Chapter 7C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
Partial-Hand Amputations: Aesthetic Restoration
Jean Pillet, M.D.
Evelyn J. Mackin, P.T.
The senior author's interest in aesthetic hand prostheses began in the 1950s with his recognition of how even the loss of a single digit could have a profound effect upon the amputees body image, self-esteem, and psychological status. The common attitude at that time was that because the prosthesis was inert and insensitive, it must be nonfunctional. However, the author's 39 years of experience in the fitting of over 6,000 amputees demonstrates that restoring near-normal appearance often improves the patient's function in a global sense by enabling him to better use what he has in the complex socioeconomic environment of today's mobile society. In addition, by providing an opposition part for the remaining digits or thumb, the prosthesis can also provide some prehensile capability that can be very useful. To more accurately reflect its dual benefits of aesthetics and function, we refer to it as a "passive functional prosthesis."
It is often difficult to recognize that certain patients would benefit from an aesthetic device because the recent amputee commonly assumes that electronic prostheses will restore all previous functioning. Once the limitations of active prostheses are understood, many prefer an aesthetic restoration.
ATTITUDE OF THE UNILATERAL AMPUTEE
After acquired amputation, the amputee experiences a major functional handicap. He believes in the miracles of surgery and the possibilities of a prosthesis. It is a period of illusions, but progressively the amputee adjusts to reality during the period of fitting, re-education, and vocational rehabilitation. It is a period mixed with hope and frustration, during which doctors, therapists, prosthetists, and psychologists all have important roles to play.
Some amputees become invalids, never able to accept their amputations. They hide their stumps and refuse to use them. They wear their functional prostheses but do not make use of them, as if the mere presence of the prostheses justified their behavior. Others accept their amputations only too well-they are delighted to be helped and to be treated as children, and their attitude reflects a psychological need.
Contrary to this small group, the majority of amputees get down to the business of leading a normal life. They reintegrate with their families and society and are able to do so because they have succeeded in making a realistic assessment of their disabilities. In conjunction with the stump, the remaining hand becomes increasingly skillful to the amazement of not only immediate family members but also the amputee himself.
Thus one may say that for certain amputees it is the unaesthetic aspect of the stump rather than the functional loss per se that is the most significant disability. Most patients finally grow accustomed to their physical impairments and learn to disregard them and even to forget about the function that has been lost. However, even this group may feel for a long time, and perhaps forever, aesthetic frustration about their altered appearance.
UNILATERAL CONGENITAL ABSENCE
In the senior author's experience, unilateral distal congenital amputees almost never ask spontaneously for a functional prosthesis. In the very rare exceptions encountered, it has been relatively easy to discern the influence of parents or family practitioners, both equally misinformed.
When one is treating a congenital amputee, it is common to commit a dual error by considering him as a disabled person and by assuming that he must have a prosthesis. He is not a true amputee but rather has an imperfect development because of a congenital deformity. He has established his own perception of his body, which differs from our perception of it. He sees himself as being complete and normal.
This mistaken reasoning whereby we imagine ourselves to have undergone an amputation as we try to "put ourselves in his shoes'' is not exclusive to normal people. Congenitally deformed persons themselves are astonished when people with more pronounced deformities than theirs are able to carry out the same tasks as they, and even just as quickly and just as well.
To require fitting a prosthesis for a patient with unilateral agenesis, however perfect the prosthesis may be, is tantamount to encumbering a normal person with a third hand. In fact, this was the reaction of such a patient when I asked why he did not have a functional prosthesis. "Doctor," he said, "what would you want with a third hand?"
Congenital unilateral amputees are therefore disabled chiefly by our perceptions. Whatever their ages, they typically manage all activities of daily living without any prostheses. They may use a technique that differs from ours. Naturally they have some frustration from not being able to do certain things, and this varies from one person to another. However, giving them insensitive prostheses will not automatically make them any more dexterous. In the 16th century, Ambroise Pare, the "father of French surgery," reported seeing "an armless man do almost all the things anyone else could do with his hands."
Unlike the traumatic amputee, an agenetic person is not subject to the initial emotional shock of losing a hand. Only gradually does he come to realize that he is not like other people. The realization is not spontaneous, but rather is a result of those around him. Generally speaking, awareness of their anomaly begins when they start their school days and new friends show their curiosity. They begin to fear medical checkups and gym. Finally, the hurdle of adolescence is most important. A young person often tends to blame his malformation for all his teen-age troubles.
The congenital amputee considers himself from the outset as being normal from a functional point of view, but he often suffers from feeling "different." These patients may have the same aesthetic need felt by the amputee who has had a traumatic loss.
AESTHETIC IMPORTANCE OF THE HAND
The aesthetic prosthesis fulfills a deep-rooted need: the wish to go unnoticed and have two hands like everybody else. This nearly universal desire demonstrates the importance of the beauty of the hand.
One must understand that for some patients the hand not only is a functional tool but also possesses expressive beauty: the appearance of the stump may seriously inhibit adaptation. For such patients the hand emphasizes the beauty of gesture, the gracefulness of a movement.
The importance of aesthetics varies from one person to another and from one culture to another. Many of our patients are of Latin origin, while very few come from Britain or Germany, and even fewer from Scandinavia. With the intermingling of ethnic groups over many generations, attitudes have become attenuated, but they have never quite disappeared. There is a strong desire for an aesthetic prosthesis in the Middle East, where amputation is sometimes used as punishment for criminals.
ESSENTIAL CHARACTERISTICS OF THE PROSTHESIS
To be of real and lasting benefit, the prosthesis must be of high quality, both technically and aesthetically. It must be very similar to the digit or hand of the opposite limb. The skin must correspond to the normal skin in all details and match the color as precisely as possible. The material of the prosthesis must be strong and repairable if torn. It must not stiffen at low temperatures within the normal climatic range and must also be heat resistant (Fig 7C-1.).
It must not be stained by ordinary materials such as newsprint and, if soiled, must be easily cleaned by washing in water with a mild soap (Fig 7C-2.). It must not irritate the skin. Fingernail details are especially important: consistency, translucency, color, and the nail and lunula length must be similar to the opposite side. A lack of all these qualities has been the reason for dissatisfaction with the commonly used polyvinylchlo-ride (PVC) gloves.
Polymers of dimethyl siloxane (silicones) allow copying of the natural hand in every detail. The opposite hand of the amputee is cast in the silicone, and from this design, a replica of the hand is made.
Fixation of the prosthesis must be secure, comfortable, and simple. When fixation is perfect, attempts at removal create a negative pressure, thereby providing a suction suspension.
FUNCTIONAL POTENTIAL OF PROSTHESES
The first objective of the prosthesis is to eliminate the psychological consequences of amputation. It should restore the appearance sufficiently close to normal to reduce the stigma associated with disfigurement. Often the disfigurement is more pronounced in the mind of the amputee than others. However, the man who finds himself unable to take his hand from his pocket, even though it is very "functional," may be as handicapped as if it were lost. By allowing the use of a stump that the amputee considers too repulsive to expose and use, the prosthesis may well improve overall function (Plates 1 and 2).
Sometimes covering a surgically reconstructed part with a thin, flexible, high-quality prosthesis may prove essential to realizing the most from the reconstruction by giving it a socially acceptable appearance.
In the incompletely amputated hand the prosthesis can often provide an essential physical part for remaining parts to oppose. It may lengthen a short thumb or become a stable thumb post against which the remaining mobile digits can work. Since potential combinations are innumerable, fitting such a hand with the optimal prosthesis is most difficult and demands the greatest ingenuity but often is also the most rewarding. Fabrication of these prostheses is made possible by the availability of tough, thin, strong, flexible new materials with which good mobility and some skin sensibility can be preserved.
Occasionally, function will be improved just by the protective effect of covering a tender stump to free the injured person from fear of using it. Often the prosthesis can be useful for holding light objects that are placed in it, even though it is totally passive.
Obviously, both psychological improvements and improvements in physical capacity contribute to a better rehabilitation potential for the amputee. When a professional activity involving frequent contacts with the public has been interrupted, the prosthesis is often the key to returning the patient to the employment for which he is already prepared. When retraining is required, the prosthesis broadens the number of vocational possibilities that one can realistically consider.
Partial or Total Amputation of the Distal Phalanx
The loss of even part of the terminal phalanx may be of considerable aesthetic and functional concern to patients. Amputations at this level require a thimble-like prosthesis extending to the middle phalanx, with the proximal interphalangeal joint left free. The proximal edge of the prosthesis is feathered to a thin edge without pigmentation, and this makes the skin juncture relatively inconspicuous. The most beautiful result is achieved when the length of the prosthesis is extended over the proximal interphalangeal joint to the proximal phalanx, even though some restriction of flexion results.
By extending the digit to its normal length, the most common type of precision grip is improved. The pulp of the thumb can now oppose the pulp of the prosthetic digit, as when picking up a pencil. The prostheses can also be used in typing and playing a musical instrument. The socket provides some flexibility for comfort. When a person's job requires that he uses his prosthesis hard, i.e., computer operator, a small dorsal thermoplastic splint can be worn over the prosthesis during work for mechanical strength and stability.
If the distal interphalangeal joint develops a fixed flexion contracture from scar formation, stiffens in a position of nonfunction, or has a spatulate appearance, surgical revision may be indicated. Experience has shown that it is much better, both functionally and aesthetically, to undergo amputation at the distal interphalangeal joint than to keep a longer but stiff stump in flexion.
Partial or Total Amputation of the Middle Phalanx
The partial or total loss of a digit at the middle phalanx level interferes with lateral or key pinch. In multiple amputations of the digits, the prosthesis provides a buttress against which the pulp of the remaining thumb can hold light objects. When a single amputation of the long finger occurs, strength is lost in key pinch. Lack of support by a missing ring finger allows the long finger to deviate ulnarly (Plate 3). Providing a prosthesis for the missing ring finger prevents deviation, adds stability to the fingers during lateral pinch, and also prevents small objects from falling out of the hand when the remaining fingers are brought together (Plate 4).
When amputation occurs at the middle phalanx or just distal to the proximal interphalangeal joint, the prosthesis is extended to the proximal phalanx. It is made very flexible at the proximal interphalangeal joint level to allow motion. With the juncture lying near the metacarpophalangeal joint the use of an ornamental ring will disguise the transition perfectly. Inside the prosthesis, the missing part of the digit is filled with some supple plastic material to give the same pulp consistency.
Partial Amputation of the Proximal Phalanx
Amputation at the proximal phalanx level requires a minimum stump length of 1.5 cm measured from the metacarpophalangeal crease for adequate fixation of a digital prosthesis. The patient with a stump shorter than 1.5 cm requires surgical interdigital web recession. If the patient refuses further surgery, prosthetic fitting of the middle or ring finger can sometimes be achieved by suspension with ornamental rings worn on the involved digit and adjacent digit; however, the result is complicated, and fixation is tenuous (Fig 7C-3.,A-C).
When the juncture lies over the proximal phalanx, use of an ordinary ornamental ring perfectly disguises the juncture, except in the case of the thumb. In the latter case, if a disguise of the juncture is desired, it is best achieved by wearing a small skin-colored plastic strip bandage as if covering an ordinary minor scratch.
The firmness and flexibility of the prosthesis depends on the functional needs. If the proximal interphalangeal joint of the fingers is present, the prosthesis is made flexible at this level to allow motion. If amputation is through the proximal phalanx, the prosthesis is firm and semicurved to oppose the thumb for purposes of prehension. Individual fitting of all four fingers is feasible if the stumps are of adequate length for secure individual fixation. Otherwise, a glove is required, usually with the thumb exposed if it is in good condition, so that one of the opposing parts has good sensibility.
Partial or Total Amputation of the Thumb
The thumb is essential for precision and power grip. Less thumb length decreases opposition proportionately. Loss of the necessary counterpressure to maintain a grip on objects diminishes power grip.
When amputation occurs at the interphalangeal joint or distal to the metacarpophalangeal joint, a thumb prosthesis will assist prehension. By lengthening the thumb, the prosthesis will provide proper opposition to the fingers. It also provides a shaft and crotch so as to make it possible to hold objects too large for the fingers themselves to encircle.
Disarticulation of the thumb at the carpometacarpal joint requires a hand prosthesis with the fingers exposed.
Metacarpal amputations can be transverse, central, or oblique. In the case of transverse amputations, the prosthesis is essentially a total hand terminating 2 to 4 cm proximal to the ulnar styloid. A watchband or tennis bracelet in summer can be worn to cover the juncture between the prosthesis and natural skin.
When only a portion of the thumb remains, it is generally covered with a total-hand prosthesis that extends the length of the thumb and provides it with a natural-looking fingernail. In such cases the prosthesis is made very thin in appropriate areas to allow free motion of the thumb remnant and sensibility through the cover. The fingers are made firm in a semiflexed position to serve as opposition posts for the mobile thumb.
When a normal thumb has been preserved, one has the option of using a complete-glove prosthesis made very thin on the part covering the thumb or allowing the thumb to protrude freely through the glove. The latter method presents the problem of disguising the opening in the glove, but for most activities having a sensate thumb outside the glove is so functionally superior that it is generally recommended.
When a useful small finger remains after an oblique metacarpal amputation in which all or most of the thumb is lost, it is best that the second metacarpal be surgically resected and the small finger fitted into the ring finger of the prosthesis. This not only is more functional, with the single finger having a better working relation to the thumb post, but also allows the prosthesis to be fabricated to the exact size of the other hand.
When a metacarpal amputation is central and involves the index, middle, and ring fingers, i.e., a punch press injury, both the thumb and small finger are preserved. Functionally, it is best to leave both the thumb and small finger protruding from the prosthesis if they are normal. The small-finger juncture can be easily covered with an ordinary ring.
Prosthetic fitting of partial-hand amputations is a most difficult problem. The variety of physical problems encountered is enormous, and potential solutions must be carefully weighed against the needs of the patient, which are almost as variable. The absence of any perfect solution gives rise to a great variety of possibilities that one must carefully consider.
Amputation Through the Wrist
Patients with amputations through the wrist require a total-hand prosthesis, and the prosthetic problems chiefly involve the best socket arrangement. When amputation is through the carpus, the prosthesis is made thin over the palm area so that useful sensibility can be readily transmitted (Fig 7C-4.,A). By extending the hand to its normal length, the prosthesis increases the functional surface of the hand, thereby enabling the patient to use it to push and as an assist in two-handed activities. The prosthesis is also useful for holding light objects that are placed in it due to the elastic memory of its components (Fig 7C-4.,B).
Amputation at the Forearm
A long stump, with preservation of sensitivity and pronation/supination, is very functional for the patient, who uses it to push. To preserve these qualities it is necessary to make a hand prosthesis rather than a forearm prosthesis to avoid restricting forearm rotation.
Amputation at the forearm level requires a minimum stump length of 5 cm (measured from the elbow crease with the elbow at 90 degrees of flexion) for good fixation of a forearm prosthesis. Fixation by suction eliminates the need for a complicated harness or suspension system. A rotational wrist unit attached to the forearm prosthesis permits manual positioning of the hand in almost any attitude of supination or pronation through a 360-degree range. Once locked into position, it enables the amputee to use the prosthesis as a stabilizer as well as functional assist in bilateral activities. Flexibility of the prosthetic digits allows the amputee to hold light objects placed in the hand.
Amputation of the humerus at least 5 cm proximal to the normal elbow crease allows incorporation of a mechanical elbow to provide flexion and extension. The fixation is similar to the forearm prosthesis. New materials and techniques now allow fabrication of prosthetic sockets that are light, soft, flexible, and secure. Those for amputation distal to the shoulder usually require no harnessing whatsoever. These self-suspending sockets represent a major step in the advancement of prosthetics.
Amputation of the proximal part of the humerus requires a stump length of 15 to 16 cm for satisfactory fixation and good muscle control. The stump should be conical in shape and firm, with bone extending the full length. If the tissues are soft, a shoulder prosthesis will be required. A stump that is too fat requires surgical revision prior to fitting of the prosthesis.
Shoulder disarticulation is less disfiguring than the forequarter amputation since the contour of the shoulder remains. The prosthesis for the shoulder disarticulation patient is very similar in design to that for the forequarter amputation, except for the extent of the shoulder cap.
Forequarter amputations leave a distressing aesthetic and functional defect. It is often difficult to fit and train these amputees in the use of a satisfactory active prosthesis. Many patients prefer to use an aesthetic prosthesis with passive function consisting of a lightweight shoulder cap that has been made to match the contour of the involved shoulder (Fig 7C-5.,A), thus improving the appearance of clothing, and to which an aesthetic forearm and wrist unit are attached. The prosthesis is secured to the patient by means of webbing straps (Fig 7C-5.,B)
AESTHETIC PROSTHESES FOR CHILDREN
The majority of children seen in consultation for prostheses are seen as the result of congenital abnormality. If the stump does not have a pinch mechanism, fitting of a prosthesis may be carried out at a very early age-usually between 6 and 18 months. Fitting at this age accustoms the child to the presence of the prosthesis and encourages bimanual activity.
If the stump has a useful pinch mechanism, the prosthesis will be functionally more bothersome than useful in the daily activities of school and play. In these circumstances it is preferable to postpone fitting until the child has attained adolescence, at which time his "self-image" becomes preeminent and he will be more motivated to accept the inconveniences of a prosthesis.
A child's physical appearance at birth is of primary importance to the parents, and it is sometimes necessary to fit a child with a prosthesis if the parents are suffering from psychological trauma. In such cases, it is the parents we are treating through the child.
AESTHETIC PROSTHESES FOR BILATERAL AMPUTEES
Physical impairment is so great for the bilateral amputee that it overshadows the aesthetic concern, but such a concern is in fact not diminished in these patients. Benefits may be derived in the bilateral amputee by fitting one side with an aesthetic prosthesis, but the need for sensibility of a part on at least one side very often precludes useful bilateral fitting.
The considerations when applying a prosthesis are many and varied. Each case must therefore be evaluated individually so that psychological, social, vocational, and avocational needs can be determined.
Although patients of all ages can be fitted with a prosthesis, the loss of one or more distal phalanges in a child or adolescent does not generally require a prosthesis. Children and teenagers usually manage to overcome the functional loss and in most cases perform all their activities. A prosthesis might be functionally more awkward than useful.
Many patients who sustain distal amputations are engaged in occupations or hobbies where finger dexterity means the difference between success and failure. A secretary, typist, or pianist who has lost the distal phalanx of any digit may find functional ability enhanced with a prosthesis.
In the fingertip amputee, a thimble-like prosthesis may provide the needed length to enable the flutist to play the flute again (Plates 5 and 6).
It is necessary to determine the patients motivation for obtaining a prosthesis and whether he has a realistic understanding of the advantages and disadvantages. If the patient is appropriately oriented to the realities of the prosthesis, he is better prepared to accept the limitations of the prosthesis when he receives it.
It is important to convey that the prosthesis may impede function and reduce sensation in an area. Also, the patient must realize that the color of his skin varies due to daylight or electric light, emotional status, position of the hand, and many other conditions that can change the blood flow. He must understand that the color of the prosthesis will be the one that most matches the "average normal" color of the skin. To make these differences less noticeable, it is recommended that a ring or small plastic strip bandage be worn at the edge of the prosthesis.
Some patients wear their prostheses for years, some only for months. We do not consider this a failure, but rather proof of the effectiveness of the prosthetic treatment that helped the patient through a difficult period of his life. The prosthesis is then considered a temporary treatment discontinued because the amputee feels himself "cured." When the amputee uses his prosthesis all his life, this means that he considers it either a so-cioprofessional accessory or a part of his body image. Then he wears it every day, all day long, and it becomes an integral part of himself.
Although patients are anxious to obtain their prostheses as soon as possible, it is necessary that sound wound healing be completed and edema controlled. Coban [*Coban. Medical Products Division, Minnesota Mining and Manufacturing Co., St. Paul, Minn.] wrapping helps to reduce edema, promote stump shrinkage, and contour the stump for the prosthesis. Coban is applied firmly distally to proximally, with less tension over joints allowing free use. When volumetric measurements of the stump have stabilized, the patient is ready for fabrication of the prosthesis.
A painful stump cannot tolerate a prosthesis. Desen-sitization techniques reduce these paresthesias and help to prepare the stump for the prosthesis. The use of constant pressure such as elastomer caps secured with Coban wrapped in a figure-of-8 bandage in a distal to proximal manner can also help to diminish hypersensitivity. If no progress is made with desensitization techniques after 1 month, surgical revision should be considered.
DURABILITY OF THE PROSTHESIS
We believe that each patient should have two prostheses, particularly in areas of wide variations in climate: one with the color adjusted to the average winter pigmentation and the other to summer. This does not necessarily increase the total cost because two prostheses will wear twice as long as one. Having a second prosthesis also ensures that one is always available if the other needs repairs and/or adjustments if the morphology of the stump changes.
It is generally recommended that the patient wear the initial prosthesis for approximately 6 months before beginning the second one. This allows time for any necessary adjustments and to verify that the patient has become a good prosthetic wearer. The average life span of an aesthetic prosthesis varies from 2 to 4 years and depends on how well the patient takes care of it as well as whether it is worn everyday or just for special occasions.
CONTRAINDICATIONS TO AESTHETIC PROSTHESES
An absolute contraindication to the provision of an aesthetic prosthesis is a patient without motivation or one with unrealistic expectations as to what the device is expected to accomplish. Relative contraindications include instances when such a device may be uncomfortable, result in significant functional loss, or even achieve a poor aesthetic result.
For example, with disarticulation of several digits, the prosthesis must cover the hand completely for adequate fixation. Attempts at fixation on very short stumps can result in trophic skin changes that will make the prosthesis unbearable. Multiple digital prostheses on the same hand can interfere with its sensibility as well as its gripping strength.
When there are bulky or badly aligned stumps, aesthetically pleasing prostheses may not be feasible without prior surgical revision. It should also be remembered that in bilateral amputations an aesthetic prosthesis should be provided on only one side.
ACCEPTANCE AND UTILIZATION OF AESTHETIC PROSTHESES
In June 1990, 700 files of patients who had been wearing the passive functional prostheses for between 10 years and 38 years and had spontaneously consulted during the last 30 months (January 1988 to June 1990) were reviewed. The patients, all unilateral amputees, were divided into two categories: acquired and congenital amputees.
Each category was further subdivided into full-time and part-time wearers. The full-time group included those who put on their prostheses each morning and removed them only for sleep, thus making the device much a part of themselves. In the part-time group, the patients treated their prostheses much as clothing and wore them regularly when out of the home or on the job, but frequently omitting them within the confines of the family circle. Acquired amputees generally fell into the group integrating the prosthesis as a part of their body, while congenital patients mostly belonged to the second group who wore them as clothing.
An aesthetic prosthesis can be equally helpful to the acquired amputee and to a patient whose malformation is attributable to agenesis. The passive functional hand prosthesis has become a major component of the comprehensive professional and social rehabilitation program for patients with either a totalor partial-hand amputation.
Such a prosthesis may fulfill the psychological and functional needs of congenital or acquired amputees to look like everybody else, with two hands, and be able to use them in public without embarrassment.
Although the primary aim and purpose of an aesthetic prosthesis is to provide an aspect of normality to a disfigured hand, the prosthesis also serves an important functional role by providing opposition to a remaining mobile finger or by lengthening a finger stump that is too short. In cases where the hand has been totally amputated, the prosthesis may be used functionally to hold light objects and, in two-handed grasping activities, as a support or to push objects.
Finally, by being aesthetic, the prosthesis encourages the amputee to use his stump for daily activities, which enables him to better integrate into the complex socioeconomic environment of todays society. The prosthesis must conform to very high standards of quality to achieve these goals.
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Chapter 7C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles