This document discusses the management of traumatic amputations in the emergency department. It provides details on initial assessment, handling of amputated parts, criteria for replantation versus amputation, and various scoring systems used to predict outcomes. Key points include controlling bleeding, administering antibiotics and tetanus prophylaxis, placing amputated parts in saline-moistened bags on ice, and consulting plastic/vascular surgeons for possible replantation depending on the level of injury and time since amputation. Scoring systems aim to guide the decision for limb salvage versus amputation based on factors like soft tissue, bone, nerve and vascular injuries.

1. Murtaza Rashid M.D
Department Of Emergency Medicine
Royal Commission Hospital, Jubail
Traumatic Amputations

2. Tooth Avulsion
 22 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 Y
The best environment for the tooth is its socket,
then
Buccal 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

3. 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.

4. Causes of Amputations
 Traffic 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

5. Some Statistical facts
The National Trauma Databank version 5, 2000-
2004
Total Amputations: 8,910 (approx 1% of
Trauma)
77%
23%
Amputations
Digit Amputation
Limb Amputation

6. 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.

7. Statistics Continued…
The 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 .

8. Guillotine

9. 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.

10. Initial Assessment continued…
 Pain 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.

11. 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.

12. Handling Of Amputated part
 Gentle 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.

13. Preserving Amputations

15. Amputated part examples

16. Amputated Part examples

17. Amputated Part examples

18. Blast Injuries

19. Handling of the Amputated part
 Amputated 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.

20. Time is muscle
 The 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.

21. Temperature rules in extending
viability !
 The most important controllable factor is the temperature
of the amputated part.
 Warm ischemia = 6-8 hrs.
 Approx 4ºC = 12-24 hrs.
Many individual reports have demonstrated varied time
differences even up to 40 hrs.
Decision to re-implant, a surgeons call.

22. Amputate or Salvage

23. Re-implantation
 Ideally we wish each and every amputation be re-implanted. But this is not
theoretically and practically possible.

24. Flexor digitorum superficialis

25. Re-implantation
 While 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.

26. Media’al Amputation

27. 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.

28. Scoring Systems
 Gustilo Mendoza Williams classification
for assessment and prognostication of
open limb injuries has been considered
sacred.
 Many Scoring systems have been
developed in recent years.

29. The Mangled Extremity
 A Limb with an injury to at least three of the four
systems.
 Soft Tissue
 Vascular supply
 Nervous supply
 Bone.
Is there a limb salvage scoring that will help in
decision making and correlate with the final limb
function ? No Clear Cut

31. Predictive salvage index (PSI)
≤ 7 good outcome; ≥ 8 poor outcome

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

33. 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.

34. Criticism of scores
 Lower 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.”

35. Life before limb

36. Penile Amputations
 Highest 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.

37. Facial Amputations
 Ears, 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

38. Sharp instrumentation

39. Reptilian tongue or zipper tongue

40. References
 Epidemiology 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): 368–
376.
 Rosen’s 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.
 Tintinalli’s 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.