Case Report

Split Viewer

Journal of Acupuncture Research 2023; 40(1): 61-66

Published online February 28, 2023

https://doi.org/10.13045/jar.2022.00241

© Korean Acupuncture & Moxibustion Medicine Society

Complex Korean Medicine Treatment after Elbow Replantation Following Traumatic Amputation: A Case Report

Eunbyul Cho †, Shin-Hyeok Park , Hyesoo Jeon , Nam Geun Cho

Department of Acupuncture & Moxibustion Medicine, College of Korean Medicine, Wonkwang University, Iksan, Korea

Correspondence to : Nam Geun Cho
Department of Acupuncture & Moxibustion Medicine, College of Korean Medicine, WonkwangUniversity, 460 Iksan-daero, Iksan 54538, Korea
E-mail: choandle@hanmail.net

Current Affiliation: KM Science Research Division, Korea Institute of Oriental Medicine, Daejeon, Korea

Received: September 23, 2022; Revised: January 20, 2023; Accepted: January 27, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Very few studies have been reported on upper extremity replantation following traumatic amputation. This case study aimed to report the progress of a patient treated with complex Korean medicine for 1 year after elbow replantation. The patient mainly complained of forearm sensory loss, muscle weakness, and hand pain after undergoing upper limb amputation and emergency replantation. He was hospitalized for approximately 50 days and then received outpatient treatment for approximately 10 months, followed by electroacupuncture, moxibustion, Chuna, herbal medicine, and transcutaneous electrical nerve stimulation. The muscle strength of the wrist joint improved to good (flexion) and fair (extension), and the forearm sensation was partially recovered approximately 10 months after the onset. To our knowledge, this is the first case report on replantation rehabilitation in Korean medicine, and it suggests that complex Korean medicine treatment might be beneficial for patients undergoing replantation after upper extremity amputation.

Keywords Hypesthesia; Moxibustion; Palsy; Replantation

Traumatic amputation corresponds to emergencies and requires replantation within a short period to reconstruct blood flow, unite fractures, regenerate amputated nerves, and suture the amputated tendon [1]. Patients with various levels of traumatic amputation exist and the possibility of replantation after traumatic amputation has increased with the development of postoperative intensive care although approximately 50 patients are diagnosed with traumatic amputation at the elbow level in South Korea annually [2,3]. Muscle strength and function recovery to daily life and work are important after replantation. A previous review indicated only 12 retrospective reviews and 1 case series worldwide on upper extremity replantation proximal to the wrist, from 2000 to January 2019. Most studies explored the surgical method, postoperative management, and long term follow-up of >2 years, with very few records on the treatment and management after the acute phase [4]. Further evidence on the progress of treatment from the acute to the subacute stage and various therapeutic approaches are needed because the accurate prediction of a patient’s chronic pain and dysfunction in the acute phase is limited [5]. Korean medicine treatments, such as acupuncture [6], electroacupuncture [7], and moxibustion [8], are known to be effective in treating peripheral nerve damage, which occurs with upper extremity amputation and is closely related to functional recovery. However, to our best knowledge, no studies have been reported on Korean medicine treatment after upper extremity replantation. Thus, this study aimed to report the progress of one patient who underwent complex Korean medicine treatment after elbow replantation approximately 1 year from the onset, in compliance with the Case Report guidelines [9].

A 50-year-old male patient was raced to Wonkwang University Hospital on December 3, 2020, after his left elbow was amputated by a pile driver. He did not have underlying diseases. Elbow replantation was performed (Fig. 1). Irrigation and debridement and split-thickness skin graft were performed for skin defect on the volar side of the forearm.

Fig. 1. The patient’s lateral elbow view (A) on December 3, 2020, (B) December 6, 2020, and (C) September 16, 2021. L, left.

The patient was hospitalized at Wonkwang University Korean Medicine Hospital from January 19, 2021, to February 19, 2021. He did not feel any pain or cutaneous sensations below the elbow. No movements of his left wrist and fingers were observed. The blood test results on January 20 revealed erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and hemoglobin levels of 2 mm/h, <0.5 mg/dL, and 11.2 g/dL, respectively. Acupuncture was performed once a day to the contralateral TE5, LI11, and GB34 to a depth of 5–10 mm, for 15 minutes. Single-use acupuncture needles (stainless steel 0.30 × 30 mm) were used. Transcutaneous electrical nerve stimulation (TENS) and infrared therapy were performed on the replanted forearm. Shipjeondaebo-tang [10] was prescribed for qi and blood exhaustion diagnoses (Table 1). The skin graft site dressing was applied daily and held on February 12. He first felt an aching pain in his left second finger on February 16. He was readmitted to the hospital from February 19 to March 5, where he was operated on, and rehabilitation treatments, including manual exercise and TENS, were performed (Fig. 2). The patient had numbness in the left forearm and left shoulder pain when lifting his arm upon rehospitalization on March 5. He had no cutaneous sensation below the elbow, and the strength of the wrist joint was grade 1+ and the finger joint was grade 0 as a result of a manual muscle test [11] that classifies muscle strength on a scale of 0–5. Treatment was limited to herbal medicine as the ward was operated in cohort isolation for 2 weeks due to the spread of coronavirus on March 8. The complete blood count, liver function test, ESR, and CRP of the patient that were examined on this day were all within the normal range.

Table 1 . Prescription and 1-day dose of Shipjeondaebo-tang during admission

Composition1-day dose (g)*
Astragalus membranaceus Bunge20–32
Panax ginseng C. A. Meyer16
Atractylodes japonica Koidzumi, Poria cocos Wolf, Rehmannia glutinosa Liboschitz ex Steudel, Paeonia lactiflora Pallas (Boiled with alcohol), Cnidium officinale Makino, Angelica gigas Nakai12
Cinnamomum cassia J. Presl, Glycyrrhiza uralensis Fischer8

*This herbal medicine was prescribed three times a day, 2 hours after meals.



Fig. 2. Timeline of the patient’s history and progress. Herbal medicine was prescribed three times a day. TENS, transcutaneous electrical nerve stimulation; Ext., extract.

The patient was discharged from the hospital on March 24 and visited as an outpatient five times a week. Acupuncture treatment for LI15, LI14, SI9, SI10, TE12, HT2, PC2, and LU3; TENS; and infrared therapy for 15 minutes in the forearm area were performed every time. Electroacupuncture (SI9–SI10 and LI14–LI15 at 120 Hz for 15 minutes), moxibustion, and Chuna (myofascial Chuna that compresses and relaxes the fascia along the median, ulnar, and radial nerve pathways in the forearm and wrist) were performed once or twice a week. Moxibustion was alternately performed on the median (PC3, PC4, and PC7), ulnar (HT3, HT4, and HT7), and radial nerve (LI5, LI7, LI10, and LI11) pathways and Ex-UE 9. Acupuncture was applied to the tender points in the shoulder when shoulder pain occurred. The patient complained of dryness in the left forearm and fatigue from May 31; thus Bojungikgi-tang (Soft Extract) was continuously prescribed. Finger flexion was observed and wrist joint strength was improved to grade 4 of flexion and grade 3- of extension on June 19 (Tables 2, 3). The patient first felt a sensation during TENS on August 13. The wrist extension muscle strength improved to grade 3 on September 11, and the wrist flexion and extension were 25° and 24° by measuring the range of motion (ROM) with a goniometer (Baseline, Fabric Enterprises Inc.). The finger flexion strength remained grade 1, without finger extension movements. He had incomplete sensation upon soft touch at the proximal one-half of the forearm but not any at the distal one-half of the forearm and hand (Table 4). Wrist flexion was restored to grade 4, wrist extension to grade 3, and finger flexion to grade 2- on November 15, but finger extension movements remained not observed. He continued to feel his hands freeze from the cold air because the weather turned cold. Treatment was terminated on January 25, 2022. He took acetaminophen twice a day as prescribed by the hospital where he had surgery throughout the treatment period.

Table 2 . Left upper extremity range of motion of the patient

MovementJanuary 19March 5June 19September 11
Shoulder flexion (°)N/T120145150
Shoulder abduction (°)N/T12080115
Elbow flexion (°)100115120115
Elbow extension (°)−30−20−15−20
Wrist flexion (°)N/TN/T2025
Wrist extension (°)N/TN/T524

N/T, not testable.



Table 3 . Manual motor test results of the patient

MovementJanuary 19January 31March 5June 19September 11November 15
Elbow flexionN/G+N/G+N/G+N/N−N/N−N/N−
Elbow extensionN/G+N/G+N/G+N/G+N/N−N/N−
Wrist flexionN/ZN/T+N/T+N/GN/GN/G
Wrist extensionN/ZN/ZN/T+N/F−N/FN/F
Finger flexionN/ZN/ZN/ZN/TN/TN/P−
Finger extensionN/ZN/ZN/ZN/ZN/ZN/Z

N, normal; G, good; F, fair; P, poor; T, trace; Z, zero.



Table 4 . Changes in the patient’s pain and sensitivity

DatePatient’s pain and sensitivity
January 1, 2021Had no pain and cutaneous sensation below the left elbow
February 16First felt an aching pain in the left second finger
March 5Felt numbness in the left forearm, but still no cutaneous sensation below the elbow
May 31Feeling of dryness in the left upper extremity
July 6No pain in the forearm, but stinging pain in the entire left hand
August 13Feeling electrical sensation during TENS
September 11Feeling dull sensation upon soft touch at the proximal one-half of left forearm, but not any soft touch, pinprick touch, or temperature sensation at the distal one-half of the forearm and hand
November 9Left hand pain like freezing
January 10, 2022Pain as if the hand freezes when exposed to cold wind

TENS, transcutaneous electrical nerve stimulation.



The Disabilities of the Arm, Shoulder, and Hand (DASH) is a tool that evaluates the symptoms, movements, and performance of the upper extremities based on the patient’s condition in the last week [12]. The patient’s DASH performance score was 82.5 on September 13. The score was 81.0 on November 16, and the patient responded with “moderate difficulty” in making a bed, carrying a heavy object, managing transportation needs, and “mild difficulty” in washing or drying hair. Items that have decreased by 2 points include “carry a heavy object (over 5 kg)” and “limitation in the work or other regular daily activities.” The patient can be graded 4 (Poor) by Chen’s functional criteria, which is a representative index to evaluate function after upper extremity replantation [13], because of finger ROM limitation and weakness, as of September 11. Regarding the Korean medicine treatment, the patient said, “I think that Korean medicine helps relieve pain. On days without treatment, such as Sunday, the pain got worse. And I felt less pain and more comfortable when I was treated with moxibustion.”

This case demonstrated no diagnostic challenges. During the entire treatment, invasive treatment below the elbow joint was not performed. Only one adverse event was reported. A first-degree burn occurred after moxibustion on the left PC7; however, it fully recovered over time.

Blood circulation and pain control are required after replantation, and sensory and motor function recovery for returning to work is important in the long term [14]. Complex Korean medicine treatments, including acupuncture, moxibustion, Chuna, herbal medicine, and physical therapy, were provided for pain control, functional recovery, and promoting qi and blood after elbow replantation in this case.

The patient’s recovery of wrist muscle strength, in particular the flexors, was significant, considering that the wrist is involved in movements related to the quality of life, such as carrying a heavy object or washing or drying hair, which the patient regarded as mild or moderate difficulty. The patient began to feel pain 2.5 months after the replantation and sequentially felt numbness, dryness, and a freezing feeling in the left forearm upon the examination of pain and sensory changes. The sensory of the forearm was recovered partially and gradually. Our patient’s ROM is larger than those reported in a previous study by Sugun et al. [15], in which patients who underwent elbow replantation as a result of 11.3 years of follow-up had, on average, 3.3° of wrist flexion, 18.3° of wrist extension, and 72.5° of elbow flexion. The patient’s incomplete sensory, muscle weakness, and ROM limitation suggest nerve damage. However, the decreased temperature in the distal forearm and hand was not detected by palpation, and no necrotic area was observed, suggesting no problem with blood circulation. His left shoulder pain seemed to be caused by the excessive use of his shoulder instead of the elbow, but the pain decreased with acupuncture treatment. Thus, acupuncture could relieve pain in areas that are used compensatory due to replantation.

We attempted to achieve left-right balance by Geojabeop (contralateral acupuncture) [16] on TE5 and LI11, located at the right forearm and elbow. GB34 was chosen to prevent and reduce muscular atrophy. One of eight meeting points is gathered in GB34 in Korean medicine where the tendon meets [17], and it has been reported to alleviate muscle weight loss in disuse muscle atrophy [18]. Moxibustion and Chuna were mainly performed on the forearm for nerve regeneration after peripheral nerve injury [8], relaxation of fasciae, blood circulation, and removal of tender points [19]. The patient experienced pain relief and strength during or after moxibustion treatment, and both the practitioner and patient could simultaneously feel the loss of tenderness. Thus, Chuna and moxibustion, which are non-invasive, may be considered as a priority for the treatment of replantation patients among various treatments.

This study has limitations. This study reported a single case in which the follow-up period was not long and the most effective treatment was unknown. The outcome of this patient is not so good, considering the previous review that the average DASH score was 40.4 regardless of the replantation level, and 21% of elbow replantation was graded 4 (Poor) by Chen’s functional criteria [4]. Changes in the patient’s pain were not quantitatively identified because they changed frequently. However, only a few studies were reported on upper extremity replantation worldwide. A previous review revealed that the number of elbow replantation was the lowest, accounting for approximately 10% of study participants among the upper extremities, making this case relatively rare [4]. This study is different in that it specifically described the patient’s progress in the short term while previous studies followed up in the long term over several years. Further studies, including observational studies and retrospective chart reviews on replantation, are needed.

We appreciate the patient for allowing us to use the medical records and report this case.

Conceptualization: EC, NGC. Data curation: EC, HJ. Formal analysis: EC. Investigation: EC. Methodology: EC. Supervision: NGC. Visualization: EC. Writing – original draft: EC, SHP. Writing – review & editing: All authors.

Informed consent was obtained from the patient to publish this case report. This study was exempted from the Institutional Review Board (IRB) of Wonkwang University Korean Medicine Hospital (IRB No. WKUIOMH-IRB-2021-10).

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Article

Case Report

Journal of Acupuncture Research 2023; 40(1): 61-66

Published online February 28, 2023 https://doi.org/10.13045/jar.2022.00241

Copyright © Korean Acupuncture & Moxibustion Medicine Society.

Complex Korean Medicine Treatment after Elbow Replantation Following Traumatic Amputation: A Case Report

Eunbyul Cho †, Shin-Hyeok Park , Hyesoo Jeon , Nam Geun Cho

Department of Acupuncture & Moxibustion Medicine, College of Korean Medicine, Wonkwang University, Iksan, Korea

Correspondence to:Nam Geun Cho
Department of Acupuncture & Moxibustion Medicine, College of Korean Medicine, WonkwangUniversity, 460 Iksan-daero, Iksan 54538, Korea
E-mail: choandle@hanmail.net

Current Affiliation: KM Science Research Division, Korea Institute of Oriental Medicine, Daejeon, Korea

Received: September 23, 2022; Revised: January 20, 2023; Accepted: January 27, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Very few studies have been reported on upper extremity replantation following traumatic amputation. This case study aimed to report the progress of a patient treated with complex Korean medicine for 1 year after elbow replantation. The patient mainly complained of forearm sensory loss, muscle weakness, and hand pain after undergoing upper limb amputation and emergency replantation. He was hospitalized for approximately 50 days and then received outpatient treatment for approximately 10 months, followed by electroacupuncture, moxibustion, Chuna, herbal medicine, and transcutaneous electrical nerve stimulation. The muscle strength of the wrist joint improved to good (flexion) and fair (extension), and the forearm sensation was partially recovered approximately 10 months after the onset. To our knowledge, this is the first case report on replantation rehabilitation in Korean medicine, and it suggests that complex Korean medicine treatment might be beneficial for patients undergoing replantation after upper extremity amputation.

Keywords: Hypesthesia, Moxibustion, Palsy, Replantation

INTRODUCTION

Traumatic amputation corresponds to emergencies and requires replantation within a short period to reconstruct blood flow, unite fractures, regenerate amputated nerves, and suture the amputated tendon [1]. Patients with various levels of traumatic amputation exist and the possibility of replantation after traumatic amputation has increased with the development of postoperative intensive care although approximately 50 patients are diagnosed with traumatic amputation at the elbow level in South Korea annually [2,3]. Muscle strength and function recovery to daily life and work are important after replantation. A previous review indicated only 12 retrospective reviews and 1 case series worldwide on upper extremity replantation proximal to the wrist, from 2000 to January 2019. Most studies explored the surgical method, postoperative management, and long term follow-up of >2 years, with very few records on the treatment and management after the acute phase [4]. Further evidence on the progress of treatment from the acute to the subacute stage and various therapeutic approaches are needed because the accurate prediction of a patient’s chronic pain and dysfunction in the acute phase is limited [5]. Korean medicine treatments, such as acupuncture [6], electroacupuncture [7], and moxibustion [8], are known to be effective in treating peripheral nerve damage, which occurs with upper extremity amputation and is closely related to functional recovery. However, to our best knowledge, no studies have been reported on Korean medicine treatment after upper extremity replantation. Thus, this study aimed to report the progress of one patient who underwent complex Korean medicine treatment after elbow replantation approximately 1 year from the onset, in compliance with the Case Report guidelines [9].

CASE REPORT

A 50-year-old male patient was raced to Wonkwang University Hospital on December 3, 2020, after his left elbow was amputated by a pile driver. He did not have underlying diseases. Elbow replantation was performed (Fig. 1). Irrigation and debridement and split-thickness skin graft were performed for skin defect on the volar side of the forearm.

Figure 1. The patient’s lateral elbow view (A) on December 3, 2020, (B) December 6, 2020, and (C) September 16, 2021. L, left.

The patient was hospitalized at Wonkwang University Korean Medicine Hospital from January 19, 2021, to February 19, 2021. He did not feel any pain or cutaneous sensations below the elbow. No movements of his left wrist and fingers were observed. The blood test results on January 20 revealed erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and hemoglobin levels of 2 mm/h, <0.5 mg/dL, and 11.2 g/dL, respectively. Acupuncture was performed once a day to the contralateral TE5, LI11, and GB34 to a depth of 5–10 mm, for 15 minutes. Single-use acupuncture needles (stainless steel 0.30 × 30 mm) were used. Transcutaneous electrical nerve stimulation (TENS) and infrared therapy were performed on the replanted forearm. Shipjeondaebo-tang [10] was prescribed for qi and blood exhaustion diagnoses (Table 1). The skin graft site dressing was applied daily and held on February 12. He first felt an aching pain in his left second finger on February 16. He was readmitted to the hospital from February 19 to March 5, where he was operated on, and rehabilitation treatments, including manual exercise and TENS, were performed (Fig. 2). The patient had numbness in the left forearm and left shoulder pain when lifting his arm upon rehospitalization on March 5. He had no cutaneous sensation below the elbow, and the strength of the wrist joint was grade 1+ and the finger joint was grade 0 as a result of a manual muscle test [11] that classifies muscle strength on a scale of 0–5. Treatment was limited to herbal medicine as the ward was operated in cohort isolation for 2 weeks due to the spread of coronavirus on March 8. The complete blood count, liver function test, ESR, and CRP of the patient that were examined on this day were all within the normal range.

Table 1 . Prescription and 1-day dose of Shipjeondaebo-tang during admission.

Composition1-day dose (g)*
Astragalus membranaceus Bunge20–32
Panax ginseng C. A. Meyer16
Atractylodes japonica Koidzumi, Poria cocos Wolf, Rehmannia glutinosa Liboschitz ex Steudel, Paeonia lactiflora Pallas (Boiled with alcohol), Cnidium officinale Makino, Angelica gigas Nakai12
Cinnamomum cassia J. Presl, Glycyrrhiza uralensis Fischer8

*This herbal medicine was prescribed three times a day, 2 hours after meals..



Figure 2. Timeline of the patient’s history and progress. Herbal medicine was prescribed three times a day. TENS, transcutaneous electrical nerve stimulation; Ext., extract.

The patient was discharged from the hospital on March 24 and visited as an outpatient five times a week. Acupuncture treatment for LI15, LI14, SI9, SI10, TE12, HT2, PC2, and LU3; TENS; and infrared therapy for 15 minutes in the forearm area were performed every time. Electroacupuncture (SI9–SI10 and LI14–LI15 at 120 Hz for 15 minutes), moxibustion, and Chuna (myofascial Chuna that compresses and relaxes the fascia along the median, ulnar, and radial nerve pathways in the forearm and wrist) were performed once or twice a week. Moxibustion was alternately performed on the median (PC3, PC4, and PC7), ulnar (HT3, HT4, and HT7), and radial nerve (LI5, LI7, LI10, and LI11) pathways and Ex-UE 9. Acupuncture was applied to the tender points in the shoulder when shoulder pain occurred. The patient complained of dryness in the left forearm and fatigue from May 31; thus Bojungikgi-tang (Soft Extract) was continuously prescribed. Finger flexion was observed and wrist joint strength was improved to grade 4 of flexion and grade 3- of extension on June 19 (Tables 2, 3). The patient first felt a sensation during TENS on August 13. The wrist extension muscle strength improved to grade 3 on September 11, and the wrist flexion and extension were 25° and 24° by measuring the range of motion (ROM) with a goniometer (Baseline, Fabric Enterprises Inc.). The finger flexion strength remained grade 1, without finger extension movements. He had incomplete sensation upon soft touch at the proximal one-half of the forearm but not any at the distal one-half of the forearm and hand (Table 4). Wrist flexion was restored to grade 4, wrist extension to grade 3, and finger flexion to grade 2- on November 15, but finger extension movements remained not observed. He continued to feel his hands freeze from the cold air because the weather turned cold. Treatment was terminated on January 25, 2022. He took acetaminophen twice a day as prescribed by the hospital where he had surgery throughout the treatment period.

Table 2 . Left upper extremity range of motion of the patient.

MovementJanuary 19March 5June 19September 11
Shoulder flexion (°)N/T120145150
Shoulder abduction (°)N/T12080115
Elbow flexion (°)100115120115
Elbow extension (°)−30−20−15−20
Wrist flexion (°)N/TN/T2025
Wrist extension (°)N/TN/T524

N/T, not testable..



Table 3 . Manual motor test results of the patient.

MovementJanuary 19January 31March 5June 19September 11November 15
Elbow flexionN/G+N/G+N/G+N/N−N/N−N/N−
Elbow extensionN/G+N/G+N/G+N/G+N/N−N/N−
Wrist flexionN/ZN/T+N/T+N/GN/GN/G
Wrist extensionN/ZN/ZN/T+N/F−N/FN/F
Finger flexionN/ZN/ZN/ZN/TN/TN/P−
Finger extensionN/ZN/ZN/ZN/ZN/ZN/Z

N, normal; G, good; F, fair; P, poor; T, trace; Z, zero..



Table 4 . Changes in the patient’s pain and sensitivity.

DatePatient’s pain and sensitivity
January 1, 2021Had no pain and cutaneous sensation below the left elbow
February 16First felt an aching pain in the left second finger
March 5Felt numbness in the left forearm, but still no cutaneous sensation below the elbow
May 31Feeling of dryness in the left upper extremity
July 6No pain in the forearm, but stinging pain in the entire left hand
August 13Feeling electrical sensation during TENS
September 11Feeling dull sensation upon soft touch at the proximal one-half of left forearm, but not any soft touch, pinprick touch, or temperature sensation at the distal one-half of the forearm and hand
November 9Left hand pain like freezing
January 10, 2022Pain as if the hand freezes when exposed to cold wind

TENS, transcutaneous electrical nerve stimulation..



The Disabilities of the Arm, Shoulder, and Hand (DASH) is a tool that evaluates the symptoms, movements, and performance of the upper extremities based on the patient’s condition in the last week [12]. The patient’s DASH performance score was 82.5 on September 13. The score was 81.0 on November 16, and the patient responded with “moderate difficulty” in making a bed, carrying a heavy object, managing transportation needs, and “mild difficulty” in washing or drying hair. Items that have decreased by 2 points include “carry a heavy object (over 5 kg)” and “limitation in the work or other regular daily activities.” The patient can be graded 4 (Poor) by Chen’s functional criteria, which is a representative index to evaluate function after upper extremity replantation [13], because of finger ROM limitation and weakness, as of September 11. Regarding the Korean medicine treatment, the patient said, “I think that Korean medicine helps relieve pain. On days without treatment, such as Sunday, the pain got worse. And I felt less pain and more comfortable when I was treated with moxibustion.”

This case demonstrated no diagnostic challenges. During the entire treatment, invasive treatment below the elbow joint was not performed. Only one adverse event was reported. A first-degree burn occurred after moxibustion on the left PC7; however, it fully recovered over time.

DISCUSSION

Blood circulation and pain control are required after replantation, and sensory and motor function recovery for returning to work is important in the long term [14]. Complex Korean medicine treatments, including acupuncture, moxibustion, Chuna, herbal medicine, and physical therapy, were provided for pain control, functional recovery, and promoting qi and blood after elbow replantation in this case.

The patient’s recovery of wrist muscle strength, in particular the flexors, was significant, considering that the wrist is involved in movements related to the quality of life, such as carrying a heavy object or washing or drying hair, which the patient regarded as mild or moderate difficulty. The patient began to feel pain 2.5 months after the replantation and sequentially felt numbness, dryness, and a freezing feeling in the left forearm upon the examination of pain and sensory changes. The sensory of the forearm was recovered partially and gradually. Our patient’s ROM is larger than those reported in a previous study by Sugun et al. [15], in which patients who underwent elbow replantation as a result of 11.3 years of follow-up had, on average, 3.3° of wrist flexion, 18.3° of wrist extension, and 72.5° of elbow flexion. The patient’s incomplete sensory, muscle weakness, and ROM limitation suggest nerve damage. However, the decreased temperature in the distal forearm and hand was not detected by palpation, and no necrotic area was observed, suggesting no problem with blood circulation. His left shoulder pain seemed to be caused by the excessive use of his shoulder instead of the elbow, but the pain decreased with acupuncture treatment. Thus, acupuncture could relieve pain in areas that are used compensatory due to replantation.

We attempted to achieve left-right balance by Geojabeop (contralateral acupuncture) [16] on TE5 and LI11, located at the right forearm and elbow. GB34 was chosen to prevent and reduce muscular atrophy. One of eight meeting points is gathered in GB34 in Korean medicine where the tendon meets [17], and it has been reported to alleviate muscle weight loss in disuse muscle atrophy [18]. Moxibustion and Chuna were mainly performed on the forearm for nerve regeneration after peripheral nerve injury [8], relaxation of fasciae, blood circulation, and removal of tender points [19]. The patient experienced pain relief and strength during or after moxibustion treatment, and both the practitioner and patient could simultaneously feel the loss of tenderness. Thus, Chuna and moxibustion, which are non-invasive, may be considered as a priority for the treatment of replantation patients among various treatments.

This study has limitations. This study reported a single case in which the follow-up period was not long and the most effective treatment was unknown. The outcome of this patient is not so good, considering the previous review that the average DASH score was 40.4 regardless of the replantation level, and 21% of elbow replantation was graded 4 (Poor) by Chen’s functional criteria [4]. Changes in the patient’s pain were not quantitatively identified because they changed frequently. However, only a few studies were reported on upper extremity replantation worldwide. A previous review revealed that the number of elbow replantation was the lowest, accounting for approximately 10% of study participants among the upper extremities, making this case relatively rare [4]. This study is different in that it specifically described the patient’s progress in the short term while previous studies followed up in the long term over several years. Further studies, including observational studies and retrospective chart reviews on replantation, are needed.

ACKNOWLEDGMENTS

We appreciate the patient for allowing us to use the medical records and report this case.

AUTHOR CONTRIBUTIONS

Conceptualization: EC, NGC. Data curation: EC, HJ. Formal analysis: EC. Investigation: EC. Methodology: EC. Supervision: NGC. Visualization: EC. Writing – original draft: EC, SHP. Writing – review & editing: All authors.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare.

FUNDING

None.

ETHICAL STATEMENT

Informed consent was obtained from the patient to publish this case report. This study was exempted from the Institutional Review Board (IRB) of Wonkwang University Korean Medicine Hospital (IRB No. WKUIOMH-IRB-2021-10).

Fig 1.

Figure 1.The patient’s lateral elbow view (A) on December 3, 2020, (B) December 6, 2020, and (C) September 16, 2021. L, left.
Journal of Acupuncture Research 2023; 40: 61-66https://doi.org/10.13045/jar.2022.00241

Fig 2.

Figure 2.Timeline of the patient’s history and progress. Herbal medicine was prescribed three times a day. TENS, transcutaneous electrical nerve stimulation; Ext., extract.
Journal of Acupuncture Research 2023; 40: 61-66https://doi.org/10.13045/jar.2022.00241

Table 1 . Prescription and 1-day dose of Shipjeondaebo-tang during admission.

Composition1-day dose (g)*
Astragalus membranaceus Bunge20–32
Panax ginseng C. A. Meyer16
Atractylodes japonica Koidzumi, Poria cocos Wolf, Rehmannia glutinosa Liboschitz ex Steudel, Paeonia lactiflora Pallas (Boiled with alcohol), Cnidium officinale Makino, Angelica gigas Nakai12
Cinnamomum cassia J. Presl, Glycyrrhiza uralensis Fischer8

*This herbal medicine was prescribed three times a day, 2 hours after meals..


Table 2 . Left upper extremity range of motion of the patient.

MovementJanuary 19March 5June 19September 11
Shoulder flexion (°)N/T120145150
Shoulder abduction (°)N/T12080115
Elbow flexion (°)100115120115
Elbow extension (°)−30−20−15−20
Wrist flexion (°)N/TN/T2025
Wrist extension (°)N/TN/T524

N/T, not testable..


Table 3 . Manual motor test results of the patient.

MovementJanuary 19January 31March 5June 19September 11November 15
Elbow flexionN/G+N/G+N/G+N/N−N/N−N/N−
Elbow extensionN/G+N/G+N/G+N/G+N/N−N/N−
Wrist flexionN/ZN/T+N/T+N/GN/GN/G
Wrist extensionN/ZN/ZN/T+N/F−N/FN/F
Finger flexionN/ZN/ZN/ZN/TN/TN/P−
Finger extensionN/ZN/ZN/ZN/ZN/ZN/Z

N, normal; G, good; F, fair; P, poor; T, trace; Z, zero..


Table 4 . Changes in the patient’s pain and sensitivity.

DatePatient’s pain and sensitivity
January 1, 2021Had no pain and cutaneous sensation below the left elbow
February 16First felt an aching pain in the left second finger
March 5Felt numbness in the left forearm, but still no cutaneous sensation below the elbow
May 31Feeling of dryness in the left upper extremity
July 6No pain in the forearm, but stinging pain in the entire left hand
August 13Feeling electrical sensation during TENS
September 11Feeling dull sensation upon soft touch at the proximal one-half of left forearm, but not any soft touch, pinprick touch, or temperature sensation at the distal one-half of the forearm and hand
November 9Left hand pain like freezing
January 10, 2022Pain as if the hand freezes when exposed to cold wind

TENS, transcutaneous electrical nerve stimulation..


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May 31, 2024 Vol.41 No.2, pp. 75~142

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