Hand Replantation With Dorsal Spanning Plate Following a Self-Inflicted Radiocarpal Amputation

Abstract

Upper extremity amputations represent a prime opportunity to restore function through replantation. There are a variety of options that treating surgeons use to protect neurovascular repairs and restore function including Kirschner wire fixation, external fixation, wrist arthrodesis, and proximal row carpectomy. Additionally, the dorsal spanning plate may be a valuable tool for protecting neurovascular repairs. Compared to temporary immobilization with Kirschner wire fixation, which has previously been described in conjunction with upper extremity replantation, dorsal spanning plates can be left in place for longer durations with a lower risk of loosening and loss of fixation and for preventing postoperative sabotage or repeat amputation of the replant by the patient. In this article, we describe a unique case of a patient with acute psychiatric illness that presented with a self-inflicted amputation through the radiocarpal joint and was initially treated with emergent replantation and application of a dorsal spanning plate to protect the neurovascular repair from patient sabotage and allow for early rehabilitation. We found the dorsal spanning plate to be an effective option in this complex clinical scenario. This case illustrates the utility of the dorsal spanning plate in protecting complex neurovascular repairs in the setting of severe skeletal and psychiatric instability.

Keywords: dorsal spanning plate; psychiatric; radiocarpal amputation; repair; replantation; upper extremity amputation.

Figure 1. (A-C) Gross specimens showing the amputated hand and amputation stump with exposed lunate and scaphoid fossa on the distal radius

Figure 2. Initial radiographs demonstrating complete amputation through the radiocarpal joint

Figure 3. The amputated hand prepared for replantation after the neurovascular structures have been identified and core sutures placed in the extensor and flexor tendons

Figure 4. (A, B) Intraoperative fluoroscopic images of the distal aspect of the dorsal spanning plate demonstrating a stable radiocarpal joint status post proximal row carpectomy

Figure 5. (A, B) Immediate postoperative appearance of the replanted hand without protruding hardware

Figure 6. Intraoperative photo demonstrating the minimal incisions required to remove the dorsal spanning plate at 4.5 months after replantation

Figure 7. (A, B) Radiographs of the left wrist six months after replantation with proximal row carpectomy and 1.5 months after the removal of the dorsal spanning plate, demonstrating stable alignment