British
Journal
of Plastic
Surgery
MULTIPLE
(1975),
28, S-9
DIGITAL
REPLANTATION.
A CASE REPORT
By J. E. BOWEN,F.R.C.S., and M. D. POOLE,F.R.C.S., F.R.A.C.S. Queen Victoria Hospital, Holtye Road, East Grinstead, Sussex RHI~ 3DZ RECENTLYin the literature several papers have advocated replantation of amputated extremities (American Replantation Mission to China, 1973; O’Brien et al., 1973). The following case report illustrates the technical feasibility of replanting not only one digit but three. A 53-year-old female machine operator was referred with a complete, clean guillotine amputation of her right index, middle and ring fingers, through the base of the proximal phalanges (Fig. I), The detached fingers were still joined to each other by some web skin and subcutaneous tissue. There was also a slicing injury of the radial side of the little fingertip. The patient arrived 32 hours after injury and the fingers had not been cooled prior to arrival. Tetanus toxoid was given, blood cross-matched and operation begun 5$ hours after injury, under general anaesthesia.
FIG. I. FIG. 2.
The amputation
The hand after replantation FIG. 3.
Functional 8
stump. of the 3 fingers.
result.
MULTIPLE
DIGITAL
REPLANTATION
9
Debridement of the stump and fingers was carried out under tourniquet with some bone shortening, and all digital nerves and arteries, tendons and some dorsal veins Bony fixation was achieved with longitudinal Kirschner wires; then the identified. extensor tendons were repaired with wire sutures. Three dorsal veins, one for each finger, were anastomosed using standard microvascular techniques and the dorsal skin closed. The 3 most suitable digital arteries, one per finger, were then anastomosed and following some initial spasm in the vessels on releasing the clamps, each finger became pink. The sublimis tendons had previously been excised and the profundus tendons, previously marked, were repaired by a single Bunnell silk suture each. The digital nerve on the radial side of the index finger was repaired but the other nerves were marked and left owing to the operating time of 6+ hours and the volar skin closed. A hypothenar split skin graft covered the little finger defect. A loose absorptive dressing was applied and the hand elevated. During and immediately following operation 2 units of blood and low molecular 2 tablets twice daily weight Dextran were given. Trimethoprim-sulphamethoxazole were begun (the patient had penicillin allergy) and aspirin 500 mg 4 hourly begun as initial anticoagulation. The following day the fingers were a good colour and the patient was heparinised, using a constant drip monitored by thrombin times. The only post-operative complication was the unusual one of a deep abdominal wall haematoma which appeared on the 5th day post-operatively after sneezing. This required blood transfusion and lowering the heparin dose. The antibiotics were ceased on the 9th day and the heparin on the 10th day and the patient went home. The Kirschner wires were removed at 5 weeks. When seen 3 months after injury there was a 40” range of active movement at the metacarpophalangeal joint from full extension. There was sensation to pin prick and paraesthesia up to the level of the distal interphalangeal joint on the radial side of the index finger and on both sides of the ring finger. The cosmetic result was good (Fig. 2) and the patient was beginning to use the hand (Fig. 3). SUMMARY
A case of simultaneous
replantation
of 3 fingers is described.
REFERENCES Replantation 1973.
surgery in China. Report of the American Replantation Mission to China, Plastic and Reconstructive Surgery, 52, 476-490. O’BRIEN, B. M., MACLEOD, A. M., MILLER, G. D. H., NEWING, R. R., HAYHURST, J. W. and MORRISON, W. A. (1973). Clinical replantation of digits. Plastic axd Reconstructizv SW:?_\‘, 5% 49Q-503.
Journal
of Plastic
Surgery
MULTIPLE
(1975),
28, S-9
DIGITAL
REPLANTATION.
A CASE REPORT
By J. E. BOWEN,F.R.C.S., and M. D. POOLE,F.R.C.S., F.R.A.C.S. Queen Victoria Hospital, Holtye Road, East Grinstead, Sussex RHI~ 3DZ RECENTLYin the literature several papers have advocated replantation of amputated extremities (American Replantation Mission to China, 1973; O’Brien et al., 1973). The following case report illustrates the technical feasibility of replanting not only one digit but three. A 53-year-old female machine operator was referred with a complete, clean guillotine amputation of her right index, middle and ring fingers, through the base of the proximal phalanges (Fig. I), The detached fingers were still joined to each other by some web skin and subcutaneous tissue. There was also a slicing injury of the radial side of the little fingertip. The patient arrived 32 hours after injury and the fingers had not been cooled prior to arrival. Tetanus toxoid was given, blood cross-matched and operation begun 5$ hours after injury, under general anaesthesia.
FIG. I. FIG. 2.
The amputation
The hand after replantation FIG. 3.
Functional 8
stump. of the 3 fingers.
result.
MULTIPLE
DIGITAL
REPLANTATION
9
Debridement of the stump and fingers was carried out under tourniquet with some bone shortening, and all digital nerves and arteries, tendons and some dorsal veins Bony fixation was achieved with longitudinal Kirschner wires; then the identified. extensor tendons were repaired with wire sutures. Three dorsal veins, one for each finger, were anastomosed using standard microvascular techniques and the dorsal skin closed. The 3 most suitable digital arteries, one per finger, were then anastomosed and following some initial spasm in the vessels on releasing the clamps, each finger became pink. The sublimis tendons had previously been excised and the profundus tendons, previously marked, were repaired by a single Bunnell silk suture each. The digital nerve on the radial side of the index finger was repaired but the other nerves were marked and left owing to the operating time of 6+ hours and the volar skin closed. A hypothenar split skin graft covered the little finger defect. A loose absorptive dressing was applied and the hand elevated. During and immediately following operation 2 units of blood and low molecular 2 tablets twice daily weight Dextran were given. Trimethoprim-sulphamethoxazole were begun (the patient had penicillin allergy) and aspirin 500 mg 4 hourly begun as initial anticoagulation. The following day the fingers were a good colour and the patient was heparinised, using a constant drip monitored by thrombin times. The only post-operative complication was the unusual one of a deep abdominal wall haematoma which appeared on the 5th day post-operatively after sneezing. This required blood transfusion and lowering the heparin dose. The antibiotics were ceased on the 9th day and the heparin on the 10th day and the patient went home. The Kirschner wires were removed at 5 weeks. When seen 3 months after injury there was a 40” range of active movement at the metacarpophalangeal joint from full extension. There was sensation to pin prick and paraesthesia up to the level of the distal interphalangeal joint on the radial side of the index finger and on both sides of the ring finger. The cosmetic result was good (Fig. 2) and the patient was beginning to use the hand (Fig. 3). SUMMARY
A case of simultaneous
replantation
of 3 fingers is described.
REFERENCES Replantation 1973.
surgery in China. Report of the American Replantation Mission to China, Plastic and Reconstructive Surgery, 52, 476-490. O’BRIEN, B. M., MACLEOD, A. M., MILLER, G. D. H., NEWING, R. R., HAYHURST, J. W. and MORRISON, W. A. (1973). Clinical replantation of digits. Plastic axd Reconstructizv SW:?_\‘, 5% 49Q-503.
