Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 748e754

Replantation of fingers and hands after

avulsion and crush injuries
M. Molski*

Department of Plastic Surgery, Medical Center for Postgraduate Education, 231 Czerniakowska Str.,
00-416 Warsaw, Poland

Received 1 November 2006; accepted 7 March 2007

KEYWORDS Summary Introduction: Avulsion and crush injuries constitute a particularly difficult prob-
Crash-avulsion injuries; lem due to extensive damage of vessels and nerves. In cases where a crush is the dominating
Hand and fingers injury factor causing complex fractures of forearm and carpal bones, shortening of the extrem-
replantations; ity is necessary for primary vessel and nerve reconstruction. Surgical experience in vessels dis-
Vein grafts; section and optimal sequence of reconstruction procedures using vessels and nerve grafts are
Ring avulsion injury of paramount importance.
Material and methods: In the years 1986e2006 the author carried out 18 replantations and 4 re-
vascularizations at various levels of distal upper limb after crush-avulsion trauma. There were 8
thumb, 7 long fingers and 7 hand amputations. Hand replantations were carried out in 5 males
aged 18e45 (mean age 33). Thumb replantations were carried out in 2 females and 5 males. There
were 4 complete amputations of a long finger (three teenagers and 32-year-old male). A vein
grafting from the forearm was the basic method used in arterial reconstructions (3 hands, 5
thumbs and 6 long fingers). Grafts of the deep radial vein were used in 2 cases (one in hand
and one in the thumb). Change in the standard sequence of the replantation procedure (i.e. re-
construction of the artery on the ulnar side of the thumb before bone stabilisation) appeared very
helpful on thumb. Rerouting veins, venous flaps or skin flaps from the dorsal surface of the index
finger were very useful in reconstruction of the blood outflow. Secondary reconstruction of
nerves were carried out in 8 patients (40%) and 5 patients are still waiting for the surgery.
Results: Sixteen out of 18 replants (88.9%) and all 4 revascularized parts survived. Overall success
rate was 90.9%.
Conclusions: Grafting technique in reconstruction of arteries and veins during the primary ves-
sels repair is a very good method and we advocate that it should be widely used. Due to extent
of trauma, majority of the patients required secondary procedures e mainly reconstruction of
nerves with nerve grafts.
2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

* Tel.: 48 22 6226054.
E-mail address: marekmolski@hotmail.com

1748-6815/$ - see front matter 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2007.03.009
Replantation of fingers and hands after avulsion and crush injuries 749

Crushing, pulling and rotating forces are responsible for the

most severe injuries to an amputated parts and are often
contraindications for replantation. Under these circum-
stances, the extent of tissue damage is difficult to assess,
particularly in vessels and nerves.1e3 Nerve fibres may be
damaged at various levels and stretched vessel walls mani-
fest as a ribbon sign.4 Both may be found in several loca-
tions and at various distances from the actual severing point.
The aim of the study is to present the authors
experience in primary treatment of patients with avulsion
and crush injuries of fingers and hand. Suggestions for
management are given. A high survival rate of replanted
tissues and good functional results were achieved despite
of the severity of trauma.
Material and methods
In the 20-year period (1986e2006) the author operated on
22 patients (16 males, 6 females) aged 13e45 (mean age 29
years) for crush-avulsion injuries of:
- hand e 7 cases (6 males, 1 female; mean age 36 years),
- thumb e 8 cases (6 males, 2 females; mean age 27 years),
- fingers e 7 cases (4 males, 3 females; mean age 24).
There were 14 complete (63.6%) and 8 incomplete
(36.4%) amputations (Table 1).
In three cases the amputated parts were attached to the
proximal parts of thumb and finger by the flexor pollicis
longus (FPL) or the flexor digitorum profundus (FDP)
tendons, only. Avulsion by high-speed rotating devices
was the most frequent cause of hand and thumb amputa-
tions (11 cases). Ring avulsion injury was the only aetiology
in the finger amputations.
Radical debridement of devitalised crushed tissues was
paramount. In three amputations at the level of forearm,
with dominating crush mechanism, bone was shortened
Table 1 Number of complete and incomplete crush-avulsion
amputations of hand, thumb and fingers
Amputation Complete Incomplete
Hand 3 4
Thumb 7 1
Fingers 4 3
Total 14 8
adequately (3e7 cm), facilitating primary neurorraphy of
the median nerve and primary arterial repair. In all remain-
ing patients after hand amputation, arterial reconstruc-
tions were performed with vein grafts.
In three patients after thumb amputation, transposition
of the radial digital artery of index finger (RAI) was
performed in arterial reconstruction (i.e. anastomosed
with distal stump of ulnar digital artery). In five remaining
cases venous grafts were used (i.e. subcutaneous veins
from anterior aspect of distal part of forearm e 4 cases,
radial artery comitans vein e 1 case).
Venous grafts in arterial reconstruction were used in all
except one patient after ring avulsion injury (two arteries
in one case). In venous repair a single vein graft was used in
three patients, two vein grafts in two patients and single
arterial graft in one patient (Fig. 1A). In one teenager two
veins on the dorsal aspect of finger were reconstructed with
H-shape venous graft (Fig. 1B).
Results
Amputated parts survived in 20 out of 22 operated patients
(90,9%). Two failures (one thumb and one finger) were due
to impaired arterial blood supply and took place on the first
post-replantation day.

Figure 1 Grafts in different tissues reconstructions. A. Small part of multilevel damaged and excised digital artery used as
arterial graft in dorsal digital vein reconstruction (see yellow arrows). B. H-shaped subcutaneous vein graft from distal forearm
used to two dorsal digital veins by-pass (see yellow arrows). C. Harvesting split-thickness sural nerve graft to more precised
secondary digital nerve reconstruction. D. Secondary lateral bands reconstruction with PL tendon graft.
750 M. Molski

Figure 2 Case 1: A. A crush-avulsion amputation of right hand with limited crash area. Gradually narrowing ends of both nerves
indicate extensive damage (see yellow arrows). B. Status after forearm exposure, arterial (see yellow arrow) and venous
Replantation of fingers and hands after avulsion and crush injuries 751

Figure 3 Case 2: A. A crush-avulsion amputation of left thumb with drilling machine with significant contusion and degloving of
soft tissues on dorsal surface of the hand. B. Avulsed proper palmar digital artery of ulnar side of thumb presents ribbon sign. The
artery was unsuitable for anastomosis. C. State after thumb replantation; princeps pollicis artery was reconstructed with 45 mm
reversed graft of radial artery comitans vein. Bone stabilisation followed arterial reconstruction. Venous outflow was restored
anastomosing one of the veins on dorsal surface of the thumb with one of superficial veins rotated with adipo-cutaneous flap
from the dorsal surface of the index finger. Donor site was covered with split-thickness skin graft. Tendon of FPL was reinserted
into muscle belly. D., E. Secondary reconstruction of proper palmar digital nerves of thumb with sural nerve grafts. Large defect
of nerves resulting from avulsion injury (see blue arrows). F., G. Functional result 11 years after the replantation. Range of move-
ment in IP joint, confirming function of reinserted FPL tendon. H. Full opposition of replanted thumb.

In the patient that suffered total hand amputation at the
level of wrist after primary reconstructions of two forearm
arteries (i.e. radial and ulnar) and two superficial veins with
vein grafts, and cephalic vein anastomosis, signs of venous
insufficiency were observed on the 5th post-replantation
day. This complication was caused by thrombosis within
venous anastomosis which was successfully solved using two
new venous grafts for reconstruction of two superficial
veins (Fig. 2C)
Secondary surgical procedures significantly improved the
function of the replanted hands, thumbs and fingers. Nerve
reconstruction with sural nerve grafts (either full thickness
or split) (Fig. 1C), restored superficial and deep sensation
with good and very good result. Primary tendon reinsertions
reduced the number of secondary procedures. In cases of
ring avulsion injury, after reinsertion of FDP tendon, pri-
mary reconstruction of lateral bands seemed to be less
effective. Secondary reconstruction with palmaris longus
(PL) tendon graft gave a good final result (Fig. 1D). Transpo-
sition of extensor indicis proprius (EIP) tendon on extensor
pollicis longus (EPL) was performed in limited number of
cases. It was indicated only when restoration of thumb in-
terphalangeal (IP) joint function was feasible and was pre-
ceded by primary reinsertion of FPL tendon to the muscle or
to the distal phalanx.
Patient reports
Patient 1
A 24-year-old man, operating a paper press machine, had
a complete crush-avulsion amputation of right hand at the
level of radio-carpal joint (Fig. 2A). Replantation was

reconstructions with venous grafts and reinsertion of tendons. C. Revision of veins was performed on the 5th post-operation day and
new vein grafts were performed (see yellow arrows). Wound was closed with split-thickness skin grafts covering reconstructed
veins. D, E, F, G. Results 3 years after the replantation. Median and ulnar nerves were secondary reconstructed with sural nerve
grafts (defect 9 and 11 cm, respectively). Replanted hand performs basic functions and even more precise movements.
752
performed 8 h after the accident. Radial and ulnar arteries
and basilic vein were reconstructed with superficial vein
grafts. The cephalic vein was anastomosed. Flexor and ex-
tensor tendons were reinserted to appropriate muscles
(Fig. 2B). Wounds were covered with split-thickness skin
graft. Gradual venous insufficiency was observed on the
5th post-replantation day. Thrombosis within the anasto-
mosis of the cephalic vein was observed. Thrombectomy
and reanastomosis were performed. Additionally, two veins
on dorsal aspect of the hand were reconstructed with two
new vein grafts (Fig. 2C). The wound and vein grafts were
skin grafted. Postoperative period was uneventful. Both
median and ulnar nerves were secondarly reconstructed
with sural nerve grafts. Physical therapy followed all sur-
geries. The Patient developed protective sensation on
palm and in all fingers 3 years after the accident. He uses
the replanted hand in basic every day activities (i.e. driving
a car, door opening) (Fig. 2E) and some more precise activ-
ities (Fig. 2F,G). Hand grip strength is 25 kg.
Patient 2
A 22-year-old man was admitted several hours after
a complete crush-avulsion amputation of left thumb with
degloving of the dorsal aspect of the hand caused by
a drilling machine. The FPL tendon was avulsed from the
muscle (Fig. 3A). Vessels were not suitable for primary su-
turing due to extensive damage (Fig. 3B). After debride-
ment, FPL muscle was exposed from an incision
performed on anterior surface of middle and distal fore-
arm. The FPL tendon was traced retrograde and reinserted
passing through the carpal tunnel using polyethylene
leader. Additionally, the incision allowed for 10-cm-long
exposure of radial vessels. Due to comparable diameters
of deep veins and the princeps pollicis artery, 45 mm
fragment from one comitans vein was used as a graft in
an arterial reconstruction without any technical problems.
After arterial repair was completed, stabilisation of IP joint
was performed with a K-wire. Thereafter, venous outflow
was restored by one vein included in dorsal flap from the
index finger. Flap donor site was covered with split-
thickness skin graft (Fig. 3C). Nerves were reconstructed
with sural nerve grafts in secondary procedures
(Fig. 3D,E). Eleven years after replantation active flexion
in IP joint was 40 (Fig. 3F,G), and full thumb opposition
was present (Fig. 3H). Two point discrimination (2PD) on
finger pulp was 8e10 mm.
Summarising of operative techniques
Management of crush-avulsion amputations is a real chal-
lenge, where proper planning and reconstruction tactics
are crucial. Our method for dealing with this severe form of
injuries can be summarised as follows:
1. Radical debridement.
In cases with a dominanting crush factor of the injury
resection of devitalised tissues (i.e. bone, muscle and skin)
was mandatory. When significant bone damage was pres-
ent, the upper extremity was shortened. This manoeuvre
allowed for primary vessels and nerves suturing as well as
reinsertion of the tendons to muscle bellies. When avulsion
M. Molski
was a dominating component of injury, debridment was less
extensive due to lesser tissue damage.
2. Bone stabilisation and management of musculoskele-
tal avulsion.
Bone stabilisation with K-wires was sufficient in all crush
and avulsion amputations. In some injuries with joint
disruption reconstruction of joint elements was required.
Debrided tendons were reinserted into appropriate muscle
bellies. Primary tendon transfers were also considered in
cases of extensive muscle damage.
3. Assessment of the vessels.
Parts of arteries presenting ribbon signs were removed.
The vessels were assessed under the microscope and any
damage to the intima necessitated its resection. Small
heamatomas around the arterial wall indicated side branches
avulsion. These lesions were found and sutured or arterial
excision was extended. Subcutaneous haematomas on dorsal
surface of digits suggested the site of vein disruption. Dorsal
venous arcades were identified and used in reconstruction.
4. Arterial reconstruction.
Primary arterial suturing was possible only after bone
shortening. Among other methods (i.e. rerouting arteries
from neighbouring fingers, comitans vein grafts, etc.),
superficial vein grafts from distal part of ipsilateral forearm
were most frequently used. Comitans veins of the radial
artery were harvested as a vein graft in thumb avulsion
amputation or crash hand amputation. One artery on ulnar
side of the thumb, one or two digital arteries on fingers,
and both ulnar and radial arteries on hand were
reconstructed.
5. Venous reconstruction.
Primary end-to-end vein anastomosis was possible with-
out bone shortening in some cases of hand avulsion and ring
avulsion injury amputations. Transferring peripherally one
end of a venous arcade located close to the wound was
a good solution in digital vein defects less than 2 cm. Short
undamaged part of multilevel injured digital artery was
used for this purpose too. Thumb amputations caused by ro-
tating device always required venous transposition from
dorsal surface of index (i.e. vein, venous flap or vast soft
tissue flap). On fingers distal forearm veins were utilised
as single grafts or H-shape graft, enabling simultaneous
two veins reconstruction.
6. Nerve reconstruction.
Similar to arteries, primary nerve repair was possible
after bone shortening. Thumb avulsions provided good
examples of the extent of injury when digital nerves were
pulled out from the median nerve trunk. On the contrary,
damage of digital nerves was less extensive and more
peripheral in ring avulsion injuries. In these cases good
spontaneous reinervation was observed without any nerve
repair in young individuals. Secondary nerve reconstruc-
tions using sural nerve grafts or split sural nerve grafts were
the best solutions.
7. Coverage.
Split thickness skin grafts (from thigh or forearm) were
widely used for the wound closure. They covered dorsal
aspect of hand, thumb or fingers with venous anastomoses
as well as venous grafts utilised in vein reconstructions.
Donor site of transferred flaps from the index finger was
grafted with full thickness groin skin.
8. Postoperative regimen.
Replantation of fingers and hands after avulsion and crush injuries
Hands were splinted in plaster of Paris and kept elevated.
Gentle passive movements were started from first post-
operative day. Wounds were inspected on a daily bases. Skin
grafts that elevated by a haematoma formation were
replaced with new one. Patients were put on a low molec-
ular weight dextran (500 ml per day) for a week and oral as-
pirin 150 mg per day for a month. Prophylactic wide
spectrum antibiotics were administered for a 5e7 days.
9. Secondary procedures.
Nineteen out of 20 patients had an indications that
required secondary operations (95%). They were performed
in 14 patients (70%). Five patients are still waiting for
reconstruction of palmar digital nerves. Nerve reconstruc-
tions with sural nerve grafts were done in 8 patients (40%) e
6 on thumb. In a teenager after reconstruction of more
damaged proper palmar digital artery, two split-thickness
sural nerve grafts were placed on radial side, the opposite
side of finger in relation to previously reconstructed artery.
Other operations included tendon transposition or PL
tendon graft and local plasty after scar excision. In one
patient new superficial vein graft replaced vein graft
aneurysm on reconstructed ulnar artery.
Discussion
In both, replantations and secondary corrections, the
authors aim was to eliminate unfavourable consequences
of reconstruction. Performed in three initial ceses trans-
position of RAI to ulnar artery of the thumb, was aban-
doned due to common anatomical variations of this vessel.
The method was replaced by vein grafting.5,6 Single thumb
replantation failure occurred due to extension of thrombus
from avulsed princeps pollicis artery to proximal part of
RAI. The rerouting vessels from neighbouring long finger
in ring avulsion injuries, advocated by some authors,7
seems to be devastating for undamaged finger and can pro-
voke cold intolerance. Harvesting of subcutaneous vein
graft from distal part of forearm is very simple and less
time consuming method.8 Even some technical problems
with distal venous graft-arterial anastomosis can be solved
by trained microsurgeon without placing a second smaller
vein graft as a conduit.8 Late survival rates of replanted
digits using transferred artery or vein grafting are compa-
rable.7,8 Twenty-six venous grafts and one arterial graft
were used in 16 patients (from 1 to 5 grafts in each
case). In two cases radial artery comitans vein grafts
were used.9 In literature of seventies one can find only spo-
radic suggestions for vein grafting.10e12 In the middle of
eighties only few authors were in favour of this method
in thumb replantations after crush-avulsion amputa-
tion.13e15 Currently, the role of vein grafting in reconstruc-
tions after crush-avulsion amputations is indisputable.16e18
Although, statistically verified data, clearly proving better
results of replantations using vein grafts, are still wanting,
only some authors suggest such an outcome in their obser-
vations.17 Fouchers method was mainly used in ring avul-
sion injuries.19 In one case both proper palmar digital
arteries were reconstructed with vein grafts. Change in or-
der of replantation stages (i.e. arterial reconstruction pre-
ceding bone stabilisation), according to Shafiroff and
Palmer, appeared to be very effective in thumb and very
753
distal digit replantations.20 When vein grafts were used in
arterial reconstruction their patency was checked, before
other structures were anastomosed. This approach allowed
for fast and easy correction of twisted or bent vein grafts.
On the contrary, when bone stabilisation and tendon sutur-
ing precede arterial anastomosis, access to artery ends was
very difficult in some cases. It was a reason of one long
digit replantation failure in presented group of patients.
Vein rerouting as well as various flaps including dorsal in-
dex venous flap were widely used as a simple and effective
method of creating blood outflow and soft tissue recon-
struction on thumb.21 The role of split-thickness skin grafts
in tension free wound closure is unquestionable. The distal
part of forearm is acceptable for the patients as a donor
area of thin skin graft when it was used to close small
wounds after finger and thumb replantations. Groin full-
thickness skin graft or thigh split-thickness skin graft
remains methods of choice in coverage of larger wounds.
It is recommended to harvest larger than needed skin
grafts. The excess tissue can be utilised as a biological
dressing in case of haematoma or seroma formation. Nerve
grafts were dominating in secondary operations. In cases
where proper palmar digital nerves had small number of
fascicles, split-thickness sural nerve grafts were used and
2 PD of 6e8 mm was achieved. The area of impaired super-
ficial sensation on lateral side of the foot was less exten-
sive than after full thickness sural nerve harvesting.
Achieved 90.9% survival rate of replanted parts after
crush-avulsion amputations confirms the effectiveness of
applied microsurgical techniques. Vein, nerve and tendon
grafts enable restoration of good functional results even
in cases of complete crash-avulsion amputations of fingers
which were disqualified from replantation not so long
ago.22 Application of presented methods by single micro-
surgeon may bring similar results of reconstructive treat-
ment, comparable with results achieved in worlds
leading centres by microsurgical teams.23,24
Conclusions
Widespread use of vein grafts in patients after crush-
avulsion amputations of hand, thumb or fingers may result
in high rate of replantation success with physiological
length of extremity being preserved. In cases of extensive
forearm or wrist bone damage (resulting from prevalence of
crush factor), the primary vessel, nerve and tendon
anastomoses are feasible after shortening of the extremity.
In both situations, secondary operations improving func-
tional effect should be performed. Various tactical solu-
tions, proper use of technical methods described herein
and rationalisations significantly facilitate primary vessel
repair, shorten operation time and improve final functional
results. The microsurgeons experience in selection of
optimal method of reconstruction is crucial for success of
replantation and final functional result of treatment.
Acknowledgements
This study was supported by grant nr 501-1-1-05-29/06 from
Medical Center for Postgraduate Education, Warsaw,
Poland.
754 M. Molski

References 10 years experience. Scand J Plast Reconstr Surg 1984;18(2):

163e73.
14. Vlastou C, Earle AS. Avulsion injuries of the thumb. J Hand Surg
1. Shang J, Zhang XY, Bi ZG. Experimental study on the extent of
[Am] 1986;11(1):51e6.
injured blood vessels in an avulsion amputation model. Zhong-
15. van der Horst CM, Hovius SE, van der Meulen JC. Results of
guo Xiu Fu Chong Jian Wai Ke Za Zhi 2000;14(3):135e8.
treatment of 48 ring avulsion injuries. Ann Plast Surg 1989;
2. Glover MG, Seaber AV, Urbaniak JR. Arterial intimal damage in
22(1):9e13.
avulsion and crush injuries in rat limbs. J Reconstr Microsurg
16. Chuang DC, Lai JB, Cheng SL, et al. Traction avulsion amputa-
1985;1(4):247e51.
tion of the major upper limb: a proposed new classification,
3. Kupfer DM, Eaton C, Swanson S, et al. Ring avulsion injuries:
guidelines for acute management, and strategies for secondary
a biomechanical study. J Hand Surg [Am] 1999;24(6):1249e53.
reconstruction. Plast Reconstr Surg 2001;108(6):1624e38.
4. Van Beek AL, Kutz JE, Zook EG. Importance of the ribbon sign,
17. Sharma S, Lin S, Panozzo A, et al. Thumb replantation: a retro-
indicating unsuitability of the vessel, in replanting a finger.
spective review of 103 cases. Ann Plast Surg 2005;55(4):352e6.
Plast Reconstr Surg 1978;61(1):32e5.
18. Ozkan O, Ozgentas HE, Safak T, et al. Unique superiority of mi-
5. Doi K. Replantation of an avulsed thumb, with application of
crosurgical repair technique with its functional and aesthetic
a neurovascular pedicle. Hand 1976;8(3):258e60.
outcomes in ring avulsion injuries. J Plast Reconstr Aesthet
6. Pho RW, Chacha PB, Yeo KQ. Rerouting vessels and nerves from
Surg 2006;59(5):451e9.
other digits in replanting an avulsed and degloved thumb. Plast
19. Foucher G, Citron N, Merle M, et al. Revascularization of digital
Reconstr Surg 1979;64(3):330e5.
avulsion injuries caused by rings. Ann Chir Main 1986;5(3):
7. Al Qattan MM, Boyd JB. Use of a vena comitans as a vein graft
256e9.
in digital replantation. Microsurgery 1994;15(2):149.
20. Shafiroff BB, Palmer AK. A simplified technique for replanta-
8. Adani R, Marcoccio I, Castagnetti C, et al. Long-term results of
tion of the thumb. J.Hand Surg 1982;7(5):623e4.
replantation for complete ring avulsion amputations. Ann Plast
21. Honda T, Nomura S, Yamauchi S, et al. The possible applica-
Surg 2003;51(6):564e8.
tions of a composite skin and subcutaneous vein graft in the re-
9. Akyurek M, Safak T, Kecik A. Ring avulsion replantation by ex-
plantation of amputated digits. Br J Plast Surg 1984;37(4):
tended debridment of the avulsed digital artery and interposi-
607e12.
tion with long venous grafts. Ann Plast Surg 2002;48(6):574e81.
22. Urbaniak JR, Evans JP, Bright DS. Microvascular management of
10. Biemer E. Vein grafts in microvascular surgery. Br J Plast Surg
ring avulsion injuries. J Hand Surg [Am] 1981;6(1):25e30.
1977;30(3):197e9.
23. Sanmartin M, Fernandes F, Lajoie AS, et al. Analysis of prognos-
11. Alpert BS, Buncke HJ, Brownstein M. Replacement of damaged
tic factors in ring avulsion injuries. J Hand Surg [Am] 2004;
arteries and veins with vein grafts when replanting crushed,
29(6):1028e37.
amputated fingers. Plast Reconstr Surg 1978;61(1):17e22.
24. Brooks D, Buntic R, Kind K, et al. The futility of the post micro-
12. Gould JS, Gould SH, Caudill-Babkes EL. Interpositional micro-
surgical classification systems in managing ring avulsion in-
vascular vein grafting. Hand 1979;11(3):332e6.
juries. In: Germann G, editor. Reconstructive Microsurgery.
13. Hamilton RB, OBrien BM, Morrison A, et al. Survival factors in
Bologna, Italy: Monduzzi Editore; 2003. p. 143e7.
replantation and revascularization of the amputated thumb e