replantations for major amputations of the upper limb have been widely reported and performed at many centres around the world .
we report a case of successful replantation of complete avulsion amputation of the right upper limb at scapulothoracic level in a 3-year - old boy . in our literature search
a 3-year - old boy was brought to the emergency room around 3 h after sustaining an injury while playing in the fields .
his right upper limb accidentally got caught in the belt of a thresher machine and was avulsed from the chest wall .
the child was taken to a nearby hospital with the amputated part [ figures 1 and 2 ] from where he was referred to our hospital .
amputated limb ( dorsal aspect ) amputated limb ( ventralaspect ) on arrival , the child was stable and the amputated limb was well preserved . the patient was evaluated to rule out other injuries and prepared for surgery while an x - ray was done for the amputated part [ figures 3 and 4 ] .
x - ray of the amputated part on examination , the skin disruption was found to be at axillary level while the upper limb had avulsed from the chest wall along with the scapula and its attached muscles ( scapulothoracic dissociation ) .
the deltoid muscle was disrupted from its origin and found in the amputated stump with the skin retracted distally over it .
the cut ends of brachial artery and its accompanying vein were found retracted under the biceps muscle .
the brachial plexus was disrupted at cord level with distal cut ends of medial , lateral and posterior cords found alongside the transected vessels .
the posterior cord was found to be of longest length suggesting higher level of avulsion .
after thorough cleaning of the amputated limb , the brachial artery and its accompanying vein were dissected out and tagged .
the brachial artery was cannulated , and infusion of cold heparinised saline ( 5000 units in 500 ml ) started .
meanwhile , the patient was shifted to the operating room and anaesthetised . on exploration of the amputation stump ,
the axillary artery was found to be transected after the branch to the latissimus dorsi muscle .
the posterior cord was not found in the wound , and an incision was given in the supraclavicular region for exploration of the brachial plexus .
however , the proximal end of the posterior cord could not be found . since the level of transection of the axillary artery was after the take - off of the thoracodorsal and circumflex scapular arteries , the anticipated blood supply to the scapular muscles after replantation would have been doubtful .
furthermore , the approach to debride the subscapularis muscle in the event of necrosis following replantation would have been cumbersome and dangerous .
the supraspinatus and infraspinatus muscles were left attached to the scapula as even in the scenario of necrosis of these muscles following replantation , they would potentially be easily approached from the dorsal side . the amputated limb was then brought into the operative field [ figure 5 ] .
the dislocation of shoulder joint was reduced and fixed with a 1.5 mm k - wire . the fracture of glenoid neck was reduced and stabilised with two 1.5 mm k - wires .
acromioclavicular joint was fixed by a k - wire , and acromioclavicular joint capsular repair was performed by figure of 8 non - absorbable sutures .
the associated elbow dislocation was managed with closed reduction , and the fracture of ulna was managed by splinting .
amputated limb following fasciotomy and prepared amputation stump axillary vessels were dissected to the healthy end . since no bone shortening was feasible in this case , an end - to - end vascular anastomosis was not possible .
an 18 cm long saphenous vein graft was harvested from the left lower leg to reconstruct the segmental defects of the axillary artery and vein ( 8 cm each ) .
the total ischaemia time was nearly 8 h ( 1 h warm/7 h cold ) .
the distal end of the posterior cord was anastomosed end to side with the proximal medial cord .
there was persistent ooze from the scapular side , which was packed with laparotomy sponges .
intraoperatively , the patient was given unfractionated heparin and 3 paediatric units of blood were transfused .
after 48 h , the sponge packs were removed from scapular site in the operating room and no further oozing was encountered .
post - fasciotomy raw area was covered with split - thickness skin graft on day 20 .
the k - wires were removed on day 90 in the outpatient department , and the arm supported in a sling , and physiotherapy started [ figures 6 and 7 ] .
the last follow - up at 18 months post - operative showed evidence of recovery of crude touch sensations up to the digits .
one year post - operative ( frontal view ) one year post - operative ( oblique view )
nonetheless , they are worthwhile as reported in a large series by sabapathy et al . in 2007 as patients with successful replants put the hand to greater use . furthermore , as reported by otto et al . in 2015
, replantation of a traumatically amputated arm leads to good function and higher satisfaction rates than a prosthesis .
although few reports are available of successful shoulder level replantation , there is none for scapulothoracic level .
although venkatarama et al . in 2015 have reported a case of scapulothoracic avulsion amputation in a 18-year - old male , the replanted limb had to be amputated due to ensuing sepsis .
hence , to our knowledge , this is the first reported case of a successful replantation of a limb separated at scapulothoracic level .
literature is rife with reports of cases with scapulothoracic dissociation which is a closed avulsion injury caused by a severe traction injury and associated with massive soft tissue swelling of the shoulder , lateral displacement of the scapula and severe neurovascular injury .
scapulothoracic muscles are devascularised and have to be debrided . with no muscles being available for scapulothoracic fixation
bone shortening is not possible , and therefore , vascular reconstruction would always involve vein grafts .
however , with the patient being a child , a reasonable degree of neural recovery is expected .
furthermore , the replanted upper limb at this level would be better than any available prosthesis .
the child and family have been saved the stigma of an amputation which can have serious psychosocial issues .
although the child is doing fine at present , there is still a long road ahead for a reasonable functional recovery , and the secondary reconstructive procedures may be required .
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
 replantations for major amputations of upper extremity have been widely performed . 
 we report a unique case of successful replantation of scapulothoracic avulsion amputation in a child . in this manuscript 
 , we discuss the various challenges faced during the procedure and chances of neural recovery . 
INTRODUCTION
CASE REPORT
DISCUSSION
Declaration of patient consent
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