No doubt an emergency physician will be first to medically evaluate victims of digital amputation. It is important, therefore, for us to know how to stabilize these patients and their injuries.
The majority of amputations occur in adults 21 to 30. (J Hand Surg 1987;12:5.) Work-related amputations account for an average of 10,000 traumatic amputations each year. (NIOSH: Worker Health Chartbook, September 2000. www2.cdc.gov/chartbook/chap4/chartbk4.htm. Accessed Sept. 1, 2003.)
The hand is the most frequently injured body part in children (Clinical Orthopaedics & Related Research 2006;445:146), and one study found that bicycles and other sports equipment are the most common cause of finger amputation in children under 3 who have digital replantation. (Plast Reconstr Surg 1994;94:139.)
Patients who present with complete or partial digital amputations should have a comprehensive medical evaluation to ensure adequate stabilization, resuscitation, and identification of potentially life-threatening associated injuries. A study from Davies Medical Center in San Francisco found that nearly one percent of 1100 patients transferred for replantation had serious concomitant injuries that were unrecognized before transfer. (J Trauma 1993;34:238.) Patients also should receive tetanus prophylaxis, appropriate analgesia, and parenteral antibiotics (generally a first-generation cephalosporin). Of note, the routine role of antibiotics has not been proven.
Jewelry should be removed from the stump and amputated digit, gross decontamination should be removed with saline irrigation, and care should be taken to prevent further damage to the already traumatized tissues. Tissue should not be cleaned with hydrogen peroxide or alcohol, which can further damage viable tissue. Vascular clamps and hemostats should not be used because of the risk of additional injury. Pressure dressings will control bleeding adequately in the majority of cases, preventing a secondary clamp injury. Tourniquets may be required to control hemorrhage for proximal amputations. (Crit Care Med 2002;30[11 Suppl™:S444.) Radiographs of the stump and proximal joint should be performed to evaluate the full extent of the injuries, but only if they do not delay transfer to a regional microvascular or hand center for definitive care.
A careful and thorough neurovascular examination should be performed and documented. The exact time of injury, handedness, and care provided to the stump and amputated part prior to ED evaluation should be noted. Handling the amputated part and stump should be minimal. Saline moistened gauze dressings should be applied to the stump, and it should be splinted for stabilization and to prevent further injury. Partial amputations should be cared for similarly, with the hand and affected digit(s) placed in near-normal anatomic position. It is important to remember that tissue should never be thrown out in the ED. The surgeon may be able to utilize it for grafting or reparative procedures.
The amputated part also should be covered with saline moistened gauze and placed in a water-tight sealed bag. This bag should then be placed in an ice-water slurry (50% ice and 50% water with the goal of an ideal temperature of 4°C), and the time should be documented. The amputated digit should not be placed directly into ice, dry ice, water, or saline, which can cause significant destruction of viable tissue.
Replantation was first done in 1960s with the advent of microsurgery, but only a fifth of traumatic amputation victims reach a surgeon in time for digital replantation. (Crit Care Nurs Q 1990;13:13.) Despite this fact, there is no contraindication to assuming that the digit is replantable. The decision to replant a severed digit is made on a case-by-case basis by a microvascular specialist. In general, any patient with a complete or partial amputation involving the hand is a candidate for replantation or revascularization, but ideal candidates have sustained sharp, guillotine-type injuries of the thumb, multiple digits, hand, or wrist that are minimally contaminated. (Tech Hand Up Extrem Surg 2004;8[3™:161.)
In general, replantation after warm ischemic times of eight to 10 hours or cold ischemic times of 24 to 36 hours is limited due to irreversible tissue changes. (AORN J 1995;62[3™:364, 369, 371.) With multiple digital amputations, however, successful replantation has been reported after 33 hours of warm ischemia and after 94 hours of cold ischemia. (Tech Hand Up Extrem Surg 2004;8[3™:161.) The general rule is, the more proximal the amputation, the less ischemic time the severed digit can tolerate. Fracture dislocations require open reduction and internal fixation. (Crit Care Med 2002;30[11 Suppl™:S444.) Although a single-digit amputation should always be replanted in children, replantation of a single digit in an adult remains controversial. (Tech Hand Up Extrem Surg 2004;8[3™:161.)
When successful, reasonable function can be expected in the replanted fingers. (J Hand Surg 1998;23:635.) In children, the replanted part can be expected to continue to grow after replantation, averaging 92 percent of normal size. (Hand Surg 1987;12:274.) For those whom replantation is not an option, a prosthetic may provide them with increased function. The average cost for a prosthesis is $3,200 per finger or $10,375 for a whole hand. (J Hand Surg 2005;30[4™:790.)
This patient had a surgical revision of first and second digital stumps and percutaneous pinning of the third digit.
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