Finger Reattachment Health Article

Aftercare

Postoperative care is vital for successful finger reattachment. The hand is wrapped in a bulky compression dressing and usually elevated. If arterial flow is impaired, then the hand should be lowered, since this maneuver will promote blood flow from the heart to the reattached finger. If venous outflow is slow, the hand must be elevated. Medications to increase blood flow (peripheral vasodilators) and an anticoagulant (heparin) are used. A tranquilizer may be given to reduce unnecessary blood vessel movement (vasospasm) that can occur due to anxiety. Careful examination of the reattached digit(s) is necessary. The surgeon frequently monitors color, the capacity of blood vessels, capillary refill, and warmth to monitor replant progress. The YSI telethermometer monitors the digital (finger) temperature with small surface probes. Skin temperature falling below 86°F (30°C) indicates poor blood perfusion
(poor blood and oxygen delivery to the affected area) of the replant. The cause of poor blood circulation must be investigated and corrected, if possible. The patient's room should be warm, and bed rest for two to three days is recommended. Patients must refrain from smoking and take antibiotics for one week after surgery. Follow-up consultations are necessary for continued wound care and rehabilitation.

Risks

The experienced surgeon can estimate the likelihood complications based on the nature of the injury. Replantations that are risky, such as those with circulatory perfusion problems, have lower success rates. Generally, the most difficult replantations are those that involve children under 10, injuries caused by a ring catching in machinery, and crush-and-tear injuries. Management of the difficult replant typically includes intravenous heparin to prevent clotting of the blood, and providing a continuous nerve block in either the median or ulnar nerve (depending on which fingers are reattached). A nerve block will cause vasodilatation, or expansion of the blood vessel. Vasodilatation will increase blood flow, bringing with it fresh oxygenated blood. Further evaluation should include checking the patient's dressing for constriction (i.e., if the dressing was placed too snugly and is constricting local blood vessels).

Normal results

Normal results may not seem encouraging. It must be considered that this is a major trauma and a highly complicated and intricate surgical repair. Generally, a normal result usually includes good nerve recovery; approximately 50% of normal for active range of joint motion; cold intolerance (usually reversed in about two years); and acceptable cosmetic results.

Morbidity and mortality rates

There are about 10,000 cases of job-related amputations in the United States each year; 94% of these involve fingers. Few statistics are available for the out-come of replantations.

Alternatives

The only alternative to this procedure is to lose the finger(s) entirely and manage the remaining hand injury.

BOOKS

American Society for Surgery of the Hand. The Hand: Primary Care of Common Problems. New York: Churchill Livingstone, 1990.

Green, David P. Operative Hand Surgery, Volume 1, 3rd Edition. New York: Churchill Livingstone, Inc., 1993.

Green, David P. Operative Hand Surgery, Volume 2, 3rd Edition. New York: Churchill Livingstone, Inc., 1993.

ORGANIZATIONS

American Association for Hand Surgery. 20 North Michigan Avenue, Suite 700, Chicago, Il 60602. (321) 236-3307; Fax: (312) 782-0553. E-mail: contact@handssurgery.org. <http://www.handsurgery.org>.

OTHER

"Superficial Fingertip Avulsion." National Center for Emergency Medicine Informatics. [cited June 2003] <http://www.ncemi.org/cse/cse1002.htm>.

"The V-Y Plasty in the Treatment of Fingertip Amputations." American Academy of Family Physicians. [cited June 2003] <http://www.aafp.org/afp/20010801/455.html>.

Laith Farid Gulli, MD, MS

Bilal Nasser, MD, MS

Robert Ramirez, BS

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

The procedure is usually performed in a hospital operating room by a microsurgeon, who may be a plastic surgeon with five years of general surgery training, plus two years of plastic surgery training and another one or two years of training in microneurovascular surgery; or an orthopedic surgeon with one year of general surgery training, five years of orthopedic surgery training, and additional years in micro-surgery training.

QUESTIONS TO ASK THE DOCTOR

• Are there any special precautions I should take with my pain medication?
• How should I care for the wound?
• When will I regain feeling and function in the affected finger(s)?
• Will I need physical therapy for the injury?
• How much function can I expect to regain?