AMPUTATIONS OF UPPER

EXTREMITY

Dr. Hussain Ali

PGT Orthopaedics
Benazir Bhutto Hospital
Rawalpindi
 Contents
• WRIST AMPUTATION
• FOREARM AMPUTATIONS (TRANSRADIAL)
includes
1. Distal transradial amputation
2. Proximal transradial amputation
• ARM AMPUTATIONS (TRANSHUMERAL) includes
1.Supracondylar area amputation
2.Amputation proximal to SC Area
 Cont..
• SHOULDER AMPUTATIONS includes
1.Amputation through the surgical neck of
humerus
2.Forequarter Amputations
• Major amputations of the upper extremity
(other than digital amputations) account for
3% to 15% of all amputations.

• Approximately 20 times less common than

amputations of the lower extremity.
 WRIST AMPUTATIONS
• Transcarpal amputation or disarticulation of
the wrist is preferable to amputation.
• Provided that the distal radioulnar joint
remains normal, pronation and supination are
preserved.
• These motions are extremely valuable to the
patient.
 Technique
• Long palmar and a short dorsal skin flap in a
ratio of 2 : 1
• Draw the tendons of the finger flexors and
extensors distally, divide them, and allow
them to retract into the forearm.
• Identify the tendons of the wrist flexors and
extensors, free their insertions, and reflect
them proximal to the level of bone section.
 Cont..
• Identify the median and ulnar nerves.
• Draw the nerves distally and section them
well proximally to prevent painful neuroma.
• Clamp, ligate, and divide the radial and ulnar
arteries proximally.
• Divide the remaining soft tissues down to
bone.
• Transect the bones with a saw and rasp all
rough edges.
 Cont..
• Anchor the tendons of the wrist flexors and
extensors to the remaining carpal bones to
preserve active wrist motion.
• With interrupted nonabsorbable sutures,
close the subcutaneous tissue and skin at the
end of the stump.
 FOREARM AMPUTATIONS
(TRANSRADIAL)
• Preserving as much length as possible is
desirable.
• It includes
1. Distal transradial amputation
2. Proximal transradial amputation
 DISTAL
TRANSRADIAL AMPUTATION
TECHNIQUE
• Equal anterior and posterior skin flaps
• Together with the skin flaps, reflect the
subcutaneous tissue and deep fascia
proximally to the level of bone section.
• Clamp, doubly ligate, and divide the radial and
ulnar arteries just proximal to this level.
 Cont..
• Identify the radial, ulnar, and median nerves;
draw them gently distally and transect them
high.
• Cut across the muscle bellies transversely
distal to the level of bone section and
interpose the muscle tissue between the
radius and the ulna.
 Cont..
• Divide the radius and ulna transversely and
rasp all sharp edges from their ends
• Close the deep fascia with fine absorbable
sutures and the skin flaps with interrupted
nonabsorbable sutures.
 PROXIMAL TRANSRADIAL
AMPUTATION TECHNIQUE
• Fashion anterior and posterior skin flaps of
equal length.
• Just proximal to this level, identify, doubly
ligate and divide the major vessels.
• Identify the median, ulnar, and radial nerves;
gently pull them distally and section them
proximally.
 Cont..
• Divide the muscle bellies transversely distal to
the level of bone section.
• Divide the radius and ulna transversely and
smooth their cut edges.
• With interrupted absorbable sutures close the
deep fascia, with interrupted non-absorbable
sutures close the skin edges.
 ARM AMPUTATIONS
(TRANSHUMERAL)
• Amputation at any level from the
supracondylar region of the humerus distally
to the level of the axillary fold proximally.
• As in all other amputations, as much length as
possible should be preserved.
 SUPRACONDYLAR AREA
AMPUTATION TECHNIQUE
• Fashion equal anterior and posterior skin
flaps, each being in length one half of the
diameter of the arm at that level.
• Doubly ligate and divide the brachial artery
just proximal to the level of bone.
• Transect the median, ulnar, and radial nerves
at a higher level
 Cont..
• Divide the muscles in the anterior
compartment of the arm 1.3 cm distal to the
level.
• Free the insertion of the triceps tendon from
the olecranon, preserving the triceps fascia
and muscle as a long flap.
• Divide the bone and smoothly round its end.
 Cont..
• Trim the triceps tendon to form a long flap,
carry it across the end of the bone, and
tenodese it to the humerus.
• Close the fascia with fine absorbable sutures
and the skin flaps with interrupted
nonabsorbable sutures.
 AMPUTATION PROXIMAL TO THE
SUPRACONDYLAR AREA
• Fashion equal anterior and posterior skin flaps
• Just proximal to the level of intended bone
section, identify, doubly ligate and divide the
brachial artery and vein.
• Identify, gently pull distally, and divide at a
more proximal level the major nerves.
• Section the muscles of the anterior
compartment of the arm.
 Cont..
• Divide the triceps muscle 3.8 to 5 cm distal to
the level of bone section.
• Incise the periosteum circumferentially and
divide the humerus.
• Bevel the triceps muscle to form a thin flap,
carry it over the end of the bone, and suture it
to the humerus and the anterior muscle fascia.
• Close the wound as described earlier.
 SHOULDER AMPUTATIONS

• Causes include
malignant bone or soft-tissue tumors.

Less commonly arterial insufficiency and

rarely for trauma or infection.
 AMPUTATION THROUGH THE
SURGICAL NECK OF THE HUMERUS
• Place the patient supine with a sandbag well
beneath the affected shoulder.
• Begin the skin incision anteriorly at the level
of the coracoid process and carry it distally
along the anterior border of the deltoid
muscle to the insertion of the muscle and
along the posterior border of the muscle to
the posterior axillary fold.
 Cont..
• Connect the two limbs of the incision by a second
incision that passes through the axilla.
• Identify, ligate, and divide the cephalic vein.
• Separate the deltoid muscle and retract it laterally.
• Divide the pectoralis major muscle and reflect it
medially.
• Isolate, doubly ligate, and divide the axillary artery
and vein immediately inferior to the pectoralis
minor.
 Cont..
• Isolate the median, ulnar, radial and
musculocutaneous nerves and divide them.
• At a point intended bone section, sever the
long and short heads of the biceps, the
triceps, and the coracobrachialis.
• Section the humerus at the level of its neck
and smooth the cut end with a rasp
 Cont..
• Suture the long head of the triceps, both
heads of the biceps, and the coracobrachialis
over the end of the humerus
• Swing the pectoralis major muscle laterally,
and suture it to the end of the bone.
 Cont..
• Tailor the lateral skin flap and underlying
deltoid muscle to allow accurate apposition of
the skin edges.
• Suture the edges with interrupted
nonabsorbable material.
• Deep to the muscles and at the end of the
bone, insert drains or plastic tubes for suction
drainage.