Amputations & prosthetics of the upper limb

Forequarter Amputation

• 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

Shoulder disarticulation

1. 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
2. Ligate cephalic vein
3. Reflect pectoralis major off its insertion
4. Locate neurovascular structures in interval between coracobrachialis and pectoralis minor
5. Ligate axillary artery and divide nerves under gentle tension allowing them to retract
6. Reflect deltoid off its insertion and divide latisimus dorsi and teres major near the bicipital groove
7. 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
  1. divide capsule and rotator cuff
  2. then reflect the cut ends of all the muscles over the glenoid and suture them there - and secure muscle ends over the glenoid cavity
  3. then bring the deltoid flap inferiorly and suture just inferior to the glenoid
  4. 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.

Elbow disarticulation

• 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

• Preserve Length

• 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.
  

Transradial Amputation

• High functional level

• Rotation proportional to residual length

• Good for myoelectric implants

Krukenberg procedure

• 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.
  

Wrist disarticulation

• 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.

Transcarpal

• 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
  

Hand Amputations

• Preserve length, function, sensation

• Salvage procedure

• Primary amputation for irreversible loss of blood supply and tumours.

• Consider:

  • Ultimate function

  • Other fingers involved

  • Delaying (use of parts)

• Salvage thumb

Fingertip

• 2' intention

• VY Atasoy/Kutler

• Skin graft

• Thenar flap

Finger Amputation

Index

• 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

• Close gap

  • Suture transverse ligaments

  • Consider metacarpal transfer

Thumb Amputation

• Preserve:

  • Length

  • Stability

  • Sensation

  • Mobility

  • Cosmesis

• Closure:

  • 2' intention

  • Graft

  • Reconstruction

  • Toe transfer

  • Pollicization

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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)

• Shoulder Amputations

  • 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)