Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XXI: Amputations

Introduction

United States Department of Defense

The prime indication for amputation is the preservation of life, i.e., the sacrifice of the part in order to preserve the whole. Three factors influence the decision to attempt salvage of a severely traumatized limb: the extent of the extremity injury, the general condition of the patient, and the experience of the surgeon. Every effort should always be made to save a limb. However, experience has shown that a severely disrupted extremity provides the potential for sepsis and causes a far greater drain on the patient's limited resources than does amputation. The foregoing notwithstanding, conservative surgical management of an injured extremity should always be the rule. Such management includes prompt institution of antibiotic therapy, early repair of vascular injuries, prompt debridement, and postoperative immobilization. Even under unfavorable tactical situations, every effort should be made to control hemorrhage and minimize the likelihood of infection prior to resorting to amputation. The judgmental decision to amputate should compare the risk to life associated with attempts to preserve a limb as compared to the realistic likelihood of ultimate reconstruction of a functional extremity. It is always desirable to secure the opinion of a second surgeon before amputating.

Amputations for trauma are of two types: elective and emergent. Near the front, essentially all amputations are of the emergency type. In the great majority of these emergent amputations, the surgeons simply complete a traumatic amputation by achieving hemostasis and debriding the stump. They are indicated to save life and are performed at the lowest level of viable tissues to preserve limb length. After one has performed adequate debridement of skin, muscle, and other devitalized tissues, thereby converting the injury to a clean surgical wound, the decision to amputate or attempt to retain a viable limb frequently becomes selfevident. In upper extremity injuries, especially those involving the hand, as much viable tissue as possible should be retained for subsequent reconstruction. Reasonable attempts should also be made to preserve the knee and elbow joints, even when their preservation results in extremely short stumps. Emergency amputation is rarely the definitive surgical procedure, as subsequent stump revision is usually required prior to prosthetic fitting. It should be kept in mind that long bone fractures and joint dislocations can cause elevated compartment pressures that, if allowed to progress unnoticed, can result in limb necrosis and subsequent limb loss.

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Operational Medicine 2001

Health Care in Military Settings

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