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Chapter 31
Upper-Extremity Amputation and
Prosthetic Rehabilitation
Click to see UE Amputation Protocol
M. Catherine Spires
Linda Miner
Miles O. Colwell
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lost his arm in battle, held his shield using an iron prosthetic hand during combat (per account by Pliny).
During the following centuries, a variety of devices
were used to replace the upper extremity. By the sixteenth
century, Ambroise Par, a French military surgeon,
designed the forerunner of todays modern upperextremity prosthesis. His design allowed the amputee to
passively position the hand and lock it into place. Though
a locksmith could duplicate his design, it was expensive. As
a result, Pars design was only available to the wealthy.
The commoner managed without a prosthesis or used a
leather socket with a stationary hook.
In the nineteenth century, Peter Baliff, a dentist,
designed the first body-powered prosthesis, which used
proximal muscle force to produce a weak prosthetic grasp
and release. Though originally designed for the belowelbow (BE) amputee, it was soon modified for the aboveelbow (AE) amputee using a chest lever to control the AE
prosthesis. During this same period, Comte de Beaufort
developed the double spring hook, the forerunner of
todays hook terminal device (TD).
The twentieth century brought major changes in
upper-extremity prosthetics. The injuries during the world
wars, as well as the thalidomide tragedy of the late 1950s,
accelerated the pace of prosthetic technology and research.
After decades of research, the myoelectric prostheses
became a reality. These prostheses remain the most successful externally powered prostheses ever developed.
Though modern prostheses are not as elegant and
complex as the human upper extremity and hand, the
current generation of upper-extremity amputees lead full
and productive lives because of the advances of prosthetic
technology and research (e.g., improved fitting and suspension techniques, new lightweight durable materials, and
more sophisticated body-powered and externally powered
components).
Prosthetic technology changes rapidly. It is impossible for a text of this type to keep pace with the rapid
changes and availability of new technology. However, the
basic principles of prosthetic restoration and rehabilitation
after upper-extremity amputation change little. This
chapter focuses on these basic principles. If the physiatrist
and other rehabilitation team members follow these fundamental principles, the upper-extremity amputee will
achieve the optimal prosthetic restoration and function
possible with todays advanced technology. As in any field
of medicine, this text cannot substitute for the clinicians
need to study ongoing research and to learn from ones
patients and their experience.
The basic surgical principles of amputation are
reviewed. Obviously, a trained surgeon is the appropriate
professional to perform amputations. However, the physiatrist, and other rehabilitation team members, need to
understand the surgical principles of limb amputation.
The informed rehabilitation specialist is able to discuss the
prosthetic and rehabilitation implications of various surgi-
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cal procedures. Collaboration between the surgeon, physiatrist, patient, prosthetist, therapists, and other rehabilitation
team members guarantees that the patient receives optimal
surgical and rehabilitation care. This chapter is written to
assist the surgical and rehabilitation team in their efforts to
collaborate and maximize the patients functional outcome.
An overview of surgical principles is presented first, followed by a presentation of prosthetic restoration and
rehabilitation.
SURGICAL PRINCIPLES
General Principles
Upper-extremity amputation is performed infrequently. As
a result, few surgeons have the opportunity to work with
upper-extremity amputees. Surgeons often consult with
physiatrists to advise them regarding the prosthetic and
rehabilitation implications of surgical decisions. Collaboration between the surgical and rehabilitation team guarantees that the patient will experience the best surgical and
functional outcome.
Many consider amputation a surgical failure: The
limb could not be saved. However, amputation does not
equate to failure. New surgical techniques and prosthetic
technology make it possible for amputation to be a part of
an overall plan of upper-extremity reconstruction, not
simply a surgery of last resort. Obviously, if amputation is
not necessary, it should not be done. But when it is the best
option for the patient, amputation can be the basis of
upper-limb reconstruction and the first step in upperextremity rehabilitation. Approaching the amputation as a
reconstructive procedure facilitates achieving a painless,
cosmetic, and functional limb. This reconstructive
approach, coupled with a patient-oriented approach,
focuses the medical teams efforts on achieving a positive
functional outcome as defined by the individuals needs.
The goal of successful rehabilitation is an individual
who can assume autonomy and responsibility for all
aspects of his or her life. The patients attitude, as well as
the attitude of the surgical and rehabilitation team, is key
to achieving this goal. The patient needs to know that a
multidisciplinary coordinated effort is being made to optimize upper-extremity repair and reconstruction.
In general, there are two types of amputation. The
open amputation, also called a guillotine amputation, is indicated when severe infection or sepsis is present. The amputation wound is not closed; treatment is directed at
resolution of the infection. Definitive closure is performed
once the infection has resolved. The second type, the closed
or definitive amputation, involves primary closure of the
amputation site. Definitive closure is indicated if the limb
is not infected and wound healing is a reasonable
expectation.
Typically, the surgical incision is best placed in a
transverse position, with anterior and posterior skin flaps of
Chapter 31
be pain free. If this is not feasible, pain should be sufficiently controlled so that the person is able to tolerate the
prosthesis.
In summary, the goals of surgical amputation are to
1) preserve functional length of the extremity, 2) preserve
useful sensation, 3) prevent symptomatic neuromas or pain
syndromes, 4) prevent adjacent joint contractures, 5) minimize recovery time, and 6) achieve early prosthetic fitting
to facilitate return to work, activities of daily living (ADLs),
recreation, and socialization (6).
Lastly, the development of sophisticated microsurgery techniques makes upper-limb replantation and
reconstruction feasible. In some situations of traumatic
limb loss, replantation is an option; replantation of the
proximal part of the arm is less successful than BE replantation. Kleinert and others (79) suggested that the lower
success rate is secondary to warm ischemia affecting a
greater muscle mass. Additionally, reinnervation must
occur over a much longer segment in proximal replantation. If replantation is performed, it is most successful in
the very young patient whose injuries do not preclude
skeletal and neurovascular reattachment (10). Functional
neurologic recovery is best in children. Since replantation
is not without risk, the patients overall status, the duration
of limb ischemia, and the likelihood of metabolic replantation toxemia must be considered (11).
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Upper/extremity amputations
030%
3050%
5090%
90100%
035%
3555%
5590%
90100%
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Therapeutic Interventions
Primary suture or closure by secondary intention is acceptable and prevents the morbidity associated with skin grafting. However with bone exposure, one must shorten the
bone or cover using a flap (12). If the amputation is
through the IP joint, the condyles are usually shaped to
improve cosmesis. Of adults with a fingertip injury and
pulp loss, 30% to 50% have cold intolerance or aberration
of sensibility regardless of the technique used (6).
The flexors and extensors of the hand are treated
differently than other upper-extremity muscles. Generally,
myodesis or myoplasty is advised when sectioning muscles
and tendons. In the hand, however, the flexor and extensor
tendons are divided and allowed to retract. These tendons
are not sewn together. This prevents the development of a
finger flexor condition, known as quadriga. Amputation
Chapter 31
Wrist Disarticulation
In the past, WD gained popularity because it preserves the
articular surface of the distal radioulnar joint and maximal
forearm supination and pronation. WD provides a tolerant
end-bearing surface. The shape of the distal end is conducive to a self-suspending socket, though additional straps
may be required for heavy work (17).
WD has disadvantages, however. The broad
distal socket required to accommodate the residual styloid
processes makes fabricating an aesthetically acceptable
prosthesis difficult. The styloid prominences can be
reduced at the time of disarticulation but some of the
advantage of the wide distal residual limb for a selfsuspending socket is lost. The addition of a prosthetic
wrist unit, which allows for an interchange of TDs such
as hands and hooks on the prosthesis, can make the artificial limb longer than the intact arm. This is more obvious
with a prosthetic hand than with a hook. Extra length
reduces cosmesis and interferes with midline hand to
mouth activities. Consequently, the selection of wrist units
and TDs is limited. Additionally, if a persons goal is to
use a myoelectric prosthesis, disarticulation is a poor choice
because myoelectric units also add length to the prosthetic
forearm. A long transradial amputation would be a better
choice if the patient is a candidate for a myoelectric
prosthesis.
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Elbow Disarticulation
Elbow disarticulation (ED) has several advantages. Preservation of the humeral condylar flares facilitates prosthetic
suspension. Because the humeral condyles fit snugly into
the prosthetic socket, humeral rotation is efficiently transmitted to the prosthesis. ED provides a longer lever arm
than an AE amputation does. Additionally, the distal end is
pressure tolerant since the articular cartilage is preserved.
Cosmesis is the primary disadvantage of ED. The
distal end of the prosthesis is bulky. Fewer prosthetic
elbows are available. At this level, outside locking elbow
hinges are required but they can damage clothing and
reduce cosmesis. Myoelectric elbow units, such as the Utah
arm, also create an abnormally long prosthetic arm. To
avoid this length differential, it is possible to fit the patient
with a hybrid prosthesis fabricated with both bodypowered and electronic components.
Transhumeral Amputation
Amputation through the humerus can be done at several
levels. The transcondylar amputation, like ED, preserves
the condylar flares which can transmit humeral rotation to
the prosthesis. Like ED, an external hinge elbow joint is
required, since other elbow units make the prosthetic limb
abnormally long. The remaining humeral condyles require
a socket with a wide distal end, detracting from the overall
appearance of the prosthesis.
A residual limb that is at least 10 cm long, measuring
from the axillary fold, is preferred according to many
sources. The greater the upper-limb loss, the less humeral
rotation is preserved. Designing the prosthesis with an
internal locking prosthetic elbow joint with a turntable for
internal and external rotation (21) offsets this loss to some
degree.
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Juvenile Amputees
Though the surgical principles of pediatric amputation are
similar to those for the adult, there are two major distinctions: A disarticulation is preferred to a transdiaphyseal
section and more heroic efforts are indicated to conserve
length (26). In children, epiphyseal preservation is important. The growth potential of the distal epiphyses is greater
than that of the proximal radial and ulnar epiphyses, while
Chapter 31
Figure-of-eight harness
with O ring
Hook TD
Triceps
cuff
Control cable
Socket
Cable housing
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Myoelectric or
powered hand
Motor
Battery
EMG amplifier
Dorsal electrode
Figure 31-4. A typical myoelectrically controlled belowelbow prosthesis with a hand terminal device.
EMG = electromyograph.
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Preparatory Prostheses
The immediate postoperative prosthesis fitting technique is available,
but it is used infrequently. While still in the operating
room, the patient is fitted with an immediate postoperative
prosthesis made of a rigid dressing with minimal, but functional prosthetic components attached. The socket can be
applied once the surgical incision is closed. Initially, the
incision is dressed with a light layer of bandages, and
plaster or fiberglass is used to form a socket on the
patients residual limb. The immediate postoperative prosthesis functions as the final wound dressing.
Immediate postoperative fitting has many advantages, including controlling postoperative edema and pain.
Reducing postoperative edema minimizes postoperative
pain and phantom pain. The immediate postoperative
prosthesis conditions and shapes the residual limb, preparing it for future prosthetic fitting. Additionally, the immediate postoperative prosthesis allows the occupational
therapist (OT) to begin training almost immediately. It is
important that prosthetic training does not begin before
the surgeon agrees. In some cases, the surgeon may allow
the OT to begin training within the first 24 hours of
surgery, whereas others prefer waiting several days. As a
result, the amputee experiences the immediate usefulness
of the residual limb and the prosthesis.
While immediate postoperative fitting sounds ideal, it
requires an experienced, multidisciplinary, surgical and
prosthetic rehabilitation team, available to fit the prosthesis
in the operating or recovery room and to ensure that the
fit is correct to prevent tissue damage and risk further limb
loss. Most amputations are the result of trauma, however,
and there is limited time to assemble an experienced multidisciplinary team.
Early fitting of a temporary prosthesis is more
common than the immediate fitting approach. Once
sutures are removed, about 1 to 2 weeks after surgery,
fitting is begun. Though early fitting occurs during
Malones golden period, some (36) question whether use of
the early fitting technique results in as much acceptance as
use of the immediate fitting approach. However, many
investigators (35,3741) found no appreciable difference
between the success rate of prosthetic use between the two
prosthetic fitting techniques.
Many of the same advantages of immediate postoperative fitting are also seen with early prosthetic fitting.
Bimanual activities are preserved and prosthetic acceptance is high. However, the early fitting approach has addi-
Definitive Prostheses
The final or definitive prosthesis represents the culmination
of all the experience and information gained during the
preparatory phase. The definitive prosthesis is the permanent one, the prosthesis the person is going to live with
(Fig. 31-5). Test driving various provisional designs ensures
that no major oversights occur in the design of the permanent prosthesis. Like the provisional prosthesis, the definitive prosthesis can be body powered, myoelectric, or a
hybrid of both. The permanent prosthesis, which must
withstand all types of activities over the long term, is constructed with more durable materials than is the provisional prosthesis.
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557
D
C
Figure 31-5. The amputee is fitted with a prosthesis in stages. A. First, a preparatory or provisional prosthesis is fabricated.
After a period of prosthetic training and use, the individual is fitted with a definitive body-powered prosthesis.
B. Definitive left below-elbow prosthesis with a hook but without a cosmetic cover. C. The same prosthesis
with cosmetic glove and hand. D. The definitive prosthesis used for everyday activities.
Harness
The harness provides suspension and a way to control the
active parts of the prosthesis. The type of socket and the
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D
C
Figure 31-6. Myoelectric prosthesis with a wrist rotator, prosthetic hand, and polyvinyl chloride glove. The rectangular
compartment on the medial aspect of the forearm contains the battery that powers the prosthesis.
and terminates on the TD. There are two basic types: the
single control system, which typically operates the TD for
the BE amputee; and the dual control system required by
the AE amputee. The amputee transmits muscle tension
along the stainless-steel cables of the prosthesis to perform
the desired motion. For example, in the BE amputee, the
cable terminates on the TD. The OT trains the patient to
perform coordinated movements of arm flexion and shoulder abduction to operate the TD. The body-powered AE
prosthesis uses the same principles but requires a second
cable to control the elbow unit.
Chapter 31
559
D
Figure 31-7. Self-contained myoelectrically powered prosthesis with a wrist rotator and Greifer hook. On the medial aspect
of the prosthetic forearm there is a panel to access the battery. A functional arm orthosis. A hook is present on
the palm of the hand, as would be needed after a partial hand amputation. Because of the flail upper
extremity, chest expansion activates the hook. However, a partial hand amputee would use arm muscles to
activate the hook.
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or vocational demands may require a very naturalappearing passive prosthesis (Fig. 31-8). Because the intact
human hand changes color with position, activity, or
ambient temperature, a prosthesis cannot perfectly replicate the human hand. A passive hand improves appearance while allowing the person to use the hand for limited
pushing or as a gross assist.
Cosmetic gloves to cover the TD of a prosthesis
are available. Though some very expensive gloves are
near-perfect replicas of the hand, the cost and quality
of cosmetic gloves vary. Most cosmetic gloves provide
satisfactory cosmesis and are fairly inexpensive. Cosmetic
gloves must be cared for properly to preserve their
appearance. They are also easily torn, stained, and
damaged.
Terminal Devices
The TD is the most distal component of an upperextremity prosthesis. A TD is either active or passive. A
passive TD is usually very light and has no moving parts.
However, some passive TDs are function specific; for
example, designed to hold a golf club (Figs. 31-9 and
31-10) (47).
The typical active prehension TD is a hook, hand, or
specialized device or tool with moveable parts (Fig. 31-11).
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561
B
A
Figure 31-9. A, B. This specialized rifle-holding terminal device allows this individual to participate in recreational target
shooting. This prosthesis is a preparatory short above-elbow prosthesis.
A
Figure 31-10. A, B. This terminal device is made specifically for holding a golf club.
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that allows them to change the TD depending on the situation, for example, cutting the lawn versus going to a
wedding. If the individual intends to vary the TD, a quick
disconnect wrist is preferred over a friction wrist, which is
screwed onto the prosthesis.
Below-Elbow Prosthesis
For UE amputation the elbow is the point of reference,
that is, AE or BE amputation. This terminology is easy to
understand and readily conveys the same information to
the physician, the therapist, and prosthetist. One can
readily generalize about the upper-extremity function
remaining, the function lost, and the basic prosthetic components needed. However, terms such as transradial and
transhumeral are more accurate anatomic descriptions and
are consistent with terms used for other common levels of
A
A
B
Figure 31-12. This child demonstrates how to use humeral
flexion to open the terminal device of the
body-powered below-elbow prosthesis.
B
Figure 31-11. A variety of tools that are also terminal
devices.
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563
B
A
Figure 31-13. A step-up elbow amplifies the amount of natural elbow flexion in the individual with a very short limb after
below-elbow amputation.
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Above-Elbow Prosthesis
The shorter the remaining humerus is, the more the
patient loses rotation, power, and leverage. An amputation
at or below the distal third of the humerus affords the
amputee many of the advantages of ED, but supracondylar suspension and rotation control are lost. Though scapular motion provides some control, humeral motion
provides primary control for the transhumeral prosthesis. A
figure-of-eight harness with dual-control design is the most
popular system.
Transhumeral amputation that is performed at least
5 cm proximal to the elbow leaves a limb that can
accommodate an internal or inside locking elbow unit (Fig.
31-14). The turntable multiple locking elbow unit, which is
the most common unit used by the AE amputee, has 11
locking positions. It provides 5 to 135 degrees of flexion,
whereas the elbow unit used in a disarticulation prosthesis
has only seven positions, or fewer if it is a heavy-duty
design. With a body-powered prosthesis, if the elbow is
unlocked, pulling the cable flexes the elbow. If however
the elbow is locked, a pull on the main cable operates the
TD (48).
A residual limb of less than 10 cm after transhumeral
amputation can be fitted with an AE prosthesis but often
requires a forearm spring lift assist incorporated into the
elbow unit. The most proximal transhumeral amputation
Chapter 31
that results in a functional limb is performed at approximately 5 cm distal to the axillary fold. A shorter residuum
is unable to control the prosthetic socket effectively (49).
Hybrids of myoelectric and body-powered systems
are very valuable for the AE amputee. A body-powered
elbow with a myoelectric hand is a common choice. The
myoelectric hand, with its stronger grip and graded
control, is valuable for the person whose work or avocation
involves a lot of holding and stabilizing objects. The myoelectric elbow with a body-powered TD affords more
sensory feedback for the patient who needs feedback
regarding TD function.
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Depending on the shoulder profile remaining, stabilizing a prosthesis can be difficult. Sockets are fabricated
using plastic laminates. Control of perspiration is more
problematic than with more distal amputations. The prosthetist is challenged to achieve an intimate socket-limb
interface to suspend the prosthesis while providing sufficient ventilation. Moisture-absorbing material placed or
worn under the socket (e.g., cotton T-shirt) helps to control
perspiration. Antiperspirants that control excess perspiration and need only to be used once or twice weekly are
available commercially. The weight of the prosthetic arm
creates high pressure over bony prominences. During
socket fabrication, sufficient relief must be provided in
these areas to avoid pain and skin breakdown.
Some individuals benefit from a prosthetic shoulder
joint while others prefer a bulkhead design. With the
bulkhead design, the prosthetic humerus is attached
directly to the socket and no shoulder motion is provided.
Omitting the shoulder unit reduces the weight of the
prosthesis, making it very attractive to some amputees. At
this level, a lightweight endoskeletal prosthesis is also an
option.
Cosmetic Prosthesis
For some patients, cosmesis far outweighs the need or
desire for a functional prosthesis. Some individuals are not
able to operate a prosthesis. Often individuals whose upper
extremity was amputated at a very proximal level prefer a
cosmetic prosthesis and do not want a prosthesis with
active components. Individuals with an FQ amputation or
SD may do best with a simple shoulder cap to restore the
profile of a normal shoulder (Fig. 31-16). The physician
must know the patient and keep in mind that prescribing a
prosthesis is typically a compromise between cosmesis and
restored function. Hybrid systems of passive and active elements, with body-powered and externally powered components, are often the best choice.
A
B
C
Figure 31-16. Forequarter amputation. Individuals who have had an amputation at this level often prefer a simple shoulder
cap without other prosthetic components. This passive prosthesis restores the shoulder profile, improving the
fit of clothing, but does not provide additional upper-extremity function.
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PEDIATRIC PROSTHETICS
Upper-extremity limb loss in children is most often congenital. The etiology is highly variant, ranging from maternal infection, chemical or drug exposure, and amniotic
band syndromes, to single gene mutations. Though some
congenital limb deficiencies are associated with known syndromes, for example, craniofacial and thrombocytopenia
absent radius (TAR) syndromes, or thalidomide exposure,
the majority is of unknown etiology. The most common
congenital limb loss is transverse deficiency of the proximal third of the left forearm (Fig. 31-17).
Acquired limb loss accounts for 40% of pediatric
limb loss, typically involving a single limb; 60% involves
the lower limb. Trauma is the most common cause; tumor
and disease are next in frequency. With trauma, the limb
loss is primarily due to power tool accidents, burns, and
motor vehicle accidents. In the toddler and preschooler,
power tools, such as lawn mowers, and household accidents are the primary causes. Regarding surgical amputations for disease, more than half are secondary to
malignant tumors in preadolescents and adolescents.
Over the years, efforts have been made to classify
and describe congenital limb deficiencies. Much of the terminology, being imprecise and ambiguous, generated confusion. The International Organization for Standardization
(ISO), involving the work of the International Society for
Prosthetics and Orthotics (ISPO), has developed a widely
accepted classification system and standard terminology for
congenital limb deficiency. There are two major classifications: transverse limb deficiencies and longitudinal limb
deficiencies. The system is restricted to skeletal absence or
reduction and does not consider the etiology or embryology. Since the classification is restricted to the absence or
reduction of normal skeletal elements, radiography, or
other methods to identify skeletal elements, is used. Lack of
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PRESCRIBING A PROSTHESIS
No two individuals are alike. No one prosthesis fits all
patients. Prescribing an upper-extremity prosthesis requires
the integration of a number of medical, rehabilitation,
social, and economic factors. The rehabilitation team not
only must assess the patients needs, preferences, capabilities, and overall medical condition, but also must consider
the anatomy of the residual limb, the functional status of
the residual limb and proximal joints, the presence of any
other impairments, and the individuals socioeconomic
situation. If this information is synthesized and incorporated into the prosthetic restoration and rehabilitation
program, the patient will receive the most appropriate
prosthesis.
The essential components of a typical functional
upper-extremity prosthesis are the socket, suspension
system, control system, and TD. The suspension system
includes cuffs and a harness. The control system is either
body powered, externally powered, or a hybrid of both.
The level of amputation determines whether a TD, wrist
unit, elbow hinge or elbow unit, and shoulder component
are needed. If the prosthesis is primarily cosmetic, few
mechanic components, if any are needed (Fig. 31-18).
It is important to prescribe the most functional, comfortable, and cosmetic prosthesis for the individual. As an
example, the most commonly prescribed generic BE prosthesis typically includes a VO split-hook TD, quickdisconnect wrist unit, flexible elbow hinge, double-wall
laminated socket, single-control cable system, triceps cuff,
and a figure-of-eight harness. For the generic AE prosthesis, the same components are used but an elbow unit and
a dual-control cable system are added.
Figure 31-18. An upper-extremity prosthetic prescription form that accurately communicates the type of upper-extremity
prosthesis prescribed. It also ensures that clinicians prescribe all the essential components and options
specifically needed for each amputee.
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PRE-PROSTHESIS MANAGEMENT
Ideally, one would like to begin prosthetic restoration
and rehabilitation before amputation. However, most
upper-extremity amputations are performed emergently.
Generally, there is little time to prepare the individual
for amputation or prosthetic restoration and
rehabilitation.
If the surgery is elective, the patient, the physicians,
and the rehabilitation team are able to collaborate and
develop a treatment plan. There is also time to educate the
patient about the level of amputation, preoperative and
postoperative course, functional implications of the amputation, and available prosthetic and rehabilitation options.
Additionally, the patient is counseled about phantom pain
and sensation as well as psychosocial concerns.
Unfortunately, the patient and the members of the
rehabilitation team typically do not meet until after
surgery. However, patient assessment and education should
begin as soon as possible. An initial assessment is performed. Information is collected about the individuals preamputation functional level, including vocational and
recreational activities, upper-extremity dominance, and
psychosocial situation. The initial assessment, or inventory,
begins the process of determining the individuals prosthetic and rehabilitation needs. An individualized prosthetic rehabilitation program is initiated, integrating
multiple factors including the status of the residual limb,
the patients overall functional status and general health,
the persons financial resources, and the amputees goals
and expectations.
As a rule, ADL training does not begin until a
person receives a prosthesis. If the individual becomes
adept doing activities with one hand he or she is less likely
to accept and use a prosthesis. Learning to be one-handed
initially seems an acceptable option. However, after 20 or
30 years of performing activities with one hand, individuals who have not used an upper-extremity prosthesis frequently develop cumulative trauma syndromes of the back,
neck, and the intact upper-extremity. Bilateral upperextremity amputees are the exception to the rule. All
efforts should be made to enable these individuals to begin
feeding and performing ADLs as soon as possible, even
before a prosthesis is available.
Other rehabilitation issues addressed early after
amputation include wound management, edema and pain
control, scar management, range of motion of the limb,
and upper-extremity strength.
Wound Management
The surgical site requires close monitoring until healing is
well established. The surgeon prescribes necessary postoper-
Range of Motion
After an uncomplicated amputation, the patient is
instructed in active ROM exercises for all residual joints on
the first postoperative day. If other injuries are involved,
such as fractures, skin grafts, and tendon repairs, appropriate restrictions are observed. Full active ROM is expected
for all joint motions with the exception of forearm or
humeral rotation, which depends on the residual bone
length. If full ROM has not been achieved after 1 week,
passive ROM exercises are added.
Pain Management
Patients experience pain after an amputation. Postoperative
incision pain can be controlled with appropriate postsurgical analgesia and resolves over a week or two. However,
other types of pain may persist after the surgical recovery
period. When managing pain, it is important to determine
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PROSTHETIC CHECKOUT
When the patient receives any prosthesis, preparatory or
definitive, the OT checks the prosthesis to make sure it is
just what the doctor ordered (56). In addition to verifying that the prosthesis meets the specifications of the prosthetic prescription, the OT evaluates cosmesis, comfort, fit,
control efficiency, stability of suspension, and the mechanical components of the prosthesis. Ideally, the prosthetist is
present and makes the appropriate modifications before
the amputee takes the prosthesis home (57).
The prosthesis should appear to be the same length,
circumference, and shape as the sound extremity. The
prosthesis should not have the same dimensions as the contralateral side or it would appear too large and bulky.
Proper length is achieved when the end of the hook or the
tip of the prosthetic thumb is level with the tip of the contralateral thumb with the arms extended at ones side
(5860). Length is important not only for appearance but
also for the most effective use of the TD. For example, if
the prosthesis is too long it will interfere with hand-tomouth activities. The cosmetic glove covering the prosthetic hand needs to be similar in color to the sound hand.
No glove will match the color of the intact hand exactly,
but reasonably priced cosmetic gloves that provide a good
match are available commercially.
Comfort is a major issue. The amputee will not wear
a prosthesis that causes pain. The socket should provide
even pressure on the residual limb. Pressure should be
eliminated or reduced at bony prominences or neuroma
sites. The socket should not leave red skin marks that last
more than 15 to 20 minutes after removal of the prosthesis. Skin irritation, breakdown, or pain suggests an unsatisfactory fit. Modification of the socket fit or suspension
system usually corrects these problems.
The prosthesis should permit maximal active ROM
of the residual limb. Often this is not feasible with a very
short residual forearm or Muenster-style sockets
(41,6163). Though harnessing systems may preclude full
shoulder flexion or abduction, active shoulder flexion
should be no less than 90 degrees (41).
The mechanical efficiency of the control system of a
body-powered prosthesis is evaluated. Stable suspension of
the prosthesis is also crucial. With a 25-kg axial load (i.e.,
50 lb or one-third of the body weight of a child), the
amount of socket displacement on the residual limb should
not exceed more than approximately 2.5 cm (41,6163). If
the socket migrates more than 2.5 cm, the harness needs
modification.
The checkout procedure is slightly different for the
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Therapeutic Interventions
PROSTHETIC TRAINING
Prosthetic training that focuses on the patient increases the
likelihood that he or she will effectively use the prosthesis.
Typically, patients learn to use the prosthesis by trial and
error once they have been instructed in the specific control
motions. Not all amputees approach activities using the
same technique. Amputees who are experienced with tools
tend to find training easier than those who are unfamiliar
with tools. The OT acts as a facilitator, encouraging independent problem solving and providing guidance and assistance as needed. Only one therapist should do the training
or the amputee will become confused by the different
approaches. An experienced therapist who is a strong
advocate of prosthetic use significantly increases the likelihood of successful prosthetic training (41). The amputee
who is not fitted with a prosthesis during the 30-day
golden period needs to relearn how to perform activities
once the prosthesis is fitted. Having to abandon onehanded techniques and relearn prosthetic techniques
reduces the likelihood that the individual will become a
successful user of the prosthesis.
The individual must have realistic expectations
regarding what the prosthesis can and cannot do. The
amputee must consider the prosthesis as an assist. In a
unilateral amputee, the prosthesis assumes the role of a
nondominant upper extremity for activities. If the amputation involved the individuals dominant hand or arm,
the contralateral limb assumes dominance. Typically, bilateral amputees use the longer residual limb as the dominant
one.
Prosthetic training is divided into three distinct
phases: orientation, controls training, and use training.
During prosthetic orientation, the patient learns about
prosthetic components. General instructions in the wear
and care of the prosthesis are reviewed. During prosthetic
controls training, the individual learns to operate all prosthetic components. The amputee must learn to operate the
components smoothly and efficiently, avoiding strain or
awkward movements. During prosthetic use training, the
person learns to perform ADLs with the prosthesis. Bilateral tasks, such as cutting with scissors, cutting meat, and
tying shoes, are emphasized.
Prosthetic Orientation
The patient first learns how to wear the prosthesis. Typically, the amputee learns to don and doff the prosthesis
using either a pullover technique or a coat technique. The
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Switch-Control Training
When myoelectric control sites are not available, other possible control motions (e.g., those that activate an on-off
rocker, button, or pull switch) are considered. These
control motions are usually proximal movements that are
not used for normal ADLs, such as shoulder elevation. As
mentioned earlier, chin nudge switches are occasionally
used. Most of the controls training for this type of
external power is conducted after the individual receives
the prosthesis.
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575
Bilateral Amputees
Persons with bilateral BE amputation can become completely independent in ADLs (Fig. 31-22). However, learning to do overhead activities is difficult. Individuals with
bilateral amputations may require driving rings, button
hooks, lever-type doorknobs, or ring pulls for zippers to
achieve independence.
In addition to AE prosthetic training, children with
congenital bilateral AE limb deficiencies should learn to
use their feet as they would hands. These amputees frequently require a bidet for toileting. Telephones with a
speaker phone work well for these individuals. Certain
activities (e.g., dressing above the waist or cutting meat) are
extremely challenging. Typically, these individuals, and
amputees with more limb loss, require assistance from
another person at various times during the day for certain
activities such as bathing.
Amputees with bilateral SD or higher limb loss find
it very difficult to don and doff prostheses independently
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CONCLUSIONS
Prosthetic restoration and rehabilitation is a rapidly
expanding field. A few basic points are important to
remember. When upper-extremity amputation is necessary,
the procedure needs to be viewed as part of a reconstructive and rehabilitation effort to restore upper-extremity
function. When the surgical and rehabilitation decisions
and interventions focus on the patient as an individual, he
or she is able to achieve maximal function and independence in spite of limb loss.
Chapter 31
577
Life-Like Laboratories
2718 Hollendale Lane, Suite 400
Dallas, TX 75234
(Horst Bruckner, president; company makes custom
silicone gloves, patented procedures, written articles)
Motion Control
(Fillauer Subsidiary)
Tel: (800) 621-3347
Fax: (801) 972-9072
3385 West 1820 South
Salt Lake City, UT 84104
(Harold Sears, PhD, vice-president and general manager;
Utah Elbow, BE procontroller)
Otto Bock Orthopedic Industry
Tel: (800) 328-4058
Fax: (612) 519-6153
3000 Xenium Lane North
Minneapolis, MN 55441
(Originated in Germany, Otto Bock Hand, Greifer, Wrist
Rotator, myoelectric components)
Pilot Hand Prostheses
Tel: (800) 441-HAND
Fax: (212) 489-7808
331 W. 57th Street, #109
New York, NY 10019
(Custom silicone gloves)
The Institute for Rehabilitation & Research
(TIRR) Amputee Center
Tel: (713) 797-5237
Fax: (713) 797-5904
1333 Moursund
Houston, TX 77030
(Diane Atkins-Jones, OTR, editor of Comprehensive Management of Upper-Limb Amputee, New York: Springer, 1989)
Therapeutic Recreation Systems (TRS)
Tel: (800) 279-1865
Fax: (303) 444-5372
2450 Central, Suite D
Boulder, CO 80301
(Bob Radocy, president; BE amputee developer of VC
Adept and Grip hooks and numerous sports terminal
devices, several videotapes for sale including one of sports)
United States Manufacturing Co.
Tel: (818) 796-0477
Fax: (818) 440-9533
P.O. Box 5030
180 N. San Gabriel Boulevard
Pasadena, CA 91107-0030
(Manufacturer quick disconnect wrist, mechanical elbows,
books)
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Therapeutic Interventions
Systemteknik AB
Prosthetics and Orthotics Group
Tel: 011-46-876-70370
Vasavgen 76 S-18141
Liding, Sweden
David Trainer
Anaplastologist
Germany
University of New Brunswick
Prosthetics Research Centre Institute
of Biomedical Engineering
Tel: (506) 453-4966 or 454-8283
Fax: (506) 452-1040
180 Woodbridge Street
Fredericton, NB, Canada E3B 4R3
(Annual myoelectric controls course and symposium on
their system in August)
Variety Ability Systems (VASI)
Tel: (416) 698-1415 or (800) 891-4514
Fax: (416) 698-5860
3701 Danforth Avenue
Scarborough (Toronto), ON, Canada M1N 2G2
(Developer of Cookie Crusher childrens myoelectric
hand, hands, elbow, gloves)
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REFERENCES
1. Hunter GA. Amputation surgery of
the arm in adults. In: Murdoch G,
Wilson AB Jr, ed. Amputation:
surgical practice and patient
management. London: Butterworth Heinemann, 1996:
305312.
2. Beasley RW. General considerations in managing upper limb
amputations. Orthop Clin North
Am 1981;12:743749.
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56. Fisher AG. Amputation and prosthetics. In: Trombley C, ed. Occupational therapy for physical
dysfunction, 3rd ed. Baltimore,
MD: Williams & Wilkins,
1989:604624.
582
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61. Wellerson TL. A manual for occupational therapists on the rehabilitation of upper extremity
amputees. American Occupational
Therapy Association. Dubuque:
Kendall/Hunt, 1958.
Therapeutic Interventions