Some Experience in Harnessing Extreme Arm Cases
Craig L. Taylor, Ph. D. *
With recent developments in shoulder
prostheses, including that for complete removal of the shoulder girdle, it is
possible to fit all upper-extremity amputees with useful arm substitutes. But of
course it does not follow that all patients with high amputations can obtain
from the available harnessing resources a uniformly good level of prosthetic
function. It is appropriate to review present experience with such cases in
order to establish realistic guides for the fitter. Although there is only a
limited number of upper-extremity amputees with multiple amputations or with
amputations at very high levels, the UCLA Case Study has accumulated
a sufficient number to make tentative conclusions possible.
Limitation in the potentialities of
shoulder harness begins with the unilateral shoulder case of the disarticulation
type. Unilateral humeral-neck amputees with an intact shoulder girdle have, in
every case known, been able to manage the shoulder dual control, and with any of
several elbow-lock arrangements they have been able to carry out all of the
operations of the prosthesis. Further unilateral shoulder losses, or losses of
both shoulders at various levels, entail such impairment of harnessable shoulder
mobility that it is impossible to attain the operating effectiveness ordinarily
to be expected from the major prosthetic controls. A review of several types of
fittings and the results obtained indicates the nature of these
limitations.
Unilateral Shoulder Amputees
In the unilateral shoulder amputee,
limitation begins with the disarticulation because the leverage on the amputated
side is then so reduced that biscapular shrug no longer gives the necessary
excursion. With most men of average to large build, however, the results usually
are satisfactory (Table 1). In the case of M.W., pelvic control was required.
T.M., a large and broad-shouldered man, obtained good function despite large,
but not complete, clavicle and scapula losses. With the fore-quarter case, P.H.,
the sound shoulder could not manage the full control, and the functional regain
was decidedly marginal.
Bilateral Above-Elbow/Shoulder
Combinations
No case of bilateral humeral-neck
amputation has thus far come to notice, but the bilateral above-elbow/shoulder
combination is comparatively frequent. Five cases of this type can be cited. All
save one are at least moderately successful. The unsuccessful case, C.B., has a
number of stump complications that have prevented a satisfactory result.
Otherwise, good operation, one prosthesis at a time, is provided by harnessing
modifications in which the elements of the shoulder-disarticulation harness from
one side and of the figure-eight from the other are combined. It should be noted
that in all these cases both shoulder girdles are intact, and there is in
addition one humeral stump. Hence, shrug and arm-flexion controls can be managed
normally.
The first case of this type, L.S., is a
young man, age 29, with a right above-elbow stump of 10 in. and a humeral-neck
amputation on the left side. The musculature and mobility of both shoulders and of the right stump
are good. Amputee L.S. is tall and slender but of moderately broad-shouldered
build. He is fitted on the right with an above-elbow dual control, on the left
with a modified shoulder-disarticulation harness with nudge control for elbow
lock. He is rated as a good wearer and is independent in nearly all
activities.
The second case, C.B., is an elderly man,
age 60. He has a right shoulder disarticulation and a left short humeral stump
supplemented with a tibial graft. Neuromata in the shoulder area and tenderness
about the tibial graft have made fitting difficult; trial fittings with numerous
types of harness have not been successful. The age of the subject, recurrent
shoulder pain, and habits of dependence have together prevented satisfactory
results.
Another case, M.C., is a young woman, age
36, with a right short above-elbow and a left humeral-neck stump, the latter
supplemented with a tibial graft not yet ready for fitting. Meanwhile, amputee
M.C. is operating well with the right prosthesis only. She has acquired skill in
eating, drives a car, does housework, and is rated a good wearer generally.
Future addition of the left prosthesis is uncertain.
Amputee R.G. is a young man, age 31, with
a right short above-elbow and a left humeralneck amputation. He is tall and rangy
with broad shoulders. Bilateral pectoral muscle tunnels had been constructed,
but they were eventually closed at the amputee's request. When last seen he was
fitted with short above-elbow dual control on the right side and
shoul-der-disarticulation dual control on the left. For a while the left elbow
lock was operated by the pectoral tunnel, but the method of elbow-lock operation
after removal of the tunnel is unknown. Over several years of observation this
amputee was rated as a moderately good wearer and was independent in most
personal activities.
Finally, J.L. is a man, age 40, with a
right above-elbow stump 9 in. long and a left amputation at the humeral neck. Of
fairly tall and rangy body build with good shoulder and stump mobility, he was
fitted with a right above-elbow dual control and a left basic
shoulder-disarticulation harness, the left elbow lock being operated by a nudge
control After fitting and training he attained a good level of performance and
as far as is known continues to be a good wearer.
Bilateral Shoulder Disarticulation
The reduced shoulder width associated
with the bilateral shoulder-disarticulation case so impairs scapular abduction
and shoulder flexion that complete control of the
prostheses is not possible. Full operation of the terminal device at elbow
angles above 90 deg. cannot be managed with the dual control, and a lower level
of operation must be accepted. The pelvic control remains a possibility, but
this expedient has so many disadvantages of inconvenience, awkwardness, and
discomfort that few if any amputees accept it for continuous use. Shoulder
control can at best be unilateral only.
Nevertheless, an acceptable level of
function may result. For example, J.G. is an elderly man, age 63, with bilateral
shoulder disarticulations. Of medium build and with rounded chest, he has to
date been completely dependent on help from others. Fitting and care have been
sporadic because of infrequent visits to the laboratory. He last was fitted
unilaterally with a right prosthesis and a reaction cap on the left shoulder.
Thus far the fit has been promising. At the last visit he had managed eating and
other activities.
With the congenital anomalies, amelia and
phocomelia, control functions usually are considered as being the same as those
for the shoulder-disarticulation case. Shoulder girdles are narrow because of
the absence of humeral heads or owing to loose and nonarticulated rudimentary
elements, so that basic shoulder control may not be adequate for bilateral
function. In phocomelia, with both forearm and hand or only hand elements,
additional help may often be obtained for secondary controls such as elbow-lock
operation. In any event, these congenitals early develop "manipulation" with the
feet, and these capabilities have not been matched, so far as is known, by any
upper-extremity prosthesis.
References:
- Gottlieb, M. S., Final report of the UCLA upper extremity amputee case study, Department of Engineering, University of California (Los Angeles), in preparation 1955.
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