Thumb amputation with segmental defect replantation

Replantation of the broken limb is the re-entry of the limb left and right, and the limb is regained blood for survival. A limb that is displaced by most or all tissues due to trauma or a Sunday surgery is called a broken limb. The limbs of the broken limb have poor blood supply or no blood supply. If the limb is not replanted, it will be necrotic. The broken limb includes: Large limb disconnection and finger, toe, or part of the finger, toe disconnection, replantation of the broken limb using the surgical conviction method to anastomosed blood vessels including arteries, veins to keep the limbs bloody, including Reconstruction or (and) internal fixation of bones and joints, as well as repair of nerves, muscles, tendons, skin and other tissues. Treatment of diseases: hand trauma, open hand injury Indication 1. The patient's general condition allows, can be replanted. 2. There is a certain degree of completeness from the limbs: cutting or sawing off limbs, neat wounds, slight damage to blood vessels and soft tissues. 3. There is a time limit for replanting: it is generally considered to be 7 to 8 hours at normal temperature. Properly preserved in the cold season or off the limb. 4. Refers to the broken finger at the root, or the broken finger with a greater influence on the function of the opponent. 5. For multiple broken fingers, first replant the fingers with the main function, or replant all. Contraindications 1. Suffering from systemic diseases, poor physical condition, or complicated with serious organ damage, it is not allowed to replant for a long time. 2. Broken finger with multiple fractures or severe soft tissue injury. 3. The integrity of the integrity of the finger vascular bed is severe. If the finger is broken by the crush injury, it is manifested as subcutaneous blood stasis on both sides of the finger. Even if the blood vessel is turned on, the soft tissue is extensively oozing, and the thrombus is replanted, and the finger is still difficult to survive. 4. If the replantation time limit is excessively exceeded and the tissue has undergone degeneration, it is not suitable for replantation. If it is not refrigerated, the finger can still replant after 24 hours of ischemia. If it is injured, it will be refrigerated and the time limit for replanting can be extended to more than 30 hours. However, the shorter the ischemic time, the higher the replantation survival rate, and the longer the ischemia time, the lower the replantation survival rate. Preoperative preparation 1. Actively prevent and treat shock, timely and adequate blood transfusion, and supplement blood volume. 2. The isolated limbs are aseptically processed and stored in a refrigerator at 2 to 4 °C. 3. Prepare appropriate fracture fixation equipment according to the site of the limb. 4. Prepare surgical microscopes and microsurgical instruments. Surgical procedure The punch injury caused the right thumb to be broken, and the broken bone and skin were severely depressed. After debridement, the middle part of the thumb and the skin are missing. Bone graft from the tibia and fill the bone defect. In the ipsilateral lumbar heel, the half-moon flap of the big toe of the humerus was designed with the iliac crest artery, nerve and toe vein. The flaps are long and proximally retaining long blood vessels and nerve ends, in order to bridge the blood vessels and nerves of the thumb defect. The toe wound was repaired with thick fault skin. The broken thumb and the removed humeral block and the lateral flap of the big toe. Use a Kirschner wire to penetrate the distal end of the thumb and the bone graft. The anastomosis of the distal end of the flap and the distal end of the thumb, the veins, nerves and nerves. The Kirschner wire is used to fix the broken thumb and the bone graft and the flap to the proximal end of the thumb. The proximal and distal movements of the thumb, veins and nerves are respectively attached to the proximal and distal movements of the graft flap. Relax the tourniquet and rebuild the blood circulation of the replanted thumb and transplanted flap. Replantation is completed. complication (1) Insufficient blood volume: The main cause of insufficient blood volume in patients with broken limbs is blood loss. Reduced blood volume can not only cause shock, life-threatening, but also cause vasospasm and thrombosis of replanted limbs due to contraction of peripheral blood vessels, leading to failure of replantation. Therefore, the pulse, blood pressure, urine volume, jugular vein filling, skin temperature, color and capillary filling time of the broken finger (toe) should be closely observed after the operation. If the systolic blood pressure is above 14.22 kPa (100 mmHg) and the urine volume is >30 ml, the external jugular vein can be seen on the clavicle. The broken finger (toe) is rosy and warm, and the capillary filling time is less than 2 seconds, indicating that the blood volume is normal. If there is insufficient blood volume, the treatment is mainly infusion and blood transfusion, supplement blood volume, avoid applying pressure-boosting drugs, especially norepinephrine, so as not to cause strong contraction of blood vessels, resulting in anastomotic thrombosis. (2) Acute renal failure: a patient who has a long-term shock, or a long-term ischemic limb ischemia, has a tissue degeneration, or has a high plane of the broken limb and has a large number of muscle injuries. After revascularization of the limbs, special attention should be paid to the occurrence of acute renal failure (expressed as oliguria, urinary retention, hemoglobinuria, low urine specific gravity, elevated blood urea nitrogen, increased blood potassium, etc.). This complication should focus on prevention; such as timely correction of shock, strict control of the indications for replantation of the broken limb, thorough debridement, removal of all inactivated muscles, incision of fascia decompression, and appropriate postoperative infusion, static point rate Urine, accelerates the excretion of toxic substances to prevent the occurrence of acute renal failure. Once it occurs, it should be actively treated, such as limiting the amount of intake, controlling hyperkalemia, correcting acidosis and azotemia. If there is no improvement, if you continue to retain the broken limb and will endanger the patient's life, you should get rid of the replanted limb as soon as possible. (3) Prevention of infection: As mentioned above, the key to preventing infection of the broken limb is a thorough debridement. Prophylactic antibiotics should continue throughout the body after replantation.