Review Question - QID 4495

Wrist-proximal amputations should be performed before 12 hours of cold ischemia time or 6 hours of warm ischemia time have elapsed.

Wrist-proximal replantation should be strongly considered for patients in whom the mechanism allows adequate debridement, the cold ischemia time is less than 12 hours, and whose general health and comorbidities allow the patient to tolerate an extended surgical procedure. In general, amputation at the distal forearm and wrist have excellent functional results with replantation when compared to amputations at other levels. Similar to other major amputations, replantation should proceed in the following sequence: 1) bone, 2) extensor tendons, 3) flexor tendons, 4) arteries, 5) nerves, 6) veins (can be done prior to nerve repair) , 7) skin.

Sabapathy et al. review replantation surgery in the upper extremity. They discuss that a “functional extremity” could be reconstructed at the upper-arm level in 22% to 34%, at the proximal forearm level in 30% to 41%, and at the distal forearm level in 56% to 80% of cases.

Hanel et al. review wrist level and proximal amputations in the upper extremity. Among other things, they state that wrist-proximal amputations should be performed before 12 hours of cold ischemia time or 6 hours of warm ischemia time have elapsed.

Figure A shows a sharp transcarpal amputation.

Incorrect Answers:
Answer 1: Replantation at the distal forearm and wrist have better functional outcomes than above the elbow replantations.
Answer 2: Arteries should be reconstructed prior to veins.
Answer 3: Bony stabilization should be performed at the beginning of the procedure.
Answer 4: Vein grafting should be used generously.