Reconstructive surgery of roller injuries of the hand

Eleven patients with roller injuries to the upper extremity are described. Nine were treated initially; two were referred for treatment within 3 weeks after injury. Six patients were injured by kneading machines in bakeries, two by hot dry-cleaning mangles, two by industrial rolling machines, and one by a transmission belt which acted as a roller. The tissue damage depends on (1) the space between the rollers, (2) the speed of the rollers, (3) the hardness of the rollers, (4) the temperature of the rollers, and (5) how violently the patient attempts to withdraw the entrapped part. Lesions may be closed, consisting of a compression of the soft tissues, which may result in skin necrosis, or a tearing and separation of the skin and soft tissues away from the deep fascia (more common on the dorsal surface of the hand), or destruction of skin and deep tissue because of burns. Closed injuries usually respond to conservative care, although decompression sometimes is necessary. Experience gained from treating these 11 patients indicates that the inexperienced surgeon often tries to replace distally based flaps. Such flaps usually die and predispose to deep infection. If the condition of the wound permits, primary skin grafts should be applied; but if the bed is of poor quality, skin grafting can be delayed for several days. If it is necessary to protect exposed deep structures, they should be covered with immediate pedicle flaps. It is better to use skin from an uninjured area for a free skin graft than to use the avulsed skin as a graft. Distant flaps should be used if secondary reconstruction is anticipated. In circumferential skin loss, a combination of pedicle skin and free skin grafts is better than encircling the part with a pedicle flap. The thumb and radial fingers should be preserved, but the ulnar fingers are expendible in severe injuries. By amputating parts of fingers, reconstruction often is simplified.