上肢截肢醫(yī)學(xué)知識專題講座培訓(xùn)課件

1、上肢截肢醫(yī)學(xué)知識專題講座上肢截肢醫(yī)學(xué)知識專題講座General PrinciplesDisability ratingsLoss of upper extremity: 50%Loss of hand: 45%Thumb amputation: 23%上肢截肢醫(yī)學(xué)知識專題講座2General PrinciplesDisability rIndications for AmputationTrauma Severe open fracture with extensive skin and muscle loss, neurologic injuryFlail limb (brachial pl

2、exus injury)TumoursPeripheral vascular diseaseInfection上肢截肢醫(yī)學(xué)知識專題講座3Indications for AmputationTrauBrachial Plexus InjuryIf 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 sublux

3、ation resulting from the weight of the arm.In this situation, the patient will not likely be able to use a prosthesis.上肢截肢醫(yī)學(xué)知識專題講座4Brachial Plexus InjuryIf the aBrachial Plexus InjuryIf the scapulothoracic joint can be stabilized, then shoulder fusion and muscle transfers to allow active elbow flexi

4、on may allow for Below-Elbow Amputation.上肢截肢醫(yī)學(xué)知識專題講座5Brachial Plexus InjuryIf the sSurgical PrinciplesLevel of amputation- usually best to maintain lengthSkin flaps - keep all viable skin initiallyNerves - resect sharply, bury to avoid neuromasDont close primarily in trauma, infections.上肢截肢醫(yī)學(xué)知識專題講座6

5、Surgical PrinciplesLevel of amTechniques上肢截肢醫(yī)學(xué)知識專題講座7Techniques上肢截肢醫(yī)學(xué)知識專題講座7Upper Arm AmputationsForequarter amputationShoulder disarticulationProximal above-elbow amputationDistal above-elbow amputationElbow disarticulation上肢截肢醫(yī)學(xué)知識專題講座8Upper Arm AmputationsForequartForequarter AmputationDone most o

6、ften for malignancyDifficult skin flapsPoor cosmesis上肢截肢醫(yī)學(xué)知識專題講座9Forequarter Amputation上肢截肢醫(yī)學(xué)知識Shoulder AmputationsProximal humeral amputations behave like a shoulder disarticulation, but have better cosmesis and prosthesis suspension上肢截肢醫(yī)學(xué)知識專題講座10Shoulder AmputationsProximal hElbow/ Humeral Amputat

7、ionBetter prosthetic suspension with elbow disarticulation but poorer cosmesisBetter function with distal humeral amputation (3.5 cm proximal to elbow)上肢截肢醫(yī)學(xué)知識專題講座11Elbow/ Humeral AmputationBetteForearm (Below-Elbow) AmputationsForearm proximalForearm distalWrist disarticulationTranscarpal上肢截肢醫(yī)學(xué)知識專題

8、講座12Forearm (Below-Elbow) AmputatiBelow-Elbow AmputationVery 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 BEA is preferable to amputation throu

9、gh or above the elbow, as long as the biceps insertion is intact.上肢截肢醫(yī)學(xué)知識專題講座13Below-Elbow AmputationVery funSurgical Pointers Below Elbow AmputationFor short stumps, leave the ulna a little longer than the radiusFor long stumps, the radius should be 1-2 cm longer than the ulna.上肢截肢醫(yī)學(xué)知識專題講座14Surgica

10、l Pointers Below ElbowWrist DisarticulationRetains distal radio-ulnar joint and therefore forearm rotation. Preservation distal radius improves prosthetic fitting.No need to retain carpal bones.Should perform tenodesis of major forearm muscle groups.上肢截肢醫(yī)學(xué)知識專題講座15Wrist DisarticulationRetains dWrist

11、DisarticulationDisadvantages:Harder to fit for myoelectric units because less space is available.上肢截肢醫(yī)學(xué)知識專題講座16Wrist DisarticulationDisadvantHand AmputationsPreserve length, function, and sensationDone as a salvage procedurePrimary amputation performed only for irreversible loss of blood supply and

12、tumours.Salvage thumb whenever possible.上肢截肢醫(yī)學(xué)知識專題講座17Hand AmputationsPreserve lengtRay AmputationGenerally includes distal half of metacarpalCan transpose the index to long finger in the case of long ray amputations.For index ray resection, reimplant first dorsal interosseous into long finger.上肢截肢醫(yī)

13、學(xué)知識專題講座18Ray AmputationGenerally includ上肢截肢醫(yī)學(xué)知識專題講座培訓(xùn)課件Proximal Phalanx AmputationDorsal skin needed for closure.Consider the “l(fā)asso procedure”, in which the FDS tendon is passed around the A2 pulley and sutured to itself. The tension of the FDS must be checked to allow full finger extension.上肢截肢醫(yī)學(xué)知

14、識專題講座20Proximal Phalanx AmputationDorMiddle Phalanx AmputationTry to maintain FDS insertion into base of middle phalanx.If FDS insertion is avulsed, there is little to gain by saving the middle phalanx.上肢截肢醫(yī)學(xué)知識專題講座21Middle Phalanx AmputationTry tDistal Phalanx AmputationIndicated when there is less

15、than 5 mm of sterile matrix remaining.Shorten and perform primary closure.Leave FDP and extensor insertion alone if possible.上肢截肢醫(yī)學(xué)知識專題講座22Distal Phalanx AmputationIndicFingertip InjuriesIf no bone exposed, allow healing by secondary intention.Consider V-Y advancement flaps when bone exposed vs. bon

16、e shortening.Full-thickness skin graftThenar flap上肢截肢醫(yī)學(xué)知識專題講座23Fingertip InjuriesIf no bone eUpper Limb ProstheticsFunction to position the hand in space.Limb length and joint salvage are directly related to functional outcome.Sensation important for function.Early fitting (85% if in 30 days, 50% wi

17、th late fitting)上肢截肢醫(yī)學(xué)知識專題講座24Upper Limb ProstheticsFunctionManagement after AmputationRigid vs soft dressingCompressionAvoid proximal compressionEarly prosthetic fitting上肢截肢醫(yī)學(xué)知識專題講座25Management after AmputationRigComplicationsDIP disarticulation: Avoid intrinsic plus finger deformity by releasing l

18、umbrical insertion as well as FDP, if performed.Quadriga: weak grasp in remaining fingers due to tethering of FDP by scarring at the amputation site. Do not suture flexor to extensor tendons.上肢截肢醫(yī)學(xué)知識專題講座26ComplicationsDIP disarticulatiComplicationsHematomaInfectionNecrosisContracturesNeuromaPhantom

19、painTerminal overgrowth (children)上肢截肢醫(yī)學(xué)知識專題講座27ComplicationsHematoma上肢截肢醫(yī)學(xué)知識專Above Elbow ProsthesesOperated by two control cables:One cable flexes elbow and opens terminal device. Cable controlled by humeral flexion or scapular protraction.Second cable locks and unlocks the elbow. Cable controlled by shoulder extension, abduction, and depression.上肢截肢醫(yī)學(xué)知識專題講座28Above Elbow ProsthesesOperatedBelow Elbow ProsthesesOperated by one control cable that controls the terminal device.Activated by scapular abduction and shoulder flexion