25.1

Amputations

Chapter 25

Amputations

Introduction

Battle casualties who sustain amputations have the most severe

extremity injuries.

 Historically, one in three patients with a major amputation

(proximal to the wrist or ankle) will die, usually of

exsanguination.

 Though amputations are visually dramatic, attention must

be focused on the frequently associated life-threatening

injuries.

Goals for initial care are to preserve life, prepare the

patient for evacuation, and leave the maximum number

of options for definitive treatment.

 The following are indications for amputation.

ο Partial or complete traumatic amputation.

ο Irreparable vascular injury or failed vascular repair

with an ischemic limb.

ο Life-threatening sepsis due to severe local infection,

including clostridial myonecrosis.

ο Severe soft-tissue and bony injury to the extremity

precluding functional recovery.

The surgeon must balance the realistic likelihood of ultimate

reconstruction of a functional extremity against the risk of death

associated with attempts to preserve a limb. It is always desirable

to secure the opinion of a second surgeon before amputating.

The tactical situation may require amputation in cases where

the limb might otherwise have been preserved.
25.2

Emergency War Surgery

 Battlefield amputations are unique.

ο Most commonly due to explosive munitions, with

penetration and blast effects (see Chapter 1, Weapons

Effects and Parachute Injuries).

ο Involve a large zone of injury with a high degree of

contamination, which may affect the level of amputation

and/or surgical intervention.

ο Require staged treatment with evacuation out of the

combat zone prior to definitive closure.

Amputations should be performed at the lowest viable

level of soft tissues, in contrast to traditional anatomic

amputation levels (eg, classic above knee (AK), below

knee (BK), and so forth), to preserve as much limb as

possible. A longer stump is desirable for final prosthetic

fitting.

 The Open Length Preserving Amputation (formerly

Open Circular Amputation) procedure has two stages.

ο Initial. Complete the amputation at lowest possible

level of bone and prepare the patient for evacuation

to the next level of care.

ο Reconstructive. Involves final healing of the limb to

obtain the optimal prosthetic stump.

ο Final level of amputation and definitive treatment

of the residual limb should occur in the stable

environment of a CONUS hospital, not in the

combat zone hospital.

o All viable skin and soft tissues distal to the indicated level

of bone amputation should be preserved for use in

subsequent closure of the amputation stump. These tissues

may be considered “Flaps of Opportunity” and can add

length to the stump. This is especially true for amputations

below the knee. Short tibial stumps can be saved with

posteriorly based flaps because the gastrocnemius and

soleus are frequently preserved following landmine injury.
25.3

Amputations

To save length, any shape or form of a viable muscle or

skin flap should be preserved. The lowest level may be an

oblique or irregular wound, creating an oblique or

irregular residual limb.

Technique of Amputation

 Surgical preparation of the entire limb, because planes of

injury may be much higher than initially evident.

 Tourniquet control is mandatory. If a tourniquet was placed

in the prehospital setting for hemorrhage control, it is prepped

entirely within the surgical field.

 Excise nonviable tissue.

ο Necrotic skin and subcutaneous tissue or skin without

vascular support.

ο Muscle that is friable, shredded, grossly contaminated, or

noncontractile. (This muscle is usually at the level of the

retracted skin.)

ο Bone that is grossly contaminated or devoid of soft tissue

support. Bone is transected at a level at which it has the

potential for coverage. (This is usually at the level of the

retracted muscle.)

 Identify and securely ligate major arteries and veins to

prevent hemorrhage in transport.

 Identify nerves, apply gentle traction, and resect proximally

to allow for retraction under soft tissue. Ligate the major

nerves.

 Preserved muscle flaps should not be sutured, but should be

held in their intended position by the dressing.

 Flaps should not be constructed at the initial surgery, to

facilitate later closure.

In blast injuries, particularly landmine injuries, the blast forces

drive debris proximally along fascial planes. It may be necessary

to extend incisions proximally parallel to the axis of the extremity

to ensure adequate surgical decontamination of the wound.

The stump is never closed primarily.
25.4

Emergency War Surgery

 Special considerations.

ο Primary Symes (ankle disarticulation) has a high failure

rate due to heel pad necrosis during transport. The wound

should simply be debrided, retaining the clean hindfoot

(talus and calcaneus).

ο Primary knee disarticulation is problematic due to skin

and tendon retraction necessitating reamputation at a

higher less functional level. It is preferable to leave even a

very short (1–2 cm) clean transtibial stump, even though

nonfunctional, to prevent retraction.

ο Fractures, when present proximal to the mangled segment,

should not determine amputation level, but must be

treated appropriately (cast, external fixator) to preserve

maximal length.

ο Plan the initial amputation solely on the qualities of the

wound and surrounding tissues, never on the hope of

achieving a particular level or flap pattern as a final result.

The combat surgeon’s goal is a thorough and complete

debridement. Trying to preserve marginal tissue in the

hope that a better stump can be constructed may lead to

subsequent infection and a higher amputation level.

Dressings and Prevention of Skin Retraction

Since amputations must be left open, skin retraction is likely,

causing the loss of usable limb length by making definitive

closure difficult. This is particularly true of a patient who is the

evacuation chain. Because of this, patients who will be evacuated

should be placed in skin traction in order to leave the wound

open and prevent skin retraction. Surgeons working for the

International Committee of the Red Cross (ICRC) in a stable

environment have successfully treated refugees by delayed

primary closure. However, ICRC surgeons work in a relatively

stable environment where evacuation is not a consideration for

the refugee population. This situation does not apply to those

in the air evacuation system.

Skin Traction

Ideally, skin traction should be maintained throughout the

course of treatment. If evacuation times are reliably very short
25.5

Amputations

(1–3 days), skin traction may be omitted. If there is the possibility

of any delay, use skin traction to preserve limb length. When

tactical conditions or resources are not available for application

of casts, skin traction may be applied through weights off the

end of the bed before and after transport.

ο Dry fine mesh gauze is loosely placed over the open

wound. Preserved flaps are not suspended freely, but are

held in their intended position by the dressing (Fig. 25-1).

ο Absorbent dressing is

placed over the stump.

ο Tincture of benzoin is

applied proximally on

the skin up to 2 cm from

the wound edge, but not

including the preserved

flap.

ο A stockinette for skin

traction is applied.

ο Wrap stockinette with a

figure-of-8 elastic wrap.

ο Two to six pounds of traction is applied through

the stockinette/wrap.

This may simply involve

a weight attached via

parachute cord to the

stockinette. However,

during transport, hanging

weights are problematic

and may be substituted with a light elastic such as surgical

tubing or elastic exercise tubing applied through a

transportation cast described below.

ο A transportation cast should be applied to prevent

contracture and allow for continuous traction (Fig. 25-2).

Postoperative Management

 Prevention of contracture.

ο BK amputations are at risk for knee flexion contractures.

These contractures are preventable by using a long leg cast.

Fig. 25-1. Skin Tractions
25.6

Emergency War Surgery

Splinting in extension requires closer monitoring. Pillows

should never support the knee, because of the increased

risk of flexion contractures.

ο AK amputations are at risk for hip-flexion contractures.

Prone positioning and active hip extension exercises will

avoid this complication. When the casualty is supine,

sandbags may be applied to the anterior distal thigh as

well.

 Prevention of hemorrhage: A tourniquet should be readily

available at the bedside or during transport for the first week

following injury.

 Pain control: Patient comfort is paramount following

amputation, particularly if dressing changes are required.

Adequate analgesia should be available and the patient

should be counseled regarding phantom limb pain.

Transportation Casts

Prior to evacuation, transportation casts should be applied to

maintain traction of the residual limb and support the soft

tissues. The transportation cast is a well-padded cast that has

integral skin traction maintained by use of an outrigger.

Cast Application Techniques

Low Hip Spica cast

 Indications: Transfemoral amputation.

 Technique.

ο Adequate anesthesia is administered and the patient is

placed on the fracture table.

Fig. 25-2. Transportation cast allows for continuous traction.

Cast Pad

Spreader

Pad
25.7

Amputations

ο Nonviable tissue is excised, as indicated above.

ο Stockinette or Webril is applied over lower abdomen and

thigh on side of amputation. Stockinette should already

be applied for skin traction.

ο Felt padding is placed over sacrum and anterior superior

iliac spine (ASIS).

ο Towel is placed over abdomen to allow breathing space.

ο Six-inch Webril or similar cotton batting is wrapped in 1–2

layers (Fig. 25-3).

ο Six-inch plaster is then rolled over the

Webril from the ASIS to the end of the

residual limb on the affected side. Splints

are applied over the posterior, lateral,

and groin areas. Use a finishing roll after

turning down the edges of the stockinette to give it a neat appearance.

ο Prior to the last roll, a Cramer wire splint

should be attached over the distal end

of the cast to provide skin traction via

the stockinette.

ο An adequate perineal space must be left

for hygiene.

ο The towel should be removed, the cast

bivalved, and a circular area over the

abdomen should be cut out.

ο Use an indelible marker to label the cast

with the date of injury and surgery(ies).

 Indications: Transtibial amputations.

 Technique.

ο Adequate anesthesia is provided. The wound is evaluated,

nonviable tissue is excised, and the wound is irrigated.

ο Stockinette is applied to the distal end of the residual limb

with tincture of Benzoin to maintain skin traction.

ο Two to three layers of Webril are applied from the

amputation to the proximal thigh.

ο A six-inch plaster is then rolled over the thigh and leg.

ο Prior to application of the last layer, a Cramer wire splint

should be incorporated over the distal end of the residual

limb. Apply skin traction when the cast is dry.

Fig. 25-3. Low

hip spica cast.
25.8

Emergency War Surgery

ο Bivalve the cast.

ο Label the cast with dates of injury and surgery(ies).

Shoulder Spica Cast

 Indications: Transhumeral amputation.

 Technique.

ο Administer adequate anesthesia.

ο Irrigate wound and excise nonviable tissue.

ο Apply stockinette to axilla for skin traction applied with

tincture of Benzoin.

ο Wrap Webril over chest wall and around to edge of residual

limb.

ο Apply 4–6 in. plaster over the Webril.

ο A Cramer wire splint outrigger should be applied with

the last roll to allow for connection of the stockinette and

application of skin traction.

ο Label the cast with dates of injury and surgery(ies).

Long Arm Cast

 Indications: Transradial amputation.

 Technique.

ο Administer adequate anesthesia.

ο After treatment of open wounds and application of a

dressing, apply a stockinette over the distal edge of the

residual limb.

ο Apply 4-inch Webril from the residual limb to the axilla.

ο Apply 4-inch plaster from the residual limb to the axilla.

ο Use plaster to incorporate a Cramer wire splint over the

distal edge of the residual limb in order to apply skin

traction.

ο Bivalve the cast.

ο Label the cast with dates of injury and surgery(ies).