Epidemiology of traumatic upper limb amputations

Accepted Manuscript Title: Epidemiology of traumatic upper limb amputations Author: G. Pomares H. Coudane F. Dap G. Dautel PII: DOI: Reference:

S1877-0568(18)30033-1 https://doi.org/doi:10.1016/j.otsr.2017.12.014 OTSR 1946

To appear in: Received date: Accepted date:

17-1-2017 1-12-2017

Please cite this article as: Pomares G, Coudane H, Dap F, Dautel G, Epidemiology of traumatic upper limb amputations, Orthopaedics and Traumatology: Surgery and Research (2018), https://doi.org/10.1016/j.otsr.2017.12.014 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Original article Epidemiology of traumatic upper limb amputations G. Pomares1, H. Coudane2, F. Dap1, G. Dautel1 1 Service

de chirurgie plastique et reconstructrice de l’appareil locomoteur Centre Chirurgical Émile Galle, CHU de Nancy, 49, rue Hermite, 54000 Nancy, France 2

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Corresponding author: Germain Pomares Service de chirurgie plastique et reconstructrice de l’appareil locomoteur Centre Chirurgical Émile Galle CHU de Nancy 49, rue hermite, 54000 Nancy, France [email protected]

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EA 7299, ETHOS, Faculté de Médecine, Université de Lorraine, 9 avenue de la forêt de Haye, 54505 Vandoeuvre les Nancy, France

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+33 (0)3.83.85.78.51

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Abstract

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Introduction: While published data on functional outcomes after upper limb amputations are plentiful, epidemiology data are relatively rare. This led us to performing an epidemiology study of traumatic upper limb amputations at our facility. Material and methods: This retrospective study spanned a 10-year period of cases seen at the SOS Main (Hand emergency center) of the Nancy University Hospital in France. Patients who suffered traumatic amputation of the upper limb were identified and divided into two groups: replantation and surgical amputation. All anatomical amputation levels were retained. Non-traumatic amputations were excluded. Epidemiology data (sex, age, dominant side, injured side) was collected along with the specific anatomical level of the injury, the injury mechanism and whether it was workrelated. We also looked at the success rate of microsurgery and whether multi-finger amputations were partial or complete. In parallel, the annual incidence of amputations seen at the SOS Main over this period was calculated. Results: Over the 10-year period, 1715 traumatic upper-limb amputations were identified, which was 3% of all cases seen at the SOS Main. Most of the cases involved middle-aged men. Revascularization was attempted in one-third of cases and microsurgery was successful in 70% of cases. The surgical amputation group consisted of 1132 patients with a mean age of 59 years, while the replantation group consisted of 583 patients with a mean age of 48 years. The primary mechanism of injury was a table saw. Discussion: This injury, which must be addressed urgently, is not very common in everyday practice. This is contrary to lower limb amputations, which are more common and occur in the context of micro- and macroangiopathy in older patients. The success rate of microsurgery in this cohort must be placed in the context of age, amputation level and mechanism. The functional outcomes are not always as good as the vascular outcomes. This data is invaluable as it fills a gap in our knowledge about amputations. Keywords: Epidemiology; amputation; upper limb; traumatic Level of evidence: IV

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Introduction

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Upper limb amputations are mostly treated at hand emergency clinics in France. This condition has been widely studied and there is plentiful literature that allows us to standardize the treatment of upper limb amputations 1-4. The functional outcomes of patients who undergo replantation and those who undergo surgical amputation have been described in the literature 5-8. The social impact and healthcare costs have also been evaluated 9. However, there is little epidemiological data on upper limb amputations 10-12, in contrast to lower limb amputations where more is known 1315. Our primary objective was to determine the epidemiology of traumatic upper limb amputations cases seen at the Nancy University Hospital in France. The secondary objectives were to determine the parameters surrounding surgical amputations, replantations and successful microsurgery.

Material and methods

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This was a retrospective and descriptive epidemiology study of cases seen at the adult hand emergency clinic of the Nancy University Hospital in France over a 10-year period, between 1 January 2004 and 31 December 2013. All records belonging to patients who suffered a traumatic amputation were identified using the CCAM codes (French procedures classification) for surgical amputation and replantation procedures of the upper limb. The number of cases seen each year at the hand emergency clinic was also determined.

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Only complete traumatic amputations of the upper limb treated at the clinic were recorded. Every anatomical level was included. Non-traumatic amputations were excluded, as were pediatric cases (under 16 years of age). Partial amputations, with and without devascularization, were excluded. The study cohort was then divided into two groups. One group consisted of patients in whom replantation was attempted and the other group of patients in whom replantation was not attempted. Epidemiological data were collected (age, sex) along with the side injured, specific anatomical location, injury mechanism, whether it was work-related, whether microsurgery was attempted and if it was successful. The incidence of traumatic amputations in the population seeking care at the hand emergency clinic of the Nancy University Hospital was evaluated, along with the epidemiological profile of the patients. This analysis was repeated in the two subgroups.

Results

General population of upper limb amputations Over this 10-year period, more than 50,000 people were seen at the hand emergency clinic, with an average of 5500 cases per year (fig 1). During this period, 2247 patients had suffered an upper limb amputation. The amputation was traumatic in 1715 cases and non-traumatic in 532 cases (Fig1). The annual incidence of traumatic amputations was 3% in the population admitted for hand-related emergencies. The mean age of this population was 57 years (19–98), with a 3.1:1 male-to-female ratio (1704 to 543). The left upper limb was injured more often than the right one (Table 1).

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Population of patients who underwent replantation Replantation was carried out in 583 patients, which corresponded to a 1% annual incidence of patients seen at the clinic. The mean age in this subgroup was 48 years (19– 84). The left upper limb was affected in 339 cases. The amputation was due to a workrelated accident is less than half the cases (Table 1). The most common injury mechanism was a saw blade and it most often involved the thumb. The amputation mainly affected the distal phalanx (Tables 2, 3). In the subgroup of patients who underwent replantation, the microsurgery was successful in 424 cases (73%) and failed in 159 cases (27%). Single-finger replantation was successful in 70% of cases (Table 4).

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Population of patients who underwent surgical amputation Amputation by closing the skin was performed immediately in 1132 cases, which is an estimated annual incidence of 2% in our population. The mean age in this subgroup was 59 years (22–98). The left upper limb was affected more than the right. Most amputations occurred outside the work context (Table 1). The most common injury mechanism was a saw blade and it most often involved the index finger. The amputation occurred through the distal interphalangeal joint in most cases (Tables 2, 3).

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Discussion

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Traumatic amputations of the upper limb are the main surgical emergency in our area of specialization due to their severity. Nevertheless, this absolute emergency is rare. In contrast to our findings, Wright 11 found a younger population with an average age of 36 years. Not surprisingly, table saws cause of the largest number of amputations. Its use leads to 2000 cases of finger amputation in the United States per year 16. In our study, mostly crush and avulsion mechanisms were found, and these are not a strong contraindication to replantation attempts. Logically, the non-dominant hand is most often injured because of its exposure to the tool. One of the differences between the two groups was the higher number of thumb injuries in the patients undergoing replantation and higher number of index fingers injuries in those undergoing surgical amputation. The amputation level was mainly beyond the distal interphalangeal joint. The vascular success rate is satisfactory for finger amputations (single or multiple) up to the wrist and are supported by another study performed in our department 17. However, more proximal amputations are plagued by a high failure rate. While these microsurgery results may be promising, we cannot forget that microsurgical success does not equate functional success 5. Traumatic amputations of the thumb are not a contraindication to microsurgery in our practice. This is not strictly the case for long finger amputations, particularly the index finger. Amputations through the first phalanx or in the proximal interphalangeal joint of the index are a formal contraindication to replantation in adults 1. Our results reach their limits given these data. Indications for immediate surgical amputation were made based on the anatomical level, and were independent of the quality of the fragment. The epidemiology of upper limb amputations differs greatly from that of lower limb amputations. Lower limb amputations are more frequent and mainly occur in the context of micro- and macroangiopathy 13-15. The population affected is also older. Our study has several limitations. The method used to identify patient records likely underestimated the true number of traumatic amputations due to errors in CCAM coding. In the same vein, there were no distal amputations in zone 1. This clinical scenario is often treated using a second-intention healing protocol and is not captured in 4

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the CCAM codes as a surgical procedure. Also, the collected data reflect a regional trend and cannot necessarily be extrapolated to the national realm. Lastly, the pediatric population was excluded from this study. Because of these biases, we believe that the number of traumatic amputations was likely underestimated.

Conclusion

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No funding was received for this study.

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The authors have no conflict of interest to disclose.

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Traumatic amputations of the upper limb are rare, with an incidence of 3% in the hand emergency clinic of the Nancy University Hospital. They mainly occur in middle-aged men and replantation is attempted in one of every three cases. Microsurgery is successful in 70% of these cases. The injury mechanism is not an absolute contraindication to replantation in our practice.

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References

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1- Dautel G, Voche P. Replantations digitales. In: Merle M, Dautel G. La main traumatique, tome 1, 4e éd. Paris: Masson; 2016; 427-471. 2- Merle M, Loda G. Replantations de la main. In: Merle M, Dautel G. La main traumatique, tome 1, 4e éd. Paris: Masson; 2016; 473-484. 3- Dautel G. « Doigt-banque ». In: Merle M, Dautel G. La main traumatique, tome 1, 4e éd. Paris: Masson; 2016; 485-493. 4- Guidicelli P, Idoux O, Martin B, Labadie C, Gomis R. 6 reconstructions digitales temporaires en urgence des pertes de substance osseuse totale et subtotale des phalanges par ciment acrylique. Chir main. 2000;19:346. 5- Dos Remedios C, Leps P, Schoofs M. Résultats de 46 replantations digitales. A un an de recul minimum. Chir main,2005;24:236-242. 6- Detammaecker R, Strugarek C, Pomares G, De Almeida YK, Dap F, Dautel G. Acceptation, reprise du travail et résultat fonctionnel des amputations basimétacarpiennes des doigts longs: série rétrospective de 41 patients. Hand Surg Rehabil 2016; 35:437. 7- Meyer Zu Reckendorf G, Coulet B, Allieu Y, Chammas M, Desbonnet P. Replantation digitale après 60 ans: A propose de sept cas. Ann Chir Main 1999;18:153-159. 8- Rabarin F, Saint Cast Y, Jeudy J, Fouque PA, Cesari B, Bigorre N, Petit A, Raimbeau G. Cross-finger flap for reconstruction of fingertip amputations: Long-terme results. Orthop Traumatol Surg Res. 2016; 104: S225-8

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9- Dap F, Bour Ch, Brugière H, Foucher G, Merle M. Le coût socio-économique des replantations digitales. A propos de quarante replantations du pouce. Ann Chir Main 1989;8:78-83. 10- Barouti H., Agnello M., Volkmann P. Amputation du membre supérieur. EMC (Elsevier Masson SAS, Paris), Kinésithérapie-Médecine physique-Réadaptation, 26269A-10, 1998. 11- Wright TW., Hagen AD., Wood MB. Prosthetic usage in major upper extremity amputations. J Hand Surg Am 1995;20:619-22. 12- Behrend C., Reizner W., Marchessault JA., Hammert WC. Update on advances in upper extremity prosthetics. J Hand Surg Am 2011;36:1711-7. 13- Dillingham TR., Pezzin LE., MacKenzie EJ. Limb amputation and limb deficiency: epidemilogy and recent trends in the United States. South Med J 2002;95:875-83 14- The amputee Statistical Database for the United Kingdom: 2006/2007 report. Tableau 12, p 31; http://www.limbless-statistics.org/documents/Report2006-07.pdf. Information Service division, NHS Scotland, on behalf of National Amputee Statistical Database (NASDAB), Edinburgh 2009 [Consulté le 25 aout Octobre 2016]. 15- Germanaud J. Etude épidémiologique des amputations majeures de membre inférieur dans le régime général en France (sur 3130 cas). Revue méd assur mal 1996;2:1-13. 16- Graham JD, Chang J. Reducing the risk of injury from table saw use: the potential benefits and costs of automatic protection. Risk Anal 2015;35:307-17. 17- Pomares G, Dap F, Dautel G. Corrélation entre degré de perméabilité artérielle et régénération nerveuse: après réparation des sections complètes des pédicules digitaux palmaires. Chir main 2014;33:415

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Figure 1: Breakdown of the population seen at the hand emergency clinic of the Nancy University Hospital between 2004 and 2013.

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Table 1: Demographic data Table 2: Mechanism of injury for traumatic upper limb amputations Table 3: Anatomical level of the amputations Table 4: Results of the replantation attempts

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Figure 1: Breakdown of the population seen at the hand emergency clinic of the Nancy University Hospital between 2004 and 2013.

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Total number of patients seen N = 55238

Non-traumatic amputations N = 532

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Traumatic amputations N = 1715

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Upper limb amputations N = 2247

Surgical amputation N = 1132

Successful N = 424

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Replantation N = 583

Failed N = 159

Table 1: Demographic data

Surgical amputation

Replantation

Total

n=583

n=1132 n=1715

Mean age (range) (19–84) Men / women 493/90

59.3 (22–98)

48.5

57.4 (19–98) 1017/115 1704/543

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Injured limb (R/L) 244/339

521/611 976/1271

Work-related injury (Yes/No) 220/363

443/689 663/1052

Anatomical level: F1 (9%) F2 (7.4%)

(19%)

452

325 (26.3%)

F3 (7.2%)

284 (23.8%)

(16.6%)

408

F4 (6%)

329

227 (19.2%)

F5 (3.6%)

258

196 (15.4%)

Hand (0.2%)

4

0 (0.2%)

Forearm (0.3%)

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127

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(13.2%)

(11.4%)

124

102

62

4

4 (0.6%)

(0.2%)

6

4 (0.5%)

(0.2%)

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153

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92 (14.3%)

(5.4%)

245

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Age in years, R: right, L: left, F: finger

Table 2: Injury mechanisms for traumatic upper limb amputations

Replantation n=583 Assault 6 Self-mutilation (0.7%)

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Surgical amputation Total n=1132 n=1715 6 (0.3%) 6 (1%)

(0.3%)

0

(0.3%)

12

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135 33 7

Burn 12 Fall 19 56 40 19 6 36 9

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22 311

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Grinder (0.8%) Crush (5.1%) Wood splitter (2.1%) Axe

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Surface planer (0.8%) Snow blower

62 9

Cleaver

5

Propeller (0.6%) Unknown

17 9

Pressure injector

16

Blender (0.6%) Harvester

11

(4.8%)

52

(1.3%)

10

(0.4%)

0

(0.7%)

0

(0.5%) (1.2%) (0.9%)

11 36 24 19

(0.3%)

0

(1.3%)

14

(0.5%)

0

(0.5%)

14

(13.5%)

88

(1.5%)

36

(0.5%)

0

(0.3%)

0

(0.4%)

10

(0.5%)

0

(0.9%)

0

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(0.6%) Pruning hook (2.1%) Strap/belt (1.4%) Knife (1.1%) Brush cutter

15

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37

(1.3%)

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(0.9%) Avulsion (3%) Blast (0.6%) Meat grinder

22 (2.1%) 83 (7.9%) 23 (2%) 7 (0.4%) 12 (0.7%) 8 (1.1%) 20 (3.3%) 16 (2.3%) 0 (1.1%) 6 (0.3%) 22 (2.1%) 9 (0.5%) 8 (1.3%) 232 (18.1%) 26 (3.6%) 9 (0.5%) 5 (0.3%) 7 (1%) 9 (0.5%) 16 (0.9%) 0 (0.6%) 5

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MVA

11 (0.3%)

0

(0.9%)

16

(0.4%)

10

0 Bite wound (0.9%) Drill (0.6%)

31 17

15 (1.8%) 7 (1%)

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Plane

28 (1.6%) 5

28 Sword

(1.6%)

0

(0.3%)

0

371

(22%)

147

5 (0.3%) 120 (9.7%) 19 (1.8%) 5 (0.3%)

(0.4%)

0

(7%)

46

0 Saw (30%)

5 Lawn mower (2.7%) Chain saw (0.7%) Fan

166 31

(0.3%)

12 0

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Table 3: Anatomical level of the amputations

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5

(1.1%)

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508

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(8.6%) Pruning shears

Surgical amputation Total n= 1132

Replantation

n=583

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n=1715 Distal amputation F1

9

(0.5%)

148

(8.6%)

191

(11.1%)

140

(8.2%)

F2

(3.3%)

F3

(5.2%)

F4

(3.7%)

Long finger amputation (zone) 1 (5.8%) 406 2 (3.7%) 151 3 (2.7%) 218 4 (1.5%) 86 5 (1%) 66 6 94

9

(0.5%)

0

90

(5.2%)

58

101

(5.9%)

90

77

(4.5%)

63

308

(18%)

98

87

(5.1%)

64

172

(10%)

46

61

(3.5%)

25

48

(2.8%)

18

94

(5.5%)

0

(23.7%) (8.8%) (12.7%) (5%) (3.8%) (5.5%)

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48

(2.8%)

52

(3%)

44

(2.6%)

17

(1%)

11

(0.6%)

Forearm (0.3%)

10

(0.6%)

Upper arm (0.3%)

9

(0.5%)

(0.6%)

0

19

(1.1%)

29

13

(0.7%)

39

12

(0.7%)

32

11

(0.6%)

6

11

(0.6%)

4

(0.2%)

4

0

(0.2%)

6

5

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Thumb amputation (zone) T1 (1.7%) T2 (2.3%) T3 (1.9%) T4 (0.3%) T5

11

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(0.6%)

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Distal amputations classified using Allen’s classification (F: finger, T: thumb) Classification of amputations based on extensor mechanism zones – Classification of the International Federation of Societies for the Surgery of the Hand

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Table 4: Results of the replantation attempts

Successful n=424

Failed n=159

One finger

312

(54%)

136

(23.3%)

Two fingers Total Partial

38 38

(2.2%) (2.2%)

5 -

(0.3%)

(0.2%) (0.1%) (0.7%)

10 -

(0.6%)

2F 1F

3 2 13

5 0 2

(0.3%)

3F 2F

0 -

Three fingers Total Partial

Four fingers Total Partial

(0.1%)

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1

(0.06%)

-

1 0 0 1 1

(0.06%)

4F 3F 2F 1F

(0.06%) (0.06%)

0 -

Hand

4

(0.2%)

0

Forearm

2

(0.1%)

4

Arm

1

(0.06%)

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(0.2%) (0.2%)

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Five fingers Total Partial

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1F

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F = finger

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