Author(s): Yunna Lee Sinskey, MD
Originally published: January 7, 2013 Last updated: March 13, 2025
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Disease/Disorder

Definition

An upper extremity (UE) amputation is the removal of any part of the UE by surgery, trauma or pathology.  Standard levels of amputation include removal of any part of the arm, forearm, hand or digits.1A major limb amputation is generally considered any amputation at or above the wrist.2

A disarticulation is an amputation through a joint, where the distal articulating bone is separated and removed from the proximal articulating bone. The advantages of wrist disarticulation compared to transradial amputation includes improved pronation and supination, longer lever arm, prevention of terminal overgrowth, and ability to preserve distal physis in children allowing growth; however, wrist disarticulation prostheses tend to be more challenging to fit.3

Goals of UE Amputation Rehabilitation Care

  • Functional Restoration: Enhancing the individual’s ability to perform activities of daily living (ADLs).
  • Prosthetic Training: Facilitating successful integration and use of prosthetic devices by providing training in device donning and doffing, control strategies, and functional tasks.
  • Pain Management: Alleviating residual limb pain, phantom limb pain, and other pain-related symptoms through medication management, physical therapy modalities, and psychological support.
  • Improving Range of Motion and Strength: Restoring or maintaining optimal ROM, muscle strength, and joint mobility in the residual limb and remaining UE to optimize functional performance and prevent secondary complications.
  • Enhancing Sensory Awareness: Promoting sensory awareness and proprioception in the residual limb and prosthetic device through sensory re-education techniques, sensory feedback systems, and sensory substitution strategies.
  • Psychological Adjustment and Coping: Supporting psychological adjustment to limb loss, addressing body image concerns, promoting self-esteem, and facilitating the development of effective coping strategies to manage emotional challenges and psychosocial stressors.
  • Community Reintegration: Facilitating successful community reintegration by addressing environmental barriers, promoting social participation and engagement, and empowering individuals to navigate social, vocational, and recreational activities.
  • Optimizing Quality of Life: Enhancing overall quality of life by addressing physical, psychological, social, and vocational needs.

These goals are often pursued through a multidisciplinary approach involving rehabilitation professionals, including physiatrists, physical therapists, occupational therapists, prosthetists, psychologists, and other healthcare providers, working collaboratively to address the complex needs of individuals with UE amputations.

 Epidemiology

The primary cause of UE amputations is trauma, with about 75% stemming from work-related accidents like crush injuries, electrical burns, gunshot wounds, or combat injuries.4 These amputations, typically affecting those aged 20-40s with a male-to-female ratio of 4:1, are often distal to the wrist at the digit level.4,5 Non-traumatic UE amputations are primarily due to cancer or tumors, often resulting in more extensive amputations like shoulder disarticulation or forequarter amputation.1 Risk factors for soft-tissue and bone tumors include previous radiation therapy, chemical exposure, immunodeficiency, prior injury, chronic irritation, bone infarcts, and genetic cancer syndromes.6 Other causes include congenital anomalies, thermal or electrical injury, frostbites, dysvascular disease, and infection.4

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Traumatic amputations typically progress rapidly, unless limb salvage is attempted beforehand. Younger trauma patients often lack age-related morbidities, which enables optimal recovery.7 Dysvascular patients experience a prolonged disease course before amputation, marked by poor blood supply, reduced sensation, and heightened infection risk. Comorbidities like diabetes, peripheral vascular disease (PVD), and hypertension hinder wound healing and may necessitate repeat surgeries.7 Primary UE tumors usually have visible masses and require staging for adequate excision. Postoperative therapies like radiation and chemotherapy may delay rehabilitation.8

Specific secondary or associated conditions and complications

Immediate complications: delayed wound healing, retained foreign body, infections, vascular injuries, blood loss, and hypotension.5

Secondary complications: phantom limb pain, neuromas, heterotopic ossification, joint contractures, myodesis/myoplasty failure, infections, neck/back pain, and overuse injury.9

Patients with UE amputation have a significantly higher risk of developing neck/upper back pain, shoulder pain, low back pain, and even lower extremity overuse injury conditions as early as 1-year post-UE amputation.10,11

Essentials of Assessment

History

  • Reason for amputation
  • Evaluation of co-morbid injuries/complications sustained at time of amputation, if applicable.
  • Handedness.
  • Future vocational and recreational goals.
  • Baseline functional status including cognition.
  • MSK history including contralateral limb and cervical spine.
  • Social history: home/work-place, family/friends support, ability to participate in frequent follow-ups with prosthetist and therapist.9

Physical examination

A comprehensive physical exam should be performed, focusing on

  • Visual inspection of the residual limb for length, volume, atrophy, incisional healing, wounds, scar tissue or grafting, and residual limb shape.
  • Bilateral UE ROM at each joint including scapular/glenohumeral joint
  • Bilateral UE muscle strength
  • Neck ROM
  • Sensation
  • Cognition

Functional assessment

An ideal candidate for amputee rehabilitation should possess cognitive abilities to comprehend and execute instructions.9 Specific UE movements, like scapular protraction/retraction and shoulder flexion/extension, are essential for body-powered prostheses, while muscle sites suitable for myoelectric prostheses need evaluation. Assessing remaining functional abilities, including supination/pronation and flexion/extension, is crucial for below elbow amputations.12 Early evaluation of independence level, hand dominance, and ADL performance, such as toileting, feeding, and grooming, is recommended.12 Standardized assessments like the Box and Block test, Jebsen–Taylor Hand Function tests, University of New Brunswick tests, Activities Measure for UE Amputation, and the Patient-Specific Functional Scale are reliable choices for UE prosthetic training evaluation.13

Imaging

  • X-rays: Assess residual limb for bony fragments, degenerative joint diseases, or fractures.
  • MRI/CT: Aid in tumor diagnosis, assess infection extent, assure surgical margins, predict amputation level, and re-amputation rate.14
  • Technetium bone scan: Evaluate for osteomyelitis, heterotrophic ossification.
  • Ultrasonography: Assess soft tissue injuries or laxity including tendon or muscle sprains, strains, tears, trapped or compressed nerves, arthritis, etc.
  • Doppler ultrasonography: Measure arterial pressure to assess adequate inflow to the ischemic limb for wound healing.14

Supplemental assessment tools

  • EMG/NCS: Performed pre-surgery to help identify the optimal surgical plan or post-surgery to help identify reasons for non-progression, weakness, or pain.
  • Myoelectric control training with EMG or pattern recognition feedback: to assess the remaining musculature in the residual limb for potential areas of sensor placement.9,15

Early predictions of outcomes

The pre-amputation function, level and cause of amputation significantly impact functional outcomes. Higher-level amputations, such as transhumeral or shoulder disarticulation, typically result in greater functional limitations compared to lower-level amputations, such as transradial or wrist disarticulation.16

Rates of UE prosthetic use range from 27%17 to 56%.18 Within the UE amputee population, those fit with a prosthesis within 30 days of amputation exhibited 93% rehabilitation success rate with 100% return to work rate within 4 months of injury. Those fit beyond 30 days had 42% success rate with 15% return to work rate in 6-24 months.19

Rejection rate of UE prostheses are higher than lower extremity prostheses with more recent studies showing prosthesis rejection rate as high as 44%.20 This can be linked to lack of training or development of skill with UE prosthesis, development of one-handedness and independence without a prosthesis, non-cosmetic appearance, discomfort, weight of prosthesis, and inability to afford prosthesis, etc.12,20–22 Successful outcomes have been linked to early prosthetic intervention, interdisciplinary team approach to care, patient education and follow up.12,21

Environmental

Identifying the patient’s discharge environment, goals, expectations, vocational/avocational activities is crucial for successful rehabilitation regardless of prosthesis use.9 Environmental factors including access to healthcare, socioeconomic status, and barriers significantly impact outcomes.23 Addressing specific barriers and providing support services enhances overall rehabilitation success.23

Psychological care

Traumatic amputation leads to significant changes in an individual’s life, impacting physical functionality, social engagement, self-esteem, psychosocial well-being, and employment prospects. The prevalence of psychiatric conditions in traumatic UE amputees are alarmingly high with prevalence of major depressive disorder of 71%, suicide ideation of 30.5% , and post-traumatic stress disorder of 20.3%.24 These findings underscore the critical need for targeted interventions to address the significant psychological distress experienced by UE amputees.

Social role and social support system

In addition to rehabilitation team, various institutions may have local amputee support groups.  National groups such as: Amputee Coalition of America, Wounded Warrior Project, Limb Preservation Foundation, Limbs for Life Foundation, American Amputee Foundation, and Veterans Affairs Hospitals have support opportunities including patient advocates for one-on-one support.

Professional issues

Pricing for UE prostheses varies based on its componentry. The 5-year average unilateral UE prosthetic and assistive device is predicted to cost $31,123-117,440.25 In general, use of microprocessor-controlled devices resulted in higher initial prosthetic and total hospital cost compared to mechanical devices, with cost being highest in prosthetic-related expenses and physical therapy during the first year post-amputation.26 Some health care policies only pay for one prosthesis or may disqualify patients based on pre-existing health conditions.25 Some states have passed bills that require health insurance companies to now cover physician-prescribed recreational prosthetic devices.27 The shortage of prosthetists and occupational therapists interested in UE amputee care also presents as a significant challenge.

Rehabilitation Management and Treatments

Phase 0: Pre-operation Education

Due to the traumatic nature of UE amputations, preoperative therapy planning is often not possible. In rare cases with some lead time before amputation, patients can benefit from education on potential post-surgery abilities and skills.

Phase 1: Immediate Postoperative Management

Immediate postoperative management may include wound care, edema reduction, residual limb shaping, proper pain control, scar tissue management, contracture prevention, total body muscle endurance and strengthening, changing hand dominance where appropriate, basic ADLs training, psychologic support, and home/DME assessment. The assessment should include bilateral limbs, neck, and trunk. The duration of this phase may be influenced by the number of limbs amputated, patient’s cognitive function, and support system.3

Phase 2: Pre-prosthetic Training

The aim is to prepare patients for successful prosthesis use by enhancing endurance, mobility, and strength. Therapists focus on specific motor skills required for prosthesis operation, such as scapular movement and shoulder control. Myoelectric prosthesis users may undergo myosite testing and pattern development. Emphasis is also placed on ROM, physical conditioning, desensitization, limb shaping, ADL progression, and psychological support. This phase ends with prosthesis acquisition.

Phase 3: Intermediate Prosthetic Training

The goal is to increase prosthesis wear time, master prosthetic control, expand functional envelope, and to start integrate prosthesis into activities. Proper training with an occupational therapist post-prosthesis fitting is crucial.28

Phase 4: Advanced Prosthetic Training

This phase is highly individualized, focusing on the patient’s vocational and avocational goals. It usually involves using tools or objects and may require onsite work assessments by therapist for environmental modifications. The aim is to conserve energy, minimize biomechanical stress, and facilitate return to pre-injury activities. Frequent therapy sessions have been related to earlier return to work.29

Regular follow-up visits with a multidisciplinary team are essential for ongoing care, including monitoring for prosthetic needs, skin issues, overuse injuries, and functionality preservation.

Main components of a prosthetic prescription

  • Socket.
  • Suspension.
  • Interface
  • Terminal device(s).
  • Interposing joint (if applicable).

Passive functional/cosmetic

Similar in appearance to the nonaffected arm or hand by replacing the missing limb. It provides simple aid in balancing and carrying. Advantages: cosmetically appealing; lightweight; simple to use; little maintenance; great for partial hands; and provides opposition.

Body powered/conventional

Operated by a cable and harness system that is controlled by specific body movements.

Advantages: heavy-duty construction of the device may give it a long life and more durability when it comes to wear and tear and getting the prosthesis wet; it also offers proprioception; is less expensive and lighter in weight than myoelectric devices; and there is a reduced cost and maintenance.

Myoelectric/external power

Powered by a battery system and is controlled by EMG signals generated during muscle contractions. The residual limb must possess measurable EMG signals to be a candidate. Proximal amputees that lack distal muscle contractions may undergo targeted muscle reinnervation(TMR) surgery, which transfers residual nerves from the amputated arm to reinnervate new muscle targets that have otherwise lost their function allowing more intuitive control of myoelectric prosthetic arms.30,31

Advantages: increased functional movements; may offer functional cosmetic restoration; can increase a person’s pinch and grip force; and harness system is reduced or eliminated offering increased comfort and ROM.32,33

Hybrid

Combines the use of body power and external power.

Advantages: greater functional envelope from the basic body-powered device; offers reduced weight from the myoelectric; offers greater grip force similar to the myoelectric; harness system is reduced; and initial costs and maintenance costs are reduced.34

Emerging/unique interventions

  • Osseointegration: A device is inserted into the residual limb bone, protruding through the skin, eliminating the traditional socket, improving suspension, mobility, and overall quality of life.36
  • Targeted muscle reinnervation: Motor nerves are reimplanted into denervated muscles to increase myoelectric control sites.30,31
  • Botulinum toxin injections for hyperhydrosis.23
  • Agonist-antagonist myoneural interface(AMI) surgery utilizes natural agonist-antagonist muscle coupling responsible for proprioceptive sensory feedback in hopes to enhance motor control and sensory feedback.37,38
  • Implantable myoelectric sensors are miniature electrodes that transmit EMG signals wirelessly to a myoelectric prosthesis via embedded electromagnetic coil within the prosthetic socket. Placing the electrodes within the muscles demonstrated greater reliability, less impedance, and improved resistance to fibrosis/longevity.39–41
  • Regenerative peripheral nerve interfaces(RPNI) surgery places a free peripheral nerve ending into a free muscle or dermal graft reducing reduces neuroma and phantom limb pain.42 RPNI surgery has also demonstrated its ability in serving as a bioamplifier of motor action potentials demonstrating prominent contractions during phantom finger flexion allowing more complex control of myoelectric protheses.44

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Directly observing UE amputee patients using their prosthesis provides insight into their challenges and provides an opportunity to discover ways to enhance their quality of life. Frequent communication with prosthetist and therapist is crucial.8

Cutting Edge/Emerging and Unique Concepts and Practice

  • Virtual and augmented reality enhance rehabilitation by reducing pain, improving UE prosthetic training, and promoting prosthetic usage.45–47
  • Streamlining the neural-prosthesis interface by tracing emission of EMG signals to specific brain areas.20
  • Pattern recognition-based myoelectric control utilizes varied EMG patterns from multiple muscles to activate specific movements in prosthetic devices, eliminating the need for independent muscle sites.51
  • Powered terminal devices, coupled with targeted muscle reinnervation, offer refined sensory feedback, potentially restoring some sensations and improving prosthesis control.49,50
  • Three-dimensional(3D) printed UE prostheses, developed individually and through online communities, are increasingly popular, especially in pediatric and underserved global health settings.48

Gaps in the Evidence-Based Knowledge

A substantially larger amount of neurologic area within the human brain is dedicated to the motor and sensory functions of the UE than the lower limb.52  However, research in UE amputee care lags behind lower limb studies, leading to a lack of consensus on rehabilitation protocols, prosthetic design, long-term outcomes, and psychosocial support.

References

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Original Version of the Topic

David R. Coons, MD, Allison J. Franklin, DO. Upper Limb Amputations. 1/7/2013

Previous Revision(s) of the Topic

Stephanie Rand, DO, Vinay Vanodia, MD. Upper Limb Amputations. 3/23/2021

Author Disclosures

Yunna Lee Sinskey, MD
Nothing to Disclose