INTRODUCTION

 The very short trans-radial amputee presents a fitting

dilemma for the prosthetist.
 Should the client be fitted with an above-elbow type of
device or a below-elbow device?
 Fitting with an above-elbow prosthesis assures adequate
suspension, weight distribution, rotational control and
availability of myoelectric sites.
 However, the resulting prosthesis is heavy and
cumbersome and restricts shoulder motion.
 Fitting as a below-elbow requires more precise socket
fitting but does enable the child to wear the lightest, least
restrictive and obtrusive powered device possible..
 This shortest of below elbow stumps present
the difficulty in achieving the basic goals of
motion,stability and comfort.
 Most people with transradial amputation have
full elbow motion in the saggital plane.
 In the short residual forearm requires a socket
designed to retain the stump while permitting
a useful range of elbow flexion and extension.
LEVEL OF AMPUTATION

 Very short below elbow- is classified in accordance with

epicondyle to styloid length.

 Stump length - 0% to 35% of forearm length.

 The very short below elbow level can complicate

suspension and limit elbow stength and motion.

 The ability to pronate and supinate diminishes as the

length of the residual limb.
ETIOLOGY OF VERY SHORT BELOW
ELBOW
1. Traumatic Injury - almost 90%
 It occurs primarily in young men between the
ages of 20 and 40.

 The ratio of men to women with new upper limb

loss is approximately 4:1.

 It is result of carelessness of when using

machinery or equipment.
2.Peripheral vascular disease
3.Tumor
4.Infection
5.Congenital limb deficiencies
Problems in Very Short Below
Elbow Stump
 Limited Range Of Motion
 It presents the most difficulty in achieving goals of
motion, stability and comfort.
 Pronation and Supination diminished.
 Less Area of Force.
 Forearm Rotation is completely restricted.
 Forearm flexion is limited.
SURGICAL CONSIDERATION OF VERY SHORT
BELOW ELBOW
 In very proximal amputation, it may be necessary to
detach the biceps tendon.
 Reattachment of biceps tendon in proximal ulna and
remove the radius.
 Only 4 to 5cm of ulnor length is sufficient for
prosthetic fitting with retention of elbow flexion and
creating a one bone forearm i.e more comfortable.
 It is important to maintain forearm length, because
forearm stength and rotation are proportional to
residual length.
EVALUATION OF VERY SHORT
BELOW ELBOW STUMP
 The Prosthetist evaluation includes -
 Location of adherent scar tissues
 Neuroma
 Range of motion
 Edema
 Location of maximum excursion.
 Power of upper limb amputee
 Weight problems
PROSTHETIC MANAGEMENT
Prosthetic management in the limb amputee
depends upon the following factors.
I. Length of the residual arm.
II. Strength of the musculature.
III. Range of motion available
IV. occupation of the patient
V. Functional and cosmetic requirements of the
amputee.
VI. Availability o prosthetic maintenance.
COMPONENTS OF VERY SHORT BELOW
ELBOW PROSTHESIS
 Veryshort below elbow prosthesis have following
components-
 SOCKET
 SUSPENSION
 CONTROL CABLE SYSTEM
 TERMINAL DEVICE
SOCKET DESIGN
 In the V.S.B.E amputee ,the short
residual forearm requires a socket
designed to retain the stump
,while permitting a useful range of
flexion and extension.

 In Very short below elbow level

we can give following sockets.
1. Split socket
2. Munster socket
3. Northwestern socket
4. Trans-radial Anatomical
Contoured Socket
SPLIT SOCKET
 The socket encases the olecranon with the proximal edge shaped
to limit stump flexion to approx.90.
 Split socket consists of a total-contact segment encasing the
residual limb and connected by hinges to a separate forearm shell
to which the wrist unit and the terminal device are attached.
 It is sometimes used in patients who have very short stumps so
that the special elbow hinges can be used to increase available
joint range of motion or to incorporate an elbow-lock mechanism
in the prosthesis.
 The limited range of flexion can also be increased by using a split
socket design with step-up hinge.
 If the stump is so weak or so limited in range of motion that it
cannot drive the forearm through a functional flexion range,the
split socket may be used with an alternate mechanical coupling
that provides an elbow lock.
 In this case, flexion of the forearm is produced by the harness and
cable control system.
 Whatever the hinge mechanism, the socket should be somewhat
flattened anteroposteriorly.
 It encompass the olecranon and epicondyles.
 It include a V shaped relief for the biceps tendon.
 If atleast 30 deg. Of flexion and 140 N of force are available,a single-
axis and stump activated locking hinge may be used.
 Extension of the stump unlocks the elbow joint.
 A half cuff with supporting billets stabilizes the elbow and the upper
arm.
 Disadvantage
Approximately twice the force is required from the stump than
would be needed with no step-up to power the same amount of
flexion.
MUNSTER SOCKET
 It is a self suspending socket.
 An alternative to the split socket (for short
transradial amputees) is the Muenster-type
socket design.
 In this, the socket and forearm are set in a
position of initial flexion and the socket encloses
the olecranon and the epicondyle of the
humerus.
 The intimate stump encapsulation, flexion
attitude, and high trimlines provide excellent
retention and security. Although there is some
limitation in the range of flexion-extension this
may be compensated by preflexing.
Trim line –
o The socket is characterised by an anterior trimline that extends
to the level of the anticubital fold with a channel provided for the
biceps tendon.

o Posterior trim line, which hooks over the olecranon.

oThese high socket borders and the overall and intimate fit
produce excellent stump socket stability and considerable lifting
force.

oBut also restrict flexion range of motion to approx.70 0 .

oThe anteroposterior corner of the socket trimline is the point

at which the humeral condyles enter the socket.
o The trimline must be 0.3cm smaller than the measured
mediolateral dimension of the condyles in this area to
the condyles pass in to the socket with only slight
expansion of the socket.
o Donning the socket may require pulling the stump in
with a sock because of the high trimlines and 35 deg.
Angle between the humeral and forearm section.
o Suspension is also affected by the flexibility of the
finished socket.
o the Münster-type prostheses are functionally
advantageous with considerable cosmetic and comfort
appeal for amputees with very short to medium below-
elbow stumps.
Northwestern socket
 It is a self suspending
socket.
 It is an atmospheric-
pressure suspension
socket.
 This socket was
constructed with a soft
, clinging rubberlike
sleeve inside a rigid
shell.
 The inner sleeve was
fastened distally,and as
the prosthesis was
loaded and the stump
started to withdraw,the
inner sleeve tightened
around the stump
preventing further
motion.
Trans-radial anatomical contoured
socket
 TRAC interface focuses the compression
anterior and slightly inferior to the
epicondyles.
 It retains the high olecranon encapsulating
post.trimline.
 Anterior trimline extending to the cubital fold.
 It transfers the load from the distal end of
radius to the more load tolerant musculature.
SUSPENSION
 The suspension system must hold the prosthesis
securely to the residual limb, as well as accommodate
and distribute the forces associated with the weight of
the prosthesis and any superimposed lifting loads.
 Suspension systems can be classified as follows :
 Harnessed-based systems
 Self-suspending sockets
• In Harness based system,the standard harness for
below elbow amputee is figure of 8 harness.
• When the residual forearm is too short to power or
stabilise the prosthesis in elbow flexion,a figure- of-8
harness with an above elbow lift and control cable
required.
• Step-up hinges used with split socket may be used in
V.S.B.E to provide increased excursion of the forearm
and terminal device but requires the amputee to use
approx. twice as much force to flex the prosthetic
forearm.
 Self-suspending sockets are capable of providing
adequate prosthetic suspension without the use of a
harness. However, either design can also be used
with a harness suspension to provide for a more
secure suspension of the prosthesis.
 For example-Munster socket with figure-of-9
harness.
 Self-suspending sockets are largely limited to wrist or
elbow disarticulations and to transradial
amputations. This socket design is most commonly
utilized with an externally powered, myoelectrically
controlled transradial prosthesis. An example of this
type is the Munster socket. Proper fit of this socket
precludes full elbow extension.
 CABLE CONTROLLED SYSTEM
 Body-powered prosthetic limbs use cables to link movements of one
part of the body to the prosthesis in order to control a prosthetic
function.
 This is usually a movement of the humerus, shoulder, or chest, which
is transferred via a Bowden cable (a single cable passing through a
single housing) to activate the terminal device of the prosthesis
 A control cable used to activate a single prosthetic component or
function is called a single-control cable, or Bowden cable system.
 This latter control cable setup is accomplished with a single cable
passing through 2 separate cable housings known as a fair lead cable
system.
 Body movements that are captured for prosthetic
control include the following:
 Glenohumeral forward flexion: A natural
movement that provides excellent power and reach
and that can activate the terminal device or flex an
elbow joint; it is good for activities away from
midline
 Biscapular abduction (chest expansion), mutual
protraction: A movement that can activate the
terminal device; however, the device must stay
relatively stationary and the force generated is
weak; this movement is easy for the amputee to do,
and it is good for fine motor activities .
TERMINAL DEVICES
 Passive terminal device
 The main advantage of most passive terminal devices is their
cosmetic appearance.
 With newer advances in materials and design, some passive hands
are virtually indistinguishable from the native hand.
 However, most of these cosmetic passive terminal devices are
usually less functional and more expensive than active terminal
devices.
 Active terminal devices
 Active terminal devices are usually more functional than cosmetic.
however, in the near future, active devices that are equally cosmetic
and functional may be available.
 Active devices can be broken down into 2 main categories: hook
and hand.
 Cable-operated active terminal devices can be of a voluntary opening design
(most commonly used) or a voluntary closing design.
 With a voluntary opening mechanism, the terminal device is closed at rest.
 The patient uses the control-cable motion to open the terminal device
against the resistive force of rubber bands (hook) or internal springs or cables
(hand).
 Relaxation of the proximal muscles allows the terminal device to close
around the desired object.
 With a voluntary closing mechanism, the terminal device is open at rest.
 The patient uses the control-cable motion to close the terminal device,
grasping the desired object.
 This type of mechanism is usually heavier and less durable than a voluntary
opening mechanism.
 A prosthetic hand is usually bulkier and heavier than a hook, but it is more
cosmetically pleasing.
 A prosthetic hand can be powered by a cable or utilize external power.