Patient-reported significant disability after major traumatic upper extremity amputation

The aims of this study were to record patient-reported outcomes of treatment of proximal upper extremity amputation injuries and subsequent return to work. A consecutive cohort of 38 patients with a traumatic amputation at or proximal to the carpus had been treated with a replantation or revision (completion) amputation in Tampere University Hospital between 2009 and 2019, and 31 of them participated in this study. The primary outcome was the Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH). Patients reported significant disability indicated by DASH score after replantation (median 30; interquartile range [IQR] 21-47) and revision (completion) amputation (median 33; IQR 16-52). Most patients had cold intolerance and reported low hand function and aesthetics scores. Out of 17 working patients, 10 did not return to their previous work. Our study demonstrates the influence of major upper extremity amputation on daily life activities, even after a successful replantation.Level of evidence: IV.

[Macroreplantation of the upper extremity: Inventory in 2024]

Macro-amputations are extremely serious traumas and represent one of the rare extreme emergencies in hand and upper limb surgery. Their rarity, especially in our developed countries, makes their treatment relatively unknown by surgical and anesthetic teams. However, the action plan to use during a macro-reimplantation, the decisive elements of pre- and post-operative management, and the key stages of the surgery, must be perfectly known, because they determine the success of a major reimplantation, for the limb survival and the future functional result. After a brief historical overview, the literature review proposed here provides an opportunity for an update on these formidable injuries and propose a treatment algorithm to guide the medical team in the management of these complex patients.

Single-staged revascularization and reconstruction after crush injury of the wrist and distal forearm: A protocolized approach

BACKGROUND

Amputation of the wrist or distal forearm after high-energy trauma due to a crushing mechanism is associated with complex tissue defects, making repair, and reconstruction challenging. Given the difficulty of this type of salvage, patients unfortunately experience a high revision amputation rate. However, a higher quality of life has been reported in patients with successful reconstructions. Herein, we described a protocolized approach for revascularization and reconstruction for functional hand salvage after traumatic amputation from a crushing mechanism using an anterolateral thigh flap (ALT).

METHODS

A retrospective review was performed between October 2016 and October 2023 for all patients who underwent single-stage emergent debridement, revascularization, and soft tissue coverage using the ALT after amputation at the level of the wrist or distal forearm secondary to high-energy crush injury. Charts were reviewed for the preoperative Mangled Extremity Salvage Score, intraoperative details including what structures were injured and the reconstructive method performed, and postoperative data such as follow-up duration, outcomes, and complications.

RESULTS

Eleven patients met the inclusion criteria with an average age of 35.5 (21-49) years old. The average size of the skin soft tissue defects was 17.3 × 8 cm (range, length: 13-25 cm, width: 6-13 cm), and all cases had associated injury to the underlying bone, nerves, and blood vessels. The average size of the ALT flap used for reconstruction was 19.2 × 9.8 cm (range, length: 14-27 cm, width: 7-15 cm). All patients had survival of the replanted limb. One patient experienced partial flap necrosis that required secondary debridement and skin graft. Nine patients healed without requiring any additional debridement procedures. Patient follow-up averaged 24.6 (12-38) months. All patients achieved satisfactory functional recovery with Grade II to III of Chen's criteria.

CONCLUSIONS

For patients with traumatic crush amputation to the wrist with surrounding soft tissue injury, thorough debridement, revascularization, and reconstruction of amputated limbs can be performed in a single stage using the ALT. A protocolized approach from two institutions is presented, demonstrating improved survival and reduced complications of the traumatized limb with improved long-term patient outcomes.

"It was like a bad dream": Making sense of violent hand amputation and replantation in South Africa

BACKGROUND

South Africa is faced with one of the highest rates of violent crime in the world. Accordingly, therapists treat high numbers of deliberate hand injuries. There is, however, a paucity of literature exploring the lived experiences of these survivors.

PURPOSE

The aim of this study was to describe and interpret the meaning of living through a violent hand amputation and replantation, the impact on occupational adaptation and to reflect on therapeutic intervention, within the context of South Africa.

STUDY DESIGN

An exploratory embedded single case study using a qualitative approach.

METHODS

Interpretative phenomenological analysis was used to analyze data from: 8 interviews with the primary participant, over a period of 33 months; an interview with his work colleague; interviews with 5 health professionals; a review of the occupational therapy rehabilitation file and a review of the audio-visuals, recorded over 2-years.

RESULTS

This narrative reveals a man who understood his terrifying assault to be part of a southern African ritual of spiritual origin - using human body parts for traditional medicine (muti crime) or witchcraft. He perceived his expensive hand replantation and therapy as surreal and violence as normal. Challenges highlighted the importance of being attentive to the psychosocial sequelae of violence; and the most valuable part of therapy was perceived as occupational engagement.

CONCLUSIONS

The perception of attempted muti murder situates this extreme and unusual case study as a novel contribution to the medical and rehabilitation literature. South African therapists are urged to be actively involved in changing the culture of violence, and hand therapists are reminded of the importance of applying holistic and occupation-based intervention.

Functional outcome using early controlled active motion in rehabilitation of a replanted hand: A case report

STUDY DESIGN

Case report.

INTRODUCTION

This case report details the postsurgical rehabilitation and outcome of a young maintenance man who sustained a complete amputation of his dominant upper limb at the level of the distal forearm. The patient underwent replantation surgery with 2-centimeter bone shortening, followed by early controlled active motion commencing on day 6.

PURPOSE OF THE STUDY

To illustrate the use of early motion after replantation.

RESULTS

The patient achieved almost full active range of motion of the digits, intrinsic function, 30 seconds on Nine-Hole Peg Test and early return to work without any additional reconstructive procedures.

DISCUSSION

Several fairly recently published protocols advocate initiating active range of motion at only 3 or 4 weeks after upper limb replantation. The following therapeutic interventions were considered important contributors to our favorable functional outcome; early controlled active motion, occupation-based therapy in combination with therapeutic exercises and many custom molded orthoses.

CONCLUSION

Future research is required to determine if bone shortening, which is an integral part of replantation surgery, reduces tendon repair tension, allowing for early active motion and thereby contributing to a favorable outcome.

Effects of Standardized Patient-Based Training on Surgical Nurses' Competencies for Managing Hand Injuries

BACKGROUND

The competence of nurses who care for patients with finger replantation is critical for positive patient outcomes. This study sought to identify the effects of standardized patient (SP)-based training on surgical ward nurses' knowledge, clinical performance, and self-efficacy regarding finger replantation.

METHOD

A wait-list control group with a crossover design was used for this study. Nurses were randomly assigned to group A (n = 10) or to the wait-list control group B (n = 10). Training consisted of a lecture, task training, and SP-based training. Knowledge, clinical performance, and self-efficacy data were collected at baseline, after the first intervention, and after 1 month at group crossover and second intervention. Data were analyzed using repeated measures ANOVA.

RESULTS

Nurses demonstrated greater knowledge, better clinical performance, and higher self-efficacy scores after the SP-based training. Following crossover, knowledge, clinical performance, and self-efficacy scores were retained 1 month after the training in group A.

CONCLUSION

SP-based training produced improvement and retention in knowledge, clinical performance, and self-efficacy. [J Contin Educ Nurs. 2020;51(4):189-196.].