Program Director EVMS Norfolk, Virginia, United States
Case Diagnosis: Bilateral Metacarpal Phalangeal Amputation Post Reconstructive Surgery
Case Description: 54-year-old female with diverticulitis status post perforation, ex lap, total colectomy and ostomy, septic shock and dry gangrene in all extremities secondary to pressor support, status post bilateral below knee amputations and bilateral metacarpal phalangeal amputations 5/1, status post iliac crest bone graft for metacarpal lengthening 6/5. The patient was admitted to inpatient rehabilitation. Shortly after admission, the bone graft in the thumb became exposed, status post debridement, and tissue rearrangement on 6/30. The patient developed wound dehiscence two weeks later, status post explant of bone graft, on 7/6 and 7/12.
Discussions: Partial hand amputations are the most common upper extremity amputations. Patients with regular prosthetic use have a greater likelihood of returning to work, increased independence in activities of daily living, and improvements in phantom and residual limb pain, and psychological well-being. However, many hand specialists remain unaware of their applicability in practice. A recent survey of hand surgeons revealed that only 36% were familiar with prosthetic options, and only 24% work in a multidisciplinary amputation team. After the amputations, our patient only met with a reconstructive hand surgeon. It is unknown how familiar the surgeon was with prosthetic options and benefits. The reconstruction option resulted in multiple surgeries, revisions, infections, and ultimately a failed graft.
Conclusions: It is the job of the physiatrist to discuss the benefits and options of prosthetics to amputee patients to avoid unnecessary surgeries and morbidity. Our patient was never able to start a preprosthetic rehabilitation plan and make any progress on her therapies because of the pain and interruptions in her rehabilitation. After failed reconstruction, the patient will have more difficulty with fitting with a prosthetic and will likely have complications from the multiple surgeries, which will further complicate and lengthen her rehabilitation.
