Double Upper-Limb Disability
KATHLEEN WATSON-WALTERS, M.B./B.S.
The loss of function in a single upper limb is not necessarily a severe disability providing moderate to good function is preserved in the remaining limbs. In a series of 50 patients with an upper-limb disability, Brewerton and Daniel1 reported 48 as being in satisfactory full-time employment. However, the loss of function in both upper limbs is universally accepted as a major handicap, whether the legs are functional or not.
Double upper-limb amputation, congenital or acquired, is an acknowledged severe disability; but many patients with this disability manage remarkably well. However, the combination of an acquired upper-limb amputation and disability of the other arm gives rise to a very severe handicap. Four patients with an upper-limb amputation and severe loss of function in the remaining upper limb will be presented and discussed.
F.B., a 30-year-old male, was admitted to Mary Marlborough Lodge for assessment and training. lie had been involved in a traffic accident and had sustained a severe head injury, with a resultant left hemiparesis, a fractured left femur, and extensive soft-tissue damage to the right arm. The latter led to an above-elbow amputation. The left upper limb was spastic and held in a position of flexion at all joints. This position was not fixed. He was able to ambulate independently with a hemiparetic gait. He was fitted with a right above-elbow prosthesis with a hook terminal device. Prior to his accident he had worked as a butcher.
On discharge the patient was able to feed himself using a feeding strap to hold a fork or spoon, which he was able to assemble independently. He was dependent in dressing, bathing, and toileting, and he drank with a straw. He was able to write sentences and sign his name using a pen in his hook and paper stabilized with his left hand ( Figure 1 ), transfer small objects with his hook, open doors, turn keys, use light switches, and insert plugs into sockets. He could use an electric mower to cut the lawn. He was able to operate his elbow mechanism well and had fair control of his hook. His gait was satisfactory for stairs, transfers, and distances.
Psychological testing did not reveal any personality or psychiatric disturbance, and it was felt that an observed personality change was compatible with a reactive depression.
The patient was placed on Dantrium 400 mg daily, and he reported that he had more control of his left hand and that it felt more relaxed. His grip strength measured 60 mm Hg, and with his wrist held in extension by an assistant it measured 110 mm Hg. The flexion forearm muscles then were injected with 5 cc of 1 per cent Lignocaine, and his grip strength improved to 90 mm Hg. Subsequently 5 cc of 42 per cent alcohol were injected to facilitate relaxation of the Ilexors so that strengthening exercise could be done on the extensors, with a view of a flexor slide operation in the future to give him a gross grip.
With his mobility he was able to get about without having to wait for assistance. Attempts were made to get him interested in an activity, but he was content to read and watch television.
D.C., a 25-year-old male, was involved in a traffic accident in which he sustained a closed head injury, bony fractures, and a right brachial-plexus injury. A right above-elbow amputation was done one year after injury, and a right gleno-humeral arthrodesis was performed 18 months after the initial injury. The remaining limbs were spastic with limited range of motion, particularly in the left upper limb. The patient had been provided with an electrically powered chair with a semi-reclining back and with swash-plate controls, which he operated with his chin, for indoor use. A similar chair without the power unit had been provided for outdoor use. He was able to ambulate only a short distance with the assistance of two people, and he was dependent in feeding, toileting, and dressing. He had a carbon-dioxide-powered prosthesis. He was able to use an electric typewriter with his right prosthesis hook, which he operated with the left upper limb via controls on the left armrest of the wheelchair ( Figure 2 ). At Mary Marlborough Lodge he was assessed for a powered outdoor chair, which was ordered. He also received alcohol injections to the left upper limb to relieve some of the spasticity. As a result of this injection and strengthening exercises he was better able to control the left upper limb and to operate the controls of his prosthesis. It is hoped that in a few months enough strength can be gained in the left limb to make feeding possible with a mobile arm support.
This patient was very active in the social affairs of the home in which he lived. He was the Chairman of their Committee and went to meetings where he met other members of residential homes. With the help of the occupational therapists he published the regular news bulletin for the home.
E.L., a 59-year-old female, developed joint pains at age 11. At age 13 a diagnosis of Still's disease was made. Her ailments continued, and when she was 22 years old she was unable to walk. At age 30 a right above-elbow amputation was performed as a result of gangrene of that limb. A prosthesis was supplied, and training was given. Over the next few years numerous surgical procedures were carried out, and at age 37 she was able to ambulate short distances using two crutches. She lived in a residential home and was plagued constantly with many illnesses. She managed to be independent in transfers and partially dependent in other activities of daily living. This patient used her free time to do mouth and hand painting and typing. At age 52 she was admitted to Mary Marlborough Lodge for reassessment, at which time all major joints were severely ankylosed, including the cervical spine and temporomandibular joints. The left hand was severely deformed by loss of movement and a missing digit.
The patient was provided an electrically powered wheelchair with adapted controls ( Figure 3 ), along with a left mobile arm support. The latter was used for feeding with an adapted fork ( Figure 4 ). This she had not done for many years. Using a lightweight upper-limb prosthesis with a gas-powered wrist and hook she was able to type and hand paint more comfortably. With training her transfers improved. The patient's demeanour also improved because she was happy with her increased mobility.
H.R., a 56-year-old male, lost his left arm above the elbow traumatically as a young man. Without the aid of a prosthesis he was gainfully employed in his own business. In 1974 the patient suffered a cerebro-vascular accident which resulted in a right hemiparesis. The right upper limb remained flaccid and weak. He was admitted to Mary Marlborough Lodge, and a mobile arm support was fitted to his regular chair. After a period of training with this aid he could use a swivel spoon to feed himself food which was prepared on a heated raised plate, and he was able to turn pages with a rubber finger tip. It was recommended that he wear a Chailey urinal so that he would be independent in toileting. He was independent in transfers from bed to chair and to the standing position. By using a board and seat he could transfer to a bath with minimal guarding. He was dependent in dressing except for fastening Velcro closures on his slippers. These adaptations greatly improved his demeanour. Because it was felt that the left above-elbow stump was too short for wearing a prosthesis, no prosthesis was supplied.
The four cases presented here are indeed a challenge in management. Fortunately, this combination of disabilities is rarely encountered even in a unit such as Mary Marlborough Lodge, where the severest of disabilities are frequently seen. These patients differ from patients with bilateral congenital upper-limb deficiencies in that at some stage they were accustomed to functioning with both limbs, and acquired disability thus presents a greater handicap. In two cases the loss was slowly progressive, giving the patients some time to become adjusted to their condition. The remaining two had no transition period. All these patients lived in residential institutions and remained heavily dependent in all areas of daily-living activities, even with many pieces of equipment, except in the area of mobility, which was maintained by use of powered chairs or remaining function in the lower limbs.
Vocationally the prospects are poor even if some slight degree of independence is achieved. The best goal to aim for is the achievement of some form of diversional activity.
Since two patients were middle-aged and two were in their twenties, theoretically they had manyyears to "look forward to" in which they also had to contend with varying manifestations of their concurrent illnesses. The retention of good mental function was present in all four cases, thus making the disability harder to bear. This situation places greater responsibility on those concerned with rehabilitation. It is essential that all possible avenues be explored and that all resources be tapped to achieve any possible independence in these patients. Independent mobility is usually achievable, and this objective should be pursued with vigor, since it will enable and encourage the patient to develop interests and hobbies which are so vital.
1. Brewerton, D. A., and J. W. Daniel, Return to work after injury. Journal of British Society for Surgery of the Hand, 1:2:125-126, September 1969.