1. Managements of pediatric digital injuries caused by automatic cup-sealing machine: Case report
曾琬玲 洪國書 李曜洲
國立成功大學附設醫院 整形外科

2. Preventable !

3. Case Report 2-year-9-month-old boy, 10 kg
Right multiple digits crush thermal injuries
2nd to 5th digits contact burn + EDC severance
3rd to 5th open fractures
5th incomplete amputation with circulation compromise
Volar skin and digital nerves remained only
Right hand crush injury - near-total amputation of LF at middle phalanx level → ulnar side digital nerve: intact → ulnar side digital artery: total severance repair with 10-0 Nylon → radial side neurovascular bundle: contusion → EDC tendon: total severance repair with 6-0 Prolene → flexor tendon: intact - MF/RF proximal phalanx: fracture → one 0.9mm K-pin at each digit - IF/MF/RF EDC tendons: total severance → repair with 6-0 Prolene

4. Debridement, bone, tendon, revascularization,
Protection by a custom-made box
Hourly monitor
Sedation
Chlorpromazine
Dextran-40, Aspirin, Dipyridamole
Chlorpromazine 1mg po Q12H
Aspirin 10mg QD
Dipyridamole 15mg BID
Dextran: 8ml/hr  4ml/hr

5. Post-OP 3 months follow-upR L 3M 3M
2016/04
RT HAND DEXTERITY: IMPAIRED Rt LF PIPJ ROM mild limited --> improved % 可綁鞋帶/自行脫衣服 DIP mild extension lag Rt LF DIP extension lag Rt hand grasping strength: 4 -->5 undressing, using smart phone+ ok R L

6. Special considerations in children
Discussion:
Special considerations in children
Anatomy / Physiology [1-5]
Better healing potential, less scar formation, better nerve regeneration, easier joint mobilization
Thinner skin  ↑ full-thickness necrosis
Epiphyseal growth plate
Sudden BP/HR drop, ↑ transfusion rate after replantation
Surgery [1-5]
More liberal + aggressive in indication of replantation
Alternative: composite graft in distal to DIP amputation
Size-related technique difficulty (< 10 kg)
More easily and severe vasospasm

7. Discussion Pediatric digital/hand injuries by cup sealing machine
Mechanism: thermal + crush ( ℃, 1-3 sec) (multilation)
Characteristic: dorsal side burn injury, thumb sparing
Severity: simple abrasion wounds to amputation
Lin HH, Huang WC, Tung KY, Chen HC. Clinical Experiences in Treatment of Heat-Press Injury of Pediatric Hand by Automatic Cup-sealing Machine. J Plast Surg Asso R.O.C. 2006;15:160-7
Tsai WP, Ling SC, Lee JW, Chiu HY. Replantation of Pediatric Multiple Digit Amputation Caused by an Automatic Cup-sealing Machine. J Plast Surg Asso R.O.C. 2007;16:352-9.
Tsai PL1, Scaglioni MF1, Lin TS1, Chen YC1. Combined Subdermal Pocket Procedure and Abdominal Flap for Distal Finger Amputations in a Toddler. Plast Reconstr Surg Glob Open Jun 5;3(5):e386.
2007, Tsai et al
2006, Lin et al
2015, Tsai et al

8. Pediatric hand trauma from automatic cup sealing machine
Age
Injury
Operation
f/u
outcome
2006
2y, F
Rt dorsal hand 3rd burn
STSG (d3)
6 m
ROM full
Rt IF,MF,RF burn with partial tendon necrosis
Joint fixation
Groin flap (d18)
10 m
Partial ankylose
2y, M
Lt 4th burn/crush hand
IF/MF compromised
Several debridement
Random flap (d14)
Several reconstruction
1 y
not pleased
2007
2y4m, M
Rt IF,MF,RF
incomplete amputation
Revascularization
Salvage (d2)
promising
2015
1y9m, F
amputation
Abdominal flap with subdermal pocket
4 y
good
Our case
2y9m M
Rt IF,MF,RF,LF
Tendon / bone
LF incomplete amputation 1y

9. Conclusion Pediatric digital/hand injuries by cup sealing machine
Complicated mechanisms, various severity
Management
Tailored
Bone: epiphyseal growth plate preservation
Other soft tissue: conservative
Revascularization: Technique demand (<10kg)
Specific procedures if needed eg. subdermal pocket
Care: as general (Chlorpromazine / sedation)
Preventable injury: machine design / regulation

10. Reference
Michalko KB1, Bentz ML. Digital replantation in children. Crit Care Med Nov;30(11 Suppl):S444-7
Abzug JM1, Kozin SH2. Pediatric replantation. J Hand Surg Am Jan;39(1):143-5.
Raja Mohan, BS, Zubin Panthaki, MD, and Milton B. Armstrong, MD. Replantation in the Pediatric Hand. J Craniofac Surg 2009;20:
Lefèvre Y1, Mallet C, Ilharreborde B, Jehanno P, Frajmann JM, Penneçot GF, Mazda K, Fitoussi F. Digital avulsion with compromised vascularization: study of 23 cases in children. J Pediatr Orthop Apr-May;31(3):
Shi D1, Qi J, Li D, Zhu L, Jin W, Cai D. Fingertip replantation at or beyond the nail base in children. Microsurgery Jul;30(5):380-5.
Buncke GM1, Buntic RF, Romeo O. Pediatric mutilating hand injuries. Hand Clin Feb;19(1):
Distal digital replantation. Plast Reconstr Surg Nov;132(5):
Fan KL1, Patel KM, Mardini S, Attinger C, Levin LS, Evans KK . Evidence to support controversy in microsurgery. Plast Reconstr Surg Mar;135(3):595e-608e.
Levin LS1, Cooper EO. Jazayeri L1, Klausner JQ, Chang J.J. Clinical use of anticoagulants following replantation surgery. Hand Surg Am Oct;33(8):
Lee JY1, Kim HS, Heo ST, Kwon H, Jung SN.Medicine (Baltimore). Controlled continuous systemic heparinization increases success rate of artery-only anastomosis replantation in single distal digit amputation: A retrospective cohort study Jun;95(26):e3979

11. Any question or comment?
Thank you!
Any question or comment?

12. Discussion Post-OP Pre-OP Intra-OP
Peri-operative managements of pediatric digital revascularization
- Vital signs
- Amputated part: avoidance of direct contact to ice
- Amputee: avoidance of direct clamp of vessels
[1-3,6]
- Warm/Cold ischemia time: 6/12 h
- Dextran-40: 8cc/kg/h after anastomosis
[1-3,6-7]
- Regional anesthesia
- Warm, X smoke/air conditioner*
- Immobilization: splinting, bed rest*
- Hourly monitor*
- Dormicum*, Chlorpromazine
- Dextran-40*, Aspirin*,
Dipyridamol*, Heparin
- Bloodletting: nailbed heparin
irrigation*, heparin-soaked pledget
- Antibiotics
[1-10]
Post-OP
Pre-OP
Intra-OP
level IV - V evidence [1-10]
* At our institution

13. Discussion Post-OP Pre-OP Intra-OP
Peri-operative managements of pediatric digital revascularization
- Vital signs
- Amputated part: avoidance of direct contact to ice
- Amputee: avoidance of direct clamp of vessels
[1-3,6]
- Warm/Cold ischemia time: 6/12 h
- Dextran-40: 8cc/kg/h after anastomosis
-[1-3,6-7]
- Regional anesthesia
- Warm, X smoke/air conditioner*
- Immobilization: splinting, bed rest*
- Hourly monitor*
- Dormicum*, Chlorpromazine
- Dextran-40*, Aspirin*,
Dipyridamol*, Heparin
- Bloodletting: nailbed heparin
irrigation*, heparin-soaked pledget
- Antibiotics
[1-10]
Post-OP
Pre-OP
Intra-OP
level IV - V evidence [1-10]
* At our institution

14. Discussion Post-OP Pre-OP Intra-OP
Peri-operative managements of pediatric digital revascularization
- Vital signs
- Amputated part: avoidance of direct contact to ice
- Amputee: avoidance of direct clamp of vessels
[1-3,6]
- Warm/Cold ischemia time: 6/12 h
- Dextran-40: 8cc/kg/h after anastomosis
[1-3,6-7]
- Regional anesthesia
- Warm, X smoke/air conditioner*
- Immobilization: splinting, bed rest*
- Hourly monitor*
- Dormicum*, Chlorpromazine
- Dextran-40*, Aspirin*,
Dipyridamol*, Heparin
- Bloodletting: nailbed heparin
irrigation*, heparin-soaked pledget
- Antibiotics
[1-10]
Post-OP
Pre-OP
Intra-OP
level IV - V evidence [1-10]
* At our institution