|Amputation for War Wounds (ICRC, 30 p.)|
Foot and ankle amputations.
Formal forefoot or Symes amputations are rarely performed in war surgery. Forefoot injuries do not always necessitate a transverse section; it may be possible to salvage the medial or the lateral portion of the foot. They require wound excision and skin closure by routine methods. Few wounds for which a Symes amputation is possible from the bone point of view have enough soft tissue remaining to cover the distal tibia.
Below knee amputation.
There are two appropriate below knee amputations; they are determined by the injury. It should be noted that a long posterior myocutaneous flap is rarely possible as the tip of the proposed flap is usually affected by the injury.
i) The lower (case A), through the middle third of the tibia, is only possible when there has been irreparable damage to the foot but the leg is unaffected. In this case a soleus muscle flap with independent skin closure is possible; this leaves the intact, musculotendinous part of the calf muscles exposed before delayed closure. The result is a long and well covered stump.
ii) More commonly, a below knee amputation through the proximal third of the tibia is necessary because the injury extends above the ankle (case B). The surgeon may have difficulty maintaining a tibial stump of acceptable length. The compartmental nature of the injury makes the primary amputation more difficult and swelling of the greater muscle bulk higher in the leg may hinder delayed closure. Under these circumstances a gastrocnemius myoplastic amputation is best (9). The gastrocnemius muscle, because it is not contained in a tight compartment and has a proximal blood supply, tends to be preserved in severe leg injuries. The technique of using the full length of the medial gastrocnemius muscle takes the compartmental pattern of injury and subsequent swelling into account whilst permitting both good cover of the stump and skin closure by flaps determined by the injury.
Through knee amputation.
This amputation is rarely performed in ICRC hospitals. The prosthetic facilities do not provide for an end bearing prosthesis. It is not suited to closure after a delay because it exposes the large cartilagenous surface of the femoral condyles or their more complex bone section. It is only suitable as a rapid amputation when the patient has multiple injuries and invariably, it has to be converted to a low femoral section.
Above knee amputation.
There are two appropriate above knee amputaions; these also are determined by the injury. The first and more common is when the injury is confined to the leg but successful below knee ampuatation is impossible (case C). An amputation utilising a vastus medialis myoplasty is suitable. This amputation gives a long stump with good cover of the femoral section. The higher above knee amputation, necessary when the thigh muscles are involved in the injury, is performed along the general guidelines. It may or may not be possible to leave one of the muscles intact for later myoplasty. The swelling of the thigh muscles is considerable and the skin flaps should be cut as long as possible to permit delayed closure. The release of a thigh tourniquet after primary amputation causes the skin to elongate and the muscle to retract. This must be accounted for when planning the levels of bone, muscle and skin section. A pitfall in either above knee amputation is that oedema fluid, haematoma or pus travel proximally around the sciatic nerve and a seemingly clean amputation can prove disastrous if this is not accounted for. Examination of fat in the track of the divided nerve is recommended; the author excises this routinely.
Hand, forarm and arm amputations.
The upper limb is easier than the lower to amputate without complication. This is probably because of the less bulk of the muscle compartments. The amputations are performed along the general guidelines described above. Only the first two operatives objectives have to be reached as the stump will not carry a weight bearing prosthesis.
Limb disarticulation and quarter amputations.
Hip and shoulder disarticulations and forequarter amputations may be necessary with severe, infected proximal injuries. They are disfiguring and dangerous in a septic patient; if successful, delayed skin closure is rarely a problem. By policy, hind quarter operations are not performed in ICRC hospitals.