In modern Life, it is not uncommon to see severed fingers caused by machinery, traffic accidents and other reasons.
The purpose of this delicate and difficult surgery is to restore the function of a severely traumatized finger by repairing the tissue and reconstructing the function of the severed finger.
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Osteofascial sheath of the hand (transverse section through the metacarpophalangeal joint of the thumb)
Early management.
Preoperative preparation of the severed finger for reimplantation is critical to the success of the procedure. It is generally believed that the wound should be closed within 6-8 hours after the finger is severed in summer and 10-12 hours after the finger is severed in winter, which is the prime Time for replantation.
After the injury, simple bandages should be applied to stop the bleeding, and the patient should be sent to the nearest hospital for treatment and routine injection of tetanus antitoxin.
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Preservation of severed fingers.
It is best to wrap the severed finger in plastic bag and store it in a low temperature (preferably around 4°C) insulated bucket.
In winter or for very short distances, the broken finger can be wrapped in a towel or gauze and sent to the hospital with the patient.
Injury assessment.
- Skin.
The prognosis varies for different types of skin breaks. Acute injuries to the skin are relatively easy to dispose of, but if the sharps are contaminated with a heterologous protein such as flesh pulp the wound is prone to infection and non-healing.
- Nerve injury.
If the injury site is far from the appearance of sensory loss, loss and motor impairment, highly suspect whether the injury to the nerve, and strive for early repair.
- Vascular.
If the wound jet bleeding, may injure the artery, to be timely pressure to stop bleeding. If the distal end of the wound pale, pulseless, skin temperature significantly reduced, mostly suggests that the site of blood transport is very poor, not anastomosis of blood vessels, reconstruction of blood circulation, the finger body can not be viable.
- Muscle and tendon injury.
If there is a certain finger or a few finger movement disorder, but not combined with sensory loss, may be due to tendon or muscle injury.
- Bone and joint injuries.
The severity of the injury should be clarified by radiographs and, if necessary, by orthogonal and oblique films of the specific finger or joint.
Indications and contraindications for surgery.
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Surgical method.
There are two sequences of finger severance replantation, one is the sequential replantation method routinely used by most scholars, clearing – bone fixation – extension and flexion tendon suture repair – dorsal finger vein anastomosis – dorsal skin suture – intrinsic finger artery anastomosis – finger nerve anastomosis – metacarpal skin suture.
The other is the retrograde reimplantation method, with debridement – palmar skin suture – finger nerve anastomosis – intrinsic finger artery anastomosis – flexor tendon suture – skeletal fixation – extensor tendon suture – dorsal finger vein anastomosis – dorsal skin suture.
The advantage of the latter method is that the hand is not turned during the operation, and it is suitable for thumb severance replantation and pediatric broken finger replantation.
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Fracture of the proximal phalanx of the left thumb due to circular sawing and fixation of the fracture with a Kristen pin
Postoperative treatment.
Patients need to be immobilized in a cast with absolute bed rest for 1-2 weeks after surgery, with elevation of the affected limb, and active and passive movements of the affected limb are strictly prohibited for 2 weeks.
In case of low temperature, severe swelling or poor peripheral circulation of the reimplanted finger, but no thrombosis has been confirmed, hyperbaric oxygen therapy can be used.
Postoperative complications.
- Early complications
Arteriovenous insufficiency and infection are the most significant early complications.
Postoperative care is focused on maximizing restoration of perfusion and reducing the risk of thrombosis.
Common clinical signs include skin color, temperature, swelling and capillary refill time, and pulse oximetry, which can help monitor the condition of the amputated and residual limb.
The clinical signs of arterial thrombosis are decreased skin temperature, pale color, and absence of pulses. Any suspected failure of vascular anastomosis or thrombosis requires urgent surgical exploration.
Patients with venous stasis may present with cyanosis and swelling due to excessive capillary reflux and may be treated with leech anticoagulation.
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A: One week after reimplantation of the thumb, a small flap graft is made on the dorsal aspect of the severed limb. Forearm incision is used to repair the ruptured long flexor thumb tendon and vein graft; B: X-ray shows the fractured end fixed with kerf pins and wires, the kerf pins are fixed obliquely and there is no impingement at the distal and proximal interphalangeal joints
- Late complications
Chills, stiffness, tendon adhesions and skeletal deformities healing or non-healing.
Limb intolerance to hypothermia usually subsides within two years.
Tendon adhesions can be released, but there is a risk of blood flow blockage in the reimplanted finger.
The bone can still regrow after reimplantation, and it has been reported that in 162 children who underwent reimplantation, 81% of the normal length of the reimplanted finger was restored in adulthood.
- Postoperative rehabilitation process
Rehabilitation begins 5-7 days after the patient’s reimplantation, depending on the injury, the level of reimplantation vessels, and the presence or absence of internal fixation of the fracture, and patients are usually asked to gradually increase functional exercise on a weekly basis.
Most patients still require secondary surgery after rehabilitation, including tendon release, bone grafting for non-healing fractures, and tendon or muscle grafting to restore function to innervated muscles, and these complications can prolong the postoperative recovery time.
The average time to return to work after finger reimplantation is 2.3 to 3 months, and patients who have forearm reimplants may take longer than a year to return to work.
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Removal of the keratin pin at 4 weeks postoperatively, 8 weeks after amputation
Postoperative evaluation.
Postoperative reimplantation sites may have worse outcomes than a well-functioning residual limb, such as decreased function, stiffness, loss of sensation, or pain.
Each patient’s situation is unique and postoperative recovery is generally assessed using one or more of the following criteria: recovery of work capacity, joint range of motion, muscle strength, and sensory capacity.
In general, better functional recovery is achieved after distal limb reimplantation. Several studies have shown that 50% of the mobility and 50% of the grip strength of the affected limb can be restored after reimplantation.
The recovery of sensory function depends on the degree of injury, nerve reimplantation, and the age of the patient. The ability to regenerate nerves decreases with age.
In adults, restoration of measurable two-point discrimination (2PD) after above-elbow reimplantation is very rare and protective sensation can be restored.
A final table for all non-orthopaedic Specialists.
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