Intro to Upper Extremity
Prosthetics
Matthew J. Mikosz, CP
David Knapp, CPO
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History of U.E. Prosthetics
• Major advancements in design and control
• A look towards the future
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1st U.E. prosthesis
• Passive prosthesis
• Earliest historical record 218201 B.C.
• Roman general, Marcus Sergius
• Iron hand by armor makers
• No major advancements until
the 19th century
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1st body powered prosthesis
• 1812 Peter Balif, dentist from Berlin
• Designed a harness that could open and
close an artificial hand
• Became today's figure 8 and figure 9
harness
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1st split hook design
• 1912 by D. W. Dorannce
• Shift from cosmetic to function
• Many activity specific designs
– Plumbers: designed to hold pipe
– Farmers: designed to hold wire
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1st external power
• 1950’s- Designed with
pneumatic and
electronic switch
controls
• 1960’s Russian Arm
– “thought control”
– Emg signals to control
TD
• 1990’s microprocessor
control
• Current- Targeted
muscle re-innervation
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Future of U.E. prosthetics
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Osseointegration
Implanted EMG sensors
Direct attachment to CNS
Sensory integration
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Osseointegration
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Direct attachment to bone
No socket needed
Problems with infection
Currently only performed
in Europe
• Possible US center at
Mass General soon.
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Osseointegration
• Can be used with
myoelectrics
• Maximize existing
ROM
• Many procedures
performed in
Europe to date
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Osseointegration
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Shoulder Joint
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Glenohumeral
Acromioclavicular
Sternoclavicular
Scapulothoracic
– Functional joint
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Current
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Glenohumeral joint
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Ball and socket joint
Flexion 180o
Extension 60o
Maintain good ROM for
prosthetic control
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Glenohumeral joint
• Adduction 180o
Abduction 50o
• Rotation
– Internal 80o
– External 60o
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Acromioclavicular Joint
• Provides motion in 3 planes
– Not used for Prosthetic control
– AP gliding of acromion during
protraction & retraction of scapula
– Tilting of acromion during
abduction & adduction of arm
– rotation of the clavicle
– Provides minimal motion for
prosthetic use
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Sternoclavicular
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Protraction 15o
Retraction30o
Elevation 40o
Depression 10o
Anteriorposterior
rotation 50o
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Scapulothoracic
• Scapular abduction
is another term
used to describe
retraction
• Functional joint
• Upward/downward
rotation
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Control System
• Glenohumeral flexion
– Excellent force
– Excellent for prosthetic
control
• Glenohumeral
Abduction
– Excellent force
– Excellent excursion
• Scapular Abduction
– Excellent strength
– Poor excursion
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Shoulder Depression
Mod. force
Mod. excursion
Used - elbow lock
Chest Expansion
Mod. strength
Poor excursion
Can be used for
elbow lock
Shoulder Elevation
Mod. force
Mod. excursion
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Amputation
Etiology
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Trauma
• 90% of UE amputations
due to trauma
• Adults – farming
• Children – lawn mower
• Peak occurrence 20-40
years of age
• Male:female = 4:1
• Right = left
• 10% bilateral
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Congenital
• 77% Transradial
• L>R (unknown)
• Hand develops
30-55 days
• Rarely due to
genetic defects
• ABS
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Abnormal growth
• Genetic
conditions that
increase or
decrease growth
rate of bone and
soft tissue can
lead to
amputation.
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Tumors
• Amputations less
frequent due to
advances in oncology
• Children – Attempt to
save the growth plateDisarticulation
• Adult – result in
proximal level
amputations
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Infections
• Amputation to prevent the spread of infection to a
more proximal or systemic level
• Examples:
– Gangrene
– Tuberculosis
– Chronic
osteomyelitis
– Immuno-compromise
– Gas producing
infections
– Necrotizing fasciitis
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Peripheral Vascular Disease
• Risk factors
– Smoking
– High blood
pressure
– High cholesterol
– Diabetes
– obesity
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Terminology
• Adopted in 1989 by
the International
Standards
Organization
• Adopted by AAOP &
AOPA in 1993
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Congenital Amputees
• Transverse – normal
development until the
point of deficiency
• Longitudinal – absence
of skeletal anatomy
within the long axis of
a limb and may include
normal anatomy
distally
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Transverse deficiency
• left or right
• body part (arm, forearm, hand)
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Arm – complete, upper, middle, or lower 1/3
Forearm – complete, upper, middle, or lower 1/3
Carpal – complete or partial
Metacarpal – complete or partial
Phalangeal – complete or partial
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Transverse deficiency
• ISO terminology
– Transverse deficiency,
carpals, partial
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Longitudinal deficiency
• Named by the bones
affected in a proximal to
distal sequence and if each
bone is totally or partially
absent
• Metacarpal bones and
phalanges are numbered
from the radial side to the
ulnar side
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Longitudinal deficiency
• ISO Terminology
– Longitudinal deficiency,
right, radius, complete,
carpals, partial,
metacarpals, 1,2, complete,
phalanges, 1,2, complete
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Acquired Amputees
Descriptions
• Trans – amputation across the long axis of a
long bone. Example trans-humeral
• Disarticulation – amputation between the long
bones. Example elbow disarticulation
• Partial – amputation of the hand distal to the
wrist joint.
• Exception – Forequarter – amputation at the
scapulo-thoracic and sternoclavicular joints
– Interscapulo-thoracic
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Hand amputation
• Transmetacarpal
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Maintain wrist motion
Good skin integrity for closure
New options now available
New materials being used
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Wrist disarticulation
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Styloids can be used for suspension
not as cosmetic
Maintains pronation and supination
Silicone suction designs
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Trans-radial
• Preserve length but not at
the expense of a good
closure and skin integrity
• Dorsal / Volar flap
• mid 1/3 preserve pronator
teres
• Upper 1/3 needs 5 cm
length for lifting surface
36
Elbow disarticulation
• Allows for rotational
control due to condyles
• Poor cosmesis
• Limited selection of
prosthetic elbow
components
• Elbow center location will
be longer on prosthetic
side with pros. elbow
• External joints
• Self-suspending socket
• Silicone liners with side
lanyards
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Trans-humeral
• Maintain length for lifting
force, but not at the
expense of a good
closure
• Need a minimum of 1.5”
from end of residual limb
to elbow center for
electric elbow
• Anterior – posterior flap
closure
• Focus on harnessing to
optimize function
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Marquardt
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Distal angular osteotomy
End bearing
Controls rotation
Suspension
Distal segment length5cm
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Shoulder disarticulation
• Amputation at the
glenohumeral joint
• No powered shoulder
joint commercially
available
• Keep light and start
simple
• Progress over time to
advanced functions
• Excursion limitations
– Consider electronics
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Forequarter
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Procedure mainly performed due to cancer
Full or partial loss of scapula
Challenge to suspend
Only have unilateral shoulder motions for
excursion
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General amputation procedures
• Myoplasty – suture of muscle to muscle
i.e. fascia
• Myodesis – suture of muscle to bone
• Neuroma – nerve bundle which can be
painful if close to the skin
• Pediatric- preserve growth plates then
perform growth arrest when indicated
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Krukenberg
• Radius and ulna are divided
• Interosseous muscles are used to provide
a pincher movement
• Usually performed in 3rd world countries
when prosthetic care is not an option
• Blind bilateral amputee
• Preserves sensation
43
Cineplasty
• Surgical procedure over
100 yrs old
• Has been performed with
bicep, triceps, wrist flexors
& extensors, as well as the
pectorallis
• Used to operate the
terminal device via cables
that connect the biceps
tendon to the TD
• Not utilized often today
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Team Approach
• Prosthetic clinic ideally
includes:
– Patient and family
– MD
– Nurse
– PT / OT
– Prosthetist
– Social Worker / Case
Manager
– psychologist
45
Clinic procedures
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Evaluation
Prescription
Pre-prosthetic therapy
Prosthetic care
Prosthetic therapy
Prosthetic check out
Follow up
46
Pre-prosthetic care/ post
surgical
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Range of motion
Muscle strengthening & endurance
Emg training
Prevent adherent scar formation
Stump molding / shrinking
Desensitizing
ADLs
Explore patient goals and body image
47
Prosthetic care
• Golden period of fitting within 30 days
(Malone Study)
• Provide a prosthesis that meets the
patient’s needs and goals
– Needs may be for functional ADLs,
cosmetic, or activity specific
– Sometimes more than one
prosthesis is needed to meet these
goals
48
Prosthetic therapy
• Therapy should include ADL’s
with and without the prosthesis
• Work with therapist to educate
on design and components
• Donning & doffing
• Skin care
• Think outside the box
49
Prosthetic Check-Out
• Prosthetic care is evaluated by rehab team
– Does the prosthetic system meet the patient’s
needs?
– Would patient benefit from adaptive devices
to assist in ADL’s or specific activities?
– Re-assess goals as therapy progresses
• Fine tune socket fit, harnessing, electronics as
needed for optimized function
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