Upper limb manual

Jakarta School of
Prosthetics & Orthotics

UPPER LIMB PROSTHETICS

COURSE WORK MANUAL
2010

Supported by:

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Upper limb manual

Table of contents
Chapter 1: Anatomy......................................................................................................2

Chapter 2: Biomechanics...........................................................................................35

Chapter 3: Upper Limb Prosthetics............................................................................41

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Upper limb manual

This manual has been compiled and edited by Aaron Williams, Ashley Morphet and
Lee Brentnall, June, 2007

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Upper limb manual

Anatomy
The upper limb is the ‘organ of manual activity’. It is feely movable, especially the
hand, which is adapted for grasping and manipulating. The upper limb is not usually
involved in weightbearing, and as a result, its stability has been sacrificed to gain
mobility. Knowledge of its structure and function are of high importance when
treating patients with an upper limb injury (Moore, 1992)
The upper limb is divided into the following areas:

The Shoulder/
Pectoral region

The Arm

The Elbow

The Forearm

The Wrist

The Hand

The Upper Limb

Picture from http://www.netterimages.com

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Upper limb manual

Bones of the upper limb

The upper limb contains 32 bones, and is attached to the trunk through the pectoral
girdle.

The Shoulder/Pectoral girdle

The shoulder girdle, consists of two bones, the scapular and the clavical. The
scapular is a flat triangular bone situated on the postero-lateral aspect of the thorax.
The glenoid fossa on the lateral scapula is where the head of the humerus
articulates to form the shoulder joint.
The Scapular
Adapted from: Palastanga et
al, 2002

The clavicle acts as a strut to hold the scapula laterally so that the arm clears the
trunk.

The clavicle
Adapted from:
Palastanga et al,
2002

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Upper limb manual

The arm
The arm consists of one single bone, the humerus. The humerus is a long bone with
a head, shaft and condyles. Proximally, the ball-like head of humerus articulates with
the glenoid fossa of the scapula and distally with the radius and ulnar. Close to the
head are the greater and lesser tubercles for the insertion of the muscles that
surround and move the shoulder joint. The anatomical neck of the humerus
separates the head and the tubercles. Distal to the anatomical neck is the surgical
neck, which is located where the bone narrows to become the body/shaft.

The Humerus
Adapted from: Palastanga et al, 2002

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Upper limb manual

The forearm
The radius and ulna together form the bones of the forearm. The radius lies laterally
and the ulna medially. The radius and ulna are connected via interosseous
membrane between the shafts of the two bones.
The radius articulates with the capitulum of the humerus and the scaphoid and
lunate bones at the wrist.
The ulna articulates with the humerus via the trochlea of the humerus but does not
articulate with the carpal bones distally, only with the radius
The semiluna notch at the proximal end of the ulnar fits over the distal end of the
humerus to form the elbow joint. The olecranon process extends proximally to the
semiluna notch and can be felt at the posterior elbow. The coronoid process also
articulates with the
humerus. The proximal
radius has a head that
articulates with the ulna
and the humerus and can
rotate against the two
bones. Both the radius
and ulna have styloid
processes distally that
provide attachments for
ligaments of the wrist.

The Radius and Ulna

Adapted from: Palastanga et al, 2002

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Upper limb manual

The Wrist and Hand

The wrist contains 8 bones, known generally as the carpal bones. These bones are
called the Scaphoid, Lunate, Triquetrium, Pisiform, Trapezium, Trapezoid,
Capitate and Hamate.
The hand contains 19 bones, containing 5 metacarpals, and 14 phalanges.
Each finger is made up of a metacarpal and three phalanges, except the thumb
which has only two phalanges.

The Wrist and Hand

Adapted from: Palastanga et al, 2002

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Upper limb manual

Joints of the upper limb

The upper limb is made up of highly mobile joints which enable positioning of the
hand. The regions of the upper-limb are separated by different types of joint. The
joints of the upper limb are represented below and explained in detail on the next
page:

Regions and Joints of the Upper limb

Adapted from: Palastanga et al, 2002

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Upper limb manual

Sternoclavicular joint – Saddle joint. The joint between the manubrium, sternum
and the clavicle, attaching the pectoral girdle to the trunk
Acromioclavicular joint – Plane joint. Found 2-3 cm medial to the acromion (which
is sometimes knows as the ‘point of the shoulder’)
The sternoclavicular and acromioclavicular joints allow movements of the shoulder
girdle:
 Retraction (medial border of scapula moves towards the vertebral column),

 Protraction (the scapula moves forwards around the chest wall ie. rounding the
shoulders),

 Elevation (the pectoral girdle lifts upwards as if shrugging the shoulders) and

 Depression (the pectoral girdle is pulled downwards).

Protraction and retraction

Elevation and depression

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Upper limb manual

Shoulder joint – Ball and socket joint. Allows multiaxial movement in all planes,
connecting the scapula and humerus.

Abduction (180 degrees) and adduction (45 degrees)

External rotation (45 degrees) and internal rotation (55 degrees)

Flexion (90 degrees) and extension (45 degrees)

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Upper limb manual

Elbow joint – Hinge joint. Allows flexion (135 degrees) and extension (0-5 degrees),
connecting the arm with the forearm. The articulating bones at the elbow are the
humerus with the radius and ulnar.

Radioulnar joint – Pivot joint. This is where the radius and ulnar bones articulate
with each other to produce pronation (90 degrees) and supination (90 degrees)
movements of the forearm. The joint can be further classified as two separate joints
– ‘Superior Radioulnar Joint’ (near the elbow) and ‘Inferior Radioulnar Joint’ (near
the wrist).

Wrist joint – Condyloid joint. Allows flexion (80 degrees), extension (70 degrees),
radial deviation (20 degrees) and ulnar deviation (30 degrees). The articulating
bones at the wrist are, proximally, the radius, and distally, the scaphoid, lunate and
triquetral (which form the proximal row of carpal bones).

Extension Radial deviation Ulnar deviation

Flexion

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Upper limb manual

Intercarpal, carpometacarpal and

intermetacarpal joints – Plane joints.
Permit gliding and sliding movements
between the carpal and metacarpal
bones (except in the thumb)

Carpometacarpal joint of the thumb – Saddle joint. Allows angular movement in

any plane, flexion, extension, adduction and abduction, as well as opposition.
Opposition of the thumb allows it to face the other fingers making the hand highly
functional. Below are the different types of grips the hand can make showing its
functional abilities.

Metacarpophalangeal joints – Condyloid joints. Allows flexion, extension,

abduction, adduction and circumduction at the base of the fingers.

Interphalangeal joints – Hinge joints. Allow flexion and extension in the fingers.
Classified as Proximal Interphalangeal Joints (PIP’s) and Distal Interphalangeal
Joints (DIP’s).

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Upper limb manual

Muscles of the upper limb

The Shoulder Region
The muscles of the shoulder are divided into three groups (from Moore, 1992):
1 – the superficial extrinsic muscles: trapezius and latissimus dorsi

2 – the deep extrinsic muscles: levator scapulae, rhomboid major, rhomboid

minor and serratus anterior

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Upper limb manual

3 – the intrinsic muscles: deltoid, supraspinatus, infraspinatus, teres minor,

teres major and sub-scapularis

Deltoid Infraspinatus and teres minor

Subscapularis Supraspinatus

Some of the intrinsic muscles of the shoulder make up the Rotator Cuff. These
muscles protect the shoulder joint and give it stability by holding the head of the
humerus in the glenoid cavity of the scapula. Muscles of the Rotator Cuff are
Supraspinatus, Infraspinatus, Teres Minor and Supscapularis.

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Upper limb manual

The Pectoral region

The pectoral region contains four muscles, all of which are attached to the pectoral
girdle and are associated with movements of the pectoral girdle and upper limb.
The pectoral muscles are: Pectoralis major, Pectoralis minor, Subclavius and
Serratus anterior. Note that Serratus anterior is sometimes classified as a deep
extrinsic muscle of the shoulder, but will be mentioned here as it still has an effect on
the pectoral region.

Muscles of the pectoral region - Pectoralis major, pectoralis minor and subclavius

Summary of Shoulder and Pectoral muscles

Table 1 - Muscles of Shoulder/Pectoral girdle
(modified from http://mywebpages.comcast.net/wnor/intro.htm)
Muscle Origin Insertion Action
Trapezius Superior nuchal line of Lateral third of Elevates
occipital bone, nuchal clavicle, median shoulder,
ligament spines of C7 & margin of acromion laterally rotates
all thoracic vertebrae scapular spine scapula, retracts
scapula on
thoracic wall
Latissimus Spinous processes of Floor of Adducts, extends,
dorsi lower thoracic intertubercular medially rotates
vertebrae, groove of humerus arm
lumbodorsal fascia,
crest of ilium
Rhomboid Spinous processes of Medial border of Retracts and
major T2 to T5 vertebrae scapula below root of medially rotates
scapular spine scapula
Rhomboid Spine of 7th cervical Medial margin of Retracts and
minor and 1st thoracic scapula at the root of medially rotates
vertebrae, lower part of the scapular spine scapula
nuchal ligament
Levator Transverse processes Medial border of Raises scapula
scapulae of C1-C4 scapula above root
of scapular spine
Supraspinous Supraspinous fossa of Superior aspect of Abducts the arm

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Upper limb manual

scapula greater tubercle of (1st 15 degrees)

humerus
Infraspinous Infraspinous fossa of Mid portion of  Rotates the arm
scapula greater tubercle of laterally
humerus
Teres minor Lateral border of Lower aspect of Rotates arm
scapula greater tubercle of laterally
humerus
Teres major Inferior medial border of Crest of lesser Adducts and
scapula tubercle of humerus rotates arm
medially
Subscapularis Subscapular fossa Lesser tubercle of Medially rotates
humerus and adducts arm,
helps hold
humerus in
glenoid cavity
Deltoid Lateral third of clavicle Deltoid tuberosity of Abduction of arm
acromion process humerus from 15 degrees
scapular spine to 90 degrees
Serratus Exteral surface of later Anterio medial Protracts and
anterior ribs 1 to 8 scapula rotates scapula
Triceps, long Infraglenoid tubercle of Olecranon process of Extends arm and
head scapula ulna forearm
Pectoralis Medial half of clavicle, Lateral lip of Flexes, adducts,
major sternum, costal intertubercular and rotates arm
cartilages and groove of humerus medially
aponeurosis of external
oblique muscle
Pectoralis Anterior aspect of 2nd- Coracoid process of Protracts the
minor 5th ribs scapula scapula pulls it
forward and down
Subclavius Junction of the 1st rib Inferior surface of Pulls clavicle
with clavicle towards the
its costal cartilage sternum

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Upper limb manual

Muscles of the arm

There are four muscles in the arm - three flexors in the anterior compartment, and
one extensor in the posterior compartment (Moore, 1992)
The three flexor muscles are Biceps Brachii (often referred to as Biceps),
Brachialis and Coracobrachialis

Flexor muscles of the arm – from left to right Biceps Brachii, Brachialis and
Coracobrachialis.
Taken from:
http://www.meddean.luc.edu/Lumen/MedEd/grossanatomy/dissector/muscles

The extensor of the arm is Triceps Brachii (often referred to as Triceps)

Extensor muscles of the
arm – Triceps
Taken from:
http://www.meddean.luc.
edu/Lumen/MedEd/gros
sanatomy/dissector/mus
cles

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Upper limb manual

Muscles of the Forearm

The muscles of the forearm act on the joints at the elbow and into the wrist and
hand. Muscles that originate in the forearm and travel down into the hand are
sometimes referred to as ‘Extrinsic Muscles of the Hand’. However, as their origin
and muscle belly is found in the forearm, they are classified here as forearm
muscles. There are many layers of muscles in the forearm, and these layers will be
explained below.
1 – The superficial and intermediate muscles on the anterior surface of the forearm
are Pronator Teres, Flexor Carpi Radialis, Palmaris Longus, Flexor Carpi
Ulnaris and Flexor Digitorum Superficialis.

Pronator teres, flexor carpi ulnaris, flexor carpi radialus, palmaris longus, flexor
digitorum superficialis

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Upper limb manual

2 – Deep muscles on the anterior surface of the forearm are Flexor Digitorum
Profundus, Flexor Pollicis Longus and Pronator Quadratus.

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Upper limb manual

3 – The superficial Muscles on the posterior surface of the forearm are

Brachioradialis, Extensor Carpi Radialis Longus, Extensor Carpi Radialis
Brevis, Extensor Digitorum, Extensor Digiti Minimi and Extensor Carpi Ulnaris.

Superficial muscles of the posterior forearm

Brachioradialis (above left), Extensor Carpi Radialis Longus (above middle),
Extensor Carpi Radialis Brevis (above right), Extensor Digitorum (below left),
Extensor Digiti Minimi (below middle) and Extensor Carpi Ulnaris (below right)
Taken from
http://www.meddean.luc.edu/Lumen/MedEd/grossanatomy/dissector/muscles

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Upper limb manual

4 – The deep muscles on the posterior surface of the forearm are Supinator,
Abductor Pollicis Longus, Extensor Pollicis Brevis, Extensor Pollicis Longus
and Extensor Indicis.

The deep muscles on

the posterior forearm
Supinator
(top left)
Abductor Pollicis
Longus (top middle)
Extensor Pollicis
Brevis (top right)

Extensor Pollicis
Longus (bottom left)
Extensor Indicis
(bottom right)

Taken from:
http://www.meddean.lu
c.edu/Lumen/MedEd/g
rossanatomy/dissector/
muscles

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Upper limb manual

Summary of Muscles of the Arm and Forearm

Table 2 - Muscles of the Arm and Forearm
Modified from: http://mywebpages.comcast.net/wnor/lesson4tableofmuscles.htm
Muscle Origin Insertion Action
Biceps brachii 1 Supraglenoid tubercle Radial tuberosity Flexes arm and
1 Long head of humerus forearm,
2 Short head 2 Coracoid process supinates hand
of humerus
Coracobrachialis Coracoid process of Inner aspect of Flexes and
scapula humeral shaft adducts arm
rd
Brachialis Distal 2/3 of humerus Coronoid process Flexes forearm
of ulna
Triceps 1 Infraglenoid tubercle of Olecranon Extends arm
1 Long head scapula process of ulna and forearm
2 Lateral head 2 Upper lateral aspect of
3 Medial head humerus
3 Lower medial aspect of
humerus
Brachioradialis Upper 2/3rds lateral Lateral side of Flexes at the
supracondylar ridge & lower end of elbow
anterior surface of radius just above especially when
intermuscular septum the styloid process forearm is in
midprone
position
Pronator teres Medial epicondyle of Lateral aspect of Pronates hand,
humerus, coronoid shaft of radius flexes forearm
process of ulna
Supinator Deep portion: supinator Upper oblique half Following
crest & anular ligament & of anterior surface pronation, the
oblique cord. of radius and its supinator
Superficial portion: lateral lateral surface supinates the
epicondyle & radial radius
collateral ligament
Flexor carpi Medial epicondyle of Bases of 2nd and Flex forearm
radialis humerus 3rd metacarpal and hand, aid in
bones pronation and
abduction
of hand
Palmaris longus Medial epicondyle of Flexor retinaculum Flexes hand
humerus of palm of hand and wrinkles
skin of palm of
hand
Flexor digitorum Medial epicondyle of Tendons split to Flexes
superficialis humerus, coronoid attach to lateral phalanges,
process of ulna, anterior sides of middle wrist, and
border of radius phalanges forearm
Flexor carpi Medial epicondyle of Pisiform, hamate Flexes forearm
ulnaris humerus, olecranon base of 5th and hand,
process and posterior metacarpal adducts hand
border of ulna

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Upper limb manual

Flexor pollicis Radius and interosseous Base of distal Flexes thumb

longus membrane phalanx of thumb
Flexor digitorum Upper anterior 3/4ths Base of distal Flexes
profundus aspect of ulna and phalanges of phalanges
adjacent interosseous fingers
membrane
Pronator Distal anterior aspect of Distal anterior Pronates hand
quadratus ulna aspect of radius
Extensor carpi Lateral supracondylar Base of 2nd Extends and
radialis longus ridge of humerus metacarpal abducts the
wrist
Extensor carpi Lateral epicondyle of Base of 3rd Extends and
radialis brevis humerus metacarpal abducts the
wrist
Extensor carpi Lateral epicondyle of Base of 5th Extends and
ulnaris humerus metacarpal adducts the
posterior border of ulna hand
Extensor Lateral epicondyle of Extensor Extends fingers,
digitorum humerus expansion over hand and
fingers forearm
Extensor digiti Lateral epicondyle of Extensor Extends little
minimi humerus expansion of little finger
finger
Anconeus Back of lateral epicondyle Olecranon Extends
of humerus process forearm
poster surface of
ulna
Supinator Lateral epicondyle of Upper third of Supinates the
humerus radius hand
crest of ulna
Abductor pollicis Posterior surface of ulnar Base of 1st Abducts thumb
longus middle aspect of radius metacarpal
Extensor pollicis Middle 1/3rd of radius Base of proximal Extends thumb
brevis phalanx of thumb
Extensor pollicis Middle 1/3rd ulna & Base of distal Extends thumb
longus interosseous membrane phalanx of thumb
Extensor indicis Posterior surface of ulna Extensor Extends index
expansion of index finger
finger

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Upper limb manual

Muscles of the Wrist and Hand

The Intrinsic Muscles of the hand are only found on the anterior/palmar aspect. All
muscles to the hand on the posterior side are extrinsic.
The intrinsic muscles of the hand can be divided into three groups:
1 – The ‘Thenar’ muscles (around the base of the thumb) are Abductor Pollicis
Brevis, Flexor Pollicis Brevis, Opponens Pollicis and Adductor Pollicis.

Minimi, Flexor Digiti Minimi Brevis

and Opponens Digiti Minimi.

2 – The Hypothenar muscles (near

base of 5th finger) are Abductor Digiti

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3 – There are 11 short muscles of the hand – four Lumbricals and seven
Interosseous muscles.

Dorsal Interossei Lumbricals Palmar interossei

Summary of muscles of the Wrist and Hand

Table 3 - Muscles of the wrist and hand
Modified from: http://mywebpages.comcast.net/wnor/lesson5tableofmuscles.htm
Muscle Origin Insertion Action
Abductor pollicis Flexor Proximal Abducts the thumb
brevis (thenar retinaculum of phalanx of
muscle) wrist thumb
scaphoid &
trapezium
Flexor pollicis Flexor Proximal Flexes the thumb
brevis (thenar retinaculum phalanx of
muscle) trapezium thumb
Opponens Trapezium & Lateral border Opposes thumb to other
pollicis (thenar flexor of 1st digits
muscle) retinaculum metacarpal
Adductor pollicis Capitate Proximal Adducts the thumb
2nd & 3rd phalanx of
metacarpals thumb
Abductor digiti Pisiform Proximal Abducts little finger
minimi phalanx of little
(hypothenar finger
muscle)
Flexor digiti Flexor Proximal Flexes little finger
minimi retinaculum phalanx of little
(hypothenar hook of finger
muscle) hamate
Opponens digiti Flexor 5th metacarpal Opposes little finger to
minimi retinaculum other digits
(hypothenar hook of
muscle) hamate
Palmar Medial side of Medial base of Adducts index finger
interosseus I 2nd index finger towards middle finger
metacarpal
Interosseous II Lateral side of Lateral base of Adducts ring finger
4th metacarpal ring finger towards middle finger
Interosseous III Lateral side of Medial base of Adducts little finger
5th metacarpal little finger towards middle finger
Dorsal Adjacent sides Lateral aspect Abducts ring finger away
interosseous I of metacarpal of extensor from middle finger
bones expansion of
ring finger
Dorsal Adjacent sides Medial aspect Abducts the middle finger
interosseous II of metacarpal of extensor away from its long axis
bones expansion of
middle finger
Dorsal Adjacent sides Lateral aspect Abducts the middle finger
interosseous III of metacarpal of extensor away from its long axis
bones expansion of
middle finger
Dorsal Adjacent sides Lateral aspect Abducts the index finger
interosseous IV of metacarpal of extensor away from the middle
bones expansion of finger
index finger
Lumbricals I & II Tendons of Lateral aspect Flex the
flexor digitorum of extensor metacarpophalangeal joint
superficialis expansion extend the interphalangeal
joints
Lumbricals III & Tendons of Lateral aspect Flex the
IV flexor digitorum of extensor metacarpophalangeal joint
superficialis expansion extend the interphalangeal
joints
Nerves of the upper limb
The nerves leading to the upper limb originate from the brachial plexus which is
formed by the nerve roots of C5, C6, C7, C8 and T1 from the spinal cord.

The areas of the Brachial Plexus can be divided into trunks, divisions, cords and
then branches. These will be explained in greater detail below.
Trunks – the nerves leaving C5 and C6 unite to form the superior trunk. The
nerve exiting C7 continues alone to form the middle trunk. The C8 and T1 nerves
unite to form the inferior trunk.
Divisions – as the trunks travel along they all divide into anterior and posterior
divisions. Anterior divisions will eventually form the anterior (flexor) parts, while
the posterior divisions will form the posterior (extensor) parts.
Cords – the three posterior divisions unite to form the posterior cord. The
anterior division of the superior and middle trunks unite to form the lateral cord,
while the anterior division of the inferior trunk continues as the medial cord.
Branches – each cord of the Brachial Plexus divides into two terminal branches.
The lateral cord divides into the musculocutaneous nerve and the lateral root of
the median nerve. The medial cord divides into the ulnar nerve and the medial
root of the median nerve. The posterior cord divides into the axillary nerve and
radial nerve.
There are other smaller branches that shoot off at various points along the
brachial plexus, for example the long thoracic or dorsal scapular nerves. Most of
these smaller branches innervate muscles around the pectoral/shoulder region,
however these will not be discussed in any detail here.
Musculocutaneous nerve – the musculocutaneous nerve (C5, C6 and C7)
supplies the muscles of the anterior arm – coracobrachialis, biceps brachii and
brachialis. It also supplies the skin on the lateral aspect of the forearm.
Median nerve – the median nerve is formed from both the lateral and medial
cords, receiving innervations from C5, C6, C7, C8 and T1. It supplies all the
flexor muscles of the forearm (except flexor carpi ulnaris and half of flexor
digitorum profundus) and some of the skin on the hand (skin of the radial half of
the palm and palmar side of the lateral 3 1/2 digits (and nail bed for these digits).
Ulnar nerve – the ulnar nerve (C8 and T1) supplies 1 ½ muscles of the forearm,
and most of the small hand muscles. It supplies the skin of the medial side of the
wrist and hand, and the skin of the medial 1 1/2 digits.
Axillary nerve – the axillary nerve (C5 and C6) supplies Teres Minor and Deltoid
muscles and the skin of the upper lateral arm.
Axillary nerve
Radial nerve – the radial nerve (C5, C6, C7, C8 and T1) supplies Triceps
Brachii, Brachioradialis and the extensor muscles of the forearm. It supplies the
skin of the posterior arm, forearm and hand.

Radial Nerve
Biomechanics

The anatomy, function, control and related biomechanics of the upper limb are
highly complex and interrelated. In consequence, the orthotic management of the
upper limb is equally complex and specialized (Bowker, Condie, Bader & Pratt,
1993).

There is a fine balance between improving function in one part of the upper limb
and restricting function in another. The ultimate aim of the orthosis is to improve
function, but the patient may consider the orthosis to be a hindrance when it is
first applied (Bowker, et. al. 1993).

Mechanics in Orthotics

The human body is always subject to external forces and moments whether
stationary or moving. These external forces and moments tend to cause motion
at the joints.

Normally, the effect of these external forces and moments are controlled by
forces generated internally in

 Passive tissues – joint capsule and ligaments

 Active tissues – muscles

In this way, a normal person can function.

When injury or disease is present, one or more of these tissues can no longer
produce the appropriate force. For example, a ligament may be torn, or a muscle
may have been paralysed.

In these cases, the external forces can be modified to restore function using an
orthosis.

Systems of Force
The basic systems of force used in orthotics is a 3-point
pressure system.

Each force in the system will have

 A point of application
 Direction
 Magnitude
3-point pressure system
acting on a finger
Changing either one of these parameters will have an effect on the force being
transmitted.

Typically, an orthosis is designed using a pressure system to do one of 4 things:

1 – Modify angular movements
2 – Modify translational movements
3 – Reduce axial load
4 – Modify the ground reaction force

However, when thinking about the upper limb, we’re concerned primarily with
modifying angular and translational movements.

Basic biomechanical principals to remember

The longer the lever arm, the less force required to do the job
The greater the surface area, the lower the forces
Biomechanics of the Upper Limb
Biceps acting as an elbow flexor.

F: The force of the biceps muscle

G: Weight of the forearm
a: Lever arm of the biceps muscle
b: Lever arm of the weight of the
forearm

The biceps flexion moment (F.a)

must be equal to the weight
moment (G.b). When the lever arm
of the muscle is small, the force
must be big to create a flexion
moment.

  Pronated position

Biceps acting as a forearm supinator

B: Biceps tendon
A: Tuberosity of radius

The biceps muscle inserts on the

tuberosity of the radius. When the forearm
is pronated, the muscle force acts from the
point where the tendon first gets in contact Middle position
with the bone.

This creates a rotating moment. The

biceps muscle will therefore supinate the
pronated forearm, from the pronated
position to the middle.
Forces about the arm when carrying an object
F: The force of the biceps muscle
G: Weight of the forearm
a: Lever arm of the biceps muscle
b: Lever arm of the weight of the forearm
C: lever arm to weight
W: weight of object

The biceps flexion moment (F.a) must be equal to the weight moment (W.c +
G.b). As the weight moment is greater when carrying an object, the force
required by the biceps to flex the elbow is greater.
Trans-radial stump/socket forces
F= force on distal end of the stump
W = weight of the ball + weight of the prosthetic hand
a = stump length
l = length of prosthesis
b = stump length

If a trans-radial amputee was carrying a ball in the prosthetic hand as above,

since b is shorter than a, the force on the short stump (F’) will be bigger than on
the long stump (F). From the same calculation, a shorter prosthesis (l) will give a
smaller force on the end of the stump.

Trans-humeral stump/socket forces

If a trans-humeral amputee was holding a ball in the prosthetic hand, since the
length b is shorter than a, the stump force of F’ on the short stump, is bigger than
the force F on the long stump. This shows that the force is greater on a short
stump than a longer stump when carrying the same weight.
f = force on the distal end of the stump
w = weight of the ball + weight of the prosthetic hand
a = stump lenth
l = length of prosthesis
b = stump length

,
Upper Limb Prosthetics
Levels of Upper Limb amputation
Partial hand amputation
Any amputation of fingers, metacarpals or rays is defined as a partial hand
amputation.
It is difficult to fabricate a partial hand or finger
prosthesis that is functional and cosmetically
acceptable. (They can be functional or cosmetic,
but rarely both). Specially designed partial hand
prostheses may be fabricated for functional tasks
and may be provided along with a cosmetic
prosthesis which can be interchanged according to
the patient’s needs. Off the shelf cosmetic
prostheses are available to replace part of the
hand or finger. Alternatively these can be custom
made with silicone rubber.

Wrist disarticulation
A wrist disarticulation maintains a functional forearm that can pronate and
supinate as well as a means for good force transmission. The shape of the distal
end may allow self suspension of the socket proximal to the styloid processes,
however for heavier work, extra straps may be required. Designs incorporating
panel opening or a split socket are common.
A wrist unit will add to the overall length of the prosthesis if it is desired to allow
interchangability of terminal devices. There will have to be a compromise
between cosmesis and function.

For children with a wrist disarticulation, as they grow, the growth of the affected
side will be less than the contralateral side, so the overall length of the prosthesis
and the use of a wrist unit may not be a problem in older age.

Trans-radial amputation
An amputation through the radius and ulna is called a trans-radial amputation.
Maintaining part of the forearm, however small, provides advantages for the
individual compared to proximal amputations. The main advantage is the
retention of the function of the elbow joint, but as the amputation moves proximal
the range of flexion is reduced. In the case of long trans-radial residual limbs,
almost normal pronation and supination will be retained. As the amputation
cxmoves proximal less and less pronation and supination is possible, but this can
be compensated by humeral abduction and adduction.

With the elbow intact, there is the possibility of using the humeral condyles to
suspend the prosthesis, much like a trans-tibial socket.

Elbow disarticulation
The distal shape of the elbow disarticulation will provide suspension and rotation
control in comparison to the trans-humeral amputation however, the extra length
of the residuum will require the use of external elbow hinges. These hinges will
only allow forearm flexion and extension and locking in a fixed number of
positions. The supination and pronation of the forearm can only be achieved
through humeral rotation. Other disadvantages of the external hinges are that
they increase the M-L width at the elbow and can cause wear and tear to the
clothes.
 Elbow disarticulation socket pressures
(Adapted from CSPO, 1997, 48)

Distal limb may provide suspension

for a lightweight prosthesis however
if greater function is required,
additional suspension and control
straps will be required. Consideration
should be given to the needs of the
patient prior to amputation at the
elbow disarticulation level, it may be
more beneficial to amputate at trans-
humeral level to enable the use of
different elbow mechanisms.

Trans-humeral amputation
The distal third of the humerus is the ideal amputation level for trans-humeral
amputations. This length allows good force transmission while also providing
enough space to use standard elbow mechanisms.

If the amputation level is more proximal often the socket needs to be made with
“wings” around the shoulder area, to assist in stabilization and transfer of forces.
This will restrict shoulder movement.

Body powered control systems may be used to activate elbow flexion and
terminal devices. As the length of the stump decreases, so does the possibility of
using body powered systems because:
 there is a reduced cable excursion available (flexion or abduction of the
shoulder results in less overall movement.)
 lower mechanical efficiency (the lever arm is reduced and thus much
more muscle activity is needed to produce the same actions.)

One problem for trans-humeral amputees is that using a harness to activate

elbow flexion / extension can require a lot of force. This is particularly true when
the arm is being used to hold something heavy, or the terminal device (especially
externally powered devices) is heavy. This may be compensated for by the use
of elbow components that combine a spring to assist in forearm flexion, or by the
use of external power.
Upper Limb Prosthetic Components

Terminal device
The terminal device is the component used to replace the missing hand.
Terminal devices can be active or passive and may be shaped like a hand or
hook or be a specialized tool required by the patient to carry out their functional
tasks.

Passive terminal devices

Many people find using an upper limb prosthesis more difficult than carrying out
functional activities without a prosthesis. A functional prosthesis can be
cumbersome and / or bulky, making cosmesis an issue.

Passive devices are often more cosmetically acceptable. In addition to cosmesis

the device may be useful for some activities such as carrying a bag, holding
handle bars of a bike, or simply acting to stabilize an object the other hand is
working on. There are various passive devices available which can have
different functions. Some have bendable fingers that can be positioned to hold
objects and some have attachments for tools.

Interchangeable tools for

use as terminal device
(adapted from Bowker &
Michael, 1992, p112)

Active terminal devices (Prehensile)

Active terminal devices or prehensile devices can be used to grasp objects. They
may be either voluntary opening or voluntary closing devices.
 Voluntary opening devices are held closed by a spring or rubber band and
opened when the controlling cable is pulled.
 Voluntary closing devices are held open and will close when the
controlling cable is pulled.

Active devices come in two basic variations – those that look like hands, and
those that are like “hooks”.
Hooks
Using a split hook as a terminal device provides greater functional abilities. It is
more mechanically efficient than a hand and has the ability to grasp large and
small objects. It is light weight and enables the user to see the surfaces grasping
an object. The hook however may be unacceptable from a cosmesis perspective
for some users.
 Voluntary opening Prosthetic
hooks, (adapted from Bowker &
Michael, 1992, p 109)

Hands
 Active prosthetic hands have limited
prehension ability due to friction
within the mechanics of the hand
and resistance of the cosmetic
cover. Due to the lack of precision,
hands may be difficult for bilateral
amputees to use with any great
function.
One disadvantage of hands is that
they block the view of the object that
the patient is trying to grasp.

Voluntary opening prosthetic hands

(adapted from Bowker & Michael, 1992,
p114)

Special and custom made terminal devices

Some people may require specialized tools to carry out their specific work duties
or hobbies. Terminal devices can be custom made to suit the needs of the
wearer or there is also a range of special terminal devices that can be ordered
from prosthetic companies.

Body Powered:
Body powered prostheses use a combination of harness, control straps and
cables along with body movements to operate prosthetic components such as
the terminal device or elbow units.
 Advantages of using body powered prostheses are that they are reliable,
low cost and light weight. They have less moving parts and thus require
less maintenance than externally powered devices.
 Disadvantages of using body power to control the prosthesis are that the
control systems (harness and straps) need to extend to the contralateral
side of the body and they require large body movements to operate the
device. The more proximal the amputation level, the more difficult it is to
use a body powered prosthesis because of reduced leverage and limb
length.

Eg. For a trans-radial amputee, elbow extension, shoulder flexion and shoulder
girdle abduction operates the terminal device. The cable can be adjusted so that
the person can work the terminal device in their own comfortable position.

Externally powered:
Externally powered prostheses use an external device such as batteries to
operate the prosthetic components. These devices can be expensive, less
reliable and require more maintenance than body powered devices.
Currently, the myoelectric prosthesis is the most commonly used externally
powered upper limb prosthesis.

Myoelectric prostheses
The prosthesis is controlled through
muscle impulses. Electrodes are
placed on the skin of the stump and
when the muscle contracts, it receives
the electrical impulses from the
muscle. The muscle impulses are
amplified 300 000 times, through the
use of a battery, to make enough
power to operate the prosthetic hand.
The electricity from the muscle
impulse does not run the motor of the
prosthesis.

It must be stressed that the

myoelectric device is not “bionic”. The
patient has to be trained to make
separate muscle contractions, and that
these contractions will trigger the
movement of the motors in the hand.
The hand does not feel, and the
patient doesn’t just make the hand
move by “thinking about it.”

Myoelectric prostheses can be used for all amputation levels. The electrodes
however should be placed on large muscles if possible.

For example for a trans-radial amputee the most common area for electrode
placement is one on the extensor muscle group and one on the flexor muscle
groups of the forearm. The terminal device can then be opened by using the
extensor muscles and closed by contracting the flexor muscles.

Wrist units
Wrist units attach the terminal device to the prosthesis and allow active or
passive pronation and supination so that the terminal device can be positioned
as desired by the amputee. The terminal device screws into the wrist unit.

 The quick disconnect wrist unit may be used if the amputee needs to change
terminal devices often as it allows easy disconnection so that terminal
devices can be changed.
 The screw fitting wrist unit also allows interchange of terminal devices
through screwing the device onto the unit.
  The permanent fixation wrist unit does not allow changing of the terminal
devices.
 Wrist flexion units have advantages for bilateral upper limb amputees to
angle the terminal device. These are usually not necessary for unilateral
amputees.
 Multi-directional ball and socket wrist joint
 Rotational wrist units are controlled by a cable and provide greater resistance
to rotation than friction units
 Friction wrist unit in which the amputee can manually rotate the terminal
device to replace supination/pronation
 Constant friction wrist units provide constant friction throughout the rotation
range.

a b c

Prosthetic wrist units; constant friction (a), quick disconnect (b) & Flexion wrist (c).
(Adapted from Smith, Michael & Bowker, 2004 p124)

Elbow units
There are some body powered elbow units available for trans-humeral amputees.
They provide forearm flexion and the ability to lock the forearm in certain
positions of flexion as well as internal and external rotation of the forearm to
replace internal/external rotation of the humerus. The units can be locked into
position through body powered cable or the contra-lateral hand. In the case of
long trans-humeral amputation or elbow disarticulation external locking elbow
hinges are used so as to maintain an acceptable prosthesis length. The external
devices cannot provide rotation of the forearm.

Elbow units; external hinge (a) and

internal unit (b) (Adapted from Smith,
Michael & Bowker, 2004 p127)

When using the external elbow hinges, often one is a locking hinge and one is a
free hinge. The locking hinge may be placed medially or laterally. If it is lateral it
is easier to operate however more noticeable as it is more bulky than the free
hinge.
In the case of cosmesis being more of a priority, friction or free motion hinges or
a ratchet hinge are all possibilities. The ratchet hinge however has a clicking
noise during forearm flexion and the prosthetic hand is unable to press
downwards to steady objects.

Shoulder units
A shoulder unit is not always necessary for shoulder disarticulation or forequarter
amputation prostheses. Most shoulder units available allow passive movement
which may be useful to assist with positioning the prosthesis.
However, passive movement might make the limb unstable if it is used to “hold”
an object while the other limb applies a force to it.

ICRC components
The ICRC elbow unit is made of polypropylene and has a manual elbow lock and
friction rotation control to position the elbow and forearm. There is a
polypropylene wrist unit, split hook made of stainless steel and a polypropylene
passive hand that can be screwed into the wrist unit.
Harness designs
There are three basic harness designs, the “Figure of 9” harness, the “Figure of
8” harness and the Shoulder saddle harness with chest strap. The designs may
need to be modified for some amputees, depending on their functional abilities,
strength and activities that are required to be carried out with the prosthesis.

The Figure of 9 harness is primarily

used for self suspending sockets that
only require the harness to operate
the terminal device, not to suspend
the prosthesis.

Figure of 9 harness. (Adapted from

Smith, Michael & Bowkder, 2004, p135)

The figure of 8 harness is the most popular harness and can be used to suspend
the prosthesis and control the terminal device.

(adapted from Bowker & Michael, 1992, pg135)

 (Adapted from CSPO, 1997, p43)
Figure of 8 harness
The shoulder saddle harness is a heavy duty harness. It will assist amputees
who do a lot of heavy lifting and will suspend the prosthesis and control the
terminal device.

(Adapted from Smith, Michael & Bowker, 2004, p134)

Shoulder saddle harness system
It is important during patient assessment to find out the patient’s aims and ab
ctivities they want to be able to carry out with the prosthesis. The prosthetic
design and component selection will relate to the findings during the assessment.

For example, if your patient needs to get back to work on a construction site then
you will need to consider the most appropriate terminal device that will be
functional for him.
Trans Radial Socket Designs
Sockets should be designed to:
 Be comfortable
 Provide good force transmission
 Use as much residual limb movement as possible

There are many variations of socket design for trans-radial amputations, with four
basic types. The use of each type is similar to Trans-tibial socket design and
depends on the length of the stump, the activity level of the patient and their
intended activities.
The four basic designs of TR socket are:
- Plug-fit (or standard)
- North Western
- Muenster
- Strathclyde Supra Olecranon socket

Plug fit
As the name suggests this is a very basic design, which uses circumferential
pressure (and sometimes end bearing) to transfer forces between the stump and
the prosthesis. The anterior and posterior aspect of the socket are flattened to
provide rotational control. It can be used in patients with long stumps with good
soft tissue coverage. The anterior trimline is usually quite distal to allow a full
range of flexion. The medial and lateral trimlines are distal to the level of the
epicondyles and the posterior trimline is at the level of the olecranon. This allows
for a full range of supination/pronation. It is not self suspending and thus requires
a harness.

North Western supracondylar design.

The basic function of this design is very similar to that of a PTB-SC. The socket
has medial and lateral flares that come proximal to the epicondyles of the
humerus and provide suspension. The addition of the flares on the medial and
lateral aspect of the socket also assist in keeping the prosthesis stable and in
transferring forces. This type of design is often used for patients who have long –
medium length stumps.

Muenster
The basic function of this design is very similar to that of the PTB-SCSP. The
socket has medial and lateral flares, as well as a posterior trimline that comes
proximal to the olecranon (like the suprapatella section of PTB-SCSP). It
provides very good suspension and stability for medium-short stumps.
The trimlines of this socket are very “high”. The anterior trimline is often proximal
to the level of the cubital crease and the posterior trimline encloses the
olecranon.
One disadvantage of this design is that it limits the range of flexion and extension
available to the patient, however as patients with short stumps usually have a
reduced range of motion it is far more important to provide a stable socket.

The ROM from elbow extension to

elbow flexion with the Muenster
socket is about 70 degrees – from
about 35 degrees of extension to
about 105 degrees of flexion.

Flexion Extension

Strathclyde Supra Olecranon socket (SSOS)

The SSOS suspends mostly over the area above the olecranon on the triceps
tendon. The socket has medial and lateral “wings” that extend over the
epicondyles parallel to the humerus. The main purpose of the wings are to
maintain the position of the socket on the limb, not to provide suspension..

Like the Muenster design the SSOS limits the range of extension available to the
patient.

In the case of long trans-radial residual limbs, almost normal pronation and
supination will be retained. Provision of a full length socket to a long trans-radial
limb will block the pronation and supination however a shorter socket will not
provide good force distribution and attachments for straps. Restricting pronation
and supination can be overcome by humeral abduction/adduction or rotation of
the wrist unit.

The designs discussed so far have distinct differences, but sometimes patients
have various needs that cannot be met by one design alone. The following
discussion focuses on the variations that can be made by altering trimlines.
Trimlines
 The anterior trimline will vary depending on the length of the stump. A long
stump does not need a proximal trimline, a short stump will need a very
proximal trimline. (Again, this is similar to Trans-tibial sockets).
 Should be trimmed to allow maximum flexion of the elbow joint.
 Medial and lateral trimlines should extend up to the centre of the medial
and lateral condyles, and in the case of supracondylar suspension the
trimlines are proximal.
 Posterior trimline extends to just distal to the olecranon or covering the
olecranon with a relief for this area.

The purpose of the medial and lateral trimlines are

 To allow attachements for suspension to be positioned close to centre of
elbow joint
 To protect the epicondyles from pressure from the attachments.

Anterior trimline
 For a long trans-radial stump the trimline can be 1/3 of the distance from
the distal end of the stump.
 The medium length trans-radial stump will require the trimline to extend to
2/3 of the distance from the distal end of the stump.

 The short stump will require a trimline to extend to the cubital crease or
more proximal.
If the anterior wall is extended more proximal, the amount of available flexion will
be reduced, between 70 to 90 degrees of flexion is satisfactory in this case. The
prosthetic forearm may be pre-flexed to about 30 degree to provide a more
functional position of the terminal device.

“Step up” hinges may be used which increase the range of flexion that can be
obtained. They are fitted with geared mechanisms that increase the range of
movement by 2 to 3 times. There is however an increase in force required to flex
the forearm which must be considered prior to prescription.
Self suspending sockets
As the name suggests these are sockets that are held on by themselves. This is
usually through using the shape of the skeletal structures around the elbow joint.

The advantages of using a self suspending socket are:

 it is easier to don and doff (does not require suspension harness).
 it is less restrictive to the contralateral side.
 when using with body powered components, a self suspending socket
can be used with minimal control straps.

Disadvantages of self suspending;

 Restriction of elbow range of motion.
 Restriction of pronation and supination.
 May cause discomfort over suspension areas for patients doing heavy
work.

Indications to a self suspending:

 When cosmesis is important.
 Passive use
 Scarring on ipsilateral axilla.
 Patient preference.
 Short stump.

Contraindications to a self suspending:

 Early post operative stage (may require suspension straps for added
security)
 Fitting of children (the child may require suspension straps to prevent the
child removing the prosthesis).
 Scar tissue or a skin graft over the area of suspension.

Harness suspension sockets

The use of a harness suspension for a trans-radial amputation may be required
if:
 The amputee has a short stump and is a heavy prosthetic user.
 New amputee with oedema and pain
 Where retention of the prosthesis is the major importance
 Bilateral amputee, depending on the entire prescription.
 Amputee who has always had this system and does not want to change.
 Young child to prevent them removing the prosthesis
Casting
Casting for a trans-radial prosthesis
A thorough patient examination should be conducted prior to prescription and
casting.

During the casting procedure, mark the bony prominences and any areas that will
need to be modified in the rectification process.

Apply a thin stockinet over the stump ensuring the tissues are not distorted.

Secure the stocking with an elastic strap placed in a figure of 8 around the
contralateral limb.

1. Landmarks
Mark bony prominences and other important areas on the stockinet:

 Medial and lateral epicondyles

of the humerus
 Olecranon process
 Cut end of radius and ulnar
 Scarred areas
 Graft areas
 Neuromas
 Approximate proximal trimline

Ensure all measurements are taken: Residual limb:

Sound side:  Distance from the medial
 Distance from the medial epicondyle to stump end
epicondyle to tip of thumb  Proximal and distal stump
 Circumference at circumference
metacarpophalangeal joints  Diameter at epicondyles and
above epicondyles
Standard socket
Casting position
The stump should be in about 45 to 60 degrees of flexion and neutral
pronation/supination. The stump flexion position is important when trimlines are
to extend proximal to the elbow to allow easy identification of olecranon and
epicondyles.

Applying some pressure over the posterior and anterior radius and ulnar will help
to stabilise the limb in the socket, preventing rotation.

Plaster application
Apply plaster bandage over the stump. Standard trans-radial casts are usually
not difficult to remove however if you notice that there may be a problem then
you may need use a slab or cut the cast off. During casting ensure position of
stump is maintained. Once the cast is
removed, it will be used as a “check socket”,
in order to ensure correct trimlines
Remove the cast from stump and trim it to the
desired trimlines and re apply it. You may put
a small hole at the end of the cast and use a
pull through stockinet to position the cast onto the limb. The proximal trimline can
then be ascertained by flexing and extending the elbow and modifying the trim so
that the socket will be comfortable and functional.

Ask the patient to flex the elbow. Look to see if the

socket is pushed off the stump, or if there is excessive
pressure on the olecranon. If this is happening, the
anterior trimline is too proximal.

Ask the patient to extend the elbow. Look to see if there

is any gapping around the anterior trimline. If this is
happening the posterior trimline is too proximal, or too
tight upon the triceps tendon.

The posterior trim should provide clearance around the

olecranon.

In the case of a short stump and Muenster style socket, we have to accept that
movement is restricted. Check to ensure that the trimlines are not overly
restricting movement.

Alignment lines
To ensure the hand and wrist units are positioned correctly during fabrication,
alignment lines must be drawn on the negative case. One line should be on the
lateral side of the cast and one on the anterior side of the cast to indicate the
position of the wrist unit in both planes.
The length of the prosthesis should
also be determined at this stage.
The length of the prosthesis is the
distance from the medial
epicondyle to the distal tip of the
thumb on the contra lateral side.

North Western Supra-

condylar suspension
socket
Casting for the supra-condylar
suspension socket should be done
in elbow flexion:
- 80-90 degree for very short residual limbs
- 70 degrees for medium length residual limbs
The supracondylar suspension will be difficult to don for long stumps.

Care should be taken to mould over the epicondyles.

Muenster socket.
The muenster socket was originally designed for very short trans-radial stumps. It
has a limited range of flexion and extension but is useful on short stumps to
prevent pistoning or when another design will not suit the anatomy of the limb.
During casting the limb should be held in 90 degrees of flexion.
Pressure is applied along both sides of the biceps tendon anteriorly and proximal
to the olecranon posteriorly. There is some pressure applied to the supracondylar
area however less than in the supracondylar suspension socket.

Once the cast is hardened, remove it carefully. It should suspend very well on the
patient, but should be able to be removed by flexing the elbow and pulling from
the proximal posterior edge.

Use cast scissors to cut out the trimlines and then place the cast back on the
patient. (A small hole may be needed in the end of the socket and a pull sock
used to don the cast fully.)

When the cast has been trimmed to the appropriate trimlines, reapply the cast
and check the amount of flexion possible (it should be approximately 70 degrees)
Now mark a midline on the cast, both on the lateral side and the anterior side.
Initial Flexion
As short trans-radial stumps have a limited range of motion, and then a Muenster
style socket limits motion further, the device needs to be made with some
additional flexion. Otherwise the patient will never be able to use the prosthetic
arm for any activities near their head.

In the case of a Muenster socket, it is usual to “pre-flex” the forearm by approx.

30 degrees.

In picture A, the forearm is aligned parallel to the long axis of the stump. The
amputee will have trouble bringing the terminal device up to his mouth. This is
because he can not flex the elbow much more than 70 degrees with the
Muenster socket.

A
In picture B, the forearm has been flexed in relationship to the long axis of the
stump. The forearm can be flexed up to about 35 degrees in relationship to the
long axis of the stump. This will help the amputee to bring the terminal device up
towards his mouth. Flexing the forearm more than 35 degrees will cause poor
cosmesis when the elbow is extended.

Strathclyde Supra Olecranon Socket (SSOS)

The SSOS suspends mostly over the area above the olecranon on the triceps
tendon. The socket has medial and lateral “wings” that extend over the
epicondyles parallel to the humerus. The main purpose of the wings are to
maintain the position of the socket on the limb, not to provide suspension. The
anterior section of the socket again is the only area that changes depending on
the length of the residuum.

The cast is taken with the elbow at 90 degrees flexion which is crucial to ensure
the suspension is effective. The forearm is neutral in pronation/supination. In the
case of abnormal positioning of the limb, ie contractures, the pronation/supination
position may be adjusted and should be in the relaxed position when arms are by
the side.
During casting the shape of the proximal section should be defined in the areas
of the epicondyles and superior to the olecranon. The position of the hands
above the epicondyles should lie parallel above the condyles. The fingers should
be parallel with the residuum and each other. If the prosthetist’s hands are not
large enough to ensure parallel loading then both hands should be used.
Narrowing the cast anteriorly could prevent flexion and narrowing the cast
posteriorly could prevent extension. Posteriorly, mould to the shape of the arm
just above the olecranon.

Measurements
M-L measurement; the tissue should be compressed so that the caliper cannot
slide down over the epicondyles.
M-L over apex of epicondyles.
Plaster wrap; start at distal end of the stump. At the elbow region the bandage
should be wrapped in a figure of 8 sequence then place hands in the desired
position.
To remove the cast you will have to make a split in the cast posteriorly to about 3
cm distal to the olecranon.
Use the cast as a check as described in previous section. In this socket design,
elbow extension will always be limited to 15-20 degrees. Patients will
compensate by extending at the shoulder joint so that the prosthetic hand is in a
more relaxed position.

Draw the alignment lines on the cast and also indicate where, on elbow
extension, the proximal socket contacts the lateral border of the humerus so that
a relief area can be built in during cast rectification.

Cast modification
1. Check measurements
2. Remove plaster from areas where additional loading is required.
3. Build up in relief areas; olecranon, epicondyles, lateral border of the humerus,
distal relief areas.
Fabrication
(The following instructions and pictures for manufacture have been taken from
the ICRC manufacturing guidelines)

Alignment lines (A-P,

M-L) are drawn on the
positive mould for
proper positioning of
the wrist. In most cases
this will be along the
central axis of the trans-
radial stump.

Drive nails into the

distal end of the cast to
ensure good adherence
for the build-up of the
plaster extension.

Positioning the wrist

Make a conical extension

tube using EVA, plastic
sheeting or some other
suitable material and place it
according to the alignment
lines for wrist positioning.
Tape the cone in place.
Fill the extension cone with
plaster up to 5 mm higher
than the level of the wrist, so
as to leave room for shaping
the correct angles of the
wrist.

Prolong the proximal alignment lines along the plaster extension in order to
facilitate positioning of the polypropylene wrist.
The measurement from the olecranon to the radial styloid process of the sound
side will determine the length of the prosthesis to the distal end of the wrist unit.

The length of the prosthesis should be 2 cm shorter than the sound side, never
longer.

Polypropylene draping
Before draping the polypropylene sheet, pull a stocking over the plaster mould.
Cut it at the proximal part of the wrist and fix it with contact glue. Dust the
stocking with talcum powder.
Measurement of polypropylene sheet:

Wrist circumference + 2 cm

Epicondyle circumference + 4 cm

Length of plaster cast + 15 cm

Thickness 3 or 4 mm, depending on patient

Heat the polypropylene in an oven for about 20 minutes at 180° C.

Drape the polypropylene over the plaster model and stick the sides together
along the posterior side. Tighten the polypropylene around the suction cone or
tube using a bicycle inner tube, rope or stocking, then open the vacuum valve.
Using scissors or a knife, cut off the leftover polypropylene of the welding seam
while it is still hot.

Keep the vacuum on

until the plastic has
cooled down.

Remove the plaster,

shape the socket trim
lines and grind the
posterior welding
seam.

Drill a hole (dia. 20 mm) on the medial/distal side for pulling the stump socket.
Flatten the polypropylene on the distal end of the wrist.

Attaching Figure 8 harness

After taking the cast, the suspension straps can be attached to determine
appropriate position, alignment and length. The same method is used after
fabrication to attach the suspension straps to the socket. This section describes
attachment of suspension and control straps for a fibure 8 harness.

1. Position chafes close to the centre of rotation of the elbow joint

(epidondyles. They should be positioned on the longitudinal mid line with
the D-ring as close to the centre of the elbow joint as possible. The medial
and lateral trimlines should be high enough so that the D rings do not
impinge on the epicondyles.
 2. When looking into the cast, the attachment points of the chafes should
both be in the midline of the socket.

The anterior v strap is attached to the rings (1/2 way between olecranon and
acromion and to the medial side of the arm) followed by the posterior retaining
strap which will prevent the stump from lifting out of the socket during axial
loading in elbow flexion.
Use pins or clamps to fix the straps in position. The anterior suspension strap is
fitted to the anterior strap and runs over the shoulder of the amputated side
under the axilla of the sound side. The posterior suspension strap is fitted to the
back strap and runs upwards over the contralateral shoulder. The anterior and
posterior straps should cross slightly towards the sound side from the midline of
the back.

The terminal device strap runs from where the straps cross posteriorly down
towards the prosthesis.
Socket design for elbow disarticulation
The socket for elbow disarticulation level may need to be split, have a removable
panel or a built up liner so that it can be donned easily.

Split socket for elbow disarticulation. (Adapted from CSPO, 1997, p48)

The forces required and the mounting areas of the elbow hinges must be
considered when positioning the split or removable panel. In the case of a
cosmetic prosthesis, suspension may be sufficient proximal to humeral
epicondyles. However additional suspension may be required for heavier tasks
as this area is not tolerant to high pressures. Silicone suspension systems may
also be used where cost is not an issue.

To provide rotational stability, the distal anterior and posterior socket is flattened.
This however may change the shape of the socket to make it less cosmetically
acceptable. The socket may be extended proximally with anterior and posterior
wings at the proximal humerus and shoulder joint. This will also prevent rotation
of the socket on the residuum while also allowing normal humeral rotation. The
long stump length will require the socket to be open at the shoulder area to allow
easy donning and prevent stump bridging. Suspension and control straps
required for this socket are similar to trans-humeral systems. Measurements
required are shown below
Forearm
Once the socket is made and joints fitted, a custom made forearm is fabricated to
match the ML size at the elbow. Some pre fabricated forearms are available
through companies also.
 Trans-humeral socket design
There are two socket designs used
for trans-humeral amputations. The
over the shoulder design consists of
a proximal socket trimline that
extends over the shoulder to allow
suspension forces to be taken
through the socket which reduces
the harness forces. The over the
shoulder socket will limit the amount
of humeral abduction available.

a.

(adapted from CSPO, 1997, p52)

Alternatively, a second socket design is one in which the proximal trimlines are
positioned below the acromion level, relying on harness straps for suspension. A
greater range of shoulder abduction is available with this socket design.

b.

(adapted from Smith, Michael & Bowker, 2004, p879

It is more difficult to self suspend a trans-humeral prosthesis when compared to

transradial sockets due to the shape of the limb. Suction and traction must be
used to self suspend a trans-humeral socket which requires a close fitting socket,
leading to difficulties in donning and if volume fluctuations are an issue. Again a
silicone suspension system may be used however will greatly increase the cost.
Casting
Prior to casting, mark the acromion and any sensitive areas on the stump. You
can also draw in your desired trimlines and ensure to take all measurements
required.

Measurements of residuum:
 Distance from acromion to end of residuum
 Distance from axilla to end of residuum
 Circumference distal and proximal residuum

Sound side measurements:

 Distance from axilla and acromion to epicondyles
 Distance from epicondyles to styloid process and tip of thumb
Position of hands for Trans-humeral casting. (adapted from Bowker & Michael 1992, p261)

During casting for a trans-humeral prosthesis, a wide slab may be applied to the
proximal section of the cast and pressure applied anteriorly and posteriorly to the
shoulder joint, to form the “wings” which will prevent rotation of the socket on the
limb. Wrap the residuum distally with the limb in an adducted position. The
mediolateral stability of the socket on the residuum will be provided by applying
forces on the medial and lateral aspects of the humerus. The medial hand should
be able to also identify the height of the medial wall in the axilla area.

Anterior and lateral alignment lines will need to be drawn prior to removing the
cast from the client. These should originate from the acromion.

Build ups will need to be made on the positive cast at the acromion, stump end
and the axilla line should be lowered 5 mm and rounded to make a comfortable
shape for your client.

Trans-humeral components
Elbow mechanisms
Trans-humeral elbow mechanisms are designed for body powered systems and
require a locking mechanism so that when the forearm is flexed to the desired
position, the elbow will lock so the amputee can then relax. Locks can be
automatic whereby they are activated by body power or hand operated by the
contra-lateral side.
With body powered elbow set up, there are usually 2 different control cables, one
to operate the elbow locking and the other to operate the terminal device and
elbow flexion.

The control cable for the forearm flexion sits across the wearer’s back to the
posterior socket at axilla level. The cable then runs medially or laterally around
the humeral socket through a lift level attached to the forearm and then the
terminal device. To operate the terminal device, the person must flex the
shoulder joint. The terminal device will only operate when the elbow is locked. If
the elbow is not locked, the action of shoulder flexion will flex the forearm.

(Adapted from Smith, Michael & Bowker, 2004, p135)

Trans-humeral control system with 2 control cables

The control cable for the elbow locking mechanism runs from the elbow lock
anteriorly to a point passing over the shoulder on the sound side. Humeral
extension and some abduction will work the lock. The first pull of the cable locks
the mechanism and the next will unlock it.

As the trans-humeral control cable is longer and has more bends in it, it is less
efficient than the trans-radial cable control, therefore when setting up the
prosthesis the friction resistance must be kept as low as possible.
 Fabrication of trans-
humeral socket
(The following directions and
photos have been taken from the
ICRC manufacturing guidelines
for trans-humeral prostheses)

Alignment lines (A-P, M-L) are

drawn on the positive mould for
proper positioning of the elbow
cup. In most cases, this will be
along the central axis of the
trans-humeral stump.

Drive nails into the distal end of

the cast to ensure good
adherence for the build-up of
the plaster extension.

Positioning of the socket cup for the

elbow unit

Make a conical extension tube using

EVA, plastic sheeting or some other
suitable material and position it
according to the alignment lines for the
elbow cup. Tape the cone in place and
fill it with plaster up to the level of the
proximal end of the elbow cup.
Prolong the proximal alignment lines along the plaster extension in order to
facilitate positioning of the elbow cup.

The

measurement from the acromion to the lateral epicondyle of the sound side,
minus the distance from the elbow axis to the distal end of the elbow cup, will
determine the length of the trans-humeral socket.

Drive a nail into the distal part of the build-up to ensure good adherence of the
cup, and fix the cup in proper alignment with wet plaster in accordance with P&O
standards (use an alignment table if available).

Polypropylene draping

Before draping the

polypropylene sheet, pull a stocking over the plaster mould. Cut it at the proximal
part of the elbow cup and fix it with contact glue. Dust the stocking with talcum
powder.

Measurements for polypropylene sheet:

Cup circumference + 2 cm
Acromion circumference + 5 cm

Length of plaster cast + 15 cm

Thickness of sheet: 4 mm

Heat the polypropylene

in an oven for about 20
minutes at 180°C.
Drape the
polypropylene over the
plaster model and stick
the sides together
along the medial side
of the socket. Tighten
the polypropylene
around the suction
cone or tube using a
bicycle inner tube, rope
or stocking, then open
the vacuum valve.

Assembly

Remove the plaster, shape the socket trim lines and grind the medial welding
seam.
Flatten the polypropylene on the distal end of the elbow cup.

Assemble the elbow unit and cut the forearm according to the measurement. The
length of the forearm, including the hook, should be 1 to 2 cm shorter than the
sound side. Fix the wrist unit with 4 pan head Phillips framing screws (8 x 3 mm).
Shoulder disarticulation and forequarter amputation
The patient’s goals must be fully understood if providing a prosthesis for shoulder
disarticulation or forequarter amputation level. A compromise may have to be
made between function and cosmesis.
After a shoulder disarticulation, the shoulders are no longer symmetrical. A
tracing of the patient can be done to determine the build up required to improve
the cosmesis of the prosthesis.

With a forequarter amputation the entire shoulder girdle and upper limb are
removed, most commonly as a result of tumour. Providing a body powered
prosthesis for this level is impossible and therefore for a functional prosthesis
externally powered components must be used. This will make the prosthesis
heavy and perhaps not highly functional so should be considered very carefully
before prescription. A lightweight prosthesis may be provide to restore cosmesis.
Osseointegration
Osseointegration is a suspension method whereby the prosthesis is connected
directly to the bone of the residual limb. A titanium screw is surgically fixated into
the bone and after time the bone bonds to the screw. A second operation is
performed to apply an extension bolt through the skin. A prosthesis can then be
mounted onto this bolt. Myoelectrics are often combined with the osseointegrated

prosthesis.

The range of motion of the stump is not reduced because the amputee does not
need a socket and there are also no problems with sweating or pressure on the
stump from the prosthesis. Osseointegration may provide better feedback to the
patient regarding the use of the terminal device.

For transradial amputees, the titanium bolts are integrated into both the radius
and the ulna and the pronation/supination is not limited.
There remains some uncertainty as to the chance of infection in the area where
the bolt comes through the skin and whether there will be any problems with the
bolt or bone throughout the years.

References

Bowker, Condie, Bader & Pratt., Biomechanical Basis of Orthotic Management,

1993. ISBN 0-7506-1380-7

Bowker & Michael, 1992, Atlas of limb prosthetics

CSPO Upper Limb Prosthetics and Orthotics course work manual

CSPO training materials, 2004

Hoppenfeld, S. (1976). Physical Examination of the spine and its extremities.

Appleton-Century Crofts.

ICRC manufacture guidelines; trans-radial prosthesis

ICRC manufacture guidelines; trans-humeral prosthesis

La Trobe University Lecture Slides from presentation ‘Biomechanics in Orthotics’,

2004

Moore, Keith L., Clinically oriented anatomy, 1992. ISBN 0-683-06133-X

Palastanga, N., Field, D. & Soames, R. Anatomy and human movement.

Structure and function Ed. 4. Butterworth Heinemann, 2002.

Smith, Michael and Bowker, 2004, Atlas of amputations and limb deficiencies,
surgical prosthetic and rehabilitation principles, 3 rd edition.

http://classroomclipart.com

http://www.eorthopod.com/images/ContentImages/shoulder/shoulder_anatomy/s
houlder_anatomy_muscles01

http://mywebpages.comcast.net/wnor/intro.htm
http://daphne.palomar.edu/ccarpenter/images/Muscles/Muscle%20images

http://www.meddean.luc.edu/Lumen/MedEd/grossanatomy/dissector/muscles

http://en.wikipedia.org/wiki/Human_anatomy

http://depts.washington.edu/anesth/regional/plexusdiagram.gif
www.medicopedia.blogspot.com
http://classroomclipart.com