Elbow/Forearm Wounds/Amputations

Wounds occurring in the forearm and elbow must be treated as an emergency because the risk of infection if left open increases about 7 hours after an injury has occurred.


Wounds occurring in the forearm and elbow must be treated as an emergency.

Injuries open for 7 hours or longer have increased risk of infection. If a wound presents after 7 hours, closure of the wound is not advised, especially if the wound results from an animal bite.

When a wound is evaluated, the type of instrument or weapon making the wound must be inquired about. When the patient’s last tetanus shot was given is important to know so a booster can be applied if necessary. The depth of the wound and type of bleeding witnessed is also important.

Types of Bleeding

  • Partial vessel laceration – Continues to bleed in spite of pressure being applied
  • Arterial laceration – Spurts blood, indicating an artery has been cut

When an open wound presents to an emergency room, the examination of active elbow, forearm and digital motion is evaluated to determine if a muscle, tendon or motor portion of a nerve has been cut. The sensation of the fingers is also checked to see if the nerves have been cut.

An amputation is the severing of a body part. Classifying Amputations:

  • Partial
  • Complete
  • Clean cut
  • Crushing
  • Avulsion – The amputated limb is pulled right off of the body. The avulsion amputation has the worse prognosis because the zone of injury is very wide.

When an amputation occurs from the mid-palm to the level of the shoulder, it is a true emergency. The limb must be replanted in no more than 4-6 hours with warm ischemia. The time can be extended to 8 hours if it is cold ischemia (when the part is placed in an ice bath) after injury. The oxygen demands and metabolism of the muscles is high, causing tissue death, or necrosis, if the blood supply is not restored within this time period.

The necrotic changes taking place in the amputated part, which lacks oxygen, will cause a dumping of necrotic material into the bloodstream.

This causes a systemic collapse called Disseminated Intravascular Coagulation (DIC), putting the replantation patient’s life at risk. If this occurs, the amputated part must be removed.

Amputations from mid-palm to fingers have more time to be replanted because less muscle is found in this area. Time to successfully replant fingers can be as long as 15 hours post amputation because no muscle is present, but the sooner the replantation is done, the better.


The treatment of an open wound begins with obtaining a clear history.

Patient History Must:

  • Determine the lacerating instrument
  • The position of the arm and hand during the laceration
  • The direction and depth of the laceration

The exam will confirm the injured tissue and the history will provide the direction the wound should be extended during surgical exploration.

The cleaning of the wound, repair of muscle, artery and tendon is done with the use of a microscope. The improved magnification allows for accurate approximation of the injured tissue.

Tetanus shot is updated if it has been longer than 10 years. For a dirty wound, the tetanus must be no longer than five years current. This avoids the danger of acquiring gas gangrene, a deadly infection from the organism, clostridium perfringens.

For one week after the repair, oral antibiotics covering skin flora are used to avoid the risk of infection.

If the wound is a farm injury or dirty, penicillin is also used to cover clostridium perfringens.

When the wound was caused by a dog bite, the use of antibiotics covering animal flora like pasturella multicida, pseudomonas, staphylococcus and streptococcus must be used.

Human bites, as in a clenched fist injury, also require antibiotics covering eikenella corrodens like augmentin.

The treatment of an amputation starts immediately after the amputation is sustained. The amputated part must be immediately wrapped in saline moistened gauze and placed in ice slush. Ice slush is made by crushing ice in a zip lock plastic bag and put in a cooler. The amputated part can then be transported to ROC for replantation.

Upon arriving at ROC’s emergency facility, the patient is prepared for surgery while the amputated part is taken to the operating room, cleaned and dissected out under a microscope to prepare for replantation.

Replantation is typically successful with amputations beginning at the base of the nail and more proximal amputations towards the shoulder.

Successful replantations are related to the size of the arteries and veins which become too small to repair if it is beyond the nail base.

Steps of Replantation

  • First, the bone is fixed
  • Second, the tendons are repaired
  • Third, the nerve(s).
  • Whether the arteries or veins are fixed next is surgeons’ choice. Fixing veins first can prevent excessive bleeding. While fixing the arteries first can allow easier visualization of the veins

The results of replantations performed from the level of the forearm to the shoulder are more functional if:

  • Patients is younger than 15 years of age, beacuase of better nerve regrowth potential
  • Amputation is a clean cut
  • The part is brought for replantation immediately

Partial amputations with the skin still attached should be left attached since valuable blood supply may be provided by the retained tissue.

With avulsion type amputations, which is a pulling injury, or a severe crush injury, the likelihood of a successful replantation is significantly less.

Special splints are applied after surgery to avoid certain movements that might damage a repair performed. The injured extremity must be elevated to at least heart level to avoid swelling of the limb. Limb swelling causes moderate pain, cuts off the blood supply and delays wound healing if allowed to occur.

Regardless of the type of amputation, it is advisable to bring in the amputated part immediately for the surgeon to examine.

The surgeon can assess the likelihood of replantation success or may use the tissue from the amputated limb as donor tissue to treat the wound base where the amputation occurred.