A referring surgeon has asked for an opinion/recommendation on the level for an upper extremity amputation. I don’t see enough upper extremity prosthetics to be comfortable with making this recommendation- your thoughts, ideas, questions would be appreciated.
This patient is a 35yo male, he is 5yrs out from a snowmobile accident that resulted in a completely flail right arm. He has a glenohumeral subluxation of approx. 2 inches. He has no pain. The only working musculature on his right arm and torso is the trapezius and pec minor. There is no muscle activity in the arm, deltoids, lats. There is no sensation in the arm, axilla, shoulder, or lateral torso. Approximately one year after the accident he had a nerve reconstruction of the brachial plexus which made no improvements. Approximately one year ago he had a nerve block at the cervical spine which did stop the pain. There is also some minor angulation to the humerus, he reports that the humerus was shattered in the accident and there is hardware, it appears to be mid-humerus. The patient is eager to amputate the arm, the entire arm if he had his choice. He owned and operated a small auto repair shop prior to the accident, he is no longer working. His main interests are fishing and snowmobiling(still).
He has not tried any type of bracing, I don’t feel that a flail arm brace would be appropriate due to the absense of sensation and the instability of the shoulder. He actually shows very little interest in wearing a prosthesis at this point. Would a shoulder disarticulation be his best option? Or maybe a transhumeral amp with fusion of the shoulder or surgery to stabilize the glenohumeral joint? It seems that his future options would be greater for prosthetics if there is a humerus to utilize for surface area, suspension etc. And with the recent advances in surgical techniques, upper ext. technology and components it is hard to predict what may be available to this young man in the future. Your ideas?
J. Owen CPO