Tissue and functional salvage of the hand following complicated traumatic amputation of the second ray: A case report and literature review.

Abstract

● Introduction: High-energy trauma to the upper extremity resulting in a "catastrophic" or severely mutilated hand represents a critical reconstructive challenge for the orthopedic surgeon. These injuries are characterized by complex, combined damage involving skin coverage, skeletal architecture, and neurovascular systems. Traumatic amputation of a digital ray, often associated with adjacent multifragmentary fractures, creates a pattern of global hand instability. Management requires a systematic approach based on established salvage principles: radical debridement, anatomical skeletal stabilization, revascularization, and early tissue coverage to avoid total limb amputation and preserve basic prehension.

● Objective: To describe the sequential surgical management, soft tissue reconstruction strategy, and mid-term functional outcomes in a severely traumatized hand with second-ray amputation and global instability.

● Methodology: A retrospective, observational case report. A male patient was evaluated following a high-energy trauma to the right upper extremity. Clinical presentation included traumatic amputation of the second ray with severe soft tissue avulsion, exposed vital structures, and global instability. Radiographic assessment revealed a complex fracture pattern: radial styloid (AO 2R3B1), base of the first metacarpal (AO 77.1.1), head of the second metacarpal (AO 77.2.3), diaphysis of the fourth proximal phalanx (AO 78.4.1), and head of the fifth proximal phalanx (AO 78.5.1). The surgical approach consisted of: 1) Exhaustive mechanical debridement, 2) Rigid skeletal stabilization of the radial column and osteosynthesis of the ulnar rays, 3) Remodeling of the second ray stump, and 4) Reconstruction of the extensive skin coverage deficit using a pedicled distant flap to protect the osseous and tendinous bed.

● Results: The sequential orthopedic and reconstructive approach enabled successful limb salvage. During follow-up, radiographic and clinical evaluations confirmed bony consolidation of the multiple fractures with no signs of osteomyelitis. The cutaneous flap integrated properly, providing stable coverage without necrosis. Following an early rehabilitation program, the patient regained stability of the first ray, successfully restoring tripod pinch function and gross grasp.

● Conclusions: Tissue and functional rescue in hands with global instability and partial amputations is feasible through a protocolized surgical intervention. Early anatomical skeletal fixation, prioritizing the stability of the radial column, combined with optimal soft tissue coverage, is a fundamental pillar to minimize disabling sequelae and maximize biomechanical recovery.