Utilization of a Skin Graft From an Amputated Hand to Cover Reservent Below-elbow Amputation Wound

Summary:

This case involves a 58-year-old man who sustained a severe left forearm injury from a motor vehicle accident. Imaging revealed comminuted fractures and arterial occlusions in the left forearm. As the injury was crush type and exploration revealed vessels with avulsion, the decision was made to perform amputation due to nonsalvageability. The patient underwent irrigation, debridement, and amputation, followed by coverage via a full-thickness skin graft from the amputated hand. Postoperatively, the patient received antibiotics and wound care, resulting in successful graft integration and healing. This case highlights the use of a full-thickness skin graft from the amputated limb for stump coverage, demonstrating that if the patient refuses to take a graft from other common sites, the amputated dorsum of the hand can be an excellent alternative site.

Motor vehicle accidents frequently lead to severe injuries, including traumatic limb amputations. Research conducted by Alshehri et al¹ in Saudi Arabia underscores their significant contribution to both upper and lower limb amputations. In any amputation injury, the decision to perform replantation depends on many factors and involves considerations specific to each patient, as there are various types of coverage and reconstruction.² Managing a below-elbow crush injury is challenging because of extensive tissue damage. The main goal in treating upper extremity crush injuries is to ensure the best possible functional recovery and aesthetic results while minimizing harm to donor sites and preventing life-threatening infections.³ However, not all cases can be reconstructed, thus resulting in amputation and coverage of the stump with a skin graft. Moreover, skin grafts that can be either full-thickness skin grafts (FTSG) or split-thickness skin grafts contain the entire dermis.^4,5 Usually, these grafts are taken from distant sites, such as the groin, but in our case, a skin graft from an amputated hand was used to cover the below-elbow amputation stump.

CASE STUDY

Patient Description

A 58-year-old man with a history of hypertension presented following a motor vehicle accident, in which he was ejected from the car onto the street and had a crush injury to his left forearm. The patient arrived at the emergency department within 1 hour of the injury; however, the amputated part was not considered salvageable because of severe crush-type injury and intimal avulsion of vessels.

Physical Examination Results

An obvious deformity in the left upper limb was seen, the forearm was mangled with exposed muscle and bones, and no arterial pulses were found (Fig. 1). A soft tourniquet was placed.

Fig. 1.

The extent of injury in the mangled left upper extremity.

Results of Pathological Tests and Other Investigations

Imaging studies, including a left upper limb x-ray (Fig. 2), revealed extensive comminuted open fractures below the elbow with soft tissue damage and occlusions of the mid-segment ulnar and distal radial arteries. Computed tomography scans revealed a mild compression fracture of the T3 and vertebral compression fracture at the L2 level with mild height loss. A brain computed tomography scan detected a mild right posterior parietal subgaleal hematoma; no other acute traumatic injuries were found.

Fig. 2.

The open comminuted below-elbow fracture of the left upper extremity.

Treatment Plan

After stabilization and resuscitation within 1 hour, the patient was taken to the operating room as an emergency. Irrigation and debridement of the left upper limb plus ligation of the vessels and nerves were done. Eventually, the tissue was clean, and the level of amputation was 5 cm below the elbow. The bone and vessels were approximated and covered with a local muscle flap, using the skin from the donor amputated dorsum of the hand due to the patient’s concern over donor site morbidity, scarring, and pain at the donor location after surgery. The grafted skin was devoid of laceration and abrasion, and there was no blackish discoloration (Fig. 3). The skin graft was meshed after harvest to reduce collection under the graft. The graft was fixed via a stapler and wet-to-dry dressing.

Fig. 3.

The harvesting of FTSG from the amputated dorsum of the left hand.

Outcome

The patient tolerated the surgery well. He was hospitalized for 10 days for monitoring, during which the surgical wound remained dry and intact (Fig. 4). Primary dressing was applied on the fifth postoperative day, and the graft was observed to be performing well with the wound remaining dry. The patient was prescribed antibiotics and was instructed to apply Fucidin for 2 additional dressings. The outcome of the follow-up after 2 weeks was satisfactory, with good graft integration and wound healing. The patient was given another follow-up appointment 2 weeks later; the graft was stable, integrating well with no wound dehiscence. However, our limitation was that the patient left the country; therefore, we lost contact and long-term assessment was not possible.

Fig. 4.

The stump after grafting shows the full-thickness graft with stability and good integrity.

DISCUSSION

This case demonstrates the effectiveness of skin grafting from the amputated limb to cover the below-elbow amputation stump, a very useful option for patients who are reluctant to use a distant site for skin graft. We used FTSG from the amputated dorsum of the hand as an alternative solution to reduce donor site morbidity, using the spare parts principle. Short-term follow-up was done at 2 and 4 weeks; the graft was stable and integrated well with no wound dehiscence. However, long-term outcomes such as phantom limb pain were not evaluated in this study. A previous study explored the use of split-thickness skin grafts for amputation stumps, emphasizing their practicality but also their limitations. Although split-thickness skin grafts are easy to harvest and apply, many graft failures have been reported. Furthermore, selecting an optimal donor site is crucial; grafts from the contralateral limb or less affected areas are recommended to minimize complications and improve prosthetic fitting, facilitating quicker patient mobilization.⁶

In our case, the grafted skin from the dorsum of the amputated hand provided excellent coverage for the below-elbow stump. This approach has been previously documented in lower limb amputations, in which FTSG from the amputated foot was used to cover a transtibial amputation stump, resulting in durable and sensate skin suitable for prosthetic use.⁷ Another study demonstrated a case in which skin from an amputated limb was used as a stump. Their case involved a traumatic crush injury to the leg. Below-knee amputation was performed, and FTSGs were harvested from the amputated part and used for the stump. The stump healed without complications except for minor areas of hyperkeratosis at the graft margin.⁸

CONCLUSIONS

This case highlights the use of FTSG from an amputated hand in managing traumatic below-elbow amputation. Amputation was performed, and the defect was reconstructed via an FTSG from the amputated dorsum of the hand within 2 hours of the injury. The patient had successful surgical outcomes and complete graft healing. The discharge plan included antibiotics to prevent infection and detailed wound care instructions; follow-up was at 2 and 4 weeks and showed excellent graft healing with no complications. The successful outcome highlights the effectiveness of the skin graft from the amputated dorsum of the hand in covering the upper limb stump. The use of FTSG has been shown to be a great option for coverage to be used if the patient does not want to have the consequence of skin harvesting complications such as scars and pain at the donor site.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

Consent was obtained in accordance with the policy of the King Abdulaziz Medical City hospital when consenting for treatment to use the data for research purposes.