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Section 2: Upper Limb
Tab le 1
(continued)
Prosthesis Type Functionality Advantages Disadvantages
Hybrid
(body-powered
elbow and myoelectric terminal
device)
Externally powered Increased grip force
VO = voluntary opening, VC = voluntary closing, EMG = electromyography.
Increased grip force
and elbow positioning
and improved elbow positioning
Increased grip force
Harness provides proprioceptive
feedback
Potential for simultaneous control
of elbow and terminal device
Potential reduction in harnessing
Responsive body-powered elbow
Increased grip force
Decreased energy expenditure
Reduction in harness tightness for
function
Linear potentiometer requires only
0.05 inches of motion for full
elbow function
EMG provides proportional control
of terminal device
Improved cosmesis
Large sockets to support the component
weight and create stability
Increased cost
Increased weight
Decreased durability
Designed for light- to medium-duty tasks
Susceptible to water and debris damage
Requires a harness for function of the
elbow
Requires a battery for function
Mechanically complex
Increased maintenance cost
Shoulder region socket designs must be
larger to support the component weight
and create stability
Increased cost
Increased component weight
Increased maintenance
Designed for light- to medium-duty tasks
Susceptible to water and debris damage
Requires a harness
Lack of proprioceptive feedback through
the harness for elbow position.
Figure 8
an interscapulothoracic amputation wearing
a protective shoulder cap with lightweight
closed-cell cross-linked polyethylene soft foam
shaping and a chest strap.
Photograph of a patient with
and other environmental assaults. After an amputation about the shoulder
region, large neurovascular bundles can
be sensitive to touch. Shoulder caps can
assist in protecting these sensitive portions of the residual limb. Protective
shoulder caps for interscapulothoracic
amputations are shaped to restore the
symmetry of the shoulders (Figure 8).
The built-in shoulder shape assists in
maintaining proper positioning of clothing on the body. The protective caps can
be lightweight; can be fabricated from a
variety of materials, such as soft foam;
and require a chest strap for suspension.
Passive Oppositional
Restoration Prostheses
Passive devices for the shoulder region
are a good option for individuals requiring a lightweight device. As the name
implies, the device can be passively positioned for various activities (Figure 9).
It is a misconception that oppositional
devices provide no functional benefits.
There is some evidence that passive devices are used to perform activities of
daily living as often as prostheses with
active grasping capabilities.19 These devices can restore the functional length
of the limb and promote bimanual functionality. A passive prosthesis can be socially beneficial because it can assist in
promoting a psychological acceptance of
the amputee’s impaired body image.20 A
restored body appearance can provide
more confidence in work and social
settings.
Endoskeletal elbow joints allow the
user to position the elbow in several different positions and lock it into place.
With the elbow locked in flexion, the
prosthesis can assist the user in functional activities such as carrying grocery
bags.
Multiple glove options are available
for a passive prosthesis. Off-the-shelf
vinyl production gloves are inexpensive
but must be replaced frequently because
of staining. These production gloves are
selected based on a color swatch and do
not match the color of the individual’s
natural skin. Another option is silicone
gloves, which do not stain as easily as
vinyl gloves but lack durability and are
more costly to replace. Silicone gloves
have a high coefficient of friction that
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
292
Chapter 23: Amputations About the Shoulder: Prosthetic Management
Figure 9
wearing a passive, oppositional prosthetic restoration during the provisional tting stage.
The prosthesis is lightweight and has passively
positioned endoskeletal componentry. The reduced weight and lack of active control permit
a reduced socket size.
Photograph of an individual
aids users in holding down objects for
contralateral hand manipulation. In
some instances, gloves are fabricated as
custom silicone restoration prostheses.
Generally, custom silicone gloves better
match the contralateral limb in color and
other aspects of physical appearance.
Adaptive Prostheses
Designing adaptive prosthetic devices
requires persistence, knowledge, and
creativity. Adaptive, activity-specific
devices are not commonly used for patients with amputations about the shoulder region, but they can be considered as
an option to meet an individual’s need
to accomplish activities of daily living,
work-related tasks, and recreational and
sporting activities. In some instances,
adaptive prostheses do not resemble a
typical prosthesis in appearance because
they are designed for a specific activity
(Figure 10).
Adaptive terminal devices can be
used on an existing passive, a body-powered, or a myoelectric prosthesis. The
individual can apply the appropriate terminal device based on the activity being
performed. This presents an attractive
option because the prosthesis can be
Figure 10
using an adaptive shoulder region prosthesis
for cycling.
Photograph of an individual
used for multiple purposes. Adaptive
terminal devices are available for a wide
range of special activities, and some can
be used with shoulder-level prostheses.
Body-Powered Prostheses
Body-powered prostheses require that
the individual is capable of generating
both force and excursion through joint
motion captured through a harness. The
excursion required to fully flex a prosthetic elbow joint and open a terminal
device is 4.5 inches. This excursion is
generally captured through two body
motions: glenohumeral flexion and biscapular abduction. For individuals with
amputations about the shoulder region,
capturing this amount of excursion is
difficult and in some cases impossible.4
Although these amputees have biscapular abduction capabilities (except at the
interscapulothoracic level), the lack of
a humerus or adequate humeral bone
length eliminates glenohumeral flexion
as a source of excursion. In the absence
of glenohumeral joint motion, an individual lacks approximately 50% of the
needed excursion required to operate
a body-powered prosthesis to its end
range. As a result, externally powered components are often required,
especially for those with interscapulothoracic-level amputations in which
approximately 25% of the total required
excursion is available.
Figure 11
dividual with a bilateral shoulder disarticulation
tted with a prosthesis using an excursion amplier to reduce the excursion requirements.
Posterior photograph of an in-
Prosthetic elbow alignment and setup are critical considerations for shoulder region prostheses. Because of the
compromises previously described, the
body-powered prosthesis needs to be set
up to capture maximum excursion. For
high-level, body-powered prostheses,
double lift assists can be coupled at the
elbow while placing the fairlead cable
slightly anterior to the elbow’s axis of rotation. This placement of the fairlead cable decreases the excursion required to
flex the elbow but increases the required
force. The double lift assists compensate
for the additional force requirements.
This principle can be applied to hybrid
designs as well. Using lift assists and
cable positioning can greatly improve
functionality.
Excursion amplifiers can be used to
reduce the required excursion; however, increased force is required to flex
the elbow and open a terminal device
(Fig ure 11). Excursion amplifier pulleys generally decrease the excursion requirement by 50% but double the force
needed to activate the component.
Other design tradeoffs can be considered for body-powered prostheses for
shoulder-region amputations. Because of
the limitations to available excursion,
body-powered devices are often designed
to dedicate cable excursion exclusively
to the activation of the terminal device
while allowing the elbow to be passively
positioned. This allows the user to have
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
293
Section 2: Upper Limb
Figure 12
der disarticulation body-powered exoskeletal prosthesis with an excursion amplier and chest
strap. Anterior chest expansion creates terminal device activation through a dedicated Bowden
cable. Elbow exion is controlled with b iscapular abduct ion through a second ded icated cable. This
individual can capture additional excursion for both movements by applying pressure to the chest
strap as it passes through the sound-side axilla to modulate its relative position. He can reach back
with his sound-side brachium and compress the chest harness against his body wall to improve
excursion capture during bilateral scapular abduction. Similarly, reaching forward with his soundside brachium and compressing the harness against his body improves cable excursion during
chest expansion.
full activation of a hook or a hand, despite the inherently limited excursion
capabilities. This mechanical tradeoff is
accomplished by using a Bowden cable
instead of a fairlead cable (Figure 12).
After the elbow is passively placed in a
midline position, 2.5 inches of captured
scapular motion allows the user to open
the terminal device for grasping.
Another tradeoff to consider for humeral neck–level body-powered prostheses is an intentional reduction of
socket stability. Because body- powered
prostheses require captured excursion
and force through a harness, it is sometimes advantageous for the humeral
neck–level socket to have less stability.
This can be accomplished by designing a smaller socket footprint that will
displace distally from the residual limb
during glenohumeral flexion and capture additional cable excursion.
Anterior (A) and po sterior (B) photographic vi ews of an individual wearing a sho ul-
more commonly, body-powered or passive elbows coupled with myoelectric
terminal devices
14,21
(Figures 13 and
14). Hybrid designs offer a lighter-weight
option compared with a fully externally
powered system and reduce the excursion requirements by approximately
50% of those seen in fully body-powered designs. At the humeral neck and
glenohumeral levels, the individual can
use biscapular motion to position the
prosthetic elbow through a harness
and control cable and myoelectrically
control the terminal device. At the interscapulothoracic level, the elbow can
be passively positioned by the soundside extremity, preserving myoelectric
sites for control of the terminal device
(Figure 14). Socket designs for hybrid
systems should provide a stable platform
to ensure that the electrodes will remain
in the proper position and provide consistent control. Hybrid designs also may
Hybrid Prostheses
Hybrid prostheses combine various
afford proprioceptive feedback through
the harness regarding elbow position.
technologies and can be designed in
many configurations, including externally powered elbows coupled with
body-powered terminal devices and,
Externally Powered Prostheses
Externally powered devices typically
use a powered elbow, powered terminal
Figure 13
dividual wearing a humeral neck–level hybrid
prosthesis with a passive locking elbow and an
externally powered hand. A Sauter half-andhalf socket design uses an integrated shoulder saddle that allows the acromion and bony
anatomy to exit the socket. The weight of the
components is then supported by the integrated saddle. The socket footprint on these socket
designs closely approximates transhumeral
designs.
Clinical photograph of an in-
device, and, in some instances, electric
wrist rotation. These components can
be set up and controlled in many configurations. Some of the input options
for controlling an externally powered
device include myoelectric surface
electrodes, switches, force-sensing resistors, and linear transducers. In some
instances, multiple inputs are required
to gain the desired function. These devices are often programmed wirelessly
using a graphic user interface and allow
the selection of multiple control strategies to customize function based on
the unique capabilities of the individual. The socket interface for externally
powered devices should be designed for
comfort, good suspension, heat dissipation, and stability (considering the additional weight of an all-electric system). A
stable socket ensures consistency of control for externally powered prostheses
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
294
and offers important functionality for
individuals with limb loss about the
shoulder region.
5
Recently, targeted muscle reinnervation surgery has been associated with
several advantages, including longterm neuronal pain management and
improved simultaneous myoelectric
control (the ability to simultaneously
control movements at multiple prosthetic joints).
22-25
The latter is more
fully realized when targeted muscle reinnervation is combined with pattern
recognition–based systems in which microprocessors recognize specific characteristics of differing myoelectric signals
and classify them into desired functions.
Various methods for advanced signal acquisition are currently being evaluated;
however, the best method to capture information from the nerves is still being
investigated.
21
Atypical Presentations
in the Shoulder Region
Brachial Plexus Injuries
Individuals with brachial plexus nerve
injuries often have similar functional
capabilities as those with amputations
about the shoulder region (depending on
the completeness of the brachial plexus
injury). Because of the lack of protective sensation, many individuals with a
brachial plexus injury will unknowingly
damage their upper limbs and are often presented with the choice of elective
amputation. If the individual has good
scapular excursion and strength and
there is no functional return expected,
a midlength transhumeral amputation
with glenohumeral arthrodesis can be
considered by the rehabilitation team.
The goal is to improve limb functionality
with or without a prosthesis.26
Arthrodesis of the glenohumeral
joint allows the individual to position
the humerus using scapular motion and
prevents shoulder subluxation. In these
cases, the glenohumeral joint is typically fused in 30° of flexion and 30° of
abduction. This fusion position allows
Chapter 23: Amputations About the Shoulder: Prosthetic Management
Figure 15
region of a patient 24 months after arthrodesis
for a brachial plexus nerve injury. (Courtesy of
Abraham Appleton, MD, Sayre, PA).
Radiograph of the shoulder
orthotic devices.3 This type of surgical
Figure 14
dividual with an interscapulothoracic-level
amputation tted with a provisional hybrid
prosthesis with a passive elbow and an externally powered hand.
Clinical photograph of an in-
the user to maintain axilla hygiene and
places the limb in an optimum position
for prosthesis use (Figure 15). Prosthetic management of such patients draws
on the general principles described for
other shoulder-level amputations. In
general, a brachial plexus injury is a
predictor of poor prosthesis use.
23
resection does not lend itself to allowing
the patient to carry objects of substantial
weight or position the forearm in greater than 90° of flexion for midline tasks
(Figures 16 and 17).
Bilateral Shoulder
Region Considerations
The prosthetic needs of individuals
with bilateral limb loss differ greatly
from those with unilateral limb loss. In
bilateral amputations about the shoulder region, the rehabilitation team must
consider all options to improve functionality, including limb lengthening for
Tikhoff-Linberg Procedure
In malignant lesions in which the
shoulder girdle must be removed but
the distal humerus, forearm and hand
are uninvolved, a Tikhoff-Linberg procedure may be considered by the rehabilitation team. In contrast to a shoulder
disarticulation, this procedure can preserve function in the arm and hand.
Although these cases are relatively rare,
they can be treated with a prosthesis using thoracic socket design concepts. The
Tikhoff-Linberg resection can be challenging to stabilize with prosthetic and
amputations at the level of the humeral
neck.27 Regardless of hand dominance
before amputation, in bilateral highlevel amputations, the longer residual
limb typically becomes the dominant
limb. Component selection is critical in
designing a functional prosthesis to improve the bilateral amputee’s indepen-
1,2
dence. A successful protocol for fitting
bilateral amputations in the shoulder
region consists of fitting the dominant
residual limb with a body-powered
system and the nondominant residual
limb with an externally powered system
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
295
Section 2: Upper Limb
Figure 16
Rheinstein, CP, FAAOP, Hanger Clinic, Austin, TX).
Figure 17
humeral support. B, Appearance of the prosthesis in place. C, The prosthesis aords a good cosmetic result under clothing.
(Figure 18). This protocol provides
some control differentiation between the
bilateral prosthetic arms. An important
consideration is providing a secondary
set of prostheses. This ensures that the
individual has a working set of prostheses in the event that the primary set
requires major repair.
The Rehabilitation Team
Using a team approach for the rehabilitation of a patient with a high-level
amputation about the shoulder region
can improve both short- and longterm outcomes. This is especially true
in those patients with bilateral upper
limb amputations. The rehabilitation
team approach should consist of a patient-centered model with access to the
Anterior (A), lateral (B) and posterior (C) clinical photographs of an individual with a Tikho-Linberg resection. (Courtesy of John
Clinical photographs of a patient who was treated with a Tikho-Linberg resection. A, Anterior view of a thoracic socket design with
surgeon, the physical medicine and rehabilitation physician, the psychologist,
the physical therapist, the occupational
therapist, and the prosthetist. The team
and patient should work together to develop the best prosthetic prescription to
accomplish activities of daily living and
work-related tasks.
It is imperative that the rehabilitation professionals are acutely aware of
the psychological aspects of limb loss.
The process of going through an amputation has been described by many
amputees as similar to going through
a grieving process, and it can affect all
aspects of the patient’s life. Individuals
experiencing amputation may also present with emotional stress related to the
unknown. Educating the individual so
that he or she understands the rehabilitation steps and the expected functional
return can alleviate some of these stress
ors. Individuals with amputations can
benefit from meeting others with a similar amputation level. This can provide
renewed hope for future functionality.
There are many organizations, including the Amputee Coalition of America,
the Amputee Empowerment Program,
and local peer support groups that can
help new amputees and their families
cope with the life-changing effects of
limb loss.
With the rapid advancement and
improvements in the functionality of
prosthetic components, comprehensive occupational therapy is required
to ensure optimal functional outcomes.
-
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
296
Chapter 23: Amputations About the Shoulder: Prosthetic Management
Figure 18
upper limb amputation with a body-powered device on the right side and an externally powered
device on the left side.
Occupational therapy in using prosthetic devices provides a foundation for the
amputee to overcome functional challenges and live a productive life.28 As
prosthetic technologies continue to advance, it is anticipated that there will be
an increasing need for therapists with
experience in the latest technologies.
Anterior (A) and posterior (B) photographic views of an individual with a bilateral
with occupational therapy provide the
best scenario for success. A thorough
knowledge of each type of prosthesis,
including features, indications, and
contraindications, allows the amputee
and rehabilitation team to make the best
decisions. A thorough knowledge in the
subtleties of component selection and
alignment of the various joint segments
Summary
The upper limbs are amazing instru
ments capable of accomplishing sophisticated tasks. Designing upper
limb prosthetic devices to replace limb
loss about the shoulder presents many
optimizes the functional characteristics
-
of the final prosthesis. Thorough evaluations and a patient-centered approach by
the rehabilitation team should improve
functional outcomes for those with am-
putations about the shoulder region.
challenges. Amputation levels need to
be evaluated closely, and the prosthesis should capitalize on the remaining
functional features of the individual’s
residual limb. It is important to understand that one socket type may not work
in all prosthetic approaches. Socket design considerations in the successful use
of a prosthesis for shoulder region amputees include comfort, anatomic contouring, stability, heat dissipation, and
suspension. Designing and selecting the
appropriate prosthetic components to
match the individual’s activities of daily
living and work-related tasks coupled
Acknowledgments
Abraham Appleton, MD, is thanked for
his clinical leadership in orthopaedics
and his contribution to this chapter.
The following individuals are thanked
for their contributions to this chapter
and their clinical leadership in the spe-
cialty field of upper limb prosthetics:
Jack E. Uellendahl, CPO; James Thom-
as Andrew, CP; John Rheinstein, CP,
FAAOP; and Leigh Radizon. Family
members Christina, Grady, and Logan
are thanked for their support during the
writing of this chapter.
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Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
298
Chapter 24
Bilateral Upper Limb Prostheses
Jack E. Uellendahl, CPO
Abstract
Aer a bilateral upper limb amputation, the ability to perform basic and routine tasks,
such as eating and self-care, become dicult or impossible without assistance. e goal
of prosthetic rehabilitation for a patient with a bilateral arm amputation is to enable the
individual to achieve functional independence and to successfully participate in vocational and recreational pursuits. Subtle details of socket t, control system conguration,
and suspension can sometimes mean the dierence between success and failure. Success
relies on selecting the most appropriate components, matching those components with
optimal control sources, and interfacing them with the human body in a comfortable and
functional manner. Equally important is the user’s dedication and motivation to succeed
in the face of adversity.
Keywords: bilateral arm prostheses; bilateral upper limb amputee;
body-powered prostheses; myoelectric
Introduction
Bilateral upper limb amputation is a profound loss for an individual. The ability
to perform basic and routine tasks, such
as eating and self-care, become difficult or impossible without assistance.
Prostheses and other assistive devices
can enable the users to regain a measure of their lost ability to manipulate
objects and allow them to successfully
accomplish a variety of tasks. However, replacement of the many exquisite
features of the physiologic hand is not
yet possible. Even simple tasks require
an amazing amount of complex manipulation. For example, these words
were typed using 10 fingers working in
concert. Each finger performs both independent and coordinated simultaneous
functions, relying on sensation and precise positioning to accurately produce
Mr. Uellendahl or an immediate family member is an employee of Hanger Clinic and New Touch
Prosthetics. is chapter is adapted and updated from Uellendahl JE: Bilateral upper limb prosthesis, in Smith DG, Michael JW, Bowker JH, eds: Atlas of Amputations and Limb Deciencies:
Surgical, Prosthetic, and Rehabilitation Principles, ed 3. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2004, pp 311-325.
the intended result. These abilities often
are taken for granted until they are lost.
The goal of prosthetic rehabilitation
for the bilateral arm amputee is to enable
the individual to achieve functional independence and successfully participate
in vocational and recreational pursuits.
Although bilateral arm prostheses restore only a small amount of the lost
functionality, users are able to perform
many activities that otherwise would
be impossible. Subtle details of socket
fit, control system configuration, and
suspension can sometimes mean the
difference between success and failure.
Unlike a patient with a unilateral arm
amputation, a patient with a bilateral
arm amputation does not have the option of compensating for the inadequacies of a prosthesis by using his or her
intact physiologic arm.1 Every detail of
prosthetic design should be optimally
accomplished. Because of the inability
to duplicate the diverse and complex
functions of the human arm, prosthetic
systems should be viewed as tools with
different components best suited for
different applications. Success relies on
selecting the most appropriate components, matching those components with
optimal control sources, and interfacing
them with the human body in a comfortable and functional manner. Equally
important is the user’s dedication and
motivation to succeed in the face of
adversity.
Patient Evaluation
Because of the complexity of bilateral
upper limb loss and the fluid nature of
the early rehabilitation period, a thorough evaluation of the new bilateral
arm amputee should take place over a
period of time. Most individuals who
sustain bilateral upper limb amputations
have experienced a traumatic injury and
have additional medical comorbidities
beyond limb loss. Ideally, a team of experienced professionals should work together to address the many challenges
facing the new amputee. The treating
or consulting professionals may include
an orthopaedic surgeon, a physiatrist, a
prosthetist, an occupational therapist,
a physical therapist, a psychologist, a
nurse, and a social worker. In addition,
the access to peer support is an invaluable adjunct to the care and treatment
provided by medical professionals. The
patient, as the center of the team, will
ultimately determine several aspects of
his or her own care, including which
type of prosthesis is preferred.
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
299
Section 2: Upper Limb
Figure 1
has developed remarkable dexterity and manipulative foot function. B, Photograph of a man with
acquired bilater al upper limb loss. Adults usua lly do not develop remarkab le foot function but may
nd foot use an ecient alternative to prosthetic function for tasks away from the body.
Factors that affect the selection of
the prosthetic component and control
scheme include cognitive level, mechanical aptitude, family life, occupation,
hobbies, and self-image. Residual limb
length, strength, and range of motion of
the upper limbs, including scapulothoracic motion, should be evaluated. These
factors have direct implications regarding the method of fitting the prosthesis. The general strength and flexibility
of the lower limbs should be assessed.
With more proximal amputations, foot
use should be encouraged, with training
dedicated to exploring and developing
the manipulative capabilities of the feet
(Figure 1). Alternatively, individuals
with comorbid lower limb involvement may need to use their upper-limb
prostheses to hold and transfer weight
through an assistive device (Figure 2).
At the conclusion of the initial evaluation process, a defined plan should be
in place regarding the prosthetic component selection and control. However, the
team should also be flexible and open
to change throughout the rehabilitation
process. It should be expected that the
prosthesis configuration will change
over time in response to the changing
needs and abilities of the user.
Throughout the evaluation process,
the prosthetist should consider the advantages and disadvantages of various
A, Photograph of an individual with a bilateral congenital upper limb absence who
component and control options as they
relate to the specific individual. To give
structure to this evaluation process, it is
useful to understand the attributes of the
ideal prosthesis and then compare those
attributes to available technologies.
The ideal prosthesis would restore
the appearance and function of the lost
limbs and control would be intuitive
and subconscious. The ideal prosthetic prehensile device would be a lightweight, durable hand that is capable of
manipulating a wide variety of objects
that differ in size, shape, and texture.
The characteristics of the objects would
be related back to the user through a
sensory feedback system. Proprioception regarding the speed of prosthetic
movement, the force exerted, and the
position of the prosthetic device would
be inherent.
Currently available, state-of-the-art
prostheses and prosthetic prehensile
devices fail to meet all of these criteria.
However, considering the needs and
priorities of each individual and comparing these against the attributes of
each prosthetic component and control
scheme will help achieve optimal use of
current technology.
Although this chapter primarily
focuses on the management of adult
amputees, many of the concepts may
have application for the management
Figure 2
needs an assistive device for ambulation. The
design of the upper limb prosthesis should
take into consideration how to best hold the
assistive device and comfortably distribute the
pressure of partial weight bearing through the
upper limbs.
Photograph of a patient who
of children. However, because of their
small size and often immature cognitive ability, children cannot be treated
as small adults. Pediatric cases are characterized by decreased force and excursion and a lower tolerance for weight
and prosthesis complexity. Congenital
bilateral limb deficiency is very rare,
and the issues regarding prosthetic fitting can be quite different from those of
adults. Children will often learn to use
their feet with remarkable dexterity to
augment their manipulative capabilities2
(Figure 3).
Staging of Care
In all patients with an arm amputation,
whether unilateral or bilateral, it is advisable to fit the prosthesis as soon as
possible, preferably within the first 30
to 90 days. The period of 30 days after amputation has been referred to as
the golden fitting period for upper limb
prosthetic devices, leading to optimal
acceptance and usage.3 There are many
advantages to early postoperative fitting,
including decreased edema and pain,
accelerated wound healing, improved
patient rehabilitation, decreased length
of hospital stay, increased prosthetic use,
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
300
Chapter 24: Bilateral Upper Limb Prostheses
Figure 3
acquired bilateral very short transhumeral amputations demonstrating the superior manipulative function provided by his sensate feet as
he stabilizes the object with his prosthesis.
Photograph of a young boy with
maintenance of some continuous type
of proprioception input through the residual limb, and improved patient psychological adaptation to amputation.3 In
patients in whom other injuries or other
complicating factors make fitting within the golden period infeasible, it may
be necessary to delay prosthetic use. In
many patients, one side may be ready to
fit before the other, and it is advisable to
do so. Initially, providing a prosthesis on
one side only is often desirable.
Prosthetic training should begin using a component configuration and control scheme that is as simple as possible
to prevent the patient from experiencing
“gadget overload.” This is especially true
at higher levels of amputation where the
possibility exists for multiple dynamically positioned components on each
limb. In these cases, it is advisable to
introduce new components sequentially,
allowing time for the user to become
accustomed to each new device before
increasing the overall complexity of the
prosthesis.
Given the dynamic nature of prosthetic rehabilitation of the bilateral
arm amputee, it is useful to develop
short- and long-term goals. As the
skills of an amputee develop, his or her
Figure 4
prototype prostheses that allow her to experience the use of various components before
implementation in the nal design. Prosthesis
alignment, length, and other parameters can
be evaluated and optimized during this stage
of the tting.
Photograph of a patient with
medical condition stabilizes and priorities change in response to the challenges of daily life. The optimal prosthetic
device, usage pattern, and individual
preferences also may change. It is reasonable to expect that this process will
take 6 to 12 months, depending on the
level of limb loss, the extent of other
complicating factors, and the speed at
which an individual adapts. A prototype
prosthesis is valuable during this period
because it will allow the amputee and
the rehabilitation team to evaluate various prosthetic systems before deciding
on a definitive prescription (Figure 4).
Short-term goals will generally focus
on mastering use of the prosthesis for
basic daily functions, including donning
the prosthesis, eating, and toileting.
Long-term goals may include dressing, vocational skills, and avocational
pursuits. During this period of experimentation, it is recommended that the
amputee spends most of his or her time
at home, returning to the rehabilitation facility periodically for prosthetic
modifications and additional training.
This allows the user to determine which
prosthetic configurations work best in
real-life situations and identify specific
problems that need attention during the
next consultation with the rehabilitation
Figure 5
can sometimes be expanded by repositioning
the prosthesis on the limb. Photograph of a
man retrieving his wallet from his back pocket, which requires operation of the prosthesis
hook behind his back.
A patient’s functional envelope
team. It is reasonable to expect that
complete independence will be achieved
by nearly all patients, except those with
the loss of both limbs at or above the
transhumeral level or in patients with
other limiting factors. However, even
some bilateral transhumeral amputees
are able to attain complete independence
in accomplishing daily tasks.
Socket Design
Generally, socket designs for the bilateral amputee do not differ from unilateral designs. However, because of the
absence of both hands, it is necessary
to consider the donning ease and the
positioning flexibility of the prosthesis.
Positioning flexibility includes the range
of motion of the intact physiologic joints
when a prosthesis is worn and, in some
instances, the ability to reposition the
prosthesis in useful ways at the limb
socket interface to increase the scope
of functional use (Figure 5).
Although the socket may not be completely self-suspending, the interface
should fit snugly and work with the suspension system to provide a prosthesis
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
301
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