Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, Denver, CO.
Division of Psychiatry, Denver Health Medical Center, Denver, CO.
J Hand Surg Am. 2023 Oct;48(10):993-1002. doi: 10.1016/j.jhsa.2023.06.011. Epub 2023 Aug 15.
Clinicians assessing patients with deliberate self-inflicted amputations face a problem of whether or not to replant. The objective of this study was to summarize the literature on this topic and provide recommendations regarding the acute management of patients following self-inflicted amputations in the upper extremity.
Two reviewers searched four databases using the keywords "Upper extremity," "Amputation," and "Self-Inflicted." The reviewers systematically screened and collected data on publications reporting cases of self-inflicted upper-extremity amputations. The findings then were summarized in a narrative fashion.
Twenty-four studies were included. Twenty-nine cases of self-inflicted upper-extremity amputations were reported. There were 25 unilateral and four bilateral extremity amputations. Amputations were most commonly at the hand/wrist (18 patients) and forearm level (6 patients). The amputations were most commonly performed with a saw (9 patients) or a knife (8 patients). Reasons for amputation included psychosis (10 cases), suicide attempt (7 cases), depression (5 cases), and body integrity identity disorder (four cases). Fifteen replantations were performed; all were successful. Reasons for not pursuing replantation were related to injury factors (ie, multilevel injury, prolonged ischemia, damaged part) rather than patient-level factors. Two patients with replantable extremities declined replantation, both of whom had body integrity identity disorder. Of the patients who underwent replantation, none expressed regret.
The literature shows that patients experiencing psychosis or depression committed self-harm during an acute psychiatric decompensation, and once medically and psychiatrically stabilized, expressed satisfaction with their replanted limb. Surgeons should not consider psychiatric decompensation a contraindication to replantation and should be aware of patients with body integrity identity disorder who consciously may elect to undergo revision amputation. When presented with patients experiencing psychiatric decompensation who refuse replantation/are not competent, surgeons should seek emergency assistance from the psychiatry team to determine the best management of a self-inflicted amputation.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapy/Prevention/Etiology/Harm V.
评估蓄意自伤性截肢患者的临床医生面临着是否进行再植的问题。本研究的目的是总结这一主题的文献，并就上肢自伤性截肢患者的急性处理提供建议。
两位审稿人使用“上肢”、“截肢”和“自伤”这三个关键词在四个数据库中进行搜索。审稿人系统地筛选和收集了报告自伤性上肢截肢病例的出版物数据。然后以叙述的方式总结发现。
纳入了 24 项研究。报告了 29 例自伤性上肢截肢病例。有 25 例为单侧，4 例为双侧肢体截肢。截肢最常见于手部/腕部（18 例）和前臂水平（6 例）。截肢最常见的工具是锯（9 例）或刀（8 例）。截肢的原因包括精神病（10 例）、自杀未遂（7 例）、抑郁症（5 例）和身体完整性认同障碍（4 例）。进行了 15 例再植术，均成功。不进行再植的原因与损伤因素有关（即，多水平损伤、长时间缺血、受损部位），而不是与患者因素有关。有 2 例可再植的肢体的患者拒绝再植，均患有身体完整性认同障碍。接受再植术的患者中，无一人表示后悔。
文献表明，患有精神病或抑郁症的患者在急性精神失代偿期间进行了自残，一旦在医学和精神上稳定下来，他们对再植肢体表示满意。外科医生不应将精神失代偿视为再植的禁忌症，应了解有意识地选择接受修正性截肢的身体完整性认同障碍患者。当遇到拒绝再植/无能力的经历精神失代偿的患者时，外科医生应向精神科团队寻求紧急援助，以确定对自伤性截肢的最佳处理。
研究类型/证据水平：治疗/预防/病因学/伤害 V。
