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CURRENT CONCEPTS

Management of Upper Limb Amputations


Jeffrey A. Marchessault, MD, Patricia L. McKay, MD, Warren C. Hammert, MD

Acquired upper extremity amputations beyond the finger can have substantial physical,
psychological, social, and economic consequences for the patient. The hand surgeon is one
of a team of specialists in the care of these patients, but the surgeon plays a critical role in
the surgical management of these wounds. The execution of a successful amputation at each
level of the limb allows maximum use of the residual extremity, with or without a prosthesis,
and minimizes the known complications of these injuries. This article reviews current
surgical options in performing and managing upper extremity amputations proximal to the
finger. (J Hand Surg 2011;36A:1718–1726. Copyright © 2011 by the American Society for
Surgery of the Hand. All rights reserved.)

loss was estimated to itation period has been the key to successful out-

U
PPER EXTREMITY LIMB
account for 34% (541,000) of the 1.6 mil- comes.3
lion people living in the U.S. with limb
loss in 2005.1 Trauma accounted for 92% of hos- INITIAL WOUND MANAGEMENT
pital discharges due to upper extremity limb loss,
The initial management of a severe upper limb
of which 41,000 were proximal to the finger.1
trauma must take into account the overall condi-
Despite the regularity of these injuries, experience
tion of the patient because many of these patients
with these injuries is often limited to larger insti-
have multisystem injuries.4 Initial wound assess-
tutions. An integrated team approach has been
ment is performed during the advanced trauma life
shown to improve outcomes in amputee care.2 In
support survey in the emergency department or
addition to hand surgery, specialties involved in
operating room.5 Multiple injury severity scores
caring for amputees include physiatry, surgery,
have evaluated traumatized extremities, but they
medicine, occupational therapy, physical therapy,
have not unequivocally been applied to the upper
mental health, social work, nursing, and prosthet-
limb to help guide the decision for amputation.6,7
ics. Involvement of the patient and family in the
The unique functions of the upper limb make the
decision-making process, treatments, and rehabil-
surgeon attempt salvage, including replantation,8
From the Integrated Department of Orthopedics and Rehabilitation, Walter Reed National Military
whenever possible. Hence, during the initial eval-
MedicalCenter,Washington,DC;NormanM.RichDepartmentofSurgery,UniformedServicesUniver- uation, amputation should be emergently per-
sity of the Health Sciences, Bethesda, MD; Department of Orthopaedic Surgery and Rehabilitation, formed only if the limb puts the patient’s life at
University of Rochester Medical Center, Rochester, NY.
risk (Fig. 1). In situations in which the patient is
Received for publication July 12, 2011; accepted July 29, 2011. stable and amputation is likely, amputation should
No benefits in any form have been received or will be received related directly or indirectly to the be delayed for consultation with the patient and
subject of this article.
Current Concepts

family to improve their understanding and accep-


The opinions and assertions contained herein are the private views of the authors (J.A.M., P.L.M.) tance of the injury.9 Bastidas et al highlight the
and are not to be construed as official or as reflecting the views of the US Air Force, US Navy, or the
Department of Defense. importance of patient communication in their re-
Correspondingauthor:Lt.Col.JeffreyA.Marchessault,MD,WalterReedNationalMilitaryMed-
view of amputation-related litigation at their insti-
ical Center, Integrated Department of Orthopedics and Rehabilitation, 8901 Wisconsin Avenue, tution.10
Bethesda, MD 20889; e-mail: jeffrey_marchess@hotmail.com. Early surgical management of the severely in-
0363-5023/11/36A10-0030$36.00/0 jured limb should follow 3 basic tenets: thorough
doi:10.1016/j.jhsa.2011.07.025
sharp debridement of contaminated tissue, reten-

1718 䉬 ©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved.


MANAGEMENT OF UPPER LIMB AMPUTATIONS 1719

tion of all viable tissue for subsequent reconstruc- paramount concern. Skin grafts, dermal substitutes,13
tion or amputation coverage, and maintaining the filleted flaps,14 and free tissue transfer15 (Fig. 3) have
highest potential for patient function with or with- been used to help preserve limb length when the
out a prosthesis.11 The initial focus is often on the residual soft tissue is inadequate to allow stump
bony injury, yet the status and handling of soft closure without further bone shortening. The upper
tissues are often the best predictors of limb length extremity’s interaction with the surroundings de-
and final closure9 (Fig. 2). Nerve injury, no longer pends on the major joints to move the hand through
considered an indication space. Baccarani et al under-
for amputation in the EDUCATIONAL OBJECTIVES scored the importance of pre-
lower extremity,12 can be ● State the 3 basic tenets of early surgical management of the severely in- serving the elbow and shoul-
addressed later with re- jured limb. der with their proposed
pair, reconstruction, or ● Discuss options to preserve limb length when the residual soft tissue is algorithm using free tissue
transfer of nerve and ten- inadequate to allow stump closure without further bone shortening. transfer to preserve adequate
don. These transfers re- ● Discuss the goals of reconstruction with regard to partial hand length and joint function.15
quire working muscle amputation.
groups to power the termi- ● List challenges for fitting a wrist disarticulation. PARTIAL HAND
nal extremity. Hence, the ● Compare and contrast the role of myoplasty in forearm and elbow ampu- AMPUTATION
degree of muscle loss (or tations. When faced with a partial
remaining muscle func- hand amputation, preser-
tion) is most likely the Earn up to 2 hours of CME credit per JHS issue when you read the related vation of 2 sensate digits
best predictor of residual articles and take the online test. To pay the $20 fee and take this month’s able to oppose each other
function.9 Ultimately, the test, visit http://www.jhandsurg.org/CME/home. will allow some prehen-
decision to perform the sion16 (Fig. 4), and more
amputation is made when limb salvage would re- proximal level amputation is discouraged. Sal-
sult in a less functional outcome than the amputa- vage of a third digit allows for a more stable
tion and the patient understands and agrees with terminal pinch, improving the patient’s precision
this approach. motions.17
When the decision is made to amputate an upper Ray resection will reduce hand width, leading to
limb, preservation of the length and joint function are of decreased grip strength but improving the appear-

FIGURE 1: A Severe crushing injury to upper limb, requiring amputation. B, C Severity of injury precluded replantation and
resulted in transhumeral amputation.
Current Concepts

FIGURE 2: A Healed, atypical skin flaps allowed preservation of adequate length for B, C functional trans-radial amputation.

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1720 MANAGEMENT OF UPPER LIMB AMPUTATIONS

FIGURE 3: A Failed arm replant at the level of the humerus. B–E Preservation of humerus length with latissimus dorsi flap.
Current Concepts

FIGURE 4: A, B Loss of central 3 fingers and partial thumb left only functional small finger and thenar muscles. C Preservation of
these 2 sensate digits allowed rudimentary prehension to allow grasping large objects. The patient desired only a cosmetic
prosthesis.

ance of finger loss.17 Patient preference has been have been used for most levels and types of partial
toward precise motion over strength;18 these risks amputation to allow for restoration of several
and benefits should be discussed with the patient grasp patterns.19 The passive prosthesis acts as a
(Fig. 5). Passive prostheses for partial hand loss post to stabilize single or bimanual grasping. Ex-

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MANAGEMENT OF UPPER LIMB AMPUTATIONS 1721

FIGURE 5: A Partial hand amputation from saw injury. B, C Healed hand wounds preserving lateral pinch. Patient declined
prosthesis.

FIGURE 6: Healed wrist disarticulation following improvised explosive device injury A allowed 50° pronation B. Longer residual
limb precluded internal batteries or motorized wrist components to myoelectric prosthesis.

FIGURE 7: A Pediatric transradial amputation, resulting from improvised explosive device, with deep flexor muscles prepared for
myoplasty to radius and ulna. B, C Sutures through bone tunnels are passed through tendinous portion of muscle for coverage of
bone ends.

ternally powered prostheses exist20 but are not patient. Challenges facing the prosthetist at this
widely used by patients with a sensate hand. level include difficulty fitting in a wrist compo-
nent, decreased space for batteries and motors for
WRIST DISARTICULATION myoelectrics, and fewer terminal device choices.22
Amputation through the wrist preserves 100° to
Current Concepts

120° of pronosupination21 (Fig. 5). Preservation of TRANSRADIAL AMPUTATION


the triangular fibrocartilage complex might im- Transradial forearm amputation is the most com-
prove this motion.9 Excision of the radial and ulnar mon level of upper extremity amputation.22 The
styloids is recommended to prevent interference residual soft tissue, particularly muscle, must pro-
with prosthetic wear. The thick palmar skin is the vide adequate soft tissue coverage of the radius
preferred flap for coverage (Fig. 6). The longer and ulna. Myodesis of the deeper forearm muscles
extremity helps stabilize objects for the contralat- to the radius and ulna provides stable bone cover-
eral hand and can function as an assist hand to the age and prevents bone-on-muscle motion that can

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1722 MANAGEMENT OF UPPER LIMB AMPUTATIONS

FIGURE 8: Artist’s rendition of transradial amputation A beginning with fishmouth incision; B development of deep and
superficial flexor mass as well as extensor muscles; C myodesis performed with sutures passed through tendinous portions of
muscle, through bone tunnels, and passed back through muscle; D myodesis of superficial flexors and extensors sutured to each
other with some tension; and E muscles contoured with myofascial sutures to accommodate tension-free closure. (Drawings
courtesy of www.vesalius.com.)
Current Concepts

FIGURE 9: A Severe injury to upper extremity resulted in stiff, insensate hand. Patient elected transradial amputation for
prosthesis wear. B Extensor and flexor muscle mass mobilized. C Sutures in place for myodesis of flexor carpi ulnaris to bone to
prevent heterotopic ossification from forming synostosis. D, E Remaining flexor and extensor muscles myodesed over bone ends. F
Myofascial sutures placed to contour muscle bellies. G Stump closure. (Photographs courtesy of Dr. M. Fred Baechler.)

lead to bursitis23 (Fig. 7). Myoplasty of the super- cles is accomplished when the 2 techniques are
ficial flexor muscles to the extensor muscles must combined (Fig. 9). Myofascial closure, often indi-
be placed on tension to allow contraction of the cated for dysvascular tissue amputations,9 is not
muscles after closure (Fig. 8). Soft tissue coverage strong enough for muscle contraction and should
of the radius and ulna with tensioning of the mus- be performed only to help contour the remaining

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MANAGEMENT OF UPPER LIMB AMPUTATIONS 1723

FIGURE 10: A Car accident resulted in elbow disarticulation. B, C Muscle flaps from lateral and medial condyles constructed to
aid in distal stump coverage. D Longer poster skin flap brought anterior for suture closure.

muscle bellies to enhance closure. Contractions of through the retained metaphyseal flares of the dis-
the superficial muscle groups are essential to trig- tal humerus; however, the length makes fitting a
ger myoelectric prosthetics. Amputation 6 to 8 cm premade prosthetic elbow difficult without extend-
proximal to the wrist joint allows for ample muscle ing the limb length. Passive elbow joints with
coverage11; however, 10 cm proximal is advocated external hinges can be fabricated, but the appear-
for increased prosthetics options.22 Forearm am- ance can be a concern for patients with high aes-
putation at least 5 cm distal to the elbow joint will thetic expectations, leading to prosthetic rejec-
allow fitting of a prosthesis.24 Although pronosu- tion.25
pination is lost with more proximal transradial When performing a disarticulation, the skin
amputation, preservation of elbow motion is flaps should be designed to bring the posterior flap
worthwhile. Transfer of the biceps tendon to the in an anterior direction (Fig. 10). Atypical skin
Current Concepts

ulna should be considered to lessen the risk of flaps should be used whenever needed to provide
flexion contracture with proximal transradial am- coverage. Sharp dissection of the triceps tendon
putations.9 and periosteum off the olecranon will provide ad-
ditional length to allow myoplasty of the triceps to
ELBOW DISARTICULATION the anterior muscles. The forearm extensor mus-
Elbow disarticulation is a divisive level with ad- cles are left attached to the lateral humeral condyle
vantages and disadvantages. This level provides and sutured to the remnants of the flexor muscles
rotational control of the upper limb prosthesis on the medial side to provide coverage to the end

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1724 MANAGEMENT OF UPPER LIMB AMPUTATIONS

FIGURE 11: A Traumatic pediatric hand amputation resulting in partial degloving of forearm skin. B Skin used in wrist
disarticulation required only full-thickness skin graft from groin to expedite coverage of healing dermis.

of the repair. Myofascial sutures are used as


needed, and the muscle bellies are contoured for
coverage by the skin flaps.

ABOVE-ELBOW AMPUTATION
When the condyles cannot be preserved, amputa-
tion of the humerus 10 cm proximal to the olecra-
non tip enables the use of all available prosthet-
ics.24 This level allows fitting of a variety of
passive, body-powered, myoelectric, and activity-
specific elbows with adequate length to suspend
and control the prosthesis. Rotational control of
the prosthetics at this level can be aided by a
Marquardt angulation osteotomy. The osteotomy
creates an angle of 70° to 110° at the distal hu-
merus through a dorsal, volar, or cuneiform osteot-
omy.26 Straightening of the osteotomy over time
has been seen in patients less than 16 years of
age.26
Preservation of shoulder function improves the am-
putee’s likelihood of prosthetic use25 because the shoul-
der girdle will stabilize the limb while in space. Tran-
shumeral amputations should preserve at least 5 to 7 cm FIGURE 12: Heterotopic ossification horn extending from
of the proximal humerus to maintain deltoid muscle ulna, causing pain with prosthetic wear.
function, improve prosthetic fit, and provide a more
acceptable shoulder contour.24 further growth, increased skin elasticity and vas-
cularity, and the future problem of terminal over-
PEDIATRIC UPPER EXTREMITY AMPUTATIONS growth.27
Congenital limb deficiencies in the pediatric pop- Preservation of growth plates allows continued
Current Concepts

ulation outnumber acquired amputations in devel- growth of the limb and decreases ultimate size
oped countries.27 Similar to adult injuries, the ma- mismatch with the opposite limb. Hence, disartic-
jority of pediatric acquired upper extremity ulation at the level of the wrist and elbow have
amputations involve the fingers and are traumatic additional advantages in the pediatric population.
in nature.28 Like their adult counterparts, pediatric The increased skin elasticity, with its robust blood
and adolescent amputees have improved results supply, will improve closure and preserve length
with a team approach, including emotional and (Fig. 11). Terminal overgrowth of bone is more
psychological issues affecting rehabilitation. 27 commonly seen in lower extremity amputations,
Three important differences between adult and pe- amputation through the diaphysis of bone, and in
diatric amputations are the children’s potential for younger children.29

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MANAGEMENT OF UPPER LIMB AMPUTATIONS 1725

SURGICAL COMPLICATIONS 7. Slauterbeck JR, Britton C, Moneim MS, Clevenger FW. Mangled
extremity severity score: an accurate guide to the treatment of the
Tintle et al presented complications in 42 of 100 severely injured upper extremity. J Orthop Trauma 1994;8:282–285.
upper extremity amputations performed for trau- 8. Graham B, Adkins P, Tsai TM, Firrell J, Bredenbach WC. Major
matic injuries in U.S. military personnel.30 Heter- replantation versus revision amputation and prosthetic fitting in the
upper extremity: a late functional outcomes study. J Hand Surg
otopic ossification (HO), causing pain or interfer- 1998;23A:783–791.
ing with prosthetic wear, was the most common 9. Shawen SB, Doukas WC, Shrout JA, Ficke JR, Potter BK, Hayda
reason (19%) for repeat surgery (Fig. 12), followed RA, et al. General surgical principles for the combat casualty with
by wound infection (13%), neuroma excision limb loss. In: Lenhart MD, ed. Combat care of the amputee. Wash-
ington, DC: Borden Institute, 2009:117–150.
(9%), scar revision (5%), and contracture release 10. Bastidas N, Cassidy L, Hoffman L, Sharma S. A single-institution
(4%). The Tintle et al retrospective review showed experience of hand surgery litigation in a major replantation center.
decreased pain medication use after surgical treat- Plast Reconstr Surg 2011;127:284 –292.
11. Tintle SM, Baechler MF, Nanos III GP, Forsberg JA, Potter BK.
ment of the complications. Traumatic and trauma-related amputations: Part II: Upper extremity
Heterotopic ossification resection at 6 months and future directions. J Bone Joint Surg 2010;92A:2934 –2945.
has been shown to be effective in several stud- 12. MacKenzie EJ, Bosse MJ. Factors influencing outcome following
ies.31–33 Potter et al excised HO in 25 patients with limb-threatening lower limb trauma: lessons learned from the lower
extremity assessment project (LEAP). J Am Acad Orthop Surg
6 complications including acute infection, seroma, 2006;14(10 Spec No):S205–S210.
and recurrent HO.31 Local radiation or nonsteroi- 13. Helgeson MD, Potter BK, Evans KN, Shawen SB. Bioartificial
dal anti-inflammatory drugs, in conjunction with dermal substitute: a preliminary report on its use for the management
of complex combat-related soft tissue wounds. J Orthop Trauma
HO resection, have not been standardized.34 One
2007;21:394 –399.
treatment or the other seems prudent.31 14. Kuntscher MF, Erdmann D, Homann HH, Steinau HU, Levin SL,
Traction neurectomy has been the standard Germann G. The concept of fillet flaps: classification, indications and
treatment of nerves when performing amputation analysis of their clinical value. Plast Reconstr Surg 2001;108:885–
896.
or amputation revision. Ducic et al35 reported im- 15. Baccarani A, Follmar KE, De Santis G, Adani R, Pinelli M, Inno-
proved pain relief in 17 of 20 residual limb pa- centi M, et al. Free vascularized tissue transfer to preserve upper
tients treated with neuroma excision and implan- extremity amputation levels. Plast Reconstr Surg 2007;120:971–981.
16. Eardley GP, Stewart PM. Early management of ballistic hand
tation into muscle, using the technique described
trauma. J Am Acad Orthop Surg 2010;18:118 –126.
by Dellon and Mackinnon.36 17. Moran SL, Berger RA. Biomechanics and hand trauma: what you
Amputation is the final result when surgical need. Hand Clin 2003;19:17–31.
salvage of the upper extremity is not possible. 18. Murray JF, Carman W, MacKenzie JK. Transmetacarpal amputation
of the index finger: actual assessment of hand strength and compli-
Preserving bony length, as well as shoulder and cations. J Hand Surg 1977;2:471– 481.
elbow function, improves the successful use of a 19. Dillingham TR. Rehabilitation of the upper limb amputee. In: Za-
prosthesis by the patient and can be accomplished jtchuk R, ed. Rehabilitation of the injured combatant. Volume 1.
with a multitude of techniques. The ultimate goal Washington, DC: Borden Institute, 1998:33–77.
20. Weir RF, Grahn EC, Duff SJ. A new externally powered, myoelec-
of amputation surgery is to provide a sensate limb trically controlled prosthesis for persons with partial hand amputa-
that can best interact with the patient’s environ- tions at the metacarpals. J Prosth and Orthot 2001;12:26 –31.
ment with and without a prosthesis. 21. Taylor CL. The biomechanics of control in upper-extremity prosthe-
ses. Artif Limbs 1955;2:4 –25.
22. Lake C, Dodson R. Progressive upper limb prosthetics. Phys Med
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3. Pasquina PF, Bryant PR, Huan ME, Roberts TL, Nelson VS, Flood Rosemont, IL: American Academy of Orthopaedic Surgeons, 2004;
Current Concepts

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emergency departments: United States, 1990 –2002. Pediatrics topic ossification in the medial elbow. J Shoulder Elbow Surg
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JOURNAL CME QUESTIONS

Management of Upper Limb Amputations What option is used to preserve limb length when
the residual soft tissue is inadequate to allow
What are the 3 basic tenets of early surgical stump closure without further bone shortening?
management of a severely injured limb?
a. Skin grafts
a. Debridement, retention of viable tissue, main-
b. Dermal substitutes
tainence of highest potential for function
c. Filleted flaps
b. Debridement, early coverage, antibiotics
c. Retention of viable tissue, vascular reconstruc- d. Free tissue transfer
tion, antibiotics e. All of the above
d. Maintain maximum length, bony coverage, re-
turn to operating room in 48 hours
e. Debridement, early coverage, return to operating
room in 48 hours

To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.


Current Concepts

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