NEW METHOD OF FIXATION IN ABOVE-WRIST REPLANTATION IN PATIENT WITH TRAUMATIC TOTAL CARPAL LOSS – A CASE REPORT


Authors: R. Burda;  M. Kitka
Authors‘ workplace: Department of Trauma Surgery, Faculty Hospital of Louis Pasteur, Košice, Slovak Republic
Published in: ACTA CHIRURGIAE PLASTICAE, 51, 2, 2009, pp. 49-52

INTRODUCTION

Replantation at wrist level is currently a common procedure; it is very difficult when there is extensive damage to soft tissues and bones. This procedure is also achievable in cases of bone defects of the distal forearm. Rigid stabilization of bones is indispensable for early postoperative rehabilitation. In wrist replantation, plate osteosynthesis is the gold standard. Plates should be used for fixation of radius/ulnar fracture or as devices for arthrodesis of carpal bones. External fixation alone should be also used, but reconstruction of vessel and nerves is usually much more demanding, since the frame of the fixator gets in the way.

The purpose of our work is to present a case where unusual fixation of bones and soft tissues was used in wrist level replantation with extensive damage to bones and soft tissues. We used intramedullary fixation of forearm bones to metacarpal bones. This method of fixation is, in our opinion, a viable alternative to standard techniques of bone fixation.

CASE REPORT

We present the case of a 36-year-old miner, whose right hand was amputated by a conveyer belt at work. Replantation was performed as a matter of urgency. The carpus was totally destroyed by the injury, and fixation of the hand to the forearm was performed with intramedullary rods connecting the radius to the 2nd metacarpal bone and the ulnar stump to the 5th metacarpal bone. Due to lesion of intermetacarpal ligaments, fixation of metacarpals was performed with Ki wires. For better control and easier postoperative manipulation a bridging fixator was added. Tendons of flexors and extensors had been pulled out from the tendinomuscular junction; only one undamaged flexor and extensor tendon was left on the stump. The distal ends of the profundus flexor tendons were sutured together and consequently sutured to the left one on the forearm stump; extensor tendons were sutured in similar fashion. The radial artery was trombotized and intimal damage spread approximately 10 cm proximally; consequently only the ulnar artery was reconstructed end to end with venous retrograde graft. The ulnar nerve on the replanted hand had been pulled off, and no reconstruction was possible – as was the case with the damaged proximal stump of the median nerve – so the proximal ulnar nerve stump was sutured on the distal median nerve stump (epi- and perineural suture). Vein reconstruction was trouble-free; two vein anastomoses were performed. Due to the massive swelling of soft tissues, fasciotomy of the forearm was also performed. Early postoperative motion was begun. After 6 weeks Ki wires and fixator were removed.

After one-year follow-up the patient has virtually no limitation of pronation and supination. Clinically the wrist is stable; during pronosupination movements no click is audible. On X-rays no bone fusion in the wrist area is observed, there is established pain free non union. Passive range of motion in all DIP, PIP and metacarpophalangeal joints of fingers is unrestricted, though active range of motion is only half the passive range of motion, due to the decreased strength of muscle contraction. The result of an assessment of median nerve repair (ulnar to median nerv suture) according to Birch and Raji is fair (accurate localization to digit, two point discrimination more than 8 mm, significant cold sensitivity and hypersensitivity). (Fig. 1–5.)

Fig. 1. Initial photo of amputated hand (A) and stump –cranial view (B)
Fig. 1. Initial photo of amputated hand (A) and stump –cranial view (B)

Fig. 2. Initial preoperative X-rays of amputated hand and stump
Fig. 2. Initial preoperative X-rays of amputated hand and stump

Fig. 3. Postoperative fixation with intramedullary rods and external fixator – X-rays (for better visibility AP projection without external fixator – picture taken immediately after fixator removal)
Fig. 3. Postoperative fixation with intramedullary rods and external fixator – X-rays (for better visibility AP projection without external fixator – picture taken immediately after fixator removal)

Fig. 4. X-ray control at one-year follow-up
Fig. 4. X-ray control at one-year follow-up

Fig. 5. Comparison of both hands in pronation (A), supination (B), finger flexion (C), and finger extension (D), one-year follow-up
Fig. 5. Comparison of both hands in pronation (A), supination (B), finger flexion (C), and finger extension (D), one-year follow-up

DISCUSSION

In the literature most articles deal with osteosynthesis in fingers during replantation, where usually application of two Ki wires and Ki wires and loops seem most favorable. Plate and screws are preferred for non union treatment. Generally complications include non union, migration of wires and infection (1, 2).

Touliatos et al. (3) found it most appropriate to insert one intramedullary Kirschner wire, supplemented by another wire which is inserted at the end of the procedure. This technique was found superior for the following reasons: A – its simplicity and the speed of the technique reduced the ischemic time; B – less bone exposure was required; C – less skeletal mass was needed for fixation; and D – prior to the insertion of the second Kirschner wire, rotation of the replanted part was possible if it was necessary to re-align the vessels or to correct any rotational deformity.

Kirchner wires usually protrude and disturb early mobilization and need later removal. An alternative technique is osteosynthesis with a bioabsorbable rod made of poly-L-lactide as an intramedullary nail. The advantages of this technique include the absence of protruding hardware that would require removal and technical simplicity. The risk of this fixation method is bone resorption (4).

Plate osteosynthesis and osteosynthesis with external fixator is still the gold standard of osteosynthesis for wrist and above wrist replantations (5).

In major limb replantations osteosynthesis must be stable, allowing early mobilization of the hand. Sometimes it is technically difficult to cover plates with adequate amount of soft tissues, so in some cases we prefer later covering of these defects with free flaps.

CONCLUSION

In cases of wrist replantation intramedullary osteosynthesis is also a method of choice, providing comparable results to traditional methods of fixation. This fixation is straightforward, fast and technically not demanding.We suggest that this technique widens the spectrum of methods of fixation used in major limb replants.

Address for correspondence:

Rastislav Burda, M.D.
Department of Trauma Surgery, Faculty Hospital of Louis Pasteur
Rastislavova 43
040 01 Košice
Slovakia
E- mail: burda@netkosice.sk


Sources

1. Brown ML., Wood MB. Techniques of bone fixation in replantation surgery. Microsurgery, 11, 1990, p. 255-260.

2. Cheng HS., Wong IY., Chiang LF., Chan I., Yip TH., Wu WC. Comparison of methods of skeletal fixation for severely injured digits. Hand Surg., 9, 2004, p. 63-69.

3. Touliatos AS., Soucacos PN., Beris AE., Zoubos AB., Koukoubis TH., Makris H. Alternative techniques for restoration of bony segments in digital replantation. Acta Orthop. Scand., Suppl., 264, 1995, p. 19-22.

4. Arata J., Ishikawa K., Sawabe K., Soeda H., Kitayama T. Osteosynthesis in digital replantation using bioabsorbable rods. Ann. Plast. Surg., 50, 2003, p. 350-353.

5. Stehlik J., Tvrdek M., Bartonicek J. The technique of osteosynthesis in replantations of the upper limb. Acta Chir. Plast., 34, 1992, p. 241-248.

Labels
Plastic surgery Orthopaedics Burns medicine Traumatology
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