Thanks heaps for your replies people. These have helped my patient make a
difficult decision and indicate why this list is so important. kind
regards, Richard
>Hi Richard
Interesting situation.
1. I would be extremely cautious about recommending amputation. The pain
situation is unlikely to change.
2. Does the patient understand the possible psychological effects of
amputation and the resulting effect on body image.
3. Has this man ever worn a flail arm orthosis? In my experience the
fitting of an orthosis, preferably at an early (within a few weeks of the
origonal injury) stage goes a long way to prevent pain problems. If an
orthosis has not been tried definitely try it before amputation.
4. A flail arm orthosis can easily be adapted to accept a prosthetic
hookwhich would probably give more function and be more cosmetic (as it is
easily removable when not required) than a tenodesis type orthosis. However
after this length of time using unilateral function it is unlikely to be
used.
5. A flail arm orthosis controls the “nuisance value” of his flail limb.
6. Look at “off the shelf” devices initially – easily and quickly fitted.
Check those by Steepers Queen Mary’s Hospital London UK
http://www.steeper.com/about.html and Wilmer
http://www-mr.wbmt.tudelft.nl/~wilmer/wdo-1.htm
Good luck
Bill Dykes
NCTEPO
University of Strathclyde
>Considering an amputation with a paralyzed arm is quite a decision.
Maybe the WILMER Carrying Orthosis is an option for treating your
customer. Are own websight is under construction, therefore, I would
like to ask you to visit the following website for product information:
www-mr.wbmt.tudelft.nl/~wilmer/
Under WILMER PRODUCTS you will find information on a shoulder orthosis and
on an elbow orthosis.
These products are currently available inside the United States through
National Labs Inc., Winter Haven, FL: Tel:(941)299-2664; Fax:
(941)299-7229.
Sincerely yours,
E. Eelco Kunst, MSc, PhD
>PLEASE PLEASE PLEASE!! Read up on the literature on this subject first
before jumping in. I would not say this idea is always a bad one but it is
terribly risky and irreversible. Amputation does not always resolve
neuropathic pain, and may even make it worse. Stellate ganglion block and
neurontin are the usual measures for pain these days in this situation I
had an old hand surgery/rehab textbook that described orthotic management,
possibly even using the existing muscles to oprate a terminal deivce
mounted on the orthosis, or if you are more ambitious, create a body
powered “tenodesis” style orthosis. The proximal joints could even be
passive pre-positioning devices that could be operated by the sound upper
extremity. I don;t know if I can find the book or not, but I bet someone
else on the list will have more details. Best regards, Vikki Stefans,
pediatric physiatrist (rehab doc for kids) and working Mom of Sarah T. and
Michael C., aka [email protected]
Arkansas Children’s Hospital/ U of A for Medical Sciences, Little Rock
…and EVERY mom is a working mom! (OK, dads too…)
>We have found in our “limited” experience that while amputation and
muscle transfer are excellent functional improvements following brachial
plexus injury, the pain is usually not resolved. I have been told that the
pain stems from the injury site itself or the inability of the
shoulder capsule to maintain the humerous within the glenoid. Often the
only resolution is shoulder fusion, again with mixed results. good luck.
Gary Berke MS, CP.
>do a thorough scapula MMT and ROM, too. surgically, you might consider
fusing the glenohumeral joint so that the scapular muscles (scapula
ab/adduction, upward and downward rotators) still functioning can be used
to position the TD in space. they are usually strong enough to operate a
TD as you will need to stabilize the prosthesis on the ipsilateral side to
get the contralateral side to activate a cable and hold the TD in a
functional position. research surgical techniques for the g-h joint as you
would for converting to a transhumeral level, even if you keep the elbow.
(as i recall relative to g-h neutral it is 30 degrees abducted, 30 degrees
flexed, 30degrees internally rotated all at the g-h joint) this gives
transfers humeral motion controlled by the scapula rom. often times then
function without a prosthesis with limited ipsilateral shoulder motion,
you should completely eval the donning and doffing ROM for harness
prescription. if the contralateral side has good ROM, dual control figure 8
will max function. if pt has
enough biceps return to actively flex the forearm for functional lifting,
single control cables with locking elbow and dual control harness would be
even better. look up the journal article with Alan Dralle about brachial
plexus fitting and strongly consider a outside locking hinge for
stabilization issues, with or without dual control cable
>amputation is NOT a solution to pain/paraesthesia, elect surgery for
function, but it will probably not solve the pain issues.
Ramona M. Okumura, CP
Lecturer, Division Prosthetics Orthotics
Dept. of Rehabilitation Medicine, #356490
School of Medicine
University of Washington
Seattle, WA 98195 USA
FAX (206)548-4761
>Have you thought of contacting BAPO for advice on this patient? They can
be contacted @bapo.com .
Please do not hesitate to contact me if I can be of any further help.
Laura Thompson
>I’m not going to be much help here, but one needs to consider the pain
issues as major problems. I have worked with amputees who had chronic pain
problems(ie.salvaged severe ankle fx’s) who opted for an amputation after
many years in pain and non-use only to get a missing limb that still causes
chronic pain but now they can’t even position it as they did previously to
limit discomfort for brief periods. This person should consult with a
first rate pain clinic for assessment. One shouldn’t think amputation
removes the pain!!!!!!! Molly Pitcher CPO
>Have you considered an orthosis in stead of amputation+prosthesis?
I’m an undergraduate student at the WILMER group of the Delft University of
Technology (in the Netherlands).
This group has done some R&D on shoulder and elbow orthoses which might
also be of interest to your case. More info is available on the net:
elbow orthosis: http://www-mr.wbmt.tudelft.nl/~wilmer/weo-5.htm
shoulder orthosis: http://www-mr.wbmt.tudelft.nl/~wilmer/wdo-1.htm
greetings
Hans de Visser
>Would you like to recommend amputation surgery to eliminate his
neuropathic pain or to improve hand function?
If your intention is to eliminate his pain, it would not be possible to
accomplish by below elbow amputation. Because his neuropathic pain may not
be from his hand or forearm but maybe from the injured brachial plexus
itself or more proximal structure as dorsal root entry zone of spinal cord
etc. So, he may have same or worse pain after the surgery.
If your intention is to improve his function, I think, it would be better
to design some special orthosis which resemble BE prosthesis. He would
still have his own arm.
Sorry for the above is only my opinion without any literature review.
So, may I ask you the summary of responses.
Thank you in advance.
Sun G. Chung M.D., Ph.D.
Dept Rehab Med
Seoul National University College of Medicine
Chong Ro Ku YeonGeon Dong Seoul
South Korea
(TEL)82-2-760-2619 (FAX)82-2-743-7473
>To my opinion a shoulderarthrodesis combined with a dynamic elbow
orthosis is a better approach in these cases.
At http://www-mr.wbmt.tudelft.nl/~wilmer/weo-5.htm you can read more about
the orthosis.
Sincerely
André Sol
Delft University of Technology
Man Machine Systems and Control group / Wilmer Research
Faculty of Design, Engineering and Production
Mekelweg 2, 2628 CD Delft, The Netherlands
phone : (+31)-15-2785622, fax : (+31)-15-2784717
>Hi, My practice received a similar request for advice a few years ago.
Our patient had even less residual function, and the surgeon suggested
transhumeral amputation with shoulder fusion to provide a stable base for a
prosthesis. He had read somewhere that it was advisable to fuse the
shoulder in 20 degrees of humeral flexion so the patient could eat with his
prosthesis. We suggested that he ask the patient how he was presently
eating, and the patient responded, rather logically, that he ate with his
contralateral hand. We also asked the surgeon to consider whether anyone
would care to walk around with a residual humerus always at 20 degrees,
with or without a prosthesis, as though constantly waving to the crowds.
The amputation was done at the distal third of the humerus, and the
shoulder was fused in neutral position. Two post-surgical observations may
be noteworthy. • The amputation did little to relieve pain, and
the patient continued to require aggressive pain management. He reported
some reduction of pain when wearing the prosthesis. • At the time
of prosthetic fitting the patient mentioned that his only desire for a
prosthesis was to help him ride the Harley which he had wrapped around an
oak tree while riding stoned, causing the original brachial plexus injury.
We presume he had the Harley repaired. With the humerus in neutral
position, the prosthesis would need a very long forearm to reach the
handlebar! To solve this dilemma, we fitted the amputation as a shoulder
disarticulation, complete with a flexion-abduction shoulder joint and a
channel for the residual humerus. This arrangement provided a much larger
range of placement for the terminal device. While this description is, of
course, anecdotal, it perhaps suggests the virtue of determining the
patient’s needs before planning surgery and prosthetic fitting. Best
wishes. C. Martin, CPO
