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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 47-49

Digit transposition; A “spare-part” surgery in a mutilating hand injury


1 Department of Orthopedics, Gujarat Research and Medical Institute, Shahibaug, Ahmedabad, Gujarat, India
2 Medical student, NHL Medical College, Ahmedabad, Gujarat, India

Date of Submission20-Nov-2019
Date of Acceptance06-May-2021
Date of Web Publication16-Jun-2021

Correspondence Address:
Dr. Kuldeep Nahar
Gujarat Research and Medical Institute, Shahibaug, Ahmedabad - 380 004, Gujarat,
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_49_19

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  Abstract 


A young Male had a RTA, causing loss of whole of middle finger & crushed skin at dorsum of Index metacarpal bone with fracture of Proximal Phalanx of ring finger along with infected Palmar Lacerated wound. He presented it two weeks after the injury. Hand salvaging surgical procedure was done by transporting the index digit to middle finger metacarpal head and fixed with K wires, sacrificing distal two-third of the second nonviable metacarpal bone. Hand appears to be more functionally and esthetically viable along with avoiding multiple different surgeries, contractures, and stiffness of the joints.

Keywords: Amputation, digit transposition, infection, mutilating hand injuries


How to cite this article:
Nahar K, Nahar N. Digit transposition; A “spare-part” surgery in a mutilating hand injury. J Orthop Traumatol Rehabil 2021;13:47-9

How to cite this URL:
Nahar K, Nahar N. Digit transposition; A “spare-part” surgery in a mutilating hand injury. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2021 Dec 9];13:47-9. Available from: https://www.jotr.in/text.asp?2021/13/1/47/318418




  Introduction Top


Severe injuries of the hand generally involve digits in a heterogeneous pattern, in which some digits are less severely damaged than others and have a higher salvational possibility. Lesser damaged digits should be prioritized for salvage, whereas the more severely injured digits may be used as a source of spare-part tissue. In process of replant, the best-preserved amputated segments are often replanted to the best-preserved stumps.[1],[2]

Transposition of the digits is an excellent concept in patients with multiple digit amputations, where some of the amputated digits are nonsalvageable.

The healthy stumps are identified and used for restoration of the digits.

The thumb is given the highest priority in the reconstructive scheme.[3],[4] The digits are replanted based on the philosophy of best finger to the best stump to reconstruct basic hand function. Spare-part surgery in early reconstruction of the hand is a relatively more useful. The spare-part surgery is a secondary reconstructive procedure to enhance the function of the hand without violating an uninjured site or creating any additional donor-site morbidity.

A less-useful digit is sacrificed as a donor to enhance the function of the remaining digits.

The spare parts need to have anatomical integrity.

Ischemia time should be within salvageable limits for revascularization for composite spare parts.

Reconstruction should offer better global function than primary amputation.

The spare part should serve a greater function when used for reconstruction of other parts than when being replanted in its anatomical location.

Use of spare parts should not exclude harvesting healthy tissue if it is necessary to obtain maximal hand reconstruction. If all the digits can be salvaged with the use of tissue from healthy donor sites, then that strategy should be adopted. Debridement is the most important step in such contaminated and necrotizing tissue to prevent infection. Next step is to provide adequate fixation and stability for transposed structures. Next step is to make sure the viability of neurovascular structures. Assessment and planning are very important for better outcomes. Approach should be tissue oriented and function centered as each digit has different importance for different individuals. Thumb is the main functional digit, so it should be given the priority. Radial-sided and ulnar-sided digits have different significance for different types of people involved in writing and manual labor workers, respectively, for grip and strength.[5],[6]


  Materials and Methods Top


A 15-year-old male who met with road traffic accident (RTA) had crush mutilating injuries in the left hand. He was treated primarily at a peripheral center for initial 2 weeks then referred to us. He had severe comminuted fracture of the index finger with skin loss and exposed dorsal surface. Loss of middle finger through Metacarpophalangeal joint. Fracture in the proximal phalanx of the ring finger and stitched infected wounds in the palm and little finger were found. [Figure 1] shows the clinical presentation.
Figure 1: (a) (b) Pre operative Clinical picture (With loss of skin , tendon & infected index metacarpal bone with loss of middle finger & fractured ring finger)

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The patient was operated by us for debris, infection, and removal of K wires. Fractured fragments of the index metacarpal were removed and whole digit was transported to the middle finger along with the neurovascular bundle and flexor tendons. Ring finger fracture was refixed. [Figure 2] shows the X-ray and intraoperative appearance.

Final appearance looks like as shown in [Figure 3].
Figure 2: (a) (b) Intra-operative Clincial Picture & its X-ray Showig loss of middle finger digit

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Figure 3: (a and b) Postoperative picture (three digit Hand cosmetically functionally more viable after transposing index digit to middle finger metacarpal head

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  Discussion Top


A tissue graft is the most common form of spare part surgery. Amputated or Non-salvageable components can be used as source of tissue graft. But there are a few pre-requisites for spare part surgery[5],[6] They are:

  1. The spare part should do better at the implanted site.
  2. It should be anatomically integrated.
  3. Re-implanted part should be fundamentally better.
  4. Ischemia time should be reasonably short.


Younger age groups have better adaptability than older people in terms of pinch and grip functions. Manual workers shouldbe provided with ulnar grip, and educated people need radial grip for finer writing work.[1],[7] If some healthy tissues are needed for betterment, then one should not hesitate to obtain that like skin grafts or nerve graft, etc.The goal should be the acceptable hand means one with three fingers with near normal length, near normal sensation and a functioning thumb.[6],[8]


  Conclusions Top


In a complicated, devastating complex trauma of the hand, the aim is early restoration of form and function of the hand while minimizing the surgical procedures as well as donor site damages. Spare part surgery should be used as a tool to use tissue from Non –salvageable digit to reconstruct a salvageable dignic rather than to waste it.

Impending for amputation or nonsalvageable digit can provide skin, nerve, vein, artery, or bone as spare part or whole digit for transposition.

Acknowledgement

Thanks for help & guidance to Dr. Kantilal Jain, Orthopaedician, GRMI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Peng YP. FRCS1 and Amitabha Lahiri, MBBS, FRCS. Semin Plast Surg 2013;27:190-7.  Back to cited text no. 1
    
2.
Midgley RD, Entin MA. Management of mutilating injuries of the hand. Clin Plast Surg 1976;3:99-109.  Back to cited text no. 2
    
3.
Büchler U. Traumatic soft-tissue defects of the extremities. Implications and treatment guidelines. Arch Orthop Trauma Surg 1990;109:321-9.  Back to cited text no. 3
    
4.
Soucacos PN. Indications and selection for digital amputation and replantation. J Hand Surg Br 2001;26:572-81.  Back to cited text no. 4
    
5.
Küntscher MV, Erdmann D, Homann HH, Steinau HU, Levin SL, Germann G. The concept of fillet flaps: Classification, indications, and analysis of their clinical value. Plast Reconstr Surg 2001;108:885-96.  Back to cited text no. 5
    
6.
Katsaros J. Indications for free soft-tissue flap transfer to the upper limb and the role of alternative procedures. Hand Clin 1992;8:479-507.  Back to cited text no. 6
    
7.
Schärli AF, Kinderchir Grenzgeb Z. Primary treatment of mutilating hand injuries (author's transl). 1980;30 Suppl: 96-100.  Back to cited text no. 7
    
8.
Nel'zina ZF, Lekomtsev SS, Lisov OL. Primary reconstructive operations in open injuries of the hand and fingers. Vestn Khir Im I I Grek 1979;123:108-11.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Materials and Me...
Discussion
Conclusions
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