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Traumatic and Trauma-Related Amputations: Part II: Upper

Extremity and Future Directions
LT Scott M. Tintle, LTC Martin F. Baechler, CDR George P. Nanos III, LCDR Jonathan A. Forsberg and MAJ
Benjamin K. Potter
J Bone Joint Surg Am. 2010;92:2934-2945. doi:10.2106/JBJS.J.00258

This information is current as of December 30, 2010

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C OPYRIGHT Ó 2010 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Current Concepts Review

Traumatic and Trauma-Related Amputations
Part II: Upper Extremity and Future Directions
By LT Scott M. Tintle, MD, LTC Martin F. Baechler, MD, CDR George P. Nanos III, MD,
LCDR Jonathan A. Forsberg, MD, and MAJ Benjamin K. Potter, MD

Investigation performed at the Walter Reed Army Medical Center, Washington, DC

ä Trauma is the most common reason for amputation of the upper extremity.

ä The morphologic and functional distinctions between the upper and lower extremities render the surgical tech-
niques and decision-making different in many key respects.

ä Acceptance of the prosthesis and the outcomes are improved by performing a transradial rather than a more
proximal amputation. Substantial efforts, including free tissue transfers when necessary, should be made to
salvage the elbow.

ä Careful management of the peripheral nerves is critical to minimize painful neuroma formation while preserving
options for possible future utilization in targeted muscle reinnervation and use of a myoelectric prosthesis.

ä Rapid developments with targeted muscle reinnervation, myoelectric prostheses, and composite tissue allo-
transplantation may dramatically alter surgical treatment algorithms in the near future for patients with severe
upper-extremity trauma.

Amputation of an upper extremity is a catastrophic event
primarily performed as the result of high-energy trauma in a
young, otherwise healthy patient population1-3. This is in stark
contrast to the population requiring lower-extremity ampu-
tation, which predominantly comprises elderly patients with
end-stage diabetes or peripheral vascular disease4,5. While the
surgical principles of upper and lower-extremity amputations
have similarities, the morphologic and functional distinctions
between the upper and lower extremities render the operative
techniques and decision-making different in many key re-
spects. Knowledge of these differences, and an awareness of
the functional outcomes and prosthesis acceptance rates as-
sociated with each amputation level, are essential to ensure
appropriate preoperative planning and to optimize patient
outcomes.
Amputation Versus Limb Salvage and/or Replantation
Accurate predictors of the outcomes after severe trauma to the
upper extremity have not been elucidated. While severity scores
for the traumatized lower extremity have been developed, their
application to the upper extremity has been equivocal and
has not consistently proven efficacious6-8. Indeed, limb salvage
considerations differ considerably between the upper and lower
extremities. One important consideration is the dramatic dif-
ference in the functional capabilities between a normal hand
and a prosthesis, despite all modern advances in prosthetic
design. The numerous degrees of freedom of the human arm
and the dexterity and sensory feedback of the hand are only
marginally replicated with current prosthetic technology. For
this reason, a ‘‘bad hand’’ may be more functional than a ‘‘good
amputation’’ in the upper extremity (Figs. 1-A, 1-B, and 1-C).

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a
member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial
entity.
Disclaimer: The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the
views of the United States Army, United States Navy, or the Department of Defense.

J Bone Joint Surg Am. 2010;92:2934-45 d doi:10.2106/JBJS.J.00258

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The difference between a ‘‘bad foot’’ and a ‘‘good lower-extremity
amputation’’ may not be nearly as important9. For instance, more
than 15% of the more than 750 lower-extremity trauma-related
amputations managed at our institutions over the last decade
were late amputations due to unsatisfactory or so-called failed
limb salvage; however, to our knowledge, only two patients
during this same time period voluntarily requested late trans-
radial amputation following an initial upper-limb salvage.
Additionally, anatomic and functional differences make the
upper extremity more amenable to limb salvage and/or replan-
tation than the lower extremity. Since the upper extremity is not
used for walking, there is less concern about limb-length equality.
Shortening osteotomies may allow primary vascular and/or nerve
repairs, as well as primary soft-tissue closure, making upper-
extremity limb salvage less of a problem and perhaps more
successful in certain circumstances2,6. The upper extremity also
has less muscle mass, decreasing the risk of a crush syndrome
with limb salvage7,10. In addition, increased collateral circulation
in the upper extremity may allow the reperfusion time to be
extended to eight to ten hours after a vascular injury7,11,12.
Graham et al.13 conducted a study in which the late
functional outcomes of major unilateral upper-extremity re-
plantation were compared with those of revision amputation
and prosthetic fitting. The authors concluded that the patients
who had been treated with replantation had better function as
assessed with the Carroll Standardized Evaluation of Integrated
Limb Function14 at an average of 7.3 years after the injury. The
Carroll Standardized Evaluation of Integrated Limb Function is
a battery of tests that assesses a subject’s ability to grasp, grip,
and pinch variously sized and shaped objects and to perform
tasks incorporating both accurate hand and object placement.
The test also includes more complex motions such as the
pouring of water from a pitcher and concludes with the sub-
ject being asked to write. The test was originally developed for
the quantification of upper-extremity limb impairment as a
result of traumatic, arthritic, or neurologic conditions. The con-
tention of the test developers was that it emphasized the inte-
grated activity of the extremity and the functional capacity of the
limb.
Graham et al.13 also concluded that if prehension of all
digits was considered achievable, then replantation was supe-
rior to amputation. If prehensile function was not considered
an achievable goal of primary treatment, then the number of
satisfactory results obtained with replantation or amputation
was similar. However, an increased proportion of excellent re-
sults in the replantation group persisted.
Length Selection and Indications for Length
Preservation Procedures
After an upper-extremity amputation, the person utilizes the
residual limb to interact with his or her environment even
when a prosthesis is not worn. With increased extremity length
and the preservation of each progressive joint, the person be-
comes exponentially more capable of positioning the terminal
extremity in space and of feeling, grasping, and manipulating
objects in the environment. For this reason, a longer residual
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
limb leads to improved outcomes in most circumstances, and it
is rare for a patient who has had an upper-extremity amputa-
tion to request limb shortening3. While the specific injury may
ultimately determine the level of amputation, it is crucial for
the surgeon to know the requirements and capabilities of pros-
theses corresponding to each amputation level when the op-
portunity for length preservation is afforded.
When the residual tissue of a traumatically amputated
limb is of inadequate quality or quantity to permit wound
closure without shortening of the limb, extended means of
wound management, such as use of a split-thickness skin graft,
pedicled flap, or even free tissue transfer, should be strongly
considered9,15. However, the fitting of a prosthesis to a residual
limb can be a challenge even in the best of circumstances, and
particularly when the residual limb is irregular in shape as a
result of flap coverage. Therefore, although preserving length
of the residual limb is of prime importance, the surgeon must
consider the ultimate size, shape, durability, and even appear-
ance of the residual limb, as these factors will affect the ultimate
satisfaction of the patient.
Baccarani et al.9 demonstrated successful length preser-
vation in thirteen well-selected patients treated with free tissue
transfer. These authors suggested the following major indica-
tions for free tissue transfer in the upper extremity to provide
soft-tissue coverage of a residual limb: shoulder joint preser-
vation (forequarter or shoulder disarticulation converted to a
transhumeral amputation), elbow joint preservation, and bone
preservation >7 cm below the shoulder or elbow (to improve
prosthetic fit and performance). Minor indications included
wrist joint preservation and skeletal preservation between 5
and 7 cm below the shoulder or elbow.
A residual limb with flap coverage will take longer to heal
and may also require operative revision before the patient is
ready for prosthetic fitting. This delay in rehabilitation is likely
more of a consideration after a lower-limb amputation than it
is after an upper-limb amputation because of the difficulty or
inability to provide early mobilization and the greater weight-
bearing requirements of a patient treated with a lower-extremity
amputation and a free tissue transfer16-18. Furthermore, with
respect to prosthetic use, the burden of direct pressure and shear
force is less of a problem for a residual upper limb than it is for a
residual lower limb. Therefore, although flap coverage is suc-
cessfully used in both upper and lower-extremity amputations to
preserve length, it should be employed more often for length
preservation of the residual upper limb16,18,19.
Nerve and Muscle Management
The proper management of muscles and nerves in upper-
extremity amputations is very important. Traction neurectomy
should be performed for each major upper-extremity nerve,
including the cutaneous sensory nerves, in order to locate the
inevitable neuromas away from the skin closure, myodesis, or
myoplasty. However, neurectomy must be performed cautiously
in order to avoid further denervation of residual muscle, which
is undesirable for several reasons. First, denervated muscle
will atrophy and possibly leave the residual limb poorly pad-
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Fig. 1-A

Fig. 1-B
Figs. 1-A, 1-B, and 1-C Clinical photographs demonstrating that a ‘‘bad hand’’ may be more functional
than a ‘‘good amputation’’ when limb salvage remains practicable following severe upper-extremity
trauma. Fig. 1-A The patient sustained loss of the ulnar three rays following an explosive blast injury to
the hand, but maintained an intact thumb and a minimally injured index ray. Fig. 1-B A pedicled groin
flap was utilized for robust soft-tissue coverage.

ded. Second, denervated muscle cannot contract and thus
cannot provide a signal for control of a myoelectric pros-
thesis. Finally, the terminal nerve branches may be trans-
ferred non-anatomically to local residual limb muscles to
create additional myoelectric control sites for more intuitive
control of a motorized prosthesis. This concept, termed ‘‘tar-
geted muscle reinnervation,’’ will be discussed in detail later in
this review20-24.
Stabilizing the muscles and tendons of a residual limb is
extremely important for successful prosthetic wear. The bone
ends must be padded to avoid painful prominences. Myodesis,
myoplasty, and myofascial techniques are all utilized in am-
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Fig. 1-C
Follow-up photograph demonstrating a successful result, with retention of prehensile function.

putation surgery to stabilize the residual muscle and maintain area of the distal part of the radius may allow increased weight-
the distal bone end in a padded and covered position. Myodesis bearing through the terminal end. The long sensate residual
is achieved when a residual muscle and its fascia are sutured limb increases the person’s functional reach. It is also a better
directly to bone through drill holes or are firmly attached to platform for a prosthetic socket. This is important for stability
the periosteum. Myodesis provides the most structurally stable of the prosthesis as well as for elbow motion; the shorter the
result. Myoplasty involves suturing a residual muscle agonist to
its antagonist over the end of the bone to create physiologic
tension. Finally, with a myofascial closure, residual muscle and
its fascia are sutured together, creating the least stable muscu-
lotendinous reconstruction. Nearly physiologic tension should
be set at the time of the myodesis or myoplasty to prevent re-
traction, simulate resting muscle length, and improve contrac-
tility characteristics, thus improving the quality of signal for
control of a myoelectric prosthesis as well as improving control
of the terminal residual limb.
No data in the literature strongly suggest the superiority of
myodesis over myoplasty; however, we recommend that myod-
esis and/or tenodesis be performed in all upper-extremity am-
putations (Fig. 2) because the mobile sling of muscle that is
formed from a myoplasty can lead to painful bursa formation or
result in exposure of prominent bone. Furthermore, myoplasty of
antagonist muscles can lead to spread of signal, resulting in in-
voluntary co-contraction and interference with myoelectric sig- Fig. 2

nal detection. Intraoperative photograph of a limb with a transradial amputation as well

Specific Amputation Levels
Wrist Disarticulation
This level of amputation has several distinct advantages. If the
distal radioulnar joint is unaffected, full forearm rotation is
completely preserved and there is no risk of painful impinge-
ment of the distal parts of the radius and ulna. The large surface
as a primary myodesis and secondary myoplasty. The brachioradialis and
extensor carpi radialis longus have been myodesed to the distal part of the
radius, and the flexor carpi ulnaris has been myodesed to the distal part of
the ulna. Secondary myoplasty has been performed with the antagonist
muscles, and a long, dorsal fasciocutaneous ‘‘flap of opportunity’’ has
been utilized for soft-tissue coverage, providing sensate, mobile skin
coverage and removing the incision line from the terminal residual limb.
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residual limb, the more likely the prosthetic socket will en- prosthetic and mechanical advantages of the transradial level
croach on the elbow and impede motion. coupled with the superior prosthesis acceptance rates oblige a
The major disadvantage of this amputation level has been surgeon to consider all reconstructive options, including free
the limited capabilities of the prosthetic devices. A survey of tissue transfer, in order to perform an amputation at this
United States surgeons conducted by Tooms25 in 1972, prior level9,27-32.
to the introduction of modern wrist prostheses, indicated a When the injury dictates that a transradial amputation
preference for distal transradial amputations over wrist disar- be performed in the proximal half of the forearm, no useful
ticulations. This was likely due to the inability to fit standard pronation and supination is generally salvaged; however, only
prosthetic components and terminal devices distal to the wrist 5 cm of residual ulna is required for prosthetic fitting and re-
while still maintaining a functionally and cosmetically acceptable tention of elbow flexion3,33,34 (Fig. 3). With an even shorter ulna,
extremity length and bulk. With modern prosthetic components a prosthetic socket can be extended proximal to the condyles
and terminal devices, however, a patient with an amputation of the elbow to aid in prosthetic suspension. At this proximal
through the radiocarpal joint can be satisfactorily fitted with a level, the biceps should be transferred to the ulna via tenodesis.
functional prosthesis. Postoperative rehabilitation should then focus on the preven-
Prerequisite to attempting amputation through the radio- tion of a flexion contracture at the elbow3. Furthermore, if the
carpal joint is an intact and healthy distal radioulnar joint3,26. In
the performance of a wrist disarticulation, the thick palmar skin
of the hand should be utilized for distal coverage, if available3.
The radial and ulnar styloid processes should be retained for
prosthesis suspension, but contouring the styloids is reasonable
to avoid osseous prominences and to facilitate robust soft-tissue
coverage. It is crucial to perform a tenodesis of the flexors and
extensors to maintain the tension in the muscle groups necessary
for successful use of a myoelectric prosthesis. In addition to the
ulnar and median nerves, careful attention must be paid to the
superficial branch of the radial nerve, the palmar cutaneous branch
of the median nerve, and the dorsal ulnar cutaneous nerve3. These
nerves should be transected proximal to the level of the closure and
transposed deep to the local musculature to protect them from
prosthetic pressure and prevent chronic pain. However, a cuta-
neous nerve should be preserved if it supplies skin that is retained
in the closure, even while the residual portion of the contributing
larger nerve is transposed.

Transradial Amputation
The transradial amputation is the most common upper-extremity
amputation27. The preservation of the shoulder and elbow as well
as the maintenance of some forearm pronation and supination
allows a terminal device to be easily positioned in space. When
practical, at least two-thirds of the forearm length should be
maintained. We advocate the removal of 6 to 8 cm of bone in
order to maximize the robustness of the soft-tissue envelope and
permit a wide variety of prosthetic options. In addition, we fre-
quently interpose local soft tissue between the distal aspects of the
radius and ulna to prevent painful convergence and instability.
The location of the amputation determines what soft tissue is
interposed. In the distal part of the forearm, the pronator qua-
dratus is utilized if intact; however, more proximally, one extensor
tendon and one flexor tendon are interposed and are secured
between the radius and ulna. Fig. 3
Benefits of a distal transradial amputation include in- Anteroposterior radiograph of a proximal, 7.5-cm transradial amputation
creased pronation and supination as well as a stable lever arm for with resection of the residual radius and tenodesis of the biceps tendon
prosthesis wear and weight-bearing. In addition, the transradial to the residual ulna. Even at this proximal level, prosthetic fitting was
level is cosmetically appealing because of the ability to fit a body- feasible with reasonable prosthetic suspension and residual limb
powered or myoelectric prosthesis with quick-disconnect com- control, and a myodesis was performed as reflected in the distal ulnar
ponents while still maintaining equal limb lengths. The obvious drill hole (arrow).
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patient also has disability related to the lower extremities and
will rely more heavily on the upper extremities for mobility,
preservation of even an extremely short ulna should be con-
sidered, as the proximal part of the ulna is a reasonably stable
and a natural weight-bearing surface.
Elbow Disarticulation/Distal Transhumeral Amputation
The elbow disarticulation and transcondylar humeral amputa-
tions are similar in nature because of maintenance of the met-
aphyseal flare of the distal part of the humerus. The shape of the
residual humerus allows improved suspension and better rota-
tional control of a prosthesis when compared with those fol-
lowing a more proximal transhumeral amputation3,26. The major
disadvantage of an elbow disarticulation is cosmetic because, in
most cases, the prosthetic elbow joint is located either distal to
the normal, contralateral elbow joint or external to the plane of
the humerus and prosthesis3,35. The improved suspension and
rotational control, however, likely outweigh the perceived poor
cosmetic appearance of the limb. As such, an immediate or
delayed humeral shortening osteotomy may be considered to
elevate the elbow joint and improve cosmetic appearance, while
preserving functionality, in selected cases35.
If the condyles of the humerus are not preserved, the
ideal level for amputation of the humerus is approximately 3 to
5 cm proximal to the elbow joint33. This level will allow fitting
of standard prosthetic components, while retaining adequate
length to suspend and control a prosthesis. A Marquardt an-
gulation osteotomy as described by Marquardt and Neff 3,36 may
also be considered for patients with a distal transhumeral am-
putation. This osteotomy creates an angulated distal residual
humerus, which provides improved suspension and rotational
control of the prosthesis, similar to that achieved with an elbow
disarticulation.
Proximal Transhumeral Amputation
Every effort should be made to salvage at least 5 to 7 cm of
residual humerus, as this will affect prosthesis suspension and
acceptance (Fig. 2)9,25,26. Skin grafting or free tissue transfer
should be considered in cases where humeral length may be
maintained. Latissimus dorsi, parascapular, and other free tissue
transfers have been successfully utilized to preserve amputation
length and facilitate salvage of humeral length9. The deltoid
muscle should be preserved even in very proximal transhumeral
amputations, to allow active control of the shoulder joint3,33. It is
also important to salvage the humeral head, whenever possi-
ble3,26,34. Doing so will improve the cosmetic appearance fol-
lowing the amputation and may eventually help the patient use a
myoelectric or body-powered prosthesis26. Without retention or
reconstruction of the insertions of the pectoralis major, latis-
simus dorsi, and deltoid, however, the result will be the same as
that of a shoulder disarticulation with regard to prosthetic fitting.
For this reason, if the humeral head is retained to improve the
cosmetic appearance of the shoulder and to potentially aid in
force transmission, glenohumeral arthrodesis can be considered,
usually as a planned, staged procedure3,34. This will prevent a
painful or disfiguring abduction contracture or subluxation,
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
which may occur as a result of the unopposed forces of the
rotator cuff (Figs. 4-A and 4-B)3,26,34.
Shoulder Disarticulation
Shoulder disarticulations are fortunately rare. They are usually
the result of serious injuries and are frequently accompanied by
substantial thoracic and abdominal trauma37,38. These amputa-
tions are usually performed as an emergency, life-saving mea-
sure. Efforts should be made to save the scapula and clavicle as
this improves the contour of the shoulder and aids in prosthetic
suspension34. Nerve and muscle management is critical at this
level. Residual muscle must not be inadvertently denervated as
this will cause atrophy and may adversely affect prosthetic fitting.
Furthermore, the terminal branches of the brachial plexus are
necessary should the patient undergo targeted muscle reinner-
vation in the future20-22. The usual flap closure consists of a
deltoid myofasciocutaneous flap, but, in the posttraumatic set-
ting, the use of any available tissue or free tissue transfer may be
required.
Outcomes
The loss of one or both upper extremities is a devastating event.
Prehensile function and the sensation of touch are two functions
that are respectively difficult and currently impossible to replace
with modern prostheses. Prosthesis acceptance is a frequently
discussed primary outcome measure in studies of upper-
extremity amputation. However, the literature lacks high-quality
evidence, and the majority of the available literature both is
dated and offers only non-standardized comparisons of a wide
variety of prostheses.
Rates of rejection of upper-extremity prostheses are fre-
quently reported to be >30%27,30,39,40. In a number of studies
ranging from nineteen to 135 patients, the reported rejection rates
for upper-extremity prostheses were 21% to 38%, with all studies
that included more than forty-five patients showing at least a 30%
rejection rate27,28,30,39-41. Additionally, if one were to consider only
functional prosthetics and exclude cosmetic prostheses, the re-
jection rates would likely be substantially higher. High rejection
rates have been loosely associated with poor training; delayed
fitting; and, most notably, proximal amputations27. In a 1995
survey, people who had undergone an upper-extremity ampu-
tation indicated that the top three reasons for their rejection of the
prosthesis were limited usefulness, weight, and residual limb/
socket discomfort27. Factors associated with increased prosthesis
acceptance have proven even more equivocal but have been
suggested to include the loss of the dominant extremity, the ab-
sence of pain in the residual limb, and prosthetic fitting within
thirty days after amputation27,28,42.
Despite inconsistencies in the available literature, it is
generally accepted that the rate of prosthesis use is directly
associated with the level of the amputation. Prosthesis accep-
tance is increased with more distal levels of amputation27-32. In
addition to increased prosthesis use, higher functional scores
are obtained by those with longer residual limbs13. Transradial
amputation is associated with the highest consistently reported
prosthesis utilization rates, which range from 80% to 94% in a
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Fig. 4-A

Fig. 4-B
Anteroposterior radiographs of a very proximal transhumeral amputation demonstrating re-
tention of the humeral head with early abduction deformity due to the unopposed pull of the
rotator cuff (Fig. 4-A) and subsequent painful dislocation requiring late humeral head excision
(Fig. 4-B).

number of reported series of ten to 127 patients (mean number thirty-one)27,28,30,32. As would be expected, shoulder disarticulation
of patients, eighty-five)27-32. This is followed by transhumeral is associated with the lowest reported prosthesis acceptance
amputation, with a reported range of 43% to 83% in reported rates27,28,43. This trend is easily explained by the increased weight
series of five to seventy-four patients (average number of patients, and complexity, decreased degree of prehensile control, and
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difficulties of prosthetic suspension at the more proximal levels.
The prosthesis acceptance rates illustrate the willingness of pa-
tients to function one-handed rather than use a burdensome,
non-intuitive prosthesis. There are two unique situations that
warrant mention: the literature indicates that people with a bi-
lateral upper-extremity amputation will almost universally use at
least one prosthesis and those with an ipsilateral brachial plexus
palsy will routinely reject a prosthesis3,27,43-45.
Another important outcome measure is the ability to re-
turn to productive employment. The available data indicate that
most people who have undergone an amputation are able to
return to work. However, one-half to two-thirds of these indi-
viduals change their occupations to accommodate for the loss of
the limb27,28,46. As would be predicted on the basis of prosthesis
usage and functional outcomes, people with a transradial am-
putation have a higher rate of employment than those with a
more proximal amputation27.
Chronic pain is also an important outcome measure in
people with an upper-extremity amputation. The prevalence of
pain in the residual limb after upper-extremity amputation was
reported to range from 7% to 49% in various series of eighteen
to 104 patients (mean number of patients, sixty-two)28,41,47-51.
The prevalence of phantom-limb pain was reported to range
from 30% to 79% in a number of series ranging from eighteen
to 104 patients (mean number of patients, sixty-two). Most
authors have reported that >50% of the patients in their series
were affected by phantom-limb pain28,41,47-51. Despite the rela-
tively high frequency of pain in patients who have had an upper-
extremity amputation, studies suggest that chronic pain does not
impair functional prosthesis wear or the ability to return to
employment in most cases27,47.
Less frequently reported pain associations were high-
lighted in a study by Hanley and colleagues49. They reported
that 104 patients with an upper-extremity amputation had an
increased rate of back pain (52%), neck pain (43%), and pain
in the contralateral, sound upper extremity (33%) as compared
with the rates in the general U.S. population52,53. Despite the
infrequency of pain in the sound limb, this pain caused the
most interference and days lost from work because of pain-
related disability. This highlights the importance of educating
patients with a new amputation about overuse-type injures of
the contralateral upper extremity49.
Future Directions
Prosthesis Design
Contemporary myoelectric prostheses routinely utilize a termi-
nal device with a tripod-type forceps grip that allows only one
degree of freedom with high-magnitude grip strength3. The ability
to design an anthropomorphic upper extremity with multiple
degrees of freedom has routinely been limited because of the
increased numbers of motors and power sources required as
well as the inability to provide comparable grip strength with a
lightweight design3. Recently, improved materials, more effi-
cient ultrasonic motors, lighter batteries, and pneumatically or
hydraulically controlled finger joints have made the design of
an anthropomorphic hand with multiple degrees of freedom a
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
reality3,54. This has led to the design of prostheses capable of mul-
tiple grasping patterns with less necessary overall grip strength. At
least two such prototypes are currently in production, and wide-
spread clinical trials of these devices will likely begin in the near
future3.
Increasingly intelligent capabilities of future prostheses
are also expected. On-board intelligent sensors will eventually
provide sophisticated haptic feedback loops capable of real-time
correction in order to automatically determine and adjust for
touch, slip, position, and temperature. Improvements to the
neural-prosthesis interface are also currently being investigated.
Improved electromyographic (EMG) sensors as well as the
possibility of implanted electrodes and even a sensory interface
may someday be a reality. With these continued developments,
it is conceivable that, in the future, an anthropomorphic pros-
thetic hand capable of near-physiologic control without visual
attention will markedly improve the quality of life of individuals
with an upper-extremity amputation3.
Targeted Muscle Reinnervation
Patients with an amputation at or above the elbow have two
major difficulties with the control of prostheses. First, the muscle
contractions necessary to signal the prosthetic device are not
intuitive. Second, the remaining muscles provide too few distinct
signals to control more than one prosthetic joint simultaneously,
necessitating slow and cumbersome sequential, alternating
control of each joint24. Targeted muscle reinnervation was de-
veloped by Kuiken and Dumanian20-22 to improve the control of
myoelectric prostheses. The premise of targeted muscle rein-
nervation is to regain the signaling ability of the nerves that
formerly innervated the lost limb through a set of novel nerve
transfers (Fig. 5). No function is lost with these nerve transfers,
as the original recipient muscles are not present as a result of
limb loss. Thus, the newly reinnervated muscle segments act like
transducers of the transferred nerves’ original function, capable
of producing electromyographic signals to control a myoelectric
prosthesis21.
In transhumeral amputations, four independently con-
trolled nerve-muscle units are obtained by transferring the distal
radial nerve to the motor branch of the lateral head of the triceps
and the median nerve to the motor branch of the medial head
of the biceps21. These transfers provide the signals for intuitive
prosthetic hand opening and closing. The long head of the triceps
and the lateral head of the biceps each keep their native inner-
vation for intuitive prosthetic elbow flexion and extension. With
a distal transhumeral amputation with an adequate remaining,
functioning brachialis, transfer of the ulnar nerve to the motor
branch of this muscle can provide a fifth control source. With
shoulder disarticulation, the choice of nerve transfers is often
dictated by the length of the remaining nerves and the anatomy of
the remaining functioning muscles. Typically, the musculocuta-
neous nerve is transferred to the motor branches of the clavicular
head of the pectoralis major; the median nerve is transferred to
the motor branches of the sternal head of the pectoralis major;
the terminal radial nerve is transferred to the thoracodorsal nerve;
and the ulnar nerve is transferred to the motor branches of the
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Fig. 5
Intraoperative photograph of targeted muscle reinnervation demonstrating vessel loops
around the larger median nerve and the branch of the musculocutaneous nerve going to
the medial head of the biceps. The biceps muscle has been split longitudinally to facilitate
the separation, denervation, and subsequent reinnervation. (Photograph courtesy of
Gregory A. Dumanian, MD, and Todd A. Kuiken, MD, PhD, Feinberg School of Medicine,
Northwestern University.)

pectoralis minor muscle moved from underneath the pectoralis
major, to the long thoracic nerve, or to a redundant motor
branch of the pectoralis major55.
Targeted muscle reinnervation makes it possible for a
patient who has undergone a transhumeral or shoulder disar-
ticulation to simultaneously control the elbow and a terminal
device with a myoelectric prosthesis21. To date, the use of tar-
geted muscle reinnervation has markedly improved the upper-
extremity prosthetic function of a small number of patients.
Patients who have undergone targeted muscle reinnervation
have all become capable of intuitive and simultaneous opening
and closing of the hand as well as extension and flexion of the
elbow 21. Early laboratory evidence in animals and clinical results
to date also suggest that targeted muscle reinnervation may help
to alleviate symptomatic neuromas55.
Advanced Pattern Recognition
Early trials with a small number of patients who had undergone
targeted muscle reinnervation have been conducted with use
of advanced pattern-recognition algorithms to decode surface
EMG data from reinnervated muscles21. Data from EMG re-
cordings have been collected from patients attempting sixteen
different complex motions with the amputation stump follow-
ing targeted muscle reinnervation. The complex EMG pattern-
recognition software is capable of allowing the reinnervated muscles
of a patient treated with targeted muscle reinnervation to in-
tuitively control an advanced, multifunctional artificial upper
extremity in real time. The development of targeted muscle
reinnervation and these advanced pattern-recognition algorithms
have provided the necessary technology to eventually produce a
prosthesis that can perform complex movements and be cus-
tomized to individual patients on the basis of their own natural
voluntary EMG patterns21.
Composite Tissue Allotransplantation/Hand Transplantation
To date, more than fifty hand, forearm, and arm transplants have
been performed worldwide in thirty-eight patients and have
shown that hand allograft survival can be achieved with highly
encouraging functional outcomes56,57. Proponents of composite
tissue allotransplantation argue that hand/forearm transplanta-
tion provides function that is comparable with, or better than,
that provided by replantation, enhances activities of daily living,
allows the patient to perform activities not afforded by a pros-
thesis, and is associated with low morbidity and no recorded
mortality to date58. Critics of composite tissue allotransplanta-
tion highlight the lack of convincing long-term functional data,
the unclear risk-benefit ratio, the possibility of life-shortening or
fatal complications, and the need for chronic immunosuppres-
sive medication for success58.
A recent review of the cases of five patients who had a
hand transplant performed in the United States illustrates both
the optimism for the future of hand transplantation and the need
for extreme caution in the performance of the procedure due to
the potential for serious complications56. Despite advancements
in immune regimens, all five patients experienced at least one
episode of acute rejection while being treated with conventional
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immunosuppression. Additionally, one transplanted hand was
amputated at nine months because of what was diagnosed as a
chronic rejection. One patient in this series required bilateral total
hip replacement because of osteonecrosis, and one patient de-
veloped a lymphoproliferative disorder. Despite the inability to
determine whether the lymphoproliferative disorder was related
to the transplant, the authors emphasized that post-transplant
lymphoproliferative disorder is a potential risk of composite tissue
allotransplantation59.
In the hand-transplant world experience, side effects ob-
served and reported to the International Registry on Hand and
Composite Tissue Transplantation (IRHCTT)60 were comparable
with those in solid-organ recipients and included opportunistic
infections as well as metabolic complications such as hypergly-
cemia, hyperlipidemia, impaired renal function, and arterial hy-
pertension. Of note, no life-threatening complications or malignant
tumors have been observed thus far. Patient and graft survival
rates at one year after transplantation are superior to what has
been achieved in any other field of transplantation61,62.
Aside from the immunological considerations to enable
graft survival, the pace and degree of nerve regeneration is key to
achieving satisfactory functional outcomes after composite tissue
allotransplantation. With regard to motor function, extrinsic mus-
cle function during the early postoperative phase allows patients
to perform grasp and pinch activities. At later stages, at an
average of nine to fifteen months post-transplantation, intrinsic
muscle recovery is observed in the majority of patients. In ad-
dition to gross and fine motor function, all patients who have
undergone a transplantation to date have demonstrated a return
of protective sensation. Ninety percent of thirty patients who
had been followed regained tactile sensibility, and several re-
cipients reported discriminative sensory function as assessed
with two-point discrimination or the Semmes-Weinstein mono-
filament test62,63. However, while the function and satisfaction of
these patients have shown composite tissue allotransplantation
to have true potential, a web-based survey of members of the
American Society for Surgery of the Hand (ASSH) reported in
200958 demonstrated that only 24% of 474 respondents were
currently in favor of hand transplantation. Forty-five percent
were against hand transplantation, and 31% were undecided.
While 71% believed that it was ethical in properly selected
patients, 69% thought that it was a high-risk endeavor. How-
ever, a higher number of members said that they would accept
hand transplantation if a less toxic but effective immunosup-
pression regimen were available58. In this regard, various modi-
fications have recently been applied to the immunosuppressive
protocols used in hand transplantation, such as steroid sparing/
avoidance attempts, cell-based immunomodulatory strategies,
conversion from tacrolimus to sirolimus for long-term therapy,
or the use of topical steroid and tacrolimus ointments to reduce
the overall amount of systemic immunosuppression64.
Hand transplantation might offer some unique advantages
to implement such strategies because continuous monitoring of
the graft, in contrast to what is possible with solid-organ trans-
plants, can be performed with simple visual inspection of the
skin, which is the main target of rejection. This allows for directed
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
biopsies and unbiased pathological confirmation of the earliest
stages of acute rejection and subsequent timely intervention,
treatment, and precise adjustments of immunosuppression on
an individualized basis. When treated adequately and effectively,
acute rejection does not seem to impair graft function or long-
term survival.
Therefore, novel strategies to minimize immunosup-
pression or even to achieve the ultimate attainable clinical goal
of transplantation to induce immune tolerance are particularly
appealing in hand transplantation and composite tissue allo-
transplantation. This trend is further fueled by recent innovative
advancements in solid-organ transplantation, where both cell-
based therapies and non-cell-based protocols have resulted in
reduction or elimination of long-term immunosuppression65,66.
With such advancements in the development of less morbid
regimens for the prevention of tissue rejection, hand trans-
plantation may become a widely accepted alternative for a pa-
tient with upper-extremity loss.
Overview
Upper-extremity amputation is a devastating event. Optimal sur-
gical treatment and rehabilitation involve many considerations
and decisions unique to the reestablishment of upper-extremity
function. Knowledge of proper amputation techniques, preferred
amputation levels, and the judicious use of tissue coverage
methods can ostensibly optimize clinical outcomes. While the
knowledge and technical skill of the surgeon are of obvious im-
portance, patient rehabilitation is maximized by the participation
of a multidisciplinary team of surgeons, nurses, therapists, pros-
thetists, mental health specialists, and social workers. Rapidly de-
veloping research that may lead to improved quality of life after
an upper-extremity amputation continues to progress. This is il-
lustrated by targeted muscle reinnervation, which was developed
in response to the improvements in mechanical prostheses and
biomechanical interfaces. Research on composite tissue allotrans-
plantation, which became possible because of microsurgical ad-
vancements and the ability to suppress tissue rejection, has also
continued to rapidly expand. Surgical treatment algorithms for
upper-extremity amputation must therefore continue to evolve in
step with technological and medical advancements. n
NOTE: The authors thank Gregory A. Dumanian, MD, and Todd A. Kuiken, MD, PhD, for their review of
the section on targeted muscle reinnervation, an evolving and promising new technique that they
jointly developed, as well as W.P. Andrew Lee, MD, for his input regarding hand transplantation.
LT Scott M. Tintle, MD
LTC Martin F. Baechler, MD
CDR George P. Nanos III, MD
LCDR Jonathan A. Forsberg, MD
MAJ Benjamin K. Potter, MD
Orthopaedic Surgery Service,
Integrated Department of Orthopaedics and Rehabilitation,
Walter Reed Army Medical Center,
6900 Georgia Avenue N.W.,
Building 2, Clinic 5A,
Washington, DC 20307.
E-mail address for B.K. Potter: Kyle.Potter@amedd.army.mil
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