Transhumeral amputation

1. Case Presentation Chua. Joaquin Transhumeral amputation

2. Patient data • 23/M • Left-handed • 24-April-198 • Single • Filipino • Roman Catholic • Ilocos

3. Chief complaint • For pre-prosthetic training

4. 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

5. (+) Loss of sensation • (+) Loss of ability to move • “Broken bones” • (+) profuse bleeding

6. Brought to Laguna hospital • X-ray evaluation • Anti-tetanus given • Dressing done • ambulance conduction to POC • (+) intense pain 10/10

7. AT POC • Evaluation of limb viability • Prepared for surgery (NPO) • Blood transfusion intraoperatively • Discharged after 10 hospital days • Co-amoxiclav 500/125mg BID, compliant

8. Patient would come in for consults, however no rehab was initiated due to lack of funds • Patient was advised prosthesis • Scheduled for rehab

9. Closed wound, no dehiscence • No fever • No erythema • No pain on the residual limb • No perception of pain on the amputated limb

10. Past Medical • No previous hospitalization • No previous surgeries • Unrecalled childhood immunization • No known allergy • No known co-morbidities

11. Family history • No known heredo-familial illnesses

12. 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

13. 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

14. 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

15. 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

16. 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

17. Physical examination • HR 80 • RR 18 • Afebrile • Not in pain • Patient is medium-built

18. Skin: no active lesions • Head and Neck: anictericsclerae, pink palpebral conjunctiva, (-) TPC, (-) CLAD • Chest: symmetric chest expansion, clear breath sounds, no rales, no wheezes • Heart: adynamicprecordium, normal rate and rhythm, good S1 and S2, no murmurs

19. 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

20. 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 extension L 5/5 R --

21. Assessment • S/P transhumeral amputation, right secondary to industrial accident

22. REHABILITATION

23. Amputation • Preoperative: • Counseling • Level of amputation • RULE: Save as much of the limb as possible

24. Levels of amputation: Upper limb • Transphalangeal • Transmetacarpal • Transcarpal • Wrist disarticulation • Transradial • Elbow disarticulation • Transhumeral • Shoulder disarticulation • forequarter

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

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

27. Upper Extremity Prosthesis

28. 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

29. 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

30. 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.

31. Leverage for prosthetic control varies directly with the length of the humerus. • As humeral length decreases, both leverage and power decrease significantly.

32. 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.

33. 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.

34. 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.

36. 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

37. 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.

38. 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

39. 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

40. 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.