Finger Reattachment

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Finger reattachment (or replantation) is defined as reattachment of a finger that has been completely amputated. In general, a finger amputation may be defined as either complete (there is no connection between the amputated finger[s] and the rest of the hand) or incomplete (the finger is connected to the rest of the hand by tendons, skin fragments, or muscle tissue).

Purpose

Reattachment can be surgically performed for the finger and such other detached body parts as the hand or arm. The first successful replantation of a severed finger tip was performed in 1814 by William Balfour, a British surgeon. Replantation of amputated fingers was not attempted on a widespread basis, however, until the invention of the operating microscope in the early 1960s. The first successful replantation of an entire arm was performed in 1962 on a 12-year-old boy who had been injured in a train accident. The technique used in the early 2000s to reconstruct the blood vessels in an injured hand was developed in 1965 by two Japanese surgeons, Shigeo Komatsu and Susumu Tamai. Reattachment of an amputated finger can be carried out in most large hospitals in the early 2000s.

Demographics

There are about 30,000 cases of traumatic amputations in the United States each year; 65% of these involve the upper limbs (arms, hands, and fingers). Most patients are between the ages of 15 and 40, and 80% are male. Good candidates for this procedure include persons with thumb or multiple digit amputation. Injury to multiple digits is an important patient selection criterion, since in some cases the least damaged digits may be moved to the least injured or most useful stump. Patient exclusion is neither clear-cut nor absolute; however, patients who have cut off their own fingers should receive a psychiatric evaluation before reattachment is attempted, as many of these patients later cut off the finger a second time. Generally, severe crushing or avulsing (tearing away) injuries to the fingers complicates replantation; however, venous grafts may help replace injured blood vessels. Additionally, older persons may have arteriosclerosis that frequently impairs function in blood vessels, especially in small vessels. Special efforts may be made to replant fingers if the person’s livelihood (such as professional music performance) depends on absolute finger control.

Description

To increase efficiency, the replantation team splits into two smaller teams. One sub-team in the operating room cleans the amputated finger with sterile solutions, places it on ice, and identifies and tags (with special surgical clips) nerves and blood vessels. Dead or damaged tissue is surgically removed with a procedure called debridement. The emergency room (ER) sub-team will assess the patient during a physical exam with x rays of the injured area, blood analysis, and cardiac (heart) monitoring. The patient is given fluids intravenously (IV), a tetanus injection (to prevent infection by Clostridium tetani, a bacterium that can invade the body through crush injuries or penetrating wounds and release a potent neurotoxin), and antibiotics. Usually, most finger reattachments are performed with a local anesthetic such as bupivacaine and a nerve block to numb the affected arm. Maintaining a warm body temperature can enhance blood flow to the affected limb.

The surgical procedure consists of several stages. The bone in the amputated finger must be shortened and fixed, which means that the bone end is trimmed. After this process, the bone is stabilized with special sutures called K-wires, and fixed pins are placed in the bone after drilling a space to insert them. This process connects the two amputated bone fragments. After bone stabilization and fixation, the extensor and flexor tendons are repaired. This step is vital, since arteries, veins, and nerves should never be surgically connected under tension. Next, the surgeon must repair (suture) severed tendons, arteries, veins, and

nerves. Healthy arteries and veins are sutured together without tension. A vein graft is used for blood vessels that cannot be reattached.

Nerve repair for finger reattachment is not complicated. Since the reattached bone parts are shorter than the original length, nerves can be reattached

KEY TERMS

Arteriosclerosis— Hardening of the arteries, also called atherosclerosis.

Avulsion— The tearing away of a body part or tissue.

Debridement— Surgical removal of damaged tissues.

Digits— Fingers or toes.

Guillotine amputation— An amputation in which the severed part is cut off cleanly by a blade or other sharp-edged object.

Prosthesis— An artificial device to replace a missing body part.

Replantation— The medical term for the reattachment of an amputated digit.

Sutures— Stitches.

Tetanus— A potentially deadly disease produced by a bacterium that may infect crush injuries or penetrating wounds.

Vasospasm— Alternating contraction and relaxation of the muscle coating of blood vessels.

Venous graft— Transfer of living vein tissue within the same host (from one place of the body to another in the same person).

without tension. A microscope is used for magnified visualization of finger nerves during reattachment. When the severed ends of the nerve cannot be reattached, a primary nerve graft is performed. Finally, it is vital to cover superficial veins on the affected finger(dorsal veins) with a skin flap to prevent death of the venous vessels. The skin over the surgical field is loosely sutured with a few sutures. Any damaged tissue that may die (necrotic tissue) is removed. No tension should be placed on the skin fields during closure of the wound. Wounds are covered with small strips of gauze impregnated with petrolatum. The upper extremity is immobilized, and compression hand dressing and plaster splints are arranged to prevent slipping and movement of the affected arm.

Diagnosis/Preparation

The diagnosis is easily made by visual inspection. The reattachment procedure is complex and involves the expertise and skill of a highly trained surgeon. There are several important factors necessary to successful replantation, including special instrumentation and transportation of the amputated finger. Surgicalloupes (binocular type eyepieces used by surgeons to magnify small structures during surgery) are necessary for this procedure. Instruments should be at least 3.9 in (10 cm) long to allow for proper positioning in the surgeon’s hands. Special clips are used to help suture blood vessels together. The best method of saving and transporting the amputated finger is to wrap it with moistened cloth (Ringer’s lactate solution or saline solution) and place it on ice. Generally, the tissues will survive for about six hours without cooling. If the part is cooled, tissue survival time is approximately 12 hours. Fingers have the best outcome for transportation survival, since digits (fingers) do not have a large percentage of muscle tissue.

Aftercare

Postoperative care is vital for successful finger reattachment. The hand is wrapped in a bulky compression dressing and usually elevated. If arterial flow is impaired, then the hand should be lowered, since this maneuver will promote blood flow from the heart to the reattached finger. If venous outflow is slow, the hand must be elevated. Medications to increase blood flow (peripheral vasodilators) and an anticoagulant (heparin) are used. A tranquilizer may be given to reduce unnecessary blood vessel movement (vasospasm) that can occur due to anxiety. Careful examination of the reattached digit(s) is necessary. The surgeon frequently monitors color, the capacity of blood vessels, capillary refill, and warmth to monitor replant progress. The YSI telethermometer monitors the digital (finger) temperature with small surface probes. Skin temperature falling below 86°F (30°C) indicates poor blood perfusion (poor blood and oxygen delivery to the affected area) of the replant. The cause of poor blood circulation must be investigated and corrected, if possible. The patient’s room should be warm, and bed rest for two to three days is recommended. Patients must refrain from smoking and take antibiotics for one week after surgery. Follow-up consultations are necessary for continued wound care and rehabilitation.

Some patients may need additional surgery at a later date to free tendons from scar tissue, transfer muscle tissue to the affected finger, or improve the functioning of the nerves in the finger. In a few cases the reattached finger may have to be removed because of complete loss of function or intractable pain.

Risks

The experienced surgeon can estimate the likelihood of complications based on the nature of the injury. Replantations that are risky, such as those with circulatory perfusion problems, have lower success rates. Generally, the most difficult replantations are those that involve children under 10, injuries caused by a ring catching in machinery (ring avulsion injury), and crush-and-tear injuries. Management of the

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

The reattachment procedure itself is usually performed in a hospital operating room by a micro-surgeon, who may be a plastic surgeon with five years of general surgery training, plus two years of plastic surgery training and another one or two years of training in microneurovascular surgery; or an orthopedic surgeon with one year of general surgery training, five years of orthopedic surgery training, and additional years in microsurgery training.

The patient may be cared for by a variety of emergency medical technicians, nurses, and physicians at the scene of the accident or in the hospital emergency department before replantation is performed. These health professionals may cleanse or splint the injured limb, administer pain medications, and perform other procedures to prepare the patient for surgery.

difficult replant typically includes intravenous heparin to prevent clotting of the blood, and providing a continuous nerve block in either the median or ulnar nerve (depending on which fingers are reattached). A nerve block will cause vasodilation, or expansion of the blood vessels. Vasodilation will increase blood flow, bringing with it fresh oxygenated blood. Further evaluation should include checking the patient’s dressing for constriction (i.e., if the dressing was placed too snugly and is constricting local blood vessels).

There are some psychological risks to replantation, as patients are often distressed by loss of function in the affected finger(s) or by the appearance of the injured hand. Since 100% of function cannot be restored, patients may find that there are some activities or hobbies that they can no longer enjoy. In some cases, they may not be able to do the work they did before their injury and may have to seek another type of employment. Some patients may need counseling in order to deal with the changes in their life that may be forced on them by loss of function in the injured hand.

Normal results

Normal results depend on several factors: how much of the finger was cut off; whether any joints were affected, or only the tip; whether the wound was a guillotine amputation (a clean cut by a sharp-edged object) or involved crushing or tearing; and the patient’s age. In general, younger patients and non-smokers recover more function and sensation in the

QUESTIONS TO ASK THE DOCTOR

• Are there any special precautions I should take with my pain medication?
• How should I care for the wound?
• When will I regain feeling and function in the affected finger(s)?
• Will I need physical therapy for the injury?
• How much function can I expect to regain?
• Will I be able to go back to my old job?

reattached finger. Reattachment following a guillotine amputation has a higher rate of success (more than 80%) than reattachment following a crush or avulsion amputation (55%).

There are two types of nerves involved in recovering the use of the fingers: sensory nerves (which detect heat, cold, roughness, and other sensations) and motor nerves (which govern the movement of muscles). Nerves in the fingers grow about an inch per month. The number of inches from the injury to the tip of the injured finger gives the minimum number of months after which the patient may begin to notice sensations in that fingertip. Results usually include good nerve recovery and 60-80% recovery of range of motion; cold intolerance (usually reversed in about two years); and acceptable cosmetic appearance.

Morbidity and mortality rates

Most finger replantations involving guillotine amputations in patients younger than 40 years are successful. Replantations in patients with crush or avulsion injuries are more likely to have complications after surgery. Smokers and patients with diabetes also have poorer outcomes. Mortality from finger reattachment is very low; fatal outcomes are almost always in patients with multilevel injuries involving the head or chest as well as amputation of a finger or hand.

Alternatives

According to the American Society for Surgery of the Hand, the surgeon will explain to the patient how much function the patient can expect to have after replantation and allow the patient to decide whether the operation itself, time spent in the hospital, and a long period of rehabilitation are worth that degree of recovery. One alternative to replantation is a prosthesis for the missing finger.

Resources

BOOKS

Berger, Richard A., and Arnold-Peter C. Weiss, eds. Hand Surgery. Philadelphia: Lippincott Williams and Wilkins, 2004.

Green, David P. Green’s Operative Hand Surgery, 5th ed. Philadelphia: Elsevier Churchill Livingstone, 2005.

Trumble, Thomas E., and Jeffrey E. Budoff. Hand Surgery Update IV, 4th ed. Rosemont, IL: American Society for Surgery of the Hand, 2007.

PERIODICALS

Brooks, D., R. F. Buntic, G. M. Kind, et al. “Ring Avulsion: Injury Pattern, Treatment, and Outcome.” Clinics in Plastic Surgery 34 (April 2007): 187–195.

Datiashvili, R. O., K. R. Knox, and G. M. Kaplan. “Solutions to Challenging Digital Replantations.” Clinics in Plastic Surgery 34 (April 2007): 167–175.

Molski, M. “Replantation of Fingers and Hands after Avulsion and Crush Injuries.” Journal of Plastic, Reconstructive and Aesthetic Surgery 60 (July 2007): 748–754.

Morrison, W. A., and D. McCombe. “Digital Replantation.” Hand Clinics 23 (February 2007): 1–12.

ORGANIZATIONS

American Association for Hand Surgery. 20 North Michigan Avenue, Suite 700, Chicago, IL 60602. (321) 236-3307; Fax: (312) 782-0553. E-mail: contact@hands surgery.org. http://www.handsurgery.org (accessed March 22, 2008).

American College of Emergency Physicians (ACEP). 1125 Executive Circle, Irving, TX 75038-2522. (800) 798-1822 or (972) 550-0911. http://www.acep.org/ (accessed March 22, 2008).

American Society for Surgery of the Hand (ASSH). 6300 North River Road, Suite 600, Rosemont, IL 60018. (847) 384-8300. http://www.assh.org/AM/Template.cfm (accessed March 22, 2008).

OTHER

American Society for Surgery of the Hand (ASSH). Replantation.http://www.assh.org/Content/NavigationMenu/PatientsPublic/HandConditions/Replantation/Replantation.htm (accessed January 15, 2008).

Kazzi, Zian M. “Replantation.” eMedicine, September 4, 2007 [cited January 15, 2008]. http://www.emedicine.com/emerg/topic502.htm (accessed March 22, 2008).

Murphy, Paul, Chris Colwell, Gilbert Pineda, and Tamara Bryan. “Traumatic Amputations: How EMS Providers Can Manage Amputations in the Field.” August 22, 2006. EMSResponder.com.http://publicsafety.com/article/article.jsp?id = 3541&siteSection = 4 (accessed January 15, 2008).

“Superficial Fingertip Avulsion.” National Center for Emergency Medicine Informatics. [cited June 2003] http://www.ncemi.org/cse/cse1002.htm (accessed March 22, 2008).

“The V-Y Plasty in the Treatment of Fingertip Amputations.” American Academy of Family Physicians. [cited June 2003] http://www.aafp.org/afp/20010801/455.html (accessed March 22, 2008).

Wilhelmi, Bradon J., and W. P. Andrew Lee. “Hand, Amputations and Replantation.” eMedicine, June 28, 2006 [cited January 15, 2008]. http://www.emedicine.com/plastic/topic536.htm (accessed March 22, 2008).

Laith Farid Gulli, MD, MS

Bilal Nasser, MD, MS

Robert Ramirez, BS

Rebecca Frey, PhD