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Background: The thumb accounts for 50% of the total hand function. This study reports the functional outcomes and complications of people with traumatic thumb amputations who underwent toe-to-thumb reconstruction., Methods: From January 2013 to January 2018, 29 patients with second-degree thumb defect underwent thumb reconstruction with distal phalangeal braided toenail flap. The footscan foot pressure gait analysis system was used to measure the index changes of the same foot before and after 1, 3 and 6 months. The contact area, peak pressure, impulse value, contact time of each gait phase, centre of gravity coordinate and foot balance were analysed statistically., Results: Twenty-nine cases of thumb reconstruction recovered well. After following up for 6-15 months, the appearance of the reconstructed thumb was close to normal, and the sensation was restored to S3 + . The two-point discrimination was 6-8 mm, and the function of the thumb was good. The function of the donor foot was well restored, and no skin ulceration, pain and claudication were noted during walking. Compared with that before the operation, the biomechanical indices of the donor foot were basically restored to normal 6 months after the operation. Only the stress and impulse values of the third metatarsal head were significantly increased, forming a stress concentration area centred on the third metatarsal head., Conclusions: This study confirmed that the toenail flap with distal phalangeal bone restored the second-degree thumb defect without destroying the main functional structure of the sole. The biomechanical indices of the donor foot were basically restored to normal 6 months after the operation. Only the stress concentration area centred on the third metatarsal head, and the pain on the forefoot was induced after the operation. Discomfort, callus formation, metatarsal fasciitis, etc., can lead to fatigue fracture of the third metatarsal bone in severe cases, which requires further follow-up and observation., Trial Registration: Clinicaltrials.gov , NCT03879941; registered on 10 March 2019, retrospectively.

Background: The past four years has seen a rapid roll-out of male medical circumcision services in South Africa in response to clinical trials showing circumcision prevents HIV acquisition in heterosexual men. Clinics conduct substantial numbers of circumcisions per day. We report three cases of glans amputation in adolescents attending high volume clinics where modified Models of Optimising Volume and Efficiency (MOVE) are implemented., Case Presentations: Three cases of glans amputation in young healthy men that presented for voluntary medical male circumcision. The procedures were performed by highly experienced medical officers in two cases. All these cases shared characteristics: younger males with immature genitalia, forceps guided circumcision, and likely operator fatigue. Voluntary male medical circumcision programs should include regular monitoring and evaluation and training of operators to ensure high quality surgical techniques such as working in clean areas and taking frequent breaks., Conclusion: Circumcision is a relatively simple medical procedure, however regular training and quality control in high volume Male Medical Circumcision sites is essential to prevent rare catastrophic adverse events.

When the index finger is injured or severed with a traumatic thumb amputation, transfer of the injured index finger can restore the function of the thumb. The purpose of this study was to evaluate the result of the transfer of an injured index finger for the traumatic loss of the thumb. A patient had a traumatic amputation at the first metacarpal level with the bone defect of the second metacarpal and proximal part of index finger. She was treated with a pedicled transfer of the injured index finger to the ipsilateral thumb. Postoperative evaluations included thumb range of motion, opposition and pinch function, grasp and pinch strength, sensation, and a patient-rated appearance of the thumb and hand. In result, the blood supply of the transferred traumatic index fingers was normal, and the transferred index fingers survived without complications. The range of motion of the first metacarpophalangeal joint and interphalangeal joint was almost the same as that of a normal thumb. The opposition and pinch function of the thumb was also normal. The patient is able to complete activities of daily living with the new thumb. Nevertheless, the sensation has not yet been completely restored. In conclusion, it is feasible to treat traumatic thumb amputation with the transfer of injured index finger.

Background: Autoamputation of the appendix is a condition associated with the Ladd's procedure, a pediatric surgical technique for correction of intestinal malrotation. A 4-year-old male patient with a history of a Ladd's procedure performed as a newborn was brought in by his mother for "passing intestine" just prior to arrival. She reported that for several weeks her son had intermittent, crampy abdominal pain that resolved after the unusual-appearing bowel movement. After reviewing an image of the bowel movement, and in consultation with pediatric surgery, it was concluded that the patient had passed a devascularized appendix in his stool immediately prior to arrival., Case Report: A 4-year-old boy with a past medical history of heterotaxy syndrome (inversion of the thoraco-abdominal organs), a double outlet right ventricle, and Ladd's procedure presented to the Emergency Department (ED) after "passing intestine" in his stool. Close examination of the photo demonstrated a tubular structure with taenia, consistent with an appendix. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Autoamputation of the appendix is an uncommon presentation in the ED. Passing a devascularized appendix is a benign condition and can present with weeks of intermittent abdominal pain that resolves with passage of appendix in the stool. Remnants of the appendix can remain within the intestinal lumen years after the Ladd's procedure. Emergency physicians with a general awareness of this rare phenomenon can confidently make the diagnosis and reassure worried parents., (Published by Elsevier Inc.)

The amputation of an extremity is commonly followed by phantom sensations that are perceived to originate from the missing limb. The mechanism underlying the generation of these sensations is still not clear although the development of abnormal oscillatory bursting in thalamic neurons may be involved. The theory of thalamocortical dysrhythmia implicates gamma oscillations in phantom pathophysiology although this rhythm has not been previously observed in the phantom limb thalamus. In this study, the authors report the novel observation of widespread 38-Hz gamma oscillatory activity in spike and local field potential recordings obtained from the ventral caudal somatosensory nucleus of the thalamus (Vc) of a phantom limb patient undergoing deep brain stimulation (DBS) surgery. Interestingly, microstimulation near tonically firing cells in the Vc resulted in high-frequency, gamma oscillatory discharges coincident with phantom sensations reported by the patient. Recordings from the somatosensory thalamus of comparator groups (essential tremor and pain) did not reveal the presence of gamma oscillatory activity.

The metacarpal-like hand is a severe hand injury, never addressed before. It describes a hand that has lost a significant degree of prehension through a wide array of amputations, involving all digits proximal to the functional length except in one finger or in two digits, including the thumb. The thumb condition can be used to differentiate between two types. In type I, the thumb is intact or amputated at or distal to the interphalangeal joint (functional length); therefore, the reconstruction is focused mainly on fingers. In type II, the thumb is amputated proximal to the interphalangeal joint; therefore, the reconstruction is focused on both the thumb and fingers. Thumb amputation level, integrity of the first basal joint, and functionality of the thenar muscles can be used to subdivide type II. Functional reconstruction should consider the patient's desire and vocational needs. The finger left with adequate functional length is assessed for its location, level of amputation, and joint motion, especially the proximal interphalangeal joint. The goal is to use the reliable techniques of toe-to-hand surgery to reconstruct more opposable units, at least two fingers, whether adjacent to each other or not, and the thumb, when needed, to achieve a functionally and aesthetically better hand instead of a functionally adequate hand, with a more acceptable to ideally natural hand cascade. Strategic, individualized toe transfer(s) is the key element in fulfilling the goals of this operation whether single or multiple toes are transplanted.

Background: Traumatic amputation of the penis is a rare surgical emergency. Although repair techniques have been well described in literature, failure of replantation and its causes are poorly understood and reported. Herein, we report the case of a 9 year old boy who underwent replantation of his amputated penis with delayed failure of the surgery, along with a discussion of recent advances in the management of this condition. CASE  PRESENTATION: A 9-year-old boy was referred to our hospital for traumatic amputation of the penis. Papaverine aided microsurgical replantation of the severed part was performed, but by 48 h, the glans became discoloured and necrosis set in by 4 days. Unfortunately, by day 12 two thirds of the re-implanted penis was lost along with overlying skin., Conclusion: Replantation of an amputated penis in a pediatric patient is a daunting task even for experienced surgeons. The vasodilatory effect of papaverine for vascular anastomosis is well described, but the use of a paediatric cannula for identification and instillation of papaverine into penile vasculature, has not been described for the repair of penile amputation. Despite its apparent failure, we believe this technique may be valuable to surgeons who might encounter this rare event in their surgical practice, especially in resource limited settings like ours.

Background: Accidents with lawnmowers can cause mutilating injuries to children. Safety guidelines regarding the use of lawnmowers were promoted by professional organizations beginning in 2001. The Pennsylvania Trauma Systems Foundation maintains a database including all admissions to accredited Levels 1 to 4 trauma centers in the state. The annual rates of admission for children in our state and the severity of injuries subsequent to introduction of safety guidelines have not been reported, to our knowledge. Ride-on lawnmowers have been associated with more severe injuries in children., Questions/purposes: We asked: (1) What was the incidence of hospital admissions for children with lawnmower-related injuries during 2002 to 2013 and did the incidence vary by age? (2) What was the severity of injuries and did the severity vary by age? (3) How often did these injuries result in amputation? (4) What types of lawnmowers were involved?, Methods: This was a retrospective study using a statewide trauma registry. We queried the Pennsylvania Trauma Outcome Study database for children 0 to 17 years old admitted to trauma centers in Pennsylvania between January 2002 and January 2014 with injuries resulting from lawnmower-related accidents. All accredited Levels 1 to 4 trauma centers in the state are required to submit their data to the Pennsylvania Trauma Systems Foundation which maintains the Pennsylvania Trauma Outcome Study database. Demographic information, Injury Severity Scores, International Classification of Diseases procedure codes, and injury location codes were recorded. Type of lawnmower was determined from the narratives and was identified in 60% (119/199) of patients. Traumatic and surgical amputations performed during the index hospitalization were included in the analysis. Information on later surgeries was not available. Subjects were stratified by age: 0 to 6, 7 to 12, and 13 to 17 years old., Results: The incidence of lawnmower injuries in Pennsylvania was a median five of 100,000 children (range, 4-12/100,000) during the study period. The median age was 6 years (range, 1-17 years). The median Injury Severity Score was 4 (range, 1-75). Children 0 to 6 years old had higher median Injury Severity Scores (median, 8; range, 1-75) compared with those 13-17 years old (median, 4; range, 1-20; difference of the medians, 4; p < 0.001). A total of 53% of the patients (106/199) underwent at least one amputation. There were 83 amputations in or of the foot, 18 in the leg, 14 in the hand, and three in the arm. Ride-on lawnmowers accounted for 92% (110/119) of mowers identified by type., Conclusions: The incidence of serious injuries to children owing to lawnmower-related trauma did not change during the 12-year study period. If children younger than 6 years had not been near the lawnmower and those younger than 12 years had not been operating one, at least 69% of the accidents might have been prevented. We recommend annual publicity campaigns during spring to remind the public of the dangers of lawnmowers to children., Level of Evidence: Level IV, therapeutic study.

Background: Amputations in general and amputations of upper extremities, in particular, have a major impact on patients' lives. There are only a few long-term follow-up reports of patients after macro-replantation. We present our findings in contrast with the existing literature., Methods: Sixteen patients with traumatic macro-amputation of an upper extremity were eligible for inclusion in this study. Altogether, the patients underwent replantation in 3 institutions between 1983 and 2011., Results: Twelve male and four female patients with an average age at injury of 40.6 years (range, 14-61 years) were included in this study. The mean follow-up period was 13.5 years (range, 4.4-32.6 years; SD, 5.7 years). The mean disabilities of the arm, shoulder and hand (DASH) outcome measure was 41 (range, 5.2-94.8; SD, 18.2), functional independence measurement (FIM) was 125 (range, 120-126; SD, 1.8). Chen I representing very good function was accounted in six, Chen II representing good function in eight, Chen III (fair) in one and Chen IV (bad function) in one patient., Conclusions: We found that while the majority of the included patients exhibited good or very good function of the extremity, none of the replanted appendages regained normal levels of functionality. In addition, all participants were very satisfied with their outcomes. Positive long-term results with high rates of subjective satisfaction are possible after replantation of upper extremities.

Background: In patients with a transfemoral amputation socket-related problems are associated with reduced prosthetic use, activity, and quality of life. Furthermore, gait asymmetries are present that may explain secondary complaints. Bone-anchored prostheses (BAPs) may help these patients. Two types of BAP are available, screw and press-fit implants. Rehabilitation following surgery for a press-fit BAP is poorly described., Purpose: To describe a rehabilitation program designed to minimize compensation strategies and increase activity using a case-report of an active, 70-year-old man with a traumatic transfemoral amputation who had used a socket prosthesis for 52 years and received a press-fit BAP [Endo-Exo Femoral Prosthesis - EEFP]., Intervention: A 13-week physiotherapy program., Outcomes: Outcomes were assessed before surgery, at the end of rehabilitation, and six-month and one-year follow-ups. After rehabilitation gait had improved, the patient had more arm movement, more pelvic shift, less hip rotation during swing phase on the prosthetic side, and absence of vaulting on the sound side. Isometric hip abductor strength was 15% higher on the sound side and 16% higher on the prosthetic side, and walking distance increased from 200 m to 1500 m. At the six-month follow-up, the patient had lower back complications and reduced hip abductor strength and walking distance. At one-year follow-up, walking distance had recovered to 1000 m and gait pattern had improved again, with yielding and absence of terminal impact on the prosthetic side., Conclusion: The described rehabilitation program may be an effective method of improving gait in patients with an EEFP even after long-term socket usage.

Purpose: To determine the demographic pattern, level, mechanism of traumatic amputation in children and adolescent age group and to compare findings with other studies., Methods: Patients aged less than 18 years with traumatic amputation attending Department of Physical Medicine and Rehabilitation, King George's Medical University, Lucknow, India between July 2013 and January 2016 were enrolled and their demographic characteristics were analyzed., Results: Fifty-three patients were included aged less than 18 years when injured. Mean age of the population studied was 9.89 ± 4.13 with male to females ratio of 3:2. Majority (69.81%) of traumatic amputations involved lower limb. Most common level was unilateral transtibial (35.85%), followed by transfemoral (16.98%). In upper limb, most common type was transradial. RTA followed by train accidents was most common mechanism of traumatic amputation. 8 patients needed revision surgery. 52.8% patients of acquired amputations complained of phantom sensation and 37.74% phantom pain., Conclusions: This study aims to visualize the current scenario and the data generated could be possibly helpful in planning policies and programs at institutional as well as at higher levels for prevention, treatment and distribution of resource to the young amputee population, to ensure their better health care and also opportunities in life.

Certain technical demands must be overcome in order to accomplish the goals of creating a functional hand when performing a central digital ray resection of the hand. One of the biggest challenges is maintaining metacarpal gap closure and in such a way that the metacarpals are balanced and not rotated. Inadequate closure of the defect created between the metacarpals by a central ray resection will produce a persistent gap between the remaining fingers as well as the potential for malalignment. Current techniques are fraught with difficulty and have frequently proven inadequate. We describe a technique for performing a central ray resection without the worry of nonunion, malunion, or increase in gap. With the development of newer fixation devices, we have been able to perform central ray resection while optimally closing the gap, controlling rotation, and providing good hand function., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Objective: To define clinical phenotypes of postamputation pain and identify markers of risk for the development of chronic pain., Design: Cross-sectional study of military service members enrolled 3-18 months after traumatic amputation injury., Setting: Military Medical Center., Subjects: 124 recent active duty military service members., Methods: Study subjects completed multiple pain and psychometric questionnaires to assess the qualities of phantom and residual limb pain. Medical records were reviewed to determine the presence/absence of a regional catheter near the time of injury. Subtypes of residual limb pain (somatic, neuroma, and complex regional pain syndrome) were additionally analyzed and associated with clinical risk factors., Results: A majority of enrolled patients (64.5%) reported clinically significant pain (pain score ≥ 3 averaged over previous week). 61% experienced residual limb pain and 58% experienced phantom pain. When analysis of pain subtypes was performed in those with residual limb pain, we found evidence of a sensitized neuroma in 48.7%, somatic pain in 40.8%, and complex regional pain syndrome in 19.7% of individuals. The presence of clinically significant neuropathic residual limb pain was associated with symptoms of PTSD and depression. Neuropathic pain of any severity was associated with symptoms of all four assessed clinical risk factors: depression, PTSD, catastrophizing, and the absence of regional analgesia catheter., Conclusions: Most military service members in this cohort suffered both phantom and residual limb pain following amputation. Neuroma was a common cause of neuropathic pain in this group. Associated risk factors for significant neuropathic pain included PTSD and depression. PTSD, depression, catastrophizing, and the absence of a regional analgesia catheter were associated with neuropathic pain of any severity., (Published by Oxford University Press on behalf of the American Academy of Pain Medicine. 2016. This work is written by US Government employees and is in the public domain in the US.)

Background: In the complex and challenging treatment of a mutilating hand injury, any available resources need to be primarily recruited. Besides direct digital replantation, the tissue of the nonreplantable "spare parts" could often be "recycled," and also some replantable or injured structures could be "redistributed" in a more functional individualized pattern, irrespective of their initial origin., Methods: Ten patients, six male and four female, were treated for multidigital mutilating injury with various "heterotopic" procedures. Immediate digital heterotopic replantations were performed in seven patients. In one case, the bone and skin of a nonreplantable digital part were used as grafts in the reconstruction of a metacarpal bone and the overlying skin defect. A neurovascular fillet flap from a nonreplantable finger for the reconstruction of the webspace and a pollicization of an injured index were undertaken in two further cases. Another patient underwent pedicled transfer of the proximal interphalangeal joint and metacarpal bone of an impaired index to the middle finger., Results: Sensate prehensile function was restored in 100 percent of the cases, and the ability for tripod pinch and more subtle tasks was restored in 90 percent. The minimum of two long fingers and a thumb was restored in every case, and the patients judged the appearance of their hands as "acceptable.", Conclusion: In the reconstruction of a mutilating hand injury, besides and beyond the straightforward microsurgery, the various heterotopic procedures are essential reconstructive tools that can enhance the versatility of the hand surgeon when pursuing a better outcome., Clinical Question/level of Evidence: Therapeutic, IV.

Since the first successful digit replantation by Japanese surgeons Komatsu and Tamai, the past half century has seen the field of digit replantation in the USA experience exponential growth followed by a steady decline in volume of cases and percentage of successful viable digits. The initial enthusiasm and technical progress of digital replantation has been tempered by mediocre functional outcomes, rising healthcare costs, and limited healthcare resources. The history and approach to digit replantation is reviewed and highlights the likely push toward the development of regional replant centers staffed by highly skilled teams to improve the functional outcomes following these complex procedures. More than 50 years have passed since the first successful digit replantation by Komatsu and Tamai who replanted a sharply amputated thumb in a 28-year-old male at the metacarpal-phalangeal joint level in a 4.5 hour procedure. Two arteries and 2 veins were anastomosed using 8-0 monofilament nylon and 7-0 braided silk suture. The patient remained in the hospital for 40 days and did not return to work for 4 months. News of this triumph of microvascular skill was heralded throughout the world as the first successful replantation of a completely amputated digit. Over the past half century, the field of digit replantation in the USA experienced exponential growth followed by a steady decline in volume of cases and percentage of successful viable digits. The initial enthusiasm and technical progress of digital replantation has been tempered by mediocre functional outcomes, rising healthcare costs, and limited healthcare resources. In the next 50 years, it is possible that the majority of digit replantation procedures in the USA may be performed in tertiary centers or regional replant centers by highly skilled teams.

Background: Stump problems (SPs) secondary to traumatic lower limb amputation had a crucial influence on amputees' ability to return to living and work. The purpose of this study was to investigate the surgical management strategies of the SPs after above-ankle amputation of the lower limb secondary to trauma., Method: A cohort of clinical cases, who were troubled by SPs after above-ankle amputation following trauma, had undergone revision surgery of the stump and was analyzed retrospectively. Various factors were noted like sex, unilateral or bilateral, amputation type, and causes of trauma. Different SPs like excess soft tissue (where a considerable amount of soft tissue interposed between the rigid elements which hindered the fitting of a prosthesis), scar, ulcers, neuromas, and bone spurs were taken as dependent variables. The relationship between factors and SPs was analyzed., Results: A total of 80 stumps were treated surgically. The frequency of excess soft tissue in above-knee amputation cases was higher than that in below-knee amputation (p = 0.007). Bone spur occurred more frequently in the unilateral amputation than in bilateral ones (p = 0.018). There was a significant difference in the ADL scores between admission and discharge (p = 0.000)., Conclusion: Stump problems secondary to traumatic lower limb amputation had crucial influence on amputees' ability to return to living and work, appropriate evaluation and timely surgical revision showed excellent results.

The treatment of acute peripheral finger injuries is part of the daily routine of surgeons in emergency departments. This article presents the most common forms of peripheral finger injuries and the specific diagnostic and therapeutic aspects. The injuries include incision and tear injuries, injuries to the nailbed, distal extensor tendon injuries, severed flexor tendons of the distal joint, bite injuries, high-pressure injection injuries and amputation injuries of the distal phalanx of fingers. For the latter, the form, level and height of the amputation are decisive for therapy. Soft tissue defects on the extensor and flexor side of the finger are also common for emergency surgeons. The basic principles of the initial management of peripheral soft tissue injuries of the hand involve the reconstruction of tendons and nerves and soft tissue coverage. Pathogenic organisms are detectable in more than 80 % of bite wounds so that prophylaxis and therapy of infections are of special importance. An adjuvant antibiotic therapy is necessary for infections as well as for high-pressure injection injuries. It is also important for the treating physician to recognize when a hand surgeon must be involved.

The article is dedicated to one of the currently important problems of present-day traumatology and angiosurgery, i. e. possibility of performing primary reconstructive operations in children with complete and incomplete amputations, open and closed bone fractures in the conditions of circulatory impairment. The authors share their experience in treatment of 92 patients presenting with such injuries, describing the main indications for carrying out repair operations, and drawing appropriate conclusions. The main stages of reconstructions are demonstrated by a series of clinical examples.

Objective: Technical success of a finger replantation depends on several factors such as surgical procedure, type of injury, number of segments amputated, amputation level and individual patient factors. Among early complications that can occur in this type of surgery the onset of venous or arterial thrombosis is the most dreaded. Local irrigating solutions, oral and intravenous anticoagulants, thrombolytic agents, plasma expanders, vasodilating, and antiaggregant drugs are routinely used in patients undergoing microvascular procedures, but currently there is only a non-standardized practice based on anecdotal personal experience., Materials and Methods: The aim of our study is to review selected literature relating to perioperative therapy in microsurgical digital replantation. We also report our case-load of 16 patients with finger avulsion describing our particular protocol for postoperative anticoagulation and restoration of fluid and electrolyte balance., Results: Following our daily pharmacological protocol, the postoperative course of the replanted fingers was uneventful. The survival rate for finger replantations performed was 100% (n = 16) with no need for surgical revisions., Conclusions: The association Dextran-40/Heparin/fluids in the proposed standardized pro-weight pharmacological protocol is an optimal postoperative prophylactic/therapeutic plan to reduce the incidence of endovascular thrombosis after replantation, so ensuring high rate of success in microvascular surgery.

Hook nail deformity results in aesthetic and functional problems after fingertip amputations. Previously described techniques do not correct the osseous defect, which may be the principle cause of the problem. We present a surgical technique based on a compound homodigital advancement flap combining bone of the distal phalanx, finger pulp, and skin. We describe this technique, report a case, and discuss the advantages over former techniques., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Traumatic hemipelvectomy is a severe, life-threatening injury, mainly occurring due to machinery injury or traffic accident. Few cases have been published in the literature. Treatment requires a rapid, multidisciplinary team approach which will result in the saving of the patient's life. We present the outcome of a male patient with traumatic hemipelvectomy.

The treatment of external genitalia trauma is diverse according to the nature of trauma and injured anatomic site. The classification of trauma is important to establish a strategy of treatment; however, to date there has been less effort to make a classification for trauma of external genitalia. The classification of external trauma in male could be established by the nature of injury mechanism or anatomic site: accidental versus self-mutilation injury and penis versus penis plus scrotum or perineum. Accidental injury covers large portion of external genitalia trauma because of high prevalence and severity of this disease. The aim of this study is to summarize the mechanism and treatment of the traumatic injury of penis. This study is the first review describing the issue.

Composite grafting, grafting without microvascular anastomoses, has been widely performed for distal fingertip amputation in children with variable results, whereas successful replantation of these amputations using microsurgical technique has been reported. However, most of these reports included a wide age-range and a mix of different amputation levels. This study reviewed our cases of paediatric digital amputation, in order to verify the value of distal fingertip replantation over composite grafting, especially in early childhood. Seventeen young children (aged 3 years and 8 months on average), with single-digit fingertip amputations in Tamai zone I were reviewed from 1993-2008. Each amputation was subdivided into three types: distal, middle, and proximal. There were three distal, 13 middle, and one proximal type zone I amputations. All were crush or avulsion injuries. All three distal-type cases were reattached as primary composite grafts with one success. For middle-type cases, the survival rate of primary composite graft without exploration for possible vessels for anastomosis was 57%. On exploration, suitable vessels for anastomosis were found 50% of the time, in which all replantations were succeeded. The remaining cases were reattached as secondary composite grafts, with one success using the pocket method. Consequently, the success rate after exploration was 67%. The only one proximal-type amputation was failed in replantation. For the middle-type zone I amputation in early childhood, replantation has a high success rate if suitable vessels can be found. Therefore, exploration is recommended for amputations at this level with a view to replantation, irrespective of the mechanism of injury.

Diabetic peripheral neuropathy (DPN) is a common cause of many lower-extremity complications. This case study illustrates the potential perils of pet ownership associated with diabetes and neuropathy. The case describes an incident resulting in traumatic digital amputations inflicted by a patient's pet feline while she was sleeping. In presenting this case, the potential risks of pet ownership for patients with DPN are discussed along with a review of the relevant literature.

External genital trauma is uncommon. However when it occurs, it can cause long-term physical, psychological, and functional quality-of-life sequelae. Rapid and proper treatment can help preserve cosmesis and function. Therefore, the treating physician must have a high index of suspicion when evaluating genital injuries. This article reviews the proper initial assessment of the injury as well as the immediate and delayed operative management of genital trauma., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: This article aims to present a technique for thumb tip amputations using a homodigital soft-tissue/periosteum flap and a portion of the amputated digit., Methods: Eight patients (aged 21-53 years) with avulsion thumb tip amputations were reviewed. We report a new technique in which a bone and nailbed composite graft was taken from the amputated portion of the thumb and a dorsoulnar flap combined with periosteum was harvested from the first metacarpal and designed to cover the volar bone. Patients were evaluated 6 months after surgery for functional and cosmetic outcomes., Results: The radiographic evaluation showed bone healing in all of the patients 5 weeks postoperatively. With regard to pulp reconstruction, there was good recovery of static two-point discrimination. For both the reconstructed area and the donor site, the final results were good in terms of reliability and coverage as well as from a cosmetic perspective., Conclusions: This technique was found to be safe and effective. It is a good option for the non-microsurgical reconstruction of crushed and avulsed amputations of the distal thumb., (Crown Copyright © 2013. Published by Elsevier Ltd. All rights reserved.)

Incidence of penile carcinoma is decreasing worldwide. Nevertheless, the incidence of penile cancer is still significant in various tropical countries, and it often presents in advanced stage. We report two unique cases of penile auto-amputation due to advanced cancer and review relevant literature. Both the patients presented with ulcerative lesion replacing penile base following automatic sloughing of the whole penis and voiding dysfunction. In addition, the first patient had metastatic inguinal lymph nodes. Supra-pubic urinary diversion was the initial management in both the patients. The first patient was treated with combined chemo-radiation, but he succumbed to death following two cycles of chemotherapy. The second patient was successfully treated with total penectomy and perineal urethrostomy. He recovered well but was lost to follow-up.

Cardiac complications of chest trauma range from arrhythmias and valvular avulsions to myocardial contusion, rupture, and--rarely--myocardial infarction. Herein, we described a 44-year-old male patient who presented to the hospital after receiving a blow from a fist directly to the chest and fingertip amputation during a fight; anterior myocardial infarction without any chest pain was coincidentally detected. Our case illustrates the importance of electrocardiography in the initial evaluation of patients with chest trauma and suspected injury to the coronary arteries.

We report a successful thumb replantation by resecting the remnants of the crushed proximal phalanx and uniting the distal phalanx with the thumb metacarpal. The procedure resulted in extreme shortening, which we managed by distraction lengthening and deepening of the first webspace., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

A persistent median artery is a well-described variation in the vascular anatomy of the upper extremity and hand, with an incidence of 1% to 30% in the general population. We present a case of a persistent median artery in a pediatric trauma patient. The median artery helped maintain blood flow to the nearly amputated hand after complete transection of radial and ulnar arteries., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Recent studies presenting functional outcomes after replantation of finger avulsion injuries have challenged the historical practice of performing revision amputation for all complete finger avulsion injuries. The aim of this study is to conduct a systematic review of the English literature of replantation of finger avulsion injuries to provide best evidence of survival rates and functional outcomes., Methods: A Medline literature search yielded 1,398 studies, using key words "traumatic amputation" or "replantation", with limitation to humans and finger injuries. Inclusion criteria required that studies meet the following requirements: (1) primary data are presented; (2) the study includes at least 5 cases with either complete or incomplete finger avulsion injuries at or distal to the metacarpophalangeal joint; (3) the study presents survival rates, total active arc of motion (TAM), or static 2-point discrimination (2PD) data; (4) data for incomplete and complete avulsions are reported separately; (5) patients are treated with microvascular revascularization or replantation. Survival rates, TAM, and 2PD data were recorded and a weighted mean of each was calculated., Results: Thirty-two studies met the inclusion criteria. Of these 32 studies, all reported survival outcomes, 13 studies reported TAM (metacarpophalangeal, proximal interphalangeal, and distal interphalangeal), and 9 studies reported sensibility. The mean survival rate for complete finger and thumb avulsions having replantation was 66% (n = 442). The mean TAM of complete finger avulsions after successful replantation was 174° (n = 75), with a large number of patients in the included studies having arthrodesis of the distal interphalangeal joint. The mean 2PD in patients after replantation was 10 mm (n = 32)., Conclusions: We found that functional outcomes of sensibility and range of motion after replantation of finger avulsion injuries are better than what is historically cited in the literature. The results of this systematic review challenge the practice of performing routine revision amputation of all complete finger avulsion injuries., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The purpose of the study was to describe the outcome after hand injury from powered wood splitters, and to investigate the relation between injury severity and outcome. Injury severity was rated according to the Hand Injury Severity Scoring System (HISS system) and the Injury Severity Score method. The patients were evaluated with the Disabilities of the Arm Shoulder and Hand outcome questionnaire (DASH), and 26 of the most severely injured patients were evaluated with the Sollerman test. The mean DASH score was moderately elevated at 15, indicating that many of these patients have sequelae. A statistically significant correlation between HISS and DASH scores was found, implying that initial injury severity is of importance for outcome. The mean Sollerman score in the injured hand was 66, which amounts to a significantly impaired hand function.

Trauma is the most common reason for amputation of the upper extremity. The morphologic and functional distinctions between the upper and lower extremities render the surgical techniques and decision-making different in many key respects. Acceptance of the prosthesis and the outcomes are improved by performing a transradial rather than a more proximal amputation. Substantial efforts, including free tissue transfers when necessary, should be made to salvage the elbow. Careful management of the peripheral nerves is critical to minimize painful neuroma formation while preserving options for possible future utilization in targeted muscle reinnervation and use of a myoelectric prosthesis. Rapid developments with targeted muscle reinnervation, myoelectric prostheses, and composite tissue allotransplantation may dramatically alter surgical treatment algorithms in the near future for patients with severe upper-extremity trauma.

Above-knee amputations are rare injuries that need emergent replantation or primary amputation. Although survival could be achieved in selective cases, postoperative function of the affected limb is usually unsatisfactory and a late amputation has to be performed for poor prognosis or severe complications. Experience of the surgical team may play an important role in primary decision making, which leads us to report one case of above-knee replantation with poor postoperative function and needing a late amputation. Scoring systems, expected results based on our case, and a brief review of literature concerning above-knee replantations are discussed., (© Thieme Medical Publishers.)

Traumatic hemipelvectomy through the sacroiliac joint is a devastating injury, mainly because of motor vehicle accidents. Recent improvements in prehospital trauma care have increased the chances of survival for victims. Besides amputation of the lower limb, associated complications usually involve digestive and urological systems. We report on 2 pediatric patients from 2 different European countries. PATIENT 1: A 9-year-old boy suffered uprooting of his left lower limb, laceration of the rectum and anal sphincter, as well as an injury to distal urethra with partial loss of cavernous bodies. Initial management included a colostomy and an essay of contention by means of a polypropylene prosthesis that had to be removed in the following months. After several attempts at urethral reconstruction, he underwent a Mitrofanoff derivation. PATIENT 2: An 18-month-old girl lost her left lower limb and suffered severe lacerations of bladder and rectum. Among other measures, management included a colostomy, a skin graft, and 2 attempts at reconstruction of her bladder neck, including a modified Casale procedure (cecum and ileocecal appendix were in a high position that made a Mitrofanoff derivation impossible) and a Malone procedure. To the authors' knowledge, she would be the youngest reported survivor of this kind of injury., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Abstract Fifteen patients (aged 21-45 years) with avulsion injuries to a fingertip were reviewed. We report a new technique, in which the subcutaneous pulp flap is combined with the cap technique of the nail complex, for avulsed fingertips in adults. The bone of the avulsed part is excised and the fat removed. The nail complex is preserved, and the subcutaneous pulp flap used to improve the take at the cap-nail complex. This technique is simple, safe, and cost and time effective. It is a good option for repair of an avulsed fingertip.

The nose is a critical aesthetic subunit of the face, but because of the difficulties in anastomosis of the small-sized arteries and veins, several cases of nasal replantation have been reported. Using supermicrosurgical techniques, we successfully replanted a patient's nasal segment which had been amputated by a falling sharp metal pipe. The result was excellent both aesthetically and functionally, and the patient was very satisfied. The nose is located at the centre of face and is thus important aesthetically. The nose also has functions in olfaction, respiration, humidification, filtration, temperature regulation and phonation. However, the nose protrudes from the face and is readily injured by trauma, and in injured cases, reconstruction of the nose is essential. Recently, with the development of microsurgery, microsurgical replantation of the amputated nose has been reported.(1-11) We performed successful replantation of the nasal alar and tip that were completely amputated and smaller in size than previous reports, using a supermicrosurgical technique., (Copyright 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: Penile trauma is common with standard management options. Gender reassignment techniques are rapidly changing and penile augmentation remains a controversial topic. Consequently, there is need for a state-of-the-art information in this area., Aim: This study aims to develop an evidence-based state-of-the-art consensus report on the management of penile trauma, gender, reassignment and penile augmentation., Methods: The study provides state-of-the-art knowledge regarding the prevalence, etiology, medical and surgical management of penile trauma, gender reassignment and penile augmentation, representing the opinion of leading experts developed in a consensus process over a 2-year period., Main Outcome Measures: Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate., Conclusions: Penile fracture should be managed surgically. Information should be readily available to patients to help them decide the surgical technique desired for gender reassignment and to justify any form of penile augmentation.

Twenty-four cases of ectopic single-finger transplantation are reported using our new "piggyback" technique for finger transfer that simplifies, with a high success rate, the hazardous second-stage transfer. Twenty-four patients (mean age, 20 years) were treated for severely crushed proximal stumps with a replantable distal part (zones 1 and 2a). In this method, after a successful ectopic transplantation, the transplanted part is transferred to the original site not as a free tissue transfer but as a pedicle flap in which the transplanted finger is piggybacked to the groin flap and then the composite tissue (groin and finger) is transferred to the stump. After a waiting period of 3 to 4 weeks, the flap is severed sequentially or in 1 setting. Graft take, complications, sensitivity, patient satisfaction, and demographic data of the patients were evaluated.Graft take was 75% in the first stage and 100% in the second stage. There were no cases of infection, and minor complications such as edema subsided with time. Distal finger amputations have the best indication for replantation. A Pearson Educational Measurement score was obtained from the patients who participated in 6-month and 1-year follow-ups, and at the end of 1 year, 85% of the patients scored above 45 points. Eighty-seven percent of the patients were satisfied with their results and stated they would choose this procedure again if indicated and also would recommend it to other patients.The piggyback method of transfer of the ectopic single-finger transplantation has simplified the arduous and risky second-stage transfer to a low-risk and highly successful operation. The advantages include a less bulky tissue transfer, no severed major artery, and 2 short surgical procedures replacing 1 lengthy, potentially risky free vascularized procedure. The only drawback of this technique is the 3-week waiting period for the pedicle flap, wherein the hand is attached to the groin. The reconstruction of the nerve, artery, and tendon and, sometimes, when it is not possible to accomplish proper bone fixation at the second stage, can be achieved with ease after severing the pedicle.

Objective: To report an extremely rare case of an autoamputated ovary with a dermoid cyst diagnosed during a Cesarean section and review the literature., Design: Case report., Setting: Tertiary hospital., Patient(s): A 33-year-old pregnant woman submitted to Cesarean section and was incidentally diagnosed with absence of the right ovary, implanted in the cul-de-sac., Intervention(s): Cesarean section and extraction of a pedunculated tumor formation from the cul-de-sac, adhesiolysis., Main Outcome Measure(s): Histologic analysis of the extracted morphoma confirmed the diagnosis of a dermoid cyst with coexistence of residual ovarian tissue., Results: The patient had an uneventful postpartum period and was discharged home., Conclusion(s): Ovarian autoamputation is an extremely rare phenomenon that has uncertain etiology; it may develop after ovarian torsion or torsion of a dermoid cyst. It may be asymptomatic. Usual site of implantation is the greater omentum.

Background: To define the epidemiological pattern of nerve injuries and traumatic amputations in Sweden, 1998-2006, and investigate possible targets for emerging neural engineering and neuroprosthetic technologies., Methods: The Swedish Hospital Discharge Register was used as the information base, including data from all public inpatient care, excluding outpatient data. ICD-10 codes were used to classify nerve injuries and traumatic amputations of high incidence levels or inpatient care time. Selected codes, causative factors, age and gender distribution were discussed in detail, and potential targets for tailored solutions were identified., Results: Incidence rate was determined as 13.9 for nerve injuries and 5.21 for amputations per 100,000 person-years. The majority of injuries occurred at the wrist and hand levels, although it could be concluded that these are often minor injuries requiring less than a week of hospitalization. The single most care-consuming nerve injury was brachial plexus injury, constituting on average 68 injuries and 960 hospital days annually. When minor amputations of fingers and toes were disregarded, the most frequent site of amputation was between the knee and ankle (24 patients/year)., Conclusions: Based on an analysis of incidence and care time, we find that brachial plexus injuries and lower leg amputations should be the primary targets of new technologies., (2009 S. Karger AG, Basel.)