Amputations, Replantation and Thumb reconstruction

Question 1

Absolute indications for reimplantation would include which of the following?

1. Amputations involving the thumb
2. Pediatric amputations
3. Bilateral amputations
4. Multiple digit amputations

Answer 1

All of the above.

Absolute indications of replantation -

1. Amputations involving the thumb
2. Multiple digit amputations
3. Bilateral amputations
4. Hemihand amputations
5. Hand amputations from the wrist to the upper forearm
6. Pediatric amputations

Question 2

Relative indications of replantation

Answer 2

1. Single digit amputations
2. Zone II amputations
3. Severe crush or avulsion injuries
4. Geriatric amputations
5. Major limb amputations

Question 3

The level of amputation determines -

1. The ease of replantation
2. The duration of acceptable ischemia
3. The ultimate function of replanted part
4. The need for a surgeon experienced in replantation

Answer 3

1. The ease of replantation
2. The duration of acceptable ischemia
3. The ultimate function of replanted part

Proximal amputations with considerable muscle tolerate ischemia for shorter periods of time compared with more distal amputations.

The level of amputation also determines the ease of replantation of amputated part and the later function of that part if it is replanted.

Replantation requires a surgeon experienced in both hand surgery and microsurgery.

Question 4

Ischemia time must be minimized in replantation cases. Acceptable operative sequence for digital replantation that would minimize ischemia time -

1. Extensor tendon
2. Bone fixation
3. Flexor tendon repair
4. Dorsal vein anastomosis
5. Arterial anastomosis
6. Neurorrhaphy

Answer 4

2-1-4-3-5-6

Listed sequence is a useful guideline for the most common replant, the zone II replant. This sequence involves turning the hand over only once, after the dorsal skin is closed over the repaired dorsal veins. The final step is volar skin closure after neurorrhaphy.

Question 5

Functional results after replantation are dependent on the zone of replantation. The level of replantation that generally produces the best result is -

1. Zone I - distal to the FDS insertion
2. Zone II - the fibro-osseous canal
3. Zone IV - the carpal tunnel
4. Between zones IV and V

Answer 5

4. Between zones IV and V

Best results from replantation are obtained proximal to the carpus but distal to the flexor muscle mass

Favourable levels for replantation -

1. Zone I
2. Zone III
3. Midpalm
4. Zone V
5. Distal forearm

Less favourable levels -

1. Zone II
2. Zone IV
3. Carpal tunnel
4. Zone VI
5. Upper arm

Question 6

Constant surface temperature monitoring is used in replantation surgery to follow the clinical progress of the replanted part. Signs of vascular compromise would include -

1. An immediate and persistent surface temperature of less than 32’C
2. A drop in surface temperature of 2’C
3. A constant temperature of 30’C
4. A drop in temperature to 34’C

Answer 6

1. An immediate and persistent surface temperature of less than 32’C - Poor prognostic sign
2. A drop in surface temperature of 2’C
3. A constant temperature of 30’C

Question 7

Goals in amputation surgery should include -

1. Eradication of any precipitating factor that necessitated the amputation
2. A comfortable stump with functional length
3. A stump with useful, pain-free sensibility
4. Early prosthetic fitting

Answer 7

All of the above

Question 8

Quadriga -

1. Occurs secondary to tethering of a profunda flexor tendon
2. Occurs secondary to lack of independence of the profunda tendons
3. Is treated by release of the fixed profunda tendon
4. Occurs secondary to adhesion of sublimis and profunda tendons

Answer 8

1. Occurs secondary to tethering of a profunda flexor tendon
2. Occurs secondary to lack of independence of the profunda tendons
3. Is treated by release of the fixed profunda tendon

Quadriga can occur after finger amputations. It occurs when one of the profunda tendon is fixed. The profunda tendons are not independent and the tethering of one will limit the range of others. Release of the fixed profunda tendon will restore complete gliding to the impaired tendon or tendons.

Question 9

Neuromas frequently occur after amputation. Certain surgical manevers are advocated to limit the occurence of the painful terminal neuroma. They include -

1. The end of the nerve should be positioned away from the scar, where it is not subjected to excessive pressure
2. The end of the nerve should be crushed
3. The end of the nerve should be isolated, disssected proximally and transected and retraction into the soft tissue
4. The end of the nerve should be coagulated.

Answer 9

1. The end of the nerve should be positioned away from the scar, where it is not subjected to excessive pressure
2. The end of the nerve should be isolated, disssected proximally and transected and retraction into the soft tissue

Question 10

Amputations of the middle or ring fingers with a short stump of proximal phalanx remaining produce a gap between the remaining fingers. This gap is a significant functional and aesthetic problem for most patients. Surgical maneuvres known to narrow this gap and improve both function and appearance of the hand include -

1. Excision of the metacarpal
2. Ray transfer
3. Repairing the transverse metacarpal ligament after metacarpal excision
4. Tightening the transverse metacarpal ligament without metacarpal excision.

Answer 10

1. Excision of the metacarpal
2. Ray transfer
3. Repairing the transverse metacarpal ligament after metacarpal excision

Question 11

Functional requirements of the thumb include -

1. Adequate sensibility
2. Sufficient length and mobility to allow for opposition to other digits
3. Painless motion
4. Adequate pinch strength

Answer 11

1. Adequate sensibility
2. Sufficient length and mobility to allow for opposition to other digits
3. Painless motion

Question 12

The most important factor in determining the appropriate procedure for posttraumatic thumb reconstruction -

1. The status of the soft tissue of the remaining thumb
2. The presence of joint contracture of the injured thumb
3. The sensibility of the injured thumb
4. The level of thumb loss

Answer 12

4. The level of thumb loss

Question 13

The primary consideration in reconstructing thumb amputations occuring in the distal third of the ray (distal to the IP joint) should be -

1. Provision of adequate skin cover
2. Restoration of normal thumb length
3. Restoration of the thumb pulp
4. Provision of skin cover that will allow return of satisfactory sensibility without pain.

Answer 13

4.Provision of skin cover that will allow return of satisfactory sensibility without pain.

Question 14

Functional requirements of a thumb amputated through the middle third of the ray (from the IP joint distally to just proximal to the MP joint) should include -

1. Added length
2. Preservation of mobility
3. Preservation of stability
4. Preservation of sensibility

Answer 14

1. Added length
2. Preservation of mobility
3. Preservation of stability
4. Preservation of sensibility

Question 15

Amputations through the proximal third of the thumb ray (at the level of the distal third of the metacarpal or more proximal) require reconstruction that will provide -

1. Total thumb reconstruction
2. At least 5 cm of additional length
3. Additional motion
4. A mobile carpometacarpal joint

Answer 15

1. Total thumb reconstruction
2. At least 5 cm of additional length
3. Additional motion

Reconstructive options for amputations through proximal metacarpal - Pollicization of a normal digit or great toe transfer

Question 16

In severe mutilating hand injuries, initial assessment and surgery are important and influence the ultimate function of these severely injured hands. Priorities in the primary treatment of these severe injuries should include -

1. Relief of vascular compromise
2. Prevention of infection
3. Bony stabilization
4. Provision of satisfactory skin cover
5. Prevention of stiffness.

Answer 16

All of the above.

Additional priority - Repair of nerves and tendons.