- Success rates of extremity replantations have now increased to 80%.
- However, most cases of limb amputations are limited to those distal to the wrist.
- This case describes forequarter amputation after a workplace-related injury where replantation was attempted.
An 18-year-old man presented to the emergency with a workplace-related injury, requiring a forequarter replantation. The man’s left shirt sleeve got caught in a cloth rolling machine which caused an avulsion and amputation of his left upper limb at the shoulder. The patient was brought to the hospital 3 hours after the incident had taken place.
Examination showed pallor of the arm with no major systemic injuries. The site of the amputation showed an exposed upper lateral chest wall without the scapula with axillary vessels and brachial plexus remnants visible.
The examination of the amputated limb was done preserved on ice without flushing any fluids. On examination it was further seen that the glenohumeral joint was intact, whereas, the attached scapular musculature was avulsed and torn. In addition, no bony injuries could be seen distal to the shoulder. Radiographs further confirmed that there were no major soft-tissue injuries.
Treatment plan
The treatment plan included an attempt at replantation after proper counselling of the patient. The patient was immediately shifted to the operating room after initial resuscitation. And the avulsed musculature was thoroughly debrided. The axillary artery, axillary vein and cephalic vein were identified for viable anastomoses. A long-segment vein graft was obtained from the left lower limb. An expedient plating of the acromioclavicular joint was also performed. Moreover, future plans included fixing the scapula to the posterior chest wall at a later date. The segmental axillary artery loss was noted after the anastomoses were completed and was bridged with the vein grafts.
During the procedure, the elements of the brachial plexus were found to be avulsed proximally and deep in the stump. For this reason, it was not advised to perform a primary nerve repair. 8 hours after injury, revascularization was finally accomplished with good perfusion. Fasciotomies were also done in the arm and forearm. Moreover, the limb was strapped to the chest wall and a strong musculotendinous repair was done around the axilla.
Post-operative outcome
The limb appeared to be well-vascularised post surgery which was determined by clinical examination, pulse oximetry and capillary refill. There were no signs of repurfusion injury, although it had been anticipated. The levels of normal creatinine, creatine kinase and blood gas were normal. However, after a few days of the procedure, the shoulder musculature showed necrosis and the patient was taken for a serial debridement of the unhealthy muscle. The patient was called in for 3 sittings of debridement. He was on antibiotics for 10 days. In addition, the limb appeared to be infected ten days after the procedure. Although, the limb was still perfused.
The patient was prescribed stronger antibiotics and the wound was thoroughly debrided. The patient was in sepsis on day 14 and the limb was grossly swollen and edematous. He was immediately taken for disarticulation, which revealed venous thrombosis. The stump was primarily closed. The patient was discharged after full recovery.
References
Forequarter Replantation and the Lessons Learnt https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596434/
