Chapter 119 - UE disease - amputation Flashcards
percentage of amputations that are UE
10-25%
Percentage of amputations that are fingers or wrist
93%
Causes of UE amputations
Trauma 80-90% Vascular disease 7% Tumour 0.6%
Reasons that UE amputations in trauma are less common than in LE
1) LE increase infection and non union 2) blast injury worse in LE 3) higher threshold for UE amputation due to lack of functional prosthetics
Rate of amputation after attempted salvage in military trauma
10%
Healing cutoff used for UE perfusion minimum
Digit pressure > 40 mmHg Wrist pressure > 60 mmHg tcPO2 > 40 mmHg
Benefit of free flap over pedicled flap in UE
1) better matching of tissue 2) avoid additional surgery to thin flap 3) Lack of joint limitation
Neuroma key points in UE
1) Difficult to prevent 2) Divide nerve far from external stimuli 3) early post-op therapy for sensory re-education
Tried strategies for preventing UE neuroma
1) proximal or distal ligation 2) coagulation 3) chemical ablation 4) simple or traction division 5) attach to other nerves 6) immediate burrial
Myodesic definition
Suture tendon or muscle to bone
Myoplastic definition
Suture tendon or muscle to opposite functional group
Principle of tendon repair with myodesic or myoplastic in UE
Ok in above wrist but not ok in fingers –> will lose functionality
Composite reattachment definition
Reattach without specific revascularization
Composite reattachment in UE
1) poor results 2) only done in < 2 year of age
Finger amputation key points
1) if insertion of flexor + extensor digitorum compromised then disarticulation 2) Quadriga effect: if flexor sew to extensor then weaker grip 3) keep enough bone to support nail bed 4) secondary intent closure is ok if < 1 cm^2 5) nerve divided 1cm from tip
Local flap closure of hand types
1) Kutler flap: lateral V-Y flap to close central tip defect 2) Atasoy flap: palmar V-Y flap 3) Palmar flap: soft tissue above tendon sheath elevated and advanced 4) Radius/ulnar flap: local flaps then STSG to donor site
Problem with local flaps in UE
joint stiffness due to obligatory immobility
Proximal phalanx amputation
Stump not functional but keep until patients want ray amputation
Ray amputation technique in finger
Longitudinal dorsal incision over metacarpal and palmar over proximal phalanx or Racket incision
Finger ray amp reduces palm size by this much
20-25%
Thumb function is this much of total hand function
40%
Pollicization definition
Reconstruct proximal thumb amputation using index, osteoplasty, bone lengthen, toe to thumb transfer
Wrist amputation technique
1) Disarticulation 2) Long palmer, short dorsal flap 3) Nerve retraction (superficial branch of radial, brachial cutaneous nerve
Ilizarov technique
Distraction osteogenesis
Forearm amputation location
Joint of distal 1/3 to mid 1/3
Krukenberg procedure
Pincer between radius and ulnar
Indication for Krukenberg procedure
1) Bilateral injury 2) Blind 3) prosthetic not practical
Site of transhumeral amp
4 cm proximal to elbow to accommodate for prosthetic joint
Ways to lengthen stump
1) Ilizarov technique 2) fibular flap 4) free flap
Techniques in shoulder disarticulation
1) Berger Anterior approach 2) Littlewood posterior approach differ in exposure of vascular structure behind clavicle
Rate of infection UE amp
5%
Failure of flap/reconstruction in UE amp
3-8%
Revision rate for UE amp
42%
Phantom pain in UE amp
40-50% worse in dominant hand
Psych issues after UE amp
30-40%
Rehab principle in UE amp
1) tissue shrink/shape 2) desensitization 3) increase ROM 4) skin health and mobility 5) muscle strength 6) augment independence 7) prosthetic options
Types of prosthetics for UE amp
1) Aesthetic prosthetic 2) body-powered prosthetic 3) myoelectrically control prosthetic
Hand transplant cases so far
70 cases between 1964 - 2013
% of patients that do not want prosthetic after UE amp
40%
Functional employment after UE amp
70% if college education 23% without
Forearm amputation anatomy and crosssection
Upper arm amputation anatomy and crosssection
Shoulder disarticulation anatomy
