Using the Internet for rapid exchange of photographs and X-ray images to evaluate potential extremity replantation candidates

OBJECTIVE

To implement a low-cost system of transmitting high-quality digital photographs of mutilating extremity injuries using the speed of the Internet.

DESIGN

A high-resolution digital camera and simple hardware and software platform are used to take and transmit images via electronic mail. The images are received within minutes by the consultant, and an assessment can be made.

RESULTS

A low-cost and high-quality system can easily be implemented. Images can be seen by consultants only a few minutes after they are obtained. The quality of the reproductions is excellent, and they are handled exactly as other photographs.

CONCLUSION

This technique can be widely applicable and inexpensive to initiate in any emergency room. It allows rapid assessment of extremity injuries and x-ray images by expert consultants, who can then evaluate the replantation or revascularization potential of extremity trauma cases. This can eliminate unnecessary and often expensive transfer of patients who are not candidates for replantation.

[Replantation of a leg after hip para-articular amputation]

Of all macroreplantations, reattachment of a leg amputated at the proximal thigh presents the biggest difficulty. A patient with no other injuries was treated in this way. A critical discussion of indications in general, the technique in the acute setting, and reconstructive procedures, including the ilizarov distraction technique, is presented. The outcome after 2.5 years is gratifying. The results obtainable in proximal thigh replantation can justify the risk of potentially lethal general complications.

Contralateral transplantation of a finger for restoration of thumb function

Transplantation of a finger from the contralateral hand for thumb reconstruction is seldom done because of possible psychological problems for the patient. We present two cases in which a previously damaged index finger of the contralateral hand was transplanted. In both patients the metacarpophalangeal joint of the index finger replaced that of the thumb. A powerful pinch to the fingers was achieved and the appearance of both the donor and the recipient hands was considerably improved.

Very distal finger amputations: replantation or "reposition-flap" repair?

Management of very distal finger amputations is still controversial. Successful replantation results in an almost normal finger but is not without problems, such as technical difficulty, risk of failure and cost. "Reposition-flap" repair is a simpler procedure: it consists of distal bone and nail bed "graft-reposition" and pulp reconstruction by a flap. We compare ten successful replantations and six reposition-flap reconstructions. Replantation has several advantages over reposition-flap repair in terms of less finger shortening, longitudinal nail curvature, absence of PIP flexion contracture and shorter time off work. The results of reposition-flap repair are less satisfactory, but it is nevertheless a useful alternative when replantation is impossible or has failed.

Distraction lengthening following growth cessation due to thumb replantation in a child

Growth disturbance due to premature physeal closure as a sequela of digit replantation, on occasion, can cause shortening, resulting in suboptimal function. A simple method for correction using only local tissues is possible via gradual bony distraction. This was attempted in a toddler, whose dominant thumb was amputated by a riding lawn mower when he was an infant, because replantation caused significant growth cessation. The first metacarpal distraction over 64 days netted 22 mm of lengthening. Because a further immobilization period to allow spontaneous consolidation by neo-osteogenesis was aborted at the family's insistence, a fibular autograft of that dimension was inserted into the created bony gap. Ultimately, after 24 months of follow-up, the distracted thumb had been increased 26% in length and was 88% of the length of the contralateral thumb at that time, compared to only 74% prior to initiating the distraction.

Cross leg flap in a bilateral traumatic amputee

A case report of a bilateral traumatic amputee who underwent a cross leg flap to preserve a knee disarticulation level amputation is presented. Salvage of amputated parts in the lower extremities to preserve stamp length provided our patient with better stability and decreased energy expenditure with ambulation.

[Traumatic hemipelvectomy. Experiences with 11 cases]

With further improvements of the prehospital rescue systems, an increasing number of patients with extreme injuries such as traumatic hemipelvectomy are admitted to trauma centers alive. The accepted definition of traumatic hemipelvectomy is: unstable ligamentous or osseous hemipelvic injury with rupture of the pelvic neurovascular bundle (open or closed integuments). A review of the literature up to 1995 yielded on 48 surving cases with such an injury. A review of 2002 consecutive patients after pelvic fractures treated from 1972-1994 at the Medical School Hannover, resulted in the identification of 11 traumatic hemipelvectomies with four survivors. The purpose of the study was the analysis of the early clinical course of the patients after traumatic hemipelvectomy and the evaluation of the late outcome of the survivors. All accessible clinical and radiological data were reviewed for the preclinical and primary clinical treatment, concomitant injuries, cause of death and complications. The survivors are under continuous follow-up at our institution and were evaluated on average 5.5 years (range 2-7 years) after trauma. All patients were managed with early and aggressive shock therapy by an emergency physician, hemorrhage control with manual compression of the wound and a short transit time to a trauma center. Immediate surgical hemostasis was attempted in all cases. Despite this, four patients died within the first 4 h secondary to uncontrollable bleeding. Another three died between 2 days and 5 weeks after accident from complications of septic or hemorrhagic shock. In four patients a limb-saving procedure was attempted. Three of these died early, and in the remaining case secondary hemipelvectomy was necessary due to sepsis and paralyses. After primary surgical completion of the hemipelvectomy, three of four patients survived. The late result was good in two children and moderate in one adult (ambulatory and socially reintegrated). A bad result occurred in one male after secondary surgical completion of the hemipelvectomy (social deterioration and drug abuse). A strict protocol has to be set for the primary treatment of a traumatic hemipelvectomy. It includes immediate prehospital hemostasis by local pressure, advanced shock therapy and prompt transfer to a trauma center. In-hospital procedures include immediate surgical hemostasis and debridement. When the criteria or traumatic hemipelvectomy are fulfilled, surgical completion of the hemipelvectomy is mandatory. Limb-saving procedures endanger the patient's life. Early and frequent second-look operations minimize wound healing problems. Early psychological support for the patient and family is advantageous for personal well-being and social reintegration.

Osseointegrated thumb prostheses: a concept for fixation of digit prosthetic devices

Three patients with traumatic amputation of the thumb at the metacarpophalangeal joint level underwent a two-stage reconstruction aimed at fixation of a thumb prosthesis to the first metacarpal bone via an osseointegrated titanium fixture. The first stage included insertion of the fixture into the medullary cavity of the first metacarpal bone in combination with transplantation of cancellous bone from the iliac crest. After 3 months, when the fixture was firmly osseointegrated into the bone, a skin-penetrating abutment was placed on top of the fixture, the surrounding skin being thinned to the thickness of a split-skin graft to minimize relative mobility. A thumb prosthesis could then be firmly attached to this fixture. At follow-up examinations between 18 months and 3 years; postoperatively perfect osseointegration of the implant persisted. There were no skin problems. Some extent of tactile discrimination was achieved in the prosthesis hypothetically based on transfer of tactile stimuli to endosteal nerves in the bone via the titanium fixture.

Nail regeneration in digits replanted after amputation through the distal phalanx

Nail regeneration was studied in 48 digits replanted after amputation through the distal phalanx. Twenty-seven were amputated through Tamai's zone I, at the nailbed level, and 21 digits were amputated through zone II, proximal to the nail. The nails of 9 digits in zone I and 14 in zone II showed almost normal nail regeneration. We observed that replantation after amputations distal to the lunula will show near normal nail regeneration if there is minimal postoperative circulatory disturbance. Amputations proximal to the lunula, however, have a greater chance of causing damage to the germinal matrix, which results in more problems with nail growth.

Traumatic arm amputation, an uncommon parachuting injury

Parachuting is a unique method of deploying troops. Accidents in parachuting are common, but usually carry minimal risk for severe injury. Most accidents occur during landing and injuries often affect the lower limbs and spine. Traumatic amputation of a limb is an extremely rare event in parachuting. We present a case of a parachutist who suffered a traumatic amputation of the left hand during jumping off the plane.

[Case report on management of grade 4 infected open comminuted tarsus fracture by tibio-Chopart arthrodesis]

We report on the treatment of a 39 year old patient who suffered from subtotal amputation of the middle foot area after fall from tall height. He was treated by an arthrodesis between ventral tibia and distal Chopart-joint which was carried out as late-primary care. Therefore calcaneus and talus were totally and os cuboideum and os scaphoideum were partially removed. This form of arthrodesis is a rare indication. With remaining blood flow and sensibility in the fore foot it is an alternative to amputation/exarticulation in the tibiotalar joint. Advantages are the improved plantar weightbearing area, a simplified supply of orthopedic shoes and a better tactile ground contact.

[Hand injuries due to fireworks explosion]

Two different series of patients with burst injuries of the hand were retrospectively reviewed: one series included 23 men, 15-55 years old, referred to the emergency department for the first-instance assessment of injuries of the right hand (13 patients) and left hand (10 patients). The other series included 44 patients (42 men and 2 women, aged 7-61 years) referred to our department for second-instance examinations: the latter patients had burst injuries involving only the hands in 43 cases and both the hand and the foot in one case. We report the radiologic patterns of traumatic bone injuries (fractures and amputations) and of musculotendinous and cutaneous injuries and discuss their mechanisms and pathogenesis. The two series were compared and the results follow: in both series the right hand was more frequently involved, metacarpal bones were most often fractured and phalanges most often amputated. In the first series, in the right hand the carpal bones were involved in one patient only, the 2nd and 3rd metacarpal bones were most frequently fractured and the 2nd finger was most frequently involved. In the left hand, the carpal bones were never affected, the 1st metacarpal bone was most often amputated and the 5th metacarpal bone most often fractured; the 2nd finger was most frequently involved. In the second series, in the right hand, the 1st metacarpal bone was most frequently fractured and the 2nd metacarpal bone most often amputated; the 2nd finger was most frequently involved. In the left hand, the 4th metacarpal bone was most frequently fractured and the 5th metacarpal bone most often amputated. The severity of the above injuries and the extent of tissue damage depend on several factors, including firecracker speed, shape, size, weight and characteristics. Radiologic exams are very useful for the accurate study of these traumatic injuries, providing indirect information about musculotendinous and cutaneous involvement. Prompted by the relative lack of information on the management of these injuries, we suggest that radiologic exams be quickly performed to help choose the most appropriate surgical approach for best cosmetic and functional results.

Osseous overgrowth after amputation in adolescents and children

We retrospectively studied the incidence of primary surgical revision for stump overgrowth in a population of childhood and adolescent amputees. The anatomic location and the etiology of amputation are critical to the occurrence of overgrowth needing revision. Metaphyseal-level amputations are the most likely to develop overgrowth requiring revision (50%), whereas diaphyseal amputations are slightly less likely (45%). Joint disarticulations never develop overgrowth. Traumatic amputations are the most frequent mode of injury requiring revision of overgrowth (43%), followed by congenital or intrauterine amputations (30%) and elective amputations (20%). Radiographic classification of the osseous overgrowth helps define its severity and degree of ossific progression. Surgical revisions are usually performed when overgrowth reaches a grade 3 classification. The majority of skeletally immature diaphyseal- or metaphyseal-level amputees, including those with certain preexisting orthopaedic conditions, retain the ability to develop osseous overgrowth at the apex of the stump skeleton.

Intraosseous wiring in toe-to-hand transplantation

Although there are many reports on bony fixations in finger replantations, information pertaining to fixation methods in toe-to-hand transplantations is scarce. The results of intraosseous wiring were evaluated in 68 toe-to-hand transplantations in 47 patients. Clinical and radiological evaluation of bony union was conducted an average of 30 months after the procedure. There was no malunion. There was one painless pseudarthrosis, with an overall nonunion rate of 1.5%. Intraosseous wiring is a simple, quick, dependable, and consistent method of fixation in toe-to-hand transplantation.

Upper limb digital replantation and revascularisation in children

Amputations in children are not common and experience in microvascular digital replantation in children is not extensive. We report our experience of ten digital replantations in eight children over a two-year period. Paediatric replantation with its minute anatomy is technically very demanding. Joints should be reconstructed, epiphyses preserved and bone shortening kept as minimal as possible. Complications are not more than those in adults. All the replanted digits in our series survived. Seven of the ten replanted digits were normal in size. Six of the eight patients regained good to excellent functional use of the replanted digits. All but three of the joints at and distal to the level of injury regained active motion ranging from 10 degrees to 70 degrees with an average of 42 degrees. One had primary fusion of the distal interphalangeal joint of his amputated index finger. All the preserved epiphyses had remained open at the last follow-up. Replantation in children may be technically difficult but is very rewarding. We had a high success rate with good functional return and continuing growth.

Combined free flap, Ilizarov lengthening and prosthetic fitting in the reconstruction of a proximal forearm amputation--a case report

A composite free latissimus dorsi musculocutaneous flap combined with Ilizarov lengthening was used in the resurfacing of the elbow and the reconstruction of the forearm following a very proximal below elbow amputation with soft tissue degloving to the level of the mid arm. The free flap provided gliding soft tissue to the elbow joint, and the deep fascia and muscle components of the flap were contoured round the bony stump so as to allow bone transport within the soft tissue envelope. The lengthening achieved was 14 cm with no bone resorption at the end of the stump. The reconstructed forearm, with a well-contoured stump covered with durable and adherent soft tissue, allowed the fitting of a forearm-based lightweight hand glove prosthesis. With the combined modalities of microsurgical free tissue transfer, the Ilizarov method of slow distraction and prosthetic fitting, we were able to achieve restoration of both form and function in a difficult case of major upper extremity amputation.

Sequential flap transplantations for total reconstruction of avulsion amputation of the fingers--a case report

The degloved and partially amputated ring and middle fingers of the left hand of a 40-year-old male was re-surfaced with two flaps transplanted sequentially: the toe wrap-around flap and the reversed pedicled metacarpal flap. Sensate and non-glabous skin was restored to the tip of the finger stumps as well as a supple full thickness reconstruction of the web space was achieved.

Osteocutaneous lateral arm flap in hand reconstruction

Complex injuries of the hand often have severe soft tissue damage and associated intercalary segmental or distal loss of bone. Bone grafting to restore the skeletal scaffold is essential for soft tissue reconstruction. With a poor vascular bed, non-vascularised free bone grafts are not desirable. We describe 14 cases of vascularised humeral bone grafting for these difficult reconstructions. The bone was harvested as an osteocutaneous lateral arm flap. Constant osseous branches from the main pedicle of the posterior radial collateral artery which travel along the lateral intermuscular septum to the bone were preserved. Humeral bone grafts as a composite with the lateral arm flap are able to provide 1.5 x 10 cm of well vascularised bone for hand reconstruction. All 14 flaps survived and X-rays of the graft at 3 to 6 months showed consolidated bony union with little or no bony resorption.

Open dislocation of the trapezoid

Isolated dislocation of trapezoid is rare. We report here a new case of open dorsal dislocation of the trapezoid following a high energy crush injury of the left hand in a factory worker. It was associated with multidigital mutilation and metacarpal fractures.

Sideswipe elbow fractures

A retrospective review of all cases of sideswipe elbow fractures (SSEFs) treated at two community hospitals from 1982 to 1992 was conducted to determine the functional outcome of the operative treatment of SSEFs. All five injuries involved the left elbow, and they included open fractures of the olecranon, the radius and ulna, the ulna and humerus, the humerus, and traumatic amputation of the arm. Concomitant injuries included three radial nerve palsies and two injuries each to the median nerve, ulnar nerve, and brachial artery. Treatment included irrigation, debridement (repeated if necessary), open reduction and internal fixation, external fixation (one case), and delayed amputation (one case). An average of 130/-10 degrees elbow flexion/extension, and 60/60 degrees supination/pronation was obtained for the three of four patients with reconstructions who returned for follow-up.

Toe-to-finger transfer combined with wrap-around flap: a new technique for four-finger amputation

A surgical technique for reconstruction of four-finger amputation, toe-to-finger transfer combined with wrap-around flap procedure, is described. Opposable ulnar fingers, reconstructed using the second and third toe, provide sufficient grip function. The long finger, reconstructed with the wrap-around flap using the lateral aspect of the great toe, provides pinch function. Improving the hand function is worthwhile despite morbidity from losing two toes.

[Elongation and coverage of an inguinal flap over a short forearm traumatic amputation stump]

A particularly short traumatic amputated forearm finally led to a simplified under-elbow prosthesis after a long surgical program including: 1) A progressive 8 cm ulnar lengthening with a Wagner device; 2) and a secondary groin flap resurfacing the distal stump. Complications essentially concerned the ulnar lengthening particularly because of a weak osseous callus. Final aesthetic and functional results are satisfying with a 6 years follow-up.

Closed traumatic forequarter amputation without fracture. A case report

Closed forequarter amputation (scapulothoracic dissociation) is a rare, easily missed, life-threatening injury. The diagnosis should be suspected in patients with a pulseless, flail limb, supraclavicular haematoma, lateral scapular displacement and clavicular disruption. Early surgery is essential to control haemorrhage and completion of the amputation with attention to closure of the resulting defect is often required. Prognosis for long-term functional recovery is poor, in spite of modern prosthetic aids.