toka machine injury: replantation left arm in a 5 year old
TRANSCRIPT
Toka machine injury: Replantation left arm in a 5 year old
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Case Report
Toka machine injury: Replantation left arm in a 5year old*
Ashish Gupta a,*, Harmandeep Singh Pawar b, Ritul Mehta c,Samta Goyal d
a Dept. of Plastic & Microvascular Surgery, SPS Apollo Hospitals Ludhiana, Indiab Dept. of Orthopaedics, SPS Apollo Hospitals Ludhiana, Indiac Dept. of Anaesthesia, SPS Apollo Hospitals Ludhiana, Indiad Dept. of Emergency, SPS Apollo Hospitals Ludhiana, India
a r t i c l e i n f o
Article history:
Received 23 December 2014
Accepted 14 February 2015
Available online xxx
Keywords:
Replantation
Child
Microvascular surgery
Psychological impact
* This is our original work and has not bee* Corresponding author. Tel.: þ91 977977111E-mail address: [email protected]
http://dx.doi.org/10.1016/j.apme.2015.02.0160976-0016/Copyright © 2015, Indraprastha M
Please cite this article in press as: Gupta(2015), http://dx.doi.org/10.1016/j.apme.2
a b s t r a c t
Replantation is defined as reattachment of a part that has been completely amputated-no
connection exists between the severed part and the patient. First Replantation was re-
ported in Boston in 1962 by Malt & McKhann in a 12 year old boy. Replantation of nearly all
amputated parts, should be attempted in healthy children. A 5 year old boy presented to
the emergency with history of complete amputation by avulsion of left arm by a fodder-
cutting machine which was successfully replanted within 6 h of injury in spite of the
avulsive nature of the injury. The superior regenerative capacity of children's nerves & soft
tissues, along with the potentially favourable psychological ramifications of improved
cosmesis, make this technically demanding operation most gratifying.
Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
Replantation is defined as reattachment of a part that has
been completely amputated-no connection exists between
the severed part and the patient. In Boston in 1962, Malt &
McKhann successfully replanted the completely amputated
arm of a 12 year old boy.1 Replantation of nearly all amputated
parts, should be attempted in healthy children. Epiphyseal
growth continues after Replantation, sensibility is usually
good and useful function can be anticipated although range of
motion is often decreased. The success of surgery depended
upon the time interval between injury and arrival to hospital;
n presented at any meet1; fax: þ91 (0) 161 661717m (A. Gupta).
edical Corporation Ltd. A
A, et al., Toka machine015.02.016
Team approach to deciding the plan and sequence of surgery;
Resuscitation of the child in Emergency; Intra-operative
management of child for smooth intra-operative and post-
operative course and Paediatric intensive care for diagnosis
and management of reperfusion injury.
2. Case history
A 5 year old boy presented to the emergency with history of
complete amputation by avulsion of left arm (Fig. 1) by a
fodder-cutting machine (Toka Machine) (Fig. 2). The child
ing or event.1.
ll rights reserved.
injury: Replantation left arm in a 5 year old, Apollo Medicine
Fig. 1 e Amputated upper limb.
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presented with hypovolemic shock with pressure dressing
over the stump in situ. The amputated limb was brought
wrapped in a cloth. The limb was washed with saline to
remove the dirt and debris and taken to Operation theatre by
the plastic surgery team for dissection of the neurovascular
pedicles and muscles which was done under loupe magnifi-
cation (�4) before the choild was to be wheeled into the
operation theatre. The Triage team resuscitated the child and
Fig. 2 e Fodder-cutting machine.
Please cite this article in press as: Gupta A, et al., Toka machine(2015), http://dx.doi.org/10.1016/j.apme.2015.02.016
the orthopaedic team brought the child to Operation theatre
for fixation of the proximal shaft humerus fracture with
locking titanium plate. The amputated limb was shortened by
2 cm and fixed to the humerus with locking titanium plate.
The radial nerve and triceps repair on the posterior aspect of
the arm with skin closure was done. The Brachial artery was
repaired with 6e0 prolene intermittent sutures first to reduce
the ischaemia time and the veins were allowed to bleed so as
to remove the products of anaerobic metabolism. The venous
repair was done by anastomosing the vena commetantes of
the brachial artery and the anticubital vein with 8e0 ethilon
suture intermittent under loupe magnification. The muscle
and nerve (median & ulnar) repair was carried out with the
elbow in flexion (Fig. 3). The nerve repair was done as a epi-
perineural fashion with 8e0 ethilon suture. The child was
managedwith post-operative heparin for 5 days and shifted to
oral warfarin on post-operative day 5 and discharged on 10th
post operative day (Fig. 4) with the elbow in flexion. The child
hadwound dehiscence over the posterior aspect which healed
by secondary intension. The bony union was complete over
both the fracture sites by the end of 2months (Fig. 5). The child
is on active physiotherapy and back to school, but lost to
follow-up.
3. Discussion
The (toka) fodder-cutting machine is an integral part of rural
families of Punjab. It has resulted in a large number of am-
putations in the past. Although chopping fodder is a common
rural household activity and many children work with the
machine as part of their family chores for making fodder.
Many cases of child workers with fodder machine-related
amputation have been documented. Fortunately the inci-
dence of this injury is on the decline yet patients still report to
the emergency with such catastrophic injuries. In this re-
ported case the child was standing next to the flywheel of the
toka machine when his clothes got caught in it causing it to
avulse the arm off the child's body.
Fig. 3 e Intra-operative view of neurovascular dissection
with bony fixation plate in situ.
injury: Replantation left arm in a 5 year old, Apollo Medicine
Fig. 4 e Child with the replanted limb after discharge.
Fig. 5 e X-ray showing the periosteal reaction with bony
union at both fracture sites.
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Please cite this article in press as: Gupta A, et al., Toka machine(2015), http://dx.doi.org/10.1016/j.apme.2015.02.016
In children, most amputations (unless the segment is
severely damaged) should be replanted because of high over
all success, satisfactory return of sensation, good total active
range of motion, and average bone growth of 93% compared
with the uninjured side. The superior regenerative capacity of
children's nerves & soft tissues, along with the potentially
favourable psychological ramifications of improved cosmesis,
make this technically demanding operation most gratifying.2
There are a set of acceptable conditions when a Replanta-
tion should and should not be performed.3 Indications: 1.
Thumb 2. All amputations in children 3. Multiple digits 4. The
palm, wrist, distal forearm. The contraindications are: 1.
Concomitant life threatening injury 2. Multiple segmental
injuries in amputated part 3. Extreme crush or avulsion 4.
Extreme contamination 5. Extremely prolonged ischaemia
time more than 6 h for levels proximal to mid-forearm 6.
Precluding systemic illness.
The success in the present case can be attributed to the 2 h
period when the patient arrived in the emergency with the
amputated limb; team effort in resuscitating the child and
achieving re-anastomosis of vessels within the 6 h warm
ischaemia time preventing reperfusion injury as muscle
necrosis.
The results of Replantation can be unfavourable in the
form of Total failure; Poor Function and/or an Anaesthetic
limb. These can be avoided or decreased by having an orga-
nized team approach to Replantation by reducing ischaemia
time; proper and quick bone fixation and use of appropriate
vascular clamps to prevent damage to vessels; Proper
assessment of the parts and adequate debridement to
bleeding live tissue on the proximal part and debriding loose
crushed tissue on the distal part; Meticulous nerve coaptation;
Adequate postoperative monitoring, splintage, and physio-
therapy; Vocational rehabilitation, if necessary.4
Any patient, who has suffered a traumatic amputation
from whatever cause, will definitely look forward to have his
limb or body part reattached to the body. The patient and the
relatives will go to any extent to have this facility available.
The onus of deciding to do reattachment or not, depends on
the surgeon and his team, also weighing into consideration
the pros and cons of reattachment. This includes well dis-
cussed criteria like ischaemia time, cause of injury, nature of
the wound, the trauma to the other parts of the body and
general condition of the patient, and definitely the vocation
and socioeconomic factors. I would also add that reattach-
ment surgery is a very demanding surgical procedure which
needs thewholehearted commitment and perseverance of the
surgeon and his team.5
Despite the fact that functional outcome of replanted
hands will never equal that of normal healthy counterpart,
Replantation has major functional, cosmetic and psychologi-
cal benefits. Our patients were very satisfied with their
replanted hands, which have helped them to return to a better
quality-of-life than they might otherwise have had.6
The limiting factor of this case studywas that the childwas
lost to follow-up and the neuro-motor recovery could not be
assessed.
Even though the viability of the limb has been established,
the functional results will only be evident after 9 months to 1
injury: Replantation left arm in a 5 year old, Apollo Medicine
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year. It can be aptly said that the battle has been won but the
war is far from over.
Conflicts of interest
All authors have none to declare.
r e f e r e n c e s
1. Malt RA, McKhann C. Replantation of a severed arm. JAMA.1964;189:716.
Please cite this article in press as: Gupta A, et al., Toka machine(2015), http://dx.doi.org/10.1016/j.apme.2015.02.016
2. Beyermann K, Hahn P, Mutsch Y, et al. Bone growth after fingerreplantation in childhood. Handchir Mikrochir Plast Chir.2000;32:88.
3. KIm JY, Brown RJ, Jones NF. Pediatric upper extremityreplantation. Clinc Plast Surg. 2005;32:1.
4. Thomas AG. Unfavorable results in replantation. Indian J PlasticSurg. May-August 2013;46:2256e2264.
5. Cheng GL, Zhang NP, et al. Digital replantation in children:along term follow up study. J Hand Surg Am. 1998;23:635.
6. Mahajan RK, Mittal S. Functional outcome of patientsundergoing replantation of hand at wrist level e 7 yearexperience. Indian J Plastic Surg. SeptembereDecember2013;46:3555e3560.
injury: Replantation left arm in a 5 year old, Apollo Medicine
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