Information for Health Care Professionals
Process/Timeline for an Amputation/Prosthesis Fitting

Preamputation | Surgical Procedure | Acute Postsurgery | Prosthesis Fitting and Testing
Below Elbow Prosthesis Case Study

Preamputation

Ideally, a patient who needs an upper extremity prosthesis should be seen by the rehabilitation team prior to the surgery. This allows a chance to evaluate postoperative needs and desires and to begin range-of-motion exercises, strengthening, and training in activities of daily living. However, since most upper extremity amputations are traumatic in nature, this may not always be possible.

Surgical procedure

During the amputation surgery, several actions can be taken to maximize the function of the residual limb. These actions include the following:

Bevel the bone end. This can help to minimize soft tissue trauma from sharp or irregular bone edges.
When severing a nerve, place gentle traction on it, sharply transect it, and allow the nerve to retract into proximal soft tissue. A severed nerve forms a neuroma (scar tissue) at the distal end.
When the neuroma forms in soft tissue, there is less likelihood of postsurgical pain.
During skin closure, position the wound edges to avoid bony prominences and the far distal end of the residual limb. This prevents future pressure on the incision from the prosthesis.

Acute postsurgery

The major issues in this phase are adequate wound healing, pain management, instruction in the performance of activities of daily living, mobility, range of motion, and strength. During this phase, a program to prepare the residual limb for the prosthesis should be initiated. A skin desensitization program consists of (1) gentle tapping on the distal portion of the residual limb to mature the site, (2) massage to prevent excessive scar formation, and (3) edema control with ace wraps, a rigid removable dressing, or a residual limb (stump) shrinker.

Prosthesis fitting and testing

A temporary prosthesis can be fit in surgery, so when the patient awakes he or she can visualize a limb in place. Temporary prostheses usually are fitted this early in healthy, young patients with traumatic amputations, in which case rehabilitation physicians work integrally with orthopedic specialists and prosthetists. Alternatively, in older patients or in those with vascular disease, a prosthesis is not fit until the suture line has completely healed. The prosthesis must be individually fitted to the patient. One size does not fit all.
Prostheses are either preparatory or definitive. The advantage to using a preparatory prosthesis is that it is fitted while the residual limb is still maturing. A preparatory prosthesis allows the patient to train with the prothesis several months earlier in the process. A preparatory prosthesis often allows a better fit in the final prosthesis as the preparatory socket can be used to mold the residual limb into the desired shape. During this period, the patient “test drives” the prosthesis and learns what it can and cannot do. Sometimes a preparatory prosthesis is not feasible because of financial considerations. In this case, a patient can only be fitted for the definitive (final) prosthesis. If a patient is being fitted for a final prosthesis without ever having a preparatory prosthesis, delay fitting for the socket until the residual limb is fully mature (usually 3-4 mo).