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MUTILATING INJURIESMUTILATING INJURIES
OF UPPER EXTREMITYOF UPPER EXTREMITY
ANDAND
REPLANTATIONREPLANTATION
By:
Dr Uzma Na...
Mangled/ Mutilating InjuriesMangled/ Mutilating Injuries
Components:
◦ Soft tissue/ integuments
◦ Nerve
◦ Vasculature
◦ B...
3
4
Etiology:Etiology:
Ballistic missile
Blast injuries
Firearm injuries
Motor vehicle accidents
Industrial injuries
Agr...
EvaluationEvaluation
Standard ATLS protocol
Control of h’age
Secondary survey
Full neurologic exam
Vascular examinati...
Radiographic ExaminationRadiographic Examination
Hand/wrist
◦ 3 views
Forearm/elbow
◦ 2 views
Complex joint injuries
◦ ...
8
Operative ManagementOperative Management
Physiologically stable pt:
◦ Immediate vascular recon in ischemia
 (repair,reco...
10
DebridementDebridement
◦ Thorough debridement
◦ Wound cultures
◦ i/v antibiotic
◦ Moist dressings
◦ Neg pressure wound the...
Vascular reconstructionVascular reconstruction
Before or after bony
stabilization?
Vein grafts
Shunts
Ligation?
12
Bony fixationBony fixation
External/internal fixation
Shortening may be performed
◦ (to allow primary repair of nerves n...
Tendon RepairTendon Repair
Tendon grafts
◦ PL, plantaris, toe extensor
Tendon transfers
◦ Recon of EPL with EIP transfer...
Nerve reconstructionNerve reconstruction
As soon as possible
Primary repair
◦ Sharp injuries
Nerve Grafting
◦ Crushed ,...
Soft Tissue CoverageSoft Tissue Coverage
STSG
Pedicled fasciocutaneous flaps
Regional flaps
Stsg covered fascial flaps...
Compartment syndromeCompartment syndrome
Diagnosis
◦ Purely clinical
◦ Five Ps in awake , cooperative pt
◦ pain with pass...
ConclusionConclusion
Complex injuries
Multidisciplinary team approach
threshold for amputation of UE should
be higher
...
REPLANTATIONREPLANTATION
20
ReplantationReplantation
Reattachment of a completely
amputated body part by reestablishing
arterial inflow and venous out...
RevascularizationRevascularization
Reattachment of incompletely
amputated parts requiring restoration
of both arterial in...
HistoryHistory
 Balfour provided the first scientific report of digital
reattachment in 1814
 Murphy in 1896 reported th...
INTRODUCTIONINTRODUCTION
Not all patients with amputation are
candidates for replantation
Decision based on:
Importance...
Indications for replantationIndications for replantation
Strong indications
• Multiple digital amputations
• Thumb amputat...
Relative contraindications toRelative contraindications to
replantationreplantation
• Concomitant life-threatening injury
...
27
28
Replantation center criteriaReplantation center criteria
1. An efficient ground and air transportation system
2. Experi...
Preoperative ManagementPreoperative Management
Transfer to a replantation center:
◦ Amputation stump:
 covered with a sa...
Preoperative ManagementPreoperative Management
◦ The amputated part:
 Thoroughly washed
 Wrapped in a saline moistened g...
Preoperative ManagementPreoperative Management
31
Preoperative ManagementPreoperative Management
Management in ER:
◦ Resuscitation and stabilization of pt
◦ Control bleedi...
Preoperative ManagementPreoperative Management
Evaluation for replantation:
◦ Complete amputation:
 Take amputated part ...
Recommended ischemia times for
reliable success:
◦ Digit: 12 hours for warm ischemia and 24
hours for cold ischemia.
◦ Ma...
Operative ManagementOperative Management
Team approach
◦ to avoid surgeon fatigue
Regional anesthesia alone or in
combin...
Operative ManagementOperative Management
Arterial or venous repair first?
 Vein first minimizes blood loss and completes...
Operative ManagementOperative Management
37
Operative ManagementOperative Management
Preparation of stump:
 Tourniquet control
 Debridement, identification, taggin...
Operative ManagementOperative Management
39
40
Operative ManagementOperative Management
Tendon repair:
 nonabsorbable sutures
 extensor tendons with 4-0 interrupted
h...
Operative ManagementOperative Management
Vein repair:
 number of venous repairs exceeds the number
of arterial repairs b...
Operative ManagementOperative Management
Arterial repair:
 Repair both arteries
 Dominant artery
 vein graft, cross an...
Operative ManagementOperative Management
Nerve repair:
 tension-free nerve repair with 8.0 suture
 posterior interosseo...
Operative ManagementOperative Management
45
Operative ManagementOperative Management
Dressing:
 Vaseline gauze
 Soft bulky dressing
 Avoid circumferential compres...
47
Postoperative ManagementPostoperative Management
Postop care
 highest risk of postop thrombosis is in the first
72 hours...
Postoperative ManagementPostoperative Management
Anticoagulation:
 a 100 mL bolus of dextran-40 intravenously
prior to r...
Postoperative ManagementPostoperative Management
Monitoring:
 monitor perfusion by examining color, pulp turgor,
capilla...
Postoperative ManagementPostoperative Management
Monitoring:
 lf there is a suspicion of compromised
perfusion,immediate...
Postoperative ManagementPostoperative Management
Therapy:
◦ Hand therapy can be started about a week after
replantation, o...
53
OUTCOMEOUTCOME
 Overall success rates for replantation approach 80%.
 Better outcome with Guillotine (sharp) amputation ...
55
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Hand replantation

  1. 1. MUTILATING INJURIESMUTILATING INJURIES OF UPPER EXTREMITYOF UPPER EXTREMITY ANDAND REPLANTATIONREPLANTATION By: Dr Uzma Naseer PGR Plastic Surgery 1
  2. 2. Mangled/ Mutilating InjuriesMangled/ Mutilating Injuries Components: ◦ Soft tissue/ integuments ◦ Nerve ◦ Vasculature ◦ Bone 2
  3. 3. 3
  4. 4. 4
  5. 5. Etiology:Etiology: Ballistic missile Blast injuries Firearm injuries Motor vehicle accidents Industrial injuries Agricultural injuries 5
  6. 6. EvaluationEvaluation Standard ATLS protocol Control of h’age Secondary survey Full neurologic exam Vascular examination Assesment of function Observation of gross deformity Digital cascade/position of limb 6
  7. 7. Radiographic ExaminationRadiographic Examination Hand/wrist ◦ 3 views Forearm/elbow ◦ 2 views Complex joint injuries ◦ CT scan Suspected vascular injury ◦ Angiographic evaluation 7
  8. 8. 8
  9. 9. Operative ManagementOperative Management Physiologically stable pt: ◦ Immediate vascular recon in ischemia  (repair,reconstruction,temporary shunting) ◦ Ischemia not present/prolonged  Complete & aggressive debridement  Bony stabilization  Vascular reconstruction  Tendon &nerve repair  Soft tissue repair/recostruction 9
  10. 10. 10
  11. 11. DebridementDebridement ◦ Thorough debridement ◦ Wound cultures ◦ i/v antibiotic ◦ Moist dressings ◦ Neg pressure wound therapy 11
  12. 12. Vascular reconstructionVascular reconstruction Before or after bony stabilization? Vein grafts Shunts Ligation? 12
  13. 13. Bony fixationBony fixation External/internal fixation Shortening may be performed ◦ (to allow primary repair of nerves n vessels) Bone grafting in gaps>3cm Vascularized bone graft in gaps>6cm 13
  14. 14. Tendon RepairTendon Repair Tendon grafts ◦ PL, plantaris, toe extensor Tendon transfers ◦ Recon of EPL with EIP transfer Free tendocutaneous flap ◦ PL, FCR from contralateral arm Allograft tendon 14
  15. 15. Nerve reconstructionNerve reconstruction As soon as possible Primary repair ◦ Sharp injuries Nerve Grafting ◦ Crushed , avulsed injuries Primarily repaired nerves have better sensory and motor recovery Younger age, distal injury, and earlier time of repair associated with better motor recovery 15
  16. 16. Soft Tissue CoverageSoft Tissue Coverage STSG Pedicled fasciocutaneous flaps Regional flaps Stsg covered fascial flaps Stsg covered free muscle flap Groin/ abdominal flaps 16
  17. 17. Compartment syndromeCompartment syndrome Diagnosis ◦ Purely clinical ◦ Five Ps in awake , cooperative pt ◦ pain with passive extension Fasciotomy 17
  18. 18. ConclusionConclusion Complex injuries Multidisciplinary team approach threshold for amputation of UE should be higher 'bad hand‘ may be more functional than a good amputation 18
  19. 19. REPLANTATIONREPLANTATION 20
  20. 20. ReplantationReplantation Reattachment of a completely amputated body part by reestablishing arterial inflow and venous outflow. 21
  21. 21. RevascularizationRevascularization Reattachment of incompletely amputated parts requiring restoration of both arterial inflow and venous outflow If the incomplete amputation needs only an arterial repair for restoring circulation, the correct term is critical arterial repair. 22
  22. 22. HistoryHistory  Balfour provided the first scientific report of digital reattachment in 1814  Murphy in 1896 reported the first successful critical arterial repair.  Kleinert performed the first successful extremity revascularization in 1958  Malt performed the first successful extremity replantation in 1962  Komatsu and Tamai performed the first successful replantation of completely amputated digit with microsurgical anastomosis in1965 23
  23. 23. INTRODUCTIONINTRODUCTION Not all patients with amputation are candidates for replantation Decision based on: Importance of the part Level of injury Expected return of function. Hand function is severely compromised if thumb or multiple fingers are lost so replants of these should be attempted. Mechanism of injury may be the most predictive variable for successful replantation. 24
  24. 24. Indications for replantationIndications for replantation Strong indications • Multiple digital amputations • Thumb amputations • Whole hand • Transmetacarpal and partial hand amputations • Any amputated part in a child • Single digit amputation distal to FDS insertion Relative indications • Sharp injuries at elbow or proximal forearm • Humeral-level amputations 25
  25. 25. Relative contraindications toRelative contraindications to replantationreplantation • Concomitant life-threatening injury • Systemic illness (e.g., small-vessel disease) • Poor anesthesia risk including old age (>70 yrs) • Mentally unstable patients • Single finger proximal to FDS insertion in adults • Multiple segmental injuries in the amputated part • Severe crushing or avulsion of the tissues • Extreme contamination • Prior surgery or trauma to the amputated part • Prolonged warm ischemia time • Ribbon sign, red line sign • smoker/drug abuse 26
  26. 26. 27
  27. 27. 28 Replantation center criteriaReplantation center criteria 1. An efficient ground and air transportation system 2. Experienced microsurgical teams 3. A well-prepared emergency room staff 4. Experienced anesthetists, operating room, and microsurgical staff available 24 hours/day, 7 days/week 5. Proper microscopes, instruments, and sutures 6. A carefully trained nursing staff for postoperative care and monitoring 7. Physical and occupational therapists trained in
  28. 28. Preoperative ManagementPreoperative Management Transfer to a replantation center: ◦ Amputation stump:  covered with a saline-moistened gauze, loosely wrapped, and elevated  Compression bandages may be required to stop bleeding 29
  29. 29. Preoperative ManagementPreoperative Management ◦ The amputated part:  Thoroughly washed  Wrapped in a saline moistened gauze  Placed in a dry, watertight plastic bag  Placed in ice 30
  30. 30. Preoperative ManagementPreoperative Management 31
  31. 31. Preoperative ManagementPreoperative Management Management in ER: ◦ Resuscitation and stabilization of pt ◦ Control bleeding ◦ Brief history ◦ X-rays of amputated part & proximal stump ◦ Routine investigations ◦ Tetanus prophylaxis ◦ Prophylactic antibiotics 32
  32. 32. Preoperative ManagementPreoperative Management Evaluation for replantation: ◦ Complete amputation:  Take amputated part to OR  Dissect, isolate & tag imp structures ◦ Incomplete amputation:  If held by only strands, divide them  If a skin bridge is present,keeping it is important 33
  33. 33. Recommended ischemia times for reliable success: ◦ Digit: 12 hours for warm ischemia and 24 hours for cold ischemia. ◦ Major replant: 6 hours of warm and 12 hours of cold ischemia. Preoperative preparation: radiography of both amputated and stump parts to determine the level of injury and suitability for replantation 34
  34. 34. Operative ManagementOperative Management Team approach ◦ to avoid surgeon fatigue Regional anesthesia alone or in combination with general anesthesia Patient preparation:  Catheterization, padded tourniquet ,lower limb preparation, temperature, padding all bony prominences 35
  35. 35. Operative ManagementOperative Management Arterial or venous repair first?  Vein first minimizes blood loss and completes the most difficult step  artery first allows selection of veins with good outflow for anastomosis Bench work:  debridement, isolation of NV structures & bone shortening  performed with the amputated part on ice pack  digits unsuitable for replantation should not be discarded  vessels & nerves tagged with small metal clips or 8-0 sutures 36
  36. 36. Operative ManagementOperative Management 37
  37. 37. Operative ManagementOperative Management Preparation of stump:  Tourniquet control  Debridement, identification, tagging  positive "spurt" test  bathed with 2% lidocaine or papaverine  Vein grafts from the volar wrist Bone fixation:  Parallel k wires,  single IO wire loop with oblique k wire  crossed K-wires or 2 perpendicular interosseous wire loops  Dynamic compression plates, screws 38
  38. 38. Operative ManagementOperative Management 39
  39. 39. 40
  40. 40. Operative ManagementOperative Management Tendon repair:  nonabsorbable sutures  extensor tendons with 4-0 interrupted horizontal mattress  flexor tendons with a combination of an epitendinous repair (6-0 suture) and a four- strand core suture (4-0 suture). 41
  41. 41. Operative ManagementOperative Management Vein repair:  number of venous repairs exceeds the number of arterial repairs by one  Tension free repair  Reversed vein graft 42
  42. 42. Operative ManagementOperative Management Arterial repair:  Repair both arteries  Dominant artery  vein graft, cross anastomosis (radial digital artery to ulnar digital artery) or transposition of a digital artery from one of the adjacent fingers 43
  43. 43. Operative ManagementOperative Management Nerve repair:  tension-free nerve repair with 8.0 suture  posterior interosseous nerve for small gaps  medial antebrachial cutaneous nerve for longer defects  Graft from discarded digits Skin closure:  Meticulous hemostasis and the skin flaps losely approximated  local skin flaps  Skin grafts  In major limb replantations, a prophylactic fasciotomy is performed to decompress TH, HTH, dorsal IO spaces ,CT, forearm muscle compartments 44
  44. 44. Operative ManagementOperative Management 45
  45. 45. Operative ManagementOperative Management Dressing:  Vaseline gauze  Soft bulky dressing  Avoid circumferential compression  Immobilization in a splint  Elevation 46
  46. 46. 47
  47. 47. Postoperative ManagementPostoperative Management Postop care  highest risk of postop thrombosis is in the first 72 hours  Arterial thrombi present on day 1,  venous thrombi present by day 2 or 3.result from fibrin clotting  NPO for 24 hrs  Preventing extrnal factors resulting in spasm and thrombosis  Warm, hydrated, elevated, pain free,avoid smoking & caffeinated drinks  Antibiotics for 5-7 days 48
  48. 48. Postoperative ManagementPostoperative Management Anticoagulation:  a 100 mL bolus of dextran-40 intravenously prior to release of the vascular clamps,  Followed by a continuous infusion of dextran- 40 at 500 mL per day for 5 days (10 ml/kg/day).  A 5,000 unit bolus of heparin after removal of the arterial clamp.  once-daily dose of 100 mg of aspirin that is continued for 3 weeks  continuous low-dose heparin infusion for 3 to 4 days for smokers 49
  49. 49. Postoperative ManagementPostoperative Management Monitoring:  monitor perfusion by examining color, pulp turgor, capillary refill and temperature.  hourly for the first 72 hours (3 days) and once every 4 hours for the next 48 hours (2 days).  soft (flaccid), pale fingertip with a delayed capillary refill (>2 seconds) indicates arterial vasospasm or thrombosis  A swollen (turgid) blue finger tip with rapid capillary refill (<1 second) indicates venous thrombosis.  pulse-oximeter probe secured to the pulp  loss of the pulse rate indicates arterial occlusion, whereas a fall in oxygen saturation below 90% indicates venous occlusion 50
  50. 50. Postoperative ManagementPostoperative Management Monitoring:  lf there is a suspicion of compromised perfusion,immediate action is taken  usually a thrombosis of an anastomosis that invariably requires the use of an interposition vein graft.  consider the use of leeches  or encourage continuous venous bleeding from the nail bed by removing a portion of the nail bed and repeatedly applying heparin-soaked pledgets 51
  51. 51. Postoperative ManagementPostoperative Management Therapy: ◦ Hand therapy can be started about a week after replantation, once anticoagulation is stopped ◦ dorsal splint is provided and the patient started on gentle active range of motion exercises. ◦ continued upto 2 to 3 months postoperatively 52
  52. 52. 53
  53. 53. OUTCOMEOUTCOME  Overall success rates for replantation approach 80%.  Better outcome with Guillotine (sharp) amputation (77%) compared to severely crushed and mangled body parts(49%).  The best results are obtained in replantation of the thumb, fingers amputated distal to the insertion of the FDS, and the hand through the wrist or the distal forearm.  Studies have demonstrated that patients can expect to achieve 50% function and 50% sensation of the replanted part.  Outcome is monitored by scoring system introduced by Tamai and chen 54
  54. 54. 55
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