Upper Limb Amputees Guide

7/29/2019 Upper Limb Amputees Guide

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Upper limb amputees Guide

Upper Extremity

Upper extremity amputees are fitted with specially designed prostheses in order to restore a

specific level of functionality and visual appearance of the missing limb.

The goal of each patient can vary, but many upper limb amputees desire to regain the ability to

perform normal day-to-day activities with their new limb.

In order to accomplish this goal, the prosthesis must meet important criteria for the patient,

including comfort, durability and when desired, aesthetic appeal.

Causes of Upper Limb Amputations

In the majority of cases, these amputations are caused by a particular trauma involving a

machinery accident, vehicle crash, severe burn, or severe frostbite. In some instances surgery

is performed to remove a limb that is diseased in some way.
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Rehabilitation Institute & Upper Extremity

Prosthetics

The Rehabilitation Institute of Indianapolis is a premier designer and fitter of uniquely tailored

prosthetic devices for upper extremity amputees.

Our professional prosthetic practitioners and assistants are highly knowledgeable and

experienced in evaluating a variety of upper limb amputations.

We apply the latest technology and techniques to help new prosthesis users make the most

successful transition possible with their new limb.

The upper extremity prostheses we offer address the following levels of amputation:

Shoulder Disarticulation

Above Elbow

Below Elbow

Wrist Disarticulation
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Choosing an Upper Limb Prosthesis

Finding the optimal upper extremity prosthesis is crucial to the ultimate success of each one of

our patients.

However, this process can be difficult and challenging without the services of the right

prosthetist.

As an experienced provider of a variety of prostheses developed specifically for upper limb

amputees, we are able to guide the user into making the best choice regarding the many

design options and operating systems available.

We educate the amputee on the various devices and components that will best suit his/her

goals for mobility and function.

Importance of Function, Comfort and Aesthetic

Appeal

Comfort, a high level of functionality and cosmetic appeal are important for most upper limb

prosthetic users. At the Rehabilitation Institute we are sensitive to these desires and apply

special emphasis on helping our patients meet these goals through a balanced approach

involving the design, fitting and training stages of the rehabilitation process.
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Upper Limb Amputation

When should therapy start for an upper limb amputee?

Physical and occupational therapy should be started soon after and if possible before upper

limb amputation. Goals of this therapy are several and include desensitization of the residual

limb, improved range of motion (ROM), strengthening, care of the residual limb, education,

introduction of a prosthesis and the appropriate ordering and use of adaptive equipment. Once

it is approved by the surgeons who performed the amputation, desensitization techniques such

as those described above should begin. With these techniques, it is important that excessive

scarring is prevented since this can produce pain and hinder normal prosthesis use. Preventing

contractures at the elbow and shoulder is important during the rehabilitation process.

Stretching of the elbow and shoulder flexors can prevent contractures from occurring. These

can be particularly problematic in individuals who have a burn. The physical and occupational

therapists can show appropriate exercises for this but also can show the amputee how to

integrate strengthening exercises into a rehabilitation program.

Many new upper limb amputees will have difficulty with bathing, feeding and toileting as well

as many other ADLs. An occupational therapist, in particular, becomes the vital member of the

rehabilitation team who helps the amputee integrate a prosthesis into the required activities

that face all of us on a daily basis. There are certain types of adaptive strategies and equipment


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that allows the unilateral or bilateral amputee to do these things to live independently. For

example, a unilateral amputee may be able to button with one hand. However a button hook is

a useful device that allows an amputee, albeit unilateral or bilateral, to button his shirt or pants

more easily. A universal cuff or leather gauntlet can be used over the residual limb so that the

amputee can perform various tasks without the use of a prosthesis. In the universal cuff or

gauntlet, various instruments such as a paint brush or writing utensil can be placed so that

activities can be accomplished more easily.

When can an upper limb amputee use a prosthesis and which one should he get?

There is no standard answer to this question and in fact some amputees may elect not to use a

prosthesis at all. Some amputees, particularly those who suffered an upper limb amputation at

a very young age or have congenital limb deficiencies, may be more accustomed at

accomplishing tasks without the use of a prosthesis. Even some adult bilateral upper limbamputees may accomplish many tasks such as putting on a shirt or bathing without a

prosthesis either. However, for most upper limb amputees who had recent surgery, use of an

initial prosthesis can begin as long as their overall health and the surgical wound are doing

well. For example, individuals who lost a limb from a burn may need a graft of extra skin to

cover the wound. These grafts can be very fragile so it may be several weeks before the

individual is approved by the surgeons who performed the graft to begin wearing an initial

prosthesis.

Although the prosthesis cannot replace all of the functions of the upper limb, there are many

options and features available for many upper limb amputees. For example, there are

prostheses that enable one to detect temperatures; other types of prostheses allow an

individual to hold equipment needed for manual labor. The amputee needs to be educated

about which prosthesis would be most ideal for his lifestyle and tasks he wants to accomplish.

The prosthetist or rehabilitation physician is probably the most capable person to answer many

of these questions and can assist the amputee in the decision process. An entire discussion of

this can be found through this website at the following link. For instance, the split hook is not

the most cosmetically pleasing but is probably one of the most commonly used and the most

functional terminal devices around. There are also terminal devices that allow one to operate

certain things such as a hammer, pliers or even tweezers. If cosmetic appearance is more

important to the amputee rather than function, then a cosmetic hand may be more appealing.

This may be more satisfactory to a high-level business person who has to interact with clients

all day. Here appearance may be more important than practicality and function.


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What are some of the common parts to an upper limb prosthesis?

The upper limb prosthesis has various components that assist the amputee in recreational

activities and activities of daily living. The various components that may be used depend

greatly on the level of the amputee as well as the persons age and comprehension. A basic

upper limb prosthesis is composed of a socket that fits onto the residual limb, a suspension

system that keeps the prosthesis on the limb, a prosthetic shoulder or elbow joint if necessary

depending on the level of the deficiency, as well as a terminal device or hand that manipulates

objects. If needed, the prosthetic shoulder, elbow and terminal device are operated with two

types of control systems. The body powered control system works through a cable that is

attached to a suspension system such as a shoulder harness. It is referred to as a body powered

prosthesis because movement of the prosthesis depends on certain arm and shoulder motions

that are used to manipulate the prosthetic limb. When the shoulder or shoulder blades are

moved a certain way, tension is placed on the cable causing a joint to move or terminal device

to open or close. The amputee can control which part of the prosthesis is being controlled by

locking various parts of the prosthesis manually. For example, in an above-elbow amputee, the

person may move the upper arm out to the side, causing the prosthetic elbow to bend. Then he

may have to push his arm into his body, which depresses a button, causing the elbow to lock in

this position. Then certain movements in the shoulder will operate the terminal device.

The other type of control system is the myoelectric system. This is a prosthesis that has sensorsinside the socket that detect muscle activity in the forearm created by the persons voluntary

movement. The sensors detect this electrical activity and amplify the signal, which in turn is

used to open or close the terminal device. Occasionally, outside electrical activity generates the

impulse, but this is less common.

The socket and suspension system used depends on the size and shape of the residual upper

limb. For example, a person who has a shoulder disarticulation may need a socket and

suspension system that is somewhat more elaborate, since there is not a residual limb to attach

a socket to. In contrast, a person with an amputation that involves the forearm will have a

normally functioning elbow and shoulder. Therefore, the socket can be fitted to accommodate

the forearm residual limb and the suspension system can wrap around the upper back and

shoulders.


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People with partial hand amputations may elect to use a prosthesis for cosmetic reasons but

may not need one for functional purposes. Amputations through the wrist or wrist

disarticulations may present a challenge. This type of residual limb can fit readily into a socket

but because of the length of the residual limb, the prosthesis may end up being longer than the

normal side and may not be cosmetically appealing. Fortunately, thinner wrist components can

be adjusted to simulate wrist motion and are not too long, thereby creating a symmetrical

length.

What are some unique problems that face upper limb amputees compared to

lower limb amputees?

Most causes of upper limb amputees in industrialized countries are due to traumatic episodes

as opposed to lower limb causes which are more likely due to diseases such as complicationsfrom diabetes, PVD and infections. Motor vehicle, motorcycle and heavy machinery accidents

are common reasons why people lose one or both upper limbs. Other traumatic causes can be

from explosions or chemical, thermal or electrical burns. Limb loss from animal attacks is

relatively uncommon. Certain diseases such as tumors, blood vessel disorders and infections

comprise the second most common reason why people experience an upper limb amputation.

Congenital upper limb deficiency is an absence of a limb that occurs prior to birth and is much

less common than the other causes listed; however, they are discussed under the pediatric

amputee section.

Since upper limb amputations are most often due to trauma, there is no time to prepare the

individual regarding the expectations of living with limb loss. In the majority of cases, an

individual may learn as he awakes from surgery that he has lost an upper limb, which can be

devastating and cause various emotional reactions from people. These people have to deal not

only with the physical pain of the injury and loss of limb but also with the uncertainty and

anxiety of the implications of losing an upper limb. Certain challenges such as dressing,

bathing, toileting, eating and other activities of daily living will be affected, particularly if the

individual has both upper limbs missing. Additionally, the loss of sensitive touch and fine

motor control that the hands and fingers offer will significantly alter the way an individual

lives. Things such as wearing a wedding ring, buttoning a shirt or cutting meat present new

challenges and implications. Also, cosmetically, upper limb amputees are usually more

noticeable then lower limb amputees who can hide their prosthesis with long pants or with a

dress and may walk normally with an adequate prosthesis and strength. In contrast, most


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people find it hard to disguise their upper limb amputation or prosthesis since most personal

interactions involve looking at someones face and upper torso. Many social interactions also

involve the shaking of hands or waving as a personal greeting, making the ability to hide the

disability more difficult.

Hand dominance can also be affected. Although many may feel that they have a dominant

lower limb, upper limb dominance is much more important for carrying out daily tasks like

writing and eating. Usually, if the dominant hand is amputated then the normal limb becomes

the new dominant limb performing fine-motor manipulation. The prosthetic limb often serves

to stabilize objects so that the normal limb can manipulate the object.

Although standard upper limb prosthesis and different adaptive devices may not be able to

replace all of the functions of a normal upper limb, many individuals who wear a prosthesis

find that when they practice diligently and have an appropriate prosthesis, they can accomplish

tasks of everyday living and are quite satisfied with performing vocational and recreational

activities.

What are the types of upper limb amputees and what advantages/challenges do

they present with regards to the prosthesis and function?

The upper limb amputee needs to understand that the length of the residual limb as well as the

presence or absence of shoulder, elbow or wrist joint can present certain advantages and

challenges not present with other types of amputations. The length of limb present beyond the

elbow or shoulder joint may significantly impact the type of prosthesis used. For example, a

very short forearm that is left after a below-elbow amputation can alter the type of socket and

suspension device used in the prosthesis. A longer residual limb is not necessarily

advantageous either. These types of amputations may make it difficult to incorporate a joint

such as an elbow into the prosthesis or may make it difficult to make the upper limbs of equal

lengths.

An individual with a wrist disarticulation is often left with a residual limb that has prominent

bony ends. These bony bulbous ends may not be ideal for fitting a prosthesis. Fitting sockets

with the appropriate suspension may become somewhat of a challenge. Often a functioning

terminal device or cosmetic hand can be fitted onto the end of the socket depending on the

wishes of the amputee. In contrast, partial hand or finger amputees may elect not to use a

prosthesis at all, being able to complete a wide array of tasks without any prosthesis. After


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discussion with the prosthetist, some may elect to just use a leather gauntlet or universal cuff to

which utensils or equipment can be attached to perform certain tasks.

People who have an amputation across the forearm (transradial or below-elbow amputee) have

the advantage of having a functional elbow and shoulder joint compared to other upper limbamputees. The presence of these joints enables the transradial amputee, with the appropriate

prosthesis and training, to become quite adept at most tasks. A wrist unit built into the

prosthesis enables him to reach most places on his own body and in his environment. There are

various socket options available for these amputees, which include a cup socket, supracondylar

socket or a silicone sleeve with a shuttle lock. Usually a self-suspending type of socket is used

with a myoelectric prosthesis and has electrodes built into it that sense muscle activity and

control the terminal device. This type of prosthesis or one with a supracondylar cuff and

voluntary closing hand may be more appropriate for a business person or administrativeassistant where appearance is important. Certainly manual laborers would probably not be able

to use this type of prosthesis because of the physical demands of their job. Instead they would

require a more secure suspension and socket system that could withstand a lot of weight as well

as a terminal device that could grip various large objects with great power.

An amputation through the elbow joint or elbow disarticulation is not an ideal type of

amputation for using a prosthesis because there is no room to use a prosthetic elbow joint. The

amputee has some options but often the prosthetic elbow joint will be built further down the

forearm or the joint can be formed outside of the prosthesis with hinge joints. Unfortunately,

these choices often make the person unhappy with the resultant cosmetic appearance or they

have difficulty fitting clothing over the prosthesis. However, some still choose this type of

amputation level particularly bilateral amputees or non-prosthetic users. Because this

amputation is through the end of a long bone at a joint, there is no chance of excessive bone

formation at the end of the limb, which can be a complication of an amputation that goes

directly through the long bone.

Above-elbow, also known as transhumeral, amputees face additional challenges that a below-elbow amputee does not have. First, these amputees need to learn how to use a prosthetic

elbow joint that is built into their prosthesis. With a body-powered above-elbow prosthesis, the

socket is suspended onto the residual limb with a shoulder harness, often shaped like a Figure

Eight, running from one shoulder and then under the armpit or axilla of the opposite shoulder.

A cable attaches to this suspension and then runs along the back part of the prosthesis and can


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move either the elbow joint or terminal device depending on motion of the shoulder. For

example, certain shoulder motions will pull on the cable and cause elbow flexion. The elbow

can then either be manually locked into this position with the normal hand or with the use of

an automatic lock that works by additional shoulder motion. An alternative to this is a manual

locking button that can be depressed by pushing the prosthesis into the body, thereby locking

the elbow joint. Once the elbow is locked, certain types of shoulder motion will then operate the

terminal device.

The type of terminal devices used for an above the elbow amputee are quite similar to those

used in a below-elbow amputee. However, the above-elbow amputee will need to be skilled

enough to switch between moving the elbow joint or terminal device. The elbow and terminal

device may be operated by the same or separate systems. A cosmetic passive prosthesis is

another option for the above-elbow amputee. This type of prosthesis is not very functional,requiring the person to manually move the elbow, wrist and hand into more realistic positions

with their normal limb.

An electronic prosthesis is also an option for an above-elbow amputee but, because of the

electronic componentry involved, it can be quite heavy. Myoelectric terminal devices are

usually controlled with sensors placed over the upper-arm muscles. The challenge with these

types of prostheses is they require greater care and maintenance.

Shoulder disarticulations usually require some type of rounded cover or cap over the shoulder

joint to restore the normal rounded appearance to the shoulder joint and allow clothing to fit

appropriately. To this a prosthesis can be fitted that has the same parts and body-powered

control as an above-elbow amputee. The only difference is that the suspension system may

need to be somewhat more secure secondary to the shape of the socket and weight of the

prosthesis. Often the functional capabilities of this type of prosthesis are limited. Usually an

individual with a shoulder disarticulation will use the prosthetic side more often to stabilize an

object so that the normal limb can manipulate the object.

A functional prosthesis is usually too heavy to be used by a forequarter amputee. Instead a

cosmetic cover or cap is placed over the upper torso, which like the shoulder disarticulation,

provides a nice rounded shoulder appearance so that clothes can be worn normally. To this, a

cosmetic endoskeletal upper limb prosthesis can then be attached. Typically the endoskeletal

prosthesis is composed of light foam and has a hand and elbow joint, which can be moved by

the individuals normal limb into the appropriate or necessary positions.


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How should my upper limb prosthesis be powered and what type of suspension

system should be used?

Upper limb body-powered prostheses are less apt to break down and may enable the amputee

to work faster than a myoelectric system would afford. In addition, body-powered systems

enable the amputee to get some sensory feedback since they are using the shoulders to open or

close the terminal device. In doing so, the amputee can sense how much tension needs to be

placed on the cable to operate the terminal device so as to perform the task. A myoelectric

prosthesis does not provide feedback on how much pressure is being applied and is also

heavier. But it allows the amputee to use muscles in the forearm or upper limb to control the

prosthesis rather than the shoulders, which may be advantageous.

Certainly the level of amputation can affect the type of suspension that can be used. Higher-level amputations such as those at the shoulder may make it more difficult to hold a prosthesis

onto the body. More straps and suspension may be needed compared to a forearm amputee

who is only missing the lower part of the arm. This individual may be able to get away with a

supracondylar cuff or silicone sleeve that wraps around the elbow and stays securely in place

without a shoulder suspension. One can realize the advantages and disadvantages of each of

these as well as the various options that exist to any upper limb amputee.

Documents

Upper Limb Amputees Guide