Traumatic amputation and part preservation

Use a catastrophic-haemorrhage-first trauma sequence. Apply firm direct pressure and haemostatic packing where anatomically possible. If bleeding remains life threatening, use a commercial tourniquet at the most distal position that controls flow and note the time visibly and in the record. Do not blindly clamp the wound because this can damage retracting nerves and vessels needed for repair. Activate major haemorrhage support, prevent hypothermia and search for head, chest, abdominal, pelvic and other limb injury.

Examine the residual limb after physiology permits. Record skin and muscle loss, contamination, fracture level, degloving and the apparent zones of crush or avulsion. Document proximal pulse, Doppler, compartments and every function still present in a near-amputation. A thin bridge must not be divided: it may contain a functioning nerve, vein or artery. Cover with saline-moistened sterile material, align gently and splint both the residual limb and any partially attached segment without tension or kinking.

Package a completely separated part immediately and correctly. Hold it with moistened sterile gauze rather than scrubbing. Remove only loose gross contamination. Wrap in gauze dampened with sterile saline, place inside a watertight sealed plastic bag and label it. Put that bag in an outer container of iced water. Tissue must not touch ice or dry ice, freeze, or sit directly in water. Record injury and cooling times and keep the package with the identified patient.

Call the appropriate replantation or major-trauma service at once. Communicate patient age and physiology, dominant side, occupation and goals, precise level, sharp versus crush or avulsion mechanism, contamination, associated injuries and estimated warm and cold ischaemia. Send policy-compliant images of the stump and part if requested without delaying transfer. Imaging of the residual skeleton and part can assist planning, but CT should not postpone haemorrhage control or direct transfer.

Replantation aims for useful function, not survival of tissue alone. Thumb, multiple digits, hand, wrist and paediatric injuries often prompt strong consideration; major proximal muscle-bearing segments have shorter tolerance and a greater reperfusion burden. Severe crush, long avulsion, multilevel destruction, heavy contamination, unstable physiology and limited reconstructive potential reduce benefit. No universal warm or cold time safely decides every tissue and level, so preserve and refer rather than rejecting a part locally.

Near-amputation or major limb replantation requires coordinated orthopaedic, plastic, vascular and anaesthetic surgery. Rapid temporary shunting may restore flow; skeletal shortening and stable fixation protect anastomoses, followed by arterial, venous, tendon, nerve and cover reconstruction in a planned sequence. Consider fasciotomy after revascularisation and monitor systemic potassium, CK, acid-base state and renal function. Debride non-viable contamination while retaining useful structures and avoid closure under tension.

When replantation is not appropriate, revision amputation still preserves maximal useful length, durable sensate cover, balanced muscle and prosthetic options. Do not sacrifice length or nerve unnecessarily during emergency tidying. A decision for early amputation of a mangled attached limb should involve at least two relevant consultants and the patient or family where possible, with rehabilitation expertise. Life-threatening sepsis, unsalvageable perfusion and predicted non-functional painful salvage shape the reasoning.

After either pathway, anticipate pain and adjustment needs. Provide multimodal analgesia, regional techniques under appropriate surveillance and early acute-pain input. Assess phantom sensation, neuroma, sleep, mood and post-traumatic stress without pathologising normal grief. Physiotherapy prevents contracture; occupational therapy supports independence and hand goals; rehabilitation medicine and prosthetics shape stump care, equipment and staged fitting. Peer support and vocational planning can materially improve long-term participation.