Elbow Disarticulation Amputation

Introduction

Over the years, advances in upper extremity amputation management have included improved surgical techniques, preoperative management, postoperative management, and prosthetic management. In the past decade the greatest advances have occurred in prosthetic technologies, fabrication techniques, and components to more effectively replace the lost function of the extremity.

Demographics

Trauma is the leading cause of upper extremity limb loss, accounting for 80% of upper extremity amputations. Tumor is the most common cause of upper extremity amputation in children. From 1988 to 1996 the rate of trauma- and cancer-related amputations declined. This decline was likely due to improved surgical reconstruction, advances in limb-sparing techniques, and prevention through improved occupational safety awareness.

Following trauma the decision to attempt limb salvage or proceed with amputation is complex. There is a bias toward limb salvage in upper extremity trauma surgery. The functional demands of the upper extremity are different from those of the lower extremity. Lack of weight-bearing forces, the ability to function with partial sensation, and limited function of upper extremity prostheses are reasons cited for limb salvage and replantation.

Elbow Disarticulation Amputation

Generally speaking, a transhumeral amputation is preferable to amputation at the elbow joint. The transhumeral level allows accommodation of an elbow joint without unnatural extension of arm length as is the case with elbow disarticulation. Elbow disarticulation has advantages and disadvantages when compared with the transhumeral level of amputation. An elbow disarticulation amputation allows anatomic suspension and rotational control of the prosthesis and reduces rotation of the socket on the residual limb. The major disadvantages are the suboptimal cosmetic appearance and limited availability of elbow components. The external hinge elbow mechanisms for elbow disarticulations are not very cosmetically pleasing.

In children with upper limb deficiency or amputation, growth and development, bony overgrowth, and more rigorous use of a prosthesis need to be considered. An elbow disarticulation amputation level for this population optimizes residual limb length and avoids bony overgrowth. The slowed humeral growth after elbow disarticulation results in a humeral length at maturity that allows the use of a prosthetic elbow while retaining the suspension and rotational control of an elbow disarticulation. In children, transhumeral amputation results in a high incidence of bony overgrowth. An elbow disarticulation preserves the epiphysis, prevents bony overgrowth, and maintains growth potential; therefore elbow disarticulation is the level of choice for children.

Amputation Surgery

Controversy exists whether a long transhumeral amputation or an elbow disarticulation. However, there are situations where elbow disarticulation may be preferred. Amputation surgery should be viewed as a reconstructive procedure. The basic principle of all upper limb amputations is preservation of maximal length consistent with optimal function, control of disease, and satisfactory surgical wound management. If the distal part of the humerus is normal and intact, then humeral shortening to preserve the condyles can be performed. The humeral condyles can prove invaluable for rotational control of a prosthesis. Adherent scarred distal tissues or redundant soft tissue should be avoided.