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Successful revascularization of an incompletely amputated finger with serious venous congestion — A case report
DEPARTMENT OF TECHNIQUE Successful revascularization of an incompletely amputated finger with serious venous congestionA case report Enrique Fossati, M.D., and Alberto lrigaray, M.D., Montevideo, Uruguay
Received for publication March 31, 1982; accepted in revised form Aug. 29, 1982. Reprint requests: Enrique Fossati, M.D., Jorge Canning 2417, Montevideo, Uruguay.
though in many cases, no suitable veins can be identified on the injured segment. The survival of replanted digits at different levels, without venous anastomosis, 1, 2 has been achieved by applying mechanical compression (milking method)3-7 or by way of multiple incisions in the skin pulp, which serve as venous drains. 8-10 We have no experience with the use of leeches. The existence of a skin bridge, no matter how small,
Fig.!. Left hand. The injury caused by a circular saw.
Fig. 2. On the fourth day, to prevent thrombosis of the sole open vein (0.4 mm diameter), the multifenestrated catheter was placed in the dorsum of the finger, permitting constant infusion wth heparin solution.
Numerous reports on digital replantation and revascularization have been published. The importance of venous drainage is emphasized by every author, alFrom the Department of Plastic and Reconstructive Surgery of Pasteur Hospital, Montevideo, Uruguay.
356
THE JOURNAL OF HAND SURGERY
Vol. 8, No.3 May 1983
Successfill rel'ascularization of an incompletely amputated finger
357
Fig. 3. The long finger survived, but there was considerable dorsoulnar tissue loss .
is important because it can include drainage elements. Experimental research confirms that new vascular channels are formed in free flaps 2 or 3 days after surgery.u This report describes the salvage of an incompletely amputated finger with serious postoperative venous problems.
Case report The patient, a 19-year-old man, was injured by a circular saw, sustaining a complete interphalangeal amputation of his thumb and an incomplete proximal interphalangeal (PIP) amputation of the index, long, and ring fingers of his left hand (Fig. 1). The type of wound of the thumb and index finger contraindicated their replantation. In the case of the thumb, the segment was sectioned obliquely. The vessels were avulsed and, in our opinion, replantation was not indicated . The index finger was not replanted since there was an avulsion of its neurovasculoar pedicles, a multiple fracture of the PIP joint, and multitendinous sections . We considered that its replantation or transfer to the thumb position was not practical. Even if survival of that segment was achieved, final functional results would have been unacceptable. The long finger had a 4 mm skin bridge on the radial side, so we proceeded with revascularization of that finger. The patient received a PIP arthrodesis with an intramedullary acrylic peg and tendinous and neural repair were done . We repaired only the ulnar digital artery and one dorsal vein . A good distal flow was verified . The finger was slightly congested. The skin was sutured without tension . No vascular repair was needed to aid the recovery of the ring finger.
Postoperative medication consisted of dextran, dipyridamole, and aspirin, in usual doses. The long finger remained a mildly congestive color during the second and third days. On the fourth day the vascular repairs were explored because the finger became cyanotic and swollen. The artery was patent and had a normal flow . The sole repaired vein was occluded by a thrombus . The venous drainage was solely by a single sectioned vessel 0.4 mm in diameter, which had not been sutured or tied and was open and patent at its tip, allowing an external drainage. In order to prevent thrombosis of this sole venous drainage, a multifenestrated siliconed catheter was applied to the dorsal side of the finger, permitting a constant infusion with heparin solution (Fig. 2) . A 3-day infusion of heparin near the open end of the vessel appeared to prevent the formation of a fibrin thrombus. 12 The external venous drainage was maintained while new vascular channels were formed .II The replanted finger could be salvaged in this manner, although there was great dorsoulnar tissue loss (more than half the circumference of the finger) that reached the bone (Fig . 3). This tissue loss was later repaired with an infraclavicular skin flap (Fig. 4). We express our gratitude to Dr. Guillermo H. Fossati, Head of the Plastic and Reconstructive Surgery Department, Pasteur Hospital, Montevideo, for his support.
REFERENCES I. Serafin D , Kutz J, Kleinert H: Replantation of a completely amputated distal thumb without venous anastomosis . Plast Reconstr Surg 52:579-81, 1973
358
Fossati and lrigaray
Fig. 4. Coverage for the area of tissue loss was supplied by an infraclavicular skin flap. 2. Foucher G, Henderson HR, Manean M, Merle M, Braun FM: Distal digital replantation: One of the best indications for microsurgery. Int J Microsurg 3:263-70, 1981 3. Maruyama Y, Nakajima H, Wada M, Kubota J, Fujino T: Replantation of an amputated finger without venous anastomosis. A case study, Keio J Med 28:27-31, 1979
The Journal of HAND SURGERY
4. Tarnai S: Personal communication. Fifth International Symposium on Microsurgery, Guaruja, Brasil, May 15-18, 1979 5. Tarnai S, Tatsumi Y, Shimizu T, Hori Y, Okuda H, Takita T, Sakamoto H, Fukui A: Traumatic amputation of digits: The fate of remaining blood-An experimental and clinical study. J HAND SURG 2: 13-21, 1977 6. Tarnai S: Digit replantation. Analysis of 163 replantations in an 11 year period. Clin Plast Surg 5:195-209, 1978 7. Tarnai S, Hori Y, Tatsumi Y, Okuda H, Nakamura Y, Sakamoto H, Takita T, Fukui A: Microvascular anastomosis and its application on the replantation of amputated digits and hands . Clin Orthop Rei Res 133: 106-21, 1978 8. O'Brien McCB et al: Clinical replantation of digits . Plastic Reconstr Surg 52:490, 1973 9. Daniel R, Terzis J: Reconstructive microsurgery. Boston, 1977, Little, Brown & Co, p 152 10. Discussion: The Sixth Symposium of the International Society of Reconstructive Microsurgery, Melbourne, Australia, February 5-10, 1981 11. Nakajima T: How soon do venous drainage channels develop at the periphery of a free flap. Br J Plast Surg 31:300-8, 1978 12. Rosenow E, Osmundson P, Brown M: Pulmonary embolism. Mayo Clin Proc 56:161-71, 1981
Received for publication March 31, 1982; accepted in revised form Aug. 29, 1982. Reprint requests: Enrique Fossati, M.D., Jorge Canning 2417, Montevideo, Uruguay.
though in many cases, no suitable veins can be identified on the injured segment. The survival of replanted digits at different levels, without venous anastomosis, 1, 2 has been achieved by applying mechanical compression (milking method)3-7 or by way of multiple incisions in the skin pulp, which serve as venous drains. 8-10 We have no experience with the use of leeches. The existence of a skin bridge, no matter how small,
Fig.!. Left hand. The injury caused by a circular saw.
Fig. 2. On the fourth day, to prevent thrombosis of the sole open vein (0.4 mm diameter), the multifenestrated catheter was placed in the dorsum of the finger, permitting constant infusion wth heparin solution.
Numerous reports on digital replantation and revascularization have been published. The importance of venous drainage is emphasized by every author, alFrom the Department of Plastic and Reconstructive Surgery of Pasteur Hospital, Montevideo, Uruguay.
356
THE JOURNAL OF HAND SURGERY
Vol. 8, No.3 May 1983
Successfill rel'ascularization of an incompletely amputated finger
357
Fig. 3. The long finger survived, but there was considerable dorsoulnar tissue loss .
is important because it can include drainage elements. Experimental research confirms that new vascular channels are formed in free flaps 2 or 3 days after surgery.u This report describes the salvage of an incompletely amputated finger with serious postoperative venous problems.
Case report The patient, a 19-year-old man, was injured by a circular saw, sustaining a complete interphalangeal amputation of his thumb and an incomplete proximal interphalangeal (PIP) amputation of the index, long, and ring fingers of his left hand (Fig. 1). The type of wound of the thumb and index finger contraindicated their replantation. In the case of the thumb, the segment was sectioned obliquely. The vessels were avulsed and, in our opinion, replantation was not indicated . The index finger was not replanted since there was an avulsion of its neurovasculoar pedicles, a multiple fracture of the PIP joint, and multitendinous sections . We considered that its replantation or transfer to the thumb position was not practical. Even if survival of that segment was achieved, final functional results would have been unacceptable. The long finger had a 4 mm skin bridge on the radial side, so we proceeded with revascularization of that finger. The patient received a PIP arthrodesis with an intramedullary acrylic peg and tendinous and neural repair were done . We repaired only the ulnar digital artery and one dorsal vein . A good distal flow was verified . The finger was slightly congested. The skin was sutured without tension . No vascular repair was needed to aid the recovery of the ring finger.
Postoperative medication consisted of dextran, dipyridamole, and aspirin, in usual doses. The long finger remained a mildly congestive color during the second and third days. On the fourth day the vascular repairs were explored because the finger became cyanotic and swollen. The artery was patent and had a normal flow . The sole repaired vein was occluded by a thrombus . The venous drainage was solely by a single sectioned vessel 0.4 mm in diameter, which had not been sutured or tied and was open and patent at its tip, allowing an external drainage. In order to prevent thrombosis of this sole venous drainage, a multifenestrated siliconed catheter was applied to the dorsal side of the finger, permitting a constant infusion with heparin solution (Fig. 2) . A 3-day infusion of heparin near the open end of the vessel appeared to prevent the formation of a fibrin thrombus. 12 The external venous drainage was maintained while new vascular channels were formed .II The replanted finger could be salvaged in this manner, although there was great dorsoulnar tissue loss (more than half the circumference of the finger) that reached the bone (Fig . 3). This tissue loss was later repaired with an infraclavicular skin flap (Fig. 4). We express our gratitude to Dr. Guillermo H. Fossati, Head of the Plastic and Reconstructive Surgery Department, Pasteur Hospital, Montevideo, for his support.
REFERENCES I. Serafin D , Kutz J, Kleinert H: Replantation of a completely amputated distal thumb without venous anastomosis . Plast Reconstr Surg 52:579-81, 1973
358
Fossati and lrigaray
Fig. 4. Coverage for the area of tissue loss was supplied by an infraclavicular skin flap. 2. Foucher G, Henderson HR, Manean M, Merle M, Braun FM: Distal digital replantation: One of the best indications for microsurgery. Int J Microsurg 3:263-70, 1981 3. Maruyama Y, Nakajima H, Wada M, Kubota J, Fujino T: Replantation of an amputated finger without venous anastomosis. A case study, Keio J Med 28:27-31, 1979
The Journal of HAND SURGERY
4. Tarnai S: Personal communication. Fifth International Symposium on Microsurgery, Guaruja, Brasil, May 15-18, 1979 5. Tarnai S, Tatsumi Y, Shimizu T, Hori Y, Okuda H, Takita T, Sakamoto H, Fukui A: Traumatic amputation of digits: The fate of remaining blood-An experimental and clinical study. J HAND SURG 2: 13-21, 1977 6. Tarnai S: Digit replantation. Analysis of 163 replantations in an 11 year period. Clin Plast Surg 5:195-209, 1978 7. Tarnai S, Hori Y, Tatsumi Y, Okuda H, Nakamura Y, Sakamoto H, Takita T, Fukui A: Microvascular anastomosis and its application on the replantation of amputated digits and hands . Clin Orthop Rei Res 133: 106-21, 1978 8. O'Brien McCB et al: Clinical replantation of digits . Plastic Reconstr Surg 52:490, 1973 9. Daniel R, Terzis J: Reconstructive microsurgery. Boston, 1977, Little, Brown & Co, p 152 10. Discussion: The Sixth Symposium of the International Society of Reconstructive Microsurgery, Melbourne, Australia, February 5-10, 1981 11. Nakajima T: How soon do venous drainage channels develop at the periphery of a free flap. Br J Plast Surg 31:300-8, 1978 12. Rosenow E, Osmundson P, Brown M: Pulmonary embolism. Mayo Clin Proc 56:161-71, 1981