Amputation: Evalaution and Treatment

SUMMARY OF CHANGES

1. New references have been added based on clinical data from the Fluid Lavage of Open Wounds Study and improved outcomes seen with newer techniques in peripheral nerve management.
2. Although recent clinical data is inconclusive as to which irrigation method is superior, additives such as iodine or castile soap should not be added to the irrigation solution when irrigating open wounds.
3. Recommendations are made to avoid traction neurectomies acutely, when possible, to allow for targeted muscle reinnervation if deemed appropriate at the time of definitive wound closure.
4. Recommendation to NOT amputate through the most proximal fracture if stabilization of the fracture can result in an improved functional outcome and the associated wounds make salvage at the more distal level possible.
5. Recommendations made that if using negative pressure wound therapy (NPWT) during transport, consideration should be made to use antibiotic beads (if available) under the NPWT dressing if vacuum dressing fails.

BACKGROUND

Most combat casualties sustain musculoskeletal injuries with varying degrees of severity. Their prevalence and complexity present a challenge in which the management of the patient’s overall pathophysiology must be balanced with efforts for limb preservation. Data from the Department of Defense Trauma Registry (DoDTR) demonstrates that 5,579 amputations have been performed from 2002-2024, with 32% of those performed on U.S. Service Members. Out of all traumatic injuries documented, the percentage of amputations range from 0.5%-8.0% per year, with the higher percentage registered during the height of the war in Afghanistan and Iraq (2002-2013). While it fluctuates in frequency of occurrence over the years, injury patterns that increase likelihood of amputations will continue to exist and may likely increase in future combat scenarios. Therefore, it is imperative that medical providers are familiar with the management of patients at high risk for amputations.

The extent of the “zone of injury” is dependent upon the mechanism of injury (i.e. blast, gunshot and crush injuries), as well as the co-morbidities and physiologic status of the casualty. Factors such as severe blood loss with massive resuscitation, burns, compartment syndrome, tourniquet use, and contamination load often extend the actual amount of tissue damage beyond that which is apparent on initial visual inspection. Amputation terminology includes traumatic amputations which are immediate extremity amputations caused by the wounding mechanism itself. Primary amputations are those performed by a surgical team after evaluation of the mangled extremity, with the decision not to pursue limb salvage. Data from DoDTR show that 19.7% of total amputations were performed in Role 2 facilities, with only 4.4% performed on U.S. Service Members. In comparison, 73% were performed in Role 3 facilities, with 20% performed on U.S. Service Members. These data suggest that there is an attempt to pursue limb salvage of U.S. Service Members on initial and subsequent evaluation during the early phases of their trauma care. Secondary amputations can occur early (within 90 days) or late (after 90 days), with the latter referring to those amputations occurring after an initial attempt at limb salvage has been undertaken. Most commonly, primary, and early secondary amputations are performed for vascular injuries not amenable to repair or resulting in prolonged limb ischemia, nerve injuries not compatible with a functional extremity, or extensive nonviable tissue with potential for uncontrolled sepsis. Of the amputations performed, DoDTR data reveal that only 13% of the amputations had arterial injuries of which 70% had an arterial procedure performed to attempt limb salvage. Other factors other than perfusion, such as nerve injuries or nonviable tissue likely contributed to decision to amputate.

Late secondary amputations are generally performed due to patient preference or major complications (e.g., flap failure, recurrent osteomyelitis, persistent poor function or pain) of attempted limb salvage. Current consensus regarding extremity amputation following battle-injury is to preserve limb length and vascularity, facilitate adequate wound drainage, and achieve eventual coverage and closure of the amputation wound.1,2