Amputation & Replantation Flashcards
List classification of functional recovery after replantation
Chen scale
- return to original work, ROM > 60%, M4 or M5, complete / near complete return of sensation
- able to return to suitable work, ROM > 40%, M3 or M4, near complete return of sensation
- able to carry on with daily life, ROM > 30%, M3, partial return sensation
- negligible function
classify amputations
- Complete vs incomplete (based on vascularity)
- Mechanism (crush, guillotine, avulsion)
- Age
- Flexor Zone, Tip Zone (Tamai/Chung)
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
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
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
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
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
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
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
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
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
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
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
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
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
