Overview
Wrist Shoulder
- transcarpal - NOH
- wrist disarticulation - shoulder disarticulation
Forearm
- distal 1/3 Forequarter
- proximal 1/3 - anterior / posterior approach
Elbow disarticulation
Above elbow
- supracondylar level
- proximal to supracondylar level
General
- all possible length should be preserved consistent with clinical judgement
- function of amputated stumps decrease progressively with each higher level of amputation
- almost any well-constructed, well healed, and satisfactory padded stump can be fitted with a prosthesis that should function in an excellent manner.
- prosthetic rejection by patient increases with the more proximal amputations
- “golden period” for fitting - 6 weeks
- most ADL’S can be performed adequately with one limb, so don’t use prosthesis
- disadvantages of prosthetic use may outweigh advantages in high level amputees
- all nerves are drawn distally into wound & sectioned so they retract well proximally to bone level of amputation, so not to form painful neuroma
- transcarpal amputation or wrist disarticulation is preferable to forearm amputation.
- preserve distal radioulnar joint and hence supination/ pronation preserved
- 50 % of pronation or supination is transmitted to prosthesis.
- Has long lever arm which increases power and ease of wrist prosthesis
- retains distal radial flare which improves prosthetic suspension.
Indications
- 4 D’s
- dead / dying / dangerous / damn nuisance
1. Transcarpal
Concept
- no advantage in retaining carpal bones over wrist disarticulation.
- can preserve flexion / extension of radiocarpal joint which transmitted partly to prosthesis
Technique
- fashion long palmar, short dorsal flaps in ratio (2:1) with apices to carpus level.
- divide tendons under tension, nerves well proximal to amputation and vessels just proximal to amputation bony level
- divide bones and smooth / round edges
- anchor wrist flexor and extensor tendons to remaining carpal bones in line of pull to allow wrist flexion/extension.
2. Wrist disarticulation
Technique
- fashion long palmar, short dorsal flaps (2:1).
- skin apices 1.3cm. distal to ulnar and radial styloids.
- divide vessels, nerves, tendons and open radiocarpal joint.
- resect radial / ulnar styloid processes & smoothen bony processes to form a smooth rounded contour
- protect distal radioulnar joint including triangular ligament to preserve supination/ pronation
- insert suction drain and skin closure
3. Forearm
- preserve as much length as possible (forearm rotation and strength proportional to length retained
- if circulation compromised, amputation through distal 1/3 forearm are less likely to heal satisfactory than at a more proximal level (ie junction middle / distal 1/3)
- Distally skin is thin and subcutaneous tissue scant
- Distally underlying tissues are relatively avascular structures such as tendons / fascia
- junction mid and distal thirds good compromise for amputation level.
- short ‘below elbow stump’ (up to 3.8-5cm long) preferable to through or above elbow.
- important to preserve elbow joint
- prosthetic use sustained in approximately 70%.
- often split socket / may need step-up hinges
Distal
- skin incision apices at level of bone cut.
- fashion equal length volar and dorsal flaps approx. ½ diameter of forearm at amput level .
- ligate radial / ulnar arteries and divide nerves under tension then transverse bone cuts and rasp edges.
- myoplastic closure maybe desirable
- fashion FDS flap long enough to be carried around bone ends
- section rest of muscles at level of bone
- suture FDS flap over dorsal fascia
Proximal third
- Fashion equal volar and dorsal flaps ideally
- divide muscle bellies distal to bone cuts to allow for retraction.
- transverse bone cuts and rasp edges.
- if stump is proximal to bicipital radial tuberosity, then resect distal 2.5cm. of biceps tendon (technique of Blair / Morris)
- This lengthens stump functionally and enhances prosthetic fitting.
- leaves Brachialis as principle elbow flexor
Krukenburg’s Amputation
- performed as a secondary procedure in ‘below elbow’ amputation.
- converts forearm amputation into radial and ulnar pincers.
- need at least 10cm. from olecranon tip & elbow flexion contracture <70 deg.
- classically used in blind bilateral below elbow amputee.
4. Elbow disarticulation
- good level for amputation due to easy fitting of prosthesis to distal humeral flare
- thus allowing transmission of humeral rotation to the prosthesis (preferable to a more proximal humeral amputation)
- due to modern prosthesis techniques, disarticulation is preferred to prox. humeral amputation
Technique
- equal anterior and posterior flaps with apices at level of humeral epicondyles.
* posterior flap extents 2.5cm. distal to olecranon tip.
* anterior flap extends just distal to biceps tendon insertion.
- divide lacertus fibrosis.
- reflect distally flexor origin off medial epicondyle.
- to expose Neurovascular bundle on medial side of biceps tendon
- divide brachial artery, median and ulnar nerves proximal to elbow joint.
- free the insertions of biceps and brachialis from radius / ulna.
- divide radial nerve as lies between brachialis and B/radialis
- divide transversely extensor mass 6.3cm. distal to joint line.
- divide posterior fascia and triceps tendon near tip of olecranon.
- divide anterior joint capsule to complete the disarticulation & remove the forearm
- leave intact articular cartilage of humerus
- suture triceps tendon anteriorly to biceps and brachialis.
- suture extensor muscle mass medially to flexor origin muscle stump.
5. Above Elbow
- most important to preserve limb length.
- transcondylar amputation fits as elbow disarticulation
- amputation proximal to axillary fold functions really as shoulder disarticulation however retains cosmetic contour of shoulder
- occasionally selected for management of a useless arm post brachial plexus injury.
- above elbow prosthesis must include :-
* Elbow-lock mechanism stabilises joint in full extension, flexion or in a position between.
o lock mechanism extends 3.8cm distally from the end of the prosthetic socket and should be level with the other side elbow.
o therefore most distal bone section should be 3.8cm from end of humerus to allow room for this mechanism.
* elbow turntable substitutes for humeral rotation
Supracondylar level
- equal anterior and posterior flaps at length ½ diameter of arm at that level.
- artery and nerve divided proximal to level of resection
- divide anterior compartment muscle flaps 1.3cm. distal to bone section level so they retract to this level.
- free triceps insertion off olecranon & preserve as a long flap.
- transverse bone cut 3.8cm. proximal to humerus end and rasp edges.
- suture long flap of triceps anteriorly to the fascia over anterior muscles.
Proximal to supracondylar level
- equal anterior and posterior flaps, slightly greater than ½ arm diameter.
- divide anterior compartment muscles 1.3cm. distal to bone cut to allow retraction.
- divide triceps 3.8-5cm. distal to bone cut and bevel tricep muscle into thin flap
- suture triceps anteriorly over bone end to anterior muscle fascia.
6. Shoulder amputations
- shoulder amputation levels require fitting as if for joint disarticulation.
- Prosthetic function is so severely impaired at shoulder level that the prostheses are used primarily as a holding device when performing activities with both hands.
Through surgical neck
- patient supine with sandbag beneath shoulder (patient’s back 45 degrees to table)
- incision from coracoid process, along anterior deltoid border to its insertion, along posterior deltoid border to posterior axillary fold
- connect the two limbs of incision by a second incision that passes through axilla then incise anteriorly through axilla.
- ligate cephalic v., separate deltoid and pectoralis major in deltopectoral groove.
- reflect deltoid laterally.
- divide pectoralis tendon at its insertion and reflect medially.
- develop plane between pectoralis minor and C/brachialis to expose neurovascular bundle
- divide axillary artery and vein inferior to pectoralis minor
- divide (M, R, U, M-C) nerves on stretch so they retract proximal to pectoralis minor
- divide deltoid insertion and reflect deltoid / lateral skin flap superiorly.
- divide teres major and latissimus dorsi at bicipital groove.
- divide short and long heads of biceps, triceps and coracobrachialis 1.9cm. distal to bone cut. & section bone at surgical NOH
- suture long head triceps, both heads biceps and coracobrachialis over end of humerus
- suture pectoralis major tendon to bone end.
- bevel deltoid to allow skin closure
Shoulder disarticulation
- patient supine with sandbag beneath shoulder (patient’s back 45 degrees to table)
- incision as for neck of humerus.
- ligate cephalic v.
- separate deltoid and pectoralis major.
- retract deltoid laterally, divide pectoralis major tendon at insertion and reflect medially.
- develop plane between pectoralis minor and C/brachialis to expose neurovascular bundle
- ligate axillary artery and vein and thoracoacromial artery.
- divide (M, R, U, M-C) nerves on stretch so they retract proximal to pectoralis minor
- divide coracobrachialis and short head biceps on coracoid process.
- reflect deltoid insertion superiorly to expose shoulder joint capsule
- divide teres major and latissimus dorsi at insertions.
- after internally rotating arm divide posterior rotator muscles at insertion & posterior capsule
- place arm in extreme external rotation & divide subscapularis anterior joint capsule
- divide triceps at infraglenoid tubercle insertion & divide inferior capsule to sever the limb.
- suture all muscles across glenoid to fill the hollow out (deltoid to inferior glenoid).
- may need to trim prominent anterior acromion to produce smoothly rounded contour.
- drain deep to deltoid
7. Forequarter
- shoulder girdle amputation / interscapulothoracic amputation
- consists of removal entire shoulder girdle / upper limb in interval between scapula and thoracic wall.
- only for malignant tumour involving upper humerus or shoulder joint or extensively infiltrating deltoid / pectoris / subscaplularis muscles.
- atypical skin flaps often used, may require axillary skin grafts.
Anterior Approach ( Berger 1887 )
- upper limb of incision begins at lateral border sternocleidomastoid and extends laterally along anterior aspect clavicle, across AC joint, over superior aspect shoulder to scapular spine, inferiorly along vertebral border of scapula to inferior angle
- lower limb starts at mid 1/3 clavicle and runs inferiorly in deltopectoral groove and then runs posteriorly through axilla to join upper limb incision at inferior scapular angle.
- subperiosteally dissect out clavicle and cut at lateral border sternocleidomastoid and through AC joint.
- External jugular divided or retracted
- release pectoralis major off humerus and pectoralis minor off coracobrachialis to expose neurovascular structures.
- ligate subclavian artery and vein, divide brachial plexus under stretch
- release Lat dorsi & remaining soft tissues that bind shoulder girdle to anterior chest wall and allow limb to fall posteriorly and down
- while holding arm across the chest divide posterior rotator cuff
- divide anterior and posterior muscles holding scapula to thoracic wall
- Trapezius Omohyoid /lev scap/Rhomboid major & minor/ Serratus anterior
- suture pectoralis major and trapezius over lateral chest wall.
- trim flaps and primary suture
Posterior Approach ( Littlewood )
- lateral decubitus position near edge of operation table
- two incisions( posterior:- cervicoscapular and anterior:- pectoroaxillary).
- make posterior incision 1st begin at medial end of clavicle, extending laterally along clavicle over acromion process to posterior axillary fold then along axillary border of scapula to a point inferior to scapular angle. Finally curve incision medially to end 5cm from midline of the back.
- same incision as for anterior approach except posterior limb runs along axillary border of scapula.
- elevate full-thickness skin flaps and subcutaneous tissue to medial border of scapula
- trapezius / lat dorsi divided parallel to medial border of scapula
- divide Levator scap/ rh min/ maj /scap attatchments of serr. Ant / omohyoid from scapula
- ligate vessels especially transverse Cervical artery and Transverse scapular artery
- free clavicle and divide at medial end with subclavius
- shoulder falls anteriorly
- Subclavian Artery & Vein / Brachial plexus on stretch ( divided close to spine )
- Anterior incision starts at mid 1/3 clavicle and runs inferiorly just lateral and parallel to deltopectoral groove and then runs posteriorly through axilla to join posterior axillary incision at lower 1/3 of axillary border of scapula.
- divide Pec major and minor & remove limb