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Fig. 8.1 The pad for raising the upper limbs
8 Postoperative Management forFinger Reconstruction
Fig. 8.4 Raise the lower limbs
Fig. 8.2 Raise the upper limbs
Fig. 8.3 The pad for raising the lower limbs
Fig. 8.5 Heating lamp
Observation ofUncomfortable Symptoms
Abdominal bloating, anorexia, nausea, constipation and
body aches, etc. at the same time depression, dysphoria,
and other emotional uctuations due to long-term bedtime
should be observed and treated in time to avoid vascular
crisis.
8.1 Postoperative Treatment andManagement
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Fig. 8.6 Lamp shade
113
Fig. 8.8 Microinjection pump
mal, from the fourth day, it could be changed to observe and
record every 2h. Generally speaking, blood circulation of
reconstructed ngers would be stable after 7–10days.
Changes ofColor
If blood circulation of reconstructed ngers is normal, the
color would be the same as that of normal nger or be slight
red. If the color changes to pale, it means arterial blood supply disorder, and if the color changes to dark purple, it means
Fig. 8.7 Keeping warm by heating lamp
venous blood supply disorder.
Changes ofTemperature
Local Observation ofReconstructed Fingers
First 72h after the operation is a high incidence period of
vascular crisis and it is required to observe and record the
changes in blood circulation every hour. If everything is nor-
The temperature of reconstructed ngers would be 1–2°C
higher than normal ones. If temperature decreases, the possibility of vascular crisis could be judged by a combination
of changes in color.
114
Fig. 8.9 Continuous
intravenous administration
8 Postoperative Management forFinger Reconstruction
Changes ofSkin Tension
If skin tension drops apparently, even nger (toe) pulp is
shriveled, it means arterial blood supply disorder. If skin tension increased signicantly, even tension blisters appear, it
means venous blood supply disorder.
Blood-Letting Test
When there is arterial blood supply disorder, no blood ow
or only small amount of dark red blood would ooze. When
there is venous blood supply disorder, blood would ooze rapidly, which would be dark red or purple-black venous blood
rst and then be bright red arterial blood.
Observation ofWound Bleeding
The dressing should be kept as dry as possible, if the dressing is rapidly permeated and active bleeding is observed, it
must be treated in time, most of which could be stopped by
local pressure. However, if it is bleeding around the anastomosed site, it must be treated carefully. First is to avoid local
pressure leading to vascular crisis, second is to avoid excessive blood loss leading to anemia and even shock, once the
treatment is not effective, it is necessary to go into the operation room for exploration.
8.1.2 Drug Treatment
Prevention ofInfection
Most nger reconstruction belongs to type I incision operation except for emergency construction, however, once
infected, it may lead to failure of surgery. Therefore, prophylactic use of antibiotics is routinely recommended, which
means the use of the rst generation cephalosporin to prevent
infection 24h before and after surgery.
Antipasmodic Therapy
Antipasmodic therapy is a routine treatment after microsurgery which is effective for the treatment and prevention of
postoperative vasospasm.
Anticoagulation Therapy
Anticoagulation therapy can prevent postoperative embolism, which is still a routinely recommended treatment and
should be used from 24 h after surgery. It is not recommended immediate use of heparin or low molecular heparin
which would easily cause bleeding in the surrounding tissue
and result in vascular crisis. And the drug should be stopped
in time if wound bleeding signicantly increased or other
tissue bleeding happens.
Postoperative Analgesia
Pain causes the body to release 5-HT which has a strong vasoconstrictor effect and would lead to vasospasm if it is not
treated in time. So postoperative analgesia is very necessary.
The routine method is let the anesthesiologist install a postoperative analgesia pump and assisted with parecoxib, compound diclofenac sodium, and other analgesia, even opioids
could be used when necessary. For those with lower pain
domain, spirit of high tension or infants and children, hibernation therapy could be used for analgesia when necessary.
8.1 Postoperative Treatment andManagement
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Neurotrophic Therapy
Neurotrophic medicines could be used after surgery such as
mecobalamin, etc.
Blood Volume Augmentation Therapy
It is generally recommended to use crystoloid solution with
40mL/kg/day to expand blood volume to avoid vascular crisis after nger reconstruction.
8.1.3 Judgment andManagement ofVascular
Crisis
Vascular crisis is a pathological phenomenon in which anastomotic blood vessels are blocked and the survival of transplanted and replanted tissues is endangered, which is divided
into arterial crisis and venous crisis in clinic, according to the
pathological classication it can be divided into vascular
embolism type and vasospasm type. The common vascular
crisis in clinic includes ve types: arterial thrombosis, arterial spasm, venous thrombosis, venous spasm, and arteriovenous thrombosis. Vascular crisis is one of the most common
and dangerous complications after microsurgery which
would directly lead to failure if it is not treated in time.
Arterial Crisis
Arterial Spasm
Most of them occur within 72h after surgery often due to
insufcient blood volume, pain, cold, mental stress or children crying, and other factors. The clinical manifestation of
arterial spasm is the color of the severed nger changes from
ruddy to pale, skin temperature drops, the capillary reaction
slows down, nger pulp is shriveled, and elasticity drops
which is not easy to be distinguished from arterial thrombosis in early stage.
Treatments: Arterial spasm should be rst considered
once arterial crisis occurs. To look for the cause of spasm
rst and carry out symptomatic treatment:if the room temperature is low, then raise it in time and strengthen the heat
preservation measures; if the spasm is caused by pain, analgesic drugs should be given in time; if the spasm caused by
changes of mood, the sedative should be used in time, etc.
After the above treatments, papaverine of 30–60mg should
be immediately intramuscularly injected, generally speaking, spasms can be relieved after 20–30 min. If it is not
relieved after 30–60min, refractory spasm or arterial thrombosis should be considered, and surgical exploration should
be performed immediately. We have encountered and
reported that the blood supply of replanted or reconstructed
ngers would be restored and nally survived without exploration after performing brachial plexus block anesthesia,
therefore nerve root block anesthesia also could be a method
of treatment for arterial spasm. During the operation, if arterial spasm is observed, papaverine could be injected into the
vascular outer membrane of the spasm segment or excised it,
the wound could be applied with warm salt water and papaverine wet gauze. If it still cannot be alleviated, the subcutaneous tunnel should be completely cut open, after the
thrombosis is eliminated, the method of segmental hydraulic
expansion, external membrane antipulling, continuous application of wet and warm papaverine could be adopted. After
operation, in addition to routine treatment, hibernation mixture should be used to make patients fall asleep and relieve
anxiety. If spasm occurs again, it is generally difcult to be
treated but should be excised and repaired with blood vessel
transplantation.
Arterial Thrombosis
Arterial thrombosis is usually caused by incomplete debridement, poor quality of anastomosis, high tension, local hematoma compression, excessive swelling and compression of
nger body, prolonged arterial spasm, and local infection
which is common within 24h and hard to be distinguished
from arterial spasm.
Treatments: Once arterial thrombosis is found or suspected, rapid intravenous infusion of 250mL normal saline
plus 200,000 units of urokinase or intravenous injection of
20 mL normal saline plus 100,000 units of urokinase from
brachial artery, if no improvements in 15–30min, exploration
should be performed immediately. During exploration, the
factors such as hematoma expression or skin compression
should be relieved rst. Embolus usually extends to the proximal end which could be still seen even after 3–5mm resection. At this time, the surgeons could use two micro tweezers
to gently pull the thrombus to the distal end and prevent it
from breaking. When the thrombus is completely pulled out,
a powerful blood spraying can be seen. If the proximal thrombus is not completely removed, it should be blocked again
with vascular clamp, and occulent substance can still be
seen after rinsing, then the segment of the artery should be
excised until the artery with a bright and complete lumen and
a powerful blood spraying can be seen. After the above treatments, if the blood vessel can be anastomosed without tension, it can be anastomosed again directly. If there is defect,
blood vessel transplantation should be performed.
Venous Crisis
The majority of clinical venous crisis are caused by venous
thrombosis which is also the most common vascular crisis
after nger reconstruction. Venous crisis is mainly caused by
low-quality of vein anastomosis, tortuous vein, high tension,
unreasonable ap design, extensive swelling of nger(toe)
body. Once venous crisis occurs, it should be dealt with in
time, otherwise, it will quickly develop into arteriovenous
crisis.
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8 Postoperative Management forFinger Reconstruction
Treatments: If the reconstructed nger is seriously swollen and has tension blisters, the affected limb can be raised
and tension blisters can be punctured, and also incisions at
the distal end of toe body to relieve the reux pressure; If the
skin is too tight, suture far away from the anastomosed site
could be removed, and remove the blood scab. At the same
time, rapid intravenous infusion of 250 mL normal saline
plus 200,000units of urokinase or intravenous injection of
20mL normal saline plus 100,000units of urokinase from
brachial artery, if no improvements in 15–30min, exploration should be performed immediately. During the exploration, 2–3 mm at the proximal side could be resected and
ushed with 1: 100 heparin normal saline until the lumen is
bright and complete. Embolus usually extends to the distal
end which could be still seen even after 3–5mm resection. At
this time, the surgeons could use two micro tweezers to gently pull the thrombus to the distal end and prevent it from
breaking. When the thrombus is completely pulled out,
venous blood will spill out. Sometimes exploration is too
late, venous thrombus extends too long to the distal end that
is difcult to be taken out with forceps, the surgeons can
squeeze the toe from far to near so that the thrombus could be
extruded and continuous venous blood ow can be seen.
After the above treatments, if the blood vessel can be anastomosed without tension, it can be anastomosed again directly.
If there is a defect, blood vessel transplantation should be
performed. Sometimes arterial crisis and venous crisis exist
at the same time, so we must be ready to judge and deal with
them both.
Treatments after Exploration
In order to prevent the occurrence of vascular crisis again,
while strengthening psychological counseling, sedation
treatment generally can be given, commonly used hibernation mixture, so that patients can fall asleep and get adequate
rest. Since the vascular intima is injured in different degrees
after exploration, thrombolytic treatment with small dose of
urokinase can be used, 100,000 units of urokinase plus
100mL of normal saline can be used once or twice a day, for
3–5days. In patients with condition, hyperbaric oxygen can
be added 3 days after exploration which can be used 1–2
times a day, and continue for 7–10days.
8.2 Cause Analysis andPrevention
ofVascular Crisis
With the development and improvement of nger reconstruction, many scholars have reported a high success rate,
but there are still some cases of failure. The incidence of vascular crisis after reconstruction is still high which is an
important factor that affects the success rate of surgery.
8.2.1 Cause Analysis
There are many reasons for vascular crisis, which may be
single or multiple exist at the same time, which are summarized as follows:
1. Physical mechanical factor: It is a major risk factor for
vascular crisis including pedicle compression, excessive
skin suture tension, skin graft compression, vascular
pedicle tortuous, hematoma compression, etc.
2. Mental and psychological factor: Among the patients of
nger reconstruction, a large part of them have experienced failure of nger replantation which has left a certain psychological shadow more or less. So a lot of
patients and their families are in the spirit of irrepressible tension which would lead to anxiety, difculty in
falling asleep, overstimulation of the sympathetic nerve,
increased blood catecholamine concentration, and contraction of small vascular smooth muscle, resulting in
spasm or even intractable spasm.
3. Vascular variation in the foot: The most common blood
supply system in toe-to-hand transfer is the dorsalis
pedics artery- deep plantar artery-rst dorsal metatarsal
artery system. Variation of dorsalis pedics artery is ne
or lack of, which reported between 4% and 6.7%. If
there is no preoperative CTA or MRA to assess variation
accurately, it will increase the risk of postoperative vascular crisis since the difculty in directly anastomosis
with radial artery needs a vein graft bridge vessel.
4. Intraoperative vascular damage: It will happen in the
process of dissociating tissue and dissection, surgeons
do not protect blood vessels enough, operate roughly,
pull blood vessels too much, forceps clamp damages, or
even cut or ligate blood vessels by mistake.
5. Unreasonable design of nger-toe joint ap: Since the
diameters of ngers and toes are not the same, the ap
must be designed reasonably. Otherwise, the skin suture
tension with be too large or the soft tissue will be exposed
which needs to be covered by skin graft. It is easy to
cause mechanical compression or exposure leading to
occurrence of vascular crisis.
6. Vascular crisis cannot be identied and explored in time:
Vascular crisis of nger reconstruction usually occurs
within 1–3days after surgery, and the high incidence is
within 12h. Therefore, an experienced nurse should be
arranged to observe the blood circulation every hour
within 24h after surgery and record it. Once any abnormality is found, it should be reported to the surgeon for
immediate treatment. If there is no improvement after
conservative treatment, surgical exploration should be
carried out immediately. According to incomplete statistics, try to explore as early as possible, the earlier the
Further Reading
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117
exploration is the higher the success rate will be, and the
prognosis will be poor after more than 8h.
7. Poor quality of vascular anastomosis: The level of
microvascular anastomosis is an important factor affecting the patency rate of blood vessels. The common problems in clinic include uneven suture distance, vascular
wall cavitation suture, high tension suture, vascular tortuosity, vascular intima injury, incomplete ligation, etc.,
which may lead to vascular crisis.
8. Unreasonable postoperative dressing change: When
changing the dressing, it must be done gently, avoid cold
stimulation, remove the blood clot around the wound
with warm saline, avoid irritating disinfectants such as
alcohol, etc. Some surgeons give the dressing work to
inexperienced doctors or interns who may operate
roughly, use irritating disinfectant or cold saline to wash
the wound, or not remove the blood scab around the
wound in time which may cause spasm.
9. Unreasonable postoperative medication: The early use
and too large dose of heparin after surgery will cause
extensive bleeding, subcutaneous hematoma leading to
vascular crisis, even hemorrhagic shock in severe cases.
According to our experience, anticoagulant therapy may
be avoided if vascular anastomosis is of high quality or
it is better to be used 12h later after surgery and it should
be stopped if excessive bleeding of the wound is found.
10. Higher incidence of vascular crisis in children: Since
children’s toe tissue structure is small and the difculty in
dissociating blood vessels that mean the incidence of vascular injury is high, coupled with the poor corporation
after surgery lead to higher incidence of vascular crisis.
11. Get out of bed too early: In general, patients should stay
in bed for 7–10 days after nger reconstruction. But
some patients have poor self-discipline after surgery,
and their defecation habit is not well trained, they
secretly get out bed to defecate which would lead to vascular crisis because of the position change.
12. Smoking: Some patients have a long history of smoking
before surgery, due to anxiety and smoking addiction
attack, they smoke secretly after surgery, or someone of
visitors smoke which may lead to vascular crisis.
Therefore, postoperative smoking ban must be paid
enough attention.
Prevention ofVascular Crisis
1. Inquire the history in detail to understand the patients’
mental state, sleep condition and smoking history, etc.
Positive psychological guidance will make them eliminate tension and actively corporate with treatment.
Smoking patients should be forced to quit smoking, and
bed defecation should be well-trained.
2. Careful preoperative evaluation of vascular condition of
the foot by Doppler ultrasound, CTA or MRA so as to be
condent in surgical design and operation.
3. In the process of dissociation, the surgeon should be careful and gentle to prevent vascular damage, especially in
those with variation, the surgeon should be calm and take
various measures to rebuilt vascular circulation.
4. Precise and accurate anastomosis should be carried out
for each blood vessel, and the proportion of arteries and
veins should be coordinated. Vessels with the same or
similar diameter should be selected for anastomosis as
far as possible so as to avoid tension and vascular tortuous. Wrong anastomosis of arteries and veins must be
avoided.
5. Reasonable preoperative design for donor and recipient
site is an important fact for successful reconstruction.
6. In the process of dissociation of toes, it is inappropriate to
carry too much subcutaneous tissue, especially around
the vascular pedicle, which would cause compression.
7. Strengthen training and communication between doctors
and nurses, enhance postoperative observation of blood
circulation and management experience, so as to nd vascular crisis and treat it in time.
8. Ward is rest environment for patients that should be light,
clear, quiet, sweet, comfortable, etc. Sedative drugs or
hibernation therapy could be applied for those who are
with mental strain and children. Smoking is forbidden.
Further Reading
Cheng GL. Replantation and reconstruction of nger. 2nd edition,
Beijing, People’s Publishing House, 2005.
Pei GX. Microsurgical Orthopaedics. Beijing, People’s Publishing
House, 2016.
Lin J, Zheng HP, Xu YQ, Zhang TH. Special Type of Finger
Replantation. Springer, 2018.
Functional Rehabilitation forFinger
Reconstruction
9
Abstract
Rehabilitation is to make those who lost some function
caused by illness, injury disability to restore and reconstruct as soon as possible by means of coordinated application of medicine, education, society, and occupation,
etc. Rehabilitation should not only focus on the disease
but also on the whole person which should be comprehensive recovery from physical, psychological, social, and
economical capacity.
Finger reconstruction is an effective method to reconstruct the damaged nger body caused by mechanical
injuries, trafc accidents, and other causes. However,
reconstruction surgery would just obtain the recovery of
appearance, functional rehabilitation still relies on systematic physical rehabilitation after surgery.
Keywords
Functional rehabilitation · Finger reconstruction
9.1 Staging ofFunction Rehabilitation
After Finger Reconstruction
Both of the reconstructed nger and the walking ability of
donor foot require the rehabilitation exercise by stages. The
rehabilitation task of early stage is to reduce muscular atrophy and joint contractures, promote tissue recovery, and
maintain health. One to 2 weeks after surgery is rehabilitation intervention stage for rehabilitation team to know about
the cause of injury, surgical method, and demands of surgeons and patients to make early function assessment and
judgment of function expectation. Proper placement of
shoulder, elbow, and ankle joints could prevent stiffness of
joints. Psychological counseling would alleviate anxiety and
depression of the patients and their families which would
also obtain understanding and cooperation with rehabilitation plan. Physiotherapy measures are not very needed in this
stage. Three to 4 weeks after surgery, in this stage, physical
measures should be carried out according to the principle of
early rehabilitation after fractures and nerve injury. Six
weeks after surgery, physical measures should be carried out
according to the principle of middle and later rehabilitation
after fractures and nerve injury. Sometimes special reformed
tools could be used for better activity of daily living recovery, such as extended toothbrushes and combs. Otherwise,
walking in bed with soft soles or walking in bed mat with
bare feet for 5–10min/tid is also needed.
9.2 Common Rehabilitation Methods
There are many functional rehabilitation methods for nger
reconstruction, including physical therapy, exercise therapy,
occupational therapy, traditional rehabilitation, occupational
and social rehabilitation, articial limbs, psychological therapy, and rehabilitation robots.
1. Physical therapy (Figs. 9.1, 9.2, and 9.3) It is a method
that takes use of natural or articial factors, such as electricity, light, sound, magnetism, heat, and motion act on
the body to reach the goal of rehabilitation which could
be chosen as needed: (1) To promote growth of granulation tissue and healing of skin and soft tissue is usually
with ultraviolet, infrared, and laser irradiation; (2) To promote healing of fractures is usually with ultrashort wave
electrotherapy and magnetic therapy; (3) Ultraviolet and
laser irradiation are often used for supercial inammation, and short wave, ultrashort wave, and microwave are
often used for deep inammation; (4) Traditional Chinese
medicine fumigation could be used in 2–4 weeks after
operation to improve skin nutrition, relieve swelling, and
pain; (5) Audio frequency-current therapy could be used
to soften scar and improve itching and pain symptoms
which should pay attention to the position of electrodes
and feeling of patients to avoid electric burning; (6)
Ultrasound therapy is performed by mobile method,
© Springer Nature Singapore Pte Ltd. 2023
J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_9
119
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Fig. 9.1 Audio electrotherapy
9 Functional Rehabilitation forFinger Reconstruction
Fig. 9.4 Joint activities during the rehabilitation
Fig. 9.2 Ultrasound therapy
Fig. 9.3 Keratherapy
1–1.5 W/cm2, 5–15 min for each site, once a day, and
15–20 times for a course of treatment; (7) Wax therapy is
usually used before exercise therapy to improve blood
circulation, soften scars, and relieve pains. But above all,
reasonable application of physical therapy is the right
way to achieve good results of rehabilitation.
Fig. 9.5 ADL training
2. Exercise therapy (Figs.9.4, 9.5, 9.6, 9.7, 9.8, 9.9, 9.10,
9.11, 9.12, 9.13, 9.14, 9.15, 9.16, 9.17, 9.18, 9.19, 9.20,
9.21, 9.22, 9.23, and 9.24) which is also called functional
exercise is basic rehabilitation method, including range of
motion exercise (ROM exercise), muscle function exercise, full-body exercise, and sensory exercise.
(a) ROM exercise: Each joint of hand has different con-
tracture law because of its special structure and function: (1) Thumb is prone to adduction contracture
which would lose abduction and opposition function;
(2) Collateral ligaments of metacarpophalangeal
joints are relaxed during exion and tense during
extension while interphalangeal joints are just opposite, so metacarpophalangeal joints are easily to construct in extended or overextended position and
interphalangeal joints are easily to construct in ex-
9.2 Common Rehabilitation Methods
Fig. 9.6 Exercise separating and paralleling ngers
Fig. 9.7 Holding function
ion position. Rehabilitation method: (1) Active or
passive motion, or a combination of both can contract
brous tissue and recover joint function gradually in
the early postoperative period (1 week after surgery);
(2) If joint function cannot be restored after early
exercise, manipulation or joint release can be performed after anesthesia, and then early continuous
passive movement (CPM) can be performed after
surgery. CPM is a relatively new treatment method
which x affected limb on special equipment that
drives the limb to do CPM for a long time, mainly for
prevention and treatment of joint adhesion and contracture caused by braking, to promote the repair of
articular cartilage, ligament, and tendon, and reduce
swelling.
Attention when applying CPM: (1) The method of exer-
cise can be selected according to the degree of articular contracture adhesion. In the early stage, when
passive movements of joints show greater elasticity
121
which will cause tension and pain, combination of
passive and active movements can be used. In those
with long course, since the lack of elasticity, passive
movements will not cause pain, joint traction and
other methods are needed to restore joint function
gradually; (2) Range of motion exercise or CPMs
should be stared 2–3 days after joint release, not continuous xation; (3) New pain should be avoided that
would lead to new injuries and muscle spasms which
could affect the outcome.
(b) Muscle function exercise: Posttraumatic immobiliza-
tion and the cessation of movement of adjacent joints
can rapidly lead to incapacitating muscular atrophy
except direct muscle damage or damage to its innervation. Incapacitating muscular atrophy is usually
reversible, but there is degeneration of the muscle in
those long-term and severe muscle atrophy which is
irreversible, such as the median nerve and ulnar nerve
injuries, of which intrinsic hand muscles usually cannot be recovered that still left to be solved. Muscle
contractions are usually divided into isotonic and isometric contractions which are necessary for daily life
and also can be used to prevent and treat muscle atrophy. In recent years, there are also isokinetic exercises and hand internal muscle exercises using special
equipment: (1) Isotonic exercise: Exercise muscles
with isotonic contractions which can be done by pulley system equal tension moment arm components
and so on; (2) Isometric exercise: Exercise muscles
with isometric contractions, such as the use of walls
and strength training equipment for isometric contractions, further use of equipment for multiple angle
isometric exercises in order to achieve hand exercises
in various aspects; (3) Isokinetic exercise: Using a
special isokinetic training equipment when exercising, the limb pushes the lever of the device around
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Fig. 9.8 Hand muscle developer
9 Functional Rehabilitation forFinger Reconstruction
Fig. 9.9 Extension and exion function exercise of the interphalangeal
joints
Fig. 9.10 Opponens function exercise by using the mobile phone
Fig. 9.11 Roller exercises for the joint function
Fig. 9.12 Playing mahjong exercises pinch, holding function
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