Initial care of amputations Wendy Willmore
Outline Initial care of the patient, stump and amputated part Indications and contraindications for replantation
Initial care of the patient As necessitated by general ATLS principles Life before limb Don t become distracted by the mess
Initial care of the stump Bleeding Control with direct pressure Apply pressure dressing for any necessary transport If unsuccessful temporary use of a blood pressure cuff or pneumatic tourniquets are recommended
Initial care of the amputated part Should be cooled to about 4ºC to prolong viability First: rinse in sterile physiologic solution to cleanse Then: Option One Wrap in sterile gauze Soak in Ringer s Place in plastic bag Seal Option Two Place in plastic bag filled with sterile saline Put on ice (avoiding contact of part with ice)
Incompletely amputated parts Handle the part gently Avoid kinking or rotation of the part Wrap distal limb and part in sterile bandages Soak with sterile saline Apply ice pack to part Splint the works with padded splints and non-constricting wrapping
DON Ts Clamp or ligate vessels on either the stump or part Use non-pneumatic tourniquets on the stump Dissect or cannulate vessels until the definitive repair is being prepared for Use non-physiologic solutions such as EtOH, formalin, iodine, etc. on the part or stump Immediately throw away the part if it is not reimplantable it may be useful for covering the stump
Replantion Pre-operative evaluation H&P Appropriate investigations Type and X-match X-rays of both stump and parts Appropriate antibiotics Tetanus prophylaxis Avoid giving unrealistic expectations Consent for flaps and nerve, muscle, vessel and nerve grafts
General considerations Age of patient Severity of injury Level of amputation Part amputated Interval between amputation and time of replantation Multiple or bilateral amputations Segmental injuries to the amputated part Patient's general condition, including other major injuries or diseases Rehabilitation potential of patient (occupation and intelligence) Economic factors
Age Children More technically difficult because of size Rehabilitation is less reliable Generally achieve better functional results Consider reimplanting almost any part Elderly Limited by poor nerve regeneration and joint stiffness Less likely to achieve hand function with anything more proximal than the proximal forearm
Acceptable injury Guillotine Minimal local crush Minimal avulsion injury Some ring degloving injuries There should be minimal damage to the rest of the limb Severity of injury
Major limb replantation Lower limb Larger muscle mass more vulnerable to ischemia Without good sensation the foot is at risk for soft tissue breakdown Most patients do well with protheses May be considered in young, healthy patients with sharp, clean injury with little warm anoxia time especially in the distal third of the leg Above the elbow, at the elbow or proximal forearm Similar criteria to lower limb reimplantation May salvage if only to preserve a functioning elbow Instrinsic hand function is often poor
Hand amputations Zone III V Reasonable chance of function superior to prostheses Zone II Generally not performed unless multiple fingers Zone I good results Thumb Almost always is worth salvaging May transplant a finger
Multiple Injuries Segmental injuries to the amputated part Generally preclude replantation Multiple fingers Try to replant at least two at long and ring and thumb for opposable use Bilateral injuries Bilateral replantations do better than bilateral protheses At least try to replant the best limb and use the other for spare parts
Time Warm anoxia time Major limbs 4-6 h Digits 8 h Replanting parts late produces significant risk of sepsis and renal failure from myoglobinuria, acidosis Cool anoxia time Major limbs 10 12 h Digits 30 40 h
Patient s general condition Contraindications - relative Previous deformity or disability of limb Vascular diseases DM, RA, SLE, significant atherosclerosis Other severe systemic illness Severe concomitant injuries Incapacitating psychiatric illness Indications Economic factors re: occupation, cost of prothetics Intelligent, motivated patient
Recap Indications
Sources Canale: Campbell s Operative Orthopedics 10 th ed. 2003. Pederson WC. Replantation. Plastic and Reconstructive Surgery. 107(3):823-841. 2001.