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The transhumeral amputation can be performed at three levels: 1.

humeral neckResidual limb length of less than 30% [residual limb (humerus) length] 2. short transhumeralResidual limb length of 30% to 50% 3. standard transhumeralResidual limb length of 50% to 90%.

Longer residual limb length (up to 90% of humeral length) will give best control and function with a prosthesis These three amputation levels in most cases require similar prosthetic components, which can beexternally powered, body powered, passive, or have a combination of these. In above-elbow amputations with residual limb lengths greater than 35%, usually the proximal trim line of the socket extends to within 1 cm to the acromion, and the socket is suspended by either a figureeight or shoulder saddle and chest strap suspension systems. Sockets for residual limbs shorter than 35% should have the proximal trim line extend 2.5 cm. medially to the acromion.

C Transhumeral/Above-Elbow (AE) Prostheses Transhumeral prostheses consist of a terminal device, wrist unit, forearm, elbow unit, an upper arm, a socket, and a harness and control-cable system. The terminal devices and wrist units are the same as those used for the transradial prostheses, but the sockets, elbow unit, and harness and control systems differ in several respects from those used in the transradial prostheses

AE Sockets As in transradial prostheses, the transhumeral socket is usually of double-wall construction, with the inner wall providing a snug, total-contact fit and the outer shell providing appropriate length and shape. The lateral socket wall extends to the acromion and the medial socket wall is flattened below the axilla to help prevent inadvertent socket rotation.

Elbow Units

When an amputation occurs at or above the elbow joint, elbow function is supplied by the use of an elbow unit, which provides for elbow flexion and for locking in various degrees of flexion Elbow-locking systems are divided into two types: 1. External (outside) locking elbow 2. Internal locking elbow The former is used with elbow-disarticulations because there is not enough space for the internal locking mechanism, and the latter is used with transhumeral and shoulder prostheses 1. Internal elbow joint Preferred because of greater mechanical durability Used in level of amputation 4 cm or more proximal to the level of the epicondyles 2. External elbow joint Used when the residual limb extends more distally than 4 cm to the level of the epicondyles to maintain the elbow joint center equal to that in the nonamputated side. Both types of elbows are flexed by means of the control cable of the dual-control system and locked at the desired flexion angle by a separate elbow-lock control cable, which is attached at one end to the elbow mechanism and at the other end to the harness The lock mechanism operates on the alternator principle, that is, locking and unlocking actions alternate with each control-cable cycle of tension and relaxation For amputees who have difficulty flexing their prosthetic forearm, an accessory in the form of a spring-assist for elbow flexion may be provided for the use with the internal elbow. In transhumeral and shoulder prostheses, passive humeral rotation is accomplished by means of a turntable between the elbow unit and the upper arm shell or socket. As in the case of a wrist unit, friction between the elbow unit and the turntable permits control of the rotation to maintain the desired plane of elbow operation.

Transhumeral Harness and Control Systems

In addition to suspending the prosthesis from the shoulders, the transhumeral harness must transmit power to flex the prosthetic forearm, to lock and unlock the elbow unit, and to operate the terminal device.

Harness in AE The harness designs most frequently used for transhumeral prosthesis are modifications of the basic figure-8 and chest-strap patterns used with the transradial prosthesis.

Control Cable System in AE ontrol Systems The typical control system for transmission of power to the prosthesis consists of a flexible, stranded stainless-steel cable with appropriate terminal fittings or coupling units and a flexible tube or housing inside which the cable slides. The terminal fittings are used to attach one end of the cable to a harnessed body control point and the other end to a point of operation or control of the prosthesis. The housing acts as a channel or guide for the transmission offered by the cable.

There are two types of control-cable systems: 1. Bowden control cable system 2. Dual-control (or fair-lead control) cable system

1. Bowden Control Cable System The Bowden control system is used in the transradial single-control cable system The dual-control system is used in the transhumeral controlcable system and in the very short transradial split-socket prosthesis with stump-activated locking hinge The Bowden control system consists of a continuous length of flexible housing through which the cable slides. The housing is fastened by a base plate and retainer to the forearm shell and by a housing cross-bar assembly to the cuff of the triceps pad; these housing retainers also

serve as reaction points when force is applied to the cable. The Bowden system is required to transmit body power for a single purposeto operate the terminal device.

2. The dual-control cable system consists of one cable with two functions: 1. Flex the elbow unit when the elbow is unlocked 2. Operate the terminal device when the elbow is locked The cable is held in place and guided by separate lengths of housing. The pieces of housing are fastened with retainers at points where the cable must be supported or operated through an angle. Since the system must provide force for elbow flexion and operation of the terminal device, two fair-lead housings are necessary; the proximal lead, through which the cable slides when the elbow is flexed; and the distal lead, through which the cable also slides when the terminal device is operated.

1. Elbow flexion and 2. Terminal device operation Elbow locking and unlocking are controlled by a second cable, the elbow-lock cable When the elbow is extended and unlocked, flexing the shoulder (humeral flexion) (assisted by biscapular abduction) transmits force to the forearm lever loop flexing the elbow to the desired level If the amputee wishes to use the terminal device at this point, first, he/she locks the elbow (by doing shoulder depression, extension and abductiondown, back, out) Then, the patient can operate the terminal device by continuation of the control motion shoulder flexion and biscapular abduction The same combination of shoulder movements done to lock the flexed elbow is needed to unlock the elbow (shoulder extension, depression, and abduction). Then, the elbow extends by gravity.

Terminal devices (TD) Most patients who suffer an upper-limb amputation and undergo prosthetic restoration require a terminal device for their prosthesis; they are used in all upper-limb prostheses for amputations at the wrist level and above TDs lack sensory feedback and have limited mobility and dexterity There are a variety of prosthetic terminal devices available and include passive, bodypowered, and externally powered hooks and hands 1. Passive TDs Lighter Have no functional mechanisms and provide no grasp a. Passive hand: Intended for cosmetic use only b. Flexible passive TDs: Mitt-shaped TDs used to absorb shock and store and release energy during sports and other activities

2. Body-powered terminal devices (hooks or hands) can be voluntary-opening or voluntary closing types Prosthetic hands provide a three-jaw chuck pinch (three-jaw chuck involves grip with the thumb and index and middle fingers) Hooks provide the equivalent of lateral or tip pinch (In the normal hand, lateral or key grip involves contact of the pulp of the thumb with the lateral aspect of the corresponding finger)

a. Voluntary-opening (VO) terminal device

Most common and practical type Device maintained in closed position by rubber bands or tension springs. The amputee uses cable-control harness powered by proximal muscles to open the terminal device against the force of the rubber bands or spring

To grasp, patient releases the opened terminal device on an object; the rubber bands or spring provide the prehensile force

The pinch force is determined by the number and type of rubber bands or springs (each rubber band provides about one pound of pinch force)

To control the amount of prehensile force, the patient must generate a continued opening force b. Voluntary-closing (VC) terminal device

More physiological function than voluntary opening Device is maintained in an open position and has to be closed voluntarily by pulling with the cable on the harness system to grasp an object

To release, the patient releases the pull on the harness, and a spring in the terminal device opens it The maximum prehensile force is determined by the strength of the individual

Disadvantage: prolonged prehension requires constant pull on the harness, heavier and less durable than voluntary opening units.

3. Externally powered (electric-powered) TDs Are controlled by switches or myoelectric signals and are powered with energy provided from external batteries. The electric-powered TD can be handlike (ie., Otto Bock system electric hands or Steeper electric hands) or nonhandlike in appearance (Otto Bock Greifer hand, Hosner NUVA synergistic prehensor and Steeper powered gripper)

a. Myoelectric-controlled TDs Use surface electrodes placed on the muscles of the residual limb. Devices can have a digital or proportional control system digital control systemon/off system proportional control systemthe stronger the muscle contraction producing the signal, the faster the action

b. Microswitch-controlled TDsuse either a push-button switch or a pull-switch to activate the TD

Prosthetic wrist units Wrist units are used for attaching terminal devices to prostheses as well as providing pronation and supination to place the terminal device in its proper position. The rotation function is passive; the amputee rotates the terminal device in the wrist unit with his sound hand or by pushing against a part of the body or other surface to produce either pronation or supination. The wrist unit also permits interchange of the terminal devices.

Two types of wrists: friction or locking: 1. Friction wrists permit pronation and supination of the terminal device and hold it in a selected position by means of friction derived from a compressed rubber washer or from forces applied to the stud of the terminal device. 2. Locking wrists permit manual rotation and then lock the terminal device in its fixed position. Advantage: The locking mechanism prevents inadvertent rotation of the TD in the wrist unit when a heavy object is grasped.

Two types of wrist-flexion units are also available: add-on and combination Add-on is worn between the wrist and the terminal device and allows manual positioning of the terminal device in either the straight or the flexed position. Combination type combines a friction wrist and a wrist-flexion component in one and provides for setting and locking in one position. Electric wrist rotator units are also available and are generally considered for bilateral upperextremity amputees.

o ring harness

shoulder saddle