This document provides information about elbow disarticulation amputations including the level of amputation, statistics, causes, management, surgical issues, prosthetic components, and functional restoration. Some key points are: - Elbow disarticulation permits normal bone growth in children and allows for a faster and bloodless surgery compared to higher levels of amputation. - In the US in 1996, 5 per 1000 amputation cases involved the upper limb, mostly affecting men aged 15-45. Upper limb amputations are less common than lower limb with a ratio of 1:6. - Causes include congenital limb deficiencies, trauma, neoplasms, vascular issues like frostbite, and infections.

1. Elbow disarticulation
Dr. G A Joshi
AP(PMR/ME)
CRC-Bhopal

2. Topics
• Background
• The Level
• Statistics
• Causes
• Management
• Surgical issues
• Prosthetic Components
• Functional restoration

3. Background
• Upper limb is the prehensile organ for human
beings
• Elbow ROM of 0o-150o provides versatile reach
combining with shoulder and wrist
• Wars have given the most amputees.
• Army has developed most of prosthetics
(www.indianarmy.gov.in/writereaddata/Docu
ments/165.pdf)

4. The level of elbow disarticulation
Advantages
• Permits normal bone
growth in children
• Faster bloodless surgery
• Good suspension
• Good rotational control
• More functional than
transhumeral esp. in
bilateral amputees
• Bilateral cases can use
pencil for writing
Disadvantages
• Poor Cosmesis
• Less durable prosthetic
elbow joints

5. Statistics
• 5 per thousand (1996 USA) cases have Upper
limb amputations
• Men in 15-45 age group
• Amputation of Lower Limb is far more
common than Upper Limb with UL:LL=1:6
• Congenital deficiency of Upper Limb is
commoner than Lower Limb

6. Causes
• Congenital limb deficiency
• Trauma – machine, road/rail, electric-burn
• Neoplastic
• Vascular – Thromboangiitis obliterans, Tropical
Diabetic Hand Syndrome, Frostbite
• Infection – Necrotizing Fasciitis

7. Management
• Conservative - thermal burns/frostbite
• Surgical
– Embolectomy
– Fasciotomy
– Reimplantation of transhumoral limb usually gives
functional elbow but poor hand function
– Amputation
– Allograft (esp. in Blind)

8. Phases of rehabilitation
• Preoperative
• Surgery/reconstruction
• Acute post-surgical
• Pre-prosthetic
• Prosthetic prescription
and fabrication
• Prosthetic training
• Community integration
• Vocational
rehabilitation
• Follow up

9. Evaluation
• ROM and strength of shoulder
• Vitality testing – clinical, Tc99mPyP nuclear
scan
• Manage any proximal bony or soft tissue
injuries
• Avoid multiple surgeries/revision amputation
as it will delay rehabilitation and thus reduce
effective use of prosthesis

10. Surgery
• Tourniquet is useful but contraindicated in
– Cancer
– Infection
• Skin and flaps
– Equal anteroposterior flaps
– Unconventional flaps like forearm extensor flap
may be brought at medial epicondyle (where skin
is thinnest) except in oncological cases

11. Soft tissue cover
Do NOT keep excess soft tissue

12. Surgery
• Bone
– May reduce epicondylar prominances in moderation
– Do not disturb articular cartilage
• Muscles
– Retain muscles esp. for myoelectric prosthesis
– Myoplasty gives firm residual limb, helps shoulder
control and improved EMG for myoelectric control
– Pectoralis cineplasty was used for elbow control in
past

13. Surgery
• Nerves
– Withdraw, cut sharp and allow to retract in soft tissue.
– Median and Ulnar nerves may be cut at different level
• Blood vessels
– Double ligation of major blood vessels
– Hemostasis and muscle tension managed after
deflating tourniquet
• Drain is essential for
– Hematoma prevention
– Fast wound healing

14. Early prosthetic fitment
• Golden period of 30 days
• Reduces edema
• Facilitates fast healing
• Reduces pain
• Enhances prosthetic use
• Early return to activities esp. two handed
grasping patterns

15. Prosthetic components
• Flat bulbous socket with snug fitting gives good
rotational control and self suspension
• External elbow joints
• Harness is Northwestern figure of 8 type or
shoulder saddle and chest strap
• Control system has 2 cables –
– Elbow lock control on medial prosthetic elbow joint
– Elbow flexion (when elbow is unlocked) cum terminal
device operation (when elbow is locked)

16. Socket
• Leather socket
• Soft insert with
supracondylar wedge
• Window with cover
plate (photo)
• Flexible bladder variant
• Screw in type sockets
(sketch)

17. Socketless design
•Mediolateral framework
•Supracondylar pads
•Straps

18. Prosthetic Elbow Joints
• Outside locking elbow hinges
• 0-135 ROM
• 3 sizes
• 5-7 locking positions

19. Harness system
• Standard figure of 8 –
– Operated by non-
amputated side
– Cross point below C7
and slightly toward non-
amputated side
• Shoulder saddle and
chest strap
– Operated by amputated
side

20. Terminal Devices
• Passive (Mitts)
• Cosmetic
• Functional
• Hook
• Greiffer
• Myoelectric
• Microchip controlled

21. Functional restoration
• Comfort fit
• Perceived value
• Follow up
– Adjusting socket to limb volume change
– Mastering functions of the prosthesis
– Re-evaluation and re-design of prosthesis as per
changing needs of patient

22. THANK YOU