Upper limb amputation: recovery, prostheses and rehabilitation in the UK

The NHS describes an amputation as the surgical removal of part of the body, such as an arm or leg. In the upper limb this can range from a finger or part of the hand to the forearm, the upper arm or the whole arm at the shoulder. Most amputations involve removing a section of a limb rather than the entire limb, according to the NHS.

The level of the amputation matters a great deal for function and for the choice of prosthesis. An NHS amputee rehabilitation leaflet notes that people with high-level amputations, above the elbow or through the shoulder, are provided with arms with the necessary joint units, and that the same hands and adaptive aids can be used with these arms.

The NHS says an amputation may be needed for many reasons, including a severe infection in a limb, gangrene, complications from diabetes, serious trauma such as a crush or blast wound, or a deformed limb with limited movement and function.

Unless an emergency amputation is needed, the NHS says you will be fully assessed before surgery to identify the most suitable type of amputation and any factors that may affect rehabilitation. This can include a medical examination, a psychological assessment and an assessment of home, work and social environments, and you may be introduced to a physiotherapist and a prosthetist.

The NHS says amputations can be done under general anaesthetic or with a regional anaesthetic, depending on the part of the body involved. The surgeon shortens and smooths the bone so it is covered by enough soft tissue and muscle, and may stitch the muscle to the bone to strengthen the remaining section, a technique called myodesis. The wound is sealed with stitches and covered with a bandage, which usually stays in place for a few days to reduce infection risk.

After surgery you may recover on a ward with fluids through a drip, and painkillers if you need them. The NHS says to tell your care team if painkillers are not working, as you may need a larger dose or a stronger one. Swelling of the stump is normal and may continue after discharge, and a compression garment helps with swelling and shape and may reduce phantom pain. Your physiotherapist will teach exercises to prevent blood clots and improve blood supply.

The NHS lists possible complications as heart problems such as heart attack, deep vein thrombosis, slow wound healing and wound infection, pneumonia, and stump and phantom limb pain. It says the risk of serious complications is lower in planned amputations than in emergencies.

The NHS says it is very important to keep the skin on the surface of the stump clean. It advises washing gently at least once a day with mild unscented soap and warm water, drying carefully, avoiding long soaks, and using an unscented moisturising cream if the skin is dry. It also says to check the stump daily for warm, red and tender skin, discharge of fluid or pus, or increasing swelling, and to contact the care team if infection is suspected.

The rehabilitation centre leaflet adds that you should check your skin daily for broken areas, using a mirror or another person if needed, avoid talcum powder, and gently moisturise but not on open areas. It notes surgical wounds and scars can take up to 18 months to fully heal and that regular massage with a gentle moisturiser helps scar suppleness. If a prosthesis is causing pain or you have skin breakdown, the leaflet says to stop wearing it and seek advice.

The leaflet also stresses that you should avoid hiding the arm, as holding it into the body can cause stiffness and pain in the shoulder, neck and upper back, and that you should take steps to reduce overuse injuries in the remaining arm, neck and shoulders.

The leaflet states that multi-articulating hands are available from the NHS but that to be eligible a person must have used a single grip myoelectric prosthesis for 12 months. It adds that the NHS cannot maintain privately purchased componentry, so ongoing costs should be considered carefully. Eligibility rules change, so ask the local service what applies now.

The NHS general amputation guidance adds that prosthetic limbs are not suitable for everyone, as an extensive course of rehabilitation is required, and that adjusting takes a great deal of energy. Before fitting, the skin of the stump may be desensitised by gentle tapping, compression bandages and rubbing, so the prosthesis is more comfortable.

The NHS says physical rehabilitation is an important part of recovery, can be long, difficult and frustrating, and that it is important to persevere. It is tailored to your needs and aims to let you do as many normal activities as possible, working with physiotherapists and occupational therapists to set realistic goals. It usually starts the day after the operation.

The leaflet describes an initial phase of advice and adaptation with the occupational therapist or physiotherapist, meeting a psychologist to discuss adapting to limb loss and meeting the prosthetist. With a prosthesis, you start with simple tasks and slowly build tolerance, and when you can use it safely and the fit is correct you take it home and gradually increase wearing time by half an hour. It notes that a prosthesis is not a replacement hand.

Training for the remaining side is tailored depending on whether the dominant or non-dominant side was amputated. If you need to use the non-dominant hand, skills such as writing and brushing teeth improve with practice, and the leaflet says that a driving assessment and adaptations such as single-handed steering aids may be needed.

After discharge, the leaflet describes amputee management clinics with a rehabilitation doctor and prosthetic management clinics for repairs and adjustments, plus annual reviews of the prosthesis.

The NHS says stump pain can have causes such as rubbing or sores where the stump meets a prosthesis, nerve damage during surgery or neuromas, while phantom limb sensations seem to come from the amputated limb and can occasionally be painful. It stresses that the term phantom does not mean imaginary: phantom limb pain is real and has been confirmed with brain imaging.

Treatments the NHS lists include medicines such as anti-inflammatories, nerve pain medicines such as pregabalin, gabapentin or amitriptyline, opioids and injections, plus self-help measures such as adjusting prosthesis fit, massage, acupuncture, TENS and mental imagery. It says stump and phantom pain usually improve over time.

The rehabilitation leaflet describes feelings of shock, sadness, anger, frustration and lowered self-confidence as natural, and says body image concerns can lead to hiding the limb or avoiding going out. If thoughts like these persist, it suggests asking for support, and notes that peer support, meeting a fellow amputee, can be an important part of recovery.

On the NHS, amputee rehabilitation and prosthetic services are provided together, and the NHS says that, depending on what is available in your local area, it can be several weeks before you get your first appointment with a prosthetist. Follow-up and maintenance of NHS-provided prostheses are part of the same service.

Some people choose to buy particular components privately, for example more cosmetic or specialised devices. The rehabilitation leaflet notes that the NHS is not allowed to maintain privately purchased componentry, so it is worth discussing the long-term costs and maintenance with the prosthetist before deciding.