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June 2006 • Vol. 2, No. 2
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Advancing Orthotic and Prosthetic
Care Through Knowledge
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Lisa Schoonmaker, CPO, FAAOP
A hybrid device using a thermoplastic custom elbow orthosis, cock-up splint with quick disconnect adapter to house a terminal device, and figure-eight harness provided limb safety, improved shoulder joint stability, and contralateral upper-extremity assist.
Introduction
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Figure 1
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Historically, treatment of the adult traumatic brachial plexus injury has been approached with various surgical techniques including but not limited to amputation, in an attempt to provide the patient with both limited limb function and pain control. Orthotic treatment goals are similar to the surgical, but unfortunately, for the patient, often these surgical and nonsurgical efforts are without positive outcomes.
To aid in ipsilateral limb function and safety, a hybrid device, or prosthosis, evolved through the combined efforts of the patient and the CPO. The upper-extremity prosthosis provides a neutral wrist, multiple locking elbow positions, and improved shoulder joint seating. Positive outcomes include contralateral limb assist and increased comfort for the patient.
Background
Patrick is a 50-year-old Caucasian male who suffered a traumatic cervical spine and brachial plexus injury to the right upper extremity as a result of a motorcycle injury in 2002. Damage includes C7 through T1 avulsions; latissimus, pectoralis, biceps, triceps, deltoids, and all distal muscle groups function at grade trace or zero. The patient presents with a flail limb including the shoulder complex (Figure 1).
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Figure 2a
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Figure 2b
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Prior to the injury, Patrick was employed as a big-game hunting guide and construction worker. Currently he is a college student and owns/operates a small hobby farm. His desired activity level and right hand dominance added to the complexity of the prosthotic treatment plan.
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Figure 3
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Before being treated at our clinic, Patrick had been using a sling provided by the hospital for positioning. In addition, he had fashioned a leather archery glove with a bent metal stock clip (Figure 2) to use in positioning the arm when the sling became too hot and cumbersome. Although the archery glove design was quite functional and ingenious, it caused skin breakdown along the thenar eminence.
Methods
The patient is casted with a neutral wrist position and elbow at 90 degrees. No supination/pronation is desired; the palm needs to be directed at midline.
The cast includes both radial and ulnar styloids, crosses the elbow and extends to the axilla. A custom light weight, thermoplastic, foam-lined elbow orthosis (EO) is fabricated including an OTS Step-Lock elbow joint. This particular joint allows multiple locked elbow positions of the involved limb and offers easy manual control by the contralateral side (Figure 3).
Next, an appropriately sized prefabricated cock-up splint is fitted to the patient. It is of great importance that the design chosen offers substantial padding to protect the thenar eminence and ulnar styloid from skin irritation and injury. Once an appropriate style is obtained and fitted, the cock-up splint is modified to include a belt clip and a Texas Assistive Devices quick disconnect wrist (Figure 4). Multiple terminal devices are easily interchanged by the patient.
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Figure 4
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The splint and orthosis are intentionally fabricated to be used as modules. Patrick has the ability to choose whether to use the devices individually or in tandem based on his given activity. All closures must include Velcro® to facilitate donning and doffing.
Lastly, a figure eight harness is attached proximally to the EO to aid in suspension and ipsilateral limb comfort. The axilla loop is padded to prevent irritation, as the weight of the flail arm is greater than that of a typical upper-extremity prosthesis. The lateral suspension strap was fabricated from elastic instead of Dacron® webbing to facilitate independent prosthotic application and removal (Figure 5).
Results and Discussion
It should be noted Patrick wore the EO and splint for one year without incident before the figure-eight harness was incorporated. The devices self-suspended effectively and his function was improved. However, his subluxed shoulder continued to cause him great discomfort.
At the patient’s request, the harness was applied, and he reported feeling immediate pain reduction. It is the author’s opinion that reduced downward vertical pull exerted by gravity, in combination with lessened glenohumeral joint space, led to the increased comfort (Figure 6).
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Figure 5
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Figure 6
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Unconventional thinking is required when treating adult traumatic brachial plexus injury. The patient’s individual vocational and recreational activities must be taken into consideration when designing the orthopedic device. In this case, combining orthotic and prosthetic principals to create a hybrid prosthosis led to effective treatment and positive outcomes for this very active, highly motivated individual.
Lisa Schoonmaker, CPO, of Tandem Orthotics & Prosthetics, Sartell, Minnesota, is an ABC Certified Examiner, a Fellow of the American Academy of Orthotists and Prosthetists, and Past President of the O&P Athletic Fund.
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