How Hand Reconstruction Can Save Function After Severe Injury

Many Severe Hand Injuries Can Be Reconstructed Rather Than Amputated

Interviewer: Most people assume that a severe hand injury, a crush, a deep laceration, or an amputation means a permanent loss of function or sometimes losing the hand altogether. But in reality, the field of hand reconstruction has advanced dramatically, and surgeons can often restore far more movement, sensation, and independence than patients initially expect, especially when specialized care comes quickly.

To walk us through what's possible, we're joined by Dr. Laura Wong, a hand surgeon with the Plastic and Reconstructive Surgery division at University of Utah Health who specializes in upper extremity reconstruction and microsurgery. Before becoming a surgeon, she earned a PhD in neuroscience, studying how nerves regrow. And today she rebuilds hands and reconnects nerves for a living.

Now, Dr. Wong, I want to kind of start with the misconceptions people might have. When someone hears hand reconstruction surgery, what are the old conceptions versus what is actually possible today?

Dr. Wong: I think a lot of patients come in thinking that they're not going to be able to save their hand or that some of these injuries just mean automatic amputation. And I would say that's not true anymore. We're able to save a lot of things.

I think then the question becomes whether or not we should save a lot of things and what your goals are and what recovery looks like. And so everyone comes in, if something's been amputated, wanting it put back on, or that's why they were transferred here. And so I think that's a more nuanced discussion.

It's an emergency, and it's a high-stress situation for the patient where something horrific has happened to their hand. But it's also somewhat elective in that you don't need your finger to save your life, but if that's something we are going to do and we're going to try to put it back on, then we need to do it quickly. Unfortunately, these seem to always come in at the middle of the night. So, often, we're doing this in the middle of the night.

Successful Hand Reconstruction Focuses on Function, Not Perfection

Interviewer: What is that most common misconception? Is it just, "Hey, I'm going to lose it, and we've got to . . ." Is that what you kind of help patients through? I mean, this is an emergent situation. So this isn't necessarily a "think about it for a while," etc.

Dr. Wong: People first think they're just going to lose it, but then as soon as the conversation of replantation or putting that finger or that part back on comes up, then I think the next misconception is that it's going to be perfect, and that isn't true. It often is a long recovery that requires a big team of hand therapists and others to get them back to their prior function.

And sometimes we can't get people back to their prior function perfectly, but we can get them better so that maybe they can do all the things they love to do with their hands.

Interviewer: Now, I do want to dive a little bit deeper into that. It sounds like it's much more than what the hand looks like. What is your main goal that you're trying to give a patient when they come to you with these types of injuries?

Dr. Wong: So my main goal is to get them back a finger that moves, if not perfectly, then good enough to be functional, and then that has sensation.

So one of our main goals is for protective sensation. If you've cut your finger off, all those nerves are cut, and they have to regenerate. And I want them to at least have protective sensation so that if they put their hand down on something hot, they have the reflexes to pull away and not further injure that finger. So that's a big part of it.

And then sensation is actually really important for how we interact with the world. And so that is also important. You want to be able to feel your loved one's hand when you hold their hand, for instance.

Movement, Strength, and Sensation Are the Goals of Reconstruction

Interviewer: So in my kind of layperson research, the three things that I came across were movement, strength, and sensation.

Dr. Wong: Yep. So I want you to have enough movement to be able to close your hand around an object. So picking up a water bottle. If your job requires you to have fine pinch, usually I want you to be able to make your thumb and your index or your middle finger meet in a way that can grab something small, like a coin, or fine tools, if that's what your job requires.

So there's big grasp where you're grabbing something wide, like a water bottle or a piece of wood or something like that, if you're in construction. But then there are also finer tasks.

Sometimes these hands just become helper hands, where your other hand, whether it be your former dominant hand or not, is doing the majority of your fine motor tasks, and the other one is helpful for more gross activities.

Interviewer: And what about strength?

Dr. Wong: So that is something that will take a while to figure out what we're going to get. But I would like you to be able to lift and do things with this hand, be able to grip something, strong enough to lift it, and be able to perform your kind of activities of daily living.

So taking care of yourself is obviously the bottom rung, being able to feed yourself and do those things. But often, especially people who are getting these types of injuries, their work is more labor-intensive. And so I want them to be able to do all those tasks again.

I have a patient who was a farmer and was doing heavy labor, and his hand, unfortunately, was injured by a sprocket, which is a gear in an industrial farm incident. And so his hand was basically cleaved in half. And now, he's back at work, and he's able to do heavy lifting with this hand, but he doesn't have fine dexterity with the hand. But that's success to him.

Modern Techniques Can Repair Bones, Tendons, Skin, and Nerves

Interviewer: What kind of injuries can actually be treated these days with the more modern advancements we've had? I mean, some of these injuries look pretty devastating on the surface. What is fixable?

Dr. Wong: So we're pretty good at fixing bones. So when you do have big fractures, we are often able to get those fractures to heal. They may not be perfectly anatomic, but at least your bones are stable.

Tendons, we are able to heal, but tendons come with their own challenge because they have to glide and move to give you back that movement and strength. We are reasonably good at tendons. The problem with tendons is the scar tissue down the line. So often there are some secondary operations we have to do for those.

Skin, that is something that myself and other colleagues in plastic surgery are quite good at. We can usually get you skin from somewhere. And that's kind of the microsurgery component of this, which means that we move tissue from some remote part of your body to your mangled hand to get your bones and tendons covered. And that's kind of the fun magic of plastic surgery.

And then nerves are good, and we can reconnect them, but then they have to regenerate. And so that is often a slow process. Nerves regenerate at a rate of about a millimeter a day, which translates, in kind of our normal lay language, to about an inch a month.

And so if your injury is at the level of your wrist, say, you're looking, depending on the size of your hands, at six or seven inches of regeneration to your fingertips. And so that's six or seven months.

Every Reconstruction Plan Is Personalized to the Patient’s Goals

Interviewer: Now, it sounds like there's a big variety and diversity of the types of injuries and the types of patients. I assume there must be also a diversity in different types of goals you have as a surgeon, depending on the patient. How do you kind of determine those goals, and what do they look like to make sure that it fits the patient?

Dr. Wong: Yeah, this is really a shared decision that we make with the patient. So I will often very quickly be trying to understand what activities you do, what your jobs are, what is important to you that you do.

So if you're an avid or professional musician, like a pianist or a guitar player, our conversation is going to be very different from the conversation I have with a construction worker who maybe needs to get back to work much faster and can't take some of the time off to do a year of rehab. We're really doing this in a shared way.

And one of the kind of challenges, but also joys of my job is to quickly build rapport with a patient and find out what's important. My goal as a hand surgeon and why I came to do this job is because I wanted to save people's lifestyles. I'm not usually saving lives, thankfully, but I want you getting back to all of those things that you absolutely love to do. And so if that's playing guitar, then your goals are sometimes different than, "I just need to get back to work to support my family."

Interviewer: What kinds of things are possible today, in the year 2026, than it was 30, 40 years ago?

Dr. Wong: We are pretty good at connecting small vessels. So I think replantation has advanced, even if it's distal. So we can put a finger back on even if those vessels are a millimeter or so in caliber. That is a huge advancement.

We have really small tools. We have even smaller micro-sutures than we've ever had before. Our sutures get smaller than a fine human hair. So they're pretty small, and that helps us a lot with these smaller vessels.

And then our microscopes have gotten absolutely incredible in terms of what they're able to see.

Not Every Amputation Is Equally Suitable for Reattachment

Interviewer: Now, I do want to talk a little bit about that reattachment and replantation. It's the question I think every patient must wonder about. "Can this be reattached?"

Dr. Wong: I would say that each part has to be examined that comes in. So if it's a clean cut, with a very sharp object, then it's more likely to be successful than something that is crushed or avulsed off by a rope, because just the zone of injury of those vessels is greater, the more trauma to the part.

I think a big misconception, actually, is that a saw . . . people think they're sharp. They are not sharp. Saw blades tend to work by tearing and ripping. And so they actually have a higher zone of injury depending on the curve of the blade. So I guess the thickness of the blade. And so that can seem like a sharp injury, but not really be that sharp, which can be challenging.

So something that was cut off, say, with a samurai sword, like in a ninja movie, that would be relatively easy to put back on because the vessels wouldn't be terribly damaged.

A rodeo injury where somebody accidentally has wrapped a rope around . . . The most common thing is their thumb, unfortunately, and it's often their dominant thumb. That gets pulled off, and so often the vessels are pulled apart, the nerves are pulled apart, the tendons can be pulled out of the muscle. That's much harder to put back on. We still try because it's often the thumb and often the dominant thumb, but I would say the success rate for those injuries is much lower.

Quick Treatment Improves the Chances of Saving an Injured Hand

Interviewer: How quickly should someone be getting these treated? Because it sounds like there are a lot of things... this is a pretty typically an emergent situation. Don't wait? Make sure to come in, grab whatever you lost?

Dr. Wong: Yep. So time is definitely tissue. So we like to try and get parts back on within six hours is the canon. So things to do with your part if it's cut off or pulled off is try to get it, maybe clean off some of the grossest contamination, and then you wrap it in moist gauze, so saline or water. You put that in a bag, and then you put that bag on ice, and that should come with the patient. We are often transporting. If it's a patient from far away, we have a big catchment area. They're often coming in a helicopter to us with their part on ice.

Interviewer: Wow. So as soon as possible.

Dr. Wong: As soon as possible.

Recovery Depends on a Team of Surgeons, Therapists, and Nurses

Interviewer: Now, beyond the surgery, who's the team behind these types of complex repair? Who's in the room the day of the surgery and what happens afterwards?

Dr. Wong: So the day of the surgery, it's usually just the hand surgeon who's on call, and then our anesthesia colleagues. We have nurses and techs in the room that help make our cases possible.

The biggest thing, I would say, is what happens after replantation. So we have a big team that takes care of patients. They do go to the ICU usually afterwards, not because they're sick, but so that the nurses can monitor that finger to make sure it stays perfused every hour. If anything were to happen, and we thought there was a reasonable chance of saving it, we would return very quickly back to the operating room.

Then after that, they're seeing the hand therapist in the hospital, and they're starting to work on therapy, because the sooner we can get therapy going, the less likely they are to have debilitating stiffness. That tends to be the thing we fight in the long run, is how stiff your hand is, which is going to take away your strength and your movement.

Interviewer: So even when they're in the ICU, they're starting to do rehab work.

Dr. Wong: Yep. So we ask our hand therapists, who are usually outpatient providers, to come into the hospital for these patients. They're making them custom splints so that we can change them, evaluate their wounds, things like that. But then they're also showing the patients what safe motion is.

And that is actually the biggest thing, is we work with an amazing team of certified hand therapists here at the University of Utah. They're familiar with what we do. They're familiar with these types of injuries. They're really incredible to work with. And so they're involved in patient care often.

And I feel like the hand therapists, actually, are the ones who make us look good. If we have a good result, it is often because of hours and hours spent with the hand therapist rather than anything we did.

Recovery Often Takes Months and May Require Multiple Surgeries

Interviewer: And once the patient has been stabilized, got their basic PT work, etc., how long is recovery for injuries like this?

Dr. Wong: Patients often are not back to work quite that quickly. It depends on their jobs. I would say people are not doing kind of fine motor or really heavy lifting with their hands for six months to a year. So it's a big-time investment to get as much function as possible.

And most often with a replantation, people need additional surgeries down the road. Usually that's entirely in the name of fighting stiffness. So it can be one to two additional surgeries for reconstruction depending on their injury.

Interviewer: So we're talking a while for recovery.

Dr. Wong: We are talking a while, yeah. My young man with the farm injury, he went back to work before, but at 15 months, I want to say, he had his last surgery. So 15 months after his injury.

Modern Hand Reconstruction Can Help Patients Return to the Activities They Love

Interviewer: Now, if anyone's listening or reading along, for someone facing this or a loved one that's supporting them, what do you want them to take away? What do you tell someone to keep them hopeful, to help them understand what is going to come next?

Dr. Wong: I think the biggest kind of take-home point for me is that we can get you back to successful function. It may not be at just one surgery; it might be more, but we have really amazing options available to us today to get back a lot of your function.

And that we're here for you, right? We have this multidisciplinary team with my orthopedic hand colleagues and us in plastic surgery and the certified hand therapists that are going to support you every step of the way.

I have patients who have become friends because I've seen them for so long to get through this, and I think every one of them has big successes in this.

Someone recently just sent me a video of them getting back to playing the piano, which had been really important to them. And so she sent me a video of her playing. It's been a year, but she has started to play piano both as a therapeutic activity she's doing for her hands, but also mentally therapeutic because she's back to something she really loves and values.

And she sent me this video because she was so excited that it happened, and she knew that we'd want to see that success and celebrate it together.