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Section 2: Upper Limb
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5. Puhaindran ME, Steensma MR,
Athanasian EA: Partial hand preservation for large so tissue sarcomas of the hand. J Hand Surg Am
2010;35(2):291-295. Medline DOI
6. Rohde RS, Puhaindran ME, Morris
CD, et al: Complications of radiation therapy to the hand aer so
tissue sarcoma surgery. J Hand
Medline DOI
7. Puhaindran ME, Rothrock CP,
Athanasian EA: Surgical management for malignant tumors of the
thumb. Hand (N Y) 2011;6(4):373-377.
Medline DOI
8. Goldner RD, Howson MP, Nunley
JA, Fitch RD, Belding NR, Urbaniak
JR: One hundred eleven thumb amputations: Replantation vs revision.
Medline DOI
9. Buncke HJ, ed: Microsurgery: Trans-
Febiger, 1991.
10. Lundborg G, Brånemark PI, Rosén
B: Osseointegrated thumb prostheses: A concept for xation of digit
prosthetic devices. J Hand Surg Am
1996;21(2):216-221. Medline DOI
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
212
Chapter 16
Partial Hand Amputation: Prosthetic Management
Jack E. Uellendahl, CPO
Abstract
Partial hand amputation is reported to be the most common upper limb amputation level
in the United States. e hand has 29 joints, and approximately 25% of the motor cortex
controls the 34 muscles that move the hand. Because these joints allow the hand to assume
many postures and produce various grasping patterns, replacement with a prosthesis is
challenging. Sensory feedback provides information about objects being grasped; loss or
compromise of this feedback results in further disability. Trauma is the most common
cause of partial hand amputation and oen damages the remaining parts of the hand.
Limited joint range of motion, malalignment of the remaining ngers, hypersensitivity or
insensitivity, scarring, and a lack of strength in the remaining portions of the hand can
be complicating factors. Prosthetic options for managing partial hand amputations have
increased substantially in recent years.
Keywords: amputation; body-powered prosthesis; hand
amputation; partial finger; partial hand; powered fingers; upper
limb
Introduction
Partial hand amputation is the most
common upper limb amputation level
in the United States. In a review of hospital discharge records between 1988
and 1996, Dillingham et al1 found that
a mean of 18,496 individuals annually
were reported to undergo upper limb
amputations or have congenital limb
deficiencies; 92% of these were below
the wrist. Partial hand amputations have
many possible presentations based on
the large number of possible hand configurations that result from traumatic
injury (Figure 1).
The hand is a marvelous tool. It has
29 joints, and approximately 25% of the
motor cortex controls the 34 muscles of
the hand. These joints allow the hand
to assume many postures and produce
a variety of grasping patterns. Therefore,
prosthetic replacement is challenging.
Mr. Uellendahl or an immediate family member is an employee of Hanger Clinic and New Touch
Prosthetics.
Sensory feedback provides information
about objects being grasped; loss or
compromise of this feedback results in
further disability. Trauma is the most
common cause of partial hand amputation and often damages the parts of the
hand that remain. Limited joint range of
motion, malalignment of the remaining
fingers, hypersensitivity or insensitivity,
scarring, and a lack of strength in the
remaining portions of the hand may be
complicating factors.2 Prosthetic options
for managing partial hand amputations
have increased substantially in recent
years. This chapter reviews the current
prosthetic options and indications for
their use.
Clinical Considerations:
Prosthetic Options
Prosthetic options can be divided into
five categories: aesthetic, oppositional,
activity-specific, body-powered, and
externally powered. Not all options are
available for all levels of partial hand
absence. However, when evaluating a
partial hand amputation, all options relevant to the amputation level should be
reviewed. When deciding on the type
of prosthesis to be used, considerations
should include age, sex, occupation,
degree of physical activity, gadget tolerance, type of amputation, functional
goals, and unilateral versus bilateral
involvement.
Because the thumb is the most
important finger, representing 40% of
hand function, its presence and condition should be carefully evaluated.3 Op
timal management of the thumb should
account for sensibility, stability, opposition, and length.4 With partial thumb
amputation, it is sometimes advantageous to restore length with a customized silicone finger prosthesis. However,
this type of prosthesis will cover sen
sate skin and can impede function in
instances in which comorbid missing
fingers have been treated with prosthetic replacement, which also provides
no sensation (Figure 2). In this case, a
short, sensate thumb may be more functional than a normal-length prosthetic
thumb without normal sensation.
Additional options include surgical solutions. A partially amputated
thumb may be treated surgically with
lengthening, web space deepening, toe
transfer, pollicization, or osteointegra-
5,6
tion
the importance of early interaction
among the patient, prosthetist, surgeon,
and therapist in developing a treatment
plan that optimizes a patient’s outcome.
2
-
-
(Figure 3). Such cases highlight
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
213
Section 2: Upper Limb
Figure 1
Figure 3
underwent bone lengthening and web space deepening to provide sucient length for functional
grasp.
Component Considerations
Aesthetic Restoration
High-definition custom silicone prostheses are the best option to reproduce
the natural appearance of the hand.7
These prostheses are appropriate for all
levels of partial hand amputation from
fingertip to complete hand prostheses.
The prosthesis is carefully matched in
size, shape, surface detail, and color to
the sound hand, which allows differences between the normal and prosthetic hand to go unnoticed by the casual
Photographs showing a variety of partial hand amputations.
Preoperative (A) and postoperative (B) photographs of a thumb amputation that
observer (Figure 4). Silicone prostheses
provide an extremely important psychologic benefit in restoring body image.7
The prostheses have a long history of
use and are generally well accepted by
patients.
7,8
They do not provide finger
movement and are often referred to as
passive prostheses. However, a study by
Fraser9 showed that, despite the lack of
movement, these prostheses are used
functionally when performing daily
tasks. Passive silicone prostheses can
provide opposition when some fingers
Figure 2
left uncovered to preserve sensation while opposing three powered ngers. The little nger
was also partially amputated and left uncovered.
Photograph of a thumb that was
remain and broaden the surface available for gripping stability. In addition,
silicone prostheses protect sensitive or
painful areas of the hand, with attendant improvements to manual function.
Although silicone has good stain resistance, the material can be damaged if
used for manual labor. Many individuals
with partial hand amputations benefit
from the use of an aesthetic prosthesis
in addition to another type of prosthesis.
Opposition Prostheses
The primary goal of an opposition prosthesis is to provide opposition for intact
fingers or the palm of the hand. These
prostheses can be made of many materials but are usually strong, robust, and
well suited for manual tasks (Figures 4,
5, and 6). Most opposition prostheses
are static, but some have joints that can
be prepositioned on a task-specific basis,
such as the CAPP Multi-Position Post
(Hosmer), APRL thumb (Hosmer), and
Vincent Finger Joint (Vincent Systems
GmhH).
Activity-Specific Prostheses
In some cases, a prosthesis is needed to accomplish a specific function.
The prosthesis may be constructed to
hold and support a specific tool, with
or without the contribution of any remaining digits (Figure 7). Alternatively,
a quick-disconnect mechanism can be
fixed onto the palm of the remnant hand
that allows attachment to a variety of
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
214
Chapter 16: Partial Hand Amputation: Prosthetic Management
Figure 4
and composite thumb prosthesis that provides
good appearance and stability for functional
opposition to the remaining ngers.
Figure 6
tion prosthesis during test tting with the st atic
ngers positioned for optimal function.
Photograph of a hybrid silicone
Photograph shows an opposi-
commercially available tools and implements. At the partial finger amputation
level, simple fingertip caps can extend
the functional length of the residual finger to enable enhanced function (Fig-
ure 8). Collectively, these prostheses
may allow participation in hobbies and
sports and can be critical to performing
job duties.
Body-Powered Prostheses
Body power refers to the use of force
and excursion produced by more proximal joints to control a prosthesis. Because of the link between the controlled
component and the proximal physiologic joints, body-powered control has
the inherent advantage of providing
proprioceptive feedback to the user
regarding force, position, and speed of
movement.10 However, a possible disadvantage is that the required movements of the proximal joint segments
may appear unnatural.2 Body-powered
prosthetic options are now available for
Figure 5
tted with a rigid thumb opposition post (B).
Figure 7
mer for a farrier. B, Photograph of the completed hybrid prosthesis composed of silicone and prepreg carbon ber, with a zipper for easy donning and dong.
Figure 8
Photographs of a thumb amputated at the metacarpophalangeal joint (A) that was
A, Photograph of an ac tivity-specic s tatic prosthesis during test tting with a ham -
Photographs of an index nger pros thesis used for guitar playing (A) and typing (B).
nearly all levels of partial hand absences.
Control is accomplished either through
rigid linkages or cables connecting the
prosthetic joint(s) to a proximal intact
joint. Examples of linkage-driven fingers
are the Naked Prosthetic Finger (Naked
Prosthetics; Figure 9) and the X-Finger
(Didrick Medical; Fig u re 10).
Alternatively, the M-Fingers and Partial M-Fingers (Partial Hand Solutions)
are cable driven. Partial M-Fingers use
metacarpophalangeal (MCP) joint flexion to drive proximal interphalangeal
(IP) joint flexion, whereas the distal IP
Figure 9
ger with distal interphalangeal (IP) joint exion
of the prosthesis driven by intact proximal IP
exion. (Courtesy of RCM Enterprises, Naked
Prosthetics, Tumwater, WA.)
Photograph of a mechanical n-
joint is fixed (Fig ures 11, 12, and 13).
M-Fingers are designed for complete finger absence at or proximal to the MCP
joints. Flexion at the MCP and proximal
IP joints is actuated by wrist flexion;
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
215
Section 2: Upper Limb
Figure 10
nger with distal interphalangeal (IP) joint and
proximal IP joint exion of the prosthes is, which
are driven by intact metacarpophalangeal joint
exion. (Courtesy of Didrick Medical, Naples,
FL.)
Figure 13
Partial M-Finger prosthesis (Partial Hand Solutions) that provide dynamic grasp for the index
and middle ngers against the intact thumb,
with the ring and little ngers replaced with
static silicone ngers to provide a broader,
more stable platform for grasp.
Photograph of a mechanical
Photograph of a combination
internal spring mechanisms return the
joints to their extended positions with
wrist extension
11
(Figure 14). Another
body-powered option is a handihook–
type device (Figure 15) in which a conventional hook terminal device, either
voluntary opening or voluntary closing,
is attached to a prosthetic socket in the
palm of the partial hand prosthesis. The
handihook is generally activated using a
cable attached to a shoulder harness.
2,12
Externally Powered Prostheses
Fitting externally powered devices to
individuals with partial hand amputations is challenging. Because a portion of
the physiologic hand remains, the space
for any prosthetic mechanism is limited.
Figure 11
prosthesis with a silicone suction socket and
prepreg carbon ber, providing rigid stabilization and connection to a Partial M-Finger
prosthesis (Partial Hand Solutions). (Courtesy
of New Touch Prosthetics, Cave Creek, AZ.)
Figure 14
M-Finger prosthesis (Partial Hand Solutions).
Wrist exion drives all four ngers with a cable
system in opposition to a passively positioned
frictio n thumb. The cable tension can b e adjusted using a quick-adjust knob (arrow).
Photograph of a partial nger
Photograph of a wrist-driven
Early efforts to develop externally powered options for partial hands were not
made commercially available.
4,13 -16
To fit
the widest variety of partial hand configurations with externally powered
options, the drive mechanism is best
contained within the prosthetic finger
itself. This allows for the successful fitting of amputations at or more proximal
to the MCP level. The first powered fingers became commercially available in
2007 with the introduction of the i-limb
hand (TouchBionics). The fingers from
the i-limb hand that were removed from
the full hand and separately configured
were referred to as ProDigits. The fingers
were later redesigned for specific application to partial hand prostheses and
renamed i-limb digits (TouchBionics)17
(Figure 16). Another system, the Powered Finger (Vincent Systems), became
available in 201018 (Fi g ure 17). Powered
finger prostheses have demonstrated
Figure 12
Partial M-Finger prosthesis (Partial Hand Solutions) showing the cab les anchored to a silicone
mounting system. Metacarpophalangeal joint
exion drives interphalangeal joint exion, and
internal springs return the ngers to extension.
(Courtesy of the Hanger Clinic, Austin, TX.)
Figure 15
an individual with carpometacarpal disarticulation who uses a body-powered handihook.
The hook opening is actuated using a conventional should er harness. The hook is at tached to
a quick-disconnect adapter, allowing exchange
of various tools in place of the cable-actuated
hook. The prosthesis has a silicone socket with
a zipper in a composite frame.
Figure 16
(TouchBionics) with a motor in the proximal
nger segment that drives the metacarpophalangeal (MCP) joint. MCP j oint exion is linked to
proximal interphalangeal (IP) joint exion with
a string, and a spring provides extension at the
proximal IP joint. The distal IP joint is xed. Various ngertip lengths are available for nger
sizing.
Photograph of a three-nger
Photograph of the lower arm
Photograph of an i-limb digit
clinical efficacy for a wide variety of
partial hand amputations and have
become a mainstay in the prosthetic
armamentarium.
2,19,20
Powered finger prostheses are advan-
tageous compared with body-powered
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
216
Chapter 16: Partial Hand Amputation: Prosthetic Management
Figure 17
Finger (Vincent Systems), which has a motor
in the proximal nger segment that drives the
metacarpophalangeal (MCP) joint. MCP exion
is linked to proximal interphalangeal (IP) joint
exion wit h a exible metal strut t hat drives the
proximal IP joint in exion and extension. The
distal IP joint is xed. Various ngertip lengths
are available for nger sizing.
Photograph of the Powered
devices because they require no force or
excursion from the user; these devices
are usually controlled using myoelectric
signals or force-sensitive resistors. This
can be an especially important consideration when the residual hand is sensitive
to pressure. Prehension is maintained
without continuous input control because the drive mechanism is not back
drivable. Grip force is also generally
greater with powered fingers than with
the currently available wrist-driven
options.
Although externally powered fingers do not provide feedback through
the control system regarding finger
force, position, and velocity, the Vincent Powered Finger system offers feedback regarding finger force by means
of vibration. The complete powered
finger system includes the fingers, finger-mounting hardware, a microprocessor control unit, power supply, and
control input(s). Because of the inherent
space limitations at distal amputation
levels, some of these components are
housed on the forearm within a forearm
cuff or a custom silicone socket (Figures
18 and 19). The motor for these powered
fingers is housed in the proximal segment of the finger and drives the MCP
joint, which is then used to drive a single
IP joint via mechanical linkage.
Externally powered thumbs are manufactured by TouchBionics and Vincent
Systems. These thumbs do not articulate
Figure 18
i-limb digits prosthesis (TouchBionics), which
uses a forearm cu to house the battery cells,
controller, and power switch.
Figure 20
to the unopposed position helps assume a at hand to provide a stable, broad surface for holding
plates, trays, or similar objects. B, Lateral preh ension is achieved with the thumb in the unopposed
position.
at the IP joint but are powered in flexion and extension at the MCP joint and
can be passively rotated from a position
opposed to the fingers or unopposed for
lateral prehension (Figure 20). The control systems are adjusted via wireless
connections to a computer or a handheld device, where system parameters
can easily be adjusted and real-time
monitoring of patient control inputs
can be viewed.
Photograph of a complete
Figure 19
Powered Finger prosthesis (Vincent Systems)
shows the bat teries, controller, and charge por t
module housed in a custom silicone forearm
cu. These components are accessed through
a zipper closure.
Photographs of an externally powered thumb prosthesis. A, Rotating the thumb
Photograph of a complete
primary gripping pattern, all fingers
are driven until motion is stopped either by contact with an object or when
the mechanical stop is encountered.
This provides a conformable grip (Fig-
ure 21). Because each finger is driven independently, it is possible to fix
the position of some fingers and drive
others. Selecting a grip mode in which
the fingers are flexed and the thumb
is active in the unopposed position is
useful for lateral prehension. A wide
Control
Myoelectrodes and force-sensitive resistors are the most common types of
control input used for powered fingers.
Other types of control input devices
include transducers and switches.
Most users prefer dual-site proportional control, but single-site methods
have been used successfully when only
one control input is available. In the
variety of additional grip patterns are
possible, including a pointed index
finger, which is valuable for keyboard
use, and a “trigger finger” for the operation of spray bottles. Other grip
patterns can be selected, generally by
using a special control command such
as co-contraction, a hold-open signal,
or a rapid impulse signal from one of
the available input sources.
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
217
Section 2: Upper Limb
Figure 21
dividually powered ngers conformed around
an irregularly shaped object, providin g a secure
grasp.
Photograph demonstrates in-
Myoelectric control sites can be located either in the hand or the forearm.
Using the intrinsic muscles of the hand
is often preferable because it allows finger control to be independent of wrist
motion. Intrinsic muscles that have
been used successfully include the thenar, hypothenar, and dorsal interossei
muscles. When intrinsic hand muscles
are not feasible as control sites, forearm
muscles have been used with good results. With practice, most users achieve
sufficient control of the fingers and wrist
independently.
If a mobile feature of the remaining
hand can be moved independently, control by force-sensitive resistors should
be considered. If all fingers are missing
and the thumb is amputated at the MCP
joint, the mobile thumb metacarpal can
be used to flex and extend the fingers
by using the metacarpal to press against
one force-sensitive resistor in the flexion
direction and another force-sensitive resistor in the extension direction. In some
instances, control has been achieved by
mixing control inputs using one electrode and one force-sensitive resistor.
Using a separate control command
to select each specific grip pattern is not
ideal. Developing control strategies such
as pattern recognition and implantable
myoelectric sensors may eventually provide more intuitive control.
21-25
Prosthesis Design
The prosthetic socket provides a stable
connection to the residual limb, securely
Figure 22
with careful attention paid to nger alignment.
Mounting frames are available that either
group the ngers in a prearranged alignment
to each other or allow the ngers to be individually positioned.
Photograph of a test tting,
suspends the prosthesis, protects sensitive areas of the residual limb, and
serves as a mount for the prosthetic
components2 (Figure 22). Materials
used include rigid, laminated material;
semirigid plastic; flexible thermoplastic; silicone, urethane, and expanded
foam padding. For many partial hand
prostheses, it is important to provide
a soft flexible elastic interface so that
bony prominences are protected, motion is not impeded by rigid edges, and
the material can stretch to allow easy
donning and doffing when bulbous
limbs are involved. For these reasons,
the preferred interface material of
this chapter’s author is silicone that is
structurally supported with composite
plastic. With high-consistency silicone
rubber, it is possible to design and fabricate silicone interfaces in which the
material thickness, stiffness, and elasticity can be selectively controlled.
26,27
It
also is possible to incorporate electrode
mounts, screw attachments, zippers,
and other hardware into the silicone
interface. Custom silicone sockets have
been reported to provide better comfort
as well as the ability to protect fragile
Figure 23
designed to allow full motion of the intact
thumb, ring, and li ttle ngers as well as full w rist
motion.
Photograph of a prosthesis
skin from breakdown compared with
other materials.28 The socket should not
restrict limb motion at the wrist, thumb,
or other remaining joints (Figure 23).
One of the most important features
of the hand is sensation. The maximum
amount of sensate skin should be exposed whenever possible.
5,16
In contrast,
when the limb is hypersensitive, covering the skin can provide protection.
These issues must be carefully evaluated
and managed when planning the design
of the prosthesis.
Summary
Currently, more prosthetic options exist
for individuals with partial hand amputation than ever before; however, fitting
the prosthesis is still challenging. The
amputation is best managed by a team
of knowledgeable professionals who can
provide surgical, prosthetic, training,
and counseling support. Appearance,
function, and comfort should be carefully considered by both the patient and
the team to determine the most appropriate prosthesis. Often, not all goals can
be achieved with one prosthesis, and
multiple devices are required. Surgical
options may eliminate the need for a
prosthesis in some patients; however,
when a prosthesis is indicated, surgery
should complement and optimize the
successful use of the prosthesis. In all
cases, a qualified therapist should educate the user regarding optimal function
with and without a prosthesis to prevent
potential overuse of the sound limb.
29
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
218
Chapter 16: Partial Hand Amputation: Prosthetic Management
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27. Uellendahl J, Mandacina S, Ramdial
S: Custom silicone sockets for myoelectric prostheses. J Prosthet Orthot
2006;18(2):35-40. DOI
28. Dodson RJ, Jowid B: e clinical
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Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
220
Chapter 17
Wrist Disarticulation and Transradial
Amputation: Surgical Management
George Peter Nanos III, MD
Abstract
Amputation of an upper limb is a catastrophic event that frequently results from high-energy
trauma in an otherwise young and healthy patient population. Transradial amputation and
wrist disarticulation are the most frequently performed amputations in the upper limbs,
report the highest prosthetic acceptance rates, and represent the amputation levels with the
greatest functional potential. Preserved shoulder and elbow joints, a long lever arm, and
forearm rotation allow the individual with an amputation below the level of the elbow to
easily position the terminal prosthesis in space. ere are special considerations unique
to amputations at these amputation levels. It is helpful to be aware of surgical techniques
to optimize residual limb length, prevent complications, and maximize the potential for
future prosthetic use to achieve the best functional results for patients.
Keywords: amputation; transradial amputation; wrist disarticulation
Introduction
Amputation of an upper limb is a catastrophic event that frequently results
from high-energy trauma in a young,
otherwise healthy patient population.
Of the 1.6 million individuals in the
US living with limb loss in 2005, 34%
(541,000) had upper limb loss; 92% of
hospital discharges attributable to upper limb loss resulted from traumatic
mechanisms of injury, 41,000 of which
were proximal to the finger.
2,200 major limb amputations have
been performed as a result of injuries
that occurred in US military conflicts
over the past decade, including Operation Iraqi Freedom and Operation Enduring Freedom, and 18% were upper
limb amputations. Of the major upper
limb amputations performed in military personnel to date for these conflicts,
50% were transradial and 10% were
wrist disarticulations (John C. Shero,
Dr. Nanos or an immediate family member serves as a board member, owner, ocer, or committee
member of the American Society for Surgery of the Hand.
4,5
More than
MHA, FACHE, Director, Extremity
Trauma and Amputation Center of Excellence, unpublished data, 2015.) Amputations below the level of the elbow
1-3
are the most frequently performed amputations in the upper limb; the transradial amputation is the most common
level in both civilian and war-related
traumatic injuries.
6
The surgical principles of upper and
lower limb amputations are quite similar, but key differences in morphology
and function require special attention
when considering upper limb amputation. The primary goals in lower limb
amputation are to provide a well-padded, durable residual limb that facilitates weight bearing, maximizes
ambulatory function, and minimizes
energy consumption required for ambulation; the goals in upper limb amputation are to maximize precise function
and provide a good cosmetic result. To
ensure appropriate preoperative planning and optimal patient outcomes, the
surgeon should be aware of prosthetic
capabilities, prosthesis acceptance rates,
and the functional outcomes associated
with transradial amputations and wrist
disarticulations.
7
General Treatment
Principles
An integrated team approach is vital
to maximize amputee care. In addition
to orthopaedic surgeons, specialists
in trauma surgery, physical medicine,
anesthesiology, pain management, rehabilitation, occupational therapy, physical therapy, mental health care, social
work, nursing, and prosthetics should
be involved in the care of an upper limb
amputee. Patient- and family-centered
participation in the decision-making
process enhances a patient’s acceptance
of the amputation and satisfaction with
its outcome.
approach is especially essential for patients with multiple limb amputations,
which frequently occur after high-energy combat injuries. The patient often
has numerous comorbid conditions and
requires complex and comprehensive
treatment.10 Good functional outcomes
and prosthetic acceptance rates can be
expected with a well-coordinated rehabilitation protocol and timely prosthetic
fitting.
A good understanding of anatomy,
adherence to sound orthopaedic surgical principles, and a systematic approach to the evaluation and treatment
of the amputee are essential to achieve
the best results.12 In general, guillotine
8,9
A multidisciplinary care
11
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
221
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