is the removal of the upper limb in the interval between the scapula and the chest wall
Mainly for malignancy
Anterior (Berger) vs posterior (Littlewood)
Difficult skin flaps
ref: Littlewood " Amputations at the shoulder and the hip" Br Med J 1: 381, 1922
- Racquet incision from tip of coracoid, along ant deltoid ,over deltoid insertion laterally, along post deltoid to post axillary fold, then back across the axilla to the ant side
- Ligate cephalic vein
- Reflect pectoralis major off its insertion
- Locate neurovascular structures in interval between coracobrachialis and pectoralis minor
- Ligate axillary artery and divide nerves under gentle tension allowing them to retract
- Reflect deltoid off its insertion and divide latisimus dorsi and teres major near the bicipital groove
- Divide biceps and triceps tendons 2cm distal to the level of bony resection (at origin of disarticulation)
- For proximal amputation
- Resect bone at desired level
- then suture the LHT, LHB + SHB, and coracobrachialis over the end of the humerus and swing pec major laterally and suture to the end of the bone
- For disarticulation
- divide capsule and rotator cuff
- then reflect the cut ends of all the muscles over the glenoid and suture them there - and secure muscle ends over the glenoid cavity
- then bring the deltoid flap inferiorly and suture just inferior to the glenoid
- Trim coracoid if too prominent
- Close skin over drains
Above Elbow Amputations
Use equal anterior and posterior flaps.
Divide flexors 1.3cm below the level of bony resection, and the triceps 4cm below the bony resection.
Suture triceps to anterior fascia.
Use equal anterior and posterior flaps with the apices at the level of the humeral condyles and flap extending 2.5cm distal to the olecranon posteriorly and to level of insertion of biceps tendon anteriorly.
Free muscle attachments to medial and lateral condyles
Ligate nerves under tension
Leave the articular surface intact and suture triceps tendon to brachialis, and remnant of flexors to extensors.
Close flaps over drains
Below Elbow Amputations
Fish mouth equal anterior and posterior flaps about 1/2 the diameter of the arm at the level of the amputation.
Myoplastic closure suturing FDS to the extensor group.
High functional level
Rotation proportional to residual length
Good for myoelectric implants
- Separate radial and ulna rays distally -> radial and ulna pincers capable of strong prehension and excellent manipulative ability.
- Especially useful for blind patients with bilateral BEA's but may be of some use in other amputees as well.
Preserves forearm rotation
Flare of distal radius improves prosthetic suspension
Difficult prosthetic fitting due to length
Fish mouth starts 1.3cm proximal to radial styloid
Resect radial and ulna styloids' without damage to distal radio-ulna joint and triangular fibro- cartilage.
Tendons are divided and allowed to retract.
Results in limited pronation and supination, flexion and extension preserved.
Use a long palmar and short dorsal fish mouth flap (2:1)
Suture tendons over the ends of the carpus
Preserve length, function, sensation
Primary amputation for irreversible loss of blood supply and tumours.
Other fingers involved
Delaying (use of parts)
Distal to PIPJ
Proximal to base Mc
Avoid damage to digital nerve
Reinsert 1st dorsal interosseous into prox phalanx of long finger
Ring/Middle Finger Amputation
Preserve proximal phalanx
Suture transverse ligaments
Consider metacarpal transfer
Upper Limb Prosthetics (also see Prosthetics Summary)
Position hand in space
Limb length and joint salvage are directly related to functional outcome
Sensation important for function (cf lower limb)
Early fitting (85% if in 30 days, 50% with late fitting)
Proximal humeral amputations behave like a shoulder disarticulation, but better cosmesis and suspension
Prostheses provide a post, and cosmesis
Elbow/ Humeral Amputation
Better suspension with elbow disarticulation but poor cosmesis
Better function with distal humeral amputation (3.5 cm proximal to elbow)