Case Report: 2-Year-Old Boy with Grade 4 Avulsion Injury of the Hand Caused by a Conveyor Belt System

Introduction

In the western world, mutilating hand injuries such as amputations and severe avulsions are more common in the working population than in children (Pomares G et al. Orthop Traumatol Surg Res 2018; 104: 273–276).

An epidemiologic retrospective study from France identified 1715 traumatic upper-limb amputations over a 10-years period with the majority of cases involving middle-aged men (Pomares G et al. Orthop Traumatol Surg Res 2018; 104: 273–276). Systematic literature search using Pubmed on conveyor belt system injuries found few articles. A recent study analyses occupational traumatic injuries in offshore seafood processors in Alaska. Processing equipment and machinery were among the leading causes of injuries, accounting for 28% of traumata (Syron et al. J Safety Res 2018; 66: 169–178). Tiwari et al. describe a collective of six children who sustained motorized machine belt entrapment injuries (Tiwari P et al. Indian Pediatr 2020; 57: 66–68). Overall mortality and paraplegia rate were 33.3% each. Those accidents mainly occured in rural areas in India. The children were caught in the belt by their clothes while their parents were working nearby. Five patients were pulled through their torso, those with involved head were dead at the time of arrival. Only one had only his limbs involved. If a conveyor belt involves the hand, severe avulsion or crush injuries result.

The outcome of reconstructive surgery in hand avulsion injuries depends mainly on the initial degree of injury (Kay et al. J Hand Surg 1989; 14: 204–213). Finger avulsion injuries are classified according to Kay’s classification. In class I injuries, tissue perfusion is still normal. Kay II injuries already show inadequate blood flow but no fracture is present. In class III injuries, perfusion is restricted and there is either an associated fracture or a joint injury. Kay IV injuries cover complete digital deglovings or amputations (Kay et al. J Hand Surg 1989; 14: 204–213). Generally, replantations for sharp injuries show higher success rates than for avulsion or crush injuries (Goodman et al. J Hand Surg Am 2017;42:456–463).

In general, the age of pediatric patients is critical to the feasibility and success rate of finger replantations and reconstructive hand surgery.

Case report

A two-year-old boy, whose family owns a shoe box manufacturing business, had his left hand caught into a running conveyor belt and suffered a severe avulsion injury to his hand ([Fig. 1]). His parents managed to pull him out. The child was then transported to our pediatric hand surgery department by rescue helicopter. Immediate surgery revealed a grade 4 avulsion injury with amputation of the fingers II and III, bony defects of the metacarpus and carpus, avulsion of the ulnar artery and defect of the deep palmar arch. Furthermore, there was an avulsion of the median nerve and a subtotal avulsion of the ulnar nerve, avulsions of all flexor tendons and devascularization of fingers IV and V. A necrectomy with amputation of the finger rays II-IV was performed. The remaining distal portion of metacarpal V was transfixed to the os hamatum to bridge a large bony defect. Revascularization of DV was performed with a venous graft between the ulnar artery and the A9 artery with 9/0 and 11/0 sutures using a microsurgical technique. The N1, N2 and N9 nerves were reconstructed with nerve grafts from the amputated fingers II and III; N10 could be reconstructed directly by 8/0 epineural sutures. Furthermore, reconstruction of the flexor pollicis longus and flexor digitorum profundus V tendon was performed according to the technique of Kirchmayr-Kessler (central two-strand sutures with 5/0 braided non-absorbable sutures and fine adaptation with 6/0 sutures) and soft tissue defect coverage with local flaps and alloplastic material (Epigard) was realized ([Figs 2] [3]). To improve perfusion, the patient received continuous crystalloid infusions to maintain a target hematocrit of about 24% (Hb 8 mg/dl) for 24 hours. In addition, he received heparin 50IE/kg intraoperatively. Subsequently, Enoxaparin-Sodium 2×0.5 mg/kg daily and acetylsalicylic acid 1 mg/kg daily were administered for four weeks. Revascularization was successful.

Fig. 1 Directly after the accident

Fig. 2 After reconstruction

Fig. 3 Postoperative X-ray

After several days, the temporary skin coverage was replaced with full-thickness skin grafts from the groin. The transfixing K-wire of the replanted fifth ray could be removed after 55 days, and the osteosynthesis remained clinically stable.

Physical reconstitution was uneventful, the boy‘s digital motor activity was supported by ergotherapy. He is now able to grasp objects with his two remaining fingers ([Fig. 4]).

Fig. 4 Reconvalescence

Publication History

Article published online:
09 September 2022