上肢截肢医学知识专题讲座.pptx

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Amputations of the Upper Extremity,Andrew H.Schmidt,MD,Created March 2023,General Principles,Disability ratings,Loss of upper extremity:50%,Loss of hand:45%,Thumb amputation:23%,Indications for Amputation,Trauma,Severe open fracture with extensive skin and muscle loss,neurologic injury,Flail limb(brachial plexus injury),Tumours,Peripheral vascular disease,Infection,Brachial 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 situation,the patient will not likely be able to use a prosthesis.,Brachial 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.,Surgical Principles,Level of amputation-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.,Techniques,Upper Arm Amputations,Forequarter amputation,Shoulder disarticulation,Proximal above-elbow amputation,Distal above-elbow amputation,Elbow disarticulation,Forequarter Amputation,Done most often for malignancy,Difficult skin flaps,Poor cosmesis,Shoulder Amputations,Proximal humeral amputations behave like a shoulder disarticulation,but have better cosmesis and prosthesis suspension,Elbow/Humeral Amputation,Better prosthetic suspension with elbow disarticulation but poorer cosmesis,Better function with distal humeral amputation(3.5 cm proximal to elbow),Forearm(Below-Elbow)Amputations,Forearm proximal,Forearm distal,Wrist disarticulation,Transcarpal,Below-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 elbow,as long as the biceps insertion is intact.,Surgical 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.,Wrist Disarticulation,Retains distal radio-ulnar joint and therefore forearm rotation.,Preservation distal radius improves prosthetic fitting.,No need to retain carpal bones.,Should perform tenodesis of major forearm muscle groups.,Wrist Disarticulation,Disadvantages:,Harder to fit for myoelectric units because less space is available.,Hand 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.,Ray Amputation,Generally includes distal half of metacarpal,Can transpose the index to long finger in the case of long ray amputations.,For index ray resection,reimplant first dorsal interosseous into long finger.,Ring/Middle Finger Amputation,Preserve proximal phalanx,Close gap,Suture transverse ligaments,Consider metacarpal transfer,Proximal Phalanx Amputation,Dorsal skin needed for closure.,Consider the“lasso procedure”,in which the FDS tendon is passed around the A2 pulley and sutured to itself.The tension of the FDS must be checked to allow full finger extension.,Middle 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.,Distal Phalanx Amputation,Indicated when there is less than 5 mm of sterile matrix remaining.,Shorten and perform primary closure.,Leave FDP and extensor insertion alone if possible.,Fingertip Injuries,If no bone exposed,allow healing by secondary intention.,Consider V-Y advancement flaps when bone exposed vs.bone shortening.,Full-thickness skin graft,Thenar flap,Upper 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),Management after Amputation,Rigid vs soft dressing,Compression,Avoid proximal compression,Early prosthetic fitting,Complications,DIP disarticulation:Avoid intrinsic plus finger deformity by releasing lumbrical insertion as well as FDP,if performed.,Quadriga:weak grasp in remaining fingers due to tethering of FDP by scarring at the amputation site.Do not suture flexor to extensor tendons.,Complications,Hematoma,Infection,Necrosis,Contractures,Neuroma,Phantom pain,Terminal overgrowth(children),Above Elbow Prostheses,Operated by two control cables:,One cable flexes 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.,Below Elbow Prostheses,Operated by one control cable that controls the terminal device.,Activated by scapular abduction and shoulder flexion.,Elbow hinge may or may not allow forearm rotation.,Terminal Devices:,Functional“claws”or hooks,Voluntary opening versus closing,Myoelectric,Cosmetic hands,Voluntary Opening,Most popular,Gripping provided by rubber bands.,Voluntary Closing,Held open by a spring,Allow graded prehension and grip.,Patients may tire more easily.,Bulkier,less durable,more expensive.,Myoelectric,Works better close to the body and overhead.,Return to,Upper Extremity,Index,