Chapter 29 Upper Extremity Amputations

This chapter will discuss the parameters used to determine limb viability. General principles for the treatment of traumatically amputated limbs, from initial (damage control) surgery to definitive shaping and closure, will be presented. The techniques for definitive amputation of the upper extremity above and below the elbow will also be presented.

Learning Objectives

By the end of this module, participants should be able to do the following:

1. Discuss the parameters used to determine limb viability.
2. Discuss the decision-making process to determine whether to do damage control or to perform a formal amputation.
3. Discuss the initial management of traumatic amputations and near-amputations of the upper extremity.
4. Demonstrate formal above-the-elbow amputation with tension-free closure.
5. Demonstrate formal below-the-elbow amputation with tension-free closure.

General Considerations

• Determining limb viability after injury can be very challenging. No parameters clearly predicting limb loss are currently available.
• In remote or resource-constrained settings, the threshold for amputation may be lower.
• When deciding upon primary amputation versus limb salvage, the likelihood of meaningful limb function and the systemic consequences are key factors.
• Vessel exposure, revascularization, timely bony fixation, and adequate soft tissue debridement and coverage, as delineated in other chapters, are the pillars of extremity salvage. Resultant limb function may be poor even if salvage is technically accomplished.
• In patients who have been selected for damage control management, the focus should be on control of hemorrhage and rapid debridement of any nonviable tissue, leaving as much healthy tissue and bone as possible.
• If perfusion can be restored to the limb (either formally or with temporary shunting), any decision regarding amputation for nerve or bone loss can potentially be deferred.
• In the acute setting, it may be better to leave the wounds open and bring the patient back to the operating room in a delayed fashion once the physiology has been restored, allowing for further evaluation of the tissues, along with consideration for definitive debridement and formal amputation.
• Amputations that result from blast wounds (such as those seen in combat actions) should never be initially formally closed, as these wounds are heavily contaminated. Even with meticulous and extensive debridement, these wounds almost always need additional
• debridement prior to formal shaping and closure of amputations.

Surgical Principles

• Tourniquets can be used to minimize blood loss during the procedure.
• The level of amputation is the most distal area with adequate perfusion to provide healing and a functional stump.
• All nonviable tissue must be removed.
• Low-pressure irrigation or lavage with normal saline is important to decrease bacterial count and soiling. High-pressure pulse lavage irrigation should be avoided.
• Open circular or “guillotine” amputations should be avoided, as this sacrifices viable soft tissue and leads to the need for more proximal revision.
• Suture ligature is preferred to electrocautery for control of transected vessels.
• Nerves should be sharply transected with distal traction (Figure 1) to minimize the formation of postoperative neuromas.

• Initially, nonviable bone should be debrided, but formal division and shaping of the bone can be left to definitive closure of the amputation.
• During definitive shaping and closure of the amputation, the bone is resected proximal to the skin and muscle flaps where periosteum is adherent to the bone. Bone edges should be filed after transection to remove sharp or irregular edges.
• As long as adequate vascularized muscle is present to cover the bones, skin grafts can be used to preserve limb length and joints.
• Formal closure is accomplished in a multilayered fashion.
• Closed suction drains are recommended to reduce dead space.

Above-the-Elbow Amputation

• An above-the-elbow (supracondylar) amputation is defined as amputation at any level from the supracondylar region to the axillary fold.
• The patient is placed in the standard supine position, with the injured arm abducted 90° on an arm table board.
• As much length as possible should be preserved, but the level of bone sectioning should be a least 4 cm proximal to the elbow joint.
• A “fish-mouth” incision is made with equal anterior and posterior flaps, the length of each being half the diameter of the arm at that level (Figure 2).

• The brachial artery is identified in the groove between the triceps and biceps muscles, with the median nerve running medially (Figure 3). The brachial artery is ligated and the median nerve transected sharply with a scalpel as seen in Figure 1.
• The ulnar nerve is located about 2–3 cm posterior to the median nerve, below the medial aspect of the triceps muscle. The radial nerve courses on the posterior aspect of the humerus. Both nerves should be identified and transected sharply with distal traction, as seen in Figure 1.
• All the muscles are divided circumferentially, with the anterior muscles divided at least 1.5 cm distal to the amputation level.
• The triceps muscle is freed from the olecranon, leaving a flap long enough to cover the bone (usually 4–5 cm).

• The tissues around the humerus are cleared with a periosteal elevator, and the bone is divided with a saw (Figure 4). The bone edges are filed with a rasp to remove any irregularities or sharp edges.
• A tension-free myofascial flap is created by bringing the triceps over the bone edge and suturing the tendon to the fascia over the anterior muscles.
• A closed suction drain is placed deep to the fascia, and the skin is closed with interrupted nonabsorbable sutures or staples.

Below-the-Elbow Amputation

• When planning a below-the-elbow amputation, it is important to preserve as much length as possible, as forearm rotation and strength are proportional to length retained.
• Underlying soft tissues in the distal forearm consist of relatively avascular structures, such as fascia and tendon, and may not always offer adequate padding for the bony stump.
• A compromise between adequate functional length and wound healing is amputation at the junction of the distal and middle third of the forearm.
• A short below-elbow stump (at least 4–5 cm long) is preferable to a through- or above-the- elbow amputation.
• The patient is placed in the standard supine position, with the injured arm abducted 90° on an arm table board.
• A “fish-mouth” incision is performed to create equal volar and dorsal flaps (Figure 5).
• The radial artery is identified laterally and the ulnar artery medially (Figure 6). Both arteries should be ligated.
• The radial and ulnar nerve are identified, placed under distal traction, and divided sharply, as seen in Figure 1.
• After the muscles are divided, the median nerve can be identified deep between the radius and ulna, lying on the interosseous membrane. The median nerve should be transected sharply while under distal traction.
• The soft tissue around the ulna and radius is cleared with periosteal elevator, and both bones are divided equally with a saw. Bone edges are filed with a rasp.
• The anterior and posterior deep fascia are reapproximated and closed over the divided bones in a tension-free fashion.
• The skin is closed with interrupted mattress sutures.

Postoperative Care

• A soft, compressive dressing is applied to the stump.
• An elastic bandage is applied over the dressing, with more pressure distally than proximally to prevent stump edema.
• Rigid dressings and casts are unnecessary in the upper extremity.
• Immediate active range of motion for remaining joints should be implemented to prevent joint contraction.

Pitfalls and Complications

• Failure to fashion a tension-free myofascial flap can lead to ischemia or wound dehiscence.
• Inadequate debridement can lead to infectious sequela, including wound breakdown, sepsis, and abscess formation.
• Premature closure of wounds prior to adequate debridement or correction of patient physiology must be avoided.
• Traditionally taught (and antiquated) circular or guillotine amputation techniques will result in inadequate tissue to cover the bone.
• Areas of tissue injury that are not clearly necrotic or unsalvageable should be preserved at the initial operation and reassessed at the next operation.
• Joint contractures are prevented by immediate postoperative active motion.