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Elbow disarticulation
Dr. G A JoshiAP(PMR/ME)CRC-Bhopal
Topics
• Background• The Level• Statistics• Causes• Management• Surgical issues• Prosthetic Components• Functional restoration
Background
• Upper limb is the prehensile organ for human beings
• Elbow ROM of 0o-150o provides versatile reach combining with shoulder and wrist
• Wars have given the most amputees. • Army has developed most of prosthetics
(www.indianarmy.gov.in/writereaddata/Documents/165.pdf)
The level of elbow disarticulation
Advantages• Permits normal bone growth
in children• Faster bloodless surgery • Good suspension• Good rotational control• More functional than
transhumeral esp. in bilateral amputees
• Bilateral cases can use pencil for writing
Disadvantages• Poor Cosmesis• Less durable prosthetic
elbow joints
Statistics
• 5 per thousand (1996 USA) cases have Upper limb amputations
• Men in 15-45 age group• Amputation of Lower Limb is far more
common than Upper Limb with UL:LL=1:6• Congenital deficiency of Upper Limb is
commoner than Lower Limb
Causes
• Congenital limb deficiency • Trauma – machine, road/rail, electric-burn• Neoplastic• Vascular – Thromboangiitis obliterans, Tropical
Diabetic Hand Syndrome, Frostbite• Infection – Necrotizing Fasciitis
Management
• Conservative - thermal burns/frostbite• Surgical – Embolectomy– Fasciotomy– Reimplantation of transhumoral limb usually gives
functional elbow but poor hand function– Amputation– Allograft (esp. in Blind)
Phases of rehabilitation
• Preoperative• Surgery/reconstruction• Acute post-surgical• Pre-prosthetic
• Prosthetic prescription and fabrication
• Prosthetic training• Community integration• Vocational
rehabilitation• Follow up
Evaluation
• ROM and strength of shoulder• Vitality testing – clinical, Tc99mPyP nuclear
scan• Manage any proximal bony or soft tissue
injuries• Avoid multiple surgeries/revision amputation
as it will delay rehabilitation and thus reduce effective use of prosthesis
Surgery
• Tourniquet is useful but contraindicated in – Cancer– Infection
• Skin and flaps– Equal anteroposterior flaps – Unconventional flaps like forearm extensor flap
may be brought at medial epicondyle (where skin is thinnest) except in oncological cases
Soft tissue cover Do NOT keep excess soft tissue
Surgery
• Bone – May reduce epicondylar prominances in moderation– Do not disturb articular cartilage
• Muscles – Retain muscles esp. for myoelectric prosthesis– Myoplasty gives firm residual limb, helps shoulder
control and improved EMG for myoelectric control– Pectoralis cineplasty was used for elbow control in
past
Surgery
• Nerves – Withdraw, cut sharp and allow to retract in soft tissue. – Median and Ulnar nerves may be cut at different level
• Blood vessels– Double ligation of major blood vessels– Hemostasis and muscle tension managed after deflating
tourniquet• Drain is essential for – Hematoma prevention– Fast wound healing
Early prosthetic fitment
• Golden period of 30 days• Reduces edema• Facilitates fast healing• Reduces pain• Enhances prosthetic use• Early return to activities esp. two handed
grasping patterns
Prosthetic components
• Flat bulbous socket with snug fitting gives good rotational control and self suspension
• External elbow joints• Harness is Northwestern figure of 8 type or shoulder
saddle and chest strap• Control system has 2 cables –– Elbow lock control on medial prosthetic elbow joint– Elbow flexion (when elbow is unlocked) cum terminal
device operation (when elbow is locked)
Socket
• Leather socket• Soft insert with
supracondylar wedge• Window with cover
plate (photo)• Flexible bladder variant• Screw in type sockets
(sketch)
Socketless design
•Mediolateral framework•Supracondylar pads•Straps
Prosthetic Elbow Joints
• Outside locking elbow hinges• 0-135 ROM• 3 sizes• 5-7 locking positions
Harness system
• Standard figure of 8 – – Operated by non-
amputated side– Cross point below C7
and slightly toward non-amputated side
• Shoulder saddle and chest strap– Operated by amputated
side
Terminal Devices
• Passive (Mitts)• Cosmetic• Functional• Hook• Greiffer• Myoelectric• Microchip controlled
Functional restoration
• Comfort fit• Perceived value• Follow up– Adjusting socket to limb volume change– Mastering functions of the prosthesis– Re-evaluation and re-design of prosthesis as per
changing needs of patient
THANK YOU