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Chapter 19
e Krukenberg Reconstruction in Children
John F. Lawrence, MD Hugh G. Watts, MD
Abstract
e Krukenberg procedure separates the forearm bones in a manner similar to a syndactyly
release to provide sensate grasp for a child who lacks one or both functioning hands. It is
particularly useful in regions of the world where the availability of prosthetic devices is
limited and costs are prohibitive. Although some surgeons have concerns about the cosmetic
appearance of the reconstr uction, the procedure is acceptable to many children and parents.
Keywords: affordable alternative; hand amputee; Krukenberg
procedure; sensate pincers
Introduction
The Krukenberg reconstruction is a
surgical procedure designed to provide
sensate grasp for a child who lacks one
or both functioning hands. In a child’s
world, which often involves play in water and dirt, the reconstruction avoids
the need for a prosthesis that may require frequent repair. The Krukenberg
procedure can be performed in a child
with loss of one or both hands who has
too expensive for the general public. An
example of the value of this procedure
in such regions is illustrated by the fact
that an American missionary surgeon in
Bangladesh (Robert Garst), who was an
enthusiastic proponent of the benefits of
the Krukenberg procedure, was honored
for his work in 1981 when Bangladesh
published a postage stamp illustrating
the result of the Krukenberg procedure
(Figure 2).
a functioning forearm and elbow. The
surgical procedure separates the forearm
bones in a manner similar to a syndactyly release. The proximal extent of separation is the area of the pronator teres.
The skin coverage is fashioned from the
sensate forearm skin (Figure 1).
Children with absent hands, especially congenital deletions, often prefer
not to wear upper limb prostheses. The
Krukenberg reconstruction adds function without the encumbrance of the
added prosthetic weight and heat of a
prosthetic socket. This procedure is particularly useful in regions of the world
where the availability of prosthetic devices is limited, and cost and repair are
Neither of the following authors nor any immediate family member has received anything of value
from or has stock or stock options held in a commercial company or institution related directly or
indirectly to the subject of this chapter: Dr. Lawrence and Dr. Watts.
History
In 1917, Hermann Krukenberg, a German surgeon, first reported the conversion of a residual forearm into sensate
pincers by separating the radius and
ulna in a bilateral adult amputee.1 The
procedure was initially performed on
World War I amputees. The first description of the procedure in the English
medical literature occurred in 1933.2
The use of the procedure in two teenage
patients with unilateral hand loss was
reported. In one patient, the hand loss
was the result of a congenital deletion,
and in the other patient the hand loss
resulted from a traumatic injury. The
Figure 1
Krukenberg reconstruction grasping a toy.
Young children can be taught to use the reconstructed limb by a skilled pediatric hand therapist. (Courtesy of John Laurence, Hugh Watts,
Joanna Patten: Krukenberg’s operation in a
child, Global HELP, 2010.)
Photograph of a child with a
use of the procedure in juvenile patients
with bilateral limb loss was described in
1964.3 Swanson3 reported on four patients with bilateral limb absences. In
each patient, one limb was fitted with a
standard prosthesis and the other side
underwent a Krukenberg reconstruction. The hand on the operated side became the predominant hand in each of
the children, and none of the patients
elected to wear a prosthesis. One of the
children subsequently published a book
detailing his experiences with a Krukenberg reconstructed limb.
4
Indications and
Contraindications
Vision Impairment
The Krukenberg procedure is especially
desirable for blind children because it
results in a sensate limb, which allows
the child tactile exploration, interaction,
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
243
Section 2: Upper Limb
Figure 2
patient with a K rukenberg reconstruc tion. (Courtesy of John Lau rence, Hugh Watts, Joanna Pat ten:
Krukenberg’s operation in a child, Global HELP, 2010.)
and feedback from his or her environment. However, the authors of this
chapter believe that sighted children
with unilateral or bilateral deletions
also derive functional benefits from the
procedure.
Photograph of th e stamp from Bangladesh d epicting the func tionality achieved in a
often candidates for the Krukenberg
procedure.6 As of 2014, it was estimated
that 59 states and 4 other areas in the
world were affected by the presence
of land mines.7 Children in war torn
countries often pick up explosive de
vices believing that they are toys. These
Forearm Length
The desired length of the pincers on the
residual limb depends in part on the age
of the child at the time of surgery. In
children 5 to 6 years old, the residual
limb length should be at the transcarpal
or wrist level. In older children, deletions at the midforearm level or longer
can be functional (Figure 3).
devises can cause devastating injuries to
both the hands and the eyes. In countries where explosive remnants of war
are an important problem, there is often substantial social disorder and poverty, and prosthetic facilities are rare.
Because children require yearly prosthesis evaluations and refurbishments, the
Krukenberg reconstruction is a valuable
treatment option in such regions.
6
Age
Children who are developmentally
4 years of age or older are good candidates for the procedure.5 Children
should have sufficient psychological
development to understand and cooperate with the postoperative exercise
program.
Cultural and Geographical
Considerations
Children with upper limb injuries
caused by land mine explosions are
Anatomic Considerations
The Krukenberg reconstruction is not
possible if there is a radioulnar synostosis or substantial elbow abnormality.
The skin of the forearm must have good
sensation. Residual limb lengths of at
least 5 cm are recommended.
Cosmetic Appearance
Versus Function
The Krukenberg modification of the
forearm has not been well accepted
Figure 3
thin object illustrates the preservation of good
sensation in the pincers that is possible with a
Krukenberg reconstruction.
Photograph of a chi ld grasping a
in the United States, where it has often been described as useful only for
bilateral amputees who are blind.8 In
1964, Swanson3 recommended that
the “almost universal antipathy toward
this procedure should be overcome.”
Although those in the US medical field
have generally professed negative feel-
-
ings regarding the cosmetic outcome of
the reconstruction, this opinion has not
been as strongly shared by those in the
nonmedical community. The authors of
this chapter believe that if the pediatric
orthopaedic medical community had
greater familiarity with the Krukenberg
procedure and the opportunity to examine children who were treated with
the reconstruction, the procedure would
have better acceptance.
The concept of active versus passive
cosmesis has been described.9 Passive
cosmesis is the appearance of a limb at
rest, whereas active cosmesis refers to
the appearance of the limb in motion.
The extraordinary dexterity provided
by a Krukenberg limb allows more natural motion than that achieved using
a prosthesis. In the experience of this
chapter’s authors, few patients who have
been provided with a prosthesis that can
be worn over the Krukenberg reconstructed arm elect to wear the prosthesis. Because of its functional advantages,
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
244
Chapter 19: The Krukenberg Reconstruction in Children
Figure 4
surface is shown on the left, the dorsal on the right.
Illustrations of the preferred locations of fasciocutaneous skin incisions. The volar
the Krukenberg procedure should be
considered as an option for any child
affected by hand loss.
In a multicenter study, Wagner et al10
reported that children with unilateral
transradial limb deficiencies often do
not wear their prostheses. Children with
transcarpal or transradial wrist-level
deficiencies are not usually appropriate
candidates for prosthetic fitting because
they already have excellent limb length
and function, with the exception of the
ability to grasp or pinch. The realistic
decision becomes whether to perform
a Krukenberg reconstruction or do
nothing.
Surgical Technique
A tourniquet is used on the upper arm
when performing a Krukenberg procedure. The forearm incisions are designed
to provide as much skin coverage to the
distal residual limbs as possible (Figure
4). Any skin distal to the wrist is preserved for use in covering the distal pincers. In a young patient, an effort should
be made to preserve the distal epiphyses
because substantial growth may occur
at that level (Figure 5).
The forearm bones are separated by
incising the interosseus membrane to
its proximal extent. It is important to
preserve two musculocutaneous flaps, if
possible. One flap includes the brachioradialis and the extensor carpi radialis
muscles. This flap should not be separated from the radius. The second flap
is an ulnar flap and includes the flexor
carpi ulnaris and the extensor carpi ulnaris. This flap should not be separated
from the ulna. To the extent possible,
sensory nerves should be preserved.
Some muscle bulk should be removed to allow good closure. The choice
of which muscles to remove depends on
which muscles are present. If the anatomy is normal, as in a traumatic amputation, many of the finger flexor and
extensor muscles should be removed.
In congenital deletions, these muscles
may not be present. The most important
muscles to preserve are the flexor carpi
Figure 5
Krukenber g procedure taken at the complet ion
of skin closure and before dressing application.
Figure 6
Note the distal radial and ulnar epiphyses.
Surgical photograph of the
Radiograph of open pincers.
ulnaris, the extensor carpi ulnaris, the
brachioradialis, and the pronator teres.
When separating the forearm bones, as
much separation as possible should be
obtained without injuring the capsules
of the proximal radioulnar joint or the
radiocapitellar joint. The length of the
pincers is determined by the distance
between the attachment of the pronator
teres to the radius and the end of the
radius. The forearm bones should be of
equal length. It is desirable to have 6 to
8 cm, but a shorter distance can be tolerated, especially when distal growth
is anticipated. In older children, the
forearm bones can be shortened for
better closure. Longer pincers have
less strength at the tips, but they have
a larger grasping potential (Figure 6).
In the growing child, closure is
best obtained by starting distally. A
full-thickness graft is used proximally
if indicated (Figure 7). Tight closure
should be avoided. The tourniquet
should be released before closure to allow a better evaluation of the circulation
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
245
Section 2: Upper Limb
to the flaps. At the completion of surgery, the pincer arms are dressed separately and separated by the amount of
space that was determined to be possible
at surgery. The limb should be elevated
for 2 to 3 days. Active exercise can begin
in 2 to 3 weeks and should be focused
on grasp and release rather than pronation and supination.
Therapy
Preoperative
Even though children with transcarpal
or transradial limb deficiencies can do
all or most age-appropriate activities of
daily living without prosthetic or surgical intervention, the Krukenberg reconstruction provides an alternative method
of performing bimanual tasks (Figure
8). The pincers have the potential for
excellent sensate functional grasp. Because the procedure alters the appearance of the limb, it is important for the
child and his or her parents to view a
video of functional activities being performed by a child with a Krukenberg
reconstruction; this should be followed
by a discussion with the treating surgeon and therapist.
Postoperative
Active grasp and release activities should
begin 2 to 3 weeks after surgery. It is
best to open and close the pincers with
abduction and adduction movements,
not with a pronation and supination
scissor-type action. The therapist can be
helpful in teaching the child the proper
motions to open and close the digits.
Flexing the elbow against resistance
while holding the ulnar post will assist
in opposing the pincers. The therapist
can also instruct the parents or caregivers on the performance of helpful
exercises.
After tenderness decreases, the patient is taught to grasp and release small
objects and then progresses to larger
objects. Grasp of fine objects, such as
paper, is learned. For most children,
grasp is strongest at the proximal part
Figure 7
sal surface is to the right. The hatched area represents the location of a full-thickness skin graft, if
needed.
of the pincers. Bimanual activities, such
as playing with toys and games and performing the activities of daily living,
Illustration of the completed procedure. The volar surface is to the left and the dor-
major contributor to strength or motion
(John F. Lawrence, MD, unpublished
data.).
are important aspects of rehabilitation
therapy.
Two years after a reconstruction, one
of the authors of this chapter worked
with a clinician experienced in electromyography to test three pediatric pa
tients to determine which muscles were
the most important for pinch and separation of the arms of the Krukenberg
forearm. The brachialis was found to
be the strongest separator of the radius
from the ulna. The flexor carpi ulnaris
and the extensor carpi radialis were the
strongest adductors. Contrary to common belief, the pronator teres was not a
Summary
The purpose of the Krukenberg reconstruction is to provide sensate pinch to
children who are neurologically intact
-
and have a functional forearm and upper limb but are missing one or both
hands. The procedure is accomplished
by splitting the forearm bones and creating two separate pincers that can be
used to manipulate and grasp objects.
The advantages of the procedure are
that it creates sensate pinch, allows skillful manipulation without the need for
visual monitoring, and creates a durable
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
246
Chapter 19: The Krukenberg Reconstruction in Children
Figure 8
bimanual function that can be obtained with a Krukenberg reconstructed limb working with a
normal limb.
limb that is not affected by adverse environmental conditions. There is no
need to replace an outgrown prosthetic
Postoperative photograph of a teenage girl styling her hair demonstrates the good
younger children. Each family should be
fully counseled regarding the procedure
so that an informed choice can be made.
socket, nor is there need for prosthetic
repairs. The disadvantages of the procedure are related to the acceptance of the
appearance of the Krukenberg limb by
surgeons, parents, and peers.
This chapter’s authors believe that
the Krukenberg reconstruction is an
appropriate choice in the treatment of a
blind or sighted child with a unilateral
or bilateral amputation at the level of the
wrist or the proximal metacarpals. The
procedure is appropriate for children
who are developmentally older than
4 years of age because postoperative
References
1. Krukenberg H: Über die Plastiche
Umwertung von Amputationstümpfen. Stuttgart, Germany, Enke Verlag,
1917.
2. Colp R: Abstract: Krukenberg amputation. Ann Surg 1933;97(2):277.
Medline
3. Swanson AB: e Krukenberg procedure in the juvenile amputee. J Bone
Joint Surg Am 1964;46:1540-1548.
Medline
training would be more difficult for
4. Lund D, Fleck B: No Hands, No Feet,
No Problem Bel Air, CA, Bookman
Publishing, 2005.
5. Harrison SH, Mayou B: Bilateral
Krukenberg operations in a young
child. Br J Plast Surg 1977;30(2):171-
173. Medline DOI
6. Watts HG: e consequences for children of explosive remnants of war:
Land mines, unexploded ordnance,
improvised explosive devices, and
cluster bombs. J Pediatr Rehabil Med
2009;2(3):217-227. Medline
7. Landmine and Cluster Munitions
Monitor, Campaign to Ban Land
Mines. Update 2014. Available at:
http://www.the-monitor.org/index.
php/LM/e-issues/Landmines.
Accessed August 12, 2015.
8. Burkhalter J: Mutilating injuries
of the hand, in Hunter J, Macin E,
Callahan A, eds: Rehabilitation of the
Hand: Surgery and erapy. St. Louis,
MO, Mosby-Year Book, 1995, vol II,
p 1055.
9. Swanson AB, Swanson GD: e
Krukenberg procedure in the juvenile
amputee. Clin Orthop Relat Res
1980;148:55-61. Medline
10. Wagner LV, Bagley AM, James MA:
Reasons for prosthetic rejection by
children with unilateral congenital
transverse forearm total deciency.
J Pediatr Orthop 20 07;19(2):51-54.
Available at: http://www.oandp.
org/jpo/library/2007_02_051.asp.
Accessed August 12, 2015.
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
247
Chapter 20
Elbow Disarticulation and Transhumeral
Amputation: Surgical Management
Mickey S. Cho, MD
Abstract
e choice between elbow disarticulation and transhumeral amputation always should be
considered in the context of the primary goal, which is to achieve the best functional outcome
for the patient. Most upper limb amputations are necessitated by trauma, and the denitive
amputation level oen is determined by the injury. e condition of the so-tissue envelope,
the residual limb length, and future prosthetic suspension options all must be considered.
Keywords: amputation complications; amputation technique; elbow
disarticulation; transhumeral amputation
Introduction
Amputation of an upper limb is a catastrophic event primarily performed
as the result of high-energy trauma,
with approximately 90% of upper limb
amputations resulting from trauma3
(Figure 1). The surgeon’s goal in selecting a definitive amputation level after
traumatic amputation is to ensure that
the residual limb has maximal length
and soft-tissue coverage so that a highly
functional prosthetic limb can be painlessly accepted (Figure 2). The amputation itself is only the first step in the
patient’s rehabilitation from injury.
General Surgical
Considerations
As much limb length as possible should
be preserved to maximize the patient’s
options for later prosthetic fitting. In addition, having a relatively long residual
limb is useful for allowing the patient to
interact with the environment when the
prosthesis is not being worn.4 The caveat
in maintaining maximal limb length is
Neither Dr. Cho nor any immediate family member has received anything of value from or has
stock or stock options held in a commercial company or institution related directly or indirectly to
the subject of this chapter.
that the soft tissues must be able to support the residual limb to achieve comfortable use of a prosthesis. The zone of
1,2
injury is the most important factor in
choosing the final limb length. Usually
the most durable coverage is achieved
with local skin flaps. The ultimate size,
shape, durability, and appearance of the
residual limb will affect a patient’s satisfaction and should be considered in
surgical decision making.
Distraction osteogenesis and microvascular techniques can be used to allow
successful soft-tissue closure during an
initial proximal transhumeral ampu-
5,6
tation.
indicated for preserving the shoulder
joint (allowing a forequarter or shoulder disarticulation to be converted to
a transhumeral amputation), the elbow
joint, or bone length of more than 7 cm
below the shoulder or elbow (to improve
prosthetic fit and performance).
proximal to the deltoid insertion functions as a shoulder disarticulation, it
Free-tissue transfer may be
Although a transhumeral amputation
4
7
has advantages over shoulder disarticulation. Retaining the proximal humerus
preserves the contour of the shoulder,
thus improving the fit of the prosthesis
and cosmesis. There is greater controversy as to whether a long transhumeral
amputation or an elbow disarticulation
is preferable. The disarticulation offers
enhanced prosthetic suspension and
rotational control because the medial
and lateral flares of the distal humerus
are preserved. However, preserving the
full length of the humerus may preclude
the use of a prosthetic elbow by limiting
the space available for a prosthesis; at a
minimum, a bulky, nonanatomic elbow
component is required. The available
external-hinge elbow mechanisms can
be cosmetically displeasing, particularly
if the patient has an unaffected contralateral upper limb. An angulation osteotomy of the distal humerus or humeral
shortening proximal to the elbow can
be used to improve rotational control
and avoid limiting prosthetic elbow
options.
above the center of rotation of the elbow
is required so that the prosthetic elbow
center is at the level of the intact elbow.
level, proper management of the nerves
and muscles of the residual limb is of
paramount importance. Adequate padding of the residual bone end and prevention of postoperative neuritic pain
substantially affect prosthetic wear comfort. To this end, myoplasty or myodesis
should be done to pad any bony prominence about the residual limb. Traction
neurectomies of the major peripheral
nerves and the cutaneous nerves should
3,8
On average, 7.6 cm of space
Regardless of the final amputation
9
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
249
Section 2: Upper Limb
Figure 1
vised explosive device. A, A more proximal level amputation is needed because of the loss of soft
tissue and gross contamination. B, The limb after thorough débridement of devitalized soft tissue
and bone. An elbow disarticulation was required.
be done to keep neuromas proximal to
the skin closure and the myoplasty or
myodesis sites. However, overly aggressive traction neurectomies can cause
denervation of residual proximal muscle and should be avoided. Tintle et al4
described several reasons for caution in
traction neurectomies. First, denervated
muscle will atrophy and can leave the
residual limb poorly padded. Second,
denervated muscle cannot contract and
Clinical photographs of an upper limb injury sustained from the blast of an impro-
decreases. The result can be diminished
wear or use by the patient. To improve
the bioprosthetic interface and function
of myoelectric prostheses, research efforts have focused on improving suspension, durability, degrees of freedom
at the terminal device, and myoelectric
control at additional intuitive input sites.
In addition, reducing the weight of the
prosthesis and extending its battery life
are being studied.
12-14
thus cannot provide a signal for control
of a myoelectric prosthesis. Finally, the
terminal nerve branches later may be
surgically transferred nonanatomically
to local residual limb muscles to create myoelectric control sites for intuitive control of a motorized prosthesis;
this technique is called targeted muscle
reinnervation.
Modern prosthetic techniques allow
comfortable fitting and function in patients who have undergone amputation
at almost any humeral level. However,
despite improved suspension tech-
Elbow Disarticulation
General Considerations
Prosthetic elbow options are limited after an elbow disarticulation because of
the length of the humerus, and cosmetic
issues may be a concern. A proximal
shortening osteotomy of the humerus,
as described by Beltran et al,3 is an attractive option that allows additional
prosthetic elbow options and improved
cosmesis while maintaining the advantages of rotational control and prosthetic
suspension (Figure 3).
niques and advances in bioprosthetic
interfaces for myoelectric prostheses, the
rejection rate of upper limb prostheses
is more than 30%.
10,11
A prosthetic limb
cannot replace the sensibility or dexterity of the natural hand, and, as the
amputation level progresses proximally,
the relative function of the prosthesis
Surgical Technique
The patient is positioned supine, with
the limb on a hand table, and a tourniquet is placed high on the brachium
and inflated to 250 mm Hg after exsanguination. Equal anterior and posterior
skin flaps are fashioned in a fish-mouth
Figure 2
denitive humeral amputation levels. The level
of an elbow disarticulation (a), a distal humeral amputation (b), a midhumeral amputation
at the level of the deltoid insertion (c), and a
proximal humeral amputation proximal to the
deltoid insertion (d) are shown.
Schematic drawing showing
pattern, with the proximal extent of the
flap at the level of the humeral epicondyles and the distal extent 3 cm distal
to the tip of the olecranon (Figure 4, A
and B). It is better to fashion flaps that
are longer than anticipated for closure
because they can always be trimmed.
The use of atypical flaps may be necessary depending on the soft tissue available for closure. The lacertus fibrosus
is identified and divided (Figure 4, C).
The lateral and medial antebrachial
cutaneous nerves are identified, and
traction neurectomies are performed.
Superficial veins are double clipped using medium or small ligating clips and
cut. Larger veins, such as the medial
cubital and cephalic veins, are ligated using 2-0 silk suture and cut. The
flexor-pronator mass is identified, released from the medial epicondyle, and
reflected distally to expose the median
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
250
Chapter 20: Elbow Disarticulation and Transhumeral Amputation: Surgical Management
nerve and brachial artery adjacent to
the biceps tendon (Figure 4, D through
F). The artery is traced proximal to the
elbow joint, double ligated using 2-0
silk suture, and cut. The median nerve
is gently drawn distally and cut sharply
using a No. 10 blade, ensuring that it
retracts at least 2 to 3 cm proximally.
The ulnar nerve is identified within the
cubital tunnel and divided sharply in
a similar manner. The biceps tendon
is released from its insertion on the
radius, and the brachialis is released
from its insertion on the ulna and reflected proximally. The radial nerve is
identified between the brachialis and
brachioradialis and divided in the same
fashion as the median and ulnar nerves,
with care to avoid an overly aggressive
traction neurectomy. The forearm extensor musculature is identified and
divided 6 cm distal to the joint line,
in a transverse fashion, and the muscle
mass is reflected proximally. The posterior fascia is divided, as are the triceps
insertion at the tip of the olecranon and
the anterior capsule of the elbow. The
medial and lateral collateral ligaments
are released from their epicondylar origins, and the disarticulation is completed (Figure 4, G).
The articular cartilage is maintained
on the distal end of the humerus. The
myoplasty is done by bringing the triceps tendon anteriorly and suturing it to
the brachialis and biceps muscles using
size 0 polyglycolic-acid absorbable suture, such as VICRYL (Ethicon). To further pad any bony prominences on the
distal humerus, the forearm extensor
muscle mass is brought medially and
sutured to the periosteum or remnants
of the flexor-pronator mass at the medial
epicondyle, using size 0 polyglycolicacid suture.
Before final skin closure, the tourniquet is deflated, and meticulous hemostasis is obtained. The subcutaneous
tissue is closed with 2-0 polyglycolicacid suture and with staples or monofilament suture for the skin (Figure 5).
Figure 3
apex lateral angulation. Postoperative AP (C) and lateral (D) radiographs of the humerus after an
osteotomy and xation with a locking compression plate. (Reproduced with permission from Beltran MA, Kirk KL, Hsu JR: Minimally invasive shortening humeral osteotomy to salvage a throughelbow amputation. Mil Med 2010;175[9]:693-696.)
A bulky soft dressing is applied over the
distal humerus in a figure-of-8 fashion,
using a sterile, woven six-ply gauze bandage and elastic wrap, and is left in place
for 3 days. A drain is not routinely used.
Preoperat ive AP (A) and lateral (B) radiograp hs of a transverse humeral f racture with
proximal to the elbow joint.5 For long
transhumeral amputations, an angulation osteotomy of the distal humerus as
described by Marquardt and Neff,8 or a
modification, should be considered. The
benefit of using an angulation osteotomy
Transhumeral Amputation
General Considerations
Every effort should be made to follow
the principles of length preservation and
soft-tissue management when selecting
a transhumeral amputation level. If the
condyles are not preserved, the ideal level of amputation should be at least 4 cm
rather than an elbow disarticulation is to
allow a wider choice of prosthetic elbow
options and to eliminate limb length
issues with prosthesis wear. The osteotomy also improves rotational control
and suspension of the prosthesis, compared with a traditional transhumeral
amputation.
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
251
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