Replantation in the Child and Adolescent

Fig. 11.1

(a–d) Avulsion-type amputation in a 7-year-old child that occurred due to a door slam. (a) Dorsal view of the thumb with exposed distal phalanx. (b) Volar view with the exposed distal phalanx. (c) Dorsal view of the amputated part. (d) Volar view of the amputated part. Note the bruising of the pulp indicating a crushing component of the injury (Published with kind permission of Joshua Abzug. © Joshua Abzug 2014. All Rights Reserved)

Fig. 11.2

Fig. 11.3

Another unusual mechanism of injury seen in the pediatric population is trauma caused by home exercise equipment. Injuries sustained due to treadmills typically result in abrasions, burns, or minor lacerations [4]; however, injuries sustained by exercycles/stationary bicycles can lead to traumatic amputations [5] (Fig. 11.4). Benson et al. reviewed 32 traumatic digital injuries, in 19 children, that occurred as the result of injuries sustained secondary to exercycles/stationary bicycles. Thirteen digits were injured by the wheel spokes, including 3 amputations, and 19 digits were injured by the chain or sprocket, including 16 amputations. Due to the recognition of home exercise equipment as a mechanism of injury involved in pediatric amputation, the authors recommended that manufacturers design shielding for the wheel spokes and enclose the entire chain axis and gear interface. Additionally, children between the ages of 18 months and 5 years should not be permitted near the home exercise equipment [5].

Fig. 11.4

Successful replantation of the long and ring fingers following an exercycle injury. Note the revision amputation required on the index finger due to the severity of injury caused by the wheel spokes (Published with kind permission of Shriners Hospital for Children, Philadelphia, PA. © Shriners Hospital for Children (Philadelphia, PA) 2014. All Rights Reserved)

Anatomic and Physiologic Differences

Children are not just little adults. There are differences related to their anatomy and physiology that are important to consider, especially in traumatic situations, such as an amputation. With regard to the bony anatomy, preservation of the physis is critical when performing any replantation, to permit continued growth. Additionally, during early childhood, the bones of the amputated part may still be primarily cartilaginous, making radiographic interpretation difficult. Lastly, with regard to the bony anatomy of children, the periosteum is thick and has a rich vascular supply, permitting for rapid bone healing.

The soft tissue structures also heal more rapidly with less scarring in children compared to adults. Most importantly, this permits faster and better recovery of nerve regeneration following repair. Furthermore, the shorter distance required for neural input following repair allows for improved muscle and sensory recovery. On the contrary, vasospasm occurs more easily in children and may be more severe than in adults. Therefore, early recognition and treatment of this is necessary [6]. However, overall, children have more favorable outcomes following replantation than adults [3, 7–9].

Initial Evaluation

The evaluation of a child who sustains an amputation begins at the scene of the accident with the first responders. As life comes before limb, the child as a whole needs to be evaluated including assessment of the airway, breathing, and circulation, prior to any evaluation of the amputated area. Therefore, standard advanced trauma life support (ATLS) and pediatric advanced life support (PALS) protocols should be initiated as soon as personnel arrive on the scene. Once the ABCs have been performed, evaluation and early treatment of the amputated part can begin.

Initially, direct pressure should be applied to any areas of bleeding, to minimize blood loss and prevent the child from going into hypovolemic shock. If the bleeding is uncontrollable and the child is hemodynamically unstable, a tourniquet should be applied to maintain adequate perfusion to the rest of the child. It is important that the time be noted when the tourniquet was applied, as this is a useful information for the replantation team and can alter decision-making processes based on the child’s overall condition. A clamp/hemostat should not be applied directly on the end of a vessel to control bleeding, as this may severely damage the vessel and prevent the opportunity for replantation.

Once the child is stabilized, attention should be turned to the amputated part. Prehospital personnel should be trained in the appropriate handling of amputated parts, which begins by placing the part in a moist sterile gauze (Fig. 11.5) and then inside a waterproof bag. Subsequently, the bag is placed in a bucket of ice. The part should never be placed directly on the ice, as this will cause frostbite and/or freezing of the tissues, again preventing the opportunity for replantation. It is also important to note that the part should never be placed on dry ice.

Fig. 11.5

Amputated part wrapped in moist sterile gauze. The part should then be placed in a waterproof bag and then on ice (Published with kind permission of Joshua Abzug. © Joshua Abzug 2014. All Rights Reserved)

Following stabilization and packaging of the patient and amputated part, rapid transport to a center capable of performing replantation in children is critical. Upon arrival in the emergency department, a formal assessment of the patient and amputated part will be made by the replantation team to determine the feasibility of replantation. Therefore, we feel that prior to this determination, it is important that the patient and their family not be told that the part will definitely undergo a replantation attempt. Thus, the replantation team needs to be notified early in the prehospital evaluation to permit adequate time for the appropriate personnel and resources to be available when the child arrives in the emergency department.

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