Wrist and Forearm Amputations Workup

  • Author: Scott G Edwards, MD; Chief Editor: Harris Gellman, MD   more...
 
Updated: Nov 21, 2011
 

Laboratory Studies

  • Hematocrit and hemoglobin levels should be monitored. In trauma situations, acute blood loss is a concern. Even with elective amputations, postoperative bleeding and hematoma formation require careful assessment. Acceptable levels are individualized based on age, associated medical problems and injuries, and baseline values. In general, a young, otherwise healthy patient should maintain a hematocrit/hemoglobin level greater than 20/6. Elderly patients or patients with underlying cardiovascular disease should be maintained at higher levels (30/10).
  • Creatinine levels should be monitored. In individuals with muscle injury and necrosis, myoglobin enters the systemic circulation and can lead to renal insufficiency and failure. This is especially true in individuals with thermal and electrical burns. If creatinine levels continue to rise more than 0.4 over baseline, preoperative, or preinjury levels, more aggressive surgical intervention and fluid hydration should be considered.
  • Potassium and calcium levels should be monitored. As dead tissue is metabolized, destroyed cells release intracellular stores of potassium and calcium into the extracellular space. Elevated levels of these electrolytes may lead to cardiac arrhythmias and seizures.
  • White blood cell count, C-reactive protein, and erythrocyte sedimentation rate values should be monitored in persons with infection. Observe that these values normalize following amputation, thus suggesting resolution of the infection. Expect the C-reactive protein to be the first laboratory value to respond to treatment, as the 2 others may take several days to weeks to normalize despite eradication of the infection. If these values remain elevated or rise further, treatment should be reassessed by considering changing to a more appropriate antibiotic, searching for an unrelated occult infection or hidden abscess, and possibly revising the amputation at a more proximal level.
  • Platelets should be monitored periodically if subcutaneous heparin is administered postoperatively. Heparin-induced thrombocytopenia may occur even in small subcutaneous doses.
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Imaging Studies

  • With few exceptions, plain radiographs should be included in preoperative planning. The presence of hardware or occult pathology in an extremity to be amputated is an embarrassing intraoperative discovery.
  • In oncology cases, a preoperative CT scan and MRI have proven invaluable in assessing the extent of tumor involvement and level of amputation. Occasionally, a preoperative CT scan or MRI is helpful to evaluate the extent of infection and abscess in these particular settings.
  • Magnetic resonance angiography remains a noninvasive alternative to arteriography. The complications of arterial puncture are avoided, the risk of contrast-related renal failure is eliminated, and sensitivity is higher than in contrast angiography in the identification of severe peripheral arterial occlusive disease. Because of the expense and expertise involved, many medical centers cannot offer this alternative.
  • Pyrophosphate nuclear scanning has been introduced as another noninvasive method of evaluating tissue viability.[10] It has been demonstrated to be a useful adjunct in predicting the need for amputation in persons with extremities damaged by electrical injury, frostbite, or invasive infection. Pyrophosphate nuclear scanning has a sensitivity of 94%, a specificity of 100%, and an accuracy rate of 96%.
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Other Tests

  • Doppler ultrasound detects blood flow, and, when used in conjunction with blood pressure cuffs, can measure arterial pressure at different levels in the upper extremity.
  • Transcutaneous oxygen tensions reflect tissue perfusion. Significant occlusive disease causes these measurements to fall below 35 mm Hg. When considering the level of amputation, it is imperative that transcutaneous oxygen tensions at the level of incision are at least 35 mm Hg because measurements below this are associated with decreased healing and wound problems. Measurement of tissue oxygen tension is not affected by incompressible calcified vessels and appears to be very sensitive in evaluating arterial occlusive disease during exercise.
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Diagnostic Procedures

  • Arteriography remains the criterion standard for the definitive analysis of vascular status. However, because this is an invasive procedure, arteriography carries increased risks for pseudoaneurysm, hematoma, and vascular embolism.
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Contributor Information and Disclosures
Author

Scott G Edwards, MD  Assistant Professor of Orthopedic Surgery, Georgetown University; Consulting Surgeon, Department of Orthopedic Surgery, Greater Metropolitan Orthopaedics

Scott G Edwards, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Coauthor(s)

A Lee Osterman, MD  Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson University

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael S Clarke, MD  Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Arthroscopy Association of North America, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, and Missouri State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

N Ake Nystrom, MD, PhD  Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD  Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

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Amputation of a hand because of tissue necrosis.
 
 
 
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