Author(s): Stephanie Rand, DO, Vinay Vanodia, MD
Originally published: January 7, 2013 Last updated: March 23, 2021
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Disease/ Disorder

Definition

An upper limb amputation is the removal of any part of the upper extremity by surgery, trauma or pathology.  Standard levels of amputation include removal of any part of the arm, forearm, hand or digits.1 A 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. Typically there is no cut or damage to the full length of the remaining proximal bone. 

Etiology

The leading cause of upper limb amputations is trauma occurring in males ages 15-25 years, followed by cancer/tumors (common cause of more proximal amputations such as a shoulder disarticulation or forequarter amputation), and then vascular complications of diseases.1 Another cause of upper limb amputations is correction of congenital anomalies. 

Epidemiology including risk factors and primary prevention

Men are more at risk for amputations related to trauma.3 Traumatic amputations most commonly are from machinery accidents, explosions, self-inflicted injury, motor vehicle collisions, assault, and work-related injuries.4

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.5

Other risk factors include exposure to thermal and electrical injury, frostbite, and dysvascular disease (peripheral vascular disease [PVD] and diabetes).6

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

In general, traumatic amputations have an abrupt disease process, 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 course from 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 tissue or bone tumors do not often progress given easy visibility of the mass; however, when they do, tumor staging is necessary to prepare for sufficient excisional margins. Rehabilitation is often delayed secondary to postoperative adjuvant therapy (radiation, chemotherapy, etc).8

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.4

Secondary complications include the following: phantom limb pain, phantom sensation, neuromas, heterotopic ossification, joint contractures, myodesis/myoplasty failure, infections, neck and back pain, and sound limb complications from overuse.9

Essentials of Assessment

History

  1. Baseline functional status.
  2. Handedness.
  3. Future goals.
  4. Evaluation of co-morbid injuries/complications sustained at time of amputation.
  5. Sound limb and spine history.
  6. Social history: home and work-place, family/friends support, and prior exposure to amputees.9

Physical examination

A complete physical exam should be completed.

Special focus should be placed on the following:

  1. Visual inspection of the residual limb for swelling, atrophy, incisional healing, dog ears, open wounds, scar tissue or grafting
  2. Bilateral UE range of motion (ROM) at each joint
  3. Bilateral UE muscle strength testing
  4. Neck ROM
  5. Scapular stability and rhythm
  6. Limb volume measurement/circumference at set locations, length of residual limb
  7. Cognition
  8. Sensation testing9    

Functional assessment

An ideal patient should cognitively be able to follow instructions to participate in amputee rehabilitation.9

Particular movements of the upper extremity such as scapular protraction/retraction, shoulder depression and humeral flexion/extension will be utilized for a body-powered prosthesis.

Viable muscle sites for a myo-electric prosthesis should also be evaluated.  Any remaining supination/pronation or flexion/extension for a below elbow amputation should be noted.10

Patient’s level of independence, one handedness, and ability to perform activities of daily living (ADLs) should be assessed early on, including toilet hygiene, self feeding, oral hygiene, dressing, grooming, etc.10

Imaging

  1. X-rays: to assess residual limb for bony fragments or associated proximal/contralateral fractures.
  2. Magnetic resonance/computed tomography: for tumor workup or to evaluate extent of infection/osteomyelitis to assure adequate surgical margins.
  3. Technetium bone scan: to evaluate for osteomyelitis, bony fractures, or bony tumors (including metastatic lesions).
  4. Doppler ultrasonography: to measure arterial pressure to assess adequate inflow to the ischemic limb for wound healing.11

Supplemental assessment tools

  1. 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 non-progression, weakness, or pain.
  2. Myoelectric control training with EMG feedback: to assess the remaining musculature in the residual limb for strength of contraction.9

Early predictions of outcomes

Rates of UE prosthetic use range from 27%12 to 56%.13 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 days had a 42% success rate with a 15% return to work rate in 6-24 months.14

The higher acceptance rate among veterans of current military conflicts is attributed to improved technology for upper extremity prosthesis, increased rehabilitation time, and a general cultural acceptance of a blending of man and machine.15

Non-prosthetic users tend to have higher amputation levels, are women, or have poor access to care.16

Rejection rate of upper extremity prostheses are higher than lower extremity prostheses and can be linked to lack of training or development of skill with upper extremity prosthesis, development of one-handedness and independence without a prosthesis, non-cosmetic appearance, discomfort, etc.10

Successful outcomes have been linked to early prosthetic intervention, interdisciplinary team approach to care, patient education and follow up.10

Environmental

It is important to identify the patient’s discharge environment in addition to their goals and expectations, vocation and avocations, to ensure success with or without a prosthesis upon discharge.9

It is also important to note the family support and level of supervision (if needed) the individual will have at home.

Social role and social support system

The rehabilitation team will initially provide support and education for the patient and family. Various institutions may have amputee support groups at their local hospital.  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 and well as patient advocates for one on one support.

Professional Issues

Pricing for upper extremity prostheses can vary based on the componentry chosen for the patient.  On average, body powered prostheses are initially less expensive than myoelectric prostheses.  A transradial body powered prosthesis may cost between $4000-$8,000 while a transhumeral body powered prosthesis with the addition of an elbow unit cost approximately $5,000-$10,000.17

Myoelectric or externally powered transradial prostheses may cost $25,000 to $50,000 and a transhumeral costing approximately $50,000 – $75,000.17

The lifetime prosthetics care costs range from $130,442 to >$877,039 for a unilateral and $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.18

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 until all 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, desensitization, scar management, exercise, flexibility, maintain joint range of motion, gross motor activity, psychologic support, and basic ADLs.

Phase 2: Pre-prosthetic Training

Occurs 2-3weeks after amputation. The goal is to prepare the patient and the residual limb to accept a well-fitted prosthetic socket and functional prosthesis. If wounds prevent socket use, myosite testing/training for 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 master the mechanical actions required for prosthetic limb control, to integrate prosthesis use in activities, 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 weeks after starting 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 a multi-stepped 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.9

Four Main Components of a Prosthetic Prescription

  1. Socket.
  2. Suspension component.
  3. Terminal device(s).
  4. Interposing joint (if applicable).

Body Powered/Conventional19

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 Power19

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 surgery, which transfers nerves used for distal arm innervation (ulnar/median) and reconnects them to proximal alternative muscle sites.20

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).

Passive Functional/Cosmetic19

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.

Hybrid19

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 entire process–from preamputation discussion through 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 the patient’s goal and work alongside the physician in long-term follow-up to assure optimal fit and function of the prosthetic device.21

Patient & family education

This should begin as soon as possible, because the more educated the patients/family are 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.

Emerging/unique Interventions

The Unilateral Upper Extremity Amputation: Activities of Daily Living Assessment is a rating guide that provides a comprehensive list of ADLs a unilateral amputee should be able to accomplish. This can be done for each type of prosthesis the patient wears.9

Other outcomes include:

  1. Level of independence.
  2. Return to work.
  3. Return to avocational activities.
  4. 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 appreciation of how challenging it is and you may identify items that improve their 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.8

Cutting Edge/ Emerging and Unique Concepts and Practice

  1. 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.15
  2. 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.15
  3. Virtual reality is incorporated into the rehabilitation process to decrease pain and increase prosthetic use.22
  4. Botulinum toxin injections for hyperhydrosis.23
  5. Streamlining the neural-prosthesis interface by tracing emission of EMG signals to specific brain areas.20
  6. Three-dimensional (3D) printed upper extremity prostheses are evolving through both individual development and larger, open-source web-based communities. They are particularly gaining popularity for use in the pediatric and under-developed global health populations.24-25

Gaps in the Evidence- Based Knowledge

When a person loses a hand, it translates to an upper-limb impairment of 100% and a whole-body impairment of 57%26. 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

References

  1. Cuccurullo, S.  (Ed) (2015). Physical Medicine and Rehabilitation Board Review:  Prosthetics and Orthotics. Third Edition.  New York, NY: Demos Medical Publishing.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. Lake C. Upper-limb prosthetics: using evidence-based practice to enhance patient care experiences. The Academy TODAY. 2011:A4-A7.
  8. 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.
  9. 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.
  10. Atkins D.  (1992). Atlas of Limb Prosthetics: Surgical, Prosthetic and Rehabilitation Principles. Rosemont, IL: American Academy of Orthopedic Surgeons.
  11. 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.
  12. Wright TW, Hagen AD, Wood MB. Prosthetic usage in major upper extremity amputations. J Hand Surg. 1995;20:619-622.
  13. 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.
  14. 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.
  15. Harvey Z, Potter B, Vandersea J, Wolf E. Prosthetic advances. J Surg Orthop Adv. 2012;21:58-64.
  16. Biddiss E, Chau T. Upper-limb prosthetics: critical factors in device abandonment. Am J Phys Med Rehabil. 2007;86:977-987.
  17. Resnik, L. et al. (2012) Advanced Upper Limb Prosthetic Devices: Implications for Upper Limb Prosthetic Rehabilitation. Archives of Physical Medicine and Rehabilitation. Volume 93, Issue 4, , Pages 710-717. doi.org/10.1016/j.apmr.2011.11.010
  18. 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.
  19. 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.
  20. Behrend C, Reizner W, Marchessault J, Hammert W. Update on advances in upper extremity prosthetics. J Hand Surg. 2011;36A:1711-1717.
  21. Orthotics and prosthetics. Available at: www.opcareers.org/entering_profession/responsiblities.asp . Accessed September 23, 2012.
  22. 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.
  23. 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.
  24. Ten Kate J, Smit D, Breedvel P. 3D-printed upper limb prostheses: a review. Disabil Rehabil Assist Technol. 2017 Apr; 12(3): 300-314.
  25. Silva K, Rand S, Cancel D, Chen Y, Kathirithamby R, Stern M. Three-Dimensional (3-D) Printing: A Cost-Effective Solution for Improving Global Accessibility to Prostheses. PMR. 2015 Dec;7(12): 1312-1314.
  26. Rondinelli R. Guides to the Evaluation of Permanent Impairment. 6th ed.: American Medical Association; 2008.

Original Version of the Topic

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

Author Disclosures

Stephanie Rand, DO
Nothing to Disclose

Vinay Vanodia, MD
Nothing to Disclose