Immediate Skin Graft Following Traumatic Upper Extremity Amputation

A forty year-old male presented after a work accident where his left upper extremity was completely avulsed at the upper third of the humerus. The patient was hemodynamically stable with a dressing in place. The mangled upper extremity arrived via EMS as well, as was immediately placed on ice. The stump was examined, and the neurovascular bundle was visualized with clot in the vessels. The patient had deltoid, biceps, and triceps muscles exposed, and the skin defect was more extensive than the muscle defect.

 The amputated arm was deemed too mangled to attempt reattachment. We prepared the patient for the operating room to get muscle coverage of the remaining humerus and get formal control of the neurovascular bundle. We also prepared the amputated limb for possible skin grafting if the wound appeared clean enough. In the operating room, the neurovascular bundle was controlled, the humerus was amputated cleanly with a saw approximately 2 cm more proximal than the site of avulsion, and the bone was covered with a flap of healthy appearing triceps muscle. The muscle was irrigated and appeared healthy without contamination. Using skin from the amputated limb, we used split thickness allograft as well as full thickness allograft, as a biologic dressing. A wound vac device was applied over the skin grafts.

The skin grafts ended up taking and becoming adherent to the underlying muscle, which exceeded our expectations. It was fortunate that the muscle bed was not too contaminated to prevent opposition of the grafts. The patient was discharged home to do home dressing changes while we continue to evaluate the grafts. Pictures from his first outpatient visit are featured below. The patient will likely require more grafting in the future, as well as continuing physical therapy.

 Traumatic wounds can be particularly challenging to treat because the potential for infection is high given the environment in which the wound is created, the mechanism of injury may extend the zone of injury beyond what is immediately apparent, and the accurate assessment of chances for recovery of structures within the wound can be difficult immediately after injury.

The main goals of coverage procedures are to achieve a healed wound and to avoid infection. The method of coverage depends on whether vital structures such as vessels, tendons, nerves, and bone, are exposed in the wound. If vital structures are present, flap coverage is preferred because it provides more substantial coverage of the structure. Flaps consist of tissues that have a self-contained vascular system and contain more tissue than skin alone. Flap coverage has been described from the amputated tissue for amputated upper and lower extremities, as well as for the ear.

If no vital structures are exposed, then skin graft coverage is indicated. Skin grafts may be partial thickness (split-thickness) or full-thickness. Split-thickness grafts are preferred for large wounds, and they can be meshed to enlarge the area of coverage. Full-thickness grafts contract less. Successful healing of skin grafts requires dressings to minimize shearing forces and create good opposition of the graft to the underlying tissue and prevent fluid accumulation under the graft.

References:

1. Halvorson EG, Disa JJ. Scientific American Surgery. Chapter 303: Principles of Wound Management and Soft Tissue Repair. 6^th edition.
2. Rees MJW, de Geus JJ. Immediate amputation stump coverage with forearm free flaps from the same limb. J Hand Surg. 1988; 13A:287-92.
3. Saad Ibrahim SM et al. Totally avulsed ear: new technique of immediate ear reconstruction. J Plast Reconstr Aesthet Surg. 2008; 61:S29-36.
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6. Oliveria et al. The use of forearm free fillet flap in traumatic upper extremity amputations. Microsurgery. 2009; 29:8-15.
7. Mardian et al. Complete major amputation of the upper extremity: Early results and initial treatment algorithm. J Trauma Acute Care Surg. 2015; 78: 586-93.
8. Tennent et al. Characterisation and outcomes of upper extremity amputations. Injury. 2014; 45:965-9.

from Lindsay Petersen, MD