Avalanche Accident Resulting in Leg Amputation

To the Editor:

Amputation injuries are rarely seen in helicopter emergency medical services missions, and complete amputations even less so. ¹ Although it has been reported that the most frequently injured part of the lower limb for skiers is the knee, no case of amputation has yet been reported among 13,381 lower extremity skiing injuries. ² We recently had to face a dramatic avalanche accident resulting in complete traumatic leg amputation, which is the first case that we are aware of described to date.

A 43-year-old man was caught in an avalanche while ski touring on a frequently used itinerary. The slope was 40 to 45 degrees. He deployed his avalanche airbag by pulling its handle. He sustained only partial burial, and his companions were able to raise the alarm using a cell phone. A rescue helicopter winched a rescue doctor directly on site. The victim was conscious and reported pain in both legs, estimated at 8 out of 10. Primary survey revealed a complete amputation of the right leg and mild bleeding and an obvious fracture of the left. The patient’s heart rate was 67 beats/min and the respiratory rate was 17 breaths/min. Oxygen was provided through a nonrebreather mask, and hemoglobin saturation was measured at 99%. Fentanyl 100 micrograms and ketamine 20 mg were administered intravenously, and a tourniquet was placed on the right mid-thigh. The patient was immobilized on a spine board with a cervical collar and a left lower limb splint. He was then winched into the helicopter and airlifted to a hospital.

He remained hemodynamically stable on admission, with a pH of 7.29, lactate of 3.3 mmol/L, and hemoglobin of 133 g/L. A radiological survey revealed a complete open avulsion of the lower leg at the right knee and open left tibial and fibular fractures. The patient was taken to the operating room for revision of the amputation stump, and a modified Gritti-Stokes amputation was performed while the fractured left tibia was stabilized by an external fixator. The postoperative course was uneventful aside from moderate posttraumatic rhabdomyolysis with peak creatinine kinase levels at 11,748 U/L, without consequent acute renal failure.

After closed reduction and internal fixation of the left lower limb fractures, the patient was fitted with a molded right leg prosthesis and underwent multidisciplinary rehabilitation. At 1-year follow-up, full healing had occurred, and he had resumed his professional as well as his prior sport activities. He reported being satisfied with his quality of life and gave consent for his case to be used in a publication.

Although the cause of death of avalanche victims is usually asphyxiation after complete burial, ³ most victims who survive experience traumatic injuries.^4,5 Lower limb injuries predominate over upper limb injuries and occur in about one-third of avalanche victims. ⁵ According to a case series of 82 avalanche victims admitted alive to a hospital, 13% of the patients had lower limb fractures. ⁵

The site of the accident described was completely snow-covered and free of trees, rocks, or obstacles. We therefore presume that a twisting mechanism of the leg was responsible for its avulsion.