The Inquisitor and Prostheses
I‘m studying for this very test on amputation, orthoses and prostheses, which occurs tomorrow, but every time I see “disarticulation” and “forces” etc., etc. I keep on thinking of the Inquisitor and Trespasser and…! I just need to write this out and then I may resume studying :D.
I know that for my own Inquisitor I chose not to go along with the idea of a prosthesis due to the fact that most anything usable in the Dragon Age setting would be completely conspicuous, and I think my Inquisitor has earned a little anonymity after saving the world.
However, a lot of people LOVE the idea of Dagna help their Quiz, and let’s be real, that’s a heck of a lot more interesting for science. So… LET’S DO IT!
Terminology:
- prosthesis - a. replacement of a missing part by an artificial substitute, such as an artificial extremity. b. An artificial organ or part, including arms, hands, joints, heart valves, teeth, and others. c. A device to augment performance of a natural function, such as a hearing aid. (1)
- disarticulation - amputation through a joint [AN: with an attempt to spare as much soft tissue as possible]. (1)
- pictoral guide (diagram, not a real picture, not graphic) of various upper extremity amputation scenarios (2).
General Concepts to Keep in Mind:
- Your body is a fantastic machine and designed to move with neurological and energetic efficiency. Any time you replace your original part with something that is not the exact same original you are going to be less efficient (with an above-knee amputation of the lower extremity, walking becomes 200-300% more energy demanding, even with a prosthesis).
- Any time you experience severe trauma, you are going to go through a lot of healing (though perhaps less than you might expect), and healing takes time.
- You will also ride a significant learning curve when it comes to using a prosthesis, and becoming knowledgeable and comfortable with its use takes time.
- There are two main causes of amputations: disease process (usually dysvascular disease like diabetes, or cancer, which are slower to encroach) or trauma. Trauma is less complicated for managing immediately, but psychologically, as you may imagine, post-surgical interventions can be harder.
- In this explanation, obviously, my stance is going to be a non-magical one with some magical intervention toward the end.
The Inquisitor has their mark for a total of 3-5 years (depending on which Bioware source you choose for your DA:I timeline), at which point they go through a stage of rapid deterioration over the course of a few days’ time. The mark grows unstable and begins to create shooting pain (3) up their arm and into their jaw. That is not a completely muscular issue but a neurological one because the innervations for these areas are different. At times we see the Inquisitor almost debilitated by their pain ;(.
After continuing to use their arm (which has pros and cons of its own in terms of creating an atmosphere for healing vs. overusing) during this intensity-building scenario through the Winter Palace and Deep Roads and Crossroads, they finally meet Solas, who, with on disposition or another, causes them to lose their arm. Though, to be fair, he saved more of them than otherwise would have been realistic. No bones about it folks, a few days earlier their arm was in perfect working condition and just after Trespasser, it is gone. This is a traumatic loss of limb!
The final scene with the Council at the WP and the final slides of the game, regardless of your ending, do not give a good indication of which length of amputation occurs, whether it is transradial (across the radius and ulna AKA forearm) or whether it is transhumeral (upper arm.) Both create a different implication for treatment and the complexity of the prosthesis that follows.
The general principle here is that the more residual limb (you only call this a “stump” if you are on close terms with the amputee and they have given you permission) that remains, the better for the amputee. They have more to work with in terms of their recovery, they have more original body AKA less trauma, and the prosthesis does not have to be as complex.
With regards to prosthetic complexity, it depends on whether or not your Inquisitor had a transradial, elbow disarticulation, or transhumeral amputation. A few months ago, @carastian-candies asked my opinion on the matter. I said, based on the sleeve length in that final walk through the Council, I thought it was transhumeral, but you can go in any direction. Let’s start distal to proximal, and I will walk you through the possibilities and what happens.
Anatomy overview:
- Transradial amputation - If this one occurred, there was very little residual limb. Several muscles exist in the forearm corresponding to the complexity of motions the hand and wrist are capable of. They help the forearm pronate (turn palm down) and supinate as well as help flex (bend the wrist/fingers) and extend the wrist/fingers. There is no more hand or wrist, so these muscles by themselves are not particularly important to function in and of themselves. Why do you need to rotate a non-existent wrist?
They remain important, however, because of the innervation that still runs in the residual soft tissue. The brachial plexus descends from nerves C5-T1 towards the shoulder, where it splits into 5 nerves that control various sensory and motor functions in the arm → musculocutaneous, axillary, median, radial, and ulnar nerves. These nerves are all criss-crossed within the plexus which means that when one radiates pain back to the spinal cord, you can have overlap at times, especially when your body doesn’t know what the hell is going on. Thanks, Solas.
As the nerves descend each one innervates various muscles with a distribution like rootlets of baby plants. Those muscles in the forearm are mostly innervated by the median, ulnar, and radial nerves, which, when they cross the elbow are very near to the surface. How many times have you hit your funny bone and found it’s not that funny? Yeah, that’s your ulnar nerve.
If there are enough of these left, and their rootlet offshoots, they can influence the muscle and Quiz will still have an elbow joint. The muscles are either attached to each other in a “free floating” sitaution at the ends (myoplasty) or they are attached to the remaining bone (myodesis). Myodesis is a much better solution because it gives you functional use of that remaining limb and it decreases chances of complications. The bones themselves are rounded off to decrease any kind of discomfort that will come from impact. Impact still hurts, but it hurts much less than a pointy bone trying to poke through your skin.
- Elbow Disarticulation - The radius and ulna are removed from the humerus. This is chosen because there is no functional reason to keep the remaining forearm bones and muscle, but it is less traumatic than cutting through the humerus. In terms of functionality, this would make a lot of sense if it were occurring at the knee, because the knee itself is made to bear weight. The humerus is not, and the muscles more proximal in the arm don’t have a job if there is no elbow left.
Nerves that remain here are all of the formerly mentioned ones, but the only muscles that remain are the two heads of your biceps, the three heads of your triceps, and the muscles that extend from your scapula and clavicle to the upper arm. The biceps and triceps are meant to flex and extend the elbow, or what remains of it, so I can definitely see the Inquisitor getting some serious muscle with repetitive use.
- Transhumeral amputation - The humerus has been bisected at some part of its length. Given the Inquisitor’s picture, again, in that final walk through the WP, to me it looks like it would be closer to the elbow. Through myodesis the Inquisitor can retain the muscles and the innervations of these remaining muscles, though all muscular motion will come from the shoulder itself, lifting the arm, extending the arm in the direction of the back. Any Inquisitor who goes through this and still plans to fight, is going to need some serious back and core power.
Why are innervations important?
In modern upper extremity prosthetic technology, sensors are embedded in the prosthesis, and they can actually read the microvoltage running through the arm. So regardless of whether the amputation is proximal or distal, during the process of fitting, the prosthetist can create a sensor site right above the nerves to know what the arm is trying to do. For example, if an Inquisitor has a hook on the end of their prosthesis (a common attachment today) and a longer cuff that extends to the elbow, the sensors can read just below the elbow (say at the remnant of the flexor carpi ulnaris) to transmit a signal in a split second to tell the hook to move. Sensors can also be embedded in the skin if the nerves have retracted too far proximally.
The downfall of this is that it is not as fast as the original human arm. Even if a prosthesis is designed to accommodate several motions it takes a second to switch between motions in different planar directions. The sensors need to be changed according to the axial motion they are intending (up and down? side to side? backwards or forwards?), and the normal arm is usually doing a combination of these motions at any point in time. The closer to the hand you are, the greater the combination of motions and the more complex it is to artificially engineer them.
So if an Inquisitor has experienced a transradial amputation the need for a prosthesis that can handle all of the motions of the hand and wrist is less complex than an Inquisitor with a transhumeral amputation, who needs to account for the fingers, wrist, and elbow.
WHY DAGNA IS AWESOME:
…In this scenario, because she makes runes! And runes do WHATEVER WE WANT, including connecting overlapping neural signals in a way that is meaningful for a prosthesis and its user.
I readily imagine that Dagna could personalize a prosthesis with slots for runes, just like weapons in-game, that first of all, sense the signals that are coming from the motor cortex, interpret those signals with the residual surrounding muscle, and give an appropriate outcome in the prosthesis. Second, don’t tell me that she wouldn’t weaponize the doody out of that arm if given the chance, and the sneakier the better, IMHO. Whatever the Inquisitor was comfortable with, I am sure Dagna would be up for.
For upper extremity current technology they even have sleeve designs that wrap around the residual limb like removable sleeves or compression garments. They still have the same sensor technology but they are much sleeker than bulky plastic/metal models. They are also a loooot more expensive, but I guess expense doesn’t really factor into a fantasy setting. Still, maybe if Dagna is feeling feisty then she switches the Inquisitor’s sleeve with plaidweave for Fool’s Day, lol.
Remaining Concerns:
- General discomfort - phantom sensation and phantom pain, with the only real difference being the Inquisitor’s perception, do exist. They are both treatable with visualization techniques and mirror therapy.
Brain mapping inconsistencies - sometimes scars may become very, very sensitive to touch (not in a pleasant way). Current therapy suggests using accommodation techniques to help individuals overcome, gradually de-sensitizing them to touch by gently touching them, rubbing a soft cloth over the site, or even sticking the residual limb in a bag of rice or bird seed.
Contracture - this is, essentially, extreme muscle tightness. If you only use a limb in one direction most of the time, the muscles opposite of that direction will become very tight. All sides of the body need their complement side for stability. Make sure your Quiz is stretching.
Scar tissue can form on the outside of the amputation site. It may also form on the inside and adhere to the bone. Scar tissue can be broken up with transverse friction massage.
If they wear clothing in which a lot of wrinkles form and leave indentations on the skin, over a short period of time that can be really, really uncomfortable. Make sure your Inquisitor is doing everything they can to have a very smooth fit between their arm and their prosthesis.
Again, if they run into anything on that edge, or if the edge is hit, it’s going to hurt.
- Cosmesis - how vain is your Quiz? Because whether they like it or not, they have a bit of a stump now. Not to mention, they lost it in a traumatic experience. It takes a while to get comfortable with this all the way around, and it needs to be actively done.
- Volume changes - it takes time to shape and mold the residual limb into something appropriate for a prosthesis, usually at least a month, while the Inquisitor is healing from the surgery, during which time they need to be wrapped (in a particular way) that encourages fluid to return to the rest of the body, instead of staying trapped in a dead end. That was a long sentence.
Even years after an amputation, amputees can have volume changes, where the prothesis fit is too small, or even too large. If it’s too large, the area can be wrapped to manage edema for a few days. If it’s too small, special socks can be worn to fill up the space.
Now go forth and amputate!
Special Request:
If you use this information in any of your writings or drawings, please send me a link to the work and credit this post! I would love to experience what you are doing :D
And now for some lazy citations:
(1) - Taber’s Cyclopedic Medical Dictionary, 22nd Edition. FA Davis Company.
(2) - Nova Scotia Health Authority. Accessed Feb 28, 2016.
(3) - DAI Banter, original post on February 22, 2016.
** I was a little bit lazy in finding visual source material from Trespasser, but if you’re reading this, you’ve played it and you remember.
