MICROSURGERY 11:255-260
1990
MARY LYNN BROWN, M.D. and MICHAEL B. WOOD, M.D.
U p p e r extremity replantation surgery becomes increasingly successful as newer, more sophisticated methods of repairing bone, vessels, nerves, tendons, and skin become available. Success is not measured merely in terms of survival of the replanted part, but by functional recovery and patient satisfaction. The sequence of repair is ultimately determined by the anatomic level and particular clinical situation. Circulation needs to be restored in an expedient manner and may be dependent on bony stability. Therefore, with few exceptions, skeletal stabilization is the cornerstone from which the remainder of the replantation is based. There are a variety of options available to achieve osteosynthesis and bony stabilization in the course of upper extremity replantation. One must balance the merits of rigid and precise bone coaptation' relative to those of minimizing operative time prior to tissue revascularization. On the one extreme rigid internal fixation provides a high level of security for early secondary operative intervention or dressing changes, may facilitate early formation of intramedullary venous channels,2 and allows joint range of motion as soon as healing of associated soft tissue injuries will permit. However, this technique also requires more extensive tissue dissection and bone exposure as well as valuable time. On the other extreme, rapid, expedient bone fixation may be preferable in order to decrease ischemic time and surgical team fatigue in those instances when early joint mobilization is not critically required and when early secondary surgical intervention is not expected.
be used in conjunction with Kirschner wire techniques (Fig. 1). A similar option is tension band wiring with or without the use of Kirschner wires. Tension band wiring is most useful for bone fixation in regions where a predictable, consistent compressive load is present on one side of the fracture site. The tension band wire (or plate) must be placed in a position to resist this consistent deforming force. It is most applicable across the wrist (dorsum) or elbow (olecranon). It is less useful in the finger where loads across the fracture site do not necessarily favor either flexion or extension. Direct interfragmentary compression is useful in long oblique fractures. This technique may employ cancellous or cortical screws by the use of the lag screw principle with overdrilling of the near fracture fragment: or with malleolar or Herbert-type screws without overdrilling. As the site of replantation moves more proximally, more aggressive techniques of rigid internal fixation are preferable. Options include the addition of plates in conjunction with lag screws and plates with the use of compression principles (Fig. 2 ) . Intramedullary devices such as Rush rods and nails can be used in the proximal arm or forearm. External fixators can provide stability in cases where the aforementioned techniques are insufficient or impossible secondary to significant bone loss. However, they may be obstructive to easy wound access during the operative procedure or during the early post-replantation period.
TYPES OF FIXATION
Prior to consideration of the most efficacious fixation for various replantation levels, initial management includes irrigation and meticulous debridement of the devitalized tissues proximally and distally. Debridement is followed by identification and labelling of all structures to facilitate later soft tissue repair. In almost all cases bone resection must be performed in order to minimize tension for later nerve, vessel, tendon, and skin r e c o n s t r u ~ t i o n . ~The ' ~ ~ amount '~ resected depends on the level of the amputation. For digits, 5 to 10 mm of bone is appropriate." At the transmetacarpal level a minimum resection of 15 mm is suggested (Fig. 3). Shortening of the metacarpal 7 mm or less is reported to result in intrinsic plus deformity secondary to contracture of the intrinsic muscle^.^.' At the proximal hand and wrist level 2 to 3 cm may be resected." Amputation at the level of the wrist can be managed by carpectomy of one or both carpal rows with or without arthrodesis.
The most widely used fixation device in replantation surgery is the Kirschner wire. Problems with Kirschner wires include a lack of rigid fixation and control of rotation if used singly," problems with accurate bone coaptation, and possible transfixation of soft tissue^.^ Circlage wiring with either single or double parallel or perpendicular configuration reduces the incidence of these problems and can
From the Section of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic/Mayo Foundation, Rochester, MN. Acknowledgments: The authors thank Diana Kohrt for preparing the manuscript. Address reprint requests to Michael B. Wood, M.D., Professor of Orthopedic Surgery, Consultant, at the Section of Hand Surgery, Department of Orthopedic Surgery, Mayo CliniciMayo Foundation, 200 First Street SW, Rochester, MN 55905. 0 1990 Wiley-Liss, Inc.
BONE SHORTENING
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Brown and Wood
Fig. 1. Radiograph of bony fixation circlage wire.
Fig. 3. Radiograph demonstrating extent of bony shortening of metacarpal-level replantation.
Fig. 2. Photograph demonstrating compression plate and screw fixation of transhumeral level limb replantation.
Extensive skeletal shortening of as much as 8 or more cm is recommended in the forearm and upper arm. Proximal-level major limb amputations are usually associated with violent injuries which produce considerable regional bone and soft tissue injury which mandate aggressive debridement.’? Shortening is usually carried out in the amputated segment unless it compromises the integrity of a functionally important joint or makes internal fixation difficult. When amputation occurs by disarticulation at the distal interphalangeal or proximal interphalangeal joint level, treatment depends on the condition of the articular surfaces.
If uninjured, joint preservation should be considered with temporary internal fixation and repair or reconstruction of joint capsule and ligaments’.” (Fig. 4A,B). In such cases skeletal shortening is not possible and hence vein grafts may be necessary for vascular repair. In most cases, however, reconstruction is impossible and primary arthrodesis with skeletal shortening is performed‘ (Fig. 5A,B). At the metacarpophalangeal joint level a resection arthroplasty may be attempted by metacarpal head resection. Implant arthroplasty is also an option at this level.9 Primary arthrodesis is generally contraindicated in a single-finger amputation at the metacarpophalangeal joint level because the loss of motion at this level may impair function of the uninjured joint^.^ METHOD OF OSTEOSYNTHESIS
The selection of the specific technique of bone internal fixation will vary with the anatomic level of replantation and the complexity of the injury. The latter consideration includes the number of digits amputated, the extent of soft tissue loss, accompanying articular damage, and other factors. Osteosnythesis should be performed expediently and in a consistent manner with consideration of intraoperative and postoperative management.
Bone Fixation Techniques in Replantation Surgery
257
Fig. 4. A: Radiograph demonstratingtranselbow level amputation in a 30 year-old woman. B: Radiograph demonstrating replantation with elbow re-articulation and reconstruction of collateral ligaments. Note temporary transarticular fixation and tension band fixation of olecranon fragment.
Phalangeal Level
Fig. 5. A: Radiograph demonstrating thumb amputation through interphalangealjoint. B: Radiograph 4 months post-replantationwith primary interphalangealjoint arthrodesis.
In general, single-finger amputations at the phalangeal level present a straightforward problem that is not especially technically challenging. Therefore, a more time-consuming method of stable internal fixation is warranted. Most often a combination of Kirschner wires and double perpendicular circlage wires is recommended. This technique provides rigid fixation, secures rotation, and provides excellent bone apposition allowing early motion. We recommend the use of one or two ,045 inch Kirschner wires and two wire loops placed 90" to each other of # 1 steel. An 18 gauge hypodermic needle is a readily available guide for placement of these wires. At times a single intraosseous circlage wire will be preferred if the extent of available bone exposure does not avail itself to placement of two wire loops in perpendicular planes (Fig. 6). Some authors have recommended intraniedullary screw fixation. We have rarely encountered patients, however, where sufficient bone stock was present on either side to permit this method. Occasionally a small compression screw may be utilized for phalangeal-level replantation with a long Oblique phalangeal fracture level. Amputations involving multiple fingers are time-con-
258
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suming, tedious replantation procedures mandating expediency more than fastidious stable internal fixation. In such cases we recommend the use of two .045 inch Kirschncr wires with care to fix the replanted digit in the proper position relative to angulation and rotation8 (Fig. 7A,B). In general, the use of compression-plate fixation for phalangeal level replantation is contraindicated. It requires considerable dissection as well as an unavoidable delay to restore tissue vascularity.
Transmetacarpal Level
At the transmetacarpal level Kirschner wires with or without circlage wiring constitute the usual treatment of choice (Fig. 8A,B). The exception is the first metacarpal where plate fixation may be equally expedient. I I When multiple rays are affected, attention to equal shortening between rays and correct rotatory alignment is more important than the type of osteosynthesis.
Wrist Level Fig. 6. Radiograph demonstrating bony fixation by Kirschner wire and circlage wire.
When the level of amputation will Permit Proximal-row carpectomy, temporary fixation with two .Oh4 inch Kirsch-
Fig. 7. A: Radiograph demonstrating bony fixation by Kirschner wires only in a patient with multiple digit replantation. B: Radiograph demonstrating bony union in patient with multiple-digit replantation with Kirschner wire bony fixation.
Bone Fixation Techniques in Replantation Surgery
259
fig. 8. A: Radiograph demonstrating Kirschner wire fixation in a patient with multiple ray transmetacarpal-level replantation. B: Radiograph demonstrating union in patient represented by A.
ner wires is appropriate. However, in many instances primary wrist fusion with total carpectomy or with excision of the distal radius and/or ulna is required. In such cases a combination of two ,064 inch Kirschner wires and a dorsal tension band wire (22 gauge) is advisable (Fig. 9). A local dorsal sliding bone graft over the fusion mass but under the tension band wire will increase the likelihood of primary fusion. l4
Forearm Level
Fig. 9. Radiograph demonstrating wrist arthrodesis by using tension band wiring and Kirschner wires following wrist-level replantation.
In the distal forearm, bone stabilization is usually best achieved in a similar fashion to forearm fractures with plates and screws. Plate fixation does require additional soft-tissue dissection, but it provides rigid internal fixation and osteosynthesis. We recommend the use of smallfragment DCP (ASIF) plates with purchase by three screws or more on either side of the fracture site. By contrast, Urbaniak" suggests using Rush pins in the forearm and arm to reduce ischemic time, supplementing the fixation with a wire mattress suture in the bone to reduce sliding. We have no experience with this technique, but believe it is less likely to proceed to uncomplicated primary bone union. In the distal forearm external fixators may be used. They are, however, somewhat awkward and at times make wound access for vessel, nerve, and tendon repair difficult.
260
Brown and Wood
non Steinmann pin throughout the postoperative period (Fig. 10A,B). This detail facilitates wound and soft-tissue defect management, minimizes postoperative edema, and aids in nursing care.I3 CONCLUSIONS
Stabilization of the upper extremity is an integral part of and usually is the initial step to a successful operative outcome. The ideal means of osteosynthesis will balance goals of stable fixation in a predictable position with those of surgical efficiency and speed. The ideal technique will vary with the specific injury, the number of digits amputated, the extent of associated injuries, and the anticipated postoperative management course.
REFERENCES I . Chapman MW, Woo SL: Principles of fracture, in Chapman MW (ed): Healing in Operutivc Orthopucdics. Philadelphia, J.B. Lippincott co.. 1988. pp 1 IS-129. 2. Lemperg KD, Arnoldi CC: Intramedullary blood flow through arthrodesis-trcatcd joints: An experimental study in rabbits. An,qio/ogT
21:368,1970.
Fig. 70. A: Radiograph demonstrating amputation at level of upper arm with concomitant radius fracture. B: Radiograph demonstrating bony fixation after replantation and plating with olecranon traction pin
for limb elevation. Elbow Level and Proximal Transelbow injuries are not amenable to compression plate fixation and require transarticular Steinmann pins or Rush rods in combination with ligament repair or reconstruction. Triceps re-insertion to the olecranon is best accomplished by the use of a 20 or 22 gauge tension band wire and one or two Steinmann pins (Fig. 4A,B). Above the elbow strong and rigid internal fixation is a major goal. Depending on the level of amputation and the need for wound access, either plates or a Rush pin may be utilized. Ideally this is achieved by standard-sized DCP (ASlF) plates with at least three screws on either side of the fracture site. Thc fixation must be sufficiently strong so that overhead traction and elevation are possible through an olecra-
3. Lister G: lntraosseous wiring of the digital skeleton. J Hcind S u q 3(5):427, 1978. 4. Mevli HC, Meyer V, Segniuller G: Stabilization of bone in replantstion surgery of the upper limb. Clin Orthop 133:179, 1978. 5 . Meyer VE. Madlard G . Maass D, Azzoni Z : Successful replantation of a hand amputated through the metacarpus. J Bone Joint Surg 5 8 : 471. 1976. 6. Meyer VE. Zwong-Wei C. Beasley RW: Basic technical considerations in reattachment surgery. Orthop C l h North Am 1237I. I9X I . 7. Meyer VE: Upper Exrremitv Repluntution: Btlsic Principles. Sur.qicul Techiiiyue. nndStrategy. New York. Churchill Livingstone, 1985. pp 47-61. 8. Sixth People‘s Hospital, Shanghai: Replantation of severed fingers. clinical experiences in 217 cases involving 373 severed fingers. Chit1 Med J [En,y] I : 184. 1975. 9. Swanson AB: Flc~rihleImplunt Resection Arthroplust?. in the Hcirid ctnd Extremitirs. St. Louis, C.V. Mosby Co., 1973. 10. Urbaniak JR, Hayes MG, Bright DS: Management of bone in digital replantation: Free vascularized and composite bone grafts. Clin Orthop 133:184, 1978. 1 1 . Urbaniak JK: Digital replantation: A twelve year experience. in Mic’rosicrgery f b r Mujor Limb Rcm)nstruction. St. Is)uis. C.V. Mosby Co.. 1987, pp 12-21. 12. Weiland AJ. Villarreal-Rios A, Kleinert HE. Kutz J . Atasoy E, Lister G : Replantation of digits and hands: analysis of surgical techniques and functional results in 71 patients with 86 replantations. J H m t l Sur,y 2:l. 1977. 13. Wood MB: Replantation about the elbow. in Morrey BF (ed): The, Elborv und I r s Disorders. Philadelphia. W.C. Saunders Company. 1985, Ch 27. pp 272-280. 14. Wood MB: Wrist arthrodesis using dorsal radial bone graft. J Hurlrl Surg 12:208, 1987.
1990
MARY LYNN BROWN, M.D. and MICHAEL B. WOOD, M.D.
U p p e r extremity replantation surgery becomes increasingly successful as newer, more sophisticated methods of repairing bone, vessels, nerves, tendons, and skin become available. Success is not measured merely in terms of survival of the replanted part, but by functional recovery and patient satisfaction. The sequence of repair is ultimately determined by the anatomic level and particular clinical situation. Circulation needs to be restored in an expedient manner and may be dependent on bony stability. Therefore, with few exceptions, skeletal stabilization is the cornerstone from which the remainder of the replantation is based. There are a variety of options available to achieve osteosynthesis and bony stabilization in the course of upper extremity replantation. One must balance the merits of rigid and precise bone coaptation' relative to those of minimizing operative time prior to tissue revascularization. On the one extreme rigid internal fixation provides a high level of security for early secondary operative intervention or dressing changes, may facilitate early formation of intramedullary venous channels,2 and allows joint range of motion as soon as healing of associated soft tissue injuries will permit. However, this technique also requires more extensive tissue dissection and bone exposure as well as valuable time. On the other extreme, rapid, expedient bone fixation may be preferable in order to decrease ischemic time and surgical team fatigue in those instances when early joint mobilization is not critically required and when early secondary surgical intervention is not expected.
be used in conjunction with Kirschner wire techniques (Fig. 1). A similar option is tension band wiring with or without the use of Kirschner wires. Tension band wiring is most useful for bone fixation in regions where a predictable, consistent compressive load is present on one side of the fracture site. The tension band wire (or plate) must be placed in a position to resist this consistent deforming force. It is most applicable across the wrist (dorsum) or elbow (olecranon). It is less useful in the finger where loads across the fracture site do not necessarily favor either flexion or extension. Direct interfragmentary compression is useful in long oblique fractures. This technique may employ cancellous or cortical screws by the use of the lag screw principle with overdrilling of the near fracture fragment: or with malleolar or Herbert-type screws without overdrilling. As the site of replantation moves more proximally, more aggressive techniques of rigid internal fixation are preferable. Options include the addition of plates in conjunction with lag screws and plates with the use of compression principles (Fig. 2 ) . Intramedullary devices such as Rush rods and nails can be used in the proximal arm or forearm. External fixators can provide stability in cases where the aforementioned techniques are insufficient or impossible secondary to significant bone loss. However, they may be obstructive to easy wound access during the operative procedure or during the early post-replantation period.
TYPES OF FIXATION
Prior to consideration of the most efficacious fixation for various replantation levels, initial management includes irrigation and meticulous debridement of the devitalized tissues proximally and distally. Debridement is followed by identification and labelling of all structures to facilitate later soft tissue repair. In almost all cases bone resection must be performed in order to minimize tension for later nerve, vessel, tendon, and skin r e c o n s t r u ~ t i o n . ~The ' ~ ~ amount '~ resected depends on the level of the amputation. For digits, 5 to 10 mm of bone is appropriate." At the transmetacarpal level a minimum resection of 15 mm is suggested (Fig. 3). Shortening of the metacarpal 7 mm or less is reported to result in intrinsic plus deformity secondary to contracture of the intrinsic muscle^.^.' At the proximal hand and wrist level 2 to 3 cm may be resected." Amputation at the level of the wrist can be managed by carpectomy of one or both carpal rows with or without arthrodesis.
The most widely used fixation device in replantation surgery is the Kirschner wire. Problems with Kirschner wires include a lack of rigid fixation and control of rotation if used singly," problems with accurate bone coaptation, and possible transfixation of soft tissue^.^ Circlage wiring with either single or double parallel or perpendicular configuration reduces the incidence of these problems and can
From the Section of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic/Mayo Foundation, Rochester, MN. Acknowledgments: The authors thank Diana Kohrt for preparing the manuscript. Address reprint requests to Michael B. Wood, M.D., Professor of Orthopedic Surgery, Consultant, at the Section of Hand Surgery, Department of Orthopedic Surgery, Mayo CliniciMayo Foundation, 200 First Street SW, Rochester, MN 55905. 0 1990 Wiley-Liss, Inc.
BONE SHORTENING
256
Brown and Wood
Fig. 1. Radiograph of bony fixation circlage wire.
Fig. 3. Radiograph demonstrating extent of bony shortening of metacarpal-level replantation.
Fig. 2. Photograph demonstrating compression plate and screw fixation of transhumeral level limb replantation.
Extensive skeletal shortening of as much as 8 or more cm is recommended in the forearm and upper arm. Proximal-level major limb amputations are usually associated with violent injuries which produce considerable regional bone and soft tissue injury which mandate aggressive debridement.’? Shortening is usually carried out in the amputated segment unless it compromises the integrity of a functionally important joint or makes internal fixation difficult. When amputation occurs by disarticulation at the distal interphalangeal or proximal interphalangeal joint level, treatment depends on the condition of the articular surfaces.
If uninjured, joint preservation should be considered with temporary internal fixation and repair or reconstruction of joint capsule and ligaments’.” (Fig. 4A,B). In such cases skeletal shortening is not possible and hence vein grafts may be necessary for vascular repair. In most cases, however, reconstruction is impossible and primary arthrodesis with skeletal shortening is performed‘ (Fig. 5A,B). At the metacarpophalangeal joint level a resection arthroplasty may be attempted by metacarpal head resection. Implant arthroplasty is also an option at this level.9 Primary arthrodesis is generally contraindicated in a single-finger amputation at the metacarpophalangeal joint level because the loss of motion at this level may impair function of the uninjured joint^.^ METHOD OF OSTEOSYNTHESIS
The selection of the specific technique of bone internal fixation will vary with the anatomic level of replantation and the complexity of the injury. The latter consideration includes the number of digits amputated, the extent of soft tissue loss, accompanying articular damage, and other factors. Osteosnythesis should be performed expediently and in a consistent manner with consideration of intraoperative and postoperative management.
Bone Fixation Techniques in Replantation Surgery
257
Fig. 4. A: Radiograph demonstratingtranselbow level amputation in a 30 year-old woman. B: Radiograph demonstrating replantation with elbow re-articulation and reconstruction of collateral ligaments. Note temporary transarticular fixation and tension band fixation of olecranon fragment.
Phalangeal Level
Fig. 5. A: Radiograph demonstrating thumb amputation through interphalangealjoint. B: Radiograph 4 months post-replantationwith primary interphalangealjoint arthrodesis.
In general, single-finger amputations at the phalangeal level present a straightforward problem that is not especially technically challenging. Therefore, a more time-consuming method of stable internal fixation is warranted. Most often a combination of Kirschner wires and double perpendicular circlage wires is recommended. This technique provides rigid fixation, secures rotation, and provides excellent bone apposition allowing early motion. We recommend the use of one or two ,045 inch Kirschner wires and two wire loops placed 90" to each other of # 1 steel. An 18 gauge hypodermic needle is a readily available guide for placement of these wires. At times a single intraosseous circlage wire will be preferred if the extent of available bone exposure does not avail itself to placement of two wire loops in perpendicular planes (Fig. 6). Some authors have recommended intraniedullary screw fixation. We have rarely encountered patients, however, where sufficient bone stock was present on either side to permit this method. Occasionally a small compression screw may be utilized for phalangeal-level replantation with a long Oblique phalangeal fracture level. Amputations involving multiple fingers are time-con-
258
Brown and Wood
suming, tedious replantation procedures mandating expediency more than fastidious stable internal fixation. In such cases we recommend the use of two .045 inch Kirschncr wires with care to fix the replanted digit in the proper position relative to angulation and rotation8 (Fig. 7A,B). In general, the use of compression-plate fixation for phalangeal level replantation is contraindicated. It requires considerable dissection as well as an unavoidable delay to restore tissue vascularity.
Transmetacarpal Level
At the transmetacarpal level Kirschner wires with or without circlage wiring constitute the usual treatment of choice (Fig. 8A,B). The exception is the first metacarpal where plate fixation may be equally expedient. I I When multiple rays are affected, attention to equal shortening between rays and correct rotatory alignment is more important than the type of osteosynthesis.
Wrist Level Fig. 6. Radiograph demonstrating bony fixation by Kirschner wire and circlage wire.
When the level of amputation will Permit Proximal-row carpectomy, temporary fixation with two .Oh4 inch Kirsch-
Fig. 7. A: Radiograph demonstrating bony fixation by Kirschner wires only in a patient with multiple digit replantation. B: Radiograph demonstrating bony union in patient with multiple-digit replantation with Kirschner wire bony fixation.
Bone Fixation Techniques in Replantation Surgery
259
fig. 8. A: Radiograph demonstrating Kirschner wire fixation in a patient with multiple ray transmetacarpal-level replantation. B: Radiograph demonstrating union in patient represented by A.
ner wires is appropriate. However, in many instances primary wrist fusion with total carpectomy or with excision of the distal radius and/or ulna is required. In such cases a combination of two ,064 inch Kirschner wires and a dorsal tension band wire (22 gauge) is advisable (Fig. 9). A local dorsal sliding bone graft over the fusion mass but under the tension band wire will increase the likelihood of primary fusion. l4
Forearm Level
Fig. 9. Radiograph demonstrating wrist arthrodesis by using tension band wiring and Kirschner wires following wrist-level replantation.
In the distal forearm, bone stabilization is usually best achieved in a similar fashion to forearm fractures with plates and screws. Plate fixation does require additional soft-tissue dissection, but it provides rigid internal fixation and osteosynthesis. We recommend the use of smallfragment DCP (ASIF) plates with purchase by three screws or more on either side of the fracture site. By contrast, Urbaniak" suggests using Rush pins in the forearm and arm to reduce ischemic time, supplementing the fixation with a wire mattress suture in the bone to reduce sliding. We have no experience with this technique, but believe it is less likely to proceed to uncomplicated primary bone union. In the distal forearm external fixators may be used. They are, however, somewhat awkward and at times make wound access for vessel, nerve, and tendon repair difficult.
260
Brown and Wood
non Steinmann pin throughout the postoperative period (Fig. 10A,B). This detail facilitates wound and soft-tissue defect management, minimizes postoperative edema, and aids in nursing care.I3 CONCLUSIONS
Stabilization of the upper extremity is an integral part of and usually is the initial step to a successful operative outcome. The ideal means of osteosynthesis will balance goals of stable fixation in a predictable position with those of surgical efficiency and speed. The ideal technique will vary with the specific injury, the number of digits amputated, the extent of associated injuries, and the anticipated postoperative management course.
REFERENCES I . Chapman MW, Woo SL: Principles of fracture, in Chapman MW (ed): Healing in Operutivc Orthopucdics. Philadelphia, J.B. Lippincott co.. 1988. pp 1 IS-129. 2. Lemperg KD, Arnoldi CC: Intramedullary blood flow through arthrodesis-trcatcd joints: An experimental study in rabbits. An,qio/ogT
21:368,1970.
Fig. 70. A: Radiograph demonstrating amputation at level of upper arm with concomitant radius fracture. B: Radiograph demonstrating bony fixation after replantation and plating with olecranon traction pin
for limb elevation. Elbow Level and Proximal Transelbow injuries are not amenable to compression plate fixation and require transarticular Steinmann pins or Rush rods in combination with ligament repair or reconstruction. Triceps re-insertion to the olecranon is best accomplished by the use of a 20 or 22 gauge tension band wire and one or two Steinmann pins (Fig. 4A,B). Above the elbow strong and rigid internal fixation is a major goal. Depending on the level of amputation and the need for wound access, either plates or a Rush pin may be utilized. Ideally this is achieved by standard-sized DCP (ASlF) plates with at least three screws on either side of the fracture site. Thc fixation must be sufficiently strong so that overhead traction and elevation are possible through an olecra-
3. Lister G: lntraosseous wiring of the digital skeleton. J Hcind S u q 3(5):427, 1978. 4. Mevli HC, Meyer V, Segniuller G: Stabilization of bone in replantstion surgery of the upper limb. Clin Orthop 133:179, 1978. 5 . Meyer VE. Madlard G . Maass D, Azzoni Z : Successful replantation of a hand amputated through the metacarpus. J Bone Joint Surg 5 8 : 471. 1976. 6. Meyer VE. Zwong-Wei C. Beasley RW: Basic technical considerations in reattachment surgery. Orthop C l h North Am 1237I. I9X I . 7. Meyer VE: Upper Exrremitv Repluntution: Btlsic Principles. Sur.qicul Techiiiyue. nndStrategy. New York. Churchill Livingstone, 1985. pp 47-61. 8. Sixth People‘s Hospital, Shanghai: Replantation of severed fingers. clinical experiences in 217 cases involving 373 severed fingers. Chit1 Med J [En,y] I : 184. 1975. 9. Swanson AB: Flc~rihleImplunt Resection Arthroplust?. in the Hcirid ctnd Extremitirs. St. Louis, C.V. Mosby Co., 1973. 10. Urbaniak JR, Hayes MG, Bright DS: Management of bone in digital replantation: Free vascularized and composite bone grafts. Clin Orthop 133:184, 1978. 1 1 . Urbaniak JK: Digital replantation: A twelve year experience. in Mic’rosicrgery f b r Mujor Limb Rcm)nstruction. St. Is)uis. C.V. Mosby Co.. 1987, pp 12-21. 12. Weiland AJ. Villarreal-Rios A, Kleinert HE. Kutz J . Atasoy E, Lister G : Replantation of digits and hands: analysis of surgical techniques and functional results in 71 patients with 86 replantations. J H m t l Sur,y 2:l. 1977. 13. Wood MB: Replantation about the elbow. in Morrey BF (ed): The, Elborv und I r s Disorders. Philadelphia. W.C. Saunders Company. 1985, Ch 27. pp 272-280. 14. Wood MB: Wrist arthrodesis using dorsal radial bone graft. J Hurlrl Surg 12:208, 1987.
