Summary Replantation is the reconstruction of an amputated portion of the upper extremity secondary to trauma. Diagnosis of an amputated digit is contingent on absence of blood supply (cold, white digit, without soft tissue attachment). Treatment involves prompt transportation of the amputated tissue and stepwise reconstruction prior to tissue ischemia and meticulous post-operative care. Epidemiology Incidence 90% of upper extremity amputation occurred after trauma Demographics 4:1 male-to-female ratio Anatomic location most amputations occur at the level of the digits Etiology Pathophysiology mechanism of traumatic amputation sharp dissection blunt dissection avulsion crush Presentation History timing of injury type and location of amputation number of digits involved preservation of amputated tissue associated injury past medical history Examination stump examined for zone of injury tissue viability supporting tissue structures contamination amputated portion inspected segmental injury bone and soft tissue envelope contamination Indications Indications for replantation after trauma primary indications thumb at any level multiple digits through the palm wrist level or proximal to wrist almost all parts in children relative indications individual digits distal to the insertion of flexor digitorum superficialis [FDS] (Zone I) ring avulsion through or above elbow Contraindications to replantation primary contraindications severe vascular disorder mangled limb or crush injury segmental amputation prolonged ischemia time with large muscle content (>6 hours) relative contraindications single digit proximal to FDS insertion (Zone II) ring finger injuires in zone II have better cosmesis and grip strenth with 4th ray resection and 5th ray transposition medically unstable patient disabling psychiatric illness tissue contamination prolonged ischemia time with no muscle content (>12 hours) Treatment Transport of amputated tissue indications any salvageable tissue should be transported with the patient to hospital modality keep amputated tissue wrapped in moist gauze in lactate ringers solution place in sealed plastic bag and place in ice water (avoid direct ice or dry ice) wrap, cover and compress stump with moistened gauze Operative time to replantation proximal to carpus warm ischemia time < 6 hours cold ischemia time < 12 hours distal to carpus (digit) warm ischemia time < 12 hours cold ischemia time < 24 hours general operative sequence of replantation vascular shunt first (for proximal replantation with large muscle mass to minimize warm ischemia time) bone fixation +/- shortening (after irrigation and debridement of soft-tissue and bone) extensor tendon repair artery repair (repair second after bone if ischemic time is >3-4 hours) venous anastomoses flexor tendon repair nerve repair skin +/- fasciotomy finger order thumb, long, ring, small, index for multiple amputations structure-by-structure sequence is most efficient digit-by-digit sequence takes the most time Postoperative Care Environment keep patient in warm room (80°F) avoid caffeine, chocolate, and nicotine Replant monitoring skin temperature most reliable concerning changes include a > 2° drop in skin temp in less than one hour or a temperature below 30° celsius pulse oximetry < 94% indicates potential vascular compromise Anticoagulation adequate hydration medications (aspirin, dipyridamile, low-molecular weight dextram, heparin) Arterial Insufficiency treat with release constricting bandages place extremity in dependent position consider heparinization consider stellate ganglion blockade early surgical exploration if previous measures unsuccessful thrombosis secondary to vasospasm is most common cause of early replant failure Venous congestion treatment elevate extremity leech application releases Hirudin (powerful anticoagulant) Aeromonos hydrophila infection can occur prophylaxis with Ciprofloxacin or Bactrim heparin soaked pledgets if leeches not available Complications Replantation failure most frequently cause within 12 hours is arterial thrombosis from persistent vasospasm decreased palmar width with ray resection Stiffness replanted digits have 50% of total motion tenolysis is most common secondary surgery Myonecrosis greater concern in major limb replantation than in digit replantation Myoglobinuria caused by muscle necrosis in larger replants (forearm and arm) can lead to renal failure and be fatal Reperfusion injury mechanism thought to be related to ischemia-induced hypoxanthine conversion to xanthine allopurinol is the best adjunctive therapy agent to decrease xanthine production Infection Cold intolerance
QUESTIONS 1 of 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.147) A patient presents with a hand injury after an accidental self-inflicted gunshot wound. The ring finger is traumatically amputated at the proximal phalanx. Which treatment option will provide optimal cosmesis and grip strength? QID: 213043 Type & Select Correct Answer 1 Early revision amputation 24% (467/1947) 2 Early replantation 6% (119/1947) 3 Delayed fourth ray resection 4% (85/1947) 4 Early fourth ray resection with fifth ray transposition 52% (1018/1947) 5 Delayed fourth ray resection with fifth ray transposition 12% (236/1947) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ18.182) What is the mechanism of action of the first-line prophylactic antibiotic used when utilizing leech therapy? QID: 213078 Type & Select Correct Answer 1 Inhibits the 30S subunit 13% (297/2235) 2 Inhibits cell wall synthesis 16% (350/2235) 3 Inhibits the 50S subunit 13% (285/2235) 4 Inhibits DNA gyrase 53% (1182/2235) 5 Inhibits RNA synthesis 4% (91/2235) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.135) A 42-year-old male sustains the injury seen in Figure A. Which of the following is true regarding management of this injury? QID: 4495 FIGURES: A Type & Select Correct Answer 1 Replantation at this level has a worse functional outcome when compared to above the elbow amputations 8% (425/5283) 2 The veins should be reconstructed prior to the arteries 16% (823/5283) 3 Bony stabilization should occur at the end of the procedure 3% (151/5283) 4 Vein grafting should not be used at this level of amputation 3% (154/5283) 5 A warm ischemia time of 8 hours is a relative contraindication to replantation 70% (3677/5283) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ12.15) A 30-year-old healthy female sustains a traumatic digit amputation while working at a factory. Which of the following is a absolute indication for digit replantation in this patient? QID: 4375 Type & Select Correct Answer 1 Isolated amputation of the index finger proximal to the FDS insertion 6% (323/5807) 2 Amputation due to crush injury 1% (78/5807) 3 Replantation of an index finger with a segmental injury 2% (101/5807) 4 Isolated amputation of the thumb proximal to the FPL insertion 89% (5186/5807) 5 Presentation 13 hours after the amputation occurred 1% (70/5807) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ11.166) A 25-year-old right-hand dominant construction worker suffers an industrial injury as seen below. He is hemodynamically stable and his only injury is to the limb below. In terms of replantation of the affected limb, which of the following is true? QID: 3589 FIGURES: A B C D Type & Select Correct Answer 1 Transpositional microsurgery offers the best results 8% (302/4004) 2 Replantation is contraindicated as the injury is through flexor zone II 3% (116/4004) 3 Replantation is contraindicated because of the extent of injury 6% (249/4004) 4 Heterotopic transplantation would offer the best function 2% (85/4004) 5 Anatomic replantation of hand offers the best results 81% (3229/4004) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ08.254) Replantation is indicated for which of the following amputations. QID: 640 Type & Select Correct Answer 1 multiple level amputation of the small finger at the proximal and distal interphalangeal joints 1% (19/3484) 2 crushed amputation through the distal phalanx of the middle finger 0% (9/3484) 3 complete ring avulsion of the ring finger with tendon injury 1% (43/3484) 4 thumb amputation though the proximal phalanx shaft 96% (3346/3484) 5 middle finger amputation though the proximal phalanx shaft 2% (55/3484) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ07.257) Each of the following are indications for microvascular replantation EXCEPT? QID: 918 Type & Select Correct Answer 1 Thumb amputation 1% (15/2892) 2 Index finger amputation in a child 3% (87/2892) 3 Through wrist amputation 4% (129/2892) 4 Long finger amputation through the proximal phalanx 86% (2479/2892) 5 Mid-palm amputation of all four fingers 6% (162/2892) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ06.71) Ischemia induced by the conversion of hypoxanthine to xanthine is thought to be involved in the mechanism of reperfusion injury following restoration of circulation after replantation. Which of the following agents inhibits conversion to xanthine and has been shown to improve outcomes following digit replantation? QID: 182 Type & Select Correct Answer 1 Tissue plasminogen activator 3% (51/1809) 2 Heparin 6% (113/1809) 3 COX 2 inhibitor 6% (101/1809) 4 Allopurinol 77% (1398/1809) 5 Leeches 7% (131/1809) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ06.265) Which of the following amputations may be considered a relative contraindication for a replantation? QID: 276 Type & Select Correct Answer 1 Ring finger through the proximal phalanx shaft 78% (2821/3614) 2 Mid forearm 6% (200/3614) 3 Thumb through the proximal phalanx 2% (55/3614) 4 Middle, ring, and small fingers through the middle phalanx shaft 9% (341/3614) 5 Complete hand just proximal to the distal palmar crease 5% (176/3614) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ06.45) What is the most important factor influencing immediate and late outcome of digit replantation? QID: 156 Type & Select Correct Answer 1 Gender 0% (7/2151) 2 Anastamosing the proximal profundus tendon stump to the superficialis tendon of the amputated digit 1% (27/2151) 3 Regular cigarette smoking 22% (471/2151) 4 Utilization of composite skin and subcutaneous vein graft 1% (22/2151) 5 Mechanism of digit amputation injury 75% (1604/2151) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ05.193) All of the following factors are favorable for digit survival after replantation surgery EXCEPT? QID: 1079 Type & Select Correct Answer 1 Sharply amputated digit 0% (18/3757) 2 Crushed amputated digit 96% (3614/3757) 3 Warm ischemia time of 8 hours 3% (94/3757) 4 Patient age of 10 years 0% (6/3757) 5 Female gender 0% (15/3757) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ05.239) A 34-year-old male undergoes a thumb replantation after an industrial meat slicer accident. At 4 hours postoperatively there is a drop from 33 degrees Celsius to 29 degrees Celsius and the pulse oximetry monitor on the thumb reads 87%. All of the following are treatment options for the management of his arterial inflow insufficiency EXCEPT: QID: 1125 Type & Select Correct Answer 1 Administer IV heparin 3% (82/2946) 2 Administer a stellate ganglion block 15% (445/2946) 3 Placement of leeches on the thumb 63% (1842/2946) 4 Inspect the dressing for any constriction 1% (24/2946) 5 Place the thumb in a dependent position. 18% (531/2946) L 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ05.270) A 34-year-old male sustains amputations of the 4th and 5th fingers at the level of the middle phalanx after cutting them with a butcher knife. Which of the following techniques would most likely increase total surgical time during replantation? QID: 1156 Type & Select Correct Answer 1 Utilizing an on-call surgical team experienced at digit replantations 1% (28/2977) 2 Digit-by-digit repair method 74% (2206/2977) 3 Structure-by-structure repair method 16% (466/2977) 4 Bone shortening procedures to avoid the need for vein grafts 2% (50/2977) 5 Obtaining a thorough inventory of the digit structures that are deficient and the structures that are available for reconstruction 7% (207/2977) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
All Videos (1) Podcasts (1) Login to View Community Videos Login to View Community Videos Cleveland Combined Hand Fellowship Lecture Series 2019-2020 Replantation and Microsurgery in the Upper Extremity: Pediatric Considerations - Anil Akoon, MD Anil Akoon Hand - Replantation D 9/15/2020 120 views 0.0 (0) Hand | Replantation Hand - Replantation Listen Now 16:29 min 11/18/2019 381 plays 5.0 (2)