Traumatic amputation of a digit or hand
Complete or incomplete amputation: assess for replantation
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Plastic SurgeryEmergency
Digital Replantation Assessment and Management
Digital Replantation Assessment and Management: Traumatic amputation of a digit or hand → Life-threatening injury first; call replant service early → In...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Warning Life-threatening injury first; call replant service early
ATLS primary survey before any care of the part
- Control bleeding: direct pressure and elevation. Life-threatening bleeding not controlled: arterial tourniquet on the arm; record the time. Do not clamp or tie vessels
- Phone the hand or replant service now. Do not refuse replantation locally
- Transfer the patient and the part together
03Action Initial management of the patient
Before transfer. On an anticoagulant or antiplatelet: record the drug and last dose and tell the surgeon
- Tetanus prophylaxis per the Australian Immunisation Handbook
- IV antibiotics per local open-fracture protocol (check allergy)
- Analgesia. Nil by mouth for surgery
- Remove rings and jewellery from the injured hand
- X-ray the hand and the amputated part
- Record the time of injury and the time cooling started
04Action Care of the amputated part
Seal the part in a bag and put the bag in ice and water. Never let the part touch ice. Never soak or freeze it. Part still attached (incomplete): do not detach it; see first detail
- Incomplete amputation: keep skin bridges intact. Saline-moist dressing; splint the digit in line; no direct ice. Ask the replant service about cooling
- Rinse gross dirt off with saline. Wrap in gauze moistened with saline. Put it in a sealed plastic bag
- Put the bag in a container of ice and water. Never freeze the part. Never soak it in water or saline
- Label the bag and send it with the patient
05Decision Amputation at wrist level or more proximal?
Part contains muscle (major limb)
- If Yes
06End Yes, major limb: this pathway does not apply
Call trauma, vascular and replant teams now. Aim for surgery within 4 hours. Outer ischaemia limit about 6 hours warm, 12 hours cold
- Needs trauma care, shunting and fasciotomy decisions
- Risk of reperfusion hyperkalaemia and myoglobinuria
If No07Action No, digit or hand: ischaemia time guide
Guide only. Parts with muscle, such as a hand through the palm: aim for surgery within 4 hours. Replants succeed beyond these limits: discuss with the replant surgeon
- DIGITS (no muscle):
- - Warm ischaemia: up to about 12 hours
- - Cold ischaemia: up to about 24 hours
- PARTS WITH MUSCLE (major replant):
- - Aim for surgery within 4 hours; keep warm ischaemia under 4 hours to avoid muscle necrosis
- - Outer limits: warm ischaemia about 6 hours, cold about 12 hours
- Hand through the palm: discuss timing with the replant surgeon at once
- Cooling the part extends the safe time
08Decision Ring avulsion injury?
Ring caught and pulled off the finger
- If Yes
09Action Yes, ring avulsion: classify (Urbaniak)
Urgent hand surgeon assessment for all classes. Class I-II: surgeon repairs soft tissue or vessels; not a replant decision
- Class I: circulation adequate. Treat bone and soft tissue
- Class II: circulation inadequate. Microvascular repair (vein graft often needed)
- Class III: complete degloving or amputation. Replantation, revision amputation or ray amputation
- Survival after replant of complete avulsion is lower (about 66%)
- Class III: go on to indications and contraindications (next steps)
10Action Indications for replantation
Strong indications: refer all for replant assessment. Single finger proximal to the FDS insertion: debated; discuss with the replant surgeon
- Thumb
- Multiple digits
- Any digit in a child
- Hand amputation through the palm
- Single digit distal to the FDS insertion
11Action Contraindications to replantation
Children: refer all for assessment. Discuss every patient with the replant surgeon before refusing
- GENERALLY AGREED:
- - Life-threatening associated injuries
- - Severe crush or mangling of the part
- - Debilitating comorbidities
- - Severe psychotic disorder
- DEBATED (relative):
- - Multi-level (segmental) amputation
- - Prolonged ischaemia beyond the limits above
- - Older age; smoking; single finger proximal to FDS
- Avulsion is not a contraindication: replant is often attempted
12Decision Replant surgeon decides: attempt replantation?
Shared decision with the patient: function, occupation, hand dominance, wishes
- If Yes
13Action Yes, replant: usual operative sequence
Replant surgeon; order can vary
- 1. Debride and identify structures
- 2. Shorten and fix bone
- 3. Repair extensor then flexor tendons
- 4. Repair digital artery (or arteries)
- 5. Repair nerves
- 6. Repair veins: aim for 2 veins per artery where possible
- 7. Loose skin closure; bulky non-compressive dressing
- Distal tip: veins may be unrepairable; surgeon plans venous outflow
14Action After replantation: monitor the digit
Pale, cool or congested digit: call the replant surgeon at once
- Frequent checks of colour, capillary refill, turgor and temperature
- Keep the patient warm, hydrated and comfortable
- Hand at heart level; avoid a dependent position
- No smoking
- Antithrombotic drugs: per the replant surgeon (no agreed regimen)
- Splint; hand therapy when the surgeon allows
15End Replant: expected outcomes and follow-up
Hand surgery and hand therapy follow-up
- Survival about 80-90% overall; lower after crush or avulsion
- Cold intolerance is common
- Hand therapy is needed for function
If No16End No, not for replantation: revision amputation
Surgeon closes the stump
- Preserve length and sensate cover
- Parts of the amputated tissue may be used as grafts
- Hand therapy
If No- Path rejoins step 10Shared downstream outcome
Guideline Source
Chang MK, Lim JX, Sebastin SJ. Current trends in digital replantation: a narrative review. Ann Transl Med 2024;12(4):66 (no formal society guideline exists; expert consensus)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Digits and hand only. Amputation at wrist level or more proximal needs trauma, vascular and replant care that this pathway does not cover
- No formal society guideline exists. Based on peer-reviewed reviews and expert consensus; the replant surgeon makes the final decision
- Ischaemia limits are a guide only; successful replants are reported beyond them
- Postoperative antithrombotic regimens vary; there is no agreed protocol
Contraindicated Populations
major_limb_amputation_wrist_or_proximalpolytrauma_with_life_threatening_injury
Applicable Regions
USEUAU
AU: Replant services are centralised in tertiary hand and plastic surgery units. Phone the state hand or replant service early (via the retrieval service where one exists) and transfer the patient and the part together. Tetanus per the Australian Immunisation Handbook.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Digital Replantation Assessment and Management?
The Digital Replantation Assessment and Management is a emergency clinical algorithm for Plastic Surgery. It provides a structured decision tree to guide clinical decision-making, based on Chang MK, Lim JX, Sebastin SJ. Current trends in digital replantation: a narrative review. Ann Transl Med 2024;12(4):66 (no formal society guideline exists; expert consensus).
What guideline is the Digital Replantation Assessment and Management based on?
This algorithm is based on Chang MK, Lim JX, Sebastin SJ. Current trends in digital replantation: a narrative review. Ann Transl Med 2024;12(4):66 (no formal society guideline exists; expert consensus) (DOI: 10.21037/atm-23-1515).
What are the limitations of the Digital Replantation Assessment and Management?
Known limitations include: Digits and hand only. Amputation at wrist level or more proximal needs trauma, vascular and replant care that this pathway does not cover; No formal society guideline exists. Based on peer-reviewed reviews and expert consensus; the replant surgeon makes the final decision; Ischaemia limits are a guide only; successful replants are reported beyond them; Postoperative antithrombotic regimens vary; there is no agreed protocol. Individual patient factors may require deviation from these recommendations.
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