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Replantation of an Amputated Extremity or Body Part

Essentials

  • Stop the bleeding by applying compression.
  • Contact specialized care immediately from the site of the accidental amputation (for indications, see below). Transport the patient directly to a place of treatment with 24-hour emergency microsurgical replantation services, as necessary.
  • Collect all severed body parts and send them with the patient. Cool them for transportation (see below).
  • Do not cut off any part that is still attached with a flap.

Indications of replantation

  • The aim of replantation is to restore functional ability and aesthetics as well as possible.
  • In some cases, replantation is justified, but it is not always beneficial for the patient.
  • The injury mechanism (crush injury, avulsion, multiple level amputation) may damage tissues so that replantation is not possible.
  • In debilitated or elderly patients, there is a significant risk of complications in association with replantation.
  • Replantation surgery takes a long time, and further hospital treatment immobilizing the patient completely will take about a week.
  • The patient's opinion about the utility of replantation should be found out.

Indications

  • Thumb amputation
  • Amputation of two or more fingers
  • Midpalm, wrist and distal forearm amputation
  • Sharp amputation of other parts of the upper extremity
  • Scalp amputation
  • Nose amputation
  • Ear amputation
  • Penis amputation
  • In children amputation of almost any body part

Relative indications

  • Other upper limb amputations
  • Foot, leg, thigh amputation

First aid

Stump

  • Accidental amputation must not be allowed to endanger the patient's life. Prevention of haemorrhagic shock is to be prioritized.
  • Bleeding should be managed by compression, primarily by topical pressure bandage.
    • The stump will nearly always stop bleeding when it is bandaged tightly and held raised.
  • If necessary, circulation in the limb can be stopped by producing sufficient compression with a manual blood pressure cuff placed proximally to the injury.
    • Please note that ischaemia produced in a limb by applying a blood pressure cuff must not continue too long uninterrupted; ask for instructions for how to proceed during transportation.
  • Use of a combat application tourniquet (CAT) is not usually indicated in the treatment of limb injuries under normal conditions. The compression will damage nerves and blood vessels and may thus affect possibilities for further treatment.
  • Ligature and electrocoagulation to control bleeding should be avoided, as nerves and blood vessels are easily injured.
  • No part that is still attached with a flap should be cut off initially.

Avulsed part of the body

  • An amputated part containing muscle tissue will tolerate ischaemia for about 6-8 hours if kept cold. An amputated part with no muscle tissue (such as a finger) will tolerate ischaemia for about 16-24 hours if kept cold. Revascularization surgery must be completed by the end of the said period of ischaemia.
  • For transportation the part should be placed in a watertight bag and the bag immersed in ice water. Amputated tissue must not be allowed to freeze or be immersed in tap water without a protective bag.

References

  • Win TS, Henderson J. Management of traumatic amputations of the upper limb. BMJ 2014;348():g255. [PubMed]
  • Miller EA, Iannuzzi NP, Kennedy SA. Management of the Mangled Upper Extremity: A Critical Analysis Review. JBJS Rev 2018;6(4):e11. [PubMed]