Source (Journal of Muscoskeletal Surgery and Research)

Fig 1: (a) Nerve anastomosis prep after completing vascular anastomosis; (b) right wrist in neutral position; and (c) full extension of the right wrist shows signs of nerve recovery
Fig 2: X-ray images before and after surgery.
Fig 3: (a) Completion of one vein and one artery anastomosis, 1: patent artery, 2: patent vein; and (b) proceeding with the next vein anastomosis, 3: pre-marked location of the vein.
Fig 4: (a) forearm bone fixation with intramedullary nailing, 1: forearm positioned on the C-arm machine for manipulation; and (b) harvesting the great saphenous vein for graft
Fig 5: Severed upper arm and microsurgical revascularization. (a) Pre-anastomosis and (b) hand pinking immediately after arterial reperfusion.


A 5-year-old girl presented to the emergency department 5.5 h after a traumatic amputation of her right arm following a motorbike accident. The child was wearing a one-armed shirt, with the other sleeve not occupied by her arm, which became entangled in the motorbike’s wheel, causing her to be thrown to the ground and resulting in the complete amputation of her right arm. She suffered a complete transection of major neurovascular structures, fractures of the humerus and both forearm bones, along with extensive soft-tissue loss. Specifically, a transverse fracture occurred in the upper third of both forearm bones, while a spiral oblique fracture occurred in the lower third of the right humerus. The triceps brachii, biceps brachii, and brachialis muscles were torn and avulsed in an irregular manner. The radial, ulnar, and median nerves were completely contused, and the brachial artery, along with the major venous structures of the arm, was completely severed. Significant amounts of dirt and sand were embedded within the wound. The case required meticulous planning to optimize replantation success within the limited ischemic time frame.

To maximize efficiency, three surgical teams operated concurrently in two separate rooms. One team performed debridement and fracture fixation using intramedullary K-wires 1.8 mm, another team prepared vascular grafts, and the third focused on revascularization and nerve repair. We conducted a soft-tissue evaluation and observed that after debridement, the muscles retained a pink color and responded to muscle contraction with thermal stimulation. There were no signs of complete tissue damage, and after flushing the vascular lumen post-debridement, the endothelium appeared smooth and pink. Therefore, we decided to proceed with vascular revascularization with shortening and complete grafting. The nerves were severed and crushed, requiring debridement of the radial, ulnar, and median nerve stumps, followed by microsurgical repair using epineural and fascicular techniques with 8.0 nylon sutures. We sutured the muscle with Vicryl 1.0 sutures and the tendon core with nylon 3.0 sutures. Despite successful arterial and venous anastomoses, the 1st post-operative day presented a major challenge: Significant bleeding at the intramedullary nail entry point, necessitating urgent re-exploration. Careful hemostasis was achieved without compromising revascularization, demonstrating the delicate balance required in pediatric microsurgical procedures.

We administered Unasyn 1.5 g intravenously at a dose of 200 mg/kg body weight/day, with intravenous injections every 6 h, in combination with gentamicin 0.08 g at a dose of 1.2 mg/kg/day, intramuscularly every 8 h. The wound condition was monitored daily, along with vital signs. A complete blood count was performed, which showed no signs of post-operative infection. Wound culture and sensitivity testing revealed continued susceptibility to Unasyn and gentamicin, so we decided to continue their use without switching to another antibiotic.

The patient was supported by the family in daily muscle strengthening exercises. We instructed the family to perform passive range-of-motion exercises for the baby’s shoulder, elbow, and hand, including simple exercises to assist with shoulder abduction and adduction, elbow flexion and extension, wrist flexion and extension, and finger movement. These exercises were to be repeated multiple times a day, with no limitation on the number of repetitions, with monthly radiographs to monitor bone healing during the first 3 months. Bone healing was confirmed to be complete, and all fixation devices were removed in the 8th month. Starting from the 3rd month post-surgery, the patient could flex and extend the elbow, and electromyography (EMG) showed recovery of the radial nerve. By the 4th month, wrist extension was possible. At the 12th month, the patient was able to flex the fingers, but thumb opposition had not yet been achieved [Video 1]. EMG at the 10th month indicated recovery of the median and ulnar nerves.

At the 12-month follow-up, the patient exhibited significant motor recovery, including wrist and finger extension [Table 1]. However, sensory restoration remained incomplete. This underscores the need for long-term follow-up and rehabilitation, which remains a challenge in pediatric microsurgery due to the geographical and economic barriers many families face.