4. Etiology: Trauma
• 90 % of Upper Extremity Amputation
• Male:Female = 4:1
• Most Amputations at level of Digit
• Major Limb Amputations less common
• Revascularization possible for incomplete
amputation
• Replantation possible for complete
amputation
15. 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
20. 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
21. 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
22. Major Limb Replantation
Include Surgical Prep of Legs
for vascular and nerve grafts
Rapid Bone Stabilization
Ready for Anastomosis
23. 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 superior to prosthetic function
24. 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 cases
Daoutix 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
25. Amputation: Technique
• Preservation of functional residual limb length
balanced with
• Soft tissue reconstruction to provide a well-
healed, nontender, physiologic residual limb
26. 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
31. 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
32. 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.
33. 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
34. 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
36. Techniques
• Bone:
– Choose appropriate level
– Smooth edges of bone
– Narrow metaphyseal flare for some
disarticulations
Postoperative Dressing:
– Soft
– Rigid
37. Techniques
• Goals of Postoperative Management
– Prompt, uncomplicated wound healing
– Control of edema
– Control of Postoperative pain
– Prevention of joint contractures
– Rapid rehabilitation
44. 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
45. 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
46. Psychological Adaptation
• Up to 2/3 of amputees will manifest
postoperative psychiatric symptoms
– Depression
– Anxiety
– Crying spells
– Insomnia
– Loss of appetite
– Suicidal ideation
47. 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
48. 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
49. Management of Amputee
• Preparation
• Good Surgical Technique
• Rehabilitation
• Early Prosthetic Fitting
• Team Approach
• Vocational and Activity Rehabilitation
53. Return to
Upper Extremity
Index
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