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Traumatic amputation — a contemporary approach

Trauma Clinical Academic Unit, The Royal London Hospital, Whitechapel Road, London E11BB, UK, AJHealey{at}doctors.org.uk

Nigel Tai

Trauma Clinical Academic Unit, The Royal London Hospital, Whitechapel Road, London E11BB, UK

The management of patients with loss or near loss of a limb secondary to high-energy trauma is particularly challenging. Management consists of an acute phase of resuscitation and initial surgery, followed by a longer chronic phase, consisting of rehabilitation, fitting of a prosthesis and stump care. Acute assessment by the full trauma team along standard CABCDE guidelines should not conflict with early stemming of on-going stump or limb haemorrhage as required. Patients with traumatic limb loss are likely to be shocked and have traumatic coagulopathy; initial and on-going resuscitation should satisfy the need to replace blood with packed cells and plasma in a 1 : 1 ratio consistent with the concept of `Damage Control Resuscitation'. The surgical goal is to tailor surgery to the patients' physiological state, removing dead and unviable tissue, restoring perfusion to live tissue, stabilising fractured bone and addressing the loss of soft tissues. The imperative to preserve length should not outweigh the need to leave the patient with a stump that will heal in a timely fashion. Lifelong prosthetic preventive maintenance is paramount as residual limbs change in volume with muscle atrophy and changes inpatient weight. Replacement may also be indicated as improved designs appear from time to time. Early rehabilitation and prosthetic fitting also improves routine prosthetic use, which has been found to positively affect return to work.

Key Words: trauma • amputation • resuscitation • surgery • prosthesis • rehabilitation

References

• Almogy G., Luria T., Richter E. et al. 2005. Can external signs of trauma guide management? Lessons learned from suicide bombing attacks in Israel. Arch Surg 140: 390-93.[Abstract/Free Full Text]
• Anderson WD, Stewart KJ, Wilson Y., Quaba AA 2002. Skin grafts for the salvage of degloved below-knee amputation stumps. Br J Plast Surg 55: 320-23.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Ascott JR 1953. Skin transfer to amputation stumps. Br J Plast Surg 6: 115-22.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Beekley AC, Sebesta JA, Blackbourne LH et al. 2008. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma 64: S28-37; discussion S37.
• Bellamy RF 1984. The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med 149: 55-62.[Web of Science][Medline] [Order article via Infotrieve]
• Bosse MJ, MacKenzie EJ, Kellam JF et al. 2001. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am 83-A: 3-14.[Abstract/Free Full Text]
• Bosse MJ, MacKenzie EJ, Kellam JF et al. 2002. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 347: 1924-31.[Abstract/Free Full Text]
• Boyd 3rd JI, Wongworawat MD 2004. High-pressure pulsatile lavage causes soft tissue damage. Clin Orthop Relat Res 427: 13-17.[CrossRef][Medline] [Order article via Infotrieve]
• Braithwaite IJ, Boot DA, Patterson M., Robinson A. 1998. Disability after severe injury: five year follow up of a large cohort. Injury 29: 55-59.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M. 2007. Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies. J Orthop Trauma 21: 70-6.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Calkins D., Snow C., Costello M., Bentley TB 2000. Evaluation of possible battlefield tourniquet systems for the far-forward setting. Mil Med 165: 379-84.[Web of Science][Medline] [Order article via Infotrieve]
• Cannada LK, Cooper C. 2005. The mangled extremity: limb salvage versus amputation. Curr Surg 62: 563-76.[CrossRef][Medline] [Order article via Infotrieve]
• Canty TJ, Bleck EE 1952. Split-thickness skin grafting of amputation stumps. Plast Reconstr Surg 1946 10: 99-115.[Web of Science]
• Cavadas PC 1996. The free forearm fillet flap in traumatic arm amputation. Plast Reconstr Surg 98: 1119-20.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Champion HR, Bellamy RF, Roberts CP, Leppaniemi A. 2003. A profile of combat injury. J Trauma 54: S13-19.[Web of Science][Medline] [Order article via Infotrieve]
• Clasper J. 2007. Amputations of the lower limb: a multidisciplinary consensus. J R Army Med Corps 153: 172-74.[Medline] [Order article via Infotrieve]
• Coupland RM, Korver A. 1991. Injuries from antipersonnel mines: the experience of the International Committee of the Red Cross. BMJ 303: 1509-12.[Abstract/Free Full Text]
• Dahl B., Andersson AP, Andersen M., Andersen GR, Ebskov LB, Reumert T. 1995. Functional and social long-term results after free tissue transfer to the lower extremity. Ann Plast Surg 34: 372-75.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• DeLisa JA, Gans BM, Walsh NE, Bockenek WL, Frontera WR eds. 2004. Physical medicine and rehabilitation: principles and practice, Lippincott Williams & Wilkins: Philadelphia: 1051-1072.
• Dillingham TR, Pezzin LE, MacKenzie EJ 1998. Incidence acute care length of stay and discharge to rehabilitation of traumatic amputee patients: an epidemiologic study. Arch Phys Med Rehabil 79: 279-87.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Dorlac WC, DeBakey ME, Holcomb JB et al. 2005. Mortality from isolated civilian penetrating extremity injury. J Trauma 59: 217-22.[Web of Science][Medline] [Order article via Infotrieve]
• Ebskov LB 1994. Trauma-related major lower limb amputations: an epidemiologic study. J Trauma 36: 778-83.[Web of Science][Medline] [Order article via Infotrieve]
• Ebskov LB, Schroeder TV, Holstein PE 1994. Epidemiology of leg amputation: the influence of vascular surgery. Br J Surg 81: 1600-03.[Web of Science][Medline] [Order article via Infotrieve]
• Erdmann D., Sundin BM, Yasui K., Wong MS, Levin LS 2002. Microsurgical free flap transfer to amputation sites: indications and results. Ann Plast Surg 48: 167-72.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Fairhurst MJ 1994. The function of below-knee amputee versus the patient with salvaged grade III tibial fracture. Clin Orthop Relat Res 301: 227-32.[Medline] [Order article via Infotrieve]
• Falstie-Jensen N., Christensen KS 1990. A model for prediction of failure in amputation of the lower limb. Dan Med Bull 37: 283-86.[Web of Science][Medline] [Order article via Infotrieve]
• Fox CJ, Gillespie DL, Cox ED et al. 2008. The effectiveness of a damage control resuscitation strategy for vascular injury in a combat support hospital: results of a case control study. J Trauma 64: S99-106; discussion S106-7.[Web of Science]
• Gaine WJ, Smart C., Bransby-Zachary M. 1997. Upper limb traumatic amputees. Review of prosthetic use. J Hand Surg [BR] 22: 73-76.[Abstract/Free Full Text]
• Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL 1993. Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation. J Bone Joint Surg Am 75: 1431-41.[Abstract/Free Full Text]
• Glattly HW 1964. A statistical study of 12000 new amputees. South Med J 57: 1373-78.[Medline] [Order article via Infotrieve]
• Gray R. 1994. War wounds: basic surgical management, International Committee of the Red Cross: Geneva, Switzerland.
• Ham R., Regan JM, Roberts VC 1987. Evaluation of introducing the team approach to the care of the amputee: the Dulwich study. Prosthet Orthot Int 11: 25-30.[Web of Science][Medline] [Order article via Infotrieve]
• Hansen Jr ST 1987. The type-IIIC tibial fracture. Salvage or amputation. J Bone Joint Surg Am 69: 799-800.[Free Full Text]
• Heikkinen M., Saarinen J., Suominen VP, Virkkunen J., Salenius J. 2007. Lower limb amputations: differences between the genders and long-term survival. Prosthet Orthot Int 31: 277-86.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Henman PD, Jain AS 2000. Skin grafting an amputation stump: considerations for the choice of donor site. Br J Plast Surg 53: 357-359.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Henrot P., Stines J., Walter F., Martinet N., Paysant J., Blum A. 2000. Imaging of the painful lower limb stump. Radiographics 20: S219-35.[Abstract/Free Full Text]
• Hess JR, Dutton RB, Holcomb JB, Scalea TM 2008. Giving plasma at a 1:1 ratio with red cells in resuscitation: who might benefit? Transfusion 48: 1763-65.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Holcomb JB, McMullin NR, Pearse L. et al. 2007. Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001-2004. Ann Surg 245: 986-91.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Howe Jr HR, Poole Jr GV, Hansen KJ et al. 1987. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. Am Surg 53: 205-08.[Web of Science][Medline] [Order article via Infotrieve]
• Hutchins PM 1981. The outcome of severe tibial injury. Injury 13: 216-19.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• James WV 1991. Principles of limb fitting and prostheses. Ann R Coll Surg Engl 73: 158-62.[Web of Science][Medline] [Order article via Infotrieve]
• James WV, McColl I. 1991. The way ahead for the amputee. Ann R Coll Surg Engl 73: 176-77.[Web of Science][Medline] [Order article via Infotrieve]
• Johansen K., Daines M., Howey T., Helfet D., Hansen Jr ST 1990. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 30: 568-72; discussion 572-73.
• Jovanovic S., Wertheimer B., Zelic Z., Getos Z. 1999. Wartime amputations. Mil Med 164: 44-47.[Web of Science][Medline] [Order article via Infotrieve]
• Kooijman CM, Dijkstra PU, Geertzen JH, Elzinga A., van der Schans CP 2000. Phantom pain and phantom sensations in upper limb amputees: an epidemiological study. Pain 87: 33-41.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Korver AJ 1993. Amputees in a hospital of the International Committee of the Red Cross. Injury 24: 607-09.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Kragh Jr JF, Walters TJ, Baer DG et al. 2008. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma 64: S38-49; discussion S49-50.[Web of Science]
• Kuntscher MV, Erdmann D., Homann HH, Steinau HU, Levin SL, Germann G. 2001. The concept of fillet flaps: classification indications and analysis of their clinical value. Plast Reconstr Surg 108: 885-96.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Lakstein D., Blumenfeld A., Sokolov T. et al. 2003. Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. J Trauma 54: S221-25.[Web of Science][Medline] [Order article via Infotrieve]
• Livingston Jr RD 1985. Orthopedic management of wartime trauma patients. Mil Med 150: 72-76.[Web of Science][Medline] [Order article via Infotrieve]
• MacKenzie EJ, Bosse MJ, Kellam JF et al. 2006. Early predictors of long-term work disability after major limb trauma. J Trauma 61: 688-94.[Web of Science][Medline] [Order article via Infotrieve]
• MacKenzie EJ, Bosse MJ, Pollak AN et al. 2005. Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am 87: 1801-09.[Abstract/Free Full Text]
• MacKenzie EJ, Morris Jr JA, Jurkovich GJ et al. 1998. Return to work following injury: the role of economic social and job-related factors. Am J Public Health 88: 1630-37.[Abstract/Free Full Text]
• McGrail Jr MP, Tsai SP, Bernacki EJ 1995. A comprehensive initiative to manage the incidence and cost of occupational injury and illness. Report of an outcomes analysis. J Occup Environ Med 37: 1263-68.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• McNamara MG, Heckman JD, Corley FG 1994. Severe open fractures of the lower extremity: a retrospective evaluation of the Mangled Extremity Severity Score (MESS). J Orthop Trauma 8: 81-87.[Web of Science][Medline] [Order article via Infotrieve]
• Navein J., Coupland R., Dunn R. 2003. The tourniquet controversy. J Trauma 54: S219-20.[Web of Science][Medline] [Order article via Infotrieve]
• Pezzin LE, Dillingham TR, MacKenzie EJ 2000. Rehabilitation and the long-term outcomes of persons with trauma-related amputations. Arch Phys Med Rehabil 81: 292-300.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Pillgram-Larsen J. 2004. Combat casualty care in ground based tactical situations: trauma technology and emergency medical procedures. In RTO HFM Symposium, St. Pete Beach, USA, RTO-MP-HFM 109, 2-1: 2-8.
• Pohjolainen T., Alaranta H. 1988. Lower limb amputations in southern Finland 1984-1985. Prosthet Orthot Int 12: 9-18.[Web of Science][Medline] [Order article via Infotrieve]
• Ramalingam T., Pathak G., Barker P. 2005. A method for determining the rate of major limb amputations in battle casualties: experiences of a British Field Hospital in Iraq 2003. Ann R Coll Surg Engl 87: 113-16.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Rotter K., Sanhueza R., Robles K., Godoy M. 2006. A descriptive study of traumatic lower limb amputees from the Hospital Hel Trabajador: clinical evolution from the accident until rehabilitation discharge. Prosthet Orthot Int 30: 81-86.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Russell WL, Sailors DM, Whittle TB, Fisher Jr DF, Burns RP 1991. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Ann Surg 213: 473-80; discussion 480-81.
• Seegenschmiedt MH, Goldmann AR, Martus P., Wolfel R., Hohmann D., Sauer R. 1993. Prophylactic radiation therapy for prevention of heterotopic ossification after hip arthroplasty: results in 141 high-risk hips. Radiology 188: 257-64.[Abstract/Free Full Text]
• Seegenschmiedt MH, Goldmann AR, Wolfel R., Hohmann D., Beck H., Sauer R. 1993. Prevention of heterotopic ossification (HO) after total hip replacement: randomized high versus low dose radiotherapy. Radiother Oncol 26: 271-74.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Spielman G., Gennarelli TA, Rogers CR 1983. Disodium etidronate: its role in preventing heterotopic ossification in severe head injury. Arch Phys Med Rehabil 64: 539-42.[Web of Science][Medline] [Order article via Infotrieve]
• Stansbury LG, Branstetter JG, Lalliss SJ 2007. Amputation in military trauma surgery. J Trauma 63: 940-44.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Stansbury LG, Lalliss SJ, Branstetter JG, Bagg MR, Holcomb JB 2008. Amputations in U.S. military personnel in the current conflicts in Afghanistan and Iraq. J Orthop Trauma 22: 43-46.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Suedkamp NP, Barbey N., Veuskens A. et al. 1993. The incidence of osteitis in open fractures: an analysis of 948 open fractures (a review of the Hannover experience). J Orthop Trauma 7: 473-82.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Thompson TC, Allredge RH 1944. Amputations: surgery and plastic repair. J Bone Joint Surg 26B: 639-44.[Abstract/Free Full Text]
• van Lunteren A., van Lunteren-Gerritsen GH, Stassen HG, Zuithoff MJ 1983. A field evaluation of arm prostheses for unilateral amputees. Prosthet Orthot Int 7: 141-51.[Web of Science][Medline] [Order article via Infotrieve]
• Walters TJ, Wenke JC, Kauvar DS, McManus JG, Holcomb JB, Baer DG 2005. Effectiveness of self-applied tourniquets in human volunteers. Prehosp Emerg Care 9: 416-22.[CrossRef][Medline] [Order article via Infotrieve]
• Wood MR, Hunter GA, Millstein SG 1987. The value of stump split skin grafting following amputation for trauma in adult upper and lower limb amputees. Prosthet Orthot Int 11: 71-74.[Web of Science][Medline] [Order article via Infotrieve]

This version was published on July 1, 2009

Trauma, Vol. 11, No. 3, 177-187 (2009)
DOI: 10.1177/1460408609337574


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This Article Abstract Free Full Text (Free PDF) Free Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Saved Citations Download to citation manager Request Permissions Request Reprints Add to My Marked Citations Citing Articles Citing Articles via Scopus Google Scholar Articles by Healey, A. J Articles by Tai, N. Social Bookmarking                         What's this?