1、上肢截肢医学知识上肢截肢医学知识专题讲座专题讲座General Principles Disability ratings Loss of upper extremity:50%Loss of hand:45%Thumb amputation:23%上肢截肢医学知识专题讲座2Indications for Amputation Trauma Severe open fracture with extensive skin and muscle loss,neurologic injury Flail limb(brachial plexus injury)Tumours Peripheral
2、vascular disease Infection上肢截肢医学知识专题讲座3Brachial Plexus Injury If the arm is flail and patient does not have scapulothoracic control,then the patient is a candidate for Above-Elbow Amputation.This unloads the shoulder joint and reduces subluxation resulting from the weight of the arm.In this situatio
3、n,the patient will not likely be able to use a prosthesis.上肢截肢医学知识专题讲座4Brachial Plexus Injury If the scapulothoracic joint can be stabilized,then shoulder fusion and muscle transfers to allow active elbow flexion may allow for Below-Elbow Amputation.上肢截肢医学知识专题讲座5Surgical Principles Level of amputati
4、on-usually best to maintain length Skin flaps-keep all viable skin initially Nerves-resect sharply,bury to avoid neuromas Dont close primarily in trauma,infections.上肢截肢医学知识专题讲座6Techniques上肢截肢医学知识专题讲座7Upper Arm Amputations Forequarter amputation Shoulder disarticulation Proximal above-elbow amputatio
5、n Distal above-elbow amputation Elbow disarticulation上肢截肢医学知识专题讲座8Forequarter Amputation Done most often for malignancy Difficult skin flaps Poor cosmesis上肢截肢医学知识专题讲座9Shoulder Amputations Proximal humeral amputations behave like a shoulder disarticulation,but have better cosmesis and prosthesis susp
6、ension上肢截肢医学知识专题讲座10Elbow/Humeral Amputation Better prosthetic suspension with elbow disarticulation but poorer cosmesis Better function with distal humeral amputation(3.5 cm proximal to elbow)上肢截肢医学知识专题讲座11Forearm(Below-Elbow)Amputations Forearm proximal Forearm distal Wrist disarticulation Transca
7、rpal上肢截肢医学知识专题讲座12Below-Elbow Amputation Very functional,70-80%of patients are able to use a prosthesis successfully.Important to maintain forearm length,because forearm strength and rotation are proportional to the residual length.Even a short BEA is preferable to amputation through or above the el
8、bow,as long as the biceps insertion is intact.上肢截肢医学知识专题讲座13Surgical Pointers Below Elbow Amputation For short stumps,leave the ulna a little longer than the radius For long stumps,the radius should be 1-2 cm longer than the ulna.上肢截肢医学知识专题讲座14Wrist Disarticulation Retains distal radio-ulnar joint a
9、nd therefore forearm rotation.Preservation distal radius improves prosthetic fitting.No need to retain carpal bones.Should perform tenodesis of major forearm muscle groups.上肢截肢医学知识专题讲座15Wrist Disarticulation Disadvantages:Harder to fit for myoelectric units because less space is available.上肢截肢医学知识专题
10、讲座16Hand Amputations Preserve length,function,and sensation Done as a salvage procedure Primary amputation performed only for irreversible loss of blood supply and tumours.Salvage thumb whenever possible.上肢截肢医学知识专题讲座17Ray Amputation Generally includes distal half of metacarpal Can transpose the inde
11、x to long finger in the case of long ray amputations.For index ray resection,reimplant first dorsal interosseous into long finger.上肢截肢医学知识专题讲座18Proximal Phalanx Amputation Dorsal skin needed for closure.Consider the“lasso procedure”,in which the FDS tendon is passed around the A2 pulley and sutured
12、to itself.The tension of the FDS must be checked to allow full finger extension.上肢截肢医学知识专题讲座20Middle Phalanx Amputation Try to maintain FDS insertion into base of middle phalanx.If FDS insertion is avulsed,there is little to gain by saving the middle phalanx.上肢截肢医学知识专题讲座21Distal Phalanx Amputation I
13、ndicated when there is less than 5 mm of sterile matrix remaining.Shorten and perform primary closure.Leave FDP and extensor insertion alone if possible.上肢截肢医学知识专题讲座22Fingertip Injuries If no bone exposed,allow healing by secondary intention.Consider V-Y advancement flaps when bone exposed vs.bone s
14、hortening.Full-thickness skin graft Thenar flap上肢截肢医学知识专题讲座23Upper Limb Prosthetics Function to position the hand in space.Limb length and joint salvage are directly related to functional outcome.Sensation important for function.Early fitting(85%if in 30 days,50%with late fitting)上肢截肢医学知识专题讲座24Manag
15、ement after Amputation Rigid vs soft dressing Compression Avoid proximal compression Early prosthetic fitting上肢截肢医学知识专题讲座25Complications DIP disarticulation:Avoid intrinsic plus finger deformity by releasing lumbrical insertion as well as FDP,if performed.Quadriga:weak grasp in remaining fingers due
16、 to tethering of FDP by scarring at the amputation site.Do not suture flexor to extensor tendons.上肢截肢医学知识专题讲座26Complications Hematoma Infection Necrosis Contractures Neuroma Phantom pain Terminal overgrowth(children)上肢截肢医学知识专题讲座27Above Elbow Prostheses Operated by two control cables:One cable flexes
17、 elbow and opens terminal device.Cable controlled by humeral flexion or scapular protraction.Second cable locks and unlocks the elbow.Cable controlled by shoulder extension,abduction,and depression.上肢截肢医学知识专题讲座28Below Elbow Prostheses Operated by one control cable that controls the terminal device.A
18、ctivated by scapular abduction and shoulder flexion.Elbow hinge may or may not allow forearm rotation.上肢截肢医学知识专题讲座29Terminal Devices:Functional“claws”or hooks Voluntary opening versus closing Myoelectric Cosmetic hands上肢截肢医学知识专题讲座30Voluntary Opening Most popular Gripping provided by rubber bands.上肢截肢医学知识专题讲座31Voluntary Closing Held open by a spring Allow graded prehension and grip.Patients may tire more easily.Bulkier,less durable,more expensive.上肢截肢医学知识专题讲座32Myoelectric Works better close to the body and overhead.Return to Upper Extremity Index上肢截肢医学知识专题讲座33
