Upper Extremity Amputation

Question 1

What are the three most common causes of UE amputation?

Answer 1

1. Trauma, 77%: MVC, industrial accidents, lawn mowers, chain saw, table saw, treadmills (kids)
2. Congenital, 8.9%: birth defects
3. Tumor, 8.2%: osteosarcomas and soft tissue traumas
4. Disease, 5.8%: CV disease, nerve injury, diabetes, gangrene

Question 2

What are the three most common causes of LE amputation?

Answer 2

1. Disease, 70%: diabetes, vascular disease, gangrene, infection
2. Trauma, 22%: MVC, industrial accidents, crush injuries, cold injuries
3. Congenital or birth defects, 4%: amniotic band syndrome, exposure to subst. in utero
4. Tumors, 4%: sarcomas, other malignancies

Question 3

What is a neuroma?

Answer 3

• small ball of nerve tissue
• can develop when axons grow toward distal end of residual limb, then turn back on themselves, producing a ball of nerve tissue
• can be very painful if neuroma adheres to scar tissue or skin that is subject to pressure

Question 4

Explain in everyday terms how a mirror box may be able to help relieve the pain of a phantom limb syndrome.

Answer 4

A mirror box tricks your brain into thinking your limb is still there. When you look in the mirror and see a complete limb the pain from your brain can be overridden.

Question 5

List three other treatments that have been used to treat phantom limb pain.

Answer 5

1. Use graded textures or particles
2. Heat or cold therapy
3. Warm water therapy
4. Ultrasound
5. TENS unit
6. Massage
7. Compression or weight bearing
8. isometric exercises and active muscle movements

Question 6

What is a “myo-boy”? What is it used for? How do patients use it?

Answer 6

• Assessment and training system designed for use by individuals with upper extremity amputation who are being fitted for an Otto Bock myoelectric prosthetic hand
• The system enables a prosthetist to conduct realistic tests of muscle tension and gather data that can be used to adjust the electrodes on the myoelectric hand. The system documents the individual’s muscle signal strength so the prosthetist can track results and print data sheets.
• The patient is attached to electrodes and is able to practice contracting the muscles needed in order for the hand to move.

Question 7

What special considerations are important in prosthesis selection and training for people with bilateral UE amputations?

Answer 7

1. ~10% of UE amputations are bilateral.
2. Bilateral amputations should NOT be treated as two unilateral amputations
3. Multidisciplinary team is needed to assess the psychosocial, equipment, and vocational needs of each individual
4. Foot skills may be more functional for some tasks or when the prosthesis isn’t worn
5. Usually, a person with bilateral UE amputations has two prostheses attached to one harness.
6. Separation of controls: The client will need to learn how to operate each prosthetic component without affecting the other components on either side = this skill can take much practice and is called “separation of controls”
7. Midline Activities with bilateral prostheses: There are other units on bilateral prostheses not commonly found on other UE prosthetics: wrist flexion unit and the cable-operated wrist rotation unit. These help the client complete midline activities.

Question 8

What are the pros of a body-powered prosthetic?

Answer 8

lower cost; don’t have to worry about a battery being charged; durable- it can be used for heavy manual work; typically lighter in weight

Question 9

What are the cons of a body-powered prosthetic?

Answer 9

not as good at fine motor skills; bulky; its large and does not have the best appearance; people tend to overuse muscles trying to activate it; must have adequate power and ROM to operate

Question 10

What are the pros of a myoelectric prosthetic?

Answer 10

no cables/straps; good for precise movements; has more natural movement; can have 20-30 lbs of grip; reduced or eliminated harnessing

Question 11

What are the cons of a myoelectric prosthetic?

Answer 11

very expensive; can break down (and then has a high repair cost); larger learning curve for use; have to remember to charge battery and even then it only lasts for a certain amount of time; can be damaged by moisture/dirt

Question 12

How are rubber bands used on body-powered prostheses? What are they for?

Answer 12

Rubber bands are used to increase the resistance for opening, thus increasing the grip strength.

Question 13

What does Pedretti recommend as a progression for upper extremity amputee wearing schedule, as a person gets used to her/his body-powered prosthesis?

Answer 13

1. Client initially wears the prosthesis 15 -30 minutes 3 x per day
2. No skin problems then wearing period is increased by 30 mins 3 x per day
3. End of first week client may be wearing prosthesis for the whole day
4. Bands can be increased 1 per day

Question 14

What are the primary elements of control training in helping a person master a prosthesis?

Answer 14

1. Pt learns minimal motions needed to operate prosthesis while maintaining proper body mechanics (done in front of mirror).
2. Pt practices individual components before combining them into more complex functional activity.
3. Pt learns to use external environment to assist (ex: using countertop to rotate terminal device into best position for a kitchen task).

Question 15

What are the primary elements of use training in helping a person master a prosthesis

Answer 15

1. Begins after the client understands how to operate and control the individual prosthetic components (applies the mechanics of operation to activities).
2. Repetition allows wearer to gain an understanding of how to pre-position the prosthesis and surrounding objects, and how to use environment to help achieve a task.
3. Includes pre-positioning and prehension training: Pre-Positioning = placing prosthetic in optimal position to approach an object / perform an activity, Prehension = terminal device control (start with large, hard objects & progress to smaller soft, then crushable objects)

Question 16

What are the primary elements of functional training in helping a person master a prosthesis

Answer 16

1. Applies the concepts of control and use of the prosthesis to completion of functional and meaningful activities (i.e., occupations)
2. The key to successful functional training is teaching the client a problem-solving approach.

Question 17

What would you as an OT do to encourage your patient to wear his/her prosthesis once a person has been fitted?

Answer 17

1. Design prosthesis-wearing schedule that allows the client to adjust to wearing the prosthesis gradually
2. Implement a progressive prosthetic training plan:
   control → use → functional training; this encourages gradual skills development from a foundation of proper body mechanics and energy conservation
3. As a therapist you should be monitoring your client’s residual limb for signs of skin breakdown and educating your client and caregivers to do the same
4. Establish rapport with your client and encourage them to communicate any frustrations and discomfort they may be feeling so that issues can be addressed by the OT and/or other members of the treatment team
5. Be realistic about goals and expectations

Question 18

What are the five most common reasons that people with amputations reject their prostheses?

Answer 18

need to answer

Question 19

Describe the role of a prosthetist in amputee rehabilitation.

Answer 19

A person who measures, designs, fabricates, fits, or services a prosthesis as prescribed by a licensed physician, and who assists in the formulation of the prosthesis prescription for the replacement of external parts of the human body.

Question 20

How can the “milieu” of a dedicated amputee rehabilitation center influence rehabilitation for patients with amputations?

Answer 20

1. Camaraderie of an environment in which many other people are in similar situations
2. Knowledge that you are not alone - sharing the burden of your challenges - could mitigate feelings of depression and isolation
3. Friendly competition and encouragement with other people who are in rehab for amputation
4. Reassurance that you are working with a team of professionals who are dedicated to supporting your rehabilitation

Question 21

List two or three overuse problems that a person with a unilateral upper extremity amputation may face?

Answer 21

Fatigue, pain, inflammation, decreased endurance, rotator cuff injuries, tendonitis, impingement, bursitis, epicondylitis, carpal tunnel

Question 22

How is the danger of foreign tissue rejection now being avoided among limb transplant patients?

Answer 22

1. During the surgery the surgeons transplant bone marrow from the donor. This may be the key to preventing limb rejection.
2. People who received limb transplants without accompanying bone marrow transplants take strong anti-rejection meds that suppress their immune systems, making them more vulnerable to other potentially deadly infections and medication side effects.
3. The recipient of the bone marrow transplant only takes one anti-rejection pill a day (as opposed to three or four like other limb transplant recipients)

Question 23

What early occupational therapy goals do you think are important in helping a hand transplant patient succeed in rehabilitation?

Answer 23

• wound care and info on positioning to promote healing, instructions on precautions, early exercises
• support psych. needs: clients often struggle with guilt and over having hand from someone who just passed away; help them stay positive and think of the hand as a gift

Question 24

Lists the steps of OT to restore function after a finger replantation.

Answer 24

Day 0-4: keep hand warm; use dorsal or volar protective orthosis (“Safe Position”)
Day 5-14: adjust orthosis if “safe pos.” not achieved; change to dorsal if initially volar; begin wound care with non-adherent dressings; early protected motion via tenodesis; teach HEP; precautions: no caffeine or nicotine
Day 14-21: begin “place and hold” ex in intrinsic plus and minus; initiate edema management with light compression if stable vascular status; wound care; HEP
Week 3-4: light coban wrap; continue protected A/PROM; scar massage
Week 4-5: composite finger flexion with wrist in neutral; A/PROM of the wrist; NMES (TENS) if poor tendon glide
Week 5-6: begin composite wrist and finger flexion/extension; gentle blocking ex; tendon gliding; dynamic flexion orthosis if needed; night time volar wrist and finger extension orthosis; light functional activity
Week 6-12: discontinue dorsal blocking splint; progress functional activity; add light resistance at 8 weeks; progress strengthening from week 8-12; sensory evaluation
Week 12+: work simulation, work conditioning; continue static progressive/dynamic orthotics; sensory evaluation every 5-6 weeks

Question 25

Name the amputations at different upper extremity levels

Answer 25

Interscapulothoracic
Shoulder disarticulation
Transhumeral (middle of the humerus)
Elbow disarticulation
Transradial (middle of the radius)
Wrist disarticulation
Transcarpal
Finger amputations

Question 26

What is meant by the “Golden Period” after amputation. What is that period?

Answer 26

If a person is fitted for an orthosis within 0-30 days of their injury, their rehabilitation success rate is 93%; 100% return to work within 4 months
When fitted after 30 days, only 15% returned to same job

Question 27

What are the most common fitting locations on the arm for a myoelectric prosthesis after transhumeral amputation?

Answer 27

On the triceps and biceps