Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_921_Библиотеки_им_академика_М_И_Перельмана
.pdf
Chapter 18
Wrist Disarticulation and Transradial
Amputation: Prosthetic Management
Joseph Karl Brenner, BSc, Biology, CP, FAAOP
Abstract
e prosthetic management of individuals with transradial amputations and wrist dis-
articulations requires special considerations. e patient’s successful use of a prosthesis
will be aected by tting timetables, component selection, and the patient’s motivation
to return to a bimanual lifestyle. To determine the most appropriate prosthetic design
for a patient, a thorough evaluation should be performed at each step of the prosthesis
tting process.
Keywords: below-elbow amputation; preparatory/training
prosthesis; prosthetic management; transradial amputation; wrist
amputation; wrist disarticulation
Introduction
The treatment of patients with upper
limb disarticulations or amputations
has become an increasingly specialized
niche in the field of prosthetics. Near
the middle of the first decade of this
century, the ratio of individuals with
an upper limb amputation to those
with a lower limb amputation was approximately 1:32, and this relationship
was increasing in importance as the
baby boomer generation entered their
sixth decade.
estimated that the ratio of upper to
lower limb amputations may eventually decrease to approximately 1:50 by
the year 2050. In addition to the decreasing ratios of upper limb to lower
limb amputations in the field of prosthetics, the increasing sophistication
of upper limb components and control strategies will require the need for
Neither Mr. Brenner nor any immediate family member has received anything of value from or ha s
stock or stock options held in a commercial company or institution related directly or indirectly to
the subject of this chapter.
1-3
Ziegler-Graham et al4
prosthetic clinicians with experience
beyond the fundamentals of general
prosthetic practice to effectively treat
people with upper limb loss.
Preoperative Prosthetic
Considerations
Most major upper limb reduction surgeries involve either wrist disarticulation
or transradial amputation.2 Although
maintaining maximal anatomic length
has long been considered advantageous
for the patient, this concept does not
apply in all situations.5 For example, in
a patient with a degloving injury and a
heavily scarred residual limb, preserving the badly injured portion of the limb
may make it more difficult for the patient to wear a prosthesis. Similarly, scar
tissue, prominent styloid bony processes, and sensitive surrounding tissue may
undermine the abilities of a prosthetist
to successfully fit a prosthesis. Although
longer limb length may optimize pronation and supination, which are important in maintaining function, these
benefits will be compromised if a patient
cannot comfortably wear a prosthesis
without complications. Therefore, it is
sometimes appropriate to remove more
of the damaged limb if this surgical approach will allow a more resilient and
pain-free residual limb.
a transradial amputation may offer more
prosthetic component fitting options
than a wrist disarticulation because
of the greater amount of space for the
prosthesis.
2,3,5
In addition,
Importance of Early Fitting
The ultimate goal of a prosthetist is to
provide a device that will not only be
functional by clinical standards but will
also provide good function for the patient. Proper suspension, a comfortable
fit, a functional design, and a good cosmetic appearance all are central prosthetic elements that can affect patient
5,6
wear.
The early introduction and use
of the prosthesis is also important. Research suggests that there is a “golden
period” for fitting upper limb prostheses.
The earlier the prosthesis can be provided to a patient to use in training and
therapy, the higher will be the rate of
acceptance of the device and likelihood
that the patient will become adept at using it as a helpful tool.
thesis has been integrated into a patient’s
daily routine, he or she is more likely
to continue to use the device and gain
improved functionality. The associated
5,7
After the pros-
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
233
Section 2: Upper Limb
Tab le 1
The Ideal Timetable for Fitting a Prosthesis After
Wrist Disarticulation or Transradial Amputation
Type of Prosthesis Postoperative Application
Immediate or early postoperative
prosthesis
Preparatory/training body-powered prosthesis 2 to 4 weeks
Denitive body-powered prosthesis 6 to 12 weeks
Preparatory/training electronic prosthesis 6 to 12 weeks
Denitive electronic prosthesis 4 to 6 months
Figure 1
rst layer of a stockinette is pulled over the protective sock covering the residual limb. B, A thick
distal pad is added to the end of the stockinette-covered residual limb and wrapped in place with
berglass casting tape that terminates below the condyles to optimize elbow exion. C, A lightweight terminal device, such as a 5XA hook (shown here), and aluminum fric tion wrist are attached
to a thermoplastic tting frame. The device is then properly aligned and temporarily wrapped in
place. D, A voluntary, full opening and closing terminal device is shown.
Photographs show t he application of an imm ediate postoperati ve prosthesis. A, The
benefits extend beyond physical ability and independence; they also affect
psychosocial areas of rehabilitation and
24 hours to 14 days
prosthesis, early intervention is an inherently important consideration in the
prosthetic fitting timeframe (Table 1).
personal acceptance of the individual’s
new reality as an amputee. Although a
comfortable fit and appropriate design
may be primary factors in the individual’s decision to accept or abandon a
Immediate and Early
Postoperative Prostheses
Immediate or early postoperative pros-
theses are essentially the same types
of devices; the difference in these two
modes of fitting is a product of the fitting
timeframe. The immediate postoperative
prosthesis is ideally applied in the operating room while the patient is under
anesthesia from the amputation surgery.
The immediate fitting of a prosthesis after an amputation reduces postoperative
pain, provides rapid implementation of
the device, and improves the psychological adjustment of the patient to his or
her new reality.
6
After the surgery is completed, the
patient’s arm is covered with a soft
stocking that will protect the suture
line, the bandages, and the surrounding
tissue. This stocking acts as an immediate barrier to the outside environment
but can be removed when soiled and
replaced with a clean stocking. A layer
of stockinette is pulled over the limb
(Figure 1, A), followed by the addition
of a soft foam pad at the distal end to act
as a cushion during use of the prosthesis
and activation of the terminal device.
Fiberglass casting tape or a plaster bandage is then wrapped over the second
layer of stockinette and the distal pad,
combining them into one rigid protective unit (Figure 1, B). A thermoplastic
frame is subsequently fashioned and attached over the rigid shell (Figure 1, C)
to serve as the attachment point for the
prosthetic wrist unit, the distal aspects
of the flexible elbow hinges, and the
anchors for the Bowden Cable system
that will be used to activate the terminal device. Cabling and the remaining
harness components are then added
(Figure 1, D) so that the patient can
immediately begin using the prosthesis
while recovering.
2,3, 5,7
Importantly, the
frame must remain removable from the
rigid shell so that adjustments can be
made if necessary.
Similar in fabrication to the immediate postoperative prosthesis, an early
postoperative prosthesis is fit after a
patient leaves the operating room but
before suture removal. This type of prosthesis aids in controlling edema, helps in
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
234
Chapter 18: Wrist Disarticulation and Transradial Amputation: Prosthetic Management
Figure 2
wearing a body-powered preparatory/training
prosthesis with a No. 7 hook (Hosmer).
Clinical photograph of a patient
dealing with the psychological aspects
of limb loss, and offers a functional replacement to prevent further trauma
during healing.
Although myoelectric versions of
these designs are not explicitly contraindicated, complications from swelling,
edema, tenderness, and wound drainage
can potentially compromise the fit and
control of a myoelectric prosthesis. This
lack of consistent electromyographic
control may frustrate the patient and
lead to potential rejection of the device.
Body-Powered Preparatory/
Training Prostheses
After the sutures have been removed
and the wound is healed, patients may
be fitted with a body-powered preparatory/training prosthesis. In the fitting
process, a see-through thermoplastic
diagnostic socket is fabricated over a
positive model of the limb (Figure 2).
The positive model is designed to fit over
the patient’s residual limb with the added volume of a fitting sock. This serves
as a cushion when activating the prosthesis and accommodates any changes
in limb volume. The transparency of the
socket allows the prosthetist to identify
any areas of focused pressure and adjust
them as necessary.8 As with the immediate postoperative prosthesis, the inside
distal aspect of the socket will often
have a soft pad that the user will push
against when activating the prosthesis.
This pad serves as the main mode of
protection from the high forces generated at the distal end of the limb and
Figure 3
thesis with a linear actuator that provides proportional control to an electric hand.
along the suture line. A humeral cuff,
typically fashioned from leather or plastic, attaches to the proximal elements of
the flexible elbow joints to maintain the
position of the anatomic elbow axis. The
harness and cabling system are attached
in the standard way and serve as an anchor point for both suspension and cable
actuation.9 This more robust design allows the user to begin more regimented
occupational therapy training in the use
of the prosthesis for activities of daily
living. The patient wears this training
Clinical photograph of a patient wearing an electronic preparatory/training pros-
the normal wear and tear of daily use
from an active user without concern for
accidental breakage. For patients who
have been managed with preparatory
prosthetic devices, insights made during
this phase can guide socket fit and componentry selection for the definitive
prosthesis. The patient will continue to
wear the definitive prosthesis until it
is either outgrown or enough volume
is lost that socket fit and function are
compromised beyond the accommoda-
tive capacity of fitting socks.
design for several weeks or even months
while the limb volume is reduced and
skill is gained in using the prosthesis.
Externally Powered
Prostheses
There are several limitations that may
Definitive BodyPowered Prostheses
After the limb volume has stabilized,
construction of a definitive prosthesis
can begin. The fabrication is similar to
that of the preparatory prosthesis except
that the socket is made of much more
resilient materials. As with the preparatory device, the socket is designed over
a positive model. Various fabrics serve
as the socket matrix or lamination layup
and are infused with a liquid laminating
resin that is cured with a chemical catalyst. This laminated design can tolerate
be encountered with the use of body-
powered transradial prostheses, includ-
ing a lack of full voluntary opening or
voluntary closing of the terminal devices
because of limited range of motion or
a lack of strength, problems with har-
nessing and control, insufficient grip
strength, or complications with suspen-
sion. When these limitations cannot be
adequately addressed with a body-pow-
ered system, an externally powered
prosthesis should be considered (Fig-
ure 3). Externally powered designs
typically offer greater grip strength;
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
235
Section 2: Upper Limb
Figure 4
wearing a denitive externally powered prosthesis with inverted locking joints and an electronic greifer.
Clinical photograph of a patient
anatomic suspension of the prosthesis; a more streamlined design, which
is often unencumbered from harnesses
and cables; an electronic control strategy
and power source; and actively powered
wrist rotation, if required (Figure 4).
Conversely, externally powered prostheses are more expensive to obtain and
maintain, more susceptible to environmental damage, and are often heavier
than their body-powered counterparts.
Control options for the externally
powered prostheses have their pros and
cons. Although myoelectric control often offers an anatomically intuitive approach, it generally requires both an
intimate skin fit and functional muscle sites and may not be appropriate in
patients with scar tissue or neurologic
problems. In some instances, a roll-on
liner with integrated electrode contacts
may mitigate some tissue problems,
10,11
and occupational therapy can often improve weak muscles. Alternatively, if a
patient lacks the necessary muscle sites
to control a myoelectric arm, he or she
may be fitted with an externally powered prosthesis that uses other control
options, such as switches, force-sensing receptors, linear actuators, and
servomechanisms.
Figure 5
voluntar y-closing terminal dev ice (right) and a composite vo luntary-opening terminal device (l eft)
are shown. A specialized adapter has been attached to both of these body-powered devices to
facilitate their use on a socket designed for the use of externally powered devices.
Component Considerations
There are many component options to
consider when evaluating, designing,
and/or fabricating upper limb prostheses. Whether the focus is on finding the
most appropriate terminal device or
wrist unit, deciding on a control strategy, or choosing the style of battery to
use for an externally powered design,
careful and comprehensive consideration is necessary because those decisions will ultimately affect a patient’s
success in using his or her prosthesis.
When possible and appropriate, fitting a preparatory training prosthesis
can give the practitioner a good idea
of the limitations and advantages of a
conceptualized design of the individual
components (Figure 5). When the preparatory device is designed in a more
dynamic fashion to allow a patient to
evaluate the prosthesis in his or her own
home and work environments, direct
feedback can be provided based on the
patient’s personal experience with the
technology.
Photographs of quick-disconnect wrist units used in patient evaluation. A metal
This initial decision will affect socket
design, suspension options, and the
choice of the remaining prosthetic components. Control options can be broadly
categorized as either body powered or
externally powered. Body-powered devices are generally controlled with cable
and harness arrays, including variations
of figure-of-8, figure-of-9, and chest
strap configurations, and they require
some degree of gross body motion.
These devices provide some level of proprioceptive input to the user regarding
the position and force experienced at
the terminal device; however, frequently
associated drawbacks include reduced
gripping force and localized pressure
caused by the harness system. Simple
modifications to the harness, such as
using a double ring approach or adding a
crossed back strap, can improve comfort
by eliminating areas of high pressure
(Figure 6).
Externally powered options include a variety of myoelectric switches, sensors, and linear actuators that
electroni cally control prehension of
Control Strategy Options
The means of controlling a prosthetic
arm is an important early consideration.
the terminal device. Although these
devices provide greater gripping force,
they are usually considerably heavier
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
236
Chapter 18: Wrist Disarticulation and Transradial Amputation: Prosthetic Management
Figure 6
harness. This type of harness can enhance comfort.
Clinical photo graph of a patient wearing a pros thesis with a Northwester n dual-ring
than body-powered options and provide no proprioceptive feedback to the
user.
Body-Powered Components
Wrist units for upper limb prostheses
vary in size, material, and function. A
main concern is choosing the appropriate wrist design for the individual
being fitted. Wrist units can be made
of plastic, metal, or a combination of
these materials. Options include the
simple friction wrist, quick-disconnect
designs, various flexion and rotational
features, or a ball-and-socket wrist that
offers infinite positioning and locking
2,12
ability.
When choosing a wrist unit,
functionality should be a primary concern. For example, if the patient will be
changing terminal devices frequently,
a quick-disconnect unit is indicated to
make exchanges easier. Flexion wrists
may be most appropriate for a bilateral
amputee who requires greater range of
motion from the prostheses, whereas an
individual with unilateral limb loss may
find the added weight of such a design
to be fatiguing.
Body-powered hooks are available
in several orientations and materials.
Stainless steel and titanium hooks are
strong, whereas aluminum hooks offer
reduced weight but are not as robust.
Variations in shape, covering, and orientation of the gripping surfaces are intended to accommodate a range of tasks
and working environments.
In contrast to hooks, mechanical
hands offer a more pleasing appearance; however, inherent limitations in
grip force and width may limit the range
of items that can be picked up and securely held.
Prosthetic elbow joints are often integral to the suspension of the prosthesis, offer added stability, can be made
of flexible or more rigid materials, and
are available in single-axis or polycentric designs. Other types of prosthetic
joints (known as step-up joints) can
be used when elbow flexion is limited
and assistance is required for full flexion of the elbow joint. These joints can
provide enhanced range of motion for
some individuals with short transradial
amputations.
Figure 7
ing an electronic preparatory prosthesis with
a Greifer terminal device (Ottobock). This type
of prosthesis allows wrist exibility in radial deviation.
Photograph of a patient wear-
Externally Powered and
Analogous Componentry
Externally powered componentry offers
many options to a patient; however, the
costs of obtaining and maintaining this
technology may be prohibitive. Terminal
device options include hands made in a
range of sizes and electronic hook-style
prehensile devices that offer a variety of
gripping surfaces and orientations in angular prehension. Features such as water
resistance and built-in wrist flexion are
available, making some designs better
suited to certain activities13 (Figure 7).
Although electronic hands require a
protective outer glove to keep environmental agents from damaging the inner
electronics and mechanisms, electronic
hooks do not have this requirement.
In addition to the terminal device,
another major component of an externally powered prosthesis is the battery. The nickel-cadmium batteries
used in early designs generally have
been replaced with more reliable and
longer-lasting lithium-ion/polymer batteries,14 which are available in varying
capacities. In addition, a flexible battery is currently available that allows
the battery pack to be wrapped around
the long axis of a prosthetic socket between the socket and shell and results
in a more streamlined appearance for
the final prosthesis.
Electronic wrist rotation units offer
active wrist pronation and supination.
Generally controlled by electric switches
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
237
Section 2: Upper Limb
Figure 8
for suspension. B, Clinical photograph of a patient donning a myoelectric preparatory prosthesis
with a snap-on electrode array and pin-locking mechanism.
or myoelectrodes, the rotator component adds weight to a prosthesis, but the
additional functionality is often worth
the increased weight. In unilateral applications, sufficient axial length is required at the end of the residual limb to
avoid a length discrepancy.
A, Photograph of a silicone liner with integrate d snap-on elec trodes and a distal pin
through and secured against the wall of
the forearm. In wrist disarticulations,
there is no space for the pin or lanyard
mechanism. However, for a short to
midlength transradial amputation, these
types of suspension liners can work
well. Liner suspension methods can be
used with prosthetic socks to maintain
Suspension Options
and Alternatives
Optimal suspension is a key requirement in a prosthesis. In an upper limb
and adjust fluctuations in limb volume.
They can also be used with snap-on
electrode sensors for myoelectric con-
trol15 (Figure 8).
prosthesis, suspension is a vital concern because gravity attempts to pull
the prosthesis from the residual limb.
Suspension options include a harness
that uses a specific strap to enhance
an already secure fit, the creation of
subatmospheric pressures to maintain
suspension, and strategic contouring of
the proximal socket contours to achieve
anatomic suspension. A figure-of-8 harness combined with a humeral cuff and
an inverted Y suspension strap is one
of the most basic and commonly used
designs. This design offers robust support and is suitable for heavy-duty use.
A more recent technique relies on a
roll-on–type suspension liner that creates inherent suction and slight compression against the wearer’s residual
limb. These liners provide an interface
of varying thickness and an integrated
threaded attachment point at the most
distal position where an attachment pin
or lanyard may be applied.
2,10,11
Pins engage with a locking mechanism inside
the distal socket. Alternatively, a lanyard
may be threaded through a hole in the
distal socket that allows it to be pulled
Socket Design
Socket design can be a primary consideration in combatting the gravitational
and torque forces acting on the residual limb. Self-suspending sockets use
targeted modifications built into the
socket shape and designed to capture
and contain the anatomy of the limb.16
This technique offers an array of functional benefits, from improved comfort
and suspension to increased range of
motion and stability.
In skin-fit sockets, which are often
9
used in myoelectric designs, the anatomic suspension method may be the
most advantageous and least complicated. These self-suspending socket
variations date back to the mid 1900s,
with the Muenster socket, which was
designed to provide stable suspension
in an individual with a short transradial
amputation (Figure 9). This approach is
characterized by 35° of preflexion at the
elbow and the use of anterior- posterior
counterforce suspension, with an antecubital channel to relieve the biceps
tendon and a proximal socket extending
17
Figure 9
socket, which is designed for use by an individual with a short transradial amputation.
This socket is characterized by the use of anterior-posterior counterforce suspension with
proximal trim lines extending into the cubital
fold anteriorly and well above the olecranon
posteriorly. In this instance, a pull-sock and distal escape channel are required to pull the limb
tissues through th e narrowed opening and into
the socket where they can then expand and ll
the larger inner socket cavity. (Courtesy of Jack
E. Uellendahl, CPO, Cave Creek, AZ.)
Photograph of a Muenster
well above the olecranon to enhance
socket stability.18 In some instances, a
pull-sock and distal escape channel are
required to elongate and distract tissues
through the narrow proximal opening
and into the socket where they can then
expand and fill the larger inner socket
cavity; this effectively traps the tissue
and enhances suspension.
A contrasting approach using mediallateral counterforce suspension was later designed by Billock19 and is better
known as the Northwestern University
supracondylar suspension technique for
below-elbow amputations. This design
uses a modification process that narrows the medial-lateral dimension over
the humeral condyles to suspend the
prosthesis (Figure 10). These socket design principles are sometimes modified
and used in conjunction with a Sauter
elbow cutout, which gives the user the
ability to pull cubital tissue into the
socket for easier donning, while providing a cooler interface and improved
airflow20 (Fig ure 11). In a variation of
this design, the proximal portion of
the socket is removed entirely and reattached with flexible straps that provide
an adjustable floating brim (Figure 12).
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
238
Chapter 18: Wrist Disarticulation and Transradial Amputation: Prosthetic Management
Figure 10
ern transradi al socket, which is designed f or use
by an individual with a midlength transradial
amputation. In contrast to the Muenster socket, this design uses a modication process that
narrows the medial-lateral dimension over the
humeral condy les to suspend the prosthe sis. As
a result, the anterior trim line can be much lower than that used in the Muenster socket. (Courtesy of Branden Petersen, CPO, Watertown, NY.)
Photograph of the Northwest-
This variation offers increased range of
motion in flexion and, for longer residual limbs, improved pronation and supination compared with rigid designs.
The transradial anatomically contoured socket offers highly stable suspension by combining elements from
the Muenster- and Northwestern-style
socket designs. It focuses on loading
the tolerant aspects of the wearer’s limb
anatomy to enhance suspension and
stabilize the underlying bones against
socket torque and loading forces.
17,21
For individuals with a wrist disarticulation and prominent styloid
processes, anatomic suspension can
be obtained over the styloids using a
flexible inner socket, a removable foam
insert, or an inflatable air bladder (Fig-
ure 13). Depending on the mechanism
used, inflatable bladders may allow adjustable compressive forces. However,
given the snug fit of the design over
Figure 11
cutout, which allows the cubital tissues to pull
into the socket for easier donning and provides
a cooler interface and improved airow. (Courtesy of Phillip M. Stevens , MEd, CPO, FAAOP, Salt
Lake City, UT.)
Figure 13
with a wrist dis articulation and prom inent bony
processes wearing a exible inner socket that
can be shaped to the anatomic contours of the
limb. A window in the rigid outer socket allows
the inner exible socket to expand during donning to allow passage of the bulbous distal end
of the residual limb. (Courtesy of Jack E. Uellendahl, CPO, Cave Creek, AZ.)
Photograph of a Sauter elbow
Photograph of an individual
the bony prominences of the styloid,
these sockets may be contraindicated
for limbs with sensitive or thin tissues.
Another suspension option is a skinfit suction design that uses a humeral
sealing sleeve (Fig u re 14). Made from
various materials, such as neoprene or
silicone, these sleeves extend over and
beyond the proximal edge of the socket
where they seal against the skin of the
Figure 12
tient wearing a pr osthesis with a test socke t that
uses oating brim suspension.
Figure 14
tient with a myoelectric preparatory prosthesis
with a humeral silicone sleeve for suspension.
Clinical photograph of a pa-
Clinical photograph of a pa-
wearer’s upper arm and create a suction environment that holds the socket
securely in place. In individuals with
a long transradial or wrist disarticulation, the trim lines of such systems
can be lowered well below the elbow
and cubital fold for added comfort and
increased range of motion.
A socket with adjustable panels or
targeted fenestrations with adjustable
tension straps provides a highly adaptive, self-suspended design that allows
the wearer to fully control the snugness
of fit within the socket (Figure 15).
The socket design chosen will de
pend on several characteristics of the
residual limb, the need for comfort
-
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
239
Section 2: Upper Limb
Figure 15
ticulation socket with a fenestrated frame and
adjustable tension straps that allows the wearer to fully control the snugness of t within the
socket. (Courtesy of Advanced Arm Dynamics,
Redondo Beach, CA.)
Photograph of a wrist disar-
versus stability, the control strategy of
the prosthesis, the ease of donning and
doffing the prosthesis, and other concerns that may become evident during
the evaluation process. Although socket
comfort is often a key consideration, adequate suspension is generally the more
important concern.
Alignment Considerations
The alignment of a prosthesis for a
transradial or wrist disarticulation is
generally considered a simple task in a
patient with a relatively standard am
putation and presentation. In unilateral
short or long transradial amputations, it
is often advisable to attach the wrist in
line with the long axis of the residual
limb to achieve the most streamlined
prosthesis. Anatomically, an unaffected
human wrist is positioned in slight ulnar deviation and extension. In contrast,
canting the wrist in radial deviation and
Figure 16
upper limb. B, Photograph after the patient was tted with a myoelectric denitive aesthetic prosthesis with a woman’s long polyvinyl chloride cosmetic glove.
the socket in slight flexion may be advantageous in certain prosthetic designs
in which midline function and reaching
the face and head are necessary. Other
variations in alignment may be indicated for patients with comorbidities that
compromise their contralateral limb
or in those with a bilateral upper limb
amputation.
A, Clinical photograph of a patient with incomplete paraxial hemimelia of the left
with transradial amputations and wrist
disarticulations. Fitting timetables,
component options, and desired outcomes all have an effect on a patient’s
successful use of a prosthesis. These
prosthetic considerations are further
affected by the individual’s own desire
and motivation to return to a functional
bimanual lifestyle. A thorough patient
evaluation at each step of the fitting
Aesthetics and Cosmetic
Considerations
All too often in prosthetics, a choice
must be made between a device that
looks aesthetically pleasing and one that
process will help determine the most
appropriate prosthetic design and will
offer the patient the highest likelihood
of incorporating his or her prosthesis
into a functional lifestyle.
performs with greater functionality. In
many instances, these two objectives
are at odds. Certain suspension options,
battery choices, and wrist components
may offer functional benefits while compromising the aesthetic appearance of
the prosthesis. However, at the levels
of a transradial amputation or wrist
disarticulation, acceptable aesthetics
-
are generally obtainable (Fig u re 16).
Because the importance of the aesthetic appearance of the prosthesis varies
among users, this factor should be assessed during the development of the
individual patient’s treatment plan.
Summary
There are several considerations in the
References
1. Dillingham TR, Pezzin LE, MacKenzie EJ: Limb amputation and limb
deciency: Epidemiology and recent
trends in the United States. South
Med J 2002;95(8):875-883. Medline
2. Brenner CD: Wrist disarticulation
and transradial amputation: Prosthetic management, in Smith DG,
Bowker J, Michael J, eds: Atlas of
Amputation and Limb Deciencies:
Surgical Prosthetic, and Rehabilitation Principles, ed 3. Rosemont, IL,
American Academy of Orthopaedic
Surgeons, 2004, pp 243-249.
3. Brenner CD: Wrist disarticulation and transradial amputation:
prosthetic management of individuals
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
240
Chapter 18: Wrist Disarticulation and Transradial Amputation: Prosthetic Management
Prosthetic principles, in Bowker
JH, Michael JW, eds: Atlas of Limb
Prosthetics: Surgical, Prosthetic, and
Rehabilitation Principles, ed 2. St.
Louis, MO, Mosby-Year Book, 1992,
pp 241-249.
4. Ziegler-Graham K, MacKenzie EJ,
Ephraim PL, Travison TG, Brookmeyer R: Estimating the prevalence
of limb loss in the United States:
2005 to 2050. Arch Phys Med Rehabil
2008;89(3):422-429. Medline DOI
5. Malone JH, Childers SJ, Underwood
J, Leal JH: Immediate postsurgical
management of upper-extremity
amputation: Conventional, electric
and myoelectric prosthesis. Orthot
Prosthet 1981;35(2):1-9.
6. Sarmiento A, McCollough NC III,
Williams EM, Sinclair WF: Immediate postsurgical prosthetics tting in
the management of upper-extremity
amputees. Artif Limbs 1968;12(1):14-
19. Medline
7. Malone JM, Fleming LL, Roberson J,
et al: Immediate, early, and late postsurgical management of upper-limb
amputation. J Rehabil Res Dev
1984;21(1):33-41. Medline
8. Supan TJ: Transparent preparatory prostheses for upper limb
amputation. Clin Prosthet Orthot
1987;11(1):45-48.
9. Fryer CM: Upper-limb prosthetics: Harnessing and controls for
body-powered devices, in Smith DG,
Bowker J, Michael J, eds: Atlas of
Limb Prosthetics: Surgical, Prosthetics, and Rehabilitation Principles, ed
2. St. Louis, MO, Mosby-Year Book,
1992, pp 133-150.
10. Salam Y: e use of silicone suspension sleeves with myoelectric ttings.
J Prosthet Orthot 1994;6(4):119-120.
DOI
11. Gaber TA, Gardner CM, Kirker SG:
Silicone roll-on suspension for upper
limb prostheses: Users’ views. Pros-
thet Orthot Int 2001;25(2):113-118.
Medline DOI
12. Fryer CM, Michael JW: Upper-limb
prosthetics: Body-powered components, in Smith DG, Bowker J, Michael J, eds: Atlas of Limb Prosthetics:
Surgical, Prosthetics, and Rehabilitation Principles, ed 2. St. Louis, MO,
Mosby-Year Book, 1992, pp 107-131.
13. Billock JN: Upper limb prosthetic terminal devices: Hands versus hooks.
Clin Prosthet Orthot 1986;10(2):57-65.
14. Stavdadahl O, Hermanson L, Hermanson L, Krristenson KT, Malvig
KE: Evaluation of built-in lithium-ion
batteries used as energy source for
externally powered upper limb prostheses. J Assoc Child Orthot Prosthet
Clin 1998;4(1):1-9.
15. Daly W: Clinical application of
roll-on sleeves for myoelectrically
controlled transradial and Transhumeral prostheses. J Prosthet Orthot
2000;12(3):88-91. DOI
16. Lake C: e evolution of upper limb
prosthetic socket design. J Prosthet
Orthot 2008;20(3):85-92. DOI
17. Miguelez J, Conyers D, Lang M,
Dodson R, Gulick K: Transradial and
wrist disarticulation socket considerations: Case studies. J Prosthet Orthot
20 08; 20(3):118-125. DOI
18. Fishman S, Kay HW: e munster-type below-elbow socket: An
evaluation. Artif Limbs 1964;8(2):4-
14. Medline
19. Billock NJ: e Northwestern
University supracondylar suspension technique for below-knee
amputations. Orthot & Prosthet
1972;26(4):16-23.
20. Sauter WF: ree-quarter type
Muenster socket. Prosthet Orthot Int
1986;10(2):79-82. Medline
21. Miguelez JM, Lake C, Conyers D,
Zenie J: e transradial anatomically
contoured (TRAC) interface: Design
principles and methodology. J Pros-
thet Orthot 2003;15(4):148-157. DOI
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
241
Соседние файлы в папке Библиотека им академика М.И. Перельмана