Hand surface landmarks. (a) Palmar surface view. (b) Dorsal surface view. 1 Proximal palmar crease. 2 Middle palmar crease. 3 Distal palmar crease. 4 Finger web. 5 First web space. 6 Proximal transverse crease. 7 Middle transverse crease. 8 Distal transverse crease
Nail appearance: 1 Nail body. 2 Lunula of the nail. 3 Nail fold. 4 Eponychium. 5 Nail groove. 6 Hyponychium
Muscle (tendon) landmarks of hand. (a) Palm of the hand. (b) Dorsal aspect of the hand. 1 Thenar. 2 Hypothenar. 3 Center of the palm. 4 Extensor pollicis longus tendon. 5 Extensor pollicis brevis tendon. 6 Extensor digitonum. 7 Extensor digiti minimi. 8 First dorsal interosseous muscle. 9 Anatomical snuffbox？
Fascial space and synovial sheath of the tendon. (a) Projection. (b) Fascial space cross section (schematic diagram). 1 Palmar septum. 2 Thenar space. 3 Midpalmar space. 4 Digital common flexor sheath. 5 Long flexor muscle tendon sheath of the thumb. 6 Lumbrical muscle canal. 7 Digital synovial sheath
Variation type of synovial bursa and digital flexor tendon sheath滑液囊与指屈肌腱鞘的变异类型
Distribution and typing of the hand’s dorsal cutaneous nerves. 1 Superficial branch of the radial nerve. 2 Hand’s dorsal branch of the ulnar nerve. 3 Forearm’s posterior cutaneous nerve. 4 Forearm’s lateral cutaneous nerve
(a) Drying and refrigeration are the main methods of storage for amputated fingers, which cannot be soaked in water or disinfectant and can be placed among ice blocks in summer. (b) The wound should be pressurized and bandaged with clean gauze in the case of emergency treatment. (c) Psychological preparation is needed for postoperative recovery. (d) General assessments should be performed by a doctor before the operation to rule out life- threatening risks, determine the indications, and rule out any contraindications.
(e) Preoperative preparations for surgical fields and surgical instruments and materials
● Preoperative Emergency Resuscitation术前急救准备
1. The preservation and perioperative treatment of amputated fingers is vital to the success of the operation. Replantation of amputated fingers is time-limited. The prime time to close the wound is 6–8 h after the finger amputation in summer and 10–12 h in winter. The injured should be taken to a hospital nearby after simple treatment and tetanus antitoxin should be conventionally injected to reduce the risk of postoperative bleeding and infection. 2. If the amputation is associated with limb fractures, the fractures should be fixed temporarily using materials nearby, such as a board, iron bar, and hardback books or magazines, before the patient is moved to avoid secondary injury. 3. The amputated finger should be wrapped in a plastic bag and put in a low-temperature barrel and taken to the hospital with the injured. Storage at room temperature or above is not permitted. The best storage temperature is 4 °C (as shown in following figure).
The methods of amputated finger preservation are断指保存的方法有:
(a) Ice bucket preservation: putting the amputated finger into a dry sealed plastic bag, then transferring the bag into an ice bucket, padded with ice cubes around the bag, and finally covering the bucket with a lid.
(b) Ice plastic bag preservation: putting the amputated finger bag into another plastic bag, which is full of ice and should be sealed.
(c) Packing method: the amputated finger is packed with a towel or gauze and taken to the hospital with the injured (the cold storage method may not be necessary in winter or during transfer within a short distance).
(a)冰桶保存: 把截去的手指放入一个干燥密封的塑料袋内，然后把袋子放入一个冰桶内，用冰块包裹袋子，最后盖上盖子。(b)冰胶袋保存: 把已截肢的手指袋放入另一个盛满冰块并须密封的胶袋内。(c)包装方法: 截断的手指用毛巾或纱布包裹，随伤者送往医院(冬季或转运途中可能不需要冷藏方法)。
At the hospital, the amputated finger should be wrapped with aseptic gauze before the operation and put in a refrigerator at 4 °C after it is debrided and disinfected by the medical staff. In the case of multiple amputated fingers, the fingers should be properly marked and wrapped separately. The amputated finger can also be preserved in a holeless plastic bag, which is then put into an ice bucket if there is no refrigerator. The finger should be wrapped with an 8-to-10-layer aseptic gauze and put into a holeless plastic bag, which is then sealed and placed into an ice bucket if the injured must be transferred to a remote place for replantation. Ice cubes can be placed close to the bags, and ice cream or ice block will also do if there are no ice cubes. The doctor should replant the fingers one by one and the remaining finger(s) should be preserved in a refrigerator and properly marked. Cryopreservation means preserving the amputated finger with liquid nitrogen at −196 °C.
●Assessment of General Conditions
The general state and medical condition of the injured should be assessed to rule out any life- threatening risks and underlying diseases.应评估伤者的一般状况和身体状况，以排除任何威胁生命的风险和潜在疾病。
●Evaluation of the Injury
It is very important to evaluate the condition of the injured because the structure of the hand is very delicate and complex. In hand trauma, the tissue that is first affected is the skin, followed by muscles, tendons, nerves, vessels, bones, and joints.
(a) Evaluation of skin conditions: The rupture of the skin is very visible, but the prognosis varies in different types of skin ruptures. Skin scratches caused by a sharp instrument is relatively easily treated, but they can still be easily infected if the sharp instrument is polluted with heterogeneous immune substances such as meat, and healing will be difficult, especially wounds caused by human or animal bites. A cotton opener will cut skin into pieces that are hard to suture and repair. It is worth noting that it is hard to judge the blood supply of a serious degloving injury, which is preferably observed under a microscope.
(b) Evaluation of nervous injuries: There should be a high degree of suspicion of whether nerves have been damaged in the case of sensory degeneration, disappearance, and (or) movement in the area distal to the wound, and the wound should be repaired as early as possible to achieve beneficial effects.
(c) Evaluation of vascular injuries: Bleeding is unavoidable in an open injury. However, pressure should be applied to the wound or a tourniquet should be used at the proximal part to stop the bleeding promptly when pulsating bleeding is seen in the wound; otherwise, this may cause arterial injury. In addition, paleness, absence of a pulse, and a reduction in skin temperature in the area distal to the wound indicate a poor blood supply in the area; in the case of no vascular anastomosis and blood circulation, the finger will not survive.
(d) Evaluation of muscle and tendon injuries: When disruption of movement occurs in one or more fingers, but it is not accompanied by sensory degeneration, the disorder may be caused by muscle and tendon injuries.
(e) Evaluation of bone and joint injuries: The occurrence of deformity and abnormal movement of bones and joints or local obvious swelling and tenderness indicates bone and joint injury. At this time, an X-ray should be performed to discover the severity of the injuries. Anteroposterior and oblique radiography films of not only the whole hand, but also the specific fingers or joint should be observed.
(e)骨与关节损伤的评估: 骨与关节发生畸形和异常运动或局部明显肿胀和压痛提示骨与关节损伤。现在，应该进行 x 光检查，以确定伤势的严重程度。不仅要观察全手的前后位和斜位 x 线片，还要观察特定的手指或关节。
● Preparation for Surgical Fields
(a) Psychological preparations for medical staff and the injured: As it is an important factor for success in the replantation of amputated fingers, the medical staff should be confidentially devoted to the rescue of the amputated finger based on the fact that every decision is made in the interest of the injured party. With kindness and patience, they should educate the injured to ease their tension and strengthen their confidence in surgery, which will make the injured cooperate closely intraoperatively and postoperatively. (b) When the injured is taken to the emergency room, medical history should be requested and a physical examination must be carried out: Rapid treatment should be given in the case of severe bleeding and shock. Amputated fingers should be put in a refrigerator at 2–4 °C and surgeons should be called for further immediate processing. Relevant departments such as the clinical laboratory, the radiology department, the blood bank, the anesthesiology department, and the operating room, should be prepared to conduct the necessary examinations and preparations, and the injured should be taken to the operation room as soon as possible.
(c) Preparation of the surgical equipment: In addition to the equipment used in the department of traumatology, the equipment for small blood vessel suture should also be prepared. For non-invasive suture needle lines, injury-free small vessel suture needles are required, which are connected at the two ends of the nylon monofilament. Currently, 7-0, 8-0, 9-0, 10-0, 11-0, 12-0 are available. Non-invasive suture lines of the corresponding model should be selected according to differences in vascular diameters. The following types of needle holder should be available: vessel forceps type, pen type or spring piece type. Small vascular forceps and vascular clamp are required: toothed and nontoothed. With regard to small scissors, we provide special microscopic surgical scissors that can be replaced by ophthalmological small scissors. Flat and sharp needle tips for flushing the blood vessels can be made by all kinds of needles whose tips have been made round, blunt, and smooth. A surgical microscope with a simple 2- or 2.5-fold magnifying glass with glasses is needed. A complex, accurately structured surgical microscope may be a vertical type or a suspending type, which can be magnified by 6, 10, and 16 times and can be used by two or three people; it is also equipped with devices for lighting, automatic control of zooming, ascending and descending, photography, filming, and video-making, etc.
(a)医务人员和伤员的心理准备: 由于这是断指再植成功的一个重要因素，医务人员应该根据每一个决定都是为了受伤方的利益而作出的这一事实，对断指的抢救给予保密。以善意和耐心教育受伤者，减轻他们的紧张情绪，增强他们对手术的信心，使受伤者在术中和术后紧密配合。(b)当伤者被送往急诊室时，应要求其病史并进行身体检查: 如出现严重出血和休克，应迅速进行治疗。截去的手指应放在摄氏2-4度的雪柜内，并立即通知外科医生作进一步处理。临床检验室、放射科、血库、麻醉科、手术室等有关部门应当做好必要的检查和准备工作，伤者应当尽快送到手术室。
(c)外科器材的准备: 除了创伤科所使用的器材外，还应准备小血管缝合器材。对于无创缝合针线，要求在尼龙单丝的两端连接无损伤的小血管缝合针。目前，7-0,8-0,9-0,10-0,11-0,12-0都可用。应根据血管直径的不同选择相应模型的无创缝线。以下类型的针座应可提供: 血管钳式，笔式或弹簧片式。需要小血管钳和血管钳: 有齿和无齿。至于小剪刀，我们提供眼科小剪刀可以替代的特殊显微手术剪。用于冲洗血管的扁平而锋利的针头可以由各种针头制成，这些针头都是圆的、钝的、光滑的。外科手术显微镜需要一个简单的2-2.5倍的放大镜和眼镜。结构复杂、结构精确的外科显微镜可以是立式或悬挂式，可放大6倍、10倍、16倍，可供两人或三人使用; 还配有照明、自动控制缩放、升降、摄影、拍摄和录像等设备。
●Indications and Contraindications
(a) The general conditions are stable, with no life-threatening risk, and the patient can tolerate the surgery.
(b) The patient and his/her family desire replantation very eagerly.
(c) The structure of amputated fingers should be comparatively complete, postoperative complications few, and the appearance and function have a good recovery.
(d) The replantation should be performed according to the time limit and the patient’s age. The tolerance of amputated fingers to ischemia would be reduced. A higher environmental temperature means a more active metabolism of histiocytes and a shorter duration of the tolerance of the amputated finger to the ischemia. Generally, there is no absolute limit for replantation time and age currently, and the right judgment should be made according to the specific conditions and after various factors have been taken into consideration.
(e) Replantation can only be performed under necessary device conditions by skilled surgeons who have professional training.
(a) Replantation is not indicated in people with systemic disease, poor constitution or concomitant serious organ injuries. The aim of replantation is to recover the function of the amputated fingers, not purely for survival; thus, maintaining the finger’s integrity is essential.
(b) Amputated fingers associated with multiple fractures or severe soft-tissue defects result in poor appearance and function.
(c) Severe damage to the integrity of the finger’s vascular bed, such as in squeezing- induced finger amputation, manifest as subcutaneous blood stasis at the two sides of fingers; even if the vessels are connected, the replanted finger cannot survive easily because of the extensive blood oozing in the soft tissues and thrombosis.
(d) Replantation is not suitable if the time-limit has been excessively exceeded and the tissues have become deformed. Amputated fingers can be replanted and survive within 24 h of the amputation without refrigeration, and the limit time for replantation can be prolonged to 30 h. The shorter the ischemic time, the higher the survival rate. Replantation is not indicated for the finger if the finger nerves, vessels, bones, and muscles have been damaged because the effect of nerve repair will be relatively poor and post- survival functions will not be as good as expected.
Hand injury draws less attention in most comprehensive hospitals, and surgery is usually performed under local anesthesia in the emergency room. However, local anesthesia often generates poor efficacy, and the anesthesia range is too narrow. This is very unfavorable to complete debridement and comprehensive injury exploration, and is very likely to lead to incomplete debridement or missed diagnosis and treatment. Generally speaking, brachial plexus block anesthesia is recommended for hand surgery because this covers the entire upper limb, during which the pneumatic tourniquet can be easily used. This practice not only reduces intraoperative bleeding, but also makes the surgical fields cleaner, thus increasing the efficiency of surgery. Currently, the most popular finger root anesthesia is tendon intrathecal injection of anesthetics. This anesthesia mode is characterized by the speed at achieving the anesthetic effect with only one injection, involving little pain for the patients and a positive anesthetic effect. General anesthesia can be considered if multiple injuries are involved, or the skin flap or tissue flap transposition at other sites are scheduled, or combined anesthesia is not an option because the patient is a child.
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