Postoperative care

After surgery, the patient is kept in a warm room to promote vasodilation for 3 to 5 days. Hematocrit, parameters for disseminated intra-vascular coagulopathy (DIC), and electrolyte balance are carefully monitored. An hematocrit of 20 to 25 is ideal and electrolyte balance is kept close to normal. Intravenous fluids are delivered at a rate of twice maintenance rate for 3 days, then routine maintenance rates thereafter. As pointed out by Askari and colleagues [13], there are inadequate data to develop a rational evidence-based approach to anticoagulation in the setting of microsurgery. We start low molecular weight dex-tran (Dextran-40) intraoperatively and if there are no untoward reactions, the dextran is continued for the next 3 to 5 days. One baby aspirin (85 mg) is given daily while subcutaneous heparin, 5000 units twice daily, are given to address potential lower extremity deep venous thrombosis associated with bed rest. Therapeutic anticoagulation with heparin and warfarin is reserved for the most desperate situations and is associated with a significantly larger blood loss and risk to the

Fig. 5. (A) Radiographs of the patient whose hand is shown in Fig. 1 demonstrate an oblique amputation of the distal forearm reflecting the mechanism, a fine-toothed chop-saw used to cut crown molding and the position of the forearm at the time of injury, pronation. (B) After debridement, the bone was shortened and rigid internal fixation was applied. (C) Next, the soft tissues were repaired from deep to superficial, with nerves being done last. (D) A 2-pin fixator spans the first web space preventing contracture and the wounds were closed with interposition flaps and skin grafts. (E) Postoperative care included CPM for the digits, and intermittent passive motion of the thumb as pictured here from a similar wrist-level replantation case. (F) Eighteen months after surgery the range of active motion is near complete and, (G) the fractures have consolidated.

Fig. 5. (A) Radiographs of the patient whose hand is shown in Fig. 1 demonstrate an oblique amputation of the distal forearm reflecting the mechanism, a fine-toothed chop-saw used to cut crown molding and the position of the forearm at the time of injury, pronation. (B) After debridement, the bone was shortened and rigid internal fixation was applied. (C) Next, the soft tissues were repaired from deep to superficial, with nerves being done last. (D) A 2-pin fixator spans the first web space preventing contracture and the wounds were closed with interposition flaps and skin grafts. (E) Postoperative care included CPM for the digits, and intermittent passive motion of the thumb as pictured here from a similar wrist-level replantation case. (F) Eighteen months after surgery the range of active motion is near complete and, (G) the fractures have consolidated.

patient. Hourly monitoring with pulse-oximetry and capillary refill is conducted until the patient is discharged.

In 48 to 72 hours the patient is returned to the operating room for a dressing change and further debridement if necessary and definitive soft tissue closure, which may require skin grafting or the use of flaps. The patient is returned to the ward and monitored for 3 to 4 days if no grafts or flaps are necessary and 6 to 10 days if flaps are required.

Rehabilitation of these complex procedures includes edema management and early motion to maintain joint pliability and prevent tendon adhesions. The former is initially controlled with strict extremity elevation and the latter is initiated as passive motion during the first 4 weeks followed by active exercises under the guidance of a hand therapist. Digital continuous passive motion (CPM) is started on the first postoperative day for forearm and wrist-level replantations (Fig. 5E). A well-padded dorsal blocking splint is required to prevent hyperextension of the meta-carpophalangeal joints and clawing of the digits. Unlike other authors, we do not advocate early wrist active-assisted motion flexion and active extension during the first weeks postoperatively, instead postponing wrist flexion and extension for at least 3 weeks [14,15]. Pressure wraps to control edema are initiated during the third week. Gentle active and active-assist wrist and digit motion is started during the fourth week. During the ensuing period, strengthening exercises are added and active motion increasingly used. Nerve recovery reflects the mechanism of injury, with sharp division providing better functional results than avulsion injuries. Patients will often require supervised therapy up to the sixth postoperative month before being released for self-maintenance regimens (Fig. 5F, G). The need for external protection for an insensate hand and the timing of secondary procedures is reflected by the mechanism of injury. Tendon transfers, tenolysis, and scar revision are postponed for a minimum of 6 months from injury and only when a 3-month interval has passed without functional improvement. In the authors' limited experience of seven forearm and two arm-level replantations, delayed tendon transfers were necessary in the two arm replantations, one for correction of a radial nerve deficit and one for correction of an intrinsic muscle imbalance (Fig. 6).

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