Case of the fortnight
Department of Plastic Surgery, Hand Surgery and Reconstructive Microsurgery

Five Finger Replant

A 24 year old owner of a printing press at Sivakasi, accidentally amputated all the five fingers of his left hand while inspecting a machine under repair at about 8.30 pm on 7 12 2001.  Picking the amputated parts he reached Madurai, from where he was referred to Ganga Hospital, Coimbatore for possible reattachment of the fingers. He reached Ganga Hospital at 5 30 am on 8 12 2001.  The replantation team at the hospital, which had prior information was ready for the job.
 
 
Dorsal view of amputated fingers Palmar view of amputated fingers Dorsal view of the Hand Palmar view of the Hand

After preliminary investigations like x rays, the team immediately went into action. The first step was to examine the amputated parts under the microscope.  Replantation is a time consuming and delicate process.  Survival depends upon successful joining of blood vessels smaller than 1 mm in diameter.  Prior to that the bone has to be fixed.  To make the reattached part function, tendons which move the joints and nerves which provide sensation have to be joined. So the first step involves identifying all these structures in the amputated part. Similar job has to be done on the proximal side (patient side).  This itself could take more than an hour for each finger.  In hospitals like Ganga, where two teams and microscopes are available, time could be saved by simultaneously doing this The identified nerves and blood vessels are tagged for easy identification during the joining process.

The bones of the finger are joined by stainless steel wires.  Then the tendons which move the finger joints are joined.  This is followed by suturing of the nerves and then the blood vessels. These blood vessels which are less than one mm in diameter are joined by sutures which are about 75 microns in diameter. This procedure has to be done for each finger. The thumb was first joined, then the index and the order followed.  Now it is 2 weeks after the operation and the patient has started rehabilitation programme. He can look forward to good use of his hand in a few months time.

The whole operation took 17 hours to complete
 
 

Dorsal  view after surgery
Lateral view 
Palmar view

Late Postop Photographs

 
  

What is special about the Operation?

Reattaching all five fingers successfully is technically more difficult than reattaching an amputated hand at the wrist or forearm.  The bigger the part, the bigger are the blood vessels.  As we go lower down and the amputated parts are only the finger tips, the vessels become very thin and small.  This calls for superior skills, patience and good team work. We need to reattach blood vessels for each finger to survive. In all 18 blood vessels, 9 nerves, 14 tendons were joined apart from the bones.

What the public should know?

Even though it is ten years since we introduced Microsurgery to Coimbatore region, still many are unaware about the possibility of replantation.  Since this has to be done immediately, high level of awareness among the public is essential to save these fingers and hands from getting into the dustbin and buried into the ground. The people must know that

1. Replantation of amputated parts is possible

2. The centre where it is possible

3. The method of bringing amputated parts.

This needs constant reinforcement to the public.

Method of Bringing the amputated parts

Step 1:  Put the amputated part into a plastic bag. Any plastic bag is OK

Step 2:  Put a water tight knot at the top.

Step 3:  Place the plastic bag with the finger into a flask or a thermocol box filled with ice

Do not put ice and the finger together.  The part gets frozen and it is difficult to get the blood flowing again.

Do not put into any solution like Glucose water or preservatives like formalin.

If the part is bigger ice could be put into the plastic bags and the part packed with ice bags all around.
 

How soon should the amputated parts be brought?

‘AS SOON AS POSSIBLE’ is the answer.  The longer the delay the lesser are the rates of success.  Parts like fingers and thumb which do not have muscle can stand being without blood supply longer. If the amputation happens above the elbow, the part has to be joined within 4-6 hours.  This is because, the amputated part has considerable muscle tissue.  Muscle starts decomposing fast without blood supply.  If blood supply is restored after a long delay, the products of decomposition get washed into the general circulation.  This could be harmful to the organs like heart and kidneys.  Hence bigger the amputated part, sooner the patient has to reach the appropriate hospital.

IF THE AMPUTATED PART IS PROPERLY STORED, THEN THE TIME FOR REACHING THE CORRECT CENTRE COULD BE EXTENDED.  In the present instance, the amputated fingers were properly packed and transported by the referring doctor at Madurai. Even though, the patient arrived 9 hours after the injury, we could perform the surgery only because it was stored properly during transport.

THE TEAM

Dr. S Raja Sabapathy headed the team of following doctors
Dr. Ravindra Bharathi
Dr. Hari Venkatramani,
Dr. Aniraj
Dr. Mashiur Rahman.
The anaesthesia for this long procedure was given by Dr.  Ravindra Bhat who was assisted by Dr.  Maheshwari. The patient was under brachial block for the first 14 hours and had GA for the last 3 hours.