Federal Scientific Clinical Center of Miners’ Health Protection, 

Leninsk-Kuznetsky, Russia

Rupture of an upper extremity at the level of the upper arm is a severe injury resulting in disability if high tech specific assistance is not given. Development of microsurgical technique and appearance of new types of surgical treatment allow solving this problem. Such operations are impossible without microsurgical techniques.

The indications for replantation are amputation of the thumb, multiple amputations of fingers in children, amputation in the region of the wrist, amputation of the forearm, the upper arm or the leg.    

The contraindications for replantation are resistant hemorrhagic shock, severe general state, older age, more than 12-14 hours of cold ischemia or 6-8 hours of heat ischemia, extensive crushing injuries to a ruptured segment, severe somatic pathologies – myocardial infarction, acute cerebrovascular accident and some other pathologies [1, 2].

Objective – to demonstrate the clinical case with the patient with traumatic rupture of the upper extremity at the level of the middle one-third of the brachium, with tissue perfusion at the brachium level realized with retrograde venous perfusion after replantation.

 

The patient I., born in 1993, was admitted to the department of traumatology and orthopedics #3, Clinical Center of Miners’ Health Protection, on February, 3, 2013. The patient received emergent surgery. He was admitted with rupture of the left upper extremity at the level of the humerus, with pain syndrome in the proximal and middle parts of the left humerus, compression of soft tissues with hemostatic arterial tourniquet. 

The patient suffered from an industrial injury 4 hours 30 minutes before admission. The left upper extremity was drawn into the drum mechanism that resulted in rupture.

From the accident site the emergency team transported the patient to Kemerovo city hospital. The doctor on duty made the examination and applied hemostatic arterial tourniquet. The blood analysis and electrocardiography were carried out. The diagnosis was made: “Complete traumatic rupture of the left upper extremity at the level of the middle one-third. Traumatic shock of degree I.” Drug therapy was made at admission: narcotic analgetics, papaverine, infusion therapy. The stump of the left upper arm was bandaged.       

For realization of specialized medical aid the team of ambulance aviation transported the patient to the admission department of Clinical Center of Miners’ Health Protection. For decreasing the terms of limb ischemia the operating room was preliminary prepared for limb replantation. From the admission department the patient was quickly transferred to the operating room where preliminary examination was made.

Objective examination: the general state of middle severity conditioned by severity of the injury and hemorrhagic syndrome. The patient is conscious and able for orientation in space and time. The skin surface and visible mucosa are pale and wet. Auscultation shows vesicular breathing without stertor. Breathing is auscultated over all pulmonary fields. Cardiac tones are clear and rhythmical. AP = 110/70 mm Hg. On the right radial artery the pulse is clear, with satisfactory filling, rhythmical (110 per min.).

Local examination: the left upper extremity is presented in view of the stump at the level of the middle one-third of the humerus, with circulatory-located gauze bandages, which are slightly saturated with blood. The arterial hemostatic tourniquet is at the level of proximal one-third humerus. The exposure of the last application of the tourniquet is 1 hour and 50 minutes. After removal of the tourniquet and dressings one can see the brachial stump in view of the humerus at the level of the middle one-third, the deltoid muscle, the proximal biceps of the arm, middle and radial nerves with signs of trunk injuries. The stump of the ulnar nerve is located at the level of the tendon of the greater pectoral muscle. There is a defect on the skin surface of the whole proximal part of the humeral stump and up to the axillary cavity. No bleeding from the stump of the left humerus. No palpation or visual definition of arterial pulsation in the axillary cavity. The detached extremity has been transported in the dry polyethylene package. The package is sealed, is located in the second package with cold water and in the third package with ice.

The replanted part is a detached segment from the level of the middle one-third of the humerus to the finger-tips. Visual examination does not show skin injuries (except for tear-off line). The level of humeral rupture is at the level of the middle-distal one-third borderline (Fig. 1a, b). On the basis of subjective, objective and paraclinical data the diagnosis was made: “Full traction rupture of the left upper extremity at the level of the middle one-third of the humerus. Posthemorrhagic anemia of middle severity. Traumatic shock of degree II”.

 

 

The X-ray examination of the detached segment of the left humeral stump and plain radiologic examination of the chest organs did not find bone traumatic changes except for the tear-off line of the humerus.

Surgery was performed on February, 3, 2013 and lasted for 7.5 hours: replantation of the left humerus with 10 cm shortening and external osteosynthesis for the humerus with 6 screw plate; plastics of the subclavicular brachial artery with 18 cm reversed autovein from the leg; microsurgical suture for median and ulnar nerves; plastics for radial nerve, suture for two veins (basal and cephalic veins) and for brachial muscles – biceps and triceps.

The revision of the humeral stump found an extensive defect of skin surface and hypoderm through the axillary brachial segment of the artery from the level of the inferior rim of the greater pectoral muscle to the crook of the arm (35 cm), as well as the defect of the main nerves from the level of brachial plexus. Resection of the humerus (by 10 cm) was produced for realization of suturing the nerve trunks and for decreasing length of the autovenous graft (from 28 to 18 cm). External osteosynthesis was realized through the posterior approach with 6 screw plate. The synthesis was stable. Then partial resection of necrotic muscles was made (biceps, triceps), followed by capron suture and microsurgical suture for median and ulnar nerves. The part of the median nerve (10 cm) was taken as a graft for radial nerve plastics. Also the defect within the interval of the ulnar joint to the inferior border of the greater pectoralis muscle was corrected. Microsurgical suturing for median and ulnar nerves was made with prolene 8/0. The autovein (18 cm) was taken from the great saphenous vein in the right leg. The cephalic vein was sutured at the level of the middle one-third of the humerus. Arterial plastics was realized with reversed autovenous graft (18 cm). Two twisted sutures were made with prolene 6/0. The adaptation was satisfactory. The perfusion restored, but it started in the hand fingers only after 30-40 minutes. Ischemia time was 10 hours. Therefore, two incisions on the forearm were made (2 cm) and subcutaneous fasciotomy for the forearm muscles was carried out. In the end of the operation the fingers were soft, perfused and without contractures. The range of motions in the finger joints was full. Then the second vein was sutured. The cephalic vein was sutured with twisted sutures (prolene 6/0). Plastics for the radial nerve was made from the inferior border of the greater pectoralis muscle to the ulnar joint near the point of entry into the muscles (prolene 6/0 and 8/0). Additional suturing was made for triceps and biceps. Suturing of the skin wounds was made as well as resection of excessive skin surface of the replanted segment in the proximal one-third, i.e. resection for the part of the scalped skin-subcutaneous-fascial flap of the most proximal part of the humerus (Fig. 2).

The wounds were with multiple grooved drains. Aseptic wounds were applied. The extremity was fixed with the plaster splint from the healthy shoulder girdle to the finger tips.                                                      

The postsurgical period was in the intensive care unit and was aimed for correcting the anemic syndrome, postanalgetic depression and disorders of water-electrolytic balance, and also for intensive observation. 7 days after the operation the patient was transferred to the department of traumatology and orthopedics #3 in Clinical Center of Miners’ Health Protection.

After completion of acute postsurgical period, ischemia in the muscles and most part of the hypoderm at the humerus level was prevented with venous arterial shunts which promoted retrograde perfusion in the tissues. However the postsurgical period was complicated with predicted development of necrosis in the most proximal part of the replanted segment with signs of developing region of microbial eczema (about 6 cm) (Fig. 3a, b).

Microbial eczema was corrected with multiple drug therapy including dressings with fucorcinum solution. 55 days after replantation the planned surgical treatment was performed for a predicted postsurgical complication (border-line necrosis of skin surface).

On March, 3, 2013 necrectomy for soft tissues in the left upper arm, and plastics with rotational vascular pedicle flap from the chest were carried out. The duration of surgery was 3 hours. The postsurgical period was without complications. The sutures were removed on the days 14-21 after surgical treatment. The healing was accompanied by primary tension. The patient was discharged in satisfactory condition on 79th day for out-patient observation. At the moment of discharge the patient had complaints about absent active motions in the replanted extremity and disordered sensitivity.         

One year after surgery (March, 31, 2014) the patient was examined for outcomes of surgical treatment. At the moment of examination he had complaints about anesthesia and deep hypesthesia of the skin of the left upper extremity and absent active motions in the joints of the left upper extremity except for the shoulder joint.

Local examination: the left upper extremity has visual changes. Hypotrophy of the muscles in the shoulder, the forearm and the hand is noted. Hypotrophy is with neurogenic characteristics. Active motions with limitation are possible only with the shoulder joint (Fig. 4). Passive range of motions in the joints is with insignificant limitation.       

The outpatient treatment was performed with continuous courses of restorative treatment: remedial physical exercises, massage for the left upper extremity, muscular myorhythmia, pulley-weights.  

The patient was examined for efficiency of the treatment two years after surgery (February, 3, 2015). At the moment of the examination we noted the positive dynamic characteristics in restoration of active motions in the joints and innervation of the extremity. During making the decisions about extremity replantation in comparison with extremity amputation the patient declared the significant superiority of replantation of the extremity and its functional importance in the daily life. The patient had complaints about limited active extension motions in the radiocarpal joint and the finger joints, active flexion in the forearm, deficiency in active flexion in the left hand, and paresthesia and anesthesia of the skin on the left upper extremity.     

Local examination: the left upper extremity has visual changes (11 cm shorter). Active motions in the shoulder joint are with insignificant limitation (Fig. 5).

Active flexion in the forearm is absent because of defect of the biceps at the level of replantation and neuropathy of the muscular skin nerve. Active extension in the forearm is with full volume. There are no active extension motions in the joints of the hand and the fingers. Passive extensions in the hand joints have full volume. Moreover, flexion in the hand and the fingers happens simultaneously, but not separately, that is common for reinnervation in suturing for all trunks of the brachial plexus (Fig. 6 a, b).           

The grip of the fingers is significantly improved with simultaneous use of a rigid fixator (Fig. 9). Fine motor skills are absent. There is disordered sensitivity in the hand in view of deep hypesthesia in the region of innervation of the ulnar nerve, and paresthesia in the region of the median nerve. Anesthesia is in the neurosome of the radial nerve. Realization of two-point test is possible in the region of innervation of the median nerve (18 mm). The examination with electroneuromyogram of the left upper extremity (February, 3, 2015) showed the rough signs of neuropathy in the median and ulnar nerves. The examination of the hand muscles resulted in the interferential curve with very low amplitude. There was no M-response during stimulation of the radial nerve. There were no disorders in blood circulation. Ultrasonic Doppler examination did not show perfusion disorders in the left upper extremity. Also we observed hypotrophy in the muscles of the upper arm and the forearm (not atrophy) that testified neurogenic genesis of hypotrophy (not ischemic). Despite of plastics for the main trunk of the brachial artery (18 cm autovenous graft from the leg), ischemic atrophy of the muscles did not occur. It gives the evidence of functional perfusion promoted by arterial venous collectors in the muscles and the soft tissues of the shoulder.

CONCLUSION

Despite the defect in the main trunk of the brachial artery (18 cm) beginning from the level of subclavicular artery, no ischemia events in the muscles and the soft tissues were found that gave evidence of functionally significant blood flow in the arterial venous shunts in the muscles and the soft tissues of the shoulder.

The primal function of the hand grip and continuous restoration of sensory innervation in the hand allow making the conclusion about preferred conduction of extremity replantation before stump formation and prosthetics.

For this patient the following reconstructive and restorative procedures are planned for further restoration and improvement of functions of the extremity: 1) transpositions of latissimus dorsi to the position of the left biceps; 2) diversion of the tendons and the flexor muscles of the hand to the position of the extensors for improving function of the hand grip. Arthrodesis or tenodesis for the radiocarpal joint are possible.

Therefore, the given clinical case supports the priority of limb replantation in comparison with its prosthetics. Additional high tech techniques are required for recovery of functioning of the extremity with proximal level of detachment.