Traumatic amputations

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Traumatic Amputations

Murtaza Rashid M.DDepartment Of Emergency MedicineRoyal Commission Hospital, JubailTraumatic Amputations

Tooth Avulsion22 y/o male calls the ED that he got punched in the face and is holding his incisor tooth in his hand. He asks you what is the best way to preserve the tooth till he reaches ED.D E N T A L E M E R G E NC YThe best environment for the tooth is its socket, thenBuccal Pouch in saliva.Cup of milk.Saline.Water and beer are less than ideal. The worst is in a dry medium. The best is hank solution, usually unavailable.

Traumatic Amputations

An amputation is defined as the surgical or traumatic separation of a limb or appendage from the body.

A traumatic amputation may involve any body part or extremity, including the arms, hands, fingers, legs, feet, toes, ears, tongue, penis.

Causes of AmputationsTraffic accidents (including bicycles, trains, motorcycles).Workplace/factory/construction accidents.Agricultural accidents (including lawn movers)Firearm/explosives/fireworks accidents (includes military casualties).Electrocution accidents.Building and car door accidents.Animal bites. (Sharks, crocodiles, Camels)Self Mutilation. RTA is the most common followed by Industrial and Agricultural

Some Statistical factsThe National Trauma Databank version 5, 2000-2004Total Amputations: 8,910 (approx 1% of Trauma)

Statistics Continued

Of those with limb amputation, 93% were single and it was also observed that lower Extremity amputations (LEA) were more than the upper extremity (UEA) (59% vs 41%).

Mechanism was mostly Blunt Trauma due to RTA = 83%

Motor vehicle collision occupants had more UEA (54.5% vs 45.5%, P < 0.001).

Motorcyclists (86.2% vs 13.8%, P < 0.001) and pedestrians (91.9% vs 8.1%, P < 0.001) had more LEA.

Statistics ContinuedThe majority of traumatic amputation victims are between ages 15 and 40 .

Nearly 80 percent of accidental amputation victims are male.

Besides Physical Trauma an Amputation has a huge Psychological and social impact .

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Guillotine

Initial Assessment Patient usually presents with an amputated part. Clinical examination is of paramount importance. Such injuries are often associated with head injury, chest or abdominal trauma, and other significant musculoskeletal traumas. Examination should be prompt and too much time wastage is not recommended. Early resuscitation and consultation with a multidisciplinary team which includes an orthopedician, plastic surgeon, vascular surgeon, hand and micro-vascular surgeon, and anesthetist is advisable.

Initial Assessment continuedPain management should begin promptly in ED and proper medication should be given to alleviate the pain. Even nerve blocks can be judiciously performed under experienced hands.Focus should be on the patient as a whole and not only on the amputated part.Bleeding should be controlled with elevation and Gauze, tourniquet should be the last option. Tetanus vaccination, if not updated.Broad Spectrum Intravenous antibiotics.

Compartment syndrome

Do not be fooled by the fact that open injuries cannot lead to the compartment syndrome. Only way to rule out is check the compartment pressure.Hyperkalaemia can be a lethal complication of crush injury due to rhabdomyolysis.

Handling Of Amputated partGentle handling of the amputated part. All unnecessary movements should be avoided.If visible dirty, clean with normal saline.The stump should be covered with a saline-moistened sterile dressing to prevent further contamination.Place the part in dry plastic bag, which in turn should be kept in ice.Direct contact between the tissue and ice should be avoided as it can lead to frostbite and freezing of the tissues.

Preserving Amputations

Amputated part examples

Amputated Part examples

Amputated Part examples

Blast Injuries

Handling of the Amputated partAmputated parts should not be discarded or sent to the pathology department because even if they cannot be replanted, they may serve as a donor source for skin, bone, or vessel grafts. Radiographs of the amputated part and proximal stump should be obtained.Blood works, including ABO and cross match.

Time is muscleThe time for which an amputated part can survive before replantation has not been determined.As a general rule, the more proximal the amputation, the less ischemia time the amputated limb can tolerate.

Temperature rules in extending viability !

The most important controllable factor is the temperature of the amputated part.

Warm ischemia = 6-8 hrs.Approx 4C = 12-24 hrs.

Many individual reports have demonstrated varied time differences even up to 40 hrs.

Decision to re-implant, a surgeons call.

Amputate or Salvage

Re-implantationIdeally we wish each and every amputation be re-implanted. But this is not theoretically and practically possible.

Flexor digitorum superficialis

Re-implantationWhile these are the general rules implemented by most of the units, leading teaching institutions continue to explore the limits of what is possible. Sky is the limit.A limb that is finally flail, painful, insensate, and nonfunctional will be inferior to amputation and prosthetic fitting. This is particularly true in the lower extremity where modern prosthetic appliances have proven to be effective in the restoration of almost normal function.

Mediaal Amputation

Re-implantation

The thumb is needed to preserve the function of opposition, and all such traumatic amputations should be considered for microvascular salvage regardless of the level of amputation or mechanism of injury.

Loss of the thumb is equivalent to a 40% loss of function of the hand.

Replanted fingers and hands never regain premorbid function and may develop cold intolerance, stiffness, pain, non and malunion etc.

Scoring SystemsGustilo Mendoza Williams classification for assessment and prognostication of open limb injuries has been considered sacred.

Many Scoring systems have been developed in recent years.

The Mangled ExtremityA Limb with an injury to at least three of the four systems. Soft TissueVascular supplyNervous supplyBone.

Is there a limb salvage scoring that will help in decision making and correlate with the final limb function ? No Clear Cut

Predictive salvage index (PSI) 7 good outcome; 8 poor outcome

The NISSSA score: Nerve injury, ischemia, soft tissue injury, skeletal injury shock & ageA score 11 had a 100% specificity and positive predictive value for amputation.

Most Recent Ganga Hospital Open Injury Severity Score GHOISS was proposed by Rajasekaran et al. in 2006. Used for Tibia FX Grade iii or more. It assessed the severity of the injury to the limb separately to each of the three components of the limb: the covering tissues (skin and facia), the skeleton (bones and joints), and the functional tissues (muscles, tendons and nerve units). A score of 14 to indicate amputation had the highest sensitivity and specificity. GHOISS was found to compare favorably with the MESS in sensitivity (98% vs. 99%), specificity (100% vs 17%), positive predictive value (100% vs 97.5%), and negative predictive value (70% vs 50%). The scoring system was found to be simple in application and reliable in prognosis for salvage and outcome measures.

Criticism of scoresLower Extremity Assessment Project (LEAP) study has questioned Lower Extremity Injury Severity Scores (MESS, LSI, PSI, NISSSA, and HFS-97). A multicenter U.S study of patients who underwent amputation or reconstruction (lower limb) concluded: that the scores were quite useful in predicting limb salvage, but the opposite (i.e., decision to amputate) was not true. All the scores in the series had low sensitivity and could not be accurate predictors of amputation.

Life before limbThis is the order

Penile AmputationsHighest in psychiatric and pediatric population.Command hallucination, depression, or religious conflicts. An act of purification.In children usually due to animal (including human) bites. Child abuse is usually by a parent exhibiting an acute psychotic episode.Managed like other amputations. Very high propensity to bleed.Do not attempt Foley catheterization. Suprapubic approach is justified.Recently high success rates of implantation. Even if it fails, erectile tissue can be located in pubic area for restoration and reconstruction.Use of prosthesis a final option.

Facial AmputationsEars, nose, lip and tongue.Besides cosmetic reasons, immense functional impact.Commonly due to accidents, falls, animal bites and interpersonal fights.Body dymorphic disorder. Check vital organs nearby viz, carotids, eye globes, trachea, c-spine, brachial plexus and facial fractures.Tongue and lip amputations can sever airway due to immense bleeding. ETT or cricothyridotomy may be attempted depending on the case.Recently high success rates of re-implantation and reconstruction flaps, thanks to highly skilled cosmetic aesthetic surgery

Sharp instrumentation

Reptilian tongue or zipper tongue

ReferencesEpidemiology of post-traumatic limb amputation: a National Trauma Databank analysis. Am Surg.2010 Nov;76(11):1214-22.Management of Major Limb Injuries. The Scientific World Journal. Volume 2014 (2014), Article ID 640430, 13 pages.The utility of scores in the decision to salvage or amputation in severely injured limbs. Indian J Orthop. 2008 Oct-Dec; 42(4): 368376. Rosens Emergency Medicine. Concepts and clinical practice. Elsevier, Saunder. 8th Edition. Vol 1 & Vol 2.Current Diagnosis and Treatment. Emergency Medicine. Lange, Mc Graw Hill. 6th Edition.Emergency Medicine. Adam J Rosh. 2nd Edition.Tintinallis Emergency Medicine. A Comprehensive Study Guide. 7th Edition.ABC of Pre Hospital Emergency Medicine. Wiley Blackwell. Tim Nut beam. 2013.Emergency Medicine Reports. Traumatic Amputations. Willis C George. 2011-11-06.