upper extremity amputation

Upper Extremity Amputation

Original Author: Andrew H. Schmidt, MD; March 2004

Revised by: David Fuller, MD; June 2006

Revised by: David Ring, MD PhD; February 2011

Amputation: Presentation Goals

• Etiology

• Techniques

• Prosthetics and Rehabilitation

Amputation: Etiology

• Trauma

• Burns

• Peripheral Vascular Disease

• Malignant Tumors

• Neurologic Conditions

• Infections

• Congenital Deformities

Etiology: Trauma

• 90% of Upper Extremity Amputation• Male:Female = 4:1• Most Amputations at level of Digit• Major Limb Amputations less common• Revascularization sometimes possible for

incomplete amputation• Replantation sometimes possible for

complete amputation

Etiology: Trauma

Etiology: Tumor

Etiology: Infection

Etiology: Gangrene/Necrotizing Fasciitis

Radiograph: Subcutaneous air throughout arm

Etiology:Failed Forearm Vascular Repair after trauma

Etiology: Vascular Disease

Ischemia after AV Fistula Procedure

Etiology: Crush

Etiology: Congenital

polydactyly

Etiology: Infarction associated with IV Drug Abuse

Etiology: Scleroderma

Amputation: Trauma and Replantation

• Candidates for Replantation after Trauma– 1. Thumb– 2. Multiple Digits– 3. Partial Hand– 4. Wrist or Forearm– 5. Above Elbow– 6. Isolated Digit Distal to FDS insertion– 7. Almost any part in child

Amputation: Trauma and Replantation

• Candidates for Replantation after Trauma– Clean cut– Limited crush– Limited contamination– Acceptable ischemia time

• 6 hours with muscle• 24 hours with digit

Replantation: Multiple Digits

Surgical Technique: Digit Replantation

• 1. Identify Vessels and Nerves• 2. Debride• 3. Shorten and fix bone• 4. Repair Extensor Tendon• 5. Repair Flexor Tendon• 6. Repair Arteries• 7. Repair Nerves• 8. Repair Veins• 9. Skin Closure (skin graft if necessary)

Amputation: Replantation

• Poor Candidates for Replantation– 1. Severely crushed or mangled parts– 2. Multiple levels– 3. Other serious injuries or diseases– 4. Atherosclerotic vessels– 5. Mentally unstable – 6. > 6 hours ischemic time– 7. Severe contamination

Amputation: Replantation

Mangled and Crushed – Poor Candidate

Ectopic “banking” of amputated parts

Ectopic “banking” of amputated parts

Indicated for extensive injuries with adequate amputated part in setting of contaminated or absent support structures.

Recipient sites described- anterior thorax, contralateral arm/leg, groin. High complication rate.

Largest and original series described by Marko Godina 1986.

Indicated for extensive injuries with adequate amputated part in setting of contaminated or absent support structures.

Recipient sites described- anterior thorax, contralateral arm/leg, groin. High complication rate.

Largest and original series described by Marko Godina 1986.

Courtesy: J. Higgins

Grip strength 80 # (unaffected side 100#)Injured right hand has remained dominant

hand

Surgical Technique: Major Limb Replantation

• Myonecrosis is greater concern than in digit replant• Immediate shunting to obtain arterial inflow may be

necessary• High Potassium levels (>6.5 mmol/l ) in venous

outflow from amputated part negative prognostic factor

• Sequence of repair similar to digit– Identify structures, Debride, Rapid bone stabilization,

Vascular repair (artery then veins), Tendons and Nerves

Upper vs Lower Limb

• Upper extremity nonweightbearing– Less durable skin acceptable– Decreased sensation better tolerated– Joint deformity better tolerated– Late amputations rare– Transplants now being performed

Major Limb Replantation

Include Surgical Prep of Legsfor vascular and nerve grafts

Rapid Bone StabilizationReady for Anastomosis

UE traumatic amputation may be associated with life threatening

hemorrhage

Courtesy of T. Higgins, M. Dietch

Aggressive resuscitation and limb repair

Courtesy of T. Higgins, M. Dietch

Amputation: Major Limb Replantation Outcomes

• >2/3 survival rate

• Can be a life threatening undertaking

• Multiple Surgeries often required– Late Nerve, Bone, Tendon Surgeries

• Function of major upper extremity replantations even though poor can be superior to prosthetic function

Outcomes: Major Limb Replantation

• Comparison of functional results of replantation versus prosthesis in a patient with bilateral arm amputation

Peacock, Tsai, CORR, 1987• Major amputation of the UE: Functional Results after

replantation/revascularization in 47 casesDaoutix et al, Acta Orthop Scand, 1995

• Major Replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcome study

Graham et al, J Hand Surg, 1998

Amputation: Technique

• Preservation of functional residual limb length

balanced with

• Soft tissue reconstruction to provide a well-healed, nontender, physiologic residual limb

Technique: Determination of Level

• Zone of Injury (trauma)

• Adequate margins (tumor)

• Adequate circulation (vascular disease)

• Soft tissue envelope

• Bone and joint condition

• Control of infection

• Nutritional status

Tumor

Forequarter Amputation

Necrotizing Fasciitis

Emergent Open Shoulder Disarticulation

Trauma

High TranshumeralNerves Avulsed

from High in Plexus

Failed Vascular Repair

Transradial

Levels of Amputation

• Wrist Disarticulation vs. Transradial– Disarticulation offers potential of better active

pronation and suppination of forearm– Transradial often difficult to transmit rotation through

prosthesis– Disarticulation poor aesthetically– Disarticulation more difficult to fit prosthetic– Transradial needs to be done 2 cm or more proximal to

joint to allow prosthetic fitting– Transradial usually favored

Levels of Amputation

• Transhumeral vs. Elbow Disarticulation– Adults: Elbow disarticulation allows enhanced

suspension and rotation control of prosthesis however retention of full length precludes use of prosthetic elbow. Long transhumeral favored

– Pediatrics: Transhumeral amputation results in high incidence of bony overgrowth. Elbow disarticulation is level of choice. Humeral growth slowed after trauma.

Levels of Amputation

• Preservation of Elbow function is a priority– Consider replantation/salvage of parts to

maintain elbow function– 4-5 cm of proximal ulna necessary for elbow

function– For very proximal amputations, it may be

necessary to attach bicep tendon to ulna

Techniques

• Debridement of all Nonviable tissue and foreign material

• Several debridements may be required• Primary wound closure often contraindicated• High voltage, electrical burn injuries require

careful evaluation because necrosis of deep muscle may be present while superficial muscles can remain viable

Techniques

• Nerve: Prevent neuroma formation– Draw nerve distally, section it, allow it to

retract proximally

• Skin: – Opportunistic flaps– Rotation flaps– Tension free– Skin grafts

Techniques

• Bone:– Choose appropriate level– Smooth edges of bone– Narrow metaphyseal flare for some

disarticulations

Postoperative Dressing:– Soft– Rigid

Techniques

• Goals of Postoperative Management– Prompt, uncomplicated wound healing– Control of edema– Control of Postoperative pain– Prevention of joint contractures– Rapid rehabilitation

Technique: Example

30 yo male, assault

Technique: Example

Be sure to identify all injuries and treat

ray amputation

Technique: Example

1 year postop

Technique: Example

debridement and preservation of viable structure

Technique:Example

Late reconstruction after initial amputation surgery

Rehabilitation and Prosthetics

Rehabilitation

• 1. Residual Limb Shrinkage and Shaping

• 2. Limb Desensitization

• 3. Maintain joint range of motion

• 4. Strengthen residual limb

• 5. Maximize Self reliance

• 6. Patient education: Future goals and prosthetic options

Psychological Adaptation

• Amputation represents loss of function, sensation and body image

• Psychological response is determined by many variables– Psychosocial/Age– Personality– Coping Strategies– Economic/Vocational– Health– Reason for amputation

Psychological Adaptation

• Up to 2/3 of amputees will manifest postoperative psychiatric symptoms– Depression– Anxiety– Crying spells– Insomnia– Loss of appetite– Suicidal ideation

Psychological Adaptation: Stages

• 1. Preoperative– Tumor, Vascular Disease, Chronic Infection– Support Groups

• 2. Immediate Postoperative– Hours to days– Safety, Pain, Disfigurement

• 3. In-Hospital Rehabilitation• 4. At-Home Rehabilitation

In-Hospital Rehabilitation

• Initial: concerns about safety, pain, disfigurement• Later: emphasis shifts to social reintegration and

vocational adjustments

• Grief Response:– 1. “numbness” or denial– 2. yearning for what is lost– 3. Disorganization: all hope is lost for recovery of lost

part– 4. Reorganization

Management of Amputee

• Preparation

• Good Surgical Technique

• Rehabilitation

• Early Prosthetic Fitting

• Team Approach

• Vocational and Activity Rehabilitation

Prosthetics• Passive

– Cosmetic

• Body Powered– Harnesses and cables

• Myoelectric– Surface EMG– Activation delay

• Neuroprosthetics– Investigational at this time

Rehabilitation

Suggested timeline for transradial amputation

• 1-14 days: immediate postop prosthesis

• 2-4 weeks: training body powered prosthesis

• 6-12 weeks: definitive body powered prosthesis

• 6-12 weeks: training electronic prosthesis

• 4-6 months: definitive electronic prosthesis

Acknowledgement

Review Articles for Reference1: Tintle SM, Baechler MF, Nanos GP 3rd, Forsberg JA, Potter BK. Traumatic and

trauma-related amputations: Part II: Upper extremity and future directions. J

Bone Joint Surg Am. 2010 Dec 15;92(18):2934-45. Review. PubMed PMID: 21159994.

2: Muilenburg TB. Prosthetics for pediatric and adolescent amputees. Cancer Treat

Res. 2009;152:395-420. Review. PubMed PMID: 20213404.

3: Jones NF, Schneeberger S. Arm transplantation: prospects and visions.

Transplant Proc. 2009 Mar;41(2):476-80. Review. PubMed PMID: 19328907.

4: Buncke GM, Buncke HJ, Lee CK. Great toe-to-thumb microvascular transplantation

after traumatic amputation. Hand Clin. 2007 Feb;23(1):105-15. Review. PubMed

PMID: 17478257.

5: Hanel DP, Chin SH. Wrist level and proximal-upper extremity replantation. Hand

Clin. 2007 Feb;23(1):13-21. Review. PubMed PMID: 17478249.

Review Articles for Reference6: Tamurian RM, Gutow AP. Amputations of the hand and upper extremity in the

management of malignant tumors. Hand Clin. 2004 May;20(2):vi, 213-20. Review.

PubMed PMID: 15201025.

7: Moran SL, Berger RA. Biomechanics and hand trauma: what you need. Hand Clin.

2003 Feb;19(1):17-31. Review. PubMed PMID: 12683443.

8: Breidenbach WC 3rd, Tobin GR 2nd, Gorantla VS, Gonzalez RN, Granger DK. A

position statement in support of hand transplantation. J Hand Surg Am. 2002

Sep;27(5):760-70. Review. PubMed PMID: 12239664.

9: Shatford RA, King DH. The treatment of major devascularizing injuries of the

upper extremity. Hand Clin. 2001 Aug;17(3):371-93. Review. PubMed PMID: 11599207.

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