Prosthetic Considerations for Patients With Quadrilateral Limb Loss

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By James Vandersea, CPO

Every patient has his or her own expectations, goals, motivations, and ideas of what to expect from a prosthetic fitting, and every clinical presentation has its own challenges. Treating patients with quadrilateral limb loss poses additional considerations for prosthetists.

A strong clinical team approach by including a PM&R physician, the prosthetist, and physical and occupational therapists is especially important for this patient population. The extended team may also include a plastic surgeon, orthopedic surgeon, adaptive driving instructor, and prosthetic manufacturers. For optimal rehabilitation results, it is imperative that perspectives from each team member be incorporated into the patient's global rehabilitation plan. Regular follow-up with the core rehabilitation team and monitoring of the patient's progress are lifelong commitments.

For good prosthetic management, you must understand your patient's desires, activities of daily living (ADLs), and goals. Ask questions about employment, hobbies, the home environment, and transportation needs. Educate the patient on the appearance and capabilities of the prostheses, and the transitions from one component to another as he or she progresses through rehabilitation.

When determining treatment order, fitting the patient with upper-limb prostheses first gives him or her some independence in eating and toileting. Additionally, the prostheses may allow the patient to propel a wheelchair, gaining mobility to better interact with the environment. Choosing whether or not to start a patient with myoelectric or body-powered upper-limb prostheses can depend on the amputation level and tasks to be accomplished. I have initially fit patients with bilateral body-powered devices with success. In some cases, a myoelectric device on one side can provide increased grip strength while a body-powered device on the other side provides fine motor dexterity. For transhumeral-level amputations, the strength and weight bearing capability of the prosthetic elbow needs to be considered. Most prosthetic elbows have a 50-pound weight limit, which will be exceeded if the patient arrests a fall with his or her prosthetic arms.

Once basic upper-limb ADL needs have been met, the team can address the lower-limb prosthetic needs. After assessing the patient's strengths and goals, he or she should be fitted with safe components that can help throughout the rehabilitation process. I fit patients with quadrilateral amputations with microprocessor knees whenever possible as the inherent stability of these devices offer increased stance stability, ambulation stability, and stumble recovery, reducing the risk of falls. People with quadrilateral amputations will have difficulty breaking a fall and regaining a standing or sitting posture by themselves should they fall.

Making sure prosthetic components are matched for height, weight, and activity level is important for a symmetrical gait. Prosthetic angles and heights should be as symmetrical as possible, with the exception of flexion contractures and other anatomical anomalies. Well-fitting prosthetic sockets that control the limbs in all planes are important in preparing patients to walk. Before the patient can begin ambulation, he or she should have good standing balance. As the patient begins ambulation, support using an overhead harness system, secure parallel bars, or staff assistance is vital to maintain stability. With hard work and a dedicated rehabilitation team, the patient can expect to reach his or her full potential in rehabilitation, vocational, and avocational endeavors.

James Vandersea, CPO, is a clinical prosthetist at Medical Center Orthotics and Prosthetics, Silver Spring, Maryland. He can be reached at .