62-year-old woman required multiple-level replantation after amputation across her left distal forearm and limb because of a tree-shredder accident.
This case is of a 62-year-old woman who required multiple-level replantation after she suffered a complete double-level amputation across her left distal forearm and wrist. The patient’s midhand got caught in a tree-shredder resulting in a severe crush injury. The cold ischemic time of the limb was less than 2 hours.
Examination showed that the amputation occurred 3 cm proximal to the radiocarpal joint, at the forearm. Treatment included revascularization of the limb proximally after bony fixation. Moreover, the crushed arterial parts were excised and repaired primarily at the midhand level. Similarly, all flexor tendons were repaired primarily. In addition, the repaired parts were flushed out with 500 cc of blood to reduce reperfusion toxicity after completion of arterial anastomoses.
The median and ulnar nerve were further repaired after completely reestablishing proximal and distal venous outflow. However, the fracture at the metacarpal level was deemed stable, therefore, not fixed.
After the procedure the patient developed disseminated intravascular coagulopathy (DIC) and was transferred to the intensive care unit. The patient required substitution of clotting factors and revision surgery after 3 hours of continuous bleeding. The bleeding was controlled with meticulous hemostasis and Arista (C.R. Bard Davol, Warwick, R.I.).
Postoperative care
The patient was prescribed high doses of vasopressors, 46 units of fresh frozen plasma, 22 and 4 units of packed red blood cells and platelet concentration including prothrombin complex replacement, fibrinogen and antithrombin III. The postoperative period was uneventful with a minor wound dehiscence at the intermediate segment. The skin was grafted after 10 days.
The 62-year-old was discharged after 20 days. Although the Kirschner wires were partially removed after 3 months, the bony union at the distal ulna was delayed after 14 months. The patient returned to work 6 months after the procedure. She was not in favour of any further corrective surgeries.
Follow-up after two years of the accident showed fair recovery of sensation with protective sensibility in the ulnar nerve distribution. There was no sensory loss in the median nerve distribution with 30 degrees of flexion and 5 degrees of extension at the wrist. However, there was no active flexion at the metacarpal-phalangeal, proximal interphalangeal, distal interphalangeal joints. She did not require pain medication on a regular basis.
References
Multiple-level Replantation in Elderly Patients: Risk Versus Benefit https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5426891/
