Amputations

AMPUTATIONS

Normal Wrist Anatomy and biomechanics

The wrist is a biomechanically complex joint allowing the wrist to move in extension (up), flexion (down), radial deviation (towards the thumb), ulnar deviation (towards the small finger) and minimal degrees of rotation. Functionally the wrist’s primary role, like the shoulder and elbow, is to position the hand in space. This accurate positioning, allows the hand to perform a vast array of activities that range from skillful manipulation of fine objects to handling heavy objects, including supporting the entire body weight.
To understand the wrist we arbitrarily divide it into 3 layers:

  1. First layer corresponds to the bones
  2. Second layer corresponds to the capsule and ligaments
  3. Third layer corresponds to the remaining soft tissues (tendons, muscles, nerves, vessels)

These three layers are covered by the skin which we will discuss below.
The first layer or bonylayer begins at the metacarpal bases distally (finger side), and extends towards the very end of the forearm bones proximally (elbow side). The bones comprising the wrist include the 5 metacarpal bases, 8 carpal bones (wrist bones) which are organized in 2 rows and the distal ends of the radius and ulna (forearm bones). From distal (finger side) to proximal (elbow side), these bones form the following joints:


The five carpo-metacarpal(CMC) joints, midcarpal joint, radiocarpal joint, ulnocarpal jointand thedistal radio-ulnar joint (DRUJ).





The First CMC joint is at the base of the thumb and articulates with the trapezium, a carpal wrist bone, shaped like a horse’s saddle, that permits a wide range of motion including thumb rotation of 120 degrees, distinguishing humans from other mammals. The First Metacarpal and Trapezium are supported by a strong set of ligaments that surroundthe joint (second layer) allowing stable, thumb opposition against the rest of the fingers. The ability to oppose the thumb is responsible for 40 % of the function generated by the hand. The CMC joints of the 2nd and 3rd digits have minimal motion secondary to short, taut ligaments that surround the joint at the 2nd (index) and 3rd (middle) metacarpals bases and the distal end of the carpal bones including the Trapezium,Trapezoid and Hamate bones. This unit serves as the stable foundation around which the thumb, ring and small finger metacarpals move around. The CMC joints of the ring and small fingers are formed by 4th and 5th metacarpals, capitate and hamate wrist bones. These joints are more mobile and together with the 1st metacarpal create a gutter or cup configuration in the palm of the hand that facilitates the gripping of instruments and small objects.

The carpal bones comprise 8 wrist bones that function as a unit by virtue of having limited motion between each other. Only 7 of the 8 carpal (wrist) bones play a significant functional role in wrist stability and mobility.
The 7 important bones are named starting at the distal row (finger side) and from the thumb side:

    1- Trapezium,
    2- Trapezoid,
    3- Capitate,
    4 Hamate, and in the proximal row starting on the thumb side the
    5- Scaphoid,
    6- Lunate and
    7- Triquetrum.

The Pisiform is the eighth bone but does not play a functional role, however, it can be a source of wrist pain when sustaining a fracture or as a consequence of degenerative arthritis in the pisotriquetral articulation. The carpal bones are almost entirely covered by cartilage and receive their limited blood supply through small vessel branches that enter the bones through little tunnels where the ligaments attach.
Just proximal to the carpal bones (elbow side) are the Radius and Ulna whose articular surfaces form a cup that complements the carpal bones. Together, they form the radiocarpal joint that serves to support the proximal carpal row in a functional ball and socket mechanism. The radius with a much larger articular surface to cradle the carpus, transfers about 80 % of the wrist load. The radius and ulna have a second joint that provides forearm rotation called the Distal Radio Ulnar Joint (DRUJ). The Triangular FibroCartilage Complex is a fibrous structure containing collagenous fibers (ligaments) embedded in a fibrocartilage matrix that complements the distal end of the radius and ulna to complete the cup configuration. The DRUJ provides a cushion between the carpus and the distal ulna and is considered the main stabilizer of the DRUJ. For full normal forearm rotation to occur, the DRUJ is complemented at the elbow by a joint called the proximal radio-ulnar joint (PRUJ).



The Second Layeris composed of the wrist ligaments, a complex intermingling of collagen fibers that join the metacarpals to the carpals and to the radius and ulna, creating stable, balanced wrist motion during our daily activities. These ligaments are taut structures embedded in a thin capsule that function to reinforce key areas of the wrist. Between the carpal bones, a deeper layer of ligaments, called the intra-carpal ligaments, allow a restricted amount of motion and is the reason that the carpal bones function as a unit. The shape and position of the carpal bones is critical for proper function and when injury occurs, it is of vital importance to re-establish the bone anatomic shapes if normal function is to be achieved.

The Third Layer is formed by the tendons, muscles, vessels and nerves.
The tendons about the wrist are divided into flexors (palmar side) and extensors (back hand side). The extensor tendons are in the back of the wrist and travel through 6 independent compartments having 9 of these tendons corresponding to finger motion and 3 tendons corresponding to wrist motion. Compartments 1 and 3 controls the thumb tendons, compartments 2 and 6 the wrist extensors and compartments 4 and 5 the finger extensors.




There are nine flexor tendons that travel through a fibro-osseous tunnel at the wrist called the carpal canal. It is formed by the carpal bones and the transverse carpal ligament. There are three tendons that flex the wrist but only one of these three, the flexor carpi radialis, travels in an independent wrist compartment in the carpal canal.
Radial Artery Ulnar Artery
The primary vessels or channels that supply blood to the hand while traveling across the wrist are the Radial and Ulnar Arteries. An arcade of smaller branches that interconnect the radial and ulnar arteriesare safety pathways that allow the continuation of blood flow if the radial and ulnar artery becomes occluded. The blood returns to the heart through the veins which are more prominent in the back of the hand and wrist. The major nerves about the wrist are the Median nerve that travels together with the 9 flexor tendons in the carpal tunnel, the Ulnar nerve that together with the ulnar artery travel through Guyon’s canal and the Radial nerve in the back of the forearm. Terminal smaller branches provide sensation to the superficial and deeper levels within the wrist.


Pathology

An amputation is the severing of a body part. Amputations are classified as partial and complete and if the amputation was a clean cut, a crushing amputation or an avulsion amputation where the amputated limb is pulled right off of the body. The avulsion amputation has the worse prognosis with the zone of injury being very wide. When an amputation occurs from the mid-palm to the level of the shoulder, it is a true emergency and must be replanted no more than 4-6 with warm ischemia but can be extended to 8 hours if it is cold ischemia (when the part is placed in an ice bath) after injury because the oxygen demands and metabolism of the muscles is high causing tissue death or necrosis if the blood supply is not restored within this time period. The necrotic changes that have taken place in the amputated part lacking oxygen will cause a dumping of this necrotic material into the bloodstream and cause a systemic collapse called Disseminated Intravascular Coagulation (DIC) that risks the persons’ life who is undergoing a replantation. If this occurs, the amputated part must be removed.


When amputation occurs, the amputated part must be immediately wrapped in gauze moistened in saline and placed in ice slush made by crushing ice and placed in zip lock plastic bag and then placing it in a cooler while transporting it to ROC for replantation. Amputations from mid-palm to fingers have more time to be replanted becausefewer muscles are found in this area. Time to replantation of fingers can be successfully done after 15 hours post amputation for this reason.

Treatment

The treatment of an open wound begins with obtaining a clear history to determine the lacerating instrument, the position of the arm and hand during the laceration, the direction and depth of the laceration. The exam will confirm the injured tissue and the history will provide the direction the wound should be extended during exploration. The cleaning of the wound, repair of muscle, artery and tendon is done best with the use of a microscope or magnifying glasses called loupes. The improved magnification allows for more accurate approximation of the injured tissue. Tetanus is updated if it has been longer than 10 years since receiving a tetanus shot or if the wound is a dirty, then the tetanus is updated if it has been five years since receiving a tetanus shot. This is to avoid the danger of acquiring gas gangrene that can be deadly. The use of oral antibiotics for one week after a repair is used as a prophylaxis to avoid the risk of infection. Special splints are applied after surgery to avoid certain movements. The injured extremity must be elevated to at least heart level to avoid swelling of the limb that can cause moderate pain, cut off the blood supply and delay wound healing.


The treatment of an amputation starts immediately after amputation. That is placing the amputated part in cold ice slush and transporting it to a replantation facility like ROC. Upon arriving in an emergency facility, the patient is prepared for surgery while the amputated part is taken to the operating room, cleaned and dissected out under a microscope, preparing it for replantation. Replantation is successful with amputations beginning at the most distal joint of the fingers (DIP joint) and more proximal amputations above the elbow. That is because the arteries and veins become too small to repair if it is beyond the DIP joint which is at the base of the nail. During a replantation, the bone is fixed first, followed by the repair of the tendons, then the nerve, then whether you fix the arteries or veins first is surgeons’ choice since some prefer to fix the vein first to prevent excessive bleeding from the veins and others prefer fixing the arteries first to more easily visualize the veins.


Amputations that are from the forearm to the shoulder are more successful if it occurs in patients younger than 15 years of age, is a clean cut and the part is brought for amputation immediately. Partial amputations with skin still attached should be left attached since valuable blood supply may still be supplied but the retained tissue. If an amputation is an avulsion which is a pulling injury, or a severe crush injury, has severe contamination, extensive tissue damage, double level of injury, the likelihood of a successful replantation is significantly less. Other important factors like time from injury, level of amputation, heart disease, diabetes, renal disease, hypertension, peripheral vascular disease, advanced age and smoking habit amongst others will affect the prognosis and final decision of whether to attempt a replantation. Regardless of the type of amputation, it is imperative to bring in the amputated part immediately for the surgeon to assess the replantation potential or for the use of the amputated part as donor tissue.

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