An 18-year-old man presented with a workplace-related injury, wherein his left shirt sleeve was caught in a cloth rolling machine and consequently his left upper limb was avulsed and amputated at his shoulder. He presented to our center 3 hours after the incident, with the amputated part brought without cooling. Initial examination showed pallor but no major systemic injuries. The stump site showed exposed upper lateral chest wall without the scapula, with visible axillary vessels and brachial plexus remnants deep in the stump.
The limb was preserved on ice and examined without flushing any fluids. The glenohumeral joint was intact, and attached scapular musculature was avulsed and torn. Distal to the shoulder, there were no bony injuries, as confirmed by radiographs, and no major soft-tissue injuries (Fig.1). After proper counseling, it was decided to attempt a replantation.
After initial resuscitation, the patient was urgently shifted to the operating room. Thorough debridement of avulsed musculature was done. The axillary artery and vein and the cephalic vein were identified for viable anastomoses. A long-segment vein graft was harvested from the left lower limb. We performed an expedient plating of the acromioclavicular joint, with a view to fixing the scapula to the posterior chest wall at a later date (Fig.2). The anastomoses were then completed, at which time segmental axillary artery loss was noted, which was bridged with the vein grafts (Fig.3).
The brachial plexus elements were found to be avulsed very proximally deep in the stump; hence, primary nerve repair was deemed unadvisable. Revascularization was accomplished at 8 hours post injury (warm ischemia time of 3 hours, cold ischemia time of 5 hours), with good perfusion. Fasciotomies were done in the arm and the forearm. A strong musculotendinous repair was done around the axilla, and the limb strapped to the chest wall.
Postoperatively, the limb was well vascularized as determined by pulse oximetry, clinical examination, and capillary refill. Reperfusion injury, though anticipated, was not seen (normal creatinine, creatine kinase, and blood gas levels). The shoulder musculature showed necrosis after a few days. The patient was taken for serial debridement of unhealthy muscle for a total of 3 sittings (on perioperative antibiotics for 10 days) (Fig.4). Ten days postoperatively, the limb appeared to be infected, though still perfusing.
Higher antibiotics were initiated, and another thorough debridement was done. On day 14, the patient was found to be in sepsis, and his limb was found to be grossly swollen and edematous. Patient was taken for an urgent disarticulation at which time venous thrombosis was noted on table. The stump was closed primarily, and the patient eventually recovered fully and was discharged.
From the Department of Plastic Surgery, St. Johns Medical College, Bangalore, Karnataka, India.
Aniketh Venkataram, MS (MCh), Department of Plastic Surgery, St. Johns Medical College, 3437, 1st G Cross, 7th Main, Subbanna Gardens Vijaynagar, Bangalore 40, Karnataka, India, E-mail: moc.liamg@vhtekina
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