Introduction

An amputation is the traumatic or surgical separation of a limb or appendage from the body. Traumatic amputations usually occur in contaminated environments as a result of severe trauma¹. The estimated number of traumatic amputations per year is 30,000 around the globe being 65% of the upper limb amputations. Males aged 15-40 represent the highest incidence group. The estimated medical care cost of traumatic amputations is approximately 7.7% of the Gross Domestic Product of the United States of America².

Complete amputations are characterized by loss of continuity between the amputated region and the body. While in partial amputations, the anatomical continuity persists, either through tendons, ligaments, or muscles. The key difference between partial amputations and severe lacerations resides in the percentage of soft tissue maintain continuity (£ 25% in partial amputations). Partial amputations are classified using the Gustilo-Anderson classification (same as for open fractures) depending on the severity of the trauma and contamination degree³,⁴.

There are just a few reports that deal with long-term outcomes of partial amputation surgical repair. War veterans case reports show that most of the patients lead normal, productive lives with no relevant limitations after lower limb amputations; however, those with upper limb amputations tend to be severely disabled. The main causes of disability are decreased functionality and mood/anxiety disorders. Long-term case studies have reported similar rates of disability among patients with amputations and those that have been undergoing reconstructive surgery. In fact, only 30% of patients are able to resume their professional activities after 2 years⁵-⁷.

The purpose of this report is describing a clinical case of a patient with partial traumatic amputation of an upper limb with an excellent functional recovery after 13 years of follow-up.

Case report

An 8-year-old male patient with severe trauma by getting his left arm jammed in the motor bands of a forage grinder received emergency medical care at the Sanatorio Médico Quirúrgico de los Altos from Tepatitlán de Morelos, Jalisco, México. The patient got an open fracture in the left arm at the junction of the middle third to the distal humerus (Fig. 1) and section of the triceps and biceps muscles leaving the brachialis muscle intact. During surgical exploration, the brachial neurovascular bundle was apparently intact (Fig. 2). The bony fragments were stabilized using 2.0 mm Kirschner wires that were introduced in a retrograde fashion through the humeral medullary cavity and coming out on the shoulder. The open reduction was performed and the nails were pulled back 3 cm to stabilize the fragments. Subsequently, biceps and triceps muscles were repaired. Finally, the subcutaneous tissue and the skin were sutured. During the post-anesthetic recovery period, the patient showed inability to extend the wrist, which was expected after the neurovascular bundle manipulation during reconstruction. Once stable and lucid, a Sarmiento brace was applied to immobilize the limb.

Figure 1 A: Surgical exploration with a loss of more than 75% in the soft tissue as well as avulsion of the biceps and triceps muscles. B: Oblique fracture of humeral bone and the entire brachial neurovascular bundle (arrow). C: The continuity in the brachial muscle is observed. 

Figure 2 A: Pre-surgical X-ray showing a humerus oblique fracture of the patient. B: Smooth Kirschner wires were used to stabilize the fracture and make soft tissue reparation. C: Control X-ray after nerve and soft tissue repair. 

During the first 3 weeks after surgery, the extension of the patient’s wrist showed no signs of improvement, so an electromyography was performed that reported severe axonotmesis of the left radial nerve. A wrist extension splint was placed in the damaged hand to facilitate cylindrical grip. Furthermore, transcutaneous electrical nerve stimulation (TENS) was applied twice a day, 10 min per session. Since there was no clinical improvement after 1 month of electrostimulation, we performed microscopic surgical exploration of the radial nerve with the help of a peripheral nerve surgery specialist. During the procedure, a slight rupture of the epineurium was evidenced including rupture of fascicles and perineurium (neurotmesis Grade V according to Sunderland classification)⁸. The injury was repaired with 10-0 and 12-0 nylon suture.

The rehabilitation with TENS continued after nerve microsurgery in combination with the use of a wrist extension splint. At 6 weeks, progressive regain of sensory perception and movement of the wrist were evident and complete neurological recovery was achieved at 5 months.

The Kirschner wires were removed during the second surgery to facilitate rehabilitation exercises for biceps and triceps as well as TENS therapy. However, the patient developed horse hoof hypertrophic pseudoarthrosis; thus, the Sarmiento’s brace was removed and the patient underwent surgery to repair the pseudoarthrosis. The medullary space was recanalized and a dynamic compression plate of 3.5 mm with six holes was used for fixation. Union occurred 3 months later.

At present, the patient is 21 years old; he works and performs activities of daily life without any limitations (Fig. 3). Physical examination of the affected limb reveals muscular hypotrophy; however, sensitivity, muscular strength, and ranges of motion of the left arm are clinically preserved.

Figure 3 A-C: Patient after 13 years. Though hypotrophic, integrity, and functionality of the left upper limb are present. D: Latest X-ray photography 13 years after surgical repair. 

Discussion

Our clinical and research team conducted a critical review of literature, noting that partial amputations in children are not common and their long-term follow-up is not either. According to the reviewed literature, we consider that this is the report of a partial amputation in a child with the longest period of clinical follow-up with the excellent functional results.

The management of partial amputations remains rather unclear in the field of reconstructive surgery⁹. At present, there is lack of consensus on both the criteria and techniques for reconstruction because the functional outcomes tend to be poor¹⁰,¹¹. There are various ways to manage partial amputations of the limbs and all depend on the viability of the extremity, surgical team’s expertise, resources, and rehabilitation availability¹². When the limb is not viable or the hospital does not have the required personnel and/or resources, complete separation of the affected extremity followed or not by prosthesis adaptation is the usual management. This approach has great psychosocial impact due to disability, job loss, and poor functioning in daily activities¹³. The repair of the damaged extremity with fracture stabilization is another approach which requires the participation of an experienced multidisciplinary team including specialists in trauma, orthopedics, vascular surgery, and neurosurgery¹⁴. The most important criteria for therapeutic decision are the integrity of neurovascular bundle since its integrity prevents extensive bleeding (reducing the risk of hypovolemic shock), ischemia below the lesion and allows functional recovery of the affected limb. When the neurovascular bundle’s integrity is lost, it has been reported failure rates ranging of 60-100%¹⁵.

We are well aware that the management here presented is not the standard approach to partial amputation surgical repair, particularly when the Kirschner wires are used for internal fixation. However, the nearest trauma center was 3 h away. Motivated by the macroscopically intact neurovascular bundle and the patient age, our surgical team decided to go for limb repair with the available resources of our general hospital instead of transferring and risking the limb’s viability.

Two events required surgery after the initial operation. The first one was radial nerve palsy, initially attributed to the manipulation of the neurovascular bundle during reparation; however, this did not resolve after 12 weeks so microsurgery was performed. Neurotmesis is a common complication of this kind of lesions and requires timely evaluation and precise repair¹⁶. The second one was the development of pseudoarthrosis, which is a known complication of open fractures¹⁷.

This is an exceptional case since the reconstruction of partially amputated upper limbs is usually associated with poor outcomes in most reports¹⁸. Several factors could account for this outcome being the most relevant the linear, non-rotated fracture, and the little amount of soft tissue crush injury. Moreover, the close medical surveillance and timely interventions were crucial in the patient’s recovery. The Zhong-Wei et al. criteria could be used to assess the functional recovery in this kind of clinical cases. These criteria are the following: (1) ability to work, (2) range of joint motion, (3) recovery of sensibility, and (4) muscular power¹⁹. The functional recovery in our clinical case could be qualified like “excellent” in all the points of the Zhong-Wei et al. criteria.

Conclusion

In the surgical management of partial amputations, the key factors that make reconstruction an option are small amount of soft tissue damage and integrity of the neurovascular bundle. In addition, the human and economic resources of the center managing the case with close patient follow-up tip the scale toward a more positive outcome²⁰. This clinical report represents a case with an excellent functional recovery witnessed through a 13-year follow-up period.