Replantation of a Multi-level Upper Extremity Amputation

Abstract

Multi-segmental amputation caused by machine is rare, multi-amputation injures is complex and difficult in operation and replantation. An 18-year-old boy presented with completely amputation of the right forearm, wrist and thumb. On admission, he had clear consciousness. The operation started 3 h after the accident and was carried out simultaneously by two replantation teams and three procedures under brachial plexus anesthesia (the right forearm team; wrist and hand team). The replanted limb, hand and thumb were survived well. Our case was unusual in replantation of severed limb. Our case stated a replantation of upper extremity with associated a very rarely seen multi-level type amputation. Case ReportIn February, 2011, an 18-year-old boy presented with completely amputation of the right forearm, wrist and thumb. On admission, he had clear consciousness. His pulse was 82, blood pressure was 180/96 mm Hg. Hemoglobin concentration was 153 g/L. By definition, the bones, nerves, tendons, and vessels of his affected limbs were broken into three pieces, and the right thumb was nearly completely severed from middle segment of the first metacarpal bone (Figure 1). Preoperative X-ray of the right elbow joint was intact (Figure 2). The wounds were seriously contaminated and there was no blood supply. The boy had no additional injuries led our decision to replant the right arm.The operation started 3 h after the accident and was carried out simultaneously by two replantation teams and three procedures under brachial plexus anesthesia (the right forearm team; wrist and hand team). The procedures of the replantation were fixation of bone, anastomoses of subcutaneous artery, veins and nerve; and closure of wound in turn. After blood flows of the severed limb were stopped with a pneumatic tourniquet, the severed limb replantation was performed by the first team; meanwhile, the severed thumb was replanted by the second team. Treated with a rapid debridement, the vessels, nerves and tendons of the 3 broken ends were all separated and tagged. The ends of the radius and ulna fixation was established with the plate and screw; wrist fused with cross kirschner wires; the fracture of the first metacarpal bone was fixed with cross kirschner wires after replacement. All of the flexor and extensor tendon ends of the forearm wrist and thumb were repaired with 0/1 pull-out tendon sutures, and the stumps of muscles were sutured respectively. After successful anastomoses on radial and ulnar arteries and their branches of the forearm wrist and thumb, which successful to recover the blood supply, the 4 subcutaneous and accompanying veins of them were anastomosed as reflux via, and then the median, ulnaris and radialis nerves and their branches were sutured at different levels by 9/0 and 10/0 microscopy. After losing the tourniquet, the injured had good blood supply. Then the wound was closed with silk sutures. The soft tissues and bones were repaired successfully; the replanted limb, hand and thumb were survived well. The total isch...