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This document discusses prosthetic options and considerations for individuals with very short below-elbow amputations. It describes how above-elbow prostheses can provide better suspension and control but are heavier, while below-elbow options allow for lighter devices but require precise socket fitting. Key socket designs for very short forearms include split, Munster, and Northwestern sockets. Suspension relies on harnesses or self-suspending socket properties. Cable systems connect body movements to terminal device control.
This document discusses prosthetic options and considerations for individuals with very short below-elbow amputations. It describes how above-elbow prostheses can provide better suspension and control but are heavier, while below-elbow options allow for lighter devices but require precise socket fitting. Key socket designs for very short forearms include split, Munster, and Northwestern sockets. Suspension relies on harnesses or self-suspending socket properties. Cable systems connect body movements to terminal device control.
This document discusses prosthetic options and considerations for individuals with very short below-elbow amputations. It describes how above-elbow prostheses can provide better suspension and control but are heavier, while below-elbow options allow for lighter devices but require precise socket fitting. Key socket designs for very short forearms include split, Munster, and Northwestern sockets. Suspension relies on harnesses or self-suspending socket properties. Cable systems connect body movements to terminal device control.
The very short trans-radial amputee presents a fitting
dilemma for the prosthetist. Should the client be fitted with an above-elbow type of device or a below-elbow device? Fitting with an above-elbow prosthesis assures adequate suspension, weight distribution, rotational control and availability of myoelectric sites. However, the resulting prosthesis is heavy and cumbersome and restricts shoulder motion. Fitting as a below-elbow requires more precise socket fitting but does enable the child to wear the lightest, least restrictive and obtrusive powered device possible.. This shortest of below elbow stumps present the difficulty in achieving the basic goals of motion,stability and comfort. Most people with transradial amputation have full elbow motion in the saggital plane. In the short residual forearm requires a socket designed to retain the stump while permitting a useful range of elbow flexion and extension. LEVEL OF AMPUTATION
Very short below elbow- is classified in accordance with
epicondyle to styloid length.
Stump length - 0% to 35% of forearm length.
The very short below elbow level can complicate
suspension and limit elbow stength and motion.
The ability to pronate and supinate diminishes as the
length of the residual limb. ETIOLOGY OF VERY SHORT BELOW ELBOW 1. Traumatic Injury - almost 90% It occurs primarily in young men between the ages of 20 and 40.
The ratio of men to women with new upper limb
loss is approximately 4:1.
It is result of carelessness of when using
machinery or equipment. 2.Peripheral vascular disease 3.Tumor 4.Infection 5.Congenital limb deficiencies Problems in Very Short Below Elbow Stump Limited Range Of Motion It presents the most difficulty in achieving goals of motion, stability and comfort. Pronation and Supination diminished. Less Area of Force. Forearm Rotation is completely restricted. Forearm flexion is limited. SURGICAL CONSIDERATION OF VERY SHORT BELOW ELBOW In very proximal amputation, it may be necessary to detach the biceps tendon. Reattachment of biceps tendon in proximal ulna and remove the radius. Only 4 to 5cm of ulnor length is sufficient for prosthetic fitting with retention of elbow flexion and creating a one bone forearm i.e more comfortable. It is important to maintain forearm length, because forearm stength and rotation are proportional to residual length. EVALUATION OF VERY SHORT BELOW ELBOW STUMP The Prosthetist evaluation includes - Location of adherent scar tissues Neuroma Range of motion Edema Location of maximum excursion. Power of upper limb amputee Weight problems PROSTHETIC MANAGEMENT Prosthetic management in the limb amputee depends upon the following factors. I. Length of the residual arm. II. Strength of the musculature. III. Range of motion available IV. occupation of the patient V. Functional and cosmetic requirements of the amputee. VI. Availability o prosthetic maintenance. COMPONENTS OF VERY SHORT BELOW ELBOW PROSTHESIS Veryshort below elbow prosthesis have following components- SOCKET SUSPENSION CONTROL CABLE SYSTEM TERMINAL DEVICE SOCKET DESIGN In the V.S.B.E amputee ,the short residual forearm requires a socket designed to retain the stump ,while permitting a useful range of flexion and extension.
In Very short below elbow level
we can give following sockets. 1. Split socket 2. Munster socket 3. Northwestern socket 4. Trans-radial Anatomical Contoured Socket SPLIT SOCKET The socket encases the olecranon with the proximal edge shaped to limit stump flexion to approx.90. Split socket consists of a total-contact segment encasing the residual limb and connected by hinges to a separate forearm shell to which the wrist unit and the terminal device are attached. It is sometimes used in patients who have very short stumps so that the special elbow hinges can be used to increase available joint range of motion or to incorporate an elbow-lock mechanism in the prosthesis. The limited range of flexion can also be increased by using a split socket design with step-up hinge. If the stump is so weak or so limited in range of motion that it cannot drive the forearm through a functional flexion range,the split socket may be used with an alternate mechanical coupling that provides an elbow lock. In this case, flexion of the forearm is produced by the harness and cable control system. Whatever the hinge mechanism, the socket should be somewhat flattened anteroposteriorly. It encompass the olecranon and epicondyles. It include a V shaped relief for the biceps tendon. If atleast 30 deg. Of flexion and 140 N of force are available,a single- axis and stump activated locking hinge may be used. Extension of the stump unlocks the elbow joint. A half cuff with supporting billets stabilizes the elbow and the upper arm. Disadvantage Approximately twice the force is required from the stump than would be needed with no step-up to power the same amount of flexion. MUNSTER SOCKET It is a self suspending socket. An alternative to the split socket (for short transradial amputees) is the Muenster-type socket design. In this, the socket and forearm are set in a position of initial flexion and the socket encloses the olecranon and the epicondyle of the humerus. The intimate stump encapsulation, flexion attitude, and high trimlines provide excellent retention and security. Although there is some limitation in the range of flexion-extension this may be compensated by preflexing. Trim line – o The socket is characterised by an anterior trimline that extends to the level of the anticubital fold with a channel provided for the biceps tendon.
o Posterior trim line, which hooks over the olecranon.
oThese high socket borders and the overall and intimate fit produce excellent stump socket stability and considerable lifting force.
oBut also restrict flexion range of motion to approx.70 0 .
oThe anteroposterior corner of the socket trimline is the point
at which the humeral condyles enter the socket. o The trimline must be 0.3cm smaller than the measured mediolateral dimension of the condyles in this area to the condyles pass in to the socket with only slight expansion of the socket. o Donning the socket may require pulling the stump in with a sock because of the high trimlines and 35 deg. Angle between the humeral and forearm section. o Suspension is also affected by the flexibility of the finished socket. o the Münster-type prostheses are functionally advantageous with considerable cosmetic and comfort appeal for amputees with very short to medium below- elbow stumps. Northwestern socket It is a self suspending socket. It is an atmospheric- pressure suspension socket. This socket was constructed with a soft , clinging rubberlike sleeve inside a rigid shell. The inner sleeve was fastened distally,and as the prosthesis was loaded and the stump started to withdraw,the inner sleeve tightened around the stump preventing further motion. Trans-radial anatomical contoured socket TRAC interface focuses the compression anterior and slightly inferior to the epicondyles. It retains the high olecranon encapsulating post.trimline. Anterior trimline extending to the cubital fold. It transfers the load from the distal end of radius to the more load tolerant musculature. SUSPENSION The suspension system must hold the prosthesis securely to the residual limb, as well as accommodate and distribute the forces associated with the weight of the prosthesis and any superimposed lifting loads. Suspension systems can be classified as follows : Harnessed-based systems Self-suspending sockets • In Harness based system,the standard harness for below elbow amputee is figure of 8 harness. • When the residual forearm is too short to power or stabilise the prosthesis in elbow flexion,a figure- of-8 harness with an above elbow lift and control cable required. • Step-up hinges used with split socket may be used in V.S.B.E to provide increased excursion of the forearm and terminal device but requires the amputee to use approx. twice as much force to flex the prosthetic forearm. Self-suspending sockets are capable of providing adequate prosthetic suspension without the use of a harness. However, either design can also be used with a harness suspension to provide for a more secure suspension of the prosthesis. For example-Munster socket with figure-of-9 harness. Self-suspending sockets are largely limited to wrist or elbow disarticulations and to transradial amputations. This socket design is most commonly utilized with an externally powered, myoelectrically controlled transradial prosthesis. An example of this type is the Munster socket. Proper fit of this socket precludes full elbow extension. CABLE CONTROLLED SYSTEM Body-powered prosthetic limbs use cables to link movements of one part of the body to the prosthesis in order to control a prosthetic function. This is usually a movement of the humerus, shoulder, or chest, which is transferred via a Bowden cable (a single cable passing through a single housing) to activate the terminal device of the prosthesis A control cable used to activate a single prosthetic component or function is called a single-control cable, or Bowden cable system. This latter control cable setup is accomplished with a single cable passing through 2 separate cable housings known as a fair lead cable system. Body movements that are captured for prosthetic control include the following: Glenohumeral forward flexion: A natural movement that provides excellent power and reach and that can activate the terminal device or flex an elbow joint; it is good for activities away from midline Biscapular abduction (chest expansion), mutual protraction: A movement that can activate the terminal device; however, the device must stay relatively stationary and the force generated is weak; this movement is easy for the amputee to do, and it is good for fine motor activities . TERMINAL DEVICES Passive terminal device The main advantage of most passive terminal devices is their cosmetic appearance. With newer advances in materials and design, some passive hands are virtually indistinguishable from the native hand. However, most of these cosmetic passive terminal devices are usually less functional and more expensive than active terminal devices. Active terminal devices Active terminal devices are usually more functional than cosmetic. however, in the near future, active devices that are equally cosmetic and functional may be available. Active devices can be broken down into 2 main categories: hook and hand. Cable-operated active terminal devices can be of a voluntary opening design (most commonly used) or a voluntary closing design. With a voluntary opening mechanism, the terminal device is closed at rest. The patient uses the control-cable motion to open the terminal device against the resistive force of rubber bands (hook) or internal springs or cables (hand). Relaxation of the proximal muscles allows the terminal device to close around the desired object. With a voluntary closing mechanism, the terminal device is open at rest. The patient uses the control-cable motion to close the terminal device, grasping the desired object. This type of mechanism is usually heavier and less durable than a voluntary opening mechanism. A prosthetic hand is usually bulkier and heavier than a hook, but it is more cosmetically pleasing. A prosthetic hand can be powered by a cable or utilize external power.