OTA 2008 Posters

Scientific Poster #121 Upper Extremity OTA-2008

Emergency Air Transport of Finger Amputations in a Level 1 Trauma Center

Kagan Ozer, MD (n); William Kramer, MD (n); Syed Gillani, MD (n);
Allison Williams, PhD (n); Wade R. Smith, MD (n);
Department of Orthopaedics, University of Colorado, School of Medicine,
Denver Health Medical Center, Denver, Colorado, USA

Purpose: Emergency air transfer is usually the most rapid method of transporting life and limb-threatening emergences. In the case of traumatic hand injuries with vascular compromise, the referring medical team is aware of the time constraints limiting successful revascularization and strives to ensure the speediest possible transfer to the tertiary center. Unfortunately, many finger amputations are nonreplantable or, if replanted, may require multiple operations and result in poor function. Many of these cases are immediately predictable when evaluated by a replantation expert. Early identification prior to transport could reduce unnecessary air transports, decrease patient and family anxiety, and, overall, spare important resources. In equivocal cases, a complete informed consent including outcome data for replantation is critical, as many patients do not realize that they will likely need more than one surgery, lose 50% range of motion, and not return to work for 7 months based on national average. The objective of our study was to evaluate all patients flown to a tertiary care hand trauma center for finger amputation and assess the rate of eventual replantation versus nonreplantation. Our hypothesis was that a significant number of flight transfers were not justified medically and could be reduced with a better program to communicate with referring physicians and patients.

Methods: Between 2003 and 2007, data were collected prospectively on all patients with traumatic hand injuries as part of a predesigned hand trauma database. Inclusion criteria for this study were all patients transferred by air with isolated amputations distal to the metacarpophalangeal joints. Patients with additional bodily injuries were excluded. Following initial evaluation, all patients were individually examined by the on-call hand surgeon prior to surgery. Informed consent included statistics regarding the number of additional surgeries that may be needed for the particular type of injury, possible expected functional outcome, and time to return to work. As a result, three different groups were identified: (1) attempted replantation, (2) refused replantation, and (3) replantation not possible. Mean age, past medical, surgical and psychiatric history, mechanism and level of injury, time from injury to surgery, and patients’ response to informed consent were analyzed.

Results: Of the 40 patients meeting inclusion criteria, the mean age was 36.2 years (range, 5.1-68.6) and mean time of transport 5.15 hours (range, 0.93-24.7). Mechanisms of finger injury were crush (n = 27, 57%), followed by clean cut (n = 7, 16%), avulsion/crush (n = 10, 22%), and gunshot wound (n = 2, 5%). No significant differences were found between replantation groups for age (P = 0.559) or time elapsed from injury to hospital arrival (P = 0.303). Replantation was attempted in 15 (37.5%) cases, refused in 6 (15.0%), and not attempted per surgeon decision in 19 (47.5%) cases. The most common reason for the refusal of replantation was inability to return to work immediately. All patients in this group have stated that they would have stayed in the local hospital if they were given the information before the transfer. The most common reasons for surgeon decision to not replant, were-single digit amputations proximal to flexor digitorum sublimis attachment (n = 7), crush/avulsion-type injuries (n = 7), premorbid health status (n = 2), and age (n = 2).

Conclusion and Significance: In this study, two of every three patients transferred via air did not have replantation surgery. While many of the nonreplantation patients required specialized hand surgery, they did not need urgent air transport. Analysis of factors leading to this outcome suggests that the majority of these costly transfers may potentially be avoided if: (1) the referring health care personnel are given the proper education regarding indications and possible outcomes after replantation surgery; and (2) online consultation can be offered, including digital photography, to the referring hospital before the actual transfer takes place.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.

• The FDA has not cleared this drug and/or medical device for the use described in this presentation   (i.e., the drug or medical device is being discussed for an “off label” use).  ◆FDA information not available at time of printing. Δ OTA Grant.