WK1: UL Amputation Surgery, Evaluation, and Anatomy Flashcards
WD and TR Surgery
Objectives
- Maximize precise function
- provide a good cosmetic result
WD and TR Surgery
Other considerations
- patient and family participation in decisions
- coordinated rehabilitation
- Early consultation with prosthetist and early prosthesis fitting
Skeletal Considerations
WD and TR Surgical Techniques
- Preserve as much bone as possible
- consider all options for soft tissue envelope
- styloids (WD) may be contoured if prominent
- dictates leverage
Myodesis
WD and TR Surgical Techniques
- preferred method
- cut muscles/tendons are sutured eto bone
- physiological tension
- preserves muscle function for potential myoelectric control
Myoplasty
WD and TR Surgical Techniques
- provides soft tissue loading
- attachment of agnosit to antagonist muscles
- secondary to myodesis which has greater stability
- may be performed for distal end soft tissue coverage
Nerves
WD and TR Surgical Techniques
- Traditional approach: gentle traction neurectomy
- painful neuromas are very common
WD Surgery Advantages
- preservation of distal radioulnar joint
- preserves pronation/supination range of approx 100-120 deg
- increase leverage due to limb length
WD Surgery Disadvantages
- Length limits wrist/TD component options
TR Surgery Considerations
- at least 2/3 of forearm length should be maintained when practical
- Removal of 6-8 cm allows for soft tissue envelope and allows “space” for distal components
- Tissue should be superimposed between radius and ulna to prevent painful radioulnar convergence
TMR
Surgical Approaches for Nerve Treatment
- targeted muscle reinnervation
- initially implemented as a way to improve muscle activation for myoelectric prosthesis control
- secondary benefit: Reduction of neuroma formation and associated reduction of pain
Regenerative Peripheral Nerve Interface
Surgical Approaches for Nerve Treatment
- no neuroma formation in animal subjects
- human subject able to proportionally control prosthetic hand in real time
- reduces phantom limb pain
Strength
Upper Limb Amputation Evaluation
- Strength should be evaluated for: Gross motions, muscle belly contractions
- possible sources of weakness: Loss of lever arm, nerve damage, lack of myodesis, deconditioning
Elbow Flexion ROM
Upper Limb Amputation Evaluation
- treat as baseline (ROM without prosthesis)
- Goals to maximize uses of range along with a prosthesis
some cases cost of stability of px can reduce available rom at joint
Forearm Pronation/Supination
Upper Limb Amputation Evaluation
- WD will preserve more of this motion
Limb Length Effect on Forearm Pronation/Supination
Upper Limb Amputation Evaluation
- Shorter skeletal length, smaller preserved ROM for total forearm rotation
- WD: 120 of availble forearm rotation range
- Medium: 100 deg
- Short: 60 deg
- Very Short (35% or less of full skeletal forearm length): 0 deg
Carrying Angle of Elbow
Upper Limb Amputation Evaluation
- angle that exists at the elbow in the coronal plane while in anatomical position
- cubitus varus/valgus
- male: 5-10 deg
- female: 10-15 deg
- naturally be preserved with TR amputation
Hanging Angle
Upper Limb Amputation Evaluation
- position of elbow flexion observed when person is standing in relaxed position
- TR amputation loss of weight of hand can cause elbow to in greater flexion at rest than sound side
- Distal components will reduce elbow flexion angle at rest
Skin Integrity
Upper Limb Amputation Evaluation
- Skin Grafts
- Wounds: healing, closed
- Scars: adherent, invaginated
- Skin thickness: firm, fragile
Anatomical Landmarks for ULP
- Most critical for measurements: acromion, epicondyles, thumb tip
Carlyle Formula
- Acromion to lateral epi = acromion to mech elbow = **.19 x height **
- lateral epi to thumb tip = lateral epi to distal TD = .21 x height
- For bilateral, dont have anatomical forearm length to use
