The treatment of major devascularizing injuries of the upper extremity

The most complex aspect of managing major devascularizing injuries is decision making. The decision to amputate or revascularize is not difficult in injuries that have extremely favorable or unfavorable outcomes. In less obvious cases, however, decision making can be extremely complex, and many factors influence the surgeon's decision. In borderline cases, the optimal decision may never become clear, even in hindsight, much less at the time of the initial surgery. Nor are the ramifications of these decisions trivial. The decision whether to attempt revascularization or perform a revision amputation can have a profound influence on the course of a patient's life. Despite the critical nature of these decisions, there are few firm data to guide the decision-making process in complex cases. In addition, there are a virtually infinite number of possible injury presentations, and each factor to be considered has shades and gradations of its own. Ultimately, the decision comes down to the surgeon's knowledge, experience, and ability to project the expected risk-benefit ratios of the various options and, at the same time, attempt to account for all the factors that may influence outcome. Where more than one reasonable option exists, the patient's or family's wishes can be a critical factor as well.