Traumatic Amputation Of Upper Limb Research Articles

Barriers and facilitators to community reintegration in adults following traumatic upper limb amputation: an exploratory study

Purpose To explore barriers and facilitators to community reintegration experienced by people following traumatic upper limb amputation (ULA). Methods An exploratory qualitative study was conducted with ten adults with major ULA due to trauma. Data from individual, semi-structured interviews was analysed using Braun and Clarke’s reflexive thematic analysis. Results Underlying and influencing community reintegration for participants, was a process of adjustment to the impacts of amputation on everyday function and re-establishing their identity. Participants felt social networks and peer support facilitated the return to social and community activities, as did drawing on personal attributes such as positivity, resilience and self-belief. Prosthetic devices were facilitative for community reintegration by minimising visible differences and unwanted attention through restored cosmesis and in the performance of functional tasks to fulfil social norms and meaningful roles despite issues with comfort and function. Despite the adaptation and evolution of abilities, perspectives and identities, the functional impact of ULA on everyday community activities was an ongoing challenge for all participants. Conclusion ULA has a significant and lifelong impact on an individual’s ability to complete tasks and fulfil meaningful roles in the community. Recommendations based on the study’s findings will inform clinicians to support community reintegration for people following traumatic ULA.

ID: 200598 Targeted Muscle Re-Innervation for Management of Terminal Neuroma in Traumatic Upper Limb Amputation

The patient is a 49-year-old male with a left wrist disarticulation in the setting of work-related trauma complicated by thrombosis and osteomyelitis (Figure 1). His case was complicated by severe constant grabbing pain in his distal residual limb, refractory to conservative treatments, functionally limiting his ability to use his prosthesis for more than 30 minutes at a time. His examination revealed significant allodynia with palpation of the left distal forearm with an intact integumentary exam.

Exploring the barriers and facilitators to community reintegration for adults following traumatic upper limb amputation: a mixed methods systematic review

Purpose Traumatic upper limb amputation (ULA) is a profound injury impacting participation in activities of daily living, including those within the community setting. The objective of this work was to review literature exploring barriers, facilitators, and experiences of community reintegration in adults following traumatic ULA. Methods Databases were searched using terms synonymous with the amputee population and community participation. Study methodology and reporting were evaluated using McMaster Critical Review Forms, with a convergent segregated approach to synthesis and configuration of the evidence. Results A total of 21 studies met the inclusion criteria, including quantitative, qualitative and mixed-method study designs. Restoring function and cosmesis with prostheses facilitated work participation, driving and socialisation. Positive work participation was predicted by male gender, younger age, medium-high education level and good general health. Work role and environmental modifications were common, as were vehicle modifications. Qualitative findings provided insight into social reintegration from a psychosocial perspective, particularly negotiating social situations, adjusting to ULA and re-establishing identity. The review findings are limited by the absence of valid outcome measures and clinical heterogeneity across the studies. Conclusion There is a dearth of literature on community reintegration following traumatic upper limb amputation, indicating a need for further research with strong methodological rigour. Implications for Rehabilitation Upper limb amputation can restrict participation in activities in the community including work, socialisation, driving, leisure, and recreation. Clinicians can support community reintegration by addressing personal and environmental factors that both facilitate or inhibit participation in community activities. Prosthetics can be a facilitator for participation in community activities through the restoration of function and cosmesis. Clinicians can facilitate return to work through work modification recommendations or supported transitions to more suitable roles.

Neurorehabilitation in Adults With Traumatic Upper Extremity Amputation: A Scoping Review

Background Most of the current literature around amputation focuses on lower extremity amputation or engineering aspects of prosthetic devices. There is a need to more clearly understand neurobehavioral mechanisms related to upper extremity amputation and how such mechanisms might influence recovery and utilization of prostheses. Objective This scoping review aims to identify and summarize the current literature on adult traumatic upper limb amputation in regard to recovery and functional outcomes and how neuroplasticity might influence these findings. Methods We identified appropriate articles using Academic Search Complete EBSCO, OVID Medline, and Cochrane databases. The resulting articles were then exported, screened, and reviewed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines. Results Eleven (11) studies met the study criteria. Of these studies, 7 focused on sensory involvement, 3 focused on neuroplastic changes post-amputation related to functional impact, and 1 study focused on motor control and learning post-amputation. Overall, these studies revealed an incomplete understanding of the neural mechanisms involved in motor rehabilitation in the central and peripheral nervous systems, while also demonstrating the value of an individualized approach to neurorehabilitation in upper limb loss. Conclusions There is a gap in our understanding of the role of neurorehabilitation following amputation. Overall, focused rehabilitation parameters, demographic information, and clarity around central and peripheral neural mechanisms are needed in future research to address neurobehavioral mechanisms to promote functional recovery following traumatic upper extremity amputation.

Development of overuse musculoskeletal conditions after combat-related upper limb amputation: a retrospective cohort study

Study designRetrospective cohort study IntroductionService members who have sustained traumatic amputations are typically young and otherwise healthy. Beyond standard care, these individuals desire long, highly active, and relatively pain-free lifestyle, whether that is returning to active duty or transitioning to civilian life. Development of overuse musculoskeletal conditions could have a significant influence on quality of life for Service members with traumatic upper limb amputation. Purpose of the studyCompare one-year incidence of overuse musculoskeletal injuries in Service members with different levels of combat-related upper limb amputation to Service members with minor combat-related upper limb injuries. MethodsService members with deployment-related upper limb injury (N = 519), 148 major upper limb amputation (55 with amputation at or above elbow, 93 with amputation below elbow) and 371 minor upper limb injury were included in the study. Outcomes of interest clinical diagnosis codes associated with overuse conditions of the upper limb, neck and upper back, lower limb, low back pain, and all regions combined, one year before and one year after injury. ResultsOverall, the one-year incidence of developing at least one musculoskeletal overuse condition after upper limb amputation was between 60% and 65%. Service members with upper limb amputations were 2.7 to 4.7 times more likely to develop an overuse upper limb condition, 3.6 to 3.8 times more likely to develop a neck and upper back condition, 2.8 to 4.4 times more likely to develop a lower limb condition, and 3.3 to 3.9 times more likely to develop low back pain as compared those who sustained minor combat-related injuries. No significant differences in the odds of developing a musculoskeletal condition was found between the above elbow and below elbow amputation groups. ConclusionsIncidence of secondary overuse conditions is elevated in Service members with upper limb amputation and warrants focused research efforts toward preventative and rehabilitative interventions.

Traumatic upper-limb amputation: The process toward acceptance

IntroductionAfter traumatic upper-limb amputation (TULA), one-third of patients develop traumatic pathological grief (PG). However, are the other two-thirds unscathed? The main aim of the present study was to assess the rate of TULA victims claiming to have dealt with the consequences and showing no PG. The secondary objective was to determine positive and negative factors enabling and preventing coping. MethodA retrospective clinical study was conducted over an 11-year period in all adult TULA cases in our department. Assessment was on questionnaire. PG was assessed on the ICG (Inventory of Complicated Grief). Factors were assessed on physical, psychological, social, functional, esthetic and epidemiological criteria. Statistical analysis used StatView software, with the significance threshold set at p<0.05. ResultsFunctional and social impacts were significantly greater in case of PG. Thumb amputation was significantly associated with PG, while PG was significantly less frequent in case of amputation at the metacarpal base. Patients in PG had significantly more often undergone neuroma resection or stump revision surgery. DiscussionFewer than a half of TULA victims achieved cure. Long-term prognosis depends on the patient's ability to accept the new situation, much more than on amputation level. Patients need support from the very first minutes, with follow-up extended well belong scar healing. Onset and healing of the narcissistic wound are inevitably delayed compared to skin healing.

Functional Outcomes of Major Upper Extremity Replantation: A Scoping Review

Background:Traumatic upper limb amputations proximal to the carpus are devastating injuries. Existing literature on outcomes following replantation is limited. Our objective was to perform a scoping review of (1) functional outcomes; (2) return to work data; and (3) secondary surgeries required following proximal to carpus replantation.Methods:A literature search of MEDLINE, EMBASE, Cochrane, and CINAHL was performed according to PRISMA guidelines. All studies reporting on functional outcomes, return to work, or secondary surgeries following replant of traumatic proximal to carpus amputation were included.Results:Of the 753 articles, 13 studies were included, accounting for 136 major upper extremity replants (0 shoulder, 36 arm, 14 elbow, 86 forearm). Average age was 35 (24 -47) years, with average follow-up of 8 years (2 -18). Chen's Functional Criteria was the most common tool for reporting outcomes (10/13). Level of injury was related to functional outcome, with excellent to good Chen scores for replants distal to elbow, and poor Chen scores for replants at or proximal to elbow. Return to work correlated with level of replantation, with successful return for 65% of forearm, 43% of elbow, and 32% of arm replants. A mean of 2.4 secondary procedures were required.Conclusions:This study provides insight into major upper extremity replantation, to assist in patient counseling and surgical decision making. Good functional outcomes and successful return to work are directly related to level of injury following major upper extremity replant. Patients should be counseled that more than 1 secondary procedure may be required.

Psychological effects of traumatic upper-limb amputations

IntroductionThe main aim of the present study was to determine the existence of pathological grief in victims of traumatic upper-limb amputation. The secondary objective was to determine risk factors for onset of pathological grief. MethodA retrospective clinical study was conducted for an 11-year period, including all cases of traumatic upper-limb amputation in adults. Patients were assessed on a questionnaire including an adaptation of the Inventory of Complicated Grief (ICG). Risk factors were assessed on surgical, personal occupational and subjective criteria. Statistical analysis on StatView software used matched Chi2 tests for comparisons, with the significance threshold set at p<0.001. ResultsWith 1058 questionnaires sent out, the response rate was 52%; 3% of returned questionnaires were non-interpretable. Thirty-nine percent showed a state of pathological grief. Risk factors comprised lack of attempted replantation (p<0.001), isolated thumb amputation (p<0.001), and multi-digit or macro-amputation (p<0.001). Subjective esthetic blemish or the feeling of being mutilated was significantly associated with pathological grief (both p<0.001). DiscussionTraumatic upper-limb amputation victims incurred a risk of pathological grief (main endpoint), with identifiable risk factors (secondary endpoint). Victim accompaniment and screening for risk of pathological grief are essential to limit the psychological impact of trauma and promote social and occupational reintegration.

Epidemiology of traumatic upper limb amputations.

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. 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 work-related. 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. 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. 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. IV.

Transplantation of a full-cut upper limb from the middle third of the arm

Background: Complete traumatic amputation of upper limb from the middle third of the arm is extremely rare. During the past years thanks to advances in scientific and microscopic methods, peripheral nerve surgery has increased the success rate of such surgeries. Case Presentation: A 2.5 yr-old girl sustained 1/3 proximal end of her right arm amputation. Amputated limb had irregular borders and was frozen in a container brought with ice for about three hours. The patient was admitted in the emergency Ward of Taleghani Hospital. She was completely conscious. Her Blood pressure was 80/50 ml and her heart beat was 130/mnts. After resuscitation, the amputated limb was cleaned. At first, fractured humerus bone was fixed by plaque and screw. Then all muscles and tendons were statured. Vessels were anastomosed by end to end and musculocutaneoum nerves have been fixed. At last, fasciotomy and skin repair have been performed. Conclusion: The 24 months follow up of the patients’ conditions revealed that the patient had touching sense, temperature and blood pressure in the replanted part and the operation was to a large extent satisfactory.

Transplantation of a full-cut upper limb (in wrist): A cases study

Background: Complete traumatic amputation of upper limb in wrist area is relatively rare. During the past years thanks to advances in scientific and microscopic methods peripheral nerve surgery has increased the success rate of such surgeries. Case Presentation: An 18 year old man with his wrist has been cut for about 6 hours in an accident was referred to emergency Ward of Taleqani Hospital of Kermanshah. The patient suffered from complete cut of left wrist in car accident in 2008. The patient was really agitated and restless. His Blood pressure was 50/90 mm ​​Hg and pulse rate was 120 per minute. Cut hand has been pressed and contaminated with soil and was wrapped in cloth and sent to the medical center. At first radius and ulnar bones were fixed by pin and articular capsule was sutured. In the second stage muscles were sutured. Arteries and veins in the third stage were anastomosed. Vessels were anastomosed end-to-end. Median, radial and ulnar nerves were restored by microscopic surgery after blood supply of hand has been flown. Finally, fasciotomy of organ was done to prevent compartment syndrome. Conclusion: Two years later it was realized that the patients' sense of touch, heat and pressure of hand was remarkably good in transplanted hand and the surgery was really successful.

Reincorporación laboral en pacientes con amputación traumática de extremidad superior

Objective To evaluate the return to the work environment of patients with upper limb amputations due to work accidents. Patients and methods A descriptive cross-sectional study was performed. The variables evaluated were obtained by telephone interview, this being return to work, occupation after and before the amputation, prosthesis requirement, use of prosthesis and pain. Results Sixty-five patients (60 male) mean age 44.4 years were enrolled. The subjects who returned to work (38 cases) reported pain less frequently ( P = .009) and when present, the pain was less intense ( P = .004). Use of prosthesis was slightly significantly higher in this group of patients ( P = .07). No significant differences were found for the rest of variables between the reinstated and non-reinstated patients. Conclusions From a clinical point of view, pain was the most important factor conditioning return to work in subjects with traumatic upper limb amputation. However, the influence of socioeconomic variables was not studied.

Direct Placement of a Brachial Plexus Neural Catheter for Analgesia after Traumatic Upper Limb Amputation

We report a case of traumatic upper limb injury that resulted in above elbow amputation. A multimodal approach was employed to optimize postoperative analgesia; this included continuous peripheral nerve blockade, initiated intraoperatively. Surgical access onto the axillary artery for proximal vascular control allowed placement of the nerve catheter under direct vision onto the brachial plexus. The pathophysiology of phantom pain is related to our case experience. This report highlights the complex challenge of controlling pain in combat casualties and promotes employment of multimodal analgesic strategies, including advanced regional anesthesia, in the military setting.

Re-emergence of hand-muscle representations in human motor cortex after hand allograft

The human primary motor cortex (M1) undergoes considerable reorganization in response to traumatic upper limb amputation. The representations of the preserved arm muscles expand, invading portions of M1 previously dedicated to the hand, suggesting that former hand neurons are reassigned to the control of remaining proximal upper limb muscles. Hand allograft offers a unique opportunity to study the reversibility of such long-term cortical changes. We used transcranial magnetic stimulation in patient LB, who underwent bilateral hand transplantation 3 years after a traumatic amputation, to longitudinally track both the emergence of intrinsic (from the donor) hand muscles in M1 as well as changes in the representation of stump (upper arm and forearm) muscles. The same muscles were also mapped in patient CD, the first bilateral hand allograft recipient. Newly transplanted intrinsic muscles acquired a cortical representation in LB's M1 at 10 months postgraft for the left hand and at 26 months for the right hand. The appearance of a cortical representation of transplanted hand muscles in M1 coincided with the shrinkage of stump muscle representations for the left but not for the right side. In patient CD, transcranial magnetic stimulation performed at 51 months postgraft revealed a complete set of intrinsic hand-muscle representations for the left but not the right hand. Our findings show that newly transplanted muscles can be recognized and integrated into the patient's motor cortex.

Training With Virtual Visual Feedback to Alleviate Phantom Limb Pain

Background. Performing phantom movements with visual virtual feedback, or mirror therapy, is a promising treatment avenue to alleviate phantom limb pain. However the effectiveness of this approach appears to vary from one patient to another. Objective. To assess the individual response to training with visual virtual feedback and to explore factors influencing the response to that approach. Methods. Eight male participants with phantom limb pain (PLP) resulting from either a traumatic upper limb amputation or a brachial plexus avulsion participated in this single case multiple baseline study. Training was performed 2 times per week for 8 weeks where a virtual image of a missing limb performing different movements was presented and the participant was asked to follow the movements with his phantom limb. Results. Patients reported an average 38% decrease in background pain on a visual analog scale (VAS), with 5 patients out of 8 reporting a reduction greater than 30%. This decrease in pain was maintained at 4 weeks postintervention in 4 of the 5 participants. No significant relationship was found between the long-term pain relief and the duration of the deafferentation or with the immediate pain relief during exposure to the feedback. Conclusions. These results support the use of training with virtual feedback to alleviate phantom limb pain. Our observations suggest that between-participant differences in the effectiveness of the treatment might be related more to a difference in the susceptibility to the virtual visual feedback, than to factors related to the lesion, such as the duration of the deafferentation.

Coping, affective distress, and psychosocial adjustment among people with traumatic upper limb amputations

Objective This study investigated the prevalence of symptoms of depression and anxiety in a sample of predominantly elderly males with acquired upper limb amputations ( n=138) and examined the contribution of coping strategies to the prediction of psychosocial adjustment. Method One hundred and thirty-eight men with injury-related upper limb amputations completed self-report questionnaires assessing coping strategies, symptoms of anxiety and depression, and psychosocial adaptation to prosthesis use. Results Prevalence of significant depressive symptoms was 28.3% [Hospital Anxiety and Depression Scale, Depression subscale (HADS-D) score ≥8]. Prevalence of significant anxiety symptoms was 35.5% [HADS Anxiety subscale (HADS-A) score ≥8]. Coping styles emerged as important predictors of psychosocial adaptation. In particular, avoidance was strongly associated with psychological distress and poor adjustment. Conclusions These findings suggest the potential benefits of interventions to reduce reliance on avoidant coping and stimulate more problem-focused approaches to coping with difficulties and challenges in order to facilitate adaptation and prevent problems in psychosocial functioning postamputation.

Continuous brachial plexus analgesia and NMDA-receptor blockade in early phantom limb pain: a report of two cases.

To provide a mechanism-based acute pain management strategy for early phantom limb pain following traumatic amputations and to collect first evidence of its acute and potentially preventative effects on the formation and maintenance of phantom limb pain. The combination of continuous brachial plexus analgesia and prolonged block of N-methyl-D-aspartate (NMDA) receptors over 4 weeks aimed to attenuate peripheral and central sensitization, currently thought to be substantially involved in establishing and maintaining phantom limb pain. Two patients, after traumatic upper limb amputations and early phantom limb pain, were treated on the second and fifth day following amputation by continuous brachial plexus analgesia with ropivacaine 0.375% (30 ml for the initial block, continuous infusion rate = 5 ml/h) for 5 (Patient 1) and 9 days (Patient 2). Both patients received oral memantine (a noncompetitive NMDA-receptor antagonist) in increasing doses from 10 to 30 mg/d over a 4-week period. Ropivacaine only produced minor motor block, with almost unimpaired motor function. Memantine was well tolerated and no relevant side effects were observed. In both patients the treatment prevented the establishment of phantom limb pain, which did not reappear during follow-up of 1 year. The combination of long-term regional analgesia with prolonged block of NMDA receptors might be effective for treatment and prevention of phantom limb pain following traumatic amputations. The absence of clinically relevant side effects, together with maintained motor function suggests this treatment to be a promising preventive strategy for phantom limb pain following traumatic amputations.

Phantom limb pain: a report of two cases

The efficacy of pre-emptive analgesia for phantom limb pain is still unclear. It is generally accepted that pre hyphen;amputation pain increases the incidence of phantom and stump pain, even if pre-emptive analgesia is performed before and during surgery and in the postoperative period. Two cases of traumatic upper limb amputations are described here with no pre-existing pain. Both received similar antinociceptive treatment by continuous block of the brachial plexus through infusion of ropivacaine 0.375% at 5ml/h for 10 days. Treatment of case 1 was initiated immediately after surgery; however, this amputee developed intensive phantom limb pain which persisted at 6 months. Early use of the prosthesis after surgery was not possible for this patient. The intensity of phantom limb pain in case 2 decreased significantly after 6 months, even though brachial plexus blockade was not started until 5 weeks post-trauma. This patient used a functional prosthesis intensively beginning early after amputation. Serial magnetoencephalographic recordings were performed in both patients. Only case 2 showed significant changes of cortical reorganization. In case 1 markedly less cortical plasticity was found. A combination of relevant risk factors such as a painful neuroma, behavioural and cognitive coping strategies and the early functional use of prostheses are discussed as important mechanisms contributing to the development of phantom pain and cortical reorganization.

FMRI of Cortical Reorganization in the Primary Motor and Sensory Cortex after Traumatic upper Limb Amputation

fMRI of Cortical Reorganization in the Primary Motor and Sensory Cortex after Traumatic upper Limb Amputation

Topical capsaicin as an adjuvant analgesic for the treatment of traumatic amputee neurogenic residual limb pain

The treatment of amputee residual limb pain can at times be a challenge for the physician. Occasionally, traditional analgesic medication regimens cannot be used or are ineffective in relieving the pain. Topical capsaicin cream has been a beneficial adjuvant medication in the treatment of some painful conditions. The authors present three patients with traumatic upper limb amputations where topical capsaicin cream was of benefit in the treatment of neurogenic residual limb pain. The hope is that these cases will increase awareness of the potential use of capsaicin cream as an adjuvant analgesic in patients with residual limb pain. Common causes of residual limb pain and the pharmacology of capsaicin cream are discussed.