traumatic amputation

In this operation, the arm is removed by severing soft tissue and bone. It is commonly referred to as a disarticulation. A traumatic amputation can be performed on a joint or on a bone. If a joint is removed, this is called a disarticulation.

species

Traumatic amputations are divided into several types: total amputation - there is a stump and a severed segment; incomplete amputation – the skin and soft tissues are preserved, tendons, nerves and vessels are damaged; Extensive amputation – both bone and soft tissue are damaged.

According to the mechanism, the following types are distinguished: scalped - the presence of a wound, traction - complete rejection, combined - multiple injuries, contusion.

Depending on the cause, the following types are distinguished: splint injury; Guillotine Injury; blast injury; chipping; kerning; Push with heavy weights, chainsaws and other machines.

signs

This pathology causes a serious condition of the victim. Excessive bleeding occurs except for shin, guillotine, and crush injuries. The patient may be restless, have a drop in blood pressure, rapid breathing, tachycardia, pale skin, and sweating. Shock and unconsciousness may occur.

The diagnostic and therapeutic measures are carried out by the accident surgeon. Upon admission to the hospital, the amount of blood loss, the time since the amputation and the general condition of the patient are determined. If necessary, laboratory tests, X-rays, ultrasound, laparoscopy, MRI and encephalogram are ordered.

causes

In ancient times, the main causes of traumatic limb amputations were attacks by wild animals, and in later eras, segregation by foreign weapons in endless wars, duels, etc. With the invention of gunpowder, shot, bombs, and similar conquests, amputations by mines and shrapnel appeared came to the fore, and with the massive introduction of industrial machinery, industrial injuries (accidents, breakdowns, negligence, etc.) came to the fore. Today, the list of the most common causes expands to include domestic accidents (carelessness and safety violations with all kinds of cutters, circular saws, angle grinders, presses), traffic accidents, terrorist attacks. In wildlife, traumatic amputations are no longer a statistically significant factor compared to what humans do to themselves and each other; such injuries are rarely reported in hunting, feral dog attacks (with a few cases of sharks in holiday resorts), or zoo assaults.

symptoms and diagnosis

Hard bones and elastic skin are more resistant to injury, bruises, and cuts than other tissues, so both total and incomplete amputations (where there is still some connection between the severed segment and the stump) are common. The most important feature of an amputation, unlike other injuries, is the loss of blood supply and with it the rapid onset of ischemic tissue changes in the lost arm. Necrosis, an acute purulent infectious and inflammatory process, can also begin in the stump. Traumatic shock combined with high blood loss is very dangerous; so is e.g. For example, the loss of both legs above the knee is often irreversible, and the higher the cut (e.g. rail impact) or tear, the more dangerous the situation. Of course, time is of the essence in this case in every respect, including diagnosis – the assessment should be as quick as possible, but still accurate. Therefore, the casualty, or (if unable to speak or unconscious) those delivering the casualty, must be prepared to answer a series of questions succinctly and clearly: the patient's age, time since amputation and application tourniquet or bandage (the bleeding must usually stop on its own), the circumstances of the injury, the approximate amount of blood lost, the presence of concomitant injuries, etc.

symptoms and diagnosis

On the one hand, the symptoms in this case are very obvious. On the other hand, several factors are decisive: how much time has passed since the amputation, the condition of the amputated finger before delivery, the condition of the patient, the stump and the amputated fragment (degree of necrotic tissue death due to ischemia, i.e. lack of blood supply; signs of infection, etc.), the type of wound closure in a partial amputation, etc.

Preparation and implementation of the operation

The decision to transplant is usually made when the joints are intact and there is no mechanical trauma to the bone and soft tissues (impact, pressure, etc.). This is well known, but needless to say, immediately after the accident, the severed phalange or fingers should be placed in a clean, airtight cellophane bag, which is then placed in another bag filled with as much cold water as possible. The entire 'container' is then covered with ice and placed in the fridge (storage temperature should be around 4 degrees). Of course, this option is optimal, but by no means always feasible, but this algorithm should be followed in any case. The most important thing is that the amputated segment does not come into contact with water and/or ice.

And of course, the patient and the container should be transported as quickly as possible to the nearest hospital with an operating room and suitably qualified surgical teams. No more than 8-10 hours should elapse from the moment of amputation, otherwise the ischemic changes in the tissues will become irreversible and the chances of successful replantation will quickly decrease.

• bed rest for at least a few days;
• smoking must be stopped for at least two weeks;
• the operated limb must not be below the level of the heart;
• strict adherence to all recommendations.

It is easy to see that all these measures are aimed primarily at restoring the blood supply, without which successful replantation is impossible.

Today, such an operation is considered successful if at least 65-80 % of the finger's function is restored.

Frequently asked questions about microsurgery

Applications of microsurgery

• Vascular, nerve and tendon injuries
• Complex fractures of the limbs
• Diseases and pathologies of the joints
• defects in appearance
• severe burns
• skin injuries

pathogenesis

The combination of mechanical, thermal, and chemical trauma, along with differences in explosive composition, distance, and environmental conditions are responsible for the significant polymorphism of blast injuries. The one-sidedness of the external injuries is related to the directional effect of the trauma factors. The predominance of closed internal injuries is due to the increased power of the pressure wave after transition to a liquid medium.

The high number of open cracks and fractures is due to the massive mechanical impact. Not only is it possible to destroy body parts, but also to penetrate them into other body parts. Due to the relatively low speed of the secondary projectiles, blind and tangential shrapnel wounds predominate in patients. Distortion is common when one is near the epicenter of the explosion. As the distance from the center increases, the injuries are less severe and more varied.

Symptoms of blast injuries

The patient is often unresponsive and has difficulty making contact. This is due not only to the severity of the physical injury, but also to the reactive psychosis that is often observed against the background of an overwhelming load, especially in mass injuries. Stupor, psychomotor restlessness, depression, distrust and unusual hysterical reactions are possible. Due to the psychiatric difficulties, the questioning of the patient is associated with considerable difficulties, so that objective examination data come to the fore.

The examination draws attention to the victim's appearance: skin and clothing are smeared with soot, hair is often burned, clothing is torn or burned. Burns, abrasions and traces of shrapnel wounds are visible on the exposed parts of the body. When undressing, one finds extensive bruising, hernias, hematomas, and hemorrhages, sometimes repeating the shape of the folds of clothing. There may be multiple fracture wounds that are often blind.

Injuries to internal organs

In chest injuries, breathing is rapid and shallow. Rib fractures are accompanied by acute pain, crepitus, abnormal mobility, swelling, and bruising at the injury site. Severe dyspnea and the absence of breath sounds on auscultation suggest lung rupture. Decreased blood pressure, tachycardia, dull percussion in the lower chest may indicate hemothorax.

Kidney injuries can be associated with lower back pain and hematuria. Abdominal injuries are manifested by weakness, tachycardia, hypotension, abdominal pain, abdominal muscle tension, and blunt percussion of the lateral region. Hemorrhagic shock with severe internal bleeding occurs.

Injuries to the extremities

Disconnected, open fractures of the limbs are typical of blast injuries. The severed limb may be totally or partially severed, often accompanied by bruising and bruising of the segment. With fractures, there is often a sharp displacement. Fragmentary fractures with multiple breaks are possible. The wounds are tattered, heavily soiled, and riddled with foreign objects in the form of shrapnel and secondary projectiles. There may be heavy bleeding.

classification

Despite the detailed description of the phases of a fall and the mechanisms of catatrauma, there is no uniform classification for this group of injuries. It is of practical importance to determine the frequency of each lesion. There are statistics on the frequency of injuries to various organs and systems:

• CMT-80 %. A significant percentage are cerebral contusions with extensive hematomas and stellate skull fractures.
• Spinal fractures account for between 30 and 70 %. Falls on the head result in cervical spine fractures, while falls on the legs result in injuries to the lower thoracic, cervical and, less commonly, lumbar spine.
• Lower limb injuries account for about 50 %. The most common fractures involve the heel bone, followed by tibia fractures.
• Lung and pleura injuries: 45 %. They can be caused by indirect trauma (concussion, impact on the chest wall), often complicated by a pneumothorax.
• Rib fractures account for 25 %. The relatively low incidence of these injuries is related to the infrequent falls directly onto the chest.

Injuries to the liver in catatrauma occur in 26 % of the cases, the spleen in 14 %, and the kidney in 23 %. With multiple and simultaneous injuries, injuries to different segments or organs can aggravate each other, worsening the prognosis.

Symptoms of catatrauma

Symptoms vary widely depending on the location and number of injuries. Patients with catatrauma are often in a severe condition and have varying degrees of loss of consciousness. In the erectile phase of traumatic shock, patients are restless, may scream, moan, or, conversely, deny the severity of their injuries and refuse an examination. Blood pressure is slightly increased, tachycardia and tachypnea are noted.

At the onset of the torpid phase, the patient becomes lethargic, apathetic, apathetic, and responds poorly to palpation of the affected segments. Blood pressure is low and pulse is fast and weak. This complicates the anamnesis and the objective examination. It is therefore important to look out for typical injuries, especially life-threatening ones, when admitting a catatrauma victim.

brain injuries

Cracks and abrasions to the head, loss of consciousness, nausea, vomiting, and memory lapses indicate possible catatraumatic brain trauma. In severe cases, coma, impairment of vital functions, focal and truncal symptoms are observed. The most common stellate (multiple linear) fractures of the cranial vault may be visually indistinct or may be associated with significant deformity up to and including destruction of the skull.

fractures of the spine

Uncomplicated fractures are characterized by pain in the area of the injury. After injuries to the cervical spine, the pain increases when the head is rotated, after injuries to the thoracic and lumbar spine when the body is rotated. Complicated fractures are accompanied by neurological disorders. Loss of feeling and movement as well as impairment of the function of the pelvic organs are possible.

Fractures of the lower limbs

Catatraumatic heel fractures are characterized by acute pain, extensive swelling in the heel area, flattening and widening of the foot, hematoma on the instep and ankle surfaces. Crepitation is not always visible. Fractures of the tibia are associated with severe pain, swelling, deformity, grinding, and abnormal mobility of the tibia. Femoral fractures result in shortening, curvature of the limb, significant swelling, abnormal mobility, crunching of the bones, and severe pain. Elevating the leg is not possible with all injuries.

Preparation and implementation of the operation

Traumatic amputation of the hand is an emergency and must be treated (surgically, of course) according to protocol. How and in what condition the lost segment is delivered is extremely important. The correct, although not always possible, option is to immediately cool the severed hand to 4-5 degrees by placing it in a clean plastic bag, which is placed in a bowl or other bag with cold water; this makeshift container should be covered with ice on the outside - and carried in this condition with the casualty to the medical facility. It is very important to remember that the hand must not come into contact with water or ice. But even with these rules, the waiting time is no more than 6-8 hours (in fact, it is usually much shorter), after this time, necrotic lesions or abscesses prevent the hand from being bandaged again.

There are clear indications and contraindications for this type of operation (especially with severe tissue crushing, as a rule, it is not possible); however, when the child is not well, surgeons often go beyond the relative contraindications and do everything possible to restore the anatomical integrity of the hand. Numerous techniques have been developed, the selection of which in the protocol for each operation depends on the specific clinical picture, diagnostic and anamnestic data. The preparation time is usually very short, but in any case antiseptic measures are taken, bleeding is stopped, X-rays are taken if possible, etc. The patient's behavior during rehabilitation is just as important as the qualifications of the surgical team and the equipment of the operating room. It is important that all the doctor's instructions and recommendations are strictly followed, especially with a view to avoiding postoperative complications (mainly related to a possible lack of blood supply to the hand). It can take months or even years to recover the lost functions of the hand, but it's worth repeating: in the vast majority of cases (provided the patient is proactive), it is possible to restore the functional status, and therefore the quality of life, to an acceptable level to get level.

keywords

A finger pull injury is an injury to the finger resulting from being pulled into a ring or ring-shaped device. The severity of injuries ranges from a simple laceration to complete scalping or amputation of the finger. Although the severity of a pulling injury is directly related to the magnitude of the force applied, even a small amount of force is enough to cause an injury.

The Urbaniak classification is mostly used to identify traction injuries, according to which three grades are distinguished: grade I - adequate blood supply, grade II - impaired blood supply, and grade III - complete scalping or amputation [1]. It is obvious that treatment tactics vary depending on the severity of the injury. The choice between amputation and finger transplantation in grade III Urbaniak injuries is often a tactical dilemma. Originally, the primary goal of surgery was the viability of the replanted finger. However, since Komatsu and Tamai performed the first human finger replantation in 1968 (2), the focus has shifted to restoring finger function after replantation (3).

We present a case of successful thumb replantation after a grade III Urbaniak ring pull injury, the difficulties encountered, and the functional outcome.

clinical observation

A 10-year-old boy presented 3 hours after injury with grade III Urbaniak ring trauma to the thumb (Fig, a) caused by an accident involving heavy sports equipment. The dominant hand is right-handed and has no comorbidities. On examination, a complete amputation of the right thumb at the distal end of the phalanx is noted. The thumb flexor longus (LSF) tendon was torn at the musculotendinous junction and lay adjacent to the severed portion (Fig. 1, b). The patient was brought to the operating room 5 hours after admission (8 hours after injury).

Figure 1. Right thumb traction injury with grade 3 Urbaniak ring (total amputation): a - Ryle tube through the flexor tendon vagina for reconstruction of the long flexor tendon of the thumb; b – Amputated part of the right thumb (note the varying degrees of damage to the skin, bones and tendons); v – The skin at the interface is sutured loosely to accommodate the swollen tissue without compressing the finger's blood vessels. A skin graft was used as a temporary cover.

After fixation with Kirschner spokes, the DSBP tendon was returned through the flexor sheath and a 4/0 blue Prolene suture was placed at its proximal end and clamped in zone 5 (proximal to the wrist) for further repair. The ulnar artery of the finger was revised and repaired because the diameter of the ulnar artery of the finger was larger (0.75 mm) than that of the radial artery of the finger (0.5 mm). Initially, an anastomosis was successfully created without a vein graft, but this did not last long as it thrombosed after 10 minutes. Further revision of the ulnar digital artery distal to the lesion revealed a luminal area with an hourglass-shaped deformation, suggesting an intimal lesion.

type and symptoms

There are two types of traumatic amputations: incomplete and complete. An incomplete amputation is characterized by the severed limb being attached to the stump by a flap of skin, tendon, or muscle.

Bone and skin offer greater resistance, so that blood vessels, muscles and nerves in the remaining limb are crushed to a greater extent than the appearance of the wound on the skin surface would suggest. The skin of the residual limb is usually detached over a large area over the wound.

Massive soft tissue and bone damage to the residual limb are the result of a high degree of severity.

The segment is transected at different levels: the vascular and nerve stumps are much more proximal to the wound. The crushed or overstretched main vessels of the residual limb are usually thrombosed, so that only the muscular and bony branches bleed. The stump wound is usually very dirty.

examination and diagnosis

An assessment is made of the time since the injury, the mechanism of the injury, the severity of the general condition, the amount of blood loss, and a preliminary evaluation of other possible injuries.

An additional diagnosis of possible injuries is necessary, especially if the symptoms, the degree of amputation, the severity of the shock and the appearance of the residual limb do not match.
If a traumatic amputation of the distal limb results in severe shock without crushing the tissue of the residual limb, it should always be checked for other injuries.

Depending on the general condition, the patient must have the residual limb x-rayed, as there is a risk of fractures above the level of amputation.

rehabilitation period

After the hand amputation, rehabilitation begins. Initially, the patient may complain of phantom pains and depression. It is assumed that motor rehabilitation, once started, helps to counteract depression.

It is important to prevent atrophy of the muscles and nerve endings. The sufferer must perform certain exercises every day. Once the residual limb has healed, a temporary prosthesis is often fitted. After discharge from the hospital, the person concerned receives a disability card and tries to get a permanent prosthesis. Gradually, he or she returns to normal life.

Benefits of Surgery at Miracle Doctor Clinic

The Miracle Doctor Clinic is able to perform high-quality hand amputation and avoid negative consequences. Doctors not only perform limb amputation, but also help with rehabilitation.

1. The operation is performed by highly qualified and experienced specialists.
2. The procedure is performed under general or local anesthesia.
3. The follow-up treatment takes place in the hospital and the patient feels comfortable.
4. Doctors make a clear diagnosis and prescribe effective treatment.

The Miracle Doctor Clinic has been in operation for more than 23 years. During this time she has acquired an excellent reputation. You can make an appointment with the doctor on the official website of the clinic. To do this, select the department, specialist, date and time. You can also call the health center to ask the doctor questions and make an appointment.

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