FOREQUARTER AMPUTATION
Shoulder Girdle Ablation | Subclavian Vessel Control | Brachial Plexus Division | Oncological Margins
INDICATIONS FOR FOREQUARTER AMPUTATION
Critical Must-Knows
- Subclavian vessels are controlled first - either from anterior (infraclavicular) or posterior (supraclavicular) approach
- Brachial plexus is divided sharply under tension, allowing retraction to reduce neuroma formation
- Anterior approach preferred for oncological cases - better visualization of neurovascular structures
- Posterior approach used when tumour involves anterior chest wall or for massive posterior tumours
- Clavicle division at junction of middle and lateral thirds; scapula removed en bloc with specimen
Examiner's Pearls
- "Control subclavian artery BEFORE vein to prevent venous engorgement and bleeding
- "Preserve pectoralis major if oncologically safe - provides soft tissue coverage
- "Divide brachial plexus roots proximally if tumour involves cords or divisions
- "Staged reconstruction with latissimus flap if primary closure not possible
Critical Forequarter Amputation Exam Points
Vascular Control Sequence
Control subclavian artery FIRST, then vein. Arterial control before venous control prevents limb engorgement and reduces blood loss. Access via infraclavicular approach (anterior) or supraclavicular approach. Know the relationship to scalenus anterior - subclavian artery is posterior, vein is anterior. Thoracic duct on LEFT side must be identified and ligated.
Oncological Margins
Wide surgical margins are non-negotiable. For sarcomas, aim for at least 2cm soft tissue margin or fascial plane. Biopsy track must be excised en bloc. Do NOT enter the tumour - contamination significantly worsens prognosis. Frozen section margins if needed. Plan incision to allow limb salvage conversion if margins positive.
Brachial Plexus Division
Level of division depends on tumour extent. For tumours not involving the plexus, divide at the level of cords or divisions. For plexus invasion, divide at root level (requires supraclavicular dissection). Traction neurectomy technique - sharp division under tension, allow proximal retraction. Phantom limb pain occurs in 60-80%.
Psychological Impact
Upper limb loss causes profound psychological impact. Body image disturbance, loss of independence, occupational implications are significant. Involve psychology/psychiatry EARLY. Prosthetic options are limited but provide cosmesis. Realistic expectation setting is crucial - discuss inability to replicate hand function.
Anterior vs Posterior Approach Selection
| Factor | Anterior Approach | Posterior Approach | Recommendation |
|---|---|---|---|
| Standard oncological resection | Preferred - direct access to vessels | Alternative if anterior chest involved | Default to anterior approach |
| Tumour involving anterior chest wall | May require chest wall resection | Preferred - avoids tumour manipulation | Posterior approach safer |
| Tumour involving posterior scapula | Preferred - vessels controlled early | Risk of tumour spillage | Anterior approach preferred |
| Brachial plexus invasion at roots | Requires supraclavicular extension | Better access to proximal roots | Combine approaches as needed |
| Trauma or infection | Rapid vascular control | May be faster for debridement | Depends on injury pattern |
| Previous surgery or radiation | May have scarring in vessels | Alternative if anterior scarred | Plan based on imaging and history |
CLAVICLE SCAPULAForequarter Amputation - Anterior Approach Steps
Memory Hook:Follow the CLAVICLE first, then sweep around to the SCAPULA - the two bones you're removing
SAVBNStructures to Control
Memory Hook:SAVBN - Save the patient by controlling vessels in order: S-Artery, V-Vein, B-Plexus, N-thoracic duct
TIPSForequarter Amputation Indications
Memory Hook:TIPS for when the limb must go - Tumour leads the way
Overview and Epidemiology
Forequarter amputation (interscapulothoracic amputation) is the ablation of the entire upper extremity including the scapula and lateral clavicle. First described by Ralph Cuming in 1808 and refined by Paul Berger in 1887, it represents the most radical amputation of the upper limb.
Epidemiology:
- Rare procedure - most major centres perform fewer than 5 per year
- Approximately 90% of cases are for oncological indications
- Malignant tumours: soft tissue sarcomas, bone sarcomas, metastatic disease
- Peak age: Bimodal - young adults (primary sarcomas) and elderly (metastatic disease)
- Male slight predominance (1.5:1)
Forequarter vs Shoulder Disarticulation
Forequarter amputation removes the entire shoulder girdle (scapula, lateral clavicle, humerus, and all soft tissues) leaving a smooth chest wall. Shoulder disarticulation preserves the scapula and clavicle, disarticulating at the glenohumeral joint. Forequarter is required when tumour involves the scapula, proximal humerus with soft tissue extension, or brachial plexus invasion.
Indications:
Malignancy (90%)
- Soft tissue sarcomas: MFH, synovial sarcoma, liposarcoma with proximal extension
- Bone sarcomas: Osteosarcoma, chondrosarcoma, Ewing sarcoma when limb salvage not possible
- Metastatic disease: Renal cell carcinoma, melanoma with local invasion
- Failed limb salvage: Local recurrence after previous surgery
- Brachial plexus invasion: Pancoast tumour extension
Non-Oncological (10%)
- Trauma: Brachial plexus avulsion with flail anaesthetic limb
- Vascular catastrophe: Unreconstructible axillary/subclavian injury
- Infection: Necrotizing fasciitis, gas gangrene, severe sepsis
- Radiation necrosis: Brachial plexopathy with non-functional painful limb
- Palliative: Fungating tumour causing suffering
Contraindications (Relative):
- Distant metastatic disease (relative - may still be palliative indication)
- Poor general health precluding major surgery
- Chest wall invasion requiring pneumonectomy (very high mortality)
- Patient refusal after informed consent
- Inadequate soft tissue for closure
Anatomy
Key Anatomical Structures
Understanding the anatomy is critical for safe forequarter amputation. The procedure involves controlling major neurovascular structures and dividing muscular attachments systematically.
Arterial Anatomy
Subclavian Artery:
- Becomes axillary artery at lateral border of first rib
- Relationship to scalenus anterior muscle is critical:
- First part: Medial to scalenus anterior (3 branches)
- Second part: Behind scalenus anterior (1 branch - costocervical trunk)
- Third part: Lateral to scalenus anterior (1 branch - dorsal scapular sometimes)
- Control is achieved infraclavicularly or supraclavicularly
Venous Anatomy:
- Subclavian vein is ANTERIOR to scalenus anterior
- More superficial than artery - encountered first in dissection
- Fragile wall - handle carefully
- Left side: Thoracic duct enters at junction with internal jugular vein
Thoracic Duct (Left Side)
On the LEFT side, the thoracic duct must be identified and ligated. It enters the venous system at the junction of the left subclavian and internal jugular veins. Injury causes chylothorax - persistent lymphatic leak into the chest. If damaged, ligate proximally and distally.
Clinical Presentation and Assessment
Presentation by Aetiology
Oncological Presentation
Typical Presentation:
- Progressively enlarging mass in proximal upper limb or shoulder girdle
- Pain - present in 50-70% of sarcomas at presentation
- Neurological symptoms if brachial plexus involved
- Vascular symptoms if axillary vessels compressed/invaded
Red Flags for Malignancy:
- Mass greater than 5 cm
- Deep to fascia
- Increasing in size
- Painful
- Recurrence after previous excision
Indications for Forequarter (Rather than Limb Salvage):
- Tumour involving neurovascular bundle that cannot be reconstructed
- Brachial plexus invasion by tumour
- Massive soft tissue involvement precluding functional limb
- Pathological fracture with extensive contamination
- Failed previous limb salvage with local recurrence
- Patient preference after informed discussion
Limb Salvage vs Amputation Decision
Limb salvage is preferred when oncologically equivalent. Forequarter amputation is indicated when: (1) Neurovascular bundle involved and unreconstructible, (2) Brachial plexus invaded by tumour, (3) Massive soft tissue involvement, (4) Local recurrence after previous limb salvage. The decision is made by the MDT including orthopaedic oncologist, medical oncologist, radiation oncologist, and radiologist.
Preoperative Workup
Preoperative Assessment Protocol
Essential for malignancy:
- MRI of entire limb (local staging, skip lesions)
- CT chest (pulmonary metastases)
- PET-CT if indicated (distant staging)
- Biopsy confirmation (prior to any surgery)
- Review biopsy track for excision planning
- MDT discussion and consensus
All cases:
- Clinical pulse examination
- Doppler assessment
- CT angiography (vessel involvement by tumour, anatomy)
- Plan for vessel ligation level
- Cardiac risk assessment
Critical for outcomes:
- Dominant hand assessment
- Occupational therapy input (ADL assessment)
- Psychological assessment (mandatory before elective amputation)
- Realistic expectations discussion
- Prosthetic options counselling
- Social work input (financial, vocational)
Preoperative checklist:
- Full blood count, coagulation, group and screen (crossmatch 4 units)
- Renal and liver function
- Cardiac assessment (echo if indicated)
- Nutritional status (albumin greater than 30 g/L)
- Smoking cessation
- Anaesthetic review
Surgical Technique
Anterior (Berger) Approach
Indications:
- Standard approach for most oncological cases
- Preferred when tumour is posterior
- Provides early vascular control
- Better visualization of neurovascular structures
Positioning:
- Semi-lateral decubitus or supine with sandbag
- Arm free-draped
- Access to both anterior and posterior chest
Incision:
- Start at sternoclavicular joint
- Along clavicle to acromioclavicular joint
- Curve inferolaterally around deltoid
- Continue down medial arm to axilla
- Return across chest wall below pectoralis
Anterior Approach Operative Steps
Incise skin along marked line.
Raise skin flaps anteriorly and posteriorly.
Preserve pectoralis major if oncologically safe.
Identify clavicle and prepare for osteotomy site.
Critical step - control vessels BEFORE mobilization.
Incise clavipectoral fascia below clavicle.
Identify subclavian/axillary artery - control with vessel loops.
Identify subclavian/axillary vein - control with vessel loops.
Ligate and divide artery FIRST, then vein.
On LEFT side, identify and ligate thoracic duct.
Divide clavicle at junction of middle and lateral thirds.
Use oscillating saw or Gigli saw.
Clear periosteum to prevent bone regrowth.
Smooth cut edges with rasp.
Lateral fragment stays with specimen.
Level of division depends on tumour extent.
Standard: Divide cords in axilla.
If plexus involved: Divide at trunk level or root level.
Apply gentle traction to each cord/trunk.
Sharp transection with fresh blade.
Allow proximal retraction.
Divide pectoralis major (or reflect if preserving).
Divide pectoralis minor from coracoid.
Divide subclavius muscle.
Release all anterior attachments of specimen.
Turn patient or work posteriorly.
Divide trapezius along medial scapular border.
Divide rhomboid major and minor.
Divide levator scapulae.
Divide serratus anterior from chest wall.
Divide latissimus dorsi (or preserve for flap).
Remove specimen en bloc.
Confirm haemostasis - inspect chest wall carefully.
Check for pleural injury.
Myoplasty: Approximate residual muscles over chest wall.
Closed suction drains.
Skin closure - consider flap if defect large.
Postoperative Care and Rehabilitation
Immediate Postoperative Care
Day 0-1:
- ICU or high-dependency monitoring
- Monitor for haemorrhage (drain output, haemoglobin)
- Chest X-ray to exclude pneumothorax
- DVT prophylaxis (mechanical and pharmacological)
- Analgesia: Multimodal approach (regional block if possible)
- Psychological support initiated
Day 1-5:
- Mobilization with physiotherapy
- Wound inspection at 48 hours
- Drain removal when output less than 30 ml/24 hours
- Respiratory physiotherapy
- Psychology review
Discharge Planning:
- Wound care instructions
- Physiotherapy exercises
- Outpatient psychology follow-up
- Prosthetic referral when wound healed
- Oncology follow-up for adjuvant therapy
Prosthetic Rehabilitation
Prosthetic Options
Cosmetic Prosthesis:
- Lightweight, realistic appearance
- No active function
- Improves body image and clothing fit
- Most commonly chosen option
Functional Prosthesis:
- Body-powered or myoelectric
- Limited function compared to lower limb prosthetics
- Requires significant training
- Heavy, often abandoned
Realistic Expectations
Upper limb prosthetics cannot replicate hand function. Unlike lower limb prosthetics which can restore walking, upper limb prosthetics provide limited functional restoration. Many patients adapt to one-handed function rather than using prosthesis. Cosmetic benefit is primary value for most.
Psychological Support
Impact of Upper Limb Loss:
- Body image disturbance is profound
- Loss of independence for bilateral activities
- Occupational implications (may not return to previous work)
- Social and intimacy concerns
- Phantom limb sensations and pain
Mandatory Psychological Input:
- Preoperative counselling and assessment
- Postoperative support and monitoring
- Peer support groups
- Long-term psychological follow-up
- Treatment for depression, PTSD if needed
Suicide Risk
Patients undergoing major upper limb amputation are at increased risk of depression and suicide. This is particularly true for traumatic amputations in young patients. Early psychological intervention, ongoing monitoring, and appropriate psychiatric referral are essential components of care.
Evidence Base and Key Studies
Forequarter Amputation for Sarcoma Outcomes
- Retrospective review of 51 forequarter amputations for malignancy
- 5-year survival: 34% (varying by tumour grade and stage)
- Local recurrence rate: 16%
- Major complications: 25% (wound problems, haemorrhage)
- Most patients (70%) returned to modified employment
Quality of Life After Forequarter Amputation
- Prospective quality of life assessment in forequarter amputees
- Physical function scores lower than general population
- Mental health and social function comparable to population norms
- Patients adapted well psychologically over time
- Cosmetic prosthesis improved body image satisfaction
Phantom Limb Pain After Upper Limb Amputation
- Prospective study of phantom phenomena after upper limb amputation
- Phantom limb pain occurred in 51% of patients
- Phantom sensations (non-painful) in 80%
- Preoperative pain was significant risk factor
- Pain decreased over time but persisted in many
Brachial Plexus Avulsion - Outcomes of Amputation
- Experience with brachial plexus injuries and management
- Amputation indicated for complete avulsion with intractable pain
- Majority of patients reported pain improvement after amputation
- Psychological adjustment variable
- Careful patient selection essential
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
"A 45-year-old woman presents with a large high-grade soft tissue sarcoma involving the proximal humerus, deltoid, and extending to the brachial plexus on MRI. CT chest shows no pulmonary metastases. The MDT has recommended forequarter amputation. How would you counsel this patient and describe your surgical approach?"
"A 28-year-old motorcyclist sustained a complete brachial plexus avulsion (C5-T1) 18 months ago. His arm is flail and anaesthetic. He has severe chronic neuropathic pain despite maximal medical therapy and has requested amputation. How would you approach this case?"
"During a forequarter amputation for a proximal sarcoma, you encounter brisk bleeding when dividing tissues in the infraclavicular region. Describe your management."
Australian Context
Epidemiology and Referral Patterns
Forequarter amputation is a rare procedure in Australia, with major sarcoma centres performing fewer than 5 cases annually. Primary bone and soft tissue sarcomas requiring this level of amputation are typically managed at designated sarcoma services, most commonly located in major metropolitan tertiary centres. The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) does not track amputations, but state cancer registries monitor sarcoma outcomes.
Treatment Pathways
Patients with suspected sarcomas requiring forequarter amputation should be referred to a specialist sarcoma multidisciplinary team (MDT) prior to any surgical intervention, including biopsy. The MDT typically includes orthopaedic oncologists, medical oncologists, radiation oncologists, specialist radiologists, pathologists, and allied health professionals. Treatment decisions, particularly the choice between limb salvage and amputation, are made collectively by the MDT with patient input.
Adjuvant and neoadjuvant treatments including chemotherapy and radiation therapy are provided through public hospital oncology departments or private oncology services. PBS-listed medications for sarcoma treatment are available, and TGA-approved prosthetic devices can be accessed through state-based artificial limb schemes.
Rehabilitation and Support Services
Prosthetic services in Australia are provided through state-funded artificial limb schemes and private providers. Upper limb prosthetics are less developed than lower limb, reflecting the limited functional restoration possible. Cosmetic prostheses are commonly chosen for improved body image. Psychological support services are available through hospital psychology departments, private practitioners, and organisations such as Limbs 4 Life which provides peer support for amputees. Access to occupational therapy for adaptation to one-handed living, vocational rehabilitation, and disability employment services are important components of the recovery pathway.
Forequarter Amputation
High-Yield Exam Summary
Indications
- •Tumour (90%): Proximal sarcoma, plexus invasion, failed limb salvage
- •Trauma: Brachial plexus avulsion with useless painful limb
- •Infection: Necrotizing fasciitis, gas gangrene (life before limb)
- •Palliative: Fungating tumour, intractable pain
Approach Selection
- •Anterior (Berger): Standard for oncology, early vessel control
- •Posterior (Littlewood): Anterior chest wall involvement
- •Combined: Large tumours, plexus invasion at roots
Critical Surgical Steps
- •Control subclavian ARTERY first, then VEIN (prevents engorgement)
- •Left side: Identify and ligate thoracic duct (prevents chylothorax)
- •Clavicle division: Junction of middle and lateral thirds
- •Brachial plexus: Divide at cords (standard) or roots (if invaded)
- •Preserve pectoralis major if oncologically safe for coverage
Vascular Relations
- •Subclavian artery: POSTERIOR to scalenus anterior
- •Subclavian vein: ANTERIOR to scalenus anterior
- •Thoracic duct: Left side only, enters at subclavian-IJV junction
Flap Options
- •Pectoralis major: First choice if preserved
- •Latissimus dorsi: Versatile if available
- •Free flap: Large defects, irradiated field
Complications
- •Haemorrhage: Meticulous vessel control, have blood ready
- •Chylothorax: Left side thoracic duct injury - ligate
- •Pneumothorax: Chest wall dissection - CXR post-op
- •Phantom limb pain: 60-80%, multimodal treatment
- •Psychological: Depression, body image - mandatory psychology
Prosthetics
- •Cosmetic: Most common choice, lightweight, improves body image
- •Functional: Limited utility, heavy, often abandoned
- •Key message: Cannot replicate hand function
Key Numbers
- •Phantom limb pain: 60-80%
- •5-year survival (sarcoma): 30-40%
- •Local recurrence: 15-20%
- •Return to employment: 70%
References
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Bhagia SM, Elek EM, Grimer RJ, et al. Forequarter amputation for high-grade malignant tumours of the shoulder girdle. J Bone Joint Surg Br. 1997;79(6):924-926.
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Wittig JC, Bickels J, Kollender Y, et al. Palliative forequarter amputation for metastatic carcinoma to the shoulder girdle region: indications, preoperative evaluation, surgical technique, and results. J Surg Oncol. 2001;77(2):105-113.
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Malawer MM, Sugarbaker PH. Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. Springer; 2001.
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Kooijman CM, Dijkstra PU, Geertzen JH, et al. Phantom pain and phantom sensations in upper limb amputees: an epidemiological study. Pain. 2000;87(1):33-41.
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Birch R, Bonney G, Wynn Parry CB. Surgical Disorders of Peripheral Nerves. Churchill Livingstone; 1998.
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Grimer RJ, Carter SR, Pynsent PB. The cost-effectiveness of limb salvage for bone tumours. J Bone Joint Surg Br. 1997;79(4):558-561.
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Canale ST, Beaty JH. Campbell's Operative Orthopaedics. 12th ed. Elsevier; 2013.
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Damron TA, Sim FH. Forequarter amputation. In: Simon MA, Springfield D, eds. Surgery for Bone and Soft-Tissue Tumors. Lippincott-Raven; 1998.
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Chan BL, Witt R, Charrow AP, et al. Mirror therapy for phantom limb pain. N Engl J Med. 2007;357(21):2206-2207.
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Flor H. Phantom-limb pain: characteristics, causes, and treatment. Lancet Neurol. 2002;1(3):182-189.