A 32-year-old woman sustained total crush avulsion amputation of the left forearm when a car overturned and she was thrown out of the vehicle (▶Fig. 64.1a, b). The hand was caught in the door edge and was ripped off. In addition she had injuries in the face, trunk, and legs and thigh, with some injuries needing skin cover. The forearm was successfully replanted. In the immediate postoperative period, she developed skin necrosis at the replant site, which was debrided and skin grafted. There was an area of major necrosis where skin graft was lost, resulting in exposure of the plates used for bone fixation (▶Fig. 64.1c). A pedicled flap was done, to cover the raw area, which settled (▶Fig. 64.1d), but the fracture site got infected resulting in loosening of the implant and nonunion (▶Fig. 64.1e). She presented for the management of nonunion 6 months after the primary surgery.
When she presented at 6 months following primary surgery, the wounds had all healed but for a sinus at the edge of the flap. Radiographs revealed implant loosening and nonunion. This is a significant complication following a major replant. The following discussion can help understand the causation and the factors to be considered while providing the solution. The injury was of crush avulsion in nature, with degloving of the skin for about 5 cm on either side of the injury with friction burns in patches. The muscles were crushed and partly avulsed and debridement was probably inadequate. Bone fixation was done by plates and screws with 3.5 cm of bone shortening. The radial artery was found avulsed and the proximal end was not available. Only the ulnar artery was present. Ulnar artery and three veins were repaired, resulting in successful revascularization. Both the median and the ulnar nerves were repaired. The problem started with skin necrosis at the replant site. With delayed flap coverage, infection and nonunion are inevitable. The infective nonunion site needs radial debridement and plan for bridging the resultant long-segment bone gap.
Infected nonunion with skin necrosis is a serious complication that could result in disasters like rupture of anastomosis and loss of the replant. This could be prevented by adhering to the principles of major replantation. The main aim is to achieve primary wound healing. If that is not achieved, we cannot expect any underlying tissue to heal primarily. In this case, there has been significant injury to the wound edges, with degloving of skin and friction burns. Debridement has been inadequate. The need for soft-tissue flap cover must have been anticipated in the beginning itself. In case of doubtful viability of skin flaps at the earliest possible time, a good flap cover must have been provided.
We have found that one of the best ways to address the problem is to shorten the bone. Up to 10 cm of shortening is tolerated with acceptable functional outcome. This often obviates the need for complex soft-tissue cover, vein, and nerve grafts, and makes available good and healthy bone ends for fixation, In this case, the problem started with inadequate debridement, failure to address the skin necrosis with early flap cover, and inadequate bone shortening.
Fig. 64.1 (a) Presentation of the forearm at the time of injury. (b) Presentation of the hand at the time of injury. (c) Development of skin necrosis in the immediate postoperative period; this was debrided and skin grafted. (d) There was an area of major necrosis where skin graft was lost, resulting in exposure of the plates used for bone fixation. (d) A pedicled flap was used to cover the raw area. (e) The fracture site got infected, resulting in loosening of the implant and nonunion.