferring a sensory skin island from a remaining finger to the contact surface of the newly reconstructed unit.
When loss of the thumb is total or nearly so, the ultimate in returning function is achieved by polliciza-tion of the index or the most radial digit. This procedure, as outlined in a previous ICIB article dealing with a congenital thumb deficiency, can be used satisfactorily for traumatic injuries. (2) In this procedure the abdominal pedicle skin is placed on the dorsum of the hand. At a later stage the space between the index and the long fingers is divided, the artery to the remaining digit is tied off, the digital nerve is separated, and, with the metacarpal divided, the index finger is rotated and shortened to a thumb position and the newly formed space created is filled with the abdominal skin (Fig. 3 Fig. 4 ). This procedure can return excellent function and appearance to the hand.
Amputation of Fingers Below a Useful Functional Level. The residuals of finger amputations that fall at the mid-level of the proximal phalanx are generally considered to be too short for useful hand function. If the other fingers are normal but the fifth finger is amputated through or below the middle third of the proximal phalanx, the remaining fragment may tend to interfere with the patient's functioning. In these cases the entire ray or the remnant of the proximal phalanx and the metacarpal may be resected, leaving the intrinsic muscles. This procedure returns a nice balance to the hand and generally enhances overall function.
Similarly, the index ray may be resected at the base of the metacarpal, preserving all the intrinsic musculature, widening the space between the thumb and the remaining third finger to give an excellent functional and cosmetic result (Fig. 5 ). If the proximal phalanx to the third finger is too short, this ray should be resected and the index metacarpal moved and pinned to fill up the space (Fig. 6 ). Similarly, if the ring finger proximal phalanx is short, the resection may be carried out at the base and the fifth metacarpal moved in to replace the defect in the hand. These procedures are well established and are all compatible with good appearance and improved hand function.
Multiple Finger Amputations (Incomplete). When sufficient thumb and fifth finger length have been preserved, a new cleft may be formed between these two widely spaced members. To accomplish this deepening, resection of useless metacarpals is usually carried out and the small intrinsic muscles are transferred to the remaining digits to maintain function. It is often necessary to rotate one of the laterally replaced digits so that pulp-to-pulp pinch can be accomplished. The appearance of this hand may be objectionable, but excellent function for precision pinch and limited grip of objects can be provided (Fig. 7 ).
Amputation of the Hand at the Level of the Metacarpophalangeal Joints or Below. At this level, bone grafting and lengthening of either the radial or ulnar side will probably be necessary, and the choice will depend on which lateral unit has more carpometacarpal motion. If there is a choice, the thumb is preferred because of the wide range of the saddle joint at the base of the thumb metacarpal. This procedure produces a variation of the Krukenberg type of extremity, with limited side-to-side opposition, and certainly has cosmetic disadvantages. Its advantages for the bilateral amputee are the presence of a sensory unit, a cradle for supporting handles and objects, and a push pad at the base of the palm, with a movable wrist, all of which can be of considerable assistance to the prosthetic appliance on the opposite side.
Where the metacarpals have been completely lost, few possibilities are available to the hand surgeon. Usually the extremity is too short for useful reconstruction, and a Kruken-berg procedure will be necessary or fitting with a wrist disarticulation prosthesis. On occasions, a sufficient amount of intrinsic musculature or small portions of metacarpal may remain in a lateral position to be lengthened by pedicle skin grafting and bone grafts. The limitations of this reconstruction are considerable but may be outweighed by the presence of two forked posts with limited function, the presence of sensation on one of the units, and length beyond the movable wrist (Fig. 8 ). With an unconventional prosthetic fitting for the portion of the extremity extending beyond the wrist, the patient could have his own "interchangeable plan" and derive the benefits of both prosthetic and nonprosthetic function.
Return of Sensation and Function To the Crippled Anesthetic Hand
The hand devoid of sensation is a "blind" hand, which the patient must observe and follow closely to avoid repeated serious injury from contact with hot or sharp objects. Loss of hand sensation is usually accompanied by loss of small-muscle intrinsic function or refined balance. Frequently, impairment of long tendon or extrinsic function is also evident. Severe injuries of this type, involving sensation plus intrinsic and extrinsic function, can be, for all practical purposes, considered as physiologic amputations, since protective sensation and gross and refined function have all been lost. The possibilities for reconstruction are usually extensive, and with careful planning and execution of multiple reconstructive procedures, the end result can be extremely rewarding. To the young patient with bilateral injury who requires prosthetic fitting on one side, the return of good, useful sensation and function to the opposite hand by surgical reconstruction offers new horizons in his total rehabilitation.
A case in point is that of E.S., an 11-year-old boy who was admitted to the State Hospital for Crippled Children, Elizabethtown, Pennsylvania, on January 30, 1961. Approximately one year prior to admission, the patient had sustained severe high tension electrical burns to both upper extremities following a fall on the high tension rail in the railroad yard.* Primary amputation in the left upper extremity was carried out, and a very short stump of approximately 1 1/4 inches below the elbow was preserved. Third-degree burns to the right forearm and palm required skin grafting. A previous attempt at exploration of the forearm to improve nerve and tendon function was apparently unsuccessful. The patient was otherwise in good general health and was alert and intelligent.
*Tissue damage from high-voltage electrical burns occurs at the point of contact with the current and the exit to the ground. Temperatures of 3,000 degrees F and more frequently cause charring of the tissues on the hands and forearms. Electric arcing may produce burns at more proximal levels around the elbow and the axilla. Children's hands and upper extremities are especially vulnerable to electrical injury around the home, workshops, and railroad high tension rails and lines. In the body, electrical current travels over blood vessels that offer little resistance, producing extensive injury to deep tissues, vascular impairment, and coagulation necrosis. Extensive loss of functional tissue in the upper extremity may require amputation. Damage to muscle, tendons, and peripheral nerves may be such that salvage of the extremity will require extensive staged reconstruction.
The appearance of the right hand and distal forearm at the time of admission is shown in Fig. 9 and 10 . Loss of the median and ulnar nerves in the forearm had produced intrinsic atrophy of all small muscles in the hand, with a claw deformity of the fingers. The skin was dry, trophic changes were noted over the palm and around the fingers and fingernails, and two draining sores were present. The flexor tendons to the fingers were bound in scar tissue in the forearm, and hand function was limited to flexion and extension of the thumb and limited extension of the metacarpophalangeal joints and wrist. Essentially, no useful function in the hand was possible.
The very short left below-elbow amputation stump was conical in character and was well healed and non-painful. Because of contracture of the joint, flexion-extension motion at the elbow was limited to 20 degrees (Fig. 11 ).
Shortly after admission, posterior capsulotomy on the left elbow was attempted but failed to increase the active range of motion. Physical therapy and dynamic splinting were started on the right upper extremity. However, these procedures were not effective because of poor sensation in the right hand and the dense scarring of the forearm tendons.
Surgical exploration of the right forearm, carried out on November 20, 1961, revealed dense scarring and fibrosis of the flexor tendons and the median and ulnar nerves. Following block resection of dense scar tissue, the gap between the severed ends of the median nerve was 4 inches and that of the ulnar nerve was 6 inches. Following dissection and freeing of the proximal segment of the median nerve in the arm and the distal segment into the palm, the elbow and wrist were acutely flexed, to permit closure of the 4-inch gap in the nerve and subsequent end-to-end suture. All superficial flexor tendons were resected, leaving intact only the four profundus tendons and the long flexor tendon to the thumb.
The median nerve was then primarily anastomosed, with the elbow and wrist in acute flexion to permit maximum relaxation, the skin was closed, and the arm was placed in a cast with the elbow and wrist in flexion. The ulnar nerve was not repaired due to the extensive loss of substance and the concern that further surgery might compromise return of median nerve sensation to the palm and to the pinch and grip surfaces of the thumb and the index, long, and ring fingers.
Following six weeks of casting, the wrist and elbow were gradually mobilized in sequence, therapy was commenced, and a program of protection and watchful waiting followed. In the meantime, preparations for prosthetic fitting on the left extremity were carried out. As the capsulotomy had been of limited success, the prosthetic team elected to fit the very short below-elbow stump with the elbow flexed in an unconventional elbow disarticulation prosthesis with outside locking hinges, Dorrance 88X hook, and figure-eight harness (Fig. 12 ). The patient continued with daily physical therapy and light dynamic splinting of the right hand.
Approximately three months after surgery, the patient began to show signs of nerve regeneration in the palm, and this regeneration continued during the months that followed. Six months following nerve repair, protective sensation returned to the thumb, the index and long fingers, and the thumb side of the ring finger. By one year, a sweating pattern returned, together with improvement in the dryness and the trophic changes in the right hand, permitting tolerance of the dynamic splint that had previously been discarded. By this time the patient had been fitted with his new prosthesis on the left and was simultaneously undergoing a training program. With this encouraging picture and the gradual return of good, useful sensation in the right hand, a total program of tendon reconstruction seemed feasible.
In preparation for opponens tendon transfer to return opposition to the right thumb, fusion of the unstable metacarpophalangeal joint to the thumb was carried out. The opponens transfer was accomplished by using the brachioradialis muscle as a motor, this muscle being chosen because it has its origin above the elbow and the belly was proximal to the site of a direct third-degree burn. The tendon was lengthened by a free tendon graft from the right foot. Due to the degree of scarring in the distal forearm, a tendon prosthesis (3) was utilized as a ring pulley around the ulna to act as a sling for the transferred tendon.
An X-ray of the hand, taken approximately two years after the opponens transfer (Fig. 13 and 14 ), shows solid arthrodesis of the metacarpophalangeal joint in a functional position, as well as physiologic acceptance of the prosthetic pulley. Following training, a good plus opponens function with sensation was achieved, permitting pulp-to-pulp and three-jaw-chuck pinch between the thumb and the index and long fingers, and reinforcement of grip (Fig. 13 and 14 Fig. 15 ).
The remaining problem in the hand was that of clawing of the fingers due to ulnar nerve intrinsic paralysis. It was elected to perform an active intrinsic tendon transfer of the Brand type; therefore, approximately three years after admission, the final reconstructive procedure was carried out. Utilizing the extensor carpi radialis longus tendon, lengthened by a free tendon graft taken from the plantaris tendon in the leg, the graft was divided into four slips which were passed through the palm, anterior to the functional axis of the metacarpophalangeal joint, and sutured into the radial (lateral) band of each finger. Following cast removal, a carefully supervised program of physical therapy and protective splinting was instituted. The patient gradually developed balanced flexion and extension of the fingers (Fig. 16 ).
In the foregoing illustrations, which represent the outcomes of five years of postinjury treatment, salient points to be noted are (1) the achievement of active extension of the proximal interphalangeal joints without excessive hyperextension of the metacarpophalangeal joints (Fig. 16 ), (2) the absence of trophic changes and the beginnings of abduction and rotation of the thumb, with the opponens tendon transfer seen beneath the skin crossing the wrist (Fig. 13 and 14 ), and (3) the attainment of grasp with active wrist extension and reinforcement by the thumb transfer and the long flexor tendon to the thumb (Fig. 15 ). For comparison, the patient's condition on admission, five years earlier, is shown in Fig. 17 .
In Fig. 18 , the patient, approaching the completion of his treatment program, is shown putting the final touches on a bookcase he had made in the hospital arts and crafts shop. It is believed that the ultimate in functional regain for this patient with severe bilateral upper-extremity injuries has been achieved.
A combination hand-prosthetic clinic team approach to the patient with severe bilateral upper-extremity injury has been discussed. Programs for returning prehension to the partially amputated hand and sensation and function to the injured hand devoid of sensation have been briefly outlined. The results suggest that although detailed and time-consuming, the rewards for the patient and the rehabilitation team are worth the effort.
James M. Hunter, M.D., Clinic Chief, and Mahaveer P. Prabhakar, M.D. with John Fenlin, M.D. aere associated with the Child Amputee Clinic State Hospital for Crippled Children Elizabethtown, Pennsylvania
1. Swanson, Alfred B., M.D., "The Krukenberg Procedure in the Juvenile Amputee," JBJS, Vol. 46-A, No. 7, October 1964.
2. Hunter, James M., MD., "Restoration of Function in the Child With a Congenital Thumb Deficiency by Staged Pollicization of the Radial Finger," ICIB, Vol. V, No. 11, August 1966.
3. Hunter, James M., M.D., "Artificial Tendons-Early Development and Application, AJS, Vol. 109, No. 3, March 1965.