THE FEATURES OF REPLANTATION OF EXTREMITY SEGMENTS IN CHILDREN
Federal Scientific Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
At the present time, replantation of detached fingers is assessed not only with the fact of a replanted segment survival, but also with restoration of its function. This is the main problem for replantation of extremity segments in children.
No doubt, finger replantation creates significant difficulties in children because of small sizes of restored formations, but, from other side, reparative processes are better in children than in adult patients, and predicted functional restoration is more optimistic due to developed adaptive mechanisms and the features of scar formation (elastic fibers prevail in composition of connective tissues). So, O’Brien [3] indicates that children should receive replantation of any amputated part which can be restored, because good outcomes of surgery for tendons and nerves give functionality to all replanted segments.
The hand of the human is the main sensitive organ, and the essential connection to the outside world in children which is as significant as other sense organs. Therefore, a child with amputated fingers has no adequate connection to the outer world, and, as result, he or she lacks full development.
Concerning adult patients one should note that a decision about segment replantation is made with consideration of many factors (presence of concurrent pathologic states, level of finger rupture, ischemia duration, amount of detached segments). As for children, we do not consider the majority of these values and we restore segments including the distal phalanges with maximal efficiency. We present one of our clinical case reports.
The child A., female, age of 3 years and 4 months, was admitted on September, 22, 2014. The diagnosis was: “Almost complete traumatic detachment of the fingers 2-3-4 of the right hand at the level of the fetlock joints. Decompensated ischemia of the fingers 2-3-4. Full traumatic rupture of the distal phalanx of the first finger of the right hand at the level of the head of phalangeal joint. Open displaced fracture of the base of the proximal phalanx of the fourth finger of the right hand”.
The child’s hand was hit by an axe (13 hours and 30 minutes before admission). The child was admitted to the Central Regional Hospital of Altay region. Under general anesthesia the primary surgical preparation of the wound was performed and the aseptic dressing was applied. Afterwards the patient was transported with a reanimobile to our clinic.
It is necessary to accent the correct transportation of the completely ruptured segments. One should remember about the simple method for storing detached segments: so called “three-package principle”. Correct conservation provides placing a detached segment into a plastic bag after covering its wound surface with drapes which are moistened with isotonic solution of sodium chloride. For prevention of contact between tissues and ice this package is placed into the second one, which is partially filled with water, and consequently – into the third package with ice. All three packages are properly sealed without interaction to each other. We call attention to preventing direct contact between tissues and ice [2].
The possibility of replantation was estimated immediately after arrival to the admission department: after removing the dressing we identified the almost full detachment of the complex of the fingers 2-3-4 which had connection through the dorsal skin bridge (the width about 1.5 cm) on the side of 4-5th interdigital space. The fingers were “empty” and cold, without vascular activity, with no blood after needle puncture, i.e. with full signs of decompensated blood circulation. The examination found full injury to the extensor tendons and the flexor tendons of the fingers 2-3-4, common digital vascular nervous bundles of the fingers 2-3 and 4-5, the digital vascular nervous bundle of the finger 2, the capsules of the metacarpophalangeal joint of the fingers 2-3-4. The first finger included the wound with defect of the distal phalanx and the head of the proximal phalanx.
The X-ray images showed the detachment of the fingers 2-3-4 at the level of the joint spaces of the metacarpophalangeal joint of the fingers 2-3-4, detachment of the first finger at the level of the neck of the proximal phalanx (Fig. 1).
Figure 1
The general appearance of the hand at admission, and the photofluorography image
The child has good physical health.
Under endotracheal anesthesia the proper washing of the extremity was performed with 0.25 % chlorhexidine bigluconate. The surgery included: replantation of the fingers 2, 3, 4, osteosynthesis for the proximal phalanx of 4th finger using pins; suturing the capsules of the metacarpophalangeal joints of the fingers 2 and 3; suturing the extensor tendons of the fingers 2, 3 and 4; suturing the deep and superficial flexors of the fingers 2, 3 and 4; microsurgical suture for 3 veins along dorsum of the hand, for 2 arteries of the fingers 2-3 and 3-4, for 3 digital nerves, namely for the digital nerve of the finger 2 and the digital nerves of the fingers 2 and 3; microsurgical plastics for the stump of the first finger with V-Y flap.
The duration of surgery was 6 hours. During the operation the tourniquet was applied to the shoulder (3 times, 1 hour and 10 minutes) for decreasing blood loss and verification of all injured structures.
All procedures were performed with microsurgical techniques: osteosynthesis, suturing for tendons, nerves and vessels.
The first stage included suturing for joint capsules and synthesis for the proximal phalanx of the 4th finger with pins, as well as suturing for extensor and flexor tendons according to Rozov, with additional adaptation of rims with use of prolene 6-0.
Two common digital arteries (the diameter is 0.5 mm) were separated, prepared and sutured after restoration of the fingers and tendons. Prolene 10/0 was used. After that separation and suturing for three dorsal veins (the diameter is 0.5 mm) was realized. The tourniquet was removed and blood flow was initiated. The fingers turned pink, the dorsal veins became full. The blood shunt was adequate. The total time of ischemia was 19 hours and 30 minutes. Such long term absence of blood flow in an injured segment in adult patients causes destructing the cell membranes and such consequences as edema, fibrosis, possible purulence resulting in decreasing viability of a replanted segment and unsatisfactory functional outcomes.
The next stage was nerve suturing with prolene 8/0 and 9/0. Adaptation of the bundles was good (the diameter of the nerves was < 1 mm). One should note that the diameter of sutured veins and arteries was less than 0.5 mm, of the digital nerves – less than 1 mm.
The last stage was initiated for prevention of additional shortening of the first finger and salvation of hand grasp. It included V-Y plastics with advanced microsurgical flap taken from the palmar surface of the finger.
Microsurgical techniques were used for suturing the skin wounds with noninvasive suturing material (Prolene 5-0). Between the skin sutures we installed many rubber discharging devices. The dressing covering the hand was saturated with sterile vein for prevention of secondary compression of a segment. One should consider that the blood and wound discharge, which soak a dressing after drying, turn into dense crust during 3-4 hours; this is the main factor preventing the normal blood flow (Fig. 2).
Figure 2
The appearance of the hand after surgery, and the photofluorography image
After completing the operation the extremity was immobilized with plaster bar in functional position.
Antibacterial therapy lasted during 7 days, rheologic therapy – 10 days, anesthesia – 7 days.
The postsurgical period was without complications.
The first change of dressing was 2 days after surgery (under mask anesthesia). There were no insufficient perfusion and phlyctena.
The primary intention was observed for all wounds.
The sutures were removed on day 14. Remedial gymnastics and active procedures for finger motion were initiated. The pins were removed on 18th day after surgery. The child was discharged in satisfactory state. Active and passive procedures and activation of fine motor skills were prolonged (LEGO games, foam sponge, a ball).
CONCLUSION
The described case proves appropriateness and efficacy of finger replantation in children of any age. Children’s soft tissues are characterized with persistent viability after cessation of blood flow during long period (hours).
Due to small diameter of vascular structures, the primary importance for realization of such operations is related to qualification of a surgical team, and equipment status in a medical facility.