Primary Surgery Vol.2 – Trauma: AMPUTATING THROUGH THE UPPER ARM

AMPUTATING THROUGH THE UPPER ARM

For the general method see Section 56.1. Prepare the operation site, and abduct the patient’s arm to about 80 $\ensuremath{^\circ }$ on an arm board. Place a block under his arm just proximal to the amputation site. Apply a tourniquet as high as you can.

THE MID UPPER ARM AS AN AMPUTATION SITE

Start proximally at the site of bone section, and mark out equal anterior and posterior skin flaps. Make the length of each flap 3/4 of the diameter of his arm at the site of section.

Find, doubly ligate, and cut his brachial artery and vein just above the site of section. Find, gently pull and cut the major nerves so that their ends retract well above the stump.

Cut the anterior muscles 1.5 cm distal to the site of section. Cut the triceps 4 cm distal to the site of section. Cut the periosteum all round the patient’s humerus and saw it through. Rasp the end of his humerus smooth. Bevel his triceps to make a thin flap, reflect it anteriorly over the end of his humerus, and sew it to the anterior muscle and fascia. Release the tourniquet, control bleeding, drain and close the stump as usual (56.1).

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Figure 56.8: AMPUTATING THROUGH THE UPPER ARM. If you can leave a patient with a reasonable length of humerus, he can use it to hold things by gripping them against his chest. After Robb and Smith with the kind permissin of Graham Stack.

THE SUPRACONDYLAR REGION AS AN AMPUTATION SITE

Starting proximally at the site of bone section, mark out equal anterior and posterior skin flaps, each as long as 3/4 of the diameter of the patient’s arm at the site of section, as in Fig. 56-8. Find, clamp, tie, and cut his brachial artery and vein just proximal to the site of section. Cut his median, ulnar, and radial nerves at a higher level so their ends retract well above the stump.

Cut the muscles in the anterior compartment of his arm 1.5 cm distal to the site of section. Free the insertion of his triceps tendon from his olecranon. Preserve his triceps fascia and muscle as a long flap.

If he has any hope of an elbow prosthesis, reflect this flap proximally and cut the periosteum all round his humerus at least 4 cm above his elbow joint to allow room for the elbow mechanisms of the prosthesis.

If he has no hope of an elbow prosthesis, leave as much bone as you can. Saw across his humerus at the level you choose, and rasp its end smooth. Trim his triceps tendon to make a long flap, carry it across the end of the bone, and sew it to the fascia over the anterior muscles.

Release the tourniquet, control bleeding, drain and close the stump as usual (56.1).

DISARTICULATING THE ELBOW

Make equal anterior and posterior skin flaps. Start at the level of the patient’s epicondyles and curve the posterior flap 2.5 cm distal to the tip of his olecranon. Bring the anterior flap just distal to the insertion of his biceps tendon. If necessary make any suitable flap.

Reflect the flaps to the level of his epicondyles. Start on the medial side. Find and divide the lacertus fibrosus. Free the origin of his flexor muscles from his medial epicondyle and reflect it distally to expose the neurovascular bundle on the medial side of his biceps tendon. Tie and cut his brachial artery just above the joint. Gently pull his median nerve and cut it proximally. Find his ulnar nerve in its groove behind his medial epicondyle and cut it proximally in the same way.

Free his biceps tendon from his radius, and his brachialis tendon from the coronoid process of his ulna. Find his radial nerve in the groove between brachialis and brachioradialis, pull it, and cut it proximally.

On the lateral side of his elbow, cut his extensor muscles 6.5 cm distal to the joint, and reflect their origin proximally.

Cut the patient’s triceps tendon near the tip of his olecranon. Cut the capsule on the front of the joint, complete the disarticulation, and remove his forearm.

Leave the articular surface of his humerus intact. Reflect his triceps tendon anteriorly and sew it to the tendons of his brachialis and biceps.

Make a thin flap from his extensor muscles, reflect it medially and sew it to the remains of his flexor muscles on his medial epicondyle. Suture the muscle mass to cover the bony prominences and exposed tendons at the end of his humerus. Put sutures through the periosteum when necessary. Close the flaps without tension.

Release the tourniquet, control bleeding, drain and close the stump as usual (56.1).