Ring Avulsion
Fig. 4.4. A,B,C, Urbaniak Class II ring avulsion with near normal restoration of range of motion after revascularization.

protective sensation is typical, and although intrinsic muscle function recovers poorly, the extrinsic muscles provide useful grasp.

Replanted digits distal to the superficialis insertion generally function well and are considered cosmetically preferable to an amputation stump or prosthesis.29-35

Ring Avulsion
Fig. 4.5. Urbaniak Class III ring avulsion injuries function poorly after replantation. This case was treated with primary amputation.

Amputations distal to the distal interphalangeal joint (DIP) can be replanted successfully if at least 4 mm of dorsal skin proximal to the nail fold remain where dorsal veins can be reapproximated. Injuries through the nail bed generally are not considered favorable for replantation. Patients with single digit amputations through zone II or proximal to the superficialis insertion can be expected to have poor interpha-langeal motion when replanted and are considered poor candidates.

Ring avulsion injuries as classified by Urbaniak36 are divided into three categories:

1. Class I—circulation adequate;

2. Class II—circulation inadequate with preservation of skeletal and tendon structure (Fig. 4.4); and

3. Class III—complete degloving or amputation (Fig. 4.5). Class II ring avulsions are good candidates for vascular repair but class III ring avulsions are not.

Major limb replantation at the level of the proximal forearm, through the elbow, and at the humeral level must be undertaken with caution. At the outset, surgeons must understand only limited function may be restored. This realization must be weighed against potential complications when making the decision to undertake replantation.28,37-39

The patient's age factors into the decision to replant an amputated part. Replantation of almost any amputated part generally is recommended for healthy children. Epiphyseal growth continues after replantation, sensibility is usually restored better than adults, and functional results are generally good.40-49 (Fig. 4.6). Advanced age increases the potential morbidity of the procedure because chronic medical conditions are more prevalent in older adults. As age increases, so also do potential complications.

Fig. 4.6. This case of pediatric multiple digit replantation from the Duke University series (References 45 and 46) illustrates the generally good results achieved when replantation is successful.

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