Arm cut-off in accident re-implanted at Apollo Chennai !

Mr Sundar Raj aged 37 years an electrical engineer by profession can now hope to return to his work in a few months time. He had a tryst with destiny when he was involved in an industrial accident on June 3rd, 2011 and got his arm cut-off. He had a call to attend to a fault in a crane at his work spot at the Chennai port trust premises. Normally his team has four members who move around in a small van within the port. Since the call was for a minor fault he decided to go alone. After finishing his job he was on his way back to his room hoping to pack for home, as his shift was to end in about 10 minutes.

However, fate had other plans for him. He tried to negotiate his van between two stationery container lorries and within seconds he found his right upper limb missing from his body. He had the shock of his life when he looked out and found his limb on the ground – he had had a total amputation of his limb. But Sunder Raj was not going to give up. Being all alone he got out of his vehicle, picked up his amputated limb and walked towards his friends seeking help.

He was then rushed by the Apollo hospital ambulance to our hospital with the severed limb well preserved in ice. He was seen by the EMR staff and our registrars who resuscitated him and got him ready for surgery. He had sustained a total amputation of his right upper limb at the level of the distal humerus. He needed to have a reimplantation of the cut-off arm and this involved a team of surgeons who would have to work over the next several hours getting his limb reattached.

The patient was soon on the operating table when Dr. Gayatri Krishnan Consultant Anaethetist and her team began to work on him to anaesthetize him. He needed to have a good IV access for various fluid and blood transfusions, arterial lines to monitor his pressures, warming of his body and his intravenous fluids and other monitoring devices. While this was being done, the plastic surgical team of Dr. Manjushree Naik and Dr. Ganapathy Krishnan started working on the amputated part. It had to be initially washed with several liters of saline to clean it of all contaminants. Next the muscles and the major nerves of the limb had to be identified and tagged as also the arteries and veins. The artery/vein was then flushed with heparinised saline to wash out the clots and keep the lumen patent.

Once the patient was anaesthetized the orthopaedic surgeon Dr. Balaji Srinivasan, got ready to fix his bone. This was done with plate and screws and bony stabilization was achieved. Next the cut nerves, arteries and veins in the arm were identified and the muscles were sutured back. Dr. N Sekar, Vascular surgeon had now to do the vascular repair getting the artery and vein repaired back in place and this established the circulation to the limb. The anaesthesia team had to carefully monitor him now as he could go into a dreaded complication called reperfusion injury wherein once the circulation to an ischemic part is restored the collected toxic metabolites could enter the main circulation and cause several abnormalities. Sunder Raj was lucky not to have any such problem.

After the circulation was reassessed and found to be fine the plastic team got to work repairing the major nerves, which are important for the future functioning of the hand. The exposed nerves and arteries/veins were also covered with a local muscle flap to protect them. To avoid a complication called compartmental syndrome the skin and the deeper layers of tissues on the forearm were cut and left open to release the pressure within the muscles, which was bound to develop. With this ended the almost 6 hour effort of the team of surgeons and anaesthetist to reattach the amputated limb and it was a happy ending.

Sunder Raj had an uneventful post operative period. After 5 days he was taken back to the OR to assess his wound, which was found to be healthy. At this stage the open wound in the forearm was covered by a skin graft taken from his thigh. At periodic intervals his wounds were examined and all his wounds had healed and he also had a good take of the skin graft. All the while he was monitored closely and was on various medications to avoid complications and to maintain a good blood flow and also needed multiple blood transfusions. Fortunately for him he developed no complications and was discharged after 2 weeks in a stable condition with a viable upper limb.

Complete amputation at the arm level is luckily quite rare and reimplantation at that level has the highest failure rate. The amount of muscle bulk below the level of the amputation which becomes ischemic is what causes the failure of the procedure. The factors that were favourable in our case were :

• Age of the patient with no associated medical diseases.
• The fact that the Plastic Surgery team were able to advise the emergency exactly how to store the amputated limb – it needs to be wrapped in moist saline gauze and placed in an empty polythene packet, which in turn needs to be placed in a packet filled with ice – never should the part be put directly into saline or be in direct contact with ice.. Since there is very little awareness about this among the lay public and also the health workers the opportunity to salvage the limb is lost many a time due to improper storage.
• The speed with which we could mobilize the case so that the vascular anastomosis could be done within the ideal ischemic time.
• The excellent team work by the various specialists.

The road back to complete recovery for the patient is going to be a long one. Though the limb is viable it is not functional yet. The nerves will need to grow from the repaired site up to the tips of the fingers. The rate of growth is approximately one mm per day. He now needs to be on regular physiotherapy to prevent atrophy of his muscles and tendons as well as stiffness of his joints and also needs to have periodic assessment to monitor the functional recovery in the hand. He may even need some ancillary reconstructive procedures at a later date.

But as with everything in life, ‘a job well begun is half done’. The day he is back to his usual profession would be the happiest day for the surgeon.