In October 2001, a thirty-four-year-old right-hand-dominant man was
working with an agricultural machine that separates corn grains from corncobs
(a corn sheller) when the machine stopped working. In order to remove the
obstruction, he put his hand into the machine without turning it off. The
rollers of the machine caught the left hand and forearm and completely
amputated the hand at the level of the wrist. It took twenty minutes to turn
off and dismantle the machine to release the injured man. He arrived at our
hospital three hours after being injured. In preparation for the surgery,
intravenous fluids and tetanus immunoglobulin were administered. As the
accident had happened in the farmyard and the wound was characterized by
extensive soft-tissue damage and contamination with parts of plants, soil,
clothes, and machine oil, a combination of imipenem and cilastatin sodium was
administered, by intravenous infusion, starting at the time of admission to
the hospital.
The amputated hand (Fig. 1)
sustained considerable damage in the area of the wrist and the whole dorsum
because of compression, avulsion, and friction burns that required a radical
débridement, leaving skin defects on the dorsum and the ulnar side of
the hand and wrist, measuring 5 × 5 cm and 3 × 7 cm, respectively.
Damage of the same type was also found on the forearm. There was complete
destruction of the soft tissues and bones of the distal aspect of the forearm
for a length of 10 cm on the ulnar side and 5 cm on the radial side.
Radiographic examination after the injury showed loss of the proximal carpal
row and the distal parts of the radius and ulna. In order to avoid infection
and to enable replantation of the hand, 3 cm of the distal aspects of the
radius and ulna, the complete carpus, and a part of the metacarpal bones on
the ulnar side of the hand were removed. Simple fixation of the metacarpal
bones to the radius and the ulna was accomplished with three Kirschner wires
(Fig. 2). All flexor and
extensor tendons were repaired. Then, the radial and ulnar arteries were
repaired directly, without grafting. On the dorsal side, three veins were
sutured end to end. The ulnar, median, and radial nerves were also sutured,
and a fasciotomy of the volar aspect of the forearm was performed. The
remaining skin defect was covered primarily with a split-thickness skin graft.
Heparin (5000 IU every six hours) was administered postoperatively for six
days. Wound cultures were negative, and the imipenem-cilastatin was
discontinued three days after the injury. Passive finger exercises were
initiated in the second week after the surgery, and active exercises began in
the fourth week.
At six months after the injury, the forearm had 13 cm of shortening and the
wrist was in 45° of ulnar deviation and had a 40° flexion deformity
(Fig. 3). In order to correct
the shortening as well as the ulnar deviation and flexion at the wrist level,
corticotomies of the distal part of the ulna and the radius were performed and
an Ilizarov apparatus was applied (Figs.
4 and
5). Elongation was begun at a
rate of 1 mm per day. During the distraction period, finger exercises were
performed regularly. Elongation of the forearm by 8 cm and complete correction
of the flexion and ulnar deviation deformities were achieved by five and ten
months, respectively (Fig. 6).
When a sufficient amount of bone had been regenerated, as confirmed
radiographically twelve months after application of the Ilizarov apparatus,
the device was removed (Fig.
7). The patient wore a plastic splint for another two months in
order to achieve additional consolidation of the regenerated bone and to
enable aggressive rehabilitation to improve finger movement (Figs.
8-A and
8-B).
At seven months after the end of treatment, the patient had a partial
return of sensation without recovery of two-point discrimination. Light touch
applied to the middle finger was felt as a touch of the middle finger and the
ulnar part of the thumb. The patient sensed touch in all fingers, the palm,
and the dorsum of the hand, but it was diminished in comparison with that on
the contralateral side. He could distinguish sharp touch from light touch. He
sensed warmth and coldness very well, and he did not have cold intolerance.
The patient felt no pain in the hand either while resting or during finger
movement.
Active motion (flexion-extension) of the thumb was from 90° to 40°
at the metacarpophalangeal joint and from 90° to 35° at the
interphalangeal joint. In the index finger, the metacarpophalangeal joint had
an active range of motion from 90° to 40°, the proximal
interphalangeal joint had a range of motion from 100° to 0°, and the
distal interphalangeal joint had a range of motion from 40° to 0°.
Active motion in the long finger was from 70° to 50° at the
metacarpophalangeal joint, from 100° to 35° at the proximal
interphalangeal joint, and from 90° to 15° in the distal
interphalangeal joint. Active motion in the ring finger was from 90° to
70° at the metacarpophalangeal joint, from 95° to 40° at the
proximal interphalangeal joint, and from 90° to 15° in the distal
interphalangeal joint. The little finger had a flexion contracture at the
metacarpophalangeal joint of 40° with no additional motion possible. The
proximal interphalangeal joint had a range of motion from 90° to 60°,
and the distal interphalangeal joint had slight motion from 50° to
40°. In comparison with the active range of motion, the passive motion was
slightly greater in all of the joints tested. The patient could grip with the
fingers and perform a thumb-index finger pinch with a power of 60% of that in
the contralateral, uninjured hand. The grip strength of the healthy hand and
of the replanted one were 24 kg and 14 kg, respectively. The forearm had
40° of pronation and 35° of supination. The patient was extremely
satisfied and stated that he used the replanted hand in everyday activities in
his work as a traffic and transport engineer.
Finger motion was compared before and after the forearm elongation. After
the forearm elongation, an increase of 30° was observed in the arc of
motion of the metacarpophalangeal joints of the index and long fingers.
In this complete amputation of the hand, the mechanism of injury,
which included compression, avulsion, and third-degree friction burns,
required radical débridement and considerable shortening to secure a
viable replanted
hand11-13.
Because of this approach, the complications of repeated débridements
and complex surgical treatment, such as microsurgical tissue transplantation,
were avoided. However, the surviving parts were insufficiently congruent to
allow replantation in the correct position. In order to avoid further
shortening of the forearm (which had already been shortened by 13 cm), the
hand was fixed to the forearm in ulnar deviation and flexion with the
intention to restore length and the alignment if the replanted hand
survived.
The Ilizarov method of distraction osteogenesis creates extraordinary
opportunities for forearm elongation and correction of hand position with use
of a minimally invasive technique, i.e., forearm
equalization14,15.
In the studies concerning extremity replantation, the Ilizarov method has been
applied for elongation of the lower
extremity16-21
and for elongation of the long finger in the upper
extremity22. As far
as I know, no report on forearm elongation after hand replantation is
available in the
literature23.
This case report demonstrates that it is possible to restore forearm length
and hand position after a replantation that results in a very shortened
forearm. Both function and appearance can be improved. Replantation of a
severely injured amputated extremity is certainly a challenge in terms of
survival, functional recovery, and cosmetic appearance. As presented here, the
concept of treatment in stages can be successful in the management of hand
amputation when there is considerable loss of bone and soft tissues. This
concept of treatment is appropriate for amputations associated with extensive
and complex injuries. The ability to elongate and restore alignment to even
very shortened parts after successful replantation increases the likelihood of
preserving the amputated part initially and restoring function secondarily.
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