Upper-Limb Prosthetic Fitting for a Patient with C-5 Quadriplegia
GEORGE M. CHAMBERLIN, M.D. TOULA LATTO, B.S., R.P.T. GEORGE BERRYMAN, C.P.
Watson-Walters 1 recently reported several cases of unilateral upper-limb amputation accompanied by severe limitation of the contralateral upper limb as well as the lower limbs. We have not encountered a previously recorded case specifically involving C-S quadriplegia accompanied by an above-elbow amputation which was subsequently treated with a prosthetic replacement. The following case is presented because of the unique nature of the injury, the difficulties in prosthetic fitting and training presented by such impairments, and because of the beneficial end results of prosthetic fitting in this case.
D. N. is a 16-year-old male who was involved in an auto accident July 1, 1975, in which he sustained a traumatic amputation of the left arm above the elbow as well as traumatic dislocation of the 5th cervical vertebra on the 6th cervical vertebra, with resultant quadriplegia at the C-5 level ( Figure 1 ). Quadriplegia was complete at the C-5 level, with the only subsequent function below this level being fair-minus function of the right extensor carpi radialis longus and poor-minus function of the right triceps. Sensory loss was complete at the C-5 level and below. The cervical-spine injury was treated with posterior cervical fusion, and good stability was eventually obtained.
The patient initially was hospitalized for three months from the day of injury. The initial hospital course was very stormy, with infection noted in the amputation site as well as pneumonitis and upper-urinary-tract infection. As soon as his condition stabilized, initial rehabilitation goals were aimed toward patient and family education for home care of the quadriplegia. He was placed on a regime of active assisted exercises for intact upper-limb muscles, mobilization of upper-limb and lower-limb joints, and wheelchair sitting tolerance. During this hospitalization, attempts were made at stump wrapping but were discontinued because of skin breakdown. Adaptive devices were fitted to his right upper limb, and after training he was able partially to feed himself and perform self-care.
His second hospitalization began on December 29, 1975, and lasted six weeks. Emphasis during this period was on spinal-cord-injury rehabilitation. X-rays of the cervical spine revealed adequate cervical stability. At this time he was fitted with a left above-elbow prosthesis having outside-locking elbow joints, Northwestern ring harness, dual-control system, manual friction wrist, and a Dorrance Model 555 hook as terminal device. The socket was made of plaster, partially because of difficulty obtaining adequate financing and partially because it was to be used as a test to see whether the patient could master the use of a prosthesis. The tolerance for prosthesis wearing was poor; and with motor strength of the left shoulder girdle graded only poor to fair, use of the prosthesis was difficult. He mastered operation of the terminal device but was unable to use the prosthesis functionally at the time of discharge on February 6, 1976. He was instructed to continue wearing the prosthesis at home, and he succeeded in strengthening the left shoulder girdle considerably as well as increasing tolerance to longer prosthetic wearing time ( Figure 2 ).
On May 25, 1976, he was readmitted primarily for cystoscopy and cystolitholapaxy. At this time he received his definitive left above-elbow prosthesis with plastic socket, and he continued mastering the use of his prosthesis. At the time of discharge on June 11, 1976, he was wearing the prosthesis five to seven hours daily with no stump problems. He could control the prosthesis well in flexing and locking the elbow and operating the terminal device; and he was able to pick up, place, and release objects of different shapes and sizes ( Figure 3 ) and type with an electric typewriter using a typing stick. He continued using his intact right arm with adaptive devices for eating and writing.
Follow-up since discharge has revealed that the patient has learned to use the prosthetic arm to a greater degree than anticipated, not only as an assistive device to his right arm but also for activities requiring greater pinch and grasp than he can achieve with his right upper limb.
In this case, major prosthetic fitting problems were initial skin breakdown, lack of trunk stability, weakness of the left shoulder girdle, and wheelchair confinement which initially limited use of the prosthesis to a small area in front of the body. These problems were overcome through trial and error on the part of all persons involved and by the patient's diligent practice with the prosthesis. Future planning includes lowering of the left wheelchair arm to increase the area in which the patient can use the prosthesis.
In our opinion this case illustrates that while a prosthesis is obviously no adequate substitute for an intact arm even with partial paralysis, a definite benefit can be obtained by prosthetic fitting with C-S quadriplegia. In this case we feel that the patient has attained greater function as a result of prosthetic fitting. In addition, the fitting, training, and improved function have provided a great deal of motivation to alleviate the depression accompanying quadriplegia and amputation. We are by no means suggesting that elective amputation and prosthetic fitting should be part of the routine treatment of the patient with C-5 quadriplegia, but rather that such quadriplegia, per se, does not contraindicate prosthetic fitting or prevent useful prosthetic function.
1. Watson-Walters, Kathleen, Double upper-limb disability. Inter-Clin Inform Bull, 5:3-4:9-13, March-April 1976.