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Thumbs up, doc: The process of reattaching limbs

SINGAPORE — Barely six weeks after Mr Dzulziflee Ismail had his right thumb severed in a freak accident at work, he can now move the thumb again after doctors successfully reattached it in a four-hour surgery at National University Hospital (NUH).

SINGAPORE — Barely six weeks after Mr Dzulziflee Ismail had his right thumb severed in a freak accident at work, he can now move the thumb again after doctors successfully reattached it in a four-hour surgery at National University Hospital (NUH).

The 38-year-old driver recounted how, in September, he had “ripped the thumb off” when he instinctively pulled his hand away after it got caught in a stack of metal racks.

His co-worker retrieved the severed thumb, which paramedics later packed in ice.

Last month, an elderly woman made headlines when her hand was severed after it got stuck between HDB lift doors in Taman Jurong. 
Unlike Mr Dzulziflee’s case, however, reattachment surgery was not attempted on the 85-year-old woman, although paramedics managed to retrieve the hand.

This raises the question: When can a body part be reattached after an accidental amputation?

According to experts TODAY spoke to, several basic conditions need to be met before doctors decide whether or not to attempt limb reattachment surgery.

Known as replantation in medical lingo, the procedure is a complex one that may take anywhere from four to 20 hours, depending on the amputated part.

PRESERVING LIFE OVER LIMB

The first priority would always be “life over limb”, said Dr Sandeep Jacob Sebastin, consultant at the Hand and Reconstructive Microsurgery Centre at NUH.

This means the patient should not have other life-threatening injuries as the replantation surgery takes time and there will be blood loss, added Dr Peng Yeong Pin, hand surgeon at Gleneagles Hospital Singapore and Mount Elizabeth Novena Hospital.

“In general, younger patients have healthier blood vessels and better health reserves. They can tolerate long surgical procedures better. Older patients may have other illnesses, like diabetes and heart disease, and may not be able to tolerate long surgery with some blood loss,” said Dr Peng.

Other considerations include how badly damaged the amputated body part is and the time since the injury occurred.

Severed body parts that are too badly crushed are not suitable for reattachment surgery. Also, lower limbs are often not replanted as the nerves usually do not recover, added Dr Peng.

“Alternatives such as lower limb prosthesis will probably serve the patient better in these cases,” he said.

A RACE AGAINST TIME

Technically speaking, the major limbs — the arm, hand and leg — have a higher chance of successful reattachment compared with fingers or toes, said Dr Sebastin. This is because the blood vessels are larger and relatively easier to repair.

“But for such cases, surgery needs to be done fast to avoid muscle death,” he added. Reattaching a limb with dead muscle can lead to life-threatening complications.

Muscle usually deteriorates more quickly without blood supply — about four to six hours — compared with other types of tissue, such as bone and tendons. This makes a severed finger more resilient than an arm.

Dr Sebastin said: “There are no muscles in the finger, so reattachment of fingers — although technically difficult — can be done at a slower pace. However, if the amputation occurs through the forearm or arm, the possibility of muscle death is extremely high if blood supply to the muscle is not restored within four to six hours.”

In the elderly woman’s case, her unstable physiological state due to significant blood loss and multiple injuries rendered her unfit for the complex surgery, said Dr Sebastin.

“The badly crushed state of her hand and forearm were additional factors as to why reattachment was not possible,” he added.

In Singapore, such surgeries are done at NUH, Singapore General Hospital and Tan Tock Seng Hospital (TTSH). The Department of Orthopaedic Surgery at TTSH treats an average of 40 to 50 cases of replantations a year.

Every year, NUH sees three to four cases of major limb amputations, of which two to three are suitable for replantation. The hospital also sees approximately 10 to 15 finger amputations each month, of which three to four cases are suitable for replantation. Amputated fingers are the most commonly seen, followed by hand, toes, leg and other body parts, said Dr Sebastin.

Replantation facilities are also available at local private hospitals with practising hand and micro-surgeons, said Dr Peng.

THE ROAD TO RECOVERY

Even after a successful surgery, patients face a long road to recovery. Not all will regain normal function of their reattached limbs, said Dr Sebastin.

In general, major-limb reattachments tend to have poorer recovery. Body parts that have gone through sharp-cut amputations also tend to do better than if they were crushed or torn off, said Dr Peng.

Currently on the mend, Mr Dzulziflee hopes to go back to work eventually as he has a family to support. He has two children aged three and four years. Dr Sebastin said Mr Dzulziflee is expected to regain more than 90 per cent of his original thumb function.

However, it will take about six to nine months for him to regain sensation in the thumb.

Mr Dzulziflee said: “I’m so thankful the doctor managed to fix my thumb even though the veins are so tiny. Without it, I won’t be able to do many things or drive for a living again.”

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