TRAUMATIC AMPUTATION
What is a traumatic amputation?
A traumatic amputation is a sudden injury to an arm or leg that results in the loss of part or all of that limb. When a mechanical force causes significant injury to the bone and soft tissue of an arm or a leg such that it is severed or any remaining tissue is not functional or might be a source of severe chronic pain, it is removed. Traumatic amputations can occur, for example, as the result of a car accident, a work accident, or an explosion. In the recent wars in Iraq and Afghanistan, many traumatic amputations have occurred.
TEACHING POINT: Traumatic amputations are the loss of all or part or the arm or leg caused by a sudden injury.
Types of traumatic amputations:
Traumatic amputations can be of the arm or of the leg and be partial or complete. Common traumatic amputations of the arm are the loss of part of all of a finger, loss of the part or all of the thumb, loss of the hand, loss of arm just below or at the elbow or at the shoulder. Common traumatic amputations of the leg are loss of a toe, loss of part or all of the foot, loss of the leg below the knee or above the knee, and loss of the leg at the hip.
Sometimes the accident breaks the bone, but the soft tissue (muscle, tendons, blood vessels) remain attached. This is called a “mangled extremity.” When a person is brought to the emergency room with a mangled extremity, a team of doctors determines if the part injured can be saved or if it is too injured and requires amputation. If an attempt is made to save the injured part the process is called limb salvage. Limb salvage is a very long and difficult process that can involve many surgeries. But, eventually the person may regain function to part of that limb.
If the arm of leg is so mangled that no return of function can be expected, then the best thing for the victim may be amputation. In some cases, an amputation is easier for the patient to recover from than trying to save the mangled part.
TEACHING POINT: Traumatic amputations are the loss of part or all of an arm or a leg.
A mangled extremity is when significant injury has occurred to the bone and soft tissue of an arm or a leg. Doctors must decide if they can try to save the part, or if it is best to amputate the part.
Treatment of traumatic amputations:
The goal of treating traumatic amputations is initially to save the person’s life, and then to restore as much function as possible. Traumatic amputations are accidents and can result in the loss of a lot of blood, and can be complicated by life-threatening infections.
Sometimes the accident itself has completely removed the arm or leg. Occasionally, reattachment can be attempted, depending on the level of the amputation and the time from amputation to treatment. The removed part can be wrapped in something like a paper towel or a plastic bag and kept cool (not frozen) if possible and transported to the hospital. In very rare instances, a special team of surgeons can re-attach the amputated part and possibly restore some function.
However, most amputated part cannot be reattached. The remaining tissue typically has dirt or road debris such as rocks or asphalt called contamination. It is very important to remove the contamination and any dead tissue completely and to treat with antibiotics to minimize the risk of infection.
Once healthy tissue is present the open wound must be cared for and eventually closed or covered. This can involve frequent dressing changes or negative pressure therapy. Negative pressure therapy involves placing a foam sponge in the wound and covering it with an airtight plastic dressing. Then, suction is applied to the sponge through a tube and special machine called a “wound VAC”. The continuous suction removes fluid from the wound, and promoted tissue healing. Most open wounds and even some infected wounds can be treated with a wound VAC.
It is very important that the bone be shaped appropriately and covered with muscle. The surgeon tries to create a stump that has muscle and soft tissue to create a soft pad covering the end of the bone. This will create at soft “stump,” called a residual limb, this should allow the patient to wear an artificial (“prosthetic”) arm or leg.
Occasionally, there is no muscle present to cover the end of the bone. So, it is necessary to cover the wound with healthy muscle or tissue obtained from somewhere else on the body. This can be as simple as a skin graft, taking skin from a healthy area and transferring it to cover the wound. Another option can be a tissue transfer of healthy muscle and skin. The muscle and its blood vessels are “rotated” from another area of the body to cover the defect. If no tissue near the wound is available to be rotated, sometimes it is taken from a healthy part of the body and it’s blood vessels are reconnected to the blood vessels near the wound. This is called a “free tissue transfer.”
TEACHING POINT: Removing the contamination and dead tissue is essential. Reattachment may be possible, most of the time it is not possible. The surgeon uses muscle to cover the end of the cone to create a cushion, so that the patient can wear a prosthetic. If there is exposed bone and not enough muscle nearby to place over the bone, it must be covered with tissue moved from another area of the body.
Complications of traumatic amputations:
Sometime an infection of the soft tissue can occur, called cellulitis. When cellulitis develops, the area around the wound becomes very red and warm. This usually can be treated with antibiotics. If the infection is walled off, also called an abscess, it requires surgery to remove the infection and then antibiotics. This involves draining pus from inside the wound.
Sometimes a bone infection, called osteomyelitis, can develop. An MRI may be needed to look at that bone to make the diagnosis. A bone infection requires long-term powerful antibiotics to treat and may require surgery to remove infected bone.
There is also a natural grieving process that may occur over a loss of a limb, which can vary in intensity from one individual to the next. Some people who undergo an amputation go through a full-blown grieving process, which means they go through stages of loss like you might experience from the loss of a loved one. These stages are: denial and isolation, anger, bargaining, depression, and at some point, acceptance. For those who have undergone an amputation after a long term illness (such as an amputation of a painful, infected limb secondary to diabetes), however, an amputation can bring a sense of relief.
TEACHING POINT: Treatment of an infection of a traumatic amputation involves antibiotics and occasionally surgery.
Long term management issues of traumatic amputations:
1. Phantom limb sensation. This is a thought in the brain that the amputated part is still there. This can be in the form of a pain, an itch, a muscle spasm or other sensations. This is common in recent amputees, and does tend to decrease over time. The first treatment is to retrain the brain with simple logic. Sometimes physical therapy and medication can help. Usually they go away with time but sometimes they don’t.
2. Prosthetics. These are a devices made by a specialist, an Orthotist, that creates a device from plastic and metal to substitute for the amputated part. These can vary from very simple to very sophisticated and technology is continually advancing.
3. Stump revisions. Sometimes there are problems with skin breakdown, or a cut nerve has formed a ball that is painful, called a neuroma, or a prominent bone causes pain with walking. This may make it difficult to wear the prosthetic. A revision of the amputation stump can be performed. Occasionally a higher amputation can offer more advanced prosthetics and a return to more physically demanding activities.
4. Finally, having an amputation is an undeniable change that may trigger stages of grieving or depression in some people. It may be helpful to meet others who have undergone an amputation and have returned to normal living before or after the amputation, if possible. Please remember that many who have undergone amputations have returned to an active life with the help of prosthetic devices. These devices can help those who were physically active before surgery can often return to a similar level of activity and lifestyle.
5. Traumatic amputations are usually the result of an accident and not something you can prevent. Make friends with a good Orthotist and work together to get a prosthetic that fits well and helps you return to the activities you enjoy. Do not consider part of yourself “lost” or less of a person. Your friends and family love and value you because of your heart not because of part of an arm or a leg.
References:
1. Szul A, Emergency War Surgery. 3rd ed. Borden Institute, 2004.
2. Porucznik MA, Orthopaedic surgeons wage war against extremity injuries, AAOS Now,
March/April 2007, Volume 1 Number 2, pp 1 and 34.
3. Pollack P, Rogers C, A brief background of combat injuries, AAOS Now, March/April 2007, Volume 1 Number 2, pp 34-35.
4. Rogers C, From Iraq – Back to Iraq: Modern combat Orthopaedic care, AAOS Now, March/April 2007, Volume 1 Number 2, pp 33 and 35
5. http://www.hopkinshospital.org/health_info/Diabetes/Reading/amputation.html
Copyright 2007, MD Kiosk
