Management of mutilating hand injuries requires solid knowledge of anatomy, biomechanics, reconstructive principles, and expertise in microsurgery.
Reconstruction of the mutilated hand is one of the most difficult challenges for hand microsurgeons. The first goal is damage control to preserve the patient's life. Some of these devastating injuries to the extremity may be associated with life-threatening damages. A primary and secondary survey and complete trauma workup is often warranted. The second goal in the treatment of mutilating hand injuries is to preserve the extremity if possible. This is followed by the goal to preserve function. In fact, a limb without function may not only be useless, but could also be more of a hindrance to the patient. The final goal is to restore lost function. Unlike the lower extremity where prostheses are tolerated extremely well after amputations, upper extremity amputations are often best served with some form of reconstruction that restores mobility and sensation such as toe-to-hand procedures. As the thumb is considered the most important functional aspect of the hand, every effort is attempted to preserve the thumb even if it can act only as a stable sensate post.
Replantation of amputated digits is without a doubt the best option to restore function, especially when multiple digits are involved. Refinements in microsurgical technique and effective postoperative monitoring have caused the survival rate of digital replantation to approach 90%. However, the challenge is not only to restore circulation to a digit, but also to create a functional hand. To this end, the restoration of an opposable thumb and at least two fingers to work against, each pain-free and sensate with mobile and stable joints, is the key priority when treating a mutilated hand.
The principles of wound management in the mutilated hand include irrigation, debridement, restoration of vascularity, stable bone fixation, repair of specialized tissue such as nerve and tendon, followed by definitive soft tissue coverage. All areas of contamination and nonviable tissue should be removed not only to avoid infection but also to allow the surgeon to realize and appreciate the exact extent of tissue is required for reconstruction. Second- or third-look surgeries are often required within 72 hours to remove contaminates and to allow compromised tissue to declare itself as either viable or nonviable. The wounds are often treated as “pseudotumors” with aggressive debridement and irrigation that ensure viability of the remaining tissue.

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