Amputation Traumatic/replantation

Basics

Description

  • Partial amputations have tissue connecting the distal and proximal parts and are treated by revascularization.
  • Complete amputations have no connecting tissue and may be treated by replantation.
  • Both of the above are treated the same from an emergency standpoint.

Etiology

Traumatic amputations may result from machinery, powered hand tools, household appliances, lawnmowers, getting caught between objects, motor vehicle collisions, crush injuries, blast injuries, gunshot wounds, knives, degloving injuries to digits (ring avulsions), and animal bites.

Diagnosis

Signs and Symptoms

History
  • Exact time of injury is critical, as ischemia time predicts success for replantation:
    • Irreversible muscle necrosis begins at 6 hr of ischemia.
    • The temperature and amount of muscle present in the tissue predicts the tolerable ischemia time.
    • Amputated digits have little muscle and can tolerate more ischemia time:
      • Warm ischemia time of 8–12 hr
      • Cool ischemia time of as much as 24 hr
    • Amputated limbs have more muscle mass and can tolerate less ischemia time:
      • Warm ischemia time of 4–6 hr
      • Cold ischemia time of 10–12 hr
  • Mechanism of injury:
    • Clean-cut or “guillotine” amputations have better prognosis for replantation than crush or avulsion injuries.
  • Comorbid illnesses that hinder successful replantation:
    • Diabetes, peripheral vascular disease, rheumatologic disease, smoking
  • Handedness
  • Social history, including occupation and major hobbies

Physical Exam
  • Assessment and documentation of injured extremity is crucial.
  • Signs of neurologic compromise:
    • Loss of sensation and 2-point discrimination
    • Loss of active range of motion
  • Signs of vascular compromise in partial amputations:
    • Distal part dusky or cyanotic
    • Delayed capillary refill (>2 sec)
    • Diminished or absent pulses (Doppler or palpation)
    • Ribbon sign (twisting of the artery in the amputated digit or limb)
    • Use Allen test in hand injuries.
    • Pulse oximetry may be helpful.
  • Soft tissue: Assess skin, muscle, tendon, and nail bed integrity.
  • Identify exposed bone and fractures (gross deformity, tenderness, crepitus).

Essential Workup

ED workup includes obtaining an accurate history and physical exam, stabilizing the patient and injured part, and consultation or transfer if replantation is an option.

Diagnostic Tests and Interpretation

Lab
Preoperative lab studies, cultures from wounded area

Imaging
Radiographs of both amputated part and stump are important, but should not delay transport.

Diagnostic Procedures/Other
Determined by surgical consultant for replantation

Differential Diagnosis

  • Involves neurologic, vascular, and soft tissue integrity and potential for replantation/revascularization
  • Do not miss other major injuries with concurrent trauma.

Treatment

Pre Hospital

  • Collect all amputated body parts, including pieces of bone, tissue, and skin.
  • See “Initial Stabilization” for care of amputated parts during transport.
  • Transport patient and body parts to the nearest microvascular replantation center unless other major injuries require transport to the nearest trauma center:
    • Air transport from remote locations should be considered if ischemia time is of concern.

Initial Stabilization/Therapy

  • Consult surgical specialist as early as possible.
  • Establish IV access.
  • Limit blood loss:
    • Elevate injured limb.
    • Direct pressure using bulky pressure dressing or pressure points if ineffective.
    • Use tourniquet if above methods fail to give desired hemostasis (BP cuff 30 mm Hg > systolic BP [SBP]).
    • Partial amputations bleed more because of lack of both retraction and spasm of blood vessels.
  • Avoid further damage to injured part:
    • Avoid vascular clamps, cautery, vessel ligation, or debridement.
    • Avoid repeated exams of the stump or amputated part.
  • Care of amputated part (complete and partial):
    • Remove gross contamination/foreign material.
    • Gently irrigate with saline (avoid antiseptics).
    • Wrap in gauze moistened with saline.
    • Place in clean, dry plastic bag or specimen cup.
    • Place sealed bag/cup in ice water (half water, half ice) or refrigerate at 4°C.
    • Never place directly onto ice or into ice water.
    • Avoid dry ice to prevent freezing.
  • Care of the stump:
    • Irrigate with saline and cover with saline dampened gauze.
    • Splint if necessary; keep partial amputations as near anatomic position as possible.
    • Keep any fragments of tissue (even if seemingly insignificant) because they may be used for skin, bone, or nerve grafting
    • If limb amputation, may cannulate proximal artery with 18G cannula and irrigate with tissue preservation formula, but this should be at the discretion of the surgeon
  • Maintain normal blood volume with IV fluids or blood products if necessary.

Ed Treatment/Procedures

  • Tetanus prophylaxis
  • Adequate IV analgesia
  • Patient NPO
  • Prophylactic antibiotics if devitalized tissue, exposed bone, or contamination:
    • Cover Streptococcus, Staphylococcus aureus, and Clostridium perfringens
  • All patients are candidates for surgical repair until a specialist deems otherwise.
  • Limit ischemia time of the amputated part (i.e., early transfer if necessary).
  • Patient considerations in decision to replant:
    • Age
    • Occupation/handedness
    • Degree of motivation
    • General physical condition and underlying diseases, particularly diabetes mellitus, peripheral vascular disease
  • Indications for replantation (no absolute indications):
    • Thumb, any level (supplies 40% of hand function)
    • Multiple digits
    • Hand amputations through the palm and distal wrist
    • Individual digit distal to flexor digitorum superficialis tendon insertion and proximal to distal interphalangeal joint (DIP)
    • Some single-digit ring avulsion injuries
    • Arm proximal to midforearm (if sharp or moderately avulsed)
    • Virtually all pediatric amputations (younger patients have lower success rates but better functional outcomes)
  • Contraindications to replantation:
    • Severely crushed or mangled parts
    • Injuries at multiple levels
    • Psychotic patients who willfully self-amputated the part
    • Single-digit amputations proximal to the flexor digitorum superficialis muscle insertion
    • Amputated parts with tendons avulsed from musculotendinous junctions
    • Lower extremities rarely attempted and usually in children
    • Unstable patients secondary to other serious injuries or diseases
    • Older patients or those with contraindications to general anesthesia
    • Inappropriately prolonged ischemia time
  • Fingertip amputations: Most common type of upper extremity amputation:
    • Distal to DIP joint
    • Primary goals of treatment:
      • Maintenance of length
      • Good soft-tissue coverage
      • Painless fingertip with durable and sensate skin
      • Nail preservation
    • Better dorsal prognosis than ventral
    • No exposed phalanx:
      • Irrigate with saline, apply petrolatum-soaked gauze and allow to heal by secondary intention (best result in wounds <1 cm2).
    • Small amount of exposed phalanx:
      • Shorten bone with rongeur below level of the tissue and close by primary intention or allow to heal by secondary intention.
      • Any bone left exposed requires additional operative procedures and consultation.
      • Replantation is an option for cosmetic reasons or for occupational consideration (e.g., musicians).
    • Considered open fractures if phalanx exposed, thus antibiotics are indicated.
    • Preserve nail bed and nail to optimize function and cosmesis.
    • Treat subungual hematomas.
    • Splint to prevent trauma to healing fingertip.
    • Consultation required if significant loss of bone or soft tissue for possible graft or flap
  • Nonlimb amputations (penis, ear, nose): Amputated parts should be cared for similarly as above and emergently referred to a specialist for replantation:
    • Penile amputations: Most often secondary to self-mutilation and psychiatric illness
    • Successful replantation unlikely beyond 24 hr of cold ischemia or 6 hr of warm ischemia
    • Ear amputations: Should be considered for replantation by appropriate specialist
    • Nose amputations: Replantation has been successfully performed with variable results.

Pediatric Considerations
  • All pediatric amputations considered for replantation
  • Fingertip amputations often left to heal by secondary intention:
    • Spontaneous regeneration of fingertip occurs in children even with volar fingertip amputations.
    • Pediatric fingertip amputations distal to the lunula of the fingernail can be successfully replanted (unlike adults).


Geriatric Considerations
Advanced age not an absolute contraindication to replantation; however, underlying medical problems often make older patients poor surgical candidates.

Medication

  • First Line: Cefazolin: 0.5–1.5 g IV or IM q6–q8h (peds: 25–100 mg/kg/d divided q8h, max. 6 g/d)
  • Second Line: Vancomycin 15–20 mg/kg IV q12h
  • If concerned about clostridia, consider using Piperacilin/Tazobactam 80 mg/kg IV q8h

Ongoing Care

Disposition

Admission Criteria
Hospitalization is required for all patients undergoing replantation or revascularization.

Discharge Criteria
  • Mild fingertip amputations or mild degloving injuries with adequate repair and stable vasculature
  • Close surgical or orthopedic follow-up is required.

Issues for Referral
  • Know exact mechanism and time of injury
  • Refer as early as possible
  • Transfer imaging and amputated parts with patient, stored in appropriate medium

Follow-Up Recommendations

Patients discharged but with significant skin loss should be considered for skin grafting and have close surgical follow-up.

Pearls and Pitfalls

  • Every effort should be made to minimize ischemia time
  • Expeditious consultation or transfer to appropriate surgeon and team is paramount.
  • Avoid any direct contact of the amputated part with ice
  • Perform thorough ATLS survey to avoid missing other less obvious, but potentially life threatening, injuries

Additional Reading

  • Davis S, Chung KC. Replantation of finger avulsion injuries: a systematic review of survival and functional outcomes. J Hand Surg. 2011;36(4):686–694.
  • Lloyd MS, Teo TC, Pickford MA, et al. Preoperative management of the amputated limb. Emerg Med J. 2005;22(7):478–480.  [PMID:15983081]
  • Lyn ET, Mailhot T. Hand, Runyon M. The Genitourinary System; Mckay M, Mayersak R, Facial Trauma. In: Marx J, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice, 7th ed. Philadelphia, PA: Mosby/Elsevier; 2010.
  • Maricevich M, Carlsen B, Mardini S, et al. Upper extremity and digital replantation. Hand. 2011;6:356–363.  [PMID:23204960]
  • Sebastin SJ, Chung KC. A systematic review of the outcomes of replantation of distal digital amputation. Plast Reconstr Surg. 2011;128(3):723–737.  [PMID:21572379]

Codes

ICD-9

  • 885.0 Traumatic amputation of thumb (complete)(partial), without mention of complication
  • 886.0 Traumatic amputation of other finger(s) (complete) (partial), without mention of complication
  • 887.4 Traumatic amputation of arm and hand (complete) (partial), unilateral, level not specified, without mention of complication
  • 897.4 Traumatic amputation of leg(s) (complete) (partial), unilateral, level not specified, without mention of complication

ICD-10

  • Complete traumatic metacarpophalangeal amputation of unspecified thumb, initial encounter
  • Complete traumatic metacarpophalangeal amputation of unspecified finger, initial encounter
  • Partial traumatic metacarpophalangeal amputation of unspecified finger, initial encounter
  • Partial traumatic transphalangeal amputation of unspecified finger, initial encounter
  • Complete traumatic amputation at unspecified shoulder joint, initial encounter
  • Partial traumatic amputation at unspecified shoulder joint, initial encounter
  • Complete traumatic amputation of unspecified forearm, level unspecified, initial encounter
  • Complete traumatic amputation of unspecified hand at wrist level, initial encounter
  • Complete traumatic transphalangeal amputation of unspecified finger, initial encounter
  • Complete traumatic amputation of unspecified lower leg, level unspecified, initial encounter
  • Partial traumatic amputation of unspecified lower leg, level unspecified, initial encounter
  • Complete traumatic amputation of unspecified great toe, initial encounter
  • Partial traumatic amputation of one unspecified lesser toe, initial encounter

SNOMED

  • 262595009 Traumatic amputation (disorder)
  • 95855003 Traumatic amputation of finger (disorder)
  • 210771000 Traumatic amputation of limb (disorder)
  • 210611002 Traumatic amputation of thumb (disorder)
  • 125657004 Traumatic amputation of digit of hand (disorder)
  • 95860004 Traumatic amputation of lower extremity (disorder)

Authors

Charlotte A. Sadler


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