TRANSHUMERAL AMPUTATION

Case PresentationChua. Joaquin

Patient data

23/M Left-handed 24-April-198 Single Filipino Roman Catholic Ilocos

Chief complaint

For pre-prosthetic training

History of Present Illness

industrial accident in Laguna While reaching for an

object under a machine, molding, fell, crushing the upper arm

Reaching about an inch away from the countertop

4 months PTC

(+) Loss of sensation (+) Loss of ability to

move “Broken bones” (+) profuse bleeding

Brought to Laguna hospital X-ray evaluation Anti-tetanus given Dressing done ambulance

conduction to POC (+) intense pain

10/10

AT POC Evaluation of limb viability Prepared for surgery

(NPO) Blood transfusion

intraoperatively

Discharged after 10 hospital days Co-amoxiclav 500/125mg

BID, compliant

Patient would come in for consults, however no rehab was initiated due to lack of funds Patient was

advised prosthesis

Scheduled for rehab

Closed wound, no dehiscence

No fever No erythema No pain on the

residual limb No perception of

pain on the amputated limb

Past Medical

No previous hospitalization No previous surgeries Unrecalled childhood immunization No known allergy No known co-morbidities

Family history

No known heredo-familial illnesses

Personal Social

5th child among 6 boys temporarily residing in a boarding

house Laguna with aunt’s family Vocational course graduate

Seafarer rating certificate course

Previously working as a trimmer, car spare parts manufacturing company for 2 months(at the time of the accident) Company pledges to cover majority of

the expenses Job placement post-therapy

Functionality

Prior to accident: Patient was independent on all self-

care activities, with no difficulty Patient was also capable of IADL –

laundry, grocery, meal preparation

After the amputation: Patient is still independent on all self-

care activities but claims to take longer dressing up, bathing, and pouring water on a cup

Patient is learning how to adjust on IADL

Review of systems

No fever, changes in weight No cough and colds, dyspnea No chest pain, palpitations No changes in bowel movement No changes in urination

Physical examination

HR 80 RR 18 Afebrile Not in pain Patient is medium-built

Skin: no active lesions Head and Neck: anicteric sclerae,

pink palpebral conjunctiva, (-) TPC, (-) CLAD

Chest: symmetric chest expansion, clear breath sounds, no rales, no wheezes

Heart: adynamic precordium, normal rate and rhythm, good S1 and S2, no murmurs

Abdomen: flat, tympanitic, soft, non-tender

Genitourinary : not examined Musculoskeletal:

(+) amputated above the elbow , right (-) erythema closed wound and dry

Neuro: GCS 15 CN intact

MMT and Sensory Sensory 100% L and 100% R Motor testing:

Lower extremity (hip, knee, plantar and dorsiflexion)L 5/5 R 5/5

Shoulder flexion and extension L 5/5 R 5/5

Elbow flexions and extension L 5/5 R --

Wrist flexion and extensionL 5/5 R --

Assessment

S/P transhumeral amputation, right secondary to industrial accident

REHABILITATION

Amputation

Preoperative: Counseling Level of amputation

RULE: Save as much of the limb as possible

Levels of amputation: Upper limb

Transphalangeal Transmetacarpal Transcarpal Wrist disarticulation Transradial Elbow disarticulation Transhumeral Shoulder disarticulation forequarter

Amputee Rehabilitation (Upper limb) Preamputation counseling Amputation surgery Acute post amputation period

Post operative mgt. Prevent edema Prevent contracture Prevent pressure sores Decrease hypersensitivity Maintain strength

UPPER EXTREMITY PROSTHESIS

Prosthesis

Several factors crucial when designing and optimizing transhumeral prostheses Length of the bony lever arm Quality and nature of soft tissue

coverage Shape and muscle tone of the residual

limb Flexibility, range of motion, and stability

of the proximal joints

Prosthesis

Other factors Expected function of the prosthesis Cognitive function of the patient Vocation of the patient

Desk job vs. manual labor Avocational interests

Hobbies Cosmetic importance of the prosthesis Financial resources of the patient

In the transhumeral case, if the adult humerus is transected 10 cm (4 inches) above the olecranon tip, all available elbow options can be utilized successfully, including external power.

Leverage for prosthetic control varies directly with the length of the humerus.

As humeral length decreases, both leverage and power decrease significantly.

Soft tissue coverage also affects prosthetic function since painful, adherent scarring may limit the force that the amputee can comfortably generate.

Conversely, too much tissue makes donning the prosthesis more difficult and often compromises prosthetic humeral length and cosmesis.

Amputation in the proximal third of the humerus (proximal to the deltoid insertion) is particularly challenging prosthetically.

Primary control is by scapular motion with assistance from the humerus.

Due to the obvious reduction in strength and leverage at this level, conventional cable-powered prosthetic control is severely limited.

Since the average adult transhumeral amputee can achieve no more than 2 ½ to 3 in. of excursion when using biscapular abduction, externally powered components are usually necessary for full function.

TYPE PROS CONSCosmetic Most lightweight

Best cosmesisLess harnessing

High cost if custom-madeLeast functionLow-cost glove stains easily

Body powered Moderate costModerately lightweightMost durableHighest sensory feedbackVariety of prehensors available for various activities

Most body movement needed to operateMost harnessingLeast satisfactory appearanceIncreased energy expenditure

Battery powered (myoelectric and/or switch controlled)

Moderate or no harnessingLeast body movement needed to operateModerate cosmesisMore function- proximal areasStronger grasp in some cases

HeaviestMost expensiveMost maintenanceLimited sensory feedbackExtended therapy time for training

Hybrid (cable to elbow or TD and battery powered)

All-cable excursion to elbow or terminal device

Battery-powered terminal device weighs forearm (harder to lift but good for elbow disarticulation or long transhumeral amputation)

Myoelectric vs. Switch

Myoelectrically controlled prosthesis Uses muscle

contractions as a signal to activate the prosthesis

Functions by detecting electrical activity from select residual limb muscles, with surface electrodes used to control electric motors

Switch-controlled prosthesis Utilize small switches rather

than muscle signals to operate the electric motors

Switch activated by movement of a remnant digit or part of a bony prominence against the switch or by a pull on the suspension harness

Good option to provide control for ext. power when myoelectric control sites are not available or when the patient cannot master myoelectric control

Components of a Body-Powered Prosthesis

Socket Suspension Control-cable system Terminal Device

Precision grip Tripod grip Lateral grip Hook power grip Spherical grip

Components for ay interposing joints as needed according to the level of amputation

A transhumeral prosthesis also includes an internal-locking elbow with a a turntable for the missing anatomic elbow, uses a dual-control cable system and does not require a triceps cuff.

Preparatory vs Definitive Prosthesis

Preparatory Fitted while the residual limb is still

maturing Allows the patient to train with the

prosthesis several months earlier in the process

Use often results in a better fit for the final prosthesis, because the preparatory socket can be used to mold the residual limb into the desired shape

Definitive

Follow-Up Most important aspect of prosthetic

rehabilitation and yet may be the most often neglected

3 important tasks during the period following prosthetic fitting Maintenance of socket fit, suspension and comfort

despite limb volume changes Monitoring to ensure that the patient fully

understands and masters the functions of his prosthesis in his home and work environment

Re-evaluation of socket style, harness design and component selection based on amputee experience

Follow-Up Successful long-term use of an upper

limb prosthesis depends primarily on its comfort and its perceived value to the amputee.

Innovative design and careful custom adaptation of socket and harness principles, careful attention to follow-up adjustments and prescription revisions based on the amputees changing needs are the essential factors for successful prosthetic rehabilitation.