PRINCIPLES IN AMPUTATION

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http://www.medical-vision.us/2017/12/08/principles-in-amputation /
Principles in Amputation
 PRINCIPLES IN AMPUTATION
Adequate blood supply of the flap should be maintained.
Proper marking of the skin incision is essential.
Tourniquet should not be used if amputation is done for vascular diseases.
Proximal part of the flap contains muscle component but distal part should contain only skin and deep
fascia.
Flap length should be adequate; not short. It should be ideally semicircular not rectangular to get a conical
stump.
Nerve should be pulled down and cut using a sharp knife and allowed to retract into the soft tissue
otherwise neuromas may develop.
In crush injury/entrapment injury/sepsisguillotine amputation is done. Later skin is pulled down by using
skin traction, eventually to have better skin coverage.
Bone should be cut with beveling and all sharp margins should be rounded.
Postoperatively regular dressings are done. Patient is mobilised using axillary crutches. After 3 months,
once scar has matured and stump has become supple, proper prosthesis is fit. Berlamont first started
immediate postoperative fitting of prosthesis to leg for early mobilisation. Plaster pylon is applied to the
stump and a prosthetic extension is fit to facilitate partial weight bearing immediately after surgery. It has
got more stump complications and so it has not become popular.
Stumps can be side bearing (sutures are on the side); end bearing/conical (sutures are on the end) or
cylindrical.
Postoperatively active exercise should be given to the proximal joint so that prosthesis can be fit to it
properly.
If there is sepsis especially in gangrene limb, flaps should be left open or loosely sutured otherwise flap
necrosis occurs.
Proper anatomy of muscles and neurovascular bundle around should be known in all amputations.
Principles in Amputation
Image Of Upper Limb Amputation
Image Of Lower Limb Amputation
 FOOT DROP
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FOOT DROP
1. Contact Phase
2. Midstance Phase
3. Propulsive Phase
 FOOT DROP

Inability to dorsiflex and evert the foot due to paralysis of the

peroneal and extensor group of muscles, as a result of common
peroneal nerve injury.
FOOT DROP
Causes
1. Fracture neck of
the fibula
2. Leprosy
3. Lead poisoning
4. Iatrogenic
5. Direct incised
wound

Clinical Features
1. High stepping gait.
2. Loss of sensation
over lateral and
dorsum of the foot.
FOOT DROP Treatment
1. Tendon transfer using
tibialis posterior
muscle. Tendon of
the muscle is
detached from its
navicular insertion
and with a tendon
graft (from plantaris)
it is transferred to
cuboid and cuneiform
bones to get
dorsiflexion and
eversion.
2. Obers procedure.
3. Barrs procedure.
 CLAW HAND
Source :
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CLAW HAND It is the hyperextension of
the metacarpophalangeal
joint with exion of the
interphalangeal joints of the
hand.
Extension of MCP joint is due
to unopposed action of
extensor digitorum.
Flexion of MCP joint and
extension of interphalangeal
joints are by extensor hood of
interossei and lumbricals. So
extensor hood is functioning
mainly by ulnar nerve and also
by median nerve. In ulnar or
median nerve palsies, these
actions are paralysed and so
patient develops claw hand.
It is actually intrinsic minus
deformity.
CLAW HAND Causes
1. Leprosy
2. Trauma
3. Entrapment neuropathies
4. Tardy ulnar palsy
5. Klumpkes palsy

Clinical Features
Typical claw hand.
Loss of sensation along the
distribution of the nerve.
Inability to grasp card
between the fingers.
While holding the book
between the thumb and
fingers, thumb will be flexed
in ulnar claw hand (positive
Froments test).
 CLAW HAND
Types

Ulnar claw hand: Only medial

two fingers are involved.
Low ulnar palsy: Here lesion is in
the wrist (at Guyons canal). Here
deformity is more because of the
overaction of the FDP.
High ulnar palsy: Here FDP is also
paralysed and overaction is not
there. So lesser deformity occurs.
Ulnar paradox: Higher the lesion
lesser the deformity, lower the
lesion more the deformity.

Median claw hand: Only lateral

two fingers are involved. It is less
common.

Combined median and ulnar

claw hand: Here all four fingers
of the hand are involved.
 CLAW HAND
Investigations
Electromyogram.
Nerve conduction studies.

Treatment
1. Paul Brands operation: Extensor carpi radialis longus or brevis (ERCB) is
transferred with a graft to the extensor hood through the lumbrical canal.
Graft is taken from palmaris longus or plantaris muscle.
2. Stye-Bunnells operation: Flexor digitorum superficialis of index finger is
used (only in ulnar claw hand) to transfer to extensor hood.
3. Fowlers operation: Extensor digitorum is used to transfer to extensor
hood.
4. Riordan operation: Flexor carpi radialis is used for tendon transfer.
5. Anterior transpositioning of the ulnar nerve in case of tardy ulnar palsy.
ULNAR NERVE INJURY
Source :
http://www.medical-vision.us/2017/12/07/ulnar-nerve-injury/
 ULNAR NERVE INJURY

After arising from the medial cord of the brachial plexus (C8 and T1), it runs on the medial
aspect of the axillary artery up to middle of the arm. Then it enters the posterior
compartment in relation to triceps muscle. After passing behind the medial epicondyle and
through two heads of flexor carpi ulnaris, it runs in front of the flexor digitorum profundus
(FDP) in the forearm. It reaches the hand in front of the flexor retinaculum through
Guyons canal. Here it divides into superficial and deep branches.
 ULNAR NERVE INJURY

Ulnar nerve supplies flexor carpi ulnaris, medial half of flexor digitorum profundus, all
muscles of the hypothenar eminence (palmaris brevis, abductor digiti minimi, opponens
digiti minimi, flexor digiti minimi), adductor pollicis of the thenar eminence and all
interossei of the hand. It also gives sensory supply to medial part of the hand, medial one
and half fingers.
 ULNAR NERVE INJURY
Ulnar nerve is affected in:
1. Supracondylar fracture
2. Injury to the medial epicondyle
3. Tardy ulnar palsy
4. Leprosy
5. Cubitus valgus deformity
Clinical Features
Claw hand deformity.
Weakness of all the muscles supplied by the
ulnar nerve.
Card test: A card is placed between the two
fingers of the patient to grasp. As the palmar
interossei are weak, patient cannot grasp [palmar
interossei are adductors of the fingers (PAD)].
Abduction of fingers are checked [dorsal
interossei are abductors (DAB)].
Froments sign: A book is placed to grasp
between fingers and thumb of the patient.
Normally thumb will be straight because of the
action of adductor pollicis muscle. As it is
paralysed in ulnar palsy, grasp is achieved by the
action of flexor pollicis longus and there will be
flexed thumb.
Loss of sensation over medial one and half
fingers and hand.
 ULNAR NERVE INJURY
Investigations
Nerve conduction studies.
Electromyogram.

Treatment
Nerve suturing or
nerve grafting.
Tendon transfer.

Intrinsic minus deformity: It is due to loss of intrinsic muscle power, i.e claw hand.
Intrinsic plus deformity: It is due to muscle contracture and brosis.
Ulnar paradox: In ulnar palsy, higher the lesion, lesser the deformity, lower the
lesion more the deformity. In higher lesion, FDP is also paralysed. In lower lesion
FDP is intact and so FDP causes more flexion (overaction) and so aggravates the
claw hand.
CARPAL TUNNEL SYNDROME
Source :
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 CARPAL TUNNEL SYNDROME

It is the compression neuropathy of median nerve in the carpus, deep to flexor

retinaculum.
Flexor retinaculum (transverse carpal ligament) maintains the concavity of wrist
and extends laterally from trapezium and scaphoid to pisiform and hook of the
hamate medially.
 Carpal tunnel is
formed by carpal
bones behind and
flexor retinaculum in
front. It contains
median nerve and
long flexor tendons
of fingers and thumb.
Ulnar nerve lies
superficially, not in
the carpal tunnel.
Median nerve gets
compressed if space
Causes of the carpal tunnel
Lunate dislocation, malunited Colles fracture. gets reduced.
Radiocarpal arthritis, flexor tendon tenosynovitis.
Myxoedema, acromegaly, pregnancy.
CARPAL TUNNEL SYNDROME
Clinical Features
1. Common in females.
2. Tingling, numbness, paranesthesia
and burning sensation in the lateral
three and half fingers supplied by
median nerve. Burning sensation
gets aggravated at night.
3. Ape thumb deformity, wasting of
thenar muscles, weakness of
opponens pollicis and abductor
pollicis brevis, i.e. features of low
median nerve palsy.
4. When BP cuff is inflated patient feels
the typical pain in the fingers.
5. Tapping the median nerve at the
distal end of forearm with the wrist
held in extension aggravates the
symptoms.
6. Condition is often bilateral.
CARPAL TUNNEL SYNDROME

Phalens Test (Wrist Flexion Test)

Flexion of the wrist causes
exacerbation of the symptoms within
1 minute and the symptoms will
disappear as the wrist is straightened.

Differential Diagnosis
Cervical spondylosis.
Cervical rib syndrome.

Diagnosis
Nerve conduction studies.
 CARPAL TUNNEL SYNDROME

Treatment
1. Surgical decompression of median nerve by cutting both superficial and deep part of flexor
retinaculum completely, by S shaped incision.
2. Surgery is usually done under local anesthesia. General or brachial block can be used. Tourniquet is
commonly used. Vertical crease incision is made in the proximal part of the palm with convexity of
the incision towards the ulnar side.
3. Skin incision is deepened. Palmar cutaneous branch of the median nerve should be preserved.
Incision is deepened to identify the flexor retinaculum. Entire length, both superficial and deep
parts should be cut properly. It is cut towards ulnar side of the wound. Only skin is sutured using
interrupted non-absorbable 3 zero polypropylene or polyethylene sutures.
4. Complications are incomplete fasciotomy and recurrence, nerve injury.
5. Using small proximal incision, endoscopy can be passed to visualize and cut the entire flexor
retinaculumminimal access surgery.
6. Postoperatively good physiotherapy is required.
7. Condition is permanently curable.
NUMBNESS PAIN
Numbness describes a loss of
sensation or feeling in a part of
your body. It's often accompanied
by or combined with other
changes in sensation, such as a
pins-and-needles feeling, burning
or tingling. Numbness can occur
along a single nerve, on one side
of the body, or it may occur
symmetrically, on both sides of the
body.
MEDIAN NERVE INJURY
Source :
http://www.medical-vision.us/2017/12/06/median-nerve-injury/
 MEDIAN NERVE INJURY
Median nerve arises from
lateral (C5, 6, 7) and medial
cord (C8 and T1) of the
brachial plexus. It is initially
lateral to the axillary artery
and becomes medial in the
lower part of the arm and in
the cubital fossa. It passes
through the pronator teres,
descends in relation to flexor
muscles and enters the palm
through the carpal tunnel at
the wrist.
It supplies pronator teres, flexor carpi radialis, palmaris longus and flexor digitorum
superficialis. Anterior interosseous branch of the median nerve supplies pronator teres,
lateral half of the flexor digitorum profundus, flexor pollicis longus and pronator
quadratus.
In the wrist, it supplies abductor pollicis brevis, flexor pollicis and opponens pollicis of
thenar eminence and lateral two lumbricals. It gives sensory supply to lateral three and
half fingers of the hand
 MEDIAN NERVE INJURY
Median nerve is affected in:
1. Injuries
Supracondylar fracture of the
elbow
Fracturedislocation of the
elbow
Direct cut injuries

2. Leprosy
3. Carpal tunnel syndrome
4. As a part of brachial plexus injury
Clinical Features of Median Nerve Palsy
In high median nerve palsy
1. Wasting of the thenar eminence. Loss of sensation on lateral three and half ngers.
2. Ochsners clasping test shows pointing index because of the inactivity of lateral two divisions of
the profundus.
3. Ape or Simian thumb deformity is due to overaction of the adductor pollicis which is supplied by
the deep branch of ulnar nerve. As all other thenar muscles are paralysed, thumb comes in the
same plane of the metacarpals.
4. Pen test: In median nerve injury, pen held in front of the hand cannot be touched by thumb as
abduction is not possible due to paralysis of the abductor pollicis brevis.
In low median nerve palsy profundus is not paralysed and so pointing index is not seen.
MEDIAN NERVE INJURY
Investigations
Nerve conduction studies.
X-ray of the part in case of fracture.
Electromyogram.

Treatment
Nerve suturing or nerve graft.
Tendon transfer.
Treat the cause like carpal tunnel
syndrome.
 SYNDACTYLY
Source :
http://www.medical-vision.us/2017/12/06/syndactyly/
SYNDACTYLY
It is webbing or fusion of fingers

Causes
1. Congenital and hereditary
common.
2. Traumatic like burns.

Types
1. Cutaneoussimple.
2. Fibrous.
3. Bonycomplex.
4. It can be unilateral or bilateral.
5. Often all four limbs may be
involved with webbing of toes.
6. It may be associated with
polydactyly or visceral
anomalies.
7. If bony type is suspected, X-ray
of the part should be taken.
SYNDACTYLY
Treatment
1. If cutaneous, release of
web is done as a staged
procedure along with Z
plasty or skin grafting.
2. If fibrous, release can be
done.
3. If bony type, release is
difficult because blood
supply may be
compromised which leads
to gangrene of the digit.
 VOLKMANNS ISCHAEMIC
CONTRACTURE
Source :
http://www.medical-vision.us/2017/12/06/volkmanns-ischaemic-contracture/
 VOLKMANNS ISCHAEMIC CONTRACTURE

It is a vascular injury leading to muscular infarction and subse- quent contracture.

Causes
1. Supracondylar fracture of the humerus.
2. IV chemotherapy.
3. Burns.
4. Closed forearm crush injuries.
5. Tight plaster after reduction of fracture
VOLKMANNS ISCHAEMIC CONTRACTURE
Clinical Features
Acute phase:
1. Pain (persistent pain in
forearm, hand, fingers
ominous symptom).
2. Pallor.
3. Puffiness (due to oedema).
4. Pulseless (absence of radial
pulse; but its presence does
not rule out the onset of
impending contracture).
5. Paresis.
6. Late phase: Deformity
Deformity (due to injury to
median nerve):
1. Wrist joint extended.
2. Extended
metacarpophalangeal joints.
o Flexed interphalangeal
joints.
 VOLKMANNS ISCHAEMIC CONTRACTURE

Volkmanns sign:

In early stage, the fingers can be extended at the interphalangeal joints, only
when the wrist is flexed fully. The fingers tend to flex if any attempt to extend the
wrist is made.
 VOLKMANNS ISCHAEMIC CONTRACTURE

Treatment
In acute phase:
1. Removal of plastic cast applied after fracture reduction.
2. Correction of fracture.
3. Exposure of brachial artery and application of 2.5% papaverine sulphate to relieve the
spasm if any.
4. Suture of arterial tear if present, often with placement of arterial graft.
5. Lateral incision over the deep fascia of forearm is placed to decompress the oedema.
VOLKMANNS ISCHAEMIC CONTRACTURE

In late phase (once deformity occurs):

Physiotherapy
1. Dynamic splints.
2. Max-Page operation: Release of flexor muscles
(forearm muscles) from their origins from the
bone and allowing it slide down until full
extension.
3. Excision of fibrous tissue and damaged muscles
along with tendon transfer.
4. Arthrodesis.
 BURSAE
Bursa is a sac like cavity containing fluid within, which in normal location prevents friction
between tendon and bone.
1. Minor injuries and pressure leads into bursitis, which will present as a swelling at the site.
2. Inflammation of this bursa due to friction causes bursitis, which commonly presents as
swelling, pain, and restricted movements.
3. Bursa secretes synovia like clear fluid in a cavity lined by flat endothelium. It reduces the
friction at the site between tendon and bone. Normally fluid content is little to cause a
swelling. Minor trauma or infection causes sudden increase in fluid secretion of the bursa
making it to enlarge and clinically palpable as pathological bursitis. Bursa is common around
knee, elbow, heel and hip.
4. Long-standing bursitis leads into thickening of its wall often with calcification making it feel
hard with indurated surface. Lining of bursa may become rough or fluid may contain loose
fibrinous particles to create grating sensation (crepitus) on the surface.
5. Often overlying skin becomes thick, cracked and horny due to repeated friction and
inflammation.
6. Bursa may get adherent to deeper tissue as well as overlying skin to make it immobile. Bursa
is usually well-localised, smooth, fluctuant, nontender swelling. Often it can be bilat- eral
in knee or elbow.
7. Joint related should be examined. Bursa may be communi- cating with the adjacent joint.
8. Gout or rheumatoid arthritis can cause bursa. For example, olecranon bursa can develop in
gout patient.
9. Bursa should be differentiated from cold abscess, soft tissue tumour, aneurysm, synovial
tumour (sarcoma) at different locations.
 BURSAE

Complications of Bursa
1. Infection of bursa can occur due to trauma to overlying skin or through blood.
2. Mechanical disturbances and discomfort.
Management
1. US of the anatomical site, X-ray of the part or MRI are very useful.
2. Avoiding friction and other aggravating factors may control many bursae.
3. Aspiration and steroid injection may be useful.
4. Bursa which is felt indurated with thick wall or calcified or infected or attained large
size or which interferes with joint movement or daily activities needs surgical excision.
Subcutaneous bursa can be excised under local anaesthesia; large or deeper bursa
requires general anaesthesia for excision.
 BURSAE
Source :
http://www.medical-vision.us/2017/12/05/bursae/
 BURSAE
Different Types
It can be anatomical or adventitious.
Anatomical
1. Anatomical bursae are located normally in a particular anatomical site with a purpose of
reducing friction. They are commonly deep and adjacent to a bone or joint.
2. They become pathological and clinically significant when it presents with bursitis.
3. They are soft, cystic, well localised, nontransilluminating swelling at known anatomical site.
4. Subhyoid bursa: An horizontally oval swelling situated below the hyoid bone and in front of
the thyrohyoid membrane.
5. Subacromial bursa: In front and lateral to humeral head in relation to supraspinatus tendon
between acromion and greater tuberosity of humerus.
6. Bicipito radial bursa.
7. Olecranon bursa (Students elbow, Miners elbow): It is subcutaneous bursa in relation to
olecranon which becomes distended due to prolonged periods of leaning over elbow. Gout
may involve this bursa.
8. Psoas bursa: A tensely cystic swelling situated beneath and below the inguinal ligament, in
the lateral aspect of the femoral triangle. But it will not extend above the inguinal ligament
in to the iliac region (unlike in psoas abscess which extends above and is cross fluctuant).
Psoas bursa lies between the psoas tendon and lesser trochanter. When it is enlarged, it
causes diffuse swelling over outer part of femoral triangle lateral to femoral vessels. When
hip is moved swelling becomes painful. It also should be differ- entiated from femoral
hernia.
 BURSAE

Anatomical

9. Prepatellar bursa (Housemaids knee/miners beat knee): It lies

subcutaneously in front of lower half of patella and upper half of patellar
tendon (upper part) undergoes inflammation in people who do much
kneeling. Joint is normal here.
10.Subcutaneous infrapatellar bursa occurs between skin and lower part of the
tibial tuberosity and ligamentum patellae. It is called as Clergymans knee.
Clergyman is Christian priest who kneels down during prayer.
11.Suprapatellar bursitis is deep to patella and vastus intermedius, in front of
lower end of femur. It communicates with knee joint.
12.Brodies bursa lies deep to medial head of gastrocnemius.
13.Semimembranosus bursa
14.Bursa anserinaunder the tendons of Guy ropes (sartorius, gracilis and
semitendinosus tendonsGooses foot).
15.Retrocalcaneum bursabetween calcaneum and tendo-Achilis.
 BURSAE

Adventitious Bursa
1. Adventitious bursa occurs in an unusual place/site due to friction/pressure
between two layers of tissue. Once it becomes chronic it may get adherent to
overlying skin or tissue underneath.
2. It may get infected, wall get scalcified, and fluid may become thick. It is well-
localised, cystic usually nontender swelling. It becomes painful and tender if
infected.
3. Lining of bursa may become rough or fluid may contain loose fibrinous
particles to create grating sensation/crepitus on the surface.
 BURSAE

Examples
1. Bunion is adventitious bursa in patient with hallux valgus occurring between
head of first metatarsal and skin.
2. Tailors bursa occurs between lateral malleolus and skin.
3. Porters bursa occurs between skin over shoulder and clavicle.
4. Weavers bursa occurs between gluteus maximus, ischial tuberosity and skin.
5. RetroAchillis bursitis occurs between skin and Achilles tendon.
6. Subcalcaneal bursitis occurs between calcaneum and heel in long distance
runners.
7. Billing gate hump appears over 7th cervical spine deep to overlying skin in
people carrying weight over it. Billing gate is a large fish market in London.
 BURSAE

Condition should be differentiated from soft tissue tumour, sebaceous cyst,

ganglion (depending on the location of bursa).

Management: X-ray of the part and FNAC of swelling should be done. Later it is
excised usually under local anaesthesia.
 Compartment Syndrome-
Treatment
Source :
http://www.medical-vision.us/2017/12/05/compartment-syndrome-treatment/
Compartment Syndrome- Treatment
 Compartment Syndrome- Treatment
Compartment syndrome is a special entity; common in leg, forearm, thigh and arm; is a
syndrome due to increased intra- compartmental pressure within a limited space area.
Causes arenarrowed space due to tight dressings/plaster cast, lying on one limb in
comatous patient; increased content within the compartment due to trauma like fractures,
oedema, ischaemic injury, haematoma, positioning after trauma, burn injury, etc.; high
pressure injection injuries like gun injury, oil based material injury, extravasation of
chemotherapeutic drugs; snake bite.
It compromises circulation and function mainly of muscles and nerves. It often maintains
the normal colour and tempera- ture of the fingers and distal pulses may not be
obliterated in spite of severe muscle ischaemia. Muscle ischaemia more than 4 hours
causes muscle death and myoglobinuria. Irrevers- ible nerve damage develops if ischaemia
persists for 8 hours. Progressive, persistent severe pain which is aggravated by passive
muscle stretching is the diagnostic sign. Tense tender regional lymph node is typical. Pulse
will be usually normally felt in compartment syndrome; but may become absent if there is
associated arterial injury. Compartment pressure more than 30 mmHg is an indication for
fasciotomy.
It is common in calf and forearm. Closed injuries cause haematoma leading to increased
pressure. It is often associated with fracture of the underlying bone which in turn
compresses the major vessel further aggravating the ischaemia causing pallor,
pulselessness, pain, paraesthesia, diffuse swelling and cold limb.
Compartment Syndrome- Treatment
 Compartment Syndrome- Treatment

If allowed to progress it may eventually lead to gangrene or chronic

ischaemic contracture with deformed, disabled limb.
Muscle necrosis releases myoglobulin which is excreted in the urine,
damages the kidneys leading into renal failure.
Note: Affected muscle when passively stretched worsens the
painthe most reliable clinical sign.
Treatment
Compartment pressure will be persistently more than 30 mm Hg. It
can be measured by placing a fine catheter in the compartment and
using a pressure monitor. This is an indication for fasciotomy.
Adequate lengthy incision involving skin, fat and deep fascia should
be done until underneath muscle bulges out properly. Multiple
incisions should be made if needed. Separate incision in each
compartment should be done.
 Compartment Syndrome- Treatment
Fasciotomy done in forearm anterior compartment is a specific method. Carpal
tunnel should be released by cutting flexor retinaculum. Incision begins at the
junction of the thenar and hypothenar area; extends proximally initially
transverse across flexion crease of the wrist at the ulnar border; then across
forearm towards radial side of forearm; then in proximal forearm towards medial
side creating convex flap towards lateral side. In the elbow it crosses along the
medial border to reach the arm where it runs in arm along the medial part of the
anterior arm. Injury to major nerves, palmar cutaneous branch of median nerve
should be avoided while placing the incision. Incision should be deepened by
cutting the deep fascia along the entire length of the incision. Dorsal fasciotomy
should be added by placing longitudinal lengthy incision in the midline. Two
longitudinal incisions on the dorsum of the hand also should be made.

1. Antibiotics.
2. Catheterisation.
3. Mannitolordiureticstocausediuresis,soastoflushthekidney.
4. Fresh blood transfusion.
5. Hyperbaric oxygen.