|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| In severe avulsive injuries, primary anastomosis is frequently not possible because of excessive gapping. The nerve ends are tagged with a silver clip for identification at a secondary nerve graft procedure.55 The gap can also be bridged with carefully placed bridging sutures, which helps to identify the nerve later. The suture also prevents retraction of the nerve ends. In these more severe injuries, primary nerve grafting is seldom performed because, most often, the gapping is caused by crushed or torn nerve tissues, or in the case of a major amputation, the larger nerves have been injured at several levels, and the final zone of nerve injury is not apparent. Furthermore, there is no significant advantage of primary repair over secondary repair.56
All nerve repair is done under the operating microscope. For digital nerves, use 9-0 microsutures, and place only as many epineural sutures as necessary to coapt the ends without tension.56 We use 10-0 for individual fascicles and distal repairs in digits. Using 8-0 microsutures, the larger peripheral nerves can be coapted by epineural repair after correctly identifying the fascicular groups.
SOFT TISSUE REPAIR
The wound should be closed loosely without undue tension on damaged tissue and without compressing underlying vascular structures. Good initial soft-tissue coverage results in more rapid healing and faster resolution of inflammation and edema. The limb can be mobilized more quickly, which improves the function of underlying tendons and joints.
| If primary closure cannot be accomplished, a meshed skin graft may be appropriate.57,58 Local flaps may be used with meshed skin grafts, or, in some cases, free flaps can be transferred at the initial operation. Pedicle flaps are sometimes used,59,60 but the necessary immobilization and the resultant patient discomfort make pedicle flaps more difficult to use than free flaps. Moreover, free flaps offer a greater choice of tissue components (muscle, skin, etc.) than do pedicle flaps.
Severe crush injuries may be covered temporarily with wet-to-dry dressings, allowing a day or two for debridement and final coverage. Moistened vital structures will not be jeopardized, and this time can be used to stabilize the patient, especially if the patient has suffered multiple injuries.
Strategies for Specific Injuries
DISTAL TIP AMPUTATIONS
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