Composite grafting, grafting without microvascular anastomoses, has been widely performed for distal fingertip amputation in children with variable results, whereas successful replantation of these amputations using microsurgical technique has been reported. However, most of these reports included a wide age-range and a mix of different amputation levels. This study reviewed our cases of paediatric digital amputation, in order to verify the value of distal fingertip replantation over composite grafting, especially in early childhood. Seventeen young children (aged 3 years and 8 months on average), with single-digit fingertip amputations in Tamai zone I were reviewed from 1993-2008. Each amputation was subdivided into three types: distal, middle, and proximal. There were three distal, 13 middle, and one proximal type zone I amputations. All were crush or avulsion injuries. All three distal-type cases were reattached as primary composite grafts with one success. For middle-type cases, the survival rate of primary composite graft without exploration for possible vessels for anastomosis was 57%. On exploration, suitable vessels for anastomosis were found 50% of the time, in which all replantations were succeeded. The remaining cases were reattached as secondary composite grafts, with one success using the pocket method. Consequently, the success rate after exploration was 67%. The only one proximal-type amputation was failed in replantation. For the middle-type zone I amputation in early childhood, replantation has a high success rate if suitable vessels can be found. Therefore, exploration is recommended for amputations at this level with a view to replantation, irrespective of the mechanism of injury.

No abstract

Traumatic orbital apex syndrome is a well-known but rare complication of craniomaxillofacial trauma that combines features of the superior orbital fissure syndrome with traumatic optic neuropathy. The optimal treatment of traumatic orbital apex syndrome has not been established, because there have been so few cases. We report a case of traumatic orbital apex syndrome combined with the blow-in type of the orbital and zygomaticomaxillary complex (ZMC) fracture, which was successfully treated by emergency decompression of impinged nerves, and had complete recovery of visual and ocular function. We also discuss the indications for and timing of surgical intervention for cases of direct traumatic orbital apex syndrome with facial fracture. CaseA 24-year-old male on a bicycle collided with a wall at the bottom of a hill due to brake failure. The main impact was sustained on the left side of his face. He was referred to our emergency center for urgent treatment of his facial injuries. On initial examination, two hours after his accident, the patient presented with a Glasgow Coma Scale score of 12.He had left periorbital ecchymosis, left lid ptosis, and decreased left visual acuity. He had only the ability to count fingers at 50 cm, compared with the ability of the nonaffected right eye to read figures without his glasses, which were lost at the trauma scene. The pupils were anisocoric: 5 mm on the left versus 3.5 mm on the right. Direct pupillary reflex was sluggish on the left eye and intact on the right. Indirect pupillary reflex of both eyes was maintained. He also had lost the left corneal reflex, and had paresthesias over the left frontal region, ocular motility disorder of the left eye in all directions of gaze, and elevated left ocular pressure on palpation (►Fig. 1). Opthalmologic evaluation performed in the emergency room was limited due to head trauma and generalized convulsion. The relative afferent pupillary defect (RAPD) was positive for the affected left eye but negative for the right eye. Although the lower eyelid was edematous, the optic media, such as the iris, lens, and vitreum was found intact. The left optic disc was found to be slightly erythematous.Computed tomography (CT) revealed a left sided orbital and ZMC fracture of the blow-in type, in which the inward displacement of the fractured segments results in decreased AbstractOrbital apex syndrome is an uncommon but severe ocular complication of craniomaxillofacial fracture. The optimal treatment strategy for this very rare traumatic syndrome has not been well established. We present a case in which traumatic orbital apex syndrome was caused by direct compression from the displaced fracture segments. Visual and extraocular function both improved quickly after emergency decompression surgery. This case suggests that managing the direct type of traumatic orbital apex syndrome with craniomaxillofacial fracture with a combination of urgent reduction of impinging bone and decompression of affected nerves is an effective strategy.

Background Conventional methods of external bleeding for congested fingertip replants exhibit notable problems, including uncontrollable bleeding and unpredictable survival of the replant. We have added a local injection of heparin calcium to the routine use of systemic heparinization for inducing external bleeding. We retrospectively examined patients who underwent external bleeding using our method. Methods Local subcutaneous injections of heparin calcium were made in 15 congested replants in addition to systemic heparinization. Each injection ranged from 500 to 5,000 U. The average duration of the injections was 4.1 days. Surgical outcomes were analyzed and compared with a control group of patients who underwent external bleeding without heparin calcium. Results The overall survival rate was 93.3%, which was higher than that of the control group (83.3%), but the difference was not statistically significant (P = 0.569). The survival rate for subzones I and II by the Ishikawa subzone classification was 100%, whereas it was 87.5% in subzones III and IV. No statistically significant difference was observed. The rate of partial necrosis was 0% in subzones I and II, whereas it was significantly higher (66.7%) in subzones III and IV (P = 0.015). The mean total blood loss via external bleeding was 588 g in 10 fingers. No patients required blood transfusion. Conclusions Congestion of a replanted fingertip can be successfully managed without blood transfusion by our method. Although complete relief from congestion in replants in subzones I and II is achievable, there is a higher risk of partial necrosis in subzones III and IV.

No abstract