Upper Limb Amputations

Upper limb amputations
Dr. Nisheet Dave
D.Ortho, DNB
Department of Orthopedics
St. Stephen’s Hospital
New Delhi.

Contents
 Introduction
 Wrist amputations
 Forearm amputations (transradial)
 Elbow disarticulation
 Arm amputations (transhumeral)
 Shoulder amputations
 Forequarter amputation
 Hand amputations

Introduction
 Trauma is the most common reason for
upper extremity amputations
◦ except for shoulder disarticulation and
forequarter amputations, for which malignant
tumors are the primary reasons.
 Small stump distal to the elbow can be
functionally better than a long above-elbow
amputation.
 A prosthetic limb cannot adequately replace
the sensibility of the hand, and the function of
a prosthetic limb decreases with higher levels
of amputation.

Wrist amputation
 Transcarpal amputation or
disarticulation of the wrist is preferable
to amputation through the forearm
 because, provided that the distal radioulnar joint
remains normal, pronation and supination are
preserved.
 In transcarpal amputations, flexion
and extension of the radiocarpal joint
also should be preserved so that
these motions, too, can be used
prosthetically.

Wrist amputation Technique
 Skin flap - a long palmar and a short dorsal in
a ratio of 2 : 1
 Finger flexors and extensors - distally, divide
them, and allow them to retract into the
forearm.
 Wrist flexors and extensors - free their
insertions, and reflect them proximal to the
level of bone section
 Median and ulnar nerves and the fine
filaments of the radial nerve - Draw the
nerves distally, and section them well
proximal to the level of amputation so that
their ends retract well above the end of the
stump.

Wrist amputation Technique
 Radial and Ulnar arteries - proximal to the
level of intended bone section, clamp, ligate,
and divide.
 Transect the bones with a saw, and rasp all
rough edges to form a smooth, rounded
contour.
 Tendons of the wrist flexors and extensors -
in line with their normal insertions, anchor to
the remaining carpal bones so that active
wrist motion is preserved.
 Closure - the subcutaneous tissue and skin at
the end of the stump, and insert a rubber
tissue drain or a plastic tube for suction
drainage.

Disarticulation of the wrist
 Incision - long palmar and a short
dorsal skin flap
◦ 1.3 cm distal to the radial styloid process,
carry it distally and across the palm, and
curve it proximally to end 1.3 cm distal to
the ulnar styloid process.
 Radial and ulnar arteries - proximal to
the joint, ligate,
and divide

 Median, ulnar, and radial nerves – draw
distally and section them
 At proximal level, divide all tendons
 Wrist joint capsule – Incise
circumferentially
 Radial and ulnar styloid processes –
Resect and rasp the raw ends of the
bones to form a smoothly rounded
contour.
◦ Take care to avoid damaging the distal
radioulnar joint, including the triangular
ligament, so that normal pronation and
supination of the forearm are preserved and

FOREARM AMPUTATIONS
(TRANSRADIAL)
 Preserve as much length as possible
 Distal third of the forearm are less
likely to heal satisfactorily than those
at a more proximal level
◦ because distally the skin is often thin and
the subcutaneous tissue is scant.
◦ The underlying soft tissues distally consist
primarily of relatively avascular structures,
such as fascia and tendons

Forearm amputations
(transradial)
 Proximal third of the forearm, - even a
short below-elbow stump 3.8 to 5 cm
long is preferable to an amputation
through or above the elbow.
 From a functional standpoint,
preserving the patient’s own elbow
joint is crucial.
 By using the Münster or a split socket
with step-up hinges, can provide an
prosthetic device for even a short
below-elbow stump.

Distal forearm (distal transradial)
amputation - Technique
 Equal anterior and posterior skin flaps
 Radial and ulnar arteries - proximal to
it, ligate and divide
 Median, ulnar, and radial nerves –
draw distally and section them
 Muscle bellies - Cut across the
transversely distal to the level of bone
section, and allow their ends to retract
to that level.

Distal forearm (distal transradial)
amputation - Technique
 Radius and ulna - Divide transversely,
and rasp all sharp edges from their
ends
 Close the deep fascia and the skin
flaps.
 Myoplastic closure - fashion an
anterior flap of flexor digitorum
sublimis muscle long enough so that
its end can be carried around the end
of the bones to the deep fascia
dorsally.
◦ suture its end to the deep fascia over the

Proximal third of forearm
(proximal transradial) amputation
 Skin flaps, arteries, nerves , muscle
bellies – same as distal amputation
 Radius and ulna – Divide transversely,
and smooth their cut edges.
◦ If the end of the stump is not at least distal to
the insertion of the biceps tendon, resect the
distal 2.5 cm of this tendon according to the
technique of Blair and Morris.
◦ This lengthens the stump functionally and
enhances prosthetic fitting.
◦ Even without biceps function, the elbow can
be flexed satisfactorily by the brachialis
muscle.

ELBOW DISARTICULATION
 The elbow joint is an excellent level for
amputation
◦ broad flare of the humeral condyles -
grasped firmly by the prosthetic socket
◦ humeral rotation - transmitted to the
prosthesis.
 more proximal amputations, humeral
rotation cannot be transmitted
◦ so a prosthetic elbow turntable is
necessary.

Elbow disarticulation -
Technique
◦ Proximally at the level of the humeral
epicondyles,
◦ Posterior flap distally to a point about 2.5
cm distal to the tip of the olecranon
◦ Anterior flap distally to a point just distal to
the insertion of the biceps tendon.
 Reflect the flaps proximally to the level
of the humeral epicondyles

Technique
 Identify and divide the lacertus
fibrosus,
 Free the origin of the flexor
musculature from the medial humeral
epicondyle, and reflect the muscle
mass distally
◦ to expose the neurovascular bundle that
lies against the medial aspect of the
biceps tendon.
 Brachial artery - Proximal to the joint
level, isolate, doubly ligate, and divide.

Technique
 Median nerve - divide it proximally so
that it retracts at least 2.5 cm proximal to
the joint line.
 Ulnar nerve - posterior to the medial
epicondyle
 Free the insertion of
◦ biceps tendon from the radius
◦ brachialis tendon from the coronoid process.
 Radial nerve - in the groove between the
brachialis and brachioradialis; isolate it,
draw it distally, and section it far
proximally.

Technique
 Extensor musculature –
◦ 6.3 cm distal to the joint line,
◦ divide transversely the that arises from the
lateral humeral epicondyle,
◦ reflect the proximal end of the muscle mass
proximally.
 Triceps tendon - Divide the posterior
fascia along with it near the tip of the
olecranon.
 Divide the anterior capsule of the joint to
complete the disarticulation, and remove
the forearm.

Technique
 Closure
◦ Leave intact the articular surface of the
humerus.
◦ Triceps tendon – bring anteriorly, and
suture it to the tendons of the brachialis
and biceps muscles.
◦ extensor muscle mass - carry it medially,
and suture it to the remnants of the flexor
muscles at the medial epicondyle.

ARM AMPUTATIONS
(TRANSHUMERAL)
 From the supracondylar region distally
to the axillary fold proximally.
◦ More distal amputations function as elbow
disarticulations;
◦ amputations proximal to the level of the
axillary fold function as shoulder
disarticulations
 As much length as possible should be
preserved

ARM AMPUTATIONS
(TRANSHUMERAL)
 Prosthesis must include
◦ an inside elbow-lock mechanism and
◦ an elbow turntable.
 The elbow-lock mechanism – stabilize the
joint in full extension, full flexion, or a position
in between.
 The turntable mechanism - humeral rotation.
 The elbow-lock mechanism – extends 3.8 cm
distally from the end of the prosthetic socket
◦ the level of the bone section should be at least
3.8 cm proximal to the elbow joint to allow room
for this mechanism.

ARM AMPUTATIONS
(TRANSHUMERAL)
 Children < 12 years
◦ osseous overgrowth of diaphyseal
amputations has been reported with the
humerus and fibula being most common.
◦ Disarticulation at the elbow is
recommended;
◦ If disarticulation is not feasible, a capping
graft of the humeral bone end should be
done.

Supracondylar area -
Technique
 Length one half of the diameter of the
arm at that level
 Brachial artery - Proximal to the level,
isolate, doubly ligate, and divide.
 Median, ulnar, and radial nerves - at a
higher level
 Muscles in the anterior compartment of
the arm -1.3 cm distal to the level of
intended bone section so that they
retract to this level.

Supracondylar area -
Technique
 Triceps tendon - Free the insertion of the
from the olecranon,
◦ preserving the triceps fascia and muscle as a
long flap.
◦ Reflect this flap proximally,
◦ incise the periosteum of the humerus
circumferentially - at least 3.8 cm proximal to the
elbow joint to allow room for the elbow
mechanism of the prosthesis.
 Divide the bone and with a rasp smoothly
round its end.
 Closure
◦ triceps tendon - suture it to the fascia over the
anterior muscles.

Amputation proximal to the
supracondylar area
 Incision, artery and nerve devision same.
 Muscles of the anterior compartment of
the arm – Section 1.3 cm distal to the
level of bone section so that their cut
ends retract to this level.
 Triceps muscle – Divide 3.8 to 5 cm
distal to the level of bone section
 Divide the periosteum and bone and with
a rasp smoothly round its end.
 Closure
◦ triceps tendon - suture it to the fascia over
the anterior muscles.

SHOULDER AMPUTATIONS
 Most amputations - performed for the
treatment of malignant bone or soft
tissue tumors that cannot be treated
by limb-sparing method.
 Less commonly - arterial insufficiency
 Rarely for trauma or infection
 Phantom pain is common
◦ best treated by proximal nerve blocks

Amputation through the surgical
neck of the humerus - Technique
 Position – supine - affected shoulder
45degree angle.
 Incision –
◦ anteriorly at the level of the coracoid
process,
◦ distally along the anterior border of the
deltoid muscle to the insertion of the
muscle
◦ along the posterior border of the muscle
to the posterior axillary fold.
◦ Connect the two limbs of the incision by a
second incision that passes through the

 Cephalic vein - Identify, ligate, and divide
in deltopectoral groove.
 IMP - between deltoid and pectoralis
major,
◦ retract the deltoid muscle laterally
◦ divide the pectoralis major muscle at its
insertion and reflect it medially.
 Develop the interval - the pectoralis
minor and coracobrachialis - to expose
the neurovascular bundle.
 Axillary artery and vein - Isolate, doubly
ligate, and divide immediately inferior to
the pectoralis minor.

 Median, ulnar, radial, and
musculocutaneous nerves – draw distally
and divide - proximal ends retract
proximal to the pectoralis minor
 Deltoid muscle – Divide at its insertion,
and reflect it superiorly together with the
attached lateral skin flap.
 Teres major and latissimus dorsi – divide
near insertions at the bicipital groove.
 Long and short heads of the biceps, the
triceps, and the coracobrachialis - 2 cm
distal to the level of intended bone
section.

 Humerus - Section the at the level of
its neck
 Closure
◦ long head of the triceps, both heads of the
biceps, and the coracobrachialis over the
end of the humerus;
◦ swing the pectoralis major muscle
laterally, and suture it to the end of the
bone

DISARTICULATION OF THE
SHOULDER - Technique
 Position and incision same
 Cephalic vein – divide in deltopectoral
groove.
 IMP - between deltoid and pectoralis
major,
 Develop the interval - the short head of
biceps and coracobrachialis - to expose
the neurovascular bundle.
 Axillary artery and vein, thoracoacromian
artery - Isolate, doubly ligate, and divide
–
◦ Allow to retract superiorly beneath the
pectoralis minor muscle.

Disarticulation of the shoulder -
Technique
 Median, ulnar, radial, and
musculocutaneous nerves – draw distally
and divide - proximal ends retract
proximal to the pectoralis minor
 Coracobrachialis and short head of the
biceps – Divide near insertions on the
coracoid process.
 Deltoid – Free insertion on the humerus,
and reflect it superiorly to expose the
capsule of the shoulder joint.
 Teres major and latissimus dorsi – divide
near insertions.

Technique
 Arm in internal rotation - expose the
short external rotator muscles and the
posterior aspect of the shoulder joint
capsule, and divide all of these
structures
 Arm in extreme external rotation - divide
the anterior aspect of the joint capsule
and the subscapularis muscle
 Triceps – Section near its insertion,
 Divide the inferior capsule of the
shoulder to sever the limb completely
from the trunk.

Technique
 Closure
◦ Reflect the cut ends of all muscles into the
glenoid cavity, and suture them there to help
fill the hollow
◦ deltoid muscle flap – inferiorly suture it just
inferior to the glenoid.
◦ Deep to the deltoid flap, insert Penrose
drains or plastic tubes.
◦ Partially excise any unduly prominent
acromion process
 to give the shoulder a more smoothly rounded
contour.

FOREQUARTER
AMPUTATION
 Removes the entire upper extremity in
the interval between the scapula and
the chest wall
 Indication - for malignant tumors that
cannot be adequately removed by
limb-sparing resections.
 The anterior approach of Berger
 The posterior approach of Littlewood
◦ more rapid and easy

FOREQUARTER
AMPUTATION
 Ferrario et al. - combined anterior and
posterior approach.
◦ Useful - normal tissue planes have been
obliterated because of radiation to the
axilla.
◦ Excellent exposure
◦ ligation of the subclavian vessels occurs
at the thoracic inlet instead of where the
vessels cross the third rib.

Forequarter amputation -
Anterior approach ( BERGER )
 Incision
◦ upper limb - at the lateral border of the
sternocleidomastoid muscle,
 extend laterally along the anterior aspect of the
clavicle, across the acromioclavicular joint, over the
superior aspect of the shoulder to the spine of the
scapula, and across the body of the scapula to the
scapular angle.
◦ lower limb - middle third of the clavicle,
 Extend inferiorly in the groove between the deltoid
and pectoral muscles and across the axilla
◦ join the upper limb of the incision at the angle
of the scapula

 Clavicular origin of the pectoralis major
muscle - release and reflect distally.
 Divide the deep fascia over the superior
border of the clavicle close to bone
◦ by dissection with a finger and a blunt curved
dissector, free the deep aspect of the
clavicle.
 Clavicle – Divide at lateral border of the
sternocleidomastoid with a Gigli saw,
◦ lift the bone superiorly,
◦ Remove by dividing the acromioclavicular

 Pectoralis major – release insertion from
the humerus
 Pectoralis minor –release origin from the
coracoid process
 Subclavian artery and vein - Isolate,
doubly ligate, and divide.
 Brachial plexus - by gentle traction
inferiorly bring it well into the operating
field;
◦ section the nerves in sequence,
◦ allow them to retract superiorly

 Release the latissimus dorsi and
remaining soft tissues that bind the
shoulder girdle to the anterior chest
wall, and allow the limb to fall
posteriorly.
 While holding the arm across the
chest - gentle downward traction,
divide from superiorly to inferiorly the
remaining muscles that fix the
shoulder to the scapula.

 Divide the muscles that hold the scapula
to the thorax,
◦ the trapezius , omohyoids, levator scapulae,
rhomboids major and minor, and serratus
anterior
 The limb falls free and can be removed.
 Closure
◦ suture the pectoralis major, trapezius, and
any other remaining muscular structures over
the lateral chest wall.
◦ skin flaps – trim to form a smooth closure.

Posterior approach (
LITTLEWOOD )
 Lateral decubitus position with the
operated side up
 Incision
◦ Two incisions
 Posterior (Cervicoscapular)
 Anterior (Pectoroaxillary)

LITTLEWOOD )◦ Posterior incision - beginning at the
medial end of the clavicle
 extending it laterally for the entire length of the
bone.
 Carry over the acromion process to the
posterior axillary fold,
 continue along the axillary border of the
scapula to a point inferior to the scapular angle.
 curve it medially to end 5 cm from the midline
of the back.

LITTLEWOOD )◦ Elevate a flap of skin and subcutaneous
tissue medial to the vertebral border of the
scapula,
 extending it from the inferior angle of the scapula to
the clavicle
 Trapezius and latissimus dorsi - divide
near scapula.
 Scapula – Draw away from the chest
wall with a hook or retractor, and divide
the levator scapulae and the rhomboids
minor and major
 Ligate branches of the superficial
cervical and descending scapular
vessels.

LITTLEWOOD ) Divide –
◦ superior digitation of the serratus anterior
close to superior angle of the scapula
◦ remaining insertion of the serratus anterior
along the vertebral border of the scapula.
 Clavicle and subclavius muscle – Divide
at medial end of the bone.
◦ allow extremity to fall anteriorly, placing the
neurovascular bundle under tension
 Cords of the brachial plexus – Divide close to
the spine

LITTLEWOOD ) Subclavian artery and vein - doubly ligate
and divide
 Take care to avoid injury to the pleural
dome.
 Divide the omohyoid muscle,
 Suprascapular vessels and external jugular
vein - ligate and divide.

LITTLEWOOD ) Anterior incision
◦ Starting at the middle of the clavicle and
curving it inferiorly just lateral to but
parallel with the deltopectoral groove.
◦ Extend it across the anterior axillary fold,
◦ carry it inferiorly and posteriorly to join the
posterior incision at the lower third of the
axillary border of the scapula.
 Divide the pectoralis major and minor
muscles, and remove the limb

LITTLEWOOD ) Closure
◦ flaps over suction drains without excessive
tension.
◦ Occasionally, it is necessary to attach a flap
to the chest wall and complete the closure
with a skin graft.
 Phantom pain in the early postoperative period
is common.
 Nerve blocks may be helpful.
 Few patients find a prosthesis useful, a
cosmetic shoulder cap is desirable.

Considerations for amputation
 An analysis of the five tissue areas
(skin, tendon, nerve, bone, and joint) is
helpful in making the decision to
amputate.
 ≥3 / 5 areas require special procedures,
such as grafting of skin, suture of tendon
or nerve, bony fixation, or closure of the
joint,
◦ amputation should be considered
◦ because the function of the remaining fingers
may be compromised by survival of a

 If amputation is indicated, it may be wise to
delay it if parts of the finger may be useful
later in a reconstructive procedure.
◦ Skin from an otherwise useless digit can be
employed as a free graft.
◦ Skin and deeper soft structures can be useful as
a filleted graft
◦ Skin well supported by one or more
neurovascular bundles but not by bone can be
saved and used as a vascular or neurovascular
island graft.
◦ Segments of nerves can be useful as
autogenous grafts.

◦ A musculotendinous unit, especially a flexor
digitorum sublimis or an extensor indicis
proprius, can be saved for transfer to improve
function in a surviving digit
◦ Tendons of the flexor digitorum sublimis of
the fifth finger, the extensor digiti quinti, and
the extensor indicis proprius can be useful as
free grafts.
◦ Bones can be used as peg grafts or for filling
osseous defects.
◦ Every effort should be made to salvage the
thumb

PRINCIPLES OF FINGER
AMPUTATIONS
1. The volar skin flap should be long enough
to cover the volar surface and tip of the
osseous structures and preferably to join
the dorsal flap without tension.
2. The ends of the digital nerves should be
dissected carefully from the volar flap,
gently placed under tension so as not to
rupture more proximal axons,
◦ resected at least 6 mm proximal to the end of
the soft tissue flap.
◦ Neuromas are inevitable, but they should be
allowed to develop only in padded areas where
they are less likely to be painful.

PRINCIPLES OF FINGER
AMPUTATIONS
3. When scarring or a skin defect makes the
fashioning of a classic flap impossible, a
flap of a different shape can be improvised,
but the end of the bone must be padded
well.
4. Flexor and extensor tendons should be
drawn distally, divided, and allowed to
retract proximally.
5. When an amputation is through a joint, the
flares of the osseous condyles should be
contoured to avoid clubbing of the stump.
6. Before the wound is closed, the tourniquet
should be released and vessels cauterized
to control bleeding.

FINGERTIP AMPUTATIONS
 Vary depending on the
◦ amount and configuration of skin lost,
◦ the depth of the soft tissue defect,
◦ whether the phalanx has been exposed or
even partially amputated
 Loss of skin alone - heal by secondary
intention or can be covered by a skin
graft
 The medial aspect of the arm just distal
to the axilla, volar forearm and wrist, and
hypothenar eminence are convenient
areas from which skin grafts can be

 If half of the nail is unsupported by the
remaining distal phalanx - a nail bed
ablation usually is indicated
◦ otherwise, a hook nail may develop
 If other parts of the hand are severely
injured or if the entire hand would be
endangered by keeping a finger in one
position for a long time, amputation
may be indicated.

 The amputated part of the fingertip is
recovered and replaced as a free graft
or cap technique
◦ This procedure requires removing bone
debris and partially defatting the distal
part before reattachment.
◦ The cap procedure is quite successful in
both children and adults
 Tendon, nerve, or bone is exposed - soft
tissue coverage may be achieved in
numerous ways.

 Cover exposed tendon and bone -
flaps or grafts
◦ distal advancement flaps include
 Kutler double lateral V-Y
 Atasoy volar V-Y advancement flaps
 Amputated proximal to the nail bed -
dorsal pedicle flap
 Dorsal defects - adipofascial turnover
flaps

 Advantages of same-digit coverage
techniques include
◦ No need for a second operation for flap
division (as with a cross finger flap),
◦ Prevention of adjacent finger stiffness that
occurs with adjacent finger coverage
techniques (especially in patients with
underlying arthritic conditions),
◦ The opportunity for coverage in patients in
whom adjacent fingers are injured.

 The cross finger flap
◦ Provides excellent coverage
◦ But stiffness not only of the involved finger
but also of the donor finger.
◦ Requires operation in two stages and a
split-thickness graft to cover the donor
site.
 Ulnar hypothenar flap –
 This retrograde flow flap
 based on the ulnar digital artery
 Used to supply sensation when the dorsal
sensory branch of the ulnar nerve is included in
the skin flap

 A local neurovascular island pedicle
flap
◦ can be advanced distally and provides a
good pad with normal sensibility
 Retrograde island pedicle flaps
 require tedious dissection
 excellent distal coverage and utility for dorsal and
volar defects
 Donor site morbidity may be reduced in
retrograde island pedicle flaps that use the
subdermal elements only.

FLAPS FOR FINGERTIP
COVERAGE
 Kutler double lateral V-Y advancement
flap
◦ When the pulp is compromised and the
lateral hyponychial skin is uninjured
 Atasoy volar V-Y advancement flap
◦ When more of the pulp skin remains

Kutler double lateral V-Y
advancement flap - Technique
 Local anesthesia
 Digital tourniquet
 Two triangular flaps,
◦ one on each side of the finger
◦ With apex directed proximally and
centered in the midlateral line of the digit.
◦ sides should each measure about 6 mm,
◦ bases should measure about the same or
slightly less

Kutler double lateral V-Y
advancement flap - Technique
 Develop flaps - by incising deeper
toward the nail bed and volar pulp.
 Divide pulp - at each apex, (usually not
more than half its thickness) to allow the
flaps to be mobilized toward the tip of the
finger.
 Avoid dividing any pulp distally.
 Closure
◦ Approximate the bases of the flaps, and
stitch them together
◦ Stitch the dorsal sides of the flaps to the
remaining nail or nail bed.

Atasoy volar V-Y advancement
flap - Technique
 Flap - distally based triangle
◦ through the pulp skin only
◦ base of the triangle equal in width to the cut
edge of the nail
◦ full-thickness flap with nerves and blood
supply preserved
 Selectively cut the vertical septa that
hold the flap in place, and advance the
flap distally.
 Suture - the skin flap to the sterile matrix
or nail.
◦ The volar defect from the advancement can
be left open and left to heal by secondary
intention

BIPEDICLE DORSAL FLAPS
 Indication –
◦ When a finger has been amputated
proximal to its nail bed
◦ When preserving all its remaining length
is essential, but attaching it to another
finger is undesirable.

Bipedicle dorsal flaps -
Technique
 Flap –
◦ Beginning distally at the raw margin of the
skin and proceeding proximally,
◦ elevate the skin and subcutaneous tissue
from the dorsum of the finger.
◦ transverse dorsal incision to create a
bipedicle flap
 Drawn distally, to cover the bone and
other tissues on the end of the stump.
 Suture the flap in place
 Cover the defect by split-thickness skin
graft

ADIPOFASCIAL TURNOVER
FLAP
 De-epithelialized flap that may be
used to cover distal dorsal defects 3
cm in length.
 Skin flap
◦ Make the width 2 to 4 mm wider than the
traumatic defect.
◦ Base-to-length ratio should be 1 : 1.5 to 1
: 3.
◦ The flap base should be 0.5 to 1 cm in
length and is made just proximal to the
defect.
 Adipofascial flap - superficial to the

ADIPOFASCIAL TURNOVER
FLAP
◦ Detached proximally and along its sides to
the flap base,
◦ Flip it over
◦ Suture it distally
 Split-thickness graft to cover the
defect at the flap site.

THENAR FLAP
 Indication - Middle and ring finger
coverage
 Complication –
◦ Donor site tenderness
◦ Proximal interphalangeal joint flexion
contractures
 Flaps should not be left in place for
more than 3 weeks.

Thenar flap - Technique
 Thumb held in abduction, flex the
injured finger so that its tip touches the
middle of the thenar eminence
 Outline on the thenar eminence
◦ pressing the bloody stump – outlines
bloodstain the size of the defect
 Base proximal, raise the thenar flap
 Make its length no more than twice its
width

Thenar flap - Technique
 Attach the distal end of the flap to the
trimmed edge of the nail by sutures
passed through the nail.
 Prevent the flap from folding back on
itself and strangulating its vessels
 At 2 weeks, the base of the flap is
detached and the free skin edges are
sutured in place

LOCAL NEUROVASCULAR
ISLAND FLAP
 Adv - normal sensibility
 Incision - midlateral incision on each
side of the finger
 Dissect the neurovascular bundle
distally
 Free a rectangular island of the skin
and underlying fat to which are
attached the two neurovascular
bundles.
 Draw this island or graft distally, and

LOCAL NEUROVASCULAR
ISLAND FLAP
 Tension compromise - dissect the
bundles more proximally or flex the
distal interphalangeal joint, or both.
 Suture the graft
 Cover the defect with a free full-
thickness graft.

ISLAND PEDICLE FLAP
 Adv - normal sensibility
 Measure the defect
 Incision - midaxial or a volar zigzag
incision to expose the neurovascular
bundle of the area of the superficial arch
 Donor - ulnar border of the small finger
and radial border of the index finger not
be used
◦ because maintaining or achieving sensation
in these areas is desirable.
 Locate the neurovascular bundle
proximally and carefully dissect this to its
superficial arch origin

ISLAND PEDICLE FLAP
 Elevate the skin paddle
 divide the artery distally.
 Place the paddle over the recipient
site
 Suture the flap loosely into position

RETROGRADE ISLAND
PEDICLE FLAP
 Relies on retrograde flow through the
proper digital artery
 Incision and flap same
 Separate the proper digital artery
proximal to the donor flap from the
underlying digital nerve.
 Ligate and divide the artery
 Raise the flap with its pedicle.
 Leave a 1-cm section of undamaged
vascular bundle undisturbed distally to
nourish the flap and act as the pivot point
for the flap.

ULNAR HYPOTHENAR FLAP
 Adv –
◦ cover defects as large as 5 × 2 cm
◦ provide sensation by suturing the ulnar
digital nerve to a cutaneous nerve
sensory branch
 Flap - distal half of the hypothenar
eminence
 Include the multiple vascular
perforators with the flap

AMPUTATIONS OF SINGLE
FINGERS - INDEX FINGER
 Indication
◦ amputated at or more proximal to its proximal
interphalangeal joint level
◦ remaining stump is useless and can hinder
pinch between the thumb and middle finger
 Complication
◦ stiffness of the other fingers - contraindicated
in arthritic hands.
◦ sunken scar - on the dorsum of the hand
◦ anchoring the first dorsal interosseous to the
extensor mechanism, rather than to the base
of the proximal phalanx, causing intrinsic
overpull.

Index ray amputation -
Technique
 Incision –
◦ Palmar line - in the second web space at
the radial base of the middle finger
 Continue proximally to the midpalmar area
 not to cross the palmar flexion creases at 90
degrees.
 Begin a second palmar line approximately 1 cm
distal to the palmar digital flexion crease of the
index finger radial base
 extend proximally to meet the first incision in
the midpalmar area

Technique
◦ Dorsal part - from the palmar lines to
converge at a point on the index
carpometacarpal joint dorsally.
 Index extensor digitorum communis and
the extensor indicis proprius tendons –
retract distally, sever and allow to retract
proximally.
 First dorsal interosseous - Detach the
tendinous insertion and dissect the
muscle proximally from the second
metacarpal shaft.
 Volar interosseous – Detach from the
same shaft,
 Transverse metacarpal ligament – divide

Technique
 Take care not to damage the radial
digital nerve of the middle finger
 Second metacarpal – divide obliquely
from dorsoradial proximally to volar-ulnar
distally about 2 cm distal to its base.
◦ Do not disarticulate the bone at its proximal
end.
 Flexor tendons - Divide
 Digital arteries - Ligate and divide
 Digital nerves – divide
◦ leaving sufficient length so that their ends
can be buried in the interossei.

Technique
 Anchor the tendinous insertion of the
first dorsal interosseous to the base of
the proximal phalanx of the middle
finger
◦ Do not anchor it to the extensor tendon or
its hood - might cause intrinsic overpull.

MIDDLE OR RING FINGER RAY
AMPUTATIONS
 Absence in either finger
◦ makes a hole through which small objects
can pass when the hand is used as a cup
or in a scooping maneuver
◦ makes the remaining fingers tend to
deviate toward the midline of the hand.
 Third and fourth metacarpal heads -
stabilize the metacarpal arch by
providing attachments for the
transverse metacarpal ligament.

 Middle finger ampute
◦ In a child or woman transposing the index
ray ulnarward to replace the third ray may
be indicated
◦ technically challenging and has significant
complications
 Excising the third metacarpal shaft removes the
origin of the adductor pollicis and weakens
pinch
 contraindicated if the hand is needed for heavy
manual labor

 Ring finger ampute
◦ Disarticulation of the ring finger at the
carpometacarpal joint allows the small
finger metacarpal base to shift radially
over the hamate facet,
◦ eliminates radial deviation of the ray

Transposing the index ray -
Peacock Technique
 Incision –
◦ proximal end of the dorsal incision slightly
toward the second metacarpal base
◦ Same on volar side
 dorsal and volar wedges of skin
removed
 Third metacarpal - divide transversely
as close to its base as possible
 Excise the third metacarpal shaft and
the interosseous muscles to the

Peacock Technique
 Ligate digital artery, vein and divide
degital nerve
 Flexor tendons - wrist is held flexed,
draw distally and divide.
 Second metacarpal - at its base divide
the bone at the same level as the third
metacarpal.
 Insert a Kirschner wire longitudinally
through the metacarpophalangeal joint of
the transposed ray,
◦ bring it out on the dorsum of the flexed wrist

Peacock Technique
 Flex all the fingers to ensure correct
rotation of the transposed ray
 Insert a Kirschner wire transversely
through the necks of the fourth and
the transposed metacarpals.

RING FINGER AVULSION
INJURIES
 when a metal ring worn on that finger
catches on a nail or hook.
 Amputation of the fourth ray with
closure of the web is the procedure of
choice in a child or woman
 Simple metacarpal amputation rather
than resection may be indicated in a
heavy laborer.
◦ Because metacarpal amputation
preserves greater strength

LITTLE FINGER AMPUTATIONS
 As much of the little finger as possible
should be saved,
 When the little finger alone is amputated,
and when the appearance of the hand is
important or the amputation is at the
metacarpophalangeal joint,
◦ Fifth metacarpal shaft is divided obliquely at
its middle third;
◦ Insertion of the abductor digiti quinti is
transferred to the proximal phalanx of the ring
finger
◦ This smooths the ulnar border of the hand

THUMB AMPUTATIONS
 In partial amputation of the thumb –
◦ thumb rarely should be shortened
 Pulp amputation - free graft, an advancement
pedicle flap or a local or distant flap.
 Skin and pulp, including all neural elements,
have been lost - neurovascular island graft
 Proximal phalanx remains - primary closure
of the wound
◦ deepening the thumb web by Z-plasty
 Amputation at metacarpophalangeal joint or
at a more proximal level, - reconstruction of
the thumb

AMPUTATIONS OF MULTIPLE
DIGITS
 In partial amputation of all fingers and
the thumb
◦ function can be improved by lengthening the
digits relatively and by increasing their
mobility.
◦ Function of the thumb –
 by deepening its web by Z-plasty
 by osteotomizing the first and fifth metacarpals and
rotating their distal fragments toward each other
◦ If the first carpometacarpal joint is functional
but the first metacarpal is quite short - the
second metacarpal can be transposed to the
first to lengthen it and to widen and deepen
the first web

DIGITS
 In complete amputation of all fingers
(with intact thumb which cannot easily
reach the fifth metacarpal head ) -
phalangization of the fifth metacarpal
◦ the fourth metacarpal is resected and the
fifth is osteotomized, rotated, and
separated from the rest of the palm

DIGITS
 Complete amputation of all fingers and
the thumb
◦ Amputation through the metacarpal necks
- phalangization of selected metacarpals
◦ Amputation through the middle of the
metacarpal shafts - hook can be
accomplished by flexing the stump at the
wrist.

PAINFUL AMPUTATION STUMP
 A neuroma located in an unpadded area
near the end of the stump is the usual
cause of pain.
◦ small mass, in line with a digital nerve, is
diagnostic.
◦ treated by padding and desensitization,
surgical excision
 Bony prominences covered only by thin
skin,
◦ such as a split-thickness graft, or
◦ by skin made tight by scarring.

PAINFUL AMPUTATION STUMP
 Painful cramping sensations
◦ in the hand and forearm
◦ caused by flexion contracture of a stump
resulting from overstretching of extensor
tendons or adherence of flexor tendons;
◦ release of any adherent tendons is helpful

RECONSTRUCTION AFTER
AMPUTATION OF THE HAND
 Krukenberg operation is helpful
◦ converts the forearm to forceps in which the
radial ray acts against the ulnar ray
◦ helpful in blind patients with bilateral
amputations because it provides not only
prehension, but also sensibility at the
terminal parts
 According to Swanson,
◦ children with bilateral congenital amputation
find the reconstructed limb much more useful
than a mechanical prosthesis;
◦ they transfer dominance to this limb when a
prosthesis is used on the opposite one.

KRUKENBERG
RECONSTRUCTION
 Incision –
◦ on the flexor surface of the forearm
slightly toward the radial side.
◦ similar incision on the dorsal surface
slightly toward the ulnar side, but on this
surface elevate a V-shaped flap to form a
web at the junction of the rays
 Separate the forearm muscles into two
groups

KRUKENBERG
RECONSTRUCTION
 The radial side comprises
◦ the radial wrist flexors and extensors,
◦ the radial half of the flexor digitorum sublimis,
◦ the radial half of the extensor digitorum
communis,
◦ the brachioradialis,
◦ the palmaris longus, and
◦ the pronator teres;
 the ulnar side comprises the
◦ ulnar wrist flexors and extensors,
◦ the ulnar half of the flexor digitorum sublimis, and
◦ the ulnar half of the extensor digitorum
communis.

KRUKENBERG
RECONSTRUCTION
 Take care not to disturb the pronator
teres.
 Interosseous membrane – Incise
throughout its length along its ulnar
attachment, do not damage the
interosseous vessel and nerve.
 The radial and ulnar rays can be
separated 6 to 12 cm at their tips
depending on the size of the forearm;
 Motion at their proximal ends occurs at
the radiohumeral and proximal radioulnar

KRUKENBERG
RECONSTRUCTION
 The adductors of the radial ray are
◦ the pronator teres, the supinator, the
flexor carpi radialis, the radial half of the
flexor digitorum sublimis, and the palmaris
longus;
 The abductors of the radial ray are
◦ the brachioradialis, the extensor carpi
radialis longus, the extensor carpi radialis
brevis, the radial half of the extensor
digitorum communis, and the biceps.

KRUKENBERG
RECONSTRUCTION
 The adductors of the ulnar ray are
◦ the flexor carpi ulnaris, the ulnar half of the
flexor digitorum sublimis, the brachialis, and
the anconeus;
 The abductors of the ulnar ray are
◦ the extensor carpi ulnaris, the ulnar half of
the extensor digitorum communis, and the
triceps.
 Close the skin over each so that the
suture line is not on the opposing surface
of either

RECONSTRUCTION OF THE
THUMB
 Absence of the thumb - 40% disability
of the hand as a whole
 When amputation has been at the
metacarpophalangeal joint or at a
more proximal level
 Joint and a useful segment of the
proximal phalanx remain - deepening
of the thumb web by Z-plasty.

THUMB
 Through the interphalangeal joint, the
distal phalanx, or the pulp of the thumb -
coverage by skin is necessary,
◦ Sensibility in the area of pinch is grossly
impaired - neurovascular island transfer
 A reconstructed thumb must meet five
requirements.
◦ sensibility
◦ stability
◦ mobility
◦ sufficient length
◦ cosmetically acceptable

THUMB
 Reconstructive procedures
◦ depends on
 the length of the stump remaining and
 the sensibility of the remaining thumb pad
◦ lengthened by a short bone graft or
distraction osteoplasty
◦ Sensibility restored by skin rotation flaps, with
the nonopposing surface skin grafted as in
the Gillies-Millard “cocked hat” procedure
◦ pollicizing a digit
◦ microvascular free transfer of a toe to the
hand

THUMB
 Congenital absence of the thumb –
◦ Pollicization of the index finger is the most
used technique
◦ Associated with other congenital
malformations, such as congenital
absence of the radius, and occasionally
with metabolic disorders, including blood
dyscrasias
◦ Done after the first 1 or 2 years of life

Lengthening of metacarpal
 Indication – amputation at
metacarpophalangeal joint or within
the condylar area of the first
metacarpal
◦ the thenar muscles are able to stabilize
the digit.
 Disadvantages –
 bone graft resorption
 ray shortening and
 skin perforation after flap contraction.

Modified Gillies & Millard
technique - lengthening of
metacarpal Incision - around the dorsal, radial, and
volar aspects of the base of the thumb
 hollow flap - elevated and slipped off the
end of the stump;
 Attach an iliac bone graft or a phalanx
excised from a toe to the distal end of
the metacarpal by tapering the graft and
fitting it into a hole in the end of the
metacarpal.
 Fix the graft to the bone by a Kirschner
wire, and place iliac chips around its
base.

Osteoplastic reconstruction &
transfer of neurovascular island
graft ( Verdan )
 when the first carpometacarpal joint has
been spared and is functional
 when the remaining part of the first
metacarpal is short.
 end of the first metacarpal - an iliac bone
graft shaped like a palette to imitate the
normal thumb
◦ Do not place the graft in line with the first
metacarpal, but place it at an obtuse angle in
the direction of opposition
 Place the end of the tubed pedicle over
the bone graft,

POLLICIZATION
 Transposition of a finger to replace an
absent thumb
 Done in pouce flottant (floating thumb)
and congenital absence of a thumb
 In traumatic, full function of the new
thumb hardly can be expected
 Performed - 9 to 12 months of age

Riordan pollicization
 Index ray is shortened by resection of its
metacarpal shaft.
 To simulate the trapezium, the second
metacarpal head is positioned palmar to
the normal plane of the metacarpal
bases
 The metacarpophalangeal joint acts as
the carpometacarpal joint of the new
thumb.
 The first dorsal interosseous is converted
to an abductor pollicis brevis,
 The first volar interosseous is converted
to an adductor pollicis.

Buck-gramcko pollicization
 Index finger has to be rotated initially
approximately 160 degrees during the
operation so that it is opposite the pulp of
the ring finger.
 This position changes during the suturing
of the muscles and the skin
◦ so that at the end of the operation there is
rotation of approximately 120 degrees.
 The pollicized digit is angulated
approximately 40 degrees into palmar
abduction.

Foucher pollicization
 Pollicized digits, grip and pinch
strength reduction (55% and 42
respectively).
 Weakness in abduction and adduction
as well as the slenderness and
cleftlike appearance of the pollicized
digit are corrected with the Foucher
technique.

Foucher pollicization
 Adduction is provided by the extensor
indicis communis (EIC), second volar
interosseous muscle (2nd VI), and
adductor pollicis
 Abduction is provided by extensor
indicis proprius (EIP) and first dorsal
interosseous muscle (1st DI).

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