The Flail Above-Elbow Stump
Chestley L. Yelton, M.D.
Functional regain is inversely proportional to the level of the amputation site. The higher the site, the lower the functional regain. In amputees with above-elbow stumps, humeral flexion is the major source of power for prosthetic forearm flexion and prehension. Therefore, an individual with a flail above-elbow stump is essentially a shoulder disarticulation amputee as far as the fitting of a prosthesis is concerned. In such cases, every effort should be made to utilize whatever sources are available to regain humeral flexion.
This paper will present two cases, one in some detail, of amputees with flail above-elbow stumps who are satisfactorily using prostheses after arthrodesis of the scapulohumeral joint. While the two cases described are adults, we believe that the procedures presented would apply equally well to children. Care would have to be taken to avoid damaging the open proximal humeral epiphysis, but this should not present any major difficulty. However, we have not yet had an opportunity to verify this assumption. If any readers of the ICIB have had experience in this area, we would be pleased to hear from them.
This 49-year-old Negro male was involved in an automobile accident in April 1960. He sustained an injury to the right upper limb and right shoulder which led to an amputation of his right upper limb above the elbow. The patient was referred to Birmingham Amputee Clinic in February 1961, at which time he complained of constant pain, swelling of his stump, and inability to control the stump.
Examination revealed a long right above-elbow stump, with the amputation site being through the distal third of the humerus. The stump was exceedingly tender, shiny in appearance, and slightly moist. The musculature around the shoulder exhibited marked atrophy, the deltoid being completely wasted away. The right scapulohumeral joint could not be used voluntarily, and the patient was unable to stabilize the humeral stump in reference to the scapula. Passive motion of the scapulohumeral joint was limited in all planes, approaching approximately 30 degrees of normal. The anterior aspect of the shoulder exhibited scarring secondary to the injury. Good power was demonstrated in the serratus anticus and trapezius muscles.
Roentgenographic examination of the right shoulder and arm (Fig. 1 ) revealed an old amputation of the right arm through the lower third of the humerus; mottled demineralization of the humerus; linear streaks of calcification in the soft tissues just below the glenoid fossa, in the soft tissues between the head of the humerus and the acromial process of the scapula, and in the area just above the wing of the scapula. A moderately wide separation of the acromioclavicular joint was also present.
The patient had been referred to the Amputee Clinic for an opinion concerning the possibility of rehabilitation and the feasibility of prosthetic fitting. The flail above-elbow stump precluded the operation of a prosthesis, but in any case he would not have been able to tolerate one because of the painful stump. We advised hospitalization for treatment of what we considered to be a reflex sympathetic dystrophy and, if this were successful, for a subsequent arthrodesis of the right scapulohumeral joint.
The patient was hospitalized on March 1, 1961, and on that same date a right stellate ganglion block, using Carbocaine and Intracaine in oil, was carried out. Following this treatment, the pain was considerably reduced, and clinically his condition was much improved. On March 3, the stellate ganglion block was repeated. Following this second block, the stump was so much improved that we felt we could proceed with the proposed surgery.
On March 6 a compression arthrodesis of the right scapulohumeral joint was performed. Compression was obtained by a clamp and two 5/32-inch Steinmann pins, one of which was placed through the clavicle and spine of the scapula and the other through the head of the humerus. The position of the humerus in relation to the scapula was approximately 45 degrees of abduction and 20 degrees of flexion. The surgery was followed by the application of a shoulder spica, which was worn until May 5.
Roentgenographs studies made at this time revealed that bony union had taken place between the humeral head and the glenoid and acromial processes of the scapula. Just prior to the removal of the clamp and pins on May 5, the patient demonstrated about
60 degrees of humeral flexion (Fig. 2 ). No residual of the reflex sympathetic dystrophy was evident, and the pain and tenderness of the stump had disappeared. He was placed on a regimen of active exercises to redevelop the muscles of the scapula and to attain maximum motion of the stump.
On July 19 the patient was fitted with an above-elbow prosthesis consisting of a double-wall socket with a short shoulder cap, a Hosmer E-400 elbow, an above-elbow figure-eight harness, a standard forearm and wrist unit, and a 5XA hook (Fig. 3 ).
After a period of training the patient demonstrated excellent use of the prosthesis. When last seen on March 21, 1962, he stated that he was wearing his prosthesis about 12 hours a day and was using it satisfactorily. Roentgenographic examination of the right shoulder at this time revealed a solid arthrodesis of the shoulder (Fig. 4 ).
A 48-year-old white male who had had poliomyelitis as a child was left with a flail left arm but with a good forearm and hand. On March 28, 1967, he developed a blood clot in his left arm as a result of "shooting drugs into it." On April 2, 1967, the left arm was amputated. He was first seen in our clinic on July 28, 1967. He exhibited a left above-elbow stump, the amputation being through the middle third of the arm. There was marked atrophy of the musculature about the shoulder, and the humeral stump was essentially flail. Excellent scapular motion and power were demonstrated.
The patient was hospitalized on August 2, and two days later a compression-type arthrodesis of the left shoulder was performed in the same manner as in the preceding case. His postoperative course and care were uneventful. On October 13 roentgenographic examination revealed that bony union had occurred at the arthrodesis site, and the spica, compression clamp, and pins were removed. On November 8 he was fitted with an above-elbow prosthesis consisting of a double-wall socket with a short shoulder cap, a Hosmer E-400-2L elbow unit (with lift assist), an above-elbow figure-eight harness, a standard forearm, a Hosmer WE 500 wrist unit, and a Dorrance No. 7 hook. It appears that he will use his prosthesis as satisfactorily as Case 1.
Arthrodesis of the shoulder may be successfully employed on the above-elbow amputee with a flail humeral stump provided good power remains in the serratus anticus and trapezius muscles. Following arthrodesis, such an amputee regains humeral flexion as a source of power for prosthetic forearm flexion and prehension.
Chestley L. Yelton, M.D. is Professor of Orthopedic Surgery University of Alabama Medical College and Chief, Birmingham Child Amputee Clinic Birmingham, Alabama