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.

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

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.

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

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 limb amputees 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.

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 sensors inside 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.

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 complications from 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

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

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 limb amputees. 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 administrative assistant 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 belowelbow 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

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.

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. Higherlevel 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.