153-上肢截肢(英文).pptVIP

Amputations of the Upper Extremity Andrew H. Schmidt, MDCreated March 2004 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 Don’t 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