Page 9 - Read Online

Page 4 of 8 Battiston et al. Plast Aesthet Res 2023;10:25 https://dx.doi.org/10.20517/2347-9264.2022.130

chondrosarcoma, osteogenic sarcoma, and Ewing sarcoma. Among the soft-tissue sarcomas, the common
subtypes are epithelioid sarcoma, synovial sarcoma, myxofibrosarcoma, rhabdomyosarcoma, and
liposarcoma.

Infections
Infections are always more frequent in hand surgery. Early identification and antibiotic treatment are
usually sufficient to achieve optimal outcomes and avoid tissue losses. However, it is not uncommon to miss
or delay diagnosis, eventually leading to the necessity for extensive trimming, amputation, or death [35,36] .
Conditions necessitating urgent attention are:

● Necrotizing fasciitis: fascia and subcutaneous tissue are involved, typically in immunocompromised
patients. Extremities are usually affected in type 2 due to group A Streptococcus and/or Staphylococcus
infections. Extensive debridement to healthy tissue is necessary and has to be repeated every 24-48 h to
reduce the risk of amputation. Nevertheless, mortality rates will not be reduced, ranging from 23% to
[36]
76% .
● Pyogenic flexor tenosynovitis: bacterial infection of the tendon sheath can lead to the "necrotic stage" (stage
3), necessitating tendon and adjacent soft tissue excision.

● Deep hand space infections are less frequent and usually result from the spread of flexor tenosynovitis or a
penetrating injury. Thenar and hypothenar abscesses might need both volar and dorsal approach, whereas
midpalmar abscesses should be approached with a midpalmar transverse incision.

● Septic arthritis: infections of the joints of the hand, if not recognized, can lead to osteomyelitis. Although
osteomyelitis is rare in hand, it has to be recognized as it can lead to amputations (especially when distal
bones are involved) or massive excisions of bone and surrounding tissues needing reconstruction.

Beyond clinical diagnosis and laboratory tests, radiological exams such as echography, CT, and MRI are
mandatory to evaluate the extent of the infection.

CLASSIFICATIONS
After accurate clinical and radiological examinations, such as those described above, the surgeon can
understand and classify the lesion. However, we suggest classifying it after the appropriate excision of the
compromised tissues, which may change the picture of the final lacking and remaining tissues. There is no
consensus on which classification is best among those described in the literature. We present the most
common classifications, differentiating those classically used to describe tissue loss consequential to a
traumatic event from those used to classify soft tissue defects consequent to other events.

Traumatic defects
Several systems are present in literature with the object of classifying lesions secondary to trauma: Gustilo-
[37]
[38]
Anderson and Tsherne and Hannover scale evaluate both soft tissues and bone lesions (open fractures).
As for systems conceived mainly for soft tissues, the AO soft tissues classification and the TIC-TAC-TOE
[39]
[40]
system are the most known and used.
The Gustilo-Anderson classification , first proposed for lower limbs open fractures, describes the
[37]
exposition size and whether intervention from a plastic or a vascular surgeon is necessary. However, it does
not help to discriminate which type of reconstruction will be needed.