Tetanus following replantation of an amputated finger: a case report
A 49-year-old Japanese man whose gloved hand was caught between a gas cylinder and a concrete floor was taken to our hospital by ambulance. His right middle finger had been amputated in the distal interphalangeal (DIP) joint region, and his right ring finger was connected only by nerve and blood vessel bundles, showing a compound fracture of the distal phalanx (Figures 1 and 2). Our institute’s approach in cases of trauma is to inject tetanus toxoid and human anti-tetanus immunoglobulin (TIG) if the wound is dirty. In this case, no tetanus toxoid was injected since there was no soil contamination. The bone was comminuted, and the crushing was found to be severe, but replantation was considered appropriate, and replantation of the middle finger and osteosynthesis of the distal phalanx of the ring finger were performed on the day that our patient was injured.
Surgery was performed under axillary block anesthesia. After irrigation with 500mL of warm saline, the DIP joint of the middle finger was fixed, and the ulnar-side finger artery and dorsal cutaneous vein were anastomosed. In the ring finger, the distal phalanx was reduced and fixed. Minimal debridement was applied to only a part of the skin.
Our patient was admitted for observation. There were no infectious signs in his hand. His middle finger was successfully replanted, but his fingertip was partially necrotized because of crushing (Figure 3), and so additional reconstruction with a reverse digital arterial flap was performed 15 days after injury. The wound of his ring finger healed completely 18 days after the injury. No particular symptoms developed and there was no problem with the condition of the flap, but aggravation of lower back pain, trismus, and convulsion suddenly occurred 21 days after the injury (Figure 4). The wound of his middle finger was immediately inspected, and discharge of a whitish turbid exudate from the region around the flap was noted. The wound was opened and irrigated with a large volume of saline. No bacterium was detected on exudate culture, and isolation or identification was not possible. On the basis of the clinical symptoms, tetanus was diagnosed and treatment was initiated. TIG (6000 units) was intravenously administered on the day of onset, and 6000 units of TIG and 0.5mL of intramuscular tetanus toxoid were administered the following day. We administered treatment with penicillin antibiotics. However, the convulsions did not remit and, in fact, slowly became aggravated. Thus, tracheal intubation was performed, and our patient underwent artificial respiratory management. Anticonvulsant and sedative were concomitantly administered, but convulsion was readily induced by light stimulation, such as irrigation of the wound. The frequency and intensity of convulsive seizures started to decrease slightly at about 10 days after onset, and a tapering of the intravenous anticonvulsant injection was initiated. Our patient was weaned from the ventilator 12 days after onset. The distal phalanx fracture of his ring finger healed 6 weeks after the injury. Conservative treatment of the open wound of his middle finger was continued, and the wound healed 8 weeks after the injury. The fingertip morphology of his middle finger was relatively favorable, but owing to rest for tetanus treatment, rehabilitation could not be performed, and joint contracture remained in his right middle and ring fingers. No systemic problem occurred afterward, and our patient was discharged 12 weeks after the injury.
Fig.1 : Amputated middle finger shortly after the time of injury.
Fig.2 : X-ray of right hand shortly after the time of injury.
Fig.3 : Maximum mouth opening when trismus developed.
Fig.4 : The phalangeal region of the middle finger was partially necrotized.