Replantation of fingers and hands after avulsion and crush injuries

Abstract

Avulsion and crush injuries constitute a particularly difficult problem due to extensive damage of vessels and nerves. In cases where a crush is the dominating injury factor causing complex fractures of forearm and carpal bones, shortening of the extremity is necessary for primary vessel and nerve reconstruction. Surgical experience in vessels dissection and optimal sequence of reconstruction procedures using vessels and nerve grafts are of paramount importance. In the years 1986-2006 the author carried out 18 replantations and 4 revascularizations at various levels of distal upper limb after crush-avulsion trauma. There were 8 thumb, 7 long fingers and 7 hand amputations. Hand replantations were carried out in 5 males aged 18-45 (mean age 33). Thumb replantations were carried out in 2 females and 5 males. There were 4 complete amputations of a long finger (three teenagers and 32-year-old male). A vein grafting from the forearm was the basic method used in arterial reconstructions (3 hands, 5 thumbs and 6 long fingers). Grafts of the deep radial vein were used in 2 cases (one in hand and one in the thumb). Change in the standard sequence of the replantation procedure (i.e. reconstruction of the artery on the ulnar side of the thumb before bone stabilisation) appeared very helpful on thumb. Rerouting veins, venous flaps or skin flaps from the dorsal surface of the index finger were very useful in reconstruction of the blood outflow. Secondary reconstruction of nerves were carried out in 8 patients (40%) and 5 patients are still waiting for the surgery. Sixteen out of 18 replants (88.9%) and all 4 revascularized parts survived. Overall success rate was 90.9%. Grafting technique in reconstruction of arteries and veins during the primary vessels repair is a very good method and we advocate that it should be widely used. Due to extent of trauma, majority of the patients required secondary procedures - mainly reconstruction of nerves with nerve grafts.