Plastic Surgery Volume 6: Hand and Upper Extremity (4th Edition) – Peter C. Neligan

888
SECTION VI
CHAPTER 39 • Hand therapy
extensor lags. Howell et al. suggest immediate controlled
active motion (ICAM) for patients with repairs in these
zones.124 This protocol includes three phases, the first of which
can be initiated between 0 and 21 days after surgery. The wrist
is immobilized in 20–25° extension, while the MP joint of the
affected digit is positioned with a “yoke” orthosis in 15–20°
of hyperextension relative to the other digits (Fig. 39.10). Both
orthoses are to be worn at all times and the patient must
achieve full active motion within the ICAM orthosis before
progressing to the next phase. Phase 2 begins 22–35 days after
repair, during which the yoke orthosis is worn at all times and
both the yoke and wrist orthoses are only worn for medium
to heavy activities. The patient is instructed to relax the digits
during wrist exercise. Phase 3 is initiated 36–49 days after
repair and includes discontinuation of the wrist orthosis with
the yoke orthosis or buddy taping continued during activities.
The yoke orthosis is removed for active motion during the
final phase.
Despite the seeming simplicity of extensor tendon as com­
pared to flexor tendon rehabilitation, attention to anatomic
specificity is very important as it pertains to final outcomes.
Edema collects easily in the dorsal hand and must be managed
immediately to avoid tendon adhesions. Attention to both
active and passive motion at all joints provides valuable
information for the choice and progression of interventions.
A passively mobile joint with an active extensor lag is best
managed via active tendon gliding in both proximal and
distal directions. Resistive exercises are an excellent method
of restoring tendon glide after the eighth week. Perhaps the
most important approach is the isolation of specific muscula­
ture to produce joint extension including the extensor digito­
rum communis for MP extension and the intrinsic musculature
for interphalangeal extension.
Tenolysis
Following flexor and extensor tendon repairs, the likelihood
of scar adhesions that limit active excursion is unfortunately
high. While early motion coupled with continual evaluation
and progression can modulate scar formation, confounding
factors including overall health, medical comorbidities, pain,
and compliance may negatively impact postoperative results.
If progress has plateaued at the 3-month interval, patients are
often evaluated as candidates for tenolysis.
educated on the avoidance of isolated joint motion that can
unnecessarily stress the terminal tendon. Lateral tracing of the
digit for daily comparison serves as an effective visual aid to
monitor for development of an extensor lag during the
orthosis-weaning process. If an extensor lag develops at any
time during this process, support in extension is resumed and
flexion exercises are decreased or discontinued.
Loss of integrity of the central slip in zone III is termed a
boutonnière deformity. As the lateral bands sublux volarly,
flexion of the PIP joint is unopposed. Flexion contractures are
common sequelae of this condition and avoidance of this
difficult complication must be pursued early in the treatment
process. In addition, extensor forces are transmitted to the DIP
joint, resulting in hyperextension of the DIP joint. Differential
diagnosis of a pseudoboutonnière from a true boutonnière is
an important component of the evaluative process. In the
former, the DIP joint remains passively flexible, whereas in
the latter, the DIP joint cannot be passively flexed. Non-
operative management of the boutonnière deformity includes
continual use of an orthosis or cast that positions the PIP joint
at 0° extension for 6–8 weeks. The DIP and MP joints do not
need to be included in the orthosis or cast, if the therapist is
successfully able to maintain the PIP joint at 0° extension,
which is often difficult. The orthosis is continued between
exercises until the tenth week following injury.
A short arc motion protocol may be initiated within 48 h of
surgical correction of a boutonnière deformity, as suggested
by Evans.122 A template is fabricated that allows 30° of PIP and
20° of DIP joint flexion. The patient is instructed to produce
finger flexion to the template and active extension to 0°. This
exercise is completed 10–20 times every 1–2 h with the wrist
held in 30° flexion and the MP joints between 0° extension and
slight flexion. The template is adjusted to 40° of flexion after
the second week if there is no active extensor lag. It is then
progressed to 50° by the third postoperative week and up to
70–80° by the end of the fourth week. The finger is immobi­
lized in full extension between exercises and an exercise
orthosis to facilitate isolated DIP flexion is also fabricated.
Injuries in zones V–VII may occur with open (such as lac­
erations) or closed (such as blunt trauma) mechanisms of
injury. Disturbance of the sagittal bands often leads to long
extensor tendon subluxation with resultant MP extensor lag.
Following surgical repair, multiple protocols are considered
effective for treating extensor tendon injuries in these zones.
The most conservative protocol includes immobilizing the
wrist in 40–45° extension and the MP joints in 0–20° flexion.
A volar interphalangeal extension orthosis is fabricated to
support the joints in full extension between exercises and at
night as a means of preventing both flexion contractures and
an extensor lag. Treatment of edema and scar is critical in this
zone as adhesions are likely and will limit both proximal and
distal glide of the extensor tendons. Exercises begin at 3–4
weeks postoperatively and include a wrist tenodesis exercise
with active MP flexion and extension as well as continued
interphalangeal active motion.
In zone VI–VII injuries, Evans and Burkhalter suggested a
dorsal dynamic extension assist orthosis to allow 30° active
MP flexion and returns the digits to 0° extension via dynamic
traction.123 The early distal glide allowed by this orthosis
makes it an excellent choice for patients who can manage a
more intricate orthosis design. Individual PIP extension
gutters are added for those patients who demonstrate
Fig. 39.10  The immediate controlled active motion protocol, as described by
Howell et al.,124 includes a wrist cock-up orthosis and a yoke orthosis, which
effectively creates hyperextension of the affected digit relative to the other digits.
(Courtesy of Rebecca Neiduski, PhD, OTR/L, CHT.)

889
Rehabilitation following tendon injury/surgery
mobilization of the transfer.126 During this period, the postop­
erative dressing is removed and the patient is immobilized in
a thermoplastic orthosis. In the case of a PT-to-ECRB transfer,
the patient is immobilized in a wrist cock-up orthosis at 45°
extension (Fig. 39.11). For those cases in which coaptation of
the muscles are considered tenuous, an orthosis that limits
forearm rotation while positioning the wrist in extension can
be fabricated. During this period, the therapist’s focus is
centered on the evaluation and treatment of edema, pain, and
infection.
In the absence of complications during the immobilization
phase, initiation of active motion typically occurs 3–4 weeks
postoperatively.125,126 The therapist initiates neuromuscular
re-education exercises, including isolation and activation of
the transfer to produce a desired motion. Central to this
process is the concept of cortical plasticity, or the capacity of
a cortical circuit to reorganize its structure or response subse­
quent to an experience.127 As suggested by Sanes and Dono­
ghue, the primary motor cortex exhibits such plasticity as a
result of repetition of simple movements.127 Combination
exercises are frequently incorporated to facilitate re-education
of a donor muscle, and include training the patient to produce
the primary movement of a denervated muscle utilizing a
new musculotendinous unit. A PT-to-ECRB tendon transfer is
performed to restore wrist extension, the patient is instructed
to pronate the forearm while simultaneously extending the
wrist. Proprioceptive feedback is preferable to visual as it
facilitates cortical reorganization and auditory feedback can
also be helpful.
The length of time it takes to isolate a transfer effectively
is highly variable, depending on the type of transfer and
specific patient factors. Isometric activation can be carefully
initiated with those patients who find combination exercises
difficult. In the case of a PT-to-ECRB transfer, gentle resistance
is provided to the wrist while the patient is producing prona­
tion with wrist extension. As the patient progresses, the goal
is isolated activation of the donor muscle in production of the
newly desired motion, in this case, wrist extension against
gravity without simultaneous pronation.
At 6–7 weeks post-surgery, the tendon has healed and is
able to tolerate functional activities and light resistance.
Passive range-of-motion exercises may also be initiated to
mitigate any residual tightness incurred during surgery or the
immobilization period.125 At 8 weeks post-surgery, progres­
sive resistance exercises may be incorporated into the exercise
regimen.125
Proper assessment of tendon gliding includes comprehen­
sive measurement and comparison of active and passive
range of motion at all joints of the affected digit(s). The optimal
candidate for tenolysis is the patient who demonstrates full
passive motion of the digit and is deemed compliant by the
therapist and surgeon. As the postoperative treatment of
tenolysis is both painful and time-intensive, thorough educa­
tion of patient and family is vital to success. A therapy
schedule for daily treatment during the first 7 days post-
tenolysis, including weekend days, should be established
preoperatively.
Direct communication between the surgeon and the hand
therapist regarding the integrity of the tendon and active
motion as accomplished during surgery should be a priority
and postoperative treatment should begin on the same day as
surgery. It is advisable to allow the patient multiple hours of
recovery time, including a full meal and initiation of pain
medication if possible to decrease the likelihood of adverse
reactions (i.e., fainting) if treatment is promptly initiated. Use
of a sterile field and gloves is important to minimize the likeli­
hood of infection as the therapist initiates hourly active
exercises to facilitate tendon glide. Edema management and
wound care are also carefully addressed as the therapist
attempts to find a balance between adequate dressings for
drainage absorption that provide minimal physical blockage
to active motion. Consistent measurement of active and
passive motion is pursued during the first 7 consecutive days
of treatment.
Therapy intensity can decrease after the first week for
patients who demonstrate compliance with hourly exercise
and the ability to complete wound care independently. The
outcomes of tenolysis are quickly recognized and difficult to
remediate after the first 3–4 weeks of treatment. For this
reason, communication between the surgeon and hand thera­
pist and careful selection of patients for this procedure are
perhaps the most influential factors influencing final outcome.
Tendon transfers
Rehabilitation following tendon transfers requires careful
communication between the plastic surgeon and hand thera­
pist and attention to detail. This detail not only includes surgi­
cal specificity but the unique needs and expectations of the
patient coupled with a neuromuscular intervention plan. For
the purposes of brevity, the example of a pronator teres (PT)
to extensor carpi radialis brevis (ECRB) tendon transfer,
as performed in cases of radial nerve injury, will be used
throughout this section as a case example.
Patient education should include the purpose of the surgi­
cal procedure, expected timeline for rehabilitation, possible
complications, and expected outcomes.125 The patient needs
to be informed that functional use will be altered following
surgery and that a tendon transfer procedure will not correct
for losses in sensation.126 Prior to surgery, efforts are instituted
to strengthen the donor muscle selected for the procedure.125
If the patient has difficulty isolating the donor muscle, bio­
feedback and exercise orthosis may be useful.125
Immediately following surgery, the transfer and all
involved joints are immobilized in a position to minimize
tension on the newly transferred tendon. An immobilization
period of 3–4 weeks is commonly implemented to allow
adequate healing and reduce the risk of tendon rupture upon
Fig. 39.11  The patient with a pronator teres to extensor carpi radialis brevis tendon
transfer is immobilized in 45° of wrist extension for 3–4 weeks following surgery.
(Courtesy of Rebecca Neiduski, PhD, OTR/L, CHT.)

890
SECTION VI
CHAPTER 39 • Hand therapy
typically a custom-fabricated orthosis, can either be hand- or
forearm-based and dorsally blocks the MP joints in flexion129,134
(Fig. 39.12).
Metacarpal fractures
Metacarpal fractures are commonly seen primarily in the
fourth and fifth metacarpal and often in adolescent males.
From an anatomic perspective, consideration of both the
metacarpals and their adjacent tendinous and connective
tissue structures directs clinical decision-making. The second
through fifth metacarpals are aligned as parallel long bones
and serve both mobility and stability functions for the digits.
The proximal bases of the second and third metacarpal are
firmly affixed to the distal carpal row, more specifically, the
trapezoid and capitate. More mobile carpometacarpal (CMC)
joints at the thumb and small finger surround this stable
center, while the fourth metacarpal demonstrates limited
mobility on the hamate. Distally, the deep transverse metacar­
pal ligament connects the heads of the second through fifth
metacarpals. The alignment of the distal carpal row, reinforced
by this ligament, creates the transverse arches of the hand that
contribute to grasp and function.
According to McNemar et al., metacarpal head fractures are
immobilized in the position of safety, with the wrist extended,
MP joints fully flexed, and PIP and DIP joints extended, in
either a cast or a custom-fabricated orthosis135 (Fig. 39.13). This
close-packed positioning maintains the length of the collateral
ligaments, counteracts the tendency towards a claw deformity,
and draws the extensor mechanism distally to support the
fracture.135 For those cases requiring open reduction and
internal fixation through an incision of the extensor mecha­
nism, early motion becomes a necessity to avoid tendon
adherence.
The more typical metacarpal neck fracture often occurs in
the fourth or fifth metacarpal and is typically seen in young
males who have been involved in an altercation. A more
conservative approach to this injury includes immobilization
of the wrist in extension and the MP joints in flexion, with
early mobilization of the PIP and DIP.135 For those fractures
that are minimally displaced with reasonable stability, a less
Rehabilitation following skeletal
injury/surgery
Proximal phalanx fractures are challenging and require careful
attention to bony integrity and maintenance of the flexor and
extensor tendon-gliding systems. Therapeutic interventions
as outlined in this section are based on the assumption that a
patient presents with one of the following: a potentially
unstable, yet non-displaced, extra-articular fracture; an inher­
ently stable fracture; or hardware fixation facilitating stability
such as an open-reduction internal fixation or closed-reduction
external fixation.
According to Feehan, structural strength following a proxi­
mal phalanx fracture is influenced by location, pattern and
displacement, type of reduction, hardware, concomitant soft-
tissue injuries, stage of healing, and the functional demands
of the patient.128 Initiation of early controlled mobilization is
based on the surgeon’s perception of structural strength and
can be altered by choosing the number of joints to be mobi­
lized, active and/or passive motion, a safe arc of motion, and
the duration or repetitions of motion.128 Isolating short arc
motion at one or more joints when possible provides tendon
glide and lengthening of connective tissue structures that will
positively facilitate final outcomes for patients following
proximal phalanx fracture. As the flexor digitorum profundus
lies in close proximity to the proximal phalanx, isolated DIP
motion should be initiated as soon as possible. Moving
the joint actively through flexion and extension will also
afford some proximal and distal excursion of the extensor
mechanism.
Following a proximal phalanx fracture, MP joint position­
ing and PIP joint mobilization have been studied as a means
of avoiding complications. MP joint flexion is the close-packed
position of the joint, or the position at which the joint space
is minimized, and the joint surfaces of the head of the meta­
carpal and the base of the proximal phalanx are maximally
congruent. In addition, MP joint flexion moves the extensor
hood distally, translates the force of the extensor digitorum to
the PIP joint, and creates circumferential compression on the
fracture.129 From a volar perspective, flexion also decreases the
proximity of the flexor tendons to the fracture site. PIP joint
range of motion has been suggested to maintain the length of
the joint capsule and increase soft-tissue gliding as well as
creating a dynamic tension band effect in conjunction with
the extensor digitorum to facilitate fracture reduction.130,131
According to Feehan, the functional and physiologic stresses
associated with early controlled mobilization increase the
quality and rate of bone healing.128
Complications following proximal phalanx fractures are
often sequelae of scar tissue that limits all structures in the
zone of injury. Typical issues include extensor mechanism
adherence and fracture deformity with resultant PIP joint
extensor lags.129,132 In a study by Kurzen et al., 52% of patients
demonstrated less than 180° of total active motion following
plate fixation of a proximal phalanx fracture.133 To avoid such
outcomes, LaStayo et al. recommend a progressive program
be initiated in the following order: protection or external
support, edema management, protected and controlled mobi­
lization of proximal and distal joints, tendon gliding, passive
range of motion, and strengthening.131 The external support,
Fig. 39.12  Following a proximal phalanx fracture, immobilization of the
metacarpophalangeal joint in flexion facilitates close-packed positioning, creates
circumferential pressure via the extensor mechanism, and decreases the proximity
of the flexor tendons to the fracture site. Allowance of proximal interphalangeal joint
motion increases the opportunity for differential tendon gliding along the fracture
site. (Courtesy of Rebecca Neiduski, PhD, OTR/L, CHT.)

891
Rehabilitation following skeletal injury/surgery
flexion, while metacarpal shortening can lead to active insuf­
ficiency of the extrinsic digit extensors and the possibility of
decreased grip strength.135 Extensor adherence can be avoided
with early motion protocols emphasizing isolated glide of the
long extensors. Composite extension of the digit will not
achieve this goal; rather, the patient is instructed in transition
from a full fist to a hook fist, which creates maximal, isolated
glide of the extensor digitorum communis. These exercises are
of increased importance following open reduction and inter­
nal fixation of metacarpal head, neck, and shaft fractures.
Thumb carpometacarpal osteoarthritis
Osteoarthritis of the first CMC joint is an extremely common
diagnosis addressed by the plastic surgeon and hand thera­
pist, most often observed in women of middle age. This
diagnosis is the subject of much debate, ranging from anatomy
to interventions.
The typical presentation of a patient with CMC osteoarthri­
tis includes marked adduction of the first CMC joint with
hyperextension of the MP joint. This positioning is influenced
by numerous musculoskeletal imbalances that are presumed
to have both causative and resultant roles. Prolonged adduc­
tion of the joint leads to shortening of the adductor pollicis,
active insufficiency of the abductor pollicis brevis and exten­
sor pollicis brevis, and decreased stabilization by the first
dorsal interossei. The extensor pollicis longus, having the
greatest moment arm for MP extension, subsequently creates
compensatory MP hyperextension to increase the first web­
space for grasp and function. Offsetting this compensatory
pattern via positioning of the MP joint in flexion has been
noted to unload the palmar surfaces of the CMC joint, sug­
gesting that the more distal MP joint may play a role in the
progression of arthritis at the proximal CMC joint.136
A recent systematic review of conservative interventions for
osteoarthritis of the hand provides evidence for numerous
interventions based on specific patient goals.137 Moderate evi­
dence was found to support heat, exercise, education on joint
protection, and issuance of adaptive equipment as adjunctive
methods for pain reduction and increased function. The use of
orthoses to decrease pain and increase function was supported
with high to moderate evidence. Numerous orthoses are avail­
able for conservative management of CMC osteoarthritis, both
custom and prefabricated. Evidence to support the superiority
of one orthosis design from a diagnostic perspective is lacking;
however, studies have shown patient preferences towards
prefabricated, hand-based orthoses137 (Fig. 39.15). The work by
Moulton et al. supports the inclusion of the MP joint in the
orthosis, positioned in flexion as a means of unloading the
volar surface of the CMC joint and decreasing forces on
the anterior oblique ligament.136
For patients with advanced stages of CMC osteoarthritis,
or those who have failed non-operative management, surgical
intervention is often recommended. Despite the numerous
surgical methods for treatment of thumb CMC arthritis
ranging from simple partial or complete trapeziectomy with
or without ligament reconstruction tendon interposition,
postoperative care is relatively straightforward. Emphasis
during the rehabilitative phase is placed on the maintenance
of stability of the newly reconstructed joint as a means of
facilitating pain-free thumb function. The surgical procedure
performed, patient factors, and surgeon preference will guide
restrictive regimen of immobilization and exercise can be initi­
ated. A cuff orthosis that creates circumferential pressure
around the hand and approximates the metacarpals towards
anatomical alignment is fabricated to allow unrestricted
motion of the wrist and MP joints (Fig. 39.14). For additional
distal alignment, the proximal phalanx of the affected meta­
carpal can be taped or strapped to the adjacent digit with
which it is optimally aligned lengthwise. Using this approach,
the patient is encouraged to perform active exercise while
avoiding sustained or forceful grasp during the healing phase.
Complications after metacarpal fractures include rotational
deformities, loss of length, and dense adhesions restricting
tendon glide of the extrinsic extensor tendons. Rotational
deformities lead to scissoring of the digits during active
Fig. 39.13  Fractures to the metacarpal head are immobilized with an orthosis or
cast in wrist extension, metacarpophalangeal joint flexion, and interphalangeal joint
extension. (Courtesy of Rebecca Neiduski, PhD, OTR/L, CHT.)
Fig. 39.14  Metacarpal neck and shaft fractures that are minimally displaced can
be immobilized using a simple cuff which approximates the metacarpals and
creates circumferential pressure. (Courtesy of Rebecca Neiduski, PhD, OTR/L, CHT.)

892
SECTION VI
CHAPTER 39 • Hand therapy
at night is often continued until the eighth postoperative
week. Strengthening should be avoided until pain is no longer
a primary complaint, and pursued only within the realm of
the function required on an individual basis.
Future directions
Advancements in the understanding of response to injury,
wound healing, and other innovations in hand surgery have
guided the advancements in hand therapy. Recognition of
cortical changes and neural plasticity has advanced our treat­
ment following nerve injury, repair, and nerve transfers.
Emphasis on sensorimotor control and methods to exploit the
neural plasticity potential have led to improved outcomes
following nerve reconstruction and nerve and tendon trans­
fers. The concept of soft-tissue mobility and methods to
improve mobility and minimize adherent scarring has
changed our practice after soft-tissue and bony injuries to the
hand. Many of the active motion protocols presented in this
chapter have been published within the past 10 years. As
these protocols become integrated into clinical practice and
future studies report the long-term outcomes, we will be
better able to build on these successes.
Conclusion
the postsurgical management and immobilization. Following
trapeziectomy with ligament reconstruction tendon interposi­
tion, the patient is typically immobilized in a forearm-based
thumb spica cast or orthosis for 4 weeks following surgery.
The interphalangeal joint is left free to facilitate tendon gliding
of the extensor pollicis longus and flexor pollicis longus across
the surgical site. This early motion can also contribute to
decreasing edema and hypersensitivity, two common sequelae
of this procedure.
After 4 weeks, a program of active circumduction range of
motion, scar management, and desensitization is initiated.
Active range of motion of the CMC joint is pursued gently,
mindful of the influence of proximal stability on distal mobil­
ity and overall function of the thumb. Close attention to the
balance of musculature about the thumb is also important,
especially as it pertains to the length of the adductor pollicis
and activation of the extensor pollicis brevis and abductor
pollicis longus. MP hyperextension should be carefully moni­
tored; blocking the interphalangeal joint of the thumb in slight
flexion during active exercise is often effective in controlling
the mechanical advantage of the extensor pollicis longus. Scar
adhesions and hypersensitivity are common complaints fol­
lowing this procedure and should be addressed with early
and progressive massage and desensitization.
While gentle passive motion can be initiated at 6 weeks,
continued use of the orthosis between exercise sessions and
Fig. 39.15  Patients with carpometacarpal osteoarthritis are often immobilized in a
hand-based thumb spica orthosis to relieve pain and provide support and
positioning to facilitate functional use. (Courtesy of Rebecca Neiduski, PhD, OTR/L,
CHT.)
Key points
1. Optimal outcomes necessitate a collaborative relationship
and open communication between the patient, surgeon,
and hand therapist.
2. A comprehensive evaluation is necessary to provide
diagnostic and prognostic information and to inform clinical
decision-making for non-operative and postoperative
management.
3. Following nerve injury, rehabilitation should be directed not
only to the distal motor and sensory recovery but also to
cortical remapping and normal movement patterns.
4. Specificity and timing of exercise following flexor tendon
repair can be optimally arranged to facilitate high excursion/
low force rehabilitation.
5. Early controlled mobilization can increase healing, tendon
glide, and joint mobility in patients with extra-articular hand
fractures.
Comprehensive evaluation and multidisciplinary treatment
approaches are advocated for patients following hand surgery
and optimal outcomes necessitate a collaborative relationship
and open communication between the patient, surgeon, and
hand therapist.
32. Amadio PC. Outcome assessment in hand surgery and hand
therapy: an update. J Hand Ther. 2001;14:63–68.
75. Ramachandran VS, Altschuler EL. The use of visual feedback, in
particular mirror visual feedback, in restoring brain function.
Brain. 2009;132:1693–1710.
92. Novak CB. Rehabilitation following motor nerve transfers. Hand
Clin. 2008;24:417–423.
99. Amadio PC. Friction of the gliding surface: implications
for tendon surgery and rehabilitation. J Hand Ther. 2005;18:
112–119.
Access the complete reference list online at

893
Conclusion
105. Cooney WP, Lin GT, An KN. Improved tendon excursion
following flexor tendon repair. J Hand Ther. 1989;2:102–106. In this
cadaveric study, postoperative rehabilitation protocols were compared,
including Kleinert, the Brooke Army Hospital modification, and
synergistic motion. Synergistic motion yielded the greatest flexor
digitorum profundus, flexor digitorum superficialis, and differential
excursion.
110. Lieber RL, Silva MJ, Amiel D, et al. Wrist and digital joint motion
produce unique flexor tendon force and excursion in the canine
forelimb. J Biomech. 1999;32:175–181. This study using a canine model
suggested that forces exerted on the healing flexor tendon are highly
dependent on wrist position. Synergistic motion was noted to result in
low passive forces on the flexor tendon with high excursion.
124. Howell JW, Merritt WH, Robinson SJ. Immediate controlled active
motion following zone 4–7 extensor tendon repair. J Hand Ther.
2005;18:182–190. The protocol described for extensor tendon injuries
includes a wrist orthosis paired with a yoke orthosis which positions the
metacarpophalangeal joint of the affected digit in hyperextension relative
to the other digits. Full active motion within the immediate controlled
active motion orthosis is expected prior to progression to the next phase
of the protocol.
128. Feehan LM. Early controlled mobilization of potentially unstable
extra-articular hand fractures. J Hand Ther. 2003;16:161–169. This
article suggests that functional and physiologic stresses associated with
active range of motion increase the quality and rate of healing in
potentially unstable extra-articular hand fractures. Control of clinical
factors is recommended as a means of incorporating early motion into
fracture management.
136. Moulton MJ, Parentis MA, Kelly MJ, et al. Influence of metacarpal
joint position on the basal joint loading in the thumb. J Bone Joint
Surg Am. 2001;83:709–716. In this cadaveric study, immobilization of
the metacarpophalangeal joint was studied as it pertained to forces on the
trapezial surface during lateral pinch. Metacarpophalangeal flexion was
noted to unload the most palmar aspect of the carpometacarpal joint
effectively, decreasing strain on the palmar oblique ligament.

893.e1
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22. Novak CB, Mackinnon SE. Evaluation of nerve injury and nerve
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24. Strauch B, Lang A, Ferder M, et al. The ten test. Plast Reconstr
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2011:977–1014.

893.e2
SECTION VI
CHAPTER 39 • Hand therapy
48. Shin EK, Bachoura A, Jacoby SM, et al. Treatment of carpal tunnel
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56. Novak CB, Katz J. Neuropathic pain in patients with upper
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58. Eberstein A, Eberstein S. Electrical stimulation of denervated
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61. Williams HB. A clinical pilot study to assess functional return
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62. Fu SY, Gordon T. Contributing factors to poor functional recovery
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63. Gordon T, Sulaiman OAR, Ladak A. Electrical stimulation for
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electrical stimulation to promote functional recovery after
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65. Gordon T, Amirjani N, Edwards DC, et al. Brief post-surgical
electrical stimulation accelerates axon regeneration and muscle
reinnervation without affecting the functional measures in carpal
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66. Dellon AL. Somatosensory Testing and Rehabilitation. Baltimore, MD:
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68. Novak CB, Kelly L, Mackinnon SE. Sensory recovery after median
nerve grafting. J Hand Surg Am. 1992;17:59–68.
69. Spicher CJ, Kohut G. Rapid relief of a painful, long-standing
posttraumatic digital neuroma treated by transcutaneous vibratory
stimulation (TVS). J Hand Ther. 1996;9:47–51.
70. Spicher CJ, Mathis F, Degrange B, et al. Static mechanical allodynia
(SMA) is a paradoxical painful hypo-aesthesia: observations
derived from neuropathic pain patients treated with
somatosensory rehabilitation. Somatosens Mot Res. 2008;25:77–92.
71. Melzack R, Wall PD. Pain mechanisms: a new theory. Science.
1965;150:971–979.
72. Rosen B, Lundborg G. Sensory re-education following nerve
repair. In: Slutsky DJ, ed. Upper Extremity Nerve Repair – Tips and
Techniques: A Master Skills Publication. Rosemont, IL: American
Society for Surgery of the Hand; 2008:159–178.
73. Rosen B, Vikstrom P, Turner S, et al. Enhanced early sensory
outcome after nerve repair as a result of immediate post-operative
re-learning: a randomized controlled trial. J Hand Surg Eur Vol.
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74. Moseley GL, Wiech K. The effect of tactile discrimination training
is enhanced when patients watch the reflected image of their
unaffected limb during training. Pain. 2009;144:314–319.
75. Ramachandran VS, Altschuler EL. The use of visual feedback, in
particular mirror visual feedback, in restoring brain function.
Brain. 2009;132:1693–1710.
76. Anastakis DJ, Chen R, Davis KD, et al. Cortical plasticity following
upper extremity injury and reconstruction. Clin Plast Surg.
2005;32:617–634.
77. Malessy MJ, Bakker D, Dekker AJ, et al. Functional magnetic
resonance imaging and control over the biceps muscle after
intercostal – musculocutaneous nerve transfer. J Neurosurg.
2003;98:261–268.
78. Duff SV. Impact of peripheral nerve injury on sensorimotor
control. J Hand Ther. 2005;18:277–291.
79. Colbert SH, Mackinnon SE. Nerve transfers for brachial plexus
reconstruction. Hand Clin. 2008;24:341–362.
80. Kozin SH. Nerve transfers in brachial plexus birth palsies:
indications, techniques and outcomes. Hand Clin. 2008;24:363–376.
81. Leechavengvongs S, Witoonchart K, Uerpairojkit C, et al. Nerve
transfer to biceps muscle using a part of the ulnar nerve in
brachial plexus injury (upper arm type): a report of 32 cases. J
Hand Surg Am. 1998;23:711–716.
82. Leechavengvongs S, Witoonchart K, Uerpairojkit C, et al. Nerve
transfer to deltoid muscle using the nerve to the long head of the
triceps, part II: a report of 7 cases. J Hand Surg Am. 2003;28:
633–638.
83. Mackinnon SE, Novak CB, Myckatyn TM, et al. Results of
reinnervation of the biceps and brachialis muscles with a double
fascicular transfer. J Hand Surg Am. 2005;30:978–985.
84. Novak CB, Mackinnon SE. A distal anterior interosseous nerve
transfer to the deep motor branch of the ulnar nerve for
reconstruction of high ulnar nerve injuries. J Reconstr Microsurg.
2002;18:459–463.
85. Novak CB, Tung TH, Mackinnon SE. Patient outcome following a
thoracodorsal to musculocutaneous nerve transfer for
reconstruction of elbow flexion. Br J Plast Surg. 2003;55:416–
419.
86. Oberlin C, Beal D, Leechavengvongs S, et al. Nerve transfer to
biceps muscle using a part of ulnar nerve for C5–C6 avulsion of
the brachial plexus: anatomical study and report of four cases. J
Hand Surg Am. 1994;19:232–237.
87. Tung TH, Mackinnon SE. Flexor digitorum superficialis nerve
transfer to restore pronation: two case reports and anatomic study.
J Hand Surg Am. 2001;26:1065–1072.
88. Tung TH, Novak CB, Mackinnon SE. Nerve transfers to the biceps
and brachialis branches to improve elbow flexion strength after
brachial plexus injuries. J Neurosurg. 2003;98:313–318.
89. Chen R, Anastakis DJ, Haywood CT, et al. Plasticity of the human
motor system following muscle reconstruction: a magnetic
stimulation and functional magnetic resonance imaging study. Clin
Neurophysiol. 2003;114:2434–2446.
90. Merzenich MM, Jenkins WM. Reorganization of cortical
representations of the hand following alterations of skin inputs
induced by nerve injury, skin island transfers and experience. J
Hand Ther. 1993;6:89–104.
91. Taylor KS, Anastakis DJ, Davis KD. Cutting your nerve changes
your brain. Brain. 2009;132:3122–3133.
92. Novak CB. Rehabilitation following motor nerve transfers. Hand
Clin. 2008;24:417–423.
93. Novak CB. Rehabilitation following nerve transfer. In: Slutsky DJ,
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Skills Publication. Rosemont, IL: American Society for Surgery of
the Hand; 2008:261–266.

893.e3
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SECTION VI • Rehabilitation
40 
Treatment of the upper extremity amputee
Gregory A. Dumanian, Jason M. Souza, and Todd Kuiken
SYNOPSIS
■ Upper extremity amputees are different from lower extremity amputees:
patients are younger and their amputations are primarily due to trauma
and tumors rather than dysvascular conditions. The patients live longer
with their residual limbs.
■ Prosthetic concerns for the two groups of patients dramatically
differ.
■ Upper extremity prostheses require more control, more movement, and
more precision than that for a leg. Fortunately, upper extremity
prostheses have less load bearing requirements, since they do not
need to support the weight of the body.
Introduction
Upper extremity amputees are different from lower extremity
amputees in many aspects. The patients are younger and their
amputations are primarily due to trauma and tumors rather
than dysvascular conditions. The patients live longer with
their residual limbs. Prosthetic concerns for the two groups
of patients dramatically differ. Upper extremity prostheses
require more control, more movement, and more precision
than that for a leg. Fortunately, upper extremity prostheses
have less load bearing requirements, since they do not
need to support the weight of the body. The purpose of this
chapter is to familiarize the reader with necessary concepts
to care for the upper extremity amputee. Handling of soft
tissues, bones, and nerves are reviewed for each of the levels
of amputation. Prosthetics and prosthetic control will be a
necessary accompaniment of this chapter. Recent advance­
ments in the field including targeted reinnervation will be
introduced.
Access the Historical perspective section online at

Aesthetic prostheses
Aesthetic prostheses refer to devices that are used to camou­
flage a limb deformity, while functional prostheses refer to
devices that are operational.5 Aesthetic prostheses assist
patients in issues of body image and self-esteem, with possible
functional gains due to a newfound social openness and
ability to expose the limb. Patients can appear fairly normal
in public with aesthetic prostheses (Figs. 40.1 & 40.2). Most of
these prostheses are custom made and require a high level of
expertise on the part of the prosthetist. Because intact skin is
used to secure the prosthetics in place, some amount of
sensory feedback of the residual limb will be lost, and this is
one drawback to these devices. Osseointegration of aesthetic
prostheses into bone has been studied at length, because of
the potential for improved tolerance of the soft tissues to the
prosthesis, the limit on the amount of soft tissues covered, and
ability to use stiffer materials in the devices for possible sec­
ondary functional gains. The bone–soft tissue–implant inter­
face for osseointegration of upper limb prosthetics remains
problematic.6
Control of upper extremity
prosthetic devices
A prosthesis is only as good as the control signals that it
receives from the user. The goal of any prosthesis is to be
moved and positioned in space smoothly, quickly, intuitively,
and with minimal exertion and mental fatigue to accomplish
this task.7 Multifunctional prostheses offer the potential for
greater functionality, but come at the cost of increased com­
plexity with regard to control strategies. Prostheses with both
a terminal “hand” device and a prosthetic elbow require
differentiation between signals intended for hand control
and those intended for elbow function. This differentiation
becomes even more critical when these functions are attempted
simultaneously.

894.e1
Historical perspective
Historical perspective
Putti documented the history of upper extremity prostheses
in the 1930s, and this work has been subsequently translated
into English.1 The field of prosthetics began soon after
advancements in battlefield surgery allowed patients to
survive limb amputations. Prior to cautery, surgeons were
forced to allow tissue to mummify, and then to slowly separate
living tissue from dead. Residual limbs developed in this
manner had poor soft-tissue coverage of bone, and therefore
were poorly able to tolerate the weight of a prosthesis.
Advances in metalworking permitted the creation of metallic
prostheses beginning in the early 1500s. A famous knight,
Gottfried von Berlichingen (c.1480–1562) was known as Gotz
of the Iron Hand for his below elbow amputation. The pros­
thesis he wore was strapped to the forearm with leather
bands, and had moveable fingers and thumb that could be
revolved and tightened around the hilt of a sword. Ambroise
Pare documented the ingenious Petit Lorrain artificial hand
that had fingers that moved into extension with springs, and
could be held in flexion by sprockets that caught metal levers.2
The Alt-Ruppin prosthesis, fished out of a canal in the town
of the same name, was constructed in the 1500s and similarly
had moveable fingers and thumb. These prostheses inspired
the imagination of onlookers, and demonstrated the ingenuity
of armor makers of the day.
The Ballif arm of 1812 was an improvement over the metal­
lic arms for its softer materials and for the active control of
the prosthetic hand. Rather than locking prosthetic fingers
into place for a static grip, the Ballif arm utilized cables
attached to the shoulder and arm to allow opening and closing
of the prosthetic hand. The Civil War created a huge number
of amputees in the United States, leading to companies such
as the A. A. Marks Company (1853) of New York and the
J. E. Hanger Company (1861, still in existence today). These
firms and others provided body-powered prostheses to the
masses by mail order. World War II led to further refinements
in body-powered prostheses due to the large numbers of
upper extremity amputees coupled with significant advances
in technology developed for the aviation industry.3 With
minor adjustments for materials and socket designs, body-
powered upper extremity prostheses have remained relatively
unchanged since the 1950s. Body-powered prostheses are
operated by using shoulder motion to pull on a housed cable
(like a bicycle brake cable) and thus transfer power to the
prosthetic joints. Generally only one joint can be operated at
a time. Thus when using a prosthesis with multiple joints, the
user unlocks only the joint he wishes to operate using a variety
of different types of switches.
The development of externally powered prostheses
powered by electricity or pressurized gas began in Germany
soon after World War I. The myoelectric hand, controlled
using Electromyogram (EMG) signals from the residual limb,
was first created by Mr. Reinhold Reiter for the Bavarian Red
Cross in 1943 during World War II and published in 1948.
Parallel efforts to create a myoelectric prosthesis began in
England, the Soviet Union, and the United States. The United
States effort was led by the Committee on Prosthetics Research
and Development of the National Research Council, with the
initial meeting held at Northwestern University. Technical
advancements were greatly aided by the miniaturization of
electric components. The first device to use transistors was the
so-called “Russian Hand” of 1959. Along with the Vaduz and
Bottomley Hands, these single-function (open and close)
devices received much publicity, but were rather slow and
clumsy to operate. Multifunction myoelectric devices with
wrist flexion/extension and pronation/supination were
introduced in the mid-1960s as a means to further improve on
these devices.4 Despite research efforts that spanned the globe,
these multifunction prostheses were limited by the difficulty
for the amputee to control the movements of the prosthesis.
Proponents of body-powered prostheses have been arguing
with the proponents of externally powered system for the last
half-century. However, both types of devices are useful and
often complementary. Body-powered prostheses are generally
lighter and more robust than external systems with batteries
and motors. Externally powered systems require more daily
maintenance for battery changes and are more fragile than the
simpler and sturdier harnesses and hooks. Functionally,
body-powered prostheses tend to give the wearer a bit more
feedback during use. A significant advantage for transradial
and more distal myoelectric prostheses is that they can be
anatomically suspended using the humeral condyles or using
suction sleeves; this eliminates the need for cumbersome
shoulder harnessing. Furthermore, as unilateral upper limb
amputees tend to use the prosthetic limb only as a helper
hand, the improved cosmetics of myoelectric devices can
make up for their many drawbacks and are often preferred.3
Hybrid systems also exist that try to combine the best features
of both body-powered and external-powered prostheses. One
example is to have a body-powered prosthetic elbow coupled
with a myoelectric hand.

895
Prosthetic implications of upper limb amputation surgery
additional switch or signal to enable the device to change
between functions.
The potential offered by myoelectric control was realized
in 1995, when Kuiken, Childress and Rymer demonstrated a
new myoelectric control strategy now called “targeted muscle
reinnervation” (TMR). TMR utilizes nerve transfers between
the transected brachial nerves and the residual limb muscles
to reclaim the neural control information that is lost as a result
of upper extremity amputation.8 As a result, prosthetic func­
tion can be directly coupled with EMG signals corresponding
to the nerves responsible for the identical function in the
previously intact limb. Clinically, this technique yields intui­
tive and relatively seamless device control. In addition, the
increased number of EMG control sites provided by TMR
enables simultaneous control of multiple functions. Kuiken
and Dumanian first reported this procedure in shoulder dis­
articulation patients in 2004,9 and in transhumeral amputees
in 2008.10
While the functional capabilities of prosthetic devices once
outpaced the amount of information available to control them,
the pendulum has now swung the other way. When it was
introduced, the number of nerve transfers performed as part
of the TMR procedure largely dictated the number of pros­
thetic functions capable of being controlled. This control
strategy, labeled “direct control”, meant that a single rein­
nervated muscle segment could be used to control only one
function via a single EMG electrode (i.e., reinnervation of
short head of biceps by median nerve for hand closure).
Recently, “direct control” has been supplanted by “pattern
recognition”, whereby advanced algorithms are used to cor­
relate the pattern of muscular contractions recorded from
many more electrodes. This approach provides greater flexibil­
ity for rehabilitation and has served to markedly improve the
functional capacity of the amputee.
Other strategies for prosthetic control are still in the inves­
tigative phase, but show promise. Implantable myoelectric
sensor systems that transmit EMG signals out to a detecting
device could improve the EMG signal quality and consistency,
as well as provide control signals from small muscle bodies
such as the individual finger extensors of the forearm.11 Direct
signal acquisition from the amputated nerves using a variety
of implanted electrodes or small muscle grafts to amplify the
nerve signals have been investigated.12,13 Prosthetic control
using fine wire electrodes was recently demonstrated in an
acute experiment in humans.14 Direct recording and stimula­
tion of the cerebral cortex has been performed in monkeys
in order to effect peripheral movement. This brain–machine
interface, if successful, could have wide applicability, not
only for amputees, but also for patients with spinal cord
injuries.15
Prosthetic implications of upper limb
amputation surgery
The surgical treatment of patients with unreconstructable
upper extremity disorders must take into account issues
unique to the amputee. The amputation must have durable
soft tissues to allow for prosthetic fitting. In all instances, an
evaluation is performed as to how to preserve intact nerves
and how to manage unavoidable end-neuromas. The means
The cable systems used by body-powered devices provide
a reliable method for control, but lack fluidity and do not offer
simultaneous control of multiple functions. Body-powered
prostheses, as previously described, utilize shoulder motions
to operate the prosthesis. This is problematic, because muscles
that are designed for strong movements – such as the latissi­
mus dorsi and the serratus anterior – are required to move
accurately and sensitively to control cables and switches.
Body-powered devices use non-intuitive shoulder muscles to
control a prosthetic elbow or hand.
Myoelectric control, derived from surface EMG recording
of residual limb muscles, provides prosthetic control without
the need for accessory shoulder movement. From the stand­
point of aesthetics and comfort, the lack of cables and pulleys
is advantageous, but is often offset by the bulk of the socket
and the increased weight of the motorized device. Myoelectric
control represented a promising technological advance,
but the prosthetic function provided by the earlier devices
remained relatively slow and disjointed, thus limiting appli­
cability. The residual limb musculature being recorded was
not usually cortically linked to the prosthetic function being
controlled (i.e., biceps brachii used to control finger flexion).
Also, as with body-powered devices, only one joint could
be operated at a time. Multifunctional devices required an
Fig. 40.1  Patient with multiple finger amputations due to sepsis and hypotension.
Fig. 40.2  Multiple-digit prostheses for improvement of cosmetic appearance.

896
SECTION VI
CHAPTER 40 • Treatment of the upper extremity amputee
by which the prosthesis will be controlled must be considered.
With these concepts in mind, a level-by-level analysis of
common upper extremity amputations is presented.
Finger amputation
Patients undergoing reconstructive upper extremity surgery
do best when the surgeon “Think(s) Nerve” first.16 Patients
can easily tolerate a painless stiff digit, while they are greatly
troubled by a mobile painful digit with a symptomatic
neuroma. Patients with wounds of the fingers should be
evaluated as to which nerves are irreparably cut, and which
digital nerves are intact. If a major portion of one of the two
digital nerves is intact, then a flap should be performed for
wound closure, rather than a shortening amputation with
division of both digital nerves. The digital nerves to the finger
pulp trifurcate approximately 2 mm distal to the volar distal
interphalangeal joint skin crease. One branch travels to the
nail fold, a second branch travels to the volar tip, and the third
branch innervates the volar pad. Amputations at or proximal
to the trifurcation have two cut digital nerves, and therefore
a revision amputation will not cut a new nerve to achieve
wound closure. In the figure shown, the ulnar digital nerve to
the ring finger is intact, while the radial digital nerve is cut
(Figs. 40.3 & 40.4). The cross finger flap is performed to achieve
wound closure, but more importantly to avoid the necessity
of dividing an intact digital nerve as part of a revision
amputation.
Much has been written about more proximal finger ampu­
tations. For these patients, a traction neurectomy is performed
to keep the nerve from trying to reinnervate the skin lacera­
tion area. The surgeon should attempt to achieve a smooth
and tapered end to the digit, rather than having a bulbous tip.
This requires removal of the condyles for joint disarticula­
tions, and longer skin incisions down the midaxial lines of the
digits for removal of 1 “dog ears”.
Partial hand
Again “Thinking Nerve”, loss of the ulnar, radial, or dorsal
aspect of the hand with preservation of the volar nerves war­
rants flap reconstruction to obviate the need to divide nerves
Fig. 40.3  Young adult with injury to half of the pulp of his ring finger. Completion
amputation was recommended at an outside institution.
Fig. 40.4  Same patient as in Fig. 40.3: 2 weeks later, with the cross-finger flap
sewn in place.
that remain in continuity. Typically, this will be either a free
flap, or a pedicled groin flap as a second choice. If the majority
of the digital nerves are divided, then the next decision is
whether there is a functional and stable wrist joint. Mainte­
nance of the wrist will allow the residual limb to be an excel­
lent helper hand, even without a prosthesis (Figs. 40.5–40.7).
In some avulsive injuries, the dorsal wrist extensors have been
removed by the injury, and it is worthwhile to reinsert exten­
sor tendons to the residual carpal bones with bone anchors
and a flap for coverage. Thicker muscle flaps are preferable to
skin flaps, as the associated atrophy will facilitate the place­
ment of passive finger prostheses that can assist in grasp.17
Body-powered and externally powered prostheses exist
for partial hand amputations, but have significant size
constraints to provide moveable components that will not
Fig. 40.5  Amputated specimen in young male.

897
Prosthetic implications of upper limb amputation surgery
division of the median, radial, and ulnar nerves from their
injury, and so a more formal amputation with manipulation
and re-division of the nerves where the soft tissues are more
supple is appropriate.
In the operating room, plans are made for soft-tissue cover­
age of the residual limb with development of palmar and
dorsal skin flaps. A dorsal approach to the wrist identifies the
proximal carpal row, and these bones are excised much like a
proximal row carpectomy. The ulnar and radial arteries are
doubly ligated. The radial and ulnar styloids are trimmed to
allow for easier prosthetic fitting without pressure points, but
the triangular fibrocartilage complex is maintained to preserve
pronation and supination. When possible, more durable volar
skin is used for coverage as opposed to thinner dorsal skin.
Handling of the nerves to prevent a symptomatic mixed
major nerve neuroma from developing is important, as a
painful neuroma will complicate prosthetic wear. Standard
treatment is traction neurectomy, where the nerves are placed
on stretch, divided, and allowed to retract away from the
incision line. A general concept is that the better “padded” is
a neuroma, the less symptomatic. Other treatments supported
both by experimental animal surgery and clinical experience
include placing the cut nerve ending within immobile muscle
as opposed to simply allowing them to retract.18,19
Clinical work with TMR has revealed that major mixed
nerves do not form symptomatic neuromas when nerve
transfers are performed. Nerve transfers are now often per­
formed at the time of a wrist disarticulation. This is not for
obtaining new control signals (although this may occur), but
rather for prevention of symptomatic end-neuromas. Through
a proximal incision between the flexor carpi ulnaris (FCU) and
flexor digitorum superficialis (FDS), the median nerve is
transferred to a motor nerve of the FDS, the ulnar nerve is
transferred to a motor nerve innervating the FCU, and the
radial nerve is transferred to the motor nerve innervating the
pronator quadratus. This strategy has been successful for
neuroma control, and there is no morbidity associated with
sacrifice of the recipient motor nerves due to the distal ampu­
tation. Also, as demonstrated clinically with every muscle flap
harvest, cut motor nerves in humans do not form symptomatic
neuroma.
If the patient is unlikely to wear a prosthesis, a wrist dis­
articulation with good soft coverage will give the patient a
longer and more functional residual limb. Wrist disarticula­
tion prostheses do well in capturing the distal bony structures
for wrist rotation; however, room is limited for prosthetic
components and the devices tend to look bulky. A long tran­
sradial amputation generally facilitates better prosthetic
Fig. 40.6  Radiograph showing preserved radiocarpal joint.
Fig. 40.7  Mobile wrist joint acts as a helper hand. The patient’s extensor tendons
were reinserted into the carpal bones with bone anchors.
Fig. 40.8  A young worker had skin grafts applied to a proximal hand stripped of
almost all soft tissues in an attempt to “save length”. He underwent a transradial
amputation for treatment of his painful immobile scarred hand.
cause the device to be longer than the opposite hand. Suspen­
sion of these devices is also difficult due to the need to not
impede wrist motion. Rather than prosthetics, improvements
in hand function for patients with thumb, multiple digit, or
partial hand amputations can be achieved with toe-to-hand
transfers.
Wrist disarticulation and transradial
amputation
Injuries that divide the digital nerves and strip the soft tissues
off of the carpal bones are better served by a wrist disarticula­
tion or a transradial amputation than by efforts to salvage a
scarred and immobile hand for the sake of “preserving length”
(Fig. 40.8). These patients have already suffered a complete

898
SECTION VI
CHAPTER 40 • Treatment of the upper extremity amputee
in an elbow disarticulation can be useful in suspension of the
prosthesis and for humeral rotation, the appearance of the
arm with its prosthetic appears too long. Very long trans­
humeral amputees can be treated with an angulation osteot­
omy (with or without shortening) of the distal humerus. It can
provide a lever arm for suspension and for rotational control
of the prosthesis.21 Finally, if a powered elbow is planned, a
transhumeral amputation 5–6 cm above the olecranon allows
room for the motor and the elbow “joint” seems to be in the
correct place. A transhumeral amputation at this level still
allows for TMR of the median, ulnar, and radial nerves.
In the operating room, anterior and posterior skin flaps are
elevated. The level of the bone division is decided, and either
the elbow capsule and ligaments are divided sharply, or else
the humerus is cut just proximal to the epicondyles. A myo­
desis of the triceps and biceps to the distal bone is performed
utilizing drill holes for several reasons. Good quality soft-
tissue coverage of the distal bone is a necessity. The end of the
residual limb should not have too much redundancy and
mobility to facilitate application of a socket and donning the
prosthesis. Finally, prevention of proximal migration of the
muscle mass during contraction is important for later signal
detection for a myoelectric prosthesis. For performance of an
angulation osteotomy, the amputation is done in the prone
position for proper plate placement.
Handling of the neurovascular structures is another impor­
tant decision branch point. Treatment of the median, ulnar,
and radial nerves is quite important at this stage. The standard
traction neurectomy is no longer the optimal treatment for
these large mixed nerves. The question is whether targeted
reinnervation should be performed at the time of the amputa­
tion or at a later date. Immediate targeted reinnervation has
the advantage of avoiding a second surgery, and the nerve
transfers would be performed when the nerves are at their
longest length, without neuromas to resect and with a full
axon complement. Benefits of immediate targeted reinnerva­
tion include a shorter time between amputation and the
possibility to have additional control signals for improved
prosthetic function. As has been mentioned, nerve transfers
are a method to prevent the development of symptomatic
fitting by allowing room for prosthetic components and pro­
viding better cosmetic appearance.
A lack of soft tissue may require a transradial amputation
as opposed to a wrist disarticulation. In these instances, the
shorter lever arm will place more stresses on the residual soft
tissues for movement of the prostheses. Pronation and supina­
tion will not be as easily translated into prosthetic movement
and positioning. Patients undergoing transradial amputations
will have similar treatments of the arteries and nerves of the
forearm. The radial nerve will be divided and allowed to
retract underneath the brachioradialis. A myoplasty of the
extensor and flexor muscles over the cut ends of the radius
and ulna will stabilize the muscle masses, and facilitate later
prosthetic fitting. Drill holes through the bones for passage of
suture are useful to prevent muscle movement over the end
of the residual limb. At least 5 cm of ulna is necessary to retain
elbow movement, but in these instances of very short residual
limbs, the insertion of the biceps tendon may need to be
transferred to the ulna. Preservation of length of bone may
require a soft tissue flap taken from the flank.20 This pedicled
flap is divided after 3 weeks, but provides thick soft tissue
and a smoother soft-tissue envelope for prosthetic fitting
(Figs. 40.9 & 40.10). The function of a transradial amputation
is much greater than a transhumeral amputation, thus aggres­
sive treatment to save the elbow and reasonable forearm
length is warranted.
Elbow disarticulation and long
transhumeral amputation
Non-reconstructable and non-replantable injuries at the elbow
level require removal of the ulna and radius. The level of
amputation depends on the plan for prosthetic rehabilitation.
If no prosthetic is planned, then the elbow disarticulation is a
more functional level than a higher amputation, because the
limb is long enough to reach a table in sitting and thus is easier
to use for moving and stabilizing objects. While the condyles
Fig. 40.9  Patient with previous transradial amputation plagued by poor soft-tissue
coverage of residual limb.
Fig. 40.10  Pedicled periumbilical perforator flap is transferred to the end of the
limb after excision of skin-grafted area, and divided 3 12 weeks later.

899
Surgery of the residual limb
of prosthetic use, even straightforward surgical solutions
are often delayed in favor of socket or behavioral modifica­
tions. Thus, the importance of close collaboration between
reconstructive surgeons and rehabilitation providers cannot
be overstated. Surgical techniques remain the most effective
ways to achieve a wound-free residual limb without painful
neuromas or poorly covered bone. The specific techniques
employed will vary based on the mechanism of amputation
and degree of injury, but largely include advancement flaps,
excision of skin grafts, Z-plasties for scar contractures, and
lipectomy either through direct excision or circumferential
liposuction (Figs. 40.11 & 40.12). The patient must be aware
that even after primary skin healing, swelling will take
many weeks to resolve, and therefore may require multiple
re-fittings and an extended period during which the patient
will be without use of the prosthetic.
Skin breakdown can occur from poor prosthetic fit, but it
also can occur when skin grafts have been used to preserve
length in the absence of adequate soft tissue. Revision ampu­
tations can be considered when the prosthetist and physiatrist
agree that a shorter residual limb with improved soft tissues
painful neuroma. The effect of targeted reinnervation on
phantom limb sensation is under investigation. Amputation
followed by a later TMR has the advantage of improved
patient education and consent, the avoidance of new proximal
incisions in a swollen traumatized limb, and the ability to
advantageously thin the subcutaneous fat to improve EMG
acquisition. If the prospect of delayed TMR exists, then the
major mixed nerves should be left long and without additional
dissection.
Transhumeral amputations through the middle third of the
humerus still allow for a mobile shoulder joint and successful
prosthetic fitting. Often TMR can be still be performed. Pedi­
cled latissimus flaps can be extremely useful to achieve wound
closure and maintain length when needed, but make delayed
TMR a bit more challenging. Short transhumeral amputations
can undergo Ilizarov lengthening or even free fibula transfer
to achieve a longer lever arm for the prosthesis.
With severe brachial plexopathies resulting in flail limbs,
amputation is often considered. Amputation will not relieve
neuropathic plexopathy pain, but can relieve traction pain at
the shoulder and it clearly removes the inconveniences of
having a paralyzed arm. We recommend a transhumeral
amputation at 25–30% of humeral length in these instances.
This removes the weight of the limb, relieving traction pain,
and preserves a nice shoulder and upper arm contour for
clothing. Fusion of the shoulder to enhance prosthetic fitting
is not recommended. Prosthetic fittings with flail residual
limbs have extremely poor outcomes and a humerus fused in
abduction and flexion interferes with some activities, espe­
cially positioning in bed.
Proximal transhumeral and
shoulder disarticulation
Loss of the biceps and triceps due to electrical injury or avul­
sive injuries are best treated with a proximal transhumeral
amputation or a shoulder disarticulation. Maintenance of the
humeral head in its glenohumeral fossa has cosmetic implica­
tions in shirt fitting, and depends on the local soft tissues.
Again, traction neurectomies should be avoided to preserve
nerve length. Preservation of a small humeral remnant under
deltoid motor control can be extremely useful to activate
switches via miniature touch pads. The deltoid muscle is
typically spared in electrical injuries due to the increased
cross-sectional area of the body. In avulsive injuries, the
deltoid is spared due to its broad origin on the scapula. The
deltoid is pulled inferiorly with sutures, and the chest skin
can be mobilized superiorly for closure of the glenohumeral
fossa.
Surgery of the residual limb
Soft-tissue improvement
Patients with traumatic amputations often have soft tissues
that are suboptimal for prolonged prosthetic wear. Contour
irregularities due to scars, skin grafts, and skin redundancy
compromise the fit of prosthetic sockets and liners. Skin
breakdown is common, resulting in discomfort and recur­
rent infections that serve to further limit prosthetic wear.
Because physiatrists or prosthetists manage most elements
Fig. 40.11  Transhumeral amputee with scarred soft tissues of her residual limb.
Fig. 40.12  Same patient as Fig. 40.11 after excision of previously placed skin
graft and closure with advanced skin flap, analogous to a brachioplasty.

900
SECTION VI
CHAPTER 40 • Treatment of the upper extremity amputee
Targeted muscle reinnervation
As noted above, TMR is a technique involving transfer of the
median, radial, ulnar and/or musculocutaneous nerves in an
amputated arm to redundant residual limb muscles. These
reinnervated target muscles then serve as biological amplifiers
for the nerve signals, providing surface EMG control signals
for improved operation of motorized prostheses. The TMR
surgical procedure was recently reviewed,8 and demonstrates
improved outcomes in comparison to standard prostheses
documented.8 The following is a brief review of the surgical
techniques.
Transhumeral level
The indications to perform TMR at the transhumeral level
include poor prosthetic function using standard body-
powered, myoelectric, or hybrid systems despite adequate
training. Good candidates are young patients with cortical
control of biceps and triceps contraction without plexopathy,
supple soft tissues, and without other cardiopulmonary risk
factors. Bilateral amputations and long residual limbs also
favor the procedure. Patients who have suffered avulsions of
the limb at the time of injury or patients with brachialplexopa­
thies are poor candidates for surgery.
On examination, Tinel’s signs signifying the ends of the
median, ulnar, and radial nerve are marked. Tinel’s signs
located at the mid-humeral level or distal have long enough
nerves to perform nerve transfers. The raphe between heads
of the biceps and triceps are palpated and marked preopera­
tively, as the absence of normal distal landmarks makes it easy
to lose orientation of the arm once the patient is positioned
on the operating room table. The anterior incision provides
access to the median, ulnar, and musculocutaneous nerves.
The median nerve is transferred to the motor nerve of the
short head of the biceps, while preserving the musculocutane­
ous nerve innervation to the lateral head of the biceps (Fig.
40.13). This transfer provides a “hand closing” signal for the
prosthesis, while preserving the native “elbow flexion” signal.
In the operating room, after raising thin skin flaps, an adipo­
fascial flap is elevated and based proximally. The neuromatous
end of the median nerve is identified, cut back to healthy
fascicles, and is mobilized into the space adjacent to the motor
will be preferable to a longer amputation covered with skin
grafts. When limb shortening is not a viable option, both
pedicle and free flaps are useful for improving padding and
durability. The goal is a smooth contour that better distributes
pressure.
In addition to addressing contour abnormalities and skin
breakdown, the function of myoelectric prosthetic control can
also be improved with soft-tissue revision. The removal of
subcutaneous fat decreases the resistance between the under­
lying muscle and skin. This can markedly increase the ampli­
tude of the EMG signals and decrease interference (cross-talk)
from neighboring muscles.22
Neuroma management
Neuromas are significant problems after upper extremity
amputations. Large series from areas of conflict document
neuromas and stump pain in over one-quarter of upper
extremity amputees.23–25 Clinically, large mixed neuromas
can be very symptomatic, as can superficial sensory nerve
neuromas. “Pure” motor nerves are less than 50% motor
fibers by staining, yet clinically they do not create symp­
tomatic end-neuromas when cut. Neuroma pain is described
as a localized area of tenderness when pressure is applied,
typically with a radiation of discomfort in the area that the
nerve had previously innervated. This is in contradistinction
to phantom sensations, which are defined as the feeling
that a deafferented body part is still present following
amputation.
Numerous strategies have been reported to be successful
in the management of painful stump neuromas. The simplest
method of neuroma excision and traction neurectomy has a
documented 70% improvement rate.26 Neuroma excision with
burying the nerve end in muscle,27 neuroma translocation
away from areas of pressure,28 and the centro-centralization
technique of Gorkisch29 have all been documented to have
high levels of patient satisfaction and low recurrence rates.
These studies are all limited by being observational studies.
Experimental neuroma work is hampered by the fact that all
peripheral nerves form neuromas in the absence of a distal
target, but not all neuromas are symptomatic, making it dif­
ficult to differentiate a quiet neuroma from a symptomatic one
in a preclinical setting.
There is now growing evidence to suggest that reconstitu­
tion of the nervous system through nerve repair, grafting, or
transfer serves to limit neuroma pain by inhibiting the disor­
ganized regeneration that underlies neuroma formation. In a
recent clinical report by Moran et al., nerve repair was shown
to be superior to neuroma excision and muscle/bone implan­
tation for treatment of symptomatic neuromas in the intact
upper extremity.30 The nerve transfers utilized in TMR provide
the transected brachial nerves a vascularized scaffold for
coordinated axon regeneration, necessary neurotrophic
factors, and a target volume of denervated muscle to rein­
nervate. TMR offers the potential to restore continuity to the
peripheral nervous system despite the absence of the native
distal nerve segments. A multicenter retrospective review
demonstrated no neuroma pain involving a transferred nerve
following 82 TMR nerve transfers in 26 patients over a 10-year
period.31 More recently, TMR has been used for management
of existing neuroma pain at all amputation levels proximal to
the wrist with good clinical results.
Fig. 40.13  Cadaveric dissection splitting the medial and lateral heads of the
biceps to expose the motor points of the musculocutaneous nerve.

901
Surgery of the residual limb
An infraclavicular approach to the plexus and proximal
nerve branches is performed incising the skin two finger­
breadths below the clavicle and carefully opening the inter­
space between the sternal and clavicular heads of the pectoralis
major (Figs. 40.15–40.19). During the approach, thin skin flaps
are raised and the thick chest adiposity is thinned for improved
signal detection in a region 10 cm in superior-to-inferior
dimension, and from the medial chest to the anterior axillary
line. The motor nerves to the clavicular head of the pectoralis
off of the lateral cord are located at the midpoint of the clavicle
and are tagged. Motor nerves to the sternal head pectoralis
are identified next and come in three clusters: a motor nerve
that is near the motor nerve to the clavicular head, a motor
nerve that travels through the pectoralis minor or is just
medial to the pectoralis minor, and a motor nerve that is on
the lateral aspect of the pectoralis. The origin of these motor
nerves does not matter – as only the size and location of these
motor point nerves as they reach the muscle (where the
transfers will be performed) is important. What major mixed
nerve can reach which motor nerve? Next, either medial or
lateral to the pectoralis minor tendon, the brachial plexus
and the musculocutaneous, median, ulnar, and radial nerves
emanating from it are identified. The radial nerve is stimu­
lated to make sure there is no triceps remnant to leave in
continuity. The identity of the nerves is made by their branch­
ing pattern off of the brachial plexus. The axillary nerve is not
seen typically at this level. Deep to the plexus, the proximal
thoracodorsal nerve is identified as a potential target.
Typically, there are four nerves to transfer and there must
be four recipients (Table 40.1). The most common transfers are
the musculocutaneous nerve to the clavicular head of the
pectoralis, the median nerve to the largest motor nerve inner­
vating the sternal head of the pectoralis, and the radial nerve
to the thoracodorsal nerve. The recipient for the ulnar nerve
is generally the motor nerve innervating the lateral aspect of
the pectoralis major. Alternatives for the ulnar nerve include
the long thoracic nerve, or the nerve innervating the pectoralis
minor. If the pectoralis minor is used, it will need to be mobi­
lized laterally, and the insertion of the pectoralis divided (if
present) so that it is moved laterally for better signal detec­
tion. When the pectoralis receives more than one innervation,
it can be divided along its fibers based on its vascular anatomy
and motor nerve anatomy. Segments should be at least 4–5 cm
in diameter for adequate signal detection. The target muscle
should be completely denervated during these transfers so
that the previous pectoral EMG signal is eliminated. Nerve
coaptations are performed as close to the entry point of the
motor nerve into the muscle as possible to decrease the time
entry point of the musculocutaneous nerve on the short head
of the biceps. The nerve transfer is completed by transecting
the motor nerve to this muscle segment and coapting the
median nerve directly to this 1–1.5 mm motor nerve (Fig.
40.14). The coaptation site should be as near to the muscle
belly as possible to decrease innervation times and to facilitate
placement of a supportive epimysial suture. In the case of
long transhumeral amputations, where the brachialis has
been preserved, the ulnar nerve can be transferred to the
motor entry point of the musculocutaneous nerve into the
brachialis. This follows an identical thought process and
procedure as that performed for the median nerve. At closure,
the adipofascial flap is placed back between the biceps heads
to spatially separate the two biceps signals. Posteriorly, the
distal radial nerve is transferred to the motor nerve innervat­
ing the lateral head of the triceps, while the native innervation
of the long head of the triceps is maintained. This creates a
“hand opening” signal, while preserving an intact “elbow
extension” signal from the proximal radial nerve. After the
elevation of a proximally based adipofascial flap, the triceps
is split between the long and lateral heads to reveal the motor
nerve to the lateral head of the triceps and the distal radial
nerve. The distal radial nerve is coapted to the newly divided
motor nerve of the lateral head of the triceps. Drains and a
mildly compressing dressing are applied. Therapy can begin
several weeks after the nerve transfer procedure.32
Shoulder disarticulation level
TMR at the shoulder level should be performed only by surgi­
cal teams possessing a significant knowledge of upper chest
and axillary anatomy.33,34 Patient evaluation begins with a
thorough history and physical examination. Patients with
brachial plexus injuries are not candidates for the procedure,
as the median, radial, and ulnar nerves must elicit action
potentials under direct cortical control. Though it may seem
obvious, patients cannot undergo TMR unless they have had
an amputation, as there is no region of the body to accept the
prosthetic arm. The indication for performing surgery is to
improve prosthetic function. Painful neuromas and uncom­
fortable areas of heterotopic ossification have been other rela­
tive indications for the procedure. A Tinel’s sign over the
major three nerves is elicited, as is confirmation that the
pectoralis, serratus, and latissimus muscles are under active
cortical control. These will be potential recipient targets for
the nerve transfers.
Fig. 40.14  Schematic of targeted muscle reinnervation nerve transfer.
Table 40.1  Targeted muscle reinnervation for shoulder
disarticulations
Nerve
Possible recipient
Musculocutaneous
Clavicular head of pectoralis major
Median
Largest motor nerve innervating sternal
head of pectoralis major
Radial
Thoracodorsal or long thoracic
Ulnar
Lateral motor nerve innervating sternal head
of pectoralis major or minor

902
SECTION VI
CHAPTER 40 • Treatment of the upper extremity amputee
Fig. 40.15  Schematic nerve coaptations for shoulder targeted muscle reinnervation.
Musculocutaneous nerve
Median nerve
Ulnar nerve
Radial nerve
Thoracodorsal nerve
Fig. 40.16  Patient with small humeral remnant undergoing shoulder-level targeted
muscle reinnervation. The clavicle is dotted, and the incision is drawn.
Fig. 40.17  Adipofascial flap is raised, exposing the interspace between the
clavicular and sternal heads of the pectoralis major.

903
Comparison of prosthetics with composite tissue allotransplantation
Targeted sensory reinnervation is also possible; the afferent
fibers of the transferred nerves will reinnervate any dener­
vated skin overlying the target muscle. When this reinnervated
skin is touched, the patient feels that their missing hand is
being touched, providing cortical feedback to the “hand”
aspect of the brain. All modalities of cutaneous sensation are
restored including pressure, vibration and thermal. Special
devices termed “tactors” may provide feedback from the
prosthesis to the brain in the correct part of the brain for
position or pressure applied by the terminal device. In doing
so, targeted motor and sensory reinnervation will “close the
loop” for prosthetic function. Sensory nerves, including the
supraclavicular nerve and the lateral intercostal nerve, have
been coapted end-to-side to medial and ulnar nerves to
provide targeted sensory reinnervation. A recent review
article provides a useful summary of the state of the art with
regard to prosthetic sensory feedback and associated tech­
nologies for neural signaling.35
Transradial level
TMR has been performed for patients with transradial ampu­
tations, but for neuroma control rather than improved pros­
thetic function. These transfers are described above in the
“Wrist disarticulation and transradial amputation” section.
Several of these transradial TMR patients are currently
enrolled in a study comparing TMR-based control to myoelec­
tric control in subjects with conventional transradial amputa­
tions. It is hoped that in combination with computer-decoding
algorithms, the intrinsic hand muscle EMG information
derived from transradial TMR will help to better control
multifunction prosthetic hands.36
Comparison of prosthetics with
composite tissue allotransplantation
Clinically, there have not been any direct comparisons between
the functional outcomes obtained with TMR-controlled pros­
thetics and those resulting from composite tissue allotrans­
plantation (CTA). While a comparison of the two techniques
is useful for highlighting and defining the capabilities and
limitations of the individual technique, there is a role for each
in the comprehensive approach to patients with upper extrem­
ity amputations.
The best patient for TMR is an above elbow amputee,
because conventional myoelectric prosthetic function is poor,
and CTA has provided unpredictable results. In the absence
of TMR, the amputee lacks the capability for simultaneous
and intuitive hand and elbow function. This amputation level
also provides ample space for advanced prosthetic compo­
nents. This contrasts with the transradial level, whereby space
for prosthetic components is inherently limited, resulting in
advanced myoelectric devices that are excessively bulky. CTA,
on the other hand, is ideal in the distal forearm, where there
is little muscle mass in the transplanted piece, and nerve topo­
graphic anatomy is defined. The total transplant load is rela­
tively low, and salvage of the patient from a failed transplant
would be facilitated by its distal location. Direct comparisons
between transradial patients rehabilitated with either TMR/
advanced prosthetics or CTA will require significant coopera­
tion between academic centers.
Fig. 40.18  The radial, median, and ulnar nerves are dissected free with hemostats
holding them laterally. The musculocutaneous nerve is visible just inferior to the
army–navy retractor.
Fig. 40.19  Radial to thoracodorsal nerve coaptation.
of reinnervation. The adipofascial flap is placed between the
pectoral heads to reduce aberrant reinnervation and to sepa­
rate the muscle bellies from each other thereby improving
EMG signal detection. The skin is closed over drains after
placement of quilting sutures to decrease seromas. The patient
may resume wearing his/her original prosthesis when there
is adequate wound healing. Prosthetic fitting for new control
sites will occur in 3–6 months. The latissimus muscle, being
farthest away from the coaptation site, will take the longest
to come under cortical control.

904
SECTION VI
CHAPTER 40 • Treatment of the upper extremity amputee
Future directions
Future advancements for the prosthetic rehabilitation of
the amputee are achievable in the near term. Osseointegra­
tion of the prosthetic into the humerus radius, femur, or
tibia will dramatically improve the control and strength of
the terminal device, as well as make the prosthetic more
comfortable to wear. The absence of a prosthetic liner will
render more facile the recording of EMG signals on the
residual limb. Improvements in TMR will be obtained by
further subdividing the nerve into smaller fascicles and the
use of regenerative peripheral nerve interfaces for direct
recording of nerve depolarizations. Alternatively, implantable
myoelectric sensors (IMES) will be able to beam the muscle
signal out to a detector without a surface electrode. Finally,
improved prosthetic processing of the complex EMG signal
termed “pattern recognition” has been shown to permit
independent finger movements, even in the most proximal
amputations.
Clinical tips
1. Targeted muscle reinnervation (TMR) requires an amputated
limb with the nerve normally connected to the brain and
spinal cord. Patients with brachial plexus injuries are not
candidates for TMR.
2. Physical examination suffices for location of end-neuromas
and muscles under cortical control. There is no need for
magnetic resonance imaging, ultrasound, and
electromyography so long as there is no history of a
brachial plexus injury in addition to the amputation.
3. Soft-tissue revision of the amputated limb can and should
be performed when indicated at the time of TMR.
4. TMR procedures can be performed in a straightforward
manner with loop magnification and a simple nerve
stimulator to identify motor nerves of adjacent muscles.
5. Free muscle flaps can be used advantageously as a
recipient for the nerve transfer when there are no available
local motor nerves.
8. Gart MS, Souza JM, Dumanian GA. Targeted muscle reinnervation
in the upper extremity amputee: a technical roadmap. J Hand Surg
Am. 2015;40:1877–1888. Current technique with cadaver dissections for
TMR in upper extremity amputees. The surgical technique is well
illustrated in this review.
9. Kuiken TA, Dumanian GA, Lipschutz RD, et al. The use of targeted
muscle reinnervation for improved myoelectric prosthesis control in
a bilateral shoulder disarticulation amputee. Prosthet Orthot Int.
2004;28:245–253. This is the initial report of TMR in a shoulder
disarticulation patient. Objective testing before and after the nerve
transfer procedure is presented.
31. Souza JM, Cheesborough JE, Ko JH, et al. Targeted muscle
reinnervation: a novel approach to postamputation neuroma pain.
Clin Orthop Relat Res. 2014;472:2984–2990.
The effect of TMR on painful neuromas is reviewed.
34. Kuiken TA, Miller LA, Lipschutz RD, et al. Targeted reinnervation
for enhanced prosthetic arm function in a woman with a proximal
amputation: a case study. Lancet. 2007;369:371–380. Illustrated case of
TMR in a shoulder disarticulation patient, with additional diagrams of
targeted sensory reinnervation.
Access the complete reference list online at

904.e1
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