A CASE OF SUCCESSFUL REPLANTATION OF THE DISTAL PHALANX OF THE FIRST FINGER IN A CHILD WITH TRACTION MECHANISM OF DETACHMENT
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
Replantation of very small segments (the distal phalanxes of the fingers) presents a specific problem relating to the sizes of the segment, the diameter of the tendons, the nerves and the arteries, and, most importantly, – veins. Separation of veins at the level of the distal phalanx is quite difficult because of veins originating from capillaries and low amount of veins. Moreover, this problem can be intensified by a mechanism of an injury: the detachment pattern (i.e. common) means rupture of small branches of developing veins resulting in postsurgical thrombosis – a defect of the intima develops at the level of detachment of the veins; here clots appear and it results in venous insufficiency and subsequent arterial thrombosis in case of the conducted replantation of the distal phalanx.
The specialists are familiar with a technique of shunt of venous blood, when after suturing one of the arteries the second artery of the implant is sutured with the dorsal vein of the finger. However such technique is possible only for guillotine amputation without a traction mechanism and with the preserved second artery. Therefore, the main problem of replantation of the distal phalanxes is restoration of the venous return along with suturing the tendons, nerves and one of the arteries [1, 3].
According to the expert estimations, the functional significance of the first finger is 40-50 % of the hand functioning. It is known that the main function of the nail is creation of rigid grasp. This function is lost in absence of the nail plate, even with restored soft tissue cover of the distal phalanx by means of displacement of local flaps, on the temporary pedicle or with vascular connections. It leads to some limitations, such as for military service [2].
Restoration of vein and arteries by type of two to one or, even better, three to one is almost ideal, but it does not warrant full absence of venous insufficiency and possible subsequent lymphostasis of the replanted segment. However the compensatory possibilities and the features of the reparative processes in children allow expecting the positive results after such operations. Basically, replantation of detached phalanxes of the first finger in children is a warranty for restoration of almost full function of the hand and the grasp of the first finger, i.e. full recovery of the hand functioning.
The hand is one of the main instruments for communication between the human and the external world. The full recovery of the hand functioning can be the basis of full-featured development and independence of the child dealing with almost any activity.
Here we present one of our cases.
The child S., born in 2002, was admitted at 2:10 p.m. on September 8, 2016. The diagnosis was: “Complete traumatic detachment of the first finger of the left hand at the level of the distal one-third of the proximal phalanx”. 3 hours earlier the child had some shop classes. With use of the milling machine he tried to saw a blocking lumber. The rotating mill knocked out the lumber. It leaded to detachment of the first finger of the left hand at the level of the head of the proximal phalanx. The patient was admitted to the pediatric multi-profile hospital in Kemerovo. The traumatologist conducted the examination. The aseptic dressing was applied onto the stump of the first finger. The detached part of the finger was stored in concordance with the rule of three packages: the reimplant was covered with the sterile drape moistened with sodium chloride saline. Then it was closed tightly and placed into the second tightly closed package with water. The two packages (one in one) were placed into the third one with ice and were transported in the special container. Therefore, direct contact between ice and the reimplant was prevented.
The possibility of replantation of the distal phalanx was estimated at the moment of admission (50:50 from technical and functional perspectives). It is known that the mill causes extensive tearing of tissues that is especially unfavorable in restoration of veins and possible suturing for arteries (Fig. 1).
Figure 1
Traction mechanism of detachment of the part of the first finger with destruction of the head of the proximal phalanx
The X-ray examination showed the detachment of the distal phalanx with the part of the head of the proximal phalanx (not more than 3 millimeters) (Fig. 2).
Figure 2
The X-ray image of the finger stump
There were not any contraindications for replantation: the child was healthy. His father received some explanations about the course of the surgery and possible complications (thrombosis, venous stasis, and henceforth – lymphostasis and others, such as simple purulence). The parents gave the consent for the surgical intervention with duration about 6-9 hours with possible use of the single chance for restoration of the fully-featured first finger.
The replant was transported to the surgery room. The revision of all anatomical structures was initiated for estimation of a possibility for replantation. Two incisions were made on the replant (along the vascular and nervous bundles) and the arteries and the nerves were separated. With significant magnification it was found that suturing the artery was possible, but it was impossible to determine the degree of detachment of the branches of these arteries. Two veins were found, one of which was detached from the implant. It had the multiple ruptures of the vascular wall and it was inappropriate for suturing.
Considering the minimal chance and the parents’ agreement for the high risk replantation, the patient was transported to the surgery room. The child was examined during revision of the implant. The analysis included the blood, urine, biochemical examination, ECG, anesthesiologist consultation.
The catheter (1.0 m in diameter) was installed and sutured with a single suture under endotracheal narcosis in combination with regional anesthesia. It allowed significant decreasing the aggressiveness and the amount of pharmaceuticals in intubation narcosis during the whole period of surgery (more than 5 hours), performing anesthesia for the segment, which functioned more than 12 hours after the surgery. The operation was initiated at 4:40 p.m. and was completed at 10:00 p.m. During the surgery we used Martin Quicklot Gauze for 40-60 minutes with 10-15 intervals between the sessions.
The operation was continued with revision of the stump of the first finger: the proximal phalanx was resected for the distance more than 1 cm, the tendons of the flexors and the extensors were separated and sutured with capron according to Rozov. The nerve and the dominant artery were verified with the microsurgical technique. Owing to the traction mechanism, the artery was skeletonized, if one may say so, along the distance of 3 cm. The recessive artery (the diameter of 0.3 mm) and the nerve were prepared.
The next stage included the fixation of the replant and the proximal phalanx of the first finger with use of two crossing pins (diameter of 0.8 mm) under the mini-EOP (Fig. 3). The extensor and flexor tendons were sutured. All further work was conducted with the microsurgical technique: suture of the recessive artery with prolene 9/0, perineural suture of the nerve. There was no venous return. Prevention of early thrombosis was realized with the single-step introduction of 5,000 units of heparin. Also the antispasmodic drugs were used. After the arterial suturing, the finger was covered with the dressing with warm (40°C) saline. There was no venous flow. Therefore, the dominant artery (1 mm or higher diameter) was separated and sutured, but it was skeletonized along its whole distance, and blood flow was not restored. We used our last chance: resection of the anastomosis of the recessive artery and recurrent suture. As result, the blood flow appeared again! However after 30-40 minutes the finger became pale. Despite this fact the single vein was sutured with prolene 9/0. The vein filled out, but the finger was pale. The nerves were sutured. The dominant artery was coagulated. The dominant artery showed the signs of thrombosis, as well as the multiple ruptures of the arterial intima of the implant after dissection of the replant. Despite of the ambiguous primary outcome of the surgery, on the basis of our long years of the experience we made a conclusion about successful preservation of the finger. The skin was sutured with prolene 5/0 with microsurgical technique. Then the finger was covered with the dressings with sterile oil for prevention of secondary compression by the wound discharge and the blood. After the surgery the extremity was fixed with the plaster splint.
Figure 3
The X-ray image after replantation
The patient was examined on the next day at 8:00 a.m. (Fig. 4): the distal phalanx was warm and pink; some phlyctenules were identified after removal of the dressings, i.e. venous outflow suffered. Multiple insections were made on the palmar surface and the nail plate of the replant with use of the injection needle. The phlyctenules were opened. The dressings with olasol contained some foam.
Figure 4
10 hours after surgery
Dressings were changed two times per day within two weeks. During dressing some insections were made. The finger was recovering. The therapy for prevention of thrombosis was initiated from the first day. This was the case with administration of heparin within the first hours of appearance of blood flow. Heparin was introduced through the abdominal skin. INR was controlled during 3 weeks and subsequent decrease of the dosage of heparin was used (Fig. 5). Simultaneously we used the drugs for improving the rheologic properties of the blood: low molecular dextrane, pentoxifylline, spasmolytics, adequate analgesia. We think that the important thing is limitation of physical activity of the patient; 2 weeks of bed rest in combination with breathing exercises and the conditioning factors: remedial gymnastics for another hand and the lower extremities (Fig. 6).
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Figure 5 10th day after replantation 
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Figure 6 After 3 weeks 
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Antibacterial therapy was used during 20 days (2 courses). Despite of all measures, some regions of superficial necrosis appeared on the distal phalanx. Therefore, the sutures were removed only a month later. The patient was discharged for outpatient observation. Epithelialization was accompanied by incrustation. We used some dressings with foam (olasol). The patient was examined after 1 and a half month. The control X-ray examination was conducted (Fig. 7-9).
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Figure 7 45 days after replantation 
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Figure 8 The pins are still not removed
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Figure 9 The X-ray image after 45 days 
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CONCLUSION
This case shows the possibility and efficiency of replantation of the segments of the fingers in children of any age and with any types of trauma, including traction one. Transposition of the vascular bundle, for example, the artery or the artery – the nerve from the 4th finger, did not get any good results, because the problems were associated with not adducting arteries, but with the arteries and the veins of the replant. This was a single chance to save the child’s first finger, and we used it.