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
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Trauma
Burns
Peripheral Vascular Disease
Malignant Tumors
Neurologic Conditions
Infections
Congenital Deformities
Etiology: Trauma
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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
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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
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Clean cut
Limited crush
Limited contamination
Acceptable ischemia time
• 6 hours with muscle
• 24 hours with digit
Replantation: Multiple Digits
Surgical Technique: Digit
Replantation
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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
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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
 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
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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 Legs
for vascular and nerve grafts
Rapid Bone Stabilization
Ready 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 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
Amputation: Technique
• Preservation of functional residual limb length
balanced with
• Soft tissue reconstruction to provide a wellhealed, nontender, physiologic residual limb
Technique: Determination of
Level
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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 Transhumeral
Nerves 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:
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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
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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
ray amputation
Be sure to identify all injuries and treat
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
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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
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Psychosocial/Age
Personality
Coping Strategies
Economic/Vocational
Health
Reason for amputation
Psychological Adaptation
• Up to 2/3 of amputees will manifest
postoperative psychiatric symptoms
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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
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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 Reference
1: 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 Reference
6: 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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