FIG. 32-10

FIG. 32-11The PIP joint of the long finger has been fused at 30 degrees with a similar technique after removal of the articular cartilage, as seen in x ray.

CASE 4

A 22-year-old mover caught his dominant hand beneath the power tailgate of a moving van, resulting in a crushing, devascularizing injury to the proximal phalanges of four fingers. The patient arrived 5 1/2 hours after the original injury, and revascularization was begun after 6 hours of warm ischemia.

FIG. 32-12 Fixation was applied as rapidly as possible with K-wires. Despite prolonged ischemia, all digits survived after an eight-hour procedure.

FIG. 32-13. X ray shows fixation.

FIG. 32-14. Multiple other methods have been described for fixation in digital replantation. Lister has popularized the combined use of single transverse intraosseous wire paired with an obliquely placed K-wire, which limits rotation and provides compression. The intraosseous wire can be placed away from rotational axis to provide a tension band function.

FIG. 32-15. Cassel describes a technique using a single intraosseous wire placed in a tetrahedral pattern through perpendicular drill holes and suggests incorporating the avulsed collateral ligaments of periarticular replants.

FIG. 32-16. The tension band principle can also be applied externally, using fine wire twisted around K-wires placed across the fracture. A figure-of-8 pattern has been applied to the dorsal cortex to oppose the distracting forces occurring during motion.

FIG. 32-17. We have used plate fixation rarely in replantation, but have found it effective in correction of nonunion.

CASE 5

A 22-year-old man suffered a transmetacarpal amputation of his nondominant hand in a quarry accident. Despite the avulsive nature of the tendon injury, the remaining structures were sharply divided and with minimal traction damage. As a manual laborer, the patient wished replantation if possible despite the prolonged reconstructive course.

FIG. 32-18. Preoperative x ray view shows the extensive tendon injury.

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