Replantation of traumatic amputation of upper limb following crush injury – A case report

Article

Summary

Upper limb traumatic amputation is a devastating injury causing significant impact to the patient. Replantation is the best available option, however possess several challenges to the clinician specially in the resource limited setting. The case report presents successful replantation of an upper limb following a crush injury. A 34-year-old male presented with total forearm amputation at the wrist due to a crush injury. Reconstruction involve proximal row carpectomy, extensor and flexor tendon repair, microsurgical revascularization of arteries and veins and coarctation of nerves. Despite the complexity, the patient recovered without major complications, with satisfactory functional outcome. Literature suggests varying success rates but overall support replantation as a superior option to prosthetic. The case underscores importance of considering the replantation in crush injuries considering the long-term functional outcome.

Introduction

Traumatic amputation is a significant concern with heavy health burden. It also causes negative socio-economic outcome. Finger amputation is the commonest. ⁽¹⁾ Lower limb amputation causes more disability. Upper limb amputation can be devastating to patients may lose the ability to perform the activities of daily living and lose the earning capacity. Globally, the incidence and prevalence of traumatic amputations of limbs are rising. ⁽¹⁾

Replantation following traumatic amputation of the upper limb is the best available management option. However, replantation of the upper limb following a crush injury is less common compared to clean-cut injuries. It is a challenging but feasible procedure. Crush injuries constitute a difficult problem due to extensive damage to muscles, nerves and vessels. Sometimes tissue loss can be seen. Herein, we present a case of upper limb amputation following crush injury , successfully replanted with satisfactory functional outcome.

Case presentation

34 year male working in a tire company presented with a crush injury to left- non dominant hand. Patient presented after 8 hours of injury. No other injuries were present. Injury was caused by a blunt edge of a rubber cutter. It resulted in total amputation of the hand at wrist level with an open comminuted intraarticular fracture in left wrist joint with distal radius and ulnar. ( Figure 1 )

Primary reconstruction was done with bony stabilization using K wires after shortening. Ulnar artery, three dorsal veins and one deep vein was anastomosed with venous graft. Ulnar, median and superficial radial nerves were coarcted. All flexor and extensor tendons were repaired with adequate shortening. ( Figure 2) Patient gradually recovered without major post operative complications and range of movement was increased with rehabilitation exercises. Patient had been followed up for six months with improving functional outcome. He is awaiting wrist fusion as secondary procedure.

Discussion

The above case report shows that emphasizing the successful reconstruction of the severely injured hand following a crush injury. A study done in 2007, reports 18 replantation and 4 vascularization of upper extremity following crush or avulsion injuries. ⁽²⁾ That study has shown almost 90% of survival rate. A study carried between 2007- 2015 describes 14 cases of upper limb amputations. ⁽³⁾ All patients in that study were males with crush injuries. All replantation were successful with minor complications which needed additional interventions.

Zeng et al describe a case of 49 year old female with traumatic crush injury of upper limb following road traffic accident. ⁽⁴⁾ Unlike our patient, the injury has not resulted in total amputation. She had several other injuries as well. That patient had undergone 9 surgeries over 10 months period. Follow up of objective functional assessment indicated satisfactory outcome.

Unlike a cut injury, crush injuries possesses challenges in replantation. The tissue and bone loss causes a lengthwise disparity in the tendons, nerves and vessels. Our patient needed a vein graft due to vessel damage. Vessel anastomosis is not always possible in crush injuries. ⁽⁵⁾ The shortening of bones was needed in our patient due to tissue loss.

The success rates of replantation following crush injury vary depending on the mechanism of injury, site of amputation and several other factors. ⁽⁷⁾ In the emergency trauma setting, clinicians need to take the decisions within a short period of time. Success after replantation depends on correct diagnosis of the limb viability and the use of appropriate surgical techniques. ⁽⁶⁾

The development of travel and transport and modern industries result in higher chance of traumatic injuries in means of road traffic accidents and machinery injuries. Replantation of the extremity is superior to prostheses and cadaveric upper extremity replantation^.(3) Increasing incidence of traumatic amputations demands the limbs amputated by high energy trauma which might have needed to be amputated in the past to be salvaged by surgical reconstruction. Surgical techniques should be evolved with newer reconstructive approaches to replantation following crush injury with involvement of several specialties.

Conclusion

Crush injury with extensive soft tissue damage to an extremity is generally considered not considered to re-implantation. Prosthesis is an available option. However good prosthesis is not easily available especially in resource limited setting. Re-plantation improves overall long-term quality of life. The possibility of replantation, even in cases of severe lesions such as avulsion injuries, can be considered, as replanted upper limbs can present superior function to available prostheses. Although the exact anatomy can’t be achieved, the functions might be restored. Multi multidisciplinary management with appropriate rehabilitation result in achieving successful outcome.

Figure 1 – Pre opertive – Total amputation of the hand at wrist level with an open comminuted intraarticular fracture in left wrist joint with distal radius and ulnar.

Figure 2 – Post operative – Primary reconstruction of hand at wrist level

Declarations

Ethics approval and consent to participate: Our institution does not need ethical approval for case reports.

Consent for publication: Informed written consent for publication were obtained from the patients prior to collecting information.

Availability of data and material: All data generated during this study are included in this published article

Competing interests: The authors declare that they have no competing interests.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

Authors’ contribution: Author SW,PN, DS,OB,PA,GE, and DD contributed to collection of information and writing of the manuscript and reviewing and editing. Author SW contributed to conceptualization, project administration, writing and final approval of the manuscript. All authors read and approved the final version of the manuscript