What is replantation?
Replantation refers to the surgical reattachment of a finger, hand, or arm that has been completely cut from a person’s body. The goal of replantation surgery is to give the patient back as much use of the injured area as possible. In some cases, replantation is not possible because the part is too damaged.

If the lost part cannot be reattached, a patient may have to use a prosthesis (a device that substitutes for a missing part of the body). In some cases, a prosthesis may give a person without hands or arms the ability to function.

Replantation is usually recommended when the replanted part will work at least as well as a prosthesis. Generally, a missing hand would not be replanted knowing that it would not work, be painful, or get in the way of everyday life. Before surgery the doctor, if possible, will explain the procedure and how much use is likely to return following replantation. The patient or family member must decide whether that amount of use justifies the long and difficult operation, time in the hospital, and months or years of rehabilitation.

How is the procedure done?
There are a number of steps in the replantation process. First, damaged tissue is carefully removed. Then bone ends are trimmed before they are rejoined. This makes putting together the soft tissue on either side of the wound easier. Arteries, veins, nerves, muscles, and tendons are sewn back together (Figure 1). Areas without skin are covered with skin that has been taken from other areas of the body. Uncovered nerves, tendons, and joints may be covered by a free-tissue transfer, where a piece of tissue is removed from another part of the body, along with its artery and veins.

What kind of recovery can I expect?
The patient has the most important role in the recovery process. Smoking causes poor circulation and may cause loss of blood flow to the replanted part. Allowing the replanted part to hang below heart level may also cause poor circulation. Younger patients have a better chance of their nerves growing back, they may regain more feeling, and may regain more movement in the replanted part.

Generally, the further down the arm the injury occurs, the better the return of use to the patient. Patients who have not injured the joint will get more movement back than those who have. A cleanly cut part usually works better after replantation than one that has been crushed or pulled off.

Recovery of use depends on regrowth of two types of nerves: sensory nerves that let you feel, and motor nerves that tell your muscles to move. Nerves grow about an inch per month. The number of inches from the injury to the tip of a finger gives the minimum number of months after which the patient may be able to feel something with that fingertip. The replanted part never regains 100% of its original use. Most doctors consider 60% to 80% an excellent result. Cold weather can be uncomfortable and a frequent complaint even for those with excellent recovery.

What about therapy and rehabilitation?
Complete healing of the injury and surgical wounds is only the beginning of a long process of rehabilitation. Therapy and temporary bracing are important to the recovery process. From the beginning, braces are used to protect the newly repaired tendons and allow the patient to move the replanted part. Therapy with limited motion helps keep joints from getting stiff, muscles moving, and scar tissue to a minimum.

Even after you have recovered fully, you may find that you cannot do everything you wish to do. Tailor-made devices may help many patients do special activities or hobbies. Talk to your physician or therapist to find out more about such devices. Many replant patients are able to return to the jobs they held before the injury. When this is not possible, patients can seek assistance in selecting a new type of work.

Are emotional problems common following replantation?
Replantation can affect your emotional life as well as your body. When your bandages are removed and you see the replanted part for the first time, you may feel shock, grief, anger, disbelief, or disappointment because the replanted part simply does not look like it did before. Worries about the look of a replanted part and how it will work are common. Talking about these feelings with your doctor often helps you come to terms with the outcome of the replantation.

Your doctor may also ask a counselor to assist with this process. You may find it helpful to talk about it with someone and work through your feelings so you can move on with your life.

Will additional surgery be necessary?
Some patients who have fully recovered from replantation surgery may need surgery later to reach full usage of the part.

Some of the most common procedures are:

• Tenolysis – frees tendons from scar tissue.
• Capsulotomy – releases stiff, locked joints.
• Tendon or muscle transfer – moves tendons or muscles to another spot so that they can work in an area that needs the tendon or muscle more.
• Nerve grafting – replaces a scarred nerve or a gap in the nerves to improve how the nerve works.
• Late amputation – removing the part later because it does not work or has become painful.

Stay in the flow of life. You have many great gifts. Even with the best medical care, you need to be strong during the course of recovery. Remember that quality of life is directly related to your attitude and expectations—not just regaining limb use.

What is Reflex Sympathetic Dystrophy?

Reflex sympathetic dystrophy, also known as RSD, is a condition of burning pain, stiffness, swelling, and discoloration of the hand. RSD includes other medical diagnoses such as casualgia, Sudeck’s atrophy, and shoulder-hand syndrome. RSD occurs from a disturbance in the sympathetic (unconscious) nervous system that controls the blood flow and sweat glands in the hand and arm. When the nervous system becomes overactive, burning pain is felt and swelling and warmth are left in the affected arm. If not treated, RSD can cause stiffness and loss of use of the affected part of the arm.

What causes Reflex Sympathetic Dystrophy?

In some cases, the cause of RSD is unknown. Often an injury can cause RSD, or the symptoms may appear after a surgery. Other causes include pressure on a nerve, infection, cancer, neck disorders, stroke, or heart attack. These conditions can cause pain, which sets off the sympathetic reflex causing RSD symptoms. Nerve injuries may change the way the nerve impulses are sent, causing a “short circuit” (Figure 2).

Signs and symptoms

The pain associated with reflex sympathetic dystrophy is often described as burning in nature. Swelling can cause painful joints and stiffness.

RSD has three stages:

• Stage I (acute) may last up to three months. During this stage the symptoms include pain and swelling, increased warmth in the affected part/limb, and excessive sweating. There may be faster-than-normal nail and hair growth and joint pain during movement of the affected area (Figure 1).
• Stage II (dystrophic) can last three to 12 months. Swelling is more constant, skin wrinkles disappear, skin temperature becomes cooler, and fingernails become brittle. The pain is more widespread, stiffness increases, and the affected area becomes sensitive to touch.
• Stage III (atrophic) occurs from one year on. The skin of the affected area is now pale, dry, tightly stretched, and shiny. The area is stiff, pain may decrease, and there is less hope of getting motion back.

Diagnosis

The diagnosis usually is made when at least three of the following symptoms are present: pain and tenderness, signs of changed blood flow (either increased or decreased), swelling with joint stiffness, or skin changes.

Treatment
Early diagnosis and treatment are important. Three forms of treatment may be combined: medication, physical therapy, and surgery. Medication taken by mouth can help decrease the symptoms. To reduce symptoms and provide long-term relief, local anesthetics may be injected into a nerve bundle at the base of the neck (stellate ganglion block). In some cases, a tourniquet is applied to the arm and medication can be injected into a vein along with an anesthetic.

Your hand surgeon may recommend therapy by a hand, occupational or physical therapist, or physician. Therapy is important to regain function and reduce discomfort caused by RSD. Successful treatment depends on the patient’s full and active effort in therapy. Occasionally, surgery is performed in the later stages, but the results can be disappointing. Your physician can advise you on the best treatment for your situation.

Description
Mallet finger injuries occur when the tip of a finger or the thumb is forcefully bent. This condition is also known as baseball finger. It happens when a ball or other object strikes the tip of the digit. The force tears the thin tendon that allows you to straighten the finger. The force of the blow may even pull away a piece of bone along with the tendon.

Symptoms
A person with this injury has pain, swelling and bruising of the fingertip. The fingertip may droop noticeably. Occasionally, blood collects beneath the nail and the nail can even become detached from beneath the skin fold at the base of the nail.

Treatment Options
If you experience a mallet finger injury, immediately apply ice and elevate your hand above the level of your heart. Seek medical attention within the first week after this injury. It is very important to seek urgent attention if you have blood beneath the nail or if the nail is detached because you could also have a nail bed laceration or open (compound) fracture.

In most cases, the doctor will order X-rays to look for a major fracture or malalignment of the joint.

The majority of mallet finger injuries can be treated without surgery. The doctor may apply a splint to hold the fingertip straight (in extension) until it heals. Most of the time, you will have to wear the splint full-time for six weeks.

After six weeks, most patients gradually wean from the splint by wearing it less frequently over a three to four week period The finger usually regains acceptable function and appearance with this treatment plan; however, many patients may not regain full fingertip extension.

In children, mallet finger injuries may involve the cartilage that controls bone growth. A doctor must carefully evaluate and treat this type of injury, so the finger does not become stunted or deformed.

Treatment Options: Surgical

In certain cases, surgical repair may be considered. These cases include mallet finger injuries with:

• Large fracture fragments
• Joint malalignment

Surgical treatment in these cases often involves repair of the fracture using pins, pins and wire, or even small screws.

Surgery may also be considered if non-operative treatment fails. Repairing soft tissue mallet fingers is uncommon and usually reserved for patients with very severe deformities and functional problems. Surgical treatment can include tightening the stretched tendon tissue, using tendon grafts, or even fusing the joint straight. Consultation with an orthopaedic surgeon should be sought in these cases.

Bone is living tissue that requires a regular supply of blood for nourishment. If the blood supply to a bone stops, the bone can die, a condition known as osteonecrosis. That’s what happens in Kienböck’s disease, which affects the lunate, one of the small bones of the hand near the wrist.

Kienböck’s Disease: Signs and Symptoms

The cause of Kienböck’s disease is unknown. Many people with Kienböck’s disease think they have a sprained wrist at first. They may have experienced some form of trauma to the wrist, such as a fall. This type of trauma can disrupt the blood flow to the lunate. In most people, two vessels supply blood to the lunate, but in some people there is only one source. This puts them at greater risk for developing the disease.

As the disease progresses, other signs and symptoms are noted, including:

• A painful and sometimes swollen wrist
• Limited range of motion in the affected wrist (stiffness)
• Decreased grip strength in the hand
• Tenderness directly over the bone (on the top of the hand at about the middle of the wrist)
• Pain or difficulty in turning the hand upward

Progression

Kienböck’s disease follows a specific progressive pattern through four stages.

• Stage 1: Symptoms are similar to those of a wrist sprain. X-rays may be normal or show a line indicating a possible fracture. Magnetic resonance imaging (MRI) may also be helpful in making the diagnosis in this early stage.
• Stage 2: The lunate bone begins to harden. On an X-ray, it may appear brighter or whiter than the surrounding bones. These changes indicate that the bone is dying. Either an MRI or a computed tomography (CT) scan may be used to assess the condition of the bone. Recurrent pain, swelling and wrist tenderness are common.
• Stage 3: The dead bone begins to collapse and break into pieces. The surrounding bones may begin to shift position. Patients experience increasing pain, weakness in gripping, and limited motion.
• Stage 4: The surfaces of adjoining bones are affected, resulting in arthritis of the wrist.

Diagnosis and treatment
In its early stages, Kienböck’s disease may be difficult to diagnose because the symptoms are so similar to those of a sprained wrist. Even X-rays of the wrist may appear normal. At this point, the goal of treatment is to relieve the pressure on the lunate and help restore blood flow within the bone. Your physician may splint or cast your wrist for two to three weeks.

Anti-inflammatory medications such as aspirin or ibuprofen will help relieve any pain and reduce swelling. If the pain continues, your physician may refer you to an orthopaedic or hand surgeon for further evaluation.

Surgical options
Although there is no cure, there are several surgical options for treating the more advanced stages of Kienböck’s disease. The right procedure for you will depend on several factors, including disease progression, your personal activity levels and goals and your surgeon’s experience with various procedures.

Do not hesitate to discuss these options with your orthopaedic or hand surgeon and to ask why he or she is recommending a particular procedure.

In some cases, returning the blood supply to the bone (revascularization) may be possible. This procedure uses a bone graft from the inner bone of the lower arm. It may be combined with an external fixator, a metal device that helps relieve pressure on the lunate and preserve the spacing between bones.

If the bones of the lower arm are uneven in length, a joint leveling procedure may be recommended. Bones can be made longer with bone grafts, or shortened by removing a section of the bone.

This reduces the compressive forces on the lunate and seems to halt progression of the disease. If the lunate is severely collapsed or fragmented, it can be removed. The two bones on either side of it are also removed. This procedure is called a proximal row carpectomy and will relieve pain while maintaining partial wrist motion.

Another way to ease pressure on the bone is to fuse several of the small bones of the hand together. However, this will not improve range of motion. If the disease has progressed to severe arthritis of the wrist, fusing the bones will reduce pain and help maintain function, although motion is limited.