Why is avulsion worse than guillotine type of amputation?
1. Larger zone of injury ➔ more skin die back
2. Due to avulsion of NV, Usually need a vein graft so worse prognosis
2. Expect more skindie back
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When will you consider finger replantation?
Depends on patient and injury factors - RECLAIM
R - Requirements of patient - function
E - Expectations of patient
C - Comorbids - unable to tolerate long op
L - level of injury - amputation proximal to palm, multiple digits, thumb
A - age of patient (child is relative indication)
I - ischemia time
M - MOI - avulsion of clean cut, segmental
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What are some contraindications, absolute and relative, to replantation?
Absolute contraindications
Unable to tolerate long op
Urbaniak 2B/3
Segmental
Prolonged ischemia time
Relative contraindications
Severe contamination
Single digit at zone 2 (poor function/ stiff)
Patient - mentally unstable, self inflicted
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What are the warm and cold ischemia times?
Distal to carpus < 12 hr [warm] , < 24 hr [cold]
Proximal to carpus < 6 hr [warm] , < 12 hr [cold]
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What options of management?
Shortening and closure - in biocontamination
Replantation
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How will you proceed with replanatation?
Pre-op, intra-op, post op
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Pre-op
P1, ensure within ischemia times, ASAP
Anaesthesia - block to block sympathetic system ➔ help w vasodilation
2 teams, II, K-wires
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Intraop
“2-team approach” = benchwork team and debridement team
Repair “structure by structure” rather than “finger by finger” ➔ faster and higher viability
Sequence of structures (BEFANVS - BE a FAN of V) : Bone (consider shortening) ➔ extensor then flexor tendon (stability) ➔ artery ➔ nerve ➔ vein (2 veins to 1 artery) ➔ skin
Sequence of fingers: Thumb ➔ Long ➔ Ring ➔ small ➔ index (1/3/4/5/2) [loss of index finger is less morbid]
For Major replant consider post replanatation fasciotomies
Post Op monitoring
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What do you order post replanatation?
Environment - warm, hourly paras, I/O Charting, good hydration
Diet - keep NBM for first 24 hours then caffeine free, no chocolate, no nicotine
Anticoagulation - aspirin (only for finger tip replant. Proximal replant no evidence for anticoagulation), nerve block to help w vasodilation