• nerve grafts - kids - good sensation, sometimes motor
• running the nerve
• combined nerve - do to both median and ulnar nerve
• extensor only to MCPJ

• one or more flaps?
• 3 flaps for thumb at base
  • ALT → fibula with spacer for CMCJ (floating) → toe
• simultaneous flap
  • alternatives to ALT – RFF flap
  • multiple E2S used along radial artery
• Radius bone defect
  • mutliple lattissimus plus fibula for radius
• alternatives to fibula for length - 2nd toe / 2nd MC and big toe

• TMR - neural signals still exists → myoelectric
• TMR nerve transfers
  • pain - neuroma better 58% to 4% - Souza CORR 2014
  • 23/26 patients (89%) able to wear prosthesis throughout the day
  • phantom limb pain is better - annals of surgery

• median to ain
• ulnar to fcu
• dsrbn to fds

• pain control
• first 2-3 weeks
• ue and LE
• can't have proximal nerve injury

* basic hand function can be achieved – we are only competing with prosthesis and transplantation

• 'basic' hand - thumb and post

• radical deb
• emergency micro
• ? later surgery

• skill levels
• time – multi-staged procedures
• resources
  1. → if one component is not available –> no more

• What is 'no more' in one centre, can become 'yes we can' in another center

• yes to no conditions
  • infection
    • reduced quality of outcome
    • increases cost
    • increases time frame of treatment

• all components but say no
• life at risk or more morbidity – major replant sick at 5 days (SpO2 100) – muscle necrosis –> amputate
• - polytrauma – “triage”

• e micro
• secondary procedures

• low threshold for seeking help