Toka machine injury: Replantation left arm in a 5 year old

Toka machine injury: Replantation left arm in a 5 year old

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Case Report

Toka machine injury: Replantation left arm in a 5year old*

Ashish Gupta a,*, Harmandeep Singh Pawar b, Ritul Mehta c,Samta Goyal d

a Dept. of Plastic & Microvascular Surgery, SPS Apollo Hospitals Ludhiana, Indiab Dept. of Orthopaedics, SPS Apollo Hospitals Ludhiana, Indiac Dept. of Anaesthesia, SPS Apollo Hospitals Ludhiana, Indiad Dept. of Emergency, SPS Apollo Hospitals Ludhiana, India

a r t i c l e i n f o

Article history:

Received 23 December 2014

Accepted 14 February 2015

Available online xxx

Keywords:

Replantation

Child

Microvascular surgery

Psychological impact

* This is our original work and has not bee* Corresponding author. Tel.: þ91 977977111E-mail address: [email protected]

http://dx.doi.org/10.1016/j.apme.2015.02.0160976-0016/Copyright © 2015, Indraprastha M

Please cite this article in press as: Gupta(2015), http://dx.doi.org/10.1016/j.apme.2

a b s t r a c t

Replantation is defined as reattachment of a part that has been completely amputated-no

connection exists between the severed part and the patient. First Replantation was re-

ported in Boston in 1962 by Malt & McKhann in a 12 year old boy. Replantation of nearly all

amputated parts, should be attempted in healthy children. A 5 year old boy presented to

the emergency with history of complete amputation by avulsion of left arm by a fodder-

cutting machine which was successfully replanted within 6 h of injury in spite of the

avulsive nature of the injury. The superior regenerative capacity of children's nerves & soft

tissues, along with the potentially favourable psychological ramifications of improved

cosmesis, make this technically demanding operation most gratifying.

Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Replantation is defined as reattachment of a part that has

been completely amputated-no connection exists between

the severed part and the patient. In Boston in 1962, Malt &

McKhann successfully replanted the completely amputated

arm of a 12 year old boy.1 Replantation of nearly all amputated

parts, should be attempted in healthy children. Epiphyseal

growth continues after Replantation, sensibility is usually

good and useful function can be anticipated although range of

motion is often decreased. The success of surgery depended

upon the time interval between injury and arrival to hospital;

n presented at any meet1; fax: þ91 (0) 161 661717m (A. Gupta).

edical Corporation Ltd. A

A, et al., Toka machine015.02.016

Team approach to deciding the plan and sequence of surgery;

Resuscitation of the child in Emergency; Intra-operative

management of child for smooth intra-operative and post-

operative course and Paediatric intensive care for diagnosis

and management of reperfusion injury.

2. Case history

A 5 year old boy presented to the emergency with history of

complete amputation by avulsion of left arm (Fig. 1) by a

fodder-cutting machine (Toka Machine) (Fig. 2). The child

ing or event.1.

ll rights reserved.

injury: Replantation left arm in a 5 year old, Apollo Medicine

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http://dx.doi.org/10.1016/j.apme.2015.02.016



Fig. 1 e Amputated upper limb.


presented with hypovolemic shock with pressure dressing

over the stump in situ. The amputated limb was brought

wrapped in a cloth. The limb was washed with saline to

remove the dirt and debris and taken to Operation theatre by

the plastic surgery team for dissection of the neurovascular

pedicles and muscles which was done under loupe magnifi-

cation (�4) before the choild was to be wheeled into the

operation theatre. The Triage team resuscitated the child and

Fig. 2 e Fodder-cutting machine.

Please cite this article in press as: Gupta A, et al., Toka machine(2015), http://dx.doi.org/10.1016/j.apme.2015.02.016

the orthopaedic team brought the child to Operation theatre

for fixation of the proximal shaft humerus fracture with

locking titanium plate. The amputated limb was shortened by

2 cm and fixed to the humerus with locking titanium plate.

The radial nerve and triceps repair on the posterior aspect of

the arm with skin closure was done. The Brachial artery was

repaired with 6e0 prolene intermittent sutures first to reduce

the ischaemia time and the veins were allowed to bleed so as

to remove the products of anaerobic metabolism. The venous

repair was done by anastomosing the vena commetantes of

the brachial artery and the anticubital vein with 8e0 ethilon

suture intermittent under loupe magnification. The muscle

and nerve (median & ulnar) repair was carried out with the

elbow in flexion (Fig. 3). The nerve repair was done as a epi-

perineural fashion with 8e0 ethilon suture. The child was

managedwith post-operative heparin for 5 days and shifted to

oral warfarin on post-operative day 5 and discharged on 10th

post operative day (Fig. 4) with the elbow in flexion. The child

hadwound dehiscence over the posterior aspect which healed

by secondary intension. The bony union was complete over

both the fracture sites by the end of 2months (Fig. 5). The child

is on active physiotherapy and back to school, but lost to

follow-up.

3. Discussion

The (toka) fodder-cutting machine is an integral part of rural

families of Punjab. It has resulted in a large number of am-

putations in the past. Although chopping fodder is a common

rural household activity and many children work with the

machine as part of their family chores for making fodder.

Many cases of child workers with fodder machine-related

amputation have been documented. Fortunately the inci-

dence of this injury is on the decline yet patients still report to

the emergency with such catastrophic injuries. In this re-

ported case the child was standing next to the flywheel of the

toka machine when his clothes got caught in it causing it to

avulse the arm off the child's body.

Fig. 3 e Intra-operative view of neurovascular dissection

with bony fixation plate in situ.




Fig. 4 e Child with the replanted limb after discharge.

Fig. 5 e X-ray showing the periosteal reaction with bony

union at both fracture sites.

a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e4 3


In children, most amputations (unless the segment is

severely damaged) should be replanted because of high over

all success, satisfactory return of sensation, good total active

range of motion, and average bone growth of 93% compared

with the uninjured side. The superior regenerative capacity of

children's nerves & soft tissues, along with the potentially

favourable psychological ramifications of improved cosmesis,

make this technically demanding operation most gratifying.2

There are a set of acceptable conditions when a Replanta-

tion should and should not be performed.3 Indications: 1.

Thumb 2. All amputations in children 3. Multiple digits 4. The

palm, wrist, distal forearm. The contraindications are: 1.

Concomitant life threatening injury 2. Multiple segmental

injuries in amputated part 3. Extreme crush or avulsion 4.

Extreme contamination 5. Extremely prolonged ischaemia

time more than 6 h for levels proximal to mid-forearm 6.

Precluding systemic illness.

The success in the present case can be attributed to the 2 h

period when the patient arrived in the emergency with the

amputated limb; team effort in resuscitating the child and

achieving re-anastomosis of vessels within the 6 h warm

ischaemia time preventing reperfusion injury as muscle

necrosis.

The results of Replantation can be unfavourable in the

form of Total failure; Poor Function and/or an Anaesthetic

limb. These can be avoided or decreased by having an orga-

nized team approach to Replantation by reducing ischaemia

time; proper and quick bone fixation and use of appropriate

vascular clamps to prevent damage to vessels; Proper

assessment of the parts and adequate debridement to

bleeding live tissue on the proximal part and debriding loose

crushed tissue on the distal part; Meticulous nerve coaptation;

Adequate postoperative monitoring, splintage, and physio-

therapy; Vocational rehabilitation, if necessary.4

Any patient, who has suffered a traumatic amputation

from whatever cause, will definitely look forward to have his

limb or body part reattached to the body. The patient and the

relatives will go to any extent to have this facility available.

The onus of deciding to do reattachment or not, depends on

the surgeon and his team, also weighing into consideration

the pros and cons of reattachment. This includes well dis-

cussed criteria like ischaemia time, cause of injury, nature of

the wound, the trauma to the other parts of the body and

general condition of the patient, and definitely the vocation

and socioeconomic factors. I would also add that reattach-

ment surgery is a very demanding surgical procedure which

needs thewholehearted commitment and perseverance of the

surgeon and his team.5

Despite the fact that functional outcome of replanted

hands will never equal that of normal healthy counterpart,

Replantation has major functional, cosmetic and psychologi-

cal benefits. Our patients were very satisfied with their

replanted hands, which have helped them to return to a better

quality-of-life than they might otherwise have had.6

The limiting factor of this case studywas that the childwas

lost to follow-up and the neuro-motor recovery could not be

assessed.

Even though the viability of the limb has been established,

the functional results will only be evident after 9 months to 1





year. It can be aptly said that the battle has been won but the

war is far from over.

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

1. Malt RA, McKhann C. Replantation of a severed arm. JAMA.1964;189:716.


2. Beyermann K, Hahn P, Mutsch Y, et al. Bone growth after fingerreplantation in childhood. Handchir Mikrochir Plast Chir.2000;32:88.

3. KIm JY, Brown RJ, Jones NF. Pediatric upper extremityreplantation. Clinc Plast Surg. 2005;32:1.

4. Thomas AG. Unfavorable results in replantation. Indian J PlasticSurg. May-August 2013;46:2256e2264.

5. Cheng GL, Zhang NP, et al. Digital replantation in children:along term follow up study. J Hand Surg Am. 1998;23:635.

6. Mahajan RK, Mittal S. Functional outcome of patientsundergoing replantation of hand at wrist level e 7 yearexperience. Indian J Plastic Surg. SeptembereDecember2013;46:3555e3560.


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Toka machine injury: Replantation left arm in a 5 year old