Replant 4 FingersReplant 4 fingers post





- reattachment of body part that has been completely severed


Revascularisation of incomplete Amputation

- vascular repair is necessary to prevent necrosis of the extremity

- retains some venous and lymphatic drainage albeit small

- revascularisation easier, quicker and better results


Mechanism of injury






Indications - Urbaniak 1987



Multiple digits

Individual digit distal to FDS insertion

Partial hand / through palm


Almost any body part in child


Wrist or forearm


Above or below Elbow 

- only if sharply demarcated




Adult single digit proximal to FDS insertion

- poor results / stiffness


Ischaemic time distal to carpus

- > 12 hours warm ischaemia time

- > 24 hours cold ischaemia time


Ischaemic time proximal to carpus

- > 6 hours warm ischaemia time

- > 12 hours cold ischaemia time


Severe crush or mangled



- through elbow

- high arm


Multiple level / segmental injury


Other serious injuries/diseases


Vessels atherosclerotic


Mentally unstable patient




Chinese red line sign 

- red streak along arterial course

- due to severe traction


Ribbon sign

- elongated tortuous arteries with pigtail appearance






Thumb has first priority

- a successfully replanted thumb is always better than any reconstruction

- thumb provides 40% of hand function

- a fixed stump / post is very useful


Detipped thumb can be successful

- need dorsal veins in stump

- need 4mm of skin proximal to nail plate

- all efforts should be made to preserve thumb length even up to nail base


Multiple amputations


Replant best digit to most useful stump

When thumb intact goal is to restore palm width


Single digit


Does well if FDS intact

- allows immediate mobilisation of digit


P1 replants


Useful function does not occur

- patient will bypass finger


Mid-palm amputations 


Absolute indication for replant 

- replant far superior to prosthesis as lose sensation and power grasp


Proximal injuries


Proximal forearm, EJ and Arm 

- usually avulsion types with extensive muscle injury

- infection and muscle necrosis very common 

- usually replant not indicated


Patient factors


High demand professionals 

- may push indications eg at P1


Age is not a barrier 


Patient must be aware of chance at viability, function, time off work etc


Premorbid conditions must be taken into account 

- DM, Smoking, HTN, peripheral vascular disease

- patient compliance




Key factor in success


Duration of allowed ischaemia varies from tissue to tissue


Recommended maximum


1.  Distal to carpus 

- 12 hours warm, 24 hours cool


Digits consist of skin, bone and subcutaneous tissue

- no muscle

- warm ischaemia tolerated for long periods

- freezing not tolerated

- digits have survived for 12 hours or longer of warm ischaemia

- when cooled replants have been performed at 36 hours


2.  Proximal to carpus 

- 6 hours warm, 12 hours cool


Major limb replants contain large volume of muscle

- only tolerate 4-6 hours of ischaemia

- because of the size of the extremity only its outer part is adequately cooled 

- the deep muscle remains relatively warm

- the allowable 6 hours can't be extended


Transport of part

4oC ideal


2 Methods


1. Wrapping the part in a moistened cloth of Ringer's or Saline

- placing in plastic bag and placing the bundle in ice water


2. Immersing the part in one of these solutions in a plastic bag 

- then putting on ice


No difference in outcome


Most important is to give clear and precise instructions to referring doctors




Dedicated replant team


Should be able to consistently achieve 90% patency rate in 1mm vessels in labratory


Operating theatre not the setting for practice


Surgical management


Operative Sequence for single digit


1. Locate and tag vessels and nerves

2. Debride

3. Shorten and fix the bone

4. Repair extensors

5. Repair flexors

6. Anastomose the arteries

7. Repair the nerves

8. Anastomose the veins

9. Obtain skin coverage


Set up

- maintain body temperature by warming the patient

- axillary block to block sympathetics

- ABx, tetanus prophylaxis




- longitudinal mid-lateral incisions for digital replants


Shorten bone

- get out of zone of injury 

- must have no tension on the grafts

- minimum 0.5 - 1cm each side

- alternative is to vein graft but is easier to shorten bone

- Shortening also helps with skin coverage


- K wire fusion DIPJ / P2


Extensor Tendons

- primary repair

- if inadequate extensor tendon for primary repair perform delayed repair


Flexor tendons 

- repaired primarily if at all possible

- otherwise 2 stage 



- 10/0 nylon interrupted

- key is repair normal intima to normal intima

- adventitia is intensely thrombogenic so ensure none in repair

- strip adventitia for 1-2mm

- repair both arteries if possible otherwise vein graft

- tourniquet acceptable

- micro-clips / bulldog clips should not be applied > 30min due to intimal damage

- heparin boluses to maintain patency (5000IU in 500 mls)

- papaverine antispasmodics

- 2 veins for every artery


Nerve repair

- 10/0 interrupted epineural repair

- primary repair if possible

- primary nerve graft if not 

- use medial cutaneous nerve of forearm 



- skin closed under no tension

- digital incisions often left open to decompress repairs

- fasciotomies in larger replants

- bulky above EJ dressing with volar slab unless flexor tendon repair then dorsal slab


Replant at level of nail bed



- No dorsal veins 



1.   Repair of volar veins (smaller and more flimsy)

2.   Anastomose one distal artery to proximal vein (AV anastomoses)

3.   Backbleeding by removing nail plate and scrapping every 2 hrs with cotton applicator and heparin dressings

4.   Medical grade leeches




Elevate gallows

- high dependency area

- high fluids

- anticoagulation controversial

- smoking strictly prohibited

- no caffeine

- warm ambient temperature

- colour, pulp, turgor, cap refill, and warmth all used as aids in monitoring the replant

- observations hourly for 72h then q4h

- if concern re myoglobinuria then maintain urine output high and alkalinise the urine



- if surface temperature <30°C poor perfusion of replant is certain


Reversal of failing patient


If appears threatened immediate action necessary

1. Relieve dressings or sutures

2. Either elevate or dependant position

3. Regional block for sympathetics

4. Relieve pain, fear and anxiety

5. Ensure patient warm and adequately hydrated

6. If return to OT necessary then must be within 4-6 hours of ischaemia




80-85% survivability


Urbaniak 1985

- 51/55 survived

- ROM 82o distal to FDS

- 35o proximal to FDS


Ring Avulsions


Urbaniak Classification


I - circulation adequate

II - circulation inadequate

III - complete degloving / amputation


Major limb replantation




Amputations proximal to metacarpal level have significant muscle bulk

- to prevent myonecrosis immediate arterial inflow is necessary

- following rapid skeletal stabilisation at least one artery must be stabilised then follow sequence for digit

- extensive fasciotomies always indicated

- any exposed vessels must be covered by rotation flap etc

- return to OT at 72 hrs for inspection and DPC


2 most common causes of failure in major limb replants 


1.  Myonecrosis with subsequent infection


2.  Failure to adequately decompress the restored vessels