Do amputacji urazowej może dojść wskutek m.in. zmiażdżenia lub wyrwania kończyny. Palce, dłoń czy stopa mogą zostać całkowicie oddzielone od ciała albo pozostać z nim połączone np. pojedynczym płatem skóry. Niekiedy możliwe jest przeprowadzenie replantacji. Zależy to jednak od rodzaju i rozległości uszkodzeń tkankowych.
Amputacja urazowa polega na przerwaniu ciągłości tkanek i krążenia krwi na obszarze ciała umiejscowionym obwodowo od miejsca zadziałania czynnika zewnętrznego. Do większości amputacji urazowych dochodzi wskutek wypadków w zakładach pracy, w których korzysta się z maszyn przemysłowych oraz narzędzi i urządzeń tnących, takich jak siekiera czy piła tarczowa lub mechaniczna.
W przeważającej liczbie przypadków amputacje urazowe dotyczą palców dłoni oraz ręki na poziomie nadgarstka czy przedramienia.
U pacjentów, u których doszło do amputacji urazowych, niekiedy przeprowadza się replantację, która obejmuje odtworzenie ciągłości ścięgien, kości, nerwów oraz naczyń krwionośnych żylnych i tętniczych. Przy podejmowaniu decyzji o replantacji chirurg bierze pod uwagę to, w jaki sposób doszło do amputacji oraz jak głębokie są uszkodzenia tkankowe. Pozwala to określić prawdopodobieństwo powodzenia operacji oraz ryzyko powikłań.
Podział amputacji ze względu na stopień oddzielenia kikuta od amputowanej części ciała:
Amputacja całkowita
Amputacja całkowita to pełne oddzielenie części amputowanej kończyny od reszty kończyny. Według danych zgromadzonych przez polski Serwis Replantacyjny w latach 2017-2019 amputacja całkowita była najczęściej występującym rodzajem amputacji urazowych.
W przypadku amputacji całkowitej możliwe jest zastosowanie niedokrwienia zimnego. Metoda ta polega na zabezpieczeniu odciętej części ciała przed martwicą poprzez obniżenie jej temperatury. Dzięki temu można przeprowadzić replantację po upływie kilku, a nawet kilkunastu godzin od urazu.
Amputacja niecałkowita
W przypadku amputacji niecałkowitej uraz nie powoduje pełnego oddzielenia części kończyny od reszty ciała. Oznacza to, że część kończyny pozostaje połączona z ciałem np. pojedynczym płatem skóry.
U poszkodowanego, u którego doszło do niecałkowitej amputacji, nie można zastosować niedokrwienia zimnego. Jednocześnie jednak na tkance łączącej kikut z amputatem, czyli odciętą częścią ciała, mogą znajdować się mikroskopijne naczynia żylne. Ich obecność wspomaga rekonstruowany przez chirurga spływ żylny. Zwiększa to prawdopodobieństwo powodzenia replantacji.
Podział amputacji ze względu na mechanizm urazu
Amputacja gilotynowa
Amputacje gilotynowe często są skutkiem wypadków z użyciem takich narzędzi jak nóż, siekiera, gilotyna do cięcia metalu czy krajalnica.
W przypadku tego typu urazu po obu stronach cięcia pozostają równe i gładkie brzegi rany. U poszkodowanego w miejscu cięcia dochodzi do niewielkich uszkodzeń tkanek zarówno kikuta, jak i amputatu.
Replantacja przeprowadzana w przypadku tego typu urazu ma wysokie szanse powodzenia. Zespoleniu poszczególnych struktur sprzyja to, że kikuty tkanek umiejscowione są równo w brzegach rany.
Amputacja ze zmiażdżeniem
Do amputacji ze zmiażdżeniem może dojść podczas używania np. prasy, magla, tokarki czy frezarki.
U poszkodowanego dochodzi do stłuczenia i zmiażdżenia tkanek. W zależności od tego, czym spowodowany był uraz, stłuczeniu lub zmiażdżeniu może ulec zarówno odcięta część ciała, jak i kikut. Uszkodzenie tkanek może obejmować niewielką powierzchnię zbiegającą się z miejscem cięcia lub zajmować obszar szerszy niż sama płaszczyzna cięcia.
Zmiażdżenie może doprowadzić do miejscowego zniszczenia tkanek. W niektórych przypadkach zniszczeniu ulega cała amputowana kończyna. Urazy zmiażdżeniowe wiążą się ponadto z silnym zabrudzeniem tkanek, a tym samym obarczone są wysokim ryzykiem zakażenia rany. Są to jedne z najczęstszych przeciwwskazań do replantacji.
Amputacja awulsyjna
Do awulsji, czyli wyrwania części ciała np. ręki, może dojść podczas pracy z m.in. rębakiem do drewna czy podajnikiem ślimakowym.
W wyniku takiego urazu poszkodowany doznaje wielopoziomowego uszkodzenia tkanek, niekiedy na dużej odległości od miejsca rozerwania. W kikucie i amputowanej części kończyny pozostają zwisające fragmenty ścięgien i nerwów, które mogą mieć od kilku do kilkunastu centymetrów długości. Niejednokrotnie dochodzi także do skalpacji, czyli rozerwania tkanek miękkich przy jednoczesnym odsłonięciu kości.
W przypadku amputacji spowodowanych awulsją bardzo często nie podejmuje się decyzji o replantacji. Uszkodzenia tkanek, do których dochodzi wskutek wyrwania, wymagają bowiem przeprowadzenia zespoleń nerwów lub naczyń na wielu poziomach. Wiąże się to ze zwiększonym ryzykiem powikłań. Ponadto, jeżeli u pacjenta doszło do dużego ubytku tkanek miękkich, po wykonaniu rewaskularyzacji istnieje duże ryzyko infekcji.
Źródła: A. Chrapusta, „Modyfikacja metody replantacji palców w II strefie Verdana w amputacjach nie-gilotynowych”, Kraków-Wrocław 2017.
A. Żyluk, A. Chrapusta, J. Jabłecki, L. Romanowski, T. Mazurek, A. Domanasiewicz, „Raport z trzyletniej (2017–2019) działalności Serwisu Replantacyjnego dla amputacji rąk w Polsce”.
Przeczytaj także:
Specjaliści z CMKP przeprowadzili replantację ręki po urazie awulsyjnym
Przeczytaj bezpłatnie pokrewny artykuł w czasopiśmie „Chirurgia Plastyczna i Oparzenia”:
Złożona subtotalna amputacja kciuka z utratą szkieletu kostnego – opis przypadku
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