Siddique Ortho & Rehabilitation Centre

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2. Siddique Ortho & Rehabilitation Centre Innovative Rehabilitation Awareness Programme Upper Limb Amputation & Prosthetic Restoration

4. Our Team • M. Asif Siddique Ch. (C.E.O) • Chief Orthotist & Prosthetist ISPO Cat-I • Hasan Shuja (Vice President) • Orthotist & Prosthetist K.E.M.U • Manzoor Elahi Sheikh (Vice President) • Orthotist & Prosthetist K.E.M.U • Ali Habib • I.T Director

5. Our Goals Are Your Goals • At SORC our small team of skilled Orthotic & Prosthetic professionals provide the best in one-on-one care to our patients. It is this high level of attention and detailed assessments that makes it possible for us to not only achieve, but exceed the goals of our patients.

6. Basic Aim Of Lecture • This lecture attempts to provide surgeons and other medical professionals with an overview of the multidisciplinary, multistage rehabilitation process and the solution options available.

7. Topics under discussion • Following topics are to be discussed in this lecture: • Rehabilitation • Amputations • Post op care of stump • Ideal stump • Discussion of amputation levels best suitable for Prosthetic consideration • Past and latest technology in Prosthetics

8. Rehabilitation

9. Rehabilitation • Is the sum of activities required to ensure patients the best possible physical conditions so that they may by their own efforts regain as normal as possible a place in the community and lead an active, productive life.

10. Clinical team approach to Rehabilitation • The rehabilitation team concept gained popularity after World War II with the need to care for a large number of injured soldier, particularly those with amputations. • Because contemporary medical care is often fragmented with insufficient communication among clinicians, it is especially worthwhile to describe a model of excellent care in which all parties work co-operatively.

11. General members of a rehabilitation team • Physician • Surgeon • Prosthetist • Orthtotist • Pedorthist • Physical therapist • Occupational therapist • Nurse • Social Worker • Psychologist • Rehabilitation counsellor

12. Amputation • Amputation is the removal of a body extremity by trauma, prolonged constriction, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for such problems.

13. Levels Of Upper Limb Amputation

14. Pre-operative Assessment • Neurovascular and functional status of extremity. • Function and Condition of residual limb (in case of traumatic amputation). • Circulatory status and function of unaffected limb. • Signs & Symptoms of infection (culture required). • Nutritional Status. • Concurrent medical problems. • Current medications.

15. Psychological Support Preparation • Emotional reaction to amputation. • Circumstances surrounding amputation (i.e. Traumatic versus surgical). • Occupational and social Rehabilitation.

16. Ideal Stump

17. Surgical Technique • The best type of surgical technique for an upper limb–deficient individual is a myodesis approach, in which the surgeon sutures the residual muscles to the bone rather than to one another. This technique creates a much more stable platform for all forms of prosthetic management. Muscles can contract independently without soliciting undesired movement in nearby muscles. This particular surgical technique also creates clean, independent muscle delineation in the myoelectric user.

18. Ideal Stump for Upper Limb Prosthetics • Some kind of prosthesis can be made for any kind of stump but for perfect prosthetic fitting a perfect stump is necessary. The characteristics of an ideal stump are: • Length • Suture line or scar • Range of motion • Musculature around the stump • Skin over stump • Tip of bone • Nerve Endings

19. Length • Limb length plays an important role in what components can and cannot be fitted to the patient. Crucial decisions are made during surgery that can affect an amputee’s prosthetic livelihood.

20. Shoulder Disarticulation • Disarticulations at the shoulder level severely hinder prosthetic function because virtually all shoulder motion is lost. In fact, the prosthesis is used primarily as a holding device when the patient is performing activities with both hands. Sparing the humeral head is preferable whenever possible to obtain the best appearance and prosthetic fit. • If humeral head is to b excised, after excising the humeral head, the cut ends of all muscles are reflected and secured into the glenoid cavity in an effort to fill the resulting hollow. Finally, partial excision of the acromion may be necessary to smooth the contour of the shoulder.

21. Trans-humeral Amputation • Ideal humeral stump remains 20 cm (8 inches), not because circulatory defects sometimes arise in longer stumps, but rather because such a length provides all the leverage needed and enables the best type of limb to be provided, with the best functional results. • To allow enough clearance for the different types of conventional and electrical elbows, the postoperative residual limb, including distal soft tissue, should be at least 14 cm (5.5 inch) proximal to the most distal aspect of the olecranon. • The retention of the head of the humerus is always advisable when it is practicable, even though there will be no functional stump.

22. Trans-humeral Cont. • Humeral stumps longer than the ideal may prevent the fitting of the type of arm that provides the best functional results, because there is not enough space for the fitting of the automatic elbow mechanism.

23. Disarticulation at the Elbow • Disarticulations at the elbow are still in disfavor: the extra leverage is of no advantage. and the prosthesis that can be fitted is not comparable in efficiency with that available for the Trans Humeral Amputation • Although suspension is optimal, and humeral rotation can be captured, this level is least desirable because of cosmetic issues and limitation of applicable prosthetic elbows.

24. Trans-radial Amputation • Ideal length continues to be 7 INCHES(17.8 cm). Owing to improved methods of fitting and suspension much shorter below-elbow stumps can now be fitted than was once found possible, and therefore the elbow joint should not be sacrificed without much consideration. Stumps longer than the ideal tend to develop circulatory defects, and the extra length is of no advantage.

25. Transcarpalstyloidlevel • The transcarpalstyloid level allows for preservation of full supination, pronation, and wrist flexion and extension, provided that no traumatic event limits motion. Surgeons can make an anatomic decision about the styloidsto enhance pronation and supination.

26. Suture line or Scar • For all arm stumps amputation by equal anterior and posterior flaps, giving a terminal transverse scar, provides the best results.

27. Range of motion (ROM) • The range of motion of the proximal joints to the stump should be full and free of pain for optimal use of the prosthesis.

28. Musculature around the stump • In upper limb amputations as myodesis technique is used, muscles should be well attached to bone ends. • This technique creates a much more stable platform for all forms of prosthetic management. • Muscles can contract independently without soliciting undesired movement in nearby muscles. This particular surgical technique also creates clean, independent muscle delineation in the myoelectric user.

29. Skin over the stump • Healthy sensate skin is essential to withstand the extra load associated with prosthetic fitting. It can also give a positional feedback of the prosthesis.

30. Tip of the bone • It should be smooth particularly the tip should be bevelled and smoothened with a rasp or a file.

31. Nerve Ending • When a nerve is severed during amputation, it will form an ending of nerve fibers called a neuroma. We want to position the nerve ending in well-cushioned soft tissue that’s away from the incision, any scar tissue, areas of pressure and throbbing vessels. There, the nerve ending will not be irritated by traction, pressure from the prosthetic socket or any other unwanted sources of contact. • Knowledge of prosthetic designs and areas of contact or pressure will aid the surgeon in nerve placement. The surgeon’s goal is to retain as much of the useful remaining nerve function in the residual limb as possible, while also carefully managing the nerves to minimize nerve scarring and painful neuromas.

33. Postoperative Management • Management during the postoperative period is crucial to the patient‘s future functional abilities. • Physical & psychological issues not addressed during this critical time can hinder a person’s recovery and quality of life.

34. Postoperative care • All postoperative protocols have similar goals to: • Heal the surgical wound. • Minimize pain. • Protect the amputated limb from trauma. • Preserve and improve the range of motion and strength of the entire body. • Reduce swelling and begin shaping the amputated limb. • Facilitate psychological adjustment to limb loss.

35. Residual Limb Shrinkage and Shaping • Shrinking and shaping of the residual limb is usually accomplished by compression from an elastic bandage, intermittent positive-pressure compression, or a tubular elastic bandage. If an elastic bandage is used, it is important that the proper technique be taught to the patient, family, and nursing staff. A figure-of-8 wrap is one that applies more pressure distally than proximally; elastic bandaging should never be done in a circumferential manner. • The wrapping process begins with the end of the bandage placed diagonally at the distal end of the residual limb. The wrap should encircle the limb from behind and wrap diagonally upward to cross over the end of the bandage. This figure-of-8 process should continue, with each pattern overlapping the previous one by approximately two thirds the width of the bandage. The bandage is then secured with tape or special clasps.

37. Residual Limb Shrinkage and Shaping • No elastic bandage should be used for more than 48 hours without being washed with mild soap and lukewarm water and thoroughly rinsed with clean water. Bandages should not be twisted, but laid flat to dry. Washers and dryers decrease their longevity and ruin their elasticity. • The wrap should be reapplied every few hours or more frequently if it slips or bunches. The elastic bandage should be worn all day and all night except when bathing. A preparatory prosthesis might also be applied early in the shaping process; however, a compression bandage is generally preferred because it affords better monitoring of skin healing and points of pressure.

38. Prosthetics Restoration

39. StateOfArtTechnology

40. Prosthetics • Prosthetics is the evaluation, fabrication, and custom fitting of artificial limbs to the amputees.

41. Prosthesis • Prosthesis is a device designed to replace, as much as possible, the function or appearance of a missing limb or body part. An orthosis, in contrast, is a device designed to support, supplement, or augment the function of an existing limb or body part.

42. Characteristics Of a Successful Prosthesis • Ideally, a prosthesis must be comfortable to wear, easy to put on and remove, lightweight, durable, and cosmetically pleasing. Furthermore, a prosthesis must function well mechanically and require only reasonable maintenance. Finally, prosthetic use largely depends on the motivation of the individual, as none of the above characteristics matter if the patient will not wear the prosthesis

43. Considerations When choosing a Prosthesis • Amputation level • Contour of the residual limb • Expected function of the prosthesis • Cognitive function of the patient • Vocation of the patient (eg, desk job vs manual labor) • Avocational interests of the patient (ie, hobbies) • Cosmetic importance of the prosthesis • Financial resources of the patient

45. Cosmetic Prosthesis • Cosmetic, or so-called passive arm prostheses, are worn by people who consider their appearance very important. The prosthesis rounds out the image they have of their body.

48. Thumb Prosthesis not attached • Same hand with thumb Prosthesis attached

49. Body Powered Prosthesis • Body-powered prostheses work by using cables to link the movement of the body to the prosthesis and to control it. Moving the body in a certain way will pull on the cable and cause it to open, close, or bend.