Upper Limb Amputation Principles

Background

Causes of UL amputation:

  • Trauma (>80%)
  • Malignancy
  • Infection
  • Vascular disease/ischaemia
  • Deformity (congenital/contracture)

UE accounts for 1/3 of amputations — 8% proximal to wrist

Trauma Amputation Indications

  • Irreparable loss of blood supply
    • Prolonged ischaemia time
  • Severe soft tissue compromise
    • Severely crushed/mangled/contaminated parts
    • Traumatic amputation at multiple levels
  • Too unwell for reimplantation/reconstruction

Amputation vs Reconstruction

Mangled Extremity Severity Score (Johansen et al. 1990)

  • Most widely utilised score for UE/LE injuries, only a guide
ComponentBasis
InjuryDegree of soft tissue injury
IschaemiaPerfusion and limb ischaemia time
ShockPresented in shock or not
AgePatient’s age

Original publication Johansen K, Daines M, Howey T, Helfet D, Hansen St Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990;30(5):568-72; discussion 572-3.

  • Actually based on lower extremity injuries but widely used for UL these days
  • MESS < 7 = good predictor for not requiring amputation (Prichayudh et al, 2009)
  • Previously MESS > 7 = 100% predictive of requiring amputation, but this is a poor predictor in upper limb trauma

Ischaemic Time

  • Varies with extremity part and whether it is cold or warm ischaemia time
  • Proximal to carpus – 6hrs warm, 12hrs cold ischaemia time max

General Principles

Functional outcomes significantly lower in UE vs LE amputations

  • Prosthesis rejection 44% UE vs 16% LE (Reichle et al. 2008)
  • All efforts should be made to salvage upper extremity limbs — always consider replantation as it has much better success rates than lower extremity

Preserve as much length as possible

  • Length increases lever arm to reduce amount of energy expenditure
  • Function of stump reduces with each higher level of amp and dexterity is related to the number of functional joints left on the stump
  • Prosthesis rejection also increases the higher the amp due to increased pressures placed on the soft tissues
  • Nerve repair and reconstruction more successful in UE and prostheses have more difficulty with replicating native dexterity and sensory feedback in UE

Traction neurectomy to prevent neuroma

Osteoplasty (smoothing/contouring underlying bone within stump) – prevent painful pressure areas

Adequate padding at amputation site

  • Skin for fingers
  • Myodesis — suturing muscle to bone
  • Myoplasty — suturing muscle to muscle = more complications (no bony fixation point = risk of developing painful bursa between sutured muscle ends and underlying bone)

2hr max tourniquet time, and not for malignancy/infection

  • Can re-inflate after 5mins for each 30mins up
    • e.g. after 20mins for 2hr previous use

Soft tissue coverage (in order of preference):

  • Local tissue flaps ideal if available
  • Skin grafting if sufficient muscle/subcut tissue coverage
  • Free tissue transfer
  • More proximal amputation to achieve tissue flap

Prostheses

Passive (cosmetic)

  • Limited to basic tasks such as pulling and pushing

Body powered

  • Make use of cables, pulleys and hooks and are affixed to patients to allow control by the remaining motility of the limb stump

Externally powered

  • Controlled via EMG signals from muscles around the stump site
  • The patient sends the specific signal to the device to perform the desired movement

Targeted muscle reinnervation

  • Invasive procedure where large nerves that would otherwise be amputated are attached to motor nerves of remaining muscles
  • E.g. a prosthesis can be designed to pick up EMG signals from a pec major that has been reinnervated by the median nerve to trigger a hand prosthesis to close, just like the action of the finger flexors

Complications

Wound breakdown — especially in peripheral vascular disease and diabetes

Oedema — minimise with pressure dressings

Pain

  • Phantom limb pain
    • Occurs in approximately 10% of patients, but up to 100% of traumatic amputations
    • Usually settles 4-6 weeks post-op
  • CRPS
    • Prevention is better than cure
    • Peri-operative epidural or post-op intra-neural anaesthesia
  • Neuroma
    • Can be prevented in most cases with gentle nerve traction before sectioning
  • Mechanical causes
    • Sharp bone ends
    • Poor soft tissue coverage
    • Skin breakdown
    • Poor fitting prosthesis
  • Osteoarthritis of proximal joint

Contractures — prevent with early aggressive mobilisation and positioning

HO and bony overgrowth

  • Most common in paediatric patients who undergo transosseous amputations
  • Disarticulation procedures are often preferred to prevent this

Achieving Good Outcomes

Patient involvement/explanation during process

Early team involvement — prosthetics, rehab

  • Appropriate prosthesis prescription and early fitting
  • Physiotherapy and occupational therapy based rehabilitation

Good surgical technique — optimal length, residual joints & soft tissue coverage

Other Radical Treatment Options

Osseointegration

Forearm transplant — varied success and need for lifelong immunosuppression

Author Contributions

Page written by Dr James Drummond

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.