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American Journal of  Medical 
Science and Innovation (AJMSI) 

Successful Distal Finger Replantation in a 9-Year-Old Child with Double Level Injury: A 
Case Report & Literature Review

Hussain M. Lawati1*, Abdulfatah Ramadan1, Aamer Galal Osman1, Sanjay H. Sharma1, Sohail Quazi2

Volume 4 Issue 1, Year 2025
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v4i1.3423
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: July 12, 2024
Accepted: August 13, 2024
Published: February 13, 2025

This study discusses a completely amputated right middle finger in a 9- year-old boy. The 
study employed a case report relating to a successful distal finger replantation in a 9-year-
old child with a double-level injury. A bicycle chain accident caused traumatic amputation 
at the distal interphalangeal joint level, requiring surgery for replantation. The fingertip’s 
properties are crucial for tracing, gripping, and protection, hence surgery was attempted. 
Post-debridement, severely crushed radial and ulnar neurovascular bundles were found. The 
proximal ulnar digital artery and nerve stumps were affected. The radial neurovascular bundle 
was crushed with segmental loss evident after exploring post-debridement. Radial distal 
structures were found to be the least damaged. One proximal digital artery was repaired, 
and single digital nerve was approximated. The artery was repaired cross-sectionally with the 
proximal ulnar digital artery anastomosed to the distal radial artery stump. As the damage 
was complex and a double-level cut, surgery was mainly performed to restore the cosmetic 
and functional characteristics of  the finger and to eliminate the requirement of  a donor site 
using another reconstructive option. This case is important in highlighting the developments 
and advancements in digital replantation procedures. This is also valid in pediatric cases if  
complex injuries occur. Besides, all these, essential insights are put into the current literature 
in the domain of  pediatric digital replantation, and this is done by a detailed surgical 
approach, potential challenges experienced, and the discussion of  outcomes. 

Keywords
Amputation, Finger Injuries, 
Functional Recovery, Nerve Repair, 
Pediatric Hand Injury, Replantation

1 Khoula Hospital, Oman
2 Hamad General Hospital, Qatar
* Corresponding author’s e-mail: lawatihussain6@gmail.com

INTRODUCTION 
Finger amputations, especially in pediatric patients are 
not easy to manage as they present a noticeable clinical 
challenge (Loewenstein & Adkinson, 2021). Replantation 
requires great attention to detail in microvascular 
techniques to recover both the form and function of  the 
injured fingers  (Tang et al., 2020). Distal finger injuries, 
particularly those that involve not only one level but 
multiple levels, are significantly complicated  (Cannon et 
al., 2016). This complication comes into play from the 
requirement to carefully reconnect small blood vessels 
and nerves, which are important for the sensation and 
function of  the finger. 
This case pertains to a 9-year-old child who had a 
complete middle finger amputation of  the right hand 
at the distal interphalangeal joint (Tamai zone II) after 
experiencing a bicycle chain accident. The injury was 
not just an ordinary one, as it was further complicated 
by crushing and an additional distal volar laceration with 
gross contamination with grease. Such injuries are not 
common and present specific threats and challenges, 
especially in those children having smaller anatomical 
structures in which attention must be paid to the smallest 
details during surgery (Hill & Remick, 2020). Moreover, 
successful replantation of  pediatric cases has immense 
importance due to multiple factors  (Leiskau et al., 2021). 
In the first place, the fingertips are important for fine 
motor skills and they are essential for a child to develop 
and perform daily activities such as writing, playing, and 

self-care (Soden, 2020). Secondly, preserving the aesthetic 
appearance of  the hand is essential, it should be cared for 
the psychological betterment of  the child. Hence, getting 
both functional and cosmetic reestablishment is vital in 
such cases. 
This report is intended to showcase the advancements and 
developments in surgical procedures that provide desired 
results in complex digital replantations (Thibedeau et 
al., 2023). We add precious information to the existing 
literature on pediatric digital replantation after presenting 
the comprehensive approach of  surgery, the potential 
challenges faced, and the outcomes obtained. This case 
ensures the importance of  an approach that is not just 
limited to one area but it is a multidisciplinary approach 
and the requirement for sustained improvement of  
microvascular surgical techniques to improve the 
prognosis for young patients with severe finger injuries 
(Stefanou et al., 2022).

Case Presentation 
A case of  a male child aged nine was presented. The 
child experienced an injury to his right middle finger that 
happened when his finger became caught in a bicycle 
chain, causing complete amputation through the distal 
interphalangeal joint (Tamai zone II) (Billig et al., 2021).

Injury Description 
The part where amputation occurred showed crushed 
wound edges with contamination by grease. An additional 



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Am. J. Med. Sci. Innov. 4(1) 53-57, 2025

distal volar laceration was also there. The injury is depicted 
in Figures 1, 2, and 3. The Ischemia time was around 3 
hours from the time of  injury when the patient arrived at 
the emergency department. 

Preoperative Considerations 
Before taking the patient to surgery, the minimal chances 
of  success to the family were explained, providing the 
nature of  the injury, the distal amputation, and the 
presence of  another deep wound over the pulp that 
makes it a double-level cut to the neurovascular bundles.

Surgical Technique 
Surgery was executed with general anaesthesia and 
having an arm tourniquet and standard microvascular 
procedures. Following proper debridement and cleaning, 
exploration showed a crushed neurovascular bundles 
proximally with a segmental loss on the radial side. 
Distally, the digital artery and nerve stumps of  the ulnar 
side were greatly damaged, whereas the radial digital 
distal structures were in acceptable condition. A decision 
regarding repairing the ulnar proximal digital artery to 
the distal radial artery by 9-0 Ethilon in a cross-fashion 
was made. After the arterial anastomosis the vascularity 
was regained in the amputated part including in the distal 
crushed portion and thus distal laceration was sutured 
without arterial repair at the distal crush end.  The radial 
digital nerve was repaired with 8-0 Ethilon, though it was 
impossible to repair the ulnar digital nerve. Both of  flexor 
and extensor tendons were repaired with 3-0 PDS by 
modified Kessler’s technique before performing the digital 
structures anastomosis. Osteosynthesis was executed using 
1mm double axial K wires, shown in Figure 

Two Dorsal Veins Were Repaired Using 9-0 Ethilon
Postoperative Care 
The hand was immobilized in a splint after restoring 
finger perfusion on the table. The patient was kept for 
2 days in the ICU postoperatively for monitoring. An 
anticoagulant, low molecular weight heparin infusion was 
initiated for five days as per the protocol in our institution. 
The colour of  the finger was pink during all this duration. 
Eventually, the patient was discharged. 

Follow-Up and Outcomes 
After six weeks of  the postoperative period, the K wires 
were cut and removed, and mobilization was started. It 
is illustrated in Figure 5. More follow-up showed a good 
range of  motion & complete healing as shown in Figure 6. 
At six months follow-up, the patient exhibited satisfactory 
functional outcomes. Motion range was also found to be 
acceptable with sensory recovery. There was a favourable 
aesthetic result, having the least scarring, in addition, 
nail growth was also acceptable. An extended follow-up 
period will be required to know how disturbances and 
more functional developments are progressing.

Figure 1: Injured fingers with crushed wound edges

Figure 2: The amputated part as a result of  injury

Figure 3: X rays scan of  the injured hand



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Findings 
History and Use of  Digital Replantation 
Digital replantation has generally been used since the 
first successful procedure of  Komatsu and Tamai. This is 
important because if  such injuries occur, this will be an 
effective approach to treat them (Duah-Asante et al., 2023).

Factors Influencing Practicality, Cost, and Suitability 
Practicality, cost, and suitability rely on the details of  the 
injury, involved digits, the patient’s demographics, and the 
experience the surgeon possesses. Such factors must be 
considered (Kwon et al., 2020). 

Common Indications for Digital Replantation 
It is usually executed for thumbs, multiple digits, and 
whatever digit in a child. Sometimes, it is performed for 

isolated digits in young individuals or those who play 
music (Fan et al., 2022). This is important to consider 
in such individuals to ensure effective utilization of  the 
hand.

Drawbacks of  Various other reconstructive Methods 
Methods including secondary intention healing, finger 
shortening, skin grafts, and flaps usually result in 
morbidity like pain & stiffness  (Kawaiah et al., 2020). 
Such pain or tenderness can further complicate the case 
and long-term disability can result. 

Disability Rates for Different Closure Techniques 
Disability rates for primary closure are 15%, Split-
thickness grafts 25%, Full- thickness grafts 26%, and 
Palmar flaps 19%. 

Benefits of  Distal Phalanx Replantation 
Replantation maintains function, provides better soft 
tissue coverage, preserves length and appearance, and 
generally requires one surgery (Winge & Røkkum, 2023). 
After surgery, complete and quick recovery is expected 
with a functional hand and fingers. 

Discussion 
This case report presents a 9-year-old boy’s right 
middle finger distal amputation requiring replantation. 
Standard microvascular methods, along with general 
anaesthesia and an arm tourniquet, were used during the 
surgery. Double axial K wires were used to accomplish 
osteosynthesis before vascular repair was performed. 
The patient exhibited appropriate mobility range and 
sensory recovery after six weeks, along with satisfactory 
functional outcomes. Komatsu and Tamai’s initial effective 
replantation through microvascular anastomosis report 
states that digital replantation has recently emerged as 
a widely accepted method  (Noh & Hacquebord, 2020). 
Regardless of  the practical, economical, and feasible 
nature of  the replantation, the outcome of  surgery relies 
on the extent and injury, the area damaged, level of  
education, financial condition and avocation. Additionally, 
some other factors, include the surgeon’s training and 
their experience. The outcome is also related to the 
indications for replantation. Replantation attempts are 
absolutely indicated in an amputated thumb, amputation 
of  multiple digits or in a child with an amputated digit  
(Goel et al., 2020). Sometimes, isolated digit amputation 
is recommended for patients due to professional or 
social reasons, like for young adults or musicians. But 
still, there remains debate over whether single amputated 
digit replantation is warranted or not. In Eastern states, 
maintaining Physical well-being is often favored over 
function leading patients to request replantation despite 
being informed that it is not mandatory for preserving 
adequate function of  the hand. 
Despite various challenges, our spirit to execute 
replantation has not declined. Several centres have 
achieved the desired outcomes, even though the small size 
of  the vessels presented a problem  (Liao & De, 2021). A 

Figure 4: X ray scan of  the specific sections of  hand

Figure 5: Injured Finger after removing K wires (6 weeks)

Figure 6: Healed up and recovered hand with its fingers 
moving freely (10 weeks)



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significant amount of  controversy is still associated with 
the distal digital replantation. A few surgeons consider 
single finger replantation imprudent. Most patients utilize 
an unaffected finger instead of  the one replanted which 
may lead to more harm caused by the replanted finger 
potentially affecting overall hand function. 
The findings of  our study relate to (Wang et al., 2022) which 
discuss various alternative procedures such as secondary 
intention healing, finger shortening, wound closure using 
skin grafts, and free flaps. With these procedures, several 
patients experience unwanted symptoms including 
continued pain, excessive tenderness, cold intolerance, 
hyperesthesia, atrophic soft tissue, damaged nails, and 
reduced grip power. 
Sturman and Duran’s study on 235 fingertip injury 
patients found that 15% received basic dressing, 25% 
had partial thickness skin grafts, 26% had full thickness 
skin grafts, and 19% had significant disability. Following 
replantation, tissue quality is superior to traditional skin 
coverage methods. Sensation after repairing the digital 
nerve in the fingertip which is planted is maintained, 
and even superior to other closure methods including 
tissue transfer from the base of  the thumb (de Berker 
et al., 2022). The finger’s length is preserved by distal 
replantation and provides the best appearance. It 
maintains movement in the metacarpophalangeal (MCP) 
and proximal interphalangeal (PIP) joints, as these joints 
are not inactivated post-replantation. This decent and 
efficient movement at the proximal joints compensate for 
no movement at the far end joint. Creation of  a neuroma 
and high sensitivity stump is avoided in the proximal end 
of  an amputated limb (Shaterian et al., 2019). which is a 
frequent post-amputation complication needing multiple 
revisions. Replantation surgery is generally secure and 
typically requires only one procedure.
According to most authors, all amputated thumbs  
and multiple digital amputations must undergo trial 
of  replantation, but there is little consensus on the 
consideration of  distally amputated parts or single 
digital replantations (Bahm, 2023). Only a few of  them 
highlighted the advantages of  distal digital replantation. 
Also, there is a minor focus on the functional distinctions 
existing between digital replants proximal and distal to 
the PIP joint (Stone et al., 2021). The study of  surgical 
techniques and rehabilitation protocols for distal digital 
replantation could offer unique advantages compared to 
proximal replants (Persitz et al., 2023). 

CONCLUSION 
This case highlights the importance of  digital replantation 
in restoring function and quality for patients having 
finger injuries. As the initial successful procedure was 
performed by Komatsu and Tamai, digital replantation 
has proven to be a crucial development in the clinical 
and surgical practice. The practicality, cost, and suitability 
of  the technique rely on different factors, such as the 
characteristics of  the injury, number of  digits involved, 
the demographics of  the patient, and the experience 

of  the surgeon. Replantation is most generally used for 
thumbs, multiple digits, and any digit in children, and is 
seldom performed for isolated digits in young individuals 
or musicians. Alternative procedures like secondary 
intention healing, finger shortening, skin grafts, and 
flaps can cause unwanted symptoms such as pain and 
tenderness. The rates of  disability for different wound 
closure techniques also change with primary closure being 
the lowest at a rate of  15%. Distal phalanx replantation is 
a cost-effective, efficient, and long-lasting procedure that 
can restore essential functions and improve the quality 
of  life for patients with finger injuries, demonstrating its 
effectiveness in a single surgery. In the future, experience 
from such cases can be utilized to treat finger injuries, 
especially those with more complications and severity. 
All the literature and the findings are evident that this 
procedure is effective, hence, it can be implemented for 
treatment with a good success rate. Fingers are important 
components of  our body, and preserving them is crucial. 
More research is required to modify and enhance the 
existing procedures and techniques to treat a wide variety 
of  injuries.
 
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