Introduction

Traumatic amputations are a challenge at any age, often requiring extensive input from the medical and therapy team to provide the patient with the optimal functional outcome. Therapists are involved in the treatment program to assist the patient in achieving functional independence through improved use of their remaining limb. In the case of a pediatric traumatic amputation, involving the parents and family in the treatment team and explaining the treatment plan and goals are of utmost importance.

Traumatic limb loss in the pediatric population is an emotionally and psychologically stressful occurrence for a child and their family. A knowledgeable healthcare team, including the medical and therapy team, is essential to minimize the stress. Children have a significant advantage in healing as compared to adults in that their bones and soft tissues heal faster, with less scar formation and adhesion, as well as impeccable speed and potential for nerve regeneration and recovery following repair.

This chapter aims to provide the treating therapist with a background of various types of traumatic amputations, medical intervention, and rehabilitation. Upper extremity traumatic amputations proximal to the digits are much less commonly seen in the pediatric population and therefore, this chapter will focus solely on traumatic digital amputation and replantation.

Mechanism of Injury

Various types of traumatic injuries are typically associated with amputations: crush injuries, avulsion-type injuries, abrasions, and lacerations. Crush and avulsion-type injuries typically occur in younger children, between 0 and 5 years old, whereas lacerations more common in adolescents and are often caused by a sharp object. Crush injuries may be caused by a finger caught in a doorway, bicycle chain or from interaction with a stationary exercise bicycle ; whereas, avulsion injuries may result from a forceful traction. ( Fig. 22.1 ). Treadmills are also a common cause of traumatic injury, often leading to abrasions and lacerations occurring when a child places its fingers in the moving parts while the parent is exercising.

Clinical photograph of an avulsion injury in a 7-year-old child who’s thumb was slammed in a door. (A) Dorsal view of thumb with exposed distal phalanx. (B) Volar view of thumb with exposed distal phalanx. (C) Dorsal view of amputated part. (D) Volar view of amputated part with visible bruising indicating a crush component to the injury as well.

Courtesy of Joshua M. Abzug, MD.

Nontraumatic amputations can also occur that are performed for various reasons including infection, tumors, congenital abnormalities, or vascular abnormalities. Typically, nontraumatic amputations are an elective procedure performed to prevent further medical issues related to a problem on a digit.

Medical Intervention

Replantation refers to the reattachment of a completely severed body part; whereas, revascularization refers to the reattachment of a part with an intact bridge of soft tissue that requires vascular repair to prevent necrosis of the partially severed distal part. Not all upper extremity amputations are appropriate for replantation procedures, although the pediatric population has better results than the adult population in terms of replantation success.

Following an acute injury, the physician will examine the patient to identify any exposed bone, tissue loss, and nail and/or nail-bed involvement. The injury is typically debrided (cleaned to remove dead tissue and contaminants) at this time to decrease the risk of infection in the wound. Radiographs may be obtained if there is concern for bony involvement. The medical team will also determine if replantation of the severed part is indicated. In pediatrics, replantation is often attempted for optimal functional outcomes and psychological considerations.

Replantations following sharp amputations are typically approached with a direct repair, and are the most favorable instance of traumatic amputation for such procedures. Although all pediatric amputations should be considered for replantation, optimal indications include clean, guillotine amputations; thumb amputations; multiple digit amputations; digit amputations distal to the flexor digitorum superficialis (FDS) insertion; and hand level and proximal amputations. Crush and avulsion amputations are often approached using grafts due to the greater extent of tissue and vascular injuries typically associated with such injury mechanisms. In cases where multiple digits have been amputated, it is recommended that a stepwise approach be performed across all fingers, working through each of the previous described steps for each finger before moving onto the repair of the next structure ( Fig. 22.2 ). Alternatively, surgeons may elect to perform complete replantations in the order of most functionality to least with the thumb, then middle digit, followed by the index, ring, and small digits. Failed replantation procedures are addressed with revisions, if possible, or ray resections.

Clinical photograph of a multidigit amputation trauma caused by fingers being trapped in a paper shredder.

Courtesy of Joshua M. Abzug, MD.

For amputated digits, the goal of operative intervention is to preserve as much tissue as possible while repairing existing structures to restore functionality. First, the vessels and nerves are identified and tagged with suture, then both the stump and the detached portion of the digit are thoroughly irrigated and debrided. The next priority is skeletal fixation, followed by repair of the flexor tendon. Then, the surgeon will perform anastomoses of the arteries with interpositional vein grafting, as needed. Following the artery anastomosis, the nerves will be repaired, and then venous anastomosis will be performed, with or without interpositional vein grafting. Finally, the skin will be closed if possible ( Figs. 22.3 and 22.4 ). It is also important to note that additional procedures, such as a tenolysis, may be necessary to improve function following a successful replantation. Postoperatively, the replanted part is placed in a bulky dressing to permit resting of the extremity in an elevated position to assist with venous return ( Fig. 22.5 ).

Clinical photograph of a child with successful replantation surgery after fingers were trapped in an exercycle machine. Note that revision amputation of the index finger was necessary because of the severity of the injury caused by the wheel spokes.

Courtesy of Shriners Hospital for Children, Philadelphia, PA.

Clinical photographs of a patient who sustained an avulsion partial amputation by getting their finger caught between a boat and a dock with significant vascular and soft tissue damage. Note the lack of perfusion to the distal aspect of the affected digit. (A) Volar view, (B) ulnar view, (C) dorsal view, (D) postoperative volar view, (E) postoperative ulnar view, and (F) postoperative bulky splint Clinical photograph of postoperative fixation. Note the incomplete wound closure due to swelling of the digit.

Courtesy of Joshua M. Abzug, MD.

Clinical photograph of a child after undergoing finger replantation. Note upright elevation of fingers and hand to promote venous return for optimal healing.

Courtesy of Shriners Hospital for Children, Philadelphia, PA.

Fingertip Amputation and Nail-Bed Injury

In the case of a nail-bed injury, the nail plate is removed, and the nail-bed laceration is repaired. The nail plate or a substitute is then replaced to act as a protective splint until new nail plate growth occurs. Complete and partial amputations may be treated operatively when it is thought that the remaining piece is viable ( Fig. 22.6 ). Alternatively, these injuries can be allowed to heal by secondary intention via scarring and epithelialization ( Fig. 22.7 ). Most children will not require formal therapy for this type of injury, as they will regain their range of motion and sensation over time. A mitten cast or cap splint may be utilized in the acute phase to limit the sensitivity that can occur when the digit is accidentally touched or banged into.

Clinical photographs of a partial amputation in a young child that was bitten by a parrot. (A) Dorsal view, (B) volar view, (C) intraoperative assessment, (D) dorsal view postoperatively, (E) ulnar view postoperatively, (F) radial view postoperatively, (G) 1-year follow-up showing near-normal appearance of the digit but persistent nail plate deformity, and (H) ulnar aspect of digit at 1 year postoperatively.

Courtesy of Joshua M. Abzug, MD.

Clinical photographs of a fingertip amputation healing by secondary intention. (A) dorsal view, (B) volar view, and (C) tip view.

Courtesy of Joshua M. Abzug, MD.

Composite grafts are another option for surgical repair of a digital fingertip amputation or avulsion injury. The benefit of such procedures is the low disruption in digit integrity, specifically the avoidance of digital shortening and functional ability by utilizing the patient’s own skin at the fingertip.

Digital Reconstruction for Skin Loss

Surgical intervention options for digital amputation include skin grafts, skin flaps, and ray resection with possible transposition procedures. Skin grafts include composite grafts, full- or split-thickness skin graft, and/or substitute skin graft materials. Skin flaps for partial digital reconstruction include regional or local soft tissue flaps such as the V–Y advancement flap, volar advancement, Moberg flap, and cross-finger flaps. In cases where the amputation occurs more proximally on the digit, near the metacarpophalangeal joint, a ray resection can be performed. A ray resection, which may improve the aesthetics following a digit amputation, can compromise hand width and grip strength.

A skin graft is used when the wound is too large in size and depth for wound closure or local flap reconstruction, thus requiring skin from an alternate donor site to cover the wound. The wound/skin graft and donor site are both closed with absorbable sutures. Following a skin graft, the postoperative management is of utmost importance. Graft survival is improved by a stringent local immobilization protocol, often requiring immobilization of associated joints with a splint or cast for protection and to decrease the risk of shearing the graft. Patients are typically referred to occupational therapy for rehabilitation. Therapy sessions should focus on wound care and scar management, mobility, and desensitization. Therapists should also address the patient’s edema, sensory reeducation, range of motion, and fine motor coordination skills, as well as protective and functional splinting ( Table 22.1 ).

Therapy

Therapists are involved in the treatment program to assist the patient in achieving their functional independence through improved use of their hand/remaining limb. The ultimate goal of treatment is for a pain-free limb, healthy skin coverage, and normal function of the hand. Although digit length and aesthetics are considered, preserving functional use with decreased pain and concerns of infection are prioritized.

A treatment guide is provided in this chapter for digit amputation and reconstruction as well as digital replantation (Appendix). Therapists are encouraged to review protocols with the referring physician before implementation to ensure agreement and appropriateness for the patient ( Table 22.2 ).

Pediatric-Specific Considerations

In all aspects of therapy, patient and family education are a constant. In the case of a pediatric amputation or replantation, involving the parents in the treatment team and explaining the treatment plan and goals are of utmost importance. The necessary education must go a step further to explain the treatment and plan, while including the patient and their parents in the treatment for carryover, and ensuring there is comfort with the intervention. It is sometimes helpful to speak to the parents without the child present to allow time for questions or concerns, and to provide reassurance. When speaking to the patient, it is vital to explain the components of treatment in terms that they understand, keeping in mind their age and grade level. Using familiar analogies and keeping the conversation as comfortable as possible for the child will ease their fear and anxiety toward the injury and treatment. Although some adult patients will embrace an attitude of “do what you have to do,” when working with children, it is generally better to explain what you are going to do before you do it to minimize the element of surprise, guarding due to the anticipation of pain, and to decrease overall anxiety. Gaining the trust of pediatric patients will make the therapy experience more positive and successful.

Pediatrics spans a wide age range, including patients from birth to until their 18th birthday. During this time frame, an extensive array of developmental milestones and levels of independence are encountered. It is beneficial to remain mindful of the child’s age, stages of development for bone formation and healing time, family/social environment, and vocabulary for communication. Furthermore, having treatment modalities that are age appropriate and engaging for the child may increase the success of a treatment session. For example, toys with music, bright colors, and blinking lights tend to be attention grabbing and intriguing for young children. Colorful stacking blocks, bouncing balls, and even a child-sized table and chair for the child to sit at may promote engagement and comfort in the treatment room for many school age children. Older children and adolescents may benefit from competitive, challenging games and activities such as beanbag toss or cornhole, video games such as Wii sports, and incorporating basic cooking skills.

The healing capacity and healing time are enhanced within the pediatric group, which differs from adult and geriatric groups. Although the injury may be similar to that of an adult, the healing time and treatment protocol varies substantially between the two populations. This is largely due to the accelerated healing time of pediatric patients that results in fewer secondary complications, as compared to adults.

General Evaluation and Assessment Considerations

Careful attention should be given to the referring physician’s protocol, clarifying restrictions and precautions the physician may have related to a specific case. The following protocol, evaluation, and treatment specifications are meant to be a guide for treating therapists. Therapists are encouraged to discuss appropriateness of the protocol with the referring physician to ensure agreement.

Upon evaluation of a pediatric patient with a digit, hand, or proximal upper extremity amputation and subsequent surgical repair, it is beneficial to assess the following: medical history, mechanism of injury, wound assessment, objective measures (range of motion and strength), fine motor coordination skills/prehensile patterns, and overall functional use of the upper extremity.

Sensory testing can produce inconsistent results in children, as they may experience a challenge with describing sensory changes or paresthesias in their hands. Dua et al. (2016) established normative values for the pediatric population using the Semmes–Weinstein Monofilament Test and two-point discrimination, static and moving, which should be used for comparison during assessment as well as to determine the level of sensory compromise. Dua et al. (2016) also determined objective testing with monofilaments to be reliable in children 4 years old and above, whereas density testing using two-point discrimination is reliable in children age 6 and above. Knowing normative values and age-appropriateness of sensory assessments are two integral pieces of information for clinicians in determining appropriateness of sensory assessments with the pediatric population.

The functional assessment includes observation of fine motor coordination skills, prehensile patterns, as well as use of the involved upper extremity with activity performance. Standardized assessments typically used to assess fine motor skills and hand function include Functional Dexterity Test, Nine Hole Peg Test ( Fig. 22.8 ), Box and Block Test ( Fig. 22.9 ), Purdue Pegboard, and Jebsen Taylor Hand Function Test. Reviewing assessment norms for age appropriateness is recommended. Observation is another method of assessing functional use of the hand and upper extremity during play activity, object handling, and manipulation, as well as during activities of daily living tasks such as self-feeding and fastener management skills.

Nine Hole Peg Test.

Courtesy of Ritu Goel, OTR/L.

Box and Block Test.

Courtesy of Ritu Goel, OTR/L.

General Treatment Considerations

General treatment considerations to have during the rehabilitation process when caring for pediatric patients who have sustained partial or complete amputation injuries are the following ( Tables 22.3 and 22.4 ).

Wound Care

Patient and family education on signs of infection should be discussed on the first therapy visit in addition to dressing change technique and frequency. Initial wound care will typically consist of a nonadherent (Xeroform or Adaptic) dressing. Specifics regarding preferred dressings should be discussed with the physician ( Table 22.3 ).

Following removal of the sutures and wound closure, scar management protocols should include massage, mobility, and desensitization, as needed. Scar massage with cocoa butter after the incision has closed using a cross-friction massage technique may assist with scar tissue breakdown, as well as improve scar and joint/limb mobility. Parents and the patient are educated on performing this technique when outside of therapy as part of a home program to minimize scar tissue development.

Despite steps taken for scar management, hypertrophic or keloid scars can present. This type of abnormal scarring can cause irritation (increased temperature, redness, and pain) around the skin, as well as increase the firmness and height of the scar. Silicone gel sheeting is an effective method of topical scar management used to minimize scar volume, tenderness, itching, and redness. Additional topical methods of scar management including elastomer putty and silicone gel digit caps (such as Silopad), can assist with scar desensitization, protection, healing, and patient comfort.