Hand Flashcards
Index Ray Amputation?

When would you consider Replantation?
INDICATIONS
Often is personal and surgeon dependent (top three most accepted reasons)
Thumb
Multiple injured digits
Children
Single digit distal to FDS
Partial hand (through palm)
Bilateral amputations
Wrist or distal forearm
Elbow or above elbow (if sharply avulsed and ischemia time not prohibitive)
Contraindication
CONTRAINDICATIONS
• Absolute
o Coexisting serious injuries/diseases that preclude a prolonged OR
• Relative
o Patient factors
§ Severe medical comorbidity or multiple system trauma
§ Neuromuscular disorder affecting that extremity
§ Current or prior trauma to the amputated part/extremity § Mental capacity/uncooperative patient
o Injury-specific factors
§ Multiple level injuries
§ Severely crushed, burned or mangled
§ Ring avulsions type injuries
§ Extreme contamination
§ Single digit zone II amputation
§ Proximal forearm
§ Destruction of sensory end organs (eg. loss of palmar skin) § Prolonged ischemia time (especially muscle)
How do you examin for vessle damage?
Ribbon sign (“corkscrew”): Tortuous-appearing vessel from avulsion or traction injury
Red-line sign: Red streak along neurovascular bundle implying distal vessel damage
o Ribbon & red-line signs are poor prognostic indicators
Cobweb sign: Intraluminal fibrin threads/webs
Telescope sign: Lumen telescopes away from outer vessel wall and past cut edge
Terminal thrombus: Indicates vessel wall disruption or damage
Measles sign: Pinpoint (petechial) bruising along vessel wall
Sausage sign: Ballooning of vessel from thrombus
What would you do if no vessle flow?
Patient:
o Make sure the tourniquet is down, relieve tension/compression proximally
o Vitals: Temp/BP - Warm the patient/OR/irrigation,
- Increase the IV fluids +/- increase BP
o Correct a metabolic acidosis
—-> Clotting o IV bolus 1500-2000u at clamp removal +/- 1000u q1h intra-operatively, +/- postop
Local:
o Remove any obvious clots
o Irrigate the proximal end with heparinized saline or 1:20 papaverine
o Resect past possibly unrecognized zone of injury
o Use a vein graft
What applications for vein graft?
Goals of the vein graft
o To bridge venous or arterial gaps
o To compensate for diameter discrepancies
o To create a Y-shaped junction to anastomose two vessels to one
How would you address the nerve gap?
If a gap is present
o Shorten the bone (even more)
o Nerve graft preferred option (donors: sural, saphenous, MABCn, LABCn, digital nerves) o Conduits (vein, polyglycolic acid)
o Nerve transfers
o Leave it and repair secondarily
How would you address venous drainage in amputated finger tip.
o Repair a volar vein (smaller, thinner)
o Create an AV fistula: one distal digital artery anastomosed to one proximal vein o Remove the nail plate, scratch it, and apply heparin-soaked pledgets
o Leeches
o Digital massage of the distal part
How would you classify ring avulsion injuries?

Systemic Complications of Replant?
systemic complications from myonecrosis, rhabdomyolysis and myoglobinuria following reperfusion
How would you plan your major replant repair?
DEBRIDEMENT
Extensive muscle debridement may be required to prevent myonecrosis and subsequent infection
Usually require a second look in OR at 48-72 hours to re-evaluate muscle and debride as necessary
BONY FIXATION
Rapid, stable fixation critical
Bone shortening to allow primary repair of median, ulnar, radial nerves
Dynamic compression plates and screws (better than pins/rods)
Crossed Steinman pins can be used across joints
ARTERIES
Usually performed immediately after bony fixation (almost always prior to veins)
Vein grafts usually needed
VEINS
• Beware systemic load of lactic acid, potassium, myoglobin and other toxic metabolites
o Allow veins to bleed out to prevent systemic complications, communicate with anesthesia
• Consider IV sodium bicarb (+/- mannitol, calcium carbonate) prior to releasing clamps on venous repair
MUSCLES/TENDONS
Try to repair most tendons primarily, can be difficult if the amputation is through the muscle bellies
In general, a healthy appearance and contraction of pronator quadratus with stimulation is an excellent prognostic indicator of forearm perfusion.
NERVES
Grouped fascicular alignment is important (these are mixed motor/sensory nerves)
If unable to coapt, tag and perform sural grafts secondarily
FASCIOTOMIES
Always indicated o Volar, dorsal, mobile wad (lateral)) compartments of forearm o Hand (10 total) – dorsal interossei x4, volar Interossei x3, thenar, hypothenar, adductor pollicus
Release carpal tunnel and Guyon’s canal
What are your post repant orders?
ROUTINE ORDERS
- Elevate hand
- Monitor digit (CTTC) q 1 h X 24 hrs
- o Maintain temp digit >31C, or >2C difference from contralateral
- o +/- pulse oximetry of digit
- NPO x 24 hrs, then micro DAT, bedrest x 5 days with dressing intact
- SC heparin (prophylactic dose)
- Warm environment (ambient +/- warming blankets)
- Proper hydration (monitor U/O)
- Adequate analgesia including APS (brachial plexus block, sympathetic blockade)
- No smoking or caffeine (for 4-6 weeks)
- IV antibiotics peri-op (continue if being leeched – Septra, quinolone or 3rd generation cephalosporin)
- 1st dressing change at day 5 (and splint made then)
- Hand therapy & social work (± Psych) to see prior to d/c
ASA action?

Heparin, LMWH, Leech Action?

Lido, Pap, Strep, tpa action?

Monitoring?
CCTT
Color, Cap refill, turgor, Temperarure
How would you discuss the immediate compliations of replatation?
Early
- Anaesthetic complications
- Usual postop complications
- Vascular insufficiency (arterial or venous)
- o Usually within 72 hrs, but may occur late ~ 10-14 days
- o Possible salvage if promptly returned to OR, but do risk injury to other digits
- Compartment syndrome, acute nerve compression syndromes
- Infection
- Bleeding/hematoma from systemic anticoagulation
- Nightmares/acute post-traumatic stress disorder
- Release of toxic metabolites from major limb replant
- o Myoglobinuria and ATN
- o ARDS
- Acidosis
- Hyperkalemia and cardiac problems
How would you discuss later complications of replant?

How would you discuss the outcomes of replantation?
OUTCOME
In a meta-analysis, survival rates for replanted digits were 91% with clean-cut mechanisms, 68% with crushing mechanisms, and 66% with avulsive mechanisms
Worse Outcomes with
o Crush/Avulsion
o Distal Phalanx
o Thumbs (more aggressive attempts at replantation)
o Smokers
o Male (related to being involved in crush/avulsion type injuries)
o Children (smaller vessels, increased risk of vasospasm, increased avulsion mechanisms, and more aggressive attempts at
replantation)
• In general, expect about 50% of previous function and 50% of previous sensation
o Nerve recovery is comparable to repair of isolated nerve injuries (50% get 2PD < 10 mm) o AROM is usually around 50% of normal
How would you classify nerve injuries?

Gram CTS Criteria
Risk factors?
(1) nocturnal numbness; (2) numbness and tingling in the median nerve distribution; (3) weakness and/or atrophy of the thenar muscles; (4) Tinel sign; (5) Phalen’s test; and (6) loss of two-point discrimination.41
Also:Threshold sensory tests such as Semmes–Weinstein monofilament measurements tend to be more sensitive for detecting early CTS than innervation density measurements.36Manual testing of abductor pollicis brevis muscle strength as well as grip and pinch strength can also be helpful. Thenar atrophy has a high predictive value in CTS, but is rarely observed
COMPRESSION NEUROPATHY: RISK FACTORS
• hypothyroidism, diabetes, obesity, pregnancy (carpal tunnel syndrome)
• No definitive association with smoking
• Repetitive work questionable, likely more with position and duration of static position • “Double crush”
• Hereditary motor-sensory neuropathies
Charcot-Marie-Tooth (Hereditary motor and sensory neuropathy – HMSN) – heterogeneous group of neuropathies affecting myelin and the axon
Hereditary neuropathy with liability to pressure palsies (HNPP) – autosomal dominant demyelinating neuropathy
Pathophys of nerve compression?

Stages of Nerve compression?

Differential for Compression Neuropathy?
- Central (ALS) or Proximal compression at cervical spine (radiculopathy) or thoracic outlet syndrome
- Peripheral neuropathy/myopathy (B12, folate, alcohol, thiamine, hypothyroid, MS)
- Tumours (benign, malignant / primary and metastatic)
- Post-traumatic injuries/scarring etc.
- Vascular insufficiencies (vasculitis, DM)
- Autoimmune/Inflammatory (Guillain Barré, RA, SLE, PAN)
- Infection (HIV , Lyme disease, leprosy)
- Toxins (gold, arsenic)
- Psychological (somatoform and factitious disorders), malingering


















































































