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Battiston et al. Plast Aesthet Res 2023;10:25 https://dx.doi.org/10.20517/2347-9264.2022.130 Page 5 of 8

[38]
The Hannover Fracture Scale (HFS) was initially conceived as an extension of the Tscherne classification,
which was not only the first to describe open fractures but also included the damage of the soft tissues in
apparently closed fractures. The HFS has been widely used to provide information on bone and soft tissue
lesions but also their contamination and possible timing of treatment. Its main disadvantage is its long and
laborious compilation, eventually leading to some difficulties when used in an emergency. As it also
requires the systematic use of culture swabs before and after the initial debridement, several Centers report
difficulties in the data compilation. Finally, it seems more suitable for research than for deciding on limb
salvage in an emergency.

AO developed an anatomical classification system describing soft tissue lesions , including skin, muscles,
[39]
tendons, vessels, and nerves [Table 1]. At the same time, fractures may be evaluated using the well-known
and used Müller AO/OTA classification. The integrity of the cutaneous layer is one of the main elements to
be considered. Lesions are then divided into closed (IC) or open (IO) with a severity degree ranging from 1
(minimal damage) to 5 (wide and severe loss of tissue). The muscle-tendinous (MT) evaluation is difficult to
be used in clinical practice, especially in closed lesions. The problem arises, for example, when the
functional deficit caused by compartment syndrome is attributed to muscle damage or a neurological
problem. The most reliable and reproducible aspect of this system is the evaluation of nerves and vessels
(NV). Carefully evaluating the nerve function is fundamental to correctly classifying the wound.

In 1997, Weinzweig and Weinzweig described their "Tic-Tac-Toe" classification system, initially thought
[40]
for mutilating hand injuries. The name comes from the anatomical part of the classification in which the
different bones of the hand are divided into nine squares similar to those of the famous homonymous game
[Table 2]. Along with the anatomical location of the lesion, this classification specifies the type of injury
(dorsal mutilation, palmar mutilation, ulnar mutilation, radial mutilation, transverse amputation, degloving
injury, and combination injury), the subtype (soft-tissue loss, bony loss, and combined tissue loss) and the
vascular integrity (intact or devascularization). This system is accurate and easy to reproduce to classify
traumatic lesions, especially when the surgeon faces complex injuries such as mutilated hands.

Non-traumatic defects
Due to the wide range of possible tissues involved, no specific classification of the tissue loss resulting from
surgical procedures for oncologic or infectious diseases exists.

However, the reconstructive plan will depend on the need to restore only skin coverage or also to
reconstruct muscle masses, vessels, and nerves. The element which may classify the problem guiding the
following reconstruction is the need for marginal or compartmental excision. In case of surgical removal of
one or more tissues involved by the tumor or the infection, the technique will aim to repair the single
damaged tissues. On the contrary, a compartmental resection will generally require a composite
reconstruction including all the tissues of that compartment preserving distal survival (vessels
reconstruction) and restituting the limb function (muscles, tendons, nerves repair).

In deciding which kind of treatment for what type of defect in the hand, we believe that Ono's classification
[41]
is very useful . It is a general soft tissue defect of the hand classification that does not consider the etiology
of the tissue loss. This classification takes into account whether the defect is palmar or dorsal, the location,
and the size of the defect. The skin on the palmar side is hairless, immobile, and thick, whereas the skin on
the ulnar side is thinner, supple, and mobile. The location follows the functional aesthetic units described by
Rehim et al. and divides the hand into a distal finger (middle and distal phalanx)/thumb (distal phalanx)
unit, a proximal finger /thumb unit (from the proximal interphalangeal joint to the metacarpal-phalangeal