This document summarizes the case of a 38-year-old man who suffered traumatic amputation of his right index finger distal phalanx. He presented to the emergency department 6 hours after the injury with the amputated part preserved on ice. The patient was stabilized and treated with antibiotics and tetanus prophylaxis. Given the viability of the amputated part and timing within acceptable warm ischemia limits, the plan was to perform replantation surgery along with postoperative monitoring and rehabilitation. Key factors regarding indications, contraindications and management of traumatic amputations are discussed.

1. NOON REPORT
November 24, 2017
Extern อภิชญา วิเศษศักดิ์สันติ
Department of Orthopedics,
Maharat Nakhonratchasima Hospital

2. CASE STUDY
Patient profile
ชายไทยอายุ 38 ปี ภูมิลำเนา อ.ประทาย จ.นครราชสีมา
อาชีพ graphic designer
Chief complaint
ถูกเลื่อยตัดปลายนิ้ว 6 ชั่วโมงก่อนมาโรงพยาบาล

3. Present illness
6 ชั่วโมงก่อนมาโรงพยาบาล (10.30 น.) ถูกเลื่อยวงเดือนขนาด
เล็กบาดปลายนิ้วชี้ข้างขวาขาด มีเลือดออก จึงนำปลายนิ้วที่ขาดแช่น้ำ ไป
โรงพยาบาลชุมชน ที่โรงพยาบาลพันแผลห้ามเลือด นำนิ้วที่แช่น้ำห่อ
gauze ใส่ถุงพลาสติกและแช่ในกระติกน้ำแข็ง และส่งมาโรงพยาบาล
มหาราชนครราชสีมา (15.45 น.)

4. Management at community hospital
• NSS irrigation 2000 ml
• Wound dressing
• Tetanus toxoid 0.5 ml IM stat
• Film right index finger AP, lateral

5. Past history + personal history
• No underlying disease
• No current medication
• Denies drug allergy
• Denies smoking
• Occasional alcohol drinking
• Drinks coffee regularly
• Last meal 8.30 am

6. Physical examination
• Vital signs : blood pressure 137/77 mmHg, pulse rate 99/min,
respiratory rate 20/min, body temperature 37.0 c
• General appearance : alert, active
• HEENT : conjunctivae not pale, anicteric sclerae
• Cardiovascular system : full regular pulse, normal S1 S2
• Respiratory system : clear, equal both lungs
• Extremities : amputated distal phalanx of the right index finger with
minimal active bleeding, intact neurovascular function

9. Problem list
• Traumatic amputation distal phalanx of right index finger

10. • admit
• CBC, electrolyte, BUN, Cr, anti-HIV, DTX
• group match for PRC 2 units
• 12-lead ECG
• 5% DN/2 1000 ml IV rate 80 ml/hr
• Dextran 500 ml 2 bags
• heparin 1 vial
• CXR, film right index finger + stump AP,
lateral
• set OR for replantation
BACK TO OUR PATIENT…
• NPO
• record V/S, I/O
• cefazolin 1 g IV q 6 hr
• gentamicin 240 mg IV OD with
stat dose
• PGS 3 mU IV q 6 hr with stat
dose
one-day order order for continuation

11.
Traumatic amputation

12. • most common location : digits
• mechanism : sharp dissection, blunt dissection, avulsion, crush
Traumatic amputation

13. • timing of injury
• amputated part preservation
• type and location of injury
• number of digits involved
• associated injury
History

14. • tissue viability
• zone of injury
• supporting tissue structures
• contamination
Examination
• segmental injury
• surrounding bone and soft
tissues
• contamination
stump amputated tissue

15. • Remove dirty material and gently wash the amputated part
• Wrap the amputated part with saline-soaked gauze and keep in a
sealed plastic bag, then place the plastic bag in iced water
What can be done
to save the amputated part?

16. • Primary survey and stabilization – bleeding control + fluid resuscitation
• NPO
• Pre-operative testing
• Group match for blood components
• Intravenous antibiotics
• Tetanus prophylaxis
• Pain control
What are initial managements
for traumatic amputation?

17. • Thumb amputation at any level
• Multiple digit amputations
• Metacarpal amputation
• Wrist or proximal to wrist
• Almost all parts in children
• Individual digit distal to FDS insertion (zone l)
• Ring avulsion injury
Indications for replantation

18. • Severely crushed/mangled parts
• Segmental amputations
• Severe vascular disorder
• Prolonged warm ischemia
• Medically unstable
• Disabling psychiatric illness
• Amputation distal to DIP joint
• Extensively contaminated amputated tissue
Contraindications for replantation

19. • Zone l : FDP distal to insertion of
FDS
• Zone ll : insertion of FDS to the
proximal edge of A1 pulley
• Zone lll : the proximal edge of A1
pulley to distal edge of carpal
tunnel
• Zone lV : within the carpal tunnel
• Zone V : proximal to the carpal
tunnel
Zones of flexor tendons

21. Warm
ischemic time
Cold
ischemic time
Distal to carpus < 12 hours < 24 hours
Proximal to
carpus
< 6 hours < 12 hours
How long can we wait?

22. • Keep warm
• Position the extremity at the heart level
• Anticoagulants (heparin, dextran, aspirin)
• Avoid caffeine, smoking for at least 1 month
• Check capillary refill, color, temperature, skin turgor
Post-operative care

23. • Replantation failure
• Reperfusion injury
• Infection
• Myonecrosis
• Stiffness
• Cold intolerance
Complications

24. • Wheeless’ textbook of orthopedics (www.wheelessonline.com)
• www.medscape.com
• www.orthobullets.com
• www.boneandspine.com
• www.microsurgeon.org
References