Catastrophic Hand Injuries in Children
Authors: Gargollo Carlos , Lopez Javier , Ferreira Francisco 
Published: September 2016

Objective: Catastrophic injuries of the hand are devastating and often lead to a significant functional and psychosocial disability. These injuries usually affect most hand structures (skin, soft tissues, bones, and joints) and compromise the function of the hand. The treatment objectives in these injuries are, in order of importance, save the life, save the limb, and restore the function. The initial care is one of the most important aspects in the treatment of catastrophic injuries of the hand. The general principles of management are debride devitalized tissue, restore the vascularization, provide rigid skeletal fixation, repair or reconstruct all damaged structures, and provide adequate soft tissue coverage. The concept of useful hand meets the following requirements: have at least 3 fingers of normal length, have at least proximal interphalangeal joint motion of the fingers, have near normal sensitivity, and have a functional opposing thumb or finger. Catastrophic injuries are not common in the pediatric population, but when they occur, they are often not properly managed. Around the world, many of the patients who suffer catastrophic injuries in the hand receive only skin coverage, and the hand reconstruction is made with secondary procedures, with poor functional results and lengthy hospital stays. Materials and Methods: We present our series of 25 cases of catastrophic hand injuries in pediatric patients aged 2 to 17 years with grade II to IV of the Hand Injury Severity Scoring System, which were managed by our team between 2010 and 2014. The main cause of injury was motor vehicle accident, followed by mangling by a machine. In all these patients, an attempt was made to repair or reconstruct all damaged structures in 1 surgical sitting, to avoid lengthy hospital stays, move the hand and fingers as quickly as possible, and diminish the psychological damage these injuries cause. Free flaps were used in 19 of the patients. No pedicled flaps were done in any of the patients, in order to be able to start the therapy program very early, sometimes on the first postoperative day. The range of surgical procedures performed in these patients was 1 to 3 surgeries. The initial reconstruction surgery was complemented in these cases with other 2 procedures such as flap thinning, hardware removal, secondary tendon grafting, etc. Results: Patients were assessed at least 1 year after the initial surgery with the Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) disability instrument (which has been validated to use on older children). In average, all patients scored 18 or better. The patients and their parents also evaluated cosmetic appearance. Conclusions: It is very important to consider special factors in the pediatric population, such as the size of anatomical structures, compliance with treatment, rehabilitation of the patient, and the psychological and emotional complications for the child and their families. We show the importance of the initial total hand reconstruction in the pediatric population in the treatment of catastrophic injuries of the hand; this approach gives the child the opportunity to have an aesthetically acceptable and functional hand in the shortest time possible.