AMPUTATION IN UPPER

LIMB
 Causes
• Amputation of limbs may be done at any
age as a result of various conditions:
• Mostly peripheral vascular disease (PVD) - this
is a common circulation probleme.
• Malignant diseases,
• Trauma.
• Congenital deformity .
 continue
Basic Principles of Phalangeal
Amputation:
- Skin incision should be mid-axial on
both sides of digit.
- Contour articular condyles - volar and
lateral. 
  - If tendon insertion site absent, sever
tendon and allow it to retract
  
- Do not suture flexors to extensors
- Dissect nerves and sharp proximal
transection (gental pull);
 - Be certain nerves are away from
cutaneous scar.
- volar flaps are preferable;
 Surgical Technique for Amputation
of the Distal Phalanx:

  - Indications:
        - Amputation and shortening of the digit may
be indicated when there is less then 5 mm of
sterile matrix, since nail adherence will be losed.
  
  - Because the nail matrix extends
considerably proximal to skin fold, extensive
dissection may be necessary to remove it
completely;
  
- With transverse amputations,
create distal midlateral incisions
on both sides of the digit, to allow
easier access to nerves, the
phalanx, and to allow easier flap
closure;
•   - shorten and contour bone for primary closure;
            - insertions of flexor and extensor tendons on most proximal
portion of the distal phalanx should be left intact if possible;
            - if flexor and extensor insertions cannot be left intact, then
the distal phalanx should be disarticulated;
                  - in this case, the flexor and extensor tendons are placed
under traction, transected, and are allow to retract;
                  - a ronguer can be used to contour the volar condyles of
the middle phalanx;
    - digital nerves are transected as proximally as possible;
    - volar skin flap is created & wound is closed dorsally;
            - inorder to avoid a club deformity, place the initial suture
centrally, and then draw the palmar skin proximally over the dorsal
stump;
                  - incise the overlapping portion of the dorsal skin (which
typically extends 45 deg from the central stitch);
                  - the resulting scar resembles an inverted horseshoe;
 complications:

          lumbrical plus finger:

                  -It can occur after amputation of the
distal phalanx if the lumbrical muscle is not
released (along w/ release of the FDP); - the
result is that the FDP becomes a paradoxical
extensor of the PIP joint, since the FDP can now
act only thru the lumbrical's insertion into the
lateral band (which coarse dorsally into the
triangular ligament);
 - Amputation thru the Middle
Phalanx:
    - Crushing injury that destroys the distal
phalanx and a portion of middle phalanx
necessitates amputation thru the middle
phalanx;
- If insertion of FDS into base of middle
phalanx can be preserved, some function
of PIP joint may be preserved as well;
 
 - if insertion of the tendon has been
avulsed, there is little reason to preserve
the middle phalanx, and disarticulation
thru PIP joint may be considered;
  - if sharp clean injury, shorten and
contour bone for primary closure;
  - preserve FDS insertion;
Proximal Phalanx Amputation

    - frequently need dorsal skin flap for closure

    - intrinsics control flexion;
    - lasso procedure:
    - one of the flexor tendons (preferably the
FDS) is kept long enough to pass around the A2
pulley, when is then sutured back to itself;
    - adjust tension, so that full extension is
possible;
• Amputation of Finger and Ray:
    - Occassionally entire finger must be amputated
because of severe injury aggressive infection, or
malignant tumor;
    - Ray resection may also be required for traumatic
proximal phalanx amputation with neuroma;
    - Generally the distal half of the respective metacarpal
is resected as well (ray amputation);
    - Ray resection is most often a consideration in the
index finger, however, this is usually done as a staged
procedure (allowing the patient to make the decision);
• - Ray resection can be performed either through
a dorsal or volar approach; palmar approach
to ray resection:
 allows for more cosmetic scar, allows for easier
access of nerves (when a neuroma is present),
and allows for easier taloring of bone w/ oblique
osteotomy;
- Technical options of ray resection include
resection with or without transposition;
  - Disadvantages of transposition: patients may
be left with decreased grip strength, scissoring
of adjacent fingers, and difficulty grasping small
objects;
•   - carpo-metacarpal disarticulation:
            - there is no purpose to midcarpal
amputation;
            - do not save the the proximal row or
single carpal bones, esp if amputee is unilateral;

    - avoidance of neuroma:
            - consider digital nerve transposition into
superficial veins;
    - references:
• - Wrist Disarticulation:
    - while the stump will pronate and
supinate, the socket will not permit this
axial rotation;
    - this level is useful because of the
strong, durable stump, not because of the
radioulnar rotation;