Download - Transhumeral amputation
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TRANSHUMERAL AMPUTATION
Case PresentationChua. Joaquin
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Patient data
23/M Left-handed 24-April-198 Single Filipino Roman Catholic Ilocos
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Chief complaint
For pre-prosthetic training
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History of Present Illness
industrial accident in Laguna While reaching for an
object under a machine, molding, fell, crushing the upper arm
Reaching about an inch away from the countertop
4 months PTC
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(+) Loss of sensation (+) Loss of ability to
move “Broken bones” (+) profuse bleeding
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Brought to Laguna hospital X-ray evaluation Anti-tetanus given Dressing done ambulance
conduction to POC (+) intense pain
10/10
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AT POC Evaluation of limb viability Prepared for surgery
(NPO) Blood transfusion
intraoperatively
Discharged after 10 hospital days Co-amoxiclav 500/125mg
BID, compliant
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Patient would come in for consults, however no rehab was initiated due to lack of funds Patient was
advised prosthesis
Scheduled for rehab
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Closed wound, no dehiscence
No fever No erythema No pain on the
residual limb No perception of
pain on the amputated limb
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Past Medical
No previous hospitalization No previous surgeries Unrecalled childhood immunization No known allergy No known co-morbidities
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Family history
No known heredo-familial illnesses
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Personal Social
5th child among 6 boys temporarily residing in a boarding
house Laguna with aunt’s family Vocational course graduate
Seafarer rating certificate course
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Previously working as a trimmer, car spare parts manufacturing company for 2 months(at the time of the accident) Company pledges to cover majority of
the expenses Job placement post-therapy
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Functionality
Prior to accident: Patient was independent on all self-
care activities, with no difficulty Patient was also capable of IADL –
laundry, grocery, meal preparation
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After the amputation: Patient is still independent on all self-
care activities but claims to take longer dressing up, bathing, and pouring water on a cup
Patient is learning how to adjust on IADL
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Review of systems
No fever, changes in weight No cough and colds, dyspnea No chest pain, palpitations No changes in bowel movement No changes in urination
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Physical examination
HR 80 RR 18 Afebrile Not in pain Patient is medium-built
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Skin: no active lesions Head and Neck: anicteric sclerae,
pink palpebral conjunctiva, (-) TPC, (-) CLAD
Chest: symmetric chest expansion, clear breath sounds, no rales, no wheezes
Heart: adynamic precordium, normal rate and rhythm, good S1 and S2, no murmurs
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Abdomen: flat, tympanitic, soft, non-tender
Genitourinary : not examined Musculoskeletal:
(+) amputated above the elbow , right (-) erythema closed wound and dry
Neuro: GCS 15 CN intact
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MMT and Sensory Sensory 100% L and 100% R Motor testing:
Lower extremity (hip, knee, plantar and dorsiflexion)L 5/5 R 5/5
Shoulder flexion and extension L 5/5 R 5/5
Elbow flexions and extension L 5/5 R --
Wrist flexion and extensionL 5/5 R --
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Assessment
S/P transhumeral amputation, right secondary to industrial accident
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REHABILITATION
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Amputation
Preoperative: Counseling Level of amputation
RULE: Save as much of the limb as possible
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Levels of amputation: Upper limb
Transphalangeal Transmetacarpal Transcarpal Wrist disarticulation Transradial Elbow disarticulation Transhumeral Shoulder disarticulation forequarter
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Amputee Rehabilitation (Upper limb) Preamputation counseling Amputation surgery Acute post amputation period
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Post operative mgt. Prevent edema Prevent contracture Prevent pressure sores Decrease hypersensitivity Maintain strength
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UPPER EXTREMITY PROSTHESIS
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Prosthesis
Several factors crucial when designing and optimizing transhumeral prostheses Length of the bony lever arm Quality and nature of soft tissue
coverage Shape and muscle tone of the residual
limb Flexibility, range of motion, and stability
of the proximal joints
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Prosthesis
Other factors Expected function of the prosthesis Cognitive function of the patient Vocation of the patient
Desk job vs. manual labor Avocational interests
Hobbies Cosmetic importance of the prosthesis Financial resources of the patient
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In the transhumeral case, if the adult humerus is transected 10 cm (4 inches) above the olecranon tip, all available elbow options can be utilized successfully, including external power.
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Leverage for prosthetic control varies directly with the length of the humerus.
As humeral length decreases, both leverage and power decrease significantly.
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Soft tissue coverage also affects prosthetic function since painful, adherent scarring may limit the force that the amputee can comfortably generate.
Conversely, too much tissue makes donning the prosthesis more difficult and often compromises prosthetic humeral length and cosmesis.
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Amputation in the proximal third of the humerus (proximal to the deltoid insertion) is particularly challenging prosthetically.
Primary control is by scapular motion with assistance from the humerus.
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Due to the obvious reduction in strength and leverage at this level, conventional cable-powered prosthetic control is severely limited.
Since the average adult transhumeral amputee can achieve no more than 2 ½ to 3 in. of excursion when using biscapular abduction, externally powered components are usually necessary for full function.
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TYPE PROS CONSCosmetic Most lightweight
Best cosmesisLess harnessing
High cost if custom-madeLeast functionLow-cost glove stains easily
Body powered Moderate costModerately lightweightMost durableHighest sensory feedbackVariety of prehensors available for various activities
Most body movement needed to operateMost harnessingLeast satisfactory appearanceIncreased energy expenditure
Battery powered (myoelectric and/or switch controlled)
Moderate or no harnessingLeast body movement needed to operateModerate cosmesisMore function- proximal areasStronger grasp in some cases
HeaviestMost expensiveMost maintenanceLimited sensory feedbackExtended therapy time for training
Hybrid (cable to elbow or TD and battery powered)
All-cable excursion to elbow or terminal device
Battery-powered terminal device weighs forearm (harder to lift but good for elbow disarticulation or long transhumeral amputation)
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Myoelectric vs. Switch
Myoelectrically controlled prosthesis Uses muscle
contractions as a signal to activate the prosthesis
Functions by detecting electrical activity from select residual limb muscles, with surface electrodes used to control electric motors
Switch-controlled prosthesis Utilize small switches rather
than muscle signals to operate the electric motors
Switch activated by movement of a remnant digit or part of a bony prominence against the switch or by a pull on the suspension harness
Good option to provide control for ext. power when myoelectric control sites are not available or when the patient cannot master myoelectric control
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Components of a Body-Powered Prosthesis
Socket Suspension Control-cable system Terminal Device
Precision grip Tripod grip Lateral grip Hook power grip Spherical grip
Components for ay interposing joints as needed according to the level of amputation
A transhumeral prosthesis also includes an internal-locking elbow with a a turntable for the missing anatomic elbow, uses a dual-control cable system and does not require a triceps cuff.
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Preparatory vs Definitive Prosthesis
Preparatory Fitted while the residual limb is still
maturing Allows the patient to train with the
prosthesis several months earlier in the process
Use often results in a better fit for the final prosthesis, because the preparatory socket can be used to mold the residual limb into the desired shape
Definitive
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Follow-Up Most important aspect of prosthetic
rehabilitation and yet may be the most often neglected
3 important tasks during the period following prosthetic fitting Maintenance of socket fit, suspension and comfort
despite limb volume changes Monitoring to ensure that the patient fully
understands and masters the functions of his prosthesis in his home and work environment
Re-evaluation of socket style, harness design and component selection based on amputee experience
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Follow-Up Successful long-term use of an upper
limb prosthesis depends primarily on its comfort and its perceived value to the amputee.
Innovative design and careful custom adaptation of socket and harness principles, careful attention to follow-up adjustments and prescription revisions based on the amputees changing needs are the essential factors for successful prosthetic rehabilitation.