RESUMEN
Importance: Optimal treatment for traumatic finger amputation is unknown to date. Objective: To use statistical learning methods to estimate evidence-based treatment assignment rules to enhance long-term functional and patient-reported outcomes in patients after traumatic amputation of fingers distal to the metacarpophalangeal joint. Design, Setting, and Participants: This decision analytical model used data from a retrospective cohort study of 338 consenting adult patients who underwent revision amputation or replantation at 19 centers in the United States and Asia from August 1, 2016, to April 12, 2018. Of those, data on 185 patients were included in the primary analysis. Exposures: Treatment with revision amputation or replantation. Main Outcomes and Measures: Outcome measures were hand strength, dexterity, hand-related quality of life, and pain. A tree-based statistical learning method was used to derive clinical decision rules for treatment of traumatic finger amputation. Results: Among 185 study participants (mean [SD] age, 45 [16] years; 156 [84%] male), the median number of fingers amputated per patient was 1 (range, 1-5); 115 amputations (62%) were distal to the proximal interphalangeal joint, and 110 (60%) affected the nondominant hand. On the basis of the tree-based statistical learning estimates, to maximize hand dexterity or to minimize patient-reported pain, replantation was found to be the best strategy. To maximize hand strength, revision amputation was the best strategy for patients with a single-finger amputation but replantation was preferred for all other injury patterns. To maximize patient-reported quality of life, revision amputation was the best approach for patients with dominant hand injuries, and replantation was the best strategy for patients with nondominant hand injuries. Conclusions and Relevance: The findings suggest that the approach to treating traumatic finger amputations varies based on the patient's injury characteristics and functional needs.
Asunto(s)
Amputación Traumática , Reglas de Decisión Clínica , Traumatismos de los Dedos , Adulto , Amputación Traumática/clasificación , Amputación Traumática/fisiopatología , Amputación Traumática/cirugía , Árboles de Decisión , Medicina Basada en la Evidencia , Femenino , Traumatismos de los Dedos/clasificación , Traumatismos de los Dedos/fisiopatología , Traumatismos de los Dedos/cirugía , Dedos/cirugía , Humanos , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Estudios RetrospectivosRESUMEN
The literature on surgical techniques and recent evidence in microsurgical digital and hand replantation is reviewed. Replantation should not be done routinely without considering postoperative functional outcomes. Achieving best outcomes is related to the success of microvascular anastomosis and to adequacy of bone fixation, tendon and nerve repair, and soft-tissue coverage. Replantation surgery has become a routine procedure. However, little is known about the decision-making process for digital and hand amputation. A study comparing the outcomes of digital and hand amputations treated with replantation or revision amputation is needed. Outcome assessment includes not only function but also patient-reported outcomes.
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Amputación Traumática/cirugía , Traumatismos de los Dedos/cirugía , Traumatismos de la Mano/cirugía , Reimplantación/métodos , Amputación Traumática/clasificación , Contraindicaciones de los Procedimientos , Dedos/cirugía , Mano/cirugía , Humanos , ReoperaciónRESUMEN
Defects on the palmar surface of the fingers are an important part of hand emergencies, especially fingertip wounds. Luckily, many coverage methods are available. We will review the anatomy of this area and the thought process for treating these defects. We will also propose an algorithm that can be used to select the best technique based on the type of injury present.
Asunto(s)
Traumatismos de los Dedos/cirugía , Traumatismos de los Tejidos Blandos/cirugía , Amputación Quirúrgica , Amputación Traumática/clasificación , Árboles de Decisión , Traumatismos de los Dedos/clasificación , Dedos/anatomía & histología , Humanos , Apósitos Oclusivos , Trasplante de Piel , Piel Artificial , Colgajos QuirúrgicosRESUMEN
The metacarpal-like hand is a severe hand injury, never addressed before. It describes a hand that has lost a significant degree of prehension through a wide array of amputations, involving all digits proximal to the functional length except in one finger or in two digits, including the thumb. The thumb condition can be used to differentiate between two types. In type I, the thumb is intact or amputated at or distal to the interphalangeal joint (functional length); therefore, the reconstruction is focused mainly on fingers. In type II, the thumb is amputated proximal to the interphalangeal joint; therefore, the reconstruction is focused on both the thumb and fingers. Thumb amputation level, integrity of the first basal joint, and functionality of the thenar muscles can be used to subdivide type II. Functional reconstruction should consider the patient's desire and vocational needs. The finger left with adequate functional length is assessed for its location, level of amputation, and joint motion, especially the proximal interphalangeal joint. The goal is to use the reliable techniques of toe-to-hand surgery to reconstruct more opposable units, at least two fingers, whether adjacent to each other or not, and the thumb, when needed, to achieve a functionally and aesthetically better hand instead of a functionally adequate hand, with a more acceptable to ideally natural hand cascade. Strategic, individualized toe transfer(s) is the key element in fulfilling the goals of this operation whether single or multiple toes are transplanted.
Asunto(s)
Amputación Traumática/cirugía , Traumatismos de los Dedos/cirugía , Huesos del Metacarpo/lesiones , Microcirugia/métodos , Procedimientos de Cirugía Plástica/métodos , Dedos del Pie/trasplante , Adulto , Anciano , Amputación Traumática/clasificación , Amputación Traumática/diagnóstico , Traumatismos de los Dedos/clasificación , Traumatismos de los Dedos/diagnóstico , Humanos , Masculino , Huesos del Metacarpo/cirugía , Pulgar/lesiones , Pulgar/cirugíaRESUMEN
INTRODUCTION: Third degree open fractures and traumatic sub-/total amputations of the upper extremity represent severe injuries and are associated with a high rate of functional impairment of the affected extremity. More than 20 years ago, the Mangled Extremity Severity Score (MESS) was introduced to predict amputation following severe lower extremity trauma. However, there have been few studies evaluating MESS in connection with the mangled upper limb. MATERIAL AND METHODS: A retrospective medical chart review was performed of all patients diagnosed with the aforementioned fractures of the upper extremity treated at the Department of trauma surgery (level I trauma center) and the Clinical division of plastic and reconstructive surgery at the general hospital of Vienna between 1994 and 2014. RESULTS: Fifty-four out of 606 patients (9%) suffered from a total of 61 third degree open fractures or traumatic sub-/total amputations of the upper extremity (Gustilo-Anderson, type IIIA, n=30; Gustilo-Anderson, type IIIB, n=15; Gustilo-Anderson, type IIIC, n=9; traumatic sub-/total amputations, n=7). Thirty-seven out of 54 patients (69%) suffered fractures of the forearm, 10/54 (19%) patients of the humerus and 7/54 (13%) patients of the forearm and the humerus. The median MESS and Injury Severity Score (ISS) for all patients was 5 (range: 3-10) and 9 (range: 4-50), respectively. Seventeen out of 54 patients (31%) were diagnosed with a MESS≥7. Twenty-one out of 54 patients (39%) suffered severe vascular injuries and 22/54 (41%) patients suffered injuries of neural structures. Throughout the therapy process, 6/54 (11%) patients died. Definite limb salvage was achieved in 45 (94%) of the 48 survivors, of whom 9/45 (20%) subjects had a MESS≥7. DISCUSSION: It became apparent that definite limb salvage could be achieved in the mangled upper extremity regardless of MESS. It should be noted that in the current study, limb functionality was not assessed. However, without a standardized scoring system, there might be significant risk of salving dysfunctional upper limbs. LEVEL OF EVIDENCE: IV: retrospective or historical series.
Asunto(s)
Amputación Traumática/cirugía , Traumatismos del Antebrazo/cirugía , Fracturas Abiertas/cirugía , Fracturas del Húmero/cirugía , Índices de Gravedad del Trauma , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Amputación Traumática/clasificación , Amputación Traumática/mortalidad , Niño , Preescolar , Femenino , Traumatismos del Antebrazo/clasificación , Traumatismos del Antebrazo/mortalidad , Fracturas Abiertas/clasificación , Fracturas Abiertas/mortalidad , Humanos , Fracturas del Húmero/clasificación , Fracturas del Húmero/mortalidad , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Lesiones del Sistema Vascular/mortalidad , Lesiones del Sistema Vascular/cirugía , Adulto JovenRESUMEN
BACKGROUND: Venous congestion/insufficiency plays a major role in failure of finger replantation. Despite acceptable salvage rates with postoperative anticoagulation or leeching, operative technique remains the most important predictor of success. However, there are no indications in the literature on the benefit of anastomosing single versus multiple veins. METHODS: A retrospective review of finger amputations from 2011 to 2013 was conducted. The analyzed endpoint was the finger survival rate at discharge depending on the number of veins repaired: multiple veins (group 1), only one vein (group 2), or no veins (group 3). Proportions were compared using v2 tests/Fisher's exact tests; p-value <0.05 was considered significant. RESULTS: Seventy-two patients with complete digital amputation were operated including 101 fingers. Twenty-seven fingers (26.7%) failed before hospital discharge, with 78% of failures due to venous complications versus 22% with an arterial etiology. Group 2 had 15 replantation failures due to venous causes as opposed to only one from group 1, representing a 1.27-fold (95% confidence interval (CI): 0.99, 1.34) increased relative risk of failure (p = 0.032). Similarly, five fingers from group 3 suffered venous complications, resulting in a 1.49-fold (95% CI: 1.02, 1.73) increased likelihood of failure in comparison to group 1 (p = 0.008). No significant difference was observed between having only one vein repaired versus none (RR: 1.1792, 95% CI: 0.83, 2.10, p = 0.502). CONCLUSION: Efforts toward favoring two-vein repair lead to better survival of the replanted fingers. More cases need to be analyzed before formulating conclusions on specific levels of amputation with regard to venous anastomoses.
Asunto(s)
Amputación Traumática/cirugía , Traumatismos de los Dedos/cirugía , Dedos/irrigación sanguínea , Dedos/cirugía , Reimplantación/métodos , Venas/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Amputación Traumática/clasificación , Amputación Traumática/patología , Anastomosis Quirúrgica/métodos , Anastomosis Quirúrgica/estadística & datos numéricos , Femenino , Lateralidad Funcional , Humanos , Masculino , Persona de Mediana Edad , Reimplantación/estadística & datos numéricos , Estudios Retrospectivos , Pulgar/lesiones , Pulgar/cirugía , Insuficiencia del Tratamiento , Procedimientos Quirúrgicos VascularesRESUMEN
The objective of this study was to compare the functional outcomes of zone II amputations treated with either replantation or revision amputation at our institution to better aid patients in their decision making process regarding these treatment options. We conducted a comparative retrospective study. All cases of single digit amputations received at our replantation center between 2007 and 2011 were screened for single digit zone II injuries. These patients were stratified based on the treatment received: replantation vs revision amputation. Patients were called and invited to participate in the research project. Those who accepted to enter the study were asked to complete the Quick-DASH, the Beck Depression Inventory-short form, and a custom made questionnaire. There were seventeen patients with single digit zone II replantation and fourteen patients with similar injuries who underwent revision amputation and agreed to take part in the study. Our data revealed that the duration of sick leave, occupation after injury, professional and social reintegration, discontinued activities, and self-confidence were not statistically different between the two groups. The average hospital stay and the follow-up period of replanted individuals were longer. The replantation group did not have higher levels of pain or cold intolerance, and the global functional and esthetic satisfaction levels were similar between the two groups. Also, Beck Depression Inventory and Quick-DASH scores were not statistically different. Yet, significantly more patients in the replantation group would opt to repeat the replantation than revised patients would opt for revision amputation. From a functional viewpoint, our study suggests that revision amputation is not superior to replantation in zone II single digit amputations. This is valuable information that should be given to patients when deciding on the treatment process and to insure a proper informed consent.
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Amputación Quirúrgica , Amputación Traumática/cirugía , Traumatismos de los Dedos/cirugía , Reimplantación , Adulto , Amputación Quirúrgica/psicología , Amputación Traumática/clasificación , Amputación Traumática/psicología , Femenino , Traumatismos de los Dedos/clasificación , Traumatismos de los Dedos/psicología , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Ocupaciones , Satisfacción del Paciente , Reimplantación/psicología , Estudios Retrospectivos , Autoeficacia , Ausencia por Enfermedad , Participación Social , Encuestas y Cuestionarios , Adulto JovenRESUMEN
PURPOSE: This study evaluated the composite graft survival rate in distal digital amputations with respect to injury type and amputation level. METHODS: Twenty-seven patients with complete fingertip amputations (32 digits) distal to the distal interphalangeal joint who were treated by composite grafting from January 2010 to February 2012 were enrolled. Injury type was classified as clean-cut, blunt-cut, or crush-avulsion. Amputation level was classified according to Ishikawa's classification: subzones I-IV. Graft survival was categorised as complete, partial, or no survival. RESULTS: The graft was more likely to exhibit complete survival in clean-cut injuries (50%) than in blunt-cut (10%) or crush-avulsion injuries (12.5%). However, when complete and partial survival were combined, there was no significant difference among injury types (clean-cut = 83.3%, blunt-cut = 70.0%; crush-avulsion = 68.8%). Composite grafting in sub-zone I provided good results (complete survival = 50%; partial survival = 50.0%; no survival = 0%). When complete and partial survival were combined, there was no significant difference with respect to amputation level except sub-zone I (II = 70.6%; III = 66.7%; IV = 60%). In sub-zone II, clean-cut injuries exhibited better graft survival than blunt-cut or crush-avulsion injuries. In sub-zones III and IV, no complete graft survival was observed. CONCLUSION: In conclusion, all types of injuries in sub-zone I and clean-cut injuries in sub-zone II are candidates for composite grafting. Blunt-cut and crush-avulsion injuries in sub-zone II are marginal candidates for composite grafting. Any type of injury in sub-zone III or IV is contraindicated for composite grafting and should be treated by microanastomosis.
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Amputación Traumática/clasificación , Amputación Traumática/cirugía , Traumatismos de los Dedos/clasificación , Traumatismos de los Dedos/cirugía , Supervivencia de Injerto , Reimplantación , Adolescente , Adulto , Anciano , Anastomosis Quirúrgica , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Lactante , Masculino , Microcirugia , Persona de Mediana Edad , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: A capture-recapture analysis was performed to estimate the total number of work-related amputations. We examined the impact of misclassification due to differential injury reporting on the estimate of total number of work-related amputations. METHODS: Bureau of Labor Statistics' Survey of Occupational Injuries and Illnesses (SOII) samples and workers' compensation records (WC) were used to estimate the total number of work-related amputations. Some of the amputation cases in one data source matched with injuries other than amputations in the other data source. We performed sensitivity analyses reassigning such cases as matched amputations. RESULTS: Depending on how we treated the cases matched with other injuries, the total number of work-related amputations ranged from 276 to 442 cases, yielding dramatically different capture rates (35-87%). CONCLUSION: Due to differential classification, estimates of work-related amputations would be biased. Our findings highlight the importance of accurately reporting and classifying work-related injuries and illnesses.
Asunto(s)
Amputación Traumática/epidemiología , Traumatismos Ocupacionales/epidemiología , Vigilancia en Salud Pública/métodos , Amputación Traumática/clasificación , Amputación Traumática/economía , Recolección de Datos , Humanos , Massachusetts/epidemiología , Registros Médicos , Modelos Estadísticos , Traumatismos Ocupacionales/clasificación , Traumatismos Ocupacionales/economía , Indemnización para Trabajadores/estadística & datos numéricosRESUMEN
BACKGROUND: Distal fingertip replantation is associated with good functional and aesthetic results. Venous anastomosis is the most challenging procedure. For replantation with an artery anastomosis-only procedure (no venous anastomosis), some protocols have been designed to relieve venous congestion involve anticoagulation and the creation of wounds for persistent bleeding. This report presents the authors' experience of fingertip survival after artery anastomosis-only replantation with no persistent external bleeding. METHODS: Twelve Tamai zone I fingertip total amputation patients who underwent artery anastomosis-only replantations were recruited from February 2009 to June 2012. Nerve repair was performed if identified. The patients were not subjected to conventional external bleeding methods. Both the blood color on pinprick and fingertip temperature difference between the replanted and uninjured digits were used as indicators of deteriorated venous congestion. RESULTS: The replanted digits of 11 patients survived. The only failed replant exhibited an average temperature difference of more than 6°C compared with the uninjured digits and consistently exhibited darker blood during the pinprick test. All other replants exhibited average temperature differences of less than 6°C. CONCLUSIONS: In these Tamai zone I artery anastomosis-only replantations, fingertips survived without the use of external bleeding method, indicating that external bleeding is probably not obligatory for survival of artery anastomosis-only replanted digits distal to Tamai zone I. An increasing temperature difference between the replanted and uninjured digits and darker blood on pinprick may be used as indicators of deteriorating congestion signs.
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Amputación Traumática/cirugía , Traumatismos de los Dedos/cirugía , Reimplantación/métodos , Procedimientos Quirúrgicos Vasculares/métodos , Adulto , Anciano , Anciano de 80 o más Años , Amputación Traumática/clasificación , Anastomosis Quirúrgica , Femenino , Dedos/irrigación sanguínea , Humanos , Masculino , Persona de Mediana EdadRESUMEN
INTRODUCTION: The accepted mechanism of blast-mediated traumatic amputation (TA) is blast wave induced fracture followed by limb avulsion from the blast wind, generating a transosseous amputation. Blast-mediated through-joint TAs were considered extremely rare with published prevalence <2%. Previous studies have also suggested that TA is frequently associated with fatal primary blast lung injury (PBLI). However, recent evidence suggests that the mechanism of TA and the link with fatal primary blast exposure merit review. METHODS: A trauma registry (UK Joint Theatre Trauma Registry) and postmortem CT (PM-CT) database were used to identify casualties (survivors and deaths) sustaining a blast-mediated TA in the 2 years from August 2008. TA metrics and associated significant injuries were recorded. Detailed anatomical data on extremity predebridement osseous and soft tissue injuries were only consistently available for deaths through comprehensive PM-CT imaging. RESULTS: 146 cases (75 survivors and 71 deaths) sustaining 271 TAs (130 in survivors and 141 in deaths) were identified. The lower limb was most commonly affected (117/130 in survivors, 123/141 in deaths). The overall through-joint TA rate was 47/271 (17.3%) and 34/47 through-joint injuries (72.3%) were through knee. More detailed anatomical analysis facilitated by PM-CT imaging revealed only 9/34 through-joint TAs had a contiguous fracture (ie, intra-articular involving the joint through which TA occurred), 18/34 had no fracture and 7/34 had a non-contiguous (ie, remote from the level of TA) fracture. No relationship between PBLI and TA was evident. CONCLUSIONS: The previously reported link between TA and PBLI was not present, calling into question the significance of primary blast injury in causation of blast mediated TAs. Furthermore, the accepted mechanism of injury can't account for the significant number of through-joint TAs. The high rate of through-joint TAs with either no associated fracture or a non-contiguous fracture (74%) is supportive of pure flail as a mechanism for blast-mediated TA.
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Amputación Traumática/epidemiología , Traumatismos por Explosión/epidemiología , Explosiones , Amputación Traumática/clasificación , Amputación Traumática/mortalidad , Traumatismos por Explosión/clasificación , Traumatismos por Explosión/mortalidad , Humanos , Personal Militar , Sistema de Registros , Análisis de Supervivencia , GuerraRESUMEN
BACKGROUND: Complex lower limb injury caused by improvised explosive devices (IEDs) has become the signature wounding pattern of the conflict in Afghanistan. Current classifications neither describe this injury pattern well, nor correlate with management. There is need for a new classification, to aid communication between clinicians, and help evaluate interventions and outcomes. We propose such a classification, and present the results of an initial prospective evaluation. PATIENTS AND METHODS: The classification was developed by a panel of military surgeons whilst deployed to Camp Bastion, Afghanistan. Injuries were divided into five classes, by anatomic level. Segmental injuries were recognised as a distinct entity. Associated injuries to the intraperitoneal abdomen, genitalia and perineum, pelvic ring, and upper limbs, which impact on clinical management and resources, were also accounted for. RESULTS: Between 1 November 2010 and 20 February 2011, 179 IED-related lower limb injuries in 103 consecutive casualties were classified, and their subsequent vascular and musculoskeletal treatment recorded. 69% of the injuries were traumatic amputations, and the remainder segmental injuries. 49% of casualties suffered bilateral lower limb amputation. The most common injury was class 3 (involving proximal lower leg or thigh, permitting effective above-knee tourniquet application, 49%), but more proximal patterns (class 4 or 5, preventing effective tourniquet application) accounted for 18% of injuries. Eleven casualties had associated intraperitoneal abdominal injuries, 41 suffered genital or perineal injuries, 9 had pelvic ring fractures, and 66 had upper limb injuries. The classification was easy to apply and correlated with management. CONCLUSIONS: The 'Bastion classification' is a pragmatic yet clinically relevant injury categorisation, which describes current injury patterns well, and should facilitate communication between clinicians, and the evaluation of interventions and outcomes. The validation cohort confirms that the injury burden from IEDs in the Helmand Province of Afghanistan remains high, with most casualties sustaining amputation through or above the knee. The rates of associated injury to the abdomen, perineum, pelvis and upper limbs are high. These findings have important implications for the training of military surgeons, staffing and resourcing of medical treatment facilities, to ensure an adequate skill mix to manage these complex and challenging injuries.
Asunto(s)
Amputación Traumática/cirugía , Traumatismos por Explosión/cirugía , Traumatismos de la Pierna/cirugía , Medicina Militar , Personal Militar , Traumatismo Múltiple/cirugía , Campaña Afgana 2001- , Amputación Traumática/clasificación , Traumatismos por Explosión/clasificación , Traumatismos por Explosión/fisiopatología , Medicina de Emergencia/educación , Medicina de Emergencia/métodos , Humanos , Puntaje de Gravedad del Traumatismo , Traumatismos de la Pierna/clasificación , Traumatismos de la Pierna/fisiopatología , Medicina Militar/educación , Medicina Militar/métodos , Personal Militar/estadística & datos numéricos , Pelvis/lesiones , Perineo/lesiones , Estudios Prospectivos , TorniquetesRESUMEN
BACKGROUND: In 1997, H. Zwipp. proposed a 5-point scoring system for the classification of complex trauma of the foot. However, outcome and quality of life after this type of injury have not been studied systematically. PATIENTS: Seventy-four patients with a complex injury of the foot were treated between 2001 and 2007. Fifty patients met the inclusion criteria for a prospective cross-sectional study. American Foot and Ankle Society score, the Short Form 12, and the Visual Analogue Scale-Foot and Ankle Score were recorded. All patients were examined by an experienced orthopedic surgeon and a certified pedorthist. Functional assessment was completed by dynamic baropedography. RESULTS: Primary amputation was necessary in 11, secondary amputation in 7 patients. A compartment syndrome was diagnosed in 29 patients. Soft tissue coverage was achieved in eight patients using a free vascular flap. The complication rate was 32%. Mean follow-up was 4 years (1-7 years). At that time, the American Foot and Ankle Society score was 66.2, the Short Form 12 score 38.2 (physical health component scale), and the Visual Analogue Scale-Foot and Ankle score was 51.9. Orthopedic shoes were necessary in 44% of the patients; however, compliance was low, and 52% of the orthopedic devices were insufficient. Pedographic evaluation demonstrated changes in gait in 82% of the patients. CONCLUSION: Early outcome after complex trauma of the foot was essentially determined by soft tissue injury, whereas long-term outcome was determined more by the trauma of the bones and joints. Objective measurements such as dynamic pedography helped to better understand patients' limitations. Orthotic supply could be improved in a reasonable number of the patients.
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Traumatismos de los Pies/cirugía , Adolescente , Adulto , Anciano , Amputación Traumática/clasificación , Amputación Traumática/cirugía , Estudios Transversales , Femenino , Pie/diagnóstico por imagen , Pie/cirugía , Traumatismos de los Pies/clasificación , Traumatismos de los Pies/diagnóstico por imagen , Marcha , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Equipo Ortopédico , Estudios Prospectivos , Calidad de Vida , Radiografía , Encuestas y Cuestionarios , Resultado del Tratamiento , Adulto JovenRESUMEN
The purpose of the study was to describe the outcome after hand injury from powered wood splitters, and to investigate the relation between injury severity and outcome. Injury severity was rated according to the Hand Injury Severity Scoring System (HISS system) and the Injury Severity Score method. The patients were evaluated with the Disabilities of the Arm Shoulder and Hand outcome questionnaire (DASH), and 26 of the most severely injured patients were evaluated with the Sollerman test. The mean DASH score was moderately elevated at 15, indicating that many of these patients have sequelae. A statistically significant correlation between HISS and DASH scores was found, implying that initial injury severity is of importance for outcome. The mean Sollerman score in the injured hand was 66, which amounts to a significantly impaired hand function.
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Accidentes de Trabajo , Actividades Cotidianas/clasificación , Amputación Traumática/diagnóstico , Traumatismos de la Mano/diagnóstico , Fuerza de la Mano/fisiología , Puntaje de Gravedad del Traumatismo , Madera , Heridas Penetrantes/diagnóstico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Amputación Traumática/clasificación , Amputación Traumática/cirugía , Niño , Preescolar , Evaluación de la Discapacidad , Femenino , Lateralidad Funcional , Mano/irrigación sanguínea , Traumatismos de la Mano/clasificación , Traumatismos de la Mano/cirugía , Humanos , Isquemia/clasificación , Isquemia/diagnóstico , Isquemia/cirugía , Masculino , Persona de Mediana Edad , Pronóstico , Derivación y Consulta , Estudios Retrospectivos , Suecia , Pulgar/lesiones , Pulgar/cirugía , Resultado del Tratamiento , Heridas Penetrantes/clasificación , Heridas Penetrantes/cirugía , Adulto JovenRESUMEN
OBJECTIVE: To investigate new classification and repair methods for the traverse amputated fingertip. METHODS: From March 2000 to October 2006, 20 cases of 20 fingers with traverse amputated fingertip, including 13 males and 7 females aged 17-47 years, were treated. Twenty patients (9 crush injuries, 5 cutting injuries and 6 sawing injuries) were classified into 4 types, namely type I (the distal one third of nail bed), type II (the middle of nail bed), type III (the proximal one third of nail bed), and type IV (the root of nail bed). There were 3 patients (2 index fingers and 1 little finger) of type I, 8 patients (2 thumbs, 3 index fingers and 3 middle fingers) of type II, 5 patients (3 index fingers, 1 ring finger and 1 little finger) of type III, and 4 patients (2 thumbs, 1 middle finger and 1 little finger) of type IV. The soft tissue defect ranged from 1.2 cm x 1.2 cm to 1.5 cm x 1.2 cm. The time from injury to surgery was 3-10 hours. Fingers of type I and type II were treated with forward flow axial flap and modified nail bed lengthening. Fingers of type III and type IV were treated with forward flow axial flap and partial nail bed replantation as well as modified nail bed lengthening. The flaps ranged in size from 1.5 cm x 1.2 cm to 2.0 cm x 1.4 cm. RESULTS: Twenty patients incisions healed by first intention and the flaps, nails and skin grafting survived. All donor sites healed by first intention. All patients were followed up for 2-6 months (4 months on average). The appearances of fingertips were good. The texture of the flap was soft, and the fingers had no tenderness and motor disturbance. The two-point discrimination was 4.5-6.5 mm. The finger nails of type I and type II extended 3-4 mm after operation, while the finger nails of type III and type IV extended 8-10 mm after operation. All finger nails were smooth and flat without pain. Hook nail happened in 1 case 6 months after operation. CONCLUSION: Classification of the injured fingers according to the condition of the amputation base is helpful in choosing repair methods, and is conducive to maximize the recovery of the function and shape of fingertips.
Asunto(s)
Amputación Traumática/cirugía , Traumatismos de los Dedos/cirugía , Reimplantación/métodos , Adolescente , Adulto , Amputación Traumática/clasificación , Femenino , Traumatismos de los Dedos/clasificación , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Uñas/cirugía , Colgajos QuirúrgicosRESUMEN
Introdução: o reimplante de dedos é uma opção no tratamento de amputações traumáticas. E tornou-se procedimento rotineiro, nos serviços onde existem profissionais com treinamento microcirúrgico.As indicações de reimplante de dedos, atualmente, estão baseadas na funcionalidade da mão. Objetivo: mostrar a modificação dos critérios para indicação de reimplante de dedos da mão. Métodos: estudo retrospectivo analisando pacientes com amputações digitais, que foram ou não reimplantados, durante os 26 anos do Serviço de Microcirurgia do Hospital Cristo Redentor em Porto Alegre. Resultados: observou-se que, inicialmente, o reimplante era aplicado a todos os segmentos amputados. Com o passar dos anos, essas indicações ficaram mais restritas, sendo contra-indicado nos pacientes com boa função remanescente, na mão traumatizada. Discussão: o principal objetivo do tratamento dos pacientes com amputações digitais é manter a funcionalidade da mão. Diversos fatores devem ser considerados para in- dicação de um reimplante digital.A reabilitação pós-operatória é fundamental para o sucesso do tratamento proposto ao segmento amputado. Conclusão: nas amputa- ções digitais, o principal critério para indicação de reimplante, além das indicações formais, deve ser a manutenção de uma boa função da mão.
Background: finger reimplant is an option in the treatment of traumatic amputations. It has become a routine procedure, when there are microsurgical trained professionals. The indications for fingers reimplant are currently based in the hand's fnctionality. Objective: to show the modification of criterions to indication finger reimplant. Methods: retrospective study analyzing digitally amputated patients, that were or weren't reimplanted during the 26 years of the Cristo Redentor Hospital's Microsurgical Service in Porto Alegre. Results: it has been observed that initially the reimplant was applied to all amputated segments. As the years have gone by, these indications are becoming more restricted. Nowadays, the reimplant is contraindicated for patients with good remaining function on the injured hand. Discussion: the main purpose on treating patients with digital amputations is to maintain the hand's fnctionality. Several factors should be considered when indicating a digital reimplant. The postoperative rehabilitation is fundamental to the success of the treatment proposed to the amputated segment. Cconclusion: in digital amputations the main criteria when indicating a reimplant, besides the formal conditions, should be keeping the good functionality of the hand.
Asunto(s)
Humanos , Amputación Traumática , Deformidades Adquiridas de la Mano , Clasificación Internacional del Funcionamiento, de la Discapacidad y de la Salud , Rehabilitación , Amputación Traumática/cirugía , Amputación Traumática/clasificación , Amputación Traumática/complicaciones , Falanges de los Dedos de la Mano/cirugíaRESUMEN
The final judgment of whether to replant may not be determined until after microscopic inspection of vessels and nerves is complete. Once committed, it is ultimately the attention to detail that will determine function; bone shortening and rigid fixation, multiple strand flexor tendon repair, and quality, meticulous repair of the extensor mechanism to permit early movement, periosteal approximation to aid gliding, radical debridement of damaged vessels and primary skin closure.
Asunto(s)
Traumatismos de los Dedos/cirugía , Dedos/cirugía , Reimplantación/métodos , Amputación Traumática/clasificación , Contraindicaciones , Supervivencia de Injerto , Humanos , Evaluación de Resultado en la Atención de Salud , Cuidados Posoperatorios , Complicaciones PosoperatoriasRESUMEN
We are reporting the case of a 29 year old male in whom we performed successful reimplantaton of both lower legs following trauma inflicted by a railroad boxcar. Five years after this accident, the patient's walk is almost normal and both deep sensitivity and two point discrimination on the soles of his feet are sufficient. The patient can walk, run and stand very well on one leg, both on even and on uneven ground.He returned to his job with the railroad 8 months after his accident. Originally the patient was employed as a railroad workman, and is now an office employee. His private life is normal and he enjoys hiking and dancing. In our opinion, sufficient function of the tibial nerve in the reconstructed extremity is important for clinically satisfactory long-term results. Both the Mangled Extremity Severity Score (MESS) and the NISSSA are helpful in making the decision on whether to primarily amputate or reconstruct Gustillo IIIC cases. Good long-term results as well as general cost reduction are achievable following reconstruction of extremities. Amputation of an extremity can be predicted with 100% certainty when MESS is 9 or more. Primary shortening and secondary lengthening of an extremity is a good method of treating Gustillo III C fractures.
Asunto(s)
Amputación Traumática/cirugía , Traumatismos del Tobillo/cirugía , Traumatismos de la Pierna/cirugía , Accidentes de Trabajo , Adulto , Amputación Traumática/clasificación , Amputación Traumática/diagnóstico por imagen , Traumatismos del Tobillo/clasificación , Traumatismos del Tobillo/diagnóstico por imagen , Estudios de Seguimiento , Fracturas Conminutas/diagnóstico por imagen , Fracturas Conminutas/cirugía , Marcha/fisiología , Humanos , Lactante , Puntaje de Gravedad del Traumatismo , Traumatismos de la Pierna/clasificación , Traumatismos de la Pierna/diagnóstico por imagen , Masculino , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/rehabilitación , Radiografía , Vías Férreas , Rehabilitación VocacionalRESUMEN
PURPOSE OF THE STUDY: The purpose of this study was to evaluate an alternative procedure for amputations distal to the distal interphalangeal joint: the reposition flap. MATERIALS AND METHODS: The reposition flap was used for 6 patients who underwent fingertip amputations in an emergency setting. Pulp was excised on the amputated segment and the remaining bone and nail bed were reattached to the proximal stump with a Kirschner wire. The pulp was reconstructed with a local advancement and sensitive flap. The patients were aged 18 to 44 years and had been victims of work accidents. All refused finger shortening. RESULTS: The fingers showed good scarring and good trophicity. Two-point discrimination was 6 mm. Bony fusion was constant but all distal interphalangeal joints remained stiff. Cosmetic results were correct except for two cases of claw nail formation. DISCUSSION: Fingertip amputations have been widely reported. Methods have varied from directed scarring to partial toe transfer. These situations present two types of challenge: insensitivity of the volar aspect or an overly sensitive pulp; cosmetic presentation and function of the dorsal aspect due to the complex role of the nail. Distal reimplantation remains the best technique, but the reposition flap offers an interesting alternative in case of failure or for patients who do not accept finger shortening. The advantage of the reposition flap is that it preserves finger length and the nail. Work stoppage and intolerance to cold can be an inconvenience due to the long time required for wound healing.
Asunto(s)
Amputación Traumática/cirugía , Traumatismos de los Dedos/cirugía , Reimplantación/métodos , Colgajos Quirúrgicos , Adolescente , Adulto , Amputación Traumática/clasificación , Amputación Traumática/diagnóstico por imagen , Amputación Traumática/fisiopatología , Urgencias Médicas , Femenino , Traumatismos de los Dedos/clasificación , Traumatismos de los Dedos/diagnóstico por imagen , Traumatismos de los Dedos/fisiopatología , Estudios de Seguimiento , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Radiografía , Rango del Movimiento Articular , Reimplantación/instrumentación , Factores de Tiempo , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
Major replantation of a traction avulsion amputation is undertaken with the goal of not only the reestablishment of circulation, but also functional outcome. This type of amputation is characterized by different levels of soft-tissue divisions involving crushing, traction, and avulsion injuries to various structures. Between 1985 and 1998, 27 cases were referred for secondary reconstruction following amputation of the upper extremity involving both arm and forearm. Replantation was performed by at least 12 qualified plastic surgeons using different approaches and management, resulting in different outcomes. Initial replantation management significantly affects the later reconstruction. For comparing studies and prognostic implications, the authors propose a new classification according to the level of injury to muscles and innervated nerves: type I, amputation at or close to the musculotendinous aponeurosis with muscles remaining essentially intact; type II, amputation within the muscle bellies but with the proximal muscles still innervated; type III, amputation involving the motor nerve or neuromuscular junction, thereby causing total loss of muscle function; and type IV, amputation through the joint; i.e., disarticulation of the elbow or shoulder joint. Some patients required further reconstruction for functional restoration after replantation, but some did not. Through this retrospective study based on the proposed classification system, prospective guidelines for the management of different types of traction avulsion amputation are provided, including the value of replantation, length of bone shortening, primary or delayed muscle or nerve repair, necessity of fasciotomy, timing for using free tissue transfer for wound coverage, and the role of functioning free muscle transplantation for late reconstruction. The final functional outcome can also be anticipated prospectively through this classification system.