RN/DREXEL Home Study Program CE CENTER

CE credit is no longer available for this article. Expired July 2005

Amy S. Clontz, RN, C, MSN, Darla Annonio, RN, MSN, and Lisa Walker, RN, CCRN, MSN, CRNP

An accident that severs a finger or limb can result in significant disability, but reattachment is often possible. Giving your patient the best possible nursing care will go a long way toward restoring function.

"Can my fingers be reattached?"

Anxious queries like this one are not uncommon for emergency medical technicians and ED nurses. Some 30,000 people in United States lose a limb, digit, or other part of their body to accidental amputation each year.¹

It's not just fingers, arms, and legs that are severed, however. Virtually any protrusion, including the nose, ears, and penis, may be cut off accidentally—or intentionally.

Most victims of traumatic amputation are male (80%) and range in age from about 15 to 30.¹ Motor vehicle crashes are a leading cause, but workplace accidents, especially in farm, factory, and construction environments, often result in traumatic amputation.² Those who work with construction equipment or heavy machinery such as conveyors and drill presses face an increased risk, but lawnmowers, saws, and other power tools can also sever a limb or digit.²

Caring for a patient who has undergone traumatic amputation requires understanding how to preserve his severed body part, maintain his physical well-being, and address his fears and psychological needs. For patients who are candidates for replantation, top-notch preoperative and postop care will bolster their chances of regaining function.

Type of injury dictates the treatment

There are a number of considerations in determining whether reattachment of a severed body part is possible. One of the key determinants is the mechanism of injury.

A crush injury, often involving heavy machinery, typically results in extensive tissue damage. A guillotine injury, also called a sharp amputation, refers to a body part that's been severed by a straight-edged laceration, like a finger cut off by a circular saw.

A limb or digit cut off in a guillotine injury is more likely to be successfully replanted than one that's amputated by a crush or avulsion injury.³ That's because crush and avulsion injuries typically involve a greater amount of irreversibly damaged tissue than guillotine injuries.³

Whether replantation surgery is attempted also depends on the patient's overall condition and how long the body part remains detached and how it's preserved. Because traumatic amputation often involves other serious injuries, it's crucial to do a rapid assessment—and to ensure that a microvascular surgeon evaluates the patient and manages his care.

How to preserve the body part

As soon as the patient's airway, breathing, and circulation have been stabilized, turn your attention to wound care and care of the amputated body part. Properly preserving the part is crucial for successful replantation, and no amputated body part—even a fingertip—is too small to be salvaged.¹

If the finger or limb is still attached to the body, clean the wound surface with sterile water or saline solution. Then, if possible, gently place the damaged skin back to its normal position. Control bleeding and bandage the wound with bulky pressure dressings.

If the body part is completely detached, control bleeding after cleansing the site by covering the wound with a pressure dressing. Then wrap the amputated body part in sterile gauze moistened with sterile saline solution or sterile water, put it in a watertight plastic container or resealable plastic bag, and label it with the patient's name and the time. Place the container in an iced saline bath.⁴

Freezing an amputated body part can damage the tissue, however, so never let it come in direct contact with ice. And never use dry ice to preserve it.⁵

Because amputated digits have less muscle mass than extremities, fingers have a longer ischemic tolerance, or ischemia time—the total time a body part can be without circulation but remain healthy enough for successful replantation. In general, the ischemic time for digits is up to eight hours, compared to four to six hours for extremities.⁵

Although cooling the amputated body part may prolong ischemic time, it's crucial to evaluate the patient and attempt replantation as quickly as possible.

Who's a candidate for replantation?

After providing wound care and preserving the body part, assess the patient from head to toe. Avoid repeatedly examining the injured site, because it's painful and it may increase the risk of vascular spasm.

For their part, the physicians and surgeons will evaluate the patient to determine if replantation is feasible. The main goals of replantation are to restore or maintain the function of the affected body part.

Whether or not replantation will be attempted depends on several factors, including which body part was amputated, how well preserved it is, the extent of disability associated with the loss of the limb or digit, and the patient's other injuries and overall health.⁵

Because the loss of a thumb will result in significant disability, surgeons almost always attempt replantation.⁶ Even if a replanted thumb has poor motor function and little sensation, the leverage it provides can't be replicated by a prosthesis.

With the exception of the thumb, single digits are generally not replanted because doing so offers the patient little or no functional benefit.^4,5 But when multiple fingers are severed, reattachment is likely to be attempted. Similarly, surgeons usually try to replant hands that have been amputated through the palm or wrist, fingertips, and arms cut off below the elbow. Because many patients function better with prosthetic lower limbs than with reattachments, replantation of the legs or feet is less common—and toes are rarely replanted.³

There is one important exception to these general practices, however. When the patient is a child, replantation is almost always attempted, regardless of which body part has been amputated.³

How badly both the patient and the limb or digit are injured also plays a role in the decision of whether or not to attempt replantation. Severely crushed, mangled, or contaminated body parts are a contraindication, as is the presence of life-threatening injuries, which obviously must be treated first.^3,5

Similarly, replantation may not be attempted in patients with systemic illness such as hypertension, diabetes, or peripheral vascular disease—the primary non-traumatic cause of amputation. Such disorders increase the risk of infection and other complications.³

Patients with severe psychiatric illness may also be poor candidates for replantation. That's because of the risk that they will not be able to follow the complex postop treatment instructions.

Preparing the patient for the OR

If your patient is a candidate for replantation surgery and has consented to the procedure, begin preparations immediately. Check that the patient has two large-bore (16- or 18-gauge) catheters. Infuse warm saline or lactated Ringer's solution.

Draw labs for a baseline coagulation profile, electrolytes, and blood counts. Request that blood be typed and cross-matched. Be sure the amputated part and affected site are X-rayed to determine if bones are missing, comminuted fragments exist, or a foreign body is embedded.⁵

Administer broad-spectrum antibiotics and a tetanus toxoid, as ordered, for prophylaxis. Antibiotics are continued during surgery and postop.

The surgeon will begin by examining the vessels of the amputated part under a microscope and identifying and putting tags on all muscle groups, nerves, tendons, and vessels.⁵ If the surgeon finds that the vessels are too damaged to restore, the surgery won't proceed. If the amputated body part has adequate vascular supply, the bones are pinned or wired, or a plate is used to assure proper alignment.

How the bones are attached depends upon the type of amputation. Fingers are generally wired in place, while metacarpal amputations are plated.⁵ To limit contractures, the tendons usually receive minimal debridement.

The surgeon will wash the wound with an antibiotic saline solution before beginning the reattachment. She'll fix the bones in place first, followed by the tendons and the nerves.⁵ The functional outcome depends largely on successful reattachment of the nerves, which can be grafted if necessary.⁵

Vascular repair typically follows nerve reattachment, but the arteries may be repaired first if the surgeon is concerned about exceeding the ischemia time.⁵ The surgeon connects the arterial supply before the venous supply. If necessary, a vein may be grafted to the damaged artery to restore adequate distal blood flow.

If the surgeon is doing a digital replantation, she'll wrap the finger in warm gauze and watch for it to "pink-up" after the arterial supply is reattached.⁵ If perfusion is poor, the finger may need a second arterial anastomosis or revision of the existing one.

Once blood flow is adequate, the veins should begin bleeding briskly. The two veins that are bleeding the most are generally reconnected.⁵ Then, if the veins and arteries look fine, the surgeon will close the skin and immobilize the extremity in the position of function.

Keeping an eye on blood flow

If possible, bring the patient to a room with a temperature that is higher than 78° F (25.5° C) after surgery. The warm environment lessens the risk of arterial spasm, which compromises blood flow.⁵

If you are providing postop care, assess the replanted body part for warmth, color, and turgor, but be careful not to manipulate it immediately following surgery. See if the patient has any sensation in his replanted body part.

Check the capillary refill of the nail beds of a patient who had his fingers replanted; refill is normally less than three seconds. Pulse oximetry or laser Doppler flowmetry can be used to assess pulse and blood flow.⁵ If you use pulse oximetry, place the probe on the digit. Changes in blood flow will give a rapid change in oxygenation.

Assess vital signs, including pain intensity, frequency, and duration. In addition, check for anything that might be aggravating or alleviating the pain. If the doctor orders patient-controlled analgesia (PCA), show the patient how to use the pump and make sure the settings are correct.

Teach your patient that the replanted digit or extremity must be elevated to reduce edema. A Carter pillow—a special pillow that helps with elevation by keeping the patient's elbow flexed—may be ordered.⁷

Most patients will receive a continuous heparin infusion for the first few days after replantation, especially if blood vessels were severely damaged or vascular thrombosis occurred during surgery.⁵ Increased bleeding is a possibility, so assess the digit or body part for bleeding and expanding hematoma. You should monitor the patient's prothrombin time/partial thromboplastin time for the duration of heparin therapy.

Aspirin is typically given for its antiplatelet effect, usually 325 mg daily for three weeks postop.⁵ Dextran, a volume expander, may be given intravenously for a few days to help increase blood supply to the reattached body part.

Instruct your patient to avoid chocolate, caffeine, and nicotine because these substances can impede blood flow. Patients who smoke have a greater risk of thrombosis postop.⁸

Consider your patient's psychological needs, as well. Take time each day to encourage him and his family to express their feelings about the accident and its aftermath.

Be aware, too, that during the postop phase many patients and families may have difficulty comprehending the information you are providing. So be prepared to repeat instructions and patient education frequently. Patients will typically need a social worker, physical and occupational therapy, and case management to provide comprehensive care.

Replantation usually succeeds

The success rate for replantation surgery averages about 80%.⁴ However, there is some risk of complications, particularly venous congestion. Suspect it if your patient has increased edema at the replantation site, or the digit or limb is warm and purple.

Venous congestion can be treated by removing tight dressings and sutures and increasing the elevation of the affected body part to promote drainage by gravity.⁴ Leech therapy can also draw out pooled venous blood from a reattached digit or limb. (See the "Leech therapy: Unusual but effective" box.)

Other potential complications include infection and failure of the replantation.^1,5 Infection is always a possibility because traumatic amputation rarely occurs in a sterile environment. Antibiotics given before, during, and after surgery help decrease this risk.

There are also some long-term effects; even a successful replantation rarely restores normal function.⁸ Almost all patients who undergo replantation experience some degree of intolerance to cold, for example.⁹ This may improve after about two years or persist indefinitely.⁵

Stiffness and decreased ROM and sensation are common, although physical therapy or occupational therapy can help build up use of the reattached limb or digits.

Rejection of the replanted part is always a possibility and can occur as a result of infection or necrosis caused by vascular problems.⁵ The only sure way to correct vascular problems in a replanted digit or limb is to perform a second surgery.⁵ Amputation of a failing replanted part is usually the last option.

A patient whose replantation fails, like any patient who loses a digit or limb, may experience phantom limb sensation—the feeling that the missing part is still there. This sensation will eventually disappear.

Phantom limb pain is a feeling of crushing, grinding, or burning pain in the place where the body part used to be.¹ It can occur immediately postop or may not start for up to six weeks.¹⁰ The reason for phantom limb pain is not fully understood, but it may be the result of inflammation or regrowth of the nerve endings.

Patients should expect a lengthy rehab

Upon discharge, tell your patient to call his surgeon or primary care provider if he develops a fever greater than 100° F (37.7° C) for more than 24 hours or has an increase in drainage, warmth, or swelling of the replanted part. Emphasize the importance of outpatient physical or occupational therapy to learn to manage activities of daily living and regain as much function as possible.

To fully recover, patients with finger or hand injuries will need to continue to work on the grasp, strength, and flexibility of their digits each day. Tell your patient to ask the doctor for pain medication to take before starting to exercise if the activity is painful.

Teach your patient that it's important to give himself time to grieve. Explain that those who undergo traumatic amputation often become anxious and may develop post-traumatic stress syndrome—even if the body part is successfully reattached. Tell patients about support organizations such as the Amputee Coalition of America (888-267-5669), and help them get a psychological evaluation and counseling if they need it.

Finally, stress the importance of patience. Sometimes it takes years for a replanted digit or limb to become a workable part of the patient's body, and few patients regain full function. Whatever the final outcome, you can rest assured that your nursing care will help ease your patient's physical and emotional distress and play a vital role in his recovery.

REFERENCES

1. Haggerty, M. "Traumatic amputations." Gale encyclopedia of medicine. www.findarticles.com/cf_dls/g2601/0013/2601001392/p1/article.jhtml (16 Apr. 2004).

2. U.S. National Library of Medicine. "Amputation-traumatic." 2002. www.nlm.nih.gov/medlineplus/ency/article/000006.htm (16 Apr. 2004).

3. Microsurgeon.org. "The decision for replantation." 2004. www.microsurgeon.org/decision_making.htm (16 Apr. 2004).

4. Wilhelmi, B. J., Lee, A., et al. "Hand, amputations and replantation." 2003. www.emedicine.com/plastic/topic536.htm (16 Apr. 2004).

5. Pederson, W. C. (2001). Replantation. Plast Reconstr Surgery, 107(3), 823.

6. Heitmann, C., & Levin, L. S. (2002). Alternatives to thumb replantation. Plast Reconstr Surgery, 110(6), 1492.

7. Papanastasiou, S. (2002). Rehabilitation of the replanted upper extremity. Plast Reconstr Surgery, 109(3), 978.

8. Koman, L. A. (2001). Replantation of digits and hands. J South Orthop Assoc, 10(2), 86.

9. Allen, D. M., & Levin, S. L. (2002). Digital replantation including postoperative care. Techniques in Hand and Upper Extremity Surgery, 6(4), 171.

10. Davidson, J. H., Jones, L. E., et al. (2002). Management of the multiple limb amputee. Disabil Rehabil, 24(13), 688.

Leech therapy: Unusual but effective

Leech therapy is frequently used to treat venous congestion that develops following replantation surgery. The leech most commonly used for therapy is Hirudo medicinalis and it—like other leeches used for this purpose—is grown in sterile conditions, specifically for use on patients.

Leeches get their energy from hemoglobin in blood. When applied to a patient, they can consume 5 – 15 ml of blood, typically in 15 – 60 minutes. However, it's the continuous bleeding that occurs after the leeches detach themselves that primarily relieves the venous congestion. That's because leeches usually leave an oozing bite that may bleed for as long as 10 hours and release up to 150 ml of blood. Saliva from a leech's bite also contains an anesthetic, which may relieve a patient's pain.

Many patients have a difficult time accepting leech therapy, so it's important to find out if your patient is psychologically prepared for it. Explain the benefits of leech therapy, and stress that it's medically accepted and has proven successful.

The number of leeches you'll need will vary; for a replanted finger, one or two are usually used. To avoid infection, the patient is given a prophylactic antibiotic. Before applying a leech, clean the patient's wound with soap and water. Use tweezers to place the leeches on the affected area, and make sure they attach to the wound. Assess the site every 15 minutes to be certain the leeches have not moved.

When the leeches finish feeding, they'll release themselves, so inspect the site frequently to collect the leeches as soon as they detach. Before disposing of the leeches, be sure to weigh them; this information is used to calculate the patient's blood loss. To get rid of the leeches, put them in a solution of 8% alcohol to numb them, then add 70% alcohol to destroy them.

After leech therapy, the patient's digits or body part should be pink and warm, with a capillary refill of less than three seconds. Patients may require several treatments of leech therapy to resolve their venous congestion.

Sources: 1. Kowalczyk, T. (2002). A low-tech approach to venous congestion. RN, 65(10), 26. 2. Pederson, W. C. (2001). Replantation. Plast Reconstr Surg, 107(3), 823.