1. Upper limb prosthesis in PP Trans humeral amputation

2. Terminology Any amputation through the shaft of the humerus = a trans-humeral amputation (or congenital absence) Any amputation through the shaft of the humerus = a trans-humeral amputation (or congenital absence) In practice a long trans-humeral stump is treated as an elbow- disarticulation. In practice a long trans-humeral stump is treated as an elbow- disarticulation. In practice a very short trans-humeral stump is treated as a shoulder disarticulation. In practice a very short trans-humeral stump is treated as a shoulder disarticulation.

3. Cosmetic prosthesis Can be endoskeletal or exoskeletal in construction. Can be endoskeletal or exoskeletal in construction. With a hand operated elbow lock. With a hand operated elbow lock. A cosmetic hand, the hand is passive. A cosmetic hand, the hand is passive. Patient should be able to operate the elbow lock through their normal clothing. Patient should be able to operate the elbow lock through their normal clothing.

4. Functional prosthesis Will have a body powered Terminal Device and possibly elbow mechanism as well. Will have a body powered Terminal Device and possibly elbow mechanism as well.

5. Build up : a) open end socket Place few nails at the distal end Place few nails at the distal end of the cast for a good connection of the cast for a good connection with the plaster extension build up. Draw the alignment lines Draw the alignment lines (A-P, M-L) on the positive mould. (A-P, M-L) on the positive mould.

6. Position of the elbow Make a conical extension tube from EVA and position it according to the alignment lines for the elbow cup placement Make a conical extension tube from EVA and position it according to the alignment lines for the elbow cup placement Fill it up with plaster up to the level of the proximal end of the elbow cup Fill it up with plaster up to the level of the proximal end of the elbow cup

7. Position of the elbow joint The length measurement from the acromion to the lateral epicondyle of the sound side The length measurement from the acromion to the lateral epicondyle of the sound sideminus the distance from the elbow axis to the distal end of the elbow cup will determine the length of the trans-humeral socket. the distance from the elbow axis to the distal end of the elbow cup will determine the length of the trans-humeral socket.

8. Position of the elbow Place a nail in the distal part of the build-up for good adherence of the cup and fix it with wet plaster in the proper alignment according to P&O standards (use an alignment table if available). Place a nail in the distal part of the build-up for good adherence of the cup and fix it with wet plaster in the proper alignment according to P&O standards (use an alignment table if available).

9. Draping the polypropylene Pull a stocking over the positive mould. Pull a stocking over the positive mould. Cut the stockinet at the distal part of the positive mould and fix it with contact glue. Cut the stockinet at the distal part of the positive mould and fix it with contact glue. Dust the form with talcum powder. Dust the form with talcum powder.

10. Draping the polypropylene Measurement of Polypropylene sheet: Measurement of Polypropylene sheet: Acromion circumference + 5cm, length of Acromion circumference + 5cm, length of plaster cast + 15cm. plaster cast + 15cm. Thickness of sheet: 4mm Thickness of sheet: 4mm Heat the polypropylene for approximately 20 Heat the polypropylene for approximately 20 minutes at 180°. minutes at 180°. Cup circumference + 2cm. Cup circumference + 2cm.

11. Polypropylene draping Drape the Polypropylene over the plaster model and seal it together along the medial side of the socket. Drape the Polypropylene over the plaster model and seal it together along the medial side of the socket. Tight the Polypropylene around the suction cone or tube with a bicycle inner hose, rope or stocking, then open the vacuum valve. Tight the Polypropylene around the suction cone or tube with a bicycle inner hose, rope or stocking, then open the vacuum valve.

12. Plaster extension B) For totally enclosed socket When the first PP socket is made: Make a conical extension tube from EVA and place it according to the alignment lines for the elbow cup placement. Make a conical extension tube from EVA and place it according to the alignment lines for the elbow cup placement. Fill it up with plaster up to the level of the proximal end of the elbow cup Fill it up with plaster up to the level of the proximal end of the elbow cup

13. Plaster extension The length measurement from the acromion to the lateral epicondyle of the sound side minus the distance from the elbow axis to the distal end of the elbow cup will determine the length of the trans- humeral socket. The length measurement from the acromion to the lateral epicondyle of the sound side minus the distance from the elbow axis to the distal end of the elbow cup will determine the length of the trans- humeral socket.

14. Plaster extension Smooth and shape the build- up Smooth and shape the build- up 1. According to the measure of the sound arm less 1,5cm circumference

15. Cable housing For the hook cable attachments; copy with plaster bandages the outside distal part of the trans-humeral socket and the forearm. Fill the two negatives with plaster and smooth them. For the hook cable attachments; copy with plaster bandages the outside distal part of the trans-humeral socket and the forearm. Fill the two negatives with plaster and smooth them.

16. Cable housing Pull a stockinet over the plaster models. Pull a stockinet over the plaster models. On the arm mould place a bicycle brake cable housing : 7cm above the distal end of the elbow cup and curb the upper part according to the harness position.

17. Cable housing Drape a 3mm Polypropylene sheet Drape a 3mm Polypropylene sheet  When the Polypropylene has cooled down.  Mark the trim lines of the hook cable attachments.  Cut it with an oscillating saw.

18. Fore arm cable housing Place the proximal cable housing dummy laterally, 3 cm from the elbow axis to enable the full flexion of the forearm. Place the proximal cable housing dummy laterally, 3 cm from the elbow axis to enable the full flexion of the forearm. The distal cable housing is placed on the anterior part of the forearm, at least 5 cm from the wrist to enable the hook rotation.

19. Cable housing Cut and shape the Polypropylene cable fixations and insert the cable housing into the channels. Cut and shape the Polypropylene cable fixations and insert the cable housing into the channels. Drill holes according to the diameter of the tubular rivet or screws

20. Cable housing At the proximal part fix a Polypropylene webbing hanger with a screw clamp. At the proximal part fix a Polypropylene webbing hanger with a screw clamp. Insert the bicycle brake cable into the housing. At the distal part make a buckle with cable and hold it with a clamp sleeve, which is flattened around the cable.

21. Assembling Take off the plaster, shape the socket trim lines and grind the medial welding seam. Take off the plaster, shape the socket trim lines and grind the medial welding seam. Flatten the polypropylene on the distal end of the elbow cup. Flatten the polypropylene on the distal end of the elbow cup.

22. Assembling Assembly the elbow unit Assembly the elbow unit  Check the forearm length measurement from the lateral or medial epicondyle to radial styloid process of the sound side, this will determine the length of the forearm.

23. Assembling Cut it according to measurement and fix the wrist unit with 4 pan head Philips framing screws (8 x 3mm). Cut it according to measurement and fix the wrist unit with 4 pan head Philips framing screws (8 x 3mm). The length of the forearm could be 1 to 2cm shorter than the sound side, but never longer.

24. Fitting Ensure that there are no rough edges. Ensure that there are no rough edges. Fasten the harness to a comfortable tightness. Fasten the harness to a comfortable tightness. The alignment should provide a cosmetically acceptable prosthesis that lies symmetrically opposite the sound arm. The alignment should provide a cosmetically acceptable prosthesis that lies symmetrically opposite the sound arm.

25. Fitting : socket & trim lines Is the medial trim line clear of the axilla? Is the medial trim line clear of the axilla? Is any part of the socket causing discomfort? Is any part of the socket causing discomfort? Does the anterior /posterior wing rub unnecessarily during humeral extension / flexion? Does the anterior /posterior wing rub unnecessarily during humeral extension / flexion? Check the lengths to the elbow dome and to the prosthetic thumb tip are cosmetically acceptable with the sound side. Check the lengths to the elbow dome and to the prosthetic thumb tip are cosmetically acceptable with the sound side.

26. Harness Can be placed onto the plaster cast, onto the check socket at fitting stage or at delivery stage. Can be placed onto the plaster cast, onto the check socket at fitting stage or at delivery stage. 1. Harness for light duty prostheses. 2. Harness for heavy duty prostheses. Harnesses can be made in different widths : Harnesses can be made in different widths : - 25 mm for men - 20 mm for woman and children

27. The harness should be pinned up while on the patient. The harness should be pinned up while on the patient. Straps can be attached temporary by bolts, staple- gun for the fitting. Straps can be attached temporary by bolts, staple- gun for the fitting. Adjustable sections have been done with buckle and eyelet sections (Velcro are being increasingly used) Adjustable sections have been done with buckle and eyelet sections (Velcro are being increasingly used) Harness for light duty prosthesis

28. Harness : fixation points The anterior part of the strap is fixed on the proximal lateral part of the socket.(elastic strap) The strap passes behind the patient's neck then goes down anteriorly on the patient's chest. Then the strap passes under the axilla of the sound limb. Non elastic strap).

29. Harness : fixation points After passing under the axilla, the strap continues posteriorly, across the back of the patient with an elastic section that is fixed to the posterior socket wing. The cable is extended the length of the elastic section and fixed on the non elastic axilla section and fixed on the non elastic axilla portion of the harness.

30. Harness for heavy duty prosthesis The harness form a " 8 figure ". The harness form a " 8 figure ".

31. Harness for heavy duty prosthesis  From this point, one anterior strap which passes over the patient shoulder (amputation side) crossing the back and heading to the patient axilla sound side.  One anterior fixation point located on the widest point of the anterior wing  The strap makes a loop around the patient arm, passes over the sound shoulder and fixed posteriorly at the mid part of the back

32. Harness for heavy duty prosthesis From a posterior fixation point located on posterior wing, a strap is heading to the mid part of the back (same point as previously seen). This posterior strap is elastic. The area that passes under the sound axilla is often padded with leather or plastic sheath. Too much padding adds to the discomfort, and should be avoided. Too much padding adds to the discomfort, and should be avoided. From the intersection point, the cable activator strap is heading to the upper arm section of the prosthesis.

33. If the attachment point is to high too high = it will abduct the socket. If the attachment point is to high too high = it will abduct the socket. Harness for heavy duty prosthesis If attachment point is too low = it will adduct the socket.

34. Delivery Exercises with the prosthesis can start Exercises with the prosthesis can start