Research & Reviews: Journal of Medical and Health Sciences
MenuISSN: 2319-9865
ISSN: 2319-9865
Sk. Murad Ahmed1*, Krishna Priya Das1, Md.Mamunur Rashid2, Ayez Mahbub3,Md. Moniruzzaman1, Nadia Zebin Khan4
1 Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh
2 Department of Orthopaedic surgery, Kurmitola General Hospital, Dhaka, Bangladesh
3 Department of Orthopaedic surgery, Dhaka Community Medical College, Dhaka, Bangladesh
4 Department of Biochemistry, Z.H.Sikder Womens Medical College, Dhaka, Bangladesh
Received: 11-Dec-2023, Manuscript No. JMAHS-23-122488; Editor assigned: 13-Dec-2023, Pre QC No. JMAHS-23-122488 (PQ); Reviewed: 27- Dec-2023, QC No. JMAHS-23-122488; Revised: 03-Jan-2024, Manuscript No. JMAHS-23-122488 (R); Published: 10- Jan-2024, DOI: 10.4172/2319- 9865.12.4.001.
Citation: Ahmed SM, et al. Functional Outcome of Spaghetti Wrist Following Surgery-Our Experience In 26 Patients. RRJ Med Health Sci. 2024;12:001.
Copyright: © 2024 Ahmed SM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
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Background: Spaghetti wrist’ is defined as laceration injury involving the volar aspect of distal forearm, in which three or more structures were completely transected. The most common injury mechanisms are glass and knife injuries. Early surgical repair and rehabilitation are recommended in all studies for spaghetti wrist.
Materials and methods: This prospective interventional study was conducted in the department of orthopaedic surgery, Bangabandhu Sheikh Mujib Medical University and a private hospital in Dhaka, Bangladesh from January’17 to December’22. A total number of 26 patients were included in the study. Post operatively follow up was given at 2 weeks, 6 weeks, 12 weeks, 6, 12 and 18 months. Final outcome was measured by tendon function, opposition, intrinsic, deformities, sensation and grip strength.
Results: Mean age of the study population was 29.30 ± 9.1 years. Out of 26 patients 12 (46.2%) were glass factory worker. 18 (69.2%) patients had glass cut injury. Out of 26 patients 19 (73.1%) patients had associated nerve injury. Final follow-up satisfactory (Excellent+Good) outcome was found in 22 (84.6%) patients and unsatisfactory (Fair+Poor) outcome was found in 4 (15.4%) patients. Conclusion: Early primary repair and good rehabilitation are of great importance for successful outcome of spaghetti wrist injury.
Spaghetti wrist; Glass cut injury; Tendon function; Laceration
The term ‘spaghetti wrist’ was originally coined by Puckett and Meyer (1984) and denoted the laceration injury involving the volar aspect of distal forearm, in which three or more structures (tendon, nerve or vessel) were completely transected [1]. Katz defined a spaghetti wrist as a laceration in which 10 or more structures were damaged. Various other definitions have been used, thus leading to some ambiguity in the literature as to what constitutes a spaghetti wrist injury. The lack of a unified definition is highlighted by Jacquet et al. who used two definitions in their study: Simultaneous laceration of both the median and ulnar nerves with flexor tendons at the wrist and/or at least 10 divided structures including the median and/or ulnar nerves [1,2]. The superficial placement of the anatomical structures on the palmar surface of the wrist and distal forearm (zone V) and the constant use of the hand to carry out tasks of daily living make these structures vulnerable to major injuries that can lead to lifelong disability and psychological, social and economic consequences [3]. The most common injury mechanisms are glass and knife injuries, occupational injuries with electrical saw, and suicide attempts. Incidence is especially high in the working population. There are, however, few data available in the literature concerning injury and functional results. Early surgical repair and rehabilitation are recommended in all studies for spaghetti wrist, but functional results and influencing factors are not well understood [4]. Complex injuries of the palmar aspect of the wrist that involve simultaneous damage to nerves, tendons and vessels frequently lead to a dysfunctional hand either due to the severity of the soft tissue injury, or due to technical difficulties and errors during surgery. Complications reported range from neuromas to loss of sensation and motor function in a varied number of fingers. The effect of the number of nerves injured is clearly more dramatic than the corresponding number of tendons, while there are no reports of ischemic contracture, necrosis or amputations after vascular damage. Soft tissue loss, scar formation and incorrect connections between the injured tendons are the most frequent causes of postoperative abnormal gliding of the tendons. Therefore, the patient should be thoroughly informed of the possibility of secondary procedures that may be required for the management of the aforementioned complications [4]. Despite their relatively frequent occurrence, few data are available in the literature to categorize these injuries and even less is known about the functional outcome. This combination of injury has received little attention in the literature and published articles are few. Early primary repair and good rehabilitation during the postoperative period are of great importance for successful results [5]. The main objective of this study was to investigate functional outcomes following spaghetti-wrist injury in terms of sensitivity, tendon function, intrinsic muscle function, opposition, hand deformity and hand function.
This was a prospective interventional study conducted in the department of orthopaedic surgery, Bangabandhu Sheikh Mujib Medical University and a private hospital in Dhaka, Bangladesh from January’17 to December’22. A total number of 26 patients were included in the study according to selection criteria. Post operatively follow up was given at 2 weeks, 6 weeks, 12 weeks, 6 months, 12 months and 18 months. Minimum follow up period was 12 months. Final outcome was measured by tendon function, opposition, intrinsic, deformities, sensation and grip strength. Tendon function was graded as excellent (85-100), good (70-84), fair (50-69), poor (Fixed contractures or adhesions) and to determine the final outcome of the study, excellent and good grades were considered as satisfactory outcome (Table 1). The nerve repair outcome was evaluated serially by using advancing Tinel’s sign, two-point discrimination and sensory perception score from S0-4, compared with normal contralateral upper limb. The muscle power was evaluated by MRC grading from M0-M5 and the range of movement was also assessed. All the data were compiled and sorted properly and the quantitative data were analyzed statistically by using statistical package for social sciences (SPSS-26). 95% CI and p<0.05 were considered as the level of significance (Figure 1).
Figure 1: Pre-operative pictures of a spaghetti wrist injury patient.
| Louisville system | ||
|---|---|---|
| Excellent | Flexion lag<1 cm | extension lag<15° |
| Good | Flexion lag 1–1.5 cm | extension lag 15°–30° |
| Fair | Flexion lag 1.5–3 cm | extension lag 30–50° |
| Poor | Flexion lag>3 cm | extension lag>50° |
Table 1. Louisville system for evaluation of functional outcome.
Selection criteria
Patient with more than three structures injury (out of which at least one nerve/artery injury was there) was included in the study. Patients with age more than 5 years and psychologically fit to follow the post-operative rehabilitation protocol were selected. Duration of injury was 2 hours to 6 months. Patient having underlying bony injury and previously nonfunctioning wrist were excluded.
According to the inclusion criteria, a total number of 26 cases of spaghetti wrist were taken according to selection criteria. Table 2 shows the demographic characteristics of study population. Mean age of the study population was 29.30 ± 9.1 years. Most of the patients (42.3%) belong to 16-25 years age group. The youngest and the oldest patients were of 16 and 44 years respectively. Out of 26 patients 20 (76.9%) were male and 6 (23.1%) were female. There is male predominance and Male-female ratio was 3.3:1. Out of 26 patients 12 (46.2%) were glass factory worker. Other patients were housewife (23.1%), driver (5.4%), service holder (7.7%) and student (7.7%). Out of 26 patients 20 (76.9%) had right sided injury and 6 (23.1 %) had left sided injury. Right sided injury is more common than left sided injury. 18 (69.2%) patients had glass cut injury, 6 (23.1%) had knife cut injury and 2 (7.7%) had road traffic accident.
| Patient characteristics | |
|---|---|
| Sex | |
| Male | 20 (76.9%) |
| Female | 6 (23.1%) |
| Age (years) | 29.30±9.1 |
| Occupation | |
| Driver | 4 (15.4%) |
| Service holder | 2 (7.7%) |
| Student | 2 (7.7%) |
| Housewife | 6 (23.1%) |
| Glass factory worker | 12 (46.2%) |
| Mechanism of injury | |
| Glass cut injury | 18 (69.2%) |
| Knife cut injury | 6 (23.15) |
| Road traffic injury | 2 (7.7%) |
| Side of injury | |
| Right | 20 (76.9%) |
| Left | 6 (23.1%) |
Table 2. Demographic characteristics of study population (n=26).
Among the study population, 5 (19.2%) patients were operated within 24 hours of injury, 15 (57.7%) were operated within 1 month and 6 (23.1%) were operated after 1 month (Figure 2).
Figure 2: Distribution of the study population (N=26) according to duration of injury.
Out of 26 patients 19 (73.1 %) patients had associated nerve injury. 10 (38.5%) had both median and ulnar nerve injury and 9 (34.6%) had only ulnar nerve injury (Figure 3). 5 (19.2%) patients had associated vascular injury (Figure 4).
Figure 3: Distribution of the study population (N=26) according to associated nerve injury.
Figure 4: Distribution of the study population (N=26) according to associated vascular injury.
Among the study population, 4 (15.4%) had post-operative complications. 2 (7.7%) patients developed superficial surgical site infection, which was managed by antibiotic and regular dressing. 1 (3.8%) had fixed flexion deformity and 1 (3.8%) had extension lag (Table 3).
| Complications | Frequency | Percentage (%) |
|---|---|---|
| Fixed flexion deformity | 1 | 3.8 |
| Extension lag | 1 | 3.8 |
| Wound infection | 2 | 7.7 |
| No | 22 | 84.6 |
| Total | 26 | 100 |
Table 3. Distribution of the study population (N=26) according to complication.
Table 4 demonstrates that, tendon function was excellent in 10 (38.5%) patients and good in 12 (46.2%) patients. Opposition excellent in 7 (26.9%) patients and good in 13 (50%) patients. Intrinsic function excellent in 8 (30.8%) and good in 14 (53.8%) patients. Deformities excellent in 12 (46.2%) and good in 14 (53.8%) patients. Sensation was excellent in 8 (30.8%) patients and good in 14 (53.8%) patients. Grip strength excellent in 8 (30.8%) patients and good in 12 (46.2%) patients. According to Louisville system at final follow up excellent result was found in 8 (30.8%) patients, good in 14(53.8%), fair in 2 (7.7%) and poor in 2 (7.7%) patients (Figure 5) [8].
Figure 5: Distribution of the study population (N=26) according to Louisville system.
| Functional Outcome | Tendon function | Opposition | Intrinsic function | Deformities | Sensation | Grip strength |
|---|---|---|---|---|---|---|
| Excellent | 10(38.5%) | 7(26.9%) | 8(30.8%) | 12(46.2%) | 8(30.8%) | 8(30.8%) |
| Good | 12(46.2%) | 13(50%) | 14(53.8%) | 14(53.8%) | 14(53.8%) | 12(46.2%) |
| Fair | 2(7.7%) | 4(15.4%) | 2(7.7%) | - | 2(7.7%) | 4(15.4%) |
| Poor | 2(7.7%) | 2(7.7%) | 2(7.7%) | - | 2(7.7%) | 2(7.7%) |
Table 4. Overall functional outcome evaluation based on tendon function, opposition, intrinsic function, deformity, sensation and grip strength.
At final follow-up satisfactory (Excellent+Good) outcome was found in 22 (84.6%) patients and unsatisfactory (Fair +Poor) outcome was found in 4 (15.4%) patients (Figure 6). Early operation has better functional outcome as there is less adhesion and better delineation of the injured structures (Table 5). Figure 7 shows the post-operative 12 weeks recovery stage of the hand function.
Figure 6: Distribution of the study population (N=26) according to final functional outcome.
Figure 7: Images of the same patient at 12 weeks post-operative follow-up showing hand function.
| Duration of injury | Excellent | Good | Fair | Poor | Total |
|---|---|---|---|---|---|
| Within 24 hrs | 3 | 2 | 0 | 0 | 5 |
| 24 hrs to 1 month | 5 | 10 | 0 | 0 | 15 |
| 1 month to 6 months | 0 | 2 | 2 | 2 | 6 |
| Total | 8 | 14 | 2 | 2 | 26 |
Table 5. Correlation between duration of injury and functional outcome.
In the present study, mean age of the study population was 29.30 ± 9.1 years. Most of the patients (42.3%) belong to 16-25 years age group. Mean number of structures injured 8.62 ± 1.65 (6-12). The youngest and the oldest patients were of 16 and 44 years respectively. Out of 26 patients 20 (76.9%) were male and 6 (23.1%) were female. There is male predominance and Male-female ratio was 3.3:1. Occupational distribution shows, 12 (46.2%) were Thai glass worker. Other patients were housewife (23.1%), driver (15.4%), service holder (7.7%) and student (7.7%). Boynuyogun et al. found mean age of the study population was 32.7 years (range, 18–47 years) [4]. Mean follow-up was 21.9 months (range, 12–50 months). Mean number of injured structures was 11.9 (range, 10–16 structures) per patient. It is comparable to our study. Stefanou et al. conducted a retrospective study where 61 patients (49 males and 12 females with average age of 34.7 years) treated for spaghetti wrist lacerations were followed up for 2 years [3]. An average of 8.86 structures was injured per patient, including 6.83 tendons, 1.24 nerves, and 0.79 arteries. The majority of the patients (28/61) had ≥ 10 structures injured (45.9 %). It is similar to our study. Spaghetti wrist injury is common among male glass worker in active age group [2,4,6].
Out of 26 patients 20 (76.9%) had right sided injury and 6 (23.1%) had left sided injury. Right sided injury is more common than left sided injury. 18 (69.2%) patients had glass cut injury, 6 (23.1%) had knife cut injury and 2 (7.7%) had road traffic accident. Yazdanshenas et al. found that, the most common cause of injury was glass window panes and bottles. Similar result was found by Stefanou et al. and Boynuyogun et al. [3,4,6].
Out of 26 patients 19 (73.1%) patients had associated nerve injury. 10 (38.5%) had both median and ulnar nerve injury and 9 (34.6%) had only ulnar nerve injury. 5 (19.2%) patients had associated ulnar artery injury. Among the study population, 5 (19.2%) patients were operated within 24 hours of injury, 15 (57.7%) were operated within 1 month and 6 (23.1%) were operated after 1 month. Stefanou et al. in their study found that, an average of 8.86 structures were injured per patient, including 6.83 tendons, 1.24 nerves, and 0.79 arteries. Hassan found an average of 9.16 structures was injured, including 6.95 tendons, 1.4 nerves, and 0.8 arteries. Yazdanshenas et al. in their study found that, the tendon functionality in 120 (78%), opposition in 115 (75.1%), and intrinsic function in 62 (40.5%) were “excellent.” Hand sensation was “fair” in 75 patients (49.1%), “good” in 46 patients (30%), and “excellent” in 28 patients (18.3%). The average return time to activities of daily living was 10 months [6,7].
Jaquet et al. in their study found that the mean Functional Symptom Score was 15.1 (SD, 16.1; range, 0 to 74) after a mean follow-up of 10.0 years (SD, 4.4; range, 2 to 18). Mean time off work was 34.7 weeks (SD, 17.9; range, 4 to 52), and 45.2 percent of the patients could not return to work within 1 year after the injury. Compared with the unaffected hand, grip and tip pinch strength were decreased with means of 23.5 percent (SD, 22.4; range, 0 to 93) and 33.9 percent (SD, 23.7; range 0 to 83), respectively. Regarding sensory recovery, 12 patients (27.9 percent) had no protective sensation [2].
Among the study population, 4(15.4%) had post-operative complications. 2 (7.7%) patients developed superficial surgical site infection, which was managed by antibiotic and regular dressing. 1 (3.8%) had fixed flexion deformity and 1 (3.8%) had extension lag. At final follow up, tendon function was excellent in 10 (38.5%) patients and good in 12 (46.2%) patients. Opposition excellent in 7 (26.9%) patients and good in 13 (50%) patients. Intrinsic function excellent in 8 (30.8%) and good in 14 (53.8%) patients. Deformities excellent in 12 (46.2%) and good in 14 (53.8%) patients. Sensation excellent in 8 (30.8%) patients and good in 14 (53.8%) patients. Grip strength was excellent in 8 (30.8%) patients and good in 12 (46.2%) patients. Yazdanshenas et al. in their study found the tendon functionality in 120 (78%), opposition in 115 (75.1%), and intrinsic function in 62 (40.5%) were “excellent.” Hand sensation was “fair” in 75 patients (49.1%), “good” in 46 patients (30%), and “excellent” in 28 patients (18.3%). The average return time to activities of daily living was 10 months. Comparable result also found in other study [3,6]. According to Louisville system [8] at final follow up excellent result was found in 8 (30.8%) patients, good in 14 (53.8%), fair in 2 (7.7%) and poor in 2 (7.7%) patients. Satisfactory (Excellent+Good) outcome was found in 22 (84.6%) patients and unsatisfactory (Fair+Poor) outcome was found in 4 (15.4%) patients. It is comparable to other studies [3-5]. Early operation has better functional outcome as there is less adhesion and better delineation of the injured structures.
Spaghetti wrist injuries are a complex and severe soft tissue injury of the palmar aspect of the wrist that involve simultaneous damage to nerves, tendons and vessels frequently lead to a dysfunctional hand. But early primary repair and good rehabilitation during the postoperative period can lead to a successful outcome.
Nill.
There are no conflicts of interest.