الفهرس 
Acknowledgement
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Abstract
In this study, reconstruction of post traumatic soft tissue defects of the hand was performed in 40 patients presented to Assuit University Hospital Trauma Unit, Plastic Surgery outpatient clinic and Microsurgery outpatient clinic with post traumatic soft tissue defects of the hand during 12 months period starting from July 2015 to June 2016. This work was approved by the local Ethical Committee of Assuit University Faculty of Medicine.
Aims of this work are to provide the candidate, within a supervised training program, with the basic knowledge aboutsoft tissue reconstruction of the hand. Also, to find the ideal donor tissue for coverage of the post-traumatic soft tissue defects of the hand while considering the extent of injury, recipient site requirements, donor site morbidity and body habits to achieve the following goals; close the wound, maintain joint and hand function, maximize sensory return, obtain satisfactory cosmetic appearance and allow further interferences.
All cases of post traumatic soft tissue defects of the hand that require reconstruction were included in this study excluding cases with soft tissue defects due to burn, cases with soft tissue defects in the fingers, cases with major life threatening injuries or sever uncontrolled medical conditions and cases with upper limb injury that is candidate for amputation.
Patients were classified into five main groups; each group has subtypes according to the applied surgical techniques into; local flaps group which included two patients with only one surgical technique which was perforator-based propeller flap. The second group was regional flaps group and included 17 patients distributed over three surgical techniques which were; distally-based radial forearm flap performed in seven patients, distally-based posterior interosseous artery flap performed in nine patients and dorsal ulnar artery flap performed in one patient. The third group was distant pedicled flaps group with 15 patients and two surgical techniques which were; pedicled groin flap performed in 12 patients and pedicled abdominal flap performed in three patients. The fourth group was distant free flaps group which included five patients operated with three surgical techniques that were; free radial forearm flap performed in one patient, free anterolateral thigh flap performed in three patients and free fibular osteocutaneous flap performed in one patient. The last group was the combined flaps group performed in only one patient which were combined distally-based posterior interosseous flap and pedicled groin flap in the same operative setting.
Most of our patients were in the third decade of life (35%) which is the most efficient man power of our society. This markedly alerts to the magnitude of socio-economic impact these injuries have. Males over numbered females with a ratio of 7:1. RTA were the most common cause of injury and it can be an easily preventable cause.
The type of hand injury was detected using T-T-T classification and the most frequent was the dorsal mutilation in 20 patients followed by combined injury in 9 patients. Hand function evaluation (using Quick DASH score) in correlation to the type of injury showed that combined and transverse injuries usually have worse affection as they are associated with tendon and/or skeletal injury.
We classified the size of the defect into three main categories; small, medium and large. The most common was large-sized defects and when comparing the relation between the size of the defect and surgical technique applied; we found that local flaps were performed in small-sized defects only, regional flaps were performed in medium-sized defects mostly, distant pedicled flaps were mostly performed with large-sized defectsand distant free flaps were applied in cases with large defects only.
The local and regional flaps have the advantages of having good vascularity, wide arc of rotation, good resistance to infection, allows early rehabilitation, and better cosmetic appearance and regional flaps has extra advantage of being suitable for larger defects than local flaps.
The distant flaps have the advantage of being easy rapid technique, well established applicability for palm and dorsum reconstruction, they cover large-sized defects without disturbing any of the main vascular pedicles of the hand. Their main disadvantages are the multi-staged procedure, and prolonged period of immobilization.
Free flaps have the advantages of being of good vascularity, good bacterial resistance, the problem of the arc of rotation is not met, and single stage reconstruction. The disadvantages are the long operative time, the need of special training and setting, and high expenses.
Complications were in the form of persistent edema in one patient that resolved conservatively with limb elevation, pressure garments and anti-edematous drugs and partial skin necrosis in four patients (10%) which healed with repeated dressings in two patients and needed secondary STSG in the other two patients. Otherwise, no major or serious complications like total flap loss was detected.
Resulting from this work, we can conclude that every method has its advantage and disadvantage and that all methods are important and should be kept in mind to reach the proper decision for soft tissue reconstruction of the hand. Also; proper postoperative physiotherapy and rehabilitation is essential to improve the functional outcome of the hand and to ensure good results.
Although of all efforts presented, the management of untidy hand injuries stills a challenging problem that arouses the skill of a multi-displinary approach to obtain the maximal functional and cosmetic result.