Overview of Upper Limb Amputation
In 2005, there were 1.6 million people who had undergone an amputation, and it’s predicted that this number could double by 2050. This predicted increase might be due to the growing number of people with diabetes, as some of them will eventually need an amputation. The chance of losing a limb becomes higher as a person gets older, with people aged 65 and above being at the highest risk.
When it comes to amputations of the upper limb or arm, the main cause is physical injury, accounting for 80% of these procedures. This is mostly seen in men between 15 to 45 years old. The other causes are cancer or tumors and issues with blood vessels because of various diseases.
Amputations are named according to where on the body they are performed. From the farthest point from the body to the nearest, amputations include: amputations of the fingers (trans-phalangeal), hand (trans-metacarpal), wrist (trans-carpal), part of the arm (wrist disarticulation, trans-radial, elbow disarticulation, trans-humeral), and at the shoulder level (shoulder disarticulation, and forequarter amputation). Of all the upper extremity amputations, 78% are amputations of the fingers.
There are different things to consider based on where the amputation is. But no matter where it is, the main goal is to keep as much of the limb as possible, as this directly helps with the person’s ability to function and maintain their quality of life.
Anatomy and Physiology of Upper Limb Amputation
The upper extremity, or arm, is quite complex. It is made up of various parts like blood vessels, lymph tissues, muscles, and bones. They all work together to help us perform our day-to-day activities. This passage will discuss the different bone structures and certain considerations to make if someone has to have part of their upper limb removed.
The shoulder is made up of the collarbone, shoulder blade, and the upper part of the arm bone. Various joints such as the sternoclavicular, acromioclavicular, and so on help the arm move easily. Many muscles like the deltoid, teres major, trapezius, and more connect the shoulder blade and collarbone to the upper arm bone. The nerves from the spinal cord segments C5 through T1 power these muscles. There are three types of arm removal surgeries that can happen in the shoulder region. The first kind is a forequarter amputation where the collarbone and everything below is removed. A shoulder disarticulation involves removing the entire arm bone. Lastly, a transhumeral amputation can occur at any length of the arm bone.
Moving on to the elbow, it’s a joint that isn’t weight-bearing and bends like a door hinge because of how the arm bone, and the two forearm bones are connected. The elbow’s stability is maintained by the humeral trochlea that fits into the elbow’s olecranon, and the medial and lateral ligaments of the elbow. Many muscles pass over the joint which further allows for rotation of the forearm. The nerves at this level control the muscles of both the upper and lower arm. In some cases, limb removal surgeries involve removing the forearm bones completely from the arm bone.
Coming to the forearm, there are two types of muscles: intrinsic and extrinsic. The intrinsic muscles allow the forearm to turn so that the palm can face up or down. The extrinsic muscles are responsible for bending and straightening the fingers. The muscles of this region are controlled by the median, ulnar, and radial nerves. Removal surgeries in the forearm region can also be classified based on the length that remains.
The wrist consists of eight small bones arranged in two rows connecting the forearm to the hand. Various ligaments provide the joint with stability. One kind of hand removal surgery involves the removal of these wrist bones and all structures below.
Finally, the hand is made up of multiple bones that make up the palm and the five fingers. The metacarpal bones form the hand and connect with the wrist bones above. The metacarpals connect with the phalanges, or finger bones, below. There are various nerves, mostly the median, radial and ulnar nerves, that control different parts of the hand. Muscles between the metacarpals, called the interossei muscles, are responsible for spreading the fingers. Amputations in this area can involve removal of the distal tip, or the intermediate or proximal phalanges, of the fingers.
Why do People Need Upper Limb Amputation
Certain conditions or situations might mean that specific types of injuries and diseases cannot be fixed, so a part of your body may have to be removed or replaced. Some of these conditions or situations include:
– Trauma beyond repair, which means an injury is so severe that it can’t be healed or restored.
– Irreparable loss of the blood supply; when there’s a critical decrease in the blood flow to a body part, this part might not survive.
– Malignancy or presence of cancer; some cancers can spread rapidly and affect other body parts, so removing the affected part might be necessary to control the disease.
– Severe contracture; that’s when your muscles, tendons, or skin shorten and become tight, restricting movement. Surgery may be necessary if other treatments can’t correct it.
– Infection that is severe or unable to be treated with antibiotics.
– Congenital deformities are birth defects that might require surgical removal or remodeling for the person to function better.
– Burns that are severe and damage the skin and tissues beneath so much that they can’t heal properly on their own.
– Thermal or electrical injuries can cause severe internal damage, making it necessary to remove the affected parts.
– Frostbite is a condition where skin and underlying tissues freeze. Severe frostbite might require the removal of the affected part to prevent further damage.
– Peripheral Vascular disease affects the circulatory system. Parts of the body may not receive enough blood and may need to be removed.
– Complications from diabetes like poor circulation or infected wounds can result in the need for amputation.
When a Person Should Avoid Upper Limb Amputation
There are some instances where it’s not beneficial for a person to have their limb operated on due to their unstable medical state, often referred to as hemodynamic instability. This term means their blood flow isn’t stable and any further strain on their body might worsen their situation.
If keeping the limb as it is can assure better function without putting the person at a higher risk of their condition getting worse, doctors may decide to avoid performing surgery.
Who is needed to perform Upper Limb Amputation?
Many different health care professionals are involved in the process of removing a limb (amputation) and helping the person recover afterwards (rehabilitation). These can include doctors like internists (who specialize in internal medicine), physiatrists (who focus on rehabilitation), vascular surgeons (who specialize in the circulatory system), or orthopedic surgeons (who focus on the bones, joints, and muscles). Depending on how complex the procedure is, other kinds of surgeons may also be involved to help ensure the operation goes smoothly.
After the surgery, plastic surgeons can help to make the area where the limb was removed look as natural as possible. If there are any issues with the wound healing properly or if it becomes infected, doctors who specialize in wound care and infectious diseases may need to be brought in for extra help.
During the recovery process, a variety of therapists are involved to help the person adapt to life after their amputation. This includes occupational therapists who provide strategies for doing everyday activities, physical therapists who help improve strength and mobility, and physiatrists who support overall functional recovery. A prosthetist, a professional who creates artificial limbs (prosthetics), will also help the person find a prosthesis that suits their lifestyle.
Additionally, psychologists and psychiatrists may also be involved to offer emotional support and help the person navigate their feelings after losing a limb.
Preparing for Upper Limb Amputation
From a surgeon’s perspective, it’s standard practice to follow strict cleanliness procedures when doing an amputation in an operating room. This means wearing a sterile gown and using sterile coverings. Before the operation, it’s also routine to use antibiotics to help prevent infections when removing a long bone in the body. The most commonly used antibiotics are vancomycin or first-generation cephalosporins, but others might be used based on the specific injury.
For smaller injuries and amputations, like when the tip of a finger has been traumatically cut off, it’s not entirely clear from current research if using preventative antibiotics is effective. Despite this, a surgeon may still choose to use antibiotics based on their professional judgement.
How is Upper Limb Amputation performed
Amputations of the upper limbs can be different based on the part that needs to be removed, the reason for removal, and any complexities that might come up during the operation. This summary will explain various types of arm amputations, starting from the farthest part of the arm (the hand) and moving towards the body (the upper arm).
The Transcarpal amputation procedure involves amputating at the wrist. It’s typically done due to injuries, circulation problems and infections. It’s quite common and better than amputations further up the arm, as it helps to keep the movement of the wrist intact. The operation involves making an incision to create a flap of skin on the palm and back side of the hand. During the operation, certain muscles, nerves and blood vessels are carefully cut and drawn back into the arm to avoid complications. The affected bones from the wrist are also removed. Lastly, the incision is closed with possible use of muscle from the fingers as padding.
A Wrist Disarticulation is another type of amputation which involves removing the hand at the wrist joint. This procedure sacrifices finger mobility and wrist movement. The procedure is done similarly to the above but the nerves are double tied at a level towards the elbow to prevent neuroma (nerve tumor) formation. The ends of arm bones (radius and ulna) are shaped for better wound closure.
The Transradial amputation procedure involves amputating somewhere along the forearm. It’s generally done so in a way to keep as much length of the forearm as possible so that the person can still twist their arm and do a wide range of movements. The doctors create flaps of skin, then cut the muscles, nerves and blood vessels in a similar way as the above procedures.
In a Tranhumeral & Elbow Disarticulation, the operation involves amputating at the elbow joint. Muscles, nerves and blood vessels are separated in a similar way to the other procedures, and the arm is detached at the elbow joint. The skin flaps created are adjusted and sutured in a way to create ample padding at the end of the upper arm.
Transhumeral Amputation is similar to elbow disarticulation but with some differences depending on where the amputation is done. If the amputation is done near or above the insertion of a muscle called the pec major then the arm can no longer be rotated. These procedures however do keep the shape of the shoulder. This procedure also repositions other muscles and skin to cover the humeral head (end of the upper arm bone) for better wound healing and appearance.
A Shoulder Disarticulation involves amputating the entire arm at the shoulder. The procedure is similar to a Transhumeral Amputation with the difference that there are additional steps for ligating (binding) and cutting the blood vessels. The muscles are then moved to fill the empty space where the shoulder joint used to be and the skin flaps are smoothed and attached together to cover the wound.
Possible Complications of Upper Limb Amputation
After an amputation surgery, some people may experience different types of pains and sensations. One type is the phantom limb pain or sensation. It feels as though the amputated limb is still there and often comes with pain. This is probably related to the nerves (neuropathic) and can usually be managed with medications designed for nerve pain, like gabapentin and pregabalin. Painkillers such as opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophen usually aren’t as effective for this type of pain.
Another type of pain, residual limb pain, is typically musculoskeletal pain that tends to affect only one area of the body. This normally happens as the scar tissues, fascia, and muscles reform. Taking care of the wound and using medications like NSAIDs, acetaminophen, opioids, and in some cases muscle relaxants, can help. Other techniques such as compression, tapping, and massage can also be used to ease the pain.
Local swelling, known as edema, is a very common aftereffect following amputation. It’s best to manage this starting as soon as possible after the surgery with a post-operative dressing. As time goes by, people can keep the swelling under control by using compressive dressings, massages, and elevation. If the person has other health problems that affect fluid balance, water pills or diuretics may be used.
Contractures, a health condition causing muscles or other tissues to become rigid or stiff, which can distort joints, is a longer-term complication. This can happen due to various reasons and often involves the muscle shrinking or atrophying. To manage these contractures, a person can try stretching exercises to retain joint movement and strength exercises for muscle bulk.
Amputation can lead to a shift in body weight distribution and can alter a person’s center of gravity, which can require compensating for in the way they walk and move. This can result in pain, spasms, or discomfort in other body areas.
Skin breakdown can also occur at the amputation site in the weeks following an amputation due to poor wound healing, infection, swelling, and improper dressing techniques. Over the long term, this complication can also occur due to the use of prostheses or devices to help with movement. One key to prevention is to shape the residual limb smoothly into a cylindrical or conical shape to decrease skin breakdown complications when a prosthesis is used.
Cosmetic acceptability can also be a significant concern post-amputation as it can impact a person’s mental and emotional wellbeing. Using a surgery technique that looks good cosmetically, providing a prosthesis that matches the person’s skin tone, and minimal bracing can help alleviate these concerns.
Lastly, over time, as the nerve tissue remodels, a benign (non-cancerous) mass of soft tissue and nerves might form, called a neuroma. This can be painful, but can be managed with nerve pain medications or nerve blocks.
What Else Should I Know About Upper Limb Amputation?
Amputations, or surgical removal of a body part, are critical procedures that can impact your ability to move, your appearance, and how you might use a future artificial body part or prosthesis. Let’s break down some common types of amputations to better understand each one:
Forequarter: This is an amputation that includes the shoulder, arm, and hand. When performing this type of amputation, doctors try to make the cut near the muscle on the side of the neck to keep the natural shape of your neck.
Transhumeral: This is an amputation through the upper arm. Surgeons aim to keep as much of your arm length as possible to help with movement and using a prosthesis. They keep at least 2-3 inches of your upper arm bone (humerus) so the prosthesis fits well. Also, they join the muscle groups and smooth the bone edges to make wearing a prosthesis more comfortable.
Elbow disarticulation: This means amputating at the elbow, leaving your upper arm intact. Doctors prefer this over transhumeral amputations because you still have some mobility. For children, they try to save the growing part of the bone to allow for growth and prevent future surgeries. In this procedure, the back muscle flap is made longer than the front so it can be wrapped around the end of the bone for cushioning.
Transradial: This is an amputation through the forearm. Preserving as much forearm length as possible is important for improved movement and prosthetic fit. Depending on the length left, you can have different degrees of rotation. In some cases, a tendon from one of your big arm muscles is moved to the bone in your forearm. This muscle tension has to be set just right so you don’t have contractures, or permanent bending of your elbow.
Wrist: For a wrist amputation, the ends of the bones are cut off to prevent them from making the prosthesis uncomfortable. The joint between the two bones of the forearm is kept intact to allow better rotation.
Hand: When fingers are amputated, it can affect how you use your hand. If the first two fingers are removed from the base, it can make it harder to grip things between your fingers. Losing your thumb can really affect how you grip things, but with practice, you can learn alternative ways to grab objects with your remaining fingers.
