Digital Replantation Assessment and Management

Algorithm Steps

1. ▶

   Start

   Digital/Limb Amputation

   Traumatic amputation requiring replantation assessment

   1. ⚠

      Warning

      Initial Management (CRITICAL)

      Time is tissue - act immediately

      • PATIENT:
      • - Control hemorrhage (direct pressure)
      • - IV access, tetanus, antibiotics
      • - NPO for surgery
      • - X-ray stump and part
      • AMPUTATED PART:
      • - Wrap in saline-moistened gauze
      • - Place in sealed plastic bag
      • - Place bag on ice (NOT directly on ice)
      • - NEVER freeze or soak in water
      • - Transport WITH patient
      1. ●

         Action

         Ischemia Time Assessment

         Critical for viability

         • DIGITS (little muscle):
         • - Warm ischemia: <6 hours
         • - Cold ischemia: <12 hours (up to 24h reported)
         • MAJOR LIMB (more muscle):
         • - Warm ischemia: <4-6 hours
         • - Cold ischemia: <6-8 hours
         • FACTORS EXTENDING TIME:
         • - Cold preservation
         • - Minimal muscle in part
         • - Pediatric patients
         1. ◆

            Decision

            Replantation Indicated?

            Weigh indications vs contraindications

            1. ●

               Action

               Strong Indications for Replantation

               These should be replanted if possible

               • ABSOLUTE INDICATIONS:
               • - Thumb (most important digit)
               • - Multiple digits
               • - Pediatric (any digit)
               • - Hand through palm
               • - Wrist or forearm level
               • RELATIVE INDICATIONS:
               • - Single digit distal to FDS insertion
               • - Individual finger in adult (functional need)
               • - Sharp, clean amputation
               • - Patient motivation/compliance
               1. ●

                  Action

                  Ring Avulsion Classification

                  Special consideration - Urbaniak/Kay

                  • CLASS I: Circulation adequate
                  • - Skin/soft tissue injury only
                  • - Standard wound care
                  • CLASS II: Circulation inadequate
                  • - Vessel injury, viable skeleton
                  • - Vessel repair ± vein graft
                  • CLASS III: Complete degloving/amputation
                  • - IIIa: Can replant (skeleton intact)
                  • - IIIb: Cannot replant (crush/avulsion)
                  • Consider ray amputation for severe III
                  1. ●

                     Action

                     Operative Sequence

                     Standard replantation technique

                     • 1. Debride and identify structures
                     • 2. Bone fixation (K-wires, plate)
                     • 3. Extensor tendon repair
                     • 4. Flexor tendon repair
                     • 5. ARTERIAL anastomosis (x1-2)
                     • 6. VENOUS anastomosis (x2 preferred)
                     • 7. Nerve repair (primary or tag)
                     • 8. Skin closure (loose)
                     • ALWAYS do more veins than arteries
                     1. ●

                        Action

                        Postoperative Care

                        Critical for survival

                        • MONITORING:
                        • - Q1h x 72h, then Q2h
                        • - Color, cap refill, turgor, temp
                        • ENVIRONMENT:
                        • - Warm room (>75°F)
                        • - No caffeine, no nicotine
                        • - Elevate hand at heart level
                        • ANTICOAGULATION:
                        • - ASA 325mg daily
                        • - ± Heparin/Dextran (varies)
                        • POSITIONING:
                        • - Splint in safe position
                        • - Avoid dependent position
                        1. ✓

                           Outcome

                           Outcomes

                           Expected results

                           • Survival rate: 80-90% (clean sharp)
                           • Survival rate: 50-70% (crush/avulsion)
                           • Thumb replant: Highest functional gain
                           • Sensory recovery: 6-24 months
                           • Cold intolerance: Common
                           • Return to work: 3-6 months
            2. ●

               Action

               Contraindications to Replantation

               When NOT to replant

               • ABSOLUTE:
               • - Severe crush/avulsion (vessel destruction)
               • - Multiple level injury
               • - Prolonged warm ischemia (>6h digit, >4h limb)
               • - Life-threatening associated injuries
               • - Severe contamination
               • RELATIVE:
               • - Single finger proximal to FDS (poor function)
               • - Elderly with comorbidities
               • - Smoker (high failure rate)
               • - Psychiatric illness/non-compliance
               • - Previous injury to same digit