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AMPUTATION, FOREARM

Introduction

Upper extremity injuries continue to be problems that are frequently seen in emergency departments (EDs) around the world. In the U.S., upper extremity amputations are very common in both work1 and home environments.2 Most cases involve the digits; forearm amputations are less common.3,4 Most work-related amputations occur in young males (>80%) with limited education beyond high school,1 during the regular work week, while using machines such as saws, punch presses, food and beverage machines, and printing presses.2,5 The industries where amputations are most common include agriculture, forestry, fishing, manufacturing, and construction.1 In many cases, machinery guards and shields are not used by the workers who injure themselves. Other causes of forearm amputations include malignancy, disease, and congenital anomalies.6 Regardless of the cause, these injuries typically cause permanent disability, psychological distress, and loss of work to the individual, which has both direct and indirect implications on each patient and society as a whole.6-8

Definitions

A forearm amputation is the loss of the entire hand, which may also include an associated portion of the forearm at any point from the carpus to just distal of the elbow.1,6 Forearm amputations can be partial or complete.2 With a partial amputation, there may be a structure still connecting part of the hand or forearm to the stump. In complete amputations, there is no visible connection between the amputated part of the hand/forearm and the stump. Amputations may also be defined by the level of the transection, depending on the location of the amputation in the forearm.  In the forearm, amputations can be defined as occurring in the proximal third of the forearm, the middle third of the forearm, or the distal third of the forearm.

Related Anatomy

Obviously, complete amputation of the forearm involves all the tissues in the amputated part. Therefore, a forearm amputation involves the skin, veins, extensor tendons, bone, flexor tendons, digital nerves, and digital arteries.

 

Amputation

Replant

Bone
  • Shorten the radius and ulna to allow for good soft tissue coverage of bone end
  • Debride bone ends and shorten proximal and/or distal to remove tension on microsurgical repairs.
  • Do some type of ORIF for the bone, frequently with plates and screws
Flexor tendons
  • Debride and allow ends to retract
  • Repair flexor tendons
Extensor tendons
  • Debride damaged edge
  • Repair the extensor tendon
Digital arteries
  • Ligate the radial and ulnar arteries at the stump level
  • Microsurgical repair
Radial, median and ulnar nerves
  • Pull digital nerve endings distally, cut sharply and allow ends to retract in surrounding soft tissue
  • Microsurgical repair
Veins
  • Cauterize or ligate veins on the stump
  • Microsurgical repair
Skin
  • Maintain healthy viable skin for stump coverage
  • Maintain healthy viable skin for coverage of the circumferential wound
  • Amputations of the upper extremity can also be divided into major and minor depending on whether the amputated part has significant muscle bulk. Major amputations encompass those at the level of the wrist or proximal, and the more proximal the amputation, the greater the muscle load.9

Overall Incidence

  • Hand and forearm amputation and subsequent replantation is far less common than digital amputations, and as a result, relevant research is less abundant.10,11
  • Conn and colleagues reported that there are >30,000 non-work-related finger amputations annually in the U.S.2 They also identified two high-risk groups: children aged <5 years and adults, usually males, aged >55 years.
    • Children often get a finger or hand shut in a door, and adults are usually injured by power saws, snow blowers, and other machinery.
    • Amputations were also found to occur secondary to a cut, crush, bite, or burn.
    • Factors such as alcohol use, fatigue, decreased dexterity, and reflex time and medication use were cited as frequent secondary causes associated with these injuries.
  • Another study used 3 years of data from the National Inpatient Sample of the Healthcare Cost and Utilization Project to identify 9,407 upper extremity amputations.4
    • Of these amputations, 6,891 involved the fingers, 1,947 involved the thumb, and 840 involved complete hands or arms. 
    • Approximately 15% of these amputations underwent replantation, including 12% of patients with hand or arm replantation. The mean cost of replantation was >$40,000.
  • In the U.S., amputations are very common in the workplace:
    • Amputation rates vary from 1.5-3.7 per 10,000 full-time workers per year.1
    • In North Carolina between 2004-2006, the amputation rate was 21.3 amputations per one million people. There was no correlation to increased numbers of immigrants.5
  • One study found that 68-78% of total trauma amputations involve the upper extremities.6
  • Specific data on upper extremity amputations in the U.S. is lacking, but for an rough estimation, the prevalence of upper extremity amputations at the wrist level or proximal is ~11.6 per 100,000 adults in Norway.12
  • In the U.S., the cost of a cosmetic arm or hand ranges from $3,000-$5,000, while a myoelectric prosthetic arm with a realistic-looking, functioning hand costs >$20,000.8

Related Injuries/Conditions

  • The majority of upper extremity amputations are secondary to traumatic injuries; however, amputations are also performed surgically to treat severe burns, neoplasms, vascular peripheral disease, nerve damage, and uncontrollable chronic infections.6
  • Congenital amputations are very rare: the Centers for Disease Control and Prevention estimates 4/10,000 babies are born with upper limb reductions.13

Differential Diagnosis

  • Traumatic amputation
  • Surgical amputation for tumor or infection control
  • Congenital amputation
ICD-10 Codes

  • AMPUTATION, FOREARM

    Diagnostic Guide Name

    AMPUTATION, FOREARM

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    AMPUTATION, FOREARM, TRAUMATIC    
    - AT ELBOW; COMPLETE S58.012_S58.011_ 
    - AT ELBOW; PARTIAL S58.022_S58.021_ 
    - BETWEEN ELBOW AND WRIST; COMPLETE S58.112_S58.111_ 
    - BETWEEN ELBOW AND WRIST; PARTIAL S58.122_S58.121_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S58
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Severe crush type forearm amputation caused by a train accident. A proximal forearm amputation revision was required.
    Severe crush type forearm amputation caused by a train accident. A proximal forearm amputation revision was required.
  • Severe crush avulsion at distal forearm/wrist level
    Severe crush avulsion at distal forearm/wrist level
Symptoms
History of traumatic amputation, surgery amputation, or birth defect
Bandaged amputation stump
Amputated part frequently arrives with the patient
Typical History

The typical patient is a 35-year-old, right-handed male who suffered a severe injury while hunting. The man, who was intoxicated, had noticed a donut on the ground that he assumed had fallen out of his friend’s bag. But when he went to reach for the donut, it triggered a bear trap, which clamped completely shut on his wrist. Fortunately, one of his friends was nearby to release the trap and his hand with it, but the trap had severed his hand entirely from just proximal to the wrist. His friend applied a pressure dressing, wrapped the hand, put the hand on ice, and took the patient immediately to the ED.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Treatment goals for amputation revision include: (1) preserve stump length; (2) provide a stump with durable soft tissue coverage, intact sensation and minimal neuroma pain; (3) minimize downtime with speedy return to work and vocational activities; (4) when appropriate, provide timely referrals for hand therapy and prosthetic fitting.5,14
  • Treatment goals for replantation are similar: (1) save hand functionality by providing intact, mobile, pain-free sensate digits; (2) minimize cold intolerance; (3) provide efficient post-operative care, rehabilitation, and early return to work and activities of daily living.4,14
Conservative
  • Nonoperative treatment is not typically indicated for forearm amputations. There are times when a potentially infected amputation might be left open or an ischemic part might be left to autoamputate, but these situations are very rare. Most guillotine forearm amputations are replanted, while crush or avaulsion forearm amputations are revised and surgically closed.
Operative
  • The two primary surgical options for forearm amputations are replantation and amputation revision with closure of the stump.
  • Amputation revision includes cutting back the protruding bone to shorten it if needed so that the soft tissues at this time can be sutured without excessive tension.
  • Revision also includes ligation of the radial and ulnar arteries and veins distally, gently pulling the radial, median, and ulnar nerves distally and the resection of the distal nerve sharply and proximally so that the digital nerve can retract into the muscles of the stump.
  • Forearm amputations are generally considered to be good indications for replantation. On the other hand, crushing, avulsing, and rotating forces that lead to the most severe of these injuries, are often contraindications for replantation (see clinical photo).15,16
    • The functional results after replantation of these injuries depends on the mechanism of amputation and warm ischemia time, as long ischemic time can have a severely negative impact on outcomes.15
  • Secondary surgery is an integral part of the treatment for complex replantations such as those of the hand and forearm. The average number of secondary procedures needed is 3, and more proximal amputations are associated with an increase in the number of secondary procedures required.9,16
  • Replantation should be considered a superior option to prosthetic management for pediatric forearm amputations because of the nerve generation that occurs in children and their general healing capacity.17
  • In certain situations, a prosthesis may the only available option to help the patient recover some degree of functionality and aesthetics. This may be indicated when replantation is not possible, when a surgical procedure alone cannot fulfill the functional requirements or cosmetic needs, when the surgeon does not recommend surgical reconstruction, or when the patient does not want to undergo reconstruction.6
Hand Therapy
  • A hand therapist can help patients recovering from hand and forearm revision and replantation surgery in the following ways:
    1. Instruct on how to regain active range of motion (ROM) in the hand after replantation
    2. Decrease edema by massage and stump wrapping
    3. Minimize neuroma symptoms by desensitization techniques
    4. Teach prosthetic use and care when appropriate
  • After replantation, physical therapy is crucial for helping patients regain function, patients must participate in therapy consistently, adequately, and for extended periods in order to properly recover from surgery. Rehabilitation after replantation usually includes intrinsic splints with outrigger supports and protected passive and active ROM exercises for the fingers. Early motion of the joints is encouraged to prevent contractures and facilitate strengthening of musculotendinous units.9
  • With forearm amputations, the patient will also need referral to an orthotist/prosthetist for evaluation and manufacturing and fitting of a prosthetic device. 
  • With the latest advances in 3D printing, 3D-printed upper extremity prostheses are emerging as affordable, lightweight, and customizable alternatives to traditional orthotist-produced prostheses.8
Complications
  • Symptomatic neuroma and diminished stump sensation
  • Psychological trauma, time off from work, and job change or loss1
  • Wound complications such as infections
  • Bone overgrowth at stump end
  • Loss of ROM 
  • Phantom limb sensation and pain
  • Replant failure and need for secondary amputation revision
  • Cold intolerance from the amputated stump or replantation
  • According to one study, although most patients have some function after forearm replantation, severe cold intolerance is a common complication.3,18
Outcomes
  • Guillotine amputations have been found to do better than crush and avulsion type injuries.14,19
  • Replantation is usually associated with an excellent cosmetic result; however, paresthesias and cold intolerance are present after amputation revision and after successful replantation surgery.20 Pain can be a posttraumatic complaint in both groups.
  • Amputation revision remains a straightforward procedure that is frequently done with a shorter hospitalization and rehabilitation.  Also, the time lost from work is usually shorter for amputation revision surgery than for replantation.
  • Despite this, lost time from work, lost jobs and placement in alternative work remain occurrences that workers often experience after amputation.1
  • When surgically treated and rehabilitated properly, the functional results of replantation for wrist-level amputations are superior to those for transmetacarpal and more proximal forearm amputations; however, these results largely depend on the mechanism of injury, as avulsion amputations carry a worse functional prognosis than clean, sharp injuries.16
  • Literature is lacking on the functional results of wrist-level replantations, and because the functional evaluation of published cases is not homogeneous, comparison is difficult.16
  • In one study that reported on 5 sharp wrist amputations treated surgically with replantation, the total active motion (TAM) of the hand was 75-85% of the contralateral hand, with limited intrinsic function and two-point discrimination <12 mm.21
  • Another study reported on 14 patients with hand replantations at the wrist level, and found TAM between 50-70% of the contralateral side, reduced intrinsic function, and two-point discrimination >10 mm.22  Clearly, the lack of complete nerve regeneration, in adults especially, remains a real problem despite successful replantation surgery.
  • An extensive systematic review has also been performed to compare wearing a prosthesis versus replantation after traumatic arm amputations—above and below the elbow—with a total of 301 replantation cases and 172 managed with prosthesis.  Although the literature on upper limb prosthesis is somewhat lacking with regard to measurement of their functional capacity and outcomes, the authors concluded that replantation is more desirable than wearing a prosthesis because of an overall higher patient satisfaction.23
  • Functional outcomes after hand and forearm replantation in children are generally good, and replantation is therefore considered superior to prosthetic management in this population despite higher cost, longer postoperative care, and increased potential for secondary surgeries.9
  • More proximal amputations have greater muscle loads, and consequently, a poorer prognosis, mainly attributed to difficulty in restoring nerve function.9
YouTube Video
Replantation and Microsurgery
Key Educational Points
  • All revision amputations have neuromas, and all replanted parts have either neuroma incontinuity or neuroma if the nerves were not repaired.
  • Symptomatic amputation neuromas are complex problems with no simple answer. Centro-central union of the digital nerves and neuroma transposition may decrease these annoying and troublesome symptoms.24
  • Patients with elective and traumatic amputations should be advised early about phantom sensations and/or phantom pain. These patients should be advised to ignore these disrupted perceptions that are caused by the damaged nerve endings sending the brain corrupted messages that are perceived as pain or the feeling that the amputated part is still present.
  • If a prosthesis is needed, ideally it should be fitted within 30 days after surgery, as long as stump healing is complete.25  Phanton pain can be a debilitatating problem and may require a multispecialty team to help the patient cope.  Because of this possibility, earlier referral is indicated if the patient does not respond to simple reassurance.  Note, this is a normal post-amputation phenomena.
  • Interestingly, some patients will have suboptimal function but may still be satisfied with their outcome because of the aesthetical aspect of the reconstruction and the extremity.9
  • With the advent of refined microscopes, sutures, and needles, along with specialized surgical training, replantation has become a routine part of hand surgery practice throughout the world;26 however, replantation and revascularization require a specialized center, well-trained teams and microsurgeons, which less likely to be available in developing countries. Consequently, the rates of replantation are far lower in these areas.27
  • Patients suffering from a traumatic amputation often demand reattachment without appreciating the implications of the procedure. Therefore, factors such as lengthy hospital stays and multiple admissions, loss of productivity, lost wages, prolonged time lost from work, family hardships and psychological stress should all be discussed with the patient before they make a treatment decision.9  However, these discussions are difficult in these emergencies.  However, these discussions are difficult in these emergencies.
References

New and Cited Articles

  1. Boyle, D, Parker, D, Larson, C, et al. Nature, incidence, and cause of work-related amputations in Minnesota. Am J Ind Med 2000;37(5):542-50.PMID: 10723048
  2. Conn, JM, Annest, JL, Ryan, GW, et al. Non-work-related finger amputations in the United States, 2001-2002. Ann Emerg Med 2005;45(6):630-5.PMID: 15940097
  3. Sturm, SM, Oxley, SB and Van Zant, RS. Rehabilitation of a patient following hand replantation after near-complete distal forearm amputation. J Hand Ther 2014;27(3):217-23. PMID: 24690132
  4. Friedrich, JB, Poppler, LH, Mack, CD, et al. Epidemiology of upper extremity replantation surgery in the United States. J Hand Surg Am 2011;36(11):1835-40. PMID: 21975098
  5. Gavrilova, N, Harijan, A, Schiro, S, et al. Patterns of finger amputation and replantation in the setting of a rapidly growing immigrant population. Ann Plast Surg 2010;64(5):534-6. PMID: 20395810
  6. Imbinto, I, Peccia, C, Controzzi, M, et al. Treatment of the Partial Hand Amputation: An Engineering Perspective. IEEE Rev Biomed Eng 2016;9:32-48. PMID: 26849872
  7. Alvial, P, Bravo, G, Bustos, MP, et al. Quantitative functional evaluation of a 3D-printed silicone-embedded prosthesis for partial hand amputation: A case report. J Hand Ther 2018;31(1):129-136.PMID: 29196160
  8. Xu, G, Gao, L, Tao, K, et al. Three-dimensional-printed upper limb prosthesis for a child with traumatic amputation of right wrist: A case report. Medicine (Baltimore) 2017;96(52):e9426. PMID: 29384921
  9. Fletcher, C. Case report and literature review of the outcome following reimplantation of the arm. Trauma Surg Acute Care Open 2017;2(1):e000124.PMID: 29766115
  10. Hegazi, MM. Hand and distal forearm replantation--immediate and long-term follow-up. Hand Surg 2000;5(2):119-24. PMID: 11301505
  11. Ramirez, MA, Duque, M, Hernandez, L, et al. Reimplantation of limbs. Plast Reconstr Surg 1967;40(4):315-24. PMID: 4863083
  12. Ostlie, K, Skjeldal, OH, Garfelt, B, et al. Adult acquired major upper limb amputation in Norway: prevalence, demographic features and amputation specific features. A population-based survey. Disabil Rehabil 2011;33(17-18):1636-49.PMID: 21174629
  13. Upper and lower limb reduction defects. Centers for Disease Control and Prevention2018-4-20. Retrieved 2018-09-12.
  14. Jebson PL, Louis DS, Bagg M. Amputations. In Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH (eds): Green’s Operative Hand Surgery 6thEdition, Philadelphia. Elsevier Churchill Livingstone, 2010.
  15. Coban, YK. Failure of replantation of middle forearm amputation exposed to hot environment. Microsurgery 2013;33(5):418-9.PMID: 23686702
  16. Cavadas, PC, Thione, A and Rubi, C. Hand Amputations at the Radiocarpal Level With Proximal Neuromuscular Avulsion. J Hand Surg Am 2016;41(1):70-5. PMID: 26710737
  17. Wolfe, VM and Wang, AA. Replantation of the upper extremity: current concepts. J Am Acad Orthop Surg 2015;23(6):373-81.PMID: 26001429
  18. Pierrie, SN, Gaston, RG and Loeffler, BJ. Current Concepts in Upper-Extremity Amputation. J Hand Surg Am 2018;43(7):657-667.PMID: 29871787
  19. Sebastin, SJ and Chung, KC. A systematic review of the outcomes of replantation of distal digital amputation. Plast Reconstr Surg 2011;128(3):723-37.PMID: 21572379
  20. Hattori, Y, Doi, K, Ikeda, K, et al. A retrospective study of functional outcomes after successful replantation versus amputation closure for single fingertip amputations. J Hand Surg Am 2006;31(5):811-8.PMID: 16713848
  21. Hoang, NT. Hand replantations following complete amputations at the wrist joint: first experiences in Hanoi, Vietnam. J Hand Surg Br 2006;31(1):9-17. PMID: 16359762
  22. Mahajan, RK and Mittal, S. Functional outcome of patients undergoing replantation of hand at wrist level-7 year experience. Indian J Plast Surg 2013;46(3):555-60. PMID: 24459349
  23. Otto, IA, Kon, M, Schuurman, AH, et al. Replantation versus Prosthetic Fitting in Traumatic Arm Amputations: A Systematic Review. PLoS One 2015;10(9):e0137729. PMID: 26340003
  24. Belcher, HJ and Pandya, AN. Centro-central union for the prevention of neuroma formation after finger amputation. J Hand Surg Br 2000;25(2):154-9.PMID: 11062573
  25. Fahrenkopf, MP, Adams, NS, Kelpin, JP, et al. Hand Amputations. Eplasty 2018;18:ic21. PMID: 30344843
  26. Boulas, HJ. Amputations of the fingers and hand: indications for replantation. J Am Acad Orthop Surg 1998;6(2):100-5. PMID: 9682072
  27. Amouzou, KS, Amakoutou, K, Bakriga, B, et al. Hand replantation: First experience in a sub-Saharan African country (Togo). Indian J Plast Surg 2016;49(1):109-11. PMID: 27274133

Review

  1. Wolfe, VM and Wang, AA. Replantation of the upper extremity: current concepts. J Am Acad Orthop Surg 2015;23(6):373-81. PMID: 26001429

Classics

  1. DOUBLE forearm amputation. Lancet1948;1(6507):765. PMID: 18914727
  2. Herbsman H, Lafer DJ, Shaftan GW. Successful replantation of an amputated hand: case report. Ann Surg1966;163(1):137-43. PMID: 5904900
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