An upper limb amputation is the removal of any part of the forearm or arm. A major limb amputation is generally considered any amputation at or above the wrist.1
Common etiologies include the following: trauma, cancer, infection, dysvascular disease, and congenital disease (for more information see the Pediatric section).
Epidemiology including risk factors and primary prevention
Men are more at risk for amputations related to trauma.2 Traumatic amputations most commonly are from machinery accidents, explosions, self-inflicted injury, motor vehicle collisions, assault, and work-related injuries.3
Soft-tissue and bone tumor risk factors include previous radiation therapy, exposure to chemicals, immunodeficiency, prior injury, chronic tissue irritation, bone infarcts, and genetic cancer syndrome.4
Other risk factors include exposure to thermal and electrical injury, frostbite, and dysvascular disease (peripheral vascular disease[PVD] and diabetes).5
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Traumatic amputations have an abrupt disease progression, unless a period of limb salvage is attempted prior to amputation surgery. Many trauma patients are younger and without age-related comorbidities, enabling optimal recovery.7
Dysvascular patients tend to have a prolonged time coursefrom disease onset until amputation. Amputation is usually preceded by evidence of poor blood supply, decreased protective senses, and wound formation all increasing infection risk. Common comorbidities, such as diabetes, PVD, and hypertension, predispose to poor wound healing and repeat amputation surgeries.7
Primary upper extremity (UE)soft tissueor bone tumors do not often progress given easy visibility of the mass; however, when they do, tumor staging isnecessary to preparefor sufficient excisional margins. Rehabilitation is often delayedsecondary to postoperative adjuvant therapy (radiation, chemotherapy, etc).6
Specific secondary or associated conditions and complications
Immediate complications include the following: delayed wound healing, retained foreign body, infections, vascular injuries, blood loss, and hypotension.3
Secondary complications include the following: phantom limb pain, phantom sensation, neuromata, heterotopic ossification, joint contractures, myodesis/myoplasty failure, infections, neck and back pain, and sound limb complications from overuse.8
2. ESSENTIALS OF ASSESSMENT
- Baseline functional status.
- Future goals.
- Evaluate comorbid injuries/complications sustained at time ofamputation.
- Sound limband spine history.
- Social history: home and workplace,family/friends support, and prior exposure to amputees.8
Complete physical should be done.
Special focus should be placed on the following:
- Bilateral UE range of motion (ROM) at each joint.
- Bilateral UE muscle strength testing.
- Neck ROM.
- Limb volume measurement/circumference at set locations.
- Wound/scar evaluation and measurements.
- Sensation testing.8
An ideal patient shouldcognitively be able tofollow instructions to participate in amputee rehabilitation.8
UEROM, neck ROM,body symmetry, core strength, and incorporation of the residual limb into activity should be evaluated. Activities of daily living (ADLs) to assess early include toilet hygiene, self feeding, and oral hygiene.
- X-rays: to assess residual limb for bony fragments or associated proximal/contralateral fractures.
- Magnetic resonance/computed tomography: for tumor workup or to evaluate extent of infection/osteomyelitis to assure adequate surgical margins.
- Technetium bone scan: to evaluate for osteomyelitis, bony fractures, or bony tumors (including metastatic lesions).
- Doppler ultrasonography: to measure arterial pressure to assess adequate inflow to the ischemic limb for wound healing.9
Supplemental assessment tools
- Electromyography (EMG)/nerve conduction study: to identify nerve injuries prior to the surgical procedure to help identify the optimal surgical plan or afterward to help identify reasons for nonprogression, weakness, or pain.
- Myoelectric control training with EMG feedback: to assess the remaining musculature in the residual limb for strength of contraction.8
Early predictions of outcomes
Rates of UE prosthetic use range from 27%10 to 56%.11 Within the UE amputee population, those fit with a prosthesis within 30 days of amputation exhibited a 93% rehabilitation success rate with a 100% return to work rate within 4 months of injury. Those fit beyond 30 dayshad a42% success rate with a 15% return to work rate in6-24 months.12
There is a higher acceptance rate amongveterans of current military conflicts,attributed to improved technology for upper extremity prosthesis, increased rehabilitation time, and a general cultural acceptance of a blending of man and machine.13
Nonprosthetic users tend to have higher amputation levels, are women, or have poor access to care.14
It is important to identify the patient’s discharge environment in addition totheirgoals, vocation, and avocations to ensure success with/without a prosthesis on discharge.8
Social role and social support system
The rehabilitation team will initially provide the support and education for the patient and family. Community 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.
Prosthetic device costs are as follows: $7000 for body-powered; $40,000 formyoelectric with an advancedhand; and $100,000 for above elbow myoelectric prosthesis. The lifetime prosthetics care costs range from $130,442 to >$877,039 for a unilateraland $227,874 to >$1,992,782 for bilateral UE amputees. Some health care policies only pay for 1 prosthesis or may disqualify patients based on pre-existing health conditions.15
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
Four Phase Upper Limb Amputee Protocol of Care
Phase 1: Initial Management and Protective Healing
Begins immediately after injury and continues untilall the wounds are closed and infection free. It usually lasts 1-3 weeks. It includes a comprehensive evaluation, wound healing, edema control (with casting or elastic bandage wrapping)and pain control, densensitization, scar management, exercise, flexibility, gross motor activity, psychologic support, and basic ADLs.
Phase 2: Preprosthetic Training
Occurs 2-3weeks after amputation. The goal is to prepare the patient and the residual limb toaccept a well-fitted prosthetic socket and functional prosthesis. If wounds prevent socket use, myosite testing/trainingfor myoelectric prostheses occurs. This phase ends with the acquisition of a prosthesis. Time is still spent on ROM,physical conditioning,desensitization, limb shaping, progression in ADLs, and psychologic support.
Phase 3: Intermediate Prosthetic Training
This is a major turning point in the UE amputee’s rehabilitation. The goal is for the patient to masterthe mechanical actionsrequired for prosthetic limb control, tointegrate prosthesis use inactivities, and achieve independence in all ADLs. The goal is to tolerate wear time for an 8 hour day and independently don/doff the prosthesis. It is easy for a person to reject a prosthesis and become 1 handed, this is the phase to prevent that.
Phase 4: Advanced Prosthetic Training
Occurs approximately 8-16 weeksafterstarting rehabilitation. This is the first highly individualized phase, because it incorporates the patient’s personal vocational and avocational goals. It usually involves working with a tool or object (machine, instrument, etc) and is amultistepped process. The patient should use their prosthesis of choice. The goal is to conserve energy, decrease biomechanical stress to the intact limb, decrease extraneous body movements, and decrease use of adaptive equipment.
Community reintegration in incorporated in every stage of this protocol. The stages are fluid, because a patient may go forward or backward or even be in2 phases at the same time.8
Four Main Components of a Prosthetic Prescription
- Suspension component.
- Terminal device(s).
- Interposing joint (if applicable).
It is operated by a harness system that is controlled by specific body movements.
Advantages: heavy duty construction of the device gives it a long life; offers proprioception; is less expensive and lighter in weight than myoelectric devices; and there is a reduced cost and maintenance.
It is powered by a battery system and is controlled by EMG signals generated during muscle contractions. The residual limb mustpossess measurable EMG signals to be a candidate. Proximal amputees that lack distal muscle contractionsmay undergo targeted muscle reinnervation surgery, which transfers nerves used for distal arm innervation (ulnar/median) and reconnects them to proximal alternative muscle sites.17
Advantages:increased functional movements;may offer functional cosmetic restoration; can increase a person’s grip force to 20-32 lbs; and harness system is reduced or eliminated (offers comfort and increased ROM).
It is 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.
This 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.
Coordination of care
Ideally, an interdisciplinary team should be incorporated throughout the entireprocess–from preamputation discussionthrough successful community reintegration. This team may include: physiatrists, surgeons, occupational, physical, and recreational therapies, mental health, social workers/case managers,patients/family, and peer visitors. An important team member is the prosthetist. They provide comprehensive assessments to identify prosthetic needs that match thepatient’s goal and work alongside the physician in long-term follow-up to assure optimal fit and function of the prosthetic device.18
Patient & family education
This should begin as soon as possible, because the more educated the patients/familyare about the processes of amputation and rehabilitation, the less fear and apprehension there is. This process is guided by the physiatrist and includes other interdisciplinary team members. Education may include specifics about protecting the contralateral limb.
The Unilateral Upper Extremity Amputation: Activities of Daily Living Assessment is a rating guide that provides a comprehensive list of ADLs an unilateral amputee should be able to accomplish. Thiscan be done for each type of prosthesis the patient wears.8
Other outcomes include:
- Level of independence.
- Return to work.
- Return to avocational activities.
- Use of prosthesis.
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
Take the time to see your UE amputee patient use their prosthesis in therapy and in the community. It will provide a new appreciationof how challengingit is and you mayidentifyitems that improvetheir quality of life. Integrate best research evidence, respect and integrate the patient’s values, and build the necessary clinical expertise to address the patient’s needs.7
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
- Osseointegration: an alloy device is inserted into the bone of the residual limb and progresses through the skin; later a prosthesis is attached via a coupling process; results in improved anchorage and greater proprioceptive feedback.13
- Targeted muscle reinnervation: motor nerves who have lost their primary muscle groups are reimplanted into deliberately denervated proximal muscles to produce more control sites for myoelectric prostheses use.13
- Virtual reality is incorporated into the rehabilitation process to decrease pain and increase prosthetic use.19
- Botulinum toxin injections for hyperhydrosis.20
- Streamlining the neural-prosthesis interface by tracing emission of EMG signals to specific brain areas.17
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
When a person loses a hand, it translates to anupper-limb impairment of 100% and a whole-body impairment of 57%. A substantially larger amount of neurologic area within the human brain is dedicated to the motor and sensory functions of the upper limb than the lower limb. This creates an engineering hurdle for manufacturers and a noticeable gap in our technical ability to replace the functions of the human hand.7
- Tseng CL, Helmer D, Rajan M, et al. Evaluation of regional variation in total, major and minor amputation rates in a national health-care system. Int J Qual Health Care. 2007;19:368-376.
- illingham TR, Pezzin LE, MacKezie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J. 2002;95:875-883.
- Barmparas G, Inaba K, Teixeira P, et al. Epidemiology of post-traumatic limb amputation: a National Trauma Databank analysis. Am Surg. 2010;76:1214-1222.
- Shmookler B, Bickels J, Jelinek J, Sugarbaker P, Malawer M. Bone and Soft-Tissue Sarcomas: Epidemiology, Radiology, Pathology and Fundamental of Surgical Treatment. Musculoskeletal Cancer Surgery: Bone and Soft-Tissue Sarcomas. New York, NY: Kluwer Academic Publishers; 2001.
- Lento P. Trauma and other causes of amputation. Disaboom: information and resources for people with disabilities. Available at: www.disaboom.com/amputations-information/trauma-and-causes-of-amputation. Accessed September 20, 2012.
- Sugarbaker, P, Bickles J, Malawer M. Above-elbow and below-elbow amputations. In: Malawer M and Sugarbaker P, eds. Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. 2nd ed. New York, NY: Kluwer Academic Publishers; 2004:300-301.
- Lake C. Upper-limb prosthetics: using evidence-based practice to enhance patient care experiences. The Academy TODAY. 2011:A4-A7.
- Smurr LM, Yancosek K. Occupational therapy for the polytrauma casualty with limb loss. In: Pasquina P and Cooper R, eds. Care of the Combat Amputee. Washington, DC: Borden Institute; 2009:493-534.
- Ertl JP, Calhoun JH. Amputations of the lower extremity workup. 2012. Available at: www.emedicine.medscape.com/article/1237886-overview#a03. Accessed September 23, 2012.
- Wright TW, Hagen AD, Wood MB. Prosthetic usage in major upper extremity amputations. J Hand Surg. 1995;20:619-622.
- Raichle K, Hanley M, Molton I, et al. Prosthesis use in persons with lower and upper-limb amputation. J Rehabil Res Dev. 2008;45:961-972.
- Malone JM, Fleming LL, Roberson J, et al. Immediate, early and late postsurgical management of upper limb amputation. J Rehabil Res Dev. 1984;21:33-41.
- Harvey Z, Potter B, Vandersea J, Wolf E. Prosthetic advances. J Surg Orthop Adv. 2012;21:58-64.
- Biddiss E, Chau T. Upper-limb prosthetics: critical factors in device abandonment. Am J Phys Med Rehabil. 2007;86:977-987.
- Blough DK, Hubbard S, McFarland LV, Smith DG, Gambel JM, Reiber GE. Prosthetic cost projections for service members with major limb loss from Vietnam and OIFOEF. J Rehabil Res Dev. 2010;47:387-402.
- Huang M, Levy C, Webster J. Acquired limb deficiencies. Prosthetic components, prescriptions, and indications. Arch Phys Med Rehabil. 2001;82(3 Suppl 1):S17-24.
- Behrend C, Reizner W, Marchessault J, Hammert W. Update on advances in upper extremity prosthetics. J Hand Surg. 2011;36A:1711-1717.
- Orthotics and prosthetics. Available at: www.opcareers.org/entering_profession/responsiblities.asp . Accessed September 23, 2012.
- Resnik L, Etter K, Klinger SL, Kambe C. Using virtual reality environment ot facilitate training with advanced upper-limb prosthesis. J Rehabil Res Dev. 2011;48:707-718.
- Charrow A, DiFazio M, Foster L, Pasquina PF, Tsao JW. Intradermal botulinum toxin type A injection effectively reduces residual limb hyperhidrosis in amputees: a case series. Arch Phys Med Rehabil. 2008;89:1407-1409.
David R. Coons, MD
Nothing to Disclose
Allison J. Franklin, DO
Nothing to Disclose