The Various Types of Prosthetic Limbs

Posted on Thursday, December 5th, 2019 at 11:51 am    

In a recently-posted article, we discussed the various types of workers compensation benefits that may be due to an injured worker when an amputation occurs as a result of an on-the-job injury. 

Here we discuss the various types of prostheses that may be employed to help amputees return to more functional lives. 

According to Amputee Coalition, there are many different types of prosthetic devices that workers who lose an arm, leg, or other body part should know about. The devices vary depending on which limb is affected. Workers need to understand what to be expect when being fit for a prosthesis.. They also need to understand how often the prosthetic will need to be replaced and what rehabilitation treatment is required. 

There are a variety of workers’ compensation issues involved with prosthetic devices. Generally, workers should fight, to hold employers to their requirement to provide quality prosthetic devices. The primary consideration should be how well the prosthesis works – and not the price of the prosthesis. Injured workers should consult with both their physicians and their North Carolina or Virginia workers’ compensation attorney to choose the right prosthesis for their medical needs.

Prosthesis vs. Prosthetic

Prosthetics is the science behind creating prosthetic devices. It’s a field of study. The singular device amputees use/wear as a substitute limb is known as a prosthesis. The plural of prosthesis is prostheses. The aim of the prosthetic is to give the worker who requires the prosthetic as much mobility and function as possible. Prostheses are also designed to help with the wearer’s lifestyle and appearance.

Leg Amputation and Prosthetics

A worker who requires a leg amputation surgery will either have his/her leg amputated above or below the knee. 

Below the Knee (Transtibial) Amputation

This type of amputation is performed between the knee and the ankle. “The prosthesis is designed with moveable and adjustable joints and pylons. These components replicate a human thigh, ankle, and foot.” It’s generally much for advantageous for the person who needs a prosthesis that the amputation be below the knee. In general, a prosthesis works better if the amputation is below the knee.

Above the Knee (Transfemoral) Amputation

This type of surgery is performed above the knee joint. Like the below the knee prosthesis, this “prosthesis is designed with moveable to joints and pylons to replicate a human knee, thigh, ankle, and foot.”

Types of Prosthetic Legs

  • Exoskeletal Prosthesis. “A wood or urethane foam prosthesis with a hard plastic shell. This prosthesis is heavier and less customizable than an endoskeletal prosthetic. But it is more durable and long-lasting.”
  • Endoskeletal Prosthesis. “A prosthesis with an inner support pylon made of light-weight materials such as aluminum or titanium. Feet and knees can be swapped out. This makes the endoskeletal prosthesis easily adjustable for different activities and active lifestyles.”
  • Knee Options. For workers who have an above the knee amputation, there are different prosthetic knee joints available. The prices and functionality differ. The two common kinds of prosthetic knee joints are: 
    • “Single-axis knees. Hinge-style knees that can only bend forward and backward.”
    • Polycentric knees. “Also referred to as “fourbar” knees, they can rotate on multiple axes.”

Some of the factors that workers need to consider when choosing a knee joint prosthesis are the amount of rehabilitation that is required, “the various stability and motion control options available” and the different price points.

Fitting a Prosthetic Leg

The worker/patient doesn’t generally wear the prosthesis immediately. They injured leg must heal first. Most workers who need a prosthesis use a temporary prosthesis during the first few months after the amputation. The test prosthesis should allow the worker to get the training and physical therapy he/she needs.

“A plaster cast of the residual limb or a 3D laser scanner creates a custom prosthetic socket. The initial test socket is flexible to adjust to the reduction of swelling in the residual limb. It serves to minimize pressure and abrasion.”

While you’re rehabbing your knee, you will give the prosthetic designer the information needed to make cast a final socket. 

Leg Amputation Resources

The Amputee Coalition recommends the following resources:

Arm Amputation and Prosthetics

The aim of an arm prostheses is to allow the user to grip and manipulate objects such as eating utensils and the things they need to live and work. The amputees are fitted either for above the elbow or below the elbow devices. “Electric prostheses can even move based on signals from the wearer’s muscles.”

Below the Elbow (Transradial) Amputation

“Below the elbow amputations are performed between the hand and elbow. Prostheses are designed to replace the forearm, wrist, and hand.”

Above the Elbow (Transhumeral) Amputation

“Above the elbow amputations are performed at or above the elbow. As most of the arm is removed, a hybrid prosthesis is the best option to provide the motion of the elbow and also provide grip.”

Types of Prosthetic Arms:

  • Body-Powered. “A three-harness cable system prosthesis that allows the wearer to grasp objects, flex and lock the elbow. This is the least expensive type of arm prosthesis. There are two varieties of body-powered prostheses that offer different hand functions:
    • Voluntary Open: opens the hand when applying tension to the cable
    • Voluntary Close: closes the hand when applying tension to the cable”
  • Electrically Powered. “An electrically powered prosthesis that resembles a real arm. The user controls it with electrical impulses through muscles in the residual limb. This option is more expensive than a body-powered prosthesis and it needs frequent recharging. It also requires a great deal of fine-tuning to get the prosthesis to interpret the electrical signals, and may not work for all people. Most electric prosthetic arms provide basic grip functionality. But some of the latest electric prostheses have fully controllable fingers.”
  • Hybrid. “A combination of both body-powered and electrical components. This type of prosthesis is generally used for above the elbow amputations. It’s specialized to enable a greater range of motion and function for the wearer.”

Fitting a Prosthetic Arm:

Many of the same principles that apply to being fitted for a leg prosthetic apply to being fitted for an arm prosthetic. With an arm prosthesis, special attention is given to how the prosthesis affects the skin.

Arm Amputation Resources

Amputee Coalition recommends the following resources for arm amputees.

Attorney Joe Miller has been a strong advocate for injured workers in North Carolina and Virginia for more than 25 years. He understands that a good part of every workers’ compensation is working with your doctors and medical team to help maximize your chances for the best recovery possible. He fights to get all your medical paid for the rest of your life. He also fights to show you inability to work is properly classified so you can the maximum wage loss benefits you deserve. For help with any work injury, including amputation, call attorney Joe Miller at 888-694-1671. or fill out my contact form to schedule an appointment.

Medical Treatments for Amputees

Posted on Monday, December 2nd, 2019 at 11:47 am    

Workers can suffer the loss of a limb or body part for many reasons. They may be injured in a vehicle accident or a fall. Often, workers lose a limb due to being crushed or pinned by workplace machinery or equipment. Our office has represented a number of clients who are amputees, and obtained settlements for them for their workers compensation cases. We recently posted another article which discussed the workers compensation benefits that an injured worker who suffers an amputation may be entitled to. 

Here, we will focus more on the medical aspects of amputations. The recovery process often includes the need for a surgical amputation or re-work of an already-amputated limb. In the best cases, the worker can be fitted for a prosthetic device. Most workers who lose a limb or appendage need to treat with multiple doctors. Some workers are able to return to work. Many workers are disabled due to the workplace accident – and they can never work again.

What is an amputation?

According to John Hopkins Medicine, an amputation is a condition that results in the loss of a limb – usually due to injury or disease. When amputations are due to trauma, in 70% of the cases, the upper limbs are the body parts that are lost. According to the National Limb Loss Information Center, about 185,000 amputation surgeries are performed each year. 

Rehabilitation after amputation

A loss of an arm, leg, foot, hand, or other body part often affects the worker’ self-esteem, his/her ability to provide self-care, the ability to move, and the loss or decrease of other functions. Generally, amputees require extensive rehabilitation. The success and length of the rehab depends on:

  • The level and type of amputation
  • The type and degree of any resulting impairments and disabilities
  • Overall health of the patient
  • Family support

Each worker’s and each amputee’s rehabilitation is different. The main goal is to help the worker gain as much function and independence as follows, “while improving the overall quality of life — physically, emotionally, and socially.”

Rehabilitation includes some or all of the following:

  • “Treatments to help improve wound healing and stump care
  • Activities to help improve motor skills, restore activities of daily living (ADLs), and help the patient reach maximum independence
  • Exercises that promote muscle strength, endurance, and control
  • Fitting and use of artificial limbs (prostheses)
  • Pain management for both postoperative and phantom pain (a sensation of pain that occurs below the level of the amputation)
  • Emotional support to help during the grieving period and with readjustment to a new body image
  • Use of assistive devices
  • Nutritional counseling to promote healing and health
  • Vocational counseling
  • Adapting the home environment for ease of function, safety, accessibility, and mobility
  • Patient and family education”

The amputation rehabilitation team

Workers who lose the loss of a limb often need to treat with some or all of the following doctors, health providers, and counselors. Some patients require treatment for months or years. Many workers require some type of lifelong assistance. The types of care required depends on how acute the amputation is and the availability of out-patient services.

  • Orthopedists/orthopedic surgeons. Orthopedic doctors who are experienced limb salvage doctors work to save as much of the limb as possible, to reconstruct the limb where possible, to prepare the limb for prosthetic use, to clean the wound, and to help leave the wound looking as best as possible.
  • Physical Medicine and Rehabilitation Doctors. These are physicians who typically specialize in working with patients who have suffered catastrophic injuries such as limb loss, and getting those patients back to maximum function. 
  • Prosthetics and orthotists. According to the Hospital for Special Surgery (HSS) in New York,  these are certified professionals who help build the best device possible so you can achieve maximum mobility and function. Amputees are fitted before the devices are prepared.
  • Psychologist/psychiatrists help workers adjust to the emotional and self-esteem problems that often accompany the loss of one or more limbs. They provide individual counseling and/or psychiatric medication. 
  • Physical therapists help build strength and help improve your function and mobility so you can be as independent as possible.
  • HSS Motion Analysis Lab: According to HHS, these “specialists and scientists perform gait analysis for diagnostic purposes, evaluation of outcomes, and clinical and translational research.”
  • Patient counselors: HSS defines these counselors as “individuals who are high-level, functioning amputees with personal experience and perspective providing support and advice, as well as running group programs and amputee walking schools

Other doctors and rehabilitation team staff include the following health providers and professionals:

  • Physiatrists
  • Internists
  • Occupational therapists
  • Social workers
  • Recreational therapists
  • Chaplains
  • Vocational counselors

A determination needs to be made to decide if a worker/patient who has a limb that is at risk from “infection, bone loss, soft-tissue compromise related to trauma, tumor reconstruction, or peripheral vascular disease” requires limb salvage surgery or amputation reconstruction surgery.”

Limb-salvage surgery generally includes bone grafts, tissue transplantation, and implanting internal devices. Limb reattachment may also be a possibility.

According to Pharmacy Times, there are two types of amputation categories:

  • “In an open-flap amputation, the surgeon amputates the diseased area but does not close the wound. The skin is drawn back from the amputation site for several days, allowing direct access to the wound should the tissue become infected.”
  • “In a closed-flap amputation, the skin flaps are sutured immediately.In performing lower-limb amputations, surgeons prefer to amputate below the knee, which is linked to improved outcomes. Knee-joint salvage enhances rehabilitation and requires less energy for ambulation.

“Prior to surgery, most patients are measured for their prostheses and receive counseling on living with an artificial limb. Prosthetic choice is individualized, ranging from externally fitted devices to patient-controlled motion robotics. “

Post-operative care for an amputation surgery generally ranges from 5 to 14 days. Most wounds heal in a month or two. Complications, according to Pharmacy Times, can include: “edema, hemorrhage, hematoma, site infections, sepsis, soft-tissue debridement, necrosis of the skin flaps, and pneumonia.” 

Many workers whose limb or appendage has been amputated suffer “phantom pain, “– the experience of pain in the limb even though the limb is no longer there.

“Along with phantom pain, 76% of patients experience phantom limb sensations, generally in the form of tingling, burning, or itching. Once thought to be psychological, phantom sensations appear to result from brain nerve-circuitry changes. Over time, phantom pain tends to decrease or disappear altogether, but when phantom pain persists longer than 6 months, prognosis for total pain relief is poor.”

The Workers Compensation Aspects of Amputation Cases

In a recently-posted article, we discussed the Workers Compensation Benefits that may occur in the case of an amputation on the job. The Workers Compensation aspects of an amputation case are generally broken down into three different types of cases. 

One-Limb Amputation-Unable to Return to Job. First, there are the cases where there are one or more limbs lost, and the injured worker is unable to return to pre-injury work due to the injuries. In these cases, a settlement is usually achieved based on the remainder of weeks in the Award. If there is an amputation to one limb, the injured worker would be entitled to no more than 500 weeks of compensation, and settlement may be achieved on that basis; however, due to the high cost of prosthetic replacement, which must typically occur every five years, the medical portion of the claim often remains open and unresolved because the settlement value would be more than the workers compensation carrier is willing to pay at once, in a lump sum. Sometimes, when the injured worker is older,  assuming the injured worker regularly takes advantage of the medical benefits available through workers compensation, a full settlement of the medical benefits may be examined and the worker and his or her attorney approached for settlement. 

Two-Limb Amputation or impairmentUnable to Return to Job. In those circumstances where there is tragically a loss of more than one limb, or even where one limb is not amputated, but clearly is damaged to the point of having significant permanent impairment in the limb, then the injured worker would not be limited to the 500-weeks of benefits, but would be eligible for lifetime compensation benefits. This is because the “loss” of two limbs is considered a permanent and total disability. This would obviously entail a much higher potential settlement value than a settlement that is limited to 500 weeks. Again, though, due to the high cost of prosthetic replacement, which must typically occur every five years, the medical portion of the claim often remains open and unresolved because the settlement value would be immense—and more than the insurance carrier is willing to pay at this point. That does not mean a medical settlement may never occur. The insurance carrier may want to wait until the injured worker is much older to consider closing out the medical portion of the claim.  

Return to Work and One-Limb Amputation. If the injured worker is able to return to work at an equal or greater wage than before the accident, despite the amputation– as is often the case in younger workers– there is still the potential value due the injured worker for the permanent partial impairment rating of the amputated limb. This would not be a final settlement, but would be a number of weeks of compensation paid to the injured worker based on the percentage of impairment assigned by his or her doctor. In some cases, such as an above-the-knee amputation, that would obviously be 100%, but in others, such as a below-the-knee amputations, it may be less. 

Virginia and North Carolina Workers’ Compensation Attorney Joe Miller Esq. understands the short-term and long-term needs of workers who lose a limb, whether it be a hand, foot, arm or leg – due to a workplace accident. He works with your doctors to understand what treatments you’ll need and for how long. He’s helped thousands of employees get the workers’ compensation recoveries they deserve. To schedule an appointment, call lawyer Joe Miller at 888-694-1671. or fill out my contact form.

Spine Impairment Ratings in North Carolina Workers’ Compensation Cases

Posted on Wednesday, August 24th, 2016 at 2:00 pm    

Medical impairment ratings are a way of assessing the severity of your work injury. They are used in cases where your injury is permanent as opposed to something that will heal in time. Doctors use various factors to determine the impairment rating that applies to your injury. Doctors can’t just pick a rating out of a hat. They need to justify their rating. That is why the North Carolina Industrial Commission provides guidelines for doctors. Doctors are required to use the guidelines to help them give the final rating/assessment of your injury.
An experienced North Carolina work injury lawyer is needed to help workers fight to get the correct rating. Attorney Joe Miller, who has helped thousands of injured workers for over a quarter century, understands the rating process. Click here to watch his video regarding permanency ratings. He works to let the doctor know all of your medical complaints and how they affect your ability to work. He reviews the medical reports for accuracy and thoroughness to help the doctor see your full medical problem.
One thing that is significant that should be noted: Unlike North Carolina, permanency ratings for the spine do NOT EXIST in Virginia. Ironically, in North Carolina, spinal impairment carries the highest potential number of weeks of impairment of any body part, namely, 300 weeks. The impairment ratings, which are expressed as percentage ratings, for the spine, pelvis, cervix, coccyx, and for ruptured lumbar (back) discs are as follows:

Cervical Spine

Please know that the statutes, as written, refer to the back, not the spine. When rating impairment to the spine, doctors should always refer to it as the back (percentage of the back, not percentage of the spine.)

CERVICAL SPINE FRACTURES
• Single, healed, with little or moderate anterior compression and without neurological findings
o Body = 10%
o and/or posterior elements—arch, transverse process (additional) = 5%
• Two or more vertebrae, each additional = 50% of above
• Add, for neurological
o Quadriplegia = 100% of man
o Nerve root, one arm, or both arms: Functional rating is added to cervical spine percentage.

CERVICAL DISC
• Anterior discectomy, with or without fusion—free of neck and arm pain—no weakness = 5%
• Postoperative—with recurrent episodes of significant cervical and arm pain associated with objective findings = 10-15%
• Posterior laminectomy—removal of ruptured disc—free of neck and arm pain—no weakness = 5%
• Postoperative—with recurrent episodes of significant cervical pain associated with objective findings = 10-15%

Thoracic Spine
• THORACIC SPINE FRACTURES (Treat As CERVICAL SPINE, A) (Correction, July 8, 2016)
• THORACIC DISC (rate as Ruptured Lumbar Disc)

Lumbar Spine
LUMBAR SPINE FRACTURES (including lower three dorsal vertebrae)
• One body = 10%
• and/or posterior elements (arch and/ or transverse process) = additional 5%
• (Two or more) = 50% of above
• Add for loss of motion
o Mild (0%-25% limitation) = 5%
o Moderate (25%-50% limitation) = 10%
o Marked (50% or more limitation) = 20%
• Add for neurological changes: (paraplegias are established)
o One or both legs, functional rating.
B. INVERTEBRAL DISC (rate as Ruptured Lumbar Discs)

*This Section clarified as of February 15, 2000*
What happens if you have more than one back injury?
If a claimant has two injuries to the back and has separate impairments, these ratings should be calculated separately and then combined. Do not add the percentages of impairment. A few examples follow:

FIRST EXAMPLE: 40% (A) & 20% (B)
• In this example, the first percentage of impairment, 40% (A) is subtracted from 100%.
o 100% – 40% = 60% (C)
• The second percentage of impairment 20% (B) is calculated from the remaining percentage (C), which in this case is 60%.
o 20% of 60% = 12% (D)
• The total percentage of impairment is the sum of 40% (A) plus 12% (D).
• 40% + 12% = 52% total percentage of impairment

SECOND EXAMPLE (When total exceeds 100%): 70% (A) and 40% (B)
• In this example, the first percentage of impairment 70% (A) is subtracted from 100%.
o 100% – 70% = 30% (C)
• The second percentage of impairment 40% (B) is calculated from the remaining percentage (C), which in this case is 30%.
o 40% of 30% = 12% (D)
• The total percentage of impairment is the sum of 70% (A) plus 12% (D).
• 70% + 12% = 82% total percentage of impairment
Pelvis (ate as percentage of spine unless acetabulum is involved)
• SYMPHYSIS SEPARATION = 10%
• ILIUM
o With pelvic ring intact = 0%
o With pelvic ring displaced 1″ or more = 10%
• ISCHIUM
o Healed, no deformity = 0%
o Healed, deformity and pain = 5-10%

• FRACTURED ACETABULUM-(evaluate on basis of hip disability-see hip section)
• PELVIC RING DISPLACED PLUS SACROILIAC JOINT DISPLACED (if leg shortening, add that) = 15%
Sacrum
• Healed, no pain = 0%
• Healed, with significant residual deformity = 10%
Coccyx
• Healed, no pain = 0%
• Healed, deformity and significant objective signs = 5-10%
• Excised (as above under healed fractures)

Ruptured Lumbar Discs

The following guide is suggested for use in rating of patients with ruptured lumbar discs from the standpoint of permanent partial impairment to the back, as recommended by the North Carolina Orthopaedic Society and the neurosurgeons of North Carolina:
• Typical episode of back and leg pain that completely recovers without neurological defect on conservative therapy = 0%
• Same as (1) with recurrent episodes of significant back pain associated with objective findings = 5-10%
• Postoperative-removal of ruptured disc-free of back and leg pain-no weakness = 5%
• Postoperative-with recurrent episodes of significant back pain associated with objective findings = 10-15%
• Postoperative-removal of ruptured disc and spinal fusion. Same as (3) = 25%
• Postoperative-removal of rupture disc and spinal fusion. Same as (4) = 25-30%

We should mention one final note on impairment ratings, which is also discussed in Joe Miller’s Video on impairment ratings. If your work injuries prevent you from returning to work, you should not really get too caught up in an analysis of the ratings. Unless you have at least two ratable body parts severely injured, the ratings are not going to be much of a factor in valuing your case. This is because you are limited to 500 weeks total TTD. The ratings cannot add to that total. So in most cases, if you are unable to return to work, the future potential TTD that you may draw is going to be far more significant than anything that a rating can provide you.

Make the Call to a Strong North Carolina Work Injury Advocate Today

The treating doctor is often one that is on a list of doctors chosen by the employer or the employer’s insurance company. To help this doctor make as objective a decision as possible, it helps to have an experienced North Carolina work injury lawyer on your side. An experienced lawyer explains to workers that they need to inform the doctor of all their complaints. The lawyer reviews the medical reports to see if the doctor is following the North Carolina Industrial Commission guidelines. For strong legal counsel phone North Carolina Workers’ Compensation attorney Joe Miller now at 888-694-1671 . You can also complete his contact form.

Medicare Set-Asides (MSA’s) in North Carolina Settlement Agreements

Posted on Thursday, October 8th, 2015 at 2:28 pm    

Employees who have an MSA (Medicare Set Aside) account as part of their settlement should get a separate check from the employer or insurance carrier to cover the cost of future medical expenses. Self-administered accounts should be deposited into a separate account that is used just to pay for the employee’s medical expenses – and no other expenses. Some MSAs are not self-administered. Here, the employee will normally get a yearly check for the anticipated medical bills. (more…)

Do’s and Don’ts for Mediation of North Carolina Worker’s Compensation Cases

Posted on Monday, September 21st, 2015 at 2:20 pm    

Mediation is a mandatory process in North Carolina where unless the Parties object, an opportunity is provided to resolve the client’s claim. The Parties and their attorneys get together in an informal setting. A Mediator is someone who the Parties agree to use to help facilitate a settlement of the claim. The Mediator really does not decide anything. He or she is just there to help the Parties come together and try to resolve the claim. (more…)

Difference between Related and Unrelated Causes under the NC Workers Compensation Death Benefit Laws

Posted on Wednesday, August 26th, 2015 at 10:27 am    

If the cause of the worker’s death is unrelated to the worker’s injury or occupational illness, then the payout is usually small. On the other hand, if the cause of death is related to the employee’s injury or occupational illness, then the payout is 400 to 500 weeks of 2/3rds of the average weekly wage plus burial benefits. For this reason, if there is reasonable argument that the death is related to the injury or job illness, then it makes sense to try to prove that causation did exist. (more…)