Traumatic finger, hand or upper limb amputations can be catastrophic injuries, and often occur in young productive patients. Common causes are assault, cut by industry machinery or saw and road traffic accident.
Total amputation refers to a complete detachment of a body part with separation of all structures while near total (subtotal) amputation occurs when there is an incomplete detachment of a body part; the blood vessels are separated but there is some remaining soft tissue connection like skin, tendon or muscle.
When total amputation happens, the expected treatment is to reattach the amputated limb. This procedure is called replantation. When near total amputation happens, the disrupted blood supply to the limb is restored by repairing the blood vessels or performing a by-pass surgery (this is called revascularization) and all other cut structures such tendons, nerves, and bones are repaired too.
Replantation refers to the surgical reattachment of a body part (such as a finger, hand, or toe) that has been completely cut from the body. The goal of replantation surgery is to reattach and restore function as much as possible.
What are the indications for replantation?
Replantation is usually recommended when the replanted part will work at least as well as a prosthesis, if not better. For example, a surgeon would not reattach a missing finger knowing that it would not work, be painful, or get in the way of the patient’s daily activities.
Is replantation possible for every amputation?
Replantation is not possible for all amputation. Sometimes, the amputated part is too damaged for replantation for example when the part is crushed badly. Occasionally, the amputated part is brought too late to the hospital, for example more than 6 hours after injury. In this scenario, the muscle which is devoid of any blood supply is dead. Replantation can actually be life-threatening because of the release of toxin from the dead muscle into the body’s blood circulation following replantation.
What will happen if replantation is not possible?
If the lost part cannot be reattached, the stump will be debrided and refashioned to allow closure of the amputated wound. This is called refashioning or terminalisation of the stump. Crucial length of the limb is preserved. After the stump has healed, patient may have to use a prosthesis, a device that substitutes for a missing part of the body. In some cases, a prosthesis may give a person without hands or arms the ability to function.
When the fingertip is amputated and replantation is not possible because of absent of vessels for repair, composite grafting can be performed. In this procedure, the fat and bone in the amputated tip is removed and the tip is secured to the stump. Success rate for this procedure is higher in children than in adult.
What should I do following an amputation at work or at home?
You should remain calm. Wrap up the stump of the limb (ie finger stump or forearm stump) with a clean towel or cloth to stop the bleeding. This is usually adequate to stop the bleeding and applying a tight bandage or tourniquet above the wound is not always necessary. Pick up the amputated part (such as the finger) and brush off any dirt and contamination. Do not soak or wash it with any solution. Cover it with a clean piece of cloth. Then place the amputated part in a tightly sealed plastic bag. Place the plastic bag in a container of iced water. Do not let the amputated part come into direct contact with the ice or ice water by ensuring that the plastic bag is sealed securely. Bring along the amputated part in that container to the nearest emergency department of a hospital and seek a hand surgeon.
What will they do in an emergency department?
You will be reviewed to ensure that you are stable hemodynamically, ie making sure you are not in shock due to the massive loss of blood. You will be given intravenous fluid, pain-killer and the tetanus prophylaxis accordingly. Emergency physician and/or the hand surgeon will then review your wound and amputated end once you are stable. X-rays may be necessary.
What is involved in a replantation surgery?
The surgery is difficult, complex and can takes several hours to complete.
In summary, the steps of the surgery are:
- Damaged tissue is carefully removed.
- Bone ends are shortened and rejoined with pins, wires, or plates and screws. This holds the part in place to allow the rest of the tissues to be restored.
- Muscles, tendons, arteries, nerves and veins are then repaired. Sometimes grafts or artificial spacers of bone, skin, tendons and blood vessels may be needed and the grafts can be taken from your own body or from a tissue bank.
What to expect after a replantation?
After surgery, the patients may need to stay in the hospital for at least a week for close monitoring. One or more operations may be needed after the initial surgery. If the blood flow to the amputated part is impaired, another operation is required to restore the blood flow. If the amputated part fails to survive after surgery, the dead amputated part will be removed surgically.
Do I need physical therapy?
Physical therapy is vital and it starts after surgery. The limb will be splinted for comfort and to protect the repaired tendon, vessels and nerves. Early motion is started to prevent stiff joints. Other therapy is initiated to keep the muscles moving, and to minimize the formation of scar tissue. Patients will require prolonged intensive therapy for months up to 1-2 years to achieve a good functional outcome.
How much function can I recover?
Recovery of function depends on regrowth of nerves to restore sensation and motion. These new nerves grow about an inch per month. Therefore, in a finger amputation, the number of inches from the injury to the tip of a finger provides an estimate of the minimum number of months after which the patient may begin to feel something with that fingertip. Recovery also depends on the recovery of the tendon. Complete tendon healing without overwhelming adhesion allows the tendon to glide smoothly and moves joints. Good function also requires the union of the fracture or the stabilization of the dislocated joints.
It takes many months of therapy to get full maximal recovery. Even after a full recovery, replantation patients may find that they cannot do everything they wish to do or did before the injury and surgery. Tailor-made devices help many patients to do special activities or hobbies.
Many replantation patients are able to return to the jobs they held before the injury. When this is not possible, patients can seek assistance in selecting a new type of work.
Will I need additional surgery later?
After the amputated limb has survived through the early period and wound has healed, some patients may need additional surgery to regain full use of the part. Some of the most common procedures are:
- Tenolysis: freeing tendons from scar tissue
- Capsulotomy: releasing stiff joints
- Tendon or muscle transfer: transferring functioning tendons or muscles to an area that needs the tendon or muscle more
- Nerve grafting: replacing a scarred nerve or a gap in the nerves to improve the nerve functions
- Late amputation: removes the part later because it does not work or has become painful