Successful Replantation of a Completely Severed Hand: A Case Report

Introduction

An amputation of the hand is a devastating injury resulting in significant physical disabilities. The amputee struggles with routine tasks, loss of independence, loss of livelihood, and psychological issues.1 In India, there are roughly 0.62 amputees per thousand population.2 This translates to close to ten lakh individuals. The most common cause of amputation is trauma (70.3%).

In 1968, Komatsu and Tamai reported the first successful replantation of the human thumb.3 Replantation is defined as the reattachment of the amputated part using microsurgical techniques to obtain ‘form’ and ‘functional’ recovery. It represents the pinnacle of team effort, advanced patient care, hospital operational efficiency, and reconstructive and microvascular surgery with expensive, advanced and specialised equipment. The goal of replantation after traumatic amputation is successful salvaging in both form and function, alleviation of the psychological distress associated with amputation, and return of the patient to his/her earning potential.

In this case report, we describe a male patient with an amputation at the level of the wrist, and the successful salvage of his hand by a multidisciplinary team.

Case report

On 18th August 2024, a 23-year-old male experienced a complete severance of his right hand at the wrist level (Figure 1). The injury occurred when a sharp-edged tile accidentally fell on his hand at a construction site. He was brought to the Emergency Department of Max Super Speciality Hospital, Vaishali, within hours of the accident. Upon arrival, he was stabilised and prepared for surgery. The reconstruction team, led by Dr. Ankur Bhatia and Dr. Pradeep K. Singh , performed the procedure according to established departmental protocols.

Figure 1: Pre-operative images showing the ventral and dorsal views of the severed hand.

The surgical process involved identification, dissection, and repair of the severed arteries, veins and tendons. The ulnar and radial artery, ulnar and median nerve, and two dorsal veins were carefully identified and repaired under magnification. Extensor tendons and flexor tendons were also repaired. Following these steps, Kirschner wire (K-wire) fixation was utilised to achieve bone stabilisation. After ensuring haemostasis, the wound was closed in layers, and a corrugated drain was placed for postoperative management (Figures 2 and 3)

Figure 2: All the structures were identified: Neurovascular bundles and tendons of dorsal and ventral side.

Figure 3: Post-operative images showing ventral and dorsal view of the replanted hand.

The Anaesthesia team ensured that the patient was stable and comfortable throughout the procedure. Postoperatively, the patient was monitored for vascular perfusion, nerve recovery, and overall functionality. The patient exhibited a good recovery and was discharged with a structured rehabilitation programme, including physiotherapy and regular follow-ups to assess functional and sensory outcomes.

Post-surgical assessments indicated satisfactory wound healing, adequate circulation, and restored motor function. The rehabilitation program emphasised improving the range of motion and nerve functionality, which are critical for long-term recovery (Figure 4).

Figure 4: Two months follow up. Tinel side advancement and partial movement recovery.

Discussion

To salvage a severed limb such as a finger or hand, immediate steps are critical. The amputated part should be rinsed gently with clean water to remove contaminants. It should then be wrapped in a moist, sterile cloth and placed in a clean, sealed plastic bag.4 This bag should be kept on ice, ensuring it does not directly touch the ice to prevent frostbite. Optimal preservation time is up to 6 hours, although successful replantation has been reported up to 12 hours under ideal conditions

Prompt transportation to a medical facility with microsurgical capabilities is essential. Rehabilitation following hand replantation is a cornerstone of achieving functional recovery. It involves physical therapy to regain strength, occupational therapy to relearn daily tasks, and psychological support to address the emotional impact of trauma and recovery.

Also, recent advances in microsurgical instruments, and the integration of robotics, have enhanced precision in replantation cases.5 While limb replantation techniques have advanced significantly, their accessibility remains limited in India due to the need for specialised infrastructure and expertise.