Upper extremity amputations are common injuries. Rates of limb salvage have increased during the last 20 years with improvements in microvascular techniques. Any patient desiring replantation should be referred to an appropriate facility. One should never promise the patient that replantation is possible. Patients are treated individually based on the nature and level of injury, associated medical conditions, time that has elapsed since the injury, and the patient’s personal desires.

By definition, replantation is a reattachment of a body part that has been totally severed from the body (complete amputation). A revascularization is reconstruction of blood vessels that have been damaged in order to prevent an ischemic body part from becoming nonviable or necrotic (incomplete amputation).

On initial assessment and treatment, the patient must be given realistic expectations about whether the injured part can be salvaged. In general, the indications for replantation include amputation of a thumb, multiple digits, or a limb through the forearm, wrist, or palm. Amputations through the elbow and proximal arm should only be replanted if the part is a sharp amputation or has minimal crush injury. Single digits distal to the insertion of the flexor digitorum profundus (FDP) tendon in the middle phalanx may be replanted in appropriate patients. A child with almost any body part amputated is a candidate, although the success rate of replantation in children is lower.

Contraindications include severely crushed or mangled parts, amputations at multiple levels, prolonged ischemic times, and amputations in patients with other serious injuries or medical illnesses. A variety of conditions may complicate limb reconstruction, including diabetes, peripheral vascular disease, smoking, or previous trauma to the affected limb. Individual fingers in adults amputated
proximal to the insertion of the FDP tendon should not be replanted because of the poor functional results that are obtained.

When the patient is being transferred from another institution, appropriate care of the patient and part must begin with the transferring institution. The part should be wrapped in gauze moistened with Ringer’s lactate or normal saline. This is placed into a plastic bag and sealed. The bag is then immersed into ice water (Fig. 1). The patient needs to be initially assessed and stabilized for transfer. A pressure dressing is applied to the stump. No attempt should be made to ligate bleeding vessels.

On arrival, a complete trauma assessment is required, particularly in amputations proximal to the wrist. Evaluation starts with the ABCs of resuscitation and includes assessment for associated injuries such as ipsilateral brachial plexus and cervical spine injuries.

The patient can be considered a candidate for replantation or revascularization after initial stabilization. The ischemia time should not exceed 6 hours when a significant amount of muscle is included in the amputated part. Digits that have been cooled have been successfully replanted up to 24 hours after amputation. In cases of incomplete amputation, perfusion via intact skin/muscle will extend the period of time that successful revascularization is possible. In all injuries, examination includes signs of tissue damage at sites remote from the site of amputation (e.g., segmental vessel injury, crush injury, burns, and evidence of tendon or nerve avulsion). The “ribbon sign,” a digital artery with multiple folds, is a sign of an avulsion injury. The “red stripe sign” is intramural hemorrhage in the walls of the digital vessel. Both of these indicate a lower chance of saving the injured part.