Four-Digit Replantation in a Mentally Retarded Person: A Case Report

History of present illness

On January 29, 2008, a 31-year-old mentally retarded man sustained a complete amputation of his right index, middle, ring, and small fingers by slipping from a shelf into a buzz saw. The patient was admitted 2 hours later to the emergency department of our hospital. The 4 fingers had been wrapped with gauze and properly preserved in a bag of icy water. Replantation procedure started 3 hours after amputation injury under general anesthesia.

Physical examination at first presentation

The 4 fingers were completely amputated through various levels of the proximal phalanges, leaving the metacarpophalangeal joints intact (see Figure 1a). The pattern of injury was:

digit II—amputation at the proximal interphalangeal joint with destruction of the joint.

digit III—amputation at the distal level of the proximal phalanges.

digit IV—amputation at the middle level of the proximal phalanges.

digit V—amputation at the proximal level of the proximal phalanges.

Figure 1. Amputated digits (a) and immediate postoperative view on replanted digits (b).

Surgical intervention

The patient was operated under general anesthesia without a tourniquet. After intraoperative x-ray evaluation, the bones were stabilized by shortening (proximal and distal to the amputation line with about 3 to 6 mm). After obtaining almost straight bone lines, a wire was used (1 mm) in an oblique fashion with a cerclage to adjust and fix the bones in anatomical position. In contrast to the authors' habits, but considering the involvement of all digits, one artery was sutured at each digit and rinsed with a bolus of 100-mg acetylsalycilacid. In case of a single-finger replantation, the author prefers to continue with the tendon repair, and afterward he performs all the microsurgical steps. After ensuring perfusion of all digits the second artery was sutured at every digit (see Figure 1b). On digits II, III, and IV, 2 veins were sutured. On digit V only, one vein was anastomosed. The extensor and superficial as well as deep flexor tendons were sutured with nonresorbable sutures. Finally, the 2 palmar nerves of each digit were sewed with a microsuture. After subtile hemostasis using bipolar coagulator, the skin was closed loosely. A soft dressing was applied and the patient was extubated after 12 hours' operating time.

Postoperative course

After surgery, the patient was kept in a warm room to promote vasodilation for 5 days. Hematocrit, hemoglobin, blood pressure, and electrolyte balance were carefully monitored. We started the patient on low-molecular-weight dextran (Dextran-40) and kept him anticoaguated (100 mg aspirin and 10.000 units of low-molecular-weight heparin via continuous intravenous application daily) for 10 days. Hourly monitoring with pulse-oximetry and capillary refill was conducted until postoperative day 14. To avoid unintentional injury by the mentally retarded patient, a sedative drug (100 mg Melperone daily) was applied intravenously. Due to a thrombosis of the vein in the fifth digit the patient was retaken to the operating room after 46 hours. To restore sufficient venous outflow an additional vein was anastomosed. Unfortunately, the fifth digit demarcated in the following days and had to be amputated with exarticulation in the metacarpophalangeal joint. On day 15, sedation was stopped, the hand was protected in a circular plaster for 4 weeks, and twice daily passive mobilization was started. Finally, the patient was discharged 6 weeks after the operation.

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One year postsurgery the patient was capable of grasping small and big objects with his hands (M5). However, function of the digits was impaired. The patient demonstrated an incomplete fist with a distance from the tip of the digits II to IV into the palm of 2, 2, and 3 cm. The main function was observed in the metacarpophalangeal joints with an excursion of 50° from a neutral joint position (ie, 0 degree) for flexion. The middle and distal interphalaneal joints were without function and mainly stiff. Nevertheless, because of a stiffness in a flexed position in the middle interphalangeal joints (about 60° for all) grasping was facilitated. He was able to write and distinguish sharp from blunt stimulus with digits II, III, and IV (see Figure 2a–2d).

Figure 2. (a) Long-term functional result after reamputation of the fifth digit. Note the patient holding a pen to write. (b) One year after operation, the patient demonstrates maximum of extension in the digits. The distance between thumb and fourth digit was 12 cm at the tip. (c) One year after operation, the maximum of finger flexion is depicted. (d) One year after the operation, the patient was able to reach all tips of the replanted fingers with his thumb.