Hand Amputation - Medical Negligence Lawyers
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Hand Amputation - Medical Malpractice
Hand amputation occurs most often following an occupational or farm accident but can come following a particularly severe motor vehicle accident. If the hand isn’t amputated with a great deal of surrounding crush injury, the hand can be reattached. Reattachments began 50 years ago when a child had his arm amputated in a train accident.
Replantation surgery has improved greatly since the beginning and now many hand amputation patients are successful candidates for hand replantation. The procedure involves the careful connection of nerves, blood vessels, and tendons.
Doctors have to make the decision as to who to replant and who to leave with an amputation. The different factors include the importance of the part, the expected return to function, the level of injury, and the mechanism of injury. Hands are pretty important parts of the body so they are preferentially reattached. If the thumb and multiple digits are severed, they are reattached because they can potentially act as a whole hand even if several digits are missing. Replants of the hand at the wrist have a good chance of recovery so this is often replanted.
It is relatively contraindicated to attach a single digit because it will likely be stiff and will take a long time trying to rehabilitate it. This is true with everything except the thumb which should be replanted if at all possible. If the injury is between the elbow and the wrist and involves the muscles it should not be replanted because there will be a poor functional recovery. The amputation has to be at the wrist or at the level of the elbow for there to be a good function of what’s left. The muscular area is relatively devascularized and doctors will not get great function even if the extremity is reattached.
The mechanism of injury is the most predictive of whether or not the replantation will survive. A guillotine type injury is the best and an avulsion with a crush injury is the worst outcome. Mangled body parts are not good body parts to replant. Fingers that have a red line in the skin over both neurovascular bundles means that the blood vessels will not realistically attach and the attachment should not be attempted. Patients who have amputated their hand themselves are considered unstable and are not candidates for reattachment.
The amputated hand should be brought to the emergency room by the emergency personnel. Any vessels bleeding from the stump should be left to clot on their own and not be clamped off. Use compression and elevation of the arm instead. Wrap the part in saline moistened gauze and put it in a plastic bag. Seal the bag and put the bag on ice. Don’t put the amputated part directly on ice as it can get a frostbite injury. Don’t immerse the amputated part in water. This makes the blood vessel repair more difficult.
There are recommended times for ischemia of the affected part. There can be only 12 hours of warm ischemia or 24 hours of cold ischemia for an amputation replantation to be successful if the amputation is a digit. There can only be 6 hours of warm ischemia and 12 hours of cold ischemia for implants of the hand or higher. Successful replants have been done with longer than these recommendations, however.
The hand and the stump need to have x-rays in order to see what kinds of fractures have occurred. Informed consent should be received by the patient before attempting a replantation of the hand. It should talk about the realistic expectations of replanting the hand and the failure rate of hand replantation. There should be preventative antibiotics given before the procedure and the tetanus status of the patient should be assessed and updated. There should be fluid resuscitation to keep the patient hydrated during the procedure. They are likely to be dehydrated and anemic from blood loss due to the injury. The patient should be warmed so they don’t suffer from hypothermia. A Foley catheter should be placed.
Prepare the hand by cleaning it with gentle irrigation. Expose the neurovascular structures of the wrist by making long incisions along the volar aspect of the hand. Sometimes zigzag incisions are made in order to expose those structures. The various neurovascular structures should be identified and tagged so that they can be identified more easily in the operating room. If a vein graft is needed, it should be harvested before the procedure has started.
After the neurovascular structures of the amputated hand have been tagged and identified, the structures are carefully retracted so that the bone can be shorted by 5-10 mm. The bone must be shortened so that the attachment of the arteries and nerves can be tension-free. The bone should be shortened on the amputated part and not on the stump so that the stump length can be maintained if the amputation fails. If the bone is shortened, the nerves can be free of tension and can regrow a lot easier and quicker.
Retrograde K wires or interosseous wires should be placed through the bone on the amputated hand. This results in higher union rates and better fracture healing. Overall, the amputated hand should be completely prepared prior to the patient ever arriving in the operating room. This might need a whole second team of surgeons. The same identification of nerves, arteries, tendons and veins, is done on the proximal part of the surgery but it is done after there is tourniquet control over the vessels.
In general, repair goes as follows: the bone is first repaired and there is essentially a fracture repair; then there is repair of all extensor tendons, extensor blood vessels and dorsal skin followed by the flexor blood vessels and nerves, and the volar tendon and skin repair. Arteries can be repaired first if there has been a long time of warm ischemia. The hand is repaired in the pronated position first and in the supinated position last.
Overall success rates for a replantation of the hand are about 80 percent. Fifty percent of the people will be able to discriminate two points at ten mm or less. Seventy percent can perceive two points at 15 mm. Fifty percent will have a reasonably normal grip strength. Younger people fared better than older people.
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The author of the substantive medical writing on this website is Dr. Christine Traxler MD whose biography can be read here