AttendMe Owl Logo
AttendMe
Sign In
All Pathways
Plastic SurgeryEmergency

Digital Replantation Assessment and Management

Digital Replantation Assessment and Management: Digital/Limb Amputation → Initial Management (CRITICAL) → Ischemia Time Assessment → Replantation Indica...

Pathway Overview

10 steps

Algorithm Steps

10 total

  1. 01Start

    Digital/Limb Amputation

    Traumatic amputation requiring replantation assessment

  2. 02Warning

    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
  3. 03Action

    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
  4. 04Decision

    Replantation Indicated?

    Weigh indications vs contraindications

  5. 05Action

    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
  6. 06Action

    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
  7. 07Action

    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
  8. 08Action

    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
  9. 09Outcome

    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
  10. 10Action

    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

Guideline Source

ASSH Digital Replantation Guidelines

DOI: N/A

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Time-dependent outcomes
  • Requires microsurgery expertise
  • Patient selection critical
  • Cold ischemia time varies by tissue

Applicable Regions

USEU
Version 1Next review: 2027-01-11

Related Plastic Surgery Pathways

Breast Reconstruction Timing Algorithm (NCCN/ASPS)

Management

Burn Center Transfer Criteria (ABA)

Diagnostic

Burn Depth Assessment Algorithm

Diagnostic

Burn Resuscitation (Parkland Formula / ABA Guidelines)

Management

Next steps

Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.

Calculator

Body Mass Index

Weight classification based on height and weight

Open page

Compare

AttendMe.ai vs UpToDate

See how this pathway workflow compares against UpToDate.

Open page

Commercial

Start free

Run the pathway in a live AttendMe account with citations and tracked usage.

Start free

Related Resources

All Clinical PathwaysClinical CalculatorsAI Chat with Auto-Detection

Frequently Asked Questions

What is the Digital Replantation Assessment and Management?

The Digital Replantation Assessment and Management is a emergency clinical algorithm for Plastic Surgery. It provides a structured decision tree to guide clinical decision-making, based on ASSH Digital Replantation Guidelines.

What guideline is the Digital Replantation Assessment and Management based on?

This algorithm is based on ASSH Digital Replantation Guidelines (DOI: N/A).

What are the limitations of the Digital Replantation Assessment and Management?

Known limitations include: Time-dependent outcomes; Requires microsurgery expertise; Patient selection critical; Cold ischemia time varies by tissue. Individual patient factors may require deviation from these recommendations.

Get AI-Powered Analysis Alongside This Algorithm

In AttendMe.ai, the Digital Replantation Assessment and Management appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.

Try AttendMe Free