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Given the right circumstances, a traumatically severed ear can now successfully be reimplanted. The career of George Washington was influenced by the involvement of his half brother Lawrence Washington in a war (1739 to 1742) fought between England and Spain on account of a severed ear. It was called The War of Jenkins' Ear.
From 1970 to 1985, 13 patients were treated as a result of an upper limb traumatic sub-amputation. Three of them were younger than 15 years and another one was only 3 years old at the time of the trauma. All the elements involved in the treatment of the lesions are described. When it was possible, an end-to-end anastomosis was used for the repair of arteries and veins. Otherwise, when the loss of tissue was marked, a saphenous vein graft was used. The fracture was treated, when possible, with an intramedullary fixation, surely less traumatizing for soft tissues than a plate. The repair of the nerve was at times simultaneous at other times delayed. The followup has shown a good functional restoration of the limb and of the joints affected by the trauma and a normal development of the patients in terms of age.
Continuous distraction can be considered as an alternative method of thumb reconstruction after traumatic loss. This technique is applicable if at least two thirds of the metacarpal length are retained and the stump is well covered by soft tissue. Elongation up to 100% of the initial length is then realizable. For a good functional precision grip it is necessary for the reconstructed thumb to reach the nail root of the opposite side. There is normal tactile gnosis after distraction. The strength of power grip is not decreased. Impaired, however, is the skillfulness of pulp-to-pulp pinch. We report on our experience in 48 cases.
Immediate survival and functional results were studied in 64 thumb replantations performed during a 3 year period. The failure rate, 27% overall, was higher in patients over 50 years of age (50%) and following avulsions with or without crushing injuries (58%). Long vein grafts from the radial artery proximally to the thumb arteries distally were employed in 15 patients to bypass the traumatized area in the first web space. A higher survival rate (90%) was associated with the use of vein grafts to restore venous return. Half of the patients followed 6 months or longer had good discriminatory sensibility (less than 10 mm). Sensory return and cold intolerance were worse in older patients and were not related to level of injury, mechanism of amputation, total ischemia time, or number of arteries or veins repaired. Loss of motion of the replanted thumb was a frequent cause for inadequate return of function. All thumbs should be considered for replantation, but the results will be poorer in older patients. If possible, motion of the interphalangeal and metacarpophalangeal joints should be preserved.
In severe traumatic injuries to the lower extremity, it is often a difficult decision to attempt heroic efforts aimed at limb salvage or to amputate primarily. To answer this question, the authors performed a 5-year review of 70 limbs in 67 patients. Patients were identified as presenting with major lower extremity trauma and an associated arterial injury. Nineteen (27%) of the 70 limbs were amputated. Limb salvage was not related to the presence or absence of shock and order of repair (orthopedic or vascular). No statistical difference was noted between the time of injury to operative repair in either the amputated or limb salvage group. Limb salvage was related to warm ischemia time and the quantitative degree of arterial, nerve, bone, muscle, skin, and venous injury. A limb salvage index (LSI) was formulated based on the degree of injury to these systems. All 51 patients with an LSI score of less than 6 had successful limb salvage (p less than 0.001). All 19 patients with an LSI score of 6 or greater had amputations (p less than 0.001). Although statistics cannot replace clinical judgment, this index can be a valuable objective tool in the evaluation of the patient with a severely traumatized extremity.
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Stump problems in amputations resulting from employment related injuries were investigated in 397 cases in the Chugoku and Shikoku districts of Japan between 1987 and 1991. Ninety-seven patients (24%) had stump problems which interfered the prosthetic fitting. Stump problems of the upper extremity were seen in about 9% (17 amputees), two thirds of which were skin troubles. Stump problems of the lower extremity were seen in about 37% (80 amputees). Certain complaints were associated with specific methods of amputation; abnormal keratosis in Syme's amputation, equinus deformity in Chopart's amputation, reduced muscle power in above the knee (A/K) amputation and joint dysfunction in below the knee (B/K) amputation. Adequate prosthetic fitting was achieved by the modification of the socket and alignment in almost all amputees with stump problems. In only two cases, Chopart's amputation required subsequent Syme's amputation due to equinus deformity with abnormal keratosis. In almost every case, stump problems are avoidable by means of surgeons' deliberate evaluation of the affected limb and adequate choice of the amputation level.
During one year a total of 451 amputations in 360 patients were registered by the Danish National Accident Insurance to which all such accidents must be reported, all except 6 of these were finger amputations. An attempt is made to estimate the candidates for replantation surgery in Denmark. Following a somewhat restricted policy the number may be no more than twenty-five to thirty-five per year. This calls for limitation of the numbers of centers which deal with such accidents.
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