eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Elbow and Above-Elbow Amputations: Workup

Author: Scott G Edwards, MD, Assistant Professor of Orthopedic Surgery, Georgetown University; Consulting Surgeon, Department of Orthopedic Surgery, Greater Metropolitan Orthopaedics
Coauthor(s): A Lee Osterman, MD, Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson University
Contributor Information and Disclosures

Updated: Nov 27, 2007

Workup

Laboratory Studies

  • Hematocrit and hemoglobin levels should be monitored. In trauma situations, acute blood loss is a concern. Even with elective amputations, postoperative bleeding and hematoma formation require careful assessment. Acceptable levels are individualized based on age, associated medical problems and injuries, and baseline values. In general, a young, otherwise healthy patient should maintain a hematocrit/hemoglobin level of greater than 20%/6 g/dL. Elderly patients or patients with underlying cardiovascular disease should be maintained at higher levels (30%/10 g/dL).
  • Creatinine levels should be monitored. In individuals with muscle injury and necrosis, myoglobin enters the systemic circulation and can lead to renal insufficiency and failure. This is especially true in individuals with thermal and electrical burns. If creatinine levels continue to rise more than 0.4 over baseline, preoperative, or preinjury levels, more aggressive surgical intervention and fluid hydration should be considered.
  • Potassium and calcium levels should be monitored. As dead tissue is metabolized, destroyed cells release intracellular stores of potassium and calcium into the extracellular space. Elevated levels of these electrolytes may lead to cardiac arrhythmias and seizures.
  • The white blood cell count, C-reactive protein levels, and erythrocyte sedimentation rate should be monitored in persons with infection. It is helpful to observe that these values normalize following amputation, thus suggesting resolution of the infection. Expect the laboratory value of C-reactive protein to be the first to respond to treatment; the other 2 values may take several days to weeks to normalize despite eradication of the infection. If these values remain elevated or rise further, treatment should be reassessed by changing to a more appropriate antibiotic, by searching for an unrelated occult infection or hidden abscess, and possibly by performing revision amputation at a more proximal level.
  • Platelets should be monitored periodically if subcutaneous heparin is administered postoperatively. Heparin-induced thrombocytopenia may occur even as a result small, subcutaneous doses of heparin.

Imaging Studies

  • Plain radiographs should be routinely included in preoperative planning. The presence of hardware, occult pathology, or other unanticipated abnormalities in an extremity to be amputated may affect the surgical plan.
  • In oncology cases, preoperative computed tomography (CT) and magnetic resonance imaging (MRI) scans have proven invaluable in assessing the extent of tumor involvement and level of amputation. When a forequarter amputation is considered in the treatment of a malignancy, CT and MRI scans should include not only the affected extremity but also the lungs. Occasionally, a preoperative CT or MRI scan is helpful in evaluating the extent of infection and abscess in these particular settings.
  • MRA remains a noninvasive alternative to arteriography. It avoids the complications of arterial puncture, eliminates the risk of contrast-related renal failure, and has a higher sensitivity than does contrast angiography in the identification of severe peripheral arterial occlusive disease.
  • Pyrophosphate nuclear scanning has been introduced as another noninvasive method of evaluating tissue viability. It has been demonstrated to be a useful adjunct in predicting the need for amputation in persons whose extremities have been damaged by electrical injury, frostbite, or invasive infection. Pyrophosphate nuclear scanning has a sensitivity of 94%, a specificity of 100%, and an accuracy of 96% when performed for this purpose.
  • Doppler ultrasonography detects blood flow, and when employed in conjunction with blood pressure cuffs, it can be used to measure arterial pressure at different levels in the upper extremity.

Other Tests

  • Transcutaneous oxygen tensions reflect tissue perfusion. Significant occlusive disease causes these measurements to fall below 35 mm Hg. When considering the level of amputation, it is imperative that transcutaneous oxygen tensions at the level of incision be at least 35 mm Hg, because measurements below this level are associated with decreased healing and wound problems. Measurement of tissue oxygen tension is not affected by incompressible, calcified vessels and appears to be very sensitive in evaluating arterial occlusive disease during exercise.

Diagnostic Procedures

  • Arteriography remains the standard for the definitive analysis of vascular status. However, because this is an invasive procedure, arteriography carries the risk of leading to a pseudoaneurysm, hematoma, and vascular embolism in the patient.

More on Elbow and Above-Elbow Amputations

Overview: Elbow and Above-Elbow Amputations
Workup: Elbow and Above-Elbow Amputations
Treatment: Elbow and Above-Elbow Amputations
Follow-up: Elbow and Above-Elbow Amputations
References
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References

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Further Reading

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Keywords

elbow disarticulation, dismemberment, prosthetics, prosthesis, transcondylar amputations, supracondylar amputations, transhumeral amputations, shoulder disarticulation, forequarter amputation, radical forequarter amputation, Tikhoff-Linberg procedure, shoulder girdle amputation, interscapulothoracic amputation

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Contributor Information and Disclosures

Author

Scott G Edwards, MD, Assistant Professor of Orthopedic Surgery, Georgetown University; Consulting Surgeon, Department of Orthopedic Surgery, Greater Metropolitan Orthopaedics
Scott G Edwards, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand
Disclosure: Nothing to disclose.

Coauthor(s)

A Lee Osterman, MD, Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson University
Disclosure: Nothing to disclose.

Medical Editor

Michael S Clarke, MD, Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine
Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, and Missouri State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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