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Fingertip Amputation

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121. Replantation (Treatment)

> Replantation Treatment & Management Updated: Nov 08, 2018 Author: L Andrew Koman, MD; Chief Editor: Harris Gellman, MD Share Email Print Feedback Close Sections Sections Replantation Treatment Medical Therapy Appropriate antibiotics and wound care are indicated to prevent infection. Next: Preoperative Details Amputated parts should be stored dampened with isotonic sodium chloride solution or Ringer's lactate in a cooled environment (on ice within a cooler or in a refrigerator). Contact with a saline ice (...) and the use of heparin-soaked pledgets to allow controlled bleeding. Late complications include loss of motion from joint stiffness and tendon adhesions. Fusions, tenolysis, or both may be required. In addition, nonunions are common because distal fragments may be avascular. Previous Next: Outcome and Prognosis The outcome and prognosis are variable. [ , ] Thumbs have the best prognosis, [ ] as do digits amputated distal to the insertion of the flexor digitorum superficialis. [ , , , ] Survival of digits

2014 eMedicine Surgery

122. Hand, Nerve Injury Repair

Abu Ibn Sina in Persia during the 10th century, and Ferrara in Italy in the 17th century. [ , , , , ] Despite this early record of physicians attempting to classify and treat nerve injuries, the common belief prior to the 19th century was that nerves did not regenerate. As a result, any kind of major nerve injury was treated nonsurgically or with amputation. During the 19th century, the development of improved microscopic devices, along with enhanced staining techniques, allowed a more detailed (...) the index finger, thumb, and proximal palm near the thenar eminence by way of the palmar cutaneous branch. The ulnar nerve supplies the ulnar side of the hand and little finger. It also supplies the dorsal ulnar region of hand via the dorsal cutaneous branch of the ulnar nerve. The digital nerves lie adjacent to the distal interphalangeal flexion crease and supply the adjacent areas, but not the fingertips. Adjuvant findings that can help with localizing innervation deficits are the presence of dry

2014 eMedicine Surgery

123. Hand, Finger Nail and Tip Injuries

like or are contraindications to crossfinger and thenar flaps because of the risk for resultant joint stiffness. The mechanism of injury can influence availability of certain local flaps. A literature review by Sindhu et al indicated that in the United States, up to 90% of fingertip amputations are not treated with replantation, while in Asian countries, as a result of moral values and the importance of body integrity, most patients with fingertip amputations undergo replantation. [ ] Occupation (...) to regenerate soft tissues. The complications potentially encountered with the open technique include loss of volume and pulp. [ ] Primary Closure and Revision Amputation Many fingertip injuries can be closed primarily or by recruiting adjacent soft tissues. Viability of the remaining soft tissues must be ascertained before application of a tourniquet. Occasionally, the fillet flap principle can be applied in reconstructing these wounds. Occasionally, bone shortening or revision amputation is required

2014 eMedicine Surgery

124. Hand Infections

, epitrochlear and/or axillary lymphadenopathy may be present. Beta-hemolytic streptococci and S aureus are the usual pathogens. Felon A is an infection of the soft tissues at the volar pad of the terminal phalanx. [ ] The soft tissue of the fingertips is divided into multiple compartments by vertical fibrous septa extending from the dermis to the distal phalanx. Infections in this area thus mimic a compartment-like syndrome. A hot, red digital pulp implies the presence of pus and should be drained even (...) of irrigation and debridement procedures, patient comorbidities, and postoperative infection following nonjoint surgery. A higher risk for arthrodesis and amputation was noted in subjects who had more than 3 irrigation and debridement procedures. [ ] Osteomyelitis Like septic arthritis, of the bones of the hand can result from local extension of other hand infections, or it may be caused by hematogenous spread from a distant site. Most occurrences result from local extension. Staphylococci and streptococci

2014 eMedicine Surgery

125. Hand, Congenital Hand Deformities

below: Most commonly, radial hypoplasia, brachysyndactyly, or brachydactyly Type VI - Constriction band syndromes, as follows: See the list below: Occurs with or without distal lymphedema; may involve amputation at any level Type VII - Generalized anomalies and syndromes This classification system is imperfect (eg, atypical cleft hands are difficult to classify, falling into 1 of 3 possible groups), and the future undoubtedly holds a classification system based on improved knowledge of the molecular (...) ; the hands show symmetrical complex syndactyly. Dysplasia of the shoulder and elbow joint are also common. The hand deformity fits into 3 general patterns, as outlined in Table 5 below. [ ] Table 5. Classification of Apert Hand Deformity Classification 1st Web Space Central Mass 4th Web Space Type I: Spade hand Incomplete simple syndactyly Digital mass flat to palmar plane Incomplete simple syndactyly Type II: Mitten or spoon hand Complete simple syndactyly Digital mass curved due to fingertip fusion

2014 eMedicine Surgery

126. Nerve Entrapment Syndromes (Follow-up)

AND TREATMENT OF POSTERIOR INTEROSSEOUS NERVE ENTRAPMENT: SYSTEMATIC REVIEW. Acta Ortop Bras . 2017 Jan-Feb. 25 (1):52-54. . Clavert P, Thomazeau H. Peri-articular suprascapular neuropathy. Orthop Traumatol Surg Res . 2014 Dec. 100 (8 Suppl):S409-11. . Lanz U. Anatomical variations of the median nerve in the carpal tunnel. J Hand Surg Am . 1977 Jan. 2(1):44-53. . Wilson KE, Tat J, Keir PJ. Effects of Wrist Posture and Fingertip Force on Median Nerve Blood Flow Velocity. Biomed Res Int . 2017. 2017:7156489 (...) . . American Academy of Orthopaedic Surgeons. MANAGEMENT OF CARPAL TUNNEL SYNDROME EVIDENCE-BASED CLINICAL PRACTICE GUIDELINE. American Academy of Orthopaedic Surgeons. 2016 feb 29; Accessed: September 21, 2017. Moriarty JM, Bandyk DF, Broderick DF, Cornelius RS, Dill KE, Francois CJ, et al. ACR Appropriateness Criteria Imaging in the Diagnosis of Thoracic Outlet Syndrome. J Am Coll Radiol . 2015 May. 12 (5):438-43. . . Dellon AL. Neurosurgical prevention of ulceration and amputation by decompression

2014 eMedicine Surgery

127. Nail Pathology (Follow-up)

of mind" technique. The parents should be informed that the composite tip graft either survives or dies with this technique. Convert to a full-thickness skin graft to treat the composite fingertip amputation in adults and in children older than 10 years. The tissue is defatted to the level of the dermis, and the nail bed is preserved. The distal phalanx is shortened just below the remaining pulp soft tissue, and the full-thickness graft is applied and held with a stent dressing. The tip pulp (...) obtained vascularity. Again, the judicious use of sterile matrix grafts or germinal matrix grafts offers the best reconstructive results. Hook-nail deformity A hook-nail deformity is usually the result of a fingertip amputation, with partial or complete loss of the supporting tuft of the distal phalanx and a loss of the distal nail bed and fingertip soft tissue. The regenerating nail plate follows the contour of the repaired fingertip amputation, angling in a dorsal to volar direction. Amputated

2014 eMedicine Surgery

128. Nerve Entrapment Syndromes (Diagnosis)

: SYSTEMATIC REVIEW. Acta Ortop Bras . 2017 Jan-Feb. 25 (1):52-54. . Clavert P, Thomazeau H. Peri-articular suprascapular neuropathy. Orthop Traumatol Surg Res . 2014 Dec. 100 (8 Suppl):S409-11. . Lanz U. Anatomical variations of the median nerve in the carpal tunnel. J Hand Surg Am . 1977 Jan. 2(1):44-53. . Wilson KE, Tat J, Keir PJ. Effects of Wrist Posture and Fingertip Force on Median Nerve Blood Flow Velocity. Biomed Res Int . 2017. 2017:7156489. . Ball C, Pearse M, Kennedy D, Hall A, Nanchahal J (...) EVIDENCE-BASED CLINICAL PRACTICE GUIDELINE. American Academy of Orthopaedic Surgeons. 2016 feb 29; Accessed: September 21, 2017. Moriarty JM, Bandyk DF, Broderick DF, Cornelius RS, Dill KE, Francois CJ, et al. ACR Appropriateness Criteria Imaging in the Diagnosis of Thoracic Outlet Syndrome. J Am Coll Radiol . 2015 May. 12 (5):438-43. . . Dellon AL. Neurosurgical prevention of ulceration and amputation by decompression of lower extremity peripheral nerves in diabetic neuropathy: update 2006. Acta

2014 eMedicine Surgery

129. Nail Pathology (Diagnosis)

of mind" technique. The parents should be informed that the composite tip graft either survives or dies with this technique. Convert to a full-thickness skin graft to treat the composite fingertip amputation in adults and in children older than 10 years. The tissue is defatted to the level of the dermis, and the nail bed is preserved. The distal phalanx is shortened just below the remaining pulp soft tissue, and the full-thickness graft is applied and held with a stent dressing. The tip pulp (...) obtained vascularity. Again, the judicious use of sterile matrix grafts or germinal matrix grafts offers the best reconstructive results. Hook-nail deformity A hook-nail deformity is usually the result of a fingertip amputation, with partial or complete loss of the supporting tuft of the distal phalanx and a loss of the distal nail bed and fingertip soft tissue. The regenerating nail plate follows the contour of the repaired fingertip amputation, angling in a dorsal to volar direction. Amputated

2014 eMedicine Surgery

130. High-Pressure Injection Injuries (Diagnosis)

that HPI injuries to the hand are relatively common, given the widespread use of pressure machinery. Previous Next: Prognosis HPI injuries often manifest as innocuous lesions on the fingertip of a patient's nondominant hand. Depending on the substance involved, these injuries may follow a benign clinical course (for air and clean water) or may be deceptively destructive and lead to soft-tissue necrosis and amputation (for grease and paint). Proper triage and management of HPI injuries of the hand (...) , leading to high amputation rates. [ , ] Grease has been shown to be associated with oleogranulomata formation (a reaction to foreign bodies), fistula formation, fibrosis, and poor functional outcomes. [ , , ] Joint contractures and ankylosis are also seen. [ ] Previous Next: Etiology Common substances involved in HPI injuries include the following [ , , ] : Grease (accounting for 57% of injuries, at pressures of up to 5000-10,000 psi) Paint (up to 5000 psi; see the images below) Diesel fuel

2014 eMedicine Surgery

131. Replantation (Diagnosis)

: L Andrew Koman, MD; Chief Editor: Harris Gellman, MD Share Email Print Feedback Close Sections Sections Replantation Overview Background Replantation of completely amputated digits has been a medical reality since 1968, when Komatsu and Tamai first reported successful replantation of a completely amputated thumb. [ ] Amputation of digits is common. Approximately 100,000 occur per year in the United States. Of those, an estimated 30% are suitable for replantation. The exact number (...) of replantations performed yearly is unknown. However, the number appears to be decreasing, secondary to more rigid selection criteria, improved workplace safety procedures, and better-designed protection devices on power tools. An image depicting digital amputation can be seen below. Complete amputation of two digits. Next: History of the Procedure Carrel performed experimental replantation of a canine hind limb in 1906. [ ] Malt successfully replanted a completely amputated arm in 1964, [ ] and Meredith

2014 eMedicine Surgery

132. Arteriovenous Fistulas (Diagnosis)

is a term reserved for a singular communication between an artery and a vein that usually has an acquired etiology. The first recorded case of an arteriovenous malformation (AVM) was in the late 16th century. In 1757, Hunter described an AVF as an abnormal communication between an artery and a vein. Krause in 1862 used injection studies of an amputated specimen to characterize the abnormal vasculature. In 1875, Nicoladoni described the reflex slowing of the pulse following occlusion of an artery (...) , Szajner M. Endovascular Treatment of Renal Arteriovenous Fistula with N-Butyl Cyanoacrylate (NBCA). Pol J Radiol . 2017. 82:304-306. . . Media Gallery Buttock port-wine stain. Lower extremity venous malformation. Upper extremity arteriovenous malformation (AVM). Hypertrophied subclavian artery resulting from low-resistance high-volume flow through an upper extremity arteriovenous malformation (AVM). Hand angiogram demonstrating arteriovenous connections. Note the steal of blood from the fingertips

2014 eMedicine Surgery

133. Replantation (Follow-up)

> Replantation Treatment & Management Updated: Nov 08, 2018 Author: L Andrew Koman, MD; Chief Editor: Harris Gellman, MD Share Email Print Feedback Close Sections Sections Replantation Treatment Medical Therapy Appropriate antibiotics and wound care are indicated to prevent infection. Next: Preoperative Details Amputated parts should be stored dampened with isotonic sodium chloride solution or Ringer's lactate in a cooled environment (on ice within a cooler or in a refrigerator). Contact with a saline ice (...) and the use of heparin-soaked pledgets to allow controlled bleeding. Late complications include loss of motion from joint stiffness and tendon adhesions. Fusions, tenolysis, or both may be required. In addition, nonunions are common because distal fragments may be avascular. Previous Next: Outcome and Prognosis The outcome and prognosis are variable. [ , ] Thumbs have the best prognosis, [ ] as do digits amputated distal to the insertion of the flexor digitorum superficialis. [ , , , ] Survival of digits

2014 eMedicine Surgery

134. Arteriovenous Fistulas (Follow-up)

are not surgically resectable. Those patients severely afflicted with malformations who are not candidates for local extirpation may be candidates for amputation and rehabilitation with a limb prosthesis. In contrast to congenital AVMs, which are difficult to treat, almost all acquired arteriovenous fistulas (AVFs) are amenable to either surgical or interventional treatment. Occlusion of the feeding vessel with coils can be done. If the AVF is between a medium-sized or large artery and a vein, then occlusion (...) artery resulting from low-resistance high-volume flow through an upper extremity arteriovenous malformation (AVM). Hand angiogram demonstrating arteriovenous connections. Note the steal of blood from the fingertips. of 5 Tables Contributor Information and Disclosures Author Sateesh C Babu, MD Professor of Clinical Surgery, New York Medical College; Chief, Vascular and Endovascular Surgery, Westchester Medical Center Sateesh C Babu, MD is a member of the following medical societies

2014 eMedicine Surgery

135. Replantation (Treatment)

PM. Preoperative management of the amputated limb. Emerg Med J . 2005 Jul. 22(7):478-80. . Maricevich M, Carisen B, Mardini S, Moran S. Upper extremity and digital replantation. Hand (NY) . December 2011. 6(4):356-63. . Chai Y, Kang Q, Yang Q, Zeng B. Replantation of amputated finger composite tissues with microvascular anastomosis. Microsurgery . 2008. 28(5):314-20. . Hattori Y, Doi K, Ikeda K, Abe Y, Dhawan V. Significance of venous anastomosis in fingertip replantation. Plast Reconstr Surg (...) == processing > Replantation in Emergency Medicine Treatment & Management Updated: Sep 12, 2017 Author: Mark I Langdorf, MD, FAAEM, FACEP, MHPE, RDMS; Chief Editor: Harris Gellman, MD Share Email Print Feedback Close Sections Sections Replantation in Emergency Medicine Treatment Prehospital Care At the scene, collect and preserve all amputated parts, even those crushed and not thought to be useful. Parts not suitable for replantation can provide tendons or bone. Cool the amputated part to 4°C to preserve

2014 eMedicine Emergency Medicine

136. Replantation (Overview)

of amputated digits has gradually moved from fantasy to reality. William Balfour performed the first successful fingertip reattachment in 1814; Thomas Hunter is credited with the first thumb replantation performed in the following year. Little progress was made until the pioneering work of William Steward Halstead and Alexis Carrel, who performed replantation experiments with dog limbs in the 1880s. Dr Carrel won the Nobel Prize in 1912 for his work on vascular anastomoses and for pioneering renal (...) Plast Reconstr Aesthet Surg . 2008 Dec. 61(12):e19-22. . Ihrai T, Balaguer T, Monteil MC, et al. [Surgical management of traumatic ear amputations: literature review]. Ann Chir Plast Esthet . 2009 Apr. 54(2):146-51. . Salah MM, Khalid KN. Replantation of multiple digits and hand amputations: four case reports. Cases J . 2008 Oct 23. 1(1):266. . Dec W. A meta-analysis of success rates for digit replantation. Tech Hand Up Extrem Surg . 2006 Sep. 10(3):124-9. . Li J, Guo Z, Zhu Q, et al. Fingertip

2014 eMedicine Emergency Medicine

137. Replantation (Follow-up)

processing > Replantation in Emergency Medicine Follow-up Updated: Sep 12, 2017 Author: Mark I Langdorf, MD, FAAEM, FACEP, MHPE, RDMS; Chief Editor: Harris Gellman, MD Share Email Print Feedback Close Sections Sections Replantation in Emergency Medicine Follow-up Further Inpatient Care Surgeons must be skilled at microvascular reanastomosis and be able to achieve a 90% patency rate in a 1-mm – diameter vessel in laboratory animals. [ ] If the vessels of partial or complete finger amputations are suitable (...) for anastomosis, a successful replantation with excellent functional and esthetic recovery can be achieved. Repair may be performed with an axillary nerve block with bupivacaine, which provides anesthesia lasting 12-16 hours. However, children must have because they do not tolerate axillary block well. The surgical sequence for replantation varies slightly with amputations distal and those proximal to the wrist and with the mechanism of injury (clean cut, crush, avulsion). Since injury distal to the wrist

2014 eMedicine Emergency Medicine

138. Replantation (Diagnosis)

of amputated digits has gradually moved from fantasy to reality. William Balfour performed the first successful fingertip reattachment in 1814; Thomas Hunter is credited with the first thumb replantation performed in the following year. Little progress was made until the pioneering work of William Steward Halstead and Alexis Carrel, who performed replantation experiments with dog limbs in the 1880s. Dr Carrel won the Nobel Prize in 1912 for his work on vascular anastomoses and for pioneering renal (...) Plast Reconstr Aesthet Surg . 2008 Dec. 61(12):e19-22. . Ihrai T, Balaguer T, Monteil MC, et al. [Surgical management of traumatic ear amputations: literature review]. Ann Chir Plast Esthet . 2009 Apr. 54(2):146-51. . Salah MM, Khalid KN. Replantation of multiple digits and hand amputations: four case reports. Cases J . 2008 Oct 23. 1(1):266. . Dec W. A meta-analysis of success rates for digit replantation. Tech Hand Up Extrem Surg . 2006 Sep. 10(3):124-9. . Li J, Guo Z, Zhu Q, et al. Fingertip

2014 eMedicine Emergency Medicine

139. Distal digital replantation. (Abstract)

replantation. They describe specific techniques and considerations for surgical repair in each of four distal zones as described by Sebastin and Chung.Zone 1A replantation involves an artery-only anastomosis of a longitudinal pulp artery. Venous anastomosis first becomes possible in zone 1B. Zone 1C involves periarticular amputations where arthrodesis of the distal interphalangeal joint is usually indicated. Repair of the artery, vein, and nerve is technically optimal in zone 1D, where venous anastomosis (...) should be performed. Overall, survival rates for distal digital replantation are similar to those reported for more proximal replantation. The literature reports good outcomes regarding nail salvage, fingertip sensibility, and range of motion, with restoration of length and aesthetic appearance.Distal replantation performed at institutions that specialize in microsurgery and specifically tailored to the level of injury is associated with good survival, function, and patient satisfaction and superior

2013 Plastic and reconstructive surgery

140. Program director opinions of core competencies in hand surgery training: analysis of differences between plastic and orthopedic surgery accredited programs. Full Text available with Trip Pro

the groups, followed by pedicled and free tissue transfer, and amputation and fingertip injuries.Despite being united under the subspecialty of hand surgery, program directors tend to emphasize clinical areas that are stressed in their respective primary disciplines. These differences promote the advantage of programs that provide exposure to both plastic surgery-trained and orthopedic surgery-trained hand surgeons.

2013 Plastic and reconstructive surgery

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