Elbow disarticulation

Dr. G A JoshiAP(PMR/ME)CRC-Bhopal

Topics

• Background• The Level• Statistics• Causes• Management• Surgical issues• Prosthetic Components• Functional restoration

Background

• Upper limb is the prehensile organ for human beings

• Elbow ROM of 0o-150o provides versatile reach combining with shoulder and wrist

• Wars have given the most amputees. • Army has developed most of prosthetics

(www.indianarmy.gov.in/writereaddata/Documents/165.pdf)

The level of elbow disarticulation

Advantages• Permits normal bone growth

in children• Faster bloodless surgery • Good suspension• Good rotational control• More functional than

transhumeral esp. in bilateral amputees

• Bilateral cases can use pencil for writing

Disadvantages• Poor Cosmesis• Less durable prosthetic

elbow joints

Statistics

• 5 per thousand (1996 USA) cases have Upper limb amputations

• Men in 15-45 age group• Amputation of Lower Limb is far more

common than Upper Limb with UL:LL=1:6• Congenital deficiency of Upper Limb is

commoner than Lower Limb

Causes

• Congenital limb deficiency • Trauma – machine, road/rail, electric-burn• Neoplastic• Vascular – Thromboangiitis obliterans, Tropical

Diabetic Hand Syndrome, Frostbite• Infection – Necrotizing Fasciitis

Management

• Conservative - thermal burns/frostbite• Surgical – Embolectomy– Fasciotomy– Reimplantation of transhumoral limb usually gives

functional elbow but poor hand function– Amputation– Allograft (esp. in Blind)

Phases of rehabilitation

• Preoperative• Surgery/reconstruction• Acute post-surgical• Pre-prosthetic

• Prosthetic prescription and fabrication

• Prosthetic training• Community integration• Vocational

rehabilitation• Follow up

Evaluation

• ROM and strength of shoulder• Vitality testing – clinical, Tc99mPyP nuclear

scan• Manage any proximal bony or soft tissue

injuries• Avoid multiple surgeries/revision amputation

as it will delay rehabilitation and thus reduce effective use of prosthesis

Surgery

• Tourniquet is useful but contraindicated in – Cancer– Infection

• Skin and flaps– Equal anteroposterior flaps – Unconventional flaps like forearm extensor flap

may be brought at medial epicondyle (where skin is thinnest) except in oncological cases

Soft tissue cover Do NOT keep excess soft tissue

Surgery

• Bone – May reduce epicondylar prominances in moderation– Do not disturb articular cartilage

• Muscles – Retain muscles esp. for myoelectric prosthesis– Myoplasty gives firm residual limb, helps shoulder

control and improved EMG for myoelectric control– Pectoralis cineplasty was used for elbow control in

past

Surgery

• Nerves – Withdraw, cut sharp and allow to retract in soft tissue. – Median and Ulnar nerves may be cut at different level

• Blood vessels– Double ligation of major blood vessels– Hemostasis and muscle tension managed after deflating

tourniquet• Drain is essential for – Hematoma prevention– Fast wound healing

Early prosthetic fitment

• Golden period of 30 days• Reduces edema• Facilitates fast healing• Reduces pain• Enhances prosthetic use• Early return to activities esp. two handed

grasping patterns

Prosthetic components

• Flat bulbous socket with snug fitting gives good rotational control and self suspension

• External elbow joints• Harness is Northwestern figure of 8 type or shoulder

saddle and chest strap• Control system has 2 cables –– Elbow lock control on medial prosthetic elbow joint– Elbow flexion (when elbow is unlocked) cum terminal

device operation (when elbow is locked)

Socket

• Leather socket• Soft insert with

supracondylar wedge• Window with cover

plate (photo)• Flexible bladder variant• Screw in type sockets

(sketch)

Socketless design

•Mediolateral framework•Supracondylar pads•Straps

Prosthetic Elbow Joints

• Outside locking elbow hinges• 0-135 ROM• 3 sizes• 5-7 locking positions

Harness system

• Standard figure of 8 – – Operated by non-

amputated side– Cross point below C7

and slightly toward non-amputated side

• Shoulder saddle and chest strap– Operated by amputated

side

Terminal Devices

• Passive (Mitts)• Cosmetic• Functional• Hook• Greiffer• Myoelectric• Microchip controlled

Functional restoration

• Comfort fit• Perceived value• Follow up– Adjusting socket to limb volume change– Mastering functions of the prosthesis– Re-evaluation and re-design of prosthesis as per

changing needs of patient

THANK YOU