SURGICAL TECHNIQUE

Transradial Amputation With Pedicled Pronator

Quadratus Interposition and Advanced
Neuroma-Prevention Techniques
John J. Bartoletta, BCompE,* Jacqueline S. Israel, MD,* Peter C. Rhee, DO, MS*

Transradial amputation is a reconstructive option for upper-extremity trauma, infection,

malignancy, and ischemia. The possible postoperative complications include residual radio-
ulnar impingement and the development of a painful neuroma. In this report, a pedicled
pronator quadratus flap interposition between the distal radius and ulna has been described.
Additionally, various techniques to mitigate the development of symptomatic neuromas have
been described. (J Hand Surg Am. 2021;46(12):1129.e1-e8. Copyright Ó 2021 by the
American Society for Surgery of the Hand. All rights reserved.)
Key words Modified centro-central neurorrhaphy, neuroma prevention, radioulnar impinge-
ment, transradial amputation.

T
RANSRADIAL AMPUTATION (TRA) is the most
common upper-extremity (UE) amputation
proximal to the wrist.1 Multiple factors must
be considered in preoperative planning for a UE
amputation. With an increased residual length and
joint preservation, the patient becomes more capable
of interacting with the environment.2 Thus, the
preservation of length is crucial for maintaining
supination-pronation range of motion.1 However, an
increased residual forearm length without distal
radioulnar joint (DRUJ) articulation leads to an
increased length of the radius and ulna lever arm and
the possible development of symptomatic distal
radioulnar impingement with compressive loading or
From the *Division of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic,
Rochester, Minnesota.
Received for publication October 29, 2020; accepted in revised form May 5, 2021.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Peter C. Rhee, DO, MS, Division of Hand Surgery, Department of
Orthopedic Surgery, Mayo Clinic, 200 First St. SW Rochester, MN 55905; e-mail: rhee.
peter@mayo.edu.
0363-5023/21/4612-0024$36.00/0
https://doi.org/10.1016/j.jhsa.2021.05.004
supination-pronation range of motion following
TRA.3 Myodesis and myoplasty using forearm soft-
tissue interposition have been used to prevent this
problem.2 However, to our knowledge, no specific
technique has been described to optimize a prosthetic
socket’s fit and prevent distal radioulnar impingement
in order to maximize prosthetic function.4
A second possible postoperative complication of
TRA is the formation of a symptomatic neuroma.
Painful neuromas are common, occurring in about
one-quarter of patients with a UE amputation.5 Even
with this high incidence, no consensus exists on the
best method for the prevention and treatment of
neuromas.6 Many techniques have been described,
including neurectomy, burying the fresh nerve ending
into an adjacent intact muscle, centro-central neuro-
rrhaphy (CCU), relocation nerve grafting, end-to-side
neurorrhaphy, creation of a regenerative peripheral
nerve interface, and targeted muscle reinnervation.6
This article describes a surgical technique for
TRA, with a focus on preventing these complications.
Distal radioulnar impingement can be successfully
mitigated by interposing a pedicled pronator quad-
ratus between the distal radius and ulna. In addition,
this technique provides a secure and stable stump,
free from compressive/impingement pain, to optimize

Ó 2021 ASSH r Published by Elsevier, Inc. All rights reserved. r 1129.e1

1129.e2 TRANSRADIAL AMPUTATION

a prosthetic socket’s fit and enhance function. Lastly,

TABLE 1. Pronation-Supination Range of Motion
the risk of the development of a symptomatic post- Based on Residual Length*
amputation neuroma is minimized with the thoughtful
management of the transected nerves. Pronation-Supination
Level of Amputation Range of Motion

ANATOMY Wrist disarticulation 120

The articulation between the radius and ulna consists 20-cm residual length 100
of 3 joints: the proximal radioulnar joint, medial 12-cm residual length 60
radioulnar joint, and DRUJ.7 The proximal radioulnar <8-cm residual length 0
joint permits the rotation of the radius relative to the
*Adapted from Fitzgibbons and Medvedev.1
ulna.7 When the radius is rotated proximally about its
axis, it results in translation and pronation/supination
of the radius distally about the ulna.7 This movement
is stabilized distally through the DRUJ and extensor
TABLE 2. Neuroma-Prevention Techniques for
retinaculum of the wrist.7 The primary articulation
Various Levels of Amputation
between the forearm and hand is through the radio-
carpal joint. The majority of the axial force in the Level of Amputation
hand is transmitted through the radiocarpal joint to Midshaft/Distal Proximal
the forearm.7 The force is then transferred between
TMR —
the radius and ulna through the interosseous mem-
CCU* CCU*
brane and medial radioulnar joint. This is accom-
plished because of the orientation of the interosseous Graft to nowhere Graft to nowhere
membrane from the radius proximally to the ulna RPNI RPNI
more distally.7 After DRUJ resection following TRA, RPNI, regenerative peripheral nerve interface; TMR, targeted muscle
there is a loss of transverse stability distally; there- reinnervation.
*CCU or modified CCU.
fore, the radius and ulna can impinge against each
other because of compressive forces, particularly with
supination-pronation. The use of a pedicled pronator
status can help guide the type of prosthesis to be
quadratus interposition can prevent this complication.
used. More specifically, the goals of care and what
the patient intends doing with their residual limb can
INDICATIONS/CONTRAINDICATIONS help with understanding the demands/stress that pa-
An overwhelming majority of TRAs are performed tients may put on their residual limb or prosthesis. A
following trauma when limb salvage is not feasible.1 preoperative consultation with a prosthetist provides
The other indications include malignancy, infection, an opportunity for the patient to survey available
and ischemia, although amputation for an infection prosthetic options and compare what they can ach-
and ischemia is performed less often in the UE than ieve with each. This has surgical implications
in the lower extremity.2 The patient factors that can because if a myoelectric prosthesis is preferred, TRA
lead to postoperative healing complications include with targeted muscle reinnervation might be the best
smoking, malnutrition, and diabetes. Prior to a sur- surgical option.8 Based on the input from the physical
gery, we recommend multidisciplinary collaboration medicine and rehabilitation physician and prosthetic
to minimize these associated risks through smoking teams, the length of the residual limb is optimized for
cessation, adequate glucose control, and nutritional the potential prosthetic.
optimization, as appropriate.

PREOPERATIVE COUNSELING LEVEL OF AMPUTATION

Regardless of the indication, a preoperative discus-
sion and planning with the physical medicine
and rehabilitation physicians and prosthetists is
paramount for providing the best functional outcome
for the patient. Specifically, considering the patient’s
preoperative level of disability and employment
When a below-elbow amputation is required in a
traumatic setting, it most commonly requires TRA;
however, in a carpal- or wrist-level amputation, wrist
disarticulation can be performed. A benefit of wrist
disarticulation over TRA is the preservation of
approximately 20 of increased pronation-supination

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FIGURE 1: Radius and ulna osteotomy and pedicled pronator quadratus interposition. Transradial amputation was performed with
pronator quadratus (green arrow, throughout) interposition to prevent distal radioulnar impingement. A The pronator quadratus is
identified and sharply dissected. B The pronator quadratus pedicle is isolated and protected. C, D The pedicled pronator quadratus is
retracted proximally, and bony cuts are performed using an oscillating saw oriented perpendicular to the anatomical axis of the radius
and ulna. E, F The pronator quadratus is interposed between the distal radius and ulna and anchored using a bone tunnel made using a
0.062-in K-wire and 3-0 nonabsorbable suture.

range of motion. The level of amputation and resul-
tant pronation-supination range of motion is provided
in Table 1. Proximally, a minimum of 5 cm of ulnar
length is needed to maintain an insertion site for the
biceps on the radius or ulna.1 The benefits of per-
forming a TRA over a wrist disarticulation include
the potential to use an articulating prosthetic wrist as
well as the preservation of bilateral UE symmetry.
Approximately 8 cm of resection from the radial
styloid is recommended to accommodate an articu-
lating wrist prosthesis.
NERVE MANAGEMENT
Since its first description in the 1980s, CCU has been
shown to be beneficial for the prevention and

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TABLE 3. Possible Allograft “Loop to Nowhere”
Coaptation Combinations*
Median to Ulnar
LABC to SBRN
LABC to DSUN
DSUN, dorsal sensory branch of the ulnar nerve; LABC, lateral
antebrachial cutaneous nerve; SBRN, sensory branch of the radial
nerve.
*A 3e5-cm allograft nerve routed deep within the soft tissues
and away from subcutaneous borders or areas of bony
prominence.
management of postamputation neuromas in digital
and lower-extremity amputations.6 Using an indi-
vidualized approach in the setting of TRA, CCU
provides an alternative and/or adjunct approach
alongside other techniques for minimizing post-
amputation pain, including targeted muscle reinner-
vation and the creation of a regenerative peripheral
nerve interface (Table 2).6,9
SURGICAL TECHNIQUE
Incision design
With the patient positioned supine under regional or
general anesthesia, a sterile high-upper-arm tourni-
quet is applied, and the UE is prepped and draped.
Exposure
Superficial exposure is performed similar to the
procedure described by Morgan et al,3 wherein dorsal
and volar fish-mouth incisions are made distal to the
level of the planned bony cuts to leave enough skin to
facilitate tension-free coverage of the underlying
bone and soft tissues following the amputation.3 If
feasible, 1 of the skin flaps is made longer in order to
position the wound closure away from the terminal
end of the amputation.3
The flexor and extensor tendons are transected as
distally as possible to facilitate later myodesis, and
the radial and ulnar arteries are double ligated just
proximal to the planned bone cuts. The median, ul-
nar, sensory branch of the radial nerve, and dorsal
sensory branch of the ulnar nerve are identified and
injected proximally with a local anesthetic to possibly
prevent residual postoperative phantom pain prior to
transection.10
Osteotomy and pronator quadratus interposition
The pronator quadratus is identified at the palmar
aspect of the radius and ulna. The muscle is sharply
dissected from the bone in a distal-to-proximal
fashion and is left attached to the anterior
J Hand Surg Am.
interosseous nerve and its blood supply originating
from the anterior interosseous artery (Fig. 1A, B).
The muscle is retracted proximally to protect it when
performing the bony cuts (Fig. 1C). Distal radial and
ulnar osteotomies are performed using an oscillating
saw oriented perpendicular to the anatomic axis of the
radius and ulna (Fig. 1C, D). The bony cuts are made
at a level that has been previously discussed with the
patient and prosthetist. If the resection results in the
cutting or release of the central band of the inter-
osseous membrane, the osteotomy is performed
slightly distal to its insertion to prevent the devel-
opment of radioulnar instability. The sharp edges of
the bone are then smoothed using a bone file to
prevent wound breakdown or discomfort. The pro-
nator quadratus is then interposed between the distal
radius and ulna using a 3-0 nonabsorbable suture
through bone tunnels created using a 1.57-mm
(0.062ein) K-wire (Fig. 1E, F).
Coaptation of terminal nerve branches (modified CCU)
The coaptation of 2 grouped nerve fascicles separated
or internally neurolyzed from the same residual nerve
ends is termed as a CCU.6 Using a modified CCU
technique, 1 residual nerve is coapted to another re-
sidual nerve nearby. In the case of TRA, the trans-
ected ulnar and median nerves are coapted to one
another using simple interrupted 9-0 nylon peri-
epineural sutures (case 1). With a minimal size
mismatch, there is less risk of aberrant axon sprout-
ing. Any 2 nerves of similar diameter that are in close
proximity to one another can be sutured to one
another.
Allograft “loop to nowhere”
As an alternative to direct coaptation, an acellular
nerve allograft can be used to manage terminal nerve
ends and potentially minimize the risk of a symp-
tomatic neuroma and phantom limb pain.6 Similar to
CCU, this technique provides a conduit, which is
modified with an interposition allograft, into which
the transected nerve axons can grow.6 A 3e5-cm
graft of an appropriate diameter, depending on the
size of the nerve ends, is interposed between 2
transected nerve ends, such as the median to ulnar
and dorsal sensory branches of the ulnar nerve to the
lateral antebrachial cutaneous nerve, using simple
interrupted 9-0 nylon epineural sutures (case 2;
Table 3). The allograft loop is routed deep into the
soft tissues and away from subcutaneous borders
where regenerating nerve axons may be susceptible to
irritation.
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FIGURE 2: Myodesis and myoplasty. A In the same patient as in Figure 1, myodesis was performed between the flexor carpi radialis and
extensor carpi radialis longus as well as the flexor carpi ulnaris (held in the forceps) and extrensor carpi ulnaris to the distal radius and
ulna. B The remaining flexor tendons, brachioradialis, and extensor tendons were used to perform myoplasty over the ends of the distal
radius and ulna. C Early and D final appearance of the residual limb.

FIGURE 3: Case 1. A 53-year-old man who underwent distal TRA with pronator quadratus interposition. A Lateral and B ante-
roposterior postoperative radiographs demonstrating parallel alignment of the radius and ulna, without impingement.

Myodesis/myoplasty/skin closure
Layered myodesis and myoplasty is performed. A
2-mm drill or 0.062-in K-wire is used to make 2
parallel drill holes in the radius and ulna for the
creation of bone tunnels to facilitate the anchoring
of the flexor carpi radialis and extensor carpi radi-
alis longus to the radius as well as the flexor carpi
ulnaris and extensor carpi ulnaris to the ulna
(Fig. 2). This is performed using a 2-0 nonabsorb-
able suture. The superficial flexor and extensor

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FIGURE 4: Case 2. A 43-year-old woman who underwent proximal or “high” TRA with modified centro-central neurorrhaphy between
the median and ulnar nerves following UE critical ischemia secondary to brachial vein thrombosis and subsequent arterial thrombosis
due to antiphospholipid antibody syndrome. A, B Transradial amputation was performed after initial compartment release because of
critical limb ischemia. C Modified centro-central neurorrhaphy was performed between the median (yellow arrow) and sensory branches
of the radial nerve (tip of the forceps) as well as D the ulnar (tip of the forceps) and lateral antebrachial cutaneous nerves (green arrow)
using 9-0 nylon simple epineural sutures.

muscles are then sutured to one another using a
2-0 absorbable suture. The tourniquet is then let
down, and hemostasis is achieved. A closed
suction drain can be used depending on surgeon
preference.
The skin is then closed in 2 layers, first, using
deep, dermal-absorbable sutures, followed by 3-
0 nonabsorbable monofilament mattress sutures. A
layered compressive dressing consisting of a non-
adherent gauze, soft wrap, plaster splint, and
elastic-fabric wrap is applied to soft tissue
compression and start shaping the residual limb.
Patients are typically admitted to the hospital for at
least 1 night for the optimization of pain control and a
consultation with the occupational therapy occupa-
tional therapist. If not done previously, the use of a
postoperative regional block and/or continuous
indwelling nerve catheter should be considered.
Following a TRA, initial therapy consists of fluid and
edema management using protective orthoses or
splints with compressive wraps or “shrinker” socks.
Patients often begin passive and active assisted elbow
flexion at 1e2 weeks and active supination-pronation
range of motion with a gradual upper-extremity
strengthening protocol at 4e6 weeks. Patients
remain in close contact with prosthetists, with initial
goals being geared toward residual limb soft-tissue
maturation and eventual prosthetics fitting and
training beginning as early as 6 weeks after the
surgery.
COMPLICATIONS
Following a TRA, the potential complications
include hematoma, seroma, difficulties with
wound healing, infection, and postamputation
pain. While patients are less likely to develop a
symptomatic neuroma after these neuroma-
prevention techniques, chronic pain after the
amputation may occur. A multidisciplinary
approach that includes the patient’s primary care
provider, the physical medicine and rehabilitation

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FIGURE 5: Case 3. A 19-year-old man sustained a traumatic, near-complete metacarpal-level right-hand amputation following a blast
injury. A TRA was performed with pedicled pronator quadratus interposition between the radius and ulna. A Myodesis of the flexor
carpi ulnaris to the extensor carpi ulnaris and extensor carpi radialis longus (top forceps) to the flexor carpi radialis (bottom forceps) to
the end of the distal ulna was performed. B Nerves were managed using the allograft “loop to nowhere” technique: coaptation of the
median and ulnar nerves was performed using a 9-0 nylon simple epineural suture and an allograft measuring 4 mm  30 mm (green
arrow). The dorsal sensory branch of the ulnar nerve and lateral antebrachial cutaneous nerve were coapted to one another in a similar
fashion using a nerve allograft measuring 3 mm  30 mm (purple arrow; Avance, Axogen Corporation). C The allograft nerve loops
were placed between the myodesis and the myoplasty of the finger flexors (tip of forceps) and the finger extensors, which were secured
to provide a stable soft-tissue envelope around the end of the amputation site. D Final residual limb appearance after a distal or “low”
TRA.

department, and pain specialists should
employed.
CASE EXAMPLES
Case 1: pedicled interposition pronator quadratus flap
A 53-year-old man sustained a partial traumatic
amputation to the right hand from a chain
saw. Multiple attempts at reconstruction were per-
formed but were complicated because of critical
ischemia, tissue necrosis, and infection with
Stenotrophomonas maltophilia. Ten days following
the injury, wrist disarticulation was performed,
followed by TRA with pronator quadratus interpo-
sition 3 days later. Postoperative radiographs
be demonstrating parallel radioulnar alignment are
shown in Figure 3. At his last clinical visit at 8
months after the surgery, the patient was noted to
have complete healing of the skin on the residual
stump. He used 3 prosthetics: a hook, hand terminal
device, and myoelectric prosthesis that he used
interchangeably.
CASE 2: MODIFIED CENTRO-CENTRAL
NEURORRHAPHY FOR NEUROMA PREVENTION
A 43-year-old right-handed woman with a history
of antiphospholipid antibody syndrome was eval-
uated for critical hand ischemia due to a radial
artery occlusion as well as brachial vein

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1129.e8 TRANSRADIAL AMPUTATION
thrombosis and resultant compartment syndrome
requiring forearm fasciotomies. She ultimately
underwent a staged proximal TRA and modified
CCU between the median and ulnar nerves
(Fig. 4). At her 10-month follow up, she was
using a body-powered prosthesis for all activities
of daily living, with no occurrence of a symp-
tomatic neuroma.
Case 3: allograft “loop to nowhere” for neuroma prevention
A 19-year-old man sustained a traumatic, near-
complete metacarpal-level right-hand amputation
following a blast injury. Because of the severity of
the soft-tissue injury, a staged TRA was performed
with pronator quadratus interposition combined
with allograft loop coaptations of the median to
ulnar and dorsal sensory branches of the ulnar
nerve to the lateral antebrachial cutaneous nerve
(Fig. 5). At 1 month after the surgery, he was
fitted with a body-powered hook. At his most
recent postoperative clinical and hand therapy visit
at 4 months, the patient had no residual pain and
had complete healing of his residual limb and
complete return to farm work using his body-
powered hook.
CONCLUSION
This article describes a pedicled interposition prona-
tor quadratus flap to potentially minimize the devel-
opment of symptomatic radioulnar impingement
during pronation-supination in distal or “low” TRA.
J Hand Surg Am.
Additionally, many adjunctive techniques can be used,
such as a modified CCU or an allograft “loop to no-
where,” to minimize the occurrence of postamputation
pain and symptomatic neuroma, which can otherwise
have a negative impact on patient satisfaction, pros-
thetic acceptance, and overall function.
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