Prosthetic management of individuals with upper extremity amputations presents all health professionals, including prosthetists and therapists, with a set of unique challenges. For those wearing an upper extremity prosthesis, the terminal device (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. 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, upper extremity limb loss deprives the patient of an extensive and valuable system of tactile and proprioceptive inputs that previously provided “feedback” to guide and refine functional movement. Even the simplest tasks related to grasp and release become challenging. The ability to position the 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 prostheses for patients in this population.

1. Upper limb
Prostheses
PRESENTED BY,
DR JOE ANTONY
MBBS,MD(PMR),FCPC,CCEPC
1
ic- Dept of PMR,KGMU,Lucknow

2. Contents
1. Terminal devices
2. Wrist unit
3. Trans radial amputation prosthesis components
4. Elbow disarticulation prosthesis
5. Trans humeral amputation prosthesis components
6. Shoulder disarticulation prosthesis
Any artificial substitute for lost
part of the body is called
prosthesis.
2
Pic- Dept of PMR,KGMU,Lucknow

3. Terminal Devices
The terminal device is usually regarded as the most important component of the upper limb prosthesis
since it provides replacement of the most required function, prehension, or ability to grasp an object
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4. Terminal devices
Most patients require a terminal device for their upper limb prosthesis.
Used in all upper-limb prostheses for amputations at the wrist level and above.
Terminal devices lack sensory feedback and have limited mobility and dexterity.
There are a variety of prosthetic terminal devices available and include
Passive,
Body-powered
Externally powered hooks and hands.
BOARD REVIEW – PMR 4

5. Passive terminal device
Lighter.
Have no functional mechanisms and
provide no grasp
ORTHOTICS AND PROSTHETICS IN REHABILITATION, KEVIN K. CHUI,4TH EDITION
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6. 1. Passive hand
◦ Intended for cosmetic use only.
2. Flexible passive terminal devices
◦ Mitt-shaped terminal devices can fit into a
glove or mitt for sports and other activities.
3. Specialty terminal devices with adapters
for sports equipment, hand tools, or
kitchen utensils
BOARD REVIEW- PMR 6

7. Body powered terminal devices
oProsthetic hands provide a 3-jaw chuck
pinch (3-jaw chuck involves grip with the
thumb, index, and middle fingers).
oHooks provide the equivalent of lateral or tip
pinch.
o In a normal hand, lateral or key grip involves
contact of the pulp of the thumb with the lateral
aspect of the corresponding finger.
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8. Body powered terminal device
VOLUNTARY OPENING
Most common and practical type.
Device maintained in closed position by rubber bands or tension springs.
Amputee uses cable-control harness powered by proximal muscles to open
terminal devices against force of rubber bands or spring.
To grasp, patient releases opened terminal device on an object; rubber bands
or Spring provide prehensile force.
Pinch force is determined by number and type of rubber bands or springs.
Each rubber band provides about 1 pound of pinch force.
To control the amount of prehensile force, the patient must generate a
continued opening force.
VOLUNTARY CLOSING
More physiological function than VO.
Device is maintained in an open position and has to be
closed voluntarily by pulling with the cable on the harness
system to grasp an object.
To release, the patient releases the pull on the harness,
and a spring in the terminal device opens it.
Maximum prehensile force is determined by the strength
of the individual.
Disadvantages: Prolonged prehension requires constant
pull on the harness; terminal device remains awkwardly
open when not in use.
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9. Externally powered terminal
devices
 Controlled by switches or myoelectric
signals and are powered with energy
provided by external batteries.
 Electric-powered terminal device can be
Handlike (e.g., Otto Bock System Electric
Hands or Steeper Electric Hands),
Non-handlike (Otto Bock Greifer Hand,
Hosner NU-VA synergistic prehensor and
Steeper Powered Gripper),
Hook-shaped.
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10. Externally powered terminal
devices
MYOELECTRIC-CONTROLLED TERMINAL
DEVICES
Use surface electrodes placed on the muscles
of the residual limb.
Devices can have a digital or proportional
control system:
Digital control system: On/off system.
Proportional control system: The stronger the
muscle contraction producing the signal, the faster
the action.
MICROSWITCH-CONTROLLED TERMINAL
DEVICES
 Use either a push-button switch or a pull-
switch to activate terminal device.
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11. Prothetic wrist unit
Wrist units are used for attaching terminal devices to prostheses as well as providing pronation
and supination to place the terminal device in its proper position
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12. Prothetic wrist unit
Usually rotation function is passive:
◦ Amputee rotates the terminal device in the wrist unit with his sound hand or by pushing against
a part of the body or other surface to produce either pronation or supination.
◦ Wrist unit also permits interchange of the terminal devices.
Electric wrist rotator units are also available and are generally considered for bilateral upper-
extremity amputees
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13. Types of Wrist units based on
rotation
FRICTION WRISTS
Permit pronation and supination of the
terminal device and hold it in a selected
position by means of friction derived from a
compressed rubber washer or from forces
applied to the stud of the terminal device.
LOCKING WRISTS
Permit manual rotation and then lock the
terminal device in its fixed position.
Advantage: The locking mechanism prevents
inadvertent rotation of the terminal device in
the wrist unit when a heavy object is grasped.
13
Pic- Dept of PMR,KGMU,Lucknow

14. Wrist flexion unit allows terminal device to be in flexed position, facilitating ability to perform
activities close to the body;
◦ Important for bilateral upper-extremity amputees (need flexion for activities of daily living
[ADLs]: Feeding, wiping
◦ If unilateral, upper-extremity amputee can use other hand
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15. Types of wrist units based on
flexion
ADD ON
Add-on is worn between the wrist and the
terminal device and allows manual positioning
of terminal device in either the straight or the
flexed position.
COMBINATION TYPE
Combines a friction wrist and a wrist-flexion
component in one and provides for setting
and locking in one position.
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16. Transradial Amputation Prostheses
In addition to terminal devices and wrist units (discussed previously), a transradial amputee with a body-powered
prosthesis will also need- a Socket Elbow-hinge, Upper arm cuff/pad, and Harness and control system
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17. Sockets
Socket must provide
Comfortable but stable, total-contact interface with
the residual limb
(to avoid inadvertent motion and prevent
uncomfortable concentrations of pressure),
Efficient energy transfer from the residual limb to
the prosthetic device,
Secure suspension,
 Adequate appearance.
To accomplish these goals,
most sockets are double walled with the inner wall
giving total contact fit
Outer wall matching the contour and the length of
the contralateral forearm.
17
Pic- Dept of PMR,KGMU,Lucknow

18. Proximally, socket extends posteriorly to the olecranon and anteriorly to the elbow
crease.
Shorter the residual limb, the closer the trim line to the crease.
Prosthetic socks or a soft interface material may be used to make the socket fit
comfortably and to allow for some accommodation of volume changes.
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19. Transradial sockets
SPLIT SOCKET
Total-contact segment encasing the residual limb and connected by hinges to a separate forearm shell to
which the wrist unit and terminal device are attached.
Used in patients who have very short residual limbs so that special elbow hinges can be used to increase
available joint ROM or to incorporate an elbow-lock mechanism in prosthesis.
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20. Transradial sockets
MUENSTER SOCKET (SELF-SUSPENDED
SOCKET)
socket and forearm are set in a position of initial flexion and the socket encloses the olecranon and the epicondyle of the
humerus.
Intimate residual limb encapsulation, flexion attitude, and high trim lines provide suspension.
Although there is some limitation in the range of flexion extension, this is compensated by pre flexing the socket.
When this type of suspension is used, a figure-9 harness can be used for control purposes only.
With these prostheses the patient can operate the terminal device in common positions and still apply full torque about the
elbow. Although these techniques yield less elbow flexion than the split socket, the reduction in force requirements and the ease
of use more than compensate for this limitation.
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21. Elbow hinges
Transradial amputation prosthesis elbow hinges connect the socket to a cuff on the upper arm
and are important for suspension and stability.
Types,
◦ Flexibile elbow hinge
◦ Rigid elbow hinge
◦ Locking elbow joint
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22. Flexible elbow hinge
Used primarily to suspend the forearm socket.
Permits active pronation and supination of the
forearm.
Used where sufficient voluntary pronation and
supination are available to make it desirable to
maintain these functions: Wrist-disarticulations
and long transradial amputations.
ATLAS OF LIMB PROSTHETICS: SURGICAL, PROSTHETIC, AND REHABILITATION PRINCIPLES. ROSEMONT, IL, AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS, EDITION 2
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23. Rigid elbow hinge
Used in short transradial amputations when normal
elbow flexion is present but there is no voluntary
pronation-supination and more stability is needed.
Types:
• Single axis. (fig A)
• Polycentric. (fig B)
• Step-up design (fig C)—used with split-socket prosthesis, in
very short transradial amputation where flexion is limited.
• By virtue of a gear or double-pivot arrangement, these
hinges permit the residual limb to drive the prosthetic
forearm through an increased ROM.
• Disadvantage is that it takes twice the force (energy cost
doubles) to provide the same amount of flexion as a
single-axis hinge joint.
ATLAS OF LIMB PROSTHETICS: SURGICAL, PROSTHETIC, AND REHABILITATION PRINCIPLES. ROSEMONT, IL, AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS, EDITION 2
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Fig A Fig B
Fig C

24. Locking elbow joint
Used when,
Inadequate strength of the elbow flexors
Inadequate range of elbow flexion
Inability to tolerate the high unit pressure on
the volar surface of the forearm when step-up
hinges are used
ATLAS OF LIMB PROSTHETICS: SURGICAL, PROSTHETIC, AND REHABILITATION PRINCIPLES. ROSEMONT, IL, AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS, EDITION 2
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25. Cuffs and Pads
Except in the Muenster socket, a half-cuff or a triceps pad with an appropriate elbow hinge is
used on the upper arm to connect the socket to the harness and help furnish socket suspension
and stability.
It also serves as an anchor for the cable-control action point. The half-cuff is used in the majority
of short transradial fittings.
The triceps pad is used with long transradial, wrist-disarticulation, and transmetacarpal prostheses
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26. Transradial Harness Suspension
Systems
The functions of the below-elbow harness are to suspend prosthesis from the shoulder so the
socket is held firmly on the residual limb, utilize body motions as sources of power or force, and
transmit this force via a cable system to operate the terminal device.
Types,
Figure 8 harness (O ring harness)
Figure 9 harness
Chest strap with shoulder saddle
26

27. Figure 8 harness
Most commonly used harness. The axilla
loop, worn on the sound side, acts as a
reaction point for the transmission of body
force to the terminal device.
The anterior suspension strap on the
involved side gives additional support for
pulling or lifting, and acts as the attachment
point for the elbow loading strap on a body-
powered above-elbow prosthesis.
27
Pic- Dept of PMR,KGMU,Lucknow

28. Figure 9 harness
Often employed with a self-suspended
transradial socket (e.g., Muenster socket)
that requires a harness only for controlling
the terminal device or for long residual limbs
with suction sockets.
Consists of an axilla loop and a control
attachment strap.
Pros: It is lighter and provides a greater
freedom and comfort by the elimination of
the usual front support strap and triceps pad
or cuff.
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29. Chest strap with shoulder saddle
Chest-strap with shoulder saddle is used if
the patient cannot tolerate the axilla loop.
Also used with those who will be doing
heavy lifting.
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30. Cable control system
Typical control cable system for transmission of power to the prosthesis consists of a flexible,
stranded stainless-steel cable which slides within a flexible housing.
The cable is attached proximally at the harness and distally at the elbow or terminal device.
Types
1. Single control cable system
2. Dual control cable system
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31. Single control cable system(Bowden
cable)
used in the transradial single-control cable system and consists of one cable to transmit body
power for a single purpose—to operate the terminal device.
Consists of a continuous length of flexible housing through which the cable slides.
Housing is fastened by a base plate and retainer to the forearm shell and by a housing crossbar
assembly to the cuff of the triceps pad; these housing retainers also serve as reaction points when
force is applied to the cable.
The muscle movements used to operate the terminal device are forward humeral flexion and
biscapular abduction.
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32. Dual-control cable system (split
cable or fair lead cable system)
Typically used in the transhumeral control-cable system as well as in the very short transradial
split-socket prosthesis with locking hinge.
Consists of one cable with two functions:
◦ Flex the elbow unit when the elbow is unlocked.
◦ Operate the terminal device when the elbow is locked.
The cable is held in place and guided by separate lengths of housing. The pieces of housing are
fastened with retainers at points where the cable must be supported or operated through an angle
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33. Dual-control cable system (split
cable or fair lead cable system)
Since the system must provide force for elbow flexion and operation of the terminal device, two
fair-lead housings are necessary:
◦ The proximal lead, through which the cable slides when the elbow is flexed.
◦ The distal lead, through which the cable slides when the terminal device is operated.
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34. Elbow disarticulation prosthesis
• Variation of a transhumeral prosthesis.
• Socket is flat and broad distally to conform to epicondyles of distal humerus, which provides
self-suspension and allows for internal and external rotation of the humerus.
• Length of residual limb requires use of external elbow joint with cable-operated locking
mechanism.
• Harness and control system the same as for transhumeral prostheses.
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35. Transhumeral prosthesis
In addition to the terminal device and wrist unit, a transhumeral body-powered prosthesis consists
of: Forearm, Elbow unit,an upper arm Socket, and a Harness and control-cable system
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36. Sockets
Usually of double-wall construction, with the inner wall providing a snug, total-contact fit and the
outer shell providing appropriate length and shape.
The lateral socket wall extends to the acromion and the medial socket wall is flattened below the
axilla to help prevent inadvertent socket rotation.
A soft interface material is often used to make the socket fit more comfortably.
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37. Elbow units
When an amputation occurs at or above the elbow joint, elbow function is supplied by the use of
an elbow unit, which provides for elbow flexion and for locking in various degrees of flexion.
Types
External locking elbow
Internal locking elbow
37
Pic- Dept of PMR,KGMU,Lucknow

38. EXTERNAL LOCKING ELBOW
Used with elbow-disarticulations because there
is not enough space for an internal locking
mechanism.
Preferred because of greater mechanical
durability and cosmetically more appealing.
Used in level of amputation 4 cm or more
proximal to the level of the epicondyles.
INTERNAL LOCKING ELBOW
Used with transhumeral and shoulder
prostheses.
Used when the residual limb extends more
distally than 4 cm to the level of the
epicondyles to maintain the elbow joint
center equal to that in the nonamputated
side.
38
Pic- Dept of PMR,KGMU,Lucknow

39. Both types of elbows are flexed by the dual-control cable system and locked at the desired flexion
angle by a separate elbow-lock control cable, which is attached at one end to the elbow
mechanism and at the other end to the anterior suspension strap.
The locking mechanism operates on the alternator principle: Locking and unlocking actions
alternate with each control-cable cycle of tension and relaxation.
For amputees who have difficulty flexing their prosthetic forearm, an accessory in the form of a
spring assist for elbow flexion may be provided for use with the internal elbow.
In transhumeral and shoulder prostheses, passive humeral rotation is accomplished by means of
a turntable between the elbow unit and the upper arm shell or socket.
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40. Transhumeral harness
In addition to suspending the prosthesis from the shoulders, the transhumeral harness must
transmit power to flex the prosthetic forearm, to lock and unlock the elbow unit, and to operate the
terminal device.
The harness designs most frequently used for transhumeral prostheses are modifications of the
basic figure-8 and chest-strap patterns used with transradial prostheses
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41. Body powered control cable
system
As previously mentioned, the dual-control (fair-lead control) cable system is used in the
transhumeral prosthesis to transmit force for two functions:
1. Elbow flexion
2.Terminal device operation
Elbow locking and unlocking are controlled by a second cable, the elbow-lock cable.
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42. BOARD REVIEW- PMR 42

43. Myoelectric control systems
Externally powered systems for below-elbow and above-elbow amputees.
Myoelectric control relies on activation of muscles in the residual limb or proximal segment.
The electrical signal produced by voluntary activation of the residual muscles is detected by
surface electrodes incorporated into the prosthetic socket.
In below-elbow amputees, wrist extensors (extensor carpi radialis longus/brevis and extensor
carpi ulnaris) are used to open the terminal device, and wrist flexors (flexor carpi radialis and
flexor carpi ulnaris) are used to close the terminal device.
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44. In an above-elbow amputee,
Biceps muscle -flex the elbow and close the terminal device,
Triceps muscle - extend the elbow and open the terminal device.
The patient can change back and forth between the terminal device and the elbow control by co-contracting
the biceps and triceps.
With short transhumeral or shoulder amputation, shoulder girdle muscles are used to control elbow function
and terminal device function.
Hybrid control systems may combine body-powered and myoelectric control in the above-elbow or shoulder
prosthesis.
This can reduce the cost, weight, and harnessing of the prosthesis.
Electric switches can also be incorporated into the harness or socket if myoelectric control is not available.
44

45. Body-Powered Versus Myoelectric
Control Systems
BODY POWERED
Advantages: Less expensive, lighter, more
durable, easier to repair, higher sensory
feedback.
Disadvantages: Mechanical appearance,
difficult to use for some people, dependent
on motor strength.
MYOELECTRIC
Advantages: Better cosmesis, less
harnessing, stronger grasp force.
Disadvantages: More expensive, heavier,
decreased durability due to electronic
components and the need for daily
recharging of batteries.
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46. Shoulder Prostheses
All shoulder prostheses consist of a terminal device, wrist unit, forearm section, elbow unit,
humeral and shoulder sections, harness, and control cable system.
• Terminal device, wrist unit, forearm section, and elbow units are identical to those used in
transhumeral prostheses.
• The shoulder section includes a socket, which provides:
◦ Comfortable, stable bearing on the residual shoulder elements and thorax.
◦ Means of utilizing remaining shoulder girdle mobility for control of the prosthesis.
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47. Thank you
References
-Board review – PMR
-Orthotics and Prosthetics in Rehabilitation, Kevin K. Chui,4th
edition
-Atlas of Limb Prosthetics: Surgical, Prosthetic, and
Rehabilitation Principles. Rosemont, IL, American Academy of
Orthopedic Surgeons, edition 2
• Dr. Ganesh Yadav, Associate
professor,PMR, KGMU
• Dr. Snigdha Mishra, SR,
PMR,KGMU
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