GUIDELINES FOR MEASUREMENT OF

AMPUTATION STUMP LENGTH

Carol A. Ross, R.P.T.
Prosthetics Research and Education Specialist
Research and Development Division'
Prosthetic and Sensory Aids Service
Veterans Administration, 252 Seventh Avenue
New York, N.Y. 10001

INTRODUCTION
Accurate measurement of limb length before amputation surgery aids
the surgeon in the election of the amputation site. Postoperatively,
accurate measurement of stump length assists the clinician in the defini-
tion of remaining musculature, intact tendinous insertions, joint
integrity, and the functional lever by which the stump can control a
prosthetic device. This information leads to the selection, fitting, suspen-
sion, and alignment of a prosthesis.
For any measurement to be reliable, it must be capable of being re-
peated on separate occasions, under similar conditions, by several differ-
ent evaluators. However, because of typical variables such as human
error, external conditions, and slight inaccuracies in the measuring
instruments (e.g., ruler or tape), a precise measurement is difficult to
obtain. The introduction of other variables, such as non-standard refer-
ence points and methods of measurement, will only serve to compou@
the problem of attaining reliable, accurate information.
Stump length measurements, in particular, should be standardized to
avoid interdisciplinary misunderstanding and misinterpretation. It is
understood that variations from these standards may be necessary when
measuring for specific purposes, for unusual or difficult cases, or when
the "standard" landmarks are unavailable or difficult to palpate.
The purpose of this paper is to review currently accepted guidelines
for measuring amputation stump length and the rationale for using the
named techniques and reference points, and to present those variations
which may be considered acceptable.

THE DEVELOPMENT OF THE PRESENT SYSTEM

Prior to 1920, amputation stumps were classified according to site, with
stump lengths grossly categorized into upper, middle, and lower thirds
Bulletin of Prosthetics Research-Spring 1972

(1). These classifications were arrived at by rough, "eye" estimates;

specific measurements were recorded. The expanded numbers of amput
veterans produced by World War I directed attention to the need f
exact measurements and resulted in the adoption of standards for mea
urement in Europe. Specific locations based on easily palpated structu
served as reference points; these landmarks varied somewhat, as did t
methods of measurement. As will be noted, these landmarks were som
what vague and indefinite.
In London, the Ministry of Pensions adopted a system of landmar
for measurement (1) that resembles the present system:
shoulder-tip of acromion
elbow-olecranon, with forearm flexed to 90 deg.
hip-tip of greater trochanter
knee-tibia1 plateau (preferably medial)
A separate system of landmarks was indicated for the measurement o
sound limbs:
humerus-lateral condyle
ulna-styloid process
I
femur-lateral condyle
tibia-medial malleolus
Exact points on these landmarks were not identified; one examin
might have chosen the superior aspect of the olecranon, for exampl
while another examiner might have chosen the apex.
Also, in London in 1923 Ernst (2) interchanged the use of the "h
joint" and the perineum as proximal reference points. His definition
a landmark for the "hip joint" is unclear.
I n Geneva, stump length was measured from "below the nearest join
(3) -
During the 1930's. A.A. Marks (4) in the United States zes%ibed tb
"point of the shoulder" and axilla as landmarks for both above-elbo
and below-elbow amputees, and the perineum as a reference point,!£
both above-knee and below-knee amputees. No distal reference poin
were specified.
Interest in prosthetics remained relatively static until World War,
( 5 ) , when a tremendous influx of amputee veterans created an upsu
of concern for these individuals, and a more scientific field of prosthe
was initiated. As authorities in the various medical and paramedlca
fields developed increased prosthetic knowledge and skill, specific rnea
urements became necessary.
With the numbers of amputee veterans to be evaluated and fitted wit
prosthetic devices, and with the increased interest and concern for prb
thetics as a science, research, medical, and-educational programs realizd

68
 Ross: Stump Length Measurement

t.le need for reliable data. The prosthetic and orthotic professions devel-
oped and became respected members of the paramedical community. The
establishment of the American Board for Certification in 1948 (6) led to
the of standards for prosthetic-orthotic professional practice
and ethical conduct. The ABC examination for prosthetic certification
utilizes those standards which are accepted and taught by universities
with prosthetic-orthotic programs.
The introduction and development of such concepts as total contact,
the suction socket, and patellar-tendon-bearing prostheses in the 1950's
and 1960's reemphasized the need for exact stump measurements. Fitting
and fabrication manuals, published by various institutions and profes-
sional organizations, noted specific locations and techniques for stump
and sound extremity length measurements adopted and published for
educational purposes. These reference points and techniques were based
on the standards taught by the universities and recognized by the Ameri-
can Board for Certification (Fig. 1, 2, and 3 ) .
It is anticipated that unusual or difficult cases may preclude the use of
these particular landmarks and techniques. Alternatives that meet the
following criteria should be noted and the particular variation recorded
along with the measurement.

CRITERIA FOR MEASUREMENTS

Several factors are considered in the standardization of landmarks and
limb positions used for measuring stump length:
1. The landmark should be a readily palpable structure.
2. The landmark should whenever possible be a bony structure,
eliminating any possible variables resulting from soft tissue
changes.
3. The landmark should be anatomically suitable for the pir;i&lar
segment that is being measured.
4. The landmark should be located at, or in proximity to, the most
distal intact joint.
5. The extremity should be positioned in such a way as to minimize
or eliminate external influences, such as muscular contraction
or stump angulation, which may obscure the true stump length.
6. Proximal-to-distal measurement should be taken in a straight
line, avoiding incorrect measurements from an obliquely placed
ruler, tape, or caliper.
With these criteria in mind, the following methods of measuring
stump lengths and their corresponding anatomical reference points are
reviewed. Variations from these methods are included, with the stipula-
tion that they meet the aforementioned criteria.
Bulletin of Prosthetics Research-Spring 1972

UPPER-EXTREMITY
MEASUREMENT CHART
 Ross: Stump Length Measurement

-
PROSTHETIC INFORMATION ABOVE-KNEE PROSTHESIS
B. PROSTHETIC MEASUREMENTS

AMPUTEE DATE

RIGHT OR LEFT AMPUTATION PROSTHETIST

~l~istanc
from
e Ischial Tuberosity to Adductor Longus Tendon

Pelvic Circumference I
Trochanter to
Anterior Midline
I]
Ischial Tuberosity
(Standing)

n
tump Length w
w
emur Length 0 0
V)
PI

0 Forefoot to Heel Circumference 0

0

Knee Width (sitting) I a

S
Top of Knee (sitting)
I IB
w
Tibia1 Plateau I,
PI

Calf Circumference r te
0

u
V)
.,-I
n

Ankle Circumference
I 1
Shoe Size -
[ I Heel Height

FIGURE2.-Lower-extremity (above-knee) measurement chart-Note that two measure-

ments are taken: "Stump Length" indicates the actual length (to fleshy end) and
"femur length" indicate; functional length (to bony end). (Adapted from a form
developed at UCLA.)
 Bulletin of Prosthetics Research-Spring 1972
- .-
1. . r-

,-- ..- PROSTHETIC INFORMATION

BELOW-KNEE PROSTHESIS

B. PROSTHETIC MEASUREMENTS

FITTING AIDS: ( ) PLASTER CAST OF STUMP i(

"A.

IED

pzqLq
.M+f \'>,$))
Tibia1 ference
Plateau

I
To D i s t a l
I A - P Caliper
-..-
To D i s t a l
-&"A-
-I+
I
Max. C a l f
Circ .

. I$--
-
n n - ~ c a l i n~.
~ -M--i -. A -n~
. -. - -k- -l -P
~-

Circ .
Knee l Width
1 A ~ tD . Side a
(sitting/- .
shoe S i r e --
I 1 ~ t u m Sock
p Size I[ Heel Height --

FIGURE3.-Lower-extremity (belon7-knee) measurement chart-Note that two me;

urements are taken: to "distal end" (fleshy end) for actual length and to :distal t i b i ~
(bony endj for fzinctional length. (Adapted from a form develo~eda t UCLA3-

UPPER EXTREMITY
!'
Figure 1 illustrates the standard measurements for stump and sou-
extremity lengths and circumferences for both above- and below-elbd
 Ross: Stump Length Measurement

amputees. In both cases, measurement of the length of the sound upper

extremity is extremely important for proper prosthetic fitting and sizing.
It is important to distinguish between the stump as a total structure
(to the fleshy end) and the stump as an "effective lever" (7) or functional
structure (measured to the bony end). Redundant tissue, although it
must be considered to describe actual stump length, does not contribute
to functional stump length. Therefore, two measurements should be
taken-one to the fleshy end for actual length and the other to the bony
end (firm pressure applied to stump end) for functional length.

Above Elbow
The most desirable surface bony landmark in the region of the shoul-
der joint is the acromion process. Ideally, either the glenoid fossa or the
head of the humerus would be the more desirable, as they are the por-
tions of the scapula and humerus that form the shoulder joint itself.
These structures, however, are not palpable in the normal shoulder joint
because of muscle bulk and a ligamentous sleeve which encapsulates the
joint. The tip of the acromion is readily palpable and, therefore, is used.
Measurement of the stump from this landmark does not provide the
prosthetist with adequate information. An additional measurement is
therefore taken from the axilla to the end of the bone. These two meas-
urements establish the functional stump length, which demonstrates the
effective lever of the stump (e.g., a patient may have some intact portion
of the humerus; however, if this stump does not extend beyond the
axillary fold, it is classified as a shoulder amputation and therefore an
ineffective lever). The axilla-to-stump-end measurement is especially
important for prosthetic fitting.
We therefore have four measurements for above-elbow stump length:
Tip of acromion to fleshy end and axilla to fleshy end for acttial stump
length, and tip of acromion to bony end and axilla to bony end +r
functional stump length (Fig. 4) .

Below Elbow
The elbow is a multi-facet joint consisting of the trochlea and
capitulum of the humerus, the trochlear notch of the ulna, and the head
of the radius.
Although the olecranon process of the ulna appears to be a suitable
reference point by its readily palpable nature, it is anatomically situated
posterior to the elbow joint; its position changes in relation to the elbow
joint (moving in a posterior direction in reference to the humerus) dur-
ing flexion-extension motions of the forearm. Therefore, the olecranon is
not usually used as a proximal landmark for measuring the below-elbow
stump. This rule does not remain firm, however. For instance, the
Northwestern University self-contained, self-suspended below-elbow
Bulletin of Prosthetics Research-Spring 1972

FIGURE4.-Above-elbolcr stump length measurements: Note that there are four meas.
urements. The above-elbolr stump should be held in slight passive abduction.

" 2
prosthesis (described in BPR 10-14) utilizes the olecranon for suspen.
sion. The olecranon-to-stump-end length is thus essential to determine
adequate suspension. In rare cases where the humeral epicondyles are
absent, the olecranon may be used. In any case, the alternatives shoulil
be noted next to the measurement.
The medial and lateral epicondyles of the humerus, which extend
slightly above the anatomical elbow joint, are prominent and easily
palpated through the skin. Both are palpated with equal facility. How-
ever, the use of the lateral epicondyle places the measuring instrument
in a more accessible position.
A major factor in measuring the forearm is its anatomical structure,
which dictates the need for especially accurate methods of measurement.
Brunnstrom (8) indicates that the trochlea of the humerus extends more
distal than the capitulum. As a result, if the forearm is held in an ex-
tended and supinated position, the forearm tends to deviate "laterally
 Ross: Stump Length Measurement

FIGURE5.-Below-elbow stump length FIGURE6.-Position of the forearm for

~~~casuretnents:The forearn1 should be medial epicondyle-to-ulnar-styloid meas-
held in a flexed, mid-pronated (neutral) urement (alternative measurement) .
position.

in relation to the humerus, which accounts for the carrying angle or cubi-
tal angle" (8). Hence, to avoid this angulation, the below-elbow stump
should be measured in a flexed, mid-pronated (neutral) position (Fig.
5) . With the forearm in this position, the measuring instrument would
be difficult to read if the medial epicondyle were used. T h e only other
position which would give an accurate measurement from the medial
epicondyle would be with the forearm flexed and mid-pronated, with the
olecrtinon held against a table (Fig. 6) . When either medial epicondyle-
to-ulnar-styloid or to-stump-end measurement is desired, this position
should be adopted. As stated previously, efforts should be made to avo$
a measurement produced by an obliquely placed ruler, tape, or caliper.
Two measurements should be recorded for below-elbow stump length:
Lateral epicondyle to fleshy end for actual stump length, and lateral
epicondyle to bony end for functional stump length. These measurements
should be taken with the stump held in a flexed, mid-pronated position
(Fig. 5) . If medial epicondyle-to-stump-end (or ulnar styloid) measure-
ments are taken, the stump (or sound limb) should be held in a flexed,
mid-pronated position with the elbow resting on a table or similar surface
(Fig. 6) .

The Sound Limb

Measurements of the sound limb are extremely important to insure
proper prosthetic fitting and sizing. Distally, the thumb tip is occasion-
ally used when the projected total length of the prosthesis, including the
Bulletin of Prosthetics Research-Spring 1972

terminal device, is desired. More often required is the distance from 6

latera1 epiconldyle to the ulnar stylc
both styloids (medial and lateral)
radial styloid (lateral), however, rotates about the ulna during pro?
tion and supination. As a result the measurement from the late!
epicondyle to the radial styloid changes as the forearm moves about
transverse axis. Measurement of the length of the sound forearm shou:
F
therefore be taken from the lateral epicondyle to the z~lnal- (media;
sty loid.
Therefore, the acromion to lateral epicondyle to ulnar styloid (0;
thumb tip) measurement is the most appropriate measurement for the
.il
sound limb (Fig. 7) . !

-
I-)
- 1

THUMB TIP-

I . 8 I .
. . J . ,

FIGURE7.-Length uneasukementi of'tfii.' sd"nt1 upper extremity for prosthetic fittigiv]

and 5sizing. The distal landuyark may be
from "Manual I~f Upper Extremity,.Prosl
. , . .

LOWER
Figures 2 and 3 illustrate those measurements for stump and sound
extremity lengths and circumferences that are considered standard. As
indicated for upper-extremity measurements, it is important to dis;
a
+

tinguish between actual stump length and junctional stump length. ',
 Ross: Stump Length Measurement

Above Knee
Location of anatomically suitable landmarks about the hip joint is a
difficult task because of the usual amount of soft tissue in that area.
Ideally, the hip joint itself would be the most desirable reference point,
but its location makes it a non-palpable structure. Traditionally, the
greater trochanter of the femur has been used as an approximate counter-
part to the hip joint. I n extremely obese or muscular individuals, how-
ever, the greater trochanter may be difficult to locate. Although the
seater trochanter meets the criteria for a suitable landmark, it is not the
nost desirable because of potential difficulties in its palpation. If unusual
ircumstances necessitate the use of the greater trochanter as a proximal
eference point, the tip should be used and this landmark should be
~otedwith the measurement.
The ischial tuberosity is located distal to the hip joint at approxi-
lately the level of the lesser trochanter. It is best palpated below the
gluteal fold when the gluteus maximus and hamstring muscles are re-
laxed (8) . This bony prominence and its surrounding soft tissue provide
the weight-bearing surface for above-knee quadrilateral sockets, below-
knee ischial-weight-bearing corsets, and some weight-bearing orthoses.
The iscllial tuberosity-to-stump-end or to-floor measurement is thus
critical in determining socket fit and correct prosthesis length. The ischial
tuberosity may be somewhat obscured by soft tissue; however, this may be
a factor in increasing socket comfort due to increased pressure distribu-
tion (Fig. 8), and should therefore be considered during the measure-
ment process.
Care should be taken to position the stump in the midline (avoid
flexion, extension, abduction, or adduction) to eliminate placement of
the measuring instrument in an oblique direction. Remember to take
two measurements-for actual and functional stump lengths (Fig. 9).
Below Knee
-*
The knee joint is a complex structure involving articulations between
the femoral and tibial condyles, with intervening menisci. The patella is
a sesamoid bone, which is imbedded in the quadriceps tendon, function-
ing as a pulley to facilitate quadriceps action. The head of the fibula
articulates with the tibia and is not an integral part of the knee joint.
The tibial plateaus are easily palpated when the knee is held in a
slightly flexed position. The medial tibial plateau is used as the standard
landmark by virtue of its easy palpation just distal to the medial femoral
condyle. The lateral tibial plateau may also be used; it is, however, less
distinct and is somewhat obscured by surrounding soft tissue and the
head of the fibula. The patella is not a satisfactory landmark, as it shifts
with quadriceps action and knee motion (9, 10) .
The patellar ligament is a soft tissue structure and, although its fibers
 Ross: Stump Length Measurement

FIGURE9.-Sound lower-extremity and above-knee stump length measurements. Stump

should be positioned in the midline, avoiding flexion, extension, abduction, or
adduction.

plateau to fleshy end (actual stump length) (Fig. 10) . Alternative refer-
ence points should, of course, be recorded with the measurement.
The Sound Limb
T o ensure uniformity, measurement of the sound limb should coincide
with measurement of the amputated limb. If ischial tuberosity or medial
tibial plateau to stump end measurements are taken for the amputated
side, then ischial tuberosity (reference line) to medial tibial plateau to
the floor on the medial side (with reference line through the medial
malleolus) should be recorded for the sound lower extremity (Fig. 9 ) .
Bulletin of Prosthetics Research-Spring 1972

FIGURE10.- Below-knee stump length ~neasurements.The stump should be held in a

slightly flexed position.

SUMMARY
T o recapitulate, the measurement of amputation stump length r
been a step i n the process of patient evaluation that has been taken f o ~
granted. Altl~oughthe universities, fitting and fabrication manuals, and
the American Board for Certification teach and expect certain standards,
various other reference points are occasionall) used and interchanged
without regard to the need for consistency.
Guidelines for proximal and distal landmarks and for positions of the
extremities during measurement have been presented; they are outlined
in Table 1.
I t is anticipated that unusual cases might preclude the use of the
standard reference points; in these cases, the alternative landmarks
should be recorded. Acceptable alternatives are presented in Table I .
 TABLE
1.-Gzridelitres for Afenstlr.ing Sttct~zpsatrd Soutrd Limbs

Stump length measurement Measurement Position for

U P P ~ of sound limb rneasure~nen~
Extremity Actual Functional
Above elbow Acromion to fleshy end Acromion to bony end - Arm in slight passive
Axilla to fleshy end Axilla to bony end abduction
Lateral epicondyle Lateral epicondyle - Forearm in flexed,
(olecranon; medial (olecranon; medial mid-pronated position
epicondyle ') to epicondyle ") to
fleshy end bony end
Sound limb - - Acromion to lateral Arm in slight passive
epicondyle to ulnar abduction, forearm flexed
Styloid (or thumb tip ') in mid-pronated position
(Medial epicondyle to
ulnar styloid")
A
Lower $
Extremity I?
- Neutral position, midline
Above knee Ischial tuberosity (or greater
trochanter ") to fleshy
Ischial tuberosity g e a t -
er trochanter ") (avoid flexion, extension, S3
end to bony end abduction, or adduction) P
- r
Below knee Medial (lateral ') tibia1 Medial (lateral ') tibia1 - Knee in flexion m
3

Sound limb
plateau to fleshy end
-
plateau to bony end
- Ischial tuberosity to medial AK-Standing with knee
s
tibia1 plateau to floor on of sound limb extended 3
m
medial side of foot (not hyperextended)
(ref. line through
medial malleolus)
BK-Sitting with knee flexed
at "90"" i
3
m
3 Recommended alternatives-if used, must be yoted on measurement chart. 5
 -
Bulletin of Prosthetics Research-Spring

ACKNOWLEDGMENTS
1972

Sincere appreciation is given to Mr. Ralph DeGaetano, C.P.

initiating the investigation, to Gustav Rubin, hl.D.,
sultant, Henry F. Gardner, Special Technical Assistant to
and Thomas Pirrello, Chief, Testing & Distribution
VA Prosthetics Center, New York City), for their sound a
couragement.

REFERENCES
1. Little, E. Muirhead: Artificial Limbs and Amputation Stumps, 25-31,
Lewis and Co., Ltd., London, 1922.
2. Ernst, F. G.: Artificial Legs for Use After Amputations and Congenital De
cies, E. T. Heron and Co., Ltd., London, 1925.
3. Martin, Florent: Artificial Limbs, International Labour Office, 5, Geneva, 19
4. Marks, A. A.: Manual of Artificial Limbs, New York, 1931.
. 5. Wilson, A. Bennett, Jr.: Limb Prosthetics-1970. Artifi. Limbs, 14
1970.
6. American Board for Certification in Prosthetics and Orthotics, Inc.: The B
Rules, Washington, D.C., December 1, 1970.
7. Staros, Anthony and Thomas Pirrello: The Construction and Eitting.of-v
Extremity Prostheses, Orthopaedic Appliances Atlas, Vol. 2:57-103, J,. W
wards, Ann Arbor, Michigan, 1960.
8. Brunnstrom, Signe: Clinical Kinesiology, 50-51, 123, 222, F. A. Dav
delphia, 1962.

versity of California Biomechanics Laboratory, Berkeley, Nov. 195

ADDITIONAL READING
Grant, J. C. Boileau: An Atlas of Anatmy, The Williams and Wil
more, 1947.
Klopsteg, Paul E. and Philip D. Wilson: Human Limbs and Their Substitutes, Haf
Publishing Co., New York, 1968.
Lambert, Claude N. and Albert T. Novotny: Amputations and Amputees-Adult a
Juvenile, Surgical Clinics of North America, pp. 119-134, February 1957.

New York, 1968.