Traumatic upper extremity amputation is a life-altering event, and recovery of function depends on proper surgical management and postoperative rehabilitation. Many injuries require revision amputation and postoperative prosthesis fitting. Care should be taken to preserve maximal length of the limb and motion of the remaining joints. Skin grafting or free tissue transfer may be necessary for coverage to allow preservation of length. Early prosthetic fitting within 30 days of surgery should be performed so the amputee can start rehabilitation while the wound is healing and the stump is maturing. Multidisciplinary care is essential for the overall care of the patient following a traumatic amputation of the upper limb.
Key points
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Initial management of the acute traumatic upper extremity amputation begins with the principles of advanced trauma life support including achievement of hemostasis, a thorough neurovascular examination, imaging, appropriate care for the amputate, debridement of devitalized tissue, antibiosis and tetanus prophylaxis, and fracture stabilization.
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Care for the traumatic amputee should be multidisciplinary to provide medical, surgical, rehabilitative, social, and psychological support.
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Replantation, when indicated, should be performed by a replantation specialist at a replantation center.
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Revision amputation should aim to preserve the maximum length of the limb and motion in the major joints, allowing for maximal function.
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Initial postoperative care should focus on preparation of the stump for prosthesis wear and minimizing complications.
Introduction
A major traumatic amputation of the upper limb, which includes injuries proximal to the carpus, is a rare but significant life-altering event. According to the National Trauma Databank, 0.09% of persons hospitalized after trauma sustained a major upper limb amputation and 34,000 people are living with a major amputation in the United States alone. Most of these injuries occur as the result of blunt trauma, with motor vehicle collisions being the most common mechanism. However, penetrating and blast injuries that result in upper limb amputation are becoming more prevalent with the US military’s involvement in Iraq and Afghanistan during the past 14 years.
Appropriate management of traumatic upper limb amputation is imperative to reduce associated morbidity and mortality while allowing the amputee to reestablish meaningful function in the effected limb. This article reviews contemporary management of traumatic upper limb amputations, with specific focus on initial management, tissue debridement, revision amputation, and postoperative complications.
Introduction
A major traumatic amputation of the upper limb, which includes injuries proximal to the carpus, is a rare but significant life-altering event. According to the National Trauma Databank, 0.09% of persons hospitalized after trauma sustained a major upper limb amputation and 34,000 people are living with a major amputation in the United States alone. Most of these injuries occur as the result of blunt trauma, with motor vehicle collisions being the most common mechanism. However, penetrating and blast injuries that result in upper limb amputation are becoming more prevalent with the US military’s involvement in Iraq and Afghanistan during the past 14 years.
Appropriate management of traumatic upper limb amputation is imperative to reduce associated morbidity and mortality while allowing the amputee to reestablish meaningful function in the effected limb. This article reviews contemporary management of traumatic upper limb amputations, with specific focus on initial management, tissue debridement, revision amputation, and postoperative complications.
Initial management
Upper extremity amputations are usually the result of high-energy mechanisms; as such the initial evaluation begins with the principles of advanced trauma life support. Securing the airway and cervical spine are of utmost importance, followed by lung ventilation. An oft encountered component of advanced trauma life support primary survey with major amputations is control of hemorrhage, which results from laceration or rupture of the major vessels. A tourniquet is used if necessary to prevent lethal exsanguination; however, hemostasis is preferably achieved with elevation and application of a compression dressing. Blind clamping of vessels in the trauma bay is not recommended because collateral damage to intact vessels and nerves may occur. Resuscitation should begin with intravenous crystalloid fluids, but it may be necessary to infuse packed red blood cells if there is significant blood loss. Broad-spectrum antibiotics and tetanus prophylaxis are initiated in the trauma bay as soon as possible. Typically, at least a first-generation cephalosporin is used for infection prophylaxis, although an aminoglycoside should be added if there is significant contamination. Penicillin is added if there is concern for Clostridium infection from farm or vegetative contamination. If the patient’s immunization status is unknown or overdue, tetanus prophylaxis is required.
Once the patient is acutely stabilized and resuscitation efforts initiated, care is directed toward a thorough history and physical examination. The history should focus on injury and patient factors that are helpful when formulating a treatment plan. Injury factors include the mechanism, timing, location, and additional injuries. Patient factors include hand dominance, prior occupation, baseline functional level, and medical history (especially diabetes mellitus, peripheral vascular disease, and prior injury to the affected extremity). Although not a contraindication to replantation, patients with diabetes, peripheral vascular disease, and smokers have lower success rates. Physical examination should focus on the remaining portion of the affected extremity, taking note of the level of injury and the amount and type of contamination. Active and passive motion of the proximal joints should be noted to aid with preoperative planning for a future prosthesis. The remaining muscle groups should be palpated and evaluated for compartment syndrome. A local anesthetic is particularly useful before ranging the limb to reduce the effect pain inevitably has on the examination. The amputate should undergo a thorough examination for additional sites or injury distal to the amputation. Significant additional injuries can preclude a replantation attempt. A thorough secondary examination is essential to identify additional injuries to other extremities or the axial skeleton.
Orthogonal radiographs of the residual limb and amputate are obtained to further characterize the bony injury to each. In particular, segmental injuries to the amputate may prohibit successful replantation and favor revision amputation.
Replant or revision amputation
When a traumatic upper extremity amputation occurs, definitive treatment should focus on ultimately providing the patient with the highest level of function possible. The initial decision making should differentiate an injury that can be successfully replanted from one that requires a revision amputation. One must keep in mind the complexity of motion in the human upper extremity; therefore, a replanted “bad hand” may provide more function than is possible with a prosthesis following revision amputation. When the expected function of a replanted extremity is less than that of an amputation with or without a prosthesis, or the patient is not a candidate for replantation, the decision should be made to perform a revision amputation.
Graham and colleagues compared late functional outcomes between major upper extremity amputation and replantation at an average of 7.3 years postinjury. Functional outcomes were determined using the Carroll Standardized Evaluation and Integrated Limb Function, which assesses one’s ability to perform simple and complex tasks. Twenty-two major upper extremity replantations were compared with 22 similar level amputees with prostheses, and the functional abilities of the replantation group were significantly better than the prosthesis group.
Proper care of the amputate precludes any discussion regarding the ability to perform a successful replantation. It should be wrapped with sterile saline-soaked gauze to prevent desiccation and then placed into a sealed, impermeable plastic bag. This bag should then be immersed into ice water to help preserve the tissues, which is particularly important if the amputate contains a large amount of muscle because of its high metabolic demand.
The decision to perform a major upper extremity replantation depends on patient factors and the injury pattern. If the amputation is one injury of a polytrauma situation, the patient may not be able to tolerate a lengthy replantation procedure or may not be able to effectively participate in postreplantation rehabilitation. If the patient is hemodynamically unstable, extremity injuries should be treated in a damage control manner and avoid attempted replantation. In general, a smaller zone of injury, such as that from a sharp amputation, results in a more successful replantation. The amount of soft tissue damage that occurs with a severe crush injury precludes replantation in most cases, because of the lack of healthy tissue throughout a large zone of injury. Cold ischemia time following the traumatic amputation should not exceed 6 to 8 hours before vascular reanastomosis. Although there are classic indications and contraindications for replantation, the final treatment decision should be made by the surgeon who is to perform the procedure in accordance with the patient’s goals and wishes.
Key points
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A revision amputation is performed if the patient is not a candidate for replantation or the resulting functional outcome is better than a successful replantation.
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Contraindications for major upper extremity replantation are polytrauma, hemodynamic instability, greater than 6 to 8 hours cold ischemia time, or severe crush injury.
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Proper care of the amputate: wrapping in saline-soaked gauze within a sealed impermeable bag, and immersing in ice water.
Procedure: revision of major upper extremity amputation
Preoperative Planning
As with most surgical procedures, preoperative planning is key for a successful outcome. Preservation of length and motion of the remaining joints are key components that ultimately determine functional ability. If active motion of the shoulder and elbow are maintained, the stump or prosthesis can be placed in space to assist with or perform many functions. Skin grafts, flaps, and free tissue transfer should be considered to preserve length in amputations where the soft tissues are not adequate for coverage. Although it is tempting to simply shorten the bone to achieve coverage, a longer limb allows for a higher level of function and thus should be preserved when able. Baccarani and coworkers described the successful use of free tissue transfer in 13 patients to preserve length of the residual limb and allow prosthetic fitting. Even if replantation cannot be performed, the amputate can be used for “spare parts,” such as skin grafting to minimize donor site morbidity.
General Procedure Details
The patient is placed supine on the operating room table with the affected upper extremity on a hand table. As with all surgical procedures, a formal timeout is performed to correctly identify the patient, operative site, and procedure to be performed. An antibiotic with gram-positive bacteria coverage is typically infused intravenously within an hour of the procedure, if the patient is not already on a standing antibiotic regimen. General anesthesia is preferred for revision amputations, and a well-padded pneumatic tourniquet is placed to aid in identification of neurovascular structures and hemorrhage control. Antimicrobial skin preparation and sterile draping is performed according to the surgeon preference and level of anticipated amputation.
In many cases of upper extremity revision amputation following a traumatic injury, skin flaps for distal coverage are irregular depending on the vital tissue remaining. If the level of amputation is proximal to the remaining tissue, a fish-mouth-type incision is typically used ( Fig. 1 ). The exception is a wrist disarticulation, where a volar flap of thick palmar skin provides more durable coverage. Care should be taken to leave enough skin and soft tissue distal to the planned osteotomy level to provide adequate bone coverage for painless use with and without a prosthetic. Hemostasis of the superficial vessels is achieved using bipolar electrocautery. Blunt dissection is used to identify and isolate the major vessels and nerves at the proposed level of amputation. The tendons and muscle bellies are then sharply transected, taking care to preserve enough remaining tissue for stump coverage. If irregular skin and soft tissue flaps remain following the traumatic injury, it is best to preserve more than is necessary until closure. The excess can always be trimmed at that time once appropriate stump coverage is ensured.
The major vessels are ligated with a nylon suture or surgical clip, and subsequently sharply transected distal to this location. The proper handling of major nerves at the amputation level is important to prevent painful neuroma formation and preserve sensation to the stump. Nerves, including major sensory nerves, are isolated by blunt dissection, and gentle traction is applied before transection so that the nerve endings retract into the soft tissues. The goal is to provide abundant coverage of the nerve ending such that the inevitable neuroma formed is not superficial and, as such, easily irritated.
Once a tensionless distal skin closure is complete, a well-padded compressive stump dressing is applied for edema control. Early prosthesis fitting is recommended to facilitate stump maturation and start prosthesis training during the wound healing process. Wound healing issues from vascular insufficiency during early prosthesis use are less of a concern in a traumatic upper extremity amputation compared with most lower extremity amputations. Particularly in unilateral upper extremity amputations where delays in prosthesis fitting can allow the amputee to develop one-handed function, early prosthesis fitting is vital to provide an additional prehensile limb to assist the uninjured limb.
Early identification and treatment of psychological pathology is an important part of the postoperative rehabilitation period. Copuroglu and colleagues followed 22 upper extremity amputees and found that whereas five required treatment of acute stress disorder, 17 required treatment of posttraumatic stress disorder 6 months after their injury. Grunert and coworkers found that visualization and memory of the traumatic amputation is a risk factor for development of flashbacks and posttraumatic stress disorder. While postoperatively monitoring upper extremity amputees, it is important for the orthopedic surgeon to maintain a high level of suspicion for these psychological disorders and provide early referrals when necessary.
Targeted Muscle Reinnervation
Since the advent of myoelectric sensors, an equipped prosthesis can be cortically controlled by the patient through electromyography waves created by innervated muscles. For more proximal amputations, however, there are limited muscle groups remaining to control multiple functions simultaneously. Targeted muscle reinnervation solves this problem by transferring nerves that previously innervated distal muscle groups to motor nerves of remaining proximal muscle groups. The goal is to successfully reinnervate the new muscle, resulting in an amplified electromyography signal for myoelectric sensor detection.
Targeted muscle reinnervation has been used in the acute setting during revision amputation, particularly in proximal amputations, such as shoulder disarticulation or transhumeral amputations. Mixed major nerve endings are transferred to nearby muscles to allow for future use with myoelectric prosthesis. An added benefit of targeted muscle reinnervation is reduction in symptomatic neuroma formation, because transfer of the nerve endings provides an end target for the transected nerve.
Wrist Disarticulation
Irreparable injuries at the level of the carpus can be treated with wrist disarticulation ( Fig. 2 ). Full pronation and supination of the remaining limb should be preserved at this level because of preservation of the distal radioulnar joint and triangular fibrocartilage complex. In comparison with a transradial amputation, painful impingement of the radius and ulna is not an issue. A historical disadvantage to wrist disarticulation was difficulty fitting a functional prosthesis at this length, leading many surgeons to prefer a transradial amputation. However, advances in modern prostheses allow satisfactory use of a functioning prosthesis at this level.
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