Hand Trauma

PRESENTAR-Dr.SUNIL C
P.G IN ORTHOPAEDICS
MODERATOR-Dr.MANJAPPA
ADICHUNCHANGIRI INSTITUTE OF MEDICAL
SCIENCES

Hand is one of the most important parts of the
human body due to its mechanical and sensory
functions.
One of the most developed structures in the human
evolution.

4 requirements for a functioning hand:
Supple (moving with ease)
pain free
Sensate
Coordinated

Topics
Relevant anatomy
Clinical approach to hand trauma
History
Examination
Imaging
Specific injuries

Relevant Anatomy
Integument
Dorsal skin
Thin and pliable.
Attached to the hand's skeleton only by loose areolar tissue, where
lymphatics and veins abundant.
Edema is manifested predominantly at the dorsum
Loose attachment makes it more vulnerable to skin avulsion
injuries.-degloving injuries .

Palmar skin
Thick and glabrous and not as pliable
Strongly attached to the underlying fascia by numerous vertical
fibers
Most firmly anchored to the deep structures at the palmar creases
Contains a high concentration of sensory nerve endings
4
Soft tissues
Muscles and tendons
Blood vessels ,
lymphatics
Nerves

Spaces of the hand
Ref. Clinical Anatomy, Richard Snell, 6
th
edition
Clinical symposia Nov.1988 surgical anatomy of the hand- earnest W.Lampe MD
Muscles and tendons

Muscles - two main groups:
Extrinsic group
Extrinsic extensors
Extrinsic flexors
Intrinsic group:
Thenar complex
lumbricals
Interosseous
Hypothenar complex

6
Anatomy of the tendon arrangement in a finger
Extensor expansion - On the dorsum
Flexor sheath - on the volar aspect
Blood vessels
2 main vessels ulnar (dominant in 80% ) and radial
Forms 2 arches in the palm-

Large Superficial mainly by ulnar- at the level of distal
border of the extended thumb.
Small deep- mainly by radial- at one finger breadth
proximal to the superficial.

Fingers proper digital arteries are end arteries .
Fingers neurovascular bundles nerves are in more
palmar than arteries in contrast to the palm.
Hand Anatomy
Intrinsic muscle of the
hand:
Have their origins and
insertions within the
hand.
Consist the following:
Thenar, Hypothenar,
adductor pollicies, the
interossei and the
lumbricals. (Refer to pg
1665 for anatomical
description)

Hand Anatomy
Extensor Tendons:
Courses over the dorsal side of the forearm, wrist
and hand.
9 extensor tendons pass under the extensor
retinaculum and separate into 6 compartments

Surface anatomy of the hand.
The tendons that are palpated
with thumb abducted and
extended form an anatomic
snuff-box.
Hand Anatomy
Extensor Tendons:
The extensor tendons gain entrance to the
hand from the forearm through a series of
six canals, five fibroosseous and one fibrous
The communis tendons are joined distally
near the MP joints by fibrous
interconnections called juncturae tendinum.
Beneath the retinaculum, the extensor
tendons are covered with a synovial sheath.
Hand Anatomy
Flexor Tendons:
Courses over the volar side of the forearm, wrist, and
hand.

Unlike the extensor tendons, the flexor tendons are
enclosed in synovial sheaths making them prone to
deep space infections.
Hand Anatomy
Flexor Tendons:
Flexor carpi
radialis, flexor
carpi ulnaris, and
palmaris longus
primarily flex the
wrist

Hand Anatomy
Hand Anatomy
9 flexor tendons pass through the carpel
tunnel:
1 tendon go to the base of the dist. Phalanx of the
thumb

The other 4 digit has 2 tendon each (FDS / FDP).

Hand Anatomy
Flexor digitorum
superficialis (FDS) insert
into middle phalanx.

Flexor digitorum
profundus (FDP) runs
deep to the FDS until the
level of the MP joint
where FDS bifurcates.

FDP inserts at the base of
the distal phalanx and
acts primarily to flex the
DIP joint as well as all
other joints flexed by FDS.
(Figure 268-5).

Hand Anatomy
Blood supply (BS):

Hand and digits has
dual (BS) with
contributions from the
radial and ulnar
arteries.

Hand Anatomy
Blood supply (BS):

Proximal portions of the hand (BS) come from the
deep and superficial arches on the palmar and
dorsal side.

BS of the fingers is distributed by the digital
arteries that arises from the superficial palmer
arch.


Nerves
- Sensory Innervation

Motor supply to hand

Ulnar nerve.
All the intrinsic muscles - of the hand except radial 2
lumbricals
Muscles of thenar eminence, with exception flexor pollicis
brevis .variations +
Muscles of hypothenar eminence are innervated by ulnar
nerve

Median nerve
LOAF" for Lumbricals 1 & 2, Opponens pollicis, Abductor
pollicis brevis and Flexor pollicis brevis



Ref. Wheeless' Textbook of Orthopaedics


Spaces of the hand
Important in infections
Radial bursa
Ulnar bursa
Mid palmar space ( continuous proximally with the
space of Parona.)
Thenar space
Dorsal subcutaneous space
Dorsal subaponeurotic space
Finger pulp spaces

Deep spaces of the hand

Radial
bursa
Ulnar bursa
Mid palmar
space
Thenar space
Space of Parona
Bones of the hand
Hand Anatomy
Hand consist of 27
bones:
14 Phalangeal bones
5 Metacarpal bones
8 Carpal bones
Carpal bones are made
up of two rows of four
bones bridged by flexor
retinaculum which forms
the carpal tunnel.
Carpal tunnel consist of
the median nerve and
the nine long flexor of
the fingers

Hand Trauma

Hand trauma account for 5-10 % of trauma.

Mechanism of injury
Blunt trauma
Lacerations & punctures
Avulsions soft tissue deficit
Ring avulsions

Structures injured
Cutaneous injuries
Muscles and Tendons
Neuro-vascular injuries
Bones and associated soft tissues


Approach to Hand Trauma
History
Examination
Imaging

Ref. Clinical Orthopedic examination -3
rd
Ed. Ronald McRae
Bailey and Loves Short practice of surgical 23
rd
Ed
Concise system of orthopaedics and fractures- 2nd Ed. Alan Graham Apley,
Louis Solomon

History
29

Important points in the history of a patient with hand
injury.
Age
Hand dominance
Occupation & hobbies
When and how the injury occurred?
mechanism of trauma
Previous history of hand trauma or relevant
medical/Rheumatic conditions




Physical examination
Entire upper limb comparing both upper limbs.
Should follow the routine order of LOOK, FEEL, MOVE

LOOK
External appearance.
local swellings -
Evidence of chronic disease(OA, RA, Gout)
Bleeding
Auto-amputations
Wounds / exposed tendons etc.
Deformities




Deformities
can be due to tendon, bone , nerve injury and joint dislocations
Specific types
Tendon injuries

Mallet finger





Swan neck deformity

Boutonniere deformity











Z deformity of the thumb

Claw hand deformities due to nerve injuries
Median, ulnar nerve injuries

Wasting of the thenar and hypothenar muscles,
interossei etc. ( Chronic )


FEEL
Temperature
Tenderness
Distal neurovascular status

MOVE

Finger cascade ( flexion and extension tendon injuries/ fractures )
Muscles- intrinsic and extrinsic
Joints
pain and stability
normal ROM
Fingers MP 0- 90 Passive - further 45
PIP 0- 100
DIP - 0- 80
Thumb MP - ext. 55
IP - flex. 80 Ext. - 20
Carpometacarpal- ext.- 20 , flex.- 15
abduction- 60

(excess mobility may be due to collateral lig. Injury Ex.
Gamekeepers thumb )



Functional capacity
Grips
Pinch grip /precision grip
Chuck grip
Palmar grip/hook grip
power grip


Types of grips of the hand
Pinch grip /precision grip
Power grip Hook grip Chuck grip
Imaging
X rays- AP, lateral &oblique views
Plain-films of the hand or wrist should be obtained when
injury suggestive of fracture or an occult foreign body.

Ultra sound
Has a growing role in locating foreign bodies and in
evaluating soft tissues
Can detect ruptured tendons and assess dynamic function
of tendons non-invasively.
MRI
Highly sensitive but not have a role in management of hand
wounds.

General Operative Principles

A bloodless field (eg, by tourniquet ischemia) is essential.
The pressure of the cuff will 100 mm Hg above systolic
pressure.- 200-250 mmHg ( max-250)
This is readily tolerated by the unanesthetized arm for 30
minutes and by the anesthetized arm for 2 hours.

Incisions must be either zigzagged across lines of tension
(eg, must never cross perpendicularly to a flexion crease),
termed Brunner incisions, or run longitudinally in "neutral"
zones- so that a healthy skin-fat flap is raised over the zone of
repair of a tendon, nerve, or artery.

Cutaneous injuries

Cutaneous injuries are very common injury.
Two Types
Open: Incised, laceration, punctured (bites),
penetration, abrasion.
Closed: Contusions, Hematomas
Vary in depth
May need to explore for underlying structural Injuries.
Conservative excision of the skin is the rule.
43
Management
Skin Laceration:
Small: Rinse and cover.
Large: Wound exploration under LA
Irrigate wound profusely with betadine or sterile
water and Explore
Close the skin wound with simple sutures.
Wounds older than 6-8 hours should not be
closed primarily.
Irrigate, explore then apply sterile dressing.
Delayed primary closure at 4 days.

44
Bites:
Should not be closed primarily but delayed
closure at 4 days if needed
Antibiotic prophylaxis is indicated in human
(including fight-bites) and cat bites and may be of
benefit in dog bites as well.

Contusions:
Cold packs with pressure for 30 to 60 min. several
times daily for 2 days. Then use warm compresses
for 20 minutes at a time.
Rest, elevate
Do not bandage a bruise.

45
Abrasions:
Superficial:
Rinse and cover.
Prophylactic antibiotic ointment

Deep:
Rinse with antiseptic or warm normal saline. Scrub gently
with gauze if necessary.
Dress with semi-permeable dressing (Tegaderm)
Changed every few days.
Keep wound moist. Enhance healing process.

46


Injured components may include skin, bone, nail, nail bed,
tendon, and the pulp, the padded area of the fingertip .

The skin on the palm side of fingertips is specialized
in that it has many more nerve endings than most other
parts of our body enabling the fine sensation.

When this specialized skin is injured, exact replacement
may be difficult.

Finger tip Injuries
Severe crush or avulsion injuries can completely remove some
or all of the tissue at the fingertip.
If just skin is removed and the defect is less than a
centimeter in diameter, it is often possible to treat these
injuries with simple dressing changes.
If there is a little bit of bone exposed at the tip, it can
sometimes be trimmed back slightly and treated with V-Y
plasty

Cross finger flap
For larger skin defects, skin grafting is recommended.
Smaller grafts can be obtained from the little finger
side of the hand. - Cross finger flap
Larger grafts may be harvested from the forearm or
groin.

Extensor tendon Injury:
Divided into Zones according to anatomical
location of injury
In the hand and wrist there are 7 extensor
tendon zones
50
Tendon injuries
Ref. http://emedicine.medscape.com Orthopedic Surgery for Flexor Tendon
Lacerations Author: Michael Neumeister, MD, FRCSC, FRCSC, FACS; Chief
Editor: Harris Gellman, MD
http://www.orthobullets.com- Flexor Tendon Injuries- Derek Moore MD


Zone Presentation Management
I Mallet Deformity
Closed: splinting 6-8 weeks
Open: suture repair for fixation.
Soft tissue reconstruction
III
Boutonnieres
Deformity
Closed: splinting MCP and PIP in
hyperextension for 6 weeks
Open: suture repair (figure of 8
suture)
V Fixed flexion of MCP
Closed: splinting ,45 extension at
wrist and 20 flexion at MCP
Open: suture repair.
VII Fixed flexion of MCP
Suture repair followed by post-op
splinting
52
Flexor tendon injuries
5 zones in the hand and the wrist
Zone 1 One tendon only (FDP)
from middle of middle phalanx
distally
Zone 2 Two tendons (FDS &
FDP) from MCP joints to middle
of middle phalanx
Zone 3 Central palm
Zone 4 Tendons in the carpal
tunnel
Zone 5 Tendons proximal to the
carpal tunnel

FDS Insertion
Flexor Sheath
Presentation Flexor injury
Zone Presentation Management
I
Loss of active flexion at
DIP joint
Hyperextension of DIP
joint
(Jersey finger )
Primary or Secondary tendon
repair
Careful suturing prevent post-op
adhesions.
II
Loss of active flexion
at MCP joint
Skin closure then secondary
repair by tendon grafting
Primary repair performed by
skilled hand surgeon to minimize
post-op adhesions.
III, IV
Thumb
Same
Primary or secondary tendon
repair
Examine carefully for thenar
muscle injury and recurrent
branches of median nerve. 54
Zone Presentation Management
V
Palm
Uncommon
Lie deep and protected by
palmar fascia
Same presentation
Superior to Tendon division: repair
is unnecessary.
Both muscles tendon division:
primary repair

VI, VII
Wrist
Multiple flexor tendon
injury
Impaired active flexion of
multiple digits
Primary tendon suturing in the
forearm to prevent post-op cross-
adherence.
Injuries to muscles in forearm
require primary repair
Post-op splinting of wrist in flexion
position and elevation for 4 weeks.
55
Nerve injuries
Effect of injury: Seddons Classification
Neuropraxia:
Disruption of Schwann cell sheath but no loss of continuity.
Axonotmesis:
Injury to both Schwann sheath and axon.
Distal part undergoes Wallerian degeneration.
Stimulation of nerve 72 hours after injury does not elicit response.
Regeneration occurs with the average rate of 1-2 mm/day.

Neorutmesis:
Injury to all anatomical components, myelin sheath, axons and the
surrounding connective tissue.
This total nerve disruption makes regeneration impossible.
Surgical intervention is necessary.
Nerve injury surgical interventions
Neurolysis:
Removal of any scar or tethering attachments to
surroundings that obstruct nerve ability to glide.
Neurorrhaphy:
End-to-end repair.
Resection of the proximal and distal nerve stumps and then
approximation.
Autologus Nerve grafting:
Gold standard for clinical treatment of large lesion gaps.
Nerve segments taken from another parts of the body.
Provide endoneural tubes to guide regeneration.
Two types: Allograft, Xenograft.

HAND FRACTURES
INDRODUCTION
Fractures and Dislocations are the most
common musculoskeletal injuries
The potential for functional loss is often
underappreciated and difficult to measure

PRINCIPLES OF MANAGEMENT
Fundamental principles of management is
that the negative effects of surgery on the
tissues should not exceed the negative effects
of the original injury.
Fracture Reduction
If the injury is reducible at all, gentle
manipulation will accomplish the reduction far
more successfully than forceful longitudinal
traction. The principle is relaxation of
deforming forces through proximal joint
positioning such as metacarpophalangeal
(MP) joint flexion to relax the intrinsics or
wrist flexion to relax the digital flexor tendons.
Splinting
Splints should immobilize the minimum
number of joints possible and allow
unrestricted motion of all other joints
Setting appropriate length-tension
relationships in the extrinsic motors (in cases
where they are deforming forces) is most
easily accomplished through immobilization of
the wrist in 25 to 35 degrees of extension.

Signs and Symptoms
Symptoms associated with a fracture or
dislocation of the hand include pain, swelling,
stiffness, weakness, deformity, and loss
of coordination. Numbness and tingling signify
associated nerve involvement (either direct
injury to the nerve or as a secondary effect of
swelling). Signs include tenderness, swelling,
ecchymosis, deformity, crepitus, and
instability.
Associated Injuries
Open Injuries
Tendons
Nerves and Vessels
Combined Injuries
Massive Hand Trauma
Bone Loss

Treatment Selection

Critical elements in selecting between
nonoperative and operative treatment are the
assessments of rotational malalignment and
stability
Contraction of soft tissues begins
approximately 72 hours following injury.
Motion should be instituted by this time for all
joints stable enough to tolerate rehabilitation
DISTAL PHALANX (P3) FRACTURES
The soft tissue coverage is limited and local
signs of fracture can usually be detected at the
surface. When fractures accompany a nail bed
injury, hematoma can be seen beneath the
nail plate. When the seal between the nail
plate and the hyponychium is also broken, the
fracture is open and should be treated
Aggresively.
Fractures in the distal phalanx can be conceived of
as occurring in three primary regions: the tuft, the
shaft, and the base
The two mechanisms of injury experienced most
frequently are a sudden axial load (as in ball-
handling sports) or crush injuries.
Dorsal base intra-articular fractures because of the
shearing component of an axial load injury should
be distinguished from avulsion fractures occurring
under tension from the terminal tendon.
The latter are smaller fragments with the fracture line
perpendicular to the line of tensile force in the tendon,
whereas the former are larger fragments comprising a
significant (greater than 20%) portion of the articular
surface with the fracture line being perpendicular to the
articular surface. These are very different injuries with
different treatment requirements.







the majority of bone flakes at the volar base of P3
are really flexor digitorum profundus (FDP) tendon
ruptures occurring through bone.
TYPES OF P3 FRACTURES
Tuft Fractures
Shaft Fractures
Dorsal Base Fractures
Volar Base Fractures
DISTAL INTERPHALANGEAL AND THUMB
INTERPHALANGEAL JOINT DISLOCATIONS
The DIP/IP joint is a bicondylar ginglymus joint
stabilized on each side by proper and accessory
collateral ligaments and the volar plate.
The joint is inherently stable owing to articular
congruity and the dynamic balance of flexor and
extensor tendons.
However, the DIP/IP joint is not as intrinsically stable
as the PIP joint and depends to a greater degree on
its ligaments
TREATEMENT
Nonoperative Management-Dorsal dislocation
should be immobilized in 20 degrees of flexion
for up to 3 weeks before instituting AROM
CRIF- K-wire stabilization
Open Reduction
MIDDLE PHALANX FRACTURES
These are perhaps the most functionally
devastating of all fractures, and dislocations of
the hand and the most technically difficult to
treat. Many other fracture patterns that occur
in the middle phalanx are the same as those
patterns seen in the proximal phalanx.
Surgical and Applied Anatomy
Fractures of the middle phalanx can be grouped by the
anatomic regions of head, neck, shaft, and base.Tendon
insertions that play a role in fracture deformation include the
central slip at the dorsal base and the terminal tendon acting
through the DIP joint. The flexor digitorum superficialis has a
long insertion along the volar lateral margins of the shaft of
the middle phalanx from the proximal fourth to the distal
fourth
Base fractures can be divided into partial articular fractures of
the dorsal base, volar base, and lateral base or complete
articular fractures that are usually comminuted and often
referred to as pilon fractures
Pilon fractures are unstable in every direction including
axially.
Fractures at the neck of the middle phalanx will usually
angulate apex volar as the proximal fragment is flexed by the
FDS and the distal fragment is extended by the terminal
tendon. Those at the base will usually angulate apex dorsal
as the distal fragment is flexed by the FDS and the proximal
fragment is extended by the central slip
TREATEMENT
PROXIMAL PHALANX FRACTURES
Types of proximal phalanx fractures that have
been recognized include intra-articular
fractures of the head, extra-articular fractures
of the neck and shaft, and both extra-articular
and intraarticular fractures of the base

Surgical and Applied Anatomy

Local Soft Tissue Relationships
The proximal phalanx is closely invested by a
sheetlike extensor mechanism with a complex
array of decussating collagen fibers . Surgical
disturbance of the fine balance between these
fibers can permanently alter the long-term
function of the digit.
Deforming Forces
At the proximal phalangeal level, both intrinsic and
extrinsic tendon forces deform the fracture. They result
in a predictable apex volar deformity for transverse and
short oblique fractures. These forces can be used with
benefit during rehabilitation. If the MP joints are
maximally flexed (the intrinsic plus position), the
intrinsic muscle forces acting through the extensor
mechanism overlying P1 create a tension band effect
that helps to maintain fracture reduction
Rehabilitation
Nonoperative management should restrict
splinting to 3 weeks followed by AROM that
can include adjacent digit strapping if
necessary. Similarly, CRIF should allow for pin
removal at 3 weeks, with AROM beginning no
later than this time. If ORIF is chosen, AROM
should begin within 72 hours of surgery and
edema control should be foremost in the
treatment plan using cohesive elastic
bandages.
METACARPOPHALANGEAL JOINT
DISLOCATIONS
Dorsal MP joint dislocations are the most common.
Simple dislocations are reducible and present with a
hyperextension posture
The other variety of MP joint dislocation is a complex
dislocation, which is by definition irreducible, most
often because of volar plate interposition.Complex
dislocations occur most frequently in the index
finger. A pathognomonic radiographic sign of
complex dislocation is the appearance of a sesamoid
in the joint space.
Most dorsal dislocations will be stable following reduction
and do not need surgical repair of the ligaments or volar
plate. Volar dislocations are rare but particularly unstable.
Volar dislocations risk late instability and should have
repair of the ligaments.
113
Obstructions to reducing volar
dislocations include the volar plate, collateral ligament, and
dorsal capsule. Open dislocations may be either reducible
or irreducible.Isolated collateral ligament injuries are more
common on the radial aspect of the small finger followed
by the index finger. A rare variant injury to the MP joint is a
dorsal capsular tear (Boxer's knuckle) that can prove
persistently symptomatic
Thumb Metacarpophalangeal Joint
Ligament Injuries
Complete rupture of the ulnar collateral ligament (UCL) of the
thumb MP joint is a common injury that less frequently may
accompany a full MP joint dislocation.Circumferential
palpation of the MP joint can often localize pain to the UCL,
radial collateral ligament (RCL), volar plate, or combinations of
these
stress testing in full extension and 30 degrees of flexion
(eliminates the false-negative conclusion of stability in the
setting of a ruptured proper collateral ligament but an intact
volar plate) should reveal any instability
Thumb Metacarpophalangeal Joint
The thumb MP joint, in addition to its primary flexion
and extension, allows abduction-adduction and a
slight amount of rotation (pronation with flexion).
The ulnar collateral ligament may have a two-level
injury consisting of a fracture of the ulnar base of P1
with the ligament also rupturing off the fracture
fragment.
59
Of particular importance is the proximal
edge of the adductor aponeurosis that forms the
anatomic basis of the Stener lesion. The torn UCL
stump comes to lie dorsal to the aponeurosis and is
thus prevented from healing to its anatomic insertion
on the volar, ulnar base of the proximal phalanx

TREATEMENT
METACARPAL FRACTURES
Fracture patterns may be broken down into those of
the metacarpal head, neck, and shaft. Transverse
metacarpal neck and shaft fractures will typically
demonstrate apex dorsal angulation. Pseudoclawing
is a term used to describe a dynamic imbalance
manifested as a hyperextension deformity of the MP
joint and a flexion deformity of the PIP joint. This
occurs as a compensatory response to the apex
dorsal angulation of the metacarpal fracture (usually
at the neck) and represents a clinical indication for
correcting the fracture angulation
CARPOMETACARPAL JOINT DISLOCATIONS
AND FRACTURE-DISLOCATIONS
Dislocations and fracture-dislocations at the finger
CMC joints are usually high-energy injuries with
involvement of associated structures, often
neurovascular.Particular care must be given to the
examination of ulnar nerve function, especially
motor, because of its close proximity to the fifth CMC
joint. Frequent pattern is one of fracture-dislocation
involving the metacarpal bases, the distal carpal
bones, or both.
9

Thumb Carpometacarpal Fracture-
Dislocations
The majority of thumb CMC joint injuries are
fracture-dislocations rather than pure dislocations.
The smaller fracture fragment at the thumb
metacarpal volar base is deeply placed and not
palpable. These fracture-dislocations are known az
Bennett (partial articular), and Rolando (complete
articular) fractures.
COMPLICATIONS

Infection
Stiffness
Hypersensitivity
Malunion and Deformity
Nonunion
Residual Instability
Posttraumatic Arthritis
Hardware Complications
Tendon Rupture
AMPUTATION AND
REPLANTATION
100
Introduction
Replantation: reattachment of a severed digit of
extremity.
Chinese surgeons at the Sixth People's Hospital
performed successful replantations in the 1960s.
However, in 1968 Komatsu and Tamai's reported o a
successful thumb reattachment

Not all patients with amputation are candidates for
replantation
Approximately 100,000 digital amputations occur per
year in the US. Of these, an estimated 30% are
suitable for replantation

Ref. http://emedicine.medscape.com- Hand, Amputations and
Replantation- Author: Bradon J Wilhelmi, MD; Chief Editor: Joseph A
Molnar, MD, PhD, FACS

101

Decision is based on:
Importance of the part,
level of injury,
mechanism of injury
expected return of function.

Because hand function is severely compromised if the thumb or
multiple fingers are not present to oppose each other, thumb
and multiple-finger replants should be attempted.
Hand Muscles at room temperature are irreversibly damaged in 6-8
hours; if cooled, it can withstand a maximum of 8-12 hours of
ischemia.
However, if digits are cooled without freezing, they may survive
longer than 100 hours

Recommended ischemia times for replantation:
Major replant: 6 hours of warm and 12 hours of
cold ischemia.
Digit: 12 hours for warm ischemia and 24 hours for
cold ischemia.

Preoperative preparation: radiography of both
amputated and stump parts to determine the level
of injury and suitability for replantation
103
104
The normal sequence of the operative procedure

Debridement
Identification and/or tagging of vital structures

Skeletal stabilization- appropriate shortening, the bone may be
stabilized interosseous wires, interosseous wire and pin, or miniplate
and/or miniscrews.

Joint damage may be managed with prosthetic joints,
resection arthroplasty, or fusion.

Extensor tenorrhaphy
Placing sutures within flexor tendon ends
Digital artery repair
Neurorrhaphy of digital nerve
Repair of flexor digitorum profundus
Venous repair
Skin closure
Dressing

Outcome
Overall success rates for replantation approach 80%.
Better outcome with Guillotine (sharp) amputation
(77%) compared to severely crushed and mangled
body parts(49%). In general, the prognosis for ring
avulsion injuries is poor.
Studies have demonstrated that patients can expect to
achieve 50% function and 50% sensation of the
replanted part.

Ref. Plastic Surgery, Goldwyn and Cohen, 3
rd
edition.
Plastic Surgery, Grabb and Smith, 3
rd
edition.


106
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