Upper Extremity Amputations

Upper extremity amputations are less common than lower extremity amputations in both wartime and civilian settings. During wartime, the incidence of upper extremity amputees is between 13% and 25% of all extremity amputations. A survey of the U.S. National Trauma Databank found 8910 amputations reported from 2000 to 2004, of which 41.1% of those with single-limb amputation were of the upper extremity.

Indications for surgery for the upper extremity differ from those for the lower extremity. The function of a hand is still far more complex than the best prosthetic hand, so care should be taken to preserve the upper extremity with extensive limb salvage techniques, if feasible. The most common indication for upper extremity amputation surgery in the United States is trauma, with a smaller number indicated as the result of tumor or vascular disease.

Major amputations of the upper extremity follow the same principles of management as for the lower extremity. The ultimate objective is to provide a functional limb for the patient, with a well-padded, pain-free residual limb that is without prominences. For all types of amputation, a myodesis (where muscle tendon is attached to bone via suture and bone tunnels) should be done to provide residual limb soft tissue coverage and to anchor the muscle for residual limb function.

There is high rate of prosthetic use for patients with transradial amputations, but prosthetic use for shoulder disarticulation and for forequarter and transhumeral amputations remains below 50%. Efforts of targeted muscle reinnervation, in which remaining arm nerves are transferred to muscles in the chest or shoulder, has shown promise to improve function in patients using a myoelectric prosthesis. The implanted nerves allow a greater, more specific signal to help the myoelectric arm. Whether this will improve the long-term outcome for transhumeral or more proximal amputations remains to be seen.

Early fitting (within 30 days after the amputation) has been shown to increase acceptance rates of prosthesis use by upper extremity amputees. Because of this, a prosthesis should be fitted early, fitting either a temporary or permanent prosthesis, depending on the residual limb.

Shoulder Disarticulation

Burkhalter reported that nine of 96 upper extremity amputees had a shoulder disarticulation at Fitzimmons Army Hospital after the Vietnam war. The majority of patients in the series had amputations as a result of war wounds. This procedure is for nonsalvageable proximal arm injuries or for severe brachial plexopathies.

The surgical technique most often cited for shoulder disarticulation was reported by Slocum after caring for amputees during World War II. The patient is placed on the operating room table at a 45-degree angle. An anterior incision is made from the coracoid just medial to the deltoid muscle. As the incision is carried distally, it is then brought circumferentially around the arm and proximally into the axilla.

Once the site is opened through the skin, the cephalic vein is identified and ligated. The deltoid is retracted laterally, and the pectoralis major is incised near its insertion and retracted medially. The axillary artery and vein and the thoracoacromial artery are then isolated and ligated before transection. The radial, musculocutaneous, ulnar, and median nerves are isolated, drawn into the field, ligated, and transected as proximally as possible. Next, the insertions of the coracobrachialis, teres minor and teres major, the deltoid, and the origin of the triceps are incised, followed by the subscapularis and the anterior joint capsule. Once the humerus is dissected free, the limb may be removed. The deltoid is then sutured inferior to the glenoid to cover the open wound, and the skin is closed ( Figure 1 ).

Postoperative care should include close monitoring of the patient for the first 24 hours. There is relatively little fluctuation in the shape of the amputation site after wound healing; therefore the patient may be fitted initially with a permanent prosthesis. In one series, three of nine patients with shoulder disarticulations became successful prosthetic wearers.