3. Background
• Upper limb is the prehensile organ for human
beings
• Elbow ROM of 0o-150o provides versatile reach
combining with shoulder and wrist
• Wars have given the most amputees.
• Army has developed most of prosthetics
(www.indianarmy.gov.in/writereaddata/Docu
ments/165.pdf)
4. The level of elbow disarticulation
Advantages
• Permits normal bone
growth in children
• Faster bloodless surgery
• Good suspension
• Good rotational control
• More functional than
transhumeral esp. in
bilateral amputees
• Bilateral cases can use
pencil for writing
Disadvantages
• Poor Cosmesis
• Less durable prosthetic
elbow joints
5. Statistics
• 5 per thousand (1996 USA) cases have Upper
limb amputations
• Men in 15-45 age group
• Amputation of Lower Limb is far more
common than Upper Limb with UL:LL=1:6
• Congenital deficiency of Upper Limb is
commoner than Lower Limb
7. Management
• Conservative - thermal burns/frostbite
• Surgical
– Embolectomy
– Fasciotomy
– Reimplantation of transhumoral limb usually gives
functional elbow but poor hand function
– Amputation
– Allograft (esp. in Blind)
8. Phases of rehabilitation
• Preoperative
• Surgery/reconstruction
• Acute post-surgical
• Pre-prosthetic
• Prosthetic prescription
and fabrication
• Prosthetic training
• Community integration
• Vocational
rehabilitation
• Follow up
9. Evaluation
• ROM and strength of shoulder
• Vitality testing – clinical, Tc99mPyP nuclear
scan
• Manage any proximal bony or soft tissue
injuries
• Avoid multiple surgeries/revision amputation
as it will delay rehabilitation and thus reduce
effective use of prosthesis
10. Surgery
• Tourniquet is useful but contraindicated in
– Cancer
– Infection
• Skin and flaps
– Equal anteroposterior flaps
– Unconventional flaps like forearm extensor flap
may be brought at medial epicondyle (where skin
is thinnest) except in oncological cases
12. Surgery
• Bone
– May reduce epicondylar prominances in moderation
– Do not disturb articular cartilage
• Muscles
– Retain muscles esp. for myoelectric prosthesis
– Myoplasty gives firm residual limb, helps shoulder
control and improved EMG for myoelectric control
– Pectoralis cineplasty was used for elbow control in
past
13. Surgery
• Nerves
– Withdraw, cut sharp and allow to retract in soft tissue.
– Median and Ulnar nerves may be cut at different level
• Blood vessels
– Double ligation of major blood vessels
– Hemostasis and muscle tension managed after
deflating tourniquet
• Drain is essential for
– Hematoma prevention
– Fast wound healing
14. Early prosthetic fitment
• Golden period of 30 days
• Reduces edema
• Facilitates fast healing
• Reduces pain
• Enhances prosthetic use
• Early return to activities esp. two handed
grasping patterns
15. Prosthetic components
• Flat bulbous socket with snug fitting gives good
rotational control and self suspension
• External elbow joints
• Harness is Northwestern figure of 8 type or
shoulder saddle and chest strap
• Control system has 2 cables –
– Elbow lock control on medial prosthetic elbow joint
– Elbow flexion (when elbow is unlocked) cum terminal
device operation (when elbow is locked)
16. Socket
• Leather socket
• Soft insert with
supracondylar wedge
• Window with cover
plate (photo)
• Flexible bladder variant
• Screw in type sockets
(sketch)
19. Harness system
• Standard figure of 8 –
– Operated by non-
amputated side
– Cross point below C7
and slightly toward non-
amputated side
• Shoulder saddle and
chest strap
– Operated by amputated
side
21. Functional restoration
• Comfort fit
• Perceived value
• Follow up
– Adjusting socket to limb volume change
– Mastering functions of the prosthesis
– Re-evaluation and re-design of prosthesis as per
changing needs of patient
