Dụng Cụ Chỉnh Hình Và Chân Tay Giả Trong Phục Hồi Chức Năng (Ấn Bản Thứ 3)

792
Section III  Prostheses in Rehabilitation
reinforcements enable the prosthesis to withstand extremely
high stresses. The child should understand that shoes must
always be worn; the plantar surface of most prosthetic feet is
not durable enough to withstand abrasion by a sidewalk, and
the alignment of the foot is intended for a shoe.
Some activities are more easily performed without a pros­
thesis or do not require a prosthesis. Children should learn
how to use crutches as an alternate mode of locomotion
when the prosthesis is being repaired. Bathing is facilitated
either by sitting on the shower floor or by using a sturdy bath
seat. Most people prefer to swim and scuba dive without a
prosthesis. They hop or use crutches to get from the dressing
room to the water's edge. Sports prostheses, such as a swim­
ming prosthesis with a fin in place of the foot, can be con­
structed. Bicycling, skiing, and mountain climbing are other
sports that can be enjoyed with or without a prosthesis.
Rehabilitation of Children with Multiple
Limb Amputation
Babies who have lower-limb deficiency, together with anom­
alies of one or both upper limbs, generally do best by being
fitted first with simple lower-limb prostheses to foster sitting
balance. The introduction of upper- and lower-limb prosthe­
ses simultaneously is apt to overwhelm the infant.
When both upper limbs are anomalous, a simple bilat­
eral fitting counteracts the tendency toward development
of positional scoliosis. The baby with bilateral upper-
limb deficiency should receive prostheses after indepen­
dent walking is established; otherwise, prostheses make it
more difficult to crawl, move about on the floor, and pull
to standing with the chin for support. Those with bilateral
upper-limb deficiency become quite skillful with foot pre­
hension. The extent to which foot use should be encour­
aged is controversial. Foot prehension is so rarely observed
in public that the child who does use the feet may expe­
rience unwanted stares. Nevertheless, feet have the tac­
tile sensation and considerable dexterity that prostheses
lack. Children with bilateral longitudinal deficiencies have
partial or complete hands; they would be encumbered by
wearing prostheses. Functional activities with and without
prostheses should be introduced according to the physical
and emotional maturity of the child. Adaptive aids may be
required for some functions, such as personal hygiene.
Infants with trimembral or quadrimembral limb defi­
ciency, possibly as a result of meningococcal septicemia,55
move about by rolling along the floor. They need oppor­
tunities to look at objects and manipulate toys with their
mouths and their residual limbs. Most infants develop
good sitting balance and can scoot along on their but­
tocks. Because of the drastic reduction in body surface,
these children can easily become overheated. They should
be dressed very lightly to enable heat dissipation. Young
children with bilateral transfemoral deficiency usually
begin with a pair of prostheses that do not have knee units
(Figure 29-19). They may walk indoors without any assis­
tive devices; however, few are willing to venture outdoors
and across streets without at least one cane. In adolescence,
many find that a wheelchair provides more efficient mobil­
ity. Those with bilateral hip disarticulations (Figure 29-20)
may be able to walk with prostheses at home, but usually
rely on a wheelchair for community travel.
FIGURE 29-19  Bilateral transfemoral prostheses without knee units
for a toddler who is beginning to walk. (Courtesy J. E. Edelstein.)
FIGURE 29-20  Boy wearing bilateral hip disarticulation prostheses.
(Courtesy Otto Bock Orthopedic Industry, Inc., Minneapolis, MN.)

Chapter 29  Rehabilitation for Children with Limb Deficiencies
793
SUMMARY
Rehabilitation of children with limb deficiencies can be most
gratifying. The physical therapist, together with all members of
the clinical team, should design the rehabilitation program to
assist the child in achieving developmental milestones associ­
ated with maturing upper and lower limb function. Psychosocial
factors govern the behavior of all children, although it appears
that those with limb deficiency behave in a comparable man­
ner to able-bodied peers.56,57 Peer support is very helpful for
children and parents. Clinic team members need to recognize
the basis for parental distress while fostering realistic expecta­
tions for the child's function by demonstrating that the child is
lovable regardless of the condition of the limbs.
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3. Stanger M. Limb deficiencies and amputations. In: Campbell
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5. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and
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6. Rijnders LJ, Boonstra AM, Groothoff JW, et al. Lower limb defi­
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8. McGuirk CK, Westgate MN, Holmes LB. Limb deficiencies in
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9. Conner KA, et  al. Pediatric traumatic amputations and hos­
pital resource utilization in the United States, 2003. J Trauma.
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10. Nguyen A, et  al. Lawn mower injuries in children: a 30-year
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12. Bhatta ST, et  al. All-terrain vehicle injuries in children:
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13. Nagarajan R, Neglia JP, Clohisy DR, et al. Education, employ­
ment, insurance, and marital status among 694 survivors of pedi­
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Cancer Survivor Study. Cancer. 2003;97:2554–2564.
14. Ginsberg JP, et  al. A comparative analysis of functional out­
comes in adolescents and young adults with lower-extremity
bone sarcoma. Pediatr Blood Cancer. 2007;40:964–969.
15. Refaat Y, Gunnoe J, Hornicek FJ, et  al. Comparison of qual­
ity of life after amputation or limb salvage. Clin Orthop.
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16. Nagarajan R, Neglia JP, Clohisy DR, et  al. Limb salvage and
amputation in survivors of pediatric lower extremity bone
tumors: what are the long-term implications? J Clin Oncol.
2002;20:4493–4501.
17. Robert RS, Ottaviani G, Huh WW, et al. Psychosocial and func­
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Cancer. 2010;54:990–999.
18. Ottaviani G, Robert RS, Huh WW, et al. Functional, psychoso­
cial and professional outcomes in long-term survivors of lower-
extremity osteosarcomas: amputation versus limb salvage.
Cancer Treat Res. 2009;152:421–436.
19. Hopyan S, Tan JW, Graham HK, et al. Functional and upright
time following limb salvage, amputation, and rotationplasty for
pediatric sarcoma of bone. J Pediatr Orthop. 2006;26:405–408.
20. Edelstein JE. Developmental kinesiology. In: Smith DG,
Michael JW, Bowker JH, eds. Atlas of Amputations and Limb
Deficiencies. 3 rd ed. Rosemont, Ill: American Academy of
Orthopaedic Surgeons; 2004:783–788.
21. Campbell SK. Understanding motor performance in children.
In: Campbell SK, Vander Linden DW, Palisano RJ, eds. Physical
Therapy for Children. 2nd ed. Philadelphia: Saunders; 2000:3–45.
22. Cech D, Martin S. Functional Movement Development across the
Life Span. 2nd ed. Philadelphia: Saunders; 2001.
23. Fishman S, Edelstein J, Krebs D. ISNY above-knee prosthetic
sockets: pediatric experience. J Pediatr Orthop. 1987;5:557–562.
24. Fixsen JA. Major lower limb congenital shortening: a mini
review. J Pediatr Orthop. 2003;12:1–12.
25. Patton JG. Training the child with a unilateral upper-extremity
prosthesis. In: Atkins DJ, Meier RH, eds. Functional Restoration
of Adults and Children with Upper Extremity Amputation.
New York: Demos; 2004:297–316.
26. Huizing K, Reinders-Messelink H, Maathuis C, et al. Age at first
prosthetic fitting and later functional outcome in children and
young adults with unilateral congenital below-elbow deficiency:
a cross-sectional study. Prosthet Orthot Int. 2010;34:166–174.
27. Edelstein JE. Rehabilitation without prostheses. In: Smith DG,
Michael JW, Bowker JH, eds. Atlas of Amputations and Limb
Deficiencies. 3 rd ed. Rosemont, Ill: American Academy of
Orthopaedic Surgeons; 2004:745–756.
28. Stoeker W. Foot skills and other alternatives to hand use. In: Meier
RH, Atkins DJ, eds. Functional Restoration of Adults and Children
with Upper Extremity Amputation. New York: Demos; 2004:133–134.
29. Kuyper MA, Breedijk M, Mulders AH, et al. Prosthetic manage­
ment of children in The Netherlands with upper limb deficien­
cies. Prosthet Orthot Int. 2001;25:228–234.
30. Sorbye R. Myoelectric prosthetic fitting in young children. Clin
Orthop. 1980;148:34–40.
31. Krebs D, ed. Prehension Assessment: Prosthetic Therapy for the
Upper-Limb Child Amputee. Thorofare, NJ: Slack; 1987.
32. Edelstein JE, Berger N. Performance comparison among chil­
dren fitted with myoelectric and body-powered hands. Arch
Phys Med Rehabil. 1993;74(4):376–380.
33. Fernandez A, Lopez MJ, Navarro R. Performance of persons
with juvenile-onset amputation in driving motor vehicles. Arch
Phys Med Rehabil. 2000;81:288–291.
34. Walker JL, Coburn TR, Cottle W, et al. Recreational terminal
devices for children with upper extremity amputations. J Pediatr
Orthop. 2008;28:271–273.
35. Edelstein J. Musical options for upper-limb amputees. In: Lee M,
ed. Rehabilitation Music and Human Well-Being. St. Louis: MMB
Music; 1989.

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36. Wright FV, Hubbard S, Naumann S, et  al. Evaluation of the
validity of the prosthetic upper extremity functional index for
children. Arch Phys Med Rehabil. 2003;84:518–527.
37. Crandall RC, Tomhave W. Pediatric unilateral below-elbow
amputees: retrospective analysis of 34 patients given multiple
prosthetic options. J Pediatr Orthop. 2002;22:380–383.
38. Routhier F, Vincent C, Morissette MJ, et al. Clinical results of an
investigation of paediatric upper limb myoelectric prosthesis fit­
ting at the Quebec Rehabilitation Institute. Prosthet Orthot Int.
2001;25:119–131.
39. Meurs M, Maathuis CG, Lucas C, et al. Prescription of the first
prosthesis and later use in children with congenital unilateral
upper limb deficiency: a systematic review. Prosthet Orthot Int.
2006;303:165–173.
40. Postema K, van der Donk V, van Limbeek J, et al. Prosthesis
rejection in children with a unilateral congenital arm defect.
Clin Rehabil. 1999;13:243–249.
41. Davids JR, Wagner LV, Meyer LC, et al. Prosthetic management
of children with unilateral congenital below-elbow deficiency.
J Bone Joint Surg Am. 2006;88:1294–1300.
42. Egermann M, Kasten P, Thomsen J. Myoelectric hand prosthe­
ses in very young children. Int Orthop. 2009;33:1101–1106.
43. James MA, Bagley AM, Brasington K, et al. Impact of prosthe­
ses on function and quality of life for children with unilateral
congenital below-the-elbow deficiency. J Bone Joint Surg Am.
2006;88:2356–2365.
44. Buffart LM, Roebroeck ME, van Heijningen VG, et al. Evaluation
of arm and prosthetic functioning in children with a congeni­
tal transverse reduction deficiency of the upper limb. J Rehabil
Med. 2007;39:379–386.
45. Hermansson L, Eliasson AC, Engstrom I. Psychosocial adjust­
ment in Swedish children with upper-limb reduction defi­
ciency and a myoelectric prosthetic hand. Acta Paediatr.
2005;94:479–488.
46. Chambers HG. Pediatric gait analysis. In: Perry J, Burnfield JM,
eds. Gait Analysis: Normal and Pathological Function. 2nd ed.
Thorofare, NJ: Slack; 2010:341–363.
47. Parry IS, Mooney KN, Chau C, et  al. Effects of skin grafting
on successful prosthetic use in children with lower extremity
amputation. J Burn Care Res. 2008;29:949–954.
48. El-Sayed MM, Correll J, Pohlig K. Limb sparing reconstruc­
tive surgery and Ilizarov lengthening in fibular hemimelia
of Achterman-Kalamchi type II patients. J Pediatr Orthop B.
2010;19:55–60.
49. Walker JL, Knapp D, Minter C, et al. Adult outcomes follow­
ing amputation or lengthening for fibular deficiency. J Bone Joint
Surg Am. 2009;91:797–804.
50. Busse JW, Jacobs CL, Swiontkowski MF, et  al. Complex limb
salvage of early amputation for severe lower-limb injury: a
meta-analysis of observational studies. J Orthop Trauma. 2007;
21:70–76.
51. Alan RK, Brown JP, Pugh LI, Stasikelis PJ. Function of children
with myelodysplasia and lower extremity amputations. J Pediatr
Orthop. 2007;27:51–53.
52. Nelson VS, Flood KM, Bryant PR, et al. Limb deficiency and pros­
thetic management. 1. Decision making in prosthetic prescrip­
tion and management. Arch Phys Med Rehabil. 2006;87:S3–S9.
53. Andrysek J, Naumann S, Cleghorn WL. Design characteristics
of pediatric prosthetic knees. IEEE Trans Neural Syst Rehabil
Eng. 2004;12:369–378.
54. Andrysek J, Naumann S, Cleghorn WL. Design and quan­
titative evaluation of a stand-phase controlled prosthetic
knee joint for children. IEEE Trans Neural Syst Rehabil Eng.
2005;13:437–443.
55. Lowe KG, Boyce JM. Rehabilitation of a child with meningococ­
cal septicemia and quadrilateral limb loss: a case report. Arch
Phys Med Rehabil. 2004;85:1354–1357.
56. Boonstra AM, Rijnders LJ, Groothoff JW, et  al. Children
with congenital deficiencies or acquired amputations of the
lower limbs: functional aspects. Prosthet Orthot Int. 2000;
24:19–27.
57. Michielsen A, Van Wijk I, Ketelaar M. Participation and quality
of life in children and adolescents with congenital limb deficien­
cies: a narrative review. Prosthet Orthot Int. 2010;34:351–361.

795
Prosthetic Options for Persons with Upper-Extremity
Amputation
John R. Zenie
IMPACT OF TECHNOLOGY
Prosthetic management of individuals with upper-­extremity
amputations presents all allied health professionals, including
prosthetists, with a set of unique challenges. For those wear­
ing an upper–extremity limb, the TD of the prosthesis is not
covered or obscured by clothing in the same way that a lower-
extremity prosthesis is “hidden” by pants, socks, and shoes.
By  the virtue of its level, the person with upper-extremity
amputation must cope with not only physical appearance
changes, but the loss of some of the most complex movement
patterns and functional activities of the human body.
In addition, limb deficiency in the upper extremity deprives
the patient of an extensive and valuable system of tactile and
proprioceptive inputs that previously provided “feedback”
to guide and refine functional movement.1,2 Even the sim­
plest tasks related to grasp and release become challenging.
The ability to position prosthetic limb segments in space, as
well as the ability to maintain advantageous postures needed
to manipulate objects, challenge the medical community to
­continuously improve the functional and ­aesthetic outcomes
of prosthetic replacement for patients in this population.3–5
Many of these challenges have been addressed with new
and emerging technologies. These new technologies have
made it possible, in some circumstances, to successfully “fit”
a patient with high-level amputation who previously would
have little or no reasonable expectation to succeed with tradi­
tional technology and fitting techniques.2,6,7 Advanced socket
interface designs and material science have afforded prosthe­
tists the ability to offer stronger, more stable platforms for all
levels of amputation, while in most cases saving substantial
amounts of weight. Similarly, more innovative suspension
strategies and interface mediums have increased the func­
tional ranges of motion a patient can comfortably achieve.8
These advancements have had a profound and positive
effect on the comfort, function, and compliance of both con­
ventional body-powered and externally powered prostheses at
all levels of amputation. Furthermore, the huge strides made
in the externally powered arena have in large part been driven
by these advancements and technological breakthroughs.
LENGTH OF THE RESIDUAL LIMB
Amputations to the upper extremity can be classified or
named by the limb segments affected (Figure  30-1). The
most distal are at the finger, partial hand or transcarpal
­levels. Amputations that separate the carpal bones from
the radius and ulna are referred to as wrist disarticula­
tions. Amputations that occur within the substance of the
radius and ulna are classified as transradial amputations.
When the humerus is preserved but the radius and ulna are
removed, the amputation is referred to as an elbow disarticu­
lation. Those that leave more than 30% of humeral length
are ­designated as transhumeral amputations. Shoulder disar­
ticulations are those in which less than 30% of the proximal
30
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to do
the following:
1. Compare and contrast prosthetic needs and expected
functional outcomes for individuals with upper-extremity
amputations at various levels.
2. Compare and contrast the fitting and control issues for
individuals with various etiologies of amputations and
residual limb lengths.
3. Describe the factors that determine recommendations
for prosthetic options (no prosthesis, passive prosthesis,
body-powered prosthesis, externally powered systems, or
hybrid prosthetic systems).
4. Compare and contrast options for donning and suspen­
sion of a prosthesis for individuals with upper-extremity
amputations of various levels.
5. Describe the biomechanical principles of transradial and
transhumeral body-powered prosthetic control systems
and the movement strategies necessary for control of elec­
tric terminal devices (TDs), elbow units, and other pros­
thetic components.
6. Explain the basic principles of myoelectric control, including
determining electrode placement and the types of muscle
contractions used to operate or switch among TDs, electric
elbow units, and other electric prosthetic components.

796
Section III  Prostheses in Rehabilitation
humerus remains. More ­proximal amputations that invade
the central body ­cavity, resecting the clavicle and leading
to derangement of the scapula, are described as forequar­
ter amputations or scapulothoracic amputations. In clinical
prosthetic and rehabilitation practices, transradial and trans­
humeral amputations account for nearly 80% of all upper-
extremity amputations.6
All patients who have amputations of the upper extremity
require a complete and thorough examination at the levels of
involvement and of associated functional and physiological
deficits associated with that specific amputation. For patients
with partial hand amputations, the range of motion (ROM)
of any remaining digits and the condition of the structural
bones of the hand have a profound effect on the selection of
possible prosthetic options. The inclusion or absence of an
intact thumb also dictates the parameters of fitting.
For those with transverse amputations of the forearm,
the length of the residual limb affects the amount of func­
tional elbow flexion and forearm pronation and supination
that will be retained independent of prosthetic intervention.1
Articulations between the radius and the ulna along the entire
forearm are necessary to provide for natural anatomical move­
ments in supination and pronation; as the level of amputa­
tion moves proximally from the styloid process of the radius
toward the elbow, the ability to perform and to use pronation
and supination during functional activities is progressively lost
(Figure 30-2). When the residual forearm is extremely short,
all transverse motion is essentially lost, and it is difficult to
gain any active functional forearm rotation for prosthetic use.
Amputations at the level of the elbow (elbow disarticula­
tion) derive little functional benefit from the added length
because the length of the limb limits options for cosmetic and
functional placement of elbow units within the prosthesis,
without substantially improving functional leverage.
Although the primary concern of surgeons who perform
an upper-extremity amputation is adequate closure of the
wound, they must also consider the potential advantages of
a fairly long lever arm, balanced by an understanding of the
space requirements for prosthetic components. Provided that
adequate skin and tissue viability are not compromised, con­
sideration should be given to adequate room for a full array of
prosthetic componentry.
UPPER-EXTREMITY PROSTHETIC
COMPONENT
Prosthetic components can be thought of as a means to replace
lost functional capacity associated with the ­anatomical loss of
limb segments. A TD is employed to replace grasp and release.
An elbow mechanism is used to replace the humeral-ulnar
articulation; a shoulder mechanism is placed proximally to
provide humeral orientation in space at the shoulder disar­
ticulation and scapulothoracic amputation ­levels. Rotators
can be placed in the forearm of the prosthesis to substitute
for pronation and supination or above the elbow unit to
­substitute for internal and external rotation of the shoulder
as well.9,10
Partial Hand, Transcarpal, and Wrist Disarticulation
Until recently, patients with digit, partial hand, or transcar­
pal amputations were often offered passive (nonfunctioning)
cosmetic prostheses (restorations).11 Depending on the char­
acteristics of the residual limb, a functional prehensile post
might have been fabricated to regain some grasp and release
capability of the affected limb. Recent advances in technology
and microprocessors have made externally powered options
Shoulder disarticulation
Short transhumeral
Transhumeral
Long transhumeral
Elbow disarticulation
Short transradial
Transradial
Long transradial
Wrist disarticulation
Transcarpal
Phalangeal
FIGURE 30-1  Classification of upper-extremity amputation and resid­
ual limbs. (From Murdoch G, Wilson AB, Amputation: Surgical Practice
and Patient Management. Oxford, UK: Butterworth, 1996. p. 308.)
Natural rotation
Residual rotation of amputee
55°
100°
140°
180°
0°
60°
100°
120°
Very short
Short
Medium
Long Disartic-
ulation
0
2
4
6
8
10
Inches
FIGURE 30-2  Potential for pronation and supination of transradial
residual limbs of differing lengths. (From Taylor CI. The biomechanics
of control in upper extremity prosthetics. Orthot Prosthet 1981;35:20.)

Chapter 30  Prosthetic Options for Persons with Upper-Extremity Amputation
797
more readily available (Figure 30-3).12 These advances permit
electric control despite the extremely distal amputation site.
Consideration must be given preoperatively to any remain­
ing functional digits. The status of sensation and mobility of
these digits should not be understated. If functional range
and sensation are inadequate, the surgeon considers a more
proximal level of amputation.
The wrist disarticulation residual limb provides a long and
functional lever for prosthetic use.13 If the radial and ulnar
styloid processes are preserved, then the prosthetist can use a
positive suspension strategy over these prominences to keep
the prosthesis and stable suspended on the residual limb,
making harnesses unnecessary. The disadvantage of wrist
disarticulation, however, is limitation in room to fit a wrist
and hand unit into a cosmetically acceptable prosthesis. If
the styloid processes have been modified or removed during
­surgery, more aggressive proximal suspension strategies are
necessary. In addition, the extra residual limb length leads to
a difference in arm length once the wrist and prosthetic hand
unit is in place, which might be cosmetically unacceptable to
the patient. In such cases, a more proximal amputation would
allow for a full complement of prosthetic options.
Transradial and Transhumeral Considerations
For most adult transradial prostheses, nearly 8 inches of space
is necessary beyond the distal residual limb for the prosthetic
wrist rotator and TD or hand.13 Similarly, at the transhumeral
level, approximately 6 inches of space must be present beyond
the distal residual limb to accommodate a mechanical elbow
mechanism within the prosthesis.14 For patients with a short
residual humerus, a conventional (body-powered) prosthetic
system may not be realistic, and even an externally powered
prosthesis may be difficult or problematic to fit, suspend, and
control. When the residual humerus is short, it may be nec­
essary to treat a transhumeral amputation functionally as a
shoulder disarticulation (Figure 30-4).
Positive models to fabricate any contemporary prosthesis
can be secured with conventional plaster direct molding tech­
niques similar to those used for lower-extremity amputations.
Model acquisition and data collection are also possible using
computer-aided design. Both direct contact and optical meth­
ods are finding ever-increasing utility in modern practice.
This technology is particularly valuable as a means to quan­
tify and document volume and shape changes, enhancing fit
and function for optimal clinical outcomes (Figure 30-5).
ETIOLOGY OF UPPER-EXTREMITY
AMPUTATION
The etiology of upper-extremity amputations varies widely.
The earliest recorded use of limb prosthesis was that of a
­soldier who reportedly amputated his own limb around
484 bc.15 One of the earliest known prostheses was fabricated
of copper around 300 bc.16 These early attempts at pros­
thetic management predate early surgical considerations for
­lifesaving reasons by many decades. Ambrose Pare, whom
many consider the father of modern orthopedic surgery,
introduced early surgical techniques around 1529.17 Public
belief is that Pare performed the earliest upper-­extremity
amputation, an elbow disarticulation, late in 1536. The inci­
dence and prevalence of upper-extremity amputation over
the past several centuries is attributed to advances in the
pharmacological and surgical management of disease, as
well as trauma.18 Upper-extremity trauma related to indus­
try, mechanized farming, and armed conflict has been the
­catalyst for medical and prosthetic advancements in the
twentieth century.6
FIGURE 30-3  Example of an externally powered prosthetic hand used
for individuals with a partial hand amputation or wrist disarticulation.
FIGURE 30-4  Example of a prosthetic shoulder joint used in individ­
uals with a shoulder disarticulation or extremely short transhumeral
residual limb.
FIGURE  30-5  A computer-assisted design model of a transradial
prosthetic socket. Note the aggressive anatomical contouring of the
socket and the anteroposterior force system (between the anterior
cubital fossa and olecranon) that will be used to suspend the socket on
the residual limb. (Courtesy CPS, Branford, CT.)

798
Section III  Prostheses in Rehabilitation
The National Center for Health Statistics reports approxi­
mately 50,000 new amputations every year in the United States.
With a ratio of 1:4 upper-extremity to lower-extremity amputa­
tions the number of existing and new upper-extremity ampu­
tees is both significant and most likely a population that is
underserved. As the number of upper limb cases is relatively
small in comparison to lower-limb cases, many prosthetic
practitioners who are highly skilled and qualified in the arena
of lower-limb prosthetics, have far lesser experience and con­
fidence when dealing with complex upper-limb management.
Furthermore, in the realm of externally powered prosthet­
ics, fewer practitioners still have the additional education and
­certifications to work with these complex systems.
Of the approximately 54 million persons in the United
States with disabilities, at least 10% have had amputations.19
Although the exact number of patients with amputations is
unknown, the number of patients with acquired and congen­
ital amputations is significant. Of all persons with amputa­
tions, the number of patients with amputations to the upper
extremity is small in comparison to all total amputations.19
Compelling evidence suggests an estimated 10,000 new
amputations to the upper extremity each year.20 These num­
bers represent a large number of individuals who require
prosthetic intervention.
The primary cause of acquired amputations is trauma.6
Other causes of upper-extremity amputation are the various
sarcomas, as well as congenital limb deformities, including
amelias and phocomelias.21–23 Amputations to address con­
genital limb deficiencies are most often performed on indi­
viduals younger than 15 years old, while amputation after
traumatic injury is most often performed on those between
15 and 45 years old.24 Seventy percent of all upper-extremity
amputations occur in persons younger than 64 years of age.6,24
Because trauma is more likely to occur in the operation of
machinery or in combat, many more amputations occur
among males than females.24
PREPROSTHETIC CARE
All patients with upper-extremity amputation, regard­
less of cause, require some degree of preprosthetic manage­
ment. This is particularly essential with a recent amputation
but includes even those persons who have worn prosthetic
devices previously. Comprehensive preprosthetic and pros­
thetic management is a strong predictor of optimal rehabili­
tation outcomes.25,26 After amputation surgery, facilitation of
wound healing and effective pain management are the foun­
dations for all other types of preprosthetic care. Care is most
effective if coordinated through a multidisciplinary team—
the prosthetist, surgeon, nurses, physical and occupational
therapists, counselors, and others as necessary.7
Edema and Volume Control
Edema and volume control are additional key elements of pre­
prosthetic care. If the wound site is adequately protected and
bandaged, compressive wraps or shrinkers should be used
as soon as possible. In most cases, multidirectional shrinker
­garments are more effective than other methods, including
elastic bandages.27 Shrinkers appear to more efficiently control
volume and shape the residual limb. When donned properly,
shrinkers have far less tendency to migrate or shift position on
the residual limb. In addition, shrinkers are more effective at
creating the consistent distal toward proximal pressure gradi­
ent that is most effective. The compressive garment should ter­
minate proximal to the joint above the amputation site when
possible. With the transhumeral amputation, this requires the
shrinker to include a modified shoulder cap. Such a device
is rarely commercially available and usually requires custom
fabrication on site. This additional effort has been shown to
produce favorable results in comparison with shrinkers that
terminate more distally.26 Due diligence must be exercised to
ensure that appropriate tension and compression gradients are
achieved and maintained. Effective and timely volume man­
agement influences more than the residual limb volume and
shape; many patients report that this compression is a surpris­
ingly efficient tool in the management of phantom sensation.27
Skin Care, Desensitization, and Range of Motion
The services of a skilled therapist have proven invaluable in
the areas of skin care, desensitization, and scar mobilization.
Preprosthetic ROM and strengthening should be undertaken
concurrently as tolerated.
Skin care can present some significant challenges, partic­
ularly when an individual has sustained a traumatic ampu­
tation. Chemical and electrical injuries with associated skin
grafts can become problematic, particularly when irregular
and uneven surface topography is present.28 Maintaining skin
integrity throughout both the fitting and postdelivery phase of
rehabilitation is extremely important. The appropriate medi­
cal professional should carefully assess any postoperative open
lesions. Blast and percussion injuries also present a complex
array of socket interface and electrical conductivity issues.29
This type of injury frequently displays an unusual soft tissue
consistency. The tissue is unlike that of crushing, degloving
injuries. Tissues exposed to the enormous energy associated
with blast injuries frequently respond to the outside compres­
sive forces of shrinkers and preparatory sockets much more
dramatically than do tissues injured by other sources. This
phenomenon must be considered carefully, as its effects pro­
foundly affect any rehabilitation plan.
The nature of any volume management protocol in and
of itself begins the limb maturation and desensitization pro­
cess simultaneously. Further and more focused efforts must
be undertaken to assure that limb volume is both stabiliz­
ing and fostering a limb shape or contour that is favorable to
donning, wearing, and operating a prosthetic device.28 Limbs
with large longitudinal contours or bulbous distal contours
are least desirable. Residuum with insignificant tissue or skin
coverage should also be avoided whenever possible. Ideally
the residual limb is long enough to provide a functional lever
arm but not so long as to preclude the use of a wide array of
prosthetic components. Residual limbs with effective myo­
desis frequently display smaller ­myoelectric artifact without
any apparent or material loss of volitional potential.

Chapter 30  Prosthetic Options for Persons with Upper-Extremity Amputation
799
Preprosthetic ROM should be maximized regardless of
the planned prosthetic intervention. Strengthening of the
­muscles about and proximal to the amputation is paramount.
However, a more global approach to strengthening affords
the patient a more expeditious and complete rehabilitation.
These efforts to maximize ROM and increase volitional power
should not overlook the secondary movers or accessory stabi­
lizers. For patients with transradial amputations, for example,
maximizing ROM and strength of pronation and supination
is an important determinant of positive functional outcomes.
Adaptation Process
Patients and families facing amputation, whether congenital
or acquired, adjust and cope with absence or loss of the limb
differently.30 The extent or level of involvement often has little
to do with the complexity of the adaptation process. All per­
sons must find ways to deal with the functional and aesthetic
issues related to limb loss. Adaptation is an ongoing process
rather than a specific event. In many cases the services of a
qualified psychotherapist are valuable, providing the patient
and caregivers are amenable to such intervention.
Most professionals agree that there is a fairly short win­
dow of opportunity within which the prospects for success­
ful rehabilitation are greatest, although there is disagreement
about the duration of this “optimal rehabilitation” period.
In most circumstances the earlier a patient can be evaluated,
fitted, and trained, the more likely a positive rehabilitation
outcome occurs.6 Malone and colleagues25 suggest high ­levels
of success with patients fit within the first 30 days follow­
ing amputation. In addition, individuals fit with a prosthe­
sis as early as possible return to work quickly, many within
4 months of injury.6,25
PROSTHETIC EXAMINATION AND EVALUATION
Examination of persons with upper-extremity amputations
should include complete documentation of the involved
limb's ROM. Care should be exercised to identify both the
active and passive ranges. Volitional muscle control should be
evaluated and documented. Limb shape and contour, as well
as tissue consistency, are important elements in the evalua­
tion. Particular attention must be paid to any grafts, scars, or
painful areas of the residuum. Pertinent medical history must
be duly noted, as it may affect not only prosthetic develop­
ment but all phases of the rehabilitation protocol.
The past medical history must adequately address any
injuries or pathologies on both sides of the body. For patients
with high-level amputations, the prosthesis, regardless of
configuration or power source, ultimately has some integrated
components across one or both of the axilla, as well as the
thoracic wall.
The objective of all prosthetic interventions should be to
restore as much functional potential as possible.31 This is best
accomplished by using components, materials, and interface
designs to most closely approximate the lost body segments
and functions. The appropriateness of any design should
address the patient's vocational, recreational, and aesthetic
needs. The needs of most patients can be met with one or
more prosthetic options.
PROSTHETIC OPTIONS
Depending on the patient's situation, the prosthetist and
rehabilitation team can make a number of recommendations.
These include not providing a prosthesis, providing a passive
prosthesis or cosmetic restoration, designing a conventional
body-powered system, or providing a sophisticated myoelec­
trically controlled prosthetic limb with multiple components.
No Prosthesis
A significant percentage of patients with upper-extremity
amputations elect not to use a prosthesis on a regular basis.6
In many cases this decision can be traced to a poorly con­
ceived or executed prosthetic device that was provided early
in the patient rehabilitation process.25 Some potential wearers
report that the devices they have been exposed to are uncom­
fortable, heavy, and too slow during use or difficult to don
and suspend.6 The advent of advanced materials has enabled
prosthetists to build lighter, stronger, and more comfortable
systems, as well as extremely cosmetic restorations. Despite
these advancements, not all individuals with amputations
integrate a prosthesis into their body image. The prosthetist
or rehabilitation team should follow patients who choose not
to use a prosthesis initially at regular intervals (often yearly)
to ensure that their functional needs are being met. Given
the rate of technological development, new components or
devices are likely to become available to address problems the
patient might have had at an earlier time.
Passive Prostheses and Restorations
This category of prosthesis consists of systems that do not
possess the ability to actively position a mechanical elbow in
space or actively provide grasp and release function, or both.
The absence of these properties does not, however, render the
prosthesis as passive as the name would suggest. These devices
are extremely functional in terms of supporting objects or sta­
bilizing items during bimanual tasks and activities, especially
for young children with congenital deficiencies.32,33 These sys­
tems most frequently have a self-suspending design and use a
realistic hand as a TD. Suspension is achieved either with spe­
cific socket interface geometry or suction negative pressure.
The absence of operational mechanical components generally
results in an extremely lightweight prosthesis.
The finish of these devices varies widely. Production latex
cosmetic gloves provide an cost-effective medium for many
patients. Many individuals, however, seek out more realistic
restorations (Figure  30-6). These restorations require sub­
stantially greater investments in time and financial resources.
This investment is most often rewarded with an extremely aes­
thetic, very natural appearing device. Silicone is the media of
choice for these cosmetic limbs, primarily because it is practi­
cally impervious to outside contaminants. Where latex read­
ily stains and deteriorates in ultraviolet light, silicone does not
mark and, for all practical purposes, is inert. Generally, the

800
Section III  Prostheses in Rehabilitation
additional cost of silicone is mitigated by its superior cosmesis,
durability, and increased coefficient of friction (Figure 30-6).
Laser scanning and computer modeling to create near
perfect “mirror “ images of high level amputations , such as
shoulder disarticulations, and scapulothoracic amputations
(see Figure 30-6, A).
Conventional Body-Powered Systems
Conventional (body-powered) systems include any prosthesis
that uses a control cable system to translate volitional muscle
force and shoulder or arm movement to operate a TD or pros­
thetic elbow.34 The patient must use specific strategies in order
to effectively create enough excursion in the cable to control
the TD or preposition the forearm in space. In most instances
the glenohumeral joint contributes the largest amount of
excursion in conventional prosthetic control. Glenohumeral
flexion typically has more than ample excursion and satisfac­
tory power to provide useful motors for this type of control.
Additional excursion can be achieved through scapular and
biscapular abduction (scapular protraction). These secondary
movements allow a well-trained and skilled prosthetic wearer
to increase the functional work envelope, the space in which
the wearer can effectively control the TD.
For most conventional upper-extremity prostheses, the
functional envelope is limited to a relatively small area below
the shoulders, above the waist, and not far outward past shoul­
der width.34 Many prosthetic wearers have significant dif­
ficulty with tasks that involve grasp-and-release tasks above
the head or down near the feet. Because the control strategy
involves generating cable excursion through flexion or pro­
traction, or both, tasks and activities occurring behind the
back are impossible. Despite these functional limitations, con­
ventional prostheses have provided many patients with reli­
able and durable prosthetic systems.
Figure-of-Eight Suspension and Control Cable
The foundation of all conventional body-powered ­prostheses
is a harnessing system that provides both a firm anchor for the
control cables and, in many cases, a stable means of suspen­
sion. Most conventional systems use a figure-of-­eight–style
harness (Figure  30-7). The terminal ends of the figure-of-
eight are formed by means of an axillary loop that is fit over
the opposite shoulder, a control attachment cable, and an
anterior suspension component on the amputated side. Most
prosthetists recommend that the center of the figure-of-eight
be positioned just below the seventh cervical vertebra and
slightly toward the sound side.34 The straps of the two axil­
lary loops can be mobile by means of attachment to a circular
ring or fixed with a sewn cross point. The use of a center ring
often makes the donning process less difficult and appears to
provide the most satisfactory ROM. Harnessing materials are
most frequently constructed of medium weight Dacron web­
bing with both leather and plastic integrated components.
Cable Control for Self-Suspending Sockets
If the prosthetist recommends a self-suspending socket, the
anterior suspension of a figure-of-eight harness is not neces­
sary. In these instances a figure-of-nine harness, consisting
mainly of the contralateral axillary loop, is used to minimize
cumbersome harnessing while still maximizing a firm anchor
for the control cable. Self-suspending sockets may be of an
A
B
C
FIGURE 30-6  Passive prostheses and restorations (A, Courtesy CPS, Branford, CT; B, Courtesy Alternative Prosthetics).
A
B
C
D
FIGURE 30-7  The figure-of-eight harness with posterior ring and
cable control systems used in a conventional (body-powered) trans­
humeral prosthesis includes an anterior suspension loop (A), the
contralateral axillary loop (B), a cable to control locking and unlock­
ing of the elbow mechanism (C), and a cable that will lift the forearm
if the elbow unit is unlocked or operate the terminal device if the
elbow unit is locked (D).

Chapter 30  Prosthetic Options for Persons with Upper-Extremity Amputation
801
anatomically contoured design or that of a flexible silicone
interface, with either a locking or suction valve mechanism.
Control and Suspension for Bilateral Prostheses
For patients with amputation of both upper extremities, care­
ful clinical consideration must be given to achieving an easily
donable and highly functional prosthetic system. Instead of
using a traditional figure-of-eight harness with a contralat­
eral axillary loop for each prosthesis, the two anterior sus­
pension components are linked.35 In this arrangement, the
bilateral prosthetic system is effectively stabilized by the equal
counteracting forces from each prosthesis. On the basis of the
patient's functional needs, the prosthetist may use either a
single- or dual-ring system to maximize the efficiency of the
conventional prostheses (Figure 30-8). The second ring in the
system, mounted below the primary ring, is used ­exclusively
for the control attachment straps. The more proximal ring
is used for the anterior suspensor straps and, for patients
with bilateral transhumeral residual limbs, the connection of
elbow locking straps.
Some patients with bilateral amputations opt to use sep­
arate and completely independent harness systems for their
prostheses, especially if they sometimes wear only one pros­
thesis or if their prostheses are dissimilar. An individual with
bilateral transradial amputations, for example, might elect to
use a conventional cable-driven system on the nondominant
side and a self-suspending externally powered prosthesis on
the dominant residual limb.
Triceps Cuff in Conventional Transradial Prosthesis
Individuals with transradial amputations using a conven­
tional harness suspension control the TD by means of a sin­
gle cable.34 In most instances a triceps cuff is used to secure
the cable housing in an optimal position, as well as provide
an integral link to the forearm section (Figure 30-9). Several
mechanisms of connection are available between the triceps
cuff and the forearm. Flexible Dacron hinges provide satis­
factory suspension and ROM for most midlength transradial
amputations. Steel cable hinges can be substituted in circum­
stances where extremely heavy axial loads can be expected
(i.e., if a wearer must carry or move heavy objects at work).
For those with short and extremely short transradial ampu­
tations, metal hinges provide better medial lateral stability
at the elbow, as well as functional stop at full extension to
­protect the residual limb.
Cable Systems to Control a Prosthetic Elbow
Patients with transhumeral amputations need a dual-cable
system; an anterior cable controls the locking and unlocking
of the elbow mechanism, while the other cable controls the
TD (if the elbow is locked) or moves the prosthetic forearm
(if the elbow is unlocked).36 The second (longer) cable that
FIGURE  30-8  The harness system used for conventional (body-
powered) bilateral transhumeral prostheses includes an upper ring
that stabilizes the prostheses on the trunk and a lower ring that
anchors the cable control systems (Courtesy CPS, Branford, CT).
B
A
A
B
D
C
FIGURE 30-9  Anterior and posterior view of a figure-of-eight harness system for a transradial pros­
thesis, with the axillary loop (A), the anterior support strap that provides stability during a down­
ward pull (B), the attachment strap for cable control of the terminal device (C), and the triceps pad
that anchors the control cable in the most effective position (D). (Modified from the Northwestern
University Printing and Duplicating Department, Evanston, IL, 1987.)

802
Section III  Prostheses in Rehabilitation
attaches to the TD requires a split-cable housing system. The
proximal portion of the housing is attached to the humeral
section, while the distal portion is attached at a location and
height anterior to the elbow center.
Most elbow mechanisms have multiple locking positions
at equally spaced intervals moving from full extension to
flexion. The locking mechanism is most frequently activated
using a rapid and forceful shoulder extension and abduc­
tion (Figure 30-10). When the elbow mechanism is “locked”
in any given position, this quick down and back movement
elongates an anterior cable that releases the lock; subsequent
shoulder flexion or scapular abduction (protraction) ­affecting
the ­posterior cable repositions the prosthetic forearm in space.
This happens because the cable running to the TD is aligned
anterior to the axis of rotation of the elbow mechanism; when
the elbow is unlocked, tension through this cable causes the
forearm to rise in flexion. When the forearm reaches the
desired inclination for the task at hand, another quick down
and back motion will reengage the lock. Once the elbow mech­
anism is locked, cable control is transferred to the TD, and sub­
sequent shoulder flexion or protraction operates the prosthetic
hook or hand. Because this control strategy is always sequential
in nature, careful consideration and assessment must be given
to the force excursion ratio. Failure to maximize these criteria
results in incomplete elbow flexion or incomplete TD control.
Cables and Cable Housings
For both transradial and transhumeral prostheses, the cable
and housings should traverse as straight a path as practical.
An abrupt or sharp radius creates excessive and unnecessary
drag as the cable passes through the housing. The mechanical
efficiency of the system is critical to successful operation, par­
ticularly for those patients with limited strength or ROM.37
Steel cable has been used successfully for many years in pros­
thetic practice. Steel cable is available in several thicknesses
so as to meet the needs of all types of users. Clearly the heavi­
est cables are well suited to heavy-work applications and are
often used for individuals wearing prostheses for both upper
extremities.
Low-friction linings are often added to the interior ­surfaces
of the cable housing to improve the mechanical efficiency.38
This technique effectively decreases the coefficient of fric­
tion of the stainless cable as it passes through the metal cable
housing. Typically, the low-friction linings wear and require
replacement before cable failure.
Recently, nonmetallic cable media with both high strength
and low coefficients of friction became available; these
improve mechanical efficiency and daily wear characteristics
of the prosthetic system.39 When nonmetallic cables are used
with low coefficient linings, the result is often an extremely
smooth and highly efficient cable system. These nonmetallic
cable alternatives are not mechanically swedged to the attach­
ment hardware used at each end of a prosthetic cable system.
Instead, cable connections are made by using highly special­
ized knots that provide a reliable connection with a smooth
profile. Should a nonmetallic cable fail, it is possible for the
wearer (with some assistance) to complete emergency repairs
without returning the facility. Furthermore, nonmetallic
cables do not leave dark residue and stains typically associ­
ated with steel cables.
Although these nonmetallic cables are every bit as strong
as their steel counterparts, one important drawback is that
they do not provide any indication that the cable is nearing
the end of its service life. Conversely, steel cables typically
become rough and begin to drag as the individual strands
of the cable part. Despite this single drawback, nonmetal­
lic cables are strongly recommended in most clinical appli­
cations. Further consideration should be given to provide all
patients with additional backup cables for times when imme­
diate access to prosthetic repair services is not available.
TERMINAL DEVICES FOR CONVENTIONAL
PROSTHESES
The TDs most often used for conventional body-pow­
ered prostheses are either a hook (Figure  30-11) or hand
(Figure 30-12).34,40 Both are available as a voluntary opening
system (the TD is closed at rest, and the wearer opens the
hand by means of the cable) or as a voluntary closing system
(the TD is open at rest, and the wearer closes the hand by
means of the cable). Each configuration has its own inherent
strengths and weaknesses.
Voluntary opening devices enable the wearer to apply
volitional force and excursion of the cable (using shoul­
der flexion or abduction) to open the TD. Once tension is
released from the cable system, the object being grasped
is “trapped” in the device, allowing the wearer to position
the object in space as the task demands. The ­prehensile
A
B
FIGURE 30-10  Dual control cable and lift loop of a conventional
(body-powered) transhumeral prosthesis. Quick and forceful down­
ward and backward shoulder motion operates the elbow locking
and unlocking mechanism via the anterior cable (A). The second
cable system (B) operates the terminal device if the elbow is locked
or lifts the forearm if the elbow is locked. This occurs because the
TD control cable is positioned anterior to the axis of the mechanical
elbow joint. (Modified from Northwestern University Printing and
Duplicating Department, Evanston, IL, 1987.)

Chapter 30  Prosthetic Options for Persons with Upper-Extremity Amputation
803
force (grip strength) is dictated by some external closing
mechanism, most frequently springs or elastic bands (see
Figure 30-11). Significant prehensile forces can be generated
by using multiple layers of elastic bands or multiple springs
but must be matched to the wearer's ability to create and sus­
tain cable excursion. Because grip strength is determined by
the number of elastics or springs used, it is constant and can­
not be voluntarily modified when handling heavy or fragile
objects. The mechanical inefficiency and friction inherent in
a cable control system increase the force necessary to open
the TD above the closing force achieved by the rubber bands
or spring systems. Finding the right combination of external
closing mechanism strength and user's motor control and
excursion for the many different daily functional tasks can be
challenging. Several manufacturers market voluntary open­
ing prehensors with settings the wearer can adjust to light or
forceful grip strength.41
In voluntary closing TDs, the volitional force and excur­
sion supplied by the wearer closes the TD from its normally
open position.42 The key advantage of a voluntary closing
TD is the ability to volitionally grade prehensile force, adapt­
ing it to the characteristics of the object to be held.43 When
a voluntary closing TD is used, significantly higher forces
can be applied through the cabling system. In fact, with most
­voluntarily closing TD and cable systems, voluntary pre­
hensile force is limited only by the motor powers available
from the wearer or by discomfort of the residual limb. In this
­control strategy the patient must maintain both excursion
and power so as to retain the object in the TD.
Voluntary closing devices are not often chosen for indi­
viduals with transhumeral amputations because the lim­
ited cable excursion available to them is also being used to
preposition the forearm in space. Functionally, much of the
cable excursions would be used to close the TD so that less
would be available to move the forearm. Although those
with transhumeral amputation frequently have adequate
motor control to position the forearm in space, many are
quite challenged to produce enough excursion to effectively
operate the elbow throughout full ranges of motion while
maintaining a graded prehension of the TD. These actions
become even more challenging if the residual transhumeral
limb is relatively short. The external passive closure of a
­voluntary opening TD tends to be more functional for these
individuals. Because cable excursion is typically limited for
those with bilateral amputations, voluntary opening devices
are also the TDs of choice if bilateral conventional prosthe­
ses are recommended.
Socket Configurations
The transhumeral and transradial prosthetic sockets used in
contemporary prosthetic practice have evolved from non­
anatomically and functionally based designs to highly con­
toured, skeletally correct and intimately fitting designs.
A significant portion of these anatomically contoured socket
advancements have come as a direct result of changes in
material technology. Until recently, upper-extremity pros­
thetic sockets were fabricated using thermal setting resins
A
B
FIGURE 30-11  A, Various conventional “hooks” are available to
meet the functional needs of individuals using conventional (body-
powered) prostheses. The top row of these voluntary opening
­terminal devices, designed for children, has a “thumb post,” as well
as coated grip surfaces that are held closed by rubber bands at the
base of the hook. Adult hooks are available in a number of configu­
rations to meet the functional and vocational needs of the wearer.
B, Terminal devices have also been designed for occupations that
require stabilizing objects, carrying objects, or holding cylindri­
cal or spherical objects. (A, Courtesy Hosmer Dorrance, Campbell,
CA; B, Courtesy Otto Bock Healthcare, Minneapolis, MN.)

804
Section III  Prostheses in Rehabilitation
for structural integrity and finish. By nature these materials
were hard and did not yield effectively to changes in muscle
contour as the wearer used the limb in functional activities.
With the advent of moldable thermoplastics and advanced
anatomically contoured socket designs, improvements in
intimacy of fit and functional ROM have been achieved.
Most contemporary upper-extremity prosthetic ­sockets use
some type of flexible interface with a rigid frame ­exterior. The
interface material is often composed of a high ­silicone con­
tent elastomer. These elastomers have dramatically improved
patients’ perceptions of fit and function with regard to comfort.
Socket Transradial Self-Suspending Sockets
Many patients with transradial amputations are now fit with
self-suspending sockets that both increase functional ROM
during activity and, more importantly, improve wearer accep­
tance and compliance.6 Highly specialized bone and ­muscle
contour promote effective control in both conventional
body-powered and myoelectrically controlled ­prostheses.
Historically, self-suspending transradial sockets encase the
medial and lateral humeral condyles to provide suspen­
sion.34 The nature of this medial-lateral compression inher­
ently decreased ROM, particularly in terminal flexion. New
designs are becoming less dependent on the condyles and are
using higher anteroposterior forces between the anterior fossa
and olecranon of the elbow to achieve suspension. This strat­
egy increases the wearer's ability to fully extend the elbow.
Advances in Donning Techniques
As the intimacy of socket designs has increased, so has the need
for more effective donning techniques. Historically, ­cotton
stockinettes or elastic bandages were adequate for ­drawing ­tissue
into prosthetic sockets and allowed for satisfactory ­donning.
Because these materials have high coefficient ­friction, they can
be difficult to pull from the socket. High friction also can be
fairly abrasive on the wearer's residual limb. A new generation
of pull socks made of low-friction cloth have been developed ().
Many have coatings impregnated into the cloth during manu­
facture to allow for effective, nonabrasive donning of intimately
contoured prosthetic sockets. With the initial tension as it is first
pulled through the opening in the socket, the pull sock encases
the soft tissue of the residual limb as if it were a cylindrical cone.
As the pull sock is drawn through the opening, it positions the
soft tissue of the residual limb as intended by the contour of the
socket. These donning tools have also enabled some individuals
with bilateral amputations to independently don aggressive self-
suspending sockets.
Advances in Transhumeral Socket Design
Whereas the traditional transhumeral prosthesis had an over-
the-shoulder cap socket design, recent advances in socket
design have resulted in sockets with lateral trim lines below
the acromion process. The additions of anterior and poste­
rior stabilizer extensions that cross toward the midline on the
amputated side provide superior rotational stability.
FIGURE  30-12  Examples of mechanical hands for a conventional (body-powered) prosthesis.
Tension of the cable opens the hand to grasp an object using a mechanical “three jaw chuck” ­grasping
pattern. Release of tension on the cable passively holds an object between the thumb and first two
­digits. To release a held object, the wearer applies tension to the cable once again, to open the mechan­
ical hand. The fourth and fifth fingers are passive and prepositioned in slight flexion but are not part
of the grasp and release function of the mechanical hand.
CASE EXAMPLE 1
An Individual with Traumatic
Transradial Amputation
P. C., 34, sustained a severe crush injury to his left hand,
wrist, and lower forearm when a rock wall he was build­
ing in his backyard collapsed as he was working on it. The
team at the trauma center determined that he was not a
candidate for limb salvage and recommended transradial

Chapter 30  Prosthetic Options for Persons with Upper-Extremity Amputation
805
EXTERNALLY POWERED SYSTEMS
All externally powered systems share a single common
denominator: an electric power cell that provides electri­
cal current to prosthetic components (Figure 30-13).44 Cell
technology has dramatically improved in the past decade.
Traditional technology involved rechargeable nickel cad­
mium batteries that, in addition to environmental concerns
on disposal, are vulnerable to a memory effect. Cell mem­
ory effect occurs when batteries are charged before reaching
a fully discharged state. As batteries incur greater and greater
amounts of memory, the maximal charge the battery accepts
decreases. As maximal charge decreases, so does the maxi­
mal time a patient can expect service from the battery. As a
practical matter, a patient cannot reasonably be expected to
use the battery until full discharge is achieved, and therefore a
rechargeable battery in this state is impractical.
As the medium that promotes electrical charge in pros­
thetic batteries has changed, memory effect has been virtu­
ally eradicated. Batteries made with lithium, lithium ion, have
no memory effect and supply significantly higher amounts of
current, while simultaneously decreasing the weight of the
battery. An active prosthetic user can now use an externally
powered prosthesis more than a full day on a single charge.
Because lithium-based cells are smaller and lighter, they are
also less challenging to “fit” cosmetically into the prosthesis.
Other than having an electric cell, externally powered pros­
theses may have little in common with each other by classifi­
cation. Electric TD componentry is available in many forms,
including hooks, hands, and specially developed work tools.
These tools can be oriented in space using electric rotators that
can substitute effectively for lost pronation and supination.9
Electric and electronic elbow mechanisms are also ­readily
available. These mechanisms provide powered flexion and
extension at the elbow joint (Figure  30-14). Substitution for
internal and external rotation of the shoulder is more difficult.
Most systems integrate a passive friction humeral rotator; this
allows the patient to reposition the distal extremity in the desired
amount of internal or external rotation.10 Although actively pow­
ered humeral rotation has been problematic in terms of design
and function, much research and development is under way.
For patients with exceptionally short transhumeral limbs
and shoulder disarticulation, most prostheses use a mechani­
cal device to replace the shoulder joint that can be passively
prepositioned.45 Electrically actuated locks are available for
clinical use and provide an effective means of locking the
position of the humerus relative to the midline of the body
for individuals with high-level amputations.
DECISION MAKING
The decision process on what input devices will provide con­
trol to externally powered components is a complex one. Full
assessment and evaluation of the available motors, ROMs,
electromyographical signal, signal separation, and limb length
and skin integrity must be considered.46 The choice of input
devices for externally powered devices represents a broad and
amputation. Now it is 8 weeks after the surgery. P. C. has
been consistent with compression of his residual limb and
his upper-­extremity home-exercise program. He is referred
for prescription of a transradial prosthesis. Clinical exami­
nation reveals a well-healed incision, with a skin graft over
the anterior surface of the cubital fossa and residual limb.
Tissue density is relatively firm. Touch and pressure sensa­
tion is slightly diminished in the area of the skin graft. P. C.
can fully extend his elbow but lacks the final 25 degrees of
elbow flexion. He has minimal pronation and supination
ability in his residual limb. Shoulder ROM and strength
are within normal limits. The residual limb measures 16
cm from the lateral epicondyle to the distal end and 12.5
cm from the cubital fold to the distal end.
P. C. is right-hand dominant. He works as a self-employed
building contractor, with a small business focused on home
remodeling. He lives with his wife and three elementary
school–age children in a three-story Victorian home that he
is in the process of rehabilitating. He is an avid water skier in
the summer and downhill skier in the winter. P. C. is appre­
hensive about his ability to return to work and support his
family.
Questions to Consider
• Given the condition and function of his residual limb,
what type of socket and interface might the team might
recommend for P. C. from among available options? Why
would these be the optimal choices? What factors are
likely to influence clinical decision making in this case?
• Given his employment and vocational interests, what
type of suspension and control system might the team
recommend for P. C. from among available options?
Why would these be the optimal choices? Will a conven­
tional cable control system allow P. C. the “work enve­
lope” required for his job as a builder? Given his skin
condition, would a myoelectrically controlled prosthesis
be possible? How would the team determine this?
• Given his employment and vocational interests, what
type of terminal device (or hand) and wrist unit might
the team recommend for P. C.? Why would these be the
optimal choices? What are the benefits and drawbacks
of a “quick disconnect” wrist unit and having activity-
specific TDs?
Recommendations
After much discussion P. C. and the team decide that
a self-suspending transradial prosthesis with a flexible
socket in a rigid frame is most appropriate. Given his role
as a builder and the need to work overhead and have suf­
ficient grip force to hold and manipulate lumber and other
building materials, the team recommends a myoelectri­
cally powered prosthesis with a power wrist control unit
and a Griefer as a terminal device to be used in his work
setting. P. C. inquires whether TDs might be interchange­
able so that he can have a prosthetic hand with a silicone
glove to wear when he is not at work.

806
Section III  Prostheses in Rehabilitation
wide-reaching array of control strategies that allow nearly all
patients the opportunity to successfully control a prosthesis.
The most common and preferred means to control a prosthesis
is with the electromyographic (EMG) signal. This technology
uses the small electrical potentials generated by contraction of
the residual muscles to operate one or more devices. Modern
circuitry and sophisticated filters allow most patients, even
those with small signals, the potential for reasonable control.
MYOELECTRIC CONTROL SYSTEMS
Ideally, the prosthetist tries to identify two independent sig­
nals in a set of physiologically paired (agonist and antago­
nist) muscles. The wearer can activate these signals over a
wide spectrum of contraction intensity to use them as elec­
trode sites. For those with transradial limbs, electrodes are
­typically positioned over flexor muscle residuum in the fore­
arm to control grasp (closing of the TD) and the extensor
muscle residuum to control release (opening of the TD).47
Many patients who, with sufficient training, master indepen­
dent contraction of these muscle groups are candidates for
even more sophisticated control.
The prosthetist selects the most appropriate myoelectrodes
from the many sizes and numerous configurations that are manu­
factured. The prosthetist also chooses electrodes on the basis of
whether they require a remote or nonremote placement of the
preamplification electronics. In selecting the myoelectrode and
­preamplification system, the prosthetist must carefully consider
the location, function, and components (TD, elbow, locking mech­
anism, and rotators) to be used. Because nonremote sensing elec­
trodes house the preamplifier in the bundle of the electrode, less
space is necessary to house electronics in the prosthesis. Placing
the preamplifier close to the electrode, however, increases the risk
that perspiration will disrupt electronic function. Electrode selec­
tion should consider the amount of soft tissue present on the resid­
ual limb, the presence or absence of scar tissue, and the material
medium with which the interface will be constructed.
Many components can interpret large or small, fast or slow
muscular contractions and respond prosthetically in a pro­
portional fashion, linking speed and force of device opera­
tion to speed and amplitude of muscle contraction under the
myoelectrode site.47 This graded control enables a patient to
develop extremely precise speed and grip strength strate­
gies. The well-developed independent control of antagonistic
muscles also is a prerequisite for mode selection, which uses
different types of contraction of the same muscle groups for
dissimilar tasks. Many patients wearing a transradial myoelec­
trical prosthesis use a quick cocontraction of forearm muscle
residuum to switch between control of the hand and the wrist
unit. For those with transhumeral prostheses, quick cocon­
traction of shoulder flexors and extensors is used to switch
between control of the electronic elbow and hand. Effective
mode selection with cocontraction requires a patient to fire
antagonistic muscles above a predetermined ­threshold at
nearly the same instant.47 Many patients find this ­technique
challenging as control training begins. Mode selection is
based on nearly simultaneous timing of contraction of ago­
nistic and antagonistic muscles. Early in training, however,
many new myoelectric prosthetic users focus on forcefulness
of contraction in an effort to increase amplitude of the signal,
rather than on producing the desired quick cocontraction.
FIGURE 30-14  An example of a myoelectrically controlled trans­
humeral prosthesis with electric elbow and hand. The socket brim
has anterior and posterior “wings” to stabilize the prosthesis on the
residual humerus. Myoelectrodes over the residual biceps are used
to flex the elbow or close the hand, while those over the residual
triceps extend the elbow or open the hand. Quick cocontraction of
biceps and triceps will switch control from elbow to hand mode.
(Courtesy Motion Control, Salt Lake City, UT.)
A
B
C
FIGURE 30-13  A, An example of a lithium power cell used in a myoelectric prosthesis. This cell must be fit somewhere
within the prosthesis (B) to power terminal devices and other prosthetic components, on the basis of signals received by the
myoelectrodes (C) embedded in the walls of the socket. (Courtesy Liberating Technologies, Boston, MA.)

Chapter 30  Prosthetic Options for Persons with Upper-Extremity Amputation
807
If a patient struggles or is unable to master cocontraction
mode selection, alternative strategies are always available. The
prosthetist can use programmable controllers to allow com­
plex muscle activity not generally associated with everyday
tasks as the mode selection trigger. Additionally, many systems
allow the user a default mode (usually to the TD) to which the
mode selector reverts after a predetermined time interval.
Programmable microprocessors have had an additional
impact on prosthetic fitting; they allow the prosthetist to
experiment with multiple strategies without having to replace
hardware. Before programmable microprocessors were avail­
able, myoelectric components were secured for individual
patients without the benefit of real-time clinical assessment.
Microprocessor control has allowed the prosthetist to max­
imize the patient's rehabilitation potential within a single
hardware construct. Enormous benefit is also derived from
the ability to save, recover, and manipulate software configu­
rations easily and quickly with immediate patient feedback.
This allows prosthetic users to experiment with a strategy for
control and then progress to alternative strategies with the
luxury of returning to the precise original strategy and set­
tings quickly. Programmable controllers allow individuals
with recent amputations to maximize their current physiolog­
ical control and then progress to significantly more complex
and involved strategies without having to replace components
or relinquishing a prosthesis for modification.
Three basic approaches are used to program the micro­
processor. In the first approach, adjustments to electronics
are made through a direct connection to a laptop or similar
computer using a graphical interface. Wireless interface com­
munication or the implementation of coding plugs enables
efficient assessment and modification of control strategies.
For some individuals with new amputations who are candi­
dates for early postoperative fitting, a myoelectrically con­
trolled TD may be integrated in a rigid dressing immediately
after surgery. The psychological and physiological benefits of
early fitting have been well demonstrated.25
ALTERNATIVE CONTROL STRATEGIES
If effective myoelectric control is too difficult to master for
a patient immediately after amputation surgery (or is inap­
propriate because of cocontraction problems), the prosthetist
may opt to use switch control as an alternative means of oper­
ating electric prosthetic components.48 Switch control does
not require myoelectric sensors against the skin. In addition,
switch control of functional grasp and release can be mas­
tered fairly readily by most new prosthetic users, without the
appreciable training time required for myoelectric ­systems.
Switch control systems require extremely small movement to
­trigger—typically an excursion in millimeters and a force in
fractions of pounds.49 This makes it much more functional
than early postoperative devices with body-powered compo­
nents that required larger cable excursions to operate TD or
lock or unlock the prosthetic elbow. The small excursion and
light force required to engage switch control makes prosthetic
use feasible for individuals with limited ROM or strength. This
technique allows for early intervention with limited exposure
to the stresses on the recently amputated residual limb . It also
allows new users to develop functional grip strength within a
short time. When switches are used to trigger externally pow­
ered prosthetic components, however, proportional control
(graded action where the action of the device is proportional
to the effort made to trigger its ­operation) is not possible.
Several other control systems are available as well. Force
sensitive resistors (FSRs, also called touch pads) have found
great utility as a primary control driver in instances when
other signals are not readily available. FSRs are designed to
interpret surface pressure on the pad and supply a resultant
proportional output. Because these devices are extremely flat
and small in diameter, they are well suited for applications
such as residual limb buds in children with congenital limb
deficiencies. Special consideration must be given, however, to
the location and preparation of sites in which an FSR is to be
used. These devices can become problematic if the base on
which they are placed is not perfectly flat. Even a small radius
can cause the conductive gel inside the sensor to fail. The
location must be placed strategically to allow any perspiration
to settle away from the sensor. Failure to adequately address
this strategic locating of the device may cause the FSR to fail.
In addition to being used in early postoperative fittings,
switches can also be used in definitive prostheses. Although
most switches are activated by pulling a cable or strap, other
applications are activated by depressing a lever or button.
Some switches are complex in nature because they have
numerous functions that are dictated by the position of the
switch. Most switches do not have the capacity to provide pro­
portional output to control electric components. The absence
of proportionality can be viewed as a limiting factor in many
switch control applications.
To achieve true proportionality, a servo-resistor or other
sensing resistor would be necessary. These devices interpret
the travel (excursion) applied to the system and translate this
input quantitatively with predetermined electrical outputs.
These devices can also translate force simultaneously or inde­
pendently with excursion to create a proportional output.
Proportional control of all electrically powered devices
(especially of elbows and the TDs) has enabled patients to
achieve unprecedented levels of fine motor control and speed
variability for skilled activity.50,51 Technology has enabled this
proportional control to further expand the functional enve­
lope of the prosthesis, with higher-speed drive motors and
clutches that allow extremely responsive and rapid control
(Figure 30-15). When proportional control is coupled with
circuitry designed to create and maintain stable prehensile
patterns within the TD, wearers can achieve increasingly
complex and sophisticated tasking patterns.
ELECTRIC TERMINAL DEVICES
Electric TDs are available in many configurations; the most
commonly used is an electric hand (Figure  30-16).52 Most
hands are available in an array of sizes, from those designed
to fit young children (Figure  30-16) with ­congenital limb

808
Section III  Prostheses in Rehabilitation
­deficiencies to those that fit adults with traumatic ­amputations.
Most hands use a “three jaw chuck” ­grasping ­pattern of the
thumb and first two digits. The remaining ­fingers (digits four
and five) follow passively but in a ­similar pattern to the active
first two digits opposing the thumb. Significant grasp pres­
sures can be achieved with most electromechanical hands; in
fact, pressures can be so significant that patients must be cau­
tioned during early training about the amount of force possible.
In myoelectric prostheses with proportional control, maximum
grip strength is achieved with corresponding maximum input
signal generated by forceful muscle contraction. Proportionality
of input signal translates to both the speed of finger movement
and the terminal force applied to the object being grasped. In
a nonproportionally based system (such as simple switch con­
trol), maximum grip strength is achieved on a time-dependent
basis. Recently, circuits have been added to provide slip control.
This allows objects to be retained in the grasp without conscious
control from patient input. Objects of a soft nature can also be
manipulated more effectively without being crushed with such
slip-sensing technology. Excellent cosmesis can be achieved in
these systems with the implementation of a custom sculpted
and painted silicon outer shell (see Figure 30-6, A).
Although hands make up the majority of externally pow­
ered prostheses with TDs, other highly functional TDs
are readily available.52 These devices range from tools that
closely resemble portable vices to terminal hardware that
closely mimics the functional characteristics of an ­electric
hook. As most prostheses include a quick-disconnect option
for the TD, prosthetic wearers can easily change TDs to
suit their functional demands. Many of the non–hand-type
TDs can generate even greater forces than the correspond­
ing hands. The geometries of the opening mechanism allow
these ­alternative tools to easily grasp larger, cylindrical, and
more irregularly shaped objects. The smaller tips of some of
these tools allow patients to grasp smaller and flatter objects
as well. When these alternative TDs are used, there is less
obstruction of the visual field. As a result, many have better
functional efficiency than possible with a prosthetic hand. To
date no system is commercially available that satisfactorily
replicates the lost proprioception and sensation of the fingers
and anatomical hand. The size and location of the visual field
blocked by the palmar surface of the hand and outstretched
mechanical fingers has a significant impact on function.
A
B
C
FIGURE 30-16  Examples of electric terminal devices.
B
A
FIGURE 30-15  A and B, Examples of terminal devices that allow
proportional control of grasp on the basis of muscle contraction
speed at the myoelectrode site or the use of programmable micropro­
cessor controllers. (A, Courtesy Motion Control, Salt Lake City, UT;
B, Courtesy Otto Bock Healthcare, Minneapolis, MN.)

Chapter 30  Prosthetic Options for Persons with Upper-Extremity Amputation
809
Until recently most externally powered hands utilized a
three jaw chuck prehension pattern. In this highly functional
grasp pattern, the active grasp is generated between the thumb
and first two fingers. Patients now can utilize more compliant
hands that have active motion in all five fingers. This advance­
ment permits many prosthetic hand tasks that were previously
impossible to be executed with ease. Generally speaking, the
maximum grip force of a multidexterous or compliant hand
is somewhat lower than the noncompliant hand. The reduced
grip force is offset by the additional surface area and contour
of multiple fingers around an object (see Figure 30-16).
TDs (hands and design tools) with wrist flexion potential
can provide the patient with advantageous approaches for
improved grasp. Wrist flexion also assists, in a small way, in
restoring the visual field when using electromechanical hands.
Electric Elbow Components
A number of externally powered elbow components are
commercially available, but many require that the prosthetist
be specially trained in their implementation and usage.53,54
Each of the commercially available electromechanical elbows
uses proprietary signal processing and drive mechanisms to
achieve design-specific functional attributes. In selecting an
externally powered elbow unit, the prosthetist considers the
specific functional needs of individual patients. The type of
inputs necessary to control the elbow mechanism, the loca­
tion of myoelectrodes, and the number of inputs necessary to
control both the elbow and TD must be weighed in the deci­
sion on what elbow mechanism is most appropriate. Most
commercially available elbow systems incorporate micro­
processors that are compatible with a large array of input
devices and can be programmed to use wrists and TDs from
a large selection of manufacturers. Most prosthetists are no
longer constrained to develop prosthetic recommendations
from a single manufacturer product line; in fact, doing so
often limits possibilities and therefore functional outcome.
Dual-Control Strategies
Microprocessor control has assisted control strategies that can be
better customized to individual patient needs.47 The traditional
control strategy for an individual using an externally powered
transhumeral prosthesis might include one myoelectrode to
capture EMG signals of the residual biceps and a second myo­
electrode over the residual triceps. Assuming both signals are of
satisfactory amplitude and differentiation, successful myoelec­
tric control of two devices—an electrically powered elbow and
an electrically powered TD—can be successfully achieved. To
grasp an object, the patient purposefully contracts the biceps;
an EMG signal from the biceps is programmed to promote
elbow flexion. This physiologically correct application uses
the biceps in a fashion similar to preamputation status. A sig­
nal is provided continuously until the forearm and elbow reach
the desired position in space. The mechanism can be locked
in this position by holding the elbow steady (no longer flex­
ing or extending) through a predetermined (see Figure 30-16)
and programmed time interval. The system then cycles to TD
(hand) control, using the same to EMG inputs. The most
commonly employed combination is contraction of the triceps
to open the hand or extend the elbow and contraction of the
biceps to close the hand or flex the elbow.
Sequential and Simultaneous Control Strategies
Myoelectric control of prosthetic pronation and supination
can be added using an electric wrist rotator.9 Under the con­
straints of a two-electrode system, the rotator is frequently
controlled using a momentary contact switch mounted on
the medial side of the humeral section, where it can be eas­
ily bumped against the body. In this configuration, three
inputs, two EMG and one switch, control forearm posi­
tion in space, pronation, and grasp and release. This type
of control strategy is often referred to as sequential because
one task must be completed before the next is executed (see
Figure 30-16).
Recent developments in microcircuitry and microproces­
sors have made simultaneous control of more than one device
possible. For simultaneous control, the same two myoelec­
trode EMG signals at the biceps and triceps are used. A wrist
rotator and TD are also installed, but the momentary contact
switch that previously controlled wrist position is removed.
Instead, control of pronation and supination is triggered to
the EMG inputs. Patients use their biceps to close the TD and
pronate the prosthetic forearm and use the triceps to open the
TD and supinate the prosthetic forearm. Mode selection, via
cocontraction of the biceps and triceps, determines whether
opening and closing of the TD or pronation and supination
of the forearm will be triggered by subsequent EMG signal.
Many individuals with upper-extremity amputations can
master mode selection using this control strategy.
Simultaneous control of the elbow and TD can now be
accomplished by adding a proportional input to the system.
Great success can be achieved by inserting a linear potentiom­
eter or strain gauge into the harnessing of the transhumeral
prosthesis. As the wearer generates excursion in either humeral
flexion or scapular protraction, the input device translates this
movement or force into a usable signal to control position in
space of the elbow mechanism. This makes both nonsequen­
tial and simultaneous control of the TD and elbow possible.
This is advantageous as a patient can approach an object by
bringing the forearm into the appropriate position while con­
currently opening the hand in preparation for grasp.
The combination of greater TD speeds and long battery life
enables myoelectrically controlled upper-extremity prosthetic
wearers to control multiple devices through ever-increasing
functional planes. They can do so over time durations compat­
ible with most everyday needs. The number of combinations
of myoelectrodes and control strategies becomes limitless as
more manufacturers develop modular componentry that is
compatible with most commercially available systems.
HYBRID PROSTHESES
For some individuals, the integration of technology from both
the conventional and externally powered systems provides the
greatest potential for functional outcome. Prosthetic systems

810
Section III  Prostheses in Rehabilitation
can be configured to use an electrically powered elbow with
a body-powered mechanical TD (Figure 30-17) or an elec­
trically powered TD with a nonpowered elbow. Compelling
arguments can be made for both control ­strategies; the
­ultimate decision for componentry and control systems must
be based on a patient's ability to use proprioceptive feedback
from the cable system, as well as available inputs for the elec­
tromechanical system. Consideration should also be given to
the motivating factors to use a hybrid. Frequently, hybridized
systems are sought because insufficient range or strength is
available to provide complete functional control at the elbow
joint and TD with conventional systems. This may be the
result of a frozen shoulder, an unstable joint that is vulner­
able to frequent subluxation, or shoulder disarticulation
(Figure 30-18). If the musculature in the residual limb can
generate satisfactory EMG signals despite the more proxi­
mal shoulder involvement, then myoelectric control of the
TD can be achieved despite impairments limiting the strong
volitional movements at the shoulder necessary to control a
conventional system. Placement of the forearm in space can
then be assisted using a large variety of spring-assisted or
forearm-balancing mechanical devices. These technologies
allow patients with varying degrees of functional capacity
to be fitted successfully with components from two differ­
ent arenas.
Activity-Specific Prostheses
Most of this chapter's discussions have revolved around func­
tions that relate to activities of daily living and vocational
pursuits. Most individuals with upper-extremity amputations
want to be involved in various pursuits beyond activities of
daily living and vocational activities, just as they were before
their amputations. A number of unique prosthetic applica­
tions, as well as adaptations and assistive tools for an exist­
ing prosthesis, can effectively address the recreational and
avocational desires of individual patients.55 Although con­
ventional wisdom suggests that these pursuits not proceed
until complete maximal rehabilitation has occurred with the
primary prosthetic device, this is not always the case; being
able to return to an important avocational activity might be
a major motivating factor in rehabilitation. However, few
patients have the financial resources for specialized prosthe­
ses for vocational and avocational activities. Most prosthetists
make every attempt to implement activity-specific devices
within the primary prosthetic design. Because the array of
FIGURE 30-18  Example of a hybrid prosthesis designed for an
individual with bilateral shoulder disarticulation as a result of
congenital deficiency. Suspension is provided by a thermoplas­
tic “jacket.” A conventional shoulder joint is used on the right,
while a myoelectric system incorporated on the left controls elbow
motion, forearm rotation, and operation of the terminal device
operation on the left.
FIGURE 30-19  Examples of terminal devices that might be used
for vocational and leisure activities. Passive terminal devices (left)
are often chosen for young children or for individuals involved
in sports that require ball handling. Voluntary closing terminal
devices (right) allow graded prehension for various skilled activities.
(Courtesy TRS.)
FIGURE 30-17  This externally powered elbow and terminal device
configuration includes a myoelectrically controlled elbow and a
cable for body-powered operation of the terminal device.

Chapter 30  Prosthetic Options for Persons with Upper-Extremity Amputation
811
activities in which persons participate is limitless, so too is
the creation of specific tools and adaptations to accommodate
these needs. Quick-disconnect wrists allow for a myriad of
options in place of the existing TD. Commercial application
of TDs can include nearly any imaginable adaptation for sport
and recreational pursuits (Figures 30-19 and 30-20). Specific
challenges such as exposure to the elements, vibration, and
impact may require more significant modification to ensure
acceptable durability to the device.
A
B
C
FIGURE  30-20  Examples of activity- or function-specific termi­
nal devices that can be used in a prosthesis with “quick disconnect”
attachment for the terminal device. A, A variety of kitchen uten­
sils and cooking tools. B, Devices for leisure and sport activities
such as fishing and golf. C, Carpentry and mechanical tools such as
hammers, files, pliers, wrenches, ratchets, and saws. The prosthetic
wearer disconnects the conventional terminal device or prosthetic
hand and attaches the tool temporarily while involved in a given
activity. (Courtesy of Texas Assistive Devices, Brazoria, TX.)
CASE EXAMPLE 2
An Individual with Traumatic
Transhumeral Amputation
E. S., 29, has been employed since high school in main­
tenance and mechanics and is responsible for cleaning
and repairing the presses during the night shift at a paper
manufacturing plant. Six months ago, while cleaning
a press that had been improperly shut down, the sleeve
of his sweatshirt became entangled in a press. His right
arm was drawn into the press almost to the level of the
axilla before his coworker could activate the safety stop
mechanism. The crush and degloving injuries were so
severe that the only option was amputation at a short
transfemoral level. In addition, steady traction on his
arm while being drawn into the press damaged his bra­
chial plexus, and E. S. has significant weakness in residual
muscles controlling his shoulder. His residual arm mea­
sures 14 cm from acromion to distal end. ROM is lim­
ited by 50% in shoulder flexion, extension, and abduction.
For 4 months, he has been wearing a body-powered dual-
cable control prosthesis suspended with a figure-of-eight
harness, including a locking elbow and voluntary open­
ing hook, but is not satisfied with the functional level this
prosthesis allows him. He has developed signs of axillary
compression (sensory impairment) in his intact left upper
extremity. He is referred for evaluation for a myoelectri­
cally controlled prosthesis.
Since the accident, E. S. has been living with his sister
and her family, but he is eager to return to his own home,
a cabin on a lake several hours from the rehabilitation and
prosthetic center where he has been receiving care. He is
seriously considering returning to college to study elec­
trical engineering or material sciences, with the goal of
becoming a prosthetist.
Questions to Consider
• Given the condition and function of his residual limb,
what type of socket and interface might the team rec­
ommend for E. S. from among available options? Why
would these be the optimal choices? What factors are
likely to influence clinical decision making in this case?
• Given his brachial plexus injury and contralateral axil­
lary compression, what type of suspension and control
system might the team recommend for the patient E.
S. from among available options? Why would these be
the optimal choices? How would the team determine if
a myoelectrically controlled prosthesis would be pos­
sible? Should other options for external power also be
considered?
• What type of prosthetic elbow, wrist unit, and terminal
device (or hand) and wrist unit might the team recom­
mend for E. S.? Why would these be the optimal choices?
What are the benefits and drawbacks of each unit?
• How would you apply the ICF framework to E.S.?
Continued

812
Section III  Prostheses in Rehabilitation
SUMMARY
Prosthetic rehabilitation of persons with upper-extremity
amputations is both challenging and rewarding. Success is
often difficult to measure purely in clinical terms; however,
maximizing individual functional potential and providing
the appropriate amount of technology to assure accept­
able outcomes are highly predictive of success. In addition
to understanding the patient's needs, consideration of the
needs and expectations of spouses, children, and extended
family is also important. Once the patient's requirements
are completely understood, careful and thoughtful reha­
bilitation plans can be developed. An effective prosthetic
prescription will detail (a) the power source and control
system (conventional or externally powered) that will oper­
ate prosthetic components, (b) the elbow design (for trans­
humeral or higher amputations), (c) the socket type and
interface medium, (d) the appropriate TD (hook, hand, or
specialized tools), and (e) the alignment of components.
Each of these five categories can be subdivided into addi­
tional criteria-based items, the number of divisions based
upon the complexity of the case and the clinical resources
that are available. Following these guidelines will eliminate
unnecessary difficulties and challenges during the design
process.
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2. Childress DS. Historical aspects of powered-limb prostheses.
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3. Millstein SG, Heger H, Hunter GA. Prosthetic use in adult upper
limb amputees. Prosthet Orthot Int. 1986;10(1):27–34.
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Disabil Stud. 1988;10(2):68–72.
5. Sherman RA. Utilization of prostheses among US veterans
with traumatic amputation: a pilot survey. J Rehabil Res Dev.
1999;36(2):100–108.
6. Atkins DJ, Heard DC, Donovan WH. Epidemiologic overview
of individuals with upper limb loss and their reported research
priorities. J Prosthet Orthot. 1996;8(2):2–11.
7. Vacek KM. Transition to a switch activated 3-S transhumeral
prosthesis: a team approach. J Prosthet Orthot. 1998;10(3):56–60.
8. Daly W. Clinical application of roll-on sleeves for myoelectrically
controlled transradial and transhumeral prostheses. J Prosthet
Orthot. 2000;12(3):88–91.
9. Sears HH, Shaperman J. Electric wrist rotation in proportional
control systems. J Prosthet Orthot. 1998;10(4):92–98.
10. Ivko JJ. Independence through humeral rotation in the con­
ventional transhumeral prosthetic design. J Prosthet Orthot.
1999;11(1):20–22.
11. Michael JW. Partial hand amputations: prosthetic and orthotic
management. In: Bowker JH, Michael JW, eds. Atlas of Limb
Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles.
2nd ed. St. Louis: Mosby-Year Book; 1992:217–226.
12. Weir RF, Grahn EC, Duff SJ. A new externally powered myoelec­
trically controlled prosthesis for persons with partial hand ampu­
tations at the metacarpals. J Prosthet Orthot. 2001;13(2):26–33.
13. Burkhalter WE, Hampton FL, Smeitzer JA. Wrist disarticu­
lation and below elbow amputation. In: American Academy
of Orthopedic Surgeons. Atlas of Limb Prosthetics. St. Louis:
Mosby; 1981:183–191.
14. Fryer CM, Michael JW. Body powered components. In:
Bowker JH, Michael JW, eds. Atlas of Limb Prosthetics.
2nd ed. St. Louis: Mosby; 1992.
15. Fliegel O, Feuer SF. Historical development of lower extremity
prostheses. Arch Phys Med Rehabil. 1966;47(5):275–285.
16. Magee R. Amputation through the ages: the oldest major surgi­
cal operation. Aust N Z J Surg. 1998;69(9):675–678.
17. Wilson AB. History of amputation surgery and prosthetics. In:
Bowker JH, Michael JW, eds. Atlas of Limb Prosthetics: Surgical,
Prosthetic, and Rehabilitation Principles. 2nd ed. St. Louis: Mosby;
1992:3–13.
18. Robinson KP. Historical aspects of amputation. Ann R Coll Surg
Engl. 1991;73(3):134–136.
19. Digest of Data of Persons with Disability; Mathematical Policy
Research. Washington DC: US National Institute on Disability
and Rehabilitation Research; January 1992.
20. Torres MM. Incidence and causes of limb amputations. Phys
Med Rehabil: State Art Rev. 1994;8:1–8.
21. Kay HW, Newman JD. Relative incidences of new amputation.
Orthot Prosthet. 1975;29(2):3–16.
22. Nielsen CC. Issues affecting the future demands for orthotists and
prosthetists. A study prepared for the National Commission on
Orthotic and Prosthetic Education, November 1996.
23. McDonnell PM, Scott RN, McKay LA. Incidence of congeni­
tal upper limb deficiencies. J Assoc Child Prosthet Orthot Clin.
1988;23:8–14.
24. Leonard JA, Meier RH. Prosthetics. In: DeLisa JA, ed.
Rehabilitation Medicine: Principles and Practice. Philadelphia:
Lippincott; 1993:330–345.
25. Malone JM, Flemming LL, Robertson J, et al. Immediate, early,
and late postsurgical management of upper-limb amputation.
J Rehabil Res Dev. 1984;21(1):33–41.
26. Manella KJ. Comparing effectiveness of elastic bandages
and shrinker socks for lower extremity amputees. Phys Ther.
1981;61(3):334–337.
27. Halburt J, Crotty M, Cameron ID. Evidence for the optimal
management of acute and chronic phantom pain: a systematic
review. Clin J Pain. 2002;18(2):84–92.
Recommendations
E. S. has not been able to fully use his initial prosthesis
effectively because of inadequate cable excursion as a con­
sequence of limitations in ROM and strength. His effort
to maximize cable excursion has resulted in compression
injury of his remaining arm, compromising function of
his left hand. The team determines that there is sufficient
myoelectric signal to operate a power elbow, forearm rota­
tor, and TD or hand. They recommend his harness sus­
pension system be replaced with a custom-fit ­shoulder
saddle to avoid further compression in the left axilla.
The prosthesis will have a flexible socket with rigid frame;
electrodes will be incorporated into the walls of the socket.
A linear potentiometer will be used to provide full ROM of
the prosthetic elbow, with simultaneous myoelectric con­
trol of the TD.

Chapter 30  Prosthetic Options for Persons with Upper-Extremity Amputation
813
28. Hunter GA. Amputation surgery of the arm in adults. In:
Murdock G, Wilson AB, eds. Amputation: Surgical Practice and
Patient Management. Oxford, UK: Butterworth-Heinemann;
1996:305–312.
29. Robinson KP. The problem amputation stump. In: Murdock G,
Wilson AB, eds. Amputation: Surgical Practice and Patient Mana­
ge­ment. Oxford, UK: Butterworth-Heinemann; 1996:285–299.
30. Pucher I, Kickinger W, Frischenschlager O. Coping with amputa­
tion and phantom limb pain. J Psychosom Res. 1999;46(4):379–383.
31. Dykes WG. Biomechanics and prosthetics. In: Murdock G, Wilson
AB, eds. Amputation: Surgical Practice and Patient Management.
Oxford, UK: Butterworth-Heinemann; 1996: 334–341.
32. Michael JW. Prosthetic considerations during the growth
period. In: Murdock G, Wilson AB, eds. Amputation: Surgical
Practice and Patient Management. Oxford, UK: Butterworth-
Heinemann; 1996:232–240.
33. Thornby MA, Krebs DE. Bimanual skill development in pediat­
ric below-elbow amputation, a multicenter cross sectional study.
Arch Phys Med Rehabil. 1992;73(8):697–702.
34. Brenner CD. Prosthetic principles: wrist disarticulation and
transradial amputation. In: Bowker JH, Michael JW, eds. Atlas
of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation
Principles. 2nd ed. St. Louis: Mosby-Year Book; 1992:241–251.
35. Miguelez JM. Management of the bilateral upper limb deficient
individual. Retrieved 2001.
36. Smith DJ, Michael JW, Bowker JH, eds. Atlas of Amputation
and Limb Deficiencies. Rosemont, IL: American Academy of
Orthopaedic Surgeons; 2004.
37. Carlson LB, Veatch BD, Frey DD. Technical forum: efficiency of
prosthetic cable and housing. J Prosthet Orthot. 1995;7(3):96–99.
38. Sammons F. The use of low-friction housing liner in upper
extremity prostheses. Bull Prosthet Res. 1983;10(4):77–81.
39. Exparza W, Ivko JJ. Technical note: friction free cable system;
alternative cable system for transhumeral level conventional
prosthesis. J Prosthet Orthot. 1997;9(3):135–136.
40. Billock JN. Upper limb terminal devices: hand versus hooks.
Clin Prosthet Orthot. 19(2):57–65.
41. Frey DD, Carlson LE, Ramaswamy V. Voluntary opening prehen­
sors with adjustable grip force. J Prosthet Orthot. 1995;7(4):124–130.
42. Radocy B. Voluntary closing control: a successful new design
approach to an old concept. Clin Prosthet Orthot. 1986;10(2):
82–86.
43. DeVisser H, Herder JL. Force-directed design of a voluntary
closing hand prosthesis. J Rehabil Res Dev. 2000;37(3):261–271.
44. Heger H, Millstein S, Hunter GA. Electrically powered prosthe­
ses for the adult with an acquired upper limb amputation. J Bone
Joint Surg. 1985;67B:278–281.
45. Miguelez JM. Critical factors in electrically powered upper
extremity prosthetics. J Prosthet Orthot. 2002;14(1):36–38.
46. Sears HH. Approaches to prescription of body powered and
myoelectric prostheses. Phys Med Rehabil Clin N Am. 1991;2(2):
1047–1051.
47. Speigel SR. Adult myoelectric upper limb prosthetic training.
In: Atkins DJ, Meier RH, eds. Comprehensive Management of the
Upper Limb Amputee. New York: Springer-Verlag; 1989.
48. Berbrayer D, Farraday WT. Switch-activated electrically con­
trolled prosthesis following a closed head injury: a case study.
J Prosthet Orthot. 1994;6(2):48–51.
49. Upper limb electronic technology moves forward. O&P Bus
News, December 20-23, 1999.
50. Eledstein JE, Berger N. Performance comparison among chil­
dren fitted with myoelectric and body powered hands. Arch Phys
Med Rehabil. 1993;74(4):376–380.
51. Stein RB, Walley M. Functional comparison of upper extremity
amputees using myoelectric and conventional prostheses. Arch
Phys Med Rehabil. 1983;64(6):243–248.
52. Heckathorne C. Components for adult externally powered sys­
tems. In: Bowker JH, Michael JW, eds. Atlas of Limb Prosthetics.
2nd ed. St. Louis: Mosby-Year Book; 1992:151–174.
53. Sears HH, Andrews JT, Jacobsen SC. Experience with the Utah
arm, hand and terminal device. In: Atkins DK, ed. Comprehensive
Management of the Upper Limb Amputee. New York: Springer
Verlag; 1989:194–210.
54. Williams TW. Use of Boston elbow for high level amputees. In:
Atkins DK, ed. Comprehensive Management of the Upper Limb
Amputee. New York: Springer Verlag; 1989:211–226.
55. Rubin G. Devices enable persons with amputation to participate
in sports. Arch Phys Med Rehabil. 1983;64(1):37–40.

814
31
Rehabilitation for Persons with Upper-Extremity Amputation
Margaret Wise
“Hands can do all kinds of things…change a tire, bake a pie,
fly a kite or catch a fly, plant a seed and help it grow, point
the way for feet to go.…Rough hands, smooth hands, plump
hands, thin hands like wrinkled apple skin. Hands can do
most anything…wear a ring, wear a glove, most important…
hands can love!”1
Edith Baer
REHABILITATION AFTER UPPER-EXTREMITY
AMPUTATION
Human hands are wonderfully complex sensory and motor
organs, capable of interpreting and interacting with the envi­
ronment. The fine manipulative skills and intricate grasp
­patterns of the hand cannot be duplicated. When a hand is lost,
the ability to perform normal daily tasks is greatly changed.
Although a prosthesis cannot duplicate hand function, it can
help substitute for basic grasp in the performance of normal
daily activities and help maintain bilateral hand function.
This chapter discusses the treatment of adults with ampu­
tations, including aspects of acute care, preprosthetic care,
basic prosthetic training, and advanced functional skills
training. Working with patients with upper limb amputa­
tion can be quite rewarding for therapists, who must draw on
manual and orthopedic skills, functional skills for training in
activities of daily living, and counseling skills to respond to
psychosocial needs.
INCIDENCE AND CAUSES OF UPPER-EXTREMITY
AMPUTATION
The primary cause of upper-limb amputations is trauma;
most commonly crush injuries, electrical burns that occur at
work, or, in times of war, traumatic injuries sustained in com­
bat. Congenital anomalies, infections, and tumors are other
causes of amputation. Because upper-extremity amputations
are ­typically occupation related, they primarily occur in young
adults between the ages of 20 and 40 years; the ratio of men to
women is 4:1. Dillingham2 reports approximately 18,500 new
upper-extremity amputations per year. Just fewer than 2000 of
these are at wrist level or higher. The ratio of upper-extremity
amputations to lower-extremity amputations is 1:9.2,3
CLASSIFICATION AND FUNCTIONAL
IMPLICATIONS
The remaining part of the amputated limb is referred to as
the residual limb. The broad categories used to describe ­levels
of upper-extremity amputation include transphalangeal,
metacarpal–phalangeal, transcarpal, wrist disarticulation
(styloid), transradial, elbow disarticulation, transhumeral,
humeral neck, shoulder disarticulation, and intrascapulotho­
racic (Figure 31-1).2–5
Functionally speaking, the more proximal the level of
amputation, the greater the loss of range of motion (ROM)
and strength that results. Of particular importance are the
loss of supination and pronation in amputations approach­
ing the mid-forearm and the loss of shoulder rotation as the
amputation approaches the axillary fold. Although a longer
31
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to do
the following:
1. Compare the roles and goals of rehabilitation in adult pati­
ents with new upper-extremity amputation in the acute,
preprosthetic, initial prosthetic training, and advanced skill
phases of rehabilitation.
2. Identify the key components of examination and evalua­
tion for patients with new upper-extremity amputation in
each of the phases of rehabilitation.
3. Discuss factors, including those in the psychosocial and
affective domains, that influence the prognosis for success­
ful prosthetic training for patients with upper-­extremity
amputation.
4. Suggest an appropriate plan of care for patients with new
amputation in each of the phases of rehabilitation, includ­
ing wound and skin care, pain and edema management,
and strategies to enhance range of motion and strength.
5. Discuss the pros and cons of the six prosthetic options the
team and family consider in prosthetic planning.
6. Identify therapeutic activities and interventions to facili­
tate functional independence in activities of daily living.
7. Explain the process of selection of electrode placement
and functional training for patients with electrically con­
trolled upper extremity prostheses.

Chapter 31  Rehabilitation for Persons with Upper-Extremity Amputation
815
residual limb provides better mechanical advantage for pros­
thetic use, limb length does not always correspond to bet­
ter prosthetic function. The length of the residual limb in an
elbow disarticulation or long transhumeral length amputa­
tion, for example, limits the space available for an electric
elbow unit and affects both cosmesis and function of the
prosthesis.
STAGES OF REHABILITATION
The rehabilitation of individuals with upper-extremity ampu­
tation can be divided into four phases: acute care, prepro­
sthetic rehabilitation, basic prosthetic training, and advanced
functional skills training. Although certain goals and activi­
ties are unique to each phase, the ultimate goal is to enhance
function so that patients with upper-extremity amputation
can return to the activities most important to them.
Acute Care
Often the most pressing issue in the first days to weeks after
traumatic upper-extremity amputation is saving the patient's
life. The patient may return to the operating room sev­
eral times for surgeons to clean the wound or perform revi­
sion surgery. The patient usually has intravenous lines for
antibiotics and pain medications; special infection control
­procedures may also be in place. The patient may not be fully
alert or even have full recollection of what took place the first
weeks after injury.
The initial goals of therapy may be quite basic and must
be modified to be appropriate to the patient's medical
­status. Goals of the acute phase of rehabilitation include the
following:
• To perform a screening evaluation to identify immedi­
ate priorities and help predict eventual outcome.
• To develop rapport with the family and patient.
• To control pain effectively.
• To promote wound healing.
• To establish a strategy for effective edema control.
• To preserve as much passive ROM of the residual limb
as possible.
Screening Evaluation
Even though the patient may not be able to participate fully
during an evaluation, the therapist can begin to gather infor­
mation to guide the early rehabilitation process. Important
facts to discern are the patient's medical status, presence
of associated injuries, wound status, ROM, and whether a
myodesis (when remnants of major muscles are surgically
attached to the bone) or myoplasty (when muscle remnants
of the antagonist muscles are sutured to each other) was per­
formed on major antagonist muscle groups during surgery.
This basic information helps the therapist develop an inter­
vention plan for early care to facilitate further rehabilitation
as the patient's medical status improves.
Rapport
During the acute care stage, when the patient's ­condition
is likely to be quite serious, the family suddenly faces many
difficult issues and often experiences emotional crisis.
Establishing rapport with and providing necessary support
to the family are key elements of the acute care stage. Family
members may be struggling with questions such as, “How did
this happen?” “Why did it happen?” and “What can the future
hold?” The family may be overwhelmed by all the medical
procedures being performed on their loved one. The therapist
should take time to talk with the family, hear their concerns,
and explain the goals for the current stage of rehabilitation as
well as the long-range prognosis. During this period of cri­
sis, neither the family nor the patient is ready to hear details
about all types of prostheses available, but rather may be com­
forted to know that general prosthetic plans are being made
and that the clinical team is working to help achieve a positive
outcome that includes a bright future. Rapport with patients
can be developed as they become more alert.
Pain Control
During this early phase, pain is primarily controlled by
intravenous medication. Strong pain medication may influ­
ence the patient's affect and attitude; the apparent anger and
unwillingness to cooperate shown by patients with trau­
matic amputation may be associated with the pain medica­
tion being used. Effective edema control also contributes to
Intrascapulothoracic
Shoulder disarticulation
Humeral neck
Transhumeral
Elbow disarticulation
Transradial
Wrist disarticulation
Transcarpal
Transmetacarpal
Metacarpal phalangeal
Transphalangeal
FIGURE 31-1  The upper-extremity residual limb is described by the
bony limb segment at which amputation occurred. (Modified, with
permission, from Kottke F, Lehman JF [eds], Krusen's Handbook of
Physical Medicine and Rehabilitation, 4th ed. Philadelphia: Saunders,
1990. p. 1011.)

816
Section III  Prostheses in Rehabilitation
pain ­management. During these first few days, when many
professionals are treating the patient day and night, sleep is
often interrupted. Coordination of schedules with nursing
helps maintain rest periods, which in turn may have a posi­
tive effect on pain management.
Wound Healing
Early wound healing and edema control go hand in hand.
Wound care protocols may vary depending on physician pref­
erence but generally include keeping the wound clean and
dry. If a skin graft has been used to close the wound, the limb
must be positioned to prevent tension over the suture lines
(Figure  31-2). Initial bandage changes may be quite pain­
ful for the patient. During the acute period, some physicians
prescribe pain medications before bandage changes. Unless
contraindicated, a nonadherent dressing such as Xeroform
(Kendall, Mansfield, MA) or Adaptic (Johnson & Johnson,
New Brunswick, NJ) can be used directly over the wound and
then covered with sterile bandages. Soaking adherent areas
with saline can ease removal of the dressing.
Edema Control
Effective edema control helps reduce the chance of adhesion
formation along the healing suture line, aids in wound healing,
and management of pain. Edema may initially be controlled by
bulky bandages and elevation. When the patient is able to tol­
erate pressure, elastic bandages may be applied in a figure-of-
eight style, with gentle compressive pressure over the distal end
that gradually tapers proximally. Ideally, the bandage should
continue up and over one joint proximal to the amputation
(e.g., above the elbow in transradial amputation) (Figures 31-3
and 31-4). Elastic wraps must be frequently checked for proper
placement and compression; close communication with nurses
involved in the patient's care can facilitate this. As wounds heal
and are able to tolerate greater compression, elastic wraps are
replaced with a “shrinker” or a roll-on liner.
FIGURE 31-2  In the days after amputation surgery, the transradial residual limb is wrapped in a
compressive dressing and a slightly elevated position is maintained to manage edema and control
pain. Note the fully extended elbow.
A
B
C
D
FIGURE 31-3  A, To apply a compressive wrap to a transradial residual limb, the patient anchors the
elastic bandage between the elbow and trunk and wraps it around the distal end of the limb. Next, a
series of overlapping figure-of-eight layers of the wrap (B and C) are applied, creating a distal-toward-
proximal pressure gradient. The wrap should continue proximally for several inches above the elbow
joint (D).

Chapter 31  Rehabilitation for Persons with Upper-Extremity Amputation
817
Range of Motion
After injury, patients tend to hold their residual limb in a posi­
tion of comfort; the arm typically adducted toward the body,
the forearm supinated and elbow flexed. Soft-tissue contrac­
tures begin to develop if the limb is consistently held in this
position. In patients with transhumeral amputation, limitations
of shoulder flexion, abduction, and external rotation are likely
to occur. For those with transradial amputation, limitations in
elbow extension and pronation are also likely to develop.
Early passive ROM exercise to gently elongate tissues of
joints most at risk of contracture formation is essential and
can be carefully performed even when intravenous lines
are in place. Passive stretching should be performed slowly
and gently, just to the point where the therapist begins to
feel tension on the muscle or the patient begins to feel pain.
Generally, with acute injuries, performing passive ROM twice
daily is sufficient to increase motion. If, however, progress is
not being made within 2 weeks, the therapist should consider
static splinting as an adjunct to passive ROM.
A
B
C
D
FIGURE 31-4  A, To apply a compressive wrap to a transhumeral residual limb, the patient anchors the
elastic bandage between the chin and clavicle and wraps it over and behind the distal end of the residual
limb. B, Once the initial figure-of-eight layer is applied to anchor the end of the bandage, the patient
continues to apply overlapping layers, creating a distal-toward-proximal pressure gradient. The wrap
continues up and over the shoulder (C), over the anterior chest wall under the contralateral axilla, and
then around the back, over the residual shoulder and under the axilla, before being secured in place (D).
CASE EXAMPLE 1
A Patient with Bilateral Traumatic Amputation
of the Forearm
T. M. is a 17-year-old high school soccer player who
underwent traumatic amputation of his right and left
forearms when the sleeves of his winter jacket became
caught in the blades of a running snow blower that had
jammed, then suddenly released, as he was trying to clear
the mechanism. T. M. was home alone when the acci­
dent occurred and had significant blood loss before he
was able to reach a neighbor's home for assistance. At the
local hospital, tourniquets were placed to control blood
loss, wounds were flushed and cleaned, intravenous fluids
with antibiotics and packed red blood cells were begun,
and morphine was administered. T. M. was prepared for
emergency transfer to the nearest trauma center.
On arrival at the trauma center, he was immediately taken
to surgery for debridement and closure of his wounds. His
parents arrived at the trauma center while he was in surgery.
The right transradial residual limb has 3 inches of radius
and ulna preserved and required a split-thickness skin graft
to close (the donor site was the anterior right thigh). The
left transradial residual limb had 7 inches of radius and ulna
preserved and was closed without skin graft.
Two days have passed since T. M.'s surgery, and he is
recovering in the surgical intensive care unit. His white
blood cell count and temperature are moderately ele­
vated. His residual limbs are in bulky dressings with
elastic compressive wraps, with significant serosanguin­
eous drainage noted at dressing changes. A morphine
pump is being used for pain management. T. M. is cur­
rently receiving supplemental oxygen by nasal cannula
and is sleeping fitfully. On questioning, he is semialert,
oriented to family members and place, but not to oth­
ers or time.
Questions to Consider
• What tests and measures are most appropriate to
include in the screening evaluation at this point in the
acute phase of T. M.'s care? What is the evidence of
reliability and validity of these screening instruments?
How will the information collected guide the develop­
ment of a plan of care for this young man?
• What immediate concerns will T. M.'s parents likely
express? In what ways can the team help establish an
effective relationship with T. M. and his parents in these
early days of care? What information is most important
to help the family cope with this crisis situation and
prepare for the days ahead? How will the rehabilitation
team assess the family's understanding of the situation
and need for emotional support?
Continued

818
Section III  Prostheses in Rehabilitation
Preprosthetic Rehabilitation
In many facilities, only when wound closure has occurred
are patients with new upper-extremity amputation referred
for rehabilitation care. During the preprosthetic therapy
phase, the patient's medical condition is often stable enough
to begin an active role in care. Education of referral sources
about goals of the preprosthetic phase can result in early
referrals.
Goals for preprosthetic rehabilitation include the following:
• Establish good rapport and trust with the patient and
family.
• Complete a comprehensive evaluation to guide
the team in determining an appropriate prosthetic
plan.
• Shape and control volume of the residual limb effectively.
• Minimize adhesive scar tissue.
• Desensitize the limb in preparation for prosthetic wear.
• Achieve full ROM in remaining joints of the residual limb.
• Strengthen the muscles of the residual limb to maxi­
mize potential for effective prosthetic use.
• Provide appropriate intervention for rehabilitation of
associated injuries.
• Help the patient develop some independence in per­
forming basic activities of daily living.
Rapport
In the acute phase of care, when the patient is quite ill, rap­
port is primarily established with family members. These rela­
tionships can help facilitate trust between the therapist and the
patient during the early preprosthetic period. Upper-extremity
amputation is a major traumatic event that affects the family
as well as the patient. As all those involved grapple with the
changes and challenges they are facing, the rehabilitation team
encourages them to express their hopes, concerns, and fears.
Psychological counseling is considered an integral part of
the early rehabilitation program and should be made avail­
able for the family and the patient.6 Some patients may ben­
efit from talking to individuals with amputations of a similar
level. Speaking with peer counselors can be helpful; how­
ever, rehabilitation professions should screen potential peer
counselors carefully. Some individuals who sustained ampu­
tations in previous years might not have had a good rehabili­
tation experience or have not had the benefit of more recent
prosthetic design and components. A professional should be
sure that peer counselors are offering objective and current
information.
Comprehensive Evaluation
Before prosthetic options are discussed, a comprehensive
examination and evaluation is required. In specialized centers
a multidisciplinary team that includes the physical and occu­
pational therapists, a prosthetist, the surgeon or physician, and
a psychologist or counselor completes the examination and
evaluation. In other facilities the therapists and prosthetists
are responsible for completing a comprehensive assessment.
The preprosthetic comprehensive examination begins with
a good history and the gathering of preliminary or background
data, including the following:
• The cause and date of amputation
• Any associated injuries that might influence the reha­
bilitation process
• Hand dominance
• All medications the patient is currently taking
The examination continues with an assessment of the
psychosocial environment as a resource for rehabilitation
and eventual discharge. The therapist assesses the following
patient characteristics:
• The availability of family and other support systems
• Living situation
• Level of education
• Prior occupation and leisure interests
The therapist then considers the condition of the residual
limb, documenting the following:
• The presence and description of any phantom limb
sensation
• The presence and description of any pain the patient is
experiencing
• The length of the residual limb
• The presence of edema, measured by limb circumference
• Skin condition and the presence of scar tissue or soft
tissue adhesion
• Detailed ROM of the residual limb to identify any con­
tractures that may have developed during the acute
care phase
• Evaluation of upper extremity strength
• Evaluation of possible sites for placement of electrodes
for myoelectric control
• What specific intervention strategies should the reha­
bilitation team use to address issues of pain control,
limb volume and edema, and wound healing in the next
2 to 5 days? How should patient and family education
be best integrated with these strategies? How should the
team assess whether these strategies are effective?
• What specific ROM is most important to target for
this young man with a short transradial residual limb
on the right and a long transradial residual limb on the
left, anticipating the need for bilateral prostheses in his
future? Which upper-extremity joints are most at risk
of contracture formation and why? What specific inter­
vention strategies should the therapists initiate to pre­
serve as much functional ROM as possible? How might
pain, medications, and level of consciousness influence
the potential development of soft tissue contractures?
• What postsurgical complications is the team most likely
to be concerned about? What are the warning signs of
these complications? What members of the team are
responsible for monitoring the development of these
complications?
• What influence will immobility and pain have on T. M.'s
ability to learn, endurance and physiological function, and
emotional status during this early phase of rehabilitation?

Chapter 31  Rehabilitation for Persons with Upper-Extremity Amputation
819
The comprehensive examination concludes with a consid­
eration of mobility and functional status, including the fol­
lowing assessments:
• Posture and skeletal alignment as a result of the missing
limb
• Pertinent limitations of the lower extremity
• Postural control (static, anticipatory, and reactionary
balance)
• Current and potential abilities to perform activities of
special interest to the individual, e.g., self-care, work,
leisure activities
If the patient previously used a prosthesis, a prosthetic his­
tory also includes the type of prosthesis used, how long the
prosthesis was worn each day, and how the prosthesis was
used in instrumental and other activities of daily living. The
team should determine the patient's opinions regarding the
positive and negative aspects of a previous prosthesis as well
as any different or additional functions that the patient wants
to achieve.
Edema Control and Limb Shaping
As the patient's medical status improves, bulky bandages are
removed and the patient becomes more mobile. The patient
must continue to use some type of compression on the limb
nearly 24 hours a day, removing it only for wound care and
bathing. At this point, elasticized shrinker socks or a roll-on
liner may replace the elastic figure-of-eight bandages because
they are more convenient and provide more consistent com­
pression (Figure  31-5). For those with transradial residual
limbs, the shrinker should extend at least 2 inches above the
elbow. For those with transhumeral residual limbs, the sock
extends as high as possible on the humerus with a strap going
across the chest to anchor it in place.
As limb volume decreases, the shrinker sock should be
made smaller (leaving the seam on the outside of the sock)
or replaced with a smaller size garment so that it still com­
presses the residual limb. If shrinker socks are not avail­
able or the patient is not yet able to tolerate the compressive
force provided by a shrinker, tubular elastic bandaging, such
as Compressogrip (Knit-Rite, Kansas City, KS) or Tubigrip
(Seton Healthcare Group, Oldham, England), is an alterna­
tive. Typically a double layer of bandage is worn, with the
layer underneath longer and extending 2 inches further prox­
imally than the second layer.
Edema can further be reduced through soft-tissue mobi­
lization and retrograde massage. Soft-tissue mobilization
around areas of adherent tissue through gentle friction mas­
sage helps enhance circulation and increase flexibility. Ending
treatment with retrograde massage with gentle stroking tech­
niques in the direction of lymphatic flow also helps control
edema.7 Heat modalities may be useful as a preparation for
subsequent massage and active exercises.
Elevation, while still important, becomes more difficult to
enforce with a mobile patient. Raising the residual limb over the
head and performing contractions of remaining musculature
at least once an hour during the day also helps control edema
(Figure 31-6). Active participation in self-care and use of the
arm as an assist during functional activities is also helpful.
Management of the Incision and Scar
When the incision lines are adequately closed and sutures have
been removed, scar management becomes a primary concern.
When adherent scar tissue forms, the tissue of the residual
limb does not move freely. Adherent scar tissue near the end
of the bone is a particular problem that may lead to skin break­
down because of friction across the scar when the prosthesis is
worn. Scar tissue adherence can be minimized by active ROM
and gentle friction massage. Circular massage directly over
the incision line, with pressure increasing as tolerated, is also
a way of minimizing adherent scar formation. A slightly sticky
cream or oil, such as pure lanolin or vitamin E oil, is preferred
so the scar can be more easily mobilized over underlying tis­
sue. Silicone gel sheeting can be used under bandages to apply
pressure directly over the scar to deter adherent scar forma­
tion. Kinesio Tex Tape (Bailey Manufacturing, Atlanta, GA)
has also been helpful in softening scar tissue.
Desensitization
Persons with recent amputation often have altered sensation
or dysesthesias, including incisional pain, phantom sensa­
tion, phantom pain, and hypersensitivity. Incisional pain is
treated with pain medications and effective edema control.
Incisional pain typically subsides as the wound heals and
begins to mature and stabilize.
Phantom sensation is a normal phenomenon experienced
by most patients with recent amputation. Patients typically
report that they “feel” all or part of their amputated limbs.
A
B
FIGURE  31-5  An appropriately applied commercially available
transradial (A) and transhumeral (B) elasticized shrinker garment.

820
Section III  Prostheses in Rehabilitation
Some describe a pulling, tingling, or burning sensation in the
missing limb. Most describe the feeling of a tight fist or a tight
band around the arm. Phantom sensation is usually more
annoying than painful. Many patients are hesitant to discuss
these sensations for fear of sounding “crazy.” For this reason,
the likelihood of experiencing phantom sensation should be
discussed with the patient as early in the rehabilitation pro­
cess as possible. As rehabilitation progresses to more motion
and prosthetic use, phantom sensation typically decreases to a
point at which it is not significantly annoying, but it does not
usually disappear entirely.
Phantom pain does not occur in all patients, but when it
does it is extremely problematic. Unlike phantom sensation,
phantom pain is a pathological condition that may persist
long after amputation, hindering functional prosthetic use
and lifestyle. A number of treatments have been suggested,
including heat, desensitization techniques, imagery, mir­
ror therapy, limb revision, and neurosurgery. Effectiveness
of these techniques vary with each patient. Other issues that
may be confused with phantom pain include proximal nerve
damage and neuromas, which may require limb revision or
neurosurgical intervention.8–10
Hypersensitivity is increased sensitivity to stimuli. Light
touch is often particularly uncomfortable for the patient with
a hypersensitive residual limb. Hypersensitivity can be effec­
tively treated with a systematic and structured program that
includes firm massage, various textures stroked on the limb,
submersion of the residual limb in various graded media (e.g.,
dried beans, rice, and popcorn), fluidotherapy, vibration,
transcutaneous electrical nerve stimulation, and increased
functional use of the residual limb during daily activities.11
Enhancing Range of Motion
Having as close to full upper-extremity ROM as possible allows
the patient to use the prosthesis to its full capability. Elbow
flexion contracture and loss of supination and ­pronation are
common occurrences in patients with transradial amputa­
tion. Patients with transhumeral amputation may lose scapula
mobility and all shoulder motions, especially external rotation
and horizontal adduction. Interventions such as heat modali­
ties, soft-tissue mobilization, gentle stretching, and active
ROM exercise can often quickly improve motion in patients
with recently developed tissue tightness and ROM restriction.
Long-term contractures may require static or static progres­
sive splinting or casting and may take longer to resolve.
The possible loss of lower-extremity ROM caused by
immobility and reduced activity during the acute and early
rehabilitative phases of care should also be addressed.
Limitations in lower-extremity range may affect balance and
impede good body mechanics. For those with bilateral upper-
extremity amputation, good balance and lower-extremity
ROM are essential for the performance of most basic and
instrumental activities of daily living.
Strengthening
When the wound has healed and pain is decreasing, strength­
ening is initiated for all muscles of the residual limb and
for major muscle groups of the other extremities. For intact
musculature, initial strengthening may be achieved through
isometric contraction or active motion. The patient usually
quickly progresses to active resistive exercises by using man­
ual resistance, weight cuffs, elastic bands, weight machines,
and functional activities.
Management of Concurrent Injuries and Limitations
Traumatic upper-extremity amputations seldom occur in
isolation. When an upper extremity is caught in a press or
other apparatus, the injured person struggles to get out of the
machine by pulling and twisting and even using other extrem­
ities to extricate the arm from the machine. The patient can
have obvious injuries such as fractures and soft tissue and
muscle damage. Other injuries are often present but are not
A
B
FIGURE 31-6  In the preprosthetic stage of rehabilitation, patients with transradial amputation are
able to take a more active role in their program, such as active ROM (A) and isometric exercise (B),
emphasizing elbow extension as a strategy to minimize risk of elbow flexion contracture.

Chapter 31  Rehabilitation for Persons with Upper-Extremity Amputation
821
obvious on initial investigation. Painful and limiting rotator
cuff injuries of the injured limb or the contralateral shoulder
are not uncommon.
Myofascial trigger points are almost always present.
Travell and Simons12 describe a myofascial trigger point as
a “hyperirritable locus within a taut band of skeletal muscle,
located in the muscular tissue and/or its associated fascia.
The spot is painful on compression and can evoke character­
istic referred pain and autonomic phenomena.” For patients
with upper-extremity amputation, trigger points are often
found bilaterally in the upper trapezius, rhomboid, and teres
minor muscles. Those with transhumeral amputations may
have additional trigger point pain in all three portions of the
deltoid as well as the biceps, and triceps muscles. Individuals
with transradial amputations may have additional trigger
point pain in the wrist and finger flexors or extensors. All
associated injuries must be treated so the patient can more
fully participate in prosthetic training.
Basic Training in Activities of Daily Living
When the dominant hand is amputated, most persons with
unilateral amputation choose to change hand dominance for
activities requiring fine coordination and manipulative skills,
such as writing and eating. Drawing, craft activities, and com­
puter games can all contribute to developing hand coordina­
tion and change of hand dominance.
Patients with an upper-extremity amputation are anxious
to quickly gain as much independence as possible in basic
or survival functional skills such as eating, dressing, and
hygiene. Initially adaptive equipment such as modified uten­
sils, button hooks, and writing adaptations may be needed.
Assuring the patient that most adaptive equipment will not be
needed when they are proficient in prosthetic use helps estab­
lish an expectation that the patient will soon be using two
“hands.” Remaining bimanual is important for ease of perfor­
mance and for minimizing risk of overuse syndrome of the
remaining extremity.
CASE EXAMPLE 2
A Patient with Transhumeral Amputation
R. O. is a 37-year-old automobile mechanic who under­
went a transhumeral amputation of the right upper
extremity 3 weeks ago after he sustained a crush injury
when a car slipped off the jack while he was changing its
tire in a neighbor's driveway, pinning him at the elbow.
While struggling to get out from under the vehicle, he seri­
ously strained his right rotator cuff. At this point, all surgi­
cal drains and sutures have been removed, and the wound
has closed except for a ¼-inch area on the medial, distal
humerus that continues to leave slight signs of clear drain­
age on the nonadherent dressing. R. O. is currently using
a double layer of elasticized Tubigrip (Seton Healthcare
Group, Oldham, England) for volume control. He reports
a sensation of a tight constrictive cuff around his “miss­
ing” right elbow and a somewhat unpredictable shooting
“electric” ­sensation into his missing forearm and hand. He
tends to hold his residual limb diagonally across his lower
chest. R. O. experiences pain in his right shoulder with
movement in all planes.
Active and passive ROM is evaluated with R. O. in the
supine position. Active ROM at the shoulder is currently 0 to
90 degrees of flexion, 0 to 70 degrees of abduction, 0 degrees
of internal rotation, and 0 to 25 degrees of external rotation.
His shoulder and residual limb can be passively moved into
115 degrees of flexion, 90 degrees of abduction, 10 degrees of
internal rotation, and 40 degrees of external rotation.
R. O. is having a difficult time imagining how he will be
able to return to work to support his young family (a wife
and two preschool-age children). He is discouraged and
impatient with his postoperative pain and phantom sensa­
tion. He is reluctant to allow his residual limb to be moved,
passively or with active assistance, toward any end ROM at
the shoulder because of impingement pain. He is discour­
aged with the skill level he has reached in self-care with his
nondominant left upper extremity.
Questions to Consider
• What are R. O.'s most immediate educational and sup­
port needs now that he has begun the early rehabili­
tative, preprosthetic period of care? What strategies
would help strengthen rapport with R. O., help him
understand the next steps in the process, and enhance
his outlook and motivation?
• What tests and measures are most important to use
in the comprehensive examination and evaluation of
R. O.'s residual limb and potential for prosthetic rehabil­
itation? What is the evidence of reliability and validity of
these measures? How will the results of the assessment
influence immediate and long-term therapeutic goals?
• Given the length of his residual limb and the status of
his incision line, what specific strategies for volume
control, edema, and limb shaping should be recom­
mend at this time? How should effectiveness of the
recommended volume control and limb shaping inter­
ventions be assessed? What are the indicators of readi­
ness for prosthetic fitting?
• Given the status of his incision line, what strategies are
now appropriate to reduce likelihood of scar formation
along the incision line? Why is expecting R. O. to be
responsible for this aspect of his care important?
• Given the dysesthesia that R. O. is currently experi­
encing, what interventions might be used to help his
residual limb become less hypersensitive to sensory
stimulation? What is the evidence of efficacy of the
interventions available? Why is addressing dysesthe­
sia important, on both a functional and psychological
level, for patients such as R. O. with recent amputation?
• Given his current level of discomfort and the concur­
rent rotator cuff dysfunction, what contractures are
most likely to develop at R. O.'s shoulder? Considering
Continued

822
Section III  Prostheses in Rehabilitation
Determining a Prosthetic Plan
Comprehensive examination and evaluation by the members
of the multidisciplinary team, which includes physician and
surgeon, therapists, prosthetists, and other team members,
determine prosthetic options that can be discussed with the
patient and family. Factors such as the patient's strength, ROM,
handedness, and other physical and psychological findings,
as well as vocational pursuits and long-term goals, are impor­
tant determinants of an individual prosthetic plan. The patient,
family, and team members decide from the following options:
1. No prosthesis
2. A passive prosthesis to meet the patient's need for
­cosmesis and function
3. A body-powered prosthesis
4. An externally powered prosthesis
5. A hybrid prosthesis (combination body-powered and
externally powered)
6. One or more activity-specific prostheses
The prosthetist and therapist discuss the pros and cons of
the various control schemes available to operate the prosthe­
sis with the patient and family, with the goals of selecting the
control schemes that will allow the patient to become the most
functional. The prosthetist may begin fabrication of the pros­
thesis as the therapist and patient work to achieve important
preprosthetic goals. At this point the patient and family see
more fully the patient-centered team in action. Involvement
of the patient and family from the beginning of the rehabili­
tation process helps the patient accept and participate in the
needed training and eventually accept the prosthesis.
Motions Required to Operate a Body-Powered Prosthesis
If plans are to use a body-powered prosthesis, strengthening
shoulder joint and shoulder girdle musculature in both upper
extremities is important. For maximal use of the prosthesis
with minimum effort, the patient must be able to isolate mus­
cle function with subtle, fluid motion. The patient needs to
be able to perform the following motions, through as large a
ROM as possible:
• Shoulder protraction or biscapular abduction
• Shoulder flexion
• Shoulder depression, extension, and abduction
The additional motions of elbow flexion and extension,
forearm supination and pronation, and shoulder inter­
nal and external rotation should also be strengthened.
Patients with very high levels of amputation or those with
brachial plexus injuries may need to use chest expansion
to operate the prosthesis. Chest expansion involves hav­
ing the patient inhale deeply to expand the chest and then
slowly exhale.
Muscle Requirements for a Hybrid Prosthesis
The hybrid is a common and reliably used prosthesis. It is
operated by a combination of control systems. For example,
a hybrid transhumeral prosthesis may use a body-powered
elbow and forearm lock while using myoelectric control for
the hand or other terminal device. Motions required to oper­
ate a hybrid prosthesis are a combination of those needed for
the body-powered and myoelectric prostheses and require
similar strength and control. The patient, prosthetist, and
therapists work together to determine the most efficient con­
trol scheme for the prosthetic user.
Muscle Requirements for a Myoelectric Prosthesis
When a muscle contracts, it generates an electromyographic
signal. The electromyographic signals produced by contract­
ing muscles can be detected by surface electrodes placed in
the socket of the prosthesis and are used to control mechanical
functions of the prosthesis. Whenever possible, with adults,
two separate muscles are used to operate the ­prosthesis.13 The
therapist is often called on to work with the prosthetist in
selecting the most appropriate electrode sites. For those with
transradial amputation, the sites most often selected are over
the muscle bellies of the wrist flexors and extensors. For those
with transhumeral residual limbs, the most frequently used
sites for electrode placement are over the biceps and triceps.
Selecting Electrode Sites
An optimal electrode site for a myoelectrically controlled
prosthetic component has seven characteristics.13,14
1. The site must be located over superficial muscles, pref­
erably not over heavy adipose tissue or graft sites.
2. The patient must have sufficient muscle strength to
activate the prosthesis without undue fatigue.
3. The sites must use motions reasonable to learn and
relate to normal movement (e.g., wrist extensors for
opening the terminal device [TD] and wrist flexors for
closing the TD).
4. The site must use muscles that the patient can control
independently of other motions.
5. The site must use muscles that, when activated, will not
interfere with, or inhibit, normal activity.
his hopes to return to work as an auto mechanic, what
shoulder motions would be most important to preserve
and enhance in preparation for prosthetic training? What
specific strategies should be used to accomplish this?
• What impact might a rotator cuff injury have on R. O.'s
potential to use a prosthesis successfully? How should
the severity of his rotator cuff impairment be assessed?
What strategies could be used to improve the function of
his shoulder, given the acuity of his rotator cuff injury?
• What types of muscle performance are most important
to address at this point? What strategies should be used
to address strength, power, and control of the various
types of muscle contraction that R. O. will need to use
his prosthesis effectively?
• What basic activities of daily living skills should be
priorities for functional training at this point? What
strategies should be used to enhance motor learning of
skilled activity with his left (nondominant) hand? How
might his residual limb be incorporated during these
functional activities?

Chapter 31  Rehabilitation for Persons with Upper-Extremity Amputation
823
6. If dual control is desired, the sites must use two sets
of muscles that the patient can physiologically contract
together as well as independently of each other.
7. The electrode sites must be able to be contained within
the critical constraints of the socket.
Precise electrode placement makes it easier for a patient
to use a myoelectric prosthesis. The therapist palpates the
most likely spot while the patient contracts the desired
muscle to test for strength and consistency of the contrac­
tion. Once a potential site is located, the skin is cleaned
and moistened with water and a surface electrode is posi­
tioned over the muscle, parallel to the muscle fibers.
The electrode is connected to biofeedback equipment,
such as a Myolab (Motion Control, Salt Lake City, UT)
or the Myoboy (Otto Bock HealthCare, Vienna, Austria)
(Figure 31-7). The strength of the signal can be read from
the meter, and precise electrode placement is adjusted as
necessary. Once the electrode site is determined for one
muscle, the second electrode site is found over the antago­
nist in a similar manner.
Control Site Training
Once the best electrode sites have been located, the patient
must learn to control consistency of muscle contraction. For
effective use of a myoelectrically controlled prosthesis, good
muscle control is more important than overall strength of
contractions. During control site training, the patient should
learn three patterns of muscle activation:
1. To contract one muscle (muscle A, agonist) to a specific
level, while leaving the other (muscle B, antagonist) at
rest or in a quiet state.
2. To contract muscle B to a specific level while leaving
muscle A at rest or in a quiet state.
3. To perform quick and equal cocontractions of muscles
A and B.
Biofeedback equipment, or muscle trainers, greatly facili­
tate this training to master effective, efficient muscle control.
Once patients can consistently produce isolated muscle sig­
nals on command without undue fatigue, they are ready to
proceed with myoelectric prosthetic training.
Basic Prosthetic Training
When the patient receives the prosthesis, the basic prosthetic
training phase of care begins. Goals in basic prosthetic train­
ing include the following:
• To become independent in skin care of the residual limb.
• To increase wearing tolerance of the prosthesis suffi­
ciently for daily functional use.
• To become independent in donning and doffing the
prosthesis.
• To understand the function and operating schemes of
various prosthetic components.
• To develop necessary skills to use and control the pros­
thesis effectively.
Learning to operate the basic controls of a body-powered
prosthesis is, of course, different from learning to operate
a myoelectrically controlled prosthesis. Once basic opera­
tions are mastered, however, training methods of using the
prosthesis are fairly similar. People with bilateral amputa­
tions may even have a different control scheme on each side.
Gaining basic control of one prosthesis at a time is most
often less frustrating for the person than trying to master
both at once.
Skin Care
Most therapists prefer that the patient wear a T-shirt under
the harness of a body-powered prosthesis, in early pros­
thetic training, to prevent skin irritation when learning to
operate the cable system. As skin tolerance develops, the
T-shirt becomes optional. For the externally or myoelec­
trically powered prosthesis, direct contact must be made
between the skin and electrode sites. Regardless of the con­
trol system being used, the residual arm and axilla must
be washed daily with mild soap and water, and the socket
of the prosthesis must be wiped clean with a damp cloth.
The harness should be removed and cleaned as needed.
Patients using a body-powered prosthesis often wear pros­
thetic socks as an interface between the skin and socket
surface. A fresh, clean sock should be used each day; in hot
weather, the sock may need to be changed several times
per day. For those using a myoelectric prosthesis, the elec­
trodes may need to be cleaned several times each day to
ensure effective contact between control site and the elec­
trode. Although skin pliability is important, the application
of moisturizers or lotions before donning the prosthesis is
generally not recommended and is contraindicated with a
myoelectric prosthesis.
New prosthetic users must understand that skin irritation,
if not quickly addressed, may lead to a prolonged period out
of the prosthesis. New users are counseled to notify the phy­
sician, prosthetist, or therapist as soon as any rash, pressure
points, or sign of ­infection is noted.
FIGURE 31-7  Surface electrodes are used to locate potential myo­
electric control sites and provide biofeedback to help patients master
the types of contractions necessary to control actions of the termi­
nal device, wrist unit, and forearm motion and elbow lock (for those
with transhumeral limbs).

824
Section III  Prostheses in Rehabilitation
Wearing Tolerance
In early prosthetic training, the prosthetic wearing period
is typically limited to 30 to 45 minutes at a time. After each
wearing period, the prosthesis is removed and skin condition
carefully examined. Areas of redness (reactive hyperemia)
that persist for more than 20 minutes after the residual limb
is out of the socket may indicate areas of high pressure; the
prosthetist should be consulted for possible modification of
the socket. For those wearing a body-powered prosthesis, the
skin of the sound axilla must also be examined. Until skin
tolerance is developed, padding placed in the axillary region
under the harness may increase comfort and allow longer
wearing time. Wearing time is gradually increased, according
to the patient's tolerance, skin condition, and need for pros­
thesis use.
Donning and Doffing
Full prosthetic use includes independence in donning and
doffing. Both body-powered and myoelectric prostheses can
be donned by either the push-in or pull-in method. Unless a
roll-on liner with pin lock is used, the pull-in method is the
preferred method for several reasons (Figure 31-8). It offers
the advantage of distributing tissue equally in the socket;
equal and consistent tissue placement is especially important
for those using an electrically powered prosthesis. Pulling-in
to the socket is accomplished in the following manner:
1. The patient applies a low-friction sleeve (often made of
parachute-type material) over the residual limb.
2. The distal end of the sleeve is positioned through a
“pull hole” in the wall of the prosthesis.
3. The patient then gently pulls each side of the sleeve,
equally and repeatedly, until the sleeve completely
comes out of the pull hole and the arm is pulled into
the socket.
Alternative methods of donning may be required for
patients with high levels of amputation. Those with very
high bilateral transhumeral amputation may need special
equipment for independence in donning and doffing. Some
­individuals with very high bilateral amputation may decide
that the effort required to don the prostheses independently
is not worth the energy expenditure.
Control of the Body-Powered Prosthesis
In the body-powered prosthesis, forces generated by gross
body motions are translated through the harness and cable sys­
tem to activate the forearm and TD (Figure 31-9). The individ­
ual with transradial amputation only needs to learn to operate
the TD. Any motion that puts tension on the cable operates
the TD (either hook or hand). A body-powered hand is usu­
ally considered passive in nature rather than functional as it
requires a considerable amount of tension on the cable to operate.
In  voluntary-opening TDs, tension on the cable opens the
TD and either rubber bands or springs close the TD. The
addition of rubber bands or springs increases pinch power.
In ­voluntary-closing TDs, the TD remains open until tension is
applied on the cable; then the device closes in proportion to the
amount of tension on the cable.
Control movements to operate the TD for the transradial
prosthesis include shoulder flexion on the sound side, shoul­
der flexion of the amputated side, or biscapular abduction
(shoulder protraction).
Individuals with long transradial limbs typically retain
active forearm supination and pronation; this active move­
ment can be used to position the TD for function. If active
movement is lost or severely limited, the TD must be passively
rotated in the wrist unit. Wrist flexion units are typically oper­
ated manually; the patient changes the angle of the TD with
the opposite hand.
The patient with transhumeral amputation must be able to
control the TD, forearm motion (flexion and extension to lift
and reach), and the elbow locking and unlocking mechanism.
When the elbow component in a transhumeral prosthesis is
locked, the TD operates exactly as the TD in the transradial
prosthesis—by using shoulder flexion or biscapular abduc­
tion. When the elbow component is unlocked, however, ten­
sion on the cable created by these movements causes the
A
B
C
FIGURE 31-8  This patient is donning his myoelectric transradial prosthesis. First, he positions his
pull-in sleeve on the residual limb (A), leaving a distal “tail” that he will thread through the distal
opening in the socket (B). Once his limb is positioned in the socket, he gently tugs the sleeve out
through the opening so that total contact between skin and socket surface is achieved (C).

Chapter 31  Rehabilitation for Persons with Upper-Extremity Amputation
825
forearm of the prosthesis to flex. When tension on the cable
gradually releases (by using eccentric contraction of these
muscles) the elbow returns to extension.
The elbow component of a transhumeral prosthesis is
locked or unlocked with a combination of motions, unlike
the motion used to operate the TD. This motion is simultane­
ous humeral abduction, extension, and depression—a quick,
“move down, and back” motion of the arm. The use of a very
different movement strategy helps ensure that the elbow com­
ponent will not unintentionally unlock during functional
activities with the TD.
To position the TD optimally for the functional task, pas­
sive motion (either with the intact limb or pressure against
a stable surface) is used to rotate the TD in the wrist unit.
Similarly, internal and external rotation of the prosthesis
is passively controlled by rotation at the elbow turntable.
Consider a carpenter wearing a transhumeral prosthesis who
wants to hold a nail steady on a piece of lumber while working
at his bench. First, he might catch his hook on the edge of the
bench and rotate it to a proper position to hold the nail. Then,
with the elbow of his prosthesis unlocked, he uses biscapu­
lar abduction to flex the forearm of his prosthesis into the
desired position to accomplish his task. Finally, he locks the
elbow to hold the forearm in proper position so that he is able
to control opening of the terminal device to grasp the nail.
A new prosthetic user may have to think carefully and per­
form each of these motions deliberately, but an experienced
prosthetic user can perform all these motions fluidly in a mat­
ter of seconds.
Control of the Electric Prosthesis
Electric prostheses can be controlled in a variety of ways.
Depending upon the patient's physical and cognitive presenta­
tion, the prosthetist may choose from surface electrodes, touch
pads, switches, rockers, and other input devices. Myoelectric
control is often used to operate the prosthesis. Control of
the myoelectric prosthesis involves deriving myoelectric sig­
nals from the voluntary contraction of muscles. Surface elec­
trodes implanted in the walls of the prosthetic socket record
electrical signals generated by muscle contraction. These sig­
nals are processed and used to control mechanical functions
of the prosthesis.13 A wide variety of components is available
to prosthetists, providing many types of control schemes. The
therapist must consult with the prosthetists on every patient
regarding the exact controls used so that the best functional
outcome can be achieved. The patient with a long transradial
amputation usually retains control of some supination and
pronation of the forearm. The patient with a shorter forearm
amputation requires a wrist rotation unit to achieve forearm
supination or pronation. Several options exist for control of
wrist and forearm rotation. The wrist unit can be passively
positioned by using the intact hand to position the TD for
task-specific function. Alternately, the wrist rotator can be
myoelectrically controlled.
Although multisite control systems are available, currently
two sites are most commonly used. When using a two-site
control system the individual with a transradial amputation
must switch from hand (or other TD) mode to wrist mode.
One way to accomplish this is for the individual to quickly
and simultaneously contract forearm flexors and extensors.
Once the unit is in wrist mode, contraction of the extensors
rotates the hand in one direction and contraction of the flex­
ors rotates the wrist in the other direction, effectively caus­
ing supination and pronation. When strength of a contraction
signal is weak, control schemes can be altered; muscles with
the most consistently reliable control should operate the func­
tion deemed most important.
Patients with transhumeral myoelectric prostheses have to
manage the additional complexity of controlling the forearm
(for flexion and extension) and the elbow (for lock and unlock
function) as well as the TD and wrist rotator. Commonly used
transhumeral control schemes use contraction of the biceps
FIGURE 31-9  The harness and cable system of a body-powered transradial prosthesis. Glenohumeral
flexion and scapular abduction (protraction) increase tension on the control cable to operate this
­voluntary-opening terminal device during activities performed away from the center of the body.
Bilateral scapular (biscapular) abduction increases cable tension for fine motor activities performed
near the midline or closer to the trunk. The same motion would allow graded prehension in a
­voluntary-closing terminal device. (Modified with permission, from Northwestern University Printing
and Duplicating Department, Evanston, IL, 1987.)

826
Section III  Prostheses in Rehabilitation
and triceps to operate the prosthetic TD and forearm. When
the elbow unit is locked, contraction of one muscle opens the
terminal device. Contraction of the opposite muscle signals
closure of the TD. When the elbow is unlocked, contraction
of the control muscle flexes the forearm. The speed of opera­
tion is matched to the rapidity and strength of the myoelectric
signal generated by muscle contraction. Graded prehension
and elbow motion is possible with practice.
Functional Changes
Engineers have realized the complexity of motions the pros­
thesis must perform for fluid, functional, upper-­extremity
motion. They are working with prosthetists, therapists, and
patients to develop new components, terminal devices, and
control schemes for more functional prostheses. In the past,
most prostheses required the elbow unit to be locked to
operate the TD. In the past 7 to 10 years several manufac­
turers developed transhumeral prosthesis with simultaneous
control of the elbow and hand. These include the Dynamic
Arm by Otto Boch and the Utah Arm-3 by Motion Control.
Both of these prostheses have contributed to a more normal
pattern of use.
New or improved terminal devices have also come on
the market. The Electronic Terminal Device introduced by
Motion Control is water resistant. This has allowed people
greater use of their TD near water at work or at home. The
Electronic Terminal Device, for example, may be used to
wash dishes.
Wrist flexion adds greatly to a person's ability to position
the terminal device for functional activities. It allows better
ergonomic positioning of the upper extremity, affords better
vision, and increases function for many activities. Both lock­
ing and multiflex (by Motion Control) wrists are available.
An exciting development in prosthetic control is targeted
muscle reinnervation. “Targeted muscle reinnervation (TMR)
is a new elective surgery that increases the number of [electro­
myographic] control signals, thus improving the potential for
enhanced prosthetic function.”15 The surgery involves trans­
ferring nerves that previously innervated muscles distal to the
amputation to denervated areas of unused muscles such as
portions of the pectoralis major. These re-innervated muscles
can then provide additional available electromyographic con­
trol sites. Although not commonly seen in practice, “TMR is
now being performed as a clinical device, not just as research
protocol. To date, TMR programs have been developed in six
different centers around the world.”16 A greater number of
electromyographic signals available may translate into simul­
taneous control of the elbow and hand and also power a wrist.
Skills Training
After mastering operation of all individual components, the
next step in training is learning to integrate individual move­
ments into smooth prosthetic operation. Similar training
principles are used whether the control system is body pow­
ered, hybrid, or myoelectric.
Actual skills training for bilateral amputees is similar to
that for unilateral users. The bilateral user, however, requires
more time, effort, and patience. Bilateral training is fur­
ther complicated by lack of sensation and proprioception
in either hand; it takes some time for visual clues and “the
feel of the prosthesis” to begin to compensate for sensation.
The new prosthetic user must learn how to control the ter­
minal device selectively so that it is opened just enough to
grasp the intended object while maintaining just enough ten­
sion on the muscle or cable to hold the object without squeez­
ing it. Practice using different sponges or soft toys give visual
feedback as to grasp pressure. Another fundamental skill to
master is the ability to operate the terminal device at various
heights and in various positions. These positions may include
tasks requiring the elbow to be flexed to 90 degrees while the
arm is held at the side of the body; tasks requiring a forward
or upward (above waist height) motion for grasping, lifting or
carrying; and tasks requiring picking objects up from a lower
surface, such as the floor. Most people find control of the TD
in a stooped position, such as needed for tying shoes, very
difficult.
Practicing how to grasp with the TD pre-positioned pre­
vents unnecessary or awkward movements. Pre-positioning
involves actively or passively turning the TD prior to reaching
for an object. As progress is made in developing simultaneous
controls of the elbow, wrist, and hand, prepositioning of the
TD may become unnecessary.
After learning basic control moves, the patient is ready to
begin incorporating prosthetic use in activities of daily living
which may include:
• Using utensils to eat, cutting food
• Making a sandwich or basic meal
• Opening and closing various types of packages, boxes,
jars, and other containers
• Brushing teeth
• Cleaning and clipping fingernails
• Holding a hairdryer while styling hair
• Bathing with or without assistive devices
• Dressing with or without adaptive equipment
• Fastening a jacket zipper
• Tying shoes
• Toileting
The amount of training and types of adaptive equipment
needed depends largely on the level of amputation, whether
the person has unilateral or bilateral amputations, and if there
are concomitant injuries.
Persons with unilateral amputation, either transradial or
transhumeral, and without other injuries can usually achieve
independence in activities of daily living with the need for
minimal adaptive equipment. Some helpful products include:
• Bath mitts or brushes
• Suction nail brush and clippers
• Suction cutting board with aluminum nails
• Rocker knives
• Tripin or spinner knob
A person with bilateral amputations faces a much greater
challenge to gain independence in activities of daily living.
The patient requires a greater amount of training and often
more adaptive equipment than a person with a unilateral

Chapter 31  Rehabilitation for Persons with Upper-Extremity Amputation
827
amputation. Good balance and core muscle strength, along
with full lower-extremity ROM is helpful in gaining indepen­
dence in activities of daily living.
Self-feeding, dressing, and toileting are especially important to
individuals with bilateral amputations and deserve special atten­
tion. Difficulty in accomplishing these tasks increases with the
level of amputation. It is important that the prosthetist under­
stand motions required to accomplish specific tasks, as pros­
thetic design can make the difference between independence and
dependence in certain tasks. For example, slight radial deviation
of the prosthetic forearm and wrist make self-feeding easier.
Self-Feeding
Activity analysis will show self-feeding to be a complicated
task. For a person with transhumeral amputation this activ­
ity requires shoulder flexion (and or abduction), locking/
unlocking of the elbow, wrist rotation (supination/prona­
tion), wrist positioning, and grasp release of a utensil. Initial
training may require the use of a swivel spork, and be fur­
ther facilitated by turning the hand off while eating to pre­
vent dropping the utensil. With progress, all but the highest
level amputee should be able to grasp and release utensils and
finger food independently. Persons with high transhumeral
or shoulder disarticulation amputations may choose to have
help with eating. Helpful equipment may include:
• Swivel spork
• Rocker knife
• Long straw
• T-handle cup
Self-Dressing
The person with bilateral transradial amputations may ini­
tially require 30 minutes to just don their pants. This is a
very frustrating and seemingly impossible activity. Guidance,
assurance, and talking with persons of similar level of ampu­
tations helps to encourage the patient to work until indepen­
dence is achieved. Most often persons with bilateral transradial
amputations can learn to dress and perform grooming activi­
ties within 30 minutes. This skilled independence may not be
achieved during the initial therapy sessions, but rather on a
return visit 3 to 6 months after initial discharge.
Equipment that may be helpful for dressing include:
• Velcro fastenings
• Various types of button hooks
• Loops sewn inside pants
• Zipper pulls
• Custom-fabricated dressing racks
Although persons with all levels of amputation may
become independent in dressing, no value judgment should
be placed on the individual who chooses to save time and
energy by accepting help from others.
Self-Toileting
Independence in toileting is always one of the first activi­
ties in which patients are interested, but not always easy to
achieve. This activity requires good balance, good ROM,
independence in managing clothing at the toilet, and a will­
ingness to consider alternate ways of task accomplishment.
Although it is not really healthy to do so, many people limit
fluid intake when away from home to limit the need to go to
a public bathroom. Amputees often plan a bowel program to
coincide with showering so that they may clean themselves
in the shower. When possible, a person with bilateral ampu­
tations will choose to use a bidet at home. Alternatively, if a
person has enough ROM, toilet paper can be wrapped around
the terminal device and moved back and forth until clean.
A flushable wet wipe can also be placed on the edge of the toi­
let bowl for the person to move back and forth for cleaning.
Finally, toilet paper or a wet wipe (or if at home, a damp wash­
cloth) can be carefully placed over the heel of the foot with the
foot propped on the toilet seat for similar cleaning.
CASE EXAMPLE 3
A Patient with Bilateral Upper-Extremity
Amputation After Electrocution
E. H. is a 19-year-old college freshman studying to become
a marine biologist. Six months ago, he participated in a
school project on a boat with an instructor and other stu­
dents to measure lake depth and take samples of under­
water plants. The day before, the local power company
had begun stringing power lines that extended over the
edge of the lake and inadvertently left these wires lower
than intended. E. H. was using an aluminum pole to mea­
sure water depth and accidentally touched these live wires
with the pole. He was immediately electrocuted, ren­
dered unconscious, and fell into the water. The other stu­
dents pulled him from the lake and resuscitated him in
approximately 4 minutes. He was medically evacuated to
the trauma center, where he was found to have burns on
both hands and forearms. The entrance wound, where the
electrical current entered his body, was in his right (domi­
nant) hand. The exit wounds were in his left forearm and
thigh. As result of the burns and subsequent tissue dam­
age, amputation was necessary on the right side at the
midtransradial level and on the left at midhumeral level;
he received a skin graft on his left thigh and left arm.
E. H. was hospitalized for 2 months near his home
and then discharged to live with his family (parents and
brother) and receive outpatient therapy. At the time of
discharge, in addition to bilateral upper extremity ROM
limitations, E. H. had severe balance deficits and limited
lower-extremity strength and flexibility bilaterally. He was
completely dependent in activities of daily living.
Three months later he is referred to an outpatient pros­
thetic center for prosthetic fitting and therapy. The goal is
to train him to use his prostheses to become as indepen­
dent as possible, including returning to school to pursue his
career in marine biology. E. H.'s wounds are well healed. His
arms are well contoured, show minimal edema, and have
few adhesions and full ROM. Hip flexion is limited to 85
degrees, extension to neutral. He is able to stand on the right
Continued

828
Section III  Prostheses in Rehabilitation
ADVANCED FUNCTIONAL SKILLS TRAINING
The full understanding of all components and the ability to
operate them to the fullest extent are necessary before dis­
charge from therapy. For example, using the forearm and hand
for fluid reach and grasp and walking with a near-normal arm
swing are important, as is using the prosthesis for indepen­
dence in self-care and basic activities of daily living. For most
people, this is not enough. The person with an amputation
wants to participate in activities having special meaning to
them. These activities may include child care, homemak­
ing, home maintenance, work, sports, and other recreational
activities. To help achieve full independence in instrumental
activities of daily living the prosthetist, therapist, and other
team members must listen to the patient's desires and help
achieve their goals.
SUMMARY
New advances in prosthetics are achieved every year, result­
ing in better socket design, increased comfort, reduced
weight, advanced componentry, and better cosmesis. These
changes have resulted in better patient satisfaction and
increased use. Therapists must help assure that patients are
aware of available prostheses, that the prostheses fit and oper­
ate well, and that the patients receive comprehensive training
by knowledgeable therapists. This chapter presents manage­
ment aspects for the treatment of adults with upper-­extremity
amputation, including acute care, preprosthetic care, basic
prosthetic training, and advanced functional skills training.
The technology available in body powered and myoelectric
prosthetics provides individuals with upper-extremity ampu­
tation the opportunity to become skillful users of prosthetic
devices that enhance function and facilitate participation in
activities of daily living. Rehabilitation professionals work­
ing together can advocate for persons with upper-extremity
amputation to assure that the best rehabilitation outcomes are
achieved.
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• What is the stage of E. H.'s rehabilitation? What tests
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• Are E. H.'s goals of returning to college to study marine
biology realistic? What problems might he face?

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