Traction avulsion amputation of the major upper limb: A proposed new classification, guidelines for acute management, and strategies for secondary reconstruction

Major replantation of a traction avulsion amputation is undertaken with the goal of not only the reestablishment of circulation, but also functional o utcome. This type of amputation is characterized by different levels of sof t-tissue divisions involving crushing, traction, and avulsion injuries to v arious structures. Between 1985 and 1998, 27 cases were referred for second ary reconstruction following amputation of the upper extremity involving bo th arm and forearm. Replantation was performed by at least 12 qualified pla stic surgeons using different approaches and management, resulting in diffe rent outcomes. Initial replantation management significantly affects the la ter reconstruction. For comparing studies and prognostic implications, the authors propose a new classification according to the level of injury to mu scles and innervated nerves: type I, amputation at or close to the musculot endinous aponeurosis with muscles remaining essentially intact; type II, am putation within the muscle bellies but with the proximal muscles still inne rvated; type III, amputation involving the motor nerve or neuromuscular jun ction, thereby causing total loss of Muscle function: and type IV, amputati on through the joint; i.e., disarticulation of the elbow or shoulder joint. Some patients required further reconstruction for functional restoration a fter replantation, but some did not. Through this retrospective study based on the proposed classification system, prospective guidelines for the mana gement of different types of traction avulsion amputation are provided, inc luding the value of replantation, length of bone shortening, primary or del ayed muscle or nerve repair, necessity of fasciotomy, timing for using free tissue transfer for wound coverage, and the role of functioning free muscl e transplantation for late reconstruction. The final functional outcome can also be anticipated prospectively through this classification system.