Review Question - QID 640

As outlined by Pederson, the contraindications to replantation are more relative than the indications, but they include the following: Single-finger replantations at the level of zone II (from the A1 pulley to the distal sublimis tendon insertion) are rarely indicated, with the notable exception of the thumb. Amputated parts that are severely crushed and those with multiple level injuries have poor function even if they survive replantation. While ring avulsion injuries with a vascular injury and no bone, tendon or nerve injury (Urbaniak type 2A ring avulsion injuries) should be repaired, ring avulsion injuries with bone, tendon or nerve injury (Urbaniak type 2B) or with complete degloving (Urbaniak type 3) have poor outcomes and Urbaniak and colleagues recommend amputation for such injuries. Very distal amputations at the level of the nail bed are marginally indicated as there needs to be approximately 4 mm of intact skin proximal to the nailfold for adequate veins to be present. Indications for replantation that rule out the other 4 choices of this question include the following: Overall, thumb replantation probably offers the best functional return. Even with poor motion and sensation, the thumb is useful to the patient as a post for opposition. A replanted thumb offers the best reconstruction available, toe transfers notwithstanding. Replantation beyond the level of the sublimis tendon insertion (zone I) usually results in good function. Multiple finger amputations present reconstructive difficulties that may be difficult to correct without replantation of one or all of the amputated digits. Any hand amputation from zone III (distally) to zone V (proximally) offers the chance of reasonable function after replantation, usually superior to available prostheses. Although usually indicated, the replantation of any hand or arm proximal to the level of the mid-forearm must be carefully considered.