Acute treatment decision-making for patients with multiple traumatic injuries including a mangled extremity is guided by the adage, “life before limb.” Non-life-threatening injuries limited to a single extremity, like the hand, pose a difficult dilemma; choosing preservation over amputation is not always the best approach for every patient. “Injuries limited to the hand are usually a result of operating machinery at work, around the home or farm, or firework-related accidents,” says Kenneth Taylor, M.D., Bone and Joint Institute, hand reconstruction specialist.
Dr. Taylor frequently attempts to stabilize the injury before deciding to preserve or amputate. “Patients are often in shock and a great deal of pain,” he explains. “Their decision may evolve over time, during or after acute care. Patients also need time to trust me personally, to listen to the information I’m sharing with them about what lies ahead during recovery.” Dr. Taylor firmly stresses, “The decision is highly personal and individual. What is possible surgically to preserve the hand is not always what is personally right for the patient.”
Deciding to preserve versus amputate a mangled hand involves a large number of factors.¹ Foremost is whether the injury involves the dominant hand or a thumb, the extent of injury to nerves, bones, soft tissue and blood vessels, patient age and overall health status. Age is key. The younger the patient, the more likely to lean toward preservation, as Dr. Taylor notes, “For younger patients, the long-term costs of amputation, in terms of prosthetics and potential work and functional disability, probably outweigh the short-term costs of preservation.”
Nevertheless, preservation is expensive, time-consuming, requires ongoing access to surgeons and rehabilitation services and a large commitment by the patient and family. Treatment at a trauma facility with surgeons experienced with complex reconstruction, is required.
For a variety of reasons, a fairly large subset of patients chooses to amputate all or a portion of the injured hand. (See images below of one case. Warning: Images are graphic in nature.) Dr. Taylor notes, “These cases most often involve injuries where amputation will not significantly impact daily function, or when the injuries are very extensive and preclude a good outcome.” The patients tend to be older, with significant comorbidities, limited insurance coverage or financial resources, or limited access to experienced surgeons or rehabilitative care.
A major hurdle for patients who choose to amputate a mangled hand is the limited usefulness of a prosthetic device. Dr. Taylor explains, “Arm and hand prostheses feel very heavy to most patients and do not restore function like a leg or foot prosthetic. They often serve a mainly aesthetic function, filling out a sleeve so that the upper body looks more normal.” Given these limitations, many patients prefer the pain and stiffness of a preserved hand.
While scoring systems designed to aid such decision-making capture the extent of damage to skin, other soft tissues, bone, nerves, and the vascular system, Dr. Taylor believes their usefulness is limited in the case of mangled hands. “Most rating systems are aimed at lower extremities and scores may be less reliable when applied to upper extremities like the hand or arm,” he says.
Kenneth F. Taylor, M.D.
Associate Professor, Orthopaedics and Rehabilitation
Chief, Division of Hand Surgery
FELLOWSHIP: Hand surgery, Walter Reed Army Medical Center, Washington, DC
RESIDENCY: Orthopaedic surgery, Walter Reed Army Medical Center, Washington, DC
MEDICAL SCHOOL: Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine, Bethesda, Md.