Combined injuries--soft tissue management

The combination of severe bone and soft tissue injuries challenges all hand surgeons. Immediate restoration of all damaged structures is the goal whenever possible, integrating soft tissue techniques with principles of internal fixation. Debridement must be radical and resulting defects in bone, vessel, nerve, tendon and skin must be reconstituted with the combination of free and vascularized grafts. Rigid internal fixation is mandatory to allow functional restoration of the hand to begin with a stable platform against which motor tendon units and gliding structures to move. The timing of subsequent reconstruction is based on the prerequisites of adequate vascularity and soft tissue coverage. Understanding the reconstructive ladder and the nuances of techniques regarding skin grafting, local and distant flaps and microsurgical reconstruction is necessary to complete reconstruction in a timely and appropriate fashion. Various soft tissue techniques are described; from simple skin grafting to the use of toe to hand transfers. The decision to amputate versus reconstruct is also important, particularly in today's cost conscious health care environment. Finally, a well thought out and directed rehabilitation program will allow patients to ultimately return to functional status after mutilating injuries of the hand. This article provides a comprehensive review of the combined injury.