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Section 2: Upper Limb
Figure 9
donning of a pull -in interface desi gn. A sheath is
used to pull the residual limb into the inter face.
Because the prosthetic interface has a smaller
circumference than the anatomic limb, volumetric pressure is created within the donned
socket.
Photograph demonstrating the
However, donning a pull-in prosthesis can be challenging. The patient
must temporarily place and hold the
prosthetic arm in position (without the
benefit of the harness because it has not
been donned) while pulling the residual
limb distally into the socket. Although
a low-friction donning sheath is used to
improve donning speed, assistance is
often required. Pull-in designs are often
used for medium to long transhumeral
amputations in which the distal volume of the limb must be managed. The
donning procedure can be prohibitive
for patients with compromised contralateral dexterity and patients with bilateral upper limb amputation.
The general shape of the transhumeral residual limb also is an
important consideration. The shape
of the lateral humeral shaft should be
evaluated for loading ability, especially
along the distal half of its bony length.
Longer limb lengths are typically flatter
along the humeral shaft, whereas elbow
disarticulations exhibit a distal lateral
concavity. Shorter limb lengths are more
Figure 10
rior (C) alignment of an endoskeletal transhumeral prosthesis.
convex because the bony substructure
is not present. Limb shape may also be
affected by the subcutaneous tissue or
the degree of muscular attachment, as
was previously mentioned. A firm residual limb with little compressible tissue,
such as an elbow disarticulation, will
have a more characteristic shape, whereas a shorter limb with a more fleshy presentation will exhibit a more rounded
and uncharacteristic shape.
The way the patient holds the limb
in the frontal plane, referred to as the
carrying angle, should be noted. Patients
with broader chests will typically hold
the upper arm in a more abducted position, whereas a more adducted position will usually be favored by patients
with narrower chests. This positioning
may be further affected by limb length
because the increased weight of a longer limb may tend to adduct the arm,
whereas the absence of distal muscular
attachments in shorter limbs may create
a more abducted carrying angle. This
positioning should be considered in the
final assembly of the prosthesis (Fig-
ur e 10). If the elbow axis is not aligned
properly based on the carrying angle,
the elbow axis will not be parallel to
the ground.
Clinical photographs of a patient demonstrate anterior (A), lateral (B), and poste-
During the evaluation process, the
underlying musculature and skeletal
structure should be noted, especially
in the load-bearing areas. The patient
should be asked to contract the musculature of the anterior biceps and posterior triceps. The apex of each muscle
belly should be evaluated for any resultant changes in shape and volume and, if
indicated, for myoelectrode placement.
Asking the patient to contract the biceps
with internal glenohumeral rotation and
the triceps with external glenohumeral
rotation may help identify the muscle
positions.
The subsurface skeletal structures
also should be examined. The locations of the clavicle and spine of the
scapula should be noted because the
proximal trim lines of the interface
are usually placed just inferior to these
pressure-sensitive areas. The position of
the acromioclavicular joint is noted by
palpating to the lateral edge of the posterior spine of the scapula. This position
is indicative of the lateral position of the
glenohumeral joint, and it is used for
limb-length assessment and measurement. The lateral shaft of the humerus
is marked as a load-tolerant surface area
that terminates 10 mm proximal to the
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
262
Chapter 21: Elbow Disarticulation and Transhumeral Amputation: Prosthetic Management and Design
Figure 11
titioner pulling the distal tissue of the residual
limb into circumfere ntial tension (beige material) using a cotton sock (white material).
Clinical photograph of a prac-
cut end where distal humeral relief is
provided.
In elbow disarticulation, the lateral
and medial supracondylar ridges and
condyles should be noted (generally
observed as a coronal dimension that
is wider than the midshaft of the humerus). The complexity of the interface
design is increased because it will be
necessary to make an allowance for
the passage of this wider dimension
into the distal interface. This may be
accomplished with alternative interface
designs, such as a removable medial
door, a padded stovepipe liner, a spiral modification, an inflatable bladder,
a clamshell, or an open design, which
are discussed later in this chapter.
As the muscular and skeletal structures are located, it is crucial to evaluate the residual limb for load-bearing
tolerance and sensitivity. Proximal load
bearing is often obtained through an
anteroposterior force couple comprised
of the deltopectoral region (bordered
by the clavicle proximally, the pectoralis medially, and the pectoralis tendon
inferiorly) and the area inferior to the
spine of the scapula. If sufficient anteroposterior pressure is achieved within
the interface, a degree of self-suspension can be created, which is especially
important with the added weight of an
externally powered prosthesis. However, the pressure of the interface against
the sensitive prominences of the humeral head and the coracoid process should
be considered.
Distally, the loading area is along the
lateral shaft of the humerus and should
terminate proximal to the cut end of the
bone. Load bearing in this area can be
compromised by scarring, wounds, internal neuromas, or a distal end of the
humerus that was inadequately beveled at the time of amputation. Relief
alone may be inadequate to off load a
tender area in this aspect of the socket.
Frequently, relief must be coupled with
loading just proximal to the sensitive
area. In addition to managing the loads
associated with the weight of the prosthesis, the distal end of the limb may
experience direct distal loading when
the arm is pushed distally against a table
or other object. This area should be evaluated for any sensitivity that may occur if
there is inadequate distal padding.
Distally, the mediolateral tension
supports the carrying angle of the
residual limb as well as maximizing
the amount of distal coupling to the
interface. A loose interface would allow
excessive motion of the socket and precipitate increased impingement on the
lateral distal area. Often, practitioners
will pad the proximolateral area if there
is a lateral gap, but this practice does
not correct the position of the socket on the limb and ultimately makes
the lateral distal end more prone to
impingement.
The range of motion of the glenohumeral and sternoclavicular joints and
the mobility of the scapula should be examined with respect to movement within the interface. This range of motion,
especially glenohumeral flexion and
extension, is dictated by the size of the
deltopectoral and infraspinous wings
incorporated within the trim line. The
longer the residual limb, the less prominent these wings need to be because
rotation can be resisted more distally.
The mobility of the shoulder is also
important when considering the control options for body or external power.
Glenohumeral flexion and biscapular
abduction are the most commonly used
biomechanical methods for operating
a body-powered prosthesis. However,
smaller movements, including shoulder elevation, biscapular retraction, or
biscapular depression, can be used to
activate electronic switches. Internal
pressure switches may be used, but the
shoulder must be able to move independently within the interface to make
consistent contact and apply pressure.
Taking a Transhumeral
Casting Impression
When taking the impression for a transhumeral interface, it is important to
consider (1) distal volume management,
(2) proximal anteroposterior musculoskeletal loading, (3) comfortable loading
with the control preference, (4) ease of
donning and doffing the prosthesis, and
(5) maximum range of motion.
Management of distal limb volume
can be achieved by using elastic plaster distally over tubular-shaped cotton
casting gauze or an elastic sock that has
been tightly fitted to the patient. If the
patient does not have firm musculature,
the limb may be pulled into a compression sock with a cotton stockinette. This
technique applies circumferential tension and pulls the tissue distally from
the proximal axilla area. Because this
technique will also have the effect of
elongating the limb 25 mm or more,
the length measurement from the axilla
should be measured after the elongation
has been done (Fig ure 11).
Careful measurements may include
the limb length from the acromion process to the distal end, from the axilla
to the distal end and circumferences at
the axilla, along the midhumeral shaft,
and at the apex of the distal end. Many
practitioners believe that the measurements are accurately represented “in
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
263
Section 2: Upper Limb
Figure 12
A, The posterior-proximal nger position. The index nger is inferior to the spine of the scapula in
the infraspinous area. B, The posterior-anterior nger position. The digits form a C-shape around
the head of the hum erus but inferior to the clavicl e. The thumb positions are cross ed. C, An alternative proximal han d grip demonstrating use of th e thenar and hypothenar emin ences of both hands
to apply load posteriorly and anteriorly. This hand hold is often recommended for prosthetists
with smaller hands. D, Secondary distal hand hold. The outer hand is placed just proximal to the
cut end of the humerus. The inner hand is placed against the thoracic area pushing into the axilla.
Notice that the ngers are aligned perpendicular to the chest wall to avoid excessive proximal
compression. Slight mediolateral pressure is applied, but not so much as to “pancake” the residual
limb. (Courtesy of Ottobock, Austin, TX.)
the mold;” however, if careful measurements are not recorded, it is difficult to
attain the correct amount of compression, especially when the limb is under
tension. If a compression sock is used,
Photographs show techniques for taking a transhumeral casting impression.
the circumferences should be measured
after the limb has been pulled into the
sock.
Proximal musculoskeletal loading
is accomplished by achieving a tight
anteroposterior dimension between the
deltopectoral groove and the infraspinous area. Before taking the impression,
this dimension should be measured
with calipers while a comfortable level
of compression is being applied. This
anteroposterior measurement should be
recorded for modification and also taken
over the impression during casting. To
preserve this position as the negative impression is removed, the calipers can be
placed into position after removal of the
casting to ensure accurate dimensional
control. This contour can be molded
with a plaster splint running from the
posterior to the anterior wing or with
recurrent back-and-forth splinting over
the shoulder to encapsulate the deltopectoral region and the scapula.
During casting, the index finger of
the posterior hand should be placed
just inferior to the spine of the scapula, and the breadth of the hand should
be placed along the posterior plateau of
the scapula (Figure 12, A). Anteriorly, the fingers should be placed around
the head of the humerus in a horseshoe
or a backward C-shape (Figure 12, B).
The fingers should not make indention
points in the impression, but rather
should provide broadened and general
loading by massaging the regions in a
circular fashion and avoiding the bony
anatomy of the spine of the scapula and
humeral head.
An alternative handhold for smaller
hands is to place the thenar and hypothenar areas of the posterior hand in
the infraspinous area, with the fingers
wrapping superiorly and anteriorly (Fig-
ure 12, C). The anterior hand is placed
with the thenar and hypothenar areas
encapsulating the head of the humerus. The fingers may then be clasped
over the proximolateral area. With this
technique, the interface creates an internal “saddle” that can partially load
the shoulder of the involved side; this
interface quality is especially important for use with externally powered
components.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
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Chapter 21: Elbow Disarticulation and Transhumeral Amputation: Prosthetic Management and Design
With this second casting strategy, the clinician should periodically
squeeze the mediolateral dimension at
the axilla (Figure 12, D). In doing so,
it is important to maintain a vertical
orientation of the medial hand relative to the long axis of the limb. If the
fingertips of the medial hand exert an
excessive push into the axilla laterally toward the humerus, a dovetailing
effect can occur at the proximomedial brim, making the socket painful
and difficult to doff. The lateral hand
should be used to form the lateral
side of the shaft of the humerus, and
the distal portion of the hand should
be placed proximal to the cut end of
the bone. At this point, if any muscle
bunching has been observed, the muscles should be repeatedly flexed and
relaxed. The muscle node should be
located and supported distally during
the impression taking. It is important
to remember that with fleshy limb
shapes, the clinician should not overflatten or “pancake” the mediolateral
dimension because this would prevent
easy donning of the prosthesis.
It is important to hold the patient’s
arm in maximal adduction with the
back of the medially positioned hand
contacting the thoracic area. A common
error is to inadvertently hold the limb
in abduction while the impression is being taken. In such cases, the evaluation
interface will appear to fit only when
the arm is in abduction rather than adduction. This also can result in lateral
distal pressure.
It must be remembered that as proximal anteroposterior shaping is achieved,
there will be increased proximolateral
deformation, which can result in substantial gapping. As the plaster begins
to harden, the depth to the tissue can be
indicated with the index finger. At the
time of modification, this volume of ma
terial may be removed to the indicated
depth. It is not uncommon for 25 mm
of material to be removed in this area
during modification.
With longer limb lengths and in elbow disarticulations, additional steps
are required distally to accommodate
the wider distal mediolateral dimension.
If a seamless impression is desired, a felt
or foam pad can be created that spans
from the medial epicondyle to the height
at which the mediolateral dimension of
the arm matches the mediolateral dimension of the distal condyles. This pad
can be secured to the casting garment
with double-sided tape before impression taking. Alternatively, the impression may be taken in a clamshell fashion.
Interface Modification
and Evaluation
Using the anteroposterior measurement
taken at the time the impression was
made and that of the mold, two-thirds
of the difference is removed at the depth
of the deltopectoral area and one-third
from the infraspinous area of the scapula. Care should be taken not to impinge
on the head of the humerus and to
ensure that the posterior modification
reflects the longitudinal, transverse,
and frontal plane angles of the scapula.
Distally, the reduction should be general
and consistent with the firmness of the
residual limb and subcutaneous tissue,
with greater reductions indicated for
softer tissue.
The evaluation interface can then be
created with the trim lines located just
inferior to the clavicle, the spine of the
scapula, and the acromioclavicular joint,
and the axilla proximally. Additional material may be removed from the
proximal wings to allow greater range of
motion. The evaluation interface should
be donned using a low friction donning
sheath, and the prosthetist should note
the distal tension within the socket (especially at the axilla). As the interface is
donned, the tension with the donning
-
sheath should be firm because of the
tight fit.
The evaluation interface should be
checked for impingement at the clavicle
and the anterior and posterior axillae,
Figure 13
a “rough” tting of a t ranshumeral prosthesis to
determine how the interface will perform with
the selected componentry. (Courtesy of Ottobock, Austin, TX.)
Photograph of a p atient during
especially during glenohumeral flexion
and biscapular abduction. The proximal
wings should be examined for rotational
stability. The posterior wall will control
external rotation for body-powered devices, and the anterior wing will control
internal rotation caused by heavier external control systems.
It is advisable for the evaluation interface to be set up with the externally controlled or body-powered components
to evaluate how the interface performs
with the associated weight and displacement. This helps the practitioner
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
265
Section 2: Upper Limb
Figure 14
ly powered transhumeral prosthesis with an
articulated thumb and powered elbow. This
prosthesis has a modied gure -of-8 harness, a
exible inn er interface, a rigid laminate d frame,
and lower proxima l trim lines. Note the positi on
of the valve to allow pull-in donning (arrow).
Photograph of an external-
evaluate how the interface reacts to harness positioning, alignment, and loading characteristics during normal use
(Figure 13). At this point in the process,
the electrode sites, trim lines, and component positioning may be refined. The
typical alignment in the frontal plane
is at the location where the proximal
turntable of the elbow is parallel to the
floor and approximately 25 mm lateral
to the hip or widest part of the body. The
sagittal alignment is usually at neutral,
with the turntable parallel to the floor.
With shorter residual limb lengths and
heavier external control systems, the
interface may be preflexed slightly to
prevent greater concentration of a load
on the anterior humerus.
Interface Construction
The transhumeral interface is created
with many of the same materials as a
transfemoral prosthesis, including a
flexible socket with a more rigid external supportive frame. A softer interface
material is chosen so that it conforms
to the contours of the shoulder. This
Figure 15
humeral prosthesis with birdcage construction.
Anterior (A) and posterior (B) photographic views of a patient wearing a trans-
material can be soft thermoplastic, an
interface liner, or custom silicone to
bend with the body. Usually, an acrylic composite laminated outer frame is
created over the mold of the flexible
interface in the correct frontal and
sagittal plane alignments as previously
described (Fig ure 14). The composite
materials typically consist of varying
layers of fiberglass, carbon, and nylon.
Between the layers, additional geometries for electrodes, batteries, and connection devices can be created as needed
and are commonly located in the distal
portion of the device between the end
of the interface and the turntable of
the elbow. The trim line of the frame
is typically 6 to 12 mm inferior to the
trim line of the interface so that it can
be adjusted as necessary. It also provides
the attachment points for the harness
and body-powered control points. These
may require special anchors and fittings
to hold the straps and cable in position.
For individuals who use their prostheses for heavy-duty tasks or in inherently dusty environments, it may be
desirable to use exoskeletal construction consisting of a laminated socket.
This is constructed by using structural
foam that is shaped to the desired cosmetic form of the interface, and then an
outer, hard laminated form is created
to form the exterior surface.21 Although
less adjustable, this method is typically
selected for users of body-powered prostheses, when greater strength and limb
stability are required. Although various
skin tones are available, patients often
decorate the laminated outer frame with
custom colors, images, logos, tattoos, or
carbon composite materials to personalize their devices.
Endoskeletal systems that are lighter
and more cosmetic also can be made
with an interface and frame construction, but are typically covered with a
more lifelike foam shell and glove to
enhance cosmetic quality.
Interface Alternatives
Socket variations are typically used
when the residual limb and the humeral
length is longer or shorter than usual.
When the residual humerus is extremely
short, the shortened interface resembles
the fitting for a shoulder disarticulation
interface. The deltopectoral and infraspinous wings project proximally from
the axilla and fit around the exposed humeral remnant. An articulating shoulder
joint can be placed more inferiorly in the
axilla or lateral to the residual limb, with
rigid support structures; this is called
birdcage construction.27 With this style
of construction, the interface is relatively
open. However, the residual limb is not
directly used for shoulder positioning,
and the prosthesis is functionally equivalent to a shoulder disarticulation prosthesis (Figure 15).
Another variation is the use of a
roll-on suspension liner, which is
popular with patients who desire selfsuspension. The liner can be custom
made, or a production liner can be
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
266
Chapter 21: Elbow Disarticulation and Transhumeral Amputation: Prosthetic Management and Design
Figure 16
trodes for a humeral prosthesis liner that allow
for improved conduction of electromyographic
signals.
Photograph of snap-on elec-
chosen to match the shape and taper of
the residual limb. Distally, the attachment is provided with a distal pin-catch
shuttle lock or a lanyard configuration in
which a narrow strap is pulled through
a slot within the interface and secured
with an external fabric hook-and-loop
fastener system. The latter method is often used for longer limb lengths when
the additional length of a pin lock system is not available.
The combination of a liner and external power requires consideration of
how the EMG signals will be conducted
through the liner to the electrodes. Holes
can be cut into the liner, but issues arise
if the holes in the liner are not aligned
with the electrode sensors in the socket wall. The patient must be instructed on how to use anatomic landmarks
to properly don the liner or the myoelectrode sensors will be blocked and
control function may be compromised.
Other options are electrodes that snap
onto studs that are attached to the liner
(Figure 16) or custom liners that use a
conductive silicone that allows the EMG
signal to be conducted through the liner to the myoelectrode mounted in the
laminated frame.
Many of the alternative socket designs are used to accommodate longer
limb lengths and elbow disarticulations
in which the distal mediolateral dimension of the humeral epicondyles is wider
Figure 17
ticulation socket using a spiral slot for donning
and suspension by screwing the epicondyles
in place. (Reproduced from Daly WK: Elbow
disarticulation and transhumeral amputation:
Prosthetic management, in Smith DG, Michael
JW, Bowker JH, eds: Atlas of Amputations and
Limb Deciencies: Surgical, Prosthetic, and Rehabilitation Principles, ed 3. Rosemont, IL, Ameri-
can Academy of Orthopaedic Surgeons, 2004,
pp 243-249.)
Illustration of an elbow disar-
than the midshaft dimension. The most
common method of addressing this dimensional difference is the creation of a
medial door through which the medial
epicondyle may pass. The opening for
the medial door spans between the distal epicondyle and the proximal border
where the mediolateral dimension is
equal to the distal dimension.
Another socket design option is a
screw-in design that uses a spiral-shaped
channel relief for the medial epicondyle.
The interface is “screwed” into position
by rotating it laterally to medially. This
method can present a challenge in mapping the spiral path of the epicondyle
as it is donned; however, it avoids the
use of medial doors, foam pads, or other
suspension methods (Figure 17).
An alternative socket design uses an
internal bladder, similar to that used
for a knee disarticulation. A lost-wax
casting technique is used to create an
internal flexible bladder, which provides a void or open air space that can
Figure 18
wearing a humeral prosthesis with a clamshell
design that is hinged proximally. (Courtesy of
Ottobock, Austin, TX.)
Photograph of an individual
be inflated to the desired levels. Usually,
this type of socket design is used for
patients with more mature limbs after
the limb volume has stabilized. Adjustment is difficult after the definitive
interface is created, and a leak in the
internal bladder will result in a loss of
suspension and the need to remake the
entire interface.
If the difference in the distal and midshaft dimension is quite pronounced, a
clamshell impression may be used. Because suspension is now provided by
supracondylar pressure, the proximal
trim lines can be much lower (approximately 25 mm inferior to the axilla medially and at the insertion of the deltoid
laterally). However, a donning strategy
will need to be developed for the patient because the interface comes in
two parts and must be secured in place.
One variation of this type of design is
a two-part clamshell prosthesis that is
hinged proximally, allowing the arm to
be positioned and encased in anterior
and posterior overlapping panels. The
arm is then secured into position. Although this design can accurately fit an
arm with a characteristic shape, its fabrication requires a high level of technical competency and the use of multiple
evaluation interfaces (Figure 18).
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
267
Section 2: Upper Limb
Figure 19
open design to achieve donning and suspension. A, Anteroposterior (AP) compression controls
rotational instability while minimizing harnessing. B, Lateral dorsal humeral pressure is aided by
padding. (Reproduced from Andrew JT: 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 255-264.)
Figure 21
A, The posterior cable retainer is positioned proximal to the cut end of the humerus. B, The interface should not block glenohumeral exion or biscapular abduction.
Other designs avoid hinges and use
bands of support over distal and proximal prominences. Originally, this type
of open-panel design was used with the
innovative Marquardt osteotomy, which
Illustrations o f an elbow disarticulatio n prosthesis using the Marquardt o steotomy
Photographs of an i ndividual tted wit h a body-powered t ranshumeral prosthesis .
creates a surgical hinge alteration of the
humeral shaft
10,12,28
(Figure 19). The
suspension band was tightened over
this distal area for suspension. A more
modern option uses a laminated socket
Figure 20
wearing a prosthesis with a laminated elbow
disarticulation socket with a lateral channel to
allow donning. (Courtesy of Ottobock, Austin,
TX.)
Photograph of an individual
that opens the channel, which can then
be secured (Figure 20).
Control Strategies
Because a transhumeral prosthesis represents an interconnected functional
system with an interface design, control
strategy, and harness, each of these factors affects the others directly and indirectly. With respect to body and external
power, the type of control has a major
effect. In body-powered devices, control
is dependent on the movement of the
residual limb. As a result, the proximal
trim lines must allow adequate excursion of the arm to enable its functional
use. The proximal trim lines are terminated at the deltopectoral groove, below
the clavicle, and at the border of the posterior deltoid distal to the spine of the
scapula. Often, they must be lowered
during the initial fitting to accommodate the requirements of glenohumeral
flexion and biscapular abduction. The
prosthetic interface must not block the
control movements, especially in glenohumeral flexion (Figure 21).
Typically, longer limb lengths can
generate a greater amount of bodypowered excursion in glenohumeral
flexion and biscapular abduction compared with shorter limb lengths. Because of the longer length of the effective
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
268
Chapter 21: Elbow Disarticulation and Transhumeral Amputation: Prosthetic Management and Design
Figure 22
prosthesis. A, The socket of the prosthesis should help distribute the weight of the device while
providing ade quate suspension and resistan ce to movement as the forearm exes . B, The proximal
posterior i nfraspinous wing of th e externally po wered interface is imp ortant in resisti ng movement.
lever arm of a longer limb, the leverage
that can be applied is greater than that
of a shorter limb. The loading forces felt
inside the interface during cable activation are localized at the anterior distal
and posterior proximal areas. A shorter limb length exhibits more localized
Photographs of an individual tted with an externally powered transhumeral
because they maintain the positioning
of the myoelectrodes. Alternative externally powered control strategies may include internal pressure switches, linear
transducers, pull switches, and touch
sensors, all of which must be appropri-
ately located.
forces at the distal end because there is
less surface area and greater movement
within the interface.
External power creates a different
set of challenges when used for a transhumeral interface. With externally
powered devices, control of the prosthesis is not dependent on movement,
so the trim lines can be extended more
proximally into the deltopectoral groove
and infraspinous areas to distribute the
added weight of the prosthetic arm
(Figure 22). Distally, the control electrodes must maintain intimate contact
with the residual limb over the available muscle sites, such as the medial
Summary
Although the prosthetic interface at
the transhumeral level presents several unique challenges, practitioners can
create comfortable and functional socket
designs by having a good knowledge of
the process and paying careful attention
to detail. It is important to listen to the
patient and identify and fully understand his or her needs. Knowledge of
the variety of socket design options will
help the practitioner meet the unique
needs and challenges of a patient with
a transhumeral amputation or an elbow
disarticulation.
biceps and medial triceps. If the limb
is especially soft, the practitioner may
choose to load those areas so that the
myosites can make better contact with
the muscle bellies. As previously men-
References
1. Billock J: Upper limb prosthetic terminal devices: Hands versus hooks.
Clin Prosthet Orthot 1986;10:57-65.
tioned, pull-in designs are often preferable for externally-powered devices
2. Berger N: Studies of the upperextremity amputee: II. e population (1953-55). Artif Limbs
1958;5(1):57-72. Medline
3. Biddiss E, Chau T: Upper-limb
prosthetics: Critical factors in
device abandonment. Am J Phys
Med Rehabil 2007;86(12):977-987.
Medline DOI
4. Burrough SF, Brook JA: Patterns of
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Section 2: Upper Limb
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Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
270
Chapter 22
Amputations About the Shoulder:
Surgical Considerations
Joseph F. Alderete Jr, MD
Abstract
Proximal upper limb amputations such as those about the shoulder and chest wall are
complex procedures requiring a thorough understanding of indications, surgical principles, alternative treatments, and rehabilitation techniques to facilitate optimal outcomes.
It is helpful to be aware of the limited range of reasons for performing shoulder-level limb
ablation and the types of classic and modied methods for performing shoulder disarticulations and forequarter amputations. In some instances, alternative coverage and limb
salvage techniques can be used to avoid shoulder-level amputations. Complications are
common with these procedures.
Keywords: forequarter amputation; intercalary shoulder resection;
shoulder disarticulation
Introduction
Shoulder-level amputations are rare. The
typical reasons for limb ablation at the
shoulder include tumor, trauma, and
infection. With the advent of modern
multiagent chemotherapy regimens and
advanced surgical techniques, 90% of
all neoplasia around the shoulder girdle can be treated with limb salvage.1
Nonablative techniques for tumor resection and even limb-threatening infections are usually successful. These
resections, with some modification,
follow the classic Tikhoff-Linberg procedure. Amputations at the shoulder
level involve either a glenohumeral disarticulation or a forequarter amputation.
Most shoulder disarticulations are not
actually disarticulations; rather, they
are ultra-high transhumeral amputations with a small part of the humeral
head and neck remaining to preserve
Dr. Alderete or an immediate family member has received research or institutional support from
the Musculoskeletal Transplant Foundation and serves as a board member, owner, ocer, or
committee member of the Musculoskeletal Transplant Foundation.
cosmesis. When tumor, trauma, and/or
infection prove amenable, such amputations are vastly preferred.
The forequarter amputation is extremely morbid in terms of body dysmorphism and function. This procedure
is reserved for tumors or life-threatening
infections in which the axillar y artery and
the brachial plexus have been contaminated, or when it is not prudent to leave
these two structures in place because of
the risk of local recurrence (Figure 1).
Most patients treated with forequarter
amputation have soft-tissue sarcoma,
osteosarcoma, recurrent malignant
melanoma, or epidermoid carcinoma.
This procedure also can be used to treat
large, ulcerated, or very painful metastatic carcinomas in which the tumor
often causes extreme pain from plexus
rad iculopathy.2 In these patients, the
entire forelimb is removed, in some
2-5
Figure 1
osteosarcoma with pathologic fracture and
soft-tissue extension to the brachial artery and
the brachial plexus.
instance with part of the chest wall, as
well as the scapula, the humerus, and a
portion of the clavicle.
Although there are classic methods
for performing these two procedures,
the procedure must be tailored to the patient and the corresponding pathophysiology. This often requires modifications
to the classic approaches to fit the individual situation. In patients injured by
high-energy trauma, amputation about
the shoulder can be performed early or
late, secondary to the wishes of patients
with a flail limb. Early posttraumatic
amputations, both shoulder disarticulation and forequarter amputation, are
predicated on the amount of viable
tissue that is free of contamination. If
the tissue around the deltoid is viable,
an ultra-high transhumeral amputation combined with shoulder fusion is
preferable to removal of the humerus
secondary to an intra-articular fracture
and distal destruction.
In keeping with the more classic approaches, several flaps must be
CT of a large proximal humeral
1,6-9
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
271
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