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p   
 
‡ Peripheral vascular disease
‡ Trauma (severe tissue damage) - traumatic
amputation
‡ Infection (chronic disabling infection, Gas
Gangrene)
‡ Tumours (Malignant)
‡ Nerve injury (trophic ulceration ± insensitive
limb)
‡ Congenital anomalies
± (eg. extra digits)
± Gross deformity (dysmelia)


‡ Return Patient to maximum level of
independent function
‡ Ablation of diseased tissue (tumor or
infection)
‡ Reduce morbidity & mortality (tumor or
infection)
‡ Considered first part of a Reconstruction
to produce a physiological end organ .
›

  
‡ m   ± sites of Election versus sites of Emergency


  

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‡ 


‡ Good bandaging to mold the stump
into Conical shape to accept the
prosthesis.
‡ Avoid proximal compression of the
limb.
‡ Prevent contracture (by splinting and /
or muscle exercises)
‡ Early prosthetic fitting
‡ V 


‡ Usually for congenital limb deficiencies


‡ Try to retain limb if possible
‡ Preserve length
‡ Disarticulate if possible to preserve growth
potential rather than trans-diaphyseal
amputation (å bony overgrowth)
‡ V  

‡ Haematoma
‡ Infection
‡ Necrosis of stump end.
‡ Contractures (due to muscle imbalance)
‡ Neuroma at the cut nerve ending
‡ Phantom pain
‡ Terminal overgrowth (children)
Pain
‡ in the postoperative period must distinguish
between normal postoperative (ie, surgical)
pain and phantom limb pain.
‡ Surgical pain usually responds well to opioids.
‡ Phantom limb pain usually is like a burning,
stinging, electric pain, and it can be increased
with anxiety and stress.
‡ phantom pain is quite common initially,
‡ if it is still present at 6 months postsurgery, the
prognosis is unfavorable.
‡ Phantom limb sensation also must be
differentiated from phantom limb pain.
‡ Phantom limb sensation is the sensation
that the amputated limb is still present.
present
‡ Patients usually report that the absent
hand/arm/limb is itching, tickling, or moving
through space.
‡ Phantom sensation is perceived as a
"funny" or "different" feeling but usually is
not perceived as painful.
Phantom limb pain theories
‡ Three theories as to why patients experience
phantom limb pain and sensation exist.
‡ One theory is that the remaining nerves
continue to generate impulses.
‡ A second theory is that the spinal cord nerves
begin excessive spontaneous firing in the
absence of expected sensory input from the
limb.
‡ The third theory is that there is altered signal
transmission and modulation within the
somatosensory cortex.
Telescoping
‡ Another common phenomenon is
telescoping.
‡ Telescoping is the sensation that the distal
part of the amputated extremity has moved
proximally up the arm.
‡ A patient might report that it feels like the
entire extremity has shrunk so that the hand
is now up at the elbow.
‡ This is a normal part of the nerve healing
process and usually fades with time.
X    
  
‡ Residual limb - The preferred term for the
remaining portion of the amputated limb
(Stump
Stump, while still used, is politically incorrect.)
‡ Terminal device - Most distal part of the
prosthesis used to do work (eg, hand)
‡ Myodesis - Direct suturing of muscle or tendon
to bone
‡ Myoplasty - Suturing muscles to periosteum
‡ Prehensile - Grasp
‡ †


 

‡ is the removal of the upper limb with the


scapula
‡ Mainly for malignancy
‡ › 

‡ Disarticulation
± divide capsule and muscles
± then reflect the cut ends of all the muscles over the
glenoid and suture them there
‡ Proximal amputation
± Resect bone at desired level
± then suture the muscles over the end of the
humerus
± Proximal humeral amputations behave like a
shoulder disarticulation, but better cosmesis and
suspension
± Prostheses provide a function and cosmesis
‡   
‡ Use equal anterior and posterior flaps.
‡ Divide the muscles 5 cm below the bony
resection.
‡ Suture triceps to anterior muscles

‡ 


‡ Leave the articular surface intact and suture


tendons of flexors to extensors.
‡ Close flaps over drains
‡ Elbow disarticulation versus Humeral
Amputation

± Better suspension with elbow disarticulation but


poor cosmesis
± Better function with distal humeral amputation (3.5
cm proximal to elbow)
‡   

‡ Try to Preserve Length


‡ Myoplastic closure or suturing flexors to
the extensor group
‡ ´
 




‡ Separate radial and ulna rays distally


‡ forming radial and ulna pincers capable of
strong prehension and excellent
manipulative ability
‡ X



‡ Preserves forearm rotation


‡ The Flare of distal radius improves
prosthetic suspension
‡ Difficult prosthetic fitting due to length
‡ Resect radial and ulna styloids' without
damage to distal radio-ulna joint
‡ u
 

‡ Use a long palmar and short dorsal fish
mouth flap (2:1)
‡ Suture tendons over the ends of the carpus

‡    
‡ Preserve length, function, sensation
‡ For irreversible Ischemia and tumours.
‡ † 
 
‡ From Distal to PIPJ (terminal phalanx)
‡ To Proximal to base Mc (Whole ray)

‡ u 

‡ Preserve:
± Length as much as possible
± Stability as good as possible
± Sensation
± Mobility
± Cosmesis
|  2 3 2 ||  4
‡ X   
  

   
 

‡ A prosthesis is a device designed to replace,


as much as possible, the function or
appearance of a missing limb or body part.

‡ An orthosis is a device designed to


supplement or augment the function of an
existing limb or body part.
Y 




‡ traumatic amputation
‡ tumors (osteosarcoma - esp. humerus) å
amputation
‡ deformity of limb (dysmelia)
‡ shortened upper-limb (phocomelia)
‡ absence of upper-limb (amelia)
V  


  
‡ finger
‡ partial hand (trans-metacarpal)
‡ hand
‡ wrist disarticulation (transcarpal)
‡ below-elbow (Trans-radial)
‡ through elbow
‡ above-elbow amputation (Trans-humeral)
‡ shoulder disarticulation & forequarter
Requirements of a prosthesis
‡ function of
± manipulation
± prehension (grip)
‡ cosmesis
‡ sensory feedback
‡ ›
     
‡ Sensory information perceived is used to manage
motor activities and correct errors in movement
through Feedback mechanism.
‡ eg. If a wrong word is written å visual and
proprioceptive feedback signals that an incorrect
motor response was made å correct it.
‡ Holding objects (errors corrected by feedback)
‡ This is done through :
± Exteroception(external senses- sight, hearing etc.)
± Proprioception (internal sense)
‡ Joint Position Sense (JPS)
‡ Tendon force & Muscle length
     
  
 
‡ A prosthesis must be comfortable to wear,
‡ easy to put on and take off,
‡ light weight and durable (strong), and
‡ cosmetically pleasing.
‡ Furthermore, a prosthesis must function well
mechanically and
‡ have reasonable maintenance.
‡ Finally, compliance with a prosthesis largely
depends on the motivation of the individual, as
‡ none of the above characteristics matter if the
patient will not wear the prosthesis.
X   
    
 

‡ What is the amputation level?


‡ What is the expected function of the
prosthesis? Cosmosis vs Function.
‡ What is the cognitive function of the patient?
‡ What is the patient's vocation (desk job or
manual laborer)?
‡ What are the patient's avocational interests (ie,
hobbies)?
‡ What is the cosmetic importance of the
prosthesis?
‡ What are the patient's financial resources?
§ Continued

‡ Past medical history


‡ Muscle testing
± Good power å better function
‡ Sensory testing
‡ Condition of other limb
± Amputated, deformed, normal
‡ Skin condition of the amputated limb
‡  


‡ Most important muscles for hand operation


located in forearm
± Flexor/Extensor Digitorum (finger muscles)
± Flexor/Extensor Policis (thumb muscles)
± Flexor/Extensor Carpi radialis/ulnaris (wrist
muscles)
‡ Intrinsics
± Finger abductors & adductors
± Lumbricals (involved in flexing fingers)
‡ Movements
± Grips
‡ power grip
± hook
± span
‡ precision (delicate, fine) grip
± tip (pinch)
± Lateral (key holding)
± Pronation/supination ("wrist motion") from rotation
of radius about ulna (limited in short stumps)
u›† ›u›p›
‡ ›  
 
  

  
 
Materials
‡ thermoplastics preferable for comfort
‡ Low density polyethylene
‡ carbon-fiber for heavy-users
Function
‡  ! ()&

‡ ,("5)6(
‡ º   ›  

‡ suction socket (-ve press.)


‡ suspension belts
‡ è      !   "

‡ Hydraulic cylinder

‡ Intelligent prosthesis - computer


adjusts rate of swing to cadence
(steps/min)
Du
 !  # "
‡ The continuum of prostheses ranges from being
mostly cosmetic on one end to being mostly
functional on the other end.
‡ The purpose of most prostheses falls somewhere in
the middle.
‡ Cosmetic prostheses can look extremely natural,
but they are often more difficult to keep clean, can
be expensive, and usually sacrifice some function
for increased cosmetic appearance.
‡ Terminal devices generally are broken down into 2
categories:  and .

 
‡ The main advantage of a passive terminal
device is its cosmetic appearance.
‡ With newer advances in materials and
design, a device that is virtually
indistinguishable from the native hand can
be manufactured.
‡ However, passive terminal devices usually
are less functional and more expensive
than active terminal devices.

 
‡ Active terminal devices usually are more
functional than cosmetic;
‡ however, in the near future, active devices
that are equally cosmetic and functional
should be available.
‡ Active devices can be broken down into 2
main categories:
± (1) hooks (Captain Hook)
± (2) prosthetic hands which is powered by:
§ cable or
§ myoelectric-based devices.
prosthetic hands
‡ A prosthetic hand usually is bulkier and
heavier than a hook
hook, but it is more
cosmetically pleasing.

‡ The Functional hand prostheses generally


can be divided into 2 categories:

± (1) body-powered protheses (cables) and


± (2) myoelectric protheses.
 $ 

 
!V"
‡ Body-powered prostheses (cables) usually are
of moderate cost and weight.
‡ They are the most durable (strong) prostheses
and have higher sensory feedback.
‡ However, body-powered prostheses are less
cosmetically pleasing than a myoelectric unit,
‡ and they require more gross limb movement.
º $

 
‡ Prostheses operated by myoelectricity may give
more proximal function and increased
cosmesis, but they can be heavy and
expensive.
‡ They function by transmitting electrical activity
that the surface electrodes on the residual limb
muscles detect to the electric motor.
‡ With the myoelectric device, the patient can
initiate palmar tip  by contracting residual
forearm flexors and
‡ can  by contracting residual extensors.
‡ Two types of myoelectric units exist.
‡ The 2-site/2-function device has separate
electrodes for flexion and extension.
‡ The 1-site/2-function device has one
electrode for both flexion and extension.
± The patient uses muscle contractions of
different strengths to differentiate between
flexion and extension.
± For example, a strong contraction opens the
device, and a weak contraction closes it.
‡ The major function of the hand that a prosthesis tries
to replicate is grip
grip. The 5 different types of grips are as
follows:
‡ Precision grip (ie, pincher grip): The pad of the thumb
and index finger are in apposition to pick up or pinch a
small object (eg, small bead, grain of rice).
‡ Tripod grip (ie, palmar grip, 3-jaw chuck pinch): The
pad of the thumb is against pads of index and middle
finger.
‡ Lateral grip: The pad of the thumb is in apposition to
the lateral aspect of the index finger to manipulate a
small object (eg, turning a key in a lock).
‡ Hook power grip: The distal interphalangeal (DIP) joint
and proximal interphalangeal (PIP) joint are flexed
with the thumb extended (eg, carrying a briefcase by
the handle).
‡ Spherical grip: Tips of fingers and thumb are flexed
(eg, screwing in a light bulb or opening a doorknob).
X
 
‡ The wrist unit functions as an attachment for the
terminal device and can be positioned manually or
myoelectrically. The wrist unit can be:
‡   
 
‡ This style is configured to allow easy exchange of
many terminal devices with specialized functions.
‡ º  
 
‡ Wrist units with a locking capacity prevent rotation
during grasping and lifting.
‡ è X
 %  
‡ In a patient with bilateral amputations,
amputations a wrist flexion
unit can be placed on the longer residual limb to allow
midline activities such as shaving or manipulating
buttons.
 
‡ Elbow units are chosen based on the level of the
amputation and the amount of residual function.
‡  †%  (allow forearm rotation)
‡ When the patient has sufficient voluntary pronation
and supination as well as elbow flexion and extension,
such as in a wrist disarticulation or a long transradial
amputation, a flexible elbow hinge usually works well.
‡ º  
‡ When a patient can achieve little or inadequate
pronation and supination but does have adequate
native elbow flexion, such as in a short transradial
amputation, a rigid elbow hinge provides additional
stability.
‡ › 
  


 

‡ When an amputation is required at the


shoulder or forequarter level, function is very
difficult to restore.
‡ This is due to a combination of the weight of
the prosthetic components, as well as the
increased energy expenditure necessary to
operate the prosthesis.
‡ For this reason, some individuals with this level
of amputation choose a purely cosmetic
prosthesis to improve body image and the fit of
their clothes.
‡ 
 

‡ Ideally, a patient who needs an upper


extremity prosthesis should be seen by the
rehabilitation team prior to the surgery å
prepare him for the matter.
‡ This allows a chance to evaluate postoperative
needs and desires and to begin range of
motion (ROM) exercises, strengthening, and
training in activities of daily living (ADL).
‡ However, since most upper extremity
amputations are traumatic in nature, this may
not always be possible.
‡ ›   
± control diabetes
± evaluate cardiac, renal + cerebral circulation
± Preoperative calorie¶s control in malnourished
patient.
‡  

 
± early plan for return to function
± preoperative counseling
± amputee support groups
‡ 
    V


± Pain clinic review
± Spinal anaesthesia
‡ 
$ 

$

‡ During this phase, a program to prepare the


residual limb for the prosthesis should be
initiated.
‡ A skin desensitization program consists of
‡ (1) gentle tapping on the distal portion of the
residual limb to mature the site,
‡ (2) massage to prevent excessive scar
formation.
‡ 
     
‡ A temporary prosthesis can be fit in surgery, so
when the patient awakes he or she can
visualize a limb in place.
‡ Temporary prostheses usually are fitted this
early in healthy, young patients with traumatic
amputations, in which case rehabilitation
physicians work integrally with orthopedic
specialists and prosthetists (team work).
work)
‡ Alternatively, in older patients or in those with
vascular disease, a prosthesis is not fit until the
suture line has completely healed.
healed
‡ The prosthesis must be individually fitted to the
patient. One size does not fit all.
‡ Prostheses are either preparatory or definitive.
‡ The advantage to using a preparatory
prosthesis is that it is fitted while the residual
limb is still maturing.
maturing
‡ A preparatory prosthesis allows the patient to
train with the prothesis several months earlier in
the process.
‡ A preparatory prosthesis often allows a better fit
in the final prosthesis as the preparatory socket
can be used to mold the residual limb into the
desired shape.
‡ During this period, the patient ³test drives´ the
prosthesis and learns what it can and cannot
do.
‡ Sometimes a preparatory prosthesis is not
feasible because of financial
considerations.
‡ In this case, a patient can only be fitted for
the definitive (final) prosthesis.
‡ If a patient is being fitted for a final
prosthesis without ever having a
preparatory prosthesis, delay fitting for the
socket until the residual limb is fully mature
(usually 3-4 months).
´  †
 !´ †"
  †
 ! †"

‡ These splints are used to avoid flexion contractions in


the joints of the body, in this case the knee- and foot.
‡ There are many diagnosis to prescribe an AFO such
as: Clubfoot, DropFoot, Osteo Imperfecta, and Polio.
‡ The KAFO is used for patients who have a weak or
very poor knee function, e.g. poliomyelitis patients.
‡ A hinge applied on the KAFO (with with or without a lock
system) is to give a knee the required stability during
walking.
KAFO with a
Swiss-Lock system
KAFO -SPLINT

AFO
(Ankle Foot Orthosis)
Finish

  

‡ u 
± Clinical - feel pulses, skin temperature, level
of dependent redness
± Doppler (U/S)± check limb circulation;
inaccurate with calcified blood vessels
± Arteriogram
‡ ›   
± control diabetes
± evaluate cardiac, renal + cerebral circulation
± Preoperative calorie¶s control in malnourished
patient.
‡  

 
± early plan for return to function
± preoperative counseling
± amputee support groups
‡ 
    V


± Pain clinic review
± Spinal anaesthesia
‡ › 
± Use defined flaps, with the apex of the fish
mouth at the level of the bony resection
± Use any available flaps in trauma to preserve
length
± Tailor flaps at least as long as the diameter of
the stump
‡ Ô 
± Divide ~5 cm distal to level of bone resection
± Stabilisation of muscle mass by good suturing.
± Adequate stump padding
± prevents atrophy (Muscle exercises)
± improves function
± Myoplasty = involves suture of flexors to the
extensors over bony stump
± Myodesis = direct suture of muscle to bone - most
useful in AK, AE and disarticulations
‡ ? 
± Divide cleanly under gentle tension proximal to
bone ends - allow to retract
± Large nerves eg sciatic, median - ligate due to large
contained vessels
‡ 

 
± Large arteries & veins should be doubly ligated and
haemostasis achieved prior to closure
‡ 

± Avoid excessive periosteal stripping (prevent spur
formation)
± Bevel & smooth the bone end
‡ V

± Do not close under tension
± Interrupted sutures preferably
‡  
± are necessary