Amputations & Prosthetics

Appendix A: Discussion of Amputations

I. Amputation and the Courts
The courts have viewed hiring policies that disqualify amputees – without providing them with an individualized evaluation (see Appendix B for evaluation criteria), in relation to the job position being sought – as discriminatory under the Americans with Disabilities Act and other statutes prohibiting discrimination against persons with disabilities. 1,2 Many, though not all, persons with limb deficits are likely to qualify as disabled for purposes of being covered by anti-disability discrimination legislation.

II. Amputation and Law Enforcement Job Functions
Existing task-based assessments designed to assess an amputee for certain occupations (e.g., Federal Motor Carrier Safety Administration, U.S. Coast Guard, Federal Aviation Administration) do not easily translate to the complexity and time sensitivity of law enforcement job functions, nor to the unpredictability and environmental challenges of the settings in which these tasks must be accomplished.3

There are currently no studies that address return to duty of law enforcement officers (LEOs) following amputations. Law enforcement activities have some significant similarities to military ground soldier activities in that LEOs must operate in a variety of terrains (e.g., navigating obstacles and responding rapidly on foot) and use weapons. A 2010 study of U.S. military personnel who sustained an amputation in the Iraq or Afghanistan wars reported a return-to-duty rate of 16.5% overall.4 If the definition of “return to duty” from Physical Evaluation Board final disposition of “fit for duty” or “return to duty” (the only two designations that are completely unrestricted5) is used, the return-to-duty rate for Iraq and Afghanistan veterans with an amputation is 2.8%. This study did not document the actual roles (i.e., what physical activity profiles) to which the amputee personnel returned.4

III. Congenital Limb Deficits and Early-Life Amputations
Persons with congenital limb deficits, as well as those with early-life (pre-adolescence) amputations, may achieve significantly higher levels of overall functionality than persons experiencing amputations later in life. This higher level of function in activities of daily activity and/or recreational activities should not be assumed to indicate that the person with an amputation can perform the LEO essential job functions. (The remainder of this discussion on assessment of amputations, unless otherwise stated, also includes LEOs with congenital deficits and early-life amputations.)

IV. Overview of Medical Evaluation of Amputees
The police physician may need to advise the department or authority having jurisdiction (AHJ) on what types of activities are most likely to be adversely affected by the amputation.

• Prior to release to unrestricted duty, the LEO with an amputation should undergo evaluation by the department for ability to perform job functions to department-defined adequacy (e.g., firearm qualification tasks and scores or pursuit driving proficiency on a department-designated course) that are likely to be affected by the amputation.
• Any evaluation must take into account the disease process or event that led to the amputation.
• As a part of the overall assessment for ability to safely and effectively perform law enforcement job functions, the LEO should have to submit to an agency-determined evaluation of ability to actually perform job functions prior to final clearance to full duty.

In the U.S., health care providers and payers rely exclusively on the Medicare Functional Classification Level (MFCL), aka K-levels (see Appendix C), to predict functional capacity of amputees for determination by Medicare and other insurers of what types of prosthetic components they will cover for lower limb amputees. This classification system is not designed to document the amputee’s physical abilities. Additionally, this classification system is not used for assessing upper extremity amputees. Existing fitness-for-duty evaluations for amputees and their limitations in certifying individuals for complex work environments has been recently reviewed.3

The treating physiatrist or other physician knowledgeable about amputee management and a certified prosthetist (if the amputee utilizes a prosthesis) should provide evaluation forms (see Appendices D and E) to the police physician documenting the amputee’s general health, underlying reason for the amputation and the type, and specifications and maintenance history of the prosthetic device. The treating physician and prosthetist should complete and submit the information requested in these forms following any revision, change, modification, or re-evaluation of the prosthesis.

For the LEO who does not use a prosthesis, the evaluation should be based on his or her ability to do the job functions without a prosthesis. For the LEO who uses a prosthesis, the evaluation should be based on his or her ability to do the job functions while wearing any prosthesis that would be used at work. If the LEO has an older model “back-up” prosthesis that is used when the primary prosthesis is being serviced, an evaluation for functional capabilities should be performed with that prosthesis as well if it will be used while on the job.

All prostheses are built with some leeway in fit to accommodate normal changes in residual limb size. Residual limb/socket fit changes are more of a concern for newer amputees whose residual limb is still remodeling and after major illness and/or weight loss or gain, and less of a concern for upper extremity amputees, congenital amputees, and/or amputees who have worn their prosthesis for several years. The incumbent LEO should be placed on restricted duty until assessed by his or her prosthetist for prosthetic fit and possible socket modification or socket replacement. Repeat evaluation of the LEO is required by the police physician after substantial technology changes (changes to foot, knee, terminal device, suspension system, socket) or any incident of prosthetic failure or loss of prosthesis (either spontaneously or during job or other life activities).

All prostheses require both scheduled and episodic maintenance. LEOs usually rely on a back-up prosthesis (typically a previous prosthesis with a duplicated socket/older components or an adaptive sports prosthesis) while their current prosthesis is being serviced. The LEO and police physician should have a clear understanding that fitness for duty is based on use of the prosthesis worn for any functional assessment. Any back-up prosthesis the LEO wishes to use for unrestricted duty should be subject to the same evaluation by the police physician and prosthetist as the primary prosthesis.

A review of the literature does not reveal a definable failure rate for either upper or lower extremity prosthetic devices or for device-patient interfaces (sockets and harnesses). Since these are mechanical devices, there is reasonable concern, however, that with time and heavy use, there may be increased risk for device failure. Thus, it is important for the police physician who clears the LEO with an amputation for return to duty to establish scheduled follow-ups that include assessment of the prosthesis components by a certified prosthetist.

Following amputation, there is no standard rehabilitation time noted for attempting physical activities similar to law enforcement job duties. A reasonable time frame from surgery to fit of the definitive prosthesis is approximately 6 months for a traumatic amputee with no comorbidities; the time frame may be longer for vascular, neoplastic, and/or infectious causes of amputation.6 However, after this time period, the amputee may need many more months to learn how to most effectively and efficiently function with the prosthesis.

Lower extremity amputees generally automatically select the step length that minimizes energy expenditure.7 Unilateral below-knee amputees are estimated to have 9-28% (3.3-3.8 METS) increase in energy cost compared to normal ambulation (3 METS). Unilateral above-knee amputees experience a 40-65% (4.2-5.0 METS) increase in energy expenditure during ambulation.8 Therefore, the LEO with a lower-extremity amputation will experience a higher level of energy expenditure for some law enforcement job functions than the LEO without limb loss.

Congenital limb and early childhood amputees who adopt prostheses early in life are likely highly proficient prosthetic users. This group of highly active amputees may utilize very specialized equipment of their own design to compete in sports from track and field to rock climbing and triathlons. Such athletic amputees may be comfortable devising and maintaining their own specialized prostheses. The LEO must, however, be evaluated in the prosthesis that will be worn during work. Performance in an activity specific device is not generally transferable to the job functions of the LEO. Commercially manufactured activity specific prostheses of any type are also usually not appropriate for unrestricted LEO duty.

V. Upper Extremity Amputations
Seventy percent of upper extremity amputations are of traumatic etiology.9 Upper extremity amputations are classified by anatomical terminology – transphalangeal, transmetacarpal, transcarpal, wrist disarticulation, transradial, elbow disarticulation, transhumeral, shoulder disarticulation, and forequarter (arm, scapula, and clavicle). Amputation of the upper extremity at or proximal to insertion of deltoid insertion is regarded as 100% impairment of the extremity.

Two types of grip – power and pinch – are of importance to law enforcement job function. Normative data exists for power grips (cylindrical, spherical, hook/palmar) and pinch grips (tip, chuck, and lateral pinch). For example, LEOs must be able to restrain resisting persons with one hand while using the other hand to perform tasks such as hold and activate a radio or manipulate handcuffs in removing them from their holder and applying them to the suspect.

For most individuals who do not have a functional hand, the most efficient prosthesis (prosthesis defined as a device to replace a missing body part) is usually the remaining opposite limb.10 Upper extremity prostheses are only expected to generate forces adequate for manipulation of light objects.10,11 While custom-made terminal devices can be used to accomplish certain heavy-duty tasks (i.e., volar wrist splint allowing fixation of a hammer for a patient thumb/fingers), these devices are task-based and require accommodations that allow the tool to be directly fixed to the socket. While many terminal devices exist to facilitate completion of activities of daily living (ADLs) or specific tasks, even the best prosthesis does not replace tactile sensation.12 A typical body-powered shoulder harness has the ability to carry approximately 4 pounds in the terminal device while maintaining elbow-flexion. Locking the elbow and substituting whole body movements will allow lifting of heavier items.10 Myoelectric devices face similar lifting limitations in addition to being heavier and requiring ready access to a power supply.

The police physician should take into account the ability to perform specific job functions required by the AHJ:

• apprehending/restraining/handcuffing a struggling, resisting suspect;
• using weapons safely and effectively;
• using a weapon while simultaneously using radio;
• using two-handed weapons;
• emergency driving;
• driving while simultaneously operating the radio or other in-vehicle instruments;
• using a flashlight, opening doors or performing other upper extremity tasks while holding a weapon with the other hand;
• weapon qualifying with both hands individually; and/or
• weapon retention.

LEOs being considered for release to full duty should undergo evaluation of capability to perform law enforcement job functions. This may be accomplished by the department requiring that the person satisfactorily complete functions in a department-based setting such as a training facility. Alternatively, this may be accomplished with a medical functional capacity examination with tasks ordered by the physician following consultation with the department regarding job functions. Testing should not include job functions that are not required of other officers without a prosthesis.

VI. Lower Extremity Amputations
Lower extremity amputations account for one third of traumatic amputations. The vast majority of lower extremity amputations are attributed to dysvascular causes. The underlying condition/event resulting in the lower extremity amputation (e.g., diabetes, neoplasm, peripheral vascular disease, blast, penetrating or blunt trauma) may also affect decisions regarding the LEO’s ability to safely and effectively perform his or her job functions.

Lower extremity amputations are classified by anatomical terminology. Toe amputations, ray amputations (counting from big toe as the first), midfoot (metatarso-phalangeal, transmetatarsal), tarsometatarsal disarticulation (Lisfranc), transtarsal (Chopart – between talus/calcaneus and distal row of tarsal bones) are all considered partial foot amputations. The Syme’s amputation is an ankle disarticulation with reattachment of the calcaneal fat pad. Transtibial (below knee), knee disarticulation, transfemoral (above knee), hip disarticulation, and transpelvic amputation or hemipelvectomy each has its particular issues regarding rehabilitation and activity capabilities. Problems encountered include:

• Syme’s amputations present problems for fitting any sort of functional prosthesis due to length of the residual limb.
• Transtibial or below-knee amputations (BKA) can be classified by tibial length (very long, long, short, very short) as the size/shape of the residual limb is important in predicting the ability of the amputee to obtain a well-fitting prosthesis. Long and very long BKA residual limbs may present problems for prosthesis fitting due to the length of the residual limb.
• Very short BKA residual limbs may present problems with socket fitting.
• Knee disarticulation prostheses extend upper leg length while in a sitting position which may interfere with sitting, entering/exiting a vehicle, or other close quarters work setting, and may impair the ability to kneel.
• Transfemoral or above-knee amputations (AKA) are classified by femoral length (long, short). An AKA with a very long residual limb may present problems for fitting any sort of functional prosthesis due to the length of the residual limb. In contrast to a BKA, the mechanism of walking with an AKA prosthesis requires using the hip muscles to control the knee. This is opposite of normal gait. Learning to walk with an above-the-knee prosthesis requires formal physical therapy to learn effective technique.

Persons with any of the following amputations are unlikely to be able to be fitted with a prosthesis that will restore adequate functional capabilities to permit the wearer to safely and effectively perform law enforcement job functions:

• above the knee proximal to 5 cm from perineum;
• hip disarticulation;
• transpelvic amputation;
• hemipelvectomy.

The following are some job function issues that the police physician needs to consider when evaluating the LEO with lower extremity amputations:

• entering/exiting a vehicle;
• driving;
• walking/standing/kneeling for prolonged period of time;
• short-burst running on uneven terrain including up and down inclines and over obstacles with lateral stepping (zig-zag running to negotiate around obstacles);
• climbing over obstacles;
• crawling;
• rapidly going up and down stairs;
• walking backwards, sideways and with lateral crossover step;
• apprehending and restraining resisting suspects; and
• ability to wear regulation footwear if required.