Traumatic Amputations

Definition

Traumatic amputation is the accidental severing of some or all of a body part. A complete amputation totally detaches a limb or appendage from the rest of the body. In a partial amputation, some soft tissue remains attached to the site.

Description

Trauma is the second leading cause of amputation in the United States. About 30,000 traumatic amputations occur in this country every year. Four of every five traumatic amputation victims are male, and most of them are between the ages of 15 and 30.

Traumatic amputation most often affects limbs and appendages such as the arms, ears, feet, fingers, hands, legs, and nose.

Causes and symptoms

Farm and factory workers have greater-than-average risks of suffering injuries that result in traumatic amputation. Automobile and motorcycle accidents and the use of lawnmowers, saws, and power tools are also common causes of traumatic amputation.

Blood loss may be massive or minimal, depending on the nature of the injury and the site of the amputation. Persons who lose little blood and have less severe injuries sometimes feel more pain than those who bleed heavily and whose injuries are life-threatening.

Diagnosis

When an injured person and the amputated part(s) reach the hospital, an emergency department physician will assess the probability that the severed tissue can be successfully reattached.

The mangled extremity severity score (MESS) assigns numerical values to such factors as body temperature, circulation, numbness, paralysis, tissue health, and the person's age and general health. This is one of the diagnostic tools used to determine the probability of success for reattachment surgery. The total score is doubled if blood supply to the amputated part has been absent or diminished for more than six hours.

A general, emergency, or orthopedic surgeon makes the final determination about whether surgery should be performed. The surgeon also considers an injured person's wishes and lifestyle. Additional concerns are how and to what extent the amputation will affect an individual's quality of life and ability to perform everyday activities.

Treatment

First aid or emergency care given immediately after the amputation has a critical impact on both a physician's ability to salvage and reattach the severed part(s) and a person's ability to regain feeling and function.

Muscle tissue dies quickly, but a well-preserved body part can be successfully reattached as much as 24 hours after the amputation occurs. Tissue that has not been preserved will not survive for more than six hours.

Initial response

The most important steps to take when a traumatic amputation occurs are:

• Contact the nearest emergency services provider, clearly describe what has happened, and follow any instructions given.
• Make sure the injured person can breathe. If not, clear an airway and administer CPR as necessary.
• Use direct pressure to control bleeding, but minimize or avoid contact with blood and other body fluids.
• Persons should not be moved if back, head, leg, or neck injuries are suspected or if motion causes pain. If none are found by an emergency medical technician (EMT), put the injured person in a supine (back down) position flat with the feet raised 1 ft (0.3 m) above the surface.
• Cover the person with a coat or blanket to prevent shock.

The injured site should be cleansed with a sterile solution and wrapped in a clean towel or other thick material that will protect the wound from further injury. Tissue that is still attached to the body should not be forced back into place. If it cannot be gently replaced, it should be held in its normal position and supported until additional care is available.

Saving a person's life is always more important than recovering the amputated part(s). Transporting the injured person to a hospital or emergency center should never be delayed until missing pieces are located.

Preserving tissue

No amputated body part is too small to be salvaged. Debris or other contaminating material should be removed, but the tissue should not be allowed to get wet.

An amputated body part should be wrapped in bandages, towels, or other clean, protective material and sealed in a plastic bag. Placing the sealed bag in a cooler or in a container that is inside a second container filled with cold water or ice will help prevent tissue deterioration.

Prognosis

Possible complications of traumatic amputation include:

• excessive bleeding
• infection
• muscle shortening
• pulmonary embolism

Improved medical and surgical care and rehabilitation have improved the long-term outlook for persons experiencing a traumatic amputation.

Phantom pain

About 80% of all amputees over the age of four experience tingling, itching, numbness, or pain in the place where the amputated part used to be. Phantom sensations may begin immediately after the amputation, or they may develop months or years later. They often occur after an injury to the site of the amputation.

These intermittent feelings may:

• occur frequently or infrequently
• be mild or intense
• last for a few minutes or several hours
• help injured persons adjust more readily to an artificial limb (prosthesis)

Health care team roles

Emergency medical technicians often provide initial assistance to persons experiencing traumatic amputation. These people are evaluated by emergency room physicians and surgeons (trauma, plastic and neurosurgeons) to establish a plan for treatment. During surgery, they are supported by anesthesiologists, nurses, and surgical assistants. Plastic surgeons may perform many other operations to restore injured body parts to a more normal condition and appearance. Infectious disease specialists may be called upon to treat infections that may accompany an accident and subsequent traumatic amputation.

After surgery, rehabilitation professionals begin to assist. Doctors trained in physical medicine and rehabilitation (physiatrists) design a general course of therapy. Physical therapists work to regain lost physical functions. Occupational therapists may assist with redeveloping fine motor coordination and control.

If a prosthetic limb (arm or leg) is needed, an orthotist may be called upon to fit such a device to an injured person. Physical and occupational therapists will assist recovering amputees to learn how to use their new artificial limbs.

KEY TERMS

Orthotist— A person who makes, fits, and adjusts prosthetic limbs.

Phantom pain— Discomfort felt by a person who has experienced an amputation. The brain interprets nerve impulses as coming from the body part that has been removed.

Physiatrist— A physician trained in physical medicine and rehabilitation.

Pulmonary embolism— A blockage of an artery in a lung. The source of the embolism may be a blood clot from a leg that was stationary for a prolonged period of time (many hours).

Supine— Lying on one's back.

Most persons who experience a traumatic amputation require some form of counseling to help them adjust to their loss and altered appearance. Psychiatrists, counselors and other therapists may conduct therapy sessions. These may continue for many months.

Physiatrists monitor and evaluate the status of reattached limbs over time. They may also be called upon to treat phantom pain.

Prevention

The best way to prevent traumatic amputation is to observe common-sense precautions such as using seat belts and obeying speed limits and other traffic regulations. It is important to take special precautions when using potentially dangerous equipment. Guards should be securely fastened over blades, belts, gears, and other moving parts. Machinery should be turned off and disconnected before attempting to service or repair it. Appropriate protective clothing should be worn at all times. Personal clothing such as scarves, ties, and other loose items of jewelry that might become entangled in machinery should not be worn.

Resources

BOOKS

Ferrera, Peter C., Steven A. Collucciello, John Marx, and Cince Verdile. Trauma Management: An Emergency Medicine Approach. St. Louis: Mosby, 2000.

Leung, K.S., and P.Y. Ko. Practical Manual for Musculoskeletal Trauma. New York: Springer-Verlag, 2001.

Mattox, Kenneth L., David V. Feliciano, and Ernest E. Moore. Trauma, 4th Ed. New York: Appleton & Lange, 1999.

Scaletta, Thomas A., and Jeffery J. Schaider. Emergent Management of Trauma, 2nd Ed. New York: McGraw-Hill, 2000.

Simon, Robert R., and Steven J. Koenigsknecht. Emergency Orthopedics, 4th Ed. New York: McGraw-Hill, 2000.

Weinzweig, Jeffrey. Mutilated Hand. Philadelphia: Hanley & Belfus, 2001.

PERIODICALS

Hankin, F.M., D.H. Janda, and B. Wittenberg. "Playground Equipment Contributing to a Ring Avulsion Injury." Injury 31, no. 8 (2000): 635-7.

Hegazi, M.M. "Hand and Distal Forearm Replantation—Immediate and Long-Term Follow-Up." Hand Surgery 5, no. 2 (2000): 119-24.

Levy, B.S., and D. Parker. "Children and War." Public Health Reports 115, no. 4 (2000): 320-5.

Moore, R.S., V. Tan, J.P. Dormans, and D.J. Bozentka. "Major Pediatric Hand Trauma Associated with Fireworks." Journal of Orthopedic Trauma 14, no. 6 (2000): 426-8.

ORGANIZATIONS

American Academy of Emergency Medicine. 611 E. Wells St., Milwaukee, WI 53202. (800) 884-2236. 〈http://www.aaem.org〉.

American Academy of Physical Medicine and Rehabilitation. One IBM Plaza, Suite 2500, Chicago, IL 60611-3604. (312) 464-9700. 〈http://www.aapmr.org/consumers/public/amputations.htm〉.

American Amputee Foundation. P.O. Box 250218, Little Rock, AR 72225-0218. (501) 666-2523.

American College of Emergency Physicians. 1125 Executive Circle, Irving, TX 75038-2522. (800) 798-1822. 〈http://www.acep.org〉.

Amputee Coalition of America. 900 E. Hill Ave., Suite 285, Knoxville, TN 37915. (888) 267-5669. 〈http://www.amputee-coalition.org〉.

National Amputation Foundation, 38-40 Church St., Malverne, NY 11565. (516) 887-3600. 〈http://www.nationalamputation.org〉.

OTHER

Medical Slides Gallery. 8 August 2001. 〈http://allprintall.virtualave.net/Trauma_eng/2.htm〉 〈http://allprintall.virtualave.net/Trauma_eng/4.htm〉.

National Library of Medicine. 8 August 2001. 〈http://www.nlm.nih.gov/medlineplus/ency/article/000006.htm〉.

University of Pittsburgh. 8 August 2001. 〈http://www.pitt.edu/ginie/disability/calink.html〉.

Wound Care Information Network. 8 August 2001. 〈http://medicaledu.com/kshp.htm〉.

Traumatic amputations

Definition

Traumatic amputation is the accidental severing of some or all of a body part.

Description

Traumatic amputation most often affects limbs and appendages such as the arms, ears, feet, fingers, hands, legs, and nose. Amputations may be partial (some tissue connects the amputated part to the body) or complete (the amputated part is completely severed from the body).

Demographics

Trauma is the second leading cause of amputation in the United States. About 30,000 traumatic amputations occur in United States each year. Four of every five traumatic amputation victims are male, and most of them are between the ages of 15 and 30.

Causes and symptoms

Some of the more common causes of pediatric traumatic amputations are accidents with lawnmowers, automobiles, motorcycles, power tools, and farm equipment. Amputations may be caused by sharp objects such as knives or blades ("guillotine" amputation) or by heavy objects or mechanisms (crushing amputation). Crushing injuries are the more common cause of traumatic amputations.

Blood loss may be massive or minimal, depending on the nature of the injury and the site of the amputation. Patients who lose little blood and have less severe injuries sometimes feel more pain than patients who bleed heavily and whose injuries are life-threatening.

Phantom pain

About 80 percent of all amputees over the age of four experience tingling, itching , numbness , or pain in the place where the amputated part used to be. About 30 percent of amputees experience a sensation of the amputated part "telescoping" or shrinking into the viable part of the limb. Phantom sensations may begin immediately after the amputation, or they may develop months or years later. They often occur after an injury to the site of the amputation.

These intermittent feelings may have the following characteristics:

• occur frequently or only once in a while
• be mild or intense
• last for a few minutes or several hours
• help patients adjust more readily to an artificial limb (prosthesis)

When to call the doctor

A partial or complete amputation is a medical emergency and as such, the affected child (and amputated body part, if possible) should be transported to an emergency center immediately.

Diagnosis

When the patient and the amputated part(s) reach the hospital, a physician will assess the probability that the severed tissue can be successfully reattached (called replantation). The Mangled Extremity Severity Score (MESS) is a diagnostic tool used to assess the probability of successful replantation and assigns numerical values to such factors as body temperature, circulation, numbness, paralysis, tissue health, and the patient's age and general health. The total score is doubled if blood supply to the amputated part has been absent or diminished for more than six hours.

A general, emergency, or orthopedic surgeon makes the final determination about whether surgery should be performed to reattach the amputated part(s). The surgeon also considers the wishes and lifestyle of the child and parents. Additional concerns are how and to what extent the amputation will affect the child's quality of life and ability to perform everyday activities.

Treatment

First aid or emergency care given immediately after the amputation has a critical impact on both the physicians' ability to salvage and reattach the severed part(s) and the patient's ability to regain feeling and function. Muscle tissue dies quickly, but a well-preserved part can be successfully reattached as much as 24 hours after the amputation occurs. Tissue that has not been preserved will not survive for more than six hours.

Initial response

The most important steps to take when a traumatic amputation occurs are:

• Contact the nearest emergency services provider, clearly describe what has happened, and follow any instructions given.
• Make sure the victim can breathe; administer CPR if necessary.
• Control bleeding using direct pressure; minimize or avoid contact with blood and other body fluids.
• Patients should not be moved if back, head, leg, or neck injuries are suspected or if motion causes pain. If none is found by a trained professional, position the victim flat, with the feet raised 12 inches above the surface.
• Cover the victim with a coat or blanket to prevent shock.

The injured site should be cleansed with a sterile solution and wrapped in a clean towel or other thick material that will protect the wound from further injury. Tissue that is still attached to the body should not be forced back into place. If it cannot be gently replaced, it should be held in its normal position and supported until additional care is available.

Saving the patient's life is always more important than recovering the amputated part(s). Transporting the patient to a hospital or emergency center should never be delayed until missing pieces are located.

Preserving tissue

No amputated body part is too small to be salvaged. Debris or other contaminating material should be removed, but the tissue should not be allowed to get wet. An amputated body part should be wrapped in bandages, towels, or other clean, protective material and sealed in a plastic bag. Placing the sealed bag in a cooler or in a container that is inside a second container filled with cold water or ice will help prevent tissue deterioration.

Replantation

A number of factors influence whether an amputated part can be successfully reattached. These include:

• age of the patient (younger patients tend to heal better and faster)
• location of amputation (replantations of the upper extremities are more successful than those of the lower extremities)
• type of wound (sharp wounds are repaired more successfully than crushing injuries)
• health of the patient (e.g. if he or she is able to withstand prolonged surgery)
• amount of contamination to the wound (a grossly contaminated part has a much lower chance of successfully being reattached)
• length of time the amputated part was detached from the body (chance of successful replantation decreases after six hours)

Post-care

Techniques such as biofeedback, cognitive-behavioral pain management , hypnosis, acupuncture, ultrasound, and physical therapy have all been used to treat post-amputation and phantom pain.

Nutritional concerns

Proper nutrition is essential to optimize healing after an amputation or reattachment surgery. A well-balanced diet rich in vitamins and with adequate caloric value is recommended to promote healing.

Prognosis

Possible complications of traumatic amputation include:

• excessive bleeding and shock
• infection
• muscle shortening
• pulmonary embolism
• death

Improved medical and surgical care and rehabilitation have improved the long-term outlook for such patients. Children tend to heal faster than adults and adapt more quickly to disability.

Prevention

The best way to prevent traumatic amputation is to observe precautions such as using seat belts and obeying speed limits and other traffic regulations. It is important to take special precautions when using potentially dangerous equipment and make sure machinery is turned off and disconnected before attempting to service or repair it. Appropriate protective clothing should be worn at all times. Children should be closely monitored when in the vicinity of lawnmowers, power tools, farm equipment, or other machinery that can cause serious injury.

Parental concerns

Parents of child amputees are faced with difficult decisions such as whether to get a limb prosthesis for their child and how to handle issues with negative body image. Parents will be encouraged to work with their child's rehabilitation team, which may include physicians, prosthetists, physical therapists, occupational therapists, psychologists, and/or teachers, to help the child adjust to the traumatic loss of a limb. Tools such as amputee dolls may be helpful in explaining how a prosthetic limb will be worn and to encourage positive body image.

KEY TERMS

Phantom pain —Pain, tingling, itching, or numbness in the place where the amputated part used to be.

Pulmonary embolism —Blockage of an artery in the lungs by foreign matter such as fat, tumor tissue, or a clot originating from a vein. A pulmonary embolism can be a very serious, and in some cases fatal, condition.

Shock —A medical emergency in which the organs and tissues of the body are not receiving an adequate flow of blood. This deprives the organs and tissues of oxygen and allows the build-up of waste products. Shock can be caused by certain diseases, serious injury, or blood loss.

Resources

BOOKS

Dalsey, William C., and Jeffrey Luk. "Management of Amputations." In Clinical Procedures in Emergency Medicine, 4th ed. Edited by James R. Roberts and Jerris R. Hedges. Philadelphia: Saunders, 2004.

PERIODICALS

Flor, Herta. "Phantom-limb Pain: Characteristics, Causes, and Treatment." The Lancet Neurology 1, no. 3 (July 2002): 182–9.

ORGANIZATIONS

Amputee Coalition of America. PO Box 2528, Knoxville, TN 37901–2528. Web site: <www.amputee-coalition.org>.

National Amputation Foundation. 40 Church St., Malverne, NY 11565. Web site: <www.nationalamputation.org>.

WEB SITES

Koman, L. Andrew. "Replantation." eMedicine, December 3, 2002. Available online at <www.emedicine.com/orthoped/topic284.htm> (accessed January 17, 2005).

Maureen Haggerty Stephanie Dionne Sherk

Traumatic Amputations

Definition

Traumatic amputations is the accidental severing of some or all of a body part. A complete amputation totally detaches a limb or appendage from the rest of the body. In a partial amputation, some soft tissue remains attached to the site.

Description

Trauma is the second leading cause of amputation in the United States. About 30,000 traumatic amputations occur in this country every year. Four of every five traumatic amputation victims are male, and most of them are between the ages of 15-30.

Traumatic amputation most often affects limbs and appendages like the arms, ears, feet, fingers, hands, legs, and nose.

Causes and symptoms

Farm and factory workers have greater-than-average risks of suffering injuries that result in traumatic amputation. Automobile and motorcycle accidents and the use of lawnmowers, saws, and power tools are also common causes of traumatic amputation.

Blood loss may be massive or minimal, depending on the nature of the injury and the site of the amputation. Patients who lose little blood and have less severe injuries sometimes feel more pain than patients who bleed heavily and whose injuries are life-threatening.

Diagnosis

When the patient and the amputated part(s) reach the hospital, an Emergency Department physician will assess the probability that the severed tissue can be successfully reattached.

The Mangled Extremity Severity Score (MESS) assigns numerical values to such factors as body temperature, circulation, numbness, paralysis, tissue health, and the patient's age and general health. This is one of the diagnostic tools used to determine how successful reattachment surgery is apt to be. The total score is doubled if blood supply to the amputated part has been absent or diminished for more than six hours.

A general, emergency, or orthopedic surgeon makes the final determination about whether surgery should be performed. The surgeon also considers the patient's wishes and lifestyle. Additional concerns are how and to what extent the amputation will affect the patient's quality of life and ability to perform everyday activities.

Treatment

First aid or emergency care given immediately after the amputation has a critical impact on both the physicians' ability to salvage and reattach the severed part(s) and the patient's ability to regain feeling and function.

Muscle tissue dies quickly, but a well-preserved part can be successfully reattached as much as 24 hours after the amputation occurs. Tissue that has not been preserved will not survive for more than six hours.

Initial response

The most important steps to take when a traumatic amputation occurs are:

• Contact the nearest emergency services provider, clearly describe what has happened, and follow any instructions given.
• Make sure the victim can breathe; administer CPR if necessary.
• Control bleeding, using direct pressure but minimizing or avoiding contact with blood and other body fluids.
• Patients should not be moved if back, head, leg, or neck injuries are suspected or if motion causes pain. If none are found by the EMT, lie the victim flat, with the feet raised 12 inches above the surface.
• Cover the victim with a coat or blanket to prevent shock.

The injured site should be cleansed with a sterile solution and wrapped in a clean towel or other thick material that will protect the wound from further injury. Tissue that is still attached to the body should not be forced back into place. If it cannot be gently replaced, it should be held in its normal position and supported until additional care is available.

Saving the patient's life is always more important than recovering the amputated part(s). Transporting the patient to a hospital or emergency center should never be delayed until missing pieces are located.

Preserving tissue

No amputated body part is too small to be salvaged. Debris or other contaminating material should be removed, but the tissue should not be allowed to get wet.

An amputated body part should be wrapped in bandages, towels, or other clean, protective material and sealed in a plastic bag. Placing the sealed bag in a cooler or in a container that is inside a second container filled with cold water or ice will help prevent tissue deterioration.

Prognosis

Possible complications of traumatic amputation include:

• excessive bleeding
• infection
• muscle shortening
• pulmonary embolism.

Improved medical and surgical care and rehabilitation have improved the long-term outlook for these patients.

Phantom pain

About 80% of all amputees over the age of four experience tingling, itching, numbness, or pain in the place where the amputated part used to be. Phantom sensations may begin immediately after the amputation, or they may develop months or years later. They often occur after an injury to the site of the amputation.

These intermittent feelings may:

• occur frequently or only once in a while
• be mild or intense
• last for a few minutes or several hours
• help patients adjust more readily to an artificial limb (prosthesis).

Prevention

The best way to prevent traumatic amputation is to observe common-sense precautions like using seat belts and obeying speed limits and other traffic regulations. It is important to take special precautions when using potentially dangerous equipment and make sure machinery is turned off and disconnected before attempting to service or repair it. Appropriate protective clothing should be worn at all times.

Resources

ORGANIZATIONS

American Amputation Foundation, Inc. P.O. Box 250218, Hillcrest Station, Little Rock, AR 72225. (501) 666-2523.

Amputee Coalition of America. P.O. Box 2528, Knoxville, TN 37901-2528. (888) 267-5669. 〈http://www.amputee-coalition.org〉.

KEY TERMS

Phantom pain— Pain, tingling, itching, or numbness in the place where the amputated part used to be.