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Thumb partial amputation: Microsurgical revascularisation

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Partial amputations of the digits are common in hand trauma practice. Whilst many of them are simply fingertip injuries and are simple to treat others will need repair of bone tendons, nerves and vessels.

Those which present with vascular compromise however need urgent intervention and are in fact more urgent than completely amputated digits. This is because they suffer with warm ischaemia whereas the ones which are complete amputations can be preserved in ice and water.

It is important to make the distinction between the terms replantation and revascularisation.
Replantation is the reattachment of a completed amputated body part through repair of anatomical structures whereas a revascularisation is repair of vessels in a partially amputated body part, with or without repair of other structures. Even if the digit is held by a narrow skin bridge it is technically a re vascularisation.
Decision making is important in managing these injuries.
The main decision is whether it is worth attempting revascularisation or to do an amputation.

The general principles guiding these decisions in the hand are covered within the indications section of this operative technique.
Thumb should be reconstructed unless distal to IP joint where repair or reconstruction of vessels and nerves are technically not possible. When there is an amputation distal to IP joint, the aim is to preserve length by doing a local flap. Examples of such flaps include a Moberg flap where the skin is advanced from the rest of the volar skin or Foucher flap where tissues are taken from the dorsum of the index finger.

The case discussed here is a partial amputation of the thumb through the interphalangeal joint in a 55 year old man who was using a circular saw and accidentally cut through his thumb from the volar aspect . Both the digital nerves, arteries and FPL tendon were divided. The volar skin was ragged and there was a soft tissue loss. There was also a fracture through the head of the proximal phalanx with loss of bone and comminution which was not  fixable.
The decision was made to stabilise the IP joint and repair the vessels and nerves. The FPL did not require repairing as the IP joint was severely damaged and will be fused later.  In this case the thumb had perfusion through the skin bridge which meant urgent rather than immediate surgery was not required.
It is important to have microsurgery training before undertaking revascularisation procedures.

OrthOracle readers will also find the following instructional techniques of interest:

Thumb partial amputation: Foucher Flap to reconstruct volar soft tissue defect

Thumb partial amputation: Moberg volar advancement flap

Digital nerve repair: Autograft using medial cutaneous nerve of forearm

Digital nerve repair: Reconstruction with Axogen Avance processed nerve allograft

Digital nerve repair: Conduit-assisted repair with Neurolac (Polyganics)

Digital nerve neurolysis plus Vivosorb barrier wrap (Polyganics) and Z-plasties to scar contracture left little finger

 

Author: Rajive Jose FRCS

Institution: Queen Elizabeth Hospital, Birmingham, UK.

Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.

In the USA contact: fda.gov
In the UK contact: gov.uk
In the EU contact: ema.europa.eu

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