Complex reconstruction following traumatic forequarter amputation

Tara M Barry; Thomas J Herron; Steven M Lorch; David J Ciesla

doi:10.4103/jctt.jctt_15_19

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CASE REPORT

Year : 2019 | Volume : 4 | Issue : 1 | Page : 55-58

Complex reconstruction following traumatic forequarter amputation

Tara M Barry, Thomas J Herron, Steven M Lorch, David J Ciesla
Department of Surgery, Division of Trauma and Acute Care Surgery, University of South Florida, Tampa, Florida, USA

Date of Web Publication

30-Dec-2019

Correspondence Address:
Tara M Barry
Department of Surgery, Division of Trauma and Acute Care Surgery, University of South Florida, Tampa, Florida
USA

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jctt.jctt_15_19

Abstract

Interscapulothoracic amputation is a radical and morbid procedure used for the management of upper extremity trauma and more commonly for resection of solid tumors. Traumatic forequarter amputation poses a unique challenge for achieving adequate tissue coverage depending on the condition of the muscle and soft tissue of the ipsilateral extremity. We present a case of a 38-year-old construction worker who suffered an almost complete forequarter amputation of his right upper extremity secondary to blunt force trauma from a crane pulley that fell from 60 ft. This is a unique mechanism of injury, as most traumatic forequarter amputations occur as a result of traction injury. Details of the case report including the unique challenges, techniques for tissue salvage, fillet flaps, and chest wall reconstruction are presented.

Keywords: Chest wall reconstruction, fillet flap, forequarter amputation, temporary intravascular shunt, traumatic scapulothoracic dissociation

How to cite this article:
Barry TM, Herron TJ, Lorch SM, Ciesla DJ. Complex reconstruction following traumatic forequarter amputation. J Cardiothorac Trauma 2019;4:55-8

How to cite this URL:
Barry TM, Herron TJ, Lorch SM, Ciesla DJ. Complex reconstruction following traumatic forequarter amputation. J Cardiothorac Trauma [serial online] 2019 [cited 2023 Jun 1];4:55-8. Available from: https://www.jctt.org/text.asp?2019/4/1/55/274203

Introduction

Traumatic forequarter amputation was first described in 1737 by John Belchier who reported a 26-year-old male whose arm and scapula were torn from his chest wall when his hand was caught in a mill wheel.^[1] It is a rare and morbid injury that usually occurs secondary to extreme tension forces and has been reported most commonly from industrial accidents involving conveyor belts or farming equipment.^[2],[3] Interscapulothoracic amputation is used for the management of upper extremity trauma and malignancy; however, it is performed infrequently due to improved limb salvage techniques. Temporary intravascular shunts have been described as an auxiliary to limb revascularization or reimplantation. To our knowledge, this is the first report of temporary intravascular shunt for staged reconstruction with fillet flap after amputation.

Case Report

A 38-year-old male construction worker presented as a trauma activation after being hit by a 2.5-ton pulley that fell approximately 60 ft from a crane on site. He had no blood pressure en route and arrived in extremis. On primary survey, he had no airway established. He had palpable carotid pulses and active hemorrhage from severe right forequarter wound which was addressed by applying direct pressure. He was taken directly to the operating room (OR) for hemorrhage control and resuscitation. Airway and central venous access were established, and he continued to receive large volume infusion. While positioning the patient in the OR, he became pulseless, and a resuscitative thoracotomy was performed. Cardiac tamponade was relieved, and pulses were restored after open cardiac massage. He was noted to have increased abdominal distention prompting abdominal exploration. He was found to have a liver laceration; perihepatic packing was performed, and temporary abdominal closure was placed.

Right shoulder exploration revealed near avulsion of the right forequarter [Figure 1]. The right clavicle, scapula, and upper ribs had open fractures. The brachial plexus, subclavian artery, and subclavian vein were avulsed at the thoracic outlet. The wound extended to the back at the level of the upper t-spine and posterior neck with palpable vertebral process fractures. Given the extensive nature of this injury (Gustilo–Anderson Grade IIIC scapulothoracic dissociation), limb salvage would not be possible. All efforts were made to preserve as much of a musculocutaneous pedicle as possible for future closure of the wound. The ends of the subclavian artery and vein were identified and blood flow established with intraluminal shunts [Figure 2]. A temporary negative pressure dressing and bilateral chest tubes were placed. Postoperative computed tomography angiogram of the right upper extremity confirmed patent subclavian, axillary, brachial, radial, and ulnar arteries and brachial vein without extravasation.

Figure 1: Near-complete avulsion of the right forequarter

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Figure 2: Right subclavian artery and vein shunts to maintain perfusion to the extremity

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The patient returned to the OR on posttrauma day 2 with the trauma, orthopedic, and plastic surgery teams for assessment of the viability of the extremity. The temporary subclavian artery and vein shunts were patent with good flow. The patient had a palpable radial pulse and good digital capillary refill; however, the hand was contracted, and forearm compartment was firm. The anterior deltoid muscle was cool to touch with minimal bleeding and appeared nonviable. Given the volume of muscle mass that was nonviable and the fact that the arm would be insensate, attempting limb salvage would put the patient's life at risk and the family agreed to proceed with amputation. The forearm was disarticulated and amputated; humerus and fragments of scapula, clavicle and nonviable muscle were sharply debrided. The patient became unstable. After securing the subclavian artery and vein shunts, another temporary negative pressure dressing was placed, and he returned to the intensive care unit for stabilization.

He underwent formal circular amputation of the right arm at the scapulothoracic level by orthopedic surgery on posttrauma day 3. He returned to the OR on posttrauma day 5 for definitive closure of his chest and amputation site. He underwent open reduction and internal fixation of ribs #3–7. The serratus anterior was mobilized from its origin on the ribs and reflected anteroinferiorly to allow access to the areas of fracture. Biaxial 8–10 hole plates were custom contoured to the curvature of the rib and fixed to the ribs with self-tapping unicortical screws [Figure 3]. To achieve complete coverage of the hardware and fracture sites, the serratus anterior was further mobilized such that it would reach the edge of the resected lateral border of the pectoralis major and minor muscles and secured with interrupted absorbable sutures. Utilizing a portion of the remaining skin and soft tissue from the amputated extremity, a fillet flap on a pedicle was used in combination with a local advancement flap to cover the defect [Figure 4].

Figure 3: Post open reduction and internal fixation of ribs #3-7, right chest using biaxial plates and unicortical screws

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Figure 4: Local advancement and fillet pedicle flaps for coverage of the defect

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The patient required minor debridements for flap necrosis but recovered well with regard to his injury. Unfortunately, on posttrauma day 36, he developed a diffuse rash and was diagnosed with disseminated varicella-zoster virus (VZV). He had a decline in mentation secondary to massive strokes from VZV central nervous system vasculitis. His family ultimately decided to proceed with comfort measures, and the patient expired shortly after.

Discussion

Forequarter amputation is a rare injury that typically occurs as a result of traction force on the extremity.^[1] This is a unique case of traumatic near amputation of the right forequarter secondary to blunt injury. The patient had concomitant injuries including multiple upper rib fractures which made the reconstruction more challenging than an isolated traumatic forequarter amputation or scapulothoracic dissociation secondary to traction injury [Figure 5].

Figure 5: Three-dimensional reconstruction showing multiple right-sided rib fractures (a) and complete scapulothoracic dissociation (b)

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The operative approach to interscapulothoracic amputation maintains the same principles as the procedure first described by Berger in 1887.^[4] For traumatic injuries, this includes hemorrhage control, debridement of devitalized tissue, coverage of exposed vasculature and brachial plexus, and minimizing time under anesthesia.

Our patient was managed appropriately per Advanced Trauma Life Support (ATLS) protocol with regard to his traumatic cardiac arrest and exsanguination. After adequate stabilization, the team recognized that it would likely be difficult to close the large defect; therefore, temporary subclavian arterial and venous shunts were created to maintain perfusion to the nearly severed extremity to salvage muscle, skin, and soft tissue for future coverage.

Temporary intravascular shunts have been used by both civilian and military physicians since the early 1900s as part of a “damage control” approach for the management of traumatic injuries of the extremities that require complex revascularization or reimplantation.^[5] This includes Gustilo IIIC fractures of the extremity as was the case in our patient. Temporary arterial shunts have decreased patency rates if the adjacent major vein is ligated; therefore, a temporary venous shunt should be placed in addition to the arterial shunt to prevent venous congestion and arterial thrombosis.^[6]

The technique of fillet flap, first described by Schmidt et al. in 1987, utilizes the “spare parts concept” using tissue from the amputated limb for coverage of the residual defect.^[7] The fillet flap may be either a free flap or a pedicled flap depending on the location of traumatic injury or malignancy in relation to the blood supply. It can be combined with a local rotational flap for total multilayer coverage [Figure 4].^[7] Our patient returned to the OR for multiple second-look procedures which allowed the tissue to demarcate, and serial debridement ensured that the tissue used for flap coverage was well vascularized.

Patients with traumatic forequarter amputation may benefit from the creation of temporary intravascular shunts to maintain perfusion to the extremity provided it does not pose an immediate threat to life. This allows for adequate resuscitation and stabilization, time to address concomitant injuries, and serial debridement to optimize the tissue to be used in the flap during reconstruction. A multidisciplinary team comprised of trauma, orthopedic, and plastic surgeons should be involved to optimize the surgical planning and treatment for this type of injury.

Financial support and sponsorship

This study was financially supported by the Chest Wall Injury Society to cover costs related to publication.

Conflicts of interest

There are no conflicts of interest.

References

1.	Alford WC, Jr., Stephenson SE, Jr. Traumatic forequarter amputation. J Trauma 1965;5:547-53.
2.	Anbarasan A, Mohamad NH, Mariapan S. Open traumatic scapulothoracic dissociation: Case report of a rare injury. Trauma Case Rep 2018;18:42-5.
3.	Hovius SE, Hofman A, van UrkH, van derMeulen JC. Acute management of traumatic forequarter amputations: Case reports. J Trauma 1991;31:1415-9.
4.	Berger P. L'Amputation Du Membre Superieur Dans La Contiguite Du Tronc (Amputation Interscapulo-Thoracique). 1^st ed. Paris: G. Masson; 1887.
5.	Feliciano DV, Subramanian A. Temporary vascular shunts. Eur J Trauma Emerg Surg 2013;39:553-60.
6.	Hobson RW 2^nd, Howard EW, Wright CB, Collins GJ, Rich NM. Hemodynamics of canine femoral venous ligation: Significance in combined arterial and venous injuries. Surgery 1973;74:824-9.
7.	Schmidt RG, Springfield DS, Dell PC. Chest Wall Reconstruction with a Free Extended Forearm Flap: A Case Report. J reconstr Microsurg 1987;3:189-91.