607

Upper Extremity Prosthetics

Chapter 23

UPPER EXTREMITY PROSTHETICS

JOHN MIGUELEZ, CP, FAAOP*; DAN CONYERS, CPO†; MACJULIAN LANG, CPO‡; and KRISTIN GULICK, OTR/L, BS, CHT§

INTRODUCTION

NOMENCLATURE AND CLASSIFICATIONS 

Amputation Level Nomenclature 

Prosthetic Options

Prosthetic Componentry 

PREPROSTHETIC PHASE

Rehabilitation Team

Surgical Considerations for Optimal Prosthetic Rehabilitation

Prosthetic Assessment and Rehabilitation Plan Formation

Patient Education

Residual Limb Management

INTERIM PROSTHETIC PHASE

Level-Specific Recommendations

Bilateral Considerations

Concomitant Considerations

ADVANCED PROSTHETIC PHASE

Advanced Prosthetic Phase Considerations

Challenges to Rehabilitation

FUTURE INNOVATIONS

SUMMARY

*President and Senior Clinical Director, Advanced Arm Dynamics, Inc, 123 W Torrance Boulevard, Suite 203, Redondo Beach, California 90277

†Upper Extremity Specialist, Advanced Arm Dynamics, Inc, 10195 SW Egret Place, Beaverton, Oregon 97007

‡Clinical Specialist, Advanced Arm Dynamics, Inc, 123 W Torrance Boulevard, Suite 203, Redondo Beach, California 90277

§

Occupational Therapist; formerly, Director of Therapy Services, Advanced Arm Dynamics, 123 West Torrance Boulevard, Suite 203, Redondo Beach, 

California
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Care of the Combat Amputee

INTRODUCTION

limb prosthetic classifications, and treatment protocols 

for the three distinct phases of prosthetic rehabilitation: 

(1) the Preprosthetic Phase, (2) the Interim Prosthetic 

Phase, and (3) the Advanced Prosthetic Phase.

Figure 23-1. The Improved Outer Tactical Vest (IOTV) accommodates Small Arms Protective Inserts (SAPIs), Enhanced 

Small Arms Protective Inserts (ESAPIs), and Enhanced Side 

Ballistic Inserts (ESBIs). 

Photograph: Courtesy of BAE Systems, Farnborough, Hampshire, United Kingdom.

Recent improvements in body armor, battlefield 

medicine, speed of evacuation, and surgical techniques 

have resulted in a high incidence of survival from blast 

wounds sustained during armed conflict (Figure 23-1). 

The mechanisms of injury include explosively formed 

projectiles, improvised explosive devices (IEDs), mobile IEDs, rocket-propelled grenades, suicide vehicleborne IEDs, and gunshot wounds. Those individuals 

who survive are frequently polytraumatized and challenged with hearing or vision impairment, burns, traumatic brain injury (TBI), upper and lower extremity 

injuries, and/or amputations. Service members with 

well-irrigated, but open, wounds are rapidly transferred from the battlefield to a rehabilitation hospital, 

which requires an organized approach to prosthetic 

rehabilitation. To enable a young and motivated amputee population to return to highly active military 

and civilian lifestyles, the military healthcare system 

has implemented a comprehensive, multidisciplinary 

model of rehabilitative care.

The entire rehabilitation process is accelerated because of the superior premorbid physical status and 

goal-oriented mindset of the service member, both of 

which have been fostered in the military environment. 

Wounded service members approach rehabilitation 

with focused determination to reach the initial goal of 

returning to active duty or reintegrating into civilian 

life. They place high expectations on themselves and 

on the care they receive. Prosthetic rehabilitation for 

these individuals is also complemented by their previous training in the manipulation of external devices, 

including weaponry and computer systems, as well 

as the excellent hand-eye coordination developed 

through military training, recreational pursuits, and 

electronic gaming. Harnessing these characteristics, 

through the protocols discussed in this chapter and 

throughout this book, provides the military amputee 

with the best opportunity to achieve and maintain high 

levels of function, productivity, and quality of life. This 

chapter reviews amputation-level nomenclature, upper 

NOMENCLATURE AND CLASSIFICATIONS

Amputation Level Nomenclature

Historically, there has been varied nomenclature 

that describes amputations and amputation levels. In 

this chapter, level-specific language was adopted to 

describe amputations (Figure 23-2). Other terminology may be used throughout this book that is based 

on local variations in descriptive wording.

Prosthetic Options

There are five principal prosthetic options to consider for the upper limb amputee:

1. electrically powered prosthesis,

2. body-powered prosthesis, 

3. hybrid prosthesis,
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Upper Extremity Prosthetics

4. passive/cosmetic restoration, and

5. task-specific prosthesis.

The types of prostheses recommended/selected are 

based on many factors, including level of amputation, 

condition of the residual limb, individual goals, and 

work requirements. Often, more than one option is 

required for an individual to accomplish all of his or 

her goals. 

Electrically Powered Prosthesis

This category of prosthesis uses small electric motors in the terminal device [TD (hand or hook)], wrist, 

and elbow to provide movement. The motors are 

powered by a rechargeable battery system. There are 

several means of controlling this type of prosthesis, 

the most common of which is myoelectric control. 

(Figure 23-3). Myoelectric signals are derived from 

the contraction of voluntary control muscles in the 

residual limb and are recorded by surface electrodes 

implanted in the prosthetic socket. Electrodes must 

maintain contact with those particular muscles from 

which the control signals are derived. The recorded 

myoelectric signal is first amplified and then processed into a control signal governing the electric 

motors that operate the prosthesis. The magnitude 

of the processed signal is roughly proportional to the 

isometric force exerted by the muscle, and the microprocessor calculates actions based on the strength of 

the myoelectric signal.1,2 Proportional control allows 

the patient to control the speed and force of the TD 

and wrist and elbow movements by varying the 

strength of the muscular contraction/signal input. 

For example, the larger the myoelectric signal, the 

greater the grip force or speed of opening and closing. This provides a more natural response with less 

effort than the traditional on/off action of a purely 

digital control system. The programmable microprocessor enables a recent amputee with relatively weak 

or unbalanced electromyographic (EMG) signals to 

control the prosthesis effectively. As the amputee’s 

EMG signals improve, further programming occurs 

to optimize control. The biophysics of myoelectric 

control and many of the technical considerations 

regarding signal extraction have been explained in 

detail previously.3–6

For amputees lacking adequate dual EMG output 

or control, or for prosthetic systems that require additional inputs to control more degrees of freedom, other 

potential methods of control include the following:

	 •	 single-site electrode control schemes,

	 •	 servo control,

	 •	 linear potentiometers,

	 •	 linear transducers,

	 •	 force-sensing resistors,

	 •	 push-buttons, and

	 •	 harness switch control mechanisms.

Transcarpal

Interscapulothoracic Transhumeral

Elbow

Disarticulation

Transradial

Partial Hand

Styloid/Wrist

Disarticulation

Glenohumeral

Disarticulation

Figure 23-2. Upper limb amputation levels.

Illustration: Adapted with permission from Otto Bock 

HealthCare, Minneapolis, Minnesota.

Figure 23-3. Transradial-level myoelectric prosthesis.

Photograph: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California. 
610

Care of the Combat Amputee

Several control schemes may be used on the same 

prosthesis to provide expanded function. The authors 

have presented technical considerations regarding 

these control options in other articles.2,6 One of the 

unique characteristics of an electrically powered prosthesis is its ability to provide superior grasping force 

and wrist rotation capabilities without exerting excessive force on the fragile and acutely healing residual 

limb. Often, an electric prosthesis can be fit effectively 

within 24 hours of suture removal for rapid return to 

function. By contrast, the tissue traction and pressure 

applied to the distal end during actuation of a bodypowered elbow or TD can significantly stress a suture 

line in the early stages of healing. 

Inherent in the design of a myoelectric prosthesis is 

the elimination of external cabling needed for control 

of a body-powered prosthesis. Because electric motors 

are used to operate hand or hook function rather than a 

conventional cable and harness, grip force of the hand 

or hook is significantly increased, often in excess of 20 

to 32 pounds per square inch. A cosmetic cover can 

also be applied to the prosthesis so that the prosthesis 

is not only highly functional, but also aesthetically 

superior. For amputations above the elbow, current 

prosthetic components allow simultaneous control of 

elbow flexion and extension while opening or closing 

the electric TD or while rotating the wrist. Historically, 

prosthetic options at and above the transhumeral level 

required the wearer to control one function at a time, 

also referred to as sequential control.

Unlike other prosthetic categories, the electrically 

powered prosthesis uses a battery system that requires 

regular maintenance (charging, discharging, eventual 

disposal, and replacement). Because of the battery 

system and the electrical motors, electrically powered 

prostheses tend to be heavier than other prosthetic 

options, although advanced suspension techniques 

can minimize this sensation. When properly fitted 

and fabricated, electrically powered prostheses do not 

require excessive maintenance. However, when repairs 

are required, they are often more complex than other 

options because of their sophistication. Additionally, 

an electrically powered prosthesis is susceptible to 

damage when exposed to moisture (Table 23-1).

Body-Powered Prosthesis

A body-powered prosthesis, sometimes referred 

to as a conventional or cable-driven prosthesis, is 

powered and controlled by gross body movements. 

These movements—usually of the shoulder, upper 

arm, or chest—are captured by a harness system and 

used to pull a cable that is connected to a TD (hook or 

hand). For some levels of amputation or deficiency, 

an elbow system can be added to provide additional 

motion. For a patient to control a body-powered 

prosthesis, the individual must be capable of producing at least one or more of the following gross body 

movements:

	 •	 glenohumeral flexion,

	 •	 scapular abduction or adduction,

	 •	 shoulder depression and elevation,

	 •	 chest expansion, and

	 •	 elbow flexion.

Additionally, a patient must possess sufficient residual limb length for leverage, sufficient musculature 

to allow movement and excursion, and sufficient range 

of motion for operation and positioning of the prosthesis. Thus, it is often difficult for the humeral neck, 

glenohumeral disarticulation, and interscapulothoracic amputation levels to control a body-powered 

prosthesis effectively (Figure 23-4).

Because of its simple design, the body-powered 

prosthesis is highly durable and can be used for 

TABLE 23-1

ADVANTAGES/DISADVANTAGES OF ELECTRICALLY POWERED PROSTHESIS

Advantages Disadvantages

Proportional grip force Battery maintenance

Ease of electric TD/wrist operation Overall weight consideration

Can be fit early in rehabilitation Repairs may be more complex

Natural appearance Susceptible to damage from moisture or excessive vibration

Can be applied to high amputation levels

Simultaneous control of elbow and TD or wrist

Larger functional work envelope than body-powered prosthesis

TD: terminal device
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Upper Extremity Prosthetics

Figure 23-5. Definitive transradial-level, body-powered 

prosthesis.

Photograph: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California.

tasks that involve water, dust, and other environments that could damage an electric prosthesis. 

Many patients who wear a body-powered prosthesis 

comment that they have a unique spatial awareness

because of cable tension proprioception, which 

gives the wearer feedback on the position of the TD 

through the harness system. Maintenance costs for 

a body-powered prosthesis are also relatively low 

(Figure 23-5).

The most common complaint reported by wearers 

of this type of prosthesis is that the control harness is 

often uncomfortable, restrictive, and wears out clothes. 

Although new materials aid in reducing discomfort, 

the harness must fit tightly to capture the movement of 

the shoulders and to suspend the prosthesis. This can 

restrict proximal joint range of motion and the effective envelope of the prosthesis. The harness and cable 

system also limits the possible grip force of the hook 

or other TD. Other patients dislike the appearance of 

the hook and control cables, and request a prosthesis 

that is more “lifelike.” Lastly, because of the inherent 

forces exerted on the residual limb during actuation 

of a body-powered prosthesis, careful consideration is 

required for those patients who have fragile, healing 

tissues about the residual limb. If a body-powered 

prosthesis is fit too early in the rehabilitation process, 

patients can experience breakdown around the suture 

line (Table 23-2).

TABLE 23-2

ADVANTAGES/DISADVANTAGES OF BODY-POWERED PROSTHESIS

Advantages Disadvantages

Durable and can be used in tasks or environments that 

could damage an electric prosthesis (ie, conditions 

involving excessive water, dust, or vibrations created by 

some motorized vehicles and power tools)

Secondary proprioceptive feedback

Lower maintenance costs than electric options

Restrictive harness

Decreased grip force compared with electric options

Forces exerted on residual limb

Difficult to control for high amputation levels

Limited function of typical body-powered hands 

Appearance of hook and cables

Figure 23-4. Figure-of-eight harness. Arrows indicate directional pull of biscapular abduction or glenohumeral flexion.

Photograph: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California.
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Care of the Combat Amputee

Hybrid Prosthesis

A hybrid prosthesis incorporates body-powered 

and electrically powered components in a single 

prosthesis. The hybrid prosthesis often uses a bodypowered elbow and a myoelectrically controlled TD 

(hook or hand). If desired by the wearer, an electric 

wrist rotator can also be included. Another type of 

hybrid prosthesis combines an electrically powered 

elbow with a body-powered hook or hand. Most 

commonly, hybrid prostheses are used for individuals with transhumeral and humeral neck amputations. Glenohumeral and interscapulothoracic level 

amputations may also be fit with hybrid prostheses. 

However, these cases require precise interface design 

because of the amount of gross body movement 

needed to operate this type of prosthesis and the EMG 

signal interference potentially created in the socket

of the myoelectrically controlled hybrid during such 

movement. It is important for the electrodes to remain 

in a constant relationship with the best EMG signal 

that is discovered throughout the patient’s range of 

motion (Figure 23-6).

There are several advantages to a hybrid prosthesis. Most important is the ability to simultaneously 

control elbow flexion or extension while opening or 

closing the electric TD or while rotating the wrist. 

Some prosthetic options require the wearer to control 

one function at a time (sequential control). The hybrid 

prosthesis also weighs less than a prosthesis with an 

electrically powered elbow while maintaining ease 

of operation and increased grip force of electric TDs 

(Table 23-3).

Passive/Cosmetic Restoration

Passive/cosmetic restoration is a popular prosthetic 

option. This involves replacing what was lost from amputation with a prosthesis that is similar in appearance 

to the nonaffected arm or hand and aids in stabilizing 

TABLE 23-3

ADVANTAGES/DISADVANTAGES OF HYBRID PROSTHESIS

Advantages Disadvantages

Simultaneous control of elbow and TD or wrist

Lighter than fully electric elbow prosthesis

Increased grip force compared with body-powered options

Ease of electric TD/wrist operation

Requires a harness for elbow control

The force needed to fully flex the elbow may be difficult to 

generate for short transhumeral and higher amputation 

levels

TD: terminal device

Figure 23-6. Transhumeral-level hybrid prosthesis with 

cable-driven elbow and myoelectric TD.

TD: terminal device

Photograph: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California.

and carrying functions. A cosmetic prosthesis is sometimes called a passive prosthesis because it is a static 

device that does not provide active grasping capability. 

Cosmetic restoration is typically achieved using one of 

three materials: (1) flexible latex, (2) rigid PVC (polyvinyl chloride), or (3) silicone. These types of prostheses 

are often lighter weight than other prosthetic options 

and require less maintenance because they have fewer 

moving parts. Cosmetic restoration using silicone often 

goes unnoticed because it so closely resembles the 

nonaffected hand. Silicone does not stain like latex, 

and it provides the highest cosmetic restoration quality, 

with a longevity of 3 to 5 years, depending on usage 

patterns. These highly detailed silicone restorations 

are also commonly used to create a covering for the 

electric hands and body-powered hands in the previously discussed sections about those options (Figures 

23-7 and 23-8; see also Table 23-4).
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Upper Extremity Prosthetics

Task-Specific Prosthesis 

Task-specific prostheses are designed particularly 

for an activity in which the use of a passive/cosmetic, 

body-powered, electrically powered, or hybrid 

prosthesis would place unacceptable limitations on 

function or durability. Often, this type of prosthesis 

is recreational in nature for activities such as fishing, 

swimming, golfing, hunting, bicycle riding, weight 

lifting, playing musical instruments, etc. Task-specific 

prostheses can also enhance work-related function 

involving the use of various tools. For more information regarding task-specific devices, see Chapter 24

on Upper Limb Prosthetics for Sports and Recreation 

(Table 23-5).

The current military prosthetic rehabilitation practice is to provide each service member an electric or 

Figure 23-8. Silicone partial hand prosthesis.

Photographs: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California.

Figure 23-7. Glenohumeral disarticulation amputee wearing 

a cosmetic silicone restoration.

Photograph: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California.

TABLE 23-4

ADVANTAGES/DISADVANTAGES OF PASSIVE 

PROSTHESIS

Advantages Disadvantages

Lightweight Difficult to perform activities that require mechanical 

grasp

Minimal harnessing Latex and PVC products 

stain easily

Low maintenance 

No control cables

Cosmesis, positive body 

image

Silicone products resist 

staining

PVC: polyvinyl chloride

TABLE 23-5

ADVANTAGES/DISADVANTAGES OF TASKSPECIFIC PROSTHESIS

Advantages Disadvantage

Enhanced function in Not appropriate for a broad

particular activity range of functions

Minimal harnessing

Limited or no control 

cables

Durable, low maintenance

Protects primary 

prosthesis from damage
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Care of the Combat Amputee

hybrid prosthesis, a body-powered prosthesis, and a 

passive silicone restoration prosthesis. As the service 

member progresses through prosthetic rehabilitation 

and his or her skills develop—allowing for exploration of sport activities and other specialized highlevel skills—the team will address the need for a 

task-specific device. In most cases, the service member 

self-selects which prosthesis to use throughout the day 

for different tasks. Most service members routinely

use all of their prosthetic options at some point while 

performing activities of daily living (ADLs). In the 

course of the rehabilitation process, a “primary” prosthesis will be identified, and this prosthetic option will 

often be duplicated to provide a backup device in the 

event that the primary prosthesis needs maintenance 

or repair. 

Prosthetic Componentry

Upper extremity prostheses incorporate componentry from one or more of the following four categories, 

depending on the level of amputation: 

1. TDs,

2. wrist units,

3. elbow systems, and

4. shoulder joints.

Terminal Devices

A large variety of TDs are available. TDs from all 

of the various manufacturers can be integrated into 

the rehabilitation plan to provide a variety of grip 

patterns, functional uses, and adaptations for specific 

tasks and appearances. Many service persons have 

identified useful TDs that can be interchangeable on a 

given prosthesis and some TDs that are best applied to 

a separate prosthesis for a unique application. Considerable ongoing research is being pursued to improve 

body-powered and electric TDs, as well as adaptive, 

task-specific TDs2(p52),7–14 (Figure 23-9).

Two common categories of TDs include (1) the 

hook and (2) the hand. Hooks are useful for both 

fine prehension and rugged tasks. Hands provide a 

more anthropomorphic appearance, particularly with 

myoelectric TDs. Power to operate the body-powered 

TD is derived from body movements through a 

cable system, and electric TDs use electric motors 

from a battery-powered system. Body-powered TDs 

typically produce a voluntary opening, with rubber 

bands or springs providing the closing force. There 

are a number of body-powered TDs that provide 

voluntary closing functions. Service members with 

an amputation at the transradial level and longer 

Figure 23-9. Examples of TDs: (top center) Motion Control 

ETD, (right) Otto Bock Greifer, (bottom center) Otto Bock 

SensorHand SPEED, (bottom left) Hosmer Dorrance 7LO 

work hook, and (top left) Hosmer 5XA hook.

ETD: Electric Terminal Device

TDs: terminal devices

Photograph: Product images used with permission from Motion Control, Inc, Salt Lake City, Utah; Otto Bock HealthCare, 

Minneapolis, Minnesota; and Hosmer Dorrance Corporation, 

Campbell, California.

are given the option to try both voluntary opening 

and voluntary closing styles, and to self-select one 

or both, depending on the activity. Most amputees 

with amputations proximal to the transradial level 

find voluntary closing to be quite difficult because 

of the amount of cable excursion required to operate both an elbow and a TD.15–17 In the United States, 

all body-powered hooks and hands have the same 

ö-inch, 20-thread stud for attachment to wrist units. 

This allows ease of TD interchangeability.15

Most hook-style TDs are made from high-density 

plastics, aluminum, stainless steel, or titanium. Plastics are used as coatings or as housings for electric 

motors. Aluminum is appropriate for lightweight/

light-duty applications. Titanium is strong and lightweight, and stainless steel is used where weight is less 

of a consideration than the overall strength of the TD 

material. One or all of these materials may be present 

in a single TD. 

The prosthetic treatment protocols detailed in the 

section on the Interim Prosthetic Phase recommend 

a combination of TD technologies for both the externally powered and body-powered prostheses. This 

methodology accommodates the broadest range of 

prehension patterns and functional applications in 

daily living activities. Users of externally powered 

prostheses are able to interchange microprocessor-controlled electronic hand TDs and different 

microprocessor-controlled electric work hook-type 

configurations.

The microprocessor-controlled electric hand provides a natural appearance and can produce a grip 
615

Upper Extremity Prosthetics

be positioned at various angles of wrist flexion and extension, enhancing the functional envelope. Featuring 

water- and dust-resistant housings, the electric hook 

TD can be used in harsher environments without increasing the maintenance and servicing required. The 

lyre-shaped fingers allow the user to easily see what 

is being held for safe and accurate usage of tools and 

machinery. In an emergency, these hook fingers can be 

opened instantly by a patented safety release feature 

(Figure 23-11).

Another prehensor-type microprocessor-controlled 

TD offers a grip force of up to 32 pounds per square 

inch and is one of the widest opening electric TDs. 

This version is durably constructed with a protective 

coating and built-in friction-controlled wrist deviation. The grip surfaces are adjustable in all planes to 

allow multiple gripping and holding functions (Figure 

23-12).

The electric hands and work hook-type TDs can 

be programmed to optimize prosthetic function. 

The programming systems provide the patient and 

the prosthetist with visual feedback of EMG signal 

strength and electronic adjustments on a computer 

screen. Once programming is complete, the patientspecific data settings are stored and can be uploaded 

to the specific TD after maintenance and repair. This 

prevents repetitious programming sessions and creates 

a comparative data cache for analysis of changes in 

muscle strength and muscle differentiation.

Figure 23-10. The Otto Bock SensorHand SPEED responds 

twice as quickly as other electric hands and offers an automatic grasp feature.

Photograph: Courtesy of Otto Bock HealthCare, Minneapolis, 

Minnesota.

Figure 23-11. Motion Control ETD offers lyre-shaped fingers 

with water-resistant housings.

ETD: Electric Terminal Device

Photograph: Product image used with permission from Motion Control, Inc, Salt Lake City, Utah.

force of up to 24 pounds per square inch (Figure 23-

10). The cylindrical grasp and palmar pinch patterns 

effectively handle cylindrical objects of various sizes, 

such as steering wheels, handlebars, control knobs, 

liquid containers, and many tools. Upgraded EMG 

processing capability enables one of these hands to 

respond to (myoelectric) muscle signals more than 

twice as quickly as standard electric hands. The sensory feedback technology and microprocessor allow 

the hand to react rapidly to changing situations. The 

automatic grasp feature of this hand monitors shear 

force and grip force, and automatically adjusts grip 

strength so that an object remains securely in the hand 

even when its center of gravity changes. Another 

microprocessor-controlled electric hand provides locking wrist flexion without the auto-grasp feature. The 

fingers of this hand can be opened instantly using the 

patented safety release feature. It is quite effective in 

all of the wrist positions.

One microprocessor-controlled hook-style TD combines powered pinch force with a tip-pinch grasping 

pattern to provide better purchase on small objects.

The locking flexion wrist feature allows the wrist to 
616

Care of the Combat Amputee

Wrist Units

Wrist units connect the TD to the prosthesis. They are 

designed to position the TD for function and to provide 

the mechanism to interchange TDs. The appropriate selection of a wrist unit can greatly improve the functionality of a wearer by enhancing the range of TD positioning. 

There are essentially three capabilities of wrist units: (1) 

rotation (supination/pronation), (2) flexion and extension (or ulnar deviation/radial deviation), and (3) quick 

disconnection. Using these functions requires use of 

the contralateral limb or an object in the environment 

to manually rotate the unit unless an electric rotator is 

used. These three capabilities are sometimes combined 

into one unit. Rotation can be controlled by friction and 

optional locking positions. The quick disconnect ability 

allows wearers to easily interchange TDs based on the 

demands of their activities. Wrist units with flexion and 

extension allow the user to set the TD in some degree of 

flexion or extension. In many situations, a combination 

of these features improves a wearer’s ability to perform 

ADLs, vocational activities, and avocational activities 

by accommodating demanding positions and achieving 

access to midline tasks. Historically, these combination 

units were predominantly used for bilateral amputees. 

However, unilateral amputees also benefit from the use 

of combination wrist units that enhance the ability to 

perform tasks with the prosthesis and the contralateral 

limb simultaneously (Figure 23-13).

These combinations can be found not only on bodypowered prostheses, but also on electrically powered 

prostheses. An electrically powered wrist offers active 

rotation and should be used in all situations, provided 

that symmetry is preserved and length considerations 

are addressed. In the preprosthetic treatment phase, 

communication of surgical considerations should include the residual limb length needed to accommodate 

this componentry and maintain the appropriate overall 

length of the prosthesis. There are several methods to 

actuate an electric wrist rotator, but many amputees 

Figure 23-12. The Otto Bock Greifer provides up to 32 pounds 

of pinch force.

Photograph: Courtesy of Otto Bock HealthCare, Minneapolis, 

Minnesota.

Figure 23-13. Example of wrist units: (top right) Hosmer 

Dorrance quick disconnect wrist unit; (bottom) Otto Bock 

four-channel processor and electric wrist rotator; and (top 

left) Sierra Wrist Flexion Unit.

Photograph: Product images used with permission from 

Hosmer Dorrance Corporation, Campbell, California, and 

Otto Bock HealthCare, Minneapolis, Minnesota.
617

Upper Extremity Prosthetics

prefer a method referred to as “quick-slow” or “fast 

access.” This scheme interprets the speed of a muscle 

contraction in a myoelectric system and immediately 

directs control to the wrist or the TD, depending on 

the speed of contraction. Another common control 

scheme used to switch between wrist and TD control 

is co-contraction. This method requires the patient to 

quickly co-contract the antagonist and agonist muscle 

groups to alternate between control of the wrist and 

TD. This creates a delay and is more cognitively taxing 

because it requires a patient to do the following:

	 •	 co-contract to select the wrist,

	 •	 position the wrist,

	 •	 co-contract to select the TD, and

	 •	 operate the TD.

As a result, co-contraction control switching can 

lead to frustration and the potential to lose track of 

which function is active at a given point in time. One 

variation in co-contraction uses a method to simplify 

the process by creating an automatic return to TD function after a preset time has elapsed, with no EMG input 

to the prosthesis. Amputees tend to prefer a high level 

of predictability when selecting a control scheme, and 

our experience has shown that quick-slow schemes are 

typically well-accepted. 

Elbow Systems

Elbow systems allow the wearer to flex or extend the 

elbow to a desired position and lock it when necessary. 

Most body-powered and electrically powered elbow 

systems also provide passively controlled humeral 

rotation (Figure 23-14).

Body-powered elbow systems require up to 4ö

inches of cable excursion to fully flex the elbow and 

operate the TD. This significant amount of excursion 

often precludes use by patients with reduced strength, 

limited range of motion, or shorter residual limbs. By 

incorporating flexion assist in their elbow systems, several manufacturers mitigate the amount of force needed 

to flex the elbow. Spring lift assists or forearm-balancing 

units will help to overcome some of the weight of the 

TD and assist in flexing the elbow. Whenever possible, 

elbow flexion assists should be used to reduce not only 

the effort required by the wearer, but also the shear 

forces applied to the residual limb so as to prevent irritation and tissue breakdown. Elbow flexion assists 

are particularly important in hybrid systems because 

of the additional weight of the electric wrist and TD. At 

the elbow disarticulation level, various manufacturers’ 

outside locking hinges are used in combination with lift 

assist mechanisms and/or automatic forearm-balancing 

units (Figures 23-15 and 23-16).

Electrically powered elbows provide motorized 

positioning of the forearm, reducing or eliminating 

the need for glenohumeral range of motion or strength 

required to operate body-powered systems. Microprocessors in the electric elbow can use a variety of control 

inputs, including electrodes, force sensors, touch pads, 

and various types of linear potentiometers. The functional advantage of an electric elbow system comes at 

the cost of increased weight. Therefore, it is important 

to factor this into preprosthetic occupational therapy 

training and into the patient’s expectations. 

Figure 23-14. Otto Bock Ergo Arm. 

Photograph: Courtesy of Otto Bock HealthCare, Minneapolis, 

Minnesota.

Figure 23-15. Otto Bock Dynamic Arm. 

Photograph: Courtesy of Otto Bock HealthCare, Minneapolis, 

Minnesota.
618

Care of the Combat Amputee

Shoulder Joints

Currently, the only commercially available shoulder joints must be passively positioned for flexion, 

extension, abduction, and adduction. The motions of 

abduction and adduction are friction based, whereas 

flexion and extension can be either friction based or 

locking (Figure 23-17).

treatment plan. During the Preprosthetic Phase, the 

Interim Prosthetic Phase, and the Advanced Prosthetic 

Phase, the prosthetist will consult with various members of the patient’s rehabilitation team. The surgical 

team will use the prosthetist’s input to identify an ideal 

amputation level and wound closure, and the occupational therapist will work closely with the prosthetist 

as the limb is prepared for prosthetic management, 

and the prosthetic devices are created and fit. During 

and following the Advanced Prosthetic Phase of initial 

rehabilitation, the prosthetist and other team members 

will work together to maintain consistent contact with 

the service member and address any subsequent prosthetic or medical issues.

Surgical Considerations for Optimal Prosthetic 

Rehabilitation

Although there are many issues for the military 

surgeon to consider in treating blast injuries, it is important to communicate the requirements of current 

prosthetic technology as they relate to residual limb 

length, shape, and musculature reattachment. The 

surgical considerations that will be described allow 

for optimal prosthetic rehabilitation for each level of 

Figure 23-16. The Motion Control Utah 3 Arm.

Photograph: Courtesy of Motion Control, Inc, Salt Lake 

City, Utah.

Figure 23-17. LTI Locking Shoulder Joint.

LTI: Liberating Technologies, Inc

Photograph: Product image used with permission from Liberating Technologies, Inc, Holliston, Massachusetts.

PREPROSTHETIC PHASE

Rehabilitation Team

Successful upper extremity prosthetic rehabilitation 

must fully address the unique constellation of clinical 

and functional requirements presented by the patient 

and is, therefore, dependent on the coordinated efforts 

of a multifaceted care team. This team must include, 

but is not limited to, the following: 

	 •	 patient;

	 •	 family, friends, and significant other;

	 •	 surgeon;

	 •	 physician/physiatrist—physical medicine

and rehabilitation;

	 •	 psychologist/psychiatrist;

	 •	 occupational therapist;

	 •	 physical therapist;

	 •	 case manager;

	 •	 prosthetist; and

	 •	 nursing staff.

The treatment plan must be tailored to the specific 

needs and goals of the injured service person. Each of 

the team members will contribute critical information 

and experience to develop a cohesive, individualized 
619

Upper Extremity Prosthetics

amputation. As prosthetic technology evolves and 

different components are developed, surgical guidelines might require modification. Concomitant injuries 

might also take priority and affect the subsequent plan. 

The historical approach to “save as much as possible” 

can sometimes present difficult issues for the service 

person, particularly considering that residual limb 

length revisions may be necessary after closure so that 

a more functional solution for prosthetic rehabilitation can be achieved. If carefully planned in advance, 

surgery to close the amputation site can include any 

necessary length modifications and minimize the number of surgical procedures. In addition to the following 

general guidelines for residual limb length, muscle 

attachment, skeletal shaping, and soft-tissue closure, 

also see Chapter 8 (General Surgical Principles for the 

Combat Casualty With Limb Loss).

Guidelines for Residual Limb Length

The length of the residual limb can limit the prosthetic componentry options and therefore might affect 

functional potential. In determining the ideal length 

for amputation, it is essential that the surgeon and the 

patient understand how the individual’s prosthetic 

options might be affected by the length of the residual 

limb. It should also be carefully explained that a residual limb that is too long might present complications 

when using a prosthesis in tight spaces or as it relates 

to cosmetic symmetry with the other arm/hand.

The following guidelines have proven helpful to 

support upper extremity prosthetic rehabilitation. 

For the transradial and transhumeral levels, formulas 

to determine optimal residual limb length have been 

suggested. These calculations were developed based 

on the sizes of an average individual and currently 

available mechanical and powered elbow, wrist, and 

TD units. In addition, patients will not use a prosthesis 

100% of the time, and they might benefit from variations on these recommendations. Formulas to determine limb length for each amputation level should 

be developed after careful consideration of available 

componentry as it relates to leverage of the residual

limb, both with and without a prosthesis.

Transcarpal and Transmetacarpal Levels. If at least 

two digits remain that are sensate and innervated 

(movable by patient), retain as much length as possible and minimize graft and scar tissue surface areas. 

If digits are insensate, lack an active range of motion, 

or are heavily grafted/scarred, revise the length to 

carpal level or styloid disarticulation, depending on 

the amount of graft and scar tissue present distal to 

the center of wrist articulation.

Styloid Level. Disarticulate at the wrist, keeping 

the radius, ulna, and interosseus membrane intact. A 

transradial-level amputation should be considered if 

supination and pronation are severely limited or absent 

secondary to injury of the forearm musculature and 

interosseus membrane.

Transradial Level. To determine optimal length that 

will accommodate current prosthetic componentry, the 

following steps are recommended (Figure 23-18):

1. Measure the contralateral/noninvolved limb 

from the lateral epicondyle to the thumb tip 

(with the elbow flexed at 90 degrees). This is X.

2. Subtract 8ø inches or 22.5 cm (average length 

of prosthetic TD and wrist unit) from X,

which will be the optimal final residual limb 

length for the affected side (or Y). A slightly 

larger value may be substituted for Y without 

a material decrease in functional levers.

3. Measure from the lateral epicondyle on the 

involved side marking the desired residual 

limb length (Y) determined in step 2. This 

should be the finished residual limb length, 

including soft-tissue padding. The ulna will 

be 1/4 to 1/2 inches (0.8 cm–1.25 cm) shorter 

than Y, and the radius will be 1/8 to 1/4 inches 

(1.25 cm–2.5 cm) shorter than overall length 

of the ulna. 

Elbow Disarticulation Level. Disarticulation 

should be performed at the elbow, thus keeping the 

shape of the epicondyles intact.

Figure 23-18. Procedure to determine preferred transradial 

residual limb length.

Measurement = X

Thumb Tip

Desired 

Limb Length

Measurement = Y

(Y = X – 83

/4”)

Lateral Epicondyle
620

Care of the Combat Amputee

Transhumeral Level. To determine optimal limb 

length using current prosthetic componentry, the following steps are recommended:

1. Measure the contralateral/noninvolved limb 

from the acromion process to the distal olecranon (with the elbow flexed at 90 degrees). 

This is X. Subtract 5ö inches or 14 cm (the 

average length of the prosthetic elbow unit) 

from X, which will be the optimal final residual limb length for the affected side (or Y). 

A slightly larger value may be substituted for 

Y without a material decrease in functional 

levers.

2. Measure from the acromion process on the 

involved side marking the optimal residual 

limb length (Y) determined in step 1. This 

should be the finished residual limb length, 

including soft-tissue padding. The humerus 

will be 1/2 to 3/4 inches (1.25 cm–2.0 cm) 

shorter than Y (Figure 23-19).

Humeral Neck, Glenohumeral, and Interscapulothoracic Levels. Follow the general surgical principles for residual limb length.

Guidelines for Muscle Attachment

Myoplasty. Attaching the transected muscles to 

themselves or others increases the incidence of cocontraction of antagonistic muscles, thereby greatly 

diminishing myoelectric control potential. Myoplasty 

limits prosthetic options. 

Myodesis. Attaching the transected muscle directly 

to bone creates a solid anchor for each muscle to pull 

against during contraction. This creates a clear and 

distinct EMG signal, which is useful for differentiating 

electromyography from multiple muscles and optimum myoelectric control potential (Table 23-6).

Guidelines for Skeletal Treatment

General surgical principles apply to the treatment 

of bone. The cut end of bone should not present any 

unnecessary sharp edges, rough prominences, or 

splintering (Table 23-7).

Soft-Tissue Closure/Distal Suture Line

Note these four points:

1. Finished amputation should have ÷ to ö

inches (0.8 cm–1.25 cm) of soft-tissue padding 

over the skeletal distal end.

2. Nerves are transected sharply under tension 

to prevent future formation of neuromas 

without negatively impacting sensation and 

innervation of associated muscles.

3. Distal suture/staple line should run medial/

lateral when the patient’s residuum is in the 

standard anatomical position.

4. Conical shape is preferred, with a smooth contour of the distal end taking care to eliminate 

or minimize both invagination of tissue and 

“dog ear” formation (note: dog ear usually refers to excess tissue at the ends of the skin closure 

Figure 23-19. Procedure to determine preferred transhumeral 

residual limb length.

Acromion

Process

Acromion

Process

Distal

Olecranon

Measurement = X

Measurement = Y

(Y = X – 51

/2”)

Desired Finished 

Distal End of the 

Residual Limb

TABLE 23-6

GUIDELINES FOR MUSCLE ATTACHMENT

Level Action

Transmetacarpal/transcarpal Follow general surgical 

principles

Transradial Attach wrist flexors and

Styloid disarticulation extensors, and supinator 

and pronator muscle 

groups to radius and ulna

Transhumeral Attach biceps and triceps

Elbow disarticulation tendons to the humerus

Humeral neck, glenohumeral Follow general surgical 

disarticulation, principles

interscapulothoracic
621

Upper Extremity Prosthetics

TABLE 23-7

GUIDELINES FOR SKELETAL TREATMENT

Level Action

Transmetacarpal/transcarpal Follow general surgical principles

Transcarpal/transmetacarpal Do not bevel styloid prominence because this skeletal

Styloid disarticulation prominence will be used for suspension of the prosthesis

Transradial Bevel and remove sharp edges from radius and ulna; 

radius should be ÷ to ö inch (0.8 cm–1.25 cm) shorter 

than the ulna

Elbow disarticulation Do not bevel epicondylar prominences because this 

skeletal prominence will be used for suspension of the 

prosthesis

Transhumeral Bevel and remove sharp edges from the humerus

Humeral neck, genohumeral disarticulation, Follow general surgical principles

interscapulothoracic

that tend to be everted/protruding—somewhat triangular and pointed like a dog’s ear). 

Prosthetic Assessment and Rehabilitation Plan 

Formation

Once the residual limb length has been surgically 

established and the wound is initially closed, a comprehensive prosthetic assessment is performed. This 

occurs prior to suture or staple removal and is often 

initiated at the bedside in the intensive care unit or 

orthopaedic ward. The evaluation may span multiple 

visits to accommodate the physical, cognitive, and 

emotional status of the patient. Often, the initial visits 

are limited because the patient is heavily medicated or 

receiving medical attention for concomitant injuries. 

The prosthetic assessment includes the following: 

	 •	 medical history,

	 •	 premorbid activities (vocational and avocational), 

	 •	 psychosocial considerations,

	 •	 residual limb status,

	 •	 concomitant injuries, and

	 •	 patient functional requirements.

It is also important to consider the family/support system available to the patient and the potential 

discharge plan. The information gathered during the 

assessment is then used to develop a prosthetic recommendation that is used by the multidisciplinary team 

to create an individualized rehabilitation plan.

Patient Education

The prosthetic assessment also marks the beginning of the patient’s education on prosthetic 

rehabilitation and the options available to him or 

her. Individuals who sustain blast wounds undergo 

myriad physical and psychological changes over the 

first weeks postinjury. Creating an open dialogue 

with service members and their families at this stage 

is essential to facilitate progression through the rehabilitation process. It is an opportunity to reconcile 

any preconceptions about prosthetic technology 

because exposure to popular films and media can 

create unrealistic prosthetic expectations. During 

this time, the service member and his or her family 

must process a significant amount of information 

regarding the injury, recovery, and implications for 

the future. Therefore, pertinent information should 

often be reiterated to ensure that it has been properly 

assimilated. Meetings with a trained peer visitor who 

has successfully completed prosthetic rehabilitation 

can also be beneficial in providing accurate information, as well as a user’s perspective. 

The anticipated timeline for prosthetic rehabilitation 

over the subsequent 12 to 18 weeks postinjury should 

be discussed during the assessment. Rehabilitation begins with residual limb management and preparation 

for prosthetic fitting, and continues beyond delivery 

of the definitive prostheses to the point wherein the 

patient is comfortable reintegrating into the community (see Interim Prosthetic Phase for level-specific 

protocols).
622

Care of the Combat Amputee

Residual Limb Management

The first step in residual limb management is to 

address edema control. Blast injuries and multiple irrigations and debridements prior to wound closure can 

produce significant edema. Compressive dressings and 

garments are applied immediately following wound 

closure for the purpose of reducing swelling. Proper 

edema management using elastic bandages, presized 

tubular compressive fabrics, or silicone/urethane rollon liners is necessary. Use of silicone liners has been 

particularly effective at edema reduction, but must not 

be implemented until drainage has ceased because of 

concerns regarding skin integrity and infection (Figure 

23-20).

During the Preprosthetic Phase, the occupational 

therapist concentrates on desensitization, range of motion, myosite training, and limb loading in preparation 

for prosthetic fitting. This phase gives the prosthetics 

team valuable information on control schemes that 

are most likely to be immediately successful with the 

patient. This also allows the patient to develop a rapport with various members of the rehabilitation team 

who will be seen daily in the Interim Prosthetic Phase 

of rehabilitation. Finally, patients are encouraged to 

build confidence in their own abilities by controlling simulators and demonstration components, and 

working through challenging situations prior to early 

postoperative prosthesis (EPOP) fitting (Figure 23-21). 

Within 24 hours of suture and staple removal, residual 

limb impressions are taken to initiate the Interim Prosthetic Phase.

Figure 23-20. Healing residual limb.

INTERIM PROSTHETIC PHASE

Military amputees, who are typically young and 

motivated, benefit from early prosthetic intervention 

because it offers greater independence, self-esteem, 

and long-term success.18 As previously noted, the 

protocol established by the military healthcare system is to sequentially provide each service member 

with an electric or hybrid prosthesis, a body-powered 

prosthesis, a passive restoration prosthesis, and taskspecific adaptations or prostheses. One of the goals 

during this stage of initial prosthetic device delivery 

is to minimize the time between suture removal and 

functional prosthetic use. Delivery of EPOP ideally 

occurs within 24 hours of suture removal. Often, the 

residual limb of these individuals presents multiple 

problems with healing, related to complicated suture 

lines, skin grafts, muscle flaps, or the presence of fragments or other foreign bodies. Therefore, a myoelectric 

EPOP device offers the safest approach to introducing 

a prosthesis to the individual in a way that minimizes 

excessive forces on the often fragile and healing distal 

residuum. The electric prosthesis is well-suited for this 

application because it does not require a restrictive harness and gross body movements for control that can 

exert unwanted forces on the healing residual limb or 

other healing areas that would be in contact with the 

harness. Myoelectric control of the EPOP also offers the 

advantages of immediate functionality, proportional 

grip strength, and TD positioning at initial delivery. 

Prior to EPOP fitting, it is important for the patient to 

have developed basic myoelectric control skills in occupational therapy during the Preprosthetic Phase. 

The EPOP is fit during this initial healing period 

Figure 23-21. Otto Bock 757M11 MyoBoy for preprosthetic 

training with demonstration myoelectric hand and wrist.

Photograph: Product image used with permission from Otto 

Bock HealthCare, Minneapolis, Minnesota.
623

Upper Extremity Prosthetics

and is modified during rehabilitation until swelling 

is stabilized and wound closures are complete. The 

patient is fit with an EPOP using an expedited fitting 

protocol. A typical expedited fitting requires 1 to 3 days 

and allows the patient to begin occupational therapy 

with a functioning, but modifiable, device that can be 

used to address changes during initial rehabilitation 

and therapy for increased efficiency. EPOP procedures 

include adjustments for alignment, length, suspension, 

pressure distribution, functional performance, and 

programming of all electronics for system optimization and positioning of electrodes, batteries, access 

openings, and components. 

The prosthetist must be prepared to accommodate 

the often dramatic volumetric changes in the residual 

limb for individuals who have sustained blast wounds. 

It is not uncommon during the first 4 to 8 weeks after 

EPOP delivery to perform multiple socket adjustments each week. A myoelectric prosthesis requires 

consistent skin-to-electrode contact to retain function. 

Therefore, it is imperative that adjustments for proper 

fit be performed in an expeditious manner. This is best 

accomplished using a thermoplastic flexible socket and 

rigid frame that can be modified several times during 

the Interim Prosthetic Phase. 

EPOP methodology was developed to address military protocols for early fitting while minimizing the 

stresses on the healing residuum. Early in Operation 

Enduring Freedom and Operation Iraqi Freedom, it 

was found that the amount of residual limb edema 

was significant secondary to methods of irrigation 

and maintenance of open wounds prior to transferring patients to stateside medical care facilities. Many 

amputees had also sustained injuries to the chest 

wall, shoulder areas, and axillary regions that would 

preclude the use of a harness for control of a bodypowered TD or elbow during the healing phase. Traditional immediate postoperative prosthesis (IPOP) has 

been bypassed because of the evolution of EPOP and 

because IPOP treatments cannot accommodate these 

rapid volume changes and preclude visual assessment 

of the healing limb, which is crucial immediately following closure. Closure of the amputated limb without 

the application of an IPOP allows the team to observe 

the healing wounds and begin preprosthetic therapy 

with shrinkers and myotraining as soon as the patient 

is cognitively and physically able. In preparation for 

the EPOP and Interim Prosthetic Phase, the surgeon 

is able to ensure that wound closure has matured to a 

point at which the mild pressures applied from a prosthetic socket that uses flexible thermoplastics against 

the skin can be tolerated. Fitting of the EPOP then 

provides the positive results of “instant gratification” 

and broad functional applications with minimal stress 

to the healing anatomy. The ability to make significant, 

frequent changes to volume, alignment, componentry, 

and programming during the EPOP Phase allows the 

rehabilitation team to keep pace with the highly motivated amputee.

At the time of EPOP delivery, focus in the patient’s 

therapy shifts to prosthetic training. When a prosthetic device is fit and delivered to a service member, 

thorough instruction on the system is given by the 

prosthetist. This instruction often takes place with the 

occupational therapist present so that various specifics 

can be noted for subsequent training sessions. Information is typically covered in a routine order, starting with 

donning and doffing. Common application techniques 

include the use of limited friction donning pull socks, 

evaporative moisture, or roll-on liners, as required by 

the design of the prosthesis. The following procedures 

are then taught from distal to proximal, dependent on 

amputation level: 

	 •	 TD on-off and positioning;

	 •	 wrist controls;

	 •	 elbow on-off and lock-unlock;

	 •	 shoulder joint movements, lock-unlock;

	 •	 harness donning, doffing, and adjustment;

and 

	 •	 battery insertion, charging and care.

These functions are later practiced in occupational 

therapy. It is also necessary to review these functions 

periodically as the use of multiple prostheses and the 

interchangeability of TDs require slight variations in 

control. Consistent communication between prosthetist 

and occupational therapist is indispensable to ensure 

that any changes that impact the fit or programming 

of the prosthesis are immediately addressed. This 

relationship continues throughout the rehabilitation 

process to facilitate problem-solving as the patient is 

challenged to higher degrees.

There will come a time when the wounds have 

adequately healed and can sustain more aggressive 

pressures from the prosthetic socket interface. At this 

point, a transition is made from the EPOP approach to a 

preparatory version of the prosthesis. This preparatory 

phase still retains the adaptability of the EPOP for ongoing volume changes, but allows the socket to become 

tighter for improved suspension, electrode contact, and 

overall control of the prosthesis in space. By this time, 

the alignment, length, and basic structure should be 

well defined. The preparatory prosthesis provides the 

rehabilitation team with the opportunity to test the prosthesis and its components in real-world applications 

outside the clinic setting. Further modifications in 

volume, alignment, length, and structure can be made 
624

Care of the Combat Amputee

easily during this phase as the team prepares to progress to the definitive prosthesis (Figure 23-22).

Once the residual limb has reached volumetric stabilization, usually within 8 to 14 weeks after suture or 

staple removal, fabrication of the definitive prostheses 

begins. A goal for this stage is to ensure that at no point 

is the user left without a prosthesis. To accomplish this, 

it is often necessary to fabricate the definitive bodypowered device prior to fabrication of the definitive 

myoelectric. Typically, both definitive devices are 

delivered within 7 to 10 days of each other. 

Completion of the definitive silicone restoration/

passive prosthesis and silicone restoration covering for 

the electric hand should coincide approximately with 

the fitting of the definitive electric and body-powered 

devices. This process typically takes 12 to 16 weeks 

from first impressions to definitive prosthesis. These 

remarkably life-like replications are custom painted 

on the inside of a clear silicone glove that is fabricated 

using a sculpted reversal of the amputee’s sound limb. 

An impression of the sound side (if present) is taken in 

the Preprosthetic Phase. In bilateral upper extremity 

loss, the patient will often choose a family member as 

a model or even detailed photos of their own hands 

prior to the injury from which the artists can sculpt the 

restoration (Figure 23-23). 

Evaluation for task-specific devices to support the 

service member’s vocational and avocational interests 

occurs throughout the rehabilitation process. Not only 

are individuals returning to preinjury pursuits but 

also, through programs sponsored for wounded service members, they are developing new interests and 

challenges with their prosthetic devices. As described 

previously, this patient population is driven, competitive, and willing to test the limits of current prosthetic 

technology to reach their goals. 

It is important to teach service members to perform 

basic maintenance on the various prostheses that they 

have received. Simple tasks (eg, cleaning, minor electrode adjustment, and cable and harness servicing) 

can be taught during the Interim Prosthetic Phase and 

reinforced in therapy as part of the treatment protocols. 

Service members are also taught to describe problems 

with their prostheses in a way that allows the prosthetist to diagnose and repair items that have broken 

or failed. In cases in which the service member has 

returned to active duty or is not near a service facility, 

the ability to describe a problem accurately will often 

help the rehabilitation team determine whether the 

service member should send a prosthesis to the center 

Figure 23-23. Steps in the silicone restoration process: (left) impression, (center) wax model, and (right) custom painting.

Figure 23-22. Preparatory transhumeral-level electric 

prosthesis.

Photograph: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California.
625

Upper Extremity Prosthetics

or directly to a component manufacturer for diagnosis 

and repair. This is especially important for the service 

member who requires a rapid turn-around of repairs 

because of essential job duties, whether military or 

civilian in nature.

The following section will address the specific and 

unique prosthetic requirements for each upper limb 

amputation level. Level-specific timelines, socket 

designs, components, and special considerations are 

discussed.

Level-Specific Recommendations

Finger, Thumb, and Partial Hand Amputations

Finger, thumb, and partial hand amputations comprise a portion of the military amputee population. 

Current prosthetic treatment approaches have been 

to create silicone restorations and to explore other 

mechanical and powered products. Typically, silicone 

restoration gives the service member some limited 

function for opposition against any remaining digits. 

The cosmetic nature of the restoration also gives the 

service member the appearance of wholeness in public, 

thus less attention is drawn to the injury. There have 

been some creative solutions to provide mechanical 

and powered function for finger and thumb prostheses. 

The current powered units are disadvantaged by the 

bulk of battery and controller shapes, as well as by the 

fragile nature of the components themselves. There are, 

however, some promising advances being made in this 

realm. A wide variety of task-specific adaptations for 

both the environment and a prosthesis have also been 

created to facilitate functioning for this population in 

ADLs, vocational activities, and avocational activities 

(Figures 23-24 to 23-26).

Styloid Disarticulation

The styloid disarticulation level has the benefit of 

an intact distal radial-ulnar joint, which preserves 

pronation and supination. Generally, the length of the 

residual limb will preclude the use of an electric wrist 

rotator or quick disconnect-style wrist unit to maintain 

length symmetry between the electric prosthesis and 

the noninjured limb. Because a quick disconnect wrist 

unit cannot be used, separate electric prostheses must 

Figure 23-24. Custom-fabricated, task-specific hockey 

prosthesis.

Photograph: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California.

Figure 23-25. Advanced Arm Dynamics powered fingers.

Photograph: Prosthesis provided by Advanced Arm Dynamics, Redondo Beach, Inc, California.

Figure 23-26. (Top) Body-powered X-Finger without silicone 

covering and (bottom) body-powered X-Finger with silicone 

covering (patent pending). 

Photographs: Courtesy of Didrick Medical, Inc, Naples, 

Florida.
626

Care of the Combat Amputee

be fabricated for each TD. Without electric wrist rotation, it is imperative for the socket to allow anatomical 

rotation. This is best achieved through the use of a selfsuspending suction socket that terminates distal to the 

olecranon and epicondyles. Suction is achieved through 

purchase over the styloids, with donning aided by the 

use of an evaporative moisture technique. In the case 

of a styloid-level, body-powered prosthesis—with the 

socket design’s inherent suspension qualities—most 

often a figure-of-nine harness is used for control of the 

TD (Figure 23-27). There are occasions when heavy lifting will require an auxiliary figure-of-eight, with triceps 

cuff and flexible hinges to assist in load bearing. There 

are also cases in which a silicone suspension sleeve 

worn over the outside of the prosthesis has proven 

useful. Significant challenges exist if the styloid-level 

amputee lacks the ability to supinate and pronate or if 

the prominence of the styloids is insufficient to achieve 

suspension and rotational control. Therefore, it is important for the styloid disarticulation-level amputee to 

be carefully evaluated for appropriate suspension in the 

prosthetic design (Table 23-8).

Transradial Amputations

Transradial amputations are the most common level 

for upper extremity amputations proximal to the hand. 

Absence of the styloids creates the need for additional 

suspensory elements in the design of the prosthesis. 

This is most commonly achieved through self-suspending socket designs that use the bony anatomy of the 

elbow and proximal forearm contours to suspend the 

prosthesis. The surgical considerations covered earlier 

in this chapter define the optimal length of transradial 

level residual limb for use of componentry. Because of 

the shorter radius and ulna and damage to the interosseus membrane, anatomical pronation and supination 

are absent. To compensate for this deficiency, active or 

passive rotation must be provided for the amputee to 

preposition the TD.

For the electric prosthesis, an anatomically suspended dynamic muscle-contoured interface design—

utilizing compression anterior to the epicondyles and 

superior to the olecranon and through the cubital 

fold—is often used. There are specific contours to allow hypertrophy of the remaining musculature in the 

residual limb. This socket design provides the best 

methodology to ensure superior suspension and skin 

to electrode contact throughout the range of motion.19

To enhance comfort and range of motion, a window 

(referred to as a 3⁄4 modification) can be removed from 

the socket about the olecranon. Residual limbs that 

are not suited for this type of prosthetic interface can, 

in some cases, be treated with silicone roll-on liners. 

Production and custom versions of these liners can be 

considered for short or irregularly shaped limbs. 

Patients may prefer to use the same socket design 

for all of their prostheses. When the dynamic musclecontoured socket is preferred, it is typically used with 

a figure-of-nine harness in the body-powered application. It is more common, however, to incorporate a 

silicone/urethane suction liner with a pin-lock system 

for the body-powered prosthesis. A figure-of-nine 

harness can also be used with this socket design, 

although there are occasions when heavy lifting will 

require an auxiliary figure-of-eight harness with triceps cuff and flexible hinges to assist in load bearing 

(Table 23-9).

Elbow Disarticulations 

Amputations at the elbow disarticulation level 

have a unique advantage for suspension and natural 

humeral rotation countered by the loss of any powered 

prosthetic elbow options. The remaining humeral epicondyles can be used to achieve anatomical/suction 

suspension. Suction is achieved through purchase over 

the epicondyles, with donning aided by the use of an 

evaporative moisture technique or a reduced friction 

pull sock. Suspension is achieved by a combination of a 

bony lock proximal to the condyles and suction, generally eliminating the need for an auxiliary suspension 

harness. In the case of an elbow disarticulation-level, 

body-powered prosthesis with the socket design’s 

inherent suspension qualities, a figure-of-eight harness is most often used for control of the elbow, elbow 

Figure 23-27. Preparatory styloid-level myoelectric 

prosthesis.

Photograph: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California.
627

Upper Extremity Prosthetics

lock, and TD. A shoulder saddle and chest strap can 

be integrated to assist with load bearing and comfort 

as needed, and is commonly used for the hybrid prosthesis as well (Figure 23-28).

The lack of space for a traditional elbow unit is a 

challenge at this level of amputation. An elbow unit 

will typically provide humeral rotation through a 

turntable mechanism, but the outside locking hinges 

required for this level do not. Additionally, if the 

elbow disarticulation-level amputee lacks sufficient 

prominence of the humeral epicondyles, suspension 

and rotational control are difficult to achieve anatomically. An externally powered prosthesis at the elbow 

disarticulation level is, therefore, a hybrid approach because there is insufficient room for an electric prosthetic 

elbow. Utilization of locking hinges limits the number 

of elbow-locking positions and often adds significant 

medial-lateral width, which can be problematic with 

use of long-sleeved clothing. Specifically, patients have 

difficulty finding jackets and outerwear that fit over 

the prosthesis (Table 23-10).

Transhumeral Amputations

At this level of amputation, an elbow system is 

required. Although there are many elbow systems 

available, they can be broadly categorized as either 

mechanical or electrical (Figure 23-29).

A mechanical elbow system requires the amputee 

to use gross body motions of the shoulder, creating 

excursion through the harness system to flex the 

elbow. Electric elbow units provide powered flexion with myoelectric, linear potentiometer, linear 

transducer, force-sensing resistor, or switch control. 

TABLE 23-8

PROSTHETIC RECOMMENDATIONS FOR THE STYLOID DISARTICULATION LEVEL

Phase Styloid Level

1 EPOP Electric*

Flexible thermoplastic inner socket, one-way mini-expulsion valve, rigid thermoplastic frame

Anatomically contoured, self-suspending suction/evaporative moisture donning technique

Myoelectric control, dual-site with two viable EMG outputs (other control options are used for patients who do not 

have two myo-sites)

EPOP used until the residual limb can sustain greater pressures from the tighter fitting preparatory prosthesis

Due to the lack of quick disconnect capability, terminal devices must be associated with separate sockets and 

frames, ie, microprocessor-controlled hand prosthesis, microprocessor-controlled powered prehensor prosthesis, 

microprocessor-controlled work hook prosthesis

2 Preparatory Electric*

Similar fabrication as EPOP with more aggressive suspension design

Multiple socket adjustments/replacements continue until residual limb volume has stabilized

3 Body-Powered

Fit concurrent with definitive fabrication of electric prosthesis

Flexible thermoplastic inner socket, one-way mini-expulsion valve, carbon fiber frame

Anatomically contoured, self-suspending suction/evaporative moisture donning technique

Titanium VO hook, VO hand, titanium VC hook, stainless-steel quick disconnect locking wrist, limited friction cable

4 Definitive Electric*

Flexible thermoplastic inner socket, one-way mini-expulsion valve, carbon fiber frame

Anatomically contoured, self-suspending suction/evaporative moisture donning technique

5 Silicone Passive 

Fit and deliver definitive custom silicone passive prosthesis with suction suspension

6 Evaluate for Task-Specific Needs

EMG: electromyographic

EPOP: early postoperative prosthesis

VC: voluntary closing

VO: voluntary opening

*Multiple socket/frames required because of a lack of quick disconnect capability: microprocessor-controlled hand prosthesis; microprocessorcontrolled powered prehensor prosthesis; and microprocessor-controlled work hook prosthesis.
628

Care of the Combat Amputee

Both electric and mechanical units provide passive 

humeral rotation. Socket design is critical and must 

allow as much range of motion of the glenohumeral 

joint as possible while eliminating any socket movement on the residuum. This can be achieved by using 

a dynamic, muscle-contoured socket that does not 

encapsulate the shoulder girdle.20 Suspension of the 

electric prosthesis is achieved most often with suction 

suspension and an auxiliary dynamic shoulder saddle 

and chest strap. Suspension for the body-powered 

prosthesis can be accomplished in a variety of ways, 

TABLE 23-9

PROSTHETIC RECOMMENDATIONS FOR THE TRANSRADIAL LEVEL

Phase Transradial Level

1 EPOP Electric

Flexible thermoplastic inner socket, rigid thermoplastic frame

Anatomically contoured self-suspension with reduced friction donning sock technique, dynamic muscle-contoured interface with 3⁄4 modification for transradial level

Myoelectric control, dual-site, TD/electric wrist rotator switching (other control options are used for patients 

who do not have two myo-sites)

Multiple interchangeable TDs through quick disconnect collar: microprocessor-controlled hand; microprocessorcontrolled prehensor; microprocessor-controlled work hook with locking wrist flexion

EPOP used until the residual limb can sustain greater pressures from the tighter fitting preparatory prosthesis

2 Preparatory Electric

Similar fabrication as EPOP with more aggressive suspension design 

Multiple socket adjustments/replacements continue until residual limb volume has stabilized

3 Body-Powered

Fit concurrent with definitive fabrication of electric prosthesis

Flexible thermoplastic inner socket, carbon fiber frame

Anatomically contoured self-suspension with reduced friction donning sock technique, dynamic muscle-contoured interface with 3⁄4 modification for transradial level

OR

Silicone suction suspension using roll-on liner with pin-lock system 

Titanium hook, VO hand, titanium VC hook, stainless-steel quick disconnect locking wrist, limited friction cable 

(with wrist flexion unit for bilateral)

Traditional flexible hinges/triceps cuff and figure-of-eight harness applied for load-bearing applications

4 Definitive Electric

Flexible thermoplastic inner socket, carbon fiber frame

Anatomically contoured self-suspension with reduced friction donning sock technique, dynamic muscle-contoured interface with 3⁄4 modification for transradial level

5 Silicone Passive 

Fit and deliver definitive custom silicone passive prosthesis with suction suspension

6 Evaluate for Task-Specific Needs

EPOP: early postoperative prosthesis

TD: terminal device

VC: voluntary closing

VO: voluntary opening

including a silicone suction and pin-lock system, a 

figure-of-eight harness and Bowden cable system, or 

a system similar to that used with the electric design 

(Figure 23-30).

It is important to note that the force required to flex 

the mechanical elbow of a body-powered transhumeral-level prosthesis increases significantly, with only 

a small additional weight in the TD. Therefore, the 

amputee’s residual limb must be carefully evaluated 

for readiness to accept the increased forces inherent in 

a body-powered design (Table 23-11).
629

Upper Extremity Prosthetics

adduction and flexion/extension. Some shoulder 

joints permit multiple locking positions in the flexionextension plane. This feature is particularly useful to 

enable patients to position the TD when operating the 

prosthesis over their heads. 

Stability of the socket on a patient of this level is 

critical because slight movements between torso and 

socket are magnified into large motions at the TD. 

Myoelectrically controlled prostheses require consistent skin-to-electrode contact that is difficult, if not 

impossible, to achieve when the socket lacks stability. 

An infraclavicular interface design is the best methodology to provide enhanced stability while reducing 

surface area coverage, therefore resulting in a lighter 

weight prosthesis that reduces heat buildup. The infraclavicular design compresses anteriorally through 

the delto-pectoral region, posteriorally through the 

spine of the scapula, and inferiorly along the intercostal 

region.21 The infraclavicular design is stabilized using 

a custom synthetic elastic harness. 

The elbow joints used in these prostheses are the 

same as the units used in transhumeral prostheses and 

are controlled in similar ways. However, as noted previously, many patients have difficulty in achieving sufficient cable excursion to fully operate a body-powered 

prosthesis at this level. Adaptive devices designed to 

assist with this limitation include excursion amplifiers, 

elbow lift assists, and nudge control switches. Often, 

the prosthetist will resort to powered systems at this 

level for improved control and functional outcome 

(Table 23-12).

Bilateral Considerations

Bilateral amputees face a much more difficult rehabilitation process to become fully independent. The 

amputee does not have a sound limb to rely on or to 

provide fine prehension and sensory feedback. This 

creates an immediate need to learn how to operate 

prostheses to accomplish virtually all ADLs. Although 

the challenge is greater for bilateral amputees, they 

generally are also the most motivated because they 

rarely achieve full independence without mastering 

the use of prostheses. 

The design of the prostheses is crucial because it must 

allow the patient to perform all ADLs as independently 

as possible. There is a tendency for the longer residual 

limb to become dominant in the bilateral amputee, and 

selecting the appropriate control scheme and prosthetic design for the now dominant side is critical for 

functionality. Design of the prostheses must allow the 

patient to bring the TDs to midline and operate them in 

that position. To achieve this positioning, the prosthetic 

Figure 23-28. Elbow disarticulation-level amputee with 

custom silicone restoration. 

Photograph: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California.

Humeral Neck, Glenohumeral Disarticulation, and 

Interscapulothoracic Amputations

Humeral neck, glenohumeral disarticulation, and 

interscapulothoracic amputations present the most 

difficult challenges for upper extremity prosthetic 

rehabilitation. At these amputation levels, there is 

little if any lever arm available to produce sufficient 

excursion for control of a body-powered prosthesis. 

Humeral neck amputations that do not leave sufficient humeral length to control a prosthesis must 

be fit in the same manner as a complete disarticulation of the glenohumeral joint. Scapular abduction 

and shoulder elevation can be captured to provide 

some of the control motions required, but this is often 

insufficient to provide the excursion required to flex 

the body-powered elbow joint or open the TD fully. 

Glenohumeral abduction, flexion, and extension are 

achieved using a prosthetic shoulder joint. Shoulder 

joints provide friction-resisted passive abduction/
630

Care of the Combat Amputee

TABLE 23-10

PROSTHETIC RECOMMENDATIONS FOR THE ELBOW DISARTICULATION LEVEL

Phase Elbow Disarticulation Level

1 EPOP Hybrid

Flexible thermoplastic inner socket, one-way removable expulsion valve, rigid thermoplastic frame, outside locking hinges

Anatomically contoured self-suspension (if epicondyles are present) with reduced friction donning sock technique or evaporative moisture technique

Shoulder saddle/chest strap harness

Myoelectric control, dual-site, TD/electric wrist rotator switching (other control options are used for patients 

who do not have two myo-sites)

Multiple interchangeable TDs through quick disconnect collar: microprocessor-controlled hand; microprocessorcontrolled prehensor; and microprocessor-controlled work hook with locking wrist flexion

EPOP used until the residual limb can sustain greater pressures from the tighter fitting preparatory prosthesis

2 Preparatory Hybrid

Similar fabrication as EPOP with more aggressive suspension design

Multiple socket adjustments/replacements continue until residual limb volume has stabilized

3 Body-Powered

Fit concurrent with definitive fabrication of electric prosthesis

Flexible thermoplastic inner socket, one-way removable expulsion valve, carbon fiber frame, outside locking 

hinges

Anatomically contoured self-suspension (if epicondyles are present) with reduced friction donning sock technique or evaporative moisture technique

Shoulder saddle/chest strap harness

Titanium VO hook, VO hand, stainless-steel quick disconnect locking wrist, limited friction cable, wrist flexion 

unit

4 Definitive Hybrid

Flexible thermoplastic inner socket, one-way removable expulsion valve, carbon fiber frame, outside locking 

hinges

Anatomically contoured self-suspension (if epicondyles are present) with reduced friction donning sock technique or evaporative moisture technique

Shoulder saddle/chest strap harness

5 Silicone Passive

Fit and deliver definitive custom silicone passive prosthesis with suction suspension

6 Evaluate for Task-Specific Needs

EPOP: early postoperative prosthesis

TD: terminal device

VO: voluntary opening

components may be angulated in relationship to the 

socket, creating preflexion for the TD. Flexion wrist 

units also improve midline accessibility by bringing 

the TD toward the head and mouth, which is essential 

for feeding and grooming activities. Many bilateral 

patients prefer a myoelectric prosthesis with an electric wrist rotator on at least one side for independent 

prepositioning of the TD. The body-powered prosthetic 

wrist unit will require manual positioning of the TD 

using the environment or another aspect of the body. 

Bilateral amputees will also face challenges in 

donning and doffing their prostheses because they 

do not have a sound side to aid in the donning of the 

prosthesis. Rather, they must use their residual limbs 

to help position the prostheses to be donned. In the 

case of higher level amputations, it is often helpful to 

supply a donning stand or tree. The stand provides 

a place to store the prostheses while not being worn 

and to position one or both prostheses for donning. 

For prostheses that require a reduced friction donning 
631

Upper Extremity Prosthetics

Figure 23-29. Transhumeral-level amputee wearing a definitive, body-powered prosthesis.

Photograph: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California.

Figure 23-30. Transhumeral-level amputee wearing a hybrid 

prosthesis with myoelectric wrist and TD and body-powered 

elbow unit.

TD: terminal device

Photograph: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California.

sock, the patient will often use his or her lower extremity to assist in pulling the limb into the socket. 

When fitting an electric prosthesis, there are some 

additional componentry options that require consideration. Bilateral patients often prefer internal battery 

systems because they do not have to remove and 

replace the battery—a task requiring a higher degree 

of dexterity. The internal battery system allows the 

amputee to simply plug the prosthesis into the charger 

without removing a battery. When removable batteries 

are used, it can be beneficial to add on/off or remote 

power switches to the prostheses. Power switches 

enable the patient to turn the prosthesis off without 

having to remove a battery. As previously described, 

electric wrist rotators offer enhanced function by allowing efficient prepositioning of the TD and should 

be included as often as possible. Wrist flexion units 

should also be considered whenever there is room 

(Figure 23-31).

Sometimes the right and left backup prostheses 

are harnessed independently for use of one or both 

prostheses as desired by the patient. This allows for 

maximum flexibility in combining different types of 

prostheses, including electric and body-powered devices, as well as use of only one prosthesis at a time. 

For the combat amputee who often has concomitant 

injuries, both residual limbs may not be ready for 

prosthetic intervention at the same time. By harnessing 

the prostheses independently, the patient may begin 

prosthetic rehabilitation at the earliest opportunity. 

Conversely, at higher amputation levels, including 

bilateral humeral neck or glenohumeral disarticulation 

levels, amputees may benefit from a socket and harness 

design that is integrated to facilitate donning, doffing, 

and suspension. This integration often creates a blending of prosthetic devices and harnessing that is donned 

and doffed much like a shirt or coat would be, often 

with the aid of a donning stand or dressing tree. 

It is important to include input from members of 

the interdisciplinary team to design or recommend a 

variety of assistive devices and modifications to adapt 

the environment of the bilateral patient for maximum 

functional independence. It is not unusual to fabricate 

or provide a custom prosthesis for a specific ADL. An 

example would be a prosthesis designed specifically 

for bathing. Home, workplace, and vehicular adaptations are commonly used to promote function and 

independence in a variety of activities both with and 

without the use of the prostheses. Complete independence becomes more challenging at higher levels 

of amputations. Refer to Chapter 18 (Occupational 
632

Care of the Combat Amputee

TABLE 23-11

PROSTHETIC RECOMMENDATIONS FOR THE TRANSHUMERAL LEVEL

Phase Transhumeral Level

1 EPOP Electric

Flexible thermoplastic inner socket, one-way removable expulsion valve, rigid thermoplastic frame

Anatomically contoured interface with reduced friction donning sock technique 

Shoulder saddle/chest strap harness

Microprocessor-controlled electric elbow unit; linear transducer control of elbow allows simultaneous control 

with myoelectric TDs or wrist rotator

Myoelectric control, dual-site, TD/electric wrist rotator switching (other control options are used for patients 

who do not have two myo-sites)

Multiple interchangeable TDs through quick disconnect collar: microprocessor-controlled hand; microprocessorcontrolled prehensor; and microprocessor-controlled work hook with locking wrist flexion

EPOP used until the residual limb can sustain greater pressures from the tighter fitting preparatory prosthesis

2 Preparatory Electric

Similar fabrication as EPOP with more aggressive suspension design

Multiple socket adjustments/replacements continue until residual limb volume has stabilized

3 Body-Powered

Fit concurrent with definitive fabrication of electric prosthesis

Flexible thermoplastic inner socket, one-way removable expulsion valve, carbon fiber frame

Anatomically contoured interface with reduced friction donning sock technique 

Shoulder saddle/chest-strap harness

Lift-assist enhanced elbow unit

Titanium VO hook, VO hand, stainless-steel quick disconnect locking wrist, limited friction cable, wrist flexion 

unit 

4 Definitive Electric

Flexible thermoplastic inner socket, one-way removable expulsion valve, carbon fiber frame

Anatomically contoured interface with reduced friction donning sock technique

Shoulder saddle/chest strap harness

5 Silicone Passive 

Fit and deliver definitive custom silicone passive prosthesis with suction suspension or skin traction suspension

6 Evaluate for Task-Specific Needs

EPOP: early postoperative prosthesis

TD: terminal device

VO: voluntary opening

Therapy for the Polytrauma Casualty) for specific recommendations regarding therapeutic techniques and 

modifications for rehabilitation of the bilateral amputee. 

Concomitant Considerations

Combat-wounded service members sustaining amputations often have concomitant injuries that can complicate rehabilitation. The following section describes 

some of the challenges encountered. See Chapter 1 

(Developing a System of Care for the Combat Amputee) and Chapter 10 (Medical Issues) for more details.

Loss of Sight

The loss of sight in one or both eyes can significantly challenge a patient’s ability to use a prosthesis. 

In the case of total blindness, the patient cannot use 

visual feedback that compensates for limited sensory 

feedback of prosthetic devices to develop prosthetic 

control skills. Typically, an amputee can observe an 

object being grasped and/or deformed by the TD and 

create an impression of the grip force being applied. At 

the transhumeral level or above, learning to operate an 

elbow system is also complicated by visual impairment 
633

Upper Extremity Prosthetics

TABLE 23-12

PROSTHETIC RECOMMENDAITONS FOR THE HUMERAL NECK, GLENOHUMERAL DISARTICULATION, AND INTERSCAPULOTHORACIC LEVELS

Phase Humeral Neck, Glenohumeral Disarticulation, Interscapulothoracic 

1 EPOP Electric

Flexible thermoplastic inner socket, rigid thermoplastic frame 

Infraclavicular interface 

Custom synthetic elastic harness

Microprocessor-controlled electric elbow unit; linear transducer control of elbow allows simultaneous control 

with myoelectric TDs or wrist rotator

Myoelectric control, dual-site, TD/electric wrist rotator switching (other control options are used for patients 

who do not have two myo-sites)

Multiple interchangeable TDs through quick disconnect collar: microprocessor-controlled hand; microprocessorcontrolled prehensor; and microprocessor-controlled work hook with locking wrist flexion

EPOP used until the residual limb can sustain greater pressures from the tighter fitting preparatory prosthesis

2 Preparatory Electric

Similar fabrication as EPOP with more aggressive suspension design

Multiple socket adjustments/replacements continue until residual limb volume has stabilized

3 Hybrid Prosthesis

Fit concurrent with definitive fabrication of electric prosthesis

Flexible thermoplastic inner socket, carbon fiber frame

Infraclavicular interface

Custom synthetic elastic harness

Lift assist-enhanced elbow unit

Myoelectric control dual-site, TD/electric wrist rotator switching 

Multiple interchangeable TDs through quick disconnect collar: microprocessor-controlled hand; microprocessorcontrolled prehensor; and microprocessor-controlled work hook with locking wrist flexion

4 Definitive Electric

Flexible thermoplastic inner socket, carbon fiber frame

Infraclavicular interface

Custom synthetic elastic harness

5 Silicone Passive 

Fit and deliver definitive custom silicone passive prosthesis with suction suspension or skin traction suspension

6 Evaluate for Task-Specific Needs

EPOP: early postoperative prosthesis

TD: terminal device

because it is difficult to ascertain the position of the 

forearm without visual confirmation. Therefore, it may 

be necessary to provide additional training on creating 

feedback through environmental awareness techniques 

or the use of other body surfaces for proprioception.

Loss of Hearing

Many electrically powered prostheses provide 

auditory or vibratory feedback for mode changes 

and low battery warning. Amputees report that, 

with experience, they learn to use the sounds and/

or vibrations produced by the motors of the elbow, 

wrist rotators, and TDs to provide positional feedback. Whereas both of these techniques take time 

to learn, they can develop into viable feedback. 

Auditory feedback may not work for the amputee 

with hearing loss; but, if vibratory feedback is strong 

enough to be noticed, it can assist. Generally the 

amputee with hearing loss, if vision is not affected, 

will rely on visual feedback for prosthesis position 

and function.
634

Care of the Combat Amputee

Traumatic Brain Injury 

It is not uncommon for a blast exposure to result in 

some level of TBI. Manifestations of TBI are diverse 

and individually unique based on the area of the brain 

that is affected. Some symptoms may include personality changes, loss of attention, changes in processing 

skills, changes in motor function, and frustration intolerance. Expeditious diagnosis of brain injury will 

allow more effective formulation of the individualized 

prosthetic and therapeutic rehabilitation plan. This 

may take the form of specific therapies for information processing, speech, motor control, and behavior 

modification. Sometimes a center specializing in TBI 

will be accessed prior to or during the other phases 

of rehabilitation. Depending on the outcome of more 

intensive treatments, some severe TBI amputees have 

successfully reintegrated into the prosthetic rehabilitation setting during or after TBI-specific treatment. It 

is useful to consider activating and training for one 

prosthetic component at a time to reduce frustration 

and encourage repetitive pattern formations. Introducing all of the possible functions of a given prosthesis 

in one visit may be overwhelming for a patient who 

has suffered TBI. 

Lower Extremity Injury/Loss

Impaired lower extremity function or lower extremity amputation places further demands on the upper 

extremities for both stability and mobility needs. For 

amputees sustaining both upper and lower extremity amputations, gait training with a lower extremity 

prosthesis often requires the upper extremity prosthesis to be fit for safe balance with walking aids. Even 

those amputees who choose to wheelchair ambulate 

for a time will often benefit from the assistance of the 

upper extremity prosthesis to assist in propelling and 

controlling the manual or powered wheelchair. An upper extremity prosthesis is also useful for donning and 

doffing a lower extremity prosthesis (Figure 23-32).

Burns/Grafting

Thermal damage to the skin may require grafting 

and result in significant scar formation. Loss or change 

of the skin integrity creates range of motion and socket 

interface tolerance challenges. Silicone or urethane 

liners are often used to provide a protective barrier 

between the sensitive healing skin and the prosthetic 

Figure 23-31. Bilateral upper limb amputee with right 

styloid-level body-powered prosthesis and left transradiallevel myoelectric prosthesis.

Photograph: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California.

Figure 23-32. Patient with concomitant injuries (unilateral 

transfemoral-level and styloid-level amputations and shrapnel injuries to the right leg).

Photograph: Prosthesis provided by Advanced Arm Dynamics, Inc, Redondo Beach, California.
635

Upper Extremity Prosthetics

and external environment. Caution should be used 

with these liners if the wounds are open. These liners 

can trap bacteria and moisture, thus creating a breeding ground for infection that negatively impacts heallifestyles or attempting new vocational and avocational goals, advanced prosthetic protocols must be 

initiated sooner during the rehabilitation process. It is 

recommended that each service member be assigned a 

case manager or patient care coordinator who should 

contact the patient on a regular basis to ascertain his or 

her satisfaction with prosthetic function, fit, and overall condition. Specific issues that must be addressed 

include the following:

	 •	 volumetric changes resulting from residual

limb maturation and/or weight fluctuation;

	 •	 repair or replacement of worn components;

	 •	 availability of new technology, as indicated

for improved function; 

	 •	 ongoing needs for therapeutic intervention;

and 

	 •	 new vocational and avocationalrequirements

(Figure 23-34).

Advanced Prosthetic Phase Considerations

Residual Limb Stabilization

Because of the nature of the blast wound, and the 

progressive care model implemented by the military 

following wound closure, the amputee’s residual limb 

is often extremely edematous. Throughout the Preprosthetic and Interim Prosthetic Phases, significant 

focus is therefore placed on reducing residual limb 

edema. Once residual limb edema stabilizes and the 

muscles cease to atrophy, the patient is ready to receive the definitive versions of the prostheses. After 

prolonged use of the definitive prostheses and full 

reintegration back into an active lifestyle with resolution of concomitant injuries, it is not uncommon for 

the muscles in the residual limb to hypertrophy. This 

is particularly notable in the myoelectric system, as 

prolonged use of EMG control results in muscle hypertrophy. The patient is also likely to gain weight as 

he or she returns to a normal diet, further changing 

residual limb size. Consistent communication with 

the service member following the delivery of the definitive prostheses is essential to ensure that volume 

changes secondary to hypertrophy or weight gain 

Figure 23-33. Patient with burn scar. can be addressed in a timely manner. It is therefore 

ADVANCED PROSTHETIC PHASE

Team members, including the patient, work together to formulate and execute a comprehensive 

rehabilitation plan beginning with the patient assessment and concluding with a long-term followup plan. Careful coordination and timing of the 

provision of services among team members result 

in seamless rehabilitation. Successful prosthetic 

intervention, combined with therapy protocols, 

contributes to the highest level of success for all 

amputation levels. When a rehabilitation plan is 

carefully executed as detailed in this chapter, it is 

imperative that functional gains and independence 

are not lost to follow-up.

Advanced prosthetic care is initiated after all definitive prostheses have been provided to the individual. 

Traditionally, this has been the end of initial prosthetic 

intervention; however, given our experience with 

service members rapidly returning to their previous 

ing graft and scar tissue. Specific occupational therapy 

modalities for this amputee population may include 

ultrasound, massage, adherent scar treatments, and 

graft integrity management (Figure 23-33).
636

Care of the Combat Amputee

important for the service member to have access to 

timely prosthetic care. The patient care coordinator should be able to arrange care in an expeditious 

manner so that prosthetic use is not interrupted. Significant lapses in care may lead to discontinuing prosthetic use because of comfort and control problems. 

Self-Selection

The military model provides amputees with electric/hybrid, body-powered, and passive prostheses. 

Thorough training is absolutely essential to successful 

use of all three prostheses. Once competency has been 

reached, it is common for the service member to select 

which prosthesis will be used for certain activities. Often, the service member will alternate use of all three 

prostheses to meet the functional demands of daily life. 

Each amputee is unique, and it is not possible, nor is it 

prudent, to try to predict which single device will meet 

each amputee’s current and evolving needs. Should an 

amputee self-select one type of prosthesis for a majority 

of activities, provision of a backup prosthesis should 

be considered to prevent discontinuation of prosthetic 

use when regular maintenance is required. 

Challenges to Rehabilitation

Interruptions to the Rehabilitation Process

Prosthetic rehabilitation of the military amputee 

is often challenged by various interruptions. These 

interruptions may include convalescent leave, wound 

breakdown because of graft failure or infection, and the 

frequent need of additional surgeries to the residual 

limb or for other comorbid injuries. Additionally, problems such as the formation of heterotopic ossification 

(HO) or migrating retained fragments within the limb 

may impair prosthetic training. Concomitant injuries 

may take precedence over prosthetic interventions and 

delay rehabilitation until they are adequately resolved. 

Depending on the length of absence from prosthetic 

rehabilitation and the point at which the interruption 

occurs, the patient may require review and relearning 

of previously learned skills. Members of the rehabilitation team should make every effort to minimize delays 

and promote consistent communication to all members 

of the team, including patients and their families.

Residual Limb 

The nature of blast wounds results in a residual 

limb that presents unique challenges. As discussed 

previously in this chapter, the resultant residual limb 

has significant edema that often contributes to pain 

issues. Proper edema management using ace wrap, 

elastic tubular sock, and silicone/urethane roll-on 

liners is necessary. Suture line breakdowns can be 

prevented with careful and regular monitoring. There 

may be times when prosthetic use must be temporarily 

suspended if the healing suture line is at risk. In addition, progression from an electric prosthesis to a bodypowered prosthesis should be predicated on soft-tissue 

healing, especially surrounding the suture line.

In some cases, traditional socket designs may not 

provide effective suspension if the transradial limb is 

too short or irregularly shaped. At this level, custom 

silicone liners can often resolve challenging fitting issues. When used with specifically designed electrodes, 

custom liners can be helpful in providing a secure 

foundation on which to build the EPOP. If successful, 

this design can be carried forward into the preparatory and definitive phases. Custom silicone liners 

without electrodes can also be used for other types of 

prostheses. Very short transhumeral or humeral neck 

residual limbs are often best fit using infraclavicular 

interface techniques normally applied to glenohumeral 

disarticulation and higher amputation levels.21

Neuroma

Following nerve transection, neuromas typically occur as axons at the nerve ending attempt to regenerate. 

Symptomatic neuromas can often interfere with prosthetic use and function. They are usually identifiable by 

palpating or tapping the residual limb and replicating 

symptoms. If suspected, neuromas should be evaluated by a physician on the team, because treatment 

Figure 23-34. Advanced skills using a prosthesis.
637

Upper Extremity Prosthetics

strategies should be used. Some common treatment 

approaches include oral medication and local steroid 

and anesthetic injections. Surgical resection may be 

necessary if there is no resolution of functionally limiting pain.2(p61),22,23

Heterotopic Ossification 

HO seems to be more prevalent in amputees who 

have sustained a blast injury, and its presence may 

significantly impact the prosthetic rehabilitation process. HO is characterized by rapid and excessive bone 

growth throughout the residual limb. Bone growth is 

random and often so extensive that protrusions through 

the skin are not uncommon. Use of three-dimensional 

imaging technology and computed tomography scan 

can provide the rehabilitation team with an accurate 

three-dimensional model of HO formation and skeletal 

structure change. The three-dimensional model can be 

particularly useful in solving prosthetic socket-fitting 

issues resulting from the development of HO. Some 

amputees may require additional surgery to remove 

the bony growth should it affect range of motion or 

cause increased pain24,25 (Figure 23-35).

Surfacing Shrapnel 

Similar to the challenges associated with HO, 

blast wound injuries can also exhibit surfacing 

shrapnel. Dependent on the size and location of the 

fragments that are surfacing, socket modification 

may be needed, minor surgeries may be necessary, 

or prosthetic use may be temporarily suspended 

until the shrapnel is removed and the residual limb 

has healed.

Emotional Stressors (Psychosocial) 

The less physical, but deeply important, aspect of 

amputation sustained in military action involves the 

psychosocial and emotional effects on the amputee. 

It is critical that each member of the team be aware 

of the status and treatment of the amputee from the 

psychological services team professionals. This will 

facilitate awareness of how service members best 

learn, what might unnecessarily frustrate them, and 

how the effects of their personal combat experience 

might compromise the aggressive rehabilitation 

plan.

FUTURE INNOVATIONS

Currently, there is a tremendous focus by independent research groups, DARPA (Defense Advanced 

Research Projects Agency), innovative prosthetic 

clinicians, and manufacturers to advance technology 

specific to the upper extremity amputee population. 

Areas of technological promise are aimed at increasing 

the degrees of freedom in componentry, as well as on 

the mechanisms for control, including:

	 •	 compliant hands,

	 •	 powered wrist units,

	 •	 powered shoulder and elbow joints,

	 •	 pattern recognition,

	 •	 targeted muscle reinnervation, and

	 •	 implantable electrodes.

Compliant hands allow for enhanced prehension 

patterns by powering independently articulating digits that can close around objects of various sizes and 

shapes. Powered wrist units that duplicate the complex 

movements of the human wrist (including rotation, 

flexion/extension, and radial/ulnar deviation) are 

currently being created and tested. Electrically powered elbow and shoulder joints that provide additional 

degrees of freedom will add functional capability for 

higher level amputees. 

Although the evolution of these components is exciting and promising, the benefits of this technology 

will not be fully realized without advances in control 

schemes. Pattern recognition is an approach that uses 

the unique EMG signal patterns produced by specific 

muscle group contraction within the residual limb. 

Currently, between six and eight reproducible patterns can be captured and trained to control up to six 

degrees of freedom. Pattern recognition is limited by 

the number of surface electrodes that can remain in 

contact with the skin and the amount of processing 

power currently available within an electric prosthesis. 

One approach to address these challenges is targeted 

muscle reinnervation (Figure 23-36). This is a surgical 

technique that separates muscle tissue within the residual limb and reinnervates newly created sections of 

the muscle bellies with nerves previously used to control (innervate) the now amputated limb.26 In another 

effort to address the limitations of surface electrodes, 

implantable electrodes are being developed that will 

use telemetry to transfer control information to the 

prosthesis. These exciting developments will undoubtedly benefit patients both now and in the future. It is 

the responsibility of rehabilitation team members to 

advance their knowledge, skills, and practices to apply 

these technologies effectively.
638

Care of the Combat Amputee

Figure 23-37. Through progressive military prosthetic rehabilitation, some service members can return to active duty.

The lifesaving benefits of body armor and battlefield 

medicine are unprecedented. In response to the increasing rate of survival with limb loss, upper extremity 

prosthetic treatment protocols have advanced to a new 

level of comprehensive care (Figure 23-37). The unique 

requirements and challenges presented by the military 

amputee population also influence the rehabilitation 

approach to prosthetic management (as outlined in this 

chapter). Preprosthetic Phase, Interim Prosthetic Phase, 

and Advanced Prosthetic Phase management using 

state-of-the-art prosthetic technology and techniques 

combined with aggressive therapy enable the amputee 

to reintegrate into a fulfilling life as successfully and 

rapidly as possible. Treatment protocols call for expedited care and the delivery of electric, body-powered, 

and passive prosthetic options with thorough training to maximize rehabilitation potential. A review of 

prosthetic categories with specific recommendations 

for socket design and component integration for each 

amputation level has been presented. It must also be 

understood that this young and motivated patient 

SUMMARY

Figure 23-36. Captain Katie Yankosek, MS, OTR/L, CHT, 

at Walter Reed Army Medical Center with Jesse Sullivan, 

a research volunteer who has undergone targeted muscle 

reinnervation and is wearing a prototype prosthesis.

Figure 23-35. (Left) Model of heterotopic ossification in the area of the scapula and clavicle. (Right) Model of heterotopic 

ossification from a transradial-level amputation.
639

Upper Extremity Prosthetics

group is helping to drive the field of upper extremity prosthetics forward. Many military amputees are 

participating actively in cutting-edge research and 

development projects, exploring (independently) 

alternative prosthetic solutions, becoming involved 

in the political arena, and pursuing careers in related 

fields. Their contributions in these areas will continue 

to challenge and inspire not only the interdisciplinary 

rehabilitation teams involved in their care, but also the 

prosthetic industry as a whole.

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