Traumatic amputation

Traumatic amputation is the severing of a limb or part of a limb as a result of traumatic injury. It can be complete or incomplete. It can occur at any level, but the distal parts of the upper extremity (fingers and hand) are more commonly affected and caused by mechanical detachment, crushing, or guillotining. Usually accompanied by profuse bleeding, it may be complicated by traumatic shock. Radiography is used to assess the condition of the affected limb. Treatment is surgical – formation of a stump or replantation of the severed part of the limb.

General information

Traumatic amputation is a partial or complete detachment of a limb caused by a traumatic impact. In a complete detachment, the distal segment is completely separated from the body; in a partial amputation, bones, tendons, nerve trunks, arteries, and veins are damaged, with partial preservation of skin and soft tissues. Orthopedic traumatologists and specialists in hand microsurgery treat traumatic amputations. Treatment tactics are determined depending on the condition of the tissues and the preservation of the distal fragment.

Reasons

Most often, traumatic amputations occur at work. At the same time, in recent decades, due to the widespread use of household power tools, the number of traumatic limb detachments in the home has increased, with one or more fingers being injured, as a rule, and damage at the hand level is less frequently detected. Limb detachments may occur during rail trauma (when a limb is run over by a streetcar or train wheel) and when large loads fall, pulling the limb into moving mechanisms.

Symptoms of traumatic amputation

The limb is entirely or partially separated from the body. In heavy falls and rail trauma, scalping or laceration of the proximal limb may be seen. Sometimes, in partial detachments, the limb in the area of injury and below resembles a shapeless sack with crushed contents. Usually, the wound is profusely contaminated. 

In guillotine amputations, the stump is flat. As a rule, traumatic amputations are accompanied by profuse bleeding, exceptions are sometimes found in rail trauma and crushing of the limb with a heavy object (in these cases, bleeding is absent or minimal due to compression of damaged vessels). The general condition of the patient is moderately severe or severe. There is a growing restlessness, skin pallor, BP drop, and increased respiration and pulse—possible loss of consciousness.

Diagnosis

The preliminary diagnosis is not difficult to make. Stump radiography is performed to assess the condition of the proximal limb and exclude fractures above the level of traumatic amputation. In the presence of other injuries, various studies are prescribed: radiography of the corresponding segments of the trunk and limbs, laparoscopy, echoencephalography, etc. A set of laboratory tests is performed to determine the degree of blood loss and the body’s general state. ECG, chest radiography, and other studies are performed during preoperative preparation.

Treatment of traumatic amputation

At the first aid stage, the traumatic agent is stopped as soon as possible (remove the weight from the limb, turn off the rotating mechanism, etc.). If necessary, resuscitation measures are carried out: indirect cardiac massage and mouth-to-mouth breathing. In the presence of bleeding, take immediate measures to stop it. A pressure dressing is applied to the stump. If the bandage is quickly soaked with blood, it is not removed and put on top of another. The limb is raised above the level of the heart; immobilization is performed using a special splint or improvised materials (boards, cardboard, folded magazines, etc.).

If bleeding cannot be stopped with a tight bandage, a tourniquet is applied to the middle third of the thigh or shoulder. In high traumatic amputations of the thigh and shoulder, tourniquet application is impossible; in such cases, bleeding is stopped by pressing the artery in the inguinal or axillary region. The amputated part of the limb is preserved regardless of its condition – the decision on the possibility or impossibility of replantation can only be made by a doctor. If the limb is partially severed, the distal part is carefully placed on a splint and bandaged with the proximal part, taking care not to damage the preserved areas and not to break the contact between the proximal and distal parts.

If traumatic amputation is complete, the severed part is wrapped in dry sterile gauze or clean cloth and placed in two plastic bags (one in the other). The bags are tied and placed in a plastic dish, covered with cold water or ice packs. A note with the date and time of injury is tied to the bag’s knot. In no case should the amputated fragment be treated with alcohol or other disinfectant liquids, soaked, placed in water, or on ice – this may lead to damage, soaking, or cold damage to tissues.

Upon admission to the Department of Traumatology and Orthopedics, assess the severity of the victim’s condition and the approximate amount of blood loss, resuscitation measures, blood transfusion, and blood substitutes if necessary. Surgery is carried out after the patient is removed from shock and respiration and hemodynamic parameters are stabilized. Tactics of surgical intervention are chosen to take into account the state of the tissues of the stump and the amputated section. If replantation is impossible, a typical amputation is performed to preserve the maximum possible length of the stump. Primary surgical treatment is performed if the tissues are crushed: nonviable tissues are removed, vessels are tied off, etc. Sutures are not applied at admission; the wound is left open. Subsequently, dressings are made, delayed sutures are applied, or reamputation is performed.

When choosing the level of amputation in children, the location of growth zones is taken into account, and soft tissue reserves are created to avoid the formation of a cone-shaped residual limb; in some cases, disarticulation is performed instead of amputation. Prosthetics in children and adults are performed 2-3 months or more after the wound has completely healed.

If there is no significant crushing and the amputated part of the limb is intact, replantation is possible. Fingers and phalanges of fingers with crushing and multiple fractures, as well as severed nail phalanges of the V and IV fingers, are not subject to replantation. In all other cases, it is possible to perform such procedure. For example, finger transposition can be performed in following clinics:
https://doctor.global/results/procedures/finger-transposition. 

Contraindications to replantation are old age, serious condition of the patient, presence of other injuries requiring urgent surgical intervention, as well as exceeding the critical period from the moment of traumatic amputation.

If the amputated part is stored at +4 degrees, the critical period for fingers is 16 hours, for hands—12 hours, and for shoulder, forearm, thigh, tibia, and foot—6 hours. In the case of storage at temperatures above +4 degrees, the critical period is reduced to 8 hours for fingers, 6 hours for hand, and 4 hours for shoulder, forearm, thigh, shin, and foot. Storage below +4 degrees may lead to tissue frostbite, after which grafting becomes impossible.

In cases of hand amputation, hand transplantation can be done in following hospitals:
https://doctor.global/results/procedures/hand-transplantation.