Clinical Review

Management of traumatic amputations of the upper limb

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g255 (Published 10 February 2014) Cite this as: BMJ 2014;348:g255
  1. Thet Su Win, core surgical trainee1,
  2. James Henderson, consultant plastic and hand surgeon2
  1. 1St Andrew’s Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, UK
  2. 2North Bristol NHS Trust, Frenchay Hospital, Bristol BS16 1LE, UK
  1. Correspondence to: J Henderson jh{at}jameshenderson.net
  • Accepted 6 January 2014

Summary points

  • Life threatening injuries must be excluded and patient resuscitated before transfer to microsurgical units for replantation

  • Critical warm ischaemia time for an amputated limb is typically 6 h, but this depends on cooling of the amputate and the level of amputation (that is, whether there is a muscle component)

  • Children have excellent neuroregenerative capacity, and attempts should be made to replant any amputated digits or limbs

  • Patients can be expected to achieve 50% sensation and 50% motor function of the replanted part

Traumatic hand or digit amputations can be catastrophic injuries, and often occur in young productive patients.1 2 3 Figures from the US national database have shown that amputation injuries represent 1% of all trauma attendances. Finger and thumb amputations were most common (69%), and more proximal amputations of the upper limb contributed a further 9%.3

Most patients with amputations are initially managed by non-specialists, before referral to microsurgical units. Good initial management is a key determinant of outcome, and expertise in the management of amputation is only available in specialist centres in most countries.4 We provide a summary of the initial management of amputation, with emphasis on amputate preservation, indications for replantation (reattachment surgery), and potential outcomes, to help non-specialists manage these emergencies and refer them appropriately.

Sources and selection criteria

Few large scale, randomised controlled trials have looked at upper extremity amputation. Data mostly come from multiple case series, case reports, or small trials. We have combined our knowledge with that published in articles identified by PubMed searches, using the terms “amputation” and “replantation” and selecting English language articles relevant to upper extremity replantation.

What is the assessment and management of traumatic amputation injuries in the emergency department?

Assessment of patient

Patients are assessed according to the Advanced Trauma Life Support (ATLS) protocol, and resuscitated as necessary.4 5 6 Multiple amputation is an independent risk factor for death.3 If bleeding vessels are clamped …

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