A 62-year-old, right-handed woman suffered a complete double-level amputation transversely across the left distal forearm and the wrist and a severe crush injury of the midhand in a tree-shredder (Fig.1). Cold ischemia time was less than 2 hours. The proximal amputation occurred at the forearm 3 cm proximal to the radiocarpal joint, the distal obliquely through the wrist at the distal carpal row. The crush injury at the midhand level proved to be a third line of interruption of blood flow with severe vascular damage of the palmar arch. After bony fixation, revascularization was carried out starting proximally. At the midhand level, the crushed arterial parts were excised and repaired primarily. Primary repair of all flexor tendons was performed. To reduce reperfusion toxicity, the replanted parts were flushed out with approximately 500 cc of blood after completion of arterial anastomoses. After reestablishing venous outflow completely proximally and distally, repair of the median and ulnar nerve were carried out. The fractures at the metacarpal level were judged stable and not fixed.
No primary repair of the extensor tendons was performed. Postoperatively the patient was transferred to the intensive care unit where she developed severe disseminated intravascular coagulopathy (DIC), requiring substitution of clotting factors. After 3 hours, continuous blood loss required revision surgery where profuse bleeding consistent with DIC was encountered. Meticulous hemostasis and use of Arista (C.R. Bard Davol, Warwick, R.I.) eventually controlled the bleeding. The patient received high doses of vasopressors, transfusion of 46 units of fresh frozen plasma, 22 units of packed red blood cells, 4 units of platelet concentrate, in addition to antithrombin III, fibrinogen, and prothrombin complex concentrate replacement. The further course was uneventful. A minor wound dehiscence at the intermediate segment was skin grafted after 10 days. The patient was discharged after 20 days. Kirschner wires were partially removed after 3 months. Bony union was delayed at the distal ulna and occurred after 14 months (Fig.2). The patient returned to light work 6 months postoperatively. Further corrective surgeries were declined by the patient.
Two years after the accident, fair recovery of sensation was present with protective sensibility in the ulnar nerve distribution. Sensation to touch was present in the median nerve distribution. The patient did not regularly use pain medication. Range of motion at the wrist was 30 degrees of flexion and 5 degrees of extension. No active flexion at the metacarpal-phalangeal, proximal interphalangeal, distal interphalangeal joints was possible.
From the Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.
Rafael G. Jakubietz, MD, Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, Oberduerrbacher Str. 6, DE 97080 Wuerzburg, Germany, E-mail: ed.wku@R_zteibukaJ
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