case conference - amputation

1. Case Conference
Thanapat Roddaje

2. • Case เคสผู้ป่วยชายไทย อายุ 45ปี
• ภูมิลาเนา จังหวัด นครราชสีมา อาเภอ ปักธงชัย
No underlying diseases
• CC: มาด้วยโดนเครื่องสับไม้ตัดนิ้วมา 2ชั่วโมง ครึ่ง PTA
• PI:2ชั่วโมงครึ่งก่อนมาโรงพยาบาลโดนเครื่องสับไม้ตัดนิ้ว ชี้ กลาง นาง ขาด นิ้วก้อย
แหว่งมือข้างขวา ขยับนิ้วได้ทุกนิ้ว ไม่มีเวียศรีษะหน้ามืดเป็นลม ผู้ป่วยเก็บนิ้วที่ขาดมาโดย
หุ้ม ด้วยผ้าก๊อซชุบnormalsalineใส่ในถุงพลาสติกแช่ในน้าแข็ง ใส่ในกระติก

3. Primary survey
• A Can speak, no limit rom of c-spine, c-spine not
tenderness
• B Equal breath sound, trachea in midline, CCT
negative, no dyspnea
• C V/S stable, no active bleeding, capillary refill < 2 sec
• D E4V5M6, pupil 3 mm RTLBE
• E amputated right index middle ring finger and nearly
amputated right little finger

4. Secondary survey
• Allergy: No history of food or drug allergy
• Medication : No current medication
• Past history : No underlying diseases
• Last meal : 5 hr PTA
• Event : as in present illness

5. Physical examination
• GA : A Thai middle-aged male patient, normosthenic built, good conscious,
well-cooperated, E4V5M6
• Vital signs : BT 37.8 C PR 101 bpm RR 20 times/min BP 120/98 mmHg
• HEENT : not pale conjunctiva, anicteric sclera
• CVS : normal s1, s2 sound, no murmur
• Lung : Clear, no adventitious sound
• Abdomen : soft, not tender, normoactive bowel sound
• Extremities : Amputated right index middle ring finger and nearly
amputated right little finger sensory intact lateral side of little finger&
loss sensation at medial side of little finger, cap refill<2sec

11. Further Investigations

12. Film
ต้องส่งอย่างน้อย 2มุมมอง
ต้องการดูตาแหน่งใดให้ตาแหน่งนั้นอยู่ตรงกลางแผ่นฟิล์ม
บาดเจ็บที่นิ้ว ต้องส่งตรวจภาพถ่ายที่นิ้ว ไม่ใช่มือ

13. Hand ap + amputated part

14. film right middle finger ap lat +
amputated part

15. film right ring finger ap lat +
amputated part

16. film right index finger ap lat +
amputated part

17. film right little finger ap lat

18. Amputated finger
Replantation

19. Amputated finger
• Trauma is the most common etiology for upper extremity
replantation
• epidemiology
• incidence
90% of upper extremity amputation occurred after trauma
• demographics
4:1 male-to-female ratio
• location
most amputations occur at the level of the digits

20. Mechanism
• sharp dissection
• blunt dissection
• avulsion
• crush

21. Initial management
Transport of amputated tissue
◦ indications
▪ any salvageable tissue should be transported with the
patient to hospital
◦ modality
▪ keep amputated tissue wrapped in moist gauze in lactate
ringers solution
▪ place in sealed plastic bag and place in ice water (avoid
direct ice or dry ice)
▪ wrap, cover and compress stump with moistened gauze

25. Specific management
• Replantation
• Closed stump

26. Absolute indication
• Thumb amputation
• Pediatric patient
• Multiple digits lost (>3digits)
• Mid-palm , Wrist ,major amputation

27. Contraindications
• Patient factor
• Severe co-morbid
• Associated life threatening injury
• Old age (>70)
• Major psychiatric disorder
• Mechanism of injury
• Multiple level amputation
• Extreme contamination
• Severe avulsion or crush

30. Indications for replantation after trauma
◦ primary indications
▪ thumb at any level
▪ multiple digits
▪ through the palm
▪ wrist level or proximal to wrist
▪ almost all parts in children
◦ relative indications
▪ individual digits distal to the insertion of flexor digitorum
superficialis [FDS] (Zone I)
▪ ring avulsion
▪ through or above elbow

31. Contraindications to replantation
◦ primary contraindications
▪ severe vascular disorder
▪ mangled limb or crush injury
▪ segmental amputation
▪ prolonged ischemia time with large muscle content (>6 hours)
◦ relative contraindications
▪ single digit proximal to FDS insertion (Zone II)
▪ medically unstable patient
▪ disabling psychiatric illness
▪ tissue contamination
▪ prolonged ischemia time with no muscle content (>12 hours)

32. Operative
◦ time to replantation
▪ proximal to carpus
▪ warm ischemia time < 6 hours
▪ cold ischemia time < 12 hours
▪ distal to carpus (digit)
▪ warm ischemia time < 12 hours
▪ cold ischemia time < 24 hours
◦

33. General operative sequence of replantation
1vascular shunt first
(for proximal replantation with large muscle mass to
minimize warm ischemia time)
2bone fixation +/- shortening
(after irrigation and debridement of soft-tissue and bone)
3extensor tendon repair
4artery repair
(repair second after bone if ischemic time is >3-4 hours)
5venous anastomoses
6flexor tendon repair
7nerve repair
8skin +/- fasciotomy

34. finger order
▪ thumb, long, ring, small, index
◦ for multiple amputations structure-by-
structure sequence is most efficient
▪ digit-by-digit sequence takes the most time

35. Complication
• Replantation failure
◦ most frequently cause within 12 hours is arterial thrombosis from persistent vasospasm
• Stiffness
◦ replanted digits have 50% of total motion
◦ tenolysis is most common secondary surgery
• Myonecrosis
◦ greater concern in major limb replantation than in digit replantation
• Myoglobinuria
◦ caused by muscle necrosis in larger replants (forearm and arm)
◦ can lead to renal failure and be fatal
• Reperfusion injury
◦ mechanism thought to be related to ischemia-induced hypoxanthine conversion to xanthine
◦ allopurinol is the best adjunctive therapy agent to decrease xanthine production
• Infection
• Cold intolerance

36. Thank you for your
attention