- Email: [email protected]
The smallest digital replant yet?
THE SMALLEST
DIGITAL REPLANT
YET?
By TAKASHIKUBO, M.D.,
YOSHIKAZUIKUTA, M.D., SHYOICHIWATARI, M.D., NOBUYOSHIOKUHIRA,M.D. and KENYA TSUGE, M.D.
Department
of Orthopaedic Surgery,
Hiroshima University School of Medicine, Hiroshima, Japan
TAMAI (1974)
Kasumi 1-2-3,
reported the successful replantation in a ao-month-old child of a little finger amputated at the proximal interphalangeal joint. Our patient was only 13 months old and the amputation was through the base of the distal phalanx of the ring finger. The injury was caused by a broken milk bottle which also lacerated the little finger and the palm; the amputation was clean cut without crushing or tearing (Fig. I). Under general anaesthesia the amputated portion was held in place with a Kirschner wire while the digital nerves and one of the digital arteries, whose outside diameter was about 0.4 mm, were anastomosed. When the tourniquet was released the finger tip turned pink and blood oozed from the cut end. Unfortunately the only veins present were only about 0.1 to 0.2 mm in diameter and attempts to anastomose them were abandoned. The palmar part of the wound was sutured accurately but the dorsal part only loosely to allow the escape of venous blood. The circulation had been interrupted for about 5 hours (Fig. 2). The colour of the finger tip slowly darkened but pressure to expel blood from the dorsal suture line turned it pink again. The mother was therefore instructed to milk
FIG.
I.
Clean cut amputation FIG.
2.
through
Immediately
FIG. 3.
the base of the distal phalanx. postoperative.
One month later. 3x3
BRITISH JOURNAL OF PLASTIC SURGERY
314
the finger tip proximally every 30 to 60 minutes. By the 8th day it no longer became cyanosed and the milking was discontinued. Heparin, 2,000 units, was given daily for II days after the operation. The result is shown in Figure 3. DISCUSSION Although Douglas (1959) reported survival of portions of finger tips when treated as composite grafts, there is no doubt that the amputated portion in our case was nourished by the anastomosed artery. While it is always desirable in such cases to anastomose one or more veins, there have been at least 2 previous reports of replants SUrViViIIg WithOUt venous anaStOmOSiS (Snyder et al., 1972; Serafin et al., 1973). The common factor was similar to that in our case: ensuring that there was adequate egress for the venous blood and that adequate drainage was promoted. Although there are still various opinions about the justification for replanting amputated digits or parts of digits other than the thumb, we firmly believe that in children they should always be replaced; functional recovery is often excellent and any future psychological or physical handicaps which a missing finger might impose on the child are avoided. REFERENCES DOUGLAS,B. (1959). Successful replacement of completely avulsed portions of fingers as composite grafts. Plastic and Reconstructive Surgery, 23, 213. SERAFIN, D., KUTZ, J. E. and KLEINERT, H. E. (1972). Replantation of a completely amputated distal thumb without venous anastomosis. Plastic and Reconstructive Surgery,
52, 579.
SNYDER,C. C., STEVENSON, R. M. and BROWNE,E. Z., JR. (1972). Successful replantation of a totally severed thumb. Plastic and Reconstructive Surgery, 50, 553. TAMAI, S. (1974). Little linger replantation in a 20 month old child. British Journal of Plastic Surgery,
27, I.
DIGITAL REPLANT
YET?
By TAKASHIKUBO, M.D.,
YOSHIKAZUIKUTA, M.D., SHYOICHIWATARI, M.D., NOBUYOSHIOKUHIRA,M.D. and KENYA TSUGE, M.D.
Department
of Orthopaedic Surgery,
Hiroshima University School of Medicine, Hiroshima, Japan
TAMAI (1974)
Kasumi 1-2-3,
reported the successful replantation in a ao-month-old child of a little finger amputated at the proximal interphalangeal joint. Our patient was only 13 months old and the amputation was through the base of the distal phalanx of the ring finger. The injury was caused by a broken milk bottle which also lacerated the little finger and the palm; the amputation was clean cut without crushing or tearing (Fig. I). Under general anaesthesia the amputated portion was held in place with a Kirschner wire while the digital nerves and one of the digital arteries, whose outside diameter was about 0.4 mm, were anastomosed. When the tourniquet was released the finger tip turned pink and blood oozed from the cut end. Unfortunately the only veins present were only about 0.1 to 0.2 mm in diameter and attempts to anastomose them were abandoned. The palmar part of the wound was sutured accurately but the dorsal part only loosely to allow the escape of venous blood. The circulation had been interrupted for about 5 hours (Fig. 2). The colour of the finger tip slowly darkened but pressure to expel blood from the dorsal suture line turned it pink again. The mother was therefore instructed to milk
FIG.
I.
Clean cut amputation FIG.
2.
through
Immediately
FIG. 3.
the base of the distal phalanx. postoperative.
One month later. 3x3
BRITISH JOURNAL OF PLASTIC SURGERY
314
the finger tip proximally every 30 to 60 minutes. By the 8th day it no longer became cyanosed and the milking was discontinued. Heparin, 2,000 units, was given daily for II days after the operation. The result is shown in Figure 3. DISCUSSION Although Douglas (1959) reported survival of portions of finger tips when treated as composite grafts, there is no doubt that the amputated portion in our case was nourished by the anastomosed artery. While it is always desirable in such cases to anastomose one or more veins, there have been at least 2 previous reports of replants SUrViViIIg WithOUt venous anaStOmOSiS (Snyder et al., 1972; Serafin et al., 1973). The common factor was similar to that in our case: ensuring that there was adequate egress for the venous blood and that adequate drainage was promoted. Although there are still various opinions about the justification for replanting amputated digits or parts of digits other than the thumb, we firmly believe that in children they should always be replaced; functional recovery is often excellent and any future psychological or physical handicaps which a missing finger might impose on the child are avoided. REFERENCES DOUGLAS,B. (1959). Successful replacement of completely avulsed portions of fingers as composite grafts. Plastic and Reconstructive Surgery, 23, 213. SERAFIN, D., KUTZ, J. E. and KLEINERT, H. E. (1972). Replantation of a completely amputated distal thumb without venous anastomosis. Plastic and Reconstructive Surgery,
52, 579.
SNYDER,C. C., STEVENSON, R. M. and BROWNE,E. Z., JR. (1972). Successful replantation of a totally severed thumb. Plastic and Reconstructive Surgery, 50, 553. TAMAI, S. (1974). Little linger replantation in a 20 month old child. British Journal of Plastic Surgery,
27, I.