UE AMPUTATION- SYNCH

Question 1

Functions of the upper limb

Answer 1

fine manipulation

power grasp

communication

interaction with the environment

self-image

completion of most ADL

Question 2

Most common cause of UE amputation

Answer 2

trauma

-50% of those with UE acquired amputation choose to wear prosthesis

-majority are young males

-male to female ratio 8:1

-21-64 years old make up 80%

Question 3

Congenital amputation

Answer 3

-transverse: limb is absent across the longitudinal axis

-longitudinal: the deficiencies are along the axis of the limb but do not cross it (radial or ulnar deficiencies)

-upper limb absences are more common than lower limb by a ratio of 60:40%

Question 4

acquired amputation

Answer 4

Traumatic: machinery, explosives, projectiles, MVA, burns, electrical and cold exposure injury

Dysvascular: necrotizing fasciitis, toxic shock, DM, etc

Malignancy of bone/joint

Question 5

Questions to ask during exam/subjective

Answer 5

current thoughts and info regarding prosthesis (before pt has their own)

any visual or short term memory problems which may affect treatment

Question 6

Signs of PTSD:

Answer 6

sleep pattern changes

presence of night/daymares or flashbacks

occurrence of sudden or disruptive anxiety/depression causing immobility/feeling of a loss of control

Question 7

Assessment of the residual limb:

Answer 7

-wound
-skin/scar: adherent, flabby/firm, flap coverage, palpable neuroma
-length
-shape
-bony prominences (for suspension)
-sensation
-A/PROM: primarily proximal, including scapula
-the strength of remaining mm. noting weakness which may be related to a peripheral nerve injury
-residual pain
-phantom sensation/phantom pain

Question 8

Levels of UE amputation

Answer 8

forequarter- loss of scapula and clavicle

shoulder disarticulation

transhumeral= above elbow (very short, short, standard, long)

elbow disarticulation

transradial - below elbow (very short, short, standard, long)

wrist disarticulation

carpal disarticulation

transmetacarpal

digital

Question 9

Options for a prosthesis for the UE:

Answer 9

no prosthesis

a passive or oppositional prosthesis

body-powered prosthesis

externally powered prosthesis

use of a combination of each (hybrid)

task-specific prosthesis

Question 10

Phases of UE amputation rehab

Answer 10

pre-op: acute rehab, 1-2 visits to talk about edema control, residual limb shaping and 1-handed ADLs
-team consult or while patient is in critical care (limb salvage)
-may occur before elective amputation for malignancy, brachial plexus injury, or revision of present amputation
-discuss: amputation level, collaboration between IP and OP staff, patient goals, plan for prosthetic use and strengthening
-address one-handed use and change of dominance
**often the patient and family are not ready to see or hear about the prosthesis at this time

post-op:
- in inpatient physical therapy
-grief
-one-handed ADLs

pre-prosthetic

prosthetic prescription and fabrication

prosthetic training

** need 3 months or more

Question 11

Incisional pain and phantom pain management

Answer 11

INCISIONAL:
-generally managed by narcotic agents delivered IV or IM in the first 3-4 post-op days, TENS

PHANTOM:
-amitriptyline (Elavil)
-isometric exercise
-guided imagery/mirror therapy (Ramachandran)

Question 12

Phantom sensation vs phantom pain

Answer 12

SENSATION
-feeling that the limb is still present or partially present
-can be helpful for prosthetic training

PAIN
-feeling or sensation of pain in the limb that was removed
-abnormal
-treated aggressively

Question 13

Where is UE ROM most commonly lost following amputation?

Answer 13

GH and elbow joints

-can begin AROM of the residual limb as early as POD 2

-gentle isometric contractions can begin at POD 5, isotonic 7-10

Question 14

What is the necessary shape of the residual limb needed for prosthetic fitting?

Answer 14

conical shape

-achieve this shape with ace wrapping in a figure-of-eight fashion with more pressure distally than proximally
-can also perform tubular elastic bandaging

Question 15

ROM, strengthening, and hygiene

Answer 15

-address chest expansion with burns due to scar tissue formation
-address scapular and glenohumeral mobility and strengthening
-distal weighting with cuff weights
-residual limb to be washed daily with soap and water, patted dry

Question 16

Strengthening during post-operative pre-prosthetic phase

Answer 16

-scapular stabilization BL

-functional strength training for core strengthening (ball)

-balance/symmetry of gait and arm swing

-strengthening of unaffected uE

-strength of remaining mm. of residual limb

-** Strengthening helps to reduce phantom limb pain

-lifting hook

Question 17

Things to watch out for when using a prosthesis during strength training

Answer 17

-blisters, abrasions and rashes due to harnessing on a body-powered prosthesis or from hanging unsupported and then being subjected to the opposite forces with sudden suction on closed chain contact

–> swelling, dark, red discoloration and a bulbous end of the limb

Question 18

Overuse of the unaffected limb- things that can be examined/ addressed

Answer 18

-activity analysis needs to be performed to address repetitive, forceful, or awkward ADL

-joint protection training

-energy conservation training

-can also have dental damage due to donning and doffing with teeth

Question 19

Two important things to focus on to maximize an individual’s independence after an UE amputation

Answer 19

-interventions to adapt to one-handed ADLs

-change of hand dominance if necessary

Question 20

Most important/impactful reason why individuals choose not to get an upper extremity prosthesis:

Answer 20

-too much time was taken before fitting–> they adapted to life without one

-easiest to accept one within the first 3 months

Question 21

Something to consider with insurance

Answer 21

-a lot of patients opt for the myoelectric prosthesis because most third-party payers will only cover one prosthetic

Question 22

Types of UE prostheses

Answer 22

IPOP - immediate post-operative prosthesis
-passive or oppositional

Body Powered -
-powered an controlled by gross body movements captured by a harness system through a cable

Externally Powered - myoelectric, switch controlled, touch pad controlled, servo controlled

Hybrid

Activity Specific/Recreational

Question 23

Where are BUE patients often seen for rehab care?

Answer 23

inpatient setting (regional amputee programs)

TIRR - Texas Institute for Rehabilitation and Research

RIC - rehab institute of chicago

Question 24

Order of how much training time is required for body powered prostheses

Answer 24

transradial (5 hours) –> transhumeral and shoulder disarticulation–> bilateral transradial –> bilateral transhumeral (20 hours)

Question 25

Donning a body bowered prosthesis

Answer 25

“coat method”
-most often used by unilateral amputees

“pullover sweater method”
-bilateral amputees most common

Question 26

Prosthetic wearing schedule:

Answer 26

start with <15 min at a time with frequent skin checks

if no skin problems–> increase wear time to 30 increments 3x/day

then at the end of the week –> patient wearing all day

clean res. limb and prosthetic socket with soap and water

change stump socks often

Question 27

Body control Motions for Body Powered Prosthesis

Answer 27

OPENING THE TD
-scapular abduction and shoulder flexion
-hook opens as you move the arm forward
-elbow must be locked first

LOCKING/UNLOCK THE ELBOW UNIT
- Scapular
Depression/Extension/Abduction; this “down, back and
out” combined motion is required to lock and unlock an
elbow unit with an AE prosthesis; this is a “two-click” cycle
-elbow must be locked before the TD can be operated

ELBOW FLEXION/EXTENSION
- Accomplished using a forearm-
lift device which responds to scapular abduction and chest
expansion when the elbow is unlocked

CHEST EXPANSION
- Used for harnessing with a forequarter,
shoulder disarticulation or high AE amputee with a cross-chest strap

Question 28

Manual controls training for body powered prosthesis:

Answer 28

Positioning of the shoulder joint:
-manually adjusted by sound hand or against an object with a friction unit

internal/external rotation
-controlled by rotation of the elbow turnable by leaning the prosthesis against an object in an internal or external rotation fashion

wrist flexion
-operate unit by pushing on the button on the forearm by sound hand or against object for BL amputee

positioning the TD in the wrist unit:
-done by passive rotation with the sound hand into pro/supination for UL
-force against another object or between the patient’s knees for BL

Question 29

How is elbow lock/unlock accomplished for forequarter or shoulder disarticulation amputees?

Answer 29

chin nudge control button attached to the thoracic socket

Question 30

Functional use training

Answer 30

-most difficult, prolonged stage during which acceptance of the prosthesis is determined

-pre-positioning of the TD is emphasized: aided with phantom limb sensation and mirroring sound hand

Question 31

What level of amputation requires prostheses to function independently?

Answer 31

bilateral above the elbow amputees

Question 32

Electrically powered prostheses

Answer 32

• Clinical use of these devices began in Europe due to government-supported healthcare and a large patient population of congenital amputees (post- thalidomide)
• The term myoelectric is often used interchangeably
  with electric prosthesis
• Myoelectric prosthesis uses mm. surface electricity to control the prosthetic hand function