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Wrist-driven prehension prosthesis for amputee patients with disarticulation of the thumb and index finger
877
PROSTHETICS/ORTHOTICS/DEVICES
Wrist-Driven Prehension Prosthesis for Amputee Patients With Disarticulation of the Thumb and Index Finger Jae-Ho Shim, MD, ¥oung-Hee Lee, MD, Jong-Min Lee, MD, Jeong Mee Park, MD, Jae-Ho Moon, MD ABSTRACT. Shim JH, Lee YH, Lee JM, Park JM, Moon JH. Wrist-driven prehension prosthesis for amputee patients with disarticulation of the thumb and index finger. Arch Phys Med Rehabil 1998;79:877-8. Partial hand amputations may leave significant functional limitations that are difficult to ameliorate by either orthoses or prostheses. Disarticulation of the thumb and index finger at the metacarpophalangeal joint level and the range of motion of the three remaining fingers would be insufficient to provide any type of grasp. In cases like this, a cosmetic hand usually seems to be the best solution. This report describes the design and use of a wrist-driven prehension prosthesis that was applied to a patient and provided a considerable improvement in function and cosmesis. © 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation PPER-LIMB LOSS can be a catastrophic obstacle and has a greater impact on activities of daily life (ADL) than the U more common lower-limb loss. The loss of both hands creates a handicap that is exceeded only by a serious brain or spinal cord injury. I Although many kinds of prostheses and orthoses have been developed to meet the various vocational and avocational demands of persons with partial hand amputations, improvements in hand function and, consequently, self-esteem are difficult. Although numerous advances in the state of prosthetic art keep pace with advances in mechanical and electrical technology, treatment for partial hand amputations has not changed significantly. Persons with partial hand amputations are more likely to reject their prostheses than persons with any other upper-limb amputations because of the poor appearance of the prostheses, lack of ventilation in the prostheses, limited function, and lack of tactile sensation. Partial-hand prostheses are therefore highly individualized devices designed to meet such specific needs as cosmetic appearance, protection of the tender area, and augmentation of grasp? There are no reports in the literature of prosthetic use by a person with disarticulation of the thumb and index finger at the metacarpophalangeal (MCP) joint level who has insufficient range of motion (ROM) of the remaining fingers to provide any type of grasp. This
From the Department of Rehabilitation Medicine, Wonju Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Kangwon-do (Drs. Shim, Y-H Lee, J-M Lee, Park); and the Department of Rehabilitation Medicine, Yongdong Severance Hospital, Yonsei University College of Medicine, Seoul (Dr. Moon), Republic of Korea. Submitted for publication August 7, 1997. Accepted in revised form November 11, 1997. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Jae-Ho Shim, MD, Department of Rehabilitation Medicine, Wonju Christian Hospital, Yonsei University Wonju College of Medicine, 162 Ilsan-Dong, Wonju, Kangwon-do, 220-701 Republic of Korea. © 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/98/7907-461753.00/0
article reports the case of a patient who was successfully treated with a new wrist-driven prehension prosthesis. CASE REPORT A right-handed, 52-year-old woman seriously injured her left hand, which had been caught in a conveyor belt. She was admitted with the diagnosis of a compression injury of the palm, comminuted fracture of the first and second metacarpus, fracture of the fifth metacarpus and third proximal phalanx, and disarticulation of the second MCPjoint. The fracture sites of the third proximal phalanx and fifth metacarpus were fixed by a K-wire. Necrotic tissue was removed and a myocutaneous flap and skin graft of the amputation site were performed after the thumb and index finger were disarticulated at the MCP joint level by the department of plastic surgery. The patient was then transferred to the department of rehabilitation medicine for proper management of physical and occupational therapy. A preliminary prosthesis, made of lowtemperature thermoplastic, on which the prosthetic thumb was in a functional position between the prosthetic index finger and the third finger, was applied to increase strength and ROM of the three remaining fingers and to prevent phantom pain. The physical and occupational therapy, such as whirlpool therapy, ROM exercise, strength and endurance exercise, and desensitization, began after the K-wires were removed. Although ROM and strength of the wrist were good, the ROM of the three remaining fingers was less good (table 1) because of adhesion of the remaining finger flexor tendons at the palm. Compromised function of the muscles inserted at the thumb and index finger, such as the abductor pollicis longus (APL), extensor pollicis brevis (EPB), extensor carpi radialis (ECR), extensor pollicis longus (EPL), and flexor carpi radialis (FCR), cansed wrist deviation to the ulnar side (fig 1). We designed a wrist-driven prehension prosthesis made of polypropylene (fig 2). The prosthetic thumb and index finger, which were made of polypropylene molding and covered with polyvinylchloride resin, were connected to the opponens in a functional position. A stainless steel actuator rod linked the forearm stabilizer and MCP joint, which is collinear with the index MCP axis of flexion and extension. The wrist joint, which is collinear with the anatomic wrist axis of flexion and extension linked the forearm stabilizer and opponens. Two attached rings for the prosthetic index and third fingers were connected side by side. The reason the rings were made was that the ulnar deviation was more prominent during the wrist movement and it was not sufficient to give a stable and good fitting of the prosthesis by the opponens strap only. This device is moved by synodesis of the wrist with an actuator rod that Table 1: ROM of the Three Remaining Fingers T h i r d Finger
F o u ~ h Finger
Fifth Finger
350-60 °
200-75 °
0°-45 °
PIPJ
0°-10 °
00-30 °
00-40 °
DIPJ
00-30 °
00-60 °
00-40 °
MCPJ
Abbreviations: MCPJ, metacarpophalangeal joint; PIPJ, proximal interphalangeal joint; DIP& distal interphalangeal joint. Arch Phys Med Rehabil Vol 79, July 1998
878
WRIST-DRIVEN PROSTHESIS, Shim
Fig 1. Loss of the thumb and index finger causes ulnar deviation of the wrist because of the compromised function of the muscles inserted at the thumb and index finger, such as the APL, EPB, ECR, EPL, and FCR.
opens the prehension by wrist flexion and closes by wrist extension, of which the action is similar to the normal physiologic prehension. She could press the prosthetic thumb with her third finger but not with her other fingers. The patient's pinch power was measured by vigorimeter. Her left pinch power elicited and controlled by the wrist measured 40kPa and the right pinch power was 25kPa. The patient could perform the prehension successfully with this new device (fig 3), and the prosthesis was worn throughout the day. The prosthesis became a useful and assistive device for ADL that required both hands, such as reading a newspaper, squeezing a tube of toothpaste, washing dishes, and preparing meals. DISCUSSION In the industrial field, partial hand amputations most commonly result from accidents with machines, such as punch presses, metal shears, conveyor belts, and meat grinders. Rarely do malignancy and vascular disease cause this type of amputation. Partial hand amputations in industrial accidents usually occur along a straight line through the phalanges or metacarpals but may be at any angle to the line through the distal row of carpal bones. The level and extent of amputation greatly affects the outcome for the patient. Partial hand amputations can be classified as (1) transphalangeal, thumb spared; (2) thenar, partial or complete; (3) transmetacarpal, distal, thumb spared or
Fig 3. Playing peg game with successful tip pinch,
involved; and (4) transmetacarpal, proximal, thumb spared or involved. 3 Prostheses for partial hand amputations can be classified as dynamic or static devices based on their working modes. 2 Static devices have static configurations and the advantage of use under the rugged conditions of factory work or mannal labor. Dynamic devices powered by residual motion at the wrist or palm may also be developed to enhance grasp. Although technically much more difficult to fit than static devices, articulated partial-hand prostheses usually offer a wider range of openings, thereby facilitating grasp of more varied objects. This case may correspond to amputation class 3, and in such cases if there is no weakness or limitation of motion of the three remaining fingers, it would be acceptable to make a static prosthetic thumb that fits over the stump of the metacarpals and straps to the hand. 3 Wedderburn and associates 4 designed a prosthesis for persons who lost all fingers but not the palm that is moved by pure wrist power without an actuator rod; it opens by wrist extension and closes by wrist flexion. The loss of the thumb and index finger causes ulnar deviation of the wrist because of the compromised function of some muscles inserted at the thumb and index finger. Two rings for prevention of this deviation were connected side by side, which was useful for a good fitting and cosmesis. We designed a dynamic device by synodesis of the wrist to provide a wide range of openings and facilitate grasp of more varied objects. This device can be prescribed to a patient with disarticulation of the thumb and any of the other fingers at the MCPjoint level and limited motion of the remaining fingers. References
Fig 2. Overview of the prosthesis.
Arch Phys Med Rehabil Vol 79, July 1998
1. Beasley RW. Surgery of hand and finger amputations. Orthop Clin North Am 1981;12:763-804. 2. Michael JW. Prosthetic and orthotic management. In: Bowker JH, Michael JW, editors. Atlas of limb prosthetics: surgical, prosthetic, and rehabilitation principles. St. Louis (MO): Mosby; 1992. p. 217-26. 3. Bender LF, Koch RD. Meeting the challenge of partial hand amputations. J Prosthet Orthot 1976;30:3-11. 4. Wedderburn Z, Cadwell RR, Sanderson ER, Olive M. A wristpowered prosthesis for the partial hand. J Assoc Child Prosthet 1986;21:42-5.
PROSTHETICS/ORTHOTICS/DEVICES
Wrist-Driven Prehension Prosthesis for Amputee Patients With Disarticulation of the Thumb and Index Finger Jae-Ho Shim, MD, ¥oung-Hee Lee, MD, Jong-Min Lee, MD, Jeong Mee Park, MD, Jae-Ho Moon, MD ABSTRACT. Shim JH, Lee YH, Lee JM, Park JM, Moon JH. Wrist-driven prehension prosthesis for amputee patients with disarticulation of the thumb and index finger. Arch Phys Med Rehabil 1998;79:877-8. Partial hand amputations may leave significant functional limitations that are difficult to ameliorate by either orthoses or prostheses. Disarticulation of the thumb and index finger at the metacarpophalangeal joint level and the range of motion of the three remaining fingers would be insufficient to provide any type of grasp. In cases like this, a cosmetic hand usually seems to be the best solution. This report describes the design and use of a wrist-driven prehension prosthesis that was applied to a patient and provided a considerable improvement in function and cosmesis. © 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation PPER-LIMB LOSS can be a catastrophic obstacle and has a greater impact on activities of daily life (ADL) than the U more common lower-limb loss. The loss of both hands creates a handicap that is exceeded only by a serious brain or spinal cord injury. I Although many kinds of prostheses and orthoses have been developed to meet the various vocational and avocational demands of persons with partial hand amputations, improvements in hand function and, consequently, self-esteem are difficult. Although numerous advances in the state of prosthetic art keep pace with advances in mechanical and electrical technology, treatment for partial hand amputations has not changed significantly. Persons with partial hand amputations are more likely to reject their prostheses than persons with any other upper-limb amputations because of the poor appearance of the prostheses, lack of ventilation in the prostheses, limited function, and lack of tactile sensation. Partial-hand prostheses are therefore highly individualized devices designed to meet such specific needs as cosmetic appearance, protection of the tender area, and augmentation of grasp? There are no reports in the literature of prosthetic use by a person with disarticulation of the thumb and index finger at the metacarpophalangeal (MCP) joint level who has insufficient range of motion (ROM) of the remaining fingers to provide any type of grasp. This
From the Department of Rehabilitation Medicine, Wonju Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Kangwon-do (Drs. Shim, Y-H Lee, J-M Lee, Park); and the Department of Rehabilitation Medicine, Yongdong Severance Hospital, Yonsei University College of Medicine, Seoul (Dr. Moon), Republic of Korea. Submitted for publication August 7, 1997. Accepted in revised form November 11, 1997. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Jae-Ho Shim, MD, Department of Rehabilitation Medicine, Wonju Christian Hospital, Yonsei University Wonju College of Medicine, 162 Ilsan-Dong, Wonju, Kangwon-do, 220-701 Republic of Korea. © 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/98/7907-461753.00/0
article reports the case of a patient who was successfully treated with a new wrist-driven prehension prosthesis. CASE REPORT A right-handed, 52-year-old woman seriously injured her left hand, which had been caught in a conveyor belt. She was admitted with the diagnosis of a compression injury of the palm, comminuted fracture of the first and second metacarpus, fracture of the fifth metacarpus and third proximal phalanx, and disarticulation of the second MCPjoint. The fracture sites of the third proximal phalanx and fifth metacarpus were fixed by a K-wire. Necrotic tissue was removed and a myocutaneous flap and skin graft of the amputation site were performed after the thumb and index finger were disarticulated at the MCP joint level by the department of plastic surgery. The patient was then transferred to the department of rehabilitation medicine for proper management of physical and occupational therapy. A preliminary prosthesis, made of lowtemperature thermoplastic, on which the prosthetic thumb was in a functional position between the prosthetic index finger and the third finger, was applied to increase strength and ROM of the three remaining fingers and to prevent phantom pain. The physical and occupational therapy, such as whirlpool therapy, ROM exercise, strength and endurance exercise, and desensitization, began after the K-wires were removed. Although ROM and strength of the wrist were good, the ROM of the three remaining fingers was less good (table 1) because of adhesion of the remaining finger flexor tendons at the palm. Compromised function of the muscles inserted at the thumb and index finger, such as the abductor pollicis longus (APL), extensor pollicis brevis (EPB), extensor carpi radialis (ECR), extensor pollicis longus (EPL), and flexor carpi radialis (FCR), cansed wrist deviation to the ulnar side (fig 1). We designed a wrist-driven prehension prosthesis made of polypropylene (fig 2). The prosthetic thumb and index finger, which were made of polypropylene molding and covered with polyvinylchloride resin, were connected to the opponens in a functional position. A stainless steel actuator rod linked the forearm stabilizer and MCP joint, which is collinear with the index MCP axis of flexion and extension. The wrist joint, which is collinear with the anatomic wrist axis of flexion and extension linked the forearm stabilizer and opponens. Two attached rings for the prosthetic index and third fingers were connected side by side. The reason the rings were made was that the ulnar deviation was more prominent during the wrist movement and it was not sufficient to give a stable and good fitting of the prosthesis by the opponens strap only. This device is moved by synodesis of the wrist with an actuator rod that Table 1: ROM of the Three Remaining Fingers T h i r d Finger
F o u ~ h Finger
Fifth Finger
350-60 °
200-75 °
0°-45 °
PIPJ
0°-10 °
00-30 °
00-40 °
DIPJ
00-30 °
00-60 °
00-40 °
MCPJ
Abbreviations: MCPJ, metacarpophalangeal joint; PIPJ, proximal interphalangeal joint; DIP& distal interphalangeal joint. Arch Phys Med Rehabil Vol 79, July 1998
878
WRIST-DRIVEN PROSTHESIS, Shim
Fig 1. Loss of the thumb and index finger causes ulnar deviation of the wrist because of the compromised function of the muscles inserted at the thumb and index finger, such as the APL, EPB, ECR, EPL, and FCR.
opens the prehension by wrist flexion and closes by wrist extension, of which the action is similar to the normal physiologic prehension. She could press the prosthetic thumb with her third finger but not with her other fingers. The patient's pinch power was measured by vigorimeter. Her left pinch power elicited and controlled by the wrist measured 40kPa and the right pinch power was 25kPa. The patient could perform the prehension successfully with this new device (fig 3), and the prosthesis was worn throughout the day. The prosthesis became a useful and assistive device for ADL that required both hands, such as reading a newspaper, squeezing a tube of toothpaste, washing dishes, and preparing meals. DISCUSSION In the industrial field, partial hand amputations most commonly result from accidents with machines, such as punch presses, metal shears, conveyor belts, and meat grinders. Rarely do malignancy and vascular disease cause this type of amputation. Partial hand amputations in industrial accidents usually occur along a straight line through the phalanges or metacarpals but may be at any angle to the line through the distal row of carpal bones. The level and extent of amputation greatly affects the outcome for the patient. Partial hand amputations can be classified as (1) transphalangeal, thumb spared; (2) thenar, partial or complete; (3) transmetacarpal, distal, thumb spared or
Fig 3. Playing peg game with successful tip pinch,
involved; and (4) transmetacarpal, proximal, thumb spared or involved. 3 Prostheses for partial hand amputations can be classified as dynamic or static devices based on their working modes. 2 Static devices have static configurations and the advantage of use under the rugged conditions of factory work or mannal labor. Dynamic devices powered by residual motion at the wrist or palm may also be developed to enhance grasp. Although technically much more difficult to fit than static devices, articulated partial-hand prostheses usually offer a wider range of openings, thereby facilitating grasp of more varied objects. This case may correspond to amputation class 3, and in such cases if there is no weakness or limitation of motion of the three remaining fingers, it would be acceptable to make a static prosthetic thumb that fits over the stump of the metacarpals and straps to the hand. 3 Wedderburn and associates 4 designed a prosthesis for persons who lost all fingers but not the palm that is moved by pure wrist power without an actuator rod; it opens by wrist extension and closes by wrist flexion. The loss of the thumb and index finger causes ulnar deviation of the wrist because of the compromised function of some muscles inserted at the thumb and index finger. Two rings for prevention of this deviation were connected side by side, which was useful for a good fitting and cosmesis. We designed a dynamic device by synodesis of the wrist to provide a wide range of openings and facilitate grasp of more varied objects. This device can be prescribed to a patient with disarticulation of the thumb and any of the other fingers at the MCPjoint level and limited motion of the remaining fingers. References
Fig 2. Overview of the prosthesis.
Arch Phys Med Rehabil Vol 79, July 1998
1. Beasley RW. Surgery of hand and finger amputations. Orthop Clin North Am 1981;12:763-804. 2. Michael JW. Prosthetic and orthotic management. In: Bowker JH, Michael JW, editors. Atlas of limb prosthetics: surgical, prosthetic, and rehabilitation principles. St. Louis (MO): Mosby; 1992. p. 217-26. 3. Bender LF, Koch RD. Meeting the challenge of partial hand amputations. J Prosthet Orthot 1976;30:3-11. 4. Wedderburn Z, Cadwell RR, Sanderson ER, Olive M. A wristpowered prosthesis for the partial hand. J Assoc Child Prosthet 1986;21:42-5.