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Flashcards in Amputation & Replantation Deck (20):
1

List classification of functional recovery after replantation

Chen scale

  1. return to original work, ROM > 60%, M4 or M5, complete / near complete return of sensation
  2. able to return to suitable work, ROM > 40%, M3 or M4, near complete return of sensation
  3. able to carry on with daily life, ROM > 30%, M3, partial return sensation
  4. negligible function

2

 classify amputations

  • Complete vs incomplete (based on vascularity)
  • Mechanism (crush, guillotine, avulsion)
  • Age
  • Flexor Zone, Tip Zone (Tamai/Chung)

3

What are principles of revision amputation

  • SKIN: volar skin>dorsal for sensation
  • BONE: remove cartilage to pevent bulbous tip w pseudo bursa
  • TENDON: prevent quadriga/lumbrical plus
  • NERVE: trim to prevent neuroma
  • ARTERY/VEIN: cauterize

4

What are late complications which can occur with DP/DIP amputations?

QUADRIGA

  • Excursion of FDP is limtied due to scarring at tip, tethered to tip
  • Tx: tenolysis, release FDP

LUMBRCAL PLUS

  • PIP extension with attempted flexion: FDP retracts and shortens lumbricals, which pull PIP to extension
  • Tx: release lumbircal insertion to extensor aponeurosis

5

What are complications in general post revision amputation?

SKIN/NAIL: scar contracture, delayed healing, deformity

BONE:  protuberance, stiffness/contracture

TENDON: quadriga/lumbrical plus/adhesions

NERVE: neuroma, cold intolerance

OTHER: chronic pain, non-functional digit

 

6

When is a ray resection indicated?

  • delayed post amputation at or near MCP jt
  • missing digit cuasing gap in palm and dropping objects
  • ray resection will cause decrease in power grip strength and key pinch

D2/D3 ray resection

  • incision on dorsum, DIO, lumbricals sectioned
  • reconstitute DTML

7

What are indications for replantation?

  • Children
  • Thumb
  • multiple digits
  • single digit distal to FDS
  • partial hand
  • bilateral hand
  • wrist or distal forearm
  • elbow or above elbow

8

What are contraindications to replantation

ABSOLUTE

  • Comorbidity/injury preclusing safety of prolonged OR

RELATIVE

  • Patient factors
    • uncooperative
    • comorbidities/multi-trauma
    • neuromuscular disorder affting that limb
    • current or prior trauma affecting that limb
  • Injury factors
    • multi-level
    • grossly contaminated
    • ring avulsion
    • single digit zone 2
    • proximal forearm
    • loss of palmar skin on hand
    • prolonged ischemia
      • digits warm >12, cold >24
      • proximal to carpus warm >6, cold >12

9

What is your management of a patient presenting with amputated digit? (not OR sequence details)

ATLS

  • AMPLE

HISTORY

  • Age handedness, occupation/hobbies, smoking
  • Mechanism, ischemia time

PHYSICAL

  • proximal stump, asssocited injuries

EXAMINATION OF PART

  • bone, skin, tendon, NV bundle

PRE-OP PREPARATION/CONSENT

  • Xray of hand and part
  • preop b/w, ecg, cxr
  • Td, IV fluids, IV abx
  • Consent - possble rev amp, grafts, prolonged rehab/hospital stay/bed rest

OR

  • Axilary block for pain and prevent vasospasm
  • warm patient, IV fluids, no pressors, positioning/padding
  • foley, tourniquet
  • side table - ID and tag structures

10

Describe the sequence of operative repair of amputated digit

  • Expose and tag structures
  • Debride skin as necessary
  • Shorten and fix bone
  • Joint capsule/ligament repair
  • Tendon repair - extensor/flexor
  • Arteries
  • Nerves
  • Dorsal veins

11

What are methods of bone fixation and Adv/DiSADV of each?

  • Kwire (paralel, short oblique, crossed)
  • Interosseous wires (90-90, parallel)
  • Intramedullary screw
  • Plates and screws
  • Ex-fix

 

KWIRE

Adv: less bone exposure, less bone stock required for fixation

DisAdv: non-rigid, pin tract infx

 

INTEROSSEOUS WIRES

Adv: little bone exposure, can supplmenet Kwire, lower non-union rates (compared ot kwire alone

DisAdv: not easily removed, more difficult to insert

 

INTRAMEDULLARY SCREW

Adv: for thumb Phalanx/MC

DisADv; problematic if infected

 

PLATES & SCREWS

Adv: rigid fixation (early ROM)

Disadv- require periostial stripping

12

What are signs of digit arterial injury?

Sausage sign; ballooning form thrombus

Measles sign : petechiae

Ribbon sign; tortuous

Red-line sign; along NV bundle

Telescope sign: lumen telescope out from outer wall

Terminal thrombus

Cobweb sign: intraluminal web/thread

13

How do you subclassify flexor zone 1 for fingertip amputations?

Ishikawa

Zone 1A - tip to lunula

Zone 1B- lunula to germinal matrix (FDP insertion)

Zone 1C - FDP insertion and neck of MP

Zone 1D - Neck of MP and FDS insertion

 

 

Tamai

Zone 1A - Tip to lunula

Zone 1B - Lunula to DIPjt

14

How do you classify Ring avulsion injuries and what is your mangement

Kay (modified Urbaniak) classification of ring avulsion injury

  • Type 1 - circulation adequate
    • Tx; repair ST
  • Type 2 - circulation not adequate, no F#
    • 2a arterial 2v venous inadeqaute
    • Tx: revascularization +/- flap for coverage of vessels
  • Type 3 - circulation not adeqaute, F#
    • Tx as above + ORIF
  • Type 4- complete amputation/degloving
    • Tx: replant if possible

 

15

What is the MOA, dose and S/E of ASA

  • MOA: anticoagulant - irreversible inhibitor of COX, inhibiting conversion of AA to PG and TXA
  • Dose: 81 daily x2wks (until endotheliazation)
  • S/E: gastric s/e, ulcer, bledding, ATN

16

What is the MOA, dose and S/E of Heparin

  • MOA: anticoagulant; thrombin inhibitor, prevent activiation of factor 5,8,9,10,11,12. Stimulate activity of AntiThrombin 3. 
  • Dose: IV 1000u/h, sc 5000u BID, topical 100u/cc. Antidote Protamine
  • S/E: bleeding, HIT, allergy

17

What is the MOA, dose and S/E of LMWH

  • MOA: anticoagulant - inhibit activation of thrombin and factor 10
  • Dose 5000sc daily, Protamine antidote not effective
  • S/E: lower risk of HIT

18

What is the MOA, dose and S/E of leeches

  • MOA: saliva contains hirudin (direct tjrombin inhibitor) and hyaluronidase (increases spread), histamine -like factor (vasodilator)
  • Dose: 1 per pt, feeds 6cc til full. Need coverage for aeromonas hydrophilia w FQ, 3' gen cephaloposin, septra. Can also contain klebsiella, serratia, pseudomonas
  • S/E: bleeding

 

19

What are complications following replantation

EARLY

  • vascular insufficiency
  • bleeding
  • infection
  • acute nerve compressions, compartment syndrome
  • PTSD
  • if major limb replant
    • myoglobinuria, ATN, ARDS
    • acidosis, hyperK

LATE

  • Skin scar contracture/delayed healing
  • Tendon: adhesions, rupture
  • Bone: mal/non union
  • Joint: stiffness
  • Nerve ; cold intolerance, neuroma

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