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Section 2: Upper Limb
Figure 19
Crank Adaptor, a speciali zed prosthetic adapter
for shing. (Reproduced with permission from
Texas Assistive Devices, Brazoria, TX.)
Figure 21
rod. (Reproduced with permission from Texas Assistive Devices, Brazoria, TX.)
fishing environments. The prosthetic
Fishing Rod (Texas Assistive Devices) is
designed to allow the rod to be directly
connected to the prosthesis or interim
wrist component. The Universal Handle Holder (Texas Assistive Devices) can
be used to capture and support the rod
near the reel (Figure 21). Myoelectric
or externally powered hands and terminal devices are capable of handling
a rod and reel but, because of the water
environment and chance of immersion,
these types of technologies are not often
used for fishing.
Fly fishing presents additional
challenges to the person with a hand
Photograph of the All Purpose
Photograph of the Universal Handle Holder terminal device supporting a shing
Figure 20
minal device for shing. (Reproduced with permission from TRS, Boulder, CO.)
Photograph of the F~ISHI ter-
absence because of the complexity of actually handing the fly line while casting
and retrieving. The rod must be controlled by a healthy hand and arm for
accurate casting. A prosthesis equipped
with a gripping device (Figure 22) is
capable of handling the delicate line
for line retrieval and allows reeling in
a wet environment. Automatic retrieval
fly reels bring in slack line, but they are
not capable of manipulating the retrieval of a wet fly line or strong enough to
bring in a fish without the assistance of
another hand or specialized prosthetic
gripping device. Electric retrieval fishing
reels with rechargeable battery packs
are available for those with more severe
upper limb involvement. Alternately, the
simplicity of the one-handed tenkara
fly fishing technique may be preferred.
Canoeing, Kayaking,
Paddling, and Rowing
The first commercially available prosthetic device for kayaking, the Hammerhead (TRS) was developed in the
mid 2000s at the request of rehabilitation personnel at Walter Reed Hospital (Figure 23). Kayaking was seen as
valuable therapy (strengthening core,
shoulder, and arm musculature and
helping improve ROM) for injured military personnel.
Activities such as canoeing, kayaking, and rowing require the user to perform a wide range of gross motor, upper
body movements while controlling and
powering an oar or paddle through the
water. The Hammerhead device can replicate the degrees of freedom required to
handle a paddle and propel it efficiently,
thus creating propulsion. Certain terminal devices are capable of handling
oars and paddles, but an activity-specific
device, such as the Hammerhead, provides improved function and enhanced
performance because of its ROM, flexible energy capture, and release capabilities, which mimic the human wrist
and forearm.
Crew and other rowing water sports
use oars rather than paddles. Oar handles are typically larger in diameter than
paddle handles and some oars have
convex-curved, gripping areas that can
provide additional holding challenges
for a prosthesis user. A device is available with a quick-release ratchet strap
system that securely controls the tension
of two flexible, polymer “mandibles”
that wrap around and provide tension
on the oar handle (Figure 24).
Externally powered prostheses are
usually not applied to these types of activities because of the rugged use they
would experience, the limited degrees
of freedom they provide while holding
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
372
Chapter 30: Upper Limb Adaptive Prostheses for Vocation and Recreation
Figure 22
duced with permission from TRS, Boulder, CO.)
Figure 24
(Reproduced with permission from TRS, Boulder, CO.)
an oar, and the adverse effect of a wet
environment on the internal electronic
elements in this type of technology.
Photograph showing the Grip 3 handling a delicate line for y shing reel. (Repro-
Photograph of the Multi-D terminal device that can be used to hold an oar handle.
is possible because the forces involved
during a fall or impact could break the
lower arm, elbow, or humerus of a prosthesis wearer. Several adaptive prosthet-
Hockey
Hockey requires quick reflexes, substantial gross upper limb motor movements,
and the need to accurately control a
hockey stick. Rigidly attaching a stick
ic devices are available that allow for safe
and effective control of a hockey stick,
including options for “top-handing”
or “shaft-handling” the hockey stick
(Figure 25).
to a prosthesis is ineffective, and injury
Figure 23
head terminal device for kayaking. (Reproduced with permission from TRS, Boulder, CO.)
Photograph of the Hammer-
Snow Skiing, Water
Skiing, and Trekking
Highly specialized activities such as
downhill and cross-country skiing
are challenging. In cross-country skiing, the upper body is highly involved
in the propulsion of the skier over the
snow. In downhill skiing, a prosthesis
controlling a ski pole can aid balance
and maneuvering through moguls and
rough terrain or varying snow conditions. Two commercial devices with
different designs exist for snow skiing,
the Ski/Fish terminal device or Ski
Hand (Hosmer; Figure 26), and the Ski
2 (TRS; Figure 27). The Ski Hand is a
one-piece molded silicone fist-shaped
device into which the ski pole is forcefit. The normal grip on the ski pole is
removed and inserted almost vertically
into the Ski Hand, where the flexible
silicone allows the pole to be snapped
forward, using its weight for momentum through a pendulum-type action
initiated by the forearm and elbow.
In contrast, the pole held in the Ski 2
mechanically pivots on the end of the
prosthesis and can be activated either
with a pendulum thrust of the arm or,
preferably, cable-driven for an accurate,
controlled pole “plant.” The cable excursion technology eliminates unnecessary
upper body movement, which allows
for improved, balanced downhill skiing
form. During cross-country skiing, the
cable drive provides efficient pole extension and placement while propelling the
skier on flat terrain or while climbing.
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
373
Section 2: Upper Limb
Figure 25
Power Play are shown. (Reproduced with permission from TRS, Boulder, CO.)
Figure 27
nal device. (Reproduced with permission from
TRS, Boulder, CO.)
The pole remains slightly retracted and
Photographs of terminal devices for holding a hockey stick. The Slap Shots and
Photograph of the Ski 2 termi-
Figure 28
permission from TRS, Boulder, CO.)
Photographs of custom-made rock climbing terminal devices. (Reproduced with
clear of the snow when the cable tension
is relaxed.
with a high risk of injury and death and
must always be approached with cau-
Mountaineering and
Technical Rock Climbing
Prosthetic adaptations for technical
climbing, whether in natural outdoor
tion. The prosthetist must be aware of
the liability and legal exposure involved
when providing climbing prostheses to
patients.
environments or indoor gyms, have
traditionally been custom-made (Fig-
ure 28). These designs incorporate standard technical rock climbing hardware
such as leepers, sky hooks, and picas
onto a custom pedestal that mounts securely to the prosthesis. The Grip 2SS
(TRS) voluntary-closing device has been
modified into a rock climbing device by
integrating a modified sky hook onto
one side of the prehensile device (Fig-
ure 29). This preserves the function of
the device while providing a laterally
mounted precision hook element for engaging and grasping rock “holds.” However, climbing is a dangerous activity
Firearms and Shooting
Holding, stabilizing, and firing a rifle,
shotgun, or carbine with a prosthesis
is possible, and several prosthetic de-
vices have been designed specifically for
such activities. Three variations of the
rubber-coated Tool Cradle (Texas Assis-
tive Devices; Figure 30) are available to
support the fore end, forearm, or front
stock portion of a rifle or shotgun. One
version of the Tool Cradle pivots for im-
proved firearm balance and control. The
Lamprey Gun Turret (TRS; Figure 31) is
an adapter that securely grasps the stock
of the gun with a flexible yoke system
Figure 26
Hand. (Reproduced with permission from Hosmer, Chattanooga, TN.)
Figure 29
terminal device for climbing. (Reproduced with
permission from TRS, Boulder, CO.)
Photograph of the Ski and Fish
Photograph of the Sky Hook
mounted to a pivoting, lockable balland-socket system and allows the shooter to swing the firearm above shoulder
level without losing control of the gun.
It can be used for bench target shooting,
in trap and skeet competitions, or for
hunting.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
374
Chapter 30: Upper Limb Adaptive Prostheses for Vocation and Recreation
Figure 30
being used to stabilize a rearm. (Reproduced
with permission from Texas Assistive Devices,
Brazoria, TX.)
Photograph of the Tool Cradle
Road and Mountain Bicycling
Bicyclists must be able to securely and
quickly manipulate handlebars, brake
levers, and the gearshift for performance
road or mountain biking pursuits. Voluntary-closing prostheses can be used
in these applications, although they are
not specifically designed for bicycling.
A nonspecific prehensile device has the
advantage of functioning for other activities such as changing punctured tires
and performing bicycle repairs. Modern
bicycle technology and accessories for
gear shifting and braking are compact
and offer multiple control modalities
such as thumb paddles, levers, twist
grips, and even electronic shifting options to help meet the needs of an individual with a hand absence or limited
hand function. These technologies can
be individually selected and combined
to achieve optimum performance and
control.
Specialized adaptive prosthetic technology for bicycling has been available
since the early 2000s. Some of these devices use strong, flexible, molded polyurethane to create components that snap
on and off the handlebars (Figure 32).
The Criterium Pivot (TRS) replicates
radial and ulnar wrist deviation for
comfortable and versatile handlebar
control. Devices designed primarily for
road biking may not function satisfactorily during the rigors of mountain,
trail, or competitive biking. Such riding
environments and styles may be better
managed with a more robust design
Figure 31
(Reproduced with permission from TRS, Boulder, CO.)
Figure 32
terminal devices, which can be used to grasp the handlebars for cycling. (Reproduced with permission from TRS, Boulder, CO.)
such as Mert’s Hand (Mert Lawill Concepts). In this design a shaft attaches to
the prosthesis at the wrist, with a distal
ball mount that engages into a socket assembly installed on the handlebar. The
ball-and-socket connection provides a
range of unrestricted movement but (for
safety) will release when movements exceed its travel limit.
In an alternate approach, The Hand
(Advanced Prosthetic Technologies) is
attached directly to the handlebar allowing unrestricted motion. The connection
Photograph of the Lamprey Gun Turret being used to grasp the stock of a gun.
Photographs (from left) of the Criterium, Criterium Wedge, and Criterium Pivot
point with the prosthesis occurs at the
wrist and can be released when necessary by pulling a cord held in the sound
hand. In transhumeral applications,
The Hand can be attached to The Arm
(Advanced Prosthetic Technologies;
Figure 33). The prosthetic elbow mechanism has a hydraulic shock absorber
that is designed to absorb impact forces transferred through the frame of the
bicycle.
Another device, the Dual Bike
Brake Lever system (TRS), was initially
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
375
Section 2: Upper Limb
Figure 33
a bicycle. (Courtesy of Phillip M. Stevens, MEd, CPO, Salt Lake City, UT.)
Photograph of a patient using The Arm and The Hand to grasp the handlebars of
developed for tandem bicycles. It controls two brake cables simultaneously
and is a good option for riders with a
prosthesis. Clustering all the controls
to one side for operation with a sound
hand simplifies cycling. The prosthesis
is used primarily for handlebar control
and balance.
Motorcycling, OffHighway Vehicles, and
Motor Vehicle Control
Vehicle steering, gear shifting, and
overall motor vehicle control requires
secure gripping capability and, in
many instances, quick reflexive release
action. Voluntary-opening split-hook
prostheses have proved inadequate
when applied to most vehicle control
circumstances because the terminal device cannot provide reliable prehension
during varying vehicle control situations. Myoelectric hands and electromechanical terminal devices are functional
for general automobile and motorcycle
operation, but are not as useful or reliable for off-highway and recreational
vehicle control. The previously described Mert’s Hand provides a secure,
versatile connection to handlebars and
is frequently used in motorcycling appli
cations. Body-powered, voluntary-closing prehensile devices have provided
the type of reflexive grasp-and-release
action and gripping forces necessary to
handle automobile driving situations,
motorcycling, bicycling, and off-road
vehicle control. Typically, the brake,
clutch, and gear-shifting controls need
to be grouped together for single-handed
or foot-assisted operation; the prosthesis is used primarily for handlebar and
steering control.
Wrestling and Martial Arts
The Dragon terminal device (TRS; Figure 34) was developed for prosthesis
users who engage in intimate contact
sports such as wrestling or martial arts.
Figure 34
duced with permission from TRS, Boulder, CO.)
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
376
Photograph of the Dragon terminal device for wrestling and martial arts. (Repro-
This device was designed to emulate the
shape of a curled fist. The soft, flexible,
Chapter 30: Upper Limb Adaptive Prostheses for Vocation and Recreation
Figure 35
sion from TRS, Boulder, CO.)
Photographs of guitar, drum, and violin bow adapters. (Reproduced with permis-
polyurethane material absorbs the shock
of punches and has a friction coefficient
high enough to enhance grappling with
an opponent.
Equestrian Sports
A variety of prosthetic devices, including both voluntary-opening and voluntary-closing body-powered terminal
devices and myoelectric hands can be
used for controlling reins for riding
horses and other equestrian pursuits.
No specific adapters have been commercialized specifically for these types of
activities. One customized adapter was
developed specifically for calf roping. It
can capture a series of rope coils, freeing
the terminal device to hold and control
reins while the sound hand is used for
tossing a lasso.
Adapters for Musical Instruments
Commercially available prosthetic adapters for musical instruments are widely
used to initiate novices into the world
of musical instruments or provide experienced musicians with the opportunity to regain instrument playing skills
(Figure 35). These adaptive devices are
simple mechanical solutions that attempt
to duplicate the subtle wrist and forearm
biomechanical movements required for
accurate instrument playing. In most
instances, it is advantageous to mount
the terminal device as close to the end of
the limb as possible for improved control
and enhanced proprioceptive biofeedback. A specialized short prosthesis can
accomplish this objective. Attaching the
musical instrument adapter directly to
a roll-on–style silicone or similar type
liner is another option.
Miscellaneous Specialty
Prosthetic Adapters
Adaptive prostheses are available for
very specialized activities, including
photography, pool and billiard playing,
and skip roping. Such specialized products allow those with a hand absence
to indulge in a wide range of pursuits.
Partial Hand Absence
Fabricating a prosthesis for partial hand
absence and/or limited hand function is
challenging. The N-Abler wrist-hand
orthosis was introduced in 2003 (Fig-
ure 36). This wrist-hand orthosis system provides a viable solution to reliably
mount adaptive prostheses to the partial or disabled hand. Tools, domestic
implements, and sports accessories can
be readily connected and disconnected.
An alternative device is the PRO CUFF
(TRS), which mounts onto the forearm
behind the wrist and can accept tools
Figure 36
wrist-hand orthotic prosthesis. (Reproduced
with permission from Texas Assistive Devices,
Brazoria, TX.)
Figure 37
prosthesis. (Reproduced with permission from
TRS, Boulder, CO.)
Photograph of the N-Abler
Photograph of the PRO CUFF
and implements and other adaptive
sports and recreational attachments
(Figure 37). Unlike the wrist-hand orthosis brace system, it has no thumb
hole and does not provide wrist support.
Summary
The number, type, and sophistication of
adaptive or activity-specific prostheses
have been increasing since the 1980s.
Various factors influenced the growth
of this segment of prosthetic technology,
including the contributions of prosthesis users, manufacturers, the military,
adaptive sports organizations and programs, medical and rehabilitation professionals, the media, and the general
massive expansion of worldwide communications and consumerism via the
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
377
Section 2: Upper Limb
Internet. In addition, changes made in
the HCPCS directly affected the justification and credibility for prescribing
specialized, adaptive, upper limb prosthetic components.
These adaptive prostheses can satisfy
a wide range of needs, including both
vocational and recreational challenges.
Emphasizing the duplication of biomechanical function and increased ROM in
upper limb prostheses has substantially
enhanced the ability of users to participate and compete in various activities
in which “bilaterality” was difficult or
impossible to achieve in the past. A wide
variety of direct attachment tools, domestic use implements, and sports and
recreational adapters are now standardized and commercially available. Adaptive solutions continue to evolve. This
progress is a result of the success that
these prosthetic technologies provide to
users by enhancing their bilateral functional capabilities. Adaptive prostheses
improve patients’ rehabilitation potential and substantially increase their
performance in vocational and recreational activities that were not previously accessible. Adaptive activity-specific
components are excellent complements
to externally powered myoelectric prostheses. More economic adaptive components enable users to select the best,
most cost-effective prostheses to use for
a specific task or activity, extending the
life of more expensive bionic prostheses.
It is expected that the success of adaptive prostheses will continue to evolve,
develop, and increase in popularity in
the future.
References
1. Stark G: Prosthetic primer: Upper-extremity limb tting. InMotion 2001;11(4):47-52. Available at:
http://www.amputee-coalition.org/
inmotion/jul_aug_01/primer.pdf.
Accessed December 19, 2014.
2. Radocy B: Upper-extremity prosthetics: Considerations and designs for
sports and recreation. Clin Prosthet
Orthot 1987;11(3):131-153.
3. Radocy B: Upper-limb prosthetic adaptations for sports and recreation, in
Bowker JH, Michael JW, eds: Atlas of
Limb Prosthetics: Surgical, Prosthetic,
and Rehabilitation Principles, ed 2. St.
Louis, MO, Mosby-Year Book, 2002,
pp 325-344.
4. Radocy R: Prosthetic adaptations in
competitive sports and recreation, 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
327-338.
5. Radocy R: Upper limb prosthetics
for sports and recreation, in Lenhart
MK, ed: Textbooks of Military Med-
icine: Care of the Combat Amputee.
Falls Church, VA, Oce of the
Surgeon General of the United States
Army, 2009, pp 641-668.
6. Atkins DJ: Adult upper limb prosthetic training, in Atkins DJ, Meier
RH, eds: Comprehensive Management
of the Upper-Limb Amputee. New
York, NY, Springer-Verlag, 1989, pp
39-59. DOI
7. Radocy R, Furlong A: Recreation and
sports adaptations, in Meier RH, Atkins DJ, eds: Functional Restoration
of Adults and Children with Upper
Extremity Amputation. New York,
NY, Demos Medical Publishing,
2004, pp 251-274.
8. Baumgartner R: Physiotherapie und
ergotherapie, in Baumgartner R, Botta P, eds: Amputation und Prosthe-
senversorgung der oberen Exremitat.
Stuttgart, Germany, Ferdinand Enke
Verlag Stuttgart, 1997, pp 249-290.
9. Dupes B: Adaptive Recreation &
Activities: Getting Back in the Game.
Available at: http://www.ampu-
tee-coalition.org/inmotion_online/
inmotion-24-03-web/index.html#/1/.
Accessed October 3, 2014
10. Alley RD: Exploring the functional
performance of interface design:
Clinical matter. O&P Business News
June 15, 2003, pp 30-33.
11. Miguelez JM, Lake C, Coners D,
Zenie J: e Transradial Anatomically Contoured (TRAC) interface:
Design principles and methodology.
J Prosthet Orthot 2003;15(4):148-157.
DOI
12. Farley M: High- ies high in new
prosthetic interface: Tissue compression/release concept gains
control. e O&P Edge, 2010.
Available at: http://www.oandp.com/
articles/2010-08_03.asp. Accessed
December 19, 2014.
13. Patents: Finned phalangeal device.
CA 1322821C. Robert Gabourie.
Available at: http://www.google.com/
patents/CA1322821C?cl=en. Accessed
October 24, 2104.
14. Powerliing watch. Mike Hummel
benches 650 lbs. with prosthetic.
Available at: http://www.powerli-
ingwatch.com/node/9839. Accessed
October 3, 2014.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
378
Chapter 31
Functional Aesthetic Prostheses: Upper Limb
omas Passero, CP, AS Kim Doolan, BA, CPV
Abstract
A successful prosthetic outcome is best achieved by balancing the elements of form and
function. For individuals with congenital or acquired amputations, aesthetic prostheses
that incorporate active or passive function can aid in enhancing vocational, avocational,
and psychological rehabilitation.
Keywords: aesthetic prosthesis; congenital amputee; cosmetic
prosthetic restoration; finger prosthesis; lower limb amputee;
partial hand prosthesis; passive functional prosthesis; psychologic
considerations of amputation; upper limb amputee
Introduction
The role of aesthetic restoration in prosthetic rehabilitation remains somewhat
misunderstood and inconsistently applied. One factor that contributes to
the confusion surrounding the terms
aesthetic (commonly defined as characterized by a heightened sensitivity to
beauty) and cosmetic (defined as decorative rather than functional) is the
mistaken assumption that little to no
functional value is associated with this
type of prosthesis.1 However, prostheses with lifelike appearances are often
indicated for individuals with both upper and lower limb amputations and
deficiencies, whether acquired or congenital. Although well documented, the
importance of both the appearance and
the function of aesthetic prostheses are
not consistently discussed with the individual who has an amputation or limb
deficiency.
function and form contribute to a successful outcome, particularly for the individual with upper limb involvement.
Mr. Passero or an immediate family member is an employee of Prosthetic & Orthotic Associates
and Handspring Rehabilitation Upper Limb Prosthetic Care and has stock or stock options in
Touch Bionics and MYOMO. Ms. Doolan or an immediate family member is an employee of Allen
Orthotics & Prosthetics.
2-12
Prostheses that balance
Misconceptions regarding the importance of aesthetic considerations in
prosthetic treatment are common. Too
frequently, aesthetic restoration is considered as a last resort when a patient
rejects a more functional prosthesis.
However, comprehensive treatment
should consider all available prosthetic options for a given amputation level,
including the associated aesthetic implications, focusing on a patient’s ultimate
acceptance and integration of his or her
prosthesis.13 A thorough patient examination enables the informed practitioner
to reasonably rate the restoration of normal appearance among the goals set by
the rehabilitation team and the patient.
The highest quality lifelike aesthetic
restorations are made of silicone because
of its versatility and compatibility with
human tissue.
generally custom designed and fabricated to intimately fit the contours of
the residual digit or limb and reproduce
a realistic appearance in both texture
and color.
5,11,13,14
These devices are
History
In the 1950s, French physician Jean Pillet noted that the loss of a single digit
could profoundly affect an individual’s
body image, self-esteem, and psychological status.9 Pillet established clinics
around the world and pioneered the use
of silicone prostheses that were sculpted
and painted to match the characteristics
of individual patients. Two decades later,
Horst Buckner developed a new fabrication method to cover conventional prosthetic components, such as mechanical
and electric hands, with lifelike silicone
skin.15 Currently, many fabrication techniques and silicone grades are used by
large and small facilities.
Function
For upper limb amputees, the term
function is often associated with grasp.
However, activities that do not require
active manipulation, including static
prehension, balance, support, stabiliza
tion, pushing, pulling, proprioception,
and communication, are extremely
important.
A Dutch study divided the function
of cosmesis or aesthetics into three categories as follows: passive cosmesis (the
appearance of the device), the cosmesis
of wearing (the naturalness with which
the amputee wears the device), and the
cosmesis of use (the naturalness with
which the amputee uses the device).12
The appearance of the prosthesis carries
subtle psychosocial implications. An
aesthetic prosthesis balances the active
and passive functional characteristics of
the residual limb. For some wearers, the
appearance of the sound side is duplicated; for others, the mechanical or robotic
look of the prosthesis is emphasized.
1,4,6,8,12,16,17
-
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
379
Section 2: Upper Limb
Historically, the prosthetic management of finger and partial hand amputations has been disregarded because
of reduced prosthetic options resulting
from space limitations. However, because the thumb and fingers comprise
90% of human arm function, the loss of
one or more fingers has a substantial effect on hand function.1 A single aesthetic
prosthesis for an index finger actively
functions in prehensile activities such
as writing, grasping small objects, and
typing on a keyboard8 (Figure 1). For a
hand without a thumb and forefinger, a
partial hand prosthesis provides opposition to the remaining fingers. For those
with unilateral total hand amputation,
an aesthetic hand prosthesis provides
opposition to the sound hand while
performing bimanual activities and aids
with nonmanipulative tasks.
Individuals with more proximal
upper limb amputations can take advantage of the entire surface of the prosthesis because its use is not limited to
the terminal device (TD). It is common
to see a prosthesis user stabilizing a
book against the forearm, sandwiching a grocery bag between his or her
hip and the prosthesis, or pushing up
from a chair by placing weight against
the elbow componentry of the device.
Fraser2 noted that fewer than 25% of
individuals used a TD for active manipulation, which is overly emphasized as
a determinant for good prosthetic use.
Psychological
Considerations
Because amputation can affect both sexes, at any stage of life, in all countries
and cultures, and involve the limb in
part or entirely, there is tremendous
variation in the psychological responses of individual patients. In addition,
the individual’s response to amputation
does not necessarily correlate with the
level of amputation.
Frequently, an individual with a new
amputation may prefer a prosthesis that
mimics the appearance of the lost digit
1
Figure 1
and in use (B). (Courtesy of Touch Bionics, Manseld, MA.)
or limb. This is especially true of upper limb amputees who cannot conceal
their changed body as easily as lower
limb amputees. A natural-appearing
prosthesis allows the wearer to blend
in, to use his or her prosthesis in public, and not be singled out as different.
After the amputee has accepted his or
her changed body image, he or she may
be more comfortable wearing a more
mechanical or robotic-looking TD. Some
individuals who were provided a metal,
tool-like device shortly after amputation
reported feeling so self-conscious that
the prosthesis was removed and hidden away. Pillet noted that, “Often the
disfigurement is more pronounced in
the mind of the amputee than others.
However, the man who finds himself
unable to take his hand from his pocket,
even though it is very ‘functional,’ may
be as handicapped as if it were lost.”
Another opposite reaction, which is
becoming more common, is for amputees to prefer that their prostheses be
noticed and acknowledged. For those
individuals, the opportunity to talk
about their amputation, recovery, and
prosthetic choice is seen as a benefit to
themselves and others.
Photographs depict a passive functional ring nger prosthesis while detached (A)
reduce postoperative and phantom limb
pain; and help with desensitization, scar
management, and edema control.
Often, therapy may be of greater value if the manipulation of small objects
is deemphasized. Using the prosthesis
in everyday situations involving sup
porting, stabilizing, pushing, pulling,
holding, and facilitating balance can
have better results.2 Thus, training must
not be limited to controlling prehension
based on the erroneous assumption that
fine motor activities require a TD. For
a unilateral amputee, the prosthesis is
typically used to assist with nondominant movements.
van Lunteren et al12 observed that
many amputees were taught direct
grasp in clinical settings in which they
used their TDs to pick up and hold an
object. However, those who learned nat-
9
ural movement with a prosthesis taught
themselves this ability and frequently
used indirect grasp by picking up an object with their sound hand and transferring it to their TD. The amputee is best
served by training protocols that teach
not only control of prosthetic componentry (TDs, wrists, elbows, and shoul
ders) but also the most efficient way to
complete daily living, occupational, and
Rehabilitation Therapy
avocational tasks (Figure 2).
The need for rehabilitation therapy for
upper and lower limb amputees should
be recognized. Individuals with passive
functional upper limb devices also benefit from occupational and physical therapy. These therapies can improve overall
body schema, strength, and the flexibility and range of motion of nearby joints;
Prosthetic Compliance
A prosthesis must be comfortable, functional, and have a pleasing appearance to
be accepted and used by the amputee.7
Other priorities include reduced weight,
durability, ease of cleaning, and length
of operation (up to 12 hours).5 Amputees
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3
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Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
380
also frequently request that the prosthesis have the correct benefit-to-burden
ratio,12 making the prosthesis as unnoticeable as possible and preventing it
from becoming an encumbrance.
Comprehensive prescription development should consider the importance
of form and function to the patient. For
most prosthetic solutions, this entails
some level of compromise, trading elements of function for a more realistic appearance and vice versa. Identifying the
patient’s priorities based on his or her
anticipated use of the prosthetic device
at home, work, and/or in recreational activities facilitates better understanding,
and ultimately, acceptance of necessary
tradeoffs.
13
Finger Amputation
Full and partial finger amputations are
among the most frequently encountered
forms of partial hand loss.6 The benefits associated with silicone restoration
of digital amputations are well documented
functional and psychological improvements, as well as appearance. The length
of the residual finger is a primary consideration for several issues related to
prosthetic design. Other issues include
the method of suspension (suction or
mechanical), the length of the prosthesis (whether the proximal edge of the
prosthesis terminates at the proximal
interphalangeal or metacarpophalangeal [MCP] joint), the shape, the flexion/
extension range of the finger, and the
choice of a hard acrylic or soft silicone
fingernail (Figure 3, A).
attached primarily using suction, osseointegration has demonstrated benefits,
including increased pinch force and
transfer of deep pressure sensation.20
The risks of osseointegration include
those commonly associated with other
surgeries. This procedure is especially
useful when the digital residuum length
is insufficient to maintain acceptable retention. Additional methods of retention
8-10,18,19
and include a range of
Although most digital prostheses are
Chapter 31: Functional Aesthetic Prostheses: Upper Limb
Figure 2
pulling (B).
Figure 3
prosthesis for multiple digit loss. (Images courtesy of Touch Bionics, Manseld, MA.)
on short residual digits include the use
of medical adhesives, incorporation of
vacuum chambers in the distal portion
of the prosthesis, and the use of adjacent
fingers and rings to anchor the prosthesis to the hand (similar to a dental crown
and bridge)21 (Figure 3, B).
Because suction is the primary means
of suspension for most passive silicone
finger prostheses to the residual digit,
it must have sufficient length (minimum, 1.0 to 1.5 cm)
shape (ideally, cylindric or bulbous). In
contrast, a short length combined with
a conical shape makes suspension unreliable, and the previously mentioned
alternative retention methods can be
Photographs show upper limb prostheses with indirect grasp for stabilizing (A) and
A, Photograph of nger prostheses for single digit loss. B, Photograph of a nger
used. If the involved hand has multiple, short residual fingers, a glove design
may be needed to establish attachment
and retention that is firm enough to
withstand the force required to grasp
and hold objects.
If the middle or distal phalanx of the
involved digit has sufficient length and
shape to adequately maintain suspension, a half-finger prosthesis is generally
indicated. This prosthesis would ter-
6,9
and appropriate
minate at the proximal interphalangeal
joint, with a feathered proximal edge
to minimize the transition between the
silicone and the natural tissue and avoid
limitations in joint range of motion. A
full-finger prosthesis terminating at
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
381
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