Ethical considerations in elective amputation after traumatic peripheral nerve injuries

Abstract

SummaryTraumatic peripheral nerve injuries often complicate extremity trauma, and may cause substantial functional deficits. We have encountered patients who request amputation of such injured extremities, with the goal of prosthetic replacement as a means to restore function. Data on long-term outcomes of limb salvage vs amputation are limited and somewhat contradictory, leaving how to respond to such requests in the hands of the treating physician. We present example cases, drawn from our experience with wounded soldiers in a peripheral nerve injury clinic, in order to facilitate discussion of the ways in which these patients stress the system of medical decision-making while identifying ethical questions central to responding to these requests. P eripheral nerve injuries (PNI) are encountered in 2%-5% of all trauma patients, 1,2 but occur much more often in wartime, where up to 88% of trauma survivors have extremity injuries, 15%-25% of which involve the peripheral nerves. 3-10 Evaluation for traumatic PNI constitutes up to 3.7% of referrals for electrodiagnostic evaluation, 11 a percentage that is likely to increase as advances in battlefield medicine and body armor improve survival of combat trauma. 5,12

The Role of Amputation and Myoelectric Prosthetic Fitting in Patients with Traumatic Brachial Plexus Injuries

“…As prostheses advance to better meet the needs of injured extremities, we approach a nexus at which the potential benefits of reconstructive efforts must be carefully weighed against the benefits of amputation and prosthetic fitting 25 . Patients with traumatic BPIs for whom surgical reconstruction was unsuccessful experienced decreased mechanical pain, increased rates of employment, and a high rate of satisfaction following amputation.…”

Elective amputation of the upper limb is an option in the treatment of traumatic injuries of the brachial plexus?

“…Patients experiencing traumatic brachial plexus injuries still present with high levels of disability owing to limitations of the current surgical repair strategies. On the other hand, the evolution of prosthetic design has provided increasing restoration of function 15 , allowing some patients to return to some of their previous activities, with obvious psychosocial and physical benefits 16 . However, regardless of advances in prosthetic technology, elective amputation and prosthetic replacement of functionally impaired limbs is not a common practice 16 .…”

Disposalscapes: ‘Estranged’ Limbs after Amputation

“…While a fuller exposition of the rationales for elective amputations is beyond the scope of this article -the number of such procedures being small in the overall landscape of amputation surgery -they do provide an interesting case study into corporeal disruption and the role of choice and decision making by patients. Useful studies on the topic include Smith et al (2014) and Quon et al (2011). 2.…”