Replantation in Emergency Medicine Clinical Presentation

Updated: Sep 12, 2017
  • Author: Mark I Langdorf, MD, FAAEM, FACEP, MHPE, RDMS; Chief Editor: Harris Gellman, MD  more...
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Presentation

History

An adequate history of the amputation injury is important and should include the following:

  • Mechanism, time, and place of injury
  • Condition of the injured part
  • Patient's hand dominance
  • Patient's general condition

Type of injury is the most important factor in determining the likelihood of survival and functionality of the replanted part. Injuries due to sharp mechanisms have a much better chance of successful replantation than those caused by blunt crushing forces. If a narrow zone of crush injury is present, replantation may be possible by excising the crush zone and replanting with clean margins.

Avulsion amputations caused by rollers offer a markedly reduced chance of successful, functional replantation, although such repairs are not impossible. Degloving injuries are those in which the soft tissue is torn from the underlying bone, as when a glove is removed from the hand. These often are a result of jewelry getting caught in machinery.

The time elapsed since injury affects the amount of local and systemic hemorrhage and, hence, the degree of ischemia in the tissue and amputated part. In addition, wound contamination progresses with time because bacteria proliferate on the wound surface. The source of contamination may influence the choice of antibiotic, method and duration of irrigation, and degree of debridement prior to replantation.

Determine the patient's dominant hand, although this information is of only relative importance.

Ask about allergies, immunizations, and chronic active disease processes.

Ask if any old injury is present. Negative prognostic factors include old age, peripheral vascular disease, congestive heart failure, and diabetes mellitus with complications. In the surgeon's judgment, these factors may make replantation inadvisable.

Assess the patient's psychiatric history. If the amputation was self-inflicted, a psychiatric evaluation is recommended.

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Physical

Perform a detailed examination of the hand, which includes distinction in function between flexor digitorum profundus and flexor digitorum superficialis. Also, describe the injury and neurovascular status. Check sensation on both sides of the distal part to assess digital nerve function before any digital nerve anesthesia.

In cases of amputated digits, determine whether the amputation is within zone II of the hand (proximal to the flexor digitorum superficialis tendon insertion). Injuries in this zone are associated with poor postoperative functional outcome due to development of a stiff proximal interphalangeal joint that negatively impacts overall hand function. [8]

A red-line sign may be seen in avulsion injuries with associated traction on the neurovascular bundle. These are small subcutaneous hematomas caused by intimal tears along the bundle. This is usually a negative prognostic sign.

A ribbon sign is seen in patients where the blood vessel was subjected to stretch and torsion. The vessel will resemble a gift-wrap ribbon. This also portends a negative prognosis.

Complete amputation of 2 digits. Complete amputation of 2 digits.
Complete thumb amputation. Complete thumb amputation.
Complete thumb amputation. Complete thumb amputation.
Surgical amputation of a left big toe. Surgical amputation of a left big toe.

Perform a general physical examination, concentrating on cardiovascular disease.

Perform a rectal examination to ensure that anticoagulation can be accomplished during or after surgery, if necessary, without placing the patient at risk for gastrointestinal bleeding.

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Causes

The 6 mechanisms of amputation injury are the following:

  • Sharp cut, as from a knife or meat slicer
  • Dull cut, as from a saw or dull edge (eg, fan blade)
  • Cut with a narrow segment of crush injury, as from a punch press
  • Cut and avulsion, as from a machine that causes partial amputation and subsequent reflexive withdrawal of the hand that completes the amputation
  • Avulsion, as from a finger or a hand caught in an anchor rope or horse reins
  • Crush avulsion, as from a machine (eg, rollers) that crushes the limb then pulls the digits off
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